Friday 16 March 2018

Friday 16 March, 11:15–12:45 Care and Collaborate

Augmenting a radiation therapist research culture across a multi‐campus service

Nigel Anderson

Peter MacCallum Cancer Centre, Melbourne, Australia

Peter MacCallum Cancer Centre (Peter Mac) is a public radiation therapy service operating five campuses across metropolitan Melbourne and regional Victoria. Radiation therapist‐driven research is critical to drive innovation, professional development and improve patient outcomes. However, providing an integrated research approach to a diverse Peter Mac workforce of 200+ radiation therapists poses many challenges. The weight of staff numbers, geography and differing priorities was fragmenting effective research pathways.

In late 2015, a new research model was introduced to respond to these challenges. The vision for radiotherapy research within the new model was to develop an equitable, integrated and transparent environment to enable multi‐level radiation therapist engagement across the organisation, regardless of previous research experience.

Numerous initiatives have resulted from the research model, including: an overarching, ethics‐approved retrospective planning study protocol, to facilitate expedited evidence based technique development; a standardised research project initiation pathway with a central project repository, enabling accountability and cross‐campus transparency; and an automated publication bulletin of current literature to facilitate ongoing professional development and currency of practice.

In the 18 months since the introduction of the research model, research outputs have increased significantly. Currently, 19 radiation therapist‐driven projects are active, with many enjoying cross‐campus collaboration. Externally delivered presentations have increased from six (2016) to 20 (2017), with a further increase forecast for 2018. Furthermore, many are on track for publication translation.

This aim of this presentation is to detail Peter Mac's newly formed research structure in order to provide insight into potential application in the wider radiation therapy community.

Impact of radiotherapy underutilisation: survival shortfall, years of potential life lost and disability‐adjusted life years

Vikneswary Batumalai, Jesmin Shafiq, Gabriel Gabriel, Timothy Hanna, Geoff Delaney, Michael Barton

Liverpool Cancer Therapy and Ingham Institute, Liverpool, Australia

Objective: Despite evidence of the benefits of radiotherapy (RT) in the treatment of cancer patients, its underutilisation has been reported for various tumour sites. The aim of this study was to estimate survival shortfall, ‘years of potential life lost’ (YPLL) and ‘disability‐adjusted life years’ (DALY) to demonstrate the impact of radiotherapy underutilisation.

Methods: Optimal and actual RT utilisation (RTU) was compared to assess RT underutilisation to estimate overall survival shortfall using 2006 data from New South Wales. Overall survival shortfall is defined as number of death due to RT underutilisation (calculated as benefit proportion X shortfall [optimal‐actual RTU] proportion X number of new cases). This was assessed for 26 common tumour sites. YPLL = survival shortfall X estimated life lost per person (overall life expectancy – median age at death for specific cancer). DALY = (years lived with disability + years of life lost) X survival shortfall.

Results: The total number of new cases with cancer in 2006 in New South Wales was 20,741. Optimal RTU was 52% while actual RTU was 24%, resulting in estimated of 261 deaths due to underutilisation. Each death resulted in an average of 11.1 YPLL. It was estimated RT underutilisation resulted in a total of 2910 YPLL and 4584 DALY overall.

Conclusion: This study illustrates the value of considering different mortality statistics, which include measures of the burden of cancer deaths on both the population and patients. Key area for further research includes health economic analysis and impact of RT underutilisation on productivity cost.

Strengthening rural medical radiation workforce through collaboration and immersive educational experiences

Tony Smith¹, Emma Cooper², John Tessier³, Daphne James³, Jamie Marjoribanks⁴, Matthew Vignes⁵, David Lyall³, Yolanda Surjan³

¹University of Newcastle Department of Rural Health, Taree, Australia ²University of Newcastle Department of Rural Health, Tamworth, Australia ³University of Newcastle, Medical Radiation Science, Callaghan, Australia ⁴University of Newcastle Department of Rural Health, Port Macquarie, Australia ⁵University of Newcastle Department of Rural Health, Coffs Harbour, Australia

The University of Newcastle Department of Rural Health (UONDRH) is funded under the Commonwealth Government Rural Health Multidisciplinary Training (RHMT) program.¹ The main UONDRH facilities are in Tamworth and Taree, with others in Armidale, Moree, Port Macquarie and Coffs Harbour. The principal aim of the UONDRH is to build rural health workforce by supporting undergraduate rural placement experiences within a collaborative, immersive learning environment.

Among 12 disciplines, UONDRH supports medical radiation science (MRS) students. As well as short‐term, two to six‐week placements, MRS students can complete their entire final year in Tamworth or Taree via an immersive program. Uniquely, UONDRH employs 2.2 full‐time equivalent MRS academics. In collaboration with the main campus and local health service providers, student support includes:

• Additional supervised clinical practice

• Subsidised accommodation, with internet access

• Profession-specific lectures and tutorials

• Interprofessional education on various topics

• Community engagement with local organisations.

Some 50% of rural MRS placements supported under the RHMT program are from the University of Newcastle. Including both long and short‐term placements, between 2003 and 2016 the UONDRH supported 594 MRS students, with an average of 42 students (range = 21–88) for 237 student‐weeks (range = 79–431) per year. Program evaluation shows high levels of student satisfaction and rural practice intention.²

The UONDRH program successfully promotes rural practice, with graduates having taken up rural positions. Longitudinal student follow‐up is ongoing, with a further need to monitor the availability of positions for new graduates in rural areas.

References

1. Australian Government Department of Health. Rural Health Multidisciplinary Training Program. Australian Government, Canberra, 2016. Available at www.health.gov.au/internet/main/publishing.nsf/content/rural‐health‐multidisciplinary‐training [Accessed 27 July 2017].

2. Brown L, Smith T, Wakely L, Little A, Wolfgang R, Burrows J. Preparing graduates to meet the allied health workforce needs in rural Australia: Short‐term outcomes from a longitudinal study. Educ Sci 2017;7(2):64.

Investigating daily wait times and patient satisfaction

Craig Everitt, Leo El‐Hage, Andrew Do

Epworth Healthcare, Richmond, Australia

Objectives: Epworth Radiation Oncology (ERO) routinely measures patient satisfaction as a key quality indicator. Overall patient satisfaction is associated with daily waiting times (WT) for treatment.¹ The primary objective of this audit was to determine the WT experienced by patients treated at ERO and the cause of any delays.

Methods: Primary and secondary codes for appointment delays were developed through consensus by senior radiation therapists. Delay codes were recorded over 10 treatment days for 142 consecutive patients (in‐patients and out‐patients) scheduled on five linear accelerators across three sites. WT were calculated as the difference between scheduled appointment time or arrival (if later than scheduled time) and bunker entry.

Results: Of 833 attendances, the mean (±SD) WT was 8.0 ± 10.7 min; 109 (13%) patients were treated early or on time; 514 (62%) waited 1–15 min; 162 (19%) waited 16–30 min and 48 (6%) waited >30 min.

Catching up from previously delayed patients indirectly caused 234 (58%) further delays. Patients presenting late for appointment caused 91 (23%) delays. Only 63 (16%) delays were directly caused by events on the unit (e.g. problem with set‐up).

Conclusion: Delays have a compounding effect and causes mostly occur before reaching the unit. These data have been utilised to minimise delays and enhance patient communication when delays do occur to ensure optimal patient satisfaction at ERO.

Reference

1. Famiglietti R, Neal E, Edwards T, Allen P, Buchholz T. Determinants of patient satisfaction during receipt of radiation therapy. Int J Radiat Oncol Biol Phys 2013;87(1):148–152.

3D printing collaboration at Liverpool Cancer Therapy Centre

Jodi Mitchell¹, Shivani Kumar^1,2,3, Breeann Plummer¹, Michael Jameson^1,2,3

¹Liverpool Cancer Therapy Centre, Sydney, Australia ²Ingham Institute for Applied Medical Research, Sydney, Australia ³University of New South Wales, Sydney, Australia

Objective: To investigate the potential of utilising patient specific 3D printed bolus as an alternative to the currently used superflab bolus for breast/chest wall and wax bolus for nose radiation therapy treatments.

Methods: CT scans were acquired of an anthropomorphic female phantom with breast attachments. Images were acquired with custom made wax bolus placed on the phantom's nose and flat standardised superflab bolus placed on the left breast. This will be repeated with customised 3D printed bolus. 3D printed bolus is currently being created through MiM Maestro (V6.7, MIM software, Cleveland, OH) and will be printed using the in‐house Lulzbot Taz 6 3D Printer (Aleph Objects, Inc., Loveland, CO) with acrylonitrile butadiene styrene, polyLactic acid and FlexiExtrud filaments. Treatment plans will be created in pinnacle and comparisons of the dosimetry of each bolus technique performed. Dosimetric assessments will be conducted using thermoluminescent dosimeters, gafchromic film and ionisation chambers.

Results: This is an approved ongoing study, on schedule for completion by November 2017. The results will be a comparison of descriptive dose statistics within bolus and phantom. Dosimetric reproducibility, cost, time, durability, practicality, density and homogeneity will be assessed. Outcomes will be related to departmental considerations for efficacy, efficiency and applicability.

Discussion: 3D printing is a novel approach to fabricating bolus and is still an emerging technique. Recently published literature supports the clinical use of patient‐specific bolus.¹ If the dosimetry and comparative analysis prove viable, this study will be expanded to include clinical patients and a wider range of anatomical sites.

Reference

1. Zhao Y, Moran K, Yewondwossen M, et al. Clinical applications of 3‐dimensional printing in radiation therapy. Med Dosim 2017;42:150–155.

Friday 16 March, 11:15–12:45 CT Contrast

Dual energy CT imaging for differentiating contrast staining versus haemorrhage in post‐thrombectomy patients

Max Tomsia

Princess Alexandra Hospital, Metro South, Brisbane, Australia

Due to the increase in neurological thrombectomy cases, we reviewed our 24 h post‐procedural unenhanced CT head scan implemented to look for haemorrhagic transformation within an infarct. High attenuation signal can frequently be seen on unenhanced CT scan within the core infarct and it is impossible to differentiate between iodine staining or haemorrhagic transformation. Evaluation of these images has always been subjective with no true diagnosis.

Dual energy CT is an established imaging modality in the differentiation of iodine and haemorrhage in high density lesions, post‐clot retrieval or after contrast administration.¹ Dual energy CT involves acquiring two simultaneous attenuation datasets at a high and low kV. The ratio of the difference in Hounsfield units in these two datasets gives us the ability to accurately differentiate different tissues. Utilising three material decomposition and iodine maps, virtual non‐contrast images are created on the Syngo VIA workstation.²

A Siemens Dual Source CT scanner is utilised to accurately differentiate between iodine staining and/or haemorrhagic transformation in patients that undergo clot retrieval, as shown in the figure below. This is a robust method of differentiating between haemorrhage and/or iodine staining.¹

The ability to accurately differentiate between iodine staining and haemorrhage in post‐thrombectomy patients in a single scan has numerous benefits. The treating team can adapt anticoagulant therapy with confidence, nursing time spent doing regular observations is greatly reduced if no haemorrhage is identified, patients can be expedited to rehabilitation wards and radiation dose from repeat scans is eliminated.

References

1. Tijssen M, Hofman P, Stadler A, et al. The role of dual energy CT in differentiating between brain haemorrhage and contrast medium after mechanical revascularisation in acute ischaemic stroke. Eur Radiol 2013;24(4):834–840.

2. Gupta R, Phan CM, Leidecker C, et al. Evaluation of dual‐energy CT for differentiating intracerebral hemorrhage from iodinated contrast material staining. Radiology 2010;257(1):205–211.

