Neumatosis intestinal y gas portomesentérico: a propósito de un caso

La neumatosis intestinal (presencia de gas en el interior de la pared intestinal y en el complejo venoso portomesentérico) es una situación clínica poco frecuente que ha sido característicamente relacionada con la isquemia intestinal y con un desenlace fatal. Existen otras causas que pueden justifi car estos hallazgos y cuya repercusión para el paciente no es inevitablemente trágica. Los avances recientes en técnicas de imagen, sobre todo en tomografía computarizada multicorte (TCMC), permiten un diagnóstico preciso fi able y precoz de estos hallazgos. En este artículo, repasamos las manifestaciones radiológicas de la neumatosis intestinal en TC así como las distintas causas relacionadas con esta entidad, en relación con los hallazgos presentes en un paciente diagnosticado de carcinoma de esófago y en tratamiento quimioterápico. INGLÉS: Intestinal pneumatosis (presence of gas in the intestinal wall and in the portomeseteric veins) is an infrequent clinical situation that has been associated with extended bowel necrosis and fatal outcome. However, there are other reasons that can justify these findings without such an outcome. Recent advances in diagnostic imaging techniques, especially multislice computerized tomography (MSCT), have allowed precise and quick diagnosis of these entities. In this article, we review the MSCT radiological manifestations of intestinal pneumatosis, as well as the different diagnoses related with the findings observed in a patient diagnosed with esophageal carcinoma under chemotherapy treatment

Diagnostic value of quantitative SPECT/CT in assessing active sacroiliitis in patients with axial spondylarthritis and/or inflammatory low back pain

Background. The diagnostic accuracy of bone scintigraphy (BS) increases with SPECT/CT imaging. It would therefore be appropriate to reassess the diagnostic utility of scintigraphy in sacroiliitis with axial spondyloarthritis (SpA). The aim of this study was to compare the diagnostic performance of MRI, SPECT/CT and a combination of both techniques in sacroiliitis, and to evaluate the correlation between quantitative SPECT/CT indices and quantitative MRI inflammatory lesion scores. Methods. Thirty-one patients with active SpA and 22 patients with inflammatory low back pain underwent MRI and SPECT/CT of the sacroiliac joints. The diagnostic accuracy of both techniques was calculated using clinical diagnosis as the gold standard. The correlation between MRI and SPECT/CT was calculated by comparing the SPECT/CT activity indices and the Berlin/SPARCC scoring systems for MRI. Results. The sensitivity and specificity values in quantitative SPECT/CT, taking the sacroiliac/promontory ratio of >1.36 as the cut-off value, were close to those from MRI published in the literature. The combination of both techniques increased sensitivity while maintaining high specificity. There was a moderate correlation between SPECT/CT and MRI total scores. This correlation was improved by using solely the MRI inflammation scores. Conclusion. Quantitative SPECT/CT showed better diagnostic accuracy than planar scintigraphy and showed a moderate correlation with MRI scores in active sacroiliitis. The combination of both tests increased the diagnostic accuracy. Quantitative SPECT/CT could play a relevant role in the diagnosis of active sacroiliitis in patients with high a suspicion of SpA and a negative/inconclusive MRI test or in patients with whom MRI studies cannot be carried out.Fundamento. La precisión diagnóstica de la gammagrafía ósea (GO) aumenta con las imágenes SPECT/TAC haciendo conveniente reevaluar su utilidad diagnóstica en la sacroilitis de la espondiloartritis axial (EA). El objetivo fue comparar el rendimiento diagnóstico de la resonancia magnética (RM), la SPECT/TC y ambas pruebas combinadas, y evaluar la correlación entre los índices cuantitativos de ambas técnicas. Métodos. A 31 pacientes con EA activa y 22 con lumbalgia inflamatoria se les realizó una RM y una SPECT/TC de las articulaciones sacroilíacas y se calculó la precisión diagnóstica de ambas técnicas respecto al diagnóstico clínico. La correlación entre ambas pruebas se calculó comparando los índices de actividad del SPECT/TC con los sistemas de puntuación Berlín y SPARCC de RM. Resultados. Los valores de sensibilidad y especificidad de la SPECT/TC cuantitativa, tomando como punto de corte el cociente sacroilíaca/promontorio >1,36, fueron similares a los publicados para la RM. La combinación de ambas técnicas aumentó la sensibilidad manteniendo una alta especificidad. La correlación entre las escalas totales de RM y SPECT/TC fue moderada y mejoraba al utilizar únicamente las escalas de inflamación. Conclusiones. La SPECT/TC cuantitativa muestra una mejor precisión diagnóstica que la GO planar en la sacroilitis activa y una correlación moderada con las puntuaciones de RM. La combinación de ambas técnicas aumenta la precisión diagnóstica. Por tanto, la SPECT/TAC cuantitativa podría tener un papel relevante en el diagnóstico de sacroilitis en pacientes con alta sospecha de EA y RM negativa/no concluyente o en aquellos pacientes en los que no se pueda realizar una RM

