New Doctors The Back Page

New Consultant Radiologist:

Dr Kenneth Sheah
New Nuclear Medicine Physician:

Dr Shahid Mahmood
Cyclotron Sneak Preview:
OUR TEAM
Dr June Chong LM,
MBBS, FAMS, ABR, CAQ in
Neuroradiology.
Special Interest:
Neuroradiology
Care • Comfor t • Connect
NEWS A Publication Of Radlink Diagnostic Imaging (S) Pte Ltd
• Issue No: 02-2008 • Mica (P) No: 050/02/2008

junechong@radlinkasia.com

Our Cyclotron is currently

under construction.
Dr Tony Stanley,
MB MCh, FRCR, FAMS. WE are proud to announce that we have commenced our PET/CT and General
Nuclear Medicine services. These services are available at our new
PET/CT centre, Singapore PET and Cardiac Imaging Centre Pte Ltd. Our range of services
Contents
This facility is scheduled Special Interest:
to produce advance Musculoskeletal imaging includes: 2 New Service
radiopharmaceuticals starting tonystanley@radlinkasia.com 64-Slice PET/CT
in Q1 2009. Please watch this service
• FDG-PET scans—Metabolic imaging using F-18 Fluoro-deoxyglucose
We are pleased to announce that we have a new We are pleased to inform you that Dr Shahid space for further updates. Dr Ng Hweena, 3-4 Our Clinic
(FDG) and PET/CT has become the cornerstone of oncologic imaging and
MBBS, FRCR.
Consultant Radiologist, Dr Kenneth Sheah. Mahmood has joined us from 1st May 2008 as has been shown to be useful in tumor staging and follow-up. PET/CT has Diagnostic injections
Special Interest:
After obtaining his medical degree from the Clinical Director, Singapore PET and Cardiac also proven useful in predicting prognosis and treatment response. of the foot and ankle —
Obstetrics /Gynecology A diagnostic injection
Imperial College School of Medicine in 1998, Dr Imaging Centre. nghweena@radlinkasia.com often aids in localizing
Sheah was admitted to the specialist accreditation Prior to this he was Clinical Director of Nuclear
• Rubidium-82 PET/CT for myocardial perfusion — When compared to the source of symptoms
board as a radiologist in 2003. He received the Young Medicine and PET Centre at Mount Elizabeth Dr Wang Wing Yee, conventional SPECT imaging, PET/CT using Rubidium- 82 coupled with and provides short term
Radiologist Award at the Singapore Radiological Society MBBS, FRCR, FAMS. relief.
Hospital, Singapore. a 64-slice CT scanner is a faster, easier, and more accurate method to
annual scientific meeting in 2001 for a presentation Special Interest:
on embolization of postnatal haemorrhage. At the
After graduation, he had his initial training in
Respiratory Imaging
measure myocardial blood flow. 5 New Doctors
Cardiology, followed by Nuclear Medicine training in • Dr Kenneth Sheah,
Radiological Society of North America annual scientific
meeting, he received a Merit Award for a presentation
the UK, where he obtained his MSc and PhD degrees Gentler, Softer Mammogram wangwingyee@radlinkasia.com
• Gallium-68 PET/CT for neuro-endocrine tumours—Neuro-endocrine Consultant Radiologist
on nasopharyngeal carcinoma recurrence. He has co- in Nuclear Medicine. He is a Fellow of Academy We take pride in making our patients as Dr Anne Tan Kendrick, tumors (NET) are a heterogeneous group of tumours that originate • Dr Shahid Mahmood,
