Radlink Issue 1 2008

NEWSNEWSCare • Comfor t • Connec t

A Publication Of Radlink Diagnostic Imaging (S) Pte Ltd • Issue No: 01-2008 • Mica (P) No: 050/02/2008

RadLink Diagnostic Imaging has provided state-of-the-art diagnostic imaging services to

the medical community since October 2000.

Our main centre located at Paragon Medical offers the full range of diagnostic scans. This includes our

3T High-Definition MRI, besides the other state-of-art imaging equipment.

We acquired Drs Lim, Hoe & Wong Radiology in December 2005 to help strengthen our presence in the

general practitioner community. With a branch located at Orchard Building and Jurong Point Shopping

Centre, this means more choice and convenience for your patients.

In July 2006, we opened a branch at Toa Payoh providing general radiology services catering to doctors

located in the central areas of Singapore.

In August 2007, we opened RadLink Women & Fetal Imaging Centre focusing mainly on expectant

mothers. This centre offers Ultrasound scanning including 3D and 4D scans by Consultants and

sonographers certified by the Fetal Medicine Foundation (UK).

We have 6 consultant radiologists who are subspecialty trained. Referring physicians would be able to

tap on their depth and breadth of diagnostic experience and collaborative support.

At RadLink, our exceptional imaging quality, compassionate care and accurate interpretations have

made us the preferred diagnostic imaging provider.

Our services

From the simple Chest X-ray to our latest 3T High-Definition MRI that provide clear views of the inner

structure and function of the body, our team of radiology professionals are ready to serve you.

Our 4 imaging centers offer a wide range of diagnostic exams and procedures. These services

include:

• MRI — 3T High-Definition & 1.5T • 64-Slice CT scanner

• Digital Mammography • Ultrasound / Colour Doppler

• Digital Radiography / Fluoroscopy • Bone Mineral Densitometry (DEXA)

Our branches:

• Paragon Branch • Orchard Building • Toa Payoh • Jurong Point

6836 0808 6737 3311 6255 0201 67926119

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Our Signa HDx 3.0T MRI system

from GE Healthcare helps doctors

definitively diagnose the most

complex cases. From sports

injuries to life-threatening heart

conditions, doctors can diagnose

them with confidence. The Signa

HDx 3.0T, which is more powerful

than previous generation MRI

systems, uses the latest High

Definition (HD) technology to

produce superb, high-resolution

images while eliminating past

trade-offs.

“MRI technology is now the

modality of choice for most sports

related injuries,” says Dr Tony

Stanley, Consultant Radiologist at

RadLink. “We often read about

MRI technology being used to

help doctors evaluate injuries in

professional athletes. Our new

at Paragon Branch

New Service

3T High-Defi nition MRI

Signa HDx 3.0T MRI scanner

Breast study

Musculoskeletal study

Neurological study

system allows us to diagnose and

characterize sports injuries in

more detail than ever before.”

Magnetic resonance imaging

uses radio waves and a strong

magnet field rather than X-rays

to produce very detailed, cross-

sectional images of the body. MRI

requires specialized equipment

and expertise and allows evaluation

of some body structures that may

not be as visible with other imaging

methods.

“The addition of our new MR

system has given us the ability to

provide better care for our patients

with state-of-the-art imaging.”

“We are pleased to be the

first in the South-East Asia to

offer the latest in High-Definition

(HD) MR imaging technology and

to provide the highest-quality

A new magnetic resonance imaging (MRI) system at RadLink Diagnostic Imaging #07-13 Paragon Medical, assists physicians in diagnosing a wide range of patient conditions and prescribing the right treatment to expedite recovery.

diagnostic power to patients and

their doctors,” says Mr. Hyder

Mukhthar. More information about

the new MRI system is available

by calling RadLink Diagnostic

Imaging at 68360808.

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We are pleased to inform you that Dr Anne Tan

Kendrick has joined our Diagnostic Imaging Centre

from 1st May 2008.

