Bone Roentgenograms Research Articles

Erdheim-Chester disease versus multifocal fibrosis and Ormond's disease: a diagnostic dilemma

The aim of the study was to evaluate the effectiveness of different imaging techniques with respect to diagnosis and differential diagnosis between Erdheim-Chester disease (ECD) and multifocal fibrosis (MF)/Ormond's disease (OD). Three cases of ECD were included, two of which were misdiagnosed as MF/OD. Findings in different imaging techniques [plain radiography, skeletal scintigraphy, computed tomography (CT) and magnetic resonance imaging (MRI)] of the lower extremities, chest MRI, craniofacial MRI, abdominal CT and MRI) were compared and ranked with regard to diagnostic efficacy. Differentiation between ECD and MF/OD is only possible by imaging the long bones. Bone roentgenograms and skeletal scintigraphy, followed by MRI and CT of the lower extremities are the most effective imaging techniques. A low threshold for carrying out plain radiography of the lower limbs in case of RF/MF will increase the number of ECD-cases.

Increased radionuclide uptake on bone scintiscans: a common but not clinically significant finding for human immunodeficiency virus type 1-infected patients free of osteoarticular symptoms.

The aim of this study was to describe findings of bone scintiscans and their clinical significance for patients infected with human immunodeficiency virus type 1 (HIV-1); 33 HIV-1-infected patients (22 men and 11 women) free of osteoarticular symptoms were included in the study. Plain bone roentgenograms, bone mineral contents (measured by dual-photon absorptiometry), and scintiscans (determined with 99mTc diphosphonate) were obtained for all subjects. Plain bone roentgenograms showed no abnormalities, and bone mineral contents were within the normal range for all patients. Radionuclide bone scans were unremarkable for eight patients (24%) and showed symmetrical abnormally increased uptake in the epiphyseal region of the appendicular skeleton in 25 (76%). Follow-up of the patients for > or = 1 year ruled out subsequent development of osteoarticular disorders. Generalized, symmetrical increased radionuclide uptake on bone scans is a common finding for HIV-1 infected patients free of osteoarticular symptoms. This finding is probably related to bone marrow hypercellularity and is of no clinical significance; therefore, other diagnostic procedures are not required in the workup of these patients.

Serum concentration of the cross-linked carboxyterminal telopeptide of type I collagen (ICTP) is a useful prognostic indicator in multiple myeloma.

Type I collagen is the main collagen type found in mineralised bone. Specific immunoassays for PICP (carboxyterminal propeptide of type I procollagen) and ICTP (cross-linked carboxyterminal telopeptide region of type I collagen) allow simultaneous assessment of the synthesis and degradation of type I collagen in serum samples, respectively. Our aim was to find out whether these metabolites of type I collagen are useful markers for following bone turnover and evaluating treatment response in multiple myeloma, which is a good model disease of excessive osteolysis. Fifteen consecutive patients were studied before and throughout their treatment. Samples for serum PICP and ICTP were collected before starting each treatment course of melphalan and prednisolon. Response to treatment was evaluated by following the changes in M protein and bone roentgenograms. The disease was progressing in four and regressive in 11 patients, but in four of these a recurrence occurred. In nonresponders the ICTP concentration was permanently elevated despite treatment. In responders both increased or normal levels of ICTP were initially observed, but they returned to or remained in the reference interval during treatment. The ICTP concentration increased upon recurring disease. There was a strong correlation between the extent of bone lesions and ICTP. There was no correlation between ICTP and PICP, the latter mainly remaining within the reference range, a finding that suggests no change in bone formation. ICTP was a significant predictor for survival in this patient group (P less than 0.05). We conclude that ICTP is a specific and sensitive marker for bone resorption. Simultaneous use of serum ICTP and PICP offers an additional and easy means to follow bone turnover and evaluate the response to therapy in multiple myeloma.

