Does a less intensive surveillance protocol affect the survival of patients after treatment of a sarcoma of the limb? updated results of the randomized TOSS study.

AIMS: A single-centre prospective randomized trial was conducted to investigate whether a less intensive follow-up protocol would not be inferior to a conventional follow-up protocol, in terms of overall survival, in patients who have undergone surgery for sarcoma of the limb. Initial short-term results were published in 2014. PATIENTS AND METHODS: The primary objective was to show non-inferiority of a chest radiograph (CXR) group compared with a CT scan group, and of a less frequent (six-monthly) group than a more frequent (three-monthly) group, in two-by-two comparison. The primary outcome was overall survival and the secondary outcome was a recurrence-free survival. Five-year survival was compared between the CXR and CT scan groups and between the three-monthly and six-monthly groups. Of 500 patients who were enrolled, 476 were available for follow-up. Survival analyses were performed on a per-protocol basis (n = 412). RESULTS: The updated results recorded 12 (2.4%) local recurrences, 182 (36.8%) metastases, and 56 (11.3%) combined (local + metastases) recurrence at a median follow-up of 81 months (60 to 118). Of 68 local recurrences, 60 (88%) were identified by the patients themselves. The six-monthly regime (overall survival (OS) 54%, recurrence-free survival (RFS) 46%) did not lead to a worse survival and was not inferior to the three-monthly regime (OS 55%, RFS 47%) in terms of detecting recurrence. Although CT scans (OS 53%, RFS 54%) detected pulmonary metastasis earlier, it did not lead to a better survival compared with CXR (OS 56%, RFS 59%). CONCLUSION: The overall survival of patients who are treated for a sarcoma of the limb is not inferior to those followed up with a less intensive regimen than a more intensive protocol, in terms of frequency of visits and mode of imaging. CXR at six-monthly intervals and patient education about examination of the site of the surgery will detect most recurrences without deleterious effects on the eventual outcome. Cite this article: Bone Joint J 2018;100-B:262-8.

Cerebral venous thrombosis: role of CT, MRI and MRA in the emergency setting.

PURPOSE: It is often difficult to diagnose cerebral venous thrombosis (CVT), an uncommon condition that more frequently affects young subjects, is responsible for 1%-2% of strokes in adults and has a subtle clinic onset. The aim of this study was to evaluate the role of computed tomography (CT), magnetic resonance imaging (MRI) and MR venography in the emergency setting and to discuss the risk factors, clinical presentation, outcome and follow-up of this disease. MATERIALS AND METHODS: We retrospectively studied 40 patients with CVT admitted to the emergency department between 1996 and 2006 and examined with unenhanced CT, MRI and MR venography. Fourteen patients also underwent digital subtraction angiography (DSA). RESULTS: Headache was the most common presenting feature (60%). Unenhanced CT showed typical signs (cord or empty delta sign) in 11 cases and nonspecific signs in the other cases. The diagnosis was achieved with MRI and MR venography in 38/40 cases (95%) and with DSA in 2/40 cases. All patients were treated with heparin. Five patients died, and only one of the remaining patients developed serious disability. CONCLUSIONS: Knowledge of the CT, MRI and MR-venography signs of CVT is crucial and enables an early diagnosis and timely treatment with heparin in the majority of cases. DSA should be reserved for doubtful cases only.

Role of diffusion- and perfusion-weighted MR imaging for brain tumour characterisation.

PURPOSE: This study was undertaken to correlate apparent diffusion coefficient (ADC) and relative regional cerebral blood volume (rrCBV) to histological findings in a large series of patients with primary or secondary brain tumours to evaluate diffusion-weighted (DWI) and perfusion-weighted (PWI) imaging in the characterisation of cerebral tumors. MATERIALS AND METHODS: Ninety-eight patients with cerebral tumours, 46 of which were primary (seven grade 0-I, nine low-grade gliomas, two gliomatosis cerebri, nine lymphomas and 19 high-grade gliomas) and 52 secondary, underwent conventional magnetic resonance (MR) imaging completed with DWI and dynamic contrast susceptibility PWI. Both ADC and rrCBV were calculated on a workstation by using Functool 2 software. Student's t test was used to determine any statistically significant differences in the ADC and rrCBV values. RESULTS: Seventeen of 98 tumours were cystic or necrotic (12/17 hypointense and 5/17 hyperintense on DWI); the ADC value of hyperintense cystic areas was 0.97+/-0.23x10(-3) mm2/s. The ADC value of solid tumours varied between 0.64 and 3.5x10(-3) mm2/s. The rrCBV value was 1.4 (sigma 0.66) in low-grade gliomas; 1.22 (sigma 0.25) in lymphomas; 4.5 (sigma 0.85) in grade III gliomas; 3.18 (sigma 1.26) in grade IV gliomas and 2.53 (sigma 1.6) in metastases. CONCLUSIONS: DWI has an important role in the differential diagnosis of cystic cerebral masses but not in tumour characterisation. PWI is helpful in differentiating high-from low-grade gliomas and lymphomas from high-grade gliomas.

Double step paraneoplastic brainstem encephalitis: a clinicopathological study.

A case of brainstem encephalitis in a man positive for both anti-Hu and anti-Ri antibodies is reported. This case had an unusual double step evolution and progressive involvement of different CNS subdivisions at MRI. Brainstem encephalitis developed abruptly, mimicking a posterior vascular deficit with vertigo and dizziness. These symptoms transiently remitted completely after a few days to relapse acutely 1 month later with sudden loss of consciousness, followed by confusion, disorientation, dysarthria, dysphagia and reduced thermic sensation on the right side. Within another few days, the patient developed acute respiratory failure and died some weeks later. MRI was negative at the beginning but later showed a progressive ascending involvement of the brainstem and thalamus. At autopsy, this picture corresponded to lymphocytic infiltration, preferentially B cells into the perivascular spaces and T cells in the brainstem parenchyma, confirming that T cells could be the effector of cytotoxicity, probably in the presence of cooperation with B cells that were well represented in this setting.

