Periauricular mold brachytherapy

PurposeWe present a patient with recurrent basal cell carcinoma (BCCA) who was treated with custom-made mold brachytherapy.Methods and MaterialsThe patient was admitted to the hospital with the complaint of recurrent BCCA of the auditory canal. He has previously treated by surgery and external beam radiotherapy. We decided to continue with reirradiation to tumor bed after surgical excision. A total of 25 Gy to 5 mm depth of surgical bed was delivered by mold brachytherapy.ResultsThe patient did well during the treatment without any acute toxicity. He was lost to followup after 2 years of treatment without any obvious late morbidity.ConclusionCustom-made mold brachytherapy is an alternative treatment modality, for reirradiation of selected group of patients, with minimal morbidity and good disease control.     

QA and QC processes in imaging

Ensuring that every unit achieves acceptable standards of quality at all times underlies every process of an imaging facility. This article summarizes the key elements of a QA program broken down by modality. Myriad oversight agencies have devised appropriate standards, which are readily available to imaging administrators and others responsible for carrying out QA procedures. QA/QC programs are not just about equipment functionality, but are also about safe working conditions for staff and providing a high level of patient care.     

Stepped-down intervention programs to promote self-managed physical activity in military service veterans: A systematic review of randomised controlled trials

ObjectivesA stepped-down program is one where clients transition from the care of a health professional to self-managed care. This study reviewed the effectiveness of stepped-down interventions to promote self-managed physical activity for health in military service veterans.DesignSystematic review.MethodsLiterature searches of 11 electronic databases were performed (up to 28th April 2020) to identify randomised controlled trials that assessed self-managed physical activity interventions in military service veterans. Data were extracted on study characteristics, intervention programs (with strategies mapped against a taxonomy of behaviour change techniques), and physical activity outcomes; secondary outcomes were physical fitness/function, psychosocial health, and cost effectiveness. Study quality was assessed using a 15-item checklist adapted from the TESTEX scale.ResultsSearches identified 26 studies (all from the United States; N = 45 to 531 participants) representing 17 intervention programs. Studies were of good quality (M = 10.7; SD = 2.3). More than half (54%) reported positive between-group intervention effects for physical activity outcomes (mean increase of 80 min/week in self-reported physical activity at 10–12 months). Physical fitness/function outcomes improved in 38% of studies, but no studies found significant intervention effects for psychosocial health or cost effectiveness outcomes. Behaviour change techniques most frequently used to elicit physical activity changes were education, goal setting, goal review and self-monitoring.ConclusionsStepped-down programs that include specific behaviour change techniques have the potential to promote self-management of physical activity in military service veterans. Multi-national randomised controlled trials that use objective physical activity measures are needed to further build the evidence base.     

Treatment of intermediate-risk prostate cancer with Cs-131: Long-term results from a single institution

PURPOSETo evaluate our institutional outcomes utilizing Cs-131 prostate brachytherapy (PB) for the intermediate-risk (IR) group of prostate cancer patients.METHODS AND MATERIALSWe reviewed a prospectively collected database of men treated with Cs-131 PB between 2006 and 2019. Patients with less than 24-months follow-up were excluded. Patients were classified as IR if they had one of the following factors: Gleason Score 7, prostate specific antigen >10 but <20 ng/mL, or T2b-c on clinical exam. We defined unfavorable-IR (UIR) as having either Grade Group 3, >1 IR factors, or ≥50% positive core biopsies. The Kaplan-Meier method was used to estimate actuarial event-time probabilities for biochemical freedom from disease (BFD).RESULTSA total of 335 patients with a median follow-up of 70.1 months (IQR 48.3–106.3 months) were identified. Androgen deprivation therapy (ADT) was used in 7.2% of patients. Favorable-IR (FIR) patients were commonly treated with PB alone (91.8%). FIR patients who underwent PB alone had a 5-year BFD of 98.1%. UIR patients were commonly treated with external beam radiotherapy plus PB (61.2%). These patients had 5-year BFD of 91.1%. The 5-year BFD for UIR patients treated without ADT was 90.9%, whereas it was 95.0% among UIR patients treated with ADT (log-rank p = 0.83).CONCLUSIONSFIR patients have excellent outcomes when treated with PB alone. External beam radiotherapy plus PB is a reasonable treatment approach for UIR patients. Future studies may elucidate which IR patients would benefit from treatment intensification.     

