Survival Outcome Analysis of Stereotactic Body Radiotherapy and Immunotherapy (SBRT-IO) versus SBRT-Alone in Unresectable Hepatocellular Carcinoma.

Introduction: While combination of stereotactic body radiotherapy (SBRT) and immunotherapy are promising, their efficacy and safety have not been compared with SBRT-alone in patients with unresectable hepatocellular carcinoma (HCC). Methods: This retrospective study included 100 patients with nonmetastatic, unresectable HCC in two hospitals. Eligible patients had tumor nodules ≤3 and Child-Pugh liver function score of A5 to B7. Seventy patients received SBRT-alone, and 30 patients underwent combined SBRT and immunotherapy (SBRT-IO). Overall survival (OS), time to progression (TTP), overall response rate (ORR), and toxicity were analyzed. We adjusted for the potential confounding factors using propensity score matching. Results: The median tumor size was 7.3 cm (range, 2.6-18 cm). Twenty-five (25%) of patients had vascular invasion. Before propensity score matching, the 1-year and 3-year OS rate was 89.9% and 59.8% in the SBRT-IO group and 75.7% and 42.3% in SBRT-alone group (p = 0.039). After propensity score matching (1:2), 25 and 50 patients were selected from the SBRT-IO and SBRT-alone group. The 1-year and 3-year OS was 92.0% and 63.9% in the SBRT-IO group versus 74.0% and 43.3% in the SBRT-alone group (p = 0.034). The 1-year and 3-year TTP was better in SBRT-IO group (1-year: 68.9% vs. 58.9% and 3-year: 61.3% vs. 32.5%, p = 0.057). The ORR of 88% (complete response [CR]: 56%, partial response [PR]: 22%) in SBRT-IO arm was significantly better than 50% (CR: 20%, PR: 30%) in the SBRT-alone arm (p = 0.006). Three patients (12%) developed ≥grade 3 immune-related treatment adverse events (n = 2 hepatitis, n = 1 dermatitis) leading to permanent treatment discontinuation. Conclusion: Adding immunotherapy to SBRT resulted in better survival with manageable toxicities. Prospective randomized trial is warranted.

Multimodal Integrative Genomics and Pathology Analyses in Neoadjuvant Nivolumab Treatment for Intermediate and Locally Advanced Hepatocellular Carcinoma.

Introduction: Immunotherapy has resulted in pathologic responses in hepatocellular carcinoma (HCC), but the benefits and molecular mechanisms of neoadjuvant immune checkpoint blockade are largely unknown. Methods: In this study, we evaluated the efficacy and safety of preoperative nivolumab (anti-PD-1) in patients with intermediate and locally advanced HCC and determined the molecular markers for predicting treatment response. Results: Between July 2020 and November 2021, 20 treatment-naive HCC patients with intermediate and locally advanced tumors received preoperative nivolumab at 3 mg/kg for 3 cycles prior to surgical resection. Nineteen patients underwent surgical resection on trial. Seven (36.8%) of the 19 patients had major pathologic tumor necrosis (≥60%) in the post-nivolumab resection specimens, with 3 having almost complete (>90%) tumor necrosis. The tumor necrosis was hemorrhagic and often accompanied by increased or dense immune cell infiltrate at the border of the tumors. None of the patients developed major adverse reactions contradicting hepatectomy. RNA-sequencing analysis on both pre-nivolumab tumor biopsies and post-nivolumab resected specimens showed that, in cases with major pathologic necrosis, the proportion of CD8 T cells in the HCC tissues predominantly increased after treatment. Moreover, to investigate noninvasive biomarker for nivolumab response, we evaluated the copy number variation (CNV) using target-panel sequencing on plasma cell-free DNA of the patients and derived a CNV-based anti-PD-1 score. The score correlated with the extent of tumor necrosis and was validated in a Korean patient cohort with anti-PD-1 treatment. Conclusion: Neoadjuvant nivolumab demonstrated promising clinical activity in intermediate and locally advanced HCC patients. We also identified useful noninvasive biomarker predicting responsiveness.

