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2.  The Medical Image Perception Society XIV conference 
The British Journal of Radiology  2013;86(1021):20120337.
doi:10.1259/bjr.20120337
PMCID: PMC3615396  PMID: 23239698
4.  MRI conditional pacemakers: the start of a new era 
The British Journal of Radiology  2011;84(1005):773-774.
doi:10.1259/bjr/86609066
PMCID: PMC3473794  PMID: 21849362
5.  Incidental fleurodeoxyglucose uptake in the prostate 
The British Journal of Radiology  2010;83(995):902-903.
This commentary confirms the rarity of prostatic cancer associated with incidental prostatic fleurodeoxyglucose (FDG) uptake. The study adds to the literature by showing that even if a prostate lesion is FDG avid it is unlikely to be due to cancer. The commentary considers the management of incidental prostate FDG uptake on the basis of the available evidence.
doi:10.1259/bjr/28173921
PMCID: PMC3473722  PMID: 20965899
6.  An unusual case of abdominal pain 
The British Journal of Radiology  2010;83(991):628-629.
doi:10.1259/bjr/22587841
PMCID: PMC3473670  PMID: 20603413
7.  A training simulator for ultrasound-guided percutaneous nephrostomy insertion 
The British Journal of Radiology  2010;83(991):612-614.
Increasing trainee numbers and changes to working patterns have resulted in a scarcity of training opportunities for training-grade doctors wishing to learn nephrostomy tube insertion techniques. A method of introducing trainees to the skills required to perform percutaneous nephrostomy in a safe, non-threatening environment, without risk to patients, is desirable. Commercial and biological nephrostomy phantoms are available, but they are expensive and not widely available, and a cheap, safe, valid alternative is desirable. We describe a simple technique for producing a gelatin-based phantom, which we suggest has face and content simulator validity. The use of this nephrostomy phantom could optimise existing clinical training opportunities through familiarisation with nephrostomy technique and equipment, and development of the psychomotor skills required for successful nephrostomy insertion prior to undertaking supervised procedures on patients.
doi:10.1259/bjr/42026587
PMCID: PMC3473683  PMID: 20603411
8.  The assessment of round lytic lesions in sternotomies 
The British Journal of Radiology  2013;87(1033):20130342.
Objective:
The aims of this study were to define imaging findings and to identify any predisposing factors for the development of the round lytic lesion across the margins of sternotomy during the process of bone healing.
Methods:
We searched all chest CT scans performed between 2007 and 2012 and selected patients who had three studies performed in the recent, late and latest post-operative periods. Patients presenting any complications related to wound healing were excluded from the study. CT features of the sternotomy and possible instability factors were assessed.
Results:
From 15 689 chest CT images analysed, 68 patients fulfilled the criteria. The development of a round lytic lesion was observed in 35 and 39 patients in the late and latest post-operative periods, respectively, and there was an association between mild misalignment of margins in the recent post-operative period and the development of a round lesion in the follow-up periods (p = 0.010 and p = 0.002, respectively).
Conclusion:
Sternotomies exhibit a delayed and unusual pattern of bone healing, and minimal instability factors during bone closure could trigger the development of a lytic lesion that is part of the normal healing process.
Advances in knowledge:
This lytic bone lesion is part of the bone healing, and its appearance should not be mistaken as infection or malignancy, even in a suggestive clinical setting.
doi:10.1259/bjr.20130342
PMCID: PMC3898968  PMID: 24297810
9.  Value of ultrasonography for detecting chronic injury of the lateral ligaments of the ankle joint compared with ultrasonography findings 
The British Journal of Radiology  2013;87(1033):20130406.
Objective:
The aim of this study was to assess the accuracy of ultrasonography in the diagnosis of chronic lateral ankle ligament injury.
Methods:
A total of 120 ankles in 120 patients with a clinical suspicion of chronic ankle ligament injury were examined by ultrasonography by using a 5- to 17-MHz linear array transducer before surgery. The results of ultrasonography were compared with the operative findings.
Results:
There were 18 sprains and 24 partial and 52 complete tears of the anterior talofibular ligament (ATFL); 26 sprains, 27 partial and 12 complete tears of the calcaneofibular ligament (CFL); and 1 complete tear of the posterior talofibular ligament (PTFL) at arthroscopy and operation. Compared with operative findings, the sensitivity, specificity and accuracy of ultrasonography were 98.9%, 96.2% and 84.2%, respectively, for injury of the ATFL and 93.8%, 90.9% and 83.3%, respectively, for injury of the CFL. The PTFL tear was identified by ultrasonography. The accuracy of identification between acute-on-chronic and subacute–chronic patients did not differ. The accuracies of diagnosing three grades of ATFL injuries were almost the same as those of diagnosing CFL injuries.
