BJR News February 2011

THE NEWS MAGAZINE FROM THE BRITISH INSTITUTE OF RADIOLOGY

February 2011 www.bir.org.uk

Imaging: IT requirements of the future UKRC 2011 update A case of chronic knee pain The launch of ACORRN

Fractionation in radiotherapy:

An idea whose time has gone?

ISSN 2044-5113

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www.bir.org.uk

contents

in this issue 3 5

Editorial Welcome to BJR News

So you think you know IGRT? Management of adult central nervous system tumours

BIR events calendar

8

Community news

Forthcoming events from the BIR scientific programme

News from the radiology and allied sciences community

15

Idea Watch

17

What’s Online

Fractionation in radiotherapy: an idea whose time has gone?

Table of contents from The British Journal of Radiology volume 84 number 997 and 998

Case of the month

30

Abstracts

41 49

BIR News

50 51

BIR President’s Column

Voxel-based diffusion tensor imaging detects pyramidal tract degeneration in primary lateral sclerosis

Imaging in bariatric surgery: service set-up, postoperative anatomy and complications

Abstracts from The British Journal of Radiology volume 84 number 997 and 998

Updates from BIR projects and committees

History of Radiology Another Curie centenary and a remarkable wrist watch

Book reviews

A case of chronic knee pain and swelling

Commentary The launch of the first UK charity devoted to radiotherapy: ACORRN – Action Radiotherapy

Using the DOI system

www

25

Review ARTICLE

Report on recent BIR eventS

7

20 22

24

Short Communication

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: Tina Giddings, Dr 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).

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 Committee Dr N Strickland Health Informatics Committee Mrs E Hunt IHE-UK Medical Imaging and Radiation Oncology Committee Dr D Robinson Industry Committee Mrs E Beckmann Magnetic Resonance Committee Professor D Lomas Nuclear Medicine and Molecular Imaging Committee Dr R Ganatra Oncology Committee Dr C Kelly Radiation and Cancer Biology Committee Dr K Williams Radiation Physics and Dosimetry Committee Professor A W Beavis Radiation Protection Committee Dr P Riley Trainee Committee Dr R Chowdhury

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

Enquiries 2

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General enquires – admin@bir.org.uk Corporate – tina.giddings@bir.org.uk Membership – jane.moynihan@bir.org.uk

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Publications – publications@bir.org.uk Regional branches – lucy.nye@bir.org.uk Scientific meetings – ruth.warne@bir.org.uk Display advertising sales – shun.tamura@tenalps.com

www.bir.org.uk

Editorial: Welcome to BJR News

Welcome to

NEWS imaging service to be accredited by ISAS. Our review article takes a close look at imaging in bariatric surgery including service set-up, post-op anatomy and complications (p25). For training and events, view the BIR’s events calendar (p7), Cancer risks from diagnostic radioxlogy and read Erika Denton’s BIR News update update on UKRC 2011 Case of the Month: A calcified conundrum (p46). Future plans for Commentary: 21st L H Gray Conference the BIR can be found in Stephen Davies’ President’s column, including an account A regional audit of kilovoltage X-rays of his first 100 days in office (p50).

A single centre We hope that you will enjoy this issue, and all the others to come this year. To send us your feedback, e-mail publications@bir.org.uk and include “To the Editors of BJR News” in the subject line.

The British Journal of Radiology, the BIR’s flagship academic journal, is still very much alive and well, and now primarily in electronic-only format, which will increase its accessibility and impact. Along with developing this wonderful new magazine, the BIR’s publications team spent much of last year working to deliver a state-of-the-art electronic journal to BIR members and institutional subscribers.

Visit the academic journal homepage at http:// bjr.birjournals.org to find out more and experience the new BJR online.

THE NEWS MAGAZINE FROM THE BRITISH INSTITUTE OF RADIOLOGY

FEBRUARY 2011 www.bir.org.uk

NEWS

Since The British Journal of Radiology launched in 1896, it has strived to bring together the best research from across the radiological community.

For over a century, the journal and its publisher the British Institute of Radiology (BIR), have remained committed to their founding ethos – a multidisciplinary approach – whether supporting BIR members through training, networking and education, or collaborating with its sister societies to produce scientific meetings or publications.

You are holding the latest manifestation of this ethos, BJR News. This is a new magazine for BIR members and the radiological community. The BIR is a multidisciplinary society; its membership includes radiologists, radiotherapists, radiographers, medical physicists, radiobiologists and industry professionals. We hope this magazine will become a vehicle for bringing together a diverse, but intrinsically linked, group of professionals to share ideas regarding the improvement, understanding and practice of radiology and the related sciences.

Each issue of BJR News will contain a lively and insightful mix of news and opinions. Leaders in the field will address key concerns and developments across the radiological disciplines. It will also contain abstracts and articles from recent issues of The British Journal of Radiology, and updates on the events and activities of the BIR and its scientific committees. BIR full members will receive a printed copy of BJR News for free and the electronic edition will be available online for free to the entire community.

In this issue, Alastair Munro writes our first Idea Watch, imagining a brave new world without fractionation (p15); PACS expert, Neelam Dugar, provides an update on imaging IT requirements for the future (p8); and Niky Sykes shares Cobalt’s experience of becoming the first

approach

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BJR News will contain a lively and insightful mix of news and opinions

Liz Hunt and Simon Blease BJR News Editors-in-Chief issue 1 february 2011

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The BIR events team organises a variety of events for external clients ranging from large annual congresses and one-off special events to intimate meetings. The department has a proven track record of efficient conference and exhibition management, having organised exhibitions from 100 - 6000m2 and delegate numbers from 12 - 4000.

We can provide a comprehensive bespoke event management service to meet your needs.

• Full event management service • Event planning and logistics • Venue sourcing • Marketing • Abstract Management • Design • Website management • Online registration and payment facilities • Audio visual requirements • Set design and production • Event recording • Catering • Entertainment BIR Events Management 36 Portland Place, London, W1B 1AT T: 020 7307 1400 E: lucy.nye@bir.org.uk W: www.bir.org.uk

CONFERENCES | EXHIBITIONS | GALA DINNERS | MEETINGS | NETWORKING EVENTS | TRAINING SESSIONS | RECEPTIONS

www.bir.org.uk

Report: Getting to know IGRT

recent BIR events

Getting to know IGRT Medical imaging lies at the heart of advanced radiotherapy treatment techniques. With increasing availability of networked radiotherapy management systems, PACS and access to newer imaging modalities, opportunities for multimodality image fusion are becoming widespread. In light of this, the BIR recently held a two day event to bring the profession together to discuss the goals, challenges and diagnostic basics of image-guided radiotherapy (IGRT).

The “So you think you know IGRT?” meeting took place on 17-18 November 2010 and aimed to consider IGRT from all perspectives. Recognising the multidisciplinary nature of this topic, presentations were delivered by speakers representing all staff groups from both the radiotherapy and diagnostic imaging disciplines.

The meeting started with a lively presentation covering pre-clinical perspectives from Yvonne Rimmer, of Addenbrooke’s Hospital, outlining the clinical rationale for using imaging to support advanced radiotherapy. She explained how collaborative working ensures the best overall outcome for the patient.

A technical presentation followed, as Marcel van Herk from the Netherlands Cancer Institute made the statistics of patient set-up uncertainties interesting and accessible, demonstrating the importance of reviewing margins with the implementation of new technologies. Three other speakers also covered the measurement of set-up errors and review of margins in their own centres.

Julie Stratford, from The Christie Hospital, addressed the practicalities and challenges of implementing new image guidance techniques, including training packages, continual review and role development, while Helen Taylor, of the Royal

Andrew Reilly, David Platten and Andy Beavis

Marsden Hospital, discussed her experience of developing advanced cone beam CT (CBCT) competencies as part of the implementation of adaptive bladder radiotherapy. Úna O’Doherty, from the Health Protection Agency (HPA), then underlined how the legislative framework applies to radiotherapy imaging, particularly in the context of IR(ME)R, whilst Kim Baldwin, also from HPA, discussed some of the problems encountered and how these can be identified and overcome.

David Platten, Northampton, went on to discuss assessment of image quality and described how objective, quantitative metrics widely employed in the diagnostic sphere can be directly applied in radiotherapy. Other presentations also concentrated on the balance between dose and image quality, with contributions from both diagnostic and radiotherapy physicists.

CBCT as a modality for set-up verification and adaptive planning was considered by a number of speakers, including Jonathan Sykes, Leeds, who provided background to the technology currently available and outlined the more advanced facilities being developed.

Jonathan also reported on the results of a

Department of Health commissioned evaluation of tomographic IGRT equipment.

There was debate of how the methodology underpinning this work could be applied to the acceptance testing, commissioning and routine quality assurance of radiotherapy CBCT and CT systems in general.

Andrew Reilly, Oxford, then introduced planar imaging technology while Andy Beavis, Hull, discussed the potential of portal dosimetry as a viable, robust and informative replacement for traditional in vivo dosimetry techniques. Presentations from Thomas Brunner, Gray Institute for Radiation Oncology and Biology, and Sairanne Wickers, UCLH, which explored the application of functional imaging in radiotherapy, concluded the meeting.

The importance of understanding clinical application and the factors essential to achieving multidisciplinary working practices were emphasised throughout the meeting, and those implementing new IGRT technology for the first time were encouraged to build on the experience of established centres who have already tackled the same challenges and concerns.

Andrew Reilly and the BIR’s Radiation Physics and Dosimetry Committee

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Report: Learning to manage CNS tumours

www.bir.org.uk

Learning to manage CNS tumours Kate Burton and Sarah Jefferies

A recent study day, entitled “Management of adults central nervous system tumours” was held on 3 November 2010 to provide delegates with knowledge of current practice and to introduce future developments in the treatment of CNS tumours.

The event, which was organised by the BIR Oncology committee, was split into two sessions. The morning session was dedicated to cerebro-spinal axis (CSA) radiotherapy for adults. Dr Frank Saran opened the day with an overview of the current indications for the use of whole CSA. The paediatric and adult literature and study data were comprehensively reviewed.

This was followed by talks from Julie Stratford and June Dean who outlined the development of supine intensity modulated radiotherapy (IMRT) for whole CSA. One centre used a class solution on a linear accelerator with cone beam imaging and the other a tomotherapy solution. Using IMRT clearly demonstrated significant dose reductions to critical structures. Additionally, the radiographers explained that the techniques reduced potential errors by removing moving gap fields. Animated discussion followed in relation as to whether all UK centres should be striving to implement an IMRT technique as the standard of care for CSA. The proffered papers yielded data from some of the largest single centre 6

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series for adult ependymoma and medulloblastoma. The session was concluded by Professor Roger Taylor who addressed the issue of whether chemotherapy should be used when

frameless stereotactic technique, use of IMRT to deliver a concomitant boost during whole brain radiotherapy and outcome data from UK centres.

Discussion illustrated the increasing

This day covered two quite different topics, but highlighted areas where neuro-oncology practice is changing and developing managing adult medulloblastoma. An excellent review of the current literature was completed with the recommendations that have been recently published for consultation by the British NeuroOncology Society.

The afternoon session focused on the treatment of CNS metastases. The first talk was given by Dr Alexander Muacevic from the European Cyberknife Centre in Munich. He presented their extensive experience in treating spinal tumours including metastases, AVMs and primary CNS lesions using the cyberknife. This session yielded practical information on the types of CNS metastasis that may particularly benefit from this technology.

The proffered paper session covered a number of topics relating to CNS metastasis treatment. These included

number of patients being referred to neuro-oncology for consideration of surgery or single fraction stereotactic radiotherapy and the need to establish protocols for managing these patients.

There was also a discussion on whether patients should be treated with WBI following these treatments. This led seamlessly into the final and very informative talk by Dr Naomi Fersht on establishing a dedicated brain metastases clinic.

This day covered two quite different topics but highlighted areas where neuro-oncology practice is changing and developing. The day benefited from discussion between the audience and the speakers and sharing of practice around the country.

Kate Burton, Sarah Jefferies and the BIR’s Oncology Committee

www.bir.org.uk

Forthcoming events

events calendAr 2011

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

Upcoming in February and March: London Cardiac CT Level II Training Course 8-11 February 2011 BIR, London

Expanding the UK IMRT Service 23 February 2011 BIR, London

Scientists in Training 25 February 2011 BIR, London

MR Angiography 18 March 2011, Crowne Plaza Hotel, Nottingham

BIR Welsh Branch Evening Seminar - Pearls in Neuroradiology for the General Radiologist

MRI and Brain Biomarkers: Autism and Beyond

29 March 2011, Princess of Wales Hospital, Bridgend

24 March 2011, London

Research Governance & Radiation - Negotiating the Regulatory Maze 29 March 2011, BIR, London

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

APRIL

MAY

JULY

Contrast Study Day

BIR President’s Conference: Cardiac Imaging

IRMER Update

15 April 2011 Post Graduate Centre, Central Manchester Trust Now in its second year the Contrast Study Day will run again in Manchester. It will benefit trainees in radiology (1st year and beyond) and established consultant radiologists wishing to keep abreast of new contrast agents and their use, with established and new imaging techniques. The course is designed to demonstrate how contrast media works in a variety of established imaging techniques, to appreciate which ones to use and why, and to provide an understanding of the safety issues involved. A basic knowledge of current radiological techniques will be assumed.

19-20 May 2011 The Wellcome Collection Conference Centre, London A two day scientific meeting covering contemporary and future issues in cardiac imaging. It is suitable for all those involved in cardiac imaging, including trainees.

This is a flagship event in the BIR calendar and complements the hands on cardiac workshops in the BIR events programme.

12 July 2011 BIR, London This meeting will provide an invaluable opportunity for sharing experiences, discussing current best practice and optimisation techniques, and provide an update on current regulatory activities. Presentations will be given by speakers from a variety of disciplines.

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Community News

community news Imaging: the IT requirements of the future The picture archiving and communication system (PACS) has been a huge success in the NHS. The underlying principle of success is the international standard of digital imaging and communications in medicine (DICOM), which mandates vendor co-operation. DICOM is the medical image global interoperability standard. It allows for radiology images created in CT scanners, ultrasound machines, MRI scanners, computed radiography readers and so on, from vendors such as Toshiba, Philips and General Electric to be stored and displayed in a different vendors PACS (e.g.

Agfa, Fujifilm etc).

15 years ago many of the modality vendors did not wish to follow DICOM and created and stored images in a proprietary image format. They sold mini-PACS systems and modality workstations to their customers. Although digital images were being created in radiology, a fragmented digital radiology image record was being produced. As a source of income, there were commercial reasons behind the mini-PACS and modality workstations, but for clinical users the digital record was a fragmented one. This resulted in the continued use of X-ray films to print the digital images. The radiology film packet produced an integrated radiology record consisting of request cards, radiology reports and X-ray films.

The emergence of PACS occurred when the clinical community were educated on the benefits of DICOM. Pressure from this community meant modality vendors were forced to comply with DICOM standards.

This resulted in an integrated digital image record and we could do away with expensive printing of radiology images. There are some areas where PACS has failed us. The radiology report that is presented on PACS lacks a document format (it is dependent on a HL7 messaging format) and we have largely lost access to requesting information (requesting was largely paper based in the 8

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NHS). Today’s PACS is not adequate for the future. PACS is producing a radiology image silo. It is separated from the rest of the clinical information, such as clinic letters, discharge summary, lab results, which currently lie largely in paper notes.

While radiology reports have been incorporated into PACS, we have lost access to radiology requests that were very much a part of the radiology film packets.

In the future, radiologists, general practitioners, hospital doctors and so on will need to be able to view a comprehensive clinical record of patients to improve patient safety. Radiology images will need to become part of this record.

The adoption of cross enterprise document sharing (XDS) of the Integrating Heathcare Enterprise (IHE) will address the deficiencies we see in PACS today. XDS is a combination of established standards of DICOM and HL7, but attempts to produce “plug and play” interoperability between healthcare information technology systems.

By adopting XDS, trusts will be able to bring images and documents together to replace the paper notes system of today, which largely contain clinical documents and some medical images. By bringing together radiology images, other medical images and all clinical documents, we will be able to move from a paper patient record that exists today to a truly electronic patient record that provides a combination of images and documents. Adoption of XDS-I (cross enterprise document sharing for imaging) by PACS vendors is the key to this process.

Radiologists of the future should not just be limited to the information available on a clinical request card to support clinical decision making. As a result of cancer multidisciplinary meetings, radiologists are well aware of the enhanced quality of an opinion on the same set of images with the availability of more clinical information.

Radiologists need to have access to electronic patient records and radiology images

must be a part of this record.

Owing to a lack of standards there has been difficulty in sharing patient information between departments within the

Adoption of XDS as a standard is crucial to the future deployment of PACS NHS. DICOM, as a standard, has been successful in providing a means of sharing radiology images between hospitals in a vendor agnostic way. However, other clinical documents are shared by means of paper and postage or courier. Adoption of the XDS as the base standard will help to address this through the cross community access profile, which is an extension of XDS. Adoption of XDS as a standard is crucial to the future deployment of PACS. A customer planning to buy a PACS must specify that “PACS is XDS-I compliant for imaging document source and consumer”. Compliance as an XDS-I document source will allow radiology images to be displayed along with other medical documents and images. Compliance as an XDS-I document consumer will allow for other documents and images, which are registered on a document registry (discharge summaries, clinic letters, lab results, etc) to be viewable on the PACS display. This will allow us to move from traditional PACS, which is a radiology data silo, to a comprehensive clinical record viewing and this will lead to improved patient care and safety.

Dr Neelam Dugar, Chairman of the RCR Imaging Informatics Group

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Community News

Cobalt: the first ISAS accredited service and confidence for Care Quality Commision compliance!

