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April 2011

2010 health white paper: an imaging perspective Beware the cardiac shadow! BIR cardiac imaging events in 2011 The development and implementation of TrueBeam

Management in the new NHS:

What does the future hold? ISSN 2044-5113

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in this issue 3 4 5



Radiology news


Idea Watch

13 16 18

Standing on the shoulders of giants

BIR eventS Cardiac imaging events in 2011


BIR events calendar Forthcoming events from the BIR scientific programme

News from the radiology and allied sciences community

Management in the new NHS: what does the future hold?

What’s Online Table of contents from The British Journal of Radiology volume 84 number 999 and 1000

Case of the month Beware the cardiac shadow!

Review Article The use of central venous catheters for intravenous contrast injection for CT examinations

Using the DOI system



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

The lumbar sedimentation sign: spinal MRI findings in patients with subarachnoid haemorrhage with no demonstrable intracranial aneurysm

Review Article Adult patient radiation doses from non-cardiac CT examinations: a review of published results



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BIR President’s Column

A digital object identifier (DOI) can be used to cite and link to electronic documents. A DOI is guaranteed never to change, so you can use it to link permanently to electronic documents. The DOI scheme is administered by the International DOI Foundation. Many of the world’s leading publishers have come together to build a DOI-based document linking scheme known as CrossRef.


Short Communication

Abstracts from The British Journal of Radiology volume 84 number 999 and 1000

The development and implementation of TrueBeam

BIR News Updates from BIR projects and committees

History of Radiology The plight of technical education and classic radiology books

Book review

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

ISSN 2044-5113 The British Journal of Radiology Editorial Board: Honorary Editors: Dr Jane Phillips-Hughes (Medical), Prof Roger G Dale (Scientific). Deputy Editors: Dr Daniel Birchall, Dr Nigel Hoggard, Prof Alan Jackson, Dr Simon Jackson, Dr Paul Sidhu, Dr Stuart Taylor (Diagnostic Radiology), Dr William Vennart (Physics & Technology), Prof Kevin Prise (Radiobiology), Prof Alastair Munro (Radiotherapy & Oncology).

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

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BIR information

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

The British Institute of Radiology has as its aim to bring together all the professions in radiology and allied medical and scientific disciplines to share knowledge, and educate the public, thereby improving the prevention and detection of disease and the management and treatment of patients. Particulars of membership and other information can be obtained from the General Secretary, BIR, 36 Portland Place, London WIB 1AT, and from the BIR’s website:

COUNCIL AND OFFICERS The Institute’s decision making body, its Council, has specific responsibilities concerned with the governance of the Institute and the management of its charitable activities. Council consists of Officers, Ordinary Council Members and Branch Representatives. Chairmen of the BIR’s Scientific Committees attend meetings as Observers.


Ordinary Members of Council

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

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

Scientific Committees

Committee Chairperson

Regional Committee Chairperson

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

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

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

Enquiries 2


General enquires – Corporate – Membership –

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Publications – Regional Branches – Scientific meetings – Display advertising sales –

Editorial: standing on the shoulders of giants

Standing on the shoulders of giants BJR News Editor-in-Chief, Simon Blease, reflects on meeting one of his heroes at RSNA 2010 Recently trustees of the British Institute of Radiology (BIR) have been working hard to plan a strategy to ensure the continuing success and relevance of the institute. Along with the more obvious aspirations, such as publishing and encouraging excellence, it is also clear that there is a duty and responsibility to record and preserve the history and heritage of endeavours within the radiological sciences. Adrian Thomas continues to work long and hard in this regard, but it is important that all members feel that they can contribute. Past President Stuart Green is heading up a special project to create a historical archive that will capture the achievements of the living and add to the records of the past, which Adrian is already curating. This project is being funded by donations from the demise of the Magnetic Resonance Radiologists Association (MRRA) (UK). It is hoped that one of the early subjects will be Dr Raymond Damadian, inventor of the first clinical MRI machine. This pioneer of radiology visited the BIR stand at RSNA 2010 in Chicago

I was accorded a special privilege similar to a previous generation

L-R: Dr Damadian with Simon Blease andBlease Stephen Davies at RSNA 2010 LR: Raymond Damadian, Simon and Stephen Davies

and I was there to meet him with BIR President Stephen Davies. After Stephen left to attend to his presidential duties, Dr Damadian stayed for the afternoon before his flight home. He turned out to be a fascinating individual, still fizzing with new ideas for clinical applications of his stand-up MR scanner. As I sat listening to this great mind working I realised that I was being accorded a privilege similar to a previous generation of radiologists spending individual time with Roentgen himself.

It was also a salutary reminder that the tools we use everyday, taken for granted or not, grew out of the sweat, toil and inspiration of others. We truly do stand on the shoulders of giants, whatever our specialty. If you have your own hero or know of someone whose contribution deserves recording for prosperity, please do let Stuart know. Time is passing and the BIR needs your help to ensure that these opportunities are not lost. Simon Blease, BJR News Editor-in-Chief

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Report: BIR Events in 2011


Cardiac imaging events in 2011 2011 sees the British Institute of Radiology hold a number of events related to cardiac imaging. We asked Ed Nicol from the Royal Brompton Hospital why these events are so relevant right now. Cardiac imaging has never before been such a critical component of the investigation of patients with suspected, or established, cardiovascular disease. All four major cardiovascular imaging modalities, whether long established techniques such as echocardiography or myocardial perfusion scintigraphy (MPS), or more recent techniques such as cardiovascular magnetic resonance (CMR) or cardiovascular CT (CCT), now play a central and increasingly critical role in the management of the most prevalent pathology in the western world. Increasingly the roles of radiology and cardiology practitioners are becoming

blurred in this fascinating specialty and the delivery of a high-quality service requires significant training and an understanding of both individual specialties, often most successfully delivered in a collaborative manner. For medical practitioners both the Royal College of Radiology and British Cardiac Society have recently updated their curricula in cardiovascular imaging and through their established special interest groups and affiliated groups (British Society of Echocardiography (BSE), British Nuclear Cardiac Society (BNCS), British Society of Cardiovascular Magnetic Resonance (BSCMR) and the British Society of Cardiovascular Imaging (BSCI)), each modality has a specialist society that have developed robust training guidelines, accreditation processes and competency documents to support the successful

training in each modality. Training opportunities are increasing, both for consultants and trainees and increasingly imaging fellowships are being developed both as part of in-programme specialty training programmes and via external fellowships. Training for other professional groups is well-established in some areas such as the BSE accreditation process for sonographers and within nuclear cardiology. Provision of specialist training for radiographers is also increasing as the demand for CMR and CCT in particular increase. The requirement for a highly skilled cadre of radiographers is essential for a high quality service as often the quality of images acquired by these professionals is the key to the quality of the entire service. With the publication of the recent NICE guidelines and the ageing demographic at risk from cardiovascular disease, cardiovascular imaging is likely to remain a key area for growth and expansion over the next decade and beyond. Multi-specialty and multiprofessional provision of these services is likely to be a key feature of the NHS for many years to come. BIR President’s Conference 2011

Wellcome Collection, London. The venue for the upcoming BIR President’s conference. Image courtesy of Wellcome Images.



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With cardiovascular imaging remaining such a key area for radiology practioners, the BIR President’s Conference 2011 will be held on 19-20 May at the Wellcome Collection in London and will cover all aspects of cardiac imaging, from scene setting, cardiac CT services and the integration of CT with other imaging modalities to workstation-based sessions, reporting coronary CT and the future of cardiac imaging. The event is sure to be a sell-out and we look forward to seeing you there!

Forthcoming events

event calendAr 2011

www For a full event listing, registration & availability visit:

Upcoming in April, May and July: Contrast study day 15 April 2011 Post Graduate Centre, Central Manchester Trust

BIR President’s conference: cardiac imaging

IRMER update

19-20 May 2011

BIR, London

12 July 2011

Wellcome Collection, London

Events booking now visit




Challenges for the radiographer in the digital age 22 September 2011

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

Clinical imaging of the liver 11 November 2011

BIR, London This one day meeting does exactly what it says on the tin. It will address the day-to-day trials and tribulations that radiographers face with imaging systems. It will provide the perfect informal setting to ask the experienced faculty questions and discuss the challenges faced in radiographical imaging in the 21st century.

BIR, London Delegates will leave the meeting with the knowledge to describe the key radiographic measurement methods for shoulder, elbow, wrist and hand and how to link these with orthopaedic decisionmaking.

October Breast MR October 2011 BIR, London This meeting will focus on the importance of breast MR in the medical society today. The distinguished faculty will provide plenty of time for questions and case discussions.

Oncology: head and neck imaging 07 October 2011

BIR, London Oncological symptoms and detections of the head and neck: Where do they present? What does this mean? How are they detected? These 3 questions will kick off the day and take you through the journey of head and neck tumours.

The BIR UK MRI course (incorporating the Somerset MRI course) 17-20 October 2011 BIR, London This intensive, interactive MR workshop will focus on all areas of MR imaging. It will be an essential teaching resource for radiologists and radiographers along with scientists and industry representatives wishing to learn more about clinical applications.

BIR and SCoR’s retired members day 28 October 2011

BIR, London A comprehensive imaging study day for the general radiologist. There will be sections on liver intervention, what the surgeon needs to know and latest radiology intervention techniques including SIRT and RFA. Topics include evaluation of malignant and benign incidental lesions and paediatric liver disease and the role of radiology screening in chronic liver disease.

The journey from research to publication 18 November 2011 BIR, London Listen to experts discuss the process of getting published from the research plan all the way through to final edits. This is a not to be missed opportunity and will take place in an informal setting, giving you the perfect chance to discuss your current research with an excellent faculty, handpicked by the BIR’s trainee committee.

BIR, London Join us for the 2011 joint BIR and SCoR Retired Members’ Day and enjoy a collection of interesting presentations and the opportunity to catch up with old colleagues. This meeting is open to anyone and is free to retired BIR and SCoR members.

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Community News

community news

BIR wins grant to provide cardiac CT training for Iraqi radiologists The British Institute of Radiology (BIR) has won an important grant funded by the British Council’s DelPHE-Iraq programme which supports partnerships between Iraqi higher education institutions and those in other countries. The BIR project will address the pressing need for advanced training in cardiac radiology for academic staff at the Baghdad Medical College and Baghdad Teaching Hospital. At present there is no capacity for providing the postgraduate study required in this area. The medical and teaching hospital will purchase new equipment later this year, but there remains little knowledge of the advanced

diagnostics involved in heart disease. Ten Iraqi radiology academic staff will participate in a 4 day intensive training course to be held later this year. The BIR faculty is headed by Dr Sujal Desai, consultant radiologist and honorary senior lecturer at London’s King’s College Hospital. Dr Laitha A Khalaf, consultant radiologist and supervisor of the postgraduate diploma in diagnostic radiology, will lead the Iraqi team. Participants will review 150 cases involving all aspects of cardiac diagnostics and specialist cases on state-ofthe-art workstations provided by Siemens. Not only will the Iraqi academics gain the knowledge to train junior staff and


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.

students when they return home, but this project is also envisaged to be the first phase of establishing an interventional radiology capability at the Baghdad Medical School and Baghdad Teaching Hospital. It is foreseen that this centre will form the nucleus for transferring skills to other centres in Iraq in the future. The BIR’s cardiac CT course is especially timely as the World Health Organization recently reported that cardiovascular disease is a leading cause of death in Iraq owing to the major risk factors smoking, hypertension and diabetes. Obesity is also a rising concern, while rheumatic heart diseases have increased in recent years.

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

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

sCotland CHaIR: dR andREw pEaRson, boRdERs gEnERal HospItal

soUtH wEst England CHaIR: nIky sykEs, Colbalt appEal fUnd

walEs CHaIR: dR gaREtH tUdoR, pRInCEss of walEs HospItal

For more information about our branch network please visit

wEssEx CHaIR: dR katIE joHnson, salIsbURy dIstRICt HospItal

Community News

2010 health white paper: an imaging perspective In 2010 the Cameron administration published a white paper entitled Equity and Excellence: Liberating the NHS, which included a wide-ranging restructuring of how funding streams will operate and services are commissioned, and this will have a major impact on how many services, including radiology, are delivered. As with many similar documents, it is taken as read that the National Health Service (NHS) is overly bureaucratic and grossly inefficient. Recent real-term spending increases are quoted, although it falls short of comparisons with other nations in western Europe. The Organisation for Economic Co-operation and Development (OECD) health data report for 2010 details how much we still lag behind in many measures of health spending, including fewer CT and MRI scanners than in “similar” countries. This is perhaps a clue to the cause of poorer cancer outcomes. The white paper quotes impressive numbers “PCTs – with administrative costs of over a billion pounds a year…” and omits others “…will together be replaced by GP consortia” (presumably working for free). The maintenance of front-line services comes at a price, with a promise to reduce NHS management costs by more than 45% over the next 4 years. Already, we have seen the bare minimum increase in spending (0.1%) described by many economists as effectively a reduction owing to the soaring costs of drugs, the ageing population and other factors. For radiology in the NHS, there are a number of challenges that lie ahead, the greatest of which will arise from the following statement: “Commissioners will be free to buy services from any willing provider; and providers will compete to provide services”. The concept of “any willing provider”

has been followed by other healthcare systems, notably the United States, the many consequences of which are elegantly explained in The Sorcerer’s Apprentice: how medical imaging is changing health care by Bruce Hillman and Jeff Goldsmith (2010). Amongst the topics discussed are how the United States models drive up imaging usage and why the attempted cost-reduction techniques fail. Previous UK experiments, including independent provision of MRI services (Wave 1), have proven to be a disaster. The provision of an apparently low-cost outpatient imaging service (abdominal ultrasound and plain films) to general practitioner (GP) patients may seem at first glance an easy way to save money. Reports may be generated by independent ultrasonographers or external radiologists who may or may not have a relationship with the local hospital network. In my experience, the report of equivocal findings prompts a letter to the local (NHS) radiologist who is then expected to opine (at no cost) and provide feedback in accordance with Royal College of Radiologists (RCR) guidelines, if indeed the images are available in a format that can be accessed via several (data commission compliant) passwords. The case may subsequently require discussion at the relevant multidisciplinary team (MDT) meeting (for which there is no tariff at present). Alternatively, the images may be felt to be inconclusive and the test repeated. Both of these are at significant cost to the local NHS. A third option would be for further imaging to be recommended by the initial report, which again may be provided by any willing provider, leading to the concept of “churning” when an equivocal result stimulates a second or third investigation. The concept of patients attending

multiple providers, who each use their own imaging protocols and generate reports that may not be available for viewing owing to isolated radiology information system/picture archiving and communication systems, leaves NHS Trusts exposed to litigation and is a potential risk for patients, which masquerades as choice. We must take steps to ensure that when GPs commission work they are not instigating a “race for the bottom” but ensure that service standards are maintained and improved. So how do we survive? NHS departments need to continue to demonstrate their efficiency, to be responsive to local needs and radiologists need to show their value as part of the local clinical team. Open access to all diagnostic modalities seems, to this radiologist, the very least that a GP can expect. This can help to avoid unnecessary outpatient attendances or even admission. As such, requesting should be straightforward and these patients need to be imaged at the earliest opportunity, with the studies tailored for each request, e.g. are all MRI sequences necessary on every patient? Finally, results need to be rapidly available to the referring GP. So, is this white paper the solution to the apparent ills of the NHS? Is the coalition administration trying to resuscitate this elderly but much loved institution, or starve it to death and sell off the jewels? If it works, and this is a substantial “if”, this white paper will revolutionise healthcare in the UK and produce the most efficient healthcare service in the world. If it fails, the position may be irrecoverable and lead to the break up of the NHS as we know it, i.e. free for all at the point of access. In either case, a turbulent 5 years ahead seems guaranteed. Ashley S Shaw, Consultant Radiologist and Associate Lecturer, Cambridge University Hospitals NHS Foundation

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Community news

Improving outcomes: what does it mean for radiotherapy services? In a short article such as this it is not possible to fully review a document as sophisticated as Improving outcomes: a strategy for cancer, published by the Department of Health (DH) team in January 2011 [1]. Therefore, this article seeks to ask questions and provoke some deeper thought on the aspects of the document that relate to radiotherapy. As is good practice, the strategy begins with three principles around which it aims to deliver progress. Paraphrasing, these are: • to put the patient at the heart of the service; • focus on improving outcomes and not just measuring processes; • empower innovation at a local level. These are powerful and important principles and the recommendations related to radiotherapy on pages 57 and 58 of the document should be consistent with them. There is also an international context to any discussion on cancer outcomes so international comparisons can give a good indication of where we are as a country, provide pointers for areas needing attention and help us to understand the degree to which substantial gains may or may not be possible from our chosen path. The key points to emerge from the radiotherapy section are that the reassurances related to increased funding are welcome but the local mechanism which ensures that this money reaches radiotherapy departments is not made explicit. Comments on reducing the side-effects of treatment are very important and these link strongly with the emphasis on intensity modulated radiotherapy (IMRT) and proton radiotherapy which are also very welcome. It is, however, unfortunate that a firm timescale for a tariff for IMRT is not stated. These paragraphs, which constitute the main statements on technical radiotherapy, align well with the three principles which should underpin the document as a whole. 8


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The main area where it is difficult to identify consistency between the recommendations and the three stated guiding principles is in the area of fractions-perlinac. Indeed, in this particular respect the recommendation appears to be diametrically opposed to all three of the guiding principles. This process measure has been in widespread use for some years and, as stated in the document, the numbers reported by trusts have not changed significantly over this period. Such a measure also deserves some analysis and comparison with the situation in other countries. Improving outcomes makes reference (annex B) to the work of the International Cancer Benchmarking Partnership,

rank are all the western European countries and North America from where we draw our main cancer outcome comparisons. The UK’s position may have improved somewhat since these figures were gathered, but other countries are also investing. One would hope that the International Cancer Benchmarking Partnership is collecting data on this issue, which will be made available in due course. If linac provision is indeed low by international standards, how should we go about driving more activity through this limited resource? Improving outcomes makes reference to the reluctance of departments to pay for out-of-hours service and upgrades, and by giving specific mention to this issue one

The reassurances related to increased funding are welcome but the local mechanism which ensures that this money reaches radiotherapy departments is not made explicit and a full section is included entitled International comparisons of drug usage. It is of some disappointment that there is no similar section comparing provision of radiotherapy equipment (linacs per million population for example) across countries. There is data available on this topic which indicates a comparatively low level of provision in the UK. Some is dated (Bentzen et al) [2] but the recent DIRAC initiative from the International Atomic Energy Agency (IAEA 2010) [3] shows the UK (along with Portugal and Spain) to be in the second rank of countries with linac provision of between 3 and 5 per million rather than the first rank at >5 per million. In the first

would imagine that significant gains could be made by this route. At my hospital, approximately 7.5% of available linac time is used for all quality assurance, servicing and upgrades, where servicing and upgrades make up substantially less than half of this total. This does not appear to be an area for substantial gains. We will attempt to rationalise this measure with the fact that we have no waiting-list and deliver the nationally recommended fractionation regimens, so have no clinical need to deliver more fractions. We also have strong clinical support for greater use IMRT and image-guided radiotherapy and of short-fractionated

stereotactic treatments for a large number of lung cancer patients. This latter technique, which is gaining ground rapidly in the UK, involves delivery of radical treatments in a small number of high-dose fractions where geometrical accuracy is paramount. Each fraction takes much longer to set-up and deliver than a standard treatment. This new development, coming on top of our time-consuming specialist paediatric and TBI practices, means that we will struggle to increase fractions per linac and may, for good clinical reasons, need to reduce this indicator. I fully appreciate that our specialist practice in Birmingham may not be completely typical for many centres, but we are also far from unique. I wonder how we should respond to commissioners

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(whoever they may be) who are further empowered to beat us with the fractions per linac stick? One significant omission from Improving outcomes relates to the growing role and great potential of molecular radiotherapy (targeted radionuclide therapy). This important subject seems to regularly fall between the radiotherapy and chemotherapy focussed expert groups which inform the overall DH strategy. Since the potential benefits to patients are very great, this omission deserves some attention by the DH team. The recent publication from he British Institute of Radiology Molecular radiotherapy in the UK: Current status and recommendations for further investigation should be helpful in this respect.

