ECR TODAY2014 DAILY NEWS FROM EUROPE’S LEADING IMAGING MEETING | SUNDAY, MARCH 9, 2014

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HIGHLIGHTS CLINICAL CORNER TECHNOLOGY FOCUS COMMUNITY NEWS Parizel takes ECR delegates Experts share strategies PACS providers plot Award-winning author on a cerebral journey of to help radiologists justify routes through a changing delivers honorary lecture discovery and hope their imaging decisions medical landscape at ECR 2014

BY FRANCES RYLANDS-MONK Experts chew the fat on obesity and present novel ways to bolster services for larger patients

Ground-breaking applications of in which there is fa y accumulation to diagnosis through a number of functional imaging techniques can plus lobular infl ammation, hepatocyte modalities including ultrasound, help radiologists play their part in ballooning and perisinusoidal fi brosis, CT, MR spectroscopy and the lesser the fi ght against the emerging obe- and which may also lead to cirrhosis, known controlled a enuated param- sity pandemic. In particular, MR elas- according to Prof. Valérie Vilgrain, eter (CAP), a measure of ultrasound tography is showing promise in the chair of imaging at Beaujon Hospital, a enuation on the fi broscan which early detection of disease, a endees Paris, France. correlated with pathological grades were told at Saturday’s State-of-the- Importantly, very recent data sug- of steatosis. Art Symposium. gest that the fi rst cause of hepatocel- “It is much more diffi cult to iden- Obesity-related illness worldwide lular carcinoma (HCC), the primary tify the dangerous subtype, NASH, is having a huge direct impact on liver cancer, is not due any more to defi ned pathologically with infl am- healthcare costs, and indirectly aff ects alcohol intake or viral hepatitis but mation and fi brosis, which are harder individual loss of productivity and to a metabolic syndrome in which to detect on imaging,” she added. its related socio-economic problems obesity plays an important role. Fur- At present, the latest development as many obese patients are deemed thermore, an increasing incidence of in obesity imaging is the application unfi t to work. It presents an obstacle HCC, including those found inciden- of functional quantitative imaging Prof. Valérie Vilgrain from Paris, Dr. Rachel Ba erham from to the population’s physical, mental tally, and benign liver tumours linked to detect infl ammation and fi bro- France. London, United Kingdom. and fi nancial well-being that health- to obesity constituted a challenge for sis. There is growing evidence that care providers can’t aff ord to ignore. radiology and oncology departments. one such new technique, functional One such associated disease is Nevertheless, NAFLD patient surveil- MR elastography, can diff erentiate Already used routinely in Vilgrain’s pared to the general population, there non-alcoholic fatty liver disease lance using imaging techniques would NASH among NAFLD patients. The hospital and in dedicated centres, is also a higher cardiovascular mor- (NAFLD), which ranges from relatively help to detect HCC and hepatocellular technique determines liver stiff ness, there is an argument for implement- tality, and such diff erentiation could benign, simple steatosis – fa y accu- adenomas. as stiff ness increases in early NASH ing MR elastography wherever obese infl uence management strategies at mulation in under 5% of hepatocytes “Now our task as radiologists is to even with no fi brosis and it further patients are managed; not only is an earlier stage. – to a more severe condition called diagnose liver steatosis and quantify increases with the severity of the there a higher liver-specifi c mortal- non-alcoholic steatohepatitis (NASH), it, which is easy,” she said, pointing disease. ity among NASH patients when com- continued on page 3

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BY PHILIP WARD Tread cautiously when it comes to MR-guided prostate biopsies, warns ECR 2015 President

MR-guided biopsies of the prostate should only be performed in selected patients, and it’s vital to keep aware of false-negative results. Also, an urgent need exists for robust multicentre trials of targe- ted biopsies of the prostate, ECR delegates learned during a Special Focus session on Saturday.

On the plus side, an MR-guided how good are we?” noted Hamm, who at the Medical University of Vienna, biopsy (MRGB) is more effi cient than will be President of ECR 2015. where he also did his medical train- a systematic transrectal ultrasound Overall, multi-parametric MRI ing. Another huge challenge is the (TRUS) biopsy, the detection rate in enables detection of signifi cant can- accuracy of negative sampling, and Prof. Bernd Hamm from Berlin, Prof. Bob Djavan from Vienna, TRUS-negative patients is between cers, and is an accepted tool, espe- imaging has a role here too. Germany. Austria. 40 and 50%, an MRGB yields longer cially in patients in whom there is “We have a problem identifying core cancer length than a TRUS a negative TRUS biopsy. An MRGB insignifi cant cancers,” he said. “Today, biopsy, an MRGB detects more sig- has high cancer detection rates, inde- active surveillance is a very popu- It’s not time to trash biopsies, but There is a great need to rationally nifi cant and fewer insignifi cant can- pendent from numbers of previous lar tool in urology. We don’t operate it’s time to change how biopsies are approach prostate cancer with new cers, fewer cores per patient are nec- TRUS-biopsies. on every cancer today, and many performed, he continued. “Just doing tools, according to session modera- essary, and an MRGB performs be er Importantly, there is also a trend patients go on to active surveillance, more biopsy and lateral is not the tor Dr. Joan Vilanova, from Clínica than a cognitive biopsy, according to in the literature and in daily routine which means we don’t treat them, solution. We need to add imaging Girona, Hospital Santa Caterina, Prof. Bernd Hamm, director of the away from in-bore MR-guided pro- we wait and we do biopsies and PSA information, specifi cally multi-par- University of Girona, Spain. Imaging Institute of Radiology at the Charité, cedures and toward MR/ultrasound (prostate-specifi c antigen). If the PSA ametric MRI, and we need to learn must come fi rst, with biopsy last, and Berlin, Germany. fusion biopsies. rises, then we operate.” how to do a good fusion.” MRI should play an important role in Conversely, an MRGB is time-con- Strategies to improve TRUS biop- Urologists need the imaging Suitable fusion technology is not improving prostate cancer detection, suming and expensive. Moreover, sies include obtaining more biopsy information that can help to reduce yet available, according to Djavan. said Vilanova, who strongly urged only limited data exist, and there cores, tackling the increased risk of unnecessary biopsies, increase It is not helpful to be able to have all ECR a endees to a end the 4th is li le or no evidence in favour infectious complications with every the detection rate, and predict the great parametric MRI exams that European Society of Urogenital Radi- of MRGBs, he explained. Whereas additional biopsy, and increasing the Gleason grade and cancer volume. look wonderful in a lecture but do not ology Teaching Course on prostate studies on MRGBs typically have biopsy cu ing length, depth, and The fusion of a TRUS and a mul- help clinically when no fusion exists. MRI, which begins in Girona on been single-centre trials involving number of cores. ti-parametric MRI is essential for “The future will not be radical June 6, 2014. between 10 and 100 patients, those From a urologist’s perspective, the this purpose, he said. prostatectomy – it pays my personal “I cannot promise you a table at on TRUS have been multi-centre prime goal is adequate detection of “Fusion means not only fusion of bills, and I’m very happy about that, El Celler de Can Roca, recently voted studies involving 1,000 or more signifi cant cancers, which is why technologies but fusion of two spe- but the future will be about not the best restaurant in the world, but patients. MRI and multi-parametric MRI is cialities: urology and radiology. We doing surgery in so many patients,” I can promise you two excellent days “Most of the studies have a poor so important, according to Prof. Bob need to work together,” urged Dja- he said. “I always say to urologists: a of learning about prostate MRI,” said adherence to standards in report- Djavan, director of the department of van. “Biopsies should be a two-de- fool with a tool is still a fool. I’m very Vilanova, who is the course director ing diagnostic accuracy. This is a urology at VA Hospital in New York partmental ma er in which imaging self-critical. If you give me an MRI, for the event. concern, giving rise to the question: University and professor of urology and urology work together.” I’m still an idiot!”

continued from page 1

“We are not going to solve the prob- with Body Mass Index (BMI), waist cir- employment are also compounded lem with just morphological imaging,” cumference and other measurements. with fi nancial costs to individuals she commented. Detecting post-surgical complica- who buy expensive but ineff ective Despite the difficulties gener- tions is an important task today, and diet products and join gyms. ally associated with imaging obese Dr. Marco Renga, a radiologist and “Health economics is a big issue patients, MRI might prove the most researcher at the Sapienza Hospital because there is only so much money accommodating, being less subject in Latina, Italy, aimed to educate del- to go round,” she said. “It’s diffi cult to to weight restrictions and body egates about what to look for in the put a fi gure on this but it’s estimated RTF MEET & GREET SESSIONS size – although these were still a case of complications following bar- that 460 billion Euros a year is spent Today, at the RTF Booth in the Rising Stars Lounge you will be able to meet the consideration, even with the bigger iatric surgery, such as extraluminal in Europe on obesity.” following Radiology Trainees Forum (RTF) representatives: bores available today. Imaging larger leak or communication of the gastric Providing food for thought on why patients therefore remains a chal- pouch with the excluded stomach. we were prone to obesity, Ba erham 09:00–11:00 Tom De Beule (Belgium) lenge, despite the relative simplicity Dr. Rachel Ba erham, medical and explained that in prehistory, those 14:00–16:00 Arta Šmite (Latvia) of many techniques such as conven- surgical lead for obesity services at that could eat the most and put on 16:00–17:00 Ales Kavka (Czech Republic) tional ultrasound. University of the City of London Hos- weight would be the ones that would Because the liver interacts with pitals (UCLH), was keen to underline survive a famine. Join your European colleagues and representatives in an informal and relaxed visceral fat, which in turn interacts the staggering statistics about obesity. “Our genes that regulate body discussion, exchange opinions and points of view with them and present your with the cardiovascular system and The condition has tripled across the weight have developed in a com- ideas. Take advantage of this great opportunity! other body systems, detailed assess- European countries since the 1980s, pletely diff erent environment from ment and quantifi cation of the sub- with 52% of the region’s adult popula- the one we live in now so we don’t cutaneous and visceral fat using MR tion now termed clinically overweight have any mechanisms to defend characteristics could diff erentiate and 17% obese, meaning those with a against pu ing on weight,” she noted. patient prognosis, said Vilgrain, hint- BMI above 30. “Multiple brain systems make eating ing at future research. The direct costs to healthcare ser- rewarding.” MRI also played an important role vices of obesity such as related dia- This was one reason why surgery in monitoring patients a er restric- betes and the indirect costs to the was a more eff ective means to help tive gastric bariatric therapy. Changes social welfare system stemming from patients lose weight to regain health in fat fraction MR correlate strongly obesity related illness preventing than diet and exercise alone, she said. myESR.org Cardiovascular and Interventional Radiological Society of Europe

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BY PHILIP WARD Parizel takes ECR delegates on a cerebral journey of discovery and hope

universe may share common fea- Emerging functional MRI, diff usion tensor imaging, tures with the growth of the internet and social networks like Facebook. and diff usion kurtosis imaging can provide a be er Parizel pointed out that the brain can modify its structure and function understanding of the micro-structure and function in response to external and internal of the brain, and help to elucidate some of the mecha- stimuli such as learning, meditation, injury, and hormonal changes. nisms involved in neuroplasticity, explained Prof. Furthermore, the process of neuro- plasticity (i.e., the ability of the brain Paul Parizel, head of the department of radiology at to change, to adapt and to reorganise neural pathways, as it needs) off ers Antwerp University Hospital, Belgium, in Saturday’s hope to patients for recovery from injury and response to disease; imag- Wilhelm Conrad Röntgen Honorary Lecture. ing techniques can help to visualise neuroplasticity in terms of white Prof. Paul Parizel from Antwerp, Parizel began his presentation Phrenology, which used bumps “The ‘scientific’ foundation of ma er rewiring and structural mod- the Netherlands. with a historical journey showing to localise function in the brain, phrenology was epitomised by the ifi cations. For instance, changes in the brain’s ability to fascinate people was developed by German physi- American Phrenological Journal. No hormonal concentrations in women through the ages. According to Hip- cian Franz Joseph Gall in 1796. It doubt it had a wonderful editor-in- during the menstrual cycle, and with pocrates (460–370 BC), “I hold that the was based on the concept that the chief and an extremely high impact use of contraceptives, infl uence neu- brain is the most powerful organ of brain is the organ of the mind, which factor!” Parizel remarked. roplasticity changes in white ma er correlation in the anterior cingulate the human body … wherefore I assert is composed of multiple distinct, Non-scientists, too, have become fi bre density and grey ma er volume. gyrus during the luteal phase, he that the brain is the interpreter of innate faculties. Each faculty must intrigued by the brain. As the Ger- Sex hormones have an eff ect elaborated. consciousness.” have a separate seat or ‘organ’ in the man fashion designer Karl Lagerfeld on brain structures and infl uence Parizel acknowledged the input During the Renaissance, dissection brain; the size of an organ is a meas- once said, “The brain is a muscle, and short-term plasticity. Coronal, axial and support of his colleagues: C. of the human brain was performed ure of its power, and the develop- I’m a kind of body-builder.” and sagi al slices can show the rela- Venstermans, F. De Belder, R. Salgado, by Andreas Vesalius (1514–1564), a ment of various organs determines Some neuroscientists have even tionship between grey ma er vol- L. van den Hauwe, J. Van Goethem, Flemish-born anatomist whose work the shape of the brain, and hence postulated that there are parallels ume and estradiol concentrations in T. Van der Zijden, M. Voormolen, W. helped to correct misconceptions dat- the shape of the skull, according to between the brain and the universe, the peripheral blood of women with Van Hecke, T. De Bondt, A. Leemans, ing from ancient times. Gall. Parizel said. The development of the a natural cycle. There is a negative F. Deferme, and M. Geldof.

BY MÉLISANDE ROUGER Diagnosing chronic back pain requires more than just looking at an image

Chronic low back pain is the most common cause of disability between the ages of 45 and 65, which means that it is something that radiologists will have to deal with during their careers. When they do, they should be able to read fi lms properly.

But reading fi lms alone will not In his talk, Wilson focused on sac- be using, and they may become be enough to make the correct diag- roiliac joint syndrome, a condition convinced that these are excellent nosis, and an image without clinical with a considerable amount of pain techniques. But, sadly, evidence in examination is nothing, according to and poor clinical signs. He stressed literature shows the exact opposite,” Prof. Afshin Gangi, chairman of radi- the role of interventional procedures he pointed out. ology and nuclear medicine at the in the diagnosis and treatment of These tests have very poor predic- Dr. David Wilson from Oxford, Prof. Afshin Gangi from University Hospital of Strasbourg, this condition. tive value, and there is no single test United Kingdom. Strasbourg, France. France, who chaired the dedicated Radiologists fi rst need to remember that is consistently valid, according Refresher Course on Saturday. that the anatomy of the region is com- to Wilson. A clinical examination “Please don’t report anything with- plicated. “The joint has an almost S alone is clearly not enough then. pain do not require an imaging exam- poor results to date with 40% accu- out having seen the patient fi rst. shape, it is curving like a snake in two Imaging can help in the assess- ination. In these cases, radiologists racy of placement. When the clinical examination is not directions,” he said. Part of the joint is ment of the syndrome. With a sen- can do tests to assess the origin of Up until two years ago, Wilson used consistent with what you see, you fi brocartilage and hyaline cartilage, a sitivity of 85%, MRI seems to be the the pain and then try to block it. fl uoroscopy. Unfortunately, things should report it exactly like this, it’s solid structure that does allow some most appropriate tool. Conventional For this, they need to place a needle did not always go well. “Extravasa- extremely important. Imaging alone, fl exibility. Ligamental structures in radiographs have poor sensitivity directly into the joint to inject a ster- tions are very common; they repre- without clinical examination, is not this area are complex, deep and thick. and should not be used except for oid/anaesthetic mixture. sent about 60% of the a empts we telling you anything, the pain could “Those of you doing interventional trauma. CT is particularly good at “This is tricky because of the anat- have made.” be anywhere. Examine your patient, procedures in these areas will be pass- detecting erosions and infl amma- omy of the joint. We all have prob- The problem with CT is the radi- read the fi lm at the same time, then ing your needles through very thick tion, but, unlike MRI, it does not lems with it,” Wilson said. The needle ation involved, as there needs to be suggest what to do. The pain could fi brous material before you get down show bone oedema, one of the ear- has to take diff erent angles according both front and rear examinations. have multiple causes,” he said. to the joint,” he said. liest signs of the disease. SPECT to which point one a acks. Image Fusion CT or MR with ultrasound Dr. David Wilson, a consultant The clinical signs of sacroiliac has a modest sensitivity of 46% to guidance is crucial in that area, and may be the answer. “Sacroiliac joint radiologist at BMI Healthcare Oxford joint syndrome include localised 72%, and there is only limited data blind injection is, with a 15% accu- imaging is now almost like cheat- Clinic, UK, agreed. “The moment you tenderness, compression across the on PET. racy of placement, “even worse than ing. I can put the needle in the joint start to use the imaging criteria as pelvis, and distraction. “All of these Some patients have mechanical tossing a coin.” without feeling the edges. I’ve never your end point, you’ll start making are techniques that physiotherapists, problems, which will not show on There is some debate around the done that before, it’s great, it doesn’t mistakes,” he said to a packed audience. rheumatologists and surgeons may imaging. Patients with severe chronic use of ultrasound, but it has yielded irradiate the patient or me.” myESR.org 6 HIGHLIGHTS ECR TODAY | SUNDAY, MARCH 9, 2014

BY FRANCES RYLANDS-MONK Serbia ‘comes home’ to European fold as its contribution gets official recognition

Serbian radiologists have warmly welcomed the chance for greater visibility at the ECR and in European radiology at large – visibility which until recently has been lacking, despite the country’s scientifi c contribution to the discipline.

Saturday’s ESR meets Serbia ses- “We don’t have to welcome Serbia. (RTF). “We Serbian radiologists feel sion began with a bi ersweet expe- Serbia is already home,” he told dele- very welcome at the ECR and happy rience outside the auditorium as gates, pointing to Serbia’s long-stand- to show what we do, what we can do delegates were off ered a choice of ing membership in the ESR and its and what we will do in collaboration spicy dark chocolate or caramel milk swi adoption of the society’s char- with our European colleagues.” Participants at the ESR meets Serbia session gave an impressive chocolate wrapped in the red, white ter on harmonisation. The invitation to the ESR meets overview of the practice of radiology in their country. and blue colours of the Serbian fl ag. In addition, Frija wished to under- session was a signifi cant step for- A heady mix of ‘East meets West’ was line that there was no such thing ward, and hopes remain high that prevalent in the cultural interludes as small or large countries when it the country will eventually become a to be an annual event conducted in imaging techniques in practice – as as well as the scientifi c lectures, some came to input because input was not full member of the European Union, a common language, will be included we are already capable of doing.” of which highlighted how latest related to country size. he told ECR Today. in the European School of Radiology. From the fi rst radiological meeting know-how can sometimes be chal- Echoing to some extent these com- “It means a lot to our country’s 550 This year the MRI School will be held in the former Yugoslavia held in 1930, lenged by modern Serbia’s specifi c ments, Prof. Milos Lučić, the pres- radiologists who bring modern imag- in Lučić’s own centre. the region’s radiological community socio-economic context and recent ident of the national radiological ing to the country’s population and Serbian prowess was prevalent in has much evolved, yielding along the geo-political upheaval. society, expressed his happiness and without whom clinical work would the society’s logo, which this year way famous Serbian experts such as Yesterday’s meeting was a lively gratitude for the chance to showcase not be possible,” Lučić said. includes Serbian-born Nikola Tesla Prof. Stojan Dedic (1889–1959), the fi rst and intriguing session that not Serbian talent. Demonstrating that the confl ict in and the slogan ‘The Power of MRI’. Roentgenology professor at Belgrade only brought Serbian radiology into “It is a real honour and pleasure the former Yugoslavia is long since “We are confi dent that Serbia is University. Today’s Serbian Society of sharper focus but also emphasised to receive the invitation from ESR. behind them, cooperation between in no way less competent than the Radiology was created in 1994, with its long-established status as a ful- For Serbian radiology it is an extraor- the radiological communities across other European countries in diagnos- the addition of subspecialty societies ly-fl edged member of Europe’s radi- dinary opportunity to present our Serbia, Croatia, Slovenia, Bosnia-Her- tic imaging expertise. The problem of of neuroradiology in 1996, digestive ological community. accomplishments and our potential,” zegovina, Macedonia, and Montene- course is the economic crisis and not radiology in 2007 and interventional ESR President Prof. Guy Frija said Lučić, chair of the diagnostic gro is thriving, he added. Last year having funds to acquire equipment,” radiology in 2012. opened the session by underlining imaging centre at the Institute of the fi rst regional MRI School took he said. “With improvement in eco- The 39th meeting of the European that Serbia had long ago created a Oncology of Vojvodina, Sremska place in Bosnia-Herzegovina for nomic conditions generally and in Society of Neuroradiology (ESNR) pivotal place for itself in European Kamenica, and former chairman of young trainees across the region. our country, we will gain the means will take place in Belgrade from 15 radiology. the ESR’s Radiology Trainees Forum Lučić hopes this project, scheduled to perform all of the novel diagnostic to 18 September 2016.

