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Dresen RC, Kusters M, Daniels-Gooszen AW, Cappendijk VC, Nieuwenhuijzen GAP, Kessels AGH, de Bruïne AP, Beets GL, Rutten HJT, Beets-Tan RGH. Absence of tumor invasion into pelvic structures in locally recurrent rectal cancer: prediction with preoperative MR imaging. Radiology 2010; 256:143-50. [PMID: 20574091 DOI: 10.1148/radiol.10090725] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE To retrospectively assess the accuracy of preoperative magnetic resonance (MR) imaging for identification of tumor invasion into pelvic structures in patients with locally recurrent rectal cancer scheduled to undergo curative resection. MATERIALS AND METHODS The institutional review board approved this study, and informed consent was waived because of the retrospective nature of the study. Preoperative MR images in 40 consecutive patients with locally recurrent rectal cancer scheduled to undergo curative treatment between October 2003 and November 2006 were analyzed retrospectively. Four observers with different levels of experience in reading pelvic MR images assessed tumor invasion into the following structures: bladder, uterus or seminal vesicles, vagina or prostate, left and right pelvic walls, and sacrum. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated, and a receiver operating characteristic curve was constructed. Surgical and/or histopathologic findings were used as the reference standard. Interobserver agreement was measured by using kappa statistics. RESULTS Preoperative MR imaging was accurate for the prediction of tumor invasion into structures with negative predictive values of 93%-100% and areas under receiver operating characteristic curves of 0.79-1.00 for all structures and observers. Positive predictive values were 53%-100%. Disease was overstaged in 11 (observer 1), 22 (observer 2), 10 (observer 3), and nine (observer 4) structures and was understaged in nine (observer 3) and two (observer 4) structures. Assessment failures were mainly because of misinterpretation of diffuse fibrosis, especially at the pelvic side walls. Interobserver agreement ranged between 0.64 and 0.99 for experienced observers. CONCLUSION Preoperative MR imaging is accurate for the prediction of absence of tumor invasion into pelvic structures. MR imaging may be useful as a preoperative road map for surgical procedure and may thus increase chances of complete resection. Interpretation of diffuse fibrosis remains difficult.
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Affiliation(s)
- Raphaëla C Dresen
- Department of Radiology, Maastricht University Medical Center, Postbus 5800, Maastricht, the Netherlands
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Fiocchi F, Iotti V, Ligabue G, Pecchi A, Luppi G, Bagni B, Rivasi F, Torricelli P. Contrast-enhanced MRI and PET-CT in the evaluation of patients with suspected local recurrence of rectal carcinoma. Radiol Med 2010; 115:906-19. [PMID: 20574705 DOI: 10.1007/s11547-010-0558-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2009] [Accepted: 09/03/2009] [Indexed: 12/19/2022]
Abstract
PURPOSE This study aimed to evaluate the role of contrast-enhanced magnetic resonance imaging (MRI) and positron emission tomography-computed tomography (PET-CT) in the assessment of local recurrence of rectal cancer. MATERIALS AND METHODS Among 200 patients scheduled for CT follow-up, 60 (48 low risk; 12 high risk) were selected due to CT findings suspicious for or suggestive of local recurrence. Patients underwent contrast-enhanced MRI and PET-CT within 2 weeks. Biopsy was considered the gold standard in 39 cases and follow-up at 6 and 12 months in the remaining 21. RESULTS Local recurrence was confirmed by histology in 15 cases (7 low risk; 8 high risk) and was excluded in 21 cases by long-term follow-up and in 24 by histology. Sensitivity, specificity, positive and negative predictive value and accuracy were 86.7%, 68.9%, 48.1%, 93.9% and 73.3% for contrast-enhanced MRI and 93.3%, 68.9%, 50%, 96.9% and 75% for PET-CT. CONCLUSIONS Contrast-enhanced MRI and PET-CT can help in the detection of local recurrence of rectal cancer, even though their roles in early detection remains debatable, as the value of these techniques in current surveillance protocols is still to be defined.
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Affiliation(s)
- F Fiocchi
- Department of Radiology, University of Modena and Reggio Emilia, Via del Pozzo 71, 41100 Modena, Italy.