Breast cancer with skeletal metastases at initial diagnosis: Distinctive clinical characteristics and favorable prognosis

Fifteen patients with breast cancer who had skeletal metastases already present at the time the primary breast lesion was detected, were retrospectively identified. The majority were postmenopausal, estrogen receptor-positive, and had large (often neglected) primary lesions. Eleven patients were asymptomatic with respect to their skeletal metastases, although bone scans and bone roentgenograms revealed multiple areas of involvement in all patients. The median survival from the time of diagnosis was 33 months (range, 1-74 months); the 5-year actuarial survival was 45%. Systemic therapy with hormones or chemotherapy was effective in producing subjective responses; radiotherapy to painful bony areas was also an effective palliative treatment. Median survival in this group of patients was significantly improved when compared to our breast cancer patients who had extraskeletal metastases at initial diagnosis (33 versus 9 months, respectively), and to previously reported series of breast cancer patients with metastases at initial diagnosis. Since patients with Stage IV breast cancer and metastases limited to the skeleton often have prolonged survival, complications from bone metastases (e.g. pathologic fracture, epidural spinal cord compression) and other intercurrent illnesses should be managed aggressively.

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<h3>PATHOLOGIC QUIZ CASE 1</h3><h3>James S. Reilly, MD, John S. Supance, MD, Pittsburgh</h3> An 8-month-old male infant was examined at the Otolaryngology Ambulatory Care Facility, Children's Hospital of Pittsburgh, for progressive left-sided facial asymmetry of three months' duration. There was no history of infection or trauma. Pertinent physical findings were limited to the head and neck. An intraoral examination disclosed a firm, nontender mass that arose from the inferomedial aspect of the left maxilla, involved the alveolar ridge, and protruded into the gingivobuccal sulcus. The mucosa was intact, and the mass was nonpulsatile. Extraoral palpation showed the mass to extend superiorly toward the left nasal bone and medially to the lateral nasal wall, with distortion of the left nasal ala and upper lip. Facial function and results of cranial nerve assessments were normal. There was no epiphora, proptosis, or evidence of infection. Facial bone roentgenograms showed an expansile, lucent lesion

The Early Diagnosis of Atypical Thyroid Acropachy

The differential diagnosis of the condition of a patient with acral thickening and normal bone roentgenograms but without obvious signs of Graves' disease may be perplexing. A patient was seen with this disorder, in which the early diagnosis of thyroid acropachy could not be made roentgenographically but was accomplished by bone-scanning techniques. To our knowledge, this is the first demonstration of the evolution of thyroid acropachy, as temporally proved by serial roentgenograms and bone radiographs. The patient complained of severe swelling and decreased finger mobility. His hands were treated in a novel manner, using fluorinated topical steroids under an occlusive dressing, because of the failure of previously described localized medical therapeutic regimens. Treatment, using one hand as a control, resulted in a substantial decrease in hand circumference and volume, as well as increased finger mobility.

Parathyroid Storm

• Primary hyperparathyroidism frequently has a chronic and relatively benign course. Occasionally, however, it may have a stormy presentation requiring prompt adequate diagnosis and urgent surgical treatment. We describe a 71-year-old woman who had severe hypercalcemia, seizures, and coma refractory to treatment with anticonvulsant drugs, intravenous infusion of normal saline, furosemide, glucocorticoids, calcitonin, and hemodialysis. Bone roentgenograms were normal, but a strikingly positive bone scan that also showed marked soft-tissue uptake prompted the diagnosis of primary hyperparathyroidism and the successful surgical removal of a large parathyroid adenoma. This was followed by a remarkable recovery and marked reduction in soft-tissue radioactive uptake on bone scan. The association of hypercalcemia and seizures and the diagnostic value of bone scanning are discussed. An up-to-date review of the literature is presented. We proposed this condition to be named "parathyroid storm" on tne basis of the rapid and lethal course unless surgery is performed without delay. (Arch Intern Med 140:1092-1095, 1980)

Alcohol-Induced Genital Pain in Recurrent Hodgkin's Disease

THE ASSOCIATION between alcohol-induced pain and Hodgkin's disease was first noted by Hoster 1 in 1950. Several series 2-7 have confirmed this association; however, pruritus, paresthesia, cough, and general malaise have also been reported. 3 Patients with other malignant 5 and nonmalignant conditions 5,6 have been described to have alcohol-induced pain. We examined a patient whose complaint of alcohol-induced pain in the labia majora led to the diagnosis of recurrent Hodgkin's disease. Report of a Case A 34-year-old woman was admitted to the hospital because of genital pain. Eight years before admission, an intermittent pain in the right hip developed, which characteristically was induced by the ingestion of alcohol, even in small quantities. She had anterior cervical lymphadenopathy, and a biopsy specimen demonstrated nodular sclerosing Hodgkin's disease. Lymphangiogram demonstrated intra-abdominal lymph node enlargement, and bone roentgenogram findings were consistent with findings of Hodgkin's disease in the right side of the

