Uterine artery embolisation for symptomatic fibroids in a tertiary hospital in Singapore.

INTRODUCTION: Transcatheter uterine artery embolisation (UAE) for the treatment of symptomatic uterine enlargement due to fibroids has been performed in several overseas centres with promising results. We report our experience with UAE in Singapore General Hospital. MATERIALS AND METHODS: Twenty women with symptomatic uterine fibroids who declined surgery were treated by transcatheter UAE. The uterine arteries were selectively catheterised and embolised with polyvinyl alcohol particles. Post-procedure analgesia was administered via a patient-controlled analgesia pump. The patients were followed up at regular intervals clinically and with transabdominal ultrasonography. RESULTS: Transcatheter UAE was performed on all patients with no major complications. Nineteen patients had both uterine arteries embolised while 1 patient had only the right uterine artery embolised on account of hypoplasia of the left uterine artery. The mean hospital stay was 3.5 days (range, 2 to 9). At a mean follow-up of 56 weeks (range, 6 to 168), all patients reported improvements in their presenting symptoms. Objective improvement in terms of reduction of uterine and fibroid sizes was determined on ultrasonography. The median size of the uterine volume decreased from 308 to 187 mL while the median diameter of the largest fibroid reduced from 6.2 to 4.6 cm. The median haemoglobin level increased to 12.7 g/dL from the pre-procedural median of 9.9 g/dL. One patient, who initially responded with a decrease in uterine and dominant fibroid size, became symptomatic (menorrhagia) at 6 months post-embolisation. She underwent a repeat procedure with complete resolution of symptoms. A second patient had recurrence of symptoms at 12 months, but was subsequently lost to follow-up. CONCLUSION: Mid-term results of UAE for the treatment of symptomatic fibroids in our hospital indicate this to be a safe and effective therapeutic option.

Percutaneous drainage of liver abscess complicated by hepato-venous fistula.

Severe systemic sepsis after percutaneous drainage of liver abscess is rare. We report two cases of hepato-venous fistulas between hepatic abscesses and hepatic/portal veins documented on abscessography during percutaneous drainage of liver abscesses, which resulted in severe sepsis and a stormy post drainage clinical course. Liver abscesses can rupture into the portal and hepatic veins causing worsening of systemic sepsis especially when they are in close proximity to each other. During percutaneous drainage, care must also be taken to avoid overinjection of the abscess, which can worsen the fistula. The ensuing sepsis is severe and requires aggressive intensive medical care and ventilatory support to tide the patient over the septic episode.

Non-consensual double reading in the Singapore Breast Screening Project: benefits and limitations.

INTRODUCTION: The aims of this study were to assess the efficacy of non-consensual double reading (against single reading) in the Singapore Breast Screening Project (SBSP) and to compare the benefits (increase in cancer detection) and limitations (increase in recall and biopsy) with published data. MATERIALS AND METHODS: The data from the SBSP was retrospectively analysed and the recommendations of the first and second readers were evaluated separately with regards to rate of recall, biopsy and cancer detection. The mean second screener contribution (MSSC) was also calculated for double reading. RESULTS: In the SBSP, double reading detected 7 additional cancers (5.2% of cancers detected) compared with single reading and the MSCC was 5.5%. Double reading also resulted in 632 additional recalls, with a decrease in the positive predictive value (PPV) of cancer in the recalled women from 8.2% for single reading to 6.1% for double reading. An additional 30 biopsies were performed with double reading which represented a small decrease in PPV (41% compared to 42.9% for single reading). CONCLUSION: In the SBSP, non-consensual double reading (compared to single reading) resulted in a modest increase in cancer detection (MSSC, 5.5%) with a modest decrease in PPV of recall (2.1%) and biopsy (1.9%). These findings were consistent with that of published data and non-consensual double reading is thus recommended.

Colorectal hepatic metastases: Role of radiofrequency ablation.

INTRODUCTION: Radiofrequency ablation (RFA) is a new minimally invasive treatment that has been increasingly used in the treatment of liver metastases. This review aims to outline the principles governing the use of RFA and to examine its role when applied to the management of colorectal liver metastases. METHODS: A Medline search of experimental and clinical studies relating to the use of RFA in the management of colorectal hepatic metastasis was carried out. RESULTS: RFA is currently used as an alternative to surgery in patients with unresectable disease, and sometimes as its companion, allowing patients hitherto considered unsuitable for resection to become surgical candidates. RFA has been shown to be safe and well tolerated, with few major complications and minimal patient discomfort. Although its use is unlikely to achieve cure in such patients, it has a definite role in palliation and relief of symptoms. Long-term data, when these become available, may also show improved survival. However, because RFA is a local ablative therapy, it does not address the progressive and systemic nature of colorectal carcinoma. CONCLUSIONS: RFA is an important alternative/complimentary tool in the management of colorectal hepatic metastases. Combining RFA with surgery or chemotherapy may reduce the incidence of local and systemic relapse.

