ECR Today 2011 Daily news from Europe’s leading imaging congress
MONDAY, MARCH 7, 2011
ECR 2012 President Iran holds out New ESR President Inside relishes the prospect hand of friendship reflects on what Today of next year’s congress to Europe lies ahead See page 3 See page 6 See page 27 Sports imaging requires open mind, anatomical know-how and great care over modality choice
By Philip Ward
Sports imaging is playing an increasing role in confirming a provisional diagnosis, detecting other conditions, planning and monitoring treatment, and reassuring patients that they can return safely to their activity and there is no significant injury, ECR delegates learned at Sunday morning’s musculoskeletal refresher course.
It is important to consider not only the mecha- nism and cause of the injury but also the asso- ciated features, said session moderator Dr. Gina Allen, radiologist and sports physician from the Oxford Soft Tissue Injury Clinic in Carlo Martinoli from Genoa, Italy. Gina Allen from Oxford, United Kingdom. Üstün Aydıngöz from Ankara, Turkey. the U.K. Among the questions to ask are: Is the athletes’ technique correct? Has their tech- nique developed as they’ve grown? Are they getting the right diet? Are they taking addi- a different altitude, or started playing sport on injury. This places great demands on image understood, but radiologists must make sure Opening Ceremony tional substances, such as drugs? Have they a different all-weather surface. These factors quality and the examiner’s skills,” said Marti- they look at the myotendinous junctions and had previous injuries? Are they overtraining? must be taken into account, she advised. noli, stressing that MRI is more sensitive and avoid putting too much pressure on the fascial What is the psychology behind the injury? reliable immediately after trauma, but then planes, he recommended. Are they presenting because they don’t want Allen said ultrasound is now a core subject in an ultrasound examination can be performed to compete? sports medicine training in the U.K., and port- several hours later. “An in-depth knowledge of muscle anatomy able scanners have become the ‘stethoscope’ of and the systematic scanning technique of “Imaging is just one key element of the proc- the sports physician. However, the modality has Muscle strains are not the result of muscle aponeuroses and intramuscular tendons is ess,” noted Allen, a member of the London its limitations. For instance, acute muscle inju- contraction alone; in fact, strains are the result essential not to miss low-grade muscle strains Olympics 2012 imaging committee. “We’re ries may be difficult to identify with ultrasound of stretching while the muscle is being acti- with ultrasound,” said Martinoli. always being asked by the patient, ‘How during the first few hours after trauma, accord- vated. Muscles are more susceptible to strain quickly can I get back to my sport?’. We don’t ing to Dr. Carlo Martinoli, associate professor injuries because they cross two joints, have a Ultrasound provides an ideal way of assessing just have to cope with the pressures of the of radiology at the University of Genoa, Italy. complex architecture, act mainly in an eccen- the sequential stages of haematoma reabsorp- patient; we also have pressure from the man- A new haemorrhage is echogenic and similar tric fashion, and contain a high percentage of tion, which occurs in six to eight weeks. The agement and the coach to get the athlete back in appearance to normal muscle, and a fresh fast-twitch (type-II) fibres, he explained. haemorrhagic cavity progressively shrinks, to the sport.” haemorrhage can mix with the normal fibro- and its walls thicken and collapse. fatty tissue within the muscle and be inconspic- After six hours, the haematoma starts to liq- For example, in tendon overuse injuries, it uous in an early ultrasound examination. uefy, and it becomes of low echogenicity over Compared with ultrasound, MRI can provide a may be that the patients have had improper the next two or three days, allowing greater more comprehensive study of musculoskeletal training or coaching. They may have changed “It is easy to underestimate or even overlook precision in the diagnosis. The pattern of the their shoes, altered their equipment, trained at muscle tears within the first few hours of the haematoma can be better appreciated and continued on page 3
myESR.org 2 ECR TODAY 2011 HIGHLIGHTS Monday, March 7, 2011
Detecting liver tumours: the search for the Holy Grail
By Frances Rylands-Monk of 43 patients who had received transplants using these criteria. Fifteen patients were dia- At yesterday’s W.C. Röntgen Honorary Lecture, gnosed with HCC and accelerated ahead of the Dr. Richard Baron used the search for hepato- others. Following transplantation five of these cellular carcinoma (HCC) in cirrhosis as the were false positives. model of the ‘Holy Grail’ for imaging because it shows why radiologists should be at the fore- “This was a very bad outcome for ten pati- front of directing patient care and research. ents. The five who didn’t need the transplant, and the five in the intensive care unit dying of Liver tumour detection has moved beyond liver failure who didn’t have a cancer, but were anatomic imaging to establishing the correla- denied the transplant because these patients tion between imaging and physiology, accor- went ahead on the list.” ding to Baron, chairman of the department of radiology at the University of Chicago. He paid Radiology has come full circle and uses tech- tribute to experts such as Drs. Itai and Matsui, niques employed three decades ago to under- who have helped radiology to acknowledge the stand the importance of the equilibrium phase. central role it plays in patient care and research through understanding tumour, contrast and “We can see the enhancing nodule of HCC but blood flow biology. many lesions enhance in the liver including focal nodule hyperplasia and benign lesions, “They have pushed our frontiers in liver ima- but it’s the wash-out of these vascular lesions ging. We have learned that imaging can paral- in equilibrium phase that is really the key point lel biologic findings,” he noted. allowing confident diagnosis of HCC,” he said.
Over the past 30 years, guidelines about pati- Now clinical outcomes are such that authori- ent management have changed, particularly ties insist that patients are not biopsied, instead for transplant in patients with HCC, making radiologists should make an imaging diagno- Richard L. Baron from Chicago, United States, receives his Honorary Lecturer diploma from the hands of radiologists pivotal determiners of individual sis of HCC. Very accurate specificity and sen- ECR 2011 Congress President Yves Menu. outcomes. sitivity in imaging means that there is clear disease management for patients with lesions “That demands that we know accurately the greater than 10 mm and showing arterial phase tumours. But the crusade must evolve to have the key means of medical triage, radiologists number of tumours and size of each tumour to hypervascularity and portal venous or equilib- impact, to deliver the value of the Grail to all,” should define the key remaining components. the decimal point. If you see a tumour of 3 cm rium phase wash-out, Baron outlined. he said. with multiple tumours in the U.S., you won’t be In research the radiological community must transplanted. If it’s 2.9 cm, you get ahead of the “We should continue to focus in narrow areas Baron urged all radiologists to develop the take the lead in using relevant clinical outco- line,” Baron said. to improve our ability to seek, characterise and skills to understand clinical medicine and its mes as the true gold standard, leading ima- detect tumours, and we did with liver-specific nuances, and integrate imaging with other ging into true multi-disciplinary participatory He questioned where this trend of steering pati- contrast agents, diffusion-weighted imaging as yet unknown critical measures to reflect research. ent care had led in the past, citing the example and some MRI bold oxygen physiology in liver patient outcome potential. If imaging is still Rising stars shine brightly at ECR
By Mélisande Rouger
The radiologists of the future were very much present at the ECR yesterday as the best medical student lectures were recognised with awards.
For the first time, medical students were invited to give a lecture at ECR, after 20 of the best sub- mitted abstracts were selected. Four of them received a certificate from Professor Adrian K. Dixon, the ESR Publications Committee Chair- man, signed by ECR Congress President Pro- fessor Yves Menu and ESR President Professor Maximilian Reiser.
Students were invited to submit abstracts on topics ranging from radiology in undergradu- ate education to the challenges for the future for radiology, among others.
“It is important to have a place for students, not only at the ECR but at all radiology congresses,” said Marcello Petrini, a student at the Medi- cal University of Milan, who was commended for his abstract ‘Radiology: a holistic medicine Carmello Messina, Alexander Sachs and Marcello Petrini were recognised for their ECR 2011 Best Presented Student Lecture. beyond medicine’.
Alexander Sachs, a student at the Medical Univer- sity of Vienna, concurred. “It was an experiment; so it was quite interesting to see what is actually and Straightforward (KISS)’. But as we had to Adrien Rácz from Budapest also received a cer- they wanted to see how students can present their going on there,” said Sachs, whose presentation do presentations, it was difficult to attend all the tificate for her presentation ‘Fascinating imag- work. I appreciate it very much, it is a great oppor- ‘Sono4You: ultrasound tutorial for students’ also sessions,” said Carmello Messina from the Medi- ing and promising research in the brain’. tunity and a good educational experience,” he said. received an award. cal University of Milan. His lecture ‘How radi- ology is changing: three unavoidable challenges Students expressed their gratitude to the Euro- Most of them were attending their first radio- “I wanted to see the whole thing. I went to the for the future’ was also chosen as one of the best. pean Society of Radiology (ESR) for giving logical congress and tried to make the most of technical exhibition and just ran around but it them this opportunity. it – even if they struggled to see everything. took me the whole day! It is not possible to see “I attended sessions on evidence-based medi- everything,” he added. cine and on incidental findings. I think it is “It is really a great honour to be here. I hope it “I was invited to the breast cancer workshop important because it is a challenge for the radi- continues like this,” Sachs said. symposium for students, organised by Siemens. “I tried to attend the musculoskeletal sessions ologist to make the right diagnosis,” said Petrini, Normally it is a topic I don’t know much about such as the categorical course ‘Keep It Simple who is sure about his vocation as a radiologist.
myESR.org Monday, March 7, 2011 HIGHLIGHTS ECR TODAY 2011 3
Bonomo turns attention to ECR 2012 and looks forward to presiding over the next congress
By Mélisande Rouger important learning tools for young people and we should make further innovations with this technol- ECR Today met ECR 2012 President, Professor ogy to increase the number of attendees at ECR. I Lorenzo Bonomo, Chairman of the Department of think this year it was organised very well, but we Radiology and Director of the Radiology Training could maybe use more monitors at EPOS. It is really Programme at the Catholic University Sacro Cuore crowded at lunchtime. One of the nice experiences in Rome. He talked about his plans for the next for ECR presidents is that with every congress, they congress, e-learning and the necessity of attracting have the chance to make improvements based on more medical students to radiology. the experience of their predecessors. We should try to enhance the quality in continuity with the past. ECR Today: What are your plans and ambitions for ECR 2012? ECRT: Are you a big fan of e-learning tools Lorenzo Bonomo: As usual, the ECR will feature a yourself? number of innovations next year. First of all, we will LB: I use them in my daily teaching activities, and add more scientific slots and the congress will start I invite my residents to visit teaching files in other on Thursday morning. This year, following a 26% web universities and use other online resources. rise in abstracts, we had a rejection rate of 70%. We need to make more room for scientific presenta- ECRT: Which will be the next countries and part- tions. ner discipline invited to take part in the ‘ESR Then, we will have two new scientific subcommit- meets’ programme? tees, on oncologic imaging and emergency imaging. LB: We invited the national societies of Egypt, Italy Usually the scientific subcommittees are related to and Romania, and one of our sister disciplines, radi- European radiological subspecialty societies, but ation oncology. In doing so, we intend to strengthen since the European Society of Oncologic Imaging our relationship with this discipline, where imaging and the European Society of Emergency Radiology has played a growing role in defining the treatment have only been created at ECR 2011, I decided to that radiation oncologists perform. Both specialties form these subcommittees. This means we will have have a very close relationship, for instance radia- Refresher Courses on these topics as well. The ECR tion oncology is part of my department. Their goal is the annual meeting of one of the biggest scientific is to treat disease with radiation and the role of societies, the ESR, which accounts for more than radiology is to give information for the best pos- 50,000 members, and this is an importance that sible treatment and to control its response. should be reflected by the congress. There will also be a subspecialty Refresher Course ECRT: Italian radiologists have always devoted to reporting. This year’s packed session (I attended the ECR in large numbers. Why do couldn’t even get in!) on standards and audits, ‘How you think that is? to write better reports’, proved once again how LB: I think my appointment as ECR President is attendees need and want to know how to report. a big recognition of Italian radiologists for their There will also be a Mini Course on molecular huge support since the foundation of the ECR. Ever imaging, with one session dedicated to theragnosis since, we have been able to work together with the (combining imaging and treatment). A large per- Italian Society of Medical Radiology (SIRM) to centage of treatment today is guided by imaging encourage attendance at the ECR by writing about and this will only increase in the future. We need it and advising it in our journals. Hopefully my ECR 2012 Congress President Lorenzo Bonomo from Rome, Italy. to keep our eye on this constantly evolving field. A presidency will translate into even higher numbers! new Mini Course will focus on controversies. Next year we will address three controversial topics in patients with cancer, an innovation started in 2010. for medical students, and the ESR Diploma, ECRT: When was your first ECR? What has abdominal imaging. Each session will be interac- The Special Focus Session ‘My Most Beautiful Mis- aimed at radiologists who have just finished their improved since then? tive; the chairman will propose several questions, takes’, which proved very successful this year, will training. What do you think of these initiatives LB: I first attended the congress in 1991 and I have receive the opinion of the audience and invite also be kept on the programme. and do you intend to expand them? noticed, as have many other colleagues, a continu- speakers to give their talks and state their positions, LB: Concerning the Rising Stars, we should defi- ous improvement in its quality, not only in terms of ultimately trying to find a consensus. ECRT: Being a chest radiologist, what did you nitely try to increase the number of Medical Stu- delegates but also in the high standards of its edu- Finally, the Foundation Course will focus on ultra- think of the sessions on chest x-ray (‘The beauty dent Sessions as it is a way to attract young medi- cational and scientific activities. sound, and two of the Categorical Courses will deal of basic knowledge’)? Is there a need for radiolo- cal students to radiology. As for the introduction with urogenital imaging and neurological emer- gists to come back to traditional modalities? of the ESR Diploma, I am very curious about the ECRT: How did you decide to become a gencies. The CLICK format introduced at ECR LB: Chest x-ray is one of the most common and examination today since I will be one of the exam- radiologist? 2011 on the most common clinical problems in a popular x-ray examinations, which can be per- iners. Actually I was one of the first radiologists to LB: In Italy, at the end of medical training, you particular field will also be repeated. formed in huge hospitals but also in very small take the European diploma back in 1977–78, when should discuss a thesis. I was very impressed by the practices. It is usually the first imaging modality it was organised by the European Association of lessons my professor of radiology gave, so I chose to ECRT: What are your impressions of ECR 2011? used to assess chest conditions and lung and heart Radiology (EAR), the predecessor of the ESR. At do my thesis on radiology, specifically chest imag- What will be continued or changed? disease. that time there were no electronic tools! I remem- ing. It was entitled ‘The role of chest x-ray in the LB: Usually the ECR is very innovative but this year I would say to the younger generations: don’t forget ber very famous examiners from France, Germany evaluation of pulmonary circulation’ and I gradu- it went even further. First, abstract submission went the old things, especially in chest imaging. Young and Italy showing me three cases on the view boxes, ated in July 1970. I have absolutely no regrets. up by 26%, which is partially due to the younger radiologists like CT and MRI, but if you want to and I had to make a diagnosis. Today, 35 years later, generation getting more and more involved. It will understand the content of chest CT, you should first I will be on the other side. I think this diploma is ECRT: How do you like to spend your time when be a great challenge for me to repeat the same suc- get to know chest x-ray very well. It is still the basic an important step, and next year our goal will be to you are not working? cess next year but I am confident that with the sup- knowledge of chest imaging. have it officially recognised by the European com- LB: I enjoy being a radiologist, but I also have hob- port of everybody at the ESR I will contribute to We will also definitely repeat these very popular, mission. bies! I was born close to the sea (in Andrea, Puglia, improving the already predominant role of the ECR fully booked sessions. ten minutes away from the coast), but I do like in the radiological world. ECRT: What do you think of the format of the mountains. I am fond of skiing and every year I We will increase the number of interactive sessions ECRT: ECR 2011 also saw the launch of two ini- Electronic Presentation Online System (EPOS™) visit the Dolomite area in Italy for this. Thanks to because it is a great way for the attendees to partici- tiatives for young radiologists, namely the Rising and other e-learning platforms at ECR? ECR, I have met other radiologists who share my pate directly with the speakers. We also will organ- Stars programme, in which students can submit LB: I visited the EPOS and ePACS areas, and we passion for trekking, and each year we try to organ- ise more multidisciplinary sessions on managing abstracts and participate in dedicated sessions should try to enlarge these. EPOS is one of the most ise a long weekend somewhere in Europe.
Sports imaging Radiologists must be aware of the delayed onset tion of a country’s healthcare payment system sometimes gets overlooked, said Aydıngöz, continued from page 1 of muscle soreness, and muscle contusion does will have an impact on modality choice in who has worked as a musculoskeletal radiolo- not necessarily occur at the myotendinous sports imaging, as in any field. Economics may gist since 1996 and was a visiting professor of (MSK) structures, including bones. Further- junction. Muscle fibres are coarse through the well dictate the selection of a primary study radiology at St. Louis University Hospital, Mis- more, MRI is less time-consuming to evaluate, abnormal region, he noted. Myositis ossificans when all modalities perform equivalently, souri, U.S., between 2005 and 2009. and during a given period, more MSK MRI and heterotopic ossification correlate with he stated. Ultrasound offers the possibility of investigations can be read, according to Prof. plain film. lower costs, facilitates dynamic imaging, and Üstün Aydıngöz, professor of radiology at Hacet- generally excels at a directed examination. tepe University School of Medicine in Ankara, The main advantages of MRI are ease of per- Turkey. On the other hand, dynamic studies are formance and radiologist, its broad field-of- Finally, attendees at the course were told not routinely possible with MRI, and ultrasound view evaluation of an anatomic region, and to make absolutely sure that they have the is clearly more advantageous in this respect. broad pathological evaluation. The organisa- patient’s full contact information. This point
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Young radiologists take the ESR Diploma to boost their careers
By Mélisande Rouger
European radiologists are increasingly working abroad, yet national board examinations still dif- fer from country to country. Radiologists in train- ing will be able to increase their chances of gain- ing employment abroad by taking a brand new examination for the ESR Diploma today at ECR.
Fifty radiologists from 14 different European countries will have their general radiologi- cal knowledge tested for this new qualification offered by the European Society of Radiology (ESR). Most of them expect success in the exam- ination to aid their career development, both nationally and internationally.
“Right now we are not certain to get equivalent work somewhere else in Europe. I think the ESR Katja Pinker from Vienna, Austria. Elodie Adel from Grenoble, France, being interviewed by Mélisande Rouger, ECR Today contibuting writer. diploma is a good way to facilitate migration,” said Elodie Adel, a medical student in radiology train- tional harmonisation of radiological standards you should have knowledge of paediatric radi- “We learn in French but we read a lot of scientific ing at Grenoble University Hospital in France. throughout Europe. ology, emergency radiology, etc. This examina- papers in English. It could actually be a good rea- tion is good to test your general knowledge, and son to learn this language better,” Adel said. Luis Riera, a paediatric radiologist at the Hospi- “I did an internship in Graz, Austria, for three it could help to travel and work everywhere in tal General de Catalunya near Barcelona, fully months, and I noticed how different things are from Europe,” said Katja Pinker, a consultant radiolo- “I feel ready for another examination; I think this agreed. “With the current economic situation home. The Austrian curriculum is, for instance, gist at the department of radiology of the Univer- is an opportunity to test myself. I don’t mind that in Spain, many people are thinking about going much more specialised. All these differences could sity of Vienna, who specialises in breast imaging. it is in English,” echoed Riera. abroad, so this diploma could be a good option make things more complicated if I were to, say, to get a European accreditation,” he said. work in the United Kingdom,” Riera said. Candidates from Austria, France, Germany, The ESR Diploma does not replace any national Greece, Hungary, Ireland, Italy, Malta, Poland, board examination and should be seen as a con- Training still differs in many countries in spite “In Austria, everything is very specialised; we Portugal, Romania, Spain, Switzerland and Turkey tinuation of and a complement to radiological of existing European guidelines. This diploma don’t have a general radiology diploma. But will sit the exam, and the fact that the examination training. represents a significant step towards interna- when you’re on call you have to do everything, will be in English didn’t seem to worry them. Iranian radiologists hold out the hand of friendship to Europe
By Philip Ward
In an attempt to promote understanding and build bridges between Europe and Iran, the country’s rich culture and heritage came under the spotlight at yesterday’s ESR Meets Session.
Until 1935, Iran was called Persia, Perse or Pars. The racial background of its 75 million inhabitants is Aria (Arya), according to Prof. Abdolrasoul R. Sedaghat, President of the Iranian Society of Radi- ology. The country occupies an area of 1,648 mil- lion sq. km., making it slightly larger than Alaska. Around 89% of the population is Shi’a Muslim, compared with 9% Sunni Muslim and 2% other reli- gions, mostly Jewish and Christian. In the Persian calendar, the current year is 1389, and the New Year begins on March 21. The official language is Farsi.
One of the nation’s many historical landmarks was the world’s first human rights document, written by Cyrus the Great of Persia during the Achaemenian Era.