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Bellomi M, Travaini LL. Imaging as a surveillance tool in rectal cancer. Expert Rev Med Devices 2010; 7:99-112. [PMID: 20021242 DOI: 10.1586/erd.09.63] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Despite advances in diagnosis and treatment, half of patients with treated rectal cancer will die owing to recurrent disease. There is no evidence of benefit on survival from an intensive surveillance program, even if presymptomatic recurrent disease is detected. The aim of this article is to review the results described for the different imaging techniques in diagnosing rectal cancer recurrence in different sites and to discuss their relative clinical impact. The sensitivity of imaging techniques is related to the performance of the machines and the site being examined. Computed tomography is the most used technique owing to its availability, speed, panoramic images and ease of use, while MRI of the pelvis and the liver produces the highest resolution, sensitivity and specificity in these anatomical areas. Owing to its high cost, [(18)F] fluorodeoxyglucose-PET should be used as a third-level examination, a 'problem-solving' method when the site of recurrence is unknown or to rule out other possible sites of recurrence before a second surgery, and, finally, because it offers the possibility to investigate the whole body. The follow-up must be designed for individual patients, taking into account a number of factors. In the near future, whole-body imaging, probably by MRI, that is free from radiation will become the method of choice for screening for recurrent disease.
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Affiliation(s)
- Massimo Bellomi
- Department of Radiology and School of Medicine, University of Milano, European Institute of Oncology, Via Ripamonti 435, 20141 Milan, Italy.
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55
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Multimodality imaging of usual and unusual sites of metastasis which occur after definitive therapy for rectal cancer. Clin Imaging 2010; 34:100-8. [DOI: 10.1016/j.clinimag.2007.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2007] [Accepted: 12/22/2007] [Indexed: 11/21/2022]
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Hoeffel C, Marcus C, Arrivé L, Bouché O, Tubiana J. [Postoperative imaging after colorectal surgery]. ACTA ACUST UNITED AC 2009; 90:954-68. [PMID: 19752833 DOI: 10.1016/s0221-0363(09)73234-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Surgery for the treatment of colorectal diseases has been evolving rapidly recently. In addition to classical surgical procedures (colectomy, abdominoperineal resection), new surgical procedures include coloproctectomy with creation of an ileoanal anastomosis and ileal pouch, pelvic reconstructions (omentoplasty, placement of myocutaneous flaps) and creation of different colic anastomoses after anterior rectal resection. Even if computed tomography and fluoroscopic contrast examinations are still commonly used to assess postoperative changes and complications, especially infections, pelvic magnetic resonance imaging is useful to depict postoperative changes, detect complications such as fistulas and tumor recurrence in patients who have undergone surgery for primary or recurrent rectal disease. The main surgical techniques, their respective indications and postsurgical imaging features will be discussed. The main complications and imaging work-up will also be reviewed.
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Affiliation(s)
- C Hoeffel
- Pôle d'Imagerie, Service de Radiologie, CHU de Reims, Hôpital Robert-Debré, 51092 Reims, France.
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Sun L, Guan YS, Pan WM, Luo ZM, Wei JH, Zhao L, Wu H. Clinical value of 18F-FDG PET/CT in assessing suspicious relapse after rectal cancer resection. World J Gastrointest Oncol 2009; 1:55-61. [PMID: 21160775 PMCID: PMC2999093 DOI: 10.4251/wjgo.v1.i1.55] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2008] [Revised: 02/17/2009] [Accepted: 02/24/2009] [Indexed: 02/05/2023] Open
Abstract
AIM: To evaluate the value of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) in the restaging of resected rectal cancer.
METHODS: From January 2007 to Sep 2008, 21 patients who had undergone curative surgery resection for rectal carcinoma with suspicious relapse in conventional imaging or clinical findings were retrospectively enrolled in our study. The patients underwent 28 PET/CT scans (two patients had two scans, one patient had three and one had four scans). Locoregional recurrences and/or distant metastases were confirmed by histological analysis or clinical and imaging follow-up.
RESULTS: Final diagnosis was confirmed by histopathological diagnosis in 12 patients (57.1%) and by clinical and imaging follow-up in nine patients (42.9%). Eight patients had extrapelvic metastases with no evidence of pelvic recurrence. Seven patients had both pelvic recurrence and extrapelvic metastases, and two patients had pelvic recurrence only. 18F-FDG PET/CT was negative in two patients and positive in 19 patients. 18F-FDG PET/CT was true positive in 17 patients and false positive in two. The accuracy of 18F-FDG PET/CT was 90.5%, negative predictive value was 100%, and positive predictive value was 89.5%. Five patients with perirectal recurrence underwent 18F-FDG PET/CT image guided tissue core biopsy. 18F-FDG PET/CT also guided surgical resection of pulmonary metastases in three patients and monitored the response to salvage chemotherapy and/or radiotherapy in four patients.
