Development of Automated Delivery Quality Assurance Analysis Software for Helical Tomotherapy.

BACKGROUND: To develop a fully automated in-house gamma analysis software for the "Cheese" phantom-based delivery quality assurance (QA) of helical tomotherapy plans. METHODS: The developed in-house software was designed to automate several procedures, which need to be manually performed using commercial software packages. The region of interest for the analysis was automatically selected by cropping out film edges and thresholding dose values (>10% of the maximum dose). The film-measured dose was automatically aligned to the computed dose using an image registration algorithm. An optimal film scaling factor was determined to maximize the percentage of pixels passing gamma (gamma passing rate) between the measured and computed doses (3%/3 mm criteria). This gamma analysis was repeated by introducing setup uncertainties in the anterior-posterior direction. For 73 tomotherapy plans, the gamma analysis results using the developed software were compared to those analyzed by medical physicists using a commercial software package. RESULTS: The developed software successfully automated the gamma analysis for the tomotherapy delivery quality assurance. The gamma passing rate (GPR) calculated by the developed software was higher than that by the clinically used software by 3.0%, on average. While, for 1 of the 73 plans, the GPR by the manual gamma analysis was higher than 90% (pass/fail criteria), the gamma analysis using the developed software resulted in fail (GPR < 90%). CONCLUSIONS: The use of automated and standardized gamma analysis software can improve both the clinical efficiency and veracity of the analysis results. Furthermore, the gamma analyses with various film scaling factors and setup uncertainties will provide clinically useful information for further investigations.

A New Approach to Quantify and Grade Radiation Dermatitis Using Deep-Learning Segmentation in Skin Photographs.

AIMS: Objective evaluation of radiation dermatitis is important for analysing the correlation between the severity of radiation dermatitis and dose distribution in clinical practice and for reliable reporting in clinical trials. We developed a novel radiation dermatitis segmentation system based on convolutional neural networks (CNNs) to consistently evaluate radiation dermatitis. MATERIALS AND METHODS: The radiation dermatitis segmentation system is designed to segment the radiation dermatitis occurrence area using skin photographs and skin-dose distribution. A CNN architecture with a dilated convolution layer and skip connection was designed to estimate the radiation dermatitis area. Seventy-three skin photographs obtained from patients undergoing radiotherapy were collected for training and testing. The ground truth of radiation dermatitis segmentation is manually delineated from the skin photograph by an experienced radiation oncologist and medical physicist. We converted the skin photographs to RGB (red-green-blue) and CIELAB (lightness (L∗), red-green (a∗) and blue-yellow (b∗)) colour information and trained the network to segment faint and severe radiation dermatitis using three different input combinations: RGB, RGB + CIELAB (RGBLAB) and RGB + CIELAB + skin-dose distribution (RGBLAB_D). The proposed system was evaluated using the Dice similarity coefficient (DSC), sensitivity, specificity and normalised Matthews correlation coefficient (nMCC). A paired t-test was used to compare the results of different segmentation performances. RESULTS: Optimal data composition was observed in the network trained for radiation dermatitis segmentation using skin photographs and skin-dose distribution. The average DSC, sensitivity, specificity and nMCC values of RGBLAB_D were 0.62, 0.61, 0.91 and 0.77, respectively, in faint radiation dermatitis, and 0.69, 0.78, 0.96 and 0.83, respectively, in severe radiation dermatitis. CONCLUSION: Our study showed that CNN-based radiation dermatitis segmentation in skin photographs of patients undergoing radiotherapy can describe radiation dermatitis severity and pattern. Our study could aid in objectifying the radiation dermatitis grading and analysing the reliable correlation between dosimetric factors and the morphology of radiation dermatitis.

The effect of hip dysplasia on some biochemical parameters, oxidative stress factors and hematocrit levels in dogs.

