Acute myeloid leukemia(AML) is the most common acute leukemia among adults in the United states with approximately 19,940 people being diagnosed of this disease in 2020 and 11,180 deaths. It is a heterogenous group of malignancy characterized by clonal expansion of blast with myeloid lineage in the bone marrow, peripheral blood and/or other tissues. Our patient is a 79-year-old male who presented to the hospital with reports of sharp, throbbing low back pain for one month, moderately controlled with pain medications. He reported 5 lb. weight loss with decreased appetite over one month but denied other constitutional symptoms. MRI Lumbar spine revealed multiple foci of marrow signal abnormality compatible with extensive metastatic disease. CT chest, abdomen and pelvis did not show any lesions concerning for primary or metastatic malignancy. CBC revealed normal WBC count, platelet count and hemoglobin level (with macrocytosis, MCV 104.7). Initial work up including Vitamin B12 and folic acid level, TSH, SPEP/IFE, serum light chain ratio and quantitative immunoglobulins were within normal limits. Pathology from a CT guided bone biopsy of the L spine lesion was concerning for high grade myeloid neoplasm. Patient had a bone marrow biopsy done at another hospital which was read as most consistent with acute myeloid leukemia (AML) with monocytic differentiation, with findings of hypocellular marrow, extensive fibrosis with focal areas of large clusters of immature cells, positive for MPO, CD33, CD43 and CD 56, Ki-67 of 60-80%. Cytogenetics showed an abnormal male karyotype with trisomy 8. FISH was negative for other AML or MDS related abnormalities. Given the above findings of AML and advanced age, patient was started on treatment with hypomethylating agent Decitabine along with BCL-2 inhibitor, Venetoclax. A repeat bone marrow biopsy after two cycles of the above regimen revealed progressive disease with extensive fibrosis and 80-90% blast on a core biopsy sample. Due to poor response to above regimen, lack of effective treatment options in older patients with AML and declining functional status, decision was made to pursue best supportive care. AML usually presents with symptoms of fevers, fatigue, dyspnea or bleeding. Skeletal lesions are usually associated with a diagnosis of multiple myeloma, or other solid organ malignancies and rare in AML. Extra medullary involvement of AML is known to happen in 2.5%-9% of patients and is termed as Myeloid Sarcoma. Due to the low incidence, prospective study data is limited. This entity is treated similarly to AML, depending on risk stratification by cytogenetics, age and targetable mutations which also govern its prognosis. This case highlights the importance of increased awareness and high index of suspicion among medical providers regarding this atypical presentation of AML since if missed or misdiagnosed could delay treatment and lead to poor outcomes.

A tomografia computadorizada (TC) é a técnica de escolha para o exame de afecções da cavidade bucal e estruturas anexas, pois permite visualização de tecidos moles e duros em um único exame sem sobreposição de imagens. Este exame oferece um significativo avanço no que se refere à definição de lesões maxilo-faciais, apresentando uma excelente resolução anatômica. Porém um dos problemas que ocorre com a TC, é o aparecimento de artefatos devido a restaurações metálicas dentárias, Estes artefatos atrapalham a interpretação das imagens, dificultando a visualização de lesões. O propósito deste estudo foi avaliar a validade de dois protocolos de TC, em cortes axiais, na observação de lesões simuladas na mandíbula e a influência dos artefatos dentários metálicos. Foram realizadas TCs, em dois protocolos, de mandíbulas secas, nas quais foram executadas perfurações simulando lesões. As imagens foram realizadas em dois momentos: na presença e na ausência de restaurações dentárias metálicas. Dois observadores, previamente calibrados, observaram as imagens de acordo com diversos critérios. Como resultado observouse que a sensibilidade e a especificidade para detecção de lesões foram de 100% nos dois protocolos, porém a detecção do número de lojas das lesões multiloculares e a determinação da localização precisa e invasão precoce para medular, obteve valores menores na determinação de sua validade, sendo estes significativamente influenciados pela presença de artefatos e a espessura de corte da aquisição da imagem. / Computed tomography is the choice technique to access oral and maxillofacial lesions, because it provides hard and soft tissues visualization in one examination without superimposition of surrounding structures. This examination offers a significative advance in maxillofacial lesions definition, with an excellent anatomic resolution. However, dental metal artifacts can be a problem in the interpretation of CT images. These artifacts lead to misinterpretations of the images, making difficult to visualize lesions in these areas. The aim of this research was to evaluate the validity of two protocols, in axial sections, in simulated mandibular lesions assessment, and the influence of dental metallic artifacts in these observations. Two CT protocols were obtained from dry mandibles in which perforations were done simulating lesions. CT was performed in two moments: With and without metallic dental restorations. Two observers, previously calibrated, evaluated the images according different parameters. As results we can observe that the sensibility and specificity in lesion detection were 100% for both protocols, but the detection of loci number of multilocular lesions; location and detection of medular invasion, obtained reduced values in their validity, and this values were significantly influenced by the artifacts presence and the slice thickness of image acquisition.

