NeXRadiology - Promoting Excellence in Medical Imaging

CME at NR

2012-01-25T08:57:00.001+08:00

Our next CME is on 25 Feb 2012 in Shah Alam @2pm. Please register early to avoid disappointment. Call Asma 03 5518 4930

Topics covered:

1. Lectures
a. Act 304 & related regulations by MOH officer
b. Radiation protection in the use of medical equipment by Medical Physicist

2. Workshops
a. Chest & Extremity Radiography for x-ray operators
b. Chest & ultrasound pathologies for GPs
c. Radiation protection & new imaging technologies for radiographers.

Tutorials at NR

2012-01-25T08:49:00.000+08:00

Chest pathology for GPs

Fascilitator: Dr A Rahman
Date: 11 Feb 12 - Saturday
Time: 3 - 5pm
Venue: Whoa Clubhouse, Level 2, Space U8, Bt Jelutong, Shah Alam
Course fee: RM50 (free with voucher)
Target groups: GPs only
To book a seat, call Pn Nor at 03 55184930

Other topics in this programme
1. How to read a Chest Radiograph?
2. Ultrasound Techniques
3. Recognising Ultrasound Pathologies
4. Radiographic Techniques
Target groups: GPs, radiographers & operators
If you are interested to attend any of these sessions, check this site again or call Pn Nor at 03-55184930 for the dates.

Sebaceous cyst

2012-01-07T10:40:00.002+08:00

This is a 6 month old baby. She has a soft palpable lump on her left thigh, detected about 3 months ago. Ultrasound revealed a hypoechoic, mildly inhomogenous appearance mass with jelly-like material within. It is cutaneous in location. No vascularity detected within the mass. No calcification seen.

Tutorials at NR Pusat Diagnostik

2011-12-19T09:24:00.004+08:00

Radiographic techniques

Fascilitator: Uncle Boey
Date: 7 Jan 2012 Saturday

Time: 1- 3pm
Venue: NR Pusat Diagnostik
Course fee: Token RM50 only
Target groups: GPs, radiographers & operators only
To book a seat, call Pn Nor at 03 55184930

Other topics in this programme
1. How to read a Chest Radiograph?
2. Ultrasound Techniques
3. Recognising Ultrasound Pathologies
4. Radiographic Techniques
Target groups: GPs. radiographers & operators
If you are interested to attend any of these sessions, check this site again or call Pn Nor at 03-55184930 for the dates.

Foreign body in left buttock

2011-12-09T15:41:00.001+08:00

7 year old male. Had an accident whereby a piece of wood penetrated into his left buttock and was pulled out immediately by his grandmother. Slight swelling was seen and wound has not healed for over a month. Ultrasound revealed a long linear echogenic object, with posterior shadowing, measuring about 4.38cm in length and 0.82cm in width.

Fibrous dysplasia right 9th rib

2011-11-24T22:16:00.000+08:00

Fibrous dysplasia little finger

2011-11-24T21:57:00.000+08:00

Features to look for are:

· An abnormal area of bone that typically has an appearance similar to that of ground glass

· Expansion of the involved area of bone

· Thinning of cortex

In a long bones, the bones may be bowed.

Moderate hydronephrosis with mid ureteric stone

2011-11-22T17:03:00.005+08:00

55 yr old male patient with right flank pain and gross hematuria.
Ultrasound showed moderate hydronehprosis in the right kidney, with hydroureter.
The examination was extended down to the mid ureter and there, a stone was seen.

FREE Tutorials at NR Pusat Diagnostik

2011-11-08T15:00:00.003+08:00

Ultrasound Tutorial for GPs

Topic: Ultrasound Techniques - antenatal & abdomen

Fascilitator: Ms Phoebe Foo

Date: 7th Dec 2011

Time: 3-5pm

Venue: NR Pusat Diagnostik

Course fee: FOC

Target groups: GPs only

To book a seat, call Pn Nor at 03 55184930

Bilateral polycystic ovaries

2011-10-13T15:15:00.002+08:00

Both left and right ovaries have numerous small cysts in the periphery.

Isolated Echogenic Intracardiac Focus

2011-08-22T10:02:00.010+08:00

A 38 years old female came for 2nd-trimester detail scan as to rule out Down's Syndrome. She was supposed to come during 11th-13th week for the NT scan for Down's Syndrome. She has previous history of miscarriaged and cleft-lip of her baby; her husband's family has the history of Down's Syndrome disease. 2nd trimester detail scan was performed. An isolated echogenic focus is detected in fetal heart, which is the soft marker for the possibility of the baby to have Down's Syndrome.

A sonographically isolated echogenic intracardiac focus with no other anomalies or markers noted on a complete genetic sonogram, was associated in our high-risk population with a 4.8-fold (95% CI: 1.8, 12.5) increase in RR for trisomy 21(P = .002).

Information taken from: Thomas CW, Amy MA, Edith YC, Cathy AK, Vivienne LS, MD Stefanie BU and David AN. Echogenic Intracardiac Focus in 2nd-Trimester Fetuses with Trisomy 21: Usefulness as a US Marker. Radiology 2000; 216:450-456.

