THE NEWS MAGAZINE FROM THE BRITISH INSTITUTE OF RADIOLOGY
december 2011 www.bir.org.uk
The year of radiotherapy, “big society” and the elephant in the room The practical application of the UK 5-point scoring system for breast imaging Call for BIR committee members Graham Bydder: The Agfa Mayneord lecture
British Institute of Radiology begins work on a new history project ISSN 2044-5113
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b o o k s
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10% discount for BJr readers High-field MR Imaging Hennig, Jurgen; Speck, Oliver; Describes the current status of high-field MR and examines the possibilities, challenges, and limitations of this fascinating technology. £162.00 • August 2011 • ISBN 9783540850878
Pattern Recognition Neuroradiology: Brain and Spine Borden, Neil M.; Forseen, Scott E. This user-friendly book provides the tools to arrive at the correct diagnosis or a reasonable differential diagnosis. £50.00 • August 2011 • ISBN 9780521727037
Primer of Diagnotic Imaging Weissleder; Ralph, Wittenberg; Jack, Harisinghani; Mukesh G., Chen; John With Expert Consult online access. £85.04 • September 2011 • ISBN 9780323065382
Duke Radiology Case Review: Imaging, Differential Diagnosis, and Discussion Provenzale, James M.; Nelson, Rendon C.; Vinson, Emily This second edition includes chapters on interventional radiology and nuclear medicine and much more. £89.00 • November 2011 • ISBN 9780781778602
Radiology On-Call: A Case-Based Manual Talanow, Roland This annotated edition includes CT, MRI, nuclear medicine and ultrasound images that accelerate on-the-spot clinical decision making. £58.99 • November 2011 • ISBN 9780071637978
Women’s Health in Interventional Radiology Ignacio, Elizabeth; Venbrux, Anthony C. This is a concise, clinical guide to interventional procedures impacting upon women’s health. £40.99 • December 2011 • ISBN 9781441958754
Skeletal Development of the Hand and Wrist: A Radiographic Atlas and Digital Bone Age Companion Gaskin, Cree M.; Kahn, S. Lowell; Bertozzi, J. Christoper; Bunch, Paul M. The Digital Bone Age Companion packaged with the book is a computer program that facilitates viewing of the atlas images in digital format. £132.00 • August 2011 • ISBN 9780199782055
Radiation Exposure and Image Quality in X-Ray Diagnostic Radiology Aichinger, Horst; Dierker, Joachim; Joite-Barfuss, Sigrid; Sabel, Manfred A complementary CD-ROM contains an Excel file database covering tables of data and graphical depictions of X-ray spectra, interaction coefficients, characteristics of X-ray beams, and other aspects relevant to patient dose calculations that can be used in the reader’s own programs. £91.80 • September 2011 • ISBN 9783642112409
Neuroradiology Companion: Methods, Guidelines, and Imaging Fundamentals Castillo, Mauricio This fourth edition provides an overview of neuroradiology and discusses the most important and common disorders of the brain, spine and head and neck regions. £59.00 • September 2011 • ISBN 9781451111750
Functional Neuroradiology Faro, Scott H.; Mohamed, Feroze B.; Law, Meng; Ulmer, John
Applied Radiological Anatomy Butler, Paul; Mitchell, Adam; Healy, Jeremiah C
An overview of functional imaging modalities and techniques used in patient diagnosis and management.
An expanded new, full colour edition, every illustration has been replaced, providing the most accurate and up-to-date radiographic scans available.
£174.42 • August 2011 • ISBN 9781441903433
£125.00 • November 2011 • ISBN 9780521766661
Radiological Imaging of the Neonatal Chest Donoghue, Veronica B. This brilliantly illustrated second edition includes an update on clinical management and appraises the various techniques available to image the newborn chest. £135.00 • September 2011 • ISBN 9783642070303
Comprehensive Radiographic Pathology Eisenberg, Ronald L.; Johnson, Nancy M. The new fifth edition provides the essential pathology knowledge needed to produce quality radiographic images. £56.99 • November 2011 • ISBN 9780323078474
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To claim your discount, enter the promo code ‘BJR’ at the checkout. Discount applies to all books on our website. For titles not yet published, your credit card will not be charged until the books are despatched. You may also order by phone: +44 (0)20 8715 1812 or email: bookshop@wisepress.com
Diagnostic Imaging of the Head and Neck: MRI with CT & PET Correlations Hasso, Anton N. Clinically oriented text, readers will find key diseases highlighted and a guide to differential diagnosis of various conditions. £95.00 • November 2011 • ISBN 9780397515370
Positron Emission Tomography Granov; Anatoliy, Tiutin; Leonid, Explains the physical and biochemical basis for PET and covers topics like instrumentation, image reconstruction, and radiopharmaceuticals production. £108.00 • October 2011 • ISBN 9783642211195
Final FRCR 2B Viva: A Survival Guide Tan, Kiat Tsong; Curtis, John; Aw, Jessie Presents a series of cases similar to those used in the FRCR exams. £35.00 • October 2011 • ISBN 9780521183079
Long Cases for the Final FRCR 2B Hanlon, Rebecca; Curtis, John; Wieshmann, Hulya; White, David; Landes, Caren; Gough, Val Revision guide containing 42 cases formatted in line with the Royal College Guidance Notes. £29.95 • August 2011 • ISBN 9780199590001
FRCR Part 1 Anatomy Mock Examinations Shaw, Aidan; Smith, Benjamin; Howlett, David C. Ten mock examinations laid out and structured in the same way as the actual papers set by the Royal College. £30.00 • August 2011 • ISBN 9781107648647
Chest X-Rays for Medical Students Clarke, Christopher; Dux, Anthony
CHEST X-RAYS FOR MEDICAL STUDENTS
CHRISTOPHER CLARKE & ANTHONY DUX
Ideal for those wishing to gain a basic understanding of the principles of chest radiology. £19.99 • September 2011 • ISBN 9780470656198 NB. Prices quoted are the publishers’ list prices at the time of going to press and may be subject to change. This offer cannot be used in conjunction with any other special offers — the higher discount will always apply.
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contents
in this issue 3 4 5
Editorial
6
Community news
15
Review article
28
Abstracts
37 40 42 45 46
BIR NEWS
recent BIR eventS BIR provides international training
BIR events calendar Forthcoming events from the BIR scientific programme
News from the radiology and allied sciences community
What’s Online Table of contents from The British Journal of Radiology volume 84 number 1007 and 1008
18 20
Case of the month
22
Short Communication
The uncontrollable shaking arm
Commentary The practical application of the UK 5-point scoring system for breast imaging: how standardisation of reporting supports the multidisciplinary team
The Agfa Mayneord lecture: MRI of short and ultrashort T2 and T2* components of tissues, fluids and materials using clinical systems
Abstracts from The British Journal of Radiology volume 84 number 1007 and 1008
Call for committee members History of Radiology BIR President’s Column Obituary
Development of a fine thermocouple-needle system for real-time feedback of thermal tumour ablation margin
Using the DOI system
www
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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.
NEWS Editors-in-Chief: Dr Simon Blease, Mrs Liz Hunt Managing Editor: Sherry Dixon Production Editor: Jenny Rooke Contributing Editors: Professor Adrian Thomas
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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www.bir.org.uk
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
issue 6 December 2011
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
Looking to the future, but remembering the past
The Mackenzie Davidson library in the BIR's previous home at Welbeck Street
Recent issues and editorials of BJR News have highlighted sad events half a world away in Japan, but there is nothing like sad news at home to bring one back to earth with a bump. The passing of Marion Frank is one of those very sad events and her obituary marks the last chapter of BJR News in 2011. Marion was very much part of the fabric of the British Institute of Radiology (BIR) and one of its most respected supporters. Our thoughts are very much with her family and friends. She was truly a giant among the personalities who make up the multifaceted character of the BIR. Her passing reminds us that we can only reach forward with confidence if we have the strongest of foundations in our history. This is why the BIR history project is of key importance and why the editorial team is delighted to bring the first fruits of that project to the readership. Professor Fowler’s story is inspiring and fascinating, not least because he was involved in steering the BIR from Welbeck Street to Portland Place. History has treated that courageous move well. Let us hope that the new direction outlined in the President’s column will be treated as favourably when reviewed in BJR News December 2045! Simon Blease, BJR News Editor-in-Chief
issue 6 December 2011
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report: Cardiac CT level ii
recent BIR events
BIR provides international training September saw the British Institute of Radiology (BIR) hosting its second practical cardiac CT level II training course. Earlier this year the BIR won an important grant funded by the British Council's DelPHE-Iraq programme, which supports partnerships between Iraqi higher education institutions and those in the rest of the world. At present there is no opportunity to provide post-graduate cardiac radiology training in Baghdad, the region of Iraq where the delegates work. It was therefore particularly significant that we welcomed 9 academic radiology staff from the Baghdad Medical College and Baghdad Teaching Hospital to attend the course in order to develop the advanced diagnostic skills required to use their new CT equipment purchased this year. The four-day event itself took place at the BIR offices in Portland Place. The course began with a familiarisation of the Siemens workstations after which the delegates began work on the 150 cases they had access to. As well as the practical
Cardiac CT training
aspect, lectures were given from the experienced and eminent faculty: Dr Simon Padley, Dr Sujal Desai, Dr Mike Rubens and Dr Ed Nicol. Dr Nicol, the course director, explains why the training is so important: "Cardiovascular disease remains one
Delegates and faculty with BIR's education coordinator, Ruth Warne
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of the world’s leading causes of premature death, and the figures from Iraq show it is no different to the rest of the world. The ability of cardiovascular CT to detect coronary artery disease (CAD) non-invasively allows early detection or exclusion of CAD and appropriate primary and secondary prevention strategies to be put in place to address this issue. Training senior colleagues from the Baghdad Medical College and Teaching Hospital will allow them to pass down these new skills to colleagues throughout Iraq and put them in a stronger position to address the growing global epidemic of cardiovascular disease". The delegates return to their institutions with the skills and knowledge to train junior staff and students. It is also hoped that this will begin the first phase of establishing an interventional radiology centre at the Baghdad Teaching Hospital and will form the nucleus for transferring these skills to other centres within the country. The BIR will be holding another cardiac level II training course in February 2012, which will be open to anyone wishing to take part.
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Forthcoming events
events calendAr 2012
www For a full event listing, registration & availability visit: www.bir.org.uk/membersarea/multievents
Upcoming in December 2011 Clinical imaging of the head and neck 02 December 2011 BIR, London
Chernobyl 25 years on: consequences, actions and thoughts for the future 12 December 2011 BIR, London
The future of radiology in the NHS: top topics for interviews 16 December 2011 BIR, London
In-vivo dosimetry and dose guided radiotherapy 8-9 December 2011 BIR, London
Events booking now
visit www.bir.org.uk/membersarea/multievents
February
March
APRIL/MAY
Controversies and uncertainties in the radiotherapy of early breast cancer
Radiology for core surgical trainees - what you need to know!
BIR president's conference 2012: CT in clinical practice: a tribute to Sir Godfrey Hounsfield
2 February 2012 BIR, London
Magnetic resonance imaging in clinical obstetric practice 3 February 2012 BIR, London
London cardiac CT level II training 7-10 February 2012 BIR, London
2 March 2012 BIR, London
Current status and future directions of SPECT/CT imaging 16 March 2012 BIR, London
25-26 April 2012 Wellcome Collection, London
Challenges for the radiographer in the digital age 11 May 2012 BIR, London
Medico-legal conference for radiologists 22 March 2012 BIR, London
RPS update 27 March 2012 BIR, London
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Community News
community news
The year of radiotherapy, “big socie 2011 has been designated the year of radiotherapy and efforts have been, and continue to be, made by a number of organisations to work together to highlight the effectiveness and cost-effectiveness of radiotherapy as a treatment modality for cancer patients. This has been a high profile and coordinated effort involving the Department of Health/ National Radiotherapy Implementation Group (DH/NRIG) team with support from all the professional bodies. It has had considerable success and a good number of positive press articles have followed. Influential independent organisations such as the Kings Fund have made clear public statements on the benefits and the need to prioritise investment in radiotherapy. The Kings Fund, in their report entitled How
to improve cancer survival: Explaining England’s relatively poor rates, stated: “It is more important to improve access to surgery and radiotherapy than access to cancer drugs. In terms of overall allocation of resources, this suggests that the contribution of the Cancer Drugs Fund to improving overall outcomes will be very limited”. This is a powerful endorsement of the importance of investments in radiotherapy and, at a time of severe financial constraint, there is good sense in putting resources where the maximum benefit is likely to be obtained. Unfortunately, while the health minister must know of the importance of radiotherapy, he still decided that for his address to this year's Conservative party conference there was more capital to be made from the
cancer drugs fund (discussed in depth) than from radiotherapy (not mentioned at all). In the real world of radiotherapy, there has been a considerable amount of good news to report this year. New departments have opened across the country bringing much needed new technology to raise the quality of radiotherapy we are able to offer. Examples include the new centres developed in Salford (a new centre opened with two Novalis Tx machines) and in Hull where, as the images below show, great attention has been paid to the design of the building and environment for patients, complementing the six state-of-the-art Varian accelerators. There have also been significant developments in Peterborough (two Varian RapidArc enabled machines) and Bracknell
Clockwise from bottom left: Views of the new radiotherapy department in Hull (courtesy of Professor Andrew Beavis). Layout of the new extension to the Nottingham department, where the three treatment bunkers are shown towards the top of the image, the large room at the bottom left is for treatment planning and the two rooms towards the left of centre at the bottom are CT scanner rooms (both with 4D capability). Image courtesy of Andrew Przeslak.
