ECR TODAY 2013 DAILY NEWS FROM EUROPE’S LEADING IMAGING CONGRESS Monday 11 March 2013

Next year’s X-ray equipment vendors Franz West ECR will be turn the spotlight firmly on Where is my Eight? Russian Affair women’s health issues and dose reduction

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A 3-piece jigsaw: patient, radiologist, clinician. But do they fit together?

By Becky McCall an image. That’s the difference in attitude and where communication The delicate balance of power and has gone wrong.” complex set of interactions between Moving on to the radiologist- radiologists, patients and clinicians patient relationship, Adam said that was the subject of some lively and done properly, radiologist-patient frank discussion at yesterday’s Pro- communication can work to the fessional Challenges Session, which patient’s advantage clinically, but followed a novel and original for- also benefit the hospital’s finances. mat. Nobody held back, considered He described a typical patient path- opinions were given and niggling way in a U.K. hospital with requests, issues were teased out by the panel reports and scans moving between members, audience and the one GPs, clinicians, radiologists, multi- brave clinician in the packed room. disciplinary meetings, and eventu- Amongst the panel members were ally reaching a surgeon. two radiologists, a medical ethicist “This could potentially take and a clinician. Former ECR Presi- weeks,” he said. “This is a crazy way dent Prof. Andy Adam kick-started to practise medicine in the 21st cen- the session by pointing out that 50% tury, there’s no earthly reason why of patients do not realise that radiol- the radiologist can’t interact with the ogists are actually medical doctors. referring clinician and the patient “I think it’s the fault of radiolo- Moderator Wofgang Wagner, Chairman Claus D. Claussen, Jim Reekers, Markus Peck-Radosavljevic, Andy Adam, Georg Marckmann. early on, and organise investigations gists because in many cases, they like a proper doctor. don’t always deal with patients like “This would not only save money, a doctor typically does. Radiologists fessor of medicine at the department imilians University of Munich, ing question is who is in the orches- but adrenaline, anxiety and worry abandon patients and damage them- of gastroenterology and hepatology Germany, offered his thoughts by tra and who plays first violin?” he for the patients and their families. I selves as a profession, disadvantage at Vienna Medical University, said saying radiologists were physicians commented. reinforce my point that a radiologist patients and increase healthcare he felt it was important that radi- and therefore had the same profes- Dr. Jim Reekers, an interven- is a doctor and he or she has to work costs,” asserted Adam, professor ologists spoke to him directly with sional obligations as any physician tional radiologist at the University like a doctor and communicate with of interventional radiology at the the details. to patients, including respecting of Amsterdam, illustrated his point the patient appropriately,” argued University of London and Clinical “It’s more a matter of practical- their well-being, using the best by describing a scenario in which Adam. Director of Imaging and Medical ity, resources and time. But if I have available diagnostic and therapeutic an internal medicine clinician either Audience members were invited Physics at King’s College, U.K. “Get- to decide between the radiologist interventions and minimising harm, calls a surgeon to come to look at a to participate and did so with ting closer to the patient will make speaking to the patient so I get the respecting patient autonomy, and patient and discuss what to do, or he enthusiasm. There was controversy radiologists more relevant. In many report in two weeks, versus the radi- contributing to social justice. orders an image from the radiolo- about the language used to ‘order’ situations they should impart appro- ologist not speaking to the patient “Healthcare delivery has evolved gist. “You don’t ask the radiologist to or ‘request’ an examination from priate information and behave like and I get results in two days, then I to a complex system of care where come over and give advice on which a radiologist, with one U.S.-based a real doctor.” prefer the latter,” he said. different disciplines and profession- image is most appropriate. With a surgeon saying that there were too The token clinician, Dr. Markus Medical ethicist Prof. Georg als work together. It is like a rather surgeon you have respect but with Peck-Radosavljevic, associate pro- Marckmann, from Ludwig-Max- complex orchestra but the interest- a radiologist you order him to do continued on page 3

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Answers for life. Monday 11 March 2013 Highlights ECR Today 2013 3

continued from page 1 many technologies and that their Gymnasts’ spines, footballers’ ankles availability needed to be reined in. “It’s like ordering from a menu of exams,” the delegate remarked. and golfers’ wrists take the strain An Irish radiologist waded in, disagreeing with the idea that radi- ologists receive ‘orders’, saying that By Philip Ward department of radiology at Zuwe ease, however. To avoid causing ogist from Leeds Teaching Hospitals he only got ‘requests’ and that if he Hofpoort Hospital in Woerden, the unnecessary anxiety to patients, and the University of Leeds, U.K. felt it was inappropriate to perform The ultra-demanding and highly Netherlands. he recommends avoiding the term In a recent survey of players on the request, he would deny it. On competitive nature of modern pro- The term ‘gymnastics’ derives Scheuermann’s disease, except for the European Tour, the results of the clinician-radiologist relation- fessional sport was visible to all from the Greek word ‘γυμνός’, and classical cases, and there is no room which are due to be published soon ship, he said, “I have a close rela- during Sunday’s refresher course when the Ancient Greeks engaged for three-quarter views. by the British Journal of Sports Medi- tionship with the clinician, I advise on overuse injuries. in the activity, they were naked. “I The frequency and intensity of cine, the wrist accounted for 35% on the best tests, I get back to them Stress reactions are the most wonder how many gymnasts today training are high. Up to the age of of total injuries, and of them, 30% on the next steps.” So addressing important lesions to recognise in would take part in it if they had to 14, talented youngsters train for were previous injuries. A total of the panel he said that he thought the gymnast’s spine, and although be naked. Probably not very many of between 15 and 25 hours a week, 128 questionnaires were completed, their points of view were extreme. there is no consensus about imag- them – I know I wouldn’t!” he joked. while national team members train representing a response rate of 84%. “If you need to communicate with ing, plain films and MRI, plus CT From a medical perspective, a for around 35 hours a week, said The golfer’s lead wrist was injured in your clinician, then just pick up the in selected cases, is the best option, major problem is that gymnasts De Jonge. 67% of cases, and of those injuries, phone.” The panel’s one clinician said Dr. Milko De Jonge, from the are so young when they start par- In professional football play- 35% were ulnar-sided, 11% were agreed with him. ticipating. In the Dutch competition ers, overuse injuries in the ankle radial-sided, 33% were dorsal, and A radiologist from Australia league, gymnasts are as young as six are particularly common, accord- 21% were other. piped up to make her point that she years old, and they are considered to ing to Dr. Patricia Cunningham, Fractures of the Hook of the believed radiologists were there to be veterans at 18. There are 245,000 a radiologist from Louth-Meath Hamate, also called the Hamulus, interact with the patients. “I think members of the country’s gymnas- Hospital Group in Ireland. She said are the most common fracture in we should always talk to them first. tics union, which represents a slight it’s important to diagnose injuries a golfer, and are usually stress frac- We need to think ‘if it was me having decline since 2010, stated De Jonge. of the ankle ligaments, includ- tures, said O’Connor, who led the the scan done, what would I want’. As many as 20 million women in ing sequelae such as anterolateral imaging team at the 2012 Olympics We need to put ourselves in their the U.S. take part in gymnastics, impingement, as well as injuries of in London. The non-dominant wrist shoes,” she said. so participation remains healthy in tendons around the ankle and bone can be affected, and they are difficult “I always tell my patients that this most parts of the world. It became and cartilage injuries in the ankle, to diagnose clinically and are occult information is part of a jigsaw puz- an Olympic sport for men in 1896, including anterior and posterior on conventional wrist radiographs. zle, and the other bits of the puzzle and for women in 1928. impingement. In sports injuries encountered at are in the hands of the referring doc- “Low back pain in gymnasts is Golfers tend to suffer most often Leeds, radiologists spend a lot of tor and if they go back to the doctor common. It originates predomi- from upper limb ailments, and time trying to differentiate between they will find the rest of the jigsaw nantly from hyperextension and radiologists need to have an under- established defects and new acute is put together.” rotation, with axial forces,” he said. standing of the swing mechanics to stress fractures, he said. For instance, This innovative session was never “Disc disease is also common.” appreciate the asymmetrical nature a 24-year-old cricketer might have going to lead to universal agree- Not all disc disease is pathog- of golf injury, according to Dr. Philip developed his defects at the age of ment, but it certainly helped to raise Milko De Jonge from Woerden, nomonic for Scheuermann’s dis- O’Connor, a musculoskeletal radiol- 14 of 15, he commented. and address important issues facing the Netherlands. the profession.

‘Unfair’ regulatory stance over radiotracers poses serious threat to PET’s future development

By Becky McCall would hamper and extend the time cal data, including toxicity, GMP to development. (good manufacturing practice) Legal and regulatory issues sur- “Tracers are considered to be production, and other safety tests. rounding the production and uses drugs by the regulator, but are Basically, authorities consider PET of radiotracers represent a signifi- used in very low quantities,” von tracers to be a drug, so you have to cant threat to PET imaging, a sen- Schulthess explained. “If you use do everything you would for a drug ior luminary told ECR attendees at tracers at high dose, then they are approval, he said. yesterday’s Professional Challenges dangerous – so Thallium for myo- “It is now such that in order to Session on the legal matters related cardial imaging at very low doses, introduce a new tracer just for to multimodality techniques. but at standard doses it is rat poi- research we have to do a toxicity Speaking emphatically on the son. We inject it at 1/50,000ths of study, which at the newly required issue, Prof. Gustav von Schulthess, the lethal dose, so it has no impact, level cost Swiss Francs 100,000 from the department of medi- but somehow the regulation agen- [around 81,000 Euros],” he said. “So cal radiology, nuclear medicine cies have a hard time distinguishing even to think of producing a new at Zurich University Hospital, between use of a drug as a therapeu- radiolabelled tracer for experiments explained his frustration with the tic agent and use as a tracer.” we have to spend 100,000 CHF.” current situation. He believes regulations with At Zurich, several PET tracers “Tracer regulations have become respect to tracers are important, but are produced. Recently we have so painful and so costly that uni- they come from the wrong corner, gotten approval for fluorine-labelled versity investigators and companies i.e., the drug corner. He cited the choline (F-choline) and so the hos- Gustav von Schulthess from Zurich, Alan Perkins from Nottingham, U.K. alike are deterred [from develop- example of iodinated contrast agent pital is the only legal provider of Switzerland. ment],” he remarked. “A radiotracer for x-rays or MR contrast agents, F-choline in Switzerland, but to get costs a lot to produce and this is which when injected, are injected at to this point a cost between Swiss which a researcher might need to fees and money, which all cause mainly to do with the regulations. pharmacologically active doses and Francs 500,000 and 1 million was use a tracer such as gallium-68 conflict,” he commented. “Radi- The world hasn’t come to grips with therefore have to be made such that accrued, which is a major cost issue, DOTATATE. ographers and technicians need this.” they leave the body immediately, he explained. Presenting in the same session to be fully trained in the relevant He added that the most exciting pointing out that these safety regu- Adding further frustration, von was Prof. Alan Perkins, professor of modalities.” activity in imaging modalities right lations were good. “But in nuclear Schulthess explained that reim- medical physics from the University In the U.K., a hospital’s radiation now was the development of new medicine, it’s different. We can treat bursement for a tracer is a separate of Nottingham, U.K. He discussed safety committee produces a set of tracers. “These will open possibili- patients with thyroid disease with step and does not automatically fol- radiation protection frameworks policies and approaches. It identi- ties of totally novel examinations, radioactive iodine even if they have low on from approval. at a regional, national and interna- fies individuals with responsibility because each new tracer generates a an iodine allergy, we can still use it Understandably, companies are tional level, and the responsibilities for safety programmes, although new ‘imaging modality’. If you look because the dose is so low that it has reluctant to invest under these cir- and training of different personnel the nuclear medicine physician has at glucose metabolism, then you see no physiological effect.” cumstances because it increases in the working environment. He overall clinical responsibility. aggressive tumour growth; if you do He explained that the exquisite the cost of getting a tracer on the thinks the single issue that stands Amongst the other staff in the Alzheimer’s plaque imaging, you see sensitivity of the tracers meant a market. Many of these tracers are out as needing particular attention department, Perkins highlighted something different, so tracers are tracer could be injected at a very low orphan applications due to the is staff training. radiographers and technicians key to this.” dose for the receptor systems and small number of potential patients. “They need to be qualified in all who need to be dual trained in all In contrast to all the excitement molecular interactions to be visible. Alzheimer’s disease is an excep- the areas they are working in. This modalities concerned, whether PET, about potential new tracers in the Von Schulthess then touched tion to this with maybe a market of is a real challenge in the hospital SPECT or MRI. “They need appro- era of personalised medicine, he upon the many legal issues around 30,000 patients in a country the size environment because there are priate training in these environ- said that if regulations around production. He said that an applica- of Switzerland (8 Mio.) but this has often turf wars involved, profes- ments. There is also a legal require- the world relating to new trac- tion for a tracer marketing authori- to be compared to 200–500 patients sional differences between physi- ment for a medical physics expert,” ers become too complicated, that sation required preclinical and clini- with neuroendocrine tumours for cians and radiologists, as well as he concluded.

myESR.org | #ECR2013 @myESR

Hot Shots from ECR 2013 6 ECR Today 2013 Highlights Monday 11 March 2013 E-learning gathers pace and becomes valuable training and education tool

By Philip Ward in Radiology and they can be done knowledge and keep up to date,” she clinical radiology at the U.K. Royal whenever a radiologist has some said. “Each module only takes 15 or College of Radiologists. The European Society of Radiology spare time, noted Dr. Sue Barter, 20 minutes to complete, and you’re To access the tests, go to the edu- (ESR) is stepping up its efforts to who chairs the Case Collection given a score at the end of it, so you cation and training section of the provide members with a compre- Committee for the European Board know exactly how well you’ve done.” ESR website and click on the ESR hensive range of self-assessment of Radiology and is a consultant The modules consist of a mix Self Assessment button on the left module that are free-of-charge, radiologist at the Cambridge Breast of conventional multiple-choice side of the page. The ESR is par- written by experts and easily avail- Unit of the Cambridge University questions (MCQs), image-based ticularly keen to hear from any- able on the ESR website. Hospitals NHS Foundation Trust, MCQs and short cases. The plan is to body who is interested in writing Among the important benefits of U.K. develop accreditation for continu- or contributing to a new module. the tests is that they map the cur- “This is a really useful way for ing medical education, according Please contact Stefanie Muzik riculum of the European Diploma anybody to brush up on their to Barter, who is also registrar for ([email protected]). Sue Barter from Cambridge, U.K. Think deeply about Spain’s ‘father of modern neuroscience’, urges Martí-Bonmatí

By Philip Ward pendent judgement, intellectual • Each problem solved stimu- community. It makes the field appeal- curiosity, perseverance, devo- lates an infinite number of new ing to the best residents, fellows and It may be something of a cliché, tion to country, and a burn- questions, and today’s discovery staff radiologists, attracts industry but you must understand the past ing desire for reputation and contains the seed of tomorrow’s and governmental funds, and pro- to see the future. This point was recognition. discovery. vides data for discussions in compe- underlined on Sunday in the Hon- • Discoveries are not the fruit of • While reading papers, particular tencies and in healthcare financing. orary Lecture by Prof. Luis Martí- outstanding talent, but rather of attention should be focused on Trainees should be encouraged to Bonmatí, from the hospital La Fe de common sense enhanced and two important things: research undertake a research project dur- Valencia, Spain. strengthened by technical educa- methods used by the author in ing their training, and connection He chose to focus on the life and tion and a habit of thinking about his work, and problems that of basic and clinical research is rec- work of Santiago Felipe Ramón y scientific problems. remain unsolved. ommended. Furthermore, profes- Cajal (1852–1934), the Spanish • The best stimulant for the begin- Used benevolently, science repre- sional and scientific societies, both pathologist, histologist, neurosci- ner is that his or her instructor, sented Cajal’s big hope for the future international and national, have to entist and Nobel laureate whose instead of demonstrating amaz- of humanity. Leading individuals with influence the future of radiology by pioneering investigations of the ing achievements, would reveal a clear research orientation are behind fostering education in research, pro- microscopic structure of the the origin of each scientific dis- successful groups, and those networks viding training during meetings and brain mean he is considered by covery and the series of errors with a well-defined structure have a courses and guidance for residency many to be the father of modern that preceded it. responsibility to lead science towards programmes, and assisting research neuroscience. • When formulating a hypothesis, truth and knowledge, he believed. groups with networking, direct fund- Having discovered the axonal Honorary Lecturer Luis Martí-Bonmatí remember that nature uses the Moving to the present day, research ing or other assistance, he said. growth cone, he provided vital evi- from Valencia, Spain. same means for equivalent ends. is the future of radiology, and a radiol- Cajal thought that progress in sci- dence for what was known as neuron View the problem in its simplest ogist can and should be a researcher, ence must be supported by a general theory, meaning the experimental Cajal’s core values and set of forms and keep in mind that according to Martí-Bonmatí. attitude in a country, and having a demonstration that the relationship beliefs remain relevant today, noted all natural arrangements have a Research provides enhanced critical profession and doing scientific work between nerve cells was not one of Martí-Bonmatí: function. thinking and problem-solving skills, mutually illuminate one another. continuity (diffuse nerve network) • Become the sculptor of your • In scientific work, means are as well as knowledge, innovation, “Let’s do both, centred in but rather of contiguity (cells and own brain. Important qualities virtually nothing, whereas the improvements and visibility in the patients and in collaboration,” said synapsis). for researchers include inde- person is almost everything. healthcare cycle and in the academic Martí-Bonmatí. Students get first-hand ultrasound experience at ECR 2013

By Mélisande Rouger device and perform scans on their more students. “Next time we will own station. also submit abstracts,” he added Students are a vital part of the dyna- The principle of the workshops enthusiastically. mism that makes the ECR so unique, – students teaching students – is When applying for the Rising and its organiser, the ESR, has been what explains its success, believes Stars programme, which gives working to make sure it is as acces- Dr. Ashraf Anas Zytoon, assistant pro- them free registration for the ECR, sible as possible to young radiolo- fessor of radiology and chief of the students can also take part in an gists. Over the weekend, 130 medical radiology department at Al-Ghad abstract competition. The best students got an instructive insight Faculty of Health Sciences in Medina, abstracts get free accommodation into ultrasound imaging during ded- Saudi Arabia. “Students speak the and travel, and they can present icated workshops, one of the Rising same language, so it really works. their work during the student ses- Stars programme’s many highlights. People really learn a lot here,” he said. sions held at the congress. “I’m glad I did it, it was so interest- Zytoon heard about the work- Emich Hermann, a fifth-year ing. In Belgium we don’t have that shops last year while he was at the medical student at the Mannheim Hands-on ultrasound training is a crucial element at ECR 2013. much practice, it’s more for radiolo- ECR. He decided to come back with Faculty of Heidelberg University in gists, so I wasn’t that familiar with six of his students, who all want to Germany, was one of the winners The workshops are held in con- session at the congress and check ultrasound,“ said Anke de Borg, a become radiographers, and served and presented his work, ‘Imaging junction with Sono4You, a project out the technical exhibition, to third-year radiography student from as their interpreter during the in the resuscitation area with an initially run by the University of discover the latest advances in Brussels, who is currently doing her workshop. emphasis on total body imaging’ Vienna, which has now been imaging. This experience has Erasmus exchange in Vienna. “I want to bring this idea back this Saturday. extended to the Mannheim Fac- also been very positive for the In the workshops, tutors – final- to Saudi Arabia, I think it is very “It was my first big congress and ulty. Registration for a workshop students. “The technical exhibi- year medical students or residents interesting. Actually this is the first my first presentation, so I am a lit- costs €30. Medical students and tion is also quite interesting; they – teach small groups of students time that students from Arab coun- tle bit more experienced now,” he radiographers in training under give you lots of information. They how to work their way around four tries have come here for training. It’s said. “I will probably apply once the age of 30 and without an aca- like students here,” de Borg said. stations: musculoskeletal, echocar- great for them to have contact with more to this competition because demic degree can apply for the More than 1,400 students visited diography, vascular, organs and European radiology, it’s an impor- you get flight and accommodation programme. the ECR last year, making it the US-guided intervention. Each stu- tant event,” said Zytoon, who plans for free, so it’s a good motivation With their Rising Stars regis- world’s leading student meeting in dent has ten minutes to try out the to come back next year with even to do it.” tration, students can attend any medicine.