Deep Learning Algorithm of the SPARCC Scoring System in SI Joint MRI.

BACKGROUND: The Spondyloarthritis Research Consortium of Canada (SPARCC) scoring system is a sacroiliitis grading system. PURPOSE: To develop a deep learning-based pipeline for grading sacroiliitis using the SPARCC scoring system. STUDY TYPE: Prospective. POPULATION: The study included 389 participants (42.2-year-old, 44.6% female, 317/35/37 for training/validation/testing). A pretrained algorithm was used to differentiate image with/without sacroiliitis. FIELD STRENGTH/SEQUENCE: 3-T, short tau inversion recovery (STIR) sequence, fast spine echo. ASSESSMENT: The regions of interest as ground truth for models' training were identified by a rheumatologist (HYC, 10-year-experience) and a radiologist (KHL, 6-year-experience) using the Assessment of Spondyloarthritis International Society definition of MRI sacroiliitis independently. Another radiologist (YYL, 4.5-year-experience) solved the discrepancies. The bone marrow edema (BME) and sacroiliac region models were for segmentation. Frangi-filter detected vessels used as intense reference. Deep learning pipeline scored using SPARCC scoring system evaluating presence and features of BMEs. A rheumatologist (SCWC, 6-year-experience) and a radiologist (VWHL, 14-year-experience) scored using the SPARCC scoring system once. The radiologist (YYL) scored twice with 5-day interval. STATISTICAL TESTS: Independent samples t-tests and Chi-squared tests were used. Interobserver and intraobserver reliability by intraclass correlation coefficient (ICC) and Pearson coefficient evaluated consistency between readers and the deep learning pipeline. We evaluated the performance using sensitivity, accuracy, positive predictive value, and Dice coefficient. A P-value <0.05 was considered statistically significant. RESULTS: The ICC and the Pearson coefficient between the SPARCC scores from three readers and the deep learning pipeline were 0.83 and 0.86, respectively. The sensitivity in identifying BME and accuracy of identifying SI joints and blood vessels was 0.83, 0.90, and 0.88, respectively. The dice coefficients were 0.82 (sacrum) and 0.80 (ilium). DATA CONCLUSION: The high consistency with human readers indicated that deep learning pipeline may provide a SPARCC-informed deep learning approach for scoring of STIR images in spondyloarthritis. EVIDENCE LEVEL: 1 TECHNICAL EFFICACY: Stage 2.

The Hong Kong consensus statements on unresectable hepatocellular carcinoma: narrative review and update for 2021.

Background and Objective: Hong Kong, like many parts of Asia, faces a high burden of hepatocellular carcinoma (HCC) caused by high endemic rates of hepatitis B virus infection. Hong Kong clinicians have developed a high level of expertise in HCC treatment across surgical, transarterial, ablative, radiotherapeutic and systemic modalities. This publication summarizes the latest evidence-based recommendations on how these modalities should be used. Methods: In two meetings held in 2020, a multidisciplinary panel of surgeons, oncologists and interventional radiologists performed a narrative review of evidence on the management of HCC, with an emphasis on treatment of HCC not amenable to surgical resection. Close attention was paid to new evidence published since the previous version of these statements in 2018. Key Content and Findings: The expert panel has formulated 60 consensus statements to guide the staging and treatment of unresectable HCC. Since the previous version of these statements, considerable additions have been made to the recommendations on use of targeted therapies and immunotherapies because of the large volume of new evidence. Conclusions: Our consensus statements offer guidance on how to select HCC patients for surgical or non-surgical treatment and for choosing among non-surgical modalities for patients who are not candidates for resection. In particular, there is a need for more evidence to aid physicians in the selection of second-line systemic therapies, as currently most data are limited to patients with disease progression on first-line sorafenib.

Sequential transarterial chemoembolisation and stereotactic body radiotherapy followed by immunotherapy as conversion therapy for patients with locally advanced, unresectable hepatocellular carcinoma (START-FIT): a single-arm, phase 2 trial.

