Osseous Pain Research Articles

A statistical symptomatic evaluation on SAPHO syndrome from 56 cases of confirmed diagnosis and 352 cases of non-SAPHO involvement.

To report a statistical evaluation of symptomatology based on 56 cases of SAPHO syndrome and 352 non-SAPHO involvement cases, to propose a symptomatic scoring system in consideration of early warning for SAPHO syndrome. A cohort comprising 56 subjects diagnosed with SAPHO syndrome was reported, as well as 352 non-SAPHO involvement cases, including their chief complaints, skin manifestations, radiological findings, and laboratory tests. We systematically reviewed previous published five representative huge cohorts from different countries to conclude several specific features of SAPHO by comparing with our case series. The score of each specific index is based on respective incidence and comparison of two cohorts was performed. In terms of complaint rates, all subjects of two cohorts suffered from osseous pain, which appeared in the anterior chest wall, spine, and limb which were calculated. In respect to dermatological lesions, SAPHO patients suffered from severe acne, and other patients (82.14%) accompanied with palmoplantar pustulosis. Having received radiological examinations, most SAPHO subjects rather than non-SAPHO involvement cases showed abnormal osteoarticular lesions under CT scanning and more detailed information under whole-body bone scintigraphy. Differences also emerged in elevation of inflammation values and rheumatic markers like HLA-B27. Based on our cases and huge cohorts documented, the early warning standard is set to be 5 scores. SAPHO syndrome case series with 56 subjects were reported and an accumulative scoring system for the early reminder on SAPHO syndrome was proposed. The threshold of this system is set to be 5 points. Key Points • Fifty-six patients diagnosed by SAPHO syndrome with detailed symptoms and radiological findings were reported. • Comparison was made between the 56 SAPHO patients and 352 non-SAPHO involvement cases. • An accumulative scoring system for the early reminder on SAPHO syndrome was proposed and the threshold of this system is set to be five points.

Effect of palliative microwave ablation on metastatic osseous pain: a single-center retrospective study.

Bone is among the most common metastasis sites in patients with advanced cancer. Approximately two-thirds of bone metastasis results in pain, the majority of which is moderate to unbearable pain, which seriously affects the quality of life of patients. With the development of ablation techniques, microwave ablation (MWA) has great potential to eliminate the pain caused by bone metastasis. This study aimed to evaluate the efficacy and safety of image-guided (computed tomography-guided) percutaneous MWA for metastatic osseous pain. This is a retrospective study involving 18 patients with cancer-related pain caused by osseous or soft tissue metastasis in the First Affiliated Hospital of Soochow University from June 2015 to October 2020. All patients (14 men and 4 women; mean age 60.2 years) underwent image-guided percutaneous palliative MWA. A paired-sample t-test was used to compare the changes in Numeric Rating Scale (NRS) score and dosage of morphine preoperatively and postoperatively (at 24 h, 3 days, and 14 days after MWA). In addition, we assessed the level of pain relief according to the patients' subjective feelings. The paired-samples t-test showed that the NRS score (6.83±0.92 vs. 1.67±0.97, P<0.05) and dosage of morphine (85.56±17.23 vs. 32.78±4.61, P<0.05) were significantly decreased at 3 days after MWA. At 14 days after MWA, the NRS score (6.83±0.92 vs. 0.94±0.87, P<0.05) and dosage of morphine (85.56±17.23 vs. 10.56±8.73, P<0.05) were also markedly decreased. Moreover, according to the patients' subjective feeling, 88.89% patients had pain relief postoperatively, while the remaining patients had no progress. Image-guided (Computed Tomography-guided) percutaneous MWA can effectively relieve pain, thus improving the quality of life in patients with osseous metastasis. MWA is a feasible, safe, and effective treatment for pain caused by bone metastasis.

Humeroplasty for pain control in multiple myeloma

Pathological fractures in patients with primary skeletal cancer or metastases are associated with significant morbidity and poor prognosis. We present three cases of patients with osseous pain despite having received radiotherapy and multimodal analgesic management. Humeroplasty was offered to treat pain and decrease the risk of fracture. We report three patients with osseous pain secondary to osteolytic tumoral activity in the humerus and a Mirels score >7. Humeroplasty was performed under sedation and under fluoroscopy guidance. The three patients reported a decrease in pain most significantly with incidental pain and improved mobility. There were no fractures noted and no other complications. Percutaneous humeroplasty could be an option in multiple myeloma patients with impending humeral fractures, especially when the osteolytic lesion is localized in the humeral head. The procedure provided good pain relief to the patient. However, more studies should be conducted to asses efficacy and complications.

