BJR News February 2011

THE NEWS MAGAZINE FROM THE BRITISH INSTITUTE OF RADIOLOGY

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

FEBRUARY 2011 www.bir.org.uk

Stereotactic body radiation therapy (SBRT) is a technique where high doses

of radiation are precisely delivered from many directions to a focused

target. This results in an ablative treatment with curative intent and spares

surrounding critical structures.

RapidArc radiotherapy technology delivers sophisticated SBRT treatments

faster than previously possible and opens up new treatment options for

your patients.

RapidArc® for SBRT. Simply Revolutionary.

Varian Medical Systems UK Ltd., Crawley, UK

Phone +44 - 1 293 601 200

www.varian.com/rapidarc [email protected]

contentswww.bir.org.uk

1

Editors-in-Chief: Dr Simon Blease, Mrs Liz Hunt

Managing Editor: Sherry Dixon

Production Editor: Jenny Rooke

Contributing Editors: Tina Giddings, Dr Adrian Thomas

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).

ISSN 2044-5113

EDiTORiAL Welcome to BJR News

REPORT ON REcENT BiR EVENTS So you think you know IGRT? Management of adult central nervous system tumours

BiR EVENTS cALENDAR Forthcoming events from the BIR scientific programme

cOMMuNiTy NEWS News from the radiology and allied sciences community

iDEA WATcH Fractionation in radiotherapy: an idea whose time has gone?

WHAT’S ONLiNE Table of contents from The British Journal of Radiology volume 84 number 997 and 998

cASE Of THE MONTH A case of chronic knee pain and swelling

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

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

REViEW ARTicLE Imaging in bariatric surgery: service set-up, post-operative anatomy and complications

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

BiR NEWS Updates from BIR projects and committees

HiSTORy Of RADiOLOGy Another Curie centenary and a remarkable wrist watch

BiR PRESiDENT’S cOLuMN

BOOK REViEWS

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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24 25 30 41

49 5051

in this issue

NEWS

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NEWSISSUE 1 FEbRUARy 2011

Stereotactic body radiation therapy (SBRT) is a technique where high doses

of radiation are precisely delivered from many directions to a focused

target. This results in an ablative treatment with curative intent and spares

surrounding critical structures.

RapidArc radiotherapy technology delivers sophisticated SBRT treatments

faster than previously possible and opens up new treatment options for

your patients.

RapidArc® for SBRT. Simply Revolutionary.

Varian Medical Systems UK Ltd., Crawley, UK

Phone +44 - 1 293 601 200

www.varian.com/rapidarc [email protected]

BiR infoRmation www.bir.org.uk

2 ISSUE 1 FEbRUARy 2011NEWS

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. Chair-men of the BIR’s Scientific Committees attend meetings as observers.

OfficersPresident Dr S G Davies Vice President Prof A JonesHonorary Treasurer Mr J GunaratnamHonorary Secretary Dr S BleaseHonorary Secretary Mrs E HuntHonorary Editor Prof R DaleHonorary Editor Dr J Phillips-Hughes

Ordinary Members of councilDr D Morgan Dr A J PearsonDr P RileyDr S TaylorDr R ChowdhuryMr C McCaffreyMrs N J SykesDr D SuttonDr A ReillyMs E Morris

Scientific committeesThe Institute’s Scientific Committees meet regularly and have the impor-tant 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.

committee chairpersonClinical Imaging Committee Dr N StricklandHealth Informatics Committee Mrs E HuntIHE-UK Medical Imaging and Radiation Oncology Committee Dr D RobinsonIndustry Committee Mrs E BeckmannMagnetic Resonance CommitteeProfessor D LomasNuclear Medicine and Molecular Imaging Committee Dr R GanatraOncology Committee Dr C KellyRadiation and Cancer Biology Committee Dr K WilliamsRadiation Physics and Dosimetry Committee Professor A W BeavisRadiation Protection Committee Dr P RileyTrainee Committee Dr R Chowdhury

Regional committee chairpersonEast of England Committee Dr T C SeeNorth of England Committee Dr K IrionSouth West Committee Ms N SykesScotland Committee Dr A PearsonWales Committee Dr G TudorWessex Committee Dr K Johnson

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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

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3NEWSISSUE 1 FEbRUARy 2011

Welcome to

NEWSSince 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 commu-nity. 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 profes-sionals 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 devel-opments 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

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), and read Erika Denton’s update on UKRC 2011 (p46). Future plans for the BIR can be found in Stephen Davies’ President’s column, including an account of his first 100 days in office (p50).

We hope that you will enjoy this issue, and all the others to come this year. To send us your feedback, e-mail [email protected] 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 publi-cations 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 experi-ence the new BJR online.

Liz Hunt and Simon Blease BJR News Editors-in-chief

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

Cancer risks from diagnostic radioxlogy

BIR News update

Case of the Month: A calcified conundrum

Commentary: 21st L H Gray Conference

A regional audit of kilovoltage X-rays

A single centre approach ISSN 2044-5113

THE NEWS MAGAZINE FROM THE BRITISH INSTITUTE OF RADIOLOGY FEBRUARY 2011 www.bir.org.ukNE

WS

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.

