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British Journal of Radiology [journal]
- Phyllodes tumours of the breast. Radiological presentation, management and follow-up. [JOURNAL ARTICLE]
- Br J Radiol 2014 Oct 1.:20140239.
Objectives: Phyllodes tumours (PT) are rare neoplasms accounting for less than 1% of breast lesions. With increased breast awareness and screening programmes, smaller PTs are being detected. The purpose of this study was to determine the clinical, radiological and pathological presentation of PT and to evaluate the role of imaging follow up, for which there are no specific guidelines. Methods: A retrospective study of all patients diagnosed with PT in a symptomatic unit between January 2006 and March 2013 was carried out. Patients were identified using Breast Care and Electronic Patient Record Databases. Results: 53 patients with 54 lesions were diagnosed as having a PT. Median age was 27.5, 35 and 38.5 years for benign, borderline and malignant PT respectively. Borderline and malignant PTs were larger than benign PTs, with mean sizes of 33mm and 42mm compared to 29mm. 38% of PTs were labelled by the reporting radiologist as fibroadenomas including 2 borderline and 1 malignant PT. In 24 % of cases the radiologist raised the possibility of PT in the report. 17 patients (40%) developed a new fibroepithelial breast lesion during follow-up of which 4 were recurrent PT. Conclusion: Despite adequate surgical management, development of further fibroepithelial lesions in the ipsilateral breast is common. Three year clinical surveillance, with the addition of 6-monthly ultrasound is advised for women with initial borderline or malignant PT histology. Advances in knowledge: We propose a follow-up protocol with ultrasound based on the grade of the PT diagnosed for 3 years to detect recurrence.
- Future development of biologically relevant dosimetry. [JOURNAL ARTICLE]
- Br J Radiol 2014 Sep 26.:20140392.
Proton and ion beams are radiotherapy modalities of increasing importance and interest. Because of the different biological dose response of these radiations as compared to high-energy photon beams, the current approach of treatment prescription is based on the product of the absorbed dose to water and a biological weighting factor, but this is found to be insufficient for providing a generic method to quantify the biological outcome of radiation. It is therefore suggested to define new dosimetric quantities which allow a transparent separation of the physical processes from the biological ones. Given the complexity of the initiation and occurrence of biological processes on various time and length scales, and given that neither microdosimetry nor nanodosimetry on their own can fully describe the biological effects as a function of the distribution of energy deposition or ionisation, a multi-scale approach is needed to lay the foundation for the aforementioned new physical quantities relating track structure to relative biological effectiveness in proton and ion beam therapy. This paper reviews the state of the art of microdosimetry, nanodosimetry, track structure simulations, quantification of reactive species, reference radiobiological data, cross section data and multi-scale models of biological response in the context of realising the new quantities. It also introduces the European metrology project, BioQuaRT, which aims to investigate the feasibility of establishing a multi-scale model as the basis of the new quantities. A tentative generic expression of how the weighting of physical quantities at different length scales could be done is presented.
- Impact of the introduction of weekly radiotherapy quality assurance meeting at one U.K. cancer centre. [JOURNAL ARTICLE]
- Br J Radiol 2014 Sep 24.:20140422.
Objectives: The complexity of radiotherapy planning is increasing rapidly. Delivery and planning is subject to detailed quality assurance checks. The weakest link is often the oncologists' delineation of the clinical target volume. Weekly departmental meetings for radiotherapy quality assurance meetings were introduced into the Royal Wolverhampton Hospital in October 2011. This paper describes the impact of this on patient care. Methods: Clinical target volumes for megavoltage photon radiotherapy courses for all radical, adjuvant and palliative treatments longer than 5 fractions (with the exception of 2 field tangential breast treatments not enrolled into clinical trials) were reviewed in the radiotherapy quality assurance meeting. Audits were carried out in January 2012 (baseline) and September 2013, each over a 4-week period. Adherence to departmental contouring protocols was assessed and the numbers of major and minor alterations following peer review were determined. Results: There was no statistically significant difference for major alterations between the two study groups; 8 alterations in 80 patients (10%) for the baseline audit versus 3 alterations from 72 patients (4.2%) in the second audit (p=0.17). A trend towards a reduction in alterations following peer review was observed. There has, however been a change in practice resulting in a reduction in variation in clinical target volume definition within our centre and greater adherence to protocols. There is increasing confidence in the quality and constancy of care delivered. Conclusion: Introduction of a weekly quality assurance meeting for target volume definition has facilitated consensus and adoption of departmental clinical guidelines within the unit.
