Objectives

Diagnostic reference levels (DRLs) are an important tool in the optimisation of clinical radiography. Although national DRLs are provided for many diagnostic procedures including dental intra-oral radiography, there are currently no national DRLs set for cephalometric radiography. In the absence of formal national DRLs, the Health Protection Agency (HPA) has previously published National Reference Doses (NRDs) covering a wide range of diagnostic X-ray examinations. The aim of this study was to determine provisional NRDs for cephalometric radiography.

Methods

Measurements made by the Dental X-ray Protection Service (DXPS) of the HPA, as part of the cephalometric X-ray equipment testing service provided to dentists and dental trade companies throughout the UK, were used to derive provisional NRDs.

Results

Dose–area product measurements were made on 42 X-ray sets. Third quartile dose–area product values for adult and child lateral cephalometric radiography were found to be 41 mGy cm2 and 25 mGy cm2, respectively, with individual measurements ranging from 3 mGy cm2 to 108 mGy cm2.

Conclusion

This report proposes provisional NRDs of 40 mGy cm2 and 25 mGy cm2 for adult and child lateral cephalometric radiographs, respectively; these doses could be considered by employers when establishing their local DRLs.

A liver abscess is a feared and potentially fatal complication following transarterial chemoembolisation (TACE) and radiofrequency ablation (RFA) of liver tumours. Iatrogenic bilio-enteric communications, such as bilio-enteric anastomosis, sphincterotomy and biliary stents, are considered major risk factors and are due to bacterial colonisation of the biliary tree with enteric flora. Naturally occurring spontaneous cholecysto-enteric fistula poses a similar risk as its iatrogenic counterparts but is rarely described in the literature. We present a case where abscess formation complicated a combined TACE and RFA in an unrecognised cholecystocolic fistula.

Objective

To assess the accuracy contrast-enhanced ultrasound (CEUS) in bladder cancer detection using transurethral biopsy in conventional cystoscopy as the reference standard and to determine whether CEUS improves the bladder cancer detection rate of baseline ultrasound.

Methods

43 patients with suspected bladder cancer underwent conventional cystoscopy with transurethral biopsy of the suspicious lesions. 64 bladder cancers were confirmed in 33 out of 43 patients. Baseline ultrasound and CEUS were performed the day before surgery and the accuracy of both techniques for bladder cancer detection and number of detected tumours were analysed and compared with the final diagnosis.

Results

CEUS was significantly more accurate than ultrasound in determining presence or absence of bladder cancer: 88.37% vs 72.09%. Seven of eight uncertain baseline ultrasound results were correctly diagnosed using CEUS. CEUS sensitivity was also better than that of baseline ultrasound per number of tumours: 65.62% vs 60.93%. CEUS sensitivity for bladder cancer detection was very high for tumours larger than 5 mm (94.7%) but very low for tumours <5 mm (20%) and also had a very low negative predictive value (28.57%) in tumours <5 mm.

Conclusion

CEUS provided higher accuracy than baseline ultrasound for bladder cancer detection, being especially useful in non-conclusive baseline ultrasound studies.

Objectives

The aim of this study was to evaluate the relationships between the severity of appendicitis as depicted on CT and blood inflammatory markers of serum white blood cell (WBC) count and C-reactive protein (CRP).

Methods

CT images in 128 patients (109 surgically proven and 19 with clinically excluded appendicitis) were retrospectively reviewed. Two radiologists by consensus evaluated and scored (using a 0, 1 or 2 point scale) severities based on CT-determined appendiceal diameters, appendiceal wall changes, caecal changes, periappendiceal inflammatory stranding and phlegmon or abscess formation. We investigated whether CT findings were significantly related to elevated WBC counts or CRP levels and performed the correlations of WBC counts and CRP levels with CT severity scores. Patients were also subjectively classified using four grades from normal (Grade I) to perforated appendicitis (Grade IV) on the basis of CT findings to evaluate differences in WBC counts and CRP levels between grades.

Results

Only appendiceal wall changes and the phlegmon or abscess formation were related to elevated WBC counts and CRP levels, respectively (p<0.05). CT severity scores were found to be more strongly correlated with CRP levels (r = 0.669) than with WBC counts (r = 0.222). On the basis of CT grades, the WBC counts in Grade I were significantly lower than in other grades (p<0.001), whereas CRP levels in Grade IV were significantly higher than in other grades (p<0.001).

Conclusion

CRP levels were found to correlate with CT-determined acute appendicitis severity and could be a useful predictor for perforated appendicitis, whereas WBC counts might be useful to detect early acute appendicitis.