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

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Medical imaging lies at the heart of advanced radiotherapy treatment tech-niques. With increasing availability of networked radiotherapy management systems, PACS and access to newer imaging modalities, opportunities for multimodality image fusion are becom-ing 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 multidisci-plinary 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 pres-entation covering pre-clinical perspectives from Yvonne Rimmer, of Addenbrooke’s Hospital, outlining the clinical rationale for using imaging to support advanced radio-therapy. 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 implemen-tation 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 devel-opment, while Helen Taylor, of the Royal

Marsden Hospital, discussed her experi-ence of developing advanced cone beam CT (CBCT) competencies as part of the imple-mentation 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 diag-nostic 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 veri-fication 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 eval-uation 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 intro-duced 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 essen-tial 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.

RepoRt: GettinG to knoW iGRtwww.bir.org.uk

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Recent BiR events

Getting to know IGRT

Andrew Reilly and the BiR’s Radiation Physics and Dosimetry committee

Andrew Reilly, David Platten and Andy Beavis

ISSUE 1 FEbRUARy 2011NEWS

RepoRt: LeaRninG to manaGe cns tumouRs www.bir.org.uk

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Learning to manage CNS tumours

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 prac-tice 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 modu-lated 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 demon-strated significant dose reductions to critical structures. Additionally, the radi-ographers 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 imple-ment an IMRT technique as the standard of care for CSA.

The proffered papers yielded data from some of the largest single centre

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

managing adult medulloblastoma. An excellent review of the current literature was completed with the recommenda-tions that have been recently published for consultation by the British Neuro-Oncology 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 prac-tical 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

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

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 metas-tases 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

This day covered two quite different topics, but highlighted areas where neuro-oncology practice is changing and developing

Kate Burton and Sarah Jefferies

foRthcominG eventswww.bir.org.uk

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

wwwevents caLenDaR 2011

events booking nowvisit www.bir.org.uk/membersarea/multievents

upcoming in february and march:

contrast Study Day 15 April 2011 Post Graduate Centre, Central Manchester TrustNow 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.

London cardiac cT Level ii Training course8-11 February 2011 BIR, London

Expanding the uK iMRT Service23 February 2011 BIR, London

Scientists in Training25 February 2011 BIR, London

MR Angiography18 March 2011, Crowne Plaza Hotel, Nottingham

MRi and Brain Biomarkers: Autism and Beyond24 March 2011, London

Research Governance & Radiation - Negotiating the Regulatory Maze29 March 2011, BIR, London

BiR Welsh Branch Evening Seminar - Pearls in Neuroradiology for the General Radiologist29 March 2011, Princess of Wales Hospital, Bridgend

BiR President’s conference: cardiac imaging19-20 May 2011 The Wellcome Collection Conference Centre, LondonA 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.

iRMER update12 July 2011 BIR, LondonThis 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.

apRiL maY JuLY


communitY neWs

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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 scan-ners, computed radiography readers and so on, from vendors such as Toshiba, Philips and General Electric to be stored and dis-played 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 propri-etary 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 expen-sive 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

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 incor-porated 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 comprehen-sive 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 docu-ments. 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 elec-tronic 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 infor-mation between departments within the

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 commu-nity 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. Compli-ance 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.

imaging: the it requirements of the future

Dr Neelam Dugar, chairman of the RcR imaging informatics Group


communitY neWs

Adoption of XDS as a standard is crucial to the future deployment of PACS

communitY neWswww.bir.org.uk

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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 Radiog-raphers 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 (incor-porating 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 stand-ards are developmental and provide a “fresh look” at the imaging department. As a complete service analysis and re-evalu-ation, 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 inde-pendent healthcare provider for the future we face many annual returns, key perfor-mance 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

Cobalt: the first ISAS accredited service and confi-dence for care Quality commision compliance!


communitY neWs

communitY neWs www.bir.org.uk

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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 ser-vices to district general hospitals should be based at cancer centres”. Furthermore, the working party soundly condemned any organisation of satellite radiother-apy 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-satel-lite 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, technolog-ical and organisational. The timing and weight exerted by each of these forces on the service varies. However, they have consistently posed a challenge to health-care 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 under-capacity issue. The impotency of this model stems from a number of reasons. First, the space constraints of existing

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.

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 chemo-therapy 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 provisionA 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 distri-bution 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 radio-therapy infrastructure shows that inequity still remains a major issue for NHS radi-otherapy services. The RCR recommend 6 linacs per million of population.

Decentralising NHS radiotherapy services


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


11

impact of information technologyRadiotherapy 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 inno-vations 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 diag-nostic 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 radia-tion 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 equip-ment within radiotherapy was due to the absence of any internationally agreed computer communication standard among medical imaging and radiotherapy equip-ment manufacturers that would facilitate the flow and exchange of information between the equipment. In other words,

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 interop-erability 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 communi-cation of medical images. The approved digital imaging and communications in medicine (DICOM) version 1.0 was super-seded by version 2.0 in 1988, and the current version 3.0 was approved in 1993.

The compound PACS and DICOM-radiotherapy protocols and standards have created a digital environment in radi-otherapy. 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 radiotherapy-specific information objects definitions (IOD), the latter highly important for radiotherapy processes. The exten-sion in 1997 consisted of four DICOM objects including: radiotherapy image, radiotherapy structure set, radio-therapy plan and radiotherapy dose (DICOM, 1997). In 1999, three addi-tional “record keeping” IODs were

created: radiotherapy beams treatment record, radiotherapy brachytherapy treatment record and radiotherapy treatment summary record. These DICOM-radiotherapy extensions facili-tated 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 inter-face capabilities coupled with advances in telecommunication facilitated the collaboration between different radio-therapy centres.

