ECR TODAY 2013 DAILY NEWS from EUROPE’S LEADING IMAGING CONGRESS Sunday 10 March 2013

ECR TODAY 2013 DAILY NEWS FROM EUROPE’S LEADING IMAGING CONGRESS Sunday 10 March 2013

CT cardiothoracic PACS developers put Accomplished imaging enters renewed emphasis professor to become an exciting phase on patient empowerment editor-in-chief of of evolution and safety European Radiology

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MR-PET demonstrates ever greater potential for detecting multifocal cancers

By Becky McCall “MR-PET is the only thing that picomolar range, the most sensitive can approach imaging the dimen- level available.” MR-PET allows superior early sions of tumour heterogeneity at this By way of example, he said there detection and evolution of cancers time,” he told ECR Today. “I think were some new developments in as they disseminate around the body. this is an enormously promising prostate cancer, such as the novel That was the key message of Prof. area and this evolving concept of [68Ga]Gallium-labelled PSMA Heinz-Peter Schlemmer in his talk cancer cells having their own ecol- tracer. This is a prostate specific at yesterday’s New Horizons Session. ogy that adapts to the surroundings membrane antigen tracer that tar- Taking the two sources of infor- can only be displayed by a multi- gets the tumour and provides a pre- mation together provides insight dimensional approach.” cise location of the tumour, thereby into both the biology and location “The same tumour in different improving diagnostic accuracy. “It of the tumour or metastases inside places at different points in time should also help with prognostic the body, according to Schlemmer, behaves differently and needs to stratification and biopsy planning professor of oncologic radiology at be treated differently. I think this and needle guidance.” the University of Heidelberg, Ger- new technology is the only way I The radiotracer used also helps many, and chair of radiology at the can imagine to get a handle on the determine whether to image simul- German Cancer Research Center. many dimensions,” he added. taneously or sequentially, according Combined MR-PET can help radi- Schlemmer pointed out that if to Schlemmer. If the radiotracer is ologists to detect cancer early and tumour cells have their metabo- slowly taken up, then it’s feasible characterise its biological behav- lism blocked in one place, then to inject the tracer and image with Heinz-Peter Schlemmer from Heidelberg, Osman Ratib from Geneva, Switzerland. iour. Also, it’s important to con- they move elsewhere. “Also, there PET followed by MRI, and later fuse Germany. sider the heterogeneity of tumours, are indications that when you irradi- the images. However, he noted that which are an evolving structure that ate a tumour, it starts to metastasise if the tracer is rapidly taken up or their disease, especially with cancer logic radiologists is that we see the started on one side of the organ and and the reason is that initially the if, for example, there are moving is becoming a chronic disease. He scope and applications.” disseminated. blood flow decreases and then the organs [such as lung or liver] then cited the example of a patient with He stressed that people need to “Different tumours in different cell realises it would be better off if there were often difficulties. prostate cancer needing repeated remember how to assess costs asso- parts of the body vary in their behav- it moved.” “When you conduct a PET and imaging to monitor progression or ciated with using MR-PET. “Imag- iour and we need to assess these dif- He acknowledged that he had seen then transfer the patient to the MR treatment evaluation. ing is expensive, but therapy is also ferences and adapt the therapy to this in prostate cancer commonly scanner there is often a misrepre- “In this situation you want to expensive. If you give the wrong the patient accordingly,” he noted. and that it was visible with MR-PET. sentation due to blurring without minimise use of ionising radiation therapy then it is also very expen- “We also need to monitor therapy However, he tempered his enthu- precise overlap,” he said, noting that to reduce harm and further cancer. sive for the patient too,” he said. “We to evaluate the intervention across siasm by stressing that MR-PET this had implications for tumour We anticipate that MR-PET use in need to weigh up everything relating the body. MR-PET will help us to is only as good as the radiotracer biopsy or tailoring radiotherapy to these cases would reduce radiation to clinical benefit and then conclude individualise and stratify therapies available. a precise location. “For these types exposure in these patients,” he said. whether it is cost effective or not. to the patient.” “Without the right radiotracer it of tumour, the combined MR-PET However, it is still early days, and This can only be answered when it is Commenting on this point, Prof. is only an MRI,” he said, adding that is more suitable.” Schlemmer remarked that to date, integrated into the whole diagnostic Herbert Kressel, from Harvard the radiotracer makes the molecules Schlemmer highlighted that the clinical benefit has not been fully and therapeutic process in oncologic Medical School in Boston, U.S., who and pathways visible. “This allows MR-PET also had implications in established. “We can only guess at imaging. We need to move beyond attended the presentation, said he the radiologist to see metabolism the treatment of oncologic patients this stage. There are no large mul- believed that heterogeneity was the and molecules distributed on the who usually require many repeat ticentre trials providing evidence. sweet-spot for this technology. cell surface with sensitivity in the studies throughout the course of However our experience as onco- continued on page 3

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Answers for life. Sunday 10 March 2013 Highlights ECR Today 2013 3 Gastrointestinal radiologists prepare to enter new era of personalised medicine

By Philip Ward therapeutic response. His advice to The main benefits of MRI fluor- ECR delegates was to embrace the oscopy are its multiplanar imaging Gastrointestinal (GI) imaging looks new responsibilities in the era of capability, the full view of soft tissue poised to make another quantum personalised medicine. structures (not just the lumen), and leap forward in the years ahead, “Technological advances have the lack of ionising radiation, which as fluoroscopic techniques are led to a revolution in GI imaging, is of particular value for repeat stud- left behind and the field develops but very importantly, all these tech- ies. The drawbacks are that its tem- beyond simply anatomical imaging, niques are complimentary,” he said. poral resolution is up to 10 times embracing increasingly functional “Clinical applications are changing, less than standard fluoroscopy, the and quantitative techniques, accord- and as radiologists, we’ve got to requirement for the patient to be in a ing to speakers at yesterday’s Special understand the strengths and limi- supine position, lack of fine intralu- Focus Session on GI imaging. tations of each diagnostic technique minal detail, and the fact that it takes Over the past decade or so, and where they sit within the clinical 20–30 minutes, according to Taylor. there have been major advances management of patients.” Gastric motility can be broadly in abdominal imaging in CT, MRI MRI fluoroscopy can replace con- divided into changes in gastric vol- and PET-CT. Given the emphasis ventional techniques in swallowing ume, for which the gold standard is on dose reduction, radiation-free and gastric emptying, and also it can the barostat device, and measure- modalities are now taking centre replace conventional methods and ment of peristaltic activity/empty- stage as radiology goes increasingly increase understanding of a patient’s ing rate, for which the gold standard mobile. condition in the case of both gas- is scintigraphy, he stated. Stuart Taylor from London, U.K. Simon Jackson from Plymouth, U.K. “As well as the functional tech- tric emptying and the small bowel, Assessment of small bowel motil- niques, we’re moving into quantita- said Dr. Stuart Taylor, who heads ity using MRI can be of particular tive techniques with which we can the development of functional MRI value, he continued. Usually it Motility information can shed follow-up of patients,” he said. “MRI look at cellularity, perfusion and in oncology and GI diseases at Uni- is vital to distend the bowel, as is light on conditions such as diabetic assessment of gastric emptying is inflammation,” said session mod- versity College London Hospitals done for MR enterography, e.g., neuropathy, pseudo-obstruction, now established as a clinical and erator Dr. Simon Jackson, a consult- (UCLH) NHS Foundation Trust in with one litre of 2–3% mannitol. Parkinson’s disease, postsurgical research tool.” ant GI radiologist at the Plymouth London. If a detailed physiological study is ileus, autonomic failure, bacterial MRI assessment of small bowel University Hospitals NHS Trust, Protocols require a technique being conducted, it is necessary to overgrowth, and Crohn’s disease. motility is possible with increas- U.K., and past chairman of the Brit- with high temporal resolution and control the time of day, smoking, However, among the remaining ingly sophisticated software tools ish Society of Gastrointestinal and reasonable spatial resolution, and caffeine intake, medication, etc. technical challenges are the need to quantity segmental and global Abdominal Radiology. “We’re mov- he explained that the two main Basic anatomical data are required for more rapid whole volume small motility, and there are multiple ing into the next era, that is the era approaches are: T1-weighted gra- to plan motility, and the aim is to bowel data acquisition, errors due to potential clinical applications, of personalised medicine.” dient echo-based imaging (usually cover most of the small bowel vol- through plane motion of loops, auto- noted Taylor, who is co-author of a This all translates into patient- with gad spiking of oral contrast) ume, using a typical slice thickness mated ROI placement, free breath- relatively recent article on this topic, tailored therapies, and GI imaging such as FLASH; and T2-weighted of 1 cm, breath-hold acquisition at ing, tagging, and the requirement for entitled ‘The future developments in has a fundamental role to play here imaging (usually with non-spiking each slice position, and 10–25 slice improved registration techniques. gastrointestinal radiology’ (Helbren in driving and defining the primary of oral contrast) such as TrueFISP positions to cover the whole small “MRI fluoroscopy is possible et al. Frontline Gastroenterol 2012 3 treatment decision and monitoring or Fiesta. bowel. and may have uses in long-term [Suppl_1], p. i36).

continued from page 1 Ratib pointed out that they wanted body MR because it is high quality, it just asking if MR-PET is better than the best of both worlds (whole body comes at the cost of the study often PET-CT or MR alone.” and regional), but that the cost for taking more than an hour.” Also speaking at the session was this was time. Schlemmer said that it was a mat- Prof. Osman Ratib, chairman of the “We would love to have whole ter of workflow. When you do PET department of radiology and head screening and regional, but that is imaging you always do whole body of the division of nuclear medicine not very practical. We want to know assessment. You might then decide at the University Hospital of Geneva, if we should apply MR-PET if we during the examination that you Switzerland. After Ratib’s and Sch- have a specific question and specific need a high resolution or functional lemmer’s talks, an audience member body area to examine. Maybe this imaging studies. But he cautioned from the Peter MacCallum Cancer is where MR-PET is the best solu- that tumours are always multi-focal Centre in Melbourne, Australia, tion but right now, PET-CT remains and often in unexpected areas. asked a pertinent question about a good technique for screening and “You only do the separate imag- whether MR-PET would be better whole body scanning because it is ing in one body part when you have directed to regional assessments fast,” he pointed out. “We realise now shown that the tumour has not rather than whole-body assessments. that whilst we are desperate for whole spread elsewhere,” he said.

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Sunday 10 March 2013 Highlights ECR Today 2013 5 Cruyff, Bergkamp, van Persie, et al. take second place behind interventional oncology

By Philip Ward “There has been a key paradigm a biomarker, and he thinks radiolo- shift towards molecular-based treat- gists are particularly well placed to Besides medicine, Prof. Jean- ments,” he said. “To be successful develop imaging biomarkers. FDG- François Geschwind’s great passion in this field, the true pioneers in PET can be used as a biomarker of in life is football in the Netherlands. interventional oncology will need tumour metabolism, but many oth- “I would love to be asked to give to understand the basic principles ers are now being developed, such a lecture about Dutch soccer, but of cancer biology and specifically as those for hyperpolarised MR unfortunately this has never hap- the hallmarks of the key signatures spectroscopy. pened, so I’m stuck giving lectures of cancer.” “How can we integrate image on interventional oncology and Identifying so-called drugga- guidance, interventional techniques liver cancer therapy. Forgive me, but ble targets is a key notion here, that are well known to all of us, and that’s what I’ll talk about today!” he Geschwind explained. Druggabil- targeted molecular therapy?” he disclosed at the start of yesterday’s ity, which involves the likelihood of asked. “If we can combine all that, Wilhelm Conrad Roentgen Honor- being able to modulate a target with we can make it a very happy mar- ary Lecture. a small-molecule drug, is essential riage. For that again you have to Interventional oncology is now to determine whether a drug discov- go back to the principles of cancer considered to be the fourth pillar ery project progresses in the devel- biology.” of oncology, and has taken root opment cycle. Predicting how drug- It’s important to build up an in many hospitals as a valid treat- gable a novel target lies at the crux of understanding of how healthy cells ment option for cancer patients, said early drug discovery. Because many at some stage undergo genetic muta- Geschwind, who is director of the of these drugs are found serendipi- tions that will lead to an uncon- division of vascular and interven- tously, it’s necessary to characterise trolled growth of a tumour, accord- tional radiology at the Johns Hop- the drug effects and understand the ing to Geschwind. This in turn will kins University School of Medicine mechanism of action. lead to great disruptions of home- in Baltimore, U.S., but originally The beauty of targeted therapy is ostasis, and homeostatic imbalance Honorary Lecturer Jean-François Geschwind from Baltimore, United States. comes from Paris. that it becomes realistic to develop may then lead to a state of disease. South African radiology demonstrates its dynamism and vibrancy on the big stage

By Becky McCall Addressing a hot and recurring logical Society of South Africa, and issue of the day, discussed in depth academic institutions in providing It’s dynamic, exciting, and evolving. during other sessions at this year’s academic and clinical training. The That’s how an engaging presenter ECR, Lockhat suggested that radi- RSSA provides an academic plat- opened her talk about the state of ologists were emerging from the form with webinars, conferences, academic radiology training in dark to interact with patients and workshops and the publication of South Africa. The reality, as dis- clinicians. Referring to a recent the South African Journal of Radi- played in the following lectures at European survey, clinicians said ology. Also, amongst today’s radi- Saturday’s ESR Meets session, cer- they wanted old fashioned access ology training tools are a mixture tainly lived up to the promise. to radiologists, and straight for- of didactic lectures, case-based Prof. Zarina Lockhat, professor of ward accurate radiology reports, learning, e-learning, and Medical radiology at the University of Preto- although she reported that in her Imaging Resource Center (MIRC) ria, spoke about radiology training opinion, reports are a work of art. teaching files, she said. in her country, and recognised that Returning to the driving force Another South African radiolo- the pace of change was fast and furi- of technology, she highlighted the gist recently performed exception- ous and that technological advance- current trend for computers to get ally well in the U.K. Royal College ment was driving the agenda. smaller. “First they were in rooms, of Radiologists’ examinations, Participants from Saturday’s ESR meets South Africa Session. “Academic radiology has to be then desktops, then in our laps, now illustrating how South African balanced against a background of in our palms and soon they’ll be on radiologists are carving a niche for leads to infection in the cerebrospi- “This showed a cortical lesion scientific and technological advance- our faces and possibly one day in themselves on the international nal fluid (CSF) and exposure of the meningitis that was not basal cis- ment,” she said. “In 2002, Tom Cruise our brains.” radiology scene. This was confirmed antigen to the basal cisterns. This ternal meningitis, but nobody could fascinated us in the film, Minority With a poignant nod to the value by other lectures during Saturday’s invokes an inflammatory response explain how something high in the Report, by using gesture recognition of traditional academic radiology, session. Dr. Janse van Rensburg, leading to CSF obstruction, which brain caused meningitis at the base,” technology and scrolling of images, and despite all the technological from the University of Stellenbosch, in turn leads to the characteristic he explained. “People suggested the but now surgeons manipulate images advances, she read out an apt quote explained a new concept about the and predictable imaging findings in patient was lying down, but they are in a sterile environment by just mov- for the radiologist in training: “You pathogenesis of tuberculosis that he children,” he said, summarising the usually walking around when diag- ing their hands. It’s a reality.” only seek what you look for and rec- had arrived at with his colleague, new theory. nosed, or due to differences in blood Furthermore, so-called reason- ognise only what you know. No mat- Dr. Richard Hewlett, from the same The Rich theory has always been vessels in the brain.” ing engines for radiologists are ter what you have – smart phones, institution. controversial over many years. Van Rensburg credits Hewlett for not so far off, she added. “Patient tablets, e-learning, e-resource – if “The concept we propose is that Van Rensberg said South African the new explanation. “His explana- observations, signs and symptoms you can’t see the abnormality you basal cisternal meningitis in chil- researchers had always been scep- tion is just the logical theory after are punched in and deep reasoning cannot make the call.” dren due to tuberculosis is not a tical because of the discrepancy doing this for 20 years. He’s the only software systems give feedback on Lockhat acknowledged the con- result of the well-known Rich focus between the MR images and the person I know with the pathology recommendations for further inves- tributions of the College of Medi- theory, but rather the result of direct gross pathology and what the origi- and neurology knowledge to bring tigations and diagnoses.” cine in South Africa, the Radio- infection of the choroid plexi, which nal work from the 1930s showed. it all together.”