Cobalt is proud to be the first service to meet the required quality standards for the Imaging Service Accreditation Scheme (ISAS). Launched at UKRC in 2009, the standard is the result of three years of development with the Royal College of Radiologists and College of Radiographers to create an assessment that is specific to radiology. The scheme helps services deliver confidence and patient focused care and is run through the United Kingdom Accreditation Scheme (UKAS).

Within ISAS, explicit outcome measures (OCMs) encourage you to continually improve and develop services against relevant performance targets. The standards are set across four domains: clinical, patient, safety and facilities (incorporating resources and workforce). There are specific statements with criteria to meet.

In summary, you work through 4 domains, 31 standard statements containing criterion to meet, and produce around 40 OCMs that help benchmark your service for continual improvement.

The web tool is fantastic; it provides guidance, information and links within each statement to relevant regulations, papers and publications. Advice is given

within each statement to show you what you should be looking to achieve and how you can assess your service with suggested OCMs and evidence.

Cobalt staff were unanimous in their support of the ISAS process. The standards are developmental and provide a “fresh look� at the imaging department. As a complete service analysis and re-evaluation, it helped to refine processes and, undeniably, improve service delivery and patient care. ISAS aided discovery of new ways of developing and ensuring a system for ongoing and continual improvement.

At the same time, Cobalt, the same as thousands of other services, faced the requirement to register with the Care Quality Commission (CQC) by 1 October 2010. As CQC covers so many service types the standards are non-specific to imaging. ISAS’s clear standards are based around CQC core values, which helped us to implement and evidence, and provided the confidence and advice to self assess against meeting the new legislation.

Personally, I believe ISAS is the only clear and comprehensive tool for assessing CQC and beneficially developing your imaging service.

Following the assessment, Cobalt are using the submission, evidence and OCMs as benchmarks and are looking towards future development. As an example, Cobalt has a project team with Philips Healthcare to implement their utilisation software in January 2011, which will help us to further understand our service. The healthcare information systems will be upgraded early next year and Cobalt has found Carestreams fully integrated RIS/PACS and VRT to be a great help because they are adaptable to our needs and exceptional for defining and automating workflow.

From my point of view, as an independent healthcare provider for the future we face many annual returns, key performance indicators and contracts. These include CQC and private medical insurers.

With such a specific standard to radiology and assessment by trained clinical external auditors it would be beneficial if ISAS accredited organisations could be accepted as compliant across the board.

Niky Sykes, Cobalt Unit Appeal Fund

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Community News

Decentralising NHS radiotherapy services Over the past three decades capacity developers and commissioners of NHS radiotherapy services have used the mantra of safety for not commissioning radiotherapy services outside of cancer centres. In 1991, a Royal College of Radiologists (RCR) working party report concluded that “non-surgical cancer services to district general hospitals should be based at cancer centres�. Furthermore, the working party soundly condemned any organisation of satellite radiotherapy treatment facilities. However, more recently there has been an NHS strategic shift towards decentralising radiotherapy services using the hub-satellite model, also known as the hub and spoke model and the linked unit model.

This article examines the events and potential impact of this change in thinking by investigating whether the hub-satellite model is an appropriate and feasible method for improving NHS radiotherapy capacity, reducing inequity of access, and providing safe and cost effective service.

Several pressures have contributed to the reshaping of NHS radiotherapy services over the past 20 years. These forces can be classified into three main categories: epidemiological, technological and organisational. The timing and weight exerted by each of these forces on the service varies. However, they have consistently posed a challenge to healthcare strategists, managers and medical professionals. In addition, the centralised delivery model has contributed to the substantial under-provision of services and has been unable to improve the undercapacity issue. The impotency of this model stems from a number of reasons.

First, the space constraints of existing 10

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facilities are preventing any horizontal expansion; second, this model has been associated with an increase in inequity of access causing substantial differences in the level of service across the United Kingdom; third, historically the model does not provide an incidence-based service.

Inequity remains a major issue for NHS radiotherapy services in the United Kingdom Epidemiological challenge

The epidemiological changes in cancer that have occurred over the past 40 years have exerted huge pressures on NHS radiotherapy and cancer services.

In England, the total cancer incidence continues to rise at a rate of 1.4% per annum. This growing cancer burden has been attributed to three main reasons: the ageing baby boom population born during the 1960s, the introduction of a number of NHS screening programmes such as those for breast, cervical and bowel cancers, and the use of non-invasive blood tests such as the prostate-specific antigen (PSA) test to diagnose a large number of prostate malignancies. Another epidemiological change is the improvement in the cancer survival rates in England. As a result the number of patients living with cancer who may require radiotherapy treatment during their lifetime has also increased.

Radiotherapy contributes to the cure of approximately 40% of the total number

of cancer patients who become disease free. It is predominantly prescribed in combination with surgery and/or chemotherapy and/or hormone therapy with a medical intention to cure. In addition to its radical role, radiotherapy has a mainstay in the palliation of cancer where it is given to patients with advance stage, secondary metastases or relapse primaries. The overall percentage of cancer patients who require radiotherapy treatment during the course of their illness is estimated to range from 50% to 60%.

Inequity in service provision

A further challenge is the stark regional variations in the proportion of patients receiving radiotherapy or the variation in rate of use of radiotherapy, which ranges between 22% and 58%.

These variations in radiotherapy use are a direct result of the differences in capacity level of radiotherapy services.

In 2007, a report published by the RCR, assessing radiotherapy capacity, highlights the issue of inequitable distribution of radiotherapy resources between different regions in the United Kingdom.

For instance, the number of radiotherapy treatment machines or linear accelerators (linacs) per million of population varied by nearly a factor of 3 (2.13 per million in the North of England and Northern Ireland compared with 6.02 per million in the South of England). More recently, a survey carried by the National Cancer Services Analysis Team (NATCANSAT) to assess the United Kingdom radiotherapy infrastructure shows that inequity still remains a major issue for NHS radiotherapy services. The RCR recommend 6 linacs per million of population.

www.bir.org.uk

Community News

Hard Copy Environment (X-ray/Documents)

Pretreatment

• 1st consultation & consenting • Conventional Stimulation (CS) • CT Scanning • Plan Verification on CS

TPS: Treatment Planning System CT: Computed Tomography

Impact of information technology

Radiotherapy in the early 1990s entered the information technology era and was the real driving force behind the fast and continuous development in radiotherapy, and a number of other innovations in medical imaging.

One important milestone was the introduction of digital imaging acquisition and management technology. The picture archiving and communication system (PACS) is an information technology system that handles electronically diagnostic images of all imaging modalities in a hospital. The radiotherapy community soon discovered that to reap the benefit of this new innovation in medical imaging technology, the radiology tailored PAC system needed to be modified to meet the different imaging requirements in radiation therapy. As a result, a separate branch of PACS was developed: the radiotherapy picture archival and communication system (RT-PACS).

However, functionally the RT-PACS was an information island. It was neither linked or interfaced to the radiotherapy treatment planning system (TPS) nor linked to the linac treatment machines. The reason for the lack of interface between the RT-PACS and the multi-vendor equipment within radiotherapy was due to the absence of any internationally agreed computer communication standard among medical imaging and radiotherapy equipment manufacturers that would facilitate the flow and exchange of information between the equipment. In other words,

Planning

• • • •

Data input on TPS Produce TP Carry necessary checks Plan sent to CS

Treatment

• Data input of machine parameters (Full course or Daily) • 1st day machine Check X-ray films

A typical radiotherapy workflow during the early 1990s

no common computer language existed to allow safe and accurate flow of medical information between different computer systems and medical equipment.

The solution to the lack of interoperability between different information systems within medical imaging came from diagnostic radiology. In 1983, the American College of Radiology along with the National Electrical Manufacturers Association (NEMA) approved the first common standard for digital communication of medical images. The approved digital imaging and communications in medicine (DICOM) version 1.0 was superseded by version 2.0 in 1988, and the current version 3.0 was approved in 1993.

The compound PACS and DICOMradiotherapy protocols and standards have created a digital environment in radiotherapy. Lack of systems connectivity and interoperability within radiotherapy has been improved tremendously with the development of this specific DICOM extension for radiotherapy.

The DICOM-radiotherapy extension was developed to establish a standard for the handling and transference of imaging and non-imaging radiotherapyspecific information objects definitions (IOD), the latter highly important for radiotherapy processes. The extension in 1997 consisted of four DICOM objects including: radiotherapy image, radiotherapy structure set, radiotherapy plan and radiotherapy dose (DICOM, 1997). In 1999, three additional “record keeping” IODs were

created: radiotherapy beams treatment record, radiotherapy brachytherapy treatment record and radiotherapy treatment summary record. These DICOM-radiotherapy extensions facilitated the flow of image and non-image based IODs between different systems.

Thus, these developments made it possible for image and non-image base-data to flow between the linac machine, TPS, the virtual simulation (VS) software, conventional simulator (CS) and radiotherapy-PACS. The interface capabilities coupled with advances in telecommunication facilitated the collaboration between different radiotherapy centres.

The advent of information technology innovations affected fundamental radiotherapy work processes by transforming many clinical practices and ultimately re-engineering the workflow in radiotherapy services. Our position is that the electronic radiotherapy environment enables most radiotherapy processes to take place outside the traditional centralised model while maintaining, or even increasing, quality outcomes in patient care.

Organisational changes

Radiotherapy workflow consists of several interdependent processes. From a management organisation perspective these processes, or work, can be grouped into three main parts or sections: pretreatment, planning and treatment. These sections have been transformed by the issue 1 february 2011

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SIMULATOR SIMULATOR

PHYSICS PLANCHECKS

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Pre-treatment Process

ENTRY

RTTPS SIMULATOR

PHYSICS PLANCHECKS

RTTPS

Treatment Process

DAILY LINAC TREATMENT

PHYSICS DAILY LINAC PLANCHECKS

WEEKLY TX CARD CHECKS

TREATMENT

LINAC 1ST DAY RADIOGRAPHERS PORTAL CHECKS & DATA FILMS ENTRY

PHYSICS PLANNING PLANCHECKSCHECKS

SIMULATOR LINAC

PHYSICS PHYSICS PLANCHECKS PLANCHECKS

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DAILY LINAC1ST DAY TREATMENT PORTAL

WEEKLY TX CARD CHECKS

FILMS

DAILY LINAC TREATMENT

PHYSICS PLANCHECKS

RTTPS

WEEKLY TX CARD CHECKS

A typical radiotherapy workflow in the early 1990s

CT

RADIOGRAPHERS CHECKS & DATA ENTRY

PHYSICS PLAN CHECKS

VIRTUAL SIMULATION

RTTPS

Community News

PORTAL FILMS

RADIOGRAPHERS Planning Process CHECKS & DATA

PLANNING CHECKS

LINAC 1ST DAY PORTAL FILMS

PHYSICS LINAC 1ST DAY PLANCHECKS

advancement in information technology and telecommunication.

WEEKLY TX CARD CHECKS

Economic evaluation

In recent years, a number of studies have been carried out to evaluate the economical benefit of different radiotherapy service delivery models i.e. centralised, fully decentralised and outreach (H&S). In 2000, a Canadian study by Dunscombe and Roberts drew the following conclusions: first, the outreach radiotherapy service model “is the economically superior service delivery model for separations between 30km and 170km”, from a societal prospective; second, the outreach staffing model offers cost saving as it uses the existing management and supervisory personnel, stationed at the central facility or hub; third, in the context of cost to the health system the H&S service model was found to be more economical compared with a fully decentralised model in such a small catchment area.

This is owing to the saving achieved by eliminating duplications and under-use of equipment, such as CT scanners and TPS. Furthermore, some have argued that the traditional centralised model imposes a higher financial burden on both urban and rural radiotherapy populations when compared with the H&S. The road ahead

PHYSICS PLAN CHECKS

WEEKLY EPI & IGRT

DAILY LINAC TREATMENT

A typical radiotherapy workflow in 2010 indicating the impact of radiotherapy-PACS and DICOM-radiotherapy

Finally, it is worth noting that any radiotherapy service provision model, whether centralised, fully decentralised or H&S, which is commissioned based on non-scientific or subjective methods will inevitably lead to either under- or overcapacity issues. Scientific forecasting of future radiotherapy needs has to be the corner stone that enables planning of adequate radiotherapy resources and insure the delivery of high-quality radiotherapy services.

avid Shahata MSc BSc, Imperial College D London. With thanks to Dr Benita Cox

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Are you ready for the future of radiation oncology?

Radiobiological Modelling in Radiation Oncology, edited by Professors Roger Dale and Bleddyn Jones, will help to prepare you for the increasing use of modelling in practical situations, including treatment gap corrections, normal tissue tolerance predictions, optimisation of therapy determined by predictive assays, multi-modality schedule design, the simulation of clinical trials, testing contemporaneous medico-legal problems and teaching general principals of radiotherapy.

Improve your understanding of the scope, applications and limitations of radiobiological modelling.

Amongst radiation oncologists and medical physicists there is a need for a greater understanding of the scope, applications and limitations of radiobiological modelling, particularly in complex situations that include multiple treatment variables, the respective influence of which are difficult to separate out by randomised trials without using radiobiologically-based analysis.

Discover how modelling will help develop a rational and cost-effective use of resources.

The move towards individually-optimised treatments, using knowledge of normal tissue and tumour radiosensitivity, proliferation rates, etc, in combination with three-dimensional planning, will need mathematical modelling to achieve its full potential. This modelling process will also be capable of helping develop a rational and cost-effective use of resources.

25% DISCOUNT for BIR Members. Price ÂŁ45 (normal price ÂŁ60).

Buy your personal copy today; visit our online bookshop http://www.bir.org.uk/bir-publications-home.aspx

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Idea watch

idea watch Fractionation in radiotherapy an idea whose time has gone?

Are we brave enough to embrace this opportunity, to innovate, to save money and, at the same time, improve the patient experience? Are we even prepared to consider treating patients radically for lung cancer, breast cancer or prostate cancer with, at most, three fractions of radiotherapy?

Why do we fractionate?

Early X-ray equipment was too unreliable to be trusted to deliver single treatments at high-doses and, subsequently, a biological rational for the use of multiple low-does treatment was developed based on differential capacities for repair in tumours and normal tissues. Treatment planning techniques of the 20th century meant that to irradiate a tumour volume homogeneously, an appreciable volume of normal tissue had to be irradiated. Fractionation selectively spares normal tissues and this means that it is possible to deliver a total dose that may be sufficient to control the tumour, but will not cause irreparable damage to any normal tissues that may be incidentally irradiated.

What are the penalties associated with fractionation?

Fractionated regimens typically involve attending treatment 5 days a week for 6 to 7 weeks (although some centres do use schedules that only take 3 to 4 weeks in total). This has social and economic costs. Treatment in 30 fractions will require at least 25 times as much time on a linear accelerator as a treatment delivered in a single fraction.

Patients’ lives are disrupted for weeks at a time and, for tumours such as lung cancer, the gains in life expectancy may

be fairly minimal. There is little pleasure to be had from spending 20% of your remaining lifespan in daily attendance at a radiotherapy department.

Physics to the rescue - with one bound we are free

Modern planning techniques and technologies (intensity-modulated radiation therapy / image guided radiation therapy, tomotherapy, Gamma Knife, stereotactic body radiation therapy) mean that we can now reliably deliver homogenous doses of radiation to irregularly shaped tumour volumes without gratuitously irradiating adjacent normal tissues. Why, therefore, would we need to spare what is not there? If normal tissues are receiving only minimal doses of radiation then there is less need to fractionate. This seems obvious, but many trials of external beam therapy using these new technologies still use conventional fractionation.

A change in culture

Anything other than conventional fractionation is regarded with deep suspicion - even when it has been demonstrated to be better than conventional fractionation. This is the lesson of the CHART trial in lung cancer.

Patterns of reimbursement in the United States (piecework, payment by the

fraction) mean that it is highly unlikely that the full economic benefits of treating in a very few fractions will ever be realised in American practice. Any move to a smaller number of fractions would, in order to preserve income, be associated with increased front-loading of the costs i.e. more payment for planning and preparation. To preserve income streams there would be no net saving. This provides us, in the United Kingdom, with a real opportunity to lead and to save money.

With modest investment in resources for planning and physics we could, by using a limited numbers of fractions, make huge savings in both the capital and revenue costs of radiation treatment. In short, we need to think more like surgeons and less like medical oncologists.

Are we brave enough to embrace this opportunity, to innovate, to save money and, at the same time, improve the patient experience? Are we even prepared to consider treating patients radically for lung cancer, breast cancer or prostate cancer with, at most, three fractions of radiotherapy?

Some basic scientific knowledge

The biology underlying radiation therapy is more complex than we used to suppose. Large (≼10Gy) single doses of radiation do more than damage DNA. Other cellular events are important issue 1 february 2011

NEWS 15

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Idea watch

in influencing the response of living tissues both locally and at a distance.

These include: effects on gene expression; membrane damage and activation of apoptosis; generation of tumour antigens (with consequent immune activation); and effects on tumour vasculature. The linear-quadratic (LQ) model, and BED values derived from it, cannot be used to extrapolate from low-dose data to these dose levels because it overestimates the cytotoxic effect of large single fractions and fails to take into account the many ancillary biological effects.

We are starting to obtain the tools and knowledge we need; models of radiation action that go beyond LQ, such as gLQ and LQ cubic, and that reliably convert fractionated regimens into their single-dose equivalents; biomarkers that correlate with tissue and tumour responses to doses of radiation; functional imaging techniques (PET/CT, fMRI) that can provide early evidence of the cellular and metabolic response to radiation. One of the unforeseen consequences of the 9/11 attacks has been an increase in funding for radiation biology research in the USA. Much of the information coming out of these programmes is of direct relevance to treatment with large single doses of radiation.

ation should be registered and followed up prospectively using a central data repository. Economic analysis must be a key part of any such endeavour.