Administration of computed tomography contrast via an intra‐osseous cannula

Amelia Hunter

Princess Alexandra Hospital, Brisbane, Australia

Introduction: Gaining vascular access quickly in critically unwell patients is an integral part of the resuscitation process. Intra‐osseous (IO) cannulas are a widely accepted route to administer life saving medications and infusions in adults when intravenous (IV) access is difficult to obtain in a timely manner. However, the ability to use an IO cannula for the administration of computed tomography (CT) contrast is not widely accepted due to the lack of clinical trials and reported cases.

Case presentation: A 48‐year‐old male was bought by ambulance to the Princess Alexandra Hospital (PAH) Emergency Department following an assault. He had a Glasgow Coma Scale score of 3 with bilateral fixed and dilated pupils. The patient had a history of IV drug use and peripheral IV cannulation failed. A 25 mm, 15 gauge, Arrow EZ‐IO^® cannula was inserted into the right proximal tibia and was used as the primary form of vascular access.

Management and outcome: A diagnostic CT angiogram of the head and neck was performed using the IO cannula. Contrast was injected at a rate of 5 mL with a monitoring delay of 10 sec. A maximum PSI of 164 was achieved and images were acquired on a Siemens SOMATOM Definition Flash.

Discussion: A protocol has been implemented in the radiology department of the PAH which outlines the ability to use IO cannulas to administer CT contrast. This has improved staff confidence and increased knowledge of the technique in order to reduce time‐to‐scan delays for critically ill patients.

Increasing efficiency and saving costs of IV contrast consumables in CT

Tony Vuong, Stephen Grill

Sydney Adventist Hospital, Wahroonga, Australia

The cost of providing CT services is increasing. Consumable costs associated with CT include contrast media and contrast delivery. The introduction of the Stellant Multi‐Patient (MP) system reduces costs while maintaining patient safety.¹

The Stellant MP system, by Imaxeon, was introduced into San Radiology CT with the aim of reaching an annual saving of $15,000 on contrast media and contrast administration consumables. The costs of contrast media and associated consumables were pre‐ and post‐implementation.

Total costs of contrast consumables decreased by 18% over time matched periods. To increase revenue in radiology, managers must find efficiencies and cost reduction strategies. The introduction of the Stellant MP system reduced the cost of contrast and contrast administration by up to $4 per scan and reduced CT appointment times by 5 min enabling additional appointments each business day.

Reference

1. Routhier J, Piazzo K, Sodickson A. Contrast and cost savings by implementation of a multidose bulk IV contrast delivery system. J Am Coll Radiol 2011;8(4):265–270.

CT chest, abdomen and pelvis – 1 series vs. 2 series: 1 year review of dose and image quality

Tegan Wilde

Global Diagnostics Australia, Busselton, Australia

Introduction: A one year follow‐up and investigation of dose comparison and image quality between one (1) and two (2) series CT chest, abdomen and pelvis (CT CAP) studies.

Methods: A retrospective data collection for dose and image quality was obtained on patients that were scanned with both the two‐series and one‐series CT CAP study during their oncology staging cycle. The image quality assessment was undertaken by two independent radiologists who graded the overall image quality, mediastinum and liver enhancement using a 4 point scale with 1 representing poor, 2 moderate, 3 good and 4 excellent image quality. Post‐contrast HU measurements were collected from within the liver parenchyma and tabulated.

Results: Data was collected on 30 patients. The two‐series protocol had a mean DLP of 1066.46mGycm; the one‐series mean DLP was 653.73mGycm. The overall mean reduction in radiation dose between the two protocols was 39%. The mean HU within the liver were 96.7HU for the two‐series, and 97.73 for the one‐series CTCAP scans. The two radiologists consistently agreed that the image and IV enhancement quality of the two‐series study was rated higher than the one series study. The combined average score for the one series protocol was 3.8 for image quality, 3.2 for mediastinum enhancement and 3.15 for liver enhancement and the current one‐series protocol.

Discussion: Altering the oncology CT CAP scan from the conventional two‐series protocol to the one series protocol significantly reduces the radiation dose to the patient by an average of 39%; whilst retaining CT scan imaging of good diagnostic quality.

The accuracy of virtual unenhanced CT imaging compared to conventional unenhanced CT imaging

Hung Do, Anthony Mulcahy

Peter MacCallum Cancer Centre, Melbourne, Australia

Objectives: To determine whether the attenuation values of virtual unenhanced (VU) computed tomography (CT) images are statistically similar to conventional unenhanced (CU) images.

Materials and methods: 20 dual‐energy datasets from different patients were randomly selected and retrospectively analysed from a pool of patients scanned from June 2016 to June 2017. Every patient underwent conventional unenhanced single‐energy CT and routine three‐phase contrast‐enhanced DSCT. VU images were generated from the portal‐venous phase at standard vendor material decomposition mixing ratios. Hounsfield unit (HU) region‐of‐interest (ROI) measurements were taken through the liver, spleen and aorta. Image noise was recorded as the standard deviation in the ROI. Quantitative data analysis was performed.

Results: Mean liver HU values were statistically higher (P < 0.05) in the CU series (56.52 ± 8.76 HU) than the VU series (52.73 ± 10.47 HU). Further statistical difference (P < 0.05) was seen in the mean HU values of the spleen and aorta. The liver showed a mean difference of 3.79 HU between the CU and VU series, 8.49 HU in the spleen and 15.2 HU in the aorta. Image noise ranged from 7–23.6 HU.

Discussion: Although there are statistical differences between VU and CU attenuation in all three measured body regions, the differences in these regions may not be perceivable to the reader due to image noise. The scanning parameters selected and the automatic dose optimisation techniques may have reduced the quality of the contrast phases and consequently the VU dataset.

Conclusion: There is a statistical difference between the attenuation values of VU and CU in the liver, spleen and aorta.

4D dynamic body computed tomography for trauma, medical management and surgical planning

Ben Rowney

Queensland Health/Princess Alexandra Hospital, Brisbane, Australia

Perfusion computed tomography (CT) imaging of the brain is a well‐established and relied upon diagnostic and planning tool for patients undergoing acute embolic stroke. It is utilised in the diagnosis, surgical/interventional planning and follow up management of stroke patients.

Body perfusion 4D imaging of other organs is an emerging practice that is demonstrating significant advantages over traditional CT imaging standards in both trauma and medical diagnosis and planning.

Techniques and applications of CT body perfusion have been developed in the clinical setting of a large tertiary hospital and have been proven valuable in trauma, medical management and surgical planning.

Trauma:

• A high speed motor vehicle accident resulting in a traumatic renal injury with delayed perfusion, query renal viability

• Blunt force trauma, haemoglobin drop, query abdominal bleed.

Medical/surgical:

• Hepatic lesions unable to be characterised on multi-phase abdominal CT. Repeat staging scan

• Upper GI bleed, history of Dieulafoy lesion

• Spontaneous renal bleed. Query arterio-venous malformation or lesion

• Surgical planning of known oropharynx lesion, functional imaging required to assess mobility, adherence to vascular involvement of lesion prior to excision.

In the past year we have seen exponential growth in the utilisation and implementation of dynamic body perfusion scanning. The question is now not a matter of if it will be of value, but of how we can best apply this new technology to our patients for maximum benefit and minimum harm.

Friday 16 March, 11:15–12:45

Combined MRS

Nicola ‘Ziggy’ Zagame

Invited Speaker

Nicola Zagame is a CT radiographer. She also works in her company's marketing team. Nicola knows how important patient care, communication and collaboration is, both on the floor dealing with patients on a day‐to‐day basis, and from a company management perspective.

Being an Olympic water polo player – competing in both the Rio 2016 and London 2012 Olympic Games, where she won a bronze medal – Nicola also has a unique experience in intense and highly stressful environments. Teamwork and trust with everyone on the team and program has an effect on a team's performance, and Nicola has some stories to tell and examples of where communication achieved wins or losses for her team.

Nicola will also share how she used the ‘three Cs’ in her experience last year on the television reality series, Australian Survivor. How being a good camp member got her closer to the half million dollars prize money, but in the end, ultimately getting her voted off the series.

Friday 16 March, 11:15–12:45 Radiographer Commenting

Development of a reliable and sustainable radiographer commenting audit

Benjamin Davis

Metro South Health, Logan, Australia

Introduction: Utilising radiographer commenting within an emergency department can improve patient safety through enhanced communication between referrers and radiographers.^1,2 With any patient safety activity, regular auditing is necessary. The objective of this study was to design a reliable and sustainable radiographer commenting audit to monitor the accuracy of radiographers’ interpretations of radiographs.

Methods: Full ethical review was waivered as this project was deemed a quality assurance activity. Over a 6‐month period, 100 radiographic examinations per month randomised alphabetically by patients surname were audited. Each examinations radiographer comment was compared to the radiologist's report so that true negative/positive and false negative/positive values could be allocated. This allowed sensitivity, specificity and diagnostic accuracy to be analysed. These overall scores were compared with a previous study at the same site that audited 3,145 examinations for the same period in 2016.

Results: From January to June 2017, 600 studies were audited. The monthly audit took an average of 60 min to undertake. The overall sensitivity was 71.14%, specificity 98.44% and overall accuracy 84.08%. For the same period during 2016 (n = 3145), the monthly audit took over six hours to undertake and produced scores of 75.91%, 99.07% and 85.34% for sensitivity, specificity and accuracy respectively.

Conclusion: The audit of 2017 data yielded comparable results to the robust yet labour intensive audit of 2016. The results indicate that the methods employed in this study yielded a sustainable and reliable audit that can be implemented for effective continual monitoring of a radiographer commenting system.

References

1. Neep MJ, Steffens T, Owen R, McPhail SM. Radiographer commenting of trauma radiographs: a survey of the benefits, barriers and enablers to participation in an Australian health care setting. J Med Imaging Radiat Oncol 2014;58(4):431–438.

2. McConnell J, Devaney C, Gordon M. Queensland radiographer clinical descriptions of adult appendicular musculo‐skeletal trauma following a condensed education programme. Radiography 2012;19(1):48–55.

Current enablers and barriers for radiographers in Australia regarding radiographer commenting

Gary Denham

ASMIRT Preliminary Image Evaluation Project Steering Committee, Melbourne, Australia

Background: The Australian Society of Medical Imaging and Radiation Therapy (ASMIRT) is undertaking a project to assist in the development and assessment for radiographer commenting within Australia. The opinions of radiographers were sought on the current enablers and barriers in Australia regarding radiographer commenting.

Methods: Ethics approval was obtained. A 19‐question questionnaire was developed and advertised in the ASMIRT News, received by all members via email and the Medical Radiation Practice Board of Australia newsletter, received by all Australian registered medical radiation practitioners. Participants’ opinions of current enablers and barriers to radiographer commenting were determined using Likert scale and open ended questions.

Results: Quantitative and qualitative data were collected from 813 questionnaire responses. Only 20.27% of respondents currently participated in a radiographer commenting system. 71.85% of respondents believed radiographer commenting was within scope of practice and 84.65% believed it contributes to patient safety. 74.46% of respondents believed the development of a credentialing process would help promote and support the practice of radiographer commenting throughout Australia. Some concerns were raised by respondents in the open ended questions.

Conclusion: Respondents were overwhelmingly supportive of a certification process for radiographer commenting but concerns were raised about legal issues, accountability and lack of support from radiologists and management.

Evaluation of radiographer accuracy in providing written comments following short course in image interpretation

Imelda Williams¹, Beverley Pearce²

¹Monash University, Melbourne, Australia ²Peninsula Health, Frankston, Australia

Objective: The pilot project examined the effectiveness of a short course in advanced radiographic clinical skills of the appendicular skeleton.

Methodology: Joint ethics approval was obtained from Monash University and Peninsula Health ethics committees. Eight (n = 8) participants were recruited to undertake two modules (3‐month period each module) covering the appendicular skeleton of the upper and lower limbs. Participants undertook pre‐tests, followed by delivery of course material, formative and summative test banks capturing responses on a dedicated opinion form based on the ABCS Search Strategy;¹ and concluded by participants undertaking post‐tests.

