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An intrauterine device is a well-tolerated and widely used contraceptive method. A rare but major complication is perforation of the uterus and migration into the sigmoid colon. In this case report, a 33-year-old woman presented for follow up after placement of a copper-T intrauterine device 4 months previously. A clinical examination found significant tenderness on palpation, and the threads could not be detected. An ultrasound was conducted, which revealed no coil in the uterine cavity. The pelvic x-ray found it in the mid-pelvis and pelvic magnetic resonance imaging confirmed the position of the T-component at the mid-sigmoid colon. The patient underwent a sigmoidoscopy, which confirmed the position in the sigmoid colonic wall. The device was removed with an endoscopy without further complications. Uterine perforation and translocation to the sigmoid colon is an unusual complication of an intrauterine device. Removal of a translocated intrauterine device is recommended in all symptomatic cases.

The World Health Organization (WHO) and numerous expert guidelines for lymphoma diagnosis and subclassification advocate the use of histology from surgical nodal excision biopsy (SEB) over core needle biopsy (CNB) due to perceived higher diagnostic yield. CNB is associated with lower morbidity and is more cost-effective compared to SEB. Furthermore, current practice increasingly demonstrates material obtained from CNB can rapidly diagnose individuals with a clinical suspicion of lymphoma and allow initiation of treatment in the majority of patients. We performed a literature review to assess the suitability of CNB in lymphoma diagnosis given recent advances in radiological and histopathological techniques in obtaining and processing tissue. Additionally, expert international guidelines in lymphoma diagnosis were compared. We found that CNB demonstrated a diagnostic efficacy between 79% and 97% (median 91%) where the diagnostic outcome was conclusive with full lymphoma subclassification. Studies demonstrate that there is a high diagnostic reproducibility amongst haematopathologists (87%-93%) in lymphoma diagnoses with full subtyping from material obtained via CNB. Furthermore, CNB is a safe, rapid and reliable method of obtaining tissue from lymph nodes for histopathological analysis. These procedures are minimally invasive, well-tolerated and should be considered the first-line diagnostic approach in clinical practice in patients with suspected lymphoproliferative disorders.

Objective: Accurate diagnosis of parotid neoplasia is a key to determine the most appropriate patient management choice, including the need for surgery. This review provides an update of the literature on current practice and outcomes of parotid tissue sampling techniques, with an emphasis on ultrasound-guided core biopsy (USCB) and comparison with fine needle aspiration cytology (FNAC). Methods: A literature review of EMBASE, Medline, PubMed and Google Scholar was conducted. Results: USCB has higher sensitivity, specificity and lower non-diagnostic rates than optimized FNAC. It also has a significantly higher sensitivity for the detection of malignancy. Significant complications post-USCB are uncommon, with only one reported case of tumour seeding and no cases of permanent facial nerve dysfunction. The technique is less operator-dependent than FNAC, with less reported variation in results between institutions. Conclusions: USCB can be considered as the optimum tool of choice for the diagnosis of parotid neoplasia. This would particularly be the case in centres utilizing FNAC with high non-diagnostic rates or reduced diagnostic accuracy when compared to USCB published data, or in centres establishing a new service. Advances in knowledge: An update of the role and outcomes of USCB in the diagnosis of parotid gland pathologies. Research shows that USCB preforms better than FNAC, in terms of sensitivity and specificity, particularly in the case of malignant neoplasia. Complications following USCB were found to be higher than that of FNAC; however, no long-term major complications following either method have been reported in the literature.

Most imaging findings relating to toxic and acquired metabolic disorders follow a certain pattern with affinity to a specific topographic area, which can help narrow the differential diagnosis. This is especially useful when the clinical presentation can be variable and there is diagnostic uncertainty. Usually, there is bilateral symmetrical abnormality within the deep grey matter structures and the cerebral cortex because of the high metabolic activity and raised oxygen requirements in these areas. Magnetic resonance imaging, particularly diffusion weighted imaging and fluid-attenuated inversion recovery sequences, is very important in differentiating between various aetiologies in this group. Magnetic resonance imaging can be useful in demonstrating both acute and chronic damage, in evaluating treatment response and in disease prognostication. This pictorial review discusses the computed tomography and magnetic resonance imaging appearances of a spectrum of toxic and metabolic disorders observed in a district general hospital with reference to clinical presentation and imaging features that may allow diagnosis. This includes carbon monoxide poisoning, hypoglycaemia, non-ketotic hyperglycaemia, osmotic demyelination syndrome, posterior reversible encephalopathy syndrome, hypoxic ischaemic encephalopathy, the syndrome of delayed post-hypoxic leukoencephalopathy, hepatic encephalopathy and cocaine toxicity.