European Radiology editor announces editorial fellowship EPOS Discussions During today’s European Radiol- We Towish enhance Dr. Zamboni interaction, an exciting discussions on hot topics in ogy editorial board meeting, Prof. and interestingradiology havelearning been experience arranged, where authors of the Maximilian F. Reiser announced the and look forward to welcoming future ESR’s new Albert L. Baert Editorial candidates.selected and best-scored posters in each fi eld will discuss Fellowship. This was the fi rst edito- them with a moderator. All discussions take place in the st rial board meeting for Prof. Reiser EPOS™ Area on the 1 level and ECR delegates are welcome since he became editor-in-chief of to join, listen, and discuss with the experts. European Radiology at the beginning of this year, taking over from Prof. Adrian K. Dixon. Sunday, March 9, 14:30–15:00 The editorial fellowship was Highlights of breast imaging founded by Prof. Albert L. Baert Moderator: Michael H. Fuchsjäger; Graz/AT and the European Radiology Private Foundation. Prof. Baert was editor- in-chief of European Radiology for 12 years, from 1996 to the end of 2007, and is now editor emeritus of the journal. The editorial fellowship programme Dr. Giulia Zamboni from Verona, Italy, pictured here with aims to provide training in editorial Prof. Maximilian Reiser (le ) and Prof. Albert L. Baert (right), skills, such as manuscript evaluation, received the ESR’s new Editorial Fellowship. manuscript editing, organisation of peer review, manuscript production and publishing, including electronic Verona, Italy. Dr. Zamboni, a special- three weeks at the editorial offi ces in publication. This year’s successful ist in the fi eld of gastro-intestinal Vienna and Munich. candidate is Dr. Giulia Zamboni, from and abdominal radiology, will spend

myESR.org ECR TODAY | SUNDAY, MARCH 9, 2014 HIGHLIGHTS 7

BY MÉLISANDE ROUGER U.K. Royal College shares experiences during EuroSafe Imaging launch

Radiation protection experts shared their know- ledge during the launch of the EuroSafe Imaging campaign, the ESR’s new initiative to promote radi- ation protection in Europe, at a session on Friday.

The fi rst three lectures of the there are a lot of lessons we hope we then every fourth year therea er. session, which was moderated by could learn.” While the fi rst edition had 73 guide- Prof. Peter Vock from Berne, Swit- Besides a legal framework for lines, the seventh and current edition zerland, and Dr. Cathy Owens from radiation protection, there needs to contains as many as 307. London, UK, focused on the main be reversed evidence-based guide- The RCR has engaged with 300 objectives of the campaign, as well lines so that clinicians know when radiologists (10% of the RCR’s mem- Dr. Peter Cavanagh from Prof. Peter Vock from Berne, as the Image Gently and Image they should be referring patients bers), and a patient liaison group was Taunton, United Kingdom. Switzerland. Wisely campaigns. and what the benefi ts of referring also involved in the current edition. A In the fourth presentation, Dr. patients are, he argued. lot of work has been poured into this Peter Cavanagh, vice-president, Team work at the national and project, and Cavanagh counted 3,000 clinical radiology, of the Royal Col- local levels is essential to this task, facilitated hours, 1,000 project lead been in place since the 1980s and working in our radiology department lege of Radiologists, talked about the and the UK has a good track record hours, 10,000 expert hours, as well 90s, Cavanagh said. “They originally and they are involved at every level lessons to be learned from the UK of team work between radiographers as 100,000 references in raw search. worked for standard radiology, but from clinical practice to equipment approach to patient safety in radia- and radiologists, he said. “However, producing the guidelines now there are CT surveys and this purchase, research, etc.,” he said, tion protection. Three areas are central to the is not the aim of the process, it’s how gives us the national benchmark of adding that national organisations “The UK has a long tradition in development of guidelines: dose we use them eff ectively,” he said. how doses can be used.” and the UK government also o en radiation protection,” Prof. Peter management, to know which dose The sixth edition of the RCR guide- Reference doses for conventional collaborate to produce guidelines on Vock reminded a packed audience is being given to patients; justifi ca- lines was accessed by 1.3 million x-ray examinations in the UK were how radiation should be used. as an introduction. tion, so that there is a system in place users. But the problem is that the fi rst proposed in 1989. The number of To conclude, Cavanagh acknowl- “This talk is about riding on the to justify dose use when there is an guidelines are not always available x-ray examinations there has more edged the importance of EuroSafe back of giants. In terms of under- investigation; and optimisation, to at the moment when they are really than doubled in the past 50 years, Imaging and other campaigns, which standing, there’s a lot of people get the best image possible. needed by the clinician, he pointed and CT has replaced radiography as in his opinion need strong leader- behind who know a lot more than “In terms of justification, we out. the most common examination tool. ship champions, public pressure, I do,” Cavanagh began, referring to believe that Europe has to have The UK also has a long history of The multidisciplinary team clear interventions, measurement, Paul Shrimpton, Barry Wall and Dave guidelines,” he said. patient dose monitoring. There is a approach is very important to con- local ownership and teamwork to be Hart, all pioneers in radiation pro- The RCR fi rst published guidelines systematic approach to measuring trolling and optimising radiation successful. tection. “History is not perfect, but on radiation protection in 1989, and radiation dose, and surveys have dose. “In the UK, we have physicists

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myESR.org Hot Shots from Day 3 9 SUNDAY, MARCH 9, 2014 CLINICAL CORNER

Childhood abdominal Radiologists explore French radiologist emergencies: what to do, body composition describes benefi ts of 10 and what not to do 13 imaging techniques 15 new cancer therapies

BY MÉLISANDE ROUGER Experts share strategies to help radiologists justify their imaging decisions

Evidence-based radiology, comparative eff ective- ness research and health technology assessment all play a role in the radiologist’s decision-making nowadays. Radiologists must ensure that they are imaging patients at the right time using the right test, and they need to justify radiological examina- tions and imaging-based interventional procedu- res on the basis of the best available evidence. The dedicated Special Focus session today at ECR 2014 will teach a endees how to use evidence to justify imaging decisions in day-to-day clinical practice.

Evidence-based radiology is a rel- involved with the use of radiation. Using these resources can only be atively new approach designed to People have become aware of the benefi cial for radiologists, Hunink inform clinicians of the most appro- fact that CT uses radiation and that believes. “If they are called to justify priate technique to use in a given if something goes wrong they could their decisions, radiologists can use clinical scenario. It has always been receive too much radiation. So radi- the analyses as a justifi cation. If they an important topic, but people have ologists really need to understand don’t know what decisions to make, recently become more aware of this that the examination needs to be they can use these analyses to make theme and expect more justifi cation justifi ed; it can’t just be done for the correct decision for an individual from the physicians, according to nothing,” Hunink said. patient; the tools facilitate precision Professor Myriam Hunink, who will Other potential risks, such as aller- medicine and personalised medicine. chair the session. She is a professor gies to contrast media, which is used And if they think the analyses are of radiology and clinical epidemi- in both diagnostic and therapeutic not applicable to their patient for ology at the Erasmus University radiology, must also be addressed. whatever reason, they can use their Medical Centre in Ro erdam, the Radiologists also need to justify judgment and reasoning to justify Netherlands, and adjunct professor the budget of an examination. The how the results of the analyses Example of a web calculator that helps determine an individual’s of health decision sciences at Har- development of new medical imag- should be modifi ed. Physicians are pre-test and post-test probability of coronary artery disease (CAD) vard University, Boston, USA. ing technologies, together with rec- free to decide what they think is as information becomes available, which is calculated depending “It’s becoming increasingly en ognition from clinicians of the value best for their patient, this is the art on age, sex, type of chest pain (basic model); also including diabetes, vogue, and more-and-more a en- of these for their patients, has led of medicine; decision analyses and hypertension, dyslipidaemia, smoking (clinical model); and including tion is being given to it, partly to signifi cantly higher costs. “People cost-eff ectiveness analyses can help also the CT coronary artery calcifi cation score (clinical model + coronary because people are insisting that realise that we are paying a lot of support their decisions,” she said. calcium score). The calculator is available at h p://rcc.simpal.com/ there should be evidence before we money for our imaging, and it’s very The session should a ract many NpfpV5. Based on data from the DICAD consortium [Genders, BMJ 2012]. (Image provided by Professor Myriam Hunink) do something. There’s a couple of clear that we can’t keep paying more delegates as the topic concerns reasons for that, the main reason and more, because the amount we every radiologist. “In the whole being that people realise that there are paying for healthcare is increas- fi eld of radiology there is always are risks associated with what we do ing every year. So we need to justify some form of risk. Maybe not of in radiology. So we constantly need these costs,” she said. the test itself, but sometimes the to make a smart decision by weigh- Comparative effectiveness risk of having a false-negative or ing those risks against the benefi ts,” research is used by healthcare sys- a false-positive result. If you send she said. tems to develop a strategic approach somebody for an ultrasound exam- Special Focus Session Radiologists need to justify the to rationalising the use of imaging ination for instance, there is no risk risks, especially those related to investigations. The health technol- from the test itself, but if you have Sunday, March 9, 16:00–17:30, Room F1 #ECR2014F1 #SF15B ionising radiation exposure, before ogy assessment approach serves to a false-positive fi nding, the patient SF 15b: Evidence-based radiology, comparative eff ectiveness deciding their imaging strategy. Not assess new and emerging imaging will go on and have other tests (a CT research, and health technology assessment only patients, but also physicians, technologies in a systematic and or a biopsy, for example) which may policy makers, ministries of health, timely manner. Diff erent tools and be risky, and if it’s a false-negative » Chairman’s introduction health insurance companies and concepts are advocated through result, then the diagnosis will be M.G.M. Hunink; Ro erdam/NL the organisations advising them these fi elds, from observational missed and the patient will not get » Evidence-based imaging are more aware of radiation-related studies to randomised clinical tri- the necessary tests and treatment. F. Sardanelli; Milan/IT risks, and they are paying more als, critical appraisal, decision-mod- So even if the test itself is not risky, » State-of-the-art methods in EBR, CER, and a ention to minimising these risks elling, and cost-eff ectiveness anal- false fi ndings can impose a risk,” HTA relevant to imaging than ever before. ysis. The session will review these Hunink said. U. Siebert; Hall i. Tirol/AT “There have been a couple of methods and show how they can reports in the media about the risks make a diff erence in clinical practice. » Translating EBR, CER, and HTA results into imaging decisions in daily practice F.J. Gilbert; Cambridge/UK » Panel discussion: Can EBR, CER, and HTA results provide justifi cation for imaging decisions and how do we implement the results? myESR.org 10 CLINICAL CORNER ECR TODAY | SUNDAY, MARCH 9, 2014

BY FRANCES RYLANDS-MONK Childhood abdominal emergencies: what to do, and what not to do

Whether working in a specialised trauma centre or in a small or medium-sized general hospital, every on-call radiologist will encounter trauma cases, whether due to car and domestic accidents, or falls from heights. Following paediatric abdominal trauma, the tendency is to perform some form of imaging, although most children will be treated conservatively.

Today’s Special Focus session on adding that for children, non-contrast Robben points to the virtually pathog- childhood abdominal emergencies scans should be avoided in accord- nomonic ultrasound appearance of an aims to outline what radiologists ance with the As Low As Reasonably intussusception that consists of multi- should know about emergency Achievable (ALARA) guidelines and CT ple alternating hypo- and hyperechoic abdominal imaging in paediatrics, must be performed with as few passes concentric rings. Daily practice shows regardless of their subspecialty, and as possible. how central ultrasound is to abdomi- aims to familiarise them with what “Modern scanners with fast acqui- nal non-traumatic emergency, accord- to expect from each modality. sitions can provide images that can ing to Robben, who approved only For trauma, CT can rapidly demon- distinguish normally enhancing two abdominal CT scans as the initial In children, high-frequency transducers allow for detailed images strate abdominal injuries, together organs, moderately high density hae- examination in children during 2013. that raise anatomical interpretation and insight in the underlying with thoracic, musculoskeletal, chest matomas and low density fl uid areas “An ‘emergency’ from the perspec- pathophysiology to a higher level, as in the case of this 9-year-old girl and brain injuries, and is the modal- without the need for a non-contrast tive of the parents can be quite dif- with a sealed perforated appendicitis. (Provided by Dr. Simon Robben) ity of choice in multitraumatised scan. Around 50% of the dose can be ferent than from the perspective of children, especially when intubated saved by using a single-phase CT scan, the clinician,” he said. “For instance, or suff ering from a spinal cord injury. instead of a double-phase non-con- abdominal pain without any labora- Abdominal tenderness and increasing trast/portal phase contrast CT scan,” tory abnormalities, without fever and discomfort, seat belt sign or bruising, Raissaki said. without signs of peritonitis may be and gross haematuria may predict a Additionally, she is keen to point to less alarming for the clinician than for threatening abdominal injury and the usefulness of ultrasound as the the patient’s family. Therefore ultra- constitute indications for CT. fi rst and potentially only tool in the sound can be used to rule out serious “In the ideal world, there should be stable child. diseases, justifying a wait-and-see the organisation to perform an ultra- “When the need for surgery is policy. A er all, time can be a very sound in the ambulance by trained potentially low, and you are experi- eff ective diagnostic tool.” personnel, and reserve the CT scan for enced with good equipment, start Radiologists’ training should include every haemodynamically stable child and fi nish with ultrasound. In many learning which normal variants sim- with a high-impact injury and positive centres when the child is stable, they ulate disease, Robben stressed. For risk factors for abdominal injuries, or do an ultrasound fi rst and proceed to instance, a Riedel’s lobe of the liver when extended focused assessment CT only if they can’t fi nd answers on may simulate hepatomegaly. Like- with sonography for trauma (eFAST) the former modality,” she said. “Ultra- wise, a duplicated collecting system is positive for unexplained fl uid or sound also has a major role in the fol- of the kidneys may simulate either reveals injuries that need to be graded,” low-up of known injuries, unless there ipsilateral hemihypertrophy or con- said session speaker Dr. Maria Rais- is rapid deterioration.” tralateral atrophy, and a benign small saki, consultant paediatric radiologist Because the chance of fi nding a sig- bowel intussusception may simulate a at University Hospital of Iraklion, nifi cant injury in a low-impact trauma pathological ileocolic intussusception. Greece. is small and because grade 1 injuries In addition, some diseases may simu- CT is most useful in the detection that may be missed by ultrasound late other diseases; a focal nephritis, and grading of the four killers: splenic, are treated conservatively, aggressive for example, may simulate a Wilms vascular, bowel and pancreatic injury, imaging should be avoided when risk tumour. Vascular injury in a fi ve-year-old girl. A: Arterial phase. Arterial blush she noted. In vascular injuries, the factors for intra-abdominal injuries There are two important rules (arrow) is seen as a stellate-shaped extravasation of contrast inside a arterial blush sign that suggests active are absent. for experienced operators to fol- large retroperitoneal haematoma (*). B: Portal phase. The extravasation extravasation of blood inside the trau- “Why irradiate a child through x-ray low, according to Robben. Firstly, an (arrows) is larger. C: Sagi al maximum intensity projection (MIP) matised organ or body part, indicates or CT instead of using ultrasound? uncommon presentation of a common reconstruction shows the site of vascular injury and the extent of the possibility of rapid deterioration You don’t need a Ferrari on an urban disease is more common than a com- haematoma (*). (Provided by Dr. Maria Raissaki) and oligaemic shock. Every radiolo- street,” Raissaki commented. mon presentation of an uncommon gist should look for the arterial blush disease. For instance, atypical infl am- sign, even if there is no hypotension or BLINDED BY ‘BLING BLING’ matory changes in the right lower other clinical evidence of active bleed- FEATURES OF CT? quadrant in a child with (sub)acute ing, according to Raissaki. Focusing on the use of ultrasound complaints is more likely to be caused Besides learning how CT may as the initial and o en fi nal examina- by ‘common’ appendicitis than by infi l- prove useful in solid organ injuries, tion that obviates the need for CT and trating growth of a Burki lymphoma. life-threatening bowel injuries and MRI, Dr. Simon Robben, a paediatric Secondly, if the initial ultrasound shock bowel, delegates at today’s radiologist at Maastricht University fi ndings do not correlate with the session will also hear how traumatic Medical Centre in The Netherlands, clinical presentation, then radiologists Special Focus Session lesions following child abuse trauma, aims to reinforce appreciation of the should proceed with the examination Sunday, March 9, 16:00–17:30, Room F2 #ECR2014F2 #SF15C should be recorded by CT scanning. detailed anatomy of children that can until they either do fi nd a solid expla- SF 15c: Childhood abdominal emergency 2014: “CT provides objective documenta- be visualised with ultrasound and nation or until they are sure that they tion that can be used in court. Ultra- demonstrate its capacity to depict have ruled out every pathology that the dos and don’ts sound is not invariably recorded and motion such as bowel peristalsis, blood might cause the complaints. when it is, it can’t always be read or fl ow, and the eff ect of compression. “Try to avoid unintentional blind- » Chairman’s introduction objectively evaluated by experts in “I am hoping my lecture will renew ness and instant gratifi cation. A er E. Alexopoulou; Athens/GR court, because of its user dependency. enthusiasm for ultrasound among all, radiologists are physicians and » The acute abdomen: US is the answer This is not the case with a good quality general radiologists in whom this sometimes more experienced than S.G.F. Robben; Maastricht/NL CT – third party experts can read it and enthusiasm has slowly faded, along the on-call junior paediatrician. In a » The acute abdomen: CT is the answer provide an opinion,” she stated. with the basics of ultrasound, as neonate with high clinical suspicion A. Paterson; Belfast/UK Because of the stochastic eff ects they’ve been blinded by the ‘bling- of renal vein thrombosis, it is not suf- » Abdominal trauma: US is be er of any exposure to ionising radiation, bling’ features of CT,” he said. fi cient to merely demonstrate colour V. Miele; Rome/IT regardless of dose size, and the lack of Ultrasound’s sensitivity and speci- Doppler fl ow within the kidney, but to ability to predict which children will fi city is over 90% in diseases such as visualise the vein itself and rule out » Abdominal trauma: CT is be er be aff ected, radiologists must always suspected intussusception, midgut the presence of a thrombus there,” M. Raissaki; Iraklion/GR justify CT. Choose a test that will help volvulus, urinary tract abnormalities Robben said. » Panel discussion: the child not the doctor, said Raissaki, and appendicitis. As a case in point, US or CT in paediatric abdominal emergencies?

myESR.org ECR TODAY | SUNDAY, MARCH 9, 2014 CLINICAL CORNER 11

BY BECKY MCCALL CT-guided biopsies and contrast-enhanced CT monitor treatment response in lung cancer

Monitoring response to targeted therapies using (All figures reproduced from: Tacelli N, Santangelo T, Scherpereel A et al (2013) Perfusion CT allows prediction of therapy response in non-small cell lung cancer treated with conventional and anti-angiogenic chemotherapy. Eur Radiol 23: 2127-2136) dynamic contrast-enhanced CT (DCE-CT), as well as a discussion of CT-guided biopsies in lung cancer as a tool for histological subtyping and genetic analyses, will come under the spotlight today in a session led by some of Europe’s leading thoracic radiologists.

