Treatment of polymyalgia rheumatica: British Society for Rheumatology guideline scope.

The last British Society for Rheumatology (BSR) guideline on PMR was published in 2009. The guideline needs to be updated to provide a summary of the current evidence for pharmacological and non-pharmacological management of adults with PMR. This guideline is aimed at healthcare professionals in the UK who directly care for people with PMR, including general practitioners, rheumatologists, nurses, physiotherapists, occupational therapists, pharmacists, psychologists and other health professionals. It will also be relevant to people living with PMR and organisations that support them in the public and third sector, including charities and informal patient support groups. This guideline will be developed using the methods and processes outlined in the BSR Guidelines Protocol. Here we provide a brief summary of the scope of the guideline update in development.

18 F-FDG PET/CT Imaging of Idiopathic Granulomatous Mastitis.

ABSTRACT: A 43-year-old woman, who presented with a suspected left breast abscess, underwent serial ultrasounds, which demonstrated inflammatory changes that were nonresponsive to antibiotics and which spread to the contralateral breast. 18 F-FDG PET/CT demonstrated diffuse heterogeneous intense FDG uptake in both breasts with reactive axillary nodes. Breast biopsy confirmed granulomatous inflammation, and overall findings were consistent with idiopathic granulomatous mastitis. In the absence of histological analysis, idiopathic granulomatous mastitis is an important differential diagnosis to consider for bilateral abnormal breast uptake, and early recognition can facilitate prompt commencement of treatment.

Metabolic tumour and nodal response to neoadjuvant chemotherapy on FDG PET-CT as a predictor of pathological response and survival in patients with oesophageal adenocarcinoma.

OBJECTIVES: 2-deoxy-2[18F]Fluoro-D-glucose (FDG) PET-CT has an emerging role in assessing response to neoadjuvant therapy in oesophageal cancer. This study evaluated FDG PET-CT in predicting pathological tumour response (pTR), pathological nodal response (pNR) and survival. METHODS: Cohort study of 75 patients with oesophageal or oesophago-gastric junction (GOJ) adenocarcinoma treated with neoadjuvant chemotherapy then surgery at Guy's and St Thomas' NHS Foundation Trust, London (2017-2020). Standardised uptake value (SUV) metrics on pre- and post-treatment FDG PET-CT in the primary tumour (mTR) and loco-regional lymph nodes (mNR) were derived. Optimum SUVmax thresholds for predicting pathological response were identified using receiver operating characteristic analysis. Predictive accuracy was compared to PERCIST (30% SUVmax reduction) and MUNICON (35%) criteria. Survival was assessed using Cox regression. RESULTS: Optimum tumour SUVmax decrease for predicting pTR was 51.2%. A 50% cut-off predicted pTR with 73.5% sensitivity, 69.2% specificity and greater accuracy than PERCIST or MUNICON (area under the curve [AUC] 0.714, PERCIST 0.631, MUNICON 0.659). Using a 30% SUVmax threshold, mNR predicted pNR with high sensitivity but low specificity (AUC 0.749, sensitivity 92.6%, specificity 57.1%, p = 0.010). pTR, mTR, pNR and mNR were independent predictive factors for survival (pTR hazard ratio [HR] 0.10 95% confidence interval [CI] 0.03-0.34; mTR HR 0.17 95% CI 0.06-0.48; pNR HR 0.17 95% CI 0.06-0.54; mNR HR 0.13 95% CI 0.02-0.66). CONCLUSIONS: Metabolic tumour and nodal response predicted pTR and pNR, respectively, in patients with oesophageal or GOJ adenocarcinoma. However, currently utilised response criteria may not be optimal. pTR, mTR, pNR and mNR were independent predictors of survival. KEY POINTS: • FDG PET-CT has an emerging role in evaluating response to neoadjuvant therapy in patients with oesophageal cancer. • Prospective cohort study demonstrated that metabolic response in the primary tumour and lymph nodes was predictive of pathological response in a cohort of patients with adenocarcinoma of the oesophagus or oesophago-gastric junction treated with neoadjuvant chemotherapy followed by surgical resection. • Patients who demonstrated a response to neoadjuvant chemotherapy in the primary tumour or lymph nodes on FDG PET-CT demonstrated better survival and reduced rates of tumour recurrence.

18F FDG PET/CT and Novel Molecular Imaging for Directing Immunotherapy in Cancer.