Global Radiology Training Prevalence Among Radiology Residency Programs

ObjectiveGlobal Radiology aims to enhance access to medical imaging services and education, worldwide. To date, few reports have evaluated Global Radiology Training (GRT) in radiology residency programs. Here, we examined how radiology residency programs perceive and incorporate GRT into their curriculum, and how this information is promoted online.MethodsTwo methods were used to examine the current state of GRT. First, radiology residency program directors (identified via the Association of Program Directors in Radiology) were surveyed on topics including: Electives, institutional partnerships, resident and faculty involvement, inquiry by prospective residents, and barriers to implementation. Second, radiology residency program websites (n = 193) were examined for existing GRT on the programs’ publicly available webpages.ResultsThere were 62 survey responses (response rate of 19%). Thirty-eight percent (24/62) of residency programs offered a Global Radiology elective to their residents within the past academic year and 27% (17/62) of programs have active affiliations with medical institutions outside of the United States. Eighty-four percent of program directors (52/62) received questions from residency applicants regarding opportunities to participate in Global Radiology. Furthermore, only 13% (26/193) of all radiology residency programs listed at least one GRT elective on their webpage.DiscussionGRT in radiology residency is more widely available than previously reported and has been underrepresented on residency program websites. In the present survey, the majority of radiology residency program directors reported that radiology is an important component of Global Health, one-third of whom have already incorporated the subject into their curriculum. However, most common barriers to GRT include, perceived lack of time in the curriculum and lack of faculty interest. The high prevalence of inquiry from residency program applicants about GRT suggests that it may be a notable factor for applicants during the ranking process. Programs build up GRT may choose to share related information seeking to may choose to emphasize work in Global Radiology on their program webpages.     

The effect of quality assurance on flight nurse documentation

This study was developed to evaluate if a structured quality assurance program has an effect on nursing documentation. A randomized, retrospective audit of records was conducted from 1985 to 1989, and in November 1987, a structured QA program was initiated for flight nurses. Each chart was audited for completeness of 69 elements from seven categories: administrative information, patient history, physical exam, management plan, vital signs, medications and intravenous access. A comparison of audit results was conducted before and after the QA program was initiated. A total of 224 charts were audited, 123 before the QA program and 101 after. There was statistically significant improvement in 4 of 13 administrative, 5 of 7 history, 21 of 31 physical exam, 2 of 6 management, 2 of 2 vital signs, 0 of 4 medication, and 0 of 6 intravenous access elements. Twenty-five of 35 categories that did not show improvement had initial completion rates greater than 90 percent. The significant improvement in documentation by flight nurses after a formal QA program was initiated lead the authors to conclude that QA benefits air medical programs by providing a mechanism to improve documentation.     

The evolution of a health hazard assessment database management system for military weapons, equipment, and materiel

During the 1970s, the Army health hazard assessment (HHA) process developed as a medical program to minimize hazards in military materiel during the development process. The HHA Program characterizes health hazards that soldiers and civilians may encounter as they interact with military weapons and equipment. Thus, it is a resource for medical planners and advisors to use that can identify and estimate potential hazards that soldiers may encounter as they train and conduct missions. The U.S. Army Center for Health Promotion and Preventive Medicine administers the program, which is integrated with the Army's Manpower and Personnel Integration program. As the HHA Program has matured, an electronic database has been developed to record and monitor the health hazards associated with military equipment and systems. The current database tracks the results of HHAs and provides reporting designed to assist the HHA Program manager in daily activities.     