Existing programmes, such as those involving high dose rate-brachytherapy or intraoperative radiation therapy, can provide information that will be useful in underpinning clinical research in the use of large single fractions of treatment.

Clinical research

What might we achieve?

Ultimately, any ideas and hypotheses concerning the routine use of large fractions in radiotherapeutic practice will need to be tested clinically. Even if benefits appear self-evident, there is still a scientific and moral duty to provide objective evidence to support such an approach. We should not be reduced to the levels of argument used to defend the widespread dissemination of proton therapy “the dose distributions are better, therefore, the clinical results must be better”. I would argue that we should apply Chalmers’ principle of randomising from the first patient treated, and that all patients treated with 21st century hypofraction-

If we adopt this approach to fractionation we will save money. We will need fewer linear accelerators and fewer staff to run them. We will need to invest more in imaging, physics and the technologies associated with planning and immobilization, but these costs are likely to be very much less than those we currently bear with our standard fractionation regimens.

It will be possible to use radiosensitisers that are either too toxic (e.g. misonidazole), or too expensive (e.g. gold nanoparticles), for repeated use to increase the therapeutic effectiveness of individual radiation treatments.

The burden of treatment upon patients

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and their families will be decreased to 3 or 4 attendances within a fortnight compared with up to 40 attendances over a period of over 2 months.

We might tailor treatment to both the anatomy and the biology of an individual patient’s tumour. We could use serum or urinary markers of radiation response (e.g. proteomic patterns, measuring H2AX in peripheral lymphocytes or cytokeratin 18 fragments) to assess the damage following a first fraction of treatment and use the data to dictate the dose given at a second, and final, session of treatment.

The change in economic climate, increasing demands for radiotherapy services and advances in the physics and technology of the delivery of radiation therapy all combine to provide a unique opportunity to re-think some of our fundamental assumptions concerning clinical radiotherapy. We may be able to liberate ourselves (and our patients) from the shackles of fractionation - but are we courageous enough to cast away our chains?

Alastair J Munro, University of Dundee

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in the online issue of BJR

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

Commentary

Short communication

Pictorial review

Review article

Full paper

The launch of the first UK charity devoted to radiotherapy: ACORRN – Action Radiotherapy

Voxel-based diffusion tensor imaging detects pyramidal tract degeneration in primary lateral sclerosis

Right heart dilatation in adult congenital heart disease: imaging appearance on cardiac magnetic resonance

The corpus callosum: white matter or terra incognita

P Price

L C Tzarouchi, A P Kyritsis, S Giannopoulos, L G Astrakas, M Diakou & M I Argyropoulou

D Beitzke, F Wolf, G Edelhauser, J Lammer & C Loewe

Statistical analysis of mammographic breast composition measurements: towards a quantitative measure of relative breast cancer risk

DOI: 10.1259/ bjr/14368804

DOI: 10.1259/ bjr/13711325

DOI: 10.1259/ bjr/33198274

A Fitsiori, D Nguyen, A Karentzos, J Delavelle & M I Vargas

C J Kotre

DOI: 10.1259/ bjr/21946513

DOI: 10.1259/ bjr/40806022

Highlighted Articles: Full papers

Case reports

Anti-tumour effects of transcatheter arterial embolisation administered in combination with thalidomide in a rabbit VX2 liver tumour model

The role of somatostatin analogues in the treatment of advanced malignant thymomas: case report and review of the literature

A Nitta-Seko, N Nitta, A Sonoda, H Otani, K Tsuchiya, S Ohta, M Takahashi & K Murata

L Pettit & A El-Modir

DOI: 10.1259/bjr/53771502

Accessory or additional renal arteries show no relevant effects on the width of the upper urinary tract: a 64-slice multidetector CT study in 2132 kidneys of 1072 patients B Glodny, K Rapf, V Unterholzner, P Rehder, K J Hofmann, A Strasak, R Herwig & J Petersen

DOI: 10.1259/bjr/79479004

Diagnostic accuracy of fused positron emission tomography/magnetic resonance mammography: initial results T A Heusner, S Hahn, C Jonkmanns, S Kuemmel, F Otterbach, M E Hamami, A R Stahl, A Bockisch, M Forsting & G Antoch

DOI: 10.1259/bjr/93330765

DOI: 10.1259/bjr/16436465

Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia: an unusual cause of cyclical ctopic adrenocorticotrophic syndrome C M Cameron, F Roberts, J Connell & M W Sproule

DOI: 10.1259/bjr/91375895

Recanalisation of the internal carotid artery via the vasa vasorum after coil occlusion T Meguro, K Muraoka, K Terada, N Hirotsune & S Nishino

DOI: 10.1259/bjr/31383692

Blind-ending branch of a bifid ureter: MDCT imaging findings E Chang, C Santillan & M K O’Boyle

DOI: 10.1259/bjr/15001058 issue 1 february 2011

NEWS 17

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in The online issue of BJR

All other articles from the January 2011 issue Full papers

Pictorial review

Correlation between mammographic and sonographic findings and prognostic factors in patients with nodenegative invasive breast cancer

Clinical presentations and imaging findings of neuroblastoma beyond abdominal mass and a review of imaging algorithm

H J Shin, H H Kim, M O Huh, M J Kim, A Yi, H Kim, B H Son & S H Ahn

C M Chu, D D Rasalkar, Y J Hu, F W T Cheng, C K Li & W C W Chu

DOI: 10.1259/bjr/92960562 DOI: 10.1259/bjr/31861984

Diffusion-weighted magnetic resonance imaging for monitoring prostate cancer progression in patients managed by active surveillance

Case of the month

V A Morgan, S F Riches, K Thomas, N Vanas, C Parker, S Giles & N M Desouza

A case of chronic knee pain and swelling

DOI: 10.1259/bjr/14556365

Pre-operative evaluation of peritoneal deposits using multidetector computed tomography in ovarian cancer S H Chandrashekhara, S Thulkar, D N Srivastava, L Kumar, R Hariprasad, S Kumar & M C Sharma

DOI: 10.1259/bjr/87415692

Dobutamine stress tagging and gradient-echo imaging for detection of coronary heart disease at 3 T D Thomas, C Meyer, K Strach, C P Naehle, J Mazraeh, T Gampert, H H Schild & T Sommer

DOI: 10.1259/bjr/59381313

Dose and image quality comparison between prospectively gated axial and retrospectively gated helical coronary CT angiography C Hlaihel, L Boussel, H Cochet, J A Roch, P Coulon, M D Walker & P C Douek

DOI: 10.1259/bjr/13222537

Intensity-modulated radiotherapy increases dose to the brachial plexus compared with conventional radiotherapy for head and neck cancer A M Chen, W H Hall, B-Q Li, M Guiou, C Wright, M Mathai, A Dublin & J A Purdyi

DOI: 10.1259/bjr/62332495

Overstaging of cartilage invasion by multidetector CT scan for laryngeal cancer and its potential effect on the use of organ preservation with chemoradiation B Li, M Bobinski, R Gandour-Edward, D G Farwell & A M Chen

DOI: 10.1259/bjr/66700901

Occupational radiation doses to the extremities and the eyes in interventional radiology and cardiology procedures P Efstathopoulos, I Pantos, M Andreou, A Gkatzis, E Carinou, C Koukorava, N L Kelekis & E Brountzos

DOI: 10.1259/bjr/83222759 18

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D Das, D F Sallomi & D C Howlett

DOI: 10.1259/bjr/24552351

Case reports

CT characteristics of a uterus-like mass in the sigmoid mesocolon S Y Shin, H J Kim, Y W Kim & K Y Lee

DOI: 10.1259/bjr/47170465

Localised right upper-lobe pulmonary oedema caused by extension of giant cell carcinoma to the mitral valve A Ono, F Okada, Y Ando, T Maeda, H Nagai, J Kadota & H Mori

DOI: 10.1259/bjr/29189288

Littoral cell angioma in a splenunculus: a case report N Venkatanarasimha, S Hall, P Suresh & M P Williams

DOI: 10.1259/bjr/60430925

Magnetic resonance cholangiopancreatography diagnosis of choledochal cyst involving the cystic duct: report of three cases J-H Yoon

DOI: 10.1259/bjr/77844300

Editorial

BJR news: a new venture for 2011 Jane Phillips-Hughes and R Dale DOI: 10.1259/bjr/26244588

www.bir.org.uk

IN THE ONLINE ISSUE OF BJR

All other articles from the February 2011 issue Short communication

Case reports

Use of the triaxial microcatheter method in super selective transcatheter arterial chemoembolisation for hepatocellular carcinoma

Lymphocoele of the thoracic duct: a cause of left supraclavicular fossa

M Shimohira, H Ogino, T Kawai, A Kushita, M Watanabe, T Kawaguchi, K Kurono, & Y Shibamoto

DOI: 10.1259/bjr/26974088

C E Offiah & S Twigg

DOI: 10.1259/bjr/28200085

Imaging findings of calcifying fibrous tumour of the liver B-J Jo, S-W Yoon, H J Ahn & S W Kwon

Review article

DOI: 10.1259/bjr/30585776

Imaging in bariatric surgery: service set-up, postoperative anatomy and complications

Left ventricular true and false aneurysms identified by cardiovascular magnetic resonance

S Shah, V Shah, A R Ahmed & D M Blunt

S Gill, D J Rakhit, S K Ohri & S P Harden

DOI: 10.1259/bjr/18405029

Full papers

DOI: 10.1259/bjr/25590962

MRI appearance of massive renal replacement lipomatosis in the absence of renal calculous disease E Fitzgerald, J Melamed, S S Taneja & A B Rosenkrantz

Comparison of conventional and three-dimensional conformal CT planning techniques for preoperative chemoradiotherapy for locally advanced rectal cancer C Corner, F Khimji, Y Tsang, M Harrison, R Glynne-Jones & R Hughes

DOI: 10.1259/bjr/42450182

Case of the month

DOI: 10.1259/bjr/33089685

Comparison of the helical tomotherapy against the multileaf collimator-based intensity-modulated radiotherapy and 3D-conformal radiation modalities in lung cancer radiotherapy

Hepatitis and a rash in an immunocompromised patient V Shah & A Saini

DOI: 10.1259/bjr/20127924

P Mavroidis, C Shi, G A Plataniotis, M G Delichas, B Costa Ferreira, S Rodriguez, B K Lind & N Papanikolaou

DOI: 10.1259/bjr/89275085

MR defecography in patients with dyssynergic defecation: spectrum of imaging findings and diagnostic value C Reiner, R Tutuian, A E Solopova, D Pohl, B Marincek & D Weishaupt

DOI: 10.1259/bjr/28989463

Non-laxative CT colonography with barium-based faecal tagging: is additional phosphate enema beneficial and well tolerated?

W Davis, P Nisbet, C Hare, P Cooke & S Taylor

DOI: 0.1259/bjr/23626544

CT enterography with polyethylene glycol solution vs CT enteroclysis in small bowel disease L M Minordi, A Vecchioli, P Mirk & L Bonomo

DOI: 10.1259/bjr/71649888

issue 1 february 2011

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Case of the month

A case of chronic kn A 67-year-old female was referred to the rheumatology clinic with a 6 year history of progressively worsening left-sided knee pain and swelling. No other joints were affected and the patient was otherwise fit and well. There was no history of trauma.

A plain radiograph of the left knee demonstrated a large suprapatellar pouch effusion (Figure 1).

What are your differentials?

Differentials

The clinical and radiological findings are consistent with monoarthritis, and the differentials can be divided into three broad categories: 1) joint infection; 2) arthropathy (e.g. gout, rheumatoid arthritis, inflammatory osteoarthritis etc.); and 3) synovial disorders (e.g. non-specific synovitis, pigmented vilonodular synovitis (PVNS), synovial osteochondromatosis, synovial haemangioma etc.).

Synovial fluid aspiration was unremarkable in terms of bacteriology and crystal microscopy; plasma white cell count, rheumatoid factor assay and auto-antibody screen were all negative.

However, serum erythrocyte sedimentation rate (ESR) was raised to 137mm h-1.

Given the lack of any significant bony abnormalities on the initial radiograph, non-specific synovitis was suspected and treatment commenced with nonsteroidal anti-inflammatory drugs, and a single dose of intra-articular steroid.

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Figure 1. Lateral radiograph of the left knee demonstrating suprapatellar softtissue density consistent with an effusion (asterisk).

Figure 2. Axial T2* image of the left knee.

High-signal effusion fluid can be seen within the joint, and multiple low-signal synovial projections are demonstrated throughout the suprapatellar pouch (arrows).

An MRI scan of the knee was requested to exclude any underlying pathology (Figures 2–5).

• What is the diagnosis? Would you recommend any further investigations?

Discussion

Diagnosis

MRI confirmed the presence of a large joint effusion (Figure 2), but reveals a diffuse, villous proliferation of the suprapatellar pouch synovium (Figures 2–4). In addition, a frondlike mass can be seen arising from the anterior aspect of the synovium (Figure 4). All of these changes are iso-intense to subcutaneous fat on all the sequences performed, including the fat-saturation sequence (Figure 5). These are classic features of lipoma arborescens.

No further investigations were required and the patient was counselled regarding arthroscopic synovectomy.

At present this has been declined for personal reasons, and symptomatic therapy with oral steroids has been commenced in the interim.

Lipoma arborescens is a rare benign synovial disorder caused by the proliferation of adipocytes within the subsynovial layer of joint capsules and bursae [1].

Lipoma arborescens occurs in both males and females and across a wide range of age groups, including children [1–3]. Typically it is a mono-articular disease with a predilection for the suprapatellar pouch of the knee. There are infrequent reports of lipoma arborescens presenting with bilateral and polyarticular disease, and isolated cases occurring within the hip, shoulder, ankle, within the extra-articular synovium of the subacromial and bicipitoradial bursae, and the ankle and wrist tenosynovium [1, 2].

Clinical presentation is insidious and the typical presenting complaint is a chronically swollen joint, usually the knee, with variable levels of longstanding pain and debilitation [1–3]. Laboratory tests including synovial fluid analysis for crystals and micro-organisms, and blood assays for inflammatory markers, rheu-

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case of the month

nee pain and swelling

Figure 3. Sagittal T1 image of the left knee.

There are multiple high-signal projections arising from the synovium of the suprapatellar pouch (arrows). The large joint effusion is demonstrated as low-signal (asterisk).

Figure 4. Coronal T1 image of the left knee.

There are multiple high-signal synovial projections that have a villous appearance (black arrows). A frond-like mass can also be seen arising from the anterior synovium (white arrows).

Figure 5. Coronal proton density fat-saturated image. Signal loss is demonstrated from the synovial mass and all of the synovial projections seen in Figure 4 (arrows).

matoid factor and auto-antibodies are all usually unremarkable [4]. The raised ESR in the present case is likely to be secondary to the presence of a concomitant nonspecific synovitis, another recognised association of lipoma arborescens [5].

Radiographs are non-specific and usually demonstrate opacity and fullness within the affected joint or bursa, partly secondary to joint effusion and partly owing to the proliferative synovium itself.

Rarely, the opacity may demonstrate areas of heterogeneous lucency, which indicates the presence of fat [2].

MRI appearances, however, are pathognomonic and three broad morphological categories have been recognised [3]. The most common consists of villous synovial projections occurring diffusely throughout the affected joint or bursa (Figure 2). The least common is an isolated frond-shaped synovial mass and the third morphology, with intermediate prevalence, is a combination of the first two categories and effectively represents the findings in our patient (Figure 4).

The subsynovial fatty proliferations of lipoma arborescens do not demonstrate contrast enhancement; however, the presence of synovitis can cause postgadolinium enhancement of the overlying synovial membrane [5]. In the largest series to date, Vilanova et al [1] have shown that unenhanced MRI is sufficient to make a diagnosis of lipoma arborescens without further investigation. Given the pathognomonic appearances in our patient, we elected not to administer contrast.

Lipoma arborescens has numerous additional findings on MRI, but by far the commonest is joint effusion, which is seen in almost all cases [1, 3]. Other findings, in descending order of frequency, include degenerative changes, meniscal tears, synovial cysts and bone erosions.

In terms of differentials, the only other synovial lesion that shows complete signal iso-intensity with fat is a synovial lipoma [1, 3]. This can be readily distinguished from lipoma arborescens, as synovial lipoma usually manifests as an isolated, well-defined, round or ovoid

mass. The various other proliferative synovial disorders mentioned in the initial differential diagnoses, such as PVNS, synovial osteochondromatosis, and synovial haemangioma can all bear a superficial resemblance to lipoma arborescens in terms of their diffuse morphology and variable fat content, but none will show the complete signal isointensity of the entire lesion to fat that is required for diagnosis.

Lipoma arborescens can be effectively treated with synovectomy and the procedure can be performed either as an open operation or arthroscopically [4]. Nonsurgical synovectomy, for example with intra-articular Yttrium-90, has also been used successfully in lipoma arborescens [6] and may be a less invasive option for our patient to consider in the future.

D Das, D F Sallomi and D C Howlett Department of Radiology, Guy’s and St. Thomas’ Hospitals, London, UK

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NEWS 21

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Commentary

commentary: PAT PRICE The launch of the first UK charity devoted to On 13th July 2010 a reception was held at the House of Lords to launch the first UK charity devoted to radiotherapy research and development: Academic Clinical Oncology and Radiobiology Research Network (ACORRN)-Action Radiotherapy. It was attended by representatives from all the groups devoted to radiotherapy development including: the British Institute of Radiology (BIR), Institute of Physics and Engineering in Medicine (IPEM), Royal College of Radiologists (RCR), Society of Radiographers (SoR), Association for Radiation Research (ARR), Cancer Research UK (CRUK), Cancer Action Team, Health Protection Agency (HPA), the private sector, members of the House of Commons and House of Lords and many of the great and the good in the field. Professor Norman Coleman of the National Institutes of Health in the USA, Chief Scientific Advisor to ACORRN, spoke at the launch [1].

