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An introduction to forensic radiography High tech radiotherapy: where does modern brachytherapy stand? Hounsfield review: the physical basis and future of radiation therapy Reading articles in a web 2.0 world

Investing in science: securing future prosperity ISSN 2044-5113

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Visit us at the Hitachi stand, UKRC, 6-8th June 2011 in Manchester Hitachi Medical Systems UK Ltd, 5 Regent Park, Booth Drive, Wellingborough, Northants NN8 6GR, Phone 0844 800 4294,


in this issue 3 5 7 8 17

Editorial Learning from disaster

recent BIR eventS Target 2012: expanding the UK IMRT service

BIR events calendar Forthcoming events from the BIR scientific programme

Community news News from the radiology and allied sciences community

What’s Online Table of contents from The British Journal of Radiology volume 84 number 1001 and 1002


Case of the month



Patient with neutropenic fever and abdominal pain showing absent bowel wall on CT

Investing in science: securing future prosperity

Using the DOI system



Short Communication

25 30

Hounsfield Review

39 47

BIR News


BIR President’s Column


Book reviews

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

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

Lumbar spine radiography — poor collimation practices after implementation of digital technology

The physical basis and future of radiation therapy

Abstracts Abstracts from The British Journal of Radiology volume 84 number 1001 and 1002

Updates from BIR projects and committees

History of Radiology Welcome to ISHRAD and books to read in the BIR library

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 CEO, 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: Learning from disaster

Learning from disaster Radiation is the key to all our work, whether it is to diagnose, treat or followup patient conditions; however, it brings with it a strong element of danger. High-profile nuclear disasters such as Chernobyl and, more recently, Fukushima have highlighted the fact that invisible radiation can have a major unwanted effect if it is not adequately controlled. Even protective systems, such as those in Japan, cannot provide a guarantee of safety. Fukushima residents had to remain in their homes or leave the area to avoid the effects of radiation. In our own practice we have a solid base of rules and recommendations that are designed to keep diagnostic doses to a minimum and target only essential tissue in radiotherapy treatment. Image guided radiotherapy — as discussed in this issue of BJR News — is enabling us to develop much more accurate treatments, which can minimise doses

and toxicity for our patients. This work is also contributing to our safety efforts. Can international disasters contribute to our knowledge base as well? Professor Mike Richards, who has kept cancer at the top of the government’s agenda, advocates earlier diagnosis through awareness campaigns and greater direct access to tests such as chest radiographs, ultrasound and MRI. The sooner we can treat our patients, the better the outcome is likely to be and patients will survive longer by living with cancer as a long-term condition. This in turn will mean that patients could be subject to a longer exposure to radiation throughout their lives. Our responsibility is to learn every lesson we can from disasters such as Fukushima and Chernobyl to make sure our staff and patients get the best possible protection as well as the treatment they deserve.

Chernobyl nuclear power plant. We must continue to learn from international disasters.

Our responsibility is to learn every lesson we can from disasters such as Fukushima and Chernobyl to protect our staff and patients

Liz Hunt BJR News Editor-in-Chief

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New Publication! 25% discount for BIR members. Visit the BIR online bookshop

BIR Report 23


Current Status and Recommendations for Further Investigation A report from The British Institute of Radiology Molecular Radiotherapy Working Party

This report reviews the current status and evidence base of Molecular Radiotherapy (MRT) in the UK and provides recommendations to improve its use and effectiveness. The motivation for this report stems from the general perception within the community that scientific developments, support for infrastructure and the availability of MRT in the UK have not kept pace with that seen in external beam radiotherapy and chemotherapy. However, an increasing number of radiopharmaceuticals are becoming available for a range of treatments and the market is expected to grow significantly in the next decade. To support this report a survey of UK centres was carried out to ascertain the range and number of treatments administered.

The report concentrates on therapy procedures that are prevalent in the UK. Issues of support for MRT are focussed on the radiopharmacy, for routine preparation and further development of radiopharmaceuticals, and on physics for imaging and internal dosimetry. ISBN: 978-0-905749-70-9 Price: ÂŁ25.00 The Molecular Radiotherapy Working Party is a subgroup of The British Institute of Radiology Radiation Physics and Dosimetry Committee. The authors of this report are: Glenn Flux, Laura Moss, John Buscombe, Mark Gaze, Matt Guy, Steve Mather, and Kim Orchard.

Report: Expanding IMRT

recent BIR events

Target 2012: expanding the UK IMRT service Rebecca Day and Andy Beavis from the Radiation Physics and Dosimetry committee report on the recent event held at the British Institute of Radiology and reflect on the day’s highlights Intensity modulated radiation therapy (IMRT) is a highly conformal radiotherapy technique that uses some of the most advanced treatment technology available and has been shown to significantly reduce toxicity. Despite 97% of linear accelerators (linac) in the UK being IMRT enabled, few centres offer the technique to more than a handful of patients each month. In 2009 the National Radiotherapy Advisory Group (NRAG) published a series of guidelines regarding IMRT service provision in England. One of these guidelines set the target that by 2012 at least one centre in each cancer network should offer IMRT. The guidelines also suggested it should be available to all patients who would benefit from it and estimated this to be approximately 30% of radical treatments. Following the NRAG recommendations, radiotherapy centres are either

ramping up their IMRT service or, for centres that have not previously offered it, commissioning IMRT services from scratch; for most radiotherapy centres this is a daunting task. The British Institute of Radiology (BIR) Radiation Physics and Dosimetry committee recognised this and decided to organise a meeting addressing the issues related to meeting NRAG targets. On the 23 February 2011 the BIR held the “Target 2012: expanding the UK IMRT service” meeting. The aim of this meeting was to equip delegates with a better knowledge and awareness of the problems associated with the expansion of IMRT services and to help centres through the practicalities of the process. It was very well attended by a multidisciplinary audience with plenty of interactive discussion. The day kicked off with an excellent talk from Tim Cooper, the Associate

Despite 97% of linear accelerators in the UK being IMRT enabled, few centres offer the technique to more than a handful of patients each month

BIR, London. The venue for the meeting

Director of the National Cancer Action Team (NCAT). He began by highlighting the development of IMRT as a long evolutionary process and the resulting slow implementation across the country. Cooper discussed the specifics of the original NRAG recommendations and gave an overview of issue 3 june 2011



Report: expanding IMRT

the NCAT sponsored national IMRT training programme. Advanced radiotherapy techniques were put into context with the mention of the new 2011 Department of Health documents Improving Outcomes: A Strategy for Cancer and the NHS outcomes framework “5 domains of clinical outcomes”. Cooper followed the talk by leading an extended discussion period along with the meeting Chair. The session yielded a lively discussion where the audience put questions to Cooper about the recommendations and raised concerns they had including staff provision for data collection (to monitor outcomes) and patient follow-up.

England offered inverse planned IMRT and that they were treating, at least, one patient per fortnight. Therefore, although “ready”, most centres were a long way from the 30% “aspirational” workload. Carl Rowbottom from the Christie Hospital gave a helpful talk on the background to the business case they had written for their successful expansion of their IMRT service. Since 2008 they increased their activity from 190 cases per annum (5%) to achieve their target figure of approximately 1200. He concluded by urging us all to set ourselves challenging IMRT targets (based on clinical justification) rather

Delegates had the opportunity to step back and examine their approach to implementing complicated technologies and to really consider the most efficient way to deliver IMRT to their patients. Kevin Sullivan of University College Hospital (UCH), London, then looked at the service delivery impacts of increasing the IMRT service. He explained time and logistical difficulties and how UCH have looked at various systems to aid efficiency in the process, such as Atlas based contouring aids, the introduction of RapidArc and the development of a radiographer role to better manage the patient pathway and minimise the need for the replanning of IMRT patients. Hayley James from Ipswich, one of the UK’s earliest adopters of IMRT, gave a comprehensive talk about the barriers to IMRT expansion and how their centre had overcome them. She had performed a survey prior to the meeting that showed 56% of NHS centres in 6


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than just settling for the minimum. John Staffurth then presented a very thorough literature review which outlined the clinical evidence for the benefit for IMRT. The literature review strongly supported the use of IMRT in head and neck cancers and arguably supports it being the standard of care. He also talked with excitement about the ART DECO head and neck trial that will look at the possible improvement in tumour control that can be obtained through dose escalation. After lunch, Catharine Clark, who is part of the IPEM/NPL radiation dosimetry steering group, talked about the “problems and pitfalls of IMRT verification”. Clark talked about plans for a UK survey of QA data and for “NPL study days” where a variety of different

systems will be used at the NPL clinical linac facility. Carl Rowbottom then gave his second talk of the day on behalf of colleagues from the Christie Hospital (Geoff Budgell and Joe Berresford) on a review of their 2009 IMRT audit and Steve Bolton gave a talk on the pilot rotational therapy audit. The final session of the day was a combination of four proffered papers. Julia Handley described how her Stoke Radiotherapy Centre had set themselves up as one of the NRAG IMRT training centres where they had successfully trained two other centres for IMRT. Gloria Beyer gave a talk on the IMRT commissioning process particularly focusing on the physics aspects of MLC commissioning. Keith Langmark from Nottingham gave an informative talk on the efficient delivery of IMRT. His approach was to analyse the rate limiting steps and address each of these individually. The final presentation was given by Andrew Williams, Norfolk and Norwich Hospital, who spoke about the heavy IMRT workload for physics staff, his centre’s use of radiographers to conduct IMRT QA and planning dosimetrists to assist with tasks such as contouring. The meeting was a great success. Speakers shared their valuable experiences on the expansion of the IMRT treatment service and how they overcame the associated problems. Delegates had the opportunity to step back and examine their approach to implementing complicated technologies and to really consider the most efficient way to deliver IMRT to their patients. The focus throughout the day was how to raise the standard of radiotherapy in the UK. There was real excitement that we are currently on the brink of being among the best in the world in offering excellent treatment to all those who will benefit. Rebecca Day and Andy Beavis BIR Radiation Physics and Dosimetry Committee

Forthcoming events

events calendAr 2011

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

Upcoming in June, July and September: East of England branch errors and risk meeting 24 June 2011 The Moller Centre, Cambridge

IRMER update 12 July 2011 BIR, London

Essentials of medical imaging schemes and developments 23 September 2011 BIR, London

PACS the second time around! 6 September 2011 BIR, London

Events booking now visit

October East of England branch annual meeting Addenbrooke’s Hospital, Cambridge 01 October 2011

Oncology: head and neck imaging BIR, London 07 October 2011

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

Welsh Branch annual meeting Princess of Wales Hospital 13-14 October 2011

The British Institute of Radiology UK MRI course (incorporating the Somerset MRI course) BIR, London 17-20 October 2011

Dispelling the myths of a managed equipment service BIR, London 27 October 2011

BIR and SCoR’s retired members’ day BIR, London 28 October 2011

Breast MR BIR, London October 2011

November The journey from research to publication BIR, London 18 November 2011

December Clinical imaging of the head and neck BIR, London 02 December 2011

In-vivo dosimetry and dose guided radiotherapy BIR, London 8-9 December 2011

Chernobyl 25 years on: consequences, actions, thoughts for the future BIR, London 12 December 2011 issue 3 june 2011



Community News

community news

High tech radiotherapy: where does modern brachytherapy stand? The physics perspective In the modern world of technological radiotherapy, brachytherapy is a relatively simple technique — the principles are straightforward, the treatment units, dosimetry algorithms and imaging requirements uncomplicated — in contrast to the technically highly advanced modalities of external beam radiotherapy. The traditional classic dosimetry systems have served the brachytherapy community well since the early 20th century. In many ways these systems, which are remarkable for their longevity, continue to guide us, for example “Manchester” and “Paris” rules still provide a basis for interstitial and intracavitary implants and the International Commission of Radiation Units (ICRU) prescription points are still reported and often used as prescription points in cervical brachytherapy [1]. In recent years external beam radiotherapy has changed significantly with the introduction of beam shaping, customised intensity modulation and imaging of the target and critical structures. These are all issues in which brachytherapy has been a “late developer”, probably owing to the physics that makes brachytherapy an effective treatment option (i.e. the inverse square law) and it therefore continues to provide effective treatments in the traditional way. It is only recently that the possibilities made available by imaging and treatment optimisation have been embraced by the brachytherapy community. To take an example, image-guided cervical brachytherapy is now routinely performed using cross-sectional imaging and dose optimisation for each fraction to maximise the planned target volume (PTV) 8


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coverage while keeping nearby critical structure doses within appropriate limits. Some centres have moved from traditional prescription to the ICRU “Point A” [1] to volume–based prescription similar to that used in external beam radiotherapy. There is nothing particularly novel about the imaging used, but its application has enabled whole– course PTV D90 doses (expressed as 2Gy equivalent doses using α/β=10) of around 85Gy or more to be delivered safely, even in cases of bulky disease [2]. To introduce this technique to the

How far can we safely deviate from the traditional technique? Modern optimisers, present on most if not all high dose rate (HDR) planning systems, will produce mathematically “good” solutions in terms of the objectives they are given, but may or may not be clinically appropriate. There is still an important role for manual intervention in the brachytherapy optimisation loop! HDR optimisation (altering the way in which active sources are distributed within applicators) permits the greater flexibility of modern applicators to be fully used. The

The key point to remember is that when new techniques are embraced we need to avoid losing sight of the methods that have served us well clinic, a significant amount of work was required to reconcile the different clinical experiences of brachytherapy, which has built up at many centres over the decades. In an important paper from GEC-ESTRO [3], it was realised that despite the different ways of prescribing, these could be harmonised, thereby enabling the accumulated clinical experience to be applied effectively in a modern, image-guided setting. The key point to remember is that when new techniques are embraced we need to avoid losing sight of the methods that have served us well for many years. The issue is that we do not yet know enough about the possibilities of toxicity induced by non-standard brachytherapy.

ring applicator, now sometimes used in place of the traditional ovoids in a cervix implant, permits greater flexibility of source positioning and thereby maximal sparing of nearby critical structures. Optimisation is also informing the development of the applicators themselves, for example singleand multi-channel balloon breast applicators have opened up new possibilities. For the treatment of prostate cancer, seed brachytherapy now has an established place as an effective treatment modality alongside external beam radiotherapy and surgery [4]. The prostate seed implant technique has itself undergone enhancement over the years, with many centres now performing real-time dosimetry with ultrasound

guidance to ensure that the implantation team is aware of the dosimetric properties of the implant actually taking place [5]. HDR prostate brachytherapy is becoming more widespread and allows exquisite conformance to the shape of the PTV and nearby rectum and urethra. It is planned either using ultrasound imaging (where treatment is delivered within the operating room) or, if treatment is delivered after the implantation procedure is complete, using CT or MR guidance [6]. Multicatheter HDR brachytherapy also opens up opportunities for the use of dose painting algorithms to boost biologically defined subvolumes within the PTV. Is there a role for brachytherapy boost of a dominant intraprostatic lesion? With appropriate geometry of implantation the dosimetry is feasible. It is an attractive proposition to create a “boost volume” using functional MR data generated immediately prior to implantation. However, validation work remains to be done. Brachytherapy dose distributions have always been generated with much simpler algorithms than their external beam counterparts. In many situations there is less need for an algorithm that separates primary and scatter. However, one recent development that will be of great interest is the application of Boltzmann-type radiation transport algorithms to brachytherapy treatment planning [7]. Such algorithms have the capability, in theory, to produce dose distributions with the accuracy of a Monte-Carlo calculation. One obvious area of application could be in situations, such as surface moulds, in which there is a lack of full scatter. The same “rules” for safe introduction of a new technique apply, although in applying a new algorithm to an existing technique, careful comparisons with current methods [8] and the classical systems of brachytherapy dose prescription need to be made. How do the new algorithms behave? for example, in the vicinity of calcifications in the patient or CT reconstruction artefacts from the applicators themselves.