Dr. Rüdiger Schernthaner, Austria Prof. Zhanar Abdrakhmanova, Kazakhstan Radiology Trainees Forum Dr. Thierry Couvreur, Belgium Dr. Viola Koen, Netherlands Dr. Ana Sverko Peternac, Croatia Dr. Elisabeth Olstad, Norway Meet & Greet with your RTF Representative Dr. Lasse Nørgaard, Denmark Dr. Domen Plut, Slovenia Dr. Peter Bannas, Germany Dr. Yulia Mironova, Ukraine Today, 13:15–13:45, Rising Stars Lounge, 2nd Level Dr. Andrea Levai, Hungary Dr. Marijana Basta Nikolic, Serbia Dr. Shai Shrot, Israel Dr. Nadya Pyatigorskaya, France

myESR.org | #ECR2013 @myESR 6 ECR Today 2013 Highlights Sunday 10 March 2013 Record participation for diploma examination at ECR

By Mélisande Rouger of the diploma two years ago, and in this regard,” said Jakubowicz, who Americans are beginning to show confirmed the huge interest among The increasingly popular Euro- an interest as well. Furthermore, young Argentinean radiologists in pean Diploma in Radiology (EDiR) the Argentine Society of Radiology working abroad. attracted a record number of candi- paid for two young radiologists to Andrés and Jakubowicz also pre- dates from all over the world to the take the diploma exam, and cov- sented papers through EPOS™ – on ECR. As many as 62 residents and ered their travel and accommoda- mammography, usual metastatic radiologists travelled to Vienna to tion costs. Dr. Mariana Jakubowicz sites in PET, whole-body PET-CT sit the examination, a 50% increase and Dr. Santiago Andrés, residents examination and on the selection in participation from last year. at the Deutsches Hospital in Buenos of biopsy sites with PET-CT. Part of This rise reflects the growing qual- Aires, found it to be a great experi- the reason why they took the exam ity and recognition of the diploma, ence and acknowledged the quality in Vienna was so they could also according to Dr. Éamann Breatnach of the examination. attend the ECR, and diploma can- from Dublin, scientific director of “The exam really covered every didates were given free access to the the European Board of Radiology aspect of general radiology. The congress this year. Conveniently, Mariana Jakubowicz and Santiago Andrés from Buenos Aires, Argentina, were amongst the (EBR), which organises the exami- written part was tough. There were the examination started a day candidates at the European Diploma in Radiology exams which took place Wednesday to Friday nation. “People start to see that the lots of questions and little time to before the beginning of the ECR, during the ECR. diploma is a qualification agreed to answer them. Cases were not the to enable candidates to attend ses- by both the EBR and the European simplest. The examination was chal- sions afterwards. Furthermore, the publication on the revised train- The examination will also be held Society of Radiology (ESR). There is lenging because of the language, examination was split over three ing charter and curriculum, the during the annual meeting of the more recognition of the value of the but I know the examiners take that days, sparing candidates long wait- journals European Radiology and Turkish Society of Radiology in diploma, which people see as use- into account. I felt more comfort- ing times between the written and Insights into Imaging, and the case November. Candidates will have the ful for their individual career paths. able during the oral exam though oral tests. material available on Eurorad. But option of taking the oral test either Holding the diploma shows your and could comment on the images. This time, diploma organis- this list is not exclusive and we are in English or in the local language. employer that you are enthusiastic Besides the examiners were very ers invited a panel of observers to aware that there are very good books Success in the examination will and have a good knowledge base, friendly and helpful,” Andrés said. attend the orals, in order to train in languages other than English, certify a standard of radiological and ultimately you can use it to look “One difficulty is that we do them to become examiners next so I want to stress that point, and knowledge deemed appropriate by for employment elsewhere,” he said. things differently back home. For year. Organisers also announced also insist on the European nature the ESR for independent practise in The diploma is officially recog- instance I would never do an MR that they would include a list of of this examination, which is not a general radiology. The examination nised by the European Union of examination for appendicitis but recommended literature for the language test,” Breatnach said. is open to radiologists and radiology Medical Specialists (UEMS), and rather an ultrasound or abdominal next examination, after candidates In the future, organisers would residents in their fifth year of train- its reputation extends well beyond CT scan, so I am not used to see- requested this option. like to see the diploma become ing. Examination costs are €500 for Europe. Candidates from the ing this pathology on MRI. That “We would like to encourage accepted as equivalent to some ESR full members and members in Gulf countries have come in large was a bit confusing. But having a people to be familiar with the ESR national qualifications, and nego- training, and €1,100 for ESR cor- numbers since the introduction mock exam beforehand could help publications, which include the tiations are currently underway. responding members. Live discussions heat up EPOS Area By Mélisande Rouger lots of good questions today, lots of computer during the whole ECR exchanges going on,” she said. reading through all the posters,” The EPOS™ (Electronic Presentation Furthermore, five posters, the best said Åhlström-Riklund, obviously Online System) Area in Foyer A is ones from a scientific, educational pleased to be back in Vienna. an essential destination at the ECR and compositional point of view, A consultant doctor specialising and attendance was high between received Magna Cum Laude awards in movement disorders, dementia Thursday and Saturday. Delegates on Friday. and PET-CT in oncologic applica- took part in live discussions on Now in its eleventh year, EPOS™ tions, Åhlström-Riklund works at hot topics in radiology, which this is one of the most popular features the University of Umeå, a small town time focused on paediatric neu- of the ECR. It provides radiologists in the North of Sweden. ”There are roimaging, MRI of the scrotum, who cannot attend the congress no old cities like Vienna in north- plaque imaging and myocardial with the opportunity to present ern Sweden. Our University is very characterisation. their work, and many say it has young for instance, it was founded During these live discussions, changed the way they interact with in 1959. Now we have 38,000 stu- poster authors can personally new information in radiology. dents, a pretty high population for introduce and comment on their More than 16,000 poster presen- a town of 160,000 inhabitants,” she work with the public. The chair- tations are currently available online said. Professor Katrine Åhlström-Riklund, chairwoman of the scientific exhibition, awarded the Magna woman of the scientific exhibition, and authors can submit their work Umeå will be the European Cap- Cum Laude Awards on Friday to five best poster authors. Professor Katrine Åhlström-Rik- throughout the year. For ECR 2013 ital of Culture in 2014 and many From left to right: Carmen Ayuso, Manuel Recio, Ana Maria Quilles, Silvia Perugin Bernardi, lund, is particularly fond of these alone, 2,785 posters were submitted. activities, concerts and perform- Kristian Micallef, Shinichiro Kitao, Katrine Åhlström-Riklund debates. “The posters cover everything. ances will be offered throughout “I think these presentations are You can read about things you deal the year. Åhlström-Riklund is very Live discussion: a good opportunity to start pre- with every day but also about things much looking forward to next year, Sunday, March 10, 12:30–13:00 senting, it’s a very friendly format. you will never be confronted with as Umeå Universty will offer events Vascular imaging: CT, MR – or something completely different? Previously there were just the post- except in the EPOS Area. There is a based on seasonal themes. Challenges in imaging peripheral artery occlusive disease ers on the wall and people went by, huge amount of knowledge in there. ECR delegates are welcome to Moderator: Christian Loewe; Vienna/AT now these discussions invite them This year is no exception, and you join, listen, and discuss with the to share their views. There were can be sitting here in front of the experts again on Sunday. #ECREPOS #ECR2013 Eurasian collaborative project gets started at ECR A ground-breaking meeting was left), the General Secretary of the Elmas (President of the Turkish Soci- held during ECR 2013 on Thursday Turkish Society of Radiology. A ety of Radiology) and Dr. Jalal Jalal to discuss the extension of Eurasian total of 20 member societies were Shokouhi (President of the Iranian radiology collaboration. identified as potential participants Society of Radiology). “We also think The main organisers of the meet- in the initiative. that scientific collaboration between ing were Dr. Mansoor Fatehi (pic- “We believe access to the state of our societies and radiology com- tured on the left), General Secretary the art radiology knowledge and munities in the region would create of the Iranian Society of Radiology improving the standards of radiol- greater opportunities for our col- and a member of the International ogy practice in this part of the world leagues by sharing expertise. In this Relations Subcommittee of the are crucially important issues,” noted regard, we are seeking your ideas on European Society of Radiology and Fatehi and Turgut in a joint statement how we can collaborate to achieve Dr. Ahmet Turgut (pictured on the that was also signed by Dr. Nevra this ambition.” Dr. Mansoor Fatehi, General Secretary of the Iranian Society of Radiology and Dr. Ahmet Turgut, the General Secretary of the Turkish Society of Radiology

#ECR2013 @myESR | myESR.org Hot Shots from Day 3

Gold Medal Ceremony at ECR 2013 from left: Gabriel P. Krestin, Maximilian F. Reiser, José Cáceres, Johannes Lammer, José I. Bilbao

Eurasian collaborative project gets started at ECR Cardiovascular and Interventional Radiological Society of Europe

ESIR 2013 Courses

European School of Interventional Radiology

Stroke Intervention Klagenfurt (AT), April 12-13, 2013 (recommended for level 4/Advanced) Embolisation Odense (DK), April 19-20, 2013 (recommended for level 2-3/Intermediate) Peripheral Arteries & Lower Extremities Amsterdam (NL), April 26-27, 2013 (recommended for level 1/Basic) Biopsies & Drainage Procedures Ankara (TR), May 24-25, 2013 (recommended for level 1/Basic) Musculoskeletal Interventions Athens (GR), June 7-8, 2013 (recommended for level 1/Basic) Lung Interventions: Embolisation & Ablation Frankfurt (DE), July 5-6, 2013 (recommended for level 4/Advanced) Renal Denervation Rome (IT), October 18-19, 2013 (recommended for level 4/Advanced) Tumour Ablation Lausanne (CH), November 8-9, 2013 (recommended for level 1/Basic)

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C RSE f o u n d a t i o n Sunday 10 March 2013 Clinical Corner ECR Today 2013 9

Imaging provides Advances in forensic Overuse injuries important imaging bring in gymnasts and INSIDE information new opportunities professional golfers about traumatic for radiology TODAY brain injury See page 10 See page 12 See page 16 CT cardiothoracic imaging enters an exciting new phase of evolution

By Frances Rylands-Monk of atypical acute chest pain related radiation dose reduction and the either to the lungs (e.g., pneumot- new heart-lung dedicated software The rapid technical evolution of horax, pneumonitis) or cardiovas- available for evaluating cardiac CT scanners has made it possible cular structures (e.g., acute aortic function, defining obstructive coro- to acquire cardiac images with fewer syndrome, pulmonary embolism, nary stenosis and characterising and motion artefacts, and studying the coronary disease). Additionally, quantifying disease processes in the heart should be mandatory for radi- different imaging findings in non- lung parenchyma. ologists who are performing a rou- contrast CT scans may reveal spe- The session should appeal to all tine chest CT examination to avoid cific cardiothoracic problems, and a radiologists, as such diagnostic overlooking important findings, hyperdense aspect in a pre-contrast imaging will be increasingly asked advocates a leading chest imaging CT scan of the thoracic aorta wall of them in the general radiology set- specialist. in a patient with acute chest pain is ting, he said, pointing to the impos- “It is essential for radiologists a hallmark of an acute intramural sibility for subspecialists alone to to consider cardiac and thoracic haematoma, according to Bonomo. manage this expanding patient assessment as a single imaging con- Expanding on the optimisation population. text,” said Prof. Lorenzo Bonomo, of CT techniques for diagnosis For dealing with cardiac motion, chairman of the department of and assessment, his colleague Dr. ECG synchronisation for imaging radiological sciences and bioimag- Riccardo Marano, from the same structures such as the heart, lungs ing at Agostino Gemelli Hospital, hospital, will be covering coronary and lung parenchyma has an ambiv- Catholic University of Rome, who artery imaging, while Prof. Edwin alent track record, and the radia- will moderate this afternoon’s spe- van Beek, SINAPSE chair of clini- tion dose involved fluctuates with cial focus session on comprehensive cal radiology at the Queen’s Medi- the type of technology available over CT cardiothoracic imaging. cal Research Institute, University time, according to Schoepf. Four- CT’s ever lower radiation dose, of Edinburgh, U.K., will discuss slice CT scans with retrospective faster acquisition speed, higher the feasibility of cardiopulmonary ECG gating meant higher radiation temporal resolution and larger scan functional imaging. exposure. Latest generation scan- volume per single rotation of the Prof. Uwe Joseph Schoepf, direc- ners using refined means of ECG tube-detector system allows good tor of cardiovascular imaging at the synchronisation deliver 1mSv or less image quality, even in patients with University Hospital of South Caro- in cardiothoracic CT scans, between high heart rates. These advantages lina, Charleston, U.S., points out one third and one quarter of normal also help to reduce the incidence of that a comprehensive examination yearly background radiation dose, non-assessable coronary segments requires knowledge of a patient’s the latter being around 3.5mSv. due to motion artefacts and increase medical background and a tailored However, 64-slice CT scanners are the modality’s capacity to assess the approach. still the most widely used platform proximal extension of acute aortic “For investigating the com- and they typically deliver higher dissection in surgical planning. plex pathologies of the heart-lung radiation doses, so radiologists “In the future, evaluation of the axis, patients need more pre-scan must adapt protocols to the clini- heart with CT imaging will be a involvement of the radiologist,” he cal question to deliver the lowest common procedure in the pre- said. “In many hospitals, there is still possible dose. operative assessment of patients, at a culture of standardised protocols “If we are only interested in the least for non-cardiac surgery, but for heart-lung imaging because it is anatomy of the chest, then we should this requires a cultural change for mainly the technologist performing use a clear-cut strategy of minimis- radiologists, surgeons and physi- the scan.” ing radiation dose and sacrificing Ultra-high pitch CT acquisition using second generation dual-source CT in a woman with acute cians,” he said. “In addition, hybrid Interaction in CT on a routine functional information through chest pain. A dose-length product of 40 mGy cm2 was applied, which roughly translates to imaging could offer the advantages basis between the radiologist and use of prospective ECG triggering 0.5mSv in effective radiation dose for the ECG-synchronised interrogation of the entire thorax. of different modalities in a single the technologist in European hospi- which will allow clear evaluation of (Provided by Prof. Uwe Joseph Schoepf) diagnostic tool.” tals may be better than in the U.S., the lung parenchyma, thoracic ves- CT is currently the gold stand- but a greater exchange is always sels and heart,” he pointed out. ard for imaging the lungs and great desirable, he elaborated. Further- Using dual-source CT scanners is thoracic vessels, both in routine more, intense institutional dialogue another way to scan the entire chest “There is no such thing as a ‘free Special Focus Session and emergency. Its role in coronary with referring physicians, such as with 1mSv or less in less than 600 lunch’ in terms of diagnosis and Sunday, March 10, 14:00–15:30, imaging, on the other hand, is estab- cardiologists and pulmonologists, milliseconds, he added. For other radiation dose, with CT,” said Sch- Room G/H lished in carefully selected patients is crucial to truly understand their patients, functional information oepf, adding that although careful SF 14b: Comprehensive CT with proven high diagnostic accu- clinical questions. may be needed (e.g., cardiac cham- patient selection is still paramount cardiothoracic imag- racy and negative predictive value. In his talk today, Schoepf plans ber function and pumping ability when using latest generation equip- ing: a new challenge for In the emergency setting, CT to outline powerful new CT tools of the heart). Retrospectively ECG ment, ECG synchronised acquisi- angiography triple rule-out pro- that compensate for cardiac motion, gated data acquisition gives ana- tion no longer involves an extra radiologists tocol can help establish the cause while discussing best methods of tomical and functional informa- penalty in radiation exposure, while ▶▶Chairman’s introduction tion for assessing pump function, maximising the diagnostic informa- L. Bonomo; Rome/IT for example, but patients will typi- tion obtained from patients. ▶▶How to optimise integrated cally receive between 12 and 25 mSv As for the future outlook, con- cardiothoracic imaging with CT of radiation exposure on a 64-slice tinuous development of different U.J. Schoepf; Charleston, SC/US scanner. technologies to synchronise CT “This is something we want to acquisitions with the patient’s ▶▶Coronary artery imaging from apply only if we have to. There are heartbeat and the evolution of ever a chest CT examination: when alternative techniques to obtain refined reconstruction techniques and how functional information at low radia- means that the journey is far from R. Marano; Rome/IT tion dose: ECG synchronised tube over. ▶▶Cardiopulmonary functional current modulation, patient-specific “We are now in an arena where imaging from a chest CT kV selection, as well as hybrid strat- CT radiation exposure can com- examination: when and how egies based on a mix of retrospec- pete with conventional x-ray,” he tive ECG gating and prospective remarked. “In a few years, all CT E.J.R. van Beek; Edinburgh/UK ECG triggering help to minimise image reconstruction will be per- ▶▶Panel discussion: Is a single radiation dose while still providing formed using iterative reconstruc- CT scan technique and functional data,” Schoepf said. tion techniques. We will also see protocol feasible for all the ECR delegates will hear how CT an expansion of indications for cardiothoracic problems? perfusion can assess pathologies like disease diagnosis, wider use of CT lung cancer or perfusion defects in perfusion for monitoring and more #SF14b #ECR2013GH Prof. Lorenzo Bonomo, chairman of the Prof. Uwe Joseph Schoepf, director of the heart muscle. It represents an quantification due to the increas- department of radiological sciences and cardiovascular imaging at the University exciting advance in terms of diag- ing availability of software solutions bioimaging at Agostino Gemelli Hospital, Hospital of South Carolina, Charleston, U.S. nostic yield, but also requires more for determining disease extent and Catholic University of Rome. radiation. activity.”

myESR.org | #ECR2013 @myESR 10 ECR Today 2013 Clinical Corner Sunday 10 March 2013 Imaging provides important information about traumatic brain injury

By Mélisande Rouger and on advice given to patients and relatives. Traumatic brain injury (TBI) is Advanced MR techniques may a major cause of death and dis- help determine outcome. “Diffusion ability worldwide, causing about tensor imaging (DTI) and proton 1.5 million deaths and leading MR spectroscopy (MRS) provide to millions of patients requiring quantitative assessment of the extent emergency treatment every year. of brain damage and have been pro- In severe cases, TBI is commonly posed as markers of axonal injury classified according to morphologi- and as indicators of long-term out- cal criteria based on CT and MRI come,” said Rovira-Cañellas, who studies. Experts will show how to will chair the session. With DTI or image TBI patients appropriately in MRS, radiologists can better clas- a dedicated Special Focus Session sify patients and see what kind of today at the ECR. injuries they have, but most impor- A B C Although MRI may be better for tantly, radiologists can use them to detecting traumatic lesions in later categorise the degree or extent of 35-year-old man with intracranial injuries phases following TBI, CT remains tissue injury. “From a clinical point sustained in a motor vehicle accident. Brain the examination technique of choice of view, it is very difficult to explore CT scan (A) performed six hours after the in the acute phase, according to Dr. a patient with severe traumatic brain accident was initially read as normal. Brain Alex Rovira-Cañellas, director of injury who is sedated in the inten- MR imaging performed six days later shows a neuroradiology at Vall d’Hebron sive unit, so the best way to assess thin subdural haematoma in the left parietal Hospital in Barcelona. “CT is the the extent of the injury is to use one region on a T1-weighted image (B), and a modality of choice for the emer- of these MR techniques. They are mild hyperintense lesion in the splenium gency setting. It is good at detecting also successfully applied in Alz- of the corpus callous on a T2-FLAIR image focal lesions that need to be oper- heimer’s, stroke and multiple scle- (C). This last finding is better identified ated upon right away. We always do rosis management,” he said. as an area of high signal intensity on the isotropic diffusion-weighted image (D) with CT first,” he said. DTI and MRS are also increas- a decreased apparent diffusion coefficient Although there is no question ingly used in research to monitor (ADC) value (E). These features are regarding the use of brain CT in treatment. New drugs are currently consistent with an area of cytotoxic oedema severe and moderate head trauma, being tested and they must first be secondary to diffuse axonal injury. there is still considerable uncer- assessed in order to improve their (Provided by Dr. Alex Rovira-Cañellas) D E tainty about the indications for efficiency in selected patients, brain CT in patients with minor depending on the type of injury TBI. Recent data indicates that the they have. liberal use of CT scanning in mild Radiologists must also remem- overlook cerebrovascular trauma, Special Focus Session TBI is cost-effective and appears ber to image cerebrovascular inju- especially in the emergency setting Sunday, March 10, 16:00–17:30, Room F1 justified. ries, which are very common after where staff resources are strained. SF 15a: Traumatic brain injury MRI is more appropriate for trauma. Quite frequently these “Polytrauma patients usually ▶▶Chairman’s introduction identifying diffuse lesions, which injuries are not identified from undergo whole-body CT from brain better relate to the patient progno- the initial CT scan, and mortality to pelvis, but we don’t pay enough A. Rovira-Cañellas; Barcelona/ES sis, and radiologists do T1, T2 and among these patients (60 percent) is attention to these lesions. We have ▶▶Acute brain trauma: CT vs MRI diffusion-weighted sequences on a much higher than the rest of trauma to look at hundreds of images in a M. Muto; Naples/IT routine basis to detect these in some patients. “You need to apply a series patient in an acute setting, so it is ▶▶New imaging techniques in the detection patients. of protocols to look specifically for not easy for one person to read all and quantification of brain damage However, both CT and conven- head and neck injuries. It is very of it in detail. In certain European S. Sunaert; Leuven/BE tional MRI fall short in accurate important to do CT or x-ray angi- countries, this situation is becoming prediction of outcome, because ography to look for these injuries, as even more unsustainable with the ▶▶Advanced imaging of brain trauma: outcome prediction of their inability to depict the full many patients may require endovas- economic crisis, and the number of D. Galanaud; Paris/FR extent of brain injury, and because cular treatment to stop or prevent people on call in hospitals has been ▶▶Cerebrovascular trauma: diagnosis and therapy they offer qualitative rather than bleeding from vascular lesions,” reduced. There are many experts in T. Krings; Toronto, ON/CA quantitative information. Outcome Rovira-Cañellas said. the same hospital, but very rarely at prediction is crucial because it has These patients should be diag- the same time,” he said. ▶▶Panel discussion: Role of neuroimaging an impact on the choice of specific nosed as soon as possible. Because Experts will provide some help- in traumatic brain injury in 2013 treatment methods, the decision of they often have injuries in other ful advice on how to face these whether or not to alter treatment, parts of their body, it is easy to restrictions. #SF15a #ECR2013F1 European Radiology now at your fingertips

