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LETTERS TO THE EDITOR
term outcomes of use in 300 patients at a sin-
gle center. Radiology 2015;276(2):588–596.
2. Wollman B, D’Agostino HB, Walus-Wigle JR,
Easter DW, Beale A. Radiologic, endoscopic,
and surgical gastrostomy: an institutional
evaluation and meta-analysis of the literature.
Radiology 1995;197(3):699–704.
3. Power S, Kavanagh LN, Shields MC, et al.
Insertion of balloon retained gastrostomy
buttons: a 5-year retrospective review of 260
patients. Cardiovasc Intervent Radiol 2013;
36(2):484–491.
4. Shaw AS, Ampong MA, Rio A, McClure J,
Leigh PN, Sidhu PS. Entristar skin-level gas-
trostomy tube: primary placement with radio-
logic guidance in patients with amyotrophic lat-
eral sclerosis. Radiology 2004;233(2):392–399.
5. Lewis D, Ampong MA, Rio A, et al. Mush-
room-cage gastrostomy tube placement in
patients with amyotrophic lateral sclerosis: a
5-year experience in 104 patients in a single
institution. Eur Radiol 2009;19(7):1763–1771.
6. Yip D, Vanasco M, Funaki B. Complication
rates and patency of radiologically guided
mushroom gastrostomy, balloon gastros-
tomy, and gastrojejunostomy: a review of
250 procedures. Cardiovasc Intervent Radiol
2004;27(1):3–8.
7. Shaw AS, Ampong MA, Rio A, et al. Sur-
vival of patients with ALS following insti-
tution of enteral feeding is related to pre-
procedure oximetry: a retrospective review
of 98 patients in a single centre. Amyotroph
Lateral Scler Other Motor Neuron Disord
2006;7(1):16–21.
8. Ammar T, Rio A, Ampong MA, Sidhu PS.
Replacement of mushroom cage gastros-
tomy tube using a modified technique to
allow percutaneous replacement with an en-
doscopic tube in patients with amyotrophic
lateral sclerosis. Cardiovasc Intervent Radiol
2010;33(3):590–595.
Response
From
Osman Ahmed, MD,* Danial Jilani,
MPH,† Sujay Sheth, MD,* Maryellen
Giger, PhD,* and Brian Funaki, MD*
Department of Radiology, Univer-
sity of Chicago Medicine, 5841 S
Maryland Ave, MC 2026, Chicago,
IL 60637*
e-mail: osman1423@gmail.com
Wright State University Boonshoft
School of Medicine, Dayton, Ohio†
We thank Dr Sidhu and colleagues for
their interest in our study (1) and agree
Radiology: Volume 278: Number 2—February 2016 n radiology.rsna.org
with many of their points. We would room-retained gastrostomy catheters: long-
like to add the following. First, as they term outcomes of use in 300 patients at a sin-
gle center. Radiology 2015;276(2):588–596.
