DIEurope Oct 2014

E U R O P E

OCTOBER 2014

D i a g n o s i s • T e c h n o l o g y • T h e r a p y • p r e v e n T i o n

Imaging of colorectal cancer liver metastases from a surgeon’s point of view

current status of radiation dose reduction in chest cT

Scaling computer aided detection from workstation to the cloud: medical image analysis today

The growing realization of the importance of breast density

improving prostate cancer screening with ShearWave elastography

Medical imaging in an integrated anatomy curriculum

optimizing iT infrastructure in a provincial hub hospital and active oncology research centre

Trans Arterial ChemoEmbolization with Lipiodol in the treatment of hCC

Carotid Mri: providing insight into cardiovascular risk

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BY AlAn BArclAY, Ph.D.

FROM THE EDITOR

The debate currently raging between on the one hand the critics of the usefulness of screen-ing mammography and on the

other the embattled radiologist involved in poring over mammograms to detect the slightest trace of suspicious lesions is lively to say the least. It is a measure of the ferocity of the debate that the recent publication in JAMA Internal medicine of a paper dealing with undesirable cancer screening is likely to give rise to involuntary spasms, nervous tics and not so sotto voce mutterings of oh no here we go again on the part of radi-ologists as they brace themselves for another attack. (Royce et al Cancer screening rates in individuals with different life expectancies, JAMA Int Medicine October 2014; 174 (10): 1558- 1565). The positions of the adversaries in the screening mammography debate have become so entrenched that it is difficult to foresee any possible middle ground or compromise, if only because of the mutual incomprehensibility of the arguments put forward on each side. In the face of the con-clusions of the epidemiologists who, armed with detailed statistical analysis of years of screening mammography data pronounce that the principal effect of such screening has simply been to overdiagnose cancers which would not in any case have resulted in the patient’s death, it is reasonable for a radiologist to ask how exactly he is sup-posed to interpret such population-based conclusions when he is confronted with a real live individual case of a woman women, in whom he has just detected a suspicious lesion.

Given the virulence of the breast screen-ing arguments it is perhaps a meagre con-solation that the latest JAMA paper is not limited to mammography screening, but in fact covers in addition three other com-mon cancers, namely prostate, cervical and colorectal. In addition, the point being made by Royce et al is not just the usual “overdi-agnosis“ charge but is instead an analysis of to what extent individuals with limited life expectancy have been subjected to unneces-sary cancer screening. Here at least it seems simply a matter of common-sense. As Royce et al point out, there is general agreement that routine cancer screening has little like-lihood to result in a net benefit for indi-viduals with limited life expectancy. This

is reflected in the guidelines of the various professional associations. For example, the American Urological Association recom-mends cessation of PSA screening in men with a life expectancy of less than ten years, and the corresponding associations dealing with colorectal and cervical cancer recom-mend not to screen in people over a certain age, which is the crude surrogate marker used for life expectancy.

Royce et al basically set out to see how such guidelines are respected in prac-tice and, having delved into the huge data bases of the US National Center for Health Statistics, come up with the conclusion that a substantial proportion of the US popula-tion with limited life expectancy did never-theless receive prostate, breast, cervical and colorectal cancer screening that is unlikely to be of any practical net benefit to the individual concerned. The findings raise inevitable concerns not only about the costs associated with such unhelpful screening, especially in the current climate of ever-tightening healthcare budget pressures, but also the possibility that the therapeutic intervention triggered by a positive result in screening may actually result in unneces-sary net harm to the patient.

Another group of researchers (Van Hees et al, JAMA Int Med 2014 Oct 1; 174(10); 1568 – 76) have specifically ana-lysed the cost-effectiveness of colonos-copy screening in people over 65 years of age at a higher frequency than that recommended in the guidelines namely repeat screen at 65 and 75). More fre-quent screening than that (which Royce et al found out to be current practice) caused the cost –effectiveness ratio per Quality Adjusted Life-Year (QALY) to rocket from the generally acceptable $32 000/QALY (well below the usual cut-off of $50 000/QALY) to an astronomic $750 000/QALY.

While the commonsense argument that cancer screening should be restricted in people with low life expectancy is widely accepted, the devil lies in the detail of determining life expectancy. Age is used most often as the statistical correlate of remaining life expectancy. Once again the danger of applying population-based sta-tistical parameters to individual patients rears its head. n

VOlUME 30, nUMBEr 5

eDiTorial aDvisory BoarD

Andreas Adam, London richard P. Baum, Bad Berka Frits h. Barneveld Binkhuysen, Elias Brountzos, Athens Amersfoort Filipe caseiro Alves, Coimbra carlo catalano, Rome Maksim cela, Tirana Patrick cozzone, MarseilleKatarzyna Gruszczynska, Anne Grethe Jurik, Arhus KatowiceAndrea Klauser, Innsbruck Gabriel Krestin, RotterdamGabriele Krombach, Giessen christiane Kuhl, BonnPhilippe lefere, Roeselare heinz U. lemke, Kuessabergluis Martí-Bonmatí, Valencia Thoralf niendorf, Berlinchristiane nyhsen, Sunderland Anne Paterson, BelfastAnders Persson, Linköping hans ringertz, Stockholm Gustav von Schulthess, Zurich Valentin E. Sinitsyn, Moscow Patrick Veit-haibach, Lucerne Thomas J. Vogl, Frankfurt

eDiTorial sTaFF

Editor Alan Barclay, Ph.D. US consulting Editor Greg Freiherr

Editorial coordinator Marika Cooper

Publisher David lansdowne Associate Publisher Bob Warren

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Cancer screening in people with low life expectancy “Lies, damned lies and statistics?”

OCTOBER 2014 D I E U R O P E 3

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TeraRecon, AquariusNet, Aquarius Workstation and VolumePro are registered trademarks of TeraRecon, Inc. Aquarius, iNtuition and the iNtuition logo, iNteract+ and the iNteract logo are trademarks of TeraRecon, Inc. Copyright© 2014 TeraRecon, Inc. All rights reserved.092414AQ-A/DIE-A1

Introducing TeraRecon’s new suite of intelligence & interoperability tools...iNteract+ is TeraRecon’s new ‘ingeniously informed’ image viewer that works in combination with any of TeraRecon’s medical image viewers and image sharing and storage solutions to provide unmatched intelligence, powerful interoperability and simplified integration capabilities.

iNteract+ solutions enhance the clinical end-user experience provided by PACS, VNA, EMR and other mission-critical image processing and image acquisition systems.

iNteract+ stands alone as the only solution capable of achieving collaborative remote access with image sharing, DICOM and non-DICOM viewing and incorporation of relevant clinical information all within one viewer.

Ingeniously Informed Imaging from the leader in advanced visualization.

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See us at JFR 2014 in Paris.

092414A-DIE.indd 1 9/24/14 1:27 PM

COMING SOON IN the NOveMber ISSue: Women’s health hybrid imaging cardiology

COver StOrYCAroTid Mri: providing insighT inTo CArdiovAsCuLAr riskcarotid plaque morphology and composition as determined by magnetic resonance (Mr) imaging can be used to identify asymptomatic subjects at risk of cardiovascular events.

By Dr Anna E. H. Zavodni & Dr David A. Bluemke � � � � � � � � � � � � � � � � � � � � � � � � � � 14

IMAGING NeWS Dose in Breast Tomosynthesis Varies According To Breast Density. . . . 5

Trial of MrI-compatible robot to improve accuracy of prostate biopsies. . . . . 5

PET-cT predicts lymphoma survival better than conventional imaging. . . . . . . . . 6

limited sensitivity of pelvic x-rays for pediatric blunt torso trauma cases. . . . 7MrI shows brain differences between Sensory Processing Disorders and Autism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Presurgical SPEcT/cT of lymph nodes more sensitive than lymphoscintigraphy . 8research shows PET and photoacoustic imaging give better picture of the gut . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

FeAture ArtICLeS Scaling cAD from workstation to the cloud. . . . . . . . . . . . . . . . . . . . . . . . 20The Growing realization of the Importance of Breast Density. . . . . . . . . . . 24

OCtOber 2014

®

E U RO P E

rePOrtS

Lipiodol Trans Arterial ChemoEmbolization (TACE) in the treatment of hepa-tocellular carcinoma

page 26

imaging of colorectal can-cer liver metastases from a surgeon’s point of view

page 10

03| FrOM the eDItOr

18| rADIAtION DOSe reDuCtION current status of radiation dose reduction in chest cT

36| hOSPItAL FOCuS:Reggio Emilia, Italy

Optimizing IT in a provincial hub hospital and active oncology research centre

39| rADIOLOGY DISPLAYS A revolutionary diagnostic display designed to meet the challenges that radiologists face every day

40| uLtrASOuND Improving Prostate cancer Screening with ShearWave Elastography

44| MuSCuLOSkeLetAL rADIOLOGY Evaluation of Osteonecrosis by radiologists

33| INDuStrY NeWS

47| teChNOLOGY uPDAte

Medical imaging in an inte-grated anatomy curriculum

page 30


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NeWSIMAGING


Dose in Breast Tomosynthesis varies according To Breast Density

Balancing the clinical benefit and the patient-specific measurement of radiation dose received during breast screening using tomosynthesis and mammography was the focus of research pre-sented in a paper given at the recent American Association of Physicists in Medicine (AAPM) Annual Meeting. In the study, sponsored by Volpara Solutions and entitled “Which Women Based on Clinical Ben-efits and Dose Should Be Considered For Breast Screening with Tomo-synthesis?” researchers

evaluated volumetric breast density and the mean glandular dose (MGD) imparted by mammography and tomosynthe-sis on a patient-specific basis in order to determine which women might benefit from tomosynthesis in consideration of the clinical benefits. Results demonstrated that for dense breasts, those with a Volpara Density Grade (VDG) (analo-gous to BIRADS) of 3 and 4, the patient-specific dose is equal or even lower for tomosynthesis than in mammogra-phy. However, for low density breasts, the dose was signifi-cantly greater in the tomosynthesis examination than for the mammogram.

“While at higher breast density the dose is approximately equal or lower, when comparing MGD in tomosynthesis and mammography examinations at lower breast density, the mammographic dose is lower than in tomosynthesis, some-times substantially. Since the possibility of lesion masking is directly related to breast density, clinicians might want to consider the diagnostic benefits versus the dose given in tomosynthesis,” said Ralph Highnam, Ph.D., CEO of Vol-para Solutions and a co-author.of the presented paper With growing emphasis on dose in medical imaging as a result of the “Image Wisely” initiative, it is reasonable to expect dose monitoring to expand to include mammography. The Size Specific Dose Estimation (SSDE) for CT was created by an AAPM Task Group in response to the fact that reported dose is not patient-specific but is that measured in a stan-dard phantom. According to research presented at AAPM 2013, mammography units today routinely under- or over-estimate dose because they provide a dose which does not include the patient’s specific volumetric breast density in the estimation. Additionally, since the algorithms used vary, the estimations are not easily compared. “With the breasts sen-

sitivity to radiation, achieving diagnostically useful images while keeping x-ray mean glandular dose as low as possible is critical in breast screening. The growing adoption of breast tomosynthesis and utilization of shorter screening intervals for high-risk women has the potential to increase patients’ exposure to radiation dose. This has renewed interest in the accurate calculation and tracking of mammographic dose on an individual patient basis,” added Dr Highnam.VOlPArA SOlUTIOnSWEllInGTOn , nEW ZEAlAnD http://volparasolutions.com

Trial of Mri-compatible robot to improve accuracy of prostate biopsies

A novel robotic system that can operate inside the bore of an MRI scanner is currently being tested as part of a biomedical research partnership program at Brigham and Women’s Hospi-tal in Boston, MA, USA with the aim of determining whether the robot, in conjunction with real-time MRI images, can make prostate cancer biopsies faster, more accurate, less costly, and less uncomfortable for the patient. The novel system also has the potential to deliver prostate cancer therapies with greater precision.