Results: Range: 71.9–89.5%; aggregated specificity (Sp): 81.3%; aggregated sensitivity (Sn): 95.2%; aggregated accuracy: 93.1%.

Conclusion: The Medical Radiation Practice Board of Australia has an expectation that radiographers should be able to convey significant findings when identified.² The short course aimed to address plain X‐ray representation of traumatic and common pathologies affecting the appendicular skeleton. Participants demonstrated improved mean scores from module 1 pre‐test (77.5%) to module 2 post‐test (83.6%) by 6.1%. All participants achieved scores above 80% by module 2 post‐test. Higher sensitivity rates in comparison to specificity rates indicate confidence in identifying abnormal cases. The accuracy rate of 93.1% demonstrates that radiographers can improve their confidence following specific training in plain X‐ray commenting. These findings strongly suggest that the radiographers who completed the course should be able to identify significant findings and provide written comments with improved confidence and accuracy when operating in emergency settings.

References

1. Chan O. ABC of Emergency Radiology, 3rd edn. Wiley‐Blackwell, BMJ Publishing Group, 2013.

2. Medical Radiation Practice Board of Australia. Professional capabilities for medical radiation practice. MRPBA, 2013; p. 10.

‘What do you mean?’ Preliminary image evaluation in rural North Queensland

Rose McWilliam

Queensland Health, Ingham, Australia

Objectives: To explore the implementation process of preliminary image evaluation within a rural North Queensland hospital and evaluate radiographer accuracy in terms of specificity and sensitivity.

Method: During a 3‐month trial period, radiographers provided a written preliminary image evaluation (PIE) for patients meeting a set inclusion criteria. This written communication was then compared to the finalised radiology report and assessed for accuracy. Comments were not made available to referring clinicians or reporting radiologists.

The radiology report was also compared to the emergency department information system discharge summary to assess the diagnostic accuracy of emergency physicians.

Results: A 3‐month PIE trial (April to June 2017) yielded an average specificity of 98% and sensitivity of 99% (see Figure). This equates to a 98% accuracy rate. Emergency clinicians yielded a slightly lower overall accuracy rate of 93%.

Discussion: The trial has shown promising results and supported the desire for formal implementation. As such, on the 27 July 2017, approval was granted for a 6‐month trial period of formal radiographer preliminary image evaluation. Comments will be made through QRIS as a ‘provisional image evaluation’ and made available for viewing on the Enterprise IMPAX system by referring physicians.

Monthly audits will be performed with the goal of achieving at least 80% sensitivity and 90% specificity, with future results to be analysed and presented at ASMIRT 2018.

Friday 16 March, 13:45–15:15 Advanced Practice/Care and Communication

Communicating memories: the second 50 years of radiotherapy (1960–2010)

Gregory Brown

University of Divinity, Melbourne, Australia

Greg Brown presents historical memories of nearly 50 years of medical radiation experience. This is an important presentation as it contains rare primary historical sources. In the theme of this conference, the presentation collaborates with contemporary colleagues by providing evidence of the origins and evolution of the central threads of scientific radiation oncology.

This historical research uses images and words to progress through the amazing world of equipment, the development of treatment planning, radiation dosimetry, the evolution of education into degree programs and the origin of our CPD. The method is grounded theory and the narrative unfolds through qualitative data analysis. The presentation raises no ethical issues and the source of all photographs is acknowledged.

The desired outcomes are that current medical radiations professionals gain some beneficial insights for their practice from the fragments of memory presented, and other experienced medical radiations professionals may be stimulated to extend this narrative by further documenting the development of our science.

The research undertaken for this presentation found that very little of the history of the medical radiation sciences in Australia has been documented using primary sources. Further, it suggests that editorial policies can be enhanced to facilitate the communication of historical research of the medical radiations sciences that is derived from all sources whether primary, secondary or contemporary.

Caring, communicating and collaborating in Canada: an international travel scholarship experience

Kelly Elsner

University of Sydney, Camperdown, Australia

ASMIRT awards four International Travel Scholarships to medical radiation professionals (MRPs) each year. Last year I was awarded this scholarship and subsequently travelled to Toronto and Ottawa in Canada to communicate and collaborate with Canadian MRP colleagues. In Toronto, I visited Princess Margaret Cancer Centre and I met the person‐centred care and radiation treatment teams at Cancer Care Ontario. In Ottawa, I promoted Australian research and collaboration by presenting at the Canadian Association of Medical Radiation Technologists (CAMRT) Annual General Conference. The research I presented focussed on radiation therapists (RT) knowledge, skills, values and training needs in providing psychosocial support to oncology patients.

The objectives of the trip were: 1) to learn how the patient's experience in the health care system can impact on health outcomes and the health care system itself; 2) to explore the use of psychosocial screening tools and psychosocial care pathways in a radiation therapy setting, 3) to understand implementation processes and how to overcome barriers to psychosocial care in routine clinical practice and 4) to learn how cancer control agencies influence service improvements for cancer care.

This experience has enabled me to contribute to the profession and to shape future service delivery through multiple avenues including: building and facilitating relationships between MRPs in Australia and Canada, facilitating knowledge exchange among MRPs and cancer control agencies, incorporating learnings into psychosocial research analysis and interpretation and reporting on the experience and the CAMRT conference in Spectrum.

Personal experience of late effects from radiotherapy treatment

Courtney Oake

The presenter will deliver an account of their experience of being diagnosed with acute lymphocytic leukaemia at the age of 14, having been continuously unwell with colds for around six months. After two years of intensive treatment including both chemotherapy and radiotherapy throughout the final years of high school, the presenter was given the all clear and went on to study at university.

The presenter became a radiation therapist and worked in different capacities both here in Australia and in the United Kingdom. Having been lost to any form of traditional long‐term follow up, the opinion of colleagues was sought when necessary. The presenter has always known that they were at risk of developing late effects from the treatment she had received.

While on a career break in 2015, the presenter was diagnosed with radiation‐induced meningiomata, predominately on the left side of their brain, 23 years after the initial leukaemia diagnosis. After an eventful surgery and recovery she is now a two‐time survivor whose life has been shaped emotionally, practically, financially and socially by their experience, and is living with the knowledge that it could happen again.

This presentation will address the impact the diagnoses have had on the presenter's life and the need for a greater understanding of the long‐term effects of the treatment delivered and the need for long term follow up of patients.

Conceptualising radiation therapy advanced practice: findings from a national focus group study

Kristie Matthews^1,2, Gillian Duchesne^1,3, Marilyn Baird¹

¹Department Medical Imaging and Radiation Sciences, Monash University, Melbourne, Australia ²Radiation Therapy Services, Peter MacCallum Cancer Centre, Melbourne, Australia ³Sir Peter MacCallum Department of Oncology, Melbourne University, Melbourne, Australia

Background: The realisation of advanced practice for radiation therapists in Australia has not been as readily achieved when compared to published international initiatives. The few examples that have been reported reveal inconsistencies relative to expectations and variation in outcomes.¹^‐³ This paper will present the initial findings of a doctoral research study intended to explore the influencing factors shaping the implementation of radiation therapy advanced practice in Australia.

Methods: Using a grounded theory methodology,⁴ a series of online focus groups (university HREC approved) was facilitated with radiation therapists, radiation oncologists and radiation oncology medical physicists from a range of geographic locations, experiences and organisational settings. The aim of the focus group phase was to explore the perceptions and assumptions of participants regarding the status of radiation therapy advanced practice implementation in Australia and the factors that may be influencing this process.

Results: The data indicate that participants felt ‘locally conceptualising advanced practice’ is challenging. Although participants have a broad understanding of radiation therapy advanced practice, contextualising the meaning of advanced practice locally appears influenced by the lack of a formal framework, advancing technologies and traditional clinical expectations. The data imply that ‘translating the concept into practice’ requires creativity, flexibility and cultural innovation.

Conclusion: The focus group data suggest radiation oncology professionals are finding it difficult to locally conceptualise radiation therapy advanced practice, which may be influencing decisions around implementation. This finding implies a national approach to advanced practice may continue to be challenging unless local considerations can be resolved.

References

1. Job M. To assess the ability of a radiation therapist to delineate simple palliative radiation therapy fields. Paper presented at CSM Melbourne; 2014.

2. Rivett M. RT‐lead post‐radiotherapy treatment reviews in rural and remote settings. Paper presented at ASMIRT Sydney; 2012.

3. Toikka C. Breast advance practice role implementation: our experience. Paper presented at ASMIRT Hobart; 2013.

4. Charmaz K. Constructing grounded theory. 2nd edn. SAGE Publications, London, 2014.

Relevance of barriers and enablers affecting rural nurse practitioners to extended scope medical radiation practice

Tony Smith¹, Karen McNeil¹, Brendan Boyle, Rebecca Mitchell, Nola Ries

¹University of Newcastle Department of Rural Health, Taree, Australia ²University of Newcastle Business School, Newcastle, Australia ³University of Technology Sydney, Sydney, Australia

Background: In the United Kingdom, advanced practice radiographer roles are well established,¹ as are radiologist assistants in the United States.² In Australia nurse practitioners (NPs) remain the only occupation with formal extended scope of practice roles, endorsement requiring 5,000 h of advanced clinical practice, a Master degree and compliance with specified practice standards. Understanding factors that facilitate and impede rural NP roles may inform role development in other occupations, including diagnostic radiography and radiation therapy.

Objectives: Following ethics clearance, qualitative research explored barriers to and enablers of NP roles in rural and remote Australia. Using the NP case study, findings are readily extrapolated to the medical radiation professions.

Methods: In‐depth interviews were conducted with 15 NPs and five co‐workers (n = 20) from various locations, clinical specialties and settings in five Australian states and the Northern Territory. Data were analysed for common themes using a socio‐institutional theoretical model of macro‐, meso‐ and micro‐perspectives.

Results: Barriers and enablers emerged that are familiar to medical radiation practitioners. At the macro‐level, scope was constrained by legal and regulatory barriers such as the Medicare Benefits Schedule and professional indemnity. Meso‐barriers included lack of funding for positions and poor understanding of roles by managers and policy‐makers. Micro‐barriers included professional status, hierarchy and identity. Enablers included Master degree level education and endorsed qualifications (macro), support from local communities (meso) and interprofessional collaborative practice (micro).

Conclusion: Using an institutional lens to view the ostensibly successful NP roles can inform pathways to developing advanced practice roles for medical radiation practitioners in Australia.

References

1. Snaith B, Hardy M, Lewis EF. Radiographer reporting in the UK: a longitudinal analysis. Radiography 2015;21(2):119–123.

2. American Society of Radiologic Technologists. Radiologist Assistant 2017. Available at www.asrt.org/main/careers/radiologist‐assistant [Accessed 5 July 2017].

Friday 16 March, 13:45–15:15 Brachytherapy

The future of brachytherapy: will emerging technologies and techniques change the way we treat patients?

Annette Haworth

Invited Speaker

Over recent years there has been an alarming decline in the international utilisation rates of brachytherapy. Within Australia and New Zealand, not all centres offer brachytherapy, but for those that do offer a service the range of practices varies and caseloads are typically low in all but a few centres. This leads to a downward spiral in training opportunities, and investment in time and money to exploit the many opportunities for introducing technical advances in treatment approaches and the realisation of the optimal selection of radiation therapy treatment for our patients. While the number of cervix cancer brachytherapy treatments has remained fairly stable within our region, the utilisation of advanced imaging techniques is limited by access to imaging equipment, and the lack of consensus in the optimal selection and sequencing of imaging methods. We eagerly await the outcome of clinical trials to provide the data necessary to demonstrate the value of advanced imaging approaches and suggest the need for Australian and New Zealand trials to validate international clinical practices is translatable to our community. In the case of prostate brachytherapy, the clinicaltrials.gov website lists 39 trials currently recruiting patients to studies with a prostate BT component. Only one of these trials is led by Australian investigators. Seven trials mention focal therapy in the title, with the remaining trials investigating a range of clinical and technical questions. In this presentation we will look at some of the many exciting advances in brachytherapy treatments and question why we are not embracing these developments within Australia and New Zealand.

