BJR News October 2011

THE NEWS MAGAZINE FROM THE BRITISH INSTITUTE OF RADIOLOGY

Potential health consequences of the Fukushima Daiichi nuclear disaster

MRI of retinoblastoma

UKRC 2011 review

MRI and cardiac pacing devices:beware the rules are changing

ISSN 2044-5113

OcTOBER 2011 www.bir.org.uk

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

of radiation are precisely delivered from many directions to a focused

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

surrounding critical structures.

RapidArc radiotherapy technology delivers sophisticated SBRT treatments

faster than previously possible and opens up new treatment options for

your patients.

RapidArc® for SBRT. Simply Revolutionary.

Varian Medical Systems UK Ltd., Crawley, UK

Phone +44 - 1 293 601 200

www.varian.com/rapidarc [email protected]

contentswww.bir.org.uk

1

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

Managing Editor: Sherry Dixon

Production Editors: Jenny Rooke

Contributing Editors: Professor Adrian Thomas

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

ISSN 2044-5113

EDiTORiAL Safety remains a key issue

REcENT BiR EVENTS UKRC 2011: A successful exhibition

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 1005 and 1006

cASE Of THE MONTH An unusual cause of persistent subcutaneous fluid collection

cOMMENTARy MRI compatible pacemakers: the start of a new era

SHORT cOMMuNicATiON MRI and cardiac pacing devices — beware the rules are changing

REViEW ARTicLE MRI of retinoblastoma

ABSTRAcTS Abstracts from The British Journal of Radiology volume 84 number 1005 and 1006

BiR NEWS Updates from BIR projects and committees

HiSTORy Of RADiOLOGy Stanley Melville Memorial Award and classic books

BOOK REViEW

BiR PRESiDENT’S cOLuMN

OBiTuARy Bryan Harrison — past Chairman of the Radiological Research Trust

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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NEWS

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.

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

www

using the DoI system

NEWSISSUE 5 oCtobER 2011

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

of radiation are precisely delivered from many directions to a focused

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

surrounding critical structures.

RapidArc radiotherapy technology delivers sophisticated SBRT treatments

faster than previously possible and opens up new treatment options for

your patients.

RapidArc® for SBRT. Simply Revolutionary.

Varian Medical Systems UK Ltd., Crawley, UK

Phone +44 - 1 293 601 200

www.varian.com/rapidarc [email protected]

BIR InfoRMatIon www.bir.org.uk

2 ISSUE 5 oCtobER 2011NEWS

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

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

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

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

committee chairpersonClinical Imaging Dr N StricklandHealth Informatics Mrs E HuntIndustry Mrs E BeckmannMagnetic Resonance Professor D LomasNuclear Medicine and Molecular Imaging Dr R GanatraOncology Dr H McNairRadiation and Cancer Biology Dr E HammondRadiation Physics and Dosimetry Professor A W BeavisRadiation Protection Dr P RileyTrainee Dr R Chowdhury

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

The British institute of Radiology 36 Portland Place, London W1B 1AT

Telephone: +44 (0)20 7307 1400 Fax: +44 (0)20 7307 1414

Registered Charity No. 215869

Founded 1897

Incorporated by Royal Charter

Patron: Her Majesty The Queen

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

councIL anD offIceRs

Enquiries General enquires – [email protected] – [email protected] – [email protected]

Publications – [email protected] branches – [email protected] meetings – [email protected] advertising sales – [email protected]

eDItoRIaL: safety ReMaIns a key Issuewww.bir.org.uk

3NEWSISSUE 5 oCtobER 2011

Safety remains a key issueAs time goes by we are getting more accu-rate and specific information on the fall out of the Japanese nuclear disaster. This month’s community news article from Patrick McLaughlin discusses the way that lifestyle has affected the end progno-sis for some of the victims.

Outcome is a key focus of the cancer reform strategy led by Sir Mike Richards whom we were fortunate enough to hear deliver this year’s excellent Agfa Mayneord lecture at UKRC 2011. His drive for early diagnosis has again highlighted the key role that imaging plays. Chest radiographs, non-obstetric ultrasound and brain MRI have been highlighted as particular areas for wider and timely availability. This is impor-tant to ensure earlier treatment and the concept of cancer as a long term disease rather than a life sentence.

Following on from August’s BJR News, safety remains a key issue for us. This month there are two articles about performing MRI on patients with pacemakers. Market forces dictate development of new technology and it would appear, from the stimulating articles by Harden (page 20) and Raj et al (page 22), that a number of compa-nies are working with clinicians and physicists to develop new pacemakers that can enable patients to undergo MRI. Owing to 50-75% of patients with Liz Hunt, BJR News Editor-in-Chief

Following on from August’s BJR News, safety remains a key issue for us.

these devices needing MRI at some point, this is an excellent move forward. On page 11 we hear from a second year medical student on her experience of radiology and it is interesting to note the use of MRI in research into foetal and adult blood.

Finally, our CEO, Jacqueline Fowler, highlights the MRI course to be held at the British Institute of Radiology in October. This will be an excellent opportunity to gain further skills and knowledge.

Articles in this edition cover patient safety and the importance of investing in MRi

New Publication!25% discount for BIR members.

A report from The British Institute of Radiology Molecular Radiotherapy Working Party

Current Status and Recommendations for Further Investigation

MOLECULAR RADIOTHERAPY IN THE UK:

BIR Report 23

Visit the BIR online bookshop -https://bir.org.uk/membersarea/shop/

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: 978-0-905749-70-9Price: £25.00

The Molecular Radiotherapy Working Party is a sub-group 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.

MRTUK 1-page for BJR News.indd 1 4/15/2011 1:26:49 PM


I am delighted with the success of this year’s UK radiological congress (UKRC). The exhibition was the busiest I have seen for several years and a number of the exhibitors commented that it was the best Congress in 10 years. The newly reno-vated Manchester Central proved to be the perfect venue. We knew from an early stage that this year’s UKRC was going to be better than expected because, despite the recession, in February we had to increase our exhibition space due to the demand for stands.

The vice-presidents Stephen Keevil (incoming UKRC president), Sue Barter, James Teh, Laurence Sutton and Glynis Wivell and their working parties, put together an excellent and varied programme, which catered for all specialist

interests in UK medical imaging. Delegate feedback on the programme has been overwhelmingly positive and our invited speakers have received excellent reviews. The clinical programme was made up of refresher courses, master classes and interactive film viewing sessions in areas such as neuroradiology, musculoskeletal imaging, paediatrics, gastrointestinal and breast imaging, which were all excep-tionally popular. Several sessions had standing room only.

The debate “This house believes that radiologists have given up enough of their professional role to radiographers” was particularly enjoyable and, by providing attendees with handheld voting kits, the faculty could ascertain collective opinions and see how they changed as the debate

developed. It was particularly interesting to see that the number of people in the audience who disagreed increased by 13% by the close of play. Congratulations to the panel for creating such a thought-provoking discussion.

I very much enjoyed the British Insti-tute of Radiology (BIR) Agfa Mayneord Eponymous talk from Professor Sir Mike Richards on “Cancer reform: the impor-tance of imaging”, which gave us a great deal to consider regarding the future of cancer imaging (full report on page 10). The eponymous talks from Dr Roland Valori and Professor James Thrall were also highlights for me.

I was impressed by the level of trainee engagement at this year's exhibi-tion and was pleased to present an award

RepoRt: ukRc 2011www.bir.org.uk

5

Recent BIR events

a successful ukRc 2011

New Publication!25% discount for BIR members.

A report from The British Institute of Radiology Molecular Radiotherapy Working Party

Current Status and Recommendations for Further Investigation

MOLECULAR RADIOTHERAPY IN THE UK:

BIR Report 23

Visit the BIR online bookshop -https://bir.org.uk/membersarea/shop/

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: 978-0-905749-70-9Price: £25.00

The Molecular Radiotherapy Working Party is a sub-group 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.

MRTUK 1-page for BJR News.indd 1 4/15/2011 1:26:49 PM

UKRC president Dr Erika Denton presents the highlights of this year's event

Delegate feedback on the programme has been overwhelmingly positive and our invited speakers have been receiving excellent reviews

This year's uKRc event was said to be the most successful of the past 10 years

several years and I am confident that he and his team will deliver another fantastic event. I hope to see you there!

UKRC returns to Manchester on 25–27 June 2012 and I have passed the reins of presidency to Dr Stephen Keevil, who has been a valued vice-president for

to Dr Manil Chouhan who submitted the winning entry in the Philips sponsored Junior Radiologists’ Forum (JRF) essay prize. Trainees were invited to submit entries on the subject of how innovation in radiology helps to deliver better patient outcomes in an era where we have an ageing society, tighter budgets and high public expectations. As a member of the judging panel, I found that Dr Chouhan’s entry on the paradigm shift in the role of diagnostic imaging in clinical practice made for very interesting reading. He was a deserving winner of the prize, which included a home entertainment system from Philips. The Royal College of Radiologists (RCR) Junior Radiologists’ Forum put together an excellent session, with talks on “Radiology research: how to enhance your CV” from Dr James O’Connor, “Becoming a consultant: how to secure your dream job” from Dr Hans-Ulrich Laasch and “The role of radi-ologists as medical managers” from Dr Paul Taylor.


RepoRt: ukRc 2011 www.bir.org.uk

6

I very much enjoyed the BIR Agfa Mayneord Eponymous talk from Professor Sir Mike Richards which gave us a great deal to consider regarding the future of cancer imaging Delegates had the opportunity to get hands-on in demonstrations from a range of companies

Erika Denton, UKRC president

L-R: Dr Jon Bell from the RcR Junior Radiologists forum, Dr Erika Denton, Dr Manil chouhan (recipient of the JRf essay prize) and Alex Mcfarlane from Philips Healthcare

foRthcoMIng eventswww.bir.org.uk

7

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

wwwevents caLenDaR 2011

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

upcoming in october:

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

Scottish Radiological Society annual general meeting 25 November 2011 Vincent Street, Glasgow

East of England branch annual meeting01 October 2011 Addenbrooke’s Hospital, Cambridge

Developments in treatment of head and neck cancer with chemotherapy, biological agents and radiotherapy07 October 2011 BIR, London

Linking orthopaedics and radiology – the plain film revisited ii: the upper limb13 October 2011 BIR, London

Welsh Branch annual meeting13-14 October 2011 Princess of Wales Hospital

clinical imaging of the head and neck 2 December 2011 BIR, London

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

chernobyl 25 years on: consequences, actions and thoughts for the future 12 December 2011 BIR, London

The future of radiology in the NHS: top topics for interviews 16 December 2011 BIR, London

noveMBeR DeceMBeR


BiR uK MRi course (incorporating the Somerset MRi course)17-20 October 2011 BIR, London

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

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

controversies and uncertainties in the radiotherapy of early breast cancer 2 February 2012 BIR, London

London cardiac cT level ii training 7-10 February 2012 BIR, London

BiR president's conference 2012: cT in clinical practice: a tribute to Godfrey Hounsfield 25 - 26 April 2012 Wellcome Collection, London

London cardiac cT level ii training 11-14 September 2012 BIR, London

coMIng up In 2012

coMMunIty news www.bir.org.uk

8

On 11 March 2011, the 9.0 magnitude Tokohu earthquake and tsunami struck the northeast coast of Japan resulting in widespread injury and loss of life. At the time of writing this article (July 2011), the Japanese National Police Agency had confirmed 15539 deaths and 7014 people still missing [1].

Compounding this tragic loss of life, a series of equipment and structural failures at the Fukushima Daiichi nuclear power plant (FDNP) resulted in the release of volatile radioisotopes including Iodine-131 (I-131), Caesium-137 (Cs-137) and Caesium-134 (Cs-134) into the atmos-phere leading to significant radioactive contamination of large areas surrounding the accident site. I-131 has a half-life of 8 days, Cs-137 approximately 30 years and Cs-134 approximately 2 years. I-131 is the major constituent of the emissions from the nuclear plant and, because of physiological thyroid uptake, remains the greatest radiation health threat to the public, especially those within a paedi-atric or adolescent age range [2].

The International Nuclear and Radiological Event Scale (INES) was introduced in 1990 by the International Atomic Energy Agency (IAEA) to enable prompt communication of the impact of the radiation accident on the safety of the population that has likely been exposed. The maximum INES rating of 7 was designated to the incident at FDNP. This was based on a total activity release of several tens of thousands of terabequerel of I-131 equivalent [3]. An INES score of 7 has been designated to only one other nuclear disaster at the Ukrainian Cher-nobyl powerplant on 26 April 1986. The Chernobyl disaster resulted in widespread

health effects including an estimated 6000 thyroid cancers to date, predominantly occurring in those exposed during child-hood or adolescence [4]. Despite similar INES scores, comparison of the Fuku-shima and Chernobyl nuclear accidents is very difficult owing to many complex differences. For example, the Japanese Nuclear and Industrial Safety Agency (NISA) currently estimates that the total activity released at the FDNP was approx-imately 10% of that released during the Chernobyl nuclear incident [3]. Predicting health effects of the FDNP accident is therefore difficult.

Health effects on radiation workersA total of three FDNP workers have

died during their battle to mitigate the radioactive fallout after the accident. These deaths have been attributed to non-radiation related causes and no confirmed health effects have been detected to date in any member of the public as a result of radiation exposure [5]. This is in contrast to the Chernobyl nuclear disaster, where 134 rescue and plant workers contracted acute radiation sickness, resulting in 28 radiation-related deaths within 4 months of the accident [6]. Myelosuppression was the major cause of death in these Chernobyl workers despite aggressive treatment including 13 bone marrow transplants [7].

Three FDNP workers were hospital-ised with non-stochastic radiation burns from inadvertent exposure to contami-nated water in a turbine well on site [5]. Exposure levels to FDNP workers were reported in the summary of the recent international expert fact finding mission by the IAEA. The agency reported

that approximately 30 FDNP workers had been exposed to effective doses of 100–250mSv and that higher internal radi-ation doses may have been sustained by radiation workers during the early days of the incident [5]. A news release by NISA on 10 June 2011 confirmed that significant internal thyroid radiation exposures were sustained by 2 employees with effective doses estimated at 590mSv and 540mSv, respectively [8].

Effective dose estimates from a cohort of approximately 600,000 Cher-nobyl recovery operators known as “liquidators” range from an average of 15mSv to 170mSv, with individual variations from <10mSv to >500mSv [9]. A cohort of early liquidators who were potentially exposed to radioio-dine internal radiation were found to have a statistically significant increase in thyroid cancer risk [10]. In a recent review Cardis et al [11] concluded that evidence also exists for increases in the risk of leukaemia, other haematolog-ical malignancies and cataracts among the Chernobyl liquidators. Cardis et al also reviewed evidence suggesting an elevated risk of cardiovascular diseases in later life following exposure to rela-tively low doses of ionising radiation, a topic recently comprehensively reviewed by the Advisory Group on Ionising Radi-ation to the Health Protection Agency in the UK [12].

Health effect on the general populationAdequate information on the radia-

tion exposure to members of the general public is not yet available and we await data from dose assessments and health surveys of “at-risk” communities, which

potential health consequences of the fukushima Daiichi nuclear disaster

ISSUE 5 oCtobER 2011NEWS

coMMunIty news

coMMunIty newswww.bir.org.uk


coMMunIty news

have recently been commissioned by the Japanese Government.

The radioactive release continues and I-131 and Cs-137 remain detectable in the air within approximately 1km of the plant at concentrations of 3Bq m-3 and 9Bq m-3, respectively (measured on 29 May 2011) [12]. The activity values observed close to the plant show daily fluctuations but with an overall decreasing trend. Deposition of I-131 has not been observed at monitoring sites in 47 prefectures surrounding FDNP since 17 May 2011 [13].

Contamination of seawater and the marine environment has occurred by both aerial deposition and by discharges

of radioactive liquid from FDNP. Activity levels of Caesium isotopes are highest in surface sediments at the near-shore stations close to the reactors. These were between 24 and 320 Bq kg-1 for Cs-137 in the middle of May [13]. Cs-134 and Cs-137 contamina-tion has been found in small numbers of routinely sampled seafood, unprocessed tea leaves, shiitake mushrooms and bamboo shoots. One sample of algae collected on 21 May showed contamina-tion above regulation values for Cs-134/Cs-137 and I-131 [13]. Radioactivity in tap water exceeded 100Bq L-1 in many prefectures including Tokyo leading to widespread drinking water restrictions for nursing infants between 21 March and 1 April 2011.

Exposure reduction measures conducted by the Japanese authorities including evacu-ation of the general public within a 20km radius of the FDNP and the restriction of drinking water and food are commendable and will have significantly decreased the potential health consequences to members of the general public [5]. Early results of paediatric thyroid dose studies involving 946 children from areas with some of the highest fallout show minimal thyroid doses of less than 100mSv [2]. Distribution of potassium iodide tablets in these areas was a crucial precaution taken to decrease I-131 thyroid uptake. Japanese children who consume one of the most iodine-rich diets

in the world would, on average, have been better protected compared with the children exposed from Chernobyl who tended to be iodine-deficient [2] and consequently would retain more iodine.

conclusionInformation on the nature of public

exposure resulting from the Fukushima nuclear disaster is not yet available. The IAEA state that certain Fukushima workers may be at increased risk of even-tually incurring some radiation induced health effects [5]. Our sympathies lie with the Japanese residents and Fukushima workers who will have lost neighbours, friends and family in the catastrophic tsunami. The disaster provides a unique opportunity for the scientific community

to help those involved and also to improve our understanding of the potential haematological, thyroid, cardiovascular, ophthalmological and psychological complications of the radionuclide fallout.

