Best of BJR 2016 by BIR Publishing

An international journal of radiology, radiation oncology and all related sciences

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BJR Issues per year: 12 ISSN: 0007-1285 eISSN: 1748-880X Citation: Br J Radiol 2014 Impact Factor: 2.026 5-year Impact Factor: 1.976

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BIR Publications publishes BJR, an international journal covering medical imaging, radiation oncology, medical physics, radiobiology and the underpinning sciences, as well its open access sister title BJR|case reports and DMFR. C O P E

COM M ITTE E ON P U B LICATION ETH ICS

Contents Editorial Board

Introduction

3 5

Promoting your paper

Professional social media

Recommendations for accurate CT diagnosis of suspected acute aortic syndrome—on behalf of the BSCI/BSCCT. Varut Vardhanabhuti et al

Radiotherapy for benign disease; assessing the risk of radiation-induced cancer following exposure to intermediate dose radiation. Stephanie R McKeown et al

Evaluation of 39 medical implants at 7.0 T. David X Feng et al

Portal vein variations in 1000 patients: surgical and radiological importance. Binit Sureka et al

Nuclear molecular imaging with nanoparticles: radiochemistry, applications and translation. D S Abou et al

Clinical application of surface projection in the localization of metal foreign bodies using computed tomography scan. Hexiang Qian et al

The value of intratumoral heterogeneity of 18F-FDG uptake to differentiate between primary benign and malignant musculoskeletal tumours on PET/CT. Masatoyo Nakajo et al

Radiation protection of the eye lens in medical workers—basis and impact of the ICRP recommendations. Stephen GR Barnard et al

Cardiac MR enables diagnosis in 90% of patients with acute chest pain, elevated biomarkers and unobstructed coronary arteries. T Emrich et al

Return of the pulmonary nodule: the radiologist’s key role in implementing the 2015 BTS guidelines on the investigation and management of pulmonary nodules. Richard N J Graham et al

Variations in CT determination of target volume with active breath co-ordinate in radiotherapy for post-operative gastric cancer. Gui-Chao Li et al

Whole-body CT-based imaging algorithm for multiple trauma patients: radiation dose and time to diagnosis. S Gordic et al

Utility of relative and absolute measures of mammographic density vs clinical risk factors in evaluating breast cancer risk at time of screening mammography. Mohamed Abdolell et al

Organizational development trajectory of a large academic radiotherapy department set up similarly to a prospective clinical trial: the MAASTRO experience. M Jacobs et al

An online open-source tool for automated quantification of liver and myocardial iron concentrations by T2* magnetic resonance imaging. K-A Git et al

X-ray phase contrast tomography; proof of principle for post-mortem imaging. Anna Zamir et al

British Institute of Radiology news

Puzzles

Abstracts

Top tips from the editors

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Editorial Board Editors-in-Chief Dr Nigel Hoggard

Medical

Professor Kevin Prise

Scientific

Senior Editors Diagnostic Radiology Professor Tarek El-Diasty Genitourinary

Dr Amy Kotsenas Neuro/Head and Neck

Dr Nicholas Screaton Respiratory/Chest

Dr Rosalind Given-Wilson Breast

Dr Kieran McHugh Paediatrics

Professor Stuart Taylor Gastrointestinal

Dr Stephen Harden Cardiothoracic

Professor Wilfred Peh Musculoskeletal

Dr Raman Uberoi Interventional

Dr Simon Jackson Gastrointestinal

Dr Andrew Scarsbrook Nuclear Medicine

Physics & Technology Professor William Vennart

Radiobiology Dr Stewart Martin

Radiotherapy & Oncology Professor Mechthild Krause

Professor Habib Zaidi

Associate Editors

Dr Zahir Amin Dr Richard Amos Dr Anneloes Bohte Dr Russell Bull Dr Alejandro Carabe-Fernandez Dr Steve Connor Dr Peter Corr Dr Barbara Dall Dr Indra Das Dr Marco Durante Dr David Eaton Dr Jonathan Eatough Dr Nitin Ghonge Dr Richard Graham Prof. Giuseppe Guglielmi Dr Christopher Harvey Dr Samantha Heller Dr John Holemans Dr Ben Holloway

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Dr David Howlett Dr Paul Humphries Dr Elizabeth Krupinski Dr Christian Lohrmann Dr Ranald MacKay Dr Lesley Malone Dr Gurdeep Mann Dr Shinichiro Mori Dr Hilary Moss Prof. Peter Munk Prof. Andrew Nisbet Dr Christopher Njeh Dr Mike Partridge Dr Tufail Patankar Dr Chirag Patel Dr Ruben Pauwels Dr Andrew Plumb Dr Niall Power Dr Shonit Punwani

Dr Madan Rehani Dr Kevin Robson Prof. Carl Roobottom Dr Anju Sahdev Dr Andrew Slater Dr Stephane Supiot Dr David Sutton Dr Katy Szczepura Dr Alberto Tagliafico Dr Paul Taylor Dr Elspeth Whitby Dr John Winder Dr Hui-Xiong Xu Dr Pat Zanzonico

Statistics Editors Dr Adam Brentnall Dr Fay Cafferty

Smaller, more fun & more content!

We’ve decided to change it up a bit for our 2016 edition of Best of BJR! Not only have we shrunk to a brief-case friendly size, we’ve included some fun radiation-themed games to keep you occupied while you travel (page 30), and we’ve managed to fit in even more complimentary content, making Best of BJR the travel reading of the season.