do, we use a push technique for our pa-
tients with ALS and agree that it has
distinct advantages in this patient pop-
ulation. However, the vast majority of Good Study, Bad Timing
our patients requiring gastrostomy do
From
not have ALS, and in this latter patient
Philipp A. Kaufmann, MD, FESC,
population avoidance of the oropharanx
FSCCT
is unnecessary. In addition, it should be
Department of Nuclear Medicine,
recognized that complete avoidance of
University Hospital Zurich, Ramistr
the oropharanyx is impossible with ei-
100 (NUK D 6), CH-8091 Zurich,
ther technique as a small-bore catheter
Switzerland
must be inserted through the nose or
e-mail: pak@usz.ch
mouth into the stomach for gastric in-
flation in both techniques. Editor:
Second, as incorrectly mentioned,
In the November 2015 issue of Radiol-
the pull technique we employ does
ogy, Dr Brand and colleagues (1) found
not require any “snaring” of a percu-
no influence of cardiac magnetic reso-
taneous guide wire (a maneuver that
nance (MR) imaging on DNA double
may be time consuming and is un-
strand breaks (DSBs) in human blood
necessary). Rather, the mid-body of
lymphocytes 5 minutes after imag-
the stomach is punctured by using an
ing. This finding is apparently at odds
18-gauge hollow-bore needle directed
with a large body of in vitro and in
at the gastroesophageal junction and a
vivo data that documented adverse ef-
Rosen guide wire (Cook, Bloomington,
fects of magnetic fields on DNA integ-
Ind) advanced directly up the esopha-
rity (2–4). Accordingly, the Interna-
gus and out of the mouth. Parentheti-
tional Agency for Research on Cancer
cally, a catheter is used to facilitate this
has classified (extremely low) gradient
process in about 20% of patients; even
fields generated during MR imaging as
in these cases, however, catheteriza-
possible human carcinogen (group 2B)
tion is completed in less than 2–3 mi-
(5). Similarly, the European Parliament
nutes in nearly all patients. Also, only
(6), as well as the International Com-
one T-fastener is deployed with our
mission on Non-Ionizing Radiation Pro-
technique, and it is cut before tube de-
tection (7,8) and the World Health Or-
ployment—which saves time. In fact,
ganization (9), have urgently called for
the entire procedure (skin puncture to
an action in order to evaluate adverse
tube deployment) with the pull tech-
biologic effects of clinical MR imaging.
nique is routinely done in less than 15
Several putative mechanisms by which
minutes in the vast majority of patients.
MR imaging may increase DSB have
We agree with Dr Sidhu and colleagues
been published, with most focusing on
that the true benefit of either technique
impairment of repair mechanisms (eg,
lies in the use of a mushroom-retained
by activating oxidative stress pathways
retention device rather than a balloon
or initiating transcription by interacting
or pigtail catheter and await compara-
with moving electrons in DNA by gen-
tive studies between push and pull tech-
erating repulsive [Lorentz] forces caus-
niques with this type of catheter.
ing chain separation at specific DNA
Disclosures of Conflicts of Interest: O.A. dis- sequences) (10). As opposed to ioniz-
closed no relevant relationships. D.J. disclosed no ing radiation with direct damage to the
relevant relationships. S.S. disclosed no relevant
relationships. M.G. disclosed no relevant relation- DNA, the impairment of repair mecha-
ships. B.F. disclosed no relevant relationships. nisms requires more time before an in-
crease in DSB can be measured. Fiech-
Reference ter et al (11) found an increase in DSB
1. Ahmed O, Jilani D, Sheth S, Giger M, Funaki 1 hour after MR imaging, Simi et al (3)
B. Radiologically guided placement of mush- found persistence up to 24 hours, and
633
LETTERS TO THE EDITOR
Lancellotti et al (12) found a DSB in-
crease 2 days after cardiac MR imaging
that reached a maximum at 1 month.
Dr Brand and colleagues were unable
to find a DSB increase after MR imag-
ing because of their study design; 5 mi-
nutes after exposure to MR imaging is
simply too soon to detect any MR imag-
ing–induced DSB increase, which con-
firms the delay hypothesis.
The criticism that the baseline levels
of 0.05 foci per lymphocyte in the study
by Fiechter et al (11) were too low and
that in previous studies no baseline
DSB levels of less than 0.05 were found
is untenable, as Dr Brand and col-
leagues must have overlooked that this
lies well within the previously observed
range from 0.04 to 0.15 DSB per cell
previously reported—peculiarly by their
own laboratory (13).
Disclosures of Conflicts of Interest: Activities
related to the present article: disclosed no rele-
vant relationships. Activities not related to the
present article: disclosed no relevant relation-
ships. Other relationships: institution has a re-
search contract with GE Healthcare.
References
1. Brand M, Ellmann S, Sommer M, et al. Influ-
ence of cardiac MR imaging on DNA double-
strand breaks in human blood lymphocytes.
Radiology 2015;277(2):406–412.
2. Ivancsits S, Diem E, Jahn O, Rudiger HW.
Intermittent extremely low frequency elec-
tromagnetic fields cause DNA damage in a
dose-dependent way. Int Arch Occup Environ
Health 2003;76(6):431–436.
