Hot Topic of Radiological Reports Draws in the Crowds at ECR

ECR Today 2011 Daily news from Europe’s leading imaging congress

SUNDAY, MARCH 6, 2011

News report Obesity epidemic Ultrasound advances Inside from ESR meets puts focus on fatty in the technical Today Brazil session liver disease exhibition halls See page 5 See page 9 See page 17 Hot topic of radiological reports draws in the crowds at ECR

By Mélisande Rouger and Erik Ridley get the radiologist on. That they failed to generate a report that incited, if you like, the appropriate Abnormal reporting is common, and is the princi- action in a timely fashion.” pal cause of lawsuits against radiologists. As they search for the best way to protect themselves, radi- The balance of the report has to be between brevity ologists have been left wondering what form their and completeness, uniformity and individualism, reports should take. Experts echoed these concerns portability and data-protection, advice and pro- in a dedicated, jam-packed session on Saturday at scription, universality and priority. ECR, addressing an issue that strikes at the very heart of their profession. The report should rather be brief, except in complex cases or in the case of significant findings. In The radiological report goes right to the essence a nutshell, it should be as long as necessary, but of being a radiologist. It demonstrates the radiolo- some cases, such as aneurysms, may require it to gists’ added value, embodies their duty of care to go beyond the basics. “Referrers want clarity and the patient, and defines their standard of care. As meaningfulness,” he said. such, careful attention should be paid to this vital Jane Adam from London, United Kingdom. Leo Lawler from Dublin, Ireland. task, according to a panel of experts. Lawler encouraged authors to keep their own style, to use the universal scientific acronyms alone and “A report should be an epiphany; it should be and it should make equal sense there as it does and the key words would have a universality about to avoid enumerations or word bytes. something you pick up and get an immediate where you are,” he said. them,” said Lawler. intuitive grasp of what the person is trying to As for the choice between free text and structure, Opening Ceremony say,” said Dr. Leo Lawler of the Mater Miseri- Technological advances should be reflected in As for their content, reports should be very concise, he was straightforward. “With modern software, we cordiae University Hospital in Dublin, Ireland. reports, he continued. The ability to image both clear, complete, and consistent and reproducible. cannot have both,” he said. Headlines are necessary “And in my opinion … if a clinician doesn’t read form and function of the body should prompt a They should also lack any ambiguity, he said. but it doesn’t mean that everything should be struc- a very well-constructed report, the radiologist re-think of the way reports are being written. How- tured. BI-RADS has served as a standard up to now. has failed in some way. But equally when he has ever, the reality is quite different. Reports should demonstrate the radiologist’s decided that there’s no longer a value to reading insight into clinical care, be accurate, and convey Finally, he advised caution when writing recom- our reports then somehow we have fallen short “We are now intervening in ways we have never the message in a meaningful way, Lawler said. mendations. “When advising additional imaging, of the mark.” done before. Our reports have to reflect that kind remember the example of the dog chasing the car. of complexity. Too often you read reports on proce- “It must be decisive and, if properly worded, should He may be running to get it but what does he get Writing an effective radiology report requires close dures in which you realise radiologists have no idea elicit the appropriate response,” he said. once he gets there?” he said. Clearly, debates on this attention to be paid to the three major pillars of about interventional procedures. They simply can’t hot topic are only starting. reporting: structure, content, and functionality, keep up; most of us can’t,” he said. Negligent reports often demonstrate good vision Lawler said. and descriptive techniques, but fail to go to the next Dr. Jane Adam, consultant radiologist at St. The report should be electronic and able to be step of forming an opinion. George̓s Hospital in London and session modera- The report structure should be dynamic and able embedded into other systems such as HIS and RIS, tor, acknowledged the high number of participants. to change over time, he said. Reports should also he said. It should also be effective by being very “It is a report that tends to distance itself from a “I think we should continue this session next year, be portable. readable, and universal. clinical issue and it’s a report that fails to prompt probably in a bigger room. We should also make it the appropriate action in a timely fashion,” he said. more interactive, for instance by equipping the room “You should be able to take a report from one insti- “If you took it to a different continent and if it was “And the literature unfortunately is replete with with keypads to let the public participate during the tution or one part of the hospital to another part deciphered, the report would make a lot of sense medico-legal cases where this is the angle they lectures. It is such an important topic,” she said.

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A91IM-30-A3-7600 Sunday, March 5, 2011 HIGHLIGHTS ECR TODAY 2011 3

To err is human, to learn from that error is vital

By Frances Rylands-Monk

Mistakes that have an impact on patient management often stem from problems of perception, and lack of background clinical information is frequently due to communication issues, delegates heard at yesterday’s Special Focus Session.

Good judgement comes from experience, but experience comes from bad judgement, speakers agreed, while emphasising that radiologists can arm themselves against potential pitfalls with methods to identify and minimise danger areas. When errors do slip through the net, doctors should retrospectively use them for education to avoid the same mistake happening again. Keeping personal and institutional records, as well as holding regular error meetings with obligatory attendance, is one way to learn. Alan Freeman from Cambridge, United Kingdom. Cornelia Schaefer-Prokop from Amsterdam, Netherlands. Lorenzo Derchi from Genoa, Italy.

“The surroundings must allow for critical appraisal explanation for the ‘left renal colic’. As the patient hurry was always a mistake. If adequate time could showed the disappearance of the ‘tumour’. He con- and constructive debate, not dispute. Reviews are was still in pain, surgery was performed, which not be allocated, doctors should refuse to read ima- cluded that it was probably chewing gum! an obligatory quality control tool to show where we found an ovarian serous cystadenoma complicated ges, as he learnt personally. need improvement and where we are good,” said by torsion. While perception and individual bias can impede Dr. Cornelia Schaefer-Prokop, chest radiologist at One particular case Freeman recounted to dele- objective reporting, technical reasons can hamper Amsterdam University Hospital and Amersfoort “Complications from torsion are associated with gates was of an 88-year old woman who had pre- diagnosis in ultrasound, specifically of upper pole Medical Centre, The Netherlands. ovarian masses in 50 to 81% of cases. So why did sented with acute abdominal pain. The case came tumours, according to Derchi. Sagittal and axial we miss the diagnosis?” Derchi asked delegates. to him late in the afternoon when a trusted colle- views of the upper pole cannot provide a good Although the ideal environment of blamelessness “First because the symptoms ‘suggested renal colic’, ague wanted to discuss what he was certain was means of evaluation, without coronal planes. Psy- and education might sometimes seem combative, the renal and extra-renal ultrasound findings were bowel ischaemia in an otherwise healthy patient. chological ‘satisfaction of search’ syndrome may anonymising cases would help to reassure radio- normal and because the cyst was considered inci- At around 16:30 Freeman suggested a CT, in which also jeopardise diagnosis. logists about the non-punitive motives for holding dental.” he saw nothing to discount ischaemia. Coronal and such reviews. In the panel discussion one delegate sagittal views seemed to show one major vessel “When reading or performing an examination, volunteered that trust was built to such an extent Other compounding factors were that the radio- supplying her GI tract. As Freeman rushed to catch once you discover a finding that explains symp- in her department’s review sessions that doctors logical considerations were not taken into account his five o’clock lift home the patient was referred to toms, your attention drops and you may miss asso- would recognise case images and admit that they or correlated to the clinical considerations; visible the surgeons. On the next day they performed a ciated findings. In seven patients with two renal were the reporting radiologists. mass or enlarged oedematous ovary and free pel- laparotomy and found adhesive disease, revealing tumours each, one large and one small, the small vic fluid are associated with strong pelvic pain and in tandem a previous history of myomectomy and one was only seen in one patient,” he said. Schaefer-Prokop pointed out that such reviews predictive of torsion. Double reading was offered appendectomy. needed to be supplemented with communication as another defence against errors; even a resident’s Size, echogenicity, and position of tumours as among each other about ongoing cases, to – as fresh pair of eyes spotting something missed by a He considers his four major mistakes to be, first, well as incomplete scanning techniques that don’t much as possible – prevent mistakes before they senior colleague, regardless of whether or not the reading images with pre-conceived ideas, in this include the three scan planes can yield false nega- occurred. This could take place through multi-dis- interpretation was correct, was better than not see- case suggested by his friend. tive ultrasound exams, he explained. cipline team meetings and more dialogue in daily ing it at all. work, ensuring that radiologists benefitted from “A teleradiologist would not have been influenced Detection errors were most often a question of appropriate and accurate clinical information. “It’s an odd paradox that screening mammograms like this,” Freeman said, recommending delegates perception and can be minimalised by comparison in which 98% show normal findings are the only also attended Monday’s session on teleradiology with previous studies, structural analysis of criti- Despite best attempts to provide this accuracy, cli- images subject to routine double reading in the ‘For Better or for worse’. cal areas, in the chest these being the upper lobes, nical information could point to something else U.K.,” said Dr. Alan Freeman, abdominal radiolo- the perihilar region and the back, according to and it was imported to know the differentials, said gist at Addenbrooke’s Hospital, Cambridge, U.K. The second mistake was hurrying. The radio- Schaefer-Prokop. Grey scale reversal and digital Prof. Lorenzo Derchi, head of radiology at the Uni- logist who acts in haste, repents at leisure, he processing tools also helped to optimise data. versity Hospital of Genoa, Italy. Increasing image production meant that double rea- warned. After this came mistaking radiology signs ding as a practice solution was unrealistic in many in axial and coronal views, and the fourth error was In terms of interpretation errors, causes were often He described how a 47-year old woman presenting instances such as chest x-ray. The sheer volume of misinterpreting anatomy. Viewed retrospectively insufficient knowledge of clinical history, absence with acute pain in the left flank and pelvis, unres- slices made CT readings more prone to mistakes, the image depicted a variation of the hepatic artery of previous studies, the presence of a more obvious ponsive to pain relief was sent to radiology with the accounting for 65% of all radiological reporting coming off the supra mesenteric artery. abnormality and a lack of experience in the rea- suggestion of possible left renal colic. Ultrasound mistakes. Compounding this is a shortage of radio- der. “Not everything that looks like a tumour is a showed normal left and right kidneys but a benign logists, resulting in hurried reading. Responding Freeman also cited another mistake of offering a ‘no tumour,” she said. “You don’t want to get sued by cyst in the right side of the uterus. A contrast- to this issue raised by session moderator Dr. Marc ifs or buts’ diagnosis in reports: one such unquesti- the man who thinks he’s dying of bronchogenic enhanced CT to rule out other non-lithiasic causes Zins, Saint-Joseph Hospital, Paris, Schaefer-Prokop onably described a CT colonography as demonstra- carcinoma and spends all his money, only to find of renal colic showed the cyst, slight dilatation on said that radiologists needed to adjust their reading ting the presence of a T3 4 cm polypoid tumour ari- that the lesion disappears because you missed the the left and a small amount of free fluid in the Dou- processes and use widely available three-dimensi- sing from the anterior wall of the transverse colon. infectious disease that caused it.” glas space, but radiologists still couldn’t provide an onal tools, while Freeman added that reading in a Repeated colonoscopies performed by the surgeon Thurnher pays homage to pioneers in spinal imaging

By Frances Rylands-Monk Use of whole-body nuclear MRI significantly alte- “Advanced spinal cord imaging does exist. Every red the diagnosis of spinal cord diseases, greater vision starts with a conceptual journey, every Knowledge of the spinal cord and its function as a spatial resolution for the first time allowing visu- success with the practical execution. It took channel for conducting messages from the brain to alisation of smaller structures such as the dorsal those visionary researchers to bring us to this the rest of the body, as well as its butterfly appea- nerve root. In the past 10 years, development of point and I want to thank them for their willing- rance in cross section, was recorded as early as 11th diffusion-weighted and diffusion-tensor imaging ness to collaborate, share their knowledge and century by the physician Avicenna in his ‘Canons techniques with 3T machines, although with take us to the next step,” she said. of Medicine’. Mediaeval and renaissance scholars limited clinical application so far, make possible followed in his footsteps, but it was not until the diagnosis of spinal cord ischaemia after a ‘nor- In an unprecedented move at the specific request late 20th century that doctors could use myelogra- mal’ MRI. Thurnher, who is associate professor of Congress President Prof. Yves Menu, male phy to look inside it while the subject was still alive. of radiology at the Medical University Hospital members of the audience were asked to rise, of Vienna, outlined that the consequences of such to deliver Thurnher, and other female delega- Awarded the title of the Pierre et Marie Curie sophisticated techniques for disease differentia- tes present, with a standing ovation to honour Honorary Lecturer, Dr. Majda Thurnher from tion, monitoring disease progression and moni- women in radiology – a fitting gesture, given the Vienna, Austria, joined the ranks of those who, toring therapy trials impacted specifically cancer title names behind this particular lecture. since the dawn of medical science, have dedi- and multiple sclerosis patients and brain tumour cated themselves to the discovery, development management in the paediatric population. “Don’t forget, this is not the end of the journey,” and clinical application of techniques for spinal he said to Thurnher. “I’m sure you’ll be entertai- imaging. Attendees at her talk on Saturday were Looking forward, research on 7T and 9T machi- ning us more in the coming years.” treated to a historical journey that has implica- nes hinted at hitherto undreamt of possibilities tions for today’s radiologists. for clinical application. Majda M. Thurnher from Vienna, Austria.

myESR.org RZ Ad3_Hitachi_Scenaria_260x405mm_17-01-10_RZAd3_Hitachi_Scenaria_260x405mm_17-01-1017.01.1116:22Seite1

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Brazilians share know-how in thoracic imaging and seek to build global cooperation

By Philip Ward

Brazilians have a thirst for knowledge-sharing, and the country offers numerous investment opportunities, but it needs substantial reforms in healthcare and education to diminish social inequalities and address public health concerns, ECR delegates learned at Saturday’s ESR Meets Session.

Brazil has a population around 185 million inhabitants, making it the world’s fifth most populated country, according to Dr. Manoel Apare- cido Gomes da Silva, President of the Brazilian College of Radiology and Diagnostic Imaging (CBR). It is also the fifth largest nation in the world in terms of land mass, and is the ninth largest global economy, with a Gross Domes- tic Product of US$2 trillion. GDP per capita is around US$10,800. Manoel Aparecido Gomes da Silva from Sao Paulo. Arthur Soares Souza Jr. from São José do Rio Preto. Pedro Daltro from Rio de Janeiro.

The country will host the football World Cup in 2014 and the Summer Olympic Games in 2016, has a cure rate of 77%, compared with the World Dr. Pedro Daltro, from CDPI- IFF FIOCRUZ in lesions can be critical for the prognosis of the so it is certain to face increasing media scrutiny Health Organization’s 2007 recommendation of Rio de Janeiro. They can range from small and foetus. Foetal chest abnormalities can be evalu- over the next few years. 85%. The percentage of cases involving multi- asymptomatic entities to large space-occupying ated with ultrasound, but MRI is an important drug-resistant TB in Brazil is 0.9%, against the masses that require immediate surgical treat- adjunct technique for the assessment of these As a multiracial society, Brazil is in a unique global average of 4.9%. There have been three ment, and hybrid conditions are often seen. pathologies, Daltro stresses. position to enable professionals to build their cases of extremely resistant TB reported in Brazil. careers, believes Gomes da Silva, who moder- Imaging has an essential role before and after An MR examination may be necessary for a foe- ated yesterday’s session, together with Prof. The main risk factors for TB are poverty, low birth, but it requires a comprehensive under- tal lung mass to confirm a finding or provide Yves Menu, President of ECR 2011. He is con- urban development, the dismantling of health- standing of the findings. He advises radiologists additional details, to clarify equivocal sono- vinced that Brazilian radiologists are keen to care systems, and HIV, explained Souza. Myco- to carefully analyse and describe airway, lung, graphic diagnosis, to evaluate the impact on build cooperation in many areas, and the CBR bacterium TB is the causative agent, and trans- mediastinal, and vascular components. Prenatal pregnancy management counselling, and opti- has an important role to play in this process. mission is via inhalation of droplets. In tissue, ultrasound and MRI are contributing to a better mise postnatal imaging algorithm. It is responsible for the professional defence of it involves the formation of granuloma with understand of this field and allow more objective its members, plus their qualifications and the caseous necrosis. It is often accompanied by counselling and more efficient treatment during Chest radiography can detect many congenital spread of scientific information. It publishes its malnutrition, alcohol or drug abuse, immuno- the postnatal period, leading him to state that he lung lesions, but CT may be useful to confirm the own journal Radiologia Brasileira. suppressive therapies, and a coexisting disease future is promising. presence of the lesion, to determine the extent of such as diabetes and silicosis. Co-infection of the lesion and to define associated abnormali- Tuberculosis represents one of Brazil’s major HIV and TB is increasingly an issue. In congenital lung lesions, the majority of masses ties, he explained. Reconstructed data from CT public healthcare problems, as outlined by Prof. are detected as an incidental finding in ultra- examinations displayed in either 3D or multi- Arthur Soares Souza Jr., from Ultra X: diagnós- Congenital lung disease in children is another sound during the second and third trimesters. planar formats can be particularly helpful in tico por Imagem, Medical School São José do Rio important topic in Brazil. Malformations include Better understanding of natural history and clin- delineating abnormalities of the bronchi, along Preto. He explained that 22 countries account a heterogeneous group of anomalies affecting ical outcomes, as well as improvements in pre- with angio CT for arterial and venous structures. for 80% of those infected with TB worldwide, the lung parenchyma, the arterial supply to the natal diagnostic parental counselling and preg- Minimising the radiation dose is compulsory, he and Brazil occupies the 19th spot with 70,000 lung and its venous drainage, and they appear nancy management decisions, are of value here. warned. new cases per year and 4,735 annual deaths. It in an isolated or combined form, according to The prenatal diagnosis of congenital thoracic The X factor: The visual world of Christian Lauer