A tomografia computadorizada (TC) é a técnica de escolha para o exame de afecções da cavidade bucal e estruturas anexas, pois permite visualização de tecidos moles e duros em um único exame sem sobreposição de imagens. Este exame oferece um significativo avanço no que se refere à definição de lesões maxilo-faciais, apresentando uma excelente resolução anatômica. Porém um dos problemas que ocorre com a TC, é o aparecimento de artefatos devido a restaurações metálicas dentárias, Estes artefatos atrapalham a interpretação das imagens, dificultando a visualização de lesões. O propósito deste estudo foi avaliar a validade de dois protocolos de TC, em cortes axiais, na observação de lesões simuladas na mandíbula e a influência dos artefatos dentários metálicos. Foram realizadas TCs, em dois protocolos, de mandíbulas secas, nas quais foram executadas perfurações simulando lesões. As imagens foram realizadas em dois momentos: na presença e na ausência de restaurações dentárias metálicas. Dois observadores, previamente calibrados, observaram as imagens de acordo com diversos critérios. Como resultado observouse que a sensibilidade e a especificidade para detecção de lesões foram de 100% nos dois protocolos, porém a detecção do número de lojas das lesões multiloculares e a determinação da localização precisa e invasão precoce para medular, obteve valores menores na determinação de sua validade, sendo estes significativamente influenciados pela presença de artefatos e a espessura de corte da aquisição da imagem. / Computed tomography is the choice technique to access oral and maxillofacial lesions, because it provides hard and soft tissues visualization in one examination without superimposition of surrounding structures. This examination offers a significative advance in maxillofacial lesions definition, with an excellent anatomic resolution. However, dental metal artifacts can be a problem in the interpretation of CT images. These artifacts lead to misinterpretations of the images, making difficult to visualize lesions in these areas. The aim of this research was to evaluate the validity of two protocols, in axial sections, in simulated mandibular lesions assessment, and the influence of dental metallic artifacts in these observations. Two CT protocols were obtained from dry mandibles in which perforations were done simulating lesions. CT was performed in two moments: With and without metallic dental restorations. Two observers, previously calibrated, evaluated the images according different parameters. As results we can observe that the sensibility and specificity in lesion detection were 100% for both protocols, but the detection of loci number of multilocular lesions; location and detection of medular invasion, obtained reduced values in their validity, and this values were significantly influenced by the artifacts presence and the slice thickness of image acquisition.

