Sunday 18 March 2018

Sunday 18 March, 09:00–10:30 Breast Imaging 1

BreastScreen TACT: results of the tomosynthesis at assessment clinic trial

Beverlee MacDonnell‐Scott

Invited Speaker

BreastScreen Northern Sydney Central Coast has recently completed a trial comparing tomosynthesis (3D mammography) in the assessment clinic to conventional assessment procedures (2D work‐up).

This presentation will outline the trial and discuss the results of introducing tomosynthesis into BreastScreen assessment clinics.

Profiling mammographic parenchymal patterns and breast cancer risk in Papua New Guinea: a baseline study

Ruth Pape^2,3, Kelly Spuur¹, Pius Umo³

¹Charles Sturt University, Wagga Wagga, Australia ²University of Papua New Guinea, Boroko, Papua New Guinea ³Pacific International Hospital, Boroko, Papua New Guinea

Aim: To document for the first time the breast density of Papua New Guinean (PNG) women as evidenced by mammographic parenchymal patterns (MPPs) and to profile breast cancer risk in this population; to examine the relationship of age and MPPs.

Methods: A retrospective analysis of 1161 screening mammograms of women who had undergone screening at the Pacific International Hospital (PIH) Port Moresby was undertaken. The Tabar classification system was used to assess images; age was recorded in years. Descriptive analysis of the data for pattern distribution and a chi‐square test, to test for relationships between age and pattern type were undertaken.

Results: The mean age was 38.8 with a range of 30–80 years; no obvious differences in mean age across categories of patterns was evidenced. The majority (51.42%) of women had Pattern I breasts; Pattern II (30.58%), Pattern III (4.31%), Pattern IV (7.24%), and Pattern V (6.46%). There was no evidence of a relationship between age and pattern type (P = <0.504). Differing from other patterns, Pattern V reported proportionally more women aged >50 and less aged in their 40 s.

Conclusion: A baseline has been established for future studies of the MPPs of PNG women. In this snapshot of women, there is no unique distribution of MPPs and no increased risk of breast cancer based on breast density profiling. This result does not help to explain the high incidence of breast cancer in PNG. A more comprehensive study of the PNG screening population is required to validate these results.

Distributions of mammographic density among women in Ras Al Khaimah, United Arab Emirates

Salman Albeshan^1,2, Zakia Hossain¹, Martin Mackey¹, Delgermaa Demchig¹, Jennifer Peat¹, Patrick Brennan¹

¹University of Sydney, Faculty of Health Sciences, Sydney, Australia ²King Saud University (KSA), Riyadh, Saudi Arabia

Objectives: This study examined the mammographic density of women living in Ras Al Khaimah (RAK) and explored variations in breast density among different ethnic groups (Emirati, Arab, African, Asian and Western women).

Methods: A cross‐sectional design was used to collect mammographic data on 366 women living in RAK. Ethical approval was obtained from the Human Research Ethics Committee of the University of Sydney (project number 2014/484) before commencing the study. Breast density was categorised as fatty (a and b) and dense (c and d) breast tissues based on the American College of Radiology Breast Imaging Reporting and Data System (ACR, BI‐RADS). Pearson's chi‐squared test was used to examine the association between categorical variables: age (>45, ≤45), body mass index (BMI) (>27, ≤27) and ethnicity (Arab, non‐Arab) with two breast density groups (fatty, dense). Multivariate logistic regression was used to derive adjusted odds ratios using ‘Enter’ method.

Results: Of the four BI‐RADS density categories, 21.5% and 43.1% of all participants were characterised as being BI‐RADS a and b respectively, while only 11% was characterised as BI‐RADS d. Adjusted analysis showed that women who were aged ≤45 years (P = 0.02), having a BMI of ≤27 kg/m² (P ≤ 0.0001) and of non‐Arab descent (P = 0.03) were significantly more likely to have denser breast tissues. Further analysis stratified by ethnicity, adjusted for age and BMI, showed that Emirati women (P = 0.04) were significantly less likely to have denser breast tissues than Western women.

Conclusion: The finding that most Emirati women had low mammographic density indicates this ethnic group was at lower risk of breast cancer. However, as cancer risks (based on greater breast density) was higher in younger, leaner and non‐Arab women, suggests that breast cancer screening by mammography should be promoted in these groups for early detection.^1–3

References

1. Assi V, Warwick J, Cuzick J, Duffy SW. Clinical and epidemiological issues in mammographic density. Nat Rev Clin Oncol 2012;9:33–40.

2. Boyd NF, Rommens JM, Vogt K, et al. Mammographic breast density as an intermediate phenotype for breast cancer. Lancet Oncol 2005;6:798–808.

3. Pettersson A, Graff RE, Ursin G, et al. Mammographic density phenotypes and risk of breast cancer: a meta‐analysis. J Natl Cancer Inst 2014;106:078.

Current practice in Australia for imaging the augmented breast in the digital setting: documenting change

Jacquelyn O'Keefe, Kelly Spuur

Charles Sturt University, Wagga Wagga, Australia

Aligning to the introduction of digital image acquisition technology, the routine mammographic series for a woman in Australia with breast implants is anecdotally known to have changed significantly. Previously in the film screen setting, a 16‐image Eklund technique series¹ comprised four non‐compressed (left and right craniocaudal and mediolateral oblique views) and 12 implant‐displacement views (left and right lateral, behind the nipple and medial views for the craniocaudal projection and left and right superior, behind the nipple and coned inframammary angle views for the mediolateral oblique projection).

However, in the contemporary digital acquisition setting imaging now typically reflects a modified Eklund technique² and involves just an 8‐image series; four non‐compressed left and right craniocaudal and mediolateral oblique views and four implant‐displacement views; left and right behind the nipple views in the craniocaudal projection and left and right behind the nipple views for the mediolateral oblique projection. There is no evidence‐base in the literature to support this change to the routine imaging series.

This research documents current practice in Australia, explores differences in the imaging series undertaken between and within diagnostic and BreastScreen imaging services; and seeks to provide explanation for the change in the digitally acquired imaging series for the augmented breast. Rationale for the change includes reduced dose and the benefit of increased diagnostic image quality afforded with the introduction of digital mammography. Where the 16 image series is still used, radiologist preference is a known driver. The imaging series for tomosynthesis technology is also explored.

References

1. Eklund GW, Busby RC, Miller SH, Job JS. Improved imaging of the augmented breast. AJR 1988;151(3):469–473.

2. Andolina VF, Lillé S. Mammographic Imaging: a practical guide. Wolters Kluwer/Lippincott Williams & Wilkins Health, Philadelphia, 2011.

Sunday 18 March, 09:00–10:30 Clinical Education

Communication‐preparing undergraduate radiation therapy students for difficult conversations

Toni Kelly^1,2, Yolanda Surjan¹, Marianne Rinks³, Helen Warren‐Forward¹

¹University of Newcastle, Newcastle, Australia ²Illawarra Shoalhaven Cancer and Haematology Network, Wollongong, Australia ³Illawarra Shoalhaven Cancer and Haematology Network, Nowra, Australia

Objective: Role‐play teaching methods have been used to facilitate development of communication skills in medical students. However, there is little evidence around the effectiveness of role‐play and concurrent inclusion of critiquing from multiple sources including peers, facilitators and patients. This study aimed to analyse the effectiveness of simulated role‐play coupled with collaborative critiquing in the development of communication skills, critical thinking and preparedness of radiation therapy students for clinical placement.

Materials and Methods: A series of communication modules were delivered (between 2008 and 2015) to first year University of Newcastle students prior to their initial contact with clinical centres and patients. These modules included didactic learning, tutorials with opportunities to observe experienced clinical communicators in clinical exchanges and laboratories providing student/patient exchanges and simulated clinical situations. Ethics approval was granted (UON QA64).

Results: Anonymous student evaluations revealed 91.6% of students found having their strengths and weaknesses critiqued by their peers in a role‐play situation to be extremely helpful or very helpful. Direct feedback from the simulated patient (actor) regarding their strengths and weaknesses was determined to be extremely helpful or very helpful for 98.4% of students participating in the workshops.

Conclusion: Simulated role‐play and collaborative peer critiquing approaches rated highly with students undertaking the workshops. It demonstrates utilising actors as patients, as well as students’ peers giving feedback among others to be effective methods to achieve effective communication training for the radiation therapy student cohort.

Using blended learning as a mechanism for radiation therapist competence development

Kristie Matthews^1,2, Christopher Marinakis¹, Glenn Trainor¹, Brent Chesson¹

¹Radiation Therapy Services, Peter MacCallum Cancer Centre, Melbourne, Australia ²Department Medical Imaging and Radiation Sciences, Monash University, Melbourne, Australia

The utilisation of cone beam CT (CBCT) to improve the accuracy of radiation therapy treatment verification is increasing, and is likely to continue with anticipated growth in adaptive techniques. As a result, the skill set required of radiation therapists (RTs) is shifting. It is essential that clinical services ensure RTs have the competence to perform soft tissue verification accurately to provide optimal patient care.

Peter MacCallum Cancer Centre provides radiation therapy across five dispersed campuses with a team of 200+ RTs, which can challenge training and competency assessment delivery when introducing significant practice change. To address this challenge, an alternative blended learning method was recently piloted with the implementation of a daily lung CBCT image guidance protocol.