How, you ask? Well, in this edition you’ll find the abstracts of 16 recent papers representing a cross-section of the broad, multidisciplinary content that can be found in BJR. Use the code and instructions on the inside cover to access the full articles for free. You’ll also find top tips from our editors, ways to promote your paper and news from the British Institute of Radiology. Featured articles include a commentary on the radiologist’s role in investigating pulmonary nodules, the safety of medical implants at 7 Tesla, the use of a WBCT imaging algorithm for multiple trauma patients and a review assessing the risks of radiation-induced cancer following exposure to intermediate dose RT, plus much more! It’s been an exciting and busy period for us with the publication of three successful themed issues in BJR covering Advances in Radiotherapy, Nanoparticles for Imaging and Radiotherapy and Emergency Radiology, with more themed content coming soon. We also launched our sister journal, BJR|case reports, which received well over 500 submissions from over 26 countries and continues to go from strength to strength. BJR’s impact continues to grow and our international editorial board is delighted to see increasingly global submissions, with articles received from over 50 countries in the last year. We’re also excited to be engaging with the community in new ways, including our ever-popular cover competition and growing social media presence. Our followers have been keen to tweet us pictures of the #BJRTravelbug mascot in a variety of far flung locations. Pick yours up at our booth and let @BJR_Radiology know where it gets to. We hope you will join our growing list of international authors, readers and reviewers by reading articles, reviewing papers and submitting your next paper to BJR. 3

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RAX technology

Multitom Rax: Join the new movement with robotic X-ray siemens.co.uk/multitom-rax In today’s healthcare environment, excellent patient care and outstanding productivity often compromise each other. Multitom Rax puts an end to “either/or”.Robotic Advanced X-ray – RAX – supports you in streamlining clinical pathways while improving diagnostic insights and treatments.

With an open design that reduces patient transfers, pain, and anxiety while offering more space to perform interventions. With twin robots to simplify, standardise, and speed up operations. All with the goal of accelerating productivity and allowing humans to do what they do best – care for patients.

How? With one scanner that offers a multitude of X-rays – in just one room and at an expert level. With movements that create natural Real 3D1) images – even under weightbearing conditions.

Prepare yourself for the future with the world’s first Twin Robotic X-ray scanner – achieving a new level of excellence with regard to diagnostic insights and treatments.

RAX – Robotic Advanced X-ray – opens up exciting new movements for enhanced patient care and outstanding productivity.

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Best of BJR A5 adverts 15.3.16.indd 4

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Top tips from our editors

Configuring a synchronisation application such as Google Drive or Dropbox across your devices allows a single reference point for your current academic work. It is an efficient way of ensuring the latest version of your manuscript is available wherever you are and however you access it. They also allow sharing of documents with co-authors and real-time collaboration.

When acting as a reviewer—remember to feel privileged to be the first to read submitted scientific work. Treat a review as you would expect others to appraise papers you have submitted. Set aside sufficient time, always be respectful of the efforts of authors and provide constructive feedback of sufficient detail—not one liners. Clear advice to the editor on the merit of a paper is important.

When sitting down to write your paper imagine explaining in 2–3 sentences to a non specialist colleague what you have found with your research. Consider and describe the main 2–3 messages. Make sure that these Nick Screaton come across clearly in your abstract and are used as the framework for your discussion.

Rosalind Given-Wilson

Andy Scarsbrook

BJR actively encourages new reviewers and offers valuable guidance in order to facilitate high quality reviews.

Provide sufficient detail when writing the methods for your manuscript, such that another individual could exactly repeat your methodology in their institution.

When asked to review a paper it is really helpful for the authors, in preparing their Stuart Taylor revisions and reply, if you number in sequence each difAlways ask someone ferent point you make about who is not an author the paper. to read the paper Kieran McHugh before submission.

Bill Vennart

Simon Jackson My top tip is to encourage authors to show meticulous attention to detail. This will serve authors well and will increase the chances of manuscript acceptance, but it is also just as applicable to reviewers of received manuscripts.

Stephen Harden 5

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Promoting your paper Whether you’ve just started writing your first paper or you’re an experienced pro with many publications under your belt, learning how to promote your work is important for researchers at all stages of their career. We’ve put together this handy page of tips to help you on your way to marketing heaven!

While writing your paper... Take a moment to consider your readers.

Choose a clear, descriptive title. Search engines weight the words in your title most heavily in determining what your article is about, so make sure anyone reading your title gets a good idea of what your article is about.

What words and key phrases would they enter in to a search engine to find articles on the topic you’re writing about?

After publication of your paper... Get social!

E-mail signatures

If you use social media don’t get shy now! Share your article on Twitter, Facebook, LinkedIn, Kudos, ResearchGate, Mendeley, Grove etc.

Once your article is online you can start directing people towards it; why not include something like this in your e-mail signature? Read my latest article on (subject) in BJR here (link)

Twitter is a great way to reach a wide audience. Get practising your editing skills – can you summarise your work and include a link to your article in 140 characters?

For these and many more tips, go to birpublications.org/promote

While you’re at it, follow us @BJR_Radiology.

birpublications.org/bjr

Professional social media BJR Senior Editor and social media maven Dr Amy Kotsenas shares her tips on using social media as a radiologist, doctor and researcher. Online reputation Social media helps you to control your online reputation. Remember when posting to social media to always keep your posts professional. Keeping up-to-date Twitter is a great way to keep up with the latest research and up-to-date clinical advances, so make sure youâ&#x20AC;&#x2122;re following all the key journals and researchers in your specialty area. Attract attention with images Make sure images you post do not contain patient data or other identifying information. If you post images from another source, always give credit. Improve patient understanding Social media is transforming the way patients make informed healthcare decisions. Use social media to disseminate accurate and complete information to establish yourself or your institution as a trusted resource. Use it to grow your network

Dr Kotsenas is Assistant Professor of Radiology at the Mayo Clinic (USA). She studied at Temple University School of Medicine and completed her residency and fellowship at Hahnemann University Hospital before taking on her current role. Her research interests include non-invasive neurovascular imaging, MR and CT brain perfusion, MR spectroscopy, neurologic FDG PET imaging, diffusion-weighted MRI and imaging of epilepsy. She has published over 25 peerreviewed publications and is renowned for her advocacy of social media.