Community News

As a research tool these algorithms will undoubtedly be important, although their role in the clinic is yet to be defined. What are our hopes for the coming years? The plethora of external beam modalities now available — intensity modulated radiotherapy (IMRT) of course, but now also stereotactic body radiotherapy (SBRT) using tomotherapy and Cyberknife — all allow high-dose conformality. Still, the inverse square law gives brachytherapy its unique dose distributions with the extreme hot spots characteristic of embedded sources, and it is these that define the essential characteristics of the modality and thereby its clinical niche. How can we better understand the radiobiological implications of the brachytherapy distribution? [9] Algorithms are becoming available for external beam IMRT to optimise not only the physical dose distribution but the tumour control probability (TCP) and normal tissue complication probability (NTCP). In brachytherapy the principles remain the same but the magnitude of the inhomogeneity is quite different, and it will be interesting to see how the radiobiology of brachytherapy impacts on the optimisation loop. An additional complication is that each treatment in a course of fractionated brachytherapy is often individually optimised. This is in contrast to a course of external beam radiotherapy, which, if it is spilt at all, is normally only into two or three phases, the same plan being used for all fractions of one phase. Therefore, radiobiologically the challenge for brachytherapy is to optimise a single fraction taking into account the dosimetry already delivered in previous fractions. This problem has still to be addressed in a clinically meaningful way. Where then does brachytherapy stand in the context of modern radiotherapy? The fundamentals have not changed; there is still the need to gain access to the site of disease and all the ramifications of this. However, the physics of the inverse square law still

provide the impetus to use this modality, and the refinements available with modern imaging and optimisation techniques have enhanced its usefulness. Maybe a greater understanding of the underlying radiobiology is around the corner. But I am extraordinarily bad at crystal-ball gazing. We shall see! References 1. ICRU Report 38: Dose and volume specifications for reporting intracavitary therapy in gynaecology. 1985 2. Dimopoulos J et al. Dose–effect relationship for local control of cervical cancer by magnetic resonance image-guided brachytherapy. Radiotherapy and Oncology 2009; 93: 311–15 3. Haie-Meder et al. Recommendations from Gynaecological (GYN) GEC-ESTRO Working Group (I): concepts and terms in 3D image based 3D treatment planning in cervix cancer brachytherapy with emphasis on MRI assessment of GTV and CTV. Radiotherapy and Oncology 2005; 74: 235–45 4. Michell DM et al. Report on the early efficacy and tolerability of I125 permanent prostate brachytherapy from a UK multi-institutional database. Clinical Oncology 2008; 20: 738–44 5. Polo A et al. Review of intraoperative imaging and planning techniques in permanent seed prostate brachytherapy. Radiotherapy and Oncology 2010; 94 :12–23 6. Hoskin P et al. High dose rate brachytherapy in combination with external beam radiotherapy in the radical treatment of prostate cancer: initial results of a randomised phase three trial. Radiotherapy and Oncology 2007; 84:114–20 7. Gifford K et al. Optimization of deterministic transport parameters for the calculation of the dose distribution around a high dose-rate 192Ir brachytherapy source. Med Phys 2008; 35: 2279-85 8. Nath R et al. Dosimetry of interstitial brachytherapy sources: Recommendations of the AAPM Radiation Therapy Committee Task Group No. 43 Medical Physics 22(2) Feb 1995 9. Armpilia C et al. Radiobiological modelling of dose-gradient effects in low dose rate, high dose rate and pulsed brachytherapy. Phys Med Biol 2006; 51: 4399–411  erry Lowe G Physicist, Mount Vernon Hospital

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Community News

High tech radiotherapy: where does modern brachytherapy stand? The clinical perspective Brachytherapy is the oldest form of radiation therapy. It is also one of the most conformal. Placement of radioactive sources directly into or very close to tumours achieves a high-dose to tumours while sparing the surrounding normal tissues. This efficiency of dose delivery may be the reason why technological developments within the field of brachytherapy lagged behind those of external beam radiotherapy (EBRT). However, recent years have seen sweeping changes in brachytherapy imaging and dose delivery. Imaging using CT and MRI scanning has enabled an evolution from estimation of dose delivered to accurate determinations of dose received. Exact knowledge of the position of organs at risk and of the conformation of target volumes combined with dose optimisation achievable with computerised after-loading source delivery allows the physician to tailor dose delivery to highly specific ideals. This has allowed improved prediction of late toxicity and the possibility for dose escalation in areas with a high tumour burden. In cancer of the cervix a new international standard has been set using MRI scanning to give improved anatomical definition and more accurate target demarcation [1]. However, this carries great financial and resource implications for the average brachytherapy department in the UK. It also raises the question of whether further site specialisation should occur with concentration of resources into fewer specialist centres treating more cases. Translational research will allow the continued technological development of brachytherapy. New biological and functional imaging modalities such as magnetic resonance spectroscopy (MRS) or PET scanning could be used to identify zones of aggressive cell repopulation then, with the use of fusion dosimetry, 10


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these sub-volumes could be specifically dose-escalated using brachytherapy. MRS-based sub-volume dose-escalation has been performed with prostate brachytherapy [2] with rapid dose fall-off in the surrounding tissue. Biological modifiers can be combined with brachytherapy to improve dose delivery, using both drug and non-drug therapies. The potential for cetuximab in head and neck brachytherapy is an obvious area to explore and the use of interstitial hyperthermia with brachytherapy has been studied in many disease sites including the prostate, head and neck, oesophagus and glioblastoma multiformae (GBM). Clinical CT-based dosimetric planning is likely to improve further as Monte-Carlo dose computation techniques become faster. This would allow for routine pretreatment planning dosimetry to account for tissue-composition heterogeneity and applicator shielding which is not possible with current computerised brachytherapy dosimetry programs. The delivery systems for brachytherapy are also likely to evolve and improve in the future. Delivery systems could be made more versatile with the capability to deliver different treatment modalities through the same applicator e.g. brachytherapy and hyperthermia or chemotherapy. Just as teletherapy moved from radioisotope cobalt sources to electronic megavoltage beam treatment, brachytherapy may move towards electronic energy generation. Miniature X-ray sources with an energy of 40-50 kVp have been developed for partial breast irradiation and superficial applications and the dosimetry compares favourably with that delivered by a 192Ir source [3]. The forthcoming ESTRO meeting in London will explore many of these themes. The combination of the ESTRO anniversary meeting and the GECESTRO annual meeting should provide an exciting opportunity to explore the role

that developing radiation technology has in modern brachytherapy. Brachytherapy has shaped the field of radiotherapy since the discovery of radium. Modern technological developments have ensured that brachytherapy continues to be an essential tool in the armoury of the clinical oncologist. Improved imaging and computerised dose delivery have enabled brachytherapy dosimetry to move from the days of orthogonal imaging for target location to computer aided dose optimisation and from reference point dosimetry to volumetric dose analysis. Future hightech developments in brachytherapy will follow other areas of cancer care with improved functional imaging and highly targeted dose delivery giving the potential for greater tumour control with decreased toxicity, although the introduction of such technology in these stretched economic times will surely prove more challenging than the dose delivery. References 1. Potter R, Haie-Meder C, Van Limbergen E, et al. Recommendations from gynaecological (GYN) GEC ESTRO working group (II): Concepts and terms in 3D image-based treatment planning in cervix cancer brachytherapy — 3D dose volume parameters and aspects of 3D image-based anatomy, radiation physics, radiobiology. Radiother Oncol 2006;78:67-77. 2. Pouliot J, Kim Y, Lessard E, et al. Inverse planning for HDR prostate brachytherapy used to boost dominant intraprostatic lesions defined by magnetic resonance spectroscopy imaging. Int J Radiat Oncol Biol Phys 2004;59:1558-64. 3. Dickler A, Kirk MC, Seif N, et al. A dosimetric comparison of MammoSite high-dose-rate brachytherapy and Xoft Axxent electronic brachytherapy. Brachytherapy 2007;6:164-8. Alex Stewart Consultant Clinical Oncologist, Royal Surrey County Hospital NHS Foundation Trust

Community News

The World Radiography Educational Trust Fund Let me tell you a little about the World Radiography Educational Trust Fund (WRETF). It was established by the International Society of Radiographers and Radiologic Technologists (ISRRT) in 1969 and became a charity in its own right in 1977. It now functions independently with no financial support from the ISRRT. Currently seven trustees administer the Trust whose appointments are ratified by the ISRRT. An Honorary Treasurer and Honorary Secretary administrate the Trust and recently the former Honorary Secretary has been appointed as the website manager. The Trustees are based in a number of countries other than the UK so that the work of the Trust can be looked after more easily. What does the Trust do?

The aim of the Trust is to promote the improvement of radiographic science and education throughout the world. It does this by providing support in the form of textbooks (new and used), journals and other educational material, such as photographic slides

The Togo workshop held in Lome in November 2010

and grants to support either research or workshops. Much of the work is in French speaking African countries, but also many English speaking ones. There has also been some support given to South American and East Asian countries. Many applications for support are received each year and the Trust does all it can to assist the radiographers of developing countries.

The WRETF trustees at the BIR in London. Back row L-R: Alan Budge, Ann Paris (Honorary Treasurer) and Julie Armstrong. Front row L-R: Dominique Zerroug, Wilma de Groot (Chairman) and Sue Marchant (Honorary Secretary).

How can you help the WRETF?

We welcome donations of radiographic textbooks — new or used, but preferably no more than 5 years old. These books are still relevant to departments throughout the world. Financial support in the form of monetary donations is always welcome since our income depends entirely from donations by generous individuals and member societies of the ISRRT. The Trust is also hoping to twin departments with those in the developing world so that journals which are no longer required can be sent to those departments that need them. I became a Trustee and honorary secretary of WRETF after my term of office as a Trustee of the British Institute of Radiology (BIR) ended in September 2010. So it feels like a home from home for me, especially since the WRETF meets twice a year at the BIR meeting rooms in Portland Place, London, courtesy of the BIR. If you would like to help with the work of the trust please get in touch via  ue Marchant S Honorary Secretary WRETF

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community news

An introduction to fo X-ray assisted in the identification of 79 (approximately 70%) and confirmed identification in 19. More recent applications of radiography have shown similar outcomes. Data from the Office of Chief Medical Examiner of New York (2003) reports that X-ray imaging assisted in the positive identification of 77% and confirmed identification in 14% of the victims retrieved from the site of the terrorist attacks of the World Trade Centre. Little was initially done to ensure a co-ordinated response to subsequent mass fatality incidents, to develop a policy to preserve the integrity of evidence or to provide training to prepare personnel to meet the challenges of imaging the dead, both technically and psychologically. Such shortcomings were highlighted in the response to the UK mass fatality incidents such as the Lockerbie air disaster or the shootings at Hungerford and Dunblane. Although consistently valued by pathologists and investigators, gaps were identified in the availability of Death of the individual imaging equipment, (Coroner’s Cases*) appropriate areas for service provision and training for radiography personnel. However, in the mid-1990s changes to the provision of Demonstration of forensic radiogChronological The Forensic Age / Fraud raphy services were Investigation of Living made following the Individuals investigations into Non-Accidental alleged war crimes Injury Demonstration Investigation in the former Yugoof Drug trafficking slavia. Mobile / contraband fluoroscopy and plain film imaging * Procurator Fiscal In Scotland

Eminent forensic radiologist Professor BG Brogdon [1] described the first use of X-rays for the conviction of the perpetrator of a shooting incident in a court case, which commenced on 24 December 1895, 3 days before Rőntgen submitted his inaugural paper describing his new discovery. Within months “roentgenograms” were being presented as exhibits in court and used in the investigation of physical assault, murder, medical negligence and work-related injuries. Today, the scope of forensic radiography includes, but is by no means limited to, the areas outlined in the figure below. The first co-ordinated use of radiography in a mass fatality setting was recorded in 1949 following the SS Noronic Steamship Fire [2]. All remains were radiographed and images were used to provide a visual record with which to compare antemortem records of the deceased to confirm (or exclude) identity. Of the 118 fatalities, The scope of forensic radiography

Mass Fatality Investigation

Archaeological Investigation

The Death Investigation

The demonstration of fraudulent antiques

Accident / Incident / criminal investigation



FORENSIC RADIOGRAPHY The Forensic Investigation of Artefacts

Archaeological Investigation

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were used to “screen” bodies for potential hazards, provide physical evidence for the criminal tribunal and for potential identification purposes, especially where dentition and personal effects were recovered from mass grave excavations. The initial radiography team comprised of civilian and military radiographers based primarily in the UK. This investigation inspired the initiation of a specialist interest group in forensic radiography which exists today as the International Association of Forensic Radiographers (IAFR). The principal aims of the IAFR are to promote best practice through the publication of guidance documents, training and advice, and the provision of a single contact point for the provision of a co-ordinated response of trained, experienced radiographers in the event of a mass fatality incident or archaeological investigation. The 93 victims of the 2004 Asian Tsunami, who were repatriated to the UK, were X-rayed by members of this response team and intra-oral radiography in particular was nominated as a highly efficient method in post-mortem identification alongside fingerprinting and DNA analysis. In June 2005 the first edition of the London Mass Fatality Plan was published, which included (for the first time) contingency planning for the provision of radiography services. This somewhat prophetic document was to be tested within days following its formal release when imaging services were required to examine all 56 bodies, bomb fragments and significant evidence retrieved from the London bombings of 7 July 2005. Comparatively, recent advances in cross-sectional imaging, particularly computed radiography, MRI, 3D and multiplanar reconstructional imaging (MPR), have meant this particular

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forensic radiography

Fluoroscopy was used in the mass fatality investigation of the London bombing 7 July 2005. (Image courtesy of the Metropolitan Police)

modality lends itself as an adjunct to, or more controversially as a potential replacement to, the clinical autopsy, although is not yet tested in the event of a mass fatality setting [3]. Home Office guidance that previously stated that radiographers and imaging equipment would be provided by local hospitals in the event of a major disaster was demonstrated to be woefully inadequate. The London bombings investigation has set the benchmark for service provision and timescales for radiography in the emergency mortuary; there is now a national plan that includes the allocation of portable digital imaging equipment and deployment of trained radiographer personnel for mass fatality incidents and UK disaster victim identification (DVI). Although commonly associated with necroscopic examinations, radiography is also frequently used to provide evidence for cases involving physical injury of the living. In 1946, paediatric radiologist Dr John Caffey first described what he termed “shaken-baby

syndrome”, [4] outlining the radiographic appearances of specific injury patterns to demonstrate what would later be recognised as non-accidental injury, which is subject to controversy following highly publicised miscarriages of justice and the involvement of the “expert witness”. Often affiliated with intentional physical injury of children, non-accidental injuries can often be seen in the abuse and assault of vulnerable adults including the elderly and those with learning difficulties. Radiography provides robust evidence to confirm the chronological age of an individual based on their “bone age”. Individuals entering the UK illegally may claim to be younger than they are to avoid prosecution and obtain asylum. Examination of the dentition using radiography, however, provides rapid confirmation of accurate chronological age of an individual and reduces the incidence of fraudulent asylum claims. Cross-sectional imaging can also be used to demonstrate ingested drug packets or “capsules” in organised drug trafficking [5]. At RSNA in 2010, Dr Patricia Flach of the Institute of Forensic Medicine at the University of Bern in Switzerland reported a study that demonstrated a 100% sensitivity rate of CT when used to identify ingested drug packets. Occasionally the radiographer will also be asked to provide images of artefacts, antiquities or even mummified items to provide further information regarding their authenticity, origin, composition or even age. Bomb fragments, sections of fuselage, shrapnel and other evidence are usually radiographed to provide a permanent, non-invasive record for the incident investigation. During the clinical imaging examination of living individuals, radiographers are in an ideal position to interact

directly, albeit briefly, with patients and any carers present without the other distractions of a busy emergency department, ward or outpatient clinic. Radiography practitioners are often the first line healthcare professionals to observe mannerisms, appearances or subtle physical signs of injury that could be indicative of non-accidental injury or abuse. This puts radiographers in a unique and at times vulnerable position which is why support is provided by the IAFR ( in the form of training for radiographers and recommendations for best practice. In addition, radiographers are accustomed to working outside the radiography department and are ideally placed to liaise with other professionals such as radiologists, pathologists, pathology technicians and mortuary managers, the coroner (or more likely his/her officers), the police, radiography archiving personnel, image archiving (PACs) managers and others to provide a valued contribution to the multidisciplinary forensic investigation. References: 1. Brogdon BG (ed). Forensic Radiology. CRC Press, Boca Raton, FL: 1998. 2. Leichtenstein J et al. The role of radiology in fatality investigations. Am J Roentgenol 1998;150:751-5. 3. Kahana T et al. Forensic radiology. Br J Radiol. 1999;72:129-33. 4. Caffrey J. Multiple fractures in long bones of children suffering from chronic subdural hematoma. Am J Roetgenol. 1946;56:163. 5. Schmidt S et al. Detection of ingested cocainefilled packets – diagnostic value of unenhanced CT. Eur J Radiol. 2008;67(1):133-8. Philip Allen and Emily Faircloth International Association of Forensic Radiographers (IAFR)

issue 3 june 2011


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IHE-UK demonstrates cross enterprise document and image sharing at E-Health Insider Live The IHE-UK 32m2 stand at E-Health Insider Live 2010 was twice as large as the previous year and received more than twice the visitors. We were also fortunate to include Christine Connelly among our visitors. Appointed in 2008 as the first Chief Information Officer for Health, Ms Connelly will focus on developing and delivering the Department’s overall information strategy and integrating leadership across the National Health Service. We also received a large contingent from the Royal College of Radiologists’ (RCR) PACS group. A series of talks were also given by experts in the presentation area. The IHE-UK interoperability demonstration for document and image sharing

We were fortunate enough to include Christine Connelly among our vistors was based on the scenario of a patient moving between two areas of the UK, within which IHE cross enterprise document sharing (XDS) had been set up. It should be stressed that we were demonstrating potential, not actual, facilities. The patient lives in one community, a local healthcare community in the Midlands, called the

Christine Connelly, Chief Information Officer for Health and Dave Harvey at the IHE-UK stand

“Home Local Healthcare Community” in the demonstration. The patient is referred by his GP to the local hospital where he is examined and drug treatment is started. He then goes on holiday to Wales where he becomes unwell and visits an accident and emergency department; because we are imagining that a pan-Wales XDS facility for document and image sharing has been set up, previous images and associated documents are immediately available for review. The drug levels are adjusted, relevant documents are submitted for sharing and the patient is able to resume his holiday. In this demonstration the patient visits his GP in the Home Local Healthcare Community where all documents and images that have been submitted for sharing in both areas are available for review. Support for the use of multiple patient identifiers and audit trail based security were also demonstrated. About IHE-UK

Evidence based interoperability demonstration diagram



issue 3 june 2011

IHE-UK provides information about IHE specifications and guidance for their use in the UK. It writes extensions to internationally used specifications to enable appropriate use in the UK, where

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required. This work is carried out in collaboration with the appropriate UK professional bodies, usually including HL7 UK since many IHE integration profiles are based on HL7 specifications. Current work of the MIRO committee

The IHE-UK Medical Imaging and Radiation Oncology (MIRO) committee provides a key forum for users and suppliers to talk together, plan and oversee UK integration profile deployments and help to promote the use of IHE specifications in support of smooth workflow in medical imaging. This in turn helps UK healthcare institutions become more productive and efficient in the current challenging financial climate. It organises IHE interoperability demonstrations at conferences and provides educational seminars. It has responded to the RCR paper “National Strategy for Radiology Image and Report Sharing� which recommended that the UK should move rapidly towards adoption of the XDS profiles. Current MIRO work includes investigating schemes for sharing DICOM images through the use of proxy systems. Further information is available from co-chair or the new clinical domains supplier co-chair

Current work of the ITI committee

The IHE ITI domain covers a range of profiles associated with sharing information within and across healthcare organisations. XDS is the most well known of these profiles and supports the registration and sharing of documents within and between healthcare organisations. The XDS profile provides a generic solution that supports the sharing of any type of healthcare information. The profile is also used as the basis for other IHE profiles, such as XDS-I to share images, which provide specialised support for the sharing of particular types of healthcare documents between departments and across facilities. Further information is available from Mark Simmons, ITI Supplier co-chair,

Dave Harvey demonstrates document and image sharing at E-Health Insider Live

IHE-UK contacts Alert Life Sciences Computing Beki Ruban (+44 121 329 4255)

E Novation UK Peter Flood (+44 1372 700790)

Forcare Harm-Jan Wessels (+31-30-699 1930)

GE Healthcare David Blake (+44 1707 263570)

IBM Mark Glading (+44 7841 493764)

Medical Connections Dave Harvey (+44 1792 390209)

Rogan-Delft Marco Koekenberg (+31 655108831)

Siemens Healthcare Ronan Kirby (+353 (1) 216 2000)

iSOFT Healthcare (Stand educational grant) Alan Budge (+44 7904 949 798)

Acuo Technologies (Presentation area educational grant) Shannon Werb (+1 952 905 3440)

issue 3 june 2011


Medical Imaging and Radiation Protection for Medical Students and Clinical Staff Edited by Colin J Martin, Philip P Dendy and Robert H Corbett

The dual purpose of this book is to provide an update on diagnostic imaging techniques and to present information for medical students, radiography students and radiologists in training on the prudent use of ionising radiation in medicine.

