Batson's Plexus Research Articles

Phenotype plasticity and altered sensitivity to chemotherapeutic agents in aggressive prostate cancer cells.

In 2023, approximately 288,300 new diagnoses of prostate cancer will occur, with 34,700 disease-related deaths. Death from prostate cancer is associated with metastasis, enabled by progression of tumor phenotypes and successful extracapsular extension to reach Batson's venous plexus, a specific route to the spine and brain. Using a mouse-human tumor xenograft model, we isolated an aggressive muscle invasive cell population of prostate cancer, called DU145J7 with a distinct biophysical phenotype, elevated histone H3K27, and increased matrix metalloproteinase 14 expression as compared to the non-aggressive parent cell population called DU145WT. Our goal was to determine the sensitivities to known chemotherapeutic agents of the aggressive cells as compared to the parent population. High-throughput screening was performed with 5,578 compounds, comprising of approved and investigational drugs for oncology. Eleven compounds were selected for additional testing, which revealed that vorinostat, 5-azacitidine, and fimepinostat (epigenetic inhibitors) showed 2.6-to-7.5-fold increases in lethality for the aggressive prostate cancer cell population as compared to the parent, as judged by the concentration of drug to inhibit 50% cell growth (IC50). On the other hand, the DU145J7 cells were 2.2-to-4.0-fold resistant to mitoxantrone, daunorubicin, and gimatecan (topoisomerase inhibitors) as compared to DU145WT. No differences in sensitivities between cell populations were found for docetaxel or pirarubicin. The increased sensitivity of DU145J7 prostate cancer cells to chromatin modifying agents suggests a therapeutic vulnerability occurs after tumor cells invade into and through muscle. Future work will determine which epigenetic modifiers and what combinations will be most effective to eradicate early aggressive tumor populations.

Spinal Tuberculosis in Children

Tuberculosis continues to be the leading cause of morbidity and mortality, with an estimated annual incidence of 10.4 million worldwide. It has been estimated that 10% of patients with extrapulmonary tuberculosis have musculoskeletal involvement, with the spine being the most common. Spinal tuberculosis (TB) accounts for 50% of cases of musculoskeletal tuberculosis.
 Spinal tuberculosis is the result of infection with Mycobacterium tuberculosis. It is a secondary infection, the primary lesion of which is in the lungs, genitourinary system, or gastrointestinal tract and can be active or latent. Involvement of the vertebral segment is the result of hematogenous spread of infection along the arterial pathway or Batson's vein plexus, lymphatic spread, or direct invasion from adjacent internal organs. 
 Computed tomography (CT) is better suited for assessing the extent of the lesion when contrast is used to enhance granulomatous tissues and abscesses, but exposes the patient to high radiation. Magnetic resonance imaging (MRI) can detect changes that occur in the early stages of the disease. WHO has suggested that any extrapulmonary tuberculosis should require sputum examination and chest x-ray, as there is a high risk of pulmonary infection. Thus, computed tomography (CT) and magnetic resonance imaging (MRI) are the main modalities for detecting tuberculous spondylitis.
 

