ECR TODAY

DAIlY nEwS fROM EUROPE’S lEADIng IMAgIng COngRESS

SATURDAY, MARCH 7, 2009

InSIDE TODAY PET/CT and CT transforms Technology focus tumour response trauma care on ultrasound

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Modality choice Adaptability should guide proves vital evolution of cancer imaging in head and

By Paula Gould Theranostics essentially combines targeted neck trauma imaging using a specific tracer with treatment Prof. Hedvig Hricak told delegates during that is directed at the same target. By Philip Ward Friday’s opening lecture that they must learn from the words of Charles Darwin: embrace To illustrate the power of targeted imaging, she CT and MRI have an essential part to play in cases change and adapt. showed three nuclear scans of a patient with of head and neck trauma, but it is important to metastatic prostate cancer. A standard bone know which modality to use under the clinical Hricak, chair of the department of radiology scan showed few bony lesions, whilst FDG-PET circumstances, according to speakers at Friday’s at New York’s Memorial Sloan-Kettering imaging revealed lesions in different locations. opening session of the mini course on major Cancer Center, quoted directly from the Only PET imaging with the radiotracer FDHT trauma. 19th century naturalist, who caused a storm (fluoro-dihydro-testosterone), which hones in with his theory of natural selection. Darwin androgen receptors, picked up the full extent CT has high sensitivity for mass effects, wrote in the Origin of Species that: “It is not of metastatic disease. ventricular configuration, bone injuries, and acute the strongest of the species that survives, nor haemorrhage, and it is rapid, compatible with life- the most intelligent that survives, it is the one “As we improve and we have targeted imaging, support equipment, and necessary for directing that is most adaptable to change.” He also it is sometimes frightening to see how little we immediate neurosurgical intervention, noted observed: “In the long history of humankind knew,” Hricak said. Dr. Ulrich Linsenmaier, from the department of those who have learned to collaborate and clinical radiology, Ludwig-Maximilians University, improvise have prevailed.” Targeted imaging could also have an important Munich, Germany. But it cannot detect small role in the management of breast cancer. For non-haemorrhagic lesions, and is insensitive for Prof. Hedvig Hricak from New York/US Opening Ceremony Radiology has evolved considerably over the example, imaging with a tracer that targeted diffuse axonal injury (DAI), increased intracranial past 50 years, and the result of this evolution oestrogen receptors would indicate which pressure, oedema, and ischaemia. has been oncologic imaging, a field that has patients were likely to benefit from the drug raised the prospect of MRI/PET replacing CT endless horizons, Hricak noted. But as this Letrozole. Similarly, a method of imaging and PET/CT in oncologic imaging – if only a “The symptoms of head trauma can be masked process of evolution continues, radiologists that highlighted HER2 receptors should show way could be found of making the technology by concomitant injuries, including blood loss, must broaden their focus beyond gross which patients would benefit from the drug cost-effective. hypotension, and intubation,” he explained. anatomy. Herceptin. “Presentation varies according to the injury. Some She concluded by setting out her ‘matrix for patients stabilise, but others deteriorate.” “It is no longer enough to be knowledgeable “Herceptin is an excellent drug, but 40% of success’ in oncologic imaging for the benefit about all the imaging modalities that we have,” patients do not have results because 40% of of ECR delegates. The incidence of head trauma is around 300 per she said. “It is equally essential to understand patients do not have HER2 receptors within 100,000 per year (0.3%) in the United States. The that imaging is just one element in the integrated their metastatic lesion,” she commented. “We need to change from a technology- mortality rate is about 25/100,000 (0.025%) in the diagnostic approach to the management of “Is targeted imaging too expensive to use in centred specialty to embrace physics, U.S. and 9/100,000 (0.009%) in the EU. Common cancer. We have no choice but to learn about the cancer treatment, or is it more expensive to chemistry and biology. We need to collaborate. causes are traffic accidents, accidents at home and importance of serum screening, proteomics and keep patients on a course of chemotherapy or An interdisciplinary and multidisciplinary work, falls, and assaults. molecular pathways.” androgen or hormonal therapy, and bring up team of clinicians and basic scientists is a their hopes while the cancer grows?” must. And we need to continuously evolve, Linsenmaier recommends follow-up CT in Hricak outlined how molecular imaging and anticipate opportunities, love change, develop cases of confirmed patient deterioration and if intervention are moving closer together in The future evolution of contrast agents and new procedures and applications and adapt to oncology with the emergence of a new field. imaging hardware was also discussed. Hricak new environments,” she noted. continued on page 3

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Changing paradigms for tumour response sparks lively debate at Focus Session

By Paula Gould 2009, still requires that uni-dimensional measu- rements are made of target lesions. The overall Yes, size does matter, but it is certainly not the tumour burden will also still be defined accor- only way of monitoring the efficacy of cancer ding to the sum of lesion diameters. treatment. The way in which lesions are measu- red is extremely important too, ECR delegates What is different, however, is the selection of were told at yesterday’s Special Focus Session on target lesions. RECIST 1.1 states that up to five the assessment of tumour response. lesions should be measured, with a limit of two per organ. This replaces the previous RECIST For the past 50 years, imaging has been regar- guidance to measure 10 lesions (five per organ). ded as a substitute or surrogate marker to assess Another change is that the criteria for ‘progres- therapy response, with the most widely used sive disease’ requires not only a 20% increase in criterion being a change in size, said Prof. Rod- size, but also that this change should be greater ney Reznek, professor of diagnostic imaging at than 5 mm. St. Bartholomew’s Hospital, London. The deve- lopment of chemotherapy drugs that act on can- All ongoing clinical trials should stick with the cers in novel ways, such as agents that are cyto- original version of RECIST, Schwartz said. This static rather than cytotoxic, has led to questions means that the revised criteria will not actually about the universal suitability of this strategy. be used for several more months yet.

“It has become apparent that size may not be Moving to functional imaging for therapy res- the most sensible or reliable criteria to assess ponse, the main modality in the frame is PET/ Prof. Wolfgang Weber from Freiburg/DE Prof. Larry Schwartz from New York/US response. For this reason, other biomarkers are CT. For some cancers, such as lymphoma, being used, one of which is functional imaging,” FDG-PET/CT has become a standard way he said. of measuring tumour response at the end of radiologist and director of clinical research at the The Quantitative Imaging Biomarker Alliance, treatment, said Prof. Wolfgang Weber, chair of Mount Vernon Cancer Centre, London. formed by the Radiological Society of North Of course, size is not being abandoned alto- nuclear medicine at the University of Freiburg, America, is looking at this latter issue, said gether. The problem is that the correlation bet- Germany. This is achieved by simply comparing Padhani outlined a range of MRI techniques that Schwartz. Questions from ECR delegates to the ween tumour shrinkage as measured on CT and a pre-therapy baseline scan against the results of can support decision-making in clinical trials speakers on the potential role of yet more func- patient survival is not quite as strong as might be post-therapy imaging. of new cancer drugs. These included MR spec- tional imaging techniques stressed the need for expected, said Prof. Larry Schwartz, chief of MRI troscopy to monitor altered metabolism, blood clarity on this topic. For example, radiology at New York’s Memorial Sloan-Kettering Cancer FDG-PET/CT is also being investigated as a pre- oxygenation-dependent MRI (BOLD) to iden- researchers in France are investigating the role of Center. dictive tool. With so many different drugs beco- tify hypoxia, diffusion MRI to assess cell prolife- ultrasound as a tool for tissue perfusion measu- ming available, it would be helpful for oncologists ration, and dynamic contrast-enhanced MRI to rements. Dynamic contrast-enhanced imaging “So while we are doing okay, we really haven’t to know sooner rather than later whether or not monitor angiogenesis through tissue perfusion. may also be performed on CT, rather than MRI, yet optimised tumour response assessment,” he their chosen agent is likely to work. Research is and the results combined with PET. noted. underway to see whether the results of an FDG- He highlighted a number of key questions that PET/CT scan after the first cycle of chemotherapy still need to be addressed as this role for imaging “What we need is some single centre trials to The size-based criteria that are used to decide could be a good indicator of patient outcome. moves forward: How do we take this informa- demonstrate proof of concept, to work out the how cancer patients in clinical trials have respon- tion and integrate it into a patient study? How do reproducibility of the techniques, and then to ded completely to their treatment have recently FDG-PET/CT is not the only functional imaging we correlate changes we are seeing with patient move that in a very rigorous and rapid way into been changed. Version 1.1 of RECIST (Response option. Many MR-based methods could equally outcomes? How do we develop common measu- Phase III trials,” Schwartz said. Evaluation Criteria of Solid Tumours), published be used to evaluate tumour response to therapy, rement and analysis methods so we can standar- in the European Journal of Cancer at the start of according to Dr. Anwar Padhani, consultant dise these and use them in multicentre studies?

continued from page 1 (Head trauma) For the face, she advocates taking thin slices with a collimation of 0.75 mm, and then reconstructing the Glasgow Coma Score is not equal to 15 after them at 1.5 mm. It is important to look at the 24 hours. Further scans are also necessary for bone and soft-tissue window settings, and she detecting delayed haematoma, hypoxic lesions, makes increasing use of intravenous contrast and cerebral oedema. media, particularly if she suspects the facial fracture extends to the skull base and there may be He noted that the primary effects of head additional vascular injuries. trauma are penetrating injuries (missile or bomb fragments), epidural haematoma, “MR is used as a second-line approach when subdural haematoma (SDH), cerebral contusion, CT has been performed but some points remain subcortical injury, DAI, and acute, subacute, unclear, such as the extent of vascular injuries, chronic, mixed, and traumatic subarachnoid optic nerve lesions that cannot be identified on haemorrhage. The secondary and vascular effects CT, and radiolucent foreign bodies,” said Becker. are intracranial herniation syndromes, traumatic cerebral oedema, traumatic cerebral ischaemia, When speaking about maxillofacial trauma, it is brain death, traumatic intracranial/extracranial vital to bear in mind that the energy applied to dissection, and traumatic carotid-cavernous the viscerocranium is a product of the mass and fistula. the square velocity, she explained. Radiologists must differentiate between high and low impact Initial assessment should be carried out in the Dr. Ulrich Linsenmaier from Berlin/DE Dr. Minerva Becker from Geneva/CH zones. High impact areas consist of bones that emergency department immediately in cases of are relatively resistant to trauma, such as the major trauma, polytrauma, and multiple trauma. supraorbital rim, frontal bone, and mandible. Low Patients with single head trauma should be seen injuries and foreign bodies. They are also useful In facial trauma, imaging provides information impact zones include the zygoma and nasal bone, within 15 minutes of arrival at hospital. A CT scan in children with suspected non-accidental injury. about the presence, location, and extent of which fracture easily when minor force is applied must be performed immediately in patients with fractures, as well as cranial nerve compromise to the facial skeleton. suspected major trauma, within one hour after For further reading, he referred course attendees and the involvement of the skull base and dura. trauma for those patients with risk factors I, and to the American College of Radiology’s It also has a role in the selection of treatment to “In as many as 50% of patients with major facial within eight hours after trauma for those with risk Appropriateness Criteria Head Trauma from stabilise facial anatomy and relieve or prevent trauma, you have associated cervical spine, factors II. 2007, the UK National Institute for Health and complications, said Dr. Minerva Becker, a airways, vascular, or brain injuries. So you Clinical Excellence’s Head Injury Guidelines from radiologist from Geneva University Hospital, don’t only have to image the face but also for all MRI is sensitive for subacute or chronic lesions, 2007, and Prof. Anne Osborn’s book, ‘Diagnostic Switzerland. the other related injuries that may be present,” atrophy, focal encephalomalacia, hydrocephalus, Imaging: Brain’ (W.B. Saunders, 2004). she said. and chronic SDH. It is not currently indicated “In most cases of major facial trauma, CT is primarily for non-haemorrhagic lesions, DAI, Later this month, he will speak at a conference the most rapid examination that performs Today’s mini-course session on body trauma vascular injuries, and dissections, Linsenmaier in Munich called ‘Battlefield Healthcare 2009: best,” she explained. “It provides a one-stop will take place in Room N/O from 08:30 to stated. From front line care through rehabilitation’. A pre- shop approach. Either you use whole-body CT 10:00. Tomorrow morning’s session will focus on conference focus day on March 24 will concentrate protocol for polytraumatised patients or you musculoskeletal trauma. Plain x-rays should be omitted in adults, and are on imaging, and he will address the topic of mass use more limited protocols for the brain and only of limited value for imaging of penetrating casualty incidents. face.”

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Comprehensive CT use revolutionises trauma care Marincek pledges to By Mélisande Rouger maintain Computed tomography has brought about a revolution in trauma care, but it must be used as part of a comprehensive approach, experts told tradition of the ECR 2009 press conference on Friday. continuous CT has become a central tool in polytrauma pati- ent care, especially during the critical first few minutes a patient spends in the emergency room change (ER). Whole-body multidetector CT (MDCT), which allows the detection of all relevant inju- ries in one procedure, has replaced conventional By Philip Ward radiographs and ultrasound in the ER, explained Dr. Michael Rieger, a radiologist at Innsbruck The creation of new ideas and concepts is University Hospital, Austria. one of ECR’s hallmarks, and ECR 2009 will follow this tradition of continuous change and “CT has really brought about a revolution in changing continuity, said ECR 2009 President emergency diagnosis. It allows very fast scanning Prof. Borut Marincek during the opening and high resolution. And most importantly for Multidetector CT of the head of a patient after frontal Multidetector CT of the lumbar spine of a patient session on Friday. polytraumatised patients, it can scan up to two collision trauma. The 3D reconstruction shows a after a fall from a great height. The 3D reconstruction metres, so it can basically scan the patient lying bursting fracture of the cranium with fractures of the shows a compression fracture of the 2nd lumbar He expressed his sincere thanks to everybody on the table from head to toe,” he said. orbital walls (arrows). (Images provided by M. Rieger vertebra with cuneiform deformation and many split for their time, effort, and commitment during and W. Voelckel) bone fragments (arrow). the preparations for ECR 2009, particularly the With whole-body CT, radiologists can visualise Programme Planning Committee, the Scientific bleeding in the head, lungs, abdomen or kid- x-ray, it can happen that the patient’s state wor- trauma anaesthesiologists, surgeons, and radio- Subcommittees, and the many researchers neys, and identify fractures of the ribs or pelvis. sens, his haemodynamics can become unstable, logists discuss patient work-up once a week in who actively contribute to the scientific and MDCT angiography enables the detection of and then we need to make more CT examina- interdisciplinary meetings. educational programme. specific artery injuries, such as carotid injury, tions later, which eventually costs more to the a common consequence of skiing accidents. hospital.” Strict compliance with emergency care protocols The Programme Planning Committee for ECR MDCT angiography of the aorta helps recog- has reduced the time from ER admission to the 2009 met for the first time in Vienna 20 months nise injuries such as traumatic aneurysm, which This does not mean that CT should be perfor- first CT scan for patients with an injury severity ago, and it has pulled together the work of all can happen after a high speed car accident. CT’s med in every case. A comprehensive approach score (ISS) of ≥ 18 to 31 minutes. The time bet- the subcommittees “just like the conductor of an precision also makes is possible to image ruptu- towards its use is needed to guarantee efficiency. ween CT images being acquired and reported orchestra coordinates the work of his musicians,” red arteries in the extremities, for instance in a has been cut to 19 minutes. he remarked. broken index finger. “Comprehensive care has become a clinical neces- sity, and I think this approach has become very This cooperation has led to encouraging results. He also gave special thanks go to the staff at the “To recognise such injuries can be very important common in Europe,” said Prof. Wolfgang Voelckel Data collected at Innsbruck’s 18-bed polytrauma ESR Office for their professionalism, efficiency, for the outcome of the patient,” Rieger stressed. from the department of anaesthesia and intensive station showed that in 486 cases of injury, only and courtesy. care, Salzburg Emergency Hospital, Austria. 10 patients had not been diagnosed on CT phase European radiologists have become more and after 19 minutes. Only three of these patients had “Dear delegates and visitors, we will probably more aware of the value of CT over x-ray or The role of the radiologist in emergency care is severe injuries. not make it to the top of the Matterhorn, but I ultrasound. Studies in head trauma and spinal becoming more and more important, especially am confident that we will reach the summit of injuries have shown that the use of CT as a stan- with interventions such as embolisation. Radio- Cooperation between emergency medicine and science!” he noted. “On behalf of the Congress dalone method is cost-effective. But it is also a logists are increasingly becoming involved in radiology is a central theme at ECR this year. Committee of the ESR, it is my special pleasure matter of common sense, Rieger said. acute medicine and life-saving procedures. Delegates are can take part in the ‘ESR meets to welcome you to ECR 2009. We will have a Emergency Physicians’ programme this after- great mix of science and pleasure, finding out “It is known that CT is more effective for exa- The set up of an effective trauma team further noon. new things, meeting old and new friends, and mining polytrauma patients. After conventional improves care. At Innsbruck University Hospital, not least enjoying the hospitality of Vienna.” Siemens receives innovation award Beckham poised to stay at AC Milan

English soccer star David Beckham looks set to remain at AC Milan until the end of the season. He will return to the Los Angeles Galaxy side from July to October, before rejoining the Serie A club for the rest of next season, according to news reports on Friday.

The deal means that 33-year-old Beckham is likely to have an opportunity to make it into his country’s squad for the World Cup qualifiers and the finals in South Africa next year.

The deal is expected to be officially confirmed by the clubs over the weekend.

This development follows weeks of negotiations between the two clubs, during which Milan objected to the size of the transfer fee demanded by Galaxy – thought to be more than 12 million Dr. Bernd Montag received the award from Prof. Borut Marincek on Friday afternoon. euros. Best of both worlds: David Beckham is likely to divide his time between Milan and Los Angeles. This year’s ‘Exhibit Europe Award’ has gone to congresses for radiology, we will also gladly In motor racing, the future of the former Honda Siemens Healthcare. Each year the European continue to support the ESR in the development Formula One team has been secured after the In cricket, a hard-hitting half-century from Society of Radiology (ESR) bestows this award on of new concepts,” said Montag. Japanese motor manufacturer agreed to pass opening batsman Phillip Hughes helped Australia one of the companies exhibiting at the congress, in ownership of the operation to Ross Brawn, who to a flying start against South Africa. The visitors recognition of its special innovative strengths in In addition, Siemens is the first of ESR’s industry becomes team principal of the new Brawn GP reached lunch on the first day of the Second Test science and technology as well as its commitment partners that has already confirmed its supporting team. The arrangement secures the future of in Durban at 119 without losing a wicket. to patient care and research. Furthermore, the membership for the coming period. veteran Brazilian Rubens Barrichello, who saw ESR also recognises the recipient’s exceptional off the challenge of fellow Brazilian Bruno Senna. Further sports round-ups will appear in the commitment to the goals and advancement of ECR. “Recently we received from Siemens Healthcare UK driver Jenson Button will also compete for the Sunday and Monday/Tuesday editions of ECR the commitment to contribute to the educational new operation. Today. Look out for more reports throughout the On Friday, ECR President Prof. Borut Marincek, activities of the ECR. As the first exhibiting congress. presented the award to Dr. Bernd Montag, Chief company, Siemens will be placing training In golf, Australian Robert Allenby was the Executive Officer Imaging & IT Division at Siemens. materials in the ECR Digital Preview System, clubhouse leader after the opening round of known as EDIPS. This will provide all ESR members the Honda Classic. Spain’s Sergio Garcia and “This award from the European Society of with access to over 1,700 scientific presentations Argentina’s Angel Cabrera were among several Radiology fills us with great pride. Since we on radiological questions contributed by leading close pursuers. consider the ECR to be one of the most important experts from around the world,” said Marincek.

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Harry’s Hot Shots from

Day One Vendors unveil new products and services ECR Today’s intrepid and multi-talented At 14:00 on Friday, the eagerly awaited opening of photographer Harry Schiffer arrived in Vienna the technical exhibition took place. on Thursday evening from his home town of Booth traffic remained busy throughout the afternoon. The exhibition will remain open from Graz. On this page is a selection of what he saw 10:00 to 18:00 on Saturday, Sunday, and Monday. through the lens of his camera.