- 4D Radiobiological modelling of the interplay effect in conventionally and hypo-fractionated lung tumour IMRT. [JOURNAL ARTICLE]
- Br J Radiol 2014 Sep 24.:20140372.
Objective: To study the impact of the interplay between respiration-induced tumour motion and MLC leaf movements in IMRT as a function of number of fractions, dose rate on population mean TCP ([Formula: see text]pop) using an in-house developed dose model. Materials and Methods: Delivered dose is accumulated in a voxel-by-voxel basis inclusive of tumour motion over the course of treatment. The effect of interplay on dose and [Formula: see text]pop is studied for conventionally and hypofractionated treatments using DICOM datasets. Moreover, the effect of dose rate on interplay is also studied for single-fraction treatments. Simulations were repeated several times to obtain [Formula: see text]pop for each plan. Results: The average variation observed in mean dose to the target volumes were -0:76±0:36% for the 20 fraction treatment and -0:26±0:68%, -1:05±0:98% for the 3- and single-fraction treatments respectively. For the 20-fraction treatment, the drop in [Formula: see text]pop was -1:05±0:39%, whereas for the 3 and single fraction treatments it was -2:8±1:68% and -4:0±2:84% respectively. By reducing the dose rate from 600 to 300 MU/min for the single-fraction treatments; the drop in [Formula: see text]pop was reduced by ~1.5%. Conclusions: The effect of interplay on [Formula: see text]pop is negligible for conventionally fractionated treatments; whereas considerable drop in [Formula: see text]pop is observed for the 3- and single-fraction treatments. Reduced dose rate could be used in hypofractionated treatments to reduce the interplay effect. Advances in knowledge: A novel in silico dose model is presented to determine the impact of interplay effect in IMRT treatments on [Formula: see text]pop.
- Trans-caval trans-jugular liver biopsy - a technical modification of trans-jugular liver biopsy. [JOURNAL ARTICLE]
- Br J Radiol 2014 Sep 24.:20140327.
Introduction: Trans-jugular liver biopsy (TJLB) is an established procedure in patients unsuitable for percutaneous trans-abdominal liver biopsy. We describe a technical modification in which the biopsy is performed directly through the inferior vena cava instead of the hepatic veins. We also report our experience of this technique in 9 patients. Objectives: (a) To describe the technical modification of trans-caval TJLB, (b) review of our series of 9 cases. Methods: We did a retrospective review of all trans-caval TJLBs performed; we assessed indications for the procedure, technical success, complications, adequacy of specimen and histologic positivity. Results: Technical success rate of procedure was 9/9 (100 %); minor complication rate was 1/9 (11 %), adequate specimen was obtained inall cases and histologicaldiagnosis was achieved in 8/9 (89 %) cases. Conclusions: This preliminary report suggests that trans-caval modification of TJLB is a relatively safe procedure that may be useful in cases where conventional TJLB is infeasible. Advances in knowledge: (a) We describe the technique of trans-caval TJLBs and report our findings in the largest series of published cases. (b) Trans-caval TJLB is relatively safe and can be used to increase the success rates of conventional TJLB.
- Obscure gastrointestinal bleeding: diagnostic performance of 64-Section multiphase CT enterography and CT angiography compared with capsule endoscopy. [JOURNAL ARTICLE]
- Br J Radiol 2014 Sep 24.:20140229.