Twitter is a great networking tool. If you have a great idea, consider using twitter to reach out to leaders in your field and ask for advice and input.

birpublications.org/bjr

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The demand for value-based care continues to grow. In response, healthcare providers are finding new ways to improve care pathways while driving down long-term asset costs. Biograph Horizon helps you offset these expenses, expand your clinical capabilities and simplify your operations.

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Abstracts Guidelines & Recommendations

Recommendations for accurate CT diagnosis of suspected Acute Aortic Syndrome (AAS)â&#x20AC;&#x201D;on behalf of the British Society of Cardiovascular Imaging (BSCI)/British Society of Cardiovascular CT (BSCCT) Varut Vardhanabhuti, Edward Nicol, Gareth Morgan-Hughes, Carl A Roobottom, Giles Roditi, Mark C K Hamilton, Russell K Bull, Franchesca Pugliese, Michelle C Williams, James Stirrup, Simon Padley, Andrew Taylor, L Ceri Davies, Roger Bury, Stephen Harden Accurate and timely assessment of suspected acute aortic syndrome is crucial in this life-threatening condition. Imaging with CT plays a central role in the diagnosis to allow expedited management. Diagnosis can be made using locally available expertise with optimized scanning parameters, making full use of recent advances in CT technology. Each imaging centre must optimize their protocols to allow accurate diagnosis, to optimize radiation dose and in particular to reduce the risk of false-positive diagnosis that may simulate disease. This document outlines the principles for the acquisition of motion-free imaging of the aorta in this context.

10.1259/bjr.20150705

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Published in issue 89(1061) birpublications.org/bjr

Review

Radiotherapy for benign disease; assessing the risk of radiation-induced cancer following exposure to intermediate dose radiation Stephanie R McKeown, Paul Hatfield, Robin JD Prestwich, Richard E Shaffer and Roger E Taylor Most radiotherapy (RT) involves the use of high doses (>50â&#x20AC;&#x2030;Gy) to treat malignant disease. However, low to intermediate doses (approximately 3â&#x20AC;&#x201C;50â&#x20AC;&#x2030;Gy) can provide effective control of a number of benign conditions, ranging from inflammatory/proliferative disorders (e.g. Dupuytren's disease, heterotopic ossification, keloid scarring, pigmented villonodular synovitis) to benign tumours (e.g. glomus tumours or juvenile nasopharyngeal angiofibromas). Current use in UK RT departments is very variable. This review identifies those benign diseases for which RT provides good control of symptoms with, for the most part, minimal side effects. However, exposure to radiation has the potential to cause a radiation-induced cancer (RIC) many years after treatment. The evidence for the magnitude of this risk comes from many disparate sources and is constrained by the small number of long-term studies in relevant clinical cohorts. This review considers the types of evidence available, i.e. theoretical models, phantom studies, epidemiological studies, long-term follow-up of cancer patients and those treated for benign disease, although many of the latter data pertain to treatments that are no longer used. Informative studies are summarized and considered in relation to the potential for development of a RIC in a range of key tissues (skin, brain etc.). Overall, the evidence suggests that the risks of cancer following RT for benign disease for currently advised protocols are small, especially in older patients. However, the balance of risk vs benefit needs to be considered in younger adults and especially if RT is being considered in adolescents or children.

10.1259/bjr.20150405

Published in issue 88(1056) birpublications.org/bjr

Full Paper

Evaluation of 39 medical implants at 7.0 T David X Feng, Joseph P McCauley, Fea K Morgan–Curtis, Redoan A Salam, David R Pennell, Mary E Loveless and Adrienne N Dula Objective: With increased signal to noise ratios, 7.0-T MRI has the potential to contribute unique information regarding anatomy and pathophysiology of a disease. However, concerns for the safety of subjects with metallic medical implants have hindered advancement in this field. The purpose of the present research was to evaluate the MRI safety for 39 commonly used medical implants at 7.0 T. Methods: Selected metallic implants were tested for magnetic field interactions, radiofrequency-induced heating and artefacts using standardized testing techniques. Results: 5 of the 39 implants tested may be unsafe for subjects undergoing MRI at 7.0 T. Conclusion: Implants were deemed either “MR Conditional” or “MR Unsafe” for the 7.0-T MRI environment. Further research is needed to expand the existing database categorizing implants that are acceptable for patients referred for MRI examinations at 7.0 T. Advances in knowledge: Lack of MRI testing for common metallic medical implants limits the translational potential of 7.0-T MRI. For safety reasons, patients with metallic implants are not allowed to undergo a 7.0-T MRI scan, precluding part of the population that can benefit from the detailed resolution of ultra-highfield MRIs. This investigation provides necessary MRI testing of common medical implants at 7.0 T.