Dr Anne Tan Kendrick obtained her medical

degree from the Universities of Cambridge and

Oxford after receiving a President’s Scholarship.

She qualified as a radiologist in 1994 and has

worked in various hospitals, including the John

Radcliffe (UK), the Hospital for Sick Children

(Toronto), National University Hospital, Kandang

Kerbau Hospital and Raffles Hospital. As the former

Head of Paediatric Radiology Service at KKH from

1998 – 2004, she was responsible for starting up

the service and growing its clinical, teaching and

research arms. She was also the 1st radiologist

outside America and Europe to receive the Caffey

Award from the Society of Pediatric Radiology for

her work in diagnosing biliary atresia on ultrasound.

She is a member of several academic societies and

is on the board of reviewers for the international

journal, Pediatric Radiology. She has also served on

many hospital and government health committees,

and was the President of the Association of Women

Doctors from 2000-2004.

Dr Anne Tan Kendrick is happy to offer her help

in all aspects of diagnostic imaging, including adult

radiography, fluoroscopy, ultrasound, MRI and CT,

in addition to her special interests in Paediatric and

Women’s Imaging.

Her email is [email protected]

Dr Anne Tan Kendrick

With this new service, we come even closer

to the essence of what’s possible in the early

detection and fight against breast cancer.

New Consultant Radiologist:

at Paragon Branch

Full Field Digital Mammogram (FFDM)

The main benefits of FFDM are:

Low Dose Exposure — Revolution™ Csi

detector for superb image quality at low

dose

Optimised Patient Comfort — Ergonomic

paddles that shape to the breast

Outstanding Image Quality — Automatically

selects all exposure parameters based on

breast radiological properties

Fullest Field of View — Groundbreaking 24 x

31cm active field of view

Significantly Lower Recall Rate for FFDM

Positive Predictive Value (PPV) Higher for

FFDM

We have installed a GE Digital Mammography

System, Senographe DS at our Paragon branch.

This system incorporates the best of GE’s

technology and the most complete full-field digital

mammography system for all clinical needs.

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The goal of evaluating the solitary pulmonary nodule is to establish benignity or malignancy. Beside thin section computed tomography, PET-CT and even biopsy may be required.

DEFINITION

A solitary pulmonary nodule is defi ned as a single, round, fairly well marginated intra-parenchymal opacity less than 3cm in diameter. The arbitrary size limitation is based on the fact that larger lesions (termed masses) are more often malignant than those smaller than 3cm.

DIFFERENTIAL DIAGNOSIS

Mimics and pseudo lesions seen on the frontal CXR include bony islands, healing rib fractures, overlapping vascular shadows and thoracic spinal osteophytes. Many so called SPNs turn out to be multiple lesions on CT. Most benign SPNs are granulomas, hamartomas or intrapulmonary lymph nodes. Most malignant SPNs are bronchogenic carcinomas.

CHRACTERISTICS OF THE SPN

• Size

Larger lesions tend to be malignant. Although 80% of benign lesions are less than 2cm, small size is not a reliable indicator of benignity because 15% of malignant lesions are less than 1cm at

The Solitary Pulmonary Nodule

diagnosis and 42% are less than 2cm. With the advent of low dose CT for routine screening, more small lesions would be picked up.

• Density and internal characteristics

Calcifi cation

(a) Benign patterns of calcifi cations include central, solid, laminated, diffuse or popcorn.

(b) Not all calcifi ed lesions are benign as these may be engulfed by a scar carcinoma.

(c) Many “non-calcifi ed” SPNs on plain radiographs have calcifi cations on thin section CT.

Our Clinic

(d) The absence of calcium is of little diagnostic value because 40-60% of benign nodules and two-thirds of carcinoid tumours do not contain appreciable calcium. Also, 5% of malignant tumours may have calcifi cations.

Cavitation

(a) Both malignant and benign lesions may cavitate.

(b) Malignant lesions tend to have thick irregular walls measuring 15mm and more.