References 1. Improving Outcomes: a strategy for cancer. en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/ DH_123371 2. S M Bentzen, G Heeren, B Cottier, B Slotman, B Glimelius, Y Lievens, W van den Bogaert. Towards evidence-based guidelines for radiotherapy infrastructure and staffing needs in Europe: the ESTRO QUARTS project. Radiotherapy and Oncology 75 (2005) 355–65 3. DIRAC (Directory of Radiotherapy Centres), 2010/IAEA, http://www-naweb. Stuart Green, Director of Medical Physics, University Hospitals Birmingham NHS Foundation Trust

Cancer, radiotherapy and saving 5000 lives Improving outcomes: a strategy for cancer (IOSC) [1] sets an aspirational challenge for the national cancer programme. Set in the context of the government reform of the health service and changes to the focus in provider, commissioning and public health agendas. The ambitious programme sets out to save at least an additional 5000 lives in England each year by 2015, equalling the European average. If we were to become world class, and equal to the best in Europe and beyond, the prize is as high as an additional 10,000 lives saved per year [2]. This assumes a level of awareness, presentation and early diagnosis that matches our European colleagues. However, earlier diagnosis is just the beginning of the picture, and our treatment delivery and technology must also be capable of matching these aspirations. Much has been made of increasing the access to radiotherapy (from 37% to around 52%). A significant contribution to this gap relates to the stage of presentation and diagnosis. However, this increase will allow another 40,000 people access to radiotherapy each year. With varying estimations on the role of radiotherapy and

its contribution to a cure [3,4] (Figure 1), the opportunity for radiotherapy services to contribute significantly to those 5000 to 10,000 lives saved is enormous. The IOSC sets out these future opportunities in the context of the government reforms. Setting out the outcomes, not the processes, will drive NHS delivery and commissioning agendas. The Department of Health (DH) has produced an outcomes framework that contains 5 domains: reducing premature mortality rates; enhancing quality of life for people with long term conditions; recovery from episodes of ill health; ensuring people have a positive experience of care; and protecting people from harm. Delivering world class radiotherapy maps well to each of these domains and intensity modulated radiotherapy (IMRT), as an example, can be argued to significantly contribute to each of the five domains. The IOSC devotes a section to radiotherapy that details commitments to access, data analysis, productivity (value for money), investment, commissioning levers and the commitment to provide access to modern radiotherapy techniques that will

improve outcomes or reduce side effects. It also sets a commitment to improving the quality control of radiotherapy so we continually improve our delivery capability. The issue of productivity has already been raised by others and whether average fractions per linear accelerator (linac) is a good measure of this. Importantly, the IOSC has made a commitment to review the National Radiotherapy Advisory Group (NRAG) metrics to ensure they remain “fit for purpose”. However, the dangers of “baby” and “bathwater” emerge in doing this. Clearly the average fractions metric is one measure of productivity (but defines capacity reached). Nonetheless, measures of productivity in a resource constrained environment by an expanding service are important. However, if we turn to pages 57 and 58 of the IOSC, read the radiotherapy section and then close the strategy, we will have significantly missed the point. The opportunity for world class radiotherapy lies in part in this section, but significantly in other areas and related documents. The operating framework [5], which is in essence the DH commissioning instrucissue 2 april 2011



Community News


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Figure 1: The contribution of different treatments to the cure of cancer (IARC/WHO Lyons)

tion to the NHS, sets out an expectation that commissioners will ensure that local access to radiotherapy and provision of “advanced radiotherapy”, such as IMRT, is appropriate for their population. The fact that the wording between the IOSC and the operating framework is very similar is not coincidence. It is a coordinated approach by the DH and the NHS to ensure that radiotherapy has the opportunity to play its part. The operating framework provides another lever for radiotherapy to deliver its share of the 5000 lives saved. The IOSC makes another commitment to radiotherapy’s ability to deliver on this opportunity, that of patient empowerment. If we accept that IMRT is no longer advanced radiotherapy, but rather the standard of care we should expect for our patients, then to provide this to all that would benefit is the goal. The National Radiotherapy Implementation Group (NRIG) commissioning guide sets out that around 30% of radical fractions should be delivered using IMRT, but those who have attained this goal some time ago are now pushing the boundaries even further. If this is the case, we should inform our patients of IMRT’s large contribution to the five outcome domains. We should be telling them where they can access IMRT and allow them to choose; page 24 of the IOSC sets out this commitment. The IOSC also restates the commitment to widening access to radiotherapy through expansion of existing and creation of new facilities. Clearly radiotherapy does not fall into the “every home should have one” context, but restating the satellite 10


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model in these difficult financial times is an important step. It is also reassuring that while unable to make a firm commitment on commissioning arrangements (it is not for the cancer programme to set the agenda for the new national commissioning board before its even properly formed) clear statements on commissioning population sizes and tariff are supportive to enable this dynamic agenda to continue forward. As part of the developing outcomes framework, understanding the early mortality and morbidity from treatment evidently sets the quality and safety agenda. As we develop the appropriate metrics to understand the radiotherapy equivalent of 30 day mortality we are clear that few will know the standard to be achieved, but setting the metric and its baseline are key work plans for assurance of case selection and quality delivery. Regarding access rates to radiotherapy for the over 70s, most will be clear that there is no discrimination and that prescribing is based on disease and co-morbidities. Yet, we are recognising a pattern in other cancer areas, but (other than the RTDS) we have no definitive data on which to base our defence or change our practice. The future of successful cancer treatment and improved outcomes relies on an ever evolving technology base and a commitment to newer forms of radiotherapy (stereotactic body radiotherapy (SBRT) and protons) are an important signal of this. The IOSC not only highlights areas for action and development, but spotlights areas

of good practice and emerging status. Radiotherapy research is recognised (through NCRI and the NCRN) to be a contributor to our ability to be world class. In a more stable and better resourced NHS the IOSC may have been able to make additional commitments. Clearly this is a long-term strategy, not a short-life working group. There is more to do; however, we have a clear call to arms for the coming few years. It will be a challenging journey, we do not underestimate the level of financial challenge in the whole health economy. Nor do we underestimate the potential to falter that change in commissioning arrangements and leadership can bring. However, I think we have the skills, enthusiasm and now the action plan to contribute our share to the 5000 lives saved each and every year. References

1. Department of Health. Improving outcomes: a strategy for cancer. London, DH, January 2011. Available at: http://www. Publications/PublicationsPolicyAndGuidance/DH_123371 2. Coleman MP, Forman D, Bryant H, Butler J, Rachet B, Maringe C, et al. Cancer survival in Australia, Canada, Denmark, Norway, Sweden, and the UK, 1995-2007 (the International Cancer Benchmarking Partnership): an analysis of populationbased cancer registry data. The Lancet 2011; 377: 127-38. 3. Tubiana M. The role of local treatment in the cure of cancer. Eur J Cancer. 1992; 28:2061-9 4. Barton M, Gebski V, Manderson C, Langlands A. Radiation Therapy: Are we getting value for money? Clinical Oncology (1995) 7:287-92 5.Department of Health(2010)Transparency in Outcomes: NHS Outcomes Framework 2011/12. Available at: uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/ DH_122944 Tim Cooper, Associate Director – Radiotherapy, National Cancer Action Team

Idea watch

idea watch Management in the new NHS: what does the future hold? As the Government moves forward with its plans to “liberate the NHS” and reform the way general practitioners commission healthcare in England, Professor Paul Goddard reflects on the plans and asks how will this impact on radiology services? What does the immediate future hold for clinical radiology and how will the changes in the NHS affect the specialty?

These are the questions that I asked myself as I sat listening to a symposium on the commissioning of services for patients with chronic obstructive pulmonary disease (COPD). COPD had been chosen as an example to demonstrate the new management structure of the NHS. Several aspects struck me immediately, and these are my opinions rather than those expressed by the speakers. Firstly the change over to general practitioners’ (GPs) commissioning cannot come soon enough. The manager who spoke in a commissioning role seemed a nice enough fellow, but as a rather young nurse now promoted to management his experience of clinical problems could not in anyway match those of doctors — and he was in charge! Secondly, there does appear to be a real desire to integrate care of patients so that they can be looked after in the community to a high standard, thus reducing the need for costly inpatient services. This is partly driven by a need for improvement and by the express wishes of patients to be treated at home and, when the time comes, to die at home (as long as their treatment is no

worse than in hospital). However, a more worrying reason for keeping patients out of hospital or discharging them as soon as possible is pushing the agenda. This will be necessary in our locale because the new hospital being built (using private finance initiative (PFI) money) will have two-thirds of the number of beds compared with the two hospitals it is replacing. There will not be enough beds in the hospital to cope with the demand. Thirdly, it was deemed desirable that specialist services for patients should be on a 7 day a week basis rather than the current 5 day a week. The main group picking up the extra work in the community appears to be hospital consultants sent out into the community to do domiciliary work in homes or GP surgeries. Domiciliary work undoubtedly takes more time

than standard outpatient or inpatient referrals. This begs the question, where will the extra consultant sessions come from? So how does this affect radiology?

You cannot provide services in the community equal to hospital services without the provision of clinical radiology. X-ray facilities, ultrasound, nuclear medicine and MRI will be necessary and the idea is that GPs would be permitted to “order” radiology services. In many places this happens anyway (we always liked to call it “request”), but not with the speed of access provided for inpatients. If the provision for patients treated in the community is to meet that of the present inpatient services, the outpatient radiology services need to be dramatically enhanced.

If the provision for patients treated in the community is to meet that of the present inpatient services, the outpatient radiology services need to be dramatically enhanced issue 2 april 2011



Idea watch

Do GPs understand the role of radiology and will the results be returned to them in a timely fashion?

Take just one very recent example: a patient with an acute soft-tissue leg problem was recently X-rayed as an outpatient in a south London hospital. She was told that the results would be back with the GP in 3 weeks time. Her problem was acute pain in her thighs — the radiograph was likely to be noncontributory and the time period was absurd. A bad choice of investigation and a lack of timely reporting would make the result irrelevant. Many GP surgeries find it impossible to obtain radiology reports outside normal working hours. The electronic patient record was meant to have changed all this, but the IT project has failed and the facilities do not exist. Many radiology departments are finding it very hard work to report all the films that they are presently asked to 12


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do. Within the hospital clinical specialists may be able to help since electronic picture archiving and communication systems (PACS) have been successfully deployed and the investigations can be interrogated from the wards, clinics and operating theatres. However, is it likely that any individual GP will see sufficient cases to build up an expertise in any area of radiology? If you do not think this is the case the only alternative is more hours of reporting in front of digital screens for our intrepid radiology consultant. If clinicians wish to get patients out of hospital quicker and quicker what will they do? Once again they will expect the radiology department to jump through impossible hoops. So do I think this will work?

Yes. But not well, I fear. There is a growing trend of reduction in hospital beds whilst the population is getting older and requiring more, not less, healthcare.

Is there an answer?

The new GP commissioning role is lopsided. It is essential that doctors should have a defining role in such management, but hospital consultants should have equal say in the commissioning. This will permit the hospital staff to put across their side of the story and explain the inherent difficulties. However, this is an era of austerity for all (except, of course, the bankers who brought the austerity upon us). Some patients will always require hospital admission and the reduction in beds and absurdly high cost of repayment for the PFIs will make the future of the NHS very difficult. Professor Paul Goddard MD, FRCR, FBIR

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in the online issue of BJR

what’s online: Featured Articles:


Short communication

Pictorial review

Pictorial ReVIEW

Full paper

Lumpy breasts and headache – a crucial ultrasound

The lumbar sedimentation sign: spinal MRI findings in patients with subarachnoid haemorrhage with no demonstrable intracranial aneurysm

Magnetic resonance imaging in cerebral malaria: a report of four cases

Magnetic resonance imaging findings in acute pulmonary embolism

D D Rasalkar, B K Paunipagar, D Sanghvi, B Sonavane and P Lonikar

B Hochhegger, J Ley Zaporozhan, E Marchiori, K Irion, A Soares Souza Jr, J Moreira, H U Kauczor and S Ley

Reduction of motion artefacts in onboard cone beam CT by warping of projection images

DOI: 10.1259/ bjr/85759874

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S Hinze, Y M Hart and R F Adams

R A Crossley, A Raza and W M Adams

DOI: 10.1259/ bjr/23418860

DOI: 10.1259/ bjr/68122723

T E Marchant, G J Price, B J Matuszewski and C J Moore

DOI: 10.1259/ bjr/90983944

Highlighted Articles: Full papers

Case reports

A method for calculating the dose length product from CT DICOM images

Pituicytoma: case report and literature review

I A Tsalafoutas, and S Metallidis

DOI: 10.1259/bjr/37630380

Evaluation of flow measurement from the first pass bolus T1 weighted images using inversion recovery sequence M Nazarpoor

DOI: 10.1259/bjr/18588668

Sensitivity and specificity: imperfect predictors of guideline utility in radiology B Roudsari, C McKinney, D Moore and J Jarvik

DOI: 10.1259/bjr/20598117

J Chu, Z Yang, Q Meng and J Yang

DOI: 10.1259/bjr/16529716

Differentiation of ante-mortem and post-mortem fractures with MRI: a case report T D Ruder, T Germerott, M J Thali and G M Hatch

DOI: 10.1259/bjr/10214495

Contrasting natural histories of thoracic spine pneumatocysts: resolution versus rapid enlargement V H Wilkinson, T Carroll and N Hoggard

DOI: 10.1259/bjr/35586720 Imaging features of intradural spinal paragonimiasis: a case report M K Kim, B M Cho, D Y Yoon and E S Nam

DOI: 10.1259/bjr/11274366

issue 2 april 2011


in The online issue of BJR

All other articles from the March and April 2011 issue Breast


Development of an imaging-planning program for screen/film and computed radiography mammography for breasts with short chest wall to nipple distance

64-Slice multidetector row CT angiography of the abdomen: comparison of low versus high concentration iodinated contrast media in a porcine model

S L Dong, J L Su, Y H Yeh, T C Chu, Y C Lin and K S Chuang

N-S Holalkere, K Matthes, S P Kalva, W R Brugge and D V Sahani

DOI: 10.1259/bjr/97507379

DOI: 10.1259/bjr/14535110

Case report: A case of lobular carcinoma in situ presenting as a solid mass

Case report: CT diagnosis of a large peritoneal loose body – a case report and review of the literature

X Zhang, N Hanamura, M Yamasita, Y Kashikura, T Ogawa and S Taizo

G Gayer and I Petrovitch

DOI: 10.1259/bjr/32795948

DOI: 10.1259/bjr/98708052


Hepatic artery guide wire targeting technique during transjugular intrahepatic portosystemic shunt

Case of month: Beware the cardiac shadow!

T Yamagami, O Tanaka, R Yoshimatsu, H Miura, T Suzuki, T Hirota and T Nishimura

R D White, A J France and P G Ramkumar

DOI: 10.1259/bjr/19972953

DOI: 10.1259/bjr/18062214

Case report: Constrictive pericarditis presenting with an outpouching of the right ventricle free wall simulating an aneurysmal dilatation I Ocak, B Turkbey and J M Lacomis

DOI: 10.1259/bjr/53714567

Comparison of diamond-like carbon-coated nitinol stents with or without polyethylene glycol grafting and uncoated nitinol stents in a canine iliac artery model J H Kim, J H Shin, D H Shin, M-W Moon, K Park, T-H Kim, K M Shin, Y H Won, D K Han and K-R Lee

DOI: 10.1259/bjr/21667521

Accuracy of multislice CT angiography for the assessment of in-stent restenoses in the iliac arteries at reduced dose: a phantom study K Perisinakis, E Manousaki, K Zourari, D Tsetis, A Tzedakis, A Papadakis, A Karantanas and J Damilakis

DOI: 10.1259/bjr/63029326

The detection and discrimination of malignant and benign focal hepatic lesions: T2 weighted vs diffusion weighted MRI D M Yang, G Jahng, H C Kim, W Jin, C W Ryu, D H Nam, Y K Lee and S Y Park

DOI: 10.1259/bjr/50130643

Case report: Travails of self-manipulation of a catheter A Mishra, A ElUsta, T Shwaish and E F Ehtuish

DOI: 10.1259/bjr/13049520

Case report: Renal granular cell tumour (Abrikossoff tumour): case report and review of the literature D S Chow, M Hsu, C Day and S Raman

DOI: 10.1259/bjr/25556016

Case report: CT and ultrasound findings of metanephric adenoma: report of two cases and literature review L J Zhang, G F Yang, W Shen and G M Lu

DOI: 10.1259/bjr/62994226

Computer applications

Short communication: To what degree is digital imaging reliable? Validation of femoral neck shaft angle measurement in the era of picture archiving and communication systems J D Wilson, W Eardley, S Odak and A Jennings

DOI: 10.1259/bjr/29690721



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All other articles from the March and April 2011 issue Genito-urinary


Interventional management for complications following caesarean section

Case report: FDG-PET/CT-guided biopsy of bone metastases sets a new course in patient management after extensive imaging and multiple futile biopsies

S Y Ko, S W Park, I S Sohn, J Y Lee, H-S Kwon, H-S Hwang and S I Jung

DOI: 10.1259/bjr/53617758

M K Werner, M P Aschoff, M Reimold and C Pfannenberg

DOI: 10.1259/bjr/26998246

Case report: Uterine cavernous haemangioma in a post-menopausal woman: CT and MRI findings mimicking uterine myoma with degeneration E J Lee, S H Kim and Y H Kim

DOI: 10.1259/bjr/56484373


The use of central venous catheters for intravenous contrast injection for CT examinations A A O Plumb and G Murphy