Intra-articular injection of two different doses of autologous bone marrow mesenchymal stem cells versus hyaluronic acid in the treatment of knee osteoarthritis: long-term follow up of a multicenter randomized controlled clinical trial (phase I/II)

Background: Mesenchymal stromal cells (MSCs) are a promising option to treat knee osteoarthritis (OA). Their safety and usefulness have been reported in several short-term clinical trials but less information is available on the longterm efects of MSC in patients with osteoarthritis. We have evaluated patients included in our previous randomized clinical trial (CMM-ART, NCT02123368) to determine their long-term clinical efect. Materials: A phase I/II multicenter randomized clinical trial with active control was conducted between 2012 and 2014. Thirty patients diagnosed with knee OA were randomly assigned to Control group, intraarticularly administered hyaluronic acid alone, or to two treatment groups, hyaluronic acid together with 10×106 or 100×106 cultured autol‑ ogous bone marrow-derived MSCs (BM-MSCs), and followed up for 12 months. After a follow up of 4 years adverse efects and clinical evolution, assessed using VAS and WOMAC scorings are reported. Results: No adverse efects were reported after BM-MSCs administration or during the follow-up. BM-MSCs-adminis‑ tered patients improved according to VAS, median value (IQR) for Control, Low-dose and High-dose groups changed from 5 (3, 7), 7 (5, 8) and 6 (4, 8) to 7 (6, 7), 2 (2, 5) and 3 (3, 4), respectively at the end of follow up (Low-dose vs Control group, p=0.01; High-dose vs Control group, p=0.004). Patients receiving BM-MSCs also improved clinically accord‑ ing to WOMAC. Control group showed an increase median value of 4 points (−11;10) while Low-dose and Highdose groups exhibited values of −18 (−28;−9) and −10 (−21;−3) points, respectively (Low-dose vs Control group p=0.043). No clinical diferences between the BM-MSCs receiving groups were found. Conclusions: Single intraarticular injection of in vitro expanded autologous BM-MSCs is a safe and feasible proce‑ dure that results in long-term clinical and functional improvement of knee OA

A Reassessment of the Barrier Effect of the Physis against Metaphyseal Osteosarcoma: A Comprehensive Pathological Study with Its Radiological and Clinical Follow-Up Correlations

Osteosarcoma is a primary malignant bone tumor usually arising at the metaphysis of long bones, particularly around the knee. The physis has been regarded as a barrier capable of blocking tumor extension, thus allowing it to preserve their epiphysis and therefore improve functional results. With the objective of clarifying how effective the physis is as a barrier to tumor spread, a large series of skeletally immature patients with osteosarcoma were reviewed. From 452 metaphyseal osteosarcomas a selection of 282 cases in which the tumor was close or crossing the physis were carried out. This sub-sample was split into two groups according to the surgical treatment (epiphyseal preservation or not). The specimens obtained by resection were studied, and the physeal and metaphyseal areas were studied by multiple sections. Immunostaining against VEGF of physis was obtained in selected cases. In about half of the patients affected by metaphyseal malignant bone tumors, the growth plate and epiphysis were not compromised by the tumor. Three sequential invasive growth patterns of an osteosarcoma in its relationship with the physis could be distinguished. An intense angiogenesis and osteoclastic reaction could be observed in the growth plate in the free zone between the tumor and the physis. The local recurrence incidence was lower in the epiphyseal preservation treated patients than it was in the conventional treatment (8% vs. 12%). Most local recurrences appeared in the first 2 years. The overall survival of patients treated with epiphyseal preservation was better than that of the patients treated without preserving the epiphysis (73% vs. 59%; p = 0.03) at a mean follow-up of 18 years. We have described an angiogenic and osteoclastic reaction in the base of the growth plate in the proximity of the advance front of the tumor, which could facilitate the osteosarcoma invasion. It is also shown that the preoperative imaging method for examination is a valid approach for the decision to carry out epiphyseal preservation. Finally, we concluded that epiphyseal preservation combined with protective chemotherapy is an excellent clinical approach for selected patients with metaphyseal osteosarcoma

