The diagnosis of thoracic outlet syndrome rests primarily on a clinical evaluation. Doppler ultrasound may be employed to investigate any vascular component. Normative data in this area have not been well established. A total of 25 asymptomatic healthy individuals were examined clinically and with ultrasound. The presence of a subclavian bruit was noted. A single operator in turn imaged each arm. The patient was examined in three provocative arm positions: 90° abduction, 90° abduction with external rotation, and an elbow braced back, Roos-type position. Colour images and Doppler spectra were obtained. The duplex was considered positive if a significant alteration in the Doppler spectrum occurred, e.g. at least to monophasic flow. A single radiologist verified all scans. Eleven female and 14 male subjects were examined, median age 27 years (20–63). Eleven (44 per cent) subjects had an arterial bruit, of which four were bilateral. Sixteen (64 per cent) subjects had a positive arterial duplex, of which four were bilateral. Venous entrapment was detected in eight arms. If for the purposes of this study, ultrasound is considered, the gold standard for the detection of arterial entrapment, the sensitivity of a bruit in detecting such entrapment is 46 per cent, and its specificity 88 per cent. Given the high prevalence of abnormal Doppler ultrasound findings in an asymptomatic population, duplex may have only a limited role in the investigation of TOCS. Although not a sensitive test, the detection of an arterial bruit correlates well with flow abnormalities appreciable on ultrasound examination. Clinical evaluation should continue to be paramount in the management of TOCS.
Introduction: Approximately 30% of patients diagnosed with pancreatic cancer will present with locally advanced unresectable disease (LAPC). Improved planning techniques provide the opportunity for dose escalation. Methods: From February 2010 to September 2010, patients with LAPC suitable for CRT were planned using contrast enhanced 4D CT scanning. We compared 4D CT treatment planned according to local protocol using 50.4 Gy (4D50.4) and 55.8 Gy (4D55.8) compared with the NCRN/SCALOP protocol (50.4 Gy SCALOP50.4). Our local protocol defines gross tumour volume (GTV) outlined on all respiratory phases of image sets generated by 4D CT with a radiologist (using the SCALOP study protocol). An internal target volume (ITV) was generated as a composite of all GTVs. This ITV was grown with 1 cm circumferential margin and 1.2 cm superior–inferiorly to define a PTV. Dose constraints and PTV coverage were defined by the SCALOP protocol. Results: We identified nine patients who had 4D CT scans from April to October 2010. We found that the mean reduction in small bowel doses for V15small bowel was 17% and the mean V45small bowel was reduced by 28% when 4D50.4 was compared with SCALOP50.4. With dose escalation to 55.8 Gy, 4D55.8 remained compliant with the organs at risk constraints and these values, including the mean small bowel doses (V15small bowel and V45small bowel) remained comparable to the SCALOP50.4. Patients set-up errors were reviewed during treatment and found to be acceptable for our PTV margins. No acute grade 3 or 4 toxicity was observed of the eight patients treated with 4D50.4 plans. Conclusion: In this study, 4D CT planning using our protocol would allow dose escalation without a significant increase in the small bowel dose.
Amyand’s hernia (AH) is characterized by the presence of the vermiform appendix in an inguinal hernia sac. Typically presenting on the right side and with manifestations similar to those seen in complicated hernias, it presents a diagnostic challenge and is frequently only diagnosed intraoperatively. We present the case of a left-sided AH on a 75-year-old man treated with appendicectomy, orchidectomy and hernioplasty without mesh.
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