Investigation and diagnostic imaging of suspected pulmonary embolism during pregnancy and the puerperium: A review of the literature

Pulmonary embolism (PE) is a leading cause of maternal mortality with women at increased risk of PE during pregnancy and the early postpartum period. Clinical assessment of suspected PE during pregnancy is challenging as signs and symptoms associated with PE overlap with physiological changes of pregnancy. Clinical tests and rules commonly used to assess pre‐test probability of PE were historically not well validated in the pregnant population. The challenges of clinical assessment in the pregnant and postpartum population result in a lowered threshold for diagnostic imaging. Computed tomographic pulmonary angiography (CTPA) and nuclear medicine lung scintigraphy or ventilation/perfusion (V/Q) scans are the main types of diagnostic imaging for suspected PE. Both methods are associated with small levels of ionising radiation exposure to mother and foetus. Accuracy of the diagnostic imaging tests is paramount. Haemodynamic changes of pregnancy, including increased heart rate, increased blood volume and altered flow velocity in the pulmonary arteries, may influence the quality of imaging. This comprehensive review examines the literature and evidence for the investigation and diagnostic imaging of suspected pulmonary embolism during pregnancy with CTPA and V/Q. Clinical decision‐making tools, biomarkers and diagnostic imaging during pregnancy and postpartum will be considered with a focus on diagnostic accuracy and yield, radiation dose exposure (maternal–foetal) and protocol modifications. Current practice guideline recommendations and recent literature on diagnostic pathways are also presented.     

Pulmonary embolism: Are we there yet?

Introduction: Clinical prediction rules (such as Wells model) are a reliable assessment tool for diagnostic work‐up of suspected pulmonary embolism (PE). When used as part of a clinical algorithm and in combination with a D‐Dimer, the model can safely exclude PE in low‐risk groups and indicate when further investigations are unnecessary. The purpose of this study was to investigate the level of adherence to local diagnostic imaging guidelines for suspected PE and to ascertain the impact of interventions. Methods: Retrospective search of all patients referred from the Emergency Department (ED) of Royal Perth Hospital for computed tomography pulmonary angiography (CTPA) or V/Q scan between 11 September 2005 to 10 March 2006 (pre‐intervention) and 1 January 2008 to 31 March 2008 (post‐intervention) was conducted. The guidelines on ‘Diagnostic Imaging Pathways’ were considered as gold standard. Interventions included orienting ED doctors to guidelines and modified request forms for mandatory completion of Wells score. A prevalence‐ and bias‐adjusted kappa (PABAK) score analysed the level of agreement between documentation on notes (R‐score) and stamp (S‐score). Results: Thirty‐five per cent (n = 187) and 22% (n = 109) deviated from the pathway pre‐intervention and post‐intervention, respectively (13% absolute reduction; P = 0.017). Stamp compliance was only 55% despite mandatory filling requirement. PABAK for ‘PE as most likely diagnosis’ was 0.25 for V/Q group and – 0.26 for CTPA. In addition, 44/60 (73%) had an intermediate or high S‐score, yet only 11 of those 44 had a matched intermediate to high R‐Score. Conclusions: Interventions reduced inappropriate practice but did not eliminate it completely. Compliance issues may be managed in the future via the introduction of electronic request linked to decision support.     

Lung scintigraphy in the diagnosis of pulmonary embolism: current methods and interpretation criteria in clinical practice

Background

In current clinical practice lung scintigraphy is mainly used to exclude pulmonary embolism (PE). Modified diagnostic criteria for planar lung scintigraphy are considered, as newer scitigraphic methods, especially single photon emission computed tomography (SPECT) are becoming more popular.

Patients and methods.

Data of 98 outpatients who underwent planar ventilation/perfusion (V/Q) scintigraphy and 49 outpatients who underwent V/Q SPECT from the emergency department (ED) were retrospectively collected. Planar V/Q images were interpreted according to 0.5 segment mismatch criteria and revised PIOPED II criteria and perfusion scans according to PISA-PED criteria. V/Q SPECT images were interpreted according to the criteria suggested in EANM guidelines. Final diagnosis of PE was based on the clinical decision of an attending physician and evaluation of a 12 months follow-up period.