In this study, it was aimed to investigate the effect of hip dysplasia on some biochemical parameters, oxidative stress factors and hematocrit values in dogs. Hematocrit values (HTC), serum calcium (Ca), phosphorus (P) levels, serum alkaline phosphatase (ALP), creatine kinase (CK) activities and oxidative stress factors were evaluated in a total of 27 dogs with healthy hip joints (n: 11) and hip dysplasia (n: 16). There was no statistically significant difference between the two groups in terms of HCT, Ca and P values (p˃0.05). ALP and CK activities were found to be statistically significantly increased in the group with hip dysplasia compared to the control group with a healthy hip joint (p˂0.05). While malondialdehyde (MDA) level, one of the oxidative stress factors, was increased in the group with hip dysplasia, decreased glutathione (GSH) levels, catalase (CAT) and glutathione peroxidase (GSH-Px) activities were significantly decreased. There was no significant difference between the two groups in terms of superoxide dismutase (SOD) level. As a result, it was determined that oxidative stress factors differ in dogs with hip dysplasia compared to dogs with the healthy hip joint.

New mesh-type phantoms and their dosimetric applications, including emergencies.

Committee 2 of the International Commission on Radiological Protection (ICRP) has constructed mesh-type adult reference computational phantoms by converting the voxel-type ICRP Publication 110 adult reference computational phantoms to a high-quality mesh format, and adding those tissues that were below the image resolution of the voxel phantoms and therefore not included in the Publication 110 phantoms. The new mesh phantoms include all the necessary source and target tissues for effective dose calculations, including the 8-40-µm-thick target layers of the alimentary and respiratory tract organs, thereby obviating the need for supplemental organ-specific stylised models (e.g. respiratory airways, alimentary tract organ walls and stem cell layers, lens of the eye, and skin basal layer). To see the impact of the new mesh-type reference phantoms, dose coefficients for some selected external and internal exposures were calculated and compared with the current reference values in ICRP Publications 116 and 133, which were calculated by employing the Publication 110 phantoms and the supplemental stylised models. The new mesh phantoms were also used to calculate dose coefficients for industrial radiography sources near the body, which can be used to estimate the organ doses of the worker who is accidentally exposed by an industrial radiography source; in these calculations, the mesh phantoms were deformed to reflect the size of the worker, and also to evaluate the effect of posture on dose coefficients.

Loss of Keratin 17 induces tissue-specific cytokine polarization and cellular differentiation in HPV16-driven cervical tumorigenesis in vivo.

Despite preventive human papilloma virus (HPV) vaccination efforts, cervical cancer remains a leading cause of death in women worldwide. Development of therapeutic approaches for cervical cancer are hampered by a lack of mechanistic insight during tumorigenesis. The cytoskeletal protein Keratin 17 (KRT17;K17) is robustly expressed in a broad array of carcinomas, including in cervical tumors, where it has both diagnostic and prognostic value. In this study, we have established multiple functional roles for K17 in the promotion of cervical tumorigenesis in vivo using the established HPV16tg mouse model for cervical squamous cell carcinoma. In HPV16tg/+;Krt17-/-relative to HPV16tg/+ reference female mice, onset of cervical lesions is delayed and closely paralleled by marked reductions in hyperplasia, dysplasia and vascularization. In addition, loss of Krt17 is associated with a cytokine polarization and recruitment of effector immune cells to lesion-prone cervical epithelia. Further, we observed marked enhancement of terminal differentiation in HPV16tg/+;Krt17-/-cervical epithelium accompanied by a stimulation and expansion in the expression of p63, a known basal/reserve cell marker in this tissue. Altogether, the data suggest that the loss of Krt17 may foster an overall protective environment for lesion-prone cervical tissue. In addition to providing new insights into the immunomodulatory and cellular mechanisms of cervical tumorigenesis, these findings may help guide the development of future therapies including vaccines.

The reference phantoms: voxel vs polygon.

The International Commission on Radiological Protection (ICRP) reference male and female adult phantoms, described in Publication 110, are voxel phantoms based on whole-body computed tomography scans of a male and a female patient, respectively. The voxel in-plane resolution and the slice thickness, of the order of a few millimetres, are insufficient for proper segmentation of smaller tissues such as the lens of the eye, the skin, and the walls of some organs. The calculated doses for these tissues therefore present some limitations, particularly for weakly penetrating radiation. Similarly, the Publication 110 phantoms cannot represent 8-40-µm-thick target regions in respiratory or alimentary tract organs. Separate stylised models have been used to represent these tissues for calculation of the ICRP reference dose coefficients (DCs). ICRP Committee 2 recently initiated a research project, the ultimate goal of which is to convert the Publication 110 phantoms to a high-quality polygon-mesh (PM) format, including all source and target regions, even those of the 8-40-µm-thick alimentary and respiratory tract organs. It is expected that the converted phantoms would lead to the same or very similar DCs as the Publication 110 reference phantoms for penetrating radiation and, at the same time, provide more accurate DCs for weakly penetrating radiation and small tissues. Additionally, the reference phantoms in the PM format would be easily deformable and, as such, could serve as a starting point to create phantoms of various postures for use, for example, in accidental dose calculations. This paper will discuss the current progress of the phantom conversion project and its significance for ICRP DC calculations.