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Community News
iety” and the elephant in the room
The team at Birmingham and the charityfunded tomotherapy HD machine
(Elekta single linac satellite centre), which follow on the heels of substantial expansions of departments in places such as Nottingham (two Elekta Synergy machines and one tomotherapy HiArt in the new extension shown opposite), Cardiff (two Elekta Synergy machines in a new extension). The reinvestment programme in Scotland is also highly significant, with the best value to the health service provided through selection of a single supplier (Varian). Not all of the recent investment has been through traditional NHS funding channels and I would particularly like to highlight the major role that charities are now playing in funding advanced radiotherapy technology around the country. Without wanting to generate a comprehensive list, some examples from 2011 include: • Barts and The London: CyberKnife, charity appeal funding machine. • Royal Marsden: charity appeal funded machine. • UHB, Birmingham: charity appeal funded one of two tomotherapy machines (see image above) and fundraising for CyberKnife is well under way. • University College London Hospital (UCLH): large charity contribution to Varian TruBeam purchase. These are significant sums of money (well in excess of £10 million in the list above), showing us that the "big society" is very much alive and well in cancer care
in our country. Of course this is not new, charities and volunteers have always been closely involved in cancer care (perhaps people who go to Eton can be excused from realising this), and many of us remember the scanner appeals of the late 1980s and early 1990s, and of course the lottery funding of the late 1990s. So we are following a strong tradition, well trodden by some of the senior members of the British Institute of Radiology (BIR) over the years. Some departments have been more effective than others in harnessing the willingness of the public, patients and hospital staff to donate and fundraise. The department at UCLH started taking the role of charities seriously some time ago. Julia Solano (Head of Radiotherapy Services at UCLH) has always been clear that: “the NHS provides the bread, and the charities help us provide the jam” This is an excellent analogy to show the role of charities in lifting the quality of technology above the basic provided by standard NHS funding models. UCLH have raised their radiotherapy quality to be amongst the very best in the country through charity funding of a linear accelerator, RapidArc planning and delivery capabilities and part-funding of a PET/CT scanner. Their efforts are a lesson to us all. Charities have an especially important role now, when money is tight and there is still no nationally agreed tariff for advanced techniques, such as IMRT/RapidArc/VMAT (pick your acronym to suit your prejudices...). And so, on to the elephant in the room. With increased positive press coverage of radiotherapy in 2011, the community hoped to lay a foundation of positive impressions on the quality of UK treatments, influencing the public, patients and referring clinicians alike. Much has been gained, but as always there are issues outside our immediate control, and UK provision of proton radiotherapy is the elephant in the room in this case. Over
this year there has been a constant stream of press articles (mainly in local papers around the country) describing efforts by families to raise money to send children overseas for proton therapy. Numbers of NHS referrals abroad (especially for children) have continued to increase, but they are outstripped by the demand from parents who see this as the best quality treatment for their children, many of whom fall outside the necessarily narrow NHS referral criteria. Of course this press attention on protons provides a contrast to the positive impression we wish to create, and again generates an undercurrent of suspicion that UK radiotherapy is not quite as good as it needs to be. We will not shake off this suspicion until UK provision of proton radiotherapy is a reality. Overall, 2011 serves as an example to the radiotherapy community for the future. We must be more proactive in publicising the excellent work we do, and the huge benefits of radiation treatment for cancer patients. This will add impetus to clinician referrals and patient acceptance of radiotherapy, and to fundraising efforts on our behalf. However, we should also remember that the press always have an eye for a good story and will not let go once they have hold (my own view is that cancer drugs suppliers learned this many years ago and have used it mercilessly). Press attention to the issue of provision of proton therapy in the UK will not go away. Even against the current background of financial constraint it remains comparable in cost to many widely prescribed cancer drugs and other expensive NHS procedures. Using funds already earmarked for referral abroad, UK treatments could be afforded for children and for the subgroup of adults that would benefit the most. Hopefully we will not have to wait too much longer for news on this important issue. tuart Green, Queen Elizabeth Hospital, S Birmingham
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Community News
Ester Hammond receives the 2011 Varian-Juliana Denekamp award The Varian-Juliana Denekamp award is presented every two years at the International Wolfsberg Meeting on Molecular Radiation Biology/Oncology, held in association with ESTRO, to young scientists who have excellence and passion for biologically driven cancer research relevant to radiation oncology. BJR News talks to Ester Hammond about receiving the prestigious award. I was delighted to receive the VarianJuliana Denekamp award. This is my first prize since becoming an independent academic and it was a wonderful experience to attend the European Society for Radiotherapy and Oncology (ESTRO) meeting in Wolfsberg, Germany. The recognition of your work by your colleagues is always a good feeling, but the opportunity to stand up and present my group’s results to the European radiation biology community was even better. This was my first Wolfsberg meeting and I was particularly impressed with the fantastic conference, which had people meeting and talking as its focus. Two Denekamp awards were presented this year. I met the other recipient, Dr Iris Eke, at an ESTRO meeting in January. Meeting her again in June and sharing the award with her has
brought us closer together and we are considering collaborating next year. I definitely hope to go to Wolfsberg again in the future. I have worked with cellular pathways since completing my post-doctorate on the mechanisms of autophagy and apoptosis. Following a period in Cambridge working on tumour suppressor genes, I went to Stanford to work with Amato Giaccia. Professor Giaccia made his name working on the pathways downstream of p53, but I chose to work upstream of p53 and this led me to the role of ATM and ATR in helping cells survive hypoxic conditions. My group continue this work today at the Gray Institute in Oxford. Hypoxia is present in all solid tumours and reduces the effectiveness of radiotherapy. Anything that helps cells survive in hypoxic conditions is
This was my first Wolfsberg meeting and I was particularly impressed with the fantastic conference, which had people meeting and talking as its focus. 8
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Dr Ester Hammond
therefore a radiation issue. Our goal is to identify drugable components of the cell survival machinery; this could make hypoxic cells more susceptible to radiation or undermine their ability to survive the hypoxic conditions that protect them from radiation. We hope to apply this in the clinic to help more people survive cancer. Juliana Denekamp was a former director of the Gray Institute and I’m delighted that the award has come to our Oxford group.
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community news
Risk and unjustified radiation exposure discussed at AAPM Elizabeth Chaloner, BIR trainee committee member, reports on her highlights of the 2011 American Association of Physicists in Medicine and European Federation of Organisations for Medical Physics Workshop held in Dublin in August. Against the architecturally impressive background of Trinity College Dublin, the international radiology and radiotherapy community gathered for the American Association of Physicists in Medicine (AAPM) and European Federation of Organisations for Medical Physics (EFOMP) workshop. The introductory lecture from Jim Malone (International Atomic Energy Agency) introduced the problems associated with communication of risk to those involved in justification. It was suggested that healthcare groups, who justify procedures, do not relate to radiation dose expressed in sieverts. The suggestion that other “dose currencies” should be used to convey risk was supported by Gaya Gamhewage of the World Health Organization, whose presentation, “Communication of Risk”, which considered different risk approaches for dealing with risk from a different perspective, gave everyone food for thought. The “Image Wisely” and “Image Gently” campaigns piloted by the AAPM were also on the justification agenda. These schemes have been introduced across the United States to ensure paediatric patients are imaged using lower dose protocols (Image Gently) and optimised protocols are applied to adult patients (Image Wisely). Herb Mower from AAPM discussed justification in radiotherapy. He emphasised that all elements of standard procedure should be documented to avoid error.
It was found that approximately 30% of CT scans for patients under 35 were unjustified and that a large proportion of unjustified scans could be replaced by MRI. On the theme of reducing unjustified ionising radiation exposures, Helja Oikarinen (Oulu, Finland) presented a study of unjustified CT scans. It was found that approximately 30% of CT scans for patients under 35 were unjustified and that a large proportion of unjustified scans could be replaced by MRI. An information card has been introduced for those who justify, which indicates the risks associated with various CT examinations. J Anthony Siebert (AAPM) discussed airport whole body scanners in the morning session. Dose measurements from a particular scanner model were presented and it was concluded that the dose to passengers was negligible. Optimisation was emphasised in the afternoon session. Melissa Martin (AAPM) and J Anthony Seibert discussed the difficulties in calculating patient dose using scanners with dose
indication values that are not necessarily representative of the average patient. To address this, the AAPM website provides size specific dose estimates and CT protocols for use with different scanners. John Boone, also of the AAPM, presented the development of a novel CT phantom to assess image quality using the modulation transfer function and noise power spectrum. Finally, Pat Horton (University of Surrey) represented the European perspective on optimisation with a round up of the European standards for acceptability of equipment (RP162 Project). Koos Geleijns (Leiden, the Netherlands) left us pondering the philosophical aspects of ionising radiation exposure in the form of “the jogger’s dilemma”. Elizabeth Chaloner, Clinical Scientist (Medical Physics), King’s College Hospital, London issue 6 December 2011
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community news
BIR begins work on a new history project The British Institute of Radiology (BIR) archives committee have started work on an exciting new history project. Sue Marchant and Stuart Green explain the motivation behind the idea and introduce the first story of the project by Professor Jack Fowler Have you ever sat and listened in wonder to the stories told by older members of our profession? Perhaps you have experienced those feelings of amazement and respect for their achievements in diagnosing and treating patients with the facilities they had to work with? The stories are captivating, but so are the people telling them. There is so much we can learn from their experiences if only we could capture those experiences and make them easily available. This simple desire has provided the motivation for the BIR's history project, which is intended to capture the experiences that make up the history of radiology in its widest sense. The idea was proposed to the Institute’s archives committee, who were enthusiastic from the start. A small group was set up to take the project forward under the management of Khalda Mohammed, the BIR’s Librarian and Information Specialist.
The objectives for the project are to generate biographies of people who have worked in radiology and radiotherapy departments, to provide a portal through which the important historical archives of the BIR are available to the public and generate public involvement and interest through patient treatment experiences. These are wide-ranging objectives, but our aim is to start small and to develop a website that evolves over time as content is added. We will involve the widest spectrum of disciplines possible including industry, which has been so important in the history of radiology. We will track stories against a history timeline that fits with the history of the BIR itself. The site will include video footage of individuals telling the stories and BIR prize lectures. It will link with other BIR resources such as the British Journal of Radiology and the retrodigitisation project.
We intend to make a special feature of BIR honorary members, our associated radiology societies and unique historical stories, such as wartime radiology and radiation martyrs. All this information will be accessible online, and work is ongoing in bringing our ideas to fruition. We have developed questionnaires to act as the foundation for the stories that we will collect. We are looking for members to help provide stories, assist with turning the questionnaire responses into stories or sending us photos. You might even consider making a monetary donation that would allow us to have access to some of our archive stored offsite. Please contact the BIR if you would like to donate or would like further information. We are delighted to share with you the first story to be developed: Professor Jack Fowler — former BIR president.
Professor Jack Fowler
Professor Jack Fowler
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I obtained my degree in physics in December 1944 from the University of South West England (now Exeter University) after leaving school with A-levels in physics, pure maths, applied maths and chemistry. I achieved a first class honours BSc, and then went on to obtain an MSc, PhD and DSc. I was first attracted to the medical aspect of physics because I did not want to research atomic bombs! At the start of my career in medical physics, measurements of X-ray doses were already taking place, having begun in 1939. The latest dosemeter at the time was the Farmer-Baldwin, which had a reliability better than 0.25% and was linked by a cable to a 0.6cc ionisation chamber designed by Frank T Farmer for whom I worked in 1946 at the Royal Victoria Infirmary in Newcastle-upon-Tyne.
The workhorses used in radiotherapy departments at the time were 250kV machines. 4MeV linear accelerators only came into use in 1950. I was able to work with Dr Farmer when the second one to be used in the UK was installed in Newcastle General Hospital. It provided the hospital with 25 years service! There was some competition between my hospital and the Hammersmith Hospital, which acquired an 8MeV machine — we tried to get ours into action faster. The story of that hard slog includes the use of a gold target, which was the way to measure output at a given energy in standard known absolute terms. Dr Frank Farmer, being a no-nonsense get-things-done physicist, went to the local jeweller and persuaded him to lend us a gold sovereign. We duly
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mounted this strongly in a retort stand just in front of our 4MeV electron beam as it emerged from the front of the linear accelerator through a thin window. We were careful to have a strong jet of cold water aimed at the back of the sovereign to prevent it from being melted by the electron beam. We switched it on for exactly 1 minute, but got a low reading. When we went back into the concrete treatment room, we found the sovereign had a neat 4mm hole in it, and a gold bead in the container below. The water jet was on the same water supply the linear accelerator used, and as soon as we switched the machine on the water pressure dropped outside it — we had to pay the jeweller the full price for the sovereign. I have seen technology in my particular field of radiotherapy physics develop into ever more powerful machines, such as the development of linear accelerators up to 6, 10, 15, 18 and 25MeV in strength. Further developments included betatrons up to 50MeV and cyclotrons of 250MeV for proton beam therapy and 15–30MeV for neutron beams. However, these went out of fashion in radiotherapy (other than for a very few specific uses i.e. prostate and salivary gland tumours) because of their unfavourable radiobiological effects. I went on to work at the Hammersmith Hospital from 1960–66 on a research project using pigs weighing over 100lbs to record skin reactions when using neutron beams. I can tell you now that the pigs were kept on the roof of the MRC cyclotron building. Our work at the Hammersmith MRC cyclotron unit, which used 16MeV deuterons on a beryllium target for the fast neutron beam, was my favourite. While at the Hammersmith Hospital, I was able to visit the United States, but this did not come about until I was 37 years old and had been working there for 2 years — quite old for a first visit to the States. My career spanned 18 years as a medical physicist; it has included 7 years as Professor at The Royal Postgraduate Medical School at the Hammersmith and 18 years as a radiobiology researcher during which time I was Director at the Gray Laboratory at Mount Vernon Hospital working mainly with mice.
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On retirement in the UK, I moved to Madison in the United States. I spent time at the University of Wisconsin Medical School in the department of Human Oncology from 1988–2004. This was quite different to working in the UK. Research in United States has meant developing applications now rather than having vague hopes in 15 years time. I think I am most proud of my involvement in defining how the mechanism of fractionated radiotherapy works. Briefly, it causes more damage to tumours than it does to normal healthy tissues, this is because normal skin and mucosa start to repopulate during irradiation at the seventh day. Tumours do not start to repopulate until 2 to 3 weeks into irradiation. I have written a number of papers on this subject where I explain the mechanism of how this happens. Some of the people I particularly
scanners (used to plan treatment areas) and CyberKnife. My involvement with the British Institute of Radiology (BIR) has involved me in discussions with colleagues on advances in physics, radiobiology issues and many more. They were all illuminating discussions, as I remember, with excellent scientific argument. My involvement with the BIR did not end there. I remember the many multidisciplinary scientific meetings held in the Reid-Knox Hall of 32 Welbeck Street (the BIR’s earlier home, which had, in the early 19th century, been the home of the Russian Embassy). Orthodox Greek citizens residing in London used to worship in its chapel. The scientific meetings covered radiation dosimetry, radiotherapy, treatment schedules and lethal radiation dose levels for mice, rats and rabbits, and a whole world of specialised knowledge now known as radiation
I think I am most proud of my involvement in defining the mechanism of fractionated radiotherapy remember working with are Julie Denekamp at the Gray Laboratory, Professor Frank Farmer, Professor Joseph Rotblat, Ingela Turesson as well as many, many more. I also remember many conditions being treated differently and the introduction of multidisciplinary clinics have now resulted in new combined methods of treating malignancies. A far cry from the days when surgeons thought radiotherapy could only cure skin cancer! I remember my work day began early and I continued to work late, long after the working day had ended to calibrate the radiotherapy machines ready for the next day’s work. Perhaps the most outstanding of improvements I have witnessed has been the introduction of computers into machines, such as linear accelerators, CT
oncology. Some of the many personalities connected with the BIR who I remember include Frank Ellis, Constance Wood, Ralston Patterson, Val Mayneord, Patricia Lindop, Richard Doll, as well as many many more. Some of these names are still with us. I was privileged to be president of the BIR from 1977–1978, a time when the BIR was looking to move from its home in Welbeck Street. Together with Professor George du Boulay and a small group of officers we decided on 36 Portland Place after what I described to Council as a rollercoaster ride. I have so many stories that I could share with you. I intend to put these together for the radiology history story website along with stories from many others, I am sure. Jack Fowler
issue 6 December 2011
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Wireless technology in radiology Neil Staff, Technical Director, and Peter Staff, Chief Executive Officer, at Xograph Healthcare discuss how radiology is embracing wireless technology Wireless communication is all around us. Mobile phones, laptops and tablet PCs mean the airwaves are full of our wireless chatter, tweets and online purchases. The term “wireless” is synonymous with all that is en vogue in computing and communications technology, but how does wireless technology impact on us in the hospital and specifically in radiography today? Wireless networking
Just as in our homes, hotels and airports, medical establishments are benefiting from the march of portable and mobile wireless technology. Wireless networks allow medical devices to connect to the physical IT network and deliver information from a remote location to the point of need without cabled connections at the point of care. Wireless technology allows patient monitoring devices, blood analysis and even endoscopes to transmit data remotely without the need for physical connection. Not only can medical staff access data on fixed computer terminals, but often on
mobile phones and wireless tablets. Just this month I read that a remote site in Central America transmitted echocardiography images for interpretation by radiologists on a smartphone application in the United States. Cool security
Wireless network transmissions have the potential to leave themselves open to interception whether intentionally or unintentionally. The importance of maintaining patient data security means strong wireless security is essential. This takes the form of complex encrypting of the data before transmission and decoding once it has arrived at its destination. Of the recent wireless local area network (WLAN) security standards one type, known as wired equivalent privacy (WEP), was found to be flawed and insecure, and so today the most common and acceptably strong forms of security standard found in mobile WLAN devices is known as WPA2. Modern products incorporate this security within the device and provide detail in their product specification.
Wireless monitors in an operating theatre showroom with wireless image transmission from a mobile digital C-Arm (image courtesy of Ziehm Imaging GmbH)
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Wireless connectivity in radiography
The first commonly used radiographic devices to use WLAN technology were mobile digital imaging devices. In the last 2–3 years, mobile surgical C-Arms and mobile digital radiography (DR) units equipped with an integrated wireless router have become more commonplace and are able to transmit images and examine data from the imaging system via WLAN to the imaging department’s radiology information system (RIS) and picture archiving and communications system (PACS). They can also receive a patient work list from the RIS to aid patient registration. As well as wireless transmission within the hospital, wireless image transfer from mobile trailers, such as those carrying full field digital mammography systems, is possible and typically uses mobile telephone communication standards, such as 3G and GPRS. A few years ago, a medical region in Italy linked an ambulance carrying a portable X-ray unit and a direct DR detector, as well as other patient monitoring devices, via a satellite link-up to the medical centre so diagnosis could be made directly at the accident scene or while the ambulance was en route to the hospital allowing time critical medical treatment to be administered. A recent project in Norway employed a radiographer to take a compact wireless direct digital X-ray unit called a “DRagon" in a van to community elderly care centres to perform chest and minor injury radiography. The resulting images were sent immediately via a wireless high-speed broadband connection. The region saved on ambulance transfers to the local hospital in the case of negative findings and I am certain the elderly patients were pleased not to have to spend a day travelling and waiting around in the nearest hospital.