authored 2 textbook chapters on topics related to X-ray of Medicine, Singapore (Nuclear Medicine), and comfortable as possible when they come MA (Cantab), BM BCh from the neural crest. These tumors are characterized by their ability Consultant Nuclear
American College of Cardiology. (Oxon), FRCR (UK), FAMS to overexpress somatostatin (SST) receptors. PET imaging using Physician
physics and, CT and MR imaging of the shoulder. for their mammograms. Since October
Special Interest: Gallium-68 (Ga-68) labeled compound-DOTATATE offers higher resolution
Previously, Dr Sheah served on the committees of Dr Shahid has an extensive clinical, academic 2008, we have been using “Woman’s 6 The Back Page
and research experience in Nuclear Medicine and Pediatrics & Women’s and improved pharmacokinetics, with promising results in the detection of • Cyclotron Sneak Preview
the Singapore Radiological Society and the College Touch MammoPad”. Basically, this is a Imaging SST receptor-expressing tumors. This is combined with contrast enhanced • Gentler, Softer
of Radiologists, Singapore. This year, he is involved non-invasive Cardiac Imaging. His areas of interest foam cushion placed between the breast annetankendrick@radlinkasia.com multi detector CT images. Mammogram
in organizing the Singapore Radiological Society's are hybrid and non-invasive cardiac imaging. He and the metal plate. This mammopad is
Annual Scientific Meeting (with a Musculoskeletal has a few book chapters and various research complementary when patients have their mammograms at RadLink Dr Kenneth Sheah,
Radiology theme), and is co-director of the Orthopaedic papers in peer review journals. He also serves MBBS, FRCR, MMed (Drad) • General Nuclear Medicine scans—Nuclear Medicine can diagnose different type of diseases. It can
Paragon branch.
Radiology-Surgery Course at the Singapore Orthopaedic on the editorial board and committees of various Special Interest: be used to identify abnormal lesions deep in the body without exploratory surgery. The procedures
Association annual scientific meeting. Your comments and enquiries are important to us. Non-Vascular Intervention can also determine whether or not certain organs are functioning normally. Our centre provides
international journals. Dr Shahid Mahmood is one
His HMDP training at the Massachusetts General and Musculoskeletal conventional nuclear medicine scans such as bone scans, liver scan, MIBI scans, thyroid scans and
of the pioneers of hybrid imaging and established Please contact: Singapore PET and Cardiac Imaging
Hospital/Harvard Medical School centered around Group Markets & Centre Pte Ltd Imaging other nuclear medicine scans.
not only PET-CT imaging, but also SPECT-CT in the
performing high definition MRI scans of the spine and Business Development Manager 290 Orchard Road #08-06 ksheah@radlink.com.sg For more information, please go to www.molecularimaging.com.sg or call our centre at 6836 1318
region. news@radlink.com.sg Paragon Medical
joints (patients included Boston Red Sox baseball and
New England Patriots American football players), as
He has also been a subject expert with International Singapore 238859
Tel: (65) 6836 1318
Dr Shahid Mahmood, FDG-PET scan is NOW
Atomic Energy Agency since 1995 and completed You can locate us at:

S$2000
well as postoperative implant imaging. He also perform Fax: (65) 6836 1381 MBBS, PhD, FAMS, FACC
diagnostic injections for patients with spine, foot and numerous assignments successfully. He has been RadLink Diagnostic Imaging To know more about us:
Special Interest:
ankle disorders (metatarsalgias, tendinopathies, and Chairman of Cardiac Imaging Committee of the 290 Orchard Road #08-08 www.radlink.com.sg Cardiac Imaging, New (excludes GST)
Paragon Medical www.molecularimaging.com.sg Tracers for PET Imaging
impingement syndromes), as part of a multidisciplinary Asian Pacific Society of Cardiology and an advisor to Singapore 238859 Please call our centre at 6836 1318 for more details
Our operating hours: mshahid@molecularimaging.com.sg
team. the Asian Society of Cardiac Imaging. Tel : (65) 6836 0808
Monday – Friday: 8.30am to 5.30pm
His email address is ksheah@radlink.com.sg His email is mshahid@molecularimaging.com.sg Fax : (65) 6836 8484 Our branches:
Saturday: 8.30am to 12.30pm
• Paragon Branch • Orchard Building • Toa Payoh • Jurong Point • PET/CT Centre
5 6
6836 0808 6737 3311 6255 0201 67926119 6836 1318
 New Service
64-Slice PET/CT service
PET is the recognized modality that can image and
measure metabolic function at the cellular level
(molecular imaging). Abnormal biological changes
occur much earlier than the anatomical changes
(disease) identifiable by imaging exams such as MRI,
CT, X-ray and ultrasound. Therefore, a PET scan
detects primary and secondary disease earlier and
more accurately than any other imaging modality.
CT (Computerized Tomography) is the standard in
anatomical imaging. Now through the advancement
in technology, a combined PET/CT scanner merges
high resolution images from both technologies into a
single test. Today, an integrated PET/CT scan is the
most advanced imaging technology for the detection
and evaluation of cancer. It has also role in certain
neurological diseases like epilepsy, as well as Coronary
Heart Disease.
Applications of PET/CT in Cardiology
When compared to
conventional SPECT
imaging, PET/CT using
Rubidium- 82 coupled
with a 64-slice CT scanner
is a faster, easier, and
more accurate method
to measure myocardial
blood flow. Cardiac
imaging with a 64 slice
PET/CT has several advantages:
• Faster acquisition times and the use of CT for
attenuation correction eliminates frequently
seen artifacts on conventional SPECT imaging in
patients with a large body habitus.
• The entire length of the study for both stress and
rest imaging is less than 30 minutes.
• Myocardial blood flow and reserve measurements
allow the detection of small vessel or balanced
three vessels disease. These patients will have normal SPECT studies
• The 64-slice CT allows for coronary artery calcium scoring which gives
additional information about the severity of the coronary artery disease
and can be an important factor for deciding the best treatment for the
patient
The combined PET multi-detector CT system allows for direct comparison of
a PET study with CT coronary angiography performed in the same sitting. In
combination, these two studies have been shown to have a negative predictive
value of nearly 100% and can help avoid unnecessary catheterizations in
normal patients
2 3
Applications of PET/CT
in Oncology
Indications:
• Differentiation of benign from
malignant lesions
• Staging of malignant disease.
Evaluating chemotherapy
response:
• Early: after one or two cycles of
chemotherapy
• Late: 3-4 weeks after completion
of chemotherapy or 2-3 months
following completion of radio-
therapy
• Differentiation of local recurrence
from post-surgical or post treat-
ment changes
Detection of early recurrence or
metastasis through timely follow-
up testing
Applications of PET/CT
in Neurology
Indications:
• Dementia: Differentiation of
Alzheimer's disease from other
types of dementia in its early
stages
• Epilepsy: Localization of
epileptogenic foci
Our Clinic
F Diagnostic injections
OOT and ankle pain is common. The variety
of bone, joint and soft tissue pathology and
complex anatomy mean that the exact source of
pain may sometimes be difficult to localize accurately.
While CT and MRI are good adjuncts to conventional
radiographs, they often reveal a multitude of coexisting
problems which are difficult to correlate with clinical
presentation.
Imaging guided injections of the foot and ankle
can help in localizing the source of pain, hence aiding
surgical planning and physical therapy/orthotics.
Administration of cortical steroids into joints and
also extra-articular structures is well described in the
literature. Percutaneous steroid injection is safe, and
effective in achieving symptomatic relief.
Before starting the procedure, informed consent
is obtained with the understanding that frequent
repeated injections can result in accelerated cartilage
destruction. Septic arthritis is a rare but potentially
serious complication. A minority of patients develop a
flare phenomenon a few days after injection with some
pain and swelling, which is self limiting.
All foot and ankle injections are performed with
meticulous sterile technique using local anaesthetic.
Ultrasound is a useful adjunct for structures such as
the tendon sheath.
We use a small amount of iodinated water soluble
contrast to document correct needle placement. After
this, the steroid and anaesthetic mixture is introduced
under fluoroscopic control, and confirmed with
progressive dilution of intra-articular contrast. At the
completion of procedure, the patients are discharged
with an instruction sheet and a confirmed appointment
with referring physician.
It is important to ensure these patients do not rest
their extremities immediately after injection in order to
accurately gauge relative pain relief. We also provide
patients with a pain diary, to document the degree of
pain before and after the injection has taken place.
The posterior subtalar joint and sinus tarsi
The subtalar or talocalcaneal joint is composed of
three facets – a broad posterior facet representing the
primary articulating surface, a medially located middle
