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Radionuclide imaging of the lymphatic system has a major role in the management of two main patient groups. First, pre-operative lymphoscintigraphy is a highly accurate method of sentinel node localization and can help guide minimally invasive surgery in a variety of tumour groups. Second, lymphoscintigraphy can play a pivotal role in assessing the cause of extremity swelling. This is the first of two pictorial essays on radionuclide imaging of the lymphatic system and will focus on sentinel node imaging in malignant melanoma. Regional nodal sampling is routinely performed in an increasing number of tumour groups and is well established in malignant melanoma and breast carcinoma. Careful attention to technical performance and image interpretation is essential to maximize the clinical utility of the test. This article provides a pictorial review of the interpretative pearls and pitfalls of sentinel node lymphoscintigraphy in malignant melanoma patients.

BACKGROUND: This study aimed to quantify the variation in oropharyngeal squamous cell carcinoma gross tumour volume (GTV) delineation between CT, MR and FDG PET-CT imaging.METHODS: A prospective, single centre, pilot study was undertaken where 11 patients with locally advanced oropharyngeal cancers (2 tonsil, 9 base of tongue primaries) underwent pre-treatment, contrast enhanced, FDG PET-CT and MR imaging, all performed in a radiotherapy treatment mask. CT, MR and CT-MR GTVs were contoured by 5 clinicians (2 radiologists and 3 radiation oncologists). A semi-automated segmentation algorithm was used to contour PET GTVs. Volume and positional analyses were undertaken, accounting for inter-observer variation, using linear mixed effects models and contour comparison metrics respectively.RESULTS: Significant differences in mean GTV volume were found between CT (11.9 cm(3)) and CT-MR (14.1 cm(3)), p CONCLUSIONS: The use of different imaging modalities produced significantly different GTVs, with no single imaging technique encompassing all potential GTV regions. The use of MR reduced inter-observer variability. These data suggest delineation based on multimodality imaging has the potential to improve accuracy of GTV definition.TRIAL REGISTRATION: ISRCTN Registry: ISRCTN34165059 . Registered 2nd February 2015.

Background and purpose To assess the accuracy of gross tumour volume (GTV) delineation for head and neck squamous cell carcinoma (HNSCC) using a diagnostic position MRI (MRI-D) deformably registered to the planning CT (pCT), by comparison with a dedicated planning position MRI (MRI-RT). Material and methods Fourteen patients with HNSCC underwent a T1-weighted MRI-D and MRI-RT. A reference GTV was defined as that delineated on MRI-RT rigidly registered to pCT. GTVs were delineated on: MRI-D and then registered to pCT by deformable image registration over the whole image (DIR-whole); MRI-D and then registered to pCT with rigid registration over a region of interest defined as GTV+3cm (Rigid-ROI); and on the pCT alone. These were compared using positional metrics to the reference. Results GTVs delineated on MRI-D followed by DIR-whole were significantly more accurate than those delineated on CT alone. The mean Dice Similarity Coefficient was 0.6 and 0.72 for pCT and DIR-whole respectively. Use of MRI-D with Rigid-ROI provided no advantage over CT-only delineation. Conclusions Contouring on MRI-RT rigidly registered to pCT should be considered as the gold standard for HNSCC. In radiotherapy centres lacking a dedicated MRI-RT, the use of an MRI-D with DIR-whole offers a significant advantage for the accuracy of GTV delineation over contouring on pCT alone.

The identification of robust prognostic and predictive biomarkers would transform the ability to implement an individualised approach to radiotherapy. In this regard, there has been a surge of interest in the use of functional imaging to assess key underlying biological processes within tumours and their response to therapy. Importantly, functional imaging biomarkers hold the potential to evaluate tumour heterogeneity/biology both spatially and temporally. An ever-increasing range of functional imaging techniques is now available primarily involving positron emission tomography and magnetic resonance imaging. Small-scale studies across multiple tumour types have consistently been able to correlate changes in functional imaging parameters during radiotherapy with disease outcomes. Considerable challenges remain before the implementation of functional imaging biomarkers into routine clinical practice, including the inherent temporal variability of biological processes within tumours, reproducibility of imaging, determination of optimal imaging technique/combinations, timing during treatment and design of appropriate validation studies.