Required reading for all students in the radiological sciences. Contents Chapter 1: Radiation is all around us Chapter 2: Radiation in medicine Chapter 3: Diagnostic radiology Chapter 4: Computed tomography Chapter 5: Nuclear medicine (radionuclide imaging) Chapter 6: Ultrasound Chapter 7: Magnetic resonance imaging Chapter 8: The effects of radiation on cells Chapter 9: Radiotherapy

Chapter 10: Effects of human exposure to ionising radiation and risk estimates Chapter 11: Risks from radiological examinations Chapter 12: Principles of radiation protection and legislation Chapter 13: Requesting an X-ray Chapter 14: Personal protection Chapter 15: Research projects involving radiation Chapter 16: Radiation protection implications of screening Chapter 17: Overall diagnostic strategy and conclusions

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in the online issue of BJR

what’s online: Featured Articles:


Short communication

Pictorial review

Review article

Full paper

Investing in science: securing future prosperity

Digital tomosynthesis – a new lease of life for the intravenous urogram?

Pictorial review of mucopolysaccharidosis with emphasis on MRI features of brain and spine

Assessment of postradiotherapy salivary glands

Repair kinetic considerations in particle beam radiotherapy

B Jones

I T P Wells, V M Raju, B K Rowberry, S Johns, S J Freeman and I P Wells

D D Rasalkar, W C W Chu, J Hui, C-M Chu, B K Paunipagar and C-K Li

S C H Cheng, V W C Wu, D L W Kwong and M T C Ying

A Carabe-Fernandez, R G Dale and H Paganetti

DOI: 10.1259/ bjr/64183983

DOI: 10.1259/ bjr/95862259

DOI: 10.1259/ bjr/59197814

DOI: 10.1259/ bjr/66754762

DOI: 10.1259/ bjr/19934996

Highlighted Articles: Full papers

Case reports

Pulsed brachytherapy: a modelled consideration of repair parameter uncertainties and their influence on treatment duration extension and daytime-only ‘‘block-schemes’’

Coarse pleural calcification in a mesothelioma patient raises the possibility of a rare tumour subtype: osteoblastic sarcomatoid mesothelioma A M Mortimer, J Rowlands and P Murphy

DOI: 10.1259/bjr/30569427

T S A Underwood, R G Dale, A M Bidmead, C A Nalder and P R Blake

DOI: 10.1259/bjr/58276427

Micro-CT enables microlocalisation and quantification of Her2-targeted gold nanoparticles within tumour regions J F Hainfeld, M J O’Connor, F A Dilmanian, D N Slatkin, D J Adams and H M Smilowitz

DOI: 10.1259/bjr/42612922

Quality assurance of RapidArc in clinical practice using portal dosimetry A Fogliata, A Clivio, P Fenoglietto, J Hrbacek, S Kloeck, P Lattuada, P Mancosu, G Nicolini, E Parietti, G Urso, E Vanetti and L Cozzi

DOI: 10.1259/bjr/72327299

MRI of a microcystic adnexal carcinoma of the skin mimicking a fibrous tumour: case report and literature review A M Tawfik, A Kreft, W Wagner and T J Vogl

DOI: 10.1259/bjr/44068180


A patient with neutropenic fever and abdominal pain showing absent bowel wall on CT H J Kim, S E Rha and W K Kang

DOI: 10.1259/bjr/13586512

Rapid vision loss in a 15-year-old boy V K Mittal, M W Ko and J Chang

DOI: 10.1259/bjr/32300567 issue 3 june 2011


in The online issue of BJR

All other articles from May and June 2011 BREAST

Case report: Post-traumatic rapidly enlarging mucinous carcinoma of the breast with intratumoural haemorrhage: MRI appearances with pathological correlation K Tsuji, M Goto, S Yuen and T Nishimura

Neutral vs positive oral contrast in diagnosing acute appendicitis with contrast-enhanced CT: sensitivity, specificity, reader confidence and interpretation time D M Naeger, S D Chang, P Kolli, V Shah, W Huang and R F Thoeni

DOI: 10.1259/bjr/20854868

CT colonography: computer-assisted detection of

DOI: 10.1259/bjr/72140684 colorectal cancer

C Robinson, S Halligan, G Iinuma, W Topping, S Punwani, L Honeyfield and S A Taylor

DOI: 10.1259/bjr/17848340


Case report: An S-shaped sinoatrial nodal artery coronary artery fistula demonstrated by multidetector CT R Macduff and G H Roditi

DOI: 10.1259/bjr/17451817

Case report: Fulminant myocarditis owing to high-dose interleukin-2 therapy for metastatic melanoma P Thavendiranathan, D Verhaert, K L Kendra and S V Raman

DOI: 10.1259/bjr/13448473

Comparison of different volumes of saline flush in the assessment of perivenous artefacts in the subclavian vein during cervical CT angiography N Takeyama, Y Ohgiya, T Haya shi, T Takahashi, D Takasu, J Nakashima, K Kato, Y Kinebuchi, T Hashimoto and T Gokan

DOI: 10.1259/bjr/86966343

Post-operative radiochemotherapy in patients with gastric cancer: one department’s experience of 56 patients M Spych, B Serbiak, A Rychter, E Jesien-Lewandowicz, L Gottwald and J Fijuth

DOI: 10.1259/bjr/25406515

Assessment of hepatocellular carcinoma by contrast-enhanced ultrasound with perfluorobutane microbubbles: comparison with dynamic CT M Mandai, M Koda, T Matono, T Nagahara, T Sugihara, M Ueki, K Ohyama and Y Murawaki

DOI: 10.1259/bjr/38682601

CT differentiation of pyogenic liver abscesses caused by Klebsiella pneumoniae versus non-Klebsiella pneumoniae N K Lee, S Kim, J W Lee, Y J Jeong, S H Lee, J Heo and D H Kang

DOI: 10.1259/bjr/23004588 GASTROENTEROLOGY

Case report: Cystic hepatic mesenchymal hamartoma: the role of radiology in diagnosis and perioperative management G Anil, M Fortier and Y Low

DOI: 10.1259/bjr/41579091

Case report: Multiphase CT in the diagnosis of haemobilia: a potentially catastrophic ruptured hepatic artery aneurysm complicating the treatment of a patient with locally advanced rectal cancer A M Mortimer, A Wallis and A Planner

DOI: 10.1259/bjr/20779582

Hepatocellular carcinoma in cirrhotic patients at multidetector CT: hepatic venous phase versus delayed phase for the detection of tumour washout A Furlan, D Marin, A Vanzulli, G Palermo Patera, A Ronzoni, M Midiri, M Bazzocchi, R Lagalla and G Brancatelli

DOI: 10.1259/bjr/18329080



issue 3 june 2011

Long-term results of radiofrequency ablation for unresectable colorectal liver metastases: a potentially curative intervention A A J M Van Tilborg, M R Meijerink, C Sietses, J H T M Van Waesberghe, M O Mackintosh, S Meijer, C Van Kuijk and P Van Den Tol

DOI: 10.1259/bjr/78268814

Use of small bowel imaging for the diagnosis and staging of Crohn’s disease: a survey of current UK practice R Hafeez, R Greenhalgh, J Rajan, S Bloom, S McCartney, S Halligan and S A Taylor

DOI: 10.1259/bjr/65972479


All other articles from May and June 2011 GENITO-URINARY


Case report: Intrascrotal extratesticular epidermoid cyst

Case report: Reversed halo sign on thin-section CT in a patient with non-specific interstitial pneumonia

A Agarwal and K Agarwal

DOI: 10.1259/bjr/36540689

Can point doses predict volumetric dose to rectum and bladder: a CT-based planning study in high dose rate intracavitary brachytherapy of cervical carcinoma? V M Patil, F D Patel, S Chakraborty, A S Oinam and S C Sharma

DOI: 10.1259/bjr/33758793

S H Hong, E-Y Kang, B K Shin and J J Shim

DOI: 10.1259/bjr/43867123

Case report: Asymptomatic adults with isolated, unilateral right pulmonary vein atresia: multidetector CT findings Y Kim, I R Yoo, M I Ahn and D H Han

DOI: 10.1259/bjr/51344661


Case report: Facial wrigglies: live extralymphatic filarial infestation in subcutaneous tissues of the head and neck S J Vaid, A Luthra, S Karnik and A T Ahuja

DOI: 10.1259/bjr/84379927


Case report: Cauda equina syndrome and dural ectasia: rare manifestations in chronic ankylosing spondylitis C-C Liu, Y-C Lin, C-P Lo and T-P Chang

DOI: 10.1259/bjr/45816561

Short communication: Lumbar spine radiography–poor collimation practices after implementation of digital technology L G Zetterberg and A Espeland

DOI: 10.1259/bjr/74571469

Another fractured neck of femur: do we need a lateral X-ray? B Almazedi, C D Smith, D Morgan, G Thomas and G Pereira

DOI: 10.1259/bjr/57316056


Hounsfield review: The physical basis and future of radiation therapy T Bortfeld and R Jeraj

DOI: 10.1259/bjr/86221320

Pictorial review: Extracranial epidural emphysema: pathway, aetiology, diagnosis and management F Cloran and L T Bui-Mansfield

DOI: 0.1259/bjr/79263160 issue 3 june 2011


Case of the month

Patient with neutropenic fever and abdom A 35-year-old Asian female with acute myeloblastic leukaemia developed fever and right lower abdominal pain 6 days after second induction chemotherapy. The white blood cell count was 10 Âľl-1 with 0% neutrophils. Peripheral blood culture was negative for aerobic and anaerobic organisms. Haematologists changed the antibiotics and started amphotericin B on the presumptive diagnosis of typhlitis. However, 13 days later, the patient again complained of severe abdominal pain. An urgent contrast enhanced abdominal CT was performed. CT showed a long segmental wall thickening of the terminal ileum, caecum and ascending colon with target-like appearance. A relatively long segment of posteromedial wall of the ascending colon was not visualised, in association with a small amount of concentrated air bubbles close to the bowel wall, regional mesenteric haziness and a large amount of loculated fluid collected along the right psoas muscle (Figures 1-4). What is the cause of these imaging findings? 20


issue 3 june 2011


Emergency laparotomy revealed diffuse necrosis of the distal ileum and proximal ascending colon and an 8cm sized perforation in the posteromedial wall of the ascending colon, consistent with extensive ischaemic necrosis caused by mucormycosis (Figure 5).


Mucormycosis, a fungal infection caused by the fungal order Mucorales, class Zygomycetes, is a relatively uncommon opportunistic infection, primarily seen in immunocompromised patients, such as those with diabetes mellitus, leukaemia or lymphoma. Most of these conditions are associated with impairment of normal neutrophil and macrophage function, resulting in increased risk for invasive fungal infections. Although aspergillosis and candidiasis are the most

common invasive fungal infections in such patients, the incidence of infectious diseases caused by Zygomycetes has risen significantly over the past decade [1]. According to the literature, five clinical manifestations caused by mucormycosis have been described, including rhinocerebral, pulmonary, cutaneous, gastrointestinal and disseminated diseases. If the gastrointestinal tract, the rarest spectrum of mucormycosis, is involved, the stomach is the most common site, followed by colon and small bowel [2]. The most characteristic feature of mucormycosis is invasion of blood vessels, resulting in ischaemia, haemorrhagic infarction and tissue necrosis, irrespective of the involved organs [3]. In the gastrointestinal tract, the fungi invade through the bowel wall and blood vessels, leading to bowel ischaemia, perforation, peritonitis or massive

Figure 2. Contrast enhanced CT image from the upper to lower level show a long segmental wall thickening of the terminal ileum, caecum and ascending colon with target-like appearance (arrows). Figure 1. Coronal reformatted contrast enhanced CT image shows abrupt discontinuity of the medial wall of proximal ascending colon (open arrow) and a long segmental bowel wall thickening of ascending colon (arrows).

case of the month

minal pain showing absent bowel wall on CT gastrointestinal haemorrhage. Imaging findings of mucormycosis involving the gastrointestinal tract have been rarely reported in the radiological literature, but in the early stage of gastrointestinal mucormycosis, CT may show nonspecific bowel wall thickening with or without target sign and decreased bowel wall enhancement, representing bowel ischaemia. When the involved bowel segment becomes necrotic, the bowel wall is thinned or even worse, disappears, as in our case. Direct visualisation of the discontinuity of the bowel wall is one of the most specific imaging findings of bowel perforation, but this finding is infrequently seen in most patients with gastrointestinal tract perforation, partly owing to the small size of the lesion [4]. However, our case showed an unusually long segmental absence of the bowel wall, which was caused by extensive haemorrhagic infarction and perfora-

Figure 3. Contrast enhanced CT image from the upper to lower level show a long segmental wall thickening of the terminal ileum, caecum and ascending colon with target-like appearance (arrows). A relatively long segment of posteromedial wall of the ascending colon (open arrows) is not visualised, in associated with small amount of concentrated air bubbles close to the bowel wall, regional mesenteric haziness and a large amount of loculated fluid collection (F) along the right psoas muscle.

tion caused by mucormycosis. In 2006, Song et al [5] reported a case of mucormycosis resulting in gastric perforation in a patient with acute myelogenous leukaemia. In that case, CT showed a long segmental absence of posterior wall of the gastric fundus with a massive collection of haematoma, which is very similar to our case. We think that CT findings of a long segmental discontinuity of bowel wall along with a large amount of haematoma and localised peritonitis may be characteristic findings suggestive of extensive infiltration of angioinvasive fungus in the proper clinical setting, although definite diagnosis can be made only by histological examination of tissue. Successful treatment consists of a combination of surgical removal of devitalised necrotic tissue along with long-term administration of intravenous antifungal therapy. Early diagnosis

Figure 4. Contrast enhanced CT image from the upper to lower level show a long segmental wall thickening of the terminal ileum, caecum and ascending colon with target-like appearance (arrows). A relatively long segment of posteromedial wall of the ascending colon (open arrows) is not visualised, in associated with small amount of concentrated air bubbles close to the bowel wall, regional mesenteric haziness and a large amount of loculated fluid collection (F) along the right psoas muscle.

of angioinvasive fungal infection at the time when they are still localised is very important for prompt patient management and improved prognosis [3]. In disseminated cases, the prognosis remains unfavourable, in spite of aggressive treatment. The mortality rate in patients with haematological malignancy who have mucormycosis is greater than 50% [6]. Therefore, timely suggestion of presumptive radiological diagnosis of angioinvasive fungal infection including mucormycosis can have important bearing on the prognosis. In conclusion, imaging findings of early gastrointestinal mucormycosis may be nonspecific, but CT findings of a long segment of absent bowel wall along with a large amount of haematoma can be suggestive of angioinvasive fungus in immunocompromised patients with neutropenic fever and abdominal pain unresponsive to the antimicrobial treatment.

Figure 5. Microscopic examination revealed colonic vessel occlusion and transmural invasion by many fungal hyphae with right angle branching, consistent with mucormycosis (arrow) (haematoxylin and eosin stain, ×100 magnification). HJ Kim, SE Rha, WK Kang Department of Radiology and Department of Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 505, Banpo-dong, Seocho-gu, Seoul, South Korea.