Feasibility of Controlling Metastatic Osseous Pain Using Three Kinds of Image-Guided Procedures for Thermal Microwave Ablation: A Retrospective Study.

ObjectivesTo evaluate the feasibility and safety of treating painful osseous metastases using image‐guided percutaneous thermal microwave ablation.MethodsThis is a retrospective study of patients treated from December 2016 to December 2019 in one institute. A total of 50 patients (35 men, 15 women; mean age 55.24 ± 11.03 years) with 56 osseous metastatic lesions underwent image‐guided percutaneous microwave ablation. There were 7 patients with multiple and 43 patients with single metastases. The numbers of patients with primary cancer were as follows: lung, 13; liver, 17; kidney, 10; prostate, 1; breast, 3; osteosarcoma, 1; and thyroid, 5. Seventeen patients had cancer combined with soft tissue masses. The radiological images for the ablative procedures were obtained by CT, fluoroscopy with ultrasound, and fluoroscopy alone in 16, 11, and 23 patients, respectively. Pain severity was estimated using the visual analogue scale before and after treatment (1 week, 1 month, and 3 months after treatment). Radiological evaluations were performed at baseline and 3 months after the procedure.ResultsIn all patients, pain reduction occurred from the first day after treatment. Pain did not recur during the 3 months of follow up. The mean total ablation time per microwave electrode was 3.99 ± 2.48 min (range, 1–15 min). The mean power of the microwave electrode was 66.40 ± 12.08 W. The average volume of bone (load‐bearing bone, such as vertebra and acetabulum) cement after ablation was 2.82 ± 0.81 mL. There were no significant differences in visual analogue scale pain scores for different imaging techniques or ablation energies. No procedure‐related complications occurred.ConclusionImage‐guided percutaneous thermal microwave ablation of osseous metastases relieves pain and improves mobility. CT remains the first choice for percutaneous ablation. Fluoroscopy combined with ultrasound is effective for cases with soft tissue masses; fluoroscopy is also suitable for combination with vertebroplasty. However, further investigations are required.

Introducing Computed Tomography Simulation–Free and Electronic Patient-Reported Outcomes–Monitored Palliative Radiation Therapy into Routine Care: Clinical Outcomes and Implementation Experience

PurposeOur purpose was to report outcomes of a novel palliative radiation therapy protocol that omits computed tomography simulation and prospectively collects electronic patient-reported outcomes (ePROs). Methods and MaterialsPatients receiving extracranial, nonstereotactic, linear accelerator-based palliative radiation therapy who met inclusion criteria (no mask-based immobilization and a diagnostic computed tomography within 4 weeks) were eligible. Global pain was scored with the 11-point numerical pain rating scale (NPRS). Patients were coded as having osseous or soft tissue metastases and no/mild versus severe baseline pain (NPRS ≥ 5). Pain response at 4 weeks was measured according to the international consensus (no analgesia adjustment). Transition to ePRO questionnaires was completed in 3 phases. Initially, pain assessments were collected on paper for 11 months, then pilot ePROs for 1 month and then, after adjustments, revised ePROs from 1 year onwards. ePRO feasibility criteria were established with reference to the paper-based process and published evidence. ResultsBetween May 2018 and November 2019, 542 consecutive patients were screened, of whom 163 were eligible (30%), and 160 patients were successfully treated. The proportion of patients eligible for the study improved from approximately 20% to 50% by study end. Routine care pain monitoring via ePROs was feasible. One hundred twenty-seven patients had a baseline NPRS recording. Ninety-five patients had osseous (61% severe pain) and 32 had soft tissue (25% severe pain) metastases. Eighty-four patients (66%) were assessable for pain response at 4 weeks. In the 41 patients with severe osseous pain, overall and complete pain response was 78% and 22%, respectively. ConclusionsBy study completion, 50% of patients receiving palliative extracranial radiation therapy avoided simulation, streamlining the treatment process and maximizing patient convenience. Pain response for patients with severe pain from osseous lesions was equivalent to published evidence.