Acinar cell carcinoma of the pancreas is a rare malignant tumour developing from acinar cells, accounting for approximately 1% of pancreatic exocrine tumours. We experienced a case of an acinar cell carcinoma with fatty change. To the best of our knowledge, this is the first case report of an acinar cell carcinoma with fatty change in the clinical literature.

The purpose of this pictorial review is to understand the embryological basis of the development of congenital hepatic vascular shunts and to review the multimodality imaging appearances of congenital and acquired hepatic vascular shunts. Hepatic vascular shunts are commonly seen in imaging. Familiarity with their characteristic appearances is important in order to accurately characterise these shunts and diagnose the underlying disorders.

Objectives

Soft tissue haemangiomas are common benign vascular lesions that can be accompanied by reactive changes in the adjacent bone structure. This study aimed to discuss the MRI features of soft-tissue haemangiomas with an emphasis on changes in bone.

Methods

The radiographic and MRI findings of 23 patients (9 males, 14 females; mean age 25 years; age range 2–46 years) with soft-tissue haemangiomas were analysed retrospectively. MR images were evaluated for location of the lesion, size, configuration, signal features, contrast patterns, proximity to adjacent bone and changes in the accompanying bone. Excisional biopsy was performed in 15 patients.

Results

Radiographs demonstrated phleboliths in 8 patients (34%) and reactive bone changes in 4 (19%). On MRI, T1 weighted images showed that most of the lesions were isointense or isohyperintense, as compared with muscle tissue; however, on T2 weighted images all lesions appeared as hyperintense. Following intravenous gadolinium-diethylene triamine pentaacetic acid (DTPA) administration, homogeneous enhancement was observed in 3 lesions and heterogeneous enhancement was seen in 19. No enhancement was observed in one patient. Bone atrophy adjacent to the lesion was observed in four patients.

Conclusion

MRI is the most valuable means of diagnosing deep soft-tissue haemangiomas. Bone changes can accompany deeply situated haemangiomas; in four of our patients, we found atrophy of the bone adjacent to the lesion. To our knowledge, this is the first report in the literature regarding atrophy of the bone adjacent to a lesion.

Objectives

The usual radical radiotherapy treatment prescribed for head and neck squamous cell carcinoma (HNSCC) is 70 Gy (in 2 Gy per fraction equivalent) administered to the high-risk target volume (TV). This can be planned using either a forward-planned photon-electron junction technique (2P) or a single-phase (1P) forward-planned technique developed in-house. Alternatively, intensity-modulated radiotherapy (IMRT) techniques, including helical tomotherapy (HT), allow image-guided inversely planned treatments. This study was designed to compare these three planning techniques with regards to TV coverage and the dose received by organs at risk.

Methods

We compared the dose–volume histograms and conformity indices (CI) of the three planning processes in five patients with HNSCC. The tumour control probability (TCP), normal tissue complication probability (NTCP) and uncomplicated tumour control probability (UCP) were calculated for each of the 15 plans. In addition, we explored the radiobiological rationality of a dose-escalation strategy.

Results

The CI for the high-risk clinical TV (CTV1) in the 5 patients were 0.78, 0.76, 0.82, 0.72 and 0.81 when HT was used; 0.58, 0.56, 0.47, 0.35 and 0.60 for the single-phase forward-planned technique and 0.46, 0.36, 0.29, 0.22 and 0.49 for the two-phase technique. The TCP for CTV1 with HT were 79.2%, 85.2%, 81.1%, 83.0% and 53.0%; for single-phase forward-planned technique, 76.5%, 86.9%, 73.4%, 81.8% and 31.8% and for the two-phase technique, 38.2%, 86.2%, 42.7%, 0.0% and 3.4%. Dose escalation using HT confirmed the radiobiological advantage in terms of TCP.

Conclusion

TCP for the single-phase plans was comparable to that of HT plans, whereas that for the two-phase technique was lower. Centres that cannot provide IMRT for the radical treatment of all patients could implement the single-phase technique as standard to attain comparable TCP. However, IMRT produced better UCP, thereby enabling the exploration of dose escalation.

Primary pancreatic tumours are extremely rare in children. We report a case of a 5-month-old male with a diffuse invasive tumour of the head of the pancreas. The tumour demonstrated peripancreatic extension into the porta hepatis, which occluded the portal vein and invaded the superior mesenteric artery. It was found to be haemangioendotheliomatosis of the pancreas. Imaging, pathological findings and a brief relevant classification of haemangioma are discussed.