Multiple myeloma (MM) involving the breast tissue is rare. We report the case of a 70-year-old woman with a background of previously treated MM in remission presenting with a breast lump. Histology showed a plasma cell neoplasm and subsequent staging investigations showed widespread extramedullary relapse of MM. Despite its rarity, this diagnosis should be considered within the differential diagnosis of breast masses as it can arise de novo or may be the first presenting feature of myeloma. The importance of the multidisciplinary team approach with triple assessment of the breast, as well as recent advances in knowledge regarding extramedullary disease in myeloma and novel treatment approaches in MM are discussed.

To evaluate current national imaging practice in myeloma with reference to National Institute for Health and Care Excellence (NICE) guidelines (NG35, 2016) and compare results with an initial survey conducted in 2017 (61 participating sites).All UK radiology departments treating myeloma patients and with a Royal College of Radiologists (RCR) Audit Lead were invited to participate. Data were collected using an online questionnaire. Descriptive statistics were performed.One hundred and fourteen hospitals supplied data (54% return rate). Skeletal survey (SS) remains the most-commonly performed first-line imaging test for suspected/confirmed myeloma or plasmacytoma (39%, 45/114 hospitals), followed by whole-body magnetic resonance imaging (WBMRI) (27%, 31/114) and whole-body computed tomography (WBCT) (19%, 22/114). Integrated positron-emission tomography/CT (PET/CT) was first-line in 14% (16/114). The NICE recommended initial investigation, WBMRI, is currently offered in 27% of surveyed hospitals (10% in 2017). Ongoing challenges to implementing WBMRI include scanner availability, financial constraints, reporting time, and radiologist training.Despite NICE recommendations regarding WBMRI in diagnosis/follow-up of myeloma, SS (poor sensitivity and specificity) remains the most commonly performed first-line test. Radiologists, haematologists, and patients should continue to emphasise the superiority and benefit of modern and more accurate imaging, such that they are prioritised in clinical service planning.

Two male patients, aged 55 and 75 years, were referred to the ENT and haematology team respectively, with an asymptomatic left supraclavicular neck mass. Investigations revealed metastatic primary testicular seminoma. CT contrast study of the thorax, abdomen and pelvis demonstrated an additional left para-aortic nodal mass in both cases. The initial presentation of a solitary left neck lump from a metastatic testicular seminoma is extremely unusual, especially in an older age group. The pattern of metastatic spread to the supraclavicular neck nodes from a single para-aortic lymph node is also an interesting finding. Although the majority of seminomas present in younger patients in the early stages when confined to the testis, seminoma can also occur in older patients and can present in an atypical manner. The ability to recognise an atypical presentation in an older patient is invaluable for prompt diagnosis, treatment and follow-up of disease. This case also highlights the importance of a multisystematic structured and an open-minded approach to investigating and diagnosing a neck mass.

Objective:A parathyroid multidisciplinary team meeting was set up at East Sussex Healthcare Trust, from November 2014 to November 2015, in order to improve and streamline services for patients with parathyroid pathology.Methods:Data were collected on all new referrals for hyperparathyroidism, and on the outcomes for each patient discussed at the meeting, including the number of operations and management outcomes. A survey was sent out to the members of the multidisciplinary team meeting to determine their perception of its effectiveness.Results:Seventy-nine new referrals were discussed throughout the year; 43 per cent were recommended for surgery, 41 per cent had a trial of conservative or medical management before re-discussion, and 16 per cent required further imaging. Ninety-two per cent of patients underwent an ultrasound, single-photon emission computed tomography/computed tomography or nuclear medicine (sestamibi) scan prior to the meeting. All ultrasound scans were performed by a consultant radiologist.Conclusion:The multidisciplinary team meeting has been successful, with perceived benefits for patients, improved imaging evaluation and efficiency of referral pathways, leading to more appropriate patient management.