#ECR2013 @myESR | myESR.org Monday 11 March 2013 Highlights ECR Today 2013 7 Next year’s ECR will be Russian Affair

By Mélisande Rouger, Michael Crean Ministry of Health limits sponsor- my colleagues to learn English, ship of congress trips in an effort because it is the lingua franca of ECR Today spoke with the ECR’s to curb corruption. Still, there are modern radiology, become ESR next president, Prof. Valentin Sin- other ways to increase attendance members and attend the ECR. We are itsyn. He is chief of the radiology from Russia, such as more involve- discussing the possibility of having department at the Federal Centre ment with our national society. The a few scientific sessions in different of Medicine and Rehabilitation Russian Association of Radiologists languages and seeing how they go. in Moscow, Russia, and currently may not have been active enough serves as president of the Euro- in the past, but last year we were ECRT: The Rising Stars pro- pean Society of Cardiac Radiology able to substantially increase ESR gramme, which grants students (ESCR). membership among Russian radi- free registration for the ECR, ologists by offering them free ESR attracts an increasing number of ECR Today: What will be the main membership. So from 200 Russian students and residents each year. highlights of ECR 2014’s scientific members a couple of years ago, we Last year more than 1,400 students programme? now have about 700 active mem- visited the congress, making it the Valentin Sinitsyn: People are bers. Of course it isn’t that much for world’s leading student meeting increasingly interested in interac- such a large population – officially in medicine. What do you think tive sessions to assess what they have there are more than 15,000 Russian of these efforts to attract young learned from a lecture. The ECR has radiologists. Every year about 300 to people? Will ECR 2014 include been developing interactive sessions 400 Russian radiologists attend the any new features to increase their for several years now, but we want ECR, but it should be thousands. I participation? to increase that. Today, you can find hope to increase this number next VS: This is a very good initiative. a lot of information on the internet year. Russian radiologists must Besides medical students, we are also and many people might not think understand that there are a lot of attracting more radiographers. This it is necessary to travel to a con- ECR 2014 Congress President Valentin Sinitsyn benefits for ESR members: congress year, for the first time there is a small gress. We want to create something from Moscow, Russia. discounts, support for young radi- team of Russian radiographers at the attractive and show that it is worth ologists, fellowships and teacher ECR, and our cooperation with the coming here. Nothing can replace programmes through ESOR. European Society of Radiographers shaking hands with your colleagues ECR 2014 will feature New gists have very good training in dis- is improving. I like these student from other countries. I would be Horizons Sessions on theranostics, eases, and they have more contact ECRT: What will be the focus of sessions because they can have their very sad if the ECR were entirely oncology and new technology, as with patients. Those hospitals where the ‘ESR meets Russia’ Session? own presentations and workshops. online. This is why we are making radiology is developing so quickly. cardiologists and radiologists work VS: It will be a multimodality ses- Another exciting initiative is live meetings more interactive. There will also be new State of the together for the benefit of the patient sion. Russia is huge, so we decided the European Diploma in Radiol- We would also like to change the Art Symposia on RECIST, ischae- usually have better results. In my to focus on the main diseases in our ogy (EDiR). Last year I was one of format of scientific sessions. We are mic stroke, cardiac imaging and hospital, we are friends but things country, namely: tuberculosis, lung EDiR’s examiners. I am glad to see currently discussing the concept of obesity. Special Focus Sessions will could be improved. Some cardiolo- cancer, breast cancer, liver tumours it is becoming so popular, with 50% a multimedia classroom, a model concentrate on topics as varied as gists think that radiologists need and pancreatic tumours. The biggest more candidates since last year. The which was successfully introduced image-guided biopsies in prostate better training in cardiology and problems in Russia are undoubtedly diploma is held in different coun- during the last SIRM congress in cancers, orphan diseases, dental better knowledge of organ pathol- breast and lung cancers. Many Rus- tries at national society annual June 2012. This multimedia class- imaging, US elastography, MR ogy, cardiac disease, physiology sians are smokers, but this year a meetings and I hope it comes to room offered 60 work stations from elastography, paediatric abdominal and anatomy. Our impression is smoking ban in public places was Russia one day. different companies with 25 differ- emergencies, safety standards and that sometimes cardiologists are introduced, and this is very good ent cases which were discussed at structured reporting. Finally, Pro- not fully aware of the potential of news. Serbia and Mexico will be our ECRT: The Social Media Wall and the end. We are currently discuss- fessional Challenges Sessions will be imaging, that some consider cardiac other guest countries. ECR Live are both in their second ing the structure with Professor dedicated to interventional oncol- CT or MRI a toy without real benefit year at ECR 2013. What value do Emanuele Neri from Pisa, who was ogy, educational challenges and the for the patient. But the truth is that ECRT: What do you think about these services add to the congress responsible for the scientific pro- role of social media in radiology. today cardiac imaging can do a lot the sessions held in Russian during and how do you see them develop- gramme of that project. for patients. the Satellite Symposium organised ing in the future? Soon we are going to use smart ECRT: Will the programme reflect by GE Healthcare Nycomed last VS: I really admire the ECR staff, phones for voting during audience your interest in cardiac radiology, ECRT: Russia will take part in the Saturday at the ECR? Do you think especially the new media team. response sessions. But wireless tech- and if so, how? ‘ESR meets’ programme as well. it would be a good idea to have sci- The ECR is so important because nology has its limits and sometimes VS: Actually, one of the major high- Do you think this will increase entific sessions in languages other it’s the most modern and innovative networks crash, so it needs a lot of lights at ECR 2014 will be the ‘ESR Russian attendance at the ECR? than English as well, and if yes, congress. People will really begin work. Keypads are an old technol- meets cardiologists’ sessions. We VS: Russia was a guest country of which ones? to appreciate these new services ogy but they are very reliable. I am will invite the European Society of the ESR meets programme in 2006. VS: It’s a very good initiative and a over the next few years. It reminds sure that next year, or the year after Cardiology to take part in joint ses- I was involved in preparing of this good example to follow. I already me of the Electronic Presentation that, everybody will be able to vote sions on cardiac imaging. The ESC meeting and it was a great expe- spoke with Russian-based com- Online System (EPOS™). When it with their own iPads or tablet. has sessions on cardiac imaging dur- rience. Participating in the ‘ESR panies about it and they took it was launched in 2003, no one fully We will also increase the number ing their congress. meets’ programme is an excellent very seriously. Siemens and Bayer understood how fantastic a tool of multidisciplinary sessions. This Cooperation with cardiologists opportunity for Russia and all coun- HealthCare will seek to do that next it would become. Now we cannot is not something we have to do just can be very tricky. Turf battles exist, tries from the former Soviet Union. year. imagine our lives as radiologists during the ECR. This year we had for instance concerning who should Language unites us, as Russian is the I want to continue this over the without it, and many other con- the Imaging Biomarker’s Course the perform cardiac MRI. For me, the second language in many of them, next few years. As I said earlier, I want gresses imitate it. But there should day before the congress, which was right answer is a multidisciplinary and every radiologist in Belarus, the number of delegates from Rus- be a balance; we don’t want to see organised by the European School of approach. Every radiologist thinks Kazakhstan and Ukraine, to name sia and neighbouring countries to people checking their e-mails, or Radiology. This will take place again cardiac imaging should be done by a few, speak Russian. increase in the future, and I believe their mobile phones and iPads next year with radiation oncology radiologists, but in close coopera- Rising attendance can prove a this is one way of doing it. One prob- while a speaker is delivering a as the topic. tion with cardiologists. Cardiolo- tough nut to crack though, as our lem is language; I always encourage presentation.

ECR2014

myESR.org | #ECR2013 @myESR 8 ECR Today 2013 Highlights Monday 11 March 2013 Professional assessment and audits prove vital to radiologists’ work

By Mélisande Rouger even within the same country, within the same department. These which can lead to mistakes. Look- discrepancies sometimes increase Experts discussed the best ways to ing at a study on MRI/CT utilisa- costs and sometimes even mor- assess the radiologist’s professional tion in 2009, Boland noticed that bidity and mortality,” he added. performance during an interactive there were differences in the uti- He recommended looking beyond session on standards and audit on lisation of imaging between the the traditional role of the radiolo- Saturday. south-east compared to the north gist, the reporting function, and Dr. Giles W. L. Boland, a radi- of the United States. “There’s a big assessing every aspect of the value ologist working at Massachusetts problem there. How do we review change. General Hospital, Harvard Medical that process? Every aspect in this “Peer review is an interpreting School, explained why radiologists value change should be reviewed. process. It should be structured, should undergo peer review. “If we If one patient is getting a CT in transparent and fair by your peers, are not analysing our own perform- one region and not in another, and you should benchmark the data ance I think we are failing in our we as radiologists should be peer against your peers. In the United duty as physicians towards patients,” reviewing that process as to why States this data is now being used for he said for starters. “We think we’re this test was ordered. The same goes credentialing,” Boland said. doing quite well but perhaps we’re with the modality: for instance do What the referring clinician thinks not. Frankly, it’s a big problem for you use CT, MRI or US to evalu- of the radiologist’s work should also medicine.” ate brain angioma?” he asked. be taken into account, according to He quoted a seminal article “And what about reporting? What Jan Bosmans, a radiologist at Ghent Jan Bosmans from Ghent, Belgium. Giles W. L. Boland from Boston, published in the United States in type of language do you use in a University Hospital and consultant United States. 2001 by the Institute of Medicine, report, are we incorporating elec- radiologist at Antwerp University in which the author estimated that tronic medical record data, what do Hospital, Belgium, who also spoke ence, while recent studies are more should always address the clinical about 100,000 deaths per year are you do with findings and how do during the session. evidence based. question, which they sometimes fail due to error. “Error is everywhere. you communicate report findings?” Clinicians mainly evaluate There have been qualitative and to do, the various authors found. Not just in the reporting and inter- he continued. the radiologist’s work through quantitative studies by clinicians Radiologists should also provide pretation of the case, but actually Boland quoted the example of an the report produced by the lat- and radiologists alike. Bosmans value to subspecialists who feel at every step of the radiology work incidental finding in a patient with ter. Radiological reports pretty compared 13 studies conducted they can interpret images them- process,” Boland said. lung cancer. The majority of radi- much look the same since the in the 1980s with recent ones, and selves, as radiologists see things cli- When polling the audience about ologists chose PET-CT because the creation of the discipline in 1896. found surprisingly similar con- nicians wouldn’t notice. The type of whether every member of their patient had cancer. “But PET-CT is “We could say that their reports clusions. Notably, he referred to a examination determines the length department performs routine care the highest radiation and costliest look remarkably modern – or study by Naik from the University of the report, which should contain review, over 70% responded nega- modality. Nobody thought of look- that our reports look remark- of Toronto in 2001, as well as the a conclusion. The report should tively. Errors can be avoided by ing at old films that were done in this ably outdated,” Bosmans said. COVER (Clinicians’ Opinions, offer advice. Clinicians also want standardising imaging utilisation, patient a year before, which would The number of studies on reports Views and Expectations on the radiologists to communicate better as well as protocols and modalities, have been the cheapest test!” has increased in the last dec- radiology Report) and ROVER and to be available for consultation. Boland believes. “Bottom line is we have huge ade. Until the 1980s, most papers (Radiologists’ Opinions, Views Finally, radiologists should educate A noticeable variation in prac- variation in our practices, which expressed the personal views of the and Expectations on the radiol- clinicians about new technologies, tices exists between countries, and affects quality and safety, even authors, based on life-long experi- ogy Report) studies. Radiologists for instance.

#ECR2013 @myESR | myESR.org Monday 11 March 2013 Clinical Corner ECR Today 2013 9

Advances in MRI Imaging plays major Applying Formula and treatments role in fight against One-type methods INSIDE increase chances head and neck can help smooth the of real progress in cancers way in urogenital TODAY multiple sclerosis emergencies See page 10 See page 12 See page 14 Radiologists emerge as central players in tackling global healthcare challenge of hepatocellular carcinoma

By Rebekah Moan for the staging and consequently the management of the patient in terms Hepatocellular carcinoma (HCC) of decision-making,” he stated. has become a worldwide problem, However, about 30% of cases do and radiologists need to learn more not show these typical findings, about it, according to two experts. despite the neoplastic nature. The Luckily, ECR delegates will have a methods are specific, but not suf- chance to educate themselves about ficiently sensitive, so even if the this disease in a special focus session radiologist does not detect typical held this morning. findings, the patient may suffer Chronic hepatitis and cirrhosis from HCC. Atypical findings are, for may lead to HCC, and they are the instance, benign nodules or vascu- underlying pathological situation in lar findings that might mimic HCC, which HCC can occur, according to according to Dr. Christoph Zech, Contrast-enhanced CT shows HCC with typical dynamic pattern. (Provided by Prof. Carlo Bartolozzi) Prof. Carlo Bartolozzi, a professor from the Clinic of Radiology and of radiology and chairman of the Nuclear Medicine at the University department of diagnostic and inter- Hospital Basel, Switzerland, who ventional radiology at the University will discuss atypical findings dur- of Pisa in Italy. The main problem ing the session. the radiologist may encounter in There are many aspects to con- his or her daily practice is to detect sider in the cirrhotic liver, includ- inside a cirrhotic liver the nodule ing regenerative activity, benign that might already be HCC or the nodules, and vascular findings that nodule that might become HCC, he might imitate HCC, he said. “It is said in an interview with ECR Today. very important to be aware of these “The role of diagnostic radiol- pitfalls and different findings, and ogy is very important because we it’s important not to overdiagnose may detect such development, and patients, to report nodules as HCC our diagnosis nowadays is abso- which are in fact benign nodules,” lutely specific, in other words, we he explained, adding that if there can make the diagnosis of HCC on is one clear HCC nodule and three Atypical presentation of HCC shown on a contrast-enhanced MR image. (Provided by Prof. Carlo Bartolozzi) the basis of typical findings,” said or four indeterminate nodules Bartolozzi, who will moderate this wrongly called HCC, the patient morning’s session. “And if we, as I might be withdrawn from a cura- have to talk about mRECIST (modi- “Delegates should attend the ses- most of the treatments are performed said, make this specific diagnosis, tive approach. fied RECIST) criteria,” he added. sion because it’s really appealing,” directly by the radiologists, consid- needle biopsy is no longer needed. On the other hand, if patients “This classification is based on the Bartolozzi said with a chuckle. “We ering that evaluation of tumour In other words, diagnostic workup in surveillance programmes with assessment of tumour necrosis.” as the radiologists are so strongly response is by radiologists. We are is over.” unclear findings have strong neg- RECIST will be addressed dur- involved … considering the diag- so deeply involved that we have to Typical findings will be reported atives and it turns out they have ing the session, but so will topics nosis is up to us, considering that know and to play our role at our best.” in depth by Prof. Carmen Ayuso HCC, then late diagnosis would such as how to evaluate the tumour from Barcelona, but in brief, con- also adversely affect prognosis. response to therapies and the effect trast material can identify hyper- HCC may be treated with liver of information technology on the Special Focus Session vascularity of the nodule and sub- transplantation, but only one out management of patients. Monday, March 11, 08:30–10:00, Room L/M sequent washout and the presence of 10 patients may undergo the ECR delegates will find the ses- SF 16c: Making homogeneous HCC readings of neoangionesis, which is the most procedure. So how do physicians sion informative and interesting for ▶▶Chairman’s introduction important finding for making a treat a huge number of patients, several reasons, according to Zech diagnosis of HCC, he added. and how do they evaluate the and Bartolozzi. C. Bartolozzi; Pisa/IT “In this way, we can make the tumour response? In oncology, “I think it is attractive for the ▶▶HCC diagnosis: how to report ‘typical’ findings diagnosis of HCC, and we can RECIST (response evaluation cri- delegates to get this comprehensive C. Ayuso; Barcelona/ES assess the volume of the lesion, the teria in solid tumours) criteria are overview, to see the typical findings ▶▶How to interpret and report ‘atypical’ findings diameter of the nodule, the number used, focusing on tumour size, they know already and which are C.J. Zech; Basle/CH of lesions,” he said. “All these ele- Bartolozzi said. good to have a repetition of, but ments are important not only for “In HCC, the classical RECIST also to see atypical findings and the ▶▶How to evaluate tumour response to therapies the diagnosis, but also important criteria are not applicable, so we diagnostic and therapeutic implica- J. Ricke; Magdeburg/DE tions,” Zech said. ▶▶Information technology: the practical impact In addition, at the end of the ses- on the management of HCC patients sion there will be a clinical case, and I. Bargellini; Pisa/IT in 10 minutes the presenters will be asked to demonstrate how to report ▶▶Panel discussion: Case-based discussion: a practical demonstration the case and how to define the imag- of how interpretation and reporting affect patient management ing findings. It will be an example of a practical report. #SF16c #ECR2013LM

A B C

Patient with several HCC nodules. The images show one representative nodule in liver segment 7. A: arterial phase CT prior to treatment. B: Partial tumour response of HCC is shown after radiofrequency therapy on contrast-enhanced angiographic depiction of this nodule with superselective angiography and subsequent drug-eluting bead transarterial chemoembolisation (TACE). MRI. (Provided by Prof. Carlo Bartolozzi) C: follow-up with CT after TACE shows the necrotic lesion. (Provided by Dr. Christoph Zech)

myESR.org | #ECR2013 @myESR 10 ECR Today 2013 Clinical Corner Monday 11 March 2013 Advances in MRI and treatments increase chances of real progress in multiple sclerosis