INCIDENTAL SOLE CONTRALATERAL PLEURAL METASTASIS FROM RENAL CELL CARCINOMA SEVEN YEARS POST NEPHRECTOMY

TOPIC: Disorders of the Pleura TYPE: Medical Student/Resident Case Reports INTRODUCTION: Renal cell carcinoma (RCC) accounts for 3% of all adult male cancers, and half of them are incidental findings on imaging [1]. 18% of patients have synchronous metastasis at RCC diagnosis, and 85% have metachronous metastasis within five years after surgery. A better prognosis is seen with a metachronous metastasis occurring after a long disease-free interval [2] CASE PRESENTATION: A 68-year-old male presented to an outside emergency department with generalized weakness, fatigue, and loss of appetite for a week's duration with no respiratory complaints. He was a former smoker who quit 40 years back. He had significant asbestos exposure as a sandblaster and changing railroad brake shoes. His initial blood work revealed an acute kidney injury with a serum creatinine of 14.8 mg/dL with no leukocytosis. Computed tomography (CT) abdomen revealed an obstructive right ureteropelvic junction stone (1.4 x 1 cm) with moderate hydronephrosis. Chest x-ray and CT revealed multiple right pleural soft tissue masses (largest measuring 7.7 x 3.1 x 3.5 cm) with no effusion concerning for malignancy (Figure A). Past medical history was significant for left clear cell RCC grade 3/4 with no invasion (T1bNxMx) treated by left radical nephrectomy seven years ago. His obstruction was relieved by urological intervention. A nuclear positron emission tomography showed hypermetabolic right pleural masses and a right paratracheal lymph node (Figure B). A CT-guided biopsy returned positive for metastatic RCC (Figure C1-C2). His creatinine improved, and he was discharged with an oncology follow-up DISCUSSION: The risk of RCC metastasis via hematogenous or lymphatic spread increases if it is locally advanced (stage 3-4), higher nuclear grade, and clear cell histology [2]. The lung is the frequent site of metastasis (45%), and pleural lesions occur in 12% along with lung spread [3]. Isolated pleural spread without an effusion is rare. Dormant metastasis uses Batson's venous plexus draining into thoracic veins (bronchial and intercostal) and reaches the pleura rather than by lung parenchyma direct extension [2]. Most reported cases of solitary pleural spread are symptomatic with effusion. Our patient was asymptomatic with incidental contralateral pleural metastasis without pleural effusion seven years postresection with a rare combination of pleural and paratracheal lymph node spread. 5-15% of patients recur with a distant spread questioning the current five-year surveillance strategy [4] CONCLUSIONS: Metastatic RCC to the pleura is a rare finding. This diagnosis should be considered in patients with RCC history, even if the presentation is many years after initial diagnosis and treatment. Postnephrectomy, the surveillance should be based on an individual's RCC risk factors REFERENCE #1: Ohnishi H, Abe M, Hamada H, et al. Metastatic renal cell carcinoma presenting as multiple pleural tumours. Respirology. 2005;10(1):128-31 REFERENCE #2: Brufau BP, Cerqueda CS, Villalba LB, Izquierdo RS, González BM, Molina CN. Metastatic renal cell carcinoma: radiologic findings and assessment of response to targeted antiangiogenic therapy by using multidetector CT. Radiographics. 2013;33(6):1691-716 REFERENCE #3: Saitoh H. Distant metastasis of renal adenocarcinoma. Cancer. 1981;48(6):1487-91 DISCLOSURES: No relevant relationships by Mohammed Alnijoumi, source=Web Response No relevant relationships by Cliff Chen, source=Web Response No relevant relationships by Tarang Patel, source=Web Response No relevant relationships by SACHIN PATIL, source=Web Response

Analysis of metastatic bone disease in a tertiary care centre

Introduction: Metastasis to the bone is the third commonest site next to lung and liver. It is one of the leading cause of morbidity and mortality in the world being, an important prognostic indicator in advanced cancers. The axial skeleton is more commonly involved than the appendicular skeleton due to the venous blood flow through the bat sons plexus. Commonest site involved are the spine, femur, pelvis, skull. Materials and Methods: A retrospective analysis of cases with metastatic bone disease confirmed by histopathology and followed by immunohistochemistry was carried out in the department of Pathology, SRMC from January 2014 to December 2016. The data of same were analyzed and recorded. Results: A total of 36 cases with bone metastasis were analyzed of which 26 patients were males and 10 were females. Metastasis from epithelial tumors were 94% as compared to 6% of deposits from mesenchymal tumor. Most common site of involvement was the spine (50%) second most common being femur (25%) followed by the iliac bone (14%) and clavicle (3%), tibia (3%), skull (3%), radius (3%) in both males and females. Most common primary site of origin were the Lung (29%), followed by prostate (17%), Gastrointestinal tract (14%), renal (11%), breast (6%), thyroid (6%), ovary (3%) penis (3%) liver (3%), Thigh – soft tissue (3%) and uterus (3%). For 3 cases (8%) the primary site was unknown. Conclusion: Patients presenting with metastatic bone disease is increasing over time but advancement in treatment and awareness among patients have helped in early detection and prompt treatment and longer survival. Keywords: Metastasis, Bone, Primary, Immunohistochemistry.