Blended learning uses combined mechanisms for teaching, usually online with in‐person elements,¹ and has been shown to be an efficient and effective method in health professional education.²^,³ In relation to the lung CBCT protocol, online content provided training and assessment of underpinning knowledge, while practical skills application were approved by a radiation oncologist within a defined patient cohort. Competence was validated once both elements were successfully completed.

Results from the online and practical assessments indicate effective learning was achieved using a blended learning model. An evaluation with the pilot RTs also indicated positive outcomes. Consequently, the lung CBCT training package has now been rolled out to all staff. This project has demonstrated that blended learning can enable all RTs to apply new skills safely, supporting the provision of optimal care.

References

1. Hainey K, Green A, Kelly LJ. A blended learning approach to teaching CVAD care and maintenance. British Journal Nursing 2017 (IV Therapy Supplement);26(2):S4‐S12.

2. Petty J. Interactive, technology‐enhanced self‐regulated learning tools in health care education: a literature review. Nurse Education Today 2013;33:53–59.

3. Petty J. Exploring the effectiveness of an interactive, technology‐enabled learning tool to enhance knowledge for neonatal nurses. Neonatal, Paediatric and Child Health Nursing 2014;17(1):2–10.

Development of a transition to practice program for newly qualified radiation therapists at Peter MacCallum

Nahal Varghayee

Peter MacCallum Cancer Institute, Melbourne, Australia

Newly qualified radiation therapists (RTs) are expected to be competent, confident and possess increased responsibilities immediately following their professional development year. It has been well documented¹ that health professionals can experience an unsettling transition period, resulting in heightened levels of stress and anxiety, which may be attributed to inadequate preparation, lack of support and experience. This can lead to errors, burnout, dissatisfaction and premature employment termination, with scope to create staff retention issues, increased sick leave and decreased workplace efficiency, potentially leading to a compromise in quality of patient care.

Transition to practice programs (TPPs) aim to provide a nurturing, supportive, collaborative and motivating environment, designed to broaden the RT's knowledge and skill. The acknowledged benefits of TPPs has led to the development of national standardised TPPs internationally,² however, currently none are available for Australian RTs.

This paper aims to articulate the development of a 6‐month TPP for newly qualified RTs and share some of the initial experiences at PMCC.

The introduction of a pilot 6‐month TPP at Peter MacCallum Cancer Centre (PMCC) is intended to address the perceived challenges associated with commencing qualified practice. The ethics approved program intends to offer support with everyday practice through peer learning, reflective practice and structured mentorship. A formal evaluation of the program will be undertaken with data collected via focus groups, and analysed using grounded theory methods.³

References

1. Oremann HGarvin F. Stresses and challenges for new graduates in hospitals. Nurse Education Today 2012;3(22):225–230.

2. Gordon C, Aggar C, Williams A, Walker L, Willcock S, Bloomfield J. A transition program to primary health care for new graduate nurses: a strategy towards building a sustainable primary health care nurse workforce? BMC Nurs 2014;13(1).

3. Creswell J, Poth C. Qualitative inquiry and research design. Thousand Oaks, Calif.: Sage Publications; 2003.

Teaching the teachers to teach

Nick Maddock

Capital Radiology, Australia

Radiographers have a wealth of knowledge to impart when collaborating and supervising radiography Interns and students. The absence of a formal education background or specific training for the large proportion of radiographers means that radiographers often lack specific skills to effectively teach and communicate ideas. Radiographers can improve their skills and the educational outcomes for participants during work‐integrated learning by applying the New South Wales Department of Education and Training (NSW DET) Quality Teaching Framework¹ into their supervision practices.

The Quality Teaching Framework is implemented in all NSW public schools to facilitate the provision of quality education. The framework helps achieve this by providing staff with a platform for critical reflection and analysis of current teaching practices and dimensions.

Through the application of the NSW DET Quality Teaching Framework to everyday clinical situations, the differing learning processes of individuals can be explored. By connecting effective questioning techniques with a learner's stage of skill acquisition and by effectively scaffolding tasks for learners, an efficient improvement in ability and skills can be facilitated by radiographers.

The NSW DET Quality Teaching Framework will be applied to a series of work‐integrated learning situations to demonstrate best‐practice structure of educational experiences, using a radiography perspective. Aspects of the learning environment, educational theory and the provision of feedback will be demonstrated through a series of real‐life examples and usable activities to demonstrate the application of the NSW DET Quality Teaching framework into the supervision practices of radiographers.

Reference

1. State of NSW, Department of Education and Training Professional Learning and Leadership Development Directorate. Quality teaching in NSW public schools: An assessment practice guide. 2nd edn. Ryde NSW: State of NSW, Department of Education and Training. Available at http://stjohnsprimarystaff.wikispaces.com/file/view/asspracg.pdf

Medical imaging clinical placements: a pilot study of students’ first clinical experience

Madeleine Shanahan, Rob Davidson

University of Canberra, Bruce, Australia

Objective: Clinical placement offer students opportunity to develop technical skills across a diverse range of patient presentations, observe role models, as well as critically reflect on their clinical experiences.^1–3 The objective of this study was to identify the type of experiences students have on their first clinical practicum.

Methods: Following completion of the practicum, all enrolled students (N = 46) were invited to complete an online survey to ascertain students’ views on their first practicum. Descriptive statistics were applied. University ethics approval was granted.

Results: Responses were received from 31 students: placement‐hospital 55%, private practice 45%. Fourteen students moved residence to attend their clinical placement. Prior to placement students described themselves as “nervous, anxious, scared”. Students agreed or strongly agreed that they had opportunity to develop technical skills across a diverse range of patients (92%), communication (100%) and problem solving (84%) skills, and reflected on what they observed and did (100%). Supervisors were perceived as good role models (100%), spending sufficient time (88%) and providing useful feedback (100%) to students. After clinical placement students described themselves as “confident, satisfied, proud, sad to leave”. Being away from home and communicating with patients were identified as most challenging aspect of their first placement.

Discussion: Clinical practicum offered students a supportive and transformative learning experience that developed their confidence and skills. Students experienced challenges as well as identified areas that they and the university could do to better prepare them for their first practicum.

Conclusion: Feedback on clinical experience assists course development for future students.

References

1. Price R, Hopwood N, Pearce V. Auditing the clinical placement experience. Radiography 2000;6:151–60.

2. Hyde E. A critical evaluation of student radiographers’ experience of the transition from the classroom to their first clinical placement. Radiography 2015;21:242–7.

3. Ogbu SOI. Radiography students’ perceptions of clinical placements – A Nigerian perspective. Radiography 2008;14:154–61.

Sunday 18 March, 09:00–10:30 Multi‐modality

Medical radiation collaboration: radiation therapy and diagnostic radiography for more care

Tony Vuong

Adventist Healthcare Ltd, Sydney, Australia

Sydney Adventist Hospital has a unique clinical setting that allows radiation therapists and diagnostic radiographers to work together. In most radiation oncology departments, the radiation therapists perform their own radiation therapy planning scans on CT scanners in their own department. At the Sydney Adventist Hospital, radiation therapists perform their planning scans in the radiology department with diagnostic radiographers.

The radiation therapists utilise a specialised CT table top and positioning aids to replicate the patients’ position during radiation therapy. Radiographers must work with the radiation therapists to acquire scans that meet the requirements of radiation therapy planning.

This presentation will provide an overview of the perspectives and priorities of each speciality, as well as how effective communication is used to overcome the workflow and access challenges that our unique arrangement creates. We will also be discussing the collaboration between radiology and radiation therapy on dose reduction for CT planning scans.

Free breathing CT pulmonary angiograms with a high‐pitch dual‐source CT scanner

Hung Do

Peter MacCallum Cancer Centre, Melbourne, Australia

Background: CT pulmonary angiograms (CTPA) are established examinations in diagnosing pulmonary emboli. Although the incidence of non‐diagnostic CTPA examinations have declined with advancements in CT technology, non‐diagnostic CTPAs are still a large problem in clinical practice. There are many factors that affect the image quality of CTPA examinations including insufficient contrast enhancement in the pulmonary arteries; motion, breathing artefacts and beam‐hardening artefacts.

Case presentation: We present a new approach that is being trialled at our institution: Free‐breathing ultra high‐pitch CT pulmonary angiograms. These CTPAs are performed on our dual source CT scanner (SOMATOM Force, Siemens Healthcare, Forchheim, Germany), which is capable of acquiring at 737 mm/s on ‘flash mode’ and has a maximum temporal resolution of 66 ms – effectively enabling us to perform sub‐second CTPA examinations.

Management and Outcome: (1) The sub‐second scan time allows for a reduction in radiation dose to the patient, (2) These scans can be performed with less contrast, (3) Our standard non‐flash CTPA can take up to 2–3 s to perform. With flash mode, there is a larger time window to allow for better opacification of sub‐segmental pulmonary arteries before the CT scan is acquired, (4) It is possible to unintentionally scan the patient in an expiratory phase, (5) It is possible to have motion artefact at the diaphragmatic and cardiac borders.

Discussion: Our trial and several studies^1,2 agree that high‐pitch CTPAs have promising results and has similar image quality to routine CTPAs.

