Can prostate cancer be NICE?

On 9 May 2019, the National Institute for Health and Care Excellence (NICE) published its updated UK guidance on prostate cancer. The publication is the culmination of a 3 year process. It is an evidence-based, carefully crafted, comprehensive "book" to compliment the pre-existing 2014 guidance. It was born from new evidence on aspects of prostate cancer treatment and, most relevant for this special edition, diagnosis. This article provides a "behind-the-scenes" on how NICE operates, using the guideline as a case study. The piece sets out to demystify this august governance body's processes: from the decision to update the existing guidance, through the scoping and discussion stages to the principles and policies that shaped the whole process. This provides the backdrop to the second half of the article wherein the 85 page guideline is condensed in to a few highly pertinent recommendations. The areas that sparked the most debate during the committee's 24-month lifespan are highlighted, finishing by asking the UK radiology community: where do we go next in this new era of multiparametric magnetic resonance imaging first?

Fluoroscopic removal of 'lost thread' IUCD's: a novel second line technique.

Intrauterine contraceptive devices (IUCDs) with lost threads are an infrequent but growing problem, and there are several successful first-line methods of retrieving the devices. In the event of retrieval failure, we propose a novel second-line technique using an endovascular snare under direct fluoroscopic guidance. A total of 137 women were referred with 'lost string' IUCDs and underwent removal using a snare device, designed for endovascular foreign body retrieval, inserted transcervically. The snare is manipulated to catch the stem of the IUCD under C-arm fluoroscopy. The successful removal rate was 89.6%. The average screening time was 3 min 29 s, with a median air kerma of 12.33 mGy and DAP of 985 mGy cm(2), which was considered minimal and comparable with similar gynaecological interventional procedures. There were no significant complications, with the procedure being tolerated and pain free in 97.8% of cases.

Prostate MRI: who, when, and how? Report from a UK consensus meeting.

The current pathway for men suspected of having prostate cancer [transrectal biopsy, followed in some cases by magnetic resonance imaging (MRI) for staging] results in over-diagnosis of insignificant tumours, and systematically misses disease in the anterior prostate. Multiparametric MRI has the potential to change this pathway, and if performed before biopsy, might enable the exclusion of significant disease in some men without biopsy, targeted biopsy in others, and improvements in the performance of active surveillance. For the potential benefits to be realized, the setting of standards is vital. This article summarizes the outcome of a meeting of UK radiologists, at which a consensus was achieved on (1) the indications for MRI, (2) the conduct of the scan, (3) a method and template for reporting, and (4) minimum standards for radiologists.

Applications of transrectal ultrasound in prostate cancer.

Transrectal ultrasound (TRUS) was first developed in the 1970s. TRUS-guided biopsy, under local anaesthetic and prophylactic antibiotics, is now the most widely accepted method to diagnose prostate cancer. However, the sensitivity and specificity of greyscale TRUS in the detection of prostate cancer is low. Prostate cancer most commonly appears as a hypoechoic focal lesion in the peripheral zone on TRUS but the appearances are variable with considerable overlap with benign lesions. Because of the low accuracy of greyscale TRUS, TRUS-guided biopsies have become established in the acquisition of systematic biopsies from standard locations. The number of systematic biopsies has increased over the years, with 10-12 cores currently accepted as the minimum standard. This article describes the technique of TRUS and biopsy and its complications. Novel modalities including contrast-enhanced modes and elastography as well as fusion techniques for increasing the sensitivity of TRUS-guided prostate-targeted biopsies are discussed along with their role in the diagnosis and management of prostate cancer.

Multicentre survey of radiologically inserted gastrostomy feeding tube (RIG) in the UK.

AIMS: To evaluate the variance in current UK clinical practice and clinical outcomes for direct percutaneous radiologically inserted gastrostomy (RIG). MATERIALS AND METHODS: A prospective UK multicentre survey of RIG performed between October 2008 and August 2010 was performed through the British Society of Gastrointestinal and Abdominal Radiology (BSGAR). RESULTS: Data from 684 patients were provided by 45 radiologists working at 17 UK centres. Two hundred and sixty-three cases (40%) were performed with loop-retained catheters, and 346 (53%) with balloon-retained devices. Sixty percent of all patients experienced pain in the first 24 h, but settled in the majority thereafter. Early complications, defined as occurring in the first 24 h, included minor bleeding (1%), wound infection (3%), peritonism (2%), and tube misplacement (1%). Late complications, defined as occurring between day 2 and day 30 post-procedure, included mild pain (30%), persisting peritonism (2%), and 30 day mortality of 1% (5/665). Pre-procedural antibiotics or anti-methicillin-resistant Staphylococcus aureus (MRSA) prophylaxis did not affect the rate of wound infection, peritonitis, post-procedural pain, or mortality. Ninety-three percent of cases were performed using gastropexy. Gastropexy decreased post-procedural pain (p < 0.001), but gastropexy-related complications occurred in 5% of patients. However, post-procedure pain increased with the number of gastropexy sutures used (p < 0.001). The use of gastropexy did not affect the overall complication rate or mortality. Post-procedure pain increased significantly as tube size increased (p < 0.001). The use of balloon-retention feeding tubes was associated with more pain than the deployment of loop-retention devices (p < 0.001). CONCLUSION: RIG is a relatively safe procedure with a mortality of 1%, with or without gastropexy. Pain is the commonest complication. The use of gastropexy, fixation dressing or skin sutures, smaller tube sizes, and loop-retention catheters significantly reduced the incidence of pain. There was a gastropexy-related complication rate in 5% of patients. Neither pre-procedural antibiotics nor anti-MRSA prophylaxis affected the rate of wound infection.

