Paediatric radiotherapy in the United Kingdom: an evolving subspecialty and a paradigm for integrated teamworking in oncology.

Many different malignancies occur in children, but overall, cancer in childhood is rare. Survival rates have improved appreciably and are higher compared with most adult tumour types. Treatment schedules evolve as a result of clinical trials and are typically complex and multi-modality, with radiotherapy an integral component of many. Risk stratification in paediatric oncology is increasingly refined, resulting in a more personalized use of radiation. Every available modality of radiation delivery: simple and advanced photon techniques, proton beam therapy, molecular radiotherapy, and brachytherapy, have their place in the treatment of children's cancers. Radiotherapy is rarely the sole treatment. As local therapy, it is often given before or after surgery, so the involvement of the surgeon is critically important, particularly when brachytherapy is used. Systemic treatment is the standard of care for most paediatric tumour types, concomitant administration of chemotherapy is typical, and immunotherapy has an increasing role. Delivery of radiotherapy is not done by clinical or radiation oncologists alone; play specialists and anaesthetists are required, together with mould room staff, to ensure compliance and immobilization. The support of clinical radiologists is needed to ensure the correct interpretation of imaging for target volume delineation. Physicists and dosimetrists ensure the optimal dose distribution, minimizing exposure of organs at risk. Paediatric oncology doctors, nurses, and a range of allied health professionals are needed for the holistic wrap-around care of the child and family. Radiographers are essential at every step of the way. With increasing complexity comes a need for greater centralization of services.

Use of super resolution reconstruction MRI for surgical planning in Placenta accreta spectrum disorder: Case series.

INTRODUCTION: Comprehensive imaging using ultrasound and MRI of placenta accreta spectrum (PAS) aims to prevent catastrophic haemorrhage and maternal death. Standard MRI of the placenta is limited by between-slice motion which can be mitigated by super-resolution reconstruction (SRR) MRI. We applied SRR in suspected PAS cases to determine its ability to enhance anatomical placental assessment and predict adverse maternal outcome. METHODS: Suspected PAS patients (n = 22) underwent MRI at a gestational age (weeks + days) of (32+3±3+2, range (27+1-38+6)). SRR of the placental-myometrial-bladder interface involving rigid motion correction of acquired MRI slices combined with robust outlier detection to reconstruct an isotropic high-resolution volume, was achieved in twelve. 2D MRI or SRR images alone, and paired data were assessed by four radiologists in three review rounds. All radiologists were blinded to results of the ultrasound, original MR image reports, case outcomes, and PAS diagnosis. A Random Forest Classification model was used to highlight the most predictive pathological MRI markers for major obstetric haemorrhage (MOH), bladder adherence (BA), and placental attachment depth (PAD). RESULTS: At delivery, four patients had placenta praevia with no abnormal attachment, two were clinically diagnosed with PAS, and six had histopathological PAS confirmation. Pathological MRI markers (T2-dark intraplacental bands, and loss of retroplacental T2-hypointense line) predicting MOH were more visible using SRR imaging (accuracy 0.73), in comparison to 2D MRI or paired imaging. Bladder wall interruption, predicting BA, was only easily detected by paired imaging (accuracy 0.72). Better detection of certain pathological markers predicting PAD was found using 2D MRI (placental bulge and myometrial thinning (accuracy 0.81)), and SRR (loss of retroplacental T2-hypointense line (accuracy 0.82)). DISCUSSION: The addition of SRR to 2D MRI potentially improved anatomical assessment of certain pathological MRI markers of abnormal placentation that predict maternal morbidity which may benefit surgical planning.

Physiological assessment of the fetal body using MRI: current uses and potential directions.

MRI assessment of the fetus using fast T2-weighted sequences is well established in defining alterations in fetal anatomy and structure, as a biomarker for disease, and in some cases prognostication. To date, the physiological assessment of the fetus using advanced sequences to characterise tissue perfusion and microarchitecture has largely been unused. Current methods of assessing fetal organ function are invasive and carry inherent risk. Therefore, the identification of imaging biomarkers of altered fetal physiology, and correlation with postnatal outcome, is attractive. This review describes the techniques which show promise for such a task and potential future directions.

Fetal lung MRI and features predicting post-natal outcome: a scoping review of the current literature.

The outcome for infants with fetal lung pathologies not only depends on the nature of the pathology, but the impact it has on the developing lungs. The main prognostic factor is the degree of pulmonary hypoplasia, but this is not detectable pre-natally. Imaging techniques aim to simulate these features with a variety of surrogate measurements, including lung volume and MRI signal intensity. Despite the complexity of the various research studies and lack of consistent methodology, this scoping review aims to summarise current applications, and promising techniques requiring further investigation.