DCE-CT imaging represents a non- imaging modality for lung carcinoma, gists and radiologists,” stated Laurent, invasive tool for the monitoring of new so more interest has been directed adding that recent profound advances targeted therapies, enabling timely toward this technology as the most in the treatment of NSCLC had encour- assessment of therapeutic response appropriate imaging method for assess- aged clinical physicians to address the before monitoring of changes accord- ing tumour angiogenesis, she added. importance of accurate histological ing to RECIST criteria as used in rou- DCE-ultrasonography is also a prom- subtyping and molecular genotyping. tine clinical practice. ising technology that allows non-inva- Guidelines from the American Tho- During today’s session, Dr. Nunzia sive imaging of tumour angiogenesis, racic Society, European Respiratory Tacelli, consultant radiologist at the but its use is limited because of the Society and the International Asso- Department of Thoracic Imaging, sound refl ection at the aerated lung, as ciation for the Study of Lung Cancer A 62-year-old male patient with a le lower lobe adenocarcinoma (Group Hospital Calme e, University Centre well as issues associated with capillary have proposed recommendations for 1 patient). Transverse CT images (3-mm-thick sections) at baseline of Lille, France, will explain that recent permeability. It does not allow for cal- appropriate handling of small speci- (TIME0) viewed at (A) lung and (B) mediastinal window se ings. advances in the molecular biology of culation of the capillary permeability mens regarding immunohistological Functional CT maps of (C) TVV (4.4 ml) and (D) TEF (4.3 ml/min). lung cancer have shed light on diff erent because the micro-bubbles, the most and molecular studies. Because many mechanisms driving carcinogenesis, commonly used contrast agent, stay lung cancer patients present with and these represent a ractive targets within the vascular compartment, and locally advanced unresectable stages, for new therapeutic agents. She plans cannot leak out into the extra-vascular the only available material for diag- to discuss why DCE-CT is a feasible space, unlike contrast agents used for nostic and therapeutic information option for non-small cell lung cancer DCE-CT and DCE-MRI, which are very is provided by biopsy specimens, and (NSCLC), in view of the growing inter- small molecules <1K Dalton, according therefore CT-guided lung biopsies can est in drugs targeting tumour angi- to Tacelli. enable suffi cient tissue sampling for ogenesis. Of note, DCE-CT provides Other imaging techniques, includ- histological subtyping and genetic functional information regarding the ing DCE-MRI, single photon emission analyses, he said. formation of new tumour blood ves- computed tomography (SPECT) and The choice of biopsy method is sels, and it can depict early change in positron emission tomography, for determined by location, size of the lung cancer vascularity before tumour assessing tumour microcirculation thoracic lesions and the risk factors shrinkage. are not o en used in routine clinical for complications. CT-guided biopsy “As a consequence of these devel- practice because of cost and/or limited is preferred for peripheral tumours, opments [genetic profi les of tumours], availability. and CT-guided percutaneous biopsies there are certain types of lung cancer At the same session, Prof. François using coaxial automated core biopsy treated with highly specifi c agents, Laurent, from l’Hôpital du Haut needles off er many advantages, he and we radiologists need to adapt the Lévêque, Pessac, France, will address continued. Coaxial automated core tumour response assessment required ‘Lung biopsy: who, how and why’. His biopsy needles provide more accurate with current and future targeted thera- talk will focus on the fact that person- sub-histological typing and molecular pies with the use of new imaging meth- alised medicine refers not only to the genotyping than cytological diagnoses ods such as DCE-CT,” noted Tacelli. choice of treatment but also to the obtained from fi ne needle, and both At her centre, pulmonologists are choice of the appropriate tool for col- methods provide similar rates of com- very active in the evaluation of new lecting tissue samples with respect to plications. Local skills and practices therapeutic options for lung cancer and international recommendations. will also usually have a part to play in A 62-year-old male patient with a le lower lobe adenocarcinoma (Group 1 patient). Transverse CT images (3-mm-thick sections) a er the fi rst there is a common willingness to move CT-guided biopsy is today an estab- the choice of the guiding method and cycle of chemotherapy (TIME1) viewed at (A) lung and (B) mediastinal from standard CT to DCE-CT. The cur- lished method for targeting thoracic the most appropriate biopsy needle for window show lesion stability according to RECIST. Functional CT maps rent limitation for radiologists concerns lesions and appears appropriate for the procedure. of (C) TVV (1.6 ml) and (D) TEF (2.2 ml/min) depict decrease in tumour with the time needed for post-process- histological subtyping and genetic Laurent will also address how the vascularity. ing, and this approach results from analyses. Furthermore, choosing patient can cooperate to aid the proce- collaboration between radiologists and CT-guided biopsy versus other meth- dure in terms of respiratory manoeu- clinicians, she pointed out. ods of tissue sampling should be a vres and breath-hold. Finally, he will RECIST (Response Evaluation Cri- multidisciplinary decision, he noted. discuss the risk of complications, teria In Solid Tumours) criteria repre- In particular, percutaneous lung biop- pointing out that knowledge of the sent the most widely accepted means sies using CT guidance are not only respective risk factors and the poten- to assess tumour response to anti- performed by thoracic radiologists but tial method of prevention or treatment cancer therapies, but several clinical also by general radiologists, and it is by operators are essential. The main observations have shown some limi- important to understand the impor- complications are pneumothorax and tations of the morphological criteria tance of accurate biopsy. haemorrhage (haemoptysis), but both in the assessment of these responses, “The decision to biopsy and the way are rarely life-threatening. He stressed which are more cytostatic rather than to do it is taken in a multidisciplinary that air embolism is very rare, but can cytotoxic. conference with respiratory physi- be lethal. “Globally, mortality is low but DCE-CT also allows the calculation cians, surgeons, oncologists, patholo- not null and this must be kept in mind!” of regional tumour blood fl ow, blood volume, fl ow-extraction product, and permeability-surface area product, over the entire tumoural volume, using Refresher Course mathematical models and dedicated Sunday, March 9, 08:30–10:00, Room D #ECR2014D #RC1204 so ware. As a proponent of DCE-CT RC 1204: Lung cancer: for the evaluation of new therapeutic staging and personalised imaging in 2014 options for lung cancer, Tacelli high- Moderator: E.J.R. van Beek; Edinburgh/UK lighted that one of the major advan- tages of DCE-CT over DCE-MRI is the A. Lung biopsy: who, how and why linear relationship between contrast F. Laurent; Pessac/FR A 62-year-old male patient with a le lower lobe adenocarcinoma (Group agent concentration and x-ray a enu- 1 patient). Transverse CT images (3-mm-thick sections) a er three cycles ation. MR signal is not linearly related B. Pre and post-treatment tumour assessment of treatment (TIME 2) viewed at (A) lung and (B) mediastinal window to changes in contrast agent concen- N. Tacelli; Brussels/BE se ings show lesion partial response according to RECIST. Functional tration, and this is responsible for a C. The role of PET-CT and whole body MRI CT maps of (C) TVV (1.1 ml) and (D) TEF (1.0 ml/ min) depict decrease in variability of results. CT is the primary F. Gleeson; Oxford/UK tumour vascularity. myESR.org 12 CLINICAL CORNER ECR TODAY | SUNDAY, MARCH 9, 2014

BY REBEKAH MOAN Teeth: The ever-present feature radiologists need to know more about

might be an interesting option to Most radiologists don’t deal much with dental visualise teeth vascularisation a er trauma, or to monitor infl ammatory imaging – but that doesn’t mean they shouldn’t be changes under therapy, such as in aware of what to look out for or know about the patients with periodontal disease. When asked what delegates will diff erence between dental MRI and cone-beam CT learn from his presentation, Rohde said, “Delegates should become (CBCT), expert speakers believe. aware of the fact that MRI in odon- tology is technically feasible and might be an alternative imaging In a session today, ECR delegates Frühwald-Pallamar, an assistant be encountered, and familiarity with technique in patients with infl am- will have a chance to learn all about professor in the radiology depart- typical dental conditions is neces- matory or neoplastic lesions, peria- dental imaging. When imaging the ment at the Medical University of sary to decide on the right therapy pical lesions, or a er teeth trauma.” head and neck region with CT or Vienna. On scans performed for for patients. MRI, teeth are always present, other indications, radiolucent or WHAT TO KNOW ABOUT CBCT according to chairperson Dr. Julia radiopaque lesions of the jaw can THE INS AND OUTS The CBCT technique is well- OF DENTAL MRI known among dentists and oral radi- “Obviously, dental MRI is not yet ologists, but it’s not so well known applied in daily routine imaging of among general radiologists. It’s very teeth or the periodontal apparatus,” important general radiologists are said Prof. Stefan Rohde, from the familiar with this technique and Klinik für Radiologie und Neurora- that they know the indications for diologie at Klinikum Dortmund, Ger- its use, according to Dr. Anni Suoma- High resolution (3-tesla) MRI of many. “However, infl ammatory peri- lainen, from the radiology depart- a patient with an infl ammatory endo-periodontal lesion at tooth odontal disease is the major cause of ment at Helsinki University Central 017 (arrow). Sagi al T2-weighted tooth loss in adults, the second most Hospital in Finland. space (A), T1-weighted plus frequent pathology of the oral cavity, CBCT is a radiographic imaging gadolinium (B). and an important cause of disability.” method that allows accurate 3D (Provided by Dr. Stefan Rohde) Imaging in these patients is usu- imaging of hard tissues. During a ally performed with 2D panoramic CBCT scan, the scanner rotates radiography, CT, or CBCT. However, around the patient’s head (180°–360°), MRI may represent a complemen- obtaining multiple sequential planar tary imaging technique to visualise projection images by a 2D detector. particular pathological processes, The scanning software collects especially infl ammatory disease of the data which are then processed the periodontal space, or teeth vas- to create a volumetric dataset cularisation a er trauma, he said. with isotopic voxels with varying His presentation will focus on the fi eld-of-view. potential of high-resolution MRI in The pitfalls with CBCT are arte- this new fi eld and compare it with facts, which are either physics-based, CT and CBCT. patient-related, or cone-beam related. Dentists may make special use of For example, metal objects in the MRI in diffi cult situations, for exam- scan fi eld can cause severe streak- ple when conventional imaging fails ing artefacts and patient motion dur- to detect infl ammatory or neoplastic ing the exposure can lead to lack of processes at an early stage, because sharpness in reconstructed images. visualisation is only possible when “Low-dose CBCT examinations resorption of the alveolar bone has with high quality will be further already started. In addition, MRI developed, as well as artefact-re- offers an alternative technique duction algorithms,” Suomalainen especially in younger patients and said. “In addition, the use of CBCT in children to avoid radiation expo- devices in other fi elds of medicine sure, he added. will be increased, and with increas- “MRI of the dental apparatus is ing research results, its use will be technically challenging as the bony more evidence-based.” T2-weighted (A) and contrast- enhanced T1-weighted images structures of the mandible and teeth A er the presentation, ECR dele- (B) of a patient with a periapical give only li le or no MR signal,” Rohde gates will be familiar with the CBCT granuloma at tooth 015 (arrow) said. “Another concern is the problem technique and will know about the and odontogenic sinusitis in the of air content and metal artefacts in indications for its use, Suomalainen maxillary sinus (open arrow). the oral cavity that limit the use added. (Provided by Dr. Stefan Rohde) of MRI in this special se ing. As a principal fi nding of our experiments, MRI proved to be superior to MDCT (multidetector CT) and to CBCT in Special Focus Session visualising periodontal structures like the periodontal space and the Sunday, March 9, 14:00–15:30, Room P #ECR2014P #SF14C adjacent lamina dura. Surprisingly, SF 14c: Dental imaging even cortical and trabecular bone were displayed be er with MRI than » Chairman’s introduction with MDCT and CBCT. Therefore, I J. Frühwald-Pallamar; Vienna/AT believe that MRI could become an » Review of dentomaxillofacial anatomy with important complementary imaging panoramic views and cone-beam CT source of the jaw and teeth appara- A. Suomalainen; Helsinki/FI tus in pathologies of tissue investing » Pre-surgical and post-surgical imaging with and supporting the teeth.” MDCT and cone-beam CT MRI could be useful to be er A. Gahleitner; Vienna/AT characterise so -tissue processes, or An example of cone-beam CT. In this instance, the lower le third detecting infl ammatory or neoplas- » Dental MRI molar (d. 38) was imaged a er panoramic radiograph with CBCT. tic pathologies at an early stage, he S. Rohde; Dortmund/DE The arrows mark the mandibular canal. (Provided by Dr. Anni Suomalainen) noted. Moreover, dynamic high-res- » Panel discussion: olution MRI with a contrast agent What is the impact of radiologists in dental imaging?

myESR.org ECR TODAY | SUNDAY, MARCH 9, 2014 CLINICAL CORNER 13

BY MÉLISANDE ROUGER Radiologists explore body composition imaging techniques

The study of body composition (BC) has become important in understanding and decoding not only diseases such as obesity and diabetes, but also processes like growth and aging, all of which impact health greatly. The dedicated Special Focus session today at the ECR will show delegates the importance of body composition for clinical practice, research and epidemiology, and teach them the advantages Fat fraction map in the proximal Professor Giuseppe Guglielmi and limitations of imaging techniques in this still femur of a young healthy male from Foggia, Italy, will chair subject. Colobar represents today’s session on body widely unexplored fi eld. fat fraction values in %. The composition. fat fraction map enables the determination of the fat content BC analysis allows relative however it has rarely been used clin- costs,1 fi gures that have most likely in the red and yellow bone amounts of muscle, fat, bone and ically, and has mostly been adopted grown since then. marrow regions. other vital parts composing the in research se ings including met- Physical activity and diet are (Images provided by human body to be quantified abolic disease, dialysis, athletics, important for addressing this new Dr. Dimitrios Karampinos) and characterised. In the last few nutrition, a variety of paediatric kind of epidemic and many tech- years, interest in understanding a conditions, and epidemiologic stud- niques and methods exist to cal- multitude of patho-physiological ies,” said Guglielmi, who will chair culate how fat is distributed in the processes has grown rapidly – e.g. the session at the ECR. body, all with their pros and cons. But obesity, diabetes, and endocrine, DXA systems provide whole-body whereas typical nutrition tests cal- gastrointestinal, renal, nervous and regional estimates of three culate how much fat is le , imaging and infectious diseases – as well as main components: bone mineral off ers the ability to not only locate physiological and para-physiological mass, lean body mass and body fat and measure fat, but also to show conditions in athletes or growth and mass. They are non-invasive, widely how the disease changes during and Axial water-fat images of the calf muscle of a female subject with aging processes. The consequences available and relatively aff ordable a er treatment, according to Dr. type 2 diabetes: water image (A), fat image (B) and fat fraction map of these diseases and processes on measurement methods that can be Dimitrios Karampinos, leader of the (C). Colobar represents fat fraction values in %. An ROI can be drawn health can be serious: for instance, applied to patients of all ages using Body Magnetic Resonance Research anywhere on the fat fraction map to compute average fat content the alterations in body fat content, minimal radiation. MRI and CT allow Group at the department of diagnos- over the ROI. and particularly body fat distribu- for the estimation of adipose tissue, tic and interventional radiology at tion, are associated with adverse skeletal muscle, and other internal the Technical University of Munich, metabolic eff ects and increased car- tissues and organs with good results Germany. “What is really unique with chemical shi diff erence between Knowledge of regional fat and lean diovascular risk. and promising improvements. imaging modalities is that they are water and fat. These techniques were body mass reproducibility seems to A wide range of non-radiological Indeed both techniques have a able to tell us how much fat people proposed a long time ago and have be important for a variety of fi elds, techniques like anthropometry, dilu- lot to off er in the management of have in their bodies and where it is previously been used to separate Guglielmi echoed. “Clinicians are tion techniques, bioelectrical imped- obesity, a disease that aff ects more located. Another interesting aspect is water and fat qualitatively. There has increasingly recognising the con- ance analysis and air displacement than a third of the population of that we can monitor someone under recently been great interest among tribution of sarcopenia, an age-re- plethysmography are available, but the United States and an increasing diet or increased physical activ- the MR community in making these lated decline in muscle function and imaging methods like dual-energy number of people worldwide. Along ity, and understand with repeated techniques quantitative, aiming for mass, in terms of increased injuries, x-ray absorptiometry (DXA), CT and with a range of related conditions imaging in this patient how body fat a non-invasive measurement of the quality of life and fracture risk. MRI are considered to be among like heart disease, stroke, diabetes amount and distribution change,” tissue fat content. ”This is really an Other researchers are focusing their the most accurate approaches for and certain types of cancers, obesity said Karampinos, who will also speak interesting option because, instead a ention on the nutritional status the in vivo quantifi cation of body puts a huge strain on healthcare sys- during the session. of needing a segmentation algorithm assessment of patients undergoing composition, according to Giuseppe tems. In 2008, the annual estimate of CT is fast and effi cient, and off ers that says at a given location this is fat chemotherapy. Cachexia, a frequent Guglielmi, professor of radiology at obesity-related costs in the US was very high spatial resolution. But and this is water on a T1-weighted complication of cancer, may play a the University of Foggia, Italy. around 150 billion dollars per year because it exposes the subject to image, we now have a way to quan- role in how patients tolerate treat- “BC analysis by DXA has been and obese people paid 1,500 dollars ionising radiation, it is not suited to titatively measure fat content in any ment drugs and their outcome,” he available for more than 20 years, more than other patients for medical follow up the eff ects of interventions location inside the body. So we can said. like diet and increased physical activ- now use MRI as a quantitative tool, Although imaging techniques ity in a patient. Conversely, MRI is which can also help us to check the off er a diff erentiated and a ractive proving increasingly central in that eff ect of treatment more accurately; analysis of BC, they still need to fi nd area, according to Karampinos. “The for instance we can determine that a defi nite position in clinical practice. Special Focus Session big advantage of MR is that we can a patient has 8% of fat in the liver at This is why every radiologist should Sunday, March 9, 16:00–17:30, Room E1 #ECR2014E1 #SF15A scan the same subject many times baseline and 4% a er a four-week a end the session today, Guglielmi without exposing him or her to radi- diet, and we can follow up fat content said. “Since the clinical rules and SF 15a: Body composition: ation. In addition, CT is mostly a sin- changes in any organ,” he said. potential applications of BC analysis a new string to the radiologist’s bow gle-contrast technique; it can give us A quantitative measurement with still appear to be mostly unexplored, primarily a single grey scale image to MRI is always challenging. However, every radiologist should a end this » Chairman’s introduction locate fat in the body. MRI can give us the accuracy and reproducibility of session in order to expand research G. Guglielmi; Foggia/IT multiple contrasts in a single exam- these techniques have been tested in se ings, create normal reference » Body composition: why and how? ination. In other words, we can run the past couple of years, and now the data, and rationalise the use of BC J.E. Adams; Manchester/UK diff erent pulse sequences to obtain time has come to start fi nding their analysis in radiological practice,” he » Computed tomography: what does it measure and how? diff erent kind of information about applications through large multicen- concluded. J. Damilakis; Iraklion/GR the fat relying on the diff erent MR tre studies so that the radiological properties of fat versus the water in community, along with obesity and 1 Eric A. Finkelstein, Justin G. Trogdon, Joel » MRI: current and future applications the tissue,” he explained. metabolic disorder physicians, can be W. Cohen and William Dietz ‘Annual Medical D.C. Karampinos; Munich/DE Spending A ributable To Obesity: Payer-And In his talk, Karampinos will fi rst shown that MRI has a very critical » DXA: technical aspects and application Service-Specifi c Estimates’, h p://content. review the basics of how to manipu- role to play, added Karampinos. At healthaff airs.org/content/28/5/w822.full.html A. Bazzocchi; Bologna/IT late MR contrast in order to segment the end of his talk, he will also discuss » Panel discussion: fat regions using well-established the potential of quantitative water- How to rationalise the use of body composition analysis in T1-weighted imaging techniques. fat MRI in the emerging application radiological practice However, the main part of his talk of measuring bone marrow fat con- will focus on discussing water-fat tent, and its association with bone separation techniques, relying on the health and metabolic disorders. myESR.org 14 CLINICAL CORNER ECR TODAY | SUNDAY, MARCH 9, 2014