By Edna Astbury-Ward that spinal cord imaging of choice investigation is double inversion should be T2-weighted images and recovery (DIR), which can be used A vital consideration in multiple proton density. However, imaging to highlight specific lesions in the sclerosis (MS) is that earlier diag- of the spinal cord is not without cortex. DIR can be particularly use- nosis minimises the potential for its difficulties in patients with MS ful because lesions in the cortex and disease-related progressive dam- due to the nature of the disease and in the spinal cord are unique to MS. age, and this is putting MRI at the increased tremor, and circulating “Patients often wait until they forefront of the battle against this cerebrospinal fluid also makes the have the next attack of MS, which complex neurological condition. process much more challenging. may not occur for a year following MRI enables radiologists to see Other difficulties include the initial investigations,” he said. “A the constant activity and brain vol- need for images that are perpen- diagnosis of MS is based on showing ume reduction (atrophy) associated dicular to the cord (transverse or disease dissemination in space and with MS, according to Prof. Frederik axial), but because of the number time. One of the main advantages of Barkhof, from the department of of images required – often hundreds adopting the revised 2010 McDon- radiology, VU University Medical – this process can become a tedi- ald criteria is that the modifications Center, Amsterdam, The Nether- ous event for the patient and a time- allow the potential to demonstrate lands. Other diseases may mimic consuming and lengthy procedure the dissemination of lesions in space ischaemic white matter disease such for the radiology department. He and time. Moreover, the revised cri- as hypertension, hypercholesterol, suggests that sagittal images provide teria make it easier and quicker to and diabetes where insufficient an adequate overview and less of form a diagnosis of MS.” blood flows to the brain leading to them are required because each slice Novel therapy options are also demyelination, and this produces is 3 mm thick. moving ahead for MS patients, with high signal lesions that can look In addition, the field strengths of drugs such as natalizumab signifi- similar to MS. It is difficult to prove MRI units are constantly increas- cantly reducing inflammation, but conclusively that ischaemic lesions ing, and what was considered to be it’s not all smooth sailing, according are MS. Ageing also contributes to high-strength a few years ago, such to Prof. Majda M. Thurnher, associ- this appearance and these silent as 1.5-Tesla, is now considered to be ate professor of radiology, depart- lesions are quite difficult to discern normal, he said. Although 3-Tesla ment of radiology, University Hos- from MS, and a definitive diagnosis systems are acceptable for diagnosis pital Vienna. is made on brain imaging examina- of suspected MS cases and have the “There is a clear need for better tions and other investigations, such capacity to identify smaller lesions monitoring of MS patients treated as lab tests, he explained. with less signal-to-noise ratio, with new therapies. Unfortunately, High-field (7T) image of an MS patient shows high conspicuity of lesions on double inversion Interestingly, some patients with researchers are now investigating MS patients treated with natalizu- recovery (DIR) image, a technique that suffers from low signal-to-noise ratio at conventional very high blood pressure appear the potential of 7-Tesla machines. mab have increased risk for devel- field strength. (Provided by Prof. Frederik Barkhof) not to get these lesions, while other They are partly experimental, but oping progressive multifocal leu- people with normal blood pressure can offer great advantages, because koencephalopathy (PML), which serious complication, MR imaging when there are rapidly progressing may get ischaemic white matter it is difficult to spot the smaller is a potentially fatal demyelinating should be evaluated carefully. The white matter lesions in patients with disease, he noted. On a population lesions on lower signal strength disorder caused by the JC virus,” she knowledge about the new drugs lymphoma or other haematological level, there is a correlation between images, according to Barkhof. noted. “PML was previously mainly and their complications is crucial malignancies with immunomodula- this and smoking, hypertension and Detection of small lesions situated diagnosed in the HIV population, for early diagnosis, and MRI plays tory therapy, she suggests. diabetes, but it is often difficult to in the cortex presents challenges to and imaging characteristics in a central role in assessing patients identify with individual patients. the radiologist, which is one rea- HIV-associated PML and natalizu- treated with natalizumab to diag- “This remains one of the biggest son why the McDonald criteria were mab-associated PML do not differ nose PML as early as possible.” confounders, and for that reason introduced. Juxtacortical lesions substantially.” The benefits of using imaging for it is very important to look at the are particularly difficult to detect, Attendees at today’s session will these patients cannot be underesti- spinal cord,” said Barkhof. “Unlike and even under a microscope, they hear about key imaging features mated, she continued. It can detect Refresher Course: Neuro the brain, where with ageing one may require specific staining. These in diagnosing PML in MS patients active disease and may find some Monday, March 11, 16:00–17:30, may accumulate these silent lesions, lesions can be in direct contact with treated with immunomodulatory cases even in the preclinical state, Room G/H for unknown reasons this does not the cortex, where no intervening therapy, and they will learn how to and the combination of MRI and RC 1911: Multiple sclerosis: occur in the spinal cord; despite white matter is seen, and although distinguish between focal MS lesions cerebrospinal fluid analysis can be 2013 update the presence of contributing fac- some lesions do extend beyond the and PML lesions. They will also hear used to establish the diagnosis of Moderator: E.T. Tali; Ankara/TR tors such as diabetes, high blood cortex, some are completely con- expert speakers explain about the PML, the risk of which increases A. Differential diagnosis pressure and smoking, the spinal tained within the cortex and not in mechanism and imaging findings with a longer treatment duration. of multiple T2-HI white cord may have a normal appearance. the white matter, he pointed out. in immune reconstitution syndrome Since both MS and PML result in matter lesions However, in patients with MS the Speakers at this afternoon’s (IRIS), a paradoxical clinical deteri- demyelination, and clinical presen- reverse is true and a lot of lesions refresher course will discuss the oration that occurs in immunologic tation depends on white matter tract A. Rovira-Cañellas; Barcelona/ES may be seen. If there is any doubt importance of early detection, new recovery that is increasingly seen in involvement, it is very difficult to B. New developments whether the lesions in the brain developments and treatment-related natalizumab-MS-PML. clinically distinguish between them, in the diagnosis of are due to ischemia or MS, imag- complications of imaging in MS. “Patients on natalizumab do not she added. multiple sclerosis ing in the spinal cord is really the They will hear how Barkhof’s team require more frequent imaging, Thurnher advises that in patients F. Barkhof; Amsterdam/NL tiebreaker.” is developing techniques that will but they do need imaging every treated with immunomodulators, It is most important to image the detect these small lesions, either by time they develop new neurologi- it is vital to look carefully for large C. Imaging of MS treatment- spinal cord, because this is where using high field strength (7 Tesla) or cal symptoms,” Thurnher stated. white matter lesions, which might related complications the majority of disability occurs in normal pulse sequences at 3 Tesla. “Although the risk of PML appears represent PML lesions rather than M.M. Thurnher; Vienna/AT patients with MS. He recommends One of the new techniques under to be small, because it is such a focal MS plaques. Think of PML #RC1911 #ECR2013GH

A B C

Natalizumab-induced progressive multifocal leukoencephalopathy in a 35-year-old patient with multiple sclerosis. A: Axial FLAIR MR image shows ‘typical multiple small oval-shaped focal MS lesions located in the periventricular white matter of both hemispheres. On coronal T2-weighted MR image (B) and axial FLAIR MR image (C) of the brain, large high signal intensity ‘scalloped’ lesion is detected in the left frontal lobe. The lesion affects the U-fibres and spreads into the cortex. Note a well-defined border on the cortical side and an ill-defined border on the white matter side. (Provided by Prof. Majda M. Thurnher)

#ECR2013 @myESR | myESR.org Monday 11 March 2013 Clinical Corner ECR Today 2013 11 Make sure you’re up to date on how to optimise contrast media administration, speakers urge

By Frances Rylands-Monk and hopefully improved outcomes,” Bongartz said. Promising new contrast agents are Today’s session should appeal to more than ever improving visualisa- both general radiologists and MR tion in MR angiography, as well as specialists, particularly through its tumour and inflammatory disease aim to shed more light on remaining perfusion data, but experts still concerns over renal insufficiency seem uncertain about exactly how patients and nephrogenic systemic and when to use the agents, particu- fibrosis (NSF). NSF, a sclerotic larly in renal insufficiency patients. disease detected in the late 1990s, Today’s refresher course on opti- usually produces a stiff scarring mising contrast administration appearance of the arms and legs will serve to update ECR delegates due to fibrocytes, recently detected on the latest thinking about media healing cells, developing from other dose and administration techniques, cells. Scarring can also occur in key and hopefully destroy any lingering organs, including the heart, which doubts and myths about blanket con- may even cause death. traindications in at-risk patients. The Not all causes of this process are course will also highlight pipeline understood, although gadolinium developments, as well as progress combined with high-grade renal made through the introduction of insufficiency is now known to be one organ- and tissue-specific agents. such trigger. It was 2006 before this In MRI, hepatocyte-specific Pri- link was made, but it was the single movist (Gd-EOB-DTPA, gadoxetic most important event for alteration acid), a gadolinium-based agent of contrast application regimes in that highlights normal liver tissue, MRI, according to Bongartz. and blood-pool agents without Contrast with weaker molecu- extracellular components such as lar binding was found to be more Ablavar (formerly Vasovist) have dangerous for such patients than demonstrated a strong relaxivity, the contrast with stronger binding, thus enabling smaller dose applica- leading to new guidelines in 2008 in tions and a completely new contrast which weaker binding agents, nota- distribution, according to session bly Omniscan and Magnevist, could speaker Prof. Georg Bongartz, vice not be given to renal insufficiency chair of radiology and nuclear medi- patients. No new cases of NSF have cine at the University Hospital of been reported since. Basel, Switzerland. Following per- Although contrast application Coronal image of the abdomen in the pancreatic parenchymal phase clearly depicts pancreatic cancer. (Provided by Dr. Peter Leander) fusion, Primovist can show where in MRI is much less variable with a tumour lies by revealing areas of respect to dose, injection rate and no enhancement. various tissues than CT, this changes “This has had a high impact on when renal impairment is part of liver imaging because very small the equation. tumours and metastasis can be “We now know that gadolinium detected. This contrast can dis- chelates in fact do show nephrotox- tinguish between the benign and icity, that dose restrictions apply for the malignant, and so is key to the all gadolinium chelates and that detection and discrimination of macrocyclic gadolinium prepara- hepatic tumours,” said Bongartz, tions are the safest contrast agents adding that blood-pool agents in this group,” he stated. “Radiolo- that enhance arteries and veins in gists must know about the dangers angiography can help to distinguish associated with high-risk contrast vascular system structures in great agents – but also that there is certain detail from tissue to reveal stenosis, risk connected to the other groups occlusions and aneurysms. as well when a patient suffers from Course attendees will hear about renal failure.” organ-specific contrast media yet to Bongartz pointed to ongoing be marketed, such as iron-loaded uncertainty among the radiology microspheres for demarcation of community about when and how macrophages, inflammatory states NSF occurs, which contrast agents and lymph nodes. These agents con- were safer than others, and whether taining ultra small particles of iron or not contrast media could even be MRI and MR angiography of the thigh of a 32-year-old male suffering from a haemangioma. Following the application of a gadolinium-based oxide (USPIO) can be taken into the applied in end-stage renal disease. contrast agent, the MRA demonstrates early perfusion while the late imaging sequence offers detail of muscular involvement. inflammatory process, with areas “This is why my part of the session (Provided by Prof. Georg Bongartz) of inflammation revealing a drop will appeal to general and subspe- in MR signal, especially in lymph- cialist radiologists alike: respect the scans, according to Dr. Peter Lean- medication of patients with contrast at first, but by understanding about node imaging. contrast media guidelines for NSF, der, regional chief radiology officer, media allergies. In addition, opti- human circulation, the tissue that “Such an agent can distinguish stay away from high-risk contrast Skåne Region, and a gastrointestinal mal diagnostic yield linked to the should be enhanced, correct con- between functional and non-func- agents in suspected renal impair- radiologist specialising in CT and speed of delivery, media volumes, trast media doses, injection param- tional tissue. A lymph node or part ment and apply contrast media of MR of the abdomen, from Skåne as well as bolus-monitoring to time eters and the CT scanner used, it of it that doesn’t take up iron, for the low or intermediate risk group University Hospital, Malmö, Swe- imaging in arterial or portal-venous becomes simpler and far more example, means infiltrations such with highest relaxivity at smallest den. For this reason, general radi- phase will be covered. Scanning fac- comprehensible.” as carcinoma. Such agents could dose,” he advised. ologists need to take an interest in tors and scan timing will also form a also be applied to inflammatory While institutes across Europe its administration, and in the risk of key part of Geneva-based Dr. Xavier Refresher Course: Molecular pathologies like atherosclerosis in continue to work on updating acute kidney injury (AKI) triggered Montet’s lecture about optimising Imaging and Contrast Media the vascular wall, which would be standardised approaches on fast by its use in older patients. PET-CT media administration. Monday, March 11, 16:00–17:30, a major advance,” he noted. multislice CT, its increased use in “Diagnostic information in elderly Leander warns delegates about Room D2 For general disease overview, MRI the aging population, due to the patients with co-morbidities such as the dangers of feeling pressured to RC 1906: How I optimise enhanced with these contrast media growth of CT angiography, for diabetes mellitus, heart failure and cover all clinical questions in one contrast media would not compete with PET-CT, example, has fuelled the move from reduced kidney function needs to be CT exam that may yield suboptimal administration but in a small lymph node, it can fixed to individualised protocols in got from reduced volumes of media results. A CT dedicated to detect- Moderator: W. Semmler; depict infiltrative processes with line with increased awareness of the at lower kV,” said Leander, noting ing a pulmonary embolism will greater sensitivity. effects of CT contrast media in dif- there has been little development in not necessarily provide answers for Heidelberg/DE “I hope that such an agent will ferent patient demographics. CT contrast media itself and those abdominal questions, for example. A. CT be on the market within the next While most CT subspecialists will on the market have been available for “We may have to choose the best P. Leander; Malmö/SE five years, because certain areas of be aware of the latest thinking about many years, but much has changed in organ-dedicated technique and B. MRI microinvasion diagnosis will be ear- how to tailor CT media administra- administration strategies. “My talk is appropriate imaging phase which G.M. Bongartz; Basle/CH lier detected with better specificity, tion, faster machines and complex less about ‘which’ we use and more may only answer one particular and will certify disease spread with- scanning techniques makes this a about ‘how’ we use media.” question, sometimes meaning that C. PET-CT out the need for diagnostic surgery vital area for general radiologists His talk will focus on how to one has to repeat a CT for other X. Montet; Geneva/CH or biopsy. This will lead to better to know about, particularly as reduce volumes for patients with questions,” he said. “Tailoring CT planning and patient management – patients live longer and have more impaired kidneys and the pre- protocols may appear complicated #RC1906 #ECR2013D2

myESR.org | #ECR2013 @myESR 12 ECR Today 2013 Clinical Corner Monday 11 March 2013 Imaging plays major role in fight against head and neck cancers

By David Zizka tion with your clinician. Although there are clear guidelines for diag- Organ-sparing surgery and radia- nosis and treatment; techniques and tion treatment such as intensity- habits may vary depending on the modulated radiotherapy (IMRT) individual surgeon, oncologist or – often combined with chemother- radiation oncologist. apy – have increased the need for Your report should of course advanced imaging in the head and primarily contain what we usually neck during pretreament and post- do in the majority of cases, such as treatment stages. Precision is vital, describing the extent of lesions. In A B C D as any tumour that remains unde- addition to that, it is useful to indi- tected outside the treatment field cate abnormalities that are decisive could adversely affect the patient’s for treatment and highlight them,” prognosis and survival, according said Vandecaveye. to Professor Vincent Vandecaveye, Tumour boards represent the per- from the department of radiology fect opportunity to directly commu- at the University Hospitals Leuven nicate with clinicians and to discuss in Belgium. reports, if anything remains unclear. It is important to spot any tumour “From my experience, you can gain recurrence as early as possible, espe- a lot of gratitude and consideration cially in the post-treatment phase, from your clinical colleagues for in order give the patient the best this, and at the same time a radiolo- E F G H possible chances of salvage treat- gist can learn a lot regarding treat- ment. The most common imaging ment and patient management,” said methods in the head and neck area Vandecaveye, recommending that remain CT, MRI and PET-CT; each radiologists join these boards. comes with its own advantages and As imaging is becoming more and disadvantages. more complex, radiologists have When ECR Today asked Vande- an evolving role as liaisons in the caveye about his thoughts on the clinical setting and should become progress taking place in the field of actively involved in diagnostic man- MRI and how this could influence agement and treatment planning. head and neck imaging he gave us As radiologists often have a more a very promising answer: “Person- general background than clinical I J K ally, I think the increasing ability of organ specialists, they also have an Multiparametric MRI for early treatment prediction of chemoradiation in oropharyngeal cancer: MRI to provide functional imaging important role in the identification Upper row is pretreatment MRI of right base of tongue cancer (A=contrast enhanced T1 as anatomical correlate; B=native b1000 diffusion- assessment, for example diffusion of patients who will eventually have weighted image; C= ADC-map; D=perfusion-map of IUAC). and perfusion-weighted MRI, of diseases other than those affecting Middle row is 2 weeks into chemoradiation: same imaging sets, tumour volume hasn’t changed. Lack of significant change in b1000, ADC or head and neck cancer for primary the head and neck, and so they can perfusion-MRI indicates non-response and thus high risk of tumour relapse after treatment. staging, recurrence imaging or treat- help refer the patient to the correct Tumour relapse at PET-CT 8 months after treatment, proven by histology (K). ment prediction holds great prom- physician. (Provided by Professor Vincent Vandecaveye) ise. MRI is not just a single modality; Another issue that is becom- I believe functional MRI techniques ing more and more important in grail, but I have rarely seen this hap- cancer imaging, each covering dif- deal with head and neck cancer can provide a better correlate to modern medicine is cost efficiency pen in clinical reality. Radiologists ferent but complementary areas while working in a more gen- metabolic imaging than the clas- and its influence on the quality of should combine their knowledge of expertise. At the same time the eral setting, and radiologists who sic anatomical imaging sequences. diagnosis. of guidelines with their common lectures provide a good mixture work in a more specialised setting. The latter are of major interest in the It is important to combine sense, clinical abilities and reason- of daily practice, advanced imag- Finally, we provide a close correla- development of hybrid PET-MRI knowledge of the different imag- ing. We should be aware; however, ing and future developments. This tion between imaging and clinics systems. Functional MRI is quite ing modalities’ abilities with clini- of what extent advanced imaging means that the topic is varied and which also brings the topic close difficult to perform in the head and cal guidelines, which are quite well truly helps the patient and clinician. interesting for radiologists, who to clinical practice.” neck, from a technical point of view, organised for head and neck cancer. We probably have a better chance but the vast progress made in MRI- For instance, the risk of distant of reducing costs by trying to avoid Special Focus Session technology, including hardware and metastases increases significantly overdiagnosis,” said Vandecaveye. Monday, March 11, 08:30–10:00, Room N/O software developments, and the with nodal metastases at the low neck The session on the fight against gradual increase in knowledge and levels, and for these patients more head and neck cancers will also SF 16b: Head and neck cancer battle: the power of imaging studies experience in several centres will stringent staging should be done feature talks by Dr. Frank Pamei- ▶▶Chairman’s introduction improve it.” in order to rule out distant metas- jer on ‘Building blocks for loco- V. Vandecaveye; Leuven/BE In the struggle against cancer we tases before initiating local therapy, regional staging of head and neck ▶▶Building blocks for locoregional staging of head and neck tumours tend to only look at the possibili- which should be done with PET-CT. tumours’, Professor Minerva Becker F.A. Pameijer; Utrecht/NL ties offered by technology and sci- However, there is no need to carry on ‘Detection of tumour recurrence ▶▶ ence, which have, without doubt, out advanced imaging for distant in head and neck cancer: challenges Detection of tumour recurrence in head and neck cancer: become extremely sophisticated and staging in patients with low risk and pitfalls’ and finally, Professor challenges and pitfalls effective in modern medicine. How- locoregional disease, and in these Roberto Maroldi on ‘Locoregional M. Becker; Geneva/CH ever, modern clinical practice also cases costs can be safely reduced treatment failure in head and ▶▶Locoregional treatment failure in head and neck cancer: depends very heavily on a multidis- by just using chest x-ray and ultra- neck cancer: causes and clinical causes and clinical implications ciplinary approach, which is only sound of the liver for distant staging. implications’. R. Maroldi; Brescia/IT possible through the establishment “Sometimes these discussions about Finally, when asked why he would P. Nicolai; Brescia/IT of clear communication strategies cost-effectiveness worry me as they recommend this session to ECR and teamwork within a hospital or create a false idea of a so-called one- attendees, Vandecaveye had this ▶▶Panel discussion: Advanced imaging in clinical practice: department. stop-shop imaging modality that to say: “I think we have excellent how does it help the patient? “I think the single most important can solve all diagnostic problems. speakers who have major experi- component is direct communica- Of course this would be the holy ence in the field of head and neck #SF16B #ECR2013NO