Hemangioma of the Tongue - a rare finding.

2011-08-07T11:40:00.005+08:00

A 42 year old chinese man came in with slow-growing tongue swelling for the past 4 years.
Ultrasound was done and showed increased vascularity and calcfications in the tongue mass.
HPE revealed the mass to be a hemangioma.

Anencephaly

2011-03-15T13:59:00.003+08:00

This is a 20 week year old foetus. There is absence of a cranial vault and brain structures.

Another case of bladder mass causing severe hydronephrosis

2011-02-21T15:06:00.006+08:00

Patient is a 71 year old male.
Ultrasound revealed a large, irregular hypoechoic mass, about 8.5 cm, occupying the bladder with very little urine seen. Below are images showing severe hydronephrosis in the right kidney (due to long standing obstruction at the vesicoureteral junction) and a normal appearing left kidney.

Pic#1 Bladder mass

Pic#2 Right kidney severe hydronephrosis

Pic#3 Normal left kidney

Colon carcinoma with metastasis to the liver

2010-11-23T12:22:00.005+08:00

This is a 35 year old male patient who presented with lower abdominal pain and constipation for about 3 months.

Ultrasound revealed significant thickened bowel wall(1st picture). On further examination, multiple echogenic solid lesions with halos were seen in the entire liver.

Acrania, Omphalocele and Spinal dysraphism

2010-10-18T13:24:00.008+08:00

This is a 22 year old patient in her 20th week of pregnancy.
The below images and abnormalities are of the same foetus.

Pic #1. Ultrasound scan showed presence of brain tissue without the presence of a calvarium. The brain tissue appeared disorganized.

Pic #2. There is also a mass seen herniating from the anterior wall of the fetal abdomen into the base of the umbilical cord.

Pic #3. Notice separation of the lateral pedicles in this coronal image of the foetal spine. Location of this defect is at the thoracic level.

Liver mass and ascites

2010-10-01T15:18:00.003+08:00

Patient is a 67 year old male and has chronic Hep B.
This is an image of an atrophic liver with a solitary liver lesion, about 7 cm, located in the right lobe. The lesion is well-defined and hypoechoic. It is most likely hepatocellular carcinoma. There is also marked ascites seen.

Bladder mass with hydroureter and severe hydronephrosis

2010-09-21T10:36:00.010+08:00

Pic#1 Bladder mass

Pic#2 Distended left renal ureter

Pic#3 Severe hydronehprosis in left kidney

Ultrasound done on a 61 year old man revealed a large hypoechoic mass, about 9 cm, occupying the bladder with very little urine seen. Further examination showed a grossly hydronephrotic left kidney with thinned out cortex and hydroureter (due to long standing obstruction at the vesicoureteral junction).

Thyroid Incidentaloma

2010-09-14T22:02:00.000+08:00

53 year old man, known case of carcinoma rectosigmoid colon, stage 3C. He was operated a year ago. PETCT done for re-staging.

In the neck, there was a 1cm focal calcified lesion in the posterior mid pole right lobe of thyroid gland, associated with intense FDG uptake (SUV max 8.5).

In the pelvis, there was an irregular soft tissue attenuation mass in the presacral space, measuring 2.0 x 3.0 x 5.8cm in size, associated with intense FDG uptake (SUV max 8.4).

A diagnosis of tumour recurrent in the presacral space of pelvis & thyroid incidentaloma was made.

Focal increased FDGuptakes in the thyroid are called incidentalomas. They are found in about 2-3% of healthy individuals. However, focal thyroid incidentalomas foundon FDG PET done for cancer staging may have a high prevalence of thyroid malignancy. Possibilities are either follicular carcinoma or thyroid metastases.

Lung carcinoma with kidney metastases

2010-09-14T21:37:00.001+08:00

55 year old man with known history of lung carcinoma 2 years ago. The tumour was operated and he underwent a complete course of chemotherapy.

Recently, he developed chest pain and frank haematuria. PETCT was done for evaluation.

Scan showed two hypodense mass in mid and upper pole of left kidney, measuring 1.2cm and 2.6cm in size. The left renal mass demonstrated intense FDG uptake (SUV max 8.8 and 9.6).

A left paraaortic node measuring 1.2cm, associated with moderate FDG uptake noted is also seen.

Clinically recognised metastases to the kidney from lung carcinoma are rare despite the fact that renal metastases from lung primaries are frequent at post mortem examination. Most patients have metastatic tumor in the other locations besides the kidney. The most common tumours which metastatise to kidney are lymphoma, leukemia, and lungs. Distinction from renal cell carcinoma is difficult to differentiate and a tissue diagnosis is imperative.

Left diaphragmatic paralysis

2010-09-07T15:39:00.008+08:00

This 45 year old patient has a known elevated left hemidiaphragm seen previously on x-ray.
Ultrasound was suggested to rule out diaphragmatic paralysis.