Conclusion:
Ultrasonography provides useful information for the evaluation of patients presenting with chronic pain after ankle sprain.
Advances in knowledge:
Intraoperative findings are the reference standard. We demonstrated that ultrasonography was highly sensitive and specific in detecting chronic lateral ligments injury of the ankle joint.
doi:10.1259/bjr.20130406
PMCID: PMC3898969  PMID: 24352708
10.  Evaluation of 99mTc-peptide-ZHER2:342 Affibody® molecule for in vivo molecular imaging 
The British Journal of Radiology  2013;87(1033):20130484.
Objective:
The aim of this study was to develop an improved method for labelling ZHER2:342 with Technetium-99m (99mTc) using Gly-(d) Ala-Gly-Gly as a chelator and to evaluate the feasibility of its use for visualization of HER2 expression in vivo.
Methods:
The Affibody® molecule ZHER2:342 was synthesized by Fmoc/tBu solid phase synthesis. The chelator, Gly-(d) Ala-Gly-Gly, was introduced by manual synthesis as the N-terminal extensions of ZHER2:342. ZHER2:342 was labelled with 99mTc. The labelling efficiency, radiochemical purity and in vitro stability of the labelled molecular probe were analysed by reversed-phase high performance liquid chromatography. Biodistribution and molecular imaging using 99mTc-peptide-ZHER2:342 were performed.
Results:
The molecular probe was successfully synthesized and labelled with 99mTc with the labelling efficiency of 98.10 ± 1.73% (n = 5). The radiolabelled molecular probe remained highly stable in vitro. The molecular imaging showed high uptake in HER2-expressing SKOV-3 xenografts, whereas the MDA-MB-231 xenografts with low HER2 expression were not clearly imaged at any time after the injection of 99mTc-peptide-ZHER2:342. The predominant clearance pathway for 99mTc-peptide-ZHER2:342 was through the kidneys.
Conculsion:
99mTc-peptide-ZHER2:342 using Gly-(d) Ala-Gly-Gly as a chelator is a promising tracer agent with favourable biodistribution and imaging properties that may be developed as a radiopharmaceutical for the detection of HER2-positive malignant tumours.
Advances in knowledge:
The 99mTc-peptide-ZHER2:342 molecular probe is a promising tracer agent, and the results in this study provide a foundation for future development of protocols for earlier visual detection of cancer in the clinical setting.
doi:10.1259/bjr.20130484
PMCID: PMC3898972  PMID: 24273251
11.  Paediatric post-septal and pre-septal cellulitis: 10 years' experience at a tertiary-level children's hospital 
The British Journal of Radiology  2013;87(1033):20130503.
Objective:
To assess the incidence and complications of pre-septal (pre-SC) and post-septal (post-SC) cellulitis over 10 years. Pre-SC and post-SC are also known as periorbital and orbital cellulitis, respectively.
Methods:
Retrospective analysis of CT scans. Data included the presence of pre-SC and post-SC, paranasal sinus disease (PNS) and complications.
Results:
Among 125 patients scanned for these suspected diagnoses, 67 had both pre-SC and post-SC, 37 had pre-SC and 4 had post-SC; there were 17 normal scans. 110 patients had PNS. 68/71 (96%) patients with post-SC had PNS. Post-SC complications included orbital and/or subperiosteal abscess (50/71: 30 medial orbital, 10 superomedial, 3 lateral, 2 anteromedial, 2 inferomedial, 1 superior, 1 anterosuperior and 1 not specified), cavernous sinus thrombosis (CST) (1), superior ophthalmic vein (SOV) thrombosis (4) and subdural frontal empyema (2); 1 patient had SOV and CST and subdural empyema.
Conclusion:
71/125 (57%) patients had post-SC. 50/125 (40%) patients imaged for pre-SC/post-SC had orbital abscess; 44/50 (88%) of these involved the medial orbit. Patients can develop solely superior or inferior abscesses that are difficult to identify by axial imaging alone, hence coronal reformatted imaging is essential. 5/125 (4%) patients developed major complications (SOV/CST/empyema), hence imaging review of the head and cavernous sinus region is essential. A diagnosis of post-SC on CT should alert the radiologist because this diagnosis can be associated with an increased incidence (5/71, 7%) of complications.