References

1. Ajlan A, Binzaqr S, Jadkarim D, Jamjoom L, Leipsic J. High‐pitch helical dual‐source computed tomographic pulmonary angiography. Journal of Thoracic Imaging 2016;31(1):56–62.

2. Martini K, Meier A, Higashigaito K, Saltybaeva N, Alkadhi H, Frauenfelder T. Prospective randomized comparison of high‐pitch CT at 80 kVp under free breathing with standard‐pitch CT at 100 kVp under breath‐hold for detection of pulmonary embolism. Academic Radiology 2016;23(11):1335–1341.

MR screening – the 2020 paradigm – Stage 1

James Nol¹, Andrew Jones²

¹Western Sydney University, Blacktown, Australia ²BMDH Imaging, Blacktown, Australia

Stage 1 – 5 min MRI screening is the new paradigm. The shift has started with a target date for completion set for year 2020.

Stage 1 – brain strokes: On 1 February a new protocol was implemented. For every CT brain referral to exclude stroke, a DWI sequence to be added to the request. That was agreed on between neurology, emergency and radiology departments.

Between 4 February 2017 and 31 July 2017, 327 requests for CT brain to rule out strokes were submitted. CT detected 14 brain strokes; MR screening detected 54 brain strokes; CT missed 43 ischaemic strokes.

The results clearly indicated that a 90 sec MR screening is a more reliable tool than the series of CT exposures, a submission has been placed to change the protocols for stroke patients and eliminate CT scanning for stroke patients.

The protocol for stroke was single DWI sequence, for heamorrhage a single flare sequence.

The study has shown that one sequence MR screening is a more reliable tool than CT scanning without the risks of ionising radiation insults on human cells. This has disqualified the notion that patients are exposed to ionising radiation because the benefits outweigh the risks.

Stage 2 started 1 June 2017 to cover:

• appendicitis

• KUB

• biliary system.

The final goal is to reduce the use of CT scans by 80% by 2021.

References

1. Mathews JD, Forsythe AV, Brady Z, et al. Cancer risk in 680 000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians. BMJ 2013;21(346):2360.

2. Li F, Han SS, et al. Reversal of acute apparent diffusion coefficient abnormalities and delayed neuronal death following transient focal cerebral ischemia in rats. Ann Neurol 1999;46:333–342.

Non‐accidental injury

Chris Houghton

Wagga Wagga Rural Referral Hospital, Wagga Wagga, Australia

Non‐accidental injury. Three words that should break the heart of every radiographer. But what do you do when you simply don't believe it? And what do you do when the parents are friends and colleagues?

Is it possible to care for the patient, the parents and staff at the same time? How do you collaborate and communicate with your colleagues to ensure that the best outcome is achieved for all?

This presentation discusses an incident that occurred at a rural hospital in New South Wales that tested the emotional intelligence¹^,² of staff, and examines the emotional impact on the staff and parents and the changes that occurred as a result.

References

1. Birks YF, Watt IS. Emotional intelligence and patient‐centred care. Journal of the Royal Society of Medicine 2007;100(8):368–374.

2. Mauricio HIM, Lesyuk O, Riberio LPV, et al. Radiographers emotional intelligence in clinical practice. Poster session presented at: ECR 2017.

The prevalence of work‐related musculoskeletal pain among medical imaging technologists and sonographers in New Zealand

Farzanah Desai, Victoria Pratt

Universal College of Learning, Palmerston North, New Zealand

Objectives: The aim of the study was to investigate the prevalence of work‐related musculoskeletal pain (WRMSP) among medical imaging technologists and sonographers in New Zealand.

Methods: Ethical approval was sought from the tertiary organisation's research committee before participants completed a self‐report WRMSP questionnaire.¹ The questionnaire comprised: demographics, scope of practice, exercise patterns, occupational information and WRMSP experienced in the past 12 months. Close‐ended multiple choice options ranged from dichotomous to Likert scale responses. Results from the questionnaire were captured using online survey development cloud‐based software. Using SPSS, the following descriptive statistics were completed: mode, mean, frequency, percentages and standard deviations.

Results: Questionnaires from 275 participants were collected and analysed (n = 275). A high proportion of participants reported to have experienced WRMSP in the past 12 months (96.2%). The data was divided into two groups as the ergonomic profile of each scope differs: general medical imaging technologist (MIT) (n = 189) and sonographers (n = 86). Despite the contrast in ergonomic profiles of each cohort, they both attributed their WRMSP to ergonomic duties (89.2%). Figure 1 shows the anatomical sites of pain. MRTs and sonographers reported repetitive movements (64.8%) and frequent repetitive work with shoulders, arms, hands or fingers (98.8%) as the most frequent ergonomic duty performed, respectively.

Conclusions: There is evidently a high prevalence of WRMSP among medical imaging technologists and sonographers in New Zealand. In the theme of ‘care, communicate, collaborate’, it is empirical for health professionals to co‐construct solutions for physical and psychological health and wellbeing of our workforce.

Figure 1. Anatomical sites of pain

Reference

1. Kuorinka I, Jonsson B, Kilbom A, et al. Standardised Nordic questionnaires for the analysis of musculoskeletal symptoms. Applied Ergonomics 1987;18(3):233–7.

Referral pathways in accessing medical imaging services in a multi‐level public health care complex

Chandra Makanjee¹, Anne‐Marie Bergh², Braam Hoffmann³

¹University of Canberra, Bruce, Australia ²University of Pretoria, Pretoria, South Africa ³Tshwane University of Technology, Pretoria, South Africa

Background: Diagnostic imaging plays an integral role in disease diagnosis and patient treatment.¹ The challenge in the context of diagnostic imaging referrals is how to collectively navigate patients through these services, intra‐ and inter‐institutionally.^2‐⁵

Objective: To map the referral processes and procedures that lead to access to diagnostic imaging services within the embedded multi‐level medico‐clinical pathways up to the point of an ultimate diagnosis as part of a patient's treatment and management plan.

Methods: This study was part of a larger qualitative study conducted at a district hospital situated in an academic hospital complex.

A total of 24 patients were chosen due to availability to participate in both the entry and exit interviews. These participants were accompanied at each point of contact within the health system complex from entry until discharge. Data collection methods included observations of various types of consultations and individual and focus group interviews with multiple health care providers.

Findings: Two main themes pertaining to referrals for diagnostic imaging were identified. The first relates to the decisions that a medical officer or specialist has to make about the sequence of activities and procedures related to each patient's condition. The second theme refers to the multi‐level routing of patients.

Conclusion: The informational interactions between providers that take place during a patient's journey inform the mapping approach to referral pathways for diagnostic imaging investigations from a systemic point of view. This process can also enhance the strategic management, for instance, monitoring timely access to imaging services within the health system complex.

References

1. Lundén M, Lundgren SM, Lepp M. The nurse radiographers’ experience of meeting with patients during interventional radiology. JRN 2012;31(2):53–61.

2. D'Amour D, Goulet L, Labadie JF, San Martín‐Rodriquez L, Pineault R. A model and typology of collaboration between professionals in health care organizations. BMC Health Serv Res 2008;8(188):1e14.

3. Longo J, Smith MC. A prescription for disruptions in care: community building among nurses to address horizontal violence. Adv Nurs Sci 2011;34(4):345e56.

4. Suter E, Arndt J, Arthur N, Parboosingh J, Taylor E, Deutschlander S. Role understanding and effective communication as core competencies for collaborative practice. J Interprof Care 2009;23(1):41e5.

5. Clark FA. Power and confidence in professions: lessons for occupational therapy. Can J Occup Ther 2010;77(5):264e9

Sunday 18 March, 09:00–10:30 Planning

A dosimetric study evaluating different treatment techniques for whole breast radiotherapy

Brock Lamprecht¹, Jennifer Harvey¹, Avalon McCluskey¹, Erika Eaves¹, Gordon Lu¹, Sharon Watson¹, Samantha Barbour², Margot Lehman¹, Tao Mai¹, Tamara Barry¹, Elizabeth Brown^1,3, Cathy Hargrave^1,3

¹Radiation Oncology Department, Princess Alexandra Hospital, Brisbane, Australia ²Radiation Oncology Centres, Greenslopes, Australia ³School of Clinical Sciences, Queensland University of Technology, Brisbane, Australia

Objectives: Breast cancer patients present for radiation therapy (RT) with variation in body habitus, organ at risk (OAR) location and planning tumour volumes (PTV).¹^,² As such, RT plan quality varies. The purpose of this study was to evaluate the impact of patient body habitus on three‐dimensional conformal radiation therapy (3DCRT) and hybrid intensity modulated radiation therapy (IMRT) plans.

Methods: Thirty early stage whole breast patient CT datasets were divided into three categories: Small, medium and large, sorted by medial to lateral distance at the posterior aspect of the PTV (patient separation). PTV and OAR volumes were created on each dataset and planned using one 3DCRT and two hybrid IMRT breast techniques (70% conformal/30% IMRT and 60% conformal/40% IMRT) to the breast. Plan dosimetry was assessed using conformity (CI) and homogeneity (HI) indices, OAR dose and PTV coverage. Ethics approval was obtained.