Focal eosinophilic infiltration in the liver: radiologic findings and clinical course.

BACKGROUND: We investigated the radiologic findings and clinical course of focal eosinophilic infiltration in the liver. METHODS: We retrospectively reviewed computed tomographic (CT) and sonographic scans in 20 patients (18 male, two female; mean age, 50 years) with pathologically or clinically proven focal eosinophilic infiltration in the liver by two experienced radiologists in our institute from August 1995 to June 1999. We also correlated radiologic findings with peripheral eosinophil count. Radiologic and clinical findings during the follow-up (range, 2-49 months; mean, 19.5 months) also were analyzed. RESULTS: Clinical symptoms and signs included abdominal pain (n = 4), easy fatigability (n = 3), weight loss (n = 1), and peripheral eosinophilia (n = 19). Twelve patients were asymptomatic. On sonographic examinations, all lesions were seen as focal, low echoic nodules. On CT, the lesions appeared isoattenuated or low attenuated in the arterial phase and low attenuated in the portal phase, except one case that showed high attenuation in the arterial phase. The margins of most lesions appeared poorly defined. Lesions were single (n = 9) and multiple: two to five (n = 6), six to 10 (n = 3), and more than 10 (n = 2). Each lesion was smaller than 2 cm; only one was 4 cm in diameter. The distribution of the lesion was subcapsular in 14 patients and central in five. Diffuse dissemination was observed in one. Eosinophil-associated abnormality was not present in other abdominal organ in all cases. The peripheral eosinophil count correlated closely with the number but not with the size of lesions. Sixteen patients who had follow-up images showed complete (n = 14) or partial regression of the lesions with a decrease in size (n = 1) or number (n = 1) after 2-22 months (mean, 6.4 months). CONCLUSION: Focal eosinophilic infiltration in the liver had somewhat characteristic radiologic findings on sonography and CT. In the correct clinical context of peripheral eosinophilia and self-limited course, these radiologic findings may be helpful in differentiating this condition from other focal hepatic lesions.

Nonpalpable breast lesions: evaluation with power Doppler US and a microbubble contrast agent-initial experience.

PURPOSE: To evaluate power Doppler ultrasonography (US) performed with a microbubble US contrast agent in the differentiation of nonpalpable breast lesions. MATERIALS AND METHODS: Fifty nonpalpable breast lesions in 50 patients were prospectively evaluated with power Doppler US before and after injection of the contrast agent SH U 508A. Lesion vascularity and the morphology of vessels on US scans were analyzed and were correlated with histologic results. RESULTS: Surgical excision revealed 22 cancers and 28 benign lesions. At nonenhanced power Doppler US, eight (36%) of 22 cancers and four (14%) of 28 benign lesions were vascular. At contrast agent-enhanced power Doppler US, 21 (95%) cancers and six (21%) benign lesions were vascular (P <.001). Irregular vessels were seen in three cancers and one benign lesion at nonenhanced power Doppler US and in 11 cancers and one benign lesion at contrast-enhanced power Doppler US. By using the presence of vascularity in the mass as the diagnostic criterion for malignancy, the sensitivity, specificity, and positive and negative predictive values of power Doppler US changed from 36%, 86%, 67%, and 63%, respectively, to 95%, 79%, 78%, and 96% after contrast agent injection. CONCLUSION: Contrast-enhanced power Doppler US was superior to nonenhanced power Doppler US in the demonstration and characterization of tumor vascularity in nonpalpable breast lesions. Contrast-enhanced power Doppler US may be useful for the differentiation between nonpalpable breast cancers and benign tumors.

CT features of intraductal intrahepatic cholangiocarcinoma.

OBJECTIVE: The objective of this report was to describe the CT features of intraductal intrahepatic cholangiocarcinoma. CONCLUSION: Segmental or lobar dilatation of the intrahepatic bile ducts associated with or without intraductal polypoid mass, amorphous structures, or both with slight hyperattenuation are common CT findings of intraductal intrahepatic cholangiocarcinoma. The size of the intraductal mass determines the visibility on CT.