Advances in knowledge:
We recommend that all patients with a suspected diagnosis of post-SC should undergo CT scan (post-contrast orbits and post-contrast head, with multiplanar reformats and a careful review of the SOV and the cavernous sinus). Particular attention should be paid to exclude intracranial complications including subdural empyema and cerebral abscess. As soon as a diagnosis of post-SC is made, in addition to informing the referring clinical team, urgent opinion should be sought from ear, nose and throat (ENT), neurology and ophthalmology with a view to urgently drain of the paranasal sinuses`.
doi:10.1259/bjr.20130503
PMCID: PMC3898973  PMID: 24288398
12.  Particle therapy using carbon ions or protons as a definitive therapy for patients with primary sacral chordoma 
The British Journal of Radiology  2013;87(1033):20130512.
Objective:
This study retrospectively evaluated the efficacy and toxicity of particle therapy using carbon ions or protons for primary sacral chordomas.
Methods:
We evaluated 23 patients with primary sacral chordoma treated with carbon ion therapy (CIT) or proton therapy (PT) between July 2005 and June 2011 at the Hyogo Ion Beam Medical Center, Hyogo, Japan. The median patient age was 72 years. 14 patients were treated with 70.4 Gy equivalents (GyE) in 16 fractions and 9 were treated with 70.4 GyE in 32 fractions. CIT was used for 16 patients, and PT was used for 7 patients.
Results:
The median follow-up period was 38 months. At 3 years, local control (LC), overall survival (OS) and progression-free survival (PFS) for all patients were 94%, 83% and 68%, respectively. The log-rank test revealed that male sex was significantly related to better PFS ( p = 0.029). No other factors, including dose fractionation and ion type, were significant for LC, OS or PFS. In nine patients, ≥Grade 3 acute dermatitis was observed, and ≥Grade 3 late toxicities were observed in nine patients. The 32-fraction protocol reduced severe toxicities in both the acute and late phases compared with the 16-fraction protocol.
Conclusion:
Particle therapy for patients with sacral chordoma showed favourable LC and OS. Severe toxicities were successfully reduced by modifying the dose fractionation and treatment planning in the later treatment era. Thus, this therapeutic modality should be considered useful and safe.
Advances in knowledge:
This is the first study including both CIT and PT for sacral chordomas.
doi:10.1259/bjr.20130512
PMCID: PMC3898974  PMID: 24288399
13.  Reduced z-axis coverage in multidetector-row CT pulmonary angiography decreases radiation dose and diagnostic accuracy of alternative diseases 
The British Journal of Radiology  2013;87(1033):20130546.
Objective:
To investigate the effect of a two-third reduction of the scanned length (i.e. 10 cm) on diagnosis of both pulmonary embolism (PE) and alternative diseases.
Methods:
247 consecutive patients suspected of acute PE had a CT pulmonary angiography (CTPA) of the thorax (standard length, L). Based on this acquisition, a second set of images was created to obtain a scan length of 10 cm caudally to the aortic arch (l). Images were anonymized, randomized and interpreted by two independent readers. The quality of enhancement, the presence of PE and the possible alternative and/or complementary diagnoses were recorded. A McNemar exact test investigated differences in discrepancies between readers and between scan lengths.
Results:
57 (23%) patients had an acute PE. Among l sets, PE was missed by both readers in one (1.8%) patient, because the unique clot was localized in a subsegmental artery out of the 10-cm range. There were discrepancies between L and l sets in 9 (3.6%) and 11 (4.5%) patients, by Readers 1 and 2 (p = 0.820), respectively. Discrepancies between the readers of L sets and those between both sets were not different regardless of the reader (p > 0.99). There were discrepancies between both sets for alternative and/or complementary diagnoses in 43 (17.2%) patients.
Conclusion:
Although its performance in diagnosing PE is maintained, CTPA should not be restricted to a range of 10 cm centred over the pulmonary hilum, because alternative and/or complementary diagnoses could be missed.
Advances in knowledge:
(1) A 10-cm CTPA acquisition reduces the radiation dose by two-thirds as compared with a standard one, but does not impair the accuracy for the diagnosis of PE. (2) Significant alternative diagnoses are missed in 17.2% of patients when reducing the acquisition height to 10 cm.
doi:10.1259/bjr.20130546
PMCID: PMC3898975  PMID: 24258464
14.  Evaluation of internal target volume in patients undergoing image-guided intensity modulated adjuvant radiation for gastric cancers 
The British Journal of Radiology  2013;87(1033):20130583.