Head and neck

Factors associated with nodal metastasis in nasopharyngeal cancer: an approach to reduce the radiation field in selected patients N Tomita, N Fuwa, Y Ariji, T Kodaira and N Mizoguchi

DOI: 10.1259/bjr/47164832

Clinical target volume delineation in glioblastomas: pre-operative versus post-operative/pre-radiotherapy MRI P Farace, M Giri, G Meliado, D Amelio, L Widesott, G K Ricciardi, S Dall’Oglio, A Rizzotti, A Sbarbati, A Beltramello, S Maluta and M Amichetti

DOI: 10.1259/bjr/10315979

Clinical challenges in the implementation of a tomotherapy service for head and neck cancer patients in a regional UK radiotherapy centre S Chatterjee, J H Mott, G Smyth, S Dickson, W Dobrowsky and C G Kelly

DOI: 10.1259/bjr/19586137

Intensity-modulated radiotherapy in patients with head and neck cancer: a European single-centre experience D Van Gestel, D Van Den Weyngaert, D Schrijvers, J Weyler and J B Vermorken

DOI: 10.1259/bjr/67058055

Directional diffusivity changes in the optic nerve and optic radiation in optic neuritis

DOI: 10.1259/bjr/26062221

Adult patient radiation doses from non-cardiac CT examinations: a review of published results I Pantos, S Thalassinou, S Argentos, N L Kelekis, G Panayiotakis and EP Efstathopoulos

DOI: 10.1259/bjr/69070614 ThorACIC

Comparison of pulmonary HRCT findings and serum KL-6 levels in patients with sarcoidosis K Honda, F Okada, Y Ando, H Mori, K Umeki, H Ishii, J Kadota, M Ando, E Miyazaki And T Kumamoto

DOI: 10.1259/bjr/65287605 Image quality of multiplanar reconstruction of pulmonary CT scans using adaptive statistical iterative reconstruction O Honda, M Yanagawa, A Inoue, A Kikuyama, S Yoshida, H Sumikawa, K Tobino, M Koyama and N Tomiyama

DOI: 10.1259/bjr/57998586

Case report: A case of tracheal varices: an unusual but important cause of mural nodules in the trachea L A Sosa Lozano, K Shahir, M Akbar and L R Goodman

DOI: 10.1259/bjr/23728020

M Li, J Li, H He, Z Wang, B Lv, W Li, N Hailla, F Yan, J Xian and L Ai

DOI: 10.1259/bjr/93494520

Prognostic significance of parameters derived from co-registered 18F-Fluorodeoxyglucose PET and contrastenhanced MRI in patients with high-grade glioma M J Paldino, T Z Wong, D A Reardon, H S Friedman and D P Barboriak

DOI: 10.1259/bjr/48528504

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Case of the month

Beware the car A 44-year-old man, with a history of injection drug misuse, presented with pyrexia and a 1 week history of a productive cough with rusty-coloured sputum. There were clinical signs of a right-sided pneumonia. A deep venous thrombosis of the right leg was also suspected, with needle marks evident in the right groin, and the possibility of a pelvic or abdominal source of sepsis was suggested. A chest radiograph on admission (Figure 1) shows right lower lobe consolidation. A CT scan of the abdomen was performed on the same day. This showed bibasal consolidation (Figure 2) and demonstrates a sinus tract passing from the skin to the right femoral vein. Thrombus in the right femoral vein extended via the common iliac vein to the inferior vena cava, with intravenous (iv) pockets of gas evident (Figures 3 and 4). Despite antibiotic therapy, the patient remained pyrexial with persisting ooze from the right groin, and a repeat CT scan of the abdomen was performed a few days later. Thrombus was again noted in the femoral veins, with iv gas no longer identified. Cavitating foci of consolidation were apparent in the lung bases and this is suggestive of pulmonary abscesses secondary to septic emboli. An additional and important abnormality was present on the repeat CT scan. This was also subsequently identified on the previous examinations in retrospect. What is it? Findings

Projected over the cardiac shadow on the chest radiograph is a 2cm linear metallic density, consistent with a broken needle fragment (Figure 5, windowed and zoomed in on the needle). Inverting the window settings on the workstation 16


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renders the needle more visible. On the repeat CT scan, the needle is again seen to be implanted in the right ventricular myocardium. There was no history of previous vascular intervention or surgery, hence this was considered to represent a migrated broken needle fragment from injection drug misuse. Discussion

The heart shadow is a critical review area on the chest radiograph. Diligence is required to maximise the chance of detection of lesions such as retrocardiac lung cancers because small tumours adjacent to the heart can be easily overlooked [1]. External artefacts may also be projected over the heart shadow. In extremely rare cases, intrathoracic yet extracardiac foreign bodies (such as retained surgical gauze [1]) or intracardiac foreign bodies may also manifest in this way on the chest radiograph. Venous embolism of bullets to the right heart has been reported following penetrating vascular trauma [2, 3], with the same mechanism postulated to have caused needle (from acupuncture and iv drug use) or iatrogenic device (such as fractured venous catheter) migration to the heart [4–6]. Needles have also been documented within the left side of the heart and in the pulmonary arterial circulation, presumed secondary to direct penetration rather than an embolic phenomenon [3]. External artefacts on the chest

radiograph are often encountered in a clinical setting, particularly in bed-bound patients who may have a number of monitoring leads or oxygen tubes, for instance. If an unexplained metallic density projected behind the heart shadow is identified when the patient is still in the imaging department, attempts should be made to exclude the possibility of the density being an artefact. If this has been ruled out, a lateral chest radiograph may be appropriate to help localise the abnormality. According to Actis Dato et al [3], management of intracardiac foreign bodies should be tailored to the individual. If symptomatic, removal is necessary regardless of location. If asymptomatic, removal is mandatory only if diagnosed immediately postinjury. Manifestations of intracardiac foreign body include cardiac tamponade, arrhythmia and fever, particularly if infective endocarditis develops. The needle was not considered to be the cause of symptoms in this case, with numerous alternative reasons for the patient’s pyrexia (including pulmonary abscesses, deep venous thrombosis/thrombophlebitis and infected needle-tract sinus). The duration of implantation in the right ventricle was unknown. Following discussion with cardiothoracic surgeons, operative intervention was deemed to be too highrisk, therefore a decision was made to leave

case of the month

ardiac shadow! the needle in situ. The patient improved and was subsequently discharged. He remains well 6 months after this episode. Nevertheless, this case should stimulate reporting radiologists to seek migrated needle tips in patients known to use iv drugs. Manual adjustment of window settings (including inverting the settings) is a quick and easily employed tool for increasing the conspicuity of abnormalities on the chest radiograph, and the authors consider that this should be performed routinely when reporting such radiographs, although this is of particular importance when faced with a drug misuse patient presenting with sepsis. This case provides a further important educational point relating to CT scan interpretation. High densities relating to the heart are not uncommonly encountered in everyday radiological practice in the form of pacemaker leads, dense coronary artery or valvular calcification. Such densities may easily be overlooked or misinterpreted. This is particularly important in abdominal CT scans, in which only a small area of the heart is visualised, as in this case. The thin slice images of the heart in this patient showed the needle as an apparent “coiled catheter/pacemaker lead tip� (Figure 2) rather than a real needle, owing to the metallic streak artefacts. This artefact should be recognised, and examining thick slice reformats or manipulating the window settings on the workstation may be necessary to enable a confident diagnosis to be made. A quick review of the patient’s clinical history or recent chest radiograph would easily exclude catheters and pacemaker leads from the differential.

Figure 1. Chest radiograph taken at the time of admission

Figure 4. Axial CT slice at the level of the iliac veins showing thrombus and pockets of gas within the right external iliac vein (arrow)

Figure 2. Axial slice through the lung bases on the initial abdominal CT scan

Figure 5. The cardiac region from the admission chest radiograph, with window manipulation to more readily demonstrate the needle fragment

R D White, A J France and P Guntur Ramkumar

Figure 3. Axial CT at the level of the groins demonstrating a sinus tract (arrow) towards the right femoral vein which contains thrombus

Ninewells Hospital and Medical School, Dundee, UK Download the full length article & references:

www DOI: 10.1259/bjr/18062214

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The use of central venous catheters for intra ven CT examinations are commonly performed with the intravenous (iv) use of iodinated contrast media (CM), either as a fundamental part of the examination or to improve soft-tissue contrast. Generally, peripheral iv access can be secured easily and safely for injection of CM via high-powered automated injectors. However, in certain patient groups, peripheral iv access is difficult and central access may be the only available route for contrast enhancement. Many emergency and critical care patients require CT examinations which would best be conducted after iv contrast. The use of existing central venous catheters (CVC) for CM injection is therefore a tempting alternative to potentially fruitless, or even damaging, attempts at peripheral access. The radiologist is best placed to weigh up the relative risks and benefits of using a CVC for power injection of CM, as they will have a clearer knowledge of the relative importance of contrast enhancement for accurate interpretation. They are also more likely to be familiar with the power-injector delivery devices in use in their department. Current practice and recommendations

A survey of 12 randomly selected radiology departments in North West England has shown that there is a considerable variability in practice. There are no published UK recommendations for the use of CVCs for this indication. The British Committee for Standards in Haematology Guidelines [5] for the management of CVCs in adults does cover this issue. In 2004, the Medicines and Healthcare Products Regulatory Agency (MHRA) issued a device alert suggesting injection at a maximum rate of 2mls-1 and a pressure 18


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limit below the manufacturer’s recommended maximum [6]. This alert has subsequently been withdrawn, apparently owing to the availability of power-injector capable CVCs, although the validity of the alert for other types of CVC remains (MHRA, personal communication, July 2009). The Northern Ireland Adverse Incident Centre has also issued a medical device or equipment alert that remains active with regard to this issue (essentially identical to the MHRA alert) [7] but this takes a blanket approach to all lines and all patient groups, and it is unclear on what evidence their suggestions are based. Similarly, the USA Food and Drug Administration (FDA) has issued its own recommendations for CVC use for power injection, but these simply state that the manufacturers’ recommendations are to be followed and do not review the available evidence [8]. Therefore, most hospitals are left to devise their own guidelines, which may contribute to the variability in use of these devices for contrast injection. Risks of incorrect use

The FDA has received reports of catheter rupture, leading to extravasation of contrast and loss of vascular access, or even fragmentation and embolisation, which has led to the need for the subsequent surgical removal [8]. Catheter obstruction and late nonfunction are also reported, occasionally leading to the loss of access for drug administration including inotropic support [7]. Furthermore, there are reports of adverse patient outcomes unrelated to failure of the catheter, but with mediastinal contrast extravasation [9], mediastinal haematoma and cardiac arrhythmia reported as risks [10]. A particular problem with tunnelled lines

is that the site of damage may be in the portion of the line that lies in the subcutaneous tunnel and therefore be invisible to the naked eye [7]. Furthermore, catheters may weaken without any external signs of damage, shortening their lifespan and potentially leading to late rupture [8]. Older catheters may be at increased risk and the MHRA recommends particular caution should be exercised with catheters over 3 months old [7]. Despite these reports, it is important to remember that the majority of these complications are relatively minor and the only intervention needed is catheter replacement owing to non-functioning. Can hand injection be a reasonable alternative?

This is an attractive option as the intuitive impression is that the pressures generated will be insufficient to damage the line. There are several disadvantages to hand injection. It is difficult to reliably deliver a set volume of contrast in a particular time, making it problematic for the radiographer to commence scan acquisition in a particular phase of contrast enhancement. A reliable, consistent column of contrast medium cannot be easily achieved, and examinations that rely on this are likely to yield inconsistent results. Hand injection, particularly when using small syringes, can generate high pressures, and in one in vitro study the pressures generated for equivalent flow rates were higher for hand injection than for power injection [13]. With power injectors a pressure limit can be specified, and therefore controlled, but the pressures being generated by hand injection are unknown, and cannot be limited. Catheter damage in relation to hand injection has also been documented in vivo [20].

REVIEW article

nous contrast injection for CT examinations A possible protocol for CVC use with power injectors

One possible solution would be to prohibit use of all CVCs for contrast power injection, unless specifically rated as power-injector capable. However, this would seem to be excessively conservative given the fact that safe use with a low event rate has been demonstrated. Perhaps the most important step is to consult with the clinicians and determine how important a contrast-enhanced CT is to their patient management. If contrast enhancement is mandatory, then under most circumstances it should be possible to reduce the injection flow rate (2.0mls-1 is a commonly used rate and recommended by the MHRA) with only minor compromise to the diagnostic image quality. If a higher flow rate is required, then either a higher risk of CVC damage must be accepted or a reduction in the quality of the scan should be expected. This may be sufficient for the exclusion of gross pathology (e.g. a large central pulmonary embolus (PE) rather than a subsegmental PE). The maximum pressure limit on the power injector should also be reduced; 100–150 psi is used in our department. At all times, it should be realised that the absolute risk of an adverse event is small, and this can be stated to the clinician. In many circumstances, it may be appropriate to accept this risk and proceed with a standard rate of injection. In practical terms, it is important to ensure that the catheter lies within the venous system. Successful low-resistance flushing of the line alone is not sufficient to confirm intravascular placement, as a catheter that has perforated the vessel wall and lies extraluminally can still often be easily flushed [22]. Successful aspiration of blood from the line makes intravascular placement

substantially more likely, but even this is not infallible. Placement of the tip within a bloody collection, such as a haemothorax, can allow aspiration of blood, which mimics the intravascular location [23]. Furthermore, the line may be intravascular but have been placed or migrated in an inappropriate vessel (e.g. cranial misdirection of a subclavian CVC into the upper jugular vein). These tests should be performed with the patient’s arms in the position that they will be located in for the duration of the scan (often above the head for body imaging, if the patient is able to do so), because subclavian lines in particular may move with arm abduction [24]. The vast majority of patients will have had a recent chest radiograph, which can be used to confirm line position. The radiograph can also be used to look for signs of impending erosion through the vessel, particularly the superior vena cava (SVC). A curve at the end of the CVC is highly suggestive of impending perforation and should prompt catheter repositioning [25]. Such a line should, therefore, not be used for contrast injection. If no recent chest radiograph is available, one solution is to obtain a CT topogram that covers the CVC. This image is analogous to a chest radiograph and can be used to help determine line position. If there is any residual doubt after these methods (line aspiration/flushing and chest radiograph/topogram), a very rare situation in practice, unenhanced axial CT slices through the line tip can be used to definitively confirm the position of the distal lumen. If a multilumen CVC is in place, the distal lumen should be used unless it is so narrow that acceptable flow rates cannot be achieved. Although this may be somewhat counterintuitive (this is the

longest lumen, and therefore by Poiuseuille’s equation a given flow rate will require a greater pressure), for several reasons. Firstly, this lumen will be located at the tip of the line and therefore it is the only lumen whose position can be demonstrated directly by the chest radiograph. Unless it is known exactly how proximal to the line tip the other luminal openings are located, their positions cannot be determined with certainty. Secondly, this is commonly the largest calibre lumen, with the increase in radius often outweighing the increase in length in terms of maximum flow rates. Thirdly, and most importantly, the risk of catheter damage is felt to be lower when using the distal lumen of a multilumen CVC [24], perhaps because the side-facing lumen may lie directly against the vessel wall and the subsequent jet of turbulent contrast medium may damage the vein. Conclusion

CVCs are commonly used vascular access devices and have multiple uses. In patients where peripheral access is difficult or impossible, the use of these lines for power injection of contrast media is feasible and safe as long as certain precautions are taken. There is approximately a 1% risk of adverse events, the majority of which are minor, lead to no patient harm and only require catheter replacement to rectify. Knowledge of the risks of CVC use for this application is vital to allow an informed decision to be made such that the best possible patient outcome can be obtained. A A O Plumb and G Murphy Manchester Royal Infirmary, Oxford Road, Manchester, United Kingdom


Download the full article incluing references and tables at: DOI: 10.1259/bjr/26062221

issue 2 april 2011


short communication

The lumbar sedimentation sign: spinal MRI findings in patients with subarachnoid haemorrhage with no demonstrable intracranial aneurysm Subarachnoid haemorrhage (SAH) can be a difficult diagnosis in patients presenting with a headache. Of all patients who present with headache 1 in 100 ultimately have a proven diagnosis of SAH [2]. In the immediate aftermath of the haemorrhage the sensitivity of CT in detecting SAH can exceed 95%. The likelihood of detection falls to 85% after 5 days, 50% after 1 week, 30% after 2 weeks and to almost zero after 3 weeks [6]. Patients who have a normal CT scan, but a clinical history suggestive of SAH, should undergo lumbar puncture. In a study by Morgenstern et al [7] of the 107 patients with “worst headache” 2 out of 89 CT negative patients had SAH detected by CSF analysis. In Van der Wee et al’s study [8] CT failed to diagnose SAH in 2 out of 119 cases of CSF proven SAH. CSF xanthochromia is detectable by spectrophotometry in all patients up to 2 weeks after haemorrhage and in 70% after 3 weeks [9]. Recently there has been some interest in assaying CSF ferritin levels as a further adjunct to diagnosis [10]. MRI of the head offers some promise in the diagnosis of SAH [11]. However, the use of this modality has traditionally been hampered by limited availability, long scanning time and difficulty in scanning confused or unwell patients. Although Mitchell et al [12] conclude that MRI of the brain had 94% sensitivity in acute SAH and 100% sensitivity in subacute SAH, other authors have published conflicting results. Chakeres and Bryan [13] concluded that high concentration haemorrhage was almost isointense to brain using conventional MRI sequences, giving CT a distinct advantage. Methods

Patients were imaged on a 1.5T magnet (Siemens Avanto, Camberley, UK). Sagittal T1 and T2 turbo spin echo (TSE) and axial T2 TSE sequences were performed. 20


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The circulation of CSF is complex [14]. There is communication between the spinal and cerebral CSF spaces but the mechanism is not completely understood. Two co-existent circulation patterns have been described: a fast flow component reliant on systolic expansion of major arteries causing CSF to enter the upper cervical spine CSF space; and a much slower bulk flow component in which CSF ascends over the cerebral surface. Patients experiencing a SAH will describe the initial ictus followed by stiffness migrating to the neck over 24h. The spinal CSF acts as a capacitance vessel by absorbing the change in pressure. The duration of recirculation of CSF within the lumbosacral region is unknown. Layering of altered blood products within the CSF at the lumbosacral junction demonstrated on MRI is only an observation in a small number of patients but does raise the possibility for further study. It may provide confirmation of haemorrhage in those patients who have failed to demonstrate blood on CT, and obviate the requirement for lumbar puncture (LP). LP is performed no earlier than 12h after ictus to allow red cell lysis and the formation of the pigments, which form xanthochromia, detectable on spectrophotometry. A prospective study is required to determine the duration of the sign and in what proportion of CT negative, but LP positive, patients it manifests. Patients with a history of thunderclap headache may present beyond the 3 week diagnostic window. In this group the diagnosis of SAH is impossible to verify by CT, MRI of the brain or by the presence of CSF xanthochromia. Increasingly, in these cases CT angiography is being used to investigate for the presence or absence of an aneurysm. However, this investigation does not allow the distinction to be made between a ruptured and an unruptured aneurysm. The two are