(c) Benign lesions tend to have thinner walls, often measuring less than 5mm. These include infectious granulomas, Wegener granulomatosis, abscesses and pulmonary infarcts.

Air-bronchograms

(a) The presence of air-bronchograms is not a characteristic of malignancy except for bronchioalveolar carcinoma and lymphoma.

(b) Air-bronchograms can also be seen in benign lesions such as organizing pneumonia, pulmonary infarcts and sarcoidosis.

Solitary Pulmonary Nodule

Review of prior radiologic studies

Pt.>35 yrs.Known malignancy

Smoker

No Prior radiographsEnlarging lesion

No growth over 2 yearsBenign calcification on CXR

Thin section CT

Benign Ca++Benign CT shape (AVM, roundedatelectasis, mucous plug, granuloma)

Hamartoma

Fat in smooth lobulated lesion < 3 cm

Absent/eccentric calcificationlobulated/spiculated margin

Benign SPN (granuloma, hamartoma)

Radiographic follow up

Radiographic follow upThin section x 2 yrs


Indeterminate SPN

Contrast enhanced CT PET Biopsy(TNB,VATS,TBNA)

+ enhancement - enhancement + uptake - uptake

Biopsy(TNB,VATS,TBNA)

Biopsy(TNB,VATS,TBNA)



Pt.<35 yrs.No primary malig.

Non smoker

Radiographic Followup

A PROPOSED DIAGNOSTIC ALGORITHM FOR THE APPROACH TO AN SPN

The solitary pulmonary nodule (SPN) is a commonly encountered clinical entity in both plain fi lm radiography as well as computed tomography (CT). An understated aspect of the evaluation of a solitary pulmonary nodule is establishing that the opacity seen on the CXR is indeed a true intra-pulmonary nodule. Once this has been established, the demographic features, including the patient’s clinical history, gender, age, smoking history, industrial or environmental exposure and prior malignancy all play an important part in the work-up of the SPN. These are independent of the imaging characteristics of the pulmonary nodule.

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Tubular or branching lesion

Would suggest benignity such as a mucocoele which would be readily apparent on thin section CT.

Fat

The identification of fat is an indication of benignity and is frequently (up to 50%) found in a pulmonary hamartoma, the third most common cause of SPN.

CT contrast enhancement

Requires pre and post-contrast acquisitions and is less accurate in larger lesions (more than 2cm) because of necrosis. Enhancement of less than 15HU is almost diagnostic of a benign lesion. Both infl ammatory and malignant lesions enhance and is therefore of limited value.

Vascularity

Malignant lesions may have enlarged supplying arteries or drainage veins. However, a tangle of vessels is in keeping with a diagnosis of an arterio-venous malformation.

• Margins

(a) A smooth, well-defi ned margin indicates benignity but 21% are malignant.

(b) Lobulated margins indicate uneven growth and suggest malignancy but 25% of hamartomas are lobulated.

(c) Spiculated margins result from cicatrization of the interstitium and is a sign of malignancy. Benign lesions with speculated margins include lipoid pneumonia, organizing pneumonia, tuberculoma and progressive massive fi brosis.

• Growth

(a) The rate of growth can be helpful.

(b) The lack of growth over at least a 2-year period is a reliable indicator of benignity.

(c) Very rapid growth on the other hand indicates an infl ammatory or infective cause.

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EXAMPLES OF A SOLITARY PULMONARY NODULE

(d) Doubling time is defi ned as a 26% increase in diameter.

(e) Computed tomography software can help calculate nodule volume.

PET-CT

Some indeterminate nodules will require further evaluation. The FDG uptake is measured semi-quantitatively and can be helpful in some cases. It is useful in distinguishing tumour and post-obstructive atelectasis. One of its principal advantages lies in mediastinal staging with a high negative predictive value of more than 90%, negating mediastinoscopy and biospsy. Detecting unsuspected metastases and recurrence are other advantages of PET-CT. Its main disadvantage is its high cost.