Objective:
To evaluate three-dimensional (3D) displacements of gastric remnant during adjuvant radiation.
Methods:
From January 2011 to September 2012, patients undergoing adjuvant image-guided intensity-modulated radiation on tomotherapy were included. Megavoltage CT (MVCT) data sets from daily treatment were coregistered with Day 1 MVCT. Residual stomach remnant was delineated on the data set, while the remaining were blinded to previous day contours. Gastric volume and centre of mass (COM) were determined for all data sets. The 3D deviation of COM was calculated for each fraction. Mean 3D and standard deviation (SD) were calculated for each patient and study population, and a 95% confidence interval (CI) was determined. Also, systematic and random errors for patient population and internal target volume (ITV) margin were calculated using the van Herk formula.
Results:
There were 119 images available for 15 patients. Mean volume of remnant was 319 cm3 (146–454 cm3). Gastric remnant expanded in different directions with no specific directional expansion. Average deviations in mediolateral, superoinferior and anteroposterior directions were 9 mm (3–25 mm; SD, 5 mm), 6 mm (3–16 mm; SD, 4 mm) and 5 mm (1–10 mm; SD, 3 mm), respectively, with 95% CI of 18, 15 and 11 mm, and ITV margins of 19.2, 13.5 and 7.8 mm, respectively.
Conclusion:
There is large variation in gastric remnant volume during the course of radiation. Large displacements observed in the present study necessitate the need to investigate adaptive techniques for optimizing intensity-modulated radiotherapy (IMRT) delivery.
Advances in knowledge:
An adaptive strategy needs to be developed to optimize IMRT delivery for adjuvant gastric irradiation.
doi:10.1259/bjr.20130583
PMCID: PMC3898977  PMID: 24288401
15.  Gadoxetic acid-enhanced MRI for T-staging of gallbladder carcinoma: emphasis on liver invasion 
The British Journal of Radiology  2013;87(1033):20130608.
Objective:
To evaluate the diagnostic performance of gadoxetic acid-enhanced MRI with an emphasis on the usefulness of the hepatobiliary phase (HBP) in T-staging of gallbladder carcinoma.
Methods:
66 patients with surgically confirmed gallbladder carcinoma underwent MRI. Two radiologists independently reviewed two sets of gadoxetic acid-enhanced MRI without and with the HBP. Local tumour spread was evaluated according to T-staging, and the results were compared with pathological findings. The diagnostic performance of two image sets to differentiate each T-stage was compared.
Results:
The sensitivities of MRI with the HBP to differentiate T1 vs ≥T2 lesions, ≤T2 vs ≥T3 lesions and ≤T3 vs T4 lesions were 96.3%, 85.7% and 100% for Observer 1 and 92.6%, 95.2% and 100% for Observer 2, respectively (p < 0.0001). By adding the HBP, the sensitivities to differentiate ≤T2 vs ≥T3 lesions were increased from 66.7% to 85.7% for Observer 1 and from 81.0% to 95.2% for Observer 2, although there was no significant difference (p > 0.05). The overall accuracies for T-staging were increased from 80.3% to 86.4% for Observer 1, a statistically significant degree (p = 0.046), and from 83.8% to 87.9% for Observer 2 (p > 0.05). The k-value for the two observers indicated excellent agreement.
Conclusion:
Gadoxetic acid-enhanced MRI provided acceptable diagnostic performance for T-staging of gallbladder carcinoma. Addition of the HBP aids in the detection of liver invasion.
Advances in knowledge:
In the T-staging of gallbladder carcinoma, gadoxetic acid-enhanced MRI with the HBP may enhance detection of liver invasion.
doi:10.1259/bjr.20130608
PMCID: PMC3898979  PMID: 24288397
16.  Reliability and accuracy of scout CT in the detection of vertebral fractures 
The British Journal of Radiology  2013;86(1032):20130373.
Objective:
The aim of the present study was to evaluate the reliability of scout CT (sCT) lateral radiograph, in terms of diagnostic accuracy and intra- and interobserver agreement in the detection of vertebral fractures (VFs).