The digital revolution in radiology continues to advance rapidly. There are a number of interesting developments within radiology informatics which may have a significant impact on education and training of radiologists in the near future. These include extended functionality of handheld computers, web-based skill and knowledge assessment, standardization of radiological procedural training using simulated or virtual patients, worldwide videoconferencing via high-quality health networks such as Internet2 and global collaboration of radiological educational resources via comprehensive, multi-national databases such as the medical imaging resource centre initiative of the Radiological Society of North America. This article will explore the role of e-learning in radiology, highlight a number of useful web-based applications in this area, and explain how the current and future technological advances might best be incorporated into radiological training.

Multiple endocrine neoplasia (MEN) is characterized by the occurrence of two or more tumors that may be associated with hyperfunction and malignancy. MEN is caused by genetic defects, and two major types, MEN 1 and MEN 2, are recognized. Each type is characterized by the development of tumors within specific endocrine organs. A multidisciplinary approach involving cooperation between endocrinologists, surgeons, oncologists, and radiologists is pivotal for optimizing patient treatment. Imaging plays a vital role in the diagnosis and management of the disease. To contribute effectively, however, the radiologist must understand the range of anatomic and functional imaging modalities used in the assessment of endocrine disorders. In addition, knowledge of the optimal techniques for evaluating the pituitary, thyroid, parathyroid, pancreatic, adrenal, and foregut carcinoid tumors that occur in these MEN syndromes is essential. Finally, an understanding of the spectrum of disease and of the manifestations of each component is crucial for accurate detection, staging, and surveillance in this diverse patient group.

Radiologists are collectors of interesting films for teaching purposes or for use in presentations and publications. Traditionally, hard copies of films have been stored in an organized fashion, usually in a filing cabinet or film library. This system has inherent limitations, such as the physical space required. Many of the shortcomings can be circumvented by development of an electronic teaching file. Whereas the implementation of an institutional radiological digital image database can require significant developmental effort and programming expertise, there are a number of web-based solutions which are freely available and can be relatively easily employed to establish a contemporary electronic image library. This article will review the various options and discuss the process of developing a digital image database.

The disorder usuallypresents with chronic localized back pain often ofseveral months’ duration. We report an unusualcase in which a non-obese person, without any ofthe above risk factors, presented acutely withsevere back pain following a lumbar puncture forsuspected subarachnoid haemorrhage. The symp-toms were subsequently found to be due to spinalepidural lipomatosis. A brief review of the relevantliterature is also presented.

Introduction: The accuracy of response assessment positron emission tomography (PET)-computed tomography (CT) following radiotherapy with or without chemotherapy for laryngeal/hypopharyngeal squamous cell carcinoma is uncertain. Methods: In all, 35 patients with laryngeal or hypopharyngeal squamous cell carcinoma who were treated between 2009 and 2014 with (chemo)radiotherapy were identified. The accuracy of response assessment PET-CT was made by correlation with clinical follow-up and pathological findings. Results: Of the 35 patients, 20 (57%) had an overall complete metabolic response. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for response assessment [18Fluorine]-fluoro-2-deoxy-d-glucose (FDG) PET-CT for primary and nodal sites, respectively, were 100%, 73%, 46%, and 100% and 83%, 95%, 83%, and 95%. Conclusions: Response assessment FDG PET-CT following (chemo)radiotherapy for laryngeal and hypopharyngeal carcinomas has a high NPV for both primary site and lymph nodes and can be used to guide treatment decisions. The PPV of residual FDG uptake at the primary tumour site is limited and requires examination and biopsy confirmation.

TO THE EDITOR: We read with great interest the recent article by Marcus et al. ([1][1]). The objective of this retrospective study on 214 patients with head and neck squamous cell carcinoma was to validate qualitative interpretation criteria for 18F-FDG PET/CT assessment of response after

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Thymoma is an uncommon tumour, which is often asymptomatic and may be detected coincidentally on cross-sectional imaging performed for other reasons. We report a case of thymoma detected on myocardial scintigraphy performed for suspected coronary artery disease. Extracardiac pathology may be suggested by abnormal non-cardiac tracer uptake on myocardial scintigraphy. An awareness of the potential causes of this is essential to allow potentially life threatening non-cardiac disorders to be recognized and treated promptly.

The authors present a case of a 16-year-old female diagnosed with rectal adenocarcinoma 10 years after receiving cranio-spinal radiotherapy for a cerebellar medulloblastoma. While the risk of a second malignancy is recognised to be increased in children previously treated with radiotherapy, rectal adenocarcinoma is a rare presentation. A child presenting with symptoms of weight loss and a change in bowel habit in a patient who has previously received radiotherapy should alert practitioners to the possibility of a colorectal malignancy.