Orientador: Solange Maria Almeida / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Odontologia de Piracicaba / Made available in DSpace on 2018-07-25T12:46:37Z (GMT). No. of bitstreams: 1 Santos_JulioCesarBentodos_M.pdf: 7612034 bytes, checksum: 606a68f5cabb358d723b7501b7c58c5b (MD5) Previous issue date: 1999 / Resumo: O presente estudo teve por finalidade avaliar três métodos radiográficos, radiografia periapical, radiografia panorâmica e sistema digital, no diagnóstico de lesões apicais produzidas artificialmente em mandíbulas maceradas. E se o tamanho das lesões interferem no diagnóstico radiográfico. Para tanto, as lesões apicais foram produzidas utilizando-se brocas esféricas com diâmetros diferentes, permitindo assim que o diâmetro das lesões sofresse alteração em tamanho conforme a broca utilizada. Assim, o estudo foi dividido em 04 fases: fase inicial ou 1, caracterizada pela ausência de lesão; fase 2, caracterizada pela lesão produzida com a broca 6 com medida da ponta ativa de 1,8mm; fase 3, caracterizada pela lesão produzida com a broca 8 com medida da ponta ativa de 2,3mm; fase 4, caracterizada pela lesão produzida com a broca 10 com medida da ponta ativa de 2,7mm; e fase cortical ou 5, quando a lesão atingia as corticais ósseas. Todas as fases foram, realizadas em 04 regiões da mandíbula: incisivo, canino, pré-molares e molares. As radiografias foram obtidas após cada fase e, posteriormente, foram analisadas por 04 radiologistas. Houve diferença estatisticamente significante na fase broca 6 (R) nos incisivos a favor do sistema digital. O mesmo ocorreu na fase cortical (LI) na região de pré-molares. Na região dos molares houve uma diferença etatisticamente significante na fase broca 10 (D) para a radiografia panorâmica e na fase cortical esta técnica foi a menos eficaz. Nas demais fases e regiões não houve uma diferença estatisticamente significante / Abstract: The aim of this study was to evaluate three radiographys techniques: periapical radiography, panoramic and digital radiography, about diagnostic accuracy of artificially produced bony lesions in human jaw dry. The periapical diseases were done using burs numbers 6, 8 and 10 thus allowing the lesions diameter to incresing according to burs size. Therefore, the study was dividided in four phases: phase 1 without periapical disease, phase 2 periapical disease made by bur number 6, phase 3 periapical disease made by bur number 8, phase 4 periapical disease made by bur number 10 and phase 5 periapical disease touchs junction area of the cortex. The phases were in four regions in the jaw, anterior, canine, premolar and molar. The radiographies were evaluated by four oral radiologists observers. The results showed that in the anterior region there was a significant statistically difference only at phase 2, that is the lesion was produced with bur 6, the digital radiography was more successfull and it was also observed in the premolar region in the cortical phase. In the molar region there was a false true result during the inicial phase, without lesion. During phase 4 (burn 10 ) and cortical phase there was a statistically significant difference in favor of the panoramic radiography / Mestrado / Radiologia / Mestre em Odontologia

Thesis (MSc (Medical Imaging and Clinical Oncology. Nuclear Medicine))--University of Stellenbosch, 2010. / ENGLISH SUMMARY: Introduction: Bone scintigraphy is used extensively in evaluating metastatic disease. There are currently no clear recommendations for the use of SPECT/CT in metastatic bone disease. Existing procedural guidelines from the Society of Nuclear Medicine (SNM) for SPECT/CT do not provide specific indications for use of SPECT/CT in bone scintigraphy, and there are currently no other guidelines for the use of SPECT/CT in bone scintigraphy that the author is aware of. The aim of this study was to investigate the additional value of SPECT/CT, and to identify the clinical indications for which SPECT/CT is most useful in patients with suspected bone metastases. Subjects and Methods: Forty-two patients with equivocal lesions on planar scintigraphy were prospectively recruited and planar imaging, SPECT, and SPECT/CT done on all patients. On reading of SPECT and then SPECT/CT, patients and individual lesions were classified as malignant, benign or equivocal. Radiological studies and available clinical information were also used during reading of scans. Review of clinical information, radiological studies and/or follow-up bone scans were used as gold standard. The results of the SPECT and SPECT/CT were compared in terms of