Results

Using 0.5 segment mismatch criteria and revised PIOPED II, planar V/Q scans were diagnostic in 93% and 84% of cases, respectively. Among the diagnostic planar scans readings specificity for 0.5 segment mismatch criteria was 98%, and 99% for revised PIOPED II criteria. V/Q SPECT showed a sensitivity of 100% and a specificity of 98%, without any non-diagnostic cases. In patients with low pretest probability for PE, planar V/Q scans assessed by 0.5 segment mismatch criteria were diagnostic in 92%, and in 85% using revised PIOPED II criteria, while perfusion scintigraphy without ventilation scans was diagnostic in 80%.

Conclusions

Lung scintigraphy yielded diagnostically definitive results and is reliable in ruling out PE in patients from ED. V/Q SPECT has excellent specificity and sensitivity without any non-diagnostic results. Percentage of non-diagnostic results in planar lung scintigraphy is considerably smaller when 0.5 segment mismatch criteria instead of revised PIOPED II criteria are used. Diagnostic value of perfusion scintigraphy according to PISA-PED criteria is inferior to combined V/Q scintigraphy; the difference is evident especially in patients with low pretest probability for PE.     

Low-dose CT protocols for guiding radiofrequency ablation for the treatment of small renal cell carcinomas

Objective: Computed tomography (CT)-guided radiofrequency ablation (RFA) results in a high radiation dose. This study aimed to assess low-dose CT protocols for guiding RFA and oncologic outcomes for the treatment of small renal cell carcinoma (RCC).

Materials and methods: Between December 2011 and December 2014, CT-guided RFA was performed in 31 patients with 31 biopsy-proven RCCs (median, 2.1?cm). RFA included planning, targeting, monitoring and survey phases. The dose length product (DLP), CT dose index volume (CTDIvol), effective dose, number of scans, scan range, tube current and exposure time of RFA phases were compared. The 3-year recurrence-free survival rate was recorded. Nonparametric or parametric repeated-measures ANOVA with Dunn’s or Tukey–Kramer multiple comparisons and Kaplan–Meier analysis were used for statistical analysis.

Results: The median total DLP, CTDIvol and effective dose of CT-guided RFA procedures per session were 1238.8 mGy (range 517.4–3391.7 mGy), 259.7 mGy (10.7–67.9 mGy) and 18.6 mSv (7.8–50.9 mSv), respectively. The median DLP, CTDIvol, effective dose, number of scans, tube current and exposure time during the targeting phase were higher than those during the other phases (p?p?>?0.05) but smaller than those in the planning and survey phases (p?Conclusions: Low-dose CT protocols for guiding RFA may reduce radiation dose without compromising oncologic outcomes. Reducing the number of scans during the targeting phase contributes to dose reduction.     

Early Results of Lung Cancer Screening and Radiation Dose Assessment by Low-dose CT at a Community Hospital

Background

The National Lung Screening Trial showed a reduction in overall and cancer-specific mortality for patients screened with low-dose computed tomography (LDCT) versus chest radiograph. Some question whether this can be achieved in community healthcare settings. Our aim was to analyze lung cancer screening outcomes and administered radiation dose using LDCT scans at a community hospital.

