Comparison of whole-body diffusion MRI and conventional radiological assessment in the staging of myeloma.

PURPOSE: In multiple myeloma, skeletal radiographs are still regarded as the reference imaging examination because they help to establish the stage of the disease according to the Durie-Salmon Staging System. Whole-body MRI using T1 and STIR sequences increases the detection of myeloma lesions. MRI-measured diffusion has demonstrated high sensitivity in terms of detection in oncology. The main objective of this study is to compare conventional radiographic staging with an MRI whole-body diffusion technique (called DWIBS) in detecting bone lesion monoclonal plasma cell pathologies (multiple myeloma, plasma cell leukaemia, plasmacytoma and MGUS). MATERIALS AND METHODS: Twenty-seven patients were included (multiple myeloma: 24; plasma cell leukaemia, MGUS and plasmacytoma: 1 each). All of them had a whole-body MRI diffusion examination (using a DWIBS sequence). Diffusion MRI and conventional radiographs were compared according to the Durie-Salmon Staging System. In case of doubtful lesions, 12 months of monitoring was used as the reference method for the definitive diagnosis. RESULTS: The overall concordance rate between the two techniques was 63%. The DWIBS sequence detected a higher number of lesions leading to a higher Durie-Salmon stage in 37% of the patients: one stage I to II, seven stage I to III, and two stage II to III. In 18.5% of the patients, the MRI was positive while the radiographs were normal and these discrepancies were most often located in sites poorly explored by X-ray (spine, pelvis and ribs). In one patient (4%), the MRI provided a stage lower than that of the X-rays (stage II vs. III). In this case, the X-rays were positive at the humerus and femur, unlike the DWIBS sequence. Our per site analysis confirmed the clear superiority of the DWIBS sequence when compared with X-rays in the exploration of the cervical spine (56 vs. 0%, P<0.001), dorsal spine (81vs. 31%,P<0.0002), lumbar spine (70 vs. 35%, P<0.0124), pelvis (81 vs. 33%, P<0.0005) and ribs (74 vs. 36%, P<0.0009). CONCLUSION: The DWIBS MRI leads to an increase in the final Durie-Salmon stage. Although its place in the preoperative treatment of multiple myeloma still has to be assessed, this study suggests its potential interest.

Optimal duration of antibiotic therapy in vertebral osteomyelitis.

OBJECTIVES: To compare the risk of relapse of vertebral osteomyelitis (VO), according to the duration of antibiotic therapy (< or =6 weeks versus >6 weeks). METHODS: We performed a 10-year retrospective study to assess the risk of VO relapse and to verify that this risk was not enhanced in patients who received 6 weeks of antibiotic therapy (Group 1) as compared with those who received a longer treatment (Group 2). VO was diagnosed based on clinical manifestations, magnetic resonance imaging and/or computed tomography findings, and isolation of a pyogenic organism in blood cultures and/or a discovertebral biopsy. Relapse was diagnosed based on isolation of the same organism in blood cultures and/or a discovertebral biopsy. Outcome was evaluated 6 months post-treatment and in December 2004. RESULTS: Group 1 included 36 patients (mean age, 58 +/- 15 years) and Group 2 included 84 patients (mean age, 67 +/- 15 years) (P = 0.003). Clinical data and microorganisms were comparable in the 2 groups. In the first 6 months, 6 (5%) patients died (Group 1, n = 2; Group 2, n = 4), and 5 (4%) in Group 2 relapsed, 2 with recurrent VO and 3 with recurrent bacteremia. In 2004, 91 patients were evaluated (mean follow-up, 40.6 +/- 31 months): 77 (85%) were cured, 13 (14%) died (Group 1, n = 3; Group 2, n = 10), 1 had VO due to a different microorganism (Group 2), and no long-term relapses occurred. CONCLUSION: Our results suggest that antibiotic therapy of VO could be safely shortened to 6 weeks without enhancing the risk of relapse.

Vertebral osteomyelitis due to Fusobacterium species: report of three cases and review of the literature.

