Click image to enlarge Normal panoramic view

This is an excellent method of demonstrating virtually all mandibular fractures, including the coronoid and condylar processes. Be aware however; occasionally symphysis menti fractures may not be seen.

Ring mandibular fracture

Panoramic and cephalometric questions

Click image to enlarge

Cephalometric image

The following question was answered by an expert in the appropriate field:
QUESTIONS:

I have some questions regarding panoramic and cephalometric dental x rays.
1. I had a cephalometric x ray before removal of my wisdom teeth 10 years ago. Given that the patient's brain is being irradiated in this exam, what is the value of having a cephalometric x ray done for the extraction of wisdom teeth? It seems to me that the area of interest is in the mouth/jaws of the patient, not the entire skull.

2. I recently had a panoramic dental x ray done. The machine used was a Yoshida 10CSU. Does the patient's head/neck region receive a huge amount of radiation from this procedure since the axis of rotation is in head/neck area?

3. I've read on some Web sites that the amount of radiation that I was exposed to is equal to the amount of radiation one receives from a cross-country flight or from a few days' worth of natural background radiation. Does this mean that a panorex will expose the organs (thyroid, brain, skin, and bone marrow) to the same amount of radiation as a few days' worth of natural background radiation or a cross-country flight?

4. Do digital panoramic machines use rare earth/image intensifying screens?

5. Do digital panoramic machines use less radiation than film-based panoramic machines? If so, how much less?

6. How much radiation does the brain, thyroid, skin, and bone marrow each receive in each of these procedures (in mrems)?

7. Why is ESE (Entrance Skin Exposure) no longer being used?

8. Can you explain what effective dose is? All the definitions that I've seen on the Web for effective dose seem very confusing.

ANSWERS

Answers: 1. I am very surprised to hear that you had a cephalometric radiograph done for wisdom teeth. Most dentists/oral surgeons prefer a panoramic radiograph so they can judge the relationships of the third molars or wisdom teeth to the adjacent teeth and nerve canal. I have never heard of anyone using a cephalometric radiograph for that purpose. Since it was so long ago, perhaps you might not be remembering the examination correctly.

2. The axis of rotation in a modern panoramic x-ray machine is constantly moving, unlike the original model that had a single rotation point. Therefore, no single spot is receiving a "huge" amount of radiation. In fact, a panoramic radiograph is one of the lowest dose dental examination techniques available today.

3. In order to compare exposure to a limited portion of the body, such as from a dental panoramic radiograph with other examinations or to exposure to the entire body as from background radiation, the exposure is commonly expressed in terms of effective dose. The dose to each tissue exposed is measured and then weighted by the type of radiation and then by a factor that accounts for the tissue's sensitivity to radiation. These weighted doses are then summed to arrive at the effective dose. This unit allows us to compare the radiation risk of the limited body exposure to the risk of a total body exposure. When we do that for a panoramic radiograph, the numbers you cited from the Web sites are typical. While certain organs receive more than that value, it is the risk to the entire body that is calculated for an effective dose. Unless someone has a special concern about a specific organ, the effective dose appears to be a useful and valuable quantity.

4. No. Standard film-based panoramic machines use rare-earth intensifying screens to reduce the amount of radiation required. Depending on the speed of the system, a dose reduction of up to 1/60 can occur compared with direct exposure film. Digital panoramic machines use an electronic detector which is either a CCD, i.e., a charge-coupled device which similar to what is in a digital camera, or a photo-stimulated storage phosphor.

5. This is highly dependent on the individual machine. There is a paper that will be published soon in Dentomaxillofacial Radiology (DMFR) that summarizes the doses for film-based panoramic machines and measures the doses for several digital machines (Gijbels et al. 2005). The article will probably be in the May or July issue of DMFR.
Typically, the effective dose for film-based panoramic examinations range from 3.9 to 10 µSv. The effective dose for digital panoramic exams range from 2.5 to 6.2 µSv. As you can see, there is overlap between film and digital. The average background radiation is 3 mSv/year or about 8 µSv/day.

6. From the same paper quoted above, the organ doses from digital panoramic radiography are: brain: 10.1-85.7 µGy; thyroid: 10.4-52.2 µGy; skin: 0.1-4.1 µGy; bone marrow: 4.6-12.1 µGy. To convert to mrem, or more actually to mrad, divide each dose in µGy by 10.

7. The problem with ESE is that there are many things not accounted for in this unit. For example, the size of the beam does not factor into the ESE, but does in calculating the effective dose as larger beams irradiate more tissue. The ESE also does not account for the radiation sensitivity of the tissue exposed. It is convenient to measure but doesn't really tell us much about doses to the patient.

8. As I explained one for of your earlier questions, it is a complex calculation, but it allows us to calculate a "weighted average" of exposure over the body. This makes it easier to compare the risks of various types of radiation exposures.

Parotid tumors D.D

pleomorphic adenoma T1

warthin tumor,parotid gland

pleomorphic adenoma T2

Click on image to enlarge Hemangioma. Axial postcontrast CT image shows diffuse enhancement of a large neck mass that replaces the deep and superficial portions of the right parotid gland in an infant.

Parotid masses
Radiology Discussion:
Typical parotid masses can be separated into benign and malignant neoplasms. Benign masses include pleomorphic adenoma, Warthin’s tumor, oncocytoma, hemangioma, lipoma, schwannoma, and neurofibroma. Malignant masses include mucoepidermoid carcinoma, adenoid cystic carcinoma, squamous cell carcinoma, adenocarcinoma, acinic cell carcinoma,undifferentiated carcinoma and carcinoma ex pleomorphic adenoma.

Epithelial-myoepithelial carcinoma is extremely rare and is rarely included on the differential diagnosis. Other solid lesions include enlarged lymph nodes, lymphoma (primarily non-Hodgkins), lymphoepithelial lesions (cystic or solid, associated with HIV), and sarcoidosis (characterized by bilaterally enlarged glands and multifocal nodules).

Mass characteristics cannot distinguish histology or benign vs malignant because margins, architecture, CT density, T1W & T2W signal overlap. The role of radiology in diagnosis and treatment is to define location, e.g., superficial or deep parotid lobe. The facial nerve and retromandibular vein are the landmarks typically used to distinguish the location. This is important in helping the surgeons plan the resection and will help determine whether or not the facial nerve can be spared.