Radiation dose and diagnostic image quality associated with iterative reconstruction in coronary CT angiography: A systematic review

The aim of this systematic review is to evaluate the radiation dose reduction achieved using iterative reconstruction (IR) compared to filtered back projection (FBP) in coronary CT angiography (CCTA) and assess the impact on diagnostic image quality. A systematic search of seven electronic databases was performed to identify all studies using a developed keywords strategy. A total of 14 studies met the criteria and were included in a review analysis. The results showed that there was a significant reduction in radiation dose when using IR compared to FBP (P < 0.05). The mean and standard deviation (SD) difference of CTDI_vol and dose‐length‐product (DLP) were 14.70 ± 6.87 mGy and 186 ± 120 mGy.cm respectively. The mean ± SD difference of effective dose (E_D) was 2.9 ± 1.7 mSv with the range from 1.0 to 5.0 mSv. The assessment of diagnostic image quality showed no significant difference (P > 0.05). The mean ± SD difference of image noise, signal‐noise ratio (SNR) and contrast‐noise ratio (CNR) were 1.05 ± 1.29 HU, 0.88 ± 0.56 and 0.63 ± 1.83 respectively. The mean ± SD percentages of overall image quality scores were 71.79 ± 12.29% (FBP) and 67.31 ± 22.96% (IR). The mean ± SD percentages of coronary segment analysis were 95.43 ± 2.57% (FBP) and 97.19 ± 2.62% (IR). In conclusion, this review analysis shows that CCTA with the use of IR leads to a significant reduction in radiation dose as compared to the use of FBP. Diagnostic image quality of IR at reduced dose (30–41%) is comparable to FBP at standard dose in the diagnosis of CAD.     

Dose evaluation for skin and organ in hepatocellular carcinoma during angiographic procedure

Purpose

The purpose of this study is to evaluate the radiation dose in patients undergoing liver angiographic procedure and verify the usefulness of different dose measurements to prevent deterministic effects. Gafchromic film, MicroMOSFET data and DIAMENTOR device of the X-ray system were used to characterize the examined interventional radiology (IR) procedure.

Materials and methods

A liver embolization procedure, the SIRT (Selective Internal Radiation Therapy), was investigated. The exposure parameters from the DIAMENTOR as well as patient and geometrical data were registered. Entrance skin dose map obtained using Gafchromic film (ESD_GAF) in a standard phantom as well as in 12 patients were used to calculate the maximum skin dose (MSD_GAF). MicroMOSFETs were used to assess ESD in relevant points/areas. Moreover, the maximum value of five MicroMOSFETs array, due to the extension of treated area and to the relative distance of 2–3 cm of two adjacent MicroMOSFETs, was useful to predict the MSD without interfering with the clinical practice. PCXMC vers.1.5 was used to calculate effective dose (E) and equivalent dose (H).

Results

The mean dose-area product (DAP_DIAMENTOR) for SIRT procedures was 166 Gycm², although a wide range was observed. The mean MSD_GAF for SIRT procedures was 1090 mGy, although a wide range was experienced. A correlation was found between the MSD_GAF measured on a patient and the DAP_DIAMENTOR value for liver embolizations. MOSFET and Gafchromic data were in agreement within 5% in homogeneous area and within 20% in high dose gradient regions. The mean equivalent dose in critical organs was 89.8 mSv for kidneys, 22.9 mSv for pancreas, 20.2 mSv for small intestine and 21.0 mSv for spleen. Whereas the mean E was 3.7 mSv (range: 0.5-13.7).

Conclusions

Gafchromic films result useful to study patient exposure and determine localization and amplitude of high dose skin areas to better predict the skin injuries. Then, DAP_DIAMENTOR or MOSFET data could offer real-time methods, as on-line dose alert, to avoid any side effects during liver embolization with prolonged duration.     

Can CT pulmonary angiography replace ventilation–perfusion scans as a first line investigation for pulmonary emboli?