Alphorn player brings the X-factor to ECR Alphorn player Eliana Burki from Switzerland enthralled the packed audience at Friday’s Opening Ceremony. She works as a part-time music therapist at the children’s hospital in Davos, helping children with mucoviscidosis, or cystic fibrosis. She has played the instrument since she was six, and at the age of nine she was playing alphorn at a Swiss yodeling festival.

Carty and Chiesa strike gold During Friday’s Opening Ceremony, shiny new gold medals were presented to two former ECR presidents: Prof. Helen Carty from Liverpool, UK, and Antonio Chiesa from Vicenza, Italy. Carty received the gold medal for her work in paediatric and orthopaedic radiology. Chiesa’s award was for his achievements in head and neck radiology.

Thousands flock to Austria Center The weather outside was dull, grey and wet, but the mood and atmosphere inside the Austria Center was bright and upbeat.

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Saturday, March 7, 2009 CLINICAL CORNER ECR TODAY 2009 9

Questions remain in Diagnosis, staging uterine fibroid and follow-up in MRI and ultrasound in InsIDe ToDay embolisation breast cancer rheumatoid arthritis

See page 10 See page 15 See page 16

Effective peripheral nerve imaging can improve quality of life for patients

By Frances Rylands-Monk MRI can depict abnormal signal intensities, enhancement, margins and the shape of the peri- New developments in ultrasound and MRI mean pheral nerves. More recent innovations include that peripheral nerve imaging is easier than ever diffusion tensor imaging (DTI) with tractography to perform and may bring higher sensitivity to (fibre tracking). DTI and tractography have found lesion detection. clinical applications in neuroradiology, but their use in the musculoskeletal field is still emerging. Because peripheral nerve disorders are relatively DTI can provide valuable information about tissue common in daily medical practice and they can microstructure and architectural organisation by mimic a variety of musculoskeletal disorders, cli- monitoring in vivo random microscopic motion nical evaluation (including a detailed history and of water protons and measuring fraction aniso- physical examination) are critical to a successful tropy and apparent diffusion coefficient values. diagnosis. This morning’s Special Focus Session The potential usefulness of such measurements for Ultrasound scan shows a schwannoma (6 mm in Fibre tracking of a median nerve neuroma. on peripheral nerve imaging aims to demonst- the differentiation between benign and malignant diameter) of the superficial peroneal nerve. (Provided by A. Cotten) rate the potential usefulness and recent advan- peripheral nerve tumours or for the assessment of (Provided by A. Cotten) ces of ultrasound and MRI in the assessment of Wallerian degeneration has been proposed. nerve lesions. making operating on lesions of 3 to 4mm, for really improve quality of life for a patient,” Mon- Moreover, tissue orientation and the course of the example, easier and quicker for surgeons than tet said. “If more radiologists are involved in it, Prof. Anne Cotten, head of the musculoskeletal nerve can be visualised with tractography. Peri- it would have been previously. This also reduces then it means more patients can be seen. Also, if radiology department at Lille University Hospi- pheral nerves have anisotropic diffusion proper- the length of hospital stay for patients, having an a patient presents with pain in the leg suggestive tal, France, will focus on tumoural, pseudotu- ties and the orientation of the nerve fibres can be additional positive impact on budgets. of neuronal origin in general radiology, it only moural and inflammatory disorders of periphe- followed to trace specific neural pathways, which takes an extra two or three minutes to look at the ral nerves. She underlines the need for surgeons may be useful for the detection of nerve lesions. “Everyone seems to think peripheral nerve ima- nerves with ultrasound, which isn’t done syste- to know in advance about the source of tumour gingECR1/4p is difficult AD:ECRTodayB/Wad to do, so the subject 16/1/09 is neglec -14:31matically Page at 1 present.” development and whether or not lesions are “Sometimes pain is related to a nerve disorder, ted, but effective peripheral nerve imaging can malignant or benign. but with usual imaging on ultrasound or MR, nothing is visualised. Functional imaging might “These lesions are unusual, but imaging is funda- detect early abnormalities and help in the dia- mental as it may represent the sole way to con- gnosis of inflammatory or tumour-related dis- firm the diagnosis, location and extent of these orders. However, future research has to be per- nerve lesions. Differentiation between schwanno- formed to assess the diagnostic performance of mas, neurofibromas, malignant peripheral nerve such techniques,” Cotten said. sheath tumours and pseudotumoural nerve lesi- ons are of high importance for the treatment and General and musculoskeletal radiologists should prognosis of these patients,” she explained. be aware of the usefulness of ultrasound and MRI in the assessment of nerve lesions and of For the assessment of such lesions, ultrasound and the new developments that may provide comple- MRI can be used in a complementary manner. mentary information, she added.

Ultrasound can be used for a dynamic examina- Co-speaker Dr. Xavier Montet, specialist in tion, which is fundamental for the assessment oncological imaging at Geneva University Hos- of entrapment syndromes, in contrast to MRI. pital, Switzerland, points out that in Europe ult- Roland Holland and Entrapment neuropathies are common disorders rasound costs six to eight times less than MRI. Henny Rijken resulting in pain, paresthesia, numbness, weak- ness and muscle wasting. Symptoms can become “With ultrasound you can follow the nerve to debilitating and chronic over time. where it ruptures or to where there is a quantity of fluid or a haematoma. This will be quicker and che- Digital “Ultrasound has excellent resolution, allowing aper than using other techniques,” he said. “While the detection of very small nerve lesions, and there are no huge advances in ultrasound tech- may provide quick, detailed imaging of the entire nique, the availability of high frequency probes, Mammography length of the major peripheral nerves, which is with high definition and resolution, means that very useful for comparison between both limbs small details within nerves can now be visualised.” SELF-ASSESSMENT and for the assessment of patients with multi- ple nerve lesions, such as in neurofibromatosis,” Compared to five or ten years ago, smaller WORKSHOP Cotten said. lesions can now be visualised with ultrasound, Saturday 7th & Sunday 8th March, 2009

CME points awarded Room 01, First Level, Austria Centre Special Focus Session Learn how to read and manipulate digital Saturday, March 7, 08:30–10:00, Room F2 mammography images and assess your skills in SF 5a Peripheral nerves detecting cancers in their early stage.

• Chairman’s introduction Join a one-hour hands-on session led by Roland Holland S. Bianchi; Geneva/CH MD, PhD and Henny Rijken, experts from the National Workshop Times • Technical issues: US, MRI Expert and Training Centre for Breast Cancer Screening X. Montet; Geneva/CH March 7th & 8th 8.30-9.30 at Radboud University Medical Centre, Nijmegen in • Brachial-plexus injuries C. Martinoli; Genoa/IT 9.45-10.45 the Netherlands. 11.00-12.00 • Inflammatory and neoplastic conditions A. Cotten; Lille/FR 12.15-13.15 14.30-15.30 • Entrapment neuropathies of the upper and lower extremities G. Bodner; Gibraltar/UK 15.45-16.45 17.00-18.00 • Panel discussion: How can imaging help in the diagnosis and follow-up of peripheral nerve disorders? © Carestream Health, Inc. 2009.

myESR.org 10 ECR TODAY 2009 CLINICAL CORNER Saturday, March 7, 2009

Important unanswered questions remain in uterine fibroid embolisation

By Paula Gould whether 100% infarction of the fibroids has been achieved. Uterine fibroid embolisation (UFE) was the sub- ject of a high profile special focus session at ECR Women requesting UFE should also be advised 2008. This year the topic is to be covered in an of the other surgical options available to them, afternoon refresher course. The subtle change in according to Belli. For example, patients who status reflects the growing acceptance of UFE as will be starting infertility treatment once their a robust interventional technique, but as spea- fibroids have been removed may be better off kers at today’s session will explain, UFE is still having a myomectomy. evolving and interventional radiologists have plenty more to learn. “On most occasions, you would say ‘no’ to some- body in that position because we really still do “There is still a lot happening and developing not understand the implication of fibroids with with UFE. We are still evaluating the technique infertility,” she said. “There are times when UFE and working our way through it,” said Prof. might be appropriate for them, but you have to Anna-Maria Belli, professor of interventional weigh it up on an individual basis.” radiology at St. George’s Hospital, London. “No matter how experienced you are, you can always Few studies have been published comparing UFE get tips from somebody else because we all do it and myomectomy, and there is a real lack of pro- MRI is preferred for the initial imaging assessment of women with symptomatic fibroids and follow-up after UFE. in a slightly different way.” spective research, according to Dr. Jana Maskova, (Provided by A-M Belli). interventional radiologist at Aberdeen Royal The session will cover the principles of UFE and Infirmary, UK. The limited available data indi- indications for its use. Although the procedure cate that patients undergoing UFE have shorter allows women to retain their uterus, it is not hospital stays and return to daily activities more necessarily the right choice for those who are quickly. Myomectomy appears to have superior seeking to become pregnant. The thorny issue of reproductive outcomes in the first two years after fertility after UFE will be addressed directly, and treatment. Both methods are associated with sig- speakers will present evidence on UFE versus nificant re-intervention and recurrence rates. surgical uterine-sparing options. The average cost of UFE is typically lower than An initial diagnosis of fibroids should be made that for myomectomy, even after follow-up pro- on either ultrasound or MRI before any thera- cedures to resolve recurrent symptoms have been peutic option is considered. The choice of moda- taken into account. Pre- and post-procedural lity may be dictated by access issues, though gro- MRI examinations will push up the cost of UFE. wing experience indicates that MRI should be The main expenses associated with myomec- performed where possible, said Prof. Belli. For tomy are surgical theatre time and the number of example, ultrasound may not be able to deter- days that patients must stay in hospital. Ultrasound can also be used for pre- and post-UFE examinations, if MRI is not available. A: Pre-embolisation. mine the presence of adenomyosis, a condition Uterine volume 1330 cc; four vascular intramural fibroids. B: One year after embolisation. Uterine volume 142 cc; one avascular fibroid. (Provided by A-M Belli) that can co-exist with uterine fibroids. Interventional radiologists should monitor the clinical outcomes of their patients closely and UFE can be achieved using a number of different keep up with published literature comparing approaches, though all require selective cathe- UFE to surgical strategies, Maskova said. terisation of both uterine arteries. Practitioners will also have their favourite embolic agent. Some “Gynaecologists have admitted that they should interventional radiologists prefer spherical partic- inform patients about fibroid embolisation as a les, whilst others opt for non-spherical particles. possible treatment option. Similarly, we should Refresher Course: Interventional Radiology Temporary agents, such as gelatine sponge, are tell patients about myomectomy if that appears used at a few institutions. Evidence in the literature to be the best option. We should know the best Saturday, March 7, 16:00–17:30, Room Q is not yet strong enough to make definite recom- way to treat individual patients,” she said. RC 809 Uterine fibroid embolisation mendations, Belli said. The cost of different embo- Moderator: lic agents may influence practitioners’ choice too. Belli agrees that interventional radiologists have J.-P. Pelage; Boulogne/FR a responsibility to explain clearly the pros and The procedure is not pain-free, and patients cons of UFE to prospective patients, and then A. Principles of UFE should be advised what to expect in terms of monitor their progress as a clinician would do. A.-M. Belli; London/UK discomfort, Belli said. Women undergoing UFE B. UFE versus myomectomy: What is the evidence? should also be told of the possible complica- “Interventional radiologists are not just techni- J. Maskova; Turnov/CZ tions and what signs to watch out for. Imaging cians who do the procedure and then wash their follow-up can be performed on either ultrasound hands of it, particularly with fibroid embolisa- C. Fertility after UFE S.A. Kapranov; Moscow/RU or MRI, though as before, the latter modality tion. They have got to see the women beforehand is recommended. Ultrasound may not show and then follow them up,” she said.

UFE can be achieved using a number of different approaches. These include percutaneous unilateral femoral artery puncture with selective catheterisation of each uterine artery in turn (A), as well as percutaneous bilateral femoral artery puncture with selective catheterisation of each uterine artery and simultaneous embolisation (B). (Provided by A-M Belli)

myESR.org Saturday, March 7, 2009 CLINICAL CORNER ECR TODAY 2009 11

Cardiac course organisers concentrate on myocardial perfusion and viability

By Karen Sandrick other imaging modality, an excellent overview Both MRI and PET/SPECT have strong negative to detect ischaemia. Adenosine is the preferred of the heart and detailed insight into specific predictive value for major adverse cardiac events. stress agent because it is safer and more conve- The popular categorical course on cardiac ima- aspects of cardiac function and anatomy,” said However, MRI does not require radiation, and it nient for patients. Adenosine stress perfusion ging will address hot topics within myocardial Prof. Dr. Jens Bremerich, from the department has better spatial resolution than nuclear ima- imaging is a robust tool. It is more sensitive and perfusion and viability during this afternoon’s of radiology, University of Basel, Switzerland. ging. MRI also provides information on function specific than scintigraphy; adenosine stress per- session. Presenters from Switzerland and the and tissue structure, which allows radiologists to fusion imaging has a sensitivity of 91% and spe- UK will discuss the pros and cons of a range “In the near future, stress perfusion MRI may identify valvular heart disease or cardiomyopa- cificity of 62% for the detection of coronary arte- of techniques, including MR perfusion, SPECT be used to exclude coronary artery disease thy, Bremerich said. ry disease. Adenosine MRI also stratifies risk for and PET. because of its strong negative predictive power. patients with suspected coronary artery disease Stress MRI cannot only exclude coronary artery Prof. Richard Underwood, director of nuclear and predicts major cardiac events. Patients with coronary artery disease die because disease but also identify infarct, myocarditis, and medicine at London’s Royal Brompton Hos- of hypoperfusion, not because of stenoses. Patients valvular disease,” he noted. pital, will review the current applications for Dobutamine, which is used when adenosine is often, in fact, have stenoses that do not severely cardiac SPECT and PET imaging and highlight contraindicated or clinicians need to evaluate compromise haemodynamics. Clinicians never- Attendees at this afternoon’s session will learn the strengths and limitations of the two nuclear dyssynchrony, has a sensitivity of 73% and spe- theless tend to focus on stenosis because they can about the role of MRI in the assessment of myo- medicine procedures. Dr. Richard Coulden, con- cificity of 83% in assessing myocardial viability. treat it with balloon angioplasty or bypass surgery. cardial ischaemia, the indications for performing sultant radiologist, University of Leicester, UK, Dobutamine also evaluates functional reserve stress MRI perfusion imaging and the value as will discuss the roles for stress echocardiography after treatment for tetralogy of Fallot. Rather than giving a static snapshot in time that well as the limitations of stress MRI. and MRI myocardial viability. Bremerich will indicates overall reduced blood flow because explain how MRI is used to evaluate myocardial These stress agents allow MRI to capture infor- of stenosis, imaging to assess stress-induced Myocardial perfusion imaging is still a cutting- perfusion by means of cardiac stress imaging. mation on cardiac function and perfusion that hypoperfusion provides a dynamic portrait of edge application of cardiac MRI that requires help determine whether patients are at risk of a the consequences of reduced blood flow. Stress- optimal hardware, software and user skills. Per- Cardiac stress MRI is indicated in patients who major adverse cardiac event, said Bremerich. induced hypoperfusion is an early indication of fusion imaging is highly demanding on both have suspected or known coronary artery disease the effect of significant coronary artery disease hardware and software because it requires ima- on the ischaemic cascade. The technique is par- ging a moving organ with optimal temporal, spa- ticularly helpful in identifying the lesion in pati- tial and contrast resolution. In the past, cardiac Categorical Course: Cardiac Imaging ents with multiple stenoses. MRI was hampered by susceptibility artefacts Saturday, March 7, 16:00−17:30, Room A from the surrounding lungs. Current MRI sys- Cardiac stress MRI also evaluates myocarditis, tems are overcoming this limitation with dedi- CC 817 Myocardial perfusion and viability and it may be useful for showing myocardial cated coils, parallel imaging and high magnetic Moderator: damage from ischaemia or inflammation in the fields, Bremerich said. A. Cuocolo; Naples/IT emergency department. A. Magnetic resonance perfusion imaging: While other imaging techniques can be used to When and how to stress the patient “Today, cardiac stress MRI is a second-line assess myocardial ischaemia, MRI is the standard J. Bremerich; Basle/CH modality for assessing the haemodynamic rele- of reference for evaluating myocardial viability. vance of coronary artery stenosis or for determi- Nuclear techniques, such as PET or SPECT, are B. Nuclear imaging: SPECT or PET? ning the severity of dyssynchrony. But cardiac not widely available and have low spatial reso- S.R. Underwood; London/UK stress MRI has the potential to become a first- lution. Stress echocardiography suffers from low C. Viability imaging: Which technique should we use? line modality because it provides, better than any reproducibility and strong observer bias. R.A. Coulden; Leicester/UK

ESOR european school of Radiology

GALEN Foundation Courses 2009

Abdominal/Urogenital Radiology Short-axis perfusion image during the first pass of gadolinium-based contrast material at adenosin stress (A) shows May 14–16 hypoenhancement of the anteroseptolateral wall (arrows). Rest image (B) shows homogeneous enhancement of left Sofia, Bulgaria

ventricular myocardium, thus indicating stress-induced hypoperfusion and ischaemia. (Provided by J. Bremerich) Oncologic Imaging June 18–20 Sarajevo, Bosnia & Herzegovina

Neuro/Musculoskeletal Radiology June 25–27 Ankara, Turkey

Chest/Cardiovascular Radiology October 15–17 Belgrade, Serbia

Paediatric Radiology November 12–14 Athens, Greece

The courses are aimed at residents in their 1st, 2nd or 3rd year of training in radiology. Further details on the courses and registration are available at www.myesR.org/esor.

An ESR initiative, in co-operation with GE Healthcare Medical Diagnostics South Central Europe.

