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Background/Objectives : The objective of this study is to prospectively collect dosimetric and clinical data on vaginal cuff electronic brachytherapy and propose a protocol for the procedure. Methods: Twenty-five patients who had proven endometrial or cervical carcinoma and had undergone radical hysterectomy have been treated with vaginal cuff electronic brachytherapy. Treatment session durations and doses to the targets and the organs at risk have been extracted from the treatment planning software. Patients have been followed up for early side effects for 3 months. Results: Treatment session times ranged from 3.0 to 6.6 min. Mean coverage of the planned treatment volume with 100% of the prescribed dose was 90%, and with 95% of the prescribed dose was 95%. Doses in the bladder were lower than those achieved in previously published studies with a mean D2cc of 4.7 Gy, and doses in the rectum were higher with a mean D2cc of 5.3 Gy. The first-month adverse events included eight G1 and three G2 toxicities, while the events registered on the third month were two G2 vaginal dryness events and one G1 urinary tract obstruction, of which only one patient with vaginal dryness did not respond to local treatment. No local relapses have been detected. Conclusions : Vaginal cuff electronic brachytherapy has demonstrated safety and effectiveness.

Introduction: Breast cancer (BC) survival has improved globally in the past years. Eastern Europe is a region with lack of epidemiological data and traditionally lower BC overall survival (OS). We aimed to investigate the epidemiology of BC in Bulgaria between 2012 and 2022 and the readiness of the state for implementing population based organized screening program., Methods and Materials: This is a retrospective study of 38 576 invasive BC cases registered in Bulgarian National Cancer Registry. We obtained data from publicly available sources - national institutes and regulatory agencies. We report descriptive statistics of distribution of cases and mammography units among the country and the compared survival of patient's groups., Results: 75 % of patients are treated in the 9 biggest cities. They are younger, diagnosed earlier and have significantly better OS than the rest of the patients. Patients over 75 years represent 18.7 % of all. The 211 installed mammography systems can secure the implementation of organized BC screening., Discussion: The survival gap between cities can be due to the limited access to care of older patients living in smaller cities. The model of collaboration between private and state centers can be highly effective in implementing of organized screening since in Bulgaria both can be reimbursed by the National Insurance Fund., Conclusion: Further centralization of care probably would not have such an impact on treatment outcomes as improvement and monitoring the quality of the provided treatment. Organized BC screening in Bulgaria is needed and technically possible step towards improving survival., 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 © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction: Various studies have demonstrated large variations in the annual occupational exposure of medical personnel working in interventional cardiology departments, ranging from 0.1 mSv to exceeding the annual effective occupational dose limit of 20 mSv., Purpose: The purpose of this study was to investigate the 17-year dynamics in the personal dosimetry records of the medical staff in one interventional cardiology department in Bulgaria., Methods: The study was performed between 2007 and 2023 and included 31 interventional cardiologists. For each of them, data from all individual dosimetry control reports were analysed. The number and complexity of interventional procedures were analysed on an annual basis. A total number of 39639 procedures performed over 17 consecutive years were classified and analysed., Results: The results have suggested that when a newly formed team gains clinical experience, the focus shifts towards optimizing radiation exposure to patients, and it has been observed to change from 40 Gy.cm2 in 2009 to 14.8 Gy.cm2 in 2023 for diagnostic and from 146 Gy.cm2 in 2009 to 51.2 Gy.cm2 in 2023 for interventional procedures, and from 19.5 mSv/year under the lead apron in 2012 and 3.7 mSv/year in 2023 for one of the interventional cardiologists among the medical staff. The optimization process in the department has been found to be slow but consistent, starting with the routine application of basic methods to reduce the likelihood of skin injury. Any practical implementation of a methodology or process requires periodic training to raise awareness of the topic and the use of different strategies to put it into practice. Most of the reported values from individual dosimetry monitoring have been found to be in the range below 4 mSv/year, consistent with the summarised results from other studies., Conclusion: The radiation protection awareness program introduced in 2014 has been found to result in between a 2- and 6-fold reduction in individual effective doses for some staff members and a 2-fold reduction in typical patient doses.