Download the full article and references: DOI: 10.1259/bjr/13586512

issue 3 june 2011



commentary Investing in science: securing future prosperity Six years ago the government presented its strategy for increasing science investment, a summary of which was published in the British Journal of Radiology [1]. At the time there was scant attention to radiation related research in healthcare, but since then the position has changed. Examples include large awards of basic technology funds for two new strategies for charged particle acceleration for cancer as well as partnerships between the Engineering and Physical Sciences Research Council (EPSRC) and Cancer Research UK (CRUK) on imaging research. Additionally, the Gray Institute was formed in Oxford to revitalise radiation research in oncology. Such developments may yield useful and interesting solutions to diagnosis and therapy of cancer. Now, however, the financial situation has changed. The government has announced deep reductions in public spending, while retaining a constant cash level of funding for scientific research. “Investing in Science: securing future prosperity” was a 2 day meeting held at Chatham House, London, on 22–23 November 2010. Fortunately, as the meeting was not subject to formal “Chatham House Rules”, it is reportable. The following account is a summary of the present state of science in the UK with some international contrasts. It is not possible to mention all of the speakers and discussions, but further information is available from science/-/speakers/ UK government policy

David Willetts MP, as Minister of State for Universities and Science, summarised the recent comprehensive spending review ( index.htm) with full acknowledgment of the importance of scientific knowledge and research for the benefits to the economy and society. The high ranking of British science and its widely respected freedom continues 22


issue 3 june 2011

to produce high quality output from a relatively modest financial input when compared with other advanced countries. Although the science research budget is effectively frozen for the next 4 years, it has fared better than many other branches of government. So, for state-sponsored science activities, much will depend on the effect of monetary inflation between now and 2015. The official and rather optimistic expectation that inflation will keep within a range that can be matched by efficiency savings was doubted by many of the delegates. In the words of Lord Rees, the process may yet prove painful but at least is potentially manageable. The effects of the fixed funding rate each year will be harder to manage in some parts of the research councils than others, depending on our currency exchange rate. This is especially the case for our present approximate £80m contribution to the Centre for Nuclear Research (CERN), Geneva, which currently has a high public profile, yet is taking an increased interest in particle beam radiobiology and therapy of cancer [2]. Heads of research and development of a variety of industries from the UK and abroad presented data about their large contributions to national and international research activities. The global aspect of business has yet to be matched by governmental global research funding initiatives, although UK research councils have accepted the need to fund research at laboratories and clinics abroad if necessary. Most attendees agreed with Brian Cox (University of Manchester, UK) that the UK research and development budget should be at least restored to its 1986 level relative to gross domestic product, which amounts to around a doubling of what will exist in 2014. Innovations clearly should depend on a combination of fundamental research and more deliberate application of known basic science, taking into account the demands of potential customers.

Worldwide aspects

In Europe, the Seventh Framework Programme (FP7) and special shared institutes like CERN continue, but there are new initiatives such as a single market for research and young principal investigator awards. It will be interesting to see if such consortia develop elsewhere in the world. France leads Europe in signing formal agreements for co-operative research with other countries, with the UK lagging far behind other European Union states. Elsewhere, in China and India for example, scientific publications will soon outstrip the western world, as will spending on science and technology with the expectation of large future gains in prosperity. The Chinese government plans for a “green” economic expansion driven by innovation at low cost. One notable example of involvement within China is that of the pharmaceutical company Merck, who have established hepatitis B vaccination production sites and other facilities in China over the past 20 years; the incidence of hepatitis B has subsequently fallen from 10% to 1%. However, developing countries need to be careful about engaging with too much blue-sky research which is initially parasitic of their resources, although capable of producing many benefits in the longer term; instead, concern about water purity, agricultural yields to relieve starvation and tropical diseases are a far greater priority. Many countries have not so far excelled in interdisciplinary projects where researchers need to have broad understanding of their collaborators’ objectives. Western countries appear to maintain a lead in this respect. Examples are obvious, most imaging research in medicine is applied physics, while bio-informatics is heavily dependent on computer science. Broadness of training and “discipline-hopping” are important to make progress. More applications of systems engineering to biology and

medicine are likely to improve efficiency of agriculture and the quality of healthcare. Public involvement

Many speakers appealed for more public involvement in science and a greater appreciation of scientific methods. The societal dangers of some pervasive pseudoscientific beliefs were also raised. Despite this, many presentations contained crude correlations that do not necessarily prove cause and effect, for example the observation that therapeutic abortions are associated with mental instability later in life. Such factual data should not be dismissed, but must be studied further. Quantitative social sciences research and good data sets are relatively sparse and are infrequently used by government at the present time. Another vexing problem is international law; scientists can face lawsuits Some solutions to the UK’s problems: • The settlement of the new UK Maxwell Institutes, designed to improve academic– industrial collaboration, might be used to persuade some of our older and most prestigious universities that doctorate courses of longer than 3–4 years might be allowed for industrially experienced students who could continue to work within their companies. • A greater acceptance that translational research in medicine is equally valid between the physics laboratory and the clinic in the same way as from the molecular laboratory to the clinic. • Greater attention to numeracy and mathematical modelling within medicine should provide considerable advantages, for example in situations where clinical trials cannot be performed, or to eliminate combinations or temporal sequences of modalities that are unlikely to provide benefits, while identifying those that have a high probability of being successful. • The joint “concordats” in science and medicine with France must be encouraged.


drafted in other countries and protective legislation is indicated. Nomenclature is another issue for public awareness and radiology in particular. The abrupt change of nuclear magnetic resonance (NMR) to MRI, in order to decontaminate the brand of any associated radioactivity, was highlighted by an Oxford astronomer (Katherine Blundell), whereas the CT scanner nomenclature denies radiation exposure when it actually exists. These two techniques were UK discoveries, which resulted in Nobel Prizes being awarded to Godfrey Hounsfield and Peter Mansfield. But the failure to develop these elegant discoveries into viable long-term products by British industry failed to realise economic advantages. It was paradoxical that the country of discoveries could barely afford to purchase the evolving commercial products from abroad; the British public were highly dependent on purchases of scanners by charities and the shortage of such equipment must have contributed substantially to diagnostic and therapeutic delays, leading in turn to disappointing cancer survival in the UK. Discussion

The present state of UK science reflects, at least partly, the provision made at schools, universities and other institutes over the past 20-50 years. More recent funding reductions e.g. during the 1990s may yet cause adverse effects. If quality of life is dependent on educational attainments, the UK has traditional strengths but many acquired weaknesses which must be overcome. The past enthusiasm for replacing agriculture and downgrading industry in favour of financial and other services must now be accepted as having been a serious mistake; judicious combinations of all these approaches to economic benefits are essential. It is noticeable that if direct taxation is used to fund healthcare, then industry and the other sectors of the economy have to produce sufficient wealth to allow progress, but individuals are now spending more of their earned income directly on health-related services. However,

any assumption that the latter route will grow with time depends upon an expansion in general economic prosperity. Greater sharing of biomedical research costs is an attractive possibility. One immediate example is the recent finding that the low energy ion ring (LEIR), which supplies heavier ions to the Large Hadron Collider at CERN, is redundant for close to 80% of the year, which opens up the possibility of biomedical research. This would be a sensible use of scarce budgets, by sharing between nations, during financially restricted times. In terms of my own preference for charged particle therapy for cancer, the UK will by 2015 allow NHS tariffs at two or three specified hospitals that deliver proton therapy only without an impressive research and development structure. This will mean that Germany, Italy, France, Austria and Japan will have more versatile beams using ranges of light ions and backed by ambitious research commitments. Unless the large cancer charities such as CRUK intervene, in partnership with a leading university the Science and Technology Facilities Council (STFC) laboratories joined up with EPSRC and the Medical Research Council, the prospect of implementing the basic technology grants seem remote and it must be questioned whether British industry retains sufficient expertise to manufacture and export such technology. Many of these ideas involve relatively small amounts of money. Perhaps the time is ripe for parts of the financial services industry to be overtly associated with such developments for the benefit of the public. This might engage public opinion, heal recent rifts and lead to a more harmonious society. There is, as always, a role for large public and private benefactions from industry, including that of private healthcare. Professor Bleddyn Jones MD, FBIR Gray Institute for Radiation Oncology & Biology, University of Oxford, Oxford, UK


Download the full article and references DOI: 10.1259/bjr/64183983

issue 3 june 2011


short communication

Lumbar spine radiography — poor collimation practices after implementation of digital technology In medical imaging, radiation doses to patients should be kept as low as reasonably achievable [1]. This requires proper collimation. Limiting the irradiated field to the area of diagnostic interest (ADI) is essential, since the dose increases with irradiated area [2]. Digital image processing programs can be used in daily practice to mask an unnecessarily large collimation so that you can no longer see whether the image is optimally collimated or electronically edited [3]. This could reduce the motivation to carry out proper collimation. However, no previous studies have evaluated this issue. We therefore examined the hypothesis that collimation practices have deteriorated since the implementation of digital radiography. Methods and materials

This study was conducted at a large Norwegian and a smaller Danish hospital. We included 86 analogue and 86 digital lumbar spine frontal radiographs, 50 of each from the Norwegian hospital and 36 of each from the Danish hospital. Both hospitals lumbar spine radiography procedures remained unchanged for the duration of the study.


The proportion of the irradiated field outside the ADI was larger in digital than in analogue images (mean 61.7% vs 42.4%, p <0.001). The distance from the ADI to the outermost edge of the irradiated field was larger cranially, caudally and on both sides (p<0.001). The irradiated area outside the ADI was also larger in digital than in analogue images at each hospital (Norwegian: mean 63.1% vs 37.5%; Danish: mean 59.8% vs 49.1%; p<0.001 for both). This applied to all sections of the Norwegian images (p < 0.001) and laterally (p < 0.001), and caudally (p=0.012) but not cranially (p=0.66) in the Danish images. Patients in the digital group were older (mean 57 24


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years, median 58 years, range 19–87 years) than patients in the analogue group (mean 52 years, median 51 years, range 18–94 years). However, the age difference did not contribute to an increase in irradiated area outside the ADI. In images matched for patient age the proportion of the irradiated field outside the ADI was significantly larger in the digital than in the analogue images (mean 60.9% vs 38.0%, p < 0.001). In the whole sample, the mean total irradiated field in digital and analogue images was 791cm2 and 541cm2, respectively (i.e. 46% larger in digital images). Discussion

We found a marked and consistent deterioration in collimation of lumbar spine radiographs at two different hospitals, with considerably larger areas being irradiated after the implementation of digital radiography. The 46% increase in irradiated field size indicates a similarly higher radiation dose to patients. Such an increase may go unnoticed, since it can be masked on the final images. The lumbar region contains radiationsensitive tissue types and has greater tissue thickness, which in turn can produce scattered radiation [5]. Lumbar spine radiography contributed a larger mean effective dose per 1000 inhabitants in Norway in 2002 (39mSv) than any other X-ray examination except barium enema (64mSv) and pelvic/ hip X-rays (45mSv) [6]. Based on national data from 2006, the Danish National Board of Health states that a 1.4mSv effective dose is the reference dose for lumbar spine radiography and that a 7mGy entrance skin dose (ESD) is the reference dose for anteroposterior projection [7]. Our findings indicate that improved collimation could be used to lower these doses. In daily practice, the irradiated field cannot exactly match the ADI. Attempts to achieve this would result in frequent retakes. However, large radiation doses

can be avoided by, at the least, reverting to the “analogue” collimation practice (analogue images were also substantially bigger than the ADI). To achieve this, one might consider continued focus on collimation in the education of radiographers, standard procedures that do not allow masking of the irradiated area and automated technology that closes the collimators when new projections are selected to ensure active collimation. Data on radiation dose, patient size and radiographer characteristics were not available. However, the large image samples prevented random errors owing to uneven distribution of patient size in the two image groups and ensured that many different radiographers had produced the images. Based on rotation plans, workforce size and the length of the data acquisition period, we estimate that the digital images were taken by 47 different radiographers. The analogue images were from a longer time period and may therefore have involved a larger number of radiographers. We have no data indicating that the deterioration in collimation may be due to reduced radiographer experience. Our consistent findings regarding lumbar spine radiographs from two different hospitals in two different countries may also be valid elsewhere. Collimation can be masked on any digital projection and we are not aware of any specific issues related to lumbar spine imaging that would cause poorer collimation compared with other images after digitalisation. Our findings are therefore likely to apply to other digital images, but this will need to be confirmed in further studies. LG Zetterberg and A Espeland Department of Public Health and Primary Health Care, University of Bergen, Bergen, Norway


Download the full article and references DOI: 10.1259/bjr/74571469

Hounsfield review


T Bortfeld, PhD and R Jeraj, PhD Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, USA


The physical basis and future of radiation therapy Only with more emphasis on medical physics research will the future of radiation therapy and other physics-related medical specialties look as bright as the past Radiation therapy would not exist without physics. This obvious but sometimes forgotten fact is the guiding principle of this review article. While radiation therapy “lives” at the interface between many disciplines, its dependence on physics is arguably the strongest. By this we mean not only the dependence on clinical physics support to make sure that radiation is being administered safely and accurately, but primarily the dependence on the science and research side of physics in general and medical physics in particular. We tend to think of medical physics as physics in medicine, to emphasise the importance of physics. One question that we will try to answer is: what is the recipe for success of physics in medicine? In Part 1 we will first identify the traditional contributions of physics in radiation therapy mostly focused on the physics of precise radiation “dose localisation”. We will then look at physics contributions beyond dose localisation and even beyond radiation therapy. In Part 2 we will discuss the role of physicists in radiation therapy and the challenges that

we currently face, especially the diminishing emphasis on the research role. Lastly, we will provide some suggestions on how to address those challenges in the future to secure a sustainable environment for long-term and high-impact of physics in medicine. Part 1: Dose localisation and beyond

Of the many “gifts” that physics has made to medicine, the discovery of X-rays is probably the greatest. The enormous potential of X-rays not only for diagnostic imaging but also for the treatment of diseases was recognised soon after the discovery. The main focus of physics in radiation therapy has always been to increase the level of precision and accuracy of dose delivery to the (tumour) target volume. Remarkable progress has been made in this area, which is based on four cornerstone developments: 1. Fundamental discoveries leading to new treatment and imaging modalities. 2. Technology inventions in radiation dose delivery.

The remarkable progress in radiation therapy over the last century has been largely due to our ability to more effectively focus and deliver radiation to the tumour target volume. Physics discoveries and technology inventions have been an important driving force behind this progress. However, there is still plenty of room left for future improvements through physics, for example image guidance and fourdimensional motion management, particle therapy, as well as increased efficiency of more compact and cheaper technologies. Bigger challenges lie ahead of physicists in radiation therapy beyond the dose localisation problem, for example in the areas of biological target definition, improved modelling for normal tissues and tumours, advanced multi-criteria and robust optimisation, and continuous incorporation of advanced technologies such as molecular imaging. The success of physics in radiation therapy has been based on the continued “fuelling” of the field with new discoveries and inventions from physics research. A key to the success has been the application of the rigorous scientific method. In spite of the importance of physics research for radiation therapy, too few physicists are currently involved in cutting-edge research. The increased emphasis on more “professionalism” in medical physics will tip the situation even more off balance. To prevent this from happening, we argue that medical physics needs more research positions and more and better academic programmes. Only with more emphasis on medical physics research will the future of radiation therapy and other physics-related medical specialties look as bright as the past, and medical physics will maintain a status as one of the most exciting fields of applied physics.