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A dental image viewer application on a smartphone and tablet PC (image courtesy of Planmeca Oy)
Wireless direct digital radiography
The earliest large area direct digital flat panel detectors for general radiography were first introduced in the late 1990s. These early devices were fixed units within an X-ray room and mobility was not generally possible. As portable flat panel detectors were developed, the first being commercially available in 2001, they relied on a cabled connection to the DR control system, either in an X-ray room or integrated into a mobile X-ray unit. The cable supplies power to the detector and allows the high-speed flow of signals and data. However, even in this wireless age, many modern and high specification DR detectors are still produced offering the comfort of a secure cabled delivery of power and data. In 2007 the first portable wireless DR detectors appeared. An on-board battery provides power for operation and wireless image data transmission back to the radiography system. Today, a growing selection of wireless portable direct digital detectors are becoming available, most with a traditional 35Ă—43cm imaging area, although one manufacturer also produces a smaller size, which is convenient for certain types of radiography, such as neonatal incubators. The latest wireless DR detectors are designed to the ISO4090 cassette size standard allowing
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the detector to fit into an existing general radiography system cassette trays and cassette tunnels in patient trolleys without modification. Remarkable, considering the amount of technology packed inside, which has to be robust, yet light enough to be comfortable to carry, especially as not much more than 10 years ago a thin sheet of film and a pair of intensifying screens was all that could be squeezed inside. Removable, rechargeable batteries in wireless DR detectors, as opposed to fixed batteries, enable them to be quickly swapped to allow work to continue should batteries become discharged at an inconvenient moment, although many wireless detectors still offer the option of a plug-in back-up cable, just in case wireless transmission issues should occur. Fast, table-top chargers allow several rechargeable batteries to be handled at once. One manufacturer explained to me that following exposure, the image data from the wireless detector's 9.5 million pixels are gathered within the detector, encrypted, wirelessly transmitted and can be viewed on the DR system's diagnostic monitor just 2.1 seconds later. This particular detector can use the less cluttered 5 GHz WLAN frequency so that issues with interference are much less likely. If any issues occur with transmission or battery power the detector is able to store the last image on board, so that it is not lost; it will automatically transmit once the network connection is restored. As well as in-room wireless DR systems we are now seeing wireless DR technology appearing on mobile X-ray units. The mobile X-ray unit is equipped with an integrated wireless access point allowing one or more DR detectors to transmit image data back to it and, after checking by the radiographer, this can be sent onward for archiving and reporting using the mobile's WLAN connectivity. The beauty of the wireless portable detector is that it can be shared with compatible DR rooms and mobiles. This means we have come almost full circle back to “cassette-type� radiography and can take the detector to the room or mobile rather than having the expensive asset locked in one place.
A DR mobile X-ray unit showing an integrated wireless access point for connectivity to the wireless DR detector (image courtesy of Shimadzu Corp)
Wireless image display technology
Recently, I visited a state of the art operating theatre in mainland Europe. The mobile C-Arm had a flat panel detector rather than an image intensifier and the theatre was equipped with ceiling-mounted wireless displays. A transmitter mounted in the mobile C-Arm sent signals wirelessly to receivers mounted high up on the ceiling then via an image server back out to the various displays within the theatre (and potentially beyond). Despite this complexsounding routing method the dynamic images displayed appeared to be pretty much instantaneous.
Wireless, why less? Give me more!
Fewer cabled networks and more wireless network access while on the move appear to be the demands of today. Wireless is in our homes, our schools and now in our hospitals. Although debates over wireless security and robustness of life critical wireless systems may take place, the positive benefits of instant access to real-time patient information from all corners of the hospital, or the globe, direct to the desks of our diagnostic specialists, can only result in the proliferation of wireless devices within the healthcare environment in the coming years. issue 6 December 2011
NEWS 13
BIR Company Subscribers 4 Ways Healthcare
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Imaging Equipment
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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
Commentary
An unusual cause of bone marrow oedema in the acetabulum
Intravenous pyelogram artefacts unique to digital tomosynthesis reconstruction
Hepatic vascular shunts: embryology and imaging appearances
Volumetric modulated arc therapy: a review of current literature and clinical use in practice
CT strokewindow settings: an unfortunate misleading misnomer?
M Eyselbergs, F M Vanhoenacker and P Boone
B K Rowberry and A Galea
P Bhargava, S Vaidya, O Kolokythas, D S Katz and M Dighe
M Teoh, C H Clark, K Wood, S Whitaker and A Nisbet
P J Turner and G Holdsworth
DOI: 10.1259/bjr/ 64824020
DOI: 10.1259/bjr/ 59924754
DOI: 10.1259/bjr/ 82649468
DOI: 10.1259/bjr/ 22373346
DOI: 10.1259/bjr/ 99730184
Highlighted Articles: Full papers
Case reports
Quantification of the UK 5-point breast imaging classification and mapping to BI-RADS to facilitate comparison with international literature
Case report: Subcutaneous calcification in the pectoralis major flap: a late complication of radiotherapy
K Taylor, P Britton, S O’Keeffe and M G Wallis
J Plzak, P Kalitova, M Urbanova and J Betka
DOI: 10.1259/bjr/29175509
DOI: 10.1259/bjr/48490964
A pilot study to evaluate assisted freehand ultrasound elasticity imaging in the sizing of early breast cancer: a comparison of B-mode and AFUSON elasticity ultrasound with histopathology measurements R E English, J Li, AJC Parker, D Roskell, R F Adams, V Parulekar, J Baldwin, Y Chi and J A Noble
DOI: 10.1259/bjr/13216246
Organ and effective dose reduction in adult chest CT using abdominal lead shielding
Case report: Synovial chondromatosis in the temporomandibular joint: a case with typical imaging features and pathological findings S W Lim, S J Jeon, S S Choi and K H Choi
DOI: 10.1259/bjr/69067316
Case report: Spontaneous cholecystocolic fistula and locoregional liver tumour ablation: a cautionary tale U Pua and E M Merkle
DOI: 10.1259/bjr/13919678
G R Iball and D S Brettle
DOI: 10.1259/bjr/53865832
Radiation protection for an intraoperative X-ray device D J Eaton, R Gonzalez, S Duck and M Keshtgar
DOI: 10.1259/bjr/29466902
issue 6 December 2011
NEWS 15
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in The online issue of BJR
All other articles from November and December 2011 Breast
Thoracic
Commentary: The practical application of the UK 5-point scoring system for breast imaging: how standardisation of reporting supports the multidisciplinary team
Case report: Fat-forming variant of solitary fibrous tumour of the pleura: CT findings
L S Wilkinson and N T F Ridley
C Y Park, J Y Rho, S M Yoo and H K Jung
DOI: 10.1259/bjr/68692634
DOI: 10.1259/bjr/51580547
Clinical dose performance of full field digital mammography in a breast screening programme J B McCullagh, P Baldelli and N Phelan
DOI: 10.1259/bjr/83821596 Gastroenterology
Case report: Polysplenia syndrome with agenesis of the dorsal pancreas and preduodenal portal vein presenting with obstructive jaundice—a case report and literature review J P Low, D Williams and J R Chaganti
DOI: 10.1259/bjr/27680217
Case report: Acinar cell carcinoma with fatty change arising from the pancreas
Case report: Primary mucosa-associated lymphoid tissue lymphoma as a pleural mass M L Barahona, V P Duenas, M T Sanchez and B V Plaza
DOI: 10.1259/bjr/28699097
Pulmonary thin-section CT findings in acute Moraxella catarrhalis pulmonary infection F Okada, Y Ando, T Nakayama, S Tanoue, R Ishii, A Ono, M Watanabe, H Takaki, T Maeda and H Mori
DOI: 10.1259/bjr/42762966
Reducing intratumour acute hypoxia through bevacizumab treatment, referring to the response of quiescent tumour cells and metastatic potential S Masunaga, Y Liu, H Tanaka, Y Sakurai, M Suzuki, N Kondo, A Maruhashi and K Ono
DOI: 10.1259/bjr/38457938
W-S Chung, M-S Park, D W Kim and K W Kim
DOI: 10.1259/bjr/15914752
Case report: Peripancreatic intranodal haemangioma mimicking pancreatic neuroendocrine tumour: imaging and pathological findings A D Karaosmanoglu, R Arellano and G Baker DOI: 10.1259/bjr/77657029
Case report: Unusual presentation of a pancreatic mass in an infant: pancreatic haemangioendotheliomatosis G Saigal, D Hildoer, C Parra-Herran and L Pelaez DOI: 10.1259/bjr/87625027
Acute appendicitis: relationships between CT-determined severities and serum white blood cell counts and C-reactive protein levels H C Kim, D M Yang, C M Lee, W Jin, D H Nam, J Y Song and J Y Kim
DOI: 10.1259/bjr/47699219 Musculoskeletal
MRI manifestations of soft-tissue haemangiomas and accompanying reactive bone changes A Pourbagher, M A Pourbagher, B Karan and G Ozkoc
DOI: 10.1259/bjr/58308513
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issue 6 December 2011
Genitourinary
Accuracy of contrast-enhanced ultrasound in the detection of bladder cancer C Nicolau, L Bunesch, L Peri, R Salvador, J M Corral, C Mallofre and C Sebastia
DOI: 10.1259/bjr/43400531
Case report: Unusual manifestation of endometrioid adenocarcinoma arising from subserosal cystic adenomyosis of the uterus: emphasis on MRI and positron emission tomography-CT findings S H Heo, K-H Lee, J W Kim and Y Y Jeong
DOI: 10.1259/bjr/24318075
Diffusion-weighted imaging in the assessment of tumour grade in endometrial cancer N Bharwani, M E Miquel, A Sahdev, P Narayanan, G Malietzis, R H Reznek and A G Rockall
DOI: 10.1259/bjr/14980811
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IN THE ONLINE ISSUE OF BJR
All other articles from November and December 2011 Cardiac
Technical
Case report: A novel approach to the management of a ruptured Type II endoleak following endovascular repair of an internal iliac artery aneurysm
Short communication: Development of a fine thermocouple-needle system for real-time feedback of thermal tumour ablation margin
S D Patel, A Perera, N Law and S Mandumula
H Ishizaka, A Shiraishi, S Awata, A Shimizu and S Hirasawa
DOI: 10.1259/bjr/42137038 Head and Neck
Case report: Giant cell tumour of the posterior cranial fossa: a case report Z H Lu and Z W Yao
DOI: 10.1259/bjr/20601291
Case of the month: The uncontrollable shaking arm
DOI: 10.1259/bjr/81796498
A preliminary comparison of total skin electron treatment techniques to demonstrate the application of a mid-torso phantom for measurement of dose penetration G Baugh, T Al-Alawi, C L Fletcher, J A Mills and R J Grieve
DOI: 10.1259/bjr/52924135 Review
F V Schraml, J Karis and B R Mullen
DOI: 10.1259/bjr/31650853
Spinous process fractures in osteoporotic thoracolumbar vertebral fractures M R N Seo, S Y Park, J S Park, W Jin and K N Ryu
DOI: 10.1259/bjr/32143781
The Agfa Mayneord lecture: MRI of short and ultrashort T2 and T2* components of tissues, fluids and materials using clinical systems G M Bydder
DOI: 10.1259/bjr/74368403
Comparing the accuracy of initial head CT reporting by radiologists, radiology trainees, neuroradiographers and emergency doctors F A Gallagher, K Y Tay, S L Vowler, H Szutowicz, J J Cross, D J McAuley and N M Antoun
DOI: 10.1259/bjr/24581602
National reference doses for dental cephalometric radiography J R Holroyd
DOI: 10.1259/bjr/26420990
Dosimetric and radiobiological comparison of helical tomotherapy, forward-planned intensity-modulated radiotherapy and two-phase conformal plans for radical radiotherapy treatment of head and neck squamous cell carcinomas S Chatterjee, N Willis, S M Locks, J H Mott and C G Kelly
DOI: 10.1259/bjr/53812025
issue 6 December 2011
NEWS 17
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Case of the month
The uncontrolla A 48-year-old male presented to the emergency department with the chief complaint of intermittent uncontrollable shaking of his left arm. He reported having had a brain tumour resected from the right frontoparietal region of his brain approximately 5 years earlier. He was admitted to hospital and underwent MRI scan of his brain. The MRI demonstrated a right frontoparietal region tumour, which was proven to be a partially resected (i.e. residual) low grade astrocytoma. The residual tumour was resected without any
Figure 1a
Figure 1b
Coronal 18-fluorodeoxyglucose positron emission tomography image of the brain without CT fusion. There is a discrete gyriform focus of intense metabolic activity (arrow).
Discussion
‘‘Interictal’’ imaging was the intended procedure to demonstrate typical decreased metabolism corresponding to the seizure focus in a quiescent state [1, 2]. However, the patient’s left arm was in status epilepticus during radiotracer injection and throughout the 50 min uptake period. The PET scan, with and without CT fusion (Figures 1, 2 and 3), revealed a discrete gyriform focus of intense metabolic activity (arrows in Figure 1) in the 18
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issue 6 December 2011
Coronal 18-fluorodeoxyglucose positron emission tomography image of the brain with CT fusion. There is a discrete gyriform focus of intense metabolic activity (arrow).
anterior margin of the right frontal resection cavity, which involved the (somewhat distorted) primary motor cortex. This is the region corresponding to the patient’s contralateral motoric activity and the presumed ictal focus [3]. As a result of the relatively prolonged uptake period of FDG, FDG PET epilepsy imaging is typically limited to interictal seizure evaluations in which the seizure focus presents as
an area of relative photopenia; while the 99Tcm cerebral perfusion tracers, 99 Tcm hexamethylpropyleneamine oxime and 99Tcm ethyl cysteinate dimer, are typically used for ‘‘ictal’’ imaging with injection at the onset of the seizure and visualisation of focally increased uptake indicating the seizure focus [1, 2]. It is not unexpected that FDG would accumulate in seizure foci if the duration of the seizure is sufficiently
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case of the month
able shaking arm apparent motor deficit. Although there was some abatement of seizure activity, focal motor seizures of the patient’s left upper extremity did not completely resolve despite anticonvulsant medication at therapeutic levels. Brain positron emission tomography (PET)/CT with 18-fluorodeoxyglucose (FDG) was performed. Selected tomographic slices with and without CT fusion are shown in Figures 1, 2 and 3. • What is the salient finding?
• What is the most likely explanation for this pattern of uptake?