proportion of equivocal findings and accuracy. Results: Forty-two patients with 189 skeletal lesions were examined. There was a diverse variety of primary tumours, although the majority had breast (n=22) or prostate cancer (n=8). Overall, SPECT/CT resulted in a significant reduction in the proportion of equivocal findings on both a patient-wise (p=0.0015) and lesion-wise basis (p<0.0001). The overall accuracy of SPECT/CT was significantly higher than that of SPECT on both a patient-wise (p=0.0026) and lesion-wise basis (p<0.0001). Generally SPECT/CT decreased the proportion of equivocal findings and increased the accuracy independent of the presence of bone pain, type of primary tumour, or skeletal region involved. SPECT/CT did not significantly improve the diagnostic confidence of readers in equivocal lumbar lesions although accuracy was significantly improved in this region. Conclusion: SPECT/CT performs significantly better than SPECT alone for the interpretation of equivocal planar lesions. There is no evidence that the benefit of SPECT/CT is dependent on the type of primary tumour or the presence of bone pain. Where resources are limited, SPECT/CT is indicated only in those patients in whom correct classification of the lesions in question is expected to alter the patient’s management. SPECT/CT images should be interpreted with the aid of a diagnostic radiologist or nuclear medicine physicians should acquire sufficient experience in Computed Tomographic image interpretation in order to optimise diagnostic benefit from SPECT/CT. / AFRIKAANSE OPSOMMING: Inleiding: Beenflikkergrafie word wyd vir die evaluering van metastatiese siekte gebruik. Daar bestaan tans geen duidelike aanbevelings vir die gebruik van Enkelfotonemissie rekenaartomografie gekombineer met rekenaartomografie (EFERT/RT, Engels SPECT/CT) in metastatiese beensiekte nie. Bestaande riglyne van die Amerikaanse Society of Nuclear Medicine (SNM) vir EFERT/RT gee nie spesifieke indikasies vir die gebruik van EFERT/RT in beenflikkergrafie nie, en daar is tans geen ander riglyne waarvan die outeur bewus is nie. Die doel van hierdie studie was om die bykomende waarde van EFERT/RT te ondersoek, en om dié kliniese indikasies waar EFERT/RT in pasiënte met vermoedelike beenmetastases mees nuttig sal wees, te identifiseer. Pasiënte en Metodes: Twee en veertig pasiënte met twyfelagtige letsels op planare skeletflikkergrafie is prospektief geselekteer en planare beelding, EFERT en EFERT/RT is op alle pasiënte gedoen. Tydens beoordeling van EFERT en daarna EFERT/RT beelde is pasiënte en individuele letsels as maligne, benigne of twyfelagtig geklassifiseer. Radiologiese studies en beskikbare kliniese inligting is ook tydens interpretasie van flikkergramme gebruik. Kliniese inligting, radiologiese studies en/of opvolg beenflikkergramme is as goue standaard gebruik. Die resultate van EFERT en EFERT/RT is ten opsigte van die aantal twyfelagtige bevindings en akkuraatheid vergelyk. Resultate: Twee en veertig pasiënte met 189 skeletale letsels is ondersoek. Daar was ‘n verskeidenheid van primêre tumore, maar die meerderheid van pasiënte het borsvi (n=22) of prostaatkanker (n=8) gehad. Die gebruik van EFERT/RT het gelei tot ‘n betekenisvolle afname in die aantal twyfelagtige bevindings, beide op ‘n pasiënt- en ‘n letselbasis (p=0.0015 en p<0.0001 onderskeidelik). Die algehele akkuraatheid van EFERT/RT was betekenisvol hoër as die van EFERT alleen, beide op pasiënt- en op letselbasis (p=0.0026 en p<0.0001 onderskeidelik). Oor die algemeen het EFERT/RT die aantal twyfelagtige letsels verminder en die akkuraatheid verhoog, ongeag die teenwoordigheid van beenpyn, die tipe primêre tumor of die area van die skelet wat betrokke was. In twyfelagtige lumbale letsels het EFERT/RT nie die diagnostiese vertroue van beoordelaars van flikkergramme verhoog nie, alhoewel die akkuraatheid vir hierdie gebied wel betekenisvol toegeneem het. Gevolgtrekking: EFERT/RT vaar betekenisvol beter as EFERT in die beoordeling van twyfelagtige letsels op planare beenflikkergramme. Daar is geen bewys dat die voordeel van EFERT/RT afhanklik is van die tipe primêre tumor of die teenwoordigheid van beenpyn nie. Waar hulpbronne beperk is, is EFERT/RT slegs aangedui in dié pasiënte waar verwag word dat korrekte klassifikasie van die betrokke letsel behandeling sal beïnvloed. EFERT/RT beelde behoort met die hulp van ‘n diagnostiese radioloog beoordeel te word, of kerngeneeskundiges moet genoegsame ondervinding in die interpretasie van rekenaartomografiebeelde hê om die diagnostiese voordeel van EFERT/RT optimaal te kan benut.