References:

1. http://www.npa.go.jp/archive/keibi/biki/higaijokyo_e.pdf2. Butler D. Fukushima health risks scrutinized, Nature 2011;472:13-4.3. http://www.nisa.meti.go.jp/english/files/en20110412-4.pdf4. United Nations Scientific Committee on the Effects of Atomic Radiation. Sources and effects of ionizing radiation: UNSCEAR 2008 report to the General Assembly with scientific annexes. Volume II: annex D. Health effects due to radiation from the Chernobyl accident. 2011.5. http://www-pub.iaea.org/MTCD/Meetings/PDFplus/2011/cn200/documentation/cn200_Final-Fukushima-Mission_Report.pdf6. Saenko V, Ivanov V, Tsyb A, Bogdanova T, Tronko M, Demidchik Y, et al. The Cher-nobyl accident and its consequences. Clin Oncol 2011;23:234-43.7. Ilyin LA. Realities and myths of Chernobyl. Moscow: Alara, 1994.8. h t t p : / / w w w. n i s a . m e t i . g o . j p / e n g l i s h /press/2011/06/en20110613-3.pdf9. United Nations Scientific Committee on the Effects of Atomic Radiation. Sources and effects of ionizing radiation. Report to the General Assembly, with scientific annexes. In: Annex J: Exposures and effects of the Chernobyl accident (vol II). United Nations, 2000.10. Ivanov VK, Chekin SY, Kashcheev VV, Maksioutov MA, Tumanov KA. Risk ofthyroid cancer among Chernobyl emergency workers of Russia. Radiat Environ Biophys 2008;47:e463-7.11. Cardis E, Hatch M. The Chernobyl accident—an epidemiological perspective. Clin Oncol 2011;23:251-60 12. HPA. Circulatory disease risk. Report of the independent Advisory Group on Ionising Radia-tion. Chilton, Doc HPA, RCE-16, 1-116 (2010)13. http://www.iaea.org/newscentre/news/tsuna-miupdate01.html

Patrick McLaughlin

The disaster provides a unique opportunity for the scientific community to help those involved and also to improve our understanding of the potential complications of the radionuclide fallout



Professor Sir Mike Richards delivered the Agfa Mayneord Memorial Lecture at this year’s UKRC. Mike delivered an interesting half an hour on the topic of “Cancer reform: the importance of imaging” to an audience eager to hear what he had to say.

The lecture focused on cancer in the mid-1990s, progress over the past 15 years, challenges ahead and the impor-tance of imaging past, present and future.

Professor Richards outlined the high incidence of cancer, especially breast and lung cancer, in England in the 1990s. There was a poor survival rate for many cancers, high mortality and a nihilistic/fatalistic attitude to cancer, even amongst health care professionals.

However, the survival rates for particular cancers (e.g. colorectal and breast cancer) did improve. Although the UK and Ireland did not have the poorest rates (this fell to Eastern Europe), neither were we high in the league tables. This may be attributed to a number of factors including poor coordination of services, no standards or guidelines, long waiting times and non-patient centred services.

This began to change at the end of 1999 and the start of 2000. Tony Blair, the prime minister at the time, called a cancer summit, a national cancer director was appointed and Professor Adrian Dixon identified a funding gap of £1–2 billon in imaging services. A decision was made to develop a compre-hensive cancer plan.

Professor Richards went on to discuss the implications of this for imaging – a subject close to the audi-ences’ hearts. The age for breast screening was extended to 70 years old and two-view mammography was implemented. There was a commit-ment to expand the imaging workforce and to introduce “skill-mix” initiatives. Diagnostic capacity was increased with the addition of a further 50 MRI scanners and 200 CT scanners as well as the Lottery New Opportunities fund of £93m.

Progress has been consistent since 2000. Screening and waiting time targets have been achieved, the workforce has expanded considerably and imaging facilities have been modernised. Cancer

outcomes show that, although the inci-dence continues to rise by approximately 1.5% per year, mortality has fallen and survival is improving, but still remains poor compared with other countries. The UK is one of the six countries that make up the International Cancer Bench-marking Partnership. When comparing the survival rates of the six countries in the partnership (Australia, Canada, Denmark, Norway, Sweden and UK), it is clear the UK still has a long way to go to improve its survival rates.

Professor Richards’s lecture outlined the various possible reasons for the poor survival rates in the UK, including late diagnosis due to poor public awareness, delays in primary care and poor direct access to diagnostics from primary care. The government is aiming to improve the UK’s survival rates to be compa-rable to those of the best performing in the International Cancer Benchmarking Partnership. The Doncaster Cough campaign was cited as one initiative to raise awareness.

There are, undoubtedly, challenges ahead for both cancer and imaging. Not least is the financial position of the NHS, the need to save money in the NHS to allow reinvestment, increasing demand on services and the need to replace older technology.

Finally, Professor Richard finished his excellent talk by saying: “We have come a long way on both cancer and imaging in the last decade. We have some way to go still before we can consider our imaging and cancer services world class, and finally we owe it to our patients to meet these challenges.”

All in all, this was a well received informative and interesting lecture.

Sue Marchant, BIR member

British Institute of Radiology's agfa Mayneord Memorial Lecture

Professor Richards’s lecture outlined the various possible reasons for the poor survival rates in the UK, including late diagnosis due to poor public awareness, delays in primary care and poor direct access to diagnostics from primary care

www.bir.org.uk coMMunIty news


If I was asked 6 months ago if I would ever consider a career in Radiology, I am pretty certain my answer would have been “no”. As a second year medical student my exposure to radiology has been fairly limited; the occasional lecture about imaging of certain body systems consisting of a mixture of radiographs, CT scans, MRI and other radiological

techniques, which neither I nor the 250 other students in the lecture theatre could make head nor tail of – literally. At my stage of learning, one of the main difficulties with MRI and other imaging techniques is judging whether all of the students in the room are at a similar level or whether I am the only one who feels like I don’t really understand.

I was thrilled when I was allocated a 6 week research attachment with the title “MRI of foetal and adult blood”, mainly because of my interest in obstetrics and gynaecology. However, before my project began I was very anxious about one component of the project – MRI. Was I going to end up making a fool of myself?

The project was ideal for me. I found

myself regularly waiting in the sluice room beside the obstetrics operating theatres peering through the window watching caesareans being performed, before the fresh placenta was brought through to me so I could extract a blood sample i.e. the foetal blood for our study.

I was aware of the concept of T1 and T2 weighting on MRI before begin-

ning the project, but all I knew was that on one, fat was white and on the other it was grey! The blood samples were imaged with various MRI sequences, both T1 and T2 weighted over the course of a couple of weeks, while being kept at room temperature. This was to deter-mine the change in signal intensity of the foetal blood samples, relative to that of adult blood samples that were obtained at the same time. The key question was: is there a difference between foetal and adult blood signal intensity on MRI when imaged over a given period of time?

The images obtained were analysed using the proprietary software supplied on the imaging work station, which would give us an arbitrary value for the

average signal intensity within a selected area. We were able to compare directly the differences in signal intensity between foetal and adult blood.

I had never thought of radiology being used in this way. In particular I had never thought about how radiology could be involved in complex social issues, such as child abuse court cases. I knew radiology was used to assist the work of doctors and surgeons, but had not thought about it as a medical department in its own right. My short introduction highlighted to me the importance of both research and radiology and their clinical application. The research in this case has the genuine potential to affect clinical practice and potentially affect the outcome of a court case.

While working on my own project in the radiology department, I was also able to see some MRI images of pregnant women. I was fascinated to see how much detail can be obtained around the foetus at such a young age and how important it can be in assessing development of the foetus quickly and accurately. Without radiology many babies would be carried to full-term without the knowledge of any developmental abnormalities. I found this area of radiology particularly interesting as it links back to my interest in obstetrics and gynaecology.

I really enjoyed my experience in radiology and it has opened my eyes to how many branches of medicine there are out there that I had not previ-ously considered. Seeing the practical application of radiology and how many different specialties it links to, I would like to change my answer to the opening question to: “it is very possible.”

opening up to radiology

Katie Knappett, second year student at The University of Sheffield Medical School

Katie Knappett describes how a foetal and adult blood imaging research project helped to open her eyes to the possibility of a career in radiology

I found myself regularly waiting in the sluice room beside the obstetrics operating theatres peering through the window watching caesareans being performed, before the fresh placenta was brought through to me so I could extract a blood sample



British Journal of Radiology awards presented at ukRc

Congratulations to the recipients of the 2009 BJR awards, which were presented by Stephen Davis, British Institute of Radiology president, at UKRC 2011

The British Journal of Radiology (BJR) hosted an evening reception at this years UKRC to present the 2009 BJR awards. A selection of members, BIR staff and our sister societies gathered to offer their congratulations to the following awardees. The 2009 Rontgen Award was awarded to Dr Roger Harrison. This is awarded annually to a member, or a team of workers including a member, whose contribution to the BJR has been of

special merit. The subject of the contri-bution must be related to radiotherapy, radiobiology or physics. The Barclay Medal was awarded to Professor Martin Leach. This prize is awarded annually to the person, whether a member of the Institute or not, whose contribution to The British Journal of Radiology over a period of years has been of special merit, contributing materially to the science and practice of radiology.

The Barclay Prize was awarded to Professor Alan Jackson. This prize is awarded annually to a member, or a team of workers including a member, whose contribution to the Journal has been of special merit. The subject of the contribution must have been diagnostic radiology, which includes the clinical or experimental aspects, or physics relating thereto.

L:R. Alan Jackson and Stephen DavisL:R. Roger Harrison and Stephen Davis L:R. Martin Leach and Stephen Davis

I have just finished my first year as a graduate medical student at King’s College London. In my previous career I was trained as a medical physi-cist, but after completing my Part A training I changed professions and started medical school. My friends at the British Institute of Radiology (BIR) have joked that I just wished to embody the spirit of the institute by becoming truly multidisciplinary all by myself! I am not sure if this is entirely true; I have volunteered myself for many more years of exams just after I finished my medical physics ones so I think I might just be a little crazy!

I am not alone however — graduate entry into UK medical schools has never been so high and many people

are retraining, deciding to pursue a medical career later in life. Indeed, the first thing that struck me about my fellow course mates was the sheer number and diversity of the graduates there. At King’s College London, grad-uates make up approximately 30% of the 440 students in each year. I there-fore did not feel too ancient, sitting in my first lecture as a 28-year-old fresher. What a relief!

I found it very interesting to talk to my fellow graduates about their back-grounds; among my close friends on the course are a human rights barrister, a chemical engineer, an English teacher and a professional saxophonist, just to list a few. Considering the diversity of the student population, I wonder how the medical profession will change in response to the increasing graduate intake in medical schools. The FY1s of the future will have varied and unex-pected skills to offer the profession like never before, and I look forward to seeing how the medical profession may evolve in response to this.

As a graduate, my first year of medical school has challenged me in unexpected ways. Having been a student

or in training most of my life, I assumed all my years of studying would put me in good stead for embarking on a new career. I naively assumed that the study techniques I had developed for learning physics would be directly transferable to medicine. It was therefore a big shock to find that learning medical science was nothing like learning the science of physics! At first, I missed physics more than I was expecting. I have spent years

studying for exams which required only a few equations to be retained to memory and instead good marks relied entirely on a deep understanding of the underpinning fundamental principles. In fact, many physicists often pride them-selves on having terrible memories. Albert Einstein was no exception, he once famously said “I never commit to memory anything that can easily be looked up in a book.” This is not the case in medicine. In the first year of a medical degree you are thrown into a very large sea of facts to digest or drown in. This aims to lay a broad scientific framework from which the deeper understanding of future years will build upon. I will admit that I found myself floundering in the beginning. I spent more time than I should have trying to gain the level of fundamental understanding that I was used to in physics. This was a futile effort. Medicine is not a science of fundamentals as physics is, but of the beautiful and highly complex system that is the human body. Medicine begins at the macroscopic and aims to under-stand the microscopic, whereas physics is the reverse.

This change in scientific outlook has been my biggest challenge. Yet I have survived my transition from phys-icist to medic! I have struggled at times with an unexpectedly steep learning curve, but now I find myself enjoying the new challenge of medical science. I will always be a mixture of physi-cist and medic and am proud of it — I get far too excited over words such as “image noise”, “k-space” and “Fourier transforms” to pretend otherwise!

coMMunIty newswww.bir.org.uk


My journey to the dark side

Elizabeth Morris MSc DipiPEMGuy’s King’s and St Thomas’ Medical School, King’s College London.

A former physicist shares her thoughts on her first year at medical school

The FY1s of the future will have varied and unexpected skills to offer the profession like never before, and I look forward to seeing how the medical profession may evolve in response to this

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In the onLIne Issue of BJRwww.bir.org.uk

15

featured articles:

highlighted articles:

what’s onLIne: bjr.birjournals.org

case of the Month

DOi: 10.1259/bjr/ 29764457

J R Medverd, A-V Ngo and P Bhargava

An unusual cause of persistent subcutaneous fluid collection

DOi: 10.1259/bjr/ 97637841

shoRt coMMunIcatIon

G Davies and M Koenen

Acoustic radiation force impulse elastography in distinguishing hepatic haemangiomata from metastases: preliminary observations

DOi: 10.1259/bjr/ 70520972

pIctoRIaL RevIew

C P Law, R V Chandra, J K Hoang and P M P Hal

imaging the oral cavity: key concepts for the radiologist

DOi: 10.1259/bjr/ 18998800

RevIew aRtIcLe

R S Z Yiin, P H Tang, and T Y Tan

Review of congenital inner ear abnormalities on cT temporal bone

DOi: 10.1259/bjr/ 86609066

coMMentaRy

S P Harden

MRi compatible pacemakers: the start of a new era

fuLL papeRs

Quantitative evaluation of viable tissue perfusion changes with contrast-enhanced greyscale ultrasound in a mouse hepatoma model following treatment with different doses of thalidomideJ H Zhou, W Zheng, L H Cao, M Liu, R Z Luo, F Han, P H Wu, and A H Li

DOi: 10.1259/bjr/14335925

Biodosimetric quantification of short-term synchrotronmicrobeam versus broadbeam radiation damage to mouse skin using a dermatopathological scoring systemR C U Priyadarshika, J C Crosbie, B Kumar and P A W Rogers

DOi: 10.1259/bjr/58503354

A method to produce and validate a digitally reconstructed radiograph-based computer simulation for optimisation of chest radiographs acquired with a computed radiography imaging systemC S Moore, G P Liney, A W Beavis, and J R Saunderson

DOi: 10.1259/bjr/30125639

case RepoRts

fluorine-18-fluorodeoxyglucose PET/cT rare finding of a unique multiorgan involvement of Wegener’s granulomatosisA Almuhaideb, R Syed, L Iordanidou, Z Saad and J Bomanji

DOi: 10.1259/bjr/22598605

case report: Vanishing bone metastases — a pitfall in the interpretation of contrast enhanced cT in patients with superior vena cava obstructionN Thomas, T B Oliver and T Sudarshan

DOi: 10.1259/bjr/50676625

case of month: Progressive onset of a low back pain: unusual imaging findings on cT and MRiP F Montoriol, R Bellini and J L Michel

DOi: 10.1259/bjr/33368552

case report: uptake of gadolinium-ethoxybenzyldiethylenetriaminepentaacetic acid in metastatic adrenal tumour from hepatocellular carcinomaS Arizono, H Isoda, E Hatano, and K Togashi

DOi: 10.1259/bjr/20594229


BIR Company Subscribers

4 Ways HealthcareTel: 01442 260 322. Contact Dr Sanjiv Agarwal, CEO.

Accuray Tel: 00 133 155 232 020. Contact Ms Sancie Nakarat, Marketing Communications Manager.

Agfa HealthCare UK LtdTel: 02082 314 900. Contact Grant Witheridge, Managing Director UK & Ireland.

Bayer Schering PharmaTel: 01444 465 864. Contact Mr Nick Laughland, Senior Product Manager, Diagnostic Imaging.

Bracco UK LtdTel: 01628 8518 500. Contact Mr Bill Pelling, Managing Director.

Carestream Health UK LtdTel: 01442 844 473. Contact Mr Charles McCafrey, Marketing Manager UK and Ireland.

Cobalt Appeal FundTel: 01242 535 910. Contact Mrs N Sykes.

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

Envirotect Ltd Tel: 01525 374 374. Contact Mr Ian Burtenshaw, Product Manager (International Division) Contrast Media.

Fujifilm UK Ltd Tel: 01234 572 229. Contact Mr Mark van Rossum, General Manager – Medical Systems.

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

IBA Molecular UK Ltd Tel: 07887 644 672. Contact Mr Michael Yon, Managing Director.

Imaging Equipment Tel: 01761 415 570. Contact Mr Nicholas Stevens, Managing Director.

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

Insignia Medical Systems Tel: 01420 540 206. Contact Mr R Dormer, Managing Director.

Landauer Europe Tel: 01865 373 008 Contact Miss I Florelli.

Matchtech Group PlcTel: 01489 898 989. Contact Mr Darren Compton, Manager.

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

NHS InnovationsTel: 01722 326 006. Contact Mrs D Postlewhaite, Marketing and Communications Lead.

