Linda Probyn

Conventional Medical Education and the History of Simulation in Radiology

Simulation is a promising method for improving clinician performance, enhancing team training, increasing patient safety, and preventing errors. Training scenarios to enrich medical student and resident education, and apply toward competency assessment, recertification, and credentialing are important applications of simulation in radiology. This review will describe simulation training for procedural skills, interpretive and noninterpretive skills, team-based training and crisis management, professionalism and communication skills, as well as hybrid and in situ applications of simulation training. A brief overview of current simulation equipment and software and the barriers and strategies for implementation are described. Finally, methods of measuring competency and assessment are described, so that the interested reader can successfully implement simulation training into their practice.

Comparative Analysis of the Radiology of Osteoporotic Vertebral Fractures in Women and Men: Cross-Sectional and Longitudinal Observations from the Canadian Multicentre Osteoporosis Study (CaMos)†

We compared two methods for osteoporotic vertebral fracture (VF) assessment on lateral spine radiographs, the Genant semiquantitative (GSQ) technique and a modified algorithm‐based qualitative (mABQ) approach. We evaluated 4465 women and 1771 men aged ≥50 years from the Canadian Multicentre Osteoporosis Study with available X‐ray images at baseline. Observer agreement was lowest for grade 1 VFs determined by GSQ. Among physician readers, agreement was greater for VFs diagnosed by mABQ (ranging from 0.62 [95% confidence interval (CI) 0.00–1.00] to 0.88 [0.76–1.00]) than by GSQ (ranging from 0.38 [0.17–0.60] to 0.69 [0.54–0.85]). GSQ VF prevalence (16.4% [95% CI 15.4–17.4]) and incidence (10.2/1000 person‐years [9.2; 11.2]) were higher than with the mABQ method (prevalence 6.7% [6.1–7.4] and incidence 6.3/1000 person‐years [5.5–7.1]). Women had more prevalent and incident VFs relative to men as defined by mABQ but not as defined by GSQ. Prevalent GSQ VFs were predominantly found in the mid‐thoracic spine, whereas prevalent mABQ and incident VFs by both methods co‐localized to the junction of the thoracic and lumbar spine. Prevalent mABQ VFs compared with GSQ VFs were more highly associated with reduced adjusted L1 to L4 bone mineral density (BMD) (–0.065 g/cm2 [–0.087 to –0.042]), femoral neck BMD (–0.051 g/cm2 [–0.065 to –0.036]), and total hip BMD (–0.059 g/cm2 [–0.076 to –0.041]). Prevalent mABQ VFs compared with prevalent GSQ were also more highly associated with incident VF by GSQ (odds ratio [OR] = 3.3 [2.2–5.0]), incident VF by mABQ (9.0 [5.3–15.3]), and incident non‐vertebral major osteoporotic fractures (1.9 [1.2–3.0]). Grade 1 mABQ VFs, but not grade 1 GSQ VFs, were associated with incident non‐vertebral major osteoporotic fractures (OR = 3.0 [1.4–6.5]). We conclude that defining VF by mABQ is preferred to the use of GSQ for clinical assessments.

Correlation of Computed Tomography Imaging Features With Pain Response in Patients With Spine Metastases After Radiation Therapy

PURPOSE To correlate computed tomography (CT) imaging features of spinal metastases with pain relief after radiotherapy (RT). METHODS AND MATERIALS Thirty-three patients receiving computed tomography (CT)-simulated RT for spinal metastases in an outpatient palliative RT clinic from January 2007 to October 2008 were retrospectively reviewed. Forty spinal metastases were evaluated. Pain response was rated using the International Bone Metastases Consensus Working Party endpoints. Three musculoskeletal radiologists and two orthopaedic surgeons evaluated CT features, including osseous and soft tissue tumor extent, presence of a pathologic fracture, severity of vertebral height loss, and presence of kyphosis. RESULTS The mean patient age was 69 years; 24 were men and 9 were women. The mean worst pain score was 7/10, and the mean total daily oral morphine equivalent was 77.3 mg. Treatment doses included 8 Gy in one fraction (22/33), 20 Gy in five fractions (10/33), and 20 Gy in eight fractions (1/33). The CT imaging appearance of spinal metastases included vertebral body involvement (40/40), pedicle involvement (23/40), and lamina involvement (18/40). Soft tissue component (10/40) and nerve root compression (9/40) were less common. Pathologic fractures existed in 11/40 lesions, with resultant vertebral body height loss in 10/40 and kyphosis in 2/40 lesions. At months 1, 2, and 3 after RT, 18%, 69%, and 70% of patients experienced pain relief. Pain response was observed with various CT imaging features. CONCLUSIONS Pain response after RT did not differ in patients with and without pathologic fracture, kyphosis, or any other CT features related to extent of tumor involvement. All patients with painful spinal metastases may benefit from palliative RT.

