A Bizarre Presentation of Bilateral Mandibular Osteoporotic Bone Marrow Defect (A Case Report)

BACKGROUND: Osteoporotic bone marrow defect of the jaw is an uncommon localized radiolucency that consists of hematopoietic red marrow with varying amounts of fatty yellow marrow. The lesion is usually asymptomatic and accidentally discovered during a routine radiographic examination; however, some studies showed different results. CASE REPORT: This is an uncommon case of bilateral mandibular osteoporotic bone marrow defect in a 40-year- old healthy female. One of the defects reoccurred, and it involves dental implants. PLAN OF TREATMENT: Lesion was managed by curettage and the patient was followed up after 1,6,12 months. CONCLUSIONS: in order to diagnose FOBMD and differentiate it from other lesions, further researches are needed to help fully understand it, since the exact incident and etiology are not established yet.

Photon interaction parameters of different tissues of human organs

<p>For proper planning in the radiography of different parts of human organs, knowledge of the photon interaction parameters in different tissues of human organs are essential. Studied the x-ray and gamma photon interaction parameters such as linear attenuation coefficient, half value layer, tenth value layer, mean free path and effective electron density of almost all tissues of human organs [Adipose tissue, Blood, Brain, Breast, Cell Nucleus, Eye Lens, GI tract, Heart, Kidney, Liver, Lung , Lymph, Muscle, Ovary, Pancreas, Cartilage, Red marrow, Spongiosa, Yellow marrow, Skin, Spleen, Testis, Thyroid, Skeleton cortical bone, Skeleton cranium, Skeleton femur, Skeleton humerus,Skeleton mandible, Skeleton ribs (2^nd,6^th), Skeleton ribs (10^th), Skeleton sacrum, Skeleton spongiosa, Skeleton vertebral column (C4) and Skeleton vertebral column (D6, L3)]. The present work is useful in the planning of radiography for different organs. This work also gives useful information for radiotherapy and dosimetry.</p>

Clinical Significance of Bone Marrow Imaging of Appendicular Skeletons By Low-Dose Multi-Detector Computed Tomography in Patients with Bone Marrow Failure Syndrome

Background: Aplastic anemia (AA), paroxysmal nocturnal hemoglobinuria (PNH) and myelodysplastic syndrome (MDS) are the heterogeneous group of bone marrow failure syndrome (BMFs). AS they often show profound hypocellular marrow, the diagnosis is often difficult by bone marrow and laboratory examination alone. Red to yellow marrow conversion occurs with age in the appendicular skeleton (AS), where red marrow is converted to yellow marrow until the age of early 20s. Although abnormal distribution of red marrow in appendicular skeleton were previously reported in small series of patients with MDS, leukemia and lymphoma by MRI, no further study has published so far. Here, we examined distribution of red marrow in AS by low-dose multi-detector CT (MDCT) in BMFs patients, and analyzed the relationship between the abnormal medullary pattern in AS and laboratory variables. The relationship between the MDCT pattern and subsequent development of leukemic transformation on survivals was analyzed in patients with BMFs. Patients: We retrospectively reviewed the medical records of 138 untreated patients (AA n=36, PNH n=5, and MDS n=97) with BMFs diagnosed in the Department of Hematology/Oncology at Kameda Medical Center, Kamogawa, Japan, from July 2008 to June 2014. Follow-up MDCTs were evaluated in 28 MDS patients when they were diagnosed as overt AML (MDS/tAML). Retrospective review of clinical and laboratory features including complete blood count, % of bone marrow blast, chromosomal analysis, and International Prognostic Scoring System (IPSS) at diagnosis was performed. WHO classification of patients with MDS was as follows: RCUD (n=21), RARS (n=2), RCMD (n=26), RAEB (n=43), and, MDS unclassified (MDS-U) (n=5). Leukemia-free survival (LFS) and overall survival (OS) were analyzed in 73 patients with MDS who were ≥65 years of age and ineligible for allogeneic stem cell transplantation (allo SCT) by the Kaplan-Meier. CT image acquisition and Image analysis: Non-enhanced CT examinations were performed from the skull to the knees by MDCT scanner (Aquilion 64, Tohshiba, Tokyo, Japan). Bony canal of humeral and femoral bone were visualized by coronal and sagittal axis image reconstruction. Medullary CT density of humerus and femurs were measured and the results were expressed as Hounsfield unit (HU). As the normal adult bone marrow was composed of rich adipocytes and called yellow marrow, it is represented by low density CT value between -30 to -100 HU. The value above -30 HU observed in long bony canals was considered as high density. Medullary pattern of AS were categorized as follows: (1) fatty pattern; showing a low signal density marrow (2) focal pattern; showing abnormally focal high density lesions (3) diffuse pattern; showing uniformly high density marrow. Results: All 36 patients with AA showed a fatty (n=13, 36.1%) or focal (n=23, 63.9%) pattern in medullary AS on MDCT, and none of them showed diffuse pattern. Five patients with PNH showed as follows: fatty/focal/diffuse, 1/3/1. Ninety-seven patients with MDS showed as follows: fatty/focal/diffuse, 24/46/27. Patients with MDS who showed diffuse pattern had a significantly low hemoglobin concentration compared to those with fatty or focal pattern (p=0.03). Among the patients with MDS, most of the patients with RCUD (n=21), RARS (n=2), RCMD (n=26), MDS-U (n=5) showed the fatty or focal pattern (fatty or focal/diffuse pattern; RCUD (18/3), RARS (2/0), RCMD (21/5), MDS-U (5/0)), but approximately half (46%) of patients with RAEB showed diffuse pattern (fatty/focal/diffuse pattern; 7/17/19). In addition, patients with transformed to MDS/tAML showed either focal (n=10, 35.7%) or diffuse (n=18, 64.3%) pattern and none of them showed fatty pattern. In 73 patients with MDS who were ≥65 years of age and ineligible for allo SCT, the group with focal or diffuse pattern had significantly shorter LFS and OS compared to the group with fatty pattern (p=0.01, p=0.05, respectively). Patients with focal pattern in AS showed longer LFS than those with diffuse pattern (p=0.05), but difference was not statistically significant in OS (p=0.22). Conclusions: This study showed that MDCT imaging of the appendicular skeletons provided important information for the diagnosis and prognosis of patients with BM. In patients with MDS, focal or diffuse pattern on MDCT showed negative prognostic impact on LFS and OS, and these patterns appeared to reflect the status of disease. Figure 2. Figure 2. Figure 3. Figure 3. Disclosures No relevant conflicts of interest to declare.