facet in which the sustentaculum tali articulates with
the medial process of the talus, and an anterior facet.
Pain originating from the posterior subtalar joint is
often secondary to subtalar degenerative joint disease
and yet may be difficult to localise clinically. Chronic
hind foot pain can arise from articular disease, and
Other joints
The talonavicular joint communicates with the middle
and anterior subtalar joint. Injection of the talonavicular
joint will result in fillng of the middle subtalar joint as
of the foot and ankle
well. A dorsal approach using a lateral projection aids
access, and about 1ml of anaesthetic is introduced into
the confined joint space. The calcaneocuboidal joint can
be approached via an oblique dorsal trajectory with a
short 23 gauge needle.
coexist with tendinopathies and sinus tarsi syndrome is characterised by lateral hind foot pain, with the
or other soft tissue impingements. sensation of hindfoot instability. Usually, trauma Joints of the mid foot and fore foot
Patients with intractable pain and documented associated with lateral ankle ligament injury is the The intertarsal and tarsometatarsal joints can
subtalar arthropathy may benefit from arthrodesis. cause of sinus tarsi syndrome. This can sometimes be injected using a dorsal approach with needle
Before surgical intervention, subtalar arthrography be aggravated by ill fitting footwear. The sinus tarsi
angulation and variable obliquity under fluoroscopy,
with an anaesthetic challenge can help confirm
injection is performed with an anterolateral approach, due to the different facetal angulations of the
this joint as pain source. The arthrogram may be
similar to that for subtalar arthrography. tarsal bones and their joints. Tarsometatarsal joint
performed via a posterolateral, posteromedial or
degeneration is common in middle aged females and
anterolateral approach. An injection of less than
Posterior impingement can severely limit a patient’s lifestyle and mobility.The
1ml of contrast is used to confirm needle placement
first tarsometatarsal joint is isolated from adjacent
followed by introduction of local anaesthetic with or
without steroids.
Imaging guided injections of the posterior ankle articulations and accommodates approximately 1ml
can also be performed in the setting of posterior
The posterior approach may be attempted, but are of total volume. The second and third as well as fourth
impingement. This occurs in the soft tissues between
limited by the relative proximity of overlying tendons and fifth tarsometatarsal joints are continuous.
the posterior articular surface of the tibia and The first metatarsophalangeal joint (MTPJ) is a
and the neurovascular bundle. Communication
between the subtalar and tibiotalar joint may be thecalcaneus. Ultrasound guided injection into common source of foot pain, related to degenerative
observed in minority cases. the thickened posterior capsule/transverse ligament joint disease and can accompany hallux valgus.
The sinus tarsi is situated between the inferior region may be performed. Fluoroscopy has an added Osteophytes can impair blind access into the joint
advantage of documenting the size of an accessory ossicle space. The presence of paired sesamoids along
talus and the superior calcaneum just anterior to the
the plantar surface, embedded in flexor hallucis
posterior subtalar joint. This space is usually filled with (os trigonum), if present. Furthermore, fluoroscopic
brevis tendons, can also complicate the anatomy.
fat, but interosseous ligaments and neurovascular needle placement into the synchondrosis between os
Sesamoditis is common, usually involving the medial/
structures are also present. The sinus tarsi syndrome trigonum and the talus can be accurately documented. tibial sesamoid. The dorsal surfaces of the sesamoids
are covered by articular cartilage and degenerative
Fig 1: Posterior subtalar Fig 2: Sinus tarsi injection changes and can be visualised on MRI.
arthrogram performed performed with the foot
The first MTPJ injection is performed via a dorsal
with an anterolateral in lateral projection.
approach and can accommodate up to 1.5mls of total
approach. Injection Contrast pooling is present,
resulted in replication of with replication of pain volume. Documentation in anteroposterior and lateral
pain symptoms, which was symptoms. Radiographic
projections as well as sequential filling images should be
relieved with lignocaine documentation of correct
and dexamethasone. This needle placement is obtained. Occasionally, a separate sesamoid metatarsal
constituted a positive important owing to the many joint injection can be performed via an angulated axial
subtalar arthrogram test. differential diagnoses for
sinus tarsi syndrome. approach.
Summary
Degenerative, traumatic or inflammatory conditions
of the foot and ankle are common, and can severely
Fig 3: First tarsometatarsal Fig 4: Flexor hallucis longus
limit the patient’s lifestyle and mobility. While static
joint injection. The dorsal (FHL) tendon sheath injection.
The FHL can be localised
or lateral approach to the imaging can reveal many coexisting problems, a
joint may be used, but sonographically, and the
arthrographic confirmation tenogram followed by local diagnostic injection often aids in localising the source
with a small amount of anaesthetic of symptoms, and has the benefit of providing short
contrast proves that the and cortisone. The patient
term relief. From our experience, patients return to
needle tip is in the correct reported relief of pain after
location. Subsequent injection. The FHL tendon their referring physicians with a greater understanding
relieve of symptoms with sheath communicates with the of their joint problems and are more motivated to seek
injection of local anaesthetic joint in some cases. Another
a solution to their long standing problems.
motivated the patient to have site for injection includes the
surgical fixation of the joint. intersesamoid space at the Dr Kenneth Sheah
base of the big toe. MBBS, FRCR, MMed (DRad),
Consultant Radiologist
4