Automated air kerma strength quality assurance of permanent seed implant prostate brachytherapy sources using vendor autoradiographs

PurposeTo develop a novel quality assurance (QA) program to determine the air kerma strength (AKS) of brachytherapy seeds within preloaded needles using autoradiographs alone, without jeopardizing sterility or necessitating procedural changes either by the vendor or in the operating room.Methods and MaterialsDigital autoradiographs of QA seed orders and sterile preloaded needles were acquired. Regions of interest of each preloaded seed were determined through an iterative scanning process identifying changes from background levels to radioactivity exposure. Average exposure values through the center of each region of interest were fitted with a Gaussian curve and Full Width at Half Maximums (FWHMs) were calculated. The two-dimensional exposure-scaled FWHM (Exp_2D) measurements for the QA seed orders were plotted against measured AKS values and related using a linear curve fit that was adjusted using the third-party assay average AKS and applied as a calibration curve to convert Exp_2D to AKS.ResultsEstimated seed AKS was found to have a strong dependence on position within the holding tray because of imager positioning inconsistencies. Calculated seed AKS for patient-specific seed orders using the curve scaling factor varied from the nominal order AKS by 1.1 ± 0.9% and from the third-party assay measurements by 0.0 ± 0.4%.ConclusionsThis work depicts a clinically useful tool to aid in QA of preloaded brachytherapy permanent seed implant needles without compromising sterility or increasing clinical workloads. With this procedure, each individual seed's AKS can be verified automatically before a patient's scheduled implant or retroactively when auditing patient records.     

Prostate-specific antigen bounce after high-dose-rate prostate brachytherapy and hypofractionated external beam radiotherapy

PurposeTo report the frequency, timing, and magnitude of prostate-specific antigen (PSA) bounce (PB) in patients who received high-dose-rate (HDR) brachytherapy (HDRB) plus hypofractionated external beam radiation therapy (HypoRT) and to assess a possible correlation between PB and biochemical failure (BF).Methods and MaterialsPatients with intermediate-risk prostate cancer received 10 Gy single-fraction ¹⁹²Ir HDRB followed by 50 Gy in 20 daily fractions of HypoRT without androgen deprivation therapy. All patients had a minimum 2-year followup. The PB was defined as PSA elevation higher than 0.2 ng/mL from previous measurement with subsequent drop to pre-bounce level. The BF was defined as PSA nadir + 2 ng/mL.ResultsA total of 114 patients treated between 2001 and 2009 were eligible for analysis. At a median followup of 66 months, the PB was found in 45 (39%) patients with a median time to bounce of 16 months (range, 3–76 months). The median time to PSA normalization after a PB was 9 months (range, 2–40 months). The median magnitude of PB was 0.45 ng/mL (range, 0.2–6.62). The BF occurred in 12 (10.5%) patients of whom three had a PB. Median time to BF was 52.5 months. Four patients (3.5%) in the PB group fit the criteria for BF.ConclusionsThe PB is common after HDRB and HypoRT and can occur up to 76 months after treatment. It can rarely fit the criteria for BF. The time to PB is shorter than the time to BF. There is a lower incidence of BF in patients with a PB. An acknowledgment of this phenomenon should be made when interpreting PSA results during followup to prevent unnecessary interventions.     

A novel approach for Venezia ovoid commissioning with a comprehensive analysis of source positions in high-dose-rate brachytherapy

PurposeThe lunar design of a Venezia ovoid makes commissioning of the applicator very challenging with traditional autoradiography. In this study, we propose a novel solution to ovoid commissioning and a quality assurance (QA) workflow to effectively assess the entire source path.Methods and materialsA two-step commissioning process, using electron radiation and radiochromic films, was developed to verify the most distal source position. The ovoid was first attached to a film and was irradiated with a 12 MeV linac beam. This process was repeated on a separate, unexposed film, followed by irradiating it with a HDR source at the most distal position. Two lengths, including the ovoid thickness and the distance between the irradiated spot and the ovoid's outer surface, were obtained from the films’ intensity maps. The offset value was calculated from the subtraction of the two measured lengths. Besides acquiring the offset, a source positional simulator (SPS) and a series of planar x-rays from two orthogonal orientations were used to characterize source movement within the ovoid.ResultsCompared to x-ray-based autoradiography, the electron exposure significantly improved the ovoid's visibility on film. Our approach did not use surrogate, which further improved measurement outcomes by decreasing inherent uncertainties. The SPS results suggested the source movement was complex within the cervicovaginal area, but it was predictable with the proposed QA workflow.ConclusionWe introduced a novel, surrogate-free method to commission the Venezia ovoid, which facilitated a manual applicator reconstruction. Additionally, we recommended QA multiple source positions to safely use the ovoid in clinical settings.     