Metastatic Osseous Pain Control: Bone Ablation and Cementoplasty.

Nociceptive and/or neuropathic pain can be present in all phases of cancer (early and metastatic) and are not adequately treated in 56 to 82.3% of patients. In these patients, radiotherapy achieves overall pain responses (complete and partial responses combined) up to 60 and 61%. On the other hand, nowadays, ablation is included in clinical guidelines for bone metastases and the technique is governed by level I evidence. Depending on the location of the lesion in the peripheral skeleton, either the Mirels scoring or the Harrington (alternatively the Levy) grading system can be used for prophylactic fixation recommendation. As minimally invasive treatment options may be considered in patients with poor clinical status or limited life expectancy, the aim of this review is to detail the techniques proposed so far in the literature and to report the results in terms of safety and efficacy of ablation and cementoplasty (with or without fixation) for bone metastases. Percutaneous image-guided treatments appear as an interesting alternative for localized metastatic lesions of the peripheral skeleton.

Metastatic Osseous Pain Control: Radiation Therapy.

Metastatic disease to the bone is a common manifestation of advanced cancer, and can result in pain, pathologic fractures, hypercalcemia, and overall functional compromise. External beam radiation is a proven, highly efficacious, and noninvasive therapy that can provide symptomatic relief from painful osseous lesions. When deciding upon the best treatment regimen, it is important to consider patient factors such as overall life expectancy, performance status, disease burden, and site of osseous metastatic pain. Determination of best treatment ideally requires multidisciplinary input from radiologists, medical oncologists, surgeons, pain management, and palliative care specialists together with radiation oncologists.

Minimally invasive techniques for pain palliation in extraspinal bone metastases: a review of conventional methods and cryoablation

Minimally invasive techniques are an effective primary or alternative modality for pain palliation in extraspinal bone metastases. Conventional pain palliation therapies consist of chemotherapy, analgesics, and localized radiation therapy, and leave a subset of patients with refractory pain. Minimally invasive techniques include cryoablation, cementoplasty, radiofrequency ablation, selective embolization therapy, laser photocoagulation, ethanol ablation, microwave ablation, and MR-guided focused ultrasound therapy. Cryoablation’s increasing popularity with regard to patients presenting with well-defined osseous pain from lytic or mixed metastases has proven effective with regard to pain relief and narcotic usage decline. Combined with external beam radiation, these effects can be enhanced. Cryoablation is one of many minimally invasive options that may be considered for palliative methods in patients with metastatic axial and appendicular skeletal metastases. Future prospective, randomized trials are much needed to compare the efficacy of these treatments.

Pain Relief by Bone Drilling and Osseous Pain Sensitization: A Hypothesis

Bone drilling (BD) is reconsidered to be a novel treatment for pain including vertebral compression fracture (VCF), vertebral spondylosis, osteoarthritis (OA) and osteonecrosis of the knee and hip, and neuropathic pain. BD is simple and harmless. The technique of BD is the similar to that of bone marrow puncture. BD is conducted under X-ray fluoroscopy and regional anesthesia. Exact penetration of bone cortex is required for intramedullary decompression, and sufficient aspiration of medullary blood is important to eliminate intramedullary inflammatory cells (ICs) and inflammatory chemical mediators (ICMs). Onset of the effect is immediate, and the effect lasts several months or a few years. However, precise of the underlying mechanisms of BD is remained unclear. On the other hand, effectiveness of BD was also shown in neuropathic pain, a representative of complex regional pain syndrome (CRPS.) Neuropathic pain was induced after the nerve root injury, and the bone is generally intact. However, BD alleviates a foot ache that is produced thereafter. This fact may indicate that subsequent medullary inflammation occurs and bone tissue is involved in CRPS. Therefore, a certain change within the bone is induced by CRPS. The fact suggests a hypothesis that a self-facilitating mechanism of pain is provided independently within bone marrow. We term this mechanism ‘osseous pain sensitization’. Also medullary ICs cause bone resorption, and the ultimate bone dystrophy due to CRPS may be ‘Sudeck dystrophe’.