ECR 2013 Smartphone App The ECR 2013 App gives iPhone and Android users a new way to experience the congress. The app is packed with features, including general congress information, scientific and educational programme details, news on arts & culture in Vienna, full abstracts, and even floor plans of the Austria Center. You can download the app from iTunes or via the QR code to the right ▶▶▶

#ECR2013 @myESR | myESR.org Monday 11 March 2013 Clinical Corner ECR Today 2013 13 Take great care to avoid confusing normal variants with disease in paediatric imaging

By Frances Rylands-Monk The session is likely to appeal to any radiologist who images paedi- Many radiologists are not suffi- atric patients, according to Rossi, ciently trained in, or familiar with, who pointed out that the vast major- the paediatric brain to appreciate ity of cases he sees stem from MRI the variants leading to unnecessary examinations undertaken at a differ- examinations and follow-up that ent hospital by a general radiologist rarely yields definite answers. Radi- with little experience in neuroimag- ologists must therefore be familiar ing or paediatrics. with the changes in the brain in rela- To avoid both under-diagnosis tion to the processes of myelination through lack of recognition of dis- and brain maturation, particularly ease and pathologies, and overdiag- in the first two to three years of life, nosis through calling normal find- according to Dr. Andrea Rossi, head ings abnormal, general radiologists of the department of paediatric neu- need to become more familiar with roradiology at G. Gaslini Children’s the paediatric brain and more con- Hospital, Genoa, Italy (see Figure 1). fident about imaging it, he believes. At today’s refresher course on “It is important that colleagues paediatric variants, he will outline are aware of the variants. Paediatric why incidental findings constitute patients are not just small adults. a major pitfall in paediatric brain Parents are keen that their children imaging. Most cases of pituitary or are properly managed with tailored pineal gland cysts are normal, but imaging and treatment,” Rossi said. they are often reported, resulting A similar message for chest and in a repeated MR scan. Moreover, abdomen imaging is likely to come in neonate brain imaging, normal from Dr. Simon Robben, a paediatric large pericerebral spaces are often radiologist at Maastricht University confused with atrophy, as is tran- Hospital, the Netherlands, who will sient shrinkage of the brain with be elaborating on common variants in enlargement of the ventricles and normal chest and abdomen findings. subarachnoid spaces in patients While many general radiologists Figure 1: Top: MR images of a normal individual at three months show the physiological lack of myelination at this age. Bottom: a pathological undergoing steroid treatment. are familiar with paediatric muscu- example of a hypomyelinating disease (Pelizaeus-Merzbacher disease), in which the central nervous system myelin does not form. The two sets of images are essentially identical, the only significant difference being the age of the two subjects. Knowledge of the normal age-dependent “Knowing the variants is less about loskeletal (MSK) imaging, it is not appearance of myelination on MRI is necessary in order to correctly discriminate what is normal and what is not. (Provided by Dr. Andrea Rossi) recognising MRI patterns and more uncommon to see a number of ‘adult about knowing the patient’s age and misoriented’ x-ray reports each year, history. Otherwise these findings according to Dr. Fermin Saez, head of can be over- or under-estimated in paediatric radiology, Cruces Univer- our tendency to concentrate on the sity Hospital, Barakaldo, Spain. Usu- image,” he said. ally x-ray is the only imaging required The availability of MR and to differentiate between normal vari- advanced MR sequences such as ants and significant pathologic enti- diffusion, perfusion, spectroscopy ties. However, in unclear cases, other and functional MR has made a sig- modalities, or even a biopsy, may be nificant impact on paediatric studies needed to make the right diagnosis. in neonates and premature babies. Overuse of these techniques, as well 3T MRI has changed the manage- as potential ensuing family anxiety, ment of several diseases particularly should be avoided through careful in the diagnosis of hypoxic ischemic combined analysis of the x-ray and encephalopathy damage in neonates clinical findings, he warned. after a complicated delivery when The most common mistakes are such scans can reveal early prog- related to normal irregularities A B C nostic implications, Rossi explained. in the ongoing ossification of the Ten years ago, T1- and infants visualised in x-ray, espe- Figure 2: Irregular ossification of the posterolateral condile in a 10-year-old boy. A, B: plain films show fragmented ossification at the T2-weighted standard MR images cially when these irregularities are posterolateral condile, not to be confused with osteochondritis dissecans. C: MRI shows normal overlying cartilage. The site of the irregularity would be undertaken at six months asymmetric. In Saez’ experience, and the normal overlying cartilage help to exclude osteochondritis dissecans. Incidentally, there is a fibrous cortical defect at the proximal tibial to look for chronic stage damage epiphyseal irregularities, ischi- metaphysis. (Provided by Dr. Fermin Saez) and likely outcome. Now, hypother- opubic synchondrosis (see Figure mic treatment is given directly after 2), and the distal femoral cortical birth and then diffusion and spec- irregularity (Figure 3) are the more troscopy are performed using MRI frequent sources of errors. In rare in the same week to show residual cases, ultrasound and MRI are the damage and give an early prognosis preferred methods in children when about the risk of motor impairment. the diagnosis is not straightforward Another area of progress is pae- in x-ray. In some cases a bone scan diatric brain tumours now that dif- or CT can also solve the problem. fusion tensor imaging can reveal CT is commonly performed the best surgical approach to avoid for congenital or developmental A B C damage to the surrounding brain. abnormalities. However, the main Functional MRI can addition- scenario for the use of MSK CT ally map critical areas that control is in polytrauma when paediatric Figure 3: Distal femoral cortical irregularity. A, B: plain films show a lytic lesion at the posteromedial distal femoral metaphysis. C: MRI confirms the ‘lesion’ and shows that it lies at the insertion of the medial gastrocnemius muscle, which is a typical location and appearance for this patient function, providing a clear patients may not be able to coop- developmental variant. (Provided by Dr. Fermin Saez) route for safer operations. erate with positioning, leading to “Paediatric invention sometimes poor quality plain films. In these trails behind, but dedicated MRI cases, CT allows the evaluation of In recent years, paediatric imag- future, paediatric total body MRI, Refresher Course: Paediatric coils for the paediatric brain and fractures in locations too difficult ing has benefitted from several PET-CT, and PET-MRI may be Monday, March 11, 16:00–17:30, spine are an important breakthrough for depiction on x-ray, such as the improvements, including differ- more widely used for multifocal Room Q as there is a better signal-to-noise pelvis, spine, and any joint. ent view settings in digital plain pathology and metastatic disease. RC 1912: Normal variants in ratio and therefore better image qual- Although dose reduction systems film to display bone and soft tis- For now, centres still needed well- paediatric imaging: not ity, especially for newborns,” he said. for CT, the use of appropriate child‐ sue adequately, high-resolution trained technicians and radiologists to be confused with Rossi will briefly touch on the lat- size machine settings, with iterative ultrasound probes that provide to perform appropriate immobilisa- disease est trends in foetal MRI of the brain reconstruction systems, make this good spatial resolution of soft tis- tion, positioning and collimation, Moderator: O.E. Olsen; London/UK and spine, a crucial adjunct to pre- technique more paediatric-friendly, sue and superficial bone lesions, which are mandatory for obtaining natal ultrasound, and a growing area concern over radiation risks in young smaller coils that improve signal a good quality x-ray examination, A. Brain for paediatric MR diagnosis. Two patients has led to an increased use to noise ratio for the MR study of according to Saez. A. Rossi; Genoa/IT thirds of prenatal MRI is performed of non-ionising imaging techniques small joints, and new immobilisa- “Most radiologists have to tackle B. Chest and abdomen to see if ultrasound-detected ven- such as ultrasound and MRI. Ultra- tion devices that help in keeping plain films performed in patients of S.G.F. Robben; Maastricht/NL tricular enlargement is connected sound is the primary means of rul- the child still, reducing the need any age, including children,” he said. to malformation, while the rest is ing out developmental hip dysplasia, for sedation in some cases. Hybrid “Count to three, and consult the lit- C. Musculoskeletal to detect acquired ischaemia, haem- while MRI is the preferred method techniques are also becoming erature available on normal variants F. Saez; Barakaldo/ES orrhage, tumours and congenital for a thorough evaluation of soft tis- increasingly recognised as useful before interpreting plain films with #RC1912 #ECR2013Q infection, he noted. sue and medullary lesions. tools for MSK oncology, and in supposedly abnormal findings.”

myESR.org | #ECR2013 @myESR 14 ECR Today 2013 Clinical Corner Monday 11 March 2013 Applying Formula One-type methods can help smooth the way in urogenital emergencies

By Edna Astbury-Ward

There is no single gold standard for training teams in medicine, but it can pay off to adapt team-working principles from other high-reliabil- ity industries such as aviation and Formula One motor racing and integrate them into crisis resource management training, according to emergency room (ER) radiologists. “Only by continuously evaluat- ing what you do, will we be able to improve our skills and understand the blind spots of our knowledge,” said Dr. Vibeke Løgager, from the department of diagnostic radiol- ogy, Hospital Herlev, University of Copenhagen. “In emergency uro- genital imaging, always expect the unexpected.” It is important that the receiving 33-year-old male with spina bifida. Reconstructed coronal maximum intensity projection CT doctors have the relevant clinical image shows bilateral staghorn calculi and horse-shoe kidney. (Provided by Dr. Sanjay Agarwal) information in order to understand whether or not the patient has suf- fered a high or low energy trauma, and therefore the clinical examina- tion and information given in the ER is very important. It is crucial that the team receiving the patient is trained in heavily wounded patients since time is valuable, she noted. ECR delegates at this morning’s categorical course will hear speakers discuss how radiologists can pre- vent misdiagnosis of subtle trauma earlier in the process and how good follow-up management may con- tribute to a reduction in morbidity and mortality. An 18-year-old female with ‘after-party amnesia’ presented with severe stomach pain and “Imagine a patient with a small bruises to the head. An investigation showed vaginal bleeding was from the bladder. Full-scale subclinical malignant tumour. This emergency room investigation showed severe left kidney fracture and contusion, but intact patient suffers a mild fall trauma, 37-year-old male with spina bifida. 3D reconstruction demonstrates the logistical difficulties of vessels and ureter. Three-month follow-up renography shows 28% kidney function on left side and due to the pain, is taken to imaging, treatment and management due to gross bony deformities. as the only sequelae. (Provided by Dr. Vibeke Løgager) the ER and the primary examina- (Provided by Dr. Sanjay Agarwal) tion including analysis of urine is indicative of not visible haematu- ease), they tend to stop and think CT due to radiation dose and MRI “The needs are obviously differ- standing of the pathophysiology ria or microscopic haematuria,” the problem is solved. We should due to logistics and availability. I ent between males and females, and clinical implications, he said. explained Løgager. “Stick to your always avoid jumping to conclusions am, however, a strong advocate for depending on the cause and extent To deal with these patients requires guidelines/algorithms of patients and consider if there are other pos- early and if necessary frequent use of physical disability and level of spi- dedication, empathy and focused with haematuria. A patient aged sibilities, she said. of these modalities with caution nal damage. It is not only important interest in the subject. Very prom- over 40 with microscopic haema- Close monitoring and early inter- and dose optimisation,” Agarwal to manage the physical and neuro- ising research is being done in this turia has the same risk of having a vention contributes to a reduction in said. “Until a few years ago, use of logical aspects, but also evaluate the area, and it will improve long-term cancer whether there has been an morbidity and mortality in urogeni- intravenous urography was routine psychological and emotional needs,” outcomes and further reduce mor- accident or not. If the clinical pic- tal imaging, according to Dr. Sanjay in several centres, now a CT KUB he said. bidity and mortality, he concluded. ture and the image are not the same, Agarwal, consultant diagnostic and (unenhanced renal tract CT) can be Currently, there is ongoing then one should always expect the interventional radiologist at Wrex- carried out with lesser dosage and research for management of neu- unexpected.” ham Maelor Hospital, Wrexham, more information. In my opinion, rogenic bladder dysfunction. In the If the patient is stable, she thinks it U.K. He considers it important to ultra low-dose CT is the way to go, short-term, simple things such as is worth doing the full plural phase keep the patient’s bladder pressure coupled with judicial use of MR safer tube drainage using biofilm Categorical Course: scans to ensure clinical colleagues low, noting that high pressure in the urography.” blocking and dispersive agents Urogenital Imaging have the necessary information to bladder is reflected back into the Imaging should be part of good and closed tube drainage systems Monday, March 11, 08:30–10:00, make the right decisions. Radiolo- ureter and the kidneys and is the follow-up protocols, which also may help with reduction in infec- Room C gists should aim for the maximum cause of most problems, especially includes clinical consultation and tion rates. More complex research imaging if the patient is stable, but if in cases of infection and deteriora- urodynamic assessment, he con- is being conducted from multiple CC 1621: The usual, the unusual this is not the case, minimise imag- tion of renal function, leading to tinued. All these are important to angles, for example application of and the dangerous ing and go straight to the operating kidney damage. reduce long-term problems with gene therapy (use of herpes simplex Moderator: S.K. Morcos; Sheffield/UK room, she recommends. Regarding follow-up of patients bladder dysfunction, but certain virus-derived vectors, etc.), develop- A. Imaging of renal Trauma When dealing with urogenital with bladder dysfunctions, he prostheses can make imaging more ment of newer medication (afferent V. Løgager; Copenhagen/DK imaging emergencies, the most advised that there is no agreed difficult, such as spinal or other pathway drugs) and tissue regenera- B. Postoperative anatomy and important requirement is having follow-up schedule, but in general, bony metal devices used for fixa- tion (tissue-engineered autologous specialist knowledge and promot- two yearly ultrasound scans and tion of trauma or corrective spinal augmentation cystoplasty). All will complications after GU inter- ing effective collaboration between plain x-ray of the kidney, ureter surgery for deformity. Prostheses have role to play in future manage- ventions clinicians and multidisciplinary and bladder should be followed. associated with the urinary tract ment of these patients, making this a H.C. Thoeny; Berne/CH teams who are trained in working However, if the patient is symp- that may also cause imaging diffi- very exciting time, Agarwal pointed C. GU complications in patients together. She cautions against com- tomatic or the symptoms are not culties are neuromodulation devices out. with spinal cord damage placency; just because experienced explained by plain radiographs and such as sacral nerve stimulators or Like Løgager, Agarwal believes S. Agarwal; Wrexham/UK radiologists know what to expect ultrasound, he cautions that there artificial sphincters. imaging evaluation is a relatively and look for in different trauma should be a very low threshold for Agarwal believes that it is espe- easy task in this group of patients; D. Interactive case discussion cases, mistakes can be made, for further imaging. cially important to address sexual more importantly, you need a multi- S.K. Morcos; Sheffield/UK instance when radiologists find one “Cross-sectional imaging is not dysfunction as an integral part of disciplinary approach to patient #CC1621 #ECR2013C cause of haematuria (or cause of dis- always routinely used at present – management of patients. management with a full under-

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#ECR2013 @myESR | myESR.org Monday 11 March 2013 Clinical Corner ECR Today 2013 15 Radiologists must pay attention to dose reduction strategies and watch out for diagnostic pitfalls in paediatric imaging