In Iranian healthcare, an important trend has been Abdolrasoul R. Sedaghat, President of the Iranian Society of Radiology, with ECR President Yves Menu and ESR President Maximilian Reiser. the significant decrease in maternal mortality, from 237 per 100,000 live births in 1974 to 25 in 2005, stated Sedaghat, who reached out to the audience ology specialist to join the combined radiology- Iranian Journal of Radiology also plays a vital role fibroids (Dr. Kavous Firouznia, associate professor by starting his lecture with the words ‘In the name radiotherapy department at the Tehran University’s meeting the training and education and informa- of radiology, Advanced Diagnostic and Interven- of God’. Faculty of Medicine in 1958, and he served there tion needs of the country’s radiologists. tional Radiology Research Centre, Tehran Uni- until 1963. He is an Emeritus Professor in Temple versity of Medical Sciences), interventional proce- There are 1,600 radiologists and 400 radiology resi- University, Pennsylvania. “From the bottom of my heart, I want to thank the dures in liver transplantation (Dr. Alireza Rasekhi, dents. More than 150 of them are attending ECR ESR for inviting us to take part in this session,” said associate professor of radiology, Shiraz University 2011, and 98 of them were at last year’s congress. Other eminent Iranian radiologists include Profes- Sedaghat. “The recent visits of several important of Medical Sciences), and radiochemoembolisation sor M. Mafi (head and neck), Professor Tayebi (pae- ESR officials to Tehran has meant a great deal to us.” of liver metastases (Dr. Mansoor Fatehi, Day Gen- The first use of x-ray in Iran is not documented, but diatrics), Professor A. Rooholamini, Professor Khal- eral Hospital Tehran). one of the first pioneers in the construction of x-ray khali (breast), Dr. J. Golzarian (interventional radio- During the clinical part of yesterday’s session, machines in Iran was Professor Mahmud Hessabi logist), Dr. M. Shahabpoor (musculoskeletal), Dr. interventional radiology was the focus of four During two interludes, a fifth speaker (Karim (1903–1992), a French-trained scientist and engi- Shirkhoda (abdominal), Dr. Alavi (molecular), and Iranian speakers, who gave presentations about Vessal from Shiraz University of Medical Sciences) neer with an interest in x-ray physics. Dr. Akbar Ganji (musculoskeletal interventionalist). how to start interventional radiology (Dr. Hossein discussed Persian physicians’ contribution to the Ghanaati, associate professor of radiology, Tehran evolution of medicine. Professor Akbar Bonakdarpour, a musculoskeletal The next annual Iranian Congress of Radiology University of Medical Sciences), uterine artery radiologist, was the first U.S.-trained Iranian radi- takes place in Tehran from May 17 to 20, 2011. The embolisation for the treatment of symptomatic
myESR.org Monday, March 7, 2011 HIGHLIGHTS ECR TODAY 2011 7
Imaging professionals strive to come to terms with age old clinical problems
By Frances Rylands-Monk
A declining birth rate and an increasing elderly population have resulted in new socio-economic and healthcare problems. Physicians are confron- ted with complex clinical scenarios arising from this situation.
Diagnostic imaging plays a valuable role in the care of older patients. In the elderly, co-morbi- dities compounded by physical and cognitive impairment can make it difficult for radiologists to provide the clinician with anticipated answers. It is important for radiologists to know the complex health scenarios occurring in geriatric patients, which are different from those seen in younger adults. They must be aware of the possi- Frederik Barkhof from Amsterdam, the Netherlands. Anne Cotten from Lille, France. Tobias Saam from Munich, Germany. bilities – and limitations – of imaging the geriat- ric population.
Yesterday’s Special Focus Session was designed to Determining whether or not patients will be able “MR or CT should be used to work up suspec- Missed vertebral fractures presented another pit- enhance doctors’ recognition of the co-existence to live independently and for how long is cru- ted dementia and rule out treatable disorders or fall for doctors. of various diseases in target patients, and dis- cial not only for the patients themselves but also suggest a specific diagnosis. If scans are negative, tinguish the healthy older person from those in for their families. Unidentified White Objects PET/SPECT should be used,” he said. “PET/MRI “Rapid diagnosis is fundamental to avoid any need of treatment. (UBOs) are probably a sign of mild hypoxia, and can also help to diagnose early dementia, even delay in treatment, or the risk to the patient in in a young subject should be reported as abnor- short of established therapy.” this population is increased morbidity and mor- Key to management of diseases in the ageing mal and lead to investigations. Once they start tality,” Cotten said. brain is understanding the structural visualised forming small bridges or become confluent, they Musculoskeletal disorders through trauma, brain changes that occur in normal ageing, should be considered abnormal, independent of degeneration or malignancy were a particular Partly focusing his talk on imaging features as which were presented by Professor Frederik age. Arterial spin labelling in subjects with exten- problem for the elderly, delegates heard from potential predictors of cardio-vascular disease, Barkhof, professor of neuroradiology at the sive white matter changes usually reveals poor Professor Anne Cotten, head of musculoskele- Dr. Tobias Saam, a radiologist at Ludwig-Maxi- Free University of Amsterdam, the Netherlands. perfusion of the tissue. tal (MSK) radiology at Hôpital Roger Salengro, milians University, Munich, Germany, began by Widening in the Virchow-Robin spaces (VRS), Lille, France. Loss of mobility and indepen- pointing out that this disease is a more common as seen in MRI, is a normal aging phenome- In one study, healthy subjects with severe conflu- dence could have devastating effects on their cause of death than cancer in any age group. non even in patients as young as 30, and of no ent lesions (Fazekas grade 2 and 3) showed a 20% quality of life. pathological significance, he said. Some degree reduction in perfusion compared to patients with Age-related changes in vascular structure could of atrophy of the medial temporal lobe was also milder lesions. A LADIS study imaging patients Radiologists should know the most common indicate different stages of atherosclerotic deve- sometimes visible. with mild, moderate or severe confluence showed MSK disorders as well as misleading presenta- lopment and therefore risk factors of developing that 60% of 639 subjects with severe white mat- tions, potentially resulting in inappropriate or cardiovascular disease. Extreme widening in VRS was more difficult to ter lesions were unable to live independently at erroneous management. Besides low impact determine. Patients often presented with head- home after three years or had died, even though falls from standing height, fractures caused by “Many studies have shown that certain imaging aches but no discernible pathologies. It still might they were doing well at the time of scanning. The osteoporosis, particularly vertebral fractures, features are associated with an increased risk, be a sign of normal ageing, while homogenous results indicate that healthy subjects with severe need careful attention as they are associated however luminal stenosis alone is an insuffici- dot-like structures of Etat Criblé was an abnor- white matter lesions have a poor prognosis, Bark- with excess mortality and significant morbidity, ent marker to identify the vulnerable plaque,” he mal finding and indicated local atrophy often hof pointed out. and because the risk of subsequent fractures was commented. associated with diffuse white matter changes and high, she said. always with a pathological finding. Premature ageing can be predicted through ima- Asked by session moderator Prof. Giuseppe ging markers, highlighting confluent white mat- When vertebroplasty is indicated, MRI should Guglielmi, from the department of radiology at “Normal ageing is often defined as the absence of ter lesions, silent infarcts, cerebral microbleeds, be performed to localise vertebral fracture and Foggia University Hospital, Italy, which modality overt disease, but there are a lot of things happe- medial temporal atrophy and amyloid markers. stabilise the vertebroplasty and deliver fast pain was best to assess the risk factors, Saam respon- ning below the threshold. There’s a small group relief, Cotten continued. ded that prospective studies were needed in PET/ of people who, if you image them, have a healthy ECR delegates heard how patients with CT and MRI, both to determine the best methods brain, but that’s uncommon because most peo- Alzheimer’s disease (AD) have increased amyloid It was also very important to be able to distingu- to screen for atherosclerosis and identify the ple with typical ageing have some subclinical binding, but presence of amyloid didn’t necessa- ish between osteoporotic vertebral collapse (VC) modality best suited to determine a patient’s indi- pathologies like white matter lesions. The predic- rily mean a patient would develop AD or predict and metastatic VC. In osteoporotic VC, imaging vidual risk. tive value of these images is only partly known,” when they would develop it. However, functional findings showed multiple affected vertebrae in Barkhof said. “Even if it’s known, there are infe- biomarkers could show whether or not amyloid the thoracolumbar spine, with diffuse increased “We could be waiting five to ten years for the rences at a group level, but on an individual level was interfering with brain function and aid in radiolucency and no osteolysis. Conversely, cases results,” he said. it is very difficult to make an exact determination predicting premature ageing. New PET tracers of metastatic VC were often unique, located in the of the impact down the line.” could rule out AD in favour of other diseases. cervical spine, with radiolucency and osteolysis.
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Cardiovascular and Interventional Radiological Society of Europe ESIR 2011
European School of Interventional Radiology
In 2011, the CIRSE Foundation will organise nine local courses in different university hospitals around Europe. All courses will be held in English.
Biliary Interventions 1-2 April, 2011 Amsterdam (NL) CLI and Diabetic Disease 8-9 April, 2011 Budapest (HU) Extrahepatic Tumour Treatment 6-7 May, 2011 Frankfurt (DE) Basic Vascular 3-4 June, 2011 Bucharest (RO) Aortic Disease 10-11 June, 2011 Milan (IT) Dialysis Access & Venous Interventions 1-2 July, 2011 Ingolstadt (DE) Embolisation 14-15 October, 2011 Rome (IT) Liver Interventions 28-29 October, 2011 Porto (PT) Drainage, Biopsies & Venous Access 4-5 November, 2011 Dublin (IE)
www.cirse.org
C RSE f o u n d a t i o n Monday, March 7, 2011 CLINICAL CORNER ECR TODAY 2011 9
Management of Images gain New techniques Inside post-treatment prominence in display promise in head and neck cases surgical suites bone tumours
Today See page 10 See page 11 See page 16
CT sheds new light on complex cases of small airway disease
By John Brosky to know the condition of the patient – whether they have fever, whether they are experiencing Modern CT scanners can provide volumetric an acute illness, or whether they have any history acquisitions with excellent spatial resolution and of connective tissue diseases. high quality images, while reducing the radiation exposure for patients. One area where high-reso- In her presentation, ‘From pattern to diagnosis’, lution CT has had a great impact is in a drama- Beigelman-Aubry will outline what she calls tically increased sensitivity for detecting signs of an optimal approach that navigates a variety of small airway disease (SAD), which quite simply schemes proposed for classifying SAD, which could not be seen on traditional x-rays. Yet even she admits can be confusing. The first step is to with CT’s powerful capabilities and sophisticated determine if there are predominantly direct signs analysis with post-processing tools, the diagnosis of inflammatory or exudative bronchiolitis, such of SAD can be difficult and, at times, confusing. as centrilobular nodules with tree-in-bud appea- rance, which can be quickly identified thanks At this morning’s Special Focus session, ‘CT of to the enhanced contrast and spatial resolution small airways: elementary images for disease of CT. The maximum intensity projection tool classification’, four specialists will help to dec- facilitates the recognition of the tree-in-bud pat- rypt the direct and indirect features of SAD to tern, which is extremely useful in the detection sharpen skills for distinguishing between either of the profusion and characterisation of micro- inflammatory/exudative or fibrotic/constrictive/ nodules. obliterative bronchiolitis. In her second step, indirect findings such as “Patients with SAD have clinical symptoms under-ventilated and vascularised areas, air which may go unexplained but may actually be trapping, mosaic attenuation, bronchial wall thi- very harmful,” said Prof. Hans-Ulrich Kauczor, ckening and dilation may characterise fibrotic/ MR image of the lung after inhalation of a bolus hyperpolarised He-3 gas shows a small ventilation defect in the who heads the radiology and diagnostic depart- constrictive/obliterative bronchiolitis. Use of the right lung (arrow), indicating an obstruction of small airways in this region. (Provided by H.-U. Kauczor) ment at the University Hospital in Heidelberg, minimum intensity projection mode may opti- Germany. “Many people think SAD is rare and mise the recognition of the mosaic attenuation does not occur in routine clinical practice, or it pattern, as well as the analysis of proximal air- is not important because incidence is rather low, ways, she notes. but this is not true.” The highlight of the session promises to bea His presentation, ‘Beyond morphology’, will panel discussion that focuses on a deceptively focus on advanced functional imaging for simple question: “When and why do signs of assessment of the functional impairment that SAD really matter?” goes along with SAD, yet his first concern is the tendency to underestimate a condition that often Beigelman-Aubry acknowledged that in some remains under-diagnosed. SAD is important in conditions, detected signs may not be at all use- any form of bronchitis or chronic obstructive ful. For example, air trapping has been described lung disease, and it might be part of any work- in diseases such as sarcoidosis as significant in up for exclusion of pneumonia, especially during the literature, but in practice, reporting of it tends the winter season, he suggested. to be of little use. Conversely, if there is a ground Numerous ill-defined ground glass opacities and micronodules with a heterogeneously distribution are difficult to glass opacity associated with lobular areas of air assess and classify on a single coronal reformatted image (left). Conversely, the tree-in-bud appearance is obvi- Knowing the patterns of SAD is extremely useful in trapping, then this pattern it is quite typical of ous with a 14 mm thick maximum intensity projection slab (right), allowing a definite recognition of the bronchi- olar origin of the anomalies related to infectious bronchiolitis. (Provided by C. Beigelman-Aubry) routine practice, as well as in acute situations, accor- interstitial lung disease related to hypersensiti- ding to Dr. Catherine Beigelman-Aubry, a radiolo- vity pneumonitis and is very useful to report. gist from the Hospital Pitié-Salpêtrière in Paris. Kauczor agrees there is often a question as to “When a patient is in intensive care and physi- whether the very small changes detected by high cians are completely unable to understand the resolution CT really mean anything with regard cause of respiratory failure, it becomes very to clinical symptoms or indications for a therapy. important that the radiologist can separate fin- “In the case of air trapping, I believe a functional dings related to small airways disease from acute assessment with 4D imaging of the respiratory interstitial lung disease, especially related to cycle helps detect real trapped volumes and helps drug toxicity or cardiac insufficiency” she said. assess the physiological condition or a patholo- gic change that needs to be treated.” Furthermore, in any clinical setting, it is always important to integrate all the patient data and Free Special Focus Session Publications Monday, March 7, 08:30–10:00, Room E2 SF 15b CT of small airways: Pick up your free copies of radiology journals and magazines … elementary images for disease classification Free access to online radiology journals … • Chairman’s introduction J.A. Verschakelen; Leuven/BE • Basic signs in small airways disease The Free Publications booths are located on the first level D.M. Hansell; London/UK • From pattern to diagnosis and on the second level, integrated into the EPOS™ Lounge. C. Beigelman; Paris/FR Enjoy another valuable service at ECR! • Beyond morphology H.-U. Kauczor; Heidelberg/DE • Panel discussion: Signs of small airways disease can be seen on CT but when and why do they really matter?
myESR.org 10 ECR TODAY 2011 CLINICAL CORNER Monday, March 7, 2011
Radiologists work hard to unravel post-therapeutic head and neck mysteries
By Philip Ward are showing promising results in the early post- treatment period (≤ six weeks). Management of the post-treatment head and neck represents a stern challenge for radiolo- “However, it should be stressed that although gists. The accurate assessment of tumour res- these techniques show promise, they have not ponse following radiotherapy or chemotherapy been compared in large studies against con- is especially problematic, according to Dr. Ann ventional imaging or FDG-PET, and at present King, from the department of diagnostic radio- their role in clinical management is unclear,” she logy & organ imaging, Prince of Wales Hospital, noted. “Diffusion-weighted imaging is a quick The Chinese University of Hong Kong. Residual and easy technique to add to a routine staging masses at primary and nodal sites are common, and post-treatment assessment MRI examina- and in the early post-treatment period, when tion. We feel that although the exact role has not salvage surgery is desirable, it can be difficult to been determined, it shows the greatest promise, distinguish a residual cancer from a benign post and in order to gain more experience, we have treatment mass. added it to our head and neck MRI protocol.”
At this afternoon’s refresher course, King and King concedes that general radiologists may her two fellow speakers will attempt to shed not be involved in the immediate post-treat- light on this complex field. ment assessment of patients with head and neck cancer, but she stresses that they may be Conventional imaging with CT or MRI requires involved at a later date during surveillance, or knowledge of expected post-treatment changes when a patient re-presents with a suspicion of Benign post-treatment mass (arrow) at the site of Residual cancer (arrow) at the site of metastatic and appearance of residual cancer. In the post- tumour recurrence, development of a second metastatic nodes successfully treated by chemoradio- nodes after unsuccessful chemoradiotherapy. treatment period, a residual/recurrent cancer tumour or a complication of treatment. Her therapy. (Provided by A. King) (Provided by A. King) (expansile mass that is moderately contrast- enhancing and on MRI of intermediate T2 signal intensity) can be distinguished from a benign post treatment mass (retracted scar tissue that is non-contrast-enhancing and on MRI is of low T2 signal intensity), she explained. The ability of MRI to identify scar tissue on the basis of low T2 signal is especially useful in post-treatment assessment, but in the earlier post-treatment period before the benign post-treatment mass has had time to mature, it may have some simi- lar features to residual cancer.
“Biopsies can have unwanted side effects in the post-treatment neck and may not confirm or exclude cancer in all cases,” King pointed out. “FDG-PET has a proven role in the assess- ment of the post-treatment neck, with more accurate results than conventional imaging. However, the best results are usually obtained at least several months after treatment, and while FDG-PET has a high negative predictive value, a positive scan is less specific and may be Coronal T1-weighted post-contrast MRI (A) and coronal T2-weighted MRI (B) show a benign post treatment mass (arrows) at the site of a squamous cell carcinoma of the maxillary sinus that had been treated successfully by chemoradiotherapy. C: ADC map shows the residual mass has a high ADC value (1.9 x 10-3 mm2/s) in keeping with a caused by tumour or post-treatment changes. benign post-treatment mass. (Provided by A. King) For those patients with indeterminate residual masses on CT/MRI/FDG-PET, there is often no substitute for close clinical and imaging ECR lecture should provide a brief oversight on time points and causes for development of treat- based predictive factors have been founded upon surveillance.” how to distinguish scar tissue from a tumour ment resistance, King concluded. morphological findings, but the landscape is and how to identify complications of treatment changing due to development of new techniques Functional MRI shows promising results in that may be confused with tumour recurrence. As treatment planning becomes progressively that analyse functional parameters like FDG- cancer treatment assessment using diffusion- She will also provide a check-list for assessing more tailored to a patient’s needs, strong pre- PET-CT and perfusion CT and DWI-MRI. weighted imaging (the residual tumour has a the post-treatment neck during imaging sur- dictive factors for the individual tumour must significantly lower absolute ADC [apparent dif- veillance. be identified, noted Prof. Roberto Maroldi, Perfusion CT and DWI-MRI are promising fusion coefficient] or lower rise in ADC from department of radiology, University of Brescia, techniques because they provide information baseline, than a benign post-treatment mass), Functional MRI for pre-treatment prediction and Italy. These factors should provide a quantita- about neo-angiogenesis and water-flow in sub- MR spectroscopy (the choline peak may per- early intra-treatment monitoring may become tive assessment of the risks of both relapse (in microscopic tissue compartments, but they still sist in residual cancer) and dynamic contrast- more important, but only the role of imaging in the primary, nodal or distant sites) and develo- require randomised trials and confirmation enhanced MR (kinetic curves show earlier and the post-treatment neck will be covered in her ping treatment-related complications. Predictors studies about the reproducibility of their inte- greater contrast enhancement in tumours com- presentation. In the field of research, serial func- are related to a tumour’s characteristics and to resting results, said Maroldi, who will moderate pared to scar tissue). Some of these techniques tional MRI during treatment may help to identify a patient’s overall clinical conditions. Imaging- and speak at today’s session.