Validez diagnóstica del SPECT/TC cuantitativo en la sacroilitis de pacientes con espondiloartritis axial activa y dolor lumbar inflamatorio y su correlación con las escalas semicuantitativas de sacroilitis en Resonancia Magnética

Introducción:A pesar de tratarse de una enfermedad muy prevalente en nuestro medio la espondiloartritis axial (EspAax) tiene un retraso medio diagnóstico desde el inicio de los síntomas de 6-8 años.Esto se debe a que los criterios sobre los que se basa el diagnóstico (clínicos,exploración física y radiología) no son específicos de esta enfermedad y muchos no están presentes en sus estadios precoces.La sociedad Europea de Reumatología (EULAR) y los criterios ASAS recomiendan el uso de la radiografía simple o la resonancia magnética (RM) como únicas técnicas de imagen diagnósticas de la sacroilitis de estos pacientes.Sin embargo, 1/3 de los pacientes en estadios precoces de EspAax presentan una RM negativa y la lesión comúnmente utilizada en RM para el diagnóstico de sacroilitis activa (el edema de médula ósea) puede llegar a aparecer hasta en un 30% de pacientes con dolor lumbar inflamatorio (DLI) no EspAax.En los últimos años la incorporación del SPECT/TC a la gammagrafía ósea (GO) ha ayudado a resolver el principal problema de esta técnica,la falta de resolución anatómica de las imágenes planares nos ha permitido obtener recuentos tridimensionales por análisis volumétrico de la articulación,mejorando así la sensibilidad y especificidad de la prueba.Ante este cambio de panorama y la falta de estudios en profundidad en la literatura médica del SPECT/TC en pacientes con EspAax activa y DLI,decidimos estudiar la aplicación de esta técnica diagnóstica en la sacroilitis activa de estos pacientes. Objetivos: Comparar el rendimiento diagnóstico de la RM, el SPECT/TC y ambas pruebas combinadas y evaluar la correlación entre los índices cuantitativos de ambas técnicas Material y método:Llevamos a cabo de estudio prospectivo de pacientes ambulatorios en consultas de reumatología de nuestro centro (Clínica Universidad de Navarra) entre los años 2012 y 2019.Los pacientes debían presentar un DLI de entre 3 meses y 10 años de evolución que debía haberse iniciado antes de los 45 años y la enfermedad debía encontrarse activa.Se reclutaron un total de 53 pacientes que se dividieron en 2 grupos, EspAax y DLI no EspAax,según los nuevos criterios de clasificación ASAS.A todos se les realizó una RM y un SPECT/ TC de las articulaciones sacroilíacas las 2 semanas posteriores a la visita médica.Se calculó la precisión diagnostica de ambas técnicas respecto al diagnóstico clínico y de las pruebas de imagen nucleares respecto a la RM como gold estandar diagnóstico.La correlación entre las diferentes pruebas se calculó comparando los índices de actividad del SPECT/TC (sacroilíaca total e inferior / promontorio sacro) con los sistemas de puntuación Berlín y SPARCC de la RM en sus diferentes escalas [inflamación, total y combinada (inflamación+erosión)] Resultados:Los valores de sensibilidad y especificidad de la SPECT/TC cuantitativo,tomando como punto de corte el cociente sacroiliaca/promontorio >1,36, fueron similares a los de la RM.La combinación de ambas técnicas aumentó la sensibilidad de forma significativa,manteniendo una alta especificidad y permitiendo que el 40% de los pacientes diagnosticados clínicamente de EspAax con RM(-) resultasen positivos,confirmando la sospecha clínica de sacroilitis activa.La correlación entre las escalas de RM y SPECT/TC fue moderada,mejorando al utilizar las escalas de inflamación y al centrar el estudio en el tercio inferior de la articulación (tercio sinovial) Conclusiones:El SPECT/TC cuantitativo muestra mejor precisión diagnóstica que la GO planar y el SPECT/TC cualitativo en la sacroilitis activa,pudiendo desempeñar un papel relevante en el diagnóstico de sacroilitis activa en pacientes con lumbalgia inflamatoria y alta sospecha de EspAax donde no pueda realizarse una RM o ésta resulte negativa o no concluyente.La combinación de ambas técnicas aumenta la precisión diagnostica reduciendo el nº de falsos negativos de la RM en fases iniciales de la EspAa