Rapid Improvement in Pain and Functional Level in a Patient with Metastatic Renal Cell Carcinoma: A Case Report and Review of the Literature

Renal cell carcinoma (RCC) represents approximately 3% of all adult cancers and is more common in males. Systemic treatment for RCC has improved following the introduction of sunitinib. Bone metastases are present in up to 50% of RCC patients. We report a case of rapid improvement in metastatic bone lesions, recorded by nuclear bone scan, in a male patient receiving localized palliative radiotherapy in addition to systemic sunitinib and zoledronic acid. Concurrently, quality of life and performance status improved dramatically. Although we are unsure of the exact mechanism for such rapid improvement in metastatic bone lesions, the swiftness this improvement deserves reporting.

Tumor Response After Stereotactic Body Radiation Therapy to Nonspine Bone Metastases: An Evaluation of Response Criteria

PURPOSE To evaluate the applicability of the Response Evaluation Criteria in Solid Tumors (RECIST 1.1) and University of Texas MD Anderson (MDA) Cancer Center criteria in the setting of stereotactic body radiation therapy (SBRT) to nonspine bone metastases. METHODS Patients who were treated with SBRT to nonspine bone metastases were identified by retrospective chart review. An independent musculoskeletal radiologist evaluated response to treatment using computed tomography (CT) scans. RESULTS Thirty-three patients were treated to 42 nonspine bone metastases. The most common primary cancer cites were renal cell carcinoma (RCC) (33.3%), lung (24.2%), and prostate (18.2%). Bone metastases were either mainly lytic (57.1%), mainly sclerotic (28.6%), or mixed (14.3%). When lytic and sclerotic lesions were evaluated according to RECIST 1.1, local control (LC) was 83%, 85%, 88%, and 80% for those with CT imaging between months 1 to 3, 4 to 6, 7 to 9, and 10 to 12, respectively. When evaluated by the MDA criteria by density, LC within each time period was slightly greater. Overall LC decreased considerably when evaluated by MDA in terms of size. CONCLUSIONS Consensus definitions of response are required as they have implications on clinical trials and disease management. Without consistent response criteria, outcomes from clinical trials cannot be compared and treatment efficacy remains undetermined.

Immediate Pain Relief and Improved Structural Stability after Percutaneous Vertebroplasty for a Severely Destructive Vertebral Compression Fracture

Approximately 10% to 30% of patients with cancer have metastases to the spine that require treatment. Spinal metastases can cause acute and chronic pain, compression fractures, spinal instability, and neurologic deficits. Vertebral compression fractures can be a significant cause of pain and impaired function. Radiation therapy is the standard treatment for patients with spinal metastases. However, this may not be the optimal treatment by itself for some patients when immediate pain relief is desirable. Percutaneous vertebroplasty is a mildly invasive treatment which involves the injection of cement, polymethylmethacrylate (PMMA) into a diseased vertebral body. We report a patient who presented with a severely destructive lesion and compression fracture at T9 with severe pain and impaired mobility. Percutaneous vertebroplasty provided immediate pain relief and restored structural stability of the diseased vertebra.