Refresher Course
Monday, March 7, 16:00–17:30, Room N/O RC 1808 Management of the post-treatment head and neck: a diagnostic dilemma • Chairman’s introduction R. Maroldi; Brescia/IT A. Expected changes after treatment R. Hermans; Leuven/BE B. Surveillance imaging, tumour recurrence and treatment complications A.D. King; Hong Kong/CN C. Predicting outcome after radiation therapy in head and neck cancer: what is evidence-based? Visit the R. Maroldi; Brescia/IT • Panel discussion:
Recurrence, inflammation, necrosis or scar: Arts & Culture Booth We © VBK Wien, 2010 is imaging useful? in the entrance hall Florentina Pakosta,
myESR.org Monday, March 7, 2011 CLINICAL CORNER ECR TODAY 2011 11
Moving image data beyond radiology promises to transform working practices
By Philip Ward ent and less costly solution is to make images automatically available by storing them in a Better and faster imaging enables more accu- ‘virtual cloud’ that is accessible to other health rate diagnoses with less risk and at lower cost care providers and patients. Several compa- than ever before. Faster scanning techniques nies are already providing this type of service, also mean a change from static to dynamic especially in the U.S. information, while increasing computer power and faster and more complex post-processing More surgical and clinical/oncologic specia- algorithms can deal with enormous datasets lists will use their own software with naviga- and provide new types of information, such as tion and visualisation tools. Radiologists need functional imaging. to become more subspecialty oriented in order to be able to create added value in this pro- “These changes require new expertise from cess, and they need to focus on competence in radiologists,” said Dr. Erik Ranschaert, a specific areas, he said. They will also need to radiologist at the Jeroen Bosch Ziekenhuis become more clinically oriented so that they (JBZ), ‘s-Hertogenbosch, the Netherlands, and are able to give useful advice. Treatment of the a speaker at this afternoon’s refresher course patient is increasingly complex and requires on image sharing. “We need to be aware of the more intensive collaboration from all players entire disease process and able to analyse this involved. To be part of this imaging chain, dynamic and functional information. Multi- from image acquisition to the report, they disciplinary collaboration is also a prerequisite have to specialise and participate with other for useful integration of these new imaging disciplines. techniques with the patient’s treatment. For The newly installed Olympus screens are now up-and-running in the endo-operation suite at the Jeroen Bosch example, cardiologists are increasingly using “We need to think more broadly and creatively,” Ziekenhuis. The four monitors and the mobile rack can be seen next to the technician. (Provided by Erik Ranschaert) non-invasive imaging techniques, and advan- Ranschaert noted. “We should not limit our ced post-processing with supercomputer tech- activities to just reading images from behind nology will eventually allow them to choose our workstation. Communication skills and a less invasive procedures. These are exciting thorough knowledge of new treatment strate- developments.” gies are necessary. To increase awareness, it is important to incorporate presentations about An increasing number of surgical interven- this theme into meetings like the ECR.” tions use computer-based image-guided navi- gation techniques, such as computer-assisted An additional consideration for the future is orthopaedic and spinal surgery (see www. imaging biomarkers, which raise the prospect caos-international.org), computer-assisted of earlier detection of some diseases and pro- head and neck and ear, nose and throat sur- mises to revolutionise basic research, drug gery, image-guided neurosurgery and mini- development and treatment. He observes that mally invasive cardiovascular and thoraco- biomarkers are already enabling researchers to abdominal surgery. Also, the increasing see in detail how candidate drugs are behaving, development of surgical laparoscopy pushes from determining the percentage of receptors for a better organisation of image distribution occupied by a drug on target cells to looking because it is of major importance for preope- at a drug’s ability to cross the blood/brain bar- rative planning and intra-operative guidance, rier. This in turn can save time and money at he noted. the drug development lab bench. In particular, he is looking forward to new developments in At the University of Pisa’s modern operating room, surgeon Prof. Andrea Pietrabissa is able to integrate preoperative In oncology, there is increasing integration of target-specific MR contrast agents, which will imaging to assist a laparoscopic intervention. (Provided by D. Caramella) imaging, particularly interventional radiology, allow the in vivo visualisation of disease pro- with treatment in several areas: CT/MR diffu- cesses. MR contrast agents are being develo- sion and perfusion for planning and follow-up ped that are bound to specific targets, of which of tumour treatment, e.g. to differentiate bet- the distribution can be evaluated using MRI ween necrotic and viable parts of the tumour; (e.g. liposomes with cholesterol and PEG-con- 3D segmentation for planning of treatment taining lipids). of liver tumours; robotics used for automated navigation of a needle or other instrument in At the University of Pisa in Italy, PACS was int- brain surgery, surgery and radiation oncology; roduced 20 years ago, and for many years these interventional techniques for embolisation of systems served as ‘production tools’ designed tumours, TACE (transarterial chemo-emboli- to enhance the provision of radiological servi- sation), radioembolisation, intra-arterial che- ces. Soft-copy reporting and online access to motherapy, radiofrequency ablation (RFA), images and reports from the clinical led to a cryoablation, etc. reduction in turnaround time and helped phy- sicians to make better use of imaging, explai- This trend has contributed to the formation ned session moderator Prof. Davide Caramella, of multidisciplinary societies such as the Soci- from the department of radiology, Santa Chi- Reporting workstations at the University of Pisa allow multimodality image viewing and advanced image ety of Cardiovascular Computed Tomography ara Hospital, Pisa. Only in recent years have processing. (Provided by D. Caramella) (SCCT), the International Cancer Imaging radiologists and clinicians worked together in Society (ICIS), the Intraoperative Imaging a real multidisciplinary environment. nication technology to improve workflow and system (TIMMS), which can pave the way to Society (IOIS), the Society for Molecular Ima- quality of care in clinical settings.” patient-specific medicine. TIMMS provides ging (SMI) and others. At today’s course, Caramella’s surgical colle- a concept and framework for the collection, ague, Prof. Andrea Pietrabissa, will explain in To complete the session, Prof. Heinz Lemke organisation, and utilisation of medical infor- At the JBZ, the new operating suite is being detail about how the advent of minimally inva- from Berlin will illustrate a conceptual design mation from sources such as the electronic equipped with large screens that can be pulled sive surgery has made preoperative imaging and implementation of a novel infrastruc- medical record, PACS, etc. down from the ceiling so that surgeons can assessment of patients of paramount impor- ture: therapy imaging and model management make better use of imaging, as the diagram tance. Preoperative planning can be enhanced shows. Real-time guidance using ultrasound by the use of 3D models of the target anatomy, will also be offered. Surgery is becoming more derived from a CT dataset. Using a 3D helmet Refresher Course and more micro-invasive due to the use of with a built-in microcamera, a surgeon’s’view Monday, March 7, 16:00–17:30, Room Q endoscopic techniques, and precise guidance of the operative field can be fused with the is increasingly important. Radiologists and preoperative 3D anatomy of the patient. RC 1805 Image sharing surgeons will work together closely in areas • Chairman’s introduction like selective tumour ablation using RFA with “Imaging is part of a changing medical envi- D. Caramella; Pisa/IT ultrasound, followed by partial liver resection. ronment,” said Caramella. “As radiologists, A. Image data beyond radiology: new techniques we have to understand that the availability of E.R. Ranschaert; ’s-Hertogenbosch/NL Sharing images with colleagues outside of a image data beyond radiology is a challenge that B. Intraoperative imaging for surgeons radiologist’s own hospital is also becoming we should not be afraid to meet. In fact, it might A. Pietrabissa; Pisa/IT easier, according to Ranschaert. For most turn out to be a splendid opportunity to make C. Images and models for CAS second opinions offered in secondary or ter- our discipline more pervasive across different H.U. Lemke; Berlin/DE tiary centres, previous imaging studies are still medical domains. The future will be shaped by • Panel discussion: transferred on CD or DVD, but a more effici- our capability to use information and commu- The take-home points
myESR.org 12 ECR TODAY 2011 CLINICAL CORNER Monday, March 7, 2011
Awareness of interventional methods among generalists leads to major improvements in care
By Philip Ward • Sacroiliac joint interventions, in the form of traditional intra-articular injections or periar- An Italian musculoskeletal expert has maintai- ticular denervation (neurotomies of posterior ned that general radiologists have a special duty rami from L4 to S3). to their patients to ensure they have an up-to- date knowledge of interventional techniques. With the right indication, each procedure can prove effective as a painkilling method, “Interventional radiology, both vascular and but it is imperative to identify the correct osteo-articular, is a very fast developing discip- indications for each technique because the line about techniques, devices and indications. most frequent cause of lack of efficacy is the I think it is of the utmost importance for the wrong interpretation of the origins of the pain, general radiologist to be informed about recent Masala said. He noted that many of the causes advances in this discipline to be able to ‘see’ when of back pain fall in a sort of borderline area a patient’s disease falls in its application field,” where traditional back surgery and interventi- said Dr. Salvatore Masala, from the department onal radiology face each other. With technique of interventional radiology at the University of refinement and precise indication, interventi- Rome Tor Vergata. “Someone once said that ‘we onal radiology is increasingly gaining ground only see what we know’.” over surgery. Both of these images come from the same left S1 adhesiolysis procedure. Left: the caudal approach for adhesiol- ysis with sacral channel and perineural sleeve (as indicated) is opacified by contrast medium. Right: the approach At the opening presentation in this morning’s Back pain affects up to 50% of working adults in of Racz catheter to left S1 root is used for targeted adhesiolysis. (Provided by S. Masala) refresher course on musculoskeletal interven- any given year, he pointed out. Diseases of the tions, Masala will focus on spinal infiltrations peripheral skeleton may also produce painful and nerve blocks. He lists the main four inter- symptomatology. Some of the algogenic structu- Interventional radiology is making an increasin- of procedures, allowing an improvement of the ventional techniques available for the relief of res of the spine and peripheral skeleton are lum- gly significant overall contribution to healthcare, results and reduction of the complications.” back pain as: bar intervertebral discs, facet joints and atlanto- according to session moderator Prof. Afshin Gangi, axial/occipital joints, sacroiliac joints, nerve root from the department of interventional radiology B, Some percutaneous techniques aim to treat pain • E pidural/periradicular drug injections, consis- dura, periosteum, ligaments and fascia. Among University Hospital of Strasbourg, France. and consolidate bone (cementoplasty). Others ting of small gauge needle (<18G) injections, several aetiologies that can involve these struc- ablate or reduce the tumour (chemical and usually via translaminar/transforaminal and tures, spine degenerative pathology plays the “Minimally invasive procedures of bone and thermal ablation techniques). Interventions are paravertebral approaches; these are virtually leading role. joint require less resources, time, recovery, and carried out either on an outpatient basis or with painless procedures with a relatively steep lear- cost, and often offer reduced morbidity and mor- 24-hour hospitalisation, which cuts costs and ning curve, but the main disadvantage is their Looking to the future, Masala thinks the only tality, compared to other modalities,” he noted. offers benefits for patients of working age. Some limited duration. certainty is the continued growth of interventi- “The interventional radiologist with an efficient minimally invasive procedures can be conside- onal techniques in this area. He said he prefers imaging-guided technique like flat-panel fluo- red as alternatives to surgery without excluding • F acet joint interventions, essentially divided not to put forward a fictitious hypothesis, and he roscopy, CT or MRI can increase the precision further surgical options, Gangi pointed out. into drug-based interventions (articular or urges radiologists to do their best with existing periarticular infiltrations) and neurotomies methods and devices and to focus on delivering (e.g. radiofrequency medial branch neuro- optimum care. Refresher Course tomy). The relative ease of drug-based inter- ventions accounts for their widespread use, but “The modern radiologist should be as close as Monday, March 7, 08:30–10:00, Room D2 the drawback is their short duration. Neuroto- possible to the patient, and that is particularly RC 1509 Musculoskeletal interventions mies are more difficult procedures, based on true for the interventional one. On the other • Chairman’s introduction the operator’s ability to target the nerve invol- hand, the best clinical practice embeds its roots A. Gangi; Strasbourg/FR ved, and the main advantage is its long life. in the perfect symbiosis with different specia- A. Guidelines for spinal infiltrations and nerve blocks lists,” he stated. “Interventional radiologists who S. Masala; Rome/IT • Di sc interventions on painful nerve roots are going to perform a procedure are first of all B. Vertebroplasty and kyphoplasty impinging disc protrusions, which may be physicians, and based on professional ethics, it T. Sabharwal; London/UK reduced by nucleus pulposus shrinkage and/ is mandatory for them to treat patients clinically C. Interventional management of painful osseous metastases or local nerve ablation by several techniques, with their own hands and to lay down the correct A.G. Ryan; Waterford City/IE including electrothermal therapy, biacuplasty, indication. Updated technical knowledge and • Panel discussion: nucleoplasty, mechanical suction and O2-O3 teamwork are the leading factors for best clinical Experience-based vs evidence-based practice in spinal intervention injections. practice.”
Staff Box
Editorial Board Editors Art Direction ESR Executive Council Julia Patuzzi, Vienna/AT Robert Punz, Vienna/AT
Philip Ward, Chester/UK Maximilian F. Reiser, Munich/DE Luis Martí-Bonmatí, Valencia/ES Layout ESR President Research Committee Chairman Sub-Editor Robert Punz, Vienna/AT Simon Lee, Vienna/AT Tine Ulbing, Vienna/AT András Palkó, Szeged/HU Éamann Breatnach, Dublin/IE ESR 1st Vice-President Education Committee Chairman Contributing Writers Marketing & Advertisements Edna Astbury-Ward, Chester/UK Betty Wilk Gabriel P. Krestin, Rotterdam/NL Luís Donoso, Sabadell/ES John Bonner, London/UK E-mail: [email protected] ESR 2nd Vice-President Professional Organisation Committee Chairman John Brosky, Paris/FR Contact the Editorial Office Christian J. Herold, Vienna/AT Fred E. Avni, Brussels/BE Sarah Edwards, Vienna/AT ESR Office Past-President Subspecialties Committee Chairman Sonja Guttenbrunner, Vienna/AT Neutorgasse 9 Eva Haas, Vienna/AT Yves Menu, Paris/FR Guy Frija, Paris/FR 1010 Vienna, Austria Monika Hierath, Vienna/AT Congress Committee Chairman National Societies Committee Chairman Phone: (+43-1) 533 40 64-0 Simon Lee, Vienna/AT Fax: (+43-1) 533 40 64-441 Lorenzo Bonomo, Rome/IT Luigi Solbiati, Busto Arsizio/IT Lisa Loibl, Vienna/AT E-mail: [email protected] 1st Vice-Chairman of the Congress Committee Communication & International Relations Lucie Motloch, Vienna/AT Committee Chairman Stefanie Muzik, Vienna/AT ECR Today is published 5x during ECR 2011. José I. Bilbao, Pamplona/ES Mélisande Rouger, Vienna/AT Circulation: 20,000 2nd Vice-Chairman of the Congress Committee Katrine Åhlström-Riklund, Umeå/SE Frances Rylands-Monk, St. Meen Le Grand/France Printed by Angerer & Göschl, Vienna 2011 Finance Committee Chairman Adrian K. Dixon, Cambridge/UK Philip Ward, Chester/UK myESR.org Publications Committee Chairman Peter Baierl, Vienna/AT Executive Director
The Editorial Board, Editors and Contributing Writers make every effort to ensure that no inaccurate or misleading data, opinion or statement appears in this publication. All data and opinions appearing in the articles and advertisements herein are the sole responsibility of the contributor or advertiser concerned. Therefore the Editorial Board, Editors and Contributing Writers and their respective employees accept no liability whatsoever for the consequences of any such inaccurate or misleading data, opinion or statement. Advertising rates valid as per January 2011. Unless otherwise indicated all pictures © ESR – European Society of Radiology
myESR.org Monday, March 7, 2011 CLINICAL CORNER ECR TODAY 2011 13
Imaging unveils epilepsy’s mysteries
By Mélisande Rouger Seizure is an irritability of the brain in which imaging studies from the brain with functio- a group of neurones begin firing. Their con- nal information, imaging can definitely guide Imaging has enabled the understanding and nections become dysfunctional and they alter surgery,” Gómez-Ansón said. treatment of epilepsy, a chronic neurological the whole network. A seizure can be trigge- disorder with multiple origins. Diagnosing red by metabolites or electrolytes, but also by Cooperation with nuclear doctors and neuro- and managing epilepsy patients has been the use of drugs or by nutritional factors. physiologists must be flawless. Another pivo- made possible through advances in MRI, tal condition in improving the management while multimodality techniques enable the “Seizure is quite an important topic because of epilepsy patients is the further education acquisition of functional information that imaging departments see many patients who and subspecialisation of neuroradiologists, may be relevant to surgery and post-surgery have suffered a seizure, and there is really no according to Gómez-Ansón. follow-up, as experts will explain during a evidence to support imaging in that clinical dedicated refresher course today at the ECR. setting. The burden on the healthcare system “I really do believe in super subspecialisation High resolution T2 weighted coronal MRI, showing is huge, as the number of patients with one in radiology, because radiology is like general a heterogeneous lesion involving the right insula and The precise cause of epilepsy is still a mystery, or just a couple of seizures is very large,” she medicine, extremely broad, and epilepsy is superior temporal girus. The right hippocampus also but knowledge is increasing hand-in-hand appears more globular, but there is no hyperintensity explained. very focused,” she said. with the development of imaging techniques. within it. This image shows the improved spatial and Over the last thirty years, improvements contrast resolution, which is crucial for evaluating Imaging offers a whole variety of tools to help In the meantime, specialists can refresh their in MRI, which can depict very small brain patients with epilepsy. (Provided by B. Gómez-Ansón) set treatment planning. Surgery may be the memories at the ECR and reflect on how structures like the hippocampus, have ena- only option in intractable epilepsy and partial much impact imaging has had on the diag- bled doctors to identify a large number of complex seizures, and more and more pati- nosis and treatment planning of intractable underlying causes, particularly for intracta- mainly caused by non-neoplastic conditions, ents are being treated with it. If these seizures epilepsy. ble epilepsy. such as hippocampus sclerosis, or abnorma- are not treated, they can damage the cognitive lities of cortical development, either congeni- functions of the patients, and eventually their “If there is a field where imaging has had tal or related to an infancy condition. entire brains. Once the affected part of the Refresher Course an impact, it is certainly in patients with brain is removed, patients may recover their Monday, March 7, 08:30–10:00, Room G/H intractable epilepsy,” said Dr. Beatriz Gómez- Tumours can also trigger seizures and lead to full cognitive status. After surgery, imaging RC 1511 Epilepsy Ansón, head of the Neuroradiology Unit epilepsy, especially in adults. Any benign or can reveal whether the lesion or tumour that at Hospital Sant Pau in Barcelona, who will malignant brain tumour can be responsible was responsible for seizures has been excised. • Chairman’s introduction chair the course. for seizures. Brain tumour-related epileptoge- B. Gómez-Ansón; Barcelona/ES nesis is not yet fully understood, but one can MRI usually provides sufficient structural A. Tumour as a cause of Intractable epilepsy only affects 5% of all epi- list a number of factors that play an important information to show, for instance, where epilepsy lepsy patients but its impact is considerable role in this process, including the disruption a tumour is located. But when MRI fails to M. Stajgis; Poznan/PL for the sufferers, with seizures that can occur of physiological neuronal structure, a tumour reveal structural pathology, other modalities B. Non-neoplastic causes as often as every minute and require constant affecting the release of neurotransmitters, and can be taken into account. Single photon- of epilepsy M.A. Papathanasiou; hospitalisation. This condition is even more abnormal electrical activity of the brain. emission computed tomography (SPECT) Athens/GR of a burden given that it is resistant to drugs, and magnetoencephalography (MEG), C. Multimodality epilepsy meaning that the only possible treatment is One should make a clear differentiation bet- among others, provide very useful functional protocol surgery. ween a couple of seizures and repeated sei- information. L. Stenberg; Lund/SE zures, as in epilepsy, Gómez-Ansón pointed • Panel discussion: Identifying the underlying causes of this con- out. “Not every seizure is epilepsy and epi- “These functional techniques may be able Imaging epilepsy? dition is crucial. Thanks to imaging, physi- lepsy is a certain condition among patients to provide indications about the area of the cians now know that intractable epilepsy is with seizures,” she said. brain that is firing. If you combine structural Molecular imaging made easy for radiologists