Direct US-guided puncture of the innominate veins for central venous access.

Maintenance of functioning venous access is recognized as the Achilles heel of long-term hemodialysis treatment. In patients who require catheter-directed hemodialysis, the internal jugular veins are recognized as the optimal veins for insertion of dialysis catheters. When these sites are no longer available, alternative venous access sites are required. The authors describe two hemodialysis patients with limited access sites in whom hemodialysis catheters were successfully inserted directly into the innominate veins with use of ultrasound-guided punctures.

Clinics in diagnostic imaging (67). Hydronephrotic horseshoe kidneys with multiple calculi.

Horseshoe kidney is the commonest congenital renal anomaly. Its inherently-poor drainage system renders the patient prone to stone formation. A 56-year-old man with bilateral renal stones in a horseshoe system associated with hydronephrosis is presented. He was treated successfully with bilateral CT-guided percutaneous nephrostomy and percutaneous nephrolithotripsy. Various treatment options, including ESWL, PCNL and open surgery, are discussed.

Indwelling catheters for the management of malignant ascites.

Paracentesis is widely employed for palliation of symptomatic malignant ascites. In some patients, there is rapid re-accumulation of fluid necessitating frequent repeat procedures. Indwelling peritoneal drainage catheters can provide more durable symptom relief, avoiding the hazards and disadvantages of multiple repeat procedures. The goal of our study was to evaluate the technical success, complications and outcome associated with the use of these drainage catheters. We carried out a retrospective review of all patients who had indwelling catheters inserted for the management of symptomatic malignant ascites over a 4-year period. A total of 45 catheters were inserted in 38 patients. Insertion was technically successful in all patients, with immediate symptomatic relief. However, 2 cases of fatal hypotension were encountered in the first 24 h after catheter insertion (acute catheter-related mortality rate of 4.4%). These were attributed to rapid drainage of peritoneal fluid, although gastrointestinal tract bleeding was contributory in the second patient. Eight patients were lost to follow-up. Of the remaining 30, 13 (35.1%) patients developed catheter-related sepsis. The rate of infection was 1.6 episodes per 100 catheter-days. Thirteen tubes were removed prematurely, 6 (16.2%) due to sepsis, 5 (13.5%) because of tube blockage and 2 (5.4%) because of loculated ascites. The median length of time for which catheters were functional was 37 days (95% CI 14.1-59.6), with an average daily drainage of 539.5 ml (range 18-4000 ml). In conclusion, indwelling peritoneal drainage catheters provide a useful alternative to paracentesis in the management of symptomatic malignant ascites. Although it avoids the need for repeated paracentesis, it is not without risks. We discuss and propose some precautions to be observed in the use of these catheters.

Body fat distribution and cardiovascular risk in normal weight women. Associations with insulin resistance, lipids and plasma leptin.

OBJECTIVE: To systematically examine the correlations between insulin resistance, plasma leptin concentration, obesity and the distribution of fat assessed by anthropometry and magnetic resonance imaging in Asian women. DESIGN: A cross sectional study of non-diabetic, normal weight women. SUBJECTS: Twenty-one healthy women aged 38.8 y (s.d. 11.7) and BMI 22.6 kg/m2 (s.d. 2.3). MEASUREMENTS: Intraperitoneal, retroperitoneal and subcutaneous abdominal fat volume was assessed by magnetic resonance imaging. Anthropometric data were collected. Total fat mass was assessed by bioelectric impedance analysis. Fasting serum lipids, insulin and plasma leptin were assayed. RESULTS: Generalized obesity correlated with subcutaneous abdominal fat mass (r=0.83, P<0.001), but not with intra-abdominal fat mass. Both intraperitoneal fat mass and retroperitoneal fat mass increased with age (r=0.58, P=0.005 and r=0. 612, P=0.003, respectively). Abdominal subcutaneous fat mass was the most important determinant of insulin resistance and plasma leptin. Of the serum lipids, only fasting triglyceride correlated significantly with the waist-to-hip ratio. CONCLUSIONS: It is possible that the large size of the subcutaneous depot compared to the intra-abdominal depot overwhelms any metabolic differences between adipose tissue from these two sites, resulting in the stronger correlation between insulin resistance and subcutaneous abdominal fat mass rather than intra-abdominal fat mass. On the other hand, the distribution of fat between subcutaneous fat depots may be important in the metabolic syndrome given the correlation of fasting triglyceride with waist to hip ratio but not with abdominal fat. However, the study population was small, younger and leaner compared to previous studies and we may not be able to generalize these results to all segments of the population. We confirm that subcutaneous fat mass is the major determinant of plasma leptin.