BY DAVID ZIZKA Future developments in MR-guided focused ultrasound

apoptosis,” Moonen explained on Currently, several applications MR-guided focused ultrasound, or short MRgFUS, the usage of MRgFUS. of MRI-guided HIFU in cancer are Afterwards MR imaging can being tested (e.g. in breast, liver, is a new therapeutic modality that allows selective be used to monitor treatment kidney and pancreas) and tech- destruction and heating of tissue in deep body response, or an MRI contrast agent nological advances should lead to can be used to determine whether higher treatment precision, rapid areas under close image guidance control. High- the therapy has actually been eff ec- volumetric treatment, and be er tive. Lesions can be detected by temperature control. But cancer intensity focused ultrasound (HIFU) is the only their dark core and the high signal care is not the only fi eld in which activity around them. The dark core MRI-controlled ultrasound may clinically viable technology that can be used to shows that the contrast agent can result in a new therapy. The tech- no longer penetrate it as the tissue nique has also been used success- non-invasively achieve a local temperature increase is no longer perfused. High signal fully in the treatment of essential activity around the edges of the tremor (or action tremor) in Canada deep inside the human body. lesion can be seen due to increased and the United States, resulting in blood fl ow in these areas. a recent paper by Elias et al. in The “There are several alternatives, but New England Journal of Medicine. The effects of high-intensity in phase at a specifi c location, high overcome, according to Prof. Chrit the approach using MRI-controlled Immediately a er the operation, focused ultrasound are based on sim- amplitude vibrations and, a er a Moonen from the University sound waves has the great benefi t the patients were able to hold a glass ple physical principles. When sound while, high temperatures increase Medical Center Utrecht, the of being entirely non-invasive. We of water and drink it unaided for the waves are absorbed, the mechanical can be seen. The dimensions of the Netherlands. therefore expect that there will be fi rst time in ten years. It is possible energy of the pressure wave is con- sound waves’ focal point are of the “During the 1950s and 1960s, the far fewer negative side eff ects. Also, to use sound waves in conjunction verted into thermal energy. This is order of the wavelength if a large Fry brothers in Illinois already the method is expected to be more with ultrasound contrast agents negligible, or unnoticeable, in ultra- aperture is used. developed an ultrasound device precise because of the real-time to temporarily and locally open up sound imaging, but at greater inten- Although these physical princi- for treating brain tumours. The idea MRI guidance. MRI-guided HIFU the blood-brain barrier, which is one sities the tissue becomes warmer. ples have been known for a long was wonderful, but in those days treatment of uterine fi broids is now of the biggest obstacles preventing By using several transmi ers at time, as well their potential in it was not possible to see exactly an accepted approach with patients eff ective medicines from ge ing once rather than one, while making medical applications, there were where the focal point of the sound going home the day of the treat- into the brain. MRI-guided HIFU sure that the sound waves are all a lot of technical diffi culties to waves was located with respect to ment,” said Moonen. also has tremendous potential in the brain structures. Besides all the positive eff ects, local drug delivery in the brain and Moreover, it was not really clear there are still technical diffi culties elsewhere, and can be used in com- just how warm the tissue actually and physical limitations to over- bination with temperature sensitive became. A major step towards clin- come. The spatial precision is lim- drug nanocarriers. ical applications was taken during ited by the ultrasound frequency Finally, when asked why he would the 1990s in Lyon by Dominique and the ultrasound transducer recommend this session to ECR Cathignol’s group. Prostate cancer needs to be as large as possible. a endees, Moonen had this to say: was treated using an endorectal Apart from perfusion, near-fi eld “The Special Focus session on MRI ultrasound transmi er. The posi- and far-fi eld heating can present guided focused US will give an excel- tioning of the device was verifi ed risks that should be carefully eval- lent insight into the basics, the tech- using ultrasound imaging. However, uated in every case. Bone and gas nical developments and accepted, the temperature could not yet be regions in the beam path represent as well as novel applications of the measured, or at any rate not non-in- obstacles for the ultrasound beam great new technique. A endants vasively,” said Moonen. path as it can be heavily absorbed learn that focusing ultrasound pre- It is a well-known fact that MRI by the bone cortex, which can be sents a huge range of possibilities in is the best approach for identify- problematic and result in unwanted medical care. Planning, controlling ing and locating abnormalities heating. In other cases, such as and evaluating this by means of in so tissue, but it might be less tumour metastases in bone, such MRI makes the technique more well-known that it is also the only heating can be used for rapid pain precise and allows us to measure currently available method to relief. Ultrasound applications in the eff ect. Local heating of tumours non-invasively measure tempera- the liver, kidney and pancreas are by ultrasound waves can kill off the You call it carving. ture changes inside the body. technically more diffi cult because of tumour. The technique is only in This is because temperature the movements caused by respira- its infancy and is still only being We call it ® changes can affect the forces tion and heartbeat, as well as by the tested clinically at a small scale. But between neighbouring water mol- fact that the ribs partially refl ect MRI-controlled ultrasound also has ecules inside the tissue, and that or absorb sound waves. New tech- numerous potential applications in will show in the MRI signal. Tem- niques are being developed to pro- chemotherapy, in combination with quattro perature measurements using vide solutions to these problems. radiotherapy.” MR make it possible to adjust the heating eff ect by modifying the delivered energy, in the same way as a thermostat does. For the fi rst Special Focus Session time, MRI-guided HIFU can raise the temperature locally in the tissue Sunday, March 9, 14:00–15:30, Room G/H #ECR2014GH #SF14B and control it, automatically and SF 14b: Treatment with MR-guided focused US (FUS) non-invasively. “This is important for the treat- » Chairman’s introduction ment since we have to make adjust- W.M.W. Gedroyc; London/UK ments for variable perfusion, vari- » Description of technique able absorption of ultrasound and C. Moonen; Utrecht/NL variable thermal insulation. If we » Uterine fi broids and adenomyosis heat tissue for a certain time, the tis- Y. Inbar; Tel Hashomer/IL sue will die off once what we refer to in professional jargon as the lethal » Transcranial FUS thermal dose has been exceeded. E. Martin; Zurich/CH It dies off almost immediately as » Panel discussion: a result of damage to proteins and How can this technology be spread more widely? membranes; we then refer to that as ablation. It does sometimes www.audi.at happen more slowly, sometimes Kraftstoffverbrauch gesamt in l/100 km: 5,1–8,9. even several days a er heating, if CO -Emissionen in g/km: 134–206. 2 biochemical reactions have to take place fi rst. This is referred to as

98x195_freestyle_range_ecr.indd 1 09.01.14 09:16 myESR.org ECR TODAY | SUNDAY, MARCH 9, 2014 CLINICAL CORNER 15

BY MÉLISANDE ROUGER French radiologist describes benefits of new cancer therapies ECR Today spoke with Eric de Kerviler, professor of radiology at Saint-Louis Hospital, University Paris Diderot, about the State of the Art Symposium ‘Tumour response assessment in clinical practice’, which he will chair today at the ECR.

ECR Today: What are non-cyto- of this targeted therapy is yet to be may occur within tumours. However, toxic targeted therapies? established. imaging biomarkers needed to mon- Eric de Kerviler: Noncytotoxic itor tumour response should be usa- molecular targeted therapies are ECRT: How do you measure the ble by everybody, and reproducible. treatments that have been devel- effi ciency of these therapies? This is the case for PET/CT, dynamic oped against growth factor recep- EdK: Morphology-based criteria contrast enhancement studies tors and tumour angiogenesis. They (RECIST), which were established and diff usion-weighted imaging. are designed to interact with spe- in cytotoxic therapy trials, are not Nuclear medicine physicians now cifi c molecules, which are part of appropriate tools for assessing routinely use most recent PET trac- the pathways and processes used the effi cacy of targeted therapy, in ers. Diff usion-weighted imaging is by cancer cells to grow, divide, and which tumour shrinkage is not nec- also done on every recent MR sys- Patient with Hodgkin’s lymphoma. Evaluation at baseline at the spread throughout the body. There essarily observed. Endpoints such tem, even though refi nements in MR end of treatment. CT indicates a shrinkage of the mediastinal mass is an overlap between cytostatic as PFS or TTP, which focus on pro- parameters are required, along with (arrows), but a partial response can be observed according to 1999 drugs and targeted therapies: some gression rather than regression, are thresholds for identifying response. Cheson’s criteria. FDG-PET indicates a complete response according cytostatic drugs are not targeted, appropriate and commonly used in Lastly, DCE is now more widely used to 2007 Cheson’s criteria since there is no persistant tracer uptake and hormone therapies used to treat clinical studies of targeted therapy. in breast or prostate protocols and within the mass. breast cancer could also be called Quantitative non-anatomic should soon become part of the pro- cytostatic therapy. imaging approaches can be used tocol for many tumours. These therapies are increasingly as a biomarker of cancer response used as a fi rst-line treatment, at to predict, or assess, the effi cacy of ECRT: What are the potential baseline or in cases of recurrence. treatment and look for changes in pitfalls of these techniques? Because many drugs are under tumour biology. Tumour density EdK: While depicting an image development, they are given on CT, vasculature on DCE studies, of molecular characteristics of dif- within the framework of clinical cellularity on DWI or metabolism at ferent tissues, PET can sometimes trials. However, many of these 18F-FDG PET are some criteria com- be imprecise in anatomical loca- drugs have already become part of monly used for assessing tumour tion. Also, if FDG is the most widely the recommended treatment. The response. investigated radiotracer, it is not spe- fi rst molecular target was the oes- cifi c at all. Diff erent levels of accu- trogen receptor for the female hor- ECRT: What molecular imaging mulation of 18F-FDG are refl ections mone oestrogen, which many breast modalities and biomarkers do you of diverse energetic needs, including cancers require for growth. Among use to follow up therapy? infl ammation, infection or tumour other examples, let us cite Imatinib, EdK: The most promising and progression. There is, therefore, a which has been approved to treat widely used modalities are PET and true place for new radiopharma- gastrointestinal stromal tumour MRI (diff usion and perfusion). To ceuticals associated with various and certain kinds of leukaemia, and a lesser extent, SPECT and tumour metabolic pathways. On the other Vemurafenib for the treatment of density on CT or CE-US can also be hand, MRI plays a more prominent certain patients with inoperable or used. More recently, elastography, role in following a tumour under metastatic melanoma. which enables tumour stiff ness to treatment. However, many patients be evaluated, has been suggested as have metastases. In these patients, Patient receiving neoadjuvant chemotherapy for breast cancer. At ECRT: Who can benefi t from a reliable tool to predict and assess doing a whole-body examination second cycle, the mass has markedly decreased in size suggesting these therapies? early tumour response. using diff usion and perfusion is a a good response. However, dynamic contrast enhancement EdK: Predictive biomarkers capa- Many imaging biomarkers are real challenge. There are also many demonstrates stable microvascular parameters (permeability and ble of discriminating between indi- already available and widely used pitfalls in the interpretation of MR interstitial volume fraction) suggesting non-response. At surgery, viduals who will benefi t from a given with cytotoxic drugs. For instance, signal. response was <50%, Sataloff C. therapy from those who will not 18F-FDG PET is very useful for (Images provided by Prof. Eric de Kerviler) are key to personalised medicine. assessing therapeutic response ECRT: When do you think these Patients with tumours demonstrat- in Hodgkin’s disease, as patients techniques will actually benefi t ing permanent biomarker expres- do not receive targeted therapy. patients? sion can benefi t from targeted ther- Using the same non-specifi c radi- EdK: Most of these new tech- apies. This is the case in patients opharmaceutical, some studies have niques are under investigation in with B-cell lymphoma receiving shown a marked decrease in 18F-FDG clinical trials. So far, clinical inves- Rituximab. This monoclonal anti- uptake in small cell lung cancer a er tigations have validated a reduction State of the Art Symposium body is targeted towards a protein administration of an EGFR antago- in 18F-FDG uptake that occurs in Sunday, March 9, 16:00–17:30, Room E2 #ECR2014E2 #SA15 called CD20 located on mature B nist. Some imaging biomarkers are oncological tissues a er antican- lymphocytes. In other patients, a more specifi c for evaluating the cer treatment in various tumours, SA 15: Tumour response assessment in clinical practice particular genomic profi le should be direct eff ect of EGFR antagonists including lung cancer and malig- tested before giving the drug. This on tumour vasculature. However, nant lymphoma, and is closely cor- » Chairman’s introduction is the case in melanoma, in which anti-angiogenic therapies do not related with fi nal outcome of ther- E. de Kerviler; Paris/FR Vemurafenib is proposed only in always result in reductions of blood apy. Choi criteria are already used » Endpoints for therapy response assessment: patients with a BRAF mutation. fl ow in the short term, and DCE MRI in the evaluation of gastrointestinal the oncologist’s perspective Many studies have shown an kinetic response relationships are stromal tumours. Therapy-induced J. Carles; Barcelona/ES improvement in the survival of not universally strong across all changes in ADC are under investi- » Revised RECIST guidelines: patients with advanced cancer when tissue sites for all drugs. Therefore, gation in lymphoma, breast cancer, principles, practical applications and pitfalls using targeted therapies. However, further research is needed to choose and rectal cancer receiving neoadju- L.S. Fournier; Paris/FR even in patients with a positive between or combine several imaging vant chemotherapy. New anticancer » Criteria beyond RECIST: predictive biomarker, undergoing biomarkers. agents will probably need to have Choi, mRECIST, EASL-AASLD, PERCIST a targeted therapy that is likely to specifi c response criteria. S. Gwyther; Redhill/UK be eff ective, primary resistance is ECRT: How promising are PET-CT, seen in about 30% of the cases, and dynamic contrast enhancement » Emerging biomarkers for response assessment: pros and cons disease recurrence occurs uniformly and diff usion-weighted imaging? M.C. Roethke; Heidelberg/DE in patients with an initial response. EdK: Depending on the targeted » Panel discussion: Therefore, the long-term effi cacy therapy that is used, many changes Personalised response criteria for personalised therapies? myESR.org 16 CLINICAL CORNER ECR TODAY | SUNDAY, MARCH 9, 2014

BY MAJDA M. THURNHER ESNR and ESR team up to launch Board of Neuroradiology

The European Society of Neuroradiology – Diagno- pean neuroradiology is on its way to the Neuroradiology Course during assuming a leading role in education the 43rd Jornada Paulista de Radio- stic and Interventional (ESNR) was founded in 1969. within and beyond Europe. logia in São Paulo, Brazil. At the third level, a number of Since its foundation 45 years ago, Over the last decade, the society has grown from a advanced courses were held in the one of the major goals of the ESNR fi elds of paediatric (Chair: Dr. Andrea has always been and will continue 300-member society to a 4,000-member society. And it Rossi), interventional (Chair: Prof. to be education. ESNR courses wel- has now taken a major step towards advancing educa- Michael Söderman), and spinal neu- come all radiologists, from those who roradiology (Chair: Dr. Mario Muto). need basic knowledge, to those who tion in neuroradiology by establishing the European Traditionally, during the ESNR want to learn to become neuroradiol- annual meetings, the European ogists, as well as those with advanced Board of Neuroradiology in conjunction with the ESR. Diploma in Neuroradiology (EDiNR) knowledge of neuroradiology. is awarded. Over the last four years, The ESNR will continue to be The board will organise exams and issue certifi cates 51 colleagues received the Neuro devoted to education, as we honestly for the society’s already popular European Diploma Diploma in Bologna, Italy, 52 in Ant- believe in Learn Advance Perform, to werp, Belgium, 66 in Edinburgh, UK, be the only teaching concept that in Neuroradiology. and 41 in Frankfurt, Germany. works for us and serves our patients. In 2013, for the fi rst time, the ESNR awarded a diploma of higher qualifi - More information about the ESNR The European School of Neurora- The second level is the success took place in Athens in April 2013. cation. Seven colleagues were given can be found at www.esnr.org diology (ESONR), chaired by Prof. Pia story of European neuroradiology. The fourth module will again take the European Diploma in Paediatric Maly-Sundgren, off ers three levels of The 12th Pierre Lasjaunias European place in Athens in April 2014. More Neuroradiology (EDiPNR). Professor Majda M. Thurnher neuroradiological courses. The fi rst Course on Neuroradiology (ECNR) than 250 participants from diff erent The ESNR has also taken the ini- from Vienna, Austria, is Vice-Pres- level was successfully implemented is split into four one-week modules. European countries and non-Euro- tiative to promote teaching in coop- ident of the ESNR. in cooperation with the European The fi rst and the third modules, pean countries (Middle East, South eration with other national societies. School of Radiology (ESOR). The under the co-directorship of Prof. America, South Africa and North In 2013, four ESNR representatives Galen Foundation Course on basic T. Tali and Prof. A. Gouliamos, took America) a ended each module. The (Prof. Paul Parizel, Prof. Turgut Tali, neuroradiology was held in 2013, by place in Antalya, Turkey, in November increased number of non-European Prof. Majda M. Thurnher and Dr. Prof. Cem Calli, in Izmir, Turkey. 2012 and 2013, and the second module participants clearly shows that Euro- Pedro Vilela) actively participated in

myESR.org 17 SUNDAY, MARCH 9, 2014 TECHNOLOGY FOCUS

Radiation safety in EIBIR appoints EMAN works medical imaging and 19 new scientifi c director 20 toward long-term goals 21 European Union law

BY JOHN BONNER PACS providers plot routes through a changing medical landscape

Changes in how hospital services are organi- sed across Europe are arguably having a greater impact on radiology departments than on other clinical disciplines. In many countries, hospitals no longer operate as stand-alone entities, but as part of a local or regional network, as healthcare admi- nistrators respond to the pressures of increasing demand, static or shrinking budgets and an ageing population.