Neumatosis intestinal y gas portomesentérico: a propósito de un caso

La neumatosis intestinal (presencia de gas en el interior de la pared intestinal y en el complejo venoso portomesentérico) es una situación clínica poco frecuente que ha sido característicamente relacionada con la isquemia intestinal y con un desenlace fatal. Existen otras causas que pueden justifi car estos hallazgos y cuya repercusión para el paciente no es inevitablemente trágica. Los avances recientes en técnicas de imagen, sobre todo en tomografía computarizada multicorte (TCMC), permiten un diagnóstico preciso fi able y precoz de estos hallazgos. En este artículo, repasamos las manifestaciones radiológicas de la neumatosis intestinal en TC así como las distintas causas relacionadas con esta entidad, en relación con los hallazgos presentes en un paciente diagnosticado de carcinoma de esófago y en tratamiento quimioterápico. INGLÉS: Intestinal pneumatosis (presence of gas in the intestinal wall and in the portomeseteric veins) is an infrequent clinical situation that has been associated with extended bowel necrosis and fatal outcome. However, there are other reasons that can justify these findings without such an outcome. Recent advances in diagnostic imaging techniques, especially multislice computerized tomography (MSCT), have allowed precise and quick diagnosis of these entities. In this article, we review the MSCT radiological manifestations of intestinal pneumatosis, as well as the different diagnoses related with the findings observed in a patient diagnosed with esophageal carcinoma under chemotherapy treatment

Diagnostic value of quantitative SPECT/CT in assessing active sacroiliitis in patients with axial spondylarthritis and/or inflammatory low back pain

Background. The diagnostic accuracy of bone scintigraphy (BS) increases with SPECT/CT imaging. It would therefore be appropriate to reassess the diagnostic utility of scintigraphy in sacroiliitis with axial spondyloarthritis (SpA). The aim of this study was to compare the diagnostic performance of MRI, SPECT/CT and a combination of both techniques in sacroiliitis, and to evaluate the correlation between quantitative SPECT/CT indices and quantitative MRI inflammatory lesion scores. Methods. Thirty-one patients with active SpA and 22 patients with inflammatory low back pain underwent MRI and SPECT/CT of the sacroiliac joints. The diagnostic accuracy of both techniques was calculated using clinical diagnosis as the gold standard. The correlation between MRI and SPECT/CT was calculated by comparing the SPECT/CT activity indices and the Berlin/SPARCC scoring systems for MRI. Results. The sensitivity and specificity values in quantitative SPECT/CT, taking the sacroiliac/promontory ratio of >1.36 as the cut-off value, were close to those from MRI published in the literature. The combination of both techniques increased sensitivity while maintaining high specificity. There was a moderate correlation between SPECT/CT and MRI total scores. This correlation was improved by using solely the MRI inflammation scores. Conclusion. Quantitative SPECT/CT showed better diagnostic accuracy than planar scintigraphy and showed a moderate correlation with MRI scores in active sacroiliitis. The combination of both tests increased the diagnostic accuracy. Quantitative SPECT/CT could play a relevant role in the diagnosis of active sacroiliitis in patients with high a suspicion of SpA and a negative/inconclusive MRI test or in patients with whom MRI studies cannot be carried out.Fundamento. La precisión diagnóstica de la gammagrafía ósea (GO) aumenta con las imágenes SPECT/TAC haciendo conveniente reevaluar su utilidad diagnóstica en la sacroilitis de la espondiloartritis axial (EA). El objetivo fue comparar el rendimiento diagnóstico de la resonancia magnética (RM), la SPECT/TC y ambas pruebas combinadas, y evaluar la correlación entre los índices cuantitativos de ambas técnicas. Métodos. A 31 pacientes con EA activa y 22 con lumbalgia inflamatoria se les realizó una RM y una SPECT/TC de las articulaciones sacroilíacas y se calculó la precisión diagnóstica de ambas técnicas respecto al diagnóstico clínico. La correlación entre ambas pruebas se calculó comparando los índices de actividad del SPECT/TC con los sistemas de puntuación Berlín y SPARCC de RM. Resultados. Los valores de sensibilidad y especificidad de la SPECT/TC cuantitativa, tomando como punto de corte el cociente sacroilíaca/promontorio >1,36, fueron similares a los publicados para la RM. La combinación de ambas técnicas aumentó la sensibilidad manteniendo una alta especificidad. La correlación entre las escalas totales de RM y SPECT/TC fue moderada y mejoraba al utilizar únicamente las escalas de inflamación. Conclusiones. La SPECT/TC cuantitativa muestra una mejor precisión diagnóstica que la GO planar en la sacroilitis activa y una correlación moderada con las puntuaciones de RM. La combinación de ambas técnicas aumenta la precisión diagnóstica. Por tanto, la SPECT/TAC cuantitativa podría tener un papel relevante en el diagnóstico de sacroilitis en pacientes con alta sospecha de EA y RM negativa/no concluyente o en aquellos pacientes en los que no se pueda realizar una RM

