BJR News August 2011

THE NEWS MAGAZINE FROM THE BRITISH INSTITUTE OF RADIOLOGY

August 2011 www.bir.org.uk

Airport body scanners are safe for public and aircrew Malignant tumours of the small intestine President’s conference 2011

Radiation risk: what can the UK learn from Japan?

ISSN 2044-5113

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contents

in this issue 3 5 7 8 15 18 20

Safe as houses?

recent BIR eventS President’s conference 2011

BIR events calendar Forthcoming events from the BIR scientific programme

Community news News from the radiology and allied sciences community

What’s Online Table of contents from The British Journal of Radiology volume 84 number 1003 and 1004

Case of the month Short Communication Development of a risk score to guide brain imaging in older patients admitted with falls and confusion

Editors-in-Chief: Dr Simon Blease, Mrs Liz Hunt Managing Editor: Sherry Dixon Production Editors: Jenny Rooke, Hazel Swain Contributing Editors: Dr Adrian Thomas

Malignant tumours of the small intestine: a review of histopathology, multidetector CT and MRI aspects

Abstracts

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BIR News

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letter to the editors/book review

A digital object identifier (DOI) can be used to cite and link to electronic documents. A DOI is guaranteed never to change, so you can use it to link permanently to electronic documents. The DOI scheme is administered by the International DOI Foundation.

Many of the world’s leading publishers have come together to build a DOI-based document linking scheme known as CrossRef.

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Review article

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Head and neck lumps in an Asian male

Using the DOI system

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Editorial

Abstracts from The British Journal of Radiology volume 84 number 1003 and 1004

Updates from BIR projects and committees

History of Radiology Historical places and classic radiology books

BIR President’s Column obitury William Mackie Ross - past President of the British Institute of Radiology

Accessing BJR articles online using a DOI is simple. Where you see this symbol, simply type the url provided into your browser. Or, open the following DOI site in your browser: http://dx.doi.org enter the entire DOI citation in the text box provided, and then click Go.

ISSN 2044-5113 The British Journal of Radiology Editorial Board: Honorary Editors: Dr Jane Phillips-Hughes (Medical), Prof Roger G Dale (Scientific).

Deputy Editors: Dr Daniel Birchall, Dr Nigel Hoggard, Prof Alan Jackson, Dr Simon Jackson, Dr Paul Sidhu, Dr Stuart Taylor (Diagnostic Radiology), Dr William Vennart (Physics & Technology), Prof Kevin Prise (Radiobiology), Prof Alastair Munro (Radiotherapy & Oncology). Commissioning Editor: Dr David Wilson.

Copyright © 2011 British Institute of Radiology. All rights reserved. Reproduction in whole or part is prohibited without prior permission of the BIR. All opinions expressed in this publication are those of the respective authors and not the publisher. The publisher has taken the utmost care to ensure that the information and data contained in this publication are as accurate as possible at the time of publication. Nevertheless the publisher cannot accept any responsibility for errors, omissions or misrepresentations howsoever caused. All liability for loss, disappointment or damage caused by reliance on the information contained in this publication or the negligence of the publisher is hereby excluded.

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BIR information

The British Institute of Radiology 36 Portland Place, London W1B 1AT Telephone: +44 (0)20 7307 1400 Fax: +44 (0)20 7307 1414 Registered Charity No. 215869 Founded 1897 Incorporated by Royal Charter Patron: Her Majesty The Queen

The British Institute of Radiology has as its aim to bring together all the professions in radiology and allied medical and scientific disciplines to share knowledge, and educate the public, thereby improving the prevention and detection of disease and the management and treatment of patients.

Particulars of membership and other information can be obtained from the CEO, BIR, 36 Portland Place, London WIB 1AT, and from the BIR’s website: www.bir.org.uk

COUNCIL AND OFFICERS The Institute’s decision making body, its Council, has specific responsibilities concerned with the governance of the Institute and the management of its charitable activities.

Council consists of Officers, Ordinary Council Members and Branch Representatives.

Chairmen of the BIR’s Scientific Committees attend meetings as Observers.

Officers

Ordinary Members of Council

President Dr S G Davies Vice President Prof A Jones Honorary Treasurer Mr J Gunaratnam Honorary Secretary Dr S Blease Honorary Secretary Mrs E Hunt Honorary Editor Prof R Dale Honorary Editor Dr J Phillips-Hughes

Dr D Morgan Dr A J Pearson Dr P Riley Dr S Taylor Dr R Chowdhury Mr C McCaffrey Mrs N J Sykes Dr D Sutton Dr A Reilly Ms E Morris

Scientific Committees

Committee Chairperson

Regional Committee Chairperson

The Institute’s Scientific Committees meet regularly and have the important remit of providing a forum for scientific, educational and technical discussions, of providing advice both to Council and to external bodies, and of devising the bulk of the Scientific Meetings programme.

Clinical Imaging Dr N Strickland Health Informatics Mrs E Hunt Industry Mrs E Beckmann Magnetic Resonance Professor D Lomas Nuclear Medicine and Molecular Imaging Dr R Ganatra Oncology Dr H McNair Radiation and Cancer Biology Dr E Hammond Radiation Physics and Dosimetry Professor A W Beavis Radiation Protection Dr P Riley Trainee Dr R Chowdhury

East of England Dr T C See North of England Dr K Irion South West Ms N Sykes Scotland Dr A Pearson Wales Dr G Tudor Wessex Dr K Johnson

Enquiries 2

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General enquires – admin@bir.org.uk Corporate – jacqueline.fowler@bir.org.uk Membership – jane.moynihan@bir.org.uk

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Publications – publications@bir.org.uk Regional branches – jacqueline.fowler@bir.org.uk Scientific meetings – ruth.warne@bir.org.uk Display advertising sales – craig.berg@tenalps.com

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Editorial: Safe as houses?

Safe as houses?

It’s a funny old saying but probably quite understandable in its origins.

Looking at the contents of this current edition of BJR News you might be forgiven for thinking that there is an obsession with safety.

Our previous editorial touched on this as well, written, as it was, at the time of the unfolding nuclear disaster in Japan. Since then, things have got worse with the authorities admitting that all three damaged reactors suffered 100% core melt-down (i.e. equal in severity to Chernobyl) and that Fukushima workers were exposed to a year's dose of radiation within minutes of entering the site. From our perspective there is an almost vicarious interest in this most unfortunate situation since we hope that this will add to our understanding of the effects of ionising radiation and how to use it safely. How we integrate the accumulated knowledge into our treatment pathways is of crucial importance and Bleddyn Jones has contributed to our Community News with an effective call to arms for an improvement in the UK therapy situation. Our Highlighted Articles includes full papers on both personal and patient dosimetry linked to safe and effective practice. More safety aspects are the subject of our news report from the holder of a NICE Scholarship (hands up who knew there was such a thing!).

However, “safety” can be a relative concept and reaching a place of safety can sometimes require bold or counterintuitive moves, as any aficionado of snooker will all too readily know. Our British Institute of Radiology President, Stephen Davies, addresses this in his column with respect to the future

safety of the Institute as its Trustees grapple with the impact of changes in charity law, finances, the modern medical workplace and expectations of members. The overall sentiment is that this a time for boldness and the recent overhaul of the journal is evidence of that. The publications team have worked tirelessly in this regard and the editorial team are assisting with the bedding down process but would sincerely welcome comments from the readership. We hope we are proceeding in the right and “safe” direction but please do let us know your thoughts.

We hope we are proceeding in the right and “safe” direction but please do let us know your thoughts.

Simon Blease BJR News Editor-in-Chief issue 4 august 2011

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New Publication!

25% discount for BIR members.

Visit the BIR online bookshop https://bir.org.uk/membersarea/shop/

BIR Report 23

MOLECULAR RADIOTHERAPY IN THE UK:

Current Status and Recommendations for Further Investigation A report from The British Institute of Radiology Molecular Radiotherapy Working Party

This report reviews the current status and evidence base of Molecular Radiotherapy (MRT) in the UK and provides recommendations to improve its use and effectiveness.

The motivation for this report stems from the general perception within the community that scientific developments, support for infrastructure and the availability of MRT in the UK have not kept pace with that seen in external beam radiotherapy and chemotherapy.

However, an increasing number of radiopharmaceuticals are becoming available for a range of treatments and the market is expected to grow significantly in the next decade. To support this report a survey of UK centres was carried out to ascertain the range and number of treatments administered.

The report concentrates on therapy procedures that are prevalent in the UK. Issues of support for MRT are focussed on the radiopharmacy, for routine preparation and further development of radiopharmaceuticals, and on physics for imaging and internal dosimetry.

ISBN: 978-0-905749-70-9 Price: ÂŁ25.00 The Molecular Radiotherapy Working Party is a subgroup of The British Institute of Radiology Radiation Physics and Dosimetry Committee.

The authors of this report are: Glenn Flux, Laura Moss, John Buscombe, Mark Gaze, Matt Guy, Steve Mather, and Kim Orchard.

www.bir.org.uk

Report: president’s conference 2011

recent BIR events

President’s conference 2011 British Institute of Radiology’s President, Stephen Davies, reports on the cardiac imaging event The 2011 President’s conference was held at the Wellcome Collection, London. It was attended by 80 delegates from around the UK. The programme was directed by Sujal Desai from Kings College National Health Service Trust, London, and assisted by his cardiology colleague Jonathan Hill, with support from the British Society for Cardiac Imaging.

Cardiac imaging was chosen because it represents a growth area for imaging and is a key area of multidisciplinary collaboration between radiologists, cardiologists, physicists, radiographers and industry. The faculty represented this cross-section and emphasised the value of good team work.

The meeting ran over 2 days. Ed Nicol, a cardiologist from the Brompton, gave advice on setting up a high quality CT service. Nicol described physicists as being “key when purchasing a scanner” with a “knowledge of technology that will blow you away”. Elly Castellano, a physicist from the Brompton, amply demonstrated this point by giving a very accessible exposition of key technological aspects of cardiac capable CT scanners. Castellano took a crosssection of the manufacturers and warned

delegates of the dangers of uninformed comparisons of dose descriptors. Nicol gave further advice and reminded delegates to “be sure that what you are looking at represents reality” and went on to discuss some of the difficulties around confident imaging of the very dangerous soft plaque in coronary arteries.

Jim Stirrup from the Brompton and subsequent speakers discussed the beneficial effects of heart rate control on image quality, principally with beta blockers. Russell Bull from Bournemouth described his success with imaging both heavy patients and those with faster heart rates and atrial fibrillation.

A consideration of dose was never far away in many, if not all, presentations. Giles Roditi from Glasgow took a risk based approach, asking “can effective doses be converted to radiation risk”. Cathy Owens from Great Ormond Street, a champion of dose reduction in children, discussed the technique of prospective dose reduction and fastdual source CT scanning with a series of outstanding images.

The highlight of the conference was the Mackenzie-Davidson Memorial Lecture given by Professor Andrew

Cardiac imaging was chosen because it represents a growth area for imaging and is a key area of multidisciplinary collaboration

BIR President, Stephen Davies, meets some of the exhibitors

Taylor from Great Ormond Street Hospital, London. His lecture “designing devices — how can cardiovascular imaging help” was supremely inspirational using cross-sectional imaging, linked with engineering and computer modelling to predict how implantable devices would work in the human state.

He drew a parallel with an incident some years ago where a seaside big dipper had failed on its first few trial runs with humans and how this is completely undesirable with implantable devices in issue 4 august 2011

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Report: president’s conference 2011

humans. His techniques were enabling paediatric cardiac surgeons to predict the efficacy of their procedures and had led to revised surgical techniques.

Another highlight of the conference was the two live case analysis sessions covering CT and MRI. Ed Nicol and Mike Rubens ran the CT session and Stephen Harden ran the MRI session.

These sessions brought the imaging

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London, gave an illuminating description.

The second double act of the conference was the Plymouth team of Carl Roobottom and Gareth Morgan-Hughes who took us through CT coronary angiography reporting and its consequences.

Charles Peebles very eloquently took delegates through a rationale for the appropriate use of CT and MRI and placed nuclear medicine and echo-

Delegates went home with a real sense of the need to work in multidisciplinary teams and to think carefully about sensible dose reduction techniques alive and inspired delegates to develop their interpretive skills in these areas.

The cardiologists showed the power of three-dimensional echocardiography and place of invasive angiography. Of course nuclear cardiology has an important role and Ashley Groves from UCLH,

cardiography in context. This eased delegates’ concerns regarding choice of technique and reminded them of the need to consider anatomy and function.

Matt Budoff had flown in from UCLA to give an informed view of calcium scoring and its place in predicting

The event took place at the Wellcome Collection in London

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Professor Andrew Taylor is presented with the Mackenzie-Davidson medal

future cardiac events, especially in intermediate risk patients. Later, Budoff gave a thought-provoking lecture on the considerations around simply evaluating the heart and reducing the field of view to exclude the lungs. This reduced the dose and avoided difficulties over pulmonary nodules.

Robin Choudhury from Oxford gave an excellent final lecture, raising important questions around imaging of plaque with intravascular ultrasound, PET and molecular imaging.

Delegates went home with a real sense of the need to work in multidisciplinary teams, to think carefully about sensible dose reduction techniques and to select the appropriate test or tests when considering questions of anatomy and function.

The conference was a success and sets the tone for next year’s President’s conference: CT in clinical practice — past, present and future — a tribute to Godfrey Hounsfield. This will be held in London on April 25-26, 2012.

Stephen Davies, BIR President

www.bir.org.uk

Forthcoming events

events calendAr 2011

www For a full event listing, registration & availability visit: www.bir.org.uk/membersarea/multievents

Upcoming in September: Radiology for surgeons

PACS the second time around!

13 September 2011 BIR, London

26 September 2011 BIR, London

Essentials of medical imaging schemes and developments 23 September 2011 BIR, London

Events booking now visit www.bir.org.uk/membersarea/multievents

Welsh Branch annual meeting

November The journey from research to publication

Addenbrooke’s Hospital, Cambridge 01 October 2011

Princess of Wales Hospital 13-14 October 2011

BIR, London 18 November 2011

Developments in treatment of head and neck cancer with chemotherapy, biological agents and radiotherapy

BIR UK MRI course (incorporating the Somerset MRI course)

December Clinical imaging of the head and neck

BIR, London 17-20 October 2011

BIR, London 02 December 2011

Dispelling the myths of a managed equipment service

In-vivo dosimetry and dose guided radiotherapy

BIR, London 27 October 2011

BIR, London 8-9 December 2011

BIR and SCoR’s retired members’ day

Chernobyl 25 years on: consequences, actions, thoughts for the future

October East of England branch annual meeting

BIR, London 07 October 2011

Linking orthopaedics and radiology – the plain film revisited II: the upper limb BIR, London 13 October 2011

BIR, London 28 October 2011

BIR, London 12 December 2011 issue 4 august 2011

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Community News

community news

The radiation risk: what can the UK learn from Japan?

The earthquakes and tsunami affecting north-east Japan have once again raised awareness of the dangers of radiation exposure among the general public, environmental activists and politicians concerned with nuclear power policy, as well as those with healthcare responsibilities.

Is there any safe dose of radiation above background level?

Radiation as a cause of cancer is common knowledge; however, few realise that human blood vessels are injured at low doses, which can result in stroke, heart disease and organ failure later in life. The only rational conclusion is that unnecessary radiation exposure should be avoided.

Nuclear fallout and cancer in Japan

Although the Japanese nuclear power reactors were designed to be earthquake proof, their pressurised water (PWR) cooling systems were inadequate to cope with the physical effects of the tsunami.

Some readers may remember the debates regarding PWR systems compared with the older and safer, but more expensive, British Magnox systems, which contained carbon dioxide gas and a better reserve cooling capacity. Following the lessons learnt from the Russian Chernobyl disaster, it appears the main risk will be curable thyroid gland cancer caused by radioiodine release. However, the population risk may well be lower in Japan as a result of the rapidly established exclusion zone, prompt issue of stable iodine containing tablets and the high fish (and seaweed) consumption 8

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in Japan, which will produce an already iodine-rich thyroid and reduce the uptake of radioactive iodine. The atmospheric release of radioactive caesium at Chernobyl also contaminated some areas of the UK; it will be 2016 before this source of radioactivity will have reached half its 1986 level.

The Japanese population should cope well with a natural and partly man-made disaster. They have a disciplined society and were prepared for a radiation accident. The Japanese government had perceived that there was a public aversion to radiation owing to the well-known increase in leukaemia, followed later by other cancers, in survivors of the Hiroshima and Nagasaki bombs. The refusal to have radiation treatment for cancer was a problem. Consequently, their prescient politicians developed a National Radiological Sciences Institute whose aims were to improve: • Acute radiation medicine • Radiological imaging • Cancer treatment by using the best available forms of radiation, especially proton and ion beams that could reduce collateral normal tissue radiation exposure and be “human friendly”.

