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AIM: To establish the diagnostic accuracy and adequacy of fine needle aspiration cytology (FNAC) within a regional cancer network, and to determine what service improvements may be required to allow successful implementation of an FNAC-based, 'one-stop' head and neck clinic, as proposed by the current National Institute for Clinical Excellence guidelines. MATERIALS AND METHODS: The Sussex cancer network serves a population of 1,200,000 and contains five hospitals within three acute trusts. In 2004, an audit was undertaken retrospectively to examine the diagnostic adequacy and accuracy of head and neck FNAC across the network. Comparisons were then made with the results of subsequent relevant surgery. For the purposes of the audit, FNAC was subdivided into three main groups: salivary gland, thyroid gland and neck node. As part of the data analysis, we also noted the clinical source of the FNAC and whether it was performed blind or under image guidance. RESULTS: In 2004, 712 FNAC procedures were undertaken in 647 patients, 276 of whom underwent subsequent surgery. Fine needle aspiration cytology was non-diagnostic in 52 per cent of patients in the neck node group, in 50 per cent in the salivary gland group and in 30 per cent in the thyroid group. With these non-diagnostic results removed, statistical analysis was performed on data from those patients who had undergone both FNAC and subsequent surgery. This gave a sensitivity of 89 per cent and a specificity of 57 per cent in the neck node group, a sensitivity of 64 per cent and specificity of 100 per cent in the salivary gland group, and a sensitivity of 62 per cent and specificity of 86 per cent in the thyroid group. Diagnostic problems with FNAC were noted, particularly in the differentiation of reactive nodal hyperplasia from lymphoma and in diagnosing follicular thyroid lesions. Ultrasound guidance was used in 50 per cent of the thyroid FNAC procedures but in only a minority of patients in the neck node and salivary gland groups. CONCLUSION: This audit demonstrated widespread diagnostic difficulties associated with head and neck FNAC in a large patient sample. It is likely that these problems will be mirrored in other cancer networks. In order for one-stop head and neck clinics to succeed, the non-diagnostic rate of FNAC in particular must be minimised. There are strategies to enable this, depending on local resources, including increased access to cytologists or cytology technicians, diagnostic ultrasound, image guidance for FNAC and the use of ultrasound-guided core biopsy. [ABSTRACT FROM AUTHOR]

Ultrasound serves as an essential adjunct to mammography and clinical examination in symptomatic breast evaluation and is the initial imaging modality of choice in some patient groups.In this review the role of ultrasound in the assessment of the symptomatic breast is discussed and examples of a variety of breast pathologies illustrated. [ABSTRACT FROM AUTHOR]

Spindle cell lipoma (SCL) is a rare neoplasm occurring predominantly in male patients between the ages of 45 and 70 years. We present a case of SCL arising in the sternomastoid muscle of a 46 year old male patient, which was completely excised at surgery. (Only 4 cases of SCL have been described within skeletal muscle and SCL has not previously been reported within sternomastoid.) The histological and magnetic resonance (MR) imaging features of this lesion are described and the differential diagnosis is discussed, with particular reference to its potential confusion with liposarcoma. [ABSTRACT FROM AUTHOR]

Aim: To assess the accuracy of ultrasound in characterizing benign and malignant parotid lesions and to review their sonographic features.Materials and Methods: A retrospective analysis of 220 ultrasound examinations was undertaken in 220 patients who presented with palpable parotid lesions over an 11-year period and correlated with the clinico-histopathological findings. The original sonographic diagnosis was compared to the final histopathology and lesions characterized using previously established sonographic criteria.Results: Histopathology results were available for all patients. Two hundred and one patients had focal lesions: 29 carcinomas, 21 lymphomata and 151 benign lesions (including 69 pleomorphic adenomas and 54 Warthin's tumours); 19 patients did not have focal lesions. The initial ultrasound report was indeterminate in 25/201 focal lesions. In the remaining 176 lesions, the sensitivity, specificity, and diagnostic accuracy for malignancy of ultrasound was 91, 93, and 93%, respectively. There were four false-negatives and nine false-positives with a crossover of apparently benign and malignant features. Pleomorphic adenomas and Warthin's tumours were poorly differentiated using ultrasound. Additional impalpable parotid lesions or adenopathy were detected in 44 patients using ultrasound.Conclusion: Ultrasound is a valuable adjunct to clinical examination, accurately differentiating benign from malignant lesions and diagnosing non-focal disease. There is an overlap in features of pleomorphic adenomas and Warthin's tumours and of some benign and malignant lesions. Diagnostic ultrasound should be combined with needle biopsy in most patients to maximize diagnostic yield. [ABSTRACT FROM AUTHOR]