The advent of information technology innovations affected fundamental radio-therapy work processes by transforming many clinical practices and ultimately re-engineering the workflow in radio-therapy 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: pre-treatment, planning and treatment. These sections have been transformed by the

•

•

•

•

1st consultation & consenting

Conventional Stimulation (CS)

CT Scanning

Plan Verification on CS

Pretreatment

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Data input on TPS

Produce TP

Carry necessary checks

Plan sent to CS

Planning

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Data input of machine parameters (Full course or Daily)

1st day machine Check X-ray films

Treatment

A typical radiotherapy workflow during the early 1990s

Hard copy Environment (X-ray/Documents)

TPS: Treatment Planning SystemcT: computed Tomography



13

advancement in information technology and telecommunication.

Economic evaluationIn recent years, a number of studies

have been carried out to evaluate the economical benefit of different radio-therapy 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 super-visory 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 popu-lations when compared with the H&S.

The road ahead 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 over-capacity 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 radio-therapy services.

SIMULATOR

RTTPSPHYSICS

PLANCHECKS

PHYSICSPLANCHECKS

DAILY LINAC TREATMENT

PLANNINGCHECKS

RADIOGRAPHERS CHECKS & DATA

ENTRY

LINAC1ST DAYPORTALFILMS

WEEKLY TX CARDCHECKS

A typical radiotherapy workflow in the early 1990s

Pre-treatment Process Planning Process

David Shahata MSc BSc, imperial college London. With thanks to Dr Benita cox

Treatment Process

A typical radiotherapy workflow in 2010 indicating the impact of radiotherapy-PAcS and DicOM-radiotherapy


SIMULATOR

RTTPSPHYSICS

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PHYSICSPLANCHECKS


PLANNINGCHECKS


ENTRY



SIMULATOR

RTTPSPHYSICS

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PHYSICSPLANCHECKS


PLANNINGCHECKS


ENTRY



SIMULATOR

RTTPSPHYSICS

PLANCHECKS

PHYSICSPLANCHECKS


PLANNINGCHECKS


ENTRY



RTTPS

DAILY LINAC

TREATMENT

CT

PHYSICS PLAN

CHECKS


ENTRY

PHYSICS PLAN

CHECKS

WEEKLY EPI & IGRT

VIRTUAL SIMULATION

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,

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15

Why do we fractionate?Early X-ray equipment was too unre-liable to be trusted to deliver single treatments at high-doses and, subse-quently, a biological rational for the use of multiple low-does treatment was developed based on differential capaci-ties for repair in tumours and normal tissues. Treatment planning techniques of the 20th century meant that to irradi-ate a tumour volume homogeneously, an appreciable volume of normal tissue had to be irradiated. Fractionation selec-tively 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 radi-ation therapy / image guided radiation therapy, tomotherapy, Gamma Knife, stereotactic body radiation therapy) mean that we can now reliably deliver homogenous doses of radiation to irreg-ularly 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 cultureAnything other than conventional

fractionation is regarded with deep suspicion - even when it has been demonstrated to be better than conven-tional 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 prepa-ration. 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 knowledgeThe 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

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?

iDea Watch www.bir.org.uk

16 ISSUE 1 FEbRUARy 2011NEWS

in influencing the response of living tissues both locally and at a distance. These include: effects on gene expres-sion; 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 radi-ation 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; func-tional imaging techniques (PET/CT, fMRI) that can provide early evidence of the cellular and metabolic response to radiation. One of the unforeseen conse-quences of the 9/11 attacks has been an increase in funding for radiation biology research in the USA. Much of the infor-mation coming out of these programmes is of direct relevance to treatment with large single doses of radiation.

clinical researchUltimately, any ideas and hypoth-

eses 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 distribu-tions are better, therefore, the clinical results must be better”. I would argue that we should apply Chalmers’ prin-ciple of randomising from the first patient treated, and that all patients treated with 21st century hypofraction-

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.

What might we achieve?If we adopt this approach to frac-

tionation 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 radio-sensitisers 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

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 indi-vidual patient’s tumour. We could use serum or urinary markers of radiation response (e.g. proteomic patterns, meas-uring 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 radia-tion 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

in the onLine issue of BJRwww.bir.org.uk

17

featured articles:

highlighted articles:

What’s onLine: bjr.birjournals.org

commentaRY

DOi: 10.1259/bjr/33198274

P Price

The launch of the first uK charity devoted to radiotherapy: AcORRN – Action Radiotherapy

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

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

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

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The corpus callosum: white matter or terra incognita

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

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Anti-tumour effects of transcatheter arterial embolisation administered in combination with thalidomide in a rabbit VX2 liver tumour model A Nitta-Seko, N Nitta, A Sonoda, H Otani, K Tsuchiya, S Ohta, M Takahashi & K Murata

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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

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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

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The role of somatostatin analogues in the treatment of advanced malignant thymomas: case report and review of the literature L Pettit & A El-Modir

