Symptomatic asymmetry in the first six months of life : differential diagnosis Asymmetry in infancy is a clinical condition with a wide variation in appearances -LRB- shape , posture , and movement -RRB- , etiology , localization , and severity . The prevalence of an asymmetric positional preference is 12 % of all newborns during the first six months of life . The asymmetry is either idiopathic or symptomatic . Pediatricians and physiotherapists have to distinguish symptomatic asymmetry -LRB- SA -RRB- from idiopathic asymmetry -LRB- IA -RRB- when examining young infants with a positional preference to determine the prognosis and the intervention strategy . The majority of cases will be idiopathic , but the initial presentation of a positional preference might be a symptom of a more serious underlying disorder . The purpose of this review is to synthesize the current information on the incidence of SA , as well as the possible causes and the accompanying signs that differentiate SA from IA . This review presents an overview of the nine most prevalent disorders in infants in their first six months of life leading to SA . We have discovered that the literature does not provide a comprehensive analysis of the incidence , characteristics , signs , and symptoms of SA . Knowledge of the presented clues is important in the clinical decision making with regard to young infants with asymmetry . We recommend to design a valid and useful screening instrument . Introduction The objective of this descriptive review is to determine and classify the possible causes of asymmetry seen in young infants who have an asymmetric head and/or body posture , as well as to present an overview of the nine most prevalent disorders in infants in the first six months of life leading to the diagnosis of symptomatic asymmetry -LRB- SA -RRB- . Asymmetric infants form an increasing and complicated group of children seen by professionals from various clinical specialties , such as well baby clinic physicians , pediatricians , pediatric physiotherapists , orthopedic surgeons , and plastic surgeons -LSB- 4 , 6 , 19 , 37 , 50 , 61 -RSB- . Asymmetry in infancy is a mostly benign symptom , but in this early phase of life , the differential diagnostics are extensive . The background of the professional influences the way in which associated clinical problems are evaluated . A screening instrument would be helpful . The first step in this process is to synthesize the current information in the literature about differential diagnostics . Twelve percent of all Dutch newborns develop a positional preference in the first few months of life , different from the physiological asymmetry -LSB- 6 -RSB- . A `` positional preference '' is defined as a condition in which the infant 's head is turned toward one side most of the time and active movement to the other side is restricted -LSB- 4 , 6 -RSB- . About 25 % of these infants -LRB- approximately 5,000 a year in the Netherlands -RRB- are referred to pediatric physical therapists -LSB- 6 -RSB- . Asymmetry in infancy is a clinical condition with a wide variation in appearances -LRB- shape , posture , and movement -RRB- , etiology , localization , and severity . From the referred infants , the asymmetry is either idiopathic or symptomatic , and originates ante - and/or postpartum -LSB- 37 , 48 , 50 , 51 , 61 -RSB- . In case of an idiopathic asymmetry -LRB- IA -RRB- , the etiology is uncertain ; environmental factors play a major role in the development of the asymmetry -LSB- 6 , 34 , 35 , 48 , 62 -RSB- . In SA , an underlying disorder , disease , or dysfunction causes the asymmetry . The majority of cases will be idiopathic , but an initial presentation of positional preference might be a symptom of a serious underlying problem . In the last decade , many studies on the appearances of IA have been published . If the focus in diagnostics and pattern recognition is on IA , there is a chance that an SA will be missed -LSB- 3 , 20 -RSB- . When examining young infants with a positional preference , differentiating SA from IA is necessary to determine the prognosis and to choose appropriate intervention strategies . This review will address the following question : which diagnoses , incidence rates , signs , and symptoms are described in the literature and are thought to cause a symptomatic asymmetrical posture or movement pattern in infants during their first six months of life ? Methods Search strategy This review is based on a comprehensive literature search on SA . The following strategy is used : peer-reviewed literature on this topic in journals with a science citation index was searched , as well as clinical textbooks from the various clinical specialties . Computerized bibliographic databases were searched -LRB- PubMed , Pedro , Cinahl , and Cochrane Controlled Trials Register -RRB- , and related papers and their references . General keywords used were : asymmetry , plagiocephaly , torticollis , posture , scoliosis , -LRB- differential -RRB- diagnosis , and screening . The search then focused on specific diagnoses that might cause asymmetry in infancy condition with the keywords : etiology , tumors , disorders -LRB- related to -RRB- vision , hearing , central nervous , or musculoskeletal system , obstetric complications , brachial plexus palsy/lesion , clinical syndromes -LRB- Grisel , Sandifer -RRB- , congenital anomalies and syndromes , gastroesophageal reflux , developmental dysplasia of the hip , paroxysmal torticollis , -LRB- birth -RRB- trauma , and clavicle fracture . Finally , we focused on the incidence and prevalence . The search was limited to citations that included : `` all infants , birth -- 23 months , '' had an abstract , were written in English , and the search terms were in the title or abstract . The year of publication was not restricted . When more papers on the same subject were found , the most current studies were chosen . Only diagnoses that could be observed in infants in the first six months of life were included . Unique case reports and innocuous abnormalities that require no specific treatment were not included . Results The prevalence and/or incidence of the various medical diagnoses leading to SA was not always documented . Some disorders had no consistency in their reported incidence rates . The majority of children with a positional preference or asymmetry during the first six months of life are diagnosed with an IA -LSB- 4 , 6 , 34 , 35 , 37 , 48 , 50 , 51 -RSB- . Table 1 shows a selection of the most frequently detected disorders causing an SA . Table 1Disorders related to symptomatic asymmetry -LRB- SA -RRB- from the literature searchDisorders with known incidenceIncidence/1 ,0001 . Developmental dysplasia of the hip -LRB- DDH -RRB- 402 . Perinatal fracture of the clavicle353 . Congenital muscular torticollis -LRB- CMT -RRB- 204 . Obstetric brachial plexus palsy45 . Central nervous system disorders26 . Craniosynostosis/lambdoid suture0 .03 Remaining groups of disorders7 . Congenital abnormalities or malformations Musculoskeletal Chromosomal8 . Sensory systems Ocular disorders Hearing disorders9 . Acquired asymmetry postpartum in one of the remaining systems -LRB- non musculoskeletal -RRB- In the last decade , discussion on positional preference leading to deformational plagiocephaly -LRB- DP -RRB- has increased substantially . A relatively high number of hits found during a search in January 2008 within PubMed resulted in the following : asymmetry -LRB- 811 -RRB- , plagiocephaly -LRB- 206 -RRB- , torticollis -LRB- 225 -RRB- , posture -LRB- 405 -RRB- , and scoliosis -LRB- 623 -RRB- . However , when combined with `` differential diagnosis '' or `` screening , '' the result decreased to less than 20 each . Differential diagnosis from craniosynostosis was often described -LSB- 24 , 33 , 36 , 51 -RSB- . The main designs were retrospective or prospective descriptive studies and reviews . In diagnoses with a low incidence , the studies were predominantly case reports . All diagnoses were classified according to the International Classification of Diseases -LSB- 1 -RSB- . The results of the literature search are presented below , starting with the diagnosis with the highest incidence rate . Developmental dysplasia of the hip Developmental dysplasia of the hip -LRB- DDH -RRB- has a high rate of co-morbidity with congenital muscular torticollis -LRB- 8 -- 20 % -RRB- -LSB- 11 -RSB- and , to a lesser extent , with postural torticollis or scoliosis -LSB- 50 -RSB- . The reported incidence rate in the Netherlands ranged from 3 to 4 % of all newborns -LSB- 4 , 11 , 48 -RSB- , with 80 % being unilateral -LSB- 5 , 56 -RSB- . The clinical signs which are described include asymmetry in hip abduction and leg length and/or asymmetrical skin folds in the inguinal and upper thigh region . The strong association with other asymmetries warrants a thorough screening on the signs of developmental dysplasia of the hip in infants with an asymmetry . Perinatal fracture of the clavicle A fracture of the clavicle during birth may induce a positional preference in the first weeks of life and , as such , may cause an asymmetry . A perinatal fracture can be an option in the differential diagnostics of asymmetry during the first weeks of life . A co-incidence with other perinatal injuries -LRB- like brachial plexus injury -RRB- was described by Perlow et al. -LSB- 49 -RSB- . The obstetric brachial plexus lesion is described separately . The incidence varies between 0.1 and 3.5 % -LSB- 28 , 40 , 49 , 54 -RSB- , and these fractures usually consolidate within 3 weeks without complications . The clinical presentation can be asymptomatic . When symptomatic , signs include : decreased or absent movement and pain , or tenderness on movement of the arm on the affected side and palpable irregularity along the clavicle -LSB- 54 -RSB- . Congenital muscular torticollis Congenital muscular torticollis -LRB- CMT -RRB- is frequently described in the literature . Unilateral fibrosis or thickening of and tightness in the sternocleidomastoid muscle can cause a characteristic posture of the head and restricted neck movements . The etiology of the pseudo-tumor or mass is unclear -LSB- 10 , 11 , 19 , 58 -RSB- . A compartment syndrome due to intra-uterine malposition is the most frequently mentioned etiological hypothesis -LSB- 10 , 12 , 19 , 39 -RSB- . An association with birth trauma and breech presentation is mentioned , but the evidence is weak , since CMT is also seen in infants born via a cesarean section -LSB- 11 , 32 -RSB- . A pseudo-tumor can be palpated in the second or third week after birth . Incidence rates of CMT vary between 0.3 and 2 % -LSB- 10 -- 12 , 19 , 58 -RSB- . Ultrasound screening soon after birth has indicated that the incidence rate could be 3.9 % . This screening method tends to be especially sensitive in detecting occult cases of fibrosis -LSB- 10 -RSB- . Fibroids of the uterus and other intrauterine tumors are described as a possible etiology to an atrophy of the sternocleidomastoid muscle of the child -LSB- 18 -RSB- . This phenomenon can cause a unilateral muscular dysfunction and a strong imbalance between both muscles . The distinction between CMT and postural torticollis is not always clear -LSB- 15 -RSB- . A CMT is primarily a condition with a structural fibroid shortening of the sternocleidomastoid muscle , visible and palpable in the first weeks of life , as opposed to a postural torticollis that occurs secondary to a positional preference and a DP -LSB- 6 , 37 , 48 , 51 , 61 -RSB- . Obstetric brachial plexus palsy Palsy of the