Immunotherapy has transformed the treatment landscape of many cancers, with durable responses in disease previously associated with a poor prognosis. Patient selection remains a challenge, with predictive biomarkers an urgent unmet clinical need. Current predictive biomarkers, including programmed death-ligand 1 (PD-L1) (measured with immunohistochemistry), are imperfect. Promising biomarkers, including tumor mutation burden and tumor infiltrating lymphocyte density, fail to consistently predict response and have yet to translate to routine clinical practice. Heterogeneity of immune response within and between lesions presents a further challenge where fluorine 18 fluorodeoxyglucose PET/CT has a potential role in assessing response, stratifying treatment, and detecting and monitoring immune-related toxicities. Novel radiopharmaceuticals also present a unique opportunity to define the immune tumor microenvironment to better predict which patients may respond to therapy, for example by means of in vivo whole-body PD-L1 and CD8+ T cell expression imaging. In addition, longitudinal molecular imaging may help further define dynamic changes, particularly in cases of immunotherapy resistance, helping to direct a more personalized therapeutic approach. This review highlights current and emerging applications of molecular imaging to stratify, predict, and monitor molecular dynamics and treatment response in areas of clinical need.

2-deoxy-2[18F]fluoro-D-glucose positron emission tomography-computed tomography in rheumatological diseases.

2-deoxy-2[18F]fluoro-D-glucose (FDG) PET-CT has revolutionized oncological imaging. The cellular processes that make cancer cells visible on FDG PET-CT also occur in a number of inflammatory cells. Exploiting this phenomenon has led to a growth of evidence supporting the use of FDG PET-CT in a wide range of infective and inflammatory diseases. Rheumatological diseases can affect multiple sites within the musculoskeletal system alongside multi-organ extra-articular disease manifestations. Inflammation is central to these diseases, making FDG PET-CT a logical choice. In this review article we describe the various applications of FDG PET-CT in rheumatological diseases using illustrative examples to highlight the beneficial role of FDG PET-CT in each case.

A case-control evaluation of pulmonary and extrapulmonary findings of incidental asymptomatic COVID-19 infection on FDG PET-CT.

OBJECTIVES: To describe the findings of incidental asymptomatic COVID-19 infection on FDG PET-CT using a case-control design. METHODS: Incidental pulmonary findings suspicious of asymptomatic COVID-19 infection on FDG PET-CT were classified as a confirmed (positive RT-PCR test) or suspected case (no/negative RT-PCR test). Control cases were identified using a 4:1 control:case ratio. Pulmonary findings were re-categorised by two reporters using the BSTI classification. SUV metrics in ground glass opacification (GGO)/consolidation (where present), background lung, intrathoracic nodes, liver, spleen and bone marrow were measured. RESULTS: 7/9 confirmed and 11/15 suspected cases (COVID-19 group) were re-categorised as BSTI 1 (classic/probable COVID-19) or BSTI 2 (indeterminate COVID-19); 0/96 control cases were categorised as BSTI 1. Agreement between two reporters using the BSTI classification was almost perfect (weighted κ = 0.94). SUVmax GGO/consolidation (5.1 vs 2.2; p < 0.0001) and target-to-background ratio, normalised to liver SUVmean (2.4 vs 1.0; p < 0.0001) were higher in the BSTI 1 & 2 group vs BSTI 3 (non-COVID-19) cases. SUVmax GGO/consolidation discriminated between the BSTI 1 & 2 group vs BSTI 3 (non-COVID-19) cases with high accuracy (AUC = 0.93). SUV metrics were higher (p < 0.05) in the COVID-19 group vs control cases in the lungs, intrathoracic nodes and spleen. CONCLUSION: Asymptomatic COVID-19 infection on FDG PET-CT is characterised by bilateral areas of FDG avid (intensity > x2 liver SUVmean) GGO/consolidation and can be identified with high interobserver agreement using the BSTI classification. There is generalised background inflammation within the lungs, intrathoracic nodes and spleen. ADVANCES IN KNOWLEDGE: Incidental asymptomatic COVID-19 infection on FDG PET-CT, characterised by bilateral areas of ground glass opacification and consolidation, can be identified with high reproducibility using the BSTI classification. The intensity of associated FDG uptake (>x2 liver SUVmean) provides high discriminative ability in differentiating such cases from pulmonary findings in a non-COVID-19 pattern. Asymptomatic COVID-19 infection causes a generalised background inflammation within the mid-lower zones of the lungs, hilar and central mediastinal nodal stations, and spleen on FDG PET-CT.