We describe three cases of Fusobacterium spp. diskitis and review with attention to risk factors, clinical features, diagnosis, treatment and outcome. In most of the reported cases, a ear-nose-throat infection was found. Clinical manifestations were similar to those of classic bacterial vertebral osteomyelitis. Clindamycin is the most appropriate antibiotic. The outcome seems to be very good without relapse with appropriate treatment compared to pyogenic vertebral osteomyelitis.

Femoral neuropathy secondary to ossification of the ligamentum flavum.

Radiculopathy resulting from ossification of the ligamentum flavum (OLF) is extremely rare and concerns only intercostal neuralgias. We describe a 37-year-old Caucasian woman with a lumbar radiculopathy revealing an OLF. Her symptoms were completely and definitively relieved by surgery.

Fourteen cases of sarcomatous degeneration in Paget's disease.

OBJECTIVE: To describe characteristics of cases of sarcomatous degeneration in Paget's disease (SDP) recorded over 10 years in 2 French university hospitals, with particular emphasis on the pattern of this entity on magnetic resonance imaging (MRI). METHODS: Fourteen cases are described. Epidemiological, clinical, radiological, histological, and MRI features (in 3 cases) are compared to others in the literature. RESULTS: Nine men and 5 women (mean age 75.2+/-7.7 yrs) were studied. Paget's disease was monostotic in 5 cases and polyostotic in 9. Neurological complications were present in 10 cases. The mean interval between the first clinical signs and diagnosis was 4.4+/-4.7 months. The locations were: limbs 2, skull 2, pelvis 7, sacrum 3. The radiological pattern was lytic in 9 cases, sclerotic in 3, and mixed in 2. MRI revealed a similar pattern in all 3 cases studied (heterogeneous low signal intensity of the tumor on T1 weighted images increased after intravenous gadolinium administration and high signal intensity on T2 weighted images), whereas the radiological pattern was lytic in 2 cases and sclerotic in one case. The diagnosis was proved by histological investigation in 11/14 patients (osteogenic sarcoma of different appearance in 7 patients, fibroblastic sarcoma in one, fibrous histiocytoma-like sarcoma in one, and undifferentiated sarcoma in 2). Four patients had pulmonary metastases and 4 patients are still alive with followup ranging from 5 months to 5 years. CONCLUSION: Paget sarcomas remain the most threatening sarcomas of bone, their prognosis being far more negative than primary sarcomas. Improvement in therapy strategies including surgery, radiation therapy, and chemotherapy might together provide better prognosis for SDP.

VAD or VMBCP in multiple myeloma refractory to or relapsing after cyclophosphamide-prednisone therapy (protocol MY 85).

263 patients (median age 65+/-10 years) with multiple myeloma were treated with cyclophosphamide-prednisone. Out of this cohort, 103 patients had progressive disease and were randomly assigned to either VAD (vincristine, doxorubicin, dexamethasone; 50 cases) or VMBCP (vincristine, BCNU, cyclophosphamide, melphalan and prednisone; 53 cases). There were no statistical differences between the two groups with the respect to clinical, biological and radiological parameters. There was no difference in survival between the VAD and VMBCP groups. The 4 months response rate was similar in the two groups (50% VAD, 56% VMBCP). With multivariate analysis for survival (Cox model), two factors had a statistically significant impact: Karnofsky index (> 60) and albuminaemia (< 34 g/l). With both Karnofsky index > 60 and albuminaemia > or = 34 g/l, the median survival was 29 months v 2 months with a Karnofsky index < or = 60 and albuminaemia < 34 g/l (P<0.05). In conclusion, VAD or VMBCP had similar activity for salvage treatment in MM refractory or relapsing to first-line treatment with cyclophosphamide-prednisone.

[RS3PE: a clinical diagnosis, a prognosis more simple than its name]. / RS3PE: un diagnostic clinique, une évolution plus simple que le nom.