Bone Marrow Carcinosis in Head and Neck Carcinoma in a Young Adult

Bone marrow carcinosis has been reported as a consequence of several solid tumors. However, in relation to head and neck squamous cell carcinoma, it is an indication of the rarity of the disease that only 2 reported cases exist in the literature. A 36-year-old male patient was admitted with the diagnosis of squamous cell carcinoma on the floor of the mouth. After the exclusion of distant metastatic disease, tumor surgery was performed. After a regular postoperative course over 3 days, the patient complained of progressive pain in the lower back. Extensive workup included position-emission tomography, which detected an enhancement of the bone marrow. Bone marrow biopsy elucidated advanced bone marrow carcinosis. Palliative chemotherapy was recommended, but the patient deteriorated rapidly and died from septic multiorgan failure within 6 weeks after surgery. Thus, bone marrow carcinosis must be considered in patients with head and neck tumor and osseous pain.

Letters to Editor Isolated metastasis to the foot as an extremely rare presenting feature of primary endometrial cancer. and review of the literature

Endometrial cancer is the most common invasive cancer of the female genital tract, with an increasing incidence rate. Abnormal uterine bleeding is the presenting symptom in 75-90% of cases [1, 2]. The majority of patients with endometrial cancer are diagnosed with no evidence of extra-uterine spread (70-80% stage I), which gives patients better prognosis [1, 3]. In more advanced disease the sites commonly affected outside the uterus are pelvic and para-aortic lymph nodes and the ovaries [4]. Similarly to uterine sarcomas, distant metastases in advanced or recurrent endometrial cancer most commonly involve the lungs, liver, central nervous system and skin [4–6]. Metastases to bones have been described in 2-15% of patients with metastatic disease, and the most common site of osseous metastases are vertebrae, with pelvic bones, ribs and sternum [3, 7]. Isolated metastases to bone extremities are extremely rare, and thought to result from the haematological spread of cancer cells [5]. The review of the Medline database by searching the items endometrial cancer and metastases to extremities showed twenty such cases, with only nine cases when metastatic tumour of the foot was the first manifestation of endometrial cancer (Table I) [3, 5, 7–13]. Table I Isolated metastasis to the bones of the extremities as the first manifestation of endometrial cancer – review of the literature A 74-year-old female suffered from pain and swelling of the right foot from October 2006. In the X-ray picture and bone scintigraphy, suspected lesion of the right calcaneus, talus and metatarsal bones was detected (Figure 1). Afterwards it was histologically verified in the biopsy as metastatic cancer (Figure 2). The patient had no vaginal bleeding or other gynaecological symptoms, but subsequent computed tomography scans showed an enlarged uterus. Uterine curettage confirmed the diagnosis of endometrial cancer. The patient was treated with total abdominal hysterectomy, bilateral salpingo-oophorectomy without pelvic lymph node dissection in December 2006. The histological diagnosis was a moderate differentiated (G2) endometrioid endometrial cancer invading the outer half of the myometrium (> 1/2) with invasion of cervical stroma. The fallopian tubes and the ovaries showed no signs of metastases. No evidence of macroscopic abdominopelvic metastases was found at surgery. Her disease was classified as clinical stage IVB according to FIGO 2009 staging, but in the TNM classification it was pT2 Nx M2. Figure 1 Radiograph of the right foot demonstrating metastases of the endometrial cancer Figure 2 Metastatic endometrial cancer cells in the fine needle aspiration of the tumour of the foot (H + E, 200× magnification) In January 2007 the patient was admitted to the department of palliative radiotherapy. She received irradiation by Co 60 until a total dose of 20 Gy to the tumour of the right foot, with complete resolution of symptoms. The patient was discharged from hospital in March 2007. During the observation from surgery in December 2006 until June 2010 no other metastases were detected. The patient remains alive and asymptomatic 43 months after the diagnosis of metastatic endometrial cancer to the foot. Our report presented in the previous section has three main peculiar features: 1) it demonstrates endometrial cancer that presented with osseous metastasis, which is a rare occurrence, 2) the metastatic tumour was located in the foot, which is extremely rare, 3) the bone lesion was a single bone metastasis, which is unusual in such cases. Additionally, the case in which isolated metastatic tumour of the extremity was the first manifestation of endometrial cancer is the tenth such case reported in the literature (Table I), and the second one located in the calcaneus and involving talus and metatarsal bones [8]. Despite the rarity of metastases to the upper and lower extremities, there is a need to have a high index of suspicion for metastasis in patients with a history of endometrial cancer who present with swelling or bony tenderness. The initial diagnosis can be challenging, as the symptoms of pain and swelling are often attributed to other more common benign conditions such as soft tissue inflammation, trauma, arthritis, and osteomyelitis [7]. It is important to consider bone metastasis as a possible diagnosis also in patients without history of cancer, but with osseous pain not responding to conservative treatment [5, 9–13]. Appropriate imaging may include plain X-ray picture and radionuclide bone scans [3]. Technetium diphosphonate bone scans can be positive up to 18 months before a lesion is detectable on plain X-ray [14]. Therefore, a biopsy should be performed in patients with suspected lesions, and who demonstrate evidence of bony destruction [4]. The treatment strategy in patients with confirmed isolated metastatic lesion in the bone extremity still remains a topic of controversy, because of the few descriptions available in the literature and the different bone sites involved. For these reasons, a common suitable treatment regimen cannot be established and treatment should be tailor suited to each patient. The treatment of irradiation with or without surgery, hormone therapy and chemotherapy is reported as effective in most cases and may be curative [4, 5, 7, 9, 11, 12]. The main goal of treatment should be to eliminate or palliate pain and prolong survival.