Pleomorphic adenoma is the most common benign tumor of salivary glands. They occur most often in middle aged patients and are more common among women than men. The typical locations are the tail or superficial lobe, although pleomorphic adenoma can appear in the deep lobe. These tumors tend to be well defined, solid, and round but may contain cystic degeneration and/or calcifications. Pleomorphic adenoma will undergo malignant transformation in a small number of cases, most commonly developing into adenocarcinoma. On CT the tumor is isodense to muscle and shows moderate enhancement. On MR, the mass is T1 hypointense (T2 hyperintense) to surrounding parotid fat and shows moderate enhancement. Pleomorphic adenoma follows the rule of 80’s:

80% of parotid tumors are benign
80% of parotid tumors are pleomorphic adenomas
80% of salivary gland pleomorphic adenomas occur in parotid
80% of parotid pleomorphic adenomas occur in the superficial lobe
80% of untreated pleomorphic adenomas remain benign

Warthin’s tumor (cystadenoma lymphomatosum) is the second most common benign tumor of parotid. It most often occurs around age 50 and is much more common among men than women. The tumor is bilateral in 10% of cases and favors the tail of the parotid gland. These masses may be cystic and do not undergo malignant transformation. On MR imaging, a Warthin’s tumor is T1 hypointense to the surrounding parotid fat but heterogeneous and variable on T2. Increased uptake of pertechnetate is helpful for equivocal FNA.

Oncocytoma is similar in appearance to pleomorphic adenoma and takes up TcO4-. Hemangioma is the most common salivary gland neoplasm in children. It is T2 hyperintense and enhances avidly on MR; it may or may not demonstrate phleboliths on CT. Lipoma is iso-dense and iso-intense to fat on imaging. Schwannoma and neurofibroma tend to occur along the facial nerve.

Mucoepidermoid carcinoma is the most common malignant tumor of the parotid gland. This tumor represents 30% of all salivary gland malignancies; 60% of them occur in the parotid. On CT, the mass is isodense to muscle. On MR, it is T1 hypointense to surrounding parotid fat but variable on T2; high-grade tumors are hypointense, while low-grade tumors may be hypointense on T2.

Adenoid cystic carcinoma is the second most common malignant tumor of parotid (and the most common in submandibular, sublingual and minor salivary glands). This slow-growing tumor has a propensity for perineural spread. On CT, it is isodense to muscle. On MR, it is T1 hypointense to surrounding parotid fat but has a variable appearance on T2-weighted images.
Squamous cell carcinoma is derived from metaplasia of ductal epithelium or intraparotid lymph node involvement of extra-parotid SCC. Adenocarcinoma typically arises from the glandular tissue of the parotid. Acinic cell carcinoma is the most common multifocal parotid malignancy. Undifferentiated carcinoma is very rare and is associated with a poor prognosis. Carcinoma ex pleomorphic adenoma is a pleomorphic adenoma that has undergone malignant transformation, typically to adenocarcinoma.

Epithelial-myoepithelial carcinoma is a rare, low-grade tumor occurring mainly in the parotid gland. It develops most often in elderly patients. The slow-growing mass is well defined, bulky and bosselated. The appellation "epi-myo-epi" refers to the distinctive epithelial tubules or ductules surrounded by neoplastic myoepithelial cells. On ultrasound, the mass is hypoechoic with a mildly heterogeneous echotexture. On CT, it is isodense to muscle and demonstrates moderate homogeneous enhancement with contrast. On MR, it is hypointense on T1 and displays dense, homogenous enhancement. The appearance on T2-weighted images is variable.

D.D. OF solitary osteolytic bone lesion.

Differential diagnosis of osteolytic bone lesion

Narrowing the likely diagnosis of a solitary lucent bone lesion is based on six steps.

Step 1 is to consider the most likely possibilities, represented by the mnemonic "FOG MACHINES":

Fibrous Dysplasia
Osteoblastoma
Giant Cell Tumor
Metastasis / Myeloma
Aneurysmal Bone Cyst
Chondroblastoma / Chondromyxoid Fibroma
Hyperparathyroidism (brown tumors) / Hemangioma
Infection
Non-ossifying Fibroma
Eosinophilic Granuloma / Enchondroma
Solitary Bone Cyst

Step 2 focuses on the patient’s age. According to Edeiken, 80% of malignant tumors can be correctly diagnosed on the basis of age alone. For a solitary lucent bone lesion, the most likely diagnoses by age include:
Under age 10: neuroblastoma (infants) and Ewing’s sarcoma of tubular bones
Age 10-30: osteosarcoma and Ewing’s sarcoma of flat bones
Age 30-40: reticulum cell sarcoma, fibrosarcoma, parosteal osteosarcoma, malignant giant cell tumor, and lymphoma
Over age 40: metastatic carcinoma, multiple myeloma, and chondrosarcoma

Step 3 is to determine how aggressive the lesion is. The continuum begins with a normal bone appearance in a non-aggressive lesion. The insidious nature is assumed to increase through the following:
Geographic, narrow zone of transition and sclerotic margin
Geographic, narrow zone of transition (without a visible margin)
Geographic, wide zone of transition
Moth-eaten appearance
Permeative appearance

Step 4 focuses on the matrix. Most lesions do not produce a matrix and thus appear radiolucent. A chondroid matrix, characterized by a "rings and arcs" appearance, is typical in enchondroma, chondrosarcoma, chondromyxoid fibroma, and other cartilage-based tumors. An osteoid matrix, typically described as "cloud-like", is a common feature of osteoma, osteoblastoma, bone island, and osteosarcoma.

Step 5 considers the periosteal reaction. Periosteal reaction varies widely and represents involvement of the outer cortical rim by the tumor. Its appearance can also be described by a continuum from non-aggressive to very aggressive. Solid periosteal reaction, the least aggressive type, can be caused by infection, benign neoplasms like osteoid osteoma and eosinophilic granuloma, hypertrophic pulmonary osteoarthropathy, or deep venous thrombosis (in the lower extremity). More aggressive reactions, including lamellated, "hair-on-end" or sunburst appearances, or Codman’s triangle, can be caused by osteomyelitis or malignant neoplasms, such as osteosarcoma, chondrosarcoma, fibrosarcoma, lymphoma, leukemia, and metastasis.

In the final step, the location within the bone is taken into account. Chondroblastoma and osteomyelitis typically arise in the epiphysis. The metaphysis is the most likely location for a primary neoplasm other than chondroblastoma, including all other entities recalled by the "FOG MACHINES" mnemonic. Similarly, all FOG MACHINES entities except chondroblastoma, giant cell tumor, and osteoblastoma may arise in the diaphysis.

By careful examination of the features of the lesion you can categorize the lesion as aggressive or non-aggressive. These features, considered within the context of the patient’s demographics and the location of the lesion, allow a reasonable differential diagnosis prior to biopsy and will serve as a guide to planning surgical management.