INTRODUCTION: RS3PE syndrome (remittive symmetrical seronegative synovitis with pitting edema) was first described by MacCarthy in 1985. It is a rare type of seronegative polyarthritis occurring in the elderly. METHODS: Retrospective report of 13 cases (including eight male and five female patients; mean age 76.7 +/- 3.7 years) and search for previously reported cases, using the Medline database. RESULTS: Pitting edema was present at onset of disease in nine cases. Joint arthritis was bilateral, occurring in the wrist (13 cases), shoulder (six cases), elbow (six cases), knee (six cases), ankle (four cases), metacarpophalangeal (four cases) and hip (one case). Radiographies were normal. Mean erythrocyte sedimentation rate was 62 +/- 19 mm at the first hour and mean C-reactive protein level was 73 +/- 35 mg/L. Mild cholestasis was present in four of the seven patients for whom data were available. HLA B7 was present in five out of 12 cases (42%). Improvement was favorable, occurring over 7 months. Mean follow-up was 22.2 months. Fifty-nine other cases have been described in the literature. This syndrome, which affects the elderly, appears to be rare. Its clinical presentation is quite constant, with sudden onset, symmetrical polyarthritis and pitting edema. Its evolution, often long, is favorable. Rheumatoid arthritis and polymyalgia rheumatica are the main differential diagnoses. CONCLUSION: Due to its favorable outcome and the usefulness of a mild corticotherapy, this syndrome, though rare, should be diagnosed where necessary in elderly patients.

[Distribution of bone metastases of cancers. A scintigraphic study of 376 cases]. / La répartition des métastases osseuses des cancers. Une étude scintigraphique de 376 cas.

Technetium 99m methylene bisphosphonate bone scans of 376 patients with cancers of breast, prostate, lung, kidney, colon, and bladder and ENT cancer were reviewed, and the distribution of skeletal metastases was analyzed. Differences were not significant for rank order of metastatic involvement in 9 selected regions in any cancer, but the breast carcinoma. Patients with breast cancer had less pelvis and more skull involvement. The rate of skull metastases was significantly higher in breast cancer than in prostatic (p < 0.001), lung (p < 0.01) and kidney (p < 0.05) cancers. These results are weakly demonstrative of a role of the vertebral veins in hematogenous spread of breast and prostate cancer. The hypothesis is proposed that this pattern of dissemination, which is suggested by experimental and clinical features, is poorly perceptible in the distribution pattern of skeletal metastases because of the concurrent arterial spread of breast and prostatic tumors cells, which is likely preponderant.

Open synovectomy for the prevention of recurrent hemarthrosis of the ankle in patients with hemophilia. A report of five cases with magnetic resonance imaging documentation.

Hemophilic arthropathy is an incapacitating complication of severe hemophilia resulting from recurrent bleeding in the same joint. Open synovectomy has been used since 1969 to prevent recurrent hemarthrosis of target joints. Between 1988 and 1993 we performed open synovectomy of the ankle in five hemophiliacs aged 6 to 9 years with early-stage hemophilic arthropathy. Magnetic resonance imaging proved very useful for evaluating the severity of joint damage, usually underestimated on plain radiographs; for determining the degree of synovial membrane hypertrophy, which is a critical factor in the decision to perform synovectomy; for planning the surgical procedure and for explaining treatment failures. A decrease in the frequency of hemarthrosis episodes occurred in all five ankles. A repeat synovectomy was needed in one case and in another patient the frequency of hemarthrosis episodes increased somewhat after the fourth year. There was no loss of range of motion. Our data suggest that open synovectomy is effective and safe for reducing the frequency of hemarthrosis and that magnetic resonance imaging should be routinely performed before the procedure.

Strategy for identifying primary malignancies with inaugural bone metastases.

The diagnosis of primary tumors with inaugural bone metastases is a serious and difficult problem commonly encountered in rheumatology. Helpful information can be derived from the radiologic appearance of the metastases, history of the patient, clinical findings, chest film, standard laboratory tests, imaging studies, serum marker assays, and histologic findings. Based on our personal experience and on previously published data, we have developed a decision tree aimed at enhancing the efficacy of the diagnostic process while ensuring optimal patient comfort and containing costs.

Prognostic factors in low tumour mass asymptomatic multiple myeloma: a report on 91 patients. The Groupe d'Etudes et de Recherche sur le Myélome (GERM).