BACKGROUND: The synergy between locoregional therapies and immune checkpoint inhibitors has not been investigated as conversion therapy for unresectable hepatocellular carcinoma. We aimed to investigate the activity of sequential transarterial chemoembolisation (TACE) and stereotactic body radiotherapy followed by avelumab (an anti-PD-L1 drug) for locally advanced, unresectable hepatocellular carcinoma. METHODS: START-FIT was a single-arm, phase 2 trial in patients with locally advanced hepatocellular carcinoma who were not suitable for curative treatment, conducted in two hospitals in Hong Kong and one in Shenzhen, China. Eligible patients were those aged 18 years or older with an Eastern Cooperative Oncology Group performance status 0-1, Child-Pugh liver function score A5 to B7, tumour size of at least 5 cm, a maximum of three tumour lesions, and adequate hepatic, renal, and bone marrow function. Participants received TACE on day 1, followed by stereotactic body radiotherapy (27·5-40·0 Gy in five fractions) at day 28. Avelumab (10 mg/kg) was administered 14 days following stereotactic body radiotherapy and every 2 weeks thereafter. The primary endpoint was the proportion of patients deemed amenable to curative treatment, defined as those who had a sustained complete or partial treatment response for at least 2 months and if curative treatment could be performed (ie, resection, radiofrequency ablation, or transplantation), analysed by intention to treat. Safety was also analysed in the intention-to-treat population. This trial is registered with ClinicalTrials.gov (NCT03817736) and has been completed. FINDINGS: Between March 18, 2019, and Jan 27, 2021, 33 patients (32 [97%] men and one [3%] woman) were enrolled. The median sum of the largest diameters of lesions was 15·1 cm (IQR 8·3-14·9). 21 (64%) patients had macrovascular invasion (hepatic vein [n=13], branched portal vein [n=3], or both [n=5]). Median follow-up was 17·2 months (IQR 7·8-25·8). 18 (55%) patients were deemed amenable to curative treatment: four (12%) of 33 patients had curative treatment (resection [n=2] or radiofrequency ablation [n=2]), and 14 (42%) had a radiological complete response and opted for close surveillance. 11 (33%) of 33 patients had treatment-related adverse events that were grade 3 or worse. The most common treatment-related grade 3 or worse adverse event was transient increase in alanine aminotransferase or aspartate aminotransferase (five [15%]) after TACE. Five (15%) patients developed immune-related adverse events of grade 3 or worse (three had hepatitis, two had dermatitis). INTERPRETATION: To our knowledge, this is the first prospective trial using the combination of immunotherapy and locoregional treatment as conversion therapy for locally advanced unresectable hepatocellular carcinoma, with promising results. Future randomised trials with larger cohorts of patients are warranted. FUNDING: Merck.

High-intensity focused ultrasound ablation of liver tumors in difficult locations.

High-intensity focused ultrasound (HIFU) has been shown to be a valuable tool in the management of small liver tumors such as hepatocellular carcinoma (HCC). It has been shown to be a safe and effective means to ablate small HCC even in the presence of advanced cirrhosis. This review examines the challenges faced during HIFU ablation when the target tumors are located in difficult locations such as the liver dome, close to the rib cage, near large blood vessels or the heart, or adjacent to hollow viscera; and the special maneuvers employed to tackle such lesions.

Statin-associated anti-3-hydroxy-3-methyl-glutaryl-coenzyme A reductase (HMGCR) myopathy: Imaging findings on thigh-muscle magnetic resonance imaging (MRI) in six patients.