Incidence and relevance of clinically indeterminate nonregional lymph nodes in the treatment of oesophageal cancer.

OBJECTIVES: Metastatic involvement of nonregional supraclavicular or superior mediastinal lymph nodes in distal oesophageal cancer is rare but has important implications for prognosis and management. The management of nonregional lymph nodes which appear indeterminate on CT and FDG PET-CT (subcentimeter nodes or those with preserved normal morphology, but increased FDG avidity) can present a diagnostic dilemma. This study investigates the incidence, work-up and clinical significance of nonregional clinically indeterminate FDG avid lymph nodes. METHODS: A single-centre retrospective review of all FDG PET-CT scans conducted over 5 years was conducted. Patients with mid- or distal oesophageal cancer with nonregional FDG avid nodes were identified. Subsequent work-up, management and outcomes were retrieved from electronic health records. RESULTS: Reports for 1189 PET-CT scans were reviewed. A total of 79 patients met the inclusion criteria. Of these, 18 (23%) were deemed to have disease and performance status potentially amenable to radical surgery and underwent further assessment. The indeterminate lymph nodes were successfully sampled via endobronchial ultrasound (EBUS) or ultrasound-guided fine-needle aspiration (US-FNA) in 100% of cases. 15/18 (83.3%) of samples were benign and proceeded to surgery. Outcomes for patients who proceeded to surgery were similar to other cohorts. None had pathology suggesting false-negative lymph node sampling. CONCLUSIONS: EBUS and US-FNA are effective means of sampling clinically indeterminate nonregional lymph nodes, and can significantly impact prognosis, and management. Further investigations in this context are of value in this cohort and should be pursued. Nonregional clinically indeterminate lymph nodes represent a diagnostic dilemma in oesophageal cancer staging. Additional investigations in the form of endobronchial ultrasound are effective at providing additional staging information, and can substantially influence patient care.

Artificial Intelligence for the Characterization of Pulmonary Nodules, Lung Tumors and Mediastinal Nodes on PET/CT.

Lung cancer is the leading cause of cancer related death around the world although early diagnosis remains vital to enabling access to curative treatment options. This article briefly describes the current role of imaging, in particular 2-deoxy-2-[18F]fluoro-D-glucose (FDG) PET/CT, in lung cancer and specifically the role of artificial intelligence with CT followed by a detailed review of the published studies applying artificial intelligence (ie, machine learning and deep learning), on FDG PET or combined PET/CT images with the purpose of early detection and diagnosis of pulmonary nodules, and characterization of lung tumors and mediastinal lymph nodes. A comprehensive search was performed on Pubmed, Embase, and clinical trial databases. The studies were analyzed with a modified version of the Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis (TRIPOD) and Prediction model Risk Of Bias Assessment Tool (PROBAST) statement. The search resulted in 361 studies; of these 29 were included; all retrospective; none were clinical trials. Twenty-two records evaluated standard machine learning (ML) methods on imaging features (ie, support vector machine), and 7 studies evaluated new ML methods (ie, deep learning) applied directly on PET or PET/CT images. The studies mainly reported positive results regarding the use of ML methods for diagnosing pulmonary nodules, characterizing lung tumors and mediastinal lymph nodes. However, 22 of the 29 studies were lacking a relevant comparator and/or lacking independent testing of the model. Application of ML methods with feature and image input from PET/CT for diagnosing and characterizing lung cancer is a relatively young area of research with great promise. Nevertheless, current published studies are often under-powered and lacking a clinically relevant comparator and/or independent testing.

The Role of PET-CT Imaging in Prostate Cancer.

Prostate cancer is the commonest malignancy to affect men in the United Kingdom. Extraprostatic disease detection at staging and in the setting of biochemical recurrence is essential in determining treatment strategy. Conventional imaging including computed tomography and bone scintigraphy are limited in their ability to detect sites of loco-regional nodal and metastatic bone disease, particularly at clinically relevant low prostate-specific antigen levels. The use of positron emission tomography-computed tomography has helped overcome these deficiencies and is leading a paradigm shift in the management of prostate cancer using a wide range of radiopharmaceuticals. Their mechanisms of action, utility in both staging and biochemical recurrence, and comparative strengths and weaknesses will be covered in this article.