Results: Hybrid techniques showed improved plan quality over 3DCRT for patient separations >26 cm with CI and HI means of 0.14 and 0.77 and 0.16 and 0.71 respectively. Dose to heart and lungs were improved using a 70/30% hybrid IMRT technique. The 60/40% hybrid IMRT technique demonstrated lower dose to non‐target tissue. Dosimetric improvements for hybrid IMRT techniques were notable for patient separations >26 cm and PTVs within 1.2 cm of midline or 1 cm of heart.

Conclusion: Patient separation and PTV proximity to midline and heart were identified as the primary factors influencing plan quality. Technique choice based on these factors aids in efficient production of high‐quality, individualised plans.

References

1. De Langhe S, Mulliez T, Veldeman L, et al. Factors modifying the risk for developing acute skin toxicity after whole‐breast intensity modulated radiotherapy. BMC Cancer 2014;14:711–720.

2. Morganti A, Cilla S, de Gaetano A, et al. Forward planned intensity modulated radiotherapy (IMRT) for whole breast postoperative radiotherapy. Is it useful? When? J Appl Clin Med Phys 2011;2:34–51.

Comparing contralateral breast dose with electronic compensators and conventional tangential fields – a clinical‐dosimetric study

Prabhakar Ramachandran, Amanda Smith, Peta Lonski, Jeremy Hughes, Beth Howard, James Hagekyriakou, Tomas Kron

Peter MacCallum Cancer Centre, Melbourne, Australia

Background: Dose to the contralateral breast (CLB) after radiotherapy (RT) treatment has potential to induce secondary breast cancer.^1–3 Subsequently, amidst the introduction of new technology in breast cancer RT management, CLB dose must be considered. Electronic compensation (eComp) has recently been implemented at the Peter MacCallum Cancer Centre to provide an alternative method to conventional 3d‐conformal RT (ConRT) planning and delivery. The aim of this ethics approved study was to measure and compare contralateral breast dose for patients undergoing tangential field radiotherapy with eComp and ConRT fields.

Methods: Forty patients undergoing tangential field breast radiotherapy were included in this study. 20 patients utilised eComp tangential irradiation. The remaining 20 patients were planned with ConRT tangential fields. Four sets of TLDs were placed on the CLB at 3 cm from the medial tangential fields (Pt1), areola (Pt3), mid‐way between Pt1 and Pt3 and at the axilla. The doses were measured with (TLD domes: 1 cm effective depth) and without (TLD strips) build‐up. Contralateral breast doses were assessed with both treatment techniques.

Results: Preliminary results show that the mean dose measured at 3 cm from the medial‐tangential border for eComp and ConRT techniques with TLD strips were 27.1 ± 0.3 cGy and 26.5 ± 0.06 cGy respectively. The dose measured with strips was almost twice that measured with domes.

Conclusion: CLB dose is dependent on the proximity of the medial‐tangential field edge to the CLB, which is very patient specific. Our study shows that CLB dose with eComp and ConRT is comparable.

Referecnes: 1. Boice JD Jr, Harvey EB, Blettner M, Stovall M, Flannery JT. Cancer in the contralateral breast after radiotherapy for breast cancer. N Engl J Med 1192;326:781–785.

2. Clarke M, Collins R, Darby S, et al. Early Breast Cancer Trialists’ Collaborative Group (EBCTCG). Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15‐year survival: an overview of the randomised trials. Lancet 2005;366(9503):2087–106.

3. Travis LB, et al. Breast cancer following radiotherapy and chemotherapy among young women with Hodgkin disease. JAMA.2003;290:465–75.

Novel approach for treatment of high grade urothelial carcinoma in multiple recurrent sites: case report

Jean Sloan

Alfred Health – Gippsland Radiation Oncology, Melbourne, Australia

Introduction: A case report of high grade urothelial carcinoma with FDG‐PET avid recurrences to the pre‐sacral space and left adrenal gland, in a very fit 64 year old man. Due to the patient's extensive medical history and efforts to provide best outcomes and quality of care to the patient, a highly conformal technique, in combination with effective communication between the patient and multidisciplinary team were essential.

Case presentation: In July 2015, the patient was diagnosed with localised bladder cancer and underwent cystoprostatectomy with formation of a neobladder. In April 2017, asymptomatic metastases to the pre‐sacral space and left adrenal were discovered.

Management and Outcome: The patient was treated to two sites simultaneously, with high‐dose radiotherapy aiming for local control, to potentially prolong survival and a small chance of cure. Rapid Arc (RA) was employed to achieve conformal dosimetry with sparing to the organs at risk. Image guided radiation therapy (IGRT) ensured accurate delivery of treatment.

Discussion: The patient's main concern was perforation of the neobladder and late effects to the left kidney as these structures abutted the plan target volumes. RA achieved favourable dosimetry with sparing of these structures. In combination with IGRT, RA is a feasible modality to deliver high doses to multiple sites simultaneously.

Dosimetric analysis: full volumetric arc therapy to a partial VMAT technique for pancreatic cancer

David Gration

North West Cancer Centre, Burnie, Australia

Purpose: To compare the dose coverage to planned target volumes (PTV) and dose sparing to local organs at risk (OAR), liver, spinal cord, kidneys and small bowel with two VMAT techniques for pancreatic carcinoma.

Method: A single full VMAT treatment plan and a treatment plan with dual partial anterior VMAT arcs was analysed on 10 retrospective patients who were treated for unresectable pancreatic cancer. Each plan was prescribed 50.4 Gy in 28 fractions (1.8 Gy/fx) with dose to 98% of each PTV volume receiving at least 95% of the prescription. Pinnacle was the treatment planning system used in this study.

Results: Analysis of the data shows that using dual partial VMAT arcs significantly reduced the mean dose to the kidneys with comparison of the dose from a single full VMAT arc plan. The small bowel, liver and spinal cord doses were all well under acceptable dose limits for both techniques. The dose to the small bowel was marginally higher in the dual arc technique.

Conclusions: Employing a dual partial arc technique significantly reduces the total mean dose to the kidneys whilst maintaining PTV coverage. The dual arc technique has a decrease in MU efficiency and results in a slightly higher dose to the bowel. This study shows that a dual arc VMAT plan is superior in avoiding the dose to the kidneys whilst maintaining dose conformity. Further study is warranted to investigate if these dose reductions translate to clinical benefits.

Virtual HDR brachytherapy: creating a clinical objectives template for prostate SBRT emulating brachytherapy boost

Andrew Le, George Hruby, Andrew Kneebone, James O'Toole, Regina Bromley, Adam Briggs, Felix Bockelmann, John Atyeo, Thomas Eade

Northern Sydney Cancer Centre, St Leonards, Australia

Objectives: To create and test a dynamic clinical objectives template based on patients’ anatomy and organ at risk (OAR) overlap for a prostate stereotactic body radiotherapy (SBRT) boost (virtual high dose rate) of 24 Gy in 2 fractions, and gross tumour volume (GTV) boost to 30 Gy.¹

Methods: The planning datasets of 10 treated patients were used for this project. Each patient was contoured, and planned using the trial protocol. Three evaluation structures were created by cropping the PTV, CTV and GTV with a 1, 2 and 3 mm margin from the OARs (nine total evaluation structures). Evaluation of the margin, which delivered the best target coverage while maintaining OAR constraints as per the protocol was completed.

Results: The 2 mm margin was the best compromise for evaluating optimal dose coverage and OAR constraints when assessing plans. This was used to create a consistent clinical objectives table. The resulting constraints to the 2 mm cropped evaluation structure were: GTVp eval V30Gy >95%, CTV HR eval V24Gy >90% and PTV HR Eval V20Gy >99%.

Discussion: Clinical objectives of previous virtual HDR plans delivering 24 Gy in 2 fractions as a boost were not reproducible from patient to patient due to differences in patient anatomy and OAR overlap, making it difficult to assess the relative quality of each treatment plan.² This new approach of assessing the plans with evaluation structures will give planners more realistic and achievable clinical objectives and goals, resulting in more consistency and quality in the boost plans.

References

1. Rossi L, Breedveld S, Heijmen BJM, Voet PWJ, Lanconelli N, Aluwini S. On the beam direction search space in computerized non‐coplanar beam angle optimization for IMRT‐prostate SBRT. Physics Medicine Biology 2012;17:57.

2. Peters LJ, O'Sullivan B, Giralt J, et al. Critical impact of radiotherapy protocol compliance and quality in the treatment of advanced head and neck cancer: results from TROG 02.02. J Clin Oncol 2010;28(18):2996–3001.

Improving plan quality and efficiency in radical oesophagus cancer patients: a retrospective planning study

Michael Liu, Prabhakar Ramachandran

Peter MacCallum Cancer Centre, Fawkner, Australia

Introduction: 3D conformal radiotherapy (3DRCT) plus chemotherapy is the current standard of care for radical oesophageal cancer (OC) patients at Peter MacCallum Cancer Centre. Studies comparing intensity modulated radiotherapy (IMRT) with 3DCRT reveal significant organ at risk dose avoidance and improved plan conformity.^1–4 The aim of this study (ethics approved) was to compare IMRT and 3DCRT dosimetric and efficiency measures in a cohort of OC radiotherapy patients.

Methods: 20 retrospective radical OC patients were used in this study. All were replanned using IMRT. Dosimetric comparison was made between the IMRT and clinical‐3DCRT plans. Efficiency measures were recorded for all IMRT plans.