Introduction: Riedel's thyroiditis is a rare inflammatory disease of the thyroid with non-specific and varied presentations. A typical presentation and ultrasound findings are reported in this case., Case Report: A 68-year-old male is referred to Ear, Nose and Throat for a neck lump that varied in size over 2 years. An ultrasound scan identified a suspicious nodule on the left thyroid that was biopsied confirming the diagnosis of Riedel's thyroiditis., Discussion: The aetiology, presentation and management of Riedel's thyroiditis are explored. The use of ultrasound and the utility of other imaging and biochemical tests are discussed., Conclusion: Riedel's thyroiditis is a difficult condition to diagnose due to rarity, varied presentation, with non-specific clinical, biochemical and radiographic findings which often mimic thyroid cancers. Definitive diagnosis of Riedel's thyroiditis requires histological analysis, and while fine-needle aspirations are typically insufficient, diagnostic samples can be taken with ultrasound-guided core biopsies., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article., (© The Author(s) 2024.)

Introduction: Metastatic disease to the submandibular gland is a rare phenomenon with limited information available on related imaging findings., Case Presentation: We report a 59-year-old female who presented with a palpable nodule in the right submandibular gland 6 years after treatment for breast carcinoma. Ultrasound findings were concerning for distant metastatic disease from breast cancer recurrence. The histopathological analysis of the biopsied tissue confirmed infiltration of the right submandibular gland with an adenocarcinoma from a breast primary., Discussion: Metastatic spread to the major salivary glands is relatively uncommon with a predilection to the parotid gland owing to its extensive intraglandular lymphatic system. Conversely, metastasis to the submandibular gland, which lacks intraglandular lymph nodes, is rare. Ultrasound is the optimal first-line imaging modality to aid in the assessment of submandibular gland disease. Malignant lesions often appear hypoechoic with heterogenous internal architecture and ill-defined borders. However, some low-grade malignancies, can have apparently benign features particularly when smaller in size. Where a focal submandibular gland lesion is identified and neoplasm is suspected, the early use of ultrasound-guided core biopsy is recommended to improve diagnostic yield for histological assessment., Conclusion: While submandibular metastasis is rare, clinical assessment, sonographic findings and use of core needle biopsy aid in prompt diagnosis and management., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Aim: To describe a UK-wide re-audit of the 2019 Royal College of Radiologists (RCR) audit evaluating patient-related data and organisational infrastructure in the radiological reporting of vertebral fragility fractures (VFFs) on computed tomography (CT) studies and to assess the impact of a series of RCR interventions, initiated to raise VFF awareness, on reporting practice and outcomes., Materials and Methods: Patient specific and organisational questionnaires largely replicated those utilised in 2019. The patient questionnaire involved retrospective analysis of between 50 and 100 consecutive, non-traumatic CT studies which included the thoracolumbar spine. All RCR radiology audit leads were invited to participate. Data collection commenced from 1 April 2022., Results: Data were supplied by 129/194 (67%) departments. One thousand five hundred and eighty-six of 7,316 patients (21.7%) had a VFF on auditor review. Overall improvements were demonstrated in key initial/provisional reporting results; comment on spine/bone (93.2%, 14.4% improvement, p<0.0002); fracture severity assessment (34.7%, 8.5% improvement, p=0.0007); use of recommended terminology (67.8%, 7.5% improvement, p=0.0034); recommendations for further management (11.7%, 9.1% improvement, p<0.0002)., Conclusions: The 2022 national re-audit confirms improvements in diagnostic performance and practice in VFF reporting. Continuing work is required to build on this improvement and to further embed best practice., (Copyright © 2023. Published by Elsevier Ltd.)