In this high-tech century, it is inevitable that we Lauer’s work has attracted much interest in should come to discuss the interactions between Belgium and abroad, resulting in various exhi- art and medicine. Christian Lauer, a German bitions in Brussels, Gent, Antwerp, Barcelona, radiologist who has been living and working in Rome and Berlin. His work reflects his personal Belgium for more than 30 years, has been fasci- experience of more than 30 years of radiology nated with the idea of fusing the two for some and human anatomy, which he feels are among time. This fascination has culminated in his the most precious and miraculous things in life. X-ART project, which offers interesting new perspectives on the human anatomy. Art in radiology is another example of how the art of photography can be a dynamic and innova- His work is based exclusively on CT exami- tive process that can create new ideas and com- nations and shows colourful and previously pletely new visual concepts. The basis of X-ART unknown aspects of the human body, exposed is x-rays, and the final result is a mirror to the freely and without limits through art, as opposed universal elements of the human being. to the precision and certainty required of radiology. To produce an x-ray image you need Christian Lauer was born in Berlin and received knowledge and are assisted by software to obtain his medical training in Fribourg/CH and perfect results. Aesthetic aspects are of little Bonn/DE, and his specialisation in Köln/DE value during this procedure; technical perfection and Recklinghausen/DE. He was head of the and the indication determine the final result. In radiological department of the OLVV-Lourdes- contrast, Christian Lauer uses the magical and Hospital in Waregem (BE), in the Flemish part artistic possibilities of the picture; qualities you of Belgium, for more than 30 years. For over 15 don’t encounter in the traditional radiological years he was the organiser of the international approach. ultrasound meeting, FIDUM. He is married with two daughters. In Lauer’s new world of X-ART, anatomical Christian Lauer, a German-born radiologist from Belgium presents his exhibition X-ART. structures are hidden in the background. At first You can visit the X-ART-exposition during glance you may not realise what you are looking ECR 2011 on the entrance level in Foyer F. at, and it is only through gradual analysis that The initial inspiration for his work was the daily stand the image. This encouraged him to accept you can detect the secrets of the transformation. experience of noticing radiological patients who the challenge of creating a different way to engage Contact: Lauer forces the observer to use the interpretive look at their own x-ray images after an examina- with radiological documents that would stimu- [email protected] methods of a radiologist to discover the hidden tion and then, after a short time, put the docu- late interest and fantasy within the observer. As www.art-in-radiology.be reality. ments back into their bags unable to really under- Picasso said, “all that you can imagine is real”.

myESR.org 6 ECR TODAY 2011 HIGHLIGHTS Sunday, March 6, 2011

Act now to avoid defeat in turf battles

By Philip Ward found to lobby within the European Union and to ensure IR’s voice is heard in Brussels. The wider recognition of interventional radiology (IR) as a separate specialty, along with a far A momentous era beckons for IR as a result of more rigorous approach to training and accred- rapid technical innovation and the significant itation, is vital to stave off looming turf battles contributions being made to patient care, he with other healthcare professionals. said. Interventional oncology, vascular intervention, venous intervention, embolisation, That’s the view of Prof. Michael Lee, from and biopsy and drainage procedures are all Beaumont Hospital in Dublin. At Saturday’s guided by imaging, and they require a techni- Professional Challenges Session, he advocated cal set of skills. The discipline will continue to back-to-basics based on a sound and carefully flourish because of future advances in nano- mapped out approach to education, training technology, molecular biology, simulation and competency. Research, professionalism, technology, and robotics. and clinical practice should also play a part in this process. “The crucial question is: who will perform the procedures?” noted Lee. “We need to listen to “We need to think about how we entice peo- our patients, and what they want above all else ple into interventional radiology, and we have is a competent interventional radiologist.” to create dedicated training pathways to ensure Michael J. Lee from Dublin, Ireland. Anna-Maria Belli from London, United Kingdom. that our new recruits are not merely ‘acciden- Between 2000 and 2010, a total of 5,788 papers tal trainees’, as they often are now,” he said. “At were published by interventional radiologists, present, interventional radiology is only seen compared with 13,224 papers from vascular sur- (EBIR), which was introduced in 2010 and Maria Belli, consultant radiologist at St. George’s as a potential elective topic in undergraduate geons and 86,545 from cardiologists. This imbal- aims to establish a common European skill Hospital in London. Regular work-based assess- teaching, and IR procedures are taught by other ance must be addressed, he stated. Interventional qualification to help standardise training and ments are essential to prove competency. specialties. This has to change.” IQ, produced by Cardiovascular and Interven- expertise in IR across Europe. tional Radiological Society of Europe (CIRSE), “This is what we need to work on and develop,” Curriculum development, more rapid moves has an important role to play in this respect. The objective must be for interventional radiolo- said Belli, adding that interventional radiolo- towards harmonisation, and greater access to gists who are patient-focused and accountable to gists must expand their clinical responsibilities research funds are all essential steps forward. CIRSE has supported the formation of a the public for delivering evidence-based, effective and take more direct control of patient care, In addition, Lee thinks an effective way must be European Board in Interventional Radiology and safe medical care, according to Prof. Anna- which has tended to be neglected in the past. CT unveils secrets of antiquities

By Mélisande Rouger

Radiology and arts walked hand-in-hand on Meet & Greet Saturday at ECR, as a highly original lecture revealed how CT can depict the materials of a your RTF work of art as well as help to assess its authenticity. Representative “When I saw his presentation I thought that no one could live without seeing it, so I sent him two This year you have the unique opportunity hundred e-mails to tell him to come! It is the per- to get in touch with your national RTF fect link between radiology and arts,” said ECR representative during the ECR! Visit the RTF 2011 Congress President Professor Yves Menu, Meeting Point in the Rising Stars Lounge introducing the lecturer, Dr. Marc Ghysels from nd Brussels, Belgium. (Foyer B, 2 Level) where the following resident representatives will be available to In a presentation showing eight pieces from a provide you with first-hand information: variety of cultures and time periods, Ghysels demonstrated the crucial role played by CT in Sunday, March 6: unveiling the mysteries of traditional craftwork. 09:00–12:00: Umut Percem, Turkey “CT is often the most accurate tool to check their authenticity,” he said in front of a captivated 09:00–10:30: Maria Paola Belfiore, Italy audience. 10:30–12:00: Ana Sverko Peternac, Croatia 10:30–12:00: Mikko Jousi, Finland Particularly poignant were the traces of the art- 12:00–12:30: Ekaterina Vasilyeva, Russia ist’s fingers on a thousand-year-old Peruvian ter- 12:00–14:00: Katarzyna Kapuscinska, Poland racotta piece revealed by CT. The function of the piece, a water whistle, was also found after scans 13:00–14:00: Patrick Omoumi, France revealed the existence of two small resonant 14:00–15:30: Thierry Couvreur, Belgium chambers in the sculpture. 14:00–15:30: Lukas Hrdina, Czech Republic

In another example, the very surprising contents Monday, March 7: of a wooden fetish from Congo were revealed 09:00–13:00: Andrea Levai, Hungary once scanned by CT: the skull of a small animal, a crushed eggshell, a needle … and most amaz- 10:00–14:00: Rüdiger Schernthaner, Austria ing of all, a crouching wooden figure containing 13:00–14:00: Patrick Omoumi, France a mixture of substances believed to have given power to the fetish. Meet & Greet the ECR President in the Rising Stars Lounge “Being able to switch from 2D to 3D was magic Marc Ghysels from Brussels, Belgium, receives his Honorary Lecturer diploma from the hands of to anthropologists,” said Ghysels, who turned Yves Menu, ECR 2011 Congress President. to arts after 20 years of clinical radiological Sunday, March 6: practice. 15:30–15:50: Prof. Yves Menu; able to demonstrate that a set of 50 blocks of ter- Finally, stereolithography revealed to a curious Paris/FR, ECR President Ghysels experimented with CT on one of his racotta had been glued together to produce the owner the existence of a standing Buddha inside own purchases, a Chinese terracotta figure that effect of an antique work of art. a miniature Burmese ivory stupa, a mound-like looked highly suspicious. “I bought the piece and structure traditional in Buddhist culture. wanted to show that it was a fake,” he explained. CT also enabled the discovery of a copy of an ala- baster worshipper that sold out for US$1,700,000 Ghysels received an honorary diploma at the Unmistakably, blue flakes appeared on the scan at Sotheby’s a couple of years ago. “Right after the end of his lecture and honoured by a round of of the statue’s face, indicating a different mate- auction, other worshippers suddenly appeared applause from an appreciative audience. rial from the body. After further research, he was on the market!” Ghysels said.

myESR.org ESR President Maximilian F. Reiser met with the future of European radiology at the Rising Stars Lounge.

Hot Shots from Day 3 More photos @ facebook.com/myESR myesR.org/ecr2011/hot-shots

All pictures © ESR – European Society of Radiology / Sebastian Kreuzberger, Lukas Schaller, Harry Schiffer cirse2011_ads1_260x405_print:cirse2011_ads2_260x405_print 10.01.2011 09:38 Seite 1

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Cardiovascular and Interventional Radiological Society of Europe C RSE Sunday, March 6, 2011 CLINICAL CORNER ECR TODAY 2011 9

What’s stopping Inside CT angiography aids 7T MR entering Imaging brings hope to stroke intervention clinical arena? prostate patients

Today See page 13 See page 15 See page 16

Worldwide obesity epidemic puts spotlight squarely on fatty liver disease

By Philip Ward relevance. He aims to determine the circum- stances in which assessment of inflammation is Fatty liver disease is of growing importance in desirable and the methods that might be used clinical practice, largely due to the global obe- to do this, and plans to conclude with a discus- sity epidemic. Non-alcoholic fatty liver disease sion on whether there is sufficient evidence that is the hepatic manifestation of the metabolic imaging techniques provide information that is syndrome, and although estimates of its preva- specific for hepatic inflammation. lence differ according to the population under investigation and the methods used to assess As for the future, he reckons protocols for hepatic fat content, experts agree that 10 and assessment of steatosis and fibrosis will be 30% of adults in the Western hemisphere have refined to incorporate the possible effects of the disease. Furthermore, fatty liver is associa- inflammation on measured parameters. Addi- ted with increased mortality compared with the tionally, metabolic profiling using in vitro general population. nuclear MR spectroscopy and/or mass spec- trometry techniques, using multivariate data, Serial liver MRI examinations can be used to demonstrate changes in liver fat. Serial proton-density fat-fraction maps Against this background, today’s timely spe- may enable discrimination of inflammatory obtained with complex MRI were acquired in a 41-year-old male with insulin resistance and recalcitrant hypertrigly- cial focus session about quantifying liver fat, processes. ceridaemia undergoing plasmopheresis, and on multiple drugs to lower serum triglycerides. Follow-up MRI demonstrates a large decrease in the concentration of fat (from 52% to 33%), and a marked decrease in the size of the liver. inflammation and fibrosis is bound to prove (Provided by S. Reader) popular. Management of fatty liver hinges on lifestyle and dietary measures to induce controlled and Inflammation is increasingly seen as a key step sustained weight loss, he commented. Manage- Therapeutic Approaches for Nonalcoholic Fatty Liver Disease in the pathogenesis of chronic liver diseases, ment of cardiovascular risk factors can help to but is difficult to measure radiologically and reduce mortality, while dietary intervention Weight Loss Lipid-Lowering Drugs certainly not validated in clinical practice, can reduce steatosis and inflammation and according to Dr. Jeremy Cobbold, a clinical pharmacological treatments show promise. A • Caloric restriction, exercise • Fibrates (gemfibrozil) lecturer in the department of hepatology and multi-system and multi-disciplinary approach • Sibutramine, orlistat • Fish oil gastroenterology, Imperial College London, St. seems necessary. Mary’s Hospital Campus, U.K. As therapies are • Weight-reduction surgery developed that may halt or reverse the disease A liver ultrasound examination is useful for Insulin-Sensitizing Agents Antioxidants process, there is a demand to identify patients confirming steatosis, according to Dr. Anna in whom there is significant inflammation. In Wieckowska and Dr. William Carey of the • Metformin • N-acetylcysteine particular there is interest in the distinction Cleveland Clinic (www.clevelandclinicmeded. • Per oxisome proliferator-activated • Vitamin E com). Fatty infiltration of the liver produces a between simple steatosis in non-alcoholic fatty receptor gamma agonists • Betaine liver disease, and steatohepatitis, which is asso- diffuse increase in echogenicity and vascular (thiazolidnedione, rosiglitazone, pioglitazone) ciated with progressive disease. blurring, but ultrasound cannot rule out stea- Source: The Cleveland Clinic Foundation tohepatitis or fibrosis, and its sensitivity drops The major pitfall to be aware of is that inflam- sharply when less than 30% of hepatocytes mation is a complex, dynamic and multifacto- contain fat droplets, they noted. “Both CT and is very uncommon to experience fat-fractions rial process and there are currently no specific MRI studies, especially MR spectroscopy, are greater than 50%, he explained. However, com- Special Focus Session and validated imaging tools for assessment of more sensitive modalities for quantifying ste- plex MRI is a more complicated technique and liver inflammation, which means interpreta- atosis. However, none of these imaging tech- may be more susceptible to some confounding Sunday, March 6, 14:00–15:30, Room F1 tion of results should be performed with cau- niques has sufficient sensitivity and specificity factors to which magnitude MRI is immune. SF 13 Quantifying liver fat, tion and in the context of the clinical infor- for staging the disease and cannot distinguish inflammation and fibrosis: routine or research? mation, stated Cobbold, who refers to himself between simple bland steatosis and nonalcoho- “One major remaining challenge is to validate as a hepatologist who has worked in related lic steatohepatitis with or without fibrosis.” current methods with tissue measures of fat • Chairman’s introduction techniques. Moreover, while imaging-based concentration. Biopsy, the accepted gold stan- C.B. Sirlin; San Diego, CA/US techniques are well-placed to assess fibrosis, Fatty liver develops when fatty acid uptake and dard for assessing fat in the liver, is inherently • Quantification of liver fat inflammation is not something that is likely to synthesis in the liver exceeds fatty acid oxida- heterogeneous and is a poor reference standard S.B. Reeder; Madison, WI/US be assessed independently. Even so, inflammation and export as triacylglycerols (TAGs), exp- for validating quantitative imaging methods. • Quantification of liverinflammation tion does affect measures of fibrosis and steato- lains Cobbold. Studies of pathogenesis indicate In addition, determining the precise role that J.F.L. Cobbold; London/UK sis, so should be taken into account as a possi- that insulin resistance, lipotoxicity, oxidative quantitative fat measurement techniques will • Quantification of liver fibrosis ble confounding factor. stress and chronic inflammation are key com- play in clinical practice remains to be determi- B. Van Beers; Clichy/FR ponents in the development and progression of ned,” noted Reeder, who anticipates that non- • Summary of presentations Ultrasound is non-invasive and relatively cheap, the disease. Some patients with fatty liver deve- invasive quantitative MRI methods for eva- C.B. Sirlin; San Diego, CA/US and applications such as contrast-enhanced lop progressive disease, but large prospective luation of liver disease will play an important • Panel discussion: ultrasound and transient elastography may longitudinal studies are still necessary. Fatty future role in paediatric patients, in whom fatty Routine or research? provide further information on inflammation, liver is associated with increased all-cause and liver is increasingly common and physicians but evidence is lacking, he points out. liver-related mortality compared with the gene- are reticent to biopsy. ral population, he concluded. “The challenge remains to find clinically relevant and specific markers of liver inflamma- Conventional methods, such as ‘in and oppo- tion,” he said. “In contrast to development sed phase’ imaging, cannot measure fat signal of markers of steatosis and fibrosis, attempts accurately, and may not produce good measu- Don’t miss today’s to develop specific markers of inflammation rements of fat, according to Dr. Scott B. Reeder, have been dogged by difficulties in defining department of radiology, University of Wiscon- Junior Image Interpretation Quiz inflammation and difficulties in distinguishing sin, Madison, U.S., who will speak about quan- inflammation from fibrosis, with which it is tification of liver fat in this afternoon’s session. 13:00–14:00, Room A often associated. Pathologically, they are inti- With in and opposed phase imaging, the effects Radiologists vs Dr. House mately linked. As imaging modalities rely on of iron and fat are opposite one another, and it the detection and measurement of physical is not possible to detect the presence of both Moderator: M.M. Thurnher; Vienna/AT parameters, a loosely defined and complex pro- at the same time. Both complex and magnitude cess such as inflammation is difficult to quan- MRI methods can measure fat and the effects of Panellists: tify with a single measure.” iron simultaneously and accurately. Complex S. Andac; Ankara/TR J. Frühwald-Pallamar; Vienna/AT MRI can measure fat-fraction over a full dyna- D. Damjanovic; Belgrade/RS A. Löve; Lund/SE Cobbold’s presentation will frame the problem mic range from 0–100%, while magnitude MRI M.L. Diaz; Pamplona/ES J.S. Rabouhans; London/UK in terms of the pathogenesis and the clinical can only measure fat from 0–50%, although it

myESR.org 10 ECR TODAY 2011 CLINICAL CORNER Sunday, March 6, 2011

Advances and limitations surface in imaging the treated breast

By Mélisande Rouger

Breast cancer is the primary carcinoma among women worldwide, and imaging is indispensable not only in detecting lesions but also in evaluating the efficacy of currently available therapies and warning of possible recurrence. In neoadjuvant treatment, functional imaging offers the option of assessing tumour response very early, eventually increasing chances of a successful outcome by guiding treatment. Radiologists can also assess residual disease after surgical biopsy at pathology with the help of both morphological and functional imaging. After therapy, annual examinations enable doctors to track any cancer reappearance. Contrast-enhanced breast MRI (subtracted image 3 Patient with breast cancer (invasive ductal carcinoma, grade II). MR subtracted images (3 minutes after contrast minutes after contrast medium injection). Patient with medium injection) before (A) and at the end (B) of the neoadjuvant chemotherapy. Initial staging: unifocal infiltra- Technological advances have improved patient a diagnosis of invasive ductal carcinoma (US-guided ting cancer. After treatment, even if there is a decrease in size of the cancer, its long axis (RECIST) is unchanged biopsies). At surgery, no cancer was found. Ultra- with a multifocal shrinkage of the tumour. Unsuccessful first breast-conserving surgery, then mastectomy. care but radiologists are still facing a number of sound examination after surgery was unable to detect (Provided by A. Tardivon) challenges, starting with the absence of standar- the lesion. At MRI, the lesion was well depicted (inner dised protocols for functional imaging, which quadrants, deep location). (Provided by A. Tardivon) limits the benefits brought by diffusion imaging and spectroscopy. The high occurrence of false positive results in findings from post-surgical followed by chemotherapy for overall survival. in a given tumour, focusing for instance on its “They should especially consider that inflamma- breast imaging necessitates a savvy combination Moreover, starting with the drug-based treatment extracellular space and chemistry, e.g. by show- tions, which are common after surgery, might of different tools. Finally, potential risks induced increases the possibility of performing conserva- ing an abnormally high or reasonable number of generate false positives because they create vas- by radiation exposure must be balanced against tive surgery, and a pathologically complete res- choline metabolites with MR-spectroscopy. DWI cular hypermeability and might take the contrast the benefits of detection of recurrent disease ponse at surgery is a surrogate marker of survival. can act as a biomarker for tumour aggressiveness product used with MRI,” she explained. after therapy. These points and many more will and monitor response to treatment by quantify- be debated by a panel of experts during a dedica- Functional imaging enables assessment of ing the apparent diffusion coefficient (ADC), Nuclear medicine tools, such as positron emit- ted refresher course at ECR 2011. tumour response as early as right after the first which provides the diffusion coefficient value. ted mammography (PEM) and scintimammo- chemotherapy session, much earlier than any graphy, offer more specificity at this stage – but The number of women treated with neoadjuvant evaluation with morphological imaging. Diffu- Unfortunately, the lack of uniformity among MR here again false positives might occur, because of treatments has significantly increased over the sion-weighted imaging (DWI), combined with protocols limits the full use of these techniques. inflammatory processes. past few years, after prospective multicentre stu- MRI, and MR spectroscopy have proved to be Since a patient is rarely examined on the same dies revealed that chemotherapy followed by sur- instrumental in assessing early tumour response. MR machine using the same imaging para- How to follow-up women who have been suc- gery was not significantly different than surgery Both enable measurement of functional changes meters, the coefficient value obtained on two cessfully treated will also be an important topic machines is generally not the same, altering its of the course. European estimations for the rate reliability. of recurrence are between 0.4 and 0.8% each year, and this rate is higher than breast cancer “These techniques are very promising but we have a incidence in the general population. real problem of application and reproducibility here,” said Dr. Anne Tardivon, radiologist at the Curie Ins- Mammography is the first modality used in the titute in Paris, who will chair the ECR course. detection of recurrent disease. It is usually car- ried out once a year, in some women for the In the absence of existing guidelines, one could rest of their lives. US can also be used together base the observation not on the value itself but with mammography, and MRI is prescribed for rather on the percentage of diminution between women with a high genetic risk as soon as they 2011 the examinations, she suggested. reach 30, and even if they have never had cancer.