Lymphoma of the neck

Click image to enlarge

Lymphoma of the neck

Lymphoma of head and neck
Patterns of lymphomatous involvement of head and neck have been categorized into four types :
1-Nodal lymphoma
Unilateral
Bilateral

2-Extranodal lymphoma
Confined to Waldeyer's ring
Outside Waldeyer's ring (extralymphatic)
3-Combined extranodal/ nodal lymphoma
4-Multifocal, extranodal involvement

NHL comprises 5% of head and neck cancers. Extranodal disease is a more common presentation in non-Hodgkin's than in Hodgkin's lymphomas. It is the second most frequent site of extranodal lymphoma after the gastrointestinal tract. Approximately 40-60% of patients presenting with head and neck disease will have systemic NHL. For staging, gallium-67 scintigraphy has the advantage of assessing the total body with a relatively high rate of detecting abnormalities, but with relatively nonspecific findings. (This method will also detect inflammatory conditions as well as gallium-avid tumors.) CT and MRI depict the local extent of the disease.
NHL can be unilateral or bilateral, with extension from the nasopharynx to the tonsils. Masses are indistinguishable from squamous cell cancer (SCC), except that SCC is less frequently multicentric and more often produces bone destruction. Both onditions may be associated with lymph node enlargement. MR may help to distinguish paranasal sinus extension from accompanying postobstruction fluid (bright on T2).

Carotid space lesions

Click image to enlarge

Ganglioma

Carotid space

Carotid space tumors
The differential diagnosis for carotid space masses includes (1):
I.Pseudotumor
Ectatic common carotid artery/internal carotid artery
Asymmetric Internal Jugular Vein
II.Inflammatory
Abscess
III.Vascular
Jugular Vein Thrombosis
Carotid Aneurysm/Thrombosis
ICA Dissection
IV.Benign Tumor
Paraganglioma
Glomus Jugulare
Glomus Vagale
Carotid Body Tumor
Neural Sheath Tumor
Schwannomas
Neurofibromas
Meningiomas
V.Malignant Tumor
Squamous Cell Carcinoma
Non-Hodgkin's Lymphoma

Hyperthyroidism

Click image to enlarge

Graves disease

Hyperthyroidism
Hyperthyroidism is most commonly caused by Graves' disease, an autoimmune disorder mediated by thyroid-stimulating antibodies. Clinical manifestations due to increased metabolism include weight loss, tremor, heat intolerance, palpitations, and exophthalmos.
The radiotracer uptake by this patient's hyperplastic and hyperfunctioning gland is uniform and intensely increased in the right lobe, left lobe, and isthmus. The pyramidal lobe, which normally has little or no tracer uptake, is also hyperplastic and demonstrates increased uptake. Therefore, the clinical manifestations and abnormal thyroid function tests correlate with the scintigraphic imaging findings.
Technetium-99m-pertechnetate (TcO4) is an efficient radiotracer for thyroid scanning. It is trapped and concentrated, but not organified, by the thyroid. The advantages of TcO4 are several: it is readily available from a molybdenum-99/Tc-99m generator, it is taken up by the thyroid in 20 minutes, and it has a short physical half-life of 6 hours. This radiotracer provides a lower radiation dose per unit administered than any of the radioiodines (I-131 and I-123) that are used for thyroid imaging. A disadvantage of TcO4 is its lower target-to-background ratio than the radioiodines. For most patients, the advantages of TcO4 outweigh its disadvantages.
Preparation of the patient prior to thyroid scanning is important. All medications that may interfere with the thyroid's uptake of the radiotracer are discontinued. Female patients must be asked whether they are pregnant or breast feeding. Thyroid scanning is contraindicated in pregnancy, especially in the first 12 weeks, because it causes suppression of the fetal thyroid tissue. The radiotracer is secreted in human breast milk, so breast feeding must be discontinued for 24 hours after the scan. Following patient preparation, TcO4 is injected intravenously using a dose of 10 mCi. The patient is placed supine with the neck extended. A gamma camera is used with a 3 to 6 mm aperture pinhole collimator (for magnification) and a 20% window centered at 140 KeV. Twenty minutes after injection, images are obtained in the anterior, right anterior oblique, left anterior oblique, and bird's eye projections for 200K to 250K counts. The bird's eye view gives an overall view of the thyroid (from the chin to the manubrium) in relation to its surrounding structures. This view also allows comparison of tracer uptake in the salivary glands to the thyroid gland. In this patient, uptake in the thyroid exceeded uptake in the salivary glands, which is consistent with hyperthyroidism. Thyroid scintigraphy with TcO4 provides practical information about the functional status of the thyroid gland.

Leukaemia

Leukaemia.
Leukaemia is a process involving the uncontrolled proliferation of the blood forming cells. The name of the particular leukaemia comes from the type of white cells that proliferate. Theories of its generation involve the idea of delayed maturation. That is if an ancestor cell in the bone marrow goes thorugh a few more cell divisions before forming the recognisable precursor adult cell then the number of those cells will increase. Research into the multiple factors in cell genetics is proceeding so fast that it is more appropriate to recommend the nearest search engine to enquiring minds.
The visible evidence of Leukamia usually follows an aggressive or a long standing abnormality. The radiologic expression of the disease is of an enlargement of the soft tissue mass of the bone marrow with loss of bone, particularly at the metaphyses where bone turnover is a little higher. The bone cortex amy also be eroded from below, giving a scalloped appearance. There may be other clues, such as splenic anlargement, visible on a radiograph of the pelvis. Lytic areas, chloromas, are rare, but are due to local masses of leukaemic cells.
The stem cell theory suggests that some cases of myelofibrosis might be included in this document, but the condition is commoner in polycythaemia.

Figure 1:This view is taken from an intravenous urogram. It shows a large, bounded, soft tissue density in the left hypochondrium which extends down to the left iliac crest. The density in the right hypochrondium, the liver density, also extends lower than is usual. Both kidneys are also lower in the abdomen than is usual, but appear grossly normal. There is no change in the visible bone structure and the patient has not lived abroad.
D=leukaemia with splenomegally

Figure 2:Clinical presentation:55 year old man with acute myloid leukaemia and recent neck pain.
The neck is flexed in both views. The first view shows some increase in the thickness of the anterior paravertebral soft tissue in a patient who isn't swallowing. There is some bone-destruction of the anterior inferior margin of the 5th cervical vertebra, indicated by the absence of a similar osteophyte to that of the upper margin of the 6th cervical vertebra.
The later view shows local angulation of the cervical spine, secondary to further bone destruction in C5 and loss of the C5/C6 disc-space. The anterior soft tissue swelling is increased.
D=Pyogenic discitis&osteomyelitis

Figure 3:Clinical presentation:Adult male with anaemia.
The particular feature is the low density of pubis and sacrum with relative sparing of ilia and femora. Patchy bone loss can be seen in both ischia and the proximal metaphyses of both femora, coarsening the visible bone architecture. There is a fairly well-defined area of patchy bone loss in the upper part of each pubic bone centred around the mid-line. Some cortical scalloping of the cortex of pubic bones is present. The density of the ilia is probably normal, except adjacent to the sacro-iliac joint margins where some more extensive destruction is seen on the right side. The density of Sacrum and vertebrae is reduced by what appears to be a patchy destructive process.
The appearance is of a patchy lytic bone process that is predominatly mid-line. This might suggest a process that affects active bone marrow, which is often restricted in the adult to the axial skeleton and the medulla of adjacent parts of long bones.
D=lk inf