A 45-year-old man presenting with abdominal pain was found to have severe hypercalcaemia with elevated parathyroid hormone. Investigations revealed a parathyroid mass and bone metastases consistent with metastatic parathyroid carcinoma. The patient underwent parathyroidectomy, with histology confirming a right inferior parathyroid carcinoma. His postoperative management was complicated by severe hypercalcaemia refractory to medical therapy, owing to the metastases continuing to produce parathyroid hormone. Despite palliative radiotherapy to the metastases, the patient died within 3 months from end-organ failure related to hypercalcaemia.

To evaluate organisational reporting infrastructure and patient-related reporting data in the diagnosis of vertebral fragility fractures (VFFs) as demonstrated on computed tomography (CT). Organisational and patient-specific questionnaires were developed by consensus between The Royal College of Radiologists, the Royal College of Physicians, and the Royal Osteoporosis Society. The patient-specific component of the audit involved analysis of CT reporting data acquired from 50 consecutive non-traumatic studies including the thoracolumbar spine. Ethical approval for this type of study is not required in the UK. All UK radiology departments with an audit lead (auditor) registered with The Royal College of Radiologists (RCR) were invited to participate in this retrospective audit. In total, 127 out of 202 departments (63%) supplied data to the study, with inclusion of 6357 patients. Overall, 1362/6357 patients (21.4%) had a fracture present on auditor review of the CT imaging. There was a lack of compliance with all audit standards: 79% of reports commented on the vertebrae (target 100%), fracture severity was mentioned in 26.2% (target 100%), the recommended terminology ‘vertebral fracture’ was used in 60.1% (target 100%), and appropriate onward referral was recommended in 2.6% (target 100%). The findings from this study should be used to provide impetus to improve the diagnosis and care for patients with osteoporotic VFFs. Solutions are multifactorial, but radiologist and local osteoporosis/fracture liaison service engagement is fundamental, combined with necessary development of electronic report notification systems and expansion of supporting fracture services. • Early detection and diagnosis of vertebral fragility fractures (VFFs) significantly reduce patient morbidity and mortality. This study describes the results of a retrospective UK-wide audit evaluating current radiology reporting practice in the opportunistic diagnosis of VFFs as demonstrated on computed tomography (CT) studies including the spine. • Key audit standards included comment made on bone integrity in primary report (target 100%), comment made on severity of fractures (90%), report used recommended terminology ‘fracture’ (100%), and report made appropriate recommendations for referral/further assessment (100%). The audit results demonstrated a lack of compliance with all audit standards; lack of compliance was most marked in the use of recommended terminology (achieved 60.3%), in relation to comment on fracture severity (achieved 26.2%) and for recommendation for referral/further assessment (achieved 2.6%). • Solutions are challenging and multifactorial but the opportunity exists for all radiologists to examine their practice and directly improve patient care.

Editor – We read with interest the CME masterclass on multiple myeloma.[1][1] We would like to highlight, however, recent changes to imaging in myeloma involving whole body magnetic resonance imaging (MRI), reflected in the 2016 National Institute for Care and Health Excellence (NICE) guidance for

An 84 year old woman with a history of atrial fibrillation, angina, and transient ischaemic attack presented to the emergency department with vomiting and acute abdominal pain, most severe in the right iliac fossa. She reported no alteration in bowel habit. During a recent hospital admission following a fall at home, the patient had not reported any abdominal pains and she had been well at the time of discharge. Initial observations were within normal limits and clinical examination revealed generalised abdominal tenderness. Blood results showed a metabolic acidosis, elevated lactate, and raised inflammatory markers (table 1). She was referred for urgent …

Pilonidal disease is a common condition, typically occurring in the natal cleft of adult males. Other sites of pilonidal sinus are rarely reported. We report a case of periareolar pilonidal abscess in the breast of a 52-year-old woman who presented via the breast clinic complaining of nipple inversion and pain. Clinical examination and imaging revealed an underlying abscess which recurred despite antibiotic therapy and needle aspiration; the patient therefore underwent surgical excision of the abscess cavity. Subsequent histology diagnosed pilonidal abscess, an important differential to consider in the case of breast abscess, particularly in cases that are slow to resolve or recur post-treatment.