Figure 2
Figure 3
Sagittal 18-fluorodeoxyglucose positron emission tomography image of the brain with CT fusion.
prolonged (e.g. status epilepticus) and there are case reports to testify to this phenomenon [4]. Unlike photopenia, which is typically associated with seizure foci in FDG PET brain imaging, increased uptake is the norm in many FDG PET brain tumour evaluations [5]. Moreover, the degree of FDG avidity has been useful in assessing brain tumour grade; the degree of uptake serves as a
Axial 18-fluorodeoxyglucose positron emission tomography image of the brain with CT fusion.
marker of the grade and potential aggressiveness of at least some brain neoplasms. Focally increased FDG uptake in the brain should raise the suspicion of malignancy as a differential diagnosis, particularly where there is a history of a brain tumour. However, the histology of the malignancy in which there is a well known lack of significant FDG avidity, the absence of demonstrable residual neoplasm on MRI following the
most recent surgery, the morphology of the metabolic focus and the cerebral cortical regional-motoric correspondence militate against a tumourous aetiology for this uptake [6]. F V Schraml, J Karis and B R Mullen Department of Radiology, Saint Joseph’s Hospital and Medical Center, Phoenix, Arizona, USA
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Download the full article and references: DOI: 10.1259/bjr/31650853
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NEWS 19
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Commentary
commentary
The practical application of system for breast imaging reporting supports the mul The Breast Imaging Reporting and Data System (BI-RADS) was initiated in the United States in the late 1980s to provide a standardised description of imaging features of breast lesions and to relate them to the underlying pathology and risk of malignancy. Features that were helpful in predicting benign or malignant pathology were chosen; originally for mammography and subsequently for ultrasound [1]. BI-RADS has been used as an education tool and to improve quality across the United States and it is now mandatory to include BI-RADS information in mammography reports. Given the diverse nature of practice in the United States with a spectrum of imaging availability and expertise including large dedicated breast centres and small practices where individual clinicians report relatively small numbers of cases, BI-RADS may have been the essential tool in achieving conformity. There are now 6 categories for each feature: 0, incomplete; 1, negative; 2, benign finding(s); 3, probably benign; 4, suspicious abnormality; 5, highly suggestive of malignancy; and 6, known biopsy proven malignancy. The fourth category is subdivided into a, b and c. The risk of malignancy for each category is well established [2] and studies evaluating observer 20
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issue 6 December 2011
variability show fair concordance for features describing categories 1, 2, 3 and 5, although there is interobserver variability for the BI-RADS 4 subcategories [3]. BI-RADS is proven to be of value in the standardisation of reporting and is intended to provide clear guidance on further management; however, it has not been widely adopted in the UK. There are philosophical differences between accepted protocols for investigating breast lesions in the United States and the UK that limit the applications of BI-RADS in the UK. In particular, lesions at a low risk of malignancy (BI-RADS 3 and 4a) [4] undergo short-term follow-up in the United States but, if palpable, would be subject to biopsy in the UK [5]. The
reasons for this are unclear, although when BI-RADS was introduced in the United States some facilities only had mammographic services and limited access to image-guided biopsy (especially core biopsy), which is now more readily available. This may account for the different approach to breast diagnosis together with other considerations, such as reimbursement policies and avoidance of litigation. A 5-point scoring system for mammography, ultrasound and cytology was described in the UK in 1998 [6]. This differed from BI-RADS as it included pathology results and supported the use of triple assessment by clinical examination, imaging and the needle test to improve sensitivity and specificity in the evaluation of breast lesions. Use of
The BI-RADS is proven to be of value in the standardisation of reporting and is intended to provide clear guidance on further management; however, it has not been widely adopted in the UK.
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Commentary
f the UK 5-point scoring g: how standardisation of ltidisciplinary team this system became fairly widespread, reinforced by the standards imposed by the National Health Service breast screening programme. The UK 5-point breast imaging scoring system has recently been formalised by Maxwell et al [7] on behalf of the Royal College of Radiologists (RCR) breast group. It promotes standardisation of reporting and is easily understood by all members of the multidisciplinary team. However, unlike BI-RADS, at present it does not give the likelihood of malignancy in each category. Therefore the article by Taylor et al [8] in the November issue of the British Journal of Radiology is timely. The article describes mammography and ultrasound data from 23741 assessment episodes to quantify the likelihood of cancer with each of the 5 points on the UK scoring system and compares them with points of equivalent cancer risk on the BI-RADS score. This will provide a benchmark for centres to audit the unit’s performance. The positive impact that BI-RADS has had on raising standards and unifying research data cannot be underestimated. It has been extensively researched and validated and it is time now for the RCR Breast Group classification to undergo this rigorous testing. The UK 5-point breast imaging scoring system should be used for
Is it time for the imaging community to collaborate and standardise practice in the UK?
communication across the multidisciplinary team with analogous systems for clinical examination, MRI, cytology and histopathology reporting. Any discordance between the clinical scoring systems must be resolved before the management of each case is concluded. The careful development and application of a universally accepted scoring system for breast lesions has played an important role in the diagnosis of breast disease, especially in improving the sensitivity and specificity of diagnosticians and optimising the diagnosis of significant disease while mini-
mising harm by over investigation. As with BI-RADS, the UK 5-point breast imaging scoring system will continue to evolve and has the capacity to incorporate emerging techniques and modalities. It provides an example of how the imaging community can collaborate to standardise practice and ultimately improve patient care. L S Wilkinson and N T F Ridley South West London Breast Screening Service, St George’s Healthcare NHS Trust, London, UK, and Breast Unit, Great Western Hospital, Swindon, UK
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short communication
Development of a fine thermocoupleneedle system for real-time feedback of thermal tumour ablation margin Thermal tumour ablation techniques, represented by the use of radiofrequency (RF) ablation, have been applied to treat tumours in various organs. These methods aim to completely remove local tumours more readily and less invasively compared with surgical resection [1]. The serious problem associated with thermal ablation, however, is that the ablation margin cannot be accurately assessed during the procedure, often resulting in either insufficient or excessive operation. The ablation size of the same RF electrode differs by up to 30% because it varies depending on the water content and blood perfusion in both the tumour and surrounding tissue [2]. Various techniques to expand the ablation area, such as overlapping ablations, temporary block of blood flow and infusion of saline around the electrode, have been used. In such cases, the ablation margin becomes even more unpredictable. Real-time feedback of the ablation margin is therefore needed to perform exact and safe ablation. MR thermal imaging to allow monitoring of the advancing margin of ablation is under investigation and appears promising [3] but will only be applicable in restricted situations. In practical terms, RF ablation is performed under sonographic guidance in many cases. We have therefore devised and tested the efficacy of a superfine thermocouple-needle system (TNS) using fresh porcine livers in vitro and rabbit back muscles and livers in vivo. Method and materials
A 17-gauge internally cooled RF electrode with a 2cm active tip (Cool-tip, Radionics, Burlington, MA) was used to ablate the organs. The single TNS was inserted in an arbitrary site 1cm from 22
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the active tip of the RF electrode and the temperature of the liver around the RF electrode was measured concurrently. After RF ablation, the porcine livers and rabbit back muscles were cut with a scalpel along a longitudinal plane passing through the axis of both the electrode shaft and the TNS. The RF electrode was removed in the rabbit livers but the TNS was left in place and contrast-enhanced CT was then performed. Results and discussion
The ablation areas in the cut surface of porcine livers and rabbit back muscles exhibited a well-defined discoloured region of left-right symmetry relative to the RF electrode. The TNS tip accurately pinpointed the margin of the ablation area in all cases (Figure 1). Contrast-enhanced CT of the rabbit livers also showed the TNS tip precisely located at the margin of areas of no contrast enhancement (Figure 2). These results were identical between the point when the RF current was stopped immediately after reaching a temperature of 60째C (n=17) and after 5 min at more than or equal to 50째C but less than 60째C (n=4). RF induced formation of a discoloured area has been reported to correspond with histological coagulation necrosis [4]. The region with no contrast enhancement after RF ablation on CT also reportedly corresponds to areas of histological coagulation necrosis with an error of less than or equal to 2mm [5]. In cases of ablation of superficial lesions or intraoperative cases, multipoint temperature monitoring is quite simple. Multipoint monitoring, however, may be troublesome for deeply situated lesions. Nonetheless, the ablated areas usually spread concentrically around the electrode and are normally
Ablation area in the cut surface of the porcine liver. The superfine thermocoupleneedle system tip corresponds to the ablation margin (arrow).
smaller in the direction perpendicular to the RF electrode axis than in the direction of the RF electrode axis (although exceptions are seen) typically owing to the conducting effect of blood vessels. We could therefore estimate with relatively good accuracy whether a sufficient margin of ablation could be obtained by placing the single TNS tip at the intended tumour-free safety margin perpendicular to the RF electrode axis. Our results indicate that the TNS accurately identified ablation margins and placement of the TNS tip at the intended ablation margin marks the defined end points and permits exact RF ablation and other thermal ablations, particularly for cases with relatively large lesions in which meticulous setting of ablation margins is required. H Ishizaka, A Shiraishi, S Awata, A Shimizu and S Hirasawa School of Radiological Technology, Gunma, Prefecture College of Health Sciences, Gunma, Japan
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review Article
REVIEW ARTICLE
G M Bydder Department of Radiology, University of California San Diego, San Diego, CA, USA
The Agfa Mayneord lecture: MRI of short and ultrashort T2 and T2* components of tissues, fluids and materials using clinical systems During the first year of clinical MRI only steady state free precession (SSFP), mobile proton density (ρm) and T1 weighted clinical images were available. Clinical heavily T2 weighted spin-echo (SE) images arrived suddenly in February 1982 and transformed the practice of MRI [15–17]. These images showed abnormalities with high signal and contrast, and they rapidly became the mainstay of clinical diagnosis in the brain. Even with the subsequent development of new types of sequences, such as fast spin echo [18], clinical diffusion weighted imaging [19] and fluid attenuated inversion recovery [20], detection of signal from longer mean T2 relaxation components still remains the dominant form of MRI for diagnosis of parenchymal disease in the brain and much of the rest of the body. However, even in 1981 low or zero level signals were recognised in cortical bone by Smith [21] and Edelstein et al [22]. The appearance was attributed to
short mean T2 components in this tissue leading to undetectable signal levels at the time of data acquisition. The lack of signal from normal tissue was useful in providing a dark background against which abnormalities in cortical bone, with mean T2s sufficiently increased to provide detectable signal, could be recognised; however, the absence of signal meant that there was no possibility of measuring normal values of ρm, T1 or T2, or of studying normal perfusion. In addition there was no opportunity for active contrast manipulation, little or no distinction between adjacent short T2 tissues and no normal contrast enhancement or effects from molecular imaging agents. As a result, the study of cortical bone and other MR “invisible” short T2 tissues, such as tendons, ligaments and menisci, has been more limited than that of other tissues, such as brain, liver and muscle, where MR signals are readily detectable with clinical systems. In spite of these difficulties, there has
been a proliferation of new approaches to imaging short T2 tissue components including options for developing tissue contrast in the short T2 and T2* range as well as methods of imaging in the presence of metal. This has included solutions and partial solutions to technical problems some of which have appeared intractable for 20 years or more. The theme of this paper is clinical MRI of “dark matter” i.e. tissues, fluids and materials that show little or no signal with conventional imaging techniques. It includes direct and indirect imaging as well as spectroscopy. As an initial step, some general principles underlying this type of imaging are reviewed.
has not been previously seen with MRI. Magnetisation transfer methods can now be applied to previously invisible tissues providing indirect access to supershort T2 components. Particular methods have been developed to target susceptibility effects and quantify them after correcting for anatomical distortion. Specific methods have
also been developed to image the effects of magnetic iron oxide particles with positive contrast. Major advances have been made in techniques designed to correct for loss of signal and gross image distortion near metal. These methods are likely to substantially increase the range of application for MRI.
General principles
The protons in rigid crystals or solids typically have very short T2s due to fixed field effects; however, in solution, motion of molecules leads to averaging of spin interactions over time and much longer
Abstract A variety of techniques are now available to directly or indirectly detect signal from tissues, fluids and materials that have short, ultrashort or supershort T2 or T2* components. There are also methods of developing image contrast between tissues and fluids in the short T2 or T2* range that can provide visualisation of anatomy, which
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Review article
T2s. This gives rise to the concept of ρm representing more mobile tissue components with T2s that are long compared with those of immobile components. The term “visible” can also be applied to the longer T2 components since they produce detectable signal, and “invisible” can be applied to short T2 components, which do not result in detectable signal. It is important to distinguish between the T2 of the tissue or fluid that reflects effects such as dipolar-dipolar interactions and chemical exchange, and the observed T2 (T2*) of tissues or fluids that also reflects local susceptibility effects, chemical shift and J- coupling as well as flow, magic angle and other effects. The dominant effect among these is often from susceptibility; this results in a shortening of T2* relative to T2 due to inhomogeneous magnetic fields within voxels and intravoxel dephasing. It is often useful to consider relaxivity R2 or R2* which is the reciprocal of T2 or T2*, i.e. 1/T2 or 1/T2 rather than the transverse relaxation times. This is because relaxivities are additive so that, for example, within a voxel:
Thus, the observed relaxivity is the sum of the tissue relaxivity and y times the inhomogeneity in B (i.e., ΔB) within the voxel. Other relaxivities owing to chemical shift, contrast agents, etc. can be added in the same way. When there is a majority of short T2/T2* components in a tissue, fluid or material, it typically appears low signal or dark with clinical imaging techniques. A minority of short T2/T2* components is common in many tissues. In this situation signal is usually apparent from longer T2/T2* components, but little or no contribution to the signal comes from the short T2/T2* components. All tissues have some short T2/T2* components from protons in large molecules including those in membranes. The focus in this paper is on tissue and fluids, but materials may also have short 24
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T2/T2*s and/or low or zero mobile proton densities. This includes relaxation agents, such as gadolinium chelates and susceptibility agents, such as magnetic iron oxide particles (MIOPs). These materials may produce very large susceptibility differences in tissues and fluids and can result in very short T2*s. Many materials, including most plastics, also have short T2s. Other materials, such as contrast agents and metals, may have no significant ρm but can produce strong effects on surrounding tissues. There is no precise definition of what constitutes a short echo time (TE) and what is an ultrashort TE (UTE), and there is argument about how TE should be measured for tissues with short T2s [23–25]. For simplicity, a short TE is taken to be less than 10ms and an ultrashort one less than 1ms. It is also possible to define short T2/T2*s as less than 10ms, ultrashort as less than 1ms and supershort as less than 0.1ms. This reflects the fact that with older MR systems and conventional SE sequences, tissues with T2 or T2*s less than 10ms produced little or no signal and were “invisible”. With more recent systems and gradient echo sequences the cut off is closer to 1ms. Ultrashort pulse sequences can often directly detect signal in the 1–0.1ms range, but indirect methods are usually required to image super short T2 (<0.1ms) tissues. MR signals are usually spatially encoded using frequency and phase effects produced by linear applied gradient fields. Susceptibility effects also include changes in the local field and these may result in errors in locating the position of the signal. In fact the local susceptibility differences may be greater than those of the encoding gradient magnetic field and result in image distortion. This means that in addition to shortening of T2 owing to susceptibility effects resulting in low signal, image distortion may be present with both loss of signal and local “pile up” i.e. increase in signal where signals from different regions are incorrectly superimposed on one another. In general terms phase encoding tolerates gross field distortion much better
than frequency encoding both for slice selection and spatial localisation. Quantitation of tissue or fluid T2*s is made difficult by the addition of other effects; this results in measured values (T2*s) that include effects from local susceptibility and other effects. Measurements may also be confounded by distortion of the spatial encoding process by susceptibility effects. It may also be difficult to assign susceptibility effects to a particular tissue and to distinguish them from inhomogeneity in B0. There are also difficulties in accurate measurement of both T2/T2* values and the relative proportions of two or more different components with the signal-to-noise levels attainable in reasonable times on clinical systems. Imaging may be regarded as direct when it detects signal from the tissues, fluid or materials of interest, and indirect when the signals are detected from other species that are affected by the short T2/ T2* tissues, fluids or materials of interest. For short T2/T2* tissues the most common way of imaging directly is to use a short or UTE to detect short T2/T2* signals before they have decayed to zero, or the noise floor. It is also possible to place highly ordered collagen rich tissues at the magic angle to prolong their T2/T2*s to make the signal detectable. In other situations it is possible to increase the TE so protons in fat and water, which are out of phase, can become in phase and the combined signal can then become detectable. Likewise spin echo sequences can be used to increase T2* by reversing the effects of local field inhomogeneities. Indirect forms of imaging short T2/T2* components include visualisation of the extent of invisible short T2 tissues when they are surrounded by a longer T2 tissue with detectable signal. Another indirect method is to observe the effect of short T2 tissue’s susceptibility or relaxation on the surrounding or adjacent longer T2 tissues. An example of this is to assess trabecular bone by the effect this tissue has on adjacent longer T2* of red or yellow bone marrow. Relaxation agents typically work in this way with no signal directly detect-
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The tissues of the human body can be divided into those that are “visible” in the sense that they provide detectable signal with clinical MR systems and those that are “invisible” because their mean T2s or T2*s are too short to provide a detectable signal. All tissues have multicomponent T2s. This means that they contain a mixture of short and long T2 components. The invisible tissues have a majority of short
T2 components and a minority of long T2 components. The latter components typically do not provide enough signal to be detectable in relation to image noise levels. The “visible” tissues of the body such as brain, liver and muscle have a majority of long T2 components that produce signal with conventional techniques. They also have a minority of short T2 components, which do not contribute significantly to the detectable signal. Within the invisible group of tissues (mean T2<10ms) it is possible to differentiate a first group including tendons, ligaments and menisci with short mean T2s of approximately 1–10ms, a second group including cortical bone and dentine with ultrashort mean T2s of 0.1–1ms. There is also a third group including dental enamel, protons in membranes and molecules, as well as crystalline bone with super short mean T2s of less than 0.1ms. Materials can also be classified in a similar way.