The clinical value of in vivo brachytherapy image guided verification (BIGV) in high‐dose‐rate prostate brachytherapy

Hayley Mack¹, Vanessa Panettieri¹, Stephanie Miller¹, Sarah Graves¹, Max Hanlon², Jeremy Miller^1,3, Bronwyn Matheson¹, Rick Franich², Ryan Smith^1,2

¹Alfred Health Radiation Oncology, Melbourne, Australia ²School of Science, RMIT University, Melbourne, Australia ³Central Clinical School, Faculty of Medicine, Nursing, and Health Science, Monash University, Clayton, Australia

Background: High‐dose‐rate (HDR) brachytherapy treatment verification is important, but is technically difficult¹ and remains unsolved. Pre‐treatment imaging can provide information to ensure the implanted catheters are in the correct position prior to dose delivery. In vivo source tracking during treatment provides further verification that the treatment is delivered to the patient as prescribed.²

We report a clinical study of our experience with our first 13 patients using our novel brachytherapy image‐guided verification (BIGV) system³ for HDR prostate brachytherapy.

Methods: A flat panel detector (FPD) was mounted in our brachytherapy treatment couch. The patient was positioned with the target region centred over the imager. Radio‐opaque markers were inserted into selected catheters and we acquired a pre‐treatment AP image for registration with the treatment planning system (TPS). Treatment commenced after the planned catheter positions were confirmed against the TPS. During treatment delivery, the position of the HDR source inside the patient was dynamically tracked, providing in vivo treatment delivery verification.

Results: Pre‐treatment imaging enabled registration with the TPS and quantitative evaluation of potential catheter displacement (see Figure). Source tracking during treatment provided a visual verification that treatment was proceeding as planned. Processing of the delivered source dwell positions verified correct treatment plan delivery. Delivered dose was reconstructed to compare with the planned TPS dose.

Conclusion: Visual in vivo source tracking provided confidence the planned treatment was delivered as prescribed and processing confirmed the treatment was delivered accurately. This system improves safety standards by allowing routine treatment verification in HDR brachytherapy.

References

1. Tanderup K, Beddar S, Andersen CE, Kertzscher G, Cygler JE. In vivo dosimetry in brachytherapy. Med Phys 2013;40(7):070902.

2. Smith RL, Haworth A, Panettieri V, et al. A method for verification of treatment delivery in HDR prostate brachytherapy using a flat panel detector for both imaging and source tracking. Med Phys 2016;43(5):2435.

3. Smith RL, Hanlon M, Panettieri V, et al. An integrated system for clinical treatment verification of HDR prostate brachytherapy combining source tracking with pre‐treatment imaging. Brachytherapy 2017; in press.

Developing and implementing a partnership based intra‐operative radiation therapy trial for early stage breast cancer

Daisy Le Cerf

Peter MacCallum Cancer Centre, Melbourne, Australia

Breast conserving surgery (BCS) is the gold standard of care for patients with early‐stage breast cancer.¹ Following BCS whole breast radiation therapy (WBRT) is routinely given for many indications over 5–6 weeks. Alternatively, five days of bi‐daily accelerated partial breast irradiation using a live brachytherapy source is offered at select centres. However, recent developments have provided a further option for early stage breast cancer patients with the introduction of an electronic brachytherapy (EB) system. The EB system replaces a traditional live brachytherapy source with an electronic X‐ray source and enables one biologically equivalent fraction of radiation therapy to be delivered at the time of BCS as intra‐operative radiation therapy (IORT).

IORT can provide a significant improvement in the management of early stage breast cancer when compared to alternate treatment options, in that it has the potential to reduce treatment from 5 to 6 weeks with WBRT to a single fraction with EB, and can mitigate an additional invasive procedure afforded by APBI delivery via live source brachytherapy.

In 2016, the long‐standing Monash Cancer Centre/Peter MacCallum Cancer Centre partnership enrolled in an international safety and efficacy study of the Zoft Axxent eBx IORT system for early‐stage breast cancer. This presentation will detail the IORT technique and subsequent clinical implementation across a partnered hospital setting. Radiation safety monitoring requirements, internal protocol and competency assessment development and preliminary clinical experience will also be discussed. Early indications suggest IORT may provide an exciting development in the multidisciplinary management of early stage breast cancer.

Reference

1. Mehta VK, Algan O, Griem KL, et al. Experience with an electronic brachytherapy technique for intracavitary accelerated partial breast irradiation. Am J Clin Oncol 2010;33(4):327–35.

True visualisation – intraoperative radiotherapy for recurrent colorectal cancer

Amanda Oates

Peter MacCallum Cancer Centre, Parkville, Australia

Patients with locoregional relapse after resection of colorectal cancer (CRC) experience poor prognoses, with median survival reported in the range of 11–15 months.¹ Treating recurrences can be very challenging due to previous surgeries and radiotherapy. Traditionally, these patients were offered surgery, external beam radiotherapy and chemotherapy salvage, often in a palliative setting. However, recent studies have shown that the addition of intraoperative radiotherapy (IORT) in appropriately selected patients can improve both local control and overall survival.

IORT is delivered via an open surgical field and provides the ultimate in target and normal tissue visualisation. This real time visualisation enables precision target localisation and sparing of surrounding structures, due to the ability to mobilise or shield surrounding tissues from the radiation field. Due to this precision and healthy tissue avoidance capability, IORT has been advocated as an important addition to the multidisciplinary management of T4 or recurrent rectal tumours.²

The Peter MacCallum Cancer Centre (Peter Mac) provides a centralised surgical/IORT pathway for recurrent CRC patients from both Victoria and interstate. The success of the service rests on a sustained and co‐ordinated multidisciplinary collaboration between colorectal surgeons, radiation oncologists, radiation therapists and medical physicists.

This presentation will articulate the patient selection, suitability criteria, theatre processes, equipment requirements, live planning processes, quality control procedures and clinical outcomes. The extended role of the radiation therapist will be discussed along with recent procedural adjustments following Peter Mac's relocation to the Victorian Comprehensive Cancer Centre.

References

1. Lloyd S, Alektiar K, Nag S, Huang Y, Deufel C, Mourtada F, Gaffney D. Intraoperative high‐dose‐rate brachytherapy: An American Brachytherpay Society consensus report. Brachytherapy 2017;16(3):446–465.

2. Morikawa LK, Zelefsky MJ, Cohen GN, et al. Intraoperative high‐dose‐rate brachytherapy using dose painting technique: Evaluation of safety and preliminary clinical outcomes. Brachytherapy 2013;12:1–7.

Moving from a multi‐step to single step procedure for high dose rate prostate brachytherapy

Angelo Tzovaras, Sylvia Van Dyk, Margaret Garth

Peter MacCallum Cancer Centre, Melbourne, Australia

Traditional high dose rate (HDR) brachytherapy for prostate cancer is a multi‐step procedure incorporating ultrasound guided insertion of brachytherapy catheters with the patient in lithotomy position, CT for planning in supine position, X‐ray verification in supine position and involves multiple patient transfers with treatment occurring many hours after catheter insertion. The overall procedure gives rise to many uncertainties and considerable patient discomfort. For these reasons, a more accurate, efficient and tolerable treatment solution was sought.

Real‐time ultrasound guided HDR prostate brachytherapy was implemented using the Nucletron Oncentra Prostate™ live planning system. This system enables catheter insertion, imaging, planning, treatment and applicator removal to occur in the one location while the patient is anaesthetised. This greatly reduces the uncertainties caused by multiple patient transfers, reduces the time for swelling to affect implant position and dosimetry and removes much of the discomfort experienced by patients.

Through a sustained and co‐ordinated multidisciplinary approach the new system was implemented in May 2017. The introduction of real time image based planning with its need for immediate decisions has opened new pathways for collaboration and interdisciplinary input into the planning and treatment of these patients.

This paper will consist of an overview of HDR prostate brachytherapy, the selection criteria for procedure eligibility, a review of previous practices in comparison to the newly adopted methods, changes to the radiation therapist's role and an overview of the benefits to the patient and the brachytherapy service.

Friday 16 March, 13:45–15:15 General X‐ray 1

Peer review

Charbel Saade

Invited Speaker

Ever since the birth of the X‐ray, the level of interest in improving the quality of health care in Australia has grown. New requirements established by continuing professional development for radiographers have increased exponentially. Peer review, a key process in the radiographer's performance and status, is geared primarily toward measuring two components: (1) diagnostic accuracy and (2) image quality critique. However, this is a new horizon in which to explore. Accuracy may be measured in terms of interpreting a positive or negative film in agreement or between a radiographer and radiologist. Each method of assessing diagnostic accuracy has strengths and weaknesses that should be carefully considered before it is implemented in a particular departmental or institutional setting. This session will explore a series of interesting cases with knowledge‐based answers before and after learning and its impact on how radiographers can play a pivotal role in medical imaging diagnosis as frontline health care workers.

Radiographers… Don't get your lines crossed!

Madeleine Bailey‐Liew, Jessica Dietrich, Mitchell Gamack, Ethan Litchfield, Martha Sloane, Sarah Woodward, Sharmaine McKiernan

University of Newcastle, Newcastle, Australia

Patient care in modern medicine often involves the use of intubation, as well as administration of nutrients and medications through catheterisation and tubing. It is crucial that a post‐insertion chest radiograph is taken to determine correct, or more importantly incorrect, positioning of the tube as malposition can lead to potential complications for the patient.

The aim of this investigation was to determine the correct positioning for the four most common chest lines known as central venous catheters. These include peripherally inserted central catheters (PICC), nasogastric tubes (NGT), endotracheal tubes (ETT) and intercostal catheters (ICC). Common poor positioning of these tubes and subsequent complications will be identified and the role of a chest radiograph in order to confirm their position will be discussed. Some of the complications that can result from improper placement include arrhythmias or cardiac tamponade from incorrect PICC placement, pneumonia or pneumothorax for poor NGT placement, misplaced ETT can cause increased risk of pneumothorax or atelectasis and ICCs can potentially cause lacerations to internal tissues.

A summation of the current literature determined that diagnostic radiography, although not standardised in the implementation of these devices, plays a significant role in assuring the correct placement of tubes. When left unchecked, problems with these lines may take time to be noticed, by which point they may have already caused significant damage to the patient.

Reliability of geometric unsharpness in determining the axial relationship between anatomical structures in radiography

Michael Fuller, Josephine Davies, Shayne Chau

Flinders Medical Centre, Adelaide, Australia

Objectives: Care in radiography is intrinsically linked to patient radiation dose. Consequently, techniques used to improve malpositioned images should be reliable. Some radiographers use geometric unsharpness as a tool in determining axial relationships.¹ The aim of this study is to determine the difference in OID at which geometric unsharpness can be reliably detected. The results will determine the practicality of this tool in repositioning the condyles of a lateral knee.

Methods: Similar to a previous study by Haliczenko et al,¹ a series of X‐ray acquisitions of an animal bone phantom at various distances from the image receptor will be conducted using direct radiography. These X‐ray images will be collated to form a survey (using Survey Monkey). Radiographers (n = 40) will participate in the survey, aiming to determine how far apart bony structures need to be to visually detect differences in cortical unsharpness. This research study has been reviewed and waived for informed consent by the Flinders Medical Centre Institutional Ethics Committee.

