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BackgroundTo determine the usefulness of ultrasonography in the assessment of post radiotherapy skin changes in postmastectomy breast cancer patients.MethodsPatients treated for postmastectomy radiotherapy in National University Hospital (NUH) and Tan Tock Seng Hospital (TTSH), Singapore between January 2004- December 2005 was recruited retrospectively. Ultrasound scan was performed on these Asian patients who had been treated to a total dose of 46-50 Gy with 1 cm bolus placed on the skin. The ultrasound scans were performed blinded to the RTOG scores, and the skin thickness of the individually marked points on the irradiated chest wall was compared to the corresponding points on the non-irradiated breast.ResultsThe mean total skin thickness inclusive of the epidermis and the dermis of the right irradiated chest wall was 0.1712 mm (± 0.03392 mm) compared with the contra-lateral non-irradiated breast which was 0.1845 mm (± 0.04089 mm; p = 0.007). The left irradiated chest wall had a mean skin thickness of 0.1764 mm (± 0.03184 mm) compared with the right non-irradiated breast which was 0.1835 mm (± 0.02584 mm; p = 0.025). These independent t-tests produced a significant difference of reduced skin thickness on the right irradiated chest wall, p = 0.007 (p < 0.05) and left irradiated chest wall p = 0.025 (p < 0.025) in comparison to the non-irradiated skin thickness investigating chronic skin reactions. Patients with grade 2 acute skin toxicity presented with thinner skin as compared to patients with grade 1 (p = 0.006).ConclusionsThis study has shown that there is a statistically significant difference between the skin thicknesses of the irradiated chest wall and the contra-lateral non-irradiated breast and a predisposition to chronic reactions was found in patients with acute RTOG scoring of grade1 and grade 2.

A case of left brachial plexus-related malignant peripheral nerve sheath tumor showing neoplastic, glandular, and rhabdomyoblastic elements in a 39-year-old Chinese man is reported. The authors suggested that this tumor be termed a malignant glandular triton tumor in view of the presence of the adenocarcinomatous component. The patient had extensive local recurrence comprising mainly the Schwann spindle cells within a year after complete piecemeal removal and died 15 months later after the initial presentation. The natural behavior of this tumor, as in other reported cases of malignant triton tumor, is extremely aggressive, unlike malignant schwannoma or glandular malignant schwannoma. The histogenesis of this tumor is likely to be from primitive neural crest cells, Schwann's cell precursors, or metaplastic malignant Schwann's cells.

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YEW-OO TAN, M.B.B.S., ERCPC, AND SOON-TEE WONC, M.B.B.S., M.R.C.P.A 69-year-old Chinese man, with no past medical illness, presented in July 1989 with a 3-month history of upper abdominal discomfort. Clinical examinations revealed an enlarged palpable liver, 3 cm below the costal margin at the epigastrium. He was not jaundiced and there were no stigmata of chronic liver disease. Initial blood investigations showed urea nitrogen 3.6 mmol per L, Na 138 mmol per L, K 3.8 mmol per L, Cl 105 mmol per L, CO2 20.2 mmol per L, creatinine 83 mmol per L, glucose 4.3 mmol per L, unconjugated bllirubin 10 pimol per L, conjugated bilirubin 0 pmol per L, total protein 70 g per L, albumin 42 g per L, gammaglutamyltransferase 135 U per L, alanine aminotransferase 38 U per L, alkaline phosphatase 94 U per L, lactic acid dehydrogenase 478 U per L, HBsAg was positive and alphafetoprotein was 2.3 pg per L. Ultrasound and computerized tomography (CT) scans showed a hypoechoic lesion measuring 5 cm in diameter, in the left lobe of the liver. A CT-guided fine needle aspiration biopsy revealed a hepatocellular carcinoma. A left bepatectomy and cholecystectomy were performed and histology confirmed a moderately differentiated hepatocellular carcinoma (Fig. 1). Postoperatively, the patient was treated with epirubicin.In September 1991, he was treated for hypertension with enalapril maleate initially and nifedipine later because of a cough with enalapril. He subsequently developed a generalized itch after 4 weeks of nifedipine. The itch continued despite stopping the medication. Liver function tests done then showed no evidence of obstructive jaundice. The total bilirubin was 18 pmol per L, conjugated bilirubin 0 pmol per L, and serum alkaline phosphatase 73 U per L. He was subsequently treated by a private dermatologist for scabies with Eurax cream and topical steroids.Three months later the patient developed severe pruritic nodular eruptions over his hand, trunk, and feet (Fig. 2). Clinical examination revealed erythematous papules with excoriation marks over the involved areas. No jaundice was noted. The dermatologic lesions resembled scabies and he was treated with malathion lotion with no improvement. Skin scrapings for scabies were negative. Biopsies of the skin lesions were performed and a diagnosis of acquired perforated dermatosis was made. The awareness that this

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