10.1259/bjr.20150633

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Full Paper

Portal vein variations in 1000 patients: surgical and radiological importance Binit Sureka, Yashwant Patidar, Kalpana Bansal, S Rajesh, Nitesh Agrawal and Ankur Arora Objective: The purpose of the study was to evaluate the spectrum and incidence of intrahepatic portal vein (PV) variations on triphasic abdomen multidetector CT (MDCT) and to discuss the surgical and radiological implications. Methods: A retrospective review of 1000 triphasic MDCT abdomen scans was performed in patients sent for various liver and other abdominal pathologies between January 2014 and August 2014. A total of 967 patients (N = 967) were included in the study. The variations in branching pattern of PV were classified according to classification used by Covey et al (Covey AM, Brody LA, Getrajdman GI, Sofocleous CT, Brown KT. Incidence, patterns, and clinical relevance of variant portal vein anatomy. AJR Am J Roentgenol 2004; 183: 1055–64) and Koç et al (Koç Z, Oğuzkurt L, Ulusan S. Portal vein variations: clinical implications and frequencies in routine abdominal CT. Diagn Interv Radiol 2007; 13: 75–80). Results: Normal anatomy (Type I) was seen in 773 patients (79.94%) out of 967 patients in our study. Trifurcation (Type II) anomaly was seen in 66 (6.83%) of cases. Right posterior vein as first branch of main PV (Type III) anomaly was seen in 48 (4.96%) of cases. Type IV anomaly and Type V anomaly was seen in 26 (2.69%) and 13 (1.34%) cases, respectively. 19 cases showed other types of variations. Conclusion: Variations in the hepatic PV branching patterns are commonly seen that are similar to variations in hepatic artery and biliary anatomy. Knowledge of these variations is extremely important for transplant surgeons and intervention radiologists. Advances in knowledge: Awareness of the variations in PV branching patterns is essential for intervention radiologists and vascular surgeons and avoids major catastrophic events.

10.1259/bjr.20150326 Published in issue 88(1055) birpublications.org/bjr

Review

Nuclear molecular imaging with nanoparticles: radiochemistry, applications and translation D S Abou, J E Pickett and D L J Thorek Molecular imaging provides considerable insight into biological processes for greater understanding of health and disease. Numerous advances in medical physics, chemistry and biology have driven the growth of this field in the past two decades. With exquisite sensitivity, depth of detection and potential for theranostics, radioactive imaging approaches have played a major role in the emergence of molecular imaging. At the same time, developments in materials science, characterization and synthesis have led to explosive progress in the nanoparticle (NP) sciences. NPs are generally defined as particles with a diameter in the nanometre size range. Unique physical, chemical and biological properties arise at this scale, stimulating interest for applications as diverse as energy production and storage, chemical catalysis and electronics. In biomedicine, NPs have generated perhaps the greatest attention. These materials directly interface with life at the subcellular scale of nucleic acids, membranes and proteins. In this review, we will detail the advances made in combining radioactive imaging and NPs. First, we provide an overview of the NP platforms and their properties. This is followed by a look at methods for radiolabelling NPs with gamma-emitting radionuclides for use in single photon emission CT and planar scintigraphy. Next, utilization of positronemitting radionuclides for positron emission tomography is considered. Finally, recent advances for multimodal nuclear imaging with NPs and efforts for clinical translation and ongoing trials are discussed.

10.1259/bjr.20150185

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Published in issue 88(1054) birpublications.org/bjr

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Clinical application of surface projection in the localization of metal foreign bodies using computed tomography scan Hexiang Qian, Changwen Shi and Guangfu Xing Objective: To analyse the clinical efficacy of surface projection in the localization and removal of metal foreign bodies using CT scan. Methods: Total 795 cases with 1008 metal foreign bodies were treated at our hospital in 2012. Pre-operative surface projection was performed to localize foreign bodies in patients under the guidance of CT scan. The removal path from the skin surface to foreign body and puncture site were then determined. Finally, the foreign bodies were extracted using proper foreign body forceps which were chosen according to the size, depth and position of the foreign bodies in different parts of the human body. The incision length, operative time and intraoperative blood loss were recorded. Additionally, outpatient follow-up was scheduled postoperatively for 1 week. Results: The accurate localization rate under the guidance of CT scan was 100%, and 1008 pieces of metal foreign bodies were all successfully removed with a removal rate of 100%. The mean incision length was 0.4 ± 0.1 cm, the mean operative time was 4.1 ± 2.0 min and the intraoperative blood loss was 1.1 ± 0.5 ml. These results showed minimal invasiveness, shorter operative time and minimal blood loss, respectively. Additionally, the results of outpatient follow-up showed that the wound healed spontaneously. Moreover, there were no significant bleeding, incision infections or complications. Conclusion: Surface projection may be an accurate and effective method for the pre-operative localization and extraction of metal foreign bodies. Advances in knowledge: (1) Surface projection was applied for localization of metal foreign bodies in our study. (2) The accurate localization rate of surface projection under the guidance of CT scan was 100%. (3) All foreign bodies were successfully removed with a removal rate of 100%. (4) Surface projection technique has advantages in the removal of foreign bodies.

10.1259/bjr.20150075 Published in issue 88(1054) birpublications.org/bjr

Full Paper

The value of intratumoral heterogeneity of 18F-FDG uptake to differentiate between primary benign and malignant musculoskeletal tumours on PET/CT Masatoyo Nakajo, Masayuki Nakajo, Megumi Jinguji, Yoshihiko Fukukura, Yoshiaki Nakabeppu, Atsushi Tani and Takashi Yoshiura Objective: The cumulative standardized uptake value (SUV)–volume histogram (CSH) was reported to be a novel way to characterize heterogeneity in intratumoral tracer uptake. This study investigated the value of fluorine-18 fludeoxyglucose (18FFDG) intratumoral heterogeneity in comparison with SUV to discriminate between primary benign and malignant musculoskeletal (MS) tumours. Methods: The subjects comprised 85 pathologically proven MS tumours. The area under the curve of CSH (AUC-CSH) was used as a heterogeneity index, with lower values corresponding with increased heterogeneity. As 22 tumours were indiscernible on 18F-FDG positron emission tomography, maximum standardized uptake value (SUVmax), mean standardized uptake value (SUVmean) and AUC-CSH were obtained in 63 positive tumours. The Mann–Whitney U test and receiver operating characteristic (ROC) analysis were used for analyses. Results: The difference between benign (n = 35) and malignant tumours (n = 28) was significant in AUC-CSH (p = 0.004), but not in SUVmax (p = 0.168) and SUVmean (p = 0.879). The sensitivity, specificity and accuracy for diagnosing malignancy were 61%, 66% and 64% for SUVmax (optical threshold value, >6.9), 54%, 60% and 57% for SUVmean (optical threshold value, >3) and 61%, 86% and 75% for AUC-CSH (optical threshold value, ≤0.42), respectively. The area under the ROC curve was significantly higher in AUC-CSH (0.71) than SUVmax (0.60) (p = 0.018) and SUVmean (0.51) (p = 0.005). Conclusion: The heterogeneity index, AUC-CSH, has a higher diagnostic accuracy than SUV analysis in differentiating between primary benign and malignant MS tumours, although it is not sufficiently high enough to obviate histological analysis. Advances in knowledge: AUC-CSH can assess the heterogeneity of 18F-FDG uptake in primary benign and malignant MS tumours, with significantly greater heterogeneity associated with malignant MS tumours. AUC-CSH is more diagnostically accurate than SUV analysis in differentiating between benign and malignant MS tumours. Published in issue 88(1055)