Background: QuADRANT was a research project funded by the European Commission to evaluate clinical audit uptake and implementation across Europe, with an emphasis on clinical audit as mandated within the BSSD (Basic Safety Standards Directive)., Aim: Focusing on the QuADRANT objectives - to obtain an overview of European clinical audit activity; identify good practices, resources, barriers and challenges; provide guidance and recommendations going forwards; identify the potential for European Union action on quality and safety focusing on the field of radiotherapy., Results: A pan-European survey, expert interviews and a literature review conducted within the framework of the QuADRANT project indicated that developments in national clinical audit infrastructure are required. While in radiotherapy, there is a strong tradition and high level of experience of dosimetry audits and well-established practice through the IAEA's QUATRO audits, few countries have a well-established comprehensive clinical audit programme or international/national initiatives on tumour specific clinical audits. Even if sparse, the experience from countries with established system of quality audits can be used as role-models for national professional societies to promote clinical audit implementation. However, resource allocation and national prioritisation of clinical audit are needed in many countries. National and international societies should take the initiative to promote and facilitate training and resources (guidelines, experts, courses) for clinical audits. Enablers used to enhance clinical audit participation are not widely employed. Development of hospital accreditation programmes can facilitate clinical audit uptake. An active and formalised role for patients in clinical audit practice and policy development is recommended. Because there is a persisting variation in European awareness of BSSD clinical audit requirements, work is needed to improve dissemination of information on the legislative requirements relating to clinical audit in the BSSD and in relation to inspection processes. The aim is to ensure these include clinical audit and that they encompass all clinics and specialties involved in medical applications using ionising radiation., Conclusion: QuADRANT provided an overarching view of clinical audit practice in Europe, with all its related aspects. Unfortunately, it showed that the awareness of the BSSD requirements for clinical audit are highly variable. Therefore, there is an urgent need to dedicate efforts towards ensuring that regulatory inspections also incorporate an assessment of clinical audit program(s), affecting all aspects of clinical work and specialties involved in patient exposure to ionising radiation., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: QuADRANT was a study funded by the European Commission to evaluate clinical audit uptake and implementation across Europe, with an emphasis on clinical audit as mandated within the BSSD (Basic Safety Standards Directive)., Aims: QuADRANT objectives-obtain an overview of European clinical audit activity; identify good practices and resources, barriers and challenges; provide guidance and recommendations going forwards; identify the potential for European Union action on quality and safety in the three core project specialties, radiology, radiotherapy and nuclear medicine., Findings and Recommendations: QuADRANT identified that developments in national clinical audit infrastructure are required. National professional societies can be pivotal in improving clinical audit implementation, but resource allocation and national prioritisation of clinical audit are needed in many countries. Lack of staff time and expertise are also barriers. Enablers to enhance clinical audit participation are not widely employed. Development of hospital accreditation programmes can facilitate clinical audit uptake. An active and formalised role for patients in clinical audit practice and policy development is recommended. There is persisting variation in European awareness of BSSD clinical audit requirements. Work is needed to improve dissemination of information on the legislative requirements relating to clinical audit in the BSSD and in relation to inspection processes to ensure these include clinical audit and that they encompass all clinics and specialties involved in medical applications using ionising radiation., Conclusion: QuADRANT provides an important step towards enhancing clinical audit uptake and implementation across Europe and improving patient safety and outcomes., (© 2023. The Author(s).)

Clinical audit is an important quality improvement activity and has significant benefits for patients in terms of enhanced care, safety, experience and outcomes. Clinical audit in support of radiation protection is mandated within the European Council Basic Safety Standards Directive (BSSD), 2013/59/Euratom. The European Society of Radiology (ESR) has recognised clinical audit as an area of particular importance in the delivery of safe and effective health care. The ESR, alongside other European organisations and professional bodies, has developed a range of clinical audit-related initiatives to support European radiology departments in developing a clinical audit infrastructure and fulfilling their legal obligations. However, work by the European Commission, the ESR and other agencies has demonstrated a persisting variability in clinical audit uptake and implementation across Europe and a lack of awareness of the BSSD clinical audit requirements. In recognition of these findings, the European Commission supported the QuADRANT project, led by the ESR and in partnership with ESTRO (European Association of Radiotherapy and Oncology) and EANM (European Association of Nuclear Medicine). QuADRANT was a 30-month project which completed in Summer 2022, aiming to provide an overview of the status of European clinical audit and identifying barriers and challenges to clinical audit uptake and implementation. This paper summarises the current position of European radiological clinical audit and considers the barriers and challenges that exist. Reference is made to the QuADRANT project, and a range of potential solutions are suggested to enhance radiological clinical audit across Europe., (© 2023. The Author(s).)