As a result, Japan has, along with the USA, Germany and Switzerland, led the world in developing cancer treatment using proton and ion beams, especially the use of carbon ions. At Chiba, not far from Tokyo, carbon atoms are stripped of 6 electrons, giving them a positive charge of 6 units, and then accelerated in a synchrotron to a high energy (over 400 million volts). At nearby Tsukuba, they use protons. Both particles enter the

human body and deposit energy selectively in “Bragg peaks”, which can be made to encompass a tumour, with little or no radiation dose beyond the peaks.

The aim is to reduce the exposure to normal tissues, which contain no cancer, to as low as possible. Cautious clinical trials began in the mid 1990s and there are now promising published results in lung, prostate, liver, uterine, head and neck, sarcoma, melanoma, some brain tumours and cancers of the kidney. Although the equipment is expensive, patients can now be treated with between 1 and 16 hospital visits and in many instances only 4. The treatment tariff is now only $15000 per course, less than complex X-ray therapy

It must be asked if the UK is as well-prepared? in the USA and many other countries.

Not only is there good survival statistics in some advanced tumours, but the patient experience appears to be much improved, especially in terms of reduced radiation-related side effects during and after treatment.

The UK position

The present plight of Japan deserves much sympathy and admiration, but it must be asked if the UK is as wellprepared? Knowledge of radiation effects within UK medicine is not uniform, as has been exemplified by the delay in obtaining the diagnosis that radiation was respon-

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Community News

The UK radiological sciences need better links with basic physical sciences for the benefit of those with cancer, as well as for the prevention and treatment of radiation accident victims. sible for the symptoms of an unfortunate Russian in London a few years ago. In the past, there were loose arrangements for radiation accident victims to be advised through various specialist hospitals. When I worked at the Clatterbridge Cancer Centre on the Wirral, there were informal arrangements to cover radiation accidents for the two nuclear power stations in north Wales, as well as the nearby uranium separation plant at Capenhurst, but no protocols were in place. Before the liberation of Kuwait, I recall being asked — in a Liverpool hospital corridor — to give advice on the potential battlefield radiation exposures sustained by severe head injury casualties that would all be taken to Liverpool; fortunately, none occurred.

It can be reasonably assumed that our population will be protected to the same extent as the Japanese population in the event of a nuclear accident. The advice of government committees such as the Committee on Medical Aspects of Radiation in the Environment (COMARE) and COBRA is crucial in this respect.

However, one cannot assume that our radiation facilities for cancer will be anywhere near as good as those available in Japan for at least a decade from now. The National Health Service (NHS) has conceded, very belatedly, to allow 1 to 3 proton centres to be built in the UK by 2015, but will not purchase the necessary expensive equipment in the chosen hospitals. This places the UK as

the only country where government has not provided capital for the first wave of new facilities. Although this policy will eventually eliminate the national embarrassment of children and young adults with cancer being sent abroad, with the present NHS plans the intention is to treat only 1–2% of all radiotherapy patients in this way. In Japan, there are already 12 centres capable of giving such treatment, which use the arguably better carbon ion beams. It is likely that all Japan’s large cities will have their own proton and ion beam equipment by 2015 and the same is true in the USA for protons. In the USA, the prestigious cancer clinics at MD Anderson, Mayo, Memorial Sloane Kettering, Massachusetts General, Philadelphia, Florida, Oklahoma, Indiana, San Francisco, Berkeley and so on will have the facilities and plan to treat more than 50% of patients with these sophisticated beams. Germany is undergoing a similar expansion and many other European countries (France, Austria and Italy) plan to treat more than 10% of their patients with particle beams. At a time when the UK aims to increase the use of X-ray intensity modulated radiotherapy (IMRT), other countries will be moving away from this form of X-ray therapy, which extends low radiation dose to more tissues than would be the case for more standard conformal X-ray techniques. The yield of second cancers owing to IMRT is not expected to rise until 2015 onwards, 20 years after it

was initiated in the USA. Yet again, the UK will be perceived as being slow to implement the best available techniques and will not possess sufficient treatment capacity for particle beams.

Part of the UK’s problem is that our Department of Health is quite separate from the departments responsible for research, business, universities and industry/skills (which repeatedly changes its title to the irritation of many), so that research and application of advanced technology is notoriously slow in healthcare.

The UK radiological sciences need better links with basic physical sciences for the benefit of those with cancer, as well as for the prevention and treatment of radiation accident victims. It is perhaps too much to hope that the NHS can provide everything that is required in this respect. Doctors working within the NHS have been slow to promote these advances; their reticence may be partly related to the more corporate structure of the NHS in recent times, as well as a collective diffidence connected with decades of heavy workloads and the continued tolerance of under-funding.

Perhaps, if UK patient representative groups could travel widely and see what is available elsewhere in the world, they could discuss what they have seen directly with politicians, healthcare planners, research councils and cancer charities.

They might also raise awareness in each city so that local charitable appeals could raise sufficient money to invest in the most advanced radiation treatment facilities, which at present are only available abroad.

This would allow the UK to participate more fully in world-class cancer research and this would be evidence of a Big (and more effective) Society. leddyn Jones B Professor of Clinical Radiation Biology at The Gray Institute for Radiation Oncology and Biology, University of Oxford and co-Director of the Oxford Martin Particle Therapy Cancer Research Institute at Oxford Physics

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Community News

BIR trainee committee member awarded NICE scholarship Amrita Kumar talks to BJR News about her experience It was my determination to impact on local and national healthcare delivery and to promote National Institute of Health and Clinical Excellence (NICE) core values that first led me to apply for the NICE scholarship.

From an early stage in my radiology training I had an interest in patient safety. I was particularly excited by the possibility of employing safety improvement techniques from other industries and applying them to the medical field.

Observing the use of training simulators in the aviation industry sparked my interest in the use of simulators in medical training. I gained first-hand experience of their use in basic life-support training using a part-task trainer and have seen the impact that they have in the day-to-day practice of medicine; from risk-free technique rehearsal to varied simulated tasks.

as a result I took the decision to pursue this research further to upgrade my professional knowledge and expertise.

The ImaGINe-S uses similar technology to an X-Box or Wii console to recreate the feeling of guiding a surgical needle into the body by moving two hand-held devices that simulate the role of an ultrasound probe and needle. Using force feedback (technology found in game controllers) users can then feel the pressure of pushing the virtual needle and guiding a wire through the body.

The technology was developed by a team of interventional radiologists, computer scientists, clinical engineers and psychologists from six UK universities and was funded by a Department of Health grant.

Using a new grant from the British Society of Interventional Radiologists, I will be carrying out a training validation study into the benefits of using the simulator

The ImaGINe-S uses similar technology to an X-Box or Wii console to recreate the feeling of guiding a surgical needle To further my interest I undertook an MSc in Surgical Technology at Imperial College London where I carried out a face and content validation study of an imaging-guided percutaneous radiological virtual reality simulation, Imaging Guided Interventional Needle puncture Simulation (ImaGINe-S). This simulation proved to be a useful training model and 10

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in training on nephrostomy procedures, which are routinely used to drain blocked infected kidneys, at the Royal Liverpool University Hospital.

My research focuses on improving the overall quality of care, with an emphasis on patient safety, by allowing trainees to improve their skills via simulation training before progressing to a real-life

Amrita Kumar

scenario. The NICE scholarship complements my decision to pursue further research in medical simulation because it has introduced me to a network of dedicated and influential individuals across the National Health Service, who can support the implementation of this practice, and even go on to develop NICE guidelines within this field.

It is a tremendous honour to be awarded a NICE scholarship. It has enabled me to leverage my medical background to full effect and gain maximum credibility, which are necessary steps in achieving my goals. It also gives me a unique opportunity to gain advice, guidance and mentoring while working on research that will help to improve patient safety, which is a priority for NICE. Amrita Kumar Royal Liverpool University Hospital

Assurance of Quality in the Diagnostic Imaging Department 2nd Edition

Prepared by The Quality Assurance Working Group of the Radiation Protection Committee of The British Institute of Radiology.

A practical guide to instituting a quality control programme.

This book is about quality assurance. Quality of what? Ultimately, of course, it is the quality of the service to the patients that matters, and in the clinical radiology context one of the most important factors is the quality of the image.

This timely edition contains new sections on CT, computed radiography, teleradiology, bone densitometry and nuclear medicine.

Contents • Image quality: a clinical perspective • Organization and methods • Reject analysis • Quality assurance • Radiation protection and legal requirements • Test types

• • • • • •

Performance guidelines Introduction to practical tests List of test areas and tests Radiographer’s daily checklist Bibliography Appendix 1. Quality control test equipment • Appendix 2. Sample data sheets

ISBN 0-905-749-48-0, 93 pp, £25.00 | 25% discount for BIR members To order your personal copy today, visit http://www.bir.org.uk/bir-publications-home.aspx

Geometric Uncertainties in Radiotherapy - Defining the Planning Target Volume The British Institute of Radiology is a Registered Charity No.215869, VAT Registration No. GB 233 7553 63

The intention of this publication is to give oncologists, physicists and radiographers the tools to estimate geometric uncertainties in their own centre and to show how these uncertainties may be minimized and accommodated by appropriate protocols.

Contents • Clinical overview. Summarizes the philosophy of ICRU Reports 50 and 62 and discusses geometric uncertainties in this context.

• Technical overview. Describes the general approach to estimating sizes of uncertainties and how to combine them: (i) how to determine the margin required to accommodate treatment preparation uncertainties that give rise to systematic errors (ii) how to calculate the additional margin for the daily treatment execution uncertainties that result in random errors.

• Reviews of geometric uncertainties for specific tumour sites: breast; lung; prostate and bladder; brain; head and neck. For each site, sources of uncertainty are described and methods for minimizing these uncertainties are proposed.

• Glossary ISBN 0 905749 53 7, 146 pp, Price: £60.00

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Community News

Dispelling the myths of a managed equipment service The working practices in all businesses are changing and this is having an impact on the way in which new technology is introduced into healthcare, in particular meeting the changing demands for imaging services and the need for faster and more efficient image and information capture and distribution systems. To fund these improvements there are a number of financing options available, such as capital purchase and leasing agreements, including operating lease and full service contracts and managed equipment service (MES).

The requirement of the National Health Service (NHS) to take long-term operational responsibility and service integrity has dramatically altered the traditional approach to procuring medical equipment. The reality is that the services element of equipping healthcare facilities is becoming of core importance as capital budgets are squeezed.

There is still a lack of understanding of the benefits an MES can bring and how the customer will see both immediate and long-term improvements in clinical productivity with the provision and ongoing implementation of this kind of service. With the NHS facing ever increasing clinical and financial targets, equipment availability and value for money are critical components in achieving quality and productivity goals.

We are therefore holding a muchneeded meeting to explain the significant advantages that a managed service can offer and dispel some of the myths surrounding this form of equipment procurement and management. It is not a private finance initiative or a public private partnership or a leasing agreement but a fully managed service.

The programme will cover all aspects from both the NHS, private sector and managed service provider’s perspectives and will give an opportunity to ask experts in this field challenging questions.

A number of different terms are used when referring to a services agreement between a Trust and services supplier.

Essentially these agreements are individually tailored to the requirements of the hospital.

MES, sometimes referred to as a managed service contract, is a strategic approach to the acquisition, installation, commissioning, management, maintenance, scheduled replacement and disposal of medical equipment over a multi-year period. It ensures the hospital has access to leading-edge, well managed systems meeting the requirements to deliver the highest standards of care to patients while securing significant financial benefits for the Trust. Each contract and any additional schedules are individually checked for HM revenue and customs compliance for value added tax (VAT) recovery.

It is the managed service provider’s responsibility to maintain service uptime, ensuring the equipment is available for efficient clinical service delivery. These agreements include vendor independence, enabling hospitals to choose from a range of available suppliers, thereby ensuring the hospital can select the most appropriate equipment for their clinical requirements when it is due for replacement.

Managed service contracts provide a range of added value and benefits including bespoke elements, choice of available suppliers and further choice when refresh points arise. It is structured to have capabilities that permit linking unrelated areas into seamless managed service packages across clinical departments such as radiology and surgery.

This model significantly reduces transaction costs, thereby increasing the VAT envelope which is legitimately recoverable, underpinning the cost of new equipment investment without recourse to new budgets or limited capital resources.

Managed service is an outsourced clinical service where a third-party is responsible for the provision of all necessary equipment and clinical staff. A managed service may be offered either as multi-year contract or as a temporary solution, for example a mobile interim rental that provides service capacity without being exposed to the risks of capital investment.

Choosing to establish a MES is an opportunity for a hospital to partner with a recognised supplier that can contribute to the long term sustainable development of the hospital, enabling it to focus on clinical service delivery in line with their strategic goals. This is achieved by handing over the management of medical technology and associated risks to the managed services provider enabling the hospital to focus on delivering maximum value to quality and efficiency improvements in the care process.

A decade of MES has seen an evolution from complicated consortia led agreements to more simplified direct relationships with Trusts. Furthermore, the contract paperwork attached to MES has had to be developed, most often being spearheaded by vendors in the marketplace.

Understanding of MES by hospitals has started to gather pace in recent years and the key advantages are now being absorbed. Of notable interest is the development of metrics that can provide tangible cost saving examples to Trusts.

These illustrate how lower operating costs can be achieved via MES routes rather than managing the same equipment themselves. In a climate of “lean” philosophies and cost reduction, MES can be seen as a vital tool.

The future of MES will see the consultancy knowledge of proven MES providers come to the fore. Partners will be selected on their ability to provide a solid and wide breadth of industry experience, especially in uncertain economic times, as well as issue 4 august 2011

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community news

MES is proven to provide the following: Certainty

Guaranteed equipment availability. If it doesn’t perform as promised, the MES provider incurs financial penalties.

Innovation

A rigorous equipment procurement and replacement mechanism delivers the latest and most appropriate equipment while maintaining the ability to cope with the changing requirements of clinical practice.

A partnership approach Close relationships with clinicians and front-line staff are central to MES arrangements.

Flexibility

Equipment specifications can be varied over the contract period to ensure future challenges are met.

Financial

An open and transparent financial model encompasses a unitary payment, with rentals payable from the Trust’s revenue budget. This negates capital charges, inflation and rising equipment and maintenance costs.

Performance

A comprehensive registration and reporting system provides detailed, clear and concise performance reports on a quarterly basis against all the agreed Key Performance Indicators (KPIs).

Support

A single point of contact is available to resolve any service issues, should they arise.

proving their ability to deliver operational improvements in practice.

Through long-term, fixed fee MES agreements, the latest medical devices are made available to clinicians and staff to speed up patient throughput and open the door to a wider range of non-invasive procedures.

Customers entering into this type of agreement have an agreed technology replacement plan, ensuring that equipment continues to meet evolving clinical and financial requirements. Since risk and responsibility for all aspects of technology procurement, deployment and maintenance is transferred to the provider, there is a 14

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corresponding reduction in administration/ management, releasing managers and clinicians to focus on clinical outcomes and patient care.

This type of MES provides clinical choice and enables the hospital to focus on patient outcomes, while benefiting from the many advantages associated with entering into partnership with a global healthcare technology leader.

Real long-term success is only possible if commitment to partnership remains a strong point for both parties, working together to improve productivity, ensure value for money and provide the best in class clinical outcomes. This could also lead to collabo-

ration in the re-design of the facility and workflow processes to provide a quality of delivery that will enhance the service and its environment. This is likely to impact positively on clinical outcomes, as it will be delivered in an atmosphere that leads to an improvement in performance and contributes to the wellbeing of the patient.