Neck subcutaneous nodule as first metastasis from broad ligament leiomyosarcoma: a case report and review of literature

BackgroundLeiomyosarcoma usually develops in the myometrium and is characterized by a high recurrence rate, frequent hematogenous dissemination, and poor prognosis. Metastasis is usually to lungs, liver, and bone, and occasionally to the brain, but seldom to the head and neck region. Primary leiomyosarcoma very rarely arises in the broad ligament.Case presentationA 54-year old woman presented to the otolaryngology department with a mass in the right posterior region of the neck 4 years after surgery for a primary leiomyosarcoma of the right broad ligament. The neck mass was removed and found to be a metastatic leiomyosarcoma. Leiomyosarcoma localizations in lungs and liver were absent. Morphological examination showed both the primary and the secondary leiomyosarcomas to have features of low-grade tumors. One year after excision of the neck mass, the patient presented with tachycardia. Echocardiography detected two intracardiac nodules suggestive of metastatic tumors. Chemotherapy was administered; the disease has been stable since then.ConclusionsWe report the first case of broad ligament leiomyosarcoma with the neck subcutaneous region being the first site of secondary involvement. We speculate that the Batson venous plexus might have been the pathway of dissemination.

S2923 Leptomeningeal Carcinomatosis as Initial Presentation of Gastric Cancer in a Patient With Rapid Deterioration of Neurological Function

INTRODUCTION: Leptomeningeal carcinomatosis (LMC) is a rare, late-stage complication typically seen in advanced solid tumors. It is found in 2–4% of all solid cancers and although the incidence is increasing, GI tract involvement is rarely reported. We report a case of LMC in a previously healthy man who presented with ataxia and slurred speech followed by rapid deterioration of neurological function as an initial presentation of signet cell gastric adenocarcinoma. CASE DESCRIPTION/METHODS: A 59-year old Caucasian man presented with progressive ataxia, slurred speech and nausea. His medical history was remarkable for flu-like symptoms two weeks prior and gastroesophageal reflux disease. Shortly after presentation, his neurologic and respiratory function suddenly deteriorated, becoming non-verbal and requiring intubation for respiratory failure. His CT head was negative for stroke, but a CTA revealed multiple enlarged cervical lymph nodes. A lumbar puncture revealed malignant cells. An MRI head was suggestive of leptomeningeal carcinomatosis and a CT chest revealed thickening of the distal esophagus. Esophagogastroduodenoscopy (EGD) revealed a 6 cm ulcerated, friable gastroesophageal junction mass encompassing 50% of the lumen. Biopsies from both EGD and cervical lymph nodes revealed poorly differentiated adenocarcinoma of the stomach with signet ring cell features. A paraneoplastic component was thought to have contributed to his worsening mental status and a trial of plasmapheresis was done without improvement. Given his worsening neurological function, spread to the leptomeninges and overall poor status, systemic and intrathecal chemotherapy was not offered. The family opted for a palliative approach and the patient died in the ensuing days. DISCUSSION: LMC is a rare complication of advanced cancer with a dismal prognosis. The incidence of LMC secondary to gastric cancer is reported to be approximately 0.14–0.24%, with signet cell morphology being particularly aggressive. Median survival of untreated patients is around 4–6 weeks. Tumor spread to the meninges can occur through arteries and lymphatics, perineural and perivascular spaces, retrograde flow of Batson's plexus and direct infiltration. Therapeutic options can include systemic and intrathecal chemotherapy, but most patients trend towards palliative care. Our case displays the latent nature of gastric cancer and highlights the need to have a comprehensive evaluation for malignancy in these patients centered around imaging, CSF studies, and endoscopy.Figure 1.: Ulcerated gastroesophageal junction mass.Figure 2.: Leptomeningeal enhancement, MRI T1 post-contrast.Figure 3.: Poorly differentiated adenocarcinoma with signet ring cell features (400x).