This is the fifth in the series of short reviews of internet-based radiological learning resources and will focus on gastrointestinal (GI) and hepatobiliary radiology. Below are details of a few of the higher quality resources currently available. Most of the sites cater for medical students and trainee or non-specialist radiologists, but may be also be of interest to specialists, especially for use in teaching. Hyperlinks are available in the electronic version of this article and were all active at the time of going to press (May 2006).

Patients with squamous cell carcinomas (SCCs) of the head and neck are increasingly treated nonsurgically. Imaging plays a critical role in helping define the targets for radiation therapy, especially intensity-modulated radiation therapy, in which the dose gradients are steep. Anatomic imaging with conventional modalities, particularly computed tomography (CT), has been used in patients with head and neck SCCs, but this approach has limitations. Functional imaging techniques, including positron emission tomography (PET) combined with CT or magnetic resonance (MR) imaging, offer complementary information and can be used noninvasively to assess a range of biomarkers in patients with head and neck SCCs, including hypoxia, cell proliferation and apoptosis, and epidermal growth factor receptor status. These biologic markers can be monitored before, during, and after treatment to improve patient selection for specific therapeutic strategies, guide adaptation of therapy, and potentially facilitate more accurate assessment of disease response. This article discusses the practical aspects of integrating functional imaging into head-and-neck radiation therapy planning and reviews the potential of molecular imaging biomarkers for response assessment and therapy adaptation. The uses of PET tracers for imaging cellular processes such as metabolism, proliferation, hypoxia, and cell membrane synthesis are explored, and applications for MR techniques such as dynamic contrast material-enhanced imaging, diffusion-weighted imaging, blood oxygenation level-dependent imaging, and MR spectroscopy are reviewed. The potential of integrated PET/CT perfusion imaging and hybrid PET/MR imaging also is highlighted. These developments may allow more individualized treatment planning in patients with head and neck SCCs in the emerging era of personalized medicine.

Objectives: To assess the impact on clinical management of introducing 18F-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET)-computed tomography (CT) in to the work-up of patients with primary and recurrent biliary malignancy. Methods: Consecutive patients with primary biliary tumours undergoing FDG PET-CT at a single large tertiary referral centre between November 2007 and September 2010 were retrospectively analysed. Findings on FDG PET-CT compared with CT/magnetic resonance imaging (MRI) and impact on subsequent patient management were evaluated. Impact was divided into: (1) major—detection of occult disease or characterisation of indeterminate lesion(s) on CT/MRI; (2) minor—confirmation of suspected metastases seen on CT/MRI; (3) no impact. Results: One hundred and eleven patients underwent 118 FDG PET-CT scans, including 30 with suspected gallbladder carcinoma and 81 with cholangiocarcinoma. Eighty-nine scans were performed for initial staging, five for restaging following neoadjuvant chemotherapy and 24 for suspected disease recurrence. In 33 cases (28 %), FDG PET-CT had a major impact on subsequent patient management (39 % gallbladder carcinoma, 26 % intrahepatic cholangiocarcinoma and 21 % extrahepatic cholangiocarcinoma). FDG PET-CT had a minor impact in 20 cases (17 %) and no impact in 65 cases (55 %). Conclusions: By detecting occult metastatic disease and characterising indeterminate lesions, FDG PET-CT can have a major influence on clinical decision-making in primary and recurrent biliary malignancy.

Objectives To assess the clinical impact of 18F-fluorodeoxyglucose positron emission tomography-computed tomography (FDG PET-CT) compared with contrast-enhanced computed tomography (CECT) in patients referred via the Specialist Skin Cancer Multidisciplinary Team (SSMDT) with recurrent stage III/IV malignant melanoma (MM). Methods Forty-five patients were referred for further evaluation with FDG PET-CT. Findings on FDG PET-CT were compared with prior CECT and the clinical impact on subsequent management decisions was determined retrospectively. A major clinical impact was defined as a change in treatment plan resulting from identification of additional sites of disease or by characterisation of indeterminate findings on prior imaging. A minor impact was defined as confirmation of known sites of disease as identified on prior CECT. Results Fifty-one PET-CT examinations were performed. FDG PET-CT had a major clinical impact in 21 cases (41.2 %), of which 18 examinations were performed in patients with proven or suspected stage IV MM. FDG PET-CT had a minor impact in 23 cases (45.1 %), and there were five false-positive cases (9.8 %) and two false-negative cases (3.9 %). Conclusion FDG PET-CT is an effective tool in recurrent stage III/IV MM with a significant clinical impact on management decisions in patients who are appropriately referred via the highly specialised forum of the SSMDT. Key Points • FDG PET-CT is an effective tool in recurrent stage III/IV malignant melanoma. • FDG PET-CT has a significant clinical impact on management decisions. • Effective use of FDG PET-CT is via referral from the Specialist Skin Cancer Multidisciplinary Team.