Mike Andrews, Business Development Manager, Philips Healthcare

This BIR scientific event will be held on 27th October 2011 visit www.bir.org.uk to book

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in the online issue of BJR

what’s online: bjr.birjournals.org Featured Articles:

Case of the month

Short communication

Pictorial review

Review article

REVIEW ARTICLE

Anterior knee pain

Normal variants of the accessory hemiazygos vein

Cerebrospinal fluid flow imaging by using phase-contrast MR technique

High-resolution CT of complications of idiopathic fibrotic lung disease

S Muly, S M V Reddy and S Dalavaye

J M Blackmon and A Franco

B Battal, M Kocaoglu, N Bulakbasi, G Husmen, H Tuba Sanal and C Tayfun

C R Lloyd, S L F Walsh and D M Hansell

Malignant tumours of the small intestine: a review of histopathology, multidetector CT and MRI aspects

DOI: 10.1259/ bjr/36248329

DOI: 10.1259/ bjr/13695502

DOI: 10.1259/ bjr/66206791

DOI: 10.1259/ bjr/65090500

M Anzidei, A Napoli, C Zini, M A Kirchin, C Catalano and R Passariello

DOI: 10.1259/ bjr/20673379

Highlighted Articles: Full papers

Case reports

Impact of the high-definition multileaf collimator on linear accelerator-based intracranial stereotactic radiosurgery

Isolated intracranial Rosai-Dorfman disease mimicking meningioma in a child: a case report and review of the literature

J A Tanyi, C M Kato, Y Chen, Z Chen and M Fuss

K Gupta, N Bagdi, P Sunitha and N Ghosal

DOI: 10.1259/bjr/19726857

DOI: 10.1259/bjr/15772106

Lymphocutaneous fistulas: pre-therapeutic evaluation by magnetic resonance lymphangiography

Haemorrhagic low-grade fibromyxoid sarcoma: MR findings in two young women

C Lohrmann, E Foeldi and M Langer

S K Kim, W-H Jee, A W Lee and Y G Chung

DOI: 10.1259/bjr/14411627

Personal dosimetry for interventional operators: when and how should monitoring be done?

C J Martin

DOI: 10.1259/bjr/24828606

Analysis of regional radiotherapy dosimetry audit data and recommendations for future audits A Palmer, B Mzenda, J Kearton and R Wills

DOI: 10.1259/bjr/18691638

DOI: 10.1259/bjr/21441528

Positron emission tomography features of hidradenitis suppurativa R C Simpson, M J S Dyer, J Entwisle and K E Harman

DOI: 10.1259/bjr/74184796

Retroperitoneal oncocytoma: case report and review of the imaging features A A Roy, C Jameson, T J Christmas and S Aslam Sohaib

DOI: 10.1259/bjr/63620790

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in The online issue of BJR

All other articles from July and August 2011 BREAST

The value of dual-time-point 18F-FDG PET/CT for identifying axillary lymph node metastasis in breast cancer patients

Case report: Nodular regenerative hyperplasia of the liver: coral atoll-like lesions on ultrasound are characteristic in predisposed patients E Caturelli, G Ghittoni, T V Ranalli and V V Gomes

DOI: 10.1259/bjr/17975057

W H Choi, I R Yoo, J H O, S H Kim and S K Chung

DOI: 10.1259/bjr/56324742

Comparison of mammography, sonography, MRI and clinical examination in patients with locally advanced or inflammatory breast cancer who underwent neoadjuvant chemotherapy H J Shin, H H Kim, J H Ahn, S-B Kim, K H Jung, G Gong, B H Son and S H Ahn

DOI: 10.1259/bjr/74430952

Case report: Variant ventral intrahepatic course of inferior vena cava: volume rendering and maximum intensity projection CT findings A Abdullah, K Williamson, T Lewis and H Elsamaloty

DOI: 10.1259/bjr/51830082

Case report: Enterolith ileus: liberated large jejunal diverticulum enterolith causing small bowel obstruction in the setting of jejunal diverticulitis D J Garnet, L R Scalcione, A Barkan and D S Katz

DOI: 10.1259/bjr/16007764

CARDIAC

Evaluation of dose to cardiac structures during breast irradiation M C Aznar, S-S Korreman, A N Pedersen, G F Persson, M Josipovic and L Specht

DOI: 10.1259/bjr/12497075

Case report: Metastatic acinar cell carcinoma of the liver from a benign appearing pancreatic lesion: a mimic of hepatocellular carcinoma Y J Kim, D J Chung, J H Byun and Y S Kim

DOI: 10.1259/bjr/36942051

COMPUTER APPLICATIONS

GENITOURINARY

CT colonography: computer-assisted detection of colorectal cancer

Diffusion-weighted imaging of solid or predominantly solid gynaecological adnexial masses: is it useful in the differential diagnosis?

C Robinson, S Halligan, G Linuma, W Topping, S Punwani, L Honeyfield and S A Taylor

DOI: 10.1259/bjr/17848340 GASTROENTEROLOGY

Biplane fluoroscopy-guided radiofrequency ablation combined with chemoembolisation for hepatocellular carcinoma: initial experience M W Lee, Y J Kim, S W Park, N C Yu, W H Choe, S Y Kwon and C H Lee

DOI: 10.1259/bjr/27559204

Effect of varying contrast material iodine concentration and injection technique on the conspicuity of hepatocellular carcinoma during 64-section MDCT of patients with cirrhosis A Guerrisi, D Marin, R C Nelson, G De Filippis, M DI Martino, H Barhart, R Masciangelo, I Guerrisi, R Passariello, and C Catalano

DOI: 10.1259/bjr/21539234

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B Bakir, S Bakan, M Tunaci, V L Bakir, A C Iyibozkurt, S Berkman, E Bengisu and A Salmaslioglu

DOI: 10.1259/bjr/90706205

Case report: Identification of the primary tumour with the help of diffusion weighted MRI in a patient with autosomal dominant polycystic kidney disease and metastatic renal cell carcinoma M Zeile, D Andreou, A Poellinger, P U Tunn and O Dudeck

DOI: 10.1259/bjr/32867810

Case report: Aggressive renal angiomyolipoma extending into the renal vein and inferior vena cava — an uncommon entity S S Bakshi, K Vishal, V Kalia and J S Gill

DOI: 10.1259/bjr/98449202

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IN THE ONLINE ISSUE OF BJR

All other articles from July and August 2011 HEAD AND NECK

THORACIC

Distribution of brain metastases: implications for non-uniform dose prescriptions

Pictorial review: MRI in lung cancer: a pictorial essay

E T Bender and W A Tome

DOI: 10.1259/bjr/30173406

Case of the month: Head and neck lumps in an Asian male S X J M Chan, T A Lim and A N Hegde

DOI: 10.1259/bjr/50300229

B Hochhegger, E Marchiori, O Sedlaczek, K Irion, C Pheussel, S Ley, J Ley-Zaporozhan, A Soares Souza, Jr and H-U Kauczor

DOI: 10.1259/bjr/24661484

Case report: Changes in chest wall thickness during four-dimensional CT in particle lung treatment planning S Mori, N Yamamoto, M Nakajima and M Baba

DOI: 10.1259/bjr/50429882

Ultrasound-guided core biopsy in the diagnosis of lymphoma of the head and neck. A 9 year experience C Burke, R Thomas, C Inglis, A Baldwin, K Ramesar, R Grace and D C Howlett

DOI: 10.1259/bjr/60580076

Short communication: Development of a risk score to guide imaging in older patients admitted with falls and confusion A J Brown, M D Witham and J George

DOI: 10.1259/bjr/78864604 Musculoskeltal

The use of joint-specific and whole-body MRI in osteonecrosis: a study in patients with juvenile systemic lupus erythematosus T C M Castro, H Lederman, M T A Terreri, W I Caldana, S C Kaste and M O Hilario

DOI: 10.1259/bjr/34972239

Ipsilateral atrophy of paraspinal and psoas muscle in unilateral back pain patients with monosegmental degenerative disc disease A Ploumis, N Michailidis, P Christodoulou, I Kalaitzoglou, G Gouvas and A Beris

DOI: 10.1259/bjr/58136533

Assessing the image quality of pelvic MR images acquired with a flat couch for radiotherapy treatment planning M McJury, A O’Neill, M Lawson, C McGrath, A Grey, W Page, and J M O’Sullivan

DOI: 10.1259/bjr/27295679

Case report: Spino-renal fistula due to gunshot injury M M Alsharef, N Christopher and T Fourie

DOI: 10.1259/bjr/54344869

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Case of the month

Head and neck lump A 60-year-old Chinese male presented with a 1 year history of bilateral painless swelling over the cheeks and right upper neck. On physical examination, firm, mobile and nontender subcutaneous masses were noted at these sites.

Bilateral parotid tumours were suspected and a CT scan was performed for evaluation. A follow-up MRI was performed 1 year later as one of the masses at the lower lip was reported to have increased in size. The diagnosis was confirmed by histopathology.

• What is the most likely diagnosis?

• What is the characteristic blood picture in this condition?

Findings

The axial contrast-enhanced CT image reveals several mildly enhancing, ill-defined plaque like soft-tissue masses in the superficial lobes of the parotid glands, along the outer table of the right mandibular angle and at the left lower lip. Small volume/enlarged intraparotid and upper cervical lymph nodes are also seen. These masses are mildly hyperintense on the axial fat saturated T2 weighted MR image. Moderate enhancement is seen in these masses on the coronal post-contrast fat saturated T1 weighted MR image.

Diagnosis

Kimura’s disease was confirmed on fine needle aspiration and cytology (FNAC). Peripheral blood eosinophilia is a typical feature of this condition.

Discussion

Kimura’s disease is a rare chronic

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inflammatory disorder of unknown aetiology, prevalent in young Asian males. As these patients present with painless subcutaneous masses in the head and neck region, more sinister conditions like lymphoma, salivary gland tumours and tuberculous adenitis are often clinically suspected. A strong male preponderance has been noted with most cases presenting in their third and fourth decades of life. Typically, peripheral blood eosinophilia and increased serum IgE concentrations are accompanying features.

Hence, an aberrant immune reaction to an unknown antigen has been postulated [1–3].

It largely occurs in the head and neck region, however, rarely the axilla, popliteal region, groin and forearm may be involved [1]. Concurrent nephropathy including nephritic syndrome has been described in some case reports [4]. Histopathological findings include

Contrast-enhanced axial CT image of the neck

prominent germinal centres with fibrous, vascular and cellular proliferation; and a cellular component consisting of dense eosinophilic infiltrates on a background of abundant lymphocytes, plasma cells, eosinophilic micro abscesses with central necrosis and Warthin-Finkeldey-type polykaryocytes [2].

Soft-tissue diseases of the head and neck are routinely evaluated with CT at our institution while MRI is usually reserved as a problem solving tool.

However, MRI is widely accepted as the modality of choice in this regard. In Europe and some parts of Asia, ultrasound is used as a first line modality for evaluating neck masses. On ultrasound, the masses are mostly solid and hypoechoic, with homogeneous or heterogeneous internal architecture and high internal vascularity.

The affected lymph nodes are often round, well-defined and hypoechoic

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case of the month

ps in an Asian male

Axial T2 weighted MRI with fat saturation

with a preserved echogenic hilum. The masses are usually iso- or hypodense on CT scan, iso- or hypointense on T1 weighted MR images and hyperintense on T2 weighted MR images [5]. Variability in the signal intensities and in the degrees of enhancement on contrast enhanced images has been attributed to varying degrees of fibrosis and vascular proliferation.

Recently, in a retrospective study of 13 cases of Kimura’s disease, Gopinathan et al [3] classified the lesions into two types; Type I lesions are well-defined, nodular masses with homogeneous enhancement, frequent in a younger age group and Type II lesions are ill-defined, plaque-like in configuration and heterogeneous in appearance with variable enhancement. These are prevalent in an older age group [3]. Well-defined rounded enhancing nodes with high vascularity have been described. [1]. The charac-

Gadolinium-enhanced coronal T1 weighted MR image with fat saturation

teristic blood picture is supportive of Kimura’s disease. FNAC may be diagnostic, but may be inconclusive and an excision biopsy may be necessitated to address the concerns of sinister conditions like parotid tumours, lymphoma, tuberculosis and angiolymphoid hyperplasia with eosinophilia, which are the clinical and radiological differentials of this condition.

The treatment options for Kimura’s disease include steroids, radiotherapy and surgical excision. Steroids provide transient relief and the disease often recurs on cessation. Local irradiation is effective in a majority of cases. Excision is often associated with recurrence.

The imaging findings of subcutaneous masses in the head and neck region with or without infiltration of the major salivary glands and regional adenopathy in an Asian male should raise the suspicion of Kimura’s disease.

References 1. Takahashi S, Ueda J, Furukawa T, Tsuda M, Nishimura M, Orita H, et al. Kimura disease: CT and MR findings. AJNR Am J Neuroradiol 1996;17:382–85.

2. Shetty AK, Beaty MW, McGuirt WF Jr, Woods CR, Givner LB. Kimura’s disease: a diagnostic challenge. Pediatrics 2002;110:e39.

3. Gopinathan A, Tan TY. Kimura’s disease: imaging patterns on computed tomography. Clinical Radiology 2009;64:994–99.

4. Sud K, Saha T, Das A, Kakkar N, Jha V, Kohli HS, et al. Kimura’s disease and minimal change nephrotic syndrome. Nephrol Dial Transplant 1996; 11:1349–51.

5. Hiwatashi A, Hasuo K, Shiina T, Ohga S, Hishiki Y, Fujii K, et al. Junichi Kimura’s disease with Bilateral Auricular Masses. AJNR Am J Neuroradiol 1999;20:1976–78.

S X J M Chan, T A Lim and A N Hegde Department of Radiology, Singapore General Hospital, Singapore

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short communication

Development of a risk score to guide brain imaging in older patients admitted with falls and confusion Patients who fall and present to medical admissions units with confusion pose a diagnostic problem because of their inability to give a coherent history. A pre-existing diagnosis of dementia often further hampers the clinical assessment. Because of these reasons, older people with falls and confusion often under go CT of the head.

The diagnostic yield of these investigations is often low. A study of 294 patients with acute confusion found a diagnostic yield of only 14% if clinical suspicion was the sole reason for referral [1]. A large number of these investigations could therefore in theory be avoided, enabling better use of resources, reducing healthcare costs and minimising patient exposure to unnecessary radiation. To better target the use of brain imaging in this patient group a risk scoring system is required. Such scoring systems have been developed for use in general [2] and paediatric patients [3] presenting with head trauma, but old age is usually included as part of the indication for scanning. As such, existing risk scoring systems may lack discrimination when used in older patients.

Pre-existing falls risk scoring systems that are widely used, such as the Tinetti score [4], are mainly designed to calculate risk of falls rather than to help preselect patients that might have significant intracranial pathology as a cause (or result) of their fall.

We therefore developed a risk scoring system specifically for use in older patients admitted to hospital with a fall who are also confused.

Methods

Consecutive adult patients admitted to a large medical admissions unit were assessed as part of an audit of indications for CT scanning. Patients were included if they were admitted with a fall, were felt to be confused by the admitting team and received CT imaging of the brain within 1 week of admission. Unenhanced CT of the brain was performed according to standard 20

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clinical protocols using a General Electric 64-slice helical scanner. Investigations were classed as positive if they were reported as showing any intracranial blood, a new ischaemic lesion or any space-occupying lesion. Other information was collected from the medical notes by a member of the acute medical team on an audit proforma that included 12 risk factors.

Each of the 12 factors was tested for univariate association with a positive CT scan using the Ď&#x2021;2 test. Factors where the p-value was <0.2 were used to construct a risk score, weighted according to the strength of association. Receiveroperator characteristic curves were constructed and an optimal cut-off was selected. Sensitivity, specificity, positive and negative predictive values were then calculated by comparing risk score categorisation with the CT categorisation.

Results

66 patients were included, with a mean age of 74.8 years (SD 12.0; range 42 Ěś 97 years). 54/66 (82%) were aged over 65 years; 59% were male. 64% of patients lived in their own home and the remainder were admitted from either residential or nursing homes. 13/66 (20%) of imaging investigations revealed significant new pathology (7 intracranial haemorrhages, 4 acute cerebral infarcts and 2 space occupying lesions).

Univariate analysis indicated atrial fibrillation, previous history of falls, face/scalp trauma, new focal neurological signs, warfarin, dementia and a GCS<14 were positively associated with new CT findings (p<0.2). Antecedent dementia was negatively associated with new CT findings. All were assigned a value of +1 point except for new focal signs (+3 points) and antecedent dementia (-1 point, as this was inversely associated with a positive CT scan).

Using the above score, the area under the ROC curve was 0.83 (95% CI 0.70 - 0.96). A cut-off score of three or above was selected

as the optimum point to balance sensitivity and specificity. We used these figures to derive a sensitivity of 83%, specificity 89%, positive predictive value of 63% and negative predictive value of 96%.

Discussion

The score that we have derived has a high negative predictive value in this population, who were predominantly aged over 65 years.

A score below three therefore potentially allows CT scanning to be safely omitted, as the yield of positive findings is very low.