More info at www.european-radiology.org Download at bit.ly/ER-app

#ECR2013 @myESR | myESR.org Sunday 10 March 2013 Clinical Corner ECR Today 2013 11 Intervention gives hope to patients with pleural effusion and lytic bone metastases

By Becky McCall

Prof. Afshin Gangi is passionate about cementoplasty, and believes it must be considered in the context of the whole patient. “Patients need to be seen before and after the procedures and interventional radiologists need to be responsible for the patient from A to Z,” he emphasises. “The patient is not just a metastasis.” Gangi, an interventional radiologist from Strasbourg Hospital, France, explained that with cementoplasty, interventional radiologists can only control pain and consolidate bone, and not treat the tumour. The procedure involves injecting acrylic A B cement or glue into lytic bone metastasis. It is usually indicated for painful, lytic bone metastasis especially A: Painful lytic L4 spinal metastasis. B: Vertebroplasty with injection of 3.5 ml of acrylic cement can provide excellent pain relief. when there is a risk of compression fracture in the spine, condyles and acetabulum. Large bones for exam- cement but they continue to grow and then an ultrasound scan to trauma, but actually it does not lie ple, after diagnosis of malignancy ple, the femoral shaft, are not a very quickly inside the spinal canal locate the fluid and remove it, fol- in the flange of the rib in the pos- is confirmed, a physician needs to good indication for cementoplasty. causing paraplegia. “Here you need lowed by a CT scan to determine if terior region, and is not protected decide if the patient is suitable for Also, non-lytic, hard metastases are to consolidate the vertebral body to the effusion is due to cancer includ- from interventional procedures per- chemotherapy and to provide the unsuitable for cementoplasty because treat pain and then use therapy to ing its extent and primary source. formed medial to the angle of the most minimally invasive procedure there is no space within the tumour. control the tumour too.” “In our work, we have shown that rib. With age, vessels become kinked possible so the patient can leave hos- Cementoplasty must always be At today’s session, Prof. Fergus ultrasound can be used for more than and the flange may not protect the pital promptly. considered alongside other anti- Gleeson, from the department of just taking the fluid off, but it can be intercostal artery as well if at all,” “The vast majority of radiolo- cancer therapies and techniques radiology at Churchill Hospital, used for diagnosis of malignancy he explained. gists and physicians don’t know when planning a patient’s disease Headington, Oxford, U.K., will dis- by looking at the pleural surface,” He will also use the session to about how best to manage pleural management, and an ablation may cuss issues around the management reported Gleeson. “Also we have present insights from his experience effusions. Advice should be sought need to be performed initially, fol- of pleural effusions, highlighting shown that it is possible to teach phy- of conducting pleurodesis as a pal- from experienced radiologists and lowed by cementoplasty, he noted. ways of managing pleural effusion sicians and others who use ultrasound liative measure. He will discuss how respiratory physicians on the man- At this afternoon’s special focus in patients as palliation in cancer to do this procedure in outpatients to train, who to drain and whether a agement of symptomatic relief of session addressing the need for pal- patients. He explained that a cancer, and the emergency department.” pleurodesis or chest drain is neces- pleural effusions,” he concluded. liative interventional techniques in whether inside or outside the chest, Addressing an ongoing debate, sary, as well as the risks associated cancer, Gangi will advise on how and can be associated with pleural fluid Gleeson will discuss the number of with these procedures. when to use cementoplasty and on either by direct invasion or by seeding fluid removals required for a reli- Pleural effusions in patients with Special Focus Session the broader aspects of disease man- along the surface that creates fluid. able diagnosis, and whether medi- malignancy are common and not Sunday, March 10, 14:00–15:30, agement. He stressed that the core “Palliative care aims to treat symp- cal thoracoscopy should be used to well managed, according to Gleeson. Room F1 message of his talk would be on the toms, most notably breathlessness. determine malignancy in addition He points out that it would be help- SF 14a: Palliative interventional need for interventional radiologists Patients can also present with pleu- to tissue biopsy. ful if all hospital healthcare provid- techniques in cancer to be more than a technician. They ral effusion when a cancer has not “You can do tests related to the ers and GPs understood a common ▶▶Chairman’s introduction need to be a complete clinician, and been diagnosed in the patient,” he pleura using PET scanning to pro- care pathway so patients do not get K.A. Hausegger; Klagenfurt/AT this is currently a weakness of inter- remarked. “Often the first symptom vide a prognosis on how aggressive missed under GP or emergency care. ventional radiology, he believes. of cancer in these patients is breath- the tumour is and the locations it The vast majority (around 75%) ▶▶Cementoplasty of lytic bone Patients referred for cemento- lessness caused by pleural effusion. might have spread to. In the case of large pleural effusions are due metastasis plasty are usually under the care of Symptoms are the same whether of mesothelioma, it is possible to to malignancies. In the U.K., with A. Gangi; Strasbourg/FR a chain of clinicians and sometimes the patient presents de novo or has measure the total glycolytic vol- a population of 60 million, there ▶▶Pleural drainage, pleurodesis certain treatment options can be a known cancer.” ume which provides a measure of would be about 100,000 malignant F. Gleeson; Oxford/UK overlooked due to a lack of com- Diagnosis of pleural effusions can how well a patient will respond to pleural effusions. It is common, and munication between the links in be conducted by sampling pleural chemotherapy,” he said. the difficulty is that imaging is so ▶▶Percutaneous nephrostomy the chain. “Everyone needs to work fluid. According to Gleeson, this In addition to his clinical work, good that tiny amounts of pleural (PCN) and ureteral stenting together; there is one conductor, and method usually provides a diagnosis Gleeson will present his research fluid can be detected in patients with F. Orsi; Milan/IT we are the musicians who need to of malignancy in 60% of patients. In that highlights a common misun- heart failure, he added. ▶▶Biliary procedures play at the right time and with the the other 40%, and also in patients derstanding of lung anatomy. He has Understanding the cause of M. Krokidis; Cambridge/UK right note otherwise it will be a with mesothelioma, the fluid is less found that the intercostal artery is pleural effusions is a huge issue catastrophe,” stated Gangi. forthcoming and diagnosis of the not necessarily where people think worldwide, which Gleeson fears is ▶▶Panel discussion: How invasive Patients with renal cell carcinoma cause of the pleural effusion may it is located. “Most people are taught managed very badly. He stressed can palliation be? When to say and bone metastases exemplify this be as low as 30%. that the intercostal artery lies in that there was a need for greater no to palliative treatment? scenario. The pain and fragility of Gleeson advocates a simple chest the flange of the rib on the under understanding of different ways of #SF14a #ECR2013F1 these metastases can be treated with x-ray to diagnose pleural effusion, surface where it is protected from managing the patient. For exam-

A B C

B A: Large painful lytic metastasis of the iliac bone with extension to the acetabulum. Pain resisting radiotherapy. The iliac metastasis doesn’t need consolidation (not weight-bearing bone) and is treated by cryoablation with two cryoprobes. Cementoplasty needle positioned in the acetabulum. A: Painful lytic rib metastasis. B: Visualisation of the ice ball during cryoabaltion of the iliac metastasis. B: Cementoplasty of the rib, again giving C: Cementoplasty of the acetabulum for consolidation and pain management. excellent pain relief. (All images provided by Prof. Afshin Gangi)

myESR.org | #ECR2013 @myESR 12 ECR Today 2013 Clinical Corner Sunday 10 March 2013 Advances in forensic imaging bring new opportunities for radiology

By Simon Lee

The ability to spot pathological imaging findings among normal post-mortem signs of degeneration may not be a universal skill among radiologists, but it could prove to be a useful, if not essential one. As the reliability of modern forensic imaging rapidly improves, forensic pathologists are increasingly seeking the help of radiologists to examine bodies non-invasively, so they should be prepared to answer that call, according to experts who will speak in a Special Focus Session on ‘Advances in forensic imaging’ today. The development of techniques such as spiral volumetric CT and, more recently, MRI, have dramatically improved the ability of radiologists to determine causes of death and detect other crucial post-mortem signs, providing an invaluable service that can supple- ment, and in some cases replace, traditional autopsy. However, training and regula- tion have not kept up with the pace of technological progress, mean- ing there is still plenty of room A B for improvement in this growing branch of radiology. This afternoon’s Bone and metal maximum intensity projection (MIP) reconstruction (A) and volume-rendered (VR) 3D-CT reconstruction (B). Homicidal death: characteristic bony and metallic fragments session will see established forensic on the exit side of the skull, where the bullet caused a large loss of brain, leading to shattering of the skull. (Provided by Prof. Giuseppe Guglielmi) radiologists review the current state of the field and discuss the most useful imaging techniques available. imaging. The recent development of skin you can make a reconstruction reproduces the conditions of per- this area, providing personnel and Due to its strengths in the visu- volumetric measurement has given of the skin; if your investigation cen- fusion in a living body, enabling the taking charge of forensic imaging, alisation of bone structure and the this lead a further boost by intro- tres on the skeleton, you can recon- radiologist to capture highly accu- then we run the risk that patholo- detection of embolisms and gross ducing the ability to obtain images struct bones; and if you are looking rate images of any abnormalities in gists will move into this area and abnormalities in soft tissue, CT has in different ways and focus more at organs, you can reconstruct the the vascular bed of the viscera, or make reports by themselves without been widely used in forensic pathol- specifically on areas of interest. soft tissue. You can manipulate the lesions of the vascular system. asking radiologists. With the excel- ogy for some time. Its advantages “Spiral volumetric computed images to find the exact answer you Based on post-mortem MDCT lent technological resources avail- over MR in terms of the availabil- tomography is largely responsible are looking for,” said session chair- studies, a new approach called able and such an obvious opportu- ity of equipment, relative simplicity, for the incredible recent develop- man Prof. Giuseppe Guglielmi, virtual anthropology has been nity for the growth of radiology, we and the time constraints inherent ment of the role of diagnostic imag- from the University of Foggia, Italy. developed. In cases of unidentified have to make sure we don’t miss the in examining corpses, have made it ing in forensic medicine. If you are “This doesn’t always remove the remains, positive identification of chance, because this belongs to our the dominant modality in forensic looking for specific details in the necessity of conducting a regular the deceased can be made by using field,” he added. autopsy, but it helps a great deal comparative or reconstructive tech- with the diagnosis and sometimes niques to determine important it proves to be enough to exclude anthropological information such Special Focus Session the need for further analysis. There as racial phenotype, age at death, Sunday, March 10, 14:00–15:30, are many exciting developments in sex and stature. More recently, MRI Room Z this field that can provide informa- has been used to augment forensic SF 14c: Advances in forensic tion about causes of death, including investigations, particularly in mus- radiology those originating from the vascu- culoskeletal, cardiovascular and lar system, time of death, identity, angiographic fields and in forensic ▶▶Chairman’s introduction anthropological information like imaging of the living, such as cases G. Guglielmi; Foggia/IT the age, sex and stature of uniden- of child abuse, survived strangula- ▶▶Imaging in forensic medicine tified human remains, and, just as tion and age estimation, according M. Thali; Zurich/CH importantly, details of an attack on, to Guglielmi. ▶▶Advances in post-mortem CT or abuse of, a living person,” said “At the moment, MRI is used for Guglielmi. very few cases because it is more angiography Thanks to the development of difficult to use on corpses than CT, S. Grabherr; Lausanne/CH specially created contrast tech- but I am sure that forensic imag- ▶▶Virtual anthropology and niques, CT can also be used to ing will increasingly turn to MRI to forensic identification investigate the post-mortem vascu- answer certain questions. It is vital using MDCT lar system. Multiphase post-mor- that we share more knowledge about F. Dedouit; Toulouse/FR tem CT-angiography (MPMCTA), forensic imaging in general, because which involves the performance of there is a serious lack of awareness ▶▶Forensic MR imaging one native CT scan and three angi- about it,” said Guglielmi. T. Ruder; Zurich/CH ographic phases (arterial, venous “Very few radiologists are well ▶▶Panel discussion: and dynamic), allows the vascular informed about this subject and it Which imaging technique for system to be imaged in a similar is vital that the national and Euro- which forensic scenario? way to standard clinical CT angi- pean societies bring more attention Post-mortem whole-body CT angiography. Pulmonary embolism: coronal multi planar ography. A mixture of paraffin oil to the topic, because it represents a #SF14c #ECR2013Z reconstruction (MPR) showing the filling defect in the right descending branch of the and a specially created oily contrast very real opportunity to extend our pulmonary artery. (Provided by Prof. Giuseppe Guglielmi) agent is injected via a device which discipline. If we are not training in

EPOS Discussions To enhance interaction, discussions on hot topics in radiology have been Sunday, March 10, 12:30–13:00 arranged, where authors of the selected and best-scored posters in each field Vascular imaging: CT, MR – or something completely different? will discuss them with a moderator. Challenges in imaging peripheral artery occlusive disease Moderator: Christian Loewe; Vienna/AT All discussions take place in the EPOS™ Area in Foyer A (2nd level) and ECR delegates are welcome to join, listen, and discuss with the experts. Today‘s discussion round will be:

#ECR2013 @myESR | myESR.org Sunday 10 March 2013 Clinical Corner ECR Today 2013 13 Excitement builds over digital breast tomosynthesis, but debate surrounds its screening role

By Rebekah Moan

Will digital breast tomosynthesis (DBT) replace mammography for breast cancer screening? The answer is ‘maybe’, and it depends on how well the modality performs in some forthcoming clinical trials, say two experts who will share their views with ECR attendees at this afternoon’s special focus session. The sensitivity of mammography for the detection of breast cancer is less than optimal, primarily because the breast is a 3D structure that is projected on to a 2D radiographic image. This means normal breast tissue can conceal a tumour. DBT The T-MIST trial should answer the question is a 3D radiographic technique that as to whether digital breast tomosynthesis reduces the effect of overlapping tis- can replace digital mammography, according sues in breast cancer detection. to Dr. Martin Yaffe, from the University of DBT appears to be gaining in Toronto, Canada. popularity. The technique improves the accuracy of finding cancers, as breast tomosynthesis be presented? well as reducing the recall rate of Can we find a presentation mode women with suspicious findings, which is acceptable in the screening especially in younger women and workflow?” those with dense breasts, according DBT is a promising tool in breast to Dr. Martin Yaffe, a senior scientist imaging, she concluded. However, of imaging research at Sunnybrook further evidence from the on- Research Institute and a profes- going trials is needed to establish sor in the departments of medical its place in breast cancer diagnosis biophysics and medical imaging at and screening. the University of Toronto, Canada. “That’s what the excitement is all about,” he said in an interview with ECR Today. Special Focus Session DBT is exciting because it’s the Sunday, March 10, 16:00–17:30, newest and most realistic competi- Room F2 tor to digital mammography that SF 15b: Digital breast has come up in years, according to tomosynthesis fellow speaker Dr. Sophia Zackris- son, an associate professor of diag- ▶▶ Chairman’s introduction In this screening case, an asyptomatic woman has a tumour that is not discernible on digital mammography (left), but appears as a clearly visible G. Gennaro; Padua/IT nostic radiology at Lund Univer- spiculated lesion on digital breast tomosynthesis (white arrow), which shows the slice where the lesion is in focus. The lesion is a 13 mm invasive sity, Skåne University Hospital in ductal carcinoma, grade 2. (Provided by Dr. Sophia Zackrisson) ▶▶Optimisation of image Malmö. acquisition and reconstruction “It is a similar technique to digital temporarily halt as each projection some cancers that have not been During his presentation, Yaffe will in DBT mammography, with images that are is acquired or may move continu- detected.” explain how tomosynthesis works, M.J. Yaffe; Toronto, ON/CA like digital mammography, so the ously during acquisition. Tomosynthesis’ most likely appli- point to preliminary results of the radiologists can easily adapt their A computer algorithm recon- cation is in breast cancer screening, T-MIST trial, show images, and ▶▶Current role of DBT in reading of this new technique,” she structs a 3D image. The images are but its precise role will only be deter- explain why tomosynthesis is bet- diagnostic imaging said. “It is also easily integrated in usually viewed as a ‘movie-loop’ mined after a study that is compar- ter than conventional projection. In S. Zackrisson; Malmö/SE the clinical setting. This is in contrast where adjacent x-y planes are dis- ing full-field digital mammography Zackrisson’s lecture, ECR delegates ▶▶Clinical aspects of computer to MRI, for instance, which is more played sequentially. Imagers are able with DBT, the T-MIST trial, a mul- will get a good overview of DBT aided detection and diagnosis expensive, time-consuming, and to see structures within the breast tivendor, multisite trial. The trial is and hear results from recent stud- in DBT more challenging in interpretation.” without overlap. The tumour is only for sites in North America, but ies with updates on the accuracy of H.-P. Chan; Ann Arbor, MI/US In tomosynthesis, the x-ray tube clearer, easier to see, and separate will have implications for countries the technique. moves over a range of angles about a from structures in the breast. on other continents as well. “Aspects of reading time and ▶▶Panel discussion: Digital pivot point located above the digital “Tomosynthesis from what we’ve “Personally, I do not think it image presentation will be dis- breast tomosynthesis: detector to obtain a series of low- seen is promising in the North (DBT) should be used in screening cussed, which is important since replacing or just supporting dose digital projection radiographs, American context, where a high before we have evidence from trials this is one of the major obstacles standard mammography? Yaffe explained. The detector may percentage of women get called showing that we gain in detection at least in screening,” she said. be stationary or also rotate about back,” he said. “We can reduce that and not lose too much on the false- “What views should be used? How #SF15b #ECR2013F2 the pivot point. The x-ray tube may rate by 30% or more as well as find positive side,” Zackrisson said. should the image stacks in digital