The challenges for service development of radiotherapy in the UK

Radiotherapy is effective and inexpensive compared with some cancer treatments and second only to surgery in its potential to cure cancer. Even small improvements in how radiotherapy is delivered could lead to large increases in the number of patients cured, and improve palliative treatment for others [3].

Until the 1980s the UK was seen as the international radiotherapy leader and provided training to many around the world. However, the UK lost its lead in the 80s and 90s. This was mainly because of expectation that the magic bullet of chemotherapy would replace radiotherapy for the treatment of many cancers. Although involvement from “big pharma” led to some advances, it 22

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was at the expense of losing our focus on radiotherapy. Radiotherapy research has declined since the mid-1980s, especially in the UK. Recent advances in technical radiotherapy (intensity modulated radiotherapy (IMRT), image-guided radiotherapy (IGRT) and particle therapy) and the combination of radiotherapy with chemotherapy has led to a resurgence of recognition for the importance of radiotherapy in cancer management. However, this has

machines were made by setting up the National Radiotherapy Advisory Group and the Cancer Action team, as well as many other important developments. All these actions are helping the UK “catchup” with other countries. The National Cancer Research Institute (NCRI) was set-up in 2001 to develop common plans for cancer research and to avoid unnecessary duplication of effort. The NCRI was instrumental in co-ordinating the development of the Gray Institute

We aim to improve radiotherapy treatment costeffectively, by mobilising and facilitating the UK-wide depth of researchers and NHS deliverers of cancer care to work together and make a step change in radiotherapy treatment in the UK. come at a time when, in the UK, the radiotherapy research field finds itself depleted and demoralised. Only 6% of cancer research funding in the UK is devoted to radiation research [4]. To compete for funding, we need to expand our academic expertise and develop our leading international researchers.

Many patients in the UK do not have access to state-of-the-art treatment, and yet the demand for radiotherapy services is predicted to increase by 91% from the 2007 levels by the year 2016 [5].

Response of government

The previous government made considerable successful efforts to improve cancer care including the appointment of a National Cancer Director who has, superbly, kept cancer on the forefront of the government agenda. Waiting lists were reduced by introducing treatment time targets and huge investments in radiotherapy

for Radiation Oncology and Biology in Oxford, supporting the set-up of ACORRN and more recently setting up the NCRI Clinical and Translational Radiotherapy Research Working Group (CTRad). CTRad is now working hard to develop and raise the profile of radiotherapy-related research and has recently held a number of well-attended events aimed at engaging and re-energising the radiotherapy community.

The UK radiotherapy workforce has worked well together in the past.

However, there are still gaps and deficiencies that need to be addressed to maximise the investment already made.

There is still a lack of radiotherapy and radiobiology researchers in the UK. The level of overall cancer research funding received is critically low at 6%. The current range of UK research funding, although fairly comprehensive, is not well suited to the needs of technical radiotherapy developments within a highly specialised area, with its diverse

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Commentary

radiotherapy: ACORRN – Action Radiotherapy needs of multidisciplinary working and the development and implementation of new technology equitably across the UK. Many feel there should be a step change in priority and strategy for radiotherapy reinvigoration, similar to the recent innovative multimillion investments in imaging research infrastructure in the UK by CRUK and the Engineering and Physical Sciences Research Council (EPSRC).

What does ACORRN do?

• Interactive forums where individual researchers and healthcare deliverers can post questions on the website and answers are delivered within minutes from around the UK. This ensures that patients in any of the 62 centres around the UK know that those managing their care have access to the best UK knowledge.

• Education and training for therapy

How can ACORRN help?

A charity dedicated to raising funds for radiotherapy research and development is long overdue and has enormous potential to support important exploratory or pilot studies that can sometimes be viewed as uncompetitive by the big funding agencies.

We have a long way to go until investment in radiotherapy research in the UK is back on a par with levels in the early 1980s or with Europe and the USA. Until then there is much we can do to help ourselves and ACORRN-Action Radiotherapy can assist in the effort by providing a unique resource in the UK. The network might even be a model for healthcare service development in this new era of austerity. We aim to improve radiotherapy treatment cost-effectively, by mobilising and facilitating the UK-wide depth of researchers and NHS deliverers of cancer care to work together and make a step change in radiotherapy treatment in the UK. We have based our philosophy on the thoughts of the Nobel Prize winner, Rutherford, who said, “When you have no money, you have to think”. Our present motto is “When you have no money, you need to network”. There are at least 62 radiotherapy centres, more than 300 radiotherapy oncology consultants, more than 2000 therapy radiographers

radiographers who have developed their Research Radiographer Starter Pack [6].

• Multidisciplinary research through across-the-board researchers linking multidisciplinary groups providing administrative assistance and an internet-based domain for sharing documents. We have successfully supported grant applications that have been awarded over £12 million in the last few years. The research ranges from accelerator physics through to patient care and to normal tissue radiobiology.

• Introducing new developments by supporting the introduction of complex technology. We developed the image guided radiotherapy road map [6] for the efficient sharing of introducing the technology. We are now developing the website for sharing radiotherapy plans and images to serve as minimum standards, quality control and audit.

and hundreds of medical physicists and biologists. We are using this resource actively together. Individually we may not be strong, but together we can be internationally competitive again. We have an interactive website with more than 1600 members stretching across the UK and also including representatives from all 5 continents. Many are

working towards finding better and safer ways to treat patients with radiotherapy, and to cure more patients with cancer.

We work together with researchers, funders, policy makers, patients and the NHS to improve radiotherapy services and treatments for cancer patients.

ACORRN has received considerable support from the BIR who see it as in line with their objectives to support the radiological sciences. ACORRN will be working closely with the BIR as it develops further and there is a vision for developing this or a similar network for the diagnostic imaging community.

Plans for the future

We hope our new website will inspire more interaction to ensure added value and a “can do” culture. We want to engage patients and their relatives in the whole process, particularly their ideas of where service can be improved and where research is needed. We want to expand our support to other groups and work with all the agencies so that they can benefit from this innovative research and development platform. We will be funding research and development where there are current gaps in the funding structure and supporting internet-based sharing of radiotherapy plans and images to improve patient care. We will be expanding our forums and working parties where there is a need. The charity ACORRN-Action Radiotherapy has launched a £5 million appeal to raise funds to support radiotherapyrelated research and development.

P Price FRCR Division of Surgery, Department of Surgery and Cancer, Imperial College, Hammersmith Hospital, London and Chair of ACORRN

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short communication

Voxel-based diffusion tensor imaging detects pyramidal tract degeneration in primary lateral sclerosis Primary lateral sclerosis (PLS) is an adult onset, non-hereditary degenerative disorder of the upper motor neuron related to a selective loss of precentral pyramidal neurons. Ιt is characterised by progressive spinobulbar spasticity owing to pyramidal tract degeneration, but preservation of the anterior horn motor neurons and no involvement of the lower motor neuron [1–4]. Currently there is no defining test or disease marker; thus, the diagnosis is usually made based on clinical presentation [1, 2].

The fractional anisotropy (FA) index is a measure of the degree of directionality of diffusion [5, 6]. The assessment of FA has been used as a measure of white matter degeneration in many diseases as it can detect and quantify the degeneration of fibres along white matter tracts [5, 6]. The method that is usually used is the region of interest (ROI) approach [7]. Nowadays, an automated method of analysis is used for a voxel-wise comparison of DTI data throughout the whole brain [8, 9].

In this report a single case of PLS was studied using DTI on a voxel-by-voxel comparison with a control group to detect upper motor neuron involvement.

Methods and results

A 52-year-old woman complained of stiffness in the legs and difficulty in walking since 2005. The symptoms gradually worsened over the years and followed an ascending pattern resulting in spastic tetraparesis.

Neurological examination showed asymmetric spasticity in lower and upper limbs, more prominent in the left leg. The jaw-jerk and limb tendon reflexes were increased with ankle clonus, bilateral Babinsky and Hofmann signs. The gait was spastic.

Data were acquired from eight healthy age-matched volunteers. Brain MRIs 24

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were normal and there was no history of neurological disease.

Voxel-based DTI analysis showed a statistically significant decrease of FA in the PLS patient when compared with controls.

The regions involved the proximal parts of the pyramidal tracts bilaterally in the precentral gyrus (Figure 1).

Discussion

The degree of upper motor neuron involvement was assessed using the FA on a voxel-by-voxel basis throughout the whole brain in a patient with PLS. Decreased FA values were observed in the patient along the proximal corticospinal track bilaterally when compared with the control group. Our patient presented with typical signs and symptoms for PLS. The sites of onset were the lower limbs followed by an ascending pattern of slowly progressive course of symptoms.

According to previous reports on patients with PLS, MRI shows atrophy of the frontoparietal part of the brain, which is most prominent in the pre-central area, with concomitant degeneration of the underlying white matter [2, 6]. Limitations of the ROI-based approach include that it is restricted to predefined regions, it is subject to operator bias, the ability to accurately determine the boundaries of the corticospinal tract and to avoid partial volume contamination from non-corticospinal tract fibres.

Voxel-based DTI is an objective, automated and unbiased technique that assesses changes in diffusion orientation and magnitude throughout the whole brain without prior assumption of brain areas of potential interest [8, 9]. The patient in our case demonstrated decreased FA along the proximal part of the descending corticospinal tract before it reached the posterior limb of the internal capsule. Without a

Figure 1. Brain regions with decreased fractional anisotropy

voxel-by-voxel analysis it would be difficult to precisely determine the margins of the pyramidal tract in that region and to evaluate differences with controls.

No significant difference in FA was observed in the internal capsule despite the fact that FA is high in that area as it contains very coherent and tightly packed fibres of the corticospinal tract. Degeneration of motor fibres and gliosis along the corticospinal tract is secondary to the upper motor neuron loss [12]. We can assume that as the disease progresses degeneration of the pyramidal tract follows a descending pattern to the spinal cord.

Conclusion

This report supports the potential role for voxel-based DTI as an objective and quantitative marker for detecting and monitoring upper motor neuron’s involvement in PLS. Such markers may improve diagnostic accuracy and enable patients with suspected PLS to access treatment sooner.

L C Tzarouchi, A P Kyritsis, S Giannopoulos et al Medical School, University of Ioannina, 45110 Ioannina Greece

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review article

REVIEW ARTICLE

S Shah, V Shah, AR Ahmed et al Department of Imaging, Imperial College Healthcare NHS Trust, London, UK

Imaging in bariatric surgery: service set-up, post-operative anatomy and complications Imaging by well-trained radiologists and radiographers is a vital component in the management of patients following bariatric surgery.

Obesity

Obesity is a multifactorial disease, which is increasing in incidence and prevalence.

Estimates suggest that at the current rate of increase, by 2010 there will be 12 million adults and 1 million children categorised as obese. It is increasingly recognised that the consequences of obesity on general health are far reaching. As well as a burden on the general health of the population, there is a huge financial burden associated with obesity.

The Health Select Committee reported that the cost of obesity and being overweight is between £6.6 and £7.4 billion

per year. If current trends in obesity continue, these costs may rise to between £7.5 and £8.4 billion per year [2]. Lifestyle and pharmacological interventions have been the main options available to health professionals caring for this population.

However, there is an increasing volume of literature expounding the benefits of bariatric surgery.

The National Institute for Health and Clinical Excellence (NICE) published updated guidance in 2006 regarding the management of obesity [2]. The estimated cost of implementing the NICE guidance is £63 million in the first

year; the cost savings of a 1% reduction in obesity prevalence would return this sum.

NICE emphasise the importance of undertaking surgery only at centres where a multidisciplinary team approach is used.

In addition, rigorous selection criteria should be applied and surgery should only be undertaken at high-volume centres; these factors may help reduce in-hospital deaths [6]. NICE also state that an essential component in a successful service is the provision of a diagnostic and interventional radiology service by well-trained radiologists and radiographers.

mortality. There are unique challenges faced by the radiology department in providing an imaging service for this population of patients, from technical and staffing requirements through to the interpretation of challenging

post-surgical images. We describe these challenges and provide an overview of the most frequently performed procedures, normal post-operative imaging findings and the appearance of common complications.

Abstract Obesity is an increasingly prevalent and costly problem faced by the healthcare system. The role of bariatric surgery in managing obesity has also increased with evidence showing a reduction in long-term morbidity and

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Bariatric surgical procedures

There are three main categories of surgical procedure: restrictive procedures induce weight loss by substantially reducing gastric capacity and promoting early satiety, malabsorptive procedures surgically alter the gut to limit nutrient absorption from the small intestine, but are not now commonly performed, and combined restrictive and malabsorptive approaches, although the primary mechanism of weight loss is thought to be restrictive rather than malabsorptive [8]. Many of the procedures are

now performed laparoscopically with the advantages of decreased recovery time and reduced number of complications. Currently, the two most commonly performed procedures worldwide are Roux-en-Y gastric bypass (RYGB) and laparoscopic gastric banding (LAGB), followed by sleeve gastrectomy [9, 10].

Normal post-operative imaging appearance Upper GI fluoroscopy using an oral water soluble contrast is the first line technique to assess for post-operative

complications. As a rule of thumb the gastric pouch should be of a size similar to that of a lower thoracic or lumbar vertebral body (15–20 ml). This comparison allows simple and reliable detection of a pouch that is either too large or too small.

Contrast may remain in the distal oesophagus and gastric pouch for a variable period before passing through the anastomosis and filling the short blind limb and alimentary (Roux) limb.

CT is not commonly performed in the post-operative assessment following RYGB, but can be useful when fluoroscopic

three categories: technical factors, training issues and service provision. With regards to technical factors there are issues relating to weight and size limits, image quality and radiation dose imparted. The weight and size limits of individual pieces of imaging equipment need to be outlined specifically in a policy document prior to the initiation of such a service. Being able to acquire images of diagnostic quality is a further challenge owing to the large volume of soft tissue there is increased absorption of the X-ray beam and higher currents need to be used.

There is also increased scatter of radiation; both these factors mean that there is an increased radiation dose imparted on the patients and the operators. The contrast resolution of these studies is compromised.

This is important because often the key question is whether there is a leak of watersoluble contrast from the site of surgery, and detecting small volumes of leaked contrast may be extremely difficult owing to poor image resolution. Similarly, ultrasound is often an unsatisfactory modality to use in these patients because of the absorption and poor reflection of ultrasound waves by the large volume of soft tissue.

The surgical procedures performed on these patients are unique and it is important that radiologists are specifically and adequately trained in the appropriate imaging techniques and normal and abnormal imaging appearances. When the service was started at our institution, the lead surgeon provided a lecture on the

surgical techniques used, their expected normal post-operative imaging findings and common complications. For the first 6 months, regular meetings were held between the surgical and radiology teams to discuss specific cases with a view to establishing experience and a “database” of normal and abnormal findings. As well as the radiologists specifically involved in gastrointestinal (GI) imaging, all other radiologists providing an “on-call” service, radiographers and interventional radiology nurses needed to be trained in issues specific to the imaging of bariatric patients. In many parts of the UK, training of radiologists is moving towards a modular programme based on tutorials on the RadiologyIntegrated Training Initiative (RITI) website [7]. A module on imaging following bariatric surgery is currently not available.

There are several logistical factors involved in providing such a service.

Fluoroscopy is one of the main imaging modalities used in the post-operative period and commonly patients are imaged in the first 48 hours following the procedure.

There must be adequate space on the routine fluoroscopy lists to be able to accommodate these patients at short notice and if there are no planned lists there must be fluoroscopy facilities, radiographers and radiologists available to provide the service as and when required. Similarly, there will be an expected increase in the use of CT and interventional radiology services for these patients.

Roux-en-Y gastric bypass

Service set-up As with any new service set-up, there is an analysis of the demand for the service against the costs, health and financial benefits of providing the service. The commissioners of the service must ensure that the service is integrated with other local health and weight management programmes [2]. They must also ensure that appropriate referral and assessment criteria are established, and frequent review of the clinical outcomes is undertaken to maintain a high-quality service. Under the new payment by results (PbR) system, a fixed tariff is paid by the primary care trust (PCT) to the hospital trust for specific procedures. There is also an additional inflationary cost added to reflect the local population. This income is then used to pay the overheads for the service, recruitment and employment of surgeons and specialist nurses. Allocated amounts are paid to the theatres, imaging and pathology departments. Generally, the income distributed to the imaging department is a fixed proportion of the surgical department’s income, regardless of the types of operation being performed. Whilst some operations require no imaging follow-up, many do, and the cost of providing the imaging service has to be met by the fixed income from the surgical department. In the near future, many imaging departments may move to a similar PbR-type system, i.e. they are paid for individual units of work rather than a lump sum.

The specific challenges faced by the imaging department can be divided into

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Normal CT appearances following Roux-en-Y gastric bypass. Antecolic position of alimentary limb; A, alimentary limb; TC, transverse colon

Contrast study demonstrating leak at gastrojejunal anastomosis; arrow indicates leak; P, gastric pouch; A, alimentary limb

review article

examinations are equivocal or for the evaluation of extraluminal complications such as intra-abdominal fluid collections.

Complications The incidence of anastomotic leak after RYGB is reported to be in the region of 2–5% [11, 12]. Clinical evaluation is difficult as patients may have no signs of peritonitis and may present with only fever, tachycardia and abdominal discomfort, which are relatively non-specific in the immediate post-operative period [13].

Fluoroscopy typically shows extravasated contrast material in the left upper quadrant.

Abdominal fluid collection and subphrenic abscess occur in fewer than 2% of all bariatric surgery patients, but are extremely serious complications with a high morbidity and mortality [12, 14]. Plain radiographs may show an air-fluid level in the left upper quadrant, although this finding can be difficult to interpret because of air in the remnant stomach. However, CT has a critical role in the work-up as it will readily demonstrate the fluid collection. In addition, the presence of air-fluid levels or contrast material is highly suggestive of anastomotic leak as the underlying cause.