Assessment of older patients admitted with falls and confusion is often initially difficult because of a lack of information. A period of observation and obtaining a collateral history will usually clarify whether confusion is owing to dementia or delirium, and may allow delirium to settle with supportive care, orientation and correction of underlying illnesses. However, the high-throughput environment of emergency departments and medical assessment units often leads to pressure for rapid investigation rather than the more time-consuming approach of information gathering and observation. It is within this high throughput environment that we propose that this risk score may be able to allow better targeting of CT scanning of the brain in this patient group.

Any test or risk score requires validation in a large population separate from the population in which it was first developed [9].

Until this is done, our risk score should not be adopted into practice. Such testing should be relatively easy to perform and may also allow further refinement to the score to improve the ability of the score to rule out the need for CT of the brain in some older patients admitted with falls and confusion.

A J Brown, M D Witham and J George NHS Tayside and Centre for Cardiovascular and Lung Biology, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK

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review Article

REVIEW ARTICLE

M Anzidei, A Napoli, C Zini, M A Kirchin, C Catalano and R Passariello Department of Radiological Sciences, â&#x20AC;&#x153;Sapienzaâ&#x20AC;? University of Rome, Rome, Italy

Malignant tumours of the small intestine: a review of histopathology, multidetector CT and MRI aspects The small intestine (SI) accounts for 75% of the length and 90% of the mucosal surface of the alimentary tract; however, because of certain unique physiological features (rapid transit, alkaline content, IgA secretion and lymphoid tissue) it is the site of only 2â&#x20AC;&#x201C;6% of all gastrointestinal (GI) neoplasms [1, 2].

Apart from obscure GI bleeding, patients may present with non-specific complaints such as abdominal pain (60%), anaemia (50%), nausea and vomiting (50%), weight loss (40%), diarrhoea (30%) and intestinal obstruction (30%) [4]. However, many patients may remain asymptomatic until the late stages of disease. SI neoplasms are also difficult to identify at diagnostic imaging and as a result delays in diagnosis are common. Until recently, barium enteroclysis has been considered the most accurate

radiological modality to detect small bowel malignancies [6]. However, this technique requires duodenal intubation and direct injection of barium and methylcellulose into the intestinal lumen and is both timeconsuming and poorly tolerated by patients.

Furthermore, barium enteroclysis is limited in its ability to accurately depict the mural and extramural extent of disease [6]. Alternatives to barium enteroclysis for imaging the SI are multidetector CT (MDCT) and MRI. Both techniques have good potential for the early diagnosis of both inflammatory and neoplastic conditions. The aims of this review are to present MDCT and MRI protocols for SI imaging, to describe the typical imaging features of common SI neoplasms and to correlate radiological findings with specific histopathological characteristics.

Imaging techniques

Patient preparation MDCT The patient should fast on the day of the examination to reduce alimentary residue in the GI tract, which may lead to inhomogeneous intraluminal attenuation. Because the SI can be partly or fully collapsed under normal physiological conditions, luminal distension is a necessary pre-requisite for imaging because collapsed bowel loops can hide even large lesions or mimic wall thickening. Whereas both MRI [7] and MDCT enteroclysis [8] allow optimal lumen distension, oral administration of contrast agent with the proper choice of oral contrast material and adequate timing can produce good results [9, 10], are more patient-friendly and less time consuming. For MDCT, the

Abstract Small bowel neoplasms, including adenocarcinoma, carcinoid tumour, lymphoma and gastrointestinal stromal tumours, represent a small percentage of gastrointestinal cancers yet are among those with the poorest prognosis compared with other gastrointestinal malignancies. Unclear clinical scenarios and difficult radiological diagnosis often delay treatment with negative effects on

patient survival. Recently, multidetector CT (MDCT) and MRI have been introduced as feasible and accurate diagnostic techniques for the identification and staging of small bowel neoplasms. These techniques are gradually replacing conventional barium radiography as the tool of choice. However, the inherent technical and physiological challenges of small bowel imaging require a familiarity with patient preparation

and scan protocols. Adequate knowledge of the histopathology and natural evolution of small bowel neoplasms is also important for differential diagnosis.

The aim of this article is to review MDCT and MRI protocols for the evaluation of small bowel tumours and to provide a concise yet comprehensive guide to the most relevant imaging features relative to histopathology.

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Review article

Adenocarcinoma. Photograph of resected and opened duodenum from a 67-year-old man and low power photomicrograph of the lesion shows neoplastic infiltration.

choice of oral contrast agent is usually determined by the anatomical SI region of interest and the clinical question to be answered.

While water is often a good option to distend the duodenum and the proximal tract of the jejunum (1 to 1.5l of tap water given 10–15 min before examination, with the last 2–3 glasses drunk in the CT room) [11], imaging of the distal jejunum and/or ileum requires a different approach, since water is rapidly absorbed by the intestinal wall during its transit through the lumen. For these regions a low-concentration contrast agent with bland osmotic activity represents the best compromise between bowel distension and lumen attenuation. Such contrast mixtures (e.g. water, sorbitol and 0.1% barium sulphate) typically require fractioned administration over a period of 50–65 min before the examination [12]. Highly concentrated barium or iodine solutions must be avoided because too high an intraluminal attenuation can jeopardise the identification of small hypervascular masses (i.e. carcinoid tumours) or

Adenocarcinoma. Multidetector CT images obtained after oral administration of a lowconcentration contrast agent demonstrate an eccentric and partially stenosing wall thickening involving one of the proximal jejunal loops.

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compromise the evaluation of mesenteric vessels [13, 14]. The use of peristalsis inhibitors such hyoscine N-butyl bromide (HBB, Buscopan, Boehringer Ingelheim GmbH, Germany) is strongly recommended (intravenous administration after completing intestinal preparation) in order to prolong lumen distension and avoid movement artefacts.

MRI The dietary recommendations are similar to those for MDCT. Oral contrast agents for MRI can be classified as positive, negative or biphasic according to their action on the signal intensity of bowel lumen [15].

Positive contrast agents are paramagnetic, i.e. water-based gadolinium (Gd) solutions that produce high-signal intensity (the so-called “luminographic” effect) on both T1 and T2 weighted sequences [16]. The main limitations of this approach are the relative high cost and the fact that wall enhancement after intravenous Gd administration can be masked by the higher lumen signal on T1 weighted sequences [17]. Negative contrast agents are superparamagnetic, i.e. water based solutions of iron oxide particles coated with silicone that produce low-signal intensity (the so-called “dark-lumen” effect) on both T1 and T2 weighted sequences [16].

Although these agents often permit better visualisation of bowel wall and mesenteric fat oedema on T2 weighted sequences [18, 19], magnetic susceptibility artefacts that affect image quality may occur on gradientecho sequences. Biphasic contrast agents are water solutions of hyperosmotic compounds (i.e. polyethilenglycole) that produce both the luminographic effect on T2 weighted sequences and the dark lumen appearance on T1 weighted sequences [16]. Biphasic agents represent the most flexible solution, with the advantage of cost containment [20, 21]. MR-enteroclysis with naso-jejunal intubation and 1500 - 3000 ml of contrast agent (administered at 80 - 150ml min-1 using infusion pumps) has proven to be highly effective for the detection of inflammatory bowel diseases and SI cancers [7]. However, in most patients adequate intestinal distension can be obtained with a conventional per

os preparation (600 ml - 1l of tap water with polyethilenglycole for 20–30min before the examination). Moreover, since there is no radiation exposure, bowel distension can be monitored dynamically and adjusted during the examination [15]. Once sufficient bowel distension is achieved, peristalsis inhibitors may be used to suppress motility induced artefacts that can produce proton dephasation inside the lumen, mimicking filling defects on T2 weighted images.

Imaging protocol

MDCT A preliminary unenhanced acquisition of the whole abdomen from the dome of the diaphragm to the pelvis is recommended in order to properly detect mesenteric calcifications or intraluminal bleeding and for the imaging of liver parenchyma if a malignancy is suspected. Thereafter, depending on the indication, arterial and/or portal venous phase imaging [14, 22] must be performed after intravenous administration of contrast agent (2ml kg-1 at 3.5–4ml s-1). Bolus tracking techniques with measurements performed in the abdominal aorta can be used to adapt the delay between contrast agent administration and scan initiation to the cardiac output of the individual patient; however, delays of 35–40s and 60–65s are often appropriate for arterial and portal-venous phase acquisitions, respectively. Arterial phase imaging is recommended when a strongly enhancing lesion (e.g. neuroendocrine tumours or metastases from melanoma) is suspected.

When using a 4-slice scanner a collimation of 4×2.5mm should be considered the minimum setting to reconstruct 3mm slices.

Conversely, a collimation of 4×1mm allows 1.25mm slice reconstruction that can be adapted to image mesenteric vessels, but at the cost of a longer scan duration, which may exceed the breath-hold capability of frail patients. The availability of faster scanners permits the routine use of sub-millimeter collimations (16×0.75mm and 64×0.75mm) that can generate almost isotropic three dimensional (3D) datasets from multiphasic acquisitions. Evaluation of MDCT datasets should be performed on off-line consoles dedicated for 3D reconstructions (the

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Atypical carcinoid tumour. Multidetector CT images demonstrate a circumferential thickening of the last ileal loop with sparing of the outer wall layers. Caudal sections show marked fluid distension of ileal and jejunal loops owing to carcinoid-induced secretory discharge.

availability of maximum intensity projection and multiplanar reformatted images facilitate the evaluation of SB lumen and its relationship with adjacent vessels) [14, 22].

MRI The effects of breathing artefacts and bowel wall motion during data acquisition are the main causes of image degradation and poor diagnostic accuracy in MRI of the SI. For this reason later generation MRI scanners operating at 1.5–3T are preferable while parallel imaging protocols and fast sequences are mandatory. Regarding acquisition geometry, the coronal plane optimally demonstrates the anatomy of the SI, mesentery and abdominal vessels, but additional axial and sagittal planes should also be considered for precise evaluation of the SI and to avoid problems with partial volume effects. According to most literature reports, there are three types of sequence that must be included in a complete MRI protocol for SI imaging: • The main advantage of T2 weighted fast spin-echo sequences, or turbo spin-echo (TSE) acquisitions, is the excellent softtissue contrast, which permits detection of

review article

diseased bowel segments and evaluation of the surrounding mesentery [23, 24]. The use of half-Fourier acquisition single-shot turbo spin-echo (HASTE) technique increases the speed of acquisition resulting in reduced or absent movement artefacts [25]. On the other hand, these sequences are susceptible to flow-related artefacts (owing to the long echo time (TE)) and thus rapid peristaltic movements may result in intraluminal flow voids that may be perceived as pseudolesions.

• True fast imaging with steady-state precession (True-FISP) sequences are fully balanced gradient-echo sequences and provide the highest signal among steadystate sequences. Contrast is a function of T1/ T2. If short repetition time (TR) and TE are used the T1 portion remains constant and the images are mainly T2 weighted, with bowel lumen appearing hyperintense. The speed and motion insensitivity of the acquisition completely eliminates breathing or peristalsis induced artefacts [17, 26]. Unlike the half-Fourier technique, intraluminal flow voids do not affect steady-state precession sequences; moreover, selective fat-suppression pulses can be used to increase the luminographic effect and remove “black boundary” artefacts caused by magnetic susceptibility [27, 28].

• T1 weighted spoiled gradient-echo (SPGRE) sequences with fat suppression are sequences that use a semi-random spoiler gradient after each echo to spoil the remaining transverse magnetisation. These T1 weighted sequences can be acquired as two dimensional (fewer motion artefacts) or 3D (higher spatial resolution) datasets. Their use after intravenous Gd administration permits excellent depiction of the mesenteric vessels and identification of hypervascular bowel walls if coupled with a selective spectral fat-suppression pulse [27, 29, 30].

Histopathology and imaging findings

Adenocarcinoma Adenocarcinoma is the most common primary malignancy of the SI and accounts for 40% of cancers. The predominant location of adenocarcinoma is the duodenum and proximal jejunum, with the incidence decreasing distally [31]. The exception to

this presentation is seen in Crohn’s disease where most adenocarcinomas occur in the ileum. Adenocarcinomas may be polypoid, infiltrating or stenosing [32]. Duodenal adenocarcinomas are usually more circumscribed with a polypoid or protuberant appearance. Conversely, jejunal or ileal lesions tend to be larger, annular, constricting tumours with circumferential involvement of the intestine wall; at the time of diagnosis most show a fully parietal penetration and involvement of the serosal surface [33]. An increased incidence of small bowel adenocarcinoma has been described in patients affected by familiary adenomatous polyposis (mainly periampullary) and Lynch syndrome. Small bowel carcinomas resemble their counterparts in the colon, but with a higher proportion of poorly differentiated tumours with glandular, squamous, and undifferentiated neuroendocrine components [34].

At imaging duodenal carcinomas often appear as polypoid, well-delineated lesions [35, 36], although high-grade cancers may show more aggressive behaviour. Central ulceration may be present in 10% of cases.

Adenocarcinomas of the jejunum and ileum usually appear as an annular narrowing with abrupt concentric or irregular “overhanging edge” stenosis that could lead to partial or complete obstruction [17, 22].

After intravenous contrast agent administration, moderate heterogeneous enhancement is usually seen [14]. Extraluminal infiltration may appear as fat stranding on MDCT and hyperintensity of the outer wall layers and fat on T2 weighted fat suppressed MR sequences. Adenocarcinoma of the ileum may mimic Crohn’s disease for its clinical and radiological features; however, in our experience the absence of significant engorgement of the vasa recta (the “comb” sign in Crohn’s disease) and the presence of a single focal lesion rather than multiple “skip” areas of wall thickening may be useful criteria to suspect malignancy. Secondary lymphoadenopathies may be present at the time of diagnosis and must be differentiated from the bulkier nodes that occur when there is lymphomatous involvement of the mesentery. issue 4 august 2011

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review article

High-grade intraluminal gastrointestinal stromal tumour (GIST). Coronal T2 weighted HASTE image and fat-saturated T1 weighted spoiled gradient-echo image obtained after intravenous gadolinium administration.

Carcinoid tumours

Carcinoid is the second most common malignancy, accounting for approximately 20â&#x20AC;&#x201C;25% of all SI lesions although its frequency has been recently reported to have increased up to 35%. These tumours arise from enterochromaffin cells situated in the crypts of LieberkĂźhn and produce serotonin and other histaminelike substances [37]. Carcinoid tumours are more common in the ileum (most within 60cm of the ileocecal valve) than in the jejunum or duodenum, and lesions may be multiple and/or metastatic (liver and lungs) at the time of diagnosis. Prognosis is usually negatively related to the

Lymphoma. Multidetector CT images demonstrate a circumferential thickening of the proximal jejunum with mucosal irregularity and sparing of the outer wall layers, bulky lymphoadenopaties are identified along the mesenteric vessels.

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age of the patient and the size of tumour.

Macroscopically carcinoid presents as an intramural or mucosal mass that may infiltrate the mesentery causing a strong desmoplastic reaction that results in calcification, fat stranding and eventually kinking of the bowel segments, often with intestinal obstruction [38]. Histologically, the tumours resemble adenocarcinomas, but with a less aggressive evolution. SI lesions show a strong argentaffin reaction and immunohistochemical staining (chromogranin, neuron specific enolase, sinaptophysin) is mandatory in order to confirm the histological classification.

At diagnostic imaging carcinoid usually appears as a parietal nodule with avid contrast enhancement in the arterial phase [14, 17, 22]. Since most lesions are small (<2cm) at the time of the examination, optimal distension of the bowel lumen must be achieved in order to properly identify the nodules. On unenhanced MR scans, carcinoid tumours usually appear as isointense to muscle on T1 weighted images and iso- or mildly hyperintense to muscle on T2 weighted images [39].

In some cases no discrete mass can be identified and in such cases the tumour usually develops as a focal thickening of the wall of a bowel loop. The most characteristic feature of carcinoid tumours is an intense desmoplastic reaction in the mesentery induced by extraparietal infiltration [14, 40]. Both MDCT and MRI can show an ill-defined soft-tissue mass with irregular margins and infiltrative character related to mesenteric fibrosis. In up to 70% of cases these mesenteric masses contain calcifications that are correctly identified only at MDCT [14].

Moreover, mesenteric calcifications can be used to differentiate carcinoid-induced fibrosis from other conditions such as mesenteric fibromatosis in which calcium precipitation is uncommon [41]. Mesenteric vessel can be involved as a result of direct tumour encasement or desmoplastic reaction. Narrowing or engorgement of the vasa recta as well as secretory discharge can occur owing to the action of hormones secreted by the neoplasm. Special attention should be paid to the identification of synchronous localisations in the SI and to

the possible presence of hypervascular liver metastases. Alternative diagnostic modalities such as somatostastin receptor scan or positron emission tomography (PET) with C11-hydroxytrytophan can be a feasible option for suspected carcinoid in the absence of confirmatory conventional cross-sectional imaging data.