The aim of this study was to assess variation of qualitative and quantitative PET/CT image quality parameters with acquisition time, injection activity and body mass for a representative group of adults undergoing whole-body PET/CT imaging. PET scan data from sixty patients were reconstructed with a scan time of 1, 2 and 3 min/bed position. These images were visually scored and three quantitative parameters were calculated: noise equivalent counts per axial length (NECpatient), noise equivalent count density (NECdensity) and liver signal to noise ratio (liver SNR). The ability of the three quantitative parameters to discriminate qualitative image quality was assessed using ROC analysis. The quantitative parameters were shown to discriminate images of good/excellent quality from those of poorer image quality with a high degree of accuracy (ROC area >0.9); further, NECpatient had significantly higher discrimination than either NECdensity or liver SNR (ROC area = 0.97). NECpatient, NECdensity and liver SNR all have high discrimination for qualitatively assessed PET image quality. NECpatient in particular is an effective objective indicator of patient image quality, which will help to assess and standardise scan protocols for purposes such as multi-centre research trials.

Paroxysmal nocturnal hemoglobinuria is a rare acquired stem cell disorder characterized by intravascular hemolysis, aplasia and an increased risk of thrombosis. We describe a patient under treatment with the anti-complement antibody eculizumab who developed pancytopenia, requiring blood transfusions, due to massive splenomegaly. The patient underwent two separate splenic embolizations, which reduced the size of the spleen and improved his blood count to the point that blood transfusions were no longer necessary. Splenic embolization was chosen over splenectomy due to the potential postoperative complications of splenectomy, especially that of thrombosis.

The aim of this study was to assess the accuracy of recombinant thyroid-stimulating hormone (rTSH)-stimulated 2-(18-fluoride)-flu-2-deoxy-D-glucose ((18)F-FDG) positron emission tomography (PET)-CT in detecting recurrence in patients with differentiated thyroid cancer.Consecutive (18)F-FDG PET-CT scans performed with rTSH stimulation between 2007 and 2010 in patients with a history of papillary or follicular thyroid carcinoma were reviewed. PET-CT findings were correlated with thyroglobulin levels, and histological, clinical and radiological follow-up.58 rTSH PET-CT scans were performed in 47 patients with a previous thyroidectomy and radioiodine ablation. The only indication for PET-CT was a raised thyroglobulin level in 46 of 58 scans, with the remainder for characterisation of equivocal radiology or staging. 25 (43%) of PET-CT scans were positive for recurrent disease. Histological correlation was available for 21 (36%) scans. The overall sensitivity, specificity, positive predictive value and negative predictive value were 69%, 76%, 72% and 73%, respectively. Median unstimulated thyroglobulin in true-positive scans was 33 µg l(-1) and 2.2 µg l(-1) in the remainder (p=0.12). 4 of 35 (11%) patients with unstimulated thyroglobulin levels10 µg l(-1) had true-positive scans. Median stimulated thyroglobulin in true-positive scans was 320 µg l(-1), and 10 µg l(-1) in the remainder (p=0.046), with no positive scans with a stimulated thyroglobulin8 µg l(-1). PET-CT directly influenced patient management in 17/58 (29%) scans.rTSH PET-CT is a useful imaging technique for detecting disease recurrence in patients with iodine-resistant differentiated thyroid cancer. Low stimulated thyroglobulin levels are potentially useful in identifying patients unlikely to benefit from a PET-CT scan.

Recent treatment advances now allow a realistic chance of cure in selected patients with metastatic colorectal carcinoma (CRC). Accurate pre-treatment staging is crucial to ensure appropriate management by identification of patients with more advanced disease who will not benefit from surgery. (18)Fluorine 2-fluoro-2-deoxy-D-glucose positron emission tomography-computed tomography (PET-CT) has a firmly established role in staging, restaging, and recurrence detection of a range of tumors. This article will review the role of PET-CT in patients with CRC with a particular emphasis on optimizing the technique in patients with potentially operable metastatic disease.