Nucletron UK LtdTel: 01829 771 111. Contact Mr J Banks, Managing Director.

Oncology Systems LtdTel: 01743 462 694. Contact Mrs Tammy Cole, Office Manager.

Philips HealthcareTel: 01737 230 418. Contact Ms Andrea Sheargold, Marketing Communications Manager.

PTW-UK LTDTel: 01476 577 503. Contact Mr Stephen Bellchambers.

QadosTel: 01252 878 999. Contact Ms Dawn Broadhead, Sales Director.

Sectra LtdTel: 01276 696 317. Contact Mr Chris Briggs, Commercial Manager - PACS and RIS.

Siemens Medical SolutionsTel: 01276 696 317. Contact Mr Mike Bell, Marketing Exhibitions and Advertising.

Southern Scientific LtdTel: 01903 604 000. Contact Mr Stephen Adams, Sales Manager.

Toshiba Medical Systems UKTel: 01293 653 700. Contact Mr S M Weeden, Manager X-ray Products.

Varian Medical Systems (UK) LimitedTel: 01293 601 324. Contact Mr Mike Poll or Mr David Scott.

Vertec Scientific LtdTel: 01734 817 431. Contact Mr B Hipgrave, Managing Director.

Wardray Premise Ltd Tel: 02083 989 911. Contact Mr R Beach, UK Sales Manager.

Xograph Healthcare LtdTel: 01666 501 501. Contact Mr Paul Andrews, Commercial Manager.

Zonare Medical SystemsTel: 08448 711 811. Contact Mr D J Thomas, Managing Director.

If you would like to find out more about the benefits of becoming a BIR Company Subscriber please visit: www.bir.org.uk/bir-join-us-home/corporate

BJRNews Company Subscribers page 4May11.indd 1 5/4/2011 4:08:22 PM


In the onLIne Issue of BJR www.bir.org.uk

16

all other articles from september and october 2011BReast

Seeding of tumour cells following breast biopsy: a literature reviewC F Loughran, and C R Keeling

DOi: 10.1259/bjr/77245199

caRDIac

Lowering heart rate with an optimised breathing protocol for prospectively EcG-triggered cT coronary angiographyL Husmann, B A Herzog, A P Pazhenkottil, R R Buechel, R Nkoulou, J R Ghadri, I Valenta, I A Burger, O Gaemperli, C A Wyss and P A Kaufmann

DOi: 10.1259/bjr/29696915

Screening for atherosclerotic plaques in the abdominal aorta in high-risk patients with multicontrast-weighted MRi: a prospective study at 3.0 and 1.5 teslaJ-H Buhk, A-K Finck-Wedel, R Buchert, P Bannas, B Schnackenburg, F U Beil, G Adam, and C Weber

DOi: 10.1259/bjr/16555263

Short communication: MRi and cardiac pacing devices — beware the rules are changingV Raj, R O’Dwyer, R Pathmanathan and R Vaidhyanath

DOi: 10.1259/bjr/22160941

case report: Bilateral persistent hypoglossal arteries: MRi findingsH Takahashi, H Tanaka, N Fujita and N Tomiyama

DOi: 10.1259/bjr/21939976

gastRoenteRoLogy

Right thoracic paravertebral anaesthesia for percutaneous radiofrequency ablation of liver tumoursM Cheung Ning, and M K Karmakar

DOi: 10.1259/bjr/28983063

case report: calcification in biliary hamartomatosis: a case reportD Gil-Bello, E Ballesteros, E Sanfeliu and F J Andreu

DOi: 10.1259/bjr/95019559

eaR, nose anD thRoat

Evaluation of radiation-induced changes to parotid glands following conventional radiotherapy in patients with nasopharygneal carcinomaV W C Wu, M T C Ying, and D L W Kwong

DOi: 10.1259/bjr/55873561

Disease control using low-dose-rate brachytherapy is unaffected by comorbid severity in oral cancer patientsR Yoshimura, H Shibuya, K Hayashi, K Toda, H Watanabe and M Miura

DOi: 10.1259/bjr/53223221

case report: Not the typical Tornwaldt’s cyst this time? A nasopharyngeal cyst associated with canalis basilaris medianusB D Lohman, B Sarikaya, A M Mckinney and M Hadi

DOi: 10.1259/bjr/95083086

case report: Differentiating osteoradionecrosis from nasopharyngeal carcinoma tumour recurrence using 99Tcm-sestamibi SPEcT/cTA E H Tan and D C E Ng

DOi: 10.1259/bjr/60136051

thoRacIc

Multidetector cT imaging of pleura: comparison of two contrast infusion protocolsV Raj, R Kirke, M J Bankart and J J Entwisle

DOi: 10.1259/bjr/55980445

conventional 3D staging PET/cT in cT simulation for lung cancer: impact of rigid and deformable target volume alignments for radiotherapy treatment planningG G Hanna, J R Van, S O Rnsen De Koste, K J Carson, J M O’Sullivan, A R Hounsell, and S Senan

DOi: 10.1259/bjr/29163167

case report: Valsalva manoeuvre effect on distribution of lung damage in heroin inhalationS J Prowse, T Lima, K L Irion and H Burhan

DOi: 10.1259/bjr/41925397

case report: Malignant peripheral nerve sheath tumour presenting as a pneumothoraxA Abbas, H Jones, G T Kingston and A Zurek

DOi: 10.1259/bjr/27394681


In the onLIne Issue of BJRwww.bir.org.uk

17

all other articles from september and october 2011

genItouRInaRy

Hysterosalpingogram: an essential examination following Essure hysteroscopic sterilisationV Shah, N Panay, R Williamson, and A Hemingway

DOi: 10.1259/bjr/95330860

Preliminary experience of a predictive model to define rectal volume and rectal dose during the treatment of prostate cancerM D Falco, M D’Andrea, D Fedele, R Barbarino, M Benassi, E Giudice, E Hamoud, G Ingrosso, P Ladogana, F Santarelli, G Tortorelli, and R Santoni

DOi: 10.1259/bjr/25741415

Assessing the daily consistency of bladder filling using an ultrasonic Bladderscan device in men receiving radical conformal radiotherapy for prostate cancerS Hynds, C K McGarry, D M Mitchell, S Early, L Shum, D P Stewart, J A Harney, C R Cardwell, and J M O’Sullivan

DOi: 10.1259/bjr/50048151

MRi-based pre-planning in patients with cervical cancer treated with three-dimensional brachytherapyM Dolezel, K Odrazka, J Vanasek, T Kohlova, T Kroulik, K Kudelka, D Spitzer, M Mrklovsky, M Tichy, J Zizka and L Jalcova

DOi: 10.1259/bjr/75446993

The value of diffusion-weighted MRi in the diagnosis of malignant and benign urinary bladder lesionsS Avcu, M N Koseoglu, K Ceylan, M Dbulutand and O Unal

DOi: 10.1259/bjr/30591350

case report: imaging findings of a primary bladder maltomaM K Gill, A F Hussain, A H A Razack, and M K Seong

DOi: 10.1259/bjr/66130737

case report: MRi findings of prostate stromal tumour of uncertain malignant potential: a case reportV F Muglia, G Saber, G Maggioni and A J C Monteiro

DOi: 10.1259/bjr/67699443

heaD anD neck

Head and neck MRi of Kimura diseaseT Horikoshi, K Motoori, T Ueda, R Shimofusa, T Hanazawa, Y Okamoto and H Ito

DOi: 10.1259/bjr/42012793

Monte-carlo radiotherapy simulations of accelerated repopulation and reoxygenation for hypoxic head and neck cancerW M Harriss, E Bezak, and E K Yeoh

DOi: 10.1259/bjr/25012212

case report: Diffusion MRi findings of cytomegalovirus-associated ventriculitis: a case reportJ H Seok, K Ahn and H J Park

DOi: 10.1259/bjr/31561378

Review: MRi of retinoblastomaA A K A Razek, and S Elkhammary

DOi: 10.1259/bjr/32022497

figure 1. Longitudinal greyscale ultrasound image of the left upper thigh shows a subcutaneous fluid collection containing avascular fat lobules (arrow)

case of the Month www.bir.org.uk

18

An unusual cause of persistent subcutaneous fluid collectionA 44-year-old male was involved in a motorcycle crash. His left lower extremity was impacted between the motorcycle and a car. He suffered left-sided rib fractures, capsular injury to his left fifth proximal interphalangeal joint and had a large haematoma in the medial aspect of the left thigh. Ultrasound of the left thigh was performed 1 week after the accident (Figure 1). The subsequent clinical course was characterised by a persistent fluid collection in the medial aspect of the left thigh that was painful and bothersome. Further evaluation with MRI of the left thigh was performed 2 months after the time of injury (Figures 2–4). Laboratory findings revealed a normal coagulation panel.

• What are the characteristics of the fluid collection on ultrasound?• What observations can you make from the MRi?• What is your diagnosis?

FindingsGreyscale ultrasound images of the left medial thigh near the time of injury revealed a compressible, well-defined, encapsulated subcutaneous fluid collection with multiple hyperechoic foci of entrapped fat (Figure 1). Colour Doppler ultrasound images (not shown) revealed these hyperechoic foci to be avascular. MRI nearly 2 months later demonstrated again an ovoid subcutaneous encapsulated hypointense fluid collection with hyperintense fat lobules on T1 weighted axial images (Figure 2). STIR coronal MRI further confirmed subcutaneous location of the fluid collection (Figure 3). Multiple fluid-fluid levels were present within the collection on T2 weighted axial MRI (Figure 4). The capsule was hypointense on all sequences. Imaged portions of the femur and thigh musculature were normal on all sequences.

DiagnosisA persistent encapsulated subcutaneous

fluid collection occurring at the site of the previous blunt trauma along with the demon-stration of entrapped avascular fat lobules on ultrasound and multiple fluid-fluid levels on MRI is representative of Morel-Lavallée

lesion (MLL). The collection was managed conservatively with application of a compres-sion sleeve supplemented by periodic patient self-massage and a warm compress. Recovery was slow, with painful enlarge-ment of the left medial thigh region which persisted for 5 months after injury before the patient entered a period of slow progressive improvement. At 8 months after injury, the collection was still present but substantially reduced in size and nearly asymptomatic.

DiscussionMLLs represent closed internal

degloving injuries resulting from blunt trauma with tangential sheer forces that separate the hypodermis from the under-lying fascia. The disrupted vascular and lymphatic supply of the injured tissue then fills the created potential space with blood, lymph and eventual necrotic debris. The lower extremity is a common location for these lesions, characteristically occurring at the greater trochanter or anterolateral aspect of the proximal thigh. The proximal medial thigh location in our patient is unusual, but consistent with the site of potential sheering forces at the time of his accident. Of note,

is the strong association of this rare lesion with pelvic fractures. The presence of a soft fluctuant area on physical examination is a typical finding. Hypermobility with hypoes-thesia of the skin over the affected area is also a useful clinical sign [4].

The imaging appearance of the MLL essentially depends on the age of the blood within it. In the acute to subacute setting, blood clots and debris may be found within an ovoid cavity of fluid. As the haematoma ages, deoxyhaemoglobin is converted into methaemoglobin that may appear increased or intermediate in intensity on T1 weighted MRI. As the haematoma continues to evolve, the clot is transformed into serosan-guinous fluid. The haematoma may develop a fibrous pseudocapsule, which is typically hypointense on all sequences. Hypointen-sity of the pseudocapsule on MRI may also be contributed to by incorporation of haemo-siderin from breakdown of the blood in the original haematoma. Furthermore, as the haematoma continues to organise, fluid-fluid levels can develop within the collection. MLL may have fat remnants both peripher-ally and within the fluid collection. These fat lobules will appear hyperechoic on greyscale



figure 2. T1 weighted axial MRi of the left upper thigh shows a subcutaneous fluid collection containing globular hyperintense fat lobules (arrows) and hypointense capsule

www

J R Medverd, A-V Ngo and P Bhargava

Department of Radiology, University of Washington School of Medicine, Seattle, USA and 2VA Puget Sound Health Care System, Seattle, USA

Download the full article and references: DOi: 10.1259/bjr/29764457

case of the Monthwww.bir.org.uk

19

An unusual cause of persistent subcutaneous fluid collection

ultrasound and hyperintense on T1 weighted MRI. MLLs can decrease in size with time, but tend to persist if not treated [4]. Conserv-ative non-invasive therapy typically involves compression wrapping. However, many MLLs are misdiagnosed or may persist despite the compressive therapy. It has been postulated that the fibrous pseudocapsule prevents reabsorption of serosanguinous and lymphatic fluid [3]. Minimally-invasive treatment methods have become increas-ingly popular and justified on the grounds that iatrogenic injury to the remaining subcu-taneous vascular supply is minimised and the overall cosmesis is improved [5]. These treatment options include serial percuta-neous aspirations and suction drainage. In refractory cases, talc or doxycycline scle-rodesis has been used successfully [2].

The differential diagnosis for this entity includes fat necrosis, pseudolipoma, coagulopathy-related haematoma, and fat-containing soft-tissue tumours. Fat necrosis is known to exhibit variable appearances at imaging. MRI criteria for fat necrosis includes the presence of linear intensities most likely related to variable stages of necrosis, oedema, haemorrhage and fibrosis

associated with fat necrosis after trauma over time. It occurs over bony prominences predis-posed to trauma, such as anterior tibia and gluteal regions. The characteristic inclusion criterion for fat necrosis is the presence of a palpable lump with lack of a discrete mass at imaging [6]. The presence of a discrete fluid collection helps exclude this entity. A pseudocapsule surrounding fat necrosis may be seen but this is an atypical feature [7]. These are usually well-circumscribed hyper-echoic masses on greyscale ultrasound with hypervascularity on colour Doppler. Arterio-venous shunting may be seen. Although they can be subcutaneous in location, presence of prominent branching and serpentine high-flow and low-flow vascular structures with contrast enhancement help differentiate this lesion from a MLL [8]. Coagulopathy related haematomas often present out of propor-tion to the corresponding trauma history or without antecedent trauma. Given our patient’s normal coagulation profile, coagu-lation-related haematoma was excluded. Fat containing sarcomas are usually hypervas-cular on colour Doppler. Although contrast was not included in the work-up of this case, the lesions would be expected to demon-

strate gadolinium enhancement, but intensity and uniformity of enhancement can vary widely depending on grade and sub-type of these tumours. Further imaging evidence to differentiate MLLs from neoplasm includes recognition of the typical ovoid margin MLLs form from peeling back subcutaneous fat from the fascia [9].

conclusionsMLLs, or closed internal degloving

injuries, present as persistent subcutaneous fluid collections with characteristic imaging findings that guide the radiologist to the proper diagnosis even when they arise in atypical locations. Ultrasound and MRI may be used to arrive at the correct diagnosis, excluding soft-tissue neoplasms, avoiding biopsy and to help direct appropriate patient management.

figure 4. T2 weighted axial MRi of the left upper thigh shows a subcutaneous fluid collection containing multiple fluid-fluid levels

figure 3. STiR coronal MRi of the left upper thigh confirms the subcutaneous location of the fluid collection. Note the typical ovoid margins and hypointense capsule

This is a commentary on the short communication by Raj et al in the September issue of the British Journal of Radiology (BJR) (see page 22).

The first rule of all radiology departments is that a pacemaker is a contraindication to MR scanning. Quite rightly, we go to great lengths in routine clinical practice to ensure that patients with an in situ pacemaker do not enter the scanning suite. This involves the clinical referrer signing part of the request card indicating there is no known contraindication to MR and rigorous questioning of the patient by the MR department radiographers and support staff before they are allowed into the controlled scanning area. There are several theoretical risks if a patient with a pacemaker under-goes an MRI examination [1]. Firstly the electronic circuits of the pacing box may malfunction and effectively be erased, particularly by the static magnetic field, which leads to a lack of pacing that could be life-threat-ening in a patient who is pacemaker dependent. Secondly, the rapidly changing magnetic field gradients may induce currents in the pacing system, which can lead to hyperstimulation and rapid over-pacing causing a negligible cardiac output. The radiofrequency (RF) pulse may also do this to some degree. Thirdly, the pacing box or lead may move as a result of the strength of the static magnetic field if there are ferromagnetic components within the pacing system. Finally, there is a risk that the pacing electrode, acting as an antenna, will absorb the RF pulses and localise this energy in the elec-trode tip as heat, which might burn and potentially rupture the myocardium,

particularly given the thin walls of the right-sided cardiac chambers.

Across the world, several hundred patients have inadvertently undergone an MR examination despite having a pacemaker in place [2]. In the majority of cases, there were no untoward events, suggesting that the actual risk is low. However, deaths have occurred and although there is little conclu-sive evidence, the identification of ventricular fibrillation in some of these

patients suggests dysrhythmia owing to rapid chaotic pacing as the likely cause of death. It seems that none of these deaths occurred when there was a physician present directly supervising or monitoring the scan [1]. In several published small studies of patients knowingly undergoing MR examina-tions with pacemakers in situ there were no reported deaths, although these studies have clearly been performed in highly specialised institutions [3].