Introduction: "Pelvic rib", "pelvic digit (finger)", or "eleventh digit (finger)" is a rare congenital anomaly, in which a finger-like bony structure is present in the soft tissue in the pelvic or abdomen (less common) area., Case Presentation: This case report presents a symptomatic "pelvic digit" discovered in a patient referred to the radiology department after prolonged unilateral hip pain, especially during long walks. To our knowledge, this is the first case report of unilateral pelvic digit occurrence in our region. It is an extremely rare condition that is often discovered incidentally due to the lack of clinical symptoms., Conclusion: To the best of the authors' knowledge, this is the tenth reported case of symptomatic pelvic digit in the literature and four of them have required surgical intervention.

Background: The purpose of this manuscript is to provide an in-depth literature review of the management of endometrial and cervical cancers with electronic brachytherapy., Materials and Methods: An extensive literature search was performed and 9 articles were selected based on preset criteria., Results: The reviewed studies provided dosimetric and clinical results. Patient populations were diverse and prescribed doses varied. When treatment plans were compared to those using cobalt 60 ( 60 Co) and iridium 192 ( 192 Ir) sources researchers found lower or equivalent doses in organs at risk while the doses at the applicator surface were significantly higher for electronic brachytherapy. In the eligible studies, a total of 72 patients received treatment with AxxentXoft vaginal applicator, 29 were treated with the Intrabeam vaginal applicator, and 8 with AxxentXoft cervical applicator., Conclusions: All authors found that electronic brachytherapy was safe and well tolerated as higher mucosal doses did not present as adverse clinical effects. Electronic brachytherapy for gynecological cancers has the potential to achieve equivalent tumor control while minimizing bowel and urinary toxicity thus improving the quality of life. More clinical data is needed to stratify patients who would benefit the most., Competing Interests: Conflict of interest None declared., (© 2023 Greater Poland Cancer Centre.)

Objectives: Constantly increasing number of procedures performed - endovascular or hybrid in patients with aortoiliac occlusive disease during the last decades finds its explanation in the lower morbidity and mortality rates, compared to bypass surgery. The purpose of the current survey was to estimate patients' radiation exposure in aortoiliac segment after endovascular or hybrid revascularization and to study the main factors which have direct contribution., Methods: A retrospective study of 285 procedures conducted with the help of a mobile C-arm system in 223 patients was performed. Procedures were grouped according to criteria such as: type of intervention, vascular access, level of complexity and operating team. Different analyses were performed within the groups and dose values., Results: The median values of kerma-air product (KAP), the number of series and the peak skin dose (PSD) significantly increase with the increasing number of vascular accesses: for one access (16.68 Gy.cm 2 , 6 and 336 mGy), for two (56.93 Gy.cm 2 , 11 and 545 mGy), and for three (102.28 Gy.cm 2 , 15 and 781 mGy). Significant dependence was observed in the case of single access site between the type of access and the dose values: hybrid and retrograde common femoral artery/superficial femoral artery (CFA/SFA) endovascular accesses, 10.06 Gy.cm 2 /301 mGy and 13.23 Gy.cm 2 /318 mGy respectively, in contrast with the contralateral CFA and left brachial access, 33 Gy.cm 2 /421 mGy and 38.33 Gy.cm 2 /448 mGy respectively., Conclusion: The results demonstrate that the most important factors increasing the dose values are number and type of vascular accesses, followed by the combination and number of implanted stents with the complexity of the procedure. The PSD values for a single procedure were between 2 and 12 times lower than those IAEA proposed as trigger levels for radiation-induced erythema. This study shows that trigger levels were not reached even for patients with repeated procedures in the same segment in 1-year period., Advances in Knowledge: The study gives important understanding and clarity on the growing awareness for dose-modifying factors during endovascular and hybrid revascularization of aortoiliac segment.