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

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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



in the onLine issue of BJR www.bir.org.uk

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all other articles from the January 2011 issuefuLL papeRs

correlation between mammographic and sonographic findings and prognostic factors in patients with node-negative invasive breast cancer H J Shin, H H Kim, M O Huh, M J Kim, A Yi, H Kim, B H Son & S H Ahn

DOi: 10.1259/bjr/92960562

Diffusion-weighted magnetic resonance imaging for monitoring prostate cancer progression in patients managed by active surveillanceV A Morgan, S F Riches, K Thomas, N Vanas, C Parker, S Giles & N M Desouza

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

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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

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intensity-modulated radiotherapy increases dose to the brachial plexus compared with conventional radiotherapy for head and neck cancerA 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 proceduresP Efstathopoulos, I Pantos, M Andreou, A Gkatzis, E Carinou, C Koukorava, N L Kelekis & E Brountzos

DOi: 10.1259/bjr/83222759

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clinical presentations and imaging findings of neuroblastoma beyond abdominal mass and a review of imaging algorithm C M Chu, D D Rasalkar, Y J Hu, F W T Cheng, C K Li & W C W Chu

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case of the month

A case of chronic knee pain and swelling D Das, D F Sallomi & D C Howlett

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

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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

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

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

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eDitoRiaL

BJR news: a new venture for 2011Jane Phillips-Hughes and R Dale

DOi: 10.1259/bjr/26244588


in the onLine issue of BJRwww.bir.org.uk

19

all other articles from the february 2011 issueshoRt communication

use of the triaxial microcatheter method in super selective transcatheter arterial chemoembolisation for hepatocellular carcinoma M Shimohira, H Ogino, T Kawai, A Kushita, M Watanabe, T Kawaguchi, K Kurono, & Y Shibamoto

DOi: 10.1259/bjr/26974088

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imaging in bariatric surgery: service set-up, post-operative anatomy and complications S Shah, V Shah, A R Ahmed & D M Blunt

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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

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

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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

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

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Lymphocoele of the thoracic duct: a cause of left supraclavicular fossaC E Offiah & S Twigg

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

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Left ventricular true and false aneurysms identified by cardiovascular magnetic resonanceS Gill, D J Rakhit, S K Ohri & S P Harden

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case of the month www.bir.org.uk

20

a case of chronic knee pain and swellingA 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.); and3) synovial disorders (e.g. non-specific synovitis, pigmented vilonodular synovitis (PVNS), synovial osteochon-dromatosis, synovial haemangioma etc.).

Synovial fluid aspiration was unre-markable in terms of bacteriology and crystal microscopy; plasma white cell count, rheumatoid factor assay and auto-antibody screen were all negative. However, serum erythrocyte sedimenta-tion 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 non-steroidal anti-inflammatory drugs, and a single dose of intra-articular steroid.

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?

DiagnosisMRI 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 frond-like 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.

DiscussionLipoma arborescens is a rare benign

synovial disorder caused by the prolifera-tion 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 supra-patellar pouch of the knee. There are infrequent reports of lipoma arborescens presenting with bilateral and polyartic-ular disease, and isolated cases occurring within the hip, shoulder, ankle, within the extra-articular synovium of the subacro-mial 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-

figure 1. Lateral radiograph of the left knee demonstrating suprapatellar soft-tissue 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).



case of the monthwww.bir.org.uk

21

a case of chronic knee pain and swelling

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 non-specific 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 morpho-logical 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 demon-strate contrast enhancement; however, the presence of synovitis can cause post-gadolinium 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 distin-guished 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 iso-intensity of the entire lesion to fat that is required for diagnosis.

Lipoma arborescens can be effectively treated with synovectomy and the proce-dure can be performed either as an open operation or arthroscopically [4]. Non-surgical 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

Download the full article and references: DOi: 10.1259/bjr/24552351

www

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).


commentaRY www.bir.org.uk

22

The launch of the first UK charity devoted to radiotherapy: ACORRN – Action RadiotherapyOn 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 repre-sentatives from all the groups devoted to radiotherapy development includ-ing: the British Institute of Radiology (BIR), Institute of Physics and Engi-neering 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 develop-ment of radiotherapy in the uK

Radiotherapy is effective and inex-pensive compared with some cancer treatments and second only to surgery in its potential to cure cancer. Even small improvements in how radio-therapy 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

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 (inten-sity 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

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 treat-ment, and yet the demand for radiotherapy services is predicted to increase by 91% from the 2007 levels by the year 2016 [5].

Response of governmentThe 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

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 “catch-up” 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

for Radiation Oncology and Biology in Oxford, supporting the set-up of ACORRN and more recently setting up the NCRI Clinical and Transla-tional 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-ener-gising the radiotherapy community.

The UK radiotherapy workforce has worked well together in the past. However, there are still gaps and defi-ciencies 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

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.

commentaRY: PAT PRICE


commentaRYwww.bir.org.uk

23

The launch of the first UK charity devoted to radiotherapy: ACORRN – Action Radiotherapyneeds 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 infra-structure in the UK by CRUK and the Engineering and Physical Sciences Research Council (EPSRC).

How can AcORRN help?A charity dedicated to raising funds

for radiotherapy research and develop-ment is long overdue and has enormous potential to support important explora-tory 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-effec-tively, 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 radi-otherapy 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

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 representa-tives 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 futureWe 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 radiotherapy-related research and development.