Results: From our initial testing, findings suggest that the differences in unsharpness become noticeable in to 200‐300 mm range. The experiment was repeated in August 2017 to test for reproducibility and inter‐ and intra‐rater reliability. The final results were collected in September 2017 for analysis.

Discussion/Conclusion: The pilot study results suggest geometric unsharpness is an unreliable tool in determining the axial relationship of objects less than 200 mm apart, such as the profile of the medial and lateral femoral condyles.

Reference

1. Haliczenko K, Hurley M, Auton T, et al. Edge sharpness as a function of depth in plain film radiography. Radiographer 2005;52(3);13–16.

Does digital tomosynthesis improve confidence in the grading of sacro‐iliac joints for sacroiliitis?

Adam Steward, Stephanie Wang, Louise Bentley, Hayley Biding

Western Health, Melbourne, Australia

Introduction: The sacroiliac joint (SIJ) is involved in most cases of axial spondyloarthropathies with the first manifestation usually being sacroilitis.¹^,² The grading of sacroiliitis can be achieved using plain radiographs according to the New York criteria.³ In Australia, the New York criteria grading of sacroiliitis plays an important role in funding and accessibility of treatment medication, particularly in ankylosing spondylitis.

Objectives: The New York criteria is achieved utilising plain radiographs, which demonstrate chronic changes. Interpreting radiographs of the SIJ is considered difficult and inter‐ and intra‐observer variations have been reported to be large.⁴^‐⁶ Digital tomosynthesis (DTS) may offer improved visualisation of this difficult joint. This study aims to determine whether utilising DTS in addition to plain radiography improves a radiologist's confidence in the evaluation and grading of the SIJ for sacroiliitis.

Methods: Two staff radiologists with experience in musculo‐skeletal imaging will independently review 105 routine radiographs of the SIJ and then radiographs with addition of DTS images. The outcome measured will be: grading of sacroiliitis according to the New York criteria, confidence in grading, confidence of assessment of joint space blurring and confidence of assessment of joint space widening/narrowing. Assessment to any changes in New York grading and confidence of scoring will be undertaken and statistically analysed for significance.

Ethics approval was obtained through the Western Health Research Ethics Panel.

Results and Conclusion: Preliminary results suggest that the addition of DTS leads to changes in the categorisation of SIJ imaging and improved confidence in diagnosis.

References

1. Braun J, Sieper J. The sacroiliac joint in the spondyloarthropathies. Curr Opin Rheumatol 1996;8(4):275–287.

2. Braun J, Bollow M, Sieper J. Radiologic diagnosis and pathology of the spondyloarthropathies. Rheum Dis Clin North Am 1998;24(4):697–735.

3. Van er Linden S, Valkenburg HA, Cats A. Evaluation of diagnostic criteria for ankylosing spondylitis. A proposal for modification of the New York criteria. Arthritis Rheum 1984;27:361–8.

4. Hollingsworth PN, Cheah PS, Dawkins RL, Owen ET, Calin A, Wood PH. Observer variation in grading sacroiliac radiographs in HLA‐B27 positive individuals. J Rheumatol 1983;10:247–54.

5. Yazici H, Turunc M, Ozdogan H, Yurdakul S, Akinci A, Barnes CG. Observer variation in grading sacroiliac radiographs might be a cause of `sacroiliitis’ reported in certain disease states. Ann Rheum Dis 1987;46:139–45.

6. Taylor HG, Wardle T, Beswick EJ, Dawes PT. The relationship of clinical and laboratory measurements to radiological change in ankylosing spondylitis. Br J Rheumatol 1991;30:330–5.

Neck of femur fracture radiography: can we do better?

Michael Fuller, Danting Luo

Flinders Medical Centre, Adelaide, Australia

The neck of femur fracture (NOF) is one of the most common traumatic injuries in the elderly population. This paper considers NOF fractures from the surgeon's viewpoint. It will be argued that radiographers should not only be aiming to demonstrate the presence or absence of a fracture, but rather attempting to provide sufficient radiographic information for the surgeon to confidently determine the most appropriate treatment.

A working knowledge of the principles and practices of surgical treatment of proximal femoral fractures will assist radiographers with the task of knowing when and how to perform additional views. We will consider a number of common and novel radiographic techniques aimed at both demonstrating neck of femur fractures and characterising the features and orientation of the fracture. Clinical cases will be examined where the surgeon did not consider the radiographic imaging to be adequate and either requested further radiographic views and/or referred the patient for CT imaging.

A sound understanding of the surgeon's imaging requirements for neck of femur fractures will facilitate improved communication and collaboration between the radiographer and surgeon and ultimately result in improved care for the patient.

Friday 16 March, 13:45–15:15 Knowledge Based Planning 1

The clinical implementation of knowledge based planning in prostate cancer using volumetric modulated arc therapy

Supun Thewa Hettige

The Alfred, Melbourne, Australia

Background: Volumetric modulated arc therapy (VMAT) is a complex radiotherapy technique offering the ability to achieve highly conformal dose distributions. Productions of VMAT plans can be time consuming and plan quality is dependent on planner expertise. Knowledge based planning (KBP) systems offer the ability to standardise planning approach and highlight sub optimal plans, improving plan consistency and quality.

KBP requires specialised software, building/validation of planning models, training the multidisciplinary team, multifaceted QA programs and development of standardised cross‐departmental protocols. Implementation of a KBP system also requires a significant shift in mindset for the entire multidisciplinary team. Establishing close collaboration between the radiation therapist's, clinicians and physicists is vital in this process.

Objective: This study assesses the clinical implementation of a commercial KBP approach in our department for the VMAT treatment of Prostate cancer. It highlights how the change was received by staff and challenges that were raised during implementation.

Methods: A select group of radiation therapists, oncologists and physicists were surveyed by interview and anonymous questionnaires regarding the use of KBP and its impact on them.

Results: The results from the evaluable respondents interview was used to define and adapt the clinical protocols that were used in the department and adapt them based on the feedback received. The questionnaire was used to gauge the understanding of the staff and change the KBP training protocol.

Conclusion: Implementation of KBP into routine clinical practice is feasible, however, careful planning is required. Successful implementation requires strong leadership, sufficient resources and extensive training.

Utilising knowledge‐based planning software as an evaluation tool to compare 3DCRT/IMRT/VMAT techniques for rectum plans

Louis Huynh, Liam Jukes, John Kenny, Rachel Chua

Icon Cancer Services – South West Regional Cancer Centre, Warrnambool, Australia

Purpose: The adoption of knowledge‐based planning software (KBPS) is increasing across many radiotherapy services due to potential for reduced planning time along with improved plan quality and consistency for inverse planned treatment techniques.¹^‐³ Use of a specific treatment technique is often implicit in the knowledge‐based model. The aim of this study is to evaluate the use of KBPS as a tool for comparing between 3DCRT, IMRT and VMAT techniques, by leveraging its modelling and statistics tools, so that the optimal model can be selected.

Method: 25 rectum patients were re‐planned by a single planner with 3DCRT, IMRT and VMAT. A knowledge‐based planning model was created for each technique. Each model was applied to a cohort of 20 new rectum volumes and their outputs were compared using the KBPS DVH estimation tools for targets and critical structures.

Results: This approach allowed knowledge‐based planning models to be used to determine the optimal treatment technique for a specific patient first, following which the selected model could be used to create an optimal plan.

Conclusion: A method for using the KBPS to evaluate planning techniques was demonstrated. Through KBPS, we have collated the results of 45 clinical rectum plans in our database to quantify the expected difference between IMRT, VMAT plans and 3DCRT plans. These results set the stage for the development of a new planning protocol that will standardise and improve care of future rectal cancer patients at ICON.

References

1. Fogliata A, Reggiori G, Stravato A, et al. RapidPlan head and neck model: the objectives and possible clinical benefit. Radiation Oncology 2017;12(1).

2. Wang J, Hu W, Yang Z, et al. Is it possible for knowledge‐based planning to improve intensity modulated radiation therapy plan quality for planners with different planning experiences in left‐sided breast cancer patients? Radiation Oncology 2017;12(1).

3. Wu H, Jiang F, Yue H, Li S, Zhang Y. A dosimetric evaluation of knowledge‐based VMAT planning with simultaneous integrated boosting for rectal cancer patients. Journal of Applied Clinical Medical Physics 2016;17(6):78–85.

Development and validation of knowledge based planning for oropharyngeal VMAT radiotherapy

James O'Toole, Kenny Wu, Regina Bromley, Mark Stevens, Thomas Eade

North Sydney Cancer Centre, Sydney, Australia

Purpose: To develop and validate knowledge based planning for oropharyngeal head and neck VMAT radiotherapy.¹

Methods and materials: Varian Rapidplan™ (RP) was used for this project. Patients with oropharyngeal SCC were identified using the head and neck database. The patients were divided into two cohorts, 70 patients to develop the model and 20 patients to validate the model. All patients had been treated clinically on a standard department protocol as previously published;² PTVHD/ID/LD to 70 Gy, 63 Gy and 56 Gy in 35 fractions, contralateral parotid mean dose <26 Gy, larynx mean dose <35 Gy and spinal cord <45 Gy.

The RP oropharynx model was created from cohort 1. Outliers were identified using RP outlier statistics and the Varian supported model analytics program. Each identified outlier was assessed and removed if it was deemed to make the model stronger. A senior member of the RP team tested the model creating a working RP Model Template. The final RP model was used to replan the validation patients. These plans were compared to the treated plans and also the department protocol.

Results: 20 patients were used for validation; six RP patients didn't meet all the constraints of the protocol. Additionally, some RP plans were comparable if not superior to the clinically treated plans.

Conclusion: Knowledge based planning for oropharyngeal SCC was developed and validated with high success using our department protocol. This has implications for patient care as the time from simulation to the start of RT may potentially reduce, and plan consistency enhanced.

References

1. Tol JP, Delaney AR, Dahele M, Slotman BJ, Verbakel WF. Evaluation of a knowledge‐based planning solution for head and neck cancer. Int J Radiat Oncol Biol Phys 2015;91(3):612–20.

2. Johnston M, Guo L, Back M, et al. Intensity‐modulated radiotherapy using simultaneous‐integrated boost for definitive treatment of locally advanced mucosal head and neck cancer: Outcomes from a single‐institution series. J Med Imaging Radiat Oncol 2013;57(3):356–363.

Development and validation of knowledge based planning for SBRT lung radiotherapy

Alexander Podreka, Kenny Wu, Andrew O'Toole, Regina Bromley, Mark Stevens, Thomas Eade

Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, Australia

Objectives: To develop and validate knowledge‐based dosimetry^1,2 for volumetric modulated arc therapy (VMAT) lung stereotactic body radiation therapy (SBRT).

Methods: Patients with lung cancer previously treated with 48 Gy in 4 fractions were identified for the study. Using Varian RapidPlan (RP) with Varian Eclipse software, and in collaboration with physicists and radiation oncologists, an RP model containing 36 patients was created and tested. This model was then used to optimise the plans of a separate cohort of eight validation patients, with plan comparisons done against their treated plans. Departmental target coverage constraints included planning target volume D98 > 100% and internal target volume (ITV) D100 > 100%. Organ‐at‐risk (OAR) constraints included chest wall (CW) V30 < 30 cc and skin V24 < 10 cc. Conformity index (100%, 50%) was also evaluated, with improvements of ≥2 Gy between OAR doses deemed significant and classified as dosimetrically superior.

Results: Of the eight patients optimised using the RP lung model, seven were evaluated to be similar to the previously treated clinical plan. Only one treatment plan optimised using the RP model was considered dosimetrically inferior due to CW V30 > 30 cc.