brachial plexus during delivery is caused by traction or compression of the plexus during labor . In most cases , the upper brachial plexus is affected ; in 15 % of the patients , hand function is also impaired . The described incidence is 0.1 -- 0.4 % -LSB- 31 , 49 , 52 -RSB- . The extent of the neural damage becomes evident during the first six months of life -LSB- 52 -RSB- , although in severe cases , the inactivity of the extremity is observed from birth onwards . Timely recognition of severe cases is important , since neurosurgical intervention can enhance future capacities . Between 20 and 25 % of the infants experience persistent functional impairments -LSB- 31 -RSB- . Central nervous system disorders Cerebral palsy -LRB- CP -RRB- syndromes , in particular , spastic unilateral CP , are neurological disorders that can cause asymmetry -LSB- 3 , 7 -RSB- . Serious disorders of the central nervous system are generally easy to recognize , but a CP may also be discrete with subtle features . Early diagnosis , before the age of six months , might be difficult -LSB- 45 , 57 -RSB- . The neurodevelopmental -LRB- motor -RRB- behavior is an important issue in early recognition : persistent infantile reflexes and abnormal muscle tone , motor delay , abnormal spontaneous movement patterns -LRB- especially `` general movements '' -RRB- , and poor postural control are more or less predictors of CP -LSB- 25 , 45 , 46 -RSB- . In a review on the epidemiology of CP , the world-wide prevalence of all types of CP is estimated at 0.2 % -LSB- 43 -RSB- . Hypotonia and developmental delay were also mentioned as causes for developing positional preference and DP . A neurological disorder might be the underlying problem , but it is not always diagnosed at this young age -LSB- 3 , 7 , 51 -RSB- . Craniosynostosis Craniosynostosis , the premature fusion of one or more cranial sutures , is most frequently described in relation to asymmetry and plagiocephaly , possibly as a result of the over-referral of infants with deformational non-synostotic DP to craniofacial or plastic surgery clinics . Primary craniosynostosis is either simple or compound and part of a genetic syndrome -LSB- 36 -RSB- . Premature closing of one lambdoid suture is the most frequently mentioned differential diagnosis of DP -LSB- 24 , 33 , 36 -RSB- . The incidence of this single suture craniosynostosis is rare -LRB- 1 -- 3 cases to 100,000 newborns -RRB- -LSB- 37 , 42 -RSB- and can be clinically differentiated from DP by four major signs : from the vertex view , a trapezoid head shape can be observed , a palpable unilateral ridge , bulging of the unilateral mastoid , and an asymmetric skull base with tilt to the ipsilateral side -LSB- 24 , 33 , 42 -RSB- . The impact of the premature closure of cranial sutures in complex craniosynostosis is impressive : strong progressive deformation of the skull , risk of increasing intracranial pressure , and developmental problems . When evident , timely surgical intervention is warranted -LSB- 24 , 33 , 36 , 50 , 51 -RSB- . The following three categories are groups of disorders . Clear incidence rates could not be found . Congenital abnormalities or malformations Musculoskeletal congenital malformations must be considered in an asymmetry that is present immediately after birth -LSB- 3 , 7 -RSB- . Well-known malformations are those of the spine , such as a Klippel-Feil syndrome , hemi-vertebrae , and a hemi-atlas -LSB- 22 , 38 , 64 -RSB- . Exceptional phenomena are hypoplasia or aplasia of the face , neck , or trunk muscles -LSB- 2 -RSB- . Patients may show defects in other systems as well , such as syndactyly , deafness , or a congenital heart disease . The co-incidence of defects may be an important sign of a syndrome . An asymmetric development or posture can be an associated finding in a variety of syndromes and abnormalities . These features are often present immediately after birth , but will not always be discovered until a second stage -LSB- 64 -RSB- . Local abnormalities , such as a vascular ring -LRB- around the trachea -RRB- or tracheomalacia , are occasionally an indirect cause of an asymmetric posture -LSB- 60 -RSB- . Disorders in sensory systems In the screening of infants with asymmetry , eye movement and/or vision and hearing disorders must be considered . Infants with congenital nystagmus and restrictive or paralytic strabismus may use anomalous head positions to maximize visual function -LSB- 26 , 47 , 63 -RSB- . No clear incidence rates were found . A predictive factor for an ocular origin of torticollis is the family history of ocular problems , in particular , congenital nystagmus . The ocular pathology may be subtle . In case of doubt , infants must be referred to an ophthalmologist -LSB- 63 -RSB- . Theoretically , a unilateral hearing disorder can induce a positional preference in young infants . In the literature search , no match was found for hearing loss and torticollis , except in syndromes such as Klippel-Feil or Moebius . A connection between ear malformation and hearing loss is mentioned -LSB- 23 -RSB- . Acquired asymmetry , non-musculoskeletal A number of disorders in systems other than the musculoskeletal system can cause a postpartum asymmetry , but the asymmetry is not the only symptom . The disorders have in common that their symptoms are not stable and occur some time after birth . The signs and symptoms can be seen as so-called `` red flags '' and require immediate medical evaluation . It may be secondary to a trauma -LSB- 27 -RSB- or to inflammatory conditions , such as pharyngitis -LSB- 8 , 13 , 29 , 55 -RSB- . Grisel syndrome -LRB- a non-traumatic atlanto-axial rotatory subluxation following infections of the upper respiratory tract -RRB- is often described , but never under the age of six months -LSB- 7 , 19 , 29 -RSB- . Another cause can be related to the cardio-respiratory or the digestive system , such as Sandifer syndrome -LRB- fluctuating asymmetry with abnormal body movements and contortions of the neck , associated with gastroesophageal reflux -RRB- -LSB- 9 , 17 , 21 -RSB- . The most alarming causes of asymmetry are related to neurological syndromes , such as syringomyelia , epilepsy , high intracranial pressure , postencephalitic syndromes , or life-threatening tumors of the central nervous system -LSB- 3 , 7 , 12 , 19 , 20 , 30 -RSB- . These disorders are mainly described in case studies , without proven incidence rates . The signs and symptoms of these non-musculoskeletal causes are described in Table 2 . Table 2Signs and symptoms of acquired symptomatic asymmetry disorders with a low incidenceSigns and symptomsHints for disordersGeneral historyHeavy painRetro-pharyngeal abscess -LSB- 13 -RSB- Vomiting/drowsinessIncreased intracranial pressure -LSB- 30 -RSB- Lethargy/irritabilityTumor -LSB- 12 , 30 -RSB- , intracranial injury -LSB- 27 -RSB- TraumaIntracranial injury -LSB- 27 -RSB- Seizures/convulsionsEpilepsy ; increased intracranial pressure ; Sandifer syndrome -LSB- 17 -RSB- Acute onsetInfection , abscess -LSB- 13 -RSB- ; Grisel syndrome -LRB- > 6 months -RRB- -LSB- 29 , 55 -RSB- Stridor , dyspneaVascular ring -LSB- 60 -RSB- RefluxSandifer syndrome ; pathological gastroesophageal reflux -LSB- 17 -RSB- FeverInfection , abscess -LSB- 13 -RSB- Specific examinationSunset phenomenonIncreased intracranial pressureBulging anterior fontanelIncreased intracranial pressure , intracranial injury -LSB- 27 -RSB- Abnormal courseIncreasing head tiltInfection -LSB- 13 -RSB- ; tumor -LSB- 12 , 30 -RSB- Recurrent episodesBenign paroxysmal torticollis -LSB- 9 , 21 -RSB- Discussion Asymmetry in infancy is a condition with a high prevalence in infants in the first six months of life . In the majority of cases , the origin is idiopathic and is often related to environmental factors -LSB- 6 , 15 , 34 , 35 , 37 , 62 -RSB- . This review addresses the possible causes , incidence rates , and symptoms of symptomatic asymmetries due to an underlying disorder , dysfunction , or disease . Not all of the incidence rates could be found , while some inconsistencies were observed in the current literature . The disorders with a high prevalence are well described in epidemiologic studies . The rarer diseases were , most of the time , documented in case reports without incidence rates . The incidence rates mentioned in the studies are inconsistent because of different opinions regarding the operationalization and assessment of the SA . Frequently , psychometric properties of instruments and concepts have not been described or evaluated . Variations in incidence rates -LRB- e.g. CMT -RRB- are inevitable , considering the variety in inclusion criteria and diagnostic tests used in the studies . The sequence in estimated incidence rates , as proposed in Table 1 , is open to debate . A clear description of signs and symptoms was not always presented in the literature . The variety in the etiology of asymmetry is considerable . The level of evidence of the included studies varies . Literature of more than 10 years ago mainly described underlying causes of SA , in particular , non-muscular torticollis -LSB- 3 , 7 -RSB- . They still turned out to be useful in establishing criteria for differential diagnostic screening and are widely cited in current studies . However , an update regarding new developments in studies on infant asymmetry is needed . The exponential increase of plagiocephaly in the last decade , related to the recommendations to put babies on their back to sleep , is reflected in the objectives of recent studies -LSB- 4 , 6 , 37 , 41 -RSB- . They mainly focused on IA and its predispositions , with little attention to SA . A number of recent papers described features to distinguish craniosynostosis from DP . Although craniosynostosis has a very low incidence , craniofacial clinics are deluged with infants with DP -LSB- 14 , 15 , 37 -RSB- . One of the positive effects of this situation is that authors from this background described useful clinical diagnostic criteria for craniosynostosis . van Vlimmeren et al. -LSB- 61 -RSB- stated in their review on diagnostic strategies , that asymmetry in infancy is a diagnosis with a large spectrum of features and a multifactorial etiology without consensus on definition , nomenclature , or classification . In the present review , a classification by virtue of etiology is proposed . The dichotomy , symptomatic versus idiopathic , is often used in medicine -LSB- 16 , 44 , 53 , 59 -RSB- and fits well with this health problem , since a large number of children have unexplained asymmetry . Although flow diagrams for diagnostic strategies are presented in some reviews -LSB- 3 , 7 , 15 , 19 , 61 -RSB- , clear clinical diagnostic criteria that could be used were not mentioned . The criteria found in the present review might be considered in a future study . An expert validation , such as a Delphi study with clinical experts , could be a next step towards establishing clinical diagnostic criteria as warning flags in young infants with IA or SA . This review presents an overview of the most common disorders underlying SA in infants less than six months of age . We have discovered that the literature does not provide a comprehensive analysis of the incidence , characteristics , signs , and symptoms of SA . Knowledge of the presented clues is important in the clinical decision making with regard to young infants with asymmetry . The endpoint of this review may be a starting document for the creation of a protocol , but it needs additional studies in order for it to become a valid and useful screening instrument .