Aim To compare paediatric radiology provision across the UK with national standards published by the Department of Health and the Royal College of Radiologists (RCR). Materials and methods Audit standards and indicators for paediatric imaging were derived from "Delivering quality imaging services for children", 1 "Standards for imaging in cases of suspected non-accidental injury" 2 and "Improving paediatric interventional radiology services" 3 and agreed jointly by the Clinical Radiology Audit Committee and the British Society of Paediatric Radiology. A questionnaire was sent to all hospitals and NHS trusts imaging children aged 16 or younger in the UK in October 2013. The target for all indicators was 100%. Eighty-seven of 196 (44%) eligible institutions submitted data, the size distribution of the institutions was representative when compared to data from "Facing the future: a review of paediatric services" 4 published by the Royal College of Paediatrics and Child health. Results Only 65% of paediatric images were obtained by staff who had had specific training and only 60% were reported by radiographers or radiologists with appropriate training. Sixty-two percent of centres did not have access to a paediatric opinion 24 hours a day, 7 days a week all year; only 34% of radiographers who regularly imaged children had had any access to continuing professional development (CPD) in the 12 months of the audit. Although all hospitals had facilities for image transfer, only 57% had any formal funding arrangements in place for external reporting of images. Conclusions The standards set for a network approach to paediatric radiology provision in "Delivering quality imaging services for children" are largely unmet. This failure to make the most of the workforce and resources puts vulnerable children at risk. The authors urge NHS England to work with the RCR to organise and administer a national network for paediatric imaging.

Liver biopsy is an integral part of evaluation of liver disease. Indications and techniques have developed to allow functional and prognostic liver assessment, along with biochemistry and dynamic imaging, in both diffuse and focal liver disease. However, non-invasive techniques are changing the way clinicians use liver biopsy.

Kenneth Arthur Howlett (“Ken”) was the eldest son of a London dockyard worker. After evacuation to Wales during the blitz, he passed his 11+examination and attended Archbishop Tenison’s grammar school (as it was then) in Kennington, south London. From school Ken obtained a scholarship and was accepted for officer training at the Sandhurst military academy. From there he entered the Royal Artillery and rose to the rank of major in an anti-aircraft regiment. After several years in …

A 48 year old woman attended the emergency department with a sudden onset of severe abdominal pain, worsening over the few hours before presentation. She underwent a computed tomography scan for further assessment. An axial section through the pelvis is included (fig 1). What radiological sign is present? Fig 1 Multiple dilated bowel loops of small bowel are seen in the pelvis, with extensive bubbles of air seen within the bowel wall (fig 2, arrows). This sign is known as pneumatosis intestinalis. Most cases occur in the jejunum and ileum. A small number involve the colon12 (pneumatosis coli).3 The left side is more commonly affected than the right.2 Fig 2 Arrows point to extensive …

Stroke poses a significant burden on healthcare and is the second largest cause of death globally. Both medical and surgical interventions to reduce the risk of stroke in asymptomatic patients have been shown to be effective but identifying the target at risk population is more problematic. Screening for carotid artery stenosis offers one pathway for this, as there is some correlation between risk of stroke and extent of stenosis. Identification of patients who are at risk of cardiovascular disease as well as stroke, allows initiation of effective medical treatment of modifiable risk factors to address this risk. In addition, carotid intima-media thickness is a way of assessing systemic atherosclerosis and may be valuable in risk stratification of patients for cardiovascular disease. Given the low prevalence of stenosis in the general population and the risks associated with undergoing surgical intervention, population wide screening is not recommended. This recommendation has not changed over the last 15 years, since the last major studies evaluating management and outcomes were published. However, both medical and surgical/endovascular treatments have advanced over that time. Further studies are underway to compare current treatments for the appropriate management of both symptomatic and asymptomatic patients with stenosis. Two of these trials, ECST-2 and CREST-2, are expected to be completed in the next 2-4 years and the results may initiate changes in the recommendations. The use of carotid intima-media thickness alongside traditional risk scores is controversial and more research is required in this area.

IgG4-mediated sclerosing fibroinflammatory disease is a rare systemic disease which has the ability to form masses in multiple organs and may mimic malignancy. In this case we describe a 53-year-old female who presented with clinical and imaging findings in her right breast consistent with inflammatory breast carcinoma and associated right axillary nodal mass. She underwent CT which also uncovered a left thyroid mass and suggested both masses were possibly malignancies. She proceeded to ultrasound-guided core biopsy of each, which showed an appearance characteristic of IgG4-mediated sclerosing fibroinflammatory disease. The patient was treated with steroids with good outcome. This is the first described case of this condition presenting in this way to our knowledge and this diagnosis should be considered in patients with similar presentations.

