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Correspondence: The Radiological Investigation of Suspected Lower Limb Deep Vein Thrombosis
Clinical Radiology (2000) 55, 79
Correspondence Letters are published at the discretion of the Editor. Opinions expressed by correspondents are not necessarily those of the Editor. Unduly long letters may be returned to the authors for shortening. Letters in response to a paper may be sent to the author of the paper so that the reply can be published in the same issue. Letters should be typed double spaced and should be signed by all authors personally. References should be given in the style specified in the Instructions to Authors at the front of the Journal.
SIR – We were interested to read the paper on ultrasound, CT and MR imaging in patients with multiple symmetric lipomatosis (Madelung’s disease) [1]. We agree with the authors that multiple symmetric lipomatosis is not as common in the Chinese population as previously suspected and there have been earlier reports of this condition [2,3]. We have previously described the pre-operative findings of ultrasound, CT and MR in eight patients with Madelung’s disease particularly in reference to the distribution of fat in the neck [4]. Patients with this condition may present with dysphagia and dyspnoea, which are usually ascribed to airway narrowing due to compression by lipomatous masses. However, in our series one of the patients had an unsuspected laryngeal carcinoma causing airway obstruction which was detected on CT and MR, while another patient from the same group later went on to develop a hypopharyngeal carcinoma. The presence of a malignant airway tumour in these patients has been reported previously [5]. We do not know whether these findings are coincidental or if the increase in malignant tumours in this group of patients is a synergestic effect of alcohol abuse and smoking [6], as there was a history of alcohol abuse in all eight patients in our study and seven of them were either smokers or ex-smokers with a 20–40 year history of smoking. We therefore suggest that patients with multiple symmetric lipomatosis, who present with symptoms of airway obstruction are evaluated by CT or MR to rule out a malignant airway tumour. A. T. AHUJA* A. D. KING* E. S. Y. CHAN†
Departments of *Diagnostic Radiology and Organ Imaging, and †Surgery Chinese University of Hong Kong Pince of Wales Hospital Shatin, NT, Hong Kong
References 1 Loke TKL, Yung CK, Chow TL, Lo SS, Chan CS. Multiple symmetric lipomatosis in the Chinese: ultrasound, CT and MR imaging. Clin Radiol 1998;53:903–906. 2 John DJ, Fung HK, van Hasselt CA, King WWK. Multiple symmetric lipomatosis – a condition not previously reported in the Chinese. Eur Arch Otorhinolaryngol 1992;249:277–278. 3 Wu WH, Fang RH. Multiple symmetric lipomatosis (Madelung’s disease): a case report. Chin Med J (Taipei) 1996;58:139–142. 4 Ahuja AT, King AD, Chan ESY et al. Madelung disease: distribution of cervical fat and pre-operative findings at sonography, MR and CT. AJNR 1998;19:707–710. 5 Ruzicka T, Vieluf D, Landthaler M, Braun-Falco O. Benign symmetric lipomatosis. J Am Acad Dermatol 1987;17:663–674. 6 Chan ESY, Ahuja AT, King AD, Lau WY. Head and neck cancers associated with Madelung’s disease. Ann Surg Oncol (in press).
0009-9260/00/010079+01 $35.00/0
THE RADIOLOGICAL INVESTIGATION OF SUSPECTED LOWER LIMB DEEP VEIN THROMBOSIS SIR – Correspondence following publication of the paper by Burn et al. [1] has highlighted several potential pitfalls in the use of colour Doppler ultrasound (CDUS) as first line investigation for suspected deep vein thrombosis (DVT). Despite these problems, we believe that the use of CDUS as first line investigation in suspected lower limb DVT is increasing in popularity. In March 1998, delegates at the London CT/MRI conference based in Gleneagles were invited to fill in a short questionnaire related to the investigation of suspected DVT. Delegates from 65 separate UK Radiology Departments replied. Forty-eight of the responders (75%) used CDUS as first line investigation of suspected DVT. This represents an increase in first line use of CDUS in this setting, compared with the 46% of Departments in March 1996 using CDUS as first line investigation described by Burn et al. Attitudes towards follow-up ultrasound after initial negative study were also of interest, given the recent British Medical Journal articles [2,3] and related correspondence advocating two separate compression ultrasound examinations one week apart in this clinical setting. Of the 48 departments using CDUS as first line investigation for suspected DVT in our survey, only two would routinely perform followup ultrasound after an initial negative result. The majority of U.K. Radiology Departments do not routinely perform follow-up ultrasound after initial negative study, presumably relying on further clinical input as to the need for follow-up. The relevant College guideline [4] suggesting that ultrasound of lower limb veins for suspected DVT is indicated, while venography is not indicated routinely, does accurately reflect current practice in the majority of U.K. Radiology Departments. P. F. WALSH
Department of Radiology, Inverclyde Royal Hospital, Greenock, U.K.
J. C. LAUDER
Department of Radiology, Victoria Infirmary, Glasgow, U.K. References
1 Burn PR, Blunt DM, Sansom HE, Phelan MS. The radiological investigation of suspected lower limb deep vein thrombosis. Clin Radiol 1997;52:625–628. 2 Cogo A, Lensing AWA, Koopman MW et al. Compression ultrasonography for diagnostic management of patients with clinically suspected deep vein thrombosis: prospective cohort study. Br Med J 1998;316:17–20. 3 Davidson BL, Deppert EJ. Ultrasound for the diagnosis of deep vein thrombosis: where to now? (Editorial). Br Med J 1998;316:2–3. 4 RCR Working Party. Making the Best Use of a Department of Clinical Radiology: Guidelines for Doctors. 4th edn. London: The Royal College of Radiologists, 1998.
q 2000 The Royal College of Radiologists
Correspondence Letters are published at the discretion of the Editor. Opinions expressed by correspondents are not necessarily those of the Editor. Unduly long letters may be returned to the authors for shortening. Letters in response to a paper may be sent to the author of the paper so that the reply can be published in the same issue. Letters should be typed double spaced and should be signed by all authors personally. References should be given in the style specified in the Instructions to Authors at the front of the Journal.
