Search

Purpose In the management of thyroid nodules, although the potential for malignancy exists, there is also the potential for overtreatment of subclinical disease. Although the TI-RADS (Thyroid Imaging-Reporting and Data System) system outlines a risk stratification score based on suspicious ultrasound findings, it has not been universally accepted. Many TI-RADS 2 or 3 patients proceed to fine needle aspiration biopsy (FNAB), potentially unnecessarily. The aim of the study was to identify whether lesions within a multinodular goiter (MNG) without suspicious features can be followed with ultrasound rather than biopsied as is recommended for single nodules. Methods Pathology records were retrospectively analysed for proven MNGs over a 5-year period. A total of 293 cases were identified. FNAB, prebiopsy ultrasound images, and reports were identified for each case. Images were reviewed and assessed for sonographically suspicious criteria guided by TI-RADS. Logistic regression was applied to determine if any sonographic features were associated with neoplasia. Odds ratios with 95% confidence intervals were calculated. Results Of 293 samples, 14 (4.7%) were neoplastic. Having no suspicious features conferred an average risk of 0.0339 (95% confidence interval: 0.02831-0.04087) of neoplasia. Risk of neoplasm significantly increased by having 1 and >1 suspicious feature ( P < .001). Regarding cytological results, of 237 patients with Thy-2 cytology, 159 were followed up and 8 had a neoplasm. Conclusion Ultrasound can be used to estimate risk of neoplasia in MNG. In the absence of suspicious radiological findings, follow-up with ultrasound rather than FNAB may be appropriate in patients who have a low clinical suspicion for neoplasia.

Introduction A 13-year-old female, presented to the Paediatric Emergency Department (PED), with a 4 week history of bruising to her right upper limb. There was no concurrent history of trauma to the limb. Bruising was progressive, and the arm had become increasingly painful in the three days prior to presentation. On the night prior to presentation, swelling of the arm was noted with associated pain, which was worse on movement. Paraesthesia of the fingers of the affected limb was also noted. Past history Her past history was notable for asthma (mild, no previous admissions) and hypermobility syndrome. Medications There was no known drug allergies. She was not on any regular medications, including any form of contraceptive. Vaccinations were up to date. Family history was notable for Raynaud’s disease. There was no history of venous thromboembolism or any coagulation disorders. Examination On examination, a visibly swollen right upper limb was noted, with a 3 cm difference in circumference and bruising as described. Dilated tortuous veins were visible. The patient was tender to palpation over the biceps muscle and site of tendon insertion. Full power and range of motion was noted at both shoulder and elbow joints. Radial pulses were present and equal. The remaining systemic examination was unremarkable. Investigations Bloods normal, including coagulation US Doppler upper limb no obvious DVT. However, dilatation of basilic vein proximally, with a possible varicosity was noted MRA right upper limb large thrombus of right subclavian vein, protruding into right brachiocephalic vein and axillary vein CT pulmonary angiogram: significant reduction in costoclavicular distance (right>left), suggestive of a thoracic outlet obstruction Treatment Therapeutic subcutaneous low molecular weight heparin was commenced. The patient was admitted for further management, which included thrombectomy and heparin infusion. Discussion Paget-Schroetter syndrome, or primary ‘spontaneous’ DVT of the upper limb, is a condition which typically affects otherwise healthy individuals. It occurs as a result of anatomical abnormalities of the thoracic outlet, which results in compression of the axillosubclavian venous system and subsequent thrombosis. It is a rare condition that is, however, important to recognize promptly as early detection and treatment have been found to reduce long-term sequelae. This case, while rare, highlights the importance to us, as paediatric physicians, to consider in differential diagnosess, disorders and problems that would typically be more attributable to adult populations.

Ultrasound evaluation of the thyroid gland is relatively easy in most cases with excellent visualization of the gland with linear transducer allowing clear characterization of lesions as well as guidance for biopsy. However when retrosternal thyroid tissue extension is present, evaluation may be difficult. We report the simple use of widely available transvaginal probe in helping to visualize and evaluate the retrosternal thyroid tissue.