Mid-sagittal T2 weighted section demonstrates layering of hypointense material with the sacral canal

completely different entities; a recently ruptured aneurysm has a high chance of early rebleed. In the prospective cooperative aneurysm study [15] rebleeding was maximal (4%) on the first day after SAH, and then constant at a rate of 1% to 2% per day over the subsequent 4 weeks. The risk of rebleeding with conservative therapy is estimated at 20–30% 1 month after haemorrhage, 30–50% 6 months after and stabilises at a rate of approximately 3% per year. There is a 70% mortality rate for patients who rebleed [16]. An unruptured aneurysm according the to cooperative aneurysm study data [15] has a low risk of rupture that varies according to size and location. The risk of treatment of an unruptured aneurysm by either coil or surgical clip can exceed the risk associated with the natural history of the disease. Persistence of the sign beyond 3 weeks may provide support for advising for or against treatment. R A Crossley, A Raza and W M Adams Department of Neuroradiology, Derriford Hospital, Plymouth Hospitals NHS trust, Plymouth, Devon, UK


Download the full length article: DOI: 10.1259/bjr/68122723

review article


I Pantos, S Thalassinou, S Argentos, N L Kelekis, G Panayiotakis and E P Efstathopoulos Department of Radiology, Medical School, University of Athens, Greece

Adult patient radiation doses from non-cardiac CT examinations: a review of published results The use of CT in medicine is now firmly established and represents one of the most important radiological procedures performed worldwide. A consequence of the wide adoption of CT in clinical practice is that radiation dose from CT is growing as a component of the total radiation dose received by patients and the general population [1, 2]. Data from

Abstract Objectives: CT is a valuable tool in diagnostic radiology but it is also associated with higher patient radiation doses compared with planar radiography. The aim of this article is to review patient dose for the most common types of CT examinations reported during the past 19 years. Methods: Reported dosimetric quantities were compared with the European Diagnostic Reference Levels (DRLs). Effective doses were assessed with respect to the

various national surveys have proved that CT is a major source of radiation exposure and provides a substantial proportion of the collective dose from medical exposure, approximately 35% in Germany [3] and 47% in the UK [4]. The introduction of faster multislice and dual source CT technology has allowed cardiac CT, large-volume high-

resolution CT and improved z-plane resolution [5–8]. The speed and ease of CT imaging and the ambition to obtain quality images and cover larger areas of the patient’s anatomy can lead to increased patient doses; although technological developments provide the opportunity to decreases individual CT doses [9]. Patient radiation dose owing to CT examination

publication year and scanner technology (i.e. single-slice vs multislice). Results: Considerable variation of reported values among studies was attributed to variations in both examination protocol and scanner design. Median weighted CT dose index (CTDIw) and dose length product (DLP) are below the proposed DRLs; however, for individual studies the DRLs are exceeded. Median reported effective doses for the most frequent CT examinations were: head, 1.9mSv (0.3–8.2mSv); chest, 7.5mSv (0.3–

26.0mSv); abdomen, 7.9mSv (1.4–31.2mSv); and pelvis, 7.6mSv (2.5–36.5mSv). Conclusion: The introduction of mechanisms for dose reduction resulted in significantly lower patient effective doses for CT examinations of the head, chest and abdomen reported by studies published after 1995. Owing to the limited number of studies reporting patient doses for multislice CT examinations the statistical power to detect differences with single-slice scanners is not yet adequate.

issue 2 april 2011


review article

is expected to be highly variable because of the use of different imaging protocols and the intrinsic differences among makes and models of CT scanners [10, 11]. To limit radiation exposure arising from CT procedures to as low as reasonably achievable (ALARA), European Guidelines on quality criteria were published and specific diagnostic reference levels (DRLs) were proposed for routine CT examinations [12]. The purpose of this study is to review published literature on patient radiation doses from common non-cardiac CT examinations, to compare findings with DRLs, to identify whether patient doses are reduced or increased for newer studies and to comment on the impact of multislice technology on patient doses. CT dosimetry CT dosimetry differs radically from conventional planar radiography and fluoroscopy dosimetry. In CT scanning

the X-ray beam rotates around the patient and it is not straightforward how the radiation dose is distributed on the surface and inside of the patient [13]. CT dosimetry is performed with physical cylindrical phantoms, which contain several openings for insertion of dosemeters [14]. Measurements are typically performed with pencil ionization chambers with an active length of 100mm inserted into the phantom openings. The measured quantity is called the CT dose index (CTDI) or more precisely CTDI100 when the ionization chamber has active length of 100mm. This is defined as the integral along a line parallel to the axis of rotation (z) of the dose profile (D(z)) for a single slice divided by the nominal slice thickness T [15] (see Equation (1)). CTDI is measured in milligrays. CTDI measured at different locations and depths in a dosimetry phantom differ. To establish an “average” CT dose index that can be used as single-number

indicator of radiation dose to a patient the “weighted” CTDI was introduced and is defined in Equation (2) [13]. To calculate CTDIw, CTDI is acquired at the centre (CTDIcentre) and at the periphery of the phantom at a 1cm depth (CTDIperiphery). To account for helical doses and axial doses when slice spacing I differs from slice thickness (n × T) (where n is the number of slices and T is the slice thickness) the indicator CTDIvolume is often used [13] (see Equation (3)). CTDIvolume spreads the dose corresponding to CTDIw over a longer or shorter z-axis length of tissue depending on the ratio (n × T)/I [16]. CT dose indices are estimates of the average radiation dose only in the irradiated volume and are independent of the scan length. Therefore, to assess the total amount of radiation deposited in the patient and determine the risk from ionizing radiation, the dose length product (DLP) has been proposed. The DLP is proportional to the total deposited

applications such as the ImPACT CT Dosimetry Calculator (St George’s Healthcare, London, UK) [20], CT Dose [21], CT Expo [22] and WinDose [23] to obtain organ doses, CTDIw, DLP and ED. To identify whether patient doses are reduced or increased in newer studies, reported results were divided into the following time periods according to publication year: 1991–1995, 1996–2000, 2001–2005 and 2005–2009. ED for head and chest CT examinations were found to be significantly higher for studies published during the earliest considered period (1991–1995) compared with more recent studies (p<0.05), while there was no statistically significant difference between studies published during the latest three periods (1999–2009). ED for abdomen CT examinations were also found to be significantly higher for the studies published during the earliest period considered (1991– 1995) compared with more recent studies (p≤0.05). Additionally, ED for abdomen

reported by the most recent studies (2006– 2009) were found to be significantly higher than those reported during the preceding period (2001–2005) (p=0.03). Finally, results for the pelvis CT examinations for the earliest period were not available and the reported ED for the pelvis in the most recent studies (2006–2009) were found to be significantly higher that those reported during the period 1996–2000 (p=0.02). The reported values for multislice scanners refer to units that acquire from 2 up to 256 slices per rotation. Median ED for multislice CT are equal or lower than those of single-slice CT. However, statistical analysis revealed that owing to the limited number of studies reporting patient doses for non-cardiac examinations with multislice CT there is no adequate statistical power to detect any significant differences between multislice CT and single-slice CT for the assessed CT scan examinations.

Results Dosimetric data for the most common CT examinations of the head and trunk were collected from 42 studies. Reported dosimetric quantities varied among studies with ED being the dose descriptor most frequently quoted. The derivation of reported dosimetric quantities also varied between studies after the following methodologies were employed: 1, the measurement in physical anthropomorphic phantoms of organ doses using suitably calibrated thermoluminescent or silicon photodiode dosemeters. Based on these measurements effective doses were calculated using appropriate organ/tissue weighting factors; 2, the CTDI and DLP values reported at the console display of the CT scanner were assessed and averaged for a patient cohort and ED were calculated by multiplying CTDI and DLP with appropriate conversion coefficients such as those given in the EUR 16262 document [12]; and 3, the scanning parameters and scanner specific CTDI data were fed into Monte Carlo based



issue 2 april 2011

review article


Median effective dose (mSv)

9.0 8.0 7.0 6.0 5.0 4.0 3.0 2.0 1.0 0.0

Head (mSv)

Chest (mSv)

Abdomen (mSv)

Pelvis (mSv)











All studies





Median effective dose for single-slice CT (SSCT) and multislice CT (MSCT) for the most common types of CT examination. The corresponding values from all studies are shown

energy and is given by Equation (4) [17]. Where L is the total scan length. DLP is measured in milligray-centimetres and it increases with an increase in total scan length or with variables that affect the CTDIw (e.g. tube current or voltage) or the CTDIvolume (e.g. pitch). In clinical practice CTDIvolume and DLP are displayed at the operation console of most CT units. Despite its proportional relationship to total deposited energy, DLP cannot be routinely used as a risk indicator because it does not take into account the radiosensitivity of the organs within the irradiated body area. For this purpose the concept of ED has been introduced by the International

Equations 1 (1) CTDI  T (2) (2) (3) (4)


Commission on Radiological Protection [18]. ED can be used for comparing doses from different diagnostic and therapeutic procedures and for comparing the use of similar technologies and procedures in different hospitals and countries as well as from use of different technologies for the same medical examinations [19]. However, for planning the exposure of patients and risk-benefit assessments, the equivalent dose or the absorbed dose to irradiated tissues is the more relevant quantity. The European Commission has proposed DRLs for the dose descriptors CTDIw and DLP for routine CT examination at the European Guidelines on Quality Criteria for CT [12]. The introduction of DRLs provides the baseline information for subsequent dose reduction or optimisation. Discussion

Published results indicate a large variation of patient doses for the same type of CT scan examination. This is unsurprising 1 considering the long time period that this 2 2 1 CTDIw  CTDI CTDIw   CTDI  CTDIcentre  CTDI centre periphery  periphery 3 review covered during which CT scanning 3 3 3 technology has evolved and examination protocols have been optimised. nT CTDI volume  CTDI w  Median CTDIw and DLP values are I below the proposed DRLs for all examinations; however, there are individual DLP  CTDI volume  L studies for which the DRLs are exceeded. Variation of results among studies 

D ( z ) dz

(maximum/minimum reported value) is evident for both dose descriptors; however, it is more profound for DLP and CT examinations of the trunk. CTDIw varies by a factor of 4.2/3.8/6.0/7.2 for studies concerning the head/chest/ abdomen/pelvis, respectively. DLP varies by a factor of 3.2/15.1/9.3/8.2 for the head/chest/abdomen/pelvis, respectively. It is anticipated that variation of CTDIw among studies can be attributed to intrinsic differences among the makes and models of CT scanners such as beam geometry, radiation quality, number of detector rows, absorption and scattered X-rays [24]. An additional significant factor of variation is the selected examination protocol and in particular the milliampere seconds selection because the dose is directly proportional to this [13]. Variations in examination protocols are attributed to different routine protocols among institutions [25] but also to different clinical indications, which can lead to variation in scanning techniques [26]. The greater variability of results for DLP is the result of an additional parameter i.e. scan length. Longer scan lengths can be attributed in part to the use of contrast media since these procedures involve a repeated scan of the same region (i.e. with and without the contrast media) [24]. Two obvious measures to reduce patient dose consequent to the above are reducing the milliampere seconds whilst maintaining diagnostic image quality, especially for thinner than standard patients, and reducing scan length as much as possible without missing any vital anatomical regions. An effect that contributes to increased patient exposure is “overscan” which arises from the requirement in spiral reconstruction algorithms for data beyond the actual volume to be reconstructed [27]. Thus, at the beginning and the end of the scan, volume areas are exposed that are not part of the medical area in question [28]. Regarding ED, results indicate that in CT examinations of the head and neck ED issue 2 april 2011


review article

1. X-ray beam filtration 2. X-ray beam collimation 3. X-ray current modulation and adaptation for patient body habitus 4. peak kilovoltage optimisation 5. improved detection system efficiency 6. noise reduction algorithms. Tube current modulation and patient size dependent tube current adaptation are 24


issue 2 april 2011


U Bladder Testes Uterus


Ovaries Kidneys Liver Stomach Esophagus Chest

CT examination

Lungs Breast Thyroid


is close to 2mSv but increases 2- to 4-fold for examinations of the trunk. Thus, ED for head examinations is lower than that of the trunk although individual organ doses for the head are considerably greater than for other parts of the body. This is owing to the uneven distribution of radiosensitive organs in the human body and the lower weighting factors for the head organs [18]. Accordingly, the correlation between DLP and ED must be separated into two parts: one for CT examinations of the head and one for CT examinations of the trunk [29]. As the relationship between DLP and ED is linear and the relationship between ED and stochastic risk is also assumed to be linear, DLP, which is normally quoted by modern scanners, can be used for comparing the stochastic risk for different CT examinations [29]. The investigation of ED variation over different time periods revealed that ED for CT examinations of the head, chest and abdomen prior to 1995 were significantly higher than for the later studies whereas over the period between 1996 and 2009 the ED remained virtually unchanged. The finding that ED for abdomen and pelvis examinations are increased during the most recent period (2006â&#x20AC;&#x201C;2009) is most likely attributable to studies from developing countries which are in the initial stages of protocol optimisation [24, 30, 31]. Significant dose reduction in more recent studies is attributed to the implementation of dose management procedures that correspond to the ALARA principle [32]. The mechanisms for dose reduction in CT equipment include [33]:

Eye lens Brain 0.0











Organ dose(mGy)

Median organ doses (mGy) per type of CT examination.

jointly referred to as automatic exposure control (AEC). The first commercially available tube current modulation systems were introduced in 1994 and provided dose reduction of up to 20% without considerable degradation of image quality [34]. Subsequent studies validated that dose reduction is achievable and that in elliptical body regions anatomically based modulation of the tube current results in up to 40% dose reduction [35]. Multislice CT technology, which is currently common in clinical practice, increases the efficacy of CT procedures and offers new promising applications such as multiphase exams, vascular and cardiac exams, perfusion imaging and screening exams of the heart, chest and colon [36â&#x20AC;&#x201C;38]. However, the expanding use of multislice CT systems may result in a considerable increase in both the frequency of CT procedures and patient exposure levels. Regarding patient exposure, a certain dose increase compared with single-slice CT is unavoidable owing to underlying physical principles and in particular dose efficiency [39]. The dose efficiency of a CT scanner refers to the fraction of the total X-rays emitted from the X-ray source/s that are captured by the detectors and contribute to image formation. Dose efficiency has two components: the absorption efficiency, which is the

fraction of X-rays that are captured by active detector area; and geometric efficiency, which is the fraction of X-rays that exit the patient and enter the active detector area [40]. The absorption efficiencies of single-slice CT and multislice CT are similar since the same type of detector is used in both cases. However, geometric efficiency for multislice CT is reduced owing to the requirement for dividers between individual detector elements along the z-axis, which create dead spaces [40]. Additionally, with multislice CT only the plateau of the trapezoid dose profile may be used to ensure equal signal level for all detector slices while the penumbra region has to be CT examinations and corresponding number of studies reporting patient doses Examination

Number of studies









Cervical Spine


Thoracic Spine


Lumbar Spine




discarded. This represents a wasted dose to the patient in contrast to single-slice CT where the entire dose profile contributes to detector signal [39, 41]. Since the penumbra accounts for a larger percentage of the beam when a narrow detector configuration is used, dose efficiency is decreased with the use of a narrow collimation. This principle applies to CT scans performed with any multislice CT scanner, but the effect on radiation dose is greater with four slice scanners (because of the small beam size) than with scanners capable of acquiring more slices per rotation [42]. Thus, the relative contribution of the penumbra region to patient dose decreases with increasing slice width and also decreases with increasing number of simultaneously acquired slices [39, 40]. To evaluate the effect of multislice technology for the most common types of CT examinations (head, chest, abdomen and pelvis), the ED were extracted from studies that reported results for singleslice CT and multislice CT. The number of studies that report ED for non-cardiac multislice CT examinations is currently limited and the results for multislice CT refer to various types of scanners that acquire from 2 to 256 slices per rotation. As previously mentioned, median effective doses for multislice CT scans are equal or lower than single-slice CT scans but the statistical power is not adequate to detect any significant differences between them. A few comparative studies have evaluated multislice CT against single-slice CT technology. A study of single-slice CT, dual-slice and quad-slice systems concluded that average ED over all examinations is increased by 10% for quad-slice systems but decreased by 26% for dual-slice systems [43]. Two subsequent studies indicate that doses are increased for multislice CT with four or more detector rows compared with singleslice CT [26, 44] and that on average multislice CT scanners deliver 35% more ED than single-slice CT scanners, although this difference is not uniformly spread across all examinations [44]. The

review article

distinction between single-slice CT and multislice CT ED is generally greatest for examinations using narrow slices (e.g. head or high resolution chest) but is less apparent for other examinations (e.g. abdomen or pelvis) [44]. This characteristic is owing to the necessity of multislice CT scanners to irradiate more of the patient than is actually imaged particularly for acquisition of narrow slices and it can result in doses up to 40% higher compared with well-collimated singleslice CT systems [45]. Regarding comparison of delivered dose among multislice CT with

However, it has to be noted that most comparative studies evaluated single-slice CT scanners that had heavily optimised protocols of exposure settings already available and implemented compared with multislice CT scanners, which were at the beginning of their optimisation process [43]. It is therefore possible that with modern multislice CT scanners, capable of acquiring 16 or more slices per rotation in combination with sophisticated exposure reduction techniques, radiation doses to patients during CT examinations could be substantially reduced. However, the improved clinical efficacy and new

Multislice CT technology, which is currently common in clinical practice, increases the efficacy of CT procedures and offers new promising applications varying number of detector rows, a study comparing radiation dose at routine chest examination between scanners with 4, 8 and 16 rows revealed a trend towards decreasing radiation dose with increasing number of detector rows [46]. Another study comparing doses associated with 16-slice and 256-slice scanners also concluded that dose reduction is achieved for all types of CT examinations with the 256-slice scanner [47]. A recent study comparing organ and ED in chest and abdominal CT examinations concluded that doses associated with 64-slice scanners are similar to those with 4-, 8and 16-slice scanners [48]. A development in multislice CT technology is the introduction of scanners with two X-ray tubes, for which patient doses could be up to a factor of two lower than a single source CT scanner of the same number of acquired slices [49]. A concurrent finding of the above comparative studies is that multislice CT scanners with more that 4 detector rows deliver higher patient dose than singleslice CT and that patient dose is decreased with increasing number of detector rows.

applications available with multislice CT are likely to lead to rising examination frequency and thorough justification of exams and an effort to minimise patient irradiation should always be undertaken. Conclusion

Patient radiation doses from CT examinations vary among studies owing to differences in CT scanner design and examination protocols. However, reported values are generally lower than the proposed DRLs. The introduction of mechanisms for dose reduction resulted in significantly lower patient ED for CT examinations of the head, chest and abdomen reported by studies published after 1995. Multislice scanners have increased the efficacy and clinical indications for CT but are also burdened, at least in theory, with increased patient irradiation. The currently limited number of studies that report patient doses for multislice CT examinations prohibit the detection of differences between multislice and single-slice scanners. www

Download the full length article including references at: DOI: 10.1259/bjr/69070614

issue 2 april 2011


The British Journal of Radiology Abstracts

Abstracts Reduction of motion artefacts in on-board cone beam CT by warping of projection images Objectives:

We describe a motion compensation method using a limited number of radio-opaque markers tracked in the projection data. Methods:

A local motion correction method for flat panel imager-based cone beam CT (CBCT) by warping of projection images has been developed and tested. Markers within or on the surface of the patient were tracked and their mean three-dimensional (3D) position calculated. The two-dimensional (2D) cone beam projection images were then warped before reconstruction to place each marker at the projection from its mean 3D position. The motion correc-

tion method was tested using simulated cone beam projection images of a deforming virtual phantom, real CBCT images of a moving breast phantom and clinical CBCT images of a patient with breast cancer and another with pancreatic cancer undergoing radiotherapy.