Assessment of US Radiology Residency Program Websites in the COVID-19 Era

ObjectiveTo provide an updated evaluation of radiology residency program websites in light of virtual interviewing during the COVID-19 pandemic and encourage programs to improve the quality of their online website presence.MethodsWe evaluated the websites of 197 US radiology residency programs between November and December 2021 for the presence or absence of 30 metrics. The metrics chosen are those considered important by applicants when choosing a program and have been used in other similar papers.ResultsOf the 197 programs, 192 (97.5%) had working websites. The average radiology residency website had 16 of 30 (54%) metrics listed on their websites. Five programs did not have accessible websites and were not included in the analysis. The most comprehensive website had 29 of 30 (97%) of metrics listed and the least comprehensive website had 2 of 30 (7%). There is a statistically significant difference in website comprehensiveness between top 20 and non–top 20 radiology program websites.ConclusionAlthough radiology residency program websites have generally become more comprehensive over time, there is still room for improvement, especially in times of virtual interviews when residency applicants are becoming more and more reliant on program websites to gain essential information about a program. Some key areas to include are diversity and inclusion initiatives, resident wellness, applicant information, program benefits, and showcase of people in the program.     

Peer-based credentialing for brachytherapy: Application in permanent seed implant

PurposeThe purpose of the study was to establish a quantitative method for implant quality evaluation in permanent seed implant brachytherapy for credentialing. Delivery-based credentialing will promote consistency in brachytherapy seed delivery and improve patient outcomes.MethodsA workflow for delivery-based credentialing was outlined and applied to permanent breast seed implant brachytherapy. Delivery simulations were performed on implantable anthropomorphic breast phantoms. Two institutions experienced in permanent seed implant brachytherapy demonstrated the peer credentialing process. Each delivery was evaluated for seed placement accuracy as the measure of implant quality, both for implant accuracy and across five simulations to assess implant variation. Initial credentialing criteria are set based on two factors; the mean seed placement accuracy (implant accuracy) and the mean standard deviation (seed variation) with the threshold for each set with the addition of two standard deviations.ResultsAcross two institutions, seed placement accuracy (±standard deviation) was calculated for all five delivery simulations to yield 6.1 (±2.6) mm. To set credentialing criteria, the implant accuracy (6.1 mm) plus two standard deviations (2.0 mm) and the seed variation (2.6 mm) plus two standard deviations (0.8) mm yield a threshold of 8.1 ± 3.4 mm. It is expected that 95% of experienced institutions would perform the phantom simulation within this threshold.ConclusionBrachytherapy programs should validate delivery accuracy by formal credentialing, which is standard in external beam programs. This quantitative implant evaluation should be combined with current credentialing standards for permanent seed brachytherapy to form a comprehensive validation of institutional brachytherapy program quality.     

IMSure QA的临床应用研究

目的 比较IMSure QA和MatriXX 两种计划验证工具,探讨IMSure QA软件在临床剂量验证中的可靠性。方法 按随机抽样的抽签法选取10例调强放疗患者,分别用IMSure QA和MatriXX进行剂量验证,比较IMSure QA和MatriXX按3%,3 mm标准进行分析后通过率的差异。结果 IMSure QA验证方式经剂量计算模型得出,MatriXX的验证通过实际测量获得,验证的治疗计划以3%,3 mm标准经γ分析后得到其通过率,MatriXX的平均通过率为（97.9±0.6）%,IMSure QA为（98.1±0.8）%（t=0.86,P>0.05）。结论 IMSure QA可用来执行调强计划的验证。     