Objective: Accurate diagnosis of parotid neoplasia is a key to determine the most appropriate patient management choice, including the need for surgery. This review provides an update of the literature on current practice and outcomes of parotid tissue sampling techniques, with an emphasis on ultrasound-guided core biopsy (USCB) and comparison with fine needle aspiration cytology (FNAC)., Methods: A literature review of EMBASE, Medline, PubMed and Google Scholar was conducted., Results: USCB has higher sensitivity, specificity and lower non-diagnostic rates than optimized FNAC. It also has a significantly higher sensitivity for the detection of malignancy. Significant complications post-USCB are uncommon, with only one reported case of tumour seeding and no cases of permanent facial nerve dysfunction. The technique is less operator-dependent than FNAC, with less reported variation in results between institutions., Conclusions: USCB can be considered as the optimum tool of choice for the diagnosis of parotid neoplasia. This would particularly be the case in centres utilizing FNAC with high non-diagnostic rates or reduced diagnostic accuracy when compared to USCB published data, or in centres establishing a new service., Advances in Knowledge: An update of the role and outcomes of USCB in the diagnosis of parotid gland pathologies.Research shows that USCB preforms better than FNAC, in terms of sensitivity and specificity, particularly in the case of malignant neoplasia.Complications following USCB were found to be higher than that of FNAC; however, no long-term major complications following either method have been reported in the literature.

Aims: To evaluate current national imaging practice in myeloma with reference to National Institute for Health and Care Excellence (NICE) guidelines (NG35, 2016) and compare results with an initial survey conducted in 2017 (61 participating sites)., Materials and Methods: All UK radiology departments treating myeloma patients and with a Royal College of Radiologists (RCR) Audit Lead were invited to participate. Data were collected using an online questionnaire. Descriptive statistics were performed., Results: One hundred and fourteen hospitals supplied data (54% return rate). Skeletal survey (SS) remains the most-commonly performed first-line imaging test for suspected/confirmed myeloma or plasmacytoma (39%, 45/114 hospitals), followed by whole-body magnetic resonance imaging (WBMRI) (27%, 31/114) and whole-body computed tomography (WBCT) (19%, 22/114). Integrated positron-emission tomography/CT (PET/CT) was first-line in 14% (16/114). The NICE recommended initial investigation, WBMRI, is currently offered in 27% of surveyed hospitals (<10% in 2017). Ongoing challenges to implementing WBMRI include scanner availability, financial constraints, reporting time, and radiologist training., Conclusion: Despite NICE recommendations regarding WBMRI in diagnosis/follow-up of myeloma, SS (poor sensitivity and specificity) remains the most commonly performed first-line test. Radiologists, haematologists, and patients should continue to emphasise the superiority and benefit of modern and more accurate imaging, such that they are prioritised in clinical service planning., (Copyright © 2021 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Many clinical guidelines for investigating lymphomas advise that surgical excision biopsy (SEB) should be performed for a confident diagnosis. It is increasingly recognized in clinical practice that ultrasound-guided core needle biopsy (USCNB) is a reliable diagnostic technique. We aimed to investigate the diagnostic efficacy of USCNB in head and neck lymphoma. A retrospective analysis of all diagnosed head and neck lymphomas between 2013 and 2018 was performed. Patient records, radiology and histopathology reports along with the biopsy technique: fine needle aspiration cytology (FNAC), USCNB, and SEB used were reviewed. The technique providing diagnosis and leading to initiation of treatment was identified. Two-hundred and thirty patients and 267 biopsy samples were included. A total of 226 patients underwent USCN. In 215 of 226 (95.1%) USCNB patients were fully diagnostic allowing for initiation of oncological treatment; 11 patients required a subsequent SEB to provide diagnosis. In four patients, SEB was the only investigation performed. Of the USCNB total number of procedures (number of patients n=230 is the same coincidentally as the number of USCNB procedures), 215 of 230 (93.5%) were fully diagnostic samples. In the majority of cases, USCNB provided a definitive diagnosis allowing initiation of oncological treatment, avoiding the need for SEB. USCNB should be considered the first-line diagnostic modality in appropriate cases, as it reduces time to initiate treatment, costs and avoids patients having to undergo unnecessary surgery and possible complications., (Crown Copyright © 2020. Published by Elsevier Inc. All rights reserved.)