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Review

Radiation protection of the eye lens in medical workersâ&#x20AC;&#x201D; basis and impact of the ICRP recommendations Stephen GR Barnard, Elizabeth A Ainsbury, Roy A Quinlan and Simon D Bouffler The aim of this article was to explore the evidence for the revised European Union basic safety standard (BSS) radiation dose limits to the lens of the eye, in the context of medical occupational radiation exposures. Publications in the open literature have been reviewed in order to draw conclusions on the exposure profiles and doses received by medical radiation workers and to bring together the limited evidence for cataract development in medical occupationally exposed populations. The current status of relevant radiation-protection and monitoring practices and procedures is also considered. In conclusion, medical radiation workers do receive high doses in some circumstances, and thus working practices will be impacted by the new BSS. However, there is strong evidence to suggest that compliance with the new lower dose limits will be possible, although education and training of staff alongside effective use of personal protective equipment will be paramount. A number of suggested actions are given with the aim of assisting medical and associated radiation-protection professionals in understanding the requirements.

10.1259/bjr.20151034

Published in issue 89(1060) birpublications.org/bjr

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Cardiac MR enables diagnosis in 90% of patients with acute chest pain, elevated biomarkers and unobstructed coronary arteries T Emrich, K Emrich, N Abegunewardene, K Oberholzer, C Dueber, T Muenzel and K-F Kreitner Objective: To assess the diagnostic value of cardiac MRI (CMR) in patients with acute chest pain, elevated cardiac enzymes and a negative coronary angiogram. Methods: This study included a total of 125 patients treated in the chest pain unit during a 39-month period. Each included patient underwent MRI within a median of 3 days after cardiac catheterization. The MRI protocol comprised cine, oedema-sensitive and late gadolinium-enhancement imaging. The standard of reference was a consensus diagnosis based on clinical follow-up and the synopsis of all clinical, laboratory and imaging data. Results: MRI revealed a multitude of diagnoses, including ischaemic cardiomyopathy (CM), dilated CM, myocarditis, Takotsubo CM, hypertensive heart disease, hypertrophic CM, cardiac amyloidosis and non-compaction CM. MRI-based diagnoses were the same as the final reference diagnoses in 113/125 patients (90%), with the two diagnoses differing in only 12/125 patients. In two patients, no final diagnosis could be established. Conclusion: CMR performed early after the onset of symptoms revealed a broad spectrum of diseases. CMR delivered a correct final diagnosis in 90% of patients with acute chest pain, elevated cardiac enzymes and a negative coronary angiogram. Advances in knowledge: Diagnosing patients with acute coronary syndrome but unobstructed coronary arteries remains a challenge for cardiologists. CMR performed early after catheterization reveals a broad spectrum of diseases with only a simple and quick examination protocol, and there is a high concordance between MRI-based diagnoses and final reference diagnoses.

10.1259/bjr.20150025 Published in issue 88(1049) 17

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Commentary

Return of the pulmonary nodule: the radiologist's key role in implementing the 2015 BTS guidelines on the investigation and management of pulmonary nodules Richard N J Graham, David R Baldwin, Matthew E J Callister and Fergus V Gleeson The British Thoracic Society has published new comprehensive guidelines for the management of pulmonary nodules. These guidelines are significantly different from those previously published, as they use two malignancy prediction calculators to better characterize the risk of malignancy. There are recommendations for a higher nodule size threshold for follow-up (≥5 mm or ≥80 mm3) and a reduction of the follow-up period to 1 year for solid pulmonary nodules; both of these will reduce the number of follow-up CT scans. PET-CT plays a crucial role in characterization also, with an ordinal scale being recommended for reporting. Radiologists will be the key in implementing these guidelines, and routine use of volumetric image-analysis software will be required to manage patients with pulmonary nodules correctly.