Fellowship Candidate Factors Considered by Program Directors

ObjectiveThe neuroradiology fellowship match has been in existence for about 20 years. However, the elements by which neuroradiology fellowship program directors evaluate candidates have not been clearly elucidated. We sought to identify the factors that program directors use to rank neuroradiology fellowship applicants.MethodsAn anonymous Qualtrics online five-question survey about educational credentials, personal traits, extracurricular activities, and demographic characteristics was sent to 72 neuroradiology program directors in April 2019. Each question required ranking of 10 factors based on different characteristics of fellowship candidates. Items included gender, nationality, US Medical Licensing Examination scores, internal applicants, work and research experience, recommendation letters, residency program, medical school attended, and visa status. Program directors had the ability to list any new characteristics that were not included in the survey.ResultsIn all, 68 of 72 (94.4%) neuroradiology programs responded to the survey. The most important criteria by which candidates were assessed were (1) residency program attended for educational credential, (2) personality as assessed by faculty at interviews for candidate personal traits, (3) research performed for candidate’s extracurricular activities, and (4) likelihood of coming to or previous experience in the fellowship geographic area. Neuroradiology program directors independently stressed residency program attended, personality assessed during the interview by faculty, internal candidate status, letters of recommendation, and research activities as their top five criteria in ranking the candidates.ConclusionMultiple factors are weighed by neuroradiology fellowship program directors in selecting fellows, but recent experiences in residency, research, and faculty interactions are prioritized. Internal candidates have an advantage for remaining as fellows within their residency programs.     

High-dose-rate brachytherapy in combination with conformal external beam radiotherapy in the treatment of prostate cancer

PurposeTo report long-term outcomes for treatment of prostate cancer using dose escalation with high-dose-rate (HDR) brachytherapy and 3-dimensional conformal external beam radiotherapy (3DCRT), and compare them with outcomes for treatment of prostate cancer with 3DCRT alone at the same institution.Methods and MaterialsFrom 1998 to 2003, 587 patients were treated for clinically localized prostate cancer. Patients received either 3DCRT (median, 46 Gy) with a single HDR brachytherapy implant (196 patients) delivering a fractionated dose of 18 Gy (combined group) or 3DCRT (median, 70 Gy; 387 patients; “3DCRT alone”). There were 41.9% patients with intermediate-risk and 42.6% with high-risk disease. In all, 441 patients (75.1%) received neoadjuvant and 116 patients (19.8%) received adjuvant androgen deprivation therapy. The American Society of Therapeutic Radiology and Oncology Phoenix definition for biochemical failure was used.ResultsThe median followup was 5.5 years. The 5- and 7-year biochemical control (BC) rates were 82.5% and 80.3%, respectively, for the combined group and 81.3% and 71%, respectively, for 3DCRT alone; for overall survival, they were 91.9% and 89.5% vs. 88.7% and 86.2%, respectively, whereas for cause-specific survival, they were 96.9% and 96.1% vs. 97.6% and 96.2%, respectively. Cox proportional hazard regression analysis for BC revealed that low Gleason grade, HDR brachytherapy combined with 3DCRT, and adjuvant androgen deprivation therapy were significant in predicting BC. Radiation Therapy Oncology Group Grade 3 late urinary and rectal morbidity rates were 7.1% and 0%, respectively. No Grade ≥4 reactions were detected.ConclusionsHDR brachytherapy combined with 3DCRT was associated with improved BC and minimal toxicity in patients with unfavorable prostate cancer compared with conventional 3DCRT.     