Figure 4:Clinical presentation:A 13 year old boy with anaemia.
There is a patchy destructive process, prodominantly in the medulla of the distal metaphyses of the left radius and ulna. The process is more marked in the distal metaphysis of the left ulna. More proximally, there is a visible reaction over the diaphyses The bone cortex is elevated and thickened. This takes the form of a thick line, separated from the cortex of the diaphysis of the right radius. A similar appearance is seen over the distal metaphyses of both humeri.
D=lk infitration

Figure 5:Clinical presentation:A 45 year old man with anaemia.
There is a patchy destructive process, prodominantly in the medulla of the distal metaphysis of the right humerus. The process undermines and thins the cortex
D=lk infiltration

Lymphoma overview

Click on the image to enlarge

Lymphoma overveiw
Lymphoma is a type of cancer involving cells of the immune system, called lymphocytes. Just as cancer represents many different diseases, lymphoma represents many different cancers of lymphocytes-about 35 different subtypes, in fact.
Lymphoma is a group of cancers that affect the cells that play a role in the immune system, and primarily represents cells involved in the lymphatic system of the body.

The lymphatic system is part of the immune system. It consists of a network of vessels that carry a fluid called lymph, similar to the way that the network of blood vessels carry blood throughout the body. Lymph contains white blood cells called lymphocytes. Lymphocytes attack a variety of infectious agents as well as many cells in the precancerous stages of development.
Lymph nodes are small collections of lymph tissue that occur throughout the body. The lymphatic system involves lymphatic channels that connect thousands of lymph nodes scattered throughout the body. Lymph flows through the lymph nodes, as well as through other lymphatic tissues including the spleen, the tonsils, the bone marrow, and the thymus gland.
These lymph nodes filter the lymph, which may carry bacteria, viruses, or other microbes. The lymph nodes, or glands as they may be called, filter the lymph, which may on various occasions carry different microbial organisms. At infection sites, large numbers of these microbial organisms collect in the regional nodes and produce the swelling and tenderness typical of a localized infection. These enlarged and occasionally confluent collections of lymph nodes (so-called lymphadenopathy) are often referred to as "swollen glands."
Lymphocytes recognize pathogens (infections and abnormal cells) and destroy them. There are 2 major subtypes of lymphocytes: B lymphocytes and T lymphocytes, also referred to as B cells and T cells.
B lymphocytes produce antibodies (proteins that circulate through the blood and lymph and attach to infectious organisms and abnormal cells). The combination attachment cell or antibody microbial organism essentially alerts other cells of the immune system recognize and destroy these intruders, also known as pathogens.
T cells, when activated, can kill pathogens directly. T cells also play a part in the mechanisms of immune system control, to prevent the system from inappropriate overactivity or underactivity.
After fighting off an invader, some of the B and T lymphocytes "remember" the invader and are prepared to fight it off if it returns.
Cancer occurs when normal cells undergo a transformation whereby they grow and multiply uncontrollably. Lymphoma is a malignant transformation of either lymphocytes B or T cells or their subtypes.
As the abnormal cells multiply, they may collect in 1 or more lymph nodes or in other lymph tissues such as the spleen.
As the cells continue to multiply, they form a mass often referred to as a tumor.
Tumors often overwhelm surrounding tissues by invading their space, thereby depriving them of the necessary oxygen and nutrients needed to survive and function normally.
Because of their uncontrolled growth, lymphomas can encroach on and/or invade neighboring tissues or distant organs.
In lymphoma, abnormal lymphocytes travel from one lymph node to the next, and sometimes to remote organs, via the lymphatic system.
While lymphomas are often confined to lymph nodes and other lymphatic tissue, they can spread to other types of tissue almost anywhere in the body. Lymphoma development outside of lymphatic tissue is called extranodal disease.
Lymphomas fall into 1 of 2 major categories. Hodgkin lymphoma (HL, previously called Hodgkin's disease) and all other lymphomas (non-Hodgkin lymphomas or NHLs).
These 2 types occur in the same places, may be associated with the same symptoms, and often have similar gross physical characteristics. However, they are readily distinguishable via microscopic examination.
Hodgkin disease develops from a specific abnormal B lymphocyte lineage. NHL may derive from either abnormal B or T cells and are distinguished by unique genetic markers.
There are 5 subtypes of Hodgkin disease and about 30 subtypes of non-Hodgkin lymphoma.
Because there are so many different subtypes of lymphoma, the classification of lymphomas is complicated and includes both the microscopic appearance and well-defined genetic and molecular rearrangements.
Many of the NHL subtypes look similar, but they are functionally quite different and respond to different therapies with different probabilities of cure. HL subtypes are microscopically distinct, and typing is based upon the microscopic differences as well as extent of disease.
Lymphoma is the most common type of blood cancer in the United States. It is the sixth most common cancer in adults and the third most common in children. Non-Hodgkin lymphoma is far more common than Hodgkin disease.
In the United States, about 54,000 new cases of NHL and 7000 new cases of HL were diagnosed in 2004, and the overall incidence is increasing.
About 24,000 people die of NHL and 1400 of HL each year, with the survival rate of all but the most advanced cases of HL greater than that of other lymphomas.
Lymphoma can occur at any age, including childhood. Hodgkin disease is most common in 2 age groups: young adults aged 16-34 years and in older people aged 55 years and older. Non-Hodgkin lymphoma is more likely to occur in older people.
PET/CT FINDINGS
Marked FDG uptake throughout the mediastinum and in the right axilla/supraclavicular area corresponding to bulky adenopathy on the CT portion of the exam compatible with malignancy.

Please see the lower image .

TREATMENT / FOLLOW UP
Chemotherapy (CHOP). Follow-up PET/CT ordered following 1 cycle.
FOLLOW UP PET/CT FINDINGS
Complete resolution of abnormal FDG activity compatible with a good response to therapy. Focal apparent FDG activity in the left supraclavicular area was not present on the uncorrected images compatible with an attenuation correction artifact. Bulky adenopathy is still present, but no increased FDG activity is present. Please see the upper image .
DISCUSSION
This case demonstrates the power of PET/CT to assess response to therapy soon after initiation. The strength of the modality is in the ability to assess an early response to therapy by assessing the metabolic changes. As shown in the second set of images, there is still considerable soft tissue abnormality present, but no increased FDG activity. Evidence suggests that for non-Hodgkin’s lymphoma, patients are to be categorized as responders (better overall survival) only if there is minimal or no residual FDG activity on follow up exams after therapy initiation. The metabolic changes can be assessed after one cycle of chemotherapy, whereas the soft tissue component will take much longer to regress and may remain indefinitely.