43rd IDKD Davos With spectroscopy, few MR scanners used in routine However, specialists do not know which modality are powerful enough to show the choline peak. New is the most appropriate – based on the age at dia- Diseases of the Heart & Chest, incl. Breast machines use 3 Tesla instead of 1.5T and are much gnosis and the type of cancer. There are no studies April 3 – 8, 2011 more appropriate, but less available in practice. available on the subject yet. The American Can- Satellite Courses Nuclear Medicine “Diamond” cer Society has given recommendations for MRI, Post-surgical imaging of the breast is also useful estimating that there was insufficient evidence to Pediatric Radiology “Kangaroo” in determining whether cancer has been fully recommend for or against MRI screening in pati- Breast Imaging removed or not. Mammography helps to evalu- ents treated for a breast cancer including DCIS. ate whether microcalcifications are left behind 1st IDKD Intensive Course in Hong Kong in the case of ductal carcinoma in situ (DCIS) Finally, the financial costs of detecting recur- and irradical operation. Ultrasound can show rent disease and the identification of subgroups Diseases of the Brain, Head & Neck, Spine whether lesions are visible near the former site of to determine the occurrence of examinations May 7 – 10, 2011 the tumour, but its accuracy is limited because of after cancer require expert consultation. One haematoma and scar tissue. could, for instance, imagine changing the inter- 4th IDKD Intensive Course in Greece val between mammography exams 10 or 15 years Breast MRI is therefore the most accurate ima- after cancer in older patients or adding MRI in Diseases of the Abdomen und Pelvis ging modality in predicting residual disease, and younger patients with dense breasts in the first 5 September 29 – October 2, 2011 specialists recommend performing an MR exa- years after cancer, Dr. Tardivon suggested. Mykonos, Greece mination three to four weeks after surgery. How- ever, radiologists must be aware of false posi- “This course will raise many interesting questi- tive results triggered by enhancing scar tissue, ons … and I hope it will also provide answers!” Dr. Tardivon pointed out. she concluded. 2012 Refresher Course

44th IDKD Davos Sunday, March 6, 16:00–17:30, Room F2 Diseases of the Brain, Head & Neck, Spine RC 1402 Evaluation of the treated breast and follow-up March 25 – 30, 2012 • Chairman’s introduction Satellite Courses Nuclear Medicine “Diamond” A. Tardivon; Paris/FR Pediatric Radiology “Kangaroo” A. Evaluation of residual disease after excisional biopsy C. Boetes; Maastricht/NL B. Evaluation of response to neoadjuvant chemotherapy P.A.T. Baltzer; Jena/DE C. Surveillance for and detection of recurrent disease after therapy F.J. Gilbert; Aberdeen/UK www.idkd.org – [email protected] • Panel discussion: The new challenge in breast cancer: evaluation of response

myESR.org Sunday, March 6, 2011 CLINICAL CORNER ECR TODAY 2011 11

CT and MRI attract praise for cardiac assessment before interventions and surgery

By John Brosky

After years of rapid adoption, the revascularisation of coronary arteries with the implan- tation of metal sleeves through percutaneous coronary intervention (PCI) has slowed significantly. Research has shown that alternative approaches, such as traditional surgery or medical therapy, can be more successful than stenting.

The accumulating evidence relies heavily on the advanced capabilities of multi-detector CT (MDCT) and MRI for the retrospective assessment of the effectiveness of stenting. The ability to predict the outcome of cardiac interventions using MDCT and MRI were roundly praised and recommended in guidelines for myocardial revascularisation published in May 2010 by the European Society of Cardiology.

This afternoon’s ECR refresher course, ‘MRI and CT before cardiac interventions or surgery’, will focus on emerging techniques for the structural and functional assessment of coronary artery disease (CAD) that play a determining role in the planning of safe and effective revascularisation. The role of CT coronary angiography will be discussed by Prof. Christian Loewe, from the Medical University of Vienna, while Dr. Marco Francone, from La Sapienza University in Rome, will speak about combined cardiac examinations with MRI for function, stress perfusion and tissue characterisation.

Both presenters will focus on predictive exams for patients with stable CAD. For patients with acute coronary syndrome, revascularisation by PCI within five hours is not only indicated but can prove to be life-saving. The five-hour Post-ischaemic dilated cardiomiopathy in a 58-year-old patient with known three-vessel coronary arteries disease. MR was planned to depict tissue viability prior to coro- limit for stenting in acute settings was rein- nary revascularisation. Left panel shows three chamber (upper row) and short axis (lower row) steady-state free precession cine-MR images of an extremely dilated forced by an MR perfusion study led by Fran- and remodeled left ventricle. On right panel, corresponding late-enhancement images show an extensive transmural area of enhancement involving the anterior, antero- cone and published in 2009 by the Journal of septal and antero-lateral mid-apical wall corresponding to extensive post-ischaemic scar. MR findings suggest no chances of functional recovery after revascularisation. the American College of Cardiology (JACC). It (Provided by M. Francone) demonstrated that after this critical point, PCI can cause more harm than good for a patient’s long-term outcome by creating haemorrhages shows such rapid and exciting progress as car- Interventional cardiologists understand that candidates for percutaneous aortic valve repla- and damaging the myocardium, the muscular diac imaging. when they implant a stent, they are effectively cement. Prof. Gabriel Krestin, chairman of the tissue of the heart. implanting a new disease, because after a num- department of radiology at Erasmus University The main value MRI brings to cardiac imaging ber of years the stent will become closed again Medical Centre in Rotterdam, the Netherlands, The problem cardiologists face is that a pati- is to move from the structural assessment of by restenosis, he pointed out. will act as the moderator. ent with CAD has multiple occlusions, and it coronary arteries now possible with MDCT to remains difficult to determine which stenosis an evaluation of the myocardium. Perfusion Also at today’s session, Dr. Roberto Salgado, can be treated and which ones should not be cardiac MR, or using a contrast agent with MR, from Antwerp University Hospital in Belgium, treated, according to Loewe. “Not all occlusi- offers a resolution and an ability to characte- will give a presentation about CT assessment of ons cause a patient’s symptoms, not all plaques rise tissue that is up to 60 times greater than have a risk of rupture, so it becomes important SPECT or nuclear medicine, Francone said. to have a diagnostic tool to differentiate bet- Refresher Course ween really dangerous coronary lesions and “We are able to characterise the nature of the Sunday, March 6, 16:00–17:30, Room I/K the lesions that pose little risk.” injury, to say how thick the ventricle wall is, to RC 1403 MRI and CT before cardiac interventions or surgery image the extent of scarring and to predict the The identification of the so-called culprit potential for functional recovery after revas- • Chairman’s introduction lesion becomes critical, and this focus for car- cularisation,” he explained. “MR plays a very G.P. Krestin; Rotterdam/NL diac imaging is creating a path to more per- important role in the clinical setting to include A. Can CT predict the outcome of percutaneous intervention? C. Loewe; Vienna/AT sonalised treatment plans. Merely because it or exclude patients from revascularisation. The B. Can MRI predict the outcome of coronary revascularisation? is possible to revascularise a patient does not heart is not some kind of water pump and an M. Francone; Rome/IT mean that this should be done in all cases, and artery should not be reopened just because it C. The value of CT before percutaneous aortic valve replacement CT can clarify which lesions should be treated is possible to do so. The treatment of a patient R. Salgado; Antwerp/BE and which should be left alone, noted Loewe, needs to be tailored according to a variety of • Panel discussion: who believes that no other field in radiology parameters.” Improve your interaction with your colleagues ECR’s Interactive Programme Planner Browse ECR 2011 Abstracts with the new Interactive Programme Planner @ Visit ipp.myESR.org (or m.myESR.org with your mobile device) and start creating your personal schedule for ECR 2011!

myESR.org 12 ECR TODAY 2011 CLINICAL CORNER Sunday, March 6, 2011

Noisier low dose CT can still prove adequate for paediatric diagnosis

By Frances Rylands-Monk “Do we have to avoid CT completely in children and only use imaging techniques The increasing indications for CT in child- like MRI and ultrasound? There are still ren due to technological advances make the indications for which CT is the best availa- modality’s role in paediatric imaging one of ble imaging technique. The potential risks of radiology’s hottest topics for debate. radiation are low but non-negligible, and if CT parameters are optimised for children, In addition to its wide availability and poten- the benefit of diagnostic imaging will cer- tial lower cost compared to MRI, CT’s speed, tainly outweigh the risks in these selected operator-independence, and excellent visua- cases,” he stated. lisation of the lungs and internal organs have increasingly made it the modality of choice Co-speaker Dr. Jean-François Chateil, head for several indications. Already well estab- of the paediatric radiology unit, University lished as an important modality in trauma, Hospital of Bordeaux, France, will address neurological and pulmonary diseases, and safety in conventional radiology, still a main- oncology, CT’s role in cardiac imaging is also stay in paediatric imaging, particularly for Dr. Rutger A.J. Nievelstein from Utrecht/NL expanding. studying thoracic and skeletal pathologies.

However, the risk of radiation-induced side ‘step-and-shoot’ scanning possible in small “One of the major pitfalls when x-raying effects, especially the induction of secondary infants, while the recently introduced dual children is a lack of knowledge about paedi- cancer, causes wariness among doctors, par- source imaging techniques can scan even atric pathology leading to needless or inap- ticularly when it comes to children, which faster and at lower dose. propriate exams,” he said. “For example, in Axial CT image of the brain of a child with a left-sided frontal chronic subdural haematoma and a right-sided are still physically developing and normally neonates, ultrasound now replaces pelvic frontal subdural haematoma with fresh blood compo- have a long lifetime ahead of them in which New developments in automatic tube cur- x-ray for hip dysplasia screening.” nents. Furthermore, there is a dilatation of the lateral secondary cancers may become detectable. rent modulation methods focused on the ventricles. (Provided by R. Nievelstein) paediatric age group are still scarce but are Chateil’s talk will focus on basic safety pre- ECR delegates who are interested in cur- becoming increasingly available on the mar- cautions in conventional x-ray, as well as jus- rent knowledge on radiation-related risks in ket. Such techniques allow tube current to tification and optimisation of dose, and cur- children, and who are seeking a frank dis- be optimised during scanning. For example, rent gold standards for achieving diagnostic cussion about paediatric CT optimisation, in the thorax, air content means there is less accuracy at low dose. should attend today’s refresher course, which need for radiation than in the abdomen. If covers conventional radiology, CT and MRI. scanning the thorax and abdomen together, the scanner will automatically lower tube “Reducing the radiation dose and its associ- current in the thorax and then raise it in the Refresher Course ated risks in children should be one of the abdomen. major goals of the radiologist, especially in Sunday, March 6, 14:00–15:30, Room Q paediatric CT,” said Dr. Rutger Nievelstein, “The main problem with these techniques is RC 1312 Safety first paediatric radiologist, University Medical that dose/noise indicators need to be fed into Moderator: R. Fotter; Graz/AT Centre (UMC), Utrecht, The Netherlands. the scanner so that it knows what kind of A. Security and dose with conventional radiology “This can be achieved by first performing CT image quality radiologists want. Such indica- J.-F. Chateil; Bordeaux/FR only when properly indicated, and second by tors are available, but are not optimal for stu- B. CT in children: dose reduction strategies adjusting the CT technique to the age and dies in children, particularly given that spe- R.A.J. Nievelstein; Utrecht/NL size of the child.” cialists are still investigating what optimising C. Ensuring safety for infants undergoing MRI image quality actually means in paediatric T.G. Maris; Iraklion/GR At the UMC’s Wilhelmina Children’s Hos- imaging,” he noted. pital during 2009, approximately 31,000 radiological examinations were performed Part of the problem stems from the fact that in children. Of these examinations, CT con- much pre-patient research is still based on stituted only 4.5%, MRI over 9%, and ult- adult-sized phantom imaging. According to rasound more than 13%. However, it is not Nievelstein, further development and testing simply a question of limiting CT studies to of special paediatric phantoms will facilitate justified indications. Doctors must be careful dosimetric studies and technical optimisa- not to simply apply adult protocols to paedi- tion of CT in children. atric patients because this results in an unne- cessarily high dose to the child. A group in the paediatric radiology division at the Medical University of Graz in Austria Implementation of dedicated paediatric pro- is currently running a project on evidence- tocols through weight-based or age-based based development of paediatric CT proto- adaptation of several CT parameters, com- cols that involves balancing dose and qua- bined with the use of automatic tube current lity with semi-anthropomorphic phantoms. modulation techniques when indicated, can Several European centres are taking part, help optimise CT studies. Defining adequate and through the European Society of Paedi- dose estimates based on age and weight is atric Radiology’s CT Taskforce Group, these still problematic because opinion is divided paediatric phantoms will be used to develop Flat panel detectors allow static and dynamic studies in paediatric x-ray examinations. (Provided by J.-F. Chateil) about what constitutes good image quality, general parameters, dose indicators and pro- but the continuous development of increa- tocols for the wider European and internati- singly sensitive detectors means that newer onal communities. CT machines require less radiation to yield diagnostic quality images. Hopefully this experience will lead to better definition of optimal image quality and will “The primary goal is to achieve a diagnostic show how it can be achieved with low dose in image quality instead of optimal image qua- children, even in CT scanners from different lity. Lower dose usually produces a noisier manufacturers. The researchers are in line image, but this doesn’t mean it can’t be used with other international initiatives such as for diagnosis,” explained Nievelstein. the Alliance for Radiation in Pediatric Ima- ging, which was founded in the U.S. in 2007 Of specific interest to paediatric radiation (www.imagegently.com) to further optimise safety has been the introduction of dynamic CT in children, in part through establishing or adaptive collimators in CT scanners over a new dose registry database to gain insight the past three years to decrease the so-called into the current level of radiation dosage to overranging effect. Overranging, i.e., star- children and how it can be lowered. ting a scan earlier and ending later than the imaged scan range for reconstruction pur- In his today’s lecture, Nievelstein aims to poses, increases radiation dose significantly, provide radiologists with tools to use CT in but now moving collimators can partially a safer way in children. He hopes that such protect parts of the body that are not being tools will encourage radiologists to be less imaged from radiation. In addition, faster reluctant to use CT in paediatric imaging, EOS slot-scanning radiographic device permits spine and lower limb imaging with low-dose exposure. scan times and larger scan ranges have made when needed. (Provided by J.-F. Chateil)

myESR.org Sunday, March 6, 2011 CLINICAL CORNER ECR TODAY 2011 13

CT angiography proves indispensable in handling cases of stroke intervention

By Philip Ward contrast media and 50 ml saline at 4 ml/sec is employed. VRT-MIP reconstructions are targe- Support is growing relentlessly for the more ted on the aortic arch, single carotid artery, ver- widespread use of CT angiography (CTA) and tebral arteries, and intracranial circle. CT perfusion technology in stroke intervention. “The low quality of a CT examination may be CTA should be performed routinely in stroke due to chronic cardiac failure, artefacts caused patients, and it represents an important tool for by dental prostheses, or contrast media reflux in defining the prognosis and possibly for deci- laterocervical veins. Another limitation of CT is ding upon the choice of therapy, noted Prof. radiation dose, but is this a real problem or an Marco Leonardi, professor of neuroradiology urban legend?” asked Leonardi. He added that at Bellaria Hospital, Bologna University, Italy. the contraindications for CTA are chronic renal New angiographic devices make it possible to failure and a previous major hyperergic reaction control cerebral conditions during treatment to iodinated contrast media. by detecting haemorrhage, ischaemia, etc., making CTA the first choice neuroimaging Finally, MRI should also be available, allowing CT angiogram after stroke confirms thrombosis of the CT angiogram after stroke shows detailed anatomy of tool in suspected stroke patients. However, the possibility of diffusion and perfusion ima- basilar artery. (Provided by M. Leonardi) the aortic arch. Evaluation of the arch is essential for there is still no gold standard in this area, and ging and MR angiography. MRI can provide the interventional approach. (Provided by M. Leonardi) the search for the perfect technique is ongoing, he added.

“A general radiologist in the emergency room is usually the first to receive the request for an urgent CT scan and CT angiogram for a stroke patient. It is essential that the general radiologist understands the importance of this diagnosis,” stated Leonardi, who is a speaker at this morning’s refresher course on stroke imaging.

When it comes to stroke intervention, the first problem is to establish when the incident took place. How much time has elapsed? How will it be possible to reach the occluded vessel? What is the condition of the patient’s vascular anatomy? These are key questions, and CT and CTA from the aortic arch to the brain is probably the best and fastest way to obtain this information, he said.