Hyperparathiroidism: Primary or Secondary Disease?

Primary hyperparathyroidism (PHPT) is characterized by the autonomous production of parathyroid hormone (PTH), in which there is hypercalcemia or normal-high serum calcium levels in the presence of elevated or inappropriately normal serum PTH concentrations.Exceptionally in symptomatic patients, a diagnosis can be established on the basis of clinical data. PHPT must always be evaluated in patients with clinical histories of nephrolithiasis, nephrocalcinosis, osseous pain, subperiosteal resorption, and pathologic fractures, as well as in those with osteoporosis–osteopenia, a personal history of neck irradiation, or a family history of multiple endocrine neoplasia syndrome (types 1 or 2).Diagnosis of PHPT is biochemical. Asymptomatic hypercalcemia without guiding signs or symptoms is the most frequent manifestation of the disease. For differential diagnosis, PTH must be measured, as well as phosphate, chloride, 25-hydroxyvitamin D, 1,25 dyhidroxyvitamin D and calcium-to-creatinine clearance.The diagnosis and differential diagnosis of primary hyperparathyroidism will be discussed here.

Free bone flap transplantation with descending genicular vessels for treatment of scaphoid nonunion

Objective To evaluate the effect of bone flap transplantation with descending genicular vessels for treatment of scaphoid nonunion.Methods From January 2007 to August 2009,6 cases of scaphoid nonunion were treated with free bone flap transplantation with descending genicular vessels.The results of the procedure were assessed in terms of osseous union,pain,grip strength and active motion of the wrist.Postoperatively treatment outcomes were evaluated by the Mayo modified wrist score system based on patients' perception of function,while vascularity of the scaphoid was evaluated by using color Doppler ultrasonography.Results Postoperative follow-up averaged 18 months.Scaphoid union occurred in all cases at an average of 12 weeks (range,11 to 16 weeks).The average pain score for these 6 patients was 1.0 points (range,0 to 2.2points) on the visual analog scale.The postoperative grip strength was 85％ of the contralateral side.The range of motion of the wrist was:flexion-extension ( 115 ± 10)°,radioulnar deviation (54 ± 14)°.An excellent outcome in the wrist function was found in 4 patients,a good outcome in 1 patient,fair in 1 patient.Vascularity of the scaphoid was good as confirmed by color Doppler ultrasonography. Conclusion Transplantation of bone flap with descending genicular vessels is an effective method for the treatment of scaphoid nonunion with avascular necrosis of the proximal fragment or with previously failed conventional bone grafting. Key words: Scaphoid bone;  Fractures,ununited;  Descending genicular vessels