A prospective study was performed to determine efficacy of diagnosis of pulmonary emboli by computed tomographic pulmonary angiography (CTPA) in patients who underwent both CTPA and ventilation–perfusion (V/Q) scanning. The results were compared with the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) study in which conventional pulmonary angiography had been performed instead of CTPA. Forty-two of 161 (26%) patients had a positve CTPA compared with a 27% prevalence in the PIOPED population. Fourteen of 16 patients (87.5%) with high-probability V/Q scans also had a positive CTPA compared with 87% in PIOPED. Twelve of 40 patients (30%) with intermediate probability V/Q scans also had a positive CTPA compared with 34.7% in PIOPED, while 12 of 80 patients (15%) who had low-probability V/Q scans had positive CTPA compared with 14.5% in PIOPED. Four of 25 patients (16%) with normal V/Q scans had positive CTPA compared with 0% in PIOPED. While the present study size was relatively small, the results compared favourably with PIOPED, suggesting that equivalent prevalence of clot was being detected using CTPA. This result, together with the cost considerations, has led us to replace V/Q scanning with CTPA for investigation of the majority of cases of suspected, acute pulmonary emboli.     

Chest wall dose reduction using noncoplanar volumetric modulated arc radiation therapy for lung stereotactic ablative radiation therapy

Purpose

Stereotactic ablative radiation therapy (SABR) to lung tumors close to the chest wall can cause rib fractures or chest wall pain. We evaluated and propose a clinically practical solution of using noncoplanar volumetric modulated arc radiation therapy (VMAT) to reduce chest wall dose from lung SABR.

Intensity-modulated radiation therapy reduces radiation-induced trismus in patients with nasopharyngeal carcinoma: a prospective study with >5 years of follow-up

BACKGROUND:

Intensity‐modulated radiation therapy (IMRT) for nasopharyngeal carcinoma (NPC) provides better temporomandibular joint (TMJ) sparing and, thus, may reduce the incidence of radiation‐induced trismus after radiotherapy. The objectives of this study were to evaluate radiation‐induced trismus in patients with NPC who had received IMRT and to assess the pretreatment factors, relevant treatment factors, and dosimetry parameters associated with trismus.

METHODS:

A prospective, single‐arm measurement study with more than 5 years of follow‐up was designed. Patients with newly diagnosed stage I through IVB NPC who received treatment with IMRT were eligible. Patients received 66 to 70 grays (Gy) to the gross tumor volume. The maximal interincisal distance (MID) was measured at baseline and 6 months, 1 year, 2 years, 3 years, 4 years, and 5 years after they completed IMRT.

RESULTS:

The trial enrolled 211 consecutive patients from 2001 to 2004. The mean dose to the TMJ ranged from 6.18 Gy to 51.36 Gy (median dose, 29.88 Gy). Compared with baseline MID levels, normalized MID levels at 6 months, 1 year, 2 years, 3 years, 4 years, and 5 years after IMRT were 94.6% ± 9.9%, 92.5% ± 10.5%, 92% ± 10.6%, 92.2% ± 10.5%, 92.1% ± 10.2%, and 90.3% ± 11.4%, respectively (P < .001). According to a revised subjective‐objective management‐analytical (SOMA) scale, grade 1/2 trismus was identified in 12 of 211 patients (5.7%), and no grade 3/4 trismus was observed. There was an increasing risk of trismus after IMRT when the MID was <40.5 mm at baseline compared with an MID >40.5 mm (P = .007). No dosimetric parameter was associated with trismus.

CONCLUSIONS:

IMRT was able to reduce the radiation dose to the TMJ and likely reduced the incidence and severity of radiation‐induced trismus after radiotherapy. Cancer 2011. © 2011 American Cancer Society.     

The effect of breast shielding during lumbar spine radiography

Background

The aim of the study was to determine the influence of lead shielding on the dose to female breasts in conventional x-ray lumbar spine imaging. The correlation between the body mass index and the dose received by the breast was also investigated.

Materials and methods

Breast surface dose was measured by thermoluminescent dosimeters (TLD). In the first phase measurements of breast dose with and without shielding from lumbar spine imaging in two projections were conducted on an anthropomorphic phantom. In the second stage measurements were performed on 100 female patients, randomly divided into two groups of 50, with breast shielding only used in one group.