PET/CT is making progress in the evaluation and analysis of cardiac disease. (Provided by Philips Healthcare)

myESR.org 12 ECR TODAY 2009 CLINICAL CORNER Saturday, March 7, 2009

emergency medicine involves being prepared for both the expected and the unexpected

By Mélisande Rouger GÖ: All patients have a physical examination, a large number have laboratory, blood and urinary Ahead of the ‘ESR meets Emergency Physi- analysis, and different types of examinations at cians’ programme presented today at ECR, the radiology department. ECR Today met the President of the European Society for Emergency Medicine (EuSEM), ECRT: How many beds are there in your Dr. Gunnar Öhlén from Stockholm, Sweden, department? How do you organise work so to learn more about the life of an emergency that there is always available space for new department and the importance of collabora- patients? tion with radiology. GÖ: We have about 40 outpatient beds and 71 inpatient beds for short stays, under 5 days. We are ECR Today: How would you describe the daily working a lot according to lean principles in order life of an emergency department? to improve our patient flow and work process. Gunnar Öhlén: You always have to be prepared to receive both the expected and the unexpected. ECRT: Are there any occasions on which your department might be overcrowded (heat wave, ECRT: When is the busiest period in an emer- acts of terror, large-scale accidents)? What gency department? protocols do you follow then? GÖ: Normally the number of patients builds up GÖ: In a situation of overcrowding it is always from 9–10am to be at the maximum between best to stick to your normal routines as long as 1–3pm. The number of patients is often some- possible before you go over to disaster treatment. what higher during the three first months of the year, depending on the number of infections. ECRT: Do emergency physicians perform ult- rasound (US) examinations themselves? If not, ECRT: How many patients do you treat in an do you think they should, and for which exa- average year? minations? GÖ: About 80,000 patients per year. GÖ: In my hospital the gynaecologists and cardi- ologists are very used to working with US on their Dr. Gunnar Öhlén has been the Head of the Emergency Medicine Department at the Karolinska University Hospital, ECRT: Is the emergency department divided own. Other specialists, like emergency physicians, Stockholm, for the past 13 years. into different sections in your hospital? are in a very early phase on the learning curve. GÖ: In the Karolinska University hospital, we have eight different specialities represented in ECRT: How would you describe your collabo- ECRT: Do you have regular meetings with the your cooperation with radiologists? Do you the emergency department: internal medicine, ration with radiologists? Could it be improved radiology department? think multidisciplinary meetings will help surgery, orthopaedic, infection, neurology, ENT, and if yes, how? GÖ: Yes, we are right now starting a very close your cooperation with other specialties? paediatrics and gynaecology. GÖ: Our collaboration with the department of process analysis of the interface between the ED GÖ: I think this is a good way to increase col- radiology is very good. In the future, I think a lot and the department of radiology, in order to save laboration. Radiology’s contribution to the ECRT: How many people work in your department? of emergency departments can benefit substanti- time in the process steps and hopefully also get EuSEM’s 2006 conference was very much appre- GÖ: 175 nurses and, during the course of a year, ally by increasing their dialogue with the depart- better quality! ciated by delegates. several hundred doctors. ments of radiology, with the aim of letting the radiologists decide what mode and technology ECRT: In Parisian hospital La Pitié-Salpêtri- ECRT: In your opinion, what are the challen- ECRT: What are the cases you see most often? can best answer the question being posed. ère, the radiology and emergency departments ges faced by emergency medicine today and in GÖ: A large number of patients are elderly pati- have signed a contract to regulate their coope- the future? ents with different kinds of diseases and younger ECRT: How do you work together with the ration. What do you think of such an idea? GÖ: The biggest challenge is to have emergency patients with more surgical and orthopaedic radiology department to gain time? Do you GÖ: I am very much in favour of this; structure medicine recognised as a basic specialty in its problems. In addition, we treat about 15,000 follow protocols to do so? and standardisation is always a good thing so the own right in all European countries. At the pre- children per year. GÖ: To improve our collaboration and work- ‘wheel is not invented again’ during late night sent time, it is recognised as a basic specialty in flow, we work in a structured way, with process hours. 17 countries. As far as the collaboration with ECRT: How do you diagnose those cases? What mapping, brainstorming for improvements, re- radiology, I think the biggest challenge during the procedures do you follow? Please, can you give designing processes and continuing step-by-step ECRT: Do you think the ‘ESR meets Emer- coming 10 years is around the development of the me some examples? improvements. gency Physicians’ initiative will be useful in use of US in the emergency medicine setting. News from esHNR – european society of Head and Neck Radiology

The European Society of Head and Neck The integration of imaging technology into the The molecular biological profile of patients may Further information can be obtained from our

Radiology (ESHNR), Europe’s premier therapeutic arena is also a reality today and be used in the future to stratify individuals into website www.eshnr.eu.

head and heck imaging society, welcomes will only improve with time. Neuronavigation risk categories. Imaging may then be used in a

anyone with an interest in head and neck using preoperative imaging has improved the screening mode for those at high risk of disease, The purpose of the Society is:

imaging. surgeon’s ability to find and resect smaller provided that early detection is accompanied by • to advance knowledge in the field of head lesions in the head and neck area. The same treatment options. and neck diagnostic radiology, interventional

Current scientific topics and future technology is applied to sinonasal and skull radiology and diagnostic imaging.

developments in head and neck radiology base surgery. Intraoperative imaging with MR These advances will certainly keep us in business • to stimulate interest in the field of head and

Where does imaging of the head and neck imaging, CT, and sonography will increase. over the next 5 to 10 years. After that, who knows? neck radiology

go from here? It is hard to imagine further Through the use of image guidance systems, In the field of head and neck imaging, higher • to promote research in head and neck radiology

anatomic advances, although the continued we will see further integration of imaging resolution imaging, metabolic information, • to improve methods of teaching radiological improvement of dedicated head and neck technology, not only in the operating room and the leverage that faster and more powerful diagnosis of diseases in the head and neck area

surface coils, higher field strength, and more but also in the radiation therapy department. computing will bring will certainly make for a • to provide meetings for the presentation of

selective contrast agents may indeed assist The fusion of CT and MR imaging and the bright future for our field. papers and the dissemination of knowledge us in the future to detect lesions at an earlier integration of these into the treatment- • to offer state of the art lectures, refresher

point in time. No doubt, the advances made planning environment will surely improve Education in head and neck radiology courses and interactive workshops on basic and

in MR imaging and spectroscopy and PET-CT the precision of radiation therapy treatment, To improve knowledge in head and neck advanced head and neck radiology topics

will improve our ability to detect recurrent which is long overdue. We are now entering an radiology the ESHNR will participate in the ESR • to foster the continuing development of head

cancer earlier. Advanced 3D workstations era when these advanced technologies will be fellowship programme and, together with the and neck radiology as a science

and new imaging systems combining CT and combined in a cohesive way to treat a patient. ESR, will finance a certain number of applicants • to improve dental and maxillofacial radiology

PET or CT and SPECT are a reality today. No longer will it be acceptable to have many for 3-month visits to one of our reference centres.

The integration of metabolic imaging devices different examinations performed on a patient Next meeting of the ESHNR

such as PET into the MR scanner, in which without the integration of this information In addition ESHNR is offering a fellowship The next annual meeting of the European Society

both high-resolution anatomic images as into a data set that is easily manipulated by the certificate to everybody who has received special of Head and Neck Radiology will be in Verona, Italy

well as metabolic profiles of this anatomy are treating physician, the radiation oncologist, or training in head and neck radiology. Candidates from October 1–3, 2009. For further information rendered, has just started. the head and neck radiologist. can apply after a well-defined training cycle. visit the congress website www.eshnr2009.org

myESR.org Saturday, March 7, 2009 CLINICAL CORNER ECR TODAY 2009 13

PR in the eR? Radiologists and emergency physicians settle their differences

By Paula Gould

A significant proportion of all diagnostic imaging studies performed in hospitals now originate in the emergency department. Although radiology has always figured prominently in the triage of emergency cases, this role is growing. Good working relationships between radiologists and emergency physicians are consequently more important than ever.

This afternoon’s ‘ESR meets’ session will bring the two sides together for 90 minutes of interdisciplinary dialogue. Such a meeting offers a valuable public relations opportunity and a chance to break down common misperceptions Dialogue between radiologists and emergency Prof. Borut Marincek, chair of the Institute of Ultrasound or CT? The debate is ongoing, according to about each other’s roles and priorities. physicians is mutually beneficial, according to Prof. Diagnostic Radiology at Zurich University Hospital, Prof. Dr. Gerhard Mostbeck, professor of radiology at Paul Parizel, chair of radiology at Antwerp University Switzerland, would like to see satellite radiology units the Wilhelminenspital and Otto Wagner Hospital and “Dialogue is mutually beneficial,” said Prof. Paul Hospital, Edegem, Belgium. in the emergency department, where possible. Medical Centres, Vienna. Parizel, chair of radiology at Antwerp University Hospital, Edegem, Belgium. “Radiologists CT is a viable option, then many radiologists would Radiology at Zurich University Hospital, hospitals, and this type of coverage is rarely sometimes think that emergency physicians leave out the ultrasound scan and go straight to CT. Switzerland, who will be co-presiding at the feasible. Teleradiology solutions can help to some ask for too many imaging studies or make These decisions depend to a great extent on the session. He would like to see satellite radiology extent, but ultimately radiologists must realise that inappropriate requests, even before having facilities available and the expertise of staff. units in the emergency department, where if they cannot provide the imaging services desired examined the patient clinically. Emergency possible. by emergency physicians, then the clinicians will physicians generally have the perception that The question of when to use ultrasound in the find a way to do it themselves, Parizel stated. radiologists don’t really understand the kind emergency setting and when to use CT is an “If the patient is entering the hospital at the of patients and stress situations that are being ongoing debate, said Prof. Dr. Gerhard Mostbeck, emergency department, then that’s where “Radiology is not just about sitting behind a handled in the emergency room.” professor of radiology at the Wilhelminenspital radiology has to be,” he said. PACS monitor with some soft music on in the and Otto Wagner Hospital and Medical Centres, background and a cup of good coffee within Parizel will be tackling the daunting topic of Vienna. Ultrasound can visualise abdominal, Emergency departments in major urban areas in easy reach,” he said. “Radiology sometimes patient triage with imaging: should ultrasound, pleural and pericardial fluid, and identify cases of the United States are often much larger than their means going down to the emergency room and CT, or MRI be used? The answer, not surprisingly, pneumothorax. Multislice CT, on the other hand, is European counterparts. It is not uncommon to providing services to those patients who are in depends on a number of variables. The specific more sensitive than ultrasound for the vast majority have one or more dedicated senior staff radiologists dire need of imaging, where imaging can really clinical scenario, patient stability, hospital of abdominal, retroperitoneal, and thoracic trauma available around-the-clock at these U.S. sites, in make a difference in deciding what management facilities and staff expertise all play a part in the injuries. A CT scan can also provide diagnostic addition to radiology residents and/or fellows. strategy to follow.” decision-making process. information on brain, facial and spinal injuries that Staffing levels are typically lower in European cannot be acquired from ultrasound. In the case of suspected brain injury, then the choice will typically be between CT and MRI. “In my experience, the role for ultrasound is quite This dilemma applies equally to traumatic small in the case of polytrauma patients if you have injuries, such as brain haemorrhage, and to non- a dedicated CT unit in the emergency department. traumatic neurological emergencies like stroke. If it is going to take 20 minutes to take the patient For patients presenting with abdominal trauma, to a CT scanner in another building, then things then doctors have another decision to make will probably look quite different,” he said. between CT and ultrasound. Here, the value of a FAST scan (focused assessment with sonography Of course, the best approach in theory may in trauma) is often regarded quite differently by not always be practical. For example, what emergency physicians and radiologists. if a patient living in a remote area suffers multiple injuries at night when the weather is “If you look at the literature, you find a number of bad and rapid helicopter transfer to hospital papers from emergency or surgical departments is out of the question? The issue of time then that claim focused ultrasound is the way to go becomes more critical. Should the patient be when triaging these patients,” Parizel said. “At driven to the nearest hospital that does not the same time, there are a number of papers have a multislice CT scanner but does have an coming out of radiology departments that are experienced ultrasonographer? Or should the more cautious.” journey be extended and the patient taken to a larger hospital that offers an out-of-hours MSCT Radiologists are likely to take the view that if trauma service? It all comes down to optimal CT is unavailable or the patient is unstable, then patient management, Mostbeck said. ultrasound is the best choice. The modality may not be as sensitive as CT, but it will provide a Radiology services need to adapt to the needs of certain amount of critical diagnostic information patients, said Prof. Borut Marincek, President of very quickly. If the patient is relatively stable and ECR 2009 and chair of the Institute of Diagnostic

ESR meets Emergency Physicians

Saturday, March 7, 16:00–17:30, Room C EM 2 Time is life Presiding: B. Marincek; Zurich/CH I.W. McCall; Oswestry/UK G. Öhlén; Stockholm/SE

• Introduction B. Marincek; Zurich/CH G. Öhlén; Stockholm/SE • Ultrasound as a time-critical diagnostic tool for the emergency department P.K. Thompson; Rockhampton, QLD/AU • The ultrasound issue: Radiologist’s view G.H. Mostbeck; Vienna/AT • Overcrowding flow in the emergency department M. Cooke; Warwick/UK • Image triage: Ultrasound, CT or MRI? P.M. Parizel; Antwerp/BE • Panel discussion

myESR.org 14 ECR TODAY 2009 CLINICAL CORNER Saturday, March 7, 2009

Tracking cells and new professional perspectives

By Mélisande Rouger

What if radiologists could play an active part in curing Parkinson’s disease or cancer? Thanks to cell imaging, this possibility no longer seems quite so remote. As cell therapy has been refin- ing itself over the past six years, researchers now want to be able to see transplanted cells evolving in the body to understand their action. A dedicated session at ECR 2009 will let radiologists foresee how they can get involved in the process by providing an update on the latest trends in cell imaging.

Brains, hearts and livers damaged after a stroke or in the course of a degenerative pathology are currently repaired in pre-clinical research by transplanting stem cells, which can renew themselves and replenish specialised cells. Although their benefit is undeniable, it is still Liver cell transplantation: Transverse MR image of unclear how they really act in the repair pro- the liver in a mouse 8 days after intraportal injection cess. This is where imaging could play a key of 8x105 labelled hepatocytes, showing mutliple foci role, researchers believe. “We don’t understand of low signal intensity (arrow), in the right side of the the mechanisms yet; exactly how cells act,” said Dr. Mike Modo, a neuroscientist at Kings’ College, London, will demonstrate the use of MRI in imaging cell transplants. liver (Luciani A et al, Eur Radiol 2008;18:59-69) Olivier Clément, Professor of Radiology at the Hôpital européen Georges Pompidou, Paris, and chairman of the ECR session. contrast agents are by far the most popular, fight the disease in case of resurgence. Trans- In the end, cell therapy itself needs to be more being used in 99% of all experiments. But they planted pancreatic cells in diabetes, which pro- developed to move forward. It is still a very Cell imaging could even be useful in monitor- provide a negative signal – a hypointensity in duce insulin, should also be made visible in the young field, and no one knows exactly how ing whether there is an inflammatory response T2-weighted scans – that might lead to confu- human body within three to four years. it will evolve. For instance stem cell lines can occurring in certain diseases, and if anti- sion with other signals such as air or blood. theoretically be developed indefinitely, but inflammatory drugs are successful, according Gadolinium, which offers a positive signal – a The potential to go on to the clinical stage is problems might still arise in the process. More to Dr. Mike Modo, a neuroscientist at Kings’ hyperintensity in T1-weighted scans – avoids here, but a number of regulatory questions research in this area is needed to be able to College, London. “In multiple sclerosis for potential misinterpretation, but generally pro- must be answered first. Issues such as the toxic- define what is really going to work and what instance, we have the case of infiltrating mac- vides a weak signal. Finally, fluorine contrast ity contained in contrast agents and their long isn’t. “Things will change over time but the rophages, and if you use an anti-inflammatory, agents could be a significant alternative, since term effect inside the cells, but also whether or only way to find out is to do the work,” con- you want to reduce the infiltration, so to be the region is naturally poor in this element, thus not agents need to be cleared from the body, cluded Modo. able to visualise macrophages would be of great affording very specific imaging of transplanted have not yet been fully addressed. They will be value,” he said. cells. Unfortunately, none of these approaches at ECR, Clément promised. is really ideal, conceded Modo, who hopes for Combined with adapted contrast agents, MRI new developments in contrast agents. offers the possibility of tracking transplanted New Horizons Session cells and macrophages in the human body. Optical cell imaging will also constitute a This modality, but also others such as optical chapter in the ECR session. But it is far less Saturday, March 7, 08:30–10:00, Room C imaging, will be presented during the session. developed than MRI for human applications, NH 5 Cell imaging: Can the radiologist see the cell? Applications rather than specific details on mainly because it uses fluorescent contrast the compounds of the physics will enable par- agents that colour the body. Speakers will also • Chairman’s introduction ticipants to grasp the basics of cell imaging. In talk of the interest in PET and SPECT in cell O. Clément; Paris/FR his presentation ‘Imaging cell transplants with imaging, and explain how to label cells with • Labelling and manipulating the cell with USPIO MRI’, Modo will show how to follow trans- ultrasmall superparamagnetic iron oxide F. Gazeau; Paris/FR planted stem cells from their point of injec- (USPIO) markers using MRI. tion in the body to where they effect repair in • Imaging cell transplants with MRI strokes. “The aim is to demonstrate how we If most of the pre-clinical work has been done M. Modo; London/UK can use MRI to understand that,” he explained. in neuro imaging so far, research has also been • Dynamic cell imaging of cancer invasion with optics gathering pace in heart and liver imaging. Cell P. Friedl; Nijmegen/NL MRI is currently the most appropriate tool for imaging is also progressing in anti cancer vac- • Panel discussion: cines, using dendritic cells removed from the visualising transplant cells in the brain. Three Cell imaging: Is it ready for clinical use? kinds of MRI contrast agents exist. Iron-based cancer once it is extracted from the body, to

staff Box

editorial Board esR executive Council Gabriel P. Krestin, Rotterdam/NL Managing editors Art Direction Research Committee Chairman Julia Patuzzi, Vienna/AT Petra Mühlmann Iain W. McCall, Oswestry/UK Philip Ward, Chester/UK Éamann Breatnach, Dublin/IE esR President Graphic Designer Education Committee Chairman sub-editor Robert Punz Christian J. Herold, Vienna/AT Luís Donoso, Sabadell/ES Simon Lee, Vienna/AT esR 1st Vice-President Professional Organisation Marketing & Advertisements Maximilian F. Reiser, Munich/DE Committee Chairman Contributing Writers Erik Barczik esR 2nd Vice-President John Bonner, London/UK E-mail: [email protected] Fred E. Avni, Brussels/BE Sarah Edwards, Vienna/AT subspecialties Committee Chairman Borut Marincek, Zurich/CH Paula Gould, Holmfirth/UK Contact the Editorial Office Congress Committee Chairman Guy Frija, Paris/FR Emily Hayes, San Francisco, CA/US ESR Office National Societies Committee Chairman Monika Hierath, Vienna/AT Neutorgasse 9 Małgorzata Szczerbo-Trojanowska, Lublin/PL Simon Lee, Vienna/AT 1010 Vienna, Austria st 1 Vice-Chairperson Luigi Solbiati, Busto Arsizio/IT Lucie Motloch, Vienna/AT Phone: (+43-1) 533 40 64-16 of the Congress Committee Communication & International Relations Stefanie Muzik, Vienna/AT Fax: (+43-1) 533 40 64-441 Committee Chairman Yves Menu, Paris/FR Julia Patuzzi, Vienna/AT E-mail: [email protected] 2nd Vice-Chairman András Palkó, Szeged/HU Mélisande Rouger, Vienna/AT of the Congress Committee Finance Committee Chairman Frances Rylands-Monk, St. Méen Le Grand/France ECR Today is published 4x during ECR 2009. Karen Sandrick, Chicago, IL/US Circulation: 20,000 Adrian K. Dixon, Cambridge/UK Peter Baierl, Vienna/AT Printed by Angerer & Göschl, Vienna 2009 Publications Committee Chairman executive Director myesR.org

The Editorial Board, Editors and Contributing Writers make every effort to ensure that no inaccurate or misleading data, opinion or statement appears in this publication. All data and opinions appearing in the articles and advertisements herein are the sole responsibility of the contributor or advertiser concerned. Therefore the Editorial Board, Editors and Contributing Writers and their respective employees accept no liability whatsoever for the consequences of any such inaccurate or misleading data, opinion or statement. Advertising rates valid as per January 2009. Unless otherwise indicated all pictures © ESR – European Society of Radiology

myESR.org Saturday, March 7, 2009 CLINICAL CORNER ECR TODAY 2009 15 swiss and spanish presenters put eCR delegates to the test in breast interventions

By Emily Hayes provide important information about lesion size, lymph node status and extensive intra- Nowadays, a number of options are open to ductal component extension to the nipple- women with breast cancer, depending on areola complex, the pectoralis muscle or the the nature and stage of their malignancy. As skin. masters of a range of imaging modalities, radiologists can help not only to diagnose Lymphadenectomy used to be routinely per- patients accurately but also to get them on formed in breast cancer patients after surgi- the best treatment path and chart their pro- cal biopsy, but the preferred technique today gress over time. is sentinel lymph node biopsy to determine cancer spread. Unaffected lymph nodes can “The radiologist’s role in treatment planning be left in place. has changed dramatically over the last five years. If you know what the surgeon requi- “This reduces the side effects of swelling and res for planning, then you can speed up the limited movement of the arms associated process by organising subsequent steps,” with extensive axilla surgery,” Kinkel said. said Dr. Karen Kinkel, associate professor of radiology at the University Hospital Geneva However, sentinel lymph node procedures in Switzerland. are only suitable for some patients, such as those who have unifocal cancer, and other Along with Dr. Julia Camps-Herrero, a women may still need to undergo traditional radiologist at the Hospital de la Ribera in lymphadenectomy. Many factors guide the Valencia, Spain, Kinkel will be co-lecturing decision about appropriateness of sentinel at a Saturday afternoon session on breast lymph node biopsy. cancer diagnosis, staging and follow-up. The duo will review the use of various modalities “These rules are not well known by radio- in making the initial diagnosis, determining logists,” she pointed out. “But a radiologist response to neoadjuvant chemotherapy, fol- working in a multidisciplinary team should lowing patients after surgery and confirming know them to help the surgeon to plan sur- suspected recurrence. g e r y.”