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O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O 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O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O B O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O

infant
symptomatic asymmetry
etiology
differential diagnosis
screening
torticollis
plagiocephaly


Thoracic

cord

compression

caused

by

disk

herniation

in

Scheuermann

's

disease

We

present

the

case

of

a

male

with

Scheuermann

's

disease

and

significant

neurological

deficit

due

to

thoracic

disk

herniation

at

the

apex

of

kyphosis

He

was

treated

with

an

anterior

decompression

anterior

and

posterior

fusion

in

the

same

setting

using

plate

cage

and

a

segmental

instrumentation

system

The

patient

had

an

excellent

outcome

with

complete

neurological

recovery

Introduction

Scheuermann

's

disease

-LRB-

juvenile

kyphosis

dorsalis

-RRB-

is

a

structural

kyphosis

of

the

thoracic

spine

initially

described

by

Scheuermann

in

-LSB-

-RSB-

It

occurs

commonly

in

adolescents

-LRB-

of

the

general

population

-RRB-

and

in

most

cases

is

characterized

by

minimal

deformity

and

few

clinical

symptoms

Scheuermann

's

disease

is

rarely

associated

with

neurological

complications

-LSB-

-RSB-

The

purpose

of

the

present

paper

is

to

present

the

case

of

a

patient

with

Scheuermann

's

disease

and

severe

neurological

deficit

due

to

a

thoracic

disc

hernia

at

the

level

of

kyphos

to

review

the

literature

and

compare

with

previously

published

similar

cases

Case

report

A

male

was

admitted

with

a

severe

spastic

paraparesis

He

had

gradually

developed

a

gait

disorder

and

bilateral

numbness

of

lower

limbs

in

the

past

months

During

that

period

his

symptoms

deteriorated

rapidly

He

was

unable

to

walk

and

a

week

before

his

admission

he

developed

spastic

paraplegia

There

was

no

history

of

trauma

Clinical

examination

revealed

spastic

paraparesis

below

The

superficial

sensation

was

diminished

below

the

dermatome

He

had

a

muscle

strength

of

grade

II

according

to

the

Medical

Research

Council

-LRB-

MRC

-RRB-

scale

A

barely

detectable

contraction

could

be

seen

below

the

knees

by

palpation

over

the

muscles

-LRB-

on

the

MRC

scale

-RRB-

Plantar

responses

-LRB-

Babinski

sign

-RRB-

were

present

on

both

sides

Knee

and

ankle

reflexes

were

brisk

bilaterally

clonus

was

present

in

both

ankles

as

well

Patient

had

hypalgesia

and

decreased

temperature

sensation

Light

touch

and

pin

prick

sensation

were

diminished

over

both

lower

limbs

and

absent

from

the

knees

downward

Rectal

tone

and

sensation

while

urinating

were

decreased

All

laboratory

findings

were

normal

including

an

investigation

for

systemic

diseases

Plain

radiographs

of

the

spine

in

standing

position

revealed

anterior

wedging

of

more

than

of

several

adjacent

vertebrae

-LRB-

-RRB-

at

the

apex

of

the

kyphosis

and

vertebral

endplate

irregularities

The

thoracic

kyphosis

from

to

measured

-LRB-

Fig.

-RRB-

These

findings

are

in

agreement

with

the

criteria

for

diagnosis

of

Scheuermann

's

disease

A

magnetic

resonance

imaging

scan

revealed

thoracic

disc

heniation

with

spinal

cord

compression

at

level

-LRB-

apex

of

the

kyphosis

-RRB-

The

intervertebral

spaces

from

to

were

also

very

narrow

and

the

vertebral

bodies

had

an

anterior

wedging

-LRB-

Figs.

-RRB-

Fig.

b

Anteroposterior

and

lateral

radiographs

of

the

thoracic

spine

in

standing

position

at

the

time

of

admission

The

thoracic

kyphosis

from

to

is

°F

ig

b

Magnetic

resonance

imaging

scan

revealed

thoracic

disc

herniation

with

spinal

cord

compression

at

level

-LRB-

apex

of

the

kyphosis

-RRB-

Fig.

reconstruction

computed

tomography

of

the

thoracic

spine

preoperatively

Surgical

treatment

was

decided

based

on

the

severity

of

the

neurological

deficit

A

right

seventh

rib

transthoracic

approach

to

the

spinal

column

was

performed

followed

by

decompression

at

level

A

disc

fragment

was

found

and

removed

behind

the

thoracic

body

of

We

performed

an

anterior

fusion

using

plate

screws

an

interbody

titanium

cage

and

also

a

posterior

fusion

from

to

using

a

double-rod

multihook

and

transpedicular

screws

segmental

instrumentation

system

Bone

grafts

were

applied

between

and

and

intertransversaly

from

to

-LRB-

Fig.

-RRB-

Fig.

b

Postoperative

anteroposterior

and

lateral

radiographs

of

the

thoracic

spine

Note

the

anterior

and

posterior

spinal

fusion

Postoperatively

the

patient

had

a

surprisingly

rapid

improvement

of

the

neurological

deficit

Four

weeks

after

the

operation

he

could

walk

steadily

and

months

later

his

neurological

examination

was

entirely

normal

At

years

follow-up

the

patient

had

a

normal

gait

he

was

symptoms

free

and

there

was

no

increase

of

the

spinal

deformity

Discussion

Scheuermann

in

-LSB-

-RSB-

described

a

condition

which

he

called

juvenile

dorsal

kyphosis

distinguishing

it

from

the

more

common

postural

kyphosis

The

etiology

of

Scheuermann

's

disease

is

unknown

Scheuermann

proposed

that

the

kyphosis

resulted

from

avascular

necrosis

of

the

ring

apophysis

of

the

vertebral

body

-LSB-

-RSB-

Schmorl

suggested

that

the

vertebral

wedging

was

caused

by

herniation

of

disc

material

into

the

vertebral

body

-LRB-

Schmorl

's

nodes

-RRB-

According

to

Ippolito

and

Ponseti

-LSB-

-RSB-

a

biochemical

abnormality

of

the

collagen

and

matrix

of

the

vertebral

endplate

cartilage

may

be

another

contributing

factor

Bradford

et

al.