Between January 1985 and July 1989 we diagnosed asymptomatic stage I multiple myeloma according to Durie and Salmon [Durie and Salmon: Cancer 36:842, 1975] in 91 patients. All patients were followed without chemotherapy. Disease progression occurred in 41 patients and the median time to progression for all patients was 48 months. In the Cox multivariate regression analysis, hemoglobin levels < 12 g/dl (P < .01), bone marrow plasmacytosis > 25% (P < .01), and M-component size > or = 30 g/l for Ig G or > or = 25 g/l for Ig A (P < .01) were the only significant prognostic factors for progression. The 38 patients without any harmful factor remained free of progression for a median of more than 50 months. The 18 patients with two or three of these characteristics (high-risk group) had the shortest median time to progression of 6 months. Despite different times to progression, the response rate and survival after chemotherapy were similar for all groups of patients. Patients in the high-risk group for progression have to be frequently monitored for disease progression and might benefit from early treatment.

[Chemonucleolysis of disk herniation with low back pain as the single symptom: 20 cases]. / Chimionucléolyse des hernies discales avec lombalgie pure: vingt cas.

Disk herniation can manifest as isolated low back pain, which is usually intermittent and accompanied with stiffness of the lumbar spine. There is almost general agreement that neither neurosurgical treatment nor chemonucleolysis is appropriate in patients with this clinical pattern. We used chemonucleolysis in 19 patients with recurrent episodes of isolated low back pain and one patient with severe permanent isolated low back pain dating back to a conservatively-treated episode of sciatica. All 20 patients had disk herniation documented by imaging studies. A very good or satisfactory outcome was recorded in ten patients after three months, 11 after six months and 12 in March 1993 after a mean follow-up of 72 months. The treatment was well tolerated, even in those patients who were not improved; a single patient developed an episode of acute low back pain that required surgical treatment. In patients with low back pain and disk herniation, there is currently no means of determining whether a causal relationship links these two abnormalities. Nevertheless, we believe that chemonucleolysis can be proposed in severe forms, provided the patients are apprised of current success rates.

[Disk calcinosis]. / Calcinoses discales.

Intervertebral disc calcification in children is a rare, primary and benign disease which often disappears after a single painful crisis, especially in cervical involvement. In adults, thoracic and lumbar discs are mainly involved; calcification is less expressive and is often detected during a casual radiograph. Intervertebral disc calcification is primary or secondary to chondrocalcinosis, apatite deposition disease, ochronosis and hemodialysis spondylarthropathy. Except CPPD deposits in chondrocalcinosis, calcium complex accounting for most discal calcinosis is hydroxy-apatite. Iatrogenic intervertebral disc calcification was recently described in patients treated with a discal injection of a long-acting corticosteroid.

Treatment of multiple myeloma with etidronate: results of a multicentre double-blind study. Groupe d'Etudes et de Recherches sur le Myélome (GERM).

OBJECTIVES: Because osteoclastic bone resorption is stimulated in multiple myeloma, we evaluated the efficacy of etidronate in this disease, in a multicentre controlled study. METHODS: Ninety-four previously untreated patients with stage II or III multiple myeloma received, in addition to the same chemotherapy, 10 mg/kg/day etidronate per os (n = 49) or placebo (n = 45) for 4 months. The evaluation was clinical (pain, Karnofsky, survival), biological and radiological. Forty-one patients had iliac bone biopsy before the treatment and 34 patients also at the end of the study. Histologic bone parameters were compared with 49 normal controls. RESULTS: No statistical difference was found between etidronate and placebo treated patients for clinical, biological and radiological parameters. Compared with controls, pretreatment biopsies showed markedly increased bone resorption and decreased trabecular bone volume. Bone resorption decreased significantly in patients with etidronate compared with those with placebo (p < 0.05). CONCLUSION: Though we found no clinical, biological and radiological difference with placebo, etidronate inhibited the increased bone resorption in multiple myeloma.

[Idiopathic retroperitoneal fibrosis and ankylosing spondylitis]. / Fibrose rétropéritonéale idiopathique et spondylarthrite ankylosante.

A case of ankylosing spondylarthritis in which retroperitoneal fibrosis developed 16 years after onset is reported. The patient also had aortic incompetence and cardiac conduction disorders. Eight other cases of ankylosing spondylitis with retroperitoneal fibrosis have been published. Potential relationships between the two conditions--including the possible role of indomethacin used by the patient for 16 years--are discussed.