The World Health Organization (WHO) and numerous expert guidelines for lymphoma diagnosis and subclassification advocate the use of histology from surgical nodal excision biopsy (SEB) over core needle biopsy (CNB) due to perceived higher diagnostic yield. CNB is associated with lower morbidity and is more cost-effective compared to SEB. Furthermore, current practice increasingly demonstrates material obtained from CNB can rapidly diagnose individuals with a clinical suspicion of lymphoma and allow initiation of treatment in the majority of patients. We performed a literature review to assess the suitability of CNB in lymphoma diagnosis given recent advances in radiological and histopathological techniques in obtaining and processing tissue. Additionally, expert international guidelines in lymphoma diagnosis were compared. We found that CNB demonstrated a diagnostic efficacy between 79% and 97% (median 91%) where the diagnostic outcome was conclusive with full lymphoma subclassification. Studies demonstrate that there is a high diagnostic reproducibility amongst haematopathologists (87%-93%) in lymphoma diagnoses with full subtyping from material obtained via CNB. Furthermore, CNB is a safe, rapid and reliable method of obtaining tissue from lymph nodes for histopathological analysis. These procedures are minimally invasive, well-tolerated and should be considered the first-line diagnostic approach in clinical practice in patients with suspected lymphoproliferative disorders., (© 2020 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Objectives: To evaluate organisational reporting infrastructure and patient-related reporting data in the diagnosis of vertebral fragility fractures (VFFs) as demonstrated on computed tomography (CT)., Methods: Organisational and patient-specific questionnaires were developed by consensus between The Royal College of Radiologists, the Royal College of Physicians, and the Royal Osteoporosis Society. The patient-specific component of the audit involved analysis of CT reporting data acquired from 50 consecutive non-traumatic studies including the thoracolumbar spine. Ethical approval for this type of study is not required in the UK. All UK radiology departments with an audit lead (auditor) registered with The Royal College of Radiologists (RCR) were invited to participate in this retrospective audit., Results: In total, 127 out of 202 departments (63%) supplied data to the study, with inclusion of 6357 patients. Overall, 1362/6357 patients (21.4%) had a fracture present on auditor review of the CT imaging. There was a lack of compliance with all audit standards: 79% of reports commented on the vertebrae (target 100%), fracture severity was mentioned in 26.2% (target 100%), the recommended terminology 'vertebral fracture' was used in 60.1% (target 100%), and appropriate onward referral was recommended in 2.6% (target 100%)., Conclusions: The findings from this study should be used to provide impetus to improve the diagnosis and care for patients with osteoporotic VFFs. Solutions are multifactorial, but radiologist and local osteoporosis/fracture liaison service engagement is fundamental, combined with necessary development of electronic report notification systems and expansion of supporting fracture services., Key Points: • Early detection and diagnosis of vertebral fragility fractures (VFFs) significantly reduce patient morbidity and mortality. This study describes the results of a retrospective UK-wide audit evaluating current radiology reporting practice in the opportunistic diagnosis of VFFs as demonstrated on computed tomography (CT) studies including the spine. • Key audit standards included comment made on bone integrity in primary report (target 100%), comment made on severity of fractures (90%), report used recommended terminology 'fracture' (100%), and report made appropriate recommendations for referral/further assessment (100%). The audit results demonstrated a lack of compliance with all audit standards; lack of compliance was most marked in the use of recommended terminology (achieved 60.3%), in relation to comment on fracture severity (achieved 26.2%) and for recommendation for referral/further assessment (achieved 2.6%). • Solutions are challenging and multifactorial but the opportunity exists for all radiologists to examine their practice and directly improve patient care.