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IMAGING NeWS

6 D I E U R O P E OCTOBER 2014

Developed by a team of robotics engineers at Worcester Polytechnic Institute (WPI) in collaboration with

colleagues at Johns Hopkins Univer-sity, Brigham and Women’s Hospital (BWH) and Acoustic MedSystems Inc., the robotic system is being used in the BWH Advanced Multimodality Image-Guided Operating suite (AMIGO).

“Prostate cancer is the last form of cancer still diagnosed with blind needle biopsies, so we are working to change that with image-guided tech-nology,” said Dr Clare Tempany, Pro-fessor of Radiology at Harvard Medi-cal School and principal investigator for the research program. “The robot gives the physician a great deal more choice about where to place the biopsy needle,” said Gregory Fischer, associate professor of mechanical engineering and robotics engineering at WPI. “The technology should permit greater accu-racy, and the odds of hitting the target on the first try should be higher. The anticipated result is fewer needle place-ments with higher sensitivity, a faster procedure, less need for repeated biop-sies, lower overall cost, and reduced discomfort for the patient.”

In biopsies now conducted as part of a Brigham and Women’s program without the new robot, physicians use a plastic grid to help position the biopsy needle. They first use multi-modality MRI scans to generate a plan showing where the needle should be inserted, then with the patient in the MRI scanner, the physician directs the needle through most appropriate guide holes in the grid. Additional scans are made periodically to verify the path of the needle and make adjustments, if needed.

Rather than restrict the needle posi-tioning to the choices offered by the

grid, WPI/JHU ‘s MRI-compatible robot manipulates a needle-guide inside the bore of the scanner to help the physician place the needle in the most optimal position as indicated by the real-time images generated by the MRI. AUTOMATIOn AnD InTErVEnTIOnAl MEDIcInE (AIM) lABWOrcESTEr POlYTEchnIc InSTITUTE, WOrcESTEr , MA, USA aimlab.wpi.edu

peT-cT predicts lym-phoma survival bet-ter than conventional imaging

PET-CT is more accurate than conventional CT scanning in mea-suring response to treatment and predicting survival in patients with follicular lymphoma, and should be used routinely in clinical prac-tice, according to new research pub-lished in The Lancet Haematology

(Trotman et al, Prognostic value of PET-CT after first-line therapy in patients with follicular lymphoma: a pooled analysis of central scan review in three multicentre studies. The Lancet Haematology, Sept 2014 doi:10.1016/S2352-3026(14)70008-0)

. “Our findings have important implications for patients with follicular lymphoma, the common and usually slow-growing lymphoma. Compared to conventional CT scanning, PET-CT is more accurate in mapping-out the lymphoma, and better identifies the majority of patients who have a prolonged remission after treatment”, explained Professor Judith Trotman, study leader and Associate Professor at Concord Hospital, University of Syd-ney, Australia.

Almost all patients with follicular lymphoma respond very well to initial treatment with immunochemother-apy, but relapse is common. Current practice is to use CT imaging to evalu-ate treatment response. However CT cannot easily distinguish patients who are likely to remain in a prolonged remission for several years from those at high risk of early relapse. By assess-ing imaging performed in three clini-cal trials, Dr Trotman and her French and Italian colleagues examined the link between PET-CT status and sur-vival following first-line immuno-chemotherapy for advanced follicu-lar lymphoma. Independent, blinded reviewers evaluated the scans of 246 patients who underwent both PET-CT and traditional CT imaging within 3 months of their last dose of therapy. The predictive power of PET-CT was much stronger than conventional CT, accurately identifying patients with an unfavourable prognosis—a PET-positive population with a high rate of disease progression and an almost seven fold increased risk of death—in whom the cancer should therefore be closely monitored. PET-CT also iden-tified that the 83% of patients who achieved PET-negativity had a reas-suringly favourable prognosis, with average remission duration beyond 6 years.. According to Prof Trotman, “We expect this research will result in PET-CT imaging replacing CT, and become the new gold standard to evaluate patients with follicular lym-phoma after treatment. Importantly, it will be a platform for future studies of response-adapted therapies aimed to improve the poor outcomes for those patients who remain PET positive.”www.thelancet.com/journals/lanhae/onlinefirst

IMAGING NeWS


limited sensitivity of pelvic x-rays for pediatric blunt torso trauma cases

Plain anteroposte-rior pelvic radiographs are commonly used to screen children for pelvic fractures or dis-locations after blunt torso trauma. The test sensitivity and utility, however, are unclear. A recent study published online in Annals of Emergency Medicine

casts doubt on a practice that has been considered the gold standard for trauma patients (Kwok M et al Sensitivity of Plain Pelvis Radiography in Children With Blunt Torso Trauma Ann Emerg Med. 2014 doi: 10.1016/j.annemerg-med.2014.06.017). Lead study author Dr M Kwok, of Columbia University Medical Center in New York, N.Y. said “Because of concerns about lifetime exposure to radia-tion in children, appropriate use of radiography is impor-tant. We just could not find enough accuracy or utility to justify the pelvic x-ray for most of these children. ”Plain pelvic x-rays had a sensitivity of only 78 percent for iden-tifying patients with pelvic fractures or dislocations. Of the patients not correctly identified as having pelvic fractures or dislocations, 98 percent were correctly diagnosed by abdominal/pelvic CT scans. Plain pelvic x-rays are useful only for hemodynamically unstable patients and for hemo-dynamically stable patients whom the physician believes may have pelvic fractures or dislocations but who are not otherwise undergoing abdominal/pelvic CT scanning. The highest risk for pelvic fractures or dislocations included pedestrians or bicyclists struck by moving vehicles and injuries involving motor vehicle collisions. Low-level falls or bicycle accidents were rarely diagnosed with pelvic frac-tures or dislocations. None of the 281 patients in the study who fell down stairs were diagnosed with pelvic fractures or dislocations.

“However CT scanning should not be used as a primary screening tool if no clinical evidence of pelvic fracture or dislocation exists,” said Dr. Kwok. “A physical examination and clinical judgment are still the first line in determining which patients need advanced imaging and which can safely skip it.”http://tinyurl.com/Kwok-et-al-paper

Mri shows brain differences between sensory processing Disorders and Autism

Over 90% of children with Autism Spectrum Disor-ders (ASD) demonstrate atypical sensory behaviors. In fact, hyper- or hyporeactivity to sensory input or unusual

interest in sensory aspects of the environment is now included in the DSM-5 diagnostic criteria. However, there are children with sensory processing differences who do not meet an ASD diagnosis but do show atypical sensory behaviors to the same or greater degree as ASD children. A group at University of California at San Francisco previ-ously demonstrated that children with Sensory Processing Disorders (SPD) have impaired white matter microstruc-ture, and that this white matter microstructural pathology correlates with atypical sensory behavior. In a new, recent study (Chang et al. Autism and sensory processing disorders: shared white matter disruption in sensory pathways but divergent connectivity in social-emotional pathways PLOS ONE. 2014 Jul 30;9=e103038), the group used diffusion tensor imaging (DTI) fiber tractography to evaluate the structural connectivity of specific white matter tracts in boys with ASD (n = 15) and boys with SPD (n = 16), rela-tive to typically developing children (n = 23). White matter tracts were defined using probabilistic streamline tractog-raphy and the strength of tract connectivity assessed using mean fractional anisotropy. Both the SPD and ASD cohorts

demonstrate decreased connectivity relative to controls in parieto-occipital tracts involved in sensory perception and multisensory integration. However, the ASD group alone showed impaired connectivity, relative to controls, in temporal tracts thought to subserve social-emotional processing. In addition to these group difference analyses, the researchers took a dimensional approach to assessing the relationship between white matter connectivity and participant function.

Thus one of the most striking new findings is that the children with SPD show even greater brain disconnec-tion than the kids with a full autism diagnosis in some sensory-based tracts. However, the children with autism, but not those with SPD, showed impairment in brain con-nections essential to the processing of facial emotion and memory.”

One of the classic features of autism is decreased eye-to-eye gaze, and the decreased ability to read facial emo-tions, he impairment in this specific brain connectivity, not only differentiates the autism group from the SPD group but reflects the difficulties patients with autism have in the real world. “In our work, the more these

IMAGING NeWS


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regions are disconnected, the more challenge they are having with social skills.” said Elysa Marco, cognitive and behavioral child neurologist at UCSF Benioff Children’s Hospital San Francisco and the study’s corre-sponding author. “If we can start by measuring a child’s brain connectiv-ity and see how it is playing out in a child’s functional ability, we can then use that measure as a metric for suc-cess in our interventions and see if the connectivities change based on our clinical interventions,”. http://tinyurl.com/Chang-et-al-paper

presurgical specT/cT of lymph nodes more sensitive than lymphos-cintigraphy

Startling data from an international multi-center trial provide growing evidence that sentinel node imag-ing is more effectively accomplished with hybrid functional imaging with SPECT/CT than with lymphoscin-tigraphy. This conclusion holds for a range of cancers displaying a variety of lymphatic drainage types associated with melanoma, an aggressive skin cancer; breast carcinoma; and malig-nancies of the pelvis, such as prostate and cervical cancer, say researchers at the Society of Nuclear Medicine and Molecular Imaging’s (SNMMI) 2014 Annual Meeting. (Heffernan et al Pro-spective IAEA sentinel node trial on the value of SPECT/CT vs planar imaging in various malignancies J Nucl Med. 2014; 55 (Supplement 1):565)

Lymph node imaging is an essential tool in the context of surgical resec-tion, because cancer spreads first to the lymph nodes, specifically the sen-tinel lymph nodes, before developing new malignancies elsewhere in the

body. Molecular imaging of sentinel nodes provides a surgical map that can improve a patient’s chances of becom-ing cancer free.