In practical terms, once an indi-vidual patient has a permanent pacemaker inserted they will never be

able to undergo an MR scan for the rest of their lives. Although pacing boxes can be changed, the pacing leads are essentially permanent. This is problem-atic for these patients, given the recent data that there is a 50–75% chance of a patient with a pacemaker or implanted cardiac defibrillator needing an MR scan at some point in their life [4]. As a result, pacing technology manu-facturers have focused their research for some time on developing an MR

compatible pacing system. Although such systems are in various stages of development, one device, the SureScan (Medtronic, Minneapolis, MN) pacing system, has been shown to be safe under specific conditions in a large cohort of patients and is available for use in clinical practice [5, 6]. There are several principles to its safety. Firstly, the lead has been designed to be a poor conductor of RF energy; secondly, the internal circuitry of the pacing system has been improved to lessen the chances of cardiac stimulation and disruption of the internal power supply; and thirdly,


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MRI conditional pacemakers: the start of a new era

The electronic circuits of the pacing box may malfunction and effectively be erased, particularly by the static magnetic field, which leads to a lack of pacing that could be life-threatening in a patient who is pacemaker dependent

References1. Levine GN, Gomes AS, Arai AE, Bluemke DA, Flamm SD, Kanal E, et al. Safety of magnetic resonance imaging in patients with cardiovascular devices: an American Heart Association scientific statement from the Committee on Diagnostic and Interventional Cardiac Catheterization, Council on Clinical Cardiology, and the Council on Cardiovas-cular Radiology and Intervention: endorsed by the American College of Cardiology Foundation, the North American Society for Cardiac Imaging, and the Society for Cardiovascular Magnetic Resonance. Circulation 2007;116:2878–91.2. Hundley WG, Bluemke DA, Finn JP, Flamm S, Fogel MA, Friedrich MG, et al. ACCF/ACR/AHA/NASCI/SCMR 2010 expert consensus document on cardiovascular magnetic resonance: a report of the American College of Cardiology Foundation task force on expert consensus documents. J Am Coll Cardiol 2010;55:2614–62.3. Martin ET, Coman JA, Shellock FG, Pulling CC, Fair R, Jenkins K. Magnetic resonance imaging and cardiac pacemaker safety at 1.5-Tesla. J Am Coll Cardiol 2004;43:1315–24.4. Kalin R, Stanton MS. Current clinical issues for MRI scanning of pacemaker and defibrillator patients. Pacing Clin Electrophysiol 2005;28:326–8.5. Sutton R, Kanal E, Wilkoff BL, Bello D, Luech-inger R, Jenniskens I, et al. Safety of magnetic resonance imaging of patients with a new Medtronic EnRhythm MRI SureScan pacing system: clinical study design. Trials 2008;9:68.6. Wilkoff BL, Bello D, Taborsky M, Vymazal J, Kanal E, Heuer H, et al. Magnetic resonance imaging in patients with a pacemaker system designed for the magnetic resonance environment. EnRhythm MRI SureScan Pacing System Study Investigators. Heart Rhythm 2011;8:65–73.

early stages for a cardiologist to also be present for the scan. Raj et al are right to emphasise the multidiscipli-nary approach required in the use of these pacing systems as the radiolo-gist cannot and must never be left to manage these cases alone. There needs to be a rigorous process of checks prior to MR scanning to ensure the patient’s safety. One can foresee difficulties with patients apparently having a safe device but with very little confirmatory documentation being present. Although the manufacturers have designed the pacing box and the electrodes to have characteristic markings that can be identified on an X-ray, it cannot be overstated that there is no point in having an MRI compatible pacing box if the leads are MRI unsafe. Finally, cardiologists need to be reminded and encouraged to insert these devices, particularly if there is a high likelihood of the patient needing an MR scan in the future; if this can be predicted at the time of pacemaker insertion. This surely is the opportunity to create a reliable local documentation, which is easily identifiable in the patient’s notes, that the device is MR compatible so that future MR scans can be planned in confidence. The manufacturer currently provides a system of recom-mended checks, documentation and advice, but this process will become more complex as more of these devices come onto the market from different manufacturers. It is likely, therefore, that local and national guidelines will be required because the stakes are high if the strict safety measures that these devices require are not followed to the letter. The message must remain — if in doubt, don’t scan.

the pacing box can be specifically set to an MR-safe mode for the purposes of the scan and then reset afterwards. These pacing systems have a safety rating of ‘‘MR conditional’’ because there are constraints on the conditions of their use i.e. they are safe only under certain well-defined conditions.

The SureScan device has largely been tested in published literature on patients undergoing MR of the brain or lumbar spine. MR examinations of the heart and thorax have been seen as the ultimate test of this device given that the pacing system is entirely within the imaging field. A number of patients with this pacing system have success-fully undergone cardiac MRI (CMRI). In September’s BJR, Raj et al present elegant MRIs of one of these pacing leads situated in the RV during a CMR study. They also detail the strict safety requirements for a patient undergoing this examination, equivalent to the conditions that make this device MR conditional. The indications for CMR, in a patient with one of these pacing devices present, remain to be deter-mined and it is not clear yet whether the image quality will be good enough to, for example, assess reliably for an RV dysplasia.

A new era indeed, but this is only the start. In the early stages of clinical use, it seems appropriate that all MR scans in patients with this device in situ are performed in regional cardiac units, with support from the local MR physics department and the manufacturers. It is clearly essential for an electro-physiology technician to be present to programme and re-programme the device before and after the scan and it would seem appropriate in these


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MRI conditional pacemakers: the start of a new era

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S P HardenDepartment of Cardiothoracic Radiology, Southampton University Hospitals NHS Trust, Southampton, UK.


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MRI and cardiac pacing devices — beware the rules are changingWe have been following the development of MRI compatible cardiac permanent pacemakers (PPM) with great interest. Recently, we have been asked to perform clinical MRI studies in patients with a MRI-compatible PPM. We would like to share our experience in performing one such study and highlight important safety measures that radiologists should under-take prior to imaging.

Conventional PPM has always been regarded as an absolute contraindica-tion for MRI. This has prevented a large number of patients from undergoing clinically important MRI studies. MRI-

compatible PPM are now available for clinical use following a prospective randomised controlled unblinded multi-center study, involving 64 patients [1, 2]. Our first patient had an Advisa DR MRI SureScan (Medtronic, Minneapolis, MN) system, which is one of the most widely used MR compatible systems. These devices have been designed to minimise thermal damage and limit induced voltages preventing unintended stimula-tion of the heart.

Performing an MRI study in these patients requires robust preparation and liaison between physicist, radiographer,

electrophysiology technicians, consultant radiologist and referring clinician. Informed consent should be obtained from the patient after discussing the benefits of the MRI study and potential complications. The following radiology specific pre-requisites should be fulfilled and adhered to and these may change depending on the manufacturer of the device:• Cylindrical bore, clinical MR systems

with a static magnetic field of 1.5 T• Gradient systems with maximum

gradient slew rate performance per axis of ≤200 T m-1 per second.

• Whole body averaged specific absorp-tion rate (SAR) must be ≤2 W kg-1 and for head <3.2 W kg-1.

• Implant must consist of an MRI-compat-ible device as well as the lead. Any other leads or broken leads remain a contrain-dication.

• The pacing system should be implanted in either the right or left pectoral region and should have been in place for more than 6 weeks.

• The patient should not be positioned on his or her side within the scanner.

• Local transmit/receive coils should not be placed over the pacing system.

Prior to taking the patient into the scanner the PPM is programmed to MRI safe mode by electrophysiologists outside the MR safety zone. Once in the scanner, continuous monitoring using electrocardi-ography (ECG), pulse oximetry and blood pressure is essential. External defibrillator must be readily available and the proce-dure should be abandoned if patient’s haemodynamic function is compromised. After completing the scan, the PPM is turned back on to normal mode and the correct pacing capture threshold is ensured prior to discharging the patient.

Our patient was a young man who underwent a cardiac MRI study for cardiomyopathy. He was involved in discussions regarding the safety of the procedure and consented prior to the study. He was extremely anxious when he went into the scanner, but relaxed as the procedure went on. He did not experience any untoward sensations or arrhythmia during the 40 min study. Standard TrueFISP (true fast imaging with steady state precession) images were degraded owing to artefacts from the leads; this was rectified by switching over to FLASH (fast low angle shot) cine images. Overall the image quality was good.

We foresee that more patients will undergo MRI scanning with compatible cardiac pacing systems. Currently there is limited evidence regarding its safety and long-term effects. We, therefore, profess extreme prudence and a multidisciplinary approach prior to scanning a patient with an MRI-compatible pacemaker.

V Raj, R O’Dwyer, R Pathmanathan and R VaidhyanathDepartments of Radiology and Cardiology, Glenfield Hospital, Leicester, UK

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Performing an MRI study in these patients requires robust preparation and liaison between physicist, radiographer, electrophysiology technicians, consultant radiologist and referring clinician


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MRI of retinoblastoma

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Retinoblastoma (RB) is the most common intraocular tumour of childhood. It is a highly malignant tumour of the primi-tive neural retina. RB is one of the most challenging problems in paediatric ophthalmology and radiology because it shows different patterns of growth, extension and recurrence. RB appears as a solid echogenic mass with high echogenic foci of calcifications on ultra-sound studies. The tumour extension is not well-delineated with ultrasound. MRI should be used to answer the key clinical questions that help in the selection of an appropriate line of treatment. It can detect the growth pattern of the tumour, determine the extension of the tumour, involvement of the optic nerve and retrob-ulbar space, presence of leptomeningeal spread or existence of a second tumour. MRI is becoming an increasingly impor-tant tool for monitoring focal response to therapy. Also, it helps to differentiate RB from simulating lesions presenting with leukocoria [1–8].

The aim of this article is to review the role of MRI in RB.

incidenceRB is the most common intraocular

tumour in children and accounts for 3% of all cancers occurring in children. It occurs in 1 out of every 18 000 to 30 000 live births worldwide. The average age at diagnosis is 18 months with 80% of cases

occurring before 3–4 years old. Approxi-mately 30% are bilateral. Lesions may be synchronous, metachronous, unifocal or multifocal. No racial or sexual bias for the development of this cancer was found [9, 10].

GeneticsRB is commonly sporadic (90%) but

can be inherited (10%). Sporadic lesions usually result from spontaneous mutation. Inherited RB has an autosomal dominant pattern of inheritance with 80 to 100% penetrance. All bilateral and multifocal forms, as well as 10 to 15% of unilat-eral forms, are related to a constitutional mutation of the RB1 gene. The cause of hereditary RB is deletion or loss of function of the tumour suppressor gene RB1 on the long arm of chromosome 13 (13q14). All children with RB should have genetic analysis to establish the presence and site of the 13q mutation [2, 5, 10].

PathologyRB is a tumour of neuroectodermal

cells that become retinal photoreceptors under normal conditions. A charac-teristic finding of RB is a presence of Flexner-Wintersteiner rosettes, which are composed of cells arranged in a circular fashion around a well-defined lumen. The tumour cells can be poorly differentiated, undifferentiated or well-differentiated [1–3, 9].

clinical presentationThe most common clinical sign of

RB is leukocoria (60%) followed by stra-bismus (20%). Leukocoria is where the normal red reflex of the retina is replaced by a yellowish or greyish white colour. Strabismus is a result of macular involve-ment by the tumour. It may also present with findings like vitreous haemor-rhage, retinal detachment, angle-closure glaucoma, hyphaema, pseudohypopyon, iris heterochromia, proptosis and pseu-doorbital cellulites [2, 8, 10].

MR techniquesMRI of the globe is commonly done

at 1.5T. The head coil is commonly used; however, the application of the surface coil improves the signal-to-noise ratio (SNR) of the globe. The surface coil is a circular polarising coil with a diameter of 4 cm positioned 1 cm above the eye. Sedation with oral chloral hydrate used for infants and children 4 years of age and younger and intramuscular ketamine for children from 5 to 8 years of age is administrated [9, 10].

Fast spin echo (FSE) T2 weighted imaging is used for the evaluation of the globe, but it has limited ability to detect calcification. High-resolution three dimensional (3D) FSE T2 weighted imaging allows thin sections (0.4 mm) with high SNR that is sensitive to the detection of calcification. Gradient-echo

We review the role of MRI in

retinoblastoma and simulating lesions.

Retinoblastoma is the most common

paediatric intra-ocular tumour. It may

be endophytic, exophytic or a diffuse

infiltrating tumour. MRI can detect

intra-ocular, extra-ocular and intracranial

extension of the tumour. MRI is essential for

monitoring patients after treatment and

detection of associated second malignancies.

It helps to differentiate the tumour from

simulating lesions with leukocoria.

aBstRact

A A K A Razek and S ElkhamaryDiagnostic Radiology Department, Mansoura Faculty of Medicine, Mansoura, Egypt and Radiology Department, KhaledEye Specialist Hospital, Riyadh, Saudi Arabia


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T2 weighted imaging has been shown to be a more effective sequence to detect calci-fied structures. Pre- and post-contrast axial T1 weighted MRI with and without fat suppression are obtained. Contrast -enhanced fat suppression T1 weighted MRI after intravenous injection of 0.1 mmol kg-1 gadopentate dimeglumine is done in axial and coronal planes as well as the parasagittal plane parallel to the long axis of the optic nerve. Finally, axial post-contrast T1 weighted imaging of the brain is obtained [11–14].

The additional sequences included short tau inversion recovery (STIR) that can detect optic nerve infiltration. Constructive interference in steady state (CISS) sequence allow performance of multiplanar reconstruction to better demonstrate tumour extension [14, 15]. Diffusion weighted images of the globe

obtained using a multislice spin-echo type of echo-planar imaging sequence with a gradient factor, b, of 0 and 1000 s mm-2. Application of parallel imaging has the potential to produce better quality diffu-sion weighted MRI and ADC maps.

Three tesla MRI with dedicated multichannel head and neck coils will result in substantially higher contrast and SNR compared with 1.5T scanner [16]. It has higher ability to visualise findings on T2 weighted images such as vitreous seedings, higher contrast and SNR on post-contrast T1 weighted images, and increased ability for 3D acquisitions with thin sections and higher resolution to better evaluate the optic nerve and the orbit.

MRi appearanceAt T2 weighted imaging, the tumour is

usually dark compared with the vitreous. The partially calcified areas may appear as hypointense foci within the tumour on gradient-echo T2 weighted and 3D FSE T2 weighted images. On T1weighted imaging, RB is slightly hyperintense to the vitreous. The vitreous may be abnor-mally bright on T1 weighted images because of increased globulin content and a decreased ratio of albumin to globulin that occurs with malignancy. The tumour shows moderate to marked enhancement. On enhanced T1 weighted images, finely dispersed areas of very low signal inten-sity became visible inside the tumour that correspond to areas of calcification [9–13]. The tumour shows restricted diffusion on diffusion weighted imaging at high b-values. It exhibits low ADC values in contrast to the high intensity of the vitreous in the ADC maps. RB is a round cell type tumour that is typically poorly differentiated, tightly packed and high nuclear-cytoplasmic ration, which is like to account for the low ADC value.

Anterior eye segment (AES) enhancement may be seen in patients with RB. AES enhancement is a hallmark of advanced RB because its degree correlates with tumour volume and optic nerve invasion. The degree

of abnormal AES enhancement may be moderate (36%) or strong (33%). The degree of abnormal AES enhancement reflects angiogenesis, hyperaemia and inflammation in the iris [17–19].

The tumour may be unifocal or multifocal within the same eye. MRI measurements of axial length, equatorial diameter and eye volume are signifi-cantly smaller in eyes with RB than in normal eyes. In addition, in patients with RB, the larger the tumour volume, the smaller the eye [20].

Growth pattern of retinoblastoma

Endophytic growthThe tumour arises from inner layers

of the retina and grows into the vitreous. Small clusters of viable tumour cells may detach from the mass, producing multiple floating tumour islands throughout the globe called vitreous seeding. The presence of a vitreous seed has a poor prognostic value. In up to 63% of patients, vitreous seeding may be identified as T1 bright and T2 dark foci in the vitreous cavity [1, 11, 14].

Exophytic growthThe tumour starts in the outer layers

and grows into the sub-retinal space, which causes non-rhegmatogeneous retinal detachment with sub-retinal exudate and possible sub-retinal tumour seeding [2, 13, 14].

Diffuse infiltrating growthThe tumour grows along the retina,

appearing as a placoid mass, simu-lating inflammatory or haemorrhagic conditions. This is a rare (1–2%) form of RB that presents at advanced age (6 years) and more frequently in boys (M:F=1.8:1). It is unilateral and sporadic. The absence of a discrete mass and lack of calcium deposits make diag-nosis difficult. Cells may be discharged into the vitreous and seed the anterior chamber, mimicking an inflamma-tory process (pseudohypopyon). It commonly presents with pseudohy-

Retinoblastoma. Axial high-resolution three dimensional T2 weighted image shows low signal intensity left intraocular mass with a few signal void regions that correspond to areas of calcification

Anterior segment eye enhancement. Axial contrast T1 weighted image shows enhancement (arrows) of anterior segment in a patient with retinoblastoma (RB), which may be due to extension of RB or a tumour-induced angiogenesis in the iris.


Prognostic valueThe risk factors for poor prognosis

and metastasis of RB include invasion to the post-laminar optic nerve, massive invasion of ocular coats (choroid and sclera), vitreous seeds and AES enhance-ment, or bilaterally of the disease. If the tumour is confined to the globe, 5 year survival is over 90%, whereas if the tumour extends outside the globe, the mortality is over 90% [19–24].

