W. C. G. Peh

Arteriovenous shunting in hepatocellular carcinoma: Its prevalence and clinical significance

Arteriovenous shunting has been reported in hepatocellular carcinoma (HCC) and is a recognized contraindication to treatment by transcatheter arterial chemoembolization. This study aims to determine the prevalence of arteriovenous shunting in patients presenting with HCC and the development of shunts in those with inoperable HCC being treated with repeated chemoembolization. In a group of 292 Chinese patients (251 men, 41 women; mean age 54.7 years) presenting with HCC, hepatic angiograms demonstrated arteriovenous shunting in 91 cases (31.2%); shunting into the portal vein was observed in 84 (28.8%) and shunting into the hepatic vein in seven (2.4%). The hepatic angiograms of a separate group of 171 Chinese patients (144 men, 27 women: mean age 55.4 years) undergoing chemoembolization for inoperable HCC were analysed. Arteriovenous shunting developed during treatment in 20 patients (11.7%). Of these 20 patients, one had shunting into the hepatic vein while 19 (11.1%) had arterioportal shunting. Arteriovenous shunting occurred through the tumour or portal vein tumour thrombus in 13 patients, and occurred at sites remote from the tumour in the other seven patients. Shunting disappeared on repeat angiograms in three patients. Various postulated mechanisms responsible for arteriovenous shunting in HCC are reviewed. The recognition of development of arteriovenous shunting during chemoembolization of HCC is important as it has a direct bearing on patient management and prognosis.

Pictorial review: Magnetic resonance imaging of benign soft tissue masses of the hand and wrist

Magnetic resonance imaging (MRI) is the imaging method of choice for evaluating the presence and extent of soft tissue masses. It is particularly useful for assessing masses in the wrist and hand, where benign lesions predominate. A specific diagnosis may be made, or strongly suspected, from the characteristic MRI features found in certain conditions like ganglion, haemangioma, arteriovenous malformation, giant cell tumour of the tendon sheath and lipoma.

Osteochondroma and secondary synovial osteochondromatosis.

Abstract Secondary synovial osteochondromatosis (SOC) is a rare disorder caused by a variety of joint disorders. Two unusual cases of secondary SOC are presented. The first patient is a 43-year-old man with extensive SOC developing within a bursa surrounding an osteochondroma of the pubic bone. The second patient is a 23-year-old man who developed florid and progressive SOC of his hip joint following excision of a femoral neck osteochondroma. SOC recurred despite three excisions over a 15-month period. Imaging was useful in pre-operative diagnosis of bursal SOC in the first patient and in detecting multiple recurrences in the second patient. Both cases illustrate prominent SOC developing secondary to osteochondroma. The different hypotheses regarding bursal and secondary SOC are reviewed.

Sacral insufficiency fractures: Spectrum of radiological features

Clinical and radiological features of 22 Chinese patients with sacral insufficiency fractures were reviewed. Twenty-one were postmenopausal women. Other risk factors were external pelvic radiotherapy (eight) and total hip replacement (two). Severe low back pain was the most common presenting complaint. Fractures initially were demonstrated by bone scintigraphy in 21 and computed tomography (CT) in seven patients. Concomitant parasymphyseal and pubic rami fractures were detected in 17 and 10 patients, respectively. Follow-up assessment by CT and bone scintigraphy in five patients showed various stages of fracture healing. Recognition of the radiological patterns of this entity is emphasized.

Intra‐abdominal follicular dendritic cell tumour: a rare tumour in need of recognition

Neoplasms of follicular dendritic cells are uncommon and the majority of them occur in lymph nodes. Rarely, they may occur inside the abdominal cavity. We describe two examples of intra‐abdominal follicular dendritic cell (FDC) tumour. One involved the liver and the other involved the ampulla of Vater. Our aims are to complement the current understanding on this disease and to alert histopathologists and clinicians to this rare entity.