10.1259/bjr.20150776

Published in issue 89(1059) birpublications.org/bjr

Full Paper

Variations in CT determination of target volume with active breath co-ordinate in radiotherapy for postoperative gastric cancer Gui-Chao Li, Zhen Zhang, Xue-Jun Ma, Xiao-Li Yu, Wei-Gang Hu, Jia-Zhou Wang, Qi-Wen Li, Li-Ping Liang, Li-Jun Shen, Hui Zhang and Ming Fan Objective: To investigate interobserver and inter-CT variations in using the active breath co-ordinate technique in the determination of clinical tumour volume (CTV) and normal organs in post-operative gastric cancer radiotherapy. Methods: Ten gastric cancer patients were enrolled in our study, and four radiation oncologists independently determined the CTVs and organs at risk based on the CT simulation data. To determine interobserver and inter-CT variation, we evaluated the maximum dimensions, derived volume and distance between the centres of mass (CMs) of the CTVs. We assessed the reliability in CTV determination among the observers by conformity index (CI). Results: The average volumes ± standard deviation (cm3) of the CTV, liver, left kidney and right kidney were 674 ± 138 (range, 332–969), 1000 ± 138 (range, 714–1320), 149 ± 13 (range, 104–183) and 141 ± 21 (range, 110–186) cm3, respectively. The average inter-CT distances between the CMs of the CTV, liver, left kidney and right kidney were 0.40, 0.56, 0.65 and 0.6 cm, respectively; the interobserver values were 0.98, 0.53, 0.16 and 0.15 cm, respectively. Conclusions: In the volume size of CTV for post-operative gastric cancer, there were significant variations among multiple observers, whereas there was no variation between different CTs. The slices in which variations more likely occur were the slices of the lower verge of the hilum of the spleen and porta hepatis, then the paraoesophageal lymph nodes region and abdominal aorta, and the inferior vena cava, and the variation in the craniocaudal orientation from the interobserver was more predominant than that from inter-CT. Advances in knowledge: First, this is the first study to evaluate the interobserver and inter-CT variations in the determination of the CTV and normal organs in gastric cancer with the use of the active breath co-ordinate technique. Second, we analysed the region where variations most likely occur. Third, we investigated the influence of interobserver variation on the dose distribution. Published in issue 89(1058)

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Full Paper

Whole-body CT-based imaging algorithm for multiple trauma patients: radiation dose and time to diagnosis S Gordic, H Alkadhi, S Hodel, H-P Simmen, M Brueesch, T Frauenfelder, G Wanner and K Sprengel Objective: To determine the number of imaging examinations, radiation dose and the time to complete trauma-related imaging in multiple trauma patients before and after introduction of whole-body CT (WBCT) into early trauma care. Methods: 120 consecutive patients before and 120 patients after introduction of WBCT into the trauma algorithm of the University Hospital Zurich were compared regarding the number and type of CT, radiography, focused assessment with sonography for trauma (FAST), additional CT examinations (defined as CT of the same body regions after radiography and/or FAST) and the time to complete trauma-related imaging. Results: In the WBCT cohort, significantly more patients underwent CT of the head, neck, chest and abdomen (p < 0.001) than in the non-WBCT cohort, whereas the number of radiographic examinations of the cervical spine, chest and pelvis and of FAST examinations were significantly lower (p < 0.001). There were no significant differences between cohorts regarding the number of radiographic examinations of the upper (p = 0.56) and lower extremities (p = 0.30). We found significantly higher effective doses in the WBCT (29.5 mSv) than in the non-WBCT cohort (15.9 mSv; p < 0.001), but fewer additional CT examinations for completing the work-up were needed in the WBCT cohort (p < 0.001). The time to complete trauma-related imaging was significantly shorter in the WBCT (12 min) than in the non-WBCT cohort (75 min; p < 0.001). Conclusion: Including WBCT in the initial work-up of trauma patients results in higher radiation doses, but fewer additional CT examinations are needed, and the time for completing trauma-related imaging is shorter. Advances in knowledge: WBCT in trauma patients is associated with a high radiation dose of 29.5 mSv.

10.1259/bjr.20140616 Published in issue 88(1047) birpublications.org/bjr

Short communication

Utility of relative and absolute measures of mammographic density vs clinical risk factors in evaluating breast cancer risk at time of screening mammography Mohamed Abdolell, Kaitlyn M Tsuruda, Christopher B Lightfoot, Jennifer I Payne, Judy S Caines and Sian E Iles Objective: Various clinical risk factors, including high breast density, have been shown to be associated with breast cancer. The utility of using relative and absolute area-based breast density-related measures was evaluated as an alternative to clinical risk factors in cancer risk assessment at the time of screening mammography. Methods: Contralateral mediolateral oblique digital mammography images from 392 females with unilateral breast cancer and 817 age-matched controls were analysed. Information on clinical risk factors was obtained from the provincial breast-imaging information system. Breast density-related measures were assessed using a fully automated breast density measurement software. Multivariable logistic regression was conducted, and area under the receiver-operating characteristic (AUROC) curve was used to evaluate the performance of three cancer risk models: the first using only clinical risk factors, the second using only density-related measures and the third using both clinical risk factors and densityrelated measures. Results: The risk factor-based model generated an AUROC of 0.535, while the model including only breast density-related measures generated a significantly higher AUROC of 0.622 (p < 0.001). The third combined model generated an AUROC of 0.632 and performed significantly better than the risk factor model (p < 0.001) but not the density-related measures model (p = 0.097). Conclusion: Density-related measures from screening mammograms at the time of screen may be superior predictors of cancer compared with clinical risk factors. Advances in knowledge: Breast cancer risk models based on density-related measures alone can outperform risk models based on clinical factors. Such models may support the development of personalized breast-screening protocols.