Results: Varying degrees of lung avoidance were observed in the IMRT cohort. V30Gy (P ≤ 0.01), V10Gy (P = 0.02) and Dmean (P = 0.01) reported significant improvement. IMRT patients experienced an insignificant increase in V5Gy (P = 0.19). IMRT also afforded greater liver avoidance (Dmean, P < 0.01; V20Gy, P < 0.01; V35Gy, P < 0.01). Furthermore, target coverage and homogeneity also improved in the IMRT cohort, in addition to the improved critical structure avoidance (PTV D99%, P = 0.04; PTV Dmax, P < 0.01; CTV D100, P < 0.01). Mean IMRT planning time was 42 min (range 15–75). All IMRT plans met pre‐determined departmental physics QA standards.

Conclusion: This study demonstrates a dosimetric and planning efficiency benefit when IMRT is utilised in this OC patient cohort. Consequently, the development of template IMRT solutions is currently underway with the intent that all radical OC patients will be planned using IMRT. Additionally, investigation into the applicability of OC VMAT is continuing, to further derive improved operational efficiencies.

References

1. Carrington R, Spezi E, Gwynne S, et al. The influence of dose distribution on treatment outcome in the SCOPE 1 oesophageal cancer trial. Radiation Oncology 2016;11(1):19.

2. Freilich J, Hoffe SE, Almhanna K, et al. Comparative outcomes for three‐dimensional conformal versus intensity‐modulated radiation therapy for esophageal cancer. Diseases of the Esophagus 2015;28(4):352–7.

3. Lin CY, Huang WY, Jen YM, et al. Dosimetric and efficiency comparison of high‐dose radiotherapy for esophageal cancer: volumetric modulated arc therapy versus fixed‐field intensity‐modulated radiotherapy. Diseases of the Esophagus.2014;27(6):585–90.

4. Roeder F, Nicolay NH, Nguyen T, et al. Intensity modulated radiotherapy (IMRT) with concurrent chemotherapy as definitive treatment of locally advanced esophageal cancer. Radiation Oncology 2014;9(1):191.

Sunday 18 March, 11:00–12:30 Breast Imaging 2

Routine radiographer QC: more than resetting baselines

Lucy Cartwright

Invited Speaker

Performing routine quality control (QC) on mammography systems is essential to ensure systems are operating optimally. This presentation will provide an update on recent QC developments, including QC requirements for tomosynthesis systems. In addition, a Q&A type discussion will be held regarding some common reasons for routine QC failure, and the appropriate steps to take when QC fails. Be sure to bring along your curliest QC related questions to present for discussion (and maybe solution!).

Can we make PGMI more effective?

Beverlee MacDonnell‐Scott

Invited Speaker

Image quality assessment is an important part of screening mammography, both as a training tool and in the assessment of a screening program's ability to detect breast cancer. The PGMI criteria has long been used as the main tool for assessing mammography, however, it has often been criticised for being too subjective or not providing adequate information.

Radiographers from BreastScreen Northern Sydney Central Coast have initiated a project to attempt to adapt the PGMI grading system in an effort to provide more detailed information about image quality.

Pain in mammography

Judy Giles

Blacktown Hospital, Sydney, Australia

Population screening programs such as breast screening are set up to survey a population and provide early intervention before a disease enters a more advanced stage. Programs need a participation rate of at least 75% to be effective. Participation rates in the BreastScreen program vary greatly. In New South Wales some areas may have a 50% participation rate and others 75%. The reasons for this can be complex, however one of the main reasons is that women can experience pain during this examination which can stop them returning for their next screen.

Pain experienced by mammography patients can also vary; some experience no pain, whereas approximately 75% in one survey said they experienced slight, moderate or severe pain with a mammography. Davey¹ separated pain into three separate groups: psychological, biological and staff related. Of the many studies examined by Keefe et al.² it was proposed that there are multiple factors contributing to a painful mammogram and a cognitive‐behavioural model has been presented which is influenced by sensory, emotional and behavioural factors (see Figure).

By applying this model to pain in mammography it is hoped that an understanding can be gained to encourage more women to attend for further mammograms.

References

1. Davey B. Pain during mammography: implications for breast screening programmes. Australis Radiol 2007;45(2):113–117.

2. Keefe F, Hauck E, Egert J, Rimer B, Kornguth P. Mammography pain and discomfort: a cognitive‐behavioral perspective. Pain 2000;(56)3:247–260.

Use of digital storytelling to teach evidence based breast imaging to radiography students

Cynthia Cowling, Susan Bower

Monash University, Clayton, Australia

Background: The sensitive and emotive environment of breast imaging involves an integrative approach encompassing the technical and psycho‐social, which is challenging to replicate for teachers of student radiographers while maintaining an appropriate level of pedagogy. The challenge was to engage both male and female students within an academic environment at a more complex level.

Method: A high quality video production featuring a woman undergoing breast imaging was produced in a digital storytelling format. It included her anxieties and her experiences, interactions with medical and health staff, and relationships with family and friends. The video was complemented and integrated with short online visual lectures which incorporated anatomy, pathology, technique, communication, special procedures and other imaging modalities. Self‐review opportunities for students, practical hands‐on sonography labs using breast phantoms and a formal online final exam were included. The content management system (Moodle) was designed such that the student was required to follow through each video section sequentially.

Results: The video illustrated tensions, pressures and anxieties of the patient and how these can be ameliorated through best practice techniques. Students were surveyed at conclusion of the module. A strong preference for the design and flexibility of the module was revealed. 70% enjoyed the module and were engaged by the storyline. Only 5% found it a distraction. Interest was sustained in fourth year by three students pursuing research projects in breast imaging.

Conclusion: As well as meeting the requirements for practical experience in the clinical workplace for student radiographers, this innovative pedagogic approach integrating knowledge, behaviour and attitudes created significant interest in the field.

Unknown relationships between the inframammary angle, age, the posterior nipple line and compressed breast thickness

Kelly Spuur¹, Jodie Webb¹, Ann Poulos², Wayne Robinson¹, Sharon Nielsen^1,3

¹Charles Sturt University, Wagga Wagga, Australia ²University of Sydney, Lidcombe, Australia ³Sharon Nielsen Statistical Consulting, Wagga Wagga, Australia

Aim: The secondary aims of this study were to examine relationships between the inframammary angle¹ (IMA) (see Figure), age, the posterior nipple line² (PNL) (breast size) and compressed breast thickness, with outcomes validated using appropriate analyses of inter‐reader and inter‐rater reliability and variability.³.

Method: A quantitative retrospective study of 2270 randomly selected paired digital mammograms performed by BreastScreen NSW was undertaken. Data was collected by direct measurement and visual analysis. Intra‐class correlation analyses were used to evaluate inter‐ and intra‐rater reliability.

Results: A linear relationship was found between the PNL and age (P < 0.001). The PNL was predicted to increase by 0.48 mm for every one‐year increment in age. The odds of demonstrating the IMA reduced by 2% for every one‐year increase in age (P < 0.001); and are 0.4% higher for every 1 mm increase in PNL length (P < 0.001) and 1.6% lower for every 1 mm increase in compressed breast thickness (P < 0.001). There was high inter‐ and intra‐rater reliability for the PNL.

Conclusion: For the first time it has been documented that demonstration of the IMA is impacted negatively by both increasing age and compressed breast thickness but positively by breast size. This has implications for breast screening services whose clientele are inherently an ageing population and subsequently the potential for radiographers to be compliant to current image quality accreditation standards both in Australia and internationally.

References

1. American College of Radiology. Mammography quality control manual. American College of Radiology, Reston, VA, 1999.

2. BreastScreen Australia National Quality Management Committee. National Accreditation Standard, Commonwealth of Australia Printing Press, Australia, 2015.

3. Gwet KL. Handbook of inter‐rater reliability: the definitive guide to measuring the extent of agreement among raters. Advanced Analytics, LLC, 2014.

Sunday 18 March, 11:00–12:30 General X‐ray 2

Undergraduate use of medical radiation science applications

Lacey R Greene¹, Kelly M Spuur²

¹Stanford University, Stanford, United States²Charles Sturt University, Wagga Wagga, Australia

Objectives: Despite the technologically intense nature of the medical radiation science (MRS) profession, literature specifically supporting the adoption of mobile learning in MRS education is scarce. To this aim, we explored student utilisation of and influences for choosing MRS applications (apps, a specific type of mobile learning) within the Bachelor of Medical Radiation Science course at Charles Sturt University (CSU), Australia. Secondary objectives briefly investigated content reliability within selected chosen apps and overall student willingness to embrace this methodology prior to mainstream integration.

Methods: A mixed‐method census survey was delivered to 415 enroled students using the software Survey Monkey to compile responses to 28 questions.

Results: Among the 97 students who completed the survey, 37% freely use MRS apps at least weekly (70%), of which anatomy atlases were reported as most popular. Peer recommendation influenced 67% of students to choose the MRS apps used. Thirty‐seven percent of students integrated only one method to check the accuracy of app content prior to download. Students who do not use MRS apps (78%) stated they were unaware of this resource however, 91% of the respondents indicated they would use MRS apps if incorporated into the curriculum.

Conclusion: The majority of CSU students agreed that apps offer a convenient way to engage in a variety of interactive content both in the classroom and on‐the‐go, using apps most pertinent to their specific curriculum and/or for revision. Students preferred to use MRS apps if integrated as supplemental study tools vetted by the lecturer.