Lymphoma

The third most common neoplasm is non-Hodgkin lymphoma (10 - 15% of cases). This neoplasm is more common in patients with coeliac disease and in patients with acquired immune deficiency syndrome (AIDS), and particularly prevalent in developing countries. Early lesions may appear as plaque-like mucosal expansions while advanced, infiltrating lesions produce full mural thickening and mucosal ulceration.

Other lesions may appear as polipoid masses, protruding into the lumen. The involvement of the outer layer of the intestinal wall often leads to wide infiltration of the muscularis propria and myoenteric plexus, causing motility failure and secondary obstruction [42]. Moreover, the lack of stromal support in larger lesions may determine ischaemia, necrosis and wall perforation.

Atypical lymphoid cells populate the superficial epithelium, subsequently replacing the submucosa and even muscle wall in advanced cases. Most SI lymphomas are B-cell type lesions, while a small percentage are T-cell lymphomas, evenly distributed between low- and high-grade lesions [43].

Because of the proteiform aspects of this neoplasm, small bowel lymphoma has a wide variety of radiological appearances. At least four major patterns of lymphomatous involvement of the SI have been described [14, 44]. The most common type of alteration (50% of cases) is represented by a full-thickness, infiltrative lesion with destruction of the normal mucosal folds (Figure 13), which can involve the muscular layer, blocking peristalsis and causing aneurysmal dilatation of the bowel loops. Adenocarcinoma should usually be considered for differential diagnosis, although this lesion typically presents without aneurysmal dilatation of the bowel [14]. Lymphoma can also present

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as multifocal nodules at multiple sites along the SI (requiring differentiation from carcinoid tumour) or as a single mass-forming lesion that may cause intussusceptions or obstruction. Alternatively, an exophytic, sarcoma-like form has been described. After contrast agent administration lymphoma demonstrates homogeneous, mild enhancement. Necrosis or fistulous tracts to the adjacent bowel loops have been described, mainly in the exophytic form [45], with increased risk of perforation during chemotherapy. Satellite lymphoadenopaties are usually bulky, larger than in other neoplasms and may be used as a differential sign [14].

Gastrointestinal stromal tumours

GI stromal cell tumour (GIST) is the fourth most common SI malignancy, accounting for less than 10% of cases. GISTs develop from the interstitial cells of Cajal, within the Auerbach plexus [46]. Grossly, GISTs appear as rounded, well-defined masses arising from the muscular layer and often developing exophytically or intraluminally, there may be mucosal ulceration present. The size of the lesion may vary from a few millimeters to more than 30cm.

Larger lesions often present central necrosis and haemorrhage. Histologically, GISTs can be classified into spindle cell and epithelioid varieties. The cellular expression of c-kit (CD117), a transmembrane protein receptor with an intracellular tyrosine kinase domain, is typical of GISTs (85–95% of cases) and can be demonstrated with immunohistochemical staining [47]. Epithelioid c-kit negative GISTs usually show early lymphonodal involvement and have a poorer prognosis. The number of mitotic figures per

Gastrointestinal stromal tumour (GIST).

Photograph of resected and opened exophitic mass originating from a jejunal loop, low power photomicrograph and CD117 antibodies stain confirms GIST diagnosis

review article

high-power-field (HPF) is usually adopted as an empirical cut-off to predict the behaviour of the lesion: 1–5 mitoses per 10 HPFs suggest potential malignancy while more than 5 per 10 HPFs indicate malignancy [48]. GISTs occur almost anywhere in the SI, although malignant lesions arise mainly in the distal ileum. GISTs may be classified as: • Submucosal: smooth, round-to-oval filling defect in the SI lumen; • Subserosal: extrinsic or exocentric masses that displace adjacent bowel loops; • Intraluminal: hypervascular lesions often correlated with haemorrhage and ulceration.

Other radiological findings that may suggest a malignant form include an irregular shape with low attenuation and internal necrosis on MDCT [49, 50] and hyperintensity on T2 weighted MRI indicating central necrosis [16, 51]. Direct spread to adjacent bowel loops, vascular encasement and metastases are common for malignant lesions. Small bowel neurofibromas are similar to benign GISTs and may be equally hypervascular. In patients with acquired immunodeficiency, multiple GISTs must be distinguished from intestinal Kaposi sarcoma [52].

Both MDCT and MRI are important in assessing the response to treatment.

Metastases

Although metastases are the least common SI malignancies, the small bowel remains the main site of metastatic disease in the GI tract. While GISTs, adenocarcinoma and carcinoid tumuors often metastasise to the SI, the most frequent extra-abdominal causes of SI metastases are melanoma [53], lung [54], breast and thyroid cancers [55]. Usually macroscopic features such as multifocality, no ulceration and a predominant extramural component may suggest metastatic disease. Histologically, metastases are typically submucosal or subserosal and are easy to distinguish from primary tumours; nevertheless, immunohistochemistry may also help to differentiate primary cancer from metastases. Metastatic spread to the

Metastases (melanoma). Multidetector CT images demonstrate a large lesion, with ill-defined lobulated margins, developing from inner wall layers of an ileal loop, while the lesion develops as a large mass with a necrotic core.

small bowel usually appears as a smooth, round or polypoid mass with the “target” aspect of an ulcerated lesion that may result in intussusception or occlusion [22, 56]. Metastases in the small bowel can also occur as extramural nodules following intraperitoneal seeding especially from primary mucinous tumours (ovaries, appendix and colon). An increase in bowel wall thickness with infiltration of the mesenteric fat (omental cake) is the classic radiological feature of intraperitoneal seeding on MDCT and MRI [57].

Since the radiological diagnosis of metastasis is not diagnostic for the primary tumour, a whole body CT scan may be beneficial to reveal the primary site.

Conclusion

Since primary and secondary small bowel neoplasms are rare, present with non-specific symptoms and are small at an early stage, they continue to pose a diagnostic challenge to radiologists. The use of state-of-the-art MDCT and MRI with appropriate application of tailored scan protocols and an understanding of the imaging signs of each pathological entity, as compared with the natural history of the tumour and microscopic histology, may be of significant help in the daily routine of GI radiologists. www

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The British Journal of Radiology Abstracts

Abstracts The value of dual-time-point 18F-FDG PET/CT for identifying axillary lymph node metastasis in breast cancer patients F-FDG PET/CT scans at 2 time-points, the first at 1h after radiotracer injection and the second 3h after injection. Where 18 F-FDG uptake was in the ALN perceptibly increased, the maximum standardised uptake values for both time-points (SUVmax1 and SUVmax2) and the retention index (RI) were calculated. Correlation between the PET/CT results and post-operative histological results was assessed.

18

Objectives:

The sensitivity of 18-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) for detecting axillary lymph node (ALN) metastases in breast cancer is reported to be low. Several studies have shown, however, that dual-time-point 18 F-FDG PET imaging provides improved accuracy in the diagnosis of certain primary tumours when compared with single-scan imaging. The purpose of this study was to assess whether the use of dual-time-point 18F-FDG PET/CT scans could improve the diagnostic accuracy of ALN metastasis in breast cancer.

Methods:

The study included 171 breast cancer patients who underwent pre-operative

ALN-positive group and the nodenegative group. The area under the receiver operating characteristic (ROC) curve for SUVmax1 was 0.90 (p<0.001) and 0.87 for SUVmax2 (p<0.001).

Conclusion:

Dual time-point imaging did not improve the overall performance of 18FFDG PET/ CT in detecting ALN metastasis in breast cancer patients

Results:

The performance of 1h and 3h PET/CT scans was equal, with sensitivity 60.3% and specificity 84.7%, in detecting ALN metastasis. Out of 171 patients, 60 had ALNs with increased 18F-FDG uptake on 1h or 3h images. There was no significant difference in RI between the metastatic

W H Choi, I R Yoo, J H O, S H Kim and S K Chung Department of Radiology, Seoul St. Maryâ&#x20AC;&#x2122;s Hospital, The Catholic University of Korea, Seoul, Korea

www Download the full length article: DOI: 10.1259/bjr/56324742

Comparison of mammography, sonography, MRI and clinical examination in patients with locally advanced or inflammatory breast cancer who underwent neoadjuvant chemotherapy Objectives:

The purpose of this study was to determine the relative accuracies of mammography, sonography, MRI and clinical examination in predicting residual tumour size and pathological response after neoadjuvant chemotherapy for locally advanced or inflammatory breast cancer. Each prediction method was compared with the gold standard of surgical pathology.

Methods:

43 patients (age range, 25â&#x20AC;&#x201C;62 years; mean age, 42.7 years) with locally advanced or inflammatory breast cancer who had been treated by neoadjuvant chemotherapy were enrolled prospectively. We compared the predicted residual tumour size and the predicted response on imaging and clinical examination with residual tumour 26

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size and response on pathology. Statistical analysis was performed using weighted kappa statistics and intraclass correlation coefficients (ICC).

Results:

The ICC values between predicted tumour size and pathologically determined tumour size were 0.65 for clinical examination, 0.69 for mammography, 0.78 for sonography and 0.97 for MRI. Agreement between the response predictions at mid-treatment and the responses measured by pathology had kappa values of 0.28 for clinical examination, 0.32 for mammography, 0.46 for sonography and 0.68 for MRI. Agreement between the final response predictions and the responses measured by pathology had kappa values of 0.43 for clinical examination, 0.44 for mammography, 0.50 for sonography and 0.82 for MRI.

Conclusion:

Predictions of response and residual tumour size made on MRI were better correlated with the assessments of response and residual tumour size made upon pathology than were predictions made on the basis of clinical examination, mammography or sonography. Thus, the evaluation of predicted response using MRI could provide a relatively sensitive early assessment of chemotherapy efficacy.

H J Shin, H H Kim, J H Ahn, S-B Kim, K H Jung, G Gong, B H Son and S H Ahn Departments of Radiology and Research Institute of Radiology, Oncology, Pathology and Surgery

www Download the full length article: DOI: 10.1259/bjr/74430952

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The British Journal of Radiology Abstracts www

For more Abstracts visit: bjr.birjournals.org

Evaluation of dose to cardiac structures during breast irradiation Objectives:

Adjuvant radiotherapy for breast cancer can lead to late cardiac complications.

The highest radiation doses are likely to be to the anterior portion of the heart, including the left anterior descending coronary artery (LAD). The purpose of this work is to assess the radiation doses delivered to the heart and the LAD in respiration-adapted radiotherapy of patients with left-sided breast cancer.

Methods:

24 patients referred for adjuvant radiotherapy after breast-conserving surgery for left sided lymph node positive breast cancer were evaluated.

The whole heart, the arch of the LAD and the whole LAD were contoured.

The radiation doses to all three cardiac structures were evaluated.

Results:

For 13 patients, the plans were acceptable based on the criteria set for all 3 contours.

For seven patients, the volume of heart irradiated was well below the set clinical threshold whereas a high dose was still being delivered to the LAD. In 1 case, the dose to the LAD was low while 19% of the contoured heart volume received over 20 Gy. In five patients, the dose to the arch LAD was relatively low while the dose to the whole LAD was considerably higher.

Conclusion:

This study indicates that it is necessary

to assess the dose delivered to the whole heart as well as to the whole LAD when investigating the acceptability of a breast irradiation treatment. Assessing the dose to only one of these structures could lead to excessive heart irradiation and thereby increased risk of cardiac complications for breast cancer radiotherapy patients.

M C Aznar, S-S Korreman, A N Pedersen, G F Persson, M Josipovic and L Specht Department of Radiation Oncology, Rigshospitalet, Copenhagen, Denmark

www Download the full length article: DOI: 10.1259/bjr/12497075

CT colonography: computer-assisted detection of colorectal cancer

Objectives:

Computer-aided detection (CAD) for CT colonography (CTC) has been developed to detect benign polyps in asymptomatic patients. We aimed to determine whether such a CAD system can also detect cancer in symptomatic patients.

Methods:

CTC data from 137 symptomatic patients subsequently proven to have colorectal cancer were analysed by a CAD system at 4 different sphericity settings: 0, 50, 75 and 100. CAD prompts were classified by an observer as either true positive if overlapping a cancer or false positive if elsewhere.

Colonoscopic data were used to aid matching.

Results:

Of 137 cancers, CAD identified 124 (90.5%), 122 (89.1%), 119 (86.9%) and 102 (74.5%) at a sphericity of 0, 50, 75 and 100, respectively. A substantial proportion of cancers were detected on either the prone or supine acquisition alone. Of 125 patients with prone and supine acquisitions, 39.3%, 38.3%, 43.2% and 50.5% of cancers were detected on a single acquisition at a sphericity of 0, 50, 75 and 100, respectively. CAD detected three cancers missed by radiologists at the original clinical interpretation.

False-positive prompts decreased with increasing sphericity value (median 65, 57, 45, 24 per patient at values of 0, 50, 75, 100, respectively) but many patients were poorly prepared.

Conclusion:

CAD can detect symptomatic colorectal cancer but must be applied to both prone and supine acquisitions for best performance.

C Robinson, S Halligan, G Iinuma, W Topping, S Punwani, L Honeyfield and S A Taylor Department of Specialist Radiology, University College Hospital, London, UK

www Download the full length article: DOI: 10.1259/bjr/17848340

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The British Journal of Radiology Abstracts

Biplane fluoroscopy-guided radiofrequency ablation combined with chemoembolisation for hepatocellular carcinoma: initial experience Objectives:

The purpose of this study was to assess the technical feasibility and local efficacy of biplane fluoroscopy-guided percutaneous radiofrequency (RF) ablation combined with transcatheter arterial chemoembolisation (TACE) for hepatocellular carcinoma (HCC).

Our retrospective study was approved by the institutional review board and informed consent was waived.

Methods:

18 patients with 19 HCCs (mean 2.5 cm diameter; range 2–4.2 cm) were treated with percutaneous RF ablation combined with TACE. After segmental TACE, 18 (95%) of 19 HCCs were visible on fluoroscopy.

Shortly (median 2 days; range 1–4 days) after TACE, percutaneous RF ablation was performed under real-

time biplane fluoroscopic guidance. We evaluated major complications, rate of technical success at immediate post-RF ablation CT images and local tumour progression at follow-up CT images.

Results:

Major complications were not observed in any patients. Technical success was achieved for all 18 visible HCCs. During the follow-up period (median 20 months; range 5–30 months), no local tumour progression was found.

Conclusion:

Biplane fluoroscopy-guided RF ablation combined with TACE is technically feasible and effective for treatment of HCC.

M W Lee, Y J Kim, S W Park, N C Yu, W H Choe, S Y Kwon, and C H Lee Department of Radiology and Research Institute of Biomedical Science, Konkuk University School of Medicine, Seoul, South Korea www Download the full length article: DOI: 10.1259/bjr/27559204

Effect of varying contrast material iodine concentration and injection technique on the conspicuity of hepatocellular carcinoma during 64-section MDCT of patients with cirrhosis Objectives:

The aim of this study was to compare the intraindividual effects of contrast material with two different iodine concentrations on the conspicuity of hepatocellular carcinoma (HCC) and vascular and hepatic contrast enhancement during multiphasic, 64-section multidetector row CT (MDCT) in patients with cirrhosis using two contrast medium injection techniques.

Methods:

Patients were randomly assigned to one of two groups with an equal iodine dose but different contrast material injection techniques: group A, fixed injection duration (25 s), and group B, fixed injection flow rate (4 ml s-1). For each group, patients were randomised 28

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to receive both moderate-concentration contrast medium (MCCM) and highconcentration contrast medium (HCCM) during two CT examinations within 3 months. Enhancement of the aorta, liver and portal vein and the tumour-toliver contrast-to-noise ratio (CNR) were compared between MCCM and HCCM. Results:

30 patients (mean age 59 years; range 45–80 years; 16 patients in scheme A and 14 in scheme B) with a total of 31 confirmed HCC nodules were prospectively enrolled. For group B, the mean contrast enhancement of the aorta and tumour-to-liver CNR were significantly higher with HCCM than with MCCM during the hepatic arterial phase (+350.5 HU vs +301.1 HU,p=0.001, and

+7.5 HU vs +5.5 HU, p=0.004).

For both groups, there was no significant difference between MCCM and HCCM for all other comparisons.

Conclusion:

For a constant injection flow rate, HCCM significantly improves the conspicuity of HCC lesions and aortic enhancement during the hepatic arterial phase on 64-section MDCT in patients with cirrhosis.