O propósito deste estudo foi avaliar a acurácia do exame de tomografia computadorizada multislice (TCM) e tomografia computadorizada por feixe cônico (TCFC) na identificação de lesões simuladas em mandíbula, em situações com e sem a presença de artefatos metálicos, em diversos protocolos de observação. Foram realizados exames de TCM e TCFC de mandíbulas secas, nas quais foram executadas perfurações simulando lesões. As imagens foram realizadas em dois momentos: na presença e na ausência de restaurações dentárias metálicas. Dois observadores, previamente calibrados, observaram as imagens avaliando-as quanto à presença ou ausência de lesão, número de lojas das lesões e a existência ou não de invasão medular. Os mesmos utilizaram programas de manipulação de imagens instalados em estações de trabalho independentes, para reconstruir as imagens nos seguintes protocolos de avaliação: axial, sagital + coronal, 3D, conjunto (axial+sagital+coronal+3D) e parassagital. A sensibilidade e especificidade (validade) da tomografia computadorizada multislice (64 cortes) (TCM) e da tomografia computadorizada por feixe cônico (TCFC) para diagnóstico de lesões ósseas (simuladas) em mandíbula, utilizando estação de trabalho independente foram demonstradas à medida que os valores encontrados foram superiores a 95% desde que com o protocolo de observação adequado. A influência de artefatos dentários metálicos foi pouco significativa na interpretação de lesões ósseas mandibulares, já que os valores de acurácia nas análises com e sem artefato foram bastante próximas. Os protocolos com aquisição por TCM sofreram mais influência dos artefatos do que os adquiridos por TCFC (valores sutilmente menores), exceto nas reconstruções em 3D, em que as originadas de aquisição por TCFC, apresentaram valores menores de acurácia. O melhor protocolo de pós processamento para interpretação de lesões ósseas simuladas foi o denominado RMP+3D. O protocolo que apresentou os piores resultados foi o que utilizou as reconstruções parassagitais. / The purpose of this study was to evaluate the accuracy of multislice computed tomography (MSCT) and cone-beam computed tomography (CBCT) in identification of simulated mandibular lesions in situations with and without metallic artifacts in several observation protocols. MSCT and CBCT examinations were performed in dry mandibles, in which holes were performed simulating lesions. The images were taken in two stages: in the presence and absence of metal dental restorations. Two observers, previously calibrated, observed the images by evaluating the images for the presence or absence of lesion, loci number and whether there were medullary invasion. Observers used image manipulation softwares, installed on independent workstations, to reconstruct the images in the following evaluation protocols: axial, sagittal + coronal, 3D, sets (axial+ coronal + sagittal + 3 D) and parasagittal. The sensitivity and specificity of MSCT (64 slices) and CBCT for diagnosis of simulated bone lesions in the mandible, using independent workstation were demonstrated as the values obtained were greater than 95% using the appropriate observation protocol. The influence of dental metallic artifacts was negligible in the interpretation of mandibular bone lesions, since the values of accuracy in the analysis with and without artifact were quite close. The images acquired with MCT suffered more influence of artifacts than the protocols acquired by TCFC, although the values were all high and quite close. Except for 3D reconstructions, which originated from the CBCT, showed the lowest accuracy. The best protocol for post-processing and interpretation of simulated bone lesions was called RMP +3 D. The protocol that showed the worst results was parasagital.