Use of magnetic resonance enterography has significantly increased and its role as an adjunct to ileocolonoscopy is best practice, particularly in the evaluation of Crohn's disease. This article reviews magnetic resonance enterography, and describes common findings related to Crohn's disease and unexpected extra-intestinal findings.

A wide range of pathologies may arise from the submandibular space (SMS) or submandibular gland (SMG) in children. We review herein the normal anatomy of the SMS and describe the role of imaging in the evaluation of SMS lesions. A schematic approach for the categorisation of SMS pathology based on imaging characteristics is provided.

Objective Current European Society for Medical Oncology (ESMO) guidelines recommend that when feasible, surgical excision biopsy (SEB) is the ideal for diagnosis, sub-typing and grading of malignant lymphoma. We undertook this retrospective study to assess the diagnostic accuracy of image-guided core needle biopsy (CNB) in the diagnosis of malignant lymphoma, to identify the proportion of cases from which oncological treatment was subsequently instigated from the CNB diagnosis, and to evaluate the potential role for minimally invasive CNB techniques in the diagnostic pathway of malignant lymphoma. Methods All cases of lymphoma amenable to CNB between 2008 and 2013 were included. Patient records were reviewed to identify the biopsy diagnostic pathway undertaken (fine needle aspiration cytology, CNB, surgical excision biopsy). CNB specimens were graded as fully diagnostic (tumour sub-typing/grading and treatment initiated), partially diagnostic (diagnosis of lymphoma but more tissue required for sub-typing/grading), equivocal or inadequate. The effects of anatomical location, needle gauge, number of core specimens and sub-type of disease on the diagnostic yield of the sample were analysed. Results 262 patients and 323 biopsy specimens were included in the study. 237 patients underwent CNB as the initial diagnostic intervention. In 230/237 CNB was fully diagnostic (97%), allowing initiation of treatment. In 7 patients, SEB was necessary in addition to CNB to provide additional diagnostic information to allow initiation of treatment. In 72 patients, SEB was the only diagnostic test performed. Conclusion Our study showed that in 97% of suitable cases, CNB provided sufficient diagnostic information to allow treatment of malignant lymphoma to be instigated. This minimally-invasive technique is well tolerated and has advantages over surgical techniques, including reduced costs, post-procedural complications and delays on the diagnostic pathway. CNB may obviate the use of surgical techniques in the majority of suitable cases, however its success is dependent on close collaboration and acceptance by clinicians and pathologists.

A 68 year old woman presented with worsening shortness of breath on exertion. She had a history of polycystic kidney disease, chronic renal failure, renal transplant, and secondary hyperparathyroidism and hypercalcaemia while she was on dialysis. She had left mastectomy for breast cancer, and was on multiple medications including tacrolimus and prednisolone. Blood tests and clinical examination were unremarkable but a chest radiograph noted multiple bilateral nodular densities. Therefore a computed tomography scan was organised. What does this cross-sectional computed tomography scan (fig 1, lung window) show? Fig 1 Axial chest computed tomography scan image Diffuse ill-defined centrilobular areas of rounded parenchymal lung density with associated calcifications, consistent with metastatic pulmonary calcifications. …

Melanomas are aggressive cancers that present as cutaneous, mucosal and ocular lesions with the ability to metastasise widely. There are, however, occasions where lesions are found in distant sites such as lymph nodes, viscera and subcutaneous tissues without clinically apparent skin involvement. This is known as metastatic melanoma of unknown primary (MUP). Its presentation in skeletal muscle is rare, and the available literature is sparse. This article presents an 85-year-old woman with a MUP presenting in the right temporalis muscle, which was diagnosed with the aid of the ultrasound-guided core biopsy. The melanoma deposit was successfully excised, and no recurrence was identified. The patient is now under close follow-up.

A 65 year old woman had an in-hospital cardiac arrest after hip replacement, and had a prolonged period of hypoxia during resuscitation. Spontaneous circulation was achieved and she was transferred ventilated to intensive care. She remained unconscious and underwent cranial computed tomography (CT) (fig 1). What does the cranial CT show? Fig 1 Axial unenhanced computed tomography (CT) section at the level of the basal cisterns There are changes of cerebral oedema with secondary apparent high density in basal cisterns and fissures—“pseudo-subarachnoid haemorrhage.” ### Discussion Unenhanced CT shows generalised reduced attenuation of the brain parenchyma, with loss of grey/white matter differentiation and effacement …

Metastatic disease affecting the submandibular gland is a rare entity, with just over a 100 cases documented. We present the case of a 55-year-old female with an apparently operable oesophageal primary adenocarcinoma, who was identified on staging PET scan and confirmed on ultrasound-guided biopsy to have metastatic disease in her left submandibular gland. The imaging and pathological findings are presented and compared with the current body of literature. Previously recognized primary sites of metastasis include the breast, thyroid, lung and genitourinary organs. We believe this to be the first documented case of oesophageal adenocarcinoma metastasising to the submandibular gland.