By Mélisande Rouger The type of disease in question also depends on the age of the patient. In Mistakes are inevitable in clinical young patients, radiologists mainly practice. In paediatric imaging, pit- look for malformations and meta- falls may be encountered when diag- bolic diseases. MR spectroscopy is nosing diseases, but may also arise the best tool to diagnose metabolic as a result of inappropriate radiation diseases, which means that the radi- protection strategies. Some settings ologist performing the examination can be particularly challenging for needs to have a thorough knowledge non-specialists, who must remem- of this technique. “MRI is a much ber that pathologies look different more complex modality than US or in children. Experts will present x-ray, so that’s another difficulty to common pitfalls and explain how take into account,” he said. to avoid them during a dedicated Patterns also look different in Special Focus session today at the paediatric musculoskeletal (MSK) ECR. imaging, whether one performs Radiation protection is vital when a US, MRI or x-ray examination. considering potential mistakes in Here as well, children’s anatomy paediatric imaging, explained and the developing body must Dr. Paolo Tomà, a paediatric radi- be considered. These differences ologist at Bambino Gesu Children’s can be particularly challenging in Hospital in Rome. “The main mis- the trauma setting, the radiolo- take in paediatric radiology could be gist pointed out. “All the pieces not to optimise the technique and of the skeleton are not fused in a not to control the dose of radiation,” child, who has cartilage between he said. the pieces, so it means that the In Europe, many hospitals do not appearance of trauma injuries have a dedicated paediatric imaging may be very different,” he said. department and a lot of paediatric The shape and the nature of dis- imaging is done by non-specialists, eases vary a lot as well, and osteo- who tend to be less aware of radiation myelitis looks different in children, dose optimisation strategies, which while juvenile arthritis is typical. are tailored to paediatric patients. Midgut malrotation with volvulus. Transverse section of the abdomen with colour Doppler: a thick small-bowel loop and the superior mesenteric This can lead to children being vein surround the superior mesenteric artery (whirlpool sign). exposed to unnecessarily high doses of radiation, particularly in trauma radiology, where CT is often the first modality used to rule out bleeding and other life-threatening injuries. “If you leave a CT scanner on the adult setting, it will of course be too much radiation for children. Paedi- atric radiologists know about these protocols, but very often examina- tions in children are carried out by other specialists, who are not so focused on this issue. They may use the adult setting for children, which is a big problem, so this is why we have to spread this knowledge,” Tomà explained. Speakers will also focus on com- mon diagnostic pitfalls in three different regions of the body, start- ing with the abdomen, where the anatomy of infants and children differs quite significantly from adults. Radiologists must be aware that even pathologies look different in children, whose organs are still growing. When using ultrasound, the gold standard of paediatric imaging, tissues and organs can also be difficult to image, especially if the patient is overweight. The anatomical difference between Ultrasound screening of hips. Developmental dysplasia of the hips Brain MRI: Left insular dermoid. an adult patient and a child, or new- with a severely dislocated hip. Fibre tracking overlaid on the isotropic diffusion map. Displaced (medially) and thinned out born, is even more apparent in imag- inferior fronto-occipital fasciculus on the left side due to the tumour compression. ing the central nervous system (CNS), (All images provided by Dr. Paolo Tomà) Tomà said. “Images of the developing brain differ massively according to the age of the patient. You have to In addition, the session’s experts Special Focus Session know about this anatomical differ- will address the current controver- Monday, March 11, 08:30–10:00, Room B ence so as not to mistake a feature sies regarding the approach chosen SF 16a: My most beautiful mistakes in paediatric radiology of the normally developing brain for US screening programmes for ▶▶Chairman’s introduction for a disease. An error could be to the development of hip dyspla- P. Tomà; Rome/IT misinterpret the MR signal because sia. “We have to discuss whether ▶▶Abdomen the appearance of the brain in infants screening should be universal or S.G.F. Robben; Maastricht/NL and newborns is different and chang- selective in paediatric patients with ▶▶CNS ing; for instance the appearance of a familiarity or clinical signs. We will B. Bernardi; Rome/IT two-month-old infant’s brain differs evaluate the problems and mistakes ▶▶Musculoskeletal facebook.com/myESR entirely from that of a one-year-old linked to both approaches,” Tomà child,” he explained. concluded. K. Rosendahl; Bergen/NO ▶▶Panel discussion: How have you changed or improved yourself after recognising your mistakes? #SF16a #ECR2013B

myESR.org | #ECR2013 @myESR 16 ECR Today 2013 Clinical Corner Monday 11 March 2013 Structured reports and learning about dosimetry can improve quality and workflow efficiency

By Rebekah Moan for complex imaging. Radiology reports are opinion. Disease doesn’t Harder, better, faster, stronger – it’s follow the rules, and that’s why you Header: Computer not just a song, it could also be the can’t have computers diagnosing Read(XML) mantra for radiologists as they try patients.” to improve workflow efficiency and Much of the complexity lies in the Document Type quality. This morning’s computer technical structure. While it sounds Sender applications refresher course will like it would be an easy task to send Receiver cover radiology reports and dose images and reports somewhere else, Patient management, plus computerised it can be quite troublesome. It’s fairly order entry. Enhancing radiology easy to transfer images because of reports and becoming more famil- DICOM standards, but trying to Body: Human Read iar with dose management regula- transfer reports from one place to (Narrative) tions and registries can help in this another may be difficult, Dugar said. process. “We have suddenly ended up with Defining the Question When it comes to reporting, there very bad practices that are going for- Findings are two types of structures: clini- ward to PACS,” she remarked. “The cal and technical. Clinical struc- worst practice we’ve ended up with Conclusion ture is important because it con- is ordering reports and images in Recommendations veys information to someone else an electronic world. That is causing about a patient. Technical structure enormous problems. Radiologists is important because it allows for would have had the request, they the easy (or sometimes not so easy) would have looked at it in a proper transfer of images and reports from light, and suddenly those images go one institution to another. off to somewhere else.” “In radiology, we can’t give nor- For instance, a radiologist in Optional: Coded Entries mal or abnormal reports – these another hospital may be asked (differ with doc types) are complex tests,” said Dr. Neelam by someone to take a look at the Dugar, consultant radiologist at images. The individual has no prior Doncaster Royal Infirmary, U.K., knowledge of what has gone on and and former chair of the U.K. Royal there is a danger of giving an inac- This figure shows an example of a clinical document architecture discharge letter. The same principles apply for a radiology report: namely, ease College of Radiologists’ Imaging curate, incomplete report. Because of conveying information. (Provided by Dr. Neelam Dugar) Informatics Group in an interview there is no report, a radiologist has with ECR Today. “We’re like the to generate a new one and time has tive of ‘Basic Safety Standards,’ some – but also to offer software to proc- patient doses in imaging procedures conductor of the orchestra. I like been wasted, Dugar explained. requirements on patient dosimetry ess these dosimetric data and to do as well as the comparison with DRLs that analogy because we’re hugely It’s important to bring together have been reinforced, and x-ray some automatic analysis,” he said. in quality programmes. involved and giving a direction to both sides of structured reporting, systems are expected to provide Radiologists need to learn about “Radiologists should know some the way the patient needs to be and from a clinical perspective, we dosimetric information with the dosimetry because the knowledge basic aspects of radiation doses managed.” need to indicate what we want from capacity to transfer the informa- of patient doses and the estima- and radiation protection as part Dugar structures clinical reports structured reports, she noted. In her tion to the exam report for all CT tion of radiation risk is a key point of the quality culture and to avoid to include the indication (why the lecture, she also aims to focus on and interventional systems, he said. when justifying some imaging pro- any unnecessary increase of radia- test is being done), findings, descrip- the IT aspects of the entire process. Patient dose limits do not apply, cedures and helpful when select- tion risk to the population,” he tion, conclusions, and recommen- Another problem area is radiation but diagnostic reference levels ing the most appropriate imaging concluded. dations. Radiologists don’t create dose. Prof. Eliseo Vaño, professor (DRLs) will be used to help opti- modality, he noted. Radiologists and reports for themselves, they create of medical physics in the radiology mise clinical procedures. The new radiographers have to optimise the reports to communicate, which is department of the Complutense European directive will require a procedure, or use the appropriate why the format, structure, narra- University in Madrid and at the periodic update when new tech- protocols to obtain the necessary Refresher Course: tive content, and technical aspects San Carlos University Hospital, nology can allow patient radiation diagnostic information with the need to be clear and easy to follow, will focus on this area during today’s dose reduction while maintaining lowest radiation dose compatible Computer Applications she added. session. enough image quality, Vaño added. with the needed image quality. Monday, March 11, 08:30–10:00, “There have been lots of talks The European directive on “These requirements will push the Vaño’s talk will cover aspects of Room Q about structured reports,” she said. medical exposure requires patient industry and the users to develop the existing and future European RC 1605: Improving workflow “Often the previous talks have radiation doses to be assessed and better strategies to evaluate patient regulations on radiation safety for efficiency and quality been about how we can structure evaluated, especially in procedures doses, to transfer these values to patients and the advances in tech- ▶▶ Chairman’s introduction the narrative content into drop- involving high doses to the patient. the patient reports – contributing nology to allow the measurement, D. Caramella; Pisa/IT down menus, which is not possible In the current draft of the new direc- to the patient dose tracking system transfer, recording, and analysis of A. Improving quality and efficiency of computerised order entry through decision support P. Mildenberger; Mainz/DE B. Improving quality and efficiency of reporting by structure and templates N. Dugar; Doncaster/UK C. Improving quality and efficiency of dose manage- ment through exchange between modalities and registries E. Vaño; Madrid/ES ▶▶ Panel discussion: Will novel IT tools really improve quality and efficiency in daily radiological practice? Radiologists must learn about dosimetry so they can estimate radiation dose and justify an Radiation protection for patients and workers is taken seriously at this cath lab at San Carlos imaging procedure. Here, radiologists perform a cardiovascular procedure at San Carlos Hospital Hospital in Madrid. (Provided by Prof. Eliseo Vaño) #RC1605 #ECR2013Q in Madrid. (Provided by Prof. Eliseo Vaño) myESR check out our videos at youtube.com/myESR

#ECR2013 @myESR | myESR.org Monday 11 March 2013 Technology Focus ECR Today 2013 17

Accurate models of Rise of mobile Efficient visual image search tumour motion to technology brings in clinical radiology INSIDE guide next generation risks as well as treatments of benefits lung cancer TODAY See page 21 See page 22 See page 23 X-ray equipment vendors turn the spotlight firmly on women’s health issues and dose reduction

By John Bonner The new product aims to lighten the load of technical staff carry- Women’s health appears to be top ing out mass screening operations. of the agenda for the digital radi- After an examination is completed, ography equipment manufacturers the system automatically opens the displaying their wares in the techni- patient scheduler, and the next cal exhibition at ECR 2013. Several patient is selected with just one of the leading companies are using click and the user interface is set for the congress as an opportunity to the whole examination. The system unveil their latest technologies in selects a single-touch rotation with the mammography field, and they a pre-set angle, and with a single hope to make routine breast cancer click the tube head is moved into screening safer, faster, more accu- position for the next procedure, rate and less stressful. Siemens stated. Siemens has a proud history Concern about radiation dose of innovation in the mammogra- is not the only reason why many phy arena, having developed the women find the process of undergo- first tungsten anode tubes for this ing mammography screening to be purpose. This year the company a challenging experience. Research is presenting another develop- carried out by GE Healthcare ment intended to reduce the dose suggests that the environment in required to produce optimal quality which the examination is carried images. Called Mammomat Inspira- out also deters many women from tion Prime Edition, it can reduce taking part. The company hopes to the average dose per examination change that with its SensorySuite, by 30%. which creates a customised envi- “We are always motivated by the ronment involving sight, smell and desire to provide the highest pos- hearing during the mammography sible image quality with the lowest procedure. dose necessary. But with mammog- “Compliance rates for annual raphy, we can never forget that the mammograms have long been an people whom we ask to come in and issue. In fact, one in four women be screened are healthy women, not avoids a mammogram because of patients. For that reason it is even worry and fear,” explained Prahlad more important that their safety is Singh, general manager for wom- taken very seriously,” said Dr. Axel en’s healthcare. “SensorySuite Hebecker, director of marketing for is designed to reduce perceived Siemens women’s health business. patient anxiety by giving them con- The new product is based on trol over their experience, and this a new reconstruction algorithm should help us fight breast cancer by named PRIME, which stands for encouraging early detection.” Progressive Reconstruction, Intel- The process begins before women ligently Minimising Exposure. arrive at the mammography clinic. The Mammomat Inspiration PRIME Edition from Siemens can reduce average dose per examination by up to 30%. A: 67 mAs without PRIME “In conventional systems, there They watch an online presentation technology. B: 45 mAs with PRIME. (Provided by MVZ Prof. Uhlenbrock & Partner, Dortmund, Germany) is a grid between the breast and the on the facility’s website that explains detector to absorb any scattered what will happen. Women can learn radiation. But these also absorb more by looking at a tablet PC in the some of the essential primary clinic waiting room, and they can radiation needed to produce the choose the sights, sounds and smells image,” he explained. “Our algo- that they will experience during the rithm eliminates the need for the actual examination. grid by identifying the structures “Healthcare is very personal and that cause scatter and recalculating this is certainly true of mammogra- the image. This reduces the primary phy. SensorySuite is a great exam- radiation needed to produce the ple of the intersection of technology image. A study carried out by one of and the human side of healthcare,” our academic partners, Prof. Detlev said Hooman Hakami, GE’s chief Uhlenbrock in Dortmund, showed executive, detection & guidance that the reduction varies according solutions. “We are confident that to the volume of breast tissue, and women around the world who expe- it is greater in women with smaller rience SensorySuite will see that GE breasts.” not only strives to develop great The new technology is also technology, but that we also aim intended to reduce the risk that to develop solutions that approach women will find their examination every element of the care continuum an uncomfortable experience. The with empathy, feeling and respect.” system features the OpComp func- While GE researchers are working tion, which applies compression to restore the ‘art’ of providing good only as long as the patient’s breast medical care, Fujifilm is focussed is soft and pliable, and for best image firmly on the science. quality, it stops at the point of opti- “On our digital radiology stand mal compression. Also, to keep this year, we will be demonstrating patients relaxed during the scan, the a new mammography system featur- new technology is presented with a ing a completely new a-Se (amor- LED light panel that creates light phous selenium) detector, which DuraDiagnost is a range of digital radiography systems capable of fast and efficient examinations conditions according to the patient’s gives outstanding performance in in the chest, shoulder and other parts of the body. (Provided by Philips) personal preferences. terms of dose reduction, speed and

continued on page 18

myESR.org | #ECR2013 @myESR 18 ECR Today 2013 Technology Focus Monday 11 March 2013

A B C

Toshiba’s Spot Collimator makes it possible to define an asymmetric region of interest without the need to move the patient table. Selecting the size and position of the desired region of interest is a two-step process performed at the table side. Choosing two reference points in the LIH (last image hold) automatically spans the live fluoroscopic area anywhere in the field-of-view, according to the manufacturer. A = uncollimated, B = conventional collimation, C = Spot Fluoro collimation. (Provided by Toshiba) continued from page 17 mammograms in routine use within ing height. Workflow features like a At the Toshiba booth, the focus dose exposure and allowing the cli- standard 2D dose levels, which can floating table top or default source to is on the SpotFluoro feature on the nician to view the critical region of detection accuracy,” said Joerg Muel- improve diagnostic confidence in image-receptor distance (SID) posi- company’s Infinix-I vascular imaging interest and the surrounding area ler, digital radiography (DR) product routine mammography. The first 3D tions simplify the processes followed system. It can reduce the radiation at the same time,” said Mark Hol- manager with Fujifilm Europe. “The mammography studies have shown in the examination room, according dose needed per examination by up mshaw, vice president of sales and new component offers an additional a significant reduction of false posi- to a company statement. to 80%, without sacrificing func- service at Toshiba Medical Systems 20% dose reduction compared with tives close to 40%, which helps to The product is equipped with tionality, image quality or field of Europe. our previous detector, which was reduce the number of biopsies fixed rather than portable detec- view, noted the vendor. This benefit Agfa HealthCare is introducing already one of the most efficient needed, he explained. tors. To provide smooth workflow is due to an improvement on tradi- the new CR 12-X tabletop computed systems on the market. At the same At ECR 2013, Philips is also display- in the examination room, it has the tional collimation methods used to radiography system at the ECR, and time, we have improved the sharp- ing mammography equipment (an SmartOne button for easier geom- reduce the dose needed by localising is showcasing a portfolio of digital ness of the images produced to a level update to its MicroDose Mammog- etry movements and EasyAlign to the image to the main region of inter- radiography (DR) systems that use we believe is unique in the current raphy SI technology), but the com- indicate correct alignment between est. Normally, this will involve fixing its Musica2 image processing soft- market.” pany is putting particular emphasis the detector and tube. the limits of the image to a position ware. These include its mobile DR The system, called the FDR Amu- on DuraDiagnost, a flexible range of One of the highlights at the symmetrical with the whole field- products, as well as high-perform- let Innovality, fully supports 3D DR systems designed for healthcare Shimadzu booth is the Trinias F12 of-view. The new approach allows ance DR rooms such as its DX-D mammography examinations, and providers with a smaller budget but angiography system, which comes in any symmetric or asymmetric region 600 system. provides different tomosynthesis a demand for fast digital workflow. It the form of a floor-mounted C-arm of interest to be chosen without the Carestream has developed the modes in terms of dose and angu- offers customisable room configura- and features a 30.5 cm ­flat-panel need to move the patient table. DRX 2530C detector as a work- lation, which enables the user to be tions and the Eleva user interface, and detector with a field-of-view able SpotFluoro combines last image in-progress. The caesium iodide more flexible, depending on each due to its x-ray tube floor stand, all to cover the entire body to support hold (LIH) with the collimated live detector is designed to offer high case. In addition, the system allows DuraDiagnost units fit into exami- cardiovascular and angiographic fluoroscopy image, giving the full efficiency for dose-sensitive pae- the technician to take direct 3D nation rooms with a normal ceil- procedures. The field size is switch- field-of-view at a minimum dose. It diatric, orthopaedic and general able in five steps, and the smallest allows the operator to maintain the radiology examinations, and is coverage is used in cardiovascular full overview of the region of inter- intended to be used with the DRX- and neuro-interventions. The unit est and its surrounding anatomical Revolution or DRX-Mobile Retrofit also features a six-axis triple-pivot markers and references. Kits for mobile imaging of neonatal construction, which achieves a “Spot Fluoroscopy is like having or paediatric patients. The smaller range of coverage close to that of a an adjustable spot light over the ref- detector is designed to fit into pae- ceiling-mounted unit. erence LIH image, helping to reduce diatric incubator trays.