-LSB-

-RSB-

claimed

that

osteoporosis

may

be

responsible

for

the

development

of

Scheuermann

's

disease

Mechanical

factors

and

repetitive

trauma

have

been

also

considered

to

play

a

significant

role

in

the

appearance

of

the

disease

-LSB-

-RSB-

Case

reports

in

monozygotic

twins

support

the

theory

that

there

is

also

a

genetic

contribution

-LSB-

-RSB-

In

conclusion

the

etiology

of

Scheuermann

's

disease

remains

unclear

and

probably

is

multifactorial

The

criteria

for

the

diagnosis

of

Scheuermann

's

disease

are

-LRB-

-RRB-

more

than

of

wedging

of

at

least

three

adjacent

vertebrae

at

the

apex

of

the

kyphosis

-LRB-

-RRB-

endplates

irregularities

and

-LRB-

-RRB-

a

thoracic

kyphosis

of

more

than

-LSB-

-RSB-

Our

patient

had

typical

roentgenografic

features

of

Scheuermann

's

disease

and

his

kyphosis

was

from

to

Neurological

complications

in

Scheuermann

's

disease

are

rare

-LSB-

-RSB-

Three

different

types

of

neural

compression

have

been

reported

-LRB-

-RRB-

extradural

spinal

cyst

-LRB-

-RRB-

compression

of

the

cord

at

the

apex

of

the

kyphos

and

-LRB-

-RRB-

disk

hernia

at

the

apex

of

the

kyphos

-LSB-

-RSB-

To

the

best

of

our

knowledge

only

cases

fall

in

the

last

category

-LSB-

-RSB-

Data

of

all

these

cases

are

presented

in

Table

Table

of

Scheuermann

's

disease

causing

spinal

cord

compression

as

the

result

of

thoracic

disc

herniationReferencesLevelAge/sexFindingsAppro

achProcedureResults

-LRB-

follow

up

-RRB-

Muller

-LSB-

-RSB-

MParaplegiaNot

reportedNot

complete

recoveryVan

Landingham

-LSB-

-RSB-

MSpastic

paraparesis

no

sphincter

laminectomyComplete

recovery

-LRB-

months

-RRB-

Roth

et

al.

-LSB-

-RSB-

MSpastic

laminectomyParaplegiaTurinese

and

Raven

-LSB-

-RSB-

MSpastic

paraparesis

sphincter

dysfunctionBed

rest

Minerva

jacketComplete

recovery

Bradford

and

Garcia

-LSB-

-RSB-

MSpastic

laminectomyResidual

hypereflexia

-LRB-

months

-RRB-

Ryan

and

Taylor

-LSB-

-RSB-

MSpastic

partial

vertebrectomy

anterior

spinal

fusionSpastic

paraparesis

-LRB-

months

-RRB-

Yablon

et

al.

-LSB-

-RSB-

MSpastic

paraparesis

sphincter

discectomy

and

fusionComplete

recovery

-LRB-

months

-RRB-

Lesoin

et

al.

-LSB-

-RSB-

-LRB-

six

cases

-RRB-

FMonoparesis

-LRB-

left

-RRB-

laminectomyNot

complete

recovery

-LRB-

months

-RRB-

FSpastic

discectomySmall

motor

deficit

-LRB-

months

-RRB-

MMonoparesis

-LRB-

right

-RRB-

PPosterior

spinal

fusionNot

complete

recovery

-LRB-

months

-RRB-

MLower

back

pain

Babinski

's

sign

-LRB-

right

-RRB-

discectomy

posterior

spinal

fusionComplete

recovery

-LRB-

months

-RRB-

MLower

back

pain

slight

motor

deficit

-LRB-

left

-RRB-

discectomy

posterior

spinal

fusionComplete

recovery

-LRB-

months

-RRB-

MSpastic

discectomy

posterior

spinal

fusionSmall

motor

deficit

-LRB-

months

-RRB-

Bohlman

and

Zdeblick

-LSB-

-RSB-

-LRB-

two

cases

-RRB-

FMonoparesis

Back

and

leg

pain

-LRB-

for

years

-RRB-

discectomy

and

fusionComplete

recovery

-LRB-

months

-RRB-

FBack

and

leg

pain

-LRB-

for

years

-RRB-

discectomy

and

fusionSignificant

pain

relief

-LRB-

months

-RRB-

Stambough

et

al.

-LSB-

-RSB-

MSpastic

discectomy

anterior

spinal

fusion

Complete

recovery

-LRB-

months

-RRB-

Bhojraj

and

Dandawate

-LSB-

-RSB-

-LRB-

three

cases

-RRB-

MSpastic

paraparesis

urinary

laminectomy

posterior

interbody

fusion

Complete

recovery

-LRB-

months

-RRB-

MSpastic

paraparesis

urinary

laminectomy

posterior

interbody

fusionComplete

recovery

-LRB-

months

-RRB-

FSpastic

laminectomy

posterior

interbody

fusionTransient

worsening

postoperatively

subsequently

complete

recovery

-LRB-

months

-RRB-

Chiu

and

Luk

-LSB-

-RSB-

FSpastic

discectomy

spinal

fusion

Small

motor

deficit

-LRB-

months

-RRB-

This

report

-LRB-

-RRB-

MRapidly

progressive

spastic

paraparesis

finally

spastic

discectomy

anterior

fusion

posterior

fusionComplete

recovery

-LRB-

months

-RRB-

M

Male

F

female

P

posterior

T

transthoracic

CT

costotransversectomy

PL

posterolateral

Despite

the

fact

that

this

condition

has

a

uniform

sex

distribution

-LSB-

-RSB-

only

of

all

cases

were

female

Males

with

Scheuermann

's

disease

are

at

greater

risk

for

the

development

of

spinal

cord

compression

in

the

second

decade

of

life

-LSB-

-RSB-

This

is

in

agreement

with

our

case

-LRB-

male

years

old

-RRB-

This

difference

between

the

sexes

is

probably

due

to

the

fact

that

males

have

more

longitudinal

spinal

growth

than

females

and

their

maximum

growth

in

trunk

length

as

well

as

the

maximum

deformity

of

the

kyphosis

occurs

about

years

later

In

all

cases

in

which

the

degree

of

deformity

was

reported

the

average

angle

was

only

The

severity

of

the

neurological

complications

had

no

obvious

correlation

with

the

magnitude

of

the

deformity

-LSB-

-RSB-

In

our

case

the

deformity

was

Lonstein

et

al.

-LSB-

-RSB-

found

that

in

cases

with

neurological

deficits

secondary

to

spinal

deformity

-LRB-

what

ever

the

etiology

-RRB-

the

average

angle

of

kyphosis

was

He

suggested

that

the

greater

the

angle

of

kyphosis

the

greater

the

risk

of

neurological

impairment

Neurological

complications

are

less

likely

to

occur

when

the

deformity

is

present

over

a

large

number

of

segments

instead

of

sharply

angular

deformities

Disc

ruptures

tend

to

occur

at

the

apex

of

the

thoracic

kyphosis

-LSB-

-RSB-

The

majority

of

them

have

occurred

at

or

at

This

is

also

confirmed

by

our

case

-LRB-

at

-RRB-

It

is

interesting

that

a

relatively

small

disc

herniation

such

as

in

our

case

produces

such

a

major

neurological

deficit

Factors

that

may

influence

the

onset

of

cord

compromise

are

the

tenuous

vascularization

and

the

relatively

small

canal

diameter

of

the

thoracic

cord

-LSB-

-RSB-

Additionally

in

young

patients

the

disc

material

is

not

degenerated

and

can

act

as

a

solid

mass

Bradford

and

Garcia

-LSB-

-RSB-

suggested

that

the

high

incidence

of

Schmorl

's

nodes

in

Scheuermann

's

disease

can

prevent

disc

herniation

by

decompressing

the

disc

space

In

our

case

there

were

no

Schmorl

's

nodes

either

at

this

level

or

at

any

other

level

Surgical

treatment

is

indicated

in

the

cases

of

Scheuermann

's

disease

with

acute

cord

compression

and

generally

combines

anterior

release

with

posterior

instrumentation

and

fusion

A

posterior

decompression

is

ineffective

because

the

compressive

force

is

acting

from

the

front

-LSB-

-RSB-

Although

some

authors

have

advocated

posterior

laminectomy

and

decompression

Patterson

and

Arbit

-LSB-

-RSB-

showed

that

of

patients

undergoing

laminectomies

for

thoracic

disc

herniations

either

had

no

relief

or

deteriorated

For

the

reported

cases

with

thoracic

disc

herniation

and

Scheuermann

's

disease

six

patients

were

treated

with

anterior

spinal

fusion

four

patients

with

laminectomy

four

with

posterior

spinal

fusion

three

patients

with

interbody

fusion

and

pedicular

screw

plate

fixation

and

one

patient

was

treated

with

discectomy

without

spinal

fusion

Only

one

patient

was

treated

conservatively

with

bed

rest

and

Minerva

jacket

without

any

decompressive

surgery

-LSB-

-RSB-

In

one

case

-LSB-

-RSB-

the

treatment

was

not

reported

If

a

significant

or

progressive

kyphosis

i.e.