Intramedullary Metastasis to the Cervical Spinal Cord from Malignant Pleural Mesothelioma: Review of the Literature and Case Reports.

Context:Malignant mesothelioma is an aggressive tumor; median survival of patients following diagnosis is 12 months.Aims:Pleural malignant mesothelioma tends to spread along preexisting tissue planes and has the rare ability to spread along the nerve root into the spinal cord. In our case, there is an evidence of exceptional direct hematogenous spread to the spinal cord by the spinal branch of the intercostal arteries or the veins of Batson's plexus.Settings and Design:The authors report a case of intramedullary hematogenous metastasis to the cervical spinal cord from malignant mesothelioma, with a review of the literature.Materials and Methods:A 68-year-old male was admitted to our department because of a slowly progressive mild weakness of both low extremities, more pronounced on the left side. The patient has been treated for a malignant mesothelioma with left thoracotomy and subsequently underwent radiotherapy. Magnetic resonance imaging of the cervical-thoracic spine revealed a contrast-enhancing intramedullary expansive lesion of the left half of the spinal cord at the C6–C7 level.Results:The patient underwent surgical treatment through a C6–C7 laminectomy. Through a median posterior spinal cord incision, an intramedullary grayish lesion was completely removed. The paraparesis progressively improved and 20 days after surgery, the patient had regained normal lower extremity function.Conclusions:Malignant mesothelioma can spread to the spinal canal by the direct extension through the intervertebral foramina, by hematogenous spread to the spinal meninges, and by perineural growth along a single nerve root. The cleavage plane of the tissue may determine whether a successful gross total resection can be achieved with a good outcome for the patient.

The spinal distribution of metastatic renal cell carcinoma: Support for locoregional rather than arterial hematogenous mode of early bony dissemination.

742 Background: To investigate the distribution of spinal metastasis in metastatic renal cell carcinoma (mRCC) and to explore relationships between biological and clinical factors and patterns of spinal spread. Methods: An institutional database was queried to identify patients with mRCC and spinal metastatic involvement from June 2005 – November 2018. A blinded radiologist examined all cross-sectional imaging involving the spine and scored each level for absence or presence of disease. Clinical and biologic features including primary tumor size and degree of spinal and non-bony metastatic involvement (including regional lymph node and distant deposits) were collected. Spinal distributions were evaluated by the Kolmogorov Smirnov test and compared across radiographic and clinical parameters. Results: One-hundred patients with 685 spinal levels involved by mRCC were evaluated. A nonuniform spatial distribution was observed across the cohort; a preponderance of thoracolumbar involvement was noted with the mode at L3 (p<0.001). No difference in metastatic distribution was observed in right versus left-sided tumors. Tumors <4cm compared to >7cm, patients who had distant spread versus bone-only disease, and patients with increasing number of spine levels involved (1 versus >5 levels) had a significantly different distribution (p<0.001 for all comparisons). Smaller tumor size, distant spread, and greater number of involved levels appeared to have a more uniform distribution of spinal metastasis. Conclusions: These data support a dominant locoregional as opposed to arterial hematogenous mechanism for the early dissemination of mRCC to the spine. This is concordant with the theory of the valveless Batson plexus acting as a conduit for such spread, as the kidneys are compartmentally distinct from, but reside just anterior to the spine at L1-L3. Characterizations of the biologic molecular features contributing to osseous tropism and aggressive tumor biology (as seen in the subset of patients with uniform spread, such as outlier patients with small tumors), have implications for surveillance and are an area of active investigation.