By Mélisande Rouger successfully been investigated with this tool. profound knowledge of pathologies and mole- As well as being reliable and relatively cheap cular mechanisms in order to select how the dia- Today, most of the research done in molecular (400,000 euros) it is also small, which could faci- gnosis should be done,” he said. imaging is performed not by radiologists but by litate its installation in hospitals or ambulances. scientists from other disciplines. As ultrasound, However, doubts remain as to whether mole- optics and MR are gaining weight in pre-clinical “Optical imaging will be widely used in clinics, cular imaging will become strong in the clinic. imaging, it is very probable that they will soon which is why I think it’s very important to talk Subspecialisation and training would certainly compete with PET and SPECT, currently the about it now,” Kiessling believes. help to raise attention to the tremendous pos- most widely used molecular imaging modali- sibilities offered by reading cellular functions. ties in practices. With this whole range of tools Experts will also present their work with ultra- The European Institute for Biomedical Imaging about to make their way into the clinic, radiolo- sound (US) in the imaging of angiogenesis, can- Research (EIBIR) already offers training work- gists should seize the opportunity to be among cer and plaque characterisation. shops in cell imaging via its ENCITE project. the first to master these techniques. But one major aim of the ECR session is to push “I did a lot of molecular MRI in the past, and I for the creation of a master’s degree in molecu- A dedicated session this morning will deliver key, am very sceptical about whether it will broadly lar imaging, Kiessling underlined. “We all think simple tips about the current possibilities offered Fabian M.A.Kiessling from Aachen/DE will chair this make its way into the clinics within the next years that it will change the diagnostic procedure in by various modalities, to spark radiologists’ inte- morning’s Special Focus Session. because it is less sensitive than PET or optics or the future, so it is very important that radiolo- rest in functional and molecular imaging. even US,” Kiessling said. However, molecular gists are going on with this,” he concluded. agents may be used to identify healthy tissues “Our aim is to give radiologists an introduction involved. Most of them have a rough idea of like lymph nodes and thus delineate patholo- to molecular imaging. It should guide them what it is about. They may know FDG-PET and gies by their non-enhancement. In the long run, through this field by giving them useful know- other PET and SPECT applications but not con- hyperpolarised agents may significantly broa- Special Focus Session ledge and explaining how they can become sider that Gd-DTPA-EOB enhanced liver MRI, den the capability of MRI in molecular imaging. Monday, March 7, 08:30–10:00, Room E1 active in their institution,” said Fabian M.A. SPIO-enhanced lymph node and liver imaging, SF 15a Molecular imaging made easy Kiessling, Professor of Experimental Molecular and MR-spectroscopy are also molecular ima- Further developments in PET and SPECT Imaging at Aachen University Hospital, who ging applications in principle,” Kiessling said. should also encourage radiologists to acquire • Chairman’s introduction will chair the session. skills in nuclear imaging. Its current use in cli- F.M.A. Kiessling; Aachen/DE In particular optical imaging could be a great nics seems to be just the tip of the iceberg and • Probes and targets in Except for a few brilliant specialists, most radio- chance for imaging professionals to get started. many more applications will be possible within optical imaging logists have limited involvement with molecular In pre-clinical imaging, optics are the classical a few years. Its refinement will trigger a redefini- C.W.G.M. Löwik; Leiden/NL imaging, but interest is growing. A session on the tool to investigate on a small animal. tion of diagnostic imaging, Kiessling envisions. • Ultrasound providing topic during the last German Congress of Radio- molecular imaging M. Palmowski; Aachen/DE logy attracted crowds of delegates, mainly young Successful examples of work done with optics “Molecular imaging is already here but there radiologists seemingly keeping an eye on these are many, from 2008 Nobel Prize chemist Roger is still much more potential. It should be of big • MR in molecular imaging E.A. Schellenberger; Berlin/DE tools from the very beginning of their training. Y. Tsien and his studies with GFP and RFP (flu- interest to the radiologist; it adds a tool to the orescent proteins) to the recent introduction of specialisation of diagnostic radiologists. In my • Panel discussion: Which role can radiologists easily play in “Currently molecular imaging research is domi- the fluorescence camera system Xiralite®, which opinion, the diagnostic radiologist as we know molecular imaging? nated by biologists, chemists and nuclear doc- enables diagnostic imaging of rheumatoid arth- him/her now will disappear, and I have the fee- A.K. Dixon; Cambridge/UK tors. But now that we are moving towards clinics, ritis in the joints of both hands. ling that in the future radiologists will become there is more point for radiologists to get closely Over the past few months, 300 to 400 cases have universal diagnostic doctors. They will need
myESR.org 14 ECR TODAY 2011 CLINICAL CORNER Monday, March 7, 2011
New interventional approaches widen horizons for liver cancer patients
By Frances Rylands-Monk RF ablation are being studied in a multicentre randomised trial now in its second year. The incidence of hepatocellular carcinoma (HCC) has increased steadily, particularly “TACE can first reduce the size of the tumour, due to the spread of chronic hepatitis C virus so that those patients who aren’t candidates (HCV). Surgery and liver transplantation are for surgery, or whose tumours are a little being used widely, but emerging interventional too large for ablation, initially can still profit techniques can offer improved palliative care from curative ablation rather than palliative and potentially life-saving cures. Further clinical treatment,” Lammer said. trial results must still be established. Where possible, surgery is still the best option Rapid advances are occurring in the trans-arterial CT of hepatocellular carcinoma (HCC) before trans- MR of HCC before TACE. in terms of patient survival, and there is less treatment of hepatic tumours, and a special focus arterial chemo-embolisation (TACE). chance of liver cancer returning, but if research session on this hot topic looks certain to generate over the next couple of years proves that a considerable interest today at ECR. combined approach is effective, its routine use in the clinical setting will increase, he added. According to the Milan Criteria, liver transplantation may be considered if a tumour In another large randomised international is less than 5 cm in diameter, or if there are two study, at present in its early stages, a combined or three lesions each of less than 3 cm in size. approach to palliative treatment using systemic If the tumour is confined to one lobe and the drug therapy with sorafenib in combination residual lobe has good function, then resection with TACE using drug-eluting beads is under becomes an option. Also, radiofrequency (RF) evaluation. ablation can be considered if the tumour is no larger than 5 cm in diameter. Radiologists who want to learn more about Angiogram of HCC before TACE. Angiogram after TACE with drug-eluting beads. which patients should be a candidate for surgery For around 80% of liver cancer patients, no (All images provided by J. Lammer) or RF ablation and find out what can be achieved conventional therapy is viable once the disease with TACE should certainly attend today’s has been diagnosed, which means that the with conventional TACE – which may damage Also under evaluation in large European session. They will also hear about the most patients become candidates for chemotherapy. the liver, reduce blood count and cause nausea multicentre studies is another therapeutic recent techniques using drug-eluting beads, However, because the liver is highly chemo- and hair loss – drug-eluting beads have option that involves radio-embolisation using radio-embolisation and the latest combined resistant, the traditional method of classical significantly fewer adverse side effects because beta-emitting Yttrium particles injected into approaches. systemic infusion chemotherapy is not very the therapeutic agent remains in the tumour and the tumour-feeding artery. This highly effective effective. This means that chemotherapeutic does not circulate in the patient’s body. local radiation can kill the tumour cells without agents such as doxorubicin must be infused damaging the liver. Additionally, therapies locally in high concentration into the artery “In terms of therapy options, this is likely to combining TACE with drug-eluting beads and supplying the tumour. After local application be news to many radiologists. It’s important using a catheter, arterial flow to the tumour for them to know that for patients with even must be blocked by embolisation. advanced tumours there is now a viable treatment,” said Prof. Johannes Lammer, Special Focus Session This method, trans-arterial chemo- director of cardiovascular and interventional Monday, March 7, 16:00–17:30, Room D1 embolisation (TACE), has shown promise in radiology at Vienna’s Medical University, who SF 18a Transarterial treatment of liver tumours: major advances randomised trials. Furthermore, drug-eluting will moderate the session this afternoon. beads allow small particles to be loaded with • Chairman’s introduction the chemotherapeutic agent to transport Previous options would have included J. Lammer; Vienna/AT doxorubicin directly into the tumour, blocking conventional TACE (intra-arterial drug • Advances in chemoembolisation of liver metastases arterial flow at the same time. infusion followed by embolisation) and bland M.A. Funovics; Vienna/AT embolisation without any chemotherapeutic • Embolisation of HCC with drug eluting beads Results published from a European multicentric agent. Another study published last year in the K. Malagari; Athens/GR randomised study (Johannes Lammer et al, Cardiovascular Interventional Radiology journal • Selective internal radiotherapy Cardiovasc. Intervent. Radiol. 2009) show by Dr. Katarina Malagari has demonstrated J.I. Bilbao; Pamplona/ES improved outcome compared to conventional that chemo-embolisation using drug-eluting • Combined therapies before and after ablation TACE. Drug-eluting beads used with beads compared to bland embolisation was R. Lencioni; Pisa/IT doxorubicin are now attracting attention as a significantly better in terms of subjective patient • Panel discussion: palliative life-prolonging treatment. Compared response and time to progression. Which treatment option is the best for the various stages of disease?
RCR develops initiatives to improve services for patients
The Royal College of Radiologists (RCR) has tion process supporting radiology services radiology, the first of its type in Europe. The In November 2010, to coincide with the anni- approximately 8,600 Fellows and members in the U.K. in their delivery of higher quality checklists are a vital tool in increasing the versary of Wilhelm Roentgen’s discovery of worldwide in the disciplines of clinical radio- patient-focused services. The scheme, which reliability and safety of care during radiology x-rays in 1985, the RCR was delighted to hold logy and clinical oncology. All members and has established the standards and criteria procedures, and will support the development the first in a planned series of free public lec- Fellows of the RCR are registered medical against which radiology services are assessed, of improved teamwork and communication tures in London, at the Royal Society of Medi- or dental practitioners. The RCR’s role is to accredited its first U.K. radiology service in in radiology. The RCR will continue to play an cine. The lecture, ‘Stop Worrying – Radiation advance the science and practice of radiology December 2010. ISAS is a new style of accre- active role in supporting the further develop- is Good for You’, looked at public attitudes and oncology, further public education and ditation scheme that is developmental and ment and implementation of these checklists, towards radiation, and a history of the use of promote study and research through setting user-focused, and this approach is fast beco- and monitoring progress. radiation in medicine since the early 20th cen- professional standards of practice. ming the model of service accreditation for tury. Further lectures on topics relating both U.K. healthcare. The RCR is exploring ways in which it can to clinical radiology and clinical oncology are Over the last year, the RCR has led on and help nuclear medicine physicians to train in planned for 2011. developed a number of initiatives, aimed at The development of the World Health the use of imaging. The training situation is improving services for patients and helping Organisation’s Surgical Safety Checklist for different in the United Kingdom, to mainland the RCR’s Fellows and members to achieve Radiological Interventions, published in Europe, and is likely to involve some training those improvements. The RCR is very proud April 2010, resulted from a collaborative pro- in core radiology. The RCR has close working to have been jointly responsible with the ject between the RCR and the National Pati- links with the radionuclide radiology and Society and College of Radiographers for ent Safety Agency (NPSA) in England. The nuclear medicine communities, and is keen to the development of the Imaging Services checklist was further developed in November work closely together to improve the current Accreditation Scheme (ISAS), an accredita- 2010 into a version covering interventional situation.
myESR.org Monday, March 7, 2011 CLINICAL CORNER ECR TODAY 2011 15
CT and MR make rapid and sustained clinical progress in brain perfusion
By Philip Ward much attention is in the evaluation of patients with cerebrovascular disease, both in the initial Perfusion imaging is proving increasingly use- assessment of perfusion as well as in evaluat- ful for analysing the biological behaviour of ing treatment response. Vymazal believes the central nervous system diseases, particularly greatest limitation of these techniques may be the haemodynamic features. Qualitative and that MRI is often not the preferred investiga- quantitative information can now be acquired tive method in acute situations. In non-emer- for evaluating pathoanatomical structures and gency settings, however, ASL has the benefit of pathophysiological changes of the lesions. not only being a powerful, noninvasive per- fusion imaging method but also that it allows Due to rapid technical developments, CT and the investigative physician access to the many MR perfusion are available on most modern other high quality soft-tissue imaging tech- scanners. Furthermore, early and accurate niques that can be applied in the MRI setting. diagnosis is a requisite condition for the suc- cessful treatment of vascular diseases, and per- “I expect that CT will continue be an essential fusion imaging should not be limited to large part of the workup of acute cases,” he predicted. centres but should be used by any institution “Hardware, software and contrast development treating acute and chronic vascular diseases, will continue to evolve at a rapid pace. This according to Prof. Josef Vymazal, from the will maintain the current trend of increasingly department of radiology, Na Homolce Hospi- superior images at lower and lower radiation tal, Prague, Czech Republic. doses. MRI will continue to evolve rapidly as well, as noninvasive techniques are further Ultrafast CT scanners can cover most of the refined and additional complementary proto- brain with perfusion imaging, but there is wide- cols are further developed and perfected.” spread concern about radiation dose levels. In general, he thinks this concern is justified. The term ‘perfusion imaging’ is extensively used, but is in fact a misnomer because per- “CT is a significant source of radiation for the fusion and blood flow are not the only imag- population of developed countries. However, ing biomarkers of microvascular structure and newer CT scanners are able to deliver high function in common use, commented Prof. quality images, while exposing the patient Alan Jackson, from the Division of Imaging to less radiation,” said Vymazal, who will be Science & and Biomedical Engineering, Uni- speaking at this afternoon’s Special Focus Ses- versity of Manchester, U.K. Indeed, in onco- sion on brain perfusion. “The radiation dose logical applications, measurements of pro- is also dependent on the type of examina- portional blood volume, endothelial capillary tion performed. For example, newer scanners permeability or vessel size can be of equal or can perform examinations of the heart while greater importance. exposing the patient to 10 times less radiation than older scanners.” At today’s session, he will review the biological rationale for using perfusion imaging in brain MRI has the advantage of performing a contrast tumours, the methods available for the imag- agent-free perfusion study using arterial spin ing of microvascular structure and function in labelling (ASL). ASL describes a group of MR brain tumours, and the methods for dynamic techniques that allow noninvasive perfusion contrast-enhanced imaging and its analysis. imaging, i.e. without the application of an exog- He also intends to discuss the clinical appli- enous contrast agent. Blood water is labelled cations, focusing on distinguishing abscess (by saturation or inversion) as it passes through from tumour, differentiating tumour types, a magnetic field gradient. As the labelled spins distinguishing glioblastoma from solitary flow into the imaging slice, the tissue mag- metastases, and predicting grade, histological These six images show a comparison between contrast-enhanced perfusion and non-contrast perfusion using arteri- al spin labelling technique in a 34-year-old male with a chronic obliteration of the right middle cerebral artery. In the netisation is altered and perfusion-weighted subtype and prognosis in glioblastoma. He will set of four contrast-enhanced perfusion images, A = time-to-peak (TTP), B = relative cerebral blood volume (CBV), images may be generated, he explained. also look at monitoring radiotherapy and pre- C = relative mean transit time (MTT), D = relative cerebral blood flow (CBF). The other two are pulsed arterial dicting radiotherapy response, as well as appli- spin labelling (QUIPPS II sequence) images. E: Sample of source data, signal in the circular region placed in the left ASL has found application in many research cations in clinical trials of novel therapeutic hemisphere is 102% of that in the right. F: Relative cerebral blood flow, signal in the circular region placed in the and clinical areas. One area that has received agents, particularly antiangiogenic agents. left hemisphere is 271% of that in the right. (Provided by J. Vymazal)
Special Focus Session
Monday, March 7, 16:00–17:30, Room F2 SF 18b Brain perfusion made easy: CT/MR? • Chairman’s introduction E.T. Tali; Ankara/TR • Techniques for CT and MR, post-processing, radiation R.A. Meuli; Lausanne/CH • Brain tumours A. Jackson; Manchester/UK • Stroke and vascular diseases J. Vymazal; Prague/CZ Mobile Guide • Panel discussion: Guidelines, recommendations, hints and tips to get more from perfusion imaging in CNS m.myESR.org pathologies Get ECR on your smartphone and always stay up to date! The ECR Mobile Guide brings ECR 2011 to the palm of your hand. Find out all about: ▶ Sessions/Lectures ▶ Abstracts ▶ Exhibitors ▶ Floorplans ▶ Places to be
myESR.org 16 ECR TODAY 2011 CLINICAL CORNER Monday, March 8, 2011
Advanced imaging has growing clinical impact on bone tumours
By Philip Ward
Advanced functional MRI offers huge clini- cal potential in the management of patients with bone tumours, but more research is needed to find out which types of tumours can be staged accurately with diffusion- weighted imaging (DWI) and dynamic con- trast-enhanced MR (DCE-MR). There is still a lack of standardisation in imaging acqui- sition and interpretation, and more training for radiologists in the interpretation of bone tumour images would be valuable.
These are the views of Dr. Steven Pans, a musculoskeletal radiologist and MR resear- cher at Leuven University Hospital in Bel- gium. He thinks DWI is an emerging tech- nique in musculoskeletal-related oncology that can be easily integrated into existing MR protocols and will soon be available on every In addition to the localisation of a lesion within the MR unit. skeleton and the affected bone, radiologists must describe the patterns of bone destruction, periosteal “There is a need for functional information response and matrix mineralisation. In this image, the on MR,” he explained. “Over the past 10 to lesion shows an eccentric epimetaphyseal localisati- 15 years, assessment of malignant tumour on in the proximal tibia. It has caused a geographic disease with MR has been based mainly on osteolysis with a narrow zone of transition, complete morphological changes, whereas functional cortical destruction, a shell-like periosteal reaction and some internal trabeculations. In a young adult changes have not been visualised. Integra- with fused growth plates, the most likely diagnosis is tion of functional data is possible by intro- giant cell tumour. (Provided by K. Wörtler) ducing DWI and DCE-MR. By the introduc- 42-year-old woman with breast cancer and pelvic pain. Bone metastases in the right iliac wing and left sacrum tion of whole-body and whole-body DWI, are visible on T1 (top left), STIR (top right) and coronal reformatted diffusion-weighted (b1000, bottom left) detection of malignancy could be useful, images. A fusion of the DWI image and a T1 image shows the locations of bone metastases (bottom right). similar to PET.” (Provided by S. Pans)
Pans will be one of three expert speakers tened, creating an opportunity to combine understanding the limitations, handling the toring therapeutic response in malignant at this afternoon’s refresher course on bone anatomical imaging with functional sequen- pitfalls and optimising the technique will bone tumours. However, the clinical impact tumours. Attendees will learn about the cli- ces like DWI and DCE-MRI. The combined help to move it forward, concluded Pans, of these techniques would be higher if they nical impact of advanced imaging and when MR examination provides sufficient infor- who is currently working on a paediatric could assess response to chemo or radio- advanced techniques should be used. mation for staging and treatment planning. study of bone sarcoma that involves compa- therapy at an earlier course of treatment, or ring and correlating DWI results with histo- even if they could predict it.” DWI can play an important role in more In multiple myeloma patients, the modality pathology. accurate staging and therapy assessment, of choice for screening is whole body MR In this regard, molecular imaging techniques and should be performed in every patient and DWI, according to Pans. Even in breast CT is typically used to obtain information on might allow for a more specific evaluation in with a suspicious malignant bone tumour, he cancer and lymphoma patients, promising a bone lesion that is not sufficiently depic- the future, added Wörtler. High-resolution noted. In certain types of bone tumours, such results have been obtained in feasibility ted by radiography, e.g. due to location at MR techniques will show the tumour and its as lymphoma and bone sarcoma, it is feasible studies comparing DWI with nuclear bone a site of complex skeletal anatomy such as relationship to adjacent anatomic structures to estimate the percentage of viable tumour scanning, CT and PET/CT. The absence of the spine, pelvis or shoulder girdle or due in more detail, and thus might improve local tissue and tumour necrosis. Also, DWI can ionising radiation makes MR interesting for to limited contrast resolution, according staging of malignancies. be useful in differentiating between malig- staging and follow-up after therapy. Because to Dr. Klaus Wörtler, associate professor of nant and benign fractures in cancer patients. of the growing need for radiation dose radiology at the University of Munich. MRI, Furthermore, an important future trend will reduction, he thinks advanced MR techno- on the other hand, is particularly helpful to be the concentration of specific knowledge at At Leuven, researchers are investigating the logy will become more important in imaging demonstrate tissue composition and internal reference centres with teleradiology facilities. feasibility of whole body DWI and PET/CT the paediatric oncology patient. morphology in cystic bone lesions and car- in screening cancer patients for bone metas- tilaginous tumours, as well as some vascular tases, particularly in breast and gastrointesti- “In screening for bone metastases by whole lesions, but the modality is limited by its ina- nal cases. They have established several study body MR and DWI in certain cancer patient bility to depict mineralised bone substance. protocols to define the role of DWI in mali- groups, there is no need for contrast admi- Therefore, radiography remains the gold gnant bone and soft tissue tumours, and the nistration,” he added. “Because of its high standard for the evaluation of solitary bone first results are very promising. Patients with sensitivity to bone marrow pathology com- lesions. a bone tumour that suggests an osteosar- pared with CT, MR can be used to guide coma or Ewing’s sarcoma are scanned with bone marrow biopsies.” “Personally, I am not too euphoric about the usual MRI sequences combined with solving all problems with new imaging tech- dynamic MR and DWI, both in a diagnostic Depending on the type of cancer, the patient niques or applications,” he warned. “In the setup and in the preoperative phase. During can be screened not only for bony metastases differentiation of benign, and in particular chemotherapy, patients are scanned at pre- but also for visceral (e.g., liver) and soft tis- low-grade, malignant tumours, imaging defined time-points to estimate or assess the sue metastases in a single MR examination. will probably not be able to replace biopsy percentage of tumour necrosis that correla- Advanced tools can also be used for haema- and histopathologic evaluation, even with tes to the outcome of the patient. The inter- tology patients and in patients suffering advanced techniques. Perfusion and diffu- val MR examinations are performed without from primary bone sarcomas or malignant sion imaging can already be used for moni- gadolinium contrast injection. bone tumours.