[Association of rheumatoid arthritis and Kaposi disease. Apropos of a case arising after intraarticular corticotherapy]. / Association polyarthrite rhumatoïde--maladie de Kaposi. A propos d'un cas survenant au décours d'une corticothérapie intra-articulaire.

A 66 year old Corsican HLA A2 and DR5-positive male with moderately active seropositive destructive rheumatoid arthritis developed Kaposi's sarcoma after intraarticular administration of corticosteroids. He had no history of oral corticosteroid therapy, organ transplantation, AIDS, or cancer. Chlorambucil proved ineffective but the outcome was spontaneously favorable following discontinuation of oral corticosteroid therapy initiated after the development of the skin lesions. Six previous reports of concomitant rheumatoid arthritis and Kaposi's sarcoma were found. All six cases occurred following systemic corticosteroid therapy. The high incidence of rheumatoid arthritis and the small number of patients with rheumatoid arthritis and Kaposi's sarcoma suggest that concomitant occurrence of the two conditions may be fortuitous. However, the responsibility of corticosteroid therapy, which preceded development of Kaposi's sarcoma in every case, cannot be ruled out.

[Infectious spondylodiscitis. Analysis of a series of 105 cases]. / Spondylodiscites infectieuses. Analyse d'une série de 105 cas.

Among 105 cases of infectious spondylitis diagnosed and treated from 1971 through 1990, 23 were due to tuberculosis (TS) and 82 to other causes (NTS). The annual number of cases of NTS rose over the study period, partly because of an increase in iatrogenic spondylitis, whereas the number of TS cases fell. In both groups, mean age of patients was higher than in earlier studies. The leading causative agents in NTS were staphylococci, followed by streptococci, then Escherichia coli. Diagnosis of spondylitis was dependent on the imaging techniques used; among available methods, the most reliable was magnetic resonance imaging which improved diagnostic performance by detecting early, specific changes. Except in patients with positive blood cultures and in TS patients with Koch bacilli recovered from other visceral foci, bacteriologic diagnosis rested on studies of samples taken from the spinal infection site. Half the subjects underwent discovertebral needle biopsy, with a success rate of 47.5%, a figure comparable with those reported in other studies. In 30% of patients, bacteriologic documentation of the infection was not obtained and diagnosis rested on a set of clinical, biological, and radiological criteria.

VAD or VMBCP in severe multiple myeloma. The Groupe d'Etudes et de Recherche sur le Myélome (GERM).

A randomized trial has been performed in which 91 patients with stage III myeloma and additional severe criteria were randomly allocated to either VAD or VMBCP. No significant difference was noted between these two groups using the following criteria: response rate (VMBCP: 54%; VAD: 39%), impact on symptoms, median survival (VMBCP: 14 months, VAD: 17 months). However, toxic effects and refusal to pursue treatment were more frequent with VAD than with VMBCP (12 v 6). Therefore, in this trial, VMBCP appears to be more useful than VAD.

[Calcifications after intra-disk injection of triamcinolone hexacetonide in lumbar disk hernia. Evaluation of therapeutical results in 3 years]. / Etude des calcifications apparues après injection intradiscale d'hexacétonide de triamcinolone dans les hernies discales lombaires. Evaluation des résultats thérapeutiques à 3 ans.

The development of disk or epidural calcifications is a frequent possibility following intra-disk injection of triamcinolone hexacetonide. It was found 10 times in 26 follow-up CT scans obtained 2 to 3 years after the injection. These calcifications are often clinically silent, but they sometimes accompany a recurrence of the initial painful symptomatology. Furthermore, evaluation at 3 years of therapeutic results in a previously published series of patients who had received an intra-disk injection of triamcinolone hexacetonide showed a marked decrease in favourable results (30% vs 67% at 6 months). These two arguments: disappointing long term results and possibility of disk calcifications, are felt by the authors to justify abandoning the technique of triamcinolone hexacetonide by intra-disk injection in the treatment of lumbar disk prolapse.