INTRODUCTION/AIMS: Anti-3-hydroxy-3-methyl-glutaryl-coenzyme A reductase (HMGCR) myopathy is a rare but serious complication of statin use. The aim of this study was to describe the imaging features of statin-associated anti-HMGCR myopathy on thigh muscle magnetic resonance imaging (MRI). METHODS: Thigh muscle MRI images of six patients with statin-associated anti-HMGCR myopathy were reviewed for muscle edema, fatty replacement, and fascial edema in four compartments of each thigh: gluteal, anterior, medial, and posterior. Signal intensity ratio (SIR) was calculated in 17 muscles in both thighs on T2-weighted fat-suppressed images. Intracompartmental comparison of T2 SIRs of different muscles were performed. RESULTS: All patients demonstrated bilateral symmetrical pan-compartmental muscle edema. Three patients had fatty infiltration, involving gluteal and/or posterior compartments. In the anterior compartment, rectus femoris and vastus lateralis most frequently demonstrated the highest T2 SIR. In the posterior compartment, semimembranosus most frequently demonstrated the highest T2 SIR. The long head of the biceps femoris always had a higher T2 SIR than the short head. DISCUSSION: Statin-associated anti-HMGCR myopathy commonly demonstrates bilateral symmetrical pan-compartmental edema on thigh muscle MRI, with anterolateral predilection in the anterior compartment, and greater involvement of the semimembranosus with relative sparing of the short head of the biceps femoris in the posterior compartment. These observations can contribute to the diagnosis of statin-associated anti-HMGCR myopathy.

Prospective Study of Stereotactic Body Radiation Therapy for Hepatocellular Carcinoma on Waitlist for Liver Transplant.

BACKGROUND AND AIMS: There are no prospective data on stereotactic body radiation therapy (SBRT) as a bridge to liver transplantation for HCC. This study aimed to evaluate the efficacy and safety of SBRT as bridging therapy, with comparison with transarterial chemoembolization (TACE) and high-intensity focused ultrasound (HIFU). APPROACH AND RESULTS: Patients were prospectively enrolled for SBRT under a standardized protocol from July 2015 and compared with a retrospective cohort of patients who underwent TACE or HIFU from 2010. The primary endpoint was tumor control rate at 1 year after bridging therapy. Secondary endpoints included cumulative incidence of dropout, toxicity, and posttransplant survival. During the study period, 150 patients were evaluated (SBRT, n = 40; TACE, n = 59; HIFU, n = 51). The tumor control rate at 1 year was significantly higher after SBRT compared with TACE and HIFU (92.3%, 43.5%, and 33.3%, respectively; P = 0.02). With competing risk analysis, the cumulative incidence of dropout at 1 and 3 years after listing was lower after SBRT (15.1% and 23.3%) compared with TACE (28.9% and 45.8%; P = 0.034) and HIFU (33.3% and 45.1%; P = 0.032). Time-to-progression at 1 and 3 years was also superior after SBRT (10.8%, 18.5% in SBRT, 45%, 54.9% in TACE, and 47.6%, 62.8% in HIFU; P < 0.001). The periprocedural toxicity was similar, without any difference in perioperative complications and patient and recurrence-free survival rates after transplant. Pathological complete response was more frequent after SBRT compared with TACE and HIFU (48.1% vs. 25% vs. 17.9%, respectively; P = 0.037). In multivariable analysis, tumor size <3 cm, listing alpha-fetoprotein <200 ng/mL, Child A, and SBRT significantly reduced the risk of dropout. CONCLUSIONS: SBRT was safe, with a significantly higher tumor control rate, reduced the risk of waitlist dropout, and should be used as an alternative to conventional bridging therapies.

Acceptability of cardiac donation after circulatory determination of death: a survey of the Canadian public.