Methods:
300 CT examinations of the thoracic and/or lumbar spine were collected and independently analysed by 3 musculoskeletal radiologists in 2 different sessions. A semi-quantitative approach was used for VF assessment on sCT, and morphometric analysis was performed when a VF was suspected. Results of multiplanar sagittal CT reconstructions interpreted by the most expert radiologist were considered as gold standard. Arthrosis was also scored. Only vertebral bodies assessable by both sCT and gold standard were considered for the analysis. Area under the receiver operating characteristic curve (AUROC), Cohen's kappa statistic and linear-by-linear association were used for statistical analysis.
Results:
1522 vertebrae were considered (130 males and 170 females; ages, 73.0±2.8 years). 73 of 1522 (4.8%) VFs were identified in 34/300 patients (11.3%). In the detection of VFs, the sensitivity and specificity of sCT were 98.7% and 99.7%, respectively. Accuracy (AUROC=0.992±0.008), as well as interobserver agreement (k=0.968±0.008), was excellent. Intra-observer agreement was perfect (k=1.000). Performance of this method was independent of arthrosis, vertebral level and type and grade of VFs.
Conclusion:
sCT is a simple but very accurate method for the detection of VFs. It should be introduced as a spine evaluation tool for the detection of VFs in examinations that are performed for other diagnostic purposes.
Advances in knowledge:
sCT lateral radiograph is an accurate tool for the detection of VFs. This technique may be used with several advantages in clinical practice.
doi:10.1259/bjr.20130373
PMCID: PMC3854570  PMID: 24100019
17.  Image guidance protocols: balancing imaging parameters against scan time 
The British Journal of Radiology  2013;86(1032):20130385.
Objective:
Optimisation of imaging protocols is essential to maximise the use of image-guided radiotherapy. This article evaluates the time for daily online imaging with TomoTherapy® (Accuray®, Sunnyvale, CA), separating mechanical scan acquisition from radiographer-led image matching, to estimate the time required for a clinical research study (VoxTox).
Methods:
Over 5 years, 18 533 treatments were recorded for 3 tumour sites of interest (prostate, head and neck and central nervous system). Data were collected for scan length, number of CT slices, slice thickness, scan acquisition time and image matching time.
Results:
The proportion of coarse thickness scans increased over time, with a move of making coarse scans as the default. There was a strong correlation between scan time and scan length. Scan acquisition requires 40 s of processing time. For coarse scans, each additional centimetre requires 8 s for acquisition. Image matching takes approximately 1.5 times as long, so each additional centimetre needs 20 s extra in total. Modest changes to the imaging protocol have minimal impact over the course of the day.
Conclusion:
This work quantified the effect of changes to clinical protocols required for research. The results have been found to be reassuring in the busy National Institutes of Health department.
Advances in knowledge
This novel method of data collection and analysis provides evidence of the minimal impact of research on clinical turnover. Whilst the data relate specifically to TomoTherapy, some aspects may apply to other platforms in the future.
doi:10.1259/bjr.20130385
PMCID: PMC3854571  PMID: 24128423
18.  A voxel-based morphometry study of anosmic patients 
The British Journal of Radiology  2013;86(1032):20130207.
Objective:
The aim of our study was to compare volume change in grey matter (GM) and white matter (WM) in a group of subjects with anosmia and a healthy control group. We tried to find a regular pattern of atrophy within and between GM and WM and to determine whether any particular areas are more sensitive to olfactory injury.
Methods:
There were 19 anosmic patients and 20 age- and sex-matched control subjects. We acquired MR images on a 3-T scanner and performed voxel-based morphometry using the VBM8 toolbox and SPM8 in a MATLAB® (MathWorks®, Natick, MA) environment.
Results:
Patients with anosmia showed a significant decrease in GM volume, mainly in the anterior cingulate cortex, middle temporal gyrus, superior temporal gyrus, fusiform gyrus, supramarginal gyrus, superior frontal gyrus, middle frontal gyrus, middle occipital gyrus, anterior insular cortex and cerebellum. In addition, we observed volume decreases in smaller areas such as the piriform cortex, the inferior temporal gyrus, the precuneus and the subcallosal gyrus. All WM areas with atrophy were near those GM areas that experienced volume loss. There was more volume atrophy in GM areas corresponding to WM areas with more volume loss. Atrophy increased with disease duration.
Conclusion:
There is simultaneous atrophy in GM and WM, and the degree of atrophy is greater with longer disease duration. Different GM and WM areas have different sensitivities to olfactory injury.