Conclusion: Knowledge based planning for SBRT lung was developed and produced plans dosimetrically similar to the treated plans in seven of eight patients. Compared to manual planning, the advantage of using the RP model was the reduced time for the dosimetrist. Although the current model has been shown to be adequate in producing dosimetrically acceptable plans, future directions include re‐evaluation of the RP model to create dosimetrically superior treatment plans.

References

1. Fogliata A, Belosi F, Clivio A, et al. On the pre‐clinical validation of a commercial model‐based optimization engine: Application to volumetric modulated arc therapy for patients with lung or prostate cancer. Radiother Oncol 2014;113:385–391.

2. Good D, Lo J, Lee W, Wu Q, Yin F, Das S. A knowledge‐based approach to improving and homogenizing intensity modulated radiation therapy planning quality among treatment centers: an example application to prostate cancer planning. Int J Radiat Oncol Biol Phys 2013;88:176–181.

Group discussion panel led by Jill Harris

Invited Speaker

Knowledge based planning: the patient's best friend or enemy?

Knowledge based planning systems are being implemented globally. They have been seen to improve efficiency and in many situations the quality of plans produced, but, is there a downside to automation?

This panel discussion will explore the concerns of radiation therapists with respect to patient safety with the increased implementation of these systems.

Friday 16 March, 15:45–17:15 CT

CTCA anatomy, Charbel Saade

Invited Speaker

Continued improvements in multi‐detector computed tomographic (CT) scanners have made coronary and cardiac CT an important clinical tool that is revolutionising cardiac imaging. Multi‐detector CT with submillimeter collimation and gantry rotation times under 0.4 seconds allows the acquisition of studies with high temporal resolution and isotropic voxels. The volumetric data set that is generated can be analysed with a depth previously not possible, requiring a solid understanding of the cardiac anatomy and its appearance on CT scans and post‐processed images. Understanding coronary and cardiac anatomy is vital to determine imaging techniques, contrast media delivery strategies as well as in understanding the potential pathological processes that affect our imaging techniques. This session will focus on coronary and cardiac CT anatomy and associated pathological findings.

High heart rate is not necessarily a contraindication for step‐and‐shoot computed tomographic coronary angiography

Karen Dobeli^1,2, John Younger¹

¹Royal Brisbane & Women's Hospital, Brisbane, Australia ²The University of Sydney, Sydney, Australia

Objectives: Step‐and‐shoot (S&S) mode is a low radiation dose method for performing CT coronary angiography (CTCA). However, image quality may be reduced if the patient's heart rate (HR) is high. The aim of this study was to perform a review of CTCAs performed at our institution to determine if high heart rate should be a contraindication for performing S&S CTCA.

Methods: The imaging report for 1264 S&S CTCAs were reviewed. The patient's maximum heart rate during the scan acquisition, the study quality and reason/s for poor study quality were noted. Study quality was classed as poor, fair, good or excellent. One‐way analysis of variance (ANOVA) was used to investigate differences in median heart rate between study quality classifications.

Results: Study quality was classed as poor for 117 (9.1%), fair for 365 (28.5%), good for 362 (28.2%) and excellent for 438 (34.2%) examinations. There was significant variation in median heart rate between study quality classifications (70, 65.5, 60 and 57 bpm for poor, fair, good and excellent study quality, respectively; P < 0.0001). 22% of patients had HR ≥ 70 bpm. 80% of studies performed with HR above 70 bpm were of diagnostic quality.

Conclusion: Higher heart rate is associated with inferior study quality for S&S CTCA. Nevertheless, the majority of examinations performed with HR over 70 bpm were of diagnostic quality. Consequently, restricting the use of S&S to patients with low heart rates would unnecessarily expose more than 20% of patients to up to 10 times higher radiation dose.

Computed tomographic visualisation of the orbit with penetration by a wooden foreign object

Peter R Traise

Western NSW LHD Imaging, Bathurst, Australia Odense University Hospital Radiology Department, Odense, Denmark

Introduction: Traumatic penetration of the orbit is a serious and potentially life‐threatening condition. Wooden foreign objects (WFO) are rare and are often missed on first reading.¹ The role of CT in locating foreign objects and demonstrating ocular injury is important for surgical management.

Case presentation: An example of extended CT imaging for an intra‐orbital WFO is given in a patient who attended the emergency department with left orbital proptosis and suspected orbital cellulitis after an apparent superficial laceration injury. Post‐IV contrast CT revealed extensive orbital emphysema and a small fracture of the orbital floor.

Management and outcome: With no obvious mechanism of injury, a thorough interrogation of the data using extended window width and finer slice extraplanar reformations revealed a 25 mm WFO penetrating the posterior inferior orbit with no ocular damage. The patient was administered IV antibiotics and referred for surgery. Recovery post‐surgical removal of WFO was unremarkable.

Discussion: While a high density metal FO is readily visible on CT, low density FOs, such as wooden objects, may be technically difficult to visualise and are often missed.² Delays in treatment may result in an increased risk of vision loss, a high incidence of intracranial abscess formation and death.

Preliminary image evaluation by the CT MRS and early co‐ordination of a multidisciplinary team is crucial for optimal surgical treatment.

Careful imaging using fine‐slice orthogonal multiplanar reformats, wide bony windowing and further characterisation of findings by extraplanar reformats will improve visualisation of these subtle yet potentially deadly injuries.

References

1. Shelsta H, et al. Wooden intraorbital foreign body injuries: clinical characteristics and outcomes of 23 patients. Ophthal Plast Reconstr Surg 2010;26(4):238–244.

2. Greaney M. Bamboo orbital foreign body mimicking air on computed tomography. Eye 1994;8(6):713–14.

Lung cancer: what are the possibilities of early detection and screening programs?

Megan Stafford

Peter MacCallum Cancer Centre, Melbourne, Australia

Lung cancer is the leading cause of cancer deaths in Australia; it is the fifth most common cancer diagnosis and has a 14% five year survival rate.¹ Australia already has successfully established, fully funded and private cancer screening programs.²

Now with the rise of ultra‐low dose CT scanning, the possibility of a lung cancer screening program seems a viable option to reduce mortality and improve outcomes.

Australian based research in this area is limited, making it difficult for medical and government bodies to develop a robust program. There are multiple requirements and issues to consider when implementing a large scale screening program.

What involvement from imaging professionals is required? This presentation will outline the current state of lung cancer screening in Australia from the perspective of a specialist cancer hospital, and looks at potential future opportunities.

References

1. Cancer Council Australia. Updated June 27 2017. Available at http://www.cancer.org.au/about‐cancer/types‐of‐cancer/lung‐cancer.html [Accessed 23 August 2017].

2. Department of Health. Updated April 27 2016. Available at http://www.cancerscreening.gov.au/ [Accessed 23 August 2017].

Improving communication in CT protocolling – scanning by numbers

Sally Ball, Tom Steffens

Princess Alexandra Hospital, Brisbane, Australia

Under Queensland regulations,¹ only radiologists are authorised to request computed tomography (CT) scans. This differs from other radiological procedures in that submitted documentation essentially serves as a referral to radiologists. Radiologists are then required to consider the clinical information and decide on the specific CT examination (if any) to be performed by the radiographer, a procedure known as ‘protocolling’. CT is complex, with factors including scan extent, contrast phases and post‐processing requirements contributing to an extensive list of ‘protocols’ to choose from.

Given that the resultant CT ‘protocol’ becomes the ‘requested examination’ performed by the radiographer, it is imperative that it is communicated clearly.

Barriers to effective communication of CT protocols include abbreviation use,^2,3 lack of familiarity with scanner protocols and illegibility of hand writing.⁴ In large departments, protocolling is often completed by radiologists in advance of the scan date, rendering follow‐up of ambiguous protocols difficult.

To address these issues, a system was devised to enhance communication between protocolling radiologists and CT radiographers in a tertiary referral hospital. The main issues identified were in keeping with the literature.

The new system involved:

• Extensive review of scan protocols across all scanners, ensuring alignment of characteristics and consistency of labelling.

• Changing from handwritten protocols to assignment of a ‘protocol number’ to each exam by radiologists. A common (numbered) protocol manual was introduced for use by radiologists and radiographers to facilitate shared understanding.

While anecdotal feedback regarding this new system has been positive, a formal review is yet to be conducted.

References

1. Queensland Radiation Safety Regulation, 2010. Available at https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/R/RadiatSafyR10.pdf

2. Sinha S, McDermott F, Srinivas G, Houghton PWJ. Use of abbreviations by health care professionals: what is the way forward? Postgrad Med J 2011;87:450–452.

3. Brunetti L, Santell JP, Hicks RW. The impact of abbreviations on patient safety. The Joint Commission Journal on Quality and Patient Safety 2007:33(9):276–283.

4. Sokol D. Poor handwriting remains a significant problem in medicine. Journal of the Royal Society of Medicine 2006;99:645.

Friday 16 March, 15:45–17:15 Dose Optimisation

Raising awareness of the role of medical physics in radiology

Adam Jones

Westmead Hospital, Westmead, Australia

The insufficient supply of qualified medical physics specialists (qMPS) in radiology throughout Australia and in particular New South Wales is a risk that is not clearly understood. This session will highlight a number of the benefits associated with having access to a radiology qMPS and consequently the risks of not. In addition, the requirements resulting from the development and implementation of the new NSW EPA Radiation Guideline documents will be discussed with a focus on how this will hopefully improve imaging standards and assist in dose optimisation within NSW. All radiographers will benefit from understanding the role of the qMPS in dose optimisation and collaborative quality radiographic practice within radiology departments.

Update on ARPANSA DRLs

Peter Thomas, Paul Marks, Toby Beveridge

Australian Radiation Protection and Nuclear Safety Agency, Yallambie, Australia

Objectives: Setting diagnostic reference levels (DRLs) for radiation dose metrics in medical imaging provides facilities with a benchmark for comparison. The ARPANSA National Diagnostic Reference Level Service (NDRLS) collects data for setting DRLs. Recommendations are presented to liaison panels comprised of representatives of relevant professional bodies for endorsement before being announced as national DRLs.

Method: In CT, representative dose metrics are derived from the median of a survey of 20 patients for a scan of a given body region. For nuclear medicine, data on administered activity was collected over a 4‐week period and representative values calculated where at least four patients underwent a given procedure. Information on CT metrics for SPECT/CT and PET/CT imaging was also collected. Data for angiography procedures is collected via standard template spreadsheets. A sample of 30 patients is requested for each survey as a wider variation is expected.

Results: For CT, 569 facilities with 678 scanners are currently registered. 1,507 surveys from 280 scanners were completed in 2016. Revisions to existing DRLs are under discussion.

For nuclear medicine, 78 facilities across Australia submitted data. DRLs were developed for 70 general nuclear medicine procedures, three PET and 10 CT protocols.

For IGIP, 40 facilities have registered and 72 surveys have been submitted to date, most for coronary angiography. Current DRLs and summary statistics are available on the ARPANSA website.

Conclusion: The use of DRLs in Australia is becoming more widespread. DRLs give facilities guidance on how doses at their site compare with the national spread.

Diagnostic reference levels for cardiac CT angiography in Australia

Ali Alhailiy, Elaine Ryan, Peter Kench, Patrick Brennan, Mark McEntee

Faculty of Health Sciences, The University of Sydney, Sydney, Australia

Objectives: This study aims to assess patient radiation dose and propose a national diagnostic reference levels (NDRLs) for cardiac computed tomography angiography (CCTA) procedures in Australian clinical practices.

Methods: A structured booklet was used to retrospectively record the baseline information related to CCTA scanning and patient parameters in CT centres across the country. Australian NDRLs for CCTA were defined as the 75th percentiles of volumetric CT dose index (CTDIvol) and dose length product (DLP).¹ Specific DRLs based on dose quantities for calcium scoring test were also proposed. Dose levels were compared to NDRLs from other countries in order to provide opportunities for participated CT facilities to compare their facility DRL values with NDRLs.²

Results: 11 CT centres participated in this survey. Data sets of 429 patients from 12 CT scanners were used for analysis. The 75th percentile and standard deviation (SD) values for the CTDIvol and the DLP for CCTA were 22 mGy (8) and 267 mGy cm (93), prospectively. DRL for calcium scoring test was 115 mGy cm (44) for DLP.