Figures A-G: CT follow-up at 10 days reveals minimal ischaemic lesion in the pons. (Provided by M. Leonardi)

Leonardi emphasised that a large team of skilled decisive information to plan the treatment for neuroradiologists is necessary to exploit the full late cases, he concluded. Refresher Course potential of emergency neuroimaging and provide 24-hour coverage. Appropriate imaging He anticipates that an important future trend is Sunday, March 6, 08:30–10:00, Room A systems are vital, and the logistical implications the establishment of stroke centres that are able RC 1111 Imaging stroke need to be studied in detail, taking account of to diagnose, treat and follow-up stroke patients, • Chairman’s introduction local needs and specific epidemiology, as well both ischaemic and haemorrhagic. The new the- R. Siemund; Lund/SE as a hospital’s facilities and requirements and rapeutic potential of thrombolysis demands an A. Etiology and pathophysiology of stroke complementary radiology services. A dedicated urgent diagnosis and the adoption of a ‘brain R. von Kummer; Dresden/DE interdisciplinary team and emergency room, attack’ or ‘stroke unit’ protocol similar to the car- B. Stroke imaging in the acute phase or in critically ill patients combined with a nearby CT facility and the avai- diology approach to heart attacks. P.M. Parizel; Antwerp/BE lability of MRI for selected cases, are mandatory. C. Intervention in stroke Radiologists involved in the management of M. Leonardi; Bologna/IT “Therapeutic neuroradiology requires a highly stroke are facing three main demands, accor- • Panel discussion: sophisticated angiographic system with biplane, ding to course moderator Dr. Roger Siemund, Where do we stand in stroke therapy today? rotatory image acquisition and 3-D reconstruc- from the department of radiology, Lund Uni- tion. The novel feature of interest in this sector is versity Hospital, Sweden. First, they must have CT-like angiographic acquisitions in soft tissues,” a good knowledge of the causes and the patho- he said. “Dynamic CT diagnosis of the ischaemic physiology of ischaemic stroke and a proper or haemorrhagic lesion should be established understanding of the current models for infarct Free Publications directly in the vicinity of the emergency room, development, as a prerequisite for rational deci- immediately followed by therapeutic embolisa- sion-making and efficient communication with Pick up your free copies of radiology journals and magazines … tion or thrombolysis without moving the patient.” clinicians. Second, they have to be able to choose Free access to online radiology journals … and use appropriate imaging modalities for the Radiologists at Bellaria Hospital use a Siemens acute work-up of patients with stroke and be The Free Publications booths are located on the first level Sensation system with a 40-slice detector and an aware of the benefits and drawbacks of CT and and on the second level, integrated into the EPOS™ Lounge. acquisition of 120Kv/120mA – 0.5/1 from the MRI. Finally, they need sound knowledge about Enjoy another valuable service at ECR! aortic arch to the supra-frontal sinus intracranial the therapy options in order to be able to support region. Intravenous administration of 50 ml of clinicians in the time-critical treatment decision.

myESR.org 14 ECR TODAY 2011 CLINICAL CORNER Sunday, March 6, 2011

Europe and USA combine expertise in oncologic imaging

By Mélisande Rouger only one organ or organ system. As soon as there is a metastatic spread, they may be distributed all Oncologic imaging is performed daily in virtu- across the body,” explained ESR President Pro- ally every radiology practice. Radiologists play fessor Maximilian F. Reiser from Munich. an essential role in detecting, characterising, and staging tumours, as well as in assessing treatment The course, which was also held at RSNA last response and monitoring for tumour recurrence. November, is divided into lectures on different tumour entities and presented by some of the In order to make the most of the latest impor- finest radiologists from both sides of the Atlan- tant developments in cancer patient manage- tic, including Reiser and Hricak, and ECR 2011 ment, radiologists need practical knowledge President Professor Yves Menu, from Paris, with and up-to-date information. This is what the a lecture on pancreatic cancer. two leading radiological societies, the ESR and RSNA, have planned to provide by holding their These lectures will provide a practical, clini- first ever joint course at this year’s ECR. cally-relevant summary of key imaging issues in common cancers (ovarian, kidney, lymphoma, “Cancer is a global disease and a global chal- colon, pancreas, prostate and liver) using an Richard L. Baron from Chicago, IL/US Christian J. Herold from Vienna/AT lenge,” said RSNA Immediate Past President interactive, case-based approach. After an over- Professor Hedvig Hricak from New York. “This view of principles of oncologic imaging and ESR/RSNA joint educational project will help to current cancer-related terminology, there will strengthen and unify our approaches to oncolo- follow organ-specific lectures focusing on how gic imaging.” imaging can optimise detection and characterisation of specific tumours and measure tumour Cross-sectional imaging, including CT, MRI treatment response, providing a value-added (with its latest addition of whole body MRI) radiology report. and PET-CT, has revolutionised the way cancers are diagnosed and treated. Imaging can now be Oncologic imaging is a wide field with a major used for many aspects of patient management, bearing on patient health but there are currently from assessment of the spread and resistance of few opportunities for subspecialisation. This can a tumour to monitoring of the response to the- cause uneasiness among radiologists, experts rapy. In addition to basic anatomic information, observe. treatment monitoring now provides more and more functional imaging parameters to assess “A large proportion of radiological practice perfusion and metabolism. involves imaging of cancer patients. Yet many Hedvig Hricak from New York, NY/US Maximilian F. Reiser from Munich/DE radiologists feel insecure when interpreting “Due to a change of paradigm regarding the such examinations, due to a lack of specialised treatment of oncologic patients, it has become training in oncologic imaging, the complexity additional step would be to promote oncologic Baron, from Chicago, who will talk about liver necessary for physicians to address the issue of of the findings, and the high stakes involved for imaging as a subspecialty. That would have con- cancers. oncologic imaging and education in oncologic the patient,” said RSNA speaker Professor David sequences for resident training in radiology and imaging in a worldwide vision,” said ESR Past Panicek, from New York, who will discuss prin- we are considering promoting fellowships in Other themes such as obesity, which is beco- President Professor Christian J. Herold, from ciples of oncologic imaging and reporting. oncologic imaging,” Herold said. ming more and more important in Europe but Vienna, one of the course coordinators. already an urgent issue in the U.S., metabolic Consequently, there are ongoing discussions Could this joint course be a springboard for diseases such as diabetes, and radiation expo- But it is also a change in the perception of onco- regarding the introduction of oncologic ima- other common educational programmes? sure could be dealt with in joint sessions, said logic imaging that prompted the idea for a com- ging as a subspecialty and its integration into Reiser. Common forces and common ideas mon initiative. “Oncologic imaging has been the radiology curriculum. “Perhaps as we work closer in education there would also make the societies more effective very focused for a long time, but we feel that will be opportunities in other areas of mutual when negotiating with political decision makers some sort of comprehensive approach is now “This joint initiative has many components: interest such as quality and safety, and research,” for instance, he added. necessary, because tumours are not located in one is the course on oncologic imaging but the suggested RSNA speaker Professor Richard L.

Mini Course Joint Course of the ESR and RSNA (Radiological Society of North America) Visit ESOR at ECR 2011: Sunday, March 6, 08:30–10:00, Room N/O Sunday, March 6, 14:00–15:30, Room N/O • Booth in entrance hall Stars Lounge • Info desk in Rising MC 1125 Essentials in oncologic MC 1325 Essentials in oncologic

• Session on March 4, imaging: what radiologists imaging: what radiologists 14:00–15:30, Room Q need to know (part 1) need to know (part 3) Moderator: D.M. Panicek; Moderator: H.-U. Kauczor; ESOR New York, NY/US Heidelberg/DE European School of Radiology A. Principles of oncologic A. Oncologic imaging: imaging and reporting terminology, definitions D.M. Panicek; and buzzwords New York, NY/US Y. Menu; Paris/FR B. Lung cancers B. Liver cancers (primary, metastases) (primary, metastases) C.J. Herold; Vienna/AT R.L. Baron; Chicago, IL/US C. Colon cancer C. Prostate cancer R.M. Gore; J.O. Barentsz; Nijmegen/NL The aim Topics and training centres Highland Park, IL/US • Questions Improving the quality of teaching represents an extremely Abdominal Imaging rewarding exercise for the future of radiology. The ESOR University of Szeged/Hungary • Questions Teach-the-Teachers Programme is designed to educate future teachers and faculty members. By implementing Cardiac Imaging Sunday, March 6, 16:00–17:30, Room N/O the use of electronic instructional technology it aims to La Sapienza University, Rome/Italy Sunday, March 6, 10:30–12:00, Room N/O MC 1425 Essentials in oncologic create luminaries in teaching. MC 1225 Essentials in oncologic imaging: what radiologists imaging: what radiologists need to know (part 4) The programme The programme will offer a structured intense training in need to know (part 2) Moderator: H.-U. Kauczor; the chosen topic - Abdominal Imaging or Cardiac Imaging. Moderator: D.M. Panicek; Heidelberg/DE Tutors will supervise and teach the trainees skills to New York, NY/US A. L ymphoma become qualified teachers in their home departments/ M.P. Federle; Stanford, CA/US countries. Three 45-minute teaching conferences are A. Pancreatic cancer organised in the subsequent six months for follow-up in F. Caseiro-Alves; Coimbra/PT B. Musculoskeletal neoplasms the trainees’ home institution. M.F. Reiser; Munich/DE B. Kidney cancer Application E.K. Fishman; Baltimore, C. Chemo- and radiation therapy-induced toxicity Online application will start on March 1, 2011. In partnership with Covidien MD/US Further details regarding the programme, eligibility H.-U. Kauczor; Heidelberg/DE C. Ovarian cancer and application process are available at • Questions www.myESR.org/esor H. Hricak; New York, NY/US • Questions

myESR.org Sunday, March 6, 2011 CLINICAL CORNER ECR TODAY 2011 15

Technical issues still prevent widespread clinical use of 7T MRI

By Philip Ward with increasing field strength several problems arise, including new image artefacts. High-field The current generation of high-field MR systems MRI will not provide a meaningful solution for (7 Tesla and above) is not ready for clinical use each and every imaging problem, and the gene- because radiofrequency coils are not available, ral radiologist should be aware of this when deci- protocols have not been optimised, and current ding which field strength to choose, Bock stated. systems are expensive and need a lot of space. However, future 7T magnets look set to be par- Noise is another issue. The forces acting on the tially shielded and will require significantly less imaging gradients increase linearly with field space and shielding measures, and emerging strength, and so an increase in sound pressure technologies such as parallel radio-frequency occurs at higher fields due to the stronger vibra- transmission will address another important tion of the gradient coils. Aware of this challenge, problem: inhomogeneities in the transmit field, MR manufacturers have included additional which cause susceptibility artefacts. sound protection measures, such as more rigid gradient coils or better damping, into their sys- These are the opinions and predictions of tems. In the 7T unit at the DKFZ, sound pressure Dr. Michael Bock, a medical physicist at the levels are now similar to those at 3T. Nevertheless, German Cancer Research Centre (Deutsches passive sound protection using ear plugs or muffs Krebsforschungs-zentrum, DKFZ) in Heidel- is always indicated at high-field strengths, he said. Two 7T images of a glioblastoma patient. A: T2-weighted image shows brain lesion with very high spatial resolution. berg, which is the largest biomedical research The heterogeneity in the lesion is already visible. B: Time-of-flight MR angiogram shows the arterial vessels at the periphery of the lesion. The irregular vessel structure indicates neo-angiogenesis, and it would be very interesting to institute in Germany. The need for sound protection measures and the see whether this vascular structure changes under new forms of neo-angiogenic therapy. (Provided by M. Bock) requirement for stronger gradient systems do “High-resolution MRI in the brain and in other not appear to have a substantial impact on over- anatomical areas (e.g., the knee) will become the all costs. The major cost comes from the magnet, Operating at increased magnetic fields makes it of high-field MRI in clinical and pre-clinical stu- first established clinical applications of high field and the gradient redesign does not add massively easier to obtain T2* contrast-enhanced images dies in a number of areas, along with the barriers MRI. For example, we are able to visualise the to the total system cost, Bock maintained. and improved implementation of susceptibility- to wider usage of 7T systems for clinical studies. tiny neo-vasculature in brain tumours, so high- weighted imaging, in which the phase of gra- field MRI might be a powerful tool to assess When the field strength rises, the signal-to-noise dient echo images provides information about Refresher Course therapy response to the more and more popular ratio (SNR) also increases about linearly. Since local variation of magnetic susceptibility, accor- neo-angiogenic treatment,” he commented. MRI is intrinsically an insensitive technology, ding to Prof. Richard Bowtell, from the Magnetic Sunday, March 6, 08:30–10:00, Room P every increase in SNR is more than welcome. Resonance Centre, School of Physics and Ast- RC 1113 High field MRI: beyond 3T The use of nuclei other than protons (sodium-23, At a higher SNR, it is possible to lower the voxel ronomy, University of Nottingham, U.K. In the Moderators: oxygen-17, phosphorus-31) will open up new pos- size (i.e., increase the spatial resolution), acquire brain, such variation appears to be dominated M. Tosetti; Pisa/IT sibilities for assessing metabolic information, but images faster, and detect MR signals from rare by differences in iron concentration and myelin A.J. van der Molen; Leiden/NL there are still many technical problems to be sol- nuclei such as sodium, he pointed out. content, so that high-field SWI may provide use- A. Challenges of high field MR ved, particularly in relation to the high and loca- ful information about the progression of neuro- M. Bock; Heidelberg/DE lised energy deposition, he warned. The higher Possible clinical applications of 7T include the degenerative disease. The elevated T1 relaxation B. A complicated solution to a energy deposition is hard to predict because local detection of very small lesions such as metastases, times at 7T also offer benefits for arterial spin complicated problem: focusing of the radio-frequency fields can occur. near-real-time imaging of the heart, and imaging of labelling and time of flight angiography. transmit array The trend to ever higher fields in MRI is typically cell vitality using sodium MRI. Furthermore, Bock K.P. Pruessmann; Zurich/CH motivated by the gain in spatial resolution that notes that the increased susceptibility contrast is In his ECR presentation, Bowtell also plans to dis- C. Is 7T ready for clinical use? can be achieved with high-field MR systems, but widely used for neuro-functional MRI (fMRI). cuss the current and potential future applications R.W. Bowtell; Nottingham/UK

Italian Society of Radiology supports research through education and multicentre studies

By Prof. Francesco Sardanelli Scientific research has been promoted by SIRM since 2002, when the society started to organise The Italian Society of Medical Radiology (SIRM) focused courses on research methodology in was founded at the beginning of 1913 and is cur- radiology. These courses were held in different rently the largest medical society in Italy, with cities all over the country, under the direction of about 5,000 full members, excluding residents, Professors Alessandro Del Maschio (2002–2005) junior and senior radiologists. About 5,500 par- and Francesco Sardanelli (2007–2010). The last ticipants attended the last national meeting, held of these courses was entitled ‘Evidence-based in Verona in June 2010. The society is ruled by a radiology and research methodology’. Radi- President and a Board of Councillors, elected by ologists and statisticians taught how to design a all members. The current President is Professor study, make a sample size estimate or data analy- Antonio Rotondo. SIRM offers a large variety of sis and carry out statistical testing. A total of 544 courses for continuing medical education con- SIRM members attended these courses; 254 of cerning each radiologic subspecialty. The SIRM them were residents in radiodiagnostics with official journal, La Radiologia Medica, founded a mean age of 30, and 290 were certified radi- in 1913, is a monthly publication distributed free ologists with a mean age of 43, showing that it is of charge to all SIRM members, published by possible to attract a substantial audience includ- Springer in both Italian and English since 2006, ing colleagues with more clinical experience. The 45th Congresso SIRM will take place in Torino, June 1–5, 2012. with a current impact factor of 1.454. The society started the promotion of multicentre trials, in particular on breast imaging, cardiac coronary artery disease (F. Cademartiri et al.); or two projects, topics considered as strategic for The scientific core of the society is organised imaging, and virtual colonoscopy resulting in 2) Adult and paediatric patient radiation doses the future of our mission in the medical world. into 19 Subspecialty Sections. They are focused papers published in high-ranked journals. from multidetector CT scans: a national survey This choice may be useful in order to give a kind on clinics (abdominal and gastrointestinal, (S. Salerno et al.); 3) CE-MRI quantification of of address to Italian radiological research, tak- breast, cardiovascular, dental and head and In the last two years, SIRM has started a new myocardial damage as prognostic indicator in ing into account the increasing role of imaging neck, emergency, musculoskeletal, neuro, pae- activity: a direct financing of multicentre stud- hypertrophic cardiomyopathy (R. Fattori et al.); in medicine and the professional challenges for diatrics, thoracic, urogenital, vascular and inter- ies using internal funds and free contributions 4) Assessment of diffusion-weighted MRI to pre- the future. The guiding idea of SIRM is that the ventional radiology), on imaging techniques from members, totalling €120,000 for 2009– dict the chemotherapy outcome in liver metas- professional game can only be won on the basis (CT, contrast materials, MRI, ultrasound), or 2010. A call for radiological research projects tases (S. Colagrande et al.). These projects are of high quality in diagnosis and image-guided other issues (ethics and legal issues, informatics, was launched in July 2009 and a scientific com- now in an advanced phase and their results are intervention. High quality clinical research and management and economics, radiobiology and mittee evaluated 11 blinded proposals in coop- expected during 2011. the increasing application of the principles and radioprotection). Each section has a President eration with two international referees. The four methods of evidence-based medicine to radi- and a Board of Councillors, elected by all sec- projects with the highest rank were funded: 1) For the next two-year period (2011–12), SIRM is ology are fundamental conditions for a bright tion members. CT coronary angiography prognostic registry for discussing the idea of choosing, at least for one future for radiology in the coming decades.

myESR.org 16 ECR TODAY 2011 CLINICAL CORNER Sunday, March 6, 2011

Major advances in prostate MR bring fresh hope to growing numbers of patients

By Edna Astbury-Ward

Out of a population of 17 million in the Nether- lands, there are around 10,000 new diagnoses of prostate cancer every year, and of this number, 25% will die as a result of their disease. Because men are living longer and leading more healthy lives, the chances of them being diagnosed is increasing to the point that prostate cancer is now almost at epidemic proportions, observed Prof. Jelle Barentsz, from the department of diagnostic radiology, University Hospital Nijmegen, the Netherlands.

Barentsz is not despondent, however, and believes the future is bright, particularly in the area of screening. Prostate specific antigen (PSA) screening can reduce mortality by up to 30%, but screening using PSA alone is not specific enough and may result in unnecessary trans- rectal ultrasound (TRUS) guided biopsies, over- diagnosis and over-treatment. The use of PSA 69-year-old male three years post external beam radiotherapy (EBRT, primary PC: Gleason 4+3 right PZ) with PSA increase to 2. MRI and TRUS-guided biopsy of this area screening, followed by multi-parametric MRI in confirmed Gleason 4+4 recurrence at right PZ (old tumour location). A: Axial T2-weighted MR image shows low signal prostate due to previous EBRT. Therefore tumour case of PSA elevation and subsequent MR-gui- (arrow) is difficult to see. At arrow, there is some “bulging”. B: Axial DCE-MRI shows increased contrast leakage at right PZ (circle), highly suspicious for PZ. C: Axial ADC map of DWI-MRI shows restriction (low signal, circle). TRUS biopsy of this area confirmed Gleason 4+4 recurrence. (Provided by J. Barentsz) ded biopsies in MR-positive patients, is much more effective and less costly, he said.

Multi-parametric MRI, which includes functional techniques such as diffusion-weighted, dynamic contrast-enhanced and spectroscopic imaging, can improve the information available to surgeons and physicians. This is partly because multi-parametric MRI helps to locate the most aggressive part of the tumour, and MRI is recommended whenever a TRUS-guided biopsy is negative in a patient with an elevated PSA.