Artificial intelligence applied to fetal MRI: A scoping review of current research.

Artificial intelligence (AI) is defined as the development of computer systems to perform tasks normally requiring human intelligence. A subset of AI, known as machine learning (ML), takes this further by drawing inferences from patterns in data to 'learn' and 'adapt' without explicit instructions meaning that computer systems can 'evolve' and hopefully improve without necessarily requiring external human influences. The potential for this novel technology has resulted in great interest from the medical community regarding how it can be applied in healthcare. Within radiology, the focus has mostly been for applications in oncological imaging, although new roles in other subspecialty fields are slowly emerging.In this scoping review, we performed a literature search of the current state-of-the-art and emerging trends for the use of artificial intelligence as applied to fetal magnetic resonance imaging (MRI). Our search yielded several publications covering AI tools for anatomical organ segmentation, improved imaging sequences and aiding in diagnostic applications such as automated biometric fetal measurements and the detection of congenital and acquired abnormalities. We highlight our own perceived gaps in this literature and suggest future avenues for further research. It is our hope that the information presented highlights the varied ways and potential that novel digital technology could make an impact to future clinical practice with regards to fetal MRI.

Chest radiograph classification and severity of suspected COVID-19 by different radiologist groups and attending clinicians: multi-reader, multi-case study.

OBJECTIVES: To quantify reader agreement for the British Society of Thoracic Imaging (BSTI) diagnostic and severity classification for COVID-19 on chest radiographs (CXR), in particular agreement for an indeterminate CXR that could instigate CT imaging, from single and paired images. METHODS: Twenty readers (four groups of five individuals)-consultant chest (CCR), general consultant (GCR), and specialist registrar (RSR) radiologists, and infectious diseases clinicians (IDR)-assigned BSTI categories and severity in addition to modified Covid-Radiographic Assessment of Lung Edema Score (Covid-RALES), to 305 CXRs (129 paired; 2 time points) from 176 guideline-defined COVID-19 patients. Percentage agreement with a consensus of two chest radiologists was calculated for (1) categorisation to those needing CT (indeterminate) versus those that did not (classic/probable, non-COVID-19); (2) severity; and (3) severity change on paired CXRs using the two scoring systems. RESULTS: Agreement with consensus for the indeterminate category was low across all groups (28-37%). Agreement for other BSTI categories was highest for classic/probable for the other three reader groups (66-76%) compared to GCR (49%). Agreement for normal was similar across all radiologists (54-61%) but lower for IDR (31%). Agreement for a severe CXR was lower for GCR (65%), compared to the other three reader groups (84-95%). For all groups, agreement for changes across paired CXRs was modest. CONCLUSION: Agreement for the indeterminate BSTI COVID-19 CXR category is low, and generally moderate for the other BSTI categories and for severity change, suggesting that the test, rather than readers, is limited in utility for both deciding disposition and serial monitoring. KEY POINTS: • Across different reader groups, agreement for COVID-19 diagnostic categorisation on CXR varies widely. • Agreement varies to a degree that may render CXR alone ineffective for triage, especially for indeterminate cases. • Agreement for serial CXR change is moderate, limiting utility in guiding management.

Neuroblastoma-associated Renal Cell Carcinoma: A Case Report and Review of the Literature.

Neuroblastoma-associated renal cell carcinoma (RCC) is a very rare subtype of renal neoplasia and only a handful of cases have been reported. Here we present a 15-year-old boy with metastatic RCC with a previous history of advanced stage neuroblastoma and germline mutation in the TP53 tumor suppressor gene. The probability of the RCC and indeed, the neuroblastoma itself being related to a cancer predisposition syndrome rather than a therapy induced second malignancy, is discussed.

Whole-body MRI in children: state of the art.

Whole-body magnetic resonance imaging (WBMRI) is an increasingly popular technique in paediatric imaging. It provides high-resolution anatomical information, with the potential for further exciting developments in acquisition of functional data with advanced MR sequences and hybrid imaging with radionuclide tracers. WBMRI demonstrates the extent of disease in a range of multisystem conditions and, in some cases, disease burden prior to the onset of clinical features. The current applications of WBMRI in children are hereby reviewed, along with suggested anatomical stations and sequence protocols for acquisition.

Super-resolution Reconstruction MRI Application in Fetal Neck Masses and Congenital High Airway Obstruction Syndrome.