POTT’S Disease

Pott's disease, sometimes reffered to tuberculous spondylitis, is an infection of tuberculosis that affects one or more vertebrae, which first described by Percival Pott. Tuberculous spondylitis is the most dangerous form of musculoskeletal tuberculosis because it can cause bone destruction, deformity and paraplegia. The spine is the most commonly affected due to bony dissemination of tuberculosis in bones. The deployment through the arteries, veins via Batson plexus and percontinuitatum by the spread of abscess paravertebral. The spread of tuberculosis infection will cause inflammation in paradiscs, and causes progressive bone destruction and then will make vertebral collapse and deformity arising shaped kyphosis (posterior angulation) called gibbus. Early diagnosis is often difficult, MRI is the best diagnostic tools for pott's disease. Tissue culture or spesimen of M. tuberculosis important to confirm the diagnosis. Medical treatment is preferred, whereas surgical therapy as a complements. Drop out of anti-tuberculous drugs is a major challenge for the treatment of spinal TB with MDR because of long duration of therapy and the cost. The prognosis for spinal TB increases with early diagnosis and rapid intervention.

Therapeutic implications of how TNF links apolipoprotein E, phosphorylated tau, α-synuclein, amyloid-β and insulin resistance in neurodegenerative diseases.

While cytokines such as TNF have long been recognized as essential to normal cerebral physiology, the implications of their chronic excessive production within the brain are now also increasingly appreciated. Syndromes as diverse as malaria and lead poisoning, as well as non‐infectious neurodegenerative diseases, illustrate this. These cytokines also orchestrate changes in tau, α‐synuclein, amyloid‐β levels and degree of insulin resistance in most neurodegenerative states. New data on the effects of salbutamol, an indirect anti‐TNF agent, on α‐synuclein and Parkinson's disease, APOE4 and tau add considerably to the rationale of the anti‐TNF approach to understanding, and treating, these diseases. Therapeutic advances being tested, and arguably useful for a number of the neurodegenerative diseases, include a reduction of excess cerebral TNF, whether directly, with a specific anti‐TNF biological agent such as etanercept via Batson's plexus, or indirectly via surgically implanting stem cells. Inhaled salbutamol also warrants investigating further across the neurodegenerative disease spectrum. It is now timely to integrate this range of new information across the neurodegenerative disease spectrum, rather than keep seeing it through the lens of individual disease states.

Batson's paravertebral venous plexus and single vertebral metastases from renal cell carcinoma

The presence of a single site bone metastasis in patients with renal cell carcinoma (RCC) is a rare clinical event. We report a single case of RCC with solitary vertebral metastasis and review of literature about renal tumor spreading in order to understand the anatomic explanation for this peculiar clinical case. We have considered the single case and reviewed current and past literature to describe the anatomic and functional background of this clinical situation. There are rare cases of single vertebral metastasis from RCC and these are characterized from a contemporary neoplastic thrombus. The neoplastic thrombus could justify the tumoral back-flow into the paravertebral anasthomoses and so into vertebral venous sinusoids. The rich anasthomotic system that surrounds kidneys and the experimental evidence of anasthomotic links among perirenal Lejars venous system and paravertebral Batson's venous system could explain these clinical evidences. Enrolment of para-vertebral Batson's venous system could have a major role in the RCC vertebral metastatic diffusion.

Usage Experience of a Microfibrillar Collagen Hemostat for Hemorrhage in Batson's Venous Plexus with a Sacral Fracture

仙骨骨折は，内椎骨静脈叢（Batson静脈叢）が骨片により損傷され出血し，致死的なショックをきたし得る．今回，仙骨骨折に起因するBatson静脈叢からの出血に対し，微線維性コラーゲン止血材を使用した症例を経験し，有用であると考えられたため報告する．症例は29歳，男性．墜落に伴った鉄骨支柱による会陰部杙創．CTで仙骨骨折に伴う腹腔内出血に対して緊急開腹を行った．術中所見ではDenis分類zone IIIの仙骨（S1）に鉄骨が刺入しており，これを抜去するとBatson静脈叢からの出血と考えられる噴出性の出血をみた．ガーゼパッキングを行い，24時間後に再開腹すると再び噴出性の出血をみたため，微線維性コラーゲン止血材を出血部位に充填したところ，良好な止血が得られた．外傷に伴う止血困難なBatson静脈叢からの出血に対しては，微線維性コラーゲン止血材の使用も一つの選択肢となり得る．