“MRI is particularly useful to demonstrate func- 48-year-old male with prostate adenocarcinoma; Gleason 7 (4+3). Patient selected for MR-guided focal laser blation (Visualase). A: ADC map shows restriction in transition tional anatomy. The future potential benefits zone (TZ); Gleason 7 (4+3) PC on MR-guided biopsy. B: Interactive MR temperature map image during laser ablation procedure, showing the “killing zone” (> 67 centigrade are earlier tumour detection, improvement of Celsius). C: Post-treatment contrast-enhanced MR image showing the destruction area, which matches with the tumour area on A and the killing zone on B. Procedure was tumour localisation and better detection and performed using In-Vivo MR-biopsy device. (Provided by Dr. John F Feller, Desert Medical Imaging, Indian Wells, California). determination of cancer aggression,” noted Barentsz, who will speak at this afternoon’s refresher course on MRI in prostate cancer. “At this moment there is a lot to be gained for the patient, as multi-parametric MRI offers the potential for tailored therapy. MRI will enable us to implement prostate cancer screening together with PSA.”

By determining the true cancer aggression and its local and distant extension, MRI can assist with decisions made about the most appropriate treatment. Furthermore, the future role of prostatic MRI will include the more widespread use of MR-guided biopsy, and subsequently will involve greater use of minimally invasive MR- guided focal therapy, which includes laser therapy / cryotherapy / brachytherapy, he predic- ted. These procedures will partly replace more aggressive prostatectomy. Additional future roles for MR in prostate cancer may involve the 68-year-old male with PSA of 8.5 in 2006 that increased to 28 in 2010; DRE T1c. Since 2006 four times 10 core TRUS biopsy was performed with negative result. MR-guided use of iron oxide particles for the detection of biopsy revealed Gleason 4+3 PC. A: Axial T2-weighted MR image shows homogeneous low signal lenticular shape area in left ventral prostate (oval), which shows restriction on ADC map (B), and increased enhancement on contrast-enhanced MR (C). (Provided by J. Barentsz) small metastases and diffusion-weighted techniques for assessment of bone marrow spread.

A more efficient route of referral for men with Earlier detection of tumour recurrence is vital, more accurate determination of extraprostatic other cross-sectional modalities, and this enab- elevated PSA or those who have prostatic symp- and MRI has significant advantages over other tumour extension helps urologists decide on the les earlier detection of a recurrent cancer. Multi- toms, may be from the primary care physician to conventional tools such as digital rectal examina- most appropriate treatment choice. Also, Tur- parametric MRI can also provide assessment of diagnostic radiologists, according to Barentsz. tion, TRUS and CT, commented Dr. Ahmet Tur- gut stressed the inherent superiority of the soft recurrence of cancer after radical prostatectomy He thinks radiologists must approach prostate gut, from the department of radiology, Ankara tissue contrast resolution of MRI compared to or radiotherapy. cancer with the same vigour and enthusiasm Training and Research Hospital, Turkey. Delega- that they have approached breast cancer. “We tes at today’s session will find out why the moda- should be ready! Urologists and radiation onco- lity is helpful for proper differentiation of post- Refresher Course logists are more ready than we are! We really can surgical fibrosis and recurrent cancerous tissue. make a difference for our patients.” Sunday, March 6, 16:00–17:30, Room E1 “MRI is particularly sensitive for the detection RC 1407 MRI in prostate cancer Radiologists must read between 10 and 15 pro- of local recurrence in patients having biochemi- • Chairman’s introduction state MR examinations every week to become cal failure with PSA values lower than 2 ng/ml,” J. Venancio; Lisbon/PT an expert, he added. His team currently reads he said. “It enables better selection of patients A. MRI in detection of prostatic cancer 1,500 prostate MR exams a year, and he antici- prior to salvage radiation therapy.” F. Cornud; Paris/FR pates that this number will increase to 3,000 in B. MRI in the post-treatment follow-up the next 18 months. Standardisation of the per- After radiation therapy, MRI is very helpful for A.T. Turgut; Ankara/TR formance and structured reporting of the exams depicting locally recurrent cancer within the C. New frontiers in imaging of the prostate remains important, and the guidelines produced prostate gland, extracapsular extension and J.O. Barentsz; Nijmegen/NL by the prostate working group of the European seminal vesicle invasion before salvage prosta- • Panel discussion: Society of Urogenital Radiology are due to be tectomy. This is important he states because bet- What is the most appropriate radiological approach published soon in European Radiology. ter prediction of the tumour aggressiveness and in patients with rising PSA levels, and when?

myESR.org Sunday, March 6, 2011 TECHNOLOGY FOCUS ECR TODAY 2011 17

3D models help Advanced methods Inside to plan and simulate give boost in Cell therapies in interventions breast cancer modern medicine

Today See page 19 See page 21 See page 23

Fusion and 3D capabilities feature prominently among ultrasound technical exhibits

By John Bonner

Image fusion continues to be all the rage within radiology, but so far it has rarely been applied when it comes to ultrasound. This may change as a result of an innovative method being shown as a work-in-progress on Siemens’ booth in the ECR 2011 technical exhibition. The company is displaying its novel image fusion technology that appears capable of integrating real-time ultrasound images with those obtained by CT and MRI.

This is not the first time that a vendor has looked to find ways of benefiting from a possible synergy between these very different modalities. But as Siemens points out, conventional fusion techniques can take up to 30 minutes to set up and usually require several Image of an umbilical cord acquired on the Acuson X300 system (Provided by Siemens) Power Doppler image/TR view of hepatic veins. attempts. Moreover, patients need to lie com- (Provided by Siemens) pletely still during the entire examination or the setup must be repeated. For its fusion solution, the company has been working on technology that automatically aligns the CT or MRI image to the ultrasound view. This approach reportedly accelerates workflow and improves the accuracy of image align- ment, allowing fusion imaging to be integrated into existing practice.

Siemens is also showcasing real-time ste- reoscopic 3D/4D imaging capability, which it claims can deliver 3D ultrasound images that are more detailed and realistic. This can improve diagnostic confidence, and it may become a standard ultrasound procedure of the future, beyond the field of obstetrics and gynaecology. The basic technology is one of an increasing number of innovations that are direct spin offs from developments in the world of entertainment. Software originally developed for use in computer games has already proved invaluable in speeding up the capture and processing of ultrasound data, and the new system utilises advanced visualisation technologies that were originally developed for companies working in immersive 3D film and video production.

These techniques are being demonstrated at ECR on Siemens’ flagship Acuson S2000 ultrasound platform. They combine two key technologies developed by Nvidia, the Santa Clara, California-based producer of graphics Invasive ductal carcinoma of the breast viewed using Hitachi’s real-time 4D tissue elastography technique. (Provided by Dr. Ako Itoh, department of surgery, Hitachi General Hospital, Ibaraki, Japan) processing units. These are the Quadro 2000 professional graphics solution and 3D ste- reoscopic glasses. Used together, they supply College of Wisconsin, Milwaukee, U.S. “Co- volumetric information and anatomic views registration of previously acquired CT and that would be impossible with conventional MR image data sets with real time Logiq E9 3D methods. ultrasound imaging in any plane often allows for more confident identification of the target Meanwhile, GE Healthcare is displaying and the proposed biopsy pathway. Volume new applications for use on its Logiq E9 ult- navigation with needle tracking (provided rasound system, launched in 2008 and now by a needle tip sensor) provides real-time used in around 3,000 hospitals around the visualisation of the needle tip, either with world. The company has launched elastogra- an in plane or out of plane approach, as it phy and needle-tracking applications that is directed at the target. These capabilities provide clinicians with tools to help interpret instil confidence and can increase procedural internal tissue structures and aid interventi- accuracy.” onal procedures such as biopsies, ablations, drainage and fluid aspiration. The features available on the Logiq E9 platform can also help increase accuracy in tre- “Liver lesion biopsies require targeted precis- ating patients with a variety of neoplasms. ion that may be difficult to achieve with stan- Targeting inconspicuous tumours during dalone imaging technology,” said Dr. Dennis Foley, chief of digital imaging at the Medical continued on page 18 3D ultrasound scan of 25- week-old foetus. (Provided by Siemens)

myESR.org 18 ECR TODAY 2011 TECHNOLOGY FOCUS Sunday, March 6, 2011

continued from page 17 For Philips, the newest introduction is the to volume imaging. The new X6-1 PureWave workflow disruption. The ultra-thin, targe- iU22 xMATRIX ultrasound system, which xMATRIX transducer delivers 2D images, ted beam provides extraordinary tissue uni- percutaneous local ablation therapy can be reportedly makes it easy to add 3D imaging and can convert to 3D to provide a more formity while decreasing noise surrounding challenging when relying only �on contrast to any examination by removing the barriers complete picture of anatomy without serious the region of interest, resulting in fewer arte- imaging that is designed to identify the index facts when compared to conventional beams, tumour, but the Logiq E9’s fusion imaging in according to the vendor. real-time acts as a potentially valuable support system throughout the procedure, ensu- The X6-1 transducer features xPlane, which ring accurate targeting, monitoring and criti- allows imaging in two planes simultaneously, cal confirmation that the ablative margin will without manually rotating the transducer. cover the entire target tumour. “Because you no longer have to rotate the transducer to see the second plane, you don’t Elsewhere in the technical exhibition, risk losing a tiny object during manual rota- Hitachi Medical Systems is unveiling the tion. Clinical trials have shown that xPlane latest addition to its Hi Vision range. The speeds workflow, improves imaging precision, Hi Vision Ascendus is being promoted as and has the potential to minimise repetitive a technology for the premium end of the stress injuries,” noted a company statement. range and a complementary system to the Hi Vision Avius, launched at ECR 2010, and the Hi Vision Preirus, which made its debut in Vienna in 2009. Using low noise and wide aperture front end technology, and with connection to Hitachi’s extensive range of standard and specialist transducers, the Hi Vision Ascendus offers first class image quality in all diagnostic fields, according to the vendor. An examination is performed using the Acuson X300 scanner (Provided by Siemens) The standard platform package comes fully loaded with a range of advanced applications, including inflow-time mapping (ITM), a parametric quantification tool for mapping contrast agent times and the company’s real-time tissue elastography (RTE) technology. The latter allows the assessment and real-time colour display of tissue elasticity, and it can help to improve the detection and visualisation of malignant disease and offers increased accuracy in tissue sampling in conditions affecting organs such as the breast, prostate, ovaries and pancreas. During ECR 2011, Hitachi plans to describe new applications for the technology, including one that enables the auto-selection of the technically optimum image on freeze, strain ratio and strain histo- Hitachi has developed medical ultrasound technology for gram quantification. Amnioscopic rendering of 3D image of 35-week foetal face (Provided by Siemens) over 40 years. (Provided by Hitachi)

159v1 - ECR Today 4th march 2011.indd 1 13/01/11 15:26 myESR.org Sunday, March 6, 2011 TECHNOLOGY FOCUS ECR TODAY 2011 19

Use of volumetric images to obtain patient-specific synthetic anatomies and guide endovascular instruments

By Vincenzo Ferrari, Sara Condino, Marina Carbone, Emanuele Neri, Davide Caramella, Carlo Bartolozzi, Mauro Ferrari, Franco Mosca, EndoCAS Center – University of Pisa, Italy

Using modern volumetric radiological scanners and developing images, it is possible to obtain patient-specific 3D models that can be used to plan or to simulate interventions, in a virtual environment, and to guide surgical interventions, localising surgical instruments in respect to the 3D model and showing them together on a display. A 3D model of a hip-bone and its ABS replica (left); a physical replica of an abdominal arterial tree obtained by segmenting a CT angiographic image (centre); separated parts of a mould including wirsung and common bile duct, and the final silicone pancreas (right). Virtual simulation is very useful for some surgical tasks while in other cases it is limited by technical challenges related to the modelling of realistic interactions between surgical instruments and the anatomy. This kind of interaction is easy to achieve using physical simulators, manufac- tured using plastic, rubber and latex. Physical simulators are often restricted to single or a few anatomical structures and they are frequently limited to a unique standard anatomy.

Regarding surgical navigation, some researchers have proposed to follow the movements of catheters using electromagnetic sensors in order to reduce or to avoid the need for fluoroscopic A catheter with two electromagnetic sensors (left); a sensorised nitinol guidewire (centre); a screenshot of our endovascular navigator (right). images to perform endovascular interventions. To completely exclude the need for x-rays and contrast medium injection it would be necessary The use of radiological images is day by day to localise, not only the catheter, but also the gui- becoming useful for more than just diagnostic dewire. purposes. We are able to obtain solid replicas of the anatomy using ABS or silicone, which can be Below are the answers proposed by the Endo- very helpful for training or to plan difficult inter- CAS Center to these issues. ventions.

Our solution to obtain Tell us your requirements, and we can try to patient-specific synthetic anatomies create an ad-hoc model for you. We developed a process to fabricate patient- specific abdominal organs, in ABS or silicone, Our sensorised catheters with realistic shape and colour, using radiolo- and guidewires for endovascular gical images. At first we segment the images electromagnetic surgical navigation and then we can obtain an ABS solid replica of We are working on a fabrication strategy to the anatomical structures using our in house obtain biocompatible sensorised catheters and rapid prototyping machine or moulds designed guidewires. An endovascular navigator, based around the anatomy where we apply silicone. on our sensorised catheters and guidewires, has Until now we have fabricated ABS solid replicas been positively in-vitro tested (on our ABS arte- of pathologic hip cotyles for the simulation of rial tree) using an intra-operative 3D C-Arm. prosthesis interventions, and arterial vessels to use in training simulations of catheterisation. In Intra-operative 3D imaging coupled with our addiction we obtained silicone replicas of liver, sensorised catheters and guidewires pave the gallbladder, stomach and pancreas, which are way to obtain image-guided endovascular inter- used to test innovative surgical strategies and ventions, reducing the need for fluoroscopic Assembled mannequin and the virtual models used to obtain the internal organs (a segmented CT dataset). instruments. guidance. All images provided by EndoCAS Center, University of Pisa) Mobile Guide m.myESR.org Get ECR on your smartphone and always stay up to date! The ECR Mobile Guide brings ECR 2011 to the palm of your hand. Find out all about: ▶ Sessions/Lectures ▶ Abstracts ▶ Exhibitors ▶ Floorplans ▶ Places to be

myESR.org 20 ECR TODAY 2011 TECHNOLOGY FOCUS Sunday, March 6, 2011

EUSOBI President outlines the significance of new techniques in breast imaging

By Thomas Helbich, EUSOBI President the European Diploma in Breast Imaging. This diploma will be a customary European qualifica- The European Society of Breast Imaging (EUSOBI) tion for the breast imager, and will help to stand- has two principle aims: to represent and promote ardise training and expertise in radiology across best clinical practice through guidelines and edu- Europe. The diploma is endorsed by the European cation; and to promote breast imaging in Europe Society of Radiology (ESR). through the ESR committee structure. Education is a major task for EUSOBI. Together For the last several years, the annual scientific with the European School of Radiology, EUSOBI meeting of EUSOBI has been successfully posi- will offer a three-month breast imaging fellowship tioned one day before the ECR. This year, the in 2011. In 2010, three candidates were selected annual meeting focuses on ‘Facts, figures, and from among more than 20 applicants, and these future perspectives of breast imaging’. The quality candidates have been trained successfully in of knowledge provided by the lecturers has been Cambridge, Vienna, and Maastricht. In addition, rated quite highly, and the scientific programme EUSOBI, together with the European School of has been praised by participants as bringing new Radiology, is offering a two-day master class on and interesting insights to the topic of breast breast imaging in November 2011, in Budapest. imaging. Highlights of the annual meeting were The class is specifically designed to help countries In 2012 Barcelona will host the EUSOBI meeting, a cooperation with the Spanish Breast Imaging Society. the EUSOBI lecture ‘Imaging Breast Microstruc- where breast imaging is less advanced. tural Elements and Cellular Properties with Advanced MRI Diffusion Methods’, presented by However, the education and training of breast reviews. Based on a long tradition, the EUSOBI survival rates compared to non-team, non-high Prof. Degani from Israel, and the keynote lecture imagers is not enough. We also need to work Executive Board fully supports the ECR Breast level experts. This is a massive undertaking, and ‘Molecular and Functional Characterization of to increase public and political expectations. Sub-Committee with ideas and help in planning the first step is radiological education. EUSOBI Breast Cancer by Ultrasound Imaging’ presented EUSOBI can support the radiological commu- the breast components of the ECR. fully supports this. by Prof. Kiessling from Germany. Workshops nity to ensure that there are radiologically-driven were offered on breast interventions and, for the guidelines for breast care in every European Over the last several years, breast screening has Looking toward the future, many new breast first time, tomosynthesis. country. Furthermore, EUSOBI is increasing its been very much in the news. In contrast to previ- imaging technologies are on the way. Almost partnership directives. EUSOBI is actually on ous years, we have heard a lot of success stories every month, a new technique is introduced, At this year’s annual meeting, we introduced, for the way to intensifying partnerships with other about mammography screening. A landmark such as tomosynthesis, contrast-enhanced mam- the first time, a student programme. Ten medi- national breast imaging societies. The Society of study from Sweden confirms that mammogra- mography, positron emission mammography cal students were invited by EUSOBI to join the Breast Imaging (SBI) from the United States will phy lowers the breast cancer death rate by nearly (PEM), gamma camera imaging, and whole- meeting. The goal of this initiative was to intro- become our first partner. We hope to hold our one-third in women aged 40–49. Thus, even the breast ultrasound units, etc. It remains to be seen duce medical students to the field of breast imag- joint meeting soon. President of the United States, Barack Obama, where all these new techniques will fit into every ing and for them to learn more about the role of stated: “For women forty years of age and over, day breast imaging. We await the results of future imaging in breast cancer detection and treatment. Breast imaging might well have the largest evi- regular mammograms and clinical breast exams trials with interest. It is clear that breast imag- It was amazing to see how well this initiative was dence base of outcome studies when compared by healthcare providers every one to two years are ing has moved to the next stage, from diagnosis appreciated by the students. I am sure that at least to most other areas in radiology, but there is the most effective way to find breast cancer early, to molecular prediction. It is only a matter of one of them will enter the field of breast imaging. still a lack of good outcome studies, particu- when it may be easier to treat,” a statement that I time before we will use these new imaging tech- larly regarding new technologies. EUSOBI will would also like to hear from the President of the nologies to diagnose, treat, and predict response EUSOBI will continue this successful pattern; thus, actively support the European Institute for EU. Another important study that was published to therapies. With these new techniques, it is in 2012, the annual scientific meeting of EUSOBI Biomedical Imaging Research (EIBIR) and in the New England Journal of Medicine shows expected that the breast imager will become will take place in Barcelona, Spain, in cooperation EuroAIM in creating an evidence-based research that a high-quality, high-volume population the conductor, rather than the first violin, of with the Spanish Breast Imaging Society. Dur- working group, in which we identify areas where screening programme, provided by dedicated the breast team. These new breast imaging tech- ing the congress in Barcelona, EUSOBI will also there is a lack of systematic reviews and where radiologically-driven teams and an interdiscipli- niques will become the bread and butter of our launch, as the first subspecialty offered by the ESR, primary studies are needed to support such nary team approach, lead to significantly higher current trainees’ careers. Treating liver metastases; can MRI with liver-specific contrast reduce overall costs?