Chronic Recurrent Multifocal Osteomyelitis: Review

Objective Chronic recurrent multifocal osteomyelitis (CRMO) is primarily a disorder of children and adolescents characterized by episodic osseous pain over several years. The objective of this article is to present overview of this entity with emphasis on imaging manifestations. Conclusion CRMO can be a difficult diagnosis, often with nonspecific imaging findings. The critical factors leading to its diagnosis are patient demographics, clinical course, and distribution. However, a greater understanding of the imaging appearance during both active and reparative phases may lead to improved detection. Introduction Chronic recurrent multifocal osteomyelitis (CRMO) is a skeletal disorder of unknown cause, occurring primarily in children and adolescents. The entity was first described by Giedion et al. [1] in 1972 as an unusual form of multifocal bone lesions with subacute and symmetrical osteomyelitis. Later, Bjorksten and Boquist [2] noted its association with pustulosis palmoplantaris and developed the term chronic recurrent multifocal osteomyelitis. Between 200 and 300 cases of CRMO have been reported in the literature worldwide, consisting mainly of case series with relatively brief follow-up durations [3]. However, because of increasing disease awareness and longer clinical observation periods, this disorder is likely more common than previously realized. CRMO is a diagnosis of exclusion based on the following criteria: lack of causative organism; no abscess formation, fistula, or sequestra; atypical location compared with infectious osteomyelitis, with frequent involvement of the clavicle and often showing multifocality; radiographic appearance of subacute or osteomyelitis; nonspecific histopathologic and laboratory findings compatible with subacute or osteomyelitis; characteristic prolonged, fluctuating course with recurrent episodic pain over several years; and accompanying pustulosis palmoplantaris or acne [2, 4]. Clinical Findings CRMO is characterized by the insidious onset of pain and swelling corresponding to the involved bones [5, 6]. Most cases (up to 85%) occur in females, with a median age of onset of 10 years [7, 8]. The disease course is typically prolonged over several years. punctuated by periodic exacerbations. Symptoms may either recur at sites affected previously or involve new areas with subsequent flare-ups. Patients may experience concomitant systemic symptoms including low-grade fevers and generalized malaise [9]. CRMO may be accompanied by many skin disorders, most commonly pustulosis palmoplantaris, that may recur along with the osseous exacerbations [2, 5, 10]. The lesions are predominantly situated in the metaphyses of tubular bones, followed by the clavicle and spine [2, 6, 11-13]. Within tubular bones there is a predilection for the lower extremities, with the distal femur, proximal tibia, distal tibia, and distal fibula most commonly affected [14]. The disease may less frequently involve the ribs [10, 12, 15-17], sternum [15], and pelvis [18]. Symmetric involvement is common [14], and multifocality is virtually always present. The clinical course of CRMO may last anywhere from 7 to 25 years [3, 11, 19]. Treatment generally involves antiinflammatory agents targeting symptomatic relief, particularly nonsteroidal antiinflammatory drugs (NSAIDs) [20]. NSAIDs are usually effective in symptomatic relief, with response rates of up to 80% [7, 21].

Knochenszintigrafie und SPECT/CT bei orthopädischen Fragestellungen

Die multimodale Bildgebung mittels SPECT/CT in der orthopädischen Diagnostik verbindet die exzellente Sensitivität der Skelettszintigrafie mit der morphologischen Information der Computertomografie als Schlüssel zu einer spezifischen Befundinterpretation. Es resultiert eine bildgebende Modalität, die auch in einem kompetitiven, durch etablierte Verfahren wie die MRI dominierten Umfeld bestehen und die orthopädische Knochendiagnostik bereichern kann. Die SPECT/CT leistet unter anderem einen wichtigen Beitrag in der Diagnostik nach komplexen ossären Traumata und eignet sich im Gegensatz zur MRT gleichermaßen bei Patienten mit Osteosynthesen oder metallischen Implantaten. Die Anwendung der SPECT/CT in der Sportmedizin ermöglicht den sehr empfindlichen und spezifischen Nachweis ossärer Stressreaktionen, noch bevor morphologische Veränderungen in der CT oder MRT fassbar werden. Auch aktive degenerative Knochenprozesse bei Patienten mit ossären Schmerzsyndromen können identifiziert und exakt lokalisiert werden. Weitere, vorzugsweise prospektive diagnostische Studien im Vergleich zu Konkurrenzverfahren sind erforderlich, um die Position der nuklearmedizinischen Diagnostik in Orthopädie und Sportmedizin zu stärken und die Implementierung der SPECT/CT in diagnostische Algorithmen zu fördern.