Wegeners granulomatosis

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Wegener's Granulomatosis

General Considerations
Hallmarks
Small to medium sized systemic vasculitis
Granulomatous inflammation
Necrosis
Unknown etiology
Incidence of 1 case per 30,000
Affects predominantly whites (91%)
M>F
Mean age at diagnosis = 45

Sites of Involvement:
Lung (>90%)
Renal (75%)
Rapidly progressing glomerulonephritis, chronic renal failure
Trachea (15-60%)
Subglottic Stenosis
Other
Paranasal sinuses, nose (saddle nose deformity)
Ears, eyes, oral cavity
Skin, joints, nervous system
Rarely
Heart, GI tract and brain
Can potentially involve any organ in the body
Diagnosis:
American College of Rheumatology Classification
(2 out of 4 criteria is 88% sensitive and 92% specific for the diagnosis)
Nasal or oral inflammation
Abnormal chest X-ray
Urinary sediment
Biopsy
Imaging Findings
Conventional Radiography
Pulmonary nodules
Most common finding (40-70%)
Typically multiple and bilateral with a tendency to cavitate (50%)
Cavitary lesions may lead to atelectasis or pneumothorax
Thick or thin walled, well or ill circumscribed
Tendency to wax and wane
Size varies (1.5-10cm)
Air space consolidation
Waxing and waning infiltrates
May be mistaken for pneumonia
Pulmonary hemorrhage or edema
Hilar lypmhadenopathy
Normal in 20%
CT
Useful in further defining extent of disease seen in plain film, and revealing lesions not seen on plain film including:
Interstitial abnormalities
Tracheobronchial Abnormalities
Findings suggestive of vasculitis
Differential Diagnosis
For cavitary lung lesions
Infarction
Septic pulmonary emboli
Carcinoma
Squamous cell carcinoma
Infection
TB, Fungal, Bacterial
Rheumatoid nodules
Prognosis and Treatment
Tracheostomy may be required for tracheal strictures
Independent Risk factors of mortality
Older age
Absence of ear, nose and throat involvement
Renal or Cardiac involvement

Langerhans histiocytosis

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Langerhans Histiocytosis

Also known as eosinophilic granuloma(tosis)
Proliferative disorder of the Langerhans cells
Normally found in the skin (and a few other organs) and serve as antigen-presenting cells
Rare diseases, affecting neonates up to adults
2:1 male to female predominance
Prognosis
Mortality and morbidity are associated with the clinical presentation and age of onset of the disease
Worst prognosis for neonates presenting with the disseminated form
Three clinical forms
Acute disseminated Langerhans cell histiocytosis (aka Letterer-Siwe disease)
Occurs most frequently in infants 2 years of age or younger (and occasionally adults)
Presents with multi system organ involvement
Cutaneous lesions resembling seborrheic dermatitis involve the scalp, face, trunk and buttocks as the dominant clinical feature (nearly 80% of patient will have this)
Infiltration of bone marrow and other organs lead to concurrent hepatosplenomegaly, lypmhadenopathy, pulmonary lesions, anemia, thrombocytopenia, recurrent infections (otitis media)
Eventually, there are destructive osteolytic bone lesions
If untreated, this disease is rapidly fatal
With chemotherapy, 5 year survival rate is approximately 50 percent
Univocal Langerhans cell histiocytosis (aka Eosinophilic granuloma or granulomatosis)
Usually only affects the skeletal system of young adults
Typically presents as an osteolytic lesion involving the
Calvaria
Vertebra
Rib
Mandible
Femur
Ilium
Scapula
Bony lesions are usually asymptomatic
In some cases, can cause pain and even pathologic fractures
Pulmonary lesions may be the only presenting symptom and organ involved, especially in adults
Skeletal lesion is usually indolent in nature
Can heal spontaneously or be cured by local excision or irradiation
Pulmonary lesions are typically followed and treated with supportive care
Multifocal Langerhans cell histiocytosis (aka Hand-Schuller-Christian disease)
Triad
Diabetes insipidus
Exophtalmos
Holes in the bone, usually the head (calvarium)
Commonly affects children
Can lead to
Lypmhadenopathy
Hepatomegaly
Splenomegally
Diabetes insipidus is secondary to infiltration of the posterior pituitary stalk by the Langerhans cell
About a third of these patients will also display cutaneous lesions
Some will experience spontaneous regression while others can be treated with chemotherapy


Langerhans histiocytosis (Eosinophilic granuloma of lung). Four selected non-enhanced axial CT scans of the chest show multiple small, irregularly-shaped, cysts of varying sizes with thin walls scattered throughout the lungs (yellow arrows) but predominantly seen in the upper lung fields while sparing the costophrenic angles and lung bases (blue arrow).

Quick Facts

Letterer-Siwe Disease
10% of histiocytosis X
Acute disseminated, fulminant form
Age at onset
Several weeks after birth to 2 years
Pathology
May be confused with leukemia
Symptoms
Hemorrhage, purpura
Severe anemia
Fever
Hepatosplenomegaly and lypmhadenopathy
Bone involvement in 50%
Widespread lytic lesions
Prognosis: 70% mortality rate
Hand-Schuller-Christian
15-40% of Histiocytosis X
Triad of:
Exophthalmos (33%)
Diabetes insipidus (30-50%)
Lytic skull lesions
Pathology
May simulate Ewing's sarcoma
Age at onset
5-10 years
Target organs
Bone
Lytic skull lesions with overlying soft tissue nodules
Large geographic skull lesions
"Floating teeth" with mandibular involvement
Soft tissue
Hepatosplenomegaly is rare
Lypmhadenopathy which may be massive
Lung
Cyst and bleb formation with spontaneous PTX
Ill-defined diffuse nodular disease often leading to fibrosis and honeycombing
Prognosis: spontaneous remissions and exacerbations
Eosinophilic granuloma
60-80% of Histiocytosis X
Usually confined to bone
Age at onset
5-10 years highest frequency
Male predominance 3:2
Location
Calvarium>mandible>spine>ribs>long bones
Most are monostotic (50-75%)
Target organs
Skull (50%)
Diploic space of parietal bone most often
Round or ovoid punched out lesions with beveled edge
Sclerotic margin during healing phase
Beveled edge=hole-within-a-hole
Button sequestrum- bony sequestrum within lytic lesion
Axial skeleton (25%)
"Vertebra plana"-"coin-on-edge"(Calve disease)=collapse of vertebral body, mostly thoracic
Most common cause of vertebra plana in children
Proximal long bones (15%)
Expansile, lytic lesions, mostly diaphyseal
Soft tissue mass
Laminated periosteal reaction
Lung (20%)
Age peak between 20-40 years
Multiple small nodules
Predilection for apices
Prototype for honeycomb lung
Recurrent pneumothoraces (25%)
Rib lesions with fractures common
Nuclear Medicine
Negative bone scans in 35%
Bone lesions usually not Ga-67 avid
Ga-67 may be helpful in detecting non-osseous lesions
Prognosis: excellent