Bilateral, trilateral and quadrilateral retinoblastoma

Bilateral RB represents the heredi-tary form of RB and occurs in 30% of patients. Trilateral RB refers to the occurrence of bilateral ocular RBs and primitive midline neuroectodermal tumour arising in the pineal region or the suprasellar cistern; trilateral RBs represent 1.5–5% of patients with RB. Tetralateral RBs present bilateral ocular RB and tumour in both suprasellar and pineal regions [1, 4, 26].

Associated brain abnormalitiesPineoblastoma (5.5%) is associated

with hereditary RB and structural brain abnormalities, such as corpus callosum agenesis. The Dandy-Walker variants are


25

popyon (59%) and can be associated with leukocoria (24%). On MRI, there is often retinal detachment without a discrete mass lesion. Diffuse irregular and nodular thickening of the detached retinal leaflets is evident, with abnormal enhancement that often extends to the anterior eye segment [3, 21].

Phthisis bulbi is a term to describe a shrunken non-functioning globe with extensive intraocular calcifications. RB presents rarely (2%) with phthisis bulbi in one eye and buphthalmos of the other eye owing to secondary glaucoma [1].

Extension of retinoblastomaRB commonly spreads by direct

extension; however, haematogenous and lymphatic dissemination have been reported. In the staging of RB, MRI should include evaluation of intra-ocular extension (choroids or sclera) and extra-ocular (optic nerve or orbital invasion) or intracranial (leptomeningeal or brain metastases) tumour spread [22–26].

Intra-ocular extensionFocal thickening or irregularity of

the choroid may indicate focal spread of the tumour. Normal choroid has fine uniform linear enhancement. Choroidal invasion is usually associated with a higher mortality rate: slight choroidal invasion increases the mortality to 24%, and significant invasion raises the mortality to 65% [19–21].Extra-ocular extension

Pre-operative detection of optic nerve extension of RB permits the physician to alter surgical manage-ment strategies. If the optic nerve is not invaded, mortality is less than 10%. If invasion of the optic nerve passes through the lamina cribrosa, mortality rises to 15%. If there is optic nerve involvement posterior to the lamina cribrosa, mortality rises to 44%. Optic nerve thickening and enhancement are indicators of tumour invasion. The length of optic nerve enhancement is a useful criterion to increase the speci-ficity of MRI, as the enhancing segment of post-laminar invasion is longer (≥2 mm) than those associated with poste-rior bulging of the lamina cribrosa (˂2 mm). The optic nerve appears thickened with an irregular outline. Abnormally high enhancement is seen within and around the affected nerve [22–24].

Orbital extension of RB develops in less than 10% of patients and is asso-ciated with a higher mortality rate. Orbital extension of RB may be through the choroidal vasculature or the optic nerve [19–21].

Intracranial extensionRB may extend into the suprasellar

region via the optic nerve [24]. Cerebro-spinal fluid seeding by RB commonly presents with diffuse leptomeningeal enhancement in the subarachnoid and intrathecal spaces [25]. Brain metastasis may occur in late stages of the disease and may be haemorrhagic [26].

Distant metastasisThe risk of distant metastasis markedly

increases with extra-ocular extension. Tumours in the orbit, conjunctiva or eyelid may gain access to blood and lymphatic vessels. Haematogenous metastases are found in the lungs, skull, distal bones and brain, while lymphatic metastases may be found in regional lymph nodes. Most cases of metastatic RB develop within 2 years following the original diagnosis, and late metastasis are rare [2, 9, 10].

Diffuse retinoblastoma. contrast T1 weighted image at 3 Tesla with surface coil shows diffuse infiltrative placode lesion with retinal detachment (arrow).

Retinoblastoma (RB) with choroidal invasion. coronal contrast T1 weighted image shows focal choroidal thickening and enhancement along the superior aspect of RB on both sides (arrows).


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restricted to patients with the 13q deletion syndrome. The incidence of pineal cysts (2.2%) in patients with RBs is similar to that in healthy children and is not associ-ated with hereditary RB [27].

Post-treatmentThe treatment of RB depends on

several parameters: tumour volume, tumour position, intraocular tumour extension, extra-ocular stage of disease and laterality of the tumour. Conserva-tive treatment with preservation of the useful vision of the eye applied in the early stages of small RB. Most children with unilateral RB are treated with eye enucleation followed with adjuvant therapy, while children with bilateral RB are treated with chemoreduction and thermotherapy [9, 10].

RecurrenceMRI has an important tool for moni-

toring focal response to therapy and development of recurrent tumours. The growth patterns of recurrent RB may be intraocular tumour (Type A), intraor-bital tumour with local spread into the optic nerve (Type B) or tumour exten-sion to the lateral aspect of orbit and invading brain via sphenoidal bone (Type C) [28]. There are difficulties in the evaluation for post-treatment recur-rence, such as post-operative changes/scar, artefacts from prostheses, metallic hardware and atrophy of the optic nerve on the side of globectomy.

Second primary malignancySecond primary malignancy is

commonly seen in heritable forms of RB. It occurs in association with radia-tion treatment or can be an independent process. The risk of developing a second primary tumour increases from 20% within 10 years to over 90% at 30 years. The secondary tumours may be mesen-chymal tumours, including osteogenic sarcoma, chondrogenic sarcoma, fibrosar-coma and malignant fibrous histiocytoma. Periodic imaging surveillance of the orbit for local recurrence and for detection of second malignancies is very useful [29].

Hour-glass deformityCharacteristic facial deformities

following irradiation during infancy occurs in patients with bilateral RBs. This includes hypotelorism, enoph-thalmos, depressed temporal bones, atrophy of the temporalis muscles and a depressed nasion. These distinctive features are termed the hour-glass facial deformity [30].

Differentiation from simulating lesions RB must be differentiated from other

intraocular lesions presenting with leuko-coria. The commonest cause of leukocoria is RB (56–72%) but other causes include persistent hyperplastic primary vitreous (19–28%), coloboma (11.5%), sclerosing endophthalmitis (6.5–16%), Coats’ disease (4–16%), retinal astrocytoma (3%), medulloepithelioma, retinal dysplasia in the form of Walker-Warburg syndrome and Noirre syndrome as well as retrolental fibroplasias of prematurity [8–10].

Coats’ diseaseCoats’ disease is a primary congenital,

non-familial idiopathic vascular anomaly of the retina. It is characterised by telan-giectatic, leaky retinal vessels that lead to progressive retinal exudates. It usually occurs in young males (70%) with an incidence peak at age 6–8 years. It is mostly unilateral (90%). Patients present with leukocoria, strabismus, failed school screening or painful glaucoma. The MRI

findings are retinal detachment without intraocular mass. The lipoproteinaceous sub-retinal exudation is usually seen as a mild to moderate hyperintense signal on T1 and T2 weighted MRI. There is enhance-ment along the leaves of the detached retina denoting presence of abnormal vessels. Proton MR spectroscopy of the lipoproteinaceous exudates shows a large peak at 1–1.6 ppm [31–34].

Persistent hyperplastic primary vitreousPersistent hyperplastic primary

vitreous is caused by the failure of the embryonic hyaloid vascular system to regress normally and extensive prolifera-tion of embryonic connective tissue. It is commonly unilateral (90%) but may be bilateral in patients with retinal dysplasia. It is characterised by a leukocoria in a microphthalmic eye. MR shows microph-thalmia; however, the eye can be normal in size or even buphthalmos in a patient with glaucoma. An enhanced triangular or tubular retrolental tissue that represents the persistent foetal tissue in the hyaloid canal (also known as the Cloquet’s canal) is a characteristic finding. The tissue may extend into the hyaloid canal, giving a

Retinoblastoma with orbital extension. Axial T2 weighted image shows right ocular mass with diffuse retro-orbital extension.

Second primary osteosarcoma. Axial contrast T1 weighted image shows intense enhanced osteosarcoma in left sphenoid bone in a patient previously treated with radiation and surgery for a right retinoblastoma (image courtesy of Dr Mauricio castillo).



27

triangular shape. The vitreous is hyper-intense with fluid-fluid levels owing to a sedimentation effect within the sub-retinal and sub-hyaloid haemorrhagic exudates. Other findings include an anterior displaced lens, small irregular lens and shallow anterior chamber [35–37].

Norrie diseaseNorrie disease is a rare X-linked

recessive syndrome consisting of retinal malformation, deafness, and mental retar-dation. Female carriers are completely healthy. The ocular changes in male patients, including retinal detachments and vitreoretinal haemorrhage. MRI shows bilateral microphthalmia with hyperintense vitreous, caused by chronic vitreous or sub-retinal haemorrhage. It may be associ-ated with bilateral persistence hyperplastic primary vitreous, hypoplastic optic nerves, abnormal lenses and developmental anom-alies of the brain [38–39].

Walker-Warburg syndromeWalker-Warburg syndrome is an auto-

somal recessive disorder caused by an abnormality of chromosome 9q34 that is characterised by profound hypotonia and ocular lesions in the form of micro-phthalmia and retinal non-attachment. MRI shows bilateral retinal detachment, sub-retinal or vitreous haemorrhage and gravitational intravitreal fluid. The congenital non-attached retina or the totally detached retina exhibits a character-istic narrow funnel shape, or a triangular intravitreal mass adjacent to hyaloid canal. Brain anomalies include diffuse cobble-stone lissencephaly and unmyelinated white matter with hydrocephalus [39–40].

Sclerosing endophthalmitis Sclerosing endophthalmitis is a granu-

lomatous chorioretinitis uveitis that devel-ops secondary to a Toxocara canis infesta-tion. It affects patients over the age of 5 years bilaterally in 85% of cases. On MRI, a central vitreous mass appears isointense to vitreous on T1 weighted images and iso- or hypointense relative to vitreous ac-cording to fibrosis. There is a moderate to

marked enhancement of the granuloma. Associated exudative sub-retinal fluid can be present with variable hyperintensity on T1 weighted and T2 weighted scans. It dif-fers from RB by its central position, it is hyperintense to vitreous on T2 weighted images, the patient age and a positive se-rologic enzyme-linked immunosorbent assay (ELISA) [10–11].

Tuberculous endophathalmitisOcular tuberculosis results from

endogenous spread from systemic foci. Chorioretinitis and uveitis are the most common type. Most patients have a chronic course of visual disturbance. On imaging, ocular tuberculosis usually manifests as a unilateral choroidal mass that shows contrast enhancement. The mass can fill the entire vitreous cavity and extend to the extraocular space in advanced cases [41].

MedulloepitheliomaMedulloepithelioma is a rare primary

malignant non-hereditary embyrogenic intraocular tumour that commonly arises from the ciliary body and rarely from retina or optic nerve. The mean age at diagnosis is 5 years. There is no known gender or racial predilection. The most common signs are leukocoria and a mass of the iris or ciliary body. This tumour is divided into non-tera-toid (60%) and teratoid (40%) histological subtypes. The tumour frequently extends locally to involve the iris or the adjacent anterior retina and may grow into the vitreous and invade through the cornea or sclera. MRI shows a mass localised to the ciliary body that is slightly to moderately hyperintense to vitreous on T1 weighted images and hypointense on T2 weighted images. The tumour shows marked homoge-neous or heterogeneous enhancement [42].

Retinal astrocytic hamartomaRetinal astrocytoma is a rare, benign

retinal low grade tumour or hamartoma that can arise from the nerve fibre of the retina or optic nerve. It can present as an isolated lesion or in association with tuberous sclerosis or neurofibromatosis.

It develops in 15% of patients who have tuberous sclerosis. It is associated with tuberous sclerosis in 50% and neurofi-bromatosis Type I in 14%. It may be associated with an exudative retinal detachment, haemorrhage and calcifica-tion. Unlike RB, it rarely grows in size and if it does, only modestly [2, 10, 11].

Retinopathy of prematurityRetinopathy of prematurity is seen in

premature, low birth weight infants. It used to be related to excessive oxygen therapy that was previously used to treat hyaline membrane disease, but it is now uncommon owing to the advent of exogenous surfactant therapy. It is usually bilateral and fairly symmetric. In early stages, the eyes may be microphthalmic. Hyperintense vitreous on T1 and T2 weighted images is common, which is a result of chronic haemorrhage. Phthisis bulbi may be the end result for the most severely affected. Calcifications may occur. Patient history, clinical findings, bilaterality and associated periventricular leukomalacia may be seen in the brain and are usually suggestive of a diagnosis [9–10].

conclusionMRI is essential for initial diagnosis,

extension, staging and treatment planning of RB. It has been used in follow-up and to monitor patients after treatment as well as differentiating RB from simulating lesions in paediatric patients with leukocoria.

Download the full article and references DOi: 10.1259/bjr/32022497

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Norrie disease. Axial T2 weighted image shows a fluid level with associated persistent hyperplastic primary vitreous (arrows). (courtesy of Dr Mauricio castillo)

aBstRacts


the BRItIsh JouRnaL of RaDIoLogy aBstRacts www.bir.org.uk

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head and neck MRI of kimura disease

Lowering heart rate with an optimised breathing protocol for prospectively ecg-triggered ct coronary angiography

Objectives: The purpose of our study was to describe the MR appearance of Kimura disease and to interpret the differences in appearance from malignant parotid gland tumours.

Methods:MR studies of seven patients with Kimura disease were reviewed. The MR studies included T1 weighted, T2 weighted, short tau inversion recovery, diffusion-weighted (DW) and dynamic contrast-enhanced imaging.

Results:Typical Kimura disease featured subcutaneous lesions, continuously infiltrated parotid lesions from the subcutaneous lesions with or without intraparotid lymphadenopathies, and reactive cervical lymphadenopathies. The subcutaneous lesions showed gradual upward enhancement on dynamic contrast-enhanced MR images. Reactive lymph nodes showed early enhancement on contrast-enhanced MR images and marked high-intensity and low apparent diffusion coefficient values on DW images.

conclusion:An indication for making the diagnosis of Kimura disease should be the subcutaneous tissue of the head and neck showing gradual upward enhancement on dynamic contrast-enhanced MRI and a lack of high intensity on DW images, associated with reactive lymph nodes.

Objectives: The aim was to prospectively characterise the effect of the level of breathhold on heart rate in CT coronary angiography (CTCA) with prospective electrocardiogram (ECG) triggering and its impact on coronary artery attenuation.

Methods:260 patients (86 women; mean age 59±11 years) underwent 64-slice CTCA using prospective ECG triggering. Prior to CTCA, heart rates were recorded during 15 s of breath-hold at three different levels of inspiration (normal, intermediate and deep). The inspiration level with the lowest heart rate was chosen for actual CTCA scanning. Coronary artery attenuation was measured, and the presence of backflow of contrast material into the inferior

vena cava (as an indicator of increased intrathoracic pressure) was recorded.

Results: The mean heart rate at breath-hold was significantly different for the three inspiration levels (normal, 60±8 bpm; intermediate, 59±8 bpm; deep, 57±7 bpm.; p<0.001). The maximum heart rate reduction in each patient at breath-hold averaged 5.3±5.1 bpm., and was observed at a normal inspiration depth in 23 (9%) patients, at an intermediate inspiration depth in 102 (39%) patients and at deep inspiration in 135 (52%) patients. Overall, there was no association between the level of breath-hold and coronary vessel attenuation (p=ns). However, the backflow of contrast material into the inferior vena cava (n=26) was found predominantly at deep inspiration levels (p<0.001), and,

when it occurred, it was associated with reduced coronary attenuation compared with patients with no backflow (p<0.05).

conclusion:The breath-hold level best reducing heart rate for CTCA should be individually assessed prior to scanning, as a mean heart rate reduction of 5 bpm can be achieved.

T Horikoshi, K Motoori, T ueda, R Shimofusa, T Hanazawa, y Okamoto and H itoDepartment of Radiology, Chiba University Hospital, Chiba City, Chiba, Japan

Download the full length article: DOi: 10.1259/bjr/42012793

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L Husmann, B A Herzog, A P Pazhenkottil, R R Buechel, R Nkoulou, J R Ghadri, i Valenta, i A Burger, O Gaemperli, c A Wyss and P A KaufmannCardiac Imaging, University Hospital Zurich, Zurich, Switzerland


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the BRItIsh JouRnaL of RaDIoLogy aBstRactswww.bir.org.uk

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hysterosalpingogram: an essential examination following essure hysteroscopic sterilisation

Right thoracic paravertebral anaesthesia for percutaneous radiofrequency ablation of liver tumours

Objectives: The aim of this study was to describe our experience of imaging following hysteroscopic sterilisation with the Essure (Conceptus Inc., Mountain View, San Carlos, Ca) microinsert, and to underline the importance of a carefully performed follow-up hysterosalpingogram (HSG) in the management of these patients.

Methods: 18 women underwent the procedure and all returned for follow-up HSG. A standard HSG technique was used and views were acquired to establish microinsert position and tubal occlusion.

Results: In 16 of the 18 women adequate microinsert positioning and bilateral tubal occlusion was present. In one woman, a unilateral microinsert occluded the fallopian tube, whereas the other fallopian tube was ligated with a clip. The final patient underwent two studies; both showed well-positioned microinserts but unilateral free spill from the right fallopian tube. There are no reported pregnancies thus far.

conclusion: Essure sterilisation coils have a unique appearance when radiographed and are an effective means of permanently occluding the fallopian tubes. HSG is a rapid and safe method of confirming satisfactory placement and tubal occlusion. Non-HSG imaging techniques are suboptimal at detecting patent fallopian tubes and exposed patients to the risk of an unwanted and potentially complicated pregnancy.