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

Download the full article and references

DOi: 10.1259/bjr/33198274www

What does ACORRN do?

•Interactiveforumswhereindividual

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.

•Educationandtrainingfortherapy

radiographers who have developed

their Research Radiographer Starter

Pack [6].

•Multidisciplinaryresearchthrough

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.

•Introducingnewdevelopments

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.


shoRt communication www.bir.org.uk

24

voxel-based diffusion tensor imaging detects pyramidal tract degeneration in primary lateral sclerosisPrimary lateral sclerosis (PLS) is an adult onset, non-hereditary degenerative disorder of the upper motor neuron related to a selec-tive loss of precentral pyramidal neurons. Ιt is characterised by progressive spinobulbar spasticity owing to pyramidal tract degen-eration, 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 direction-ality 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 degen-eration 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 compar-ison 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 resultsA 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 asym-metric 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

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).

DiscussionThe 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]. Limita-tions 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-corti-cospinal 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 corti-cospinal tract before it reached the posterior limb of the internal capsule. Without a

voxel-by-voxel analysis it would be diffi-cult 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. Degenera-tion 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.

conclusionThis report supports the potential role

for voxel-based DTI as an objective and quantitative marker for detecting and moni-toring 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

Download the full article and references DOi: 10.1259/bjr/14368804

www

figure 1. Brain regions with decreased fractional anisotropy


RevieW aRticLewww.bir.org.uk

25

imaging in bariatric surgery: service set-up, post-operative anatomy and complications

RevieW aRticLe

ObesityObesity 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 reach-ing. 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 over-weight is between £6.6 and £7.4 billion

per year. If current trends in obesity con-tinue, 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 bari-atric surgery.

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

year; the cost savings of a 1% reduc-tion 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 essen-tial component in a successful service is the provision of a diagnostic and interven-tional radiology service by well-trained radiologists and radiographers.

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

Imaging by well-trained radiologists and radiographers is a vital component in the management of patients following bariatric surgery.

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

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

aBstRactpost-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.


RevieW aRticLe www.bir.org.uk

26

Bariatric surgical proceduresThere are three main categories of

surgical procedure: restrictive proce-dures 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 malabsorp-tive approaches, although the primary mechanism of weight loss is thought to be restrictive rather than malabsorp-tive [8]. Many of the procedures are

now performed laparoscopically with the advantages of decreased recovery time and reduced number of complica-tions. 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].

Roux-en-y gastric bypass 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 verte-bral 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 oesoph-agus 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

Service set-up 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 water-

soluble 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

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

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 Radiology-

Integrated 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.



27

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

examinations are equivocal or for the evalu-ation 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 discom-fort, 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 gastroje-junal 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 disten-sion 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


RevieW aRticLe www.bir.org.uk

28

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 endoscopi-cally; 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 bandingNormal 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 adjust-able 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 anter-oposterior 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

with nocturnal reflux, vomiting and upper abdominal discomfort. Typical fluoroscopic findings include a narrowed or obstructed stoma with proximal concentric pouch dila-tation, 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 tech-nique [26–29].

Acute gastric perforation is rare, occur-ring 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 reopera-tions 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

Normal appearances following sleeve gastrectomy, schematic illustration.



29

a low incidence of approximately 0.9% [31]. Fluoroscopy demonstrates extravasa-tion 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 proce-dure 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 aban-doned 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 radiologyOne 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 bariatric-surgery patients can also be successfully managed with interventional radiology tech-niques. 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 fluid

collections. Other techniques that may be required include imaging-guided placement of jejunal feeding tubes in cases of gastroje-junal 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].

conclusionBariatric 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.

Download the full article and references DOi: 10.1259/bjr/18405029

www

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

Consider surgery for people with severe obesity if:

BMI ≥40kgm-2 or more, or 35–40kgm-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

aBstRacts


the BRitish JouRnaL of RaDioLoGY aBstRacts www.bir.org.uk

30

anti-tumour effects of transcatheter arterial embolisation administered in combination with thalidomide in a rabbit vX2 liver tumour model

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

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

Methods: 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-diphe-nyltetrazolium 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 anti-tumour effects were assessed by the

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.

Results: The viability of cells grown under hypoxic and normal conditions was not signifi-cantly 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.

Objectives: Transcatheter arterial chemoembolisation (TACE) has been widely used for inop-erable hepatocellular carcinoma (HCC). Super-selective TACE is preferable to non-selective 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 micro-catheter. 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

the triaxial microcatheter method than with previous TACE using a conven-tional microcatheter.

Results: With conventional microcatheters the level of embolisation was a lobar artery in 4 cases, segmental in 8 cases, subseg-mental 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 micro-catheter, 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

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

conclusion: The triaxial microcatheter method appears to be useful.

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

Download the full length article: DOi: 10.1259/bjr/53771502

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


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the BRitish JouRnaL of RaDioLoGY aBstRacts

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

Dose and image quality comparison between prospectively gated axial and retrospectively gated helical coronary ct angiography

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 treat-ment (progressors; n=17) compared with those who did not (non-progres-sors, 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 non-progressors. 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 non-progressors (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.

Objectives: Our aim was to compare image quality, coronary segment assessability and radia-tion 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.