Carestream’s Vue PACS display is designed to integrate images with Changes in how hospital services ogy exams,” explained Bernard “With digital images and the reports and enable cost-eff ective teleradiology capabilities. are organised across Europe are Algayres, GE’s general manager for advanced image analysis algorithms arguably having a greater impact radiology IT in Europe. available today, we can provide a on radiology departments than on In the radiology arena, Centricity more solid objective platform for the other clinical disciplines. In many 360 is a convergence between a tra- subsequent diagnostic conclusions. countries, hospitals no longer oper- ditional PACS and advanced visual- In addition, image analysis has the ate as stand-alone entities, but as isation technologies, he said. It will potential to add new examination part of a local or regional network, as be launched in Europe during the possibilities not available in the ana- healthcare administrators respond fi rst half of 2014 with a patient case logue microscope,” she explained. to the pressures of increasing transfer capability, and additional At ECR 2014, Sectra staff are demand, static or shrinking budgets services will be added later. Eventu- showing the results so far, although and an ageing population. ally, the company hopes to develop Ekström acknowledges that there As providers of medical services the service as a ‘virtual meeting are still considerable hurdles to to other clinical departments, radi- space’ for multidisciplinary team overcome, particularly in relation to ologists are also adapting to their meetings. handling the huge volume of digital changing role of providing diagnos- “The work tools available with the data likely to be generated by a busy tic expertise to colleagues working service are intended to help commu- histopathology unit. in institutions tens or even hun- nities of specialists to collaborate Meanwhile, SIEMENS HEALTH dreds or thousands of kilometres more effi ciently. Regionalisation is CARE is working to provide radiol- away. However, some of the technol- transforming the way that health- ogists with a speedier workfl ow and ogies that will help ESR members to care technology providers design greater diagnostic precision when deal with shi ing demands on their their products, and we think we are working on MR and CT images. time are on show in the commercial ahead of the game,” Algayres added. The new VA30 version of its syngo. exhibition. Another vendor at the forefront via routine 3D and advanced read- GE HEALTHCARE aims to of eff orts to advance distributed ing so ware contains the General improve the capability of medical radiology services is SECTRA. Its Engine package of automated and staff throughout the hospital to technical staff are keen to explain standardised applications. It fea- work with colleagues across medical how the company is trying to tures ‘anatomical range presets’, disciplines, administrative bound- strengthen one of the weak links which provide a quick, precise and The syngo.via General Engine from Siemens is a new package of aries and even national frontiers. in the chain of diagnostic services optimal view of key anatomical fea- automated and standardised applications. The ‘anatomical range The company is demonstrating in many advanced health systems: tures without the need for the radi- presets’ feature displays a quick, precise and optimal view of selected its new Centricity 360 concept – a problems in ge ing an opinion from ologist or technician to spend time anatomical regions. cloud computing service rather a specialist pathologist on a biopsy choosing and creating projections than a product – intended to pro- sample. This is caused by a combi- manually, according to the fi rm. vide healthcare professionals with nation of dated technology in the Marc Lauterbach, vice-president internet access to a wide range of form of glass microscope slides that for marketing with at the SYNGO adjacent structures such as the On the PHILIPS stand, staff are distributed services and the ability can be broken or lost, and a shortage business unit, believes a key bene- humerus bone, looking for signs of unveiling the latest refi nements to to share patient information both of pathologists in many countries. fi t of the new edition of its routine a fracture,” he noted. its Intellispace technology. Intellis- securely and in real time. “In some states or regions it can 3D and advanced reading so ware The new edition is also designed to pace is described as a thin-client “This is not a radiology service, take several weeks for the referring syngo.via is the inclusion of ALPHA minimise potential delays in dissem- solution requiring no dedicated it is much broader than that. It is physician to receive a report, and in (automatic landmarking and pars- inating the results with its advanced workstation on which to perform intended to help connect all health- oncology patients, that is just not ing of human anatomy) technology. reporting tool, which helps radiolo- the advanced analysis functions care professionals to work with col- acceptable,” said Marie Ekström, “Landmarking is a well-estab- gists to create clear, well-structured that it off ers. leagues to achieve be er treatment general manager for radiology IT lished concept in the imaging indus- reports for the referring physician. “Our new version contains the CT for their patients. That isn’t just staff at Sectra. try but the parsing element is new It off ers standardised templates, trauma package which addresses working in the same building but Assisted by funding from Vin- and very exciting. ALPHA not only making it easier to produce stand- the workfl ow challenges faced by colleagues who are at home or work nova, the Swedish national research identifi es anatomical landmarks but ard reports that can then be cus- radiologists. A CT scan is obviously in a diff erent hospital or a diff er- agency, Sectra is working with it really understands their meaning tomised to individual needs. Also, the fi rst priority for assessing a ent country. It is not only radiology academic partners on a project to and those of adjacent structures. So fi ndings from multiple diff erent patient who may have head, spine images that can be exchanged but develop the technology needed to it will automatically align images of, examinations can be consolidated or internal organ injuries following all relevant studies in the hospital scan, store and display digitised his- say, the shoulder joint in a trauma into a single report through a simple system such as cardiology or pathol- topathology images. patient, to look along the axis of ‘drag and drop’ process, he added. continued on page 18 myESR.org 18 TECHNOLOGY FOCUS ECR TODAY | SUNDAY, MARCH 9, 2014

continued from page 17

an accident. But a modern scanner medical information in a non-pro- Finally, AGFA is keen to impress may create 3,000 individual images prietary, interchange format that on visitors to its stand the potential in just 10 seconds and examining allows it to adapt to any enterprise advantages of its latest Impax Agil- all that data is an impossible task or departmental information-shar- ity PACS, a departmental imaging for one person,” said Dr. Jerome ing workfl ow and open standard. platform designed to improve pro- Galbrun, head of marketing for Clinicians have access to a unifi ed ductivity, reduce cost and facilitate Philips’ Intellispace portal. “We have view of their patients’ clinical infor- quality outcomes. produced so ware that can extract mation across disparate systems According to a statement, “This the relevant information as quickly with a global or single access virtu- comprehensive solution redesigns as possible and identify the critical ally anytime, anywhere, according capabilities typically found in a RIS, areas that the radiologist and sur- to a company statement. multi-departmental PACS, voice rec- geon need to look at in planning Another work-in-progress is Care- ognition reporting and connectiv- treatment.” stream’s planned enhancements ity into one single system. IMPAX In addition, Philips has updated to the digital breast tomosyn- Agility streamlines navigation with the service to include advanced thesis module on its Vue Mammo a dynamic user interface and diag- applications for MR and nuclear workstation intended to produce nostic tools to support enhanced medicine examinations in a vendor DICOM-compliant 2D synthetic productivity. A powerful task-based Multi-modality tumour tracking results page on Philips’ Intellispace neutral technology capable of pro- views calculated from the 3D workfl ow engine helps to ensure Portal 6 shows the progress of tumours, calculated as RECIST, in numeric cessing images derived from any dataset. that users follow the appropriate and graphical presentation, in addition to the volumetric images of the company’s scanner. Its ability to The display systems manufac- steps for each procedure and cir- tumours in the body. combine the results of CT, MR and turer BARCO is also introducing a cumstance, from ordering to result PET imaging modalities will prove number of extensions to its product distribution. This supports the hos- invaluable in monitoring treatment range. Lynda Domogalla, vice pres- pital in meeting regulatory obliga- of oncology patients by providing ident for healthcare product mar- tions and workfl ow best practices, objective and accurate data on how keting, drew a ention to the per- as well as improving clinical com- the size of the tumour has changed formance of the company’s Mammo munication through mobile apps.” over time, he said. Tomosynthesis 5MP, which she says Across the hall on the CARE is the only digital mammography STREAM stand, the company is display that has been designed spe- showing its new generation Vue cifi cally for breast tomosynthesis. PACS as a work in progress designed “Featuring up to four times more to integrate images with reports and brightness and double the lifetime enable cost-eff ective teleradiology of other mammography displays, it capabilities. A further highlight is also presents up to 15% increased the Vue Vendor Neutral Archive, visibility of small microcalcifi ca- a portfolio of solutions that store tions,” she said. A histopathology sample displayed on the Sectra viewer.

BY STEPHEN HOLLOWAY Big data clouds signal end for enterprise PACS storage

Healthcare IT is undergoing a has grown, new solutions for the bining each discrete data element painful evolution. Spurred by spi- broader need have emerged. into a centralised ‘big data’ silo could ralling healthcare costs, healthcare have revolutionary consequences for providers are waking up to the reality VENDOR NEUTRAL the provision of healthcare. that their sector is lagging behind. ARCHIVING (VNA) Large-scale health data interop- Radiology to date has tended to be The need for digitalisation across erability, o en referred to as Health ahead of the curve in adoption of the hospital conceived VNA storage. Information Exchange (HIE), is healthcare IT, evident in the wide- While VNA is o en bound to many touted as off ering game-changing spread implementation of Picture solutions, a true VNA off ers wide- benefi ts for patients and provid- Archiving and Communication Sys- spread use for all fi le formats, allow- ers alike. The ability to pull patient tems (PACS). However, over-reliance ing storage of DICOM and non-DI- records and history between hos- on PACS and stubborn resistance COM fi les. Each hospital department pital, regions or country, improves to broader co-operation with other has its own specifi c need and require- administration, billing and clinical hospital stakeholders is slowing ments for IT system and storage. The treatment. Patients with pre-exist- healthcare IT development. Below, majority opt for specialist vendor ing conditions could even carry their we take a quick look at the dynamic solutions, regardless of whether this records and history with them on Forecast development: World radiology PACS vs. VNA changes impacting this rapidly evolv- connects well with other departmen- smartphone devices. Furthermore, (Revenues [$ millions] - includes new systems and maintenance) ing industry. tal systems or storage. This produces pooling of healthcare data also off ers a complex hospital IT eco-system real clinical benefi ts. Tracking of dis- PACS with few common vendors or system ease prevalence and epidemiology on PACS off ered radiology a glimpse types. While there is a trend towards a large scale could bring about new governmental, state and hospital through widespread PACS roll-out into the future. The ability to archive, centralised hospital contracting for care protocols, decision support level regulation, not to mention the to drive the next generation of user query, annotate and share images IT in a bid to reduce cost, many users for diagnosing physicians and new sheer cost of upgrading existing IT friendly, smart VNA? across departments and clinics was are unwilling to change to a less-spe- globalised standards in treatment. and connectivity infrastructure to Hospitals today need multi-format, the fi rst building block of the ‘digital cialist vendor. Therefore VNA is the Healthcare spending could also be manage such a complex system. vendor-neutral storage. They need hospital’. Keen to be at the forefront only sensible IT storage solution that managed more effi ciently; resources, Yet, scaling such challenges must seamless interoperability and fl exi- of cu ing-edge technology, radiolo- allows each department still to main- supplies and expertise could be more begin with overcoming smaller bar- bility between departments, sites and gists embraced PACS. Jargon-heavy tain a semi-discrete status. It’s also accurately monitored, analysed and riers towards a common goal – HIE users. Most importantly, they need upgrades, touting ‘game-changing’ one of the few current solutions that actioned based on large-scale data roll-out. Over-reliance and use of storage that will push them in the solutions and ‘transformational’ fi t the future long-term development evidence. PACS as a storage solution is one direction of a common goal: greater image sharing capabilities contin- of healthcare IT. such barrier that is simpler to correct. use of ‘big data’. PACS has certainly ued to drive momentum for larger THE CHALLENGE AHEAD The inherent design and concept of played a signifi cant part in driving and more complex PACS systems. Yet, BIG DATA AND HEALTH Admi edly, seamlessly integrated PACS was for departmental manage- healthcare IT integration. However, PACS was originally a single-depart- INFORMATION EXCHANGE HIE still has a long way to go, with ment of DICOM images. It was never it is unlikely to play as signifi cant a ment concept – it was never intended The biggest challenge for health- only a few sub-regional or multi-hos- intended as a one-size fi ts all solution. role in the future of healthcare IT. to provide interoperability at the care IT improvement is bringing pital systems in place currently. Roll- With this in mind, why are vendors multi-department or multi-site level. together various healthcare IT sys- out of such systems has huge barriers and radiologists alike continuing to Stephen Holloway is Associate Therefore as demand for IT systems tems to a point where interoperabil- to face including patient confi denti- push enterprise PACS solutions? Why Director at Medical Devices & outside of the radiology department ity of data is commonplace. Yet, com- ality, public and private integration, not instead use the experience gained Healthcare IT, HIS.

myESR.org ECR TODAY | SUNDAY, MARCH 9, 2014 TECHNOLOGY FOCUS 19

BY ALENA MORRISON EIBIR appoints new scientific director

Prof. Gabriel P. Krestin will assume the role of scientifi c director of the European Institute for Biomedical Imaging Research (EIBIR) a er being nominated for the role during the organisation’s General Meeting yesterday.

Commi ed to radiology research, to EIBIR’s role as coordinator and ECRT: What are some of the chal- Krestin worked with the ESR to administrator of biomedical imaging lenges that the organisation will establish EIBIR, which aims to foster research in Europe. Furthermore, I face in the future? and strengthen biomedical imaging hope that some new joint research GK: Sustainable funding is and research in Europe and has been initiatives will start in image-guided remains the main problem for EIBIR. involved with the organisation since interventions, radiation therapy, pae- While EIBIR services have led to a its founding in 2006. He also recently diatric imaging, and neuroimaging. high number of positively reviewed served as chairman of the General Moreover, the intention is to set up and funded European projects, the Meeting. Since its inception, EIBIR a virtual contract research organi- upfront costs for such services are has developed into a key platform sation that will enable multicentre quite high and not refundable from Professor Gabriel P. Krestin from Ro erdam, the Netherlands, is the for supporting research networking imaging trials, initiated by research- dedicated project costs. So these new EIBIR Scientifi c Director. activities, spreading good practice ers or by industry, to be performed. EIBIR expenses have to be covered and promoting common initiatives by the membership fees and indus- and interoperability in the fi eld of ECRT: In the longer term, how do try contributions. Therefore, I would biomedical imaging research. Stake- you think EIBIR will contribute to like to encourage every European holders in the EIBIR network have biomedical imaging research within organisation interested in research EIBIR Session at ECR 2014 also continued to grow and include Europe? to become an active network mem- European research institutes, share- GK: The ultimate goal for the years ber of EIBIR. In that way we will Sunday, March 9, 16:00–17:30, Room P #ECR2014P holder organisations and industry to come is for EIBIR to become, and be able to extend our services and ENCITE based insights for molecular imaging partners. to be recognised as, the most effi - start to initiate and support larger in guidance of therapy ECR Today spoke with Krestin to cient and eff ective research sup- multicentre studies in which EIBIR Chairman: M. Neeman; Rehovot/IL hear some of his thoughts about port organisation for all biomed- provides support with study design, EIBIR and his ideas for the future ical imaging related research in monitoring and data management. » Introduction of the organisation. Europe. I would like to see EIBIR M. Neeman; Rehovot/IL known by every radiologist and ECRT: As EIBIR’s scientifi c direc- » A dual-modality gene reporter for in vivo imaging ECR Today: Looking towards every researcher involved in imag- tor, what are you most looking for- K. Brindle; Cambridge/UK 2014, what activities and initia- ing research. The more requests and ward to about your new role? tives would you like to see begin questions EIBIR receives, and hope- GK: I am very much looking for- » MR imaging for pancreatic cells transplantation this year? fully solves, the be er. I hope that the ward to working together with the M. Hájek; Prague/CZ Gabriel Krestin: We will have to newly appointed Scientifi c Advisory enthusiastic and expert EIBIR offi ce » Optical imaging in the clinic strengthen the strategy and further Board of EIBIR will play a proactive team under the guidance of Monika J. Dijkstra; Leiden/NL extend the activities of EIBIR in the role in encouraging multidisciplinary Hierath and with the members of » Mesenchymal stem cells constructs for image-guided cell coming years. For now, I hope that at collaboration, initiating innovation the Scientifi c Advisory Board. Their therapy in myocardial ischemia and digestive fi stulas least some of the applications to the and development of new technolo- input will be needed for initiating O. Clément; Paris/FR fi rst call for proposals in the Horizon gies, and proving the eff ectiveness of new ideas and for supporting EIBIR » Is cell imaging relevant for the clinic? Lessons to be 2020 research funding framework of the established ones. I also hope that with expert opinion in all research learned from pre-clinical research the EC will go into the second phase. the commitment of the increasing policy questions that may aff ect U. Himmelreich; Leuven/BE That would keep the EIBIR offi ce number of EIBIR shareholders will imaging research and innovation in very busy in the coming months foster this kind of collaboration. Europe. » Discussion but would also give a new boost

ESMRMB promises another year of high-quality educational activities

Professionals in magnetic reso- » Professional and didactically expe- know that two courses are planned certifi ed teacher in a specifi c fi eld of Meeting 2015. Another exciting pro- nance meet in cities all over Europe rienced teachers in 2014: applied MRI (e.g. musculoskeletal, gramme will be put together with the to share their expertise, gain knowl- » Accredited by UEMS/EACCME with » Course duration: 2.5 days cardiac, abdominal MRI). Commi ee Members and enriched edge and contribute to the high up to 15 credits per course » 50% vendor specific hands-on by your participation. We are looking standards of the European Society » Maximum 65 participants per training on the scanner and ESMRMB ANNUAL forward to welcoming you to Edin- for Magnetic Resonance in Medicine course workstations SCIENTIFIC MEETINGS burgh, UK, on October 1–3, 2015. and Biology (ESMRMB)’s educational » Accredited by UEMS/EACCME with A er celebrating its 30th Annual programme. LECTURES ON MR up to 12 credits per course Scientifi c Meeting in Toulouse in Find out more at www.esmrmb.org Assured and encouraged by highly MR physicists and other basic or » Maximum 30 participants per 2013, the ESMRMB is delighted to and join us on Facebook and Twi er. appreciated positive feedback in 2013, clinical scientists are warmly wel- course announce its Joint Meeting with the we are determined to keep our high come to 6–10 courses in 2014: International Society for Magnetic standards. » Course duration: 2 – 2.5 days TEACH THE TEACHER Resonance in Medicine (ISMRM) on » 40% of the total teaching time is IN CLINICAL MRI May 10–16, 2014, Milan, Italy. Join over SCHOOL OF MRI used for repetitions, exercises, and The ESMRMB is proud to 6,000 clinicians, physicists, engineers, Physicians and MR technologists/ practical demonstrations announce the fi rst training course biochemists and technologists from radiographers are cordially invited » Accredited by EFOMP of its Teach the Teacher Programme more than 70 countries around the to 10 advanced clinical English lan- » Maximum 50 participants per in 2014. The ESMRMB and ISMRM world for the premier meeting in the guage courses: course together off er young academic radi- global MR community. » Course duration: 2.5 days ologists from emerging countries The ESMRMB and the Scientifi c » Interactive character with 50% of HANDS ON MRI a two-month fellowship in one of Programme Commi ee chair for the total teaching time used for MRI technologists, radiographers the world’s leading MRI centres to 2015, Marion Smits, would also like repetitions in small groups and interested physicians should be trained as an ESMRMB/ISMRM to invite you to the Annual Scientifi c myESR.org 20 TECHNOLOGY FOCUS ECR TODAY | SUNDAY, MARCH 9, 2014

BY GRACIANO PAULO, ON BEHALF OF THE EMAN STEERING COMMITTEE EMAN works toward long-term goals

Medical diagnostic procedures constitute by far the greatest man-made source of ionising radia- tion exposure to the general population. Although the benefi t for the patients exposed will normally outweigh the risk associated with the radiation, there is concern that patients may undergo radio- logical examinations that will not have any posi- tive impact on their clinical assessment, or that unnecessarily high doses of radiation could be deli- vered with regard to the diagnostic outcome.

Moreover, the increasing use of and ethical aspects. To support the (EFRS) and the European Federation to radiological protection and to ionising radiation in the medical task regarding optimisation of pro- of Organisations for Medical Phys- provide tools for the assessment sector also has an impact on occu- cedures, the European Commission ics (EFOMP) – decided to ensure the of optimisation of radiological pational radiation exposure. funded the EMAN (European Medi- sustainability of the Network and protection In order to strengthen radiological cal ALARA Network) Tender Project signed a Le er of Intent in Septem- » To potentially expand the scope to protection in the fi eld of medicine that formally ended in October 2012. ber 2012, forming the new EMAN other clinical areas of optimisation and promote a patient safety culture, A er the successful conclusion of Steering Commi ee. This paved the The long-term vision of the EMAN a variety of stakeholders have to be the EC-funded Tender Project, the way for the post-project activities of Network is to contribute to optimis- addressed and involved, pinpoint- three professional organisations the Network and further outreach to ing radiation protection for health- ing the specifi c roles of the diff er- involved – the European Society other relevant stakeholders. care workers and patients through- ent health professionals as well as of Radiology (ESR), European Fed- The EMAN Network structure out Europe and to further contribute education, training, organisational eration of Radiographer Societies includes a Steering Committee to an eff ective safety culture in the (ESR, EFRS and EFOMP), a Man- medical sector. agement Offi ce (ESR), stakeholders, The main assets the Network and observers. To date the following builds on are the radiation protec- Professor Graciano Paulo from organisations have joined EMAN: tion strategies developed during the Coimbra, Portugal, is President Nuclear Protection Evaluation EC-funded phase in the areas of com- of the European Federation of Center, France (CEPN) as a stake- puted tomography, interventional Radiographer Societies (EFRS) holder; European Radiation Dosim- radiology, cardiology and radiological and member of the EMAN etry Group e. V. (EURADOS), Federal practices performed outside the radi- Steering Commi ee. Offi ce for Radiation Protection in ology department. Three working Germany (BfS), Swedish Radiation groups with representatives of the Safety Authority (SSM) and the Euro- professionals involved, medical radi- pean Commission (EC) as observers. ologists, cardiologists, radiographers, ments and recommendations of the The Steering Committee has medical physicists and regulators, working groups. reached out to a number of addi- worked for two years to identify the The current focus of the EMAN tional medical professional organi- needs and priorities for the imple- Steering Commi ee is to develop a sations, international organisations mentation of elements to increase strategic plan for future activities, and regulatory bodies inviting them the level of radiation protection, both laying down priorities and realistic to join the Network and is hoping to for patients and, when relevant, staff . goals in alignment with the lead- further enlarge the Network in the The results achieved by the three ership of the ESR, EFRS, EFOMP near future. multidisciplinary groups provide and the EC, that will serve as the the methodology for other fi elds of basis for outreach to stakeholder THE OBJECTIVES OF THE diagnosis and therapy. It is recom- organisations. EMAN NETWORK ARE: mended that the same methodol- The ongoing activities of the new » To collaborate among professional ogy be applied at the hospital level, Network include reaching out to partners in medical radiation pro- establishing multidisciplinary ‘core stakeholders, encouraging active par- tection in order to improve optimi- teams’ to implement exposure opti- ticipation, revising and updating the sation and to expand the network misation in the diff erent areas. The project website, and disseminating established under the EC Tender role of the core team is to develop documents developed during the EC project optimised procedure protocols, train Tender Project to ensure uptake and » To specifi cally update and expand staff and supervise practice. The implementation of the suggested optimisation in CT, interven- knowledge, competence and skills of optimisation measures. Collabora- tional procedures and the use of the members of the core team have tion focuses on the scope of activi- x-rays outside the departments of to be defi ned together with training ties of the EC-funded project. To that radiology initiatives, supported by EMAN and end, the three working groups are » To increase the visibility of EMAN scientifi c societies. encouraged to resume their activi- among all groups of stakeholders Each working group developed ties, update their documents and in order to bring awareness, knowl- synthesis documents and recom- build upon the achievements of the edge, skills and competences to mendations addressed to the Euro- project. individual members of the medical pean Commission, standardisation Experts, who are interested in the workforce and regulatory bodies, manufactur- Network and share our interest in » To disseminate up-to-date infor- ers and, users. The documents are improving this safety culture, are mation about literature, studies, available on the EMAN website for welcome to contribute to the activ- research and good practices relat- consultation and dissemination. ities of the working groups. Please ing to the ALARA principle in the The fi rst annual EMAN meeting to contact the EMAN Secretariat, who medical sector review activities, discuss the way for- will be happy to put you in contact » To provide a platform for mul- ward and disseminate achievements with the relevant EMAN members. ti-stakeholder exchange and dis- was held during ECR 2013 in March. cussion in the fi elds of medical Moreover, EMAN already published www.eman-network.eu radiation protection three newsle er editions in Febru- » To identify and communicate chal- ary, June and October 2013, which lenges faced by hospitals in regard focused on the activities, achieve-

myESR.org ECR TODAY | SUNDAY, MARCH 9, 2014 TECHNOLOGY FOCUS 21

BY GEORGI SIMEONOV Radiation safety in medical imaging and European Union law

The European Union (EU) has more than fi y years of experience in enacting laws on health protection of workers and the general public against the dangers of ionising radiation. This legislation has been adopted under the Euratom Treaty,1 which entrusts the European Commission (EC, ‘the Commission’) with the task of proposing ‘basic safety standards’ (EU BSS) a er having received the opinion of the group of scientifi c experts referred to in Article 31 of the Treaty. Legislation development process