“Early treatment response, treatment pre- Different vendors are involved in developing Refresher Course diction and outcome will become the major software for handling the data of advanced issue in oncology-related radiology,” Pans imaging, and this helps interpretation of the Monday, March 7, 16:00–17:30, Room E1 predicted. “I believe in the potential clinical images and comparing different MR exams RC 1810 Bone tumours role of DWI in certain types of bone tumours during follow up, stated Pans. To define the • Chairman’s introduction and in treatment of bone metastases in seve- different b-values, the number of b-values and J.L. Bloem; Leiden/NL ral types of cancer. It could have a guiding the apparent diffusion coefficient (ADC) value A. Diagnosis: from radiographs to MRI role in treatment planning. Further studies of the different types of bone tumours is essen- K. Wörtler; Munich/DE are necessary to confirm this opinion.” tial to compare the results of different studies, B. Staging and intervention and this means uniformity in scan protocols S. James; Birmingham/UK In his department, almost every patient with is necessary for future success. Multicentre C. New techniques (including DWI) a suspicious malignant bone tumour and soft studies are necessary for development of more S. Pans; Leuven/BE tissue tumour is scanned with high-resolu- standardised protocols and sequences. • Panel discussion: tion anatomical sequences combined with What is the clinical impact of advanced imaging, dynamic MR and DWI. The total acquisition DWI is likely to remain a largely research and when should what kind of advanced/sophisticated time and scan sequences have been shor- topic for the next three or four years, but imaging be used?
myESR.org Monday, March 7, 2011 TECHNOLOGY FOCUS ECR TODAY 2011 17
Computer assistance Advanced News from the Inside for diagnosis neuroimaging Romanian Society and therapy becomes reality of Radiology
Today See page 19 See page 21 See page 23
Vendors line up to display innovation in mammography among digital and computed radiography exhibits
By John Bonner
Visitors to this year’s ECR technical exhibition have been able to see colour x-ray images produ- ced by a new generation of detectors. The spect- ral imaging application will soon be available on Sectra’s MicroDose Mammography system, and it is no gimmick designed merely to brighten the lives of those reading the images, according to the vendor. Instead, it aims to be a valuable dia- gnostic tool that will spare thousands of women the stress and discomfort of biopsies after routine screening has highlighted a suspicious lesion.
Prof. Mats Danielsson, who is head of the research group at the Royal Institute of Techno- logy in Stockholm that designed the new detec- tors, thinks that using spectral imaging may help to identify the 25% or so of tumours that are difficult to spot in a conventional mammo- gram. Key to the process is the detectors’ ability to count photons of different energy levels in the same low dose exposure. As different types of breast tissue absorb specific photon energies, the detectors measure variations in the transmitted radiation corresponding to the presence of fluid- filled cysts or much denser lobular cancers. Then they convert these variations into colour diffe- rences in the resulting image. Images of a hand taken with a standard CR phosphor plate (left) and a high-quality needle detector (NIP, right image). (Provided by Agfa) Breast examinations can be carried out with or without an iodine-based contrast agent. When given with contrast, image quality matches that ted radiography (CR) mammography systems, achievable with breast MRI but at a fraction of Agfa Healthcare and Carestream. Both com- the cost. Used as a screening tool without con- panies have been independently researching trast, the system allows the same short scan phosphor needle-based detectors that can pro- times as a standard mammogram. Indeed, the duce quality images at a lower radiation dose technology upgrade allows spectral imaging to than traditional phosphor powder screens. At be performed on existing mammography units the end of last year, Carestream launched the normally be used to produce standard ima- SNP-M1 Screen as an upgrade for its range of ges, with the colour function used only to look mammography systems, while Agfa unveiled its more closely at suspicious lesions. The system is DX-M digitiser in the early summer. also likely to assist investigations in challenging cases, such as women with breast implants, again Industry’s renewed focus on detector techno- providing additional detail on tissue composi- logy reflects the concerns over x-ray dose and tion from a single acquisition. patient safety, especially for children, and these concerns have filtered through from the CT area The clinical value of this product is currently to the other radiation-based imaging modali- being assessed at five hospitals before becoming ties, according to Marc De Fré, global marketing commercially available later in 2011. Danielsson, manager for Agfa’s digital radiography (DR) who co-founded Sectra’s mammography subsidi- business. The new crystalline needle phosphor ary, Sectra Mamea AB, in 2000, reckons the only plate makes more efficient use of the radiation competitor providing equivalent information is exposure, and the introduction of new image GE Healthcare’s dual energy technique, which processing software allows further reductions in acquires two consecutive exposures at different dose. “The amount of radiation is continuously voltages. “There is a big difference in the under- monitored by creating an exposure index for lying technology, with theirs being focussed on every x-ray examination that the technician per- the radiation source and ours on the detector forms. We have carried out clinical studies on system,” he said. both sides of the Atlantic and these have shown a dose reduction of between 30 and 50% com- Both approaches could affect the diagnostic effici- pared with standard systems, depending on the ency and workflow in a modern radiology depart- type of examination,” he explained. ment, but he feels that the Sectra system can pro- duce the more fundamental changes. “This is the He thinks that developments like this will finally first time that colour images have been produced put an end to speculation as to whether DR will using conventional x-rays. We have been looking eventually replace CR, or vice versa. “It is not in black and white for more than 110 years, so we going to be a case of ‘either/or’; the two tech- have completely changed the game.” nologies will continue to co-exist. The choice The mammogram shows a round lesion that could be either malign or benign. This would have been hard to deter- depends of various factors – it depends on the mine by using regular mammography without the spectral information (left). Using spectral technology (right), it was found that the lesion’s composition was very close to water and therefore most probably a benign cyst rather More innovation is on display at the exhibition than cancerous. The result was confirmed by a needle biopsy. (Provided by Sectra) booths of two major manufacturers of compu- continued on page 18
myESR.org 18 ECR TODAY 2011 TECHNOLOGY FOCUS Monday, March 7, 2011
continued from page 17
hospital, the workflow and the types of examina- tions performed. What we have shown is that CR examinations can be performed using a dose that almost matches that used in DR and at a much more affordable price.”
Tony Graule, European sales and development manager for Carestream’s CR/DR product port- folio, emphasises that the radiologist and hospi- tal administrator will share in the benefits of the introduction of needle phosphor technologies. “In studies that we will be describing at ECR, we have demonstrated that there is a significantly reduced noise level in the signal, which results in improved diagnostic detail. We can see the sort of microcalcifications that are sometimes missed in conventional mammography systems. So that means a more secure diagnosis, a more efficient screening programme with fewer recalls and bet- ter productivity.”
Vendors are also looking to improve on flat panel detectors for the mobile digital x-ray systems that are used throughout the hospital, but particu- larly in operating rooms and intensive care units. Jens Felsner, head of product management for The Mobilett XP from Siemens is a digital mobile x-ray system with flat panel detector technology and instantaneous image display that can be integrated into standard clinical mobile x-ray systems at Siemens, reckons that processes. wireless systems will soon become the industry standard because they offer a range of benefits in while its compact design, counterbalanced swivel business. “Detectors with cables for portable Performance studies have shown that the new terms of convenience with high quality images. arm and integrated motor make it easily mano- x-ray devices have been available for some time, system will allow a 40 to 50% reduction in dose His company is demonstrating the first of these euvrable in a cramped and busy environment. but we have had misgivings about them. They compared with conventional analogue x-rays, products as a work-in-progress at ECR. Furthermore, with its newest DR system, Sie- tend to be cumbersome, difficult to position and yet it has the same detector technology and the mens is offering the sort of integrated service and unhygienic. They come equipped with cables up same pre and post image processing software as The detector is being developed for use with Sie- remote fault diagnosis that has only been available to 3 m long that can easily pick up bacteria and large fixed systems, he said. mens’ Mobilett XP digital platform, which repor- previously with high-end MR and CT machines. transport it all around the hospital, even to the tedly offers the highest imaging power for its bedside of a critically ill patient.” The technical exhibition will be open today bet- size of any mobile system on the market. Its high Infection control is another issue that must ween 10:00 and 14:00 hours. resolution, seven million pixel detector provides be considered, observed Christian Neumann, A new product from Philips in this area should comparable image quality to a fixed position unit, director of strategic marketing for Philips’ x-ray be available during the second half of 2011. ESTI: chest radiology beyond lung structure
By Hans-Ulrich Kauczor, ESTI President
Chest radiology has become a key discipline for a series of recent groundbreaking technological developments. They involve all major radio- logical imaging techniques such as CT, MRI, PET, hybrid imaging and ultrasonography, and benefit from high imaging speed; gating tech- niques, either respiratory, cardiac or intrinsic; signal enhancement technologies including new contrast agents and mechanisms, as well as new probes and targets.
The Scientific work of ESTI The aim of the European Society of Thoracic Imaging (ESTI) is to promote cutting edge sci- ence, basic knowledge, and expertise in clinical applications, with the current major topics being: • MRI of the chest for comprehensive imaging of structure and function for a broad range of lung diseases, especially cystic fibrosis • Inflammation imaging The 19th annual ESTI meeting, a joint meeting with the Fleischner Society, will take place in Heidelberg, Germany, June 23–25, 2011. • M ultidirectional blood flow imaging • D ual energy or spectral CT of the lung, e.g. ventilation imaging using xenon gas regard to European guidelines for lung cancer The international faculty with world-renowned Fleischner Society, Society of Thoracic Radiol- • D ose reduction on chest CT including iterative screening and the respective offers of healthcare speakers will also serve new formats: ogy (STR), Japanese Society of Thoracic Radiol- image reconstruction and filters providers. • Multidisciplinarity: radiology, imaging, respi- ogy and Korean Society of Thoracic Radiology. • Real-time visualisation of lung function: ‘watch ratory medicine and oncology the lungs work’ Chronic airway disease and definition of CT- • ESTI meets the European Respiratory Society For 2011, ESTI announces a new affiliation with • Imaging of tumour biology phenotypes in COPD are important for the (ERS) the Journal of Thoracic Imaging (JTI) as our sub- • Imaging of cardiopulmonary interaction assessment of smoking-associated lung disease • Dedicated training course in chest radiology in specialty journal, publishing a variety of ESTI • Interventional radiology in the chest in screening cohorts for lung cancer as well as for German (Fit für den Facharzt) content, including annual meeting abstracts, genotype-phenotype correlation in large cohort • ESTI meets the Italian ‘Sezione Radiologia selected society announcements and advertise- These ongoing, mainly translational research studies, such as COPACETIC; COSYCONET toracica - Società Italiana Radiologia Medica ments for the annual ESTI meeting. ESTI mem- activities are complemented by a renaissance and COPDGene. (SIRM)’ bers will also receive individual subscriptions to of straightforward CT applications due to cur- • How-to-do-it courses JTI (hardcopy and online). With JTI becoming rent large-scale studies and the generated evi- ESTI meeting 2011 • Read-with-the-expert sessions its official chest radiology journal, ESTI will suc- dence. These include screening for lung cancer, All these topics will be highlighted during the • The lung in screening and population-based ceed in both generating new attractive benefits as the American National Lung Screening Trial 19th annual ESTI meeting, which will be held as imaging for our members and in gaining increased vis- (NLST) just reported a significant survival ben- a joint meeting with the Fleischner Society, with ibility for our activities and the research of our efit for low dose CT screening. The NLST is a a strong interdisciplinary scope, in Heidelberg, We believe that ESTI 2011 will, as always, be an members. randomised trial involving more than 53,000 Germany, on June 23–25, 2011. Beyond plenary excellent meeting and a great opportunity for current and former heavy smokers aged 55 to 74 sessions of the major lung diseases, two parallel all to join together and address best practice in From 2011 onwards, ESTI will also enter into in order to compare the effects of low-dose CT tracks will be offered: chest radiology. a closer collaboration with the STR, to foster and standard chest x-ray on lung cancer mortal- • Current methodological and technological exchange between Europe and America. ity. Participants in the CT arm had 20% fewer aspects of chest imaging Recent achievements of ESTI lung cancer deaths than in the chest x-ray arm. • The clinical role of imaging decision making As ESTI, we are strengthening our links with Further information can be found at This result requires careful interpretation with and basic knowledge for non-radiologists our partner societies worldwide such as the www.esti2011.org; www.esti-society.org
myESR.org Monday, March 7, 2011 TECHNOLOGY FOCUS ECR TODAY 2011 19
Computer assistance for image-based diagnosis and therapy
By Guido Prause, Fraunhofer MEVIS, Institute for Medical Image Computing
Fraunhofer MEVIS, Institute for Medi- cal Image Computing, in Bremen/DE, is a research and development centre for compu- ter assistance in image-based medicine. After almost 15 years of being an independent non- for-profit research centre at the University of Bremen it was transformed in 2009 into an institute of the Fraunhofer Society, the largest organisation for applied research in Europe.
Directed by Prof. Heinz-Otto Peitgen, Fraun- hofer MEVIS has strengthened its expertise in four particular fields of research: model- ling and simulation, medical image acquisi- tion, image registration, and computer-aided detection and diagnosis. Recent develop- ments of Fraunhofer MEVIS will be presented at the IMAGINE Workshop presented by the European Institute for Biomedical Imaging Research (EIBIR).
The development of clinically useful image- based computer assistance for patient-speci- fic diagnosis and therapy has been the focus of Fraunhofer MEVIS since its inception in 1995. Based on the software platform MeVisLab (www.mevislab.de), more than 70 interdisciplinary researchers are developing image-based software assistants for epidemio- logically significant diseases such as oncologi- Combined aspects of multimodality breast imaging and diagnosis in HAMAM. Registered multimodal images (MRI, US and PEM) of the segmented lesion representing different physical and biological properties. They are visualised together with a correlated view of the breast MRI volume and the mammographic projections. cal disorders, diseases of the brain, liver and lung, as well as the cardiovascular system.
Fraunhofer MEVIS is connected with the liver, RFA-induced thermo lesions can be University of Bremen and the Jacobs Univer- calculated and optimised in advance, taking sity Bremen through four professorships. In into account the cooling effects of the blood April 2010, the Fraunhofer MEVIS Project flow. Group for Image Registration was founded at the University of Lübeck, Germany. The field • Medical image acquisition (Prof. Matthias of computer-aided detection and diagnosis Guenther): Efficient medical image com- (CAD) is developed through a partnership puting requires close interaction with the with the University of Nijmegen, the Nether- image acquisition. This is especially true lands. for MRI with its huge variety of imaging protocols and sequences. The mutual opti- HAMAM misation of MR image acquisition and com- An example of the R&D activities of Fraun- putation for various clinical applications is hofer MEVIS is the project HAMAM (Highly therefore a second recently developed field Accurate Breast Cancer Diagnosis through of research at Fraunhofer MEVIS. Like the Integration of Biological Knowledge, Novel working group for modelling and simula- Imaging Modalities, and Modelling) funded tion, the group for medical image acquisi- by the European Commission within the tion is headed by a dedicated foundation Seventh Framework Programme. The aim of professorship. HAMAM is the seamless integration of patient information and multimodality image data in • Image registration (Prof. Bernd Fischer): Risk analysis for surgical resection of a centrally located tumour. The individual liver anatomy was calculated a clinical workstation for improved diagnosis Accurate and efficient fusion of images from based on pre-operative CT images. The distance of the hepatic vessels to the tumour is indicated by a traffic light of breast cancer via established (mammogra- different modalities, time points, or pati- colour scheme. The planned cutting planes preserve the entire left liver and part of the right liver, maximising the phy, DCE-MRI) and newer (tomosynthesis, ents is a ubiquitous task in medical image volume of tumour-free remnant tissue. Risk structures such as the surrounding of important vessels crossing the 3D-US, PEM) breast imaging modalities. computing. It has a strong relevance to cutting planes are colour-coded according to their distance to the vessel. Eight of the leading European research ins- many clinical applications such as multi- titutes and centres for breast cancer diag- modality imaging, therapy planning, image nosis cooperate in the HAMAM project. It guidance, and response monitoring. This is scientifically coordinated by Fraunhofer field of strategic importance is developed in MEVIS and supported by an international cli- close cooperation with the newly establis- nical advisory board consisting of recognised hed Fraunhofer MEVIS Project Group at the experts from Europe and the U.S. University of Lübeck.
Recent Developments • Computer-aided detection and diagnosis: Medical images enable generalised models CAD applications for early detection of of biophysical and pathological processes, as breast and lung cancer are developed in a well as diagnostic and therapeutic concepts, partnership with Prof. Karssemeijer and to be adapted and optimised to the specific Prof. van Ginneken at the University Medi- needs of an individual patient. Recent deve- cal Center in Nijmegen. lopments at Fraunhofer MEVIS are targeting four promising fields of medical imaging and Fraunhofer MEVIS maintains an internatio- image computing: nal network of more than 150 clinical, scien- tific, and academic partners. In cooperation • Modelling and simulation (Prof. Tobias with the spin-off MeVis Medical Solutions Preusser): Mathematical modelling and AG and other industrial partners, Fraunho- numerical simulation of biophysical and fer MEVIS has established a quality-assured pathological processes are essential for a innovation chain from basic research, to clini- reliable patient-specific diagnosis and the- cal prototypes, to certified medical products. Simulation-based calculation of heat distribution for an RFA applicator derived from patient-individual CT images. rapy. An example is the planning and risk The temperature is calculated in the grid crossings. Areas of high temperature variation around the applicator assessment of radiofrequency ablations Information: www.mevis.fraunhofer.de (heat source) and the vessels (heat sink) are resolved by a finer grid. The red isolines represent locations of same (RFA) of liver tumours. Based on the know- temperature. The small distances of isolines close to the applicator indicate a large decrease in temperature. The ledge of the individual anatomy of a patient’s cooling effect of vessels induces a deformation of isolines.
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Doctors and engineers go hand in hand to bring advanced neuro-imaging from research to clinical reality
By Stefan Sunaert, Paul Suetens; Medical Imaging Research Center, University Hospitals Gasthuisberg, K.U.Leuven, Belgium; Paul M. Parizel, Jan Sijbers; Dept. of Radiology, Antwerp University Hospital & Vision Lab, University of Antwerp, Belgium; Dirk Loeckx, Wim Van Hecke; icoMetrix, Belgium
Neurodegenerative and neuro-oncologic dis- orders impose an ever-increasing burden on society. In the coming decade, neuroscientists will face the daunting challenge of unravelling the complex pathophysiology of these disorders. There is hope that innovative neuro-imaging Multimodal quantitative tumour characterisation: Axial images in a patient with a left frontoparietal brain tumour. From left to right: axial T2-weighted image, apparent methods (including new data acquisition tech- diffusion coefficient (ADC) map, cerebral blood volume (CBV) map, and Gd-enhanced T1-weighted image. Tumour heterogeneity can be derived from patterns of increased/ niques and image analysis software) will help to decreased ADC, CBV, and/or Gadolinium enhancement, indicating breakdown of the blood-brain-barrier. (Provided by S. Sunaert) tackle this challenge. The increased complexity of neuro-imaging protocols requires a close col- laboration between medical doctors, engineers and physicists. Diffusion tensor imaging (DTI) is a relatively Such a partnership is available in the Medical new MR technique, which is used to characte- Imaging Research Center (MIRC) in Leuven, rise the orientation and integrity of white matter Belgium. The MIRC, headed by professor Paul fibres. In DTI group studies, images of multiple Suetens, is a multidisciplinary research centre patients are registered and compared. In this way, that merges extensive expertise in life-sciences the investigator can study and quantify changes and engineering. MIRC is physically located in white matter structure caused by the disease. within the university hospital. By placing medi- Thanks to the combination of state-of-the-art cal doctors and imaging engineers side-by-side, viscous fluid image registration and image pro- we are able to conceive, develop, validate and cessing methodologies specifically adapted to disseminate innovative medical imaging applica- DTI images, we have developed a highly accurate tions. The juxtaposition promotes cross-fertilisa- framework for voxel-based DTI studies. tion to produce technically feasible solutions to clinically relevant problems. The DTI group study has been extensively vali- dated and applied. We have successfully used The MIRC is proud to be a co-founding partner this technique to show significant white matter of EIBIR and has developed significant collabo- differences between mildly impaired MS patients rations with other research groups. For several and control subjects. In addition, our diffusion years there has been a fruitful and productive measures correlated with measures of cognitive alliance with Prof. Paul M. Parizel and the neuro- decline in parietal, frontal, as well as temporal radiology group at Antwerp University Hospital white matter (WM) regions. It has been shown (UZA), as well as with Prof. Jan Sijbers and his that DTI-derived parameters have the requi- team of medical physicists at the Vision Lab of red sensitivity to quantify neural changes rela- the University of Antwerp (UA). This article pro- ted to chemotherapy-induced mild cognitive vides a few examples of how this collaboration impairment. Furthermore, we have performed leads to novel research and diagnostic methods. DTI group studies in patients with Amyotro- phic Lateral Sclerosis, Huntington’s disease, and In the neurosciences, group studies are recei- autism, with many more ongoing. ving an ever-increasing amount of attention. In group studies, multiple patients (and control Multidisciplinary collaboration leads to direct subjects) are studied jointly. By accurately ali- improvements in diagnosis and treatment. For gning or registering the images, corresponding example, multimodal quantitative tumour cha- brain regions can be statistically compared. With racterisation [Fig 1] requires the combined the adoption of non-rigid image registration analysis and interpretation of multiple MR Presurgical fMRI and DTI in a patient with a meningioma, which compresses the right frontal lobe. (A) Three fMRI methods to align the images, group studies allow acquisition techniques, all of which contain experiments were performed: lip pouting (top row), bilateral finger tapping (middle row) and toe flexion/extension investigators to study and quantify the evolution complementary information about the tumour. (bottom row). The somatotopical organisation of the primary sensorimotor cortex (SM1) is clearly demonstrated, with the foot representation located most medially, the lip representation most laterally and the hand representa- of a neurologic disease over time, study the effect This allows more accurate classification of brain tion in between. In the right hemisphere, activation foci corresponding to the hand and lip representation in SM1 of therapy, and compare different patient groups. tumours and improves treatment planning and are slightly displaced posteriorly, as compared with the normal left hemisphere. Note that the activation of the As an example, we present two of our recent con- follow-up. supplementary motor area (SMA) is located in close vicinity to the lesion. (B) The corticospinal tracts were recon- tributions: SPARC and voxel-based DTI group structed using fibre tractography. The right corticospinal tract is compressed by the meningioma and is situated studies. Treatment planning can further be improved in close proximity to the border of the tumour. (Provided by S. Sunaert) by taking into account both functional (fMRI, SPARC presents a unified framework for auto- perfusion) and structural (DTI) information. matic Segmentation, Probabilistic Atlas const- Functional imaging yields information about the neers. Both disciplines increase their understan- fast and secure internet connections, image data ruction, Registration and Clustering of anatomi- displacement and re-organisation of functional ding of each other, providing real solutions to can be transferred from the hospital to an image cal brain MR images. It offers the opportunity to brain units around the tumour, with the goal of clinical problems. analysis centre. Scientists at the image analysis perform a global population analysis, providing saving functionally important cortex. DTI pro- centre process the data and return a report to new insights in disease-specific structural chan- vides the neurosurgeon with detailed informa- A major future challenge for our researchers is the requesting physician, providing the reques- ges and characterising subtypes of a particular tion about the displacement or invasion of white the translation of the innovative, joint medical/ ted analysis results or data quantification. This disorder. matter tracts, and can assess the connectivity of technical methodologies to clinical practice. The advanced, quantitative image interpretation is of white matter tracts between the functional units development and practical application of these great value in establishing the correct diagnosis, We have applied the SPARC framework to and the rest of the body. new image analysis methods, such as group stu- especially for those patients with early changes. neurodegenerative diseases. For example, in dies, requires highly specialised technical skills Alzheimer research, SPARC is able to automa- These examples are merely an introduction to that are hard to assimilate. For that purpose, we have founded icoMetrix, tically classify healthy volunteers, patients with the translational research performed at research a spin-off company that aims to offer advanced mild cognitive impairment, and patients with institutions such as the MIRC and UZA-UA. In our vision, widespread access to advanced medical image analysis services to the medical Alzheimer’s disease into three different groups. Other fields include cardiology, nuclear medi- image analysis methods, both for research and for community, in the field of neuro-imaging and In another study, SPARC was able to separate cine, image-guided cancer treatment, virtual clinical purposes, will be provided by the emer- beyond. icoMetrix is a joint initiative of doctors normal controls from patients with Huntington’s forensics and small-animal imaging studies. The gence of medical image analysis centres, which and engineers of the academic hospitals and disease, and indicate the morphological differen- multidisciplinary setting in the MIRC fosters are specialised in advanced data processing and medical image computing groups of the univer- ces between both groups. close collaboration between doctors and engi- quantitative analysis of medical images. Thanks to sities of Leuven and Antwerp.