An interesting and rare case where a longstanding multinodular goitre causes sudden onset symptoms of superior vena cava obstruction. The symptoms were caused by bilateral brachiocephalic vein compression against the first rib. The patient's symptoms included upper limb and facial swelling, whereas her lower limbs were not oedematous (figure 1). The patient underwent CT imaging which showed a multinodular retrosternal thyroid filling the space created by the first rib, sometimes known as the thoracic outlet. The goitre expanded sufficiently to compress the brachiocephalic vein on both sides as shown in figures 2 and 3. This prevented venous drainage from the upper limbs and head. The goitre was also large enough to cause deviation of the trachea although there was no airway compromise. This case is interesting as it is very rare for a benign condition such as a multinodular goitre to cause symptoms of superior vena cava obstruction.

Objective:We report a case of a patient with symptomatic primary hyperparathyroidism who was found, through a thorough radiological investigation, to also have papillary and medullary thyroid carcinomas.Case report:A 59-year-old female was diagnosed with primary hyperparathyroidism. A further radiological investigation found suspicious areas within both thyroid lobes that were later diagnosed as foci of papillary and medullary thyroid carcinomas. Appropriate treatment was commenced. Reports of similar occurrences of synchronous thyroid and parathyroid pathologies are discussed.Conclusion:To our knowledge, this is the first reported case of two synchronous thyroid cancers occurring in the context of primary hyperparathyroidism. We strongly recommend a thorough radiological investigation of all patients with primary hyperparathyroidism to prevent missing concurrent thyroid cancers.

A 64 year old woman presented to the emergency department with a history of sudden onset severe generalised headache after waking, associated with nausea. She had no medical history. On examination, the pain had not eased but she appeared alert with no other discernible features. She underwent a computed tomography scan of the head (fig 1). What is the diagnosis, and are further investigations warranted? Fig 1 Axial unenhanced computed tomography section at the level of the pons Perimesencephalic subarachnoid haemorrhage …

A 52 year old woman with a history of breast cancer has pain in her right hip after a minor fall. What does the radiograph of her right hip (fig 1⇓) show? Fig 1 Radiograph of the right hip The radiograph shows a pathological avulsion fracture of the lesser trochanter (fig 2⇓). There is proximal femoral lucency, which represents an underlying bone …

A 59 year old woman with diabetes mellitus presented to her general practitioner with a swollen, erythematous, and painful left foot. Her symptoms had been worsening over several months. There was no history of a recent trauma. A plain radiograph was obtained (fig 1⇓). What does this show? Fig 1 Plain x ray of a left foot Neuropathic osteoarthropathy, sometimes known as a Charcot foot. ### Discussion The findings on the radiograph are consistent with advanced neuropathic osteoarthropathy, …

A 35 year old man presented to his general practitioner with lower back pain that was getting progressively worse. The pain was now severe enough to wake him in the night. What does the radiograph show (fig 1⇓) and what is the diagnosis? Fig 1 The radiograph shows multiple signs pointing to …

A 75 year old woman was referred to the emergency department from her nursing home because of increasing confusion. She had a history of falls and was taking warfarin for atrial fibrillation (international normalised ratio 2.6). On examination the patient appeared confused but had no focal neurological deficit. She underwent cranial computed tomography (CT) (fig 1⇓). What does this show? Fig 1 The CT scan shows two subdural haematomas: one on the right (fig 2 …

A 24 year old woman was admitted to the surgical assessment unit with a tender, distended abdomen. She mentioned increasingly frequent bloody diarrhoea for the past week. Clinically she was dehydrated and pyrexial (38.6°C). She was also tachycardic (124 bpm) and had a raised white cell count (14×109/L). A supine abdominal radiograph was obtained (fig 1 …