A Guerrisi, D Marin, R C Nelson, G De Filippis, M DI Martino, H Barhart, R Masciangelo, I Guerrisi, R Passariello and C Catalano Department of Radiological Sciences, University of Rome Sapienza, Rome 00159, Italy www Download the full length article: DOI: 10.1259/bjr/21539234

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The British Journal of Radiology Abstracts

Diffusion-weighted imaging of solid or predominantly solid gynaecological adnexial masses: is it useful in the differential diagnosis?

Objectives:

This study investigated whether diffusionweighted imaging (DWI) and apparent diffusion coefficient (ADC) values provide specific information that allows the diagnosis of solid or predominantly solid gynaecological adnexial lesions, especially whether they can discriminate benign and malignant lesions.

Methods:

DWI was performed in 37 patients with histologically proven solid or predominantly solid adnexial lesions (22 malignant and 15 benign neoplasms). The lesions in our data set were divided into two groups, all adnexial lesions or lesions of ovarian origin, for evaluation. The areas of the highest signal intensity on DWI (b=800 s mm-2) and the lowest ADC values within the lesions were evaluated.

Results:

On DWI, high signal intensity was observed more often in malignant than in benign lesions (p<0.0001). There was no significant difference between the ADC values of the malignant and benign lesions in either the adnexial (0.88±0.16 vs 0.84±0.42; p=0.96) or the ovarian (0.85±0.14 vs 1.05±0.2; p=0.133) lesions. When signal intensities on DWI were compared, however, malignant lesions had higher values than the benign lesions in both the adnexial (0.69±0.21 vs 0.29±0.13; p<0.0001) and the ovarian lesions (0.75±0.14 vs 0.37±0.24; p=0.003).

Conclusion:

On DWI, high signal intensity was observed more frequently with the malignant lesions.

B Bakir, S Bakan, M Tunaci, V L Bakir, A C Iyibozkurt, S Berkman, E Bengisu and A Salmaslioglu Department of Radiology, Istanbul University, Istanbul Medical School, Istanbul, Turkey www Download the full length article: DOI: 10.1259/bjr/90706205

Impact of the high-definition multileaf collimator on linear accelerator-based intracranial stereotactic radiosurgery Objectives:

The impact of two multileaf collimator (MLC) systems for linear acceleratorbased intracranial stereotactic radiosurgery (SRS) was assessed.

Methods:

68 lesions formed the basis of this study. 2.5mm leaf width plans served as reference. Comparative plans, with identical planning parameters, were based on a 5mm leaf width MLC system. Two collimation strategies, with collimation fixed at 0 or 90 and optimised per arc or beam, were also assessed. Dose computation was based on the pencil beam algorithm with allowance for tissue heterogeneity. Plan normalisation was such that 100% of the prescription dose covered 95% of the planning target volume. Plan evaluation

was based on target coverage and normal tissue avoidance criteria.

albeit small, for the investigated range of intracranial SRS targets.

Results:

Conclusion:

The median conformity index difference between the MLC systems ranged between 0.8% and 14.2%; the 2.5mm MLC exhibited better dose conformation.

The median reduction of normal tissue exposed to ≥100%, ≥50% and ≥25% of the prescription dose ranged from 13.4% to 29.7%, favouring the 2.5mm MLC system. Dose fall-off was steeper for the 2.5mm MLC system with an overall median absolute difference ranging from 0.4 to 1.2mm. The use of collimation optimisation resulted in a decrease in differences between the MLC systems.

The results demonstrated the dosimetric merit of the 2.5mm leaf width MLC system over the 5mm leaf width system,

The clinical significance of these results warrants further investigation to determine whether the observed dosimetric advantages translate into outcome improvements.

J A Tanyi, C M Kato, Y Chen, Z Chen and M Fuss Department of Radiation Medicine, Oregon Health and Science University, Portland, OR, USA

www Download the full length article: DOI: 10.1259/bjr/19726857

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The British Journal of Radiology Abstracts

Distribution of brain metastases: implications for non-uniform dose prescriptions Objectives:

The aim of this study was to determine the disease-specific distribution of brain metastases and, using radiobiological modelling, estimate how these anatomical tendencies might be exploited when delivering prophylactic whole-brain radiotherapy for small cell lung cancer in complete remission.

Methods:

Disease-specific brain metastasis atlases were created by mapping brain metastases to a standard image set from a database of patients who were to receive external beam radiation therapy. The specific diseases investigated included lung (both small cell and non-small cell), breast, renal and gynaecological cancers as well as melanoma. Radiobiological modelling was used to estimate how much improvement, in terms of the

metastasis-free rate at 3 years, might be possible with non-uniform dose distributions if there are spatial biases in the incidence of micrometastases from small cell lung cancer.

irradiation compared with the same integral whole-brain dose delivered as a uniform prescription.

Results:

For lung and breast cancer, there was an increased probability of cerebellar metastases compared with what would be predicted based solely on brain volume.

This trend was not evident for renal cancer, gynaecological malignancies or melanoma.

Conclusion:

Radiobiological models suggest that if there is a non-uniform distribution of microscopic brain metastases in patients with small cell lung cancer, higher population-based metastasis-free rates might be achievable with non-uniform

E T Bender and W A Tome Department of Human Oncology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA

www Download the full length article: DOI: 10.1259/bjr/30173406

Ultrasound-guided core biopsy in the diagnosis of lymphoma of the head and neck. A 9 year experience Objectives:

This retrospective study aimed to evaluate the diagnostic utility of ultrasound guided core biopsy (USCB) in lymphoma of the head and neck, in particular, whether core biopsy can provide sufficient diagnostic information for definitive treatment.

Methods:

All lymphomas diagnosed in the head and neck at Eastbourne General Hospital between January 2000 and June 2009 were identified. Radiology and pathology reports were reviewed and the diagnostic techniques recorded. The type of biopsy (fine needle aspiration, needle core, surgical excision biopsy) used to establish a diagnosis sufficient to allow treatment i.e. the “index” diagnostic technique was identified. Previous inconclusive or inadequate biopsies were noted. Pathology 30

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reports based on USCB were graded 0–3 according to diagnostic completeness and ability to provide treatment information.

excision, biopsy was the index modality in 104 cases.

Conclusion:

Results:

Of 691 overall cases of lymphoma diagnosed over the 9 year period, 171 different patients presented with lymphoma in the head and neck. Of these 171, 83 had USCB biopsy during diagnostic work up. 60 were regarded as grade 3 where a confident diagnosis of lymphoma was made. In seven patients ,clinical management proceeded on the basis of a suggestive (grade 2) pathology report without surgical excision and these were therefore also included as “index” biopsies. Overall therefore 67/83 core biopsies (81%) provided adequate information to allow treatment. Surgical

In the majority of cases USCB is adequate for confident histopathological diagnosis avoiding the need for surgical excision biopsy in cases of suspected head and neck lymphoma.

C Burke, R Thomas, C Inglis, A Baldwin, K Ramesar, R Grace, and D C Howlett Departments of Radiology, Eastbourne District Hospital, Kings Drive, East Sussex BN21 2UD, UK

www Download the full length article: DOI: 10.1259/bjr/60580076

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The British Journal of Radiology Abstracts

The use of joint-specific and whole-body MRI in osteonecrosis: a study in patients with juvenile systemic lupus erythematosus Objectives:

This study aimed to estimate the prevalence of osteonecrosis (ON) in juvenile systemic lupus erythematosus (SLE) patients using joint-specific and whole body MRI; to explore risk factors that are associated with the development of ON; and to evaluate prospectively patients 1 year after initial imaging.

Methods:

Within a 2 year period, we studied 40 juvenile SLE patients (aged 8–18 years) with a history of steroid use of more than 3 months duration. Risk factors including disease activity, corticosteroid use, vasculitis, Raynaud’s phenomenon and lipid profile were evaluated. All patients underwent MRI of the hips, knees and ankles using joint specific MRI. Whole-body STIR (short tau inversion recovery) MRI was performed in all patients with ON lesions.

Results:

Osteonecrosis was identified in 7 patients (17.5%) upon joint-specific MRI. Whole-body STIR MRI detected ON in 6 of these 7 patients. There was no significant difference between the ON and non-ON groups in the risk factors studied. One patient had pre-existing symptomatic ON. At 1 year follow-up, the ON lesions had resolved in one patient, remained stable in four and decreased in size in two.

No asymptomatic patients with ON developed clinical manifestations.

Conclusion:

Whole-body STIR MRI may be useful in detecting ON lesions in juvenile SLE patients but larger studies are needed to define its role.

T C M Castro, H Lederman, M T A Terreri, W I Caldana, S C Kaste and M O Hilario Department of Pediatrics, Division of Allergy, Clinical Immunology and Rheumatology, Universidade Federal de São Paulo, Brazil www Download the full length article: DOI: 10.1259/bjr/34972239

Ipsilateral atrophy of paraspinal and psoas muscle in unilateral back pain patients with monosegmental degenerative disc disease Objectives:

To assess the cross-sectional area (CSA) of both paraspinal and psoas muscles in patients with unilateral back pain using MRI and to correlate it with outcome measures.

Comparison of CSAs of muscles between the affected vs symptomless side was carried with Student’s t-test and correlations were conducted with Spearman’s test.

Results:

Methods:

40 patients, all with informed consent, with a minimum of 3 months of unilateral back pain with or without sciatica and one-level disc disease on MRI of lumbosacral spine were included. Patients were evaluated with self-report measures regarding pain (visual analogue score) and disability (Oswestry disability index). The CSA of multifidus, erector spinae, quadratus lumborum and psoas was measured at the disc level of pathology and the two adjacent disc levels, bilaterally.

The maximum relative muscle atrophy (percentage decrease in CSA on symptomatic side) independent of the level was 13.1% for multifidus, 21.8% for erector spinae, 24.8% for quadratus lumborum and 17.1% for psoas. There was significant difference (p<0.05) between sides (symptomatic and asymptomatic) in CSA of multifidus, erector spinae, quadratus lumborum and psoas. However, no statistically significant correlation was found between the duration of symptoms (average 15.5 months), patient’s pain

(average VAS 5.3) or disability (average ODI 25.2) and the relative muscle atrophy.

Conclusion:

In patients with long-standing unilateral back pain owing to monosegmental degenerative disc disease, selective multifidus, erector spinae, quadratus lumborum and psoas atrophy develops on the symptomatic side. Radiologists and clinicians should evaluate spinal muscle atrophy of patients with persistent unilateral back pain.

A Ploumis, N Michailidis, P Christodoulou, I Kalaitzoglou, G Gouvas and A Beris Department of Surgery, Division of Orhthopedics and Rehabilitation, University of Ioannina, Greece www Download the full length article: DOI: 10.1259/bjr/58136533

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www.bir.org.uk

The British Journal of Radiology Abstracts

Lymphocutaneous fistulas: pre-therapeutic evaluation by magnetic resonance lymphangiography Objectives:

Lymphocutaneous fistulas with intractable lymphatic leakage represent a serious clinical condition leading to a severe impairment of quality of life for the affected patients. To date, no adequate diagnostic imaging modality is in existence, to allow selection of the correct treatment option. The aim of this study was to perform a pre-therapeutic evaluation of the lymphatic system in patients with lymphocutaneous fistulas by magnetic resonance lymphangiography (MRL).

Methods:

Eight lower extremities in four patients with lymphocutaneous fistulas were examined by MRL. Three locations were examined: first, the lower leg and foot regions; second, the upper leg and

the knee region; and third, the pelvic and retroperitoneal regions. A T1 weighted three-dimensional (3D) spoiled gradient echo and a heavily T2 weighted 3D turbo spin echo (3D-TSE)sequence were utilised to undertake MRL.

(100%) suffered from an ipsilateral lymphoedema of the lower extremity, whereby in two patients with diffuse lymphangiomatosis, the lymphatic vessels were consecutively enlarged up to a diameter of 6 mm.

Conclusion:

Results:

In all four patients (100%), the clinically suspected lymphocutaneous fistulas (groin and forefoot) were exactly delineated by MRL. In two patients (50%) adjacent diffuse lymphangiomatous changes were detected, extending into the upper leg, pelvis, retroperitoneum, abdomen and abdominal walls. In one patient (25%) with primary lymphoedema of the right lower extremity, MRL revealed an aplasia of the lymphatic collectors at the levels of the lower and upper leg. All patients

MRL is a safe and accurate imaging modality for a comprehensive evaluation of the lymphatic system in patients suffering from lymphocutaneous fistulas.

C Lohrmann, E Foeldi, and M Langer Department of Radiology, University Hospital of Freiburg, Hugstetter Strasse 55, D-79106, Freiburg, Germany

www Download the full length article: DOI: 10.1259/bjr/14411627

Assessing the image quality of pelvic MR images acquired with a flat couch for radiotherapy treatment planning Objectives:

To improve the integration of MRI with radiotherapy treatment planning, our department fabricated a flat couch top for our MR scanner. Setting up using this couch top meant that the patients were physically higher up in the scanner, and, posteriorly, a gap was introduced between the patient and radiofrequency coil.

Methods:

Phantom measurements were performed to assess the quantitative impact on image quality. A phantom was set up with and without the flat couch insert in place, and measurements of image uniformity and signal to noise were made. To assess clinical impact, six patients with pelvic cancer were recruited and scanned on both couch types. The image quality of pairs of 32

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scans was assessed by two consultant radiologists.

Results:

The use of the flat couch insert led to a drop in image signal to noise of approximately 14%. Uniformity in the anteroposterior direction was affected most, with little change in right-toleft and feet-to-head directions. All six patients were successfully scanned on the flat couch, although one patient had to be positioned with their arms by their sides. The image quality scores showed no statistically significant change between scans with and without the flat couch in place.

Conclusion:

Although the quantitative performance of the coil is affected by the integration of a flat couch top, there is no discernible

deterioration of diagnostic image quality, as assessed by two consultant radiologists. Although the flat couch insert moved patients higher in the bore of the scanner, all patients in the study were successfully scanned.

M McJury, A Oâ&#x20AC;&#x2122;Neill, M Lawson, C McGrath, A Grey, W Page, and J M Regional Medical Physics Service, Northern Ireland Cancer Centre, Queenâ&#x20AC;&#x2122;s University, Belfast, Northern Ireland, UK

www Download the full length article: DOI: 10.1259/bjr/27295679

www.bir.org.uk

The British Journal of Radiology Abstracts

Personal dosimetry for interventional operators: when and how should monitoring be done?

Objectives:

Assessment of the potential doses to the hands and eyes for interventional radiologists and cardiologists can be difficult. A review of studies of doses to interventional operators reported in the literature has been undertaken.

Methods:

Distributions for staff dose to relevant parts of the body per unit dose–area product and for doses per procedure in cardiology have been analysed and mean, median and quartile values derived. The possibility of using these data to provide guidance for estimation of likely dose levels is considered.

Results:

Dose indicator values that could be used to

predict orders of magnitude of doses to the eye, thyroid and hands from interventional operator workloads have been derived, based on the third quartile values, from the distributions of dose results analysed.

Conclusion:

Dose estimates made in this way could be employed in risk assessments when reviewing protection and monitoring requirements. Data on the protection provided by different shielding and technique factors have also been reviewed to provide information for risk assessments.

Recommendations on the positions in which dosemeters are worn should also be included in risk assessments, as dose measurements from suboptimal dosemeter use can be misleading.

C J Martin Health Physics, Gartnavel Royal Hospital, Glasgow, UK

www Download the full length article: DOI: 10.1259/bjr/24828606

Analysis of regional radiotherapy dosimetry audit data and recommendations for future audits Objectives:

Regional interdepartmental dosimetry audits within the UK provide basic assurances of the dosimetric accuracy of radiotherapy treatments.

Methods:

This work reviews several years of audit results from the South East Central group including megavoltage (MV) and kilovoltage (KV) photons, electrons and iodine-125 seeds.

Results:

Apart from some minor systematic errors that were resolved, the results of all audits have been within protocol tolerances, confirming the longterm stability and agreement of basic radiation dosimetric parameters between centres in the audit region.

There is some evidence of improvement in radiation dosimetry with the adoption of newer codes of practice.

Conclusion:

The value of current audit methods and the limitations of peer-to-peer auditing is discussed, particularly the influence of the audit schedule on the results obtained, where no ‘‘gold standard’’ exists. Recommendations are made for future audits, including an essential requirement to maintain the monitoring of basic fundamental dosimetry, such as MV photon and electron output, but audits must also be developed to include new treatment technologies such as imageguided radiotherapy and address the most common sources of error in radiotherapy.

A Palmer, B Mzenda, J Kearton, and R Wills Medical Physics Department, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK

www Download the full length article: DOI: 10.1259/bjr/18691638

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NEWS 33

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BIR NEWS

CEO Report Last summer we asked you, our members, what the most important objective for the British Institute of Radiology (BIR) should be. Your response was to provide education in a CPD-accredited format that is accessible either centrally, locally or online.