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

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

for more Abstracts visit: bjr.birjournals.org

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V A Morgan, S f Riches, K Thomas, N Vanas, c Parker, S Giles & N M DesouzaMRI Unit, Royal Marsden Hospital, Sutton, Surrey


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c Hlaihel, L Boussel, H cochet, J A Roch, P coulon, Md Walker And P c DouekLouis Pradel Cardiovascular and Pneumology Hospital, Bron, France


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pre-operative evaluation of peritoneal deposits using multidetector computed tomography in ovarian cancer

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

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 contrast-enhanced MDCT of the abdomen and pelvis. All CT scans were performed on a four-slice MDCT scanner with thin-slice 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. Perito-neal deposits and thickening were noted for each of the nine segments of the abdomen and pelvis (i.e. bilateral hypo-chondria, bilateral lumbar, bilateral iliac fossa, epigastrium, umbilical region and hypogastrium) and used to determine the accuracy of MDCT in the depiction of peritoneal carcinomatosis.

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 subdi-aphragmatic region (18 cases).

conclusion: Despite the improved scanning tech-nology, 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 loca-tions in the abdomen and pelvis.

Objectives: 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.

Methods: The study protocol was approved by the local ethics committee. For stress testing, a standard high-dose dobu-tamine 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.

Results: 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 abnor-malities (WMAs), detected by sGRE and SPAMM-GRE, WMAs were detected at a lower stress level by tagging.

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

at lower stress levels compared with sGRE alone.

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


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


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the BRitish JouRnaL of RaDioLoGY aBstRactswww.bir.org.uk

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

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

Objectives: The preferential use of intensity-modulated 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.

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-

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

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

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).

Results: On mammography, non-spiculated masses with calcifications were associated with all poor prognostic factors: high histolog-ical 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 enhance-ment, calcifications in-or-out of masses and diffusely increased vascularity on sonography were associated with high histological grade and negative ER. Asso-ciated 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.

conclusion: Several sonographic and mammographic features can have a prognostic value in the subsequent treatment of patients with node-negative 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.

A M chen, W H Hall, B-Q Li, M Guiou, c Wright, M Mathai, A Dublin & J A PurdyDepartment of Radiation Oncology, University of California Davis Cancer Center, CA, USA


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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


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overstaging of cartilage invasion by multidetector ct scan for laryngeal cancer and its potential effect on the use of organ preservation with chemoradiation

occupational radiation doses to the extremities and the eyes in interventional radiology and cardiology procedures

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 carci-noma 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 path-ological 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 detec-tion of invasion through cartilage, with sensitivity being 100% and specificity 96%. For detection of any cartilage invasion (minor, major or through carti-lage 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 signifi-cant proportion of patients who were treated by total laryngectomy could have been appropriately offered organ preservation if more accurately staged at initial diagnosis.

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 proce-dures and monitored occupational dose for all laboratory personnel. Each indi-vidual 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

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 consid-erably 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). Occupa-tional 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 inter-ventionists considering the actual number of procedures performed annually

revealed that dose limits for the extremi-ties 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


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


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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.

Methods: A patient with PLS was compared with eight age-matched controls. Differ-ences in fractional anisotropy (FA) index were assessed using DTI on a voxel-by voxel basis. Results: Decreased FA was observed in the proximal part of the pyramidal tract

bilaterally, which indicated degenera-tion of the pyramidal cells.

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

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


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comparison of the helical tomotherapy against the multileaf collimator-based intensity modulated radiotherapy and 3D conformal radiation modalities in lung cancer radiotherapyObjectives: The aim of this study was to compare three dimensional (3D)-conformal radi-otherapy and the two different forms of IMRT in lung cancer radiotherapy.

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 radiobio-logical measures.

Results: The applied plan evaluation method shows the MLC-based IMRT and the HT treatment plans are almost equivalent over the clinically useful dose prescrip-tion 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 effec-tive 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.

conclusion: A radiobiological treatment plan evalu-ation can provide a closer association of the delivered treatment with the clinical outcome by taking into account the dose–response relations of the irra-diated tumours and normal tissues. The use of P-effective uniform dose diagrams can complement the tradi-tional tools of evaluation to compare and effectively evaluate different treat-ment plans.

P Mavroidis, c Shi, G A Plataniotis, M G Delichas, B costa ferreira, S Rodriguez, B K Lind & N PapanikolaouDepartment of Medical Radiation Physics, Karolinska Institute abd Stockholm University, Stockholm, Sweden


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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 adminis-tration 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 exami-nation 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

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 path-ological 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


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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 three-dimensional (3D) conformal planning vs conventional planning of pre-operative chemoradiotherapy (CRT) for locally advanced rectal cancer (LARC) on small bowel and bladder sparing and in optimising coverage of tumour target volume.

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

movement. The conventional plan was created using digitally reconstructed radiographs (DRRs). Patients were treated with a dose of 45 Gy in 25 frac-tions 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 conven-tional plan in all patients.

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.

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.

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


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

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

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.

Methods: 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, speci-ficity, positive predictive value (PPV), negative predictive value (NPV) and accuracy for the detection of breast

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.

Results: 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.

Objectives: The purpose of this study was to inves-tigate the efficacy and tolerance of an additional phosphate enema prior to non-laxative CT colonography (CTC).