An important factor in this context is the magic angle effect [26, 27] because it can greatly increase the T2 of short T2 tissues, such as tendons, ligaments and meniscii. When the orientation of tissues that contain highly ordered collagen is changed their T2 varies from a minimum at θ=0° where dipolar interactions are greatest, to a maximum where 3cos2 θ–1≈0 and θ=55° where θ is the orientation of the fibres to B0. The increase can be large, for example from 0.6ms to 21ms [26] or from 7ms to 23ms [27] in the Achilles tendon. A recently described phenomenon is directional susceptibility in tendons whereby their bulk magnetic susceptibility varies with orientation to B0 with signals at the water end of the proton spectrum when fibres are parallel to B0 and at the fat end of the spectrum (lower frequency) when fibres are perpendicular to B0 [6]. The difference is relatively large (of the order of three parts per million).
Several different approaches are being used to image short and ultrashort T2 and T2* tissues, fluids and materials. • The first approach is direct and regards the problem as essentially one of imaging short T2 components. This can be addressed by using either a short/UTE and/or a method of increasing T2/T2* so that signal can be detected from the tissue or fluid. This approach is frequently associated with methods of reducing or suppressing the signal from longer T2 components to isolate the short T2 components and improve conspicuity or assist with quantitation. • The second approach is MT that is indirect. This may be extended to invisible tissues by using short TE approaches. The definition of free and bound pools then changes and there may be increased problems in isolating MT effects because of direct saturation of the newly visible pool. • The third approach has been termed SWI where magnitude and/or phase data from a gradient echo sequence are typically used to recognise loss of signal from the tissue itself and/or surrounding tissues if the T2* levels of the tissue are too short
to be detectable with the TE in use. The TE necessary to produce useful contrast between normal and abnormal tissues in an organ may result in loss of signal in other areas of the image where greater susceptibility differences are present. The technique has limitations in situations where the signal becomes undetectable so that it is not possible to calculate magnitude or phase data and in situations where the image becomes distorted because of problems in slice selection and/or frequency encoding. A development from this is quantitative susceptibility imaging (QSI) or susceptibility SWI mapping (SWIM) where approaches are used to assess and correct for the effect of static field perturbations on spatial encoding of the signal and, therefore, to try to avoid compromising signal values. • The fourth is positive contrast or white matter imaging, which assesses the effect of MIOPs. These particles typically reduce the signal from tissues as a result of a decrease in T2 and susceptibility effects. This tends to produce a loss of signal in the area of the image that is of most interest. This can be a particular problem when it occurs in tissues with pre-existing very low signals so that the
reduction is undetectable; however, it is also a problem in other areas where the loss of signal may lead to loss of anatomical detail and poor localisation of the site of contrast agent accumulation. • The fifth group of techniques is targeted at imaging in the presence of metal. Metals may show very large susceptibility differences from those of tissues and can produce very large susceptibility effects with loss of signal due to T2* shortening and gross image distortion. The primary objective in this situation is to deal with the image distortion and restore image integrity to a sufficient degree to make the images clinically useful. In the process short T2* tissues and fluids may become detectable. There is an overlap between these approaches and they may be combined. In some situations it may be appropriate to ignore the effects of susceptibility differences in producing image distortion and regard the problem as one of detecting short T2 signals, whereas in other situations image distortion due to susceptibility is the primary problem that needs to be addressed.
able from them, but the effects detectable through relaxation or susceptibility effects produced on the protons in associated water or other tissues. A third indirect method is magnetisation transfer (MT) that typically magnetically saturates invisible short T2 components and results in a change in the magnetisation transferred to the longer T2 components. This usually results in a shortening of T1 and a reduction in detectable signal in the detected longer T2 component. Tissue, fluid and material properties
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review article
The ρm of tissues also varies markedly; bone has a ρm of 15–20% and semisolid tissues, such as tendons and ligaments, have values of 60–70%. ρm is generally a more important factor in generating contrast with short T2 tissues than it is with longer T2 tissues. The low ρm for bone places a limit on the maximum signal than can be obtained from it. Both the low ρm and the short T2* of cortical bone contribute to its low signal intensity. The mean T1s of some tissues with a majority of short T2 components is short with cortical bone having a particularly short T1, in fact less than that of fat [28]. The relative differences in mean T2 or T2* between normal and abnormal tissues are often much greater than those in mean T1. Relative to air, soft tissues generally show a susceptibility difference of approximately -9ppm, and bone and calcified tissue approximately -11 ppm. By comparison the principal peak of fat resonates at approximately -12 ppm. Paramagnetic materials show small positive frequency shifts and superparamagnetic materials show greater positive shifts. Metals, for example titanium, metal alloys and some types of stainless steel, may show very large positive shifts of 10s to 1000s of parts per million. The changes in field may be considerably greater than machine gradient fields used to encode MR signals and therefore may cause image distortion. In disease, increases in T2 are frequently seen, but decreases in T2 may be seen with increased iron content and in other disease processes. Loss of magic angle effect may be seen in degeneration and fibrosis. Acquisition methods for short T2/T2* components
Some of the techniques now being used to directly detect signal from tissues on clinical systems have been used in material science and tissue studies using small bore high field spectrometers for many years. The methods are now in use on clinical systems that are usually lower performance in terms of B0, gradient strength, slew rate and peak B1 field. The prototype sequence for imaging short T2 tissues is single26
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point imaging (SPI) where a single point in k-space is acquired with an UTE. This is typically used with three-dimensional (3D) phase encoding, which tolerates field distortions well, but unfortunately makes the technique time consuming even with optimised k-space sampling [29]. It is possible to acquire several points at a time, which makes the sequences more time efficient but results in longer TEs for the additional points [30]. There are also free induction decay (FID)-based techniques where a radial line of k-space is acquired from the centre out [31]. This can be coupled with long T2 water and fat suppression to selectively image short T2 components as water and fat-suppressed proton projection imaging (WASPI) [32]. Other trajectories in k-space are possible including a stack of spirals (SOS) [33] and echo planar imaging (EPI). A particularly innovative method of imaging short T2 components is to divide the excitation pulse into sub-pulses and acquire data after each of these pulses. This is known as sweep imaging with Fourier transformation (SWIFT) or simultaneous excitation and acquisition (SEA). The acquired data needs to be deconvolved with the excitation pulse, but the end result is a much more time efficient acquisition than with typical 3D acquisitions [34–37]. Other techniques that have only been used in the pre-clinical phase include methods in which radiofrequency (rf) absorption is assessed rather than signal detection [38]. The methods borrow from continuous wave spectroscopy and electron spin resonance where electronic T2s are extremely short and may be of the order of a microsecond. Magnetisation preparation signal suppression techniques and pulse sequences
Traditional contrast mechanisms exploiting differences in ρm, chemical shift and other tissue properties can be used in ways that are already well known from conventional imaging. There are also numerous old contrast mechanisms operating in new ways as well as new contrast mechanisms that are of
interest in imaging short/ultrashort T2/T2* components in tissue. They are typically used in conjunction with the acquisition techniques mentioned in the previous section. These provide a wide range of possible ways of effecting magnetisation. For example, 90°, 180°, fat saturation and magnetisation transfer pulses can all be used to suppress unwanted long T2 signals and to produce T2 contrast in the short T2 range. There are some fairly new potential mechanisms (as far as clinical imaging is concerned) that involve reductions in dipolar coupling [39, 40] and double quantum filters [41]. These techniques are usually used in conjunction with one of the acquisition methods previously described. Magnetisation transfer
When used for short T2/T2* tissues this differs from conventional clinical approaches because short/UTE acquisitions makes it possible to study MT in tendons, ligaments, menisci and cortical bone [42], and tendon [43]. The definition of the bound (short T2) and free (long T2) pools may change because previously undetected signals are included in the free (detectable) pool. Direct saturation is a greater problem. There may be a greater degree of magnetisation exchange present in short mean T2 tissues. The technique provides indirect access to supershort T2 relaxation components in tissues with T2s of approximately 5–15us, which are not directly accessible with most UTE techniques. Susceptibility weighted imaging
SWI has been in use for a considerable amount of time. It usually exploits reductions in T2* to develop contrast; the imaging may use both magnitude and phase data [44, 45]. The T2* may be so short that it becomes, in effect, an indirect form of imaging using the reduction in signal of adjacent longer T2 components. The applicability of the technique and related methods can be expanded by using forms of data collection with short or UTEs that can detect signal from very short T2* components [46, 47]. Quantitative methods of imaging susceptibility
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changes need to account for errors in spatial encoding, which may require solutions to complex inverse problems [48, 49]. To date, the techniques have mainly been applied to brain imaging. Phase and frequency changes can be detected in ordered fibrous structures even with UTE sequences [47]. Positive contrast and white marker imaging
These forms of imaging have been used to describe particular situations with MIOPs that may not only reduce T2 and T2*, but produce local field distortions. A variety of different methods are available. It is possible to selectively excite only off resonance spins. It is also possible to apply an additional gradient so that only the magnetisation of spins in regions affected by MIOPs is refocused. The inhomogeneities from the particles induce echo shifts and these can be used to calculate and correct for the field distortion. The images reflect both tissue MIOP concentration and deviations of the local magnetic field produced by the particles [50–54]. Techniques using SWIFT [55] and UTE [56–58] have also been successful for imaging MIOPs. Imaging in the presence of metal
When forms of metal are implanted in the body an extreme situation may arise in which there is very marked T2* shortening, but the image distortion is so great that images of regions adjacent to the metal can not be interpreted. This has been a longstanding problem. A variety of solutions have been proposed in the past, but these have had relatively little clinical impact. The recent development of multi-acquisition variable-resonance image combination (MAVRIC) [59] and slice encoding for metal artefact correction (SEMAC) [60] has resulted in a remarkable degree of restoration of images that are grossly degraded by metallic artefact when imaged using conventional approaches [61]. The use of MAVRIC irradiation and detection of signal at the same off-resonant frequency can image signals whose resonant frequency has been shifted by metal. The results from different off resonance frequencies
review article
are then combined. SEMAC uses phase encoding during slice selection to relocate signals that are improperly located by the slice selection process. View angle tilting (VAT) [62] is then used with this technique to correct for errors with in-plane spatial encoding. Faster versions [63, 64] and a MAVRIC-SEMAC hybrid [65] have also been implemented; the term multispectral imaging (MSI) has been applied to these approaches. UTE alone shows an improvement over conventional techniques [66], but this technique may be more effective in combination with MAVRIC [67]. It may also be used in the form of radial sampling with off resonance recognition (RASOR) [68]. There is continued technical progress in mapping gradient and B1 distortion [69, 70]. Imaging of boundaries involving short T2/ T2* tissues
Structures of interest in the short T2 range include thin layers, such as those in entheses, periosteum and the deep layers of articular cartilage where there are short T2 tissues, susceptibility effects between the soft (or semisolid) tissues and bone, as well as partial volume effects between these tissues that are present over curved surfaces. In this situation high resolution 3D isotropic UTE imaging often has a distinct advantage since it can detect short T2/T2* signals as well as reduce the impact of susceptibility differences and partial volume effects. Imaging of ordered fibrous structures, such as tendons and ligaments, include some of the above issues, but in addition loss of contrast of the fibre structure or “blurred” appearance may arise from obliquity of the fibres relative to the imaging slice. This effect may simulate changes due to disease. There are also distinctive artefacts at boundaries from chemical shift effects including those associated with radial acquisitions.
Clinical proton applications
There are now two-dimensional (2D) and 3D UTE sequences available with imaging times of 5–6min and clinically acceptable spatial resolutions [33, 71]. In general, the difficulty of acquiring short/
ultrashort T2/T2* signals means that invisible tissues are imaged at lower spatial resolution, but with signal levels and contrast that are not attainable with conventional techniques. There is a balance necessary to obtain qualitative and/or quantitative information which is novel with spatial resolutions that are sufficient to show anatomical features with acceptable clarity. Conclusion
Imaging of short T2 and T2* components is an expanding area of application for MRI, which has seen a convergence of methods primarily targeted at tissues with short T2 components, SWI, MIOP imaging and metal artefact control. The methods have borrowed from solid state imaging, spectroscopy (including continuous wave methods), electron spin resonance and MR microscopy. The much lower technical performance of clinical systems compared with small bore spectrometers is a major limitation, but innovative methods for overcoming this problem are now being developed. The tissues of interest have mainly been in the musculoskeletal system, but all tissues of the body have some short T2 components and study of these may prove to be of diagnostic importance. Some techniques, such as imaging in the presence of metal (Figure 8) are likely to be immediately useful in the clinical domain, while others will probably require validation and comparative assessment to establish their role. Quantitative approaches may be useful given the large fractional changes in short T2 and T2* components that may be seen in disease. The techniques used for imaging often require high gradient performance with control of short term eddy currents to a level not previously thought necessary in clinical MR systems. In spite of these and other technical difficulties, application of the study for short T2 and T2* tissues appears to be an area of MRI that will be of considerable importance in the near future. www
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The British Journal of Radiology Abstracts
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Abstracts Quantification of the UK 5-point breast imaging classification and mapping to BI-RADS to facilitate comparison with international literature Objective:
The UK 5-point breast imaging scoring system, recently formalised by the Royal College of Radiologists breast group, does not specify the likelihood of malignancy in each category. The breast imaging and reporting data system (BI-RADS) is widely used throughout North America and much of Europe. The main purpose of this study is to quantify the cancer likelihood of each of the UK 5-point categories and map them to comparable BI-RADS categories to facilitate comparison with North American and European literature and publication of UK research abroad.
Methods:
During the 8 year study period, mammogram and ultrasound results were UK scored and the percentage
of cancer outcomes within each group calculated. These were then compared with the percentage incidence of the BI-RADS categories. Results: Of 23741 separate assessment episodes, 15288 mammograms and 10642 ultrasound examinations were evaluated. There was a direct correlation between UK scoring and BI-RADS for categories 1 and 5. UK Score 2 lipomas and simple cysts correlated with BI-RADS 2, with the remaining UK Score 2 lesions (mostly fibroadenomas) assigned to BI-RADS 3. BI-RADS 4 incorporates a wide range of cancer risk (2â&#x20AC;&#x201C;95%) with sub-divisions a, b and c indicating increasing, but unspecified, likelihood of malignancy. UK Score 3 correlated with BI-RADS 4
a/b and UK Score 4 corresponded with BI-RADS 4c. Conclusion: This study quantifies the cancer likelihood of the UK scoring and maps them to parallel BI-RADS categories, with equivalent cancer risks. This facilitates the ability to share UK research data and clinical practice on an international scale.
K Taylor, P Britton, S Oâ&#x20AC;&#x2122;Keeffe and M G Wallis Department of Radiology, Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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A pilot study to evaluate assisted freehand ultrasound elasticity imaging in the sizing of early breast cancer: a comparison of B-mode and AFUSON elasticity ultrasound with histopathology measurements Objective:
This pilot study investigates the role of assisted-freehand ultrasound (AFUSON) elasticity imaging of the breast in assessing the contour, size and area of 23 early breast cancers by making comparison of AFUSON with the equivalent B-mode images and gold standard histopathology slides. Methods:
The B-mode, AFUSON and digitised histopathology slides of three early breast cancers were compared for contour, size and area with histopathology scans. AFUSON features that corresponded to areas of known malignant change on the histopathology slides were regarded as diagnostic. These diagnostic criteria were then applied to the B-mode and AFUSON 28
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elasticity images of all 23 breast cancers in the pilot study without having the availability of the histopathology scans for reference. Corresponding diameters were measured and the results were compared with the equivalent measurements on the scans of the histology slides. The results were tabulated in histogram form. Diagnostic confidence levels were evaluated. Results: Size dimensions accuracy increased from 66% using B-mode alone to 82% using combined B-mode and AFUSON elasticity images. Tumour area accuracy was also increased. A small number of cases had a striking visual similarity of shape on AFUSON elasticity scans and histopathology slides.
Conclusion: In spite of the shortfalls in this study, AFUSON elasticity imaging was capable of acquiring some high-quality images that showed strong correlation between AFUSON elasticity and scans of histology slides. Further studies will be carried out to refine the technique and determine if it has a role in the diagnosis and management of breast cancer.