Preoperative evaluation of Klatskin tumor: accuracy of spiral CT in determining vascular invasion as a sign of unresectability.

BACKGROUND: To assess the accuracy of spiral computed tomography (CT) in predicting the resectability of Klatskin tumor as determined by vascular invasion. METHODS: Twenty-one consecutive patients with Klatskin tumor who had undergone laparotomy were included in this study. The preoperative thin-section (5-mm-thick) spiral CT scans of these patients were assessed for the surgical resectability of tumor by evaluating the vascular invasion. The criterion for vascular invasion indicating unresectability was the tumoral invasion of the proper hepatic artery or main portal vein or simultaneous invasion of one side of the hepatic artery and the other side of the portal vein. RESULTS: All nine patients with tumors thought to be unresectable on the basis of CT findings had tumors that were unresectable at surgery (positive predictive value, 100%). Of 12 patients with tumors thought to be resectable, six had resectable tumors (negative predictive value, 50%). Spiral CT failed to detect small hepatic metastasis (n = 1), lymph node metastasis (n = 1), extensive tumor (n = 2) and variation of bile duct (n = 2), which precluded surgical resection. CONCLUSION: Spiral CT is a reliable method for detecting vascular invasion and unresectable tumors. However, it has limitations in detecting variations of the bile duct or the intraductal extent of tumor.

Gadolinium mesoporphyrin as an MR imaging contrast agent in the evaluation of tumors: an experimental model of VX2 carcinoma in rabbits.

OBJECTIVE: We determined the enhancement features of experimentally induced malignant tumors on MR imaging with the use of gadolinium mesoporphyrin, a recently developed MR contrast agent that may be necrosis-specific. MATERIALS AND METHODS: VX2 carcinoma was inoculated into 24 rabbit thighs. T1-weighted contrast-enhanced MR imaging with IV gadopentetate dimeglumine (2-min delay) and gadolinium mesoporphyrin (20-hr delay) was performed 3-4 days (n = 6), 6-7 days (n = 6), 10-11 days (n = 5), and 13-14 days (n = 7) after the implantation of VX2 carcinoma. All tumors were sectioned along the same plane of MR images, and a detailed MR imaging-histopathologic correlation was performed. RESULTS: Pathologically, areas enhanced with gadolinium mesoporphyrin included necrotic tissue, viable tumor, inflammatory granulation tissue, hemorrhage, and fibrosis. On gadopentetate dimeglumine-enhanced MR images, unenhanced areas of the tumor corresponded with intratumoral necrosis and hemorrhage. CONCLUSION: Gadolinium mesoporphyrin enhances tumor necrosis on delayed phase MR imaging; however, it is impossible to specifically depict necrosis with gadolinium mesoporphyrin because it also enhances other parts of lesions, including viable tumor.

Factors influencing vascular and hepatic enhancement at CT: experimental study on injection protocol using a canine model.

PURPOSE: The purpose of this work was to evaluate the effects of contrast medium injection parameters on aortic, portal vein, and hepatic enhancement at spiral CT and to assess optimal injection protocol for hepatic CT. METHOD: Ten 15 kg dogs underwent single level dynamic CT through the hepatic hilum at 5 s intervals just after the injection of contrast medium for 3 min. With use of different volumes (1, 2, and 3 ml/kg), injection rates (0.5, 1, and 2 ml/s), and concentrations (150, 200, and 300 mg/ml), a total of 270 spiral CT scans were performed. In each scan, time-attenuation curves of aorta, portal vein, and liver were obtained. The degree of maximum contrast enhancement (Imax), time to maximum enhancement (Tmax), and time to equilibrium phase (Teq) for to each injection protocol were analyzed. RESULTS: Alterations in contrast material volume, injection rate, and concentration had significant impact on contrast enhancement of the liver. With increasing volume of contrast medium, Imax, Tmax, and Teq of aorta, portal vein, and liver increased (p < 0.005). With increasing rate of injection, on the other hand, Imax of aorta and liver increased (p < 0.05), but Tmax and Teq decreased (p < 0.005). Change of concentration of contrast medium had a significant effect on Imax of vessels (p < 0.05). CONCLUSION: Maximum contrast enhancement of liver and vessels was influenced mainly by injection volume of contrast medium and the time to peak enhancement by injection rate of contrast medium. Under given amounts of contrast medium, therefore, the strategy of increasing volume by dilution and faster injection might give better Imax values without penalty for the duration of an optimal temporal window (Tmax and Teq).