Using real-life case studies, Kinkel and MRI is viewed as the most accurate imaging Camps-Herrero will take turns testing con- modality for local staging, aside from lymph gress attendees during the session, which node assessment. In particular, the modality forms part of a series of European Excellence has proven to be superior for determining in Education Interactive Teaching Sessions. the size of a specific lesion and helping to Other sessions in the series cover imaging show whether cancer is present in the con- of low back pain, prostate cancer, colorectal tralateral breast. cancer and the acute abdomen. Use of breast MRI prior to surgery has incre- Kinkel will devote considerable lecture time ased dramatically during the past year or so, to ultrasound and mammography, both because ground-breaking research showed commonly used in interventional breast the modality’s value in finding occult cancer procedures. In Europe, practice tends to be in the contralateral breast. Previously, the organised more by organ systems and less technique was mainly used for patients with by technique, so radiologists are expected to dense breasts or for assessing certain types of have a good grounding in all modalities used malignancies, such as invasive lobular can- in guiding biopsies, she said. cer.

Whereas surgical biopsies were standard in In Switzerland, among other countries, breast the past, image-guided biopsies using either MRI is now routinely performed before sur- ultrasound or mammography are now the gery, said Kinkel, who is a co-author of the procedure of choice for assessing suspicious recently published breast MRI guidelines breast lesions. Use of 9-gauge to 14-gauge from the European Society of Breast Imaging needles and vacuum-assisted systems helps (Eur Radiol. 2008 Jul;18(7):1307-18). cut down on the number of false negative results. If breast MRI indicates additional suspicious findings, radiology departments can antici- Thanks to diagnostic improvements and pate what other follow-up studies and proce- greater participation in mammography pro- dures will be needed and can schedule them grammes, radiologists are detecting more in advance, instead of waiting to be instruc- lesions before they are palpable, and these ted to do so, she noted. findings should be thoroughly documented.

After a malignancy is detected, the first thing a surgeon wants to know is whether the can- cer is in situ or invasive. Imaging studies also

E³ − European Excellence in Education Inter active Teaching Session

Saturday, March 7, 14:00−15:30, Room E2 E³ 720 Breast cancer: Diagnosis, staging and follow-up Craniocaudal (A) and mediolateral (B) mammographic images in a 60 year-old woman after preoperative localisa- Moderator: tion of two foci show biopsy-proven invasive ductal cancer in the upper left breast. The 10 mm lesion in the upper M.G. Wallis; Cambridge/UK outer quadrant (wire with clip) was identified at screening mammography and biopsied using ultrasound guidance. The 5 mm lesion in the upper inner quadrant (wire without clip) was identified at staging breast MRI and biopsied K. Kinkel; Chêne-Bougeries/CH at second-look ultrasound after MRI. Large breast volume compared to small tumour size allowed double breast- J. Camps-Herrero; Valencia/ES conserving surgery with negative tumour margins, although preoperative diagnostic and interventional breast imaging indicated bifocal breast cancer in two different quadrants. (Provided by K. Kinkel)

myESR.org 16 ECR TODAY 2009 CLINICAL CORNER Saturday, March 7, 2009

MR imaging and ultrasound can reveal early signs of rheumatoid arthritis in patients

By Paula Gould period of time is suggestive of chronic disease or a reduction in inflammatory activity. Rheumatoid arthritis (RA) affects approximately 2.9 million people in Europe, and it can be difficult Scoring criteria based on MRI observations are to differentiate from other degenerative arthritic being developed so that disease progression and conditions. Without an early diagnosis, however, therapy response can be assessed more objec- it is impossible to assess the true effect of promi- tively. Measurements may include the thickness sing early intervention strategies. Could an alter- of the inflamed synovium, the brightness of syn- native diagnostic imaging strategy be the answer? ovial contrast enhancement, and the area affected by BMEP. Speakers at this morning’s special focus session will address the value of ultrasound and MRI Glaser regards MRI and ultrasound as comple- in diagnosing RA and monitoring the effects of mentary tools rather than rivals for the diagnosis therapy. Both of these modalities are used in the and follow-up of RA. Ultrasound has unparalleled research setting to characterise inflammatory spatial resolution when applied to small joints, arthropathies, detect changes in disease pro- though its value depends on the experience of the gression, and/or identify responses to treatment user. MRI results are far less dependent on opera- before such changes become clinically apparent. tor expertise. Routine implementation is now just a matter of time, according to the session’s chair, Dr. Andrew “It would be very practical for a doctor diagnosing Grainger, musculoskeletal radiologist at the Leeds or treating a rheumatology patient to use ultra- Teaching Hospitals NHS Trust, UK. sound to examine a specific small joint, perhaps in a finger or toe, to assess a pattern of destruction Studies have shown that ultrasound can demons- or inflammatory activity,” he said. “With MRI, you trate the hallmarks of inflammatory arthropa- RA in a metacarpophalangeal joint. Longtitudinal ultrasound shows synovitis, neovascularity, and early erosion of can get a complete overview of the hand, wrist or thy with good sensitivity and specificity, said the metacarpal head. Vascular ingrowth into the erosion is also observed. (Provided by P. O’Connor) ankle area, and you can visualise regions deeper Dr. Philip O’Connor, who is also a musculoskel- in the body not readily accessible to ultrasound.” etal radiologist at the Leeds Teaching Hospitals NHS Trust. A definitive diagnosis of RA is typi- O’Connor agrees that ultrasound and MRI can cally made when these imaging findings are com- work well together. Software packages are now bined with clinical signs, a patient’s history, and available that allow 3D MRI datasets to be regis- biochemical information. tered to an ultrasound examination in real time. As the ultrasound probe is moved across the pati- “I have been using ultrasound in rheumatoid ent, the MR images shown will re-orientate to arthritis since 1996,” he said. “It adds a lot to the the same position. Findings from each modality clinical examination and it adds a lot to clini- can be correlated with one another and new tech- cal management and decision-making in these niques validated. patients. If you had a close relative with early inflammatory arthritis, you would want them to Ultrasound is likely to make the transition from have an ultrasound scan to determine what was research tool to clinical practice more easily going on inside those joints.” than MRI, O’Connor said. The modality is che- aper, and examinations are more comfortable for Contrast-enhanced MRI has the potential to patients. Concerns over reproducibility may be speed up definitive diagnoses of RA, according to eased by the introduction of 4D techniques where Dr. Christian Glaser, radiologist at the University blocks of data are acquired. However, ultrasound Hospital of Munich-Grosshadern, Germany. Pati- remains a hands-on modality, and advances in ents attending the Munich hospital are already MRI-ultrasound fusion. Axial section of a metacarpophalangeal joint affected by erosion and synovitis in a patient technology will not obviate the need for good with RA. (Provided by P. O’Connor) referred for an MR examination if doctors suspect training. RA but the clinical signs are unclear. row edema pattern (BMEP). This appears as regi- defects in the bone, you are likely to proceed to “The problem is that there is no real training pro- The earliest indication of RA is the appearance ons of “fluffy” hyperintensity in the affected areas joint destruction,” he noted. gramme in radiology built around inflammatory of synovitis. This finding is seen in osteoarthritis of bone, Glaser said. BMEP typically precedes arthritis scanning with ultrasound,” he noted. “It too, though it is much less common and severe. structural changes to the bone known as erosions. Dynamic contrast-enhanced MRI can be espe- is my belief that this will become a rheumatolo- Contrast-enhanced MRI can detect synovitis as These bite-like defects in the cortical bone indi- cially helpful. Studies suggest that a rapid rise gical procedure. Rheumatologists are developing early as two months after the onset of symptoms. cate the onset of irreversible damage. in enhancement in affected joints, shortly after their own training schemes and courses. I don’t contrast is administered, can be taken to indicate think radiologists have the time or manpower to Another early stage in disease progress is inflamm- “These bony erosions are very slow to heal, if they the presence of an active inflammatory process. offer this service.” atory invasion of the bone marrow, or bone mar- heal at all. If you have many erosions and cartilage A steadier increase in enhancement over a longer

Special Focus Session

Saturday, March 7, 08:30–10:00, Room L/M SF 5b Rheumatoid arthritis

• Chairman’s introduction A.J. Grainger; Leeds/UK • US in early diagnosis and monitoring P.J. O’Connor; Leeds/UK • MRI in early diagnosis and monitoring C. Glaser; Munich/DE • Dynamic contrast-enhanced MRI: When and how? R.J. Hodgson; Leeds/UK • Scoring systems for monitoring M. Østergaard; Hvidovre/DK • Panel discussion: Advanced imaging techniques: Ready for the daily routine? Is US left for rheumatologists?

Dynamic enhancement MRI study before and after administration of a therapeutic anti-TNF-alpha blocking agent. (Provided by C. Glaser)

myESR.org Saturday, March 7, 2009 TECHNOLOGY FOCUS ECR TODAY 2009 17

Studies on combining Fully automated 3D Three-dimensional 2D and 3D angiography segmentation of presentation of InSIDe ToDay data liver tumours cerebral vaculature

See page 18 See page 22 See page 23

Emergence of elastography gives renewed impetus and vigour to ultrasound market

By John Bonner we are able to acquire data at a rate of 10,000 Smart Touch Control Panel to give the opera- frames per second. Conventional cardiac tor better control of the system and to improve Elastography is one of the emerging technolo- ultrasound machines can capture 200 to 500 the screen display. gies on display at ECR 2009, reflecting the gro- images per second, so our produce is more wing importance of imaging techniques that than 10 times faster.” The company states that its latest offering compare the inherent stiffness of healthy and provides the highest image quality optimised abnormal tissues in advancing the diagnostic The Aixplorer scanner provides quantifiable patient-to-patient with one key operation value of ultrasound. Elastography’s clinical measurements of tissue stiffness. The transdu- using the PSS (Patient Specific Selector) func- applications will be discussed at two separate cer sends the pulses necessary to generate tissue tion. This also allows the operator to employ lunchtime satellite symposia on Saturday and deformation. A disadvantage of previous systems combinations of multiple scanning parame- Sunday, and they look certain to be popular is that they require the operator to compress the ters and sophisticated signal processing tech- events. tissue, and so the results may depend on that nologies which can be customised and swit- person’s skills and training, he explains. ched simultaneously in one key operation. The principles behind elastography may date Above all, it offers next level performance back to the earliest days of medicine, when SuperSonic’s technology was developed ini- on many Hitachi original technologies, such Hippocrates and his followers used manual tially for use in breast imaging, but there are as real-time tissue elastography and is com- palpation to help characterise tumours, but plans to develop a number of other clini- patible with the company’s extensive range there is nothing old-fashioned about the tech- cal applications, including the detection of of transducers while introducing new single nologies for further developing those con- thyroid nodules, liver fibrosis and prostate crystal probe technology, the company says. cepts. They are visible to all ECR delegates in disease. The company’s satellite symposium the technical exhibition. will take place tomorrow from 12:30 to 13:30, Another ultrasound satellite symposium will and it will follow on from today’s lunchtime be held tomorrow from 12:30 to 13:30. Orga- Established in 2005, SuperSonic Imagine is symposium about real-time tissue elastogra- nised by GE Healthcare, the meeting is entitled based in Aix-en-Provence, France, and is phy organised by Hitachi Medical Systems. ‘Agile acoustic architecture, the most recent making its first appearance at the congress. innovation in modern ultrasound’. The vendor Its Aixplorer scanner incorporates ideas from Hitachi has 25 years’ experience in designing plans to highlight the clinical utility of its new a surprising source to meet the demand for and manufacturing ultrasound systems and LOGIQ E9 platform. This unit incorporates ever faster processing of ultrasound data – the ECR 2009 will be unveiling its latest platform, the company’s proprietary Agile Acoustique video games industry. HI VISION Preirus, which features a new sys- architecture, and is based on Beamformer tem architecture developed through collabo- technology. It can process up to 3 GB of data Philips continues to expand the clinical capabilities of “Companies that make these games have very ration between the company’s imaging divi- per second, which is around 30 times faster its premium iU22 platform. similar requirements to our own. They need sion and its central research laboratory. Two than conventional ultrasound machines. to process a huge amount of data very quickly of the key benefits of the new product are its if the movement of figures on the screen is to flexibility and user-friendliness, and it has a By combining high technical specifications “I believe ABVS can make a significant con- appear life-like,” says the vendor’s founder and unique ergonomic design that adapts to any with a range of advanced applications, GE tribution in diagnostic confidence for women CEO Jacques Souquet. “So we have adapted scanning environment, style of examination is hoping to change the way that ultrasound with dense breast tissue and inconclusive some of the key hardware elements – micro- and operator position, according to Hitachi. is used within a typical hospital radiology mammograms. Examinations performed with processors, graphics boards – to be part of our Its second-generation Graphical User Inter- department. this new technology generally take less than software-driven technology. The result is that face combines extra-wide image display with a 15 minutes, which is time well spent if you “Ultrasound has always stood apart from the consider the extended diagnostic capabili- rest of the work in the department, and it has ties of ultrasound in dense breasts,” observed been seen as something of a side-line,” said Bernd Montag, CEO of Siemens’ imaging and Pierre Radzikowski, marketing manager for IT division. the company’s European ultrasound busi- ness. “But with our system’s fusion imaging tool, we can provide information that can be The technical exhibition area is open combined with previously acquired informa- today from 10:00 to 18:00. tion from CT, MR or any other DICOM data source. Ultrasound can be repositioned as a key modality in the diagnosis, treatment plan- ning and monitoring of interventions.” ZONARE Medical Systems, based in Mountain View, California, has also been investigating Side-by-side fusion imaging of real-time high-frequency The thoracic diaphragm wall was examined using a The product’s V Nav package offers the GPS new solutions for imaging challenging pati- ultrasound and MR images show the paediatric spine high-frequency matrix linear transducer. function. This tool allows the clinician to ents. At ECR, it is demonstrating technology in a neonate with meningitis. (Provided by GE Healthcare) track markers in the patient’s body placed on designed to provide better quality imaging (Provided by GE Healthcare) lesions, erosions or other anatomical features. of patients who are overweight, elderly, very The positional information can be stored on muscular, or who have a thick body wall. The the unit’s hard-drive and compared with the company has created new proprietary software images obtained on follow up to check the effi- for its ZONE Sonography technology. cacy of treatment. “When combined with our new C3-0.5 trans- GE is not the only imaging giant to be unvei- ducer, clinicians have an important new tool ling its latest hardware at ECR 2009. Siemens for imaging their most technically difficult will demonstrate the capabilities of the Acu- patients with advanced image clarity,” said son S2000 Automated Breast Volume Scanner Lars Shaw, ZONARE’s vice-president for mar- (ABVS), a multi-use, automated volume breast keting. ultrasound system. This automatically and quickly acquires full-field sonographic volu- Finally, Philips has announced the Vision 2009 mes for comprehensive review and diagnosis upgrade, a fourth major enhancement of its of the breast, streamlining workflow and redu- iU22 product. The iU22 ultrasound unit now cing operator dependence and variability. The offers tissue aberration correction on breast system also features the intuitive, anatomical transducers to compensate for speed of sound 3D contrast-enhanced ultrasound vascular rendering Pre-procedure liver imaging: dual-view fusion imaging coronal plane, which is not available using variations of dense tissue, improving detail of a colon cancer metastasis. of real-time contrast-enhanced ultrasound with conventional ultrasound. This view provides resolution and conspicuity of lesion details. (Provided by GE Healthcare) previously acquired CT volume dataset. (Provided by a more understandable representation of the T. De Baère, Institut Gustave-Roussy, Paris) global anatomy and architecture of the breast.

myESR.org 18 ECR TODAY 2009 TECHNOLOGY FOCUS Saturday, March 7, 2009

ECR’s new Technology Highlight Area hosts full scale model of Siemens’ latest innovation

By Simon Lee The unit features a gantry that rotates around its own axis in just 0.28 seconds, providing a scan In keeping with the character of the European speed of 43 cm per second with a temporal re- Congress of Radiology and its trend for breaking solution of 75 milliseconds, which for example new ground, this year’s congress will see another enables a thoracic examination to be carried out first. On the 1st Level, at the heart of the Austria in 0.6 seconds, eliminating the need for breath- Center, you will find the newly established ‘Tech- holds. Due to this high speed, the SOMATOM nology Highlight Area’. This island of technology Definition Flash also enables the heart to be exa- in an area predominately populated by publishers mined at impressively low radiation doses, inclu- will be the temporary home of the first full-scale ding the possibility of performing heart examina- model CT scanner ever to be displayed at the ECR. tions in the sub-mSv range.

We have opened up this zone of the congress venue We are proud to help Siemens Healthcare show to Siemens Healthcare, who will bring with them a off their latest development and delighted they one-to-one model of their brand new SOMATOM have chosen to demonstrate a full size model of Definition Flash; a new dual-source CT scanner this product at the European Congress of Radio- that boasts not only the fastest scanning speed in logy. Visit the Technology Highlight Area and see Siemens’ Somatom Definition Flash: A new CT device combining unprecedented scan speed and lowest dose. CT but also extremely reduced radiation doses. it in action! (Provided by Siemens Healthcare) Reconstruction of flow dynamics by combining 2D and 3D angiography data: A feasibility study

By Guoyan Zheng1, Jan Gralla2, Gerhard Schroth2, Andreas Raabe3, Lutz-Peter Nolte1, Stefan Weber1; Bern/CH

Intracranial aneurysms are relatively common. A recent review reported a prevalence of 0.4% and 3.6% in retrospective and prospective auto- psy studies, respectively, and 3.7% and 6.0% in retrospective and prospective angiographic stu- dies, respectively. Most aneurysms are asympto- matic and will not rupture, but they grow unpre- dictably and even small aneurysms carry a risk of rupture.

In neuroradiology, three-dimensional rotatio- nal angiography (3D-RA) and 2D digital sub- straction angiography (DSA) are two imaging techniques among others for the diagnosis and monitoring of intracranial aneurysms. These two imaging means provide complementary infor- mation about intracranial aneurysms. On the one hand, 3D-RA provides highly accurate ima- ges of the vessel geometry, which are essential for making a diagnosis and the planning of inter- ventions. On the other hand, additional insight about the vascular disease can be gained if the A: Initial example of available digital subtraction angiography data with overlay of 3D vessel model of Carotis interna. B: Registered 3D vessel model with colour coded flow (i.e. flow dynamics and the effective blood volume contrast) information.(Provided by ARTORG Center) flow to the brain are precisely measured. To date, such information has been obtained from digi- 3D rotational x-ray angiography data, as well as Data preparation: A surface model of the visible Our first results demonstrate that it is feasible tal substraction angiography with a high spatial 2D biplanar angiograph data (Siemens Axiom vessel structures was interactively segmented to reconstruct 3D blood flow information in 3D and temporal resolution. However, DSA as a 2D Artis Zee Angio; Resolution: 2000x3000 Pixels), from the 3D-RA data using Amira (Mercury rotational X-ray angiography from 2D biplane imaging means lacks depth information. Thus, were acquired after administration of a contrast Computer Systems GmbH, Berlin, Germany) and angiography, which provides additional informa- it is clinically difficult to precisely estimate flow agent to a patient with an aneurysm in the left then registered to the biplanar angiograph data. tion for clinical decision making. dynamics in biplanar DSA imaging. The goal of carotis interna. Each contrast flow intake was this work is to investigate the feasibility of map- imaged (f = 26 fps; t = 5 sec). The 2D biplanar Reconstruction of flow dynamics: Flow informa- 1 ARTORG Center – ISTB, University of Bern ping the blood flow information offered by 2D angiograph data were acquired at a roughly tion was then reconstructed by means of a for- 2 Department of Interventional and Diagnostic biplane angiography into 3D vessel models that orthogonal angle, with one acquired along the ward projection of all vessels’ surface segments Neuroradiology, Inselspital, University of Bern areAZ_ECR-2009_k21 extracted from a reconstructed19.01.2009 rotational13:31 Uhr anterior-posterior Seite 1 (AP) direction and the other to both biplanar projections series capturing the 3 Department of Neurosurgery, Inselspital, University of Bern angiography data set. along the lateral-medial (LM) direction. propagation of the contrast agent. In more detail, due to the fact that the 3D surface model is alig- Premium quality ned with the biplanar angiograph data, for each surface segment we can always find the corre- PROTEC’s digital solutions today Expo C sponding two pixels in AP and LM images, res- comprise CR-systems, retrofit DR- booth 343 pectively. Subsequently, the corresponding grey systems, as well as medical imaging values of the two pixels (one in the AP image and software systems CONAXX and PROPAXX. the other in the LM image) at each time frame are projected to the 3D vessel surface segment. Visit the An outstanding advantage of RAPIXX DR-flatpanels is the opportunity to benefit The mean value of these two pixel values is taken from the comfort in handling/workflow and as the concentration of the contrast agent at the IMAGINE Area speed of a direct-radiography system while surface segment. Combining all time frames, we nd avoiding the investment into a new X-ray can obtain a reconstruction of the flow dynamics on the 2 level unit – just keep the existing X-ray unit and along the 3D vessel surface model. To better visu- integrate the RAPIXX retrofit DR-systems! alise the flow dynamics, the reconstructed con- Come and see latest product novelties centration of the contrast agent along the 3D ves- at the PROTEC ECR booth located in sel model at each time frame was colour-coded. Expo C, booth 343. PROTEC® GmbH & Co. KG · medical systems More quantitative information about the flow Lichtenberger Str. 35 · D-71720 Oberstenfeld dynamics can be obtained from the reconstructed [email protected] · www.protec-med.com dynamic models. myESR.org Saturday, March 7, 2009 TECHNOLOGY FOCUS ECR TODAY 2009 19

EIBIR leads the way with original research into cell therapy

By Monika Hierath jects 1 to 3 and develop specific tools relevant to 5 major fields of cell therapy application. Within The European Institute for Biomedical Imaging each of the work packages, staff have been hired Research (EIBIR) has taken over the coordi- and initial studies have been started. nation of a European large-scale research pro- ject. An international research group from ten Studies relevant to cellular imaging of de novo countries will develop imaging technologies and tissue formation and in vivo imaging of cell fate, methods in the area of cell therapy. in vivo visualisation of neurogenesis and angio- genesis are in progress and plans relevant to task EIBIR was founded in January 2006 and is a non- simultaneous monitoring of graft survival and profit, limited liability company with more than immune response are being made. As far as the 230 member institutions from 27 countries. The musculoskeletal field is concerned, studies with mission of EIBIR is to co-ordinate and support regard to the characterisation of musculoskeletal the development of biomedical imaging techno- tissues at physiological and pathological states logies and the dissemination of knowledge with and stem cell tracking in musculoskeletal disease the ultimate goal of improving diagnosis, treat- have been initiated according to schedule and are ment and prevention of disease. in progress, as is the case in the field of diabetes.

The project ENCITE – European Network for With regard to dendritic cell therapy, studies rele- Cell Imaging and Tracking Expertise – was sub- vant to in vivo visualisation of DC-NK cell inter- ENCITE consortium members at the kick-off meeting in Freising, Germany, in June 2008. mitted to the call HEALTH-2007-1.2-4 ‘In vivo action have been initiated according to schedule. image-guidance for cell therapy’ and is funded by the European Commission within the 7th Frame- imaging methods to improve the spatio-tem- Initial work on work package 1.2. (image post- As far as cancer T-cell therapy is concerned, stu- work Programme with roughly €12m. This large poral tracking of labelled cells, to develop new processing tools) has focused on the develop- dies relevant to the migration and homing effici- integrated project consists of 21 project partners methods for quantitative assessment to generate ment of post-processing tools to analyse DCE- ency of adoptively transferred T cells, activation (listed at www.encite.org) with leading expertise reliable biomarkers of the cell fate and therapeu- MRI data and for semi-automated morphometric of adoptively transferred T cells, cytolytic effector in the field of cell imaging, with EIBIR as the tic effects as well as novel image post-processing evaluation. functions and imaging interactions between T coordinating partner. The 4-year project began techniques to allow stable and reproducible eva- cells and stroma, have been initiated according on June 1, 2008. In order to complement the luation of experimental results. This includes Subproject 2 to schedule and are in progress. A single colour expertise represented by the 21 project partners, tools for visualisation and co-registration, as well Novel Imaging Reporter Probes mouse tumour model has already been develo- ENCITE will seek additional partners to provide as algorithms for quantitative evaluation. This subproject is led by the University of Torino, ped for monitoring the dynamics of tumour and input to certain work packages and specific issues Italy, with the aim to increase the number of tumour microenvironment. related to cell imaging and cell tracking to be The first few months of the project were dedi- available reporter genes for MRI by evaluation of addressed by the project. To this end, a competi- cated to the implementation and testing of key novel candidate reporters. In addition, this sub- tive call will be published in 2009. methods for use in the project. Development of project will significantly expand the utilisation of methodology has focused on methods for tra- MRI reporter genes, applying them for monito- Currently, there is no single imaging modality cking with USPIO-labelled agents. A 3D cell-tra- ring the constitutive expression of genes, as well that meets the requirements of stem cell therapy. cking method based on a 3D-FLASH sequence as detection of changes in gene expression and Within the framework of the project, new MRI was successfully implemented and used to track imaging of cell differentiation. imaging methods and biomarkers will be deve- labelled dendritic cells following allogeneic loped and tested in order to get a more compre- haematopoietic cell transplantation in a mouse So far no imaging approach has been reported for Subproject 5 hensive picture of the cell fate and the reaction model. direct detection of cell proliferation, biolumine- Translation towards Clinical Applications of the immune system. Eventually, the plan is to scence imaging has been used for determination This Subproject is led by the Radboud University apply in the treatment of cancer, cardio-vascular Currently, a survey to assess specific needs for of increases in cell number. By combining stra- Nijmegen Medical Centre, the Netherlands. The diseases and diabetes. new methods is under preparation as a first step tegies for simultaneous imaging of cell prolifera- group exploited dendritic cells (DC) to vaccinate towards implementing the work plan. This will tion, differentiation and death, multi-parametric melanoma patients and recently demonstrated After just half a year since the official start of the be used to develop specifications for method information on the state and fate of the delivered a statistically significant correlation between project ENCITE, its scientific activities are now and software packages for use by the application cells will be retrieved. Development and valida- favourable clinical outcome and the presence of in full swing. We are pleased to provide you with groups. tion of such strategies will also be a focus point vaccine-related tumour antigen specific T cells in an overview of the scientific progress achieved by in Subproject 3. delayed type hypersensitivity (DTH) skin biop- each of the subprojects. With respect to the aim of developing advanced sies. However, favourable clinical outcome is only methods and protocols for cell characterisation, Subproject 3 observed in a minority of the treated patients. Subproject 1 measurement techniques for characterisation Novel Tools for Cell Labelling Therefore, it is obvious that current DC-based Novel Imaging Technologies of tumour neoangenesis by dynamic contrast This subproject is led by the Weizmann Institute, protocols need to be improved. For this reason, The subproject is led by the University of Frei- enhancement (DCE-MRI) based on an IR-true- Israel. Apoptosis is a cell death process which the fate, interactions and effectiveness of the burg, Germany, with the aim to achieve metho- FISP sequence for direct quantitative T1-mea- plays an important role in the development of injected DC are studied in small proof-of-prin- dological developments of MR imaging methods. surement has been implemented and tested on multicellular organisms and in the regulation and ciple trials. The objective of this subproject is to provide new mice. maintenance of cell populations in tissues upon physiological and pathological conditions. Dendritic cell immu- notherapy has been The aim is to establish a technique that will ena- introduced in the cli- ble capture of intra-cellular protein interactions nic. It has proven to known to occur during apoptosis. Such a method be feasible, non-toxic would be valuable for in-vivo imaging and for and effective in some identifying new proteins involved in the apop- cancer patients, parti- totic process using siRNA screens. This work is cularly if the DC are a collaboration between the labs of Profs. Michal appropriately matured and activated. However, Neeman and Atan Gross, both from the Depart- many questions still remain. One of the con- ment of Biological Regulation at the Weizmann cerns related to ex-vivo generated DC is how to Institute. ensure effective migration to the T cell areas in the lymph node. Subproject 4 Pre Clinical Validation Portraits of dedicated staff as well as more This subproject is led by the Erasmus Medical detailed updates on progress reports are available Centre Rotterdam, the Netherlands, and will vali- at the ENCITE project website www.encite.org. date the generic tools developed under Subpro-

Molecular imaging training workshop in Prague

A workshop on molecular imaging is planned to take place at the congress centre of IKEM in Prague on May 7–8, 2009. The programme of the public workshop will be designed and held by the ENCITE consortium and will include progress reports of the project as well as other major aspects and latest advances in the field of molecular imaging.

Please visit www.eibir.org or www.encite.org for more information and registration.

The ENCITE website

myESR.org 20 ECR TODAY 2009 TECHNOLOGY FOCUS Saturday, March 7, 2009

6th Hospital Management Symposium at ECR 2009: Management, IT and Finance for hospital managers and radiologists

Committee. Since 2002, 17 Root Causes Analyses of particularly significant events have been Accreditation and standards of performed and two analyses are being performed using the FMEA (Failure Mode and Effect Analysis) method; these analyses are focused on two very important processes: the administration of therapies excellence in Europe in the ICU and the administration of chemotherapy in the day hospital.

Dr. Leonardo la Pietra is the Chief Medical Officer of To monitor safety, 23 indicators have been defined which are regularly debated at different levels: Division, Clinical Directors Committee, Management Committee, Patient Safety and Clinical Risk the European Institute of Oncology, a care and research Management Committee. cancer centre in Milan, Italy (www.ieo.it). He is Chairman of AIDOS (Italian Medical Records Since 2003 a reporting system of adverse events has been implemented; at present, this system is available in a web version of the IEO intranet. IEO is strongly investing in sensitisation and continuous Association), AIRISS (Italian Association of Risks in education, by means of a continuous and capillary diffusion of the culture of safety aimed at getting Healthcare) and SIMM Lombardy (Italian Association over the ‘blame culture’ at every level. of Medical Managers). His main professional and scientific interests are focused on quality improvement, performance evaluation, clinical indicators, patient Lean architecture that reflects quality of care safety and risk management, medical records and information management, hospital planning and design, and international David Wormald is the present Integrated Assistant health policies. Vice President Diagnostic Services at Hamilton Health Dr. la Pietra studied Medicine & Surgery and Hospital Management at Sciences and St. Joseph’s Healthcare, Hamilton, in the Catholic University in Rome, and holds an MBA (Master in Business Ontario Canada. Administration) from INSEAD, Fontainebleau, France. He is currently working on the provincial Ontario Evidence Based Imaging Project and MRI coaching team Dr. la Pietra will speak at the Management Session of the symposium. initiatives. David Wormald is a graduate of the Michener Institute The European Institute of Oncology (IEO) is a research and care organisation devoted to the field of oncology, on a basis of full integration between the different areas of the fight against cancer: for Applied Health Sciences, holds a dual registration laboratory and clinical research, prevention, diagnosis, treatment, and training. IEO applies a new with the College of Medical Radiation Technologists principle in cancer treatment by shifting the focus from the disease to the patient. The immediate of Ontario in Radiography and Magnetic Resonance Imaging. He has also transfer of new research results to clinical applications allows abandonment of traditional therapies, based on the heaviest treatment the patient can tolerate, and to replace them with innovative methods received a diploma in Healthcare Administration from the Ontario Hospital which, while providing equal effectiveness, ensure minimal harm to the person. Thus, the Institute has Association and an undergraduate degree in Political Science from the Uni- introduced into every healthcare action the principle of ‘minimum effective treatment’ in place of the versity of Toronto. He is currently working on his Master in Business Admin- ‘maximum tolerable treatment’. Today, 100,000 patients are treated on this principle. istration at McMaster University, De Groote School of Business. The Institute invests its funds both in clinical research, to improve the treatments available to patients, and in basic research, carried out in laboratories where researchers try to understand the underlying David Wormald will speak at the Management Session of the symposium. genetics of cancer and develop new drugs. Today, more and more research is surfacing about how the healthcare environment is directly linked IEO’s clinical activities focus on three main areas: Prevention and Diagnosis, Surgery, and Medical to positive patient outcomes. Evidence-based design helps create an environment in which patients Care. All the activities are conducted with a multidisciplinary approach which, through discussion and families feel as safe and comfortable as possible. It also promotes efficiency in staff workflow and between the different specialists in the three areas, offers patients a treatment path with the support helps decrease levels of stress and anxiety in patients, family members and staff. of the best clinical skills. When the redevelopment of St. Joseph’s perioperative service resulted in the need to relocate the Continuous improvement of the quality of our services is one of the main objectives in the European hospital’s Diagnostic Imaging Department, management of the Diagnostic Services were given the Institute of Oncology’s mission. To achieve and maintain its standards of excellence, IEO has developed opportunity to take a look at the current departmental design, flow, and utilisation, and consider how an improvement process based on a rigorous quality plan, modelled on some of the top national and a new design could improve the quality and efficiency of the healthcare we provide. To ensure that international benchmarks (ISO standards, Joint Commission) now extended to all our departments St. Joseph’s Healthcare remains on the cutting edge of diagnostic imaging and continues to provide and services. the highest quality of healthcare in the most timely and efficient way, we decided to take an evidence- based approach to designing the new facility. IEO is strongly oriented towards developing, experimenting and perfecting innovative processes and original methods that can be used to improve clinical performance and, most of all, to become more Specifically, St. Joseph’s Healthcare used lean thinking to design the new facility. Working with GE and more effective levers of governance. The main areas of interest are patient safety and security and Healthcare Hospital of the Future specialists, we were able to ‘design in’ clinical benefits and clinical clinical risk prevention (in particular related to the surveillance and control of hospital infections and the efficiencies that will remain with us for the life of the new facility. Workflow patterns, process prevention of pharmacological errors), clinical performance monitoring and evaluation, the promotion improvements and the impact of expected future changes in technology were overlaid on architectural of generic and specific appropriateness in treatments, the equity of access conditions, the respect of drawings for the new facility and studied using lean analytics. This Hospital of the Future methodology regulations and of deontology, professional growth, humanisation, environmental comfort, etc. In this allowed us to interpret how performance would change in the new facility (better or worse) and perspective, the Medical Office has promoted a quality improvement and education path at every level. informed our design decisions. This iterative approach resulted in the selection of the best conceptual design, around which we built our new facility. All these initiatives are made more explicit in the Documental System of the Institute, which includes plans, programmes, policies, the proceedings of the meetings of the various committees, and the whole institutional “Progressive healthcare providers now realize the tremendous benefits of applying lean systems documentation; these documents can be accessed both on paper and on the intranet of the Institute. management to improve the effectiveness of healthcare delivery. The lean system enables our frontline teams to focus on value delivery, providing high quality, patient-centred care. It simplifies and builds Among the methodologies used by IEO to reach and maintain high quality standards, some are strong control into our operations to enable the highest standards of patient safety and quality of care; particularly important, such as the adherence to the philosophy of Clinical Governance, which smooth work, information, and patient flows; and effective facility utilisation.” provides for a strong involvement and responsibility of clinical operators in IEO decision processes. Today, the expanded St. Joseph’s Diagnostic Imaging facility boasts the following: Clinical Governance in IEO is developed in all its components, as described in the literature: Performance Evaluation, Quality and Safety, Audit, Education, Evidence-Based Medicine, and • A separate inpatient journey from an outpatient journey Customer Satisfaction. • Efficiencies that translate into a more timely and more satisfying patient journey (e.g. patient flow, procedure flow, supply flow, radiologist/technologist/support workflow, information flow) Similar to any good maintenance processes, where the activities being performed must be monitored, • Increased patient privacy in the ultrasound rooms, CT prep rooms, and at registration the Balanced Scorecard (BSC) methodology has been adopted. • Overall noise reduction (e.g. wireless access for radiologists to help decrease frequency of overhead pages) BSC aims at supporting: focus and communication of the strategic goals; alignment and convergence • Use of lighting, colour and texture for way-finding of staff actions and behaviours towards these goals; and control of the achievement of the agreed goals. • Use of natural products, and visual distractions to decrease patient anxiety The main element of innovation of Balanced Scorecard is its multidimensional nature. BSC aims at • Improved infection control (e.g. operating room quality air for interventional rooms, hand washing making visible the growth and development abilities and opportunities of IEO, besides spreading its sinks, soiled holding, etc.) mission and value at the international level. The new Diagnostic Imaging Department at St. Joseph’s Healthcare is now well positioned as a re- The analysis and monitoring of patient satisfaction are performed every six months by the Quality sult of employing an innovative approach to designing its new facility. The benefits are far-reaching and Accreditation Office, in which the trends and the main problem areas of the Units are highlighted. and to date include a 54.3% improvement in clinical efficiency and an 8.5% improvement in patient To improve the level and the quality of patient information on topics of paramount importance (e.g. travel distances. The ability to achieve these efficiencies in an expanded facility were necessary in our therapies, alimentation, rehabilitation, post-discharge), IEO has published a collection of booklets, the environment of staffing shortages, increasing demand for procedures, our aging population and our IEO Booklets by the Health Education Committee. growing clinical services. This project was consistent with St. Joseph’s culture of continuous improve- ment, which fully engages our committed workforce in optimising our patient care environments, our The topic of patient safety, part of the Quality Plan of IEO, has been continuously performed since patient outcomes and overall hospital performance. 2001, with the creation of the Risk Management Office and of the Patient Safety and Risk Management myESR.org Saturday, March 7, 2009 TECHNOLOGY FOCUS ECR TODAY 2009 21

6th Hospital Management Symposium at ECR 2009: Management, IT and Finance for hospital managers and radiologists

Ageing populations and lifestyle behaviours, in particular, dramatic rises in adult and child obesity Teleradiology – moving from ‘black box’ will drive demand and the rapid introduction of technological and medical advances will also play a solutions to integrated partnership part in increasing healthcare costs. What is the answer? In short, doing more for less. A seminal review in the UK concluded that while Dr. Henrik Agrell is Vice President and co-founder of Telemedicine Clinic significant increases in funding had delivered notable improvements – more staff and equipment; (TMC), a leading medical imaging group, based in Barcelona, that supports improved infrastructure; significantly reduced waiting times and better access to care, there were not public and private hospitals across Europe in solving the concurrent increases in productivity. challenges they may face in medical imaging, partly by The healthcare system in England now has a whole series of levers that are intended to create a more offering professional teleradiology solutions. efficient and responsive service – these include performance management targets, devolved providers who are subject to contracts which are nationally priced to encourage competition on quality, a new Dr. Agrell completed his medical degree at the Karo- range of quality incentives, patient choice for non urgent acute care, and various forms of regulation linska Institute of Stockholm. He has extensive experi- and benchmarking which look at both patient experience and outcomes as well as value for money. ence in the areas of e-Health and Telemedicine. Prior to What is less clear is how powerful each of these levers will prove to be or how well they will work with co-founding TMC, Dr. Agrell participated in building up one another. NetDoktor.se, the largest medical web portal in Scandi- What is clear is that efficiency and productivity will have to join quality as driving forces; savings navia. He has published several scientific articles within need to be achieved not by the traditional methods of freezing posts, delaying care and cutting back these fields. on ‘administration’ but by genuine redesign of services and setting clear priorities. Providers and commissioners of healthcare must ensure they have the leaders in place who can deliver value by ensuring that even as money becomes tighter, care improves. This is not an impossible task – poorly Dr. Agrell will speak at the IT Session of the symposium. designed services ultimately waste money. As Don Berwick of the Institute of Healthcare Improvement in the US states clearly, “higher quality costs less”. Technological and medical advances are allowing The major challenges facing national healthcare systems worldwide call for new and innovative more care options in more places. Electronic patient records and the miniaturisation of diagnostics solutions for the production and delivery of healthcare services. In the field of medical imaging, there free clinicians and patients from hospital buildings, and offer the potential for more patient-focused is a problematic imbalance between an increasing demand for imaging services, partly due to an aging services. population, and a growing shortage of medical staff and funding. In addition to this, more and more advanced imaging processes require access to sub-specialist radiologists for an increasing number The onus now is on local healthcare managers and clinicians to create a shared vision for their health of cases. Professional teleradiology services could be one potential solution to these challenges. services, ensuring that the right incentives are in place to get them there, despite the stormy financial Centralising sub-specialist competence in a highly-efficient and quality-controlled production waters ahead. environment and distributing this resource via integrated IT solutions at point of need, could give public and private healthcare players access to exactly the resource they need, when they need it. Financing of medical equipment within Teleradiology has been tested for decades in a huge number of more-or-less successful projects. However, some years ago when the first teleradiology service providers entered the market, hospitals hospital groups – which strategy? started to use this solution on a more continuous basis. In its infancy, teleradiology was a fairly basic service with remote radiologists reporting directly to the hospitals’ RIS/PACS environments during their spare time. With growing competition and increased awareness amongst the clients, Dr. Axel Paeger has been CEO of the AMEOS Group, teleradiology is now rapidly developing from a ‘black box’ outsourced solution to a highly integrated Zurich, Switzerland, since 2003. He is also its co- partnership, which requires different structures and new and more sophisticated production processes founder. He received his medical degree from the for teleradiology service providers to be able to meet a different level of demand in the market. Ludwig-Maximilians-University in Munich, Germany, In this presentation, you will be able to follow the development of Telemedicine Clinic (TMC), and an MBA and MBI from Erasmus University the largest European teleradiology service provider, with specific focus on efficiency and various Rotterdam School of Management, the Netherlands. challenges related to this area. He was member of the board of the Pacific Health Corporation in Long Beach, CA/US, and from 1999 to More for less – driving up performance 2003 Chief Managing Officer of the Asklepios Clinics, in acute care Ger many. Dr. Paeger will speak at the Finance Session of the symposium. Niall Dickson joined The King’s Fund in London, UK, as Chief Executive in January 2004. He began his career in teaching before taking up posts in Financing sources for hospital technology are increasingly heterogeneous and mixed. While public funding is still the most frequently used instrument, equity is becoming increasingly important, national charities involved with older people. He was particularly where the investment might be recovered at least partially via charges. The same holds Editor of Therapy Weekly for the allied health professions true for debt, which currently has the advantage of being fairly cheap. Leasing is another option that and then of Nursing Times. He moved to the BBC in is gaining importance. While leasing relieves the balance sheet to a certain degree, leasing payments have to be earned just like interest or return on equity. Most decisions in favour of leasing are based on 1988 as Health Correspondent, became Chief Social strategic considerations: since a hospital should concentrate on its core competency – patient care – it Affairs Correspondent and then, in 1995, Social Affairs seems to make sense to enter into an operative leasing contract that allows the hospital to hand over all Editor. equipment management tasks to a partner. Particularly public hospitals, however, opt for this scenario Dickson is a member of the Cabinet Office Honours for purely economic reasons: the leasing partner pays his staff much lower salaries and can thus offer the services at a better price than the in-house technology department. Committee (Health) and ministerial advisory group on social care funding and the NHS National Stakeholder Forum. In 2008 he chaired a cross-party commission on accountability in health for the Local Government Association (LGA). He is a trustee of the Consumers’ Association and of the Leeds Castle Foundation. Among his honorary awards he is a Fellow of the Royal College th of Physicians and of the Royal College of General Practitioners. 6 Hospital Neill Dickson will speak at the Management Session of the symposium. Management Symposium Public spending on health and long-term care is a major source of fiscal pressure in most OECD Saturday, March 7, 8:30–13:30, Room K countries, amounting to, on average, some 9% of GDP in 2006, and reaching as much as 15% in the United States. Spending growth at the rate it has been seen in the last ten years in most countries is unsustainable.

There is no doubt that growing economic pressures will limit growth in healthcare funding. At organised in cooperation with the same time governments will face sustained demand for investment driven by rising public expectations. While the World Health Organisation report of the Commission on the Social Determinants of Health reported that healthcare built on the principle of universal coverage is important, healthcare systems across Europe are under pressure. A sustained economic downturn may result in a move towards a ‘safety net’ of provision only. In any event, the increasing pressure on healthcare resources in the face of growth in demand and in capacity to treat is likely to drive a tighter definition of benefits packages.

myESR.org 22 ECR TODAY 2009 TECHNOLOGY FOCUS Saturday, March 7, 2009

Fully automated 3D segmentation of liver tumours moves a step further towards clinical reality

By Günter Schmidt, Gerd Binnig, body is separated from the background, while Markus Kietzmann, Johann Kim; within the body initial Image Objects (e.g. fat Definiens, Munich, Germany tissue, muscle layer, organs, skeleton) are refi- ned based on their volume and intensity. From The reliable detection of liver tumours in CT these distinguished body parts an additional scans and their precise measurement form the layer of 3D edge information is calculated, basis for effective diagnosis, surgery planning which provides a reference for further refine- and therapy control in liver cancer. Since manual ment. After this pre-processing step, the left measurement of 3D structures is extremely and right lungs are classified as Image Objects time-consuming, cost-intensive and subjective, with maximal volume on the left and right automated methods offer promise for today’s sides of the body. Adjacent to the right lung, challenging clinical environment. However, due the gall bladder is segmented. In combination to significant variability in the appearance and with the skeleton this provides further cons- shape of liver tumours, reliable automated seg- traints for the liver. Finally, the liver is located mentation represents a nontrivial task. below the right lung and is demarcated by the gall bladder and the skeleton (particularly the In this study, Definiens Cognition Network ribs). The liver is thus classified as an Image Technology® was utilised to develop an applica- Object with maximal volume. tion for the fully automatic segmentation of liver tumours. The results were evaluated on a set of During the second part, the tumours are seg- six CT scans containing ten tumours, using the mented: The liver is partitioned into segments Screenshot of an MPR view of segmented liver lesions. following comparison metrics: volumetric over- with high, medium, and low intensity. Seg- lap, volume difference, average surface distance, ments with high or low intensity provide the The above algorithm was applied to both the to be satisfactory. Since tumours can be both RMS and maximal surface distance. tumour candidates. The surfaces of the tumour training and test sets. The figure shows an brighter and darker than the surrounding candidates are smoothed using a ‘shrink and example of the segmentation results. liver, small parts of blood vessels proximal to The data set used in the analysis was provided grow’ strategy and are filtered according to tumours were misinterpreted as belonging to by the organisers of the Medical Image Com- a volume threshold. ‘Normal’ liver parts (i.e. Visual inspection of the segmentation results the tumours. puting and Computer Assisted Intervention liver segments with medium intensity) that indicates that the tumour segmentation algo- Society (MICCAI) 2008 workshop. It contai- are enclosed by tumour candidates are mer- rithm tended to identify a superset of the refe- In summary, we presented an algorithm based ned ten annotated tumours from four patients ged with the latter. The tumour candidates rence segmentations without a smooth sur- on Definiens Cognition Network Technology® (training set) and ten tumours from six pati- are further refined through comparison to a face. This is a consequence of our conservative for the segmentation of liver tumours in 3D ents without annotations (test set). given surface tension and volume criterion is approach to ensure a guaranteed enclosure for data using contextual information. Although again used to remove candidates considered each tumour. Additional smoothing with cer- the current iteration is not considered suitable The segmentation algorithm was developed too small. Further refinement is performed tain restrictions may improve this method. for clinical use, the results indicate it repre- in Definiens’ Cognition Network Language by growing the tumour candidates and sub- sents a promising step in the development of (CNL) and contained the following two parts: sequent filtering according to roundness and Furthermore, we do not yet consider the dif- a computer-aided diagnosis system for liver In the first part, the liver is segmented: The relative proximal borders to the liver. ferentiation of tumours from blood vessels tumours.

myESR.org Saturday, March 7, 2009 TECHNOLOGY FOCUS ECR TODAY 2009 23

Three-dimensional presentation of cerebral vasculature facilitates greater understanding

By Wieslaw L. Nowinski, Biomedical Imaging Lab, Agency for Science Technology and Research (A*STAR), Singapore/SG

The human cerebral vasculature is highly com- plex and variable, and despite the existence of a huge body of knowledge and the availability of numerous textbooks, the current ways of presentation are limited. Presentation is typi- cally restricted to a few traditional views. The complete course of vessels, partly hidden in the sulci, is not shown and the arterial and venous systems are presented separately, without their relationships to each other being shown. The vessel naming is limited to certain locations, information on geometry (such as diameters or distances) is scarce, and the vessels are typically not related to brain structures.

Presentation of cerebrovasculature in three dimensions (3D) along with its correlation to the surrounding neuroanatomy greatly facili- tates learning and understanding. Advances in angiography imaging, including high field MR and 320-detector CTA, facilitate the depiction of vasculature in 3D.

Multiple MR high resolution scans of a healthy subject were acquired on 3T and 7T including MPRAGE, TOF, SWI, and SPGR. Three inter- active 3D atlases (continuously enhanced) have been created: cerebrovascular atlas from 3T (cum Laude, RSNA 2006), atlas of cerebral arte- rial variants (Summa cum Laude, ASNR 2008), and cerebrovascular atlas from 7T (Certificate of Merit, RSNA 2008). Figure 1: The Cerefy Atlas of Cerebral Vasculature. The complete vascular model is displayed, along with surface and sectional neuroanatomy. The Cerefy Atlas of Cerebral Vasculature The Cerefy Atlas of Cerebral Vasculature (CACV) (Nowinski et al, Thieme, New York Interactive 3D Atlas of 2009) correlates the cerebrovasculature with Cerebral Vasculature from 7T surface and sectional neuroanatomy for a wide The interactive atlas of cerebral vasculature deri- use in neuroradiology, neurosurgery, neurology, ved from 7T is an enhanced version of the CACV neuroanatomy, neuroscience, and neuroeduca- with extended content and a new (even more ele- tion. It provides an intelligent navigation, dyna- gant) user interface. It contains about 700 fully- mic scene composition allowing the user to build labelled vessels, the smallest of which is 0.1 mm any vascular network, and self-testing. in diameter, as shown Figure 3.

At its core is a 3D cerebrovascular model with the Having the atlases derived from 3T and 7T scans arterial and venous systems derived from a 3T 3D enables comparison of various acquisition tech- TOF (MRA) scan. It was constructed manually niques, as shown in Figure 4. by employing a dedicated vascular editor. The cerebrovascular model is co-registered with MRI Conclusion and future developments and MRA scans presented as a triplanar in 3D. All The atlases created facilitate studying and under- the vessels are labelled at any location with their standing of cerebral vasculature along with the names and diameters. In addition, 3D surface surrounding anatomy and its variations in 3D. models of the hemispheres and the ventricular They are useful for medical students, educators system are extracted from the 3T MRI scan and to prepare teaching materials, researchers, and Figure 2: The atlas of the arterial variants. The variants of the ICA siphon are shown (right). co-registered with the cerebrovascular model. clinicians. A light version of the vascular atlas is also publicly available at: The CACV provides abounding functionality www.cerefy.com/dswMedia/iCACVlite.htm for presentation and exploration of the cerebro- vasculature along with the surrounding surface Though the CACV is our sixth brain atlas pub- and sectional neuroanatomy, including: model/ lished by Thieme, this is the first atlas of a new triplanar display, vessel selection, vessel labeling, generation. This new generation of atlases is fully model/triplanar manipulation, and quantifica- 3D, extendible, electronically dissectible, stereo- tion (3D coordinates, vessel diameter, and 3D tactic, meta-labelled, and with the exportable distance measure), as shown in Figure 1. contents that can be employed in the user’s appli- cations and further extended by the community. Interactive 3D Atlas of This generation is based on a pyramid concept, Cerebral Arterial Variants meaning that the atlas content will be extended The knowledge of cerebrovascular variants is cri- in height and breadth, while preserving its con- tical in diagnosis and treatment. Numerous text- cept and main features. books and articles describe these variants and present them in the form of drawings or autopsy photographs. However, there is no interactive atlas providing 3D vascular models and exploration tools enabling a better and faster understanding of vascular variants and their spatial relationships.

We have created such an atlas with 60 cerebral arterial variants along with their incidence rates. They can be explored individually or embedded into the reference vasculature. User friendly tools are developed for variant selection, display, manipulation, and labelling as well as saving of Figure 4: Comparison of deep cerebral veins on 3T composed images. (left) and 7T (right). Figure 3: The cerebrovascular atlas derived from 7T.

myESR.org 24 ECR TODAY 2009 TECHNOLOGY FOCUS Saturday, March 7, 2009

Provision of training is priority in cardiac radiology

By Michael Rees, Gwynedd/UK; is the mainstay of general cardiac imaging, but ESCR President high field MRI is gradually emerging as the plat- form for brain imaging, particularly in functio- The last decade has seen a rapid advancement nal MRI. Faster imaging and high signal-to-noi- in the technological ability to image the heart se are offset by greater fragility in image quality non-invasively. High resolution fast multi-slice and increased artefacts. CT has made a huge impact on coronary arte- ry disease diagnosis and MRI has developed As a research tool however, high field cardiac significantly to challenge nuclear medicine and MRI may offer advantages over conventional echo techniques in the diagnosis of myocardial systems in plaque imaging and greater sensitivi- ischaemia and viability. Given that cardiac radio- ty in viability diagnosis and capillary circulation. logists now have the tools by which they can The development of high field MRI and research make an impact on cardiology diagnosis, what into functional MRI techniques for the heart is challenges are there for this group of doctors to an exciting challenge. be recognised for the role they can play in the clinical management of the cardiology patient? The Training and Educational Challenges Even greater than the technological challenges The Technological and Research Challenges are the training and manpower challenges in car- Despite the rapid development of cardiac imaging diac radiology. At the moment, the number of technology there are still marked technological fully trained cardiac radiologists is few in compa- challenges in cardiac imaging. If asked, all cardiac rison to the need for trained personnel required The ESCR annual meeting 2008 in Porto/PT proved to be a huge success. radiologists would like faster, clearer low radiation to take advantage of the available technology. We technology in CT and faster more reliable MRI. are rapidly moving into a phase where the ave- mand the respect and support of their colleagues gnition of training in cardiac radiology at centres However there are advances that could be achie- rage hospital has the technological capacity to in clinics and operating theatres. We often refer of excellence and teaching courses sponsored by ved in the near future, including software packages perform high quality cardiac imaging. To fulfil to these doctors as our ‘clinical colleagues’ for- the ESR and ESCR is another vital step in the that provide a user-friendly interface between the the potential of this expansion of available equip- getting that what we do is no less clinical and development of the specialty. machine, the radiologist and the clinician, which ment and technological development we will central to patient management. Radiologists can be translated between imaging environments. need a rapid expansion of the number of trained need to be integrated into the clinical team and We are now starting to work more closely with This would not only facilitate clinician and patient cardiac radiologists. The ESCR and the ESR are help with the management of the patient so the our technical colleagues; we already have a lar- understanding of the examination, but it would already embarking on fellowship programmes question is no longer what ‘can’ we image but ge number of physicists and other scientists who also allow for standardised multi-centred trials, and teaching courses to provide the cardiac how ‘should’ we image so that the workup and come to our meetings. The ESCR will be hos- which comprise a vital part of the knowledge base radiologists of the future. Recognition and accep- treatment of the patient is optimised to the clini- ting joint sessions with for non-invasive and invasive cardiac trials. tance of this training at national and EU level cal problem at hand. radiographers, starting may be required before this can be truly effective. at its annual meeting This knowledge base and the ability to conduct Widening of training in cardiac radiology must The ESCR is helping in this process by publishing in Leipzig in October trials is one of the major strengths of cardi- be a priority for the ESCR and the ESR. guidelines which are meant to be of practical use 2009, and I would like ology and needs to be at least replicated if not in clinical practice. Building on this process we to extend our welcome surpassed for cardiac radiology to be a serious The Professional Challenges will be consulting with other cardiac imaging to our colleagues in contender for research funding and the attention Trained cardiac radiologists who can provide societies to produce consensus documents to radiography for that RZ Ad_Hitachi_Preirus_260x195mm_23-01-09:RZ Ad_Hitachi_Preirus_260x195mm_23-01-09 23.01.2009 17:47 Uhr Seite 1 of governmental and EU funding. 1.5 Tesla MRI service reliably and enthusiastically will com- provide guidance on patient management. Reco- meeting. .artundwork designbüro

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myESR.org Saturday, March 7, 2009 COMMUNITY NEWS ECR TODAY 2009 25

Don’t miss today’s InSIDE TODAy Introducing the EURORAD Wilhelm Conrad Röntgen What’s on today sections and editors Honorary Lecture in Vienna?

See page 27 See page 29 See page 30

ESR awards diplomas to 33 young radiologists

In 2008, 33 radiologists in training participated Zsuzsanna M. Lénárd, Budapest/Hungary Milena Spirovski, Sremsila Kamenica/RS ESOR looks forward to offering more extended in the newly established trainee programmes of Topic: Neuroradiology/Head and Neck Training Centre: University of Basel/CH educational programmes in 2009 and would like ESR, namely the Visiting Scholarship Program- Training Centre: Hospital de Sant Pau, to encourage all young doctors to take the chance me and the Exchange Programme for Cardiac Barcelona/ES Oliver Springer, Aarau/Switzerland to receive training in a pre-selected, highly estee- Imaging Fellowship, organised through ESOR Training Centre: University of Leipzig/DE med reference training centre in Europe. Further (European School of Radiology). The program- Suat-Jin Lu, Singapore information on all activities can be found at the mes consisted of two to three months of struc- Topic: Urogenital Radiology Ajay Varghese, Harrow/United Kingdom ESOR booth in the entrance hall of the Austria tured and comprehensive training on a chosen Training Centre: Addenbrooke’s Hospital, Training Centre: University Medical Center, Leiden/NL Center or online at myESR.org/esor. topic and were complemented with tutorials, lec- Cambridge/UK tures, and hands-on teaching of routine clinical cases and/or modality techniques and protocols. Karolina Markiet, Gdansk/Poland ESOR Session Topic: Urogenital Radiology The courses were realised in partnership with vo- Training Centre: Policlinico Universitario Saturday, March 7, 14:00–15:30, Room Z lunteer reference training centres, subspecialty Tor Vergata, Rome/IT New opportunities for education societies and industry partners (Bracco). ESOR At its first session ever held at ECR, ESOR will give an insight into the is delighted that all young doctors successfully Ana-Maria Maxim, Timisoara/Romania variety of educational programmes established for young radiologists completed their training and will honour their Topic: Multidetector CT Protocols in training. achievements on the occasion of the first ESOR Training Centre: University Hospital of session ever held at ECR (see info box). Radiology, Innsbruck/AT • What the school means for ESR I.W. McCall; Oswestry/UK The following trainees completed the three-month Nikoloz Onashvili, Tbilisi/Georgia • Education in partnership Visiting Scholarship Programme. Topic: Cardiac Imaging N. Gourtsoyiannis; Iraklion/GR Congratulations! Training Centre: Medical University of Vienna/AT • GALEN meets young radiologists M. Szczerbo-Trojanowska; Lublin/PL Miraude Adriaensen, Utrecht/Netherlands Emel Onur, Izmir/Turkey P. Aspelin; Stockholm/SE Topic: Musculoskeletal Radiology Topic: Cardiac Imaging • The Radiology Trainees Forum Training Centre: Mater Misericordiae Hospital, Training Centre: Erasmus MC, Rotterdam/NL C. Nyhsen; Sunderland/UK Dublin/IE • My experience as an ESOR trainee Raluca Pegza, Bucharest/Romania A. Hambardzumyan; Yerevan/AM K. Pinker; Vienna/AT Daniela Baca, Bucharest/Romania Topic: Oncologic Imaging M. Spirovski; Sremsila Kamenica/RS Topic: Musculoskeletal Radiology Training Centre: Pitié-Salpêtrière, Paris/FR Training Centre: University Hospital ESOR Awards of Strasbourg/FR Katja Pinker, Vienna/Austria On the occasion of the session the certificates for successfully completing Topic: Breast Imaging the Visiting Scholarship Programme and the Exchange Programme for Anvita Bieza, Riga/Latvia Training Centre: Barts and The London NHS Cardiac Imaging Fellowship will be awarded. Topic: Neuroradiology/Head and Neck Trust, London/UK Training Centre: Addenbrooke’s Hospital, Cambridge/UK Sara Seitun, Genoa/Italy Topic: Cardiac Imaging Lorenzo Cereser, Udine/Italy Training Centre: University Hospital, Zurich/CH Topic: MRI Protocols Training Centre: Hôpital Erasme, Brussels/BE Ana Silva, Matosinhos/Portugal Topic: Breast Imaging Kabilan Chokkappan, Chennai/India Training Centre: Addenbrooke’s Hospital, Topic: Neuroradiology/Head and Neck Cambridge/UK Training Centre: Hôpital Robert Debré, Paris/FR ESOR Matej Vrabec, Ljubljana/Slovenia European School of Radiology Maria Lourdes Diaz, Pamplona/Spain Topic: Neuroradiology/Head and Neck Topic: Oncologic Imaging Training Centre: UZ Leuven/BE Training Centre: Mater Misericordiae Hospital, Visiting Scholarship Programme Dublin/IE Marius Wick, Innsbruck/Austria Topic: Musculoskeletal Radiology Allina Dimopoulou, Uppsala/Sweden Training Centre: Barts and The London NHS The ESOR Visiting Scholarship Programme offers qualified trainees the opportunity to get to know another training envi- Topic: Neuroradiology/Head and Neck Trust, London/UK ronment, and to kick off an interest for subspecialisation in Training Centre: Barts and The London NHS radiology. Throughout three months of training the scholars Trust, London/UK will be provided with a structured, modular introduction to The following trainees completed the two-month different subspecialties and will be supervised by a special- Sofia Gourtsoyianni, Iraklion/Greece ised tutor in a pre-selected, highly esteemed academic train- Exchange Programme for Cardiac Imaging ing centre. The programme is aimed at residents in their 3rd, Topic: Oncologic Imaging Fellowship. Congratulations! 4th or 5th year of training. Training Centre: Barts and The London NHS 26 scholarships on various topics will be offered. Trust, London/UK Mustafa Baris, Izmir/Turkey Training Centre: Medical University of Vienna/AT TOPICS • Abdominal Radiology Anush Hambardzumyan, Yerevan/Armenia • Breast Imaging Topic: Neuroradiology/Head and Neck Konstantin Kalugin, Stavropol/Russia • Cardiac Imaging Training Centre: Chu de Montpellier/FR Training Centre: Cardiology Research Center, • Chest Imaging Moscow/RU • Musculoskeletal Radiology Angeliki Karatasiou, Athens/Greece • Neuroradiology • Oncologic Imaging Topic: Breast Imaging Menka Lazareska, Skopje/Macedonia • Urogenital Radiology Training Centre: University La Sapienza, Training Centre: University La Sapienza, Rome/IT • PET-CT Protocols Rome/IT • MRI Protocols Dimitra Loggitsi, Athens/Greece Further details are available at www.myESR.org/esor Daniel Knap, Katowice/Poland Training Centre: University of Bangor/UK Topic: MRI Protocols Training Centre: University Medical Center, Assia Litcheva Guerguieva, Madrid/Spain

Groningen/NL Training Centre: University Medical Center, E T T E R I - K N G N C A A O N L C S Groningen/NL E

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Maria Kuzarova, Brno/Czech Republic In partnership with Bracco and MSKCC. O

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• Cancer Center • Topic: Multidetector CT Protocols Nuno Ribeiro da Costa, Lisbon/Portugal E S 4 T 8 A 1 8 Training Centre: Medical University of Vienna/AT Training Centre: Ludwig Maximilians B L I S H E D University, Munich/DE

myESR.org 26 ECR TODAY 2009 COMMUNITY NEWS Saturday, March 7, 2009

Swiss radiologists confront growing number of challenges

By Mélisande Rouger highest densities of MR magnets in Europe ECRT: In which clinical cases do you use abdom- and probably worldwide. The number of 3.0T inal and pelvic MRI? What is the current status Two months before ECR 2009, ECR Today met magnets, particularly in private practice, is of high field abdominal and pelvic imaging? Bernhard Allgayer, President of the Swiss Soci- increasing. 3T has allowed clinical implemen- BA: The role of 3.0T MRI in the abdomen and pel- ety of Radiology, to learn more about radiology tation of sequences that were difficult to per- vis is not yet defined. 3.0T offers various advan- in the European country with the highest ratio form previously such as arterial spinlabelling tages, but has its disadvantages. In addition, of high-field MR units per inhabitant. perfusion. imaging at 1.5T has reached a very high level, and at some point it is difficult to top this. In general, ECR Today: How is Swiss radiology doing and ECRT: What are you going to talk about under 3.0T imaging has now reached the robustness and how does it position itself in Europe? the theme ‘Matterhorn: top of Europe’? imaging level of 1.5T in the abdominal and pel- Bernhard Allgayer: Swiss radiology has an BA: The Matterhorn is one of the most famous vic region. With regard to morphologic imaging, increasing role in the medical community with mountains in Europe and the ratio of high-field 3.0T imaging seems to be superior at displaying many clinical and scientific connections to MR units per inhabitant in Europe is the high- the biliary and pancreatic duct anatomy, in par- other European countries. est in Switzerland. The presentation will focus ticular in patients without dilatation of the ducts. on stroke MRI. Moreover, MR angiography is profiting from the ECRT: How many radiologists are currently higher field strength. Morphologic imaging is working in Switzerland? What is the propor- ECRT: What are the demographics of stroke superior in displaying the anatomy of the pelvic tion of men, women and young people? What in Switzerland? How does it compare to the organs and the pelvic floor, and probably 3.0T Professor Bernhard Allgayer has been the Director is the ratio of radiologists to inhabitants? rest of Europe? imaging makes the use of endorectal coils for of the Radiology Department of the Lucerne Canton Hospital, Switzerland, since 1997. His main interests BA: Currently 919 radiologists are working BA: Stroke is one of the three highest causes of prostate imaging unnecessary. However, I per- are clinical research in CT, MRI, mammography and in Switzerland, with 193 in private practices, mortality in Switzerland, with cardiac diseases sonally believe that in the future the superiority interventional radiology. and about 30 to 35 young radiologists per year and cancer, as it is in other developed countries. of 3.0T will be shown, in particular for the func- undergo the board examination. Switzerland It has a major socio-economic impact. In Swit- tional applications (such as diffusion, perfusion has 7.56 million inhabitants, so the ratio is one zerland there is a trend to aggressively diagnose assessment, and hybrid imaging). radiologist per 8,226 inhabitants. and treat these patients at early stages. Here, ventional vascular radiology, and with cardi- MR technology plays an important role in the ECRT: What are the typical sports injuries in ologists in heart CT and MRI. ECRT: How do you see the demography of management of these patients. Switzerland? your profession evolving in the near future? BA: Injuries from winter and summer sport ECRT: How would you judge the importance BA: I think the total number of radiologists will ECRT: What are the advances made in clinical activities, such as skiing, snowboarding, biking of the exchange of knowledge between Swiss increase about 3 to 5% per year. Neuro-MR of stroke? and running. radiologists and the rest of the world? Is BA: In Neuro-MR, the advent of high field Switzerland’s geographical place in Europe an ECRT: Regarding your introduction to the magnets has allowed us to improve the rou- ECRT: What are the main challenges faced by advantage? ‘ESR meets Switzerland’ session, could you tine acquisition of the following techniques: radiology in Switzerland nowadays and what BA: This exchange is important for us. There- please briefly explain: What is the role of 3.0 perfusion imaging, diffusion tensor and diffu- are the strategies developed by your society to fore we have a longstanding tradition of T in Switzerland? sion-weighted imaging, susceptibility-weighted cope with them? exchange between Swiss radiologists and others BA: Out of 207 MRI units, 42 of them are 3.0T imaging, arterial spin labelling perfusion, and BA: The main challenges for Swiss radiology around the world. For many years it has been units. Switzerland has probably one of the clinical functional MRI. in the future are: a shortage of board-certified a tradition, particularly in academic institu- radiologists, in particular in public hospitals; tions, that young radiologists undertake a fel- turf battles in different areas of radiology; and lowship in another country. In addition, there decreasing revenues because of decreasing is an increasing number of radiologists who reimbursement by the healthcare providers. were trained in Switzerland and who now work in faculty positions in leading radiology centres ECRT: Skilled staff are a prerequisite for the worldwide. Additionally, we also have a long- implementation and maintenance of high- standing tradition for postgraduate teaching quality radiological services – what do you do courses, which are performed in collaboration to promote postgraduate education and train- with leading international radiology experts. ing in modern imaging methods? Finally, we foster international contracts BA: We offer national and international courses, through the annual meeting of our society such as the Davos course, and many other local where we invite opinion leaders for state of the Get SharpView and Lower and international activities. art lectures. Furthermore, the society rewards excellence through various honours and prizes. Your CT Dose Today! ECRT: How is Swiss radiology meeting the growing need for a multidisciplinary ECRT: What are the potential benefits of SSR approach in radiology? taking part in the ‘ESR meets’ programme? BA: We have daily clinical meetings, and inter- BA: To learn more about radiology and the work disciplinary meetings with orthopaedic sur- of radiologists in other European countries. geons, oncologists, cardiologists, and others. ECRT: What future trends and challenges do ECRT: Is there any competition between Swiss you foresee in radiology? Now more than ever, less is more. This radiological services and other services? If so, BA: The trends will focus on higher fields and certainly applies to SharpView® CT, the how does radiology work together with those faster imaging. The challenge will be to com- product that enables CT-dose reduction specialities to improve the situation? bine technological changes and clinical excel- by 30–70 percent*. And with preserved BA: There is competition with angiologists, lence. The next step in radiology is imaging of or even better image quality! vascular surgeons and cardiologists in inter- function, cellular and molecular imaging.

Want to learn more about SharpView CT? You will be warmly welcomed when you ESR meets Switzerland drop by our booth 426, Expo D. Saturday, March 7, 10:30–12:00, Room A

* depending on anatomy scanned and the diagnostic EM 1 New opportunities for education requirements Presiding: B. Allgayer; Lucerne/CH B. Marincek; Zurich/CH I.W. McCall; Oswestry/UK

• Introduction B. Allgayer; Lucerne/CH • Perfusion imaging in the heart of Europe: 1.5 Tesla and more J. Bremerich; Basle/CH • The impact of high field MRI on stroke management K.-O. Løvblad; Geneva/CH • Abdominal and pelvic MRI: From 1.5 to 3.0 Tesla D. Weishaupt; Zurich/CH SharpView® and SharpView® CT are registered trademarks SharpView AB owned and controlled by SharpView AB. The SharpView Storgatan 39, SE-582 23 Linköping, Sweden • Does sports imaging need 3.0 Tesla? product is CE marked according to MDD 93/42/EEC and Phone +46 13 23 50 30, Fax +46 13 31 88 60 H. Bonel; Berne/CH has a 510(k) clearance from the FDA. The Company’s quality www.sharpview.com | [email protected] system is certified according to SS-EN ISO 13485:2003. • Panel discussion myESR.org Saturday, March 7, 2009 COMMUNITY NEWS ECR TODAY 2009 27

The composition of EURORAD: Introducing the sections and editors, part 2 By Stefanie Muzik Today, we would like to introduce you to EURORAD’s head and neck, liver/biliary system/pancreas/spleen, musculoskeletal, neuro and paediatric sections. We have asked the section editors to introduce their section and themselves to all ECR participants.

Head & Neck Imaging Liver, Biliary System, Pancreas, Spleen “In the head and neck imaging section, cases illustrating pathology of the sinonasal cavities, maxil- “In accordance with the aims of EURORAD to give medical students, residents in radiology and se- lofacial skeleton, temporal bones, skull base, and soft tissue of the head and neck are published. Cases nior radiologists the opportunity to increase their awareness of diagnostic and interventional tech- illustrating the appearance of head and neck cancer, either on CT or MRI, would be especially welcome, niques, the liver, biliary system, pancreas and spleen section serves to present cases from authors who as this is a disease with a very heterogeneous presentation on imaging. Also considered for publication have illustrated them with high quality radiological images. A prerequisite for acceptance of a case is are cases showing particular anatomical relationships, important to know in the evaluation of disease. proof by surgery, histology, or clinical follow-up. Since the tendency of authors is to submit complex Cases illustrating an anatomical variant, possibly mimicking disease, are also welcome. Potential au- cases, everyday cases are selected as well. thors are also encouraged to submit cases describing temporal bone pathology, as relatively few cases Knowledge in abdominal radiology is expanding dramatically and the application of new tech- on this challenging structure are available in the database. niques, especially MDCT, MRI or specific contrast agents, has resulted in amazing breakthroughs with When submitting cases on disease conditions, it is important that the radiological diagnosis has been the refinement of sophisticated diagnostic imaging tests and image-guided interventions. It follows confirmed by pathological examination, or depending on the condition described, has been verified in that submission of cases with patients not examined by state-of-the-art imaging modalities have to be some other way. Cases showing pathology of intracranial structures, unless originating from the skull rejected because of low educational value.” base, should be submitted to the neuroradiology section.” Section Editor: Prof. Borut Marincek is Professor of Radio- Section Editor: Prof. Robert Hermans is Professor of Radiology logy and Chairman of the Institute of Diagnostic Radiology at the University Hospitals of Leuven/BE. He specialises in head at the University Hospital Zurich/CH. He was nominated and neck radiology, with a special interest in imaging of head and Section Reviewer in 2000 and took over as Section Editor in neck cancer. Prof. Hermans is also a deputy editor of European 2004. He is not only the president of ECR 2009, but currently Radiology, where he manages the interpretation corner (see article also serves as President of the European Society of Gastroin- on p. 32). testinal and Abdominal Radiology (ESGAR) for 2007–09.

Musculoskeletal System Neuroradiology “It is a great honour and pleasure to coordinate the musculoskeletal section of EURORAD. In this “The neuroradiology section of EURORAD comprises brain and spine cases that have been collected section all unusual cases are welcome that are supported by high quality images obtained with dif- based on their peculiarity and/or educational impact. The first goal of EURORAD is helping non-ex- ferent imaging techniques and with a discussion that takes into account all the features introducing perienced radiology in a specific field, thus we encourage submission of all those cases by which useful the possible criteria of differential diagnosis. Another recommendation is that the reference should information for the diagnosis, but also treatment and prognosis, can be argued. Pathologic-radiologic be updated and pertinent. I believe that all these aspects are relevant for educational purposes, which correlations are preferred (when available) but not mandatory. Intriguing cases are welcome but well- is the main goal of the EURORAD initiative. Finally, other criteria to be followed for the selection of described short review cases from daily practice can be accepted as well. Anatomic review can be the case submission should be a preliminary overview of cases already submitted and available in the accepted too. A well described clinical approach to the patient (including therapy and outcome when EURORAD database, in order to avoid unnecessary repetition.” possible) is important and necessary in most cases. The final diagnosis must be proven either patho- logically and/or clinically. Presumptive diagnosis will not be considered. Multi-modality approaches Section Editor: Prof. Giuseppe Guglielmi is Professor of Ra- to diagnosis are welcome. A short but comprehensive discussion including recent references will help diology at the University of Foggia/IT. “The reasons for my readers. Quality of images must be outstanding.” interest in being a EURORAD editorial reviewer originate from my educational background, since I participated in a Section Editor: Prof. Alessandro Bozzao is an associate Radiology and RadioGraphics editorial fellowship program- Professor of Neuroradiology in the University La Sapienza me. I found this activity very stimulating and I have con- in Rome/IT. His main interests are in the field of diagnostic tinued working in this field and actually I serve as deputy neuroradiology with advanced MRI technique. He is respon- editor of La Radiologia Medica and I serve as member of the sible for one of the few high field MRI units in the world. editorial boards of several journals.” He is married to Francesca, with two children, Beatrice and Luigi, and beyond neuroradiology he loves sport (swimming and biking) and reading.

Paediatric Radiology Vascular Imaging “The paediatric section of EURORAD is unique in that it is the only one that is defined by the age of the “The vascular imaging section is devoted to pathologies and disorders involving the vascular system, patient rather than the anatomical area. Consequently, the paediatric section includes all the different including arteries, veins and lymphatic system. Because of the existence of an interventional radiology anatomical systems within it. All cases that involve children in imaging are welcome, however, greater section, this database will only include diagnostic cases. Any diagnosis of a pathology or vascular ano- emphasis and importance are placed on those cases that are unique to paediatrics or have a particular maly in which vascular imaging is contributive (including conventional angiography, CT angiography, message that is pertinent for paediatric radiologists. Issues relating to radiation protection and avoiding MA angiography and ultrasound, CT, MRI) is welcome.” unnecessary irradiation of children are important. The paediatric section contains a large number of interesting and often rare conditions and further additions to these types of cases are encouraged.” Section Editor: Prof. Julien Struyven is Professor of Radiology at the Hôpital Universitaire Erasme in Brussels/BE. “As mentioned in the history page of the EURORAD website, I laun- Section Editor: Dr. Karl Johnson is a Consultant Paediatric Radiologist at Birmingham ched the idea to build an EAR teaching database in 1995, and this is why I am still interested Children’s Hospital in Birmingham/UK. “I am involved with EURORAD to promote paedia- in the subject. I started diagnostic angiography, including coronary, in 1966 (a long time ago) tric radiology, and in particular to highlight the need for appropriate high quality imaging of when angiography was not only a tool to diagnose specific vascular pathology but also the children and the avoidance of unnecessary irradiation.” only diagnostic procedure for organ pathology. The natural evolution towards interventional radiology happened in the early seventies and I started coronary angioplasty in 1980. Since 1977, beside my duties as head of department and professor of radiology I wanted to be ‘in- terventionally’ active, mostly in interventional cardiology, except for the last five years where I moved back to interventional radiology. My main hobbies are classical and contemporary music and contemporary art.”

Visit the EURORAD Booth on the entrance level in Foyer E.

myESR.org 28 ECR TODAY 2009 COMMUNITY NEWS Saturday, March 7, 2009

ESMRMB looks forward to an exciting annual MR meeting in Turkey

The European Society for Magnetic Resonance in Sir Peter Mansfield Opening Lecture by Prof. on the basis of feedback from the participants. After successful introduction of a new course on Medicine and Biology (ESMRMB) looks forward Kamil Ugurbil. The plenary, scientific and clinical Moreover, the long-standing involvement of the Advanced MR imaging in paediatric radiology to welcoming Europe’s MR community to its focus sessions as well as the mini categorical course organisers guarantees the constant high in 2008, another new course topic will be Annual Scientific Meeting and to its numerous courses will offer a wide range of novelties in quality of the programme. Course organisers introduced this year, covering advanced MR teaching activities. the various aspects of magnetic resonance. They and their faculties have established a learning imaging of the chest. excellently complement the teaching programme curve that provides the best guarantee of meeting The first course will be held in Dubai from It is our great pleasure to invite you to the beautiful organised by Prof. Arend Heerschap and the the quality requirements of the School in the March 26–28, 2009 on Advanced MR Imaging location of Belek/Antalya for our 2009 Annual Education and Workshop Committee. various centres where the courses take place. of the Abdomen. Scientific Meeting. ESMRMB comes for the first The concept of repetition classes in small groups time to Turkey, hosted by Prof. Muhtesem Agildere The congress, to be held from October 1–3, 2009, with not more than 15 participants has become a Hands-On MRI – A new course as Chair of the Local Organising Committee. is at the Maritim Pine Beach Hotel, situated highly appreciated teaching format. programme for technologists approximately 40 minutes from the airport. This The Hands-On MRI programme will focus on ESMRMB, which now has more than 1,000 resort will accommodate every scientific activity, Over the years the course programme has practical applied MRI in the more advanced MR active members, continues to attract more host an industrial exhibition in a compact and become increasingly well-established within the techniques. The courses will be an optimal addition and more participants to its Annual Scientific convenient manner, and offer an excellent setting radiological community. to the current School of MRI courses. The course Meetings, with a record attendance last year for a lively and enjoyable atmosphere. programme is aimed at radiographers as well as in Valencia of over 1,200. This year ESMRMB Another element of the spirit of the School physicians interested in performing advanced MR holds its 26th congress in the very same spirit Student and resident members of ESMRMB of MRI is the European approach and the examinations on their own. In 2009 three courses that founded our society in 1984 as a platform enjoy free registration to the meeting! We international atmosphere. Following the concept will take place in the fields of MR Angiography for clinicians, physicists and basic scientists hope that many of you will consider coming that all courses have to rotate throughout the (MRA), Cardiac MRI, and fMRI & DTI. with an interest in the field of MR. The society and joining us in Turkey in early October European countries, the distribution of the has continuously favoured multidisciplinary as the ESMRMB is proud to invite the world- total of 77 courses since 2000 has included 18 Lectures on MR – A programme tailored interactions and has tried to attract the largest wide Magnetic Resonance Community to its European countries – well balanced between to the needs of physicists number of students and young researchers, who 26th Annual Scientific Meeting. north, central, south and east – and two African Educational courses, exercises, and practical have been quite numerous from the beginning, countries. On the other hand the total of more demonstrations on MR physics, spectroscopy to attend ESMRMB congresses. These events ESMRMB School of MRI – than 3,000 participants came from 79 countries and engineering for MR physicists are again on offer a much appreciated forum for integrated Successful as never before worldwide, 90% of them from Europe, 6% from ESMRMB’s agenda in 2009. Six courses will be European research activities in basic and The ESMRMB School of MRI, focusing on Africa, 5% from Asia and the rest from America offered, including three new courses on fMRI, clinical MR applications and the missions to the education of physicians and technicians, and even Australia/New Zealand. MRI and Molecular Imaging in Experimental support educational activities and research in was successful as never before in 2008. All 12 Neuroscience and RF coil design. MR encompass an even larger scope with the courses were fully or nearly fully booked and In 2008 the School of MRI of ESMRMB entered new Strategic Plan, expanding to other imaging four courses even had waiting lists and were into a cooperation with the European School of Visit the ESMRMB booth on the entrance modalities related or comparable to MR. not able to fulfil all registrations. Certainly, the Radiology (ESOR) of the ESR. In this way we were level to obtain the latest course pro- most important factor in this story of success is able to avoid competition with this organisation To do so, the Scientific Programme Committee, the quality and the expertise of the lecturers and and could profit from better visibility within the grammes and more detailed information! chaired by Prof. Bernard Van Beers, has prepared teachers. Evaluation of all teachers in every single radiological community by being integrated into a very attractive programme, starting with the course enables us to constantly increase quality the advertising activities of the ESR.

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Neuroradiology pioneer presents today’s Honorary Lecture about systems radiology In recognition of his outstanding achievements and pioneering work in neuroradiology, Professor Dieter R. Enzmann from Los Angeles, CA/US, will present the Wilhelm Conrad Röntgen Honorary Lecture ‘Navigating toward systems radiology’ today at ECR 2009.

By Mélisande Rouger Medicine at the University of California, Los of Neuroradiology’s Cornelius G. Dyke Award Angeles (UCLA). He has been responsible for for outstanding research and was awarded two Dieter R. Enzmann was born in 1945 in West the academic and clinical radiology programmes National Institutes of Health (NIH) grants for Germany. He obtained a bachelor’s degree with at the UCLA School of Medicine and at affiliated central nervous system (CNS) research projects, honours from the University of Wisconsin hospitals since then. ‘Experimental Brain Abscess and CSF Flow’ and (Madison) and a medical degree from Stanford ‘Pathogenesis of Chiari l Syringomyelia’. University in 1972. He started a residency in dia- Prof. Enzmann’s major interests and research gnostic radiology at Stanford University Medical contributions are in the areas of CNS infections, He has published numerous papers, scores of Center in 1972, which he completed in combina- particularly bacterial infections, and cerebro-spi- chapters and two books. His third book, ‘Survi- tion with a fellowship in neuroradiology at the nal fluid (CSF) physiology and its relationship to ving in Health Care’, received the American Col- University of California, San Francisco, in 1977. brain motion and cerebral blood flow. His early lege of Physician Executive’s Robert A. Henry interest in CNS infections is reflected in his first Literary Achievement Award for its contribution After his residency, Prof. Enzmann started at book entitled ‘Imaging of Infections and Inflam- to medical management. Stanford University Medical School as Assistant mations of the Central Nervous System: Comput- Professor of radiology specialising in neurora- ed Tomography, Ultrasound and Nuclear Magne- A big fan of aquatic sports, Prof. Enzmann also diology. In 1983 he was promoted to Associate tic Resonance.’ Prof. Enzmann contributed to the enjoys reading and colour photography in his “I find it a true honour to be asked Professor and to full Professor in 1990. He was basic understanding of imaging cerebral absces- free time. He is married to Diana and has three to present the Wilhelm Conrad Director of MRI at the Department of Diagnostic ses by relating key imaging features of brain daughters, Lyssa, Brittany and Brisa. Radiology & Nuclear Medicine as well as sec- abscesses to histopathology, and more generally Röntgen Honorary Lecture, ‘Navi- tion chief of neuroradiology in the department. by emphasising the interplay between the micro- gating toward systems radiology’ at He took two sabbatical years in 1984–85 and organism and the host response, especially in an the 2009 European Congress of 1992–93, during which he attended the Stanford immunosuppressed context. He was one of the Wilhelm Conrad Röntgen Radiology. This invitation repre- Graduate School of Business. In 1996 he became early investigators to exploit flow-sensitive MR Honorary Lecture Professor and Chairman of the Department of scanning techniques. These techniques help to sents a great opportunity to unite Radiology at Northwestern University Medical qualitatively and quantitatively understand CSF Saturday, March 7, 12:15–12:45, Room A and integrate the specialty of ra- School and Northwestern Memorial Hospital in flow dynamics to blood flow and its association diology on an international scale. Chicago. with brain and spinal cord motion. ‘Navigating toward systems radiology’ We can learn much from each other In January 2001, he assumed the Leo G. Rigler A Mellon Foundation Fellow for four years, Dieter R. Enzmann, Los Angeles, CA/US and better yet, we can accomplish Chair position at the David Geffen School of Prof. Enzmann received the American Society much together.” News from the Faculty of Radiologists, Royal College of Surgeons in Ireland

The Faculty of Radiologists, Royal College of tants is consistently very high, as evidenced by Surgeons in Ireland is the body responsible for the high level of participation in international provision of postgraduate training in diagnostic meetings, including the ECR. The development radiology and radiation oncology in the Repub- of Academic Medical Centres on best practice lic of Ireland. At present, there are 86 Specialist international lines will, it is hoped, help the stra- Registrars in Diagnostic Radiology and 13 Speci- tegic evolution of imaging research. alist Registrars in Radiation Oncology in full time training in their specialties, spread across seven The standard of equipment in diagnostic and centres in diagnostic radiology and two in radia- therapeutic departments in the country is rela- tion oncology, in three major cities in Ireland. tively high, but variable. Equipment purchase and replacement is the function of a central Both programmes are spread over five years of health service authority and budgeting is not training, with the exam for the Fellowship for based upon a depreciation model. Therefore, the Faculty taken initially in the fourth year. The replacement of old equipment is haphazard and Primary Fellowship exam, covering elements of not planned in advance. basic science relevant to the specialties, is taken at the end of the first year’s training. The principle service issues facing our special- ties, particularly in times of economic decline, After satisfactory completion of five years of trai- are the need to increase consultant numbers ning, having passed the Fellowship exam, candi- (and to achieve commensurate increase in trai- dates are eligible for inclusion on the Specialist nee numbers to keep pace) in order to ensure Register of the Medical Council of Ireland, and safe delivery of timely service to patients, and a are eligible to apply for permanent consultant need to budget for development of departments posts in their specialty. Nonetheless, most of and replacement of equipment in a more plan- tern countries, Ireland’s healthcare budget is where possible, with employment and regulatory our trainees pursue further training abroad after ned fashion. being cut dramatically in 2009, and major new authorities to keep our standards high and we completion of training in Ireland, principally developments are in doubt at present. look forward to a strong future with our Fellows in the United States, Canada and the UK, but Current government policy in Ireland is to cen- and trainees remaining at the centre of high qua- increasingly in other European countries. tralise cancer care in eight regional cancer cen- A major issue for the Faculty of Radiologists lity medical care delivery. tres. This policy is presently being implemented is to inform the development of uniform, best There are approximately 180 consultant radiolo- for breast cancer care; planning is underway practice Quality Assurance Programmes across gists in full time practice in the Republic of Ire- for similar centralisation for management of the country. This must obviously be done with land. The number of consultant and trainee posts other cancers. The implications for delivery of patient safety at its core. There is however a par- in the public sector is controlled by the central first-class diagnostic services are significant; at allel process of educating and informing society health authorities. The ratio of consultants to present, many forms of cancer are managed to so as to set realistic expectations. population is low in comparison to some of our a high standard in particular hospitals that have neighbouring countries, and the numbers of stu- evolved very experienced teams in specific niche Despite these difficulties, the specialties of radia- dies performed by individual consultants is quite areas. Movement of staff and expertise may be tion therapy and diagnostic radiology are strong high by international standards. Understandably, required to achieve the political goal of centra- and well-respected in Ireland. Our specialties this places great pressure on practicing radiolo- lisation. It remains to be seen if the resources attract some of the brightest graduates every gists and radiation therapists, but despite this, necessary to implement these changes will be year, and competition for places on our trai- the research output of our trainees and consul- available in recessionary times. Like many wes- ning schemes is very intense. We work closely,

myESR.org 30 ECR TODAY 2009 ARTS & CULTURE Saturday, March 7, 2009

What’s on today in Vienna?

Theatre Please note that all performances are in German! Akademietheater 20:00 Untertagblues 1030 Vienna, Lisztstrasse 1 by Peter Handke phone: +43 1 51444 4145 www.burgtheater.at

Burgtheater 19:00 Trilogie des Wiedersehens 1010 Vienna, Dr. Karl-Lueger-Ring 2 by Botho Strauß phone: +43 1 51444 4145 www.burgtheater.at

Rabenhof 20:00 Die deutsche Kochschau 1030 Vienna, Rabengasse 3 Anarchistic, iconic Austrian cabaret by phone: + 43 1 712 82 82 and with Dirk Stermann and Christoph www.rabenhof.at Grissemann

Schauspielhaus 20:00 Zwei arme Polnisch sprechende Rumänen 1090 Vienna, Porzellangasse 19 by Dorota Masłowska phone: + 43 1 317 01 01 www.schauspielhaus.at

Theater in der Josefstadt 19:30 Die Wirtin 1080 Vienna, Josefstädter Straße 26 by Peter Turrini phone: +43 1 42 700 300 www.josefstadt.org

Volkstheater 19:30 Drei Schwestern 1070 Vienna, Neustiftgasse 1 by Anton Tschechow phone: 43 1 52111 400 www.volkstheater.at Untertagblues by Peter Handke © Georg Soulek / Burgtheater

Concerts & Sounds

Konzerthaus (Classical Music) 19:30 Polina Leschenko, piano 1030 Vienna, Lothringerstrasse 20 J. Haydn, N. Medtner, J. Brahms, www.konzerthaus.at P.I. Tchaikovsky, S. Rahmaninoff

Musikverein (Classical Music) 19:30 Vienna Symphony Orchestra 1010 Vienna, Bösendorferstrasse 12 conductor Andrey Boreyko www.musikverein.at R. Buchbinder, piano C. Debussy, M. Ravel, A. Zemlinsky

Porgy & Bess (Jazz) 20:00 JT Lewis / Herve Samb / 1010 Vienna, Riemergasse 11 Melvin Gibbs ‘Middle Passage Squad’

Polina Leschenko © Marco Borggreve www.p orgy.at

Opera & Musical Theatre

Volksoper 19:00 Die Hochzeit des Figaro 1090 Vienna, Währingerstraße 78 Opera by Wolfgang A. Mozart www.volksoper.at

Wiener Staatsoper – 19:30 Eugen Onegin Vienna State Opera by Pyotr I. Tchaikovsky 1010 Vienna, Opernring 2 conducted by Seiji Ozawa www.wiener-staatsoper.at with Tamar Iveri, Nadia Krasteva, Simon Keenlyside, Ramón Vargas, Ain Anger

Wiener Kammeroper 19:30 Le Pescatrici – Die Fischerinnen 1010 Vienna, Fleischmarkt 24 by Joseph Haydn, based on a libretto www.wienerkammeroper.at by Carlo Goldoni conducted by Daniel Hoyem-Cavazza with Alfred Werner, Anna Pierard, Sebastian Huppmann, Jennifer Davison, Auxiliadora Toledano

Raimundtheater 19:30 Rudolf – The Mayerling Affair 1060 Vienna, Wallgasse 18-20 Musical by Frank Wildhorn & Jack Murphy

Die Hochzeit des Figaro by W.A. Mozart © Dimo Dimov / Volksoper Wien Mozart © Dimo Dimov / Volksoper Die Hochzeit des Figaro by W.A. www.musicalvienna.at

myESR.org See Vienna’s pictorial treasures

Revel in the abundance of fine arts at Vienna’s numerous outstanding museums. For one, don’t miss Albrecht Dürer’s world-famous Young Hare from 1502, one of the highlights of the world’s largest graphic collections presented at the Albertina. Albrecht Dürer, Young Hare, 1502 © Albertina, Wien Young Albrecht Dürer, 32 ECR TODAY 2009 COMMUNITY NEWS Saturday, March 7, 2009

Introducing the Interpretation Corner and Prof. Robert Hermans

By Stefanie Muzik training programme at the University Hospitals of head and neck diseases, so that turned out to of Leuven, and became a certified radiologist in be the perfect combination of all my interests. The interpretation corner (IC) quiz is an annual 1991. He was appointed as a staff member of the competition for European Radiology readers, Department of Radiology at the same institution ECRT: How long have you been involved which consists of 12 monthly parts. In each one year later. His primary interest is head and in European Radiology? How did you get issue of the journal, a quiz type case report with neck radiology. into it? an open diagnosis is published, and readers are RH: I got involved in 1995, when my chairman invited to send in their answers. Introduced In 1997, he spent a visiting fellowship in the at that time, Prof. Baert, became the Editor- in 2003 as a new section, IC has become very Department of Radiology of Shands’ Hospital in-Chief and asked me to help him as editorial popular with authors and readers. It provides in Gainesville (University of Florida). In 1998, assistant. It was a wonderful experience to see a shortened history and one or more images he obtained a doctorate in medical sciences the journal steadily grow under his leadership. from cases that have proved to be diagnostic (PhD) at the Katholieke Universiteit Leuven, When Prof. Dixon took over, he asked me to challenges at the authors’ institution. The with a thesis on laryngeal cancer imaging. He become deputy editor, with the specific job of authors’ affiliations are not revealed at this stage was appointed Assistant Professor in 1998, and taking care of the ‘Interpretation Corner’. and the case report does not lead easily to the Associate Professor in 2000, at the faculty of diagnosis. Every quiz case is followed by the Medicine of the same university. In 2004, he was ECRT: What is so special about Interpretation solution case report, which describes exactly promoted to Professor. Corner articles and why are they so attractive the investigations at the host institution, the for readers? diagnosis finding and the teaching points of He is a member of several scientific societies, has RH: We try to select cases that are more or the case. IC cases are of course unique and not served as President of the International Cancer less unusual, but also have clear educational routine cases, but pose a diagnostic challenge. Imaging Society (ICIS), and is a member of the value. By analysing the images together with Prof. Robert Hermans from Leuven, Belgium is one of executive committee of the European Society of the clinical information, it should be possible the Deputy Editors of European Radiology. At the end of each calendar year, the reader Head and Neck Radiology (ESHNR). to reach a specific diagnosis. The ideal case who has supplied the highest number of correct requires careful analysis, the building of a answers is recognised at the Editorial Board He has published over 150 articles to date, as differential diagnosis, and reduction of this list ECRT: Is there any special field of radiology Meeting, which is held annually during ECR. author or co-author, and several book chapters to one most likely diagnosis. Most cases require which is more favoured by authors? Or do you Last year, Dr. Annemie Snoecks from Antwerp, on different topics in head and neck imaging, some detective work, consulting textbooks or prefer special topics? Belgium, again submitted the most correct mainly focusing on neoplastic disease. He is searching the internet, and I guess this is one RH: We receive cases from all subdisciplines, answers and unbelievably won the Interpretation editor of the books Imaging of the Larynx, of the aspects radiologists like the most about and there is no preference for a special topic. Corner for the fourth time in a row. Head and Neck Cancer Imaging, Squamous their job. Cell Cancer of the Neck, and associate editor ECRT: When did you come to ECR for the first European Radiology is a successful and growing of the Encyclopedia of Medical Imaging. He ECRT: What should an author consider before time? What were your impressions? scientific journal, not only because of a strong is regularly invited to lecture at national and submitting his case to European Radiology? RH: The first time was in 1993 and since then society and excellent authors, but also because international radiology meetings. What does the case need to be interesting? I have attended all ECR meetings. I am always of the people ‘behind the scenes’ who together RH: The diagnosis should not be straight- impressed by the superb organisation, and I very make up the editorial team supporting Editor- ECR Today: Why did you choose medicine forward, but it is certainly not required that the much like the Viennese atmosphere. Over the in-Chief Prof. Adrian K. Dixon. The Deputy and radiology as your profession? What was presented pathology is extremely rare. Cases years, ECR has evolved to such a high standard Editors, of which there are 5, supervise various so interesting about radiology when you were for Interpretation Corner are published in two that one can not simply skip a meeting without topics or areas within the spectrum of radiology. a young student? parts. Part A should only contain very concise missing important innovations. Prof. Robert Hermans: I decided quite late to but relevant clinical information, and a few We would like to personally introduce one start studying medicine, during the last months representative images without annotations. ECRT: How do you see radiology in 20 years? of them, Prof. Robert Hermans from Leuven, at secondary school. I was actually thinking These should allow the final diagnosis to be What do you think will be the developments Belgium, who coordinates the IC. about studying applied sciences, but finally my reached. Part B is more like a regular case and ‘hot topics’? love for biology and related sciences was stronger report, and is published a few months later, RH: Let’s hope developments in molecular Robert Hermans, born in 1962, studied medicine than that for mathematics and physics. Also my after the readers have been able to submit their imaging will become available in daily practice. at the Katholieke Universiteit in Leuven. He choice for radiology was a very late decision. My most likely diagnosis. In part B, the differential I also think progress in hardware and software spent practical training periods in several first option was to specialise in ENT diseases, diagnosis is very important. It should also will introduce new possibilities. I refer for hospitals in Belgium and South Africa. He but eventually there was an opportunity to contain an explanation of why the other possible example to the possibilities offered by diffusion- gained his MD with distinction in 1987. After start with radiology. During the last year of my diseases in the differential diagnosis are less weighted MRI in oncology, something hardly his medical studies, he entered the radiology training, I could further subspecialise in imaging likely to be the correct ones. heard of a couple of years ago.

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