(1) Background: We aimed to analyze currently available studies with intraoperative radiotherapy (IORT) as a choice of treatment where the Xoft Axxent ® electronic brachytherapy (eBx) system was used as a single-dose irradiation and an exclusive radiotherapy approach at the time of surgery in patients with early breast cancer (EBC). We also compared the results of the systematic review to the Bulgarian experience. (2) Methods and Materials: We performed a systematic review of the studies published before February 2021, which investigate the application of a single-fraction 20 Gy radiation treatment, delivered at the time of lumpectomy in EBC patients with the Xoft Axxent ® eBx System. A systematic search in PubMed, Scopus, and ScienceDirect was performed. The results are reported following the PRISMA guidelines. The criteria on patients' selection for IORT (the additional need for EBRT), cosmetic outcomes, and recurrence rate from the eligible studies are compared to the treatment results in Bulgarian patients. (3) Results: We searched through 1032 results to find 17 eligible studies. There are no published outcomes from randomized trials. When reported, the cosmetic outcomes in most of the studies are defined as excellent. The observed recurrence rate is low (1-5.8%). Still, the number of patients additionally referred to postoperative external breast radiotherapy (EBRT) is up to 31%. Amongst the 20 patients treated in Bulgaria, the cosmetic outcomes are also evaluated as excellent, five of which (25%) are referred for EBRT. Within median follow-up of 39 months, there was one local and one distal recurrence. (4) Conclusions: Current evidence demonstrates the Xoft Axxent ® eBx system as a safe and feasible technique for IORT delivery in EBC patients. There are no randomized controlled trials conducted at this time point to prove its long-term effectiveness. Better patient selection and a reimbursement strategy have to be proposed to extend the application of this technique in Bulgaria.

Background There is lack of guidance on specific CT protocols for imaging patients with coronavirus disease 2019 (COVID-19) pneumonia. Purpose To assess international variations in CT utilization, protocols, and radiation doses in patients with COVID-19 pneumonia. Materials and Methods In this retrospective data collection study, the International Atomic Energy Agency coordinated a survey between May and July 2020 regarding CT utilization, protocols, and radiation doses from 62 health care sites in 34 countries across five continents for CT examinations performed in patients with COVID-19 pneumonia. The questionnaire obtained information on local prevalence, method of diagnosis, most frequent imaging, indications for CT, and specific policies on use of CT in COVID-19 pneumonia. Collected data included general information (patient age, weight, clinical indication), CT equipment (CT make and model, year of installation, number of detector rows), scan protocols (body region, scan phases, tube current and potential), and radiation dose descriptors (CT dose index and dose length product). Descriptive statistics and generalized estimating equations were performed. Results Data from 782 patients (median age, 59 years [interquartile range, 15 years]) from 54 health care sites in 28 countries were evaluated. Less than one-half of the health care sites used CT for initial diagnosis of COVID-19 pneumonia and three-fourths used CT for assessing disease severity. CT dose index varied based on CT vendors (7-11 mGy; P < .001), number of detector rows (8-9 mGy; P < .001), year of CT installation (7-10 mGy; P = .006), and reconstruction techniques (7-10 mGy; P = .03). Multiphase chest CT examinations performed at 20% of sites (11 of 54) were associated with higher dose length product compared with single-phase chest CT examinations performed in 80% of sites (43 of 54) ( P = .008). Conclusion CT use, scan protocols, and radiation doses in patients with coronavirus disease 2019 pneumonia showed wide variation across health care sites within the same and between different countries. Many patients were imaged multiple times and/or with multiphase CT scan protocols. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Lee in this issue.