How to reduce nephropathy following contrast-enhanced CT: a lesson in policy implementation.

In excess of 50 contrast-enhanced computed tomography (CT) examinations are typically undertaken in our tertiary hospital NHS Trust each weekday, approximately 13,000 each year. In the Department of Radiology alone, we inject more than 1300 l of iodinated contrast medium per annum. There is a real need to devise a policy to anticipate contrast medium-induced nephropathy (CIN) and minimize its effects, without disrupting the high-intensity CT service. Having written a comprehensive yet pragmatic policy to reduce the incidence of this iatrogenic condition, it seemed sensible to share it with the wider radiology community and share the experience and lessons learnt in engaging all the stakeholders, ushering in the change with as little fuss as possible. The ramifications on primary and secondary care had to be anticipated, resource implications managed, and staff trained. This review is therefore presented in four sections: framing the problem, assessing its size and nature; a succeeding section on the available guidelines and their uptake; the policy itself to reduce CIN in CT is presented in the third section; and crucially, a description of the policy introduction process in the last section.

The utility of CT in imaging chest infections in HIV-negative patients.

This article focuses on the recent developments in CT imaging of chest infections in patients who are immunocompetent or immunosuppressed, but not infected with HIV. Although simple viral and bacterial infections predominate, more "exotic" infections are now being encountered. First, a re-emergence of mycobacterial disease has occurred. Second, a growing population of transplant recipients (i.e., lung, solid organ, and bone marrow) is susceptible to a wide range of pathogens. These trends are reflected in the forthcoming discussion. In particular, several important articles on immunosuppressed (HIV-negative) patients and on imaging fungal disease have been written within the past year.

The radiological investigation of lumbar spondylolysis.

Lumbar spondylolysis represents a stress fracture of the pars interarticularis and occurs most commonly at the L5 level. Pars defects can be imaged with plain radiography, bone scintigraphy, computed tomography (CT) and magnetic resonance imaging (MRI). Plain radiographic projections of particular value include the coned lateral view of the lumbosacral junction, which displays the majority of defects, and the anteroposterior view with 30 degrees cranial angulation. The value of oblique radiography is unproven. Planar bone scintigraphy (PBS) is more sensitive than radiography and single photon emission computed tomography (SPECT) more sensitive and specific than PBS. Both these techniques, however, are less specific than radiography and CT. CT, when performed with a reverse gantry angle and thin sections, is the investigation of choice for identifying radiographically occult lyses. Conventional lumbar spine MRI techniques are valuable for demonstrating normality of the pars, but may be associated with a high false positive rate for the diagnosis of pars defects.

Image processing and spiral CT of the thorax.

The data set of the thorax acquired by spiral CT is volumetric. Such data can be processed so that conventional axial sections are supplemented by reconstructed images, in an attempt to answer specific clinical questions. This review considers three reconstruction techniques: multiplanar reformation, three-dimensional rendering and sliding-thin slab reconstruction. Their relative benefits and limitations are considered, as are the implications of image processing in general.

Major vascular injury during lumbar laminectomy.

Major vascular injury during lumbar laminectomy is an extremely rare complication of one of the commonest surgical procedures performed in orthopaedic and neurosurgical units. Its occurrence may be associated with high morbidity and mortality, particularly if it is not diagnosed in the early stages. Early diagnosis and repair is associated with an improved prognosis in the long term. We illustrate these points with a description of two cases, and discuss the anatomical factors predisposing to these injuries and the importance of angiography in the management and early diagnosis of suspected cases.

Diethyl pyrocarbonate can detect a modified DNA structure induced by the binding of quinoxaline antibiotics.

The reactivity of the 160 bp tyrT DNA fragment towards diethyl pyrocarbonate (DEPC) has been investigated in the presence of bis-intercalating quinoxaline antibiotics and the synthetic depsipeptide TANDEM. At moderate concentrations of each ligand, specific purine residues (mainly adenosines) exhibit enhanced reactivity towards the probe, and several sites of enhancement appear to be related to the sequence selectivity of drug binding. Further experiments were performed with echinomycin at pH 5.5 and 4.6 to facilitate the protonation of cytosine required for formation of Hoogsteen GC base pairs. No significant increase in reactivity was observed under these conditions. Additionally, no protection of deoxyguanosine residues from methylation by dimethyl sulphate was observed in the presence of echinomycin. We conclude that the structural anomaly giving rise to drug-dependent enhanced DEPC reaction is not simply the formation of Hoogsteen base pairs adjacent to antibiotic binding sites. Nor is it due to a general unwinding of the double helix, since we show that conditions which are supposed to unwind the helix lead to a uniform increase in purine reactivity, regardless of the surrounding nucleotide sequence.