Vascular findings on FDG PET/CT.

Since its introduction into clinical practice, 2-deoxy-2-[18F]flu-D-glucose (FDG) positron emission tomography/computed tomography (PET/CT) has become firmly established in the field of oncological imaging, with a growing body of evidence demonstrating its use in infectious and inflammatory vascular pathologies. This pictorial review illustrates the utility of FDG PET/CT as a diagnostic tool in the investigation of vascular disease and highlights some of the more common incidental vascular findings that PET reporters may encounter on standard oncology FDG PET/CTs, including atherosclerosis, large vessel vasculitis, complications of vascular grafts, infectious aortitis and acute aortic syndromes.

Ultrasound, CT, MRI, or PET-CT for staging and re-staging of adults with cutaneous melanoma.

BACKGROUND: Melanoma is one of the most aggressive forms of skin cancer, with the potential to metastasise to other parts of the body via the lymphatic system and the bloodstream. Melanoma accounts for a small percentage of skin cancer cases but is responsible for the majority of skin cancer deaths. Various imaging tests can be used with the aim of detecting metastatic spread of disease following a primary diagnosis of melanoma (primary staging) or on clinical suspicion of disease recurrence (re-staging). Accurate staging is crucial to ensuring that patients are directed to the most appropriate and effective treatment at different points on the clinical pathway. Establishing the comparative accuracy of ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET)-CT imaging for detection of nodal or distant metastases, or both, is critical to understanding if, how, and where on the pathway these tests might be used. OBJECTIVES: Primary objectivesWe estimated accuracy separately according to the point in the clinical pathway at which imaging tests were used. Our objectives were:• to determine the diagnostic accuracy of ultrasound or PET-CT for detection of nodal metastases before sentinel lymph node biopsy in adults with confirmed cutaneous invasive melanoma; and• to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for whole body imaging in adults with cutaneous invasive melanoma:○ for detection of any metastasis in adults with a primary diagnosis of melanoma (i.e. primary staging at presentation); and○ for detection of any metastasis in adults undergoing staging of recurrence of melanoma (i.e. re-staging prompted by findings on routine follow-up).We undertook separate analyses according to whether accuracy data were reported per patient or per lesion.Secondary objectivesWe sought to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for whole body imaging (detection of any metastasis) in mixed or not clearly described populations of adults with cutaneous invasive melanoma.For study participants undergoing primary staging or re-staging (for possible recurrence), and for mixed or unclear populations, our objectives were:• to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for detection of nodal metastases;• to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for detection of distant metastases; and• to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for detection of distant metastases according to metastatic site. SEARCH METHODS: We undertook a comprehensive search of the following databases from inception up to August 2016: Cochrane Central Register of Controlled Trials; MEDLINE; Embase; CINAHL; CPCI; Zetoc; Science Citation Index; US National Institutes of Health Ongoing Trials Register; NIHR Clinical Research Network Portfolio Database; and the World Health Organization International Clinical Trials Registry Platform. We studied reference lists as well as published systematic review articles. SELECTION CRITERIA: We included studies of any design that evaluated ultrasound (with or without the use of fine needle aspiration cytology (FNAC)), CT, MRI, or PET-CT for staging of cutaneous melanoma in adults, compared with a reference standard of histological confirmation or imaging with clinical follow-up of at least three months' duration. We excluded studies reporting multiple applications of the same test in more than 10% of study participants. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted all data using a standardised data extraction and quality assessment form (based on the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2)). We estimated accuracy using the bivariate hierarchical method to produce summary sensitivities and specificities with 95% confidence and prediction regions. We undertook analysis of studies allowing direct and indirect comparison between tests. We examined heterogeneity between studies by visually inspecting the forest plots of sensitivity and specificity and summary receiver operating characteristic (ROC) plots. Numbers of identified studies were insufficient to allow formal investigation of potential sources of heterogeneity. MAIN RESULTS: We included a total of 39 publications reporting on 5204 study participants; 34 studies reporting data per patient included 4980 study participants with 1265 cases of metastatic disease, and seven studies reporting