R E English, J Li, A J C Parker, D Roskell, R F Adams, V Parulekar, J Baldwin, Y Chi and J A Noble Oxford Breast Imaging Centre, Oxford Radcliffe Hospitals NHS Trust, Oxford UK
www Download the full length article: DOI: 10.1259/bjr/13216246
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The British Journal of Radiology Abstracts www
For more Abstracts visit: bjr.birjournals.org
Organ and effective dose reduction in adult chest CT using abdominal lead shielding Objectives:
The purpose of this study was to evaluate and compare organ and effective dose savings that could be achieved using conventional lead aprons and a new, custom-designed shield as out-of-plane shielding devices during chest CT scans. Methods:
Thermoluminescent dosemeters were used to measure doses throughout the abdomen and pelvis during CT scans of the chest of a RANDO phantom. Dose measurements were made with no shielding, with lead aprons and with the new shield around the abdomen and pelvis in order to quantify the achievable organ and effective dose reductions.
Results: Average dose savings in the 10 phantom sections ranged from 5â&#x20AC;&#x201C;78% with the highest point dose saving of 93% being found in the mid-pelvis. When shielding was used, the maximum measured organ dose reduction was a 72% dose saving to the testes. Significant dose savings were found throughout the abdomen and pelvis, which contributed to an effective dose saving of 4% that was achieved over and above the dose savings obtained through conventional optimisation strategies. This could yield significant population dose savings and reductions in collective radiation risk.
Conclusion: In this study significant organ and effective dose reductions have been achieved through the use of abdominal shielding during chest CT examinations and it is therefore recommended that out-of-plane patient shielding devices should be used for all chest CT scans and potentially for every CT scan, irrespective of body part.
G R Iball and D S Brettle Department of Medical Physics & Engineering, Old Medical School, Leeds General Infirmary, Leeds, UK
www Download the full length article: DOI: 10.1259/bjr/53865832
Radiation protection for an intraoperative X-ray device Objectives:
Partial breast irradiation can be delivered intraoperatively using the Intrabeam 50 kVp compact X-ray device. Spherical applicators are added to the source to give an isotropic radiation dose. The low energy of this unit leads to rapid attenuation with distance, but dose rates are much greater than for diagnostic procedures. Methods:
To investigate the shielding requirements for this unit, attenuation measurements were carried out with manufacturer-provided tungstenâ&#x20AC;&#x201C; rubber sheets, lead, plasterboard and bricks. A prospective environmental dose rate survey was also conducted in the designated theatre.
Results: As a result of isotropic geometry, the scattered dose around shielding can be 1% of primary and thus often dominates measured dose rates compared with transmission. The absorbed dose rate of the unshielded source at 1 m was 11.6 mGy h-1 but this was reduced by 95% with the shielding sheets. Measured values for the common shielding materials were similar to reference data for the attenuation of a 50 kVp diagnostic X-ray beam. Two lead screens were constructed to shield operators remaining in the theatre and an air vent into a service corridor. A lead apron would also provide suitable attenuation, though a screen allows greater flexibility for treatment operators. With these measures, staff doses were reduced to negligible quantities. Survey measurements taken
during patient treatments confirmed no additional measures were required, but the theatre should be a controlled area and access restricted. Conclusion: Results from this study and reference data can be used for planning other facilities.
D J Eaton, R Gonzalez and S Duck Radiotherapy Physics, Royal Free Hospital, London, UK
www Download the full length article: DOI: 10.1259/bjr/29466902
issue 6 December 2011
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The British Journal of Radiology Abstracts
Clinical dose performance of full field digital mammography in a breast screening programme Objectives:
BreastCheck, the Irish Breast Screening Programme, has employed three different models of full field digital mammography (FFDM) system since its transition to a digital service in 2007. The three models from GE Healthcare, Hologic and Sectra exhibit differences in their design and function, the most significant of which include anode target/filter choice, detector technology and the type of exposure automation. Methods:
The aim of this study was to use the results from a clinical breast dose survey to examine the differences between three different FFDM models in terms of exposure selection, breast mean glandular dose (MGD) and automatic exposure control (AEC) dose contribution.
Results: The accuracy of the dose estimation was improved by inclusion of the AEC pre-exposure dose contribution. The photon-counting system demonstrated the lowest average MGD. The GE Healthcare and Hologic flat-panel detector systems demonstrated a small but statistically significant dose difference. The pre-exposure dose contribution did not exceed 13% of the total exposure dose for any system in the survey. A comparison of the system calculated organ dose estimate from each machine with the corresponding MGD calculated from medical physics measurements indicated reasonably accurate organ dose estimates for most systems in the survey.
Conclusion: The results of this study provide a comprehensive assessment of the breast dose performance of current digital mammography systems in a clinical screening setting.
J B McCullagh, P Baldelli and N Phelan BreastCheck, The National Cancer Screening Service, Infirmary Road, Cork, Ireland
www Download the full length article: DOI: 10.1259/bjr/83821596
Acute appendicitis: relationships between CT-determined severities and serum white blood cell counts and C-reactive protein levels Objectives:
The aim of this study was to evaluate the relationships between the severity of appendicitis as depicted on CT and blood inflammatory markers of serum white blood cell (WBC) count and C-reactive protein (CRP). Methods:
CT images in 128 patients (109 surgically proven and 19 with clinically excluded appendicitis) were retrospectively reviewed. Two radiologists by consensus evaluated and scored (using a 0, 1 or 2 point scale) severities based on CT-determined appendiceal diameters, appendiceal wall changes, caecal changes, periappendiceal inflammatory stranding and phlegmon or abscess formation. We investigated whether CT findings were significantly related to elevated WBC counts or CRP levels 30
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and performed the correlations of WBC counts and CRP levels with CT severity scores. Patients were also subjectively classified using four grades from normal (Grade I) to perforated appendicitis (Grade IV) on the basis of CT findings to evaluate differences in WBC counts and CRP between grades. Results: Only appendiceal wall changes and the phlegmon or abscess formation were related to elevated WBC counts and CRP levels, respectively (p<0.05). CT severity scores were found to be more strongly correlated with CRP levels (r =0.669) than with WBC counts (r=0.222). On the basis of CT grades, the WBC counts in Grade I was significantly lower than in other grades (p<0.001), whereas CRP levels in Grade IV were significantly higher than in other grades (p<0.001).
Conclusion: CRP levels were found to correlate with CT-determined acute appendicitis severity and could be a useful predictor for perforated appendicitis, whereas WBC counts might be useful to detect early acute appendicitis.
H C Kim, D M Yang, C M Lee, W Jin, D H Nam, J Y Song and J Y Kim Department of Radiology, EastWest Neo Medical Center, KyungHee University, 149 Sangil-dong, Gangdong-gu, Seoul, Republic of Korea
www Download the full length article: DOI: 10.1259/bjr/47699219
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The British Journal of Radiology Abstracts
MRI manifestations of soft-tissue haemangiomas and accompanying reactive bone changes Objectives:
Soft-tissue haemangiomas are common benign vascular lesions that can be accompanied by reactive changes in the adjacent bone structure. This study aimed to discuss the MRI features of soft-tissue haemangiomas with an emphasis on changes in bone. Methods:
The radiographic and MRI findings of 23 patients (9 males, 14 females; mean age 25 years; age range 2â&#x20AC;&#x201C;46 years) with soft-tissue haemangiomas were analysed retrospectively. MR images were evaluated for location of the lesion, size, configuration, signal features, contrast patterns, proximity to adjacent bone and changes in the accompanying bone. Excisional biopsy was performed in 15 patients.
Results:
Radiographs demonstrated phleboliths in 8 patients (34%) and reactive bone changes in 4 (19%). On MRI, T1 weighted images showed that most of the lesions were isointense or isohyperintense, as compared with muscle tissue; however, on T2 weighted images all lesions appeared as hyperintense. Following intravenous gadolinium-diethylene triamine pentaacetic acid (DTPA) administration, homogenous enhancement was observed in 3 lesions and heterogeneous enhancement was seen in 19. No enhancement was observed in one patient. Bone atrophy adjacent to the lesion was observed in four patients.
Conclusion:
MRI is the most valuable means of diagnosing deep soft-tissue haemangiomas. Bone changes can accompany deeply situated haemangiomas; in four of our patients we found atrophy of the bone adjacent to the lesion. To our knowledge, this is the first report in the literature regarding atrophy of the bone adjacent to a lesion.
A Pourbagher, M A Pourbagher, B Karan and G Ozkoc Baskent University Faculty of Medicine, Department of Radiology, Adana, Turkey
www Download the full length article: DOI: 10.1259/bjr/58308513
Pulmonary thin-section CT findings in acute Moraxella catarrhalis pulmonary infection Objectives:
Moraxella catarrhalis is an important pathogen in the exacerbation of chronic obstructive pulmonary disease. The aim of this study was to assess the clinical and pulmonary thin-section CT findings in patients with acute M. catarrhalis pulmonary infection. Methods:
Thin-section CT scans obtained between January 2004 and March 2009 from 292 patients with acute M. catarrhalis pulmonary infection were retrospectively evaluated. Clinical and pulmonary CT findings in the patients were assessed. Patients with concurrent infection, including Streptococcus pneumoniae (n=72), Haemophilus influenzae (n=61) or multiple pathogens were excluded from this study.
Results:
The study group comprised 109 patients (66 male, 43 female; age range 28â&#x20AC;&#x201C;102 years; mean age 74.9 years). Among the 109 patients, 34 had communityacquired and 75 had nosocomial infections. Underlying diseases included pulmonary emphysema (n=74), cardiovascular disease (n=44) or malignant disease (n=41). Abnormal findings were seen on CT scans in all patients and included groundglass opacity (n=99), bronchial wall thickening (n=85) and centrilobular nodules (n=79). These abnormalities were predominantly seen in the peripheral lung parenchyma (n=99). Pleural effusion was found in eight patients. No patients had mediastinal and/or hilar lymph node enlargement.
Conclusion: M catarrhalis pulmonary infection was observed in elderly patients, often in combination with pulmonary emphysema. CT manifestations of infection were mainly ground-glass opacity, bronchial wall thickening and centilobular nodules.
F Okada, Y Ando, T Nakayama, S Tanoue, R Ishii, A Ono, M Watanabe, H Takaki, T Maeda and H Mori Department of Radiology, Oita University Faculty of Medicine, Oita, Japan
www Download the full length article: DOI: 10.1259/bjr/42762966
issue 6 december 2011
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The British Journal of Radiology Abstracts
Reducing intratumour acute hypoxia through bevacizumab treatment, referring to the response of quiescent tumour cells and metastatic potential Objectives:
The aim was to evaluate the influence of bevacizumab on intratumour oxygenation status and lung metastasis following radiotherapy, with specific reference to the response of quiescent (Q) cell populations within irradiated tumours.
tumours were isolated and incubated with a cytokinesis blocker. The responses of the Q and total (P + Q) cell populations were assessed based on the frequency of micronuclei using immunofluorescence staining for BrdU. In the other tumourbearing mice, macroscopic lung metastases were enumerated 17 days after irradiation.
Conclusion:
Bevacizumab has the potential to reduce perfusion-limited acute hypoxia and some potential to cause a decrease in the number of lung metastases as well as nicotinamide.
Methods:
B16-BL6 melanoma tumour-bearing C57BL/6 mice were continuously given 5-bromo-2-deoxyuridine (BrdU) to label all proliferating (P) cells. They received c-ray irradiation following treatment with the acute hypoxia-releasing agent nicotinamide or local mild temperature hyperthermia (MTH) with or without the administration of bevacizumab under aerobic conditions or totally hypoxic conditions, achieved by clamping the proximal end of the tumours. Immediately after the irradiation, cells from some
Results:
3 days after bevacizumab administration, acute hypoxia-rich total cell population in the tumour showed a remarkably enhanced radiosensitivity to c-rays, and the hypoxic fraction (HF) was reduced, even after MTH treatment. However, the hypoxic fraction was not reduced after nicotinamide treatment. With or without c-ray irradiation, bevacizumab administration showed some potential to reduce the number of lung metastases as well as nicotinamide treatment.
S Masunaga, Y Liu, H Tanaka, Y Sakurai, M Suzuki, N Kondo, A Maruhashi and K Ono Department of Particle Radiation Oncology, Research Reactor Institute, Kyoto University, Osaka, Japan
www Download the full length article: DOI: 10.1259/bjr/38457938
Accuracy of contrast-enhanced ultrasound in the detection of bladder cancer Objectives:
To assess the accuracy of contrastenhanced ultrasound (CEUS) in bladder cancer detection using transurethral biopsy in conventional cystoscopy as the reference standard and to determine whether CEUS improves the bladder cancer detection rate of baseline ultrasound. Methods:
43 patients with suspicion of bladder cancer underwent conventional cystoscopy with transurethral biopsy of the suspicious lesions. 64 bladder cancers were confirmed in 33 out of 43 patients. Baseline ultrasound and CEUS were performed the day before surgery and the accuracy of both techniques for bladder cancer detection and for number of detected tumours was analysed and compared with the final diagnosis. 32
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Results: CEUS accuracy was significantly better than ultrasound accuracy in terms of presence or absence of bladder cancer: 88.37% vs 72.09%. Seven of eight uncertain baseline US results were correctly diagnosed using CEUS. CEUS sensitivity was also better than that of baseline US per number of tumours: 65.62% vs 60.93%. CEUS sensitivity for bladder cancer detection was very high for tumours larger than 5 mm (94.7%) but very low for tumours <5 mm (20%) and also had a very low negative predictive value (28.57%) in tumours <5 mm.
Conclusion:
CEUS provided higher accuracy than baseline ultrasound for bladder cancer detection, being especially useful in non-conclusive baseline ultrasound studies.
C Nicolau, L Bunesch, L Peri, R Salvador, J M Corral, C Mallofre and C Sebastia Diagnostic Imaging Center, Hospital Clinic, University of Barcelona, Barcelona, Spain
www Download the full length article: DOI: 10.1259/bjr/43400531
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The British Journal of Radiology Abstracts
Diffusion-weighted imaging in the assessment of tumour grade in endometrial cancer Objectives:
Endometrial cancer is the most common gynaecological malignancy in developed countries. Histological grade and subtype are important prognostic factors obtained by pipelle biopsy. However, pipelle biopsy ‘‘samples’’ tissue and a high grade component that requires more aggressive treatment may be missed. The purpose of the study was to assess the use of diffusionweighted MRI (DW-MRI) in the assessment of tumour grade in endometrial lesions. Methods: 42 endometrial lesions including 23 endometrial cancers and 19 benign lesions were evaluated with DW-MRI (1.5T with multiple b-values between 0 and 750 s mm-2). Visual evaluation and the calculation of mean and minimum apparent diffusion coefficient (ADC) value were performed and correlated with histology.
Results:
The mean and minimum ADC values for each histological grade were 1.02±0.29×103 mm2s-1 and 0.74±0.24×10-3mm2s-1 (Grade 1), 0.88±0.39×10-3mm2s-1 and 0.64±0.36×103 mm2s-1 (Grade 2), and 0.94±0.32×10-3mm2s-1 and 0.72±0.36×10-3mm2s-1 (Grade 3). There was no statistically significant difference between tumour grades. However, the mean ADC value for endometrial carcinoma was 0.97±0.31, which was significantly lower (p<0.0001) than that of benign endometrial pathology (1.50±0.14). Applying a cutoff mean ADC value of less than 1.28×103 mm2s-1 we obtained a sensitivity, specificity, positive predictive value and negative predictive value for malignancy of 87%, 100%, 100% and 85.7%, respectively.
Conclusion: Tumour mean and minimum ADC values are not useful in differentiating histological tumour grade in endometrial carcinoma. However, mean ADC measurement can provide useful information in differentiating benign from malignant endometrial lesions. This information could be clinically relevant in those patients where pre-operative endometrial sampling is not possible.