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myESR.org | #ECR2013 @myESR 14 ECR Today 2013 Clinical Corner Sunday 10 March 2013 Keep aware of looming difficulties in assessment of MR-compatible devices

By Edna Astbury-Ward basis for compatibility of a certain ology department immediately to will – for example, voluntary risk “Ignore social media at your implanted device in the patient, allow the MR personnel (or special- may include such things as ciga- peril! If you say that the internet Most radiologists have a basic and also take into account the con- ist staff) time to check for contrain- rette smoking or engaging in risky only has rubbish on it, then it is understanding of which implanted dition of the implanted device,” dications or compatibility issues of sexual behaviour – whereas forcing your job to direct patients to reli- devices are contraindicated for an Peeters commented. “If in any the device,” said Peeters. a person to do this against their able sites. You need to give people MRI scan, but due to the rapid doubt, radiologists should contact Responsibility can differ, depend- wishes may increase their percep- information on the channels that development in MR-compatible experts such as specialist radiolo- ing on what is filled in on the check- tion of the riskiness.” they want,” she noted. “I feel it’s devices, it is very difficult to stay gists or MR physicists to check for list and if the checklist is correctly Gamhewage advises that for some vital to incorporate risk commu- completely up-to-date with the wide compatibility.” completed and the presence of an patients, the emotional response to nications training into continuing array of new devices and implants. Many patients do not understand incompatible device has been stated, the risk is disproportionate to the medical education. We can’t be Help is now on hand at this the difference between CT, PET and but if the patient still enters the MRI actual risk involved, so interper- egotistic and say ‘well I told them’, morning’s risk assessment and risk MRI, and few patients understand system, the healthcare professional sonal skills and levels of sensitiv- because that’s not how the world communication refresher course, the risk associated with these pro- who carries out the procedure is ity and intelligence are important is any more.” at which ECR attendees will learn cedures and implantable devices, responsible. If the problematic when communicating actual and about the importance of being aware according to Peeters. Therefore, it is device was not mentioned on the perceived risk to patients. Staff may of the latest trends and develop- always very important that referring checklist, then the responsibil- need to engage on an emotional level ments in MR-compatible devices clinicians check for any possible ity may lie with the clinician who to gain the trust and co-operation of and where to go for the best advice implanted devices in their patients ordered the scan, or the patient the patient initially and then provide on this important topic. They will prior to MRI procedures. If radiolo- who may not have properly filled the facts – a process referred to as also learn about the best ways to gists require further compatibility in the questionnaire, he explained. Dr. Ronald Peeters discusses a complex case with his colleague. explain about risk to patients. details, most of the latest informa- On the other hand, if the manufac- “In the near future it will be tion is available on the internet and turer states wrongly that the device more and more difficult to assess in online product manuals, he noted. is compatible and an adverse inci- precautionary advocacy. Outrage Refresher Course: the safety of different patients enter- Manufacturers also provide an ID/ dent occurs and the manufactur- management, on the other hand, is Physics in Radiology ing the MR suite because there is a product card that patients carries er’s conditions for scanning have about getting people to calm down Sunday, March 10, 08:30–10:00, trend towards the use of more pow- with them, stating the devices type/ been followed, the manufacturer is so they will listen. erful MRI machines, higher main number and possible compatibility responsible. “It’s no good just telling people to Room L/M field strength, stronger gradients, issues and conditions of use. The task of communicating risk calm down, when clearly they are RC 1213: Risk assessment and and more and more ‘MR compat- Many compatible devices are varies from case to case, as individu- angry about something. It’s about risk communication ible’ devices are coming to market, actually conditionally compatible, als’ levels of knowledge and exper- explanation and being on their side; ▶▶Chairmen’s introduction which makes it particularly difficult like maximum main field strength tise about specific subjects vary, said for example, ‘I can see you are angry M.M. Rehani; Vienna/AT to assess compatibility,” said Dr. allowed, maximum gradient Dr. Gaya Gamhewage, from the about that, let me explain why we P. Vock; Berne/CH Ronald Peeters, from the Medical strength allowed, maximum spe- department of communications in are doing this’. You need to validate A. Radiation risks for patients Imaging Research Center, Leuven cific absorption rate allowed, which the Office of the Director-General what they feel. Unless you under- and staff Catholic University, Belgium. scanning protocols are allowed, etc., at the World Health Organization, stand on an emotional level about Although the advent of MR-com- and therefore the correct literature Geneva, Switzerland. their anxieties, people will let you E. Vaño; Madrid/ES patible devices such as pacemakers, and correct type of device must be “As experts, our perception of speak but they won’t heed your B. Risk in MRI defibrillators and neurostimulators, known before proceeding to MR risk from a radiological proce- advice,” she said. R. Peeters; Leuven/BE should increase the possibility of scan. dure is vastly different to patients’ Looking to the future of risk man- C. Communication of risk to patients undergoing MRI, it is not “Before a patient enters the radi- understanding of the concept of agement, Gamhewage commented patients and public a green light to scan all patients ology department, the importance risk from undertaking such a pro- that the area of risk management G. Gamhewage; Geneva/CH without checking, he added. of procedural adherence cannot be cedure. Communicating risk to is competing with the internet, “Previously it was quite straight- underestimated, and when a clini- patients is complex and requires which is a source of both reliable ▶▶Panel discussion: forward: patients with pacemak- cian requests an MR examination, time,” she said. “Voluntary risk- and unreliable information. Doctors How to communicate risk to ers or neurostimulators were not a checklist must be completed. If taking amongst people is com- were once the only trusted source of patients and the public? allowed on the MR scanner. Now patients answer ‘yes’ to certain ques- pletely different from enforcing a health information for patients, but one has to check on an individual tions, they must contact the radi- person to take a risk against their that’s no longer the case. #RC1213 #ECR2013LM

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#ECR2013 @myESR | myESR.org Sunday 10 March 2013 Clinical Corner ECR Today 2013 15 Imaging proves value in impingement syndromes, but turf battles loom over musculoskeletal ultrasound

By Frances Rylands-Monk Ultrasound findings of subacromial impingement are clear, usually When it comes to cases of shoulder showing a thickened subacromial subacromial impingement, imaging bursa with fluid in it. Dynamic has a crucial role to play in diagnosis assessment with ultrasound and and decision-making. Ultrasound shoulder movement can allow radi- not only aids diagnosis but also helps ologists to see if the bursa is catching to broaden the treatment options. on the ligament or on the acromion, X-ray still forms the mainstay of requiring surgical treatment. impingement imaging in Europe As image quality increases in owing to speed and cost, delegates ultrasound and the modality will learn at this afternoon’s state of becomes more cost-effective, it will the art symposium, which will also gain further ground, according to cover the ankle and hip. Robinson, who thinks general MSK Shoulder impingement patients ultrasound may eventually become are a significant referral group in an extension of the clinical exami- daily clinical practice. Awareness of nation conducted by MSK doc- the usefulness of ultrasound contin- tors or shoulder surgeons, rather ues to increase, and many general than being separately referred to radiologists now attend dedicated radiology. courses, according to Dr. Philip “There will be increasing turf Robinson, musculoskeletal (MSK) battles as GPs and surgeons do consultant radiologist and clini- more ultrasound. In Germany, for cal director of radiology at Leeds instance, MSK ultrasound is nearly Teaching Hospitals, U.K. exclusively performed by non-radi- “Three to four patients can be ologists,” he said. examined by ultrasound for tears or While the imaging regime is rela- inflammation during the same time tively simple in shoulder impinge- it takes for one patient to be scanned ment, the causes of common Ultrasound image in a patient with subacromial impingement shows a normal humeral head (H) and rotator cuff (S). Arrowheads show a with MRI, with results explained to impingement syndrome are still thickened low signal bursa. (Provided by Dr. Philip Robinson) the patient at the time of examina- open to debate. Cases of postero- tion. If a tear is excluded but symp- superior impingement, on the other shoulder impingement imaging. In Dr. Klaus Wörtler, associate profes- there remain diverging opinions toms are severe, treatment such as hand, are rare and more clinically countries where there is a lower pro- sor of radiology at the department about the clinical relevance of sev- an ultrasound-guided injection of difficult to diagnose in patients portion of MRI systems and fewer of diagnostic and interventional eral imaging findings and also about corticosteroid and anaesthetic only who are often young and athletic. MRI-related training opportunities, radiology, Technische Universität treatment strategy for FAI patients, adds minutes to a normal examina- Its causes and treatment tend to be ultrasound is more commonly used München, Munich. explained Wörtler. Nevertheless, tion,” he said. hotly disputed, and even MSK radi- among shoulder specialists, includ- The primary role of imaging is to patients with FAI should be treated Patients with tears should usually ologists may be less familiar with it, ing surgeons and soft-tissue doctors. reveal abnormalities that develop as early as possible in order to pre- be referred for surgical opinion on he noted. At today’s symposium, the advan- from the process. Imaging findings vent premature osteoarthritis, in possible repair, and the success of a This more complex syndrome tages and limitations of each imag- can support the diagnosis of FAI light of a recent study showing that repair is likely to depend on several involves rotator cuff tears with shoul- ing modality for diagnosis and pre- through their capacity to depict advanced degenerative changes can imaging factors, including how large der microinstability, and therefore treatment assessment will also be predisposing osseous deformities, already be seen in two thirds of the tear is and the presence of joint needs MRI assessment, usually via covered by Prof. Mario Maas, pro- assess the presence and extent of patients who undergo arthroscopy degeneration or muscle atrophy. In an MR arthrogram to increase the fessor of radiology with a special joint damage, and rule out other with the clinical diagnosis of FAI. some centres, pre-treatment assess- contrast between tissues to define focus on MSK imaging based at the causes of hip pain. “If the spatial and contrast reso- ment of impingement might involve joint margins, ligaments and carti- Academic Medical Center, Univer- The basic imaging technique is lution limitations in assessment of the use of MRI, which can assess lage. Because contrast enters areas sity of Amsterdam. In particular, plain x-ray of the pelvis, but MRI articular cartilage of the hip can be muscle atrophy and provide a more of defect, MR arthrograms can assess he plans to highlight the additional is the next step if advanced degen- overcome, MR imaging will be the global assessment of the shoulder cartilage or ligament injury, as well as value of multidetector CT in pos- erative changes can be excluded. most important imaging modality joint. In other centres, ultrasound more subtle partial tears in the rota- terior and anterior ankle imaging. To increase the sensitivity of this in the future. Such improvement and x-ray alone or combined can tor cuff that can’t be picked up easily In the hip, meanwhile, diagnosis method for the detection of labral may allow for better visualisation point to joint degeneration, muscle by ultrasound or standard MRI. of femoro-acetabular impingement and cartilaginous pathology, MR of cartilage delamination, which atrophy or bony abnormalities on Differences in MRI accessibility (FAI), a pain syndrome caused by arthrography is recommended for represents a typical finding in FAI,” the acromion ahead of surgery. across Europe pose a challenge to impingement of the soft tissue struc- suspected cases of FAI, but the he continued. tures between the acetabulum and depiction or exclusion of articular For now, radiologists should the proximal femur, cannot be estab- cartilage lesions of the hip is still a become familiar with the imaging lished solely on the basis of imag- significant limitation, even in MR findings of FAI, and the specific ing findings. In such cases, a clinical arthrography, according to Wörtler. weaknesses of different imaging diagnosis is essential, according to In a patient with cam-type FAI, a techniques. In addition, confirma- typical pattern of findings would be tion of FAI or any other hip, shoul- an anterosuperior labral tear with an der or ankle impingement can only adjacent articular cartilage lesion be established in conjunction with a in combination with deformity of thorough clinical examination. the femoral head-neck junction. In a patient with pincer-type FAI, the combination of an anterosuperior labral tear, posteroinferior labral damage, and acetabular over- State of the Art Symposium coverage or retroversion would be Sunday, March 10, 16:00–17:30, typical. However, many orthopaedic Room E2 surgeons believe that FAI can only SA 15: Imaging impingement be evaluated intraoperatively. For syndromes clinical practice this means, that ▶▶Chairman’s introduction many patients will undergo surgery C.W.A. Pfirrmann; Zurich/CH regardless of the imaging findings, ▶▶Shoulder believes Wörtler. P. Robinson; Leeds/UK “These imaging patterns are not necessarily seen in every patient ▶▶Ankle with FAI. The joint lesions only M. Maas; Amsterdam/NL represent the chronic sequels of ▶▶Hip In this case of posterosuperior impingement, the dynamic process of impinge- K. Wörtler; Munich/DE ment, but the process itself cannot MR arthrography shows the area of ▶▶ impingement between the humerus (H), be visualised on imaging,” he said. Panel discussion: Form or glenoid labrum (arrow), and rotator cuff (*). High-resolution MR systems function: is impingement a Coronal T1-weighted MR arthrogram with fat suppression shows typical combination of labral The arrowhead shows a thickened irregular have to a certain degree improved clinical or imaging diagnosis? tear and adjacent delamination of articular cartilage (arrow) in a patient with cam-type femoro- partial tear of the articular rotator cuff. radiologists’ ability to evaluate the acetabular impingement. (Provided by Prof. Klaus Wörtler) (Provided by Dr. Philip Robinson) labrum and articular cartilage, but #SA15 #ECR2013E2

myESR.org | #ECR2013 @myESR 16 ECR Today 2013 Clinical Corner Sunday 10 March 2013 Overuse injuries in gymnasts and professional golfers

By David Zizka found a prevalence of 39 percent When asked why congress for spinal pathology; the numbers attendees should choose to attend Overuse injuries due to excessive therefore vary within the literature. his talk, Dr. De Jonge gave a clear exercise are normally seen in pro- There is also a great deal of varia- answer: “There are lots of things that fessional athletes, but they are also tion in the prevalence of lower back radiologists have to be aware of if becoming more frequent in ama- pain, just from patient history not they deal with athletes in general teur athletes. The Refresher Course objective imaging numbers, from and gymnasts in particular. They on overuse injuries in sports will 25 to 85 percent. The most common need knowledge of the sport-spe- present three examples of how these injuries to the spine are stress reac- cific injuries; so awareness is very injuries, caused by different sports, tions, stress fractures, degenerative important and they must have good can be diagnosed and treated. disk disease and Scheuerman’s dis- contact with sports physicians and Gymnastic exercises, for example, ease,” said Dr. Milko De Jonge from other professionals who are deal- are very demanding, not only on the the department of radiology at the ing with the athlete to obtain the axial but also the peripheral skel- Zuwe Hofpoort Hospital in Woer- best possible information about the eton, and they involve strong forces den and the department of plastic, patient. The sensitivity and specifi- due to hyperextensive and hyper- reconstructive and hand surgery city of the different imaging modali- flexion exercises. A certain degree at the Academic Medical Center ties used is important. For instance of hypermobility and increased of the University of Amsterdam in the diagnosis of a stress injury of the flexibility is necessary to perform the Netherlands, when asked about lumbar spine can be missed if no some gymnastic exercises, and so the risk of injury to the axial spine fat-saturated images are used in the training is required to improve this from sports overuse. MRI exam. I am going to address all flexibility. Unnatural movements The imaging modalities most these issues during my talk.” are sometimes necessary in order commonly used are radiography, The Refresher Course will also fea- to increase this hypermobility and computer tomography and mag- ture a talk by Dr. Philip O’Connor, flexibility. netic resonance imaging. Less consultant musculoskeletal radiol- Although the human spine can common is the use of scintigraphy, ogist at Leeds Teaching Hospitals endure these movements, it is although SPECT can be helpful. NHS Trust, who led the imaging mainly suited to withstanding axial Radiography should always be the team at the 2012 Olympic Games loads. Prolonged exposure to hyper- method of first choice as it comes in London. His talk at ECR 2013 flexion and hyperextension forces with some undeniable advantages will focus on more conventional will ultimately lead to injuries, as such as availability, usability and injuries, like upper limb overuse the level of force exceeds the regen- cost efficiency. injuries in golfers. erative capacity of the bones and In terms of sensitivity, radiogra- The most common injuries we see ligaments. phy comes with some drawbacks, in professional golfers are overuse Children are able to perform especially with regard to stress injuries to the tendons and bones. these exercises more easily than lesions, prior to the development These are a result of a higher fre- adults due to the relative laxity of of spondylolisthesis; and radia- quency of play and practice, together their ligaments, which allows them tion dose, in comparison to other with the fact that they have more to move beyond the normal range methods (except CT) although it repetitive swing motions, channel- of motion. However, this also puts is relatively low. According to Dr. ling the forces repeatedly through the spinal column at increased risk. De Jonge, MRI is basically the gold the same areas of the kinetic chain The increased peak axial load for standard and is ideal for detect- and skeleton. The lead wrist, spine, Sagittal short tau inversion recovery (STIR) image of a 16-year-old female gymnast. Oedema gymnasts is also much higher than ing bone-marrow oedema, one of lead hip and lead shoulder are the can be seen in the posterior element / pedicle of the fourth lumbar vertebra (white arrow) for non-gymnasts due to repeated the hallmarks of bone disease (i.e. most common areas of injury in indicating a stress injury. jumps and landings. active disease). The same applies professionals. Amateurs on the A comparison between the inju- to the diagnosis of soft tissues and other hand, tend to have less repeti- specific injuries. The first step is 2013. “The development of a struc- ries seen in children and adults is intervertebral disc pathology. tive swings and are more prone to to modify equipment and training tured medical service including hard to draw as there are hardly any But the results of MRI examina- acute traumatic injury. They are also regimens in terms of the type of musculoskeletal imaging has been adult gymnasts; so it’s difficult to tions always depend strongly on the generally older so are prone to exac- play and frequency of play. Golfers the most important recent devel- determine what long-term overuse chosen sequences; otherwise subtle erbations of pre-existing conditions. should hit off dry soft grass rather opment in golf imaging for me. A injuries adults will develop. Overall, abnormalities can easily be missed. “Magnetic resonance imaging is than mats, hard ground or heavy wet multidisciplinary approach with a it can be said that stress and apophy- Stress reactions, for example, can the modality of choice for imag- grass, as this can take some pressure structured research programme has seal injuries are the most common sometimes be difficult to see. ing golfers, though ultrasound can off the wrist. helped us learn a great deal about all findings in children and adolescents, CT is basically the best imaging be of great value in terms of the General conditioning is also aspects of golf injury. To date our whilst degeneration, predominantly method for evaluating cortical bone dynamic assessment of structures important, as in any sport golfers focus has been on the wrist and of joints, is frequently seen in adults. and picking up subtle cortical frac- and in guiding injection therapies”, tend to be more prone to injury shoulder. In 2013, we are going “It is difficult to establish an esti- tures. It is easier to detect spondy- explained Dr. O’Connor. when fatigued or recovering from to launch a grant-funded three- mate of how big the risk of back lolysis with CT than with MRI, The wrist is the most common injury. year study assessing hip disease in injury is in gymnasts. Soler and but the examination unfortunately area of overuse injury in the upper When asked about any recent or golfers.” Calderon, in 2000, gave a prevalence comes with relatively high levels of limb, accounting for 50 percent of future developments in upper limb The session will begin with a talk of 17 percent for stress injury of the radiation, which excludes it from golf injuries, but there are some sim- imaging, Dr. O’Connor said that from Professor Stephen Eustace, spine, while in 1991 Goldstein et al being the main method. ple methods for preventing these there is a large study coming up in radiologist from the Mater Mis- ericordiae Hospital in Dublin, on overuse injuries in the footballer’s ankle.