data per lesion included 417 study participants with 1846 potentially metastatic lesions, 1061 of which were confirmed metastases. The risk of bias was low or unclear for all domains apart from participant flow. Concerns regarding applicability of the evidence were high or unclear for almost all domains. Participant selection from mixed or not clearly defined populations and poorly described application and interpretation of index tests were particularly problematic.The accuracy of imaging for detection of regional nodal metastases before sentinel lymph node biopsy (SLNB) was evaluated in 18 studies. In 11 studies (2614 participants; 542 cases), the summary sensitivity of ultrasound alone was 35.4% (95% confidence interval (CI) 17.0% to 59.4%) and specificity was 93.9% (95% CI 86.1% to 97.5%). Combining pre-SLNB ultrasound with FNAC revealed summary sensitivity of 18.0% (95% CI 3.58% to 56.5%) and specificity of 99.8% (95% CI 99.1% to 99.9%) (1164 participants; 259 cases). Four studies demonstrated lower sensitivity (10.2%, 95% CI 4.31% to 22.3%) and specificity (96.5%,95% CI 87.1% to 99.1%) for PET-CT before SLNB (170 participants, 49 cases). When these data are translated to a hypothetical cohort of 1000 people eligible for SLNB, 237 of whom have nodal metastases (median prevalence), the combination of ultrasound with FNAC potentially allows 43 people with nodal metastases to be triaged directly to adjuvant therapy rather than having SLNB first, at a cost of two people with false positive results (who are incorrectly managed). Those with a false negative ultrasound will be identified on subsequent SLNB.Limited test accuracy data were available for whole body imaging via PET-CT for primary staging or re-staging for disease recurrence, and none evaluated MRI. Twenty-four studies evaluated whole body imaging. Six of these studies explored primary staging following a confirmed diagnosis of melanoma (492 participants), three evaluated re-staging of disease following some clinical indication of recurrence (589 participants), and 15 included mixed or not clearly described population groups comprising participants at a number of different points on the clinical pathway and at varying stages of disease (1265 participants). Results for whole body imaging could not be translated to a hypothetical cohort of people due to paucity of data.Most of the studies (6/9) of primary disease or re-staging of disease considered PET-CT, two in comparison to CT alone, and three studies examined the use of ultrasound. No eligible evaluations of MRI in these groups were identified. All studies used histological reference standards combined with follow-up, and two included FNAC for some participants. Observed accuracy for detection of any metastases for PET-CT was higher for re-staging of disease (summary sensitivity from two studies: 92.6%, 95% CI 85.3% to 96.4%; specificity: 89.7%, 95% CI 78.8% to 95.3%; 153 participants; 95 cases) compared to primary staging (sensitivities from individual studies ranged from 30% to 47% and specificities from 73% to 88%), and was more sensitive than CT alone in both population groups, but participant numbers were very small.No conclusions can be drawn regarding routine imaging of the brain via MRI or CT. AUTHORS' CONCLUSIONS: Review authors found a disappointing lack of evidence on the accuracy of imaging in people with a diagnosis of melanoma at different points on the clinical pathway. Studies were small and often reported data according to the number of lesions rather than the number of study participants. Imaging with ultrasound combined with FNAC before SLNB may identify around one-fifth of those with nodal disease, but confidence intervals are wide and further work is needed to establish cost-effectiveness. Much of the evidence for whole body imaging for primary staging or re-staging of disease is focused on PET-CT, and comparative data with CT or MRI are lacking. Future studies should go beyond diagnostic accuracy and consider the effects of different imaging tests on disease management. The increasing availability of adjuvant therapies for people with melanoma at high risk of disease spread at presentation will have a considerable impact on imaging services, yet evidence for the relative diagnostic accuracy of available tests is limited.

UK guidelines on 18F-fluciclovine PET/CT in prostate cancer imaging.

The purpose of these guidelines is to assist specialists in Nuclear Medicine and Radionuclide Radiology in recommending, performing, interpreting and reporting F-fluciclovine PET/computed tomography. It should be recognised that adherence to the guidance in this document will not assure an accurate diagnosis or a successful outcome. These guidelines will assist individual departments in the formulation of their own local protocols. The guidelines apply to studies on adults. All that should be expected is that the practitioner will follow a reasonable course of action based on current knowledge, available resources and the needs of the patient in order to deliver effective and safe medical care.

British Thoracic Society quality standards for the investigation and management of pulmonary nodules.