Roentgenographic identification of human remains

BONE roentgenograms as a means of identifying human remains can be of great value to medical examiners. This is especially true when there is need to identify an unknown decomposed body of an adult without fingerprints. Teeth, as landmarks, may be of help, but they may be absent (as in the case presented) or antemortem dental records may not be available for comparison. Since bone roentgenograms are common diagnostic examinations, an antemortem study may be available for comparison. The following case illustrates this point, and in the Comment legal points are made about using this kind of evidence. <h3>Report of a Case</h3> On July 6, 1977, a human skull with a missing mandible was found on the shore of Deer Island in Boston Harbor. Only one upper molar tooth was present, and the remaining tooth sockets were empty. One month later skeletal remains consisting of a torso and limbs with

Roentgenographic Identification of Human Remains

BONE roentgenograms as a means of identifying human remains can be of great value to medical examiners. This is especially true when there is need to identify an unknown decomposed body of an adult without fingerprints. Teeth, as landmarks, may be of help, but they may be absent (as in the case presented) or antemortem dental records may not be available for comparison. Since bone roentgenograms are common diagnostic examinations, an antemortem study may be available for comparison. The following case illustrates this point, and in the Comment legal points are made about using this kind of evidence. <h3>Report of a Case</h3> On July 6, 1977, a human skull with a missing mandible was found on the shore of Deer Island in Boston Harbor. Only one upper molar tooth was present, and the remaining tooth sockets were empty. One month later skeletal remains consisting of a torso and limbs with

Mental retardation and osteosclerosis

We report a girl with profound mental retardation who, at 3 years of age, began to show a progressive osteosclerosis on bone roentgenograms. The bony changes were slightly suggestive of osteopetrosis from which they differed by a number of unusual features.

Hypo-Hyperparathyroidism: Evidence for a Defective Parathyroid Hormone

Biochemical evidence for hypoparathyroidism and roentgenographic evidence for hyperparathyroidism were present in a 7-year-old girl with seizures and tetany. She was hypocalcemic (4.7 mg/dl), hyperphosphatemic (11 mg/dl), and normomagnesemic, with elevated parathyroid hormone level (2,603 pg/dl and 3,693 pg/dl in immunoassays utilizing two different antisera). Somatic features of pseudohypoparathyroidism were absent. Increased serum alkaline phosphatase activity (335 IU/liter) with evidence of subperiosteal bone resorption suggested parathyroid hormone activity on bone. Intramuscular administration of parathyroid extract caused a rise in serum calcium level (9.6 mg/dl) and a fall in serum phosphorus level (7.9 mg/dl). The serum calcium, phosphorus, and alkaline phosphatase activity became normal during vitamin D therapy. Parathyroid hormone values and bone roentgenograms became normal. With serum calcium and phosphorus levels normal, ethylenediaminetetraacetic acid infusion was followed by an increase in plasma parathyroid hormone level but not in urinary cyclic adenosine monophosphate (AMP) or phosphaturia; in contrast, parathyroid extract induced cyclic AMP excretion and phosphaturia. These results suggest that endogenous parathyroid hormone in this patient affects bone resorption but not renal handling of phosphate. We infer that this represents a defective endogenous parathyroid hormone.

Aspartylglucosaminuria: Unique biochemical and ultrastructural characteristics

The observation of vacuolated lymphocytes in a coarsely featured two year old female with hepatosplenomegaly, mitral insufficiency, and mild psychomotor retardation led to the first diagnosed case of aspartylglucosaminuria in the United States. Although physical characteristics and bone roentgenograms were consistent with a mucopolysaccharide disorder, analysis of the urine showed no mucopolysaccharide elevation. The chromatographic, enzymatic, and ultrastructural studies confirming the diagnosis are presented.

Bone metastases from breast cancer at the time of radical mastectomy as detected by bone scan.Eight-year follow-up

Sixty-four women with Stage II breast cancer who had Sr85 bone scans at the time of radical mastectomy were followed for 8 years in a prospective study. Those women with positive scans had a slight, but statistically significant, increased incidence of metastic disease, particularly for metastases to bone.However, 40% of those women with positive bone scans and negative roentgenograms survived 8 years without evidence of any metastatic disease. Therefore, it has not been shown at this time that bone scans should be obtained in order to exclude bone metastasis before regional therapy for breast cancer is instituted. Also, a significant percentage of women with negative bone scans developed both bone and soft tissue metastases. As many as 30% of asymptomatic women with a history of breast cancer and positive bone scans and negative bone roentgenograms may still harbor disease in bone after 8 years.