A 60 year old woman presented with a hoarse voice and persistent dry cough. Flexible nasendoscopy showed a smooth, round swelling on the posterior third of the tongue. What abnormality is shown in the midline at the posterior tongue base on this axial T2 weighted magnetic resonance image (fig 1⇓)? Fig 1 Axial section, T2 weighted magnetic resonance image at the level of the tongue base. A cystic remnant of the thyroglossal duct (thyroglossal cyst). ### Discussion The magnetic resonance image shows a thin walled, cystic lesion in the …

An 80 year old woman presented to the emergency department with increasing shortness of breath on exertion and “noisy breathing.” She was easily able to complete full sentences, but on examination there was a faint biphasic stridor. The patient stated that she had been breathing like this for months but that it was slowly worsening. She had no polyphonic expiratory wheeze and on …

A 72 year old woman was referred to the respiratory clinic with a recent history of cough and haemoptysis. She had no history of smoking or weight loss. What does this plain chest radiograph show (fig 1)? Fig 1 A pulmonary fungal ball within the …

A 38 year old man presented to the emergency department with a 12 hour history of central and right sided severe abdominal pain. The pain had been getting gradually worse, he had vomited, and he was finding it difficult to walk. On examination he looked unwell, his temperature was …

Aims. To identify the prevalence of colonic and extraenteric incidental findings in magnetic resonance enterography (MRE) and their clinical significance.Methods. We retrospectively analysed 470 MRE studies carried out between March 2012 and 2014. Incidental findings were defined as those not expected from or made apparent on the referral. MRE reports were reviewed for colonic and extraenteric findings, subcategorised into “clinically significant” and “insignificant.” Follow-up was identified from the electronic patient record.Results. The majority of MRE requests were made for inflammatory bowel disease (97%). In total, 114 incidental findings were noted in 94 (20%) scans performed. There were 29 “colonic” findings (25%) with 55% having a diagnosis of colitis. Out of 85 extraenteric findings, ovarian cysts (25%), renal cysts (10%), and abdominal lymphadenopathy (9%) were the commonest. Cumulatively, 59 cases were clinically significant (52%); of these, 30 findings were not previously diagnosed, amounting to 26% of all incidental findings. This led to intervention in seven patients.Conclusions. Incidental findings are common in MRE and there is a substantial proportion that is clinically significant and requires further investigation. There need to be stratification of risk and employment of local guidelines in order to achieve this.

Introduction This study aims to review our 11 year experience of diagnosing metastatic squamous cell carcinoma presenting as head and neck lumps. The techniques of Ultrasound guided Core Biopsy (USCB), Fine Needle Aspiration Cytology (FNAC) and Surgical Excision Biopsy (SEB) are compared. Materials and methods All patients with metastatic squamous cell carcinoma (SCC) involving the lymph nodes of the head and neck or parotid gland, diagnosed at Eastbourne District General Hospital between January 1998 and November 2009 were identified. The following data items were collated: biopsy location (e.g. cervical lymph node or parotid), any history of likely primary SCC and site, type of biopsy used to establish a conclusive diagnosis (index diagnostic technique), previous biopsies, the technique and their results, subsequent histology results. Results A total of 90 patients were diagnosed with metastatic squamous cell carcinoma. The index diagnostic technique was USCB in 48 patients, FNAC in 29 and SEB in 13. In 72 (80%) patients the index biopsy was the sole tissue sample taken prior to surgery or other treatment. The remaining 18 patients underwent a total of 22 previous biopsies prior to the index biopsy. 95% (21/22) of these previous biopsies were non-definitive FNAC and 5% (1/22) was a non-definitive USCB. FNACs also demonstrated the highest non-diagnostic rate (42%). The accuracy of USCB and FNAC in correlating with final histopathology was 97% and 85% respectively. Conclusions USCB demonstrates excellent results in the diagnosis of metastatic SCC in the head and neck with higher accuracy and greater reliability than FNAC.