PURPOSE: Cardiac transplantation is a definitive therapy for end-stage heart failure, but demand exceeds supply. Cardiac donation after circulatory determination of death (cardiac DCDD) can be performed using direct procurement and perfusion (DPP), where cardiac activity is restored after heart recovery, or (NRP), where brain blood supply is surgically interrupted, circulation to the thoraco-abdominal organs is restored within the donor's body, followed by heart recovery. While cardiac DCDD would increase the number of heart donors, uptake of programs has been slowed in part because of ethical concerns within the medical community. These debates have been largely devoid of discussion regarding public perceptions. We conducted a national survey of public perceptions regarding cardiac DCDD. METHODS: We surveyed 1,001 Canadians about their attitudes towards cardiac DCDD using a rigorously designed and pre-tested survey. RESULTS: We found that 843 of 1,001 respondents (84.2%; 95% confidence interval [CI], 81.8 to 86.3) accepted the DPP approach, 642 (64.1%; 95% CI, 61.1 to 67.0) would agree to donate their heart using DPP, and 696 (69.5%; 95% CI, 66.6 to 72.3) would consent to the same for a family member. We found that 779 respondents of 1,001 respondents (77.8%; 95% CI, 75.1 to 80.3) accepted the NRP approach, 587 (58.6%; 95% CI, 55.5 to 61.6) would agree to donate their heart using NRP, and 636 (63.5%; 95% CI, 60.5 to 66.4) would consent to the same for a family member. Most respondents supported the implementation of DPP (738 respondents or 73.7%; 95% CI, 70.9 to 76.3) and NRP (655 respondents or 65.4%; 95% CI, 62.4 to 68.3) in Canada. CONCLUSION: The results of this national survey of public attitudes towards cardiac DCDD will inform the implementation of cardiac DCDD programs in a manner that is consistent with public values.

Attitudes of healthcare providers towards cardiac donation after circulatory determination of death: a Canadian nation-wide survey.

PURPOSE: The number of patients on cardiac transplant waitlists exceeds the number of available donor organs. Cardiac donation is currently limited to those declared dead by neurologic criteria in all but three countries. Cardiac donation after circulatory determination of death (cardiac DCDD) can be conducted using direct procurement and perfusion (DPP) or normothermic regional perfusion (NRP). Implementation of cardiac DCDD in many countries has been slowed by ethical debates within the donation and transplantation community. We conducted a national survey to determine the perceptions of healthcare providers regarding cardiac DCDD. METHODS: We conducted an electronic survey of 398 healthcare providers who are involved in the management of heart donors and/or heart transplant recipients in Canada (226 nurses, 82 critical care physicians, 31 donation specialists, and 59 transplant specialists). Our primary outcomes were their attitudes towards and concerns regarding cardiac DCDD protocols and their implementation in Canada. We distributed the survey electronically through several Canadian donation and transplantation organizations. RESULTS: We identified that 361 of 391 respondents (92.3%; 95% confidence interval [CI], 89.6 to 95.1) believed that DPP is acceptable, and 329 of 377 respondents (87.3%; 95% CI, 83.9 to 90.7) supported its implementation in Canada. We found that 301 of 384 respondents (78.4%; 95% CI, 74.2 to 82.6) believed that NRP is acceptable and 266 of 377 respondents (70.6%; 95% CI, 66.0 to 75.2) supported its implementation in Canada. CONCLUSION: This is the first survey describing the attitudes of healthcare providers towards cardiac DCDD. We identified widespread support for cardiac DCDD and its implementation in Canada among Canadian healthcare providers within the organ donation and transplantation community in Canada.

Apparent Diffusion Coefficient as an Imaging Biomarker for Spinal Disease Activity in Axial Spondyloarthritis.