Aims To analyse the diagnostic accuracy of delayed response assessment 2-[ 18 F]-fluoro-2-deoxy- d- glucose (FDG) positron-emission tomography–computed tomography (PET-CT) following (chemo)radiation for locally advanced head and neck squamous cell carcinoma (HNSCC). Material and methods Forty-four consecutive patients who underwent a baseline and response assessment using FDG PET-CT for HNSCC following (chemo)radiation between August 2008 and April 2011 were identified retrospectively. Clinicopathological findings and serial clinical follow-up provided the reference standard. Results Median follow-up was 14 months (range 5–43 months). Response assessment FDG PET-CT was performed at 16.8 weeks (inter-quartile range 15.8–18.6 weeks). Thirty-one out of 44 (70%) response assessment examinations showed a complete metabolic response. Seven out of 40 (18%) assessable primary tumours were positive. Eight out of 41 (20%) patients with pre-treatment nodal disease had equivocal or positive FDG uptake at response assessment. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for primary disease and nodal disease were 100, 89, 43, 100, and 100%, and 92, 63, and 100%, respectively. Seven patients had residual FDG-negative soft tissue detectable on the unenhanced CT component of the response assessment images; all remained disease free after clinical observation. Distant metastases were detected on response assessment FDG PET-CT in four out of the 44 patients (10%). Conclusion The diagnostic accuracy of response assessment with FDG PET-CT performed at approximately 16 weeks post-(chemo)radiotherapy is good. The very high NPV of a complete metabolic response can be used to guide management decisions. Although the PPV is limited for local residual disease, FDG PET-CT is a powerful screening tool for the detection of interim metastatic disease.

Background: Riedel’s thyroiditis is characterised by chronic inflammatory invasive fibrosclerosis of the thyroid gland, surrounding structures, and extrathyroidal fibrosis. We present a case of Riedel’s thyroiditis associated with nodular fibrosis of the lungs and liver. Case: A 40-year-old woman presented with a 3-month history of neck swelling, difficulty swallowing and breathlessness on exertion. Core biopsy of the goitre revealed dense fibrous tissue with mixed chronic inflammatory cells. A staging computed tomography scan revealed a large thyroid mass encasing the oesophagus and compressing the trachea, multiple bilateral pulmonary nodules with no evidence of lymphadenopathy, and multiple suspicious nodular lesions in the liver. A thorascopic biopsy of a lung lesion in its entirety revealed a hyalinising lung lesion with no evidence of malignancy. Following the introduction of levothyroxine replacement, symptomatic improvement occurred in parallel with improvements in imaging. Conclusion: To our knowledge, this is the first description of Riedel’s thyroiditis presenting with nodular extrathyroidal fibrosis, and which showed resolution following institution of levothyroxine.

Introduction. To determine the value of a FDG-PET-CT scan in patients with locally advanced head and neck squamous cell carcinoma (HNSCC) prior to chemoradiotherapy. Materials and Methods. Consecutive patients with stage III or IV HNSCC who had undergone a staging FDG-PET-CT scan prior to chemoradiotherapy between August 2008 and April 2011 were included. Clinical details and conventional imaging (CT and/or MRI) were, retrospectively, reviewed, a TNM stage was assigned, and levels of cervical lymph node involvement were documented. This process was repeated with the addition of FDG-PET-CT. Radiotherapy plans were reviewed for patients with an alteration identified on TNM staging and/or nodal level identification with FDG-PET-CT and potential alterations in radiotherapy planning were documented. Results. 55 patients were included in the analysis. FDG-PET-CT altered the TNM stage in 17/55 (31%) of patients, upstaging disease in 11 (20%) and downstaging in 6 (11%); distant metastases were identified by FDG-PET-CT in 1 (2%) patient. FDG-PET-CT altered the lymph node levels identified in 22 patients (40%), upclassifying disease in 16 (29%) and downclassifying in 6 (11%). Radiotherapy plans were judged retrospectively to have been altered by FDG-PET-CT in 10 patients (18%). Conclusions. The use of FDG-PET-CT potentially impacts upon both treatment decisions and radiotherapy planning.