Which imaging method is best in a patient with niques, Zech and colleagues set up a randomised with liver-specific contrast, the need of a second as they do not allow direct evaluation of the liver. liver metastases from colorectal cancer? As often comparison study including 40 major medical imaging procedure was close to zero. In MRI with “You simply cannot put an ultrasound transdu- in medicine, there is no easy answer. Whether a centres in Europe and Asia. The VALUE study extracellular contrast, 15.8% of the patients had cer on the liver surface to check your findings particular procedure makes sense or not is not (sponsored by Bayer Healthcare AG) eVALUatEs to be re-examined, while contrast-enhanced liver like you can during liver surge,”“, explains Zech. only a matter of finding the exact diagnosis reli- outcomes and resource needs of imaging and CT led to a second imaging procedure in 36.3%. ably, it also depends on its impact on decision- treatment following Primovist®-enhanced MRI “I was surprised that the advantages of MRI with The current clinical study was set up to evaluate making, clinical outcomes and – in times of limi- by prospectively comparing three methods: Gd- liver-specific contrast turned out to be as strong results from a prior publication3 based prima- ted money in health systems – of cost. EOB-DTPA-enhanced MRI, MRI with extracel- as the clinical data now tells us,” says Zech. rily on a theoretical model: It had demonstrated lular contrast and contrast-enhanced liver CT. lower total work-up cost for patients with liver “We tend to automatically think that new tech- At ECR 2011, Zech presents an interim analysis Diagnostic confidence, another variable of the metastases from colon cancer when Gd-EOB- niques are expensive, but scarcely base this based on 284 patients with a history of colorectal study, was also best for MRI with Gd-EOB- DTPA-enhanced MRI was used as the initial ADVERTORIAL feeling on facts,” says Christoph Zech, Ludwig- cancer and known or suspected liver metastases. DTPA: It turned out to be ‘very high’ in 70%. It imaging method compared to MRI with extra- Maximilians-University, Munich, Germany. Stu- was considerably lower for MRI with extracellu- cellular agents. MDCT cost was comparable. dies including cost are rare. “Our study suggests that MRI with hepatocyte- lar contrast (44%) and contrast-enhanced multi- specific agent decreases cost in the long run for detector CT (30%). These results are backed by This was true even though contrast-enhanced Since surgical resection is the only potentially this particular group of patients,” says Zech, the combined rates of ‘some confidence’ and ‘low CT was the most inexpensive imaging method, curative treatment for patients with liver meta- adding that the results contradict the well-esta- confidence’: They were 33% for contrast-enhan- as with Gd-EOB-DTPA, pre-operative planning stases, diagnostic imaging needs to identify pati- blished clinical dogma of starting a diagnostic ced CT, 12% for MRI with extracellular contrast was improved and unnecessary surgery was avo- ents who benefit from surgery. Various clinical work-up with the easiest and cheapest method. and 2% for Gd-EOB-DTPA enhanced MRI. Alt- ided: Not only was the rate of confirmed surgical studies1,2 have already shown that MRI with the Although the preliminary study findings do hough high diagnostic confidence is a rather soft planning expected to be higher for Gd-EOB- hepatocyte-specific agent Gd-EOB-DTPA (Pri- not yet include all patients and all variables, he parameter, it very much influences further diag- DTPA-enhanced MRI than for MDCT and MRI movist®) increases the accuracy of liver lesion expects similar results from final evaluation, nostic and therapeutic proceedings. If the diag- with extracellular contrast, it also led to iden- detection, classification and characterisation which is due this spring. nostic confidence is low, second or unnecessary tifying a larger proportion of unresectable cases compared with spiral CT. But how does this procedures are more likely. Although microthe- prior to surgery. translate into overall cost? The study for example analysed whether further rapies like radio ablation were not explicitly eva- imaging was needed after the initial method. luated in the study, Zech expects further benefit 1Halavaara J et al. J Comput Tomogr 2006; 30(3):345-354 2Hammerstingl R et al. Eur Radiol 2008; 18:457-467 To better understand both the clinical and the Additional examinations are costly, time-con- from hepatocyte-specific agents for these thera- 3Zech CJ et al. Eur Radiol 2009; Vol. 19, Suppl. 3 economic impact of current liver imaging tech- suming and put stress on the patient. After MRI pies. They rely even more on accurate imaging, G.DI.02.2011.0093

myESR.org Sunday, March 6, 2011 TECHNOLOGY FOCUS ECR TODAY 2011 21

Digital fight against breast cancer

By Sonja Guttenbrunner A B C D

Despite advances in modern imaging technology, both early detection and accurate diagnosis of breast cancer are still unresolved challenges. Unnecessary biopsies are taken and tumours frequently go undetected until a stage where therapy is costly or would be unsuccessful.

The EU-funded project HAMAM (Highly Accurate Breast Cancer Diagnosis through Integration of Biological Knowledge, Novel Imaging Modalities, and Modelling) has set itself the ambitious target of improving the early detection and accurate diagnosis of breast cancer by integrating the available multi-modal images and patient information on a single clinical workstation. Based on knowledge gained from a large multi-disciplinary database, populated within the scope of this project, suspicious breast tissue will be characterised and classified.

The project is funded by the European Com- mission within the Seventh Framework Pro- Multi-scale contrast adjustment between cross-vendor current-prior mammograms. Left pair: prior (a) and current (b) mammogram pair displayed in their original contrast gramme, with a financial contribution of setting. Due to the acquisition on two systems, the contrast appearance of current and prior is different. Right pair: the contrast of the prior (c) mammogram has been €3.1m. It commenced in September 2008 and adjusted to the current mammogram (d) in a multi-scale fashion. (Provided by Fabian Zöhrer, Fraunhofer MEVIS, Bremen) consists of nine international scientific partners from seven countries, with the European and prototype platform for multi-modal With the establishment of new imaging modal- assessing the value of various new modalities Institute for Biomedical Imaging Research breast diagnosis. ities and growing numbers of images (e.g. for breast cancer diagnosis. This represents a (EIBIR) as the coordinating partner. because of advanced screening programmes) major challenge, to provide the necessary tools To ensure clinical impact, leading European the radiologists day-to-day work has become to efficiently use the set of multi-modal imag- The exact diagnosis of suspicious breast tis- clinicians in the area of breast cancer diagno- more and more challenging. In breast cancer ing techniques to move towards an optimised sue is ambiguous in many cases. HAMAM sis are contributing as members of the clinical diagnosis the most ambiguous cases involve and individualised patient care. will resolve this using statistical knowledge advisory board. the largest number of different imaging extracted from the large case database. The modalities and the most complex workup, but At the end of the project, a prototype of the clinical workstation will suggest additional Expected final results and their potential in exactly these cases the least computer sup- described workstation will be available. imaging modalities that may be employed impact and use port is available. HAMAM addresses this issue to optimally resolve these uncertainties. The HAMAM aims to contribute to a reduction in with tools that provide an accurate assessment For more information please visit the project workstation thus guides the clinician in estab- breast cancer-induced mortality by providing of multimodal information for these cases. website or contact: EIBIR gemeinnützige lishing a patient-specific optimal diagnosis. means for a more reliable diagnosis and more GmbH, Neutorgasse 9, 1010 Vienna, Austria, This ultimately leads to a more specific and verified treatment decisions. Thus, the final The workstation will support an efficient [email protected], www.hamam-project.org sensitive individual diagnosis. results of the project comprise: workflow, including advanced pre-processing to co-register the images within and across Project Partners: The project proposes a sound statistical and • Improved scientific knowledge regarding the modalities, novel patient-centric view layouts • E uropean Institute for Biomedical Imaging mathematical framework to integrate and formation and genetics of breast cancer and with a timeline (patient history) overview and Research, Vienna (AT) combine the whole spectrum of patient infor- its appearance in various imaging modali- easier reporting of findings across modalities. • University College London (UK) mation. HAMAM also goes beyond currently ties, both conventional (mammography, Registration contributes to quicker navigation • Fraunhofer MEVIS, Bremen (DE) available technology by developing a prototype magnetic resonance imaging) and novel between image series and modalities. • MeVis Medical Solutions, Bremen (DE) solution that will be able to efficiently integrate (tomosynthesis, positron emission mam- • S wiss Federal Institute of Technology, all relevant clinical and imaging information mography) HAMAM is not driven by the extensive utilisa- Zuerich (CH) within a single platform. The overall strategy • A workstation that incorporates advanced tion of technological achievements or by foster- • R adboud University Medical Centre, of the project is to foster exchange and col- image presentation and analysis methods. ing a high-tech medicine that applies virtually Nijmegen (NL) laboration between basic scientists, clinicians, every available diagnostic option to all patients • University of Dundee (UK) and IT experts, and to condense all informa- Additionally, HAMAM takes into account that in question. Instead, the goal is to deliver • C harité Medical University Berlin (DE) tion and knowledge in a common database the clinical workflow needs to be enhanced. objective information that is fundamental to • B oca Raton Community Hospital (USA)

The Dutch Radiology Progress Test A useful tool in evaluating knowledge acquisition during residency

By Cécile Ravesloot, Olle ten Cate, the test twice a year and so far there has been as a whole and for each of the subspecialty Furthermore the average score of the resi- Marieke van der Schaaf, Jan van Schaik, an almost 100% compliance. The DRPT con- domains. The percentile scores are also cal- dents of each training programme is calcu- Erik Beek, University Medical Center tains 200 written true/false/don’t-know ques- culated in relation to the scores of the par- lated. Programme directors receive an anony- Utrecht, The Netherlands tions and assesses radiological knowledge in ticipants at a similar stage of training. A fifth mous report which shows their programme’s nine subspecialty domains: neuroradiology, year resident can score in the 55th percentile rank among all training programmes so as to Progress testing was introduced in The Neth- gastrointestinal radiology, chest radiology, among all residents, but among the fifth year get an indication of the performance of their erlands in 2003 to monitor the acquisition cardiovascular radiology, genitourinary radi- residents this score will likely be around the residents. Generally a programme director of knowledge by radiology residents during ology, head and neck radiology, breast imag- 20th percentile, signalling that the theoreti- will share the information of this report with their training. In progress testing students ing, paediatric radiology and musculoskeletal cal knowledge of this resident is well below the staff members and residents. This stimu- regularly sit an exam at an end-of-curric- radiology. Ten to fifteen percent of the items average. lates the department to provide residents with ulum level during their training. Test items contain radiological images. Knowledge of more structured education, and to encourage (questions) are equal for all participants of radiological physics is tested separately in the To get an indication of the quality of the and guide residents to acquire radiological all training levels. In this way, progress in curriculum. DRPT, results of subsequent tests from 2003 knowledge. We are convinced that the mere knowledge acquisition on an individual level to 2010 were analysed. More experienced presence of the DRPT has led to a better level can be evaluated and feedback can be given to Every semester members of the examination residents obtained significantly higher scores of theoretical knowledge. stimulate ongoing learning. committee, which consists of eight expert than the juniors on all administered tests. radiologists, develop test items. After the test, This indicates that the DRPT is an effective The Dutch experience with the DRPT indi- The Dutch Radiology Progress Test (DRPT) is scores are obtained by subtracting the incor- measure of required radiological knowledge. cates that progress testing is a useful knowl- not a test that must be passed, but has a form- rect scores from the correct scores. Residents Internal consistencies of all the tests were edge assessment tool in radiology training. ative purpose, which is to provide feedback to and their programme directors receive the high. Cronbach’s alphas were on average .90, participants and programme directors. Every test scores. The results are reported as abso- whereas a value above .70 is regarded as an Dutch radiology resident is expected to sit lute scores and as percentile scores for the test indication of good reliability of test scores.

myESR.org 22 ECR TODAY 2011 TECHNOLOGY FOCUS Sunday, March 6, 2011

ESSR provides forum for education and research in musculoskeletal radiology

By Anne Cotten, ESSR President

The aim of the European Society of Musculoskel- etal Radiology (ESSR) is to advance the knowledge, diagnosis and treatment of the normal and abnormal musculoskeletal systems by means of imaging, and to provide a European forum for education and research in musculoskeletal (MSK) radiology. The society has to deal with a huge interest in MSK radiology, as attendance at MSK refresher courses and scientific sessions at the ECR demonstrates.

This interest can be easily explained by the frequency of the MSK disorders encountered in clinical practice and the variety of imaging modalities that can be used in this subspecialty. Indeed, MSK radiology is probably the sole subspecialty that benefits from the impressive technological evolu- tion of all imaging modalities, including interven- The next ESSR Meeting will be held June 9–11, 2011, in Crete, Greece. tional radiology and functional imaging (diffusion and tractography, perfusion, spectroscopy) and roduced in clinical practice by non-radiologist ESSR is intensely involved in education program- Updated information will be provided through hybrid techniques (PET/CT, PET/MR). clinicians. mes such as the Erasmus Course, the European invited lectures, scientific papers and scientific School of MRI, the European School of Radiology electronic posters. This meeting also includes a Indeed, scientific progress in MSK radiology is Finally, the high spatial resolution that is now and other educational activities related to the ESR. very popular hands-on workshop in MSK ultra- everywhere. Even with x-rays, significant pro- provided by the different imaging modalities sound and the topic this year will be the shoulder gress has been made by the recent promising requires an excellent knowledge of the normal It also organises its own meeting once a year girdle and upper arm. introduction of tomosynthesis. anatomy and its most frequent variants, which is and indeed, the ESSR Annual Meeting con- not an easy task in MSK radiology. tinues to attract more and more people, with The ESSR provides special benefits to full mem- High resolution ultrasound also represents a more than 800 participants in Lille, France, in bers, such as access to a dedicated website with fantastic imaging modality for the assessment All these features explain the fundamental role of 2010. The next ESSR Meeting will be held June continually updated information and course of many MSK disorders. The most recent deve- the ESSR and its subcommittees on Continuous 9–11, 2011, in Crete, Greece. The scientific pro- programmes, reduced registration fees for the lopments of the technique have been focused Medical Education and Research. The society conti- gramme, focusing on bone marrow disorders, annual meeting and special subscription rates on elastography, fusion imaging and contrast nues to work hard to clarify the role for each moda- will be associated with six special focus sessions for Skeletal Radiology and Seminars in Muscu- enhancement. Unfortunately, ultrasound is still lity, the optimisation of each technique, and the including sport-specific injuries, tumour ima- loskeletal Radiology. Further information can be insufficiently practised by radiologists and is int- standardisation of the protocols and reports. The ging, inflammatory conditions and osteoporosis. found on the ESSR website www.essr.org.

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myESR.org Sunday, March 6, 2011 TECHNOLOGY FOCUS ECR TODAY 2011 23

ENCITE – In search of the best visible cell therapies in modern medicine

By Eva Haas

In order to address the extreme variety of cell therapies on generic and disease-oriented levels, the European Network for Cell Imaging and Tracking Expertise (ENCITE), has seen the birth of an extensive collaboration between experts to develop and implement novel imaging tools in cellular therapy.

Many working groups from different disciplines (physics, chemistry, biology, informatics, endocrinology, immunology, neurology, nuclear medicine, radiology) are involved and have joined forces to benefit from each other’s expertise and thereby expedite the translation and implementation of novel cell imaging techniques and tools into the clinic.

The mission of ENCITE is to develop and test new MR and optical imaging methods and biomarkers to get a more comprehensive picture of cell fate and the reaction of the immune system and to ultimately improve and further develop cell therapy for the benefit of patients in Europe.