The diagnosis and management of vascular anomalies of the extremities can be challenging as these disorders are uncommon and may clinically overlap. The aim of this paper is to describe the clinical, radiologic, and histopathologic features of fibro-adipose vascular anomaly (FAVA), a previously unrecognized disorder of the limb.The clinical, imaging, operative, and histopathologic data from patients with a unique intramuscular lesion of the extremities comprising dense fibrofatty tissue and slow-flow vascular malformations were retrospectively reviewed.Sixteen patients diagnosed with FAVA of the extremity (3 male and 13 female individuals) met the clinical, radiologic, and histopathologic inclusion criteria. The age at presentation ranged from the time of birth to 28 years. The locations of the lesions were: calf (n=10), forearm/wrist (n=3), and thigh (n=3). Fourteen patients presented with severe pain. Seven of the patients with calf lesions had limited ankle dorsiflexion. On imaging, the complex intramuscular lesions replaced muscle fibers with fibrofatty overgrowth and phlebectasia (dilation of the veins). The extrafascial component comprised fatty overgrowth, phlebectasia, and an occasional lymphatic malformation. The histopathologic features comprised dense fibrous tissue, fat, and lymphoplasmacytic aggregates within atrophied skeletal muscle. Adipose tissue also infiltrated skeletal muscle at the periphery of the lesion. There were large, irregular, and sometimes excessively muscularized venous channels and smaller, clustered channels. Other findings include organizing thrombi, a lymphatic component, and dense fibrous tissue-encircled nerves.The constellation of clinical, radiologic, and histopathologic features constitutes a distinct entity comprising fibrofatty infiltration of muscle, unusual phlebectasia with pain, and contracture of the affected extremity. The clinical and radiologic findings permit the diagnosis of FAVA with major therapeutic implications.Level III.

Meningioma growth has been previously described in patients receiving oestrogen/progestogen therapy. We describe the clinical, radiological, biochemical and pathologic findings in a 45-year-old woman with congenital adrenal hyperplasia secondary to a defect in the 21-hydroxylase enzyme who had chronic poor adherence to glucocorticoid therapy with consequent virilisation. The patient presented with a frontal headache and marked right-sided proptosis. Laboratory findings demonstrated androgen excess with a testosterone of 18.1 nmol/L (0–1.5 nmol) and 17-Hydroxyprogesterone >180 nmol/L (

Avascular necrosis (AVN) is a rare presenting feature of endogenous hypercortisolism. If left untreated, complete collapse of the femoral head may ensue, necessitating hip replacement in up to 70% of patients. The majority of the described patients with AVN due to endogenous hypercortisolaemia required surgical intervention. A 36-year-old female, investigated for right leg pain, reported rapid weight gain, bruising and secondary amenorrhoea. She had abdominal adiposity with violaceous striae, facial plethora and hirsutism, atrophic skin, ecchymosis and proximal myopathy. Investigations confirmed cortisol excess (cortisol following low-dose 48h dexamethasone suppression test 807nmol/L; 24h urinary free cortisol 1443nmol (normal

Peripancreatic pseudoaneurysm formation is a recognized complication of pancreatitis. When associated with an acute episode of pancreatitis, surgical treatment is often difficult due to the inflammatory process that surrounds the pseudoaneurysm. In the stable patient, transcatheter embolization is the treatment of choice of this complication. However, this is not always technically feasible, as the aneurysm may be supplied by small inaccessible branch vessels. Recently, percutaneous thrombin injection has been described as a possible alternative for pseudoaneurysms. This is generally performed under computed tomography guidance in stable patients with non-ruptured pseudoaneurysms. We describe an acutely ruptured peripancreatic pseudoaneurysm in a critically ill patient, in whom percutaneous thrombin injection under computed tomography guidance resulted in immediate stabilization and cure of the pseudoaneurysm.

We describe an inferior vena cava filter retrieval technique requiring triple venous access performed in a 35-year-old male who was referred for filter removal 16 months after its insertion. The filter showed a right-sided tilt with endothelialization of the distal filter struts into the caval wall. Access was required via both internal jugular veins to straighten the filter using a snared-loop technique. Further 18 F right common femoral vein access was required to snare and remove the filter, which could not be completely collapsed distally due to endothelialized tissue, precluding normal removal via the jugular venous route.