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Hounsfield review

3. Technology inventions in treatment planning. 4. Technology inventions in imaging. More efficient, more compact and cheaper treatment solutions

Radiation therapy is still a relatively cheap cancer treatment modality compared with, say, molecular targeted therapies. Yet, with all the new technology that is being used in the field, the cost increase over the years has been substantial. In particular, the case of proton therapy has been used as a negative example of how technology drives up the cost of healthcare [25]. It is therefore a worthwhile goal to use physics and technology to make the treatments simpler, faster and cheaper, without compromising their quality (i.e. the dose distribution). Several developments are already

based on the classic Emami et al [48] tables describing relationships between dose, treated volume and outcome. As these tables are now 20 years old and have several deficiencies, a comprehensive analysis of more recent data has been performed and published by the Quantitative Analyses of Normal Tissue Effects in the Clinic (QUANTEC) task group [49]. While this is clearly a step in the right direction, it is surprising that a further 20 years of research and treating patients with radiation has not produced a more solid body of data and understanding of normal tissue complications. Great care has to be used in integrating the QUANTEC results into NTCP models [50]. The difficulty in collecting solid complication data for the development of reliable NTCP models stems from multiple reasons: complications in

Even with the most advanced physical and biological targeting...there is always a tradeoff to be made between target dose and normal tissue dose under way with this goal in mind. For example, the recent development of volumetric modulated arc therapy (VMAT) has been embraced by many clinics because it promises to deliver essentially the same intensity modulated radiotherapy (IMRT) treatment in a much shorter time by delivering it in a dynamic rather than step-and-shoot fashion [26]. Better understanding of normal tissue response

Besides knowing what the tumour target volume is and how much radiation dose it needs, the reliable prediction of normal tissue complication probabilities (NTCP) in each organ is clearly important for both treatment planning of individual patients and assessment of the benefit of new treatment modalities. Unfortunately, this is a challenging and largely unsolved problem. Existing NTCP models are often 26


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radiation therapy which are, fortunately, relatively rare; large uncertainties in the underlying historical dose and volume data (contouring of the organs) exist; and there are substantial uncertainties in the assessment of the outcome. The fact that most normal organs are non-homogeneous and that they can exhibit different types of complications (from acute reactions to the development of secondary cancers [19, 51]) further complicates matters. The advancement of alternative temporal dose fractionation schemes has shown great potential [52], but it adds another dimension (i.e. time) to NTCP modelling. Lastly, recent animal experiments have led to interesting insights into the “dose bath” effect [53, 54] and have challenged standard NTCP models. The addition of a very small “bath” of dose can have a much bigger effect than would be expected based on the typical assumption

of a mean or maximum dose response. Implications for treatment planning: robust optimisation and multicriteria optimisation

The issue of uncertainties in target definition, treatment delivery and outcome modelling has surfaced in the previous discussion. It is important to protect patient treatments against those uncertainties. Traditionally this has been done through the addition of margins (to account for spatial uncertainties) and conservative dose prescription (“first, do no harm”), i.e. through manual “robustification” of the treatment plans. Computerised robust optimisation techniques have recently been developed [60–62]. These robust optimisation techniques are becoming essential in advanced intensity-modulated particle therapy [63], and especially in biologically-guided treatment planning with additional uncertainties in the underlying biological models. Also, even with the most advanced physical and biological targeting discussed above, and assuming that uncertainties can be reduced or otherwise dealt with, there is always a tradeoff to be made between target dose and normal tissue dose. Furthermore, there is typically more than one normal organ involved and tradeoffs between dosing the various normal organs have to be made as well. The standard way to find the most suitable tradeoffs for an individual patient is by trial and error. A more scientific approach uses concepts of multiobjective optimisation [64, 65], and in particular the concept of Pareto optimality [66, 67]. Interestingly, decision making with multiple objectives is a well-developed scientific field in economy and public health [68], but it has not been widely used in radiation therapy.

Beyond radiation therapy

Traditionally, the strongest involvement of physicists in medicine has been in radiation therapy and imaging. A smaller number of physicists are already involved in multimodality therapy, especially in the modelling aspects of combined radiation and chemotherapy [71]. In the future, phys-

Hounsfield review

Spectrum of medical physics roles. Each of the four primary roles: cutting edge research, translational research, technology improvement and clinical implementation, are equally important, even although they are not, and do not need to be, equally represented.

icists could and should reach out to other territories that could benefit enormously from their involvement. Fast developments of life sciences in the last decades are rapidly transforming the way in which medicine is practised. Genetic screening and molecular biomarkers are having a profound impact on disease prevention, screening, diagnosis and treatment. Traditional boundaries between disciplines are being shifted and blurred by strong realisation that a complex, multifaceted approach is needed. Furthermore, the emphasis on translational research is pushing towards better merging of basic and clinical sciences. If medical physics is to remain a strong player in the future, it must not be shy of moving to these territories. The realisation that physicists can make an important contribution in many areas in medicine, especially in areas that traditionally do not normally involve physicists, has been widely recognised, but rarely acted upon. A recent initiative by the National Cancer Institute (NCI) to establish physical sciences-oncology centres was set-up to explore new and

innovative approaches to better understand and control cancer by exploring a systematic convergence of the physical sciences with cancer biology. By partnering with scientists from various non-biological disciplines, NCI envisions novel approaches to help generate answers to some of the major questions and barriers in cancer research. NCI’s initial goal was to join these often disparate areas of science by building a collaborative network composed of physical sciences-oncology centres. Working in cross-disciplinary teams, those centres will explore the physical laws and principles that shape and govern the emergence and behaviour of cancer at all scales in an effort to open up new areas and support the development of clinical advances. While this is only the first initiative, it is certainly not the last one. Part 2: Physics role, challenges and future

Medical physicists playing a spectrum of different roles with two distinctive extremes: the clinical role, with the primary goal of securing safe clinical operation

of medical procedures; and the research/ academic role, with the primary goal of academic development of the medical physics field. The spectrum of medical physics roles can be further divided into subcategories, each employing a different proportion of medical physicists. The majority of medical physicists, in the order of 80%, are primarily focused on clinical implementation, with little or zero research/academic component. A smaller subset of medical physicists, in the order of 10%, is still carrying a primarily clinical role, but has started to bridge towards research. However, most of their research is limited to solving day-to-day problems, resulting in predominantly clinical technology improvements. While research is not the major emphasis or goal, the on-thejob problems might also require innovative approaches and novel solutions, but with often limited time dedicated to research, it cannot really lead to major advances in the field. The professional development of this group follows the same path as the “clinical practice” group. On the other side of the spectrum there is a small minority of medical physicists, probably less than 1%, with a main research/ academic focus, and primary role to perform cutting-edge research. The time horizon of this research is typically 10–20 years or more. In contrast to the clinical practice group, the professional foundation for this group of physicists is not well-established. While there are several outstanding institutions worldwide doing excellent medical physics research, the trends show increasing difficulties for sustainable performance of this group, in a large part owing to the absence of a well-organised academic path. With the predominantly research role, a much larger fraction of medical physicists, in the order of 5%, could be characterised as performing translational research, that is primarily performing high-quality research in newly identified and expanding areas, often linked to direct clinical application. The time horizon of the research for this group is in the order of 5 years. Most of the medical physicists in this group are strongly confined to a specific medical physics issue 3 june 2011


review article

subfield (e.g. radiation oncology), often preventing them from easily bridging across to other medical physics subfields as well as towards other professions. What are the challenges?

The research grant funding situation has become very hard owing to the worldwide economic troubles, even though some of the recent signs are more positive. The impression shared by many research medical physicists is that the quality of the medical physics research presented at many conferences and in scientific papers is declining, even though it is hard to provide hard data for it. The major scientific journals, Physics in Medicine and Biology and Medical Physics, are still performing strongly but it may be an indicator that the most recent impact factor (ISI) for Medical Physics from 2009 has, for the very first time, dropped substantially, by 30%. One of the biggest challenges is the mismatch between the current educational structure of medical physicists and the typical role that medical physicists are playing. According to a survey of the American Association of Physicists in Medicine (AAPM), the majority of medical physicists are currently at the PhD level. While a PhD is necessary to perform research, it is clear from the previous discussion that the majority of medical physicists are not involved in research, at least not the research at the level that would result in scientific publications or research grants. This situation means that we currently experience an overflow of overqualified and academically over-trained medical physicists with poor prospects for the future, which will naturally lead to the equilibrium, especially in radiation oncology, requiring fewer PhDs. The technological orientation of clinical medical physics is reflected in the fact that more and more services, traditionally performed by medical physicists, have been transmitted either to other professions (e.g. dosimetrists, technologists) or even outsourced to the companies. While medical physicists sometimes do not want to admit that their level of education and 28


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expertise might be too high, it is increasingly realised by the hospital management when less skilled (and less expensive) professionals are put in place instead of medical physicists. It is expected that this trend will continue. In addition, many PhD level medical physicists enter the clinical world through the “back door” without proper professional practical training. As such, medical physics stands out among other medical professions. This situation has been realised in the United States by the main medical profession certification body, the American College of Radiology (ABR), pressuring the medical physics community to provide adequate clinical training. Part of the response to the so-called “2012/14 ABR requirements” has been through establishment of the professional Doctorate of Medical Physics (DMP) degree, which would provide masters level academic training followed by organised practical training. One might debate whether a DMP is actually the correct title, or whether Doctorate of Medical Technology might be more appropriate, since most of the training is aimed at mastering technology rather than physics. While the clinical arm of medical physics seems to be getting appropriate attention and training, the research/academic arm does not. The medical physics profession as a whole is lacking organised academic training. Most of the medical physicists hold BSc degrees in physics, but their MSc and PhD training is often in a different physics specialty, traditionally nuclear or particle physics or engineering. While this might have been acceptable in the past when the professional training requirements were less stringent and when medical physics was smaller and one would acquire necessary practical training “on-the-job”, it would be hard to argue that this is still acceptable. Strong, rigorous and focused academic medical physics training is absolutely essential. However, only taking care of graduate education is not enough, medical physics should also precipitate to the undergraduate physics level. At present finding physics departments that have medical physics as part of their under-

graduate curriculum is almost impossible. Clearly the situation has to change. Vitalising research in medical physics: two suggested solutions

Given the current focus on the professional, non-scientific side of medical physics and the fact that radiation oncology has relied so much on the application of the scientific method as well as on the groundbreaking innovations coming from physics and medical physics, there is a risk that radiation oncology will “dry out” and medical physics with it. Some have argued that radiation therapy physicists have already become glorified technicians [72]. Those few clinical physicists with protected research time of, say, 1 day per week cannot be expected to invent the next CT or IMRT. It takes more quality time to take a step back from the busy clinical environment, look at the bigger picture, ponder ideas and test them out. It also needs the right creative environment, a “playground” to explore new ideas and cross-fertilise within a group. A good first step could be to allow physicists to take sabbaticals of 6-12 months to dig deeper on a problem or idea that they had, perhaps during their clinical service. However, this is very difficult if not completely impractical in small departments. We believe that a long-term solution to the problem of the lack of research focus has to include the creation of a research and academic career path in medical physics, in parallel to the existing professional track. A fundamental requirement for that is to create more research positions and establish more academic programmes in medical physics. How can this be accomplished?

Create more research positions

The first option is to create research positions (with >80% protected research time) in the hospital environment. To create a new research physics position will certainly face some resistance from the department chairs and hospital administration. One of the first questions will be why create a research position for a physicist and not, for example, a biologist or clinician scientist.

Another option within the hospital environment is to convert a vacant clinical position to a research position. Naturally, this can only be done in bigger departments with more than five physicists. Even then, this option will face resistance from the other clinical physicists who will have to pick up the extra work. Nevertheless, there are examples where this option has worked with great success and those examples can be used as role models. Until the academic career path in medical physics has been fully-established, an intermediate solution to recruiting research physicists at the post-doctoral level might be to create a hybrid residency-postdoctoral position. The price for that is a prolonged training period, but the candidates will benefit from the extra research exposure in their clinical career and it will keep the option open for them to pursue a research career later. Another option for creating more research positions is to join forces with physics departments. While this might seem like the most straightforward solution, it is obviously not a trivial one; otherwise we would have witnessed much more synergy between medical physics and physics departments so far. Create more academic programmes

Creating more research positions could be seen as a short-term strategy to improve the quality of medical physics research. However, long-term improvement can only be created by starting at the source i.e. from academic programmes. While there might not be enough room for many academic medical physics departments because of servicing to mostly graduate level scientists, the need is large enough to warrant many more academic programmes than currently exist. In general three types of academic programmes could be created: independent medical physics departments, medical physics department within clinical departments and medical physics programmes within physics departments. As the creation of any new departments carries significant consequence, the case should be made carefully and only

review article

where the environment is ready to support such an endeavour. An alternative solution would be to create medical physics academic programmes within the existing clinical or physics departments. In clinical departments this would require a large number of research orientated physicists without excessive clinical duties who could devote a substantial amount of time for academic duties. Establishing medical physics academic programmes within physics departments would require a large number of existing physics faculty members that have at least some interest in medical physics. This option would only

interdisciplinary and translational research components. One could of course argue that no programme would be good enough for the small fraction of students that will be in the “cutting edge research” category. What research academic programmes really need to serve are the students that fall into “translational research” category. The bottom line

The strong standing of radiation therapy today is based substantially on physics research from the past. The scientific method has played an important role in this evolution over the past

Every effort is needed to ensure the future remains as bright as the past, and medical physics remains one of the most exciting professions be feasible in large physics departments or small physics departments that decide to make medical physics one of their priorities. When considering new academic programmes one should not skip a very important question – how should medical physics programmes of the future be designed? It is clear that current programmes are not optimal. They are a mix of programmes that have trained students for both professional and research careers. In the United States, this “redundancy” was first realised by the professional part of medical physics, creating professional medical physics programmes, which would lead to DMP professional degrees. This training eliminates, to a large degree, research and any courses that do not directly lead to clinically useful knowledge. Creation of these programmes should actually be the last call for academic programmes that want to train students for the other research part of the spectrum. Research medical physics curricula should be modernised by adding components of training that modern research requires, including collaborative,

century. New challenges and opportunities are waiting for research orientated physicists in the traditional domain of radiation therapy, as well as outside it. However, the current focus on the professional side of medical physics away from research makes it more difficult to address those future challenges. Radiation therapy as a field is biting the hand that feeds it. Proliferation of medical physics training programmes focused on professional development further dilutes the high-end research strength of the field. We are missing strong, rigorous and focused academic medical physics training programmes. We are missing academic research environments that will secure a sustained long-term influx of new research ideas and overall development of the field. This imbalance is severely jeopardising the long-term future of medical physics. Every effort is needed to change this to ensure the future remains as bright as the past, and medical physics remains one of the most exciting professions. www

Download the full article and references DOI: 10.1259/bjr/86221320

issue 3 june 2011


The British Journal of Radiology Abstracts

Abstracts Comparison of different volumes of saline flush in the assessment of perivenous artefacts in the subclavian vein during cervical CT angiography Objectives:

We studied attenuation values in the central vein and perivenous artefacts at the subclavian vein in cervical CT angiography (CTA) when using 40 ml contrast material (CM) followed by different volumes (25 ml vs 40 ml) of saline flush (SF). Methods:

61 patients underwent CTA between the aortic arch (AA) and distal to the circle of Willis (cW). After calculating test-bolus time to peak enhancement at the cW (Tc), scanning delay was represented as [(Tc+4) – scan duration between AA and cW] s. 28 patients (Group A) received 40 ml of 370 mg iodine (I) ml-1 CM followed by 25 ml SF, and 33 patients (Group B) received

the same CM followed by 40 ml SF, both administered through the right antecubital vein. Arterial attenuation was measured at seven points in the aorto-carotid artery and at 3 points in the vertebrobasilar artery. Venous attenuation in the central vein was measured at 4 points. Mean attenuation values were analysed quantitatively. Axial and post-processing three-dimensional images were assessed qualitatively.

showed no differences between the two groups overall, perivenous artefacts at the subclavian vein were assessed as less prominent (p<0.01) in Group B. Conclusion:

When compared with CTA followed by 25 ml SF, CTA followed by 40 ml SF can reduce venous attenuation values and perivenous artefacts at the subclavian vein.


When Groups A and B were compared, there were no differences in the mean attenuation values in either the aorto-carotid artery (p=0.78) or the vertebrobasilar artery (p=0.82). Mean venous attenuation values were lower (p=0.002) in Group B than in Group A. Although the qualitative assessment of arterial images

N Takeyama, Y Ohgiya, T Hayashi, T Takahashi, D Takasu, J Nakashima, K Kato, Y Kinebuchi, T Hashimoto and T Gokan Department of Radiology, Showa University Fujigaoka Hospital, 1-30 Fujigaoka, Aoba-ku, Yokohama, 227-8501, Japan

www Download the full length article: DOI: 10.1259/bjr/86966343

Hepatocellular carcinoma in cirrhotic patients at multidetector CT: hepatic venous phase versus delayed phase for the detection of tumour washout Objectives:

Our aim was to compare retrospectively hepatic venous and delayed phase images for the detection of tumour washout during multiphasic multidetector row CT (MDCT) of the liver in patients with hepatocellular carcinoma (HCC). Methods:

30 cirrhotic patients underwent multiphasic MDCT in the 90 days before liver transplantation. MDCT was performed before contrast medium administration and during hepatic arterial, hepatic venous and delayed phases, images were obtained at 12, 55 and 120 s after trigger threshold. Two radiologists qualitatively evaluated images for lesion attenuation. Tumour washout was evaluated subjectively and objectively. Tumour-to-liver contrast 30


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(TLC) was measured for all pathologically proven HCCs. Results:

48 HCCs were detected at MDCT. 46 of the 48 tumours (96%) appeared as either hyper- or isoattenuating during the hepatic arterial phase subjective washout was present in 15 HCCs (33%) during the hepatic venous phase, and in 35 (76%) during the delayed phase (p<0.001, McNemar’s test). Objective washout was present in 30 of the 46 HCCs (65%) during the hepatic venous phase, and in 42 of the HCCs (91%) during the delayed phase (p=0.001). The delayed phase yielded significantly higher mean TLC absolute values compared to the hepatic venous phase (-16.1±10.8 HU vs -10.5±10.2 HU; p<0.001).


The delayed phase is superior to the hepatic venous phase for detection of tumour washout of pathologically proven HCC in cirrhotic patients.

A Furlan, D Marin, A Vanzulli, G Palermo Patera, A Ronzoni, M Midiri, M Bazzocchi, R Lagalla and G Brancatelli Institute of Radiology, Department of Medical and Morphological Research, University of Udine, Udine, 33100, Italy

www Download the full length article: DOI: 10.1259/bjr/18329080

The British Journal of Radiology Abstracts www

For more Abstracts visit:

Neutral vs positive oral contrast in diagnosing acute appendicitis with contrastenhanced CT: sensitivity, specificity, reader confidence and interpretation time Objectives:

The study compared the sensitivity, specificity, confidence and interpretation time of readers of differing experience in diagnosing acute appendicitis with contrast-enhanced CT using neutral vs positive oral contrast agents.

confidence scores (1=poor to 4=excellent). Receiver operating characteristic (ROC) curves were generated. Total interpretation time was recorded. Each reader’s interpretation with the two agents was compared using standard statistical methods.