Leptomeningeal Carcinomatosis From Gastric Signet Ring Cell Carcinoma Presenting With SIADH and Neurological Symptoms

Introduction: Leptomeningeal carcinomatosis (LMC) is a rare but ominous complication of metastatic gastric cancer. LMC is found in 3-8% of all solid cancers and is generally a manifestation of advanced disease usually discovered late in the treatment phase. We report the case of a young man with LMC in the form of syndrome of inappropriate antidiuretic hormone secretion (SIADH) and seizures as presenting findings of metastatic gastric signet ring cell carcinoma. Case: 47-year old Hispanic man presented with transient episodes of blank stares and gaze deviation followed by loss of consciousness and post-ictal confusion. There was no significant medical history reported; however, review of systems was remarkable for two-month history of occipital headaches, nausea, loss of appetite and a forty-pound weight loss. Laboratory results were significant for hyponatremia (sodium level 122) and urine studies suggested SIADH. CT scan of the abdomen revealed a thickened gastric wall with extensive lymphadenopathy. Esophagogastroduodenoscopy was concerning for linitis plastica (Figure 1). Biopsies confirmed high grade invasive signet ring cell adenocarcinoma. Hospital course was complicated by worsening headaches and nuchal rigidity. MRI of the brain showed findings suggestive of LMC. CSF cytology depicted malignant cells similar in morphology to concurrent gastric surgical pathology specimen (Figure 2). Given advanced intra-abdominal involvement and spread to the leptomeninges, systemic chemotherapy was not offered. Patient and his family opted for palliative therapy, and within two weeks of initial diagnosis, he passed away due to deteriorating neurological function.Figure: Esophagogastroduodenoscopy showing diffuse infiltrating gastric cancer (linitis plastica).Figure: Above: CSF cytology with clusters of signet ring cells. Below: Gastric biopsy showing diffuse sheets of signet ring cells.Discussion: LMC is a rare but devastating complication of advanced cancer. Patients present relatively acutely, with symptoms emerging over days to weeks. Its incidence due to gastric cancer is approximately 0.14-0.24%; with signet ring type morphology having greatest tendency for metastasis to the brain. It has been hypothesized that tumor cells spread via arterial circulation, Batson's venous plexus, perineural spaces or lymphatics, and direct infiltration. Overall prognosis remains poor with median survival of 3-4 months. Hence, palliative care remains mainstay of management. Our case highlights not only the occult nature of this type of gastric cancer but also provides insight into the importance of comprehensive assessment for underlying malignancy in patients with SIADH neurological symptoms.

Bilateral Rounding of the Shoulders Obstructs Vertebral Vein Drainage of the Vertebral Venous Plexus/Batson's Plexus: MRI/MRA/MRV

INTRODUCTION. Costoclavicular compression of the brachiocephalic veins decreases vertebral vein drainage of the vertebral venous plexus / Batson's plexus of the vertebral column. This causes painful head and neck, upper extremity and sacral complaints. Bilateral MRI/MRA/MRV displays sites of venous, lymphatic, and arteries with binding nerve roots. METHODS and MATERIALS. Monitored multiplanar images with 2D Time of Flight MRA/MRV without contrast are acquired on a 1.5 Tesla GE Signa LX unit, 44 cm field of view, 512 x 256 matrix and saline water bags to enhance signal to noise ratio and Fast Spin Echo (FSE) to display lymphedema. RESULTS. Two patients were selected: one post trauma from utility wire exploration with anomalous course of the right axillary artery inferior to the vein and the other from repetitive stress injury with an enlarged thymus gland. CONCLUSIONS. MRI/MRA/MRV is the only monitored imaging modality that displays altered fascial plane anatomy of the brachial plexus. Health professionals need to know landmark anatomy to make an accurate diagnosis.