You requested scientific meetings covering “hot” topics and updates relevant to radiology, and were keen that these should offer valid CPD. You also requested that CPD should be accessible online, including podcasts with assessments or quizzes in the British Journal of Radiology or Imaging.

While respondents showed little interest in visiting the library in person, there was considerable support for it to offer information services online to support education and research, and to continue to offer search and enquiry services.

As a result, one of the key objectives of our new strategy is: “To deliver an educational programme to meet the professional training and CPD requirements of members in a modern and accessible format, including a strong regional presence through the BIR branches”.

Our first action was to set up an Education Committee chaired by Andrew Jones, the BIR’s vice-President, to map the BIR’s programme against relevant curricula, CPD requirements and the opportunities offered by sister organisations. This will help to identify where the organisation could fill niche gaps across its multidisciplinary strengths. We will look to complement rather than compete and, where appropriate, collaborate with organisations, such as professional bodies and industry partners in educational delivery.

We will also aim to revise the format of our programmes by incorporating the use of new technologies and educational methodologies to provide a more interactive experience for participants, such as hands-on workshops, and enhance these with a “knowledge hub” comprised of online tools, best practice advice and guidance, and other relevant material via podcasts, special-interest discussion groups, image and case study libraries and assessment opportunities. The aim is to deliver a generic “core” programme of events that

can be rolled out across the country and will be complemented by niche “thought leader” events on hot topics to respond to the need of rapidly developing areas in radiological science. We will also continue to run larger, more extensive events, such as the annual President’s conference.

All of this will take time and key to its success is a more “joined up” approach within the BIR. As a result, we have reorganised our team with a new education manager, soon to take up post, assisted by an events coordinator and assistant. The library’s information specialist will also be integrated into the team to ensure that best use is made of the library’s resources by embedding them as a key element of the educational offer, both in terms of providing additional supplementary information to enhance a participant’s learning experience and to deliver CPD resources online.

We welcome any comments from our members. Please watch out for the announcement of an online discussion forum in the near future.

Jacqueline Fowler, Chief Executive, BIR

issue 4 august 2011

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BIR Company Subscribers 4 Ways Healthcare

Matchtech Group Plc

Tel: 01442 260 322. Contact Dr Sanjiv Agarwal, CEO.

Tel: 01489 898 989. Contact Mr Darren Compton, Manager.

Accuray

Medica Group

Tel: 00 133 155 232 020. Contact Ms Sancie Nakarat, Marketing Communications Manager.

Agfa HealthCare UK Ltd Tel: 02082 314 900. Contact Grant Witheridge, Managing Director UK & Ireland.

Bayer Schering Pharma Tel: 01444 465 864. Contact Mr Nick Laughland, Senior Product Manager, Diagnostic Imaging.

Bracco UK Ltd Tel: 01628 8518 500. Contact Mr Bill Pelling, Managing Director.

Carestream Health UK Ltd Tel: 01442 844 473. Contact Mr Charles McCafrey, Marketing Manager UK and Ireland.

Cobalt Appeal Fund Tel: 01242 535 910. Contact Mrs N Sykes.

Covidien UK Commercial Ltd Tel: 01329 224 159. Contact Mrs Susy Matthews, Marketing Manager.

Envirotect Ltd Tel: 01525 374 374. Contact Mr Ian Burtenshaw, Product Manager (International Division) Contrast Media.

Fujifilm UK Ltd Tel: 01234 572 229. Contact Mr Mark van Rossum, General Manager â&#x20AC;&#x201C; Medical Systems.

GE Medical Systems Medical Diagnostics

Tel: 08450 569 750. Contact Mr D Turner, Marketing Manager.

NHS Innovations Tel: 01722 326 006. Contact Mrs D Postlewhaite, Marketing and Communications Lead.

Nucletron UK Ltd Tel: 01829 771 111. Contact Mr J Banks, Managing Director.

Oncology Systems Ltd Tel: 01743 462 694. Contact Mrs Tammy Cole, Office Manager.

Philips Healthcare Tel: 01737 230 418. Contact Ms Andrea Sheargold, Marketing Communications Manager.

PTW-UK LTD Tel: 01476 577 503. Contact Mr Stephen Bellchambers.

Qados Tel: 01252 878 999. Contact Ms Dawn Broadhead, Sales Director.

Sectra Ltd Tel: 01276 696 317. Contact Mr Chris Briggs, Commercial Manager - PACS and RIS.

Siemens Medical Solutions Tel: 01276 696 317. Contact Mr Mike Bell, Marketing Exhibitions and Advertising.

Southern Scientific Ltd Tel: 01903 604 000. Contact Mr Stephen Adams, Sales Manager.

Toshiba Medical Systems UK Tel: 01293 653 700. Contact Mr S M Weeden, Manager X-ray Products.

Tel: 01494 542 778. Contact Mr D G Rothery, Marketing Manager, Contrast Media.

Varian Medical Systems (UK) Limited

IBA Molecular UK Ltd

Vertec Scientific Ltd

Tel: 07887 644 672. Contact Mr Michael Yon, Managing Director.

Tel: 01734 817 431. Contact Mr B Hipgrave, Managing Director.

Imaging Equipment

Tel: 02083 989 911. Contact Mr R Beach, UK Sales Manager.

Tel: 01761 415 570. Contact Mr Nicholas Stevens, Managing Director.

Infinitt UK Ltd Tel: 01344 312 100. Contact Mr Graeme Russell, Managing Director.

Insignia Medical Systems Tel: 01420 540 206. Contact Mr R Dormer, Managing Director.

Landauer Europe Tel: 01865 373 008 Contact Miss I Florelli.

Tel: 01293 601 324. Contact Mr Mike Poll or Mr David Scott.

Wardray Premise Ltd Xograph Healthcare Ltd Tel: 01666 501 501. Contact Mr Paul Andrews, Commercial Manager.

Zonare Medical Systems Tel: 08448 711 811. Contact Mr D J Thomas, Managing Director.

If you would like to find out more about the benefits of becoming a BIR Company Subscriber please visit: www.bir.org.uk/bir-join-us-home/corporate

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BIR news

Airport body scanners are safe for public and aircrew Airport body scanners are safe, and the public should be informed and reassured regarding their use. Those are the findings in a report, Airport Security Scanners & Ionising Radiation, from a working group of The Royal College of Radiologists (RCR) and the British Institute of Radiology (BIR).

The group reviewed the published literature on the two types of body scanner currently being tested in the UK and abroad: • the backscatter X-ray scanner is the system currently being appraised in the UK; this emits very low levels of ionising radiation. The group observed that the average dose from a single scan is 100,000 times lower than the average annual dose of radiation a person receives from natural background radiation and medical sources.

• the millimetre wave scanner; this uses radiowave frequencies rather than ionising radiation and is currently being trialled at some airports in France. Both systems are in use in the United States.

Dr Peter Riley, a Consultant Radiologist and Chair of the Working Group and the BIR’s Radiation Protection Committee, said, “All available data suggests that the radiation doses for air travellers and aircrew from airport

Airport scanners provide a lower radiation dose than the annual average a person receives from natural background radiation and medical sources. Picture: Shutterstock

scanners are tiny. Such doses are only a small fraction of the exposure those same travellers will receive from cosmic radiation as they fly at 30,000 feet. In medicine, the small risk to health from diagnostic doses of radiation is offset by the quantifiable benefits of early diagnosis and treatment; in the airport context, the benefit is one of higher travel security.”

All available data suggests that the radiation doses for air travellers and aircrew from airport scanners are tiny

Dr Tony Nicholson, Dean of the RCR’s Faculty of Clinical Radiology said, “Both passengers, and airport and airline workers, have the right to be informed about the levels of radiation they are exposed to. However, they should be reassured that these levels are very low indeed, and are well regulated in the UK, being subject to the Ionising Radiation Regulations 1999, enforced by the Health and Safety Executive.”

For a copy of the report, Airport Security Scanners & Ionising Radiation: Report of BIR Short Life Working Group, please visit the BIR website: www.bir. org.uk/bir-online-news-home/pressreleases.aspx issue 4 august 2011

NEWS 37

www.bir.org.uk

bir news

Annual scientific meeting of the Welsh Branch The annual scientific meeting of the Welsh Branch of the British Institute Radiology (BIR) will take place on the 13th and 14th of October 2011. The meeting will be held at the post graduate department of the Princess of Wales Hospital, Bridgend.

The topics will be of interest to radiologists, radiographers, physicists, clinicians and allied health professionals. There will be an opportunity to participate in the annual golf match on the morning of the 13th October. In the afternoon the programme will consist of trainee presentations, which are open to Radiology, Radiographer and Physicist trainees. We are also hoping to have our first Welsh BIR Trainee poster presentation section.

On the morning of the 14th the meeting is divided into three sections with the opportunity for discussion after each section: Cardiac imaging (Dr Andrew Wood,

Princess of Wales Hospital, Bridgend

Radiologist Cardiff and Dr Nav Masani, Cardiologist Cardiff); 3T magnetic resonance imaging (Dr John Evans, Physicist Cardiff and Mrs Sian Roberts, Radiographer Swansea); and radiology in national screening programmes (Dr Gareth Davies, Radiologist AAA screening Wales and Dr Gareth Tudor,

BRANCH

NETWORK The BIR has a regional network of branches throughout the UK. Regional branches offer BIR members and professionals within the radiological community local educational meetings and networking opportunities.

Radiologist Bowel screening Wales).

Delegates attending the meeting will hopefully gain information regarding the current techniques in cardiac imaging, the advantages of 3T MR imaging and the current status of radiology within some of the national screening programmes.

East of England CHaIR: dR tEIk CHoon, CambRIdgE UnIvERsIty HospItals foUndatIon tRUst

noRtH of England CHaIR: dR klaUs IRIon, lIvERpool HEaRt & CHEst HospItal

sCotland CHaIR: dR andREw pEaRson, boRdERs gEnERal HospItal

soUtH wEst England CHaIR: nIky sykEs, Colbalt appEal fUnd

walEs CHaIR: dR gaREtH tUdoR, pRInCEss of walEs HospItal

For more information about our branch network please visit

branches@bir.org.uk 38

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wEssEx CHaIR: dR katIE joHnson, salIsbURy dIstRICt HospItal

Developments in Treatment of Head & Neck Cancer with Chemotherapy, Biological Agents and Radiotherapy 7 October 2011 BIR, London

CALL FOR PAPERS

Invited speakers Professor Jean Bourhis (France), Professor J B Vermorken (Belguim), Professor Michelle Saunders, Dr H Yosef (BOC, Glasgow), Dr Werner Dobrowsky (Newcastle), Dr Andrew Sykes (Christie Hospital), Dr Lisa Licitra (Milan), Dr Chris Nutting (London), Dr Charles Kelly (Newcastle), Professor Vincent Gregoire (Brussels), Dr Kevin Harrington (London)

AD

Presentations are invited on the following topics: •Biology of combined chemotherapy & radiotherapy/radiosensitisers •Combined chemotherapy, biological agents & radiotherapy for nasopharynx, oropharynx, oral cavity and for laryngeal preservation •Place of neo-adjuvant chemotherapy and post-op chemo/radiotherapy •Benefit of IMRT in combined chemo/radiotherapy •Re-treatment with chemo-radiotherapy Please send abstracts to Dr H Yosef, Beatson West of Scotland Cancer Centre, Gartnavel General Hospital, Glasgow G12 0YN (electronic submission preferred) Fax +44 (0)141 301 7124 or email vicky.law2@ggc.scot.nhs.uk Abstract deadline: 31 August 2011 Proffered speakers will have free registration for the meeting

For more information and to register for this event please visit www.bir.org.uk

In-vivo Dosimetry and Dose Guided Radiotherapy 8-9 December 2011 | BIR, London For more information and to register for this event please visit www.bir.org.uk

The complexity of radiotherapy treatment planning and delivery has increased in the last 10 years. In an attempt to improve the quality assurance of treatment delivery In-vivo Dosimetry has been recommended by both Towards Safer Radiotherapy and the Chief Medical Officer in 2006. However, how to implement this effectively and efficiently still remains a challenge. This 2-day meeting explores this topic at length. Day 1 covers the rationale of in-vivo dosimetry and methods of EPID dosimetry that are being explored. There will also be an opportunity for departments to present their experience. Day 2 will focus on dose guided techniques and potential improvement in outcome will be discussed. The topic is current and relevant to all departments and will include national and international expert speakers.

CALL FOR PAPERS! We are looking for abstracts for proffered presentations relating to any of the topics listed in the programme and welcome all applicants. Please ensure your abstract is submitted as a word document and limited to 250 words.

Please send your abstract to ruth.warne@bir.org.uk by 12 September 2011. Presentation time should not exceed 15 minutes.

Thursday, 8 December 09:00 Registration & Refreshments 09.20 Welcome INTRODUCTION 09:30 Background and Update Una Oâ&#x20AC;&#x2122;Doherty, Health Protection Agency 10:00 Review of Methods of EPID Speaker TBC 10.30 Review of Errors Detected by Diodes Geri Briggs, Berkshire Cancer Centre 11:00 Refreshments METHODS OF EPID DOSIMETRY 11.15 EPID Dosimetry - With Elekta Equipment Vibeke Nordmark Hansen, Royal Marsden Hospital 11:45 EPID Dosimetry - With Siemens Equipment Speaker TBC 12.15 EPID Dosimetry - With OSL Equipment Speaker TBC 12.45 EPID Dosimetry - With Varian Equipment Speaker TBC 13:15 Discussion 13.30 Lunch and Exhibition PROFFERED PAPERS 14:15 Calibration of EPID Detector for Dosimetry Julia Pearce, National Physics Laboratory 14:45 Proffered Papers 15:30 Refreshments 15:45 Registration/Non Rigid Registration Gerry Hanna, Northern Ireland Cancer Centre 16:15 Dose Painting Chris South, Royal Marsden NHS Foundation Trust 16:45 New Department Approach Martin Cooling, Peterborough and Stamford Hospitals NHS Trust 17:15 Discussion and Close

Friday, 9 December DOSE GUIDED AND ADAPTIVE RADIOTHERAPY 09:15 Clinical Overview - The Potential of Adaptive RT Speaker TBC 09:45 Implementation/Technical: Dosimetry Consequences of Adaptive Radiotherapy David Nicholas, Cromwell Hospital 10:15 Discussion 10.30 Refreshments 11:00 Tools For Adaptive RT Raj Jena, Addenbrookes Hospital 11:30 Adaptive Radiotherapy Clinically Julie Stratford, Christie Hospital 12:00 Head and Neck Russell Moule, Mount Vernon Hospital 12:30 Bladder Fiona McDonald, Royal Marsden Hospital 13:00 Lunch and Exhibition

SYLVANUS THOMPSON MEMORIAL LECTURE 14:00

Reflections on the Safety of Radiotherapy Equipment: Have Linacs Become Computer Peripherals?

Hamish Porter, Radiation Physics Consultant, Edinburgh and London

PROFERRED PAPERS 14:45 Proffered Papers 15:30 Refreshments 16:00 Adaptive Radiotherapy in Lung Cancer Patients Carsten Brink, Odense University Hospital 16:45 Discussion 17:00 Evaluation and Close RCR CPD Credits have been applied for

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bir news

GE Fellowship travel awards 2011

Kiran Reddy receiving his award from BIR President Dr Stephen Davies

GE Healthcare have generously funded two fellowship awards. The first award is intended to sponsor a visit to one or more centres abroad. It is hoped that the recipient of the award will learn a technique not currently available in the UK and then be in a position to bring back and share the expertise. The second is an award for students and is a prize of up to ÂŁ500 to support an elective

abroad containing a significant radiology/nuclear medicine component.

The GE Medical Diagnostics Fellowship Award for 2011 was awarded to Owen Arthurs. Owen is a trainee academic paediatric radiologist at the University of Cambridge. He will be attending the Hospital Robert-Debre in Paris to learn about foetal body and placental MRI, which has not yet been

This yearâ&#x20AC;&#x2122;s programme focuses on the clinical role of new imaging techniques in patients with cancer

Owen Arthurs, who was unable to attend the conference, was awarded the GE Medical Diagnostic Fellowship Award

established in the UK. Kiran Reddy, a fourth year medical student at Kings College, was awarded the GE Healthcare Medical Student Bursary for 2011. Kiran will be studying the latest developments in the fields of Diagnostic and Interventional Radiology during a 4 week placement at Yale University and a second at Virginia Commonwealth University.