Refresher Course: Musculoskeletal Sunday, March 10, 08:30–10:00, Room E1 RC 1210: Overuse injuries in sport: a multimodality approach Moderator: E. Llopis; Valencia/ES A. Overuse injuries in the footballer’s ankle S.J. Eustace; Dublin/IE B. Overuse injuries in the gymnast’s spine M.C. De Jonge; Amsterdam/NL C. Upper limb overuse injuries in golfers P.J. O’Connor; Leeds/UK #RC1210 #ECR2013E1 AP and Lateral views of the lumbar spine of a 14-year-old male gymnast. The spine shows left Axial CT image of a lumbar vertebra of an 18-year-old elite gymnast. bilateral stress or convex scoliosis. The normal lordosis is effaced. There are multiple abnormalities seen at the spondylolysis (black arrows) is visible, with increased sclerosis indicating the chronic nature of level of the endplates of several vertebrae most likely disturbances in the development of the the condition. apophyseal ring. (All images provided by Dr. Milko De Jonge)

#ECR2013 @myESR | myESR.org Sunday 10 March 2013 Technology Focus ECR Today 2013 17

Dedicated work- Towards instant CT colonography: stations crucial for computational Accurate registration INSIDE success of low- support for inter- of prone and supine dose CT lung cancer active diagnosis endoluminal surfaces screening of colon TODAY See page 19 See page 20 See page 21 PACS developers put renewed emphasis on patient empowerment and safety

By John Bonner company. For older technology, it may also be possible to acquire the PACS is now a mature technology in information manually. DoseTrack Europe, but who has benefitted from can manage information from CT, its introduction? Certainly, radiolo- fluoro/angio, conventional x-ray gists and radiographers have gained and mammography. because they now have a reliable tool “Patient safety is obviously the for storing and accessing vital diag- main driver for this technology, but nostic data. Also, hospital admin- there are other reasons. It is helpful istrators tend to feel reassured that for different clinics to determine the medical staff in all departments can doses given to patients in the vari- work more efficiently and provide a ous modalities and it will also alert higher quality of service. the technicians if there is something Yet what about the patients them- wrong with the equipment used,” selves? In truth, it is unlikely that explained Marie Ekström, vice- many of them will have even heard president of Sectra’s radiology IT about the huge changes in working business. “Clearly, different modali- The Vue Cloud service from Carestream offers the flexibility of a monthly fee and can practices that have occurred over ties will create different exposure accommodate growth without the need for hospitals to fund and manage network expansions. the past two decades as a result of to radiation, so this helps staff to the digital revolution, but that situ- steer their investigations towards ation is changing rapidly, as visitors the modality which will provide the to the commercial exhibition at ECR optimal results in terms of radiation 2013 can see. exposure and the clinical informa- Companies in the healthcare IT tion obtainable.” sector are developing PACS applica- She noted that the system can also tions that don’t just passively support be used to set thresholds for dose the diagnostic process by provid- alerts, and it creates a way of inte- ing key information. Instead, there grating reports with national reg- is increasing evidence that these istries. But at the local level, it will technologies can actively direct the also put the radiology department decisions made by medical staff and back where it belongs at the centre also help patients to have a say in of all activity within the hospital treatments they are given. and empower individual patients, Sectra, for instance, has devel- she claims. oped its DoseTrack software to “It is important in cases such as automatically monitor the radia- those individuals who may have tion dose received by patients in to be given chest examinations as the course of their treatment and neonates. Later in life, they will to help physicians to keep the dose know to avoid unnecessary exami- as low as possible. The product has nations. So this helps the patient to been in use since 2008 in a network take control over their own health- of 10 hospitals in the Skåne region care, which is something that is hap- of southern Sweden, where it has pening all over the world,” Ekström analysed data from more than 2 said. million examinations in a range of Carestream Healthcare is aware different radiology modalities. The of this trend, and is making its original project was set up by Mats contribution through the MyVue Nilsson, a professor in the depart- patient portal that it is showing ment of medical radiation physics at for the first time at ECR 2013. Skåne University Hospital, Malmö, This application allows patients to Part of the screen image for Sectra’s Dose and developed as a collaborative securely access, manage and share Track comparing radiation levels in different project between the academic and their medical images and radiology hospitals and modalities. industry partners. reports with their own physician Siemens’ syngo.Breast Care Reading is the client-server application for state-of-the-art DoseTrack can access and store and other healthcare providers. The mammography and unique tomosynthesis reading. information from any imaging hospital creates a unique and secure modality that can transfer dose log-in that is emailed to the patient information using a DICOM after an examination. Through this, radiation dose structured report the patient can download informa- or DICOM modality performed procedure step, according to the continued on page 18

The syngo.via WebViewer from Siemens enables fast reading and viewing of images within the Fuji’s Synapse Enterprise suite of products aims to provide improved image visualisation, hospital. Connection is possible from anywhere within reach of the hospital network through a enhanced ease-of-use and increased efficiency. secure VPN connection.

myESR.org | #ECR2013 @myESR 18 ECR Today 2013 Technology Focus Sunday 10 March 2013

continued from page 17 Meanwhile, Siemens Healthcare material from CT, MRI, nuclear medi- available today on the dedicated MR interface with a look and feel that is is striving to improve diagnostic cine and angiography, and the new workstation in Philips’ portfolio. easy to learn and able to adapt to tion to a PC, laptop, or tablet. It is decision-making and speed work- version launched at ECR 2013 also However, optimised workflow and radiologists’ preferences, automat- easier to use and more convenient flow throughout the hospital and includes a mammography function. task guidance have been introduced ing examination setup. Referring than managing DVDs, CDs or other beyond with new applications for For users of mobile devices, Sie- to create an easy to use and more physicians can access the viewer physical storage formats for medical its 3D routine and advanced read- mens will also show how products effective system, according to the from anywhere, and patients can records. ing softwaresyngo .via, as well as an like the iPad can be used for diag- vendor. It will enhance the ability get from the examination to their “The healthcare industry is mov- update for its syngo.plaza system. nostic reading when the physician is of customers to perform their work results in less time, GE explained. ing to embrace new technolo- “The latest version of syngo.via on the move. The latest version of the without the need to move between Fujifilm is promoting ‘clini- gies that allow patients to play a doesn’t just give our customers the syngo Web Viewer provides access to locations or systems. Furthermore, cal value’ products at ECR 2013. greater role in their medical care,” opportunity to view images, it gives images from CT, MRI, computed and by allowing physicians to review Synapse 3D aids clinical decision said Saskia Groeneveld, European them the full picture, allowing them digital radiography, PET and PET- data without the need to install ded- support by providing a comprehen- regional marketing manager for the to dig deeper into that image and CT devices. It features new layouts icated workstations, it will enhance sive suite of advanced visualisation company’s healthcare information extract more clinical information,” that allow the display of multiplanar the ability of different hospitals to applications aimed at improving solutions business. “With MyVue, said Dr. Marc Lauterbach, director reconstructions on one screen. collaborate more easily in making diagnosis and surgical outcomes, healthcare providers can also ben- of global marketing with Siemens’ At the Philips booth, the com- the final diagnosis, the company the company states. SYNAPSE ERm efit because they can use the patient syngo business unit. “A good exam- pany is demonstrating the fruits explained. is a specialist mobile application for portal to boost referral volumes ple of this is our new bone applica- of its efforts to extend the ability GE Healthcare is heading in a acute stroke and emergency treat- while simultaneously reducing the tion for CT images. When looking of teleradiology users to influence similar direction with the launch ment. It supports fast and easy com- time and cost of outputting medical for fractures or metastases in a rib, clinical decisions by including new of its Universal Viewer, which brings munications while also providing exams on to DVD/CDs or radio- radiologists would normally have to modalities. It has broadened the vis- together advanced visualisation, images and related clinical data on graphic film.” scroll through the image and exam- ualisation capabilities available on intelligent productivity tools, and mobile devices, enabling special- MyVue is currently available as ine multiple planes. This application its web portal, IntelliSpace, with the multimodality workflow for oncol- ists outside of a hospital to support an option for the Vue PACS and automatically ‘unfolds the ribs’ and introduction of advanced MR car- ogy and breast imaging, all within emergency diagnosis and treatment. Vue Archive (which uses third-party presents the different bones in an diac and neuro processing features. one intuitive workspace that can be Finally, Agfa HealthCare is dem- PACS) users and is now available unobstructed view. It also labels each First launched in 2010, IntelliSpace accessed anywhere, anytime. The onstrating its IMPAX Radiation as part of the Vue Cloud Service. bone so that the site of the lesion can is a thin-client applications server system is compatible with Centric- Exposure Monitoring (REM) solu- Launched in February 2013, the be rapidly identified in the report.” and ‘virtually access-anywhere ity PACS, Centricity PACS-IW, and tion, which provides an automated service reportedly offers the flex- Syngo.via is still a relatively new solution’ for multimodality clini- the Centricity Clinical Archive. way to collect, organise and ana- ibility of a monthly fee and can product, and researchers from Sie- cal review, analysis and diagnosis, Based on independent research, lyse a patient’s radiation exposure accommodate growth without the mens are busy developing software with key applications for CT, nuclear GE said Universal Viewer has the data. It tracks radiation exposure need for healthcare facilities to fund to incorporate new imaging modali- medicine, and MRI. potential to provide a 5% produc- information across multiple modali- and manage network expansion in ties. The current version allows staff in The underlying technology is tivity improvement in departments ties, departments and institutions, terms of additional patient users. client hospitals to access and display similar to the advanced capabilities using the system. It has a unified user according to Agfa.

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

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

PACS in 2013: back to the future of radiology By Theo Ahadome better able to deliver on certain In the advanced diagnostics field, functions. Indeed, there is a strong technology barriers continue to be After focusing on enterprise IT case for PACS to withdraw all broken – techniques which were (vendor-neutral archiving, EMR- proprietary enterprise access and previously considered advanced integration, cloud storage and analytics functions, allowing mid- visualisation (AV), including maxi- advanced analytics) over the last dleware specialities to tackle these mum intensity projection (MiP) and three years with limited success, while the PACS provides a stronger multiplanar reconstruction (MPR), there are renewed calls for PACS to front-end. In other words, there is are now increasingly being incor- return to a focus on radiology. In no need for any PACS to try to be porated into imaging systems as particular there is a need for PACS a VNA and advanced visualisation standard. This has proven valuable product development to be realigned tool, as well an enterprise analytics to both clinicians and radiologists with the current and future require- engine. Moreover, these are not the as a diagnostic aid, to improve con- ments of radiologists, including the major requirements of their core fidence and for pre-operative plan- need for improved productivity and users – radiologists. However, as ning. Where a third-party system enhanced diagnostic capabilities. IT purchasing power increasingly is available, and PACS in itself does Over the past three years, goes towards the enterprise, PACS not provide advanced visualisation PACS has provided, or at least has suppliers stand the risk of neglecting tools, then the key is integration – attempted to provide, enterprise their core users by trying to appease the ability to seamlessly access and Key strengths of different imaging informatics software. Overlap indicates required combination functionality including enterprise their new partners. apply AV from PACS as though they of products to achieve combined benefits. archiving, universal access and ana- Rather, there is a need for PACS to were one complete solution. How- lytics. However, the failings of PACS come back to radiology by reducing ever, third-party AV is not necessar- diagnostic analysis to third-party proven. That, however, distracts enterprise functions were exposed the time radiologists have to spend ily the answer, and as radiologists systems. from the core of the argument – for as workflow became more complex, analysing images, improving and increasingly use advanced visu- The combinations of PACS and PACS to refocus on what it is good requiring true application interoper- streamlining the user interface and alisation tools some AV functions third-party systems achieve radiol- at: helping radiologists perform ability. In addition, new data sharing enhancing diagnostics. Productivity will be delivered by PACS. The key ogy and enterprise benefits through their work better. protocols and economic pressures gains, for example, are achieved via is to define the threshold between a best-of-breed, application neutral could not cope with rising storage sophisticated hanging protocols that tools required routinely and those environment (Figure). Best-of- volumes and the subsequently large pre-determine optimal image pres- only needed for advanced analy- breed here refers to systems, not data handling costs. entation, and intelligent systems that sis in a smaller number of cases. vendors – there is a whole different Theo Ahadome is a senior market Today’s PACS challenge is to learn and help repeat a user’s preferred Increasingly, radiologists are per- debate as to whether any one ven- analyst at the healthcare IT research choose which enterprise and ana- workflow per study type. Research forming 3D cross-referencing and dor can provide more than one best- group at InMedica, a division of IHS lytics component, if any, can be and development efforts should focus post-processing for CT, PET-CT, of-breed system. It is this author’s (NYSE:IHS). InMedica is a provider reliably delivered by PACS, and on introducing such features that MPR and MiP. It is those tools that opinion that it can be achieved – so of market research and consultancy ensuring PACS works well with improve radiologist’s productivity PACS should increasingly incorpo- long as application independence in the medical electronics industry the third-party systems that are and make PACS easier to use. rate, while leaving more advanced and interoperability can be clearly (www.in-medica.com).

#ECR2013 @myESR | myESR.org Sunday 10 March 2013 Technology Focus ECR Today 2013 19

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

By Colin Jacobs, ing at high sensitivity, is supported. Eva M. van Rikxoort, In this reading mode, the user can Jan-Martin Kuhnigk, reject incorrect CAD marks, but Thorsten Twellmann, does not have to inspect the entire Pim A. de Jong, scan section by section. Ernst T. Scholten, Furthermore, a completely auto- Cornelia M.M. Schaefer-Prokop, matic elastic registration between the Mathias Prokop, current and prior scans is performed Bram van Ginneken to allow linked scrolling. Prior scans of the same patient are presented on a At present, lung cancer is the most second screen and the radiologist can common and most deadly cancer easily switch between various prior in men and women worldwide. scans to compare lesions over time. The five-year survival rate for all Importantly, the elastic registration stages combined is only 16 percent. is also used to add annotated lesions If the disease is still localised when from prior scans to the current scans, detected, the five-year survival rate which have to be accepted or rejected is substantially increased (52 per- by the radiologist. cent). Therefore, screening has been Advanced segmentation algo- proposed as a means to detect lung rithms have been included, which cancer at an early stage. The recent have been designed to handle com- positive results from the National plex vascular and pleural attach- Lung Screening Trial (NLST) in the ments, and subsolid nodules can United States have provided scientific be delineated automatically in 3D. evidence that screening with low- Volumetric segmentations of the dose chest CT reduces lung cancer same lesion in prior scans are dis- Computer-aided detection (CAD): marks for both solid and subsolid nodules are precomputed for each case to be accepted or rejected by the user mortality. The National Comprehen- played to allow the user to check (Case courtesy of the NELSON screening programme). sive Cancer Network has revised its for consistency of the segmenta- recommendations for screening and tions over time. Important charac- now strongly recommends the use of teristics of the lesion are calculated low-dose CT screening for individu- automatically, such as volume, mass, als at high risk of lung cancer. average density, equivalent diam- In its current form, however, the eter, volume doubling time (VDT), large scale introduction of CT lung and mass doubling time (MDT). screening would put an enormous Mass has been shown to be a more burden on radiologists. Therefore, it important predictor of growth for is crucial to develop dedicated chest subsolid nodules. Lesions with sus- reading workstations with a number picious values for VDT or MDT are of innovations that allow for an opti- automatically flagged. mised high throughput workflow Finally, findings have been sum- for reporting on low-dose chest CT marised in a structured report in scans. Building upon our clinical HTML and PDF format in a data- and technical experience in reading, base, and can be sent to physicians image analysis and data processing and PACS upon request. Follow- for large screening trials in Europe up recommendations according to (over 30,000 CT scans from 10,000 various screening algorithms and participants) and a careful review of guidelines from leading societies, the existing commercially available including the upcoming revised lung workstations, we have devel- Fleischner Society guidelines for the oped a prototype for a dedicated management of pulmonary nodules, chest reading workstation. can be included in the reports. An important component of the The application is currently avail- workstation is computer-aided able as a research prototype and Side-by-side comparison of segmentations of the same lesion, from current and prior scans, in three orthogonal directions is supported, allowing detection (CAD) of pulmonary is in use at five sites. The current segmentation consistency and lesion growth to be checked. Each column shows a time point. The rows show axial, sagittal and coronal views, nodules. We have developed two prototype will be presented at the respectively (Case courtesy of the NELSON screening programme). CAD systems for detecting solid IMAGINE Workshop presented by nodules and subsolid nodules, both the European Institute for Biomedi- Radboud University Nijmegen STAFF BOX of which have been extensively eval- cal Imaging Research (EIBIR). Medical Centre; J.-M. Kuhnigk uated using data from the Dutch- from Bremen/DE is associated clini- Editors Marketing & Advertisements Julia Patuzzi, Vienna/AT Konrad Friedrich Belgian lung cancer screening trial More information about the cian at the same institute; C.M.M. Philip Ward, Chester/UK E-mail: [email protected] (NELSON). Both CAD systems project can be found at Schaefer-Prokop from Amersfoort/ have been integrated in the work- www.diagnijmegen.nl, NL is chair at the same institute. Editorial Team Contact the Editorial Office Michael Crean, Vienna/AT ESR Office station and the user can adjust the www.mevis.fraunhofer.de T. Twellmann works at MeVis Medi- Simon Lee, Vienna/AT Neutorgasse 9 number of marks that are displayed cal Solutions AG in Bremen/DE; 1010 Vienna, Austria Contributing Writers Phone: (+43-1) 533 40 64-0 by the CAD systems. Presented C. Jacobs, E. M. van Rikxoort, P. A. de Jong works at the Univer- Edna Astbury-Ward, Chester/UK Fax: (+43-1) 533 40 64-441 marks can quickly be accepted or M. Prokop, and B. van Ginneken sity Medical Center Utrecht/NL; and John Bonner, London/UK E-mail: [email protected] rejected. High throughput reading belong to the Fraunhofer MEVIS, E. T. Scholten is from Haarlem- Michael Crean, Vienna/AT Javeni Hemetsberger, Vienna/AT ECR Today is published 6x during with CAD, as a first reader operat- Diagnostic Image Analysis Group, merliede/NL. Simon Lee, Vienna/AT ECR 2013. Becky McCall, London/UK Circulation: 22,000 Rebekah Moan, San Francisco, CA/US Printed by Holzhausen, Vienna 2013 Alena Morrison, Vienna/AT Mélisande Rouger, Vienna/AT myESR.org Frances Rylands-Monk, St. Meen Le Grand/ The Image Interpretation sessions, two traditional highlights France of every ECR, provide both education and entertainment. Two Philip Ward, Chester/UK panels of distinguished radiologists will share their knowledge David Zizka, Vienna/AT and diagnosis strategies with you. Panellists: G. Gherarducci; Pisa/IT Layout Philipp Stöhr, Vienna/AT Sunday, March 10, 13:00–14:00, Room A C. Sayer; Brighton/UK Junior Image Interpretation Quiz: Golden Eye C.M. Sommer; Heidelberg/DE Moderator: A. Alguersuari; Sabadell/ES L. Tzarouchi; Ioannina/GR Co-Moderator: E. Belmonte; Barcelona/ES A. Vanrossomme; Brussels/BE

myESR.org | #ECR2013 @myESR 20 ECR Today 2013 Technology Focus Sunday 10 March 2013 Towards instant computational support for interactive diagnosis