Neuroendocrine tumours (NETs) are rare, heterogeneous, and often hormonally active neoplasms. Nuclear medicine (NM) imaging using single photon- and positron-emitting radiopharmaceuticals allows sensitive and highly specific molecular imaging of NETs, complementary to anatomy-based techniques, such as computed tomography (CT) and magnetic resonance imaging (MRI). Somatostatin-receptor scintigraphy is a whole-body imaging technique widely used for diagnosis, staging and restaging of NETs. The increasing availability of hybrid single-photon emission CT (SPECT)/CT cameras now offers superior accuracy for localization and functional characterization of NETs compared to traditional planar and SPECT imaging. The potential role of positron-emission tomography (PET) tracers in the functional imaging of NETs is also being increasingly recognized. In addition to 2-[ 18 F]-fluoro-2-deoxy-d-glucose (FDG), newer positron-emitting radiopharmaceuticals such as 18 F-dihydroxyphenylalanine (DOPA) and 68 Ga-1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid (DOTA) peptides, show promise for the future. This article will summarize the role of current and emerging radiopharmaceuticals in NM imaging of this rare but important group of tumours.

Defining the target for head and neck radiotherapy is a critical issue with the introduction of steep dose gradients associated with intensity-modulated radiotherapy. Tumour delineation inaccuracies are a major source of error in radiotherapy planning. The integration of 18-fluoride fluorodeoxyglucose positron emission tomography ((18)FDG-PET) and magnetic resonance imaging directly into the radiotherapy planning process has the potential to greatly improve target identification/selection and delineation. This raises a range of new issues surrounding image co-registration, delineation methodology and the use of functional data and treatment adaptation. This overview will discuss the practical aspects of integrating (18)FDG-PET and magnetic resonance imaging into head and neck radiotherapy planning.

1778 www.thelancet.com May 22, 2010 a unique means of collecting relevant maternal mortality data), the main contributor to maternal mortality is indirect causes in the UK, hypertensive disorders in the Netherlands, and haemorrhage in France. Although thromboembolism con stitutes an important issue in pregnancy, it is important to keep in mind the actual pattern of causes of maternal mortality, in order to prioritise prevention strategies.

Integrated positron emission tomography/CT (PET/CT) with 2-[18F]fluoro-2-deoxy-d-glucose (FDG) is a hybrid imaging modality which has recently become established in the staging, restaging and therapy response assessment of oncology patients. FDG PET/CT has several recognised applications in colorectal cancer (CRC) imaging including preoperative evaluation of apparently limited metastatic disease, detection of disease recurrence, clarification of equivocal lesions at initial staging, investigation of unexplained rising tumour markers, and incidental detection of occult primary colonic tumours. With a constantly advancing body of evidence and increasing availability, applications of PET/CT in CRC are likely to emerge in therapy response assessment, radiotherapy planning, use of novel tracers and ‘one-stop’ imaging techniques such as iodinated contrast-enhanced PET/CT. With the use of illustrative clinical examples, this article reviews the utility of FDG PET/CT in the management of CRC, discussing its role and limitations in the multimodality imaging of these patients.

Hybrid imaging with combined positron emission tomography/computed tomography (PET/CT) plays an important role in the staging and management of a wide variety of solid tumours. However, its use in the evaluation of musculoskeletal malignancy has not yet entered routine clinical practice. Cross-sectional imaging with magnetic resonance imaging (MR) and computed tomography have well-established roles but there is increasing evidence for the selective use of PET/CT in the management of these patients. The aims of this article are to review the current evidence and clinical applications of PET/CT in primary musculoskeletal tumours and discuss potential future developments using novel PET tracers and integrated PET/MR.

Integrated positron-emission tomography/computed tomography (PET/CT) with 2-[ 18 F]-fluoro-2-deoxy- d- glucose (FDG) has revolutionized oncological imaging in recent years and now has a firmly established role in a variety of tumour types. There have been simultaneous step-wise advances in scanner technology, which are yet to be exploited to their full potential in clinical practice. This article will review these technological developments and explore how refinements in imaging protocols can further improve the accuracy and efficacy of PET/CT in oncology. The promises, and limitations, of emerging oncological applications of FDG PET/CT in radiotherapy planning and therapy response assessment will be explored. Potential future developments, including the use of FDG PET probes in oncological surgery, advanced data analysis techniques, and the prospect of integrated PET/magnetic resonance imaging (PET/MRI) will be highlighted.