Multifocal eosinophilic granuloma (“Hand-Schuller-Christian disease”): Report illustrating H-S-C chronicity and diagnostic challenge

We here describe an unusual case of multifocal eosinophilic granuloma (“Hand-Schuller-Christian disease”) in a middle-aged woman. The case underscores the varied and subtle nature of the disease presentation and the extent to which many organ systems may become involved. Unusual features of her case include atypical bone roentgenograms, cutaneous anergy, panhypopituitarism and evidence of diffuse central nervous system dysfunction. Several features of multifocal eosinophilic granuloma present in the older age group are different from those presenting in children and young adults. Finally, multifocal eosinophilic granuloma may present all the cllinical and laboratory features of a progressive, chronic disease.

BONE TUMOR IMAGING BY SCINTIGRAPHY OF THE SKELETON, MARROW RETICULOENDOTHELIAL SYSTEM, AND THE PROLIFERATIVE TISSUE

Paralleled clinical studies of radioisotopic imaging or tumor metastases in the bone were undertaken with Tc99m pyrophosphate, Ga67 citrate, and Tc99m sulfur colloid. All three were capable of anticipating the bone roentgenograms. A critical analysis suggested that positive delineation with Ga67 citrate would sometimes be superior to the others. This deserves further investigation. Clinically the combined use of Tc99m pyrophosphate with Ga67 for the chest areas and extremties or with Tc99m colloid for the pelvic and abdominal areas would be more frutiful in early detection and exact localization of bone metastases.

Interpretation of Bone Scans

An informal survey of nonacademic nuclear medicine laboratories indicates that about three fourths do bone scans; most do only a few, but some do more than 50 a month. Approximately 800,000 were done in 1973. The indications for the procedure are simple. The patient has cancer, primarily of the breast, prostate gland, or lung, or has recently developed pain seemingly localized to bone. The choice of therapy hinges on the presence and extent of metastases to bone. The interpretation of the scan is usually simple. It is read as within limits, or it is equivocal for various reasons, or it shows one or more regions of definite osteoblastic activity. A few laboratories report 75% of their scans as normal. Some report almost no normals. The frequent occurrence of a normal bone roentgenogram with an abnormal bone scan, and the less frequent abnormal roentgenogram with normal scan causes confusion among

Normal Fluoride 18 Bone Scans in Metastatic Bone Disease

The occurrence of metastatic bone disease is proved by needle bone biopsy in two patients with negative fluoride 18 bone scans and bone roentgenograms. Hypercalcemia suggested the possibility of metastatic disease.

Primary Neonatal Hyperparathyroidism—An Unusual Cause of Failure to Thrive

The case of a 6-day-old infant with pathologic findings of primary neonatal hyperparathyroidism is presented. This is one of the youngest patients to be reported, and similar cases in the neonatal period are summarized. Suggestive signs and symptoms include hypotonia, weakness, weight loss, constipation, and vomiting. Serum calcium and phosphorus levels are diagnostic of this condition; electrocardiograms and bone roentgenograms are helpful adjuncts. Prompt suspicion and diagnosis may salvage infants with this rare condition, for surgical extirpation of the hyperplastic parathyroid glands is the treatment of choice.

Scintiscanning in Malignant Lymphomatous Involvement of Bone

The reported radiographic and autopsy incidence of lymphomatous involvement of bone has been reviewed. Results of 19 patients with malignant lymphoma studied with bone scintiscans and roentgenograms are presented. Scintiscans were positive in 84.2% of the patients and roentgenograms were positive in only 10.5%. Bone marrow biopsy was positive in only three out of 16 cases. Necropsy material obtained from vertebral bones which were positive on scanning revealed histological evidence of disease in all the six cases. The scintiscan is an excellent means of evaluating early lymphomatous involvement of bone and the incidence in relatively asymptomatic patients is probably much greater than can be appreciated roentgenographically or suspected clinically. The early detection of osseous involvement may be an important guide to therapy.