Endovascular repair of isolated iliac artery aneurysms is an established safe and effective management option. Type II endoleak is a potential complication, but rarely results in significant morbidity or mortality. We report a case of a patient who presented with a ruptured internal iliac artery aneurysm secondary to a Type II endoleak. To our knowledge this and the following method of managing this have not been previously reported. Established methods of managing endoleaks, such as intravascular transfemoral embolisation and open or laparoscopic ligation, were not possible. Therefore, we resorted to a novel approach to this type of aneurysm and successfully performed a transcutaneous direct puncture and embolisation of the superior gluteal artery.

Haemangiomas are common benign tumours that are generally detected within the skin, mucosal surfaces and soft tissues. However, intranodal haemangiomas are extremely rare and are among the benign primary vascular abnormalities of the lymph nodes that include lymphangioma, haemangioendothelioma, angiomyomatous hamartoma and haemangiomas. In this case report, we present the imaging and pathological findings of an intranodal haemangioma in the pancreatic head simulating a pancreatic neuroendocrine tumour. To the best of our knowledge, this is the first report of an intranodal haemangioma in this location.

A variety of techniques are now available to directly or indirectly detect signal from tissues, fluids and materials that have short, ultrashort or supershort T2 or T2* components. There are also methods of developing image contrast between tissues and fluids in the short T2 or T2* range that can provide visualisation of anatomy, which has not been previously seen with MRI. Magnetisation transfer methods can now be applied to previously invisible tissues, providing indirect access to supershort T2 components. Particular methods have been developed to target susceptibility effects and quantify them after correcting for anatomical distortion. Specific methods have also been developed to image the effects of magnetic iron oxide particles with positive contrast. Major advances have been made in techniques designed to correct for loss of signal and gross image distortion near metal. These methods are likely to substantially increase the range of application for MRI.

Primary pleural lymphoma is a rare entity that has been described in association with human immunodeficiency virus (HIV) infection or pyothorax. It occurs in only 7% of primary lymphoma cases. We report the case of a 52-year-old male with no history of HIV infection or pyothorax who was diagnosed of obstructive sleep apnoea syndrome (OSAS) and underwent a routine chest X-ray to screen for any organic cause of the symptoms. The radiograph revealed two voluminous masses with extraparenchymatous features but without pleural effusion. A contrast-enhanced CT was performed and confirmed the existence of the pleural masses that showed homogeneous attenuation. Neither mediastinal lymphadenopathy nor pleural effusion were present. A percutaneous CT-guided fine needle aspiration cytology (FNAC) with a 25-G needle was performed (two samples were obtained) and the first diagnosis was of non-Hodgkin's lymphoma. The final diagnosis of primary pleural mucosa-associated lymphoid tissue (MALT) lymphoma was confirmed by a CT-guided core biopsy with a 20-G needle. To the best of our knowledge, no cases of MALT lymphoma presenting as pleural masses without pleural effusion have been reported in immunocompetent patients. In this report, we describe the case of a patient with a primary pleural MALT lymphoma and include a short review of the literature.

Thermal tumour ablation techniques such as radiofrequency (RF) ablation are applied for radical removal of local tumours as an easier, less invasive alternative to surgical resection. A serious drawback of thermal ablation, however, is that the ablation area cannot be accurately assessed during the procedure. To achieve real-time feedback and exact and safe ablation, a superfine thermocouple-needle system (TNS) comprising a 0.25-mm diameter thermocouple embedded in a 22-G, 15-cm-long needle was devised and efficacy was tested in vitro using porcine livers (n = 15) and in vivo using rabbit back muscles (n = 2) and livers (n = 3). A 17-gauge RF electrode with a 2 cm active tip was used for ablation. The TNS was inserted 1 cm from the active tip of the RF electrode and liver temperature around the electrode was measured concurrently. The RF current was cut off when the temperature reached 60°C or after 5 min at ≥50°C. Porcine livers and rabbit back muscles were then cut along a plane passing through the axes of the electrode and the TNS. In rabbit livers, contrast-enhanced CT was performed to evaluate ablation areas. Ablation areas in cut surfaces of porcine livers exhibited well-defined discoloured regions and the TNS tip precisely pinpointed the margin of the ablation area. Contrast-enhanced CT of rabbit livers showed the TNS tip accurately located at the margin of areas without contrast enhancement. These results indicate that the TNS can accurately show ablation margins and that placing the TNS tip at the intended ablation margin permits exact thermal ablation.

Objectives

In the UK, the treatment of patients with mycosis fungoides using total skin electron (TSE) beam therapy is undertaken using a number of different irradiation techniques. As part of a review of these techniques, a comparative set of measurements would be useful to determine how the techniques differ in terms of dose distribution. A dose penetration intercomparison method that could be used as part of such a study is presented here.