N Bharwani, M E Miquel, A Sahdev, P Narayanan, G Malietzis, R H Reznek and A G Rockall Department of Imaging and Department of Clinical Physics, Barts and The London NHS Trust, London, UK
www Download the full length article: DOI: 10.1259/bjr/14980811
Spinous process fractures in osteoporotic thoracolumbar vertebral fractures Objectives:
To evaluate the incidence and pattern of spinous process fractures (SPFs) in patients with osteoporotic compression fractures (OCFs) of the thoracolumbar spine. Methods:
Spinal MRI or CT of 398 female patients (age range 50–89 years, mean age 70 years) who had OCFs in the thoracolumbar spine were retrospectively reviewed. The incidence, location and imaging results for the SPFs were evaluated.
Results:
Of the 398 patients who had thoracolumbar OCFs, 14 (3.5%) had SPF. In six patients with single compression fractures, the SPF occurred at the level just above the vertebral compression fracture. In six out of seven patients with multiple continuous compression fractures, the SPF occurred just one level above the uppermost level of the compression fracture. The remaining one patient who had thoracolumbar spinal fixation at T12–L2 with continuous compression fractures in T12–L5 had a SPF in L2. In one patient who had multiple compression fractures in discontinuous levels (fractures at T10 and L1, respectively), the SPF occurred at T12. The directions of the fractures were vertical or oblique vertical (perpendicular to the long axis of the spinous process) in all cases.
Conclusion: In the presence of an OCF in the thoracolumbar spine, a SPF was found in 3.5% of cases, and most of the fractures were located just one level above the compression fracture. Therefore, in patients who have OCF, the possibility of a SPF in the level just above the compression fracture should be considered.
M R N Seo, S Y Park, J S Park, W Jin and K N Ryu Department of Radiology, Kyung Hee University Medical Centre, Dongdaemunku, Seoul, Korea
www Download the full length article: DOI: 10.1259/bjr/32143781
issue 6 December 2011
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The British Journal of Radiology Abstracts
Comparing the accuracy of initial head CT reporting by radiologists, radiology trainees, neuroradiographers and emergency doctors Objectives:
Demand for out-of-hours cranial CT imaging is increasing and some departments have considered addressing this shortfall by allowing non-radiologists to provisionally report imaging studies. The aim of this work was to assess whether it is appropriate for non-radiologists to report head CTs by comparing the misreporting rates of those who regularly report head CTs with two groups of non-radiologists who do not usually report them: neuroradiographers and emergency doctors.
Methods:
62 candidates were asked to report 30 head CTs, two-thirds of which were abnormal, and the results were compared by non-parametric statistical analysis.
Results: There was no evidence of a difference in the score between neuroradiographers, neuroradiologists and general consultant radiologists. Neuroradiographers scored significantly higher than senior radiology trainees, and the emergency doctors scored least well.
Conclusion: The results of this preliminary study show that appropriately trained neuroradiographers are competent at reporting the range of abnormalities assessed with this test and that their misreporting rates are similar to those who already independently report these studies.
F A Gallagher, K Y Tay, S L Vowler, H Szutowicz, J J Cross, D J McAuley and N M Antoun Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge,UK
www Download the full length article: DOI: 10.1259/bjr/24581602
National reference doses for dental cephalometric radiography Objectives:
Diagnostic reference levels (DRLs) are an important tool in the optimisation of clinical radiography. Although national DRLs are provided for many diagnostic procedures, including dental intra-oral radiography, there are currently no national DRLs set for cephalometric radiography. In the absence of formal national DRLs, the Health Protection Agency (HPA) has previously published National Reference Doses (NRDs) covering a wide range of diagnostic X-ray examinations. The aim of this study was to determine provisional NRDs for cephalometric radiography.
Methods: Measurements made by the Dental X-ray Protection Service (DXPS) of the HPA, as part of the cephalometric X-ray equipment testing service provided to dentists and dental trade companies throughout the UK, were used to derive provisional NRDs.
Conclusion: This report proposes provisional NRDs of 40 mGy cm2 and 25 mGy cm2 for adult and child lateral cephalometric radiographs, respectively; these doses could be considered by employers when establishing their local DRLs.
Results:
Dose-area product measurements were made on 42 X-ray sets. Third quartile dose-area product values for adult and child lateral cephalometric radiography were found to be 41mGy cm2 and 25 mGy cm2, respectively with individual measurements ranging from 3mGy cm2 to 108 mGy cm2.
J R Holroyd Health Protection Agency, Occupational Services Department, Hospital Lane, Cookridge, Leeds, UK
www Download the full length article: DOI: 10.1259/bjr/26420990
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The British Journal of Radiology Abstracts
Dosimetric and radiobiological comparison of helical tomotherapy, forward-planned intensity-modulated radiotherapy and two-phase conformal plans for radical radiotherapy treatment of head and neck squamous cell carcinomas Objectives:
The usual radical radiotherapy treatment prescribed for head and neck squamous cell carcinoma (HNSCC) is 70 Gy (in 2 Gy per fraction equivalent) administered to the high-risk target volume (TV). This can be planned using either a forward-planned photon-electron junction technique (2P) or a single-phase (1P) forward-planned technique developed in-house. Alternatively, intensity-modulated radiotherapy (IMRT) techniques, including helical tomotherapy (HT), allow image-guided inversely planned treatments. This study was designed to compare these three planning techniques with regard to TV coverage and the dose received by organs at risk. Methods: We compared the doseâ&#x20AC;&#x201C;volume histograms and conformity indices (CI) of the three
planning processes in five patients with HNSCC. The tumour control probability (TCP), normal tissue complication probability (NTCP) and uncomplicated tumour control probability (UCP) were calculated for each of the 15 plans. Further, we explored the radiobiological rationality of a dose-escalation strategy. Results:
The CI for the high-risk clinical TV (CTV1) in the 5 patients were 0.78, 0.76, 0.82, 0.72 and 0.81 when HT was used; 0.58, 0.56, 0.47, 0.35 and 0.60 for the singlephase forwardplanned technique; and 0.46, 0.36, 0.29, 0.22 and 0.49 for the two-phase technique. The TCP for CTV1 with HT were 79.2%, 85.2%, 81.1%, 83.0% and 53.0%; for single-phase forward-planned technique, 76.5%, 86.9%, 73.4%, 81.8% and 31.8%; and for the two-phase technique, 38.2%, 86.2%, 42.7%,
0.0% and 3.4%. Dose escalation using HT confirmed the radiobiological advantage in terms of TCP. Conclusion: TCP for the single-phase plans was comparable to that of HT plans, whereas that for the two-phase technique was lower. Centres that cannot provide IMRT for the radical treatment of all patients could implement the single-phase technique as standard to attain comparable TCP. However, IMRT produced better UCP, thereby enabling the exploration of dose escalation. S Chatterjee, N Willis, S M Locks, J H Mott and C G Kelly Northern Centre for Cancer Care, Freeman Hospital, Newcastle upon Tyne, UK
www Download the full length article: DOI: 10.1259/bjr/53812025
A preliminary comparison of total skin electron treatment techniques to demonstrate the application of a mid-torso phantom for measurement of dose penetration Objectives:
In the UK the treatment of patients with mycosis fungoides using total skin electron (TSE) beam therapy is undertaken using a number of different irradiation techniques. As part of a review of these techniques a comparative set of measurements would be useful to determine how the techniques differ in terms of dose distribution. A dose penetration intercomparison method which could be used as part of such a study is presented here.
Methods:
The dose penetrations for six treatment techniques currently or recently used in four centres in the UK were measured. The variation of dose with skin depth was measured in a WT1 solid water midtorso phantom. The phantom is portable and suitable to be used in all the techniques. It is designed to hold four small radiochromic film dosemeters to investigate the variation in dose around the mid-torso. For each treatment technique the phantom was irradiated using the clinical set-up. Results:
The phantom performed well and was able to measure dose penetration and the uniformity of penetration for several treatment techniques.
Conclusion:
These preliminary results demonstrate that there is some variation in dose distribution between different TSE treatment techniques and that the phantom could be used in a more comprehensive intercomparison. The results are not intended to demonstrate comprehensively the range of penetration which can be achieved in clinical practice as, for one of the treatment techniques, the penetration is customised for the extent of the disease.
G Baugh, T Al-Alawi, C L Fletcher, J A Mills and R J Grieve Department of Clinical Physics and Bioengineering, University Hospital, Coventry, UK
www Download the full length article: DOI: 10.1259/bjr/52924135
issue 6 December 2011
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FEBRUARY
BIR SPRING 2012 EVENTS
Controversies and Uncertainties in the Radiotherapy of Early Breast Cancer 2 February 2012 BIR, London Magnetic Resonance Imaging in Clinical Obstetric Practice 3 February 2012 BIR, London London Cardiac CT Level II* Training 7-10 February 2012 BIR, London
MARCH Radiology for Core Surgical Trainees - What you need to know! 2 March 2012 BIR, London Current Status and Future Directions of SPECT/CT Imaging 16 March 2012 BIR, London Medico-legal Conference for Radiologists 22 March 2012 BIR, London Radiation Protection Safety Update 27 March 2012 BIR, London
APRIL BIR Presidentâ&#x20AC;&#x2122;s Conference 2012: CT in Clinical Practice: A Tribute to Sir Godfrey Hounsfield 25-26 April 2012 Wellcome Collection, London
For more information and to register visit www.bir.org.uk Registered Charity No: 215869
CPD accreditation has been applied for from the College of Radiographers and The Royal College of Radiologists *This course offers the chance to study up to 150 cardiac cases. It is not a prerequisite that the course is level II
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BIR NEWS
CEO Report The 2012 British Institute of Radiology (BIR) President’s Conference “CT in clinical practice: a tribute to Sir Godfrey Hounsfield” will take place at the Wellcome Collection in London on 25-26 April. April 2012 marks the 40th anniversary of the announcement of the CT scanner by Godfrey Hounsfield and James Ambrose at the 32nd Annual Congress of the BIR, which was held at Imperial College. Their paper “Computerised axial tomography (a new means of demonstrating some of the soft tissue structures of the brain without the use of contrast media)” was delivered during a session chaired by former BIR President, George du Boulay. As might be expected, the paper produced a sensation and the first press announcement was made in The Times the following day. The presentation appeared as an abstract in the British Journal of Radiology (BJR) with three papers appearing in the BJR later that year. Fred Plum, a leading American neurologist, said that it would soon become unethical for a neurologist to practise without access to a brain machine
since it saved many patients from the unnecessary suffering caused by the techniques that were currently available. As a result, the Nobel Prize in Physiology or Medicine for 1979 was awarded jointly to Allan Cormack and Godfrey Hounsfield for their development of computer-assisted tomography. The CT scanner not only transformed medical care but changed the way we look at the body. Wilhelm Conrad Röntgen’s discovery of the X-ray in 1895 swept the world even more rapidly than the invention of CT scanning. Its demonstration of living anatomy changed the way we look at ourselves. The discovery of X-rays also resulted in a Nobel Prize; Röntgen received the first Nobel Prize for Physics in 1901. On the 1 October 1971, the prototype scanner was installed at Atkinson Morley’s Hospital. Hounsfield’s move from the primitive lathe bed apparatus to the prototype CT scanner in one step is quite remarkable. This prototype CT scanner looks very similar to modern CT scanners and is on display in the Science Museum in South Kensington, while the lathe bed is on display in the BIR library.
The BIR is publishing a biography of Sir Godfrey Hounsfield to coincide with the 2012 President’s Conference. Three former colleagues of Hounsfield at EMI, Richard Waltham, Stephen Bates and Liz Beckmann, and Adrian Thomas (BIR Honorary Librarian and Consultant Radiologist) have authored the book, which will include a large amount of unpublished material from the EMI archives, which are held by the BIR, as well as personal recollections and interviews. The President’s Conference promises to be an exciting event with expert national speakers and three eponymous lectures delivered by Dr Stuart Taylor of UCL and Professor David Hansell from the Royal Brompton Hospital and Professor Willi Kalendar from Germany. If you are interested in attending, please contact our Education Department on 020 7307 1400 or book a place via our website at www.bir.org.uk Many thanks to Professor Adrian Thomas for his help in researching this article. Jacqueline Fowler, Chief Executive, BIR
issue 6 December 2011
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FIRST
ENT EM
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Sept 2011
BIR President’s Conference 2012 CT in clinical practice: A tribute to Sir Godfrey Hounsfield 25 - 26 April 2012 Wellcome Collection, London
For more information and to register visit
www.bir.org.uk
London Cardiac CT Level II* Teaching Course 7 - 10 February 2012 BIR, London This unique, four day course is designed to provide case volume, formal teaching and hands on training required for Level II* SCCT or BSCI accreditation in Cardiac CT. Visit www.bir.org.uk to book your place today *This course offers the chance to study up to 150 cardiac cases. It is not a prerequisite that the course is ‘Level II’
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bir news
The second annual East of England branch meeting has a multidisciplinary focus The British Institute of Radiology East of England meeting highlighted the importance of collaborative working and discussed the evolution of imaging
The East of England branch with their guest speakers
Professor Adrain Thomas delivers his lecture at the second annual meeting of the East of England branch
The East of England branch of the British Institute of Radiology (BIR) organised a successful second annual meeting on Saturday 1 October 2011. The meeting took place in the Clinical School at Addenbrooke’s Hospital, Cambridge. The aim of the meeting was to focus on the evolution of imaging, from the discovery of X-rays to the development of novel imaging technology. Over 70 delegates from around the region attended the meeting, and it was very well-received. The speakers explored the role of different state-of-the-art imaging modalities in improving medical diagnosis and different imaging-guided techniques in refining therapy. We also discussed the latest issues relating to information technology, radiology management and medical industry. A workshop was held by the imaging service accreditation scheme over the lunch break and parallel sessions gave medical physicists/radiographers and radiology nurses a voice. Another objective of the meeting was to encourage multidisciplinary interaction by paying particular attention to information sharing and collaborative working. Apart from radiologists, radiographers and scientists, the role of nursing care in an imaging service was highlighted. The branch has taken the initiative to collaborate with an imaging nursing group to achieve a cohesive working group for future educational and scientific development. Excellent talks were delivered by various speakers including two past presidents of the BIR – Dr Stuart Green and Mr Günter Dombrowe. Dr T C See, Chair, East of England Branch
issue 6 December 2011
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Committee applications
Competition 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:
Call for British Ins committee member
Who has written the first story for the BIR history project?
The British Institute of Radiology welcomes applications for magnetic resonance committee, oncology committee, and
Send your answer along with your name and contact details to: publications@bir.org.uk by 10 January 2012.
Radiation physics and dosimetry committee
Sudoku 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 40
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We are looking for people who will become enthusiastic and active committee members. The committee is responsible for organising scientific and educational meetings as well as creating working parties that contribute reports and publications for the institute. We aim to embrace the multidisciplinary nature of the institute and would like applications from a variety of professionals who are at any stage of their career. The term of office is typically three years and during that time you will get
experience in managing meetings as well as enjoying contributing to one of the institute’s vibrant committees. We meet three times a year, twice by phone conference and once in London. Please apply by sending a short resume of key reasons for seeking membership. Ideally you would highlight relevant experience (including publications).
Magnetic resonance committee The committee is responsible for organising scientific and educational meetings as well as contributing to reports and publications for the institute. We also provide comment and advice regarding regulatory and research developments relating to MRI. We are particularly keen to attract members interested in helping us to develop and establish an annual modular MRI educational course based in London. The committee embraces the multidisciplinary nature of the institute and invites applications from all professional groups involved in clinical or pre-clinical MRI at any stage of their career. The term of
office is typically three years and during that time you will get experience in developing educational programmes, reviewing national and international MR policy as well as enjoying contributing to one of the institute’s vibrant committees. We meet three times a year, typically twice in London and once by teleconference. Please apply by sending a short resume of key reasons for seeking membership. Ideally you would highlight relevant experience (including publications) and whether you are able to represent a particular MR related professional community.
www.bir.org.uk
Committee Applications
stitute of Radiology r applications the radiation physics and dosimetry committee, nuclear medicine and molecular imaging committee
Oncology committee The BIR oncology committee is a multidisciplinary group of clinicians, physicists, radiographers and oncology nurses. The group not only represents a spectrum of disciplines, but also specialists within the disciplines, including education, research and site specialists. The overall aim of the committee is to promote and facilitate teaching and research in clinical oncology and related professions. The strength of the multidisciplinary ethos is seen in the scientific meetings organised. Within the BIR the committee advises
council on matters relating to oncology and responds and advises on documents from other bodies. We are looking for people who will become enthusiastic and active committee members. The term of office is typically three years and the committee meets three times a year, twice by telephone conference and once in London. Please apply by sending a short resume of key reasons for seeking membership. Ideally you would highlight relevant experience (including publications).
