Inter-rater reliability between musculoskeletal radiologists and orthopedic surgeons on computed tomography imaging features of spinal metastases.

INTRODUCTION: The primary objective of this pilot study was to examine the inter-rater reliability in scoring the computed tomography (ct) imaging features of spinal metastases in patients referred for radiotherapy (rt) for bone pain. METHODS: In a retrospective review, 3 musculoskeletal radiologists and 2 orthopedic spinal surgeons independently evaluated ct imaging features for 41 patients with spinal metastases treated with rt in an outpatient radiation clinic from January 2007 to October 2008. The evaluation used spinal assessment criteria that had been developed in-house, with reference to osseous and soft tissue tumour extent,presence of a pathologic fracture,severity of vertebral height loss, andpresence of kyphosis.The Cohen kappa coefficient between the two specialties was calculated. RESULTS: Mean patient age was 69.2 years (30 men, 11 women). The mean total daily oral morphine equivalent was 73.4 mg. Treatment dose-fractionation schedules included 8 Gy/1 (n = 28), 20 Gy/5 (n = 12), and 20 Gy/8 (n = 1). Areas of moderate agreement in identifying the ct imaging appearance of spinal metastasis included extent of vertebral body involvement (κ = 0.48) and soft-tissue component (κ = 0.59). Areas of fair agreement included extent of pedicle involvement (κ = 0.28), extent of lamina involvement (κ = 0.35), and presence of pathologic fracture (κ = 0.20). Areas of poor agreement included nerve-root compression (κ = 0.14) and vertebral body height loss (κ = 0.19). CONCLUSIONS: The range of agreement between musculoskeletal radiologists and orthopedic surgeons for most spinal assessment criteria is moderate to poor. A consensus for managing challenging vertebral injuries secondary to spinal metastases needs to be established so as to best triage patients to the most appropriate therapeutic modality.

Two cases of acrometastasis to the hands and review of the literature.

This paper reports two cases of acrometastasis to the hands. The first case involved a 78-year-old woman with a permeative osteolytic lesion in her proximal second metacarpal. A biopsy of this lesion suggested a diagnosis of non-small-cell lung carcinoma with secondary osseous metastasis. This was the first presentation of the woman's primary diagnosis. A single 8-Gy fraction of palliative radiotherapy was delivered to the patient's left hand. The treatment proved successful: the woman soon experienced pain relief and regained the use of her hand. The second case involved a 69-year-old woman with extensive lytic destruction involving the proximal two thirds of her third metacarpal. This patient had been diagnosed with carcinoma of the breast in 1990. She also received a single 8-Gy fraction of radiation, which improved both her pain and her hand mobility.An extensive review of the literature uncovered 257 previously reported cases of acrometastasis. Articles were analyzed based on age and sex of the patient, site of the primary carcinoma, metastatic locations within the hand and affected appendage or appendages, the treatment given, and the patient's length of survival. Men were almost twice as likely to experience acrometastasis as women, and the median age of the patients overall was 58 years (range: 18 months-91 years). Lung, kidney, and breast carcinoma were the three most prevalent primary diagnoses reported in the literature. Cancers of the colon, stomach, liver, prostate, and rectum affected the remainder of the population.Overall, the right hand was more often host to the metastatic lesions. In addition, almost 10% of the patients experienced lesions in both hands. The third finger was the digit most affected by osseous metastases reported in the literature. Lesions of the thumb, fourth finger, second finger, and fifth finger were less commonly reported. The region of the digit most often affected within the patient population was the distal phalanx. The metacarpal bones, proximal phalanges, and middle phalanges comprised the remainder of the four most frequent acrometastatic sites. In the literature, single lesions were more prevalent than multiple bony lesions.Based on the reported cases, amputation appeared to be the preferred method of treatment. Radiation, excision, and systemic therapy were the next most frequently used treatments. Patient survival was not well documented within the literature. However, the median survival of patients in the reported cases was 6 months. Thus, our review suggested that a diagnosis of hand metastasis is an indication of poor prognosis.This report serves to emphasize the importance of properly diagnosing acrometastases. Identifying and effectively treating these metastases in a timely manner can lead to a dramatic improvement in a patient's quality of life.

Discordance between receptor status in primary and metastatic breast cancer: an exploratory study of bone and bone marrow biopsies.

AIMS: The treatment of bone metastases in breast cancer is traditionally based upon the receptor status of the primary tumour. However, retrospective studies have shown significant discordance in receptor expression between primary and metastatic tumours. Therefore, the aim of this study was to prospectively assess the incidence of discordant receptor status in primary and metastatic disease and evaluate the role of bone marrow biopsies for the reassessment of receptor status. MATERIALS AND METHODS: Nine patients with known bone metastases were assessed with both a radiologically guided bone biopsy and a bone marrow aspirate and trephine. The oestrogen receptor and progesterone receptor status of these samples was assessed and compared with the primary breast cancer. Bone and bone marrow samples were also evaluated for HER2/neu status and compared with the status of the primary tumour if available. RESULTS: Tumour cells were found in six of the nine bone metastasis specimens and five of the nine bone marrow samples. A discordance rate for the oestrogen receptor was seen in five of nine patients (56%) and for the progesterone receptor in four patients (44%). There seemed to be a correlation between bone and bone marrow biopsies. CONCLUSION: The receptor discordance rate in this study was similar to previous retrospective studies. It seems that bone marrow biopsy may be a simple, safe and well-tolerated way to obtain tissue to reassess the receptor status of metastatic breast cancer.

Solitary bone metastasis beneath the shoulder shield: coincidence or cause?

Post-mastectomy radiotherapy has been demonstrated to improve locoregional control in breast cancer patients. We report a case involving a 44-year-old breast cancer patient who presented with a solitary bone metastasis in the area beneath the shoulder shield, likely from a coincidental recurrence.

Cord blood serum in newborns of diabetic mothers.

Serum cholesterol, triglycerides and lipoprotein cholesterol were measured in cord bloods from 117 newborns. Group I consisted of 39 infants of diabetic mothers and Group II (control) consisted of 78 newborns of non-diabetic mothers. The most significant difference in serum lipids between the two groups was the higher levels of LDL cholesterol and lower levels of HDL cholesterol in the newborns of diabetic mothers. Cord blood serum cholesterol was slightly, but not significantly, higher in children born of diabetic mothers. Serum triglycerides were also not significantly different between the groups. While it remains to be established whether elevated levels of LDL cholesterol and decreased levels of HDL cholesterol at birth in these infants represent a transient phenomenon, this study suggests that newborns of diabetic mothers may be predisposed early in life to LDL hypercholesterolemia and thus may be at a greater risk of developing coronary heart disease later in life.