Purpose: Patients with hematuria and renal colic often undergo CT scanning. The purpose of our study was to assess variations in CT protocols and radiation doses for evaluation of hematuria and urinary stones in 20 countries., Method: The International Atomic Energy Agency (IAEA) surveyed practices in 51 hospitals from 20 countries in the European region according to the IAEA Technical cooperation classification and obtained following information for three CT protocols (urography, urinary stones, and routine abdomen-pelvis CT) for 1276 patients: patient information (weight, clinical indication), scanner information (scan vendor, scanner name, number of detector rows), scan parameters (such as number of phases, scan start and end locations, mA, kV), and radiation dose descriptors (CTDI vol , DLP). Two radiologists assessed the appropriateness of clinical indications and number of scan phases using the ESR Referral Guidelines and ACR Appropriateness Criteria. Descriptive statistics and Student's t tests were performed., Results: Most institutions use 3-6 phase CT urography protocols (80 %, median DLP 1793-3618 mGy.cm) which were associated with 2.4-4.9-fold higher dose compared to 2-phase protocol (20 %, 740 mGy.cm) (p < 0.0001). Likewise, 52 % patients underwent 3-5 phase routine abdomen- pelvis CT (1574-2945 mGy.cm) as opposed to 37 % scanned with a single-phase routine CT (676 mGy.cm). The median DLP for urinary stones CT (516 mGy.cm) were significantly lower than the median DLP for the other two CT protocols (p < 0.0001)., Conclusions: Few institutions (4/13) use low dose CT for urinary stones. There are substantial variations in CT urography and routine abdomen-pelvis CT protocols result in massive radiation doses (up to 2945-3618 mGy.cm)., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Purpose: We present the development and the current state of the MaXIMA Breast Lesions Models Database, which is intended to provide researchers with both segmented and mathematical computer-based breast lesion models with realistic shape., Methods: The database contains various 3D images of breast lesions of irregular shapes, collected from routine patient examinations or dedicated scientific experiments. It also contains images of simulated tumour models. In order to extract the 3D shapes of the breast cancers from patient images, an in-house segmentation algorithm was developed for the analysis of 50 tomosynthesis sets from patients diagnosed with malignant and benign lesions. In addition, computed tomography (CT) scans of three breast mastectomy cases were added, as well as five whole-body CT scans. The segmentation algorithm includes a series of image processing operations and region-growing techniques with minimal interaction from the user, with the purpose of finding and segmenting the areas of the lesion. Mathematically modelled computational breast lesions, also stored in the database, are based on the 3D random walk approach., Results: The MaXIMA Imaging Database currently contains 50 breast cancer models obtained by segmentation of 3D patient breast tomosynthesis images; 8 models obtained by segmentation of whole body and breast cadavers CT images; and 80 models based on a mathematical algorithm. Each record in the database is supported with relevant information. Two applications of the database are highlighted: inserting the lesions into computationally generated breast phantoms and an approach in generating mammography images with variously shaped breast lesion models from the database for evaluation purposes. Both cases demonstrate the implementation of multiple scenarios and of an unlimited number of cases, which can be used for further software modelling and investigation of breast imaging techniques. The created database interface is web-based, user friendly and is intended to be made freely accessible through internet after the completion of the MaXIMA project., Conclusions: The developed database will serve as an imaging data source for researchers, working on breast diagnostic imaging and on improving early breast cancer detection techniques, using existing or newly developed imaging modalities., (Copyright © 2019. Published by Elsevier Ltd.)

Objective: To survey procedures and protocols in paediatric computed tomography (CT) in 40 less resourced countries., Methods: Under a project of the International Atomic Energy Agency, 146 CT facilities in 40 countries of Africa, Asia, Europe and Latin America responded to an electronic survey of CT technology, exposure parameters, CT protocols and doses., Results: Modern MDCT systems are available in 77 % of the facilities surveyed with dedicated paediatric CT protocols available in 94 %. However, protocols for some age groups were unavailable in around 50 % of the facilities surveyed. Indication-based protocols were used in 57 % of facilities. Estimates of radiation dose using CTDI or DLP from standard CT protocols demonstrated wide variation up to a factor of 100. CTDI(vol) values for the head and chest were between two and five times those for an adult at some sites. Sedation and use of shielding were frequently reported; immobilisation was not. Records of exposure factors were kept at 49 % of sites., Conclusion: There is significant potential for improvement in CT practice and protocol use for children in less resourced countries. Dose estimates for young children varied widely. This survey provides critical baseline data for ongoing quality improvement efforts by the IAEA.

Objective: The purpose of this study was to assess the frequency of pediatric CT in 40 less-resourced countries and to determine the level of appropriateness in CT use., Materials and Methods: Data on the increase in the number of CT examinations during 2007 and 2009 and appropriate use of CT examinations were collected, using standard forms, from 146 CT facilities at 126 hospitals., Results: The lowest frequency of pediatric CT examinations in 2009 was in European facilities (4.3%), and frequencies in Asia (12.2%) and Africa (7.8%) were twice as high. Head CT is the most common CT examination in children, amounting to nearly 75% of all pediatric CT examinations. Although regulations in many countries assign radiologists with the main responsibility of deciding whether a radiologic examination should be performed, in fact, radiologists alone were responsible for only 6.3% of situations. Written referral guidelines for imaging were not available in almost one half of the CT facilities. Appropriateness criteria for CT examinations in children did not always follow guidelines set by agencies, in particular, for patients with accidental head trauma, infants with congenital torticollis, children with possible ventriculoperitoneal shunt malfunction, and young children (< 5 years old) with acute sinusitis. In about one third of situations, nonavailability of previous images and records on previously received patient doses have the potential to lead to unnecessary examinations and radiation doses., Conclusion: With increasing use of CT in children and a lack of use of appropriateness criteria, there is a strong need to implement guidelines to avoid unnecessary radiation doses to children.