Childhood sweets and adult violance

Childhood sweets link to adult violence May encourage impulsive behaviour
Children who eat sweets and chocolate every day are more likely to be violent as adults, new research has found.
Results from the research showed that 10-year olds who ate sweets and chocolate almost every day were significantly more likely to have been convicted for violence at age 34.
Previous research has shown that diet can be associated with behavioural problems, including aggression. However, UK scientists wanted to find out how childhood diet affected behaviour as an adult.
In the study, published in this month's British Journal of Psychiatry, scientists analysed data from almost 17,500 people born in 1970. They discovered that 69% of participants who were violent at the age of 34 had eaten sweets and chocolate nearly every day during childhood, compared to 42% who were non-violent.
This association between sweets and violence as an adult remained after adjusting for other factors such as where the child lived, educational qualifications and car ownership.
The researchers put forward several explanations for the link. Dr. Simon Moore from Cardiff University said: "Our favoured explanation is that giving children sweets and chocolate regularly may stop them learning how to wait to obtain something they want.
"Not being able to defer gratification may push them towards more impulsive behaviour, which is strongly associated with delinquency.
The researchers concluded: "Targeting resources at improving children's diet may improve health and reduce aggression."

Smoking in pregnancy

Smoking in pregnancy linked to child psychosis Risk highest in children of heavy smokers
Smoking has long been implicated as a cause of many diseases, including in the babies of mothers who smoke. A new study has now linked the emergence of psychotic symptoms in teenagers to smoking by their mothers during pregnancy.
Over 6,000 12-year olds were studied as part of the research. They were asked about the occurrence of psychotic symptoms such as hallucinations or delusions. Just over 11% had suspected or definite symptoms of psychosis.
Smoking during pregnancy was found to be associated with an increased risk of psychotic symptoms in the children. The researchers observed a 'dose-response effect', meaning that the risk of psychotic symptoms was highest in the children whose mothers smoked the most heavily during pregnancy.
Curiously, smoking cannabis during pregnancy seemed to have no link to psychosis, although the number of mothers reported this behaviour was small.
Drinking alcohol during pregnancy was linked to psychosis in children, but only in mothers who drank more than 21 units a week in early pregnancy.
The nature of the link between smoking in pregnancy and psychosis in children is not clear. It is estimated that between 15% and 20% of women in the UK continue to smoke during their pregnancy.
One of the leaders of the study, Dr Stanley Zammit, said: "If our results are non-biased and reflect a causal relationship, we can estimate that about 20% of adolescents in this cohort would not have developed psychotic symptoms if their mothers had not smoked. Therefore, maternal smoking may be an important risk factor in the development of psychotic experiences in the population."
The study was carried out by researchers at universities in Cardiff, Bristol, Nottingham and Warwick and was published in the October issue of the British Journal of Psychiatry.

Thinning of hair

Over the years, there have been many myths regarding thinning hair.
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However, scientists have now proven that “clogged” hair follicles and poor scalp circulation do not cause thinning hair. In addition, researchers have also found that wearing hats or helmets does not lead to hair loss.
Unfortunately, genetics account for more than 90% of all cases of men and women with thinning hair. Illness, stress, poor diet, and certain prescription medications can also aggravate hair loss. However, hair loss that can be attributed to one of these factors is generally much easier to treat than thinning hair that is solely the result of genetic influences. Speaking to a doctor or dermatologist may help you determine what is causing your thinning hair.The medical term for hair loss caused by thinning hair is alopecia. Some people who suffer from thinning hair begin to notice hair loss in their early teens, although most hair loss doesn’t occur until the 30s or 40s. Hair loss is more common among men, but typically causes greater stress for women who have been raised to believe their hair is an important part of their femininity.Hair loss caused by thinning hair cannot be cured, but several non-surgical treatment options are available. Rogaine brand hair treatment products, containing a minoxidil liquid solution, are available over-the-counter in versions formulated for both men and women. Men who suffer from thinning hair may have suitable results with the prescription medication finasteride, sold under the brand name Propecia. Corticosteroids injections, pills, or creams are sometimes prescribed for patients suffering from persistent hair loss that has not responded to other alternative treatments. These treatment methods require a commitment to continual use, however, since any improvement in thinning hair will be reversed after treatment is discontinued.
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While the type of hair care products you use can make it easier to style your hair, products can’t slow or stop the hair loss process. However, poor quality shampoos, conditioners, and styling aids may cause hair breakage that can sometimes be mistaken for hair loss. If you’re bothered by thinning hair, switching to salon quality hair care products might be a worthwhile investment.Hair transplants and scalp reduction surgery can be used to treat thinning hair. However, these treatments are expensive, painful, and carry serious risks. Most experts will only recommend surgery if other treatment methods have failed and you feel your thinning hair is having a substantial impact on your quality of life.

Your first prenatal test

Most women are excited for their first ultrasound. It offers a sneak peak of the unborn baby and might offer hints at its sex. Your doctor will let you know how often you need an ultrasound. Most women will have one or two ultrasounds during pregnancy. Here's what to expect for this prenatal test.
What is an ultrasound?
An ultrasound uses high-frequency sound waves to create a picture of your unborn baby. It also shows images of your uterus, amniotic sac, placenta and ovaries.
In this procedure, a small device called a transducer sends sound waves into the body. The waves reflect off internal structures, including your baby. Then the transducer receives the sound waves and sends a picture to a screen.
The images appear on the screen during the exam. Pictures can be printed or the whole procedure can be recorded on video. Your doctor can usually discuss results of an ultrasound with you soon after the exam is over.
Why is ultrasound used in pregnancy?
Ultrasound is used to:
Check on your baby's health status, including position, movement, breathing, growth and heart rate
Make sure the placenta is healthy and attached normally
See the number of fetuses
Calculate the expected due date
Detect some birth defects
See how much amniotic fluid is in the uterus
Ultrasound can also be used to diagnose a possible miscarriage or ectopic pregnancy, or to determine the cause of vaginal bleeding. Sometimes it can give you a hint as to the sex of the baby. This is not always accurate, though.
How do I prepare for an ultrasound?
You'll need to have a full bladder, which can be uncomfortable, especially during pregnancy. But a full bladder pushes the uterus up for better viewing. You may be asked to drink up to six glasses of water in the two hours before the exam. You can't urinate until the ultrasound is over. Wear clothes that make it easy to expose your abdomen. The exam usually takes 15 to 20 minutes.
What are the different types of ultrasounds?
There are two main types of ultrasounds: abdominal and vaginal.
Abdominal ultrasound. You'll lay on a table with your abdomen exposed. Then the ultrasound technician puts a gel on your abdomen. The gel improves how the transducer works on your skin. The transducer is gently placed on your abdomen and moved over your stomach and pelvis. There are two more detailed types of abdominal ultrasounds:
Doppler. Higher-intensity sound waves are used to study the movement of blood and listen to the baby's heartbeat.
Three- and four-dimensional (3-D and 4-D). The 3-D ultrasound takes thousands of images at once, making the image look more realistic. A 4-D ultrasound shows movement as well as still shots.
Vaginal ultrasound. The vaginal ultrasound can take a closer look at the organs and fetus. It is used more often in early pregnancy.
For this procedure, you will change into a hospital gown, lie down and put your feet into stirrups, like you are preparing for a pelvic exam. A protective sheath is placed over the transducer and then it's inserted into the vagina. The ultrasound procedure is painless. You may feel mild discomfort from the pressure of the transducer.
Is ultrasound safe?
There is no evidence that ultrasounds are harmful to mom or baby. They have been done for many years without problem. But the American College of Obstetricians and Gynecologists and the American Institute of Ultrasound in Medicine discourage the use of ultrasounds for nonmedical purposes. Using an ultrasound to detect the sex of the baby or to take a keepsake photograph should be done only if the ultrasound is needed for medical reasons - and only by certified medical personnel. Even though there are no known risks linked to ultrasounds now, it is possible that some will be found in the future. Radiation is not used for ultrasound.