O propósito deste estudo foi avaliar a acurácia do exame de tomografia computadorizada multislice (TCM) e tomografia computadorizada por feixe cônico (TCFC) na identificação de lesões simuladas em mandíbula, em situações com e sem a presença de artefatos metálicos, em diversos protocolos de observação. Foram realizados exames de TCM e TCFC de mandíbulas secas, nas quais foram executadas perfurações simulando lesões. As imagens foram realizadas em dois momentos: na presença e na ausência de restaurações dentárias metálicas. Dois observadores, previamente calibrados, observaram as imagens avaliando-as quanto à presença ou ausência de lesão, número de lojas das lesões e a existência ou não de invasão medular. Os mesmos utilizaram programas de manipulação de imagens instalados em estações de trabalho independentes, para reconstruir as imagens nos seguintes protocolos de avaliação: axial, sagital + coronal, 3D, conjunto (axial+sagital+coronal+3D) e parassagital. A sensibilidade e especificidade (validade) da tomografia computadorizada multislice (64 cortes) (TCM) e da tomografia computadorizada por feixe cônico (TCFC) para diagnóstico de lesões ósseas (simuladas) em mandíbula, utilizando estação de trabalho independente foram demonstradas à medida que os valores encontrados foram superiores a 95% desde que com o protocolo de observação adequado. A influência de artefatos dentários metálicos foi pouco significativa na interpretação de lesões ósseas mandibulares, já que os valores de acurácia nas análises com e sem artefato foram bastante próximas. Os protocolos com aquisição por TCM sofreram mais influência dos artefatos do que os adquiridos por TCFC (valores sutilmente menores), exceto nas reconstruções em 3D, em que as originadas de aquisição por TCFC, apresentaram valores menores de acurácia. O melhor protocolo de pós processamento para interpretação de lesões ósseas simuladas foi o denominado RMP+3D. O protocolo que apresentou os piores resultados foi o que utilizou as reconstruções parassagitais. / The purpose of this study was to evaluate the accuracy of multislice computed tomography (MSCT) and cone-beam computed tomography (CBCT) in identification of simulated mandibular lesions in situations with and without metallic artifacts in several observation protocols. MSCT and CBCT examinations were performed in dry mandibles, in which holes were performed simulating lesions. The images were taken in two stages: in the presence and absence of metal dental restorations. Two observers, previously calibrated, observed the images by evaluating the images for the presence or absence of lesion, loci number and whether there were medullary invasion. Observers used image manipulation softwares, installed on independent workstations, to reconstruct the images in the following evaluation protocols: axial, sagittal + coronal, 3D, sets (axial+ coronal + sagittal + 3 D) and parasagittal. The sensitivity and specificity of MSCT (64 slices) and CBCT for diagnosis of simulated bone lesions in the mandible, using independent workstation were demonstrated as the values obtained were greater than 95% using the appropriate observation protocol. The influence of dental metallic artifacts was negligible in the interpretation of mandibular bone lesions, since the values of accuracy in the analysis with and without artifact were quite close. The images acquired with MCT suffered more influence of artifacts than the protocols acquired by TCFC, although the values were all high and quite close. Except for 3D reconstructions, which originated from the CBCT, showed the lowest accuracy. The best protocol for post-processing and interpretation of simulated bone lesions was called RMP +3 D. The protocol that showed the worst results was parasagital.