10.1259/bjr.20150522 Published in issue 89(1059) 21

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Organizational development trajectory of a large academic radiotherapy department set up similarly to a prospective clinical trial: the MAASTRO experience M Jacobs, L Boersma, A Dekker, E Hermanns, R Houben, M Govers, F van Merode and P Lambin Objective: To simultaneously improve patient care processes and clinical research activities by starting a hypothesis-driven reorganization trajectory mimicking the rigorous methodology of a prospective clinical trial. Methods: The design of this reorganization trajectory was based on the model of a prospective trial. It consisted of (1) listing problems and analysing their potential causes, (2) defining interventions, (3) defining end points and (4) measuring the effect of the interventions (i.e. at baseline and after 1 and 2 years). The primary end point for patient care was the number of organizational root causes of incidents/near incidents; for clinical research, it was the number of patients in trials. There were several secondary end points. We analysed the data using two sample z-tests, χ 2 test, a Mann–Whitney U test and the one-way analysis of variance with Bonferroni correction. Results: The number of organizational root causes was reduced by 27% (p < 0.001). There was no effect on the percentage of patients included in trials. Conclusion: The reorganizational trajectory was successful for the primary end point of patient care and had no effect on clinical research. Some confounding events hampered our ability to draw strong conclusions. Nevertheless, the transparency of this approach can give medical professionals more confidence in moving forward with other organizational changes in the same way. Advances in knowledge: This article is novel because managerial interventions were set up similarly to a prospective clinical trial. This study is the first of its kind in radiotherapy, and this approach can contribute to discussions about the effectiveness of managerial interventions.

10.1259/bjr.20140559 Published in issue 88(1049) birpublications.org/bjr

Full Paper

An online open-source tool for automated quantification of liver and myocardial iron concentrations by T2* magnetic resonance imaging K-A Git, L A B Fioravante and J L Fernandes Objective: To assess whether an online open-source tool would provide accurate calculations of T2* values for iron concentrations in the liver and heart compared with a standard reference software. Methods: An online open-source tool, written in pure HTML5/Javascript, was tested in 50 patients (age 26.0 ± 18.9 years, 46% males) who underwent T2* MRI of the liver and heart for iron overload assessment as part of their routine workup. Automated truncation correction was the default with optional manual adjustment provided if needed. The results were compared against a standard reference measurement using commercial software with manual truncation (CVI42® v. 5.1; Circle Cardiovascular Imaging; Calgary, AB). Results: The mean liver T2* values calculated with the automated tool was 4.3 ms [95% confidence interval (CI) 3.1 to 5.5 ms] vs 4.26 ms using the reference software (95% CI 3.1 to 5.4 ms) without any significant differences (p = 0.71). In the liver, the mean difference was 0.036 ms (95% CI −0.1609 to 0.2329 ms) with a regression correlation coefficient of 0.97. For the heart, the automated T2* value was 26.0 ms (95% CI 22.9 to 29.0 ms) vs 25.3 ms (95% CI 22.3 to 28.3 ms), p = 0.28. The mean difference was 0.72 ms (95% CI 0.08191 to 1.3621 ms) with a correlation coefficient of 0.96. Conclusion: The automated online tool provides similar T2* values for the liver and myocardial iron concentrations as compared with a standard reference software. Advances in knowledge: The online program provides an open-source tool for the calculation of T2* values, incorporating an automated correction algorithm in a simple and easy-to-use interface.

10.1259/bjr.20150269

Published in issue 88(1053) 23

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Short communication

X-ray phase contrast tomography; proof of principle for post-mortem imaging Anna Zamir, Owen J Arthurs, Charlotte K Hagen, Paul C Diemoz, Thierry Brochard, Alberto Bravin, Neil J Sebire and Alessandro Olivo Objective: To demonstrate the feasibility of using X-ray phase-contrast tomography to assess internal organs in a post-mortem piglet model, as a possible noninvasive imaging autopsy technique. Methods: Tomographic images of a new-born piglet were obtained using a freespace propagation X-ray phase-contrast imaging setup at a synchrotron (European Synchrotron Radiation Facility, Grenoble, France). A monochromatic X-ray beam (52 keV) was used in combination with a detector pixel size of 46 × 46 m2. A phase-retrieval algorithm was applied to all projections, which were then reconstructed into tomograms using the filtered-back projection algorithm. Images were assessed for diagnostic quality. Results: Images obtained with the free-space propagation setup presented high soft-tissue contrast and sufficient resolution for resolving organ structure. All of the main body organs (heart, lungs, kidneys, liver and intestines) were easily identified and adequately visualized. In addition, grey/white matter differentiation in the cerebellum while still contained within the skull was shown. Conclusion: The feasibility of using X-ray phase-contrast tomography as a postmortem imaging technique in an animal model has been demonstrated. Future studies will focus on translating this experiment to a laboratory-based setup. Advances in knowledge: Appropriate image processing and analysis enable the simultaneous visualization of both soft- and hard-tissue structures in X-ray phasecontrast images of a complex, thick sample.

10.1259/bjr.20150565

Published in issue 89(1058) birpublications.org/bjr

Figure 2 24

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British Institute of Radiology news Looking back, leaping forward The British Institute of Radiology (BIR) was the world’s first radiological society and is proud of its long tradition of welcoming members from all professions including radiologists, radiographers, physicists and oncologists. Our webinar programme continues to grow and thousands of professionals have tuned in to view them live or on demand. Do take a look at our wide-ranging programme, which can also be streamed so you can all view, learn and debate together as a team. If you missed one of our in-person events, members can view again online. Just log in to ‘MyBIR’, our new members’ portal. This year, we struck an alliance with the American Roentgen Ray Society (ARRS) when we became a member of their Global Partner Scheme. This offers BIR trainee members free membership of ARRS, while more senior members can join at a reduced rate. Finally, as the world of radiology (and the BIR!) take giant leaps forward, take a moment to wonder at those historic milestones which enable scientists of today to deliver extraordinary treatments and diagnoses never dreamt of by the founders of the BIR. Visit the history section on our website, which reflects the role the BIR and our historic journal, BJR, played in this extraordinary journey. Jacqueline Fowler Chief Executive, The British Institute of Radiology

BIR has launched a new scheme to BIR sets standards The ensure that your educational event or training course meets a strict set of standards estabwith “BIR Approved” lished and approved by the BIR’s accreditation committee. The criteria for setting the standard relate to content, learning outcomes, scheme teaching methods, and experience and skills of the presenters to deliver the content. This ensures that processes are in place to seek feedback on quality and educational value. These standards apply to all internal BIR educational activities and are now offered to external organisations who would also wish to seek BIR approval of their educational activities. Find out more at www.bir.org.uk

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The BIR reaches out across the Atlantic We are pleased to announce that the BIR has joined the American Roentgen Ray Society Global Partner Scheme, which offers special rate membership for our members and completely free membership for all BIR trainees. BIR members also benefit from access to free monthly articles in the American Journal of Radiology (AJR). We are delighted to be part of this initiative and look forward to collaborating with our latest international partner. Left to right: Jonathan Lewin, MD, President of ARRS and Dr David Wilson, President of the BIR.