CONCLUSION: 18F-FDG PET/CT is useful for evaluating suspicious locoregional recurrence and distant metastases in the restaging of rectal cancer after curative resection.
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Affiliation(s)
- Long Sun
- Long Sun, Wei-Min Pan, Zuo-Ming Luo, Ji-Hong Wei, Long Zhao, Hua Wu, Minnan PET Center and Department of Nuclear Medicine, the First Hospital of Xiamen University, Xiamen 316003, Fujian Province, China
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58
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Valentini V, Aristei C, Glimelius B, Minsky BD, Beets-Tan R, Borras JM, Haustermans K, Maingon P, Overgaard J, Pahlman L, Quirke P, Schmoll HJ, Sebag-Montefiore D, Taylor I, Van Cutsem E, Van de Velde C, Cellini N, Latini P. Multidisciplinary Rectal Cancer Management: 2nd European Rectal Cancer Consensus Conference (EURECA-CC2). Radiother Oncol 2009; 92:148-63. [PMID: 19595467 DOI: 10.1016/j.radonc.2009.06.027] [Citation(s) in RCA: 222] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2009] [Revised: 06/11/2009] [Accepted: 06/27/2009] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE During the first decade of the 21st century a number of important European randomized studies were published. In order to help shape clinical practice based on best scientific evidence from the literature, the International Conference on 'Multidisciplinary Rectal Cancer Treatment: Looking for an European Consensus' (EURECA-CC2) was organized in Italy under the endorsement of European Society of Medical Oncology (ESMO), European Society of Surgical Oncology (ESSO), and European Society of Therapeutic Radiation Oncology (ESTRO). METHODS Consensus was achieved using the Delphi method. The document was available to all Committee members as a web-based document customized for the consensus process. Eight chapters were identified: epidemiology, diagnostics, pathology, surgery, radiotherapy and chemotherapy, treatment toxicity and quality of life, follow-up, and research questions. Each chapter was subdivided by a topic, and a series of statements were developed. Each member commented and voted, sentence by sentence thrice. Sentences upon which an agreement was not reached after voting round # 2 were openly debated during a Consensus Conference in Perugia (Italy) from 11 December to 13 December 2008. A hand-held televoting system collected the opinions of both the Committee members and the audience after each debate. The Executive Committee scored percentage consensus based on three categories: "large consensus", "moderate consensus", and "minimum consensus". RESULTS The total number of the voted sentences was 207. Of the 207, 86% achieved large consensus, 13% achieved moderate consensus, and only 3 (1%) resulted in minimum consensus. No statement was disagreed by more than 50% of the members. All chapters were voted on by at least 75% of the members, and the majority was voted on by >85%. CONCLUSIONS This Consensus Conference represents an expertise opinion process that may help shape future programs, investigational protocols, and guidelines for staging and treatment of rectal cancer throughout Europe.
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Affiliation(s)
- Vincenzo Valentini
- Cattedra di Radioterapia, Università Cattolica del Sacro Cuore, Policlinico Universitario A. Gemelli, largo Gemelli 8, Rome, Italy.
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McMahon CJ, Smith MP. Magnetic resonance imaging in locoregional staging of rectal adenocarcinoma. Semin Ultrasound CT MR 2009; 29:433-53. [PMID: 19166041 DOI: 10.1053/j.sult.2008.10.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
A comprehensive overview of the current status of magnetic resonance imaging (MRI) in the locoregional assessment and management of rectal adenocarcinoma is presented. Staging systems for rectal cancer and treatment strategies in its management are discussed to give the reader the context that shapes MRI acquisition techniques and interpretation. Findings on MRI are detailed and their accuracy reviewed based on currently available evidence. Optimization of MRI acquisition and relevant pelvic anatomy are reviewed. A detailed description of our approach in interpreting MRI for locoregional staging of rectal cancer is given and future directions are also introduced.