Clinical and Prognostic Significance of Bone Marrow Imaging of Appendicular Skeletons By Low-Dose Multi-Detector Computed Tomography in Patients with Aplastic Anemia and Myelodysplastic Syndorme

Background: Myelodysplastic syndrome (MDS) and aplastic anemia (AA) comprise a heterogeneous group of bone marrow failure disorders. As both show profound hypocellular marrow with minimal morphological atypia, differentiation of MDS and AA is often difficult by bone marrow and laboratory examination alone. Red to yellow marrow conversion occurs with age in the appendicular skeleton (AS), where red marrow is converted to yellow marrow until the early 20s. Although an abnormal distribution of red marrow in AS has previously been reported in small numbers of patients with MDS, along with leukemia and lymphoma by MRI, there have been no further reports to date. Here, we examined the distribution of red marrow in AS by low-dose multi-detector CT (MDCT) in AA and MDS. We analyzed the relationships between the abnormal medullary pattern in AS and laboratory variables, subsequent development of leukemic transformation, and survival in MDS patients. Patients: We performed low-dose MDCT of the humerus and femur in 103 untreated adult patients with AA (n = 32) and MDS (n = 71). We retrospectively reviewed the medical records of patients with AA and MDS diagnosed in the Department of Hematology/Oncology at Kameda Medical Center, Kamogawa, Japan, from July 2008 to June 2014. A retrospective review of clinical and laboratory features, including complete blood count, % bone marrow blasts, chromosomal analysis, and International Prognostic Scoring System (IPSS), was performed. WHO classification of MDS patients was as follows: RA (n = 22), RARS (n = 2), RCMD (n = 17), RAEB 1 (n = 18), RAEB 2 (n = 11), and MDS unclassified (n = 1). Overall survival (OS) and leukemia-free survival (LFS) were analyzed in 71 MDS patients by the Kaplan–Meier method and differences between curves were calculated by two-sided log-rank test. CT image acquisition and image analysis: Non-enhanced CT examinations were performed from the base of the skull down to the knee joint with an MS-CT scanner (AQUILION 64; Toshiba, Tokyo, Japan). The bony canals of the humeral and femoral bones were visualized by coronal and sagittal axis image reconstruction. The effective radiation dose associated with whole-body MD-CT was 10.1 mSv (ICRP 26). The dose was comparable to whole-body CT (2.4 mSv). Medullary CT density of the humerus and femur were measured and the results are expressed in Hounsfield units (HU). As the normal adult bone marrow was composed of rich adipocytes and called yellow marrow, it is represented by a low-density CT value between –30 and –100 HU. A value above –30 HU observed in long bony canals was considered to indicate a high-density lesion. The medullary pattern of the appendicular skeleton was categorized as follows: (1) fatty, showing a low signal density marrow; (2) focal, showing abnormally focal high-density lesions; (3) diffuse, showing uniformly high-density marrow. Results: All 15 patients with AA showed a fatty (n = 12, 37.5%) or focal (n = 20, 62.5%) pattern in medullary AS on MDCT, and none showed a diffuse pattern. Among the 71 patients with MDS, 22 (30.9%) had a fatty pattern, 32 (45.1%) had a focal pattern, and 17 (23.9%) had a diffuse pattern. Seventeen patients with diffuse infiltration pattern on MDCT had significantly shorter LFS (P < 0.01, P = 0.02) compared to 23 patients with fatty pattern and 32 patients with focal medullary pattern (median LFS: 18 months vs. not reached vs. not reached, respectively). Seventeen patients with a diffuse infiltration pattern on MDCT had significantly shorter OS (P = 0.04) compared to 23 patients with a fatty pattern, but the difference was no significant compared to 32 with a focal medullary pattern (P = 0.15) (median OS: 22 months vs. not reached vs. not reached, respectively). The characteristics of the patients with diffuse pattern did not differ significantly in terms of sex, age, WBC count, platelet count, karyotype, WT1, or IPSS classification from those of patients with a fatty or focal pattern, but patients with a diffuse infiltration pattern on MDCT had a significantly low hemoglobin concentration compared to those with a fatty or focal medullary pattern (P = 0.03). Conclusions: This study showed that MDCT imaging of the appendicular skeleton provided important information for the diagnosis and prognosis of patients with MDS and AA. In patients with MDS, a diffuse pattern on MDCT emerged as an independent negative prognostic indicator on LFS and OS. Figure 1 Figure 1. Figure 2 Figure 2. Disclosures No relevant conflicts of interest to declare.