myESR.org 22 ECR TODAY 2011 TECHNOLOGY FOCUS Monday, March 7, 2011
ESMRMB looks forward to a year of high level educational programmes and its 28th Annual Scientific Meeting
By ESMRMB Office
The European Society for Magnetic Resonance in Medicine and Biology (ESMRMB) has more than 1,100 active members, and aims, as a non- profit organisation, to support educational activities and research in the field defined by the society’s name. Our society was founded in 1984 as a platform for clinicians, physicists and basic scientists with an interest in the field of MR.
ESMRMB congresses offer a forum for inte- grated European research activities in basic and clinical MR applications. This year the ESMRMB will organise its 28th Annual Scientific Meeting from October 6–8, 2011, in Leipzig/Germany, offering the following highlights:
• S ir Peter Mansfield Lecture presented by Pro- fessor Richard Ernst, 1991 recipient of the Nobel Prize in Chemistry • P lenary Lectures on ‘In vivo histology by MRI?’, The next ESMRMB Annual Scientific Meeting will take place in Leipzig, Germany, October 6–8, 2011. The picture shows the entrance hall of the famous Trade Fair. ‘Gender differences in health’ and ‘MR imaging beyond the proton’ • Hot Topic Debate on the question ‘Is ASL ready School of MRI: education for physicians • 40% of the total teaching time is used for rep- European MRI Academy – Middle East: for routine clinical use in perfusion MRI?’ and technicians etition, exercises, and practical demonstra- education for physicians and technicians • Round Table Discussion on ‘MR tractography: • Eleven English language courses and one Span- tions to gain practice and intensify the learning • On e course will be held in Dubai in 2011 why DTI is not enough’ ish language course in 2011 experience. (Advanced Head & Neck MR Imaging) • EFO MP/ESMRMB Session on ‘Hybrid systems’ • D uration of course: 2.5 days, Thursday to Sat- • A ccredited by the European Federation of • 50% of the total teaching time is used for repe- • Mini-Categorical Courses including one course urday Organisations for Medical Physics (EFOMP) tition sessions in small groups (max. 15 people focusing on cellular imaging, organised by the • Interactive character with 50% of the total and the European Accreditation Council for per group) to intensify the learning experience European Network for Cell Imaging and Track- teaching time used for repetition sessions in Continuing Medical Education (EACCME) • P rofessional and didactically experienced ing Expertise (ENCITE) small groups (max. 15 people per group) to • Limited to 50 participants per course teachers from Europe • T eaching Sessions and Scientific/Clinical Focus intensify the learning experience • Accredited by the European Accreditation Sessions • P rofessional and didactically experienced Hands-On MRI: education for MRI technolo- Council for Continuing Medical Education teachers gists, radiographers and interested physicians (EACCME) and the Dubai Health Authority Clinicians and scientists under 35 years of age (as • A ccredited by the European Accreditation • Three courses are planned for 2011 (DHA) per January 1, 2011) are invited to compete for Council for Continuing Medical Education • Duration of course: 2.5 days, Thursday – Sat- • Limited to 72 participants the Young Investigator Award (YIA). In addition (EACCME) with up to 15 credits per course urday to a significant monetary prize, the prestige of • L imited to 60 participants per course • 50% vendor-specific hands-on training on The ESMRMB looks forward to welcoming the Young Investigator Award may lead to sig- scanners and workstations Europe’s MR community to its Annual Scientific nificant career benefits for the winner! Lectures on MR: education for MR physicists • Accredited by the European Accreditation Meetings and to its numerous teaching activities! and other basic or clinical scientists Council for Continuing Medical Education Besides its annual meetings, the ESMRMB offers • S ix courses are planned for 2011 (EACCME) Find out more at www.esmrmb.org a variety of educational activities: • Duration of course: 2 to 2.5 days • L imited to 30 participants Subspecialisation in academic radiology in Switzerland Current situation and views of the Chairmen of the five radiological University Departments
By Christoph D. Becker, Geneva, It is greatly appreciated by all academic teachers ing on local referral patterns, workload, logistics, All Swiss academic teachers believe that at least for the Chairmen of the Swiss Academic that the Swiss Society of Radiology has decided and existing staff positions, and different com- part of the fellowship training should be accom- Radiology Departments to officially recognise the certificates of the Euro- promise solutions and patterns therefore exist in plished abroad; fellowship grants are available pean Subspecialty Societies at the national level. each university department. at local and national levels. A period of com- Impact of Subspecialisation and recognition plementary training in a corresponding clinical of European Subspecialty Board Certificates Organisational and practical aspects There is also consensus among all university discipline is also to be recommended for some The concept of subspecialisation covers a stra- The key to implementation of sub-specialised chairmen that even in the era of radiological subspecialties, such as interventional radiology. tegic need for the future of academic radiol- radiology in a university hospital is a sufficient subspecialisation, common management of the ogy in Switzerland, regarding the domains of number of academic staff positions as well as fel- technical platform, logistics, imaging physics All academic teachers in Switzerland motivate patient care, postgraduate training, and clinical lowship positions for subspecialty training. As staff, and medical training programmes remains their candidates for subspecialty training to research. a general rule, continuous coverage of a subspe- important in order to allow efficient organisation obtain the board examinations as far as they are cialty at tumour boards, interdisciplinary confer- and to guarantee cohesion of a modern academic offered at national level (e.g. diagnostic neuro- Creation of organ-related or disease-related ences and clinical services requires at least two or radiology department. radiology, interventional neuroradiology and multidisciplinary treatment centres is currently preferably three staff members to be trained in the paediatric radiology), or at European level (e.g. underway in many large Swiss hospitals. Integra- respective field. If continuous 24-hour coverage by Postgraduate training neuroradiology, interventional radiology, and tion of radiology in such centres requires sub- subspecialists is needed, e.g. for neuroradiology or As a rule, a training programme for a radiological head and neck radiology). specialised radiologists who interact on a regular interventional radiology, even four trained staff subspecialty may be accomplished in a two-year basis with their specialised colleagues in the dif- members are required. This, however, does not period. Although five years of formal training are Last but not least, it remains important for the ferent fields of surgery, internal medicine, etc. necessarily imply exclusive activity of each staff required for the Radiology Board in Switzerland, majority of radiologists having accomplished member in the respective domains. some candidates may be able to accomplish the subspecialty training that they maintain general Although local priorities may differ from one objectives within four years, and thus dedicate radiological skills, not only in order to facilitate institution to another, the subspecialty domains Each of the ten defined subspecialties is repre- one year of their basic training to a subspecialty. internal institutional organisation, but also to be defined by the European Society of Radiology sented in at least one academic institution in the In practical terms this usually implies that the prepared for a potential future career outside the and represented by the ten corresponding Euro- country. However, the organisational structure resident or fellow participates in the daily activi- academic environment. pean Subspecialty Societies are generally consid- of sub-specialised radiology in the Swiss aca- ties of the respective subspecialty unit rather than ered appropriate for Swiss radiology. demic institutions varies considerably depend- continuing his modality-related rotations.
myESR.org Monday, March 7, 2011 TECHNOLOGY FOCUS ECR TODAY 2011 23
The EuroAIM initiative for the Evidence-Based Radiology Working Group
By Claudia Muzzupappa and Second, we must avoid unnecessary imaging 1. Involving at least one of the imaging modali- Veronica G. Nardella, Milan/IT examinations, saving money and reducing radia- ties, including interventional diagnostic/thera- tion exposure. Third, we should keep EBR within peutic procedures and nuclear medicine tests; The European Network for the Assessment of the radiologists’ remit, as a cornerstone of pro- 2. Written in English; Imaging in Medicine (EuroAIM) was initiated fessionalism. 3. Regarding humans; because evidence for the rational use of ima- 4. With an available abstract. ging technology is frequently lacking. The Euro- The main points of the work programme are as pean Institute for Biomedical Imaging Research follows: A total of 3,147 abstracts were initially found. (EIBIR) therefore decided to establish a network At a preliminary evaluation, 1,699 studies were to assess radiological technology and the evi- • To assess by means of systematic research discarded due to not fulfilling the stated inclu- dence for its best use in clinical practice. The which radiological topics are covered by sys- sion criteria. Of the remaining 1,448 papers, 807 mission of EuroAIM is to have a strong commit- tematic review or meta-analyses and which (56%) concerned diagnostic imaging procedures ment towards the field of imaging and radiology topics are not covered; and 45 (3%) concerned interventional procedu- among European radiologists, in particular defi- • To assess which radiological topics not covered res performed by radiology/nuclear medicine ned by a clinical and mathematical commitment. by systematic review or meta-analyses have specialists; 243 (17%) and 158 (11%), concerned The European Working Group on evidence- enough original primary studies to be meta- diagnostic imaging or interventional procedures based radiology (EBR WG) was initiated by analysed and which topics do not; also performed by non-radiology/nuclear medi- Francesco Sardanelli from Milan/IT Prof. Gabriel Krestin in the context of the ESR • To select more relevant topics on which pri- cine specialists, respectively. A further 13% of is Director of EuroAIM. Research Committee and produced a position mary studies are available while systematic papers (n=195) were on the estimation of a treat- paper on evidence-based radiology (F. Sardanelli reviews and meta-analyses are lacking; ment effect using diagnostic imaging or interven- et al, Eur Radiol 2010; 20:1-15). • T o create an EBR youth group with web-based tional procedures as a surrogate end-point. As a educational aims. matter of fact, there is a clear underrepresenta- Interested radiologists and residents as well as Under the lead of Prof. Francesco Sardanelli (as tion of secondary radiological studies. Moreover, colleagues from non-European countries are Director of EuroAIM) the launch meeting of the During 2010, the EBR WG performed a systema- the role and number of radiologists in the author- very welcome to contact Prof. Francesco Sarda- EBR WG was held during ECR 2010 in Vienna tic literature search for secondary studies publis- ship of radiological secondary studies as well as nelli or Dr. Giovanni Di Leo at [email protected]. on March 5, 2010, involving more than 40 mem- hed between January 2000 and April 2010. Using the publishing journal should be investigated. bers from twelve countries. There are three fun- the two main medical databases (MEDLINE and More details on the session programme can be damental reasons for this initiative. The first one EMBASE), studies were selected according the These first results were presented at the EIBIR/ found on the news page at www.eibir.org is an ethical aim: to do the best for our patients. following inclusion criteria: EuroAIM Session on March 6. News from the Romanian Society of Radiology and Medical Imaging
By Dragos Negru, President of the Romanian Society of Radiology and Medical Imaging
The Romanian Society of Radiology was founded in 1929 in Bucharest. Between 1945 and 1989 the society acted as a branch of the Medical Scientific Societies Union, and after the 1989 revolution was renamed the Romanian Society of Radiology, Imaging and Nuclear Medicine. In 2005 nuclear medicine organised its own society, so today the official name of the society is: the Romanian Society of Radiology and Medical Imaging (SRIM).
According to the statutes, the Romanian Society of Radiology and Medical Imaging is an apolitical, non-governmental and non-profit organisation, with its aim being to increase the scientific level of its members by giving access to facilities and the organisational, functional and material means to organise symposia, In October 2011, SRIM will hold the national congress in Cluj together with the Balkan Congress of Radiology. conferences and congresses. programme. During training the resident should replacement of old machines is not planned and hold the national congress in Cluj together with The structure of the society consists of six local pass exams after each module and at the end is the subject of some controversy. the Balkan Congress of Radiology. It is a special branches, founded in the traditional university of residency. Having passed the final exam, the event, planned with our colleagues from Balkan centres: Bucharest, Iasi, Cluj, Timisoara, resident becomes a radio-diagnostic specialist We are still facing another important problem countries, which will help us to better understand Craiova and Targu-Mures, which are each led and is eligible to apply for a post as a radiologist concerning the migration of our specialists our status and better integrate into Europe. by a local committee. The branches coordinate in the public or private sector. and residents in radiology abroad, especially to the scientific activity in their area and have France and Belgium but increasingly to Great Working close with the ESOR leadership, a Galen autonomy in developing scientific projects. In Romania, there are approximately 1,200 Britain and northern countries. Foundation Course was held in 2010, in Sibiu, radiologists and 250 residents in radiology. The and in 2011, Iasi will be the host for a Galen The Romanian Society of Radiology and Medical number of posts in the public sector is controlled In Romania, radiologists are allowed to work Foundation Course on neuroradiology. We expect Imaging is the body responsible for the provision by the Ministry of Health. The ratio of radiology both in the public and private sectors. The a visit from the European Training Assessment of postgraduate training in diagnostic radiology specialists to population (1,200/22 million) is low private sector is growing more and more, is Programme (ETAP) subcommittee during 2011. in Romania. This year the board of the society in comparison to most EU countries and thus extremely flexible and offers new and competitive decided to change the curricula for residents. the number of studies performed by individual machines, much more attractive salaries and We also have to mention that many of our After fruitful debates, the board adopted the radiologists is extremely high. better conditions compared to the public sector. colleagues have become members of the ECR European Curricula as the training programme We may say that today there is real competition committees and also of the boards of the various for our residents. Until 1993 the residency in The standard of equipment in diagnostic between the public and private sectors and subspecialty societies. The Romanian Society of radiology in our country was three years. Starting departments in the country is relatively low, according to the state policy concerning Radiology and Medical Imaging was extremely in 1993 the programme changed to five years. especially in small towns and rural areas. The healthcare it is not difficult to see which will be honoured to receive the invitation to participate Unfortunately, this year in July, the Ministry of purchase and replacement of the equipment the winner in the near future. in the ‘ESR Meets’ programme at ECR 2012 and Healthcare decided to reduce the residency time depends on the Ministry of Health. In the same this represents a real challenge for us. in our specialty from five to four years. We totally way as in 2009, the healthcare budget was cut SRIM holds its congresses every two years. In disagree with this point of view and we cannot in 2010 to 3.8% of the entire country’s budget 2010 the subspecialty societies for neuroradiology We are looking forward to better integrating understand the reason for such a measure. With and major new developments are in doubt at and interventional radiology, breast imaging, Romanian radiology into Europe and building the help of the ESR, we will hopefully change present. Budgeting for radiological equipment musculoskeletal and sectional imaging (CT and honest partnerships with the ESR and all other this decision and return to a five-years training is not based on a clear model and therefore MRI) held conferences. In October 2011, SRIM will European radiological societies.