By Katja Bühler, David Major, the selection and connection of Jiří Hladůvka and Rainer Wegenkittl relevant vessels, can be performed semi-automatically on the client Fully automated computer-aided within seconds. The integration of detection (CAD) systems are used, anatomical region dependent rules even today, in only a few special leads to a highly robust solution cases. Imaging methods and diag- delivering, in most cases, the whole nostic questions are constantly tree of relevant vessels with just one evolving and demand a paradigm click, even in the presence of vessel shift from previously envisioned gaps caused by small or medium static CAD systems towards more size stenosis or soft plaque. Our flexible interactive support systems method has been tuned and tested integrating, rather than replacing, A method that automatically labels the spine on CT scans, based on a combination of a machine learning-based classification approach and for CTA datasets of peripheral the diagnostic abilities of the radi- iterative matching of local models, captures the appearance and morphometry around two subsequent vertebrae, presented by researchers from vessels of the lower limbs. Future ologist. The majority of readings in the VRVis centre in Vienna. work includes the extension of the daily clinical routine are still done method to other vascular systems. in an interactive manner and often them to enhance the automatic part of the human body. Its usage manipulate the result delivered as We would like to invite you to with just basic computational sup- results through online interaction requires the semantic annotation an offline pre-processing step on share your opinion and ideas on port. Although sophisticated image within seconds, allowing them to of vertebrae and disks, which is, the server. For cases of complete our approaches and solutions in a analysis, quantification and annota- reach a final diagnostic decision. especially in 3D data sets, an incon- failure it is possible to initialise a personal discussion with us. Our tion methods have been proposed The goal of our research is to mini- venient task. We present a method new labelling sequence by placing software is on display at the VRVis by the research community, many mise the user interaction and time that automatically labels the spine a single label that delivers almost booth at IMAGINE. of them have not been integrated required for expensive server-side on CT scans based on a combina- instantaneous results. into common radiological work- image processing tasks by exploiting tion of a machine learning-based Computer-aided tracking of flows yet. Their hardware and time the time from scanner to worksta- classification approach and iterative blood vessels in CTA images is Katja Bühler, David Major and Jiří requirements are often incompatible tion. The major challenge we face in matching of local models, capturing the basis for many higher level Hladůvka work at VRVis Zentrum with real world settings in a clini- this context is splitting the process- the appearance and morphometry diagnostic tasks in the context of für Virtual Reality und Visualis- cal environment, where results have ing pipeline into parts, which can around two subsequent vertebrae. vascular diseases. The high mor- ierung Forschungs-GmbH in Vienna/ to be delivered within seconds on be robustly implemented in a fully The algorithm showed robust han- phological variability of vessel AT. Rainer Wegenkittl works at standard hardware. automated manner and react inter- dling of full and partial scans of the systems and high variations in AGFA Healthcare, Vienna/AT. Our research aims at bridging the actively and semi-automatically, spine. Our tests report high recall contrast agent saturation hamper VRVis is Austria’s leading centre for gap between academic research in almost in real time; even under real (95.5 percent) and precision (99 the development of completely applied research in the field of visual medical image analysis and real world conditions. percent) rates. Nevertheless, the automatic methods. We present computing and acts as a bridge between world applications. We investigate During the IMAGINE session we method might deliver shifted results, a hybrid solution that performs academia and industry. The presented methods amalgamating sophisti- will showcase two solutions follow- or even fail completely, in certain the time consuming model-based projects are results of a joint technology cated, fully automated server-side ing this paradigm: The spine pro- cases like the presence of extreme tracking of possible vessel seg- transfer project with AGFA Healthcare image processing with the cognitive vides an internal frame of reference pathologies. For these cases we have ments as a preprocessing step on and are supported by FFG as part of skills of the radiologist by enabling to describe positions in the superior included the ability to interactively the server. Vessel tree growing, i.e. the Austrian COMET initiative. .artundwork designbüro

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#ECR2013 @myESR | myESR.org Sunday 10 March 2013 Technology Focus ECR Today 2013 21 CT colonography: accurate registration of prone and supine endoluminal surfaces of colon

By Thomas Hampshire, Holger Roth, views. An additional pairwise cost Emma Helbren, Andrew Plumb, function compares the geometric Darren Boone, Greg Slabaugh, relationship between neighbouring Steve Halligan, David Hawkes pairs of haustral folds in the prone and supine CTC images. The prob- Colorectal cancer is a leading cause lem is modelled as a Markov ran- of cancer mortality with 1.23 mil- dom field and solved to estimate the lion individuals developing the dis- correct fold labelling. This process ease and 608,000 deaths annually. can establish an accurate corre- Population screening aims to pre- spondence between a set of posi- vent the development of advanced tions in the two views, even in cases cancers through early detection and where endoluminal collapses occur, removal of both localised cancers which is very common in clinical and premalignant adenomas, from practice. An accuracy of 96.1 per- Figure 1: External (left) and internal (right) surface models of the endoluminal colon surface. The haustral folds have been automatically which more than 80 percent of cent was achieved when comparing segmentated and are shown in red. cancers are thought to arise. Opti- the resulting fold matches against a cal colonoscopy is the current gold reference standard of 1,743 corre- standard method to inspect the sponding fold pairs over 17 valida- whole colon. However, colonoscopy tion datasets, five of which exhibited is time consuming and uncomfort- local colonic collapse. able for the patient, and is occasion- Most scenarios require obtaining a ally associated with serious compli- one-to-one surface correspondence cations such as colonic perforation. between acquisitions, for example Computed tomographic colonog- locating a possible polyp posi- raphy (CTC) is now widely con- tion in both the prone and supine sidered the preferred radiological views. Our surface-based registra- technique for detecting cancer and tion algorithm recognises that the polyps, and has comparable sensi- colon is topologically cylindrical tivity to optical colonoscopy while and reduces the complexity of the being more acceptable to patients registration by mapping each point and relatively safe. Patients undergo on the endoluminal surface onto a full bowel preparation to cleanse the cylindrical representation with the colon, which is then insufflated with use of a conformal mapping tech- gas immediately before helical CT nique. This allows the registration to imaging of the abdomen and pelvis account for the large 3D deforma- (gas insufflation maximises attenu- tions between the prone and supine ation contrast between the endo- views as a more simple 2D cylindri- luminal surface and intraluminal cal deformation (see Figure 3). The space). Graphics rendering software registration is then represented as is used to generate high resolution a transformation between the two ‘virtual colonoscopy’ images of the cylinders and includes non-linear three-dimensional colon surface, stretching along the cylinder, and simulating those obtained using local torsion and rotation. We use conventional colonoscopy. the set of haustral folds, for which CTC is performed routinely with we have found matching positions in the patient in both prone and supine both views, alongside a shape index Figure 2: An overview of the registration process. The prone (top) and supine (bottom) CTC surface meshes are converted to a cylindrical positions to redistribute gas and metric calculated at each point of representation before registration using a shape index metric (displayed with colour scheme) and the matching positions of residue within the colon. This helps the cylindrical image to create a detected HaUstral folDs. differentiate fixed colonic pathology non-rigid registration in the cylin- from mobile faecal residue because drical domain. This registration abnormalities whose position achieves correspondence between remains fixed in relation to the colon the two views over the entire colon luminal wall in both acquisitions are surface. Using the same set of 1,743 more likely to be true polyps. Using references standard points, a mean two data acquisitions also increases error of six millimetres was achieved the chance of discovering pathology over 17 CTC cases. occluded by retained fluid or hidden by luminal collapse. Matching cor- The authors are from University responding locations between prone College London, Centre for Medical and supine endoluminal colonic sur- Image Computing, London, UK. faces is therefore an essential aspect of interpretation by radiologists. For more detailed technical However, interpretation can be dif- information see: ficult and time-consuming due to the Hampshire, T, Roth, H., & Boone, considerable colonic deformations D. (2012). ‘Prone to Supine CT Figure 3: CT colonography images with the patient in the prone (left) and supine (right) positions. Note the polyp indicated by the arrow. that often occur during reposition- Colonography Registration Using a ing of the patient. These deforma- Landmark and Intensity Composite tions can induce diagnostic error and Method’. Abdominal Imaging. Com- increase interpretation time. Hence, putational and Clinical Applications. a method for automatic registration Lecture Notes in Computer Science., of prone and supine datasets has the 7601, 1–9. potential to improve efficiency and Hampshire, T., Roth, H., Hu, diagnostic accuracy. M., Boone, D., Slabaugh, G., Pun- We propose a novel method for wani, S., Halligan, S., et al. (2011). automatically establishing cor- ‘Automatic prone to supine haustral Insights into Imaging Education and strategies in European radiology respondence between the two fold matching in CT colonography acquisitions. The problem is first using a Markov random field model’. simplified by detecting and match- Medical image computing and coming corresponding haustral folds, puter-assisted intervention : MIC- The clearest insights… for all to see! which are elongated, ridgelike CAI ... International Conference endoluminal structures that can be on Medical Image Computing and identified by extracting curvature Computer-Assisted Intervention, Open Access – Indexed in PubMed/PubMedCentral measurements from a triangular 14(Pt 1), 508–15. Radiological education without restrictions mesh representation of the colonic Roth, H. R., McClelland, J. R., lumen (see Figure 2). Image patches Boone, D. J., Modat, M., Cardoso, are generated at the fold positions M. J., Hampshire, T. E., Hu, M., www.i3-journal.org using depth map renderings of the et al. (2011). ‘Registration of the Full articles at www.i3-journal.org/articles endoluminal surface and used to endoluminal surfaces of the colon support virtual camera optimisa- derived from prone and supine tion, providing cost value for the CT colonography’. Medical physics, matching of folds between the two 38(6), 3077–89.

myESR.org | #ECR2013 @myESR 22 ECR Today 2013 Technology Focus Sunday 10 March 2013 Present and future trends in imaging informatics

By Osman Ratib sary to become an IT expert, but to These topics should provide ECR • An international high-level have an idea of current concepts and participants with a wide scope of expert panel on ‘image compres- With the evolution towards fully IT tools that could help radiologists education exhibits and up-to-date sion’ initiated by the ESR digital imaging departments, imag- improve their daily work. information on: • New developments in image man- ing informatics have become an To help the radiology community • The principles of DICOM, which agement and image processing integral part of our daily practice keep up with some of the recent has become the standard in med- There will also be a chance to and have fundamentally changed developments and technical evolu- ical imaging, and IHE, which is meet experts in this area. Inter- the daily workflow of many radi- tions, the ESR’s eHealth and Infor- an initiative to enhance interested visitors are welcome to share ologists. The rapid evolution of matics Subcommittee has prepared operability of modalities and their experience and expertise information technology (IT) and some informative posters on differ- information with the eHealth and Informatics the wide accessibility of modern ent relevant topics in information • The development of the report- Subcommittee. communication tools have driven technology: ing workflow, which has changed the industry to adopt many con- • Introduction and overview on completely over the past decade, sumer-market solutions into their DICOM and IHE now including 3D imaging, CAD products. From the adoption of • Workstation development and and new concepts in reporting Visit the eHealth and Informatics portable tablets to the seamless multimodality viewing • Technical developments to Information Booth in Foyer A on storage of data in the ‘cloud’, inno- • Structured reporting enhance the documentation and the 2nd Level. vations in technology have brought • Image access on tablets and port- tracking of radiation exposure; Professor Osman Ratib us many convenient solutions for able devices new recommendations on the use from Geneva, Switzerland. wider access to information, adding • Image compression of image compression or image Professor Osman Ratib from flexibility and mobility for a more • Radiation exposure monitoring sharing with portable media (e.g. Geneva, Switzerland, is Chairman efficient workflow. • eLearning: overview of ESR CD, DVD, USB Memory) of the ESR eHealth and Informatics Acquiring knowledge in this field activities • How to use digital infrastructure Subcommittee. can help radiologists better under- • Integrating teaching files into to improve activities in research stand recent developments in infor- PACS using IHE/TCE and education mation technology, and keep up • eHealth: developments and ini- • The development of eHealth and with the latest trends. It is not neces- tiatives in Europe the influence of radiology

#ECR2013 @myESR | myESR.org Sunday 10 March 2013 Technology Focus ECR Today 2013 23 Cardiac radiology society has another successful year

By Valentin Sinitsyn meeting took place in the splen- part of the ESR-endorsed Euro- did city of Barcelona. This vibrant pean Board of Cardiac Radiology Cardiac radiology represents one of multicultural city is a very popular (EBCR) Diploma. During the last the most dynamic fields in modern location for all kinds of medical con- congress, top European and inter- radiology. This is evident from the gresses and conferences, making it an national experts delivered state-of- constant growth of cardiac radiol- ideal location for the ESCR Annual the-art lectures and presentations ogy papers submitted to the ECR Meeting. This meeting was a repeat on major fields of cardiac radiol- – up to 21 percent in 2013. of the success seen at the ESCR 2011 ogy. The meeting’s educational The Annual Scientific Meeting Congress in Amsterdam. The meet- programme gave all the informa- of the European Society of Cardiac ing in Barcelona attracted 466 par- tion necessary to pass the cardiac Radiology is the most remarkable ticipants from 44 countries. The top imaging examination and get the and visible of its activities. Every five countries, by number of partici- Diploma in Cardiac Radiology. ESCR annual meeting is a per- pants, were Spain, the Netherlands, There were also live teaching case fect combination of tradition and Germany, Russia and Italy. Congress presentations during ESCR 2012. innovation. president, Dr. Teresa de Caralt con- An Electronic poster (EPOS) area The ESCR Annual Scientific Meet- tributed immensely to the success of with free internet access provided ing 2012 continued the society’s the meeting. an excellent opportunity to become focus on the most important scien- The meeting in Barcelona had acquainted with electronic posters tific and practical issues in cardiac many memorable events. One of from current and previous meet- radiology. In 2012, the ESCR annual them was the opening ceremony: ings. The Asian Society of Cardiac the famous Spanish-American car- Radiology (ASCI) held a scientific diologist Professor Josep Brugada session during the Barcelona meet- (everybody knows about the genetic ing, presenting lectures from our cardiac disease called Brugada syn- friends and colleagues in Asia. Professor Josep Brugada delivered a brilliant lecture at the drome) delivered a brilliant lecture, Long-standing industry partners ESCR 2012 Opening Ceremony in Barcelona. ‘New concepts in cardiac imaging of the ESCR (Bayer HealthCare applications for arrhythmias evalua- Medical Care, Bracco, Circle Car- (YAPP), helping them attend annual The president of this congress will tion’, which was complemented by a diovascular Imaging, Covidien, GE meetings and present their papers be Professor Michael Rees, who is presentation from ESCR vice-presi- Healthcare, RAPID Biomedical, and posters. In 2014, the ESCR is past-president of the ESCR. dent, Professor Matthias Gutberlet. Siemens, TeraRecon, Toshiba and going to expand this project, offer- We are going to offer you an inter- In Barcelona, the Society pre- Wisepress) offered participants the ing more grants and holding special esting programme and some sur- sented and launched its long- opportunity to visit their booths at sessions for medical students. Eight prises and look forward to seeing awaited pan-European project, the exhibition area, and they had young radiologists, with the eight you in London. the ‘MR/CT Registry’ (www.mrct- interesting and well-attended com- best posters, received ESCR Magna registry.org). We invite you to join; pany symposia, which highlighted Cum Laude, Cum Laude and Certifi- More information about the ESCR details can be found on the website. the latest in imaging equipment and cate of Merit diplomas. can be found at www.escr.org Another major event at every contrast media. In 2013, the ESCR Annual Scien- ESCR annual congress, since 2009, The ESCR continued supporting tific Meeting will be held at BMA Professor Valentin Sinitsyn from Professor Valentin Sinitsyn has been the Cardiac Imaging Exam- young radiologists through its Young House, London/UK; headquarters Moscow, Russia, is President of the from Moscow, Russia. ination, which is now an essential Abstract Presenter Programme of the British Medical Association. ESCR. Croatian Society of Radiology brings balance to research and education

By Damir Miletić with the risk of handing over tra- proliferation of cardiac catheterisa- hospitals has to be matched with involved not only in patient diag- ditional radiological disciplines to tion labs in many Croatian hospitals an increase in equipment and staff. nosis but also in multidisciplinary The Croatian Society of Radiology other clinical specialties, and the have probably contributed to this Teleradiology is a recent challenge teams responsible for follow-up and has approximately 400 radiologists general radiology approach, which situation. We have tried to stimulate for our radiological community. We treatment of patients. Due to the and residents among its members. recognises the exponential growth interest in interventional radiology believe that it could strongly influ- abundance of imaging modalities There is a very long tradition of of radiological knowledge and the through enhanced activity by the ence the radiologist’s motivation available to referring clinicians, radiology practice in our country. necessity for the radiologist to section for interventional radiol- and yield substantial benefits for radiologists actually have to per- Our society was founded in 1928 understand not only imaging, but ogy, with a focus on education and our patients. This process has begun form diagnostic imaging proce- as the Roentgenology Society, also clinical data and basic medi- training. with clinical radiology in Croatian dures for a referred patient, while and after several changes in name cal disciplines. As a relatively small Professional relations and under- hospitals, aiming to incorporate all also allowing for the diagnostic reli- became known as the Croatian Soci- society we are still very coherent and standing between radiologists and radiological facilities into this net- ability and availability of different ety of Radiology, after independ- are traditionally known as one of radiological technologists (radi- work. Alongside IT technology, a modalities, cost-benefit ratio, and ence in 1991. Our regular activities the most active societies within the ographers) is our next impor- significant improvement in teleradi- total patient radiation exposure. include nine professional meetings Croatian medical community. tant concern. Therefore, we have ology requires compatible imaging These demanding tasks increase the per year and a national congress The Croatian Society of Radiology undertaken several initiatives to protocols and guidelines. We also amount of clinical time dedicated every four years. We also continu- endeavours to harmonise the edu- define teamwork and the roles of expect teleradiology to balance to multidisciplinary team meetings ally participate in the organisation cation of residents at the national each profession in the interests of the workload of radiology teams and decrease the amount of time of international and regional meet- level, insisting on regular structured patient safety. The quality control of across the country. However, the available for traditional image inter- ings, as well as symposia such as the lectures and continual knowledge imaging services is becoming more reimbursement model for radiology pretation and intervention. This is Alpe-Adria radiological meeting or tests. National level written exams common in recent years, but quality services needs to be refined. Bear- a great challenge which makes the the Hungarian-Slovenian-Croatian are our next goal for residents’ edu- assessment structures still need to ing in mind our past experiences in radiologist an important and indis- meeting. cation. Another important task is be better defined. implementing teleradiology, experts pensable part of the clinical setting. Education, professional issues to develop an academic radiology Balancing radiological equip- in particular fields of radiology were and science are all within the scope network, as well as coordinate edu- ment procurement with the actual additionally burdened by the fact of our activity. The Croatian Society cation and research in clinical and requirements of radiology depart- that they received no actual com- More information about the of Radiology also acts within profes- interventional radiology. A lack of ments in our hospitals, as well as pensation, and it is not surprising Croatian Society of Radiology can sional fields including neuro, inter- interest among young radiologists improving the utilisation of existing that they are not eager to contribute be found at www.radiologija.org ventional, and thoracopulmonary in interventional radiology has been equipment and radiological exper- to this initiative again. radiology. Our main challenge is noticed in previous years. Problems tise, remain major challenges. The As a professional society we pro- to find the ideal balance between with equipment and budgeting for growing volume and complexity of mote the idea of the clinical radi- Professor Damir Miletić is President the narrow subspecialty approach, interventional radiology, and the the radiological workload in clinical ologist as an advisory physician, of the Croatian Society of Radiology.