Methods

The dose penetrations for six treatment techniques currently or recently used in four centres in the UK were measured. The variation of dose with skin depth was measured in a WT1 solid water mid-torso phantom. The phantom is portable and suitable to be used in all the techniques. It is designed to hold four small radiochromic film dosemeters to investigate the variation in dose around the mid-torso. For each treatment technique, the phantom was irradiated using the clinical set-up.

Results

The phantom performed well and was able to measure dose penetration and the uniformity of penetration for several treatment techniques.

Conclusion

These preliminary results demonstrate that there is some variation in dose distribution between different TSE treatment techniques and that the phantom could be used in a more comprehensive intercomparison. The results are not intended to demonstrate comprehensively the range of penetration that can be achieved in clinical practice as, for one of the treatment techniques, the penetration is customised for the extent of the disease.

Objectives

The aim was to evaluate the influence of bevacizumab on intratumour oxygenation status and lung metastasis following radiotherapy, with specific reference to the response of quiescent (Q) cell populations within irradiated tumours.

Methods

B16-BL6 melanoma tumour-bearing C57BL/6 mice were continuously given 5-bromo-2-deoxyuridine (BrdU) to label all proliferating (P) cells. They received γ-ray irradiation following treatment with the acute hypoxia-releasing agent nicotinamide or local mild temperature hyperthermia (MTH) with or without the administration of bevacizumab under aerobic conditions or totally hypoxic conditions, achieved by clamping the proximal end of the tumours. Immediately after the irradiation, cells from some tumours were isolated and incubated with a cytokinesis blocker. The responses of the Q and total (P + Q) cell populations were assessed based on the frequency of micronuclei using immunofluorescence staining for BrdU. In the other tumour-bearing mice, macroscopic lung metastases were enumerated 17 days after irradiation.

Results

3 days after bevacizumab administration, acute hypoxia-rich total cell population in the tumour showed a remarkably enhanced radiosensitivity to γ-rays, and the hypoxic fraction (HF) was reduced, even after MTH treatment. However, the hypoxic fraction was not reduced after nicotinamide treatment. With or without γ-ray irradiation, bevacizumab administration showed some potential to reduce the number of lung metastases as well as nicotinamide treatment.

Conclusion

Bevacizumab has the potential to reduce perfusion-limited acute hypoxia and some potential to cause a decrease in the number of lung metastases as well as nicotinamide.

Objective

Moraxella catarrhalis is an important pathogen in the exacerbation of chronic obstructive pulmonary disease. The aim of this study was to assess the clinical and pulmonary thin-section CT findings in patients with acute M. catarrhalis pulmonary infection.

Methods

Thin-section CT scans obtained between January 2004 and March 2009 from 292 patients with acute M. catarrhalis pulmonary infection were retrospectively evaluated. Clinical and pulmonary CT findings in the patients were assessed. Patients with concurrent infection including Streptococcus pneumoniae (n = 72), Haemophilus influenzae (n = 61) or multiple pathogens were excluded from this study.

Results

The study group comprised 109 patients (66 male, 43 female; age range 28–102 years; mean age 74.9 years). Among the 109 patients, 34 had community-acquired and 75 had nosocomial infections. Underlying diseases included pulmonary emphysema (n = 74), cardiovascular disease (n = 44) or malignant disease (n = 41). Abnormal findings were seen on CT scans in all patients and included ground-glass opacity (n = 99), bronchial wall thickening (n = 85) and centrilobular nodules (n = 79). These abnormalities were predominantly seen in the peripheral lung parenchyma (n = 99). Pleural effusion was found in eight patients. No patients had mediastinal and/or hilar lymph node enlargement.

Conclusions

M. catarrhalis pulmonary infection was observed in elderly patients, often in combination with pulmonary emphysema. CT manifestations of infection were mainly ground-glass opacity, bronchial wall thickening and centilobular nodules.

This commentary will discuss the use of the “stroke window” settings in the evaluation of CT head examinations and advocate their more widespread use in patients who present with neurological symptoms in addition to patients with suspected stroke. We present examples of the use of stroke windows, which revealed subtle abnormalities that were not readily apparent on default brain window settings and were subsequently confirmed on MRI or follow-up CT. As a result we suggest that stroke windows should be routine in the review of all CT head examinations.

The aim of this article is to provide a perspective on the relative importance and contribution of different imaging modalities in patients with valvular heart disease. Valvular heart disease is increasing in prevalence across Europe, at a time when the clinical ability of physicians to diagnose and assess severity is declining. Increasing reliance is placed on echocardiography, which is the mainstay of cardiac imaging in valvular heart disease. This article outlines the techniques used in this context and their limitations, identifying areas in which dynamic imaging with cardiovascular magnetic resonance and multislice CT are expanding.