myESR.org
Monday, March 7, 2011 Community News ECR TODAY 2011 25
Wroclaw: home town Exclusive interview Inside of Poland’s with incoming Find out what’s on radiology boss ESR President in Vienna today
Today See page 26 See page 27 See page 32
ESR launches European Diploma in Radiology to ensure harmonised standards in training
By Benjamin Ohr also guaranteed through the eligibility criteria, MR: The aforementioned reasons of medical mig- Comment from Dr. Éamann Breatnach, which require candidates to be members of a ration are one major factor. Apart from this, the Chairman of the Working Group on the Today at ECR 2011, examinations will take place national radiological society and have a licence ESR Diploma is an additional qualification that is European Diploma: that will be the very first to be taken as part of to practise in their respective country; the ESR always of value in terms of career development. the European Diploma in Radiology; a brand Diploma is an additional qualification. When the ESR Executive Committee decided new qualification that will provide radiologists Experience has also shown that examinations sti- to institute a European Diploma in Radiology with an objective, ESR-endorsed test of their If national societies feel in the future that the Euro- mulate learning and therefore increase the level examination it was realised that this was ability. ECR Today spoke to ESR President, Prof. pean Diploma might be a useful instrument for of knowledge and expertise. What could be better indeed a daunting task. Though the timeframe Maximilian F. Reiser, to find out more about the them to certify a European standard of qualifica- than starting postgraduate education with an exa- between this decision and the first examina- background, aims, and potential future of this tion for potential medical working migrants, this mination? tion was short, a huge amount of work has long-anticipated initiative. could lead to a legal status someday. But this would been done and it is a source of satisfaction to all be worked out in collaboration with national But also for experienced radiologists it might be the ESR that the first Europe-wide diploma will ECR Today: The vision of a European Diploma radiological and medical societies and authorities. good to prove their competence as a general radio- take place at ECR 2011. in Radiology has existed for a long time and logist. But some candidates see it as additional has been intensively discussed for years. Under ECRT: How will the examination be structured? proof of qualification independent of their nati- In order to develop the examination structure, a your presidency, the ESR has now established MR: Basically I can say that this is a high-quality onal standards. The young generation of radiolo- working group was created consisting of a wide this Diploma in a relatively short time period. examination conducted by respected European gists are thinking more ‘European’. It must also not spectrum of internationally recognised educatio- What are the main reasons for your decision to educators who are also experienced examiners. be forgotten that a certificate that you have passed nal experts in radiology, from all parts of Europe. realise this vision? The case material and questions have been pro- an examination conducted in English is of high Maximilian F. Reiser: First of all I would like to vided by experts from all subspecialty societies as value in all non-English-speaking countries. Within the working group a number of task clarify that although I was very much pushing well as the oral examiners. forces have addressed the major structural this idea it was not my single decision but one of The overall message is: ‘Take it and be proud of it!’ aspects of the diploma, including eligibility cri- the whole ESR Executive Council and it was also From the technical side it is important to point teria, the structure of the examination, and strongly supported by other European leaders out that the written parts will be run through the ECRT: Currently the examination is only open the collection of case and question material. including the national societies. This project is a ESR Assessment Tool, which has been designed to full ESR members, which means to European major step for the society and shows its efficiency. especially for radiological needs and also partially radiologists only. Will corresponding mem- The number one priority of all concerned was adapted for this Diploma examination. Also the bers be allowed to take the examination in the to create a robust, reproducible and high-qua- I think this initiative is so important as it is a case-based oral examination will be of high-qua- future? lity test of knowledge requirements in general major step in the direction of harmonising trai- lity, as it will be performed on dedicated ePACS MR: Indeed it is limited to Europeans during radiology as set out by the ESR in the ESR ning throughout Europe, showing that the Euro- stations, allowing high-resolution DICOM studies. the first run as we wanted to concentrate on our European Training Curriculum (revised 2011). pean Society of Radiology takes responsibility European members first. We have a lot of requests for radiology education and its established trai- ECRT: How is the issue of radiology subspecia- from non-European radiologists who would like I wish to thank all concerned for their com- ning standards. lisation relevant in this context? to participate in the programme. As the ESR is an mitment and their timely responses to their MR: Indeed subspecialisation is an important international society with many members from allocated tasks. I also wish to thank the nati- It might also be an instrument to facilitate medi- issue as it is reality; knowledge of all subspecialty outside Europe we are considering a similar pro- onal and subspecialty societies for their close cal migration in the future as many national areas will also be tested during the examination. It gramme for corresponding members. This is still cooperation in the nomination of examiners radiological societies are waiting for pan-Euro- is no coincidence that the ESR also supports and under discussion. and production of appropriate case material. pean structures to be established that allow them endorses subspecialty diploma and examination to assess and certify radiologists from other coun- programmes and has already defined a frame- ECRT: What are the challenges for the future? As Chairman of this working group I can report tries, especially when no national examination work for ESR endorsement. Several societies are MR: Keeping the high quality in terms of case that the structures and enthusiasm within the exists. The ESR should play a major role in this already running or planning such initiatives. material and examiners, raising the numbers of ESR have accommodated the challenge well, development and the Diploma is the basis for this. candidates as well as financing the project will and we look forward to an ongoing project, But the ESR Diploma clearly emphasises the idea be challenges for the future and upcoming presi- which represents a major educational step We have not re-invented the wheel by the way; of a being a general radiologist after specialty dents. forward for the ESR. about 20 medical specialties already run Diploma training (considering the concept of subspecialty or board examination programmes. interest training as laid out in the curriculum). Structure of the examination Postgraduate subspecialty training is also an I think this initiative also has a symbolic message ESR policy as long as it is conducted under the Part 1 (written) – Knowledge questions (MCQs) underlining the unity of the specialty. At the end umbrella of the specialty of radiology. I think the • Web-based. of the day we are all radiologists and responsible ESR could and must act as an umbrella organi- • 60 Multiple Choice Questions to the patients: ‘prove your excellence in order to sation, especially in this context, and define a • Knowledge in all subspecialty areas (including anatomy, medical physics and safety) will be become an excellent radiologist’. framework for European subspecialty examina- tested. tions. Although the societies are free to decide • The MCQs will reflect knowledge in General Radiology at a standard to be expected at the end of training as outlined in the ESR curriculum. ECRT: Does this mean that radiologists who are the details of their examinations and eligibility • Single best answer format – a single stem with 6 answer options but only one correct answer. ‘only’ nationally certified can’t be excellent ones? criteria the idea is to have uniform structures • No negative marking for incorrect answers. MR: Of course they can. Many countries have well and terminology and that the ESR is involved • The MCQ section will last 90 minutes. established high-quality training programmes and informed. Again, the ESR Diploma is meant and standards, and most of them have very good to certify general radiologists. Part 2 (written) – Short cases board examinations as well. Good training is the • Web-based radiological clinical case material. basis for good radiologists. ECRT: How many candidates have been accep- • The initial task will be a series of short imaging studies where candidates are asked to indi- ted for the first run? cate ‘normal/normal variant’ or ‘abnormal’. Nevertheless I believe that an additional volun- MR: We have limited the application to 40 can- • This will be followed by 24 short clinical radiological cases where candidates are required to tary examination shows the willingness to do didates as this was the first run and it takes a lot respond to four questions per imaging case. • Knowledge will be tested in all ten ESR-recognised subspecialty areas (see ESR curriculum). more than the minimum. We support this idea of time to examine 40 candidates orally. We are • Case material will reflect knowledge in General Radiology at a standard to be expected at the and give those with the motivation the opportu- planning to expand the limit of candidates in the end of training as outlined in the ESR curriculum. nity to do more than required. future (at least at examinations during the ECR). • The short case section will last 90 minutes.
ECRT: Does the ESR Diploma have any legal ECRT: Does that mean there will be other exa- Part 3 (oral) – Oral examination relevance and will it replace national examina- minations, aside from at the ECR? • The oral exam will be conducted by internationally recognised radiology educators working tions in the future? MR: We are planning to hold the examination under the auspices of the European Society of Radiology. MR: The national societies and authorities twice a year. Currently I cannot say more about • Two examiners per candidate. always have the last word in terms of education this. We will announce the date of the second exa- • The oral examination will last 20 minutes per candidate (10 minutes per examiner). and this will not change in the near future. At the minations when everything is finally decided. • During this part of the examination, candidates will be shown a variety of case material and will be tested on their knowledge of various aspects of the cases under discussion, including moment the ESR Diploma is in no way under- diagnosis, differential diagnosis, procedural details, outcomes, complications, safety, etc. mining any national certification or examination ECRT: Why should an individual take the exa- process and it is not intended to do so. This is mination?
myESR.org 26 ECR TODAY 2011 C Ommunity NEWS Monday, March 7, 2011
ESR spearheads consortium to identify needs in radiation protection training
By Monika Hierath grammes harmonised at EU level is a key prere- European stakeholders and professional groups quisite in order to ensure excellence in radiation relevant to radiation protection training in the One work package is dedicated to the develop- Today it is widely recognised that medical expo- protection and to implement programmes for medical field. ment and implementation of the EU study on sure continues to be by far the most significant dose optimisation in medicine. It is essential that radiation protection training of medical pro- manmade source of exposure to ionising radiation. all stakeholders in radiation protection ensure The consortium includes the European Fede- fessionals; another one deals with the organisa- It is important to know that large differences have that proper education and training are in place, ration of Organisations for Medical Physics tion of a European workshop on radiation pro- been observed in the population dose from all particularly with regard to new technologies and (EFOMP), the European Federation of Radio- tection training of medical professionals in the medical exposures between developed countries. complex medical exposure procedures that have grapher Societies (EFRS), the European Soci- EU Member States; and the third work package been developed in recent years and that are being ety for Therapeutic Radiology and Oncology aims at developing European guidance on radi- To find out whether these differences are real or introduced into clinical practice at a rapid pace. (ESTRO), the European Association of Nuclear ation protection training containing appropriate can be explained by differences in the metho- Medicine (EANM), as well as the Cardiovascu- recommendations in this field. dologies used for medical exposure surveys, or Certainly the level of education and training lar and Interventional Radiological Society of by the associated uncertainties, recent national needs to be adapted to the various specialties Europe (CIRSE). The project is supported by an Expert Advisory surveys in ten European countries have been involved, including diagnostic radiology, radio- Panel that will advise the consortium on pro- reviewed. The review included national regula- therapy, nuclear medicine, cardiology, dentistry, Although there have been individual publica- ject-related issues and observe the develop- tory frameworks, healthcare systems, methods, etc., as well as to the different kinds of work and tions and reports on the overall practical imple- ments made. The members of the panel consist and national strategies for assessing frequencies responsibility of the medical staff (medical doc- mentation of the EC Medical Exposure Directive of representatives from relevant international and doses. In summary, a difference of a factor tors, medical physicists, radiographers, mainte- in certain EU Members States, there is a need for organisations such as ICRP, WHO and IAEA, of about four in the mean per capita effective nance engineers, etc.). a comparative study on the implementation of representatives from government bodies such as dose from all x-ray examinations was observed the training aspects covered in the Directive to the German Federal Office for Radiation Protec- between the highest and the lowest estimates. In order to evaluate the status of implementation gather intelligence on the status quo of training tion, as well as representatives of European pro- The observed differences in the population dose of the EC Medical Exposure Directive’s (97/43) requirements, to identify gaps in implementa- fessional groups not covered by the consortium from medical x-rays in Europe are thought to be requirements on radiation protection training of tion, as well as to develop recommendations to members (e.g. cardiologists, gastroenterologists, real, i.e. much larger than the recognised uncer- medical professionals in the European Union, the improve harmonisation. paediatricians, dentists etc.). tainties originating from survey design. European Commission has launched an invita- tion to tender in spring 2010. Based on the result Based on the proposal submitted, the European The kick-off meeting was held at the European The differences were found to be primarily due of the tender, the 116 Radiation Protection Gui- Commission awarded the tender to the consor- Commission offices in Luxembourg in early Feb- to the different healthcare systems operating in delines on Education and Training in Radiation tium led by the ESR and assigned a budget of ruary, where project partners presented the metho- each country, which resulted in considerable Protection for Medical Exposures shall be revised. approximately €330,000. The project started in dology to be used and agreed on the next steps. variations in the amount of equipment and man- late December, 2010, and will last for 27 months. power, but also in the education and training of The European Society of Radiology (ESR) recog- It is divided into three technical work packages, For more information on the project, check the healthcare professionals. nises the importance of education and training all contributing to achieving the common objec- EU Affairs section of the ESR website. A dedi- in reducing patient doses while maintaining tive of improving the implementation of the cated project web space will also be available Therefore an integrated approach to education the desired level of quality in medical proce- Medical Exposure Directive provisions related to shortly. and training with high-standard training pro- dures, and has set up a consortium of the main radiation protection training. Poland builds its radiological future on an exceptional history
By Marek Stajgis, PLTR (May 2010, Szczecin). The new President, Vice-President for International Affairs, Prof. Marek Sasiadek, Head of the Department Polish Medical Society of Radiology of Radiology, Wrocław Medical University is full of ideas, power and willingness – the whole The Polish Medical Society of Radiology (Polskie radiological community believes in his success. Lekarskie Towarzystwo Radiologiczne – PLTR) Reorganisation of the national radiological has long traditions and is one of the oldest educational programme is also among the most radiological societies in Europe. In 2010 we urgent issues. There is a country-wide discussion celebrated the 85th anniversary of the PLTR. considering the future model of training, whether to offer five years of general radiology Our society was established during the 12th or 3+2 (general and subspecialty). Education is Congress of Polish Doctors and Naturalists which not the only issue, of course. Scientific research is was held in Warsaw, on July 13–15, 1925. In also one of the main aims of our society. The fast 1926 the society started to publish the scientific growing number of publications in European magazine Polish Radiological Review (currently and international journals is one of the things Polish Journal of Radiology). The first Editor-in- that the society is proud of. Chief was Professor Zygmunt Grudzinski, an outstanding Polish radiologist who developed The PLTR is responsible for interfacing with the a unique method of localising foreign bodies in Ministry of Health and Ministry of Education, the eyeball. Pole Maria Skłodowska-Curie, a truly The beautiful old town of Wrocław is the home of Prof. Marek Sasiadek, the new President of the and like in many other countries this requires a remarkable figure in the history of science, perhaps Polish Medical Society of Radiology. lot of strength and patience. One can not forget the most famous of all women scientists and the about the working conditions of radiologists and first person ever to receive two Nobel Prizes had technicians – this is also a goal in our daily work. very strong relations with our society, resulting of Neuroradiology (Cracow, 2008). A number among different medical specialties, to maintain in the publishing of some highly notable articles. of meetings were held in 2009–2010 with active the high level of study and research, to continue Looking at the very near future – we deeply These are only a few examples in the tremendous participation from world-renowned lecturers, international cooperation and, probably most encourage everyone to take part in the XIVth history of the Polish Medical Society of Radiology. with Advances in Neuroradiology (Kazimierz importantly, to train and educate residents and Annual Meeting of the Polish-German Dolny, 2009) being one that is difficult to forget. young radiologists. The next generations of Radiological Society, which will be held in the During 85 years of activities our society has Four courses were held under the supervision radiologists can gain a high level of knowledge beautifully located Kliczków Castle in south-west gained an esteemed and important position of the European School of Radiology (ESOR) at many regional and national scientific and Poland, on May 26–28, 2011. The topics of the among different Polish and European scientific in several Polish university centres, with a high training events. The most popular are the Polish meeting are advances in oncological diagnostic societies. Recent years have been very successful attendance of young radiologists from various School of MRI held every early autumn, with imaging and new interventional approaches. The for Polish radiology. International cooperation countries. The crowning achievement among attendance exceeding 450 participants, and the other important event in the near future is an is an extremely important part of the PLTR’s our European activities was the Presidency of Polish School of Radiology held twice yearly annual meeting on Advances in Neuroradiology activities, and we have held some highly the European Congress of Radiology ECR 2010, with attendance of around 600 trainees. in Kazimierz, on May 20–22, 2011. More successful European meetings in the recent held by Prof. Małgorzata Szczerbo-Trojanowska. detailed information on those and other events times, including the Congress of the European This congress was a great success in many fields. Education is one of the key points in the one can be found at www.polradiologia.org – the Society of Magnetic Resonance in Medicine and activities of the new board of the Polish Medical official website of the Polish Medical Society of Biology (Warsaw, 2006) and the 33rd Congress The present primary aims of the PLTR are to Society of Radiology, which was elected during Radiology. and Advanced Course of the European Society promote modern diagnostic imaging techniques the International Radiological Congress of the
myESR.org Monday, March 7, 2011 C Ommunity NEWS ECR TODAY 2011 27
Communication and cooperation are key issues for incoming ESR President
By Mélisande Rouger plinary teams, especially in areas like oncolo- gic and emergency care. ECR Today met with new ESR President András Palkó, Professor of Radiology at Sze- ECRT: Do you plan to increase cooperation ged Medical School in Hungary, who made it with any countries or societies in particular? clear that he wants to bring the society closer AP: The ESR traditionally endeavours to to its members than ever. As well as tackling extend and improve its professional and the many issues facing radiology in Europe, social ties with societies of countries and Palkó hopes to make the voices of East Euro- regions outside of Europe. This effort is pean countries better heard and to open ave- focused in many areas (we may see very good nues of closer cooperation with radiologists examples of good and/or expanding connec- in the region. tions with the professional societies of Japan, South Korea, Australia, South America and ECR Today: What are your plans and ambi- the Middle East), but while maintaining and tions regarding your presidency? further advancing these relationships we András Palkó: I come to office following a have to pay more and more attention to very line of highly esteemed, innovative and ext- rapidly developing countries and regions like remely successful former presidents who not China, India and Asia in general. Forms of only created the ESR as the common house much closer institutional cooperation with of European radiology but shaped the society them must be elaborated very soon. Last but to be very effective in achieving results in the not least, our very close cooperation with the most varied fields of political representation, RSNA must be mentioned, which has further education and radiological research, and sped up in the recent years in areas of educa- made huge and, in most cases, fruitful efforts tion, postgraduate training and research. to achieve their goals for the benefit of the radiological community. ECRT: Many subspecialties of radiology are facing a crisis in manpower across Europe. In this respect, it is on the one hand much Do you have any plans to promote radio- easier, and on the other hand much more logy among young physicians who may difficult to express the plans and ambitions have not yet decided on their specialty? of the incoming president. Easier because if AP: The best way to recruit young doctors for nothing else happens but the achievements our specialty is to provide high quality and are preserved and developed further and the attractive training in radiology during the ongoing projects come to effect during my medical school years. A working group dedi- presidency, I may consider myself successful; cated to evaluating the European arena from and difficult because it is challenging to iden- this point of view will report on its experien- tify new tasks and directions beyond those ces and proposals during ECR 2011, and on already defined. Nevertheless there is at least this basis we will decide about our attitude one point that I feel is of the utmost impor- and possible moves in close cooperation with tance to strive towards: we have to fashion the the national societies. Beyond this we intend society to be a much more service-providing to increase the involvement of medical stu- organisation than before, by rendering new dents in the activities of the annual mee- provisions to our individual and institutio- Incoming ESR President Prof. András Palkó outlines his plans for the society’s future. ting and intend to motivate the subspecialty nal members, improving the visibility of the societies to act accordingly. society by giving very detailed information about the activities and achievements of our of uniform regulations for graduate, post- ECRT: This year the ESR launched the ECRT: What would be your message to governing bodies, and bringing it closer to graduate training and continuous medical European Day of Radiology, in coopera- aspiring radiologists? the members by introducing and/or further education on a European level; decreasing tion with 19 European national societies, AP: I keep telling my students that radio- developing communication lines in both prestige of academic versus ‘money-making’ to inform the European public about the logy is one of the most wonderful special- directions with them. radiology; and so on, and so forth. Even for benefits brought by imaging. Do you plan ties among medical disciplines because of its a huge and professional organisation with other public awareness campaigns in the multifaceted nature, satisfying the curiosity More specifically: we will carry on the matter multiple activities like the ESR it is a major upcoming months? of those interested in physics, informatics, of the European Diploma, based on the expe- assignment to try to tackle all or even most AP: Public awareness about the significance engineering, biochemistry, molecular sci- riences of the first exam in Vienna; upgrade of them. Nevertheless, our existing strategic of radiology in the healthcare system is one of ence, and nanotechnology; but also those the European Training Charter; proceed plan introduces a timeline to deal with them the main political goals to be achieved since planning to be involved in patient care both with creating the appropriate structures to in an incremental way. the attitude of the public greatly influences on the diagnostic and the therapeutic side give homes to molecular/functional, onco- our acceptance by and influence on decision- may find their fascination in this profession logic and emergency imaging; fine-tune the ECRT: How will you make sure that the makers at both the national and the European – not to mention the guaranteed opportunity activities of the European School of Radio- steps recently taken by the ESR regarding levels – that is why the initiative of launching to work at home or abroad as a highly estee- logy, allowing more space for e-learning and potentially damaging EU legislation will be the European Day of Radiology has high pri- med member of the medical community. self-assessment; improve cooperation with continued? ority among the tasks of the Executive Coun- fellow societies like the EANM, ESMRMB AP: The highest risk our specialty is expo- cil and its committees; and it is of utmost ECRT: You are the first ESR President from and others; make further efforts to be effec- sed to is the temporarily suspended direc- importance that many national societies con- an East European country. Do you think tive, influential and well recognised with the tive regulating working conditions in vary- tribute actively to this project. Nevertheless, your presidency will influence the status of EU bodies; and last but definitely not least, ing electromagnetic fields, which would before making further plans about future the ESR in this part of Europe? provide for the annual European Congress affect very unfavourably our diagnostic and campaigns we will have to evaluate the expe- AP: Being not only the first ever society presi- of Radiology the professional independence, research activities in magnetic resonance riences gained during this pilot action to find dent from Hungary but also the first from the financial safety and potential to further deve- imaging laboratories. The Alliance for MRI the optimal way to proceed in this field. whole region doubles my responsibility in my lop as one of the most important and highest (of which the ESR is one of the major stake- new function because beyond the obligation quality professional meetings in the world. holders) has so far been very successful in ECRT: What future trends do you foresee in to do my best for the further development preventing this directive from coming into radiology in Europe? and strengthening of our society, I have to ECRT: What are the challenges faced by effect, but there is a lot more to be done. AP: There are several factors that outline pos- satisfy the expectations I feel from our fellow European radiology today? Similarly we must pay close attention to what sible trends in radiology in the near future in radiologists residing and working in these AP: Radiology in Europe faces multiple chal- happens in Brussels in connection with the Europe and worldwide. Among these, pro- countries. This may partly be a symbolic act, lenges, the list of which includes – not neces- regulation of cross-border health activities, bably the most important are the ongoing but must also be much more than that, in the sarily in order of significance – turf battles e-health, future amendments on regulation technical developments making our equip- form of making the voice of these countries with other specialties; shortage of trained of medical devices, activities of the European ment more efficient than ever; the growing better heard among our ranks and opening radiologists/radiographers; uncontrolled Medicines Agency, EU Clinical Trials Regis- significance of hybrid imaging; the increasing avenues for those who may have the ability migration of professionals (mostly from ter, recognition of professional qualifications importance of functional and molecular ima- but have not had the opportunity so far to the East to the West); lack of proper regu- directive and many other issues. The ESR ging in concordance with the changing para- get involved in our activities; and I am most lation of cross-border activities including Office closely follows up these moves and digm of pre-emptive versus reactive medi- convinced that through this the visibility and teleradiology; unfavourable EU regulations; our experts – coordinated by the ESR Past- cine and personalised/targeted therapy; the impact of the ESR in these countries may be insufficient funding of research compared President, responsible for EU affairs – make rapidly growing role of IT support and neural further improved for the overall benefit of to the United States; need to improve or re- the necessary efforts to make our voice heard networks in everyday activities, in the form our society. establish cooperation with partner organi- in Brussels. It may also be an advantage that of computer-assisted detection, data-mining, sations like the UEMS, IAEA, WHO; lack of during the first third of my presidency we will decision-support, etc.; and the changing role harmonisation in specialty and subspecialty be cooperating with the Hungarian EU pre- of the radiologist from being a ‘generalist’ to training between European countries; lack sidency. becoming a specialist member of multi-disci-
myESR.org 28 ECR TODAY 2011 C Ommunity NEWS Monday, March 7, 2011
The Spanish Society of Medical Radiology (SERAM) in 2011
By Dr. Pablo Valdés Solís be the invited society at the 2011 ARRS Annual Meeting in Chicago, represented by four Spanish The Spanish Society of Medical Radiology professors. (SERAM) has continued with the implementa- tion and development of its strategic plan that We celebrated the third iteration of our Interna- has positioned the society among the most influ- tional Affiliates Meeting which took place at the ential radiological societies in the world, and Instituto Cervantes, Chicago, and is now consid- particularly among Spanish-speaking countries. ered the day of Spanish speaking radiology at the RSNA Congress. SERAM is facing the fast technological changes and developments in our specialty and is com- This event, widely appreciated among our inter- mitted to the position of leadership in medical national affiliates, gathers a huge representation imaging. of Latin American societies. This year, the topic chosen was ‘Different healthcare models, and We should highlight some facts: their influence in medical imaging’, with lecturers coming from Europe, South America and Spain. Cooperation agreements were made with other scientific societies, including the Spanish Society Publications of Nuclear Medicine, which yielded the Third Radiología Esencial, a vast compilation of state- Course on Molecular Imaging and Biomarkers, of-the-art radiological knowledge, published in and the Spanish Society of Cardiology, which January 2010, has been a great success, both in will result in our first co-organised Congress terms of scientific acknowledgement and com- in 2011. Another agreement signed with the mercial reception, with a second edition to be Front: Carlos Macaya (left), President of the Spanish Society of Cardiology and Eduardo Fraile Moreno, Spanish Society of Radiological Protection, will launched in early 2011. In this area, SERAM is SERAM President (right). Back: Gorka Bastarrika (left) and Miguel Pastrana (right) from SERAM, generate agreed documents and procedures con- preparing an edition specially aimed at students in the middle Río Aguilar (responsible of cardiac imaging at SEC). cerning the area of safety. of medicine, as a guide to medical imaging and the possibilities for the future specialist. The Spanish Foundation of Radiology also con- The course, held in Valencia, was on the topic of SERAM is developing future collaboration tinues its commitment to education, in the form ‘Imaging and electronic science in breast cancer’ agreements with primary care scientific socie- Our peer-reviewed journal, Radiología continues of several grants awarded every year and the cel- with a multidisciplinary approach, where biolo- ties, as we are aware of technologies now in wide- its growth and is available to our international ebration of the International Course of Radio- gists, engineers and IT experts shared common spread use, such as ultrasound, that radiologists affiliates. Radiología is considered the most pathological Correlation. This course, aimed at experiences. must lead. important radiological publication in the Span- radiologists in training, has attracted increasing ish language. numbers of attendees each year. SERAM with the patients SERAM is aware that cooperation with other sci- One of the objectives of our strategic plan is to entific societies is of utmost interest and will be Education Collaborative projects foster the visibility of radiology and what radi- another important undertaking in our society. SERAM continues with its policy on education SERAM is currently carrying out some col- ology and radiologists mean to the patient. We and training. Our courses for radiologists in laborative projects with the industry, on fields have launched Inforadiología, a section of our SERAM is integrating the full process of medi- training are well established and constitute an as important as oncology, cardiac imaging and website where the public can access information cal imaging and during our XXXth National excellent source of competent professionals. vascular and molecular imaging. The radiologi- about the fundamental radiological techniques, Congress we will hold Instructional courses for Furthermore, SERAM is engaged with its inter- cal community should lead these fields of devel- what they are used for, recommendations and technicians, something that will definitively be national affiliates and has implemented a pro- opment and SERAM intends to be a key player best practice. incorporated into our future events. gramme of visiting teachers, with the participa- in this research. tion of more than ten lecturers in 2010, at vari- Last but not least, we are continuously updating Apart from that, we should mention our ous congresses abroad. SERAM also continues SERAM organised with the Portuguese Society our website, with official documents, develop- increased visibility and cooperation with inter- to support scientific activities, in the form of of Radiology and Nuclear Medicine what is now ments in good practice and standards, guide- national societies such as ESR, the RSNA, ARRS research and training grants for our national and the second international course held by the two lines, etc. and others from Latin America. SERAM will international affiliates. societies.