Conclusion: Results:


Contrast-enhanced CT for right lower quadrant or right flank pain was performed in 200 patients with neutral and 200 with positive oral contrast including 199 cases with proven acute appendicitis and 201 with other diagnoses. Test set disease prevalence was 50%. Two experienced gastrointestinal radiologists, one fellow and two first-year residents blindly assessed all studies for appendicitis (2000 readings) and assigned

demonstrated improved appendix identification (average 90% vs 78%) and higher confidence scores for three readers. Average interpretation times showed no statistically significant differences between the agents.

Average reader sensitivity was found to be 96% (range 91–99%) with positive and 95% (89–98%) with neutral oral contrast; specificity was 96% (92–98%) and 94% (90–97%). For each reader, no statistically significant difference was found between the two agents (sensitivities p-values >0.6; specificities p-values >0.08), in the area under the ROC curve (range 0.95–0.99) or in average interpretation times. In cases without appendicitis, positive oral contrast

Neutral vs positive oral contrast does not affect the accuracy of contrast enhanced CT for diagnosing acute appendicitis. Positive oral contrast might help to identify normal appendices, we continue to use neutral oral contrast given its other potential benefits. D M Naeger, S D Chang, P Kolli, V Shah, W Huang and R F Thoeni University of California San Francisco, Medical School, Department of Radiology and Biomedical Imaging, PO Box 1325 www Download the full length article: DOI: 10.1259/bjr/20854868

CT colonography: computer-assisted detection of colorectal cancer Objectives:

Computer-aided detection (CAD) for CT colonography (CTC) has been developed to detect benign polyps in asymptomatic patients. We aimed to determine whether such a CAD system can also detect cancer in symptomatic patients.


CTC data from 137 symptomatic patients subsequently proven to have colorectal cancer were analysed by a CAD system at 4 different sphericity settings: 0, 50, 75 and 100. CAD prompts were classified by an observer as either true positive if overlapping a cancer or false positive if elsewhere. Colonoscopic data were used to aid matching.


Of 137 cancers, CAD identified 124 (90.5%), 122 (89.1%), 119 (86.9%) and 102 (74.5%) at a sphericity of 0, 50, 75 and 100, respectively. A substantial proportion of cancers were detected on either the prone or supine acquisition alone. Of 125 patients with prone and supine acquisitions, 39.3%, 38.3%, 43.2% and 50.5% of cancers were detected on a single acquisition at a sphericity of 0, 50, 75 and 100, respectively. CAD detected three cancers missed by radiologists at the original clinical interpretation. False-positive prompts decreased with increasing sphericity value (median 65, 57, 45, 24 per patient at values of 0, 50, 75, 100, respectively) but many patients were poorly prepared.


CAD can detect symptomatic colorectal cancer but must be applied to both prone and supine acquisitions for best performance.

C Robinson, S Halligan, G Iinuma, W Topping, S Punwani, L Honeyfield and S A Taylor Department of Specialist Radiology, University College Hospital, London, UK

www Download the full length article: DOI: 10.1259/bjr/17848340

issue 3 june 2011



The British Journal of Radiology Abstracts

Post-operative radiochemotherapy in patients with gastric cancer: one department’s experience of 56 patients Objectives:

Prognosis in patients with locally advanced stomach cancer undergoing surgery alone is poor. High local failure rates in gastric cancer have been reported of up to 70%. When a relapse occurs, attempts at curative treatment are generally unsuccessful. A retrospective analysis was performed in order to determine whether post-operative radiochemotherapy improves treatment results in patients with locally advanced gastric cancer.


Between November 2004 and July 2008, 56 patients with clinical Stage IB–IV cancer of the stomach underwent curative gastrectomy and adjuvant radiochemotherapy. Patients with distant metastases were excluded from the analysis. The total radiation dose

was 45.0 Gy. The chemotherapy regimen comprised a 5 day cycle of 5-fluorouracil at 425 mg m–2 and leucovorin at 20 mg m–2. Overall survival and disease-free survival, as well as toxicity, were estimated for all patients. Results:

Within the study group there were 7 (13%) local recurrences, 4 (7%) distant metastases and 8 (14%) local and distant relapses. The 2 year overall survival was 48%. A total of 19 (34%) patients developed Grade 3 gastrointestinal toxicity. There were no treatment-related deaths.


Post-operative radiochemotherapy is an effective and safe regimen in patients with curatively resected locally advanced gastric cancer.

M Spych, B Serbiak, A Rychter, E Jesien-Lewandowicz, L Gottwald and J Fijuth Radiotherapy Department, Medical University of Lodz, Lodz, Poland

www Download the full length article: DOI: 10.1259/bjr/25406515

Assessment of hepatocellular carcinoma by contrast-enhanced ultrasound with perfluorobutane microbubbles: comparison with dynamic CT Objectives:

The aim of this study was to evaluate tumour vascularity and Kupffer cell imaging in hepatocellular carcinoma (HCC) using contrast-enhanced ultrasonography (CEUS) with Sonazoid (perfluorobutane) and to compare performance with dynamic < CT. Methods:

We studied 118 nodules in 88 patients with HCC. HCC was diagnosed as a hyperenhancement lesion in the arterial phase with washout in the portal phase on dynamic CT or by percutaneous biopsy. We observed tumour vascularity at the early vascular phase (10–30 s after contrast injection) and Kupffer imaging at the postvascular phase (after 10 min).



issue 3 june 2011


Detection of vascularity at the early vascular phase was 88% in nodules that were found to be hypervascular on dynamic CT and 28% in hypo-/ isovascular nodules; the detection of local recurrence nodules was 92%. The detection of vascularity was significantly lower in nodules >9 cm deep than in those ≤9 cm deep, but was not affected by tumour size. The detection of tumours at the post-vascular phase on CEUS was 83% in nodules with low density in the portal phase on dynamic CT and 82% in nodules with isodensity. The rate did not depend on the severity of underlying liver disease; rates decreased in nodules deeper than 9 cm, those smaller than 2 cm in diameter and in iso-enhancing nodules at the early vascular phase of CEUS.


CEUS with Sonazoid is a useful tool for assessing the vascularity of HCC and is equal to that of dynamic CT; however, the detectability of HCC vascularity is affected by location.

M Mandai, M Koda, T Matono, T Nagahara, T Sugihara, M Ueki, K Ohyama and Y Murawaki Second Department of Internal Medicine, Faculty of Medicine, Tottori University, Japan

www Download the full length article: DOI: 10.1259/bjr/38682601

The British Journal of Radiology Abstracts

CT differentiation of pyogenic liver abscesses caused by Klebsiella pneumoniae versus non-Klebsiella pneumoniae Objectives:

Klebsiella pneumoniae is one of the organisms most commonly isolated from pyogenic liver abscesses in Asian populations. We compared CT findings in liver abscesses caused by K. pneumoniae with those caused by other bacterial pathogens.

ment, septal enhancement, the double target sign, internal necrotic debris, internal gas bubbles and underlying biliary disease. The presence of diabetes and metastatic infection was also compared between groups. Statistical analyses were performed using univariate (Student’s t-test and χ2 test) and multivariate analyses.


A thin-walled abscess, internal necrotic debris, the presence of metastatic infection and the absence of underlying biliary disease may be useful CT findings in the early diagnosis of K. pneumoniae liver abscesses.


Of 214 patients with liver abscesses examined over a 5 year period, 129 patients with positive blood or aspirate cultures were enrolled. The patients were divided into two groups: the K. pneumoniae monomicrobial liver abscess (KLA) group (n=59) and the non K. pneumoniae monomicrobial or polymicrobial liver abscess (non-KLA) group (n=70). Two radiologists blinded to the culture results evaluated the CT images, recording the number, size, location, and configuration of abscesses, the thickness of the abscess wall, the pattern of rim enhance-


Multivariate analysis showed that a thin wall, necrotic debris, metastatic infection and the absence of underlying biliary disease were the most significant predictors of KLA. When three of the four criteria were used in combination, a specificity of 98.6% was achieved for the diagnosis of KLA.

N K Lee, S Kim, J W Lee, Y J Jeong, S H Lee, J Heo and D H Kang Department of Radiology, Pusan National University Hospital, Busan, Republic of Korea

www Download the full length article: DOI: 10.1259/bjr/23004588

Long-term results of radiofrequency ablation for unresectable colorectal liver metastases: a potentially curative intervention Objectives:

The long-term results and prognostic factors of radiofrequency ablation (RFA) for unresectable colorectal liver metastases (CRLM) in a single centre with >10 years of experience were retrospectively analysed.


A total of 100 patients with unresectable CRLM (size 0.2–8.3 cm; mean 2.4 cm) underwent a total of 126 RFA sessions (237 lesions). Mean follow-up time was 29.0 months (range 6–93 months). Lesion characteristics (size, number and location), procedure characteristics (percutaneous or intra-operative approach) and major and minor complications were carefully noted. Local control, mean survival time, recurrence-free and overall survival were statistically analysed.


No direct procedure-related deaths were observed. Major complications were present in eight patients. Local RFA site recurrence was 12.7% (n=30/237); for tumour diameters of <3 cm, 3–5 cm and >5 cm, recurrence was 5.6% (n=8/143), 19.5% (n=15/77) and 41.2% (n=7/17), respectively. Centrally located lesions recurred more often than peripheral ones 21.4% (n=21/98) versus 6.5% (n=9/139); p=0.009. Including additional treatments for recurring lesions when feasible, lesionbased local control reached 93%. The mean survival time from RFA was 56 (95% confidence interval [CI] 45–67) months. Overall 1, 3, 5 and 8 year survival from RFA was 93%, 77%, 36% and 24%, respectively.


RFA for unresectable CRLM is a safe, effective and potentially curative treatment option; the long-term results are comparable with those of previous investigations employing surgical resection. Factors determining success are lesion size, the number of lesions and location.

A A J M Van Tilborg, M R Meijerink, C Sietses, J H T M Van Waesberghe, M O Mackintosh, S Meijer, C Van Kuijk and P Van Den Tol Department of Radiology, VU University Medical Centre, Amsterdam, The Netherlands

www Download the full length article: DOI: 10.1259/bjr/78268814

issue 3 june 2011


The British Journal of Radiology Abstracts

Use of small bowel imaging for the diagnosis and staging of Crohn’s disease — a survey of current UK practice Objectives:

This study used a postal survey to assess the current utilisation of small bowel imaging investigations for Crohn’s disease within National Health Service (NHS) radiological practice and to gauge gastroenterological referral patterns.


Similar questionnaires were posted to departments of radiology (n=240) and gastroenterology (n=254) identified, by the Royal College of Radiologists or the British Society of Gastroenterologists, as centres in which small bowel imaging was used to assess Crohn’s disease. The responses to the questionnaires described clinical scenarios including first diagnosis, disease staging, and assessment of suspected extraluminal complications, obstruction and disease flare. The data were stratified according to patient age.


63 (27%) departments of radiology (20 in teaching hospitals and 43 in district general hospitals (DGHs)) and 73 (29%) departments of gastroenterology replied. These departments were in 119 institutions. Of the 63 departments of radiology, 55 (90%) routinely performed barium followthough (BaFT), 50 (80%) CT, 29 (46%) small bowel ultrasound (SbUS) and 24 (38%) small bowel MRI. BaFT was the most commonly used investigation across all age groups and indications. SbUS was used mostly for patients younger than 40 years of age with low index of clinical suspicion for Crohn’s disease (in 44% of radiology departments (28/63)). MRI was most frequently used in patients of less than 20 years of age for staging new disease (in 27% of radiology departments (17/63)) or in whom obstruction

was suspected (in 29% of radiology departments (18/63)). CT was preferred for suspected extra-

luminal complications or obstruction (in 73% (46/63) and 46% (29/63) of radiology departments, respectively). Gastroenterological referrals largely concurred with the imaging modalities chosen by radiologists, although gastroenterologists were less likely to request SbUS and MRI. Conclusion:

BaFT remains the mainstay investigation for luminal small bowel Crohn’s disease, with CT dominating for suspected extraluminal complications. There has been only moderate dissemination of the use of MRI and SbUS. R Hafeez, R Greenhalgh, J Rajan, S Bloom, S McCartney, S Halligan and S A Taylor Department of Surgery, University College London, London, UK

www Download the full length article: DOI: 10.1259/bjr/65972479

Can point doses predict volumetric dose to rectum and bladder: a CT-based planning study in high dose rate intracavitary brachytherapy of cervical carcinoma? Objectives:

Point doses, as defined by the International Commission on Radiation Units and Measurements (ICRU), are classically used to evaluate doses to the rectum and bladder in high dose rate intracavitary brachytherapy (HDR-ICBT) in cervical cancer. Several studies have shown good correlation between the ICRU point doses and the volumetric doses to these organs. In the present study we attempted to evaluate if this correlation could be used to predict the volumetric doses to these organs.


A total of 150 HDR-ICBT insertions performed between December 2006 and June 2008 were randomly divided into two groups. Group A (n=50) was used to derive the correlation between the point and volumetric doses using regres34


issue 3 june 2011

sion analysis. This was tested in Group B (n=100) insertions using studentised residuals and Bland–Altman plots.

±41%, respectively , which makes these equations unreliable for clinical use. Conclusion:


Significant correlations were obtained for all volumetric doses and ICRU point doses for rectum and bladder in Group A insertions. The strongest correlation was found for the dose to 2 cc volumes (D2cc). The correlation coefficients for bladder and rectal D2cc versus the respective ICRU point doses were 0.82 and 0.77, respectively (p<0.001). Statistical validation of equations generated in Group B showed mean studentised residual values of 0.001 and 0.000 for the bladder and rectum. However, Bland–Altman analysis showed that the error range for these equations for bladder and rectum were ±64% and

Volumetric imaging is essential to obtain proper information about volumetric doses.

V M Patil, F D Patel, S Chakraborty, A S Oinam and S C Sharma Department of Radiotherapy, Cobalt Block, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India

www Download the full length article: DOI: 10.1259/bjr/33758793

The British Journal of Radiology Abstracts

Another fractured neck of femur: do we need a lateral X-ray? Objectives:

This study aimed to define the role of the lateral X-ray in the assessment and treatment planning of proximal femoral fractures. Occult fractures were not included. Methods:

Radiographs from 359 consecutive patients with proximal femoral fractures admitted to our emergency department over a 12 month period were divided into anteroposterior (AP) views and lateral views. Three blinded reviewers independently assessed the X-rays, first AP views alone then AP plus lateral views, noting the fracture classification for each X-ray. These assessments were then compared with the intraoperative diagnosis, which was used as the gold standard. A 2×2 contingency square table was created and Pearson’s χ2 test was used for statistical analysis.


The rate of correct classification by the reviewers was improved by the assessment of the lateral X-ray in addition to the AP view for intracapsular fractures (p<0.013) but not for extracapsular fractures (p=0.27). However, the only advantage obtained by assessing the lateral view in intracapsular fractures was the detection of displacement were the fracture appeared undisplaced on the initial AP view. Conclusion:

This study provides statistical evidence that one view is adequate and safe for the majority of hip fractures. The lateral X-ray should not be performed routinely in order to make considerable savings in money and time and to avoid unnecessary patient discomfort.

B Almazedi, C D Smith, D Morgan, G Thomas and G Pereira Department of Trauma and Orthopaedics, University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, UK

www Download the full length article: DOI: 10.1259/bjr/57316056

Pulsed brachytherapy: a modelled consideration of repair parameter uncertainties and their influence on treatment duration extension and daytime-only ‘‘blockschemes’’ Objectives:

The radiobiological modelling of all types of protracted brachytherapy is susceptible to uncertainties in the values of tissue repair parameters. Although this effect has been explored for many aspects of pulsed brachytherapy (PB), it is usually considered within the constraint of a fixed brachytherapy treatment time.Here the impact of repair parameter uncertainty is assessed for PB treatments of variable duration. The potential use of ‘‘block-schemes’’ (blocks of PB pulses separated by nighttime gaps) is also investigated.


PB schedule constraints are based on the cervical cancer protocols of the Royal Marsden Hospital (RMH) but the methodology is applicable to any

combination of starting schedule and treatment constraint. Calculations are performed using the biologically effective dose (BED) as a tissue-specific comparison metric. The ratio of normal tissue BED to tumour BED is considered for PB regimens with varying total pulse numbers and/or ‘‘block-schemes’’. Results:

For matched brachytherapy duration, PB has a good ‘‘window of opportunity’’ relative to the existing RMH continuous low dose rate (CLDR) practice for all modelled repair halftimes. The most clearcut route to radiobiological optimisation of PB is via modest temporal extension of the PB regimen relative to the CLDR reference. This option may be practicable for those centres with scope to extend their relatively short CLDR treatment durations.


Although daytime-only ‘‘blockscheme’’ PB for cervical cancer has not yet been employed clinically, the possibilities appear to be theoretically promising, providing the overall (external beam plus brachytherapy) treatment duration is not extended relative to current practice, such that additional tumour repopulation becomes a concern.