SIR – We were interested to read the paper on ultrasound, CT and MR imaging in patients with multiple symmetric lipomatosis (Madelung’s disease) [1]. We agree with the authors that multiple symmetric lipomatosis is not as common in the Chinese population as previously suspected and there have been earlier reports of this condition [2,3]. We have previously described the pre-operative findings of ultrasound, CT and MR in eight patients with Madelung’s disease particularly in reference to the distribution of fat in the neck [4]. Patients with this condition may present with dysphagia and dyspnoea, which are usually ascribed to airway narrowing due to compression by lipomatous masses. However, in our series one of the patients had an unsuspected laryngeal carcinoma causing airway obstruction which was detected on CT and MR, while another patient from the same group later went on to develop a hypopharyngeal carcinoma. The presence of a malignant airway tumour in these patients has been reported previously [5]. We do not know whether these findings are coincidental or if the increase in malignant tumours in this group of patients is a synergestic effect of alcohol abuse and smoking [6], as there was a history of alcohol abuse in all eight patients in our study and seven of them were either smokers or ex-smokers with a 20–40 year history of smoking. We therefore suggest that patients with multiple symmetric lipomatosis, who present with symptoms of airway obstruction are evaluated by CT or MR to rule out a malignant airway tumour. A. T. AHUJA* A. D. KING* E. S. Y. CHAN†
Departments of *Diagnostic Radiology and Organ Imaging, and †Surgery Chinese University of Hong Kong Pince of Wales Hospital Shatin, NT, Hong Kong
References 1 Loke TKL, Yung CK, Chow TL, Lo SS, Chan CS. Multiple symmetric lipomatosis in the Chinese: ultrasound, CT and MR imaging. Clin Radiol 1998;53:903–906. 2 John DJ, Fung HK, van Hasselt CA, King WWK. Multiple symmetric lipomatosis – a condition not previously reported in the Chinese. Eur Arch Otorhinolaryngol 1992;249:277–278. 3 Wu WH, Fang RH. Multiple symmetric lipomatosis (Madelung’s disease): a case report. Chin Med J (Taipei) 1996;58:139–142. 4 Ahuja AT, King AD, Chan ESY et al. Madelung disease: distribution of cervical fat and pre-operative findings at sonography, MR and CT. AJNR 1998;19:707–710. 5 Ruzicka T, Vieluf D, Landthaler M, Braun-Falco O. Benign symmetric lipomatosis. J Am Acad Dermatol 1987;17:663–674. 6 Chan ESY, Ahuja AT, King AD, Lau WY. Head and neck cancers associated with Madelung’s disease. Ann Surg Oncol (in press).
0009-9260/00/010079+01 $35.00/0
THE RADIOLOGICAL INVESTIGATION OF SUSPECTED LOWER LIMB DEEP VEIN THROMBOSIS SIR – Correspondence following publication of the paper by Burn et al. [1] has highlighted several potential pitfalls in the use of colour Doppler ultrasound (CDUS) as first line investigation for suspected deep vein thrombosis (DVT). Despite these problems, we believe that the use of CDUS as first line investigation in suspected lower limb DVT is increasing in popularity. In March 1998, delegates at the London CT/MRI conference based in Gleneagles were invited to fill in a short questionnaire related to the investigation of suspected DVT. Delegates from 65 separate UK Radiology Departments replied. Forty-eight of the responders (75%) used CDUS as first line investigation of suspected DVT. This represents an increase in first line use of CDUS in this setting, compared with the 46% of Departments in March 1996 using CDUS as first line investigation described by Burn et al. Attitudes towards follow-up ultrasound after initial negative study were also of interest, given the recent British Medical Journal articles [2,3] and related correspondence advocating two separate compression ultrasound examinations one week apart in this clinical setting. Of the 48 departments using CDUS as first line investigation for suspected DVT in our survey, only two would routinely perform followup ultrasound after an initial negative result. The majority of U.K. Radiology Departments do not routinely perform follow-up ultrasound after initial negative study, presumably relying on further clinical input as to the need for follow-up. The relevant College guideline [4] suggesting that ultrasound of lower limb veins for suspected DVT is indicated, while venography is not indicated routinely, does accurately reflect current practice in the majority of U.K. Radiology Departments. P. F. WALSH
Department of Radiology, Inverclyde Royal Hospital, Greenock, U.K.
J. C. LAUDER
Department of Radiology, Victoria Infirmary, Glasgow, U.K. References
1 Burn PR, Blunt DM, Sansom HE, Phelan MS. The radiological investigation of suspected lower limb deep vein thrombosis. Clin Radiol 1997;52:625–628. 2 Cogo A, Lensing AWA, Koopman MW et al. Compression ultrasonography for diagnostic management of patients with clinically suspected deep vein thrombosis: prospective cohort study. Br Med J 1998;316:17–20. 3 Davidson BL, Deppert EJ. Ultrasound for the diagnosis of deep vein thrombosis: where to now? (Editorial). Br Med J 1998;316:2–3. 4 RCR Working Party. Making the Best Use of a Department of Clinical Radiology: Guidelines for Doctors. 4th edn. London: The Royal College of Radiologists, 1998.
q 2000 The Royal College of Radiologists