After nearly three years, ENCITE is extremely Cytotoxic T lymphocytes (blue) attacking a tumour (red cells with green/yellow nuclei) in an in vitro three-dimensional culture model. proud to present key findings:

New imaging methods, optical and MRI reporter genes were develo- cancer serve to monitor how cytotoxic lym- nes will prevent metastases in high risk tumour post-processing and visualisation tools ped. A bicistrionic vector was generated and phocytes migrate into and kill tumours and patients. Details: www.encite.org Methodologies for cell tracking including ima- introduced into embryonic stem cells. CMV- help to identify soluble factors released by the ging methods for specific contrast agents and HA-ferritin-IRES-fLuc was stably expressed in tumour, which impair immune-cell function. Training workshops in the spotlight new biomarkers to monitor cell fate were deve- a human glioblastoma line. These factors are then antagonised in immuno- A special highlight of ENCITE’s training activi- loped and optimised. Further developments competent mouse models of cancer to test their ties will be the Scientific Symposium on ‘Ima- include methods for a meaningful integration Novel tools for cell labelling suitability for therapy in patients. ging Cellular Decisions’, held at the Weiz- and post-processing of imaging data (molecu- The use of reporter probes for monitoring cell mann Institute of Science, Rehovot/Israel, on lar, functional and anatomical data). MR-based differentiation and programmed cell death pro- Beyond in vitro models, the experts monitor March 27, 2011, 09:00–17:00. cell tracking was implemented and methods for ved to be feasible in animal models. the migration and anti-tumour function of preclinical drug evaluation were optimised. 3D immune cells in patients during therapy. One This one-day symposium will expose the and 4D MRI datasets from the brain and heart, Pre-clinical validation in major disease areas focus is on specialised antigen-presenting Europe and Israeli research communities to generated under various conditions, form the Since specific problems sometimes require spe- cells (dendritic cells), which are generated the latest advanced technologies that provide backbone of the new, publicly available mouse cific solutions, a number of research groups from patients’ monocytes by a standardised temporal and spatial information on cell fate and rat atlases. have been focusing on the development of in vitro culture method and then loaded with from the living organism. This event is open tailored imaging tools and techniques within melanoma-specific tumour antigens. In ethi- to anyone interested, please feel welcome to New MRI reporter probes provide some specific major disease areas of cell the- cally approved phase I-II trials, melanoma pati- attend! Registration details: www.encite.org a more comprehensive picture rapy applications: neurological disease (stroke); ents with advanced disease repeatedly receive of molecular imaging applications cardiovascular disease (myocardial infarction), their dendritic cells as ’tumour vaccines’. After We would like to welcome you to the ENCITE High sensitivity paramagnetic Gd-based pro- musculoskeletal disease, diabetes and cancer. therapeutic application, dendritic cells mig- Session in Room Z today, 08:30–10:00, to meet bes have been designed and tested, and inno- rate to various lymphoid organs and instruct the ENCITE experts and to get a picture of how vative concepts for imaging-responsive agents Basic and translational research on the cytotoxic immune cells to spot and combat the visualisation of cell therapy meets clinical have been conceived. Preferred target applica- immunotherapy of cancer were fostered the melanoma antigen. If successful, cytotoxic application. tions are in the field of stem cells and imaging To increase the efficacy of cancer immuno- T-cells and other immune effector cells are acti- reporters of gene expression. therapy, basic scientists and clinicians work vated by the dendritic cells, invade the metasta- Please visit the EIBIR Booth on the entrance together to create better tools for understan- ses, and destroy the tumour cells. level to get more information on the project As a start towards targeting, a process was ding how a tumour avoids elimination and how and other EIBIR activities. developed to coat gram amounts of iron oxide these ‘escape mechanisms’ can be combated With this vision ENCITE pays tribute to the particles for use in binding. Constructs with therapeutically. In vitro and mouse models of hope of clinicians that one day tumour vacci-

ENCITE Session EuroAIM Session Sunday, March 6, 08:30–10:00, Room Z Sunday, March 6, 10:30–12:00, Room Z Visualisation of cell therapy meets clinical application Evidence-based radiology: why is evidence-based radiology crucial? Moderator: G.P. Krestin; Rotterdam/NL Moderators: G.P. Krestin; Rotterdam/NL The European Network of Cell Imaging and Tracking Expertise (ENCITE) is pleased to present F. Sardanelli; Milan/IT cutting-edge developments of novel cell therapies pointing to clinical applications. Within the The experts from the European Network for Assessment of Imaging in Medicine (EuroAIM) European community of cell imaging, this advance is of specific interest as, according to the will reply to this question. A special highlight will be the presentation of results of preliminary recent developments, novel imaging tools are absolutely vital for the understanding of thera- analysis focusing on the radiologist’s role in the production of secondary evidence, which is the peutic effects to patients. Three examples of visualisation show promising results. best way to make impact on the whole medical world. • ENCITE – a translational approach Abstracts of more than 3,000 published articles (1/2000 to 5/2010) were reviewed in for novel cell therapy applications order to select systematic reviews and meta-analyses regarding imaging and interventional S. Aime; Turin/IT procedures. About 40% of them were submitted for analysis to the members of the Evidence- • V isualising transplanted neural stem cells and tissue regeneration by MRI Based Radiology Working Group promoted by the European Network for Assessment of M. Modo; London/UK Imaging in Medicine (EuroAIM). • Imaging dendritic cell vaccinations in melanoma patients • Applying EBM to radiology – the EuroAIM project (A-356) M. Srinivas; Nijmegen/NL F. Sardanelli; Milan/IT • Monitoring of SPIO labelled pancreatic islets in human liver by MRI • Secondary evidence for diagnostic imaging (A-357) M. Hajek; Prague/CZ L.M. Sconfienza; Milan/IT • Discussion and exchange • Secondary evidence for interventional radiology (A-358) D. Vorwerk; Ingolstadt/DE • The ACRIN experience (A-359) B.J. Hillmann; Charlottesville, VA/US • Discussion and Reception

myESR.org European Diploma in Radiology (EDiR) Prove your excellence! Take the ESR Diploma.

The ESR is proud to announce the launch of the European Diploma in Radiology (EDiR); a brand new qualification that will provide General Radiologists with an objective, ESR-endorsed test of their ability. All parts of the examination will be held in English but non-native language skills will be taken into consideration by the oral examiners.

The first examination will take place at ECR 2011, on Monday, March 7, in Vienna.

Information at www.myESR.org/diploma Sunday, March 6, 2011 Community News ECR TODAY 2011 25

European Inside Roentgen’s birthplace Radiology Journal watch: Find out what’s on undergoes refit European Radiology in Vienna today

Today See page 26 See page 27 See page 32

European School of Radiology: building an international radiological community

By Iris Kovacs at general radiologists and private practitioners. These courses are tailored to address recognised National radiological societies in Europe play a needs and thus, new topics were delivered and leading role in assessing and fulfilling the requi- new destinations reached. rements of radiological education in their countries. Ever since its inception, ESOR has focused One of these international courses, an advanced on and contributed to supporting their efforts. abdominal imaging course, was held in partner- Recently, ESOR has increasingly played an impor- ship with Covidien in the Middle East. A high tant additional role in establishing outreach trai- quality programme was delivered by an inter- ning programmes overseas, to meet needs of the nationally renowned faculty in Beirut, Lebanon, international radiological community. bringing together radiologists from Lebanon, Bahrain, Egypt, Jordan, Kuwait, Lebanon, Libya, The first educational project delivered outside Saudi Arabia, Syria and the United Arab Emi- Europe was AIMS – Advanced Imaging Multi- rates. The fully booked course was attended by modality Seminars. These seminars were esta- 65 radiologists in all. ESOR was happy to also blished in China to continue strengthening the involve local speakers, who contributed some ties between the Chinese Society of Radiology highly appreciated lectures and workshops. (CSR) and the European Society of Radiology (ESR). The seminars are organised in close The long-term partnership with Bracco was cooperation with the CSR and are supported by strengthened this year through the establish- an unrestricted educational grant from Bracco. ment of a new ASKLEPIOS course on Advanced The programme comprises six courses each year, Ultrasound and Contrast Enhanced Ultrasound, held in six different Chinese cities by Chinese which was organised in collaboration with and European speakers, with topics carefully the Korean Society of Ultrasound in Medicine A delegation of internationally renowned European speakers was welcomed by the Chilean Society of Radiology to selected by the two societies. Since 2007 the (KSUM) in Seoul, Korea. This course was very exchange scientific expertise between European and Chilean radiology. seminars have attracted more than 3,400 Chi- popular with the 95 attendees, resulting in an nese radiologists. invitation to visit Korea with a second course.

Another ESOR project to reach beyond Europe ESOR further expanded to another continent – was the series of ASKLEPIOS courses, which in South America – with an ASKLEPIOS course 2010 (only their second year) were extended to held in partnership with the Chilean Society the Middle East, Asia and South America. Con- of Radiology. The maximum of 90 radiologists tent-wise these were advanced multi-thematic followed a programme on advanced abdominal or multimodality courses, aimed in particular imaging, delivered by European speakers.

Visit ESOR at ECR 2011: • Booth in entrance hall Stars Lounge • Info desk in Rising • Session on March 4, 14:00–15:30, Room Q

ESOR More than 90 radiologists from mainly Chile, but also Argentina and Peru, participated in the courses and were European School of Radiology fascinated by the content of the programme and the excellent organisation.

A portion of the programme was also delivered an international course in Mexico City in 2012 is in Spanish, which greatly improved the opportu- currently being explored with the Mexican Soci- nity for interaction and exchange. ety of Radiology.

ESOR is very happy that national societies out- Through collaborative relationships with invalu- side Europe are steadily seeking to enrol in such able partners from overseas, ESOR gives many partnerships, to the benefit of their members, radiologists around the world the opportunity while the impact of the ESR and its educational to benefit from a very high standard of modular In Europe: Worldwide: activities is becoming more and more evident education, and ultimately to achieve the qualifi- Advanced Ultrasound and Radiologic-Pathologic Correlation and appreciated. cations to meet tomorrow’s requirements. Contrast Enhanced Ultrasound of the Abdomen May 12–13, Brussels/Belgium March 30–31, Jeddah/Saudi Arabia In 2011, ESOR will further extend its worldwide ESOR will continue to be a strong advocate for Multimodality & Multidisciplinary Advanced Abdominal Imaging Course for General Radiologists and presence. Efforts are continuing in the Middle continuing education for radiologists throug- August 19–20, Rio de Janeiro/Brazil Private Practitioners East in partnership with Covidien, with a course hout the world, not only by means of courses September 2–3, Padova/Italy Advanced Abdominal Imaging on oncologic imaging to be held in Amman, and seminars, but also via a growing number of Multi-thematic Course for Radiologists August 20–21, Belo Horizonte/Brazil Jordan, while ESOR’s new overseas partners will international scholarships. For further informa- from Russia include the national societies of Brazil and Saudi tion please visit myESR.org/esor. October 2–3, Kaliningrad/Russia Oncologic Imaging October 27–28, Amman/Jordan Arabia. At the end of March, an advanced course Advanced Ultrasound and dedicated to radiologic-pathologic correlation of ESOR worldwide at a glance: Contrast Enhanced Ultrasound the abdomen will take place in Jeddah, in part- November 17–18, Munich/Germany ESOR in Europe: nership with the Radiological Society of Saudi 50 courses, 23 countries, 41 cities Arabia, and in August, Brazilian radiologists will ESOR in the Middle East: benefit from lectures and workshops delivered in 3 courses, 3 countries, 3 cities the cities of Rio de Janeiro and Belo Horizonte. ESOR in Asia: An ESR initiative, in partnership with Bracco, Covidien, Euromedic These courses will be kindly supported by the 30 courses, 2 countries, 28 cities and the National Societies of Brazil and Saudi Arabia Brazilian College of Radiology and the Radiolo- www.myESR.org/esor ESOR in South America: gical Society of Minas Gerais. The possibility of 3 courses, 2 countries, 3 cities

myESR.org 26 ECR TODAY 2011 C Ommunity NEWS Sunday, March 6, 2011

Leading gastrointestinal radiologist invites audience to join the search party in today’s Honorary Lecture

By Simon Lee The ECR was my first introduction to the radiology community outside In recognition of his distinguished achievements and leadership in radiology, as well as in research of North America, almost 20 years ago. It is vital for the community to and teaching, Professor Richard L. Baron from share ideas and approaches to common problems and overcome the Chicago, USA, has been invited to present the Wilhelm Conrad Röntgen Honorary Lecture barrier of oceans. The colleagues and friendships that have resulted ‘Detecting liver tumours: the search for the Holy from these interactions have been among the most stimulating of my Grail’ today at 12:15. career. Richard L. Baron is currently chairman of the Department of Radiology at the University of Chicago, where he has served since 2002. the University of Washington, he was chairman Sociedad Argentina de Radiología and the Feder- of the Department of Radiology at the Univer- acion Argentina de Asociaciones de Radiología, In 1972 he completed his undergraduate educa- sity of Pittsburgh from 1992 to 1999. He was the Diagnostico por Imagenes y Terapia Radiante; tion at Yale University cum laude, and in 1976 founding President and CEO of the University of Sociedad Chilena de Radiología) and honorary graduated from the Washington University, St. Pittsburgh Physicians, an academic healthcare fellowship (European Society of Gastrointestinal Louis School of Medicine as a member of the enterprise of over 1,400 physicians and served in and Abdominal Radiology). Richard L. Baron from Chicago, IL/US Alpha Omega Alpha Medical Honor Medical that role from 1997 to 2002. Society. He has served as an associate editor for Radio- Professor Baron has over 135 published articles logy and for Liver Transplantation and served in tunities for younger faculty and trainees,” said “Since I was a young child I always enjoyed puzz- and 26 book chapters, predominately in liver and leadership roles for multiple national radiology Baron. “The world is truly getting smaller, and les and mysteries for personal enjoyment,” said biliary tract imaging. He has been the recipient societies, including serving as President of the organisations and meetings like the ESR and Baron. “In medical school I quickly realised that of numerous awards for his research, including Society of Computed Body Tomography/Magne- ECR are vital to that process!” the work of a radiologist is exactly that. There the Hounsfield Award from the Society of Com- tic Resonance and the Society of Gastrointestinal is no other field of medicine that allows one to puted Body Tomography and Magnetic Reso- Radiologists and on the board of directors of the provide such large benefits to patients in such a nance and The Roscoe E. Miller Award from the Radiological Society of North America (RSNA) Honorary Lecture stimulating environment for a physician.” Society of Gastrointestinal Radiologists, as well and the American Roentgen Ray Society. as numerous Magna Cum Laude and Cum Laude Sunday, March 6, 12:15–12:45, Room A Following an internship in internal medicine at exhibit awards from the Radiological Society of “Through the connections developed with the Wilhelm Conrad Röntgen Yale, he completed his radiology residency and North America. ECR over the years, networks have been deve- Honorary Lecture fellowship at the Mallinckrodt Institute of Radio- loped that have resulted in inter-continental ‘Detecting liver tumours: logy at Washington University. After serving on Various international organisations have bes- research projects and publications, visiting the search for the Holy Grail’ the faculty at the University of Pennsylvania and towed upon him honorary memberships (La professorships, and exchange training oppor- Richard L. Baron; Chicago, IL/US The German Radiological Society invests in the discipline’s future

By Anja Johenning, Press Department DRG information and interaction, and it attracts medical students from other disciplines as well. The Acquisition of Röntgen’s Birthplace DRG also offers travel grants for young authors It is an old, Bergisch slate-house at the Gänse- of lectures and abstracts at European subspe- markt in the village Lennep, now part of Remsc- cialty congresses taking place in Germany. In heid, and on first sight it looks quite unimpres- 2011, there are ten grants available for both the sive. But it is the birthplace of the most impor- ESTI Congress in Heidelberg and the CIRSE tant scientist of our discipline, and the eponym Congress in Munich. of our society: Wilhelm Conrad Röntgen. Since last December, the Deutsche Röntgengesells- Scientists for Future chaft (DRG) can proudly call this place its own. Forscher für die Zukunft’ (‘Scientists for Future’) The city of Remscheid has relinquished it to the – this is the title of the new initiative of excel- DRG for a symbolic amount due to its need of lence that was launched jointly by the DRG and rehabilitation. By means of an all-encompassing the KLR (conference of heads of radiological renovation, the house is now intended to become university departments) in 2010, to promote the an international meeting centre. Prospectively it junior scientific staff in research. Each year, 30 will be used for radiological training and semi- selected radiological trainees are invited to spe- nars and will be included in the concept of the cial seminars dedicated to research topics of high nearby Röntgen Museum as a permanent exhibi- current interest. This year, participants have the tion the personal belongings of Röntgen will be chance to be informed about the recent advances put in a broader perspective. in Molecular Imaging, Advanced Methods in MRT, Clinical Studies and Nanotechnology by The Smartest Brains for Radiology: the eminent authorities of each field. “The firm Mentoring and Grant Programmes goal of the FFZ Training is to extend the research The DRG is highly committed to the promotion horizon of the participants. I especially enjoyed of young radiologists. Last year 160 awardees of the chance to meet the experts face to face, and the mentoring programme ‘the smartest brains to discuss the strengths and also weaknesses of for radiology’ participated at the German Rönt- certain methods with them,” reports Dr. Peter Röntgen’s Birthplace at Remscheid, Germany genkongress, and have thus become part of the Bannas of the UKE Hamburg and participant in fascination of radiology! For this year’s congress the programme. the mentoring programme is being repeated. It To answer these questions, the German imaging Furthermore, the survey demonstrates that the provides all radiological teachers the chance to Perception and Image of the societies initiated a large-scale, representative fear of negative impacts of medical radiation is name their ‘smartest brain’, and to offer him or ‘Radiating Disciplines’ opinion poll which was conducted in autumn much lower in public than assumed. The survey her free participation at the coming congress How are our disciplines – radiology, nuclear 2010. It revealed some expected, but also some is the first stage and the foundation for a long- in June 2011 in Hamburg. The programme is medicine and radiation therapy – perceived in surprising results. First, patients want to meet term image campaign to improve the knowledge accompanied by the associated website www. society? How can we achieve broader public the radiologist as a medical doctor who cares about the benefits of radiology, nuclear medicine hellste-koepfe.de, which is aimed at medical stu- knowledge about our field and its special advan- about them. They expect more information, con- and radiotherapy. dents and young radiologists. The site combines tages in providing the best healthcare support? sultation and care when they see the radiologist.

myESR.org Sunday, March 6, 2011 C Ommunity NEWS ECR TODAY 2011 27

The ESR’s official journal keeps on thriving

By Sarah Edwards The prime aim of the journal is to provide a plat- ECRT: Can you name some risks and benefits form for hypothesis–driven, original, prospec- of the use of CME online? Thanks to new technology, ways to disseminate tive, scientific research. AKD: A key benefit is that a radiologist can gain and exchange scientific research have multiplied. some CME credits without necessarily having to ECR Today spoke to European Radiology’s Edi- ECRT: In your experience as Editor-in-Chief attend conferences. This is especially important tor-in-Chief, Professor Adrian K. Dixon from of European Radiology, what is the value of for young radiologists with family commitments Cambridge, U.K., to find out more about recent the ISI Impact Factor and how does it relate to who may find conferences costly and time-con- trends affecting the future of the journal, such as research quality? suming. It should also help maintain radiolo- teleradiology, social networks, and new approa- AKD: Perhaps academic promotion in Europe gists’ general education outside their immediate ches to Continuing Medical Education (CME). depends more heavily on the impact factor of field of interest. On the downside, such educatio- the journal in which a candidate’s articles have nal activities may reduce the social networking ECR Today: What is the most important cri- been published than in the USA. It certainly is afforded by conferences and workshops, which terion in selecting research to be published in an important feature for a grant-giving body is an important ingredient of the success of the ER? How do you decide whether the topic fits when evaluating further claims from an appli- European Society of Radiology. the journal’s needs? cant. Most journals now ‘play the impact factor Adrian K. Dixon: Ultimately, the most important game’ whereby they try to identify high quality ECRT: What potential do you see in harnessing feature is originality – and thereby the likelihood research articles that will be widely cited. Few social networking tools for building awareness of being widely cited. But this has to be coup- journals now publish case reports (rarely cited) of European research in the clinical specialty Adrian K. Dixon is European Radiology’s Editor-in-Chief. led with its likely influence on the wider field of and most have a healthy input of review articles of radiology? radiology in the coming 5–10 years. A purely from leaders in their field. AKD: Of course these tools are important and experimental in vitro study with no obvious long I hope there will soon be bite-size resumes of from cover to cover electronically? In the prin- term clinical impact may well be considered too ECRT: Teleradiology is increasingly used to articles in European Radiology available for ted version there is the fun of leafing through experimental for this journal. Likewise a local improve operational efficiency. Do you see widespread dissemination by these means. Fur- pages in other areas of interest, even if it is only audit or a management discussion article may be potential in this emerging practice with a view thermore, the list of contents of our journals a cursory reading of the abstracts/looking at the deemed to be more appropriate for Insights into to breakthroughs in radiological research? should be more widely promulgated via social images. Imaging. AKD: Teleradiology has now reached some matu- networking tools. rity and is here to stay. It has many excellent uses, ECRT: Is it conceivable to cease print publica- ECRT: For research to be called ground-brea- not least the transmission of a patient’s previous ECRT: There can be no doubt about the increa- tion of European Radiology in favour of elect- king and warrant publication in European images obtained at other centres. Obviously, tele- sing attractiveness of electronic publication to ronic publication one day in the not-so-distant Radiology, does it matter more to have tech- radiology also facilitates expert interpretation the scientific community. What are the struc- future? nological application or to solve a scientific for remote centres and hospitals where there is a tural consequences of the recent paradigm AKD: I rather hope not; I like the permanency problem? shortage of radiologists. With regard to research, change from traditional print publication to of the printed word. Taken ad absurdum, that AKD: ‘Technical Developments’ are very much teleradiology facilitates multicentre large popula- electronic publication of research results? would mean the abandonment of all printed encouraged and have a slightly different format tion studies and this aspect has been well exploi- AKD: I do not think that there is a ‘one size fits material and the extinction of libraries, which to an original scientific article. But there pro- ted by the ACRIN studies in the USA and now, all’ solution here. Of course the electronic source contribute so much to the civilisation of our bably would not be more than one or two such increasingly, by the European Institute for Biome- is readily available and immediate on desk tops society. papers in any given issue of European Radiology. dical Imaging Research (www.eibir.org). etc. However, will people really read a journal

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myESR.org 28 ECR TODAY 2011 C Ommunity NEWS Sunday, March 6, 2011

The Hungarian Society of Radiologists in 2011

By István Battyány, President, Society of Hungarian Radiologists

The Hungarian Society of Radiologists was founded in 1922 for the purpose of forming a collective forum for radiologists developing the scientific standards in the field of radiology, and to exchange experience, introduce novel technology, and to share information about education and patient care. The HSR consists of eight different subsections and is governed by the elected President of the Executive Board, and the General Assembly.