PATHOLOGIC DIAGNOSIS OF SPNs

Transthoracic needle biopsy

Image-guided transthoracic needle biopsy is a semi-invasive procedure of choice for defi nite characterization of peripheral SPNs. It is more sensitive for malignant lesions with a positive yield of more than 90%. Biopsy for benign lesions often yield a nonspecifi c infl ammatory return. Some benign lesions resist biopsy attempts because they are too sclerotic.

Bronchoscopy

Bronchoscopy is preferred for central lesions. Diagnostic yield from brushings, washings and endo or transbronchial needle aspirates vary widely with size and location of lesion and experience of bronchoscopist.

Video-assisted thoracoscopic Surgery (VATS)

Performed by a surgeon under general anesthesia and single lung ventilation. It is less invasive than thoracotomy and can be therapeutic for small lesions.

Dr Wang Wing YeeMBBS, FRCR, FAMS

Consultant Radiologist

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Case 4: 50 year old male. Biopsy of metastatic lymph node in neck yielded small cell carcinoma. CT thorax showed spiculated SPN posterior and inferior to the heart.

Case 3: 68 year old male with persistent cough. Screening low dose CT scan picked up SPN.

Case 2: 30 year old female. Pre-employment CXR. Persistent opacity left lower lobe. CT revealed left intralobar sequestration.

Case 1: 27 year old male with lobulated SPN found on routine pre-employment CXR. A small speck of calcifi cation is present and a hamartoma or granuloma is suspected.

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Our team of doctors will answer your

doubts and queries through state-

of-the-art imaging techniques.

Services provided at RadLink

Women & Fetal Imaging centre

include:

Viability Scans

These scans ensure the fetus is alive

and is able to date the pregnancy

for women who cannot recall their

last period, have irregular cycles,

or just unsure of dates. This is

extremely useful for those who

have previous miscarriages or

who are experiencing pain and/or

bleeding.

It can also determine the

number of fetuses present and

calculate the expected date of

delivery.

Nuchal Translucency (NT) ScanThis is used in the assessment of

the risk of Down’s Syndrome and

other chromosomal abnormalities.

Extensive research has established

that Nuchal Translucency (NT) can

detect 70% of affected fetuses.

The combination of, NT scan and

mother’s blood tests for free Beta-

HCG and PAPP-A improves the

rate of detection by up to 90%.

Fetal Anomaly (FA) ScanBetween 18 to 24 weeks into

pregnancy, the FA scan examines

in detail the brain, face, spine,

heart, stomach, bowel, kidneys

and limbs to ensure normal growth.

It may be conducted also to check

the placental position. Uterine

RadLink Women & Fetal Imaging Centre

Stop Press

blood flow and umbilical studies

can be performed for those with a

problematic obstetric history.

3D/4D Scans4D scans are really 3D scans taken

in real-time. They create dramatic

life-like views of your baby moving

inside you. 4D scans enable your

baby’s activity and well being to be

studied in greater detail. 4D scans

can aid in the confirmation of

normal development. Your baby’s

face can be seen best between

23 and 30 weeks into pregnancy.

4D scans can give you a unique

opportunity to bond with your

unborn baby.

Growth and Well-being Scans These scans aim to assess how

well the baby is growing. Placental

location, amniotic fluid volume,

umbilical artery and uterine arterial

Doppler can assess blood flow to

detect early intrauterine growth

retardation. For appointments and

enquiries, please call 6836 6288.

0 week 11-13 weeks 18-24 weeks 23-30 weeks 26 weeks onwards6-9 weeks

Viability scans NT scans FA scans 3D/4D scans Growth & well-being scans

Fig 1. Heartbeat

Fig 2. NT scan

Fig 3. 4 Chambers of heart

Fig 4. Orbits & cerebellum

Fig 5. 3D/4D scans

Fig 6. Growth & well-being scan

TYPICAL SCAN FLOWCHART FOR EXPECTANT MOTHERS

This centre started operations in August 2007 focusing mainly on expectant mothers. We offer Ultrasound scanning including 3D and 4D scans by Consultants and sonographers certifi ed by the Fetal Medicine Foundation (UK).