or

more

exists

a

combined

posterior

spinal

fusion

and

instrumentation

should

be

considered

-LSB-

-RSB-

Due

to

the

age

of

the

described

patient

and

to

the

degree

of

kyphosis

we

performed

discectomy

decompression

anterior

and

also

posterior

fusion

using

a

double-rod

multihook

and

transpedicular

screws

segmental

instrumentation

system

The

majority

of

the

reported

cases

had

good

results

In

out

of

cases

the

patients

had

complete

recovery

while

only

in

one

case

the

final

outcome

was

paraplegia

-LSB-

-RSB-

Our

patient

had

an

excellent

result

with

complete

recovery

in

months

At

the

final

follow-up

years

postoperatively

he

is

neurologically

entirely

normal

and

the

spinal

fusion

is

solid

This

case

is

interesting

because

of

the

severity

of

the

symptoms

The

patient

had

a

progressive

bilateral

spastic

paraparesis

and

finally

a

spastic

paraplegia

Spastic

paraparesis

was

the

most

common

symptom

in

all

cases

but

neurological

symptoms

were

not

so

severe

to

result

in

paraplegia

Only

one

case

had

paraplegia

as

the

described

patient

-LSB-

-RSB-

It

is

impressive

that

despite

the

significant

neurological

deficit

there

was

a

complete

recovery

It

seems

that

when

symptomatic

compression

of

the

spinal

cord

occurs

surgery

is

the

best

option

Conclusion

Thoracic

disc

herniation

is

an

extremely

rare

complication

of

Scheuermann

's

disease

resulting

in

cord

compression

and

marked

neurological

deficit

most

commonly

in

young

patients

This

rare

form

of

spinal

cord

compression

once

demonstrated

should

be

treated

as

soon

as

possible

with

surgical

decompression

and

stabilization

of

the

spine

anteroposteriorly

O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O 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O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O

thoracic disc herniation
spinal cord compression
spastic paraparesis


New

coil

concept

for

endoluminal

MR

imaging

Our

aim

was

to

conduct

a

prospective

study

to

evaluate

staging

accuracy

of

a

new

coil

concept

for

endoluminal

magnetic

resonance

imaging

-LRB-

MRI

-RRB-

on

ex

vivo

gastric

carcinomas

Twenty-eight

consecutive

patients

referred

to

surgery

with

a

clinically

proven

primary

gastric

malignancy

were

included

Surgical

specimens

were

examined

with

a

foldable

and

self-expanding

loop

coil

-LRB-

diameter

-RRB-

at

Tesla

immediately

after

total

gastrectomy

and

and

opposed-phase

sequences

-LRB-

axial

frontal

sections

to

slice

thickness

-RRB-

were

acquired

Investigators

blinded

to

any

patient

information

analyzed

signal

intensity

of

normal

gastric

wall

gastric

tumor

and

lymph

nodes

Findings

were

compared

with

histopathological

staging

On

surgical

specimens

gastric

wall

layers

could

be

visualized

All

gastric

tumors

-LRB-

carcinomas

two

lymphomas

-RRB-

were

identified

on

endoluminal

MR

data

-LRB-

-RRB-

Overall

accuracy

for

T

staging

was

-LRB-

-RRB-

sensitivity

to

detect

serosal

involvement

was

and

specificity

N

staging

correlated

in

-LRB-

-RRB-

with

histopathology

-LRB-

N

versus

N

-RRB-

The

endoluminal

coil

concept

is

feasible

and

applicable

for

an

ex

vivo

setting

Endoluminal

MR

data

provided

sufficient

detail

for

gastric

wall

layer

differentiation

and

therefore

identification

of

T

stages

in

gastric

carcinoma

is

possible

Further

investigations

in

in

vivo

settings

should

explore

the

potential

of

our

coil

concept

for

endoluminal

MR

imaging

Introduction

Despite

the

fact

that

the

incidence

of

gastric

cancer

is

declining

in

most

Western

countries

it

remains

the

second

leading

cause

of

cancer

mortality

worldwide

-LSB-

-RSB-

Simultaneously

the

incidence

and

prevalence

of

cancer

arising

from

the

gastric

cardia

has

been

increasing

since

the

-LSB-

-RSB-

Adenocarcinoma

of

the

esophagogastric

junction

can

be

classified

according

to

Siewert

et

al.

based

on

morphology

and

anatomical

location

-LSB-

-RSB-

Adequate

surgical

resection

-LRB-

-RRB-

is

the

only

potentially

curative

therapy

for

eligible

patients

with

gastric

carcinoma

-LSB-

-RSB-

In

the

West

gastric

cancer

is

often

diagnosed

at

an

advanced

stage

of

disease

not

eligible

for

surgery

Fewer

than

of

patients

undergo

resection

-LSB-

-RSB-

Recently

new

concepts

of

multimodal

treatment

strategies

for

locally

advanced

gastric

carcinoma

have

been

investigated

-LSB-

-RSB-

Local

treatment

by

endoscopic

mucosal

resection

for

early

gastric

carcinomas

is

currently

being

evaluated

-LSB-

-RSB-

Several

phase

II

and

III

clinical

trials

for

neoadjuvant

chemotherapy

in

gastric

carcinoma

showed

its

feasibility

and

safety

-LSB-

-RSB-

Its

purpose

is

to

eliminate

or

delay

systemic

metastasis

and

reduce

micrometastatic

spread

of

disease

Another

benefit

is

potential

reduction

of

tumor

volume

in

initially

unresectable

advanced

tumor

stages

-LRB-

downstaging

-RRB-

therefore

increasing

resectability

rate

An

adequate

treatment

strategy

especially

in

regard

to

the

concept

of

neoadjuvant

chemotherapy

requires

precise

clinical

staging

to

depict

relevant

prognostic

factors

and

identify

resectable

tumor

stages

This

also

accounts

for

endoscopically

treated

early

gastric

cancers

as

well

as

for

adenocarcinomas

of

the

gastroesophageal

-LRB-

GE

-RRB-

junction

since

each

type

of

tumor

requires

a

different

surgical

approach

Thus

the

exact

knowledge

of

tumor

morphology

and

tumor

invasion

into

gastric

wall

is

a

crucial

information

for

clinical

staging

Up

to

now

computed

tomography

-LRB-

CT

-RRB-

and

magnetic

resonance

imaging

-LRB-

MRI

-RRB-

have

not

provided

the

spatial

resolution

to

fulfill

this

requirement

with

sufficient

accuracy

-LSB-

-RSB-

Results

for

staging

accuracy

of

endoscopic

ultrasound

-LRB-

EUS

-RRB-

also

seem

to

be

improvable

-LSB-

-RSB-

The

main

aspect

of

gastric

wall

differentiation

is

spatial

resolution

By

using

endoluminal

radiofrequency

-LRB-

RF

-RRB-

coils

for

MRI

image

quality

and

spatial

resolution

can

be

enhanced

MRI

provides

superior

soft

tissue

contrast

which

makes

it

useful

for

tumor

invasion

detection

furthermore

information

not

obtainable

by

other

imaging

modalities

is

acquired

Various

authors

reported

the

use

of

endoluminal

RF

coils

as

a

diagnostic

and

staging

tool

in

gastrointestinal

diseases

and

rectal

and

prostate

cancer

-LSB-

-RSB-

A

major

problem

with

endoluminal

RF

coils

is

placement

close

to

the

region

of

interest

and

depth

of

visualization

Our

approach

uses

a

foldable

and

afterward

self-expanding

loop

coil

design

-LRB-

diameter

-RRB-

which

enhances

spatial

resolution

and

depth

of

visualization

The

aim

of

our

study

was

to

assess

normal

gastric

wall

architecture

and

signal

intensity

-LRB-

SI

-RRB-

on

endoluminal

MRI

as

well

as

signal

intensity

and

appearance

of

gastric

carcinomas

and

their

related

lymph

nodes

Subsequently

we

used

endoluminal

MRI

as

staging

modality

on

ex

vivo

gastric

carcinomas

Findings

were

compared

with

histopathological

staging

Materials

and

methods

Patients

A

prospective

study

was

conducted

on

patients

with

gastric

malignancies

referred

for

total

gastrectomy

to

the

surgery

department

of

our

university

hospital

They

were

included

in

the

study

if

the

lesion

was

identified

by

EUS

or

CT

suggesting

a

gastric

carcinoma

or

if

histological

workup

of

biopsies

confirmed

the

diagnosis

The

study

protocol

was

approved

by

the

institutional

review

board

and

informed

consent

was

acquired

from

each

patient

prior

to

surgery

We

investigated

consecutive

patients

women

and

men

-LRB-

age

range

median

years

-RRB-

Tumors

were

located

at

the

cardiac

region

in

cases

the

fundal

area

in

two

the

corpus

in

six

and

the

antropyloric

area

in

nine

Immediately

after

surgery

gastrectomy

specimens

were

taken

to

the

MR

suite

to

conduct

the

examination

within

a

time

frame

of

h

-LRB-

Fig.