Stay free in this summer

Stay safe this summer An introduction to our summer health guides
Summer is a great time of year with holidays, sunshine, long warm evenings and barbecues all adding to the fun.
So it would be a shame if our enthusiasm for outdoor pursuits at this time of the year affected our health. Sunburn, damage to our eyes and food poisoning are hazards that we can easily avoid if we follow some simple tips and guidelines.
So we have put together a set of handy guides for the main danger areas you will encounter in the sun this summer.
Why not print them out and pack them in your suitcase before heading off on holiday? And even if you are having a so-called "staycation" don't be fooled by the summer rain we always seem to get. In between the clouds the sun shines brightly and just as dangerously as it does in the med so make sure you select the right suncreams and keep your skin covered.
Just follow these guides to be safe in the sun.

Keep slim and help save the planet

Keep slim and help save the planet, say scientists Rising BMIs across the world contribute to climate change
Maintaining a healthy body weight is good news for the environment, according to a study which appears today in the International Journal of Epidemiology.
Because food production is a major contributor to global warming, a lean population such as that in Vietnam, will consume almost 20% less food and produce fewer greenhouse gases compared with a population in which 40% of people are obese (close to that seen in the US today).
Transport-related emissions will also be lower because it takes less energy to transport slim people. The researchers based at the London School of Hygiene and Tropical Medicine, estimate that a lean population of 1 billion people would emit 1.0 GT (1,000 million tonnes) less carbon dioxide equivalents per year compared with a fat one.
In nearly every country in the world, average body mass index (BMI) is rising. Between 1994 and 2004 the average male BMI in England increased from 26 to 27.3, with the average female BMI rising from 25.8 to 26.9 (about 3 kg - or half a stone - heavier). Humankind - be it Australian, Argentinean, Belgian or Canadian - is getting steadily fatter.
'When it comes to food consumption, moving about in a heavy body is like driving around in a gas guzzler', say scientists Professor Ian Roberts and Dr. Phil Edwards who led the study.
'The heavier our bodies become, the harder and more unpleasant it is to move about in them, and the more dependent we become on our cars.
Staying slim is good for health and for the environment. We need to be doing a lot more to reverse the global trend towards fatness, and recognise it as a key factor in the battle to reduce emissions and slow climate change', they conclude.

Football is better for Women

Football better than running for women Better physical and social benefits
Football is better than running for improving women's overall fitness, according to new research.
What's more, scientists from the University of Copenhagen also found that women are less likely to drop playing football from their busy lives compared with running.
In a two year study, due to be published in the Scandinavian Journal of Medicine and Science in Sports, researchers compared the physical, psychological and social benefits of women's football compared with running.
One hundred women were separated into three groups - football, running and a control group. Both the footballers and runners trained twice a week for an hour.
After 16 weeks, the researchers found that the women footballers showed a "marked improvement in maximal oxygen uptake, muscle mass and physical performance.
Although women usually prefer cardiovascular training, some type of strength training is needed to maintain bone and muscle strength for later in life, the scientists said.
"While playing soccer, the women have high heart rates and perform many sprints, turns, kicks and tackles, making soccer an effective integration of both cardio and strength training," said Professor Peter Krustrup, who led the study.
The social aspects of football - meeting other women and taking part in a team sport, also meant that women were more likely to continue with football than running. And women found it easier to fit in football - which requires a fixed place and time - into their busy lives rather than running.
“In the recent decade, we have seen a significant rise in women and girls playing soccer. It seems as though women are really beginning to take in soccer and make it a popular sport for women on their own terms.
"This is a very positive step forward, not only because of the improved physical fitness and health profile but also for the enjoyment of sports”, Mr Krustrup concluded.

Fruit and Health

Smoothies count towards your 5 daily fruit and veg Claims upheld by Advertising Standards Authority
It's not always easy to reach the daily recommended intake of 5 portions of fruit and veg every day.
So the idea of drinking a handily packaged fruit smoothie as part of our daily routine is an attractive one. This was the claim made by the Innocent smoothie brand in a TV advert which was challenged by some complaining viewers.
But now in a ruling by the Advertising Standards Authority (ASA) - the official advertising watchdog - this claim has been upheld.
Innocent claimed that "each one of our cartons contains all this fruit, which means each glassful contains two whole portions. Two of your five a day".
This was made possible because the Department of Health had recently changed it's guidelines to allow smoothies containing all edible parts of a fruit, or 100% fruit juice, to count as two portions of fruit.
The ASA said: ''We understood that each 250ml serving contained all the edible parts of the pulped fruit, contained a sufficient amount of edible fruit and of fruit juice, and, additionally, did not include a dairy product. Because of that, we understood that a 250ml portion from Innocent's current smoothie range could provide two portions of a person's five a day.''
You can read the Department of Health's guidelines here.
In order for a smoothie to qualify, it must be purely made from fruit. Some smoothies contain other ingredients, such as dairy products or sugar. These would therefore not qualify.