3. Simi S, Ballardin M, Casella M, et al. Is the
genotoxic effect of magnetic resonance neg-
ligible? Low persistence of micronucleus
frequency in lymphocytes of individuals after
cardiac scan. Mutat Res 2008;645(1-2):39–43.
4. Knuuti J, Saraste A, Kallio M, Minn H. Is
cardiac magnetic resonance imaging causing
DNA damage? Eur Heart J 2013.
5. IARC Working Group on the Evaluation of
Carcinogenic Risks to Humans. Non-ionizing
radiation, Part 1: static and extremely low-
frequency (ELF) electric and magnetic fields.
IARC Monogr Eval Carcinog Risks Hum
2002;80:1–395.
6. Mattsson MO, Auvinen A, Bridges J, Norppa
H, Schütz J. European Parliament and the
Council. Research needs and methodology
to address the remaining knowledge gaps on
the potential health effects of EMF. Scientific
634
Committee on Emerging and Newly Identified
Health Risks (SCENIHR). http://ec.europa.eu/
health/ph_risk/committees/04_scenihr/docs/
scenihr_o_024.pdf. Accessed August 8, 2015.
7. Vecchia P, Hietanen M, Ahlbom A, et al. In-
ternational Commission on Non-Ionizing Ra-
diation Protection (ICNIRP). Guidelines on
limits of exposure to static magnetic fields.
Health Phys 2009;96(4):504–514.
8. Vecchia P, Hietanen M, Ahlbom A, et al. In-
ternational Commission on Non-Ionizing Ra-
diation Protection (ICNIRP). Amendment to
the ICNIRP “Statement on medical magnetic
resonance (MR) procedures: protection of
patients.” Health Phys 2009;97(3):259–261.
9. Belyaev I. Static fields environmental health
criteria no. 232. World Health Organization,
WHO, Geneva, Switzerland. http://www.
who.int/peh-emf/publications/EHC_232_
Static_Fields_full_document.pdf 2006. Ac-
cessed August 8, 2015.
10. Blank M, Goodman R. Electromagnetic initi-
ation of transcription at specific DNA sites. J
Cell Biochem 2001;81(4):689–692.
11. Fiechter M, Stehli J, Fuchs TA, Dougoud
S, Gaemperli O, Kaufmann PA. Impact of
cardiac magnetic resonance imaging on hu-
man lymphocyte DNA integrity. Eur Heart J
2013;34(30):2340–2345.
12.Lancellotti P, Nchimi A, Delierneux C, et al.
Biological effects of cardiac magnetic reso-
nance on human blood cells. Circ Cardiovasc
Imaging 2015;8:e003697.
13.Kuefner MA, Hinkmann FM, Alibek S, et
al. Reduction of x-ray induced DNA double-
strand breaks in blood lymphocytes during
coronary CT angiography using high-pitch
spiral data acquisition with prospective ECG-
triggering. Invest Radiol 2010;45(4):182–187.
Response
From
Michael Brand, MD
Department of Radiology, University
Hospital Erlangen-Nuremberg,
Maximiliansplatz 1, D-91054 Erlan-
gen, Germany
e-mail: michael.brand@uk-erlangen.
de
Dr Kaufmann (co-author of the article
by Fiechter et al [1]) expressed con-
cerns about our study, “Influence of Car-
diac MR Imaging on DNA Double-Strand
Breaks in Human Blood Lymphocytes.”
He noted that we only measured
one time point (5 minutes after MR im-
aging) and mentioned that Fiechter et
radiology.rsna.org
al (1) found an increase in DSB 1 hour
after MR imaging. Unfortunately, this
time point was not mentioned in their
original article (1), so we can only spec-
ulate about this time point. In addition,
Dr Kaufmann noted that other authors,
for example Simi et al (2) and Lancel-
lotti et al (3), reported a DSB increase
from 2 hours until 1 month after MR
imaging, but he does not offer an expla-
nation for the large range in time points
(2). Moreover, there is no explanation
as to why Fiechter et al (1) chose 1 hour
after MR imaging to obtain blood even
though other authors had indicated that
2 hours or 1 month after MR imaging
might be the best time points. Thus, it
is hard to understand his notion that we
have chosen the wrong timing as, ac-
cording to the articles he cited, Fiech-
ter et al (1) chose the wrong timing.