The purpose of this study was to evaluate the safety and efficacy of sonography-guided percutaneous core needle liver biopsy in infants and children.We conducted a retrospective analysis of all patients who underwent sonography-guided percutaneous core needle liver biopsies over a 7.5-year period by pediatric interventionalists at a single tertiary center.A total of 597 procedures were performed in 470 patients (270 male and 200 female), with a mean age of 10.5 years (age range, 1 month-21 years). The main indications for biopsies were abnormal liver enzymes (n=129, 21.6%), grading and staging of chronic hepatitis B or C (n=105, 17.6%), evaluation of transplanted liver (n=111, 18.6%), iron overload (n=73, 12.2%), miscellaneous other diffuse parenchymal abnormalities (n=124, 20.7%), and focal hepatic lesions (n=55, 9.2%). The procedures were performed either under sedation (n=311, 52.1%) or general anesthesia (n=286, 47.9%). Diagnostic yield was obtained in 596 biopsies (99.8%) from an average of 2.4 cores in patients with diffuse disease (n=541, 90.6%) and 6.5 cores in patients with focal disease (n=55, 9.2%). Ten patients (1.7%) experienced a major complication, including pneumothorax (n=1, 0.2%), abdominal wall pseudoaneurysm (n=1, 0.2%), and symptomatic bleeding (n=8, 1.3%). Five of these children required transfusion, two were only admitted for observation, and one required surgical evacuation. There were no procedure-related deaths. Minor complications (n=49, 8.2%) included a symptomatic subcapsular hematoma (n=35) and stable small hemoperitoneum (n=9).Sonography-guided percutaneous core liver biopsy is a safe and effective procedure in children that has a high diagnostic yield and very low complication rate.

The development and improvement of interventional tools and image guidance has allowed for expansion of the use of percutaneous interventions in pediatric thoracic disorders. In this chapter, we discuss the main thoracic pathologies for which the interventional procedures offer a safe, minimally invasive therapeutic alternative. Integration of interventional procedures into the management of many of these disorders has become the standard of care at many institutions and a key component of a successful, interdisciplinary treatment plan.

Despite the frequency of open and laparoscopic herniorraphy the effect of the hernia and subsequent repair on testicular function is unknown. Our objective was to determine if there is an association between inguinal hernia and hernia repair on testicular function.Thirty-seven men aged 18 to 70 years were enrolled in a prospective internally controlled cohort study. They underwent Doppler ultrasonography and serum testicular hormone analysis pre- and post- either open Lichtenstein's repair or laparoscopic totally extraperitoneal hernioplasty. These surrogates of testicular function were measured up to 6 months postrepair.Thirty-seven consecutive patients underwent either Lichtenstein (n = 17) or totally extraperitoneal hernioplasty (n = 20) hernia repair as per surgeon preference. Preoperatively there was a significant elevation in the sonographic resistive index (RI) in the affected (hernia) side compared with the normal side (0.601, 0.569; p0.001). This elevation in RI was reversed posthernia repair at a median followup of 6.1 months. Inguinal hernia or repair did not affect testicular volume. The choice of either Lichtenstein or totally extraperitoneal hernioplasty hernia did not significantly alter the testicular function.Patients with inguinal hernia have an elevated testicular vascular resistance, which is reversed after repair. The choice of laparoscopic or open herniorraphy did not affect reversal of this surrogate of testicular function.

The authors report a case of a giant fibrovascular polyp of the oesophagus in which CT with multiplanar reformatting gave valuable information as to both location of the lesion as well as size and anatomical attachment proximally, which was pivotal in directing surgery. It was instructive in this case that initial endoscopy was reported to be normal. The lesion was well demonstrated by barium swallow.

A case of extraperitoneal leakage of dialysate producing massive acute scrotal oedema complicating peritoneal dialysis is presented. Important diagnostic features including select clinical images, the role of imaging modalities and appropriate management are discussed.

Delayed liver laceration following transjugular intrahepatic portosystemic shunt (TIPS) is a serious and likely underdiagnosed complication. It is however an important complication following TIPS, which remains one of the most technically challenging interventional procedures performed. In addition to laceration, a number of complications regarding bleeding and perforation are well described following TIPS procedures. We feel the adoption of techniques such as ours and that of other authors described in the literature using an ultrasound-guided percutaneous transhepatic approach with a small caliber needle provides a safer and less traumatic procedure and should reduce complications of bleeding and almost completely eliminate the risk of liver laceration. Our procedure was successfully performed under conscious sedation rather than general anaesthesia further reducing the overall procedural risk to the patient.