The emergence of hybrid imaging, combining anatomical computed tomography (CT) and functional scintigraphic imaging has increased the armoury of techniques available to image disease. Single photon emission computed tomography/CT (SPECT/CT) is a dual modality technique which increases the sensitivity and specificity of existing radionuclide imaging and helps characterise equivocal lesions detected by other imaging methods. In addition to the many established clinical applications for SPECT/CT, there are new clinical uses emerging in a spectrum of benign and malignant diseases. In this article, we will discuss the established and emerging uses of hybrid SPECT/CT and illustrate the incremental value of the technique in a variety of clinical applications.

To the Editors: An essential role of the lung cancer multidisciplinary team (MDT) is to provide an accurate and prompt diagnosis enabling resection of malignant disease where appropriate, while minimising the risk of unnecessary surgical intervention. Since 2005, 18F-deoxy-d-glucose positron emission tomography–computed tomography (18FDG PET-CT) has been recommended for all patients with potentially radically treatable disease as part of the routine lung cancer staging process 1. The Leeds Teaching Hospital (Leeds, UK) lung cancer MDT is a regional centre with an approximate workload of 500 patients with lung cancer per year. Within the lung cancer MDT, concern was raised regarding a series of patients referred for surgical resection who had a nonmalignant diagnosis at lung resection. It was decided to audit patients referred for surgical resection to determine the frequency of a benign diagnosis at resection. Standard practice within the lung cancer MDT …

Thyroid nodules may be coincidentally detected as a result of neck imaging, and most are benign; the authors discuss how best to decide which nodules are most likely to be malignant and require further evaluation

This article will specifically deal with preparing for consultant interviews in clinical radiology by providing a list of carefully selected resources comprising of training courses and internet sites available for trainee radiologists nearing the end of their training. It will also be of use to established consultant radiologists seeking a new post, those applying for consultant positions in other specialties, and doctors applying for more junior positions in radiology. Hyperlinks are available in the electronic version of this article.

Positron-emission tomography-computed tomography (PET/CT) is rapidly being integrated into the imaging pathways of several different tumour types, most frequently using the glucose analogue 2- [(18)F]-fluoro-2-deoxy-D-glucose (FDG). Integrated FDG-PET/CT combines functional and anatomical imaging to improve sensitivity and specificity of tumour detection. The aim of this article is to review the established, emerging, and future roles of FDG-PET/CT in the management of patients with colorectal cancer (CRC).

To retrospectively evaluate the clinical impact of FDG PET-CT on the management pathway of patients with lung cancer.One hundred and sixty-one patients with suspected lung cancer undergoing FDG PET-CT during the study period were analyzed. Before PET-CT, lung cancer MDT recorded scan indication, conventional clinical stage, and proposed treatment plan. The accuracy of integrated PET-CT compared with stand alone CT in preoperative staging of lung cancer was evaluated with pathological staging used as the reference standard. The effect of PET-CT on the subsequent management of patients was also evaluated.The agreement between CT and integrated PET-CT in preoperative staging of lung cancer was significant (p0.001). In 16 (10%) patients PET-CT excluded tumour as there was no FDG uptake. PET-CT revealed occult metastasis in 25 (16%) patients. It was also a better overall predictor for T status (64% vs. 58%) and N status (78% vs. 65%). For N staging PET-CT was more accurate for N1 (82% vs. 72%) and N2 (85% vs. 80%) disease. Regression analyses suggested that PET-CT was a better predictor of overall TNM staging for lung cancer. FDG PET scanning changed or influenced management decisions in 66 (41%) patients with lung cancer. Changes in TNM staging following PET-CT were significant predictors (p=0.02) in making a decision to abandon thoracotomies.Addition of PET-CT to comprehensive evaluation of lung cancer can have significant clinical impact. There is marked improvement in staging the disease. Patients were frequently spared unnecessary treatment, and management was more appropriately targeted. PET permits reduction in the number of thoracotomies performed for non-resectable disease with predicted reduction in the morbidity rate and cost associated with unnecessary interventions.

A 38-year-old woman with known von Hippel-Lindau syndrome underwent In-111 pentetreotide (OctreoScan) scintigraphy to evaluate a suspected pancreatic neuroendocrine tumor. The patient had undergone surgical resection of a left adrenal pheochromocytoma and a large right cerebellar hemangioblastoma several years previously. Although there was no evidence for recurrence of pheochromocytoma and no uptake within the pancreatic lesion, there was focal tracer accumulation within the left cerebellar hemisphere. MR imaging of the brain confirmed the presence of recurrent hemangioblastoma in the left cerebellum.