Moreover, the criticism regarding
the baseline DSB levels is out of con-
text. In the study by Fiechter et al (1)
not only the low baseline level but also
the course of DSB levels is questionable
and inconsistent with those from previ-
ous studies. In contrast, our DSB levels
are in agreement with those from the
literature (4–10).
Although it is true that the European
Parliament, the International Commis-
sion on Non-Ionizing Radiation Protec-
tion, and the World Health Organization
have called for an action to evaluate ad-
verse biologic effects of clinical MR im-
aging, this does not mean that they must
conclude that there are negative effects
of MR imaging.
Disclosures of Conflicts of Interest: disclosed
no relevant relationships.
References
1. Fiechter M, Stehli J, Fuchs TA, Dougoud S,
Gaemperli O, Kaufmann PA. Impact of car-
diac magnetic resonance imaging on human
lymphocyte DNA integrity. Eur Heart J
2013;34(30):2340–2345.
2. Simi S, Ballardin M, Casella M, et al. Is the
genotoxic effect of magnetic resonance negli-
gible? Low persistence of micronucleus
frequency in lymphocytes of individuals after
cardiac scan. Mutat Res-Fund Mol M.
2008;645(1-2):39–43.
3. Lancellotti P, Nchimi A, Delierneux C, et al.
Biological effects of cardiac magnetic reso-
n Radiology: Volume 278: Number 2—February 2016
LETTERS TO THE EDITOR
nance on human blood cells. Circ Cardiovasc
Imaging 2015;8:e003697.
4. Schwab SA, Brand M, Schlude IK, et al.
X-ray induced formation of gamma-H2AX
foci after full-field digital mammography
and digital breast-tomosynthesis. PLoS One
2013;8(7):e70660.
5. Rothkamm K, Lobrich M. Evidence for a lack
of DNA double-strand break repair in human
cells exposed to very low x-ray doses. Proc
Natl Acad Sci U S A 2003;100(9):5057–5062.
6. Kuefner MA, Hinkmann FM, Alibek S, et
al. Reduction of x-ray induced DNA double-
strand breaks in blood lymphocytes during
coronary CT angiography using high-pitch
spiral data acquisition with prospective
ECG-triggering. Invest Radiol 2010;45(4):
182–187.
7. Kuefner MA, Grudzenski S, Schwab SA, et
al. DNA double-strand breaks and their re-
pair in blood lymphocytes of patients under-
going angiographic procedures. Invest Radiol
2009;44(8):440–446.
8. Kuefner MA, Grudzenski S, Hamann J, et al.
Effect of CT scan protocols on x-ray-induced
DNA double-strand breaks in blood lympho-
cytes of patients undergoing coronary CT
angiography. Eur Radiol 2010;20(12):2917–
2924.
9. Kuefner MA, Brand M, Ehrlich J, Braga L,
Uder M, Semelka RC. Effect of antioxidants
on x-ray–induced gamma-H2AX foci in hu-
man blood lymphocytes: preliminary obser-
vations. Radiology 2012;264(1):59–67.
10. Brand M, Sommer M, Achenbach S, et al.
X-ray induced DNA double-strand breaks
in coronary CT angiography: comparison
of sequential, low-pitch helical and high-
pitch helical data acquisition. Eur J Radiol
2012;81(3):e357–362.
Who Gets to Decide?
From
Rebecca Smith-Bindman, MD,* Mari-
lyn L. Kwan, PhD,† and Diana L.
Miglioretti, PhD‡
Department of Radiology and Biomed-
ical Imaging, University of Califor-
nia, San Francisco, 350 Parnassus
Ave, Suite 307, San Francisco, CA
94143-0336*
e-mail: rebecca.smith-bindman@
ucsf.edu
Division of Research, Kaiser Perman-
ente Northern California, Oakland
Calif†
Radiology: Volume 278: Number 2—February 2016
Department of Public Health Sci-
ences, University of California Da-
vis School of Medicine, Davis, Calif‡
Editor:
Contrary to the summary by Dr Harvey
and colleagues in the May 2015 issue of
Radiology (1), evidence of carcinogenesis
from radiation in the range of that with
computed tomography (CT) is substan-
tial, and recent analyses of directly ob-
served data among atomic bomb survi-
vors found cancer risks are even higher
than previously thought, not lower (2).