Neck infection associated with pyriform sinus fistula: imaging findings.

BACKGROUND AND PURPOSE: Acute suppurative neck infections associated with branchial fistulas are frequently recurrent. In this study, we describe the imaging findings of acute suppurative infection of the neck caused by a third or fourth branchial fistula (pyriform sinus fistula). METHODS: Imaging findings were reviewed in 17 patients (11 female and six male patients, 2 to 49 years old) with neck infection associated with pyriform sinus fistula. Surgery or laryngoscopic examination confirmed the diagnoses. Fourteen patients had a history of recurrent neck infection and seven had cutaneous openings on the anterior portion of the neck (all lesions were on the left side). Imaging studies included barium esophagography (n = 16), CT (n = 14), MR imaging (n = 2), and sonography (n = 3). RESULTS: A sinus or fistulous tract was identified in eight of 16 patients on barium esophagograms. In 14 patients, CT studies showed the inflammatory infiltration and/or abscess formation along the course of the sinus or fistulous tract from the pyriform fossa to the thyroid gland. In nine patients, CT scans showed the entire course or a part of the sinus or fistulous tract as a tiny spot containing air. MR images showed a sinus or fistulous tract in two patients, whereas sonograms could not depict a sinus or fistulous tract in three patients. All 17 patients were treated with antibiotics. In one patient, the sinus tract was surgically excised, while 15 patients underwent chemocauterization of the sinus or fistulous tract with good outcome. Follow-up was possible for 16 of the 17 patients. CONCLUSION: When an inflammatory infiltration or abscess is present between the pyriform fossa and the thyroid bed in the lower left part of the neck, an infected third or fourth branchial fistula should be strongly suspected.

Dynamic contrast-enhanced MR imaging of bacterial abscess and VX2 carcinoma in rabbits: comparison of gadopentetate dimeglumine and a macromolecular contrast agent.

OBJECTIVE: The objective of this study was to compare enhancement patterns of a blood-pool contrast agent, Gadomer-17, with those of gadopentetate dimeglumine in bacterial abscesses and VX2 carcinoma in rabbits. MATERIALS AND METHODS: Fourteen rabbits with experimentally induced bacterial abscesses and VX2 carcinoma in both thighs underwent dynamic contrast-enhanced MR imaging with Gadomer-17 and gadopentetate dimeglumine at a 24-hr interval. The enhancement ratios (postcontrast to precontrast signal intensities) of lesions in the same animal were assessed and correlated with microvessel density. RESULTS: For Gadomer-17, the enhancement ratio of the abscesses (1.66 +/- 0.39) peaked 15 min after the injection, while that of the carcinoma (2.05 +/- 0.16) peaked at 10 min. The enhancement ratios of the carcinoma were consistently higher than those of the abscesses up to 30 min. For gadopentetate dimeglumine, peak enhancement ratio of the abscesses (2.30 +/- 0.75) was seen 5 min after the injection, while that of the carcinoma (2.32 +/- 0.51) was seen at 3 min. The enhancement ratios of the carcinomas were significantly higher at 1 min, but significantly lower at 20-30 min, compared with those of the abscesses, as a result of rapid decrease of enhancement ratios in the carcinomas. The microvessel density was 9.8 +/- 5.2 vessels per field of view for the abscesses and 36.3 +/- 9.5 vessels per field of view for the carcinoma (p < 0.001). CONCLUSION: Delayed peak enhancement and slow decay were found in both bacterial abscess and VX2 carcinoma with Gadomer-17, whereas early peak enhancement and rapid decay were found especially in VX2 carcinoma with gadopentetate dimeglumine. Enhancement ratios on MR imaging with a blood-pool contrast agent correlated well with the microvessel density in bacterial abscess and VX2 carcinoma.

Scientific publication productivity of Korean medical colleges: an analysis of 1988-1999 MEDLINE papers.