A report of congestive myelopathy as a result of chronic chylous reflux syndrome.

Dear Editor, We would like to share an interesting case of congestive myelopathy involving a 26-year-old female with chronic gynecological chylous reflux disease who presented with bilateral lower extremities weakness, decreased sensation, and urinary incontinence of 2 months duration. A medical review revealed chronic vaginal discharge and lower-extremity swelling due to chronic chylous reflux disease. Upon examination, the patient had normal muscle strength in the upper extremities, motor power grades of 4 in the left lower extremity (LLE) and 1 in the right lower extremity (RLE), and loss of rectal tone. Sensory examination revealed decreased touch and vibratory sensation in both lower extremities. All cranial nerve and cerebellar functions were intact. Spinal MRI revealed T2-weighted hyperintense signals and atrophy of the thoracic cord with enhancing curvilinear T2-weighted hypointense signals within the thecal sac and flow voids anterior and posterior to the conus medullaris (Fig. 1). The findings were suggestive of a dural arteriovenous malformation (AVM). Surprisingly, subsequent spinal angiography did not reveal any evidence of either a dural AVM or a fistula. We therefore diagnosed this patient with congestive myelopathy secondary to venous drainage dysfunction as a result of chylous reflux syndrome. Fig. 1 Thoracic spine T2-weighted MRI. Sagittal view (A) and cross-sectional view (B) showing hyperintense signal and atrophy of the thoracic spinal cord (arrows). Primary chylous reflux syndrome is a rare lymphatic disorder that is characterized by retrograde flow of chyle from its normal route. Hypothesized pathophysiologies include an incompetent lymphatic valvular system, lymphatic hypoplasia, and dilated incompetent megalymphatics. However, the definite pathophysiology remains unclear.1,2 Approximately 20 cases of primary chylous reflux syndrome have been reported during the past century. The common manifestations are lymphedema, chyluria, and chylous genital discharge. Some patients may experience complications such as chylothorax, chyloperitoneum, and chylopericardium.3 However, neurological deficits have never been reported in association with this condition. This patient had been diagnosed with primary chylous reflux syndrome as a young child, and was conservatively managed with dietary control. At the age of 26 years she gradually developed venous congestive myelopathy or Foix-Alajouanine syndrome. Given that the most common cause of venous congestive myelopathy is spinal dural arteriovenous fistula, extensive investigations including MRI/MRA and spinal angiography were conducted.4 The results were negative for concurrent vascular malformations. To date, only 14 cases of venous congestive myelopathy without concurrent vascular malformation have been reported,5 none of which had underlying chylous reflux syndrome. Chyle is normally absorbed through the lacteals, drains into the thoracic duct, and empties into the venous system. In patients with chylous reflux disorder, the retrograde flow of lymph may contribute to retention of lymph within the pelvic cavity, with efflux into the vagina, causing vaginal discharge. These can ultimately lead to the development of aberrant vascular channels and can increase the lymph absorption through the venous system, as evidenced in the present patient by increased lower-extremity swelling. This can result in chylous reflux disorder eventually involving the spinal venous plexus or Batson venous plexus and causing chronic venostasis, contributing to venous congestive myelopathy. The treatment of choice for primary chylous reflux disorder remains lymphangiography- or lymphoscintigraphy-guided surgery. Removal of the pelvic megalymphatics can theoretically redirect the chylous lymphatic flow toward the thoracic duct.6 However, there is no recommendation regarding the treatment of venous congestive myelopathy resulting from chylous reflux syndrome. Our patient has been refusing surgery since she was young, and at this admission again selected conservative treatment with rehabilitation. The paraplegia was slightly improved in approximately 8 weeks (motor power grades: 5/5 in LLE and 2/5 in RLE) and the patient could finally ambulate with crutches.