Diffusion-Weighted Magnetic Resonance Imaging and ADC Maps in the Diagnosis of Intracranial Cystic or Necrotic Lesions. A Retrospective Study on 49 Patients.

This study evaluated the usefulness of diffusion-weighted (DW) magnetic resonance imaging (MRI) and ADC maps in the differential diagnosis of brain abscesses from cystic or necrotic neoplasms. MR images of 49 patients with 54 lesions were examined retrospectively. All patients underwent conventional MRI and DWI, and ADC values were calculated by placing ROIs of 30 mm(2) manually over the cystic part of the lesions. On DWI, all cystic portions of abscesses were hyperintense. Mean ADC values were 0.48×10 mm(2)/s (range 0.41-0.54×10 mm/s) for pyogenic abscesses, 0.73×10 mm(2)/s (range 0.65-0.91×10 mm/s) for mycotic abscesses and 0.6 mm(2)/s for Nocardia abscess. Cystic areas appeared hypointense on DWI in 33/44 tumours (mean value ADC 1.96 mm(2)/s). Eleven tumours (11/44) appeared hyperintense on DWI: eight metastases from lung cancer (mean ADC value 0.86 mm(2)/s, range 0.75-1.2 mm(2)/s), two GBMs (mean 0.7 mm(2)/s, range 0.67-0.76 mm(2)/s) and one anaplastic astrocytoma (ADC value 1.24 mm(2)/s). ADC values may help in differentiating pyogenic abscess from brain tumors or metastatic lesions.

Reversible encephalopathy syndrome: report of 12 cases with follow-up.

We report the clinical and neuroradiological features of reversible encephalopathy syndrome and follow-up results in 12 patients. This syndrome seems to be the result of an acute encephalopathy showing with brain edema mainly in the white matter (vasogenic edema). Diffusion-weighted magnetic resonance images are useful to distinguish this entity from acute ischemia. Early recognition and treatment often lead to complete neurological recovery. If unrecognized, the patient's condition can progress to central nervous system failure.

Primitive cerebral melanoma: case report and review of the literature.

BACKGROUND: Central nervous system primary malignant melanoma accounts for approximately 1% of all the cases of melanoma; reports in the literature are relatively rare. CASE DESCRIPTION: A 74-year-old man was hospitalized because of an episode of aphasia. The neuroradiologic examinations demonstrated a round homogeneous lesion extending near the left sylvian fissure. He had no extracranial abnormalities. The patient underwent a neurosurgical procedure and the tumor was macroscopically totally excised. Pathological examination of the surgical specimen revealed a histological appearance similar to that of melanoma. A diagnosis of primary CNS melanoma was made after careful dermatologic and ophthalmologic examination, which ruled out presence of cutaneous or choroidal melanoma. The patient did not receive any further treatment and he is free of disease 2 years after diagnosis. CONCLUSIONS: We report a case of primary cerebral melanoma of the left temporal lobe; clinical, neuroradiological, and histological findings are discussed with review of the literature. Primary melanoma of the CNS may present either with localized intra/extra-axial mass lesions or with meningeal spread, which carries a worse prognosis. The prognosis of cerebral primitive melanoma is variable, although it is common opinion that primitive cerebral melanoma has a better prognosis than cutaneous melanoma, with two cases in the literature surviving 9 and 12 years.

Psychiatric symptoms as late onset of Wilson's disease: neuroradiological findings, clinical features and treatment.

We describe a case of Wilson's disease with late psychiatric onset. Major depressive disorder was the first clinical manifestation at the age of 38 years. After pharmacotherapy with antidepressive agents, a manic episode was observed. Extrapyramidal hand tremor and micrography were the first neurological signs. Emotional lability occurred during worsening of extrapyramidal signs. Diagnosis was based on urinary and serum copper levels, ceruloplasmin serum level, Kayser-Fleischer ring, and liver biopsy that detected cirrhosis. Magnetic resonance imaging revealed basal ganglia hyperintensity on T1-weighted images, and hypodensity in the central part and hyperintensity in the peripheral part of the lentiform nucleus on T2-weighted images. Hyperintensity on T2-weighted images was also observed in the dorsal part of the midbrain. 123I-iodobenzamide single photon emission computed tomography (IBZM-SPECT) detected a normal distribution of the drug in the brain, with better signal in the right side and deficit of D2-dopaminergic receptors in the basal ganglia. Abnormal manganese erythrocyte level was observed. Treatment was based on penicillamine, zinc salts, low-copper diet, antidepressant agents, interpersonal psychotherapy and neurorehabilitation.

MRI diagnosis of intramedullary metastases from extra-CNS tumors.

The purpose of this study was to evaluate the topography, morphology and contrast enhancement of the intramedullary metastases (IM) from extra-CNS neoplasms. We report the results of a multicenter retrospective study on 18 patients with 26 IM examined with a 0.5T MR imaging system; intravenous injection of Gd-DTPA was performed in all cases. We found that the lesions are most frequently single, oval shaped, and small, with little or no deformation of the spinal cord (14 of 26 IM). They appear isointense on spin-echo T1-weighted images (24 of 26 IM), with a homogeneous and generally nodular high contrast enhancement after Gd-DTPA injection (21 of 26 IM), and present on T2- and proton-density-weighted sequences with a pronounced perilesional, pencil-shaped hyperintensity of the surrounding cord which is more evident in the cranial part of the cord referring to the IM.