-RRB-

Specimens

where

then

sent

to

histopathology

unchanged

from

the

procedure

Fig.

of

study

design

Endoluminal

RF

coil

The

endoluminal

RF

coil

-LRB-

patent

issued

German

Patent

and

Trade

Mark

Office

No

Grenacher

et

al.

-RRB-

developed

in

collaboration

with

Fraunhofer

Institute

for

Biomedical

Engineering

-LRB-

IBMT

St.

Ingbert

Germany

-RRB-

consists

of

a

foldable

and

self-expanding

receiver

loop

-LRB-

diameter

-RRB-

It

is

coated

with

a

biocompatible

material

-LRB-

silicone

-RRB-

to

prevent

direct

contact

of

the

wire

with

stomach

tissue

-LSB-

-RSB-

The

flexible

characteristics

of

the

shape

memory

metal

-LRB-

nitinol

-RRB-

used

allow

passage

through

the

instrument

channel

-LRB-

diameter

-RRB-

of

a

specially

designed

MR-compatible

endoscope

The

MR-compatible

endoscope

was

not

used

in

this

study

and

is

described

elsewhere

but

it

is

mentioned

in

this

context

because

RF

coil

design

is

reflected

by

the

specifications

of

the

endoscope

A

nonferromagnetic

tuning

box

connects

the

RF

coil

via

a

standard

interface

with

a

MRI

scanner

-LRB-

Symphony

Siemens

Erlangen

Germany

-RRB-

which

was

used

in

this

study

Gastrectomy

specimens

were

placed

in

a

container

with

l

of

sodium

chloride

solution

to

ensure

good

contrast

with

gastric

tissue

and

adequate

expansion

of

gastric

folds

The

loop

of

the

RF

coil

was

placed

on

the

mucosa

side

of

the

tumor

After

the

tumor

was

located

with

a

scout

sequence

images

where

acquired

in

axial

and

frontal

sections

of

to

thickness

Scanning

was

performed

with

and

and

opposed-phase

sequences

-LRB-

Table

-RRB-

Table

sequence

parametersSequenceRepetition

time

-LRB-

TR

-RRB-

Echo

time

-LRB-

TE

-RRB-

AcquisitionsSlice

thickness

-LRB-

mm

-RRB-

MatrixField

of

view

-LRB-

FOV

-RRB-

-LRB-

mm

-RRB-

Pixel

size

-LRB-

mm

-RRB-

GRE1,0503513512x5122200.43x0.43T1-weighted

GRE

opposed

TSE

turbo

spin

echo

GRE

gradient

recalled

echo

Image

evaluation

Image

data

were

read

on

certified

diagnostic

work

stations

independently

by

two

board-certified

radiologists

with

and

years

of

experience

respectively

and

one

board-certified

surgeon

with

years

of

experience

in

endoscopic

ultrasound

on

gastric

carcinomas

Investigators

were

blinded

to

any

clinical

information

as

well

as

patient

identification

After

separate

reading

a

discussion

was

held

about

the

quality

of

data

and

unique

features

of

the

case

Additionally

final

agreement

was

achieved

if

disagreement

on

tumor

stage

had

initially

occurred

With

respect

to

the

unique

imaging

technique

the

resolution

and

detail

of

image

data

a

consensus

staging

was

reasonable

Radiological

and

histopathological

classification

of

the

tumor

was

done

according

to

the

Tumor

Node

Metastisis

-LRB-

TNM

-RRB-

staging

system

of

the

Union

Internationale

Contre

le

Cancer

-LRB-

UICC

-RRB-

-LSB-

-RSB-

Determination

of

tumor

stage

was

done

as

follows

tumor

invasion

of

the

lamina

propria

of

mucosa

or

invasion

of

submucosa

wall

thickening

and

signal

intensity

changes

confined

to

these

tumor

invasion

extended

to

the

muscularis

propria

and

additional

thickening

through

gastric

layers

with

signal

intensity

changes

showing

either

a

homogeneous

or

inhomogeneous

lesion

without

serosal

abnormalities

If

invasion

extended

beyond

muscularis

propria

into

an

adjacent

fat

tissue

plane

without

serosal

infiltration

it

was

considered

as

tumor

invasion

of

mucosa

submucosa

and

muscularis

propria

with

infiltration

of

the

serosa

or

changes

in

signal

intensity

presenting

with

micronodular

strands

as

growth

into

extraserosal

fat

tumor

invasion

into

adjacent

organs

or

structures

clearly

presenting

as

contiguous

tumor

extension

or

a

mass

with

similar

signal

intensity

as

the

gastric

tumor

N

staging

was

done

counting

the

lymph

nodes

detectable

on

MRI

regarding

them

as

pathologic

due

to

their

signal

intensity

Since

gastrectomy

samples

varied

in

lymph

node

content

due

to

surgical

technique

and

extension

of

the

gastrectomy

not

comparable

to

an

in

vivo

situation

N

factor

was

graded

into

N

for

positive

findings

of

lymph

nodes

and

into

N

for

absence

of

lymph

nodes

In

each

case

normal

gastric

wall

features

were

assessed

Signal

intensities

of

the

mucosa

submucosa

muscularis

propria

and

serosa

or

subserosa

were

recorded

as

well

as

the

amount

of

layers

in

which

the

normal

gastric

wall

could

be

differentiated

into

A

score

system

from

to

-LRB-

poor

very

good

-RRB-

was

used

for

several

study

items

to

weigh

the

power

of

their

findings

Each

sequence

for

example

was

rated

for

image

quality

on

a

range

from

to

representing

insufficient

to

very

good

Signal

intensity

and

morphology

of

the

gastric

tumors

and

demarcation

to

normal

gastric

wall

were

used

to

describe

characteristics

of

tumor

presentation

The

lesion

was

identified

by

irregular

architecture

of

gastric

wall

abnormal

thickening

and

change

in

signal

intensity

of

gastric

wall

layers

which

usually

present

with

sharp

and

clear

demarcation

into

three

to

five

different

layers

with

distinct

signal

intensities

and

thickness

Tumor

size

was

not

measured

as

it

does

not

influence

T

staging

or

provide

further

information

Histopathology

was

considered

the

gold

standard

and

radiological

data

where

compared

with

its

results

All

data

are

presented

as

absolute

numbers

and

relatively

as

percentages

Concordance

of

histopathological

results

and

radiological

findings

are

reported

as

overall

accuracy

Sensitivity

specificity

and

accuracy

for

T

factor

N

factor

are

provided

Detection

rate

of

serous

membrane

invasion

or

the

differentiation

between

and

stages

was

assessed

as

it

defines

advanced

stages

of

disease

Ninety-five

percent

confidence

intervals

-LRB-

CI

-RRB-

are

given

if

statistically

applicable

Results

The

setup

of

our

study

proved

to

be

feasible

as

shown

elsewhere

-LSB-

-RSB-

Two

cases

were

not

included

because

of

insufficient

image

quality

Histopathology

found

carcinomas

-LRB-

adenocarcinomas

nine

signet

cell

carcinomas

two

mixed

type

carcinomas

-RRB-

and

two

gastric

lymphomas

Four

tumors

were

classified

as

as

as

and

as

Gastric

lymphomas

were

excluded

from

the

study

although

they

where

detected

as

such

in

both

cases

-LRB-

-RRB-

Gastric

tumor

staging

In

-LRB-

-RRB-

cases

the

tumor

was

identified

Initially

-LRB-

-RRB-

of

T

stages

were

staged

correctly

of

tumors

of

tumors

of

tumors

and

of

tumors

were

classified

correctly

-LRB-

Table

-RRB-

Interpretation

of

image

data

was

done

without

knowledge

of

tumor

location

in

respect

to

the

gastric

region

such

as

cardia

fundus

corpus

or

antrum

as

it

would

be

possible

on

an

in

vivo

setting

such

as

endoscopy

or

CT.