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

myESR.org | #ECR2013 @myESR 24 ECR Today 2013 Technology Focus Sunday 10 March 2013 New EIBIR research projects kick off this month

By Alena Morrison invasive or non-invasive cancers, or surrounding breast tissues. Next, a predict the rate of transformation proof of concept and demonstra- In March the European Insti- from one to the other. Because of the tor for treatment decision support tute for Biomedical Imaging shortcomings of current diagnostic is carried out, followed by the final Research will start two new EU 7th tools, many women in Europe are stage during which all basic and Framework Programme research subject to overdiagnosis, overtreat- advanced processing modules from projects to improve health out- ment, and unsuccessful treatment. earlier work process are integrated comes for breast cancer and The key issue underlying these prob- to develop a phenotyping concept, dementia patients. lems is poor individual phenotyping predictive treatment models and Last year saw the successful con- of highly heterogeneous cancers. visualisation tools. clusion of three research projects VPH-PRISM will substantially Proposed in response to a call coordinated by EIBIR: ENCITE contribute to overcoming major from the EU 7th Framework Pro- (European Network for Cell obstacles that currently lead to over- gramme, VPH-PRISM has been Imaging and Tracking Expertise), diagnosis, overtreatment and unsuc- successfully evaluated by the Euro- HAMAM (Highly Accurate Breast cessful treatment of breast cancer pean Commission and had the first Cancer Diagnosis through Integra- in women. By linking research and meeting before the start of the ECR tion of Biological Knowledge, Novel disciplines and integrating data 2013. Running for 36 months, the Imaging Modalities, and Modelling) from a variety of sources (clinical, project will receive € 3.7m of fund- and PEDDOSE.NET (Dosimetry biological, epidemiological and ing from the EC. and Health Effects of Diagnostic environmental), predictive models Contributing to the project are Applications of Radiopharmaceuti- of breast cancer development and nine organisations representing five An outline of the VPH-DARE@IT project cals with Particular Emphasis on the more accurate imaging will allow countries. EIBIR will be responsible Use in Children and Adolescents). for early, accurate and effective for the project management as well EIBIR’s coordination efforts in treatment. as dissemination activities. and memory deficits and its specific Also starting in March 2013, Euro-BioImaging will continue During the initial stages, data clinical diagnosis. VPH-DARE@IT will run for through 2013, and two new projects acquisition of images, whole-slide VPH-DARE@IT Twenty-one organisations from 48 months and will receive have begun this month. Both digital pathology and non-imaging There are currently about 36 million nine countries will participate in over €18m in funding from the projects will tackle diseases with a data will feed into a data model individuals suffering from dementia the project. EIBIR will provide dis- European Union FP7 research major impact on the European pop- alongside data analysis for environ- and by 2050 that number is expected semination channels to the relevant programme. ulation. VPH-PRISM will focus on ment-tissue interactions. Statistical to rise to 115 million. Acknowledg- academic and industrial stakehold- EIBIR is honoured to be taking breast cancer, while VPH-DARE@ correlations to quantitatively char- ing the impact dementia is having ers to ensure adequate outreach to part in such innovative research IT is concerned with dementia. acterise breast tissue will be realised worldwide, the WHO declared the scientific and industry commu- projects and the opportunity to through the integration of radiolog- dementia a global health priority in nities, an essential prerequisite for collaborate with the scientists and VPH-PRISM ical and histopathological images, 2012, highlighting the urgent need the development of the exploitation research organisations who are The positive effects of breast cancer efficient processing of high-volume for improvement in this area. strategy and business plan within contributing. If you would like screening are unquestionable; how- digital images as well as develop- Addressing these challenges, the project. Additionally, EIBIR to discuss any of EIBIR’s projects ever, breast cancer screening is not ment of specific algorithms that VPH-DARE@IT promises to will contribute to training activi- – concluded or commencing – 100 percent accurate, nor is screen- automatically quantify and char- shorten the current average time- ties to foster knowledge transfer please visit the EIBIR Booth in the ing able to differentiate between acterise early breast cancers and lapse between the onset of cognitive and awareness of the results. entrance hall.

#ECR2013 @myESR | myESR.org Sunday 10 March 2013 Community News ECR Today 2013 25

Ten years of EPOS: Horizon 2020: The Metamorphoses A decade of digital EU’s Framework of Egon Schiele INSIDE innovation Programme for Research and Innovation TODAY See page 26 See page 26 See page 30 Accomplished professor to become editor-in-chief of European Radiology

By Mélisande Rouger nal of international repute. To this biostatic methods. Wherever pos- end, innovative thoughts and ideas sible, authors should not only dem- ECR Today spoke with Professor will certainly be required, which I onstrate the diagnostic significance Maximilian Reiser from Munich, would like to develop, discuss and of a radiological method but also Germany, about his ambitions and implement together with the ESR the outcome for the patient. It goes the challenges he expects to face as leadership. without saying that clearly defined head of European Radiology. reference methods need to be used ECRT: Could you please tell us in every article. ECR Today: You will become edi- about your experience in journal tor-in-chief of European Radiol- editing? How many publications ogy in 2014. What are your plans have you authored? ECRT: Where do you see scientific and ambitions regarding this new MR: I have been editor-in-chief of publishing in ten years? Will there position? the German journal Der Radiol- be any print journals at all? If not, Maximilian Reiser: Professors Liss- oge for many years, serial editor of do you think this will reduce the ner, Baert and Dixon, together with the book series Medical Radiology scientific quality of publications? their deputy editors, the advisory – Diagnostic Imaging (Springer), MR: Electronic media offer many editorial board, editorial staff, sec- member of the advisory editorial very interesting possibilities for tion editors and the scientific edito- board of European Radiology and editors, authors and readers. Along rial board, have worked hard and reviewer for several radiological with the increase in online material, shown impressive dedication, as well journals. I have authored or co- however, more guidance is needed to as admirable and generous commit- authored 502 publications since allow the reader to find valuable and ment, in making European Radiol- 2002, which owes to the fact that trustworthy information. Therefore, ogy what it is today – the flagship we have a very active scientific team I am absolutely convinced that peer- of radiology in Europe. I am aware at our institute. reviewed journals will continue to that it will not be easy to follow in Professor Maximilian Reiser their footsteps, but Prof. Dixon has ECRT: Do you have any advice play a very important role in the from Munich, Germany offered to give me an in-depth intro- for aspiring authors? What is the future – regardless of their form of duction to my new task – an offer best way for them to present their distribution (online or printed). In which I have gladly accepted. My work? both cases, of course, the ethics of ambition is to consolidate and fur- MR: It is important that authors publishing and handling scientific ther develop the scientific impact of present significant topics with data will have to be strictly followed European Radiology, which is a jour- valid methods and use adequate and clearly laid out.

Research is best way to turn resources into knowledge, states today’s Honorary Lecturer

By Michael Crean As a researcher, Prof. Martí- transfer to the clinical innovation,” Bonmatí’s interests lie mainly in Prof. Martí-Bonmatí explained. In recognition of his dedication the fields of liver MR and CT, On top of his work as a clinician to scientific research and devel- abdominal and pelvic MRI, con- and academic, Prof. Martí-Bonmatí opment, Professor Luis Martí- trast agents, image processing, and has also been engaged in strength- Bonmatí from Valencia, Spain, imaging biomarkers. With more ening international ties within the has been invited by the European than 200 articles listed in PubMed field of radiology. He is an active Society of Radiology to present the and 55 book chapters to his name, member of many European sci- Santiago Ramón y Cajal Honorary he is an established scientific author. entific societies and has served as Lecture, ‘Research and Science: As an editor he has contributed to president of the Spanish Society of from Individuals to Societies – eight books. He has also supervised Radiology, the European Society for the Ramón y Cajal background,’ more than 25 Ph.D. students, and Magnetic Resonance in Medicine at ECR 2013. has delivered hundreds of presenta- and Biology and the Spanish Society Luis Martí Bonmatí is director of tions at scientific meetings, sympo- of Abdominal Imaging. In addition Medical Imaging at La Fe University sia, and international conferences. to these presidencies, he has served and Polytechnic University Hospi- “In my position as director of as vice-president of the European tal, and chief of radiology at Quirón medical imaging, my work focuses Society of Gastrointestinal and Hospital, Valencia, Spain. He is also on the paradigm change; from Abdominal Radiology. professor of radiology at Valencia improving diagnostic performances He is a long-time member of the University. to taking care of the patient, and European Society of Radiology and After completing his undergradu- its particular clinical conditions in currently serves as chairman of the ate medical training at the Univer- an integrated and individualised society’s Research Committee. sity of Valencia in 1983, Prof. Martí- manner. In this way, we execute “Research is also at the fore- Bonmatí worked as a resident at La the necessary diagnostic and ther- front of my career. Both in Valen- Fe University Hospital Valencia apeutic procedures that are better cia and as chairman of the ESR’s until 1987. He then began work on for integral patient care, using the Research Committee, I recognise Professor Luis Martí-Bonmatí his Ph.D. thesis, ‘MRI in the study whole technological potential and that research is the best way to turn from Valencia, Spain and characterisation of focal liver biological knowledge of the disease. resources into knowledge across the lesions’, earning him a doctorate To do this requires the help of every scientific world and that innovation Sunday, March 10, 12:15–12:45, Room A with excellence from the University staff member and an increase in consists of developing,” Prof. Martí- Santiago Ramón y Cajal Honorary Lecture of Valencia in 1990. research activity and technological Bonmatí stated. Research and science: from individuals to societies – the Ramón y Cajal background Luis Martí-Bonmatí; Valencia/ES

myESR.org | #ECR2013 @myESR 26 ECR Today 2013 Community News Sunday 10 March 2013 Ten years of EPOS: A decade of digital innovation

ECR Today spoke with Professor for around 1,500 presenters – it has EPOS was also a revolution in Nicholas Gourtsoyiannis, founder developed into a very powerful tool terms of sustainability, as all post- of EPOS™, on the platform’s tenth for the ECR. ers are stored electronically and can anniversary. be accessed online, not only during ECRT: How was the idea of EPOS the congress, hence making science ECR Today: This year the Elec- born? available all year long. tronic Presentation Online Sys- NG: The idea was to move forward tem (EPOS™) is celebrating its 10th with time – how could a very mod- ECRT: The EPOS Lounge is always birthday. How far has it come in ern, advanced and technical spe- a popular destination at the ECR. ten years? How would you gauge cialty like radiology, working with Have you used it yourself? Have the success of this enterprise? high quality images, stick to paper you noticed any developments Nicholas Gourtsoyiannis: A timeless printouts? Considering the many over time (more visitors, location change, productive, useful and crea- important features of digital posters expansion, etc.)? tive, the first of its kind, which has (ability to zoom into images and play NG: Due to my many commit- literally transformed the way major videos), the answer was obvious. ments, I unfortunately have not radiological congresses function, by There was a need for a revolution, to used the EPOS Area as often as I going completely digital. ECR 2003 enhance the quality and attractive- would have liked. What I can see is was of course the first big meeting ness of the congress, for authors as that over the years, it has become a ever to introduce and stage EPOS, well as for participants. We felt the central location within the Austria presenting all its posters electroni- need for an effective change, allow- Center, which is always crowded cally. The immediate major benefits ing scientific dialogue to expand and with many different people, tell- were that it stimulated the whole continue after the ECR, as well as a ing me that the concept of hav- world of digital natives, and it need to offer the corpus of the whole ing a lounge in front of the EPOS opened up new horizons for thou- congress digitally. room to sit, relax and chat, is good sands of radiologists who could not A positive result was that there and enjoyed by the congress par- Professor Nicholas Gourtsoyiannis from Athens, Greece, attend or present at the ECR. Poster was room for more posters, which ticipants. I have the impression founder of EPOS™ presentations are essential for every came with the growth of the ECR. that EPOS has become a central young radiologist’s career, as it gives Poster panels need space, which can element of ESR’s online activities future for EPOS and the ECR, and eLearning. There should not be any them a platform to prove their excel- now be used for other projects, such and, especially at the congress, I am very excited to see these future congress without e-posters, so that lence and professionalism, even if as special exhibitions, lounges, or consolidates many projects, such developments. their contents are accessible to all they are not yet advanced enough more lecture rooms. as self-assessment, Eurorad and I am proud that the ECR Elec- radiologists, and so young radiolo- to become an oral lecturer. There Cases of the Day. tronic Poster Online System has gists will no longer be excluded from are thousands of radiologists in the ECRT: What has EPOS brought to been called EPOS, a four-thousand- contributing towards the progress of world that want to present their the world of radiology? ECRT: Do you have a personal year-old Greek word, which refers to our specialty. work, but as we all know, space and NG: It has brought international wish or message for EPOS on its a narrative celebrating heroic deeds. Last but not least, I hope that time are limited. congresses to another level – not 10th anniversary? Our vibrant scientific community is no radiologist will be excluded Starting with 870 posters at ECR on its own, but as part of the ongoing NG: Being Greek, I would say τά embracing it as their platform for from our scientific community just 2003, EPOS today includes more revolution that the ECR has begun: πάντα ῥεῖ (ta panta rhei), which dialogue and integration. Inevitably because they cannot attend a meet- than 2,500 posters per congress, it is beautiful, modern and develops means everything is in constant it will prosper even more in light ing for financial reasons or any other in essence an eLearning library in new trends, and therefore drives the change – I am confident that there of the growing popularity of social reason – EPOS should always com- itself, and is the connecting platform radiological meeting scene. will be a lot of new things in the media and other electronic tools for plement personal interaction.