Free human anatomy you need medically accurate images for your software Do presentations? Would detailed 3D illustrations help you with your revision? All BIR members have FREE access to anatomy.tv by Primal Pictures. Use this renowned anatomy software to teach, learn and practise. Ideal for all clinicians, radiographers, lecturers and students. Log in to MyBIR and try it out today!

CPD accredited events in the UK Our educational programme has a diverse range of one-day, evening events, practical â&#x20AC;&#x153;hands-onâ&#x20AC;? workshops and longer courses addressing a wide range of topics in radiology, radiation science and radiotherapy. Most of our events are geared to a multidisciplinary audience but we also have a programme of events aimed at trainees and refresher courses to keep you abreast of the latest developments. The BIR Annual Congress has something for everyone and offers a chance to hear international speakers and to mix with multidisciplinary peers from across the UK and beyond. Anyone can attend our educational events, and we offer special rates to BIR members. Book online at www.bir.org.uk 27

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Visit the BIR blog “Was Marie Curie’s notebook actually dangerously radioactive?”, “Should radiographers be permitted to report on X-rays?”, “Do you have a radiology disaster plan?”. These are just some of the intriguing questions posed on the BIR blog by a range of contributors from radiology professors to radiography fashion designers! Take a look and subscribe to alerts. We welcome posts from across the world. If you would like to contribute, contact communications@bir.org.uk https://blog.bir.org.uk

The pioneers of radiology So who were the radiology martyrs and what are the origins of radiotherapy? These answers and more are covered in the fascinating history section of our website, including topics on the history of radiobiology, medical physics and diagnostic imaging dating back to the origins of radiology. Test your knowledge and delve into the past. You’ll be surprised at what a big part our very own journal BJR played in the origins of this enthralling aspect of medical history.

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Group membership InHealth, a corporate member of the BIR, have provided membership for all their radiography staff. Many universities, private hospitals and multidisciplinary departments have also signed up for reduced rate membership for teams of five people or more. To join as a group, contact membership@bir.org.uk Left to right: Wendy Wilkinson, Director of Radiography Services, InHealth and Jacqueline Fowler, CEO BIR

The BIR Jobs board: for your next move If you are job hunting then make the BIR Jobs Board the place you look first. You will find radiology, radiography and physicist posts as well as managerial roles. You can search for relevant jobs and set a job alert to be notified when a job matching your skills is posted. Get noticed by uploading your CV so employers can find you. We offer special rates for BIR members. Contact advertising@bir.org.uk

Online education on demand It’s not always possible to get to one of our educational events, especially if you have a busy diary, live in a remote area or are an international member. That’s why we’ve filmed many of our key lectures and made them available to view, free of charge, in the members’ area of our website. To access, simply log in to MyBIR.

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Across 4. Type of CT where signal-receiving elements are in a two-dimensional array of as opposed to linear array. [13] 13. PET in full [8,8,10] 15. Discovered X-rays (lastname) [7] Down 1. Method of repeated algorithms used to reconstruct 2D and 3D images [9,14] 2. Technique used to visualize the inside, of blood vessels and organs of the body. [11] 3. Inventor of CT (lastname) [9] 5. For example Iodine-123, Thallium-201, Technetium-99m [12] 6. Typically large-scale method of identifying those with increased risk of a particular condition [9] 7. Dosimetry verification tool, used in QA. Or ghost. [7] 8. The effect describing a change in frequency of a wave for an observer moving relative to its source. [7] 9. Unit of measurement of the strength of the magnetic field [5] 10. The only person to win Nobel Prizes in multiple sciences [5,5] 11. Radiation treatment where total dose is divided into large doses and given once a day or less often. [16] 12. Line joining the points of equal Percentage Depth Dose [7,5] 14. Agent which makes tumor cells more susceptible to the effects of radiation therapy [15]

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Find as many words as you can All words must have at least three letters, use the letters only once and contain the letter in the centre. Can you find the 12 letter word?

____________

R I

G Y S

Answers on page 32

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BJR|case reports does not charge fees to submit a manuscript. An article processing charge (APC) is only incurred after a manuscript has been peer-reviewed and accepted for publication. All published articles are free to read under an open access CC BY licence. Subject areas covered All systems and modalities of radiology, medical physics, nuclear medicine and radiotherapy. Preparing your submission BJR|case reports publishes case reports, case reviews, technical notes and letters to the editor. For more information including: Full international editorial board Author guidelines www.birpublications.org/bjrcr For any questions regarding submissions and peer-review: bjrcroffice@bir.org.uk

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Rigorous peer review | Rapid publication | Open access Answers Crossword: 1. Iterative reconstruction, 2. Angiography, 3. Hounsfield, 4. Multidetector, Phantom, 5. Radionuclide, 6. Screening, 7. Phantom, 8. Doppler, 9. Tesla, 10. Marie Curie, 11. Hypofractionated, 12. Isodose curve, 13. Positron Emission Tomography, 14. Radiosensitiser, 15. Rontgen. Word wheel: Scintigraphy

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