INTRODUCTION: The purpose of the quality standards document is to provide healthcare professionals, commissioners, service providers and patients with a guide to standards of care that should be met for the investigation and management of pulmonary nodules in the UK, together with measurable markers of good practice. METHODS: Development of British Thoracic Society (BTS) Quality Standards follows the BTS process of quality standard production based on the National Institute for Health and Care Excellence process manual for the development of quality standards. RESULTS: 7 quality statements have been developed, each describing a key marker of high-quality, cost-effective care for the investigation and management of pulmonary nodules, and each statement is supported by quality measures that aim to improve the structure, process and outcomes of healthcare. DISCUSSION: BTS Quality Standards for the investigation and management of pulmonary nodules form a key part of the range of supporting materials that the Society produces to assist in the dissemination and implementation of guideline recommendations.

18F-FDG PET/CT Detected Delayed Endoleak in an Aortoiliac Endovascular Aneurysm Repair.

We present a case of a type Ia endoleak detected using F-FDG PET/CT 10 years after an abdominal aortoiliac endovascular aneurysm repair in an 83-year-old man. The F-FDG PET/CT scan was performed to evaluate a solitary pulmonary nodule but, in addition, demonstrated unexpected blood pool activity outside the stent graft and within the abdominal aortic aneurysm sac, indicating an endoleak; no FDG activity should be present within the aneurysm sac after stent graft placement. A subsequent CT angiogram confirmed the endoleak. This case illustrates the value of PET/CT in unexpectedly demonstrating this serious, late complication of endovascular aneurysm repair.

Recurrent Malignant Melanoma Detected on 18F-Fluciclovine PET/CT Imaging for Prostate Cancer.

A 66-year-old man presented with biochemical recurrence of prostate cancer and underwent F-fluciclovine PET/CT to detect sites of recurrence. He had a history of resected truncal stage IIIC malignant melanoma, with bilateral axillary node involvement on sentinel node biopsy, in complete remission for 3 years. F-fluciclovine PET/CT demonstrated an incidental fluciclovine-avid right axillary node (SUVmax = 4.3). Diagnostic sampling confirmed recurrent malignant melanoma.

Diagnostic and response assessment FDG PET-CT in neurolymphomatosis.

FDG PET-CT is a useful imaging tool in the diagnosis and response assessment of neurolymphomatosis, especially in cases of otherwise unexplained neuropathy following conventional diagnostic work-up including lumbar puncture, CT, and MRI. The use of a novel PET reconstruction algorithm improves image quality and lesion detection through increased signal-to-noise ratio.

Multimodality imaging with CT, MR and FDG-PET for radiotherapy target volume delineation in oropharyngeal squamous cell carcinoma.

BACKGROUND: This study aimed to quantify the variation in oropharyngeal squamous cell carcinoma gross tumour volume (GTV) delineation between CT, MR and FDG PET-CT imaging. METHODS: A prospective, single centre, pilot study was undertaken where 11 patients with locally advanced oropharyngeal cancers (2 tonsil, 9 base of tongue primaries) underwent pre-treatment, contrast enhanced, FDG PET-CT and MR imaging, all performed in a radiotherapy treatment mask. CT, MR and CT-MR GTVs were contoured by 5 clinicians (2 radiologists and 3 radiation oncologists). A semi-automated segmentation algorithm was used to contour PET GTVs. Volume and positional analyses were undertaken, accounting for inter-observer variation, using linear mixed effects models and contour comparison metrics respectively. RESULTS: Significant differences in mean GTV volume were found between CT (11.9 cm(3)) and CT-MR (14.1 cm(3)), p < 0.006, CT-MR and PET (9.5 cm(3)), p < 0.0009, and MR (12.7 cm(3)) and PET, p < 0.016. Substantial differences in GTV position were found between all modalities with the exception of CT-MR and MR GTVs. A mean of 64 %, 74 % and 77 % of the PET GTVs were included within the CT, MR and CT-MR GTVs respectively. A mean of 57 % of the MR GTVs were included within the CT GTV; conversely a mean of 63 % of the CT GTVs were included within the MR GTV. CT inter-observer variability was found to be significantly higher in terms of position and/or volume than both MR and CT-MR (p < 0.05). Significant differences in GTV volume were found between GTV volumes delineated by radiologists (9.7 cm(3)) and oncologists (14.6 cm(3)) for all modalities (p = 0.001). CONCLUSIONS: The use of different imaging modalities produced significantly different GTVs, with no single imaging technique encompassing all potential GTV regions. The use of MR reduced inter-observer variability. These data suggest delineation based on multimodality imaging has the potential to improve accuracy of GTV definition. TRIAL REGISTRATION: ISRCTN Registry: ISRCTN34165059 . Registered 2nd February 2015.