In

a

second

reading

session

the

interpreters

were

informed

about

the

gastric

region

of

the

primary

tumor

for

each

case

In

knowledge

of

gastric

region

six

first

as

classified

carcinomas

of

the

cardia

were

correctly

staged

as

and

one

first

as

classified

tumor

-LRB-

cardia

-RRB-

was

correctly

identified

as

-LRB-

Table

-RRB-

This

gives

an

overall

accuracy

of

-LRB-

-RRB-

-LRB-

CI

-RRB-

-LRB-

Table

-RRB-

The

mean

score

for

T-factor

staging

was

-LRB-

range

-RRB-

Sensitivity

specificity

and

accuracy

for

detecting

serosal

involvement

was

and

with

a

mean

score

of

-LRB-

range

Table

-RRB-

Overstaging

occurred

in

three

tumors

were

classified

as

or

stages

and

one

tumor

was

identified

as

stage

-LRB-

Table

-RRB-

In

this

case

the

tumor

replaced

all

gastric

wall

layers

and

invaded

perigastric

fat

tissue

but

did

not

infiltrate

the

serous

membrane

Insufficient

separation

of

gastric

wall

layers

and

the

presence

of

abnormal

signal

intensities

most

likely

desmoplastic

reactions

or

peritumor

inflammation

were

identified

retrospectively

as

reasons

for

overstaging

of

tumors

Two

tumors

-LRB-

-RRB-

were

understaged

as

and

stage

One

case

was

a

diffuse

type

adenocarcinoma

with

disseminated

infiltration

into

the

muscularis

propria

which

is

not

visualized

and

thus

presented

as

stage

Table

of

histologic

with

endoluminal

findings

without

knowledge

of

tumor

region

Endoluminal

magnetic

resonance

imaging

-LRB-

MRI

-RRB-

findingsHistologic

-LRB-

n

-RRB-

of

histologic

findings

with

endoluminal

findings

acquired

with

knowledge

of

tumor

region

Endoluminal

magnetic

resonance

imaging

-LRB-

MRI

-RRB-

findingsHistologic

-LRB-

n

-RRB-

specificity

and

accuracy

for

each

T

stage

overstaging

and

understaging

rates

24 24/24

Understaging

Table

for

serosal

invasion

detectionEvaluation

of

serosal

invasionSensitivity4/5Specificity17/19Accuracy21

intensities

of

gastric

wall

layers

on

and

opposed-phase

imaging

from

inside

to

outside

imaging

-LRB-

n

-RRB-

imaging

-LRB-

n

-RRB-

aOpposed

phase

imaging

-LRB-

n

-RRB-

aTwo

layers

-LRB-

n

-RRB-

bHigh

IntermediateThree

layers

-LRB-

n

-RRB-

bHighIntermediateHighLowHighLowIntermediateIntermediateHighFour

layers

-LRB-

n

-RRB-

bHighIntermediate

LowLowIntermediateIntermediateLowLowfive

layers

-LRB-

n

-RRB-

Intermediate

HighIntermediateLowIntermediateaNumber

of

sequences

analyzedbNumber

of

sequences

with

n

layers

Nodal

involvement

Lymph

node

detection

resulted

in

N

for

detected

lymph

nodes

in

cases

with

N

in

cases

Sensitivity

for

detecting

N

was

specificity

and

accuracy

This

reflects

the

limitation

of

the

study

design

Ex

vivo

gastrectomy

specimens

do

not

provide

the

same

quantity

of

lymph

nodes

as

pathological

workup

The

mean

score

rating

N

factor

staging

was

-LRB-

range

-RRB-

Image

analysis

Separation

of

gastric

wall

layers

ranged

from

a

minimum

of

two

visible

layers

to

five

distinct

visible

layers

-LRB-

mean

-RRB-

in

analyzed

sequences

and

sequences

and

three

opposed-phase

sequences

-LRB-

Table

-RRB-

sequences

depicted

an

average

of

gastric

wall

layers

sequences

Mean

score

for

image

quality

of

the

sequences

used

was

-LRB-

range

-RRB-

with

for

and

for

sequences

Image

analysis

revealed

that

in

four

out

of

six

incorrectly

staged

T

factors

tumors

were

described

as

inhomogeneous

or

diffuse

concerning

demarcation

to

normal

gastric

wall

This

may

be

one

reason

for

misinterpretation

of

T

factor

Signal

intensity

of

the

mucosa

for

sequences

was

mostly

classified

as

hyperintense

for

it

was

intermediate

Submucosa

muscularis

propria

and

serosa

or

subserosa

presented

with

hypointense

intermediate

hypointense

SI

for

hyperintense

intermediate

hypointense

for

sequences

-LRB-

Table

-RRB-

Lymph

node

and

tumor

appearance

correlated

in

-LRB-

sequences

-RRB-

with

intermediate

SI

for

and

sequences

Out

of

eight

sequences

without

correlation

in

lymph

node

and

tumor

SI

two

sequences

showed

a

homogeneous

tumor

in

and

an

inhomogeneous

lesion

in

images

-LRB-

Fig.

-RRB-

In

three

opposed-phase

sequences

lymph

nodes

-LRB-

hypointense

-RRB-

showed

different

signal

intensity

than

the

primary

tumor

-LRB-

intermediate

-RRB-

sequences

-LRB-

Table

-RRB-

visualized

more

gastric

wall

layers

and

provided

the

interpreter

with

a

better

demarcation

of

tumor

volume

from

normal

gastric

wall

than

did

sequences

showed

a

better

delineation

and

contrast

of

lymph

nodes

in

adjacent

structures

-LRB-

Fig.

-RRB-

Fig.