Clinical CBCT images showed improved image quality in the locality of the radiotherapy target after motion correction.


In phantom studies, the method was shown to greatly reduce motion artefacts in the locality of the radiotherapy target and allowed the true surface shape to be accurately recovered. The breast phantom motion compensated surface was within 1 mm of the true surface shape for 90% of surface points and greater than 2 mm from the true surface at only 2% of points.

T E Marchant, G J Price, B J Matuszewski and C J Moore North Western Medical Physics, The Christie NHS Foundation Trust, Manchester, UK

www Download the full length article: DOI: 10.1259/bjr/90983944

A method for calculating the dose length product from CT DICOM images Objectives:

The dosimetric calculations in CT examinations are currently based on two quantities: the volume weighted CT dose index (CTDIvol) and the doseâ&#x20AC;&#x201C;length product (DLP). The first quantity is dependent on the exposure factors, scan field of view, collimation and pitch factor selections, whereas the second is additionally dependent on the scan length. Methods:

In this study a method for the calculation of these quantities from digital imaging and communication in medicine (DICOM) CT images is presented that allows an objective audit of patient doses. This method was based on software that has been developed to enable the automatic extraction of the 26


issue 2 april 2011

DICOM header information of each image (relating to the parameters that affect the aforementioned quantities) into a spreadsheet with embedded functions for calculating the contribution of each image to the CTDIvol and DLP values. The applicability and accuracy of this method was investigated using data from actual examinations carried out in three different multislice CT scanners. These examinations have been performed with the automatic exposure control systems activated, and therefore the tube current and tube loading values varied during the scans. Results:

The calculated DLP values were in good agreement (5%) with the displayed values. The calculated average CDTIvol values were in similar agreement with

the displayed CTDIvol values but only for two of the three scanners. In the other scanner the displayed CTDIvol values were found to be overestimated by about 25%. As an additional application of this method the differences among the tube modulation techniques used by the three CT scanners were investigated. Conclusion:

This method is a useful tool for radiation dose surveys.

I A Tsalafoutas and S Metallidis Medical Physics Department, Agios Savvas Hospital, 171 Alexandras Avenue, 115 22, Athens, Greece

www Download the full length article: DOI: 10.1259/bjr/37630380

The British Journal of Radiology Abstracts www

For more Abstracts visit:

Evaluation of flow measurement from the first pass bolus T1 weighted images using inversion recovery sequence Objectives:

Previous studies have shown that the organ blood flows (OBFs) calculated using the T1 weighted MRI technique were lower than the expected values. The aims of this study were a flow measurement comparison between the theoretical and experimental flows based on the technique before and after corrections (coil non-uniformity and inflow) using a flow phantom at two different concentrations (0.8 and 1.2 mmol l–1).

phantom and dividing them by the time taken to fill these volumes. T1 weighted turbo fast low angle shot images were used to measure signal intensity change during the first bolus passage of the contrast medium through the phantom using linear phase-encoding acquisition. Results:

The corrected experimental flow based on the technique shows a good agreement with the theoretical flow, where the flow rate is low at the two concentrations.


A flow phantom was designed to produce three different flow rates at the same time. Theoretical flow was calculated by measuring the volumes of the

flow rate is low, such as capillaries. For measuring high flow rate (e.g. artery), additional correction factors should be considered.


The T1 weighted MRI technique after the two correction factors can be used to measure the absolute flow, where the

M Nazarpoor Department of Radiology, Paramedical School, University of Tabriz Medical Sciences, Tabriz, Iran

www Download the full length article: DOI: 10.1259/bjr/18588668

Sensitivity and specificity: imperfect predictors of guideline utility in radiology Objectives:

Many ‘‘guideline development studies’’ have presented the sensitivity (SN) and specificity (SP) of a new decision tool to describe the potential improvements in utilization of imaging techniques as a result of adopting the new guideline. However sensitivity and specificity are measures designed to assess how well a new guideline compares to a gold standard. These measures do not evaluate how many patients with a positive test actually have the disease; nor do they evaluate how many patients with a negative test do not have the disease. Methods:

To evaluate these characteristics of a decision tool other measures, namely the positive predictive value (PPV)

and negative predictive value (NPV), should be calculated. This report highlights some of the main methodological challenges in interpretation of the studies that attempt to evaluate the development of an imaging guideline and the effectiveness of an imaging guideline in real world practice. We define four key measures of a decision tool: sensitivity (SN), specificity (SP), positive predictive value (PPV) and negative predictive value (NPV). Using data from two hypothetical populations, we explain how these measures can be calculated and interpreted. We place special emphasis on the purpose of and differences between the SN-SP and PPV-NPV. Results:

Borrowing information from two studies,

we demonstrate how these measures should be used in the radiology health care services research to evaluate decision guidelines. Conclusion:

The use of appropriate measures for the specific question at hand will ensure the guidelines are useful, safe, costreducing and effective clinical tools.

B Roudsari, C McKinney, D Moore and J Jarvik School of Public Health, Southwestern Medical School, University of Texas, Dallas, Texas, USA

www Download the full length article: DOI: 10.1259/bjr/20598117

issue 2 april 2011


The British Journal of Radiology Abstracts

Development of an imaging-planning program for screen/film and computed radiography mammography for breasts with short chest wall to nipple distance Objectives:

Imaging breasts with a short chest wall to nipple distance (CWND) using a traditional mammographic X-ray unit is a technical challenge for mammographers. The purpose of this study is the development of an imaging-planning program to assist in determination of imaging parameters of screen/film (SF) and computed radiography (CR) mammography for short CWND breasts. Methods:

A traditional mammographic X-ray unit (Mammomat 3000 Siemens, Germany) was employed. The imaging-planning program was developed by combining the compressed breast thickness correction, the equivalent polymethylmethacrylate

thickness assessment for breasts and the tube loading (mAs) measurement. Both phantom exposures and a total of 597 exposures were used for examining the imaging-planning program. Results:

The phantom study showed that the tube loading rapidly decreased with the CWND when the automatic exposure control (AEC) detector was not fully covered by the phantom. For patient exposures with the AEC fully covered by breast tissue, the average fractional tube loadings, defined as the ratio of the predicted mAs using the imaging-planning program and mAs of the mammogram, were 1.10 and 1.07 for SF and CR mammograms, respectively. The predicted mAs values were comparable to the mAs values, as determined by the AEC.


By applying the imaging-planning program in clinical practice, the experiential dependence of the mammographer for determination of the imaging parameters for short CWND breasts is minimised.

S L Dong, J L Su, Y H Yeh, T C Chu, Y C Lin and K S Chuang Department of Biomedical Engineering and Environmental Sciences, National Tsing Hua University, Taiwan, Republic of China

www Download the full length article: DOI: 10.1259/bjr/97507379

Comparison of diamond-like carbon-coated nitinol stents with or without polyethylene glycol grafting and uncoated nitinol stents in a canine iliac artery model Objectives:

Neointimal hyperplasia is a major complication of endovascular stent placement with consequent in-stent restenosis or occlusion. Improvements in the biocompatibility of stent designs could reduce stent-associated thrombosis and in-stent restenosis. We hypothesised that the use of a diamondlike carbon (DLC)-coated nitinol stent or a polyethylene glycol (PEG)-DLCcoated nitinol stent could reduce the formation of neointimal hyperplasia, thereby improving stent patency with improved biocompatibility Methods:

A total of 24 stents were implanted, under general anaesthesia, into the iliac arteries of six dogs (four stents in each dog) using the carotid artery 28


issue 2 april 2011

approach. The experimental study dogs were divided into three groups: the uncoated nitinol stent group (n=58), the DLC-nitinol stent group (n=58) and the PEG-DLC-nitinol stent group (n=58). Results:

The mean percentage of neointimal hyperplasia was significantly less in the DLC-nitinol stent group (26.7±7.6%) than in the nitinol stent group (40.0±20.3%) (p=0.021). However, the mean percentage of neointimal hyperplasia was significantly greater in the PEG-DLC-nitinol stent group (58.7±24.7%) than in the nitinol stent group (40.0±20.3%) (p=0.01). Conclusion:

Our findings indicate that DLC-coated nitinol stents might induce less neoin-

timal hyperplasia than conventional nitinol stents following implantation in a canine iliac artery model; however, the DLC-coated nitinol stent surface when reformed with PEG induces more neointimal hyperplasia than either a conventional or DLC-coated nitinol stent.

J H Kim, J H Shin, D H Shin, M-W Moon, K Park, T-H Kim, K M Shin, Y H Won, D K Han and K-R Lee Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

www Download the full length article: DOI: 10.1259/bjr/21667521

The British Journal of Radiology Abstracts

Accuracy of multislice CT angiography for the assessment of in-stent restenoses in the iliac arteries at reduced dose: a phantom study Objectives:

We investigated the potential of low-dose CT angiography for accurate assessment of in-stent restenoses (ISRs) of the iliac artery. Methods:

A Rando anthropomorphic phantom (Alderson Research Labs, Stanford, CA), custom-made wax simulating hyperplastic tissue and a nitinol stent were used to simulate a patient with clinically relevant iliac artery ISRs. The cylindrical lumen was filled with a solution of iodine contrast medium diluted in saline, representing a patient’s blood during CT angiography. The phantom was subjected to standard and low-dose angiographic exposures using a modern multidetector (MD) CT scanner. The percentage of ISR was determined using the profile along a

line normal to the lumen axis on reconstructed images of 2 and 5 mm slice thickness. Percentage ISRs derived using the standard and low-dose protocols were compared. In a preliminary study, seven patients with stents were subjected to standard and low-dose MDCT angiography during follow-up. Results:

The resulting images were assessed and compared by two experienced radiologists. The accuracy in measuring the percentage ISR was found to be better than 12% for all simulated stenoses. The differences between percentage ISRs measured on images obtained at 120 kVp/160 mAs and 80 kVp/80 mAs were below 6%. Patient image sets acquired using low-exposure factors were judged to be of satisfactory diagnostic quality. The assessment of ISR

did not differ significantly between image sets acquired using the standard factors and those acquired using the low-exposure factors, although the mean reduction in patient effective dose was 48%. Conclusion:

A reduction in exposure factors during MDCT angiography of the iliac artery is possible without affecting the accuracy in the determination of ISRs.

K Perisinakis, E Manousaki, K Zourari, D Tsetis, A Tzedakis, A Papadakis, A Karantanas and J Damilakis Department of Medical Physics, Faculty of Medicine, University of Crete, PO Box 2208, 71003 Heraklion, Crete, Greece

www Download the full length article: DOI: 10.1259/bjr/63029326

64-slice multidetector row CT angiography of the abdomen: comparison of low versus high concentration iodinated contrast media in a porcine model Objectives:

In this study we aimed to assess the image quality and degree of vascular enhancement using low-concentration contrast media (LCCM) (300 mg ml–1) and high concentration contrast media (HCCM) (370 mg ml–1) on 64-slice multidetector row CT (MDCT) abdominal CT angiography (CTA). In addition, we aimed to study the feasibility of using HCCM with a reduced total iodine dose.

and Group C HCCM with 20% less iodine dose. The total iodine injected was kept constant (600 mg kg–1) in Groups A and B. Qualitative and quantitative analyses were performed to study and compare each group for image quality, visibility of the branch order of the superior mesenteric artery (SMA), artefacts, degree of enhancement in the aorta and main stem arteries and uniformity of enhancement in the aorta. Groups were compared using the analysis of variance test.

as compared with Groups A and C (p≤0.05). Uniform aortic enhancement was achieved with the use of LCCM and HCCM with 20% less iodine dose. Conclusion:

64-slice MDCT angiography of the abdomen was of excellent quality. HCCM improves contrast enhancement and overall CTA image quality and allows the iodine dose to be reduced.


CTA of the abdomen on a 64-slice MDCT was performed on 15 anaesthetised pigs. Study pigs were divided into three groups of five each based on the iodine concentration and dose received: Group A (LCCM; 300 mg ml–1), Group B (HCCM; 370 mg ml–1)


The image quality of 64-slice MDCT angiography was excellent with a mean score of 4.63 and confident visualisation of the third to fifth order branches of the SMA in all groups. Group B demonstrated superior vascular enhancement,

N-S Holalkere, K Matthes, S P Kalva, W R Brugge and D V Sahani Boston Medical Center, Department of Radiology, Boston, MA 02118, USA

www Download the full length article: DOI: 10.1259/bjr/14535110

issue 2 april 2011


The British Journal of Radiology Abstracts

Hepatic artery guide wire targeting technique during transjugular intrahepatic portosystemic shunt Objectives:

This study evaluated the feasibility and safety of the transjugular intrahepatic portosystemic shunt (TIPS) procedure using the hepatic arterytargeting guidewire technique for the puncture step.

hepatic artery. At the puncture step, the tip of the metallic cannula was aimed 1cm posterior to the distal part of this micro-guidewire, after which the TIPS procedure was performed. Success rate, number of punctures and complications were evaluated.



We retrospectively reviewed 11 consecutive patients (5 men and 6 women, aged 46–76 years (mean 64 years)) with portal hypertension in whom the TIPS procedure was performed. As the first step in the TIPS procedure in all cases, a micro-guidewire was inserted into the hepatic arterial branch accompanying the portal venous branch through a microcatheter coaxially advanced from a 5-French catheter positioned in the coeliac or common

The TIPS procedure was successfully performed in all 11 patients. The mean number of punctures until success in entering the targeted portal venous branch was 5 (range 1–14). In 3 patients (27%), the right portal venous branch was entered at the first puncture attempt. The hepatic artery was punctured once in one patient and the bile duct was punctured once in another patient. No serious procedure-induced complications occurred.


The TIPS procedure can be accomplished safely, precisely and relatively easily using the hepatic artery-targeting guidewire technique.

T Yamagami, O Tanaka, R Yoshimatsu, H Miura, T Suzuki, T Hirota and T Nishimura Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Japan

www Download the full length article: DOI: 10.1259/bjr/19972953

The detection and discrimination of malignant and benign focal hepatic lesions: T2 weighted vs diffusion weighted MRI Objectives:

The purpose of this study was to evaluate the use of diffusion weighted imaging (DWI) for the detection and characterisation of focal hepatic lesions compared with the use of T2 weighted imaging.

images and dynamic T1 weighted images. Breathhold fat-suppressed single-shot echo planar DWI was performed with the following parameters: 1338/66; b factors, 0, 50 and 800smm–2. Two independent observers reviewed the T2 weighted images and the DWI to detect and to characterise the hepatic lesions.



45 patients with 97 hepatic lesions (51 malignant lesions and 46 benign lesions) were included in this retrospective study. Malignant hepatic lesions included 12 hepatocellular carcinomas, 26 metastases and 13 intrahepatic cholangiocarcinomas. Benign hepatic lesions included 19 haemangiomas and 27 cysts. The MRI protocol for the upper abdomen included T2 weighted images, in- and opposed-phase T1 weighted

For detection of malignant hepatic lesions, the use of DWI showed a significantly higher detection rate than the use of T2 weighted images (p<0.05). However, there was no significant difference between the use of DWI and T2 weighted images for benign hepatic lesions. For the differentiation between malignant and benign hepatic lesions, there was no significant difference in sensitivity, specificity and accuracy



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between the use of T2 weighted images and the use of DWI. Conclusion:

The use of DWI was better for the detection of malignant hepatic lesions than the use of T2 weighted images. However, for detection of benign hepatic lesions and characterisation of hepatic lesions, the use of DWI was equivalent to the use of T2 weighted images.

D M Yang, G Jahng, H C Kim, W JIN, C W Ryu, D H Nam, Y K Lee and S Y Park Department of Radiology, Kyung Hee University East-West Neo Medical Center, 149 Sangil-Dong, GangdongGu, Seoul, Korea

www Download the full length article: DOI: 10.1259/bjr/50130643

The British Journal of Radiology Abstracts

Interventional management for complications following caesarean section


This study aimed to evaluate the efficacy and safety of interventional management for various intractable complications following caesarean section. Methods:

Between August 2005 and September 2009, 18 consecutive women were referred to interventional radiology for treatment of complications developing after caesarean section. Complications included vaginal bleeding (n=14), haemoperitoneum with abdominal wall haematoma (n=2), caesarean scar pregnancy (CSP) (n=1) and post-cesarean fluid collection (n=1). Results:

17 women underwent transcatheter arterial embolisation (TAE) with a variety of embolic materials, and

two women underwent percutaneous drainage (PCD) for fluid collection and haemoperitoneum. 5 of the 14 women with vaginal bleeding had extravasation of contrast media on angiography; the other nine had no visible bleeding foci. The two women with haemoperitoneum with abdominal wall haematoma had injury to the inferior epigastric artery from angiography. TAE and PCD were successfully performed in both women. The CSP was successfully managed and the serum β-human chorionic gonadotropin (β-hCG) level finally normalised. Hysterectomy or dilatation and curretage was required in women with placenta accrete and undetectable bleeding foci. Interventional management including TAE and PCD is effective and safe in controlling complications following caesarean section.


Use of these procedures can help avoid high-risk surgery, but subsequent procedures including hysterectomy may be required in cases of placental abnormalities and undetectable bleeding foci.

S Y Ko, S W Park, I S Sohn, J Y Lee, H-S Kwon, H-S Hwang and S I Jung Department of Radiology and Research Institute of Medical Science, Konkuk University Hospital, Seoul, Korea

www Download the full length article: DOI: 10.1259/bjr/53617758

Factors associated with nodal metastasis in nasopharyngeal cancer: an approach to reduce the radiation field in selected patients Objectives:

The purpose of this study was to investigate factors associated with lymph node (LN) metastasis to identify which nasopharyngeal cancer (NPC) patients can undergo a reduction in the prophylactic radiation field. MRI of biopsy-proven NPC patients was evaluated to determine primary tumour extension and the existence of LN metastasis. Methods:

Sex, age, pathological type, T stage, primary tumour size, existence beyond the midline of the nasopharynx at the primary site and parapharyngeal extension of the primary tumour were assessed regarding their impact on the laterality of LN metastasis using the χ2 test.