Objectives: Percutaneous radiofrequency ablation (PRFA) of liver tumours performed under local anaesthesia and intravenous sedation can cause severe pain to patients. This prospective study evaluated the efficacy of a right thoracic paravertebral block (TPVB) for anaesthesia and analgesia during PRFA of liver tumours.

Methods: 220 patients, aged 44–74 years, with liver malignancies received a multiple injection TPVB at the T6–10 levels 30 min before the PRFA. An intravenous infusion of propofol (3–5 mg kg–1 h–1) was administered to patients who requested to be sedated and intravenous fentanyl (25 μg bolus) was administered as rescue

analgesia. Pain during the TPVB and PRFA was assessed using a numerical rating scale (NRS; 0, no pain; 10, worst imaginable pain). Patients were also assessed for residual pain and analgesic consumption during the 24 h after the intervention.

Results:The TPVB was well tolerated and produced ipsilateral sensory anaesthesia with satisfactory spread (median (range); 8 (6–11) dermatomes). The PRFA procedure caused mild pain (mean (standard deviation (SD)); NRS 1.4 (1.9)) during the insertion of the ablation needle and the peak pain intensity during the therapeutic burn was moderate (mean (SD); NRS 5.0 (3.3)) in severity. During

the 24 h after the PRFA, patients reported minimal pain and consumed very few analgesics. The mean (SD) satisfaction score (0, totally dissatisfied; 10, very satisfied) of the patients was 8.9 (1.1) and that of the radiologists was 8.8 (1.4).

conclusion:A right TPVB is safe and effective for anaesthesia and analgesia during PRFA of malignant liver tumours.

for more Abstracts visit: bjr.birjournals.org

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V Shah, N Panay, R Williamson, and A HemingwayDepartment of Imaging, Hammersmith and Queen Charlotte Hospitals, Imperial College Healthcare NHS Trust, London, UK


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M cheung Ning, and M K KarmakarDepartment of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong SAR, People’s Republic of China


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Multidetector ct imaging of pleura: comparison of two contrast infusion protocols

evaluation of radiation-induced changes to parotid glands following conventional radiotherapy in patients with nasopharygneal carcinoma

Objectives: Imaging of the pleura by multidetector CT (MDCT) can be challenging. There is no clear evidence or guidelines on contrast infusion parameters for imaging pleura. We compared two contrast protocols for assessing pleural pathology on MDCT.

Methods: This was a prospective study in which consecutive patients with MDCT for suspected pleural disease on chest radiograph were randomised into two groups. The first group received 150 ml of intravenous contrast at a rate of 2.5 ml s–1 and the second group received 100 ml at 2 ml s–1. Images were acquired after a 60 s delay. Hounsfield units of the pleura, thoracic aorta, main pulmonary artery, portal vein and superior mesenteric artery were measured and analysed by two independent readers.

Results: 40 patients (20 in each group) who had pleural enhancement on MDCT were included for final analysis. The mean pleural enhancement value was 83 HU (Group A) vs 59 HU (Group B) (p=0.0004). The mean aortic enhancement was 241 HU (A) vs 141 HU (B) (p<0.0001); main pulmonary artery enhancement was 208 HU (A) vs 139 HU (B) (p<0.0002); portal venous enhancement was 169 HU (A) vs 115 HU (B) (p<0.0001); and the superior mesenteric artery enhancement was 215 HU (A) vs 128 HU (B) (p<0.0001).

conclusion: Enhancement of the pleura and major vessels was significantly higher in the group receiving more contrast at a greater infusion rate. This technique of a single scan through the entire pleural surface with a delayed acquisition is promising. When pleural disease is suspected, contrast infusion protocols should be modified to achieve the best results and clinicians should be encouraged to specifically request a ‘‘pleural CT’’.

Objectives: Xerostomia is a common post-radiotherapy (post-RT) complication in nasopharyngeal carcinoma (NPC) patients. This study evaluated the relation of post-RT parotid gland changes with the dose received.

Methods:Data from 18 NPC patients treated by radiotherapy between 1997 and 2001 were collected. Parotid gland volumes were measured and compared between their pre-RT and post-RT CT images; both sets of CT were conducted with the same scanning protocol. Doppler ultrasound was used to assess the haemodynamic condition of the glands after radiotherapy. Doppler ultrasound results were compared against 18 age matched normal participants. A questionnaire was used to evaluate

the patients’ comments of xerostomia condition. Radiotherapy treatment plans of the participants were retrieved from the Eclipse treatment planning system from which the radiation doses delivered to the parotid glands were estimated. The correlations of parotid gland doses and the post-RT changes were evaluated.

Results:The post-RT parotid glands were significantly smaller (p<0.001) than the pre-RT ones. They also demonstrated lower vascular velocity, resistive and pulsatility indices (p<0.05) than normal participants. The degree of volume shrinkage and subjective severity of xerostomia demonstrated dose dependence, but such dependence was not definite in the haemodynamic changes.

conclusion:It was possible to predict the gland volume change and subjective severity of xerostomia based on the dose to the parotid glands for NPC patients. However, such prediction was not effective for the vascular changes. The damage to the gland was long lasting and had significant effects on the patients’ quality of life.

V Raj, R Kirke, M J Bankart and J J EntwisleDepartment of Radiology, Glenfield Hospital, University Hospitals of Leicester, Leicester, UK


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V W c Wu, M T c ying, and D L W KwongDepartment of Health Technology and Informatics, Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong SAR and Department of Clinical Oncology, University of Hong Kong, Pokfulam, Hong Kong SAR


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Assessing the daily consistency of bladder filling using an ultrasonic Bladderscan device in men receiving radical conformal radiotherapy for prostate cancer

Preliminary experience of a predictive model to define rectal volume and rectal dose during the treatment of prostate cancer

Objectives: Consistency in target organ and organ at risk position from planning to treatment is an important basic principle of radiotherapy. This study evaluates the effectiveness of bladder filling instructions in achieving a consistent and reproducible bladder volume at the time of planning CT and daily during the course of radical radiotherapy for prostate cancer. It also assessed the rate of bladder filling before and at the end of radiotherapy.

Methods: 30 men attending for radiation therapy planning for prostate cancer received written and verbal bladder-filling instructions. They had their bladder volume assessed using a bladder ultrasound scanner post-

void, immediately prior to planning CT scan then daily immediately prior to treatment while in the therapy position. The inflow was calculated using the void and full bladder volumes and the time for the bladder to fill.

Results: The mean bladder volume at the time of planning was 282 ml (range 89–608 ml, SD=144.5 ml). This fell during treatment with a mean value for all treatments of 189 ml (range 11–781 ml, SD = 134 ml). During radiotherapy 76% (828/1090), 53% (579/1090) and 36% (393/1090) of bladder volumes had >50 ml, >100 ml and >150 ml difference, respectively when compared with their volume at the time of planning. Inflow reduced from 4.6 ml min–1, SD=2.9 min–1 at planning to 2.5 min–1, SD=1.8 min–1 after radiotherapy.

conclusion: The Bladderscan device provides an effective means of assessing bladder volume prior to radiotherapy for prostate cancer. The evaluated bladder filling protocol does not produce consistent, reproducible bladder volumes for radiotherapy.

S Hynds, c K McGarry, D M Mitchell, S Early, L Shum, D P Stewart, J A Harney, c R cardwell, and J M O’Sullivan Radiotherapy Department, Cancer Centre, The Queen’s University, Grosvenor road, Belfast, UK


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Objectives: The aim of this study was to define a method to evaluate the total dose delivered to the rectum during the whole treatment course in six patients undergoing irradiation for prostate cancer using an offline definition of organ motion with images from a cone beam CT (CBCT) scanner available on a commercial linear accelerator.

Methods:Patient set-up was verified using a volumetric three-dimensional CBCT scanner; 9–14 CBCT scans were obtained for each patient. Images were transferred to a commercial treatment planning system for offline organ motion analysis. The shape of the rectums were used to obtain a mean dose–volume histogram (<DVH>), which was the average of the DVHs of

the rectums as they appeared in each verification CBCT. A geometric model of an average rectum (AR) was produced using the rectal contours delineated on the CBCT scans (DVHAR). To check whether the first week of treatment was representative of the whole treatment course, we evaluated the DVHs related to only the first five CBCT scans (<DVH5> and DVHAR5). Finally, the influence of a dietary protocol on the goodness of our results was considered.

Results:In all six patients the original rectal DVH for the planning CT scan showed higher values than all DVHs.

conclusion:Although the application of the model to a larger set of patients is necessary to confirm this trend, reconstruction of

a representative volume of the rectum throughout the entire treatment course seems feasible.

M D falco, M D’Andrea, D fedele, R Barbarino, M Benassi, E Giudice, E Hamoud, G ingrosso, P Ladogana, f Santarelli, G Tortorelli, and R SantoniDepartment of Diagnostic Imaging, Molecular Imaging, Interventional Radiology and Radiotherapy, Tor Vergata University General Hospital, Rome, Italy


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Quantitative evaluation of viable tissue perfusion changes with contrast-enhanced greyscale ultrasound in a mouse hepatoma model following treatment with different doses of thalidomide

MRI-based pre-planning in patients with cervical cancer treated with three-dimensional brachytherapy

Objectives:This study aimed to quantify intratumoural viable tissue perfusion with contrast-enhanced greyscale ultrasound to evaluate tumour response to antiangiogenic treatment.

Methods: H22 hepatoma-bearing mice were treated with low-dose thalidomide (Group B), high-dose thalidomide (Group C) or 0.5% carboxylmethylcellulose (Group A). Contrast-enhanced greyscale ultrasound was performed after 7 days of treatments to evaluate the percentage of non-enhanced area for each tumour; regions of interest within the enhanced area were analysed offline to determine the area under the curve (AUC), maximum intensity (IMAX), perfusion

index (PI), mean transit time (MTT), time to peak (TTP) and quality of fit (QOF). Immunohistochemical analysis was performed for evaluation of microvascular density (MVD).

Results: The percentage of non-enhanced area was significantly larger in Group C than in Groups A and B (p<0.05); however, there was no significant difference between Groups A and B. Treatment with thalidomide resulted in a significant decrease in AUC, PI and IMAX compared with Group A (p<0.05). Immunohistochemistry showed significant decreases in MVD in Groups B and C compared with Group A (p<0.05); however, there was no significant difference in MVD between Groups B

and C. MVD was positively correlated with IMAX (r=0.419, p=0.023) and PI (r=0.455, p=0.013).

conclusion: Quantitatively analysing intratumoural viable tissue perfusion enables early evaluation of tumour response to anti-angiogenic therapy before apparent changes in tumour necrosis.

Objectives: The aim of this study was to analyse the feasibility and determine the benefits of MRI-based pre-planning with CT/MRI data fusion in patients with cervical cancer treated with radical radiotherapy.

Methods: Patients underwent MRI examination prior to external beam radiotherapy and prior to the first and fourth fraction of brachytherapy with applicators in place. Insertion of applicators at the radiology department was performed under paracervical anaesthesia. The benefit of MRI pre-planning was determined by comparing conventional treatment planning with dose specification to ‘‘point A’’ and dose specification to 90% of the high-risk clinical target volume (HR-CTV D90). Tolerance of MRI evaluation with applicators, coverage of HR-CTV and

dose–volume parameters for organs at risk (OAR) has been assessed in 42 brachytherapy procedures.

Results: Insertion of applicators at the radiology department was successful in all patients and there were no complications. The target dose was higher for MRI planningthan for conventional planning (5.3 Gy vs 4.5 Gy). Maximum doses in the bladder and rectum were significantly lower (p<0.05) for MRI planning than for the conventional approach (6.49 Gy vs 7.45 Gy for bladder; 4.57 Gy vs 5.06 Gy for rectum). We found no correlation between the International Commission on Radiation Units (ICRU) point dose for OAR and the maximum dose in OAR. Nevertheless, a strong correlation between the maximum dose in OAR and the minimal dose in a volume of 2 cm3 has been observed.

conclusion: MRI-based pre-planning with consecutive CT/MRI data fusion is feasible and safe, with the advantage of increasing the dose to the tumour and decreasing the dose to the organs at risk.

J H Zhou, W Zheng, L H cao, M Liu, R Z Luo, f Han, P H Wu, and A H LiDepartments of Ultrasound, Interventional Center, State Key Laboratory of Oncology in Southern hina, Cancer Center, Sun Yat-Sen University, Guangzhou, People’s Republic of China, 510060


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M Dolezel, K Odrazka, J Vanasek, T Kohlova, T Kroulik, K Kudelka, D Spitzer, M Mrklovsky, M Tichy, J Zizka and L JalcovaOncology Centre, Pardubice Regional Hospital, Pardubice RegionalHospital, Pardubice, czech Republic


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Biodosimetric quantification of short-term synchrotron microbeam versus broad-beam radiation damage to mouse skin using a dermatopathological scoring system

Objectives: Microbeam radiotherapy (MRT) with wafers of microscopically narrow, synchrotron generated X-rays is being used for pre-clinical cancer trials in animal models. It has been shown that high dose MRT can be effective at destroying tumours in animal models, while causing unexpectedly little damage to normal tissue. The aim of this study was to use a dermatopathological scoring system to quantify and compare the acute biological response of normal mouse skin with microplanar and broad-beam (BB) radiation as a basis for biological dosimetry.

Methods:The skin flaps of three groups of mice were irradiated with high entrance doses (200 Gy, 400 Gy and 800 Gy) of MRT, and BB and low dose BB (11 Gy, 22 Gy and

44 Gy). The mice were culled at different time points post-irradiation. Skin sections were evaluated histologically using the following parameters: epidermal cell death, nuclear enlargement, spongiosis, hair follicle damage and dermal inflammation. The fields of irradiation were identified by cH2AX-positive immunostaining.

Results:The acute radiation damage in skin from high dose MRT was significantly lower than from high dose BB and importantly, similar to low dose BB.

conclusion:The integrated MRT dose was more relevant than the peak or valley dose when comparing with BB fields. In MRT-treated skin, the apoptotic cells

of epidermis and hair follicles were not confined to the microbeam paths.

screening for atherosclerotic plaques in the abdominal aorta in high-risk patients with multicontrast-weighted MRI: a prospective study at 3.0 and 1.5 tesla

Objectives: This prospective study compares MRI of atherosclerotic plaque in the abdominal aorta at 3 T with that at 1.5 T in patients suffering from hereditary hyperlipidaemia, a major risk factor for atherosclerosis.

Methods: MRI of the abdominal aorta at 1.5 and 3 T was performed in 21 patients (mean age 58 years). The study protocol consisted of proton density (PD), T1, T2 and fat-saturated T2 weighted black blood images of the abdominal aorta in corresponding orientation. Two independent radiologists performed image rating. First, image quality was rated on a five-point scale. Second, atherosclerotic plaques were scored according to the modified American Heart Association (AHA) classification

and analysed for field strength-related differences. Weighted κ statistics were calculated to assess interobserver agreement.

Results: Interobserver agreement was substantial for nearly all categories. MRI at 3 T offered superior image quality in all contrast weightings, most significantly in T1 and T2 weighted techniques. Plaque burden in the study collective was unexpectedly moderate. The majority of plaques were classified as AHA III lesions; no lesions were classified above AHA V. There was no significant influence of the field strength regarding the AHA classification.

conclusion: Abdominal aortal plaque screening isbasically feasible at both field strengths, whereas the image quality is rated superior

at 3 T. However, the role of the method in clinical practice remains uncertain, since substantial findings in the high-risk collective were scarce.

J-H Buhk, A-K finck-Wedel, R Buchert, P Bannas, B Schnackenburg, f u Beil, G Adam, and c WeberDepartments of Diagnostic and Interventional Radiology Medical Clinic, University Medical Center Hamburg Eppendorf, Hamburg, Germany


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R c u Priyadarshika, J c crosbie, B Kumar and P A W Rogers, Department of Pathology, Southern Health, Monash Medical Centre, Clayton, Victoria, Australia


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the value of diffusion-weighted MRI in the diagnosis of malignant and benign urinary bladder lesions

Objectives: The aim of this study was to investigate the role of diffusion-weighted MRI (DWI) in the diagnosis of urinary bladder (UB) tumours by means of measuring apparent diffusion coefficient (ADC) values.

Methods: A total of 83 people aged between 18 and 86 years were included in the study: 63 patients with UB pathology (46 malignant, 17 benign) constituted the case group; 20 individuals without any UB pathology constituted the control group. DWI was applied to all individuals. The ADC values were measured based on the tissue of the UB mass entities and normal UB wall in the control group.

Results: The mean ADC value in the UB carcinoma group was significantly lower than that in the control group: 1.0684±0.26 × 10-3 mm2 s–1 and 2.010±0.11 × 10-3 mm2 s–1, respectively (p<0.01). There was a significant difference among the mean ADC values of different grades of malignant tumours, corresponding to 0.9185±0.20 mm2 s–1 and 1.281±0.18 mm2 s–1 in high-grade and low-grade malignant UB carcinomas, respectively (p<0.01). The ADC value in the carcinoma group was significantly lower than that in the benign lesion group: 1.0684±0.26 × 10-3 mm2 s–1 and 1.803±0.19 × 10-3 mm2 s–1, respectively (p<0.01). All 46 malignant lesions displayed a restriction in diffusion; 4 of the 17 benign lesions displayed a mild restriction in diffusion.