Anastomotic narrowing at the gastrojejunal anastomosis has a reported incidence ranging from 3% to 9% and is more common with a circular stapled gastrojejunostomy [11, 15]. Clinically, this presents with dysphagia, post-prandial pain and vomiting [14]. Fluoroscopy demonstrates narrowing at the gastrojejunal anastomosis, expansion of the gastric pouch and delayed passage of contrast material into the Roux limb. In the immediate post-operative period this is usually the result of anastomotic oedema [16]. In these cases, follow-up examinations should show improvement if the delay is caused by oedema. Persisting pouch distension on follow-up and air/contrast material levels in the pouch and oesophagus are suggestive of a stricture. Stricture at the jejunojejunal anastomosis is rare, with an incidence of 0.8% [17]. On fluoroscopy, contrast material is seen in a distended alimentary limb.

Small-bowel obstruction is reported in 4–5% of patients [18]. It can be difficult to issue 1 february 2011

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distinguish small-bowel obstruction caused by adhesions from that caused by internal hernia on CT. However, clustering of dilated small-bowel loops in the left upper quadrant is more suggestive of internal herniation [19]. In the case of herniation through the transverse mesocolon, the herniated cluster of bowel is located posterior to the stomach and transverse colon.

Stomal ulceration incidence is in the region of 10%. It is thought to occur as a result of increased acid production within the pouch and is, therefore, associated with larger gastric pouches [20]. Patients usually present with severe dyspepsia, burning retrosternal pain and vomiting.

The diagnosis is usually made endoscopically; however, imaging studies may detect complications such as stricture, perforation and gastrogastic fistula.

Gastrogastric fistula is a connection between the gastric pouch and remnant and is a rare complication, with a reported incidence of <1%. The primary finding on fluoroscopy is detection of contrast material in the gastric remnant.

Adjustable gastric banding

Normal post-operative imaging appearance On fluoroscopic studies, the gastric pouch should be relatively symmetric in shape and measure approximately 3–4 cm in maximum dimension when distended with contrast material. The stoma diameter should measure approximately 3–4 mm in diameter, with prompt emptying of the pouch [24]. In addition, the adjustable band, catheter and subcutaneous port can all be visualised. Another factor that should be assessed is the orientation of the gastric band, which should lie obliquely.

This can be more formally measured using the phi angle, which is the angle created by intersecting a line drawn parallel to the spinal column with a line drawn parallel to the plane of the gastric band on an anteroposterior projection. Normally this angle should range from 4° to 58° [25].

Complications Stomal stenosis and acute concentric pouch dilatation are the most common complications after LAGB [26], and present 28

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Normal appearances following sleeve gastrectomy, schematic illustration.

with nocturnal reflux, vomiting and upper abdominal discomfort. Typical fluoroscopic findings include a narrowed or obstructed stoma with proximal concentric pouch dilatation, delayed passage of contrast material and oesophageal reflux.

Chronic pouch dilatation incidence is 3–8% [26, 27]. In contrast to acute pouch dilatation, it occurs in the presence of a normal stoma and is usually owing to chronic volume overload of the pouch secondary to overeating.

Pouch prolapse, also termed band slippage, is the superior herniation of the distal stomach wall and may occur despite adequate initial band placement. Incidence ranges from 3 to 13% and is decreasing with modifications to the surgical technique [26–29].

Acute gastric perforation is rare, occurring in <1% of cases, and is usually owing to surgical trauma to the stomach wall [26, 28]. Fluoroscopy and CT may demonstrate leak of contrast into the left upper quadrant.

Sleeve gastrectomy

Normal post-operative imaging appearance Upper GI fluoroscopy after SG is the first line study to detect leaks and other

post-operative complications. The normal post-operative fluoroscopic anatomy is a thin tubular pouch, the diameter of which varies according to the size of the bougie tube used. In the majority of cases contrast passes freely through the sleeve to the antrum, with a slight delay at the pyloric valve. However, in some cases, there can be failure to propel contrast with a hold up in the proximal sleeve [33].

This is thought to be due to gastric antral malfunction or “stunning” in the early post-operative period, but usually settles with time and the aid of a prokinetic agent. A linear streak of contrast may be seen within non-excised fundus, which may be mistaken for an extraluminal leak.

Complications Gastric dilatation is one of the primary drawbacks of this procedure, and reoperations are required in up to 4.5% of cases [31]. Fluoroscopy demonstrates increased diameter of the sleeve, with loss of the normal tubular appearance.

Gastric leak and abdominal collections as a result of disruption of the staple line are a potential concern following SG because of the significant gastric resection and long staple line, although the literature suggests

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review article

collections. Other techniques that may be required include imaging-guided placement of jejunal feeding tubes in cases of gastrojejunal complications in RYGB, and imaging guided gastrostomy of the gastric remnant for temporary decompression in cases of BP limb distension secondary to obstruction at the jejunojejunostomy [40]. Although most often performed via endoscopy, stenosis at the gastrojejunal anastomosis can also be dilated with the aid of fluoroscopic guidance [41]. In addition, percutaneous transhepatic techniques can be used in the management of biliary complications such as choledocholithiasis in RYGB patients, as conventional endoscopic access to the biliary tree is limited in this group [42].

Conclusion Normal appearances following sleeve gastrectomy. CT; S, gastric sleeve; arrow shows gastric suture line

a low incidence of approximately 0.9% [31]. Fluoroscopy demonstrates extravasation of contrast material into the left upper quadrant. Intra-abdominal abscess is a potential sequelae (incidence 0.1%) and may be detected on plain radiography as an air-fluid level in the left upper quadrant as there is no remnant stomach. However, CT is the imaging modality of choice in cases where this is suspected.

SG is thought to predispose the patient to post-operative reflux symptoms because the gastric resection adversely affects the angle of His. Studies have demonstrated incidences of up to 21% at 1 year, reducing to 3% at the 3 year follow-up [35]. Reflux of contrast into the oesophagus can be readily demonstrated on fluoroscopy.

Other techniques

Vertical-banded gastroplasty This is an older, purely restrictive procedure and its use has decreased significantly with the popularity of the RYGB, the advent of laparoscopic adjustable gastric banding and problems with long-term weight loss [37]. Imaging is important to help bariatric surgeons plan revisional surgery.

Jejunoileal bypass

The jejunoileal bypass (JIB) was the original bariatric surgical procedure [38].

Today, the JIB has long since been abandoned because of the severe malnutritional state and the resultant side-effects [39].

Despite the fact that JIB is no longer used, to treat patients who underwent this procedure knowledge of the procedure is important for radiological imaging.

Role of interventional radiology

One of the most frequently requested interventional procedures is ultrasound or fluoroscopically guided percutaneous access to the port for LAGB adjustment, which cannot be accessed clinically owing to excess adipose tissue. Operators should be aware that a specialist needle (Huber) should be used to access the port. This is a non-cutting needle allowing puncture of the port without damaging the membrane.

Several complications in bariatricsurgery patients can also be successfully managed with interventional radiology techniques. Indeed, in many cases, image guided percutaneous procedures can obviate the need for emergency surgical exploration, and commonly performed techniques include aspiration and drainage of abdominal ďŹ&#x201A;uid

Bariatric surgery is increasingly performed to control morbid obesity.

The imaging of this group of patients following surgery is a vital component of their management and presents unique and varied challenges.

Consider surgery for people with severe obesity if: BMI â&#x2030;Ľ40kgm-2 or more, or 35â&#x20AC;&#x201C;40kgm-2 and other significant disease (e.g. Type 2 diabetes or hypertension) that could be improved if they lost weight All appropriate non-surgical measures have been tried but have failed to achieve or maintain adequate, clinically beneficial weight loss for at least 6 months They are receiving or will receive intensive management in a specialist obesity service They are generally fit for anaesthesia and surgery They commit to the need for long-term follow-up Consider surgery as a first-line option for adults with a BMI >50kgm2 in whom surgical intervention is considered appropriate; consider orlistat before surgery if the waiting time is long.

BMI, body mass index www

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The British Journal of Radiology Abstracts

Abstracts Anti-tumour effects of transcatheter arterial embolisation administered in combination with thalidomide in a rabbit VX2 liver tumour model Objectives:

Using a liver tumour model we investigated whether thalidomide enhances the anti-tumour effect of transcatheter arterial embolisation (TAE).

tumour proliferation rate using MRI and by immunohistochemical analysis of the area of intratumour vessels. ANOVA and Tukey’s honestly significant different test were used for statistical analysis.

Methods:

Results:

First, the viability of VX2 tumour cells co-cultured with thalidomide in a 21% and 1% O2 atmosphere was assessed by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay. Secondly, we randomly assigned 20 rabbits bearing VX2 liver tumours to 4 groups: Group 1 (thalidomide plus TAE), Group 2 (TAE only), Group 3 (thalidomide only) and Group 4 (control). Thalidomide was orally administered for 5 days. The antitumour effects were assessed by the

The viability of cells grown under hypoxic and normal conditions was not significantly different, nor was there a difference among the four groups. The tumour size increased by 55.9±29.3% in Group 1, 250.6±73.3% in Group 2, 355.2±51.7% in Group 3 and 424.7±110.7% in Group 4; the difference between Group 1 and the other three groups was significant. The area of intratumour vessels in specimens was 0.22±0.28% in Group 1, 0.42±0.29% in Group 2, 1.44±1.00% in Group 3 and

6.00±2.17% in Group 4; the difference between Group 1 and the other groups was statistically significant, as was the difference between Groups 3 and 4.

Conclusion:

Thalidomide used in combination with TAE enhanced anti-tumour effects in rabbits bearing VX2 liver tumours.

A Nitta-Seko, N Nitta, A Sonoda, H Otani, K Tsuchiya, S Ohta, M Takahashi & K Murata Department of Radiology, Shiga University of Medical Science, Shiga, Japan

www Download the full length article: DOI: 10.1259/bjr/53771502

Use of the triaxial microcatheter method in super-selective transcatheter arterial chemoembolisation for hepatocellular carcinoma Objectives:

Transcatheter arterial chemoembolisation (TACE) has been widely used for inoperable hepatocellular carcinoma (HCC).

Super-selective TACE is preferable to nonselective therapy, because it maximises the impact of treatment on the tumour while minimising damage to tumour-free liver parenchyma. It is therefore important to advance the catheter tip as close as possible in the feeding artery. There is now a new microcatheter with a 1.9-Fr tip with no taper, which can be inserted into a 2.7-Fr microcatheter. In this study we describe the new technique of using the two microcatheters called the triaxial microcatheter method.

Methods:

We evaluated 30 TACE procedures to investigate whether or not the catheter tip could be advanced closer to HCC with 30

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the triaxial microcatheter method than with previous TACE using a conventional microcatheter.

procedures (93%) we could successfully advance a catheter tip closer than with the previous TACE.

Results:

Conclusion:

With conventional microcatheters the level of embolisation was a lobar artery in 4 cases, segmental in 8 cases, subsegmental in 15 cases and sub-subsegmental in only 1 case. TACE could not be performed in 2 cases. When using the triaxial microcatheter method the level of embolisation was subsegmental in 8 cases, including 2 in which the level was the same as that with a conventional microcatheter, sub-subsegmental in 13 cases and more distal in 7 cases. In the two cases in which TACE could not be performed with the conventional microcatheter, it could be performed sufficiently using the new method. As a whole, in 28 of the 30

The triaxial microcatheter method appears to be useful.

M Shimohira, H Ogino, T Kawai, A Kushita, M Watanabe, T Kawaguchi, K Kurono & Y Shibamoto Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Japan

www Download the full length article: DOI: 10.1259/bjr/26974088

The British Journal of Radiology Abstracts www

For more Abstracts visit: bjr.birjournals.org

Dose and image quality comparison between prospectively gated axial and retrospectively gated helical coronary CT angiography Objectives:

Our aim was to compare image quality, coronary segment assessability and radiation dose in prospectively gated axial (PGA) coronary CT angiography (CTA) and conventional retrospectively gated (RGH) helical coronary CTA. Methods:

Institutional review committee approval and informed consent were obtained. RGH CTA was performed in 41 consecutive patients (33 males, 8 females; mean age 52.6 years), then the PGA CTA technique was evaluated in 41 additional patients (24 males, 17 females; mean age 57.3 years) all with a pre-scan heart rate of ≤70 beats per minute (bpm). Two radiologists, blinded

to clinical information, independently scored subjective image quality on a five-point ordinal scale.

in radiation dose compared with RGH CTA, with comparable image quality for patients with heart rates below 70 bpm.

Results:

The mean effective dose in the PGA group was 4.7±0.9 mSv, representing a 69% dose reduction compared with the RGH CTA group (15.1±1.9 mSv, p<0.001). The mean segmental image quality score was significantly higher in the PGA group (3.4 vs 3.2) than in the RGH CTA group (p<0.005). The percentage of assessable segments was 98.1% in the PGA group and 97.3% in the RGH group (p=0.610).

Conclusion:

PGA CTA offers a significant reduction

C Hlaihel, L Boussel, H Cochet, J A Roch, P Coulon, Md Walker And P C Douek Louis Pradel Cardiovascular and Pneumology Hospital, Bron, France

www Download the full length article: DOI: 10.1259/bjr/13222537

Diffusion-weighted magnetic resonance imaging for monitoring prostate cancer progression in patients managed by active surveillance Objectives:

We studied patients managed by active surveillance to determine whether there was a difference over time in the apparent diffusion coefficient (ADCs) derived from diffusion-weighted MRI in those who progressed to radical treatment (progressors; n=17) compared with those who did not (non-progressors, n=33).

Methods:

50 consecutive patients (Stage T1/2a, Gleason grade ≤3+4, prostate-specific antigen (PSA) <15 ng ml-1, 50% cores positive) were imaged endorectally (baseline and 1–3 years follow-up) with T2 weighted (T2W) and echoplanar diffusion-weighted MRI sequences.

Regions of interest drawn on ADC maps with reference to the T2W images

yielded ADCall (b=0–800), ADCfast (b=0– 300) and ADCslow (b=300–800) for whole prostate (minus tumour) and tumour (low signal intensity peripheral zone lesion in biopsy-positive octant).

Results:

Tumour and whole prostate ADCall and ADCfast were significantly reduced over time in progressors (p=0.03 and 0.03 for tumours, respectively; p=0.02 and 0.007 for the whole prostate, respectively). There were no significant changes in ADC over time in nonprogressors. A 10% reduction in tumour ADCall indicated progression with a 93% sensitivity and 40% specificity (Az of receiver operating curve (ROC) curve=0.68). Percentage reductions in whole prostate ADCall, ADCfast and ADCslow were also significantly

greater in progressors than in nonprogressors (p=0.01, 0.03 and 0.008, respectively).

Conclusion:

This pilot study shows that DW-MRI has potential for monitoring patients with early prostate cancer who opt for active surveillance.

V A Morgan, S F Riches, K Thomas, N Vanas, C Parker, S Giles & N M Desouza MRI Unit, Royal Marsden Hospital, Sutton, Surrey

www Download the full length article: DOI: 10.1259/bjr/14556365

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The British Journal of Radiology Abstracts

Pre-operative evaluation of peritoneal deposits using multidetector computed tomography in ovarian cancer Objectives:

In managing epithelial ovarian cancer (EOC) identification of peritoneal deposits is the most important prognostic factor. We conducted a prospective study to evaluate the role of multidetector CT (MDCT) in identifying peritoneal deposits pre-operatively.

Methods:

38 previously untreated patients (median age 50 years; range 26–70 years) were evaluated with contrastenhanced MDCT of the abdomen and pelvis. All CT scans were performed on a four-slice MDCT scanner with thinslice image acquisition. Multiplanar coronal, sagittal or oblique images were constructed and all images were reviewed by at least two radiologists.

The extent of disease was determined

and mapped for all areas of the abdomen and pelvis. CT scans were reviewed and compared with surgical findings. Peritoneal deposits and thickening were noted for each of the nine segments of the abdomen and pelvis (i.e. bilateral hypochondria, bilateral lumbar, bilateral iliac fossa, epigastrium, umbilical region and hypogastrium) and used to determine the accuracy of MDCT in the depiction of peritoneal carcinomatosis.

Conclusion:

Despite the improved scanning technology, image reconstruction and viewing ability of MDCT, its overall accuracy for detection of peritoneal deposits is not significantly improved compared with conventional CT; however, MDCT is useful in the assessment of disease at specific locations in the abdomen and pelvis.

Results:

Sensitivity, specificity, positive and negative predictive values and accuracy of CT in the detection of peritoneal deposits were similar to those reported in the literature. The most common sites to have peritoneal deposits were the pouch of Douglas (18 cases) and the right subdiaphragmatic region (18 cases).

S H Chandrashekhara, S Thulkar, D N Srivastava, L Kumar, R Hariprasad, S Kumar & M C Sharma Department of Radiology, All India Institute of Medical Sciences, New Delhi, India

www Download the full length article: DOI: 10.1259/bjr/87415692

Dobutamine stress tagging and gradient-echo imaging for detection of coronary heart disease at 3T Objectives:

Results:

The purpose of this study was to evaluate the feasibility and diagnostic accuracy of a combined spoiled gradient-echo (sGRE) and tagged gradient echo (SPAMM-GRE) protocol for detection of coronary artery disease (CAD) during high-dose dobutamine stress at 3T.

The mean image quality score was 2.6±0.6 for the sGRE sequence and 2.4±0.6 for the SPAMM-GRE sequence (p>0.05). Sensitivity, specificity and diagnostic accuracy were 0.81, 0.86, 0.84 and 0.88, 0.86, 0.86 for the sGRE and SPAMM-GRE, respectively. In three cases with new wall motion abnormalities (WMAs), detected by sGRE and SPAMM-GRE, WMAs were detected at a lower stress level by tagging.