Congratulations to both and thanks to GE Healthcare for their generous sponsorship.

Would you like to contribute to BJR News?

E-mail us at: publications@bir.org.uk or tweet us @BJRNews issue 4 august 2011

NEWS 41

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bir news

New BBC series explores diverse use of imaging technology in Britain

The prize this month is your choice of book from the current list on the BIR’s online bookshop To win just read through the magazine carefully and reply to the following question: What is the next conference topic?

President’s

Send your answer along with your name and contact details to: publications@bir.org.uk by 15 September 2011.

Sudoku Image courtesy of Hugh Turvey

Mentorn Media, an award winning factual television production company, is developing a new series idea with the BBC. The series will explore, in the broadest sense, the diverse use of imaging technology being used in Britain today, so this will include material science and engineering, as well as medical imaging. The series will effectively explore and celebrate what has been achieved since the discovery of X-rays.

The programme makers’ plan is to meet people from around the country working in areas as diverse as research at Diamond to flaw detection in oil rigs and the MRI of thought processes in the brain.

As part of the series the programme makers will work in partnership with the imaging community to build visual sequences that demonstrate the work they are doing and why it is relevant 42

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to the viewers. For example animating time series of images to make video sequences of processes and events, or combining a number of technologies together i.e. a laser scan of a building could be used in conjunction with thermal imaging of people.

Mentorn Media are already working with the British Institute of Radiology’s artist in residence, Hugh Turvey, but would like to hear from anyone whose work impacts on the public in an unknown or innovative way. They would want to ensure their research is comprehensive so would like readers of BJR News to help bring them up-to-date with the latest news. Additionally, ideas from readers about how the images they work with could be developed into video sequences would be welcome.

Please contact Bcherrington@Mentorn. tv if you would like more information on the project.

Logic-based, combination number placement puzzle. The objective is to fill a 9×9 grid so that each column, each row and each of the nine 3×3 boxes (also called blocks or regions) contain the digits from 1 to 9 only once.

Completed puzzles are usually a type of Latin square with an additional constraint on the contents of individual regions. Leonhard Euler is sometimes incorrectly cited as the source of the puzzle, based on his related work with Latin squares.

Sudoku from www.puzzlechoice.com

www.bir.org.uk

A Page of History

Historical places: Royal Victoria Hospital, Netley As humans have developed increasingly sophisticated weapons for warfare, medicine has had to adapt to cope with the volume and the changing nature of the injuries.

The Royal Victoria Hospital was located at Netley near Southampton (from 1856-1978). In an article about Netley Hospital from 1897 it was noted that “the developments, of late years, in artillery and infantry fire increase the proportion of the wounded”. Of interest to us is that in May 1896 there was a demonstration by Sidney Rowland (the editor of what later became the British Journal of Radiology) to Surgeon-Lieutenant-Colonel William F Stevenson of a case of complex tibial plateau fracture. The journalist William Dick observed that: “of the scientific attainments brought to bear in treating the wounded here, I had an opportunity to

form a judgement from personal observations. Colonel Stevenson and Major Dick, professors of surgery at the school, were engaged in experiments with the latest appliances for locating bullets by Röntgen rays...What bungling and haphazard all former methods seem to be by comparison with this!”

By mid-1898 X-ray sets were either being operated or installed at military hospitals in Netley, Aldershot, Dublin, Woolwich (The Royal Herbert) and Gibraltar. Also of interest is that in 1903 the British Army Medical School at Royal Victoria Hospital Netley offered “a course of X-ray instruction” and this was the first school of radiography in the world. In 1910 William F Stevenson wrote that “there is, of course, no question as to the necessity of X-ray apparatus and an officer qualified in its

Royal Victorial Hospital chapel, Netley

use being supplied to all general and stationary hospitals in war”. All that is left of the Royal Victoria Hospital is the chapel, which contains a museum. It is well worth a visit; however, the pioneer radiology history is sadly not mentioned. r Adrian Thomas BSc FRCP FRCR FBIR D Honorary Librarian, BIR

Classic radiology books: Wounds of War: The mechanism of production and their treatment This fascinating book by Surgeon-General William Flack Stevenson went through many editions and was the standard textbook for military surgery of its time. The later editions, including the third edition in 1910, are profusely illustrated with radiographs (and shown as positives as was the fashion of the time). Stevenson was Professor of Clinical and Military Medicine at the Royal Army Medical School. The book included a section of the localisation of foreign bodies

by Sir James Mackenzie Davidson (Rontgen Society President 1912-13).

Following the demonstration of Röntgen Rays by Sidney Rowland to him in May 1896, Stevenson became an enthusiast and promoted radiography. Stevenson was the Principal Medical Officer for British Forces during the Boer War and he ensured that general hospitals had X-ray apparatus as part of their essential equipment. His book has

detailed information on radiography and its use in military surgery. There is an account of the weapons used, the mechanism of injuries and the treatments needed. The book is a good example of clinical-radiologicalpathological correlation. He demonstrated the different injuries caused by the various weapons and the resulting radiographic features. He was also as concerned with cost as we are. He notes that X-ray tubes cost from 18s 6d (92.5p) to £5. He felt that there was little to choose between the cheap and expensive tubes and that it was better to buy five cheap tubes than one expensive tube!

It is always salutary to read these old books. We can imagine that we live in particularly difficult times; however, we can be encouraged by seeing that the past is not rosy as some depict it. Our predecessors solved their problems and we will hopefully solve ours.

r Adrian Thomas BSc FRCP FRCR FBIR D Honorary Librarian, BIR

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My column this month will find some members earning a well deserved summer holiday. The needs and opportunities for members are changing and the British Institute of Radiology (BIR) needs to move with both our existing and potential members.

The National Health Service (NHS) has become more diverse and is undergoing a continual reform. Our members’ values are changing; there is an increased emphasis on work-life balance and increasing difficulty in obtaining time and funding to attend the Institute. Yet the demand for information and education continues to grow. The wider community and the public require authoritative scientific advice. An important component of the BIR membership is the corporate sector and its needs are changing as the procurement landscape in the NHS has changed. The BIR recognises its leading role in providing scientific advice to the wider community.

The BIR is the oldest radiology society in the world and there is a strong association with the radiology historical archive in the UK. The BIR continues to have a major role in the publication of scientific material.

However, the Institute must modernise the way in which it delivers its objectives. It must recognise the changing needs of its members and stakeholders and embrace

president’s column

modern methods of working and delivering education and scientific advice in both the spoken and written word. The BIR must operate on a sound financial basis and be fully compliant with charity law.

With this background in mind, the Institute has developed a strategy to modernise the organisation and deliver a structure that is relevant, fit for purpose, proactive and technologically-advanced for current and future members, particularly the younger community.

Council Trustees approved a strategy for 2011-2016 in April. The full summary is on the BIR website. The key themes are as follows: the multidisciplinary membership of the BIR should be strengthened including the revitalisation of company membership; the education strategy is key to the future of the BIR and it is discussed further in the Chief Executive Officer’s column; the publications department introduced a new strategy in 2009 and this was re-affirmed with a commitment to develop British Journal of Radiology, BJR News and Imaging; information and communication technology will be modernised to communicate with members and the public. We recognise the limitations that the modern NHS places on members and will design our ICT strategy with this in mind.

Finally, the BIR and its needs have changed since it first occupied 36 Portland Place in the 1970s and it will continue to evolve as it realises its new strategy. This will place less dependence upon a facility for meetings and lectures and more upon a workplace that facilitates modern methods of working and communication with its membership. A detailed review of the premises and financial governance associated with the premises was commissioned

by Council. It has Trustee, management and external representation. The progress will be reported to members.

The new strategy and reduced external events contracts have necessitated a restructuring of staff at the BIR. This has and will in the next year mean that there are number of sad farewells to some of the staff at the BIR. On a different note to end, I thought that I would let you know about my 2012 President’s conference “CT in clinical practice – past present and future – a tribute to Godfrey Hounsfield”. This will reflect the role of CT in modern clinical practice and also develop future perspectives and will be held in London on April 25-26 2012.

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www.bir.org.uk

Obituary

William Mackie Ross - past President of the British Institute of Radiology William Mackie Ross, known to family and colleagues as Bill, has died after a short illness, at the age of 88. He was a leading figure in the medical profession, particularly in his speciality of radiotherapy.

Bill, the eldest child of Harry and

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Kate Ross, was born in Glasgow on 14th December 1922. Part of his childhood was spent at the clubhouse of what is now Mount Oswald Golf Club in Durham, where Harry was the resident professional.

After achieving high grades at the Durham Johnston School, Bill won a

state scholarship to study medicine at Kingâ&#x20AC;&#x2122;s College, University of Durham, graduating with MB, BS in 1945.

Following a short period as House Surgeon, he became Registrar in radiotherapy at Shotley Bridge Hospital in 1947. By 1949 he was Senior Registrar and in 1953 was appointed Consultant to Newcastle Regional Hospital Board, becoming Consultant in Charge in 1973, where he remained until his retirement in 1987. Simultaneously, Bill held the posts of Honorary Lecturer in Radiotherapy and Head of the Department of Radiotherapy at the University of Newcastle-upon-Tyne.

Bill led an active military life. His National Service began in 1951 in the Royal Army Medical Corps, when he was specialist in radiology to the British troops in Austria. This was followed by over 20 years of voluntary service in the Territorial Army (RAMC), as senior specialist in radiology. He retired in the rank of Colonel, having commanded 201 (N) General Hospital. Bill received the Territorial Decoration (TD) in 1968 and became Deputy Lieutenant (DL) for Northumberland (later Tyne and Wear) in 1974.

In addition to his full schedule of clinical work across the north-east, Bill held office in many professional bodies.

He was a Fellow of both the Royal College of Surgeons and the Royal College of Radiologists (RCR), and was made an Honorary Fellow of the American College of Radiology and the Royal College of Surgeons (Edinburgh).

During his 40 year association in the regional radiotherapy service, Billâ&#x20AC;&#x2122;s interest was in ensuring the delivery of an effective service from the Newcastle centre to all patients in the region.

One important aspect was that patients

www.bir.org.uk

William Ross with his wife Mary after receiving his CBE

and colleagues in peripheral districts received attention equal to those in the teaching centre. As it became apparent that it was impracticable to provide a

obituary

for consultants working away from Newcastle. In addition, consultation with other hospital colleagues was increased over the years with the establishment in every district general hospital of a regular radiotherapy consultative clinic open to referrals from both consultants and general practitioner.

From the earliest post-war days, the service, although nominally a “radiotherapy service”, was increasingly involved in the medical (chemotherapeutic and supportive) aspects of the care of patients with cancer, as well as maintaining close contact with surgical practice. Such a region-wide and multidisciplinary service is now accepted as essential for best practice of clinical oncology. On a technical level, Bill was involved in the initial evaluation of the linear accelerator as therapy equipment; one of the first such machines purchased by the Government in around 1951 was sited in Newcastle.

Subsequently he was concerned with its comparison with telecobalt apparatus, the design of a treatment simulator and in the development of intracavity forms of radiotherapy. He undertook a large series of pituitary implantations for acromegaly and other pituitary lesions between 1960 and 1980.

During his 40 year association in the regional radiotherapy service, Bill’s interest was in ensuring the delivery of an effective service from the Newcastle centre to all patients in the region proper service, for the whole region, from Newcastle, Bill was instrumental in developing units in Cleveland and Cumbria, which served the local population for the majority of treatments but retained links with the regional centre for more sophisticated procedures, and he gave clinical sessions at the centre

Throughout his clinical career, Bill was involved in clinical trials, some locally based, but many were multicentre national studies. Examples include the Kings Cambridge Breast Trial (where he served on the working party from inception), the National Lymphoma Investigation and the Treat-

ment of Children with Nephroblastoma and Neuroblastoma.

For the North of England Cancer Campaign, Bill was concerned with the assessment of project applications, and in particular the steps which led to the formation of the Oncology Centre at the Newcastle General Hospital, and the £1 million endowment, which resulted in the establishment of the NECRC Cancer Research Unit.

During his Vice-Presidency (196970) at the RCR, Bill stimulated discussion that resulted in a place in the College for Nuclear Medicine and later in the Intercollegiate Committee on Nuclear Medicine. He was examiner for the RCR final examination, including in Australasia and the Far East, and as President (1983-86) he initiated discussions that led to the formation of the Joint Council for Clinical Oncology.

Bill has also held office as President, British Institute of Radiology (197879); President, Section of Radiology, Royal Society of Medicine (1979-80); and President, Section of Radiotherapy, European Association of Radiology (1985-89). In addition he served on other committees and working parties, from local to international levels.

He had over 50 papers published in the medical press, in addition to the chapters he contributed to books.

He also gave nine invited lectures at symposia and congresses.

When not engaged in his medical work or TA activities, Bill enjoyed car rallying, taking part as navigator in both local and national events, notably the RAC Rally of Great Britain.

In 1987 he was appointed a CBE for services to Medicine, and he has been listed in “Who’s Who” and “People of Today”.

Bill was married to Mary Burt in 1948, and they celebrated their Diamond Wedding in April 2008. Mary died later that year. Bill died on 15th March 2011. He will be sadly missed by his daughters Heather and Hilary, his son Duncan and his five grandchildren. issue 4 august 2011

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www.bir.org.uk

LEtter to the editors/book review

letter to the editors

A curious exception to publishing positives Dear Editors, Classic radiology books

I was interested to read Adrian Thomas’s column on British authors in BJR News (Issue 2).

He did not mention that it was an unusual publication, in that the images were always published as “positives”, but with one curious exception in the fourth edition. The chapter on small bowel imaging was written by W G

Scott-Harden, a very eminent radiologist from Carlisle, under who I had the pleasure and privilege to study for a short period as a trainee.

He was honoured to be asked to write the chapter on the small bowel, but was very annoyed to be informed by the publishers that his images would be published as positives just like anyone else. Geoffrey was furious about this and so submitted all his images as positives himself. The publishers then inverted

them. Hence they appeared as negatives in this one chapter of the fourth edition, much to Geoffrey’s glee.

Keep up the good work.

Robert H. Corbett Consultant Radiologist (Retired)

Let us know what you think publications@bir.org.uk

book review

Diagnosis of Breast Diseases

By Volker Barth ISBN: 978-3-1314-3831-7 Thieme Medical Publishers, Stuttgart ̶ New York

This work represents a synthesis of a very impressive atlas and an excellent contemporary textbook. It explains how important it is to know all the diagnostic possibilities in the breast, not only mammography. The editor and main author Professor Volker Barth is quite right when he says that “the early detection of breast cancer can be effective only when the three pillars – clinical investigation, mammography and ultrasound – are united within a structured, quality-assured program”.

Following an extensive introduction, section 2 discusses tumour biology including causes, growth factors, endocrine influences, hormone replacement, therapy in menopause and predisposing genetic factors. Section 3 focuses on prognostic factors: growth rate, tumour size, lymph node involvement and prognosis. Section 4 provides information on macroanatomy, histology, radiography

and ultrasound. In the fifth section under the title “Early Detection and Appropriate Treatment” are the topics diagnostic options, possibilities and limitations of complementary investigation and therapy.

In this section the reader will find chapters on physical examination, mammography (technical aspects, BIRADS classification and grading of breast cancer, digital mammography, future trends, double reading, case presentation and screening), ultrasound (technique, schematic protocol, basic structures of the breast and their variants on ultrasound with mammographic correlation), MRI and positron emission tomography. There are special chapters dealing with neoplasms in younger women, changes during pregnancy and lactation, the male breast as well as text reviewing therapy and perioperative management, sentinel lymph node biopsy, treatment related reactions, complications and errors, post-operative changes and follow-up.

The book is based on an excellent knowledge of the problems and the author’s own experience. The level of scientific

content is high. All the latest developments are presented and discussed. Other important features are the precise clinicopathological correlations, the principles of best practice and the cultivation of clinical understanding of the patient. Particularly useful is the presentation of cases demonstrating difficulties and pitfalls in breast diagnosis as well as the possibility of self-testing.

The structure of the book is coherent and balanced. The text is concise and clearly written throughout. There are more than 1500 illustrations, many of them in colour, including clinical, histological, cytological and other photographs; ultrasound images and mammograms, which are overall of high quality. Well selected literary references are given at the end of the work. An extensive index helps the reader to find information quickly. The layout style is elegant and the printing quality is superb.

I believe that this outstanding modern book will be highly valued by radiologists, oncologists, surgeons and other specialists.

L Diankov www

Download the full book review bjr.birjournals.org

BJR News is now on twitter.

Follow us: @BJRNews 48

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issue 4 august 2011

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