Obstruction of the thoracic duct(s) causes chronic lymphedema of the upper limb in patients presenting with symptoms of thoracic outlet syndrome: MRI/MRA/MRV

INTRODUCTIONObstruction of the thoracic duct(s) causes chronic upper extremity lymphedema. Lymphatics have bicuspid valves like the venous system. Metaplastic fibrosis resulting from obstruction of lymph drainage in the upper extremities impedes vertebral venous plexus / Batson's plexus circulation. The upper limb undergoes painful swelling into the axilla and compresses the brachial plexus. Patients present with tingling/numbness and weakness of the affected arm; lightheadedness; blurred vision and floaters in the visual fields, and tinnitus with whooshing sounds in the ear on the affected side and increased hair growth and nail changes in the affected limb.METHODSBilateral MRI/MRA/MRV displays the sites of obstruction of lymphatics, draining veins of the neck and the subclavian and axillary arteries with binding nerve roots. Monitored multiplanar images are acquired on a 1.5 Tesla GE Signa LX unit, 44 cm field of view, 512 × 256 matrix and saline water bags to enhance signal to noise ratio and Fast Spin Echo (FSE) to display lymphedema (JNMA 1999; 91:333–341).RESULTSTwo patients were selected: one with acquired obstruction of the thoracic lymph duct with lipoma extending into the left hemithorax, the other with developmental fibrosis of the right thoracic duct complicated by pulmonary emboli. Cannulation of the lymphatics could not be performed because of obstructed lymphatic flow.CONCLUSIONSMRI/MRA/MRV is the only alternative to lymphangiogram in patients with obstruction to lymph flow.

MRI of the carcinomatous meningitis: Rare form of prostate cancer dissemination

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Aspergillus osteomyelitis of the lumbar spine complicated with orbital apex syndrome: A potential role of the Batson's plexus in disease propagation

We report a rare case of orbital apex syndrome following epidural steroid injections of the lumbar spine in an immunocompetent individual with osteomyelitis and discitis caused by Aspergillus fumigatus. We suspect that the craniospinal venous system, also known as the Batson's plexus, was the main route for steroid-facilitated disease propagation from the spine to intracranial structures.

Have We Forgotten the Batson Plexus?

Have We Forgotten the Batson Plexus?

Group B streptococcus meningitis and infection surrounding the spinal canal caused by bacterial transmission from rectal ulcer via Batson's plexus

A 62-year-old man was admitted to our hospital because of fever and disturbed consciousness. He suffered from persistent constipation due to diabetic autonomic neuropathy. On admission, neck stiffness and weakness of the lower extremities were observed. Cerebrospinal fluid (CSF) pleocytosis and decreased CSF glucose concentration showed the presence of meningitis. Bacterial culture of CSF was negative. One week after admission, he suddenly suffered from massive bleeding from the rectum, where a hemorrhagic ulcer caused by severe persistent constipation was observed. Contrast-enhanced CT scans and gadolinium-enhanced MR scans demonstrated a lumbar spinal epidural abscess, paraspinal muscle abscess, and cervical osteomyelitis. Streptococcus agalactiae, a bacterial species belonging to the group B streptococci, was isolated from pus obtained by needle puncture of the paraspinal muscle abscess. His entire condition was treated successfully with ampicillin and cefotaxime. Group B streptococci normally colonize the mucous membrane of the genital or lower gastrointestinal regions and rarely cause a spinal epidural abscess. However, in this case, the existence of a rectal ulcer probably made it possible for S. agalactiae to cause an infection of the epidural space or paraspinal muscles via the spinal valveless venous system named Batson's plexus communicating with the sacral, pelvic, and prostatic venous plexus. Our case indicated the importance of Batson's plexus in group B streptococcus infections surrounding the spinal canal and the necessity to explore for intrapelvic lesions including a rectal ulcer.