The official journal of the HSR is entitled Hun- garian Radiology, published in Hungarian in quarterly issues. It provides scientific information for all registered members of the society about the clinical and technical aspects of diagnostic imaging. Our website also plays an important role in communication among HSR members, as a capital source of up-to-date news about the HSR, educational courses, Hungarian and international scientific meetings and congresses. Both the journal and the website provide important guidelines and educational material as well. The aim of the HSR is to initiate publication of an English language journal and website in order to Budapest will be the venue for May’s ICIS meeting on cancer imaging. cooperate with international radiological societies. Our objective is to apply the 2.0 standards focused on the following major topics: imaging ing. This excellent highly professional event pro- malignancies, as well as liver and abdominal can- for our webpage to develop quality and to facili- in emergency radiology, imaging in neurology, vided an opportunity to upgrade the knowledge cers. Workshops will provide opportunities for tate a more interactive operation. non-vascular neurological interventions, mus- of central European radiologists interested in participants to upgrade their knowledge in head culoskeletal imaging (from the perspective of non-invasive cardiovascular imaging. and neck oncology, targeted therapy, oncologic Our society has already taken steps towards sport medicine), special MRI methods in the interventions and multimodality imaging. cooperation with other international radiologi- radiology practice, and imaging in oncology. This year, on May 18–20, Budapest will host the cal societies, particularly the Croatian Society International Cancer Imaging Society’s (ICIS) For further information, contact the local organ- of Radiology and the Slovenian Association of Cooperation in organisation of international sci- Satellite Meeting on Cancer Imaging, with the ising committee, the Hungarian Cancer Society Radiology. The Croatian-Hungarian-Slovenian entific events is being emphasised more and more most respected lecturers from the field of oncol- www.oncology.hu, or contact Mária Gödény, Radiological Congress takes place every second by our society. The Central European Congress ogy imaging (Jay Heiken/USA, Richard Gore/ MD, PhD., Society of Hungarian Radiologists, year in one of the organising countries. To avoid of Non-invasive Cardiovascular Imaging took USA, Theresa McLoud/USA, Rodney Reznek/UK, by e-mail: [email protected]. the language barrier, the official language of place in Pécs, the Cultural Capital of Europe Kenneth Miles/UK, Robert Hermans/BE, Heinz the congress is English. The French-Hungarian in 2010, and it was organised by the Radiology Peter Schlemmer/DE, Nicole Freling/NL, Daniel Representatives of the Hungarian Society of Radiological Symposium is an annual scientific Department, University of Pécs (István Battyány, Vanel/IT, Ernst Rummeny/DE), thereby guar- Radiologists regularly present lectures at major meeting to enhance the scientific connection MD, PhD) and the HSR. Highly acknowledged anteeing a very high professional standard. The international scientific meetings and congresses between French and Hungarian radiologists and lecturers (Robert M. Steiner, U. Joseph Sch- aim of the meeting is to provide education in like the European Congress of Radiology. This is held in the French Institute in Budapest. oepf, Thomas G. Flohr, Hans-Christoph Becker, the rapidly advancing area of cancer imaging year Professor András Palkó, Victor Bérczi, and Arthur E. Stillman, Alan H. Maurer, Rainer K. and to emphasise its role in the multidiscipli- Zsolt Tarján are our invited ECR lecturers from The HSR national scientific congress is held every Rienmuller, Albert de Roos) were invited from nary management of malignancy. This satellite Hungary. two years. The 25th Congress of the Hungarian all over the world for this prestigious congress, meeting is designed for radiologists and oncolo- Society of Radiologists took place in Kaposvár which was held on September 24–26, 2010. The gists with a special interest in the diagnosis and For more information about the Hungarian (organised by Prof. Imre Repa), on July 1–3, scientific programme focused on advanced car- management of cancer. The programme provides Society of Radiology, all ECR participants are 2010, with nearly 700 participants from all over diac imaging, mainly on CT, MRI and PET/CT multidisciplinary symposia on gynaecologi- kindly invited to visit our stand, and encouraged Hungary and abroad. The scientific programme methods of non-invasive cardiovascular imag- cal cancers, gastrointestinal tumours, and ENT to see our website: www.socrad.hu.

Staff Box

Editorial Board Editors Art Direction ESR Executive Council Julia Patuzzi, Vienna/AT Robert Punz, Vienna/AT

Philip Ward, Chester/UK Maximilian F. Reiser, Munich/DE Luis Martí-Bonmatí, Valencia/ES Layout ESR President Research Committee Chairman Sub-Editor Robert Punz, Vienna/AT Simon Lee, Vienna/AT Tine Ulbing, Vienna/AT András Palkó, Szeged/HU Éamann Breatnach, Dublin/IE ESR 1st Vice-President Education Committee Chairman Contributing Writers Marketing & Advertisements Edna Astbury-Ward, Chester/UK Betty Wilk Gabriel P. Krestin, Rotterdam/NL Luís Donoso, Sabadell/ES John Bonner, London/UK E-mail: [email protected] ESR 2nd Vice-President Professional Organisation Committee Chairman John Brosky, Paris/FR Contact the Editorial Office Christian J. Herold, Vienna/AT Fred E. Avni, Brussels/BE Sarah Edwards, Vienna/AT ESR Office Past-President Subspecialties Committee Chairman Sonja Guttenbrunner, Vienna/AT Neutorgasse 9 Eva Haas, Vienna/AT Yves Menu, Paris/FR Guy Frija, Paris/FR 1010 Vienna, Austria Monika Hierath, Vienna/AT Congress Committee Chairman National Societies Committee Chairman Phone: (+43-1) 533 40 64-0 Simon Lee, Vienna/AT Fax: (+43-1) 533 40 64-441 Lorenzo Bonomo, Rome/IT Luigi Solbiati, Busto Arsizio/IT Lisa Loibl, Vienna/AT E-mail: [email protected] 1st Vice-Chairman of the Congress Committee Communication & International Relations Lucie Motloch, Vienna/AT Committee Chairman Stefanie Muzik, Vienna/AT ECR Today is published 5x during ECR 2011. José I. Bilbao, Pamplona/ES Mélisande Rouger, Vienna/AT Circulation: 20,000 2nd Vice-Chairman of the Congress Committee Katrine Åhlström-Riklund, Umeå/SE Frances Rylands-Monk, St. Meen Le Grand/France Printed by Angerer & Göschl, Vienna 2011 Finance Committee Chairman Adrian K. Dixon, Cambridge/UK Philip Ward, Chester/UK myESR.org Publications Committee Chairman Peter Baierl, Vienna/AT Executive Director

The Editorial Board, Editors and Contributing Writers make every effort to ensure that no inaccurate or misleading data, opinion or statement appears in this publication. All data and opinions appearing in the articles and advertisements herein are the sole responsibility of the contributor or advertiser concerned. Therefore the Editorial Board, Editors and Contributing Writers and their respective employees accept no liability whatsoever for the consequences of any such inaccurate or misleading data, opinion or statement. Advertising rates valid as per January 2011. Unless otherwise indicated all pictures © ESR – European Society of Radiology

myESR.org Sunday, March 6, 2011 C Ommunity NEWS ECR TODAY 2011 29 eHealth: need for European action

By Sonja Guttenbrunner Cross Border eHealth directive does not include regulations that apply The EC now considers teleradiology to be a After a long-winded process, the European Par- the same safety and quality standards to eHealth medical act. However, in the EC’s opinion a eHealth, including telemedicine and teleradio- liament finally approved this new law in January as to non-electronic health services. A European medical act can also be an information society logy, is one of the big future challenges within 2011. The directive sets out patients’ rights to eHealth Network will be established to foster service, which is a position the ESR clearly dis- the European Union. Therefore, a lot of diffe- seek medical care in another EU country. The cooperation between Member States and to agrees with. The problem is that this opinion rent initiatives are being undertaken to build directive is primarily focused on ensuring that draw up guidelines on cross-border patient data, covers the whole range of telemedicine, of which homogenous legislation and to enhance stan- patients from one country within the EU may this cooperation is weakened by being entirely teleradiology is only a small element. Next to dardisation. One of the first milestones was obtain healthcare within another EU country voluntary. At least some provisions regarding the this problem, other questions arise in the realm the European Commission Communication without hindrance. The main emphasis of the registration of health professionals were inclu- of eHealth, e.g. patient information, and liability. entitled ‘Telemedicine for the benefit of patients, directive is to make it easier for patients to obtain ded in the directive, an issue that was also highly healthcare systems and society’ (COM 2008/689), approval and for an organised financial frame- emphasised by the ESR. Therefore, the ESR claims: published in November 2008, which laid down work to be put in place to pay for the healthcare. • The regulation of telemedicine and teleradio- a number of specific actions in the area of tele- Teleradiology is a medical act logy should be the responsibility of the mem- medicine and telemonitoring. This document set This approach is overdue as there have been seve- The ESR will now continue its efforts in order ber state where the patient undergoes the ima- out to build confidence and acceptance of tele- ral cases settled by the European Court of Justice not to leave the important area of teleradiology ging or telemedical referral. medicine services, to bring legal clarity as well since 1998 and this proposal would bring about unregulated. One of the main claims is that tele- • Patient must give informed consent when the as to solve technical issues and facilitate market the needed legal clarity. In addition, it emphasi- radiology must be defined as medical act. clinical details and images are electronically development. One of the actions foreseen in this ses the importance of quality and safety of care transferred from one EU country to another. document was the drafting of a ‘staff working for patients travelling across borders for health- According to the EC, most telemedicine services, paper on EU legislation applicable to telemedi- care. However, from the beginning the European including teleradiology, fall under the definition The ESR strongly supports that cine services’. This working paper should mark Society of Radiology (ESR) has been concerned of information society services (ISS) (Art. 1(2) of • Responsibility/liability for cross-border telera- the beginning of a legislative process to regulate that there is little in the initial draft to ensure Directive 98/34, as amended by Directive 98/48): diology services lie within the member state of this sensitive area and to create a homogeneous quality and safety for patients whose treatment “any service normally provided for remunera- the patient. legislative framework. involves cross border eHealth. This is the reason tion, at a distance, by electronic means, at the • M ember states should ensure the safety of the why the ESR has tried to raise the awareness of individual request of a recipient of service”. patient; that doctors undertaking cross-border Although several discussions and workshops have several decision makers in the European Com- telemedicine and teleradiology should have the already taken place to gather first impressions of mission and the European Parliament, as well The fact that the EC considers teleradiology equivalent regulatory requirement to those of what should be included in this paper (e.g. the as at member state level, to this important lack an ISS means that the e-Commerce directive is the country where the patient accesses health- eHealth session at ECR 2010, where the respon- since the moment the proposal for the directive applicable where the country of origin principle care. sible EC policy officer outlined the key issues) this was tabled. applies. This affects the licensing/registration of working paper is still on hold until another Euro- health professionals: the professional has to be Interested in further information on this topic? pean law is adopted – the directive on the applica- However, the text approved by MEPs in January licensed in the country where he/she is establis- tion of patients’ rights in cross-border healthcare. is the result of an agreement reached with the hed, while no registration is required in the coun- Please visit the EU Affairs section at The reason is that this piece of legislation will Council, which must also give its formal appro- try of the patient. Member states are not allowed myESR.org or contact [email protected] include provisions for cross border eHealth that val. To achieve this compromise the regulations to impose a specific prior authorisation, which is should also be reflected in the paper. in the area of eHealth were downscaled. The specifically and exclusively targeted at ISS.

Tonight

ECR Party 2011, March 6 Don’t miss the sensational ECR 2011 Party! It’s getting burlesque! Fasten your seatbelts and enjoy an exciting, sensational and glamorous party night in Austria’s biggest disco.

Tickets available at the Travel Service counter in the entrance hall.

‘Dinner, Show and Party’ ticket €80 incl. VAT (starts at 19:30) ‘Party Only’ ticket €40 incl. VAT (starts at 21:45)

Pratergalerien & Prater Dome, Riesenradplatz, 1020 Vienna

myESR.org

Burlesque Kiki Kogelnik, Marisol, and Niki de SaintPhalle. de Kogelnik,NikiMarisol,and Kiki Drexler, Dichgans,Rosalyn Jann Christa WithHaworth,Evelyne worksbyCorita, Sisterrespects. DorothyAxell, Iannone, manyin colleagues male their of artists’ displayfemalethose resembleworkson nine contoursgraphic the forms,andreduced – protagonists.colours,loud male Plastic,with associated been primarily hasmovement todayreinterpret until art tothat aims an Dorothy Iannone’sfulfils UP outstandingPOWERPopRediscoveringfemale artists, showThe years. combativefifty promiseafter Art UP.Pop POWER Female Exhibition: Special Bilbao Guggenheim). Guggenheim). Bilbao the Pompidou, and Centre the Paris Helsinki, Tate (together Kiasma, Europe London, with the in Modern, institutions art modern best the six among Wien the Kunsthalle ranked ARTE magazine arts the Italian 2002, In 1945. after art to Austrian contributions significant and artists contemporary of important to retrospectives dedicated elements are programme world. Other present-day art the to from Modernism andcorrelations developments present exhibitions subject-specific Large, to media. new installations and photography, from film range video, highlights Programme MuseumsQuartier). the and (Karlsplatz city of the centre the in tions two loca- at in Vienna art contemporary international for facilities liveliest the as one of itself established has Wien The Kunsthalle Kunsthalle Wien N o vember 5, 2010 – – 2010 5, vember M a rch 8, 2011 8, rch

Kiki Kogelnik, War Baby, 1972 © Kiki Kogelnik Foundation Wien New York Evelyne Axell, Ice Cream, 1964, Courtesy Serge Goisse, Belgium © Estate of Evelyne Axell and VBK, Wien, 2010 www.kunsthallewien.at pm am–10 10 Thursday hours: Opening 1 Museumsplatz Vienna, 1070 Kunsthalle daily 10 am–7 pm am–7 10 daily 32 ECR TODAY 2011 AR TS & CULTURE Sunday, March 6, 2011

What’s on today in Vienna? Theatre & Dance Please note that all performances are in German! Akademietheater 19:00 Di e Kunst der Unterhaltung 1030 Vienna, Lisztstraße 1 by Jan Lauwers & Needcompany phone: +43 1 51444 4145 www.burgtheater.at

Burgtheater 16:00 W as ihr wollt 1010 Vienna, Dr. Karl-Lueger-Ring 2 by William Shakespeare phone: +43 1 51444 4145 www.burgtheater.at

Theater in der Josefstadt 15:00 C ampiello 1080 Vienna, Josefstädter Straße 26 by Peter Turrini based on Carlo Goldoni phone: +43 1 42 700 300 19:30 C ampiello www.josefstadt.org by Peter Turrini based on Carlo Goldoni heater in der Josefstadt T Volkstheater 19:30 D er Alpenkönig und der Menschenfeind 1070 Vienna, Neustiftgasse 1 by Ferdinand Raimund phone: 43 1 52111 400 www.volkstheater.at urrini © Erich Reismann / T Campiello by Peter

Concerts & Sounds

Konzerthaus (Classical Music) 19:30 Latvian National Symphony Orchestra, 1030 Vienna, Lothringerstraße 20 conductor Karel Mark Chichon www.konzerthaus.at Elina Garanca, mezzo-soprano ‘Habanera’, A. Márquez, G. Verdi, A. Ponchielli, G. Donizetti, N. Rimski-Korsakow, G. Bizet …

Musikverein (Classical Music) 16:00 T onkünstler-Orchester Niederösterreich, 1010 Vienna, Bösendorferstraße 12 conductor Michail Jurowski www.musikverein.at Lars Vogt, piano C.M. von Weber, L. van Beethoven, D. Shostakovich 19:30 Wiener Symphoniker, conductor Adam Fischer Denis Matsuev, piano Z. Kodály, F. Liszt, J. Brahms

Porgy & Bess (Jazz) 20:30 G ilad Atzmon & 1010 Vienna, Riemergasse 11 The Orient House Ensemble www.porgy.at

Arena (Alternative Music) 19:00 Bubble Beatz 1030 Vienna, Baumgasse 80 www.arena.co.at

Szene Wien (Alternative Music) 20:00 Combichrist as Carmen © www.elinagaranca.com 1110 Vienna, Hauffgasse 26 www.szenewien.com Elina Garanca

Opera & Musical Theatre

Volksoper 16:30 Der Mantel / Gianni Schicchi 1090 Vienna, Währingerstraße 78 Opera by Giacomo Puccini www.volksoper.at

Wiener Staatsoper – 19:30 Madama Butterfly Vienna State Opera by Giacomo Puccini, conducted by 1010 Vienna, Opernring 2 Michael Halász

/ Rolf Bock www.wiener-staatsoper.at with Hui He, Neil Shicoff, Eijiro Kai W Raimundtheater 18:00 Ich war noch niemals in New York 1060 Vienna, Wallgasse 18–20 by Udo Jürgens & Gabriel Barylli www.musicalvienna.at ichael Kunze © VB M Ronacher 18:00 Tanz der Vampire 1010 Vienna, Seilerstätte 9 by Jim Steinman & Michael Kunze www.musicalvienna.at by Jim Steinman & der Vampire Tanz

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