Systemic lupus erythematosus patients with respiratory symptoms: the value of HRCT

Ten Chinese patients with systemic lupus erythematosus (SLE) and with persistent respiratory symptoms were evaluated with high resolution computed tomography (HRCT), chest radiographs and lung function tests. Fourteen of 15 HRCT scans performed were abnormal. The predominant disease pattern, seen in 60% of patients, was one of chronic interstitial lung disease with honeycombing, architectural distortion, parenchymal bands, pleural irregularity, and a lower zone predominance. Three of 10 patients had histological evidence of either lung fibrosis or interstitial pneumonitis. Airways disease and pleural thickening were seen in 20% and 87% of scans, respectively. Pleural thickening and honeycombing were present in 53% and 20% of chest radiographs, respectively. All concurrent lung function tests were abnormal. Reduced diffusion capacity of carbon monoxide (DLCO/VA) was observed in 60% of lung function tests. There was no correlation between duration of disease and DLCO/VA. However, pathological reduction of DLCO/VA was seen in 71% of patients with honeycombing, and 88% of patients with ground glass opacity. Our study has documented a high incidence of HRCT features of chronic lung destruction and a lower zone predominance in SLE patients with persistent respiratory symptoms.

Lead arthropathy: a cause of delayed onset lead poisoning

Patients who suffer gun shot wounds often have retained bullet fragments within their bodies. These are usually of no clinical consequence. We describe three patients with retained bullets within their hip joints. One of these patients, who had extensive ground intra-articular bullet fragments and secondary osteoarthritis of the hip, presented with signs, symptoms, and laboratory data consistent with lead intoxication. The bullet and metallic fragments were removed surgically with good clinical response. Two patients whose bullets were implanted entirely within the femoral head and whose joints showed smaller degrees of lead fragmentation had no symptoms of lead intoxication. The degree of intra-articular fragmentation of the bullet and the surface area of lead exposed to synovial fluid are emphasized as decisive factors with respect to appropriate therapy.

Spectrum of Papillary Lesions of the Breast: Clinical, Imaging, and Pathologic Correlation

OBJECTIVE Papillary lesions of the breast are a heterogeneous group of lesions that are difficult to diagnose as benign or malignant. The purpose of this article is to review clinical presentation, imaging features, and pathologic correlation of papillary lesions of the breast and to discuss the prognosis and management of these lesions. CONCLUSION Recognition of the variety of benign and malignant papillary lesions of the breast will facilitate diagnosis and proper management.

Childhood Intussusception: Ultrasound-Guided Hartmann's Solution Hydrostatic Reduction or Barium Enema Reduction?

A comparison was made of the efficacy of ultrasound guided Hartmanns solution hydrostatic reduction on 23 patients (US group) with the same number of consecutive patients in whom hydrostatic reduction was done by barium enema (BE group) under fluoroscopy for childhood intussusception. The US group was diagnosed by ultrasound scan and reduction was attempted under the guidance of ultrasonography with Hartmanns solution at 100 mm Hg pressure. Excluded were patients older than 12 years, patients in shock, patients with peritonitis, bowel perforation, and gross abdominal distension as well as recurrent intussusception of more than three episodes. There were three patients excluded in this group. The diagnosis of intussusception and complete reduction were confirmed by gastrografin enema. This US group had three recurrences (3 of 26, 11.5%), one lead point (1 of 23, 4.4%), and 19 successful reductions (19 of 26, 73%). Incidentally, there were also three patients excluded in this period of barium enema reduction. There was only one recurrence (1 of 24, 4.2%), one leadpoint (1 of 23, 4.4%), and 12 successful reductions (12 of 24, 50%) in these 23 BE patients. The success rates for the ileo-colic intussusceptions with Hartmanns solution reduction and barium enema reduction were 91% (19 of 21) and 55% (12 of 22), respectively (P = .00865). There was no complication in either group, and the accuracy of diagnosing a complete reduction was 100% in both forms of reduction. Hence, ultrasound-guided hydrostatic reduction for childhood ileocolic intussusception is preferred because it is safe, accurate, has a higher success rate, and can avoid radiation exposure risk.

Magnetic resonance arthrography: Current status

Magnetic resonance imaging (MRI) is frequently considered the best method of diagnosis in musculoskeletal disorders. Intraarticular fluid improves joint assessment by helping to delineate intraarticular structures, separating otherwise closely-apposed structures, and filling potential spaces which lie within or communicate with the joint. Initially, it was anticipated that plain MRI would replace arthrography. The message from our surgical colleagues is that this ideal has not yet been achieved. Greater precision should reduce the need for more invasive techniques, such as diagnostic arthroscopy which is why direct and indirect MR arthrography are being employed. This article reviews the current status of MR arthrography as an evolving technique in the imaging of joint disorders.