Norwegian radiology focuses on research
By Nils-Einar Kløw, President alities. However, there are four sub-specialised our society. Presently, the Norwegian radiologist groups within radiology, including neuroradiol- Arnulf Skjennald is the chief editor. Additionally, The society is a member of the Norwegian Medi- ogy, paediatric radiology, interventional radiol- we publish the journal Noraforum in Norwegian cal Association and includes 841 members. This ogy and thoracic radiology. We plan to establish four times a year. This journal is published in includes 565 (up from 512 in 2009) active certi- more groups to improve the quality and collabo- cooperation with nuclear medicine. fied radiologists and 157 radiologists in training. ration, and to increase research. Currently 41% of members are women and this Teleradiology has been in focus this year. Three number increases to 51% for members under 50. An important task has been to increase research radiologists, Aslak Aslaksen, Roar Pedersen and Recruitment to radiology is good. With a popu- in radiology. The Norwegian Radiology Research Pål Bache Marthinsen, released a document for lation of 4.9 million there is one radiologist per Forum was established in 2007 with help from discussion in October. The report included liter- 8,700 people. The financial status in our country European Institute for Biomedical Imaging ature research, a survey of present teleradiology is good, meaning access to MRI and 64-slice and Research (EIBIR). The chairman is Prof. Jarle in Norway and legal aspects. The recommenda- higher CT is good. However, the availability of Rørvik. Research programmes and discussions tions are based on the white paper written by PET/CT (5) and Spect/CT (6) is still low. are now part of every national meeting. The strat- the European Society of Radiology (ESR) in col- egy plans have been completed and these include laboration with Union of European Medical Spe- All medical doctors have one and a half years of basic science using imaging, translational imag- cialists (UEMS). We hope the report will guide clinical practice before certification as a medical ing research, clinical radiology, and health and the members, societies, leaders, patients and doctor and before entering into specialisation. public radiological science. The research pro- governments in their use of teleradiology. With Nils-Einar Kløw from Oslo is President of the The Norwegian Medical Association currently gramme is integrated into the work done by the the presence of PACS all over the country, the Norwegian Society of Radiology. administers the specialisation educational pro- board of the Radiological Society. This year, five location of the radiologist is less important than gramme. The programme committee is elected radiologists have completed a PhD programme. before. The radiologist on call may be central- an extended part of the clinical examination by the Norwegian Radiology Society. The dura- ised, a second opinion is more easily available, and therefore helpful in experienced hands. tion of training in radiology is five years, eight- The Nordic Radiological Societies publish Acta and radiographers can be given more responsi- Education of the doctor should be part of the een years of which is required to be in a univer- Radiologica in collaboration, which is important bility for patient handling and imaging. specialisation for certification. Radiologists will sity hospital and one year of which may be clini- for the publication of both Nordic and other contribute to the education and the candidates cal practice, scientific work or teaching. During radiological research. This year the journal has The Norwegian Medical Association established are encouraged to include radiology into their residency there are ten mandatory week-long changed publisher to the Royal Society of Medi- a working group on ultrasound for specialists rotation. The ultrasound should not replace courses which end with written examinations. cine Press. Most members will have access to in General Practice. We have supported this ultrasound examinations performed by radiolo- Nuclear medicine is not part of the curriculum the online edition only. The change has had a work and a final report was presented at the gists and the choice of modality should not be and there are no formal radiological sub-speci- large positive impact on the financial status of end of 2010. Ultrasound may be recognised as influenced by these examinations.
myESR.org Monday, March 7, 2011 C Ommunity NEWS ECR TODAY 2011 29
EURORAD Editor-in-Chief highlights importance of increased international communication
By Lucie Motloch that a close cooperation with the Spanish spea- case report and improve your skills in becoming king radiology community would be beneficial an author. Having started in 1995 as a search tool for radio- in the future? logical documents on the internet, EURORAD Hans L. Bloem: Our Spanish colleagues did a My advice is to take this opportunity and keep was soon redesigned as an independent case great job in translating so many new cases into your eyes open for all the interesting and edu- database, and has by now developed into an Spanish. This is of vital importance to EURO- cationally important cases that you encounter. important collection of radiological cases and a RAD and the ESR in their mission to provide a Convert these opportunities to a publication and valuable teaching platform used by young and high quality educational tool to the international a learning experience at the same time. This is experienced radiologists alike. radiological community. The quality of radio- killing two birds with one stone. logy in Spain and the Americas is very high, and All cases are peer-reviewed by expert radiolo- the eagerness of these radiological communities ECRT: To maintain the high quality of case gists to guarantee high quality standards, and to share knowledge matches this high standard. reports published in this radiological data- an individual DOI makes each case fully citable. base it is important to promote high standards The growing success of EURORAD is reflected Since English often is not used as the primary for ethical research. Which strategies should in submission figures that have risen by almost language to communicate professionally in this authors develop to avoid accidental plagiarism? 30% in 2010 compared to the previous year, and vast territory, it makes sense to use Spanish to HB: Staying away from plagiarism is of the nearly 20,000 unique users per month thanks connect and increase communication between utmost importance. Plagiarism is unethical and to the cooperation with the ARRS GoldMiner® the European and Spanish-speaking American a self inflected damage that eventually hurts the search engine. radiological communities to the benefit of both. authors who do this the most. Read the referen- Obviously Spain is the ideal bilingual linking pin ces and identify the added value of your own In 2010, several new features were implemented EURORAD Editor-in-Chief Prof. Hans L. Bloem in this exchange. It is without doubt that ope- manuscript. Be original. It is enriching to con- in order to improve the submission system and promotes originality for submissions. ning this pathway allows synergy, resulting in tribute original work to our profession, and it is standardise the cases. The main change is that increased professional quality and socio-cultural downgrading and sad to try to cheat the system authors can now refer to pre-specified guidelines exchange in our communities. It is no coinci- and your colleagues, including yourself. and structure their discussion according to this downloadable author certificate can be obtai- dence that both these qualities, professionalism standard by focusing on background, clinical ned for each case. and socio-cultural exchange, are highly valued ECRT: Can you give an example for a case that and imaging perspective, outcome and teaching in the radiological worlds now connected in this does not conform to those standards? points. Word limits were slightly reduced and the Prof. Hans L. Bloem from Leiden, the Nether- partnership. The challenge is upon us to expand HB: Originality is the key word; texts should be segments were renamed to facilitate clear and lands, took on the role of Editor-in-Chief of on this substantial beginning, and to increase original. It is unethical to copy a few sentences, concise case descriptions. EURORAD in 2007, and since then has introdu- interaction with the Americas. or even one sentence from another text, espe- ced many changes that improved the workflow, cially when not referenced accordingly. It beco- An important new element is the differential reduced turnaround times of the peer review to ECRT: The specifications for new cases have mes more and more easy to detect these copied diagnosis list, giving the reader a better over- an average of 4 weeks, and helped promote the been improved to make the cases more concise sentences, and all ESR publication media are view of the possible diagnoses based on clini- case database among researchers. ECR Today and better structured. What is your advice for working together closely to keep our platforms cal examination and imaging. Authors can now asked him about the present and future of authors regarding their case descriptions? free of these behaviours. The impact of getting also choose several additional image data to EURORAD. HB: For junior authors, it is easier to create a case caught trying to cheat by copying is tremend- describe their figures, which are listed as key- report using this format. Enthusiasm and know- ously damaging to your career, as one has to words in the advanced search to help the reader ECR Today: More than a thousand cases are ledge can now easily be channelled into a case know that the department deputies will be infor- find images and cases of interest. Revised and available in Spanish on EURORAD, translated report, meeting the highest quality standards. med if a case is proven. When in doubt, you improved guidelines for authors and review- by radiologists from the Sociedad Española de Reading a few case reports and following the should always consult a successful senior author. ers are now available on the homepage, and a Radiología Medica (SERAM). Do you think guidelines will be a time-efficient way to write a
Education is key for Turkish radiology
By Okan Akhan, The Turkish Society of Radiology has estab- retical exam and one practical exam. Only Diagnostic and Interventional Radiology was President of the Turkish Society of Radiology lished a Winter School for the training of res- the participants who succeed the theoretical accepted for indexing in the Science Citation idents. With this programme, every resident exam can attend the practical exam. We aim Index Expanded. The Impact Factor of Diag- The Turkish Society of Radiology is a non- will get a two-week training programme once to ensure that our residents who go through nostic and Interventional Radiology in 2009 govermental organisation, dedicated to pro- in their residency period. Every year, we aim the winter school training programme will was 0.771. This journal is also available free to moting radiological education and coopera- to provide approximately 200 residents with take the theoretical exam before the final all readers on the web (www.dirjournal.org). tion among its members with regard to pro- training at the fundemantal level from dis- exam of the residency period. fessional, social and legal issues. Accordingly, tinguished lecturers (there are 800 residents The number of scientific articles by Turkish the main radiological issues that our society in training in all educational hospitals). The The Turkish Congress of Radiology was held authors in radiological journals has increased handles are related to education. first winter school programme was in Decem- on November 7–12, 2010, in Antalya, with substantially in the last 15 years and Turkey ber 2010, at which 180 residents were edu- 1,568 ragiologists attending the meeting. has frequently ranked in the top ten coun- Radiolgy education in Turkey is currently cated for two weeks. The second one was in Every year the number of attending radiolo- tries submitting articles to journals such as provided predominantly by univesity hos- January 2011 with 175 residents participating. gists is growing. At the Turkish Congress of American Journal of Roentgenology, Cardio- pitals and education and training hospitals The winter school programmes took place Radiology 2010, sessions were held by 103 vascular and Interventional Radiology, Euro- governed by the Ministry of Health in Tur- in Antalya in a 5-star hotel with all expenses Turkish lecturers and seven lecturers from pean Journal of Radiology, American Journal key. There are 50 state university hospitals, covered by the Turkish Society of Radiology. Europe and the United States. A total of 136 of Neuroradiology, Pediatric Radiology and seven private university hospitals and 23 oral presentations and 709 electronic exhibits European Radiology. I think a steep increase government education and training hospi- The Turkish Society of Radiology has also were presented. The main topic of the categor- in the number of articles published in radiol- tals in Turkey. Radiology residency train- established a Scholarship Programme to ical course was ‘Inflammation and Radiology’. ogy journals from Turkey will continue in the ing programmes are under the legal author- support young radiologists in their further future. ity of the Ministry of Health. Unfortunately, education. This programme was implemented In addition to the Turkish Society of Radiol- the training period was reduced from five to to support our young colleagues who want to ogy, several other societies exist in Turkey, Turkey is an ESR member country that devel- four years by the decision of the Ministry of get higher education in the field of radiology including the Society of Medical Ultrasonog- ops infrastructures and human resources Health last year. The Turkish Society of Radi- in Turkey or abroad for six to twelve months. raphy, the Turkish Magnetic Resonance Soci- rapidly; implements high quality training ology is actively trying to increase the train- The Turkish Society of Radiology will support ety, the Turkish Society of Interventional programmes for the residents and young col- ing period back to five years as a residency the candidates with $1,200 (US dollars) per Radiology, the Turkish Society of Neurora- leagues and makes an invaluable scientific training programme of this length, which has month for education abroad and $750 (US diology and the Turkish Society of Thoracic contribution to the international community. already been prepared by the Turkish Society dollars) per month for education in Turkey. Radiology, all of which organise annual I hope that these characteristics will gradually of Radiology, is intended to be implemented In 2010, seven young colleagues were given national meetings as well as international increase in the future. in all educational centres. schorships with the programme. With this meetings and courses, every year. programme, we aim to support 30 colleagues The Turkish Society of Radiology initiated per year. The Turkish Society of Radiology publishes two important educational programmes for the quarterly peer-reviewed journal Diagnos- residents and young radiologists in 2010. We Radiology board exams have been adminis- tic and Interventional Radiology. This journal, hope that in ten years time the best educated tered since 2004 by the education council of which has been published since 1994, has physicians among medical specialists will be the Turkish Society of Radiology. The board the highest standards of peer-review, edito- radiologists, thanks to these two projects: exams are composed of two parts: one theo- rial content and publication quality. In 2007
myESR.org 30 ECR TODAY 2011 AR TS & CULTURE Monday, March 7, 2011 ien
Sammlung Essl W T he Essl Collection With 5,000 exhibits, the Essl Collection offers an excellent overview of Austrian painting since 1945, placing it in an international context. The collectors have acquired a number of works by those artists who have been of decisive importance for Austrian art. Creating a collection of real depth was the essential idea of this collection, with the aim of showing the artists’ development in the course of their œuvre. The scope of the Austrian exhibits in the collection ranges from Abstract Expressionism of the 1950s and 1960s to Vienna Actionism and New Painting of the 1980s, all the way to the reductionist art of the 1990s. In addition to the post- war paintings, the collection contains an important group of works of Classical Austrian Modernism. Artists such as Herbert Boeckl and Albert Paris Gütersloh, who played an important role in the new Austrian art after 1945, are of particular significance, but the collection also includes high-quality works by Alfred Kubin and the artists of the ‘Nötscher Kreis’.
September 10, 2010 – May 8, 2011 Special Exhibition: Beautiful Klosterneuburg The German artist Albert Oehlen will put on his curator’s hat and show his personal choice of works from the Essl Collection. In the
seven gallery rooms he will present paintings and sculptures by artists including Rudolf Hausner, Friedensreich Hundertwasser as well Spittelauerlände, 1993 © Sammlung Essl Privatstiftung, Klosterneuburg/ as contemporary art by Paul McCarthy and Heimo Zobernig. In the 1980s, Albert Oehlen was part of the Neue Wilde group, which included names such as Martin Kippenberger, Werner Büttner and his own brother Markus Oehlen. These ‘new savages’ took an ironic stance and challenged the entire medium of painting. Martha Jungwirth, Julian Schnabel, Without title, 1985 © Sammlung Essl Privatstiftung, courtesy Julian Schnabel www.sammlung-essl.at 6pm) after admission 10am Wednesday 10am Tuesday–Sunday hours: Opening 1 Donau-Au der An Klosterneuburg, 3400 Essl Sammlung
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9 pm (free (free pm
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6 pm pm 32 ECR TODAY 2011 AR TS & CULTURE Monday, March 7, 2011
What’s on today in Vienna?
Theatre & Dance Please note that all performances, except at Vienna’s English Theatre, are in German! Akademietheater 19:30 Die Kunst der Unterhaltung 1030 Vienna, Lisztstraße 1 by Jan Lauwers & Needcompany phone: +43 1 51444 4145 www.burgtheater.at
Theater Drachengasse 20:00 Der Kaktus 1010 Wien, Fleischmarkt 22 by Julie Zeh www.drachengasse.at
Theater in der Josefstadt 19:30 K ap Hoorn 1080 Vienna, Josefstädter Straße 26 by Igor Bauersima phone: +43 1 42 700 300 www.josefstadt.org
Vienna’s English Theatre 19:30 Cat on a Hot Tin Roof 1080 Vienna, Josefsgasse 12 by Tennessee Williams phone: +43 1 402 12 60 0 www.englishtheatre.at
Volkstheater 19:30 Harold und Maude 1070 Vienna, Neustiftgasse 1 by Colin Higgins phone: 43 1 52111 400 www.volkstheater.at Harold und Maude by Colin Higgins © Lalo Jodlbauer / Volkstheater
Concerts & Sounds
Arena (Alternative Music) 20:00 UK Subs + The Vibrators 1030 Vienna, Baumgasse 80 www.arena.co.at
Gasometer (Alternative Music) 20:00 Maroon 5 BA-CA Halle Gasometer 1110 Vienna, Guglgasse 8 www.planet.tt Vpress.com MT © Maroon 5
Opera & Musical Theatre
Volksoper 19:00 Die Blume von Hawaii 1090 Vienna, Währingerstraße 78 Operetta by Paul Abraham www.volksoper.at
ien Wiener Staatsoper – 19:30 Ariadne auf Naxos W Vienna State Opera by Richard Strauss, conducted by Jeffrey Tate 1010 Vienna, Opernring 2 with Alexander Pereira, Stephanie Houtzeel, www.wiener-staatsoper.at Burkhard Fritz, Julia Novikova, Nina Stemme
Ronacher 19:30 Tanz der Vampire 1010 Vienna, Seilerstätte 9 by Jim Steinman & Michael Kunze www.musicalvienna.at by Paul Abraham © Dimo Dimov / Volksoper Die Blume von Hawaii by Paul Abraham © Dimo Dimov / Volksoper
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