OBJECTIVE: Reliable airway patency diagnosis in fetal tracheolaryngeal obstruction is crucial to select and plan ex utero intrapartum treatment (EXIT) surgery. We compared the clinical utility of magnetic resonance imaging (MRI) super-resolution reconstruction (SRR) of the trachea, which can mitigate unpredictable fetal motion effects, with standard 2-dimensional (2D) MRI for airway patency diagnosis and assessment of fetal neck mass anatomy. STUDY DESIGN: A single-center case series of 7 consecutive singleton pregnancies with complex upper airway obstruction (2013-2019). SETTING: A tertiary fetal medicine unit performing EXIT surgery. METHODS: MRI SRR of the trachea was performed involving rigid motion correction of acquired 2D MRI slices combined with robust outlier detection to reconstruct an isotropic high-resolution volume. SRR, 2D MRI, and paired data were blindly assessed by 3 radiologists in 3 experimental rounds. RESULTS: Airway patency was correctly diagnosed in 4 of 7 cases (57%) with 2D MRI as compared with 2 of 7 cases (29%) with SRR alone or paired 2D MRI and SRR. Radiologists were more confident (P = .026) in airway patency diagnosis when using 2D MRI than SRR. Anatomic clarity was higher with SRR (P = .027) or paired data (P = .041) in comparison with 2D MRI alone. Radiologists detected further anatomic details by using paired images versus 2D MRI alone (P < .001). Cognitive load, as assessed by the NASA Task Load Index, was increased with paired or SRR data in comparison with 2D MRI. CONCLUSION: The addition of SRR to 2D MRI does not increase fetal airway patency diagnostic accuracy but does provide improved anatomic information, which may benefit surgical planning of EXIT procedures.

Quantitative assessment of terminal ileum motility on MR enterography in Crohn disease: a feasibility study in children.

OBJECTIVES: Investigate the relationship between quantified terminal ileal (TI) motility and histopathological activity grading, Crohn Disease MRI Index (CDMI) and faecal calprotectin. METHODS: Retrospective review of children with Crohn disease or unclassified inflammatory bowel disease, who underwent MR enterography. Dynamic imaging for 25 patients (median age 12, range 5 to 16) was analysed with a validated motility algorithm. The TI motility score was derived. The primary reference standard was TI Endoscopic biopsy Assessment of Inflammatory Activity (eAIS) within 40 days of the MR enterography. Secondary reference standards: (1) the Crohn Disease MRI Index (CDMI) and (2) faecal calprotectin levels. RESULTS: MR enterography median motility score was 0.17 a.u. (IQR 0.12 to 0.25; range 0.05 to 0.55), and median CDMI was 3 (IQR 0 to 5.5). Forty-three percent of patients had active disease (eAIS > 0) with a median eAIS score of 0 (IQR 0 to 2; range 0 to 5). The correlation between eAIS and motility was r = - 0.58 (p = 0.004, N = 23). Between CDMI and motility, r = - 0.42 (p = 0.037, N = 25). Motility score was lower in active disease (median 0.12 vs 0.21, p = 0.020) while CDMI was higher (median 5 vs 1, p = 0.04). In a subset of 12 patients with faecal calprotectin within 3 months of MR enterography, correlation with motility was r = - 0.27 (p = 0.4). CONCLUSIONS: Quantified terminal ileum motility decreases with increasing histopathological abnormality in children with Crohn disease, reproducing findings in adults. TI motility showed a negative correlation with an MRI activity score but not with faecal calprotectin levels. KEY POINTS: • It is feasible to perform MRI quantified bowel motility assessment in children using free-breathing techniques. • Bowel motility in children with Crohn disease decreases as the extent of intestinal inflammation increases. • Quantified intestinal motility may be a candidate biomarker for treatment efficacy in children with Crohn disease.

Major skull manifestations of skeletal dysplasias - pictorial essay.

Skeletal dysplasias are a large group of rare conditions with widely heterogeneous manifestations and a reputation for being diagnostically difficult. Involvement of the brain and craniovertebral junction are features familiar to the paediatric neuroradiologist. Involvement of the skull itself represents an area of overlap between the domains of the neuroradiologist and the skeletal dysplasia radiologist. In this pictorial essay, we review the principal skull manifestations of skeletal dysplasias as they present to the neuroradiologist.

Emergency imaging in paediatric oncology: a pictorial review.

Despite the decline in mortality rates over the last 20 years, cancer remains one of the leading causes of death in children worldwide. Early recognition and treatment for acute oncological emergencies are vital in preventing mortality and poor outcomes, such as irreversible end-organ damage and a compromised quality of life.Imaging plays a pivotal and adjunctive role to clinical examination, and a high level of interpretative acumen by the radiologist can make the difference between life and death. In contrast to adults, the most accessible cross-sectional imaging tool in children typically involves ultrasound. The excellent soft tissue differentiation allows for careful delineation of malignant masses and along with colour Doppler imaging, thromboses and large haematomas can be easily identified. Neurological imaging, particularly in older children is an exception. Here, computed tomography (CT) is required for acute intracranial pathologies, with magnetic resonance imaging (MRI) providing more definitive results later.This review is divided into a 'body systems' format covering a range of pathologies including neurological complications (brainstem herniation, hydrocephalus, spinal cord compression), thoracic complications (airway obstruction, superior vena cava syndrome, cardiac tamponade), intra-abdominal complications (bowel obstruction and perforation, hydronephrosis, abdominal compartment syndrome) and haematological-related emergencies (thrombosis, infection, massive haemorrhage). Within each subsection, we highlight pertinent clinical and imaging considerations.The overall objective of this pictorial review is to illustrate how primary childhood malignancies may present with life-threatening complications, and emphasise the need for imminent patient management.