Geometric concepts in radiography

Michael Fuller, Victoria Pierce

Flinders Medical Centre, Adelaide, Australia

Introduction: This paper considers aspects of X‐ray beam geometry that can be incorporated into everyday radiographic techniques. These radiographic understandings and techniques can have a significant impact on the efficiency and effectiveness of radiographic practice as well as reducing radiation doses to patients. All three of these factors impact patient care.

The following concepts will be explored:

• Implications of demonstrating 3-dimensional anatomy in two dimensions (clinical examples provided)

• Separation of the vertical/horizontal ray and central ray when utilising the table/wall bucky respectively (theoretical basis and clinical examples provided)

• Matching the divergent beam to patient anatomy (theoretical basis and clinical examples provided)

• The efficacy of utilising compound X-ray tube angles (theoretical basis and clinical examples provided).

Discussion: Each of these concepts will be considered in conjunction with theoretical understanding as well as corroborating with clinical examples and equipment test results where applicable.

Outcomes: While X‐ray beam geometry might appear to be a purely academic/technical consideration, the authors aim to demonstrate the link between a sound understanding of X‐ray beam geometry, good radiography, patient dose reduction and patient care.

Plain film ribs: when are they worth the dose?

David Allen

Bolsover Radiology, Rockhampton, Australia

Despite longstanding controversy, requests for rib X‐rays to diagnose possible fractures remain a common occurrence following minor trauma.¹ Regardless of the identification of a fracture on X‐ray, treatment frequently remains unchanged.¹^,² Management is only altered when secondary complications are noted on X‐ray such as a flail chest or pneumothorax.³ Even more direct interventional procedures such as open reduction internal fixation (ORIF) surgery are a rarity.² As clinicians, we must consider when performing oblique projections of the ribs provides an actual consequential benefit to the patient.³ Multiple factors including the specificity, sensitivity and reliability of detecting rib fractures on plain X‐ray will be considered. In addition, the qualitative experience of the patient and when the time, dose and cost can be justified without violation of duty of care will be discussed.³ Collaboration and communication with referring clinicians must also be maintained to ensure confidence in any consequent treatment prescribed.

This paper will provide a review of current literature and propose an evidence‐based clinical framework to guide clinicians and radiographers when specific views of the ribs to identify fractures are appropriate.

References

1. Hoffstetter P, Dornia C, Schäfer S, et al. Diagnostic significance of rib series in minor thorax trauma compared to plain chest film and computed tomography. J Trauma Manage Outcomes 2014;8:(10).

2. Shuaib W, Vijayasarathi A, Tiwana MH, et al. The diagnostic utility of rib series in assessing rib fractures. Emerg Radiol 2014;21:159–164.

3. American College of Radiology. ACR Appropriateness Criteria Rib Fractures. Available at https://acsearch.acr.org/docs/69450/Narrative/ [Accessed 1 August 2017].

Collaborative evaluation of mobile versus departmental chest X‐ray examinations in geriatric patients

Tim McCosker¹, Andrew Emerson¹, Michelle Moscova³, Nadine Thompson², Raymond Cabela¹, Doungkamol Sindhusake⁴, Charles Wang¹, Lakshmi Venkateswaran¹, Noel Young¹

¹Westmead Hospital, Westmead, Australia ²Sydney Adventist Hospital, Wahroonga, Australia ³University of New South Wales, Kensington, Australia ⁴Western Sydney University, Parramatta, Australia

Objectives: Chest X‐ray examinations (CXRs) are the most common form of imaging investigation for the geriatric patient.¹^,² CXRs are commonly performed for geriatric patients in the radiology department and also mobile on the ward. There are currently no guidelines for requesting mobile imaging at our facility. Mobile imaging should only be used for medically unstable patients,³ however, this is not always the case at our facility. Doctors often request mobile imaging to speed up the examination time. This study evaluates the use of mobile imaging in the geriatric patient population.

Method: All CXRs performed on patients admitted under the geriatric team at our facility between 1 July 2015 and 1 July 2016 were compared in this ethics approved study. The clinical justification, provided by the referring doctor, was compared for departmental and mobile examinations by two geriatric clinicians.

Results: A total of 1816 CXRs were performed on geriatric patients during the study period, 63% were performed in the department. Clinical justification was lacking in 40% of requests. On average, departmental examinations took 185 min longer than mobile examinations to complete. Mobile examinations have a higher odds ratio (OR 5.7) of requiring a repeat examination within 24 h without a change in patient's clinical status.

Conclusion: There was no clear difference in clinical justification provided for mobile and departmental geriatric CXR requests. Mobile examinations were performed faster, but are more likely to require a repeat examination than a departmental examination. Facility guidelines would assist referrers in ensuring mobile examinations are justified.

References

1. Kjelle E, Lysdahl K. Mobile radiography services in nursing homes: a systematic review of residents’ and societal outcomes. BMC Health Services Research 2017;17:231.

2. O'Brien J, OBaerlocher M, Asch M, Myers A. Role of radiology in geriatric care: a primer for family physicians. Can Fam Physician 2009;55(1):32–37.

3. American College of Radiology. ACR practice parameter for the performance of portable (mobile unit) chest radiography [Internet]. American College of Radiology. Available at https://www.acr.org/~/media/38249F67D295479A8B3F2BE073C37B65.pdf/ [Accessed 10 August 2017].

From past to present – the history of medical imaging at a tertiary Queensland hospital

Alex Hollingsworth

Princess Alexandra Hospital, Brisbane, Australia

Medical imaging has always been a rapidly advancing technology, with major developments occurring on average each decade. Those involved are always looking toward the next new technique or new equipment, but it is not often that we stop to look at where we have come from and the advancements in regard to patient care that have already been made.

In one of Queensland's tertiary public health facilities, the question: “How did medical imaging at this hospital begin?” was asked. A single chapter in a lone history book¹ and a paper written by a staff member about their experiences in the 1970s was all that surfaced on the topic. Not satisfied with this brief offering, more research was performed to answer the questions: “How did medical imaging start at this site?”, “What procedures have been performed in this department?” and “What equipment have previous radiographers used at this hospital?”

Through intense research at the Queensland State Archive and interviews with past and current staff members (ethics approval for these interviews was sought however, it was deemed not required), a clearer image of the department's history emerged. The existing history book was proven inaccurate,² and threads that tie into a larger, national history exposed. Naturally, the history was followed through the exciting times surrounding the implementation of CT and MRI and concludes in the current day as we move into the digital era that we are currently familiar with and how these new technologies improved our professions standard of patient care.

References

1. Hall P. Princess Alexandra Hospital – The Jubilee Volume 1956–1981. 1st edn. Brisbane: Princess Alexandra Hospital, 1981.

2. Item 2021 – X‐ray plant. South Brisbane Auxiliary Hospital (Item 1740, Fol 2242). Brisbane: Queensland Radium Institute; 1951. QSA Item ID: 814888.

Interpreting ankle radiographs in the emergency department: are three views necessary?

Lauren Williams

Metro South Health, Brisbane, Australia

Objectives: Medical imaging plays a vital role in the assessment of ankle trauma.¹^,² There is limited evidence that a three‐view radiographic ankle series (anteroposterior, mortise and lateral) is superior in detecting acute injuries than a two‐view combination (mortise and lateral). The aim of this study was to determine whether the three‐view series could be replaced by the two‐view combination.

Methods: A retrospective review of acute ankle radiographic series was undertaken over a 6‐month timeframe with 60 examinations collected. Two folders were created: one containing all three views while the other had the anteroposterior view removed. Three radiographers of varying experience levels were asked to provide a preliminary evaluation on each of the examinations in each folder. The first round of interpretation was of the two‐view combination folder and the second round of testing, performed two weeks after, included all three views.

Results: The results provide little support for preferring the two‐view series for evaluation of acute ankle injuries. The three‐view series identified 85.6% of abnormalities present in the sample, while the two‐view combination only identified 77.8%. There were seven studies where the injury was commented on the two‐view combination and not the three‐view.

Discussion/Conclusion: This study demonstrated that when radiographers were providing a preliminary evaluation on a trauma ankle radiographic series their accuracy was higher when viewing a three‐view ankle series. This highlights the utility of the anteroposterior view in conjunction with the mortise and lateral ankle views.

References

1. Pankovich AM. Trauma to the ankle. Disorders of the foot and ankle: medical and surgical management. 2nd edn. Philadelphia: Saunders, 1991.

2. Greenspan A. Orthopedic imaging: a practical approach. Lippincott Williams & Wilkins, 2011.

Sunday March 18, 11:00–12:30 Student Prize Winners (MI)

Megaprosthesis

Wendy Geng

University of South Australia, Adelaide, Australia

Introduction: Amputation was commonly the only treatment option for large bone defects in the extremities caused by extensive primary or metastatic tumours, severe trauma or end‐stage revision arthroplasty.¹ However, the development and recent advances of megaprostheses used in orthopedic surgery allowed for limb salvage surgery as it replaced and reconstructed large skeletal defects.^1,2 This presentation aims to educate viewers on the use of megaprostheses in orthopedic surgery, with a particular focus on indications, contraindications, prosthetic components and potential complications.