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Affiliation(s)
- Colm J McMahon
- Department of Radiology, Beth israel Deaconess Medical Center, Boston, MA 02215, USA
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Baumann T, Ludwig U, Pache G, Fautz HP, Kotter E, Langer M, Schaefer O. Continuously moving table MRI with sliding multislice for rectal cancer staging: image quality and lesion detection. Eur J Radiol 2009; 73:579-87. [PMID: 19179029 DOI: 10.1016/j.ejrad.2008.12.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2008] [Revised: 10/04/2008] [Accepted: 12/10/2008] [Indexed: 12/27/2022]
Abstract
PURPOSE To determine image quality and lesion detection of sliding multislice (SMS), a recently developed moving table MRI technique, in patients with rectal cancer. MATERIALS AND METHODS Twenty-seven paired SMS (Avanto, Siemens Medical Solutions) and MDCT (Sensation 64, Siemens Medical Solutions) examinations of abdomen and pelvis were performed in patients with rectal cancer and compared for detection of liver, lymph node and bone metastases by two independent observers. A contrast-enhanced, fat saturated 2D gradient echo sequence (TE, 2.0 ms; TR, 102 ms; slice, 5 mm) was acquired with SMS and a standard contrast-enhanced protocol (100 ml @ 2.5 ml/s; slice, 5 mm) was used for abdominal MDCT. Standard of reference consisted of a consensus evaluation of SMS, MDCT, and all available follow-up examinations after a period of 6 months. Artifact burden and image quality of SMS was assessed in comparison to stationary gradient echo sequences obtained in an age-matched group of 27 patients. RESULTS Whereas SMS achieved a mean quality score of 3.65 (scale, 0-4) for the liver, representing very good diagnostic properties, strong breathing artifacts in the intestinal region were observed in 19 cases by both observers. The retroperitoneum still achieved a mean quality score of 3.52, although breathing artifacts were noted in 12 and 15 cases (observers 1 and 2, respectively). The sensitivities of SMS to detect hepatic metastases were 91.2% and 94.1% for both observers, respectively, compared to 98.5%/98.5% for MDCT. The sensitivities for lymph node metastases were 87.5%/81.3% for SMS compared to 78.1%/81.3% for MDCT. The sensitivities for bone metastases were 91.7%/100% for SMS compared to 8.3%/16.7% for MDCT. CONCLUSION With slightly reduced image quality in the intestinal region, SMS exhibits equal detection of lymph node and liver metastases compared to MDCT. SMS MRI proved to be superior to MDCT in detection of bone metastases.
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Affiliation(s)
- Tobias Baumann
- Department of Diagnostic Radiology, University Hospital Freiburg, Freiburg, Germany.
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Lucić MA, Miucin-Vukadinović IS, Lucić SM, Koprivek KM, Spirovski M, Kozarski D, Saranović D. [Newer techniques in diagnostic imaging of colorectal carcinoma]. ACTA CHIRURGICA IUGOSLAVICA 2009; 56:113-119. [PMID: 20420006 DOI: 10.2298/aci0904113l] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
A wide spectrum of nowadays availible radiological and imaging methods in the diagnostic evaluation of patients with colorectal cancer enabled not only the improvement of primary colorectal malignancy detection, precise staging, regional involvement and metastatic spread assessment, but also the posttherapeutical estimation and follow-up. Having in mind that the exact diagnostic assessment of colorectal carcinoma by use of different imaging modalities still raises a lots of contradictories, in this report we have tried to present the possibilities of newer imaging techniques in the diagnostic evaluation of the patients with colorectal cancer.
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Affiliation(s)
- M A Lucić
- Centar za imidzing dijagnostiku, Institut za onkologiju Vojvodine, Sremska Kamenica
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Pinilla I, Rodríguez-Vigil B, Gómez-León N. Integrated FDG PET/CT: Utility and Applications in Clinical Oncology. Clin Med Oncol 2008; 2:181-98. [PMID: 21892279 PMCID: PMC3161686 DOI: 10.4137/cmo.s504] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Accurate diagnosis and staging are essential for an optimal management of cancer patients. Positron emision tomography with 2-deoxy-2-fluorine-18-fluoro-D-glucose (18FDG-PET) and, more recently, 18FDG-PET/computed tomography (18FDG-PET/CT) have emerged as powerful imaging tools in oncology, because of the valuable functional information they provide. The combined acquisition of PET and CT has synergistic advantages over its isolated constituents and minimizes their limitations. It decreases examination times by 25%–40%, leads to a higher patient throughput and unificates two imaging procedures in a single session. There is evidence that 18FDG-PET/CT is a more accurate test than either of its components for the evaluation of various tumors. It is a particularly valuable tool for detection of recurrence, especially in asymptomatic patients with rising tumor markers and those with negative or equivocal findings on conventional imaging tests. Yet, there are some limitations and areas of uncertainty, mainly regarding the lack of specificity of the 18FDG uptake and the variable 18FDG avidity of some cancers. This article reviews the advantages, limitations and main applications of 18FDG-PET/CT in oncology, with especial emphasis on lung cancer, colorectal cancer, lymphomas, melanoma and head and neck cancers.