Results

On average, breast exposure dose in lumbar spine imaging in both projections (anteroposterior (AP) and lateral) was found reduced by approximately 80% (p < 0,001) when shielding with 0.5 mm lead equivalent was used (from 0.45±0.25 mGy to 0.09±0.07 mGy on the right and from 0.26±0.14 mGy to 0.06±0.04 mGy on the left breast). No correlation between the body mass index (BMI) and the breast surface radiation dose was observed.

Conclusions

Although during the lumbar spine imaging breasts receive low-dose exposure even when shielding is not used, the dose can be reduced up to 80% by breast shielding with no influence on the image quality.     

Detailed dosimetric evaluation of intensity-modulated radiation therapy plans created for stage C prostate cancer based on a planning protocol

Background

Intensity-modulated radiation therapy (IMRT) has been employed as a precision radiation therapy with higher conformity to the target. Although clinical outcomes have been reported for many investigations, detailed treatment planning results have not been mentioned to date. The aim of this study was to evaluate the dose specifications of our IMRT treatment plans for locally advanced prostate cancer.

Methods

Seventy-seven clinically applied IMRT plans treated between September 2003 and December 2005, in which patients were irradiated with 78?Gy in the prone position, were retrospectively analyzed. Dosimetric data output from dose volume histograms were evaluated in detail.

Results

The mean dose?±?standard deviation, homogeneity index, and conformity index to the planning target volume (PTV) were 78.3?±?0.7?Gy (100.4?±?0.9%), 13.7?±?3.0, and 0.83?±?0.04, respectively. For the clinical target volume, the mean dose was 80.3?±?0.7?Gy (102.9?±?0.9%).The V40, V60, and V70?Gy of the rectal wall were 58.3?±?2.8, 29.6?±?2.7, and 15.2?±?3.0%, respectively. Planning difficulties were encountered in patients whose bowels were displaced downward, as constraints imposed by the bowel position altered the dose index of the PTV. In many cases, additional bowel optimization parameters were required to satisfy constraints for organs at risk. However, major deviation could be avoided by inverse planning with computer optimization.

Conclusion

IMRT allowed the creation of acceptable and practical treatment plans for locally advanced prostate cancer. Reports regarding detailed dosimetric evaluations are mandatory for interpreting clinical outcomes in the future.     

Ionizing radiation exposure as a result of diagnostic imaging in patients with lymphoma

Purpose

Survival rates among patients with lymphoma continue to improve. Strategies aimed at reducing potential treatment-related toxicity are increasingly prioritized. While radiological procedures play an important role, ionizing radiation exposure has been linked to an increased risk of malignancy, particularly among individuals whose cumulative radiation exposure exceeds a specific threshold (75 millisieverts).

Methods

Within this retrospective study, the cumulative radiation exposure dose was quantified for 486 consecutive patients with lymphoma.

Results

The median estimated total cumulative effective dose (CED) of ionizing radiation per subject was 69 mSv (42–118). However, younger patients (under 40 years) had a median CED of 89 mSv (55–124).

Conclusion

This study highlights the considerable radiation exposure occurring among patients with lymphoma as a result of diagnostic imaging. To limit the risk of secondary carcinogenesis, consideration should be given to monitoring cumulative radiation exposure in individual patients as well as considering imaging modalities, which do not impart an ionizing radiation dose.

     

Breast cancer following radiotherapy for a hemangioma during childhood

Purpose

A cohort study was performed to investigate the carcinogenic effect of treatment of skin hemangioma with ionizing radiation in early childhood. This paper presents the incidence of breast cancer (BC) in this cohort and its association with radiotherapy.

Methods and materials

In an incidence study, 3,316 women treated for a skin hemangioma between 1941 and 1977 at the Institut Gustave-Roussy were included, among whom 2,697 had received radiotherapy. The mean age at first exposure was 0.7?years, and the mean absorbed dose to the breast was 70?mGy. Treatment reconstruction and the estimation of radiation doses delivered to the breast were obtained for 92% of the women who had received radiotherapy. External and internal analyses were performed.