T S A Underwood, R G Dale, A M Bidmead, C A Nalder and P R Blake Royal Marsden NHS Foundation Trust, Fulham Road, London, UK

www Download the full length article: DOI: 10.1259/bjr/58276427

issue 3 june 2011


The British Journal of Radiology Abstracts

Micro-CT enables microlocalisation and quantification of Her2-targeted gold nanoparticles within tumour regions Objectives:

Gold nanoparticles are of interest as potential in vivo diagnostic and therapeutic agents, as X-ray contrast agents, drug delivery vehicles and radiation enhancers. The aim of this study was to quantitatively determine their targeting and microlocalisation in mouse tumour models after intravenous injection by using micro-CT.

tumours in opposite thighs were prepared. Gold nanoparticles alone, conjugated to Herceptin or to a non-specific antibody were compared. After intravenous injection of the gold nanoparticles, gold concentrations were determined by atomic absorption spectroscopy. Microlocalisation of gold was carried out by calibrated micro-CT, giving both the radiodensities and gold concentrations in tumour and non-tumour tissue.



Gold nanoparticles (15 nm) were coated with polyethylene glycol and covalently coupled to anti-Her2 antibodies (Herceptin). In vitro, conjugates incubated with Her2+ (BT-474) and Her2– (MCF7) human breast cancer cells showed specific targeted binding with a Her2+ to Her2– gold ratio of 39.4±2.7:1. Nude mice, simultaneously bearing subcutaneous Her2+ and Her2– human breast

All gold nanoparticle constructs showed accumulation, predominantly at tumour peripheries. However, the Herceptin– gold nanoparticles showed the best specific uptake in their periphery (15.8±1.7% injected dose g–1), 1.6-fold higher than Her2– tumours and 22-fold higher than surrounding muscle. Imaging readily enabled detection of small, 1.5 mm-thick tumours.


In this pre-clinical study, antibodytargeted 15 nm gold nanoparticles showed preferential uptake in cognate tumours, but even untargeted gold nanoparticles enhanced the visibility of tumour peripheries and enabled detection of millimetre-sized tumours. Micro-CT enabled quantification within various regions of a tumour.

J F Hainfeld, M J O’connor, F A Dilmanian, D N Slatkin, J Adams and H M Smilowitz Nanoprobes, Inc., 95 Horseblock Rd., Yaphank, NY 11980, USA

www Download the full length article: DOI: 10.1259/bjr/42612922

Quality assurance of RapidArc in clinical practice using portal dosimetry

Quality assurance data from five centres were analysed to assess the reliability of RapidArc radiotherapy delivery in terms of machine and dosimetric performance.

imaging device measurements. Evaluation was carried out according to a gamma agreement index (GAI, the percentage of field area passing the test); the threshold dose difference was 3% and the threshold distance to agreement was 3 mm.




A large group of patients were treated with RapidArc radiotherapy and treatment data recorded. Machine quality assurance was performed according to Ling et al (Int J Radiat Oncol Biol Phys 2008;72:575– 81). In addition, treatment to a typical clinical case was delivered biweekly as a constancy check. Pretreatment dosimetric validation of plan delivery was performed for each patient. All measurements and computations were performed at the depth of the maximum dose in water according to the GLAaS method (Radiat Oncol 2008;3:24) using electronic portal 36


issue 3 june 2011

A total of 275 patients (395 arcs) were included in the study. Mean delivery parameters were 31.0±20.0° (collimator angle), 4.7±0.5 cm s–1 (gantry speed), 343±134 MU min–1 (dose rate) and 1.6 ±1.4 min (beam-on time) for prescription doses ranging from 1.8 to 16.7 Gy/fraction. Mean deviations from the baseline doserate and gantry speed ranged from 20.61 to 1.75%. Mean deviations from the baseline for leaf speed variation ranged from 20.73 to 0.41%. The mean GAI of repeated clinical fields was 99.2±0.2%. GAI varied

from 84.7 to 100%; the mean across all patients was 97.1±2.4%. Conclusion:

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

A Fogliata, A Clivio, P Fenoglietto, J Hrbacek, S Kloeck, P Lattuada, Pmancosu, G Nicolini, E Parietti, G Urso, E Vanetti And L Cozzi Department of Bio-Imaging & Radiological Sciences, Radiology, UCSC, Rome, Italy

www Download the full length article: DOI: 10.1259/bjr/72327299

The British Journal of Radiology Abstracts

Repair kinetic considerations in particle beam radiotherapy Objectives:

A second-order repair kinetics model is developed to predict damage repair rates following low or high linear energy transfer (LET) irradiations and to assess the amount of unrepairable damage produced by such radiations. The model is a further development of an earlier version designed to test if low-LET radiation repair processes could be quantified in terms of second-order kinetics. The newer version allows calculation of both the repair rate of the proportion of DNA damages that repair according to secondorder kinetics and the proportion of DNA damages that do not repair.


The original and present models are intercompared in terms of their goodness-of-fit to a number of data sets

obtained from different ion beams. The analysis demonstrates that the present model provides a better fit to the data in all cases studied. Results:

The proportions of unrepairable damage created by radiations of different LET predicted by the new model correspond well with previous studies on the increased effectiveness of high-LET radiations in inducing reproductive cell death. The results show that the original model may underestimate the proportion of unrepaired damage at any given time after its creation as well as failing to predict very slow or unrepairable damage components, which may result from high-LET irradiation.


It is suggested that the second-order model presented here offers a more realistic view of the patterns of repair in cell lines or tissues exposed to high-LET radiation.

A Carabe-Fernandez, R G Dale and H Paganetti Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA

www Download the full length article: DOI: 10.1259/bjr/19934996

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

issue 3 june 2011


Assurance of Quality in the Diagnostic Imaging Department 2nd Edition Prepared by the Quality Assurance Working Group of the Radiation Protection Committee of The British Institute of Radiology

A practical guide to instituting a quality control programme.

Ultimately, of course, it is the quality of the service to patients that matter, and in the clinical radiology context, one of the most important factors is the quality of the image.

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CEO Report Last year the British Institute of Radiology (BIR) undertook a major review of the benefits package for members. This involved extensive research of other membership bodies across a range of professions and a survey of our members to find out what you would like to achieve from membership of our organisation. The results are two-fold. Firstly, we are using the feedback you have given us to help inform our new strategy, details of which will be published in a future BJR News. Secondly, we have relaunched our membership package so that “full” membership should become more affordable to non-consultants. As of 1 January 2011 full membership has been tiered to reflect ability to pay, i.e. • Level 1 £170: Consultants and equivalent (consultant radiologists, consultant oncologists and radiotherapists, consultant scientists, other medical, scientific and radiographer staff of Grade 8b and above, or company personnel of equivalent salary); • Level 2 £60 (or £5 per month): All

other medical, scientific and radiographer staff of Grade 8a and below or company personnel of equivalent salary. The BIR is a multidisciplinary charity and membership organisation connecting radiology professionals and industry at all levels for the benefit of the patient. We provide educational and networking opportunities for those with an interest in radiology and radiation oncology to exchange new ideas and gain new perspectives on technologies and treatments. Through scientific meetings, peer-reviewed journals and regional and online networks, the BIR fosters respect and understanding between doctors, scientists, other medical staff and people of business, and seeks to create a wider appreciation of the importance of partnerships. Benefits of membership include: free online subscription to Imaging, discounts on books and publications, discounted rates for educational meetings and courses across the UK, free use of the BIR’s information centre, the opportunity to join BIR

committees and seek election to Council, the opportunity to apply for BIR prizes and awards and full voting rights. Members are also able to access for free the full version of the British Journal of Radiology (BJR) online (with printed copies available at an additional cost). The BJR is the world’s oldest radiology journal and the UK’s top ranked radiological journal with regard to impact factor. In addition, all full members receive a free printed copy of the bimonthly magazine BJR News. Membership is also open to trainees and rates for 2011 are as follows: Training Year Fee Year 1 £12 Years 2-3 £24 Years 4+ £48 Undergraduates can also join for free. Further details can be found at membership/ or by contacting the BIR’s Membership Officer on 020 7307 1400 or at Jacqueline Fowler, Chief Executive, BIR

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Reading articles in a web 2.0 world The landscape around us at home and at work is changing. We are all moving at breakneck speed towards an increasingly digital future — a future where we spend more time connected to the web and are reliant on its content. The concept of web 2.0 was born in 2006. The idea is that we were moving away from an internet that just served us data to an internet that we interact with [1, 2]. We’ve seen the rise of online banking, online shopping and social media. We’ve made use of the burgeoning number of websites that offer us a staggering amount of information instantaneously whether

and how do we save articles of interest? Keeping up to date is relatively easy. Most publishers will email a table of contents as each journal is published. However, there are other ways to keep abreast of the myriad of published articles including the use of RSS (really simply syndication) feeds [4]. As a technology, RSS is not new but is very powerful. To make use of it, you will need a reader (somewhere to find out what has been published). Once you have subscribed to an RSS feed in your RSS reader, every time a new article is published, it will show up in your reader and often the abstract will be included. Readers may be purely online

The digital landscape is changing and as we move towards consuming increased amounts of information from online sources, the way we search for and save articles will also have to change that be in the form of a search from Google or an article from Wikipedia. Importantly, we’ve started to learn how to use this information and how to check its validity. Medicine has been slow to engage with the changing web and the benefits envisioned more than 5 years ago [3]. However, we are making progress slowly. Over recent years, we have seen an increase in the number of journal articles available online and many journals are offering free access to all articles more than 6 months old. Publishers have taken advantage of the ability to print online first and some, such as the British Journal of Radiology, have gone online only. While this is exciting, it brings with it new problems, in particular, how best do we keep up-to-date with published articles

(e.g. Google reader) or be a desktop applications (e.g. Feedreader) but whichever you choose they can handle multiple feeds at a time. You can subscribe to multiple journals, news feeds, your favourite blogs and sporting feeds all in one place. So, rather than trawling around the internet looking to see if any of the journals or websites you are interested in have published new content, you can go to one central place and see all the new content delivered directly to you. When it comes to cataloguing what you are reading, have read or want to read, the internet has the answer. Several websites and other programs allow you to catalogue your reading. For example, if you use the Firefox browser, an extension called Zotero ( can, with the click of a button, save the current

journal article to your local database. If you want to cite it in the future, all you need to do is open the library and drag it into Word to create a formatted citation. CiteULike ( and Connotea ( are online libraries where you can save your articles and see what other people who have read it also recommended. The icing on the cake is that searching and linking between articles is getting more sensitive and complete. Pubmed searching ( pubmed/) is no longer the laborious task that it used to be — there is now just one search bar. You can easily find links to related articles and articles that have cited the original, and there’s always Google Scholar to try too. In conclusion, the digital landscape is changing and as we move towards consuming increased amounts of information from online sources, the way we search for and save articles will also have to change. This is made even more important with the shift to mobile access from iPhones, iPads and android devices. Moreover, we must recognise that we must constantly weigh the quality of the online source of information. References 1. O’Reilly T. What Is Web 2.0. O’Reilly Network. Accessed on 2006 08 06 2. O’Reilly Media Web 2.0 conference —from the conference site, June 2004 3. Giustini D. How Web 2.0 is changing medicine. BMJ 2006;333(7582):1283 4. Cooke CA. Current awareness in the new millennium: RSS. Med Ref Serv Q. 2006;25 (1): 59-69.  r J B Jones, Specialist Registrar in D Clinical Radiology, Leeds

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If you are a trainee and want to see your article in a copy of BJR News, send us an email with either the idea or a draft copy:

issue 3 june 2011


bir news

Radiology errors meeting: speakers announced This year’s East of England Branch errors and risk meeting, which is being held on 24 June 2011 at The Moller Centre in Cambridge, covers the important subject of safe clinical practice and addresses a wide range of issues related to radiological errors. The meeting will cover standard setting, performance management, incident reporting, litigations, complaints and revalidation. Specific topics on errors related to imaging of the chest, abdomen, trauma, neuroand interventional radiology are highlighted. This meeting is relevant to radiologists of all grades and subspecialties. It is also of educational value to allied health professionals working in radiology departments. Delegates from outside the East of England region are also encouraged to attend.

Talks will include: • Standard setting in radiological accuracy Dr Richard Fitzgerald, The Royal, Wolverhampton Hospitals • Radiologist performance management in a teleradiology service Dr Howard Galloway, Imaging Partners Online • IRMER reportable incidents Mr Cliff Double, Care Quality Commission • Managing errors Dr TC See and Dr Sara Upponi, Addenbrooke’s Hospital • Radiology related negligence Professor Carol Seymour, Medical Protection Society • Dealing with litigation, claims and complaints Dr Sally Old, Medical Defence Union


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.

• Chest imaging Dr John Curtin, Norfolk & Norwich University Hospital • CT abdomen Dr Alan Freeman, Addenbrooke’s Hospital • Interventional radiology Dr Raman Uberoi, John Radcliffe Hospital • How to save lives in trauma Dr Otto Chan, BMI Healthcare • Missed breast cancers: a radiology perspective Dr Peter Britton, Addenbrooke’s Hospital • Neuroradiology Dr Daniel Scoffings, Addenbrooke’s Hospital This meeting has been awarded 7 RCR CPD Credits and SCoR CPD Now accreditation. Registration is now open at

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 42


issue 3 june 2011

wEssEx CHaIR: dR katIE joHnson, salIsbURy dIstRICt HospItal

bir news

A quick guide to UKRC 2011 UKRC 2011 is a must attend event for all professionals with an interest in the radiological sciences. This year, UKRC returns on 6-8 June at Manchester Central Convention Centre, which has recently undergone a £28million redevelopment, designed by the award-winning Manchester-based architects, Stephenson Bell. The completed redevelopment is sympathetic to the Grade II listed frontage of what was once the city’s historic Central railway station and provides substantial operational benefits to UKRC’s delegates and visitors. In the exhibition hall at UKRC 2011

The UKRC exhibition is free to attend and will host impressive stands from major players in the UK and international medical imaging industry as well as the UKRC partner societies (British Institute of Radiology, Society and College of Radiographers, Royal College of Radiographers and Institute of Physics and Engineering in Medicine). There are multiple opportunities to earn CPD credits in our “Education on the Stands” initiatives brought to you by our industry partners. For full exhibitor listings, programme information and registration details, please visit

Satellite sessions

There will be a full programme of satellite symposia from the industry partners, including: Burnbank Systems Limited: Data sharing – the challenges, the benefits and the future This session aims to raise awareness of the potential issues and solutions around data sharing, the demonstrable benefits and a view to what the future holds. Carestream Health: Experiences and productivity improvement achieved using cassette-sized wireless DR detector in a mobile environment

Manchester Central Convention Centre: the venue for UKRC 2011

This is a follow up to the Carestream satellite symposium at UKRC 2009/2010 where the cassette-sized wireless DR detector was introduced, discussed and launched. At that time there were no UK clinical sites or UK evaluation of the technology in use in a mobile environment. This symposium will share the experiences of a UK installation and the impact this technology has provided to the department, staff and patients and will include quantitative data on user experience covering many aspects of mobile radiography. GE Healthcare: Innovations in CT using new technologies to improve patient pathways This session will see three clinical speakers demonstrating clinically how new CT technologies deliver benefits to the patient and clinician. NHS improvement: support stroke – tackling the challenging issues; demonstrating how the challenges of providing imaging to support stroke services can be addressed; and interventional radiology: why, where and how?

This session will update delegates on the current status of the benefits of interventional radiology, provision in the UK and examples of best practice. Siemens Healthcare: innovations in interventional angiography The aim of this session is to give an overview of some of the latest pioneering advanced applications within the growing field of interventional angiography imaging and guided therapies Simultaneous whole-body MR-PET hybrid imaging: technical considerations and first results By attending this session, delegates will gain state-of-the-art knowledge of the technical background for the integration of MR and PET into one hybrid system, the specifics and workflow of a simultaneous MR-PET examination and first clinical examples.

To access the programme planner, abstracts and registration information, please visit issue 3 june 2011


In-vivo Dosimetry and Dose Guided Radiotherapy 8-9 December 2011 | BIR, London For more information and to register for this event please visit

The complexity of radiotherapy treatment planning and delivery has increased in the last 10 years. In an attempt to improve the quality assurance of treatment delivery In-vivo Dosimetry has been recommended by both Towards Safer Radiotherapy and the Chief Medical Officer in 2006. However, how to implement this effectively and efficiently still remains a challenge. This 2-day meeting explores this topic at length. Day 1 covers the rationale of in-vivo dosimetry and methods of EPID dosimetry that are being explored. There will also be an opportunity for departments to present their experience. Day 2 will focus on dose guided techniques and potential improvement in outcome will be discussed. The topic is current and relevant to all departments and will include national and international expert speakers.