The sensitivity, specificity and accuracy of DWI in the diagnosis of malignant UB lesions was 100%, 76.5% and 93.65%, respectively.

conclusion: DWI can be beneficial in the differentiation of benign and malignant UB lesions, as well as of high-grade and low-grade UB carcinomas, using quantitative ADC measurements.

S Avcu, M N Koseoglu, K ceylan, M Dbulutand and O unalDepartment of Radiology, School of Medicine, Yuzuncu Yil University, Van, Turkey


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Monte carlo radiotherapy simulations of accelerated repopulation and reoxygenation for hypoxic head and neck cancer

Objectives: A temporal Monte Carlo tumour growth and radiotherapy effect model (HYP-RT) simulating hypoxia in head and neck cancer has been developed and used to analyse parameters influencing cell kill during conventionally fractionated radiotherapy. The model was designed to simulate individual cell division up to 108 cells, while incorporating radiobiological effects, including accelerated repopulation and reoxygenation during treatment.

Methods:Reoxygenation of hypoxic tumours has been modelled using randomised increments of oxygen to tumour cells after each treatment fraction. The process of accelerated repopulation has been modelled by increasing the symmetrical stem cell

division probability. Both phenomena were onset immediately or after a number of weeks of simulated treatment.

Results:The extra dose required to control (total cell kill) hypoxic vs oxic tumours was 15–25% (8–20 Gy for 562 Gy per week) depending on the timing of accelerated repopulation onset. Reoxygenation of hypoxic tumours resulted in resensitisation and reduction in dose required by approximately 10%, depending on the time of onset. When modelled simultaneously, accelerated repopulation and reoxygenation affected cell kill in hypoxic tumours in a similar manner to when the phenomena were modelled individually; however, the degree was altered, with non-additive results. Simulation results were in good agreement with

standard linear quadratic theory; however, differed for more complex comparisons where hypoxia, reoxygenation as well as accelerated repopulation effects were considered.

conclusion:Simulations have quantitatively confirmed the need for patient individualisation in radiotherapy for hypoxic head and neck tumours, and have shown the benefits of modelling complex and dynamic processes using Monte Carlo methods.

W M Harriss-Phillips, E Bezak, and E K yeoh Department of Medical Physics, Royal Adelaide Hospital Cancer Centre, Adelaide, SA, Australia


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a method to produce and validate a digitally reconstructed radiograph-based computer simulation for optimisation of chest radiographs acquired with a computed radiography imaging system

Objectives: The purpose of this study was to develop and validate a computer model to produce realistic simulated computed radiography (CR) chest images using CT data sets of real patients.

Methods: Anatomical noise, which is the limiting factor in determining pathology in chest radiography, is realistically simulated by the CT data, and frequency dependentnoise has been added post-digitally reconstructed radiograph (DRR) generation to simulate exposure reduction. Realistic scatter and scatter fractions were measured in images of a chest phantom acquired on the CR system simulated by the computer model and added post-DRR calculation.

Results: The model has been validated with a phantom and patients and shown to provide predictions of signal-to-noise ratios (SNRs), tissue-to-rib ratios (TRRs: a measure of soft tissue pixel value to that of rib) and pixel value histograms that lie within the range of values measured with patients and the phantom. The maximum difference in measured SNR to that calculated was 10%. TRR values differed by a maximum of 1.3%.

conclusion: Experienced image evaluators have responded positively to the DRR images, are satisfied they contain adequate anatomical features and have deemed them clinically acceptable. Therefore,

the computer model can be used by image evaluators to grade chest images presented at different tube potentials and doses in order to optimise image quality and patient dose for clinical CR chest radiographs without the need for repeat patient exposures.

c S Moore, G P Liney, A W Beavis, and J R SaundersonRadiation Physics Department, Queen’s Centre for Oncology and Haematology, Castle Hill Hospital, Hull and East Yorkshire Hospitals, Castle Road, Hull, UK


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conventional 3D staging pet/ct in ct simulation for lung cancer: impact of rigid and deformable target volume alignments for radiotherapy treatment planning

Objectives: Positron emission tomography (PET)/CT scans can improve target definition in radiotherapy for non-small cell lung cancer (NSCLC). As staging PET/CT scans are increasingly available, we evaluated different methods for co-registration of staging PET/CT data to radiotherapy simulation (RTP) scans.

Methods: 10 patients underwent staging PET/CT followed by RTP PET/CT. On both scans, gross tumour volumes (GTVs) were delineated using CT (GTVCT) and PET display settings. Four PET-based contours (manual delineation, two threshold methods and a source-to-background ratio method) were delineated. The CT component of the staging scan was co-registered using

both rigid and deformable techniques to the CT component of RTP PET/CT. Subsequently rigid registration and deformation warps were used to transfer PET and CT contours from the staging scan to the RTP scan. Dice’s similarity coefficient (DSC) was used to assess the registration accuracy of staging-based GTVs following both registration methods with the GTVs delineated on the RTP PET/CT scan.

Results: When the GTVCT delineated on the staging scan after both rigid registration and deformation was compared with the GTVCT on the RTP scan, a significant improvement in overlap (registration) using deformation was observed (mean DSC 0.66 for rigid registration and 0.82 for deformable registration, p=0.008). A similar comparison

for PET contours revealed no significant improvement in overlap with the use of deformable registration.

conclusion: No consistent improvements in similarity measures were observed when deformable registration was used for transferring PET-based contours from a staging PET/CT. This suggests that currently the use of rigid registration remains the most appropriate method for RTP in NSCLC.

G G Hanna, J R Van, S O Rnsen De Koste, K J carson, J M O’Sullivan, A R Hounsell, and S Senan Department of Radiotherapy, VU University Medical Center, De Boelelaan 1117, Postbox 7057,1007 MB, Amsterdam, The Netherlands

www Download the full length article: DOi: 10.1259/bjr/29163167




Disease control using low-dose-rate brachytherapy is unaffected by comorbid severity in oral cancer patients

Objectives: The aim of this study was to evaluate the outcome and complications of low-dose-rate brachytherapy (LDR-BT) for oral cancer according to comorbidity.

Methods:The records of a total of 180 patients who received LDR-BT for T1-2N0M0 oral cancers between January 2005 and December 2007 were analysed. The comorbidities of the patients were retrospectively graded according to the Adult Comorbidity Evaluation-27, and the relationships between the comorbidity grades and survival, disease control and the incidence of complications were analysed.

Results:The 2 year overall survival rates of patientswith no comorbidity, Grade 1, Grade 2 and Grade 3 comorbidity were 87%, 85%, 76% and 65%, respectively, and the reduction in the survival rate according to comorbid severity was significant in a univariate analysis (p = 0.032) but not in amultivariate analysis including other clinical factors. Cause-specific survival, locoregional control and local control were not related to the comorbidity grade, or any other clinical factors. Grade 2 or 3 complications developed in 27% of the patients. The incidence of complications was unrelated to the comorbidity grade.

conclusion:The disease control of oral cancer and the incidence of complications after LDR-BT were not related to comorbid severity. LDR-BT is a useful and safe treatment for patients regardless of the presence of severe comorbidity.

R yoshimura, H Shibuya, K Hayashi, K Toda, H Watanabe and M Miura Department of Diagnostic Radiology and Oncology, Head and Neck Reconstruction Division, Graduate School, Tokyo, Japan


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To view these and the rest of the abstracts available this month visit The British Journal of Radiology online at http://bjr.birjournals.org/

coMMIttee appLIcatIonswww.bir.org.uk


The committee embraces the multi-disciplinary nature of the institute and invites applications from all profes-sional groups involved in clinical or pre-clinical MRI at any stage of their career.

The term of office is typically three years and during that time you will get experience in developing educational programs, reviewing national and inter-national MR policy as well as enjoying contributing to one of the institute’s vibrant committees. We meet three times a year, typically twice in London and once by teleconference.

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Please apply by sending a short resume of key reasons for seeking membership. Ideally you would high-light relevant experience (including publications) and whether you are able to represent a particular MR related professional community.

call for British Institute of Radiology committee member applications

tate teaching and research in clinical oncology and related professions. The strength of the multidisciplinary ethos is seen in the scientific meetings organ-ised. Within the BIR the committee advises council on matters relating to oncology and responds and advises on documents from other bodies.

We are looking for people who will become enthusiastic and active committee members. The term of office is typically three years and the committee meets three times a year, twice by telephone conference and once in London.


Please apply by sending a short resume of key reasons for seeking membership. Ideally you would high-light relevant experience (including publications).

Magnetic resonance committeeWe are looking for people who will

be enthusiastic and active committee members. The committee is responsible for organising scientific and educational meetings as well as contributing to reports and publications for the institute. The committee also provides comment and advice regarding regulatory and research developments relating to MRI.

We are particularly keen to attract members interested in helping us to develop and establish an annual modular MRI educational course based in London.

All applications should be a maximum of 500 words and submitted in the form of a MS Word document to Lucy Stewart ([email protected]). Applicants should include full contact details. Non-members of the institute are welcome to apply, provided they become Full Members of the BIR prior to their first committee meeting.

The British Institute of Radiology welcomes applications for the radiation physics and dosimetry committee, magnetic resonance committee and oncology committee

Radiation physics and dosimetry committeeWe are looking for people who

will become enthusiastic and active committee members. The committee is responsible for organising scientific and educational meetings as well as creating working parties that contribute reports and publications for the institute. We aim to embrace the multi-disciplinary nature of the institute and would like applications from a variety of professionals who are at any stage of their career.

The term of office is typically three years and during that time you will get experience in managing meetings as well as enjoying contributing to one of the institute’s vibrant committees. We meet three times a year, twice by phone conference and once in London.


Please apply by sending a short resume of key reasons for seeking membership. Ideally you would high-light relevant experience (including publications).

Oncology committeeThe BIR oncology committee is

a multidisciplinary group of clini-cians, physicists, radiographers and oncology nurses. The group not only represents a spectrum of disciplines, but also specialists within the disci-plines, including education, research and site specialists. The overall aim of the committee is to promote and facili-

SEPTEMBERPACS the 2nd Time Around!26 September 2011 BIR, LondonDon’t miss out on our early bird discount, book now to register for just £95! (valid until 31 August 2011)

OCTOBEREast of England Branch Annual Meeting1 October 2011 Addenbrooke’s Hospital, Cambridge Developments in Treatment of Head & Neck Cancer with Chemotherapy, Biological Agents and Radiotherapy7 October 2011 BIR, London Linking Orthopaedics and Radiology – The Plain Film Revisited II: The Upper Limb13 October 2011 BIR, London BIR Welsh Branch Annual Meeting14-15 October 2011 The Princess of Wales Hospital, Bridgend The BIR UK MRI Course (incorporating the Somerset MRI course)17-20 October 2011 BIR, LondonThe BIR presents its’ first multi-day MRI training course Dispelling the Myths of Managed Equipment Service27 October 2011 BIR, LondonDon’t miss out on our early bird discount, book now to register for just £95! (valid until 31 August 2011)

BIR and SCoR’s Retired Members Day28 October 2011 BIR, London

NOVEMBER The Journey from Research to Publication18 November 2011 BIR, London DECEMBERClinical Imaging of the Head and Neck2 December 2011 BIR, London In-Vivo Dosimetry and Dose Guided Radiotherapy8-9 December 2011 BIR, London Chernobyl 25 years on: Consequences, Actions and Thoughts for the Future12 December 2011 BIR, London

The Future of Radiology in the NHS: Top Topics for Interviews 16 December 2011 BIR, London

CPD accredited by

and The Royal College of Radiologists

For more information and to register visit www.bir.org.uk

Registered Charity No: 215869

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BJR Advert 2 Oct.indd 1 10/08/2011 12:19:22

BIR NEWSBIR newswww.bir.org.uk

39

During the autumn our newly-formed Education Department, led by Education Manager Sarah Adibi, will be running an interesting and diverse range of scientific meetings and courses for our members and other radiologists, radiographers, medical physicists and those in training.

BiR uK MRi courseLater this month we will be launching

the British Institute of Radiology (BIR) UK MRI course, which will amalgamate the Somerset MRI course with elements of our own well-received “MR physics without the pain!” programme. This four-day course of intensive, interactive MR workshops will focus on all areas of MRI and is underpinned by relevant and accessible MR physics and updates on technology. It will be an essential teaching resource for radiologists and radi-ographers along with scientists and industry representatives wishing to learn more about clinical applications. With an internation-ally renowned faculty, this is a meeting that cannot be missed! This course allows you to choose which components you attend; if

your diary doesn’t allow you to attend all four days (17-20 October), attend those you can and then join us for the rest in 2012.

The journey from research to publicationOn 18 November, the BIR’s proactive

trainee committee is putting on an indis-pensable guide through the journey from research to publication. From different ways to fund your research, through to paper writing methods and finally to common pitfalls associated with publication, this conference aims to discuss the techniques associated with successful paper writing and, with parallel training sessions, to provide the opportunity to discuss these skills with experts in the field. As part of this day there will be a poster competition and a talk on converting posters to papers. The best of the received abstracts will be selected for display on the day. A winner will be selected from the displayed posters to receive a prize.

clinical imaging of the head and neckOn 2 December we are running a scien-

tific meeting on clinical imaging of the head

and neck, which is based on the recently updated head and neck issue of Imaging, with lectures based on the individual articles. The meeting will provide a useful guide to the more frequent problems confronting the head and neck imager and will provide an overview and revision of a comprehensive range of head and neck imaging topics. It will emphasise contemporary but pragmatic approaches to imaging frequent clinical problems of the head and neck. On successful completion of the meeting, delegates will know how to image and systematically interpret imaging in a range of head and neck scenarios and will understand the importance of sound anatomical, patho-logical and clinical knowledge in order to improve detection and communication of abnormalities in the head and neck.

If you are interested in attending any of the above events, please contact our Education Department on 020 7307 1400 or book a place via our website at www.bir.org.uk

Jacqueline fowler, Chief Executive, BIR

CEO Report


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BIR newswww.bir.org.uk

41NEWS

The British Institute of Radiology East of England branch held its second event (since its formation in 2010) on 24 June 2011 at the Møller Centre, Churchill College, Cambridge. The event focused on radiology errors, which was extremely well received with approximately 80 del-egates from imaging professionals across the Eastern region and beyond.

Radiology errors is a very important and highly relevant issue in radiology governance. The morning session focused on the very important aspect of safe clinical practice addressing standard setting, performance management, inci-dents reporting, errors management, litigations, complaints and claims. The afternoon session concentrated on specific topics on errors related to imaging of the chest, abdomen, trauma, breast, neuro-

a second successful event for the BIR east of england branch

www.esti2012.org





eSt

i2012


Congratulations to British Institute of Radiology competition winner, Dr Sumita Chawla, SpR, Radiology, Mersey Deanery. Sumita won spon-sorship to attend UKRC 2011. We asked her why she felt it so important to attend the event.

"UKRC is a great multidiscipli-nary meeting for all radiology allied professionals."

Sumita went on to explain how important the event was for trainees.

"As a radiology trainee, this annual event keeps me updated with current, developing and future diag-nostic imaging trends. The multitude of lectures, presentations, technical exhibits and workshops all serve as informative learning tools. Working in the field of radiology, I feel UKRC has a wide range of educational resources to offer together with the added benefit of an enjoyable sociable environment".

competition winner 2011

competition winner Sumita chawla

Dr T C See and committee hosted the Radiology Errors, Risks and Complications Study Day on 24 June 2011 at the Møller Centre in Cambridge

and interventional radiology. Some difficult clinical scenarios were discussed. The meeting provided an opportunity for interactive discussion on learning from previous errors, how to avoid errors and exploring the various pathways that may be involved in managing errors. It was also highly educational in sharing and debating information relating to clinical and legal implications of radiology errors.

The success of the meeting also reflects the progress made by the BIR in developing regional branches to provide a regional platform for educational activities and professional networking. Dr TC See, chair of the East of England branch and his committee expressed their gratitude to all the speakers for their contribution and to all the delegates for their support and active participation of the event.

The East of England committee and speakers at the Møller centre

British Institute of Radiology UK MRI Course (incorporating the Somerset MRI Course)

17 – 20 October 2011 BIR, London

Amalgamating our own well received MR Physics without the Pain! programme and the extremely successful Somerset MRI Course, this is an event that cannot be missed.

Visit www.bir.org.uk to book your place today

*This course offers the chance to study up to 150 cardiac cases. It is not a prerequisite that the course is ‘Level II’

London Cardiac CT Level II* Teaching Course7 – 10 February 2012 BIR, London

This unique, four day course is designed to provide case volume, formal teaching and hands on training required for Level II* SCCT or BSCI accreditation in Cardiac CT.

Visit www.bir.org.uk to book your place today

competition

BIR newswww.bir.org.uk


online learning and revision resources

Sudoku

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:

When is the BIR UK MRI course being held?

Send your answer along with your name and contact details to:[email protected] by 11 November 2011. Congratulations to last issues winner:Michael Fell

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

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

Sudoku from www.puzzlechoice.com

Inspired by September’s British Journal of Radiology letter from Dr Christopher Burke (Guy and St Thomas’ NHS Trust) on the electronic reading habitats of radiology trainees (DOI: 10.1259/bjr/ 29853241), BJR News takes a look at some of the online resources available.