Advances in knowledge:
This study examines the atrophy pattern in and between GM and WM—a subject that has not been widely researched previously.
doi:10.1259/bjr.20130207
PMCID: PMC3856544  PMID: 24133057
19.  The impact of saddle embolism on the major adverse event rate of patients with non-high-risk pulmonary embolism 
The British Journal of Radiology  2013;86(1032):20130273.
Objective:
Wider application of CT angiography (CTA) improves the diagnosis of acute pulmonary embolism (PE). It also permits the visualisation of saddle embolism (SE), namely thrombi, which are located at the bifurcation of the main pulmonary artery. The aim of this study was to assess the prevalence of SE and whether SE predicts a complicated clinical course in patients with non-high-risk PE.
Methods:
In total, 297 consecutive patients with non-high-risk PE confirmed using CTA in the emergency department were studied. The presence of SE and its ability to predict the occurrence of major adverse events (MAEs) within 1 month were determined.
Results:
Of the 297 patients, 27 (9.1%) had an SE. The overall mortality at 1 month was 12.5%; no significant difference was observed between the SE and non-SE groups (18.5% vs 11.9%, p=0.32). However, patients with SE were more likely to receive thrombolytic therapy (29.6% vs 8.1%, p<0.01) and had significantly more MAEs (59.3% vs 25.6%, p<0.01).
Conclusion:
At the time of diagnosis, SE, as determined using CTA, is associated with the development of MAE within 1 month. It may be a simple method for risk stratification of patients with non-high-risk PE.
Advances in knowledge:
The prognosis of patients with SE, especially those who are haemodynamically stable, is unclear. This study shows that patients with SE, determined with CTA, is associated with the development of MAE.
doi:10.1259/bjr.20130273
PMCID: PMC3856545  PMID: 24058095
20.  Advantage of 3D volumetric dosemeter in delivery quality assurance of dynamic arc therapy: comparison of pencil beam and Monte Carlo calculations 
The British Journal of Radiology  2013;86(1032):20130353.
Objective:
To evaluate the accuracy of pencil beam calculation (PBC) and Monte Carlo calculation (MCC) for dynamic arc therapy (DAT) in a cylindrically shaped homogenous phantom, by comparing the two plans with an ion chamber, a film and a three-dimensional (3D) volumetric dosemeter.
Methods:
For this study, an in-house phantom was constructed, and the PBC and MCC plans for DAT were performed using iPlan® RT (BrainLAB®, Heimstetten, Germany). The A16 micro ion chamber (Standard Imaging, Middleton, WI), Gafchromic® EBT2 film (International Specialty Products, Wayne, NJ) and ArcCHECK™ (Sun Nuclear, Melbourne, FL) were used for measurements. For comparison with each plan, two-dimensional (2D) and 3D gamma analyses were performed using 3%/3 mm and 2%/2 mm criteria.
Results:
The difference between the PBC and MCC plans using 2D and 3D gamma analyses was found to be 7.85% and 28.8%, respectively. The ion chamber and 2D dose distribution measurements did not exhibit this difference revealed by the comparison between the PBC and MCC plans. However, the 3D assessment showed a significant difference between the PBC and MCC (62.7% for PBC vs 93.4% for MCC, p = 0.034).
Conclusion:
Evaluation using a 3D volumetric dosemeter can be clinically useful for delivery quality assurance (QA), and the MCC should be used to achieve the most reliable dose calculation for DAT.
Advances in knowledge:
(1) The DAT plan calculated using the PBC has a limitation in the calculation methods, and a 3D volumetric dosemeter was found to be an adequate tool for delivery QA of DAT. (2) The MCC was superior to PBC in terms of the accuracy in dose calculation for DAT even in the homogenous condition.
doi:10.1259/bjr.20130353
PMCID: PMC3856546  PMID: 24234583
21.  Clinical-dosimetric relationship between lacrimal gland dose and ocular toxicity after intensity-modulated radiotherapy for sinonasal tumours 
The British Journal of Radiology  2013;86(1032):20130459.
Objective:
To characterise the relationship between lacrimal gland dose and ocular toxicity among patients treated by intensity-modulated radiotherapy (IMRT) for sinonasal tumours.
Methods:
40 patients with cancers involving the nasal cavity and paranasal sinuses were treated with IMRT to a median dose of 66.0 Gy. Toxicity was scored using the Radiation Therapy Oncology Group morbidity criteria based on conjunctivitis, corneal ulceration and keratitis. The paired lacrimal glands were contoured as organs at risk, and the mean dose, maximum dose, V10, V20 and V30 were determined. Statistical analysis was performed using logistic regression and the Akaike information criterion (AIC).