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And learn all about the most recent developments in healthcare technology. Opening hours: EXPO Halls and EXPO Foyer D Friday, March 8 to Sunday, March 10: 10:00–18:00 Monday, March 11: 10:00–14:00

First Level (Gallery) Thursday, March 7: 14:00–18:00 Friday, March 8 to Monday, March 11: 10:00–18:00

#ECR2013 @myESR | myESR.org Monday 11 March 2013 Technology Focus ECR Today 2013 19 New FPD technology in digital x-ray drives modular future

By Stephen Holloway adoption of automated, multi-plate or critical to be taken to the fixed- systems and tables will further drive system, most commonly in the The fundamentals of static x-ray gains in efficiency, a positive out- intensive care or emergency medi- imaging have changed little in come for many healthcare provid- cine scenarios. Using wireless FPD decades, prompting the majority ers struggling in the current age of mobile x-ray, manoeuvrability of the of radiologists to pay scant atten- austerity. detector is improved, thereby reduc- tion to developments in this sec- Another notable trend has been ing risk for the patient. Near-instant tor. However, the emergence and the creation of a tiered FPD fixed processing and review achieved with increasing use of flat panel detector room market, providing more FPD also removes the need for the technology (FPD) is producing sur- options in terms of configuration user to return to central processing prising results, improving workflow, and panel type, allowing customi- locations to check the image, cutting image quality, cost of ownership and sation for the requirements of each out any need for the radiographer to patient safety. Below, we discuss unique user. Increased availability return later to re-do the same scan. how FPD technology is shaping the of lower priced fixed room systems Wireless FPD mobile x-ray fur- future of x-ray imaging. is also forecast to rapidly increase ther offers inherent flexibility for uptake of FPD systems in smaller hospitals, allowing sharing of wire- Fixed room x-ray institutions and emerging markets, less panels between mobile systems, critically underserved by ageing raphy is now allowing far greater Fixed FPD x-ray rooms have particularly with panel prices con- or even between fixed-room and analogue x-ray systems. Assum- customisation of systems, evolving become a mainstay of general radi- tinuing to decline year-on-year. mobile systems. While in many large ing FPD prices continue to decline towards a truly ‘modular’ market. ography in Western Europe, offering healthcare institutions equipment is as has been observed in the last 5 Yet at the same time, making real near instant processing, lower dose Mobile in near-constant use, smaller facili- years, retrofit FPD solutions could changes to the way x-ray imaging and near-seamless integration with The evolution of mobile x-ray equip- ties can make significant savings. soon be affordable users in these is conducted, increasing efficiency, healthcare IT solutions. While the ment has also been heavily shaped regions. Furthermore, an increas- saving money and providing tangi- initial cost of these systems caused by FPD technology, particularly Retrofit ing number of vendor-neutral ret- ble opportunity for emerging mar- many to question the benefits of with more widespread use of wire- In terms of increasing accessibility rofit solutions are commercially kets’ to adopt 21st century imaging. FPD over analogue and computed less FPD panel technology. Mobile to digital FPD x-ray, the develop- available, allowing more flexibility Maybe it’s time to take a closer look radiography (CR) x-ray, manufac- x-ray has often been overlooked on ment of retrofit FPD x-ray solu- and choice for users. at what’s on show in the x-ray exhi- turers have clearly established the account of the lower price of sys- tions could have the greatest impact bition this year. long-term benefits in workflow and tems and relatively low utilisation of all. While onlookers may view Conclusion life-time cost of ownership. compared to fixed-room systems. retrofit upgrades as a short-term The changes discussed above The main beneficiaries of this shift However, digital mobile x-ray sys- response to the current challenging have all developed through prod- Stephen Holloway is a senior market to FPD have primarily been larger tems offer even greater rewards in economic climate, it may in fact uct evolution of one technology, analyst in the healthcare IT research hospitals and imaging centres; here, terms of efficiency, workflow and bring FPD digital x-ray imaging refining and developing products group at InMedica, a division of IHS reducing processing time across cost saving over system lifespan within reach of those that need it based on the demands of users (NYSE:IHS). InMedica is a provider large-scan volumes has significant than fixed rooms. most. In the wider EMEA region, in today’s challenging healthcare of market research and consultancy benefits both in terms of efficiency A large portion of mobile x-ray many parts of Eastern Europe, the market. FPD technology applied in the medical electronics industry and cost. More recently, projected use occurs with patients too unwell Middle East and Africa remain across all forms of general radiog- (www.in-medica.com). Next generation MRI: integrated, affordable, progressive, accessible?

By Stephen Holloway ever, use of hybrid or fusion MRI in greater access of MRI technology Europe still remains relatively new, to the wider population in these Development of MRI technology restricted by the high initial cost and emerging areas. has undoubtedly exceeded expec- extensive multi-department plan- tations in the last decade, boosted ning required. Assuming economic Ultra-High Field MRI by advances in high-field magnet recovery is forthcoming, use of com- MRI will also remain a constant at technology, computer processing bination imaging should proliferate the cutting edge of clinical research. power and analogue-digital signal as understanding of the clinical and The development of commercially processing; they have even managed economic benefits multi-modality available 7 Tesla MRI and experi- to develop a quiet one. imaging increases. mental 9 Tesla MRI systems for Such progress has placed MRI at research are already highlighting the pinnacle of advanced imaging ‘Value’ MRI the future potential when exploit- technology, while also providing a Investment in improving health- ing this unique imaging modality. flexible platform for use in multi- care services in emerging regions Recent investigations are provid- ple clinical disciplines. However the of Eastern Europe, the Middle East ing a fascinating insight into the demands of modern healthcare are and Africa has become big busi- potential of such technology for changing the way MRI is used. The ness, driven by strong economic better understanding diseases such users. Most evident has been the highlighting how advanced tech- majority of hospitals and facilities in growth and huge demand for as Alzheimer’s Syndrome, Osteoar- clear shift in focus of manufacturers nology can be used safely to pro- Europe currently rely on scanners improvements in healthcare serv- thritis and in diagnosis and decision towards workflow and managing vide accurate, high quality images shared between multiple disciplines. ices. Yet, investment in advanced making in the treatment of critical the cost of ownership for health- for diagnosis across a vast range With coil technology continuing to imaging, most notably MRI, in spinal lesions. Many questions and care providers. The emergence of of clinical fields and applications. improve and system average selling these regions has been restricted concerns remain still surround the healthcare IT in the last decade Future obstacles to development prices continuing to decline, how to major hospitals in metropoli- potential safety and scalability of has demanded improved workflow will undoubtedly slow or divert the will the next generation of MRI be tan centres. However, average sell- 7T MRI; despite this, initial results solutions from imaging solutions, future development of MRI equip- used? ing prices have continued to fall and research suggest it will feature further facilitated by increasingly ment, be it economic, legislative or with improvements in technol- heavily in the future of advanced stringent legislation across many political. However, as the trends and Fusion and Hybrid MRI ogy, manufacturing processes and imaging. countries regarding advanced evidence observed above demon- Some of the highest-profile increasing supplier completion. imaging optimisation. Combined, strate, MRI is set to play a lead- advances in the MRI-field have been This has led to the emergence of ‘Workhorse’ MRI these factors have driven signifi- ing role in the future of diagnostic demonstrated in combination with ‘value’ MRI, relatively low-cost While the majority of the evidence cant progress in scan-speed, meas- imaging. other imaging modalities, taking MRI systems (mostly 1.5T field discussed here suggests MRI differ- urement, processing and archiv- advantage of the inherent flexibil- strength) with solid performance entiating into ‘user-defined’ groups ing. Moreover, manufacturers are ity of MRI. Examples such as fusion and image quality but few advanced with specific MRI systems for each actively highlighting and offering Stephen Holloway is a senior ana- imaging with ultrasound (both for features. The economic downturn clinical modality, current and future new solutions to address the longer- lyst in the medical imaging research diagnostic and treatment purposes) has admittedly slowed uptake of restrictions will undoubtedly mean term costs of ownership, rather than group at InMedica, a division of IHS and hybrid MRI solutions in OR these systems more recently; how- the ‘workhorse’ hospital MRI sys- past focus on just initial price of (NYSE:IHS). InMedica is a provider suites have already demonstrated ever demand is projected to resume tem will still play a part. However, the system. of market research and consultancy the effectiveness of combining in the next two or three years pro- new technology and innovation is MRI has long been the gold in the medical electronics industry MRI with other modalities. How- viding a major opportunity for also driving significant gains for standard of imaging technology, (www.in-medica.com).

myESR.org | #ECR2013 @myESR Top radiologists read more than just images Monday 11 March 2013 Technology Focus ECR Today 2013 21

EIBIR presents IMAGINE After last year’s success, EIBIR is again hosting the IMAGINE Workshop, under the heading ‘Novel technology that shapes radiology’. IMAGINE aims to stimulate interaction between imaging researchers and radiologists. Lead- ing international academic and industrial research groups present their latest developments in medical image analysis and image-guided interventions. During the interactive software demonstration sessions the visitors get hands-on experience with developed techniques and tools. The presenters of the workshops were invited to introduce their work in ECR Today. Accurate models of tumour motion to guide next generation treatments of lung cancer

By James Martin and Jamie McClelland For our simulated case, compared (e.g. organs at risk) is the focus of to assuming the average tumour future work. Lung cancer is the most common position, mean error was reduced cancer in the world, with less than from 4.1 to 1.0 millimetres, with James Martin and Jamie McClel- 10 percent of those diagnosed sur- maximum errors reduced from land are from the University College viving for more than five years. 16.5 to 4.0 millimetres. For our London, Centre for Medical Image Radiotherapy is an important patient datasets, our results pro- Computing in London, UK. method available to clinicians, with vided mean absolute errors under treatment occurring over a series of 2.5 millimetres when compared to fractions. The use of cone-beam CT clinically identified tumour cen- For more detailed information, to position the patient immediately tres, with maximum errors under please see: Improvement of tumour visibility in cone-beam CT projection during prior to each fraction has greatly 7.5 millimetres. The patient data Martin, James, et al. ‘Motion mod- and after tumour enhancement. improved the accuracy with which included a case where the patient elling and motion compensated the tumour can be aligned with the may have coughed during the cone- reconstruction of tumours in Reconstruction in Cone Beam intended dose. However, breathing beam CT. See Figure 3 for recon- cone-beam computed tomography.’ Ct.’ Radiotherapy and Oncology 99 motion still remains an issue. If this structions before and after motion Mathematical Methods in Biomedi- (2011): S184. can be accounted for then margins correction. Note that since only the cal Image Analysis (MMBIA), 2012 Martin, James, et al. ‘Lung tumour around the tumour could be shrunk, tumour motion is being accounted IEEE Workshop on. IEEE, 2012. motion models from cone-beam sparing healthy tissue and increas- for, anatomy outside this region McClelland, J., J. Martin, and D. CT.’ Image-Guidance and Multi- ing the dose delivered to the cancer- will appear more blurred. Account- Hawkes. ‘457 poster Lung Tumour modal Dose Planning in Radiation ous region. ing for motion of other anatomy Tracking and Motion Compensated Therapy: 50. Our approach involves enhanc- ing the appearance of the tumour in the cone-beam CT, and relating the motion seen to an external breath- ing trace. Figure 1 shows how vis- ibility of the tumour is improved after enhancement. A motion model is used, which can accommodate for changes in inhale and exhale tumour trajectories, length of breathing cycles and depth of breathing. Markers are not needed, avoiding the surgical risks and inconven- iences associated with implantation of markers. We use the VisionRT optical imaging system to obtain a 3D representation of the patient’s chest (Figure 2). This system allows the patient to be monitored continu- ously throughout treatment with- out delivering an extra dose. The patient and fraction-specific motion model provides a prediction of tumour position for each real-time chest surface; hence we intend our method to drive cutting-edge gated or tracked radiotherapy treatments. Results have been presented on Sample reconstructions before (left) and after (right) motion correction. Since just the tumour motion is being modelled, notice that only tumour appearance is improved. simulated data and patient data.

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myESR.org | #ECR2013 @myESR 22 ECR Today 2013 Technology Focus Monday 11 March 2013 Rise of mobile technology brings risks as well as benefits

By Simon Lee view of the current status of tablet they are very important; they can technology and a discussion on the help to improve quality, avoid mis- Tablet computers can be a surpris- pros and cons of the use of tablets takes, and generally improve serv- ingly divisive subject. The passion in radiology. Talks will touch on ices to patients, but I think perhaps with which some people argue all aspects of how tablets can assist not enough hospitals are aware the relative merits of competing working radiologists, residents, and of the safety and security issues devices and operating systems students, including a review of radi- raised by mobile technology,” said can be almost frightening. In the ological resources and a close look at Ranschaert. field of medicine, however, there DICOM viewers, but the downsides A report last year by the Pone- appears to be very little argument will not be overlooked. man Institute, an American research about the top product, with pro- “It’s a fact that the use of the centre focusing on privacy, data fessionals from many disciplines iPad is increasing exponentially protection and information secu- enthusiastically embracing the among medical doctors, not only rity, suggests that although employ- iPad as a tool for research, educa- radiologists, but there are still a lot ees in approximately 81 percent of tion and general communication. of issues that need to be examined. healthcare organisations “are using Dr. Erik Ranschaert (left – pictured here with Dr. Jan Schillebeeckx) from ‘s-Hertogenbosch, Instead the most important debate For example, when you’re sending mobile devices to collect, store the Netherlands, will speak on mobile teleradiology with tablet computers in this is focused elsewhere, on matters of images to mobile applications, how and/or transmit some form of Special Focus Session. data security and patient privacy. safe is it and how can you guaran- protected health information, 49 As mobile technology spreads tee patient confidentiality is not percent admit their organisations throughout the hospital, data natu- lost? The range of clinicians who are not doing anything to protect However mobile technology Special Focus Session rally follows, and it is slowly falling make use of and require access to these devices.”1 One concern is that develops, these issues are clearly into the hands of an increasingly images is increasing, so images are mobile devices are easily lost, and if in need of greater consideration, Monday, March 11, 16:00–17:30, broad spectrum of people. Radiolo- on the move more frequently and confidential patient data is stored so that when guidelines are created Room F1 gists and clinicians therefore need this is all due to the availability on board or within applications, it in future, more attention is paid to SF 19: Tablet computers to be aware, not just of the many of these new technologies,” said can potentially be accessed by any- the very specific safety aspects of in radiology: mobile applications and resources Ranschaert. one. Ideas to deal with such risks mobile ‘teleradiology’ inside and friend or foe? that can potentially aid their work, Cardiologists, emergency doc- include management from a central outside the hospital. Aside from the but of the associated risks and best tors and surgeons, among others, location, so that a stray device can risks, all medical staff using mobile ▶▶Chairman’s introduction practices concerning the use of tab- are finding more and more uses be locked down or even wiped at a technology need to be familiar with E. Neri; Pisa/IT let technology. for iPads, from showing images to certain distance. the consequences of data breaches, ▶▶ “When it comes to the iPad, it’s patients during bedside consulta- Such problems may be accen- which as well as the violation of Tablet computers: the same for radiologists as it is tions, to using them for orientation tuated by a tendency towards the patient privacy, may extend to a technical overview for everyone else; everyone wants in surgery; and patients themselves ‘bring your own device’ (BOYD) fines, lawsuits or negative publicity. J. Fernandez-Bayó; Sabadell/ES to use them,” said Dr. Erik Ran- are also gradually taking posses- model, in which employees use As with any other kind of security ▶▶Radiological features of the schaert, staff radiologist at the sion of their own images in digital their personal devices for work, issues, until firm recommendations tablet computer Jeroen Bosch Ziekenhuis teaching formats. With data flowing more entailing an additional set of secu- or directives are in place, the key L. Faggioni; Pisa/IT hospital in ‘s-Hertogenbosch, the freely, and mobile applications rity and safety issues. For instance, to heading off potential problems Netherlands. “I use mine to keep up beginning to appear that offer unless specific security measures is awareness. ▶▶Reading DICOM images with literature and store important patients services like second opin- are put in place, when personally “These things need to be dis- on the tablet articles, to take notes and integrate ions, clarification of findings, and owned devices connect with a hos- cussed and brought to the atten- O. Ratib; Geneva/CH pictures, and I also use it during report explanations, the question pital network, data shared between tion of everyone, and that’s one ▶▶Mobile teleradiology with image interpretations, when I need of how to safeguard patient confi- them is often not encrypted, leav- of the many reasons for a session tablet computers: to look things up like literature or dentiality is becoming all the more ing it vulnerable to hacking. BOYD like this one. People have to start a critical appraisal anatomy. There are a vast number pressing. also requires additional investment, thinking about it; they have to not E.R. Ranschaert; of tools available for radiologists on “Especially in hospitals, it’s not just in IT infrastructure, but in only consider the advantages but ‘s-Hertogenbosch/NL the iPad and I think curiosity among becoming more and more common training and manpower, to apply also the disadvantages, because radiologists, of how to make the best to have a general hospital policy that and monitor appropriate lines of there is an initial enthusiasm ▶▶Panel discussion: Are we ready of them, is very high.” before doctors start using mobile defence against data breaches. about these mobile applications and confident enough to use Ranschaert will speak during applications or tablets, they should and devices, which is fantastic, tablet computers in clinical today’s Special Focus Session ‘Tab- sign an agreement to guarantee pri- but there is also a downside and practice? How and when? lets in radiology: friend or foe’, vacy and security. Images should 1 (source: http://www.ponemon.org/blog/post/ we have to take that into account,” which aims to provide an over- be available everywhere because second-annual-patient-privacy-study-released) noted Ranschaert. #SF19 #ECR2013F1

ESOR Training Programmes, 2013

Visiting Scholarship Programmes (Europe) residents in training years 3–5 Exchange Programmes for Fellowships board-certified radiologists within their first three years of practice Visiting Professorship Scholarships for Chinese Radiologists board-certified radiologists, specialists or younger academic radiologists from China Teach the teachers programme future teachers and faculty members

Pick up the complete ESOR 2013 Programme Brochure from the ESOR Booth.