Evaluación diagnóstica y diagnóstico diferencial del hiperparatiroidismo primario

El hiperparatiroidismo primario (HP) se caracteriza por la producción autónoma de parathormona (PTH), en el cual hay hipercalcemia o calcio sérico normal-alto, con valores séricos de PTH elevados o inapropiadamente “normales”. Excepcionalmente, en pacientes sintomáticos, el diagnóstico puede hacerse a partir de la sintomatología. El HP siempre debe cribarse en pacientes con historia de cálculos renales, nefrocalcinosis, dolor óseo, fracturas patológicas, resorción subperióstica o que presenten osteoporosis-osteopenia en densitometría ósea de doble fotón o con historia personal previa de irradiación en cuello o familiar de neoplasia endocrina múltiple tipo 1 o 2. El diagnóstico de HP es bioquímico. La hipercalcemia (calcio total corregido por albúmina), asintomática, sin signos ni síntomas guía, es la manifestación más frecuente de la enfermedad. Para el diagnóstico diferencial, además de la PTH 1-84 , debe medirse fósforo, cloro, 25-hidroxivitamina D, 1,25-dihidroxivitamina D y calciuria. La PTH 1-84 suprimida, o inapropiadamente baja, orienta el diagnóstico a hipercalcemia tumoral y, de forma menos frecuente, a enfermedades granulomatosas (sarcoidosis, tuberculosis, etc.), toma inadecuada de calcitriol o 1α-hidroxivitamina D, intoxicación por vitamina D o A, toma de litio, endocrinopatías (hipertiroidismo, enfermedad de Addison, etc.), o tratamiento con tiazidas, entre otras. El diagnóstico de HP se confirma cuando hay hipercalcemia, o calcio en el rango normal-alto, en presencia de PTH 1-84 alta o inapropiadamente normal, excepto si la excreción urinaria de calcio corregido por creatinina es menor de 0,01, en ausencia de toma de tiazidas, o deficiencia grave de vitamina D, que orienta el diagnóstico a la hipocalciuria hipercalcémica familiar. Las técnicas de imagen son útiles para localizar HP, pero no para su diagnóstico. Primary hyperparathyroidism (PHPT) is characterized by the autonomous production of parathyroid hormone (PTH), in which there is hypercalcemia or normal-high serum calcium levels, in the presence of elevated or inappropriately normal serum PTH concentrations. Exceptionally, in symptomatic patients, a diagnosis can be established on the basis of clinical data. PHPT must always be evaluated in patients with clinical histories of nephrolithiasis, nephrocalcinosis, osseous pain, subperiosteal resorption, and pathologic fractures, as well as in those with osteoporosis-osteopenia on dual-energy X-ray absorptiometry (DEXA), a personal history of neck irradiation, or a family history of multiple endocrine neoplasia syndrome (types 1 or 2). Diagnosis of PHPT is biochemical. Asymptomatic hypercalcemia (total serum calcium corrected by albumin), without guiding signs or symptoms, is the most frequent manifestation of the disease. For the differential diagnosis, PTH 1-84 must be measured, as well as phosphate, chloride, 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D and calcium-to-creatinine clearance. Suppressed or inappropriately low PTH1-84 guides the diagnose toward tumoral hypercalcemia and less frequently to granulomatous disease (sarcoidosis, tuberculosis, etc.), inadequate intake of 1α-hydroxyvitamin D or calcitriol, vitamin D or A intoxication, lithium intake, endocrinopathies (hyperthyroidism, Addison's disease, etc.) or treatment with thiazides, among other possibilities. Diagnosis of PHPT is confirmed by demonstrating persistent hypercalcemia (or normal-high serum calcium levels) in the presence of inappropriately normal or elevated serum PTH 1-84 concentrations, unless the urinary calcium-to-creatinine clearance ratio is lower than 0.01. In these cases, in the absence of thiazide intake or severe vitamin D deficiency, diagnosis should focus on benign familial hypercalcemic hypocalciuria. Parathyroid gland imaging is useful for localization of PHPT, but not for diagnosis of this entity.

Bone metastases in vulvar cancer: a rare metastatic pattern

Bone metastases from a vulvar carcinoma are exceptionally rare with only five reported cases in the literature. We report on a patient who was initially treated with radical vulvectomy and bilateral inguinal lymphadenectomy for a vulvar cancer (pT2, pN2 (6/37), M0; G2). Due to a positive nodal status, adjuvant radiation of the vulva and the pelvis was performed additionally. The patient presented 4 months after initial therapy with severe pain in the right humeral shaft due to a pathologic fracture based on an osteoclastic metastasis. During osteosynthetic stabilization histologic and immunohistochemical stain gave evidence of a metastasis of the known vulvar carcinoma. Bone scan showed enhancements in both humeral heads as well as the right distal femur, whereas plain radiographs confirmed further metastases in all suspected areas. In conclusion, bone metastases should be considered in the differential diagnoses of unclear osseous pain in women with a history of vulvar cancer. Immunohistochemical examinations might be important to depict the epithelial character of the tissue and allude to the metastatic nature of such rare lesions. The atypical location should alert the physician to suspect distant metastasis, rather than locoregional disease.