Results:
The maximum and mean dose to the ipsilateral lacrimal gland were 19.2 Gy (range, 1.4–75.4 Gy) and 14.5 Gy (range, 11.1–67.8 Gy), respectively. The mean V10, V20 and V30 values were 50%, 25% and 17%, respectively. The incidence of acute and late Grade 3+ toxicities was 23% and 19%, respectively. Based on logistic regression and AIC, the maximum dose to the ipsilateral lacrimal gland was identified as a more significant predictor of acute toxicity (AIC, 53.89) and late toxicity (AIC, 32.94) than the mean dose (AIC, 56.13 and 33.83, respectively). The V20 was identified as the most significant predictor of late toxicity (AIC, 26.81).
Conclusion:
A dose–response relationship between maximum dose to the lacrimal gland and ocular toxicity was established. Our data suggesting a threshold relationship may be useful in establishing dosimetric guidelines for IMRT planning that may decrease the risk of acute and late lacrimal toxicities in the future.
Advances in knowledge:
A threshold relationship between radiation dose to the lacrimal gland and ocular toxicity was demonstrated, which may aid in treatment planning and reducing the morbidity of radiotherapy for sinonasal tumours.
doi:10.1259/bjr.20130459
PMCID: PMC3856547  PMID: 24167183
22.  Image-guided volumetric modulated arc therapy for breast cancer: a feasibility study and plan comparison with three-dimensional conformal and intensity-modulated radiotherapy 
The British Journal of Radiology  2013;86(1032):20130515.
Objective:
To test the feasibility of volumetric modulated arc therapy (VMAT) in breast cancer and to compare it with three-dimensional conformal radiotherapy (3D-CRT) as conventional tangential field radiotheraphy (conTFRT).
Methods:
12 patients (Stage I, 8: 6 left breast cancer and 2 right breast cancer; Stage II, 4: 2 on each side). Three plans were calculated for each case after breast-conserving surgery. Breast was treated with 50 Gy in four patients with supraclavicular lymph node inclusion, and in eight patients without the node inclusion. Multiple indices and dose parameters were measured.
Results:
V95% was not achieved by any modality. Heterogeneity index: 0.16 (VMAT), 0.13 [intensity-modulated radiotherapy (IMRT)] and 0.14 (conTFRT). Conformity index: 1.06 (VMAT), 1.15 (IMRT) and 1.69 (conTFRT). For both indices, IMRT was more effective than VMAT (p=0.009, p=0.002). Dmean and V20 for ipsilateral lung were lower for IMRT than VMAT (p=0.0001, p=0.003). Dmean, V2 and V5 of contralateral lung were lower for IMRT than VMAT (p>0.0001, p=0.005). Mean dose and V5 to the heart were lower for IMRT than for VMAT (p=0.015, p=0.002).
Conclusion:
The hypothesis of equivalence of VMAT to IMRT was not confirmed for planning target volume parameter or dose distribution to organs at risk. VMAT was inferior to IMRT and 3D-CRT with regard to dose distribution to organs at risk, especially at the low dose level.
Advances in knowledge:
New technology VMAT is not superior to IMRT or conventional radiotherapy in breast cancer in any aspect.
doi:10.1259/bjr.20130515
PMCID: PMC3856548  PMID: 24167182
23.  Detection of ischaemic myocardial lesions with coronary CT angiography and adenosine-stress dynamic perfusion imaging using a 128-slice dual-source CT: diagnostic performance in comparison with cardiac MRI 
The British Journal of Radiology  2013;86(1032):20130481.
Objective:
We assessed the diagnostic performance of adenosine-stress dynamic CT perfusion (ASDCTP) imaging and coronary CT angiography (CCTA) for the detection of ischaemic myocardial lesions using 128-slice dual-source CT compared with that of 1.5 T cardiac MRI.
Methods:
This prospective study included 33 patients (61±8 years, 82% male) with suspected coronary artery diseases who underwent ASDCTP imaging and adenosine-stress cardiac MRI. Two investigators independently evaluated ASDCTP images in correlation with significant coronary stenosis on CCTA using two different thresholds of 50% and 70% diameter stenosis. Hypoattenuated myocardial lesions on ASDCTP associated with significant coronary stenoses on CCTA were regarded as true perfusion defects. All estimates of diagnostic performance were calculated and compared with those of cardiac MRI.