Objective: To compare the diagnostic capabilities between capsule endoscopy (CE) and multislice computed tomography enterography (MSCTE) in combination with MSCT angiography (MSCTA) for assessment of obscure gastrointestinal bleeding (OGIB). Methods: A total of 127 patients with OGIB were studied in this study. Eighty-two patients (aged 42.7±19.1 years; 34 males) were assigned to receive MSCT diagnosis and 67 patients (aged 53.9±16.2 years; 28 males) received CE diagnosis. Among them, 22 patients (aged 54.1±19.1 years; 12 males) received both examinations. Oral isotonic mannitol and intramuscular injection of anisodamine were performed, nonionic contrast (iopromide, 370 mg I/ml) were intravenously administered, and then multiphase scanning was conducted at arterial, small intestinal and portal venous phases in MSCT. The results were compared with findings of reference standards including double balloon enteroscopy (DBE), digital subtraction angiography (DSA), intraoperative pathological examination, and/or clinical diagnosis. Results: Administration of anisodamine markedly increased the satisfaction rate of bowel filling (94.67% vs 28.57%, P<0.001) but not the diagnostic yield (P=0.293) of MSCT. Compared to MSCT, CE showed an improved overall diagnostic yield (68.66% vs 47.56%, P=0.010), which was also observed in overt bleeding patients (i.e. patients with continued passage of visible blood) (76.19% vs 51.02%, P=0.013) and patients aged less than 40 years (85% vs 51.28%, P=0.024). However, CE had similar positive rates to MSCT (P>0.05). Among the 22 cases who conducted both examinations, CE showed no significantly different diagnostic capability compared to MSCT (P=0.4597).
- A systematic review of ultrasound guided FNA of lesions in the head and neck - focusing on operator, sample inadequacy and presence of on-spot cytology service. [JOURNAL ARTICLE]
- Br J Radiol 2014 Sep 23.:20130571.
Objectives To perform a systematic review of ultrasound guided FNA services for head and neck lesions with assessment of inadequacy rates and related variables such as the presence of immediate cytological assessment. Methods A computer based systematic search of articles in English Language was performed using MEDLINE (1950 to date) from NHS evidence healthcare database and Pubmed. Full texts of all relevant articles were obtained and scrutinised independently by two authors according to the stated inclusion and exclusion criteria. Results The primary search identified 932 articles, but only 78 met all the study criteria. The overall inadequacy rate was 9.3%, 16 studies had onsite evaluation by a cytopathologist/specialist clinician with a rate of 6.0%. In 7 studies a cytotechnician was available to either to assess the sample or to prepare the slides with an average inadequacy rate of 11.4%. In one study the assessment was unclear, but the inadequacy rate for the remaining 54 studies, without immediate assessment was 10.3%. The rate for the cytopathologist/specialist clinicians was significantly different to no on-site assessment but this was not found for assessment by cytotechnicians. Conclusions The review suggests that the best results are obtained with a cytopathologist led FNA service, where the pathologist reviews the specimen immediately, in relation to the clinical context, thereby deciding on adequacy and need for further biopsies. Advances in knowledge A systematic review looking at ultrasound guided FNA of head and neck lesions has not been published previously.
- Use of an internal reference in semi-quantitative dynamic contrast enhanced MRI (DCE MRI) of indeterminate adnexal masses. [JOURNAL ARTICLE]
- Br J Radiol 2014 Sep 19.:20130730.
Objectives: Semi-quantitative DCE MRI has proven useful in discriminating benign from borderline/malignant adnexal lesions. Our aim was to assess if use of a lesion to internal reference ratio improved performance, and which internal reference was suitable. Methods: Semi-quantitative DCE MRIs of 71 indeterminate adnexal lesions were retrospectively reviewed. A region of interest (ROI) was manually drawn onto the enhancing solid component, psoas muscle and normal outer myometrium. The DCE parameters were evaluated and lesion to internal reference ratios were calculated. Results: When the wash-in-rate (WIR) of the lesion was higher than the myometrium, 97% specificity and 12% sensitivity for borderline/malignancy was reached. When the maximum relative enhancement (SIrel) and maximum absolute enhancement (SImax) of the lesion was less than the psoas, 100% specificity for benignity was achieved. The highest AUC (0.807) was achieved using a SImax lesion-myometrium ratio. A slightly lower AUC (0.799) was achieved using a SImax lesion-psoas ratio, but psoas muscle was more frequently measurable in the same slice as the lesion ROI. Although the AUC was higher using ratios than the individual DCE values, this was not significantly different. Conclusion: DCE has added diagnostic value in the assessment of adnexal lesions, and use of internal references enables high specificity for malignancy and benignity. Lesion-internal reference ratios have no added diagnostic value over DCE values alone. Advances in knowledge: Both psoas muscle and myometrium are suitable internal references in the DCE assessment of adnexal lesions enabling high specificity for malignancy and benignity.