Methods: 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

of the enema was assessed via question-naire. 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.

Results: 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 (exclu-sion 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-laxa-tive CTC leads to greater retained fluid reducing diagnostic confidence and is not recommended.

W Davis, P Nisbet, c Hare, P cooke & S TaylorDepartment of Imaging, University College Hospital, London, UK


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T A Heusner, S Hahn, c Jonkmanns, S Keummel, f Otterbach, M E Hamami, A R Stahl, A Bockisch, M forsting & G AntochDepartment of Diagnostic & Interventional Radiology & Neuroradiology, University Hospital Essen, University of Duisburg-Essen, Germany


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

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: We describe the spectrum of findings and the diagnostic value of MR defecog-raphy in patients referred with suspicion of dyssynergic defecation.

Methods: 48 patients (34 females, 14 males; mean age 48 years) with constipation and clin-ically suspected dyssynergic defecation underwent MR defecography. Patients were divided into patients with dyssyn-ergic defecation (n=18) and constipated patients without dyssynergic defeca-tion (control group n=30). MRIs were analysed for evacuation ability, time to initiate evacuation, time of evacu-ation, 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 defeca-tion were calculated.

Results: 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 defeca-tion of 100% (95% confidence interval (CI) 97–100%), but only a specificity of 23% (95% CI 7–40%). A lower sensi-tivity (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

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

conclusion: 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.

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 addi-tional 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 hydrone-

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 inde-pendent 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 PetersonDepartment of Radiology, Innsbruck Medical University, Innsbruck, Austria


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


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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 measure-ments 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 there-fore be necessary to make comparisons with a disease-free population matched for age and breast size.

Methods: A large number of breast glandular thick-ness measurements were analysed to investigate the statistics of breast compo-sition 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 compo-sition used in the current UK method of breast radiation dosimetry. Results: It is demonstrated that a non-linear trans-formation 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

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

c J Kotre Regional Medical Physics Departement, Freeman Hospital, Newcastle-upon-Tyne, UK


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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 I’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 coordi-nator, 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 assis-tant, 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 respec-tively 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 (edito-rial administrator). We are delighted that Hazel and Rachel have joined a team that is forging ahead with publishing innova-tions, 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 secre-tary, servicing all our committees from Council downwards.

I am delighted to have the combina-tion of wise experience and youthful energy on board to deliver an increasing range of benefits to our members. Watch this space for future developments – the right people are on the bus!

Jacqueline fowler, Chief Executive, BIR

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The innovator’s muse has been miniaturi-zation for over a century, so you might expect the research dominating radiology over the next ten years to be micro-minis-cule. You wouldn’t expect the most important innovation in radiology to be 27km long and able to fire protons at 7 tril-lion 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 indi-vidually. This allows the spectroscopic discrimination of different materials within the object, resulting in the produc-tion 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 intel-ligent techniques to determine physical property than photon radiation. CERN will herald more sophisticated tech-niques, 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,

combined with an increasingly non-irra-diating 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 sub-specialised 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 compli-cated 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 micro-biological, biochemical and histology reports from a patient momentarily super-imposed over a diagnostic imaging at the touch of a button, rather like the futuristic Philips Intellisphere. This will challenge the radiologist to maintain the biochem-ical 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 high-light pathological processes.

Of course the informatics develop-ment 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 gate-keepers to their personal online imaging bank, available to any doctor with viewing privileges anywhere in the world. A non-ionising 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 increas-ingly 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 knowl-edge and a generalist imaging approach will ensure a bright future.

BiR neWs www.bir.org.uk

42

P J N Rogers, Peninsula Deanery

The challenges facing clinical radiology over the next decade The winning essay from the Philips trainee radiologists’ award 2010


Dr Katie Johnson has been a Consult-ant 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 radi-ology.

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

BIR Business Development Coordi-

nator Lucy Nye asked Dr Johnson how she would like to see the branch devel-oped during her term as chair, to which she replied:

“I would like to continue to coor-dinate the Regional meetings for local Consultants and trainees. I would like to encourage as many non-clinical attendees as possible, particularly radiog-raphers 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

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


44

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 tech-nology 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 devel-opment 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 profession-ally 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 elec-tronically 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

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 even-tually become the first step within the NHS – timely diagnosis aids timely treat-ment and a more favourable outcome for patients. When I started working in diag-nostic 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

there are many disciplines involving prac-titioners 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 under-standing of radiology and our professions.

The opportunity to communicate with all disciplines that have an interest in radi-ology 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 profes-sional associations and colleges within the region to help educate our multidisci-plinary community and provide meetings that have a broad appeal.

South West Branch launch

Niky Sykes, Cobalt

Introducing the new Wessex Branch Chair


As members of an expert institute, we can help train, educate and provide a greater understanding of radiology.

Dr Katie Johnson, Salisbury Hospital

Katie Johnson

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image title to go here if you want.


46

In 2011, UKRC celebrates its tenth anni-versary 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, radi-ologist-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 prac-titioner 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 Interpreta-tion” respectively.• Dr Jeff Bamber from the Institute of Cancer Research will discuss “Ultra-sound Elastographic Techniques: past, present and future” in the Institute of Physics and Engineering in Medicine John Mallard Lecture.

clinical StreamsWithin 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 facili-ties 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 Resolu-tion CT, and live ultrasound demonstrations.