Of the 167 patients, 149 (89%) showed nodal involvement. The existence beyond the midline of the nasopharynx was significantly associated with the laterality of LN metastasis (p<0.0001). Most patients (82%) with primary tumour presence within the midline showed only ipsilateral LN metastasis or no LN metastasis. In addition, contralateral LN metastases were seen only at Level II and the retropharyngeal LN among most of other patients.

retropharyngeal LN. Whether disease control is compromised by reducing the radiation field for subclinical diseases is a problem that should be solved in the future by prospective study.


These results suggest that LN areas other than Level II and the retropharyngeal LN on the contralateral side could be omitted in patients with primary tumour presence within the midline and without the contralateral Level II or the

N Tomita, N Fuwa, Y Ariji, T Kodaira and N Mizoguchi Department of Radiation Oncology, Aichi Cancer Center Hospital, Nagoya, Japan

www Download the full length article: DOI: 10.1259/bjr/47164832

issue 2 april 2011



The British Journal of Radiology Abstracts

Clinical target volume delineation in glioblastomas: pre-operative versus postoperative/pre-radiotherapy MRI Objectives:

ping and composite volumes.

Delineation of clinical target volume (CTV) is still controversial in glioblastomas. In order to assess the differences in volume and shape of the radiotherapy target, the use of pre-operative vs postoperative/pre-radiotherapy T1 and T2 weighted MRI was compared. Methods:

4 CTVs were delineated in 24 patients preoperatively and post-operatively using T1 contrast-enhanced (T1PRE CTV and T1POSTCTV) and T2 weighted images (T2PRECTV and T2POSTCTV). Pre-operative MRI examinations were performed the day before surgery, whereas postoperativeexaminations were acquired 1 month after surgery and before chemoradiation. A concordance index (CI) was defined as the ratio between the overlap-


The volumes of T1PRECTV and T1POST CTV were not statistically different (248±88 vs 254±101), although volume differences 100 cm3 were observed in 6 out of 24 patients. A marked increase due to tumour progression was shown in three patients. Three patients showed a decrease because of a reduced mass effect. A significant reduction occurred between pre-operative and post-operative T2 volumes (139±68 vs 78±59). Lack of concordance was observed between T1PRECTV and T1POSTCTV (CI=0.67±0.09), T2PRECTV and T2POSTCTV (CI=0.39±0.20) and comparing the portion of the T1PRECTV and T1POSTCTV not covered by that defined on T2PRECTV images (CI=0.45±0.16 and 0.44±0.17, respectively).


Using T2 MRI, huge variations can be observed in peritumoural oedema, which are probably due to steroid treatment. Using T1 MRI, brain shifts after surgery and possible progressive enhancing lesions produce substantial differences in CTVs. Our data support the use of postoperative/pre-radiotherapy T1 weighted MRI for planning purposes.

P Farace, M Giri, G Meliado, D Amelio, L Widesott, G K Ricciardi et al Department of MorphologicalBiomedical Sciences, Section of Anatomy and Histology, University of Verona, Italy

www Download the full length article: DOI: 10.1259/bjr/10315979

Clinical challenges in the implementation of a tomotherapy service for head and neck cancer patients in a regional UK radiotherapy centre Objectives:

Intensity-modulated radiotherapy (IMRT) is increasingly being used to treat head and neck cancer cases. We discuss the clinical challenges associated with the set-up of an image guided intensity modulated radiotherapy service for a subset of head and neck cancer patients, using a recently commissioned helical tomotherapy (HT) Hi Art (Tomotherapy Inc, WI) machine in this article. Methods:

We also discuss the clinical aspects of the tomotherapy planning process, treatment and image guidance experiences for the first 10 head and neck cancer cases. The concepts of geographical miss along with tomotherapy-specific effects, including that of field width and megavoltage CT (MVCT) imaging strategy 32


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has been highlighted using the first 10 head and neck cases treated. There is a need for effective streamlining of all aspects of the service to ensure compliance with cancer waiting time targets. We discuss how patient toxicity audits are crucial to guide refinement of the newly set-up planning dose constraints.

approach and relies heavily on good team working and effective communication between different staff groups.


This article highlights the important clinical issues one must consider when setting up a head and neck IMRT, imageguided radiotherapy service. It shares some of the clinical challenges we have faced during the setting up of a tomotherapy service. Conclusion:

Implementation of a clinical tomotherapy service requires a multidisciplinary team

S Chatterjee, J H Mott, G Smyth, S Dickson, W Dobrowsky and C G Kelly Northern Centre for Cancer Care and Regional Medical Physics Department, Freeman Hospital, Newcastle-upon-Tyne, UK

www Download the full length article: DOI: 10.1259/bjr/19586137

The British Journal of Radiology Abstracts

Intensity-modulated radiotherapy in patients with head and neck cancer: a European single-centre experience Objectives:

The purpose of this study was to analyse retrospectively the intensity-modulated radiotherapy (IMRT) results in patients with head and neck cancer (HNC) treated between November 2003 and June 2007. Methods:

Patients with early and locoregionally advanced HNC were treated with inverse-planned step-and-shoot IMRT. The prescribed dose varied from 66 Gy to 70 Gy in those receiving IMRT as definitive treatment and from 60 Gy to 70 Gy in the post-operative setting. IMRT was given alone, after induction chemotherapy (ICT), with concomitant chemotherapy (CRT) or with both. Acute and late toxicities are reported; locoregional control (LRC), locore-

gional relapse-free survival (LRRFS) and overall survival (OS) were calculated from the start of radiation.

60.3% in the definitive IMRT group and 85.4%, 82.5%, 85.9% in the post-operative setting, respectively.



IMRT was used in 78 patients (48 as definitive treatment, 30 post-operatively), of whom 20 also received ICT and 35 CRT. Three patients stopped IMRT early, one for toxicity (mucosa). Acute toxicity scoring revealed 5 cases (6%) of severe skin toxicity and 65 cases (83%) of severe mucosal toxicity. After a median follow-up of 18.7 months, late toxicities included xerostomia (44%), loss of taste (14%) and fibrosis of the neck (9%). 16 patients had died, of whom 10 due to tumour recurrence/ progression and 2 due to treatment (but not IMRT related). The LRC, LRRFS and OS at 3 years are 66.1%, 48.5%,

We consider IMRT for locoregional HNC feasible not only as a single modality but also after surgery, after induction chemotherapy and concurrently with chemotherapy.

D Van Gestel, D Van Den Weyngaert, D Schrijvers, J Weyler and J B Vermorken Department of Radiotherapy, University of Antwerp, Antwerp, Belgium

www Download the full length article: DOI: 10.1259/bjr/67058055

Directional diffusivity changes in the optic nerve and optic radiation in optic neuritis Objectives:

Optic neuritis (ON) is defined as an inflammation of the optic nerve and provides a useful model for studying the effects of inflammatory demyelination of white matter. The aim of this study was to assess the diffusion changes in both the optic nerve and optic radiation in patients with acute and chronic ON using diffusion tensor (DT) MRI. Methods:

33 patients with idiopathic demyelinating optic neuritis (IDON) and 33 gender- and age-matched healthy controls were examined with DT-MRI and with T1 and T2 weighted MRI. Results:

Compared with controls, both first-

episode and recurrent patients with IDON in the acute stage showed significantly increased radial diffusivity (λ┴) and decreased mean fractional anisotropy (FA) in the affected nerves. Reduced FA, increased λ┴, mean diffusivity (MD) and axial diffusivity (λ//) were determined in patients with subacute IDON. We found no significant difference in the directional diffusivity of optic radiation in patients whose disease had lasted less than 1 year compared with healthy controls. However, significant changes in the FA and λ┴ of the optic radiation were detected in patients with disease duration of more than 1 year. Conclusion:

These results show the great potential and capacity of DT-MRI measures as

useful biomarkers and indicators for the evaluation of myelin injury in the visual pathway.

M Li, J Li, H He, Z Wang, B Lv, W Li, N Hailla, F Yan, J Xian and L Ai Department of Radiology, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China

www Download the full length article: DOI: 10.1259/bjr/93494520

issue 2 april 2011


The British Journal of Radiology Abstracts

Prognostic significance of parameters derived from co-registered 18FFluorodeoxyglucose PET and contrast-enhanced MRI in patients with high-grade glioma Objectives:

The aim of this study was to determine the prognostic significance of the volume and intensity of abnormal 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) accumulation within areas of contrast-enhancement on post-therapeutic volumetric MRI. Methods:

A total of 10 patients with Grade III or IV glioma were treated with resection followed by intracavitary radiation therapy with 131I-labelled antitenascin monoclonal antibody. Patients underwent serial FDG-PET and 1.5 T MR imaging. For each patient, MR and FDG-PET image volumes at each time point were aligned using a rigid-body normalised mutual information algorithm. Contrast enhancing regions-of-interest (ROI) were

defined using a semi-automated k-means clustering technique. Activity within the ROI on the co-registered PET scan was calculated as a ratio (mean activity ratio; MAR) to activity in contralateral normal appearing white matter (NAWM). The PET lesion was defined as the portion of the ROI associated with activity greater than two standard deviations above the mean in NAWM. Survival was assessed using the log-rank test.


Following intracavitary radiation therapy, the development of contrastenhancing lesions that are associated with high mean FDG-PET accumulation suggests poor prognosis.


Larger contrast-enhancing ROIs were strongly associated with an increased MAR (r=0.51; p<0.002). Enhancing lesions with an MAR >1.2 were associated with decreased survival (p<0.016). In nine patients who died, the MAR on PET correlated inversely with survival duration (r = -0.43; p<0.01), whereas PET lesion volume did not.

M J Paldino, T Z Wong, D A Reardon, H S Friedman and D P Barboriak Duke University Medical Center, Department of Radiology, Durham, NC, USA

www Download the full length article: DOI: 10.1259/bjr/48528504

Comparison of pulmonary HRCT findings and serum KL-6 levels in patients with sarcoidosis Objectives:

This study aimed to compare thinsection CT images from sarcoidosis patients who had either normal or elevated serum KL-6 levels.

KL-6 levels, retrospectively and independently interpreted CT images for parenchymal abnormalities, enlarged lymph nodes and pleural effusion.

(p>0.001, p>0.005, p>0.001, p>0.001, p>0.001 and p>0.001, respectively). By comparison, there was no significant difference in frequency of lymph node enlargement between the two groups.

Results: Methods:

101 patients with sarcoidosis who underwent thin-section CT examinations of the chest and serum KL-6 measurements between December 2003 and November 2008 were retrospectively identified. The study group comprised 75 sarcoidosis patients (23 male, 52 female; aged 19–82 years, mean 54.1) with normal KL-6 levels (152–499 Uml-1, mean 305.7) and 26 sarcoidosis patients (7 male, 19 female; aged 19–75 years, mean 54.3) with elevated KL-6 levels (541–2940 Uml-1, mean 802.4). Two chest radiologists, unaware of 34


issue 2 april 2011

CT findings in sarcoidosis patients consisted mainly of lymph node enlargement (70/75 with normal KL-6 levels and 21/26 with elevated KL-6 levels), followed by nodules (50 and 25 with normal and elevated levels, respectively) and bronchial wall thickening (25 and 21 with normal and; elevated levels, respectively). Ground-glass opacity, nodules, interlobular septal thickening, traction bronchiectasis, architectural distortion and bronchial wall thickening were significantly more frequent in patients with elevated KL-6 levels than those with normal levels


These results suggest that serum KL-6 levels may be a useful marker for indicating the severity of parenchymal sarcoidosis.

K Honda, F Okada, Y Ando, H Mori, K Umeki, H Ishii, J Kadota, M Ando, E Miyazaki And T Kumamoto Faculty of Medicine, Oita University, Oita, Japan

www Download the full length article: DOI: 10.1259/bjr/65287605

The British Journal of Radiology Abstracts

Image quality of multiplanar reconstruction of pulmonary CT scans using adaptive statistical iterative reconstruction Objectives:

We investigated the image quality of multiplanar reconstruction (MPR) using adaptive statistical iterative reconstruction (ASIR). Methods:

Inflated and fixed lungs were scanned with a garnet-detector CT in high-resolution mode (HR mode) or non-high resolution mode (non-HR mode), and MPR images then reconstructed. Observers compared 15 MPR images of ASIR (40%) and ASIR (80%) with those of ASIR (0%), and assessed image quality using a visual five-point scale (1, definitely inferior; 5, definitely superior), with particular emphasis on normal pulmonary structures, artefacts, noise and overall image quality (LRC), locoregional relapse-free survival (LRRFS) and overall survival

(OS) were calculated from the start of radiation.

image quality; ASIR did not suppress the severe artefacts of contrast medium.



The mean overall image quality scores in HR mode were 3.67 with ASIR (40%) and 4.97 with ASIR (80%). Those in non-HR mode were 3.27 with ASIR (40%) and 3.90 with ASIR (80%). The mean artefact scores in HR mode were 3.13 with ASIR (40%) and 3.63 with ASIR (80%), but those in non-HR mode were 2.87 with ASIR (40%) and 2.53 with ASIR (80%). The mean scores of the other parameters were greater than 3, whereas those in HR mode were higher than those in non-HR mode. There were significant differences between ASIR (40%) and ASIR (80%) in overall image quality (p<0.01). Contrast medium in the injection syringe was scanned to analyse

In general, MPR image quality with ASIR (80%) was superior to that with ASIR (40%). However, there was an increased incidence of artefacts by ASIR when CT images were obtained in non-HR mode.

O Honda, M Yanagawa, A Inoue, A Kikuyama, S Yoshida, H Sumikawa, K Tobino, M Koyama and N Tomiyama Osaka University Graduate School of Medicine, Osaka, Japan www Download the full length article: DOI: 10.1259/bjr/57998586

To view these and the rest of the abstracts available this month, visit The British Journal of Radiology online at

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The development and impl Designed to treat a moving target with unprecedented speed and accuracy, Varian’s TrueBeam system incorporates numerous technical innovations that dynamically synchronise imaging, patient positioning, motion management and treatment delivery during a radiotherapy or radiosurgery procedure. Introduced last April, TrueBeam has been designed from the ground-up to advance the treatment of lung, breast, prostate, head and neck and other types of cancer. An important feature of the TrueBeam system is its high intensity mode, which makes it possible to deliver doses up to four times faster than can be accomplished with other radiosurgery machines, significantly shortening treatment times. This capability makes the system ideal for stereotactic radiosurgery (SRS) and respiratory or hypofractionated radiotherapy treatments. Cutting down treatment time by a factor of between



issue 2 april 2011

two and four makes a big difference to patients, and it can enhance treatment accuracy by leaving less time for tumour motion during dose delivery. Using the TrueBeam system, a standard intensitymodulated treatment that would typically take 10min can be completed in less than 2min. Such advances in speed of treatment enable greater throughput at busy radiotherapy centres. The flexibility of the system offers a selection of an optimal treatment approach in each case, from 3D conformal and intensity-modulated radiotherapy (IMRT) to SRS, from stereotactic body radiotherapy (SBRT) to volumetric arc (RapidArc) therapy. In addition, a new gated RapidArc capability makes it possible to use RapidArc with tumours that are subject to respiratory motion, such as many tumours of the lung or liver. “Intelligent” automation further speeds treatment with up to a five-fold

reduction in the number of steps needed for imaging, positioning and treating patients. The user interface is more workflow oriented, while optical indicators prompt the user to the next logical step in set-up, imaging and treatment. A 9-field IMRT treatment that would have required 52 separate steps or mouse-clicks using earlier generations of technology can now be completed in fewer than 10 steps. Central to the system’s improved performance and new capabilities is Maestro, a new electronic controller which establishes a new level of synchronisation between imaging, patient positioning, motion management, beamshaping and dose-delivery technologies. Accuracy checks are performed every 10ms throughout the treatment, and over 100 000 data points are monitored continually as the treatment progresses. The TrueBeam system has a complete suite of powerful imaging tools to image and therefore treat with confidence. 3D anatomical images are generated in 60% less time, with a 25% reduction in X-ray dose to the patient when compared with earlier generations of technology. This reduction has been achieved thanks to an improved, faster cone beam CT reconstruction algorithm, a new X-ray beam-hardening filter and better scattering compensation calculations. Imaging is not limited to pre-treatment patient position verification – the treatment delivery can easily be monitored and documented using kV image acquisition during treatment and respiration-synchronised MV and kV radiographs. TrueBeam is the result of 10 years’ development work at Varian’s research and development and engineering facilities in the United States, Switzerland and the UK. The desire was to create a new radiotherapy treatment device from the ground up, integrating all recent technological advances into a new platform


lementation of TrueBeam

The TrueBeam system

rather than having them as “bolt-ons” to previous systems. Such an approach would bring ergonomic and treatment benefits as well as enabling future advances to take place. Indeed, among the features on TrueBeam is a “developer mode”, an easily accessible non-clinical research mode that is intended to unlock the imagination of users and encourage future enhancements. Zürich University Hospital became the first hospital in the world to commence treating cancer patients with the TrueBeam system last year. Two patients with vestibular schwannomas (benign nerve sheath tumours) were the first to receive RapidArc SRS treatments on the hospital’s new TrueBeam system. At the highest dose-delivery rate available on the system these treatments took just over 1.6 min to deliver (treatments that would require 6-8 minutes at conventional dose-delivery rates). Professor Urs

M Lütolf, clinical director and chairman of the Department of Radiation Oncology at Zürich University Hospital, said, “It’s a quarter of the time we needed for this type of treatment before.” Since the first treatment, doctors at the hospital have delivered treatments for prostate and lung cancer, as well as schwannomas, and brain and spinal metastases. VU University Medical Centre in Amsterdam introduced clinical TrueBeam treatments shortly after Zürich University Hospital. “From a clinical perspective, TrueBeam enables better integration between imaging and treatment delivery, much faster dose output using the flattening filter free mode, and a much shorter time is needed for pre-treatment set-up due to the user-friendly nature of the equipment,” said Professor Ben Slotman, the hospital’s head of radiation oncology. He continued, “Thanks to the higher dose rate delivery capabilities of TrueBeam

and the speed of RapidArc, we are able to minimise the time needed on the treatment couch and really limit the opportunity for tumour motion during treatment.” Also among the first hospitals to introduce TrueBeam treatments was the UAB Comprehensive Cancer Center in Birmingham, Alabama. UAB clinicians have used the TrueBeam system to deliver fast, highly precise treatment for tumours of the brain, spine, lung, liver, prostate, head and neck, and pancreas. Dr John Fiveash said, “We are tremendously excited about this powerful and fully integrated high-end system, and regard it as a significant step forward in our ongoing commitment to providing patients with access to the best of available contemporary radiosurgical technology”. Recently a 54-year-old head and neck cancer patient became the first person in Italy to be treated using a TrueBeam system at the Humanitas Clinic in Rozzano-Milan. The patient, who suffered from cancer of the rhino pharynx, received the required dose of radiotherapy in five treatment sessions using 2-arc RapidArc radiotherapy, after which clinicians said his symptoms had alleviated considerably. Dr Marta Scorsetti, chief physician at the private clinic, said the TrueBeam accelerator will be used to treat 50 patients a day and treatments will focus on hypofractionated SBRT, in particular for liver and pancreatic cancer, non small-cell lung cancer and lymph-node metastases. “TrueBeam will enable us to offer treatments for different kinds of pathologies than have previously been possible with radiosurgery here at Humanitas,” said Dr Scorsetti. “In particular we will be able to treat patients with previously treated recurrences which could not have been re-treated otherwise.” Peter Vereecke, Product Manager Delivery Systems, Varian Medical Systems

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The BIR events team organises a variety of events for external clients ranging from large annual congresses and one-off special events to intimate meetings. The department has a proven track record of efficient conference and exhibition management, having organised exhibitions from 100 - 6000m2 and delegate numbers from 12 - 4000. We can provide a comprehensive bespoke event management service to meet your needs. • Full event management service • Event planning and logistics • Venue sourcing • Marketing • Abstract Management • Design • Website management • Online registration and payment facilities • Audio visual requirements • Set design and production • Event recording • Catering • Entertainment BIR Events Management 36 Portland Place, London, W1B 1AT T: 020 7307 1400 E: W:


bir news


CEO Report The British Institute of Radiology (BIR) is delighted to be spearheading the development of a website that tells the history of radiology. We plan to draw together all the relevant resources held by the BIR, working in collaboration with sister societies and other relevant organisations from around the world. The aim is to document the history of radiology through stories, photographs, film and sound clips and bring it up-to-date with the most recent breakthroughs and research. We hope to include items such as: • A timeline, showing the key years in the development of radiology and its context with major world events • History stories, gathered from senior and retired members of the BIR and sister organisations • Documentary evidence, with film footage from television documentaries and dramas • Biographies of eminent past and present people from the radiology community • A photo album

• Details of relevant Nobel prizes and excerpts from prize winners’ speeches • A history of the BIR and an emphasis on the British contribution to the field • A members-only link to the digitised back issues of the BJR • Equipment gallery, showing the evoltion of radiological equipment • Company histories. The website would be available to everyone. We believe that it will raise our profile with the general public; attract new members; raise the profile of radiology to new audiences, making it a useful resource for research and education; promote interest in careers in radiology; help to develop links with other bodies, nationally and internationally; allow us to sort, catalogue and utilise much of the BIR’s extensive archived collection; and assist us with completing the retrodigitisation of The British Journal of Radiology through funding for this project. Our information specialist, Khalda Mohammed, is managing this project and working with volunteer members.

