Introduction and aims: Despite advances in local therapy, there is an ongoing risk of local recurrence after treatment for soft tissue sarcoma. Early detection of local recurrence with MRI scanning may improve outcomes for patients. The purpose of this retrospective study was to evaluate the usefulness of routine postoperative MRI scans in diagnosing clinically occult local recurrence after surgery for trunk and extremity soft tissue sarcomas.

Material and Methods: We reviewed the clinical and radiology records of all patients who underwent surgery for trunk or extremity soft tissue sarcoma in our service with the potential for 3 years of follow up. We looked at the number of postoperative MRI scans performed, the indications for the scans (routine or clinical suspicion of recurrence) and the scan results.

Results: Between 1998 and 2003, 151 patients met the inclusion criteria. The mean age was 59 (17 – 94) years. The diagnosis was liposarcoma in 37%, malignant fibrous histiocytoma in 17%, and leiomyosarcoma in 15%. Reflecting differences in practice between consultants, 79 patients had routine postoperative MRI scans, 8 patients had MRI scans following clinical suspicion of a local recurrence, and 64 patients did not have a postoperative MRI scan. Of 79 patients undergoing a total of 354 routine postoperative scans, 2 had detection of a local recurrence not suspected clinically. This represents a cost of £55,224 per recurrence detected. Of the 8 patients who underwent MRI scanning for a clinical suspicion of local recurrence, 4 had a local recurrence confirmed on scanning.

Conclusions: Most local recurrences are detected clinically. The cost of detecting local recurrence of a trunk or extremity soft tissue sarcoma by MRI scanning is high. The benefit of earlier detection over clinical examination is not known.

Aim: To audit the accuracy and efficacy of injections for subacromial impingement administered by our medical staff and specialist role physiotherapist.

Methods: 49 patients presenting to the outpatient clinic with subacromial impingement agreed to take part in the study. They were allocated according to date of referral to either the consultant, the physiotherapist or registrar grade for injection via an anterior approach into the subacromial bursa. The therapeutic injection contained a specified volume of radiocontrast as well as depomedrone and lignocaine.

Antero-posterior and scapula-Y radiographs were performed immediately after injection. The Constant shoulder score was evaluated before and at six weeks after injection and all radiographs were reviewed by an independent, blinded radiologist recording the position of contrast.

Results: Accuracy rates of 67% through an anterior approach were obtained by both the consultant and the physiotherapist. At registrar level 48% accuracy was achieved.

Improvement in shoulder score was obtained in 70% of patients with accurate injections, but additionally in 59% of patients with inaccurate injections.

Only 7% of cases had contrast confined to the subacromial space; in the remainder, contrast tracked medially around the rotator cuff muscle bellies in 59%, gleno-humeral joint in 20% and within the cuff tendon in 16%.

Conclusions: In our practice, the specialist physiotherapist already has an established role in administering therapeutic subacromial injections. Our audit demonstrates acceptable and equal accuracy to the consultant which we feel justifies this particular part of their role. However, at registrar grade the level of accuracy is reduced and most likely reflects inexperience, as over time accuracy improved.

Interestingly, shoulder function scores have improved in over half of impingement patients with inaccurate injections which may reflect a generalised ‘field’ effect of steroid on the shoulder.

Bone lesions of the tibia are encountered commonly in radiology practice.

The range of pathologies is large and it can be difficult to reach a diagnosis based upon conventional radiographic features alone. Cross-sectional imaging (CT and MRI) can help narrow down the differential and in many cases provide a definitive diagnosis.

We present a pictorial review of the imaging features a comprehensive range of pathologies involving the tibia on conventional radiography, CT and MRI and discuss features to aid accurate diagnosis.

Objective: To report a rare case of lymphomatous transformation in a Pagetic bone

Methods: A 61yr old lady with an 8yr history of monostotic Paget’s disease affecting her right proximal humerus presented with increasing right arm pain. Initial investigations including plain films, a radioisotope bone scan and MRI scan showed evidence of malignant transformation.

Results: The patient was admitted for an incision biopsy. Initial pathological examination suggested a high grade Paget’s sarcoma. However, further stains and immunohistochemical markers showed bone involvement by a malignant B-cell lymphoma.

Conclusion: Although sarcoma is by far the commonest malignant transformation of Pagetic bone, rare cases of lymphoma must also be considered, especially since the management and prognosis are radically different.