Dr Harvey and colleagues state that ra-
diation in the CT range may even be pro-
tective, citing a study of Taiwanese res-
idents who received low-dose cobalt-60
exposures (3). However, that study found
a significant 20% increased risk of leu-
kemia, a borderline-significant 12% in-
creased risk of breast cancer, and a non-
significant 4% increased risk for all solid
cancers, with a wide confidence interval.
Pearce et al (4) found that children
and adolescents in the United Kingdom
who underwent multiple CT examina-
tions with 50-mGy bone marrow doses
or 60-mGy brain doses—doses we fre-
quently encounter (5)—had triple the
risk of leukemia and brain cancer as chil-
dren exposed to less than 5 mGy. Study
criticisms including imprecise dose
quantification and no unexposed con-
trol subjects reduce statistical power but
do not undermine their results. Reverse
causation is not a legitimate concern as
the results did not change when the au-
thors allowed for a 10-year lag time, and
confounding by indication is unlikely to
affect risk estimates (6,7).
Dr Harvey and colleagues reference
several other small European CT stud-
ies, none of which indicate that radia-
tion is safe. For example, Journy et al
(8) found increased leukemia risk of the
same magnitude as that found by Pearce
et al (4), with wide confidence intervals
owing to a small sample size. Adjust-
ments for confounding by indication had
no meaningful effect on the results (9).
A recent pooled analysis of 308 297
radiation workers monitored across
many countries found an excess relative
risk of leukemia mortality associated
with low-dose exposures (10). The Ca-
n radiology.rsna.org
nadian worker studies with incomplete
dose assessment as noted by Dr Har-
vey and colleagues were not included in
these pooled results.
Patients want to know about radi-
ation risks when deciding about imag-
ing (11,12). Suggesting that radiation
risks are unknown is inconsistent with
the extensive literature on cancer risks
from radiation and the written opinions
of all major medical radiation societies.
Although more data are forthcoming,
including from our current National
Institutes of Health–funded study to
quantify cancer risks of imaging in chil-
dren and adolescents, we urgently need
a meaningful way to share knowledge
on the abundant existing data. Risk-
benefit discussions are rare in radiology
and are seldom initiated by clinicians.
Furthermore, patients tend to be dis-
satisfied with the information provided
(13). Developing tools for shared deci-
sion-making between patients and cli-
nicians about CT, including information
about both risks and benefits, is im-
perative (14,15). Informed consent is
a promising start, and its requirement
would help motivate the development
and widespread use of these tools.
Disclosures of Conflicts of Interest: R.S. Activ-
ities related to the present article: institution re-
ceived a grant from the National Institutes of
Health (R01CA18687). Activities not related to the
present article: disclosed no relevant relationships.
Other relationships: disclosed no relevant relation-
ships. M.L.K. disclosed no relevant relationships.
D.L.M. disclosed no relevant relationships.
References
1. Harvey HB, Brink JA, Frush DP. Informed
consent for radiation risk from CT is unjusti-
fied based on the current scientific evidence.
Radiology 2015;275(2):321–325.
2. Ozasa K, Shimizu Y, Suyama A, et al. Stud-
ies of the mortality of atomic bomb survi-
vors, Report 14, 1950-2003: an overview of
cancer and noncancer diseases. Radiat Res
2012;177(3):229–243.
3. Hwang SL, Hwang JS, Yang YT, et al. Esti-
mates of relative risks for cancers in a popu-
lation after prolonged low-dose-rate radiation
exposure: a follow-up assessment from 1983 to
2005. Radiat Res 2008;170(2):143–148.
4. Pearce MS, Salotti JA, Little MP, et al. Radi-
ation exposure from CT scans in childhood
and subsequent risk of leukemia and brain
635