We have already undertaken the scoping and planning exercise and are moving into the stage of cataloguing archived material. We hope to launch the website in December, the 100th anniversary of Marie Curie winning the Nobel Prize for chemistry. Both individuals and companies can help us by forwarding history stories, historical documents, photos, memorabilia, equipment, etc., for inclusion in the project. We also seek volunteers to (a) help us sort through approximately 400 boxes of archived material, (b) research and write features for the site and (c) assist with copyediting. While we are delighted to have received funding from the Magnetic Resonance Radiologists Association (UK), we very much need more funding in the form of donations, legacies and corporate sponsorship. If you would like to offer assistance or support in any way, please contact Khalda Mohammed on khalda.mohammed@bir. or 020 7307 1400. Jacqueline Fowler, Chief Executive, BIR

issue 2 april 2011


BIR news

Is radiology the most pivotal part of modern medicine? Chowdhury-Wilson Radiology Prize 2010 The Chowdhury-Wilson Radiology Prize, sponsored by Wiley-Blackwell for students, was launched in 2010 in conjunction with the undergraduate textbook Radiology at a Glance, co-authored by BIR Trainee Committee Chair Rajat Chowdhury. First prize was awarded to Markand Patel, a final year medical student at the University of Southampton. Here is his winning essay... Being the son of a surgeon, with much encouragement from his father, Kieran had developed an interest in medicine, and in particular surgery. It was graduation day. Seated in the ceremony, Kieran looked up noticing the exquisite architecture of the dome above. In the centre, the intricate and precious keystone caught his eye. He was reminded of the words of Matsuo Bashō, the 17th century Japanese poet: “Do not seek to follow in the footsteps of the wise. Seek what they sought.” He realised where his future lay. It began with a sixth form trip for those interested in becoming doctors. The idea was to give Kieran and his classmates an insight into medicine. They travelled to the local hospital and, under dimmed lighting, were shown a department where they saw patients between a variety of complex machines, through faintly tinted windows. People dressed in white tunics were running in and out of rooms fiddling with controls and what looked like doctors were concentrating on grey pictures filling the computer screens of the dark side rooms. Modern medicine was promoted to the budding doctors through the Radiology department. It was this trip that intrigued Kieran and soon after led him to undertake a physics project in medical imaging. A hectic year passed and Kieran was excited about finally starting medical 40


issue 2 april 2011

school. The first term began with a foundation course, recently revamped to accommodate alterations to the curriculum, reflecting the changes in modern medical education. Week one began with the characteristic smell of the prosection room. The demonstrator introduced herself as a trainee radiologist. Wasn’t anatomy once taught by surgeons? Radiological anatomy was being taught with its corresponding specimens, as this apparently was how doctors nowadays encountered anatomy in daily practice. A few weeks had passed and Kieran was just about adjusting to the nine-to-five day. He looked at his timetable which surprisingly read “Practical Radiology”. This was an innovative addition to the curriculum, now taught alongside the core pre-clinical subjects such as anatomy, physiology and pathology. Two years passed quickly, but during the systems-based course Kieran noticed a recurring element; whether it was the cardiopulmonary, gastrointestinal or musculoskeletal system, every speciality introduced elements of radiology into their teaching. It illustrated disease processes through living anatomy and made difficult concepts much easier to grasp. It was in the third year that Kieran started clinical placements. Surgery was his first – four weeks with the urology team. Following introductions he turned up at his first clinic of medical school, the “OneStop Haematuria Clinic”. Kieran sat on the uncomfortable chair behind the consultant, observing the patient. He had already had an ultrasound scan of his kidneys and a flexible cystoscopy, the results of which were being discussed. During the clinic he saw patients who had already had or were being referred for X-rays, intravenous urograms, CTs or isotope scans for urolog-

ical symptom investigation. Too many radiological techniques to understand in a day! He also saw ultrasound regularly being used for differentiating between benign and malignant conditions of the testes, and in transrectal ultrasound-guided biopsies of the prostate, the gold standard investigation for prostate cancer. Later on in the placement, Kieran spent some time with the urologists in the interventional radiology suite, where he saw them work together with the radiologists performing a percutaneous nephrolithotripsy. By the end of his first placement it was evident that urology was heavily dependent on radiology for diagnosis and treatment. Kieran’s next placement was on the vascular team; here the majority of investigations were radiological, including duplex ultrasound, CT and MRI. Noninvasive angiography in arterial disease using CT/MR was becoming the preferred diagnostic investigation rather than percutaneous angiography. Kieran took a history and examined a very interesting patient with a suspected abdominal aortic aneurysm. He accompanied the patient to CT and was amazed to see a 7cm aneurysm on screen as the patient passed through the scanner. Diagnosis was not the only role for radiology. The radiologists, again working closely with the vascular surgeons, performed an endovascular aneurysm repair on this patient. Kieran saw how the use of somewhat complex, but conceptually clean, wire and stent systems saved the patient a major open operation with its attendant perioperative morbidity. In addition he watched the interventional radiologists perform percutaneous transluminal balloon angioplasty and stenting. While Kieran stood with his hands tucked under the heavy lead apron he was wearing,

he learned this was much more cost-effective than its surgical counterpart, especially useful in the current economic climate. Kieran also spent time at the â&#x20AC;&#x153;OneStop Breast Clinicâ&#x20AC;?. These one-stop clinics offered patients convenience, quicker investigation and swift access to treatment. Patients noticing a lump would have an initial consultation and be sent for a mammogram and ultrasound in radiology. They returned within the hour for results and decisions on how to proceed, and most looked relieved. Radiologists had performed the ultrasound and discussed findings of this and the mammograms already, thus providing reassurance. In some cases the radiologist had performed an ultrasound-guided fine needle aspiration or core biopsy for a cyto- or histopathological specimen based upon their findings, saving the patient the anxiety of another trip to hospital. Breast MRI was booked for those requiring re-evaluation or in the case of multiple lesions. He noticed an extremely efficient service which was incredibly reliant on radiology. Furthermore, Kieran appreciated the breast screening service, where asymptomatic women underwent mammograms to detect early invasive lesions or carcinoma in situ measuring only a few millimetres before even being palpable. This use of radiology was revolutionary in breast medicine, picking up tens of thousands of cancers, thus allowing treatment and saving many lives. It was then winter, and paediatrics. Hips, heads and lungs were the common reasons children required a visit to radiology. It seemed like every other admission was for bronchiolitis. As well as the common, Kieran witnessed the important but uncommon, from observing the radiologist examine a skeletal survey for non-accidental injury to trying to make out anatomical markings on a foetal MRI. One memory he wouldnâ&#x20AC;&#x2122;t forget was a micturating cystourethrogram being performed on a baby with recurrent urinary tract infections. The radiologist and radiographers waited and waited, with the cones tight to limit dose and their

bir news

feet hovering over the screening peddle for baby to begin micturating. Ultimately he did, without any warning! The New Year had passed, and in obstetrics the use of ultrasound as a nonionising imaging method was limitless. Expectant mums were overjoyed with the printouts from the sonographer-operated machines. Gynaecology too was a big user of radiology, from patients with pelvic pain and masses to uterine anomalies and fibroids, the latter of which Kieran saw being embolised in the interventional

itself. Neurotheatre was the session Kieran had always been looking forward to. To his astonishment, he discovered that it was led by a neuroradiologist, something unheard of until now. Details followed that rather than having an aneurysm surgically clipped, the neuroradiologist was to coil it using digital subtraction angiography for visualisation. Awe struck, he was captivated by the entire procedure! Surely there was no role for radiology in palliative care? Kieran found the contrary; during his placement at the hospice, Kieran

He realised that radiology was his future. It, like the keystone, remains glistening at the centre of medicine suite. Infertility too involved radiology; Kieran witnessed a contrast hysterosalpingogram for tubal patency, providing useful diagnostic information. Medicine was next, and Kieran was placed on the stroke unit and it was not long until he was called to an emergency. A patient presenting with sudden onset left-sided weakness had an urgent CT head requested, showing a right-sided acute ischaemic stroke. Discussion with the radiology registrar deemed the patient suitable for thrombolysis. Kieran saw how the radiologist whilst not overseeing the day-to-day care of the patient, played a major role in directing treatment which could substantially improve outcome. With recent advances in MRI, Kieran also saw diffusion-weighted imaging in assessing acute infarcts which would otherwise be difficult on CT or conventional MRI sequences. In the afternoons he attended clinics for patients suspected of having a TIA. After assessing lifestyle risks, he saw carotid Doppler scans being performed, with many of the patients being referred for a brain scan with CT/MR angiography to assess narrowing of the carotid arteries. On neurology the introductory lecture seemed to be focusing on various imaging techniques rather than neurological disease

met a terminally ill patient with oesophageal cancer and peritoneal metastases. To his surprise, the patient had visited the radiology department twice recently. Firstly for a palliative oesophageal stent and secondly an ultrasound-guided chest drain insertion for the malignant pleural effusion. Apart from these procedures, he learned that radiologists were also able to give intra-arterial chemotherapy infusions, provide pain relief through neurolysis and perform percutaneous tumour ablation, thus improving the quality of life for patients. In the fourth year, owing to his previous encounters with radiology, Kieran decided to undertake a research project in imaging. The project looked at further developing advanced imaging technologies and involved working with a diverse multidisciplinary team. Protocols were written with a mathematician, data collected with a medical physicist, novel tools were developed with a computer scientist, with constant clinical input from a neurologist and links to the neuropsychiatry team. Not only did Kieran experience radiology in its many multidisciplinary team roles within the clinical environment but also its counterpart roles within research science. The first clinical placement in the fourth year was ENT. It seemed like a very issue 2 april 2011


BIR news

specific subject, yet required a great deal of radiology. Those with ear symptoms and hearing loss required MR imaging, neck lumps and thyroid disease required ultrasound scans, and patients presenting with salivary duct obstruction had sialograms. For the first time Kieran had the auditory ossicles pointed out to him on a CT scan, having previously never realised they were visible. Radiology was essential in orthopaedics and rheumatology. Joints were imaged using X-rays and soft tissue using MRI. The introductory morning was spent on radiograph case-based discussions. Fractures, arthritis, osteoporosis, metalwork and metastases were commonly imaged. Kieran also saw a vertebroplasty in the interventional suite on a patient with fractures from spinal metastases, thus requiring a subsequent reduction in analgesia dose. Soft-tissue injuries of the knee were all too common, with MRI being the most sensitive non-invasive method for evaluation. Kieran also saw ultrasound-guided steroid injections given by radiologists to ease painful joints, as well as ultrasound-guided drainage of collections post-hip replacement. It was coming to the end; the acute medical unit was where Kieran proudly wore his shiny new “Final Year Medical Student” badge. Clerking patients and suggesting initial investigations was his job. Almost every admission warranted a radiological investigation, whether it was a cough, dyspnoea, chest pain, arrhythmia, shock, abdominal pain, GI bleed, vomiting, diarrhoea, constipation, heart failure, liver failure, confusion or coma. Patients suspected of having meningitis or a sudden severe headache with suspicions of subarachnoid haemorrhage were CT scanned, thus excluding differentials and raised intracranial pressure for the proceeding lumbar puncture. Patients with suspected deep vein thrombosis had an ultrasound and Kieran also saw how the radiologists inserted an IVC filter for those with a high risk of having pulmonary embolism who could not be anticoagulated. Suspicions of pulmonary embolism 42


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warranted a CTPA, the gold standard for diagnosis, which Kieran could pretty much read by now having seen so many. It was then time for a couple of weeks of “interprofessional learning”. The aim was to develop respect and understanding of the roles of the health and social care interprofessional team members. Kieran was placed in a group consisting of nursing, social work, radiography and other medical students. It was during this time that all members of the group realised that radiographers too played a key role in the health service alongside the doctors and nurses. Back onto placements, and word was going around that upper GI and hepatopancreato-biliary consultants were fire-breathing dragons towards medical students. Feeling like he knew nothing, he reluctantly joined the team. Soon enough he actually felt at home as he began to realise their true involvement in radiology. From barium swallows in dysphagia and contrast-enhanced MRI in hepatocellular carcinoma to magnetic resonance cholangiopancreatography and endoscopic ultrasound, he saw near impossible peri-aortic lymph node biopsies without imaging being performed under CT guidance. Interventions were numerous; he witnessed a radiologically inserted gastrostomy, pancreatic drain insertion and embolisation in gastrointestinal haemorrhage. He also learned that patients with liver metastases now had a better prognosis with the introduction of radiofrequency ablation rather than resection. In the surgical assessment unit, ultrasound and CT scans were regularly requested for investigating the acute abdomen rather than a diagnostic laparotomy. Looking at abdominal radiographs and CT studies was the norm at the 8am colorectal ward rounds which always involved extra effort to get out of bed for. Clinics would resonate with “CT colonography”, “pelvic MRI” and “contrast study”. One such study was a defecating proctogram in which the radiologist, radiographers and Kieran were hidden behind a draped bed sheet at the control station, in a dimly lit fluoroscopy suite, helping the patient feel more comfortable! Kieran

thought maybe he could take a break from all this radiology sometime, but lunchtime MDT meetings too were crammed with abdominal, PET/CT and staging scans. Radiologists seemed to be knowledgeable and skilled in all arts, playing the central role within the team by providing diagnoses, suggesting further investigations and offering treatment options to the surgeons. A&E was hectic. Seeing patients in minors would involve running back and forth to the PACS station between almost every patient, from inversion injuries and falls on outstretched hands to sporting injuries. It didn’t help that it was half-term and there was an ice-rink nearby. A&E review clinics would involve patients slowly making their way into the consultation room on crutches or casts then being sent for follow-up X-rays. PACS had revolutionised hospital radiology by making radiological studies easily available for viewing across the entire hospital. Scans would be available before the patient had even come back from radiology. The fact that Kieran noticed specialist PACS computers across the hospital suggested that radiology was in fact vital to every department. Radiology knew no bounds in the hospital, it interacted with every speciality. On one occasion, a patient following a motorcycle accident arrived in resus supported by a neck collar. C-spine, chest and pelvic X-rays were taken according to protocols and Kieran, donning the red crash bag on his back, accompanied the patient to CT for a head scan. It wasn’t too far as the hospital had specifically been designed to ensure radiology had good access and was in proximity to A&E, theatres and the acute medical and surgical assessment units. Not only did Kieran realise that the radiology department was the centre of the hospital, but so too did the architects designing it. The time for graduation was approaching. Kieran stared at the keystone of the dome above. He realised that radiology was his future. It, like the keystone, remains glistening at the centre of medicine, providing constant support to and connections with all, and without which nothing else would be possible. Markand Patel, University of Southampton

bir news

Social events at this year’s UKRC UKRC 2011 returns to Manchester Central this year and promises to be yet another essential event for all UK radiological imaging professionals. As well as the excellent scientific and education programme and full technical exhibition at UKRC 2011, there are also fantastic social events currently being planned for delegates to continue their networking and socialise with friends and colleagues outside of the conference venue. On Monday 6 June, the ever-popular nightclub evening will be taking place at the Pitcher & Piano on Deansgate Locks. With private use of the venue, an exclusive drinks promotions and a DJ playing all your favourite hits late into the night, this will be a great chance to continue socialising after dinner. Tickets are available at www.ukrc. and onsite at UKRC for £8, and for £10 at the door of the venue. Together with our industry partners, we bring you a glittering night of live music, entertainment and gaming at

Enjoy a drink and the delcious buffet dinner

the opulent Manchester 235 casino on Tuesday 7 June. Learn to play blackjack and roulette on arrival, enjoy a delicious buffet dinner and dance into the night with live music in the private events suite. Tickets are available now at

Learn to play blackjack at the Manchester 235 casino before dinner

The three day multidisciplinary event will take place from Monday 6 to Wednesday 8 June 2011 and will provide CPD opportunities, hands-on workshops, talks delivered by high-profile speakers and accredited education on the stands. UKRC is aimed at all those involved in the field of radiological science, including radiographers, radiologists, physicists, academics, hospital managers, engineers and technicians, and attracts between 3000-5000 people a year. Lecture topics already confirmed for this year’s event include: • Cancer reform: the importance of imaging • Ultrasound elastographic techniques: past, present and future • The role of information technology in optimising radiology practice • If it is not broken - mend it! The holistic approach to image interpretation • Creating and sustaining a high quality, patient-centred endoscopy service. Register before the 6 April 2011 to save up to 11%. Lucy Nye Development Image title Business to go here if you want. Coordinator, BIR

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bir news

Radiology and the NHS The British Institute of Radiology East of England branch held its inaugural full day event at the Clinical School, Addenbrooke’s Hospital, Cambridge. The theme of the day was “Radiology and the NHS” and it received an overwhelming response with almost 100 delegates from imaging professionals across the Eastern region and beyond. The main programme was highly relevant with excellent talks related to imaging and the NHS, including NICE, Imaging Implementation, Error in Radiology, Towards the best NHS Services and Education and Professionalism. The meeting provided a platform for interactive discussion and debate on these issues as well as opening up opportunity for the participants to take back useful information with a view of improving imaging quality and services. The three parallel sessions (radiology

“This emphasises the importance of close collaboration among imaging professionals and other clinical specialty to work together towards high quality and cost effective imaging services in the NHS” trainees, radiographers/physicists and nurses) provided delegates with the opportunity to discuss issues surrounding education and research as well as future development and improvement within their individual groups. Dr T C See, chair of the BIR East of England branch, commented, “This inaugural meeting was extremely well received and very successful due to

multidisciplinary contribution and participation. This emphasises the importance of close collaboration among imaging professionals and other clinical specialty to work together towards high quality and cost effective imaging services in the NHS.” L ucy Nye Business Development Coordinator, BIR

Forthcoming East of England meetings Errors and risk in radiology study day – 24 June 2011 The committee of the BIR East of England branch have put together an excellent programme for the study day which will take place at the award winning Moller Centre in Cambridge on 24 June 2011.