Aim: A national audit reviewing compliance of imaging departments with the Royal College of Radiologist (RCR) standards for cancer multidisciplinary team meetings (MDTMs)., Materials and Methods: The audit consisted of a generic and subspecialty component completed for breast, colorectal, and lung cancer MDTMs., Results: The study achieved the highest response from a RCR national audit with 145/191 (76%) hospitals responding. Compliance with the RCR standards was suboptimal, particularly relating to MDTM attendance, documentation, and reviewing MDTM imaging. Comprehensive radiology MDTM attendance occurred in 52-65%, a supplementary report denoting staging/treatment plans happened in 15-26%, and late additions were discussed frequently without prior review of imaging (44-77%). Contributing factors maybe 13% of radiologists had no programmed activity for MDTMs in their job plan and a perceived negative impact of increasing MDTM referrals (51%). Adjuncts to improve MDTM workload, such as treatment pathways/algorithms (breast/colorectal 54%) and pro-forma (43-50%), were poorly implemented. Discrepancies with the original imaging report highlighted at MDTMs were well documented (92-94%) and frequently presented at discrepancy meetings (70-81%). Learning from involvement in MDTM was well communicated with 76-84% providing peer feedback., Conclusions: Radiologists are unable to comprehensively attain the RCR MDTM standards on providing and documenting a specialist opinion on the imaging. Increasing referrals to the MDTM appears the predominant factor and differentiating complex cases that benefit from MDTM discussion from those that can be managed via treatment pathways is required. Improved utilisation of pre-MDTMs/pro-forma and information technology in MDTMs may further aid radiologists to provide consistent high-quality contribution towards MDTMs., (Crown Copyright © 2020. Published by Elsevier Ltd. All rights reserved.)

Aim: To evaluate the provision of imaging in severely injured patients and com pliance with national guidelines., Materials and Methods: Two data collection tools were sent to all Royal College of Radiologist audit leads in radiology departments with an emergency department throughout the UK. The first focused on configuration of radiology departments, number of patients scanned for major trauma and service configuration for major trauma. The second focused on reporting times for 30 patients scanned for major trauma., Results: Eighty-five out of 191 (45%) eligible departments responded: 16 (19%) from major trauma centres, 52 (61%) from trauma units and 17 (20%) from other hospitals with an emergency department. Data were collected for 2,161 scans: 450 from major trauma centres, 1,400 from trauma units and 311 from emergency departments. Seven hundred and eighty-four (36%) scans were performed in hours and 1361 (63%) out of hours. Two hundred and forty (11%) scans had a primary survey report documented, of which 53 (22%) were unavailable to clinicians after 20 minutes. Time to final consultant report was within 1 hour for 1,033 (48%) scans and within 2 hours for an additional 540 (25%) scans. 34/85 (40%) departments have registrars first on call for major trauma who report scans out of hours and have a consultant final report the next day., Conclusions: This study highlights significant deficiencies in care and imaging of severely injured patients within major trauma centres and trauma units. Infrastructure and staffing have been underfunded and under resourced to meet rapidly changing best practice requirements in the management of major trauma., (Copyright © 2019 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Competing Interests: Competing interests The BMJ has judged that there are no disqualifying financial ties to commercial companies. The authors declare the following other interests: none. Further details of The BMJ policy on financial interests is here: https://www.bmj.com/about-bmj/resources-authors/forms-policies-and-checklists/declaration-competing-interests

Ultrasound-guided wire localization (USGWL) was originally developed for the removal of impalpable breast lesions. More recently, USGWL has been described in head and neck surgical practice and it has a number of applications in this field, with the potential to guide surgical exploration and the benefits of reducing operative time and morbidity. This technical note describes the use of preoperative USGWL to facilitate the removal of an impalpable neck node. A review of the current literature relating to the present applications of this technique in head and neck surgery is reported, highlighting its advantages and disadvantages., (Crown Copyright © 2018. Published by Elsevier Ltd. All rights reserved.)

Competing Interests: Competing interests: We have read and understood the BMJ policy on declaration of interests and declare no competing interests.