Ectopic extramedullary hematopoiesis: evaluation and treatment of a rare and benign paraspinal/epidural tumor

Ectopic extramedullary hematopoiesis (EMH), defined as the formation of blood cells outside the bone marrow, usually occurs in a scenario of chronic anemia when, even after conversion of the bony yellow marrow to red marrow, the body is still unable to meet the demand for red blood cells. Ectopic extramedullary hematopoiesis most commonly occurs in the liver and spleen but may, in fact, occur almost anywhere in the body. Although previous reports have documented EMH presenting as paraspinal masses, such lesions have almost always been associated with a predisposing hematological disorder such as hemolytic anemia, myelofibrosis or myelodysplastic syndromes, thalassemia, polycythemia vera, leukemia, or lymphoma. The authors of this report describe the first reported instance of EMH in a patient presenting with a symptomatic epidural and paraspinal cervical lesion arising from the posterior spinal elements and no known predisposing hematological disease. Initial radiographs revealed a bony lesion arising posteriorly from the C2–3 laminae and spinous processes. Subsequent imaging suggested the diagnosis, which was confirmed by CT-guided biopsy, peripheral blood smears, and bone marrow aspirate. Despite epidural compression and slight displacement of the cervical cord and thecal sac, the patient's symptoms were limited to pain and diminished cervical range of motion. Therefore, surgery was deferred in favor of nonsurgical therapy. Several alternative modalities for the treatment of EMH have been suggested in the literature, including cytotoxic agents and radiotherapy. The authors opted for an approach utilizing directed low-dose radiotherapy of a total of 25 Gy divided in 2.5-Gy fractions. At the 3-month follow-up, the patient continued to be asymptomatic, and MRI demonstrated a significant reduction in the dimensions of the lesion. Extramedullary hematopoiesis with spinal cord compression in the absence of a preexisting hematological disorder has not been described in the context of clinical neurosurgical practice. Recognizing that EMH may present as an epidural or paraspinal lesion is important since chemotherapy and radiotherapy are effective therapeutic options in the majority of patients who suffer few if any symptoms. Extensive evaluation for underlying hematological disorders is necessary before undertaking directed therapy. Inadvertent resection of these highly vascularized masses may risk catastrophic intraoperative hemorrhage with no proven benefit as compared with medical treatment, which usually provides excellent long-term outcomes.

Bone Marrow Imaging of Appendicular Skeleton by Multi-Detector Computed Tomography in Patients with Aplastic Anemia and Hypoplastic MDS.

