Adenocarcinoma in situ, minimally invasive adenocarcinoma, lepidic predominant adenocarcinoma and invasive mucinous adenocarcinoma are relatively new classification entities which replace the now retired term, bronchoalveolar carcinoma (BAC). The radiographic appearance of these lesions ranges from pure, ground glass nodules to large, solid masses. A thorough understanding of the new classification is essential to radiologists who work with MDT colleagues to provide accurate staging and treatment. A 2-year review was performed of all surgically resected cases of adenocarcinoma in situ, minimally invasive adenocarcinoma and lepidic predominant adenocarcinoma in our institution. Cases are broken down by age, gender, tumour type and tumour location. A pictorial review is presented to illustrate the radiologic and pathologic features of each entity.

No abstract

Introduction. Primary malignant melanoma of the urethra is a rare tumour (0.2% of all melanomas) that most commonly affects the meatus and distal urethra and is three times more common in women than men. Case. A 76-year-old lady presented with vaginal pain and discharge. On examination, a 4 cm mass was noted in the vagina and biopsy confirmed melanoma of a balloon type. Preoperative CT showed no distant metastases and an MRI scan of the pelvis demonstrated no associated lymphadenopathy. She underwent anterior exenterative surgery and vaginectomy also. Histology confirmed a urethral nodular malignant melanoma. Discussion. First-line treatment of melanoma is often surgical. Adjuvant treatment including chemotherapy, radiotherapy, or immunotherapy has also been reported. Even with aggressive management, malignant melanoma of the urogenital tract generally has a poor prognosis. Recurrence rates are high and the mean period between diagnosis and recurrence is 12.5 months. A 5-year survival rate of less than 20% has been reported in balloon cell melanomas along with nearly 20% developing local recurrence. Conclusion. To the best of our knowledge, this case is the first report of balloon cell melanoma arising in the urethra. The presentation and surgical management has been described and a literature review provided.

No abstract

The value of using the technique of magic angle MR imaging to demonstrate finger tendons is explored. Images of fresh frozen cadaveric specimens are presented and the structures that can be visualized in the finger are described. The results suggest that magic angle MR imaging may be a useful non-invasive technique of visualizing the details of the tendons and their surrounds in the hand.

Replacement of almost the entire native abdominal wall in patients with massive contaminated abdominal wall defects is possible, without the need for prosthetic material or microvascular free flaps. The subtotal pedicled thigh flap is a safe and effective method of providing definitive treatment for patients with massive enteroatmospheric fistulation.

We present the case of an 80-year-old female admitted with multiple fragility fractures on a background of stage 4 chronic kidney disease (CKD). Baseline bloods revealed secondary hyperparathyroidism, hypocalcaemia and lownormal 25-hydroxy vitamin D (Table 1). She had never had a bone biopsy or bone densimetry, but osteoporosis was considered the most likely pathology given a parathyroid hormone (PTH) level within target, low-normal vitamin D levels, normal alkaline phosphatase (ALP) and an elevated baseline P1NP (serum type 1 procollagen) of 486 ug/L (normal range <90 ug/L). Her established CKD precluded bisphosphonate therapy, so the treating team elected to administer a 60 mg dose of denosumab subcutaneously. Post-treatment hypocalcaemia was anticipated, but the patient's low dose cholecalciferol (25 mcg daily) was mistakenly continued instead of transitioning to 1,25-dihydroxycholecalciferol as planned. Subsequently, the patient developed hypocalcaemic tetany day 4 postdenosumab, necessitating use of intravenous calcium gluconate. She was discharged with calcitriol 0.5 mcg four times a day (QDS), calcium carbonate 3 g three times a day (TDS) and plans for outpatient monitoring. Before this could eventuate, she was readmitted with altered mentation due to hypercalcaemia and required a further 13 day admission. Readmission values revealed a suppressed PTH; taken alongside the low-normal non-specific ALP, this might suggest induction of adynamic bone state as a result of high-dose vitamin D analogues and denosumab. Bone formation markers were, unfortunately, not re-assayed at that time.Denosumab is an anti-RANKL (nuclear factor-kappa B ligand) fully humanized monoclonal antibody, used in the management of osteoporosis and to prevent skeletal-related events in patients with metastatic malignancy.1 Favourable pharmacokinetics and lack of associated renal toxicity have popularized denosumab in CKD, despite sparse experimental data subject to criticism of study design 2,3 and no evidence of efficacy in CKD stages 4 and 5.4 Hypocalcaemia postdenosumab is common, with reported rates ranging from 5.5% to 20.8%. Pre-existing CKD is an independent risk factor for this, 1,2 presumably via induction of a 'hungry bone'-like state. The risk can be abrogated with use of high-dose calcium and vitamin D, and calcitriol is the preferred analogue in the CKD population. 5 Our case again illustrates a need for caution with denosumab in CKD, and the importance of close monitoring of serum calcium levels after induction of lowturnover states to avoid rebound hypercalcaemia.

No abstract