This retrospective study aimed to evaluate the diagnostic utility of ultrasound-guided core biopsy (USCB) in lymphoma of the head and neck, in particular whether core biopsy can provide sufficient diagnostic information for definitive treatment.All lymphomas diagnosed in the head and neck at Eastbourne General Hospital between January 2000 and June 2009 were identified. Radiology and pathology reports were reviewed and the diagnostic techniques recorded. The type of biopsy (fine needle aspiration, needle core, surgical excision biopsy) used to establish a diagnosis sufficient to allow treatment, i.e. the "index" diagnostic technique, was identified. Previous inconclusive or inadequate biopsies were noted. Pathology reports based on USCB were graded 0-3 according to diagnostic completeness and ability to provide treatment information.Of 691 overall cases of lymphoma diagnosed over the 9 year period, 171 different patients presented with lymphoma in the head and neck. Of these 171, 83 had USCB biopsy during diagnostic work up. 60 were regarded as grade 3 where a confident diagnosis of lymphoma was made. In seven patients, clinical management proceeded on the basis of a suggestive (grade 2) pathology report without surgical excision, and these were therefore also included as "index" biopsies. Overall therefore, 67/83 core biopsies (81%) provided adequate information to allow treatment. Surgical excision biopsy was the index modality in 104 cases.In the majority of cases USCB is adequate for confident histopathological diagnosis avoiding the need for surgical excision biopsy in cases of suspected head and neck lymphoma.

Ultrasound-guided wire localization of impalpable lesions is a well-recognized technique in the management of breast pathology, but its use in the head and neck is not well described. Performed under local anesthesia, high-resolution ultrasound provides real-time imaging for accurate placement of the wire resulting in fewer complications. Wire localization can focus the surgical approach, which reduces operating time and minimizes trauma to surrounding tissues. In this technical note, we describe two cases of pre-operative ultrasound-guided wire localization to facilitate the surgical excision of impalpable neck lesions.

A 34 year old woman presented to the emergency department with a history of worsening right iliac fossa pain over several days. She described the pain as alternating dull and sharp, and had found simple analgesia (paracetamol, non-steroidal anti-inflammatory drugs) to be ineffective. She had no other associated signs or symptoms and no history other than insertion of an intrauterine contraceptive device (IUCD) several years ago. A transvaginal ultrasound was unremarkable except that it showed a trace of free fluid in the pelvis, close to the uterus, and the IUCD was not visualised. The patient …

This article reviews the role of imaging in the management of trauma patients. First the trauma series is reviewed, principally the chest, pelvis and cervical spine radiographs along with an approach to their interpretation. The role of computed tomography in trauma imaging is then discussed.

Interventional radiology uses a range of radiological techniques to precisely and accurately diagnose and treat pathologies. This article discusses patient preparation and selection and highlights its strengths and weaknesses as well as introducing its use in each of the systems of the body.

This is a case of a woman in her fifth decade of life who presented with a lump in her left breast. The patient underwent extensive breast investigations which did not confirm one particular diagnosis. The lesion was excised, and histological findings confirmed the diagnosis of a giant breast hamartoma. This case is interesting due to the largeness. As well as this, giant breast hamartomas are uncommon, and this case highlights the difficulty in their diagnosis and frequent misdiagnoses, potentially contributing to their reported low incidence rates. Diagnosis is difficult due to the complex appearance of the mass on imaging, raising the possibility of malignancy. Core biopsy is unremarkable, with the final diagnosis only possible on histological examination of the resected mass.

Aim To assess the accuracy of ultrasound in characterizing benign and malignant parotid lesions and to review their sonographic features. Materials and methods A retrospective analysis of 220 ultrasound examinations was undertaken in 220 patients who presented with palpable parotid lesions over an 11-year period and correlated with the clinico-histopathological findings. The original sonographic diagnosis was compared to the final histopathology and lesions characterized using previously established sonographic criteria. Results Histopathology results were available for all patients. Two hundred and one patients had focal lesions: 29 carcinomas, 21 lymphomata and 151 benign lesions (including 69 pleomorphic adenomas and 54 Warthin's tumours); 19 patients did not have focal lesions. The initial ultrasound report was indeterminate in 25/201 focal lesions. In the remaining 176 lesions, the sensitivity, specificity, and diagnostic accuracy for malignancy of ultrasound was 91, 93, and 93%, respectively. There were four false-negatives and nine false-positives with a crossover of apparently benign and malignant features. Pleomorphic adenomas and Warthin's tumours were poorly differentiated using ultrasound. Additional impalpable parotid lesions or adenopathy were detected in 44 patients using ultrasound. Conclusion Ultrasound is a valuable adjunct to clinical examination, accurately differentiating benign from malignant lesions and diagnosing non-focal disease. There is an overlap in features of pleomorphic adenomas and Warthin's tumours and of some benign and malignant lesions. Diagnostic ultrasound should be combined with needle biopsy in most patients to maximize diagnostic yield.