Results

During an average follow-up of 35?years, a total of 17 women developed an invasive BC, compared to 7.5 expected in the French general population (SIR?=?2.3, 95% CI, 1.4?C3.5), and the absolute excess risk strongly increased with attained age. Compared to individuals with no radiotherapy, the risk of BC increased with increasing radiation dose with RRs of 3.2, 6.3, and 8.0 for dose categories of >0?C10, 10?C100, and >100?mGy, respectively; however, dose?Cresponse relationship was not significant.

Conclusion

This study confirms that radiation treatment performed in the past for hemangioma during childhood increases the risk of BC.     

The Geneva prognostic score and mortality in patients diagnosed with pulmonary embolism by CT pulmonary angiogram

This study prospectively evaluates whether a previously established adverse outcome score (the Geneva prognostic score) predicts 3 and 12‐month overall mortality among the patients diagnosed with pulmonary embolism (PE) by a CT pulmonary angiogram (CTPA). Five hundred twenty‐three consecutive patients who had CTPA for suspected PE were recruited prospectively from March 2003 to October 2004. The Geneva prognostic score was calculated for all patients. Twelve‐month follow up was completed in all patients in December 2005. There were 105 patients diagnosed with PE. The mean score was 2.71 (standard deviation (SD) 1.25) for those patients who had died (n = 7) and 1.14 (SD 1.19) for those patients who were alive (n = 98) at 3‐month follow up (P < 0.001). The mean scores were 2.69 (SD 0.95) for those who had died (n = 13) and 1.04 (SD 1.15) for those patients who were alive (n = 92) at 12‐month follow up (P < 0.001). At 3‐month follow up, among the 88 patients with a score of 2 or less, three patients (3.4%) died and among 17 patients with a score of greater than 2, four patients (23.5%) died (P = 0.01). At 12‐month follow up, five patients (5.7%) with a score of 2 or less died and eight patients (47.1%) with a score of three or more died (P < 0.0001). The Geneva prognostic score stratifies patients with low and high risk for overall mortality at 3 and 12 months among patients diagnosed with PE by CTPA.     

Hearing preservation in patients with unilateral vestibular schwannoma who undergo stereotactic radiosurgery

BACKGROUND:

The objective of this study was to identify the prognostic factors for hearing preservation that would allow the more accurate stratification of patients who undergo stereotactic radiosurgery (SRS) for unilateral, sporadic vestibular schwannoma (VS).

METHODS:

In total, 119 patients with VS who had serviceable hearing underwent SRS as primary treatment. The mean (±standard deviation) patient age was 48 ± 11 years, and the mean (±standard deviation) follow‐up duration was 55.2 ± 35.7 months. The median marginal radiotherapy dose was 12.0 grays (Gy), and the mean (±standard deviation) tumor volume was 1.95 ± 2.24 cm³. The mean (±standard deviation) pure tone average (PTA) score was 26 ± 12 decibels (dB) (range, 4‐50 dB), and the mean (±standard deviation) maximum speech discrimination score was 91 ± 12% (range, 52‐100%). The mean (±standard deviation) baseline values for the interlatency (IL) of waves I and III (IL I‐III) and the IL of waves I through V (IL I‐V) on auditory brainstem response were 2.58 ± 0.60 milliseconds (mS) (range, 1.92‐4.30 mS) and 4.80 ± 0.61 mS (range, 3.80‐6.40 mS), respectively.

RESULTS:

In multivariate analysis, the PTA score and IL I‐V were significant and independent prognostic factors (hazard ratio, 1.072; 95% confidence interval, 1.046‐1.098; P < .001; and hazard ratio, 1.534; 95% confidence interval, 1.008‐2.336; P = .046, respectively). By using the PTA score and IL I‐V, the patients were classified into 4 groups. The ratios of patients with serviceable hearing after SRS were 89.6%, 64.0%, 25.8%, and 6.7%, respectively, in Groups A through D (P < .001).