The aim of the meeting is to help us understand how we can improve standards of radiology services, not just on a local scale but a national one too and we welcome speakers and delegates from throughout the UK. Full programme details can be found at and registration is now open. We are offering very attractive delegate fees with discounts for all BIR members. The programme is of interest to consultant and trainee radiologists and all allied health professionals.

Once again taking place in the clinical school of Addenbrooke’s Hospital, the committee is formulating an excellent multidisciplinary programme with break-out sessions specific to your professional interests. Visit for further details and registration information.

BIR East of England branch annual meeting – 1 October 2011 Following the success of the 2010 inaugural meeting of the branch, we are pleased to announce the second annual meeting for 2011. Venue for the study day



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The Moller Centre in Cambridge

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BIR news

BIR awards trainees for The British Institute of Radiology held a sell-out trainee event at the Holiday Inn, Regents Park in December last year where Dr Thomas Gordon and Dr Aleksander Januz were presented with prizes for the poster and e-poster competitions, respectively. Here are their winning abstracts Automatic cardiac and respiratory gating of biplane fluoroscopy for catheter reconstruction in cardiac catheterisation Background


Cardiac catheterisation procedures are routinely guided by X-ray fluoroscopy but suffer from poor soft tissue contrast and a lack of depth information. Methods exist for combining these images with pre-operative MRI or CT models of the heart for treatment planning and intra-operative guidance. However, current methods are limited in their ability to account for the effects of cardiac and respiratory motion. We developed an automatic cardiac and respiratory gating algorithm from image data alone to yield the best catheter reconstruction for combining these imaging modalities.

Our algorithm gated the cardiac and respiratory cycles to end diastole (ED) and end expiration (EX), respectively, using image processing techniques. We then quantified how well ED and EX were matched based on minimisation of a back-projection distance metric. This provided the best image pair from which to perform accurate catheter reconstruction for 2D-3D image registration of the fluoroscopic and MRI images.


We found our method of cardiac gating had an accuracy of 80% and a precision of 81% for correctly deter-

mining ED, with an uncertainty of Âą0.9 frames. For respiratory gating of EX, an accuracy of 85% and a precision of 71% were observed. Conclusion and implications

This work presents a method for cardiac and respiratory gating of an X-ray image sequence using only image processing methods and a mechanism for quantifying how well phase matched two frames of this sequential sequence are. We envision our technique to reach full automation and be deployed in a real-time clinical setting for the use in cardiac catheterisation procedures. TJ Gordon, MVN Truong, K Rhode

L-R: Dr Thomas Gordon recives his prize from BIR President Stephen Davies. Dr Aleksander Janusz is awarded his prize



issue 2 april 2011

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outstanding abstracts The ultrasound examination: do we deliver patient–focused practice? A prospective analysis from interactive interviews of 61 patients The notion of ultrasonographic examination as a clinical consultation is a recognised concept. Consistent with this there is paucity of data on awareness of patients’ expectations when USS is performed. The authors believe that doctors’ ability to engage with the patient, explain findings or break bad news is an essential skill underrated in training and practice. This pilot study included 61 patients (mean age 54 years) in a busy district general hospital. Data investigating perception of the USS examination was collected during a personal interview lasting 8-15min, recorded using

an original standardised questionnaire. Various outpatient (n=46) and inpatient (n=15) procedures were studied. A significant minority (n=9, 15%) of patients had received suboptimal explanation of the procedure from the sonographer/ radiologist. 15 patients (24%) felt discouraged to ask questions or did not receive the expected explanation of scan findings. Moreover, patient preparation by the referring clinician demonstrated further lack of understanding of reasons for and type of scan intended. There was also correlation between age, background, education and previous exposure to USS and the perceived quality of explanation received.

Results demonstrate a significant failure of individualised information and patients’ active inclusion in the diagnostic process. This is particularly significant considering that this pilot was performed on a sample operated by experienced consultant radiologists not blinded to the trial. Higher rates can be expected in real life. Authors anticipate to extend this study embracing various radiology grades to establish the questionnaire as a vital feedback tool in training ultrasound operators to ensure patient orientated service. Dr Aleksander Janusz Oxford Radcliffe Hospitals NHS Trust

7-9 June 2010 | UKRC 2011| MANCHESTER UKRC is a three day multidisciplinary Congress covering all aspects of diagnostic imaging and oncology, as well as radiology informatics and service delivery. UKRC is the leading and largest diagnostic imaging event in the UK: • • • • •

Over 3000 delegates and visitors Comprehensive Exhibition Focus on current and emerging technologies Prestigious international speakers Eponymous Lectures from the UKRC partner societies

Multiple CPD opportunities; including hands on workshops, sunrise refresher schools, talks delivered by high-profile speakers and accredited education on the stands. Programme Highlight Join Professor Mike Richards as he delivers the much anticipated BIR Eponymous Lecture for UKRC 2011 - Cancer Reform: The Importance of Imaging.

Programme planner now available at This interactive tool allows you to plan your perfect conference by identifying the topics and sessions relevant to your professional interests. issue 2 april 2011


To register for the conference and social events please visit

bir news

Meet the BIR’s information specialist

Competition Oncology Systems Limited have kindly donated a £75 voucher from buyagift. com for this issue of BJR News. To win just read through the magazine carefully and reply to the following question: Who is the BIR’s new information specialist? Please send your correct answer to: with your name and contact details by 3 May 2011. This time there will be four lucky winners.

Khalda Mohammed

Hello members. I am the information specialist at the British Institute of Radiology (BIR) and my role is to manage the Information Centre and provide library services to support your research and education needs. I joined the Institute in May 2010. Previously, I worked at the Community Practitioners and Health Visitors Association, part of Unite the Union, as the information officer where I managed the information centre and the health sector websites. My background is in information science. At the BIR, my role includes running the Information Centre in liaison with the Honorary Librarian, providing information services, maintenance, development and promotion of information services for internal and external customers and other stakeholders. I manage print, digital and archived resources and update the Information Centre pages of the BIR website. I have been involved in the library review working in collaboration with BIR departments, committees and members to investigate membership information needs, and hence have been researching technologies and collections that will be used to develop the future BIR e-library. Services are being developed in response to user feedback from the BIR member survey which was conducted 48


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in May 2010, for the type of information services members would like to access from their library. The following are some of the services currently being developed: • Information Centre web pages – resources and factsheets that will aid research and an up-to-date directory of useful resources in radiology. • Journals – there are 72 titles of hardcopy and e-journals. Access to the 14 e-journals is available in the library. New e-journals are added annually. Check out the BIR journal collection at uk/bir-information-centre-home/library/ journals.aspx • Books – the current collection of books are available for reference use and new ones are added annually. The book collection can be searched on the online catalogue at For more information about BIR library services please visit the Information Centre at You can email your requests to or call in and speak to me at the BIR Information Centre at the BIR’s headquarters, situated in Portland Place, between 9am-5pm, Monday to Friday. Khalda Mohammed, Information Specialist, BIR

Sudoku Fun Logic-based, combination number placement puzzle. The objective is to fill a 9×9 grid so that each column, each row and each of the nine 3×3 boxes (also called blocks or regions) contain the digits from 1 to 9 only once. Completed puzzles are usually a type of Latin square with an additional constraint on the contents of individual regions. Leonhard Euler is sometimes incorrectly cited as the source of the puzzle, based on his related work with Latin squares.

Sudoku from

A Page of History

The plight of technical education It is interesting to see Andrew Adonis, the director of the Institute for Government, who has previously promoted university technical colleges now saying that “a century late the technical school is with us at last” (The Sunday Times, 8 January 2011). A major concern of the British Institute of Radiology’s first president Silvanus Thompson was technical education and he made a series of continental tours to study different approaches. In 1879 he gave a paper at the Society of Arts entitled Apprenticeship, Scientific and Unscientific where he detailed the deficiencies in technical education in England. Thompson recognised that technical education was the means by which scientific knowledge could be put into

Silvanus Thompson, staff and students at Finsbury Technical College

action and spent the rest of his life putting his vision into practice. In 1878 the City & Guilds of London Institute for the Advancement of Technical Education was founded. Finsbury

Technical College was a teaching institution created by the City & Guilds institute and it was as its Principal and Professor of Physics that Silvanus Thompson was to devote the next 30 years. Finsbury College was for persons of either sex who wished to receive a scientific and practical education for intermediate posts in industrial works. In his report to the governors 5 years after his appointment, Thompson wrote, “the course of instruction is thoroughly practical...The College exists to give a training, not to enable persons to cram for examinations.” So nothing changes, the issues facing us then are the same as now.  r Adrian Thomas BSc FRCP FRCR FBIR D Honorary Librarian, BIR

Classic radiology books I first came across British Authors as old unused books in corners of departmental X-ray libraries. One of the most significant events of the 1930s was the publication of A TextBook of X-ray Diagnosis by British Authors, the highly influential multiauthor textbook covering all aspects of medical imaging. Diagnostic radiology came of age in this decade and these books celebrated the knowledge that had been obtained in the previous 40 years. The editors were EW Twining, C Cochrane Shanks and Peter Kerley, and the first edition was published in 1938. The books were expensive and volume 1 cost 50 shillings (£2.50). The standard that was set was quite outstanding and no other country produced anything that could compare, either in printing or in the illustrations.

The books were required reading for generations of radiologists studying for examinations. Bill Park wrote that “during the lifetime of this book, the role of the radiologist has advanced from a type of “aircraft spotter” to that of an established clinical diagnostician. We should gratefully recognise the contribution of this book and particularly its editors, Dr Cochrane Shanks and Sir Peter Kerley for such a fundamental change in attitudes.” The final edition of the book was the 4th edition (edited by Cochrane Shanks and Kerley following the untimely death of Twining) with volume 6 appearing in 1974. In our world dominated by crosssectional imaging we should remember those who worked with X-rays alone and who laid the foundations of our speciality. Peter Kerley would have loved MRI!  r Adrian Thomas BSc FRCP FRCR FBIR D Honorary Librarian, BIR

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The service delivery and financial pressures in the NHS mean that we need to provide more local educational activities.



We live in interesting times. All organisations need to review their strategy and the British Institute of Radiology (BIR) is no different. Trustees have been working hard with the senior management and staff at the BIR on a new strategy for 2011-2016. We are fortunate to have active and committed trustees who have a wealth of ideas. The global recession and more immediately the pressures on healthcare professionals in the NHS, the independent sector and companies means that some reshaping of our activities will be necessary. The outcome of the strategic review will be published in the next month or so. I am pleased to report that trainees are now engaging in many areas of life at the BIR. To start with, they have a clear voice on Council and have been fully engaged in the strategic review. I would like to see a trainee member on every scientific committee at the Institute and there are plans for a regular trainee column in the new BJR News. Our regional branches network continues to grow and good things are planned for 2011. We have refocused the branch in the south-west. Niky Sykes is the new branch chair and is keenly developing a truly multidisciplinary programme. Please keep an eye on the website for branch activities in your region. I am firmly of the view that the BIR should reach out across the UK and develop activities closer to your home and place of work. The service delivery and financial pressures in the NHS mean that we need to provide more local educational activities.

issue 2 april 2011

We are actively developing our London programme and this year my Presidents Conference in May will be on cardiac imaging. We know that there is growth in cardiac imaging in the UK and that there is an appetite for knowledge across the radiology spectrum. The Somerset MRI course has now moved to the BIR. Last year, I was invited to be the final Chairman of the Somerset MRI and this provided the ideal opportunity, with the blessing of Alliance Medical, to refocus the Somerset MRI course as an annual BIR MRI teaching course in October. I am delighted the Vice President Andrew Jones will be enhancing the physics section of the meeting with an excellent one-day programme. In future years I expect that the BIR MRI committee will take full ownership of this course and it will continue to flourish. Finally, we had an excellent collaborative meeting with BMUS, celebrating the life of Ian Donald the ultrasound pioneer, with a series of excellent presentations charting the history and modern uses of ultrasound, including a live ultrasound on a dog. This was followed by a scientific day on obstetric ultrasound and finally a third day, the schools day, when school children came to the special sound exhibition.

Book review

Breast Cancer Cambridge University Press Edited by Michael Michell ISBN: 978-0-521-51950-2

This volume is the latest in the series of multidisciplinary monographs on contemporary issues in cancer imaging. Breast cancer is the commonest cancer affecting women worldwide. Over the past 20 years, it has been a high profile health issue in western nations, with regular media coverage and debate over breast cancer screening programmes for this much-feared condition. This book takes a very multidisciplinary approach to the subject of breast cancer and is a valuable contribution for all those who are involved with this disease. Since Leborne’s early work on mammography, diagnostic imaging in breast disease has continued to develop

at a rapid pace. In the past 20 years, with the advent of screening and improved techniques such as digital mammography, ultrasound and newer techniques such as MRI, imaging and management of the disease has almost altered beyond recognition. In this multi-authored text, all aspects of this disease are covered, including epidemiology, pathology and treatment. The chapter on the epidemiology of female breast cancer is a particularly useful introduction to the risk factors for this condition. A book like this could not ignore the subject of breast screening and this is dealt with succinctly, while still including the relevant statistical information. Other chapters cover advances in X-ray mammography, breast ultrasound and MRI imaging. Pathological contributions are not given short shrift. Current issues around the pathology of duct carcinoma


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in situ are discussed and the difficulties involved are made clear. There is an excellent chapter on the radiological assessment of the axilla and also newer techniques, such as positron emission tomography and its role in the assessment of breast cancer. The final chapter covers the advances in the adjuvant treatment of early breast cancer. Overall, the multidisciplinary discussion of breast cancer is highlighted in this book and everyone involved in the diagnosis and management of these patients would benefit from reading this volume. I found this book extremely useful; it is up-todate and extensively referenced. It is not solely about diagnostic imaging and, as such, will appeal to all members of the multidisciplinary team involved in looking after patients with this disease. Dr A K Banerjee

Cardiac Imaging | 19-20 May 2011 | London This is a two day scientific meeting covering contemporary and future issues in Cardiac imaging. It is suitable for all those involved with Cardiac imaging, including those in training. This is a flagship event in the BIR Calendar and complements the hands on cardiac workshops in the BIR Events programme.

DAY 1 - 19 MAY 2011

DAY 1 - 20 MAY 2011

09:30 09:55

09:00 Registration and refreshments INTEGRATION OF CT WITH OTHER MODALITIES 09:30 3D Echocardiography: Who, When and Why? Professor Mark Monaghan, King’s College Hospital 10:00 Cardiac MRI Professor Eike Nagel 10:30 Nuclear Cardiology: Is There Still a Role? Dr Andrew Kelion 11:00 Invasive Angiography: Who, When and Why? Dr Jon Byrne, King’s College Hospital 11:30 Refreshments REPORTING CARDIAC CT 11:45 CT Coronary Angiography: How I Report Professor Carl Roobottom, Derriford Hospital 12:15 CT Coronary Angiography: How I Act on the Report Dr Gareth Morgan-Hughes, Derriford Hospital 12:45 Lunch ISSUES IN CARDIAC IMAGING 13:30 Coronary CT Angiography: What is the Current Evidence-Base? Dr Stefan Achenbach 14:00 MRI vs CT: Competing or Complementary Tests? Dr Charles Peebles, Southampton General Hospital 14:30 A Non-specialist’s Guide to Congenital Heart Disease Dr John Simpson, St Thomas’ Hospital 15:00 Paediatric Cardiac CT Dr Cathy Owens, Great Ormond Street Hospital 15:30 Refreshments 15:45 Perfusion CT 16:15 Coronary Artery Imaging: What Next? Dr Robin Choudhury, John Radcliffe Hospital 16:45 Close

Registration and refreshments Introduction Dr Stephen Davies, Royal Glamorgan Hospital SCENE SETTING 10:00 Coronary Artery Disease: The Scale of the Problem Dr Matt Budoff 10:30 Chest Pain: How I Currently Investigate Patients Dr David Brennand-Roper, London Bridge Hospital 11:00 NICE Guidelines: Problems and Prospects Dr Jon Byrne, King’s College Hospital THE CARDIAC CT SERVICE 11:30 Cardiac Radiologists or Radiocardiologists: Setting Up a Cardiac CT Service Dr Jonathan Hill, King’s College Hospital 12:00 Lunch 12:45 Cardiac CT: What’s in a Machine? Dr Ed Nicol and Ms Elly Castellano, Royal Brompton Hospital 13:15 Cardiac CT: Optimising the Image Dr Simon Padley, Royal Brompton Hospital 13:45 Cardiac CT and Radiation Dose: How Low Can You Go? Dr Giles Roditi, Glasgow Royal Infirmary THE MACKENZIE-DAVIDSON MEMORIAL LECTURE 14:15 Designing Devices - How Can Cardiovascular Imaging Help Professor Andrew Taylor, Great Ormond Street Hospital 15:15 Refreshments LEARN WITH THE EXPERTS (Work-based sessions) 15:30 Cardiac CT Dr Michael Rubens and Dr Ed Nicol, Royal Brompton Hospital 16:30 Cardiac MR Dr Stephen Harden, Southampton General Hopsital 17:30 Close

april 2011 Presidents Conference ad half pa1 1

NEWS 51 11/01/2011 12:19:51

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BJR News April 2011