Nuclear medicine and molecular imaging committee Applications to join the BIR Nuclear Medicine and Molecular Imaging Committee are welcomed. We are an enthusiastic team with joined forces from the Nuclear Medicine and Molecular Imaging Committees and we are now looking for new recruits for our team. A number of posts are available including radiologists, nuclear medicine physician, junior medical representative, scientists, technologists and radiographers. We also welcome applications from industry to comply with the BIR vision of multidisciplinary committees with collaborative working between industry and the Health Service.
Please apply by sending a short resume of key reasons why you are seeking membership. Ideally you would highlight relevant experience (including publications).
All committees' terms can be found on the BIR website http://www.bir.org.uk/bir-getinvolved-home/commitee-vacancies.aspx All applications should be a maximum of 500 words and submitted in the form of an MS Word document to Lucy Stewart (lucy. stewart@bir.org.uk). Applicants should include full contact details. Non-members of the institute are welcome to apply, provided they become full members of the BIR prior to their first committee meeting.
issue 6 December 2011
NEWS 41
www.bir.org.uk
a page of history
Reflecting on the Institute's history At this time of change, with the Institute proposing to leave Portland Place, it is worth reflecting on our history. I have been a British Institute of Radiology (BIR) member since 1981, when I was a trainee registrar at Hammersmith Hospital. The BIR moved into Portland Place in 1982 and on 11 February of that year Her Majesty the Queen graciously visited us to open the house. We had moved to Portland Place from 32 Welbeck Street W1, which had been our home since 1922. Our time at Welbeck Street had been very happy and it was the centre of British radiology. As our past-President, Roger Berry, has said the Institute “was multidisciplinary at its core”. The BIR had only ever leased Welbeck Street for limited terms, and it might have appeared to lack a permanent home. The Institute had been saving to purchase the lease; however, the huge increase in property values in post-war
Book label No 93, from when we were based at the Institute of Electrical Engineers
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London had made this untenable. The Royal College of Radiologists had moved to Portland Place and so by moving next door the desire was to unite the medical and multidisciplinary. The history of the Institute begins when the news of Röntgen’s discovery reached Britain on 6 January 1896. A meeting was held on the 18 March 1897 at the house of the Medical Defence Union to set-up a new society to study X-rays. It was decided that membership should “include all who are interested in the scientific study of the Röntgen Rays”, and this decision was to prove crucial to the ethos of the organisation. A second meeting took place on 2 April 1897 and an advertisement appeared in the British Medical Journal on 10 April. The first general meeting was held on the 3 June 1897 at the Medical Society of London in Chandos Street and the inaugural meeting was held on the 5 November 1897 in the old St Martin’s Town Hall with Silvanus Thompson as the first President. The X-Ray Society became the Röntgen Society and the Archives of Clinical Skiagraphy was adopted by the Society to become the Archives of the Röntgen Ray. This journal, started by Sidney Rowland in May 1896, continues today as the British Journal of Radiology. For a long time, the Society met at 20 Hanover Square. In 1911, the Society moved to the Institution of Electrical Engineers’ offices and towards the end of the Great War moved again to the offices of the Royal Society of Arts. The period during and after the war was not an easy time for scientific societies and there was considerable financial stress; however, the Society kept up a full programme of Thursday evening meetings throughout the year. The concept of a radiological institute was first suggested in 1906 and revived again in 1917. The British Association for the Advancement of Radiology and Physiotherapy (BARP) was founded in 1917 and the Diploma in Medical Radi-
Logo of the Rontgen Society
ology and Electrotherapy (DMRE) was set-up at the University of Cambridge. The BARP formed an institute in 1924 with broad aims, including providing a meeting place for those interested in radiology, providing information of all kinds and having an international influence. Part of the reason for having a physical home was to house a reference library and a museum of radiographic films and lantern slides, and so the house in Welbeck Street was acquired. The modern Institute was created in 1927 as an amalgamation of the Röntgen Society and the British Institute of Radiology. Many had worked hard for a long time to enable this merger to come about. From the very beginning, the three pillars of the Institute have been meetings, publications and a library. However, the nature of these pillars is now radically different from those of the last century for a variety of reasons. For the Institute to have a successful future, the nature of meetings, publications and library have to change. It may well be as an organisation we will now resemble more how we were in the early 20th century. The Institute has had many changes during its long history and we will continue to change to meet the contemporary needs of our members. Professor Adrian Thomas BSc FRCP FRCR FBIR Honorary Librarian, BIR
A must go to event for all professionals working with medical radiation exposures. A unique opportunity to attend an IRPA congress, held worldwide only once every 4 years, within the UK. IRPA13 will include: A comprehensive scientific and technical programme covering all aspects of medical radiation protection An excellent opportunity for continuing professional development Extensive technical exhibition and technical visits programme A superb environment for networking An opportunity to visit Scotland and its many delights
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13/10/2011 11:24
Your FREE BIR 2012 wall calEndaR* is included in this issue of BJR news. A great tool to plan your meetings and events for the entire year! Stay up to date with BIR scientific meetings and conferences, publication mailing dates, and other related meeting dates. If you have not received the wall chart or would like additional copies please contact the BIR at contact@bir.org.uk.
*Visit the BIR website, www.bir.org.uk, for details of its entire educational programme for 2012.
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
I have decided for my December column to reproduce the announcement I made on 30 September in case it did not reach you. â&#x20AC;&#x153;The BIR strategic review that has been conducted over the last 12 months is arguably one of the most important developments in the recent history of the BIR. Council has welcomed the careful deliberation, consultation and recommendations of a number of working groups to ensure future strength in key areas such as education, publications, membership and premises and the views of a wide range of other stakeholders including, most importantly, our members. We are all aware of the major changes taking place both within the NHS and the wider economic environment. The BIR finds itself at an important crossroads where it has to ensure it delivers its aims in an increasingly global community, continues to meet and exceed the needs of its members and safeguards its future financial stability. Trustees have had to consider the recommendations from the strategic review, combined with expert advice, within this context. Following consul-
presidentâ&#x20AC;&#x2122;s column
tation with members, Council took a major decision on Thursday 29th September on the future of the BIR premises and has decided to relocate from 36 Portland Place. Despite being our home for over 30 years, Trustees recognised that 36 Portland Place was no longer fit for purpose. The BIR needs to modernise its operation and interact with the full membership around the UK and further afield. Trustees also wished to ensure increased financial stability to support the delivery of strategic objectives. The BIR wishes to invest more of its funds in a modern and more e-enabled organisation rather than maintaining a costly building in central London. On behalf of the Council, I would like to thank members for your support and provide assurance that your needs are at the centre of our strategic development. The BIR continues its major activities of publishing, scientific meetings and scientific committees and will continue to meet its key objectives whilst ensuring it is well positioned to meet the challenges of the future.â&#x20AC;?
and move on to more modern premises, which will be fit for purpose and release funds for us to invest in the future of the BIR, as informed by our new strategy. There have been one or two misconceptions around this. Firstly, that we are abandoning face-to-face meetings and scientific meetings. This could not be further from the truth. These are really key activities for our community and we will continue to meet and interact face-to-face. What we are going to do is add a new layer of communication and interaction by recognising the evolving needs of our membership. Secondly, that "this is the end of the BIR". This too is a complete misconception. From time to time all organisations need to take stock. We recognise the very different world we occupy in 2011 and in the future and the rapidly evolving needs of our members. Our whole strategy is aligned to the future membership and organisational needs. We are revitalising the BIR for the future.
So as you can see, Trustees have taken the decision to sell 36 Portland Place issue 6 december 2011
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Obituary
Marion Frank: a lost treasure and loyal member of the BIR With the death of Marion Frank radiography has lost a treasure and the British Institute of Radiology (BIR) has lost a loyal member. The world of radiography had its home in Marion’s flat in Lancaster Gate, London, and her spare room was in constant use. Her visitors’ books were fascinating to read and recorded the constant stream of visitors. Marion was a loyal member of the Osler Club of London, and she shared many of Sir William’s qualities, particularly his interest in education and his hospitality. Sir Williams’s house in Norham Gardens, Oxford was nicknamed the “open arms” and the same could be said for Marion’s flat. Her passion was education and her hospitality was legendary. The door of her flat was always open to visiting radiographers from all over the world. Marion was born in Germany with an 8 minute gap between her and her twin Ellen, and they remained close friends throughout their lives. This was not an easy time in Europe. Marion’s father was sent to prison following Kristallnacht, a night, in 1938, of violence against Jews and destruction of business and property. Marion’s father had two factories that manufactured worsted cloth; following his arrest the workers surrounded the prison so he could not be taken to a concentration camp. On his arrival in England, he became manager of Broadhead and Graves in Huddersfield, which manufactured superfine worsteds. Marion described both her parents as strong personalities. Marion and Ellen had left Germany in 1937, when they were sent to a French School in Switzerland. In Switzerland, Marion shared a bedroom with an English girl whose father was a general practitioner in England. When the twins came to England in July 1938 they stayed with Dr Prentiss and his family in Sherard House, 46
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Sir Godfrey Hounsfield and Marion Frank
Hawkhurst, Kent. Marion's brother, Gunter Max Frank, had changed his name to George Franklin when he came to England. He joined the Pioneer Corps and was killed on D-day as he came off his landing craft. He is buried in Hermanville-sur-Mer, which is one of the smaller British cemeteries in Normandy and is the last resting place for 1005 allied soldiers who fell in the battle to take Sword Beach and the surrounding area. It was 18 days before the family was informed of his death. Marion and Ellen had initially wanted to be doctors, but circumstances prevented this. The sisters therefore began looking for medical-related jobs and obtained work in the pathology department of the Royal Northern Hospital in London. At the Royal Northern they were assigned to the post-mortem room. Here they encountered the pioneer radiographer Kathleen Clara Clark who, having just finished her famous
book Positioning in Radiography and was looking for students, persuaded them to study radiography. Their European qualifications were accepted and to pay her tuition fees of £50 per year Marion worked as a typist at the chest hospital. I remember Marion telling me she did not apply to the government for money. She also recounted they used Kathleen Clark's book to replace the missing third leg of a wardrobe! As was typical at that time Marion trained in both diagnostic and therapeutic radiography. After training at the Royal Northern Hospital she went on to work at Putney Hospital and then to Derbyshire Royal Infirmary where she took her Higher Diploma in Diagnosis and Therapy. She also taught radiography at Derby. Dr Seymour Cochrane Shanks (1893–1980), the director of radiology at University College Hospital, invited Marion to apply to work in his department. At the end of the war, Marion went to the United States “to
www.bir.org.uk
Obituary
get other ideas and see new things”. She also spent time at the Montreal Neurological Centre where she met and was influenced by the pioneer neurosurgeon, Wilder Penfield (1891–1976). When Marion was in Canada, Professor Sir Brian Windeyer KBE (1909–1994) contacted her and invited her to attend the Middlesex Hospital for an interview. While on the boat back to the UK, she told a fellow passenger that she was returning for an interview, their reply was "she needed to wear a hat and gloves!" Marion developed a close working relationship with Windeyer. Windeyer was made the first professor of radiology (therapeutic) at the Middlesex Hospital in 1942 and was Dean of the Middlesex Hospital Medical School (1954–1967). Marion progressed rapidly at the Middlesex Hospital and was both superintendent and teacher at the School of Radiography. Under her leadership the Middlesex Department became one of the most respected departments in the country. Marion told me she had a wonderful time there. She was President of the Society of Radiographers and enjoyed herself in her main role as a communicator. Marion would give three pieces of advice to young people: you cannot change your personality, you must aim high if you want to
get on professionally and you must offer something in addition to what others give. Marion summed herself up by saying “I have never been a good radiographer, but I knew how to get out of trouble”. Marion was always very disparaging of her own skills as a radiographer and declared that she “was a better teacher than a radiographer”. She developed a reputation as a strict examiner; however, her own view was that “I was not a fearsome examiner, but the rumour went around …” Marion became very interested in world radiography and, along with Kathleen Clark, was involved in the foundation of the International Society of Radiographers and Radiological Technologists (ISRRT). Speaking about Clark, Marion exclaimed “She was a lady. I wasn’t”. Marion was a lifelong friend of Clark and visited her every Saturday following her stroke. Her involvement with ISRRT was facilitated by her gift with languages. At the ISRRT she worked closely with Ernest Ray Hutchinson who was a pioneer of mould room work in Cardiff. Hutchinson was secretary of ISRRT, and Marion was vice-President of ISRRT for Europe and Africa and Chairman of the Education Committee. Marion had many interests and was an active member of the BIR, the Osler Club of London and the British Society
for the History of Radiology. She loved the Deutsches Röntgen Museum in Remscheid and took many students there for visits. Marion enjoyed life and her enthusiasm was contagious. Radiography was her life; however, her heart belonged to the Deutsches Röntgen Museum and the Middlesex Hospital. The greatest regret of her last years was she could not make that final visit to the museum in Remscheid, which she loved so dearly. In her last years she was actively involved in researching the history of the Middlesex Hospital. Marion received many honours. She greatly valued her BIR Fellowship and was always encouraging radiographers to join and take an active part in the Institute. Marion made an anonymous donation to support the Hounsfield lecture and was concerned about the poor acoustics in the lecture theatre. She was an honorary member of both the French and Dutch Radiography Societies, and in September 2010 her contribution to international radiography was recognised at the ISRRT World Congress where she was presented with the Dien Van Dijk Award. Unfortunately, by this time her health was failing and it was a personal privilege for me to be able to present her with the award at her flat in Lancaster Gate in London. Characteristically she said that she did not deserve the award; however, she was obviously delighted to receive it and the award took pride of place in her flat. Marion was awarded the Fellowship of the Society of Radiographers and received their gold medal. She was also the first radiographer to receive honorary membership of the Royal College of Radiologists. Marion had an affinity with young people and, as her nephew John Gumball said, her family was not limited to relatives. I don’t think Marion realised the depth of affection with which she was regarded around the world. There will be many who will miss her. Marion was always and unashamedly herself at all times and she leaves a gap that cannot be filled. Professor Adrian Thomas
Marion Frank holding the Dien Van Dijk Award
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BIR prize nomination
Nomination open for BIR prizes British Institute of Radiology prizes 2012 Silvanus Thompson Memorial Lecture
Lecture by a scientist in memory of Prof Silvanus Thompson, the first President of the Röntgen Society. Award of engraved medal and certificate
Mackenzie Davidson Memorial Lecture
Lecture by a medical person. Founded in memory of Sir James Mackenzie Davidson, a pioneer in British radiology. Award of engraved medal and certificate
Sir Godfrey Hounsfield Memorial Lecture
Self-nominated award open to all BIR members. Lecture to be on a major recent advance in radiology. Award of certificate and honorarium of £1000
Stanley Melville Travel award
Award to BIR members who wish to visit a clinic or institution abroad. Award of certificate and £500
Nic McNally Prize for Cancer Research
Open to all scientists aged under 35 to travel to a scientific conference or meeting. Awarded for original work in cancer biology or radiation biology. Award of certificate and £500
Philips Travel Bursary
Self-nominated award open to BIR members to enable a scientist, radiographer, technician, nuclear medicine physician, radiologist or radiopharmacist to visit one or more centres abroad to learn a new technique not available at home base. Award of up to £3000
Barclay Medal
Awarded annually to the person, member or non-member, whose contribution to the BJR over a period of years has been of special merit, contributing particularly to the science and practice of radiology. Award of certificate and medal
Röntgen Prize
Awarded annually to a member or team of workers including a member, whose contribution to the BJR has been of special merit. The subject of the contribution must be related to radiotherapy, radiobiology or physics. Certificate award
Young Investigator
Selected by BJR Editorial Board and Publications Committee. Award of certificate and £250
Honorary Fellowship
Honorary Membership is normally awarded to individuals, member or non-member, whose original research has contributed to the advancement of radiology and its allied sciences or who have rendered services for which the Institute wishes to confer honour.
BIR Fellowship
Fellows will be members of at least five years standing who have rendered service to, or on behalf of the Institute.
Nominations should be forwarded to Lucy Stewart (lucy.stewart@bir.org.uk) and received by 28th February 2012.
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ESTI2012
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