Background A quantifiable imaging measure to gauge the intensity of individual inflammatory lesions in axial spondyloarthritis (SpA) has not been well established. Previous studies have shown that diffusion-weighted (DW) MRI reflects disease activity in axial SpA. Purpose To determine the association between apparent diffusion coefficient (ADC) at MRI of discovertebral lesions and disease activity in individuals with axial SpA. Materials and Methods In this prospective study, 243 study participants (mean age ± standard deviation, 43.2 years ± 13.5) with back pain who fulfilled the Assessment of SpondyloArthritis International Society criteria for SpA were recruited from four rheumatology centers between April 2014 and March 2018. There were 132 men (mean age, 41.4 years ± 13.3) and 111 women (mean age, 45.3 years ± 13.4). Clinical, biochemical, and radiologic parameters were collected. All participants underwent whole-spine MRI by using a short inversion time inversion-recovery sequence and DW imaging. Two independent readers identified the presence of discovertebral lesions. ADCs were measured and normalized with normal bone marrow. Regression analysis was performed to determine association between the mean, maximum, and normalized mean and maximum ADCs of the discovertebral lesions and disease activity and functional parameters (Bath Ankylosing Spondylitis Disease Activity Index [BASDAI], Bath Ankylosing Spondylitis Functional Index [BASFI], and Bath Ankylosing Spondylitis Global Index [BASGI]). Results Ninety-one discovertebral lesions (five cervical, 61 thoracic, 25 lumbar) were present in 55 of the 243 study participants (22.6%). After adjusting for confounding factors, increased maximum ADC was independently associated with increased BASFI (regression coefficient [ß] = 1.94 [×10-3 mm2/sec], P = .04). Increased normalized maximum ADC was independently associated with BASDAI question 2 (ie, back pain score) (ß = 0.45, P = .01), mean stiffness score (ß = 0.41, P = .04), and BASGI (ß = 0.43, P = .04). Increased normalized mean ADC was independently associated with BASDAI question 2 (ß = 0.61, P = .04). Conclusion Apparent diffusion coefficients at MRI of discovertebral lesions were associated with disease activity, functional impairment, and patient global assessment in axial spondyloarthritis. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Guermazi and Roemer in this issue.

Ultrasound-MRI Fusion for Targeted Biopsy of Myopathies.

OBJECTIVE. The purpose of this article is to describe the use of ultrasound-MRI fusion imaging to guide precise and targeted muscle biopsy in patients with suspected myopathies. CONCLUSION. Ultrasound-MRI fusion-guided muscle biopsy allows targeted sampling of tissues with active inflammatory changes and facilitates diagnosis of myopathies.

Opportunistic screening for osteoporosis in abdominal computed tomography for Chinese population.

This study assessed the possibility of diagnosing and excluding osteoporosis with routine abdominal CT scans in a Chinese population who underwent both DXA and CT for unrelated reasons. Statistical correlation was made between the HU measured of the spine on CT and various parameters on DXA. Diagnostic cutoff points in terms of HU were established for the diagnosis (≤ 136 HU) and exclusion (≥ 175 HU) of osteoporosis on sagittal reformatted images. There was excellent positive and negative predictive value for the DXA-defined diagnostic subgroups and were also comparable with previous studies in Caucasian populations. The authors exhort radiologists to report these incidental findings to facilitate early detection and treatment of osteoporosis in unsuspecting patients to prevent fractures and related complications. PURPOSE: The suspicion for osteoporosis can be raised in diagnostic computed tomography of the abdomen performed for other indications. We derived cutoff thresholds for the attenuation value of the lumbar spinal vertebrae (L1-5) in Hounsfield units (HU) in a Chinese patient population to facilitate implementation of opportunistic screening in radiologists. METHODS: We included 109 Chinese patients who concomitantly underwent abdominal CT and dual X-ray absorptiometry (DXA) within 6 months between July 2014 and July 2017 at a university hospital in Hong Kong. Images were retrospectively reviewed on sagittal reformats, and region-of-interest (ROI) markers were placed on the anterior portion of each of the L1-L5 vertebra to measure the HU. The mean values of CT HU were then compared with the bone mineral density (BMD) and T-score obtained by DXA. Receiver operator characteristic (ROC) curves were generated to determine diagnostic cutoff thresholds and their sensitivity and specificity values. RESULTS: The mean CT HU differed significantly (p < 0.01) for the three DXA-defined BMD categories of osteoporosis (97 HU), of osteopenia (135 HU), and of normal individuals (230 HU). There was good correlation between the mean CT HU and BMD and T-score (Pearson coefficient of 0.62 and 0.61, respectively, p < 0.001). The optimal cutoff point for exclusion of osteoporosis or osteopenia was HU ≥ 175 with negative predictive value as 98.9% and with area under curve (AUC) of ROC curve as 0.97. The optimal cutoff point for diagnosis of osteoporosis was HU ≤ 136 with positive predictive value as 81.2% and with AUC of ROC curve as 0.86. CONCLUSION: This is the first study on osteoporosis diagnosis with routine CT abdominal scans in Chinese population. The cutoff values were comparable with previous studies in Caucasian populations suggesting generalizability. Radiologists should consider routinely reporting these opportunistic findings to facilitate early detection and treatment of osteoporosis to prevent fractures and related complications.