A er consulting the European The revised EU BSS bring several been introduced for the exposure Parliament, the Council of Ministers important changes to radiation of asymptomatic individuals. adopted the Euratom BSS Directive safety in medical imaging. The Arti- » Optimisation has been strength- (Figure A), which has to be enacted cle 31 group’s Working Party on Med- ened. DRLs have to be regularly in the national law of the 28 EU ical Exposures (WPMED) was deeply reviewed and will cover also inter- member states. The Commission involved in the EU BSS revision, and ventional procedures. Written has the power to review enactment many of the proposed changes were protocols are required for ‘rele- measures, issue recommendations presented at European and interna- vant categories of patients’, e.g. and take infringement action against tional meetings. The most impor- children. The involvement of a member states. tant amendments – as agreed by medical physicist is obligatory in The EU’s legal framework for radi- the national governments – are as interventional procedures and CT, ation protection has expanded over follows: and her/his availability for consul- the last few decades, and currently » The occupational dose limit for the tation and advice is required in all consists of several legal instruments lens of the eye has been reduced other imaging. covering diff erent issues. EU leg- from 150 to 20 mSv. This is par- » Equipment installed a er the EU islation on radiation protection ticularly relevant to interventional BSS enactment deadline should of patients was fi rst issued in the radiologists and cardiologists, for meet several new requirements for 1980s and revised in the 1990s. The whom eye protection and dose the display, reporting and recording EU BSS development process current Medical Exposure Directive monitoring should become a stand- of radiation doses. (MED) is an elaborate piece of EU ard practice. » Accidental and unintended expo- The European Commission is expe- and be er coordinate action among legislation that deals with a number » Medico-legal procedures – now sures are subject to recording, anal- rienced in taking action to support the diff erent stakeholders. Coopera- of ma ers, including the justifi ca- called ‘non-medical imaging expo- ysis and, in some cases, reporting the implementation of EU legisla- tion on all levels – locally, nationally, tion and optimisation of radiolog- sures’ – have been taken out of the to national authorities. The refer- tion, and new initiatives on radia- regionally and internationally – is ical procedures, the distribution medical chapter and should be rer and the patient should receive tion safety in imaging will soon fol- the key to success in maintaining of responsibilities, the training of treated according to specifi c new information about clinically signif- low. In 2007, the European national and, where necessary, improving medical staff , procedural aspects requirements. This includes a more icant accidents. authorities for radiation protection radiation protection of patients and and equipment use. rigorous justifi cation and develop- established the HERCA network health professionals without pu ing The EU BSS were recently revised ment of national guidelines, spe- The revised EU BSS Directive has (www.herca.org) and the protection an undue burden on regulators, cli- with two main objectives: a) to con- cifi c protocols and diagnostic ref- to be implemented in 28 EU mem- of patients is high on their agenda. nicians and the industry. solidate the existing legal basis for erence levels (DRL). ber states no later than four years The European societies and federa- the protection of workers, patients » Justifi cation has been reinforced. following its publication. This is a tions of key medical professionals Georgi Simeonov is Policy Offi cer and the general public, and b) to The term ‘prescriber’ has been major task, requiring leadership are cooperating on radiation pro- at the European Commission update the legislation in line with replaced by ‘referrer’ in order to from national authorities and the tection issues (www.eman-network. Directorate-General for Energy. recent scientifi c, technical and soci- emphasise the right of the radi- involvement of scientifi c bodies, pro- eu). Equipment manufacturers are etal developments. The revision and ological practitioner to select the fessional societies, manufacturers engaged in a dialogue with radiation 1 The Treaty establishing the European negotiation process took more than appropriate procedure. Patients and other stakeholders. protection regulators (www.cocir.org) Atomic Energy Community (Euratom) was signed in Rome in 1957, together with the fi ve years. Having been adopted in have to be informed about the European cooperation will facil- on a European level. Treaty that established the European Eco- December 2013 (Figure B), the revised benefi ts and risks of the examina- itate the effi cient and transpar- The revision of the EU BSS and nomic Community. These ‘Treaties of Rome’ EU BSS will repeal and replace fi ve tion, and the radiation dose should ent implementation of regulatory their implementation in the next are cornerstones of the European common current Directives, including MED, be indicated in the examination changes and should bring similar four years should be taken as an market and of today’s European Union. as of February 2018. report. New requirements have benefi ts to patients all over Europe. opportunity to enhance cooperation

VISIT THE EUROSAFE IMAGING POSTER EXHIBITION IN THE M BUILDING More than 40 posters from experts around the world on safety practices in paediatric CT and from stakeholders in the wider fi eld of radiation safety, including professional organisations, international societies and industry partners

www.eurosafeimaging.org myESR.org 22 TECHNOLOGY FOCUS ECR TODAY | SUNDAY, MARCH 9, 2014 Radiologists prepare for change in Irish healthcare

Therefore, the replacement of old ment of uniform, best practice, qual- The Faculty of Radiologists, the Royal College of equipment is haphazard and not ity assurance programmes across Surgeons in Ireland, is the body responsible for the planned in advance. The principal the country. This must obviously be service issues facing our specialties done with patient safety at its core. provision of postgraduate training in diagnostic are the need to increase consultant There is, however, a parallel process numbers (and to achieve a commen- of educating and informing society radiology and radiation oncology in Ireland. At pre- surate increase in trainee numbers so as to set realistic expectations. to keep pace) in order to ensure The National Quality Assurance sent, there are 82 specialist registrars in diagnostic safe delivery of timely service to Programme is currently under ten- patients, and a need to budget for der for provision of the programme’s radiology and 13 specialist registrars in radiation the development of departments technical aspects but is expected to oncology in full time training in their specialties. and replacement of equipment in a be rolled out in 2014. more planned fashion. Despite these difficulties, the Current government policy in Ire- specialties of radiation therapy and These trainees are spread across but increasingly in other European tion therapists, but despite this, the land is to centralise cancer care in diagnostic radiology are robust and 11 centres in diagnostic radiology countries and Australia. research output of our trainees and regional cancer centres. The impli- well-respected in Ireland. Our spe- and three in radiation oncology in There are approximately 340 con- consultants is consistently very high, cations for delivery of fi rst-class cialties a ract the brightest gradu- Ireland. Both programmes have sultant radiologists in full time prac- as evidenced by the high level of par- diagnostic services are signifi cant. ates every year, and competition for a fi ve-year training programme. tice in the Republic of Ireland (300 ticipation in international meetings At present, many forms of cancer places on our training schemes is Following satisfactory completion diagnostic and 40 radiation oncol- such as the ECR. The development are managed to a high standard in very intense. We work closely, where of training and having passed the ogy). The number of consultant and of Academic Medical Centres on best hospitals that have evolved very possible, with employing and regu- fellowship examination, candidates trainee posts in the public sector practice international lines will, it is experienced teams in specifi c niche latory authorities to maintain our are eligible for inclusion on the is controlled by the Health Service hoped, help the strategic evolution areas. The movement of staff and high standards, and we look forward specialist register of the Medical Executive (HSE). The ratio of consult- of imaging research. expertise has been and will con- to the future with our fellows and Council of Ireland, and are eligible ants to population is low in compar- The standard of equipment in tinue to be required to achieve the trainees remaining at the centre of to apply for permanent consultant ison to most EU countries, and the diagnostic and therapeutic depart- political goal of centralisation with high-quality medical care delivery. posts in their specialty. Nonetheless, number of studies performed by ments in the country is relatively limited resources to implement most of our trainees pursue further individual consultants is quite high high, but variable. Equipment pur- these changes in continuing times More information about the Fac- training abroad a er completion of by international standards. Under- chase and replacement is the func- of austerity. ulty of Radiologists, the Royal Col- training in Ireland, principally the standably, this places great pressure tion of the HSE, and budgeting is not A major issue for the Faculty of lege of Surgeons in Ireland, can be United States, Canada and the UK, on practising radiologists and radia- based upon a depreciation model. Radiologists is to inform the develop- found at www.radiology.ie

BY MICHAEL FUCHSJÄGER Breast imaging society’s membership growing steadily

For the European Society of Breast Imaging (EUSOBI), 2013 was an even more successful year than 2012. EUSOBI can look back on many positive developments from last year.

First and foremost, EUSOBI is grow- these highly sought a er courses will interested in breast cancer screening. ing. The annual meeting last year in take place in Dubrovnik in June. The Each participant will be able to read Rome, held in conjunction with the fi rst EUSOBI Digital Breast Tomosyn- 900 screening examinations individu- Breast Study Group of the Italian Soci- thesis Course, held in Vienna a few ally. The programme will incorporate a ety of Medical Radiology (SIRM) was days ago (March 4–5, 2014) was also series of lectures by several experts in a ended by a record 597 radiologists fully booked. During this course not the fi eld of radiology, pathology, breast from 51 diff erent countries, compared only was there an overview of the cancer screening, epidemiology, phys- to 551 in 2012 and 248 in 2011. Among currently available tomosynthesis ico-technical aspects of digital breast these were 92 a endees from non-EU systems, but results from diff erent cancer screening, according to the countries; so not only are the numbers ongoing clinical trials were presented organiser, Ruud Pijnappel. The 2014 EUSOBI Annual Meeting, which will take place in increasing but our area of infl uence is and hands-on expert training in tomo- Ruud Pijnappel is also the local Amsterdam from 26–27 September, will be held jointly with the Dutch expanding. Furthermore, within the synthesis interpretation was off ered. organiser of the 2014 EUSOBI Annual College of Breast Imaging (DCBI). last two years the number of EUSOBI Another EUSOBI initiative is Meeting, which will take place in members has increased from 200 to focused on the publication of recom- Amsterdam from 26–27 September, age, and the important question of ardise training and expertise in breast 391. mendations for women’s informa- and will be held jointly with the Dutch whether or not we really need high- imaging across Europe. Notably, this Last year, EUSOBI established tion. The article on mammography, College of Breast Imaging (DCBI). This fi eld or ultra-high-fi eld breast MRI will diploma has gained the interest of some new subcommi ees, including ‘Mammography: EUSOBI recommen- congress will continue the focus on be answered. many non-European radiologists, educational, scientifi c and interna- dations for women’s information’ in radiologic-pathologic correlation During ECR 2014, the European especially from the Middle East. The tional relations commi ees. These Insights into Imaging 2012; 3:7-10, will which began at the Barcelona meet- Board of Breast Imaging (EBBI) next EBBI examination will be held commi ees have been highly active; be followed by a similar publication ing in 2012, and will include, ‘What a examination will take place for the in September in Amsterdam at the Julia Camps-Herrero, chairperson of dedicated to breast MRI in 2014. radiologist needs to know about mod- fourth time. Since its implementation EUSOBI Annual Meeting. the International Relations Commit- From June 2–6 the fi rst Interna- ern/molecular breast pathology’. A er at the annual meeting in Barcelona tee, organised a Breast MRI course in tional EUSOBI Breast Cancer Screen- the highly acclaimed EUSOBI meets in 2012, 23 radiologists have taken the More about the EUSOBI can be Cancun, Mexico, in June 2013, aimed at ing Course in cooperation with the Egypt and Chile sessions in Rome, exam, 20 of these passed the exam and found at www.eusobi.org the promotion and training of profes- Dutch National Expert and Training EUSOBI will meet India in Amster- obtained the European Diploma of sionals in breast imaging. Centre for Breast Cancer Screening dam. Highlight sessions will focus on Breast Imaging (EDBI). The European Professor Michael Fuchsjäger Other initiatives included two fully (LRCB) will take place in Nijmegen, the specifi c populations le out of Diploma in Breast Imaging, endorsed from Graz, Austria, is a member booked (100 a endees each) high-end, the Netherlands. This course is spe- organised population-based screening by the European Society of Radiology, of the EUSOBI International Rela- state-of-the-art Breast MRI Courses cifi cally designed for radiologists who programmes; the age groups below is a common European qualifi cation tions Commi ee. in Vienna and Rome. The next one of perform breast cancer screening or are 50 years of age and above 70 years of for breast imagers and will help stand-

myESR.org ECR TODAY | SUNDAY, MARCH 9, 2014 TECHNOLOGY FOCUS 23

BY FEDERICA ZANCA, XOCHITL LOPEZ-RENDON, LUDOVIC D’HULST, HILDE BOSMANS, MARIA-HELENA SMET, PHILIPPE DEMAEREL , STEVEN PANS, RAYMOND H. OYEN Belgian hospital enhances optimisation and monitoring in paediatric CT

CT Head CTDI DLP Over the last decade, there has been growing con- vol Age of the child (y) (mGy) (mGy cm) cern regarding the potential risk of cancer induc- 0 to 1 13.3 239.9 tion from CT due to its exponentially increased 1 to 5 17.4 330.6 1 use in medicine. Although there is no doubt about 6 to 10 21.6 419.1 the clinical benefi t of CT in appropriate clinical 10 to 16 39.4 750.5 se ings, keeping radiation doses as low as reaso- >17 41.2 814.9 nably achievable remains fundamental to decrea- Table I: CTDIvol and DLP as extracted from 426 paediatric head CT examinations, grouped by age. Protocols used for these examinations sing radiation-related risks and increasing patient were sequential or spiral, single phase (without intravenous contrast medium injection). kV varied between 80 and 120, depending on protection. patient size. Automatic tube current modulation was active. Data are reported for a 16cm phantom.

At the University Hospitals Leu- the radiographer and the physi- (ATCM), automatic selection of tube ven, Belgium, there is a strong com- cist ensure that the examination potential, adaptive collimation, new CT Thorax CTDIvol DLP mitment to minimising radiation is carried out with a state-of-the- reconstruction algorithms like itera- Age of the child (y) (mGy) (mGy cm) dose for all patients and children in art technique by optimising the tive reconstruction techniques, and particular. This can be achieved with CT scan parameters and using the protocols tailored to patient size and 0 to 1 0.7 13.7 high-end scanners and in several ‘right’ dose, meaning the lowest age. 1 to 5 1.2 26.0 ways. More specifi cally, the appro- dose needed to answer the diagnos- In particular, a scanner is available 6 to 10 1.3 32.8 priateness of the CT exams should tic question. The options for dose that allows the tube potential to be be validated and the radiation dose reduction include the standard set as low as 70 kV. This is extremely 10 to 16 3.3 100.5 tailored to the size of the child. rules: minimal anatomical length, useful for dose reduction when per- >17 5.6 200.7 correct patient positioning, reduc- forming CT of babies. APPROPRIATENESS tion of the exposure se ings, and The department of radiology

The most eff ective way to reduce a selected number of scan phases. also takes advantage of improving Table II: CTDIvol and DLP as extracted from 109 paediatric thorax radiation exposure is to avoid radi- Indeed patients undergoing CT may technology, by performing contin- CT examinations, grouped by age. Protocols used for these ation when it is not needed. This be exposed to high doses even with uous research (medical physicists examinations were spiral, single phase and without intravenous is independent of the CT scanner an optimised protocol, just because and physicians) to assess these lat- contrast administration. kV varied between 80 and 120, depending on and its technical parameters and simple methods like careful posi- est technologies and to ultimately patient size. Automatic tube current modulation was active. CTDIvol relates only to the concept of jus- tioning are o en overlooked. This improve patient care. For these as reported on the scanner is for a 32cm phantom. The conversion factor for converting the CTDI for a 32cm phantom size to a 16cm tifi cation (the net benefi t must be aspect has been the subject of pre- aspects, a close and mutual collab- vol phantom size for paediatric body protocols is 2.2. So for example the positive). Justifi cation is imple- vious publications.2 oration with the vendors has been CTDI for a child of 1 year for a CT thorax is 0.7x2.2= 1.54 mGy. mented in clinical practice by apply- In addition, a quality initiative set up, resulting in scientifi c pres- vol ing the Belgian referral guidelines was set up in the radiology depart- entations and papers. for medical imaging, a concept of ment, with the aim of harmonising CT Abdomen CTDI DLP good practice against which the and optimising CT procedures for F. Zanca, X. Lopez-Rendon, vol Age of the child (y) (mGy) (mGy cm) needs of the individual patient are all scanners. In collaboration with H. Bosmans, M. Smet, P. Demae- balanced against the risks (h p:// a university spin-off , Qaelum (www. rel , S. Pans, R. Oyen are from 0 to 1 1.8 52.1 www.health.belgium.be/richtlij- qaelum.com), a so ware tool is being the Department of Radiology & 1 to 5 2.1 63.9 nen-medische-beeldvorming). developed to create a web repository Department of Imaging & Pathol- At present, the number of pae- of all CT examination procedures, ogy, University Hospitals Leuven, 6 to 10 1.8 66.4 diatric CT examinations that lack track voluntary and involuntary Belgium. 10 to 16 3.3 135.3 appropriateness is not systemati- changes, and to register patient spe- cally assessed. In cases of equivocal cifi c dose.3 This allows CT patient L. D’Hulst works at the Center >17 7.5 314.0 indications, the radiologist contacts protocols and doses in a clinical of Competency for Medical Doc- the referring clinician and suggests workfl ow to be tracked and doses to tors, University Hospitals Leuven, Table III: CTDIvol and DLP as extracted from 45 paediatric abdomen an alternative examination (or be collected in a register. Diagnostic Belgium. CT examinations, grouped by age. Protocols used for these rejects the exam if needed). Empir- reference levels (DRLs) can then be examinations were spiral, single phase and without intravenous ical data based on personal com- determined. contrast. kV varied between 80 and 120, depending on patient size. 1 Radiation Dose from Multidetector CT, munication with paediatric radiol- As a result, most of the CT exam- Automatic tube current modulation was active. CTDIvol as reported ogists suggest that around 15–20% inations performed at our institu- Editors: Denis Tack, Mannudeep K. Kalra, on the scanner is for a 32cm phantom. Conversion factors for Pierre Alain Gevenois. Springer, 2012. converting CTDI a 32cm phantom size to a 16cm phantom size for of CT referrals could be declined, tion have a dose level well below 2 Zanca F, Demeter M, Oyen R, Bosmans H. vol the majority trauma and oncol- the reference levels proposed by the Excess radiation and organ dose in chest and paediatric body protocols is 2.2. So for example the CTDIvol for a child ogy patients. In the future, actual Federal Agency for Nuclear Control abdominal CT due to CT acquisition beyond of 1 year for a CT abdomen is 1.8x2.2= 3.96 mGy. assessment is the goal. The reasons (FANC) (see Table I–IV). expected anatomical boundaries. Eur Radiol. 2012 Apr;22(4):779-88. for rejecting or modifying CT exams 3 Federica Zanca, Jurgen Jacobs, Patrick include: an alternative modality is USE OF HIGH END Lievens, Walter Coudyzer, Raymond H. DRL in CTDIvol DRL in DLP more appropriate (US or MRI can CT SCANNERS Oyen, Hilde Bosmans. Implementation of (mGy) (mGy.cm) be gained from the CT examination, Additional opportunities to fur- a Controlled and Up-to-date Repository of CT exam 25th percentile 75th percentile 25th percentile 75th percentile the interval between consecutive CT ther reduce dose come from techni- CT Protocols to Control Radiation Exposure and Image Quality Proactively, RSNA 2012, examinations is too short, or sin- cal innovations as provided by the Chicago. Brain 31 75 430 869 gle-phase CT is more appropriate manufacturers. The CT equipment Thorax 1.9 5.2 43 140 than the requested multi-phase CT. is mainly composed of the latest technology to obtain the highest Abdomen 2.9 6.8 101 316 CUSTOMISING THE CT DOSE diagnostic image quality with the TO THE CHILD’S SIZE lowest possible radiation dose. Table IV: National dose reference levels (DRLs) (25th and 75th Once referral for CT examination These technical innovations include percentile) for CTDIvol and DLP of paediatric head, thorax and has been justifi ed, the radiologist, automatic tube current modulation abdomen CT.