Case presentations: Two patient cases requiring megaprosthetic reconstructions are presented and the role of medical imaging throughout the patient's clinical pathway is outlined. The first case study presents a female with grade three chondrosarcoma in her left proximal femur and underwent a left hip megaprosthetic reconstruction after aggressive tumour resection. The second case study focuses on a patient who sustained severe trauma to his right femur and tibia. Limb salvage surgery was then undertaken by implanting a megaprosthesis.

Management and outcome: The patient in the first case study required continuous follow‐up imaging and experienced no complications after her megaprosthetic reconstruction. The right lower limb of the second patient case has been salvaged and he is able to weight bear three months after surgery.

Conclusion: Megaprosthetic reconstruction is the treatment option that provides the most stability and mobility to patients requiring a large resection of bone in limb salvage surgeries.³ This presentation introduces medical radiation professionals to the use of megaprostheses in orthopedic surgery and presents two patient cases requiring megaprosthetic reconstruction.

References

1. Gkavardina A, Tsagozis P. The use of megaprostheses for reconstruction of large skeletal defects in the extremities: a critical review. Open Orthop J 2014;8:384‐9.

2. Pala E, Trovarelli G, Calabrò T, Angelini A, Abati CN, Ruggieri P. Survival of modern knee tumor megaprostheses: failures, functional results, and a comparative statistical analysis. Clin Orthop Relat Res 2015;473(3):891‐9.

3. Donati F, DiGiacomo G, D'Adamio S, et al. Silver‐Coated Hip Megaprosthesis in Oncological Limb Savage Surgery. Biomed Res Int 2016;2016:1‐6.

Clinical value of patient‐specific three‐dimensional printing of congenital heart disease: quantitative and qualitative assessments

Ivan Lau, Zhonghua Sun

Curtin University, Perth, Australia

Introduction: Current diagnostic assessment tools remain suboptimal in demonstrating complex morphology of congenital heart disease (CHD). This limitation has posed challenges in preoperative planning,¹ communication in medical practice,² and medical education.³ This study aims to investigate the dimensional accuracy, as well as the clinical value of three‐dimensional (3D) printing of CHD in the areas mentioned above.

Methods: Ethical approval was obtained from Human Research Ethics Committee. Using cardiac computed tomography angiogram (CTA) data, a 3D model of a 20‐months‐old heart with double outlet right ventricle was printed in TangoPlus material. Pearson correlation coefficient was used to evaluate correlation of the measurements taken at analogous anatomical locations between the CTA and 3D printed model. Surveys were also conducted with six health professionals (two radiologists, two cardiologists and two cardiac surgeons) and three medical academics to assess the clinical value of the 3D printed model.

Results: Excellent correlation (0.99) was noted in the measurements between CTA and 3D printed model. Four out of six health professionals found the model to be useful in facilitating preoperative planning, while all of them thought that the model would be invaluable in enhancing patient‐doctor communication. All three medical academics found the model to be helpful in teaching, and thought that the students will be able to learn the pathology quicker with better understanding.

Conclusion: A patient's heart anatomy can be accurately replicated using 3D printing technology. 3D printed heart models could serve as excellent tool in facilitating preoperative planning, communication in medical practice, and medical education.

References

1. Olejnik P, Nosal M, Havran T, et al. Utilisation of three‐dimensional printed heart models for operative planning of complex congenital heart defects. Kardiologia Polska 2017;75(5):495–501.

2. Biglino G, Capelli C, Wray J, et al. 3D‐manufactured patient‐specific models of congenital heart defects for communication in clinical practice: feasibility and acceptability. BMJ Open 2015;5(4):1‐8.

3. Costello J, Olivieri L, Krieger A, et al. Utilizing three‐dimensional printing technology to assess the feasibility of high‐fidelity synthetic ventricular septal defect models for simulation in medical education. World J Pediatr Congenit Heart Surg 2014;5(3):421‐426.

The power of reflection in action

Alison Mau

Queensland University of Technology, Brisbane, Australia

The Medical Radiation Practice Board sets out professional capabilities for medical radiation practice.¹ Domain 3 outlines that registered practitioners must be able to apply critical and reflective thinking to resolve clinical challenges. Reflective practice is a key part of learning in radiography, especially for students to become reflective practitioners in the future. It has been reported that reflective practitioners are more proficient in handling difficult situations as they are able to analyse a situation critically from an objective perspective and develop new ways of practice.² During clinical placements, students are encouraged to use the 4Rs model of reflection: report the issue, relate the relevance of the issue, reason about the significant factors using academic literature or theory and reconstruct future practice from the experience. The discussion highlights the importance of reflective practice through a case study that emphasises the importance of analysing images, reporting on significant findings to relevant health practitioners and performing supplementary imaging.

References

1. Medical Radiation Practice Board of Australia. Professional capabilities for medical radiation practice [updated 25 June 2015]. Available at www.medicalradiationpracticeboard.gov.au/Registration/Professional‐Capabilities.aspx [Accessed 28 Oct 2017].

2. Citewrite.qut.au [QUT Website]. Reflective writing [updated 26 Oct 2017]. Available at www.citewrite.qut.edu.au/write/reflectivewriting.jsp [Accessed 28 Oct 2017].

Predicting femoral geometry using an articulated statistical shape model constrained to simulated motion capture markers

Hogan Sharpe¹, Matthew Dimmock¹, Desney Greybe², Thor Besier², Richard Bassed³, Sarah Parsons³, Wendy Macleod¹

¹Monash University, Clayton, Australia ²Auckland Bioengineering Institute, Auckland, New Zealand ³Victorian Institute of Forensic Medicine, Southbank, Australia

Objectives: Motion capture analysis incorporates the use of sparsely located landmarks to analyse the biomechanics of the lower limb during locomotion. Conventionally, the underlying model used for gait analysis is based on the crude scaling of a reference volume.¹ This research presents results from the combined use of an articulated statistical shape model (aSSM) and simulated skin‐mounted motion capture markers to predict femoral geometry to enable patient‐specific gait analysis.

Methods: Ten post‐mortem computed tomography (PMCT) scans with corresponding demographic information were retrospectively acquired. The simulated skin‐mounted markers were placed on the CT datasets and the aSSM was constrained to the landmark points. The resulting predicted femoral geometries were compared to the manually segmented ground‐truth volumes.

Results: A surface‐to‐surface mean absolute error (MAE) of 4.0 mm and root‐mean‐squared error (RMSE) of 5.4 mm was found across all ten cases. Moderate (R² = 0.62) and strong (R² = 0.73) correlations were found between mean error and mass and mean error and BMI respectively. Region‐based deviations of 12–15 mm were observed over the proximal femur and femoral condyles. By incorporating a skin‐padding factor for individuals whom were obese, the model's prediction was improved by an average of 45%.

Conclusion: Femoral geometry was best predicted for individuals that were classified with a BMI below 30. In individuals classed as obese or morbidly obese, the femoral epicondyles showed poor agreement due to excessive soft tissue. Incorporating a skin‐padding factor improved these predictions greatly. Proximal inaccuracies were attributed to lack of proximal landmark data.

Reference

1. Zhang J, Fernandez, J, Hislop‐Jambrich, J, Besier, TF. Lower limb estimation from sparse landmarks using an articulated shape model. J Biomech 2016;49:3875–81.

Optimising plain radiographic imaging of the abdomen for obese patients

Jennifer Van Den Heuvel, Sarah Lewis

The University of Sydney, Lidcombe, Australia

Objective: The aim of this study was to determine an optimal model for plain projection imaging of the abdomen of obese patients.

Methodology: A two round Delphi study was undertaken in order to establish a consensus within a reference group of expert clinical educator diagnostic radiographers as to the best practice of imaging the abdomen of obese patients. In designing the questions, a conceptual map of issues regarding imaging obese patients was undertaken by analysing the transcripts interviews with expert radiographers. Delphi rounds 1 and 2 used an online questionnaire completed by clinical educator radiographers employed at New South Wales public hospitals. The consensus threshold was set at responses with <75% ‘agreement/disagreement’ and 15 and 14 radiographers participated in rounds 1 and 2 respectively.

Results: The questionnaire had four main themes and rounds 1 and 2 saw a total of seven of the 11 statements reach consensus. Consensus on using a combination of kVp and mAs to increase radiation exposure, increased SID and tighter collimation was achieved. However there was no clear consensus in regards to most patient positioning or communication practices.

Conclusion: Decisions based on numerical technical changes were more likely to reach consensus. However no clear method of best practice is recognised by clinical experts in the more humanistic practices of radiography. Variations in opinions may be due to the varied nature of obese patients’ presentation and this study has identified the need for extensive empirical evidence and education of radiographers when imaging obese patients.

References

1. Carucci L. Imaging obese patients: problems and solutions. Abdom Imaging 2013;38(4):630–646.

2. Aweidah L, Robinson J, Cummings S, Lewis S. Australian diagnostic radiographers’ attitudes and perceptions of imaging obese patients: a study of self, peers and students. Radiography 2016;22(4):258–263.

Sunday March 18, 11:00–12:30 Student Prize Winners (RT)

Technology in oncology: addressing the implications of survivorship

Alexandra Berlangieri

Austin Health, Melbourne, Australia

Aim: Due to greater detection and treatment interventions, there is a growing population of breast cancer survivors. This review aims to analyse the implications survivorship patients experience and management strategies that can be implemented. There will be an emphasis on technology and future directions of interventions.