To identify where the quality research activity has been and is carried out in Korea, and to examine to what extents Korean medical colleges play leading roles in the production of international research papers, we investigated the publication productivity of Korean medical colleges and their medical departments as measured by the number of papers published in foreign journals indexed in MEDLINE. The 12-year period from 1988 to 1999 is covered. A total of 4,881 papers is published in MEDLINE foreign journals by the researchers in Korean medical colleges during the period. The production of MEDLINE papers are concentrated in a few universities. More than 60% of MEDLINE foreign journal papers is published by top five universities 25% by Seoul National University, and 15% by Yonsei University. The newly established medical colleges at the University of Ulsan and Sungkyunkwan University produced outstanding numbers of papers in less than ten years. Radiology has led the internationalization of Korean medical papers. It was the most productive specialty identified in this study. The productivity of Internal medicine is on the rise from the mid-1 990s, and the field began to produce the most number of papers since then.

Metallic punctate densities in the breast after Chinese herbal treatment: mammographic findings.

PURPOSE: To describe the mammographic features of metallic punctate densities seen in women who were treated with the herb go-yak for breast abscess and to explain the cause of these findings. MATERIALS AND METHODS: Mammograms showing metallic punctate densities that appeared to be microcalcifications in 34 women were analyzed retrospectively with attention to the location, shape, distribution, and depth of the lesions. In all patients, go-yak was applied into the open wound after abscess drainage 6-42 years before mammography. In six patients, histopathologic specimens were obtained after needle localization. RESULTS: Metallic densities were in the subareolar or central breast in 24 (71%) of 34 patients. The shape was predominantly round or punctate in all patients, but rod-shaped or linear lesions were found in seven patients. The distribution and depth of lesions were variable, but they extended to the subcutaneous fat in 29 patients (85%). A high concentration of lead was found in the histopathologic specimens and herb samples. CONCLUSION: Lead deposits associated with go-yak treatment should be included in the differential diagnosis when the suspected microcalcifications are of unusually high density, are central in location, and extend into the subcutaneous fat in Asian women with a history of breast abscess.

Heterotopic pancreas of the stomach: CT findings correlated with pathologic findings in six patients.

BACKGROUND: The purpose of this study was to characterize the computed tomographic (CT) findings of heterotopic pancreas of the stomach. METHODS: CT scans of six surgically proven cases of heterotopic pancreas of the stomach were reviewed. Three were dynamic spiral CT scans, with both arterial dominant and late phase scans. In other three, both unenhanced and contrast-enhanced scans were obtained by using conventional techniques. Particular attention was given to the enhancement of the heterotopic pancreas. Pathologic and surgical findings were correlated with CT findings. RESULTS: The locations were in the gastric antrum in five cases and in the mid-body in one. Size ranged from 1 cm to 3 cm (mean = 2.1 cm). Three cases showed homogeneous, strong enhancement similar to the pancreas and consisted mainly of pancreatic acini with the same histologic features as the normal pancreas. Two cases showed poor enhancement and consisted mainly of ducts and hypertrophied muscle; pancreatic acini were a minor component. In one case appearing as a cystic lesion on CT, a pseudocyst was found with many ducts and some nests of pancreatic acini. CONCLUSIONS: Heterotopic pancreas of the stomach showed a diverse spectrum of CT findings. Good understanding of these CT findings may be helpful in making a correct diagnosis.

Nodular hepatocellular carcinoma: variation of tumor conspicuity on single-level dynamic scan and optimization of fixed delay times for two-phase helical CT.

PURPOSE: The purpose of this work was to determine the optimal delay times in two-phase helical CT for nodular hepatocellular carcinoma (HCC). METHOD: Twenty-four patients with nodular HCC (size 2.1-6.7 cm, mean 4.2 cm) were divided into three groups to undergo single-level dynamic CT with 150 ml of contrast material (iodine load of 45 g) at a rate of 3 ml/s. CT acquisition started 10, 30, or 60 s after the injection for each group, respectively, and lasted for 110 or 120 s. The optimal 20 s windows that allowed a tumor-to-liver contrast of >10 HU were determined in the pooled tumor-to-liver contrast curve. RESULTS: The determined temporal windows were 36-56 and 130-150 s, respectively. However, each window was not appropriate in seven (33%) and five (36%) patients because of the individual variations of the contrast curve. CONCLUSION: There is no optimal fixed delay time that is appropriate in all individual patients. The best delay times are 36 and at least 130 s with our injection protocol.