Radiological changes on CT after stereotactic body radiation therapy to non-spine bone metastases: a descriptive series

BACKGROUND In recent years, stereotactic body radiation therapy (SBRT) has become increasingly used for the management of non-spine bone metastases. Few studies have examined the radiological changes in bone metastases after treatment with SBRT and there is no consensus about what constitutes radiologic response to therapy. This article describes various changes on CT after SBRT to non-spine bone metastases in eight selected cases. METHODS A retrospective review was conducted for patients treated with SBRT to non-spine bone metastases between November 2011 and April 2014 at Sunnybrook Health Sciences Centre. A musculoskeletal radiologist identified eight illustrative cases of interest and provided a description of the findings. RESULTS Different radiological changes following SBRT were described, including: remineralization of lytic bone metastases, demineralization of sclerotic bone metastases, pathologic fracture, size progression and response in different lesions, as well as lung fibrosis after SBRT to a rib metastasis. CONCLUSIONS We reviewed the radiological images of eight selected cases after SBRT to nonspine bone metastases and a number of characteristic findings were highlighted. We recommend future studies to correlate radiologic changes with clinical outcomes including pain relief, toxicity and long-term local control.

Radiology Research in Quality and Safety: Current Trends and Future Needs

Promoting quality and safety research is now essential for radiology as reimbursement is increasingly tied to measures of quality, patient safety, efficiency, and appropriateness of imaging. This article provides an overview of key features necessary to promote successful quality improvement efforts in radiology. Emphasis is given to current trends and future opportunities for directing research. Establishing and maintaining a culture of safety is paramount to organizations wishing to improve patient care. The correct culture must be in place to support quality initiatives and create accountability for patient care. Focused educational curricula are necessary to teach quality and safety-related skills and behaviors to trainees, staff members, and physicians. The increasingly complex healthcare landscape requires that organizations build effective data infrastructures to support quality and safety research. Incident reporting systems designed specifically for medical imaging will benefit quality improvement initiatives by identifying and learning from system errors, enhancing knowledge about safety, and creating safer systems through the implementation of standardized practices and standards. Finally, validated performance measures must be developed to accurately reflect the value of the care we provide for our patients and referring providers. Common metrics used in radiology are reviewed with focus on current and future opportunities for investigation.

Computed Tomography Evaluation of Density Following Stereotactic Body Radiation Therapy of Nonspine Bone Metastases.

Introduction: Stereotactic body radiation therapy allows for the precise delivery of high-dose radiation to disease sites and is becoming increasingly used to treat nonspine bone metastases. Previous studies have shown that remineralization of lytic bone metastases follows after conventional radiotherapy. The objective of this study was to investigate changes in bone density in nonspine bone metastases following stereotactic body radiation therapy. Methods: A retrospective review was conducted for all patients treated with stereotactic body radiation therapy to nonspine bone metastases between May 2011 and April 2014. A minimum of 1 pretreatment and 1 posttreatment computed tomography scan was required. An independent musculoskeletal radiologist contoured the lesions on the most representative computed tomography slices. Density was measured in Hounsfield units and analyzed using pretreatment and posttreatment ratios. Results: Forty sites were treated (55% lytic, 30% sclerotic, and 15% mixed). The median follow-up duration was 7 months. Lytic osseous metastases from renal cell carcinoma progressed during initial follow-up imaging and then returned to baseline. Of 9 lytic lesions not from renal cell carcinoma, 6 showed an immediate increase in density and 2 remained stable. Six of 7 sclerotic lesions from prostate cancer showed decreased density throughout all follow-ups. Conclusion: Stereotactic body radiation therapy is efficacious in the remineralization of lytic and demineralization of sclerotic nonspine bone metastases.

Symptomatic palliation with radiotherapy in extensive heterotopic ossifications

Heterotopic ossification (HTO) is the dystrophic formation of mature lamellar bone outside the confines of normal osseous tissues. It is frequently a complication which occurs following traumatic insult, both iatrogenic and non-iatrogenic, and neurological compromise. While mild degree of disease is often asymptomatic, significant pain and mobility limitations may result in reduced quality of life in advanced cases. Currently, the commonly accepted management for patients experiencing significant symptomatic HTOs is a combination therapy of surgical excision with prophylactic radiotherapy in the immediate perioperative period. In this article, we present a patient who achieved satisfactory pain relief and improvements in overall quality of life with the sole use of external beam radiation to illustrate the possibility of using radiotherapy alone for symptomatic management of HTO.