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

Horizon 2020: European Union’s Framework Programme for Research and Innovation

By Javeni Hemetsberger 2014–2020 period, has been caught have been proposed, which are dis- between fundamental research Horizon 2020’s three main objec- up in the tense negotiations between turbing as they call for a six percent projects and projects closer to the tives: maintaining and promoting The framework programme for the European Parliament and Mem- cut to the total EU budget and a 12 industry. excellence in research, develop- research and innovation, horizon ber States over the EU budget. percent cut to the research, inno- Given that the Parliament and ing competitive industries and, 2020 is going to run from 2014– Due to a lack of progress on the vation and education budget com- the Council could still amend pro- most importantly, building a better 2020 and will integrate the Euro- EU budget, the chairs of the Euro- pared to the Commission’s proposed cedures proposed in the Horizon society. pean framework programme, the pean People’s Party (EPP) and the budget. 2020 programme, the Commis- programme for the competitiveness Progressive Alliance of Socialists An agreement on Horizon 2020 sion has not yet defined the 2014 More information on Horizon of enterprises and SMEs (COSME), and Democrats (S&D) have signed will not be reached before spring work programme and subsequent 2020 can be found at as well as the European Institute of a letter, along with Horizon 2020 2013. It is still unclear how this will project calls. The Irish Presidency ec.europa.eu/research/horizon2020 Innovation and Technology (EIT). Rapporteurs Christian Ehler, Teresa impact preparatory work for the is expected to push for a deal with The overall budget, which the Euro- Riera Madurell and Maria da Graca call for proposals, or whether the the European Parliament ahead of Please contact pean Commission has put forward, Carvalho, asking Herman Van European Commission will be able a meeting of research ministers in [email protected] will amount to €80 billion, of which Rompuy (president of the European to launch the first calls in January May 2013. if you have any questions. €8bn will be dedicated to health Council) to support an increase in 2014 as planned. The adoption of legislation by the research. the Horizon 2020 budget in the EU On November28, the European Parliament and Council on Horizon budget discussions. Parliament’s Industry and Research 2020 is slated for the end of 2013. Tense negotiations between At a meeting of the European Committee (ITRE) adopted its posi- Horizon 2020 will be launched on European Parliament and Council on November 22 in Brus- tion on Horizon 2020, voting to January 1, 2014. Member States over the sels, no agreement could be reached increase the total budget from €80 The ESR has issued a statement on EU budget 2014–2020 between the Member States on the billion to €100 billion. The ITRE Horizon 2020, outlining the ESR’s The Horizon 2020 package, which 2014–2020 EU budget. However, Committee is also seeking to strike view on the future of EU scientific provides research funding for the disproportionate cuts to research a balance in the attribution of funds research. This view is in line with

#ECR2013 @myESR | myESR.org Sunday 10 March 2013 Community News ECR Today 2013 27 Turkish radiologists delighted by growing international influence

By Nevra Elmas ing programme has been prepared by the Turkish Society of Radiology The Turkish Society of Radiology for educational centres around the is one of the foremost medical spe- country. cialty organisations in Turkey. It was The Turkish Society of Radiology formed in 2000, from the merger of has initiated two important educa- the two main radiology societies in tional programmes for residents and Turkey, one of which was founded young radiologists in 2010. With as early as 1924 (the other, the these two projects, we expect radi- Turkish Society of Medical Imag- ologists to become the best educated ing and Interventional Radiology, physicians in the country. was founded in 1991). The society’s The Turkish Society of Radiology main office is in Ankara (capital of has established the Winter School for Turkey) and has 1,930 members in the training of residents. In this pro- good standing. It aims to promote gramme, each resident undergoes a radiological education and coop- two-week training programme once eration among its members with they begin their residency period. regard to professional, social and Every year, approximately 200 resi- legal issues. dents are trained in the fundamen- The Turkish Society of Radiology, tals of radiology by distinguished which is a member of the Turkish lecturers (there are 800 residents in Medical Specialist Board, an offi- training in educational hospitals). cial body of the Ministry of Health The first Winter School programme in Turkey, is a non-governmental was in December 2010, 180 resi- organisation, dedicated to promot- dents took part, while the second ing radiological education and one was in January 2011 with 175 cooperation among its members residents, and the third one, in Janu- with regard to professional, social ary 2012, had 357 participants. All and legal issues. Accordingly, the costs were covered by the Turkish main radiological issues that our Society of Radiology and residents society handles are related to edu- participated free of charge. The next Turkish Congress of Radiology is going to be held on November 6–10, 2013 in Antalya. cation. Radiology education in The Turkish Society of Radiol- Turkey is mostly provided by uni- ogy has also established a Scholar- we aim to support 30 colleagues per of 149 oral presentations and 897 the most respected radiology jour- versity hospitals, as well as teach- ship Programme to support young year. electronic exhibits were presented. nals such as the American Journal of ing hospitals run by the Turkish radiologists in furthering their Radiology board exams have There were three main topics: Roentgenology, Cardiovascular and Ministry of Health. There are 50 education. This programme was been administered by the educa- ‘Women Imaging’, ‘How to do it?’ Interventional Radiology, European state-run university hospitals, nine introduced to support our young tion council of the Turkish Society and ‘Radiologic Physics’. Journal of Radiology, American private university hospitals and 29 colleagues who want to get a better of Radiology since 2004. The board Our next National Radiology Journal of Neuroradiology, Pediat- government teaching hospitals in education in the field of radiology, exams are composed of two parts: Congress is going to be held on ric Radiology and European Radiol- Turkey. Radiology residency train- in either Turkey or abroad, for 6 one theory exam and one practical November 6–10, 2013 in Antalya. ogy. I think growth in the number ing programmes are under the legal to 12 months. The Turkish Society exam. Only participants who pass The Turkish Society of Radiol- of articles published in radiology authority of the Ministry of Health. of Radiology supports candidates the theoretical exam can take the ogy publishes the quarterly peer- journals from Turkey will continue Unfortunately, the training period with a stipend of $1,200 per month practical exam. We encourage our reviewed journal Diagnostic and in the future. was reduced to four years, from five for training abroad and $750 per residents, who go through the Win- Interventional Radiology. This jour- The Turkish Society of Radiol- years, by the Ministry of Health last month for training within Turkey. ter School training programme, to nal, which has been published since ogy is an ESR Institutional Mem- year. The Turkish Society of Radi- In 2011, seven young colleagues take the theoretical exam before the 1994, has the highest standards of ber Society, which develops infra- ology is actively trying to have the were awarded scholarships by the final exam of the residency period. peer-review, editorial content and structure and human resources, training period restored to five programme. With this programme, The Society holds an annual publication quality. In 2007, Diag- implements high quality training years; a five-year residency train- national congress of radiology, as nostic and Interventional Radiology programmes for residents and well as symposia and other small- was accepted for indexing in Index young colleagues, and shares invalu- scale meetings. Attendance at Medicus and SCIE (Science Citation able scientific knowledge with the annual congresses is in the range of Index-Expended). The Impact Fac- international community. I hope 1,500 to 2,000 radiologists. Impres- tor of Diagnostic and Interventional that these endeavours will gradu- sive numbers of world-renowned Radiology in 2011 was 1.1. This jour- ally increase in the future. radiologists, from many subspecial- nal is also available free to all readers ties of radiology, attend these meet- on the web (www.dirjournal.org). It ings to present lectures. is one of the best medical journals The 33rd Turkish Congress of published in Turkey, south-eastern More information about the Radiology was held on November Europe and the Middle East. Turkish Society of Radiology can 7–11, 2012 in Antalya, and 1,736 The number of scientific articles be found at www.turkrad.org.tr radiologists attended. Every year the by Turkish authors in radiology number of participants grows. At journals has increased substantially the Turkish Congress of Radiology over the last 15 years, and Turkey Professor Nevra Elmas from Izmir, 2012, there were 19 lecturers from consistently ranks among the top Turkey, is President of the Turkish The Board of the Turkish Society of Radiology. Europe and the United States; a total five countries submitting articles to Society of Radiology.

Customise your congress! Plan and personalise your ECR 2013 experience with the Interactive Programme Planner. ipp.myesr.org

myESR.org | #ECR2013 @myESR BOOST YOUR CAREER. TAKE THE EUROPEAN DIPLOMA IN RADIOLOGY (EDiR)

EXAM DATES: June 6–8, 2013, Wroclaw/PL (Congress of the Polish Medical Society of Radiology)

October 18–22, 2013, Paris/FR (JFR)

October 28 – November 2, Antalya/TR (TURKRAD 2013)

www.myESR.org/diploma Sunday 10 March 2013 Community News ECR Today 2013 29 Eventful year for Serbian radiology

By Milos A. Lucic a large number of very prominent European neuroradiologists. It was The Radiological Society of Serbia a successful demonstration of what (RSS) is an association representing to expect from the upcoming ESNR radiology specialists, radiologists Annual Meeting in 2016. in training, and other profession- November 8, 2012 is an impor- als working in the field of diagnos- tant date for the RSS, and it strongly tic and interventional radiology, supported the celebration of the as well as diagnostic medical and first International Day of Radi- functional-molecular imaging in ology (IDoR) 2012. Numerous Serbia. The RSS is an institutional newspapers, radio and TV news member of the European Society programmes informed the pub- of Radiology (ESR) and the Inter- lic in our country of the Interna- national Society of Radiology (ISR). tional Day of Radiology 2012 and Last year, the city of Novi Sad the importance of radiologists in hosted two important radiological medical care. It did so by raising events: the first European School of awareness of our profession and Radiology Galen Foundation Course the process of establishing the diag- in Neuroradiology in April, and a nosis and the treatment decision- European School of Interventional making process. Radiology course on tumour abla- The RSS strongly supported and tion in May, which attracted many encouraged the establishment of prominent international speakers, the new subspecialty society: the including Professor Paul M. Parizel, Serbian Society of Interventional ESNR past-president, and Professor Radiology, founded in September Nicholas Gourtsoyiannis, director 2012 and led by elected president of ESOR, as well as participants Professor Petar Bosnjakovic. from numerous countries around Another important task for ESOR Galen Foundation Course in Neuroradiology, held in Novi Sad, University School of Medicine, April 26–28, 2012. Pictured from left: the world. Prof. Bosnjakovic this year, and Prof. Dr. Nicholas Gourtsoyiannis, ESOR Director; Prof. Dr. Tatjana Stosic-Opincal, Serbian Society of Neuroradiologists president; Prof. Dr. Paul M. The Serbian Society of Neuro- also for the RSS, will be the Ser- Parizel, ESNR past president. Standing from left: Assoc. Prof. Dr. Katarina Koprivsek, faculty and Prof. Dr. Milos Lucic, RSS president. radiologists, headed by Professor bian Congress of Radiology 2013, Tatjana Stosic-Opincal held the which will be held in Nis, October to be surpassed by the upcoming In addition, the RSS runs many More information about the third Serbian Congress of Neuro- 24–27, 2013. The national biennial one. Numerous programme topics radiological and multidiscipli- Radiological Society of Serbia radiologists and Advanced Course congress will be held for a second selected by the scientific commit- nary courses in collaboration with can be found at in Interventional Neuroradiology, time, in close cooperation with tee will be presented at the Serbian numerous other professional organ- www.udruzenjeradiologasrbije.org which took place in Belgrade from the Radiological Society of Serbia Congress of Radiology 2013, not isations, offering a wide spectrum of May 31 to June 2, 2012, with par- and the Section for Radiological only by foreign academics but also core and advanced state-of-the-art ticipation from the vast majority of Diagnostics of Serbian Medical by our local lecturers, in a united radiological knowledge in various Professor Milos A. Lucic from Srem- Serbian diagnostic and interven- Doctors Society. We expect the effort to raise the quality of the sci- fields of radiology and subspecialty ska Kamenica, Serbia, is Chairman tional neuroradiologists along with last extremely successful congress entific programme. disciplines. of the Radiological Society of Serbia.

Meet & Greet at RTF Highlighted Rising Stars Programme the Rising Stars Lectures and Basic Sessions Lounge the RTF General Sunday, March 10, 08:30–10:00, Studio 2013 Assembly Basic Session on Interventional Radiology ‣‣ Management of aortic aneurysm and dissection PIN WIN R. Morgan; London/UK Meet & Greet with your ‣‣ Overview of the development of interventional radiology techniques RTF Representative Make sure you catch the RTF Highlighted B. Ganai; Newcastle/UK Lectures and the RTF General Assembly ‣‣ Embolisation of liver malignancies Don’t miss the opportunity to get in touch M.A.A.J. van den Bosch; Utrecht/NL with your national RTF representative during the ECR! Visit the RTF Meeting Point in Sunday, March 10, 10:30–12:00, Room Q the Rising Stars Lounge (Foyer B, Student Sessions 2nd Level) where resident representatives Radiology Trainees Forum from various countries will be available RTF Highlighted Lectures Sunday, March 10, 14:00–15:00, Studio 2013 daily from 13:15 to 13:45 to provide you Moderators: D. Bulja; Sarajevo/BA Final Student Session The final draw for the The four best student presenters will be awarded by the ESR during this session. with first-hand information. V.H. Koen; Harleem/NL Pin to Win game ▶▶Emergency radiology Student Hands-on Workshops on Ultrasound takes place today in ESR President in the Rising Stars management in patients with In cooperation with Sono4You Lounge polytrauma After last year’s success, hands-on workshops exclusively for students will again be held at Extension Expo A U. Linsenmaier; Munich/DE Take the unique chance to meet and ECR 2013. greet the ESR President in the Rising Stars ▶▶Imaging of non-traumatic An expert team of tutors will lead the students through the workshops, which will include at the Samsung Lounge during the ECR. six different workstations to give every participant the chance to familiarise themselves intracranial haemorrhage with the wide range of possibilities with ultrasound. Z. Merhemic; Sarajevo/BA Booth, between ‣‣ Workshop Advanced: Sunday, March 10, 12:45–13:05 ▶▶Case-based learning in 5:00 and 5:30 p.m. radiology Sunday, March 10, 16:00–18:00 Prof. Gabriel P. Krestin P. Pokieser; Vienna/AT (Netherlands) Suitable for advanced students and residents. All workshops take place in Room X ESR President st RTF General Assembly (1 level). Sunday, March 10, 14:30–16:00

rd Registration: Meeting Room 9, 3 Level This workshop is fully booked. Places may become available at short notice onsite.

myESR.org | #ECR2013 @myESR

Gameto 30 ECR Today 2013 Arts & Culture Sunday 10 March 2013 The Metamorphoses of Egon Schiele The Leopold Museum reveals the Expressionist’s ability to transform

Following the huge success of the Portrait with Physalis’ and ‘Portrait exhibition ‘Melancholy and Provo- of Wally Neuzil’ which depict Egon cation’, which highlighted the antith- Schiele and his great love Wally and eses in the œuvre of Egon Schiele are among the most famous pairs (1890–1918) – the profound sadness of paintings in art history. Much and world weariness on the one hand in keeping with the theme of their and the provocative, stirring aspect amour fou, Elisabeth Leopold also on the other – the Leopold Museum presents the work ‘Cardinal and now presents Schiele masterpieces Nun’, symbolising a ‘forbidden’ but from the Leopold Collection in a nevertheless inescapable attraction new context. The exhibition, curated between man and woman. The ‘Self- by Elisabeth Leopold, is dedicated to Portrait with Raised Bare Shoulder’ Schiele’s ability to transform. shows a face full of panic and horror. Seemingly forced into a corner, the Metamorphoses: Schiele artist screams open-mouthed and transformed his own figure wide-eyed in protest of a hostile into various shapes world that refuses to understand The main focus of the exhibition, his message. which comprises some 20 paintings as well as documents and Farewell paintings and autographs, is on the artist’s self- anthropomorphic houses portraits. Since the Renaissance Another part of the exhibition is the self-portrait has been a central dedicated to Schiele’s landscapes. theme for many artists, includ- The work ‘Sinking Sun’ (1913) is a ing Albrecht Dürer, Anthonis van farewell painting. The foreground Dyck and Rembrandt. Schiele, how- is dark and infused with an infinite ever, transformed himself in his sense of cold, the sea is grey. The self-portraits. “Schiele often used sky glows in a faint shade of car- himself as a model, changing and mine red. The horizontal lines are Egon Schiele, Self-portrait with winter cherries, 1912 transforming his body into various broken up by two young, almost © Leopold Museum, Vienna, Inv. 454 shapes,” explains Elisabeth Leopold. bare trees whose dry leaves are stiff- These transformations could best be ened by the cold. The sun is sink- described as ‘metamorphoses’. The ing almost imperceptibly as a small intensity with which Egon Schiele ball into the sea. It is taking its leave, used body language as a medium of and perhaps it will never return. expression is largely unprecedented. This section also includes Schiele’s According to Elisabeth Leopold “the anthropomorphic houses inspired depicted becomes a symbol of the by the Bohemian city of Český dying man who becomes a hermit, Krumlov on the Moldova River, naked and levitating”. with its Gothic and Renaissance buildings set in narrow lanes and Hermits and Levitation: surrounded by the black river. transformation of life into death Right at the start of the exhibition ‘No-man’s-land and the end visitors encounter three large-scale of the world’: figural depictions which are among Schiele’s Houses by the Sea Egon Schiele’s most important paint- According to Elisabeth Leopold ings. The 1912 work ‘The Hermits’ “these houses are expressions of the sees Egon Schiele and Gustav Klimt artist’s spiritual world”. She points melting into a double-figure under out the slightly animated contours Egon Schiele, Sinking Sun, 1913 Egon Schiele, The Hermits, 1912 a black cloak. The two figures also and the subdued colours, which © Leopold Museum, Vienna, Inv. 625 © Leopold Museum, Vienna, Inv. 466 appear as generalised types of men. are occasionally shot through with In a letter to the industrialist and emi- bright objects such as gutters, win- nent art collector Carl Reininghaus dow frames and hung up laundry. To Schiele explained, “They are the bod- Elisabeth Leopold these renderings ies of sensitive beings”. In his impres- represent “landscapes of the soul” sive early masterpiece ‘Seated Male which are “permeated by a sense Nude (Self-Portrait)’ of 1910 the artist of melancholy and transience”. The rendered himself as a highly expres- highlight of this part of the exhi- sive, gesticulative figure. A few years bition is the rarely exhibited work later Schiele showed the transforma- ‘Houses by the Sea’ (1914). A partial tion of life into death in his two-figure settlement could be reached last year depiction ‘Levitation’ (1915). concerning this painting with the sole heir of the work’s original owner Oneiric images and Jenny Steiner. Elisabeth Leopold forbidden love says of it: “Each house resembles These three chief works are framed a human face. A sharp, horizontal by the surreal oneiric images that boundary line behind the buildings Schiele presented in his 1911 exhi- marks the transition to the light grey bition at the reputable Galerie sea from which rocks emerge in the Miethke under artistic director distance that stand out against the Carl Moll: ‘Lyricist’, ‘Self-Seer II’ dark grey sky. Rudolf Leopold called and ‘Revelation’. The same room also this horizon ‘the eternal line of the hosts numerous significant works no-man’s-land and the end of the from 1912, most importantly ‘Self- world’.”

Leopold Museum at the MuseumsQuartier | Museumsplatz 1, 1070 Vienna Opening Hours: The Museum is open daily: 10am to 6pm Thursdays: 10am to 9pm Closed on Tuesdays www.leopoldmuseum.org Egon Schiele, ‘Self-Seer’ II (Death and Man) © Leopold Museum, Vienna, Inv. 451

#ECR2013 @myESR | myESR.org Egon Schiele, Self-portrait with raised naked shoulder, 1912 © Leopold Museum, Vienna, Inv. 653 32 ECR Today 2013 Arts & Culture Sunday 10 March 2013 What’s on today in Vienna?

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

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

19:00 Einige Nachrichten an das All 15:00 Forever Young by Franz Wittenbrink by Wolfram Lotz 19:30 Forever Young by Franz Wittenbrink

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

19:00 Der Ignorant und der Wahnsinnige 15:00 Ratgeber für den intelligenten by Thomas Bernhard Homosexuellen zu Kapitalismus und Sozialismus mit Schlüssel zur Heiligen Schrift by Tony Kushner

Concerts & Sounds

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

11:00 Wiener Philharmoniker, 20:00 Long Distance Calling (Germany) + conductor Zubin Mehta Sólstafir (Iceland) A. Bruckner

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

20:30 David Friesen Trio (US)

Opera & Musical Theatre

Volksoper Raimundtheater 1090 Vienna, Währingerstraße 78 1060 Vienna, Wallgasse 18–20 www.volksoper.at www.musicalvienna.at

18:00 Die verkaufte Braut by Bedrich Smetana 18:00 Elisabeth by Michael Kunze & Sylvester Levay

Wiener Staatsoper – Vienna State Opera Ronacher 1010 Vienna, Opernring 2 1010 Vienna, Seilerstätte 9 www.wiener-staatsoper.at www.musicalvienna.at

16:00 Don Giovanni by Wolfgang Amadeus Mozart, 18:00 Natürlich Blond by Laurence O’Keefe, Nell conducted by Louis Langrée Benjamin & Heather Hach With Ildar Abdrazakov, Marina Rebeka, Toby Spence, Véronique Gens, Erwin Schrott

#ECR2013 @myESR | myESR.org