Methods:

The study protocol was approved by the local ethics committee. For stress testing, a standard high-dose dobutamine protocol was employed. Image quality at the highest stress level, diagnostic accuracy of the sGRE and SPAMM-GRE sequences were compared. The final study population consisted of 37 patients.

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at lower stress levels compared with sGRE alone.

Conclusion:

The combined sGRE and SPAMMGRE high-dose dobutamine protocol at 3T is feasible and delivers good diagnostic accuracy. Tagging increases the sensitivity of high dose dobutamine stress testing for detection of CAD and may allow for detection of new WMAs

D Thomas, C Meyer, K Strach, C P Naehle, J Mazraeh, T Gampert, H H Schild & T Sommer Department of Radiology, University of Bonn, Germany

www Download the full length article: DOI: 10.1259/bjr/59381313

www.bir.org.uk

The British Journal of Radiology Abstracts

Correlation between mammographic and sonographic findings and prognostic factors in patients with node-negative invasive breast cancer Objectives:

Results:

Conclusion:

The purpose of this study was to correlate sonographic and mammographic findings with prognostic factors in patients with node-negative invasive breast cancer.

On mammography, non-spiculated masses with calcifications were associated with all poor prognostic factors: high histological grade, LVI, an EIC, positive HER-2/ neu status and negative ER. Other lesions were associated with none of these poor prognostic factors. Hyperdense masses on mammography, the presence of mixed echogenicity, posterior enhancement, calcifications in-or-out of masses and diffusely increased vascularity on sonography were associated with high histological grade and negative ER. Associated calcifications on both mammograms and sonograms were correlated with EICs and HER-2/neu overexpression. The ICC value for disease extent was 0.60 on mammography and 0.70 on sonography.

Several sonographic and mammographic features can have a prognostic value in the subsequent treatment of patients with nodenegative invasive breast cancer. Radiologists should pay more attention to masses that are associated with calcifications because, on mammography and sonography, associated calcifications were predictors of positive EIC and HER-2/neu overexpression.

Methods:

Sonographic and mammographic findings in 710 consecutive patients (age range 21–81 years; mean age 49 years) with 715 node-negative invasive breast cancers were retrospectively evaluated. Pathology reports relating to tumour size, histological grade, lymphovascular invasion (LVI), extensive intraductal component (EIC), oestrogen receptor (ER) status and HER-2/neu status were reviewed and correlated with the imaging findings. Statistical analysis was performed using logistic regression analysis and intraclass correlation coefficient (ICC).

H J Shin, H Kim, M O Huh, M J Kim, A Yi, H Kim, B H Son & S H Ahn Department of Radiology and Research Institute of Radiology, College of Medicine, University of Ulsan, South Korea

www Download the full length article: DOI: 10.1259/bjr/92960562

Intensity-modulated radiotherapy increases dose to the brachial plexus compared with conventional radiotherapy for head and neck cancer Objectives:

The preferential use of intensitymodulated radiotherapy (IMRT) over conventional radiotherapy (CRT) in the treatment of head and neck cancer has raised concerns regarding dose to non-target tissue. The purpose of this study was to compare dose–volume characteristics to the brachial plexus between treatment plans generated by IMRT and CRT using several common treatment scenarios.

Methods:

The brachial plexus was delineated on radiation treatment planning CT scans from 10 patients undergoing IMRT for locally advanced head and neck cancer using a Radiation Therapy Oncology Group-endorsed atlas. No brachial plexus constraint was used. For

each patient, a conventional three-field shrinking-field plan was generated and the dose–volume histogram (DVH) for the brachial plexus was compared with that of the IMRT plan.

cantly increased among patients undergoing IMRT compared with CRT for head and neck cancer. Preliminary studies on brachial plexus-sparing IMRT are in progress.

Results:

The mean irradiated volumes of the brachial plexus using the IMRT vs the CRT plan, respectively, were as follows: V50 (18±5 ml) vs (11±6 ml), p=0.01; V60 (6±4 ml) vs (3±3 ml), p=0.02; V66 (3±1 ml) vs (1±1 ml), p=0.04, V70 (0±1 ml) vs (0±1 ml), p=0.68. The maximum point dose to the brachial plexus was 68.9 Gy (range 62.3–78.7 Gy) and 66.1 Gy (range 60.2–75.6 Gy) for the IMRT and CRT plans, respectively (p=0.01).

Conclusion:

Dose to the brachial plexus is signifi-

A M Chen, W H Hall, B-Q Li, M Guiou, C Wright, M Mathai, A Dublin & J A Purdy Department of Radiation Oncology, University of California Davis Cancer Center, CA, USA

www Download the full length article: DOI: 10.1259/bjr/62332495

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The British Journal of Radiology Abstracts

Overstaging of cartilage invasion by multidetector CT scan for laryngeal cancer and its potential effect on the use of organ preservation with chemoradiation Objectives:

The two currently acceptable treatment options for locally advanced laryngeal cancer are total laryngectomy and organ preservation using chemoradiation. To facilitate therapeutic decision making, the accurate pre-treatment evaluation of cartilage invasion is of paramount importance. The purpose of this study was to evaluate the positive predictive value (PPV) and negative predictive value (NPV) of detecting neoplastic cartilage invasion in laryngeal cancer patients using fast-speed multidetector CT (MDCT).

Methods:

61 consecutive patients with clinically staged T3 or T4 squamous cell carcinoma of the larynx or hypopharynx who underwent total laryngectomy

were analysed. All patients had MDCT of the neck within 2 weeks prior to surgery. Central radiographic and pathological review was performed in an attempt to correlate findings. MDCT invasion of cartilage was graded based on objective criteria.

Results:

MDCT scan was found to have a PPV of 78% and an NPV of 100% for detection of invasion through cartilage, with sensitivity being 100% and specificity 96%. For detection of any cartilage invasion (minor, major or through cartilage invasion), PPV and NPV were 63% and 92%, respectively. The sensitivity was 85% and specificity was 75%. For the detection of tumour invasion through cartilage or major cartilage invasion, MDCT scan had a PPV of 53% and an

NPV of 95%. 47% (9/19) of patients were down-staged from T4 to T3 after central pathology review.

Conclusion:

The low PPV for cartilage destruction using MDCT suggests that a significant proportion of patients who were treated by total laryngectomy could have been appropriately offered organ preservation if more accurately staged at initial diagnosis.

B Li, M Bobinski, R Gandour-Edward, D G Farwell & A M Chen University of California, Davis Medical Center, CA, USA

www Download the full length article: DOI: 10.1259/bjr/66700901

Occupational radiation doses to the extremities and the eyes in interventional radiology and cardiology procedures Objectives:

The aim of this study was to determine occupational dose levels in interventional radiology and cardiology procedures.

Methods:

The study covered a sample of 25 procedures and monitored occupational dose for all laboratory personnel. Each individual wore eight thermoluminescent dosemeters next to the eyes, wrists, fingers and legs during each procedure.

Radiation protection shields used in each procedure were recorded.

Results:

The highest doses per procedure were recorded for interventionists at the left wrist (average 485 µSv, maximum 5239 µSv) and left finger (average 324 µSv, maximum 2877 µSv), whereas 34

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lower doses were recorded for the legs (average 124 µSv, maximum 1959 µSv) and the eyes (average 64 µSv, maximum 1129 µSv). Doses to the assisting nurses during the intervention were considerably lower; the highest doses were recorded at the wrists (average 26 µSv, maximum 41 µSv) and legs (average 18 µSv, maximum 22 µSv), whereas doses to the eyes were minimal (average 4 µSv, maximum 16 µSv). Occupational doses normalised to kerma area product (KAP) ranged from 11.9 to 117.3 µSv/1000 cGy cm2 and KAP was poorly correlated to the interventionists’ extremity doses.

Conclusion:

Calculation of the dose burden for interventionists considering the actual number of procedures performed annually

revealed that dose limits for the extremities and the lenses of the eyes were not exceeded. However, there are cases in which high doses have been recorded and this can lead to exceeding the dose limits when bad practices are followed and the radiation protection tools are not properly used.

E P Efstathopoulos, I Pantos, M Andreou, A Gkatzis, E Carinou, C Koukorava, N L Kelekis & E Brountzos Department of Radiology, Medical School, University of Athens, General University Hospital, Athens, Greece

www Download the full length article: DOI: 10.1259/bjr/83222759

www.bir.org.uk

The British Journal of Radiology Abstracts

Voxel-based diffusion tensor imaging detects pyramidal tract degeneration in primary lateral sclerosis Objectives:

Primary lateral sclerosis (PLS) is a progressive degenerative disorder affecting upper motor neurons and requires a clinical diagnosis. Diffusion tensor imaging (DTI) is a quantitative method for assessing white matter fibre integrity. The purpose of the study was to evaluate the involvement of upper motor neurons by using DTI in PLS.

bilaterally, which indicated degeneration of the pyramidal cells.

Conclusion:

Voxel-based DTI could be used as an objective marker for detecting upper motor neuron degeneration in PLS.

Methods:

A patient with PLS was compared with eight age-matched controls. Differences in fractional anisotropy (FA) index were assessed using DTI on a voxel-by voxel basis.

L C Tzarouchi, A P Kyritsis, S Giannopoulos, L G Astrakas, M Diakou & M I Argyropoulou Medical School University of Ioannina, Ioannina, Greece

Results:

www Download the full length article:

Decreased FA was observed in the proximal part of the pyramidal tract

DOI: 10.1259/bjr/14368804

Comparison of the helical tomotherapy against the multileaf collimator-based intensity modulated radiotherapy and 3D conformal radiation modalities in lung cancer radiotherapy Objectives:

Results:

Conclusion:

The aim of this study was to compare three dimensional (3D)-conformal radiotherapy and the two different forms of IMRT in lung cancer radiotherapy.

The applied plan evaluation method shows the MLC-based IMRT and the HT treatment plans are almost equivalent over the clinically useful dose prescription range; however, the 3D-conformal plan was inferior. At the optimal dose levels, the 3D-conformal treatment plans give an average P+ of 48.1% for an effective uniform dose to the internal target volume (ITV) of 62.4 Gy, whereas the corresponding MLC-based IMRT treatment plans are more effective by an average ΔP+ of 27.0% for a Δ effective uniform dose of 16.3 Gy. Similarly, the HT treatment plans are more effective than the 3D-conformal plans by an average ΔP+ of 23.8% for a Δ effective uniform dose of 11.6 Gy.

A radiobiological treatment plan evaluation can provide a closer association of the delivered treatment with the clinical outcome by taking into account the dose–response relations of the irradiated tumours and normal tissues.

The use of P-effective uniform dose diagrams can complement the traditional tools of evaluation to compare and effectively evaluate different treatment plans.

Methods:

Cases of four lung cancer patients were investigated by developing a 3D-conformal treatment plan, a linac MLC-based step-and-shoot IMRT plan and a HT plan for each case.

With the use of the complication-free tumour control probability (P+) index and the uniform dose concept as the common prescription point of the plans, the different treatment plans were compared based on radiobiological measures.

P Mavroidis, C Shi, G A Plataniotis, M G Delichas, B Costa Ferreira, S Rodriguez, B K Lind & N Papanikolaou Department of Medical Radiation Physics, Karolinska Institute abd Stockholm University, Stockholm, Sweden

www Download the full length article: DOI: 10.1259/bjr/89275085

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The British Journal of Radiology Abstracts

Comparison of conventional and three-dimensional conformal CT planning techniques for pre-operative chemoradiotherapy for locally advanced rectal cancer Objectives:

We assessed the impact of threedimensional (3D) conformal planning vs conventional planning of preoperative chemoradiotherapy (CRT) for locally advanced rectal cancer (LARC) on small bowel and bladder sparing and in optimising coverage of tumour target volume.

movement. The conventional plan was created using digitally reconstructed radiographs (DRRs). Patients were treated with a dose of 45 Gy in 25 fractions with concurrent chemotherapy over 5 weeks. Dose volume histograms (DVHs) were created and compared for GTV, PTV, small bowel and bladder.

The GTV was covered by the conventional plan in all patients.

Methods:

Conformal and conventional plans were created for 50 consecutive patients. The conformal plan delineated a gross tumour volume (GTV), a clinical target volume (CTV) 1 to cover potential subclinical disease spread, a to CTV2 outline the mesorectum and lymph node areas at risk and a planning target volume (PTV) to cover set-up error and organ

Conclusion:

3D conformal CT planning is superior to conventional planning in terms of coverage of the tumour volume.

It significantly reduces the volume of small bowel irradiated with no decrease in the rate of R0 resection compared with published data, and at the present time should be considered as the standard of care for rectal cancer planning.

Results:

Significant differences were shown for median PTV coverage with conformal planning compared with conventional planning: 99.2% vs 94.2% (range 95.9– 100% vs 75.5–100%) p<0.05.The median volume of irradiated small bowel was significantly lower for CT plans at all DVH levels. Median bladder doses did not differ significantly.

C Corner, F Khimji, Y Tsang, M Harrison, R Glynne-Jones & R Hughes Mount Vernon Cancer Centre, Middlesex, UK

www Download the full length article: DOI: 10.1259/bjr/33089685

CT enterography with polyethylene glycol solution vs CT enteroclysis in small bowel disease Objectives:

The aim of the study is to compare CT enterography with polyethylene glycol solution (PEG-CT) with CT enteroclysis (CT-E) in patients with suspected small bowel disease.

Methods:

145 patients underwent abdominal contrast-enhanced 16-row multidetector CT after administration of 2000 ml of PEG by mouth (n=75) or after administration of 2000 ml of methylcellulose by nasojejunal tube (n=70). Small bowel distension, luminal and extraluminal findings were evaluated and compared with small bowel follow-through examination in 60 patients, double contrast enema in 50, surgery in 25 and endoscopy in 35. Statistical evaluation was carried out by χ2 testing. For both techniques we 36

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have also calculated the effective dose and the equivalent dose in a standard patient.

Results:

Crohn’s disease was diagnosed in 64 patients, neoplasms in 16, adhesions in 6. Distension of the jejunum was better with CT-E than PEG-CT (p<0.05: statistically significant difference). No significant difference was present for others sites (p>0.05). Evaluation of pathological ileal loops was good with both techniques. The values of sensitivity, specificity and diagnostic accuracy were, respectively, 94%, 100% and 96% with CT-E, and 93%, 94% and 93% with PEG-CT. The effective dose for PEG-CT was less than the dose for the CT-E (34.7 mSv vs 39.91 mSv).

Conclusion:

PEG-CT shows findings of Crohn’s disease as well as CT-E does, although CT-E gives better bowel distension, especially in the jejunum, and has higher specificity than PEG-CT.

L M Minordi, A Vecchioli, P Mirk & L Bonomo Department of Bio-Imaging & Radiological Sciences, Radiology, UCSC, Rome, Italy

www Download the full length article: DOI: 10.1259/bjr/71649888

www.bir.org.uk

The British Journal of Radiology Abstracts

Non-laxative CT colonography with barium-based faecal tagging: is additional phosphate enema beneficial and well tolerated?

Objectives:

The purpose of this study was to investigate the efficacy and tolerance of an additional phosphate enema prior to nonlaxative CT colonography (CTC).

of the enema was assessed via questionnaire. Data were analysed between those using and not using the enema by Mann– Whitney and Fisher’s exact test. 18/71 patients declined the enema.

Methods:

Results:

71 patients (mean age 80 years, 28 male, 43 female) underwent non-laxative CTC following 4 oral doses of diluted 2% w/w barium sulphate. Patients were invited to self-administer a phosphate enema 2 h before CTC. An experienced observer graded the volume of retained stool (1 (nil) to 4 (>75% bowel circumference coated)), retained fluid (1 (nil) to 4 (>50% circumference obscured)), retained stool tagging quality (1 (untagged) to 5 (≥75% to 100%) tagged) and confidence a polyp ≥6 mm could be excluded (yes/no) for each of six colonic segments. Tolerance

There was no reduction in residual stool volume with enema use compared with non-use either overall (mean score 2.6 vs 2.7, p=0.76) or in the left colon (mean 2.3 vs 2.4, p=0.47). Overall tagging quality was no different (mean score 4.4 vs 4.3, p=0.43). There was significantly more retained left colonic fluid post enema (mean score 1.9 vs 1.1, p<0.0001), and diagnostic confidence in excluding polyps was significantly reduced (exclusion not possible in 35% segments vs 21% without enema, p=0.006). Of 53 patients, 30 (56%) found the enema

straightforward to use, but 4 (8%) found it unpleasant.

Conclusion:

Phosphate enema use prior to non-laxative CTC leads to greater retained fluid reducing diagnostic confidence and is not recommended.

W Davis, P Nisbet, C Hare, P Cooke & S Taylor Department of Imaging, University College Hospital, London, UK

www Download the full length article: DOI: 10.1259/bjr/23626544

Diagnostic accuracy of fused positron emission tomography/magnetic resonance mammography: initial results Objectives:

The aim of this study was to evaluate the diagnostic accuracy of fused fluorodeoxy glucose positron emission tomography/ magnetic resonance mammography (FDG-PET/MRM) in breast cancer patients and to compare FDG-PET/ MRM with MRM.

cancer lesions. Furthermore, the number of patients with correctly determined lesion focality was assessed. Differences between both modalities were assessed by McNemars test (p<0.05). The number of patients in whom FDG-PET/MRM would have changed the surgical approach was determined.

Methods:

Results:

27 breast cancer patients with a mean age of 58.9±9.9 years underwent MRM and prone FDG-PET. Images were fused software based to FDG-PET/ MRM images. Histopathology served as the reference standard to define the following parameters for both MRM and FDG-PET/MRM: sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy for the detection of breast

58 breast lesions were evaluated. The sensitivity, specificity, PPV, NPV and accuracy were 93%, 60%, 87%, 75% and 85% for MRM, respectively. For FDG-PET/MRM they were 88%, 73%, 90%, 69% and 92%. FDG-PET/MRM was as accurate for lesion detection (p=1) and determination of the lesions’ focality (p=0.7722) as MRM. In 1 patient FDGPET/MRM would have changed the surgical treatment.