The proliferation of multidisciplinary team meetings (MDTMs): how can radiology departments continue to support them all?

OBJECTIVES: To quantify the changes in multidisciplinary team meeting (MDTM) workload for consultant radiologists working in a single UK tertiary referral cancer institution, assess its impact and suggest solutions to these challenges. METHODS: The annual number of MDTM cases was collated over a 5-year period (2009 - 2013). Qualitative information was obtained through questionnaire-based interviews of 47 consultant radiologists. Data analysed included number of MDTMs involved with, type of MDTM (oncological or non-oncological), time allocation for preparation and perceived deficiencies in the current MDTM. RESULTS: Thirteen thousand and forty-nine cases were discussed in MDTMs in 2009 with a continued yearly increase over the 5-year period. Fifty-five percent of MDTM attendances were at oncological MDTMs. Consultant radiologists attended a median of two MDTMs per week, each requiring 4 hours time commitment; 60 % used out-of-hours time for MDTM preparation. The most frequently cited MDTM deficiency was lack of sufficient clinical input. CONCLUSIONS: The MDTM is a challenging but worthwhile demand on the modern radiologist's time. Solutions to the increasing MDTM workload include demonstration of the benefits of MDTMs to hospital administrators to justify additional resources required, improving MDTM efficiency and ensuring this increased workload is accurately represented and remunerated in individual job plans. KEY POINTS: • MDTMs improve cancer outcomes and are being recommended for non-oncological conditions. • MDTM cases have more than doubled over 5 years at our institution. • Incorporating MDTM workload into current consultant radiologist job plans is difficult. • Solutions include demonstrating MDTM related benefits, improved efficiency, and accurate job planning.

Alterations in anatomic and functional imaging parameters with repeated FDG PET-CT and MRI during radiotherapy for head and neck cancer: a pilot study.

BACKGROUND: The use of imaging to implement on-treatment adaptation of radiotherapy is a promising paradigm but current data on imaging changes during radiotherapy is limited. This is a hypothesis-generating pilot study to examine the changes on multi-modality anatomic and functional imaging during (chemo)radiotherapy treatment for head and neck squamous cell carcinoma (HNSCC). METHODS: Eight patients with locally advanced HNSCC underwent imaging including computed tomography (CT), Fluorine-18 fluorodeoxyglucose (FDG) positron emission tomography (PET)-CT and magnetic resonance imaging (MRI) (including diffusion weighted (DW) and dynamic contrast enhanced (DCE)) at baseline and during (chemo)radiotherapy treatment (after fractions 11 and 21). Regions of interest (ROI) were drawn around the primary tumour at baseline and during treatment. Imaging parameters included gross tumour volume (GTV) assessment, SUVmax, mean ADC value and DCE-MRI parameters including Plasma Flow (PF). On treatment changes and correlations between these parameters were analysed using a Wilcoxon rank sum test and Pearson's linear correlation coefficient respectively. A p-value <0.05 was considered statistically significant. RESULTS: Statistically significant reductions in GTV-CT, GTV-MRI and GTV-DW were observed between all imaging timepoints during radiotherapy. Changes in GTV-PET during radiotherapy were heterogeneous and non-significant. Significant changes in SUVmax, mean ADC value, Plasma Flow and Plasma Volume were observed between the baseline and the fraction 11 timepoint, whilst only changes in SUVmax between baseline and the fraction 21 timepoint were statistically significant. Significant correlations were observed between multiple imaging parameters, both anatomical and functional; 20 correlations between baseline to the fraction 11 timepoint; 12 correlations between baseline and the fraction 21 timepoints; and 4 correlations between the fraction 11 and fraction 21 timepoints. CONCLUSIONS: Multi-modality imaging during radiotherapy treatment demonstrates early changes (by fraction 11) in both anatomic and functional imaging parameters. All functional imaging modalities are potentially complementary and should be considered in combination to provide multi-parametric tumour assessment, to guide potential treatment adaptation strategies. TRIAL REGISTRATION: ISRCTN Registry: ISRCTN34165059 . Registered 2nd February 2015.