Discussion/Conclusion: NDRLs for CCTA in Australia have been recommended for the first time. DRLs are lower than most published NDRLs studies due to the current use of dose‐saving technology such as prospective ECG gated mode. Considerable variations in patient doses remain between hospitals for the most frequently used CCTA protocols, indicating the need to implement DRLs as an optimisation parameter for radiation protection in CT facility.

References

1. European Commission. Health protection of individuals against the dangers of ionizing radiation in relation to medical exposure. Council Directive 97/43/Euratom. Official Journal of the European Communities 1997;180.

2. Vassileva J, Rehani M. Diagnostic reference levels. AJR Am J Roentgenol 2014;204(1):1–3.

Teaching an old dog new tricks: exposure selection in the digital age

Adam Steward¹, Michael Tarollo¹, Giovanni Mandarano²

¹Western Health, Melbourne, Australia ²Deakin University, Waurn Ponds, Australia

Introduction: There exist a number of physical principles and clinical rules that have historically been used to guide exposure selection for film‐screen radiography and determine the dose to patients. This study aimed to assess the relevance of these existing relationships in the digital age, investigating the linear relationship of mAs and exposure incident on the detector, the 15% rule linking a 15% increase in kVp to a doubling of exposure incident on the detector and the relationship of kVp to image contrast.

Methods: An anthropomorphic body phantom was imaged with an FFD of 100 cm and a collimated field of 41x14 cm, which was centred to include the lumbar spine. A tube potential of 70kVp was selected at 2.5mAs, with mAs doubled consistently for each subsequent image, concluding at which point that saturation of the detector was reached. Secondly, the mAs was maintained at 20mAs and images then recorded at 50, 60, 70 and 80kVp and then also at 95kVp and 110kVp. Five images were then taken at 60kVp and 40mAs, 70kvp and 20mAs, 80kVp and 10mAs, 95kVp and 5mAs and 110kVp and 2.5mAs.

Results: The principle linking a linear relationship between mAs and detector exposure was able to be confirmed, likewise, the 15% rule was proven accurate on the direct digital radiography system. The relationship of kVp to image contrast was not demonstrated.

Conclusion: Given the results of the study, the authors have adapted this study to clinical practice with dramatically reduced outcomes in radiation exposure, while maintaining quality.

Using local DRLs for flouroscopic procedures to improve patient care

Chris Houghton

Wagga Wagga Rural Referral Hospital, Wagga Wagga, Australia

Objectives: To determine local DRLs for common fluoroscopic procedures within our department and to use this information to improve training programs and to provide better care to our patients.

Methods: A retrospective review of screening times(s) and DAP (mGycm²) for common fluoroscopic examinations at our site to determine local dose reference levels (LDRLs).

Data will be analysed to determine LDRLs for a number of common (local) fluoroscopic procedures and compared to established national DRLs (NDRLs).¹

Results: Formal results are pending but will be available at time of presentation.

Discussion: DRL is defined as ‘dose levels for typical examinations for groups of standard sized patients’.¹ The 75th percentile of standard doses is set as a national DRL, with local DRLs set at the median.²

Conclusion: Knowledge of local and national DRLs can be used for quality improvement activities. LDRLs can be used to inform radiographers and radiologists and to allow a collaborative approach to dose reduction training.

References

1. ARPANSA. NDRLS frequently asked questions. Canberra: ARPANSA; 2016. Available at www.arpansa.gov.au/research/surveys/national‐diagnostic‐reference‐level‐service/frequently‐asked‐questions [Accessed 17 August 2017].

2. Liang CR, Chen PXH, Kapur J, Ong MKL, Quek ST, Kapur SC. Establishment of institutional diagnostic reference level for computed tomography with automated dose‐tracking software. Journal of Medical Radiation Sciences 2017;64(2):82–89.

Friday 16 March, 15:45–17:15 IGRT 1

Bladder volume surveillance for patients receiving radiation therapy for anal cancer

Andrea Wright

Peter MacCallum Cancer Centre, Melbourne, Australia

Introduction: Best patient care in radiotherapy for anal cancer requires consideration of consistency in bladder volume. Suboptimal filling may result in higher bladder and bowel doses and subsequently increased toxicity risk. Ultrasound volumetric imaging of the bladder can be utilised to assess bladder volume.¹ The aim of this study was to investigate current bladder filling protocols and their efficacy in maintaining consistent volumes, and optimal bladder size to enable bladder and small bowel avoidance.

Methods: 10 anus radiotherapy patients were analysed in this ethics approved retrospective study. Patients were instructed to have a comfortably full bladder at CT and treatment. CBCTs were acquired weekly. CBCT scans were imported into the treatment planning system. Bladder and small bowel were contoured and dosimetrically analysed.

Results: A trend was identified suggesting increased bladder volume to a decreased volume of irradiated small bowel. 15% of patients that exceed the V30 Gy<350 cc planning constraint had a bladder volume less than 150 cc. However, without a strict protocol for minimum bladder size requirement at CT, it was difficult to derive such a relationship when at times constraints were impossible to achieve purely on the basis of bladder volume, regardless of the plan.

Conclusion: Published advantages of bladder volume ultrasound verification in post prostatectomy patients provided an excellent foundation for work in anal cancer patients.^₁ Results of this study demonstrate the importance of bladder volume consistency prior to planning and treatment, to ensure greater compliance in this complex radiotherapy patient cohort.

Reference

1. Haworth A, Paneghel A, Bressel M, et al. Prostate bed radiation therapy: the utility of ultrasound volumetric imaging of the bladder. Clin Oncol (R Coll Radio) 2014;(12):789–96.

Bladder volume measurement methods for prostate patients undergoing external beam radiation therapy

Lisa Nguyen, Belinda Hua, Marika Bazley

Gippsland Radiation Oncology – Alfred Health, Melbourne, Australia

Background: The importance of maintaining bladder volume consistency from planning and throughout treatment to reduce acute toxicities in prostate cancer patients is well documented.¹^,² Patient positioning and bladder volume measurements can be obtained by using kilovoltage‐cone beam computerised tomography (KV‐CBCT) while the patient is in the treatment position. However, due to daily variability in bladder volume, removal of the patient from the treatment couch may be necessitated if bladder filling is inadequate, with a repeat CBCT adding extra dose to the patient.

Objective: The purpose of this paper is to review the reliability of transabdominal ultrasound (US) bladder scanner in assessing adequate bladder filling prior to treatment, preventing unnecessary kV‐CBCT images being repeated.

Methods: Evidence was gathered from Science Direct, PubMed, Scopus, CINAHL, Cochrane Library Database and Proquest Central from 2006 to 2015. Studies included were prostate cancer (regardless of staging), US bladder scanner and methods for bladder filling. Keywords included bladder filling, radiation therapy, ultrasound bladder scanner, prostate cancer.

Results: A total of 27 articles were included in this literature review. Evidence from original articles suggests US bladder scanner is a reliable imaging tool and there is a strong correlation between the bladder volume at CT to the bladder volume acquired by the US bladder scanner.

Discussion: US bladder scanning is considered a reliable tool for assessing adequacy of bladder filling prior to treatment. It is non‐ionising and a non‐invasive method to confirm and acquire instant bladder volume reading for both prostate intact and prostate bed patients.

References

1. Haworth A, Foroudi F, Paneghel A, et al. Prostate bed radiation therapy: the utility of ultrasound volumetric imaging of the bladder. Clin Oncol 2014;26(12):789–96.

2. Hynds S, McGarry CK, Mitchell DM, et al. Assessing the daily consistency of bladder filling using an ultrasonic bladderscan device in men receiving radical conformal radiotherapy for prostate cancer. Br J Radiol 2011;84(1005):813–8.

Setup reproducibility and junction stability in DIBH and free breathing nodal irradiation for breast cancer

Melissa Benson, Tara Milburn, Katie Beer, Joel Poder, Anna Ralston

St George Hospital Cancer Care Centre, Kogarah, Australia

Objective: The primary objective of this study is to determine whether the deep inspiration breath hold (DIBH) technique for patients receiving nodal irradiation for breast cancer results in a more reproducible setup than free breathing (FB). We hypothesise that dose received across the junction will be more reproducible than for FB patients. The dose represented on the radiotherapy plan across the junction level will therefore be more accurate.

Method: A minimum of 20 patients (10 FB and 10 DIBH) were set up for treatment with a kV imaging threshold of 0.3 cm and DIBH patients were treated using Varian Real‐time Position Management (RPM) software with a 0.5 cm amplitude threshold. Orthogonal kV images of DIBH and FB patients were reviewed to determine the range of isocentre shifts in the Sup/INF direction. The patients had Gafchromic EBT3 films placed over the supraclavicular and tangent junction for six fractions throughout their treatment.

Results: The EBT3 films showed acceptable dose uniformity in the junction region for all patients. The average Sup/INF shift was 0.2 cm ± 0.2 cm (1 SD) and 0.5 cm ± 0.4 cm (1 SD) for DIBH and FB respectively (see Figure).

Discussion: As expected, FB patients had significantly greater Sup/INF shifts than DIBH patients. FB patients have the same imaging threshold however no threshold for respiration is applied, resulting in dose feathering across the junction throughout the full respiratory cycle. A junction with both RPM and imaging thresholds (DIBH) should provide greater intra‐fractionation stability and accuracy in dose as represented on the radiotherapy plan.

Figure 1. Incidence and sup/INF shift in free breathing vs. DIBH techniques.

Targeting pancreatic cancer: fiducials and surrogates versus bony anatomy for image guided radiation therapy

Meegan Shepherd, Andrew O'Toole, Corrine Simitsiotis, Judith Martland, George Hruby, Andrew Kneebone

Northern Sydney Cancer Centre, St Leonards, Australia

Background: Advances in radiation therapy for pancreatic cancer, including image guided radiation therapy (IGRT) with cone beam computed tomography (CBCT)¹ and motion evaluation using 4D‐CT², provide dosimetric benefits by allowing reduced target margins and dose to organs at risk (OAR). The quality of treatment delivery however, is highly dependent on precise target localisation.

Objectives: This study investigates the accuracy of fiducial or surrogate IGRT structures compared to bony anatomy for eligible pancreatic patients at the Northern Sydney Cancer Centre (NSCC).

Methods: Positional data from daily orthogonal kV or CBCT images was analysed in four patients using fiducial (3) or stent (1) based IGRT to the intact pancreas.

Ninety fiducial IGRT image sets were retrospectively co‐registered to bony anatomy using Varian's ‘Offline Review’, and shifts were recorded in the left‐right, anterior‐posterior and superior‐inferior directions.

Results: Preliminary results demonstrate that mean daily shifts (ranges) between bony anatomy and fiducial matches were 0.33 cm (−1.2 cm to 1.81 cm), −0.31 cm (−0.73 to 0.36 cm) and −0.46 cm (−1.82 to 0.77 cm) in the lateral, vertical and longitudinal axes respectively.

Conclusion: Despite the small sample size, the results of this study reflected the literature,³ suggesting that bony anatomy IGRT has a negative impact on PTV coverage and OARs. This supports the use of pancreatic fiducial markers and stent surrogacy in IGRT for pancreatic cancer.

References

1. Ohira S, Isono M, Ueda Y, et al. Assessment with cone‐beam computed tomography of intrafractional motion and interfractional position changes of resectable and borderline resectable pancreatic tumours with implanted fiducial marker. Br J Radiol 2017;90:1072.