Conclusion:

FDG-PET/MRM is as accurate as MRM for the evaluation of local breast cancer.

FDG-PET/MRM defines the tumours’ focality as accurately as MRM and may have an impact on surgical treatment in only a small portion of patients. Based on these results FDG-PET/MRM cannot be recommended as an adjunct or alternative to MRM.

T A Heusner, S Hahn, C Jonkmanns, S Keummel, F Otterbach, M E Hamami, A R Stahl, A Bockisch, M Forsting & G Antoch Department of Diagnostic & Interventional Radiology & Neuroradiology, University Hospital Essen, University of Duisburg-Essen, Germany

www Download the full length article: DOI: 10.1259/bjr/93330765

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The British Journal of Radiology Abstracts

MR defecography in patients with dyssynergic defecation: spectrum of imaging findings and diagnostic value Objectives:

We describe the spectrum of findings and the diagnostic value of MR defecography in patients referred with suspicion of dyssynergic defecation.

Methods:

48 patients (34 females, 14 males; mean age 48 years) with constipation and clinically suspected dyssynergic defecation underwent MR defecography. Patients were divided into patients with dyssynergic defecation (n=18) and constipated patients without dyssynergic defecation (control group n=30). MRIs were analysed for evacuation ability, time to initiate evacuation, time of evacuation, changes in the anorectal angle (ARA-change), presence of paradoxical sphincter contraction and presence of additional pelvic floor abnormalities.

Sensitivity, specificity, positive and negative predictive value and accuracy for the diagnosis of dyssynergic defecation were calculated.

of abnormal ARA-change and paradoxical sphincter contraction allowed for the detection of 94% (95% CI 81–100%) of the patients with dyssynergic defecation.

Results:

Conclusion:

The most frequent finding was impaired evacuation, which was seen in 100% of patients with dyssynergic defecation and in 83% of the control group, yielding a sensitivity for MR defecography for the diagnosis of dyssynergic defecation of 100% (95% confidence interval (CI) 97–100%), but only a specificity of 23% (95% CI 7–40%). A lower sensitivity (50%; 95% CI 24–76%) and a high specificity (97%; 95% CI 89–100%) were seen with abnormal ARA-change.

The sensitivity of paradoxical sphincter contraction was relatively high (83%; 95% CI 63–100%). A combined analysis

MR defecography detects functional and structural abnormal findings in patients with clinically suspected dyssynergic defecation. Impaired evacuation is seen in patients with functional constipation owing to other pelvic floor abnormalities than dyssynergic defecation.

C S Reiner, R Tutuian, A E Solopova, D Pohl, B Marincek & D Weishaupt Institute of Diagnostic Radiology, University Hospital Zürich, Zürich, Switzerland

www Download the full length article: DOI: 10.1259/bjr/28989463

Accessory or additional renal arteries show no relevant effects on the width of the upper urinary tract: a 64-slice multidetector CT study of 2132 kidneys in 1072 patients Objectives:

The aim of this study was to find out, on an unselected patient group, whether crossing vessels have an influence on the width of the renal pelvis and what independent predictors of these target variables exist.

Methods:

In this cross-sectional study, 1072 patients with arterially contrasted CT scans were included. The 2132 kidneys were supplied by 2736 arteries.

Results:

On the right side, there were 293 additional and accessory arteries in 286 patients, and on the left side there were 304 in 271 patients. 154 renal pelves were more than 15 mm wide. The greatest independent factor for hydrone38

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phrosis on one side was hydronephrosis on the contralateral side (p<0.0001 each). Independent predictors for the width of the renal pelvis on the right side were the width of the renal pelvis on the left, female gender, increasing age and height; for the left side, predictors were the width of the renal pelvis on the right, concrements, parapelvic cysts and great rotation of the upper pole of the kidney to dorsal. Crossing vessels had no influence on the development of hydronephrosis.

Only anterior crossing vessels on the right side are associated with widening of the renal pelvis by 1 mm, without making it possible to identify the vessel as an independent factor in multivariate regression models.

Conclusion:

The width of the renal pelvis on the

contralateral side is the strongest independent predictor for hydronephrosis and the width of the renal pelvis. There is no link between crossing vessels and the width of the renal pelvis.

B Glodny, K Rapf, V Unterholzner, P Rehder, K J Hofmann, A Strasak, R Herwig & J Peterson Department of Radiology, Innsbruck Medical University, Innsbruck, Austria

www Download the full length article: DOI: 10.1259/bjr/79479004

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The British Journal of Radiology Abstracts

Statistical analysis of mammographic breast composition measurements: towards a quantitative measure of relative breast cancer risk Objectives:

A number of studies have identified the relationship between the visual appearance of high breast density at mammography and an increased risk of breast cancer. With the advent of digital mammography and the promise of routine measurements of parameters associated with breast composition, the possibility arises of using breast composition in a quantitative manner to predict relative breast cancer risk. Previous measurements have shown that the average proportion of glandular and adipose tissue within the breast varies with both age and breast size. In order to be able to identify individual women with an unusually high volume of glandular tissue, it will therefore be necessary to make comparisons with a disease-free population matched for age and breast size.

Methods:

A large number of breast glandular thickness measurements were analysed to investigate the statistics of breast composition across a disease-free population as a test of a suitable methodology for relative risk estimation. The large data set is also used to revisit the trends in breast composition used in the current UK method of breast radiation dosimetry.

unusually glandular breasts and so provide a basis for cancer risk estimations.

Results:

It is demonstrated that a non-linear transformation can be used to produce normal statistical distributions suitable for producing a standardised “Z-score” for breast composition.

Conclusion:

A standardised “Z-score” approach is recommended to identify women with

C J Kotre Regional Medical Physics Departement, Freeman Hospital, Newcastle-uponTyne, UK

www Download the full length article: DOI: 10.1259/bjr/40806022

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SIEMENS LECTURE THEATRE IBA ROOM JAN LEWANDO ROOM DU BOULAY ROOM

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We pride ourselves on our impeccable service and our dedicated team are always on hand to offer bespoke events packages to suit your needs.

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Peter Coverdale - Facilities Manager Direct Line: 020-7307-1415 E-mail: peter.coverdale@bir.org.uk Web: www.bir.org.uk

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bir news

BIR NEWS

CEO Report The British Institute of Radiology has been going through considerable changes during the past 18 months, not least in terms of its in-house staff, so I thought Iâ&#x20AC;&#x2122;d use this opportunity to introduce the team to our members.

There are 20 staff in the BIR, of which 4 are part-time. They are divided into four small teams servicing marketing and events, publishing, library and facilities, and finance. We are delighted that as of the end of 2010 we are fully staffed for the first time in many months.

The marketing and events team, led by Lizette van Niekerk, has changed beyond recognition during the past year. Lucy Nye, our business development coordinator, is the longest-serving member of this team. You will see her across the country, leading the development of our regional branch network and the branch committees, in conjunction with her assistant, Lizzy Eaton. Tina Giddings, our marketing and fundraising coordinator, is responsible for all the promotional material you receive and is a key contact

for corporate subscribers, while Ruth Warne and Liz Appleyard are our events coordinator and events officer respectively and are responsible for organising all the in-house educational activities that the BIR delivers. You will see all of the team run off their feet as they organise UKRC 2011 in Manchester on 6-8 June.

The newest members of the team are Hazel Swain (production editor) and Rachel Huntington (publishing assistant), who have joined our busy and expanding publishing team. They join established members of the team Sherry Dixon (publisher), Jenny Rooke (production coordinator) and Vanessa Brunt (editorial administrator). We are delighted that Hazel and Rachel have joined a team that is forging ahead with publishing innovations, the new online BJR and this new BJR News magazine, which has been nearly two years in the planning.

Many of you will know our library and facilities team if you visit the building. Led by Peter Coverdale the team comprises our receptionists, Geoff

Twynam and Jane Moynihan, who will be your first point of contact at reception if you visit or ring the switchboard. Jane is additionally our membership officer, so will be your main contact for membership queries. Lesley Coverdale is likely to be your key on-the-day contact if you attend scientific meetings in Portland Place.

Khalda Mohammed is our information specialist, who manages the library and online resources for members.

Ash Patel is our head of finance and IT and, together with his assistant, Liz Jones, is responsible for our accounting.

Lastly, but by no means least, Lucy Stewart is my executive assistant and our very valuable committee secretary, servicing all our committees from Council downwards.

I am delighted to have the combination of wise experience and youthful energy on board to deliver an increasing range of benefits to our members. Watch this space for future developments â&#x20AC;&#x201C; the right people are on the bus!

Jacqueline Fowler, Chief Executive, BIR

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BIR news

The challenges facing clinical radiology over the next decade The winning essay from the Philips trainee radiologists’ award 2010 The innovator’s muse has been miniaturization for over a century, so you might expect the research dominating radiology over the next ten years to be micro-miniscule. You wouldn’t expect the most important innovation in radiology to be 27km long and able to fire protons at 7 trillion electronvolts. A CT scan for planets?

No. Before you expand your department, relax – we only need one Hadron collider.

The challenge will be to use the findings from CERN (the European Organization for Nuclear Research) to drive innovation for a generation.

It has already helped drive forward technology. One associated research group has developed the standard overall measurement of the attenuation of X-rays to measure the energy of each photon individually. This allows the spectroscopic discrimination of different materials within the object, resulting in the production of a colour CT image that doesn’t rely on reconstruction software.

There is the potential at CERN over the next ten years to establish the basic science basis of proto-particulate interaction, allowing for far more intelligent techniques to determine physical property than photon radiation. CERN will herald more sophisticated techniques, which, used in combination with MRI, will create ever faster, continuous, non-harming body imaging.

The challenge will be to argue that the role of imaging remains central to the patient pathway, but not so intrinsic that the clinician would become better, and patient treatment pathways more efficient, by using it themselves. As modern surgical and medical trainees progress, advanced imaging will become second nature and, 42

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combined with an increasingly non-irradiating era of imaging (making IRMER defunct), there will be one less barrier against the clinician appropriating the imaging themselves.

Instinct suggests that the only response to this is to become more subspecialised to keep one step ahead of the pack and make your skills indispensable.

Another approach is to aspire to be the “generalist” of the hospital. We can be the diagnostic masters where complicated cases will increasingly require a multi-system imaging approach. The challenge is to maintain and expand our knowledge and connections with other clinical fields.

Diagnostic software over the next ten years will assist us by becoming as user friendly as some of the interfaces used in popular media. Different software systems will synchronize together to create a true overview of a patient’s results. For instance, imagine having the recent microbiological, biochemical and histology reports from a patient momentarily superimposed over a diagnostic imaging at the touch of a button, rather like the futuristic Philips Intellisphere. This will challenge the radiologist to maintain the biochemical and physiological knowledge which will help ensure up-to-date and relevant advice to clinicians. This is particularly important as imaging is becoming more molecular, with nanotechnology using target reactive-ligands to interact with cell-surface antigens or receptors to deliver imaging payloads in order to highlight pathological processes.

Of course the informatics development in radiology will extend to patients as well, and radiologists will find them-

selves becoming increasingly involved with patient communication. At the moment, the most medically dependent generation are also the least computer literate, but as this changes patients will want more access to their “virtual selves”.

This means that radiologists will spend more time discussing disease appearances with patients, who may wish to be gatekeepers to their personal online imaging bank, available to any doctor with viewing privileges anywhere in the world. A nonionising imaging world will one day also mean disease self-surveillance and more reliance on patient self-care.

Failure to embrace new roles and responsibilities will heighten the scrutiny of the exact role of the radiologist.

However, perhaps the biggest challenge will be to secure effective collaboration and utilisation of resources in an increasingly economically vulnerable western world. The government’s own track record on IT commissioning suggests that misguided, large scale software and imaging installation can be wasteful. With information technology set to have such an impact on radiology and patient care, evidence for new schemes must reach the same level of scrutiny and rigor as clinical research prior to commissioning to ensure cost-effectiveness.

In conclusion, the inevitable rise of quick, non-irradiating imaging techniques and the rapid integration of radiology into the spheres of nanotechnology, molecular imaging and real time functional imaging will demand the radiologist to be a master of all trades, where high specialist knowledge and a generalist imaging approach will ensure a bright future.

P J N Rogers, Peninsula Deanery

AD

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bir news

South West Branch launch This is an ideal time for focusing and developing a South West Branch of the BIR. The region has an exciting and dynamic radiology community which is involved in providing leading edge technology and a fantastic team of experts across radiology, physics and health care information systems.

With our current financial climate and cuts across all sectors, it has been a challenging time for professional development and further education for many in all healthcare disciplines. Increased workloads, reduced flexibility for study leave and budget restraints have made it more difficult to develop professionally and have reduced the opportunities to network, discuss and keep up with best practice.

Education may need to be delivered differently too – and as a branch this is an area we will also be keen to look at.

There is a trend towards a more “value added” education with hands on, real use opportunities or follow up further education that can be delivered electronically afterwards.

Many of us work not only in the NHS but also within the independent sector, and this offers opportunities to explore our educational needs. There are many centres with a range of advanced equipment in the south west with which we can engage and

there are many disciplines involving practitioners who have extended roles and with whom we should engage and interact. As members of an expert institute, we can help train, educate and provide a greater understanding of radiology and our professions.

As members of an expert institute, we can help train, educate and provide a greater understanding of radiology. work in partnership to provide interesting training and development initiatives.

Medical imaging in particular has progressed and now features at an earlier stage in the patients’ pathway, and many envisage that diagnostics could eventually become the first step within the NHS – timely diagnosis aids timely treatment and a more favourable outcome for patients. When I started working in diagnostic imaging, I can’t think of how we would have reacted to receiving a referral from anyone but a Consultant. Now the face of radiology referral has changed and

The opportunity to communicate with all disciplines that have an interest in radiology is unique and, to me, is a key appeal of the BIR. We hope to deliver both specialist radiology meetings and collaborations, working in partnership with other professional associations and colleges within the region to help educate our multidisciplinary community and provide meetings that have a broad appeal.

Niky Sykes, Cobalt

Introducing the new Wessex Branch Chair Dr Katie Johnson has been a Consultant Radiologist at Salisbury District Hospital since 1998. Her subspecialty interests are paediatric imaging and chest imaging. Katie trained at the Royal London Hospital medical school and did a medical rotation there before going to Southampton to train in radiology.

Dr Johnson has been the secretary of the Wessex BIR for three years and organised the Regional meeting at Salisbury in 2008.

BIR Business Development Coordi44

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nator Lucy Nye asked Dr Johnson how she would like to see the branch developed during her term as chair, to which she replied: “I would like to continue to coordinate the Regional meetings for local Consultants and trainees. I would like to encourage as many non-clinical attendees as possible, particularly radiographers but also scientists and those from the companies. I think it is important to maintain high standards of teaching, training and research locally and allow a low cost and therefore accessible

Katie Johnson

series of meetings. This is very relevant at a time when study leave budgets are significantly compromised.”

For further details about the BIR Wessex branch, please visit www.bir.org.uk Dr Katie Johnson, Salisbury Hospital

BIR Company Subscribers 4 Ways Healthcare Tel: 01442 260 322. Contact Dr Sanjiv Agarwal, CEO.

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

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

Envirotect Ltd

Tel: 01525 374 374. Contact Niven Smith, Managing Director.

Ferrania UK Ltd

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

Fujifilm UK Ltd

Tel: 01234 326 780. Contact Mr R G Brown, Director.

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

PTW-UK LTD

Tel: 01476 577 503. Contact Mr Stephen Bellchambers, Area Sales Manager.

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Tel: 01908673107. Contact Mrs Jane Rendall, Sales Director.

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Tel: 01276 696 317. Contact Mr Mike Bell, Marketing Exhibitions and Advertising Manager.

Southern Scientific Ltd

Tel: 01903 604 000. Contact Mr Trevor Nicholls, Sales Director.

Toshiba Medical Systems UK

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

Varian Medical Systems (UK) Limited

Tel: 01293 601 324. Contact Mr David Scott, Area Sales Manager.

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Imaging Equipment

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Landauer Europe

Tel: 01865 373 008 Contact Mrs Helen Matthews, Office Manager. If you would like to find out more about the benefits

Matchtech Group Plc

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

of becoming a Company Subscriber please visit: www.bir.org.uk/bir-join-us-home/corporate

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BIR news

Plenty of opportunities at UKRC 2011 In 2011, UKRC celebrates its tenth anniversary and I am delighted to be presiding over this prestigious congress for the second year. This UK medical imaging event is aimed at a multidisciplinary audience and encompasses the medical, scientific, educational and management issues which are relevant to the fields of radiological sciences.

Whatever your specialist subject, there are learning opportunities in this year’s conference programme which are tailored to your professional needs, fulfil all of your CPD and CME requirements and provide stimulating speakers in areas of research and development.

UKRC 2011 Eponymous Speakers

• The British Institute of Radiology has invited national cancer director, Professor Sir Mike Richards, to deliver a talk on “The Importance of Imaging within the Cancer Reform Strategy”.

• The Royal College of Radiologists has secured Professor Jim Thrall, radiologist-in-chief at the Massachusetts General Hospital, to speak on “The Role of Information Technology in Optimising Radiology Practice”.

• The two eponymous lectures from the College of Radiographers will be delivered by Dr Roland Valori, national clinical director for endoscopy at the Department of Health, and Hazel Harries Jones, lead advanced radiography practitioner from Poole Hospital NHS Foundation Trust. They will speak on “Creating and Sustaining a High Quality, Patient-Centred Endoscopy Service” and “If It Is Not Broken…Mend It! The Holistic Approach to Image Interpretation” respectively.