Ultra-low dose whole-body CT for attenuation correction in a dual tracer PET/CT protocol for multiple myeloma

Purpose: To investigate within phantoms the minimum CT dose allowed for accurate attenuation correction of PET data and to quantify the effective dose reduction when a CT for this purpose is incorporated in the clinical setting. Methods: The NEMA image quality phantom was scanned within a large parallelepiped container. Twenty-one different CT images were acquired to correct attenuation of PET raw data. Radiation dose and image quality were evaluated. Thirty-one patients with proven multiple myeloma who underwent a dual tracer PET/CT scan were retrospec- tively reviewed. 18F-fluorodeoxyglucose PET/CT included a diagnostic whole-body low dose CT (WBLDCT: 120 kV-80mAs) and 11C-Methionine PET/CT included a whole-body ultra-low dose CT (WBULDCT) for attenuation correction (100 kV-40mAs). Effective dose and image quality were analysed. Results: Only the two lowest radiation dose conditions (80 kV-20mAs and 80 kV-10mAs) produced artifacts in CT images that degraded corrected PET images. For all the other conditions (CTDIvol ≥ 0.43 mGy), PET contrast recovery coefficients varied less than ± 1.2%. Patients received a median dose of 6.4 mSv from diagnostic CT and 2.1 mSv from the attenuation correction CT. Despite the worse image quality of this CT, 94.8% of bone lesions were identifiable. Conclusion: Phantom experiments showed that an ultra-low dose CT can be implemented in PET/CT procedures without any noticeable degradation in the attenuation corrected PET scan. The replacement of the standard CT for this ultra-low dose CT in clinical PET/CT scans involves a significant radiation dose reductio

Ultra-low dose whole-body CT for attenuation correction in a dual tracer PET/CT protocol for multiple myeloma

Purpose: To investigate within phantoms the minimum CT dose allowed for accurate attenuation correction of PET data and to quantify the effective dose reduction when a CT for this purpose is incorporated in the clinical setting. Methods: The NEMA image quality phantom was scanned within a large parallelepiped container. Twenty-one different CT images were acquired to correct attenuation of PET raw data. Radiation dose and image quality were evaluated. Thirty-one patients with proven multiple myeloma who underwent a dual tracer PET/CT scan were retrospec- tively reviewed. 18F-fluorodeoxyglucose PET/CT included a diagnostic whole-body low dose CT (WBLDCT: 120 kV-80mAs) and 11C-Methionine PET/CT included a whole-body ultra-low dose CT (WBULDCT) for attenuation correction (100 kV-40mAs). Effective dose and image quality were analysed. Results: Only the two lowest radiation dose conditions (80 kV-20mAs and 80 kV-10mAs) produced artifacts in CT images that degraded corrected PET images. For all the other conditions (CTDIvol ≥ 0.43 mGy), PET contrast recovery coefficients varied less than ± 1.2%. Patients received a median dose of 6.4 mSv from diagnostic CT and 2.1 mSv from the attenuation correction CT. Despite the worse image quality of this CT, 94.8% of bone lesions were identifiable. Conclusion: Phantom experiments showed that an ultra-low dose CT can be implemented in PET/CT procedures without any noticeable degradation in the attenuation corrected PET scan. The replacement of the standard CT for this ultra-low dose CT in clinical PET/CT scans involves a significant radiation dose reductio