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The Lighter Side

Disclaimer: The above stories and articles are meant only to provide a brief, fleeting distraction from the wretchedness of reality, and are not intended to be insensitive, callous, or offensive, or to otherwise belittle the medical profession. Any resemblance to actual persons or events is purely coincidental.

1. Nitrates — Cheaper than day rates

2. Node — Was aware of

3. Outpatient — A person who has fainted

4. Post Operative — Letter carrier

5. Recovery Room — Place to do upholstery

6. Seizure — Roman Emperor

7. Terminal Illness — Getting sick at the

airport

8. Urine — Opposite of 'you're out'

9. Artery — The study of paintings

10. Barium — What Doctors do when patients

die

11. Caesarean Section — A neighbourhood in

Rome

12. Cauterize — Made eye contact with her

13. Colic — A sheep dog

14. Dilate — To live long

15. Enema — Not a friend

16. Fibula — A small lie

17. Impotent — Distinguished, well known

18. Labour Pain — Getting hurt at work

19. Morbid — A higher offer

Politically Incorrect Medical Dictionary

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OUR TEAMOUR TEAM

Dr Tony Stanley, MB Mch, FRCR, FAMS.

Special Interest: Musculoskeletal imaging

[email protected]

Dr June Chong LM, MBBS, FAMS, ABR, CAQ in Neuroradiology. Special Interest: Neuroradiology

[email protected]

Dr Ng Hweena, MBBS, FRCR. Special Interest: Obstetrics /Gynecology

[email protected]

Dr Wang Wing Yee, MBBS, FRCR, FAMS. Special Interest: Respiratory Imaging

[email protected]

Dr Anne Tan Kendrick, MA (Cantab), BM BCh (Oxon), FRCR (UK), FAMS Special Interest: Pediatrics & Women’s Imaging

[email protected]

Dr Michael Benedict Toh, MBBS, DMRD, FAMS Special Interest: General Radiology

[email protected]

Please contact: Group Markets & Business Development [email protected]

You can locate us at:290 Orchard Road #08-08Paragon MedicalSingapore 238859Tel : (65) 6836 0808Fax : (65) 6836 8484

Diary

2nd June 2008Relocation Notice for Jurong Point branch

Please be informed that as of 2nd June 2008, our Jurong Point branch will be located at:

1 Jurong West Central 2#B1A-19C Jurong Point Shopping CentreSingapore 648886

The contact numbers for this new location remain unchanged:Tel: 6792 6119 Fax: 6792 1170

2nd June 2008Mammography Services now available at Jurong Point branch

We are pleased to inform that mammography services will be available at our new branch at #B1A-19C from 2nd June 2008.

However, this service and Ultrasound service will only be available in the morning and strictly by appointment only.

The list prices are as follows:

Mammogram $100

Mammogram with Breast Ultrasound $150

Prices are subjected to prevailing GST.

For appointment, please call our Jurong Point branch hotline at 67926119.

6th June 2008Women Fetal & Imaging Centre (WFI)

Please take note that WFI is now part of RadLink Diagnostic Imaging. We are now situated at #08-08 Paragon Medical (within the premises of RadLink Diagnostic Imaging). We provide a comprehensive list of services catered to expectant mothers. Our services include:

• Fetal Vialibility Scan • Nuchal Translucency Scan (for Down syndrome)

• Fetal Anomaly Scan • Fetal Growth & Well-being Scan

• 4D Fetal Scan

Along with our highly skilled sonographers, our Consultants are certified by the Fetal Medicine Foundation (UK). Please call us at 6836 6288 to make an appointment.

To know more about us:www.radlinkasia.com

Our operating hours:Monday – Friday: 8.30am to 5.30pmSaturday: 8.30am to 12.30pm

Your comments and enquiries are important to us.

Radlink Issue 1 2008

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