Magnetic resonance imaging of penile metastases: a report on five cases.

Five cases of penile metastases are presented. Axial and sagittal T1-weighted and T2-weighted scans were performed in all patients. In some, coronal images were also obtained. The penile metastases were most often seen as discrete masses in the corpora cavernosa or corpus spongiosum. An atypical pattern of diffuse infiltration is also illustrated. Limitations of cavernosography, ultrasound (US) and computed tomography (CT) are discussed. The magnetic resonance (MR) features of penile metastases and possible role MR may have in the management of these patients are described.

Outcome of tunnelled central venous haemodialysis catheters inserted by radiologists.

Radiologists have only recently been involved in the percutaneous placement of tunnelled central venous haemodialysis catheters. We report our initial experience with our first 60 catheters. All catheters were successfully inserted. Immediate complications encountered included puncture site haemorrhage in 3 patients (5%) and puncture of the left brachiocephalic vein in 1 patient (1.7%). These were managed conservatively without any clinical sequelae. About 80% of the catheters were uncomplicated and removed electively. Slightly more than 80% of the catheters were in place for more than 30 days. Infection and blocked catheters were the most common short-term complications. Ten catheters (17%) were infected resulting in premature removal of 9. There was 1 death from presumed line sepsis. Mean duration before the onset of infection was 53 days; the rate of infection was 0.28 episodes per 100 catheter days. Five catheters (8%) were blocked or had poor flow. The mean duration before the onset of blockage was 39 days and the rate of blockage was 0.14 episodes per 100 catheter days. A higher proportion of catheters inserted from the left encountered complications. In conclusion, percutaneous insertion of tunnelled haemodialysis catheters by radiologists is safe and effective. The right internal jugular vein should be the preferred access site. Precautions should be taken to avoid infectious complications given the high rate of catheter removal amongst infected catheters.

Magnetic resonance imaging of the whole spine in suspected malignant spinal cord compression: impact on management.

Patients with suspected malignant spinal cord compression may present with a misleading sensory level or have multiple levels of compression that are not apparent clinically or on imaging of a limited area of the spine. To estimate how often this occurs and to evaluate a policy of magnetic resonance imaging (MRI) of the whole spine for any patient with suspected cord compression, data from 127 patients who had undergone MRI scans of the whole spine were reviewed. In 85 of 127 scans, there was evidence of compression of or impingement upon the spinal cord. A sensory level was present in 47 of these 85 patients, but in 12/47 (26%) the sensory level was four or more segments below or three or more segments above the actual lesion. Multiple levels of compression or impingement were found in 33 of 85 (39%) patients; in 24 of these, more than one region (cervical/thoracic/lumbar) of the cord was involved. For 32 patients who commenced radiotherapy to a treatment volume based on clinical criteria before the MRI scan was available, the radiotherapy fields needed modification in 16 (50%) as a result of the MRI findings. The results support a policy of MRI of the whole spine in any patient with suspected malignant spinal cord compression.

MRI of the fornix and mamillary body in temporal lobe epilepsy.

We performed MRI on 27 patients with clinically proven temporal lobe epilepsy (TLE), all with prior EEG lateralisation, and 10 volunteers, studied to evaluate disparity in size arising from biological variation (group 1). Three-dimensional spoiled GRASS (3DSPGR) sequences provided 2-mm contiguous sections of the limbic system, enabling assessment of the hippocampus (HC), fornix (FN) and mamillary body (MB). Measurements of FN and MB width were made from a workstation. Any percentage difference in size was computed. In 19 cases there was unilateral abnormality in the HC (group 2); in 18 and 19 cases respectively there was a smaller FN and MB on the same side as the abnormal HC. This percentage difference in size was significantly greater than that in group 1 in the FN and MB in 17 and 17 cases respectively. Comparison of percentage difference computations for FN and MB between groups 1 and 2 showed high statistical significance (P < 0.0002). In 5 patients with clinical TLE the HC was normal on MRI (group 3). Unequal FN and MB sizes were found in 4, significant in 2. Comparison of percentage difference computations for FN and MB showed statistical significance (P < 0.0005 and P < 0.0003 respectively). There was no case of discordance between the sides of hippocampal abnormality and the smaller FN or MB or between the sides of smaller FN and MB. The strong concordance between the changes in the HC and those in the FN and MB suggests that this combination will play an important role in the assessment of TLE and limbic system abnormality.

Involvement of the inferior vena cava by adrenal phaeochromocytoma--MRI findings.

Involvement of the inferior vena cava (IVC) by adrenal phaeochromocytoma is rare. Only angiographic and sonographic features have been described previously. We present a case with magnetic resonance demonstration of the IVC invasion.