Comparing diffusion weighted imaging with clinical and blood parameters, and with short tau inversion recovery sequence in detecting spinal and sacroiliac joint inflammation in axial spondyloarthritis.

OBJECTIVES: To investigate the usefulness of diffusion weighted imaging (DWI) by comparing with clinical features, blood parameters and traditional short tau inversion recovery (STIR) sequence in detecting spinal and sacroiliac (SI) joint inflammation in axial spondyloarthritis (axSpA) patients. METHODS: One hundred and ten axSpA patients were recruited. Clinical, radiological and blood parameters were recorded. DWI and STIR MRI were performed simultaneously and results were scored according to the Spondyloarthritis Research Consortium of Canada (SPARCC) for comparison. Apparent diffusion coef cient (ADC) values were also calculated. RESULTS: DWI did not correlate with clinical parameters or blood parameters. It also had lowered sensitivity. When compared with STIR sequence, it correlated well with STIR sequence at the SI joint level (CC 0.76, p<0.001), but weakly at the spinal level (CC 0.23, p=0.02). At the SI joint level, the presence of inflammation on both STIR sequence and DWI was associated with an increase in maximum (B=0.24, p=0.02 in STIR; B=0.37, p<0.001 in DWI) and mean ADC values (B=0.17, p=0.003 in STIR; B=0.15, p=0.01 in DWI). Maximum (B=0.19, p=0.04) and mean spinal ADC values (B=0.18, p=0.01) were also positively associated with DWI detected spinal inflammation. Presence of Modic lesions showed positive correlation with STIR sequence (B=7.12, p=0.01) but not spinal ADC values. CONCLUSIONS: Despite DWI correlates with STIR sequence, it has lower sensitivity. However, ADC values appear to be independent of Modic lesions and may supplement STIR sequence to differentiate degeneration.

A rare disease in an atypical location-Kimura's Disease of the upper extremity.

Kimura's disease is a rare chronic inflammatory disorder predominantly affecting young Asian male patients, occurring mainly in the head and neck regions. Kimura's disease of the upper extremity is extremely rare, and previous case reports in the literature show similar imaging characteristics with consistent location at the medial epitrochlear region, predominantly with unilateral involvement. We present the first reported case of Kimura's disease affecting the anterolateral aspect of the upper arm, sparing the medial epitrochlear region, illustrating that with typical MR appearance and serology, the involvement of this rare disease in an atypical location still warrants consideration of this diagnosis. There was also bilateral asymmetrical involvement in our patient, suggesting the possibility of a propensity for Kimura's disease affecting the upper extremities to have bilateral involvement, which may necessitate imaging of the clinically asymptomatic contralateral limb in these patients for early lesion identification and treatment.

Embolisation of hypervascular bone tumours: a pictorial essay with literature review.

Bone tumours, either primary or secondary, can present in various debilitating manners, including pain and pathological fracture. The situation is particularly problematic when the tumours are hypervascular, and located in regions where a high risk of neurological compromise is anticipated during operation, such as in the spine or sacrum. In such situations, bone tumour embolisation is a useful and effective adjunctive treatment for reducing intra-operative blood loss. This is particularly relevant in primary bone tumours such as giant cell tumours and metastatic renal cell and thyroid tumours. With a proper pre-embolisation angiogram and knowledge of anatomy, careful selective cannulation of the arterial supplies and experience in using embolic agents, the risks of non-target embolisation can be kept to minimum and the best result achieved.