Abstract 2817 Background: Myelodysplastic syndrome (MDS) and aplastic anemia (AA) are the heterogeneous group of bone marrow failure disorders. AS both shows profound hypocellular marrow without minimal morphologic atypia, differentiation of MDS and AA is often difficult by bone marrow and laboratory examination alone. Red to yellow marrow conversion is occurs with age in the appendicular skeleton (AS), where red marrow is converted to yellow marrow until the age of early 20s. Although abnormal distribution of red marrow in appendicular skeleton has previously reported in small series of patients with MDS, leukemia and lymphoma by MRI, no further study has published so far. Here, we examined distribution of red marrow in AS by low-dose multi-detector CT (MDCT) in AA and MDS. We analyzed the relationship between the abnormal medullary pattern in AS with laboratory variables, subsequent development of leukemic transformation and survivals MDS patients. Patients: We performed a low-dose MDCT of humerus and femurs in 64 untreated adult patients with AA (N=15) and MDS (N=49). Retrospective review of clinical and laboratory features including complete blood count, % of bone marrow blast, chromosomal analysis, and International Prognostic Scoring System (IPSS) was performed. WHO classification of MDS patients was as follows: RA (N=17), RARS (N=2), RCMD (N=9), RAEB (N=19) and MDS unclassified (N=2). Overall survival (OS) and leukemia-free survival (LFS) were analyzed in 49 MDS patients by the Kaplan-Meier and differences between curves were calculated by two-sided log-rank test. Multivariate analysis was Used to assess the effects of prognostic factors - hemoglobin, platelet, bone marrow blast, cytogenetic abnormalities, IPSS score, WHO classification, and MDCT patterns. CT image acquisition and Image analysis: Non-enhanced CT examinations were performed from the base of skull down to the knee joint by MS-CT scanner (AQUILION 64, Tohshiba, Tokyo, Japan). Bony canal of humeral and femoral bone were visualized by coronal and sagittal axis image reconstruction. The effective radiation dose associated with whole body MD-CT was 10.1 mSv. (ICRP 26). The dose was comparable to whole body CT (2.4 mSv.). Medullary CT density of humerus and femurs were measured and the results were expressed as Hounsfield unit (HU). As the normal adult bone marrow was composed of rich adipocytes and called yellow marrow, it is represented by low density CT value between −30 to −100 HU. The value above −30 HU observed in long bony canals was considered as high density lesions. Medullary pattern of appendicular skeletons were categorized as follows: (1) fatty; showing a low signal density marrow (2) focal; showing abnormally focal high density lesions: (3) diffuse; showing uniformly high density marrow. Results: All 15 patients with AA showed a fatty (N=10, 66%) or focal (N=5, 33%) pattern in medullary AS on MDCT and none of them showed diffuse pattern. Conversion from fatty to focal marrow was observed in 9 of 15 AA patients after successful immunosuppressive treatment. Among the 49 patients with MDS, 15 (31%) had fatty pattern, 21 (43%) had focal pattern, and 13 (27%) had diffuse pattern. Patients with diffuse infiltration pattern on MDCT had a significantly low hemoglobin concentration (p<0.01) and shorter OS (p<0.01) compared to those with fatty or focal medullary pattern. The characteristics of the patients with diffuse pattern did not differ significantly in terms of sex, age, WBC count or karyotype from those of the patients with fatty or focal pattern. Among 13 MDS patients with diffuse pattern, 6 developed AML during their follow-up periods (median, 17 months; range, 2 to 38 months). LFS and OS of 13 patients with diffuse patterns were significantly shorter than that of the 36 patients with fatty and focal patterns (74% vs 19% at 3 years; p<0.01 and 79% vs 40% at 3 years; p<0.01, respectively). On multivariable analysis, diffuse pattern on MDCT was emerged as independently negative prognostic impact on LFS and OS in patients with MDS. Conclusions: This study showed that MDCT imaging of the appendicular skeletons provided important information for the diagnosis and prognosis of patients with MDS and AA. Disclosures: No relevant conflicts of interest to declare.

Alterations of the Temporomandibular Joint on Magnetic Resonance Imaging according to Growth and Development in Schoolchildren

The paper explains the alterations of the temporomandibular joint (TMJ) visualized by magnetic resonance imaging (MRI) according to the growth and development of schoolchildren. Appearance and disappearance of a “double contour-like structure” (DCLS) of the mandibular condyle on MRI according to the growth and development of schoolchildren were demonstrated. In addition, possible constituents of DCLS and the significance of detection of DCLS on MRI were also speculated. The relationship between red marrow and yellow marrow in the articular eminence of temporal bone, the disappearance of DCLS, and alterations of the mandibular condyle have been elucidated.