- Advancing pharmacovigilance through academic-legal collaboration: the case of gadolinium-based contrast agents and nephrogenic systemic fibrosis-a research on adverse drug events and reports (RADAR) report. [Journal Article]
- Br J Radiol 2014 Oct; 87(1042):20140307.
To compare and contrast three databases, that is, The International Centre for Nephrogenic Systemic Fibrosis Registry (ICNSFR), the Food and Drug Administration Adverse Event Reporting System (FAERS) and a legal data set, through pharmacovigilance and to evaluate international nephrogenic systemic fibrosis (NSF) safety efforts.The Research on Adverse Drug events And Reports methodology was used for assessment-the FAERS (through June 2009), ICNSFR and the legal data set (January 2002 to December 2010). Safety information was obtained from the European Medicines Agency, the Danish Medicine Agency and the Food and Drug Administration.The FAERS encompassed the largest number (n = 1395) of NSF reports. The ICNSFR contained the most complete (n = 335, 100%) histopathological data. A total of 382 individual biopsy-proven, product-specific NSF cases were analysed from the legal data set. 76.2% (291/382) identified exposure to gadodiamide, of which 67.7% (197/291) were unconfounded. Additionally, 40.1% (153/382) of cases involved gadopentetate dimeglumine, of which 48.4% (74/153) were unconfounded, while gadoversetamide was identified in 7.3% (28/382) of which 28.6% (8/28) were unconfounded. Some cases involved gadobenate dimeglumine or gadoteridol, 5.8% (22/382), all of which were confounded. The mean number of exposures to gadolinium-based contrast agents (GBCAs) was gadodiamide (3), gadopentetate dimeglumine (5) and gadoversetamide (2). Of the 279 unconfounded cases, all involved a linear-structured GBCA. 205 (73.5%) were a non-ionic GBCA while 74 (26.5%) were an ionic GBCA.Clinical and legal databases exhibit unique characteristics that prove complementary in safety evaluations. Use of the legal data set allowed the identification of the most commonly implicated GBCA.This article is the first to demonstrate explicitly the utility of a legal data set to pharmacovigilance research.
- A new variable for SRS plan quality evaluation based on normal tissue sparing: the effect of prescription isodose levels. [Journal Article]
- Br J Radiol 2014 Nov; 87(1043):20140362.
A new dosimetric variable, dose-dropping speed (DDS), was proposed and used to evaluate normal tissue sparing among stereotactic radiosurgery (SRS) plans with different prescription isodose lines.40 plans were generated for 8 intracranial SRS cases, prescribing to isodose levels (IDLs) ranging from 50% to 90% in 10% increments. Whilst maintaining similar coverage and conformity, plans at different IDLs were evaluated in terms of normal tissue sparing using the proposed DDS. The DDS was defined as the greater decay coefficient in a double exponential decay fit of the dose drop-off outside the planning target volume (PTV), which models the steep portion of the drop-off. Provided that the prescription dose covers the whole PTV, a greater DDS indicates better normal tissue sparing.Among all plans, the DDS was found to be the lowest for the prescription at 90% IDL and the highest for the prescription at 60% or 70%. The beam profile slope change in the penumbra and its field size dependence were explored and given as the physical basis of the findings.A variable was proposed for SRS plan quality evaluation. Using this measure, prescriptions at 60% and 70% IDLs were found to provide best normal tissue sparing.A new variable was proposed based on which normal tissue sparing was quantitatively evaluated, comparing different prescription IDLs in SRS.