#ECR2013 @myESR | myESR.org Monday 11 March 2013 Technology Focus ECR Today 2013 23 Efficient visual image search in clinical radiology

By Georg Langs that facilitates quick browsing, and provides transparency regarding the Imagine the following: you’re looking source and its quality. Sources range at a high resolution CT and see a pat- from literature databases and sec- tern you are uncertain about. You click ondary sources to image databases on the image and within a few seconds (PACS) within hospitals. get all cases in your department, or region, containing similar patterns, Visual queries: searching the together with the corresponding PACS for patterns in image data report; that’s all before you even enter A particularly relevant area of radi- a search keyword. The patterns that ological research is content-based match your query are highlighted, and image retrieval (CBIR). The aim is you can quickly browse through them to use image data itself – for instance and the attached reports. Wouldn’t a region of interest in a CT volume that be helpful? marked by the user – to query large Search and information retrieval image databases for similar patterns, is an active area of research. Since and to provide the user with quick the advent of internet search engines access to the corresponding data, we know that they are a driving- such as images, reports, or even force in knowledge acquisition, and outcomes. have become central to our daily The key to successful content- work. We understand that retrieval based image retrieval is the extrac- is only useful if it is able to deliver tion of visual features that capture An early version of the search system, showing the query case, and results together with the corresponding radiology report data. reliable information efficiently, relevant characteristics of the imaged and if it answers a specific need for structure, together with fast match- the retrieval of anomalies suggest far more comprehensive models to KHRESMOI (www.khresmoi.eu) is information. Recent findings have ing and ranking algorithms that that methodology developed at be learned, while at the same time an integrated project (IP) funded highlighted the potential of fast, robustly identify similarities across the interface of machine learning, attracting attention to unsupervised by the European Union aiming efficient and accurate information millions of samples. CBIR, in the computer vision and medical imag- modelling approaches. The meth- to develop information retrieval retrieval to contribute substantially context of radiology, raises additional ing can provide clinically relevant odological challenges touch on systems for patients, medical pro- to improving radiological reporting. challenges to those in other domains. search results. Current research is interesting mathematical problems fessionals, and in particular radi- Since 2010, the European Union The visual information relevant to focusing on further improving the ranging from basics such as graph ologists. The CIR Lab (www.cir. has been funding the integrated matching pathological features is accuracy of the search. theory, or algebra, to machine learn- meduniwien.ac.at) at the Medi- project KHRESMOI. It is a joint often subtle compared to differences ing and pattern recognition. cal University of Vienna leads the effort to develop a multilingual across organs. The variability of ana- Scaling methods to make use of While methodological research work package on large scale bio- and multimodal search system for tomical appearance, even in a healthy large data continues, there is agreement medical image search. Video demo: biomedical information. The cen- population, renders the learning of A central insight is that transition- regarding the goal. The knowledge http://tinyurl.com/ck6vm53. tral user group which the project models challenging. ing from hundreds of data exam- that can be gained from millions focuses on is radiologists and their Nevertheless, search results from ples to millions changes many of radiological imaging data, which information needs during daily rou- realistic samples of several tera- established paradigms. On the one have only been examined once so tine, research, or teaching. Queries bytes of medical imaging data have hand, it makes efficient algorithms far, is tremendous. Make it more in such a search system can be based proved promising. The automatic for matching and representation accessible, and gaining structure on a few keywords, an image, or identification of anatomical struc- essential. On the other hand, the from this data are key to helping Georg Langs works at the CIR Lab both. The system presents results tures and the location of images enormous amount of variability clinicians, researchers and teachers at the Medical University of Vienna, together with relevant information work accurately. Initial results on represented in the data allows for take full advantage of it. Austria. Georgians become regional leaders in radiology

By Fridon Todua cialty of their choice. We consider the postgraduate period of teaching The Georgian Association of Radi- to be our great achievement: after ology (GAR), since its foundation receiving their degree, young doc- in 1995, has played a very important tors who pass their exams receive role in the development of radiol- licenses which are in accordance ogy in Georgia, and it continues to with European standards. During contribute to the development of this period, alongside radiology radiology. Due to its work, various training, they attend lectures and specialties in radiology and therapy take courses on different subjects: such as CT, MRI, US diagnostics, e.g. surgery, neurology, etc. As a nuclear medicine and radiotherapy result we have achieved our main have been brought together as one goal; doctors and radiologists who discipline; medical radiology. The are clinically-oriented. association organises international One of the main goals of our asso- congresses, symposia and seminars. ciation is the development of medi- There are also training courses dedi- cal radiology through the unifica- cated to various fields of radiology tion of the medical, scientific and for young specialists. technical resources of our country. Scientific research takes prior- The Research Institute of Clinical Figure 1 and 2 display deviation and disruption of white matter tracts by the infiltrative intraaxial glial tumour. ity in the activities of the Georgian Medicine at the University Clinic is Association of Radiology. Many the main scientific base of the asso- members of GAR have scientific ciation. It is equipped with four MR a department of nuclear medicine ing different diseases. FMRI, arte- Considering the modern techni- degrees and young radiologists scanners with which investigations equipped with two E. Cam systems. rial spin labelling, diffusion tensor cal equipment and high professional have been awarded grants. Many are carried out using functional MRI These conditions attract young spe- imaging, magnetic resonance spec- standards of radiologists in Geor- young members of the association imaging, tractography and MRI cialists from all over the southern troscopy, and perfusion CT; these gia, it has developed a reputation have participated in the ECR and spectroscopy. These methods are Caucasus to master radiology. advanced methods give us unique as regional leader in the Caucasus. the RSNA’s Annual Meeting, as well used for the presurgical diagnosis In recent years, with achievements opportunities for research. At the Specialists are referring patients as in conferences and workshops of patients. There are 64-, 128- and in advanced methods in medical same time the obtained results can from many parts of the southern throughout Europe. In Georgia a 640-slice CT scanners as well. The radiology, the Institute of Clinical be implemented in clinical routine. Caucasus to Georgian centres. radiologist must master all areas 640-slice CT enables radiologists to Medicine, as a leading institution in In Georgia, surgery and neurosur- of radiology. We have a three-year make a precise diagnosis of cardio- this field in Georgia, is applying new gery, in particular, have benefited a residency programme with one year vascular and brain pathologies. It methods of investigation, research great deal from these techniques – for subspecialisation and doctoral is also possible to investigate brain and therapy in our country. The new surgery can be planned with more study. In the first term of residency perfusion and perform CT cor- high-field MR and 640-slice CT precision and postsurgical outcome they study roentgenoanatomy. onarography. Today in Georgia, the scanners have given us the ability is better in these cases; indeed it is Professor Fridon Todua from Tbilisi, After residency, young specialists Research Institute of Clinical Medi- to investigate not only structural, very efficient for the general surgery Georgia, is the President of the Geor- perfect their skills in the subspe- cine is the only institution that has but also functional changes dur- as a whole. gian Association of Radiology.

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Monday 11 March 2013 Community News ECR Today 2013 25

ECR 2013 Franz West What’s on today Special Where is my in Vienna? INSIDE Exhibition Eight?

TODAY See page 27 See page 30 See page 32 ESR set to tackle personalised medicine and face economic realities in 2013

By Mélisande Rouger have to appreciate its impact on edu- very simply, for improving quality of cation. I will ask two or three sub- care. Previous campaigns conducted In an interview with ECR Today, specialties to reconsider their train- in America have shown their useful- incoming ESR President, Professor ing charters in light of these new ness, and I think we have to learn Guy Frija explained how the ESR developments. The data explosion from these experiences. The devel- should address the challenges raised related to these changes raises not opment of such public campaigns in by the explosion of ‘omics’ data and only the problem of their manage- Europe could be beneficial; however the advent of personalised medi- ment, but also of their interpretation we have to consider European diver- cine, as well as how it should assess in an integrated way: the imaging sity and adapt campaigns. the impact of the financial crisis on parameters should be included in the specialty. this new data knowledge organisa- ECRT: You are a former chairman tion, where knowledge modelling of the National Societies Commit- ECR Today: What are your plans will become a major challenge. The tee of the ESR. Do you think the and ambitions regarding your establishment of imaging biobanks level of cooperation between the presidency? should be promoted along with ESR and these societies has been Guy Frija: The development of the adapted data privacy regulation. good enough? How could it be ESR since its establishment in 2005 I would say that we are facing improved? has been amazing: the ESR is now huge scientific challenges, and I GF: An important characteristic of the biggest radiological society in will propose to the ESR Executive the ESR is its institutional mem- the world, and its annual meeting, Council that a scientific advisory bership, i.e. the national societies, the European Congress of Radiol- board be set up in order to help bet- subspecialties and allied sciences ogy (ECR), is one of the best radi- ter define ESR policy. societies. Let me first remind you ology congresses worldwide. All of Apart from this, we can’t ignore that the foundation of the ESR was this is the result of intense activity the fact that several European coun- the result of the political action in several fields, such as education, tries are facing a severe economic of five national societies in 2002. Professor Guy Frija is head of the imaging department at the Georges Pompidou European research, professional challenges crisis which we hadn’t considered Institutional Member Societies Hospital (Hôpital Européen Georges Pompidou, H.E.G.P.) in Paris. and publications, for the develop- until now; I will ask the Executive represent the political pillar of the ment of which the role of my prede- Council to set up a working group society, and therefore should be recent years and probably haven’t such as in stroke. I think that the cessors was instrumental, along with on economics, in order to estimate considered in accordance. The rela- been widely integrated yet. IT should development of teleradiology is the dedication of many of our col- the impact of the crisis on our spe- tionship with national societies can serve the patient; the development of inevitable, and that radiologists leagues. Therefore my first goal is to cialty. The national societies will be be described as rather good, but it the electronic health record (EHR) should shape its development by keep up this momentum and run the solicited for this task. is a fact that it should be improved. is crucial but still slow, and imaging’s including it in their practice and society appropriately, in accordance As you can see, if our specialty I will invite some of them to the place is not well defined in terms management. with its new statutes. However, life is needs to take a new scientific leadership meetings, and set up an of content and architecture. Patient challenging, and we will have to face approach in order to prepare for the e-newsletter specifically dedicated radiation protection management ECRT: How would you encourage many new issues in the coming year. future, then we also have to look at to Institutional Member Societies. is often limited to dose recording, medical students to choose radiol- The explosion of ‘omics’ (such as the situation in our specialty across I also hope that the economics while other key aspects would have ogy as their specialty? Why is radi- metabolomics, proteomics, genom- Europe. working group will help improve to be included. Finally, eLearning ology an interesting field? ics) data is changing the face of med- our relations. needs to be structured and devel- GF: This is a very critical issue. The icine so considerably and rapidly ECRT: The ESR launched the oped. All of the above mentioned best approach is probably through that, if we don’t pay enough atten- International Day of Radiology on ECRT: One of your interests is issues will be highlighted during my the early introduction of imaging tion, our specialty could be threat- November 8, 2012, to build aware- IT, and the H.E.G.P. is the most presidency. into medical training. Focused pub- ened. Personalised medicine is not ness about the benefits brought advanced hospital in France in this lic campaigns using social networks a just a dream, but an actual reality, about by imaging. What do you field. Do you think there is suffi- ECRT: What are the remaining should also be used. Invitations for and we have to adapt our specialty to think of this initiative? cient investment in IT services in issues faced by teleradiology in students to attend national society this new paradigm. This year, DNA GF: The International Day of Radi- European hospitals today? Europe? annual meetings could also be use- sequencing could become availa- ology was very successful; the ESR GF: I think that IT is the backbone GF: The ESR has always stated that ful. Finally, showing that radiology ble for less than €750 (US$1,000), played a key role and has to be con- of the development of quality and teleradiology is a medical act, which is not only a full clinical specialty, and in the UK, the Prime Minis- gratulated. I think that this day has safe practices, and it is also key to should comply with the quality and but also a key specialty for diagno- ter David Cameron has launched a to be considered as a first step on improving efficiency. Even if I don’t safety requirements of face-to-face sis and treatment through interven- programme for the development of the path towards awareness. Talk- have the figures for IT in Europe, I practice. I hope that teleradiol- tional techniques should be used to personalised medicine. The devel- ing about the benefits is certainly am quite sure that its distribution ogy will not only be developed to promote our specialty. In my coun- opment of personalised imaging, important; but we also have to varies across different countries. In decrease costs, but also to improve try, radiology is chosen by the best which has already begun in oncol- promote better use of imaging, not addition, IT technological advances quality of care. There are several residents, so I am not worried about ogy, should be taken further, and we only for safety reasons, but also, and have been extremely important in examples of its useful application, the future. ESOR School of MRI

Course Programme 2013 Advanced Cardiac MR Imaging September 12–14, Marseille/FR Body Diffusion-Weighted MR Advanced MR Imaging of the Chest Imaging: September 19–21, 2013, Valencia/ES From Theory to Practice April 4–6, 2013, Lisbon/PT Advanced Head & Neck MR Imaging September 19–21, 2013, Krakow/PL Clinical fMRI & DTI: Theory and Practice Advanced Neuro Imaging: Diffusion, May 30 – June 1, 2013, Rotterdam/NL Perfusion, Spectroscopy October 17–19, 2013, Split/HR Advanced MR Imaging of the Musculoskeletal System Advanced MR Imaging of the July 4–6, Malta/MT Abdomen October 24–26, Brugges/BE Advanced MR Imaging in Paediatric Radiology September 5–6, 2013, Graz/AT

myESR.org | #ECR2013 @myESR 26 ECR Today 2013 Community News Monday 11 March 2013 Proposed European data protection regulation puts the EU’s eHealth vision at risk

By Javeni Hemetsberger of health professionals, citizens, The Staff Working Paper (SWP) In January 2012, the European tection legislation is its legal charac- patient groups, healthcare man- on the legal aspects of telemedi- Commission adopted a proposal ter; regulations become immediately Previous editions of ECR Today have agers, hospitals, health insurers, cine aims to clarify the legal situ- for regulating the processing of per- enforceable law in all EU Member mentioned the ESR’s engagement in eHealth experts and public health ation of telemedicine at European sonal data and the free movement of States with no transposition period EU politics, such as its involvement organisations) and industry with level, particularly cross-border sit- such data. Since Directive 95/46/EC as with Directives. in European legislation on electro- direct interest and activity in infor- uations. The following legal issues on the processing of data and free However, the proposed ‘General magnetic fields (Alliance for MRI), mation and communications tech- are addressed by the white paper: movement of such data was adopted Data Protection Regulation’ has a the European Commission’s pro- nology (ICT). licensing/registration of healthcare in 1995, this new proposal aims to number of stipulations which are posal on the modernisation of the On December 7, 2012, the Euro- professionals performing telemedi- revise the existing Directive and thus detrimental to health research Professional Qualifications Direc- pean Commission – in consulta- cine services, reimbursements poli- enhance enforcement and address and the European Union’s eHealth tive 2005/36/EC, and the Euro- tion with the eHealth Stakeholder cies, data protection (e.g. processing the fragmentation of national data vision, including cross-border pean Union’s research framework Group – published the eHealth health-related data), legal liability, protection legislation, legal uncer- healthcare. programme Horizon 2020. package, comprising of three core relevant jurisdiction, and applicable tainty due to the increased scale of The ESR has therefore developed a Apart from the activities men- documents: the ‘eHealth Action laws in cases of injury. data sharing, as well as development statement on the proposed General tioned above, the ESR’s EU Affairs Plan 2012–2020’ and the ‘Inter- The European Commission’s of new technologies. Data Protection Regulation outlin- Subcommittee is closely monitor- nal Staff Working Document on objective is to develop evidence- The proposed regulation has ing its position. ing several other policy areas such the eHealth Action Plan 2012– based clinical practice guidelines for several new elements such as new The full ESR statement on the as the European Commission’s 2020’, as well as the long-awaited telemedicine services, with a partic- definitions (e.g. genetic data or data European Commission’s proposal proposals on medical devices and ‘Internal Staff Working Paper on ular emphasis on nursing and social concerning health), data minimisa- for a regulation on the protection clinical trials. It is actively involved the legal aspects of telemedicine care workers, via Horizon 2020. It tion (data should be limited to the of individuals with regard to the in the EU’s eHealth initiatives, and services’. plans to start policy discussions on minimum necessary), ‘right to be processing of personal data and it has developed a statement on the The eHealth Action Plan’s objec- eHealth at a global level and foster forgotten’ (data subjects can obtain on the free movement of such data proposed European data protection tive is to foster cross-border health- interoperability, the use of interna- the destruction of his personal data) can be found on the ESR website regulation. care, health security, solidarity, uni- tional standards, develop ICT skills, and ‘one-stop-shop’ (one set of rules www.myESR.org > EU Affairs Since February 2012, the ESR has versality and equity. compare evidence of the effective- for all EU Member States and the > European Data Protection been a member of the European The key targets of the eHealth ness of eHealth and promote eco- establishment of national contact Regulation. Commission’s eHealth Stakeholder Action Plan include improving systems of innovation in eHealth. points in each Member State). Group, an expert group aiming to chronic disease and multimorbid- The European Commission aims Moreover the proposed legislation contribute to the development of ity management, strengthening to propose an eHealth Interoper- seeks to clarify issues regarding the legislation, or policy, for eHealth prevention and health promotion ability Framework based on the international transfer of such data, by providing reports, opinions, rel- practices, as well as increasing results of studies, pilots and research and it proposes sanctions for the evant data and consultation to the the sustainability and efficiency of projects by 2015. misuse of personal data and the For further information please European Commission. health systems by facilitating inno- Another area the ESR is particu- abuse of data subjects’ rights. contact the ESR Department of The eHealth Stakeholder Group vation and achieving wider interop- larly interested in is European Data One of the most important steps EU and Public Affairs at represents both users (in terms erability of eHealth services. Protection legislation. towards uniform EU wide data pro- [email protected]

ECR 2014 Abstract Submission for electronic exhibits (EPOSTM) starts May, 2013 www.myESR.org/epos_submission

Browse through thousands of electronic posters from ECR 2003–2013 and other congresses www.myESR.org/epos TRADEMARK OF

#ECR2013 @myESR | myESR.org Monday 11 March 2013 Community News ECR Today 2013 27 Ukraine aims for European radiological standards

By Volodymyr Rogozhyn Officially, Ukraine has a com- prehensive, guaranteed package of Ukraine is Europe’s second largest healthcare services provided free country by area and has a popula- of charge at the point of use, as a tion of 46 million, as of 2009, which constitutional right. Nevertheless is 12 percent smaller than in 1991 ‘charitable donations’ are widely when the country gained independ- levied in the Ukrainian health sys- ence from the USSR. Heavy indus- tem. Modern Ukrainian radiology try and manufacturing is concen- is not an exception in this process. trated to the east and south of the One of the main problems for country, whereas the west is more Ukrainian radiology is its ageing agricultural. There is a political split equipment. Seventy percent of all along similar geographical lines. radiological units were installed The population in western regions during the soviet era. Over the last shows stronger support for candi- few years there has been a positive dates advocating EU and NATO trend in the purchasing of modern accession, while the population in systems for digital radiography. the eastern and southern regions Recently, 50–60 percent of mod- (where more Russian-speakers ern equipment has been purchased live) supports candidates looking through private investment. to maintain closer ties with the Rus- The second problem for Ukrain- sian Federation. In 1991, Ukraine ian radiology is the training of inherited an extensive and highly Ukrainian radiologists. We have a centralised Soviet health system, lot of talented specialists, but post- which could not be maintained graduate training in Ukraine is not during the economic downturn that equal to that in the European Union. followed independence; the system In Ukraine, a radiologist can be Swallow’s Nest castle, Yalta was considerably decentralised. The qualified after one and a half years level of general government expend- of internship work and six months General practitioners and family percent of them are members of most important radiological event iture on health as a proportion of of specialisation. Specialists in ultra- physicians, who send patients for the Association of Radiologists of in Ukraine. total health expenditure is only 55.7 sound diagnostics only train for six radiological diagnosis, are mostly Ukraine. The official journal of the ARU percent. However, in most other months. The European Training unaware of the possibilities of mod- The main aims of the ARU are the is Radiodiagnostics, Radiotherapy respects the system still remains Charter for Clinical Radiology has ern radiology and do not know the development and improvement of (ISSN 1993-1689), with four issues largely unreformed. not yet been introduced in Ukraine. basic indications and contraindica- radiology in Ukraine, education and per year. The Association of Special- tions for certain radiological proce- training of its members and young ists in x-ray, CT and MRI publishes dures. They are not familiar with the radiologists, cooperation with other the quarterly Radiology Bulletin criteria of adequacy for radiological national radiological societies, and (ISSN 1993-1743). methods in the differential diagno- integration into European and inter- The ARU constantly strives to sis of disease. national radiology. widen its professional contacts and The Association of Radiologists The ARU is an institutional its communication with colleagues of Ukraine (ARU) is a non-profit, member of the European Society in other countries in order to non-governmental public organi- of Radiology. But only 100 radiolo- exchange experiences in the appli- sation and was established in 1991. gists from Ukraine are individual cation of new modern radiological It is the official successor to the members of the ESR. methods. Ukrainian Society of Roentgenolo- Each year, the ARU organises and gists, founded in 1936. holds several scientific conferences More than 8,200 radiologists, on the most current issues in x-ray, More information about the Asso- including specialists in x-ray, CT, CT, MRI, US diagnostics, nuclear ciation of Radiologists of Ukraine MRI, US diagnostics, interven- medicine, interventional radiology, can be found at www.aruk.org tional radiology, nuclear medicine, and medical physics. The congress radiation oncology and medical of the ARU, with participation Professor Volodymyr Rogozhyn physics work within the field of from leading radiological authori- from Kiev, Ukraine, is President of radiology in different medical insti- ties from other countries, is held the Association of Radiologists of St. Michael’s golden-domed monastery, Kiev tutions around Ukraine. Nearly 51 once every five years and is the Ukraine.