myESR.org

25 SUNDAY, MARCH 9, 2014 COMMUNITY NEWS

ESR promotes role of Rising Stars exposes students to Top tips for imaging in personalised “the charms of radiology”, says trainees and teachers 27 medicine 28 former ECR President 29 Part 4: Research

Award-winning author delivers honorary lecture at ECR 2014

Though well-known for his In recognition of his great contributions to abdo- non-fi ction accounts of scientifi c development, Prof. Meyers is an minal radiology and his insightful publications on experienced radiologist and has the history of science and medicine, Prof. Morton published extensively within the fi eld. His popular textbook Meyers’ A. Meyers from East Setauket, NY, United States, Dynamic Radiology of the Abdo- men, hailed as ‘the book that rev- will deliver the Samuil A. Reinberg Honorary Lec- olutionised abdominal radiology’, is now in its sixth edition and has ture entitled, ‘The Tempestuous Genesis of MRI: been translated into Spanish, Ital- ian, Japanese and Portuguese. He Credit and Discredit’ at ECR 2014. has also been actively involved in the publication of medical and sci- Prof. Morton A. Meyers is distin- dents: Serendipity in Modern Medical In addition to teaching at SUNY, entifi c work. He edited a series of Prof. Morton A. Meyers from guished professor of radiology and Breakthroughs. Prof. Meyers has served as visiting volumes dealing with iatrogenic dis- East Setauket, NY, United States. medicine, as well as chairman emeri- His book, Happy Accidents, won professor at more than 70 medical eases and a major textbook, with 55 tus of the department of radiology at the prestigious CHOICE Outstand- schools around the United States. international contributors, on the “With great delight, I have the State University of New York at ing Academic Title award in 2009 for He has also been in great demand staging of abdominal cancer, and he witnessed the rapid growth of Stony Brook (SUNY). He is author of excellence in scholarship and pres- as a lecturer, having received invi- is the senior author of more than the ECR, now clearly established the critically acclaimed books; Prize entation, signifi cance of contribution tations to lecture in Japan, South 200 articles – several of which have as a renowned international Fight: The Race and Rivalry to be to the fi eld and value as an important Africa, China, Israel, Canada, Mexico been designated as citation classics forum. The inspired leadership the First in Science and Happy Acci- treatment of the subject. and throughout Europe, to name but by the Science Citation Index, based of the ESR serves as a model for a few places. He has also received a upon their frequency of citation – all professional societies in our number of awards from national and and 70 book chapters. Prof. Meyers specialty and I am very pleased to international societies, as well as the has illuminated the pathways of count among its members many Walter B. Cannon Medal of the Soci- spread and localisation of cancer colleagues and friends.” Samuil A. Reinberg Honorary Lecture ety of Abdominal Radiology. Notably, in the abdomen. He founded the Sunday, March 9, 12:15–12:45, Room A #ECR2014A he delivered the Opening Lecture at internationally recognised journal The tempestuous genesis of MRI: credit and discredit ECR 2003, since which he is proud Abdominal Radiology 38 years ago to serve as an Honorary Member of and continues to serve as its editor- Morton A. Meyers; East Setauket, NY/US the ESR. in-chief today. ESCR boosts educational activities in 2014

cational off ers some of the existing The European Society of Cardiac Radiology gaps can be closed in the curriculum, (ESCR) membership exceeded 1,000 members in from beginners to experienced car- diac radiologist and members of the 2013. This has helped it further strengthen its EBCR. One of the Society’s recent role as the leading professional organisation in achievements was the creation of a combined registry for cardiac MR cardiac imaging in Europe and one of the largest and CT (www.mrct-registry.org) to document and certify cardiac subspecialty societies within the ESR. examinations by ESCR members and institutions. The documenta- tion in the cardiac MR/CT Registry Research, science and, fi rst and Two diff erent modules will be the European Society of Thoracic will be a prerequisite for Cardiac foremost, education are the major off ered this spring, one on cardiac Imaging (ESTI), ESOR, the Interna- Diploma applications. It will help fi elds of the society´s activities. CT from April 30 to May 1, and one on tional Society of Radiology (ISR) and the society to identify high-volume Prof. Ma hias Gutberlet from The fi eld of non-invasive cardio- cardiac MRI on May 2–3, 2014. These the Society for Cardiovascular Mag- centres as training centres for fel- Leipzig, Germany, is vice- vascular imaging has dramatically courses are organised by Prof. Chris- netic Resonance (SCMR). There will lowships in cardiac CT and MR, president of the ESCR. expanded during the last decade, tian Loewe from Vienna, Austria, and also be an ASKLEPIOS multimodality establish multicentre trials in car- which demands that subspecialty Dr. Marco Francone from Rome, Italy. course in Vilnius, May 23–24, 2014, a diac imaging and create a platform societies also off er additional ser- The venue of the workshops will be joint session with ASCI at Jeju-Is- to document the prognostic impact vices to their members to keep up the brand-new ESR Learning Centre, land in Korea on June 12–14, 2014 and of cardiac imaging procedures (MR with developments. Starting at ECR ideally located on the famous Passeig another joint session with the ISR in and CT) on patient outcome in the The current vice-president 2014, aspiring cardiac radiologists de Gracia in Barcelona, and will be Dubai on September, 9–12, 2014. near future. The registry has been Prof. Gutberlet, on behalf of the have the opportunity to take the organised and lectured by members The ESCR educational year will a success from the very beginning ESCR, would like to encourage all European Board of Cardiac Radiol- of the EBCR. A limit of 30 att endees end with the 12th Annual ESCR and, as of February 1, 2014, contains ESCR members to document their ogy (EBCR) Diploma examination, will ensure all participants get the Meeting in Paris on October 2–4, approximately 30,000 documented anonymised cardiac cases in the organised by Prof. Jens Bremerich most out of the workshops and enjoy 2014, with a highly educational cardiac CT and cardiac MRI cases ESCR’s MRCT Registry and use the from Basel, Switzerland. This year, the friendly atmosphere. combination of the latest research from 338 contributing users from ESCR website or Facebook page to the society will also launch a series Furthermore, diff erent educational results, workshops and educational 103 institutes in 14 European coun- share ideas and problems with the of educational workshops in car- activities will be provided as joint courses, as well as case presentations. tries. “The growth is very impres- European cardiac imaging com- diac imaging to add to the already activities with the Asian Society of There are three parallel sessions for sive, and the number has increased munity, which may help to further established joint workshops with Cardiovascular Imaging (ASCI), the beginners, advanced cardiac imagers around 50% over the last 6 months,” improve the society for their mem- the European School of Radiology International Congress on Cardiovas- and experts in the fi eld. The Society says Prof. Matt hias Gutberlet from bership services. (ESOR) and others. cular Magnetic Resonance (EuroCMR), hopes that with the additional edu- Leipzig, Germany. myESR.org 26 COMMUNITY NEWS ECR TODAY | SUNDAY, MARCH 9, 2014 Royal College takes on major issues in 2014

WORKFORCE The Royal College of Radiologists week services. Despite the advanced role in education as far as the public The biggest issue facing UK radiol- (RCR) has had some success in per- development of the skill mix in the and patients are concerned. ogy is the need for a larger workforce. suading the UK planning authori- UK with radiographer reporting, we In the UK, we have a long tradition The growing demand and complex- ties of the need to increase training know that simply will not fulfi l what of managing radiation protection ity of the workload is outstripping places; that has yet to be backed up by is required. carefully through ionising radiation the ability of the current workforce the requisite funding. We also have a regulations. This is one of the best to respond eff ectively. Add to that constant struggle to ensure that the PATIENT SAFETY, QUALITY developed monitoring and reporting several other factors: need to expand interventional radi- AND RADIATION PROTECTION regimes in radiology and has served » an aging population with a growing ology services is not achieved at the There is a growing focus on patient us well. Nevertheless we are alive to demand for healthcare services expense of diagnostic services. Thus, safety across the UK. This has been the need to ensure that the protocols » a growing reliance across medicine while we have secured 30 additional especially stimulated by the fi ndings and reporting structures are working on imaging services training places for England and four of a major public inquiry into the eff ectively and will be contributing » the number of radiologists per for Wales, whether those places will failings at a hospital in the English to any review of the regulations. 100,000 population in the UK being be funded and fi lled remains uncer- Midlands. The Francis report issued Quality improvement is also a well below that of comparable tain. Despite that, it was a massive in February, 2013, contains some 290 watchword of the College, and the European countries achievement to have the 30 places recommendations and there was quality of care was one of the major » a cash-strapped public health ser- allocated in England – apart from action for the College to take. As part themes of the Francis report. The vice (which is responsible for the general practice and psychiatry; ours of our response we have appointed a RCR has delivered active and success- planning and delivery of the vast was the only medical specialty to be patient safety adviser (a Fellow of the ful programmes of national clinical 63 Lincoln’s Inn Fields is home to majority of healthcare in the UK) recognised for growth. College) to work with us for a year, audit for many years, and we are now the Royal College of Radiologists » meeting the specifi c demand for On a positive note, a recent English ending this summer, to help embed looking to develop that expertise into in London, United Kingdom. specialist imaging which is also health service document planning patient satiety into our programmes quality improvement so as to ensure growing for seven-day-week service delivery of work and in particular into our that the learning from audit is seen » the need to develop and deliver con- recognised the crucial role that imag- standards and guidance documents. through, and that systems and pro- Scientifi c Meeting. Now a vibrant sistent and eff ective interventional ing and interventional radiology can Patient interest in safety and dis- cesses change as a result. We have and growing three-day event, which radiology services across the UK play. Another recent document has crepancy is obviously heightened charged a new Quality Improvement has doubled in size over the last few » the need to develop radiology ser- pointed out the variation in services by documents such as the Francis Working Party with doing just that. years, it takes place at the Barbican in vices for primary care – as a means across the country and the conse- report and we are working with our the City of London and has a devel- to help integrate the UK healthcare quent need for investment. newly re-formed lay member net- LEADERSHIP, EDUCATION AND oping international profi le. The 2014 system and to deliver more timely The College continues to make work to discuss the human factors SUPPORT: THE THREE PILLARS meeting takes place on September and cost eff ective diagnosis the case for growth in the workforce in imaging, the limitations in accu- OF THE RCR 8–10. Full details of the programme, » ever growing patient expectations with the commissioners of services, racy despite huge advances in the Support for, and engagement, with early bird registration before » and in particular, the expectation service providers, workforce plan- technology, the multiple safeguards with the College’s membership is a the end of May 2014 can be found at that services will be of similar or ning groups and those responsible in place, and what happens when key pillar of what we as the College www.rcr.ac.uk the same quality and responsive- for planning training. We are also discrepancies occur. This will draw aim to deliver alongside our leader- ness seven days per week, not just advocating networking solutions to on the growing volume of literature ship and education roles. These three fi v e help meet the demand for seven-day- and is part of the College’s important pillars come together at our Annual

BY CARLO FALETTI Italian society steams on

The Italian Society of Medical Radiology (Società Italiana di Radiologia Medica – SIRM), which I am honoured to preside over, has achieved a signifi - cant position in the fi eld of Italian health over the last few years.

This is not only thanks to the tion (also in the transposition of the which is directly managed by SIRM, Italian version complete with case constant att ention paid to how European laws covering this sector). as well as off ering the possibility of reports. radiology specialties must be estab- There is now a clear commitment reliable and inexpensive insurance In conclusion, as SIRM celebrated lished and run in order to achieve and role for the medical radiologist coverage. its fi rst 100 years of activity last year, the specifi c goals set by this sector, in conventional radiology, echogra- However, the real challenge to be it will continue with its eff orts in but also thanks to the role of the phy, CT and MRI techniques, and we faced in the future is surely that of Italy and the world over as strong radiologist. This role, owing to inno- need to make the most of what these becoming progressively more and as the slogan that has accompanied vative technology and professional techniques have to off er. more involved in the most innova- it along this century long road: the commitment, is now recognised as The progressive computerisation tive applications in the fi eld of radi- future comes from a solid past. a milestone in the diagnostic and of radiology must be integrated into ology, such as cardioMRI and, above Here, at this congress today, we therapeutic steps involved in various our everyday routine. Indeed, SIRM all, interventional radiology, that is have the pleasure and honour to fi elds of application. has taken on the dissemination of an to say the extension of echography welcome Prof. Lorenzo Bonomo as All this has enabled us to identify initiative set-up to identify the crite- and CT-guided surgery to all medical incoming president of the ESR. We the position radiology has in the ria necessary to ensure that the most fi elds. hope he will be able to share the emergency sett ing, whether it be in appropriate examination for a spe- Finally, I would like to mention knowledge and professionalism he Professor Carlo Fale i from specialised trauma reference centres, cifi c pathology has been requested, that the next few months will wit- has acquired as a medical radiologist Torino is the SIRM President. HUBs, in one of the many referral as well as how data can be stored ness the birth of a new scientifi c over the years, as well as his experi- centres, SPOKES, or within the var- and transmitt ed. All of which is to journal for radiologists; the Italian ence working for our society, with the ious territorial structures that have be done in accordance with the laws Journal of Medical Radiology, which world of European radiology. been selected for their technology governing privacy whilst, at the same will complement the prestigious and skills. time, maintaining the best possible journal, Medical Radiology, availa- More information about the Ital- The defi nition of the medical radi- cost/effi cacy ratio, keeping public ble only on the web and in English. ian Society of Medical Radiology can ologist’s role in what has been called expenditure to a minimum. On the one hand, this will make the be found at www.sirm.org the radiological area was a funda- Our society has now widened its information gathered by our scien- mental step. This area includes all horizons beyond its well-known tifi c society available to the entire Professor Carlo Fale i from health professionals that make up scientifi c ones to include ever more scientifi c world, and, on the other, it Torino is the SIRM President. our discipline and is based legisla- professional coaching and training, will provide our members with an

myESR.org ECR TODAY | SUNDAY, MARCH 9, 2014 COMMUNITY NEWS 27

BY JAVENI HEMETSBERGER ESR promotes role of imaging in personalised medicine

cial notifi ed bodies to be designated revise the existing Directive and thus The ESR has been a member of European Alli- by the European Medicines Agency enhance enforcement and address (EMA). the fragmentation of national data ance for Personalised Medicine (EAPM) since 2013, The ESR welcomes the creation protection legislation, legal uncer- of special notifi ed bodies but is con- tainty due to the increased scale of which is a multi-stakeholder coalition acting on a cerned about creating a centralised data sharing, as well as development European level to improve patient care by accelera- role for the EMA. of new technologies. The discussions between the EP In October, aft er prolonged discus- ting the development, delivery and uptake of per- and Council have started. The mem- sions within the European Parlia- ber states have voiced disagreements ment the Civil Liberties Committ ee sonalised medicine and diagnostics. regarding the pre-market approval (LIBE) adopted its report on the new mechanism of high-risk devices, data protection regulation and the reprocessing, post-market surveil- German Rapporteur Jan Philipp In October 2013, the ESR together markers and biobanks, improved EUROPEAN MEDICAL lance, as well as the timeframe for Albrecht (Greens) started negoti- with the EAPM, organised a round- framework conditions for research, DEVICES LEGISLATION adoption, and seem to favour the ations with the Council. Proposed table discussion on ‘the role of and greater effi ciency in translat- Another dossier the ESR is closely Commission proposal over the EP measures include stricter rules for radiology/imaging in personalised ing scientifi c research into practical following is the European medical report. It is unlikely that an agree- data transfers between the EU and medicine – How to provide the outcomes. devices legislation. ment will be reached before the third states, the introduction of an right prevention and treatment to Two weeks later, the European In the wake of the PIP breast European Parliament holds its elec- explicit consent requirement, the the right patient at the right time?’ Commission published its staff implant scandal back in 2012, the tions in May 2014. ‘right to be forgott en’, as well as fi nes which took place at the European working paper on the use of ‘omics’ European Commission published of up to €100 million for companies Parliament in Brussels. technologies in the development a proposal revising the existing DATA PROTECTION breaking data protection rules. The event was hosted by Croa- of personalised medicine, which – legislative framework, taking into REGULATION The European Commission and tian MEP Dr. Biljana Borzan (S&D) contrary to the expectation of ESR account new technologies, enhanc- In January 2012, the European the EP are in favour of concluding and focused on the necessity for – paid very litt le att ention to imaging ing the quality standards, introduc- Commission adopted a proposal for the dossier prior to the EP elections cooperation between policymakers, in this fi eld. The ESR submitt ed a ing stronger market surveillance and a Regulation on the protection of in May. However, it is unlikely that medical professionals, patients and statement on the report to the EC providing greater transparency. individuals with regard to the pro- an agreement will be reached within the industry in order to raise aware- requesting a clearer reference to the In October, a European Parliament cessing of personal data and on the the coming months, since the mem- ness of the crucial role imaging role of imaging in order to ensure plenary session discussed the pro- free movement of such data. Since ber states’ positions on the proposal plays in driving forward the devel- bett er visibility. The ESR will con- posed medical devices regulation. the last Directive, 95/46/EC on the are still highly divergent. opment of personalised medicine. tinue its eff orts in enhancing the Among the main amendments protection of individuals with regard The discussion concluded that the visibility and importance of imaging adopted were a new committ ee for to the processing of data and free For more information please con- key issues requiring action include in the development of personalised case-by-case assessments of high- movement of such data, was adopted tact eu-aff [email protected] the development of imaging bio- medicine. risk devices and the creation of spe- in 1995 this new proposal aims to

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PLEASE VISIT US AT BOOTH N°5, EXT. EXPO A, FOR A DEMONSTRATION myESR.org 28 COMMUNITY NEWS ECR TODAY | SUNDAY, MARCH 9, 2014

BY MÉLISANDE ROUGER Rising Stars exposes students to “the charms of radiology,” says former ECR President

ECR Today spoke with Professor Małgorzata Szczerbo-Trojanowska, from Lublin, Poland, patron of the Rising Stars programme.