Results:
With use of a threshold of 50% diameter stenosis on CCTA, the diagnostic estimates per-myocardial segment were as follows: sensitivity, 81% [95% confidence interval (CI): 70–92%]; specificity, 94% (95% CI: 92–96%); and accuracy 93% (95% CI: 91–95%). With use of a threshold of 70%, the diagnostic estimates were as follows: sensitivity, 48% (95% CI: 34–62%); specificity, 99% (95% CI: 98–100%); and accuracy, 94% (95% CI: 92–96%).
Conclusion:
Dynamic CTP using 128-slice dual-source CT enables the assessment of the physiological significance of coronary artery lesions with high diagnostic accuracy in patients with clinically suspected coronary artery disease.
Advances in knowledge:
Combined CCTA and ASDCTP yielded high accuracy in the detection of perfusion defects regardless of the threshold of significant coronary stenosis.
doi:10.1259/bjr.20130481
PMCID: PMC3856549  PMID: 24096592
24.  Evaluation of adverse reactions to contrast media in the hospital 
The British Journal of Radiology  2013;86(1032):20130418.
Objective:
To determine and analyse the characteristics of contrast media adverse reactions (CM-ARs) reported in a hospital.
Methods:
A retrospective review of CM-ARs from the electronic spontaneous adverse drug reaction (ADR) report system between January 2011 and August 2012 was conducted. CM-ARs were evaluated in terms of causality, severity, preventability and affected organs. Also, agreement and correlation among the tools used to evaluate CM-ARs were analysed.
Results:
The overall reaction rate was 1.5% (n = 286). In total, 269 CM-ARs were identified. For ADR causality, 96.7% (n = 260) and 98.5% (n = 265) were evaluated as “probable” ADR using the Naranjo probability scale and the World Health Organization–Uppsala Monitoring Centre causality categories, whereas 98.1% (n = 264) were evaluated as “certain” with Korean algorithm v. II. Of these, 91.4% (n = 246) were mild in severity and 96.7% (n = 260) were unpreventable. Most patients (n = 233, 86.7%) could be managed with observation and/or simple treatment. The most frequent reaction (n = 383, 79.5%) was dermatological. Spearman's correlation coefficient was 0.667 (p < 0.01), and the agreement was 98.1% between the Naranjo scale and the World Health Organization–Uppsala Monitoring Centre categories. No relationship was seen between CM-AR severity and gender or between in- and outpatients.
Conclusion:
In our study, most CM-ARs were mild and managed with simple treatment. However, as the number of patients undergoing CT procedures continues to increase, it is essential to identify and observe patients at risk for CM-ARs to prevent severe ADRs.
Advances in knowledge:
Continuous careful review of reporting and treatment protocols of CM-ARs is needed to prevent morbidity and mortality.
doi:10.1259/bjr.20130418
PMCID: PMC3856550  PMID: 24191123
25.  A national dosimetry audit of intraoperative radiotherapy 
The British Journal of Radiology  2013;86(1032):20130447.
Objective:
National dosimetry audits are a fundamental part of quality assurance in radiotherapy, especially for new techniques. Intraoperative radiotherapy with a compact mobile kilovoltage X-ray source is a novel approach for the treatment of breast and other cancers. All seven current clinical sites in the UK were audited by a single visiting group and set of measurement equipment.
Methods:
Measurements of output, isotropy and depth doses were performed using an ion chamber in solid water, thermoluminescent dosemeters and radiochromic film, respectively.
Results:
The mean difference between measured and planned dose across all centres was −3.2±2.7%. Measured isotropy was within ±3% around the lateral plane of the X-ray source and +11±4% in the forward direction compared with the lateral plane. Measured depth doses were agreed within 5±2% of manufacturer-provided calibration values or a mean gamma index of 97% at a tolerance of 7%/0.5 mm.
Conclusion:
Agreement within measurement uncertainties was found for all three parameters except forward anisotropy, which is unlikely to be clinically significant. Steep dose gradients increase the sensitivity to small variations in positioning, but these tests are practical for use in interdepartmental audits and local baseline comparison.
Advances in knowledge:
The first UK interdepartmental audit of intraoperative radiotherapy builds confidence in the delivery of this treatment.
doi:10.1259/bjr.20130447
PMCID: PMC3856551  PMID: 24133058

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