Fluid signal changes around the knee on MRI are associated with increased volumes of subcutaneous fat: a case-control study.

BACKGROUND: Fluid in the subcutaneous fat is a common finding anterior to the knee on MRI. This may be caused by chronic low-grade shearing injuries in patients who are overweight. The purpose of this study was to determine if there is a difference in the amount of subcutaneous fat around the knee between patients with these appearances and controls. METHODS: This was a retrospective case-control study. Following a sample size calculation on pilot data, eighteen sequential patients demonstrating hyper-intense subcutaneous signal changes around the knee on fat-saturated T2-weighted MRI were identified from PACS (18 females, mean age 45, range 31-62). Age and gender-matched patients without abnormal T2 MR signal changes were selected. Two observers independently drew regions of interest representing cross-sectional areas of bone and fat. The location of T2 signal hyper-intense lesions was characterized by consensus. RESULTS: Inter and intra-rater intraclass reproducibility was "excellent" (ICC > 0.8). The mean cross-sectional area of bone for patients with T2 hyper-intense lesions was 31.79cm2 (SD 2.57) and for controls 30.11cm2 (SD 3.20) which was not significantly different (p = 0.09). The median cross-sectional area of fat for the study group was 62.29cm2 (IQR 57.1-66.5) and for controls was 32.77cm2 (IQR 24.8-32.3) which was significantly different (p < 0.0001). Consensus agreement demonstrated all T2 hyper-intense lesions were anterior to the knee extensor mechanism. CONCLUSION: Subcutaneous fluid around the knee is associated with an increased amount of subcutaneous fat, anterior to the knee extensor mechanism. This may be caused by shearing injuries in fat with reduced elasticity associated with metabolic syndrome.

Spontaneous regression of a chiari malformation type 1 in a 58-year-old female.

Studies have established a complex age-related variation of the position of the cerebellar tonsils relative to the foramen magnum (FM). Chiari malformation type 1 (CM1) is generally defined by a protrusion >5 mm from the FM and may be an asymptomatic incidental finding. Symptoms include headache, nausea and neurological disturbances, including trigeminal neuralgia. Moreover, tonsils are often peg shaped and associated with syringohydromyelia. Symptomatic CM1 may be managed with decompression of the posterior cranial fossa, but spontaneous regression in adults has been reported occasionally. Theories include restoration of normal cerebrospinal fluid dynamics around the FM after rupture of subarachnoid adhesions or the syrinx itself during transient episodes of raised intracranial pressure. Supratentorial neurosurgery has also been implicated. We present a 58-year-old female diagnosed with CM1 and no associated syringohydromyelia following MRI investigation of trigeminal neuralgia. Managed medically, she re-presented 6 years later with new neurological symptoms. A subsequent MR study of the posterior cranial fossa showed resolution of the CM1, with only residual tonsillar ectopia. At no point was intracranial intervention performed, nor were there any events that might favour CM1 regression. This case demonstrates spontaneous resolution of CM1 without surgical intervention.

Soothing suffering swimmers: a systematic review of the epidemiology, diagnosis, treatment and rehabilitation of musculoskeletal injuries in competitive swimmers.

BACKGROUND: This review details the examination, diagnosis, treatment and management of injuries encountered by competitive swimmers. Primarily, these involve the shoulder, however, the spine, knee and hip can be involved. Using the Coleman methodology score, we show that the methods used in obtaining and reporting clinical findings and intervention results could be improved. Where possible, we suggest improvements. SOURCES OF DATA: A literature review was conducted in English, Italian, French and German using PubMed, Google Scholar and Ovid search engines with strict inclusion/exclusion criteria. AREAS OF AGREEMENT: Poor technique, and high training intensity and distance are the most common cause of missed swim practice and competition through injury. AREAS OF CONTROVERSY: Few articles agree on a single method of each of clinical examination, diagnosis, treatment and rehabilitation. GROWING POINTS: Articles are consistently retrospective with few investigating spine, hip and knee injuries. AREAS TIMELY FOR DEVELOPING RESEARCH: Clinical findings and rehabilitation methods should be reported using a more structured method possibly based on the Coleman methodological scoring system.