ECR Today: The Rising Stars pro- the charms of radiology from the The educational basic sessions are gramme is under your patronage early years of their education. This dedicated this year to cardiac radiol- this year. What motivated you to is the way to raise their interest in ogy, neuroradiology and oncologic take on this role? this specialty and get them involved imaging. Małgorzata Szczerbo-Trojanowska: in radiology research. It is in the best As an extension of the programme, Medical students and residents will interest of the future of radiology. So we will off er case-based diagno- create the shape of radiology in the when I was off ered to take patron- sis training on Monday aft ernoon. future. Therefore, those of us who age of the Rising Stars programme, Training will consist of two sessions, care for our specialty should make an I didn’t hesitate for even a second. which will be divided by a short eff ort to encourage the best, bright- interlude. The sessions, which were est and most enthusiastic students ECRT: Why should a medical stu- prepared by two excellent lectur- to choose diagnostic imaging as their dent or radiology trainee take part ers, Dr. Soraya Robinson and Prof. professional career. in this programme? Klaus Friedrich, are aimed mainly at I am very pleased to be involved in MST: The European Congress of residents and focus on case-based the preparation of the Rising Stars Radiology, one of the world’s leading learning. programme, which aims to create an radiological meeting, off ers medical interesting educational agenda for students and residents a unique ECRT: What do you think students and to encourage them to opportunity to see the greatest sci- of the quality of the students’ actively participate in the congress entists, practitioners, lecturers and presentations? sessions specifi cally designed for teachers present some fascinating MST: Judging from the very well them. achievements of modern radiology. prepared abstracts, I assume that the I think this programme is a very There are also many chances to learn presentations will also be excellent. Professor Małgorzata Szczerbo-Trojanowska is Head of the important initiative of the European the state of the art in a wide variety Last year, I chaired two sessions and Department of Interventional Radiology and Neuroradiology at the Society of Radiology and the ECR. of imaging methods for a plethora of I remember the very high quality of Medical University in Lublin, Poland. She served as ECR Congress Having been an academic teacher diseases, and to fi nd answers to com- the presentations’ contents, struc- President in 2010. for many years, I am aware of the plex problems of contemporary med- ture and slides, and the excellent great signifi cance of undergraduate icine provided by world-renowned language, timing and performance. education. It has always been my experts. Participation in the ECR It was really a diffi cult task to select aim as chairperson of the radiol- shows the importance of radiology the best paper of the session. It is ogy department at my university to in patient care, its great impact on worth mentioning that the discus- Rising Stars at ECR 2014 off er att ractive forms of radiology other areas of medicine, and its rel- sions following each presentation Basic Sessions #ECR2014Studio teaching and to expose students to evance in the progress of medicine. were educational and mature, and By taking part in the Rising Stars proved the authors’ profound knowl- Special sessions suitable for residents, students, Staff Box programme, medical students, radi- edge of the topics. radiographers and radiographers-in-training ology trainees and radiography train- Sunday, March 9, 10:30–12:00, Studio 2014 ees have an opportunity to give a ECRT: How relevant is it to off er Editors Basic Session on Oncologic Imaging Julia Patuzzi, Vienna/AT presentation on the results of their peer-teaching ultrasound work- Philip Ward, Chester/UK own research work and opinions, or shops for students? ideas, related to medical studies. MST: Many student congress par- » Lung cancer Associate Editors J. Vilar; Valencia/ES Michael Crean, Vienna/AT Visiting the ECR technical exhibi- ticipants showed interest in ultra- Simon Lee, Vienna/AT tion is always an exciting and stimu- sonography in the past. For those » Kidney cancer Contributing Writers lating experience, providing a unique who have already had training in B. Brkljačić; Zagreb/HR John Bonner, London/UK opportunity to become acquainted ultrasonography, workshops are an » Rectal cancer Michael Crean, Vienna/AT with cutt ing-edge technologies and excellent chance to learn and ben- M. Maas; Maastricht/NL Florian Demuth, Vienna/AT new solutions. efi t from contact with experts in Javeni Hemetsberger, Vienna/AT Cynthia Keen, Sanibel Island, FL/US The congress is also an excellent this fi eld. For those who have never Simon Lee, Vienna/AT platform for young people to meet used this imaging modality yet, it is Sunday, March 9, 14:00–15:15, Studio 2014 #ECR2014Studio Becky McCall, London/UK peers and colleagues from various an exciting experience showing the Final Student Session Rebekah Moan, San Francisco, CA/US continents and countries, and estab- power of this most popular diagnos- Alena Morrison, Vienna/AT lish friendships that last a lifetime. tic tool. I am sure, based on many The best student presenters from Mélisande Rouger, Vienna/AT Frances Rylands-Monk, St. Meen Le The special dedicated lounge and examples, that a lifelong interest in Student Sessions 1 to 4 will be awarded. Grand/France the wonderful Rising Stars party a particular area of radiology can be Philip Ward, Chester/UK will allow the participants to meet initiated by a single meeting with a Sunday, March 9, 12:00–14:00, Room Z #ECR2014Z David Zizka, Vienna/AT new friends. brilliant educator. Pamela Zolda, Vienna/AT Student Hands-on Workshops on Ultrasound Art Direction ECRT: What do you think of the ECRT: Do you have any advice Hands-on Workshop on Ultrasound 4 Petra Mühlmann, Vienna/AT topics of the sessions? for residents and medical students Andreasz Diesenreiter, Vienna/AT Musculoskeletal Ultrasound (shoulder, brachial plexus, ankle MST: As always the topics were in general? Why should students and nerves of the lower extremity, knee) Design & Layout very carefully selected. This year choose radiology as a specialty? Robert Punz, zerozero.graphicdesign, Vienna/AT four new topics for student scien- MST: I would encourage medical tifi c sessions were chosen: awareness students to choose radiology because Marketing & Advertisements of the role of radiology in medicine it is the most dynamically evolving and treatment. This can be achieved it stimulates personal development Konrad Friedrich E-Mail: [email protected] among medical students and radiog- discipline in the whole area of med- by close cooperation with medical and, at the same time, gives tremen- raphers-in-training, multiple-choice icine. Accurate and early diagnosis is specialists from other disciplines. dous satisfaction. Actively partici- Contact the Editorial Offi ce ESR Offi ce questions (MCQ), oral exams, ‘My vital to successful treatment. Radiol- Those who would like to be involved pating in research in the discipline Neutorgasse 9 educational student project at uni- ogists are, nowadays, the key play- not only in the diagnostic part, but you have chosen has this exciting 1010 Vienna, Austria versity’, and ‘My fi rst medical scien- ers in the management of patients. also actively participate in treatment feeling of contributing to its further Phone: (+43-1) 533 40 64-0 tifi c work’. The number of submitt ed Imaging departments are the fast- can specialise in interventional radi- development. E-Mail: [email protected] papers surpassed 160, which proves est growing sector in medicine and ology, which off ers a wide and rapidly ECR Today is published that the topics were att ractive to the will remain so in the future. I would expanding range of minimally inva- daily during the ECR. students. We were also pleased to see advise students and radiology res- sive treatment methods. Circulation: 22,000 that the quality of the abstracts was idents to expand their knowledge I would personally encourage Printed by Gerin, Vienna 2014 very good. The best of the best were beyond imaging modalities to under- students and residents to engage myESR.org chosen for the congress presenta- stand the clinical background and in academic careers and research. tions; fi ve papers for each session. relevance of radiological diagnosis Scientifi c work is demanding, but

myESR.org ECR TODAY | SUNDAY, MARCH 9, 2014 COMMUNITY NEWS 29

BY CHRISTIANE NYHSEN Top tips for trainees and teachers Part 4: Research

enhance the quality of your research Inspired to start research by the excellent speakers tremendously. you have heard at this year’s ECR? Not sure where ECRT: Do you have any advice on to start? Get some top tips from Prof. Hans-Ulrich how and where to get funding? HUK: Nothing specifi c. It is always Kauczor, the ESR’s Research Committ ee chairper- about the well-known players. Remem- ber, most of the funding agencies son and professor at the prestigious University of are politically-driven, and their pro- grammes have to be, or at least sound, Heidelberg, Germany. Even if you work in a smaller diff erent every time and serve a general need, such as to fi ght unemployment, hospital, there may still be opportunities. Prepare increase chances for kids, provide a bet- ter environment, save energy, support your study well, don’t be afraid of statistics and the ageing population, etc. Be creative don’t be disheartened by early failures – experience and think about novel applications of radiology to serve those needs. Hans-Ulrich Kauczor is professor will help you achieve your goals. and chairman of radiology at ECRT: What should trainees the University of Heidelberg and director of diagnostic and know before looking to publish interventional radiology at ECR Today: Not all trainees are ard-of-care provided to the general your research and defi ne a clear and their research? University Hospital Heidelberg fortunate enough to work in a public with regard to standardised sound study plan and design your HUK: A good command of the lan- in Germany. He chairs the ESR’s university hospital. What kind of procedures and quality, as well as study accordingly. guage of the journal, mainly English. Research Commi ee. research do you think is feasible in cost eff ectiveness entering the fi eld Know how to structure a scientifi c an average-sized general hospital of health technology assessment ECRT: Many trainees and teach- paper and remain strictly within the or a smaller hospital? (HTA) are becoming more and more ers are overwhelmed by statistics. topic of your study. Hans-Ulrich Kauczor: Unfortu- important. What do you think they should do nately, the opportunities are limited to overcome this? ECRT: Do have any other advice in non-university and especially in ECRT: What do you think are HUK: Be strong and acquire some for trainees embarking on a non-academic hospitals. The two the most important things for a basic knowledge yourself. Part- research project? Dr. Christiane Nyhsen is con- best ways will be to participate in trainee to remember when planning ner with biostatisticians. Always HUK: Be prepared for failure and sultant radiologist at Sunderland multi-centre clinical trials and to a research project? include some funds for biostatis- learn from it. This is the best way Royal Hospital, UK, and former affi liate with a university hospital. HUK: Think before you start the tics if you write grant applications. to improve your skills, and you will chairperson of the ESR Radiology In addition, evaluations of the stand- project. Defi ne the hypothesis of This is money well spent as it will perform bett er next time. Trainees Forum. Spanish Society helps bring European and Latin American radiologists together

We, at the Spanish Society of Med- with international societies like between European and Latin Amer- grants, the special grant in cooper- substantial increase in our presence ical Radiology (SERAM), feel proud the European Society of Radiology ican radiology. ation with the European School of on most media channels, specialised of our sustained growth in affi liates, (ESR), American Roentgen Ray Soci- Radiology (ESOR), and the Interna- and general. The number of visits visibility, infl uence and scientifi c ety, Radiological Society of North PUBLICATIONS tional Course on Radiopathological to our website has doubled, and we activities. America and those of Latin Amer- Our peer-reviewed journal, Radi- Correlation. In 2014, the 25th edition, are more and more present in social ica, like the Inter-American College ology is gaining visibility and is now or silver anniversary, of this classic networks. SCIENTIFIC WORK of Radiology. the radiological magazine of refer- course in cooperation with AIRP It is clear that radiology practices SERAM has increased its scientifi c Our International Affi liates Meet- ence in Spanish. SERAM introduced will take place. SERAM keeps close should establish a strong presence work in the form of research grants, ing celebrated its 6th edition at the its editorial grant in 2012, and has contact with most of the technician’s on social media. collaborative projects with the indus- last RSNA with ‘Virtual Radiology: a now increased the number of grants associations, as there are many in We supported the second Interna- try, courses and publications. Last world of opportunities’ as the main awarded, due to the wide demand Spain, and is preparing a teaching tional Day of Radiology with a big year saw the formation of a highly topic of discussion. Our international and interest. publication aimed as informative impact in both local and national positive partnership with the indus- presence has been reinforced with The Society continues the publica- material for use in most of their newspapers. Again, celebrations took try. We organise our highly popular our Visiting Professor Programme, tion of its Monographic on an annual schools. place at the headquarters of the Aso- special training courses with them, in which SERAM sends faculty mem- basis. This publication gathers ciación Española Contra el Cáncer called the Areas of Special Interest. bers to scientifi c meetings abroad. state-of-the-art information about SCIENTIFIC SOCIETIES with speakers from diff erent patient Other courses last year included: We also participated in CIR@RSNA relevant topics. The edition in 2013 We take part in collaborative pro- associations. Advanced MR beyond morphologi- 2013, a session of the Inter-Amer- was entitled, ‘Diff usion MRI: basics, jects and agreements with Spanish cal imaging, Cardiac Imaging (5th Edi- ican College of Radiology in Span- concepts, techniques and clinical societies in the areas of cardiology, SERAM’S 32ND tion), Vascular Imaging (2nd Edition), ish on imaging of infection and applications’. nuclear medicine, and radiological NATIONAL CONGRESS Imaging in Oncology (4th Edition) infl ammation. protection. We participate in working These days we are busy preparing and the SERAM Master Class, a new SERAM and its sections have EDUCATION AND TRAINING groups with the Spanish Society of our 32nd National Congress, which area, specially devoted to discussing also hosted several international We have a programme of estab- Oncology, Spanish Association for will take place in Oviedo, May 22–25. pharmacokinetics, as well as the congresses in Spain, not to men- lished educational courses for the Study of the Liver and the Span- The main topic of the congress will properties and clinical indications tion the meetings of ESGAR (Bar- residents during their full stay as ish Group of Sarcoma, among others. be ‘Thoracic radiology: from incep- of contrast media in radiology. celona), ESSR (Marbella) and CIRSE trainees. Introduction to Radiology, tion to nowadays’. There will be four These courses were really well (Barcelona). Instrumentation and Techniques, SERAM WITH PATIENTS AND pre-congress monographic sessions: received, and they show how positive SERAM has expanded the num- Scientifi c Publications and Man- PROACTIVE COMMUNICATION research in radiology, scientifi c pub- cooperation with the industry in areas ber of its international affi liates agement are consolidated activities, One of our objectives is to foster lications, radio physics, and a techni- of common interest can be achieved. and has cooperation agreements recommended and addressed to the the visibility of radiology and show cian’s course. with several European societies diff erent years of residency. what radiology and the radiologist We expect more than 2, 000 att end- INTERNATIONAL PRESENCE & and 21 from Latin America. We have We would also like to mention the can do for the patients. In that sense, ees from all over Spain and abroad. AFFILIATES recently signed an agreement with activities of the Spanish Foundation we are improving InfoRadiologia, our Our congress is a real international We would like to highlight our the SPR, the Portuguese-speaking of Radiology, with its commitment web section for the public, and we event. increased visibility and cooperation society. SERAM is the natural bridge to education in the form of annual have established a press offi ce with a Find out more at www.seram.es myESR.org SIEGFRIED ANZINGER

AT THE BANK AUSTRIA KUNSTFORUM WIEN

Siegfried Anzinger, Bar Scene 1, 2013 © Siegfried Anzinger ECR TODAY | SUNDAY, MARCH 9, 2014 ARTS & CULTURE 31

Bank Austria Kunstforum

Freyung 8 1010 Vienna

Opening hours: Daily 10 am–7 pm Friday 10 am–9 pm

www.bankaustria-kunstforum.at

The Bank Austria Kunstforum Wien is holding a major exhibition of works by the Austrian artist Siegfried Anzinger. The focus of the show, including around 80 works, is on new paintings specially created by the artist for the exhibition. The painted works will be supplemented by drawings, water- colours and pastels produced at intervals alternating with the distemper pictures. Part of the exhibition is devoted as well to selected pictures in the context of Anzinger’s participation in the 1988 Biennale di Venezia. These works manifest the artist’s progressive rejection of the label of ‘Wilde Malerei’ (Wild Painting) and testify to a multi-lay- ered painterly subtlety in graphic structure and tension – qualities that had a sustained formative influence on the subsequent decades in Anzinger’s artistic œuvre. In recent years, popular culture in the form of a motif rep- ertoire taken from comics and trash literature has entered Anzinger’s panel pictures – particularly Cowboy and Indian scenes – which he combines among others with traditional iconographic motifs from the Bible. The decisive aspects here are the breaks with form and content associated with traditionally established canons, classical elements, and perfected skills. The artist continually breaks expectations, skilfully sidesteps and surprises us with new work blocks. In its matte quality the thinly applied distemper paint makes a noble retreat and imparts the effect of a ceiling fresco to the painting: a thoroughly contemporary interpretation of Baroque mural painting is combined with an iconography of the profanely popular and religiously sublime. The subject of his bright, colourful palette is the figure. From vaguely abstract suggestions of bodies and soft lines to detailed scenes bordering on the cartoon and the humorous, the viewer discovers a cornucopia of expressive, painterly forms and motifs: Madonnas with oversized noses, grotesque portrayals of saints, naked women in trees, or episodes from the world of cowboys and Indians. Despite the narrative content, they also always refer to something beyond what is depicted – to painting as painting. Siegfried Anzinger was born in Weyer, Upper Austria, in 1953. After studying with Maximilian Melcher at the Akade- mie der Bildenden Künste in Vienna in den 1970s, he moved to Cologne, Germany, in 1981. In 1998 he became professor of fine arts at the Kunstakademie Düsseldorf.

BANK AUSTRIA KUNSTFORUM The Kunstforum is a top address for art lovers, especially for classical modern painting of the post-war years. Every year, 300,000 people visit the temporary exhibitions held in this private institution, shows that are unique across the globe. Leading museums present their works here as well as private collectors. Whether van Gogh or Miró, Kandinsky or Chagall, Warhol or Lichtenstein, the great names of art are united here. Since 2000, there have also been exhibitions devoted to con- temporary artists.

Siegfried Anzinger, Orange Rubber Raft , 2013 © Siegfried Anzinger 32 WHAT’S ON TODAY IN VIENNA? ECR TODAY | SUNDAY, MARCH 9, 2014

Sandra Cervik, Tonio Arango and Florian Teichtmeister in Botakoz Mukasheva © Michele Pauty Lise de la Salle © Marco Borggreve – Naïve August Diehl, Andrea Clausen and Albrecht Abraham Schuch in Joseph und seine Brüder – Die Berührte by Thomas Mann Hamlet by William Shakespeare © Bernd Uhlig © Moritz Schell

Albert Herring by Benjamin Britt en © Barbara Pálff y / Volksoper Wien

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

Akademietheater 1030 Vienna, Lisztstraße 1 19:00 Begin the Beguine by John Cassavetes Phone: +43 1 51444 4145 www.burgtheater.at

Burgtheater 1010 Vienna, Dr. Karl-Lueger-Ring 2 16:00 Hamlet by William Shakespeare Phone: +43 1 51444 4145 www.burgtheater.at

Museumsquartier – Halle E+G 1070 Vienna, Museumsplatz 1 20:00 Red Bull – Flying Bach Unique performance combining Johann Sebastian www.halleneg.at Bach and Breakdance, interpreted by the Breakdance world champions Flying Steps and opera director Christoph Hagel

Schauspielhaus 1090 Vienna, Porzellangasse 19 20:00 Princip (Dieses Grab ist mir zu klein) by Biljana Srbljanović Phone: + 43 1 317 01 01 www.schauspielhaus.at

stadtTheater walfi schgasse 1010 Vienna, Walfi schgasse 4 20:00 Halbe Wahrheiten by Alan Ayckbourn Phone: + 43 1 512 42 00 www.stadtt heater.org

Theater in der Josefstadt 1080 Vienna, Josefstädter Straße 26 19:30 Joseph und seine Brüder – Die Berührte by Thomas Mann Phone: +43 1 42 700 300 www.josefstadt.org

Volkstheater 1070 Vienna, Neustift gasse 1 20:00 Woyzeck by Georg Büchner with songs by Tom Waits Phone: +43 1 52111 400 www.volkstheater.at

Concerts & Sounds

Konzerthaus (Classical Music) 1030 Vienna, Lothringerstraße 20 19:30 Wiener KammerOrchester, conductor Balázs Bánfi www.konzerthaus.at Botakoz Mukasheva, violin, Sivan Magen, harp D. Collatt i, P. Vasks, C. Debussy, W.A. Mozart

Musikverein (Classical Music) 1010 Vienna, Bösendorferstraße 12 11:00 Wiener Symphoniker, conductor Osmo Vänskä www.musikverein.at Lise de la Salle, piano W.A. Mozart, J. Sibelius

19:30 Sächsische Staatskapelle Dresden, conductor Christian Thielemann A. Bruckner

Porgy & Bess (Jazz) 1010 Vienna, Riemergasse 11 20:30 Thomas Faulhammer Quartet (Austria) www.porgy.at

Opera & Musical Theatre

Volksoper 1090 Vienna, Währingerstraße 78 18:00 Albert Herring by Benjamin Britt en www.volksoper.at

Wiener Staatsoper – 1010 Vienna, Opernring 2 16:00 L’Elisir d’Amore by Gaetano Donizett i, conducted by Guillermo Garcia Calvo Vienna State Opera www.wiener-staatsoper.at With Nino Machaidze, Charles Castronovo, Alessio Arduini, Erwin Schrott

Ronacher 1010 Vienna, Seilerstätt e 9 19:30 Der Besuch der alten Dame by Michael Reed, Moritz Schneider www.musicalvienna.at

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