CONCLUSIONS:

The current results indicated that the classification system based on using the PTA score and the IL I‐V of the auditory brainstem response may be useful and specific for predicting the rate of hearing preservation in each individual. Cancer 2012. © 2012 American Cancer Society.     

Preoperative contralateral lung radiation dose is associated with postoperative pulmonary toxicity in patients with locally advanced non-small cell lung cancer treated with trimodality therapy

Purpose

In patients with non-small cell lung cancer (NSCLC) who undergo trimodality therapy (chemoradiation followed by surgical resection), it is unknown whether limiting preoperative radiation dose to the uninvolved lung reduces postsurgical morbidity. This study evaluated whether radiation fall-off dose parameters to the contralateral lung that is unaffected by NSCLC are associated with postoperative complications in NSCLC patients treated with trimodality therapy.

Curiethérapie à haute dose dans le cancer du col utérin : utilisation de l’applicateur en anneau

Purpose

To evaluate the local control and the tolerance of cervical high-dose-rate (HDR) brachytherapy using an applicator ring.

Patients and methods

This is a retrospective study of 105 patients treated in the radiotherapy department for cervical cancer and who received brachytherapy in HDR with an applicator ring in addition to external-beam radiation therapy (EBRT) at the National Institute of Oncology (INO) in Rabat between January 2007 and October 2012.

Results

The mean age of our population was 51.7 ± 12.7 years old; According to the International Federation of Gynecology and Obstetrics (FIGO) 52.4% of patients were stage II, 28.6% stage I, and 19% stage III. Dosimetry was in 2D for 83 patients (78.2%) and 3D for 22 patients (22.8%). For 2D dosimetry, the mean dose to point A was 7.66 ± 0.46 Gy, the mean dose to the bladder point was 4.5 ± 1.5 Gy, and the average dose at the rectum point was 2.7 ± 1.4 Gy. The biological equivalent doses (BED) averages were 91.8 ± 23.2 Gy for the bladder and 68 ± 16 Gy for the rectum (including the dose received by the EBRT with α/β = 3 for organs at risk (OAR). In 3D dosimetry the BED averages for the volume 2 cm³ were 5.8 ± 0.5 Gy for the bladder and 3.5 ± 0.7 Gy for the rectum, with an equivalent 2 Gy dose (EQD2) average of 86 ± 6 Gy for the bladder and 65 ± 7 Gy for the rectum. The mean dose to CTV high risk (D₉₀) was 86.44 ± 3.45 Gy. After a median follow-up of 23 months, the evolution was marked by three local recurrences, two lymph node recurrences and one lung metastases; the rate of recurrence-free survival in our population was 83.7%. Side effects found in our patients were as follows: radiation cystitis in 16 cases (69% grade 1 and 31% grade 2) and radiation proctitis in 8 cases 56% of our patients presented vaginal narrowing (synechiae, atresia). No statistically significant correlation was found between the occurrence of complications and the type of dosimetry (2D or 3D).

Conclusion

Using the applicator ring in cervical HDR brachytherapy provides good local control with acceptable complications.     

Atypical squamous cells,cannot exclude a high‐grade intraepithelial lesion and its clinical significance in postmenopausal,pregnant, postpartum,and contraceptive‐use patients

BACKGROUND.

Previous studies have confirmed the low predictive value of a diagnosis of atypical squamous cells, cannot exclude a high‐grade squamous intraepithelial lesion (ASC‐H) in a Papanicolaou (Pap) smear for subsequent high‐grade dysplasia in the postmenopausal age group. It appears plausible that the decrease in estrogen inherent in the postmenopausal state likely produces reactive cytologic atypia, which is misinterpreted as ASC‐H. The change in hormone levels observed in pregnant patients, postpartum patients, and contraceptive users, as a corollary, potentially could create a similar diagnostic dilemma. In the current study, the impact of age and altered hormone status on the frequency of ASC‐H was assessed to answer the following questions: Is the low predictive value of ASC‐H in postmenopausal women an age‐related phenomenon, and do other states that result in decreased levels of estrogen relative to progesterone have a similar association?