2. Huguet F, Yorke ED, Davidson M, Zhang Z, Jackson A. Modeling pancreatic tumor motion using 4‐dimensional computed tomography and surrogate markers. Int J Rad Onc Bio Phys 2015;91:3:579.

3. Varadarajul S, Trevino J, Jacob R. Impact of EUS‐guided fiducial markers in management of patients with pancreatic cancer (PAN‐CAN) undergoing image guided radiation therapy (IGRT). Gastrointestinal Endoscopy 2009;69(5):AB325–AB326.

Expiration breath‐hold stereotactic ablative body radiotherapy for primary liver cancer

Briana Welsh, Richard Khor, Anna Seeley, Nikki Shelton, Benjamin Harris

Austin Health, Melbourne, Australia

Stereotactic ablative body radiotherapy (SABR) has a growing role in the management of hepatocellular carcinoma (HCC), and is technically challenging due to potential motion of the liver and surrounding organs due to respiration. Liver SABR may be delivered during normal free breathing, using an internal target volume (ITV) approach defined from 4DCT. However, delivery during breath‐hold significantly reduces respiratory motion and therefore the volume of normal tissue irradiated, potentially decreasing toxicity including radiation induced liver disease.

Expiration breath‐hold (EBH) for liver patients requires effective communication to ensure accurate delivery. High‐quality patient education in the use of the Elekta Active Breathing Coordinator™ (ABC) is essential for successful planning and treatment processes. A planning CT with multi‐phase contrast acquisitions in breath‐hold and acquisition at treatment of a ‘stop‐and‐go’ 3D CBCT over several breath holds can only be achieved with successful collaboration between radiation therapists and the patient.

Liver EBH SABR was successfully implemented through collaboration with both international colleagues and institutional medical imaging and radiation oncology departments. High‐quality diagnostic imaging in EBH allows for precise target and normal tissue definition. Ultrasound‐guided fiducial marker insertion allows for increased confidence in IGRT for liver SABR. The EBH technique has enabled safe and efficient liver SABR delivery, with potential to improve the outcomes for patients undergoing radiotherapy for HCC.

Analysis of oesophagus and heart motion in SBRT: is more care needed for thoracic OARs?

Arabella Norman, Aaron Pritchard

Western Sydney Local Health District, Sydney, Australia

Background: Stereotactic body radiation therapy (SBRT) in the thoracic region involves a planning 4‐dimensional computed tomography (4DCT) in which 10 scans are captured at a particular point in the breathing cycle. These are then combined to create an average scan for tumour delineation. However, this average scan does not account for motion of radiosensitive organs at risk (OARs), which may vary in position due to intrafractional motion.

Aims: Quantify organ motion of the oesophagus and heart to analyse whether there is a necessity for planning organ at risk volumes (PRVs) for future SBRT patients.

Methods: Ten patients who had a planning 4DCT for SBRT were analysed to ensure their scan covered the entire oesophagus and heart. The oesophagus and heart were contoured on each phase of the breathing cycle on Eclipse Treatment Planning System using RTOG contouring guidelines.¹ The greatest area of motion was measured in the transverse, sagittal and coronal planes; including the volumetric and dosimetric differences using dose volume histogram (DVH) data. The data collected is compared to the respective organ on the average scan.

Results and Discussion: The oesophagus and heart had an average area of motion of 0.95 cm and 1.8 cm; volumetric difference of 37.7% and 18.93% when compared to the average scan respectively.

Conclusion: The results show unaccounted motion of the oesophagus and heart when treating SBRT thoracic patients. To improve care, implementation of an expanded PRV structure as protocol could lower dose received and account for intrafractional motion; however more research is necessary.

Reference

1. Kong F, Quint L, Machtay M, Bradley J. Atlases for organs at risk (OARs) in thoracic radiation therapy. RTOG 1106. Radiation Therapy Oncology Group.

Friday 16 March, 15:45–17:15 Virtual Learning

The role of virtual and augmented reality in teaching clinical anatomy and medical imaging

Michelle Moscova

Invited Speaker

Learning anatomy is integral to the education of radiographers and health care professionals. While cadaver‐based anatomy education remains golden standard, the time students are able to spend using cadaver laboratory is limited. This may not allow adequate time to practice and consolidate knowledge.

Virtual reality (VR) and augmented reality (AR) are some of the latest technologies that have ability to overcome these challenges and provide learning opportunities for students outside the cadaver laboratory. These technologies promise to enhance learning anatomy by enhancing student experience and revolutionising distance learning. Use of CT imaging and advanced segmentation algorithms expands the potential of VR and AR by creating authentic and accurate anatomical models of individual patient's normal and pathological anatomy.

While VR and AR hold many promises, these technologies are still new and research on effectiveness of these technologies is scarce. This presentation will discuss current use of VR and AR in anatomy education, what is known about its effectiveness and its potential in the near future.

Collaborative learning using virtual radiography

Madeleine Shanahan^1,2, Angela Drew², Cara Kerr²

¹University of Canberra, Bruce, Australia ²RMIT University, Bundoora, Australia

Objective: Projection VR™ is a valuable educational tool supporting students to develop radiographic skills in chest, abdomen and axial skeleton.^1,2 Extremity applications were recently added to this virtual radiography simulation. The objective of this study was to introduce and evaluate the extremity applications as learning tools for radiography students.

Methods: Extremity applications were integrated into the laboratory component of an undergraduate course. Purposefully designed worksheets were developed to support authentic learning experiences within a collaborative environment. Following completion of the course, all enrolled students (N = 76) were invited to complete an online survey to assess the educational value of the software. Descriptive statistics were applied. University ethics approval was granted.

Results: Responses were received from 64 students. Perceived primary benefits of using the simulation were ability to repeat activities until satisfied with results (95%) and being able to quickly see images and understand if changes needed to be made (97%). Students reported using the simulation increased their confidence, ability, and that they thought more about setting up radiographic procedures (84%, 86%, 89%), evaluating radiographic images (95%, 97%, 95%) respectively, and feel better prepared for clinical practice (83%).

Discussion: Authentic learning experiences using Projection VR™ encourages students to consider technical aspects of radiographic examinations whilst collaborating with staff and fellow students to improve their practice. Pre‐clinical technical preparation of students is enhanced allowing them to concentrate more on patient interactions on clinical placements.

Conclusion: The implemented Projection VR™ extremity activities empowered students to develop confidence, technical and cognitive skills in preparation for clinical placement.

References

1. Shanahan M. Student perspective on using a virtual radiography simulation. Radiography 2016;22:217–222.

2. Shanahan M. Utilising activity theory as a framework to evaluate the implementation of a virtual simulation educational tool. In: Proceedings of EdMedia 2016‐World Conference on Educational Media and Technology (pp. 775–784). Vancouver, BC, Canada: Association for the Advancement of Computing in Education (AACE).

CT learning via high‐fidelity simulation for undergraduate radiography students

Kristal Lee¹, Marilyn Baird¹, Sarah Lewis², Shannon Wiseman³, Matthew Dimmock¹

¹Monash University, Clayton, Australia ²The University of Sydney, Cumberland, Australia ³Monash Health, Bentleigh East, Australia

Objectives: A commonwealth funded remote‐access CT scanner (NETRAD CT) administered by the University of Sydney offers enhanced simulated learning. This study compared the educational outcomes of two high‐fidelity simulation environments: remote‐access versus locally accessed CT scanners for undergraduate radiography students.

Methods: Third year Monash University radiography students (n = 71) were randomly assigned into two different workshop groups. Group 1 ‘remote‐access’ (n = 36) attended a facilitated 1.5‐h workshop introducing the NETRAD CT scanner. Each student was assigned a personal login to access the scanner outside of class without facilitation. Group 2 ‘local‐access’ (n = 35) attended a facilitated 1.5‐h workshop at a locally accessed CT scanner with no additional logon opportunities. Both groups completed identical tasks scanning head and neck regions of phantoms covering core CT principles (scan planning, technique factors and image reconstruction). After workshop learning but prior to attending a dedicated CT clinical placement, all students were assessed via a multiple‐choice and short‐answer formative knowledge assessment test on the core CT principles. After completion of their clinical placement students sat an equivalent summative test.

Results: Student test results between the two groups demonstrated no significant difference in core CT knowledge pre (P = 0.67) and post (P = 0.58) clinical placement. Significant improvement, however, was noted (IWI < Wcrit) from pre‐ to post‐test scores of CT knowledge within each group.

Discussion/Conclusion: Simulation via remote access with reduced facilitation does not impact on learning of core CT knowledge compared to simulation in a local, tactile environment.

Cross sectional imaging Newcastle: a VERT Collaboration Project

Debra Lee, John Tessier

University of Newcastle, Callaghan, Australia

Within the medical radiation science (MRS) professions there is a continuing and marked increase in the use of cross‐sectional imaging. Undergraduate students from both diagnostic radiography (DR) and radiation therapy (RT) are required to develop multi‐planar image interpretation skills.

The VERT lab at the University of Newcastle has been used since 2013 as a pivotal part of the undergraduate RT program. This study investigates the use of VERT as an interdisciplinary collaborative tool, used to facilitate students’ ability to understand cross‐sectional images and the relationships between anatomical structures.

Second year MRS student volunteers were randomly allocated into groups consisting of RT students, with previous VERT experience and knowledge, and DR students with no prior VERT experience. The investigation was undertaken in small groups of 4–8 students.

Multiple evaluation sessions were conducted in the VERT lab under academic supervision. The sessions were interspersed with formative evaluations (pre‐, mid‐ and post‐project) to identify anatomical structures in cross‐sectional images. These tests consisted of randomly selected questions from a pool created prior to the commencement of the project. Custom questionnaires were used to obtain feedback from participating students to assist in future development of this learning module.

Analysis of test performance revealed improvements between the pre and mid tests, and again between mid‐ and post‐project tests. Feedback supported the expansion and continuation of this format, highlighting the advantage of collaboration between RT and DR streams, and the benefits of using the VERT technology.

Radiography students practising patient‐centred and inter‐professional communication in a hybrid simulation environment: a design journey

Emma Cooper¹, Jessica Stokes‐Parish²

¹Hunter New England Health/University of Newcastle Department of Rural Health, Tamworth, Australia ²University of Newcastle Department of Rural Health, Tamworth, Australia

Practice‐based education seeks to extend learning beyond clinical tasks. It encompasses the students’ need to develop professional relationships and standards of practice alongside technical capabilities in an authentic environment. Recognised among eight key practices within the Practice‐Based Education Framework for Professional Education,¹ simulation has a well‐documented presence in the medical and nursing literature but very little in relation to radiography.

Simulated learning in diagnostic radiography has been predominantly mono‐professional and skill‐based, utilising mock X‐ray laboratories and mannequins of varying sophistication and, more recently, avatars and virtual reality environments. The University of Newcastle Department of Rural Health (UONDRH) in Tamworth offers integrated simulation technology and a simulated patient program that is utilised within medical, nursing and physiotherapy programs. Collaborating inter‐professionally within the UONDRH, the authors are designing a novel research framework within which to explore the use of hybrid simulation as an adjunct to inter‐professional and patient‐centred learning for radiography students.

This presentation will chart the process of and progress towards designing this research framework. Challenges include combining sound practice‐based pedagogy and research methodology, complex human ethics considerations and collaborative writing of a fit‐for‐purpose hybrid simulation scenario that captures the nuances of inter‐professional and patient‐centred communication.

The aim is to achieve a high degree of realism in the engagement of radiography and nursing undergraduates with a simulated patient, faculty confederate(s) and simulated patient monitoring. The product will be a framework that can facilitate wider implementation, evaluation and validation of simulation in diagnostic radiography.

Reference

1. Higgs J. Practice‐based education: a framework for professional education. Australian Learning and Teaching Council, Sydney, 2011.