CALL FOR PAPERS! We are looking for abstracts for proffered presentations relating to any of the topics listed in the programme and welcome all applicants. Please ensure your abstract is submitted as a word document and limited to 250 words. Please send your abstract to by 12 September 2011. Presentation time should not exceed 15 minutes. Thursday, 8 December 09:00 Registration & Refreshments 09.20 Welcome INTRODUCTION 09:30 Background and Update Una Oâ&#x20AC;&#x2122;Doherty, Health Protection Agency 10:00 Review of Methods of EPID Speaker TBC 10.30 Review of Errors Detected by Diodes Geri Briggs, Berkshire Cancer Centre 11:00 Refreshments METHODS OF EPID DOSIMETRY 11.15 EPID Dosimetry - With Elekta Equipment Vibeke Nordmark Hansen, Royal Marsden Hospital 11:45 EPID Dosimetry - With Siemens Equipment Speaker TBC 12.15 EPID Dosimetry - With OSL Equipment Speaker TBC 12.45 EPID Dosimetry - With Varian Equipment Speaker TBC 13:15 Discussion 13.30 Lunch and Exhibition PROFFERED PAPERS 14:15 Calibration of EPID Detector for Dosimetry Julia Pearce, National Physics Laboratory 14:45 Proffered Papers 15:30 Refreshments 15:45 Registration/Non Rigid Registration Gerry Hanna, Northern Ireland Cancer Centre 16:15 Dose Painting Chris South, Royal Marsden NHS Foundation Trust 16:45 New Department Approach Martin Cooling, Peterborough and Stamford Hospitals NHS Trust 17:15 Discussion and Close

Friday, 9 December DOSE GUIDED AND ADAPTIVE RADIOTHERAPY 09:15 Clinical Overview - The Potential of Adaptive RT Speaker TBC 09:45 Implementation/Technical: Dosimetry Consequences of Adaptive Radiotherapy David Nicholas, Cromwell Hospital 10:15 Discussion 10.30 Refreshments 11:00 Tools For Adaptive RT Raj Jena, Addenbrookes Hospital 11:30 Adaptive Radiotherapy Clinically Julie Stratford, Christie Hospital 12:00 Head and Neck Russell Moule, Mount Vernon Hospital 12:30 Bladder Fiona McDonald, Royal Marsden Hospital 13:00 Lunch and Exhibition


Reflections on the Safety of Radiotherapy Equipment: Have Linacs Become Computer Peripherals? Hamish Porter, Radiation Physics Consultant, Edinburgh and London

PROFERRED PAPERS 14:45 Proffered Papers 15:30 Refreshments 16:00 Adaptive Radiotherapy in Lung Cancer Patients Carsten Brink, Odense University Hospital 16:45 Discussion 17:00 Evaluation and Close RCR CPD Credits have been applied for

bir news

ICIS 2011: a course not to be missed! The eleventh annual teaching course of the International Cancer Imaging Society will take place this year in the stunning city of Copenhagen, Denmark from 3-5 October. Following the huge success of the 2010 meeting in Edinburgh this year’s President, Professor Vincent Chong, has put together another fantastic programme, which focuses on the clinical role of new imaging techniques in patients with cancer that will aid clinical decision-making and improve outcomes. Special focus sessions will cover a wide range of cancers including prostatic carcinoma, head and neck neoplasms, paediatric oncological imaging, lung cancer screening and pelvic malignancies. Other topics covered will include imaging in post-treatment imaging, imaging in radiation oncology, the value

of FDG PET/CT in oesophageal cancer, MRI-guided high intensity focused ultrasound ablation of breast cancer and contrast-enhanced ultrasound in oncology. Owing to the overwhelming demand for the “hands-on” workshops last year, delegates will again have the opportunity to gain practical experience during

This year’s programme focuses on the clinical role of new imaging techniques in patients with cancer

sessions dedicated to advanced prostate MRI, breast MRI and whole body diffusion MRI. There will also be keynote lectures from Ken Miles, who will discuss “Can imaging help improve survival of cancer patients?” and Gina Brown, who will talk about “Integrating morphological and functional imaging in assessment to response”, along with a film interpretation session and “focus on” sessions. The annual teaching course is always about more than educational learning, there are fantastic opportunities to network with senior colleagues and exhibitors at the welcome reception and course dinner. ICIS 2011 is truly a course that cannot be missed! To register now and for further detailed information please visit

International Cancer Imaging Society

This course will focus on the clinical role of new imaging techniques in patients with cancer that will aid clinical decision-making and improve outcomes. Special focus sessions will cover a wide range of cancers including prostatic carcinoma, head & neck neoplasms, paediatric oncological imaging, lung cancer screening, and pelvic malignancies. Keynote lectures will address the important issues of whether imaging can help improve survival of cancer patients, and the integration of morphological and functional imaging in assessment to response. A Film Interpretation Session with teams of recognised experts will offer insight into oncologic imaging and more … Scientific sessions, dedicated to proffered papers, will present research in the field of imaging in oncology. There will also be poster sessions and the best overall paper and poster will be awarded a prize.

Society Meeting & 11th Annual Teaching Course

Copenhagen (Denmark) 3rd – 5th October 2011

Workshops for smaller groups will focus on a variety of clinical topics. In addition, registrants will have the opportunity to gain practical skills at “hands-on” workshops dedicated to advanced prostate MRI, breast MRI and whole body diffusion MRI.

Call for abstracts Deadline 27th May 2011


Royal College of Radiologists and European Accreditation Council for Continuing Medical Education (EACCME) accreditation has been applied for.

For further information please contact: ICIS Secretariat, Conference Office, British Institute of Radiology, 36 Portland Place, London W1B 1AT, UK Tel: +44 (0)20 7307 1400 Fax: +44 (0)20 7307 1414 Email: website:

To promote education and research in cancer imaging and to foster its role in the multidisciplinary management of malignancy Course President: Prof. Vincent Chong (Singapore) Faculty include

J. Barentsz (Nijmegen) M. Bellomi (Milan) G. Brown (London) V. Chong (Singapore) C. Collins (Dublin) S. Diederich (Düsseldorf) I. Francis (Ann Arbor) A. Giovagnoni (Ancona) R. Gore (Chicago) M. Haider (Toronto)

R. Hermans (Leuven) M. Hoyer (Aarhus) J. Husband (London) M. King (London) D-M. Koh (London) J-M. Lee (Seoul) D. MacVicar (London) H. Madsen (Aarhus) B. McCarville (Memphis) K. McHugh (London) T. McLoud (Boston)

K. Miles (Brighton) R. Reznek (London) G. Morana (Treviso) H-P. Schlemmer (Heidelberg) L. Ollivier (Paris) A. Sohaib (London) M. Oudkerk (Groningen) J. Spencer (Leeds) W. Oyen (Nijmegen) H. Thoeny (Bern) A. Padhani (London) M. van den Bosch (Utrecht) G. Petralia (Milan) D. Vanel (Bologna) L. Quint (Ann Arbor) C. von Buchwald S. Rankin (London) (Copenhagen) F. Rasmussen (Aarhus) C. Rechnitzer (Copenhagen)

bir news

No CT without The Beatles? True or false? Sir Godfrey Hounsfield would not have made his illustrious discoveries without the Beatles. If it weren’t for the money that EMI earned from selling Beatles records, the funds would not have been available to support Sir Godfrey Hounsfield’s pioneering research. This is just one of the many stories, myths and revelations that are being explored by Des Burkinshaw in his forthcoming documentary, Without the Beatles, currently in production by his company, magnificent tv. Burkinshaw’s programme, which includes interviews with a wide range of individuals including musicians, music executives, and radiologists, including former British Institute of Radiology (BIR) President, Professor Dame Janet Husband, explores where the world would be if the Beatles had never existed. While filming Dame Janet in the BIR library recently, Burkinshaw explained that the programme’s premise is that history is a web of interconnected events. Unravelling those links takes time and distance to uncover with often surprising results. There are few artists whose influence and impact are as genuinely global, intergenerational, and as pervasive as the Beatles. Thus, even the most unlikely circumstances – the discovery of CT and the Beatles – can be linked. For the record, in this instance, the answer is technically false. EMI’s research programme was not directly funded by Beatles’ royalties at any point, but EMI itself may well have folded without the Beatles’ impact on record sales after the company made catastrophic business decisions in the late 50s. Later, when EMI failed to recoup its huge investment in taking CT to market, it was the music arm of EMI that saved the company again. Sir Godfrey had worked for EMI since 1951, working in several areas, from radar to guided weapons and computers. The computer that Sir Godfrey eventually developed for EMI, the Emidec 1100, 46


issue 3 june 2011

The prize this month is your choice of book from the current list on the BIR’s online bookshop To win just read through the magazine carefully and reply to the following question: Where is UKRC being held? Send your answer along with your name and contact details to: by 15 July 2011.

Professor Husband during filming at the BIR library

Britain’s first all transistor computer was not a success and EMI eventually sold off its computer division in 1962. However, by 1967, Hounsfield, still with EMI but now working in its Central Research Laboratory (CRL), was give a free rein in pursing product research of his own choosing. Burkinshaw’s film questions whether the CRL would have still existed in 1967 without the tenfold growth in profits the Beatles unexpectedly generated for EMI throughout the Sixties. By 1972, at a meeting of the BIR, Sir Godfrey reported on a machine he had developed at EMI for creating images of the brain. He had invented the CT scanner which would revolutionise the world of radiology and won him the Nobel Prize in Physiology or Medicine (jointly with Allan M Cormack) in 1979. It is acknowledged that the commercialisation of his amazing discovery, the CT scanner, would not have been possible without the support of a company like EMI. Burkinshaw says nothing can take away from the genius of Sir Godfrey, but still finds it surprising how the Beatles’ influence spread so far.

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

Sudoku from

A Page of History

Welcome to ISHRAD A new society has been formed in which members of the British Institute of Radiology (BIR) have been actively involved. The new society is ISHRAD (the International Society for the History of RADiology). There have been discussions for some years about setting up this group. The membership is very varied and the one thing that brings everyone together is a passion for the history of radiology and all aspects of medical imaging and therapy. Medical imaging is changing all the time and is increasingly central to patient management and care. The story of radiology is fascinating and needs to be celebrated and recorded. The inaugural meeting of ISHRAD was held on 5 March 2011 during the European Congress of Radiology and was

attended by 26 participants. BIR pastpresident, Elizabeth Beckmann, opened and chaired the first part of the meeting. The first chairman is Adrian Thomas, the BIR honorary librarian and the vicechairman is Alfredo Buzzi from Buenos Aires. Alfredo has visited the UK on many occasions. The honorary secretary is Uwe Busch, the deputy-director of the Deutsches Röntgen Museum in Remscheid and BIR honorary member. The honorary treasurer is BIR Library Committee member Arpan Banerjee and the co-opted members are Rene van Tiggelen, Jean-François Moreau, Michael Jackson and Elizabeth Beckmann. It is hoped the next meeting of the ISHRAD will be in November 2011

in the Deutsches Röntgen Museum in Remscheid. A website is being developed at Please contact me if you want details about membership adrian.thomas3@ Be part of the future of the past! Dr Adrian Thomas BSc FRCP FRCR FBIR Honorary Librarian, BIR

Books to read in the BIR library Pioneers and Early Years was published in 1986 and was written by Edmund “Ted” Burrows (1927-2002). Ted was a distinguished consultant radiologist in Southampton, a past president of the British Society of Neuroradiologists and author of the book Neuroradiology. Ted’s interests in history were wide and varied and included naval and colonial history and he also wrote A History of Medicine in South Africa. He had a wide interest in the early radiological history of the UK and he was a founder member of our Radiology History Committee that became the British Society for the History of Radiology. His deep knowledge of radiological history and his enthusiasm was invaluable to our fledgling group.

I have lost count of the number of times I have referred to Pioneers and Early Years and it is my constant source of reference for early radiological history. The book starts with Röntgen’s discovery of X-rays in 1895 and moves on to discuss its reception in the UK following the announcement of “a new sort of rays”. The work and lives of the pioneers are detailed and there are excellent accounts of the early radiological departments. There are descriptions of the early radiology manufacturers and of their apparatus. is a constant source of reference for early radiological history

The development of radiology as a profession up to the 1930s is described as are the origins of the first radiology examination the Cambridge DMRE. There is an excellent account of the origins of the British Institute of Radiology (BIR) and of the “Archives of Clinical Skiagraphy” (1896) that became the British Journal of Radiology (BJR). There is a chapter on military radiology and the book closes with an account of the injuries sustained by the early radiological martyrs and the gradual development of radiation protection. The book is well illustrated and is fully referenced. Do look at this great book when you are next in the BIR’s library. Your interest in radiological history will be stimulated and you may want to take this further. There are copies of the book available on the internet with prices varying from £25 to £80.  r Adrian Thomas BSc FRCP FRCR FBIR D Honorary Librarian, BIR

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Are you ready for the future of radiation oncology? Prepare yourself for the increasing use of modelling in practical situations, including treatment gap corrections, normal tissue tolerance predictions, optimisation of therapy determined by predictive assays, multi-modality schedule design, the simulation of clinical trials, testing contemporaneous medico-legal problems and teaching general principals of radiotherapy. Improve your understanding of the scope, applications and limitations of radiobiological modelling. Discover how modelling will help develop a rational and cost-effective use of resources.

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

Like most membership organisations the British Institute of Radiology (BIR) is keen to grow its membership. Many of our members joined either because an existing member asked them to join or, alternatively, they were asked to join one of the scientific committees. We revised our membership rates in 2011 and we have tried to link the membership subscription rate to ability to pay. This means that there is now a full membership rate of £60 (£5 per month) that will be applicable to most scientists, radiographers, technologists and engineers working in imaging, radiotherapy and medical physics. Please spread this good news amongst your colleagues and friends. I am very keen that we are much more transparent in recruitment of new scientific committee members. This year we will be advertising committee vacancies on the website. We welcome non-member applications but do point out that if selected for a committee, full membership will be mandatory. We are keen to draw on the breadth of our radiology community. After more than 10 years as the event organiser for UKRC the BIR will hand over to an independent company after UKRC 2011. UKRC has been a big part of the work for our events team in the last 10 years. This change means that we will now have more time to focus on our own events programme, both in London and in the regions. The BIR regional (branches) network continues to develop. Please look out

president’s column

I am very keen that we are much more transparent in recruitment of new scientific committee members. This year we will be advertising committee vacancies on the website. for a branch meeting happening in your region. The BIR will continue to be a partner in UKRC and UKRO. Next year, my President’s conference will be on CT. We will hold the meeting in April/May. CT was chosen to coincide with the celebration of the 40th anniversary of Godfrey Hounsfield’s groundbreaking paper presented at the BIR’s annual Congress on 23 April 1972. The meeting will concentrate on current and future applications of CT, thinking carefully about dose reduction and contrast administration. The clinical emphasis will be on emergency and growth areas of CT. There will be historical content celebrating the anniversary. Please make an advance note in your diary or a mental note of this meeting!

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book reviews

SBAs for the FRCR 2A By S Currie, E Rowbotham, S Karthik, and C Wilkinson ISBN: 978-0-521-15564-48 Cambridge University Press

SBAs for the FRCR 2A is a recent addition to the growing cohort of revision books aimed at the single best answer (SBA) format FRCR 2A exam. The new format FRCR exam was held in autumn 2009; this book aims to provide essential reading for radiology trainees preparing for the six modules of this examination. The authors are four radiology trainees from Leeds and the book contains 360 SBA questions (60 per module), with referenced answers following each module. The topics are well chosen and the questions are consistently clear and well constructed. Single best answer questions can be particularly difficult to write, but the authors have integrated clinical and radiological findings within each stem and avoid ambiguity in the short clinical vignettes. A range of SBA question are also used (i.e. not simply ‘what is the most likely diagnosis?’ each time) to challenge the reader’s knowl Expert

differential diagnosis in paediatrics

By Christopher G Anton, Alexander J Towbin, Bernadette L Koch, Eva Ilse Rubio and Daniel J Podberesky ISBN: 978-1-931-88413-6 Amirsys Inc

This is a well illustrated book on differential diagnosis in paediatrics. There are seven sections covering cardiac, chest, GI, GU, MSK, brain, head and neck and spinal conditions. Headings are included under both clinical presentation, such as high output cardiac failure, obstructive sleep apnoea and acute abdomen; and radiological signs, such as destroyed femoral heads and dilated aorta. A differential diagnosis for each heading is given followed by an essential information heading, which details key differential 50


issue 3 june 2011

edge and reflect the nature of the exam. Each answer is accompanied by a detailed explanation and helpfully (in many cases) explains why the other answers are incorrect. The answers are also referenced, and a wide range of textbooks and journal articles are cited to help the reader to consolidate areas that require more revision. The main criticism of the book is the number of questions. At 360, SBAs for the FRCR 2A contains considerably fewer questions than competing titles and this inevitably leads to relatively less of the curriculum being interrogated. For some trainees, it will also be a disappointment that there are not enough questions per module to undertake a full mock exam paper. On a more minor point, many of the questions are drawn from Radiology Review Manual by Wolfgang Dahnert and from journal articles published more than five years ago. It could be argued that these sources are less likely to be used in FRCR 2A questions than UK textbooks and more recent publications. Overall, SBAs for the FRCR 2A provides a thoroughly well written collection of questions that accurately reflect the style and difficulty of the new format FRCR 2A

examination. The book has a relatively small number of questions, but the detailed and well-referenced answers will be of real value to radiology trainees approaching this exam.

diagnosis issues. Next is a section including helpful clues for common diagnosis and then helpful clues for less common diagnosis, and, finally, helpful clues for rare diagnosis. State-of-the-art images are supplied for each of the differential diagnosis, with pertinent features detailed on each image. The images are excellent quality and well labelled. They consist of plain radiographs, CT and MRI where appropriate. This book is an ideal quick reference and has the advantage over many other books by differentiating between conditions, detailing why and providing appropriate imaging to illustrate the point, rather than “dry lists” of conditions. The book also comes with a licensed link to a website that has continuous updates and additional images. I would recommend this book to anybody involved in paediatrics; either the radiologist in training, radiologists with an interest in paediatrics or to physicians to aid in their

understanding of the radiology reports.

A McQueen and A Yeung


Download the full book review

S Ryan

www Download the full book review


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BJR News June 2011  
BJR News June 2011  

BJR News was a news magazine from the British Institute of Radiology (BIR). BJR News featured a mix of news and opinions from leaders in th...