• Dr Jeff Bamber from the Institute of Cancer Research will discuss “Ultrasound Elastographic Techniques: past, present and future” in the Institute of Physics and Engineering in Medicine John Mallard Lecture.

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Clinical Streams

Within each clinical stream there are masterclasses, with lectures given by experts in the field and refresher courses providing comprehensive overviews. Film viewing for the FRCR and beyond will be presented using interactive voting facilities to encourage analysis and discussion.

Highlights include sessions on PET CT, neurological emergency scenarios, tricky situations in the abdomen and the 2012 Olympics. There will be interactive, hands on sessions on Cardiac CT and High Resolution CT, and live ultrasound demonstrations.

Advances in Technology

The Advances in Technology stream will feature an array of sessions, ranging from veterinary radiology to clinical applications of elastography (a special session linked to the John Mallard Lecture). There will also be sessions showcasing the latest CT and MRI developments and a masterclass on quantitative imaging for the future, focusing on imaging biomarkers for cancer trials.

Imaging Informatics

Issues surrounding the new PACS systems, image data transfers, Vendor Neutral Archives and data sharing across healthcare communities will be addressed as part of the RCR PACS group meeting.

Following on from the previous year’s well attended sessions on Computed Radiography, Digital Radiography and Digital Mammography, there is an updated programme addressing advances in these areas. There will also be a session looking at what non-radiological clinicians require from PACS and supporting IT. Service Delivery

The Service Delivery stream will include a workshop on “Understanding Patient Flow” to help teams understand the relationship between patient flow, cost and quality, and the impact that delays in imaging have for other areas of the

Erika Denton

NHS. There will also be topical debate on who should deliver 21st century imaging services, entitled “This house believes that radiologists have given up enough of their professional role to radiographers”.

In the Exhibition Hall

The UKRC exhibition is free to attend and all conference delegates will receive complimentary catering. The new General Interest stream taking place in the exhibition hall will include “An Update of Key Policy Messages”. This session will provide information on what is happening in Interventional Radiology Services, Stroke Imaging, Aortic Aneurysm screening, PET CT after the National Contract and extensions to the NHS Breast Screening Programme. As the Department of Health’s national clinical director for imaging, I will be giving an update on imaging from the DH perspective in light of the new government.

There is a full programme of satellite sessions taking place in our two exhibition lecture areas from industry supporters and partner societies. These sessions are fully CPD accredited by the RCR and the CoR and are an excellent way to fulfil your professional development needs. Our exhibitors will also host Education on the Stands initiatives, providing short educational activities of 10-15 minutes. These are incredibly popular and it is worth booking in advance.

Full details of the conference programme and registration information can be found at www.ukrc.org.uk.

Image title to go here if you want.

Erika Denton, UKRC President 2011

www.bir.org.uk

bir news

Multidisciplinary Collaboration: Training and Beyond The BIR Trainee Committee put on what can only be described as an amazing event for trainees of all radiologically related disciplines on 10 December 2010.

The event, entitled “Multidisciplinary Collaboration: Training and Beyond”, was the first of its kind in the UK and provided a unique forum where trainees were able to interact with, and learn from, the current leaders in radiology about how to succeed in their careers. The event also focused on both the clinical and research aspects of current trainees in radiology, radiography and medical sciences, allowing both existing and new prospective trainees to gain a valuable insight into each of the respective disciplines. This unique approach highlights the core value of the BIR which is to create and foster relationships with all radiologically-related disciplines.

The BIR Training Committee

The current status of both NHS and independent sector radiology were touched upon. The BIR are congratulated for having the foresight in creating this trainee committee which has brought together the next generation of the leaders in UK radiology. Under the

BRANCH

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

guidance and expertise of current leaders, this new committee has proven that it is capable and ready to steer radiology into what promises to be a bright and fruitful future.

Dr Avnesh Thakor, Academic Clinical Fellow, Addenbrooke’s Hospital

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

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

sCotland CHaIR: dR andREw pEaRson, boRdERs gEnERal HospItal

soUtH wEst England CHaIR: nIky sykEs, Colbalt appEal fUnd

walEs CHaIR: dR gaREtH tUdoR, pRInCEss of walEs HospItal

For more information about our branch network please visit

branches@bir.org.uk

wEssEx CHaIR: dR katIE joHnson, salIsbURy dIstRICt HospItal

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bir news

Artistic X-rays for a shocking new design

Competition Siemens have kindly donated four £25 Waterstones vouchers for this issue of BJR News.

To win just read through the magazine carefully and reply to the following question: What date is the Cardiac CT course being held on?

As contemporary British artist Nick Veasey teams up with Foxtons to create an electrifying new design for its fleet of Minis, he explains how he’s using X-rays to bring art to life.

Tiring with the limits of traditional photography, Nick Veasey imprinted himself on the international art scene using the unlikely medium of a radiography machine, X-raying everything from a pair of Jimmy Choos and a tarantula through to a pig and a Boeing 777. Invited to submit pieces for the Victoria & Albert British Collection of Photography, he finally realised his dream of X-raying a car, choosing to depict a classic Mini with all its inner workings revealed. This proved the perfect precursor to his commission from Foxtons, equipping him with exactly the experience he needed to transform the fleet.

A photographer who made his name by redefining the parameters of his field, there is definitely a detectable symbiosis in Veasey’s relationship with Foxtons. “It’s great that Foxtons has such a large fleet of these Minis. Every artist wants to connect with the public and by bringing my art to the streets of London, I can reach out to people rather than trying to get them into a gallery,” he reflects. “I do hope it makes people stop and think for a second about how things are made and what goes on under the surface.

Beauty, after all, is more than skin deep.”

After receiving a former Foxtons Mini at his specially built studio, he promptly set upon it with power tools. “The process 48

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begins by cutting the car into manageable sections but BMW makes the Mini in an incredibly complex way,” Veasey explains.

“It took two weeks to angle grind just one side; on the classic Mini, the job was done in three days. The old cars were much simpler in their construction.” While he nostalgically refers to the classic Mini as “one lovely piece of design”, the X-ray process illuminates the second generation’s ergonomic curves and high-spec technology.

To achieve the transparent finish which encompasses the entire car, Veasey took more than 100 photos: “The real challenge was ensuring we had X-rayed all the components from every angle, taking different shots to cover each perspective – including the roof.” After digitally stitching all these images together to form complete panels, the final artwork was applied to vinyl shapes and then smoothed across the bodywork.

Despite the extra hours’ work it entails, Veasey says this project has further fuelled his passion for three-dimensional art. “In my most recent exhibition I fused lightboxes into real objects: half real object, half X-ray light box. My process is fundamentally twodimensional so seeing the results on a 3D scale is always fascinating,” he adds.

Veasey’s ambitious artistic nature is obvious, but it seems that his desire to push X-ray art to the limits knows no bounds: “I am keen to experiment with X-ray effects on buildings – I’d like to see through walls,” he concludes.

For full article see www.foxtons.co.uk

Send your answer along with your name and contact details to: marketing@bir.org.uk by 3 March 2011. This time there will be four lucky winners.

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

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

Sudoku from www.puzzlechoice.com.

www.bir.org.uk

A Page of History

Another Curie Centenary In 2003 we celebrated the centenary of Marie Curie receiving her first Nobel Prize for physics. Marie and Pierre Curie shared the award with Antoine Henri Becquerel “for their discovery of the spontaneously radioactive elements.” The winner of the Nobel Prize for chemistry for 1903 was reported as saying that the discovery of radium was the single most important discovery in that subject for the past century, but the award citation made no specific mention of the discovery of either radium or polonium and so the possibility of a further Nobel Prize for chemistry remained.

This was the case and on 11 November 1911, Marie Curie received a telegram telling her that she was to be awarded the Nobel Prize for chemistry “in recognition of her services in the advancement of chemistry by the

discovery of the elements radium and polonium, by the isolation of radium and the study of the nature and compounds of this remarkable element.”

There has been much discussion over the years about this second Nobel Prize since the work being rewarded was

essentially the same as that which had been recognised in the 1903 award. At the award ceremony on the 10 December 1911, it was explained that the reason for giving her the second Nobel Prize for the same work was because of the major significance of radium and that the study of radium was important in two areas. Firstly, radium showed that the long standing view that atoms were unchanging was false and that one element could transform itself into another. There were also major medical uses of radium in cancer treatments.

Marie Curie was awarded honorary membership of the Institute in 1921 and this year we salute and remember our distinguished past member. r Adrian Thomas BSc FRCP FRCR FBIR D Honorary Librarian, BIR

A remarkable wrist watch The Institute was recently offered a watch by Yvonne Beech that had been presented to Corporal E Wallwork RAMC by Doctors Ironside Bruce (1879-1921), Stanley Melville (1867-1934) and George Harrison Orton (1873-1947). The presentation of the watch was as a token of appreciation for his work in the X-ray department of the King George Hospital from 1915-1919.

All of the three doctors were deeply involved in the BIR or its previous incarnations. Sadly all three suffered from radiation-induced disease and their names are all recorded on the X-ray martyr’s memorial in the grounds of St Georges Hospital in Hamburg.

Bruce was on the staff of Charing

Cross Hospital and the Hospital for Sick Children in Great Ormond Street. The British radiological world was shocked when Bruce died of radiation-induced aplastic anaemia in 1921 at the age of 42 and the outcry following his death resulted in the formation of a national radiation protection committee.

Orton was a pioneer of radiotherapy and was in charge of the X-ray department at St Mary’s Hospital in London. After his death it was said in his obituary that he

was “perhaps the last martyr pioneer of radiology”, while Melville worked at St George’s Hospital in London and was BIR president in 1934. Both Orton and Melville served as co-secretary with Sidney Russ of the newly formed British X-ray and Radium Protection Committee.

It is great that the Institute has this watch and we extend our thanks to Yvonne Beech for her kind gift.

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

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www.bir.org.uk

PRESIDENTâ&#x20AC;&#x2122;S COLUMN

BJR News is an exciting new publication to communicate broadly across the radiology community

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The first 100 days of my presidency has been a formative time. Following my inauguration we held a strategy day at the BIR to develop a plan for 2011-2016. It was encouraging to be surrounded by trustees, past and present, who are full of ideas and enthusiasm for the BIR. The staff at the BIR had also spent considerable time in preparing the way with a series of informative documents. Currently we are distilling this into the 2011-2016 plan which will be published in the summer.

Our trainee section is growing rapidly and we now have more than 1000 trainee members. In order to support this development we have had to introduce a modest membership fee with the clear aim of investment in this section of the membership. The trainee section is bringing new ideas into the BIR, and the trainee committee organised an excellent one day meeting in December which was rounded off with yours truly as quizmaster.

My 2011 Presidents Conference is on the theme of cardiac imaging for which an excellent programme has been drawn up by Sujal Desai. It will be held on 19-20 May 2011 and full details are available on the website. Cardiac imaging is a growing area and I encourage you to attend and to invite all colleagues with an interest in this area. The conference will feature the Mackenzie Davidson Memorial lecture.

In my first column, I highlighted that trainee engagement is a key theme of my presidency. The second key theme is development of the regional strategy through our expanding branch network.

issue 1 february 2011

The BIR wants to reach out across the UK and provide more educational events and offer a good opportunity for networking at a regional level.

The regional branches programme is going from strength to strength, with excellent progress in Scotland, East of England, Wales, Northern, South West and Wessex Branches in the last few months. I intend to visit each of the Branches once a year. It is an important strategic aim of the BIR to develop the branch network and to get closer to our membership around the country. I was absolutely delighted that the inaugural Eastern Branch drew 100 delegates from across the radiology community. The branches are making a really positive effort to be multiprofessional, attracting radiographers and physicists in addition to radiologists.

I hope that you will have noticed a major transformation in our flagship publication, the British Journal of Radiology which is now exclusively online. BJR News is an exciting new publication which we aim to make the focus of our BIR activities and to communicate broadly across the radiology community. This development of our publications arena is a great example of how the collective enthusiasm of BIR members, trustees and staff can lead to positive change. I am pleased to report that Imaging is making very good progress through the collective efforts of the publications team and the editorial board.

www.bir.org.uk

Book review

Gastric Cancer

By Richard M Gore ISBN: 978-0-521513-83-8 Gastric cancer is second only to lung cancer in terms of worldwide cancer deaths. This book sets out the epidemiology and pathology of the disease, and then details the role of endoscopy and double contrast barium in the initial diagnosis, with evaluation of the role of CT, EUS, PET/CT and MRI in the staging and management of the patients diagnosed.

Further chapters detail the surgical and systemic treatment of the disease, and finally there is a chapter on current

Radiotherapy in Practice Imaging

By P Hoskin and V Goh ISBN: 978-0-199-23132-4 A recent â&#x20AC;&#x153;point/counterpointâ&#x20AC;? article in Medical Physics (May 2010) discussed the adequacy of training programs in reflecting the heightened importance of medical imaging. The article discussed this in relation to medical physics training, but it highlighted this need within all professional disciplines owing to our increasing dependence on imaging within the field of radiotherapy; both pre-treatment and during treatment through newly available image guidance technologies.

This book, one in a series examining practical aspects of radiotherapy, helps to fill the gap in training in a detailed and highly illustrative way.

As with the other books in the series edited by Peter Hoskin, it is a multi-author work examining the role of imaging in each major clinical site. There are good general introductory chapters on the role of imaging and the basic principles for plain radiographs, CT, ultrasound, MR, radionuclide and PET imaging. The

trends and future opportunities.

All images are state-of-the-art, with sections on virtual gastroscopy, optical coherence tomography and perfusion imaging as a nod to the future directives of imaging. The book also boasts some exquisite fluoroscopic images in homage to the well established role of double contrast fluoroscopy.

The book is well researched, with leaders in the field contributing to each section. It is 209 pages long, and the information is well presented and concise.

As the authors state, gastric cancer remains a common and deadly malignancy. Prevention and early detection offer the best chance of cure. Increased

clinical chapters have a consistent format that discuss clinical background, diagnosis, TNM staging, radiotherapy imaging and target volume definition, therapeutic assessment, follow-up and including a bullet-point summary for all clinical sites.

Each chapter can stand alone, which allows the reader to dive straight into their own clinical specialty, and there is excellent use of illustrations throughout all chapters, some in colour. The sections on TNM staging are clearly laid out and particularly comprehensive and informative for the reader. There is a welcome chapter on the concomitant doses involved with imaging at all stages in the patient pathway, and the importance of understanding and recording these as part of the clinical protocol, particularly with respect to the IR(ME)R. Like other chapters it is extremely informative and discusses typical doses and risk factors in the clinical setting.

If there are any complaints, they are minor ones. It would have been useful, particularly now that on-treatment volumetric imaging is now (technically) widely available, to discuss how this is beginning to help adapt radiotherapy in vivo, both geometrically and dosimetrically. Similarly, aspects of four dimensional imaging (both pre-treatment and on-treatment) could have been expanded upon more;

physician awareness is surely part of this process, and this book is an easyto-read synopsis on the current status of diagnosis, staging and treatment of the disease, with future directives also described.

I would recommend this book to any healthcare professional with an interest in this disease.

A useful addition to my book shelf and would whole heartedly recommend it as an essential reference book in all ultrasound departments.

Dr Susan Ryan

www Download the full book review bjr.birjournals.org

particularly as it tremendously enhances our ability to define and treat more accurately our clinical target volumes for lung tumours. It may also have been useful to tabulate the good information on target volume definition (in particular margins used and their derivation) in the same style as the excellent TNM staging discussions.

However, the authors cannot be expected to write about every development â&#x20AC;&#x201C; or the work would never get submitted for publication! This does not detract from what is an extremely comprehensive work for which the authors and editors should be commended.

The book is stated as being primarily for clinical oncologists and radiologists, but it has a place within training programs for both physicists and radiographers too, particularly those specialising in virtual simulation and computerised treatment planning. Overall, it is a welcome addition to radiotherapy and oncology teaching, an excellent work and highly recommended.

Mike C Kirby, Consultant Clinical Scientist (Radiotherapy)

www Download the full book review bjr.birjournals.org

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NEWS 51

Assurance of Quality in the Diagnostic Imaging Department 2nd Edition

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

A practical guide to instituting a quality control programme.

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

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

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

• • • • • •

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

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

Radiation Shielding for Diagnostic X-Rays Report of a joint BIR/IPEM Working Party

Edited by D G Sutton & J R Williams The UK’s first and most comprehensive report on the topic produced by a joint BIR/IPEM Working Party.

This report is designed to be a compendium of information for radiation physicists involved in specification of shielding requirements for X-ray facilities.

A scientifically based, realistic and straightforward approach to shielding specification.

Sets out a framework for shielding calculations based on patient-dose area product and entrance surface dose information.

Includes a review of the dose criteria employed in light of revised ionising radiation legislation and re-evaluates assumptions made in earlier methodologies.

25% DISCOUNT for BIR Members. Price £15.00 (normal price £20.00).

Buy your personal copy today; visit our online bookshop http://www.bir.org.uk

Can you diagnose a heart condition in under a minute?

See it at London Cardiac CT Level II Training Course 8 - 11 February 2011

syngo.via – the new imaging software that facilitates faster reading of cardiac CT images Get your cases ready faster. Let syngo®.via* segment the heart and the coronary arteries, let it “remove” the rib cage and blood pool and rely on its guidance when creating your report. Have your places networked. Access and share information anywhere** with the unique networking of imaging modalities and IT. All your needs are anticipated with continued innovations and support when you need them. syngo.via. Images, my way. www.siemens.com/syngo.via

Answers for life. * syngo.via can be used as a stand-alone device or together with a variety of syngo.via-based software options, which are medical devices in their own rights (e.g. syngo.CT Coronary Analysis) ** Prerequisites include: Internet connection to clinical network, DICOM compliance, meeting of minimum hardware requirements and adherence to local data security regulations