Bacterial Vaginosis

Exercise and Children

UK children not exercising enough Happier texting or logging on
Only one in eight UK children get the recommended 60 minutes exercise a day, according to a survey released today by the British Heart Foundation (BHF).
The survey also found that:
1 in 3 children exercise for less than an hour a week
78% of children did not know the recommended daily amount of exercise
30% admitted they "can't be bothered" to exercise
1 in 5 children considered exercise to be a "chore"
Over half of the children surveyed claimed to spend more than a hour each day texting or chatting on websites such as Facebook and MySpace.
This is despite the fact that recent research has predicted if current trends continue, two thirds of all children will be overweight or obese by 2050.
Former Olympic sprinting champion Sally Gunnell expressed her concern about the results: "As a mum, I know how children can benefit from being active. It's something that all children should enjoy as part of a healthy lifestyle and is also a great way to socialise with friends."
Dr Mike Knapton, BHF Director of Prevention and Care, said: "We have a generation of kids growing up who have a shockingly blasé attitude towards exercise and being active."
To counter this trend, the BHF is launching an "Ultimate Dodgeball" fund-raising event for young people to encourage them to become active.
Dr Knapton explained: "Ultimate Dodgeball is a great way to get children interested in sport and physical activity - young people need to switch off their square eyes and get in the habit of exercising now."
The BHF is also relaunching its Yoobot web site which is designed to help young people make better choices about the food they eat.
The survey is part of the BHF's Food4Thought campaign.
More information

Anti-Atkins diet extends life

"Anti-Atkins" diet extends life... ...in flies. It's a start!
The high protein Atkins diet was a fad among weight obsessed celebrities some years ago. Now a new study suggests that a low protein diet may be able to extend life - at least in flies.
Although a reduced protein diet leads to an overall reduction in the body's processing of proteins for energy, the study found a surprising increase in one particular mechanism in the body's cells responsible for the generation of energy from nutrients.
Even more surprisingly, when the scientists turned this process off by genetic manipulation, the low protein diet had no effect on lifespan, and when they enhanced its effectiveness they were able to extend the lifespan of flies even when fed a high protein diet.
Study leader Pankaj Kapahi said: "In flies, we see that the long-lived diet is a low protein diet and what we have found here is a mechanism for how that may be working."
The results, which appear in the October edition of the journal Cell, also provide a new level of understanding of the regulation of mitochondrial genes and suggests new areas of research into the interplay between mitochondrial function, diet and energy metabolism.
Mitochondria act as the "powerhouse" of the cells. It's well known that mitochondrial function declines with age in many animal species, and in humans with Type II diabetes and obesity. "Our study shows that dietary restriction can enhance mitochondrial function hence offsetting the age-related decline in its performance," said Dr Kapahi.
These results follow on from other studies that have suggested that reducing your calories can lead to longer and healthier life spans for a number of different animals. So far these findings have not been confirmed in humans.

Self Male Breast Examination

SMV Thrombosis

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Breast Calcification Workup

BREAST CALCIFICATION WORK UP:
-When you look to a mammography film containing calcification, the first sign to be observed is if this calcification diffuse or regional.
-If it is diffuse, and whether this calcification is covering the whole breast or seen as multiple similar clusters, both appearances are considered to be benign calcification with BI RADS category 2.
-If it is regional, the second sign to be evaluated is whether this calcification with no ductal distribution or with ductal distribution.
-If there is no ductal distribution , look to the size of this calcification.
-If the size of calcification is more than 0.5mm looks to the shape of this calcification.
-If it is rounded, coarse and with smooth borders, it is considered to be ROUND CALCIFICATION which is of benign nature with BI RADS categories 2.
-If it is with irregular shape and size, it is considered to be coarse, heterogeneous calcification which is of suspicious nature with BI RADS category 4.
-I f the size is less than 0.5mm, look to the shape whether it is round or flakes and small in size with hazy appearance or thin linear or curvilinear with discontinuity.
-If it is the former, this called amorphous calcification, which could be bilateral and diffuse with category 2, or bilateral and clusters with category 3, or unilateral with clusters, or new lesion in follow up, or with contra lateral cancer, the latter three should be considered BI RADS category 4(suspicious).

-If it is less than 0.5 with variable size and shape could be pleomorphic calcification which is more cancerous than amorphous one,if it is in linear distribution,it is considered to be category 5,and if it is in a segmental distribution considered to be in category 4.Usually amorphous and pleomorphic could be seen together.
-If it is linear or curvi linear with discontinuity, this should be considered as calcification with high probability of malignancies with BI RADS category 5.
-Also, if the size is less than 0.5mm with the volume of breast tissue affected more than 2cc this will be considered benign calcification with BI RADS category 2.
- Also, if the size is less than 0.5mm with cluster of calcification contain at least 5 points of calcification in a small volume of breast tissue less than 1cc, this will be considered suspicious with category 4.
-Finally, if the calcification showed ductal distribution in the form of segmental, ducts or branches of ducts or segmental or lobar, this should be considered suspicious with category 4.If it is with ductal calcification with linear pattern this should be considered as high probability of malignancies with category 5.
CONCLUSION:
-Look to the calcification, and then answer the following questions
-Is it diffuse or regional?
-If it is diffuse, considered it benign entity with BI RADS category 2
-If it is regional, look to the configuration of calcification, whether it is of ductal or no ductal distribution.
-If it is of no ductal distribution, look to the size of the lesion, if it is more than or less than 0.5mm.
-If it is more than 0.5mm, it will be either round calcification with category 2 or coarse and heterogeneous calcification with category 4, this depend on the shape of these calcification.
-If it is less than 0.5mm, it will be either amorphous calcification with different categories according to their distributions, or thin linear or curvilinear calcification which is categorized as 5.
-If it is of ductal distribution, it could be either of curvilinear shape(category 5) or other shape rather than curvilinear with segmental distribution, lobar distribution which could be categorized as 4(suspicious).

Midgut Volvulus

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How Mammography was performed

Radiology Round

Health and Salt

People unaware of hidden salt in their diet Bread, meat and cereals worst offenders
Over three quarters of people don't know that bread and cereals are among the top salt-containing foods in their diet, according to a new study.
In a survey of 2,267 people carried out by the Food Standards Agency (FSA), 73% of people questioned thought crisps and snacks contributed most salt to their diet, followed by ready meals (65%) and meat products (36%).
Only 13% of people mentioned bread and 12% thought cereals were among the top ten salt-containing foods in their diet. Most people thought foods which tasted the saltiest were the worst offenders rather than the every-day foods which we eat most often.
The survey also revealed that many people (40%) thought that supermarket value ranges contributed the most salt to their diets. However, in these budget conscious times, the good news is that this is not always the case. Some "big brand” foods actually contain more salt than their supermarket equivalent.
The FSA strongly advises everyone to check the labels. On average, people in the UK are eating 8.6g of salt a day - most from everyday foods such as bread and cereals. We should all be aiming to cut down to 6g of salt a day, preferably less!
Rosemary Hignett, Head of Nutrition at the FSA, said: "We are not suggesting people stop eating or even cut down on bread and breakfast cereals, because they are an important part of a healthy diet. But we are saying take a look at the labels to find one that is lower in salt.
"This could be a supermarket own-label product, and maybe one from the "value" range. If so, any cost saving is an added bonus."
Past research has shown that high salt levels in a person's diet put them at increased risk of high blood pressure, heart disease and stroke.