METHODS.

Pap smears that were diagnosed as ASC‐H were divided into postmenopausal, pregnant, postpartum, and contraceptive‐use categories. Each Pap smear slide was reviewed to assess the degree of atrophy and the character of atypical cells. The frequency of high‐grade follow‐up (histology and/or Digene Hybrid Capture II) in the postmenopausal group was compared with the frequency of high‐grade follow‐up in the pregnant, postpartum, and contraceptive‐use categories using the chi‐square test. The pregnant, postpartum, and contraceptive‐use categories also were compared statistically among each other with the chi‐square test.

RESULTS.

In total, 195 cases met the criteria for study inclusion. The percentage of patients who had subsequent high‐grade follow‐up was 22.5% in the postmenopausal group, 79.6% in the pregnant group, 66.7% in the postpartum group, and 60% in the contraceptive‐use group. When these data were subjected to the chi‐square test, there was a statistically significant difference (P<.0001) between the predictive value of subsequent high‐grade follow‐up in the postmenopausal group compared with the other patient groups. When the chi‐square test was applied to the intercomparison of the pregnant, postpartum, and contraceptive‐use categories, there were no significant differences (P > .05) in high‐grade follow‐up between any of these groups.

CONCLUSIONS.

The diagnosis of ASC‐H in postmenopausal Pap smears has a low predictive value in the subsequent diagnosis of high‐grade squamous lesions in stark contrast to the pregnant, postpartum, and contraceptive‐use categories. This suggests that age rather than hormone alterations affects the capacity of ASC‐H to predict subsequent high‐grade squamous intraepithelial lesions. In addition, there are no definite cytomorphologic criteria that can be used to distinguish reliably between benign cellular changes and possible high‐grade squamous lesions in these Pap smears. Digene Hybrid Capture II testing, although helpful, does not have 100% correlation with subsequent tissue/Pap smear follow‐up and cannot be used alone to triage this group of women for colposcopy. Cancer (Cancer Cytopathol) 2008. © 2008 American Cancer Society.     

Computed tomography versus intravenous urography in diagnosis of acute flank pain from urolithiasis: A randomized study comparing imaging costs and radiation dose

The equivalent sensitivity of non‐contrast computed tomography (NCCT) and intravenous urography (IVU) in the diagnosis of suspected ureteric colic has been established. Approximately 50% of patients with suspected ureteric colic do not have a nephro‐urological cause for pain. Because many such patients require further imaging studies, NCCT may obviate the need for these studies and, in so doing, be more cost effective and involve less overall radiation exposure. The present study compares the total imaging cost and radiation dose of NCCT versus IVU in the diagnosis of acute flank pain. Two hundred and twenty‐four patients (157 men; mean age 45 years; age range 19–79 years) with suspected renal colic were randomized either to NCCT or IVU. The number of additional diagnostic imaging studies, cost (IVU A$136; CTU A$173), radiation exposure and imaging times were compared. Of 119 (53%) patients with renal obstruction, 105 had no nephro‐urological causes of pain. For 21 (20%) of these patients an alternative diagnosis was made at the initial imaging, 10 of which were significant. Of 118 IVU patients, 28 (24%) required 32 additional imaging tests to reach a diagnosis, whereas seven of 106 (6%) NCCT patients required seven additional imaging studies. The average total diagnostic imaging cost for the NCCT group was A$181.94 and A$175.46 for the IVU group (P < 0.43). Mean radiation dose to diagnosis was 5.00 mSv (NCCT) versus 3.50 mSv (IVU) (P < 0.001). Mean imaging time was 30 min (NCCT) versus 75 min (IVU) (P < 0.001). Diagnostic imaging costs were remarkably similar. Although NCCT involves a higher radiation dose than IVU, its advantages of faster diagnosis, the avoidance of additional diagnostic imaging tests and its ability to diagnose other causes makes it the study of choice for acute flank pain at Christchurch Hospital.