Method: Key search terms included breast cancer, survivorship, survivors, psychological, physical, implications, technology and apps. Sixteen articles were reviewed which assessed patient experience or management strategies. Several of these reviewed applications which have been trialled.

Discussion: Survivors report feelings of anxiousness, fatigue, sexual issues and a decrease in functionality. Care plans can assist patients in feeling control over their care path. The Smart Survivor app is a ‘one stop shop’ for personalised care information.¹ bWell has been developed by physiotherapists for patients who experience upper limb dysfunction and includes a number of exercise interventions.² There is also a vast selection of exercise and medication apps which can be of benefit to survivorship patients.

Conclusion: It is paramount that staff involved in cancer care are aware of the challenges survivors face and can suggest viable strategies of management. Progression in mobile apps and their convenience appear favourable to breast cancer survivorship patients. However, the lack of specificity and validity in app content may have the risk of potentially endangering patient safety.

References

1. Baseman J, Revere D, Baldwin LM. A mobile breast cancer survivorship care App: pilot study. JMIR Cancer 2017;3(2).

2. Harder H, Holroyd P, Burkinshaw L, et al. A user‐centred approach to developing bWell, a mobile app for arm and shoulder exercises after breast cancer treatment. Journal of Cancer Survivorship 2017;24:1‐1.

Into the future: custom 3D printed bolus in radiation therapy

Mikaela Dell'Oro

University of South Australia, Adelaide, Australia

Learning objectives:

1. Compare custom 3D printed bolus against commercially available bolus.

2. Evaluate the current clinical implementation of custom three-dimensional (3D) printed bolus in radiation therapy treatment.

3. Educate professionals on the current advantages and shortcomings of custom 3D printed bolus in literature.

Background: Commercial bolus is generally used across centres to conserve time and resources required to custom construct bolus by hand. However due to the presence of ‘air gaps’ commercial bolus may not be the best option for patients with irregular surface contours.¹

Summary of interesting situation: 3D printed bolus has the propensity to improve clinical outcome through the removal of these ‘air gaps’ and increase dose homogeneity. Recent studies evaluate the dosimetric benefit of 3D printed bolus materials (i.e. polyactic acid and polyamide) to demonstrate the clinical efficacy and accuracy of fabrication of bolus.^2,3

With the recent increase in implementation of intensity modulated/volumetric arc therapy radiation therapy techniques more precise ancillary equipment is required to reduce dose variation between the planning and treatment stages. The techniques produce small field sizes not accounting for the variability produced by ‘air gaps’ from large bolus pieces placed on uneven patient surfaces. Further research is required to ensure that bolus is translatable in treatment planning systems.¹

Conclusion: The presentation demonstrates the clinical efficacy of custom 3D printed bolus across treatment sites compared to commercially available bolus. At the forefront of radiation therapy technology custom 3D printed bolus improves treatment outcome, quality of care and conservation of resources.

References

1. Pugh R, Lloyd K, Collins M, Duxbury A. The use of 3D printing within radiation therapy to improve bolus conformity: a literature review. J Radiother Pract 2017;16(3):319–25.

2. Fujimotoa K, Shiinokia T, Yuasa Y, Hanazawa H, Shibuya K. Efficacy of patient‐specific bolus created using three‐dimensional printing technique in photon radiotherapy. Phys Med 2017;38(1):1–9.

3. Zou W, Fisher T, Zhang M, et al. Potential of 3D printing technologies for fabrication of electron bolus and proton compensators. J Appl Clin Med Phys 2015;16(3):90–8.

Investigating the role of volumetric arc therapy in radiotherapy to the whole breast and internal mammary chain

Jarrod Hallinan¹, Vikneswary Batumalai², Kylie Dundas^2,3, Rebecca Bartlett², Miriam Boxer²

¹University of Newcastle, Newcastle, Australia ²Liverpool Cancer Therapy Centre, Liverpool, Australia ³Ingham Institute for Applied Medical Research, Liverpool, Australia

Objectives: Despite widespread adoption of intensity modulated radiation therapy (IMRT) as the gold standard of care for patients with early stage breast cancer, three dimensional conformal radiotherapy (3D‐CRT) remains the treatment of choice for patients also requiring nodal irradiation.¹ Whilst 3D‐CRT and deep inspiration breath hold (DIBH) is typically able to keep heart, lung and contralateral breast doses below tolerance, it has been suggested that volumetric arc therapy (VMAT) can improve target coverage and reduce doses to organs at risk (OAR).² Therefore, the current study aimed to determine a consistent approach to treating the internal mammary chain (IMC) by comparing the target coverage and OAR doses achievable with conventional 3D‐CRT and a novel VMAT technique.

Methods: Ten patients previously treated at Liverpool Cancer Therapy Centre with 50 Gy/25 fraction 3D‐CRT prescriptions to the whole breast, supraclavicular fossa (SCF) and IMC were retrospectively replanned using a VMAT technique consisting of four 480 arcs delivered from tangential angles. Target and OAR doses were evaluated for the clinical 3D‐CRT plans and the VMAT plans respectively. Preliminary results for four left‐sided patients are presented in Figure 1.

Discussion: Early results indicate that whilst VMAT has the ability to improve target coverage and reduce heart and lung doses, this comes at the cost of higher low‐dose spillage across midline into the contralateral breast and lung. This is not ideal given that higher contralateral breast doses increase the risk of developing secondary malignancies in the contralateral breast.³ Further assessment is required with a larger number of patients.

References

1. Dundas K, Pogson E, Batumalai V, et al. Australian survey on current practices for breast radiotherapy. Journal of Medical Imaging and Radiation Oncology 2015;59(6):736–742.

2. Munshi A, Sarkar B, Anbazhagan S, et al. Short tangential arcs in VMAT based breast and chest wall radiotherapy lead to conformity of the breast dose with lesser cardiac and lung doses: a prospective study of breast conservation and mastectomy patients. Australasian Physical & Engineering Sciences in Medicine. 2017. Available at: https://link.springer.com/article/10.1007URLPERC; 2Fs13246‐017‐0558‐y [Accessed 14 July 2017].

3. Stovall M, Smith S, Langholz B, et al. Dose to the contralateral breast from radiotherapy and risk of second primary breast cancer in the WECARE Study. IJROBP 2008;72(4):1021–1030.

It's a no‐brainer! The role of hippocampal sparing in whole brain radiation therapy

Isaiah Pobar, Sophie Streets, Kimberly Brain

Queensland University of Technology, Brisbane, Australia

Background: Whole brain radiation therapy (WBRT) provides local control of brain malignancies, reducing the risk of recurrence and improves overall survival rates for patients who are ineligible for invasive surgical intervention. However, there are reports of decreased hippocampal neurogenesis; impairing learning and memory function. Hippocampal‐sparing whole brain radiation therapy (HS‐WBRT) approaches have the potential to reduce the neurocognitive side effects and henceforth improve patients’ quality of life.

Objectives: The purpose of this review is to examine the clinical significance of utilising HS‐WBRT. To achieve this, the dose tolerances in the literature, risk of metastasis to the hippocampal region and the best treatment technique to implement HS‐WBRT were critically evaluated.

Methods: A review of the literature on HS‐WBRT was conducted using PUBMED, EMBASE and ScienceDirect databases. Peer‐reviewed journal articles published in the last 5 years (2012–2017) were included.

Results: The results obtained were consistent; the majority of the studies implemented the RTOG 0933 protocol for dose prescription and contouring guidelines. However, an idealistic hippocampal dose tolerance was variable. There was a clear consensus that the risk of metastasis to the hippocampal avoidance area from all primary malignancies was low. Moreover, HS‐WBRT patients received neurocognitive benefits. Coplanar volumetric modulated arc therapy (VMAT) techniques resulted in superior treatment time efficiency, optimal target coverage and organ at risk sparing.

Conclusions: HS‐WBRT is clinically effective and provides an improvement in the therapeutic ratio for patients receiving WBRT. There is a requirement for further investigation into specific dose constraints that offer greater hippocampal protection.

Sunday 18 March, 13:30–15:30 Closing Ceremony

A way of seeing is a way of not seeing – an artist's perspective on imaging

Michael Fuller, Steph Fuller

Flinders Medical Centre, Adelaide, Australia

The question of whether to characterise radiography as an art or a science is as old as the profession itself. This paper follows Steph Fuller's journey as she looks at medical imaging from an artist's perspective.

Steph is an emerging photographic artist from South Australia. She was awarded the Artist in Residence at Flinders Medical Centre (FMC) for 2017. Steph's application for residency proposed to “poeticise medical images” through the medium of photography. Steph spent time in all of FMC's medical imaging modalities making notes and sketches of the images she saw.

It was no small coincidence that Steph chose medical imaging as her host department. Her radiographer father, Michael Fuller, was technical adviser in the process of producing this artwork. This paper details the background story of how the art was produced with all the twists and turns of vision, frustration, failure and success. The images are stunning and the process of producing the images is absorbing.

This is an example of a fascinating and possibly unique collaboration and will provide a perspective that will cause you to question whether medical imaging is a purely scientific endeavour.

Lateral knee plain film Image © Steph Fuller, 2017