bTwo

consecutive

images

-LRB-

a

b

-RRB-

of

a

early

gastric

carcinoma

-LRB-

white

arrowheads

-RRB-

well

differentiated

-LRB-

intestinal

type

of

Lauren

classification

-RRB-

located

at

the

subcardial

region

Lymph

nodes

in

adjacent

fat

tissue

with

a

high

signal

intensity

-LRB-

white

arrows

-RRB-

are

visualized

Morphology

of

normal

gastric

wall

is

pointed

out

by

open

arrows

-LRB-

-RRB-

marks

the

position

of

the

receiver

coilFig

signet

cell

tumor

of

the

cardia

region

-LRB-

diffuse

type

of

Lauren

classification

white

arrowhead

-RRB-

on

-LRB-

a

-RRB-

and

imaging

-LRB-

b

-RRB-

The

extent

of

tumor

mass

and

the

diffuse

infiltration

into

gastric

wall

is

better

visualized

on

images

due

to

the

mucinous

character

of

the

tumor

-LRB-

black

arrowheads

-RRB-

The

tumor

appears

more

homogeneous

on

images

-LRB-

a

-RRB-

-LRB-

-RRB-

marks

the

position

of

the

receiver

coil

Discussion

Endoluminal

MRI

has

been

used

by

various

groups

to

asses

its

ability

for

locoregional

imaging

of

esophageal

and

gastrointestinal

disease

The

first

group

-LSB-

-RSB-

to

introduce

an

MR

endoscope

reported

promising

results

for

the

diagnosis

of

gastrointestinal

diseases

and

pointed

out

limitations

of

their

design

-LSB-

-RSB-

Image

quality

of

endoluminal

MRI

was

not

as

clear

as

those

acquired

by

EUS

and

their

success

rate

of

obtaining

clear

images

of

the

stomach

was

low

-LRB-

-RRB-

-LSB-

-RSB-

Although

their

study

achieved

for

T-staging

accuracy

its

patient

collective

consisted

mainly

of

advanced

gastric

carcinomas

-LRB-

-RRB-

Other

authors

reported

the

use

of

an

MR

endoscope

with

a

similar

design

-LSB-

-RSB-

sharing

the

incorporation

of

the

RF

coil

with

and

mm

into

the

tip

of

the

MR

endoscope

This

is

a

useful

design

for

imaging

at

the

esophagus

where

both

groups

showed

good

results

in

staging

esophageal

cancer

-LSB-

-RSB-

The

small

cylindrical

RF

coil

design

implemented

in

the

tip

of

the

MR

endoscope

may

be

a

reason

for

problems

in

obtaining

sufficient

images

in

the

stomach

Our

approach

using

an

insertable

and

self-expandable

RF

coil

-LRB-

diameter

-RRB-

independent

from

the

MR

endoscope

seems

to

be

more

suitable

for

imaging

of

the

stomach

by

providing

enhanced

depth

of

visualization

In

sufficient

image

data

was

obtained

Detection

of

resectable

lesions

can

only

be

accomplished

by

exact

knowledge

of

tumor

invasion

in

relation

to

gastric

wall

layers

New

multimodal

treatment

strategies

require

the

information

of

tumor

stage

as

it

defines

enrollment

into

neoadjuvant

therapy

approach

Clinical

staging

based

on

imaging

studies

can

provide

important

information

for

adequate

therapy

decision

if

they

fulfill

this

requirement

Gastric

wall

differentiation

and

identification

is

essential

for

accurate

staging

of

gastric

malignancies

Our

approach

can

depict

between

two

to

five

gastric

wall

layers

and

therefore

deliver

sufficient

detail

as

basis

for

tumor

invasion

detection

Signal

intensities

of

gastric

layers

assessed

in

our

study

correspond

mainly

to

those

reported

previously

by

other

authors

-LSB-

-RSB-

Visualization

of

the

serosa

layer

remains

a

problem

in

all

published

studies

with

MRI

or

endoluminal

MRI

on

gastric

wall

Some

authors

investigated

ex

vivo

gastrectomy

specimen

with

a

MRI

device

and

were

able

to

differentiate

up

to

five

different

gastric

layers

but

visualization

of

the

serosa

or

subserosa

was

not

achieved

-LSB-

-RSB-

One

reported

study

used

a

MRI

system

and

failed

as

did

another

study

with

a

MRI

system

to

visualize

serosa

or

subserosa

as

a

distinct

layer

-LSB-

-RSB-

One

work

group

reported

possible

identification

of

serosa

or

subserosa

on

gastrectomy

specimens

after

fixation

with

formalin

-LSB-

-RSB-

With

the

use

of

a

MRI

device

and

a

loop

coil

muscularis

propria

and

serosa

or

subserosa

showed

isointense

signal

intensities

but

were

outlined

by

subserosal

fat

tissue

with

contrasting

signal

intensity

The

results

were

confirmed

by

another

work

group

using

a

similar

setup

-LSB-

-RSB-

Identification

of

the

serosa

is

necessary

to

securely

differentiate

between

and

gastric

carcinoma

Although

a

detection

rate

of

for

serosal

involvement

was

achieved

in

this

study

serosa

as

a

single

gastric

wall

layer

was

not

clearly

visualized

In

seven

cases

with

four

to

five

visible

gastric

layers

a

thin

outer

layer

on

sequences

was

detected

and

could

possibly

be

identified

as

serosa

or

subserosa

with

subserosal

fat

tissue

This

finding

was

inconsistent

and

varied

in

different

T-stage

carcinomas

This

may

be

because

of

isointense

signal

intensity

of

muscularis

mucosae

and

serosa

or

subserosa

or

the

fact

that

the

thickness

of

the

serosa

layer

is

not

sufficient

for

secure

identification

-LSB-

-RSB-

It

is

not

certain

whether

tumor

invasion

into

or

close

to

the

serosa

or

subserosa

layer

changes

its

signal

intensity

presentation

Indirect

detection

by

subserosal

fat

tissue

seems

possible

but

in

our

experience

there

is

some

variance

in

the

thickness

of

subserosal

fat

tissue

in

gastric

carcinoma

specimens

One

reason

for

this

could

be

tumor

cachexia

An

interesting

learning

point

is

reflected

by

the

results

of

T

staging

Knowledge

of

the

gastric

region

where

the

tumor

is

located

is

important

since

T

staging

of

the

stomach

depends

on

the

gastric

region

Tumors

of

the

cardia

and

part

of

the

fundus

region

where

a

serosal

layer

is

missing

are

considered

whereas

they

would

be

in

other

gastric

regions

The

study

setup

was

intended

to

be

as

close

as

possible

to

a

future

in

vivo

setting

with

an

MR

endoscope

but

tumor

location

and

gastric

region

can

not

be

read

on

image

data

from

gastrectomy

specimens

An

in

vivo

setting

would

enable

investigators

to

acquire

this

information

After

providing

the

tumors

gastric

region

T

staging

accuracy

improved

to

Thus

the

gastric

region

of

tumor

location

is

an

important

fact

for

adequate

staging

of

tumor

invasion

While

this

study

used

an

ex

vivo

model

of

gastric

carcinomas

and

the

amount

of

patients

included

could

be

higher

the

entire

range

of

T

factors

for

gastric

carcinomas

is

covered

Another

limitation

of

this

study

is

the

missing

congruence

of

lymph

nodes

present

in

the

gastrectomy

specimens

due

to

surgical

technique

to

those

available

for

histopathology

This

is

reflected

by

N-factor

staging

results

An

in

vivo

setting

should

be

more

accurate

but

poses

new

problems

such

as

motion

artefacts

due

to

patient

or

endoscope

movement

Modern

rapid

MRI

sequences

and

spasmolytic

agents

may

be

able

to

overcome

these

obstacles

in

an

in

vivo

setting

but

this

is

a

goal

for

future

studies

It

is

important

to

point

out

pitfalls

of

this

imaging

technique

as

overstaging

is

a

problem

in

many

imaging

modalities

Peritumor

inflammation

micronodular

affection

of

the

serosal

membrane

and

diffuse-type

gastric

carcinoma

were

retrospectively

identified

as

reasons

for

misinterpretation

of

tumor

invasion

Overstaging

occurred

in

with

three

tumors

not

correctly

classified

This

is

encouraging

since

all

tumors

were

detected

as

tumors

but

in

two

cases

were

classified

as

tumors

and

one

as

Only

one

incorrectly

classified

tumor

contributed

to

overstaging

This

indicates

that

overstaging

was

not

a

problem

of

differentiation

between

and

stages

of

disease

It

is

necessary

to

focus

on

carcinomas

as

experience

with

carcinomas

in

imaging

modalities

in

Western

countries

is

low

due

to

the

fact

that

most

gastric

cancers

are

diagnosed

at

an

advanced

stage

It

is

important

to

learn

more

about

signal

intensity

and

morphologic

presentation

of

early

gastric

carcinomas

on

endoluminal

MRI

to

improve

detection

rate

Endoluminal

MR

imaging

provides

enough

detail

to

visualize

a

tumor

-LRB-

Fig.

-RRB-

Endoscopic

mucosal

resection

as

one

treatment

option

for

early

gastric

carcinoma

requires

an

imaging

method

that

is

able

to

visualize

and

identify

these

stages

securely

and

provide

information

that

is

observer

independent

Further

studies

should

include

a

larger

quantity

of

early

stages

of

gastric

carcinomas

to

analyze

accuracy

potential

of

endoluminal

MRI

MR

images

provide

information

not

obtainable

by

other

imaging

modalities

A

gastric

tumor

can

present

with

different

appearances

on

imaging

than

on

a

imaging

-LRB-

Fig.

-RRB-

Depth

of

visualization

of

a

method

is

essential

for

staging

a

gastric

tumor

assessing

its

depth

of

invasion

into

gastric

wall

and

into

adjacent

organs

and

structures

as

well

as

depicting

involved

lymph

nodes

Our

image

data

can

provide

detailed

information

about

gastric

wall

invasion

as

well

as

organ

invasion

-LRB-

Figs.

and

-RRB-

Fig.

gastric

tumor

-LRB-

intestinal

type

of

Lauren

classification

open

arrows

-RRB-

on

images

of

the

same

plane

Transition

of

normal

gastric

wall

into

tumor

mass

-LRB-

white

arrows

-RRB-

Pancreas

-LRB-

white

arrowheads

-RRB-

adjacent

to

the

gastric

wall

demonstrates

depth

of

visualization

-LRB-

a

-RRB-

Tumor

invasion

into

pancreas

-LRB-

black

arrowheads

-RRB-

-LRB-

b

-RRB-

In

this

study

we

have

shown

that

our

concept

is

functional

and

feasible

for

MRI

of

the

stomach

and

staging

results

comparable

with

other

imaging

modalities

were

achieved

Endoluminal

MRI

in

combination

with

conventional

MRI

could

assess

local

and

regional

imaging

in

one

session

giving

accurate

information

about

local

staging

and

metastatic

spread

of

disease

Secondary

contrast

media

should

be

evaluated

for

its

use

in

improving

gastric

wall

layer

discrimination

and

identification

as

well

as

tumor

demarcation

Additional

studies

are

needed

to

assess

the

clinical

feasibility

of

this

coil

concept

in

vivo

for

imaging

of

the

upper

gastrointestinal

tract

High-resolution

imaging

of

the

pancreas

could

be

another

possible

application

Today

most

tumors

of

the

stomach

and

esophagus

are

staged

by

conventional

methods

such

as

endoscopy

EUS

or

CT.

Future

prospects

of

endoscopic

MRI

may

be

limited

to

certain

tumor

entities

such

as

early

or

advanced

carcinomas

but

it

could

be

able

to

answer

additional

specific

clinical

questions

for

relevant

therapy

decisions

Summary

Endoluminal

MRI

with

the

coil

concept

is

feasible

and

applicable

T

staging

of

ex

vivo

gastric

carcinomas

is

possible

Results

for

T-factor

staging

are

preliminary

but

promising

as

they

reflect

the

first

experience

with

this

technique

Image

quality

and

resolution

obtained

with

the

endoluminal

RF

coil

are

convincing

for

future

use

in

gastrointestinal

imaging

Limitations

of

this

study

include

missing

congruence

in

quantity

of

lymph

nodes

for

N

staging

a

limited

amount

of

some

T-stage

gastric

carcinomas

and

the

ex

vivo

setting

Taking

the

limitations

into

account

the

coil

design

should

be

investigated

in

an

in

vivo

setting

after

assessing

safety

aspects

to

evaluate

the

prospects

given

by

the

ex

vivo

results

The

clinical

potential

may

be

limited

by

providing

a

staging

tool

for

certain

tumor

entities

With

more

experience

in

endoluminal

MRI

and

interpretation

of

endoluminal

image

data

its

use

could

be

extended

toward

other

fields

in

gastrointestinal

imaging

O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O

stomach neoplasms
neoplasm staging
experimental study