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63
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Soyka JD, Veit-Haibach P, Strobel K, Breitenstein S, Tschopp A, Mende KA, Lago MP, Hany TF. Staging Pathways in Recurrent Colorectal Carcinoma: Is Contrast-Enhanced 18F-FDG PET/CT the Diagnostic Tool of Choice? J Nucl Med 2008; 49:354-61. [DOI: 10.2967/jnumed.107.048249] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
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Denecke T, Rühl R, Hildebrandt B, Stelter L, Grieser C, Stiepani H, Werk M, Podrabsky P, Plotkin M, Amthauer H, Ricke J, Lopez Hänninen E. Planning transarterial radioembolization of colorectal liver metastases with Yttrium 90 microspheres: evaluation of a sequential diagnostic approach using radiologic and nuclear medicine imaging techniques. Eur Radiol 2008; 18:892-902. [PMID: 18175122 DOI: 10.1007/s00330-007-0836-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2007] [Revised: 10/22/2007] [Accepted: 11/26/2007] [Indexed: 12/20/2022]
Abstract
The purpose of the study was to establish a diagnostic approach to the preparation of patients with colorectal liver metastases considered for transarterial radioembolization (RE). Twenty-two patients sequentially underwent computed tomography (CT; thorax/abdomen), magnetic resonance imaging (MRI; liver; hepatocyte-specific contrast), positron emission tomography (PET/PET-CT; F18-fluoro-desoxy-glucose), and angiography with perfusion scintigraphy [planar imaging; tomography with integrated CT (SPECT-CT)]. The algorithm was continued when no contraindication or alternative treatment option was found. The impact of each test on the therapy decision and RE management was recorded. Patient evaluation using CT revealed contraindications for RE in 4/22 patients (18%). Of the remaining 18 patients, 2 were excluded and 3 were assigned to locally ablative treatment based on MRI and PET results (28%). The remaining 13 patients entered the planning algorithm: SPECT-CT revealed gastrointestinal tracer accumulations in 4 (31%) patients [SPECT, 2 (15%)], making a modified application necessary. In five patients (38%), planar scintigraphy revealed relevant hepatopulmonary shunting. Therapy was finally administered to all 13 patients without therapy-related pulmonary or gastrointestinal morbidity. Each part of the diagnostic algorithm showed a relevant impact on patient management. The sequential approach appears to be suitable and keeps the number of unnecessary treatments and therapy risks to a minimum.
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Affiliation(s)
- Timm Denecke
- Klinik für Strahlenheilkunde, Bereiche Radiologie und Nuklearmedizin, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany.
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Fugazzola C, Iosca S. Imaging of colorectal cancer: Introduction. Surg Oncol 2007; 16 Suppl 1:S47-8. [DOI: 10.1016/j.suronc.2007.10.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Miles K, Burkill G. Colorectal cancer: imaging surveillance following resection of primary tumour. Cancer Imaging 2007; 7 Spec No A:S143-9. [PMID: 17921088 PMCID: PMC2727969 DOI: 10.1102/1470-7330.2007.9011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Most patients with colorectal cancer undergo treatment with curative intent and subsequently enter a surveillance programme. The primary aim of surveillance is to identify patients with disease relapse at a resectable stage. However, the identification of local recurrence and metachronous carcinoma are also important aspects of follow up. Patients under observation may be referred for imaging either because regular imaging forms part of the surveillance strategy, or because tumour relapse is suggested by the development of new symptoms or a rise in tumour markers. This paper reviews the use of new and existing imaging techniques during surveillance following resection of primary colorectal cancer. The use of imaging for this surveillance is an application of cancer imaging that is supported by evidence-based clinical guidelines. Computed tomography provides the mainstay modality on grounds of good overall diagnostic performance combined with high availability and low cost. Improvements in survival with more aggressive follow up and treatment are likely to demand more accurate imaging techniques in the future.
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Affiliation(s)
- Ken Miles
- Brighton & Sussex Medical School, Brighton, UK.
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