Tweet us @BJRNews

www emedicine.medscape.com

www rsna.org

www imaging.consult.com

www pastest.co.uk

www onexamination.com www riti.org.uk

Named after the common term in radiology for a radiological finding with no differen-tial diagnoses, the auntminnie site contains forums and the latest news and informa-tion in radiology. There are discussion boards for a variety of interest groups and a buyer’s guide containing links to manu-facturer information.

Mescape is a free to register website that provides articles, news and commentary for each speciality. The site contains thou-sands of articles and each one is associated with a subspecialty “textbook”.

RSNA online provides access to Radiology and RadioGraphics along with online edu-cation including the self directed Point of Care Learning, refresher courses and tests linked to Radiology and RadioGraphics.

Imaging Consult is an online product from the publisher Elsevier. The site includes a search facility to find images by modal-ity or anatomical region. There are patient cases, step-by-step procedure guides and links to differential diagnosis for compari-son. You can register for a free 30-day trial.

Pastest provides online revision tools in the form of exam-format questions and expert written answers, e-lectures and podcasts. Price varies depending on the exam.

The Radiology Integrated Training Ini-tiative resource was created by the Royal College of Radiologists, the Department of Health and the NHS to address the shortfall in UK trained radiologists. Three academies have been created that provide access to computer linked e-learning sessions and validated teaching where trainees can study images and films of actual cases alongside their pathologies and diagnoses. There are also skills labs to practice techniques, a library and tuto-rial/lecture room facilities.

Onexamination is a website from the BMJ. It includes revision questions for the FRCR exam, self-assessment and video tutorials. You can select the amount of time you wish to have access for and prices start at £36 for 1 month. There is also a free question of the day.

auntminnieeurope.comwww

a page of hIstoRy www.bir.org.uk


This prestigious award was founded in 1948 in memory of the British Institute of Radiology (BIR) past-President Dr Stanley Melville. The £1000 award is intended to allow full members of the BIR to visit insti-tutions and clinics abroad. These visits abroad have two consequences: firstly, new techniques and knowledge can be acquired and so as St Augustine said: “The world is a book, and those who do not travel read only a page.” Secondly, travel also makes us look at our own practice and assump-tions in a new light and therefore, as GK Chesterton said: “The whole object of travel is not to set foot on foreign land; it is at last to set foot on one's own country as a foreign land”.

Stanley Melville was born in 1867 and died in 1934. He was one of the primary architects of British radiology and was greatly respected as a negotiator and planner. He was a Lancastrian by birth and was described as being meticulously correct in the way he spoke and dressed. His home town was Liverpool and he entered Univer-

sity College in London to study law. Melville was called to the bar at Lincoln’s Inn and subsequently studied medicine, qualifying as a doctor in 1891. He then had a general medical practice in Nevern Square. Melville became interested in X-rays following their discovery in 1895 and, quickly realising their potential, he devoted all his time to radiology from 1898.

He was an early member of the Röntgen Society and the Electro-Therapeutic Section of the Royal Society of Medicine. He worked at three hospitals: St George’s Hospital in London, the West London Hospital at Hammersmith and the Brompton Hospital. His own private consulting rooms were at 9 Chandos Place and this became a centre for British radiology.

He was a member of many committees including the British X-ray and Radium Protection Committee. Melville was a founder and the second President (1923-26) of the Society of Radiographers and is commemorated in their Stanley Melville Memorial Lecture. He was President of the

Electro-Therapeutic Section of the Royal Society of Medicine (1924-25), of the British Institute of Radiology (1934) and was Medical Editor of the British Journal of Radiology (1934). He was injured by radiation and his hands were damaged causing him considerable discomfort. His life was not shortened by this but he is one of the original 14 British names inscribed on the X-ray Martyrs Memorial at St George’s Hospital in Hamburg.

In selecting classic books from the BIR library it is easy to imagine that the impor-tant books are all written in the early 20th century. However, Medical Imaging was first published in 1979 and came at the end of one of the most remarkable decades in medical imaging. The 1970s witnessed developments in radiology, with the intro-duction of CT scanning in 1972, which emerged as the most significant diagnostic technique in the study of neurological disorders and it showed a major promise in the investigation of the chest and abdomen. Ultrasound and interventional radiology were also finding their place and we saw the development of early MRI.

There is a perceptive introduction to this book by Robert Steiner who was professor at the Hammersmith hospital and a major figure in the development of cardiovascular

imaging. As he says in his introduction, who would have thought 10 years ago (1969) that such momentous developments were possible? Indeed, there were many who believed that diagnostic radiology had reached its zenith and that there was little room for new innovations. This book shows how very wrong they were in their predic-tions. It came out at the beginning of the applications of these new techniques and it was difficult at the time to predict just how far they were going to advance our ability to establish even more accurate and definitive diagnoses. Steiner predicted that the time would come when medical imaging would produce a reliable in vivo tissue diagnosis, possibly on a par with a histological diag-nosis of a biopsy. We are not at this stage yet but we are well on the way. He also asked the question: how much further can we

go and should we advance our diagnostic refinement even further if these achieve-ments cannot be matched in the therapeutic field? He was quite right in saying that there are exciting times ahead.

The book is based on a conference at the Department of Radiology at North-wick Park Hospital in London and was held at a Clinical Research Centre in December 1977.

The book has chapters by Godfrey Hounsfield, Peter Wells, George du Boulay, Ian Isherwood, Jamie Ambrose, Ivan Moseley, Hilton Meire and many others. Do have a look at this book and get some insight into the remarkable changes of the 1970s when speciality of radiology made such profound advances.

Stanley Melville Memorial Award

classic radiology books: Medical Imaging by Louis Kreel

Professor Adrian Thomas BSc fRcP fRcR fBiR Honorary Librarian, BIR

Professor Adrian Thomas BSc fRcP fRcR fBiR Honorary Librarian, BIR

Stanley Melville

Book RevIewwww.bir.org.uk


Diagnostic Imaging: Brainby ag osborn et al ISbN: 978-1-93188472-3Amirsys, USA

Book RevIew

www Download the full book review bjr.birjournals.org

A K Banerjee

East of England

CHaIR: dR tEIk CHoon, CambRIdgE UnIvERsIty HospItals foUndatIon tRUst

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

sCotlandCHaIR: dR andREw pEaRson, boRdERs gEnERal HospItal

soUtH wEst EnglandCHaIR: nIky sykEs, Colbalt appEal fUnd

walEsCHaIR: dR gaREtH tUdoR, pRInCEss of walEs HospItal

wEssExCHaIR: dR katIE joHnson, salIsbURy dIstRICt HospItal

For more information about our branch network please visit

[email protected]

BRANCH NETWORK

The BIR has a regional network of branches throughout the UK.

Regional branches offer BIR members and professionals within the radiological community local

educational meetings and networking opportunities.

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

This is the second edition of a previously well-received textbook edited by the distin-guished radiology educator Anne Osborn, who needs no introduction to the radiology community. She is well-renowned for her lectures, teaching and successful textbooks, which convey in print her enthusiasm and encyclopaedic knowledge of neuroradiology.

This multi-authored text provides a comprehensive overview of current neuroradiology. In the first section, congenital malformations are covered. In the second section there is a detailed description of neurotrauma. Other sections covered include subarachnoid haemorrhage, strokes, vascular malfor-mations and, of course, neoplasms. There

is also an excellent section on infectious diseases. Acquired toxic and metabolic degenerative diseases are also covered, including the dementias that are being seen much more commonly in western medical practice.

The second part of the book is titled "Anatomy based diagnosis" and covers normal variants of neuroanatomy, including conditions such as hydroceph-alus. The pituitary gland and its various pathologies are also included, as are the meninges, scalp and skull.

This second edition includes the newest World Health Organization clas-sifications on tumours and grading of ischaemia. There are several new images, tables, charts, diagrams and pathology images in this edition compared to the previous one.

The text is easy to read, well annotated and profusely illustrated. A particular useful feature of the book is that all of the indi-

vidual chapters covering separate diseases include, not only imaging findings, but also discussions on clinical issues and pathology as well as differential diagnoses and refer-ences where necessary. Key facts are also provided, which are a useful aid memoire for learning. The text book is so comprehensive that it will be a useful reference for general radiologists performing neurological exam-inations and even neuroradiologists who wish to brush up on their knowledge. It should also be well thumbed by trainees who will find the wealth of material in this textbook useful for their exams.

I have enjoyed dipping into this book and will continue to refer to it regularly, I suspect. It is a superb contribution to the radiology literature, and the author and her team deserve to be congratulated for producing such a fine work.

Geometric Uncertainties in Radiotherapy Defining the Planning Target Volume

Prepared by a Working Party of The British Institute of Radiology

Clinical overview. Summarizes the philosophy of ICRU Reports 50 and 62 and discusses geometric uncertainties in this context.

Technical overview. Describes the general approach to estimating sizes of uncertainties and how to combine them:

(i) how to determine the margin required to accommodate treatment preparation uncertainties that give rise to systematic errors

(ii) how to calculate the additional margin for the daily treatment execution uncertainties that result in random errors.

Reviews of geometric uncertainties for specific tumour sites: breast; lung; prostate and bladder; brain; head and neck. For each site, sources of uncertainty are described and methods for minimizing these uncertainties are proposed.

Glossary

Shop online, visit http://www.bir.org.uk/membersarea/shop/

The intention of this publication is to give oncologists, physicists and radiographers the tools to estimate geometric uncertainties in their own centre and to show how these uncertainties may be minimized and accommodated by appropriate protocols.

Contents

Geo uncert for BJR News April.indd 1 07/02/2011 16:02:47

pResIDent’s coLuMnwww.bir.org.uk

47NEWSISSUE 5 oCtobER 2011 47

I hope that as many of you as possible have been able to take a Summer break and time away from the workplace. It gives us all a chance to reconnect with our friends and families and to put just a little distance from work. Perspec-tive helps with all the difficult issues. For me, this means dealing with some important matters that will have a fun-damental impact on the British Institute of Radiology (BIR).

In my last column, I talked about BIR’s changing needs regarding its premises at 36 Portland Place. Trustees have been taking a critical look at the costs associated with running and main-taining the building in the context of the overall finances of the institute. A premises working group was formed to look in detail at the building’s use and the legal and financial aspect of our occupation of 36 Portland Place, which is required for the good financial govern-ance of the institute. The activities of the BIR and the use of the building are changing to reflect our changing world. The library is rarely visited and books are seldom read. Our lecture theatre, despite the best efforts of our education and facilities team, is only used 8% of the time. The current National Health Service spending restrictions have

resulted in little opportunity for study leave time and funding.

Our trustees are charged with ensuring the sound financial govern-ance of the BIR. They have asked the premises group to develop a range of options around the use of the premises to address the fundamental question: is 36 Portland Place both viable and fit for purpose in the context of the charity’s assets and activities? This is difficult territory; however, the trustees are quite clear that we must safeguard the future of the BIR. In addition we must ensure that the BIR’s strategy (http://www.bir.org.uk/media/5497/strategic%20plan%20web.pdf ) is realised and that the BIR remains relevant and attractive to its current and future members.

By the time you receive this copy of BJR News you will have received a consultation document that invites you to give your views on the BIR premises in the context of safeguarding the future of the BIR. I do hope that you will respond. Trustees will be consid-ering your views at council on the 29th September. On the same day you are invited to attend an extraordinary general meeting to discuss the issue of the premises. This will be followed by the annual general meeting.

The plans for the president’s conference 2012 are going very well. I have received a great response from the invited speakers. The conference will again be held at the Wellcome Collection on Euston Road on April 25-26th 2012. Next years topic is CT in clinical practice – past present and future – a tribute to Godfrey Hounsfield. This reflects the role of CT in modern clinical practice and future perspectives. There will be a series of keynote lectures reflecting the major contribution Godfrey Hounsfield made to radiology.

The activities of the BIR and the use of the building are changing to reflect our changing world

Geometric Uncertainties in Radiotherapy Defining the Planning Target Volume

Prepared by a Working Party of The British Institute of Radiology

Clinical overview. Summarizes the philosophy of ICRU Reports 50 and 62 and discusses geometric uncertainties in this context.

Technical overview. Describes the general approach to estimating sizes of uncertainties and how to combine them:

(i) how to determine the margin required to accommodate treatment preparation uncertainties that give rise to systematic errors

(ii) how to calculate the additional margin for the daily treatment execution uncertainties that result in random errors.

Reviews of geometric uncertainties for specific tumour sites: breast; lung; prostate and bladder; brain; head and neck. For each site, sources of uncertainty are described and methods for minimizing these uncertainties are proposed.

Glossary

Shop online, visit http://www.bir.org.uk/membersarea/shop/

The intention of this publication is to give oncologists, physicists and radiographers the tools to estimate geometric uncertainties in their own centre and to show how these uncertainties may be minimized and accommodated by appropriate protocols.

Contents

Geo uncert for BJR News April.indd 1 07/02/2011 16:02:47

oBItuaRy www.bir.org.uk


Bryan harrison — past chairman of the Radiological Research trustBryan Harrison was the past Chairman of the Radiological Research Trust (RRT) where he worked tirelessly for many years with his brother-in-law the late Professor George du Boulay, the founder of the RRT.

He brought to the RRT a diverse range of business skills and knowledge,

which he gained over his years working in the reinsurance world.

He was fortunate enough to find a career that he loved early on and he worked ambitiously, tirelessly and with integrity throughout his working life.

He had clients all over the world, but the most interesting and complex

was the Israeli road accident victims’ compensation scheme. This was a government-run scheme by which anyone injured in a motor accident could receive compensation when they were unable to recover damages from an insurance company due to the motor insurance policy being invali-dated because the driver was uninsured, driving whilst disqualified, under-age, unlicensed for the vehicle in question or some other reason that enabled the would-be insurers to avoid liability.

Regularly this reinsurance renewal took Bryan to Israel where he became well versed in the courtesies and culture of the Israeli nation and he was very popular with all those he had dealings, both in his commercial and social life. His role also took him around France Germany and Switzerland where the companies who reinsured the scheme were based.

His dry and at times wicked sense of humour thrived on the material collected on these trips and made him a great raconteur.

His great sense of fun during his younger years is clearly evident in photographs that show him leaning against racy cars, doffing his cap at the top of the Empire State building, sharing a meal with Israeli business colleagues or relaxed and seated on cushions on the ground with his family.

He loved cricket, music and Alde-burgh, he enjoyed travel and adored Tarifa in Spain. He enjoyed history, Eleanor of Acquitaine in particular, and he loved the odd glass of wine.

His guiding hand and support will be a great loss to the RRT and he will be sadly missed by all who knew him.

Bryan Harrison died 14 April 2011.

naMe of pagewww.bir.org.uk

3NEWSISSUE 4 AUgUSt 2011

To find out more about current opportunities,and register your details, please contact the team on

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34596 birnews 280x210:Layout 1 9/3/11 12:08 Page 1

The annual scientific meeting of the Welsh Branch of the BIR will take place on the 14th and 15th of October 2011. The meeting is being held at the post graduate department of the Princess of Wales Hospital, Bridgend. The meeting has been organised by the Welsh Branch committee of the BIR. Topics covered will be of interest to Radiologists, Radiographers, Physicists, clinicians and allied health professionals.There will be an opportunity to participate in the annual golf match on the morning of the 14th of October. In the afternoon the programme will consist of Trainee presentations which are open to Radiology, Radiographer and Physicist trainees. We are also hoping to have our first Welsh BIR Trainee poster presentation section.

14 October 2011 09:00 Golf Tournament at the Vale Resort

14:00 Trainee Presentations

CALL FOR PAPERSOpen to Radiology, Radiographer and Physicist trainees. This is your opportunity to inform colleagues in the region of your work. Submissions are encouraged from a multidisciplinary audience therefore all topics will be considered. The presentations will be judged by the committee and the selected winner will be awarded with a certificate and cheque for £100. Abstracts (no more than 250 words) should be submitted to [email protected] no later than Monday 19 September. There will also be the opportunity to present posters.

19:00 Welsh BIR Dinner at Coed-Y-Mwstwr Hotel, Coychurch, BridgendA perfect networking opportunity open to all wishing to attend.

FeesGolf Tournament £40Trainee Presentations FREEDinner £39

15 October 2011 9:00 Registration

9:30 Title of talk TBCDr. Andrew Wood

10:00 Title of talk TBCDr. Navroz Masani

10:30 High Field MR Physics: Advantages and Disadvantages of 3T (and beyond)Dr. John Evans

11:00 3T in a Clinical Environment: A MR Superintendents PerspectiveMrs. Sian Evans

11:15 Coffee

11:30 Abdominal Aortic Aneurysm Screening ProjectDr. Gareth Davies

12:00 Bowel Cancer Screening - initial results from the first round in WalesDr. Gareth Tudor

12:30 Disscussion

1:00pm Lunch

FeesBIR Consultant Member £20BIR Non-Consultant Member £15BIR Trainee/Retired Member £10Non-Member Consultant £30Non-Member Non-Consultant £20Non-Member Trainee/Retired £15

14-15 October 2011

Princess of Wales Hospital, Bridgend

BIR Welsh Branch Annual Meeting

accredited by

and the Royal College of

Radiologists

For more information

and to register visit

www.bir.org.ukRegistered Charity

No: 215869

Welsh Branch BJR Ad.indd 1 23/08/2011 16:03:28

BJR News October 2011

Documents

Transcript of BJR News October 2011