Douleurs osseuses fébriles chez l’enfant drépanocytaire : apport de l’IRM

Purpose The aim of this study was to report the MRI findings that can suggest a vaso-occlusive crisis in cases of febrile osseous pain in children suffering from sickle cell disease. Materials and methods MRI (T1 and T2 weighted sequences and T1 weighted sequence with fat saturation before and after gadolinium injection) was performed in 10 children with sickle cell disease, presenting with febrile osseous pain. The diagnosis of vaso-occlusive crisis was made after fast improvement due to symptomatic treatment and negative bacteriological result. Results MRI was abnormal in all cases. A multifocal localisation was found in 2 cases. Bone marrow abnormalities were constant. In 10 cases, high T1 and T2 signal and metaphyso-diaphysial lesions were noted. Heterogeneous medullar enhancement with “ink stain” feature was constant. Early periosteal abnormalities were noted in 8 cases with inflammatory or stratified features. Cortical thinning was found in 1 case. Soft tissue abnormalities were observed in 5 cases with inflammatory features in 4. Conclusion Multifocal synchronous localisation, medullar abnormalities resulting from hemoglobin degradation, heterogeneous enhancement, early periosteal abnormalities and associated soft tissues swelling are MRI findings suggesting acute vaso-occlusive disease.

Radiopharmaceuticals for Palliation of Painful Osseous Metastases

Bone pain secondary to metastases may develop in more than half of patients with metastatic cancer. The treatment of metastatic osseous pain usually begins with oral analgesics following the WHO-ladder followed by external beam radiotherapy, ablative nerve blocks and implantable devices. Despite aggressive interventions, pain control seems challenging in this population. Treatment strategies including bisphosphonates, mitoxantrone and hormonal therapy have recently come into light. In some cases of osseous metastasis, radiopharmaceuticals may prove to be beneficial as an additional non-invasive therapy. This discussion will review different radiopharmaceutical agents available today including Strontium-89 chloride, Phosphorus-32 orthophosphate and Samarium-153 lexidronam and their clinical considerations.

Osteoarticular pain and bone mineral density in renal transplantation

Introduction The reduction of bone mineral density (BMD) levels is an important complication after renal transplantation. The prevalence of nontraumatic lesions may reach 22%. Patients with lower osseous mass suffer the highest number of lesions. Objective Evaluate BMD in patients over 30-years old who have undergone renal transplantation more than 1 year prior, who attend a medical facility complaining of osteoarticular pain and were prescribed rest or any analgesia. Patients and methods One hundred twenty-three patients who received a renal transplant from a cadaveric donor from 1980 through 2000 were included in the present study to measure BMD levels in the hips and the vertebral column using a densitometer (Hologic 4500 QDR). Our study complied with WHO recommendations, which define normal values as a T score >−1 SD osteopenia as a (T score between <−1 and >−2.5 SD), and osteoporosis as a T score <−2.5 SD. Patients were divided into three groups according to gender and hormonal status. The following clinical and analytic data were collected: age, gender, race, age at onset of menopause, diabetes mellitus (DM), weight, size, retransplantation, period of evolution after transplantation, and parathormone (PTH), creatinine, and renal clearance values. Results There were 51 men (41.1%) included. Forty postmenopausal (32.5%) and premenopausal women (26%) were also included. In all patients we observed a correlation between a reduction in BMD values and age, duration post-transplantation, and body weight ( P < .05). Reduced BMD levels in premenopausal women were related with lower body weight, ( P < .05) and elevated PTH levels ( P < .024). Conclusions We observed that patients who had undergone transplantation displayed a moderately higher risk of suffering a fracture. Such risk increased in the case of women with more frequent fractures in the vertebral column. In 23.8% of patients reporting osseous pain, there was no reduction in BMD levels. Therefore, we must look for other disorder, responsible for the pain and prescribe adequate treatment.