Advances in TechnologyThe 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 quan-titative imaging for the future, focusing on imaging biomarkers for cancer trials.

imaging informaticsIssues 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 DeliveryThe 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

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 HallThe UKRC exhibition is free to attend

and all conference delegates will receive complimentary catering. The new General Interest stream taking place in the exhi-bition 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 exhibi-tion 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 exhib-itors will also host Education on the Stands initiatives, providing short educational activ-ities 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.

plenty of opportunities at ukRc 2011

Erika Denton, UKRC President 2011

East of England

CHaIR: dR tEIk CHoon, CambRIdgE UnIvERsIty HospItals foUndatIon tRUst

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

sCotlandCHaIR: dR andREw pEaRson, boRdERs gEnERal HospItal

soUtH wEst EnglandCHaIR: nIky sykEs, Colbalt appEal fUnd

walEsCHaIR: dR gaREtH tUdoR, pRInCEss of walEs HospItal

wEssExCHaIR: dR katIE joHnson, salIsbURy dIstRICt HospItal

For more information about our branch network please visit

[email protected]

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.

BIR Branches ad half page.indd 1 28/10/2010 09:10:33


Erika Denton

BiR neWswww.bir.org.uk

multidisciplinary collaboration: training and BeyondThe 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 disci-plines. This unique approach highlights the core value of the BIR which is to create and foster relationships with all radiologically-related disciplines.

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

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

sCotlandCHaIR: dR andREw pEaRson, boRdERs gEnERal HospItal

soUtH wEst EnglandCHaIR: nIky sykEs, Colbalt appEal fUnd

walEsCHaIR: dR gaREtH tUdoR, pRInCEss of walEs HospItal

wEssExCHaIR: dR katIE joHnson, salIsbURy dIstRICt HospItal

For more information about our branch network please visit

[email protected]

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.

BIR Branches ad half page.indd 1 28/10/2010 09:10:33

The BIR Training Committee


48

As contemporary British artist Nick Veasey teams up with Foxtons to create an electri-fying 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

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 nostalgi-cally refers to the classic Mini as “one lovely piece of design”, the X-ray process illuminates the second generation’s ergo-nomic 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 compo-nents 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 two-dimensional 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.

artistic X-rays for a shocking new design

for full article see www.foxtons.co.uk

Competition

Sudoku Fun

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?

Send your answer along with your name and contact details to:[email protected] by 3 March 2011. This time there will be four lucky winners.

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 addi-tional 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.


a paGe of histoRYwww.bir.org.uk

49

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 discov-ery 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 chem-istry “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.

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 presenta-tion 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 incar-nations. 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 radia-tion-induced aplastic anaemia in 1921 at the age of 42 and the outcry

following his death resulted in the forma-tion of a

national radia-tion 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 Protec-tion Committee.

It is great that the Insti-tute has this watch and

we extend our thanks to Yvonne Beech for her kind gift.

Another Curie Centenary

A remarkable wrist watch


Dr Adrian Thomas BSc fRcP fRcR fBiR Honorary Librarian, BIR

Dr Adrian Thomas BSc fRcP fRcR fBiR Honorary Librarian, BIR


pResiDent’s coLumn www.bir.org.uk

50

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. Cur-rently 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 member-ship. 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.

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

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 commu-nity. The branches are making a really positive effort to be multiprofessional, attracting radiogra-phers and physicists in addition to radiologists.

I hope that you will have noticed a major trans-formation in our flagship publication, the British Journal of Radiology which is now exclusively online. BJR News is an exciting new publica-tion 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.

Book RevieWwww.bir.org.uk

51

Gastric cancer is second only to lung cancer in terms of worldwide cancer deaths. This book sets out the epidemi-ology 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 diag-nosed.

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

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 malig-nancy. Prevention and early detection offer the best chance of cure. Increased

physician awareness is surely part of this process, and this book is an easy-to-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.

Gastric cancer

A recent “point/counterpoint” 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 train-ing, but it highlighted this need within all professional disciplines owing to our increasing dependence on imaging within the field of radiotherapy; both pre-treat-ment 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

clinical chapters have a consistent format that discuss clinical background, diag-nosis, 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, partic-ularly 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 volu-metric imaging is now (technically) widely available, to discuss how this is beginning to help adapt radiotherapy in vivo, both geometrically and dosimetrically. Simi-larly, aspects of four dimensional imaging (both pre-treatment and on-treatment) could have been expanded upon more;

particularly as it tremendously enhances our ability to define and treat more accu-rately 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 – or the work would never get submitted for publi-cation! 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.

Radiotherapy in practice -imaging

by Richard m GoreISbN: 978-0-521513-83-8

by p hoskin and v GohISbN: 978-0-199-23132-4

Dr Susan Ryan

Mike c Kirby, consultant clinical Scientist (Radiotherapy)


www Download the full book review bjr.birjournals.org

www Download the full book review bjr.birjournals.org

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.

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.

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• Image quality: a clinical perspective

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• 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

Contents

QA2 2010 for BJR News.indd 1 03/12/2010 17:20:55

Radiation Shielding for

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Edited by D G Sutton & J R Williams

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

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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.

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BJR News February 2011

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Transcript of BJR News February 2011