Pic #1: On the right hemidiaphragm, satisfactory movement and contractility is noted. M-mode showed diaphragm excursion of 4.02 cm

Pic #2: On the left hemidiaphragm, ultrasound revealed very little or no movement and contractility. This is depicted by a flat line in M-mode.

Non-Hodgkin's lymphoma

2010-09-06T06:12:00.000+08:00

37 year old man known case of non-Hodgkin's lymphoma. Completed treatment 2 years ago but has been feeling lousy recently. His x-ray showed multiple enlarged nodes in the mediastinum - mediastinal lymphadenopathy.

Colon cancer with lung metastases

2010-08-31T17:19:00.000+08:00

53 year old man complained of shortness of breath. He is a known case of colon cancer. Surgery was done 3 years ago. His chest x-ray showed a loculated effusion (fluid in the fissure - red arrow) and a 1cm nodule (yellow arrow). The fluid is most likely a malignant effusion and the nodule is most likely lung metastases from his colon cancer.

EZ DETECT Home Test for Early Warning Signs of Colorectal Disease - 1 ea

HOW TO DO APICAL VIEW? Guide for doctors

2010-08-28T15:00:00.000+08:00

The apical view is done to assess the apical region. In the apex, super-imposition of the first and 2nd ribs and the clavicle may obscure or mimic pathology.

How do we position the patient?

There are 2 principal versions of the projection. However all the general principal is to "stretch out" the lung apices and avoid superimposition of the clavicles over the apices. The differences between the projections are,

a) Horizontal central ray with patient's coronal plane angled i.e lordotic

b) Angled central ray with patient erect

If you need to show fluid level in a cystic structure, the first position is better.

However, the second position is more comfortable and safer for the patient.

Position 1: Horizontal central ray -patient's coronal plane angled (lordotic)

The patient stands AP erect approximately 30 cm from the cassette then leans back so the coronal plane is 30 degrees parallel to the cassette, the head and dorsal skin surface in contact with the cassette, the backs of the hands are placed on the lateral aspects of the waist and the shoulders rolled forward. Exposure is made on suspended inspiration.

Position 2: Angled central ray with patient erect

The patient stands AP erect with the back parallel to the cassette. The tube is angled 30 degrees cephalad.

Radiation protection:

Always ask the patient to wear lead apron.

Central Ray:

The horizontal central ray is centered in the midline midway between the sternal notch and the xiphisternum, the top of the cassette needs to be approximately 10 cm above the apical skin surface.

Evaluation of the Image:

ID and markers must be present and correct in the appropriate area of the film.
Limits of anatomy, superiorly the skin margins of the apices, inferiorly the T4, laterally the ribcage.
No rotation, The apices should be symmetrical about the midline.
Centering at T6
The medial ends of the clavicles should be projected above the lung apices.
The scapulae should be clear of the lungfields.
Penetration: the vertebral outlines should be visible.
Density: the average density of the lung field should be approximately 1.

Example of apical view showing right apical fibrosis

PULMONARY GRANULOMA Dilemna for doctors

2010-08-28T14:58:00.002+08:00

If your foreign worker has pulmonary granuloma, he is considered unfit for employment in Malaysia. Why?

Granulomas are known to harbour tubercle bacilli. These bacilli are dormant and may become re-activated anytime the patient’s immunity drops. In fact, granulomas contain macrophages, T & B lymphocytes and fibroblasts. By forming an aggregate, they prevent dissemination of mycobacterium. Within the granulomas, T lymphocytes (CD4+) secrete cytokines such as interferon gamma, which activates macrophages to destroy the bacteria with which they are infected. Without doubt, granuloma is an important form of body defense against tuberculous infection.

How do granulomas appear on chest radiograph?

Granulomas are seen as rounded discrete nodules between 3-8mm in diameters. Typically, they are within the upper lobes but may be seen at any part of the lung fields. They may also calcify and are then called calcified granulomas. They may also have satellite lesions (ie, small discrete nodules in the vicinity of the granuloma).

How do you differentiate them from end-on vessels?

I would say this is the most common dilemma in chest x-ray reporting. Granulomas and end-on vessels may look alike and differentiating them can sometimes be difficult. This is especially so if the ‘nodule’ is in the middle 1/3 of the lung field.

Can you see the nodule? I forgive you if you cannot see the it as granulomas are often between 3-8mm in size.

MY RULES OF THUMB ARE:

Granuloma is more likely if the ‘nodule’ is in the upper zones or the outer 1/3 of the lung fields.
Granuloma is less likely if the ‘nodule’ is in the medial 1/3 of the lung fields.
Granuloma is less likely if there is a vascular structure leading to or adjacent to the ‘nodule’.
Granuloma is less likely if there is an end-on bronchus next to it (appears as a rounded hollow shadow).
Granuloma is more likely if the ‘nodule’ is calcified.

What to do if you are still unsure?

Send the film for 2^nd opinion reporting.
Request for a CT scan of the chest.