A dose verification tool for high-dose-rate interstitial brachytherapy treatment planning in accelerated partial breast irradiation

PurposeTo develop a dose verification tool for high-dose-rate interstitial brachytherapy treatment planning in accelerated partial breast irradiation.Methods and MaterialsWe have developed a software tool for interstitial brachytherapy treatment planning assessment. The software contains a database of seven ¹⁹²Ir source models and is able to estimate the dose distribution using the Task Group 43 and the Sievert integral algorithms. Dose–volume histogram analysis and dose quality assurance (QA) criteria including conformity (COnformal INdex [COIN] and conformation number [CN]), homogeneity (homogeneity index [HI]) parameters were implemented in the software to evaluate and to compare between the doses estimated by the two algorithms and a dose extracted from an external treatment planning system (TPS).ResultsThe tool was evaluated and validated on four clinical cases treated by high-dose-rate interstitial brachytherapy. The doses provided by the Task Group 43 and the Sievert integral algorithms were evaluated by establishing the dose–volume histogram analysis and then by calculating the QA criteria. The algorithms were validated by comparing the dose at different anatomic points with their corresponding dose points provided from TPS. The differences were considered in good agreement (within 5%).ConclusionsPretreatment dose verification is an important step in the QA of brachytherapy accelerated partial breast irradiation. A simple, fast, and accurate method of dose verification is therefore needed. The software proposed in this study could fulfill these requirements. In addition, it is freely available for using by anyone wishing to do a QA on any TPS.     

Evaluation of Pediatric Radiology Fellowship Website Content in USA and Canada

PurposeProspective radiology fellows often rely on the internet to obtain valuable information regarding the application process as well as the unique qualities and aspects of different fellowship programs. The aim of this study was to analyze the content of Accreditation Council for Graduate Medical Education (ACGME) Pediatric Radiology Fellowship websites within the USA and Canadian Accredited Pediatric Radiology Fellowship program websites.MethodsAll active ACGME Pediatric Radiology fellowship websites as of October 2018 were evaluated using 26 criteria in the following domains: application process, recruitment, program structure, education, research, clinical care, and incentives. Fellowships without websites were excluded from the study. Canadian programs were compiled from a list obtained as of October 2018 from the Canadian Association of Radiologists fellowship directory. Each fellowship program was evaluated using the same 26 criteria as the US programs.Results45 active ACGME Pediatric Radiology fellowship programs and 9 Canadian programs were identified. 43 of the US fellowships (96%), and 8 of the Canadian fellowships (89%) had dedicated fellowship websites available for analysis. For US data, websites on average contained 8 out of the 26 data points (31%). Whereas, in Canada, websites on average contained 11 out of the 26 data points (41%).ConclusionMost fellowship websites demonstrate several information deficiencies. This presents an actionable opportunity for individual programs to better inform trainees, promote Pediatric Radiology, and attract the highest quality applicants.     

Estimated Mortality of Breast Cancer Patients Based on Stage at Diagnosis and National Screening Guideline Categorization

PurposeTo compare overall and stage I to IV mortalities of patients diagnosed with breast cancer, calculated from stage at diagnosis using the Surveillance, Epidemiology, and End Results (SEER) database stage mortality estimates, which are based on national screening guideline categorization.MethodsFrom the stage at diagnosis of new breast cancer patients between 2010 and 2014, percentages of invasive cancers, stage 0 + I of total cancers, and stage I of invasive cancers, were calculated. Five-year estimated overall and invasive mortalities were calculated based on stage at diagnosis and SEER survival data. Program categories defined included an Annual Program, based on the ACR (annual screening age 40 and above), a Biennial Program, based on the US Preventative Services Taskforce (biennial screening ages 50 to 74 years), and a Hybrid Program, based on the American Cancer Society (annual screening ages 45 to 54 years, then biennially at ages 55 and above), including respective interval cancers.ResultsIn all, 445 breast cancers met the study inclusion criteria. Comparing program categories, the Annual Program had the lowest percentage of invasive cancers (75.3%), highest percentages of stage 0 + I of total cancers (75.3%) and stage I of invasive cancers (67.1%), and the lowest 5-year estimated overall (10.1%) and stage I to IV (12.0%) mortalities. Estimated overall and stage I to IV mortalities for the Annual Program was 37.3% and 30.6% less, respectively, than the Biennial Program, and 31.8% and 26.8% less, respectively, than the Hybrid Program.ConclusionsBased on stage at diagnosis, the greatest mortality reduction is achieved with mammography utilization starting at the age of 40.