STAFF BOX

Editors ECR 2013 Julia Patuzzi, Vienna/AT Philip Ward, Chester/UK SPECIAL EXHIBITION Editorial Team Michael Crean, Vienna/AT Simon Lee, Vienna/AT A notably popular feature at the European Congress of Radiology is the special Contributing Writers exhibition, initiated and compiled by Prof. Hermann Vogel from Hamburg, Germany, in Edna Astbury-Ward, Chester/UK cooperation with the Deutsches Röntgenmuseum, which has been part of the annual John Bonner, London/UK Michael Crean, Vienna/AT meeting for years. This year’s exhibit is entitled: X-Rays: Evidence and Threat. Javeni Hemetsberger, Vienna/AT Simon Lee, Vienna/AT Becky McCall, London/UK This year’s exhibition covers a wide variety of instances where imaging has been used, Rebekah Moan, San Francisco, CA/US Alena Morrison, Vienna/AT from the outlandish to the downright gruesome. It includes images of injuries sustained Mélisande Rouger, Vienna/AT from terrorist attacks, accidents and torture. It also demonstrates how imaging has Frances Rylands-Monk, St. Meen Le Grand/ France been used to detect drugs and explosives hidden inside the human body, as well as Philip Ward, Chester/UK some other more benign cosmetic implants. David Zizka, Vienna/AT Layout Philipp Stöhr, Vienna/AT This exhibition provides a unique insight into the physical aftermath of many tragic incidents while also delving into some non-medical imaging applications. Marketing & Advertisements It promises to be an eye-opening experience for all. Konrad Friedrich E-mail: [email protected] Contact the Editorial Office Prof. Hermann Vogel is former head physician at the Albers-Schönberg-Institute, the ESR Office department of radiology at St. Georg Hospital in Hamburg. The new exhibition, which Neutorgasse 9 1010 Vienna, Austria will be shown for the first time at ECR 2013, again features more than Phone: (+43-1) 533 40 64-0 20 posters with partly provocative images. Fax: (+43-1) 533 40 64-441 E-mail: [email protected] nd ECR Today is published 6x during The exhibition is presented on the 2 level of the congress venue ECR 2013. next to the EPOS Area. Circulation: 22,000 Printed by Holzhausen, Vienna 2013 myESR.org

myESR.org | #ECR2013 @myESR Watch videos from ECR 2013 and more youtube.com/myESR Monday 11 March 2013 Community News ECR Today 2013 29 Norwegian Society improves research opportunities for radiologists

By Gaute Hagen This is about to be changed as future medical doctors will have to apply The Norwegian Society of Radiology directly to hospitals for a one-year is a member of the Norwegian Med- position and, after that, half a year as ical Association and includes more a general practitioner. Having done than 900 members. Recruitment to this they are then entitled to apply radiology is good. Since 2010 there for full certification. The Norwegian has been an increase in the number Medical Association currently runs of certified practising radiologists the educational programme for spe- from 565 to 615, and radiologists cialisation in radiology, but the pro- in training from 157 to 170. Cur- gramme committee is appointed by rently 41 percent are women, and the Norwegian Society of Radiology. this number increases to 51 percent The duration of training in radiol- for those younger than 50 years of ogy is five years, of which a year age. With a population of five mil- and a half in a university hospital lion there is one certified radiologist is required. One of the five years may per 8,100 inhabitants. The economy be spent within clinical practice, in our country is strong and CT scientific work or teaching. Dur- resources are especially good, with ing residency there are ten manda- more than 130 units installed. The tory week-long courses, which end Norwegian Radiation Protection with written examinations. Nuclear Authority is concerned about the medicine is not part of the curricu- high number of CT examinations lum. There is no system of collect- performed annually. In 2008, 195 ing CME points yet. However, we CT examinations per 1,000 inhabit- are working on changes so that our ants were carried out; much higher training programme will corre- On May 21–24, 2013 the 60th Congress of the Nordic Society of Radiology will be held in the lovely city of Bergen, on the west coast of Norway. than in neighbouring countries. spond with ESR recommendations. However, the distribution of the There are no formal radiologi- population, the low availability of cal subspecialties, but there is an Research programmes and discus- government-funded budgets and it On May 21–24, 2013 the 60th other modalities such as PET-CT, increasing number of subspecial- sions are now part of every national is up to each health enterprise to Congress of the Nordic Society of and other factors may have influ- ised groups within radiology. Today meeting, and a strategy for research earmark resources for research. The Radiology will be held in the lovely enced this figure. there are seven such groups, includ- has been completed. This includes minimum percentage for research city of Bergen, on the west coast Currently medical students are ing neuro, paediatric, interven- basic science using imaging, trans- should probably be about five per- of Norway. This time it will be a automatically offered a year and a tional, thoracic, abdominal, breast, lational imaging research, clinical cent of the budget but is much lower collaborative congress, from the half of clinical practice before they and musculoskeletal radiology. The radiology, as well as health and pub- at the moment. Some medical spe- Norwegian societies of radiology, qualify as medical doctors and begin board of the Norwegian Society of lic radiological science. The research cialities have been able to include radiography and medical physics. their specialisation in radiology. Radiology uses these groups to solve programme is integrated into the research time into normal working The president of the congress will and answer all enquiries, distrib- work of the board of the Norwegian hours. This is the case for only a few be Prof. Karen Rosendahl. Further ute information, and contribute to Society of Radiology. In 2012, six radiologists, but we are working on information may be obtained from educational programmes; which radiologists completed a PhD pro- improving this. www.nordiccongress.org. The offi- improves both the quality of our gramme and defended their theses. The Nordic Radiological Societies cial language will be English. work and collaboration. Our hope Similar to other countries there is in publish Acta Radiologica in collabo- is that this will improve research Norway a need to further strengthen ration, and the journal is important within radiology. research opportunities. Because of for the publication of Nordic radi- More information about In order to increase research in the constantly increasing demand ological research. The Norwegian the Norwegian Society of radiology, the Norwegian Radiol- for radiology services, radiology radiologist, Prof. Arnulf Skjennald Radiology can be found at ogy Research Forum was estab- staff are pushed, more and more, to is chief editor. Additionally, we pub- www.radiologforeningen.no lished in 2007 with help from EIBIR do routine work and unfortunately lish the journal Noraforum in Nor- (European Institute for Biomedical research work will often suffer. On wegian. This journal is published Professor Gaute Hagen from Oslo, Imaging Research). The current a departmental level the research in cooperation with the Society of Norway, is President of the Norwe- Professor Gaute Hagen from Oslo, Norway chairman is Prof. Nils-Einar Klöw. responsibility varies. Hospitals have Nuclear Medicine. gian Society of Radiology. Kazakhstani radiology strengthens links with Europe

By Zhangali Khamzabaev adapt it to the new demands and MR), as well as interventional radi- Society of Kazakhstan, under the requirements of a young country, ology, it is evident that the medical presidency of Professor Zhangali After the collapse of the Soviet Union which has a responsibility towards specialty of radiology will play an Khamzabaev, to meet the standards in 1991, Kazakhstan came under the its fast growing population. essential role in Kazakhstan’s new of the ESR, we are very pleased to leadership of its current president, Apart from these issues, Kaza- healthcare system. have become a full Institutional N. Nazarbaev and became the inde- khstan is suffering the effects of As a result, the radiological com- Member Society of the ESR. Our pendent ‘Republic of Kazakhstan’, radioactive fallout in the region of munity of Kazakhstan is very pleased goal is to participate actively in with a population of 16 million peo- Semipalatinsk, causing a very high and thankful for the help it received the organisational structures of ple, of whom one million live in the rate of oncologic diseases like breast from the former European Associa- the ESR and ECR, and hopefully new capital Astana and two million carcinoma, congenital diseases and tion of Radiology, under the leader- ESOR too. in the old capital of Almaty. an extremely high rate of tuberculo- ship of Professor Albert Baert, and In our country we are in the proc- There are three other major cit- sis. As a result of the rapidly improv- later from ESOR and its educational ess of training young physicians to ies, each with a population of one ing standard of living there is also director, Professor Nicholas Gourt- become fully-qualified radiologists million, and five cities with 300,000 an increasing number of lifestyle- soyiannis, who supported the partici- as defined by the ESR. We offer to 400,000 people. The remaining related diseases like hypertension, pation of 76 Kazakhstani radiologists English-language courses in order population of eight million is dis- coronary heart disease, diabetes in the Graz Tutorials, organised by to better communicate with our tributed over a territory of 2,724,900 mellitus, etc. Professor Rainer Rienmueller. international colleagues. We are square kilometres, with two-thirds Therefore, it is necessary to build Here we received, for the first supporting the participation of our of the country living west and one- new hospitals, clinics, and new pro- time, valuable information about a young physicians in international Professor Zhangali Khamzabaev is third living east of the Ural Moun- fessional medical and non-medical modern work-flow in a busy univer- radiological conferences, especially President of the Radiological Society tains, which are often considered the organisations, including new medi- sity hospital and the role of modern the ECR and ESOR. of Kazakhstan. boundary between Europe and Asia. cal universities and post-graduate imaging methods. Of course, we And of course, we are actively The process of becoming an educational programmes for physi- also learned about the role, activi- involved in all areas of diagnostic independent country was, and still cians and medical staff. ties and meaning of the ESR, ECR imaging, as well as the medical does, involve a tremendous amount Based on the great progress in and ESOR. And last but not least, and organisational issues related of political, economic, social and medical imaging technologies we learned about life in democratic to the main health problems in our cultural change. such as CT, MR, ultrasound, and west European countries. country. We are very grateful for It has also become necessary to radionuclide imaging methods like After adapting the organisational all the support we have received revitalise the healthcare system and SPECT and PET (PET-CT, PET- structures of the Radiological from the ESR.

myESR.org | #ECR2013 @myESR 30 ECR Today 2013 Arts & Culture Monday 11 March 2013 Franz West Where is my Eight?

Franz West was one of the most used are turned into ‘untouchable’ After it has closed in Vienna the important Austrians in the interna- examples of the development of his Franz West ‘Where is my Eight?’ tional art world. The artist, who died early work. Adaptives are also part exhibition will be shown at the MMK in July 2012, achieved worldwide of a combi-wall which, along with Museum für Moderne Kunst Frank- fame with his ‘Passstücke’ (adap- various works on paper, exhibits furt am Main, Germany (June 29 – tives), his furniture and his sculp- photos of people interacting with October 13, 2013). tures for interior and exterior spaces. them. When supplemented by fur- It is now sixteen years ago that the niture, walls of this kind, ‘Kasseler Franz West mumok organised Franz West’s first Rippchen’ (Kassel-style Spare Ribs, Franz West was born in 1947 in comprehensive retrospective. Now, 1996) or ‘Träumerei’ (Dreamy, Vienna, where he also died in 2012. once again, it is dedicating a large- 1997) for example, become room- With no formal training he began to scale exhibition to his work that was filling installations. make art at the age of twenty-three. initiated and co-developed by him One of the central exhibits is Between 1977 and 1982 West was a with great enthusiasm. ‘Redundanz’ (Redundancy), a student of Bruno Gironcoli at the three-part papier-mâché sculpture Academy of Fine Arts in Vienna. Combination und Recombination which is held to be a significant Though his work was only known to The focus of the thematically struc- early example of West’s practice of his circle of friends during the first Exhibition view – Franz West. Where is my Eight? tured presentation is on West’s combination and recombination. ten years, the 1980s saw the begin- Photo: mumok/Gregor Titze © Franz West/mumok combi-pieces, predominantly instal- Shown in Vienna for the first time ning of his international career. He lative works in which the artist com- in 1986, the artist considered it nec- was represented at the documenta bined various individual pieces and essary to supplement it with another twice (1992 and 1997) and in 1990 subsequently recombined them in sculpture thus replacing a part that provided the Austrian contribution different configurations. The combi- had been sold against his will. The to the Venice Biennial. In 2011 he nation and recombination of differ- new version was entitled ‘Reduk- was awarded a golden lion there for ent kinds of work such as adaptives, tion’ (Reduction). Since 2011 both his life’s work, the highest award for furniture, sculpture, videos or works versions of this work are part of the a living artist. on paper, from all different creative mumok’s holdings. Despite his world career, Vienna periods, means that the exhibition not only remained the centre point provides an overview of the whole Permanent Change, Participa- of his life, it was rather more; all his spectrum of his œuvre. Works by tion and Interaction life he felt a particular affinity for the artist friends such as Martin Kip- Franz West’s œuvre is fundamen- city and it its culture. penberger, Rudolf Polanszky, Jason tally participatory; it seeks dialogue Rhoades or Heimo Zobernig are with the recipient. Every one of also included in these works. his art products are invitations to “Everything we see could also interaction. This can take place on be otherwise,” said Franz West in the physical level – as in the case of Franz West, Curaçao, 1996 1988, quoting philosopher Lud- the adaptives which are meant to Friedrich Christian Flick Collection im Hamburger Bahnhof, Berlin, wig Wittgenstein, whom he valued ‘adapt’ to the body – but also on the Photo: mumok © Franz West highly, and addressing an essential mental or intellectual level, as is the aspect of his own artistic approach. case with his sculptures or works on The principle of combination and paper. The latter are usually accom- recombination also corresponds to panied by texts which offer further his conviction that the meaning of stimulus for reactions. a statement – or a visual element – West’s creations are the starting is never a fixed and clearly defined points for experiences, considera- one but, rather, changes according tions, associations and delibera- to context and the reaction of the tions, the trigger mechanism for a recipients. game with various possibilities of experiencing and viewing the world Works in the exhibition with an ever-changing result that Visitors will be met by one of his depends on the recipient, context ‘Lemurs’ at the entrance to the and atmosphere. museum: large-scale head-like West’s art exhibits uncertain- forms with oversized openings for ties in a way that is unpretentious, mouth and nose. In his writings almost light-footed, and humorous Franz West, Redundanz, 1986 (Redundancy) West connected these with Hera- although it is founded on an intense Photo: mumok © Franz West clites’s famous dictum about things engagement with philosophical undergoing continuous change: writings, an early concern which “Ever newer waters flow on those intensified throughout the artist’s who step into the same river, and life. (ever new) souls step from the The title chosen by West for the wetness.” Heraclites Fragment 12 exhibition is a further example of [1]. Thus this work provides an his practice of combination and introduction to the subject of the recombination: the starting point exhibition. is the gouache ‘Lost Weight’ (2004) The Genealogie des Ungreifbaren which features a woman who, hav- (Genealogy of the Untouchable, ing dieted, shows off her much-too- 1997) that stands right at the begin- large trousers. The artist’s omission ning of the show is a work which of the ‘W’ transformed ‘Lost Weight’ proves that the artist has never clung to ‘Lost Eight’ which led to the dogmatically to his own concepts. question in the title: Where is my In a large vitrine-like box he com- Eight? West leaves the answer to this Franz West, 2007 bined three early adaptives with question open, thus creating a space Photo: Jens Preusse, Courtesy Franz West one of his first chairs. Thus works for us to make various associative Privatstiftung © Franz West that were originally intended to be connections. Franz West, Kasseler Rippchen, 1996 (Kassel-style Spare Ribs) Hauser & Wirth Collection, Schweiz / Switzerland, Photo: mumok/Gregor Titze © Franz West MUMOK Stiftung Ludwig at the MuseumsQuartier | Museumsplatz 1, 1070 Vienna Opening Hours: Monday 2pm – 7pm Tuesday to Sunday 10am – 7pm Thursday 10am – 9pm www.mumok.at

#ECR2013 @myESR | myESR.org Franz West, Habitus, 1996 Hauser & Wirth Collection, Switzerland, Photo: mumok © Franz West 32 ECR Today 2013 Arts & Culture Monday 11 March 2013 What’s on today in Vienna?

Theatre & Dance Please note that all performances are in German!

Akademietheater Theater in der Josefstadt 1030 Vienna, Lisztstraße 1 1080 Vienna, Josefstädter Straße 26 Phone: +43 1 51444 4145 Phone: +43 1 42 700 300 www.burgtheater.at www.josefstadt.org

19:30 Der Talisman by Johann Nestroy 19:30 Hedda Gabler by Henrik Ibsen

Burgtheater Volkstheater 1010 Vienna, Dr. Karl-Lueger-Ring 2 1070 Vienna, Neustiftgasse 1 Phone: +43 1 51444 4145 Phone: 43 1 52111 400 www.burgtheater.at www.volkstheater.at

19:00 Der 11. März 1938 19:30 Die Comedian Harmonists An evening of remembrance by Franz Wittenbrink

Die Comedian Harmonists by Franz Wittenbrink © Lalo Jodlbauer / Volkstheater

Concerts & Sounds

Musikverein (Classical Music) Arena (Alternative Music) 1010 Vienna, Bösendorferstrasse 12 1030 Vienna, Baumgasse 80 www.musikverein.at www.arena.co.at

19:30 Münchener Kammerorchester 20:00 Broadway Calls (US) conductor Alexander Liebreich Sivan Silver, piano, Gil Garburg, piano F. Mendelssohn Bartholdy, L. van Beethoven

Porgy & Bess (Jazz) 1010 Vienna, Riemergasse 11 www.porgy.at

20:30 Anna Lauvergnac Quartet ‘Unless there’s Love’ (I/D/GR/US) Münchener Kammerorchester © Marek Vogel

Opera & Musical Theatre

Volksoper 1090 Vienna, Währingerstraße 78 www.volksoper.at

19:00 Die Fledermaus by Johann Strauß

Wiener Staatsoper – Vienna State Opera 1010 Vienna, Opernring 2 www.wiener-staatsoper.at

16:00 Masterworks of the 20th Century Ballet by Nils Christe, Roland Petit, Serge Lifar

Die Fledermaus by Johann Strauß © Dimo Dimov / Volksoper

#ECR2013 @myESR | myESR.org