“We found significantly more sen-tinel lymph node involvement with SPECT/CT, which altered surgical planning for many of our patients—a finding that was repeated across all malignancies and clinical institu-tions,” said Dr Thomas N.B. Pascual, co-author of the study and a research scientist from the section of nuclear medicine and diagnostic imaging and division of human health of the Inter-national Atomic Energy Agency in Vienna, Austria. Study findings showed that SPECT/CT breast cancer imaging detected 13 percent more cancerous sentinel nodes—2,165 nodes versus 1,892 using planar lymphoscintigra-phy. The hybrid SPECT system also detected 11.5 percent more sentinel nodes when imaging for melanoma, with 602 versus 532 nodes detected. In addition, 29.2 percent more nodes were imaged using SPECT/CT to detect pel-vic cancer—195 nodes found versus 138 with planar imaging. Changes in surgical planning as dictated by SPECT/CT were substantial—16.9 percent of breast cancer surgeries underwent a change in management, 37 percent of surgeries for melanoma changed and 64.1 percent of surgical plans for pelvic cancer were changed due to detection of additional sentinel nodes. Calculated mismatch between sentinel nodes and lymphatic terri-tories using the two imaging systems was gauged at 17 percent for breast carcinoma, 11.2 percent for melanoma and 50 percent for pelvic imaging. The significantly higher mismatch in pelvic tumors was thought to be due to rela-tively deeper lymphatic drainage and location of pelvic sentinel nodes.http://tinyurl.com/SNMMI-abstract

research shows peT and photoacoustic imaging give better picture of the gut

There is a need for safer and improved methods for non-inva-sive imaging of the gastrointestinal tract. Modalities based on X-ray

radiation, magnetic resonance and ultrasound suffer from limitations with respect to safety, accessibil-ity or lack of adequate contrast. Functional intestinal imaging of dynamic gut processes has not been practical using these exist-ing approaches. To meet these challenges, a multi-institutional team of researchers has developed

a new nanoscale agent for imag-ing the gastrointestinal (GI) tract. (Zhang Y et al, Non-invasive mul-timodal functional imaging of the intestine with frozen micellar naph-thalocyanines. Nat Nanotechnol. 2014; 9:631). The team developed a family of nanoparticles that can withstand the harsh conditions of the stomach and intestine, avoid systemic absorption, and provide good optical contrast for pho-toacoustic imaging. They then demonstrated that by using pho-toacoustic imaging and positron emission tomography (PET), they have created a multimodal func-tional imaging agent that could be used to perform noninvasive func-tional imaging of the intestine in real time. So far, the researchers have conducted successful test tri-als in mice and are hoping to move to human trials soon.

In practice patients would drink a liquid containing the nanoparticles to allow an imaging technician to noninvasively view the illuminated intestine with photoacoustic imaging. The team hopes the imaging agent can be targeted to look for certain disease-related markers and be used in therapeutic applications in the near future. http://tinyurl.com/Zhang-et-al-paper

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IMAGINGLIvER


By Dr Eduard Jonas

Imaging of colorectal cancer liver metastases from a surgeon’s point of viewThe current resectability paradigm for patients with colorectal cancer liver metastases underscores the necessity for high-resolution liver imaging to enable early detection and accurate hepatic staging.

INTROduCTIONColorectal cancer (CRC) is the third leading cause of cancer death in the world and a leading cause of tumor-associated deaths in Western countries [1]. Between 25 and 50% of patients diagnosed with CRC will turn out to have liver metastases [2,3]. In approxi-mately 50% of patients the metastases will be detected synchronous to the diagnosis of the primary tumor, the rest being detected later during the course of the disease.

Liver resection, regarded as the gold standard for curative-intended treat-ment of colorectal cancer liver metas-tases (CRCLM), will be performed in around 30% of patients, approximately 15% primarily resectable and another 15% after downstaging. The remaining patients will be treated palliatively.

The indications for resection of CRCLM have changed during recent years [4]. Historically, resection was lim-ited to patients who fulfilled a number of tumor-based criteria. Amongst oth-ers, these criteria include tumor num-ber, size and distribution in the liver. A tumor-free surgical margin at liver resection of less than 1 cm was regarded as insufficient and the presence of extra-hepatic disease was an absolute contra-indication to liver surgery.

In the current paradigm the focus is on the future liver remnant (FLR) with resectability being defined as the abil-

ity to perform a complete (R0) resec-tion while preserving a FLR sufficient for the maintenance of post-operative function and regeneration. The pres-ence of resectable extra-hepatic disease is not regarded as a contraindication to liver surgery. Thus, with the current resectability paradigm, unresectability is defined as the inability to create a tumor-free FLR because of combina-tions of the segmental tumor extent, tumor engagement of structures vital to functioning of the FLR (arterial and portal supply; biliary and venous drain-age) or insufficient volume of the FLR.

From a surgical perspective, patients with CRCLM can be divided into one of three therapeutic groups. These are: readily resectable; unresectable at time of diagnosis, but with the potential to downstage or convert to resectable; or initially unresectable and unlikely to ever become resectable. In patients initially not resectable, downstag-ing strategies are designed to address the specific cause(s) of unresectability. These include for example clearing of the potential FLR with staged surgery and/or local ablation (LA) in cases where resection is precluded by the extent of segmental engagement, onco-logic tumor-reducing therapy in case of tumor proximity to structures vital to FLR function and liver volume manip-ulation (portal vein embolization/liga-tion) in the event of insufficient FLR volume. The multitude of interventional options and the increasing use of tai-lored neo-adjuvant and adjuvant che-motherapy have resulted in individual patient-specific multiple modality treat-ment regimes [5]. To optimize assess-ment and therapeutic decision-making, treatment decisions are ideally made

in multidisciplinary treatment (MDT) conferences settings or tumor boards.

Overall 5-year survival ranges between 35% and 58% after liver resec-tion have been reported [6]. Hepatic recurrence can be expected in 50-60% of patients operated for hepatic metas-tases, predominantly as the result of undiagnosed disease in the FLR [7-9]. In patients treated palliatively 5-year survival rates around 5% have been reported [10].

HEpATIC IMAGING fOR pATIENTs wITH COLORECTAL CANCERImaging of the liver is standard practice in patients with newly diagnosed colorec-tal cancer [11]. After colorectal resection, hepatic imaging is performed according to structured follow-up protocols or at the discretion of the surgeon, mostly using ultrasonography or computed tomogra-phy (CT). It should be emphasized that liver metastases, regardless of the time point of detection, are present at the time of diagnosis of the primary tumor and potentially detectable. Early detection of metastases and accurate hepatic staging of the disease, preferably before inter-vention for the primary tumor, enables optimal oncologic and surgical treatment planning from the onset. For example, in limited hepatic disease definitive man-agement of the liver metastases, and in planned staged resection, the first opera-tion can be combined with the primary tumor operation. In selected patients with synchronous detection of the liver metastases where the extensive liver dis-ease is the life-threatening component of the disease complex, liver resection first might be prudent.

With the less restrictive indications for liver resection according to the

The author :

Eduard Jonas, M.d., ph.d.

Department of Upper abdominal Surgery,

Karolinska University hospital,

Karolinska Institutet,

141 861, Stockholm, Sweden

email: [email protected]


new paradigm, emphasis is on convert-ing more patients from unresectable to resectable, using innovative combinations of tumor and parenchyma manipulation, staged surgery and ablative therapies. Plan-ning of these increasingly risky endeavours requires, apart from the oncologic informa-tion, high-resolution imaging-based ana-tomic information. In patients planned for resection the operative strategy is based on pre-operative imaging. However, the final assessment regarding resectability is made at surgical exploration with intraoperative ultrasonography (IOUS) [12]. Deviations from the pre-operative surgical plan neces-sitated by additional intra-operative find-ings are suboptimal both from a logistical point of view and undesirable from a patient perspective, especially where the extent of the disease precludes any resection.

MRI is recognised as the best imaging method for detection and characterization of focal liver lesions [13,14]. The value of adding a hepatobiliary contrast agent like gadoxetic acid (Gd-EOB-DTPA) in further enhancing detection and characterization capabilities has been emphasized in a number of non-controlled trials [15,16]. In practice, MRI is still widely regarded as a problem-solving modality in case of equivocal findings on CT or ultrasound imaging, rather than a first-line imaging modality. Depending on the number of unclear cases, this strategy might, how-ever, result in an overall increased number of imaging procedures with consequences for cost and optimal resource use [17].

THE vALuE TRIALThe results of the VALUE trial, a multicen-tre, prospective, randomized trial compar-ing Gd-EOB-DTPA-MRI, MRI with extra-

cellular contrast media (ECCM-MRI) and contrast-enhanced MDCT (CE-MDCT) for hepatic staging of patients with suspected or confirmed metachronous CRCLM have recently been published [18]. The hypothe-sis was that the higher accuracy of gadoxetic acid-enhanced MRI of the liver would, com-pared to the other two imaging modalities, reduce the need for additional pre-treatment staging examinations, a more reliable surgi-cal plan with less frequent intra-operative deviations from the plan due to additional intra-operative findings.

Patients were randomized to initial imaging with either Gd-EOB-DTPA-MRI, ECCM-MRI or CE-MDCT [Table 1]. Imag-ing was reviewed by the treating radiologist and surgeon to assess whether a confident therapy decision could be made (primary efficacy parameter), or whether further imaging followed by a second consensus meeting was required to clarify equivocal findings. The choice of an on-site consensus meeting, as opposed to centralized blinded reading was deliberate in order to repre-sent routine clinical practice. The level of confidence in the treatment decision was also documented on a five-point scale (very low, low, moderate, high and very high). In patients assessed as in need of further imaging, the treating physicians could

choose either of the two remaining imaging methods. The number, size and segmental involvement of suspected metastases were documented, as well as details of the treat-ment plan. In primarily resectable patients (assumed to be tumor-free following one operative intervention without the need for pre-operative tumor or volume manipula-tion) intra-operative deviation from the pre-operative surgical plan was docu-mented. The extent of disease as assessed at the consensus meeting(s) was compared with the intraoperative assessment, includ-ing (IOUS) and, in resected cases, the histo-pathological extent of disease.

REsuLTsOut of a total of 360 patients that were enrolled in the study, efficacy was analysed in 342 (118, 112 and 112 randomized to Gd-EOB-DTPA-MRI, ECCM-MRI and CE-CT respectively). Results [summarized in Table 2] show that additional imaging was not deemed necessary for any patient in the Gd-EOB-DTPA-MRI group, compared to 19 (17,0%) in the ECCM-MRI group and in 44 (39,%) in the CE-CT group, the difference being statistically significant. Confidence in the diagnosis and treatment plan was high or very high in 98,3% of patients in the Gd-EOB-DTPA-MRI group, compared with 85,7% and 65,2% in the ECCM-MRI and CE-CT groups respectively. For the 63 patients undergoing a second imaging procedure, Gd-EOB-DTPA-MRI was the preferred imaging modality in all patients initially randomized to ECCM-MRI (19) and in all but one patient (43) initially randomized to CE-CT. Liver metastases were diagnosed in a higher proportion of patients with initial Gd-EOB-DTPA-MRI (85/118 (70.0%)), compared to ECCM-MRI (72/112 (64,3%)) and CE-CT (66/112 (58•%)) [Figure 1].. Furthermore patients in whom metastases were detected by Gd-EOB-DTPA-MRI were more likely to be operated on (47/85 (5%) compared to 35/72

Table 1. Flow chart for the VALUE study.

Table 2. The principal conclusions of the VALUE study


LIver IMAGING

(49%) in the ECCM-MRI group and 30/66 (45%) in the CE-CT group). In operated patients the information provided by Gd-EOB-DTPA-MRI resulted in a decreased number of patients with intra-operative modifications of the surgical plan (13/47 (28%) compared to ECCM-MRI (8/25 (32%)) and CE-CT 8/17 (47%).

CONCLusIONGood surgery starts with good imaging using a high-resolution method with high sensitivity and specificity for detection and characterization. Low sensitivity, inevitably leading to delayed diagnosis, could mean missing the time window of opportunity for potential cure. Over-staging might deprive some patients of the opportunity of curative-intended surgery and possible long-term survival, whereas under-staging will result in tumor recurrence after resection with the curative-intended intervention being of questionable advantage for the patient.

REfERENCEs1. Adam r, De Gramont A, Figueras J, Guthrie A,

Kokudo n, Kunstlinger F, et al. The oncosurgery approach to managing liver metastases from colorectal cancer: a multidisciplinary international consensus. Oncologist. 2012;17(10):1225.

2. Bengtsson G, carlsson G, hafström l, Jönsson PE. natural history of patients with untreated liver metastases from colorectal cancer. Am J Surg. 1981;141(5):586.

3. Sjövall A, Järv V, Blomqvist l, Singnomklao T, cedermark B, Glimelius B, et al. The potential for improved outcome in patients with hepatic metas-

tases from colon cancer: a population-based study. Eur J Surg Oncol. 2004;30(8):834.

4. Pawlik TM, Schulick rD, choti MA. Expanding crite-ria for resectability of colorectal liver metastases. Oncologist. 2008;13(1):51.

5. Vauthey J-n, Kopetz SE. From multidisciplinary to personalized treatment of colorectal liver metasta-ses: 4 reasons to consider rAS. cancer. 2013 Dec 1;119(23):4083.

6. Pawlik TM, choti MA. Surgical therapy for colorectal metastases to the liver. J Gastrointest Surg. 2007 Aug;11(8):1057.

7. choti MA, Sitzmann JV, Tiburi MF, Sumetchotimetha W, rangsin r, Schulick rD, et al. Trends in long-term survival following liver resection for hepatic colorec-tal metastases. Ann Surg. 2002;235(6):759.

8. Pawlik TM, Scoggins cr, Zorzi D, Abdalla EK, Andres A, Eng c, et al. Effect of surgical margin status on survival and site of recurrence after hepatic resec-tion for colorectal metastases. Ann Surg [Internet]. 2005 May;241(5):715–22–discussion 722 - 24.

9. Abdalla EK, Vauthey J-n, Ellis lM, Ellis V, Pollock r, Broglio Kr, et al. recurrence and outcomes follow-ing hepatic resection, radiofrequency ablation, and combined resection/ablation for colorectal liver metastases. Ann Surg. 2004;239(6):818–25–dis-cussion825–7.

10. Van den Eynde M, hendlisz A. Treatment of colorectal liver metastases: a review. rev recent clin Trials. 2009 Jan;4(1):56–62.

11. Wald c, Scheirey cD, Tran TM, Erbay n. An update on imaging of colorectal cancer. Surg clin north Am. 2006 Aug;86(4):819–47.

12. Ferrero A, langella S, Giuliante F, Vigano l, Vellone M, Zimmitti G, et al. Intraoperative liver ultra-sound still affects surgical strategy for patients with colorectal metastases in the modern era. World J Surg. 2013 nov;37(11):2655.

13. Floriani I, Torri V, rulli E, Garavaglia D, compagnoni A, Salvolini l, et al. Performance of imaging modalities in diagnosis of liver metastases from colorectal cancer: a systematic review and meta-analysis. J Magn reson Imaging [Internet]. 2010 Jan;31(1):19–31.

14. niekel Mc, Bipat S, Stoker J. Diagnostic imag-ing of colorectal liver metastases with cT, Mr imaging, FDG PET, and/or FDG PET/cT: a meta-analysis of prospective studies including patients who have not previously undergone treatment.

radiology. 2010;257(3):674. 15. Muhi A, Ichikawa T, Motosugi U, Sou h, nakajima

h, Sano K, et al. Diagnosis of colorectal hepatic metastases: comparison of contrast-enhanced cT, contrast-enhanced US, superparamag-netic iron oxide-enhanced MrI, and gadoxetic acid-enhanced MrI. J Magn reson Imaging. 2011;34(2):326.

16. Seo hJ, Kim M-J, lee JD, chung W-S, Kim Y-E. Gadoxetate disodium-enhanced magnetic resonance imaging versus contrast-enhanced 18F-fluorodeoxyglucose positron emission tomog-raphy/computed tomography for the detection of colorectal liver metastases. Investigative radiol-ogy [Internet]. 2011 Sep;46(9):548.

17. Zech cJ, Grazioli l, Jonas E, Ekman M, niebecker r, Gschwend S, et al. health-economic evaluation of three imaging strategies in patients with sus-pected colorectal liver metastases: Gd-EOB-DTPA-enhanced MrI vs. extracellular contrast media-enhanced MrI and 3-phase MDcT in Germany, Italy and Sweden. Eur radiol [Internet]. 2009 Jun;19 Suppl 3: S753.

18. Zech cJ, Korpraphong P, huppertz A, Denecke T, Kim M-J, Tanomkiat W, et al. randomized multicentre trial of gadoxetic acid-enhanced MrI versus conventional MrI or cT in the staging of colorectal cancer liver metastases. Br J Surg. 2014 May;101(6):613.

FigUre 1. [A-F]. Axial images of a patient previously operated for CRCLM with a right-sided hemihepatectomy. Gd-EOB-DTPA (Primovist) MRI [Figure 1, A,B,C,D] was performed two weeks after CE-CT. On MRI two lesions are clearly visible, one in segment 2 (arrow) and the other in segment 4a (arrowhead). The lesions have moderately high signal intensity (SI) on T2-HASTE [A] and very high SI on DWI with a b-value of 800sec/mm2 [B)] indicating restricted diffusion. On the 3D T1-weighted sequence after the IV injection of gadoxetic acid, the lesions enhance homogeneously in the arterial phase C) and exhibit well-demarcated hypointensity in the hepatobiliary phase, obtained 20 min later (D). None of the lesions were detected with CE-CT [E,F].(Images are courtesy of Dr Nikolaus Kartalis, Department of Radiology, Karolinska University Hospital, Stockholm, Sweden)

Gadoxetic Acid

Gd-EOB-DTPA

Gd-EOB-DTPA (Primovist®, Eovist®) is a hepatocyte specific MRI contrast agent with equal renal and hepatobil-iary elimentation. Hepatocyte uptake is via the OATP1B1 and OATP1B3 carriers and it is excreted in an unchanged form into the bile canali-culi by the ATP dependent multidrug resistance protein (MRP2).In the first phase after IV administra-tion, the major part of the adminis-tered dose of Gd-EOB-DTPA is still intravascular and can therefore be utilized in the same fashion as extra-cellular contrast-enhanced dynamic imaging.Due to the hepatocellular uptake of the Gd-EOB-DTPA and subse-quent shortening of T1 relaxation, hepatocytes will enhance more on T1 weighted imaging in later phases, compared to liver lesions not contain-ing hepatocytes, strongly increasing the liver-to-lesion contrast. Maximum enhancement occurs at approximately 20 minutes in a healthy liver.

The molecular structure of gadoxetic acid (Gd-EOB-DTPA), marketed by Bayer under the commercial names Primovist and Eovist.

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These one-day teaching courses will be limited to 36 participants, each with their own imaging workstation and content delivered through lectures and hands-on case-based learning.

The courses will highlight current imaging techniques,and focus on image interpretation, with a workbookof cases provided to enhance the learning experience.

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Register your interest at:www.icimagingsociety.org.uk

ICIS Interactive Series

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Masterclass in Imagingof Pancreatic Tumours

These one-day teaching courses will be limited to 36 participants, each with their own imaging workstation and content delivered through lectures and hands-on case-based learning.

The courses will highlight current imaging techniques,and focus on image interpretation, with a workbookof cases provided to enhance the learning experience.

Masterclass in Imagingof Prostate Cancer

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CARdIOvAsCuLAR


By Dr Anna E. H. Zavodni & Dr David A. Bluemke

Carotid MrI – providing insight into cardiovascular riskCardiovascular events are a major source of morbidity and mortality within the aging popula-tion, a process most commonly triggered by atherosclerotic disease. This article summarises studies carried out in a prospective cohort of asymptomatic individuals, to determine if carotid plaque morphology and composition as determined by magnetic resonance (MR) imaging can be used to identify asymptomatic subjects at risk of cardiovascular events. This non-invasive means of vascular assessment has a potential future role for imaging biomarkers in clinical management and as a surrogate endpoint in future research studies.

Cardiovascular events are a major source of morbidity and mortality within the aging population; they are most commonly triggered by atherosclerotic disease. Athero-sclerosis is a systemic process that can develop silently or asymptomatically but otherwise may manifest itself in numerous ways, such as via chest pain, transient ischemic attack or limb claudication or through major adverse car-diovascular events such as heart attack, stroke, or sudden death. These major events frequently occur without previ-ous warning [1].

Before promoting a course of preventive therapy, it is important to clearly define the level of cardiovascular risk and the goals of future management. Medical therapies can have side effects, making appropriate risk stratifica-tion essential in order to target aggressive medical and surgical management to those most vulnerable — in other words, appropriately balancing the risk-benefit trade-off. Traditionally, cardiovascular risk has been determined by calculating a Framingham risk score [2]. Framingham risk factors include age, sex, hypertension, hyperlipidemia, and smoking. Limitations of the predictive powers of the Framingham model have prompted the search for further means of risk stratification through new blood and imag-ing markers.

The carotid arteries are perfectly appropriate for imag-ing evaluation. These vessels are ideally located for non-invasive assessment: they are sufficiently superficial to

easily allow access by imaging probes and surface coils positioned within the narrow crook of the neck, thus allowing for high resolution ultrasound or magnetic reso-nance imaging (MRI) acquisitions to be obtained rela-tively easily. Compared to other vascular beds, the carotid arteries are moderate in size and relatively immobile, allowing for the vessel wall to be more accurately assessed. The bifurcation within the carotid system creates a region of greater shear stress, resulting from pressure variations between the low-resistance cerebral circulation and the high resistance facial muscles [3]. These factors help opti-mize the assessment of the vessel wall in regions most vulnerable to atherosclerotic change.

It is for these reasons and others that the carotid arteries have long been considered an important surrogate marker of our overall vascular health.

Different imaging modalities offer various means of quantifying atherosclerotic disease. While conventional catheter-based contrast injection and fluoroscopic imag-ing provides a relative evaluation of luminal narrowing, other techniques, such as ultrasound or MRI provide a cross sectional assessment that enables volumetric analy-sis. The total plaque burden has been shown to be a good predictor of future cardiovascular risk [4-6].

Autopsy studies of patients who have died from vascular events have taught us several predictive features of vulner-able plaque prone to rupture [7-10].

Features of vulnerable plaque include a lipid core with a thin fibrous cap, ulceration and intraplaque hemorrhage [11, 12]. Plaques containing these features are more likely to be symptomatic and the patients in whom these plaques exist are more likely to suffer from a future major adverse cardiovascular event [13].

While various imaging techniques can provide differ-ent insights into plaque composition, their appropriate application depends on the patient context. The methods include invasive testing with catheter-based fluoroscopic imaging, endoscopic ultrasound or optical coherence tomography (OCT) as well as non-invasive assessment

The Authors :

Anna E. H. Zavodni, Md, MHsc

cardiothoracic Division, Department of Medical Imaging University of Toronto, Sunnybrook health Sciences centre, Toronto, Ontario, canada


&

david A. Bluemke, Md, phd

national Institute of Biomedical Imaging and Bioengineering, Bethesda, Maryland, United States



with ultrasound or MRI. The invasive techniques suffer from

the obvious disadvantages of increased patient risk, discomfort and cost. As a non-invasive method, ultrasound is widely available and relatively inexpen-sive. However, this approach suffers from significant operator-dependence.

MRI emerges as the most robust means of non-invasive assessment [14, 15]. It offers superior contrast resolution, allowing for a reproducible assessment of plaque components.

As radiologists, we have several important questions to answer. Does carotid plaque morphology and compo-sition play a role in predicting cardio-vascular risk? With our current imaging techniques, can we adequately define the vulnerable plaque components within an asymptomatic population (with a relative low disease burden)? Does the identifi-cation of these vulnerable features add prognostic value over and above the sim-ple knowledge of the presence of, or the area and extent of disease?

CAROTId MRI IN AsYMpTOMATIC INdIvIduALsThe Multi-Ethnic Study of Atherosclero-sis (MESA) is a study sponsored by the National Institutes of Health involving six communities in the United States. From July 2000 through September 2002, a total of 6814 adults aged 45-84 years were recruited. These individuals were free of

cardiovascular disease at enrollment. His-tory, physical exam, blood and imaging biomarkers were measured at several intervals throughout the study (people acquiring clinical data were blinded to the imaging results and those perform-ing the imaging tests were blinded to the clinical information).

Carotid imaging was performed on 6624 participants using ultrasound and internal and external intima-media thickness (IMT) measurements carried out. From these results, the patients with the thickest carotid wall (above the 85th percentile according to inter-nal carotid artery IMT) were recruited into the MRI sub-study along with a random sampling of the remaining MESA population.

Carotid MRI was performed on a total of 946 participants. The MRI protocol included time-of-flight imag-ing and electrocardiographically gated T1- and T2-weighted fat-suppressed inversion recovery black blood spin-echo images. In those participants who agreed, gadolinium-based con-trast agent was administered and after a 5 minute delay the T1-weigted imaging was repeated. Five slices were obtained perpendicular to the lumen through the internal carotid artery in the region of greatest wall thickness. One slice was obtained through the common carotid artery 1 cm below the bifurcation [Figure 1].

IMAGE ANALYsIsWe can determine the wall composition by varying different image parameters across different acquisitions during the MRI exam. These algorithms have been validated surgically through the correla-tion of pre-operative imaging studies and ex vivo MRI evaluation of the pathologi-cal specimens post carotid endarterec-tomy [16].

Plaque burden can be quantified in several ways. The total wall area can be calculated by tracing the outer and inner contours of the vessels and subtracting the inner wall area from the outer wall [Figure 2]. When the total wall area is multiplied by the slice thickness, the total wall volume is obtained. Within the liter-ature, a popular calculation is the remod-eling index, defined as the outer wall vol-ume divided by the total wall volume. This remodeling index better reflects the positive remodeling phenomenon seen in early disease by partially correcting for variability in vessel size between individ-uals within the population unrelated to atherosclerotic thickening. Higher values of the remodeling index indicate greater atherosclerotic burden independent of vessel size [17, 18].

In MESA, image analysis was per-formed prospectively — early on, before any events occurred— in a blinded fash-ion: the imaging team did not know the history, risk factors or event status of the participant. MRI imaging demonstrated the presence of a lipid core, calcium and ulceration in 19.1%, 2.4% and 0.2% of participants, respectively.

EvENTsIn the MESA study, a separate committee, blinded to imaging results determined events. This group obtained records related to hospitalization and death. They inspected these medical charts to deter-mine if the local diagnosis met the study criteria for confirmed cardiovascular death, cardiac arrest, nonfatal myocardial infarction, angina with coronary revascu-larization or stroke. During the 5.5 ± 1.2 years of follow-up, 59 (6%) of the study participants experienced an incident car-diovascular event. In keeping with our intuitive understanding of

FigUre 1. The protocol consisted of time-of-flight imaging and ECG-gated T1- and T2-weighted spin-echo images. In consenting participants, gadolinium contrast was administered and after a 5 minute delay the T1-weigted imag-ing was repeated. Five slices were obtained perpendicular to the lumen through internal carotid artery in the region of greatest wall thickness. One slice was obtained through the common carotid artery 1 cm below the bifurcation.


CArDIOvASCuLAr

cardiovascular risk, the participants who experienced an event tended to be older and a higher proportion were male, hyper-tensive and diabetic.

REsuLTsMultivariable Cox proportional hazard models were created including the Framingham risk score alone and with one or more imaging parameters. According to our analysis, the carotid MRI remodeling index and presence of a lipid core or calcium within the internal carotid artery are all independent predictors of cardiovascular events. The combination of Framingham risk score with the remodeling index and presence or absence of the lipid core actually improved the net reclassification index of asymptomatic patients by 7% for participants without car-diovascular events and 16% of individuals with a cardiovascular event (p-value of 0.02).

The net reclassification index is a measurement of the num-ber of individuals within a population who are correctly re-categorized by a test and reassigned into a risk group which more appropriately reflects their actual clinical outcomes [19]. It is a means of determining whether or not additional testing adds value to the original model. In our case, carotid morphology and composition were both important in improving the correct clas-sification of cardiovascular risk for patients stratified according to their Framingham risk factors. The cardiovascular risk groups are defined by the current United States National Cholesterol Education Program guidelines as low (<1% per year), intermedi-ate (1-2% per year) or high (>2% per year) risk [20].

LIMITATIONsOur study was performed in the context of an epidemiological examination of asymptomatic individuals. As a result of the low overall disease burden within the population, important plaque features such as plaque ulceration, thin fibrous cap, and

intraplaque hemorrhage were rare findings and thus were not included in the statistical analysis.

Availability and cost-effectiveness will both be important determinants of whether carotid MRI is adopted clinically in cardiovascular risk assessment. Our study did not address these socioeconomic factors. It can be noted, that establishing carotid MRI as an effective biomarker of cardiovascular risk should also allow its use as a surrogate marker in future therapeutic studies.

CONCLusIONsWe demonstrated in a prospective cohort of asymptomatic individuals that the characterization of carotid plaque mor-phology and composition, the remodeling index and presence of a lipid core, respectively, with MRI improves cardiovascular risk assessment above baseline Framingham risk factors. This non-invasive means of vascular assessment supports a potential future role for these imaging biomarkers in clinical manage-ment and as a surrogate endpoint in future research studies.

REfERENCEs1. rosenberg MA, lopez Fl, Bůžková P et al. height and risk of sudden cardiac death:

the Atherosclerosis risk in communities and cardiovascular health studies. Ann Epidemiol 2014;24(3):174-179.

2. Wilson PW, D’Agostino rB, levy D et al. Prediction of coronary heart disease using risk factor categories. circulation 1998;97(18):1837-1847.

3. Malvà M, chandra S, García A et al. Impedance-based outflow boundary conditions for human carotid haemodynamics. comput Methods Biomech Biomed Engin 2014;17(11):1248-1260.

4. chambless lE, heiss G, Folsom Ar, et al. Association of coronary heart disease inci-dence with carotid artery wall thickness and major risk factors: the Atherosclerosis risk in communities (ArIc) Study, 1987-1993. Am J Epidemiol 1997;146(6):483-494.

5. O’leary Dh, Polak JF, Kronmal rA et al. carotid artery intima media thickness as a risk factor for myocardial infarction and stroke in older adults. cardiovascular health Study collaborative research Group. n Engl J Med 1999;340(1):14-22.

6. Polak JF, Pencina MJ, Pencina KM et al. carotid-wall intima-media thickness and cardiovascular events. n Engl J Med 2011;365(3):213-221.

7. Davies MJ. Anatomic featues in victims of sudden coronary death: coronary artery pathology. circulation 1992;85(1,Suppl):I19-I24.

8. Davies MJ, richardson PD, Woolf n et al. risk of thrombosis in human atherosclerotic plaques: role of extracellular lipid, macrophage, and smooth muscle cell content. Br heart J 1993;69(5):377-381.

9. Farb A, Burke AP, Tang Al et al. coronary plaque erosion without rupture into a lipid core: a frequent cause of coronary thrombosis in sudden coronary death. circulation 1996;93(7):1354-1363.

10. richardson PD, Davies MJ, Born GV et al. Influence of plaque configuration and stress distribution on fissuring of coronary atherosclerotic plaque. lancet 1989;2(8669):941-944.

11. Altaf n, Daniels l, Morgan PS et al. Detection of intraplaque hemorrhage by magnetic resonance imaging in symptomatic patients with mild to moderate carotid stenosis predicts recurrent neurological events. J Vasc Surg 2008;47(2):337-342.

12. Ture G, Oppenheim c, naggara O et al. relationships between recent intraplaque hemorrhage and stroke risk factors in patients with carotid stenosis: the hIrISc study. Arterioscler Thromb Vasc Biol 2012;32(2):492-499.

13. Takaya n, Yuan c, chu B et al. Association between carotid plaque characteristics and subsequent ischemic cerebrovascular events: a prospective assessment with MrI – initial results. Stroke 2006;37(3):818-823.

14. Duivenvoorden r, de Groot E, Elsen BM et al. In vivo quantification of carot-id artery wall dimensions: 3.0-Tesla MrI versus B-mode ultrasound. Eur radiol 2009;19(6):1470-1479.

15. harloff A, Zech T, Frydrychowicz A, et al. carotid initima-media thickness and dis-tensibility measured by MrI at 3T versus high-resolution ultrasound. Eur radiol 2009;19(6):1470-1479.

16. Wasserman BA, Smith WI, Trout hh 3rd et al. carotid artery atherosclerosis: in vivo morphologic characterization with gadolinium-enhanced double-oblique MrI imaging – initial results. radiology 2002;223(2):566-573.

17. Kerwin W, Xu D, liu F et al. Magnetic resonance imaging f carotid atherosclerosis: plaque analysis. Top Magn reson Imaging 2007; 18(5):371-378.

18. Saam T, Yuan c, chu B et al. Predictors of carotid atherosclerotic plaque progres-sion as measured by noninvasive magnetic resonance imaging. Atherosclerosis 2007;194(2):e34-e42.

19. Pencina MJ, D’Agostino rB Sr, D’Agostino rB Jr et al. Evaluating the added predic-tive ability of a new marker: from area under the rOc curve to reclassification and beyond. Stat Med 2008;27(2):157-172; discussion 207-212.

20. Expert Panel on Detection, Evaluation, and Treatment of high Blood cholesterol in Adults. Executive summary of the third report of the national cholesterol Education Program (ncEP) expert panel of detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III). JAMA 2001;285(19):2486-2497.

FigUre 2. Left common carotid artery (CCA), internal (ICA) and external (ECA) branches on sagittal (A) and cross-sectional images (B & C, just above the bifurca-tion of the vessel, corresponding to the red line). The green line surrounds the outer wall, the yellow line encompasses the lumen, the region in between these lines outlines represents the total wall area. The blue region (C) surrounds the lipid core.

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RAdIATION DOSe reDuCtION


By Dr T Kubo

Current status of radiation dose reduction in chest Ct

There is continuing and increasing concern regarding the level of radiation dose in CT exaninations. There are however many approaches which can result in significant dose reduction without any sac-rifice of diagnostic accuracy. This article reviews the current status of such approaches in chest CT.

The reduction of radiation dose in CT examinations is an impor-tant issue in current diagnostic radiology [1,2]. Overall, the expo-sure of patients to radiation as a result of medical imaging has grown significantly [3]. CT examinations are the largest, and fast-est growing, source of ionizing radiation exposure to patients. As a result several initiatives have been introduced to reduce the radia-tion dose in, such as ALARA or “as low as reasonably achievable”.However, in the era of digital imaging the identification of cases of overdosing is not easy in practice. An image acquired using too much X-ray exposure may even be considered as a ‘good’ image because it has lower image noise and fewer artifacts. It takes a lot of careful attention to recognize overexposure. A starting point is to define clearly the level of image quality that is needed for the examination purpose. For example, if the lesion being investigated is a 10 mm solid lung nodule, there is no problem in using a dose that results in an increased noise level. Thus, aggressive reduction in radiation dose may be achievable in cases where an image with high noise level is acceptable. On the other hand, an investigation of small lesions, or lesions with low contrast compared to background cannot be reliably performed using “noisy” images.

METHOds Of RAdIATION dOsE REduCTION

It is vital to observe proper image acquisition technique to be able to minimize radiation dose to the patients. Aspects of patient posi-tioning, such as table height, centering of the patient and limb posi-tioning can all affect image quality and consequently are related to the radiation dose [4]. Use of an appropriate scan range is also desirable. Scanning an area outside the region of clinical interest results in unnecessary radiation dose and should be avoided. The radiation dose that the patient receives is directly related to the tube current and tube voltage of the X-ray generator, but the results of changes in each of these parameters are different. The effect of tube current is easy to understand since it correlates linearly with the parameter known as fluence, or photon flux over time. Tube voltage is also related to photon fluence but this relation is not linear, but exponential. The nature of these relationships explains, for example, that switching from 120 to 100 kVp (a change of 17%) results in a dose reduction of over 30%.

X-ray penetration also correlates with tube voltage and therefore the physique of the patient should also be taken into account when reducing tube voltage. Generally low voltage scans are not suitable for large or obese patients. In practice, the selection of tube voltage is not as flexible as that of tube current but is limited to several preset values (e.g., 80, 100, 120, or 140 kVp). However, there is an unique advantage to the reduction of tube voltage, namely that the enhancing effect of iodine is emphasized by lowering peak X-ray energy. Thus, in contrast-enhanced CT tube voltage reduction is particularly useful for reducing radiation dose without loss of image quality.In recent years several technological innovations have been intro-duced which provide good opportunities to decrease radiation exposure to patients. Automatic exposure control (AEC) sys-tems and iterative reconstruction (IR) methods are important examples of such advances.

AuTOMATIC ExpOsuRE CONTROL

AEC allows dynamic tube current adjustment during an exami-nation [5] so that the image noise level is kept constant through-out the range of scan. Incorporated in most modern CT scanners, AEC systems adjust the current in three dimensions by combin-ing current adjustment during gantry rotation (angular modu-lation) and during table feed (longitudinal modulation). The effectiveness of AEC in radiation dose reduction has been well demonstrated [5]. In practice AEC systems differ to some degree between CT machines from different manufacturers. Depending on the manufacturer they are known by different names, e.g. 3D mA modulation (General Electric), DoseRight (Philips), CARE Dose 4D (Siemens) and SureExposure 3D (Toshiba).When the AEC system is operating, the actual value of tube current is not set directly, but instead, the user simply selects the desired quality of image. It is important to realize however that the dose-sparing effect depends on this user choice. If the target image quality is set too high, AEC will increase the radiation dose to attain the image quality set by the operator. Thus knowledge of the image quality necessary for a particular clinical question is

The author :

Takeshi Kubo, M.d.

Assistant Professor, Department of Diagnostic Imaging and nuclear Medicine

Kyoto University hospital , 54 Kawaharacho, Shogoin, Sakyo-Ku

Kyoto 606-8507, Japan

Fax +81-75-771-9709 email: [email protected]

All modern CT machines are equipped with iterative reconstruction algorithms, whose use can result in high quality inages at lower dose.


important even with AEC systems.ITERATIvE RECONsTRuCTION For reconstruction of CT images, filtered back projection (FBP) has long been the standard method. However, significant reduction in radiation dose can be attained by the relatively newly-introduced method known as iterative reconstruction [6]. Through the repeated pro-cess of data correction and comparison, the method produces a final CT image that is much closer to an ideal image with lower image noise and fewer artifacts. Improved image quality can correspond to a potential radiation dose reduction of over 50%. The IR algorithms are available in different versions depending on the manufacturer and have different names: ASIR and VEO from General Electric, IRIS and SAFIRE from Siemens, AIDR 3D from Toshiba and iDose4 from Philips.Theoretically, a fully-fledged IR process can involve long computation time that could be as long as hours. However, CT scanner ven-dors have devised ways to reduce computa-tional time and costs by various modification of the IR process. IR reconstruction methods are applicable in the routine clinical practice in most of recently introduced scanner models.

RAdIOsENsITIvE ORGANs

Selective dose reduction can be applied when radiosensitive organs are located within the scan volume. In the area of chest CT, the female breast is the critical organ. The radiation dose that the breast tissue is exposed to can be low-ered using one of two different methods. One is to block the passage of X-rays through the mammary gland by placing radiopaque shields made of bismuth over the breasts [7]. However, heavily radiopaque shield material can cause artifacts and therefore careful attention must be paid to the shield position to minimize dete-rioration of image quality. The other way of breast protection is to reduce the tube X-ray output when the tube comes closest to the breasts. This method, known as organ-based tube-current modulation, involves adjusting the tube current during a gantry rotation as in angular tube current modulation [8]. The X-ray intensity in other projections is increased so that, overall, the image noise remains the same throughout the image.

THE NEEd fOR sTudIEs Of dIAGNOsTIC ACCuRACYThe confident and safe use of dose reduction techniques rely on proven evidence for the effec-

tive application of dose reduction techniques. Only such hard evidence will encourage sceptics and lead to more frequent use of low dose CT.

Many studies have compared the image quality of low dose CT with higher/standard dose CT images. Image quality is typically evaluated in terms of an objective index of image noise (i.e. the standard deviation of CT numbers) or by a subjective scoring system. Most of these studies have concluded that, based on subjective evaluation, the image quality of low dose images was satisfactory [1].

The best way to convince sceptical users to routinely implement low dose methods is to demonstrate that the diagnostic accu-racy remains the same with the newer, dose-sparing methods. Such evaluations in terms accuracy and confidence level of the diag-nostic performance are available in a limited number of disease conditions. For example, the effectiveness of low dose CT examination has been investigated for pathologies such as pulmonary nodules, pulmonary emboli, emphysema, air trapping, bronchiectasis and cystic fibrosis. Studies of diagnostic accuracy generally focus on testing only one partic-ular pathology. However, things are not so simple in clinical practice. Usually there are more than one disease process to be evalu-ated at a time. Frequently physicians expect CT examinations to provide even fortuitous discoveries of clinically silent abnormalities. Of course it would be preferable to be able to prove the accuracy of low dose chest CT for chest diseases in general but this is much harder to achieve in practice. A large and well-designed study carried out by Mayo et al. ten years ago compared original images obtained at 100 mAs and simulated low dose images at 40 mAs. They showed a significant dif-ference in the accuracy of chest CT findings [9]. Although the result of this study is not directly applicable to modern, state-of-art CT scanners, there still is a point where noise and artifacts prevent readers from detecting abnormal findings.

Thus, new proof of the accuracy of cur-rent low dose CT images is needed. One future approach is to set the limit of lowest image qual-ity possible for commonly encountered findings such as nodules, airway abnormalities, emphy-sema, ground glass attenuations, consolidations, etc., and then categorize abnormal findings into three or four groups according to the level of image quality recommended for the evaluation. These would then serve as a guide for radiolo-

gists and technologists to select the appropriate scan parameter for image acquisition.

CONCLusIONIn the face of the ever-increasing use of CT examinations, efforts to reduce dose in CT should be made routinely. Recent develop-ments of CT technology have brought impor-tant advances in radiation dose reduction, particularly AEC systems and IR methods, which should be incorporated in the routine CT protocol whenever applicable. Education is an integral part of the overall radiation dose reduction endeavor. For example, it should be well understood that beautiful images may not always be necessary; more often than not they mean that there is a room for dose reduction. Radiation dose efficiency is expected to con-tinue to improve thanks to ongoing advances in image acquisition techniques. However, with all those technological refinements, the choice of imaging procedure still needs need to be made as a function of the clinical ques-tions to be answered together with a sound knowledge of the pathophysiology and likely imaging findings of the suspected condition.

Medical personnel, especially diagnostic radiologists, must continue to play their role in the improvement of imaging practice to conform to the ALARA principle.

REfERENCEs1. Kubo T, lin PJ, Stiller W, et al., radiation dose reduc-

tion in chest cT: a review. AJr Am J roentgenol 2008;190(2):335-43.

2. Kubo T, Ohno Y, Kauczor hU, hatabu h, radiation dose reduction in chest cT-review of available options. Eur J radiol 2014;83(10):1953-61.

3. Mettler FA,Jr, Bhargavan M, Faulkner K, et al., radiologic and nuclear medicine studies in the United States and worldwide: frequency, radiation dose, and comparison with other radiation sources--1950-2007. radiology 2009;253(2):520-31.

4. Kaasalainen T, Palmu K, reijonen V, Kortesniemi M, Effect of patient centering on patient dose and image noise in chest cT. AJr Am J roentgenol 2014;203(1):123-30.

5. lee ch, Goo JM, Ye hJ, et al., radiation dose modulation techniques in the multidetector cT era: from basics to practice. radiographics 2008;28(5):1451-9.

6. Willemink MJ, leiner T, de Jong PA, et al., Iterative recon-struction techniques for computed tomography part 2: initial results in dose reduction and image quality. Eur radiol 2013.

7. Kim YK, Sung YM, choi Jh, Kim EY, Kim hS, reduced radiation exposure of the female breast during low-dose chest cT using organ-based tube current modulation and a bismuth shield: comparison of image quality and radia-tion dose. AJr Am J roentgenol 2013;200(3):537-44.

8. Matsubara K, Sugai M, Toyoda A, et al., Assessment of an organ-based tube current modulation in tho-racic computed tomography. J Appl clin Med Phys 2012;13(2):3731.

9. Mayo Jr, Kim KI, MacDonald Sl, et al., reduced radiation dose helical chest cT: effect on reader evaluation of structures and lung findings. radiology 2004;232(3):749-56.

CAd


By Dr Olga Kubassova

Scaling computer aided detection from workstation to the cloud: medical image analysis todayThe primary goal of Computer aided detection (CAD) software is to increase accuracy of disease detection by reducing the false negative rate due to observational oversights of physicians interpreting medi-cal images. The use of a computer rather than a second radiologist or specialist has the advantage of not increasing the demands on the radi-ologist (or trained observer) pool. Hence, CAD platforms should offer advanced objective and reproducible processing solutions capable of providing supplementary evidence in the detection of early and subtle changes in the patient to help in the optimization of treatment. For example, CAD can offer objective quantification of early changes in Rheumatoid Arthritis (RA) patients undergoing treatment with disease-modifying anti-rheumatic drugs, through automatic or semi-automatic measurement of the extent of synovial inflammation, bone marrow edema or bone changes. Additionally, CADs have the potential to increase work-flow efficiency; they also help radiologists alleviate their workload in daily clinical practice by optimising those steps of their workflow suitable for automation.

The extensive use of CAD in clinical practice is hindered by the need for dedicated expensive high-performance workstations able to run com-putational-intense processing analysis, especially if the results are required to be delivered in real-time. Additionally, the proliferation of multi-site collabo-rations and the inexorable lifestyle trends that make the geographic mobility of patients easier require robust and secure solutions capable of sharing patient information among institutions both in research and daily clinical practice.

Cloud-based image storage combined with CAD techniques is becoming increasingly recognized as a sensible solution to address the requirements of performance, scalability and reliability (PSR), nec-essary to achieve high efficiency in the analysis of medical images in radiology practice. However, due to their distributed structure, cloud-based imaging CAD platforms face additional challenges such as keeping calculations and image overlays up to date

whilst providing good user experience across band-widths and latencies that are outside the platform’s control. Security regarding safe storage and manage-ment of data is a major concern and requires special

The author :

dr Olga Kubassova

Founder and cEO

Image Analysis ltd

london, UK

email: [email protected] FigUre 1. Schematic diagram of the architecture of Dynamika.


attention due to the sensitive nature of patient data information. Finally, ease of integration is required not only with the information systems from hospitals (PACS, RIS) but with other technologies such as Business Intelligence or big data solutions that can facilitate new algorithms and clinical developments.

A wORKfLOw-dRIvEN MuLTI-TIER IMAGING CAd pLATfORMWith this in mind, we at Image Analysis designed a novel approach to a multi-tier architecture imple-mented on a software platform, called Dynamika. The system pro-cesses and quantitatively scores static and dynamic MRI from patients with inflammatory and auto-immune conditions.

The architecture of Dynamika was designed through close co-operation with Key Opinion Leaders (KOLs) in the RA field to gain insight from our users’ requirements. We obtained feed-back from university and key hospital users experienced in analyz-

ing RA MRI examinations and also from MRI researchers in pharmaceu-tical companies developing drugs for the treatment of RA. This enabled us to gain a full understanding of radi-ologists’ clinical workflow not only in the context of multi-site random-ized controlled trials but also in daily clinical practice.

Hence, the server side of Dynamika makes use of a back-end framework of Spring and Hibernate since we found this architecture adequate to perform computational-intense tasks . It also allows for the addi-tion of more computing resources if required (scalability) in a transparent way to the user.

In order to reproduce the work-flow typically followed by the radi-

ologist, Dynamika relies on Spring Webflow to guide the user through the application. Webflow has been enhanced to allow for tightly con-trolled batch processing (i.e. upload-ing several hundreds of scan studies to calculate a full automated patient motion correction followed by the computation of statistical parametric maps), which is broadly utilized in clinical trials or routine analysis, and in ad hoc investigator analysis. The platform makes use of web services to allow easy integration with big data technologies such as those based on semantic tagging and text mining of reports generated with Dynamika.

Since the imaging platform is acces-sible from a web browser, it can be run under Mac, Windows or Linux systems. The interface is based on Google Web Toolkit to give high performance in the client, allowing user interaction usually only available on desktop programs. By separating the business layer, located at the server, from the interface, the platform can be easily extended in the shape of apps for handheld devices.

FigUre 2. Workflow-driven interface of Dynamika.

“...Due to the sensitive nature of patient data information, security is one of the main concerns of a cloud-based imaging CAD platform...”


CAD

The Aixplorer ® is one of the best systems on the market. It’s easy to use, and thanks to SuperSonic Imagine’s commitment to their customer needs, we were able to discuss our clinical challenges and see the implementation of our suggestions.

Prof. Fritz Schäfer, MDKiel, GermanyKiel, Germany

Powerful Performance to Meet All Your Ultrasound NeedsOnly the Aixplorer ® ultrasound system combines:

Impeccable image qualityto improve diagnosis

An UltraFast™ Platform to bring you true technological advancement

Real-time, quantitative, Real-time, quantitative, ShearWave™ Elastography on all transducers and across a variety of clinical applications

“

“

Liver / Prostate / Thyroid / Vascular / Musculoskeletal / Abdomen / Gynecology / Obstetrics / Breast / Breast 3D / PediatricsThe SuperSonic Imagine Aixplorer® ultrasound system is indicated for use in the following applications: Abdominal, Small Organs, Musculoskeletal, Superficial Musculoskeletal, Vascular,

Peripheral Vascular, OB-GYN, Pelvic, Pediatric, Neonatal Cephalic, Urology, Trans-rectal Trans-vaginal and Brain* (*only for Europe)

Additionally, special effort was put into developing an imaging CAD platform that is not dependent on the imaging equipment or PACS system being from a particular manufacturer.

Due to the sensitive nature of patient data information, security is one of the main concerns of a cloud-based imag-ing CAD platform. In our particular case, we opted for a centralized database ruled by a security layer to ensure safe data managing and storage. In that way, Dynamika provides, through a secure login from a web browser, easy access to patient data and analysis results and the capability to easily share cases and reports in the context of multiple-site collaborations. The adoption of an architecture based on web services permits adaptation of the data sharing to emerging connectivity technologies that allows mobile devices to seamlessly interact with each other.

pERfORMANCE IN pRACTICEThe imaging CAD package was built using the architecture described above and has been benchmarked against a conventional standalone workstation solution from the point of view of two aspects: user experi-ence and development efficiency.

The performance of the cloud architecture was shown to have com-parable, or better, performance than workstations in scrolling through images with complex overlays and performing intensive calculations such as patient motion correction, saving on average 12,5 seconds per case.

In a study with 54 RA patients who had conventional and Dynamic Contrast-Enhanced MRI (DCE-MRI), we compared the assessment of inflammation in the wrist of RA patients using DCE-MRI analyzed by our computer-aided approach with the semi-quantitative scores of synovitis and bone marrow edema (BME) using the OMERACT-RA MRI Scoring (RAMRIS) system. The results obtained from the computer-aided analysis of DCE-MRI data were shown to correlate with the semi-quantitative RAMRIS of synovitis and BME. The analysis was twice as

fast to perform, which of course leads to increased productivity.

OpTIMIZEd dEvELOpMENT Of NEw ALGORITHMsThe time required to implement new in-house algorithms was measured by recording the total time needed for coding and testing. These times were measured on the standalone work-station solution and compared with those from the the cloud-based imag-ing CAD platform. Incorporation of new functionalities was up to 10 times quicker in the cloud architecture: one man-week of development in the cloud-based solution vs. 11 man-weeks for the workstation. Being capable of improving the implementation time is key to the efficient translation of the use of imaging markers from research and academia into clinical practice.

sECuRE sHARINGThe distributed nature of Dynamika properly supports collaboration and sharing and can be used from any device with network connection to examine images and create reports laptops, tablets, even smart phones. The platform supports a fast and secure exchange and storage of image information which is of benefit to multi-site collaborations, and elimi-nates the need for patients to travel between hospitals. The amount and cost of consumables such as CDs and paper reports is reduced.

pERspECTIvEs ANd CONCLusIONsCloud-based CAD platforms have significant growth potential. They enable users to run highly demand-ing algorithms effortlessly from a web browser without any worry about the maintenance and expense of the server that performs the cal-culations. However, in the medi-cal environment, there is still some resistance to the use of such systems where data must travel outside the institution’s servers. For these cases where tools such as patient anony-mization of data scans, secure access through VPN and monitoring of the actions performed by each user on each shared data do not seem suffi-cient to abandon the approach of the

standalone workstation, some flex-ibility is required. We have found a compromise solution for such insti-tutions which consists of installing the server side of our platform within

the hospital network and provide integration with PACS. In this way any radiologist securely connected to the institution network can share and access the imaging data, analysis, information and reports generated by the Dynamika system.

The challenges of handling large image datasets and real-time over-lay calculations have been addressed through the novel architecture described. Validation in real clini-cal practice has shown that a cloud-based CAD architecture gives the same or better performance than a workstation solution. The repro-ducible and objective quantifica-tion methods that are implemented can lead to increased productivity in radiology departments, both for routine clinical practice and clinical research. Further, the system sup-ports multi-centre collaboration and seamless data sharing. The develop-ment of new in-house functionality is much faster and is automatically deployed to all users without further reinstallations or updates.

REfERENCEs[1] ronald A castellino. computer aided

detection (cAD): an overview. cancer Imaging. 2005; 5(1): 17–19.

[2] M. hinton, O. Kubassova, A. Ancill, r. Boerg, M.Boesen. An Enterprise class computer Aided Detection Platform Scalable from laptop to cloud. Proceedings of 99th Annual Meeting rSnA, December 1 – 6, 2013.

[3] Boesen M, Kubassova O, Bouert r, et al. correlation between computer-aid-ed dynamic gadolinium-enhanced MrI assessment of inflammation and semi-quantitative synovitis and bone marrow oedema scores of the wrist in patients with rheumatoid ar thritis--a cohort study. rheumatology (Oxford). 2012; Jan;51(1):134-43

“...Validation in real clinical practice has shown that a cloud-

based CAD architecture gives the same or better performance than a workstation solution...”

The Aixplorer ® is one of the best systems on the market. It’s easy to use, and thanks to SuperSonic Imagine’s commitment to their customer needs, we were able to discuss our clinical challenges and see the implementation of our suggestions.

Prof. Fritz Schäfer, MDKiel, GermanyKiel, Germany

Powerful Performance to Meet All Your Ultrasound NeedsOnly the Aixplorer ® ultrasound system combines:

Impeccable image qualityto improve diagnosis

An UltraFast™ Platform to bring you true technological advancement

Real-time, quantitative, Real-time, quantitative, ShearWave™ Elastography on all transducers and across a variety of clinical applications

“

“

Liver / Prostate / Thyroid / Vascular / Musculoskeletal / Abdomen / Gynecology / Obstetrics / Breast / Breast 3D / PediatricsThe SuperSonic Imagine Aixplorer® ultrasound system is indicated for use in the following applications: Abdominal, Small Organs, Musculoskeletal, Superficial Musculoskeletal, Vascular,

Peripheral Vascular, OB-GYN, Pelvic, Pediatric, Neonatal Cephalic, Urology, Trans-rectal Trans-vaginal and Brain* (*only for Europe)

heALthwOMEN’s


By Rives Bird

the Growing realization of the Importance of breast DensityThere is a growing awareness of the importance of breast density and its impact on breast cancer. Not only do dense breasts reduce the sensitivity of the detec-tion of lesions but also there is evidence that dense breast tissue is a risk factor for breast cancer in its own right. In practice there is a need to incorporate auto-mated breast density assessment systems in the investigation of women with potentially increased breast cancer risk. This article summarizes the situation in the USA and in Europe.

Our understanding of breast density and its impact on a woman’s risk for developing breast cancer has been evolving rapidly. Most clinicians agree that the importance of breast density is two-fold.

First, mammographic density impacts the detection of breast cancer. The sensitivity of detecting breast cancer is markedly lower in women with very dense breasts than with fatty breasts due to the masking of lesions by dense tissue. The sensitivity issue is a result of the fact that fibroglandular tissue appears white on a mammogram as do cancers. The fibroglandular tissue can mimic and thereby obscure breast cancers. In a large-scale study, mam-mography had only 48% sensitivity in dense breasts and 98% sensitivity in fatty breasts [1].

Second, there is a steady increase in research findings sug-gesting that mammographic density is an independent risk factor for breast cancer. Women with a BI-RADS 4 breast den-sity have over four times the relative risk of developing breast cancer as compared to those with BI-RADS 1 - 2. Research published in 2011 by Cuzick’s group in London, UK found that women on tamoxifen who experienced a reduction in breast density of at least 10 percent had a 63 percent reduc-tion in breast cancer risk, while women who experienced less than a 10 percent reduction in density did not experience a reduction in risk [3]. This indicates that dense tissue in itself is a major risk factor.

At the recent 2014 European Breast Cancer Conference Dr. Louise Eriksson and her colleagues from the Karolinska Insti-tutet in Stockholm, Sweden presented results of their study that found women with denser breasts had nearly double the risk of their cancer recurring, either in the same breast or in the sur-rounding lymph nodes, than women with less dense breasts [4].

AwARENEss GROws: GRAss ROOTs EffORTs IMpACT THE u.s.With broadening research on breast density, it is no surprise

that awareness within the medical community has been on the rise. Medical societies around the world acknowledge the

impact of breast density as a risk factor for breast cancer. In addition, public awareness has grown.

In the United States, grass roots efforts from an advocacy organization called “Are You Dense” began a veritable revolution surrounding breast density. As of September 2014, 19 US states have passed some form of legislation requiring physicians to inform women of their breast density following their mammo-gram. Some of the laws go so far as to mandate that additional screening be covered by insurance companies for those women identified as having high breast density.

In addition to the state legislative activity, a Federal bill, the Breast Density and Mammography Reporting Act was intro-duced by the Senate and House in July 2014. If it passes, the bill would set a minimum federal standard, as designated by the Sec-retary of Health and Human Services (HHS), for notification of breast density status and would recommend that women discuss with their doctors whether additional screening is necessary. The bill also directs HHS to study improved screening options for women with dense breast tissue.

The bill caused accelerated awareness and interest among women, physicians and the media surrounding breast density.

At Boston Breast Diagnostic Center, located just outside Boston, Massachusetts, the need to automate the breast density process became clear as the noise level surrounding breast den-sity increased. As a breast radiologist for over 25 years, Dr Elsie Levin, Medical Director, recently implemented M-Vu Breast Density, an automated breast density tool into her practice. “The decision to invest in an automated breast density assessment tool, was impacted by several factors. First, it offers a reliable and reproducible assessment year over year for my patients by replacing a subjective estimation with an objective measurement using advanced computer algorithms. In addition, if a woman has dense tissue and needs additional screening, the objective assessment provides “back-up” for the insurance company”.

Dr Levin reflects what many breast radiologists are experienc-ing across the U.S. There is a growing need to address the issue of breast density, and offer a solution to patients and referring physi-cians on how to best screen those women with dense breast tissue.

pERspECTIvEs ON BREAsT dENsITY: EuROpEThroughout Europe, there is also a growing awareness about the role of breast density in breast cancer. Not only is there a marked increase in interest in the subject at clinical conferences and at

The author :

Rives Bird,

clinical Affairs,

VucOMP

Plato, Tx. USA



learned society meetings, but also advocacy groups such as Europa Donna (www.europadonna.org) have recognized the link between breast cancer and density. Nevertheless, in contrast to the situation in the United States, there is as yet no sign in Europe of any legislative activity addressing the breast density issue. Why?

One reason could be recent studies from Dr C Colin’s group in Lyon, France [5,6]. They suggested that accepting that mam-mographic breast density as an important independent risk factor for breast cancer in the general population could have a signifi-cant economic health care impact, since it could lead to increasing screening frequency or an increase in the use of sometimes costly alternative modalities. The impact of density as a risk factor has thus to be carefully investigated and the precise overall socio-economic implications evaluated.

Despite this potentially negative economic impact, the over-whelming majority of breast radiologists throughout Europe agree that breast density influences their assessment of a woman’s risk of developing breast cancer.

Professor Ingrid Schreer, M.D. of the Breast Center, University Hospital Schleswig-Holstein, Kiel, Germany points out also that having an automated tool to objectively assess breast density is neces-sary as our understanding of the role of density in breast cancer risk evolves. “A standardized method to measure breast density would be the prerequisite to prospectively or retrospectively investigate the assumed increased breast cancer risk.”

AssEssING BREAsT dENsITYMammography still remains the gold standard for screening around the world, but for women with dense breast tissue, additional screen-ing with ultrasound, magnetic resonance imaging or molecular breast imaging is often recommended. Therefore, it is important to accurately identify those women who can benefit from these addi-tional screening options.

In clinical practice, radiologists visually assess breast density, assigning each patient an ACR BI-RADS composition category of a, b, c, or d, defined respectively as: almost entirely fatty; showing

scattered areas of fibroglandular density; heterogeneously dense; and extremely dense [7].

Unfortunately, visual assessment is subjective and suffers from significant intra- and inter-observer variability [8-10]. Thus BI-RADS categories for the same patient as assessed by different readers — or by the same reader at different times — may vary significantly. To mitigate this variability, automated methods for measuring breast density have been developed.

NEw TECHNOLOGIEs: AuTOMATEd BREAsT dENsITY AssEssMENTThere are two approaches for assessing breast density that are cur-rently commercially available.

The first approach (Volpara, Matakina Technology) measures the physical absorption of X-rays (given by the pixel values in the mam-mogram) to estimate the percent volume covered by fibroglandular tissue [11]. The percent volume is then mapped to a score from a to d, analogous to the BI-RADS category [11].

The second approach (M-Vu Breast Density, VuCOMP, Inc.) assesses breast density by examining the mammographic texture and appearance of the dense tissue, emulating – quantitatively – the approach advocated by the ACR. This approach considers the percent breast density, and also analyzes the texture and dispersion pattern of the tissue. As with the Volpara approach, the result is then mapped to a score from a to d, analogous to the BI-RADS category.

CONCLusIONOur understanding of the impact of breast density on breast cancer will continue to evolve. But there is no doubt that the reliable and accu-rate assessment of a woman’s risk of developing breast cancer based on her breast density is critically important. With the onset of legislation and changing guidelines, it is likely that a quantitative and objective measurement will be required to ensure that those women who can benefit the most from adjunctive screening are properly identified.

REfERENCEs1. Kolb, TM, lichy, J, newhouse, Jh, Occult cancer in women with dense breasts:

detection with screening US--diagnostic yield and tumor characteristics. radiology, 1998; 207.

2. Mccormack, V. A., dos Santos Silva, I.,Breast density and parenchymal patterns as markers of breast cancer risk: a meta-analysis. cancer Epidemiol Biomarkers Prev, 2006; 15:11599.

3. cuzick J et al. Tamoxifen-induced reduction in mammographic density and breast cancer risk reduction: a nested case-control study. J natl cancer Inst. 2011;103: 744.

4. Dense breasts can nearly double the risk of breast cancer recurrence. Available at http://www.ecco-org.eu/Global/news/EBcc8-Pr/2012/03/21_03-Dense-breasts-can-nearly-double-the-risk-of-breast-cancer-recurrence.aspx; retrieved on 8/28/14.

5. colin c et al. can mammographic assessments lead to consider density as a risk factor for breast cancer? Eur J radiol. 2013; 82:404.

6. colin c et al. Mammographic density is not a worthwhile examination to distin-guish high cancer risk women in screening. Eur radiol. 2014; 24: 2412.

7. American college of radiology. Breast Imaging reporting and Data System (BI-rADS) 5. reston, Va : s.n., 2013.

8. Gao, Jinnan, et al. reproducibility of visual assessment on mammographic density. Breast cancer res Treat,. 2008; 108: 121.

9. Berg W A et al. Breast Imaging reporting and Data System: inter- and intra-observ-er variability in feature analysis and final assessment. AJr Am J roentgenol, 2000; 174: 1769.

10. Martin K E et al. Mammographic density measured with quantitative computer-aided method: comparison with radiologists’ estimates and BI-rADS categories. radiology. 2006; 240: 656.

11. highnam r et al. Breast composition measurements using retrospective stan-dard mammogram form (SMF). Phys Med Biol. 2006; 51: 2695.

M-Vu Breast Density from VuCOMP provides a quantitative assessment of breast density by using advanced computer vision algorithms. Above is an example of an M-Vu Breast Density output that correlates to the ACR BI-RADS breast density categories.

IMAGINGTHERApEuTIC


By Dr T. de Baere

Lipiodol trans Arterial Chemoembolization (tACe) in the treatment of hepatocellular carcinomaThe recent approval by the French Regulatory authorities of Lipiodol/drug emuslsions for the visu-alization, localization and vectorization of hepaatocellular carcinoma has focussed attention on this therapeutic application of a product originally introduced to the market decades ago as an iodine-based X-ray contrast agent. The U.S. Food and Drug Administration Agency (FDA) recently announced that the French company Guerbet — the manufacturer of Lipiodol — was one of only two drug companies selected to receive a Drug Shortage Assistance Award for its role in prevent-ing or alleviating drug shortage of Lipiodol in the US This article reviews the current status of the use of Lipiodol/drug emulsions in Trans Arterial ChemoEmbolization for the treatment of intermediate stage hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is the most common primary tumor of the liver and accounts for 7% of all tumors. Worldwide, it is the sixth most common cancer and is the second most common cause of death due to cancer. HCC develops most often in the cirrhotic liver be it alcohol-induced or viral. More rarely, HCC may develop in non-alcoholic steatohepatitis (NASH). The choice of the most appropriate therapeutic approach for the treat-ment of HCC should therefore take into account not only the staging of the cancer itself but also the degree of the underlying cirrhosis. To facilitate the evaluation of these aspects, several scoring systems have been developed for both diagnostic and therapeutic staging purposes [1, 2].

TRANs ARTERIAL CHEMOEMBOLIZATION (TACE) TACE is recommended in cases of intermediate stage HCC, as defined by the European Orgnaisation for Research and Treatnment of Cancer (EORTC} and the European Association for the Study of the Liver (EASL) [1]. Intermediate stage HCC generally occur in patients in otherwise good general health with a relatively well-compensated cirrhosis but which cannot be treated by curative techniques such as surgical resection, radiofre-quency ablation or transplantation.

Developed initially in Japan in the early 1980s the tech-nique of chemoembolization was more widely adopted after the publication of two randomized controlled trials. One of these trials used doxorubicin [3] as the therapeutic agent and the other cisplatin [4]. The technique is now considered as the method of choice for the treatment

of intermediate stage HCC. Chemoembolization using Lipiodol is currently the only treatment course for inter-mediate stage HCC which has been shown to be superior to supportive care in terms of efficacy.

The author :

Thierry deBaere, Md.,

Therapeutic Imaging,

Imaging Department, cancer campus Grand Paris,

Insitut Gustave roussy Villejuif, France


FigUre 1. Screenshot of the injection of Lipiodol/doxorubicin emulsion in the hepatic artery, catheterized with a 5F catheter and a microcatheter (arrow-heads). Droplets of Lipiodol can be seen at the tip of the catheter (white arrows). Numerous drops are selectively migrating into the tumor-feeding arter-ies (black arrows) to reach the tumors (asterisks) which have already taken up Lipiodol as can be seen by the dense staining.


The technique consists of injecting an emulsion of Lipiodol (iodinated ethyl esters of fatty acids isolated from poppy seed oil) together with a chemothera-peutic drug (usually doxorubicin or cisplatin). Lipiodol was first introduced to the market as an iodine-based X-ray contrast agent several decades ago and has an impressive toxicological safety record built up over the years. In TACE the emulsion is slowly injected into the artery or arteries feeding the tumor.

The advantage of the use of Lipiodol emulsion lies in its pharmacokinetic characteristics which result in a decrease of the escape of the doxorubicin into the systemic circulation, so resulting in a higher intra-hepatic or intra-tumoral concentration of the drug [5]. During the TACE procedure using Lipiodol emulsion, the ratio of the concentra-tion of doxorubicin in the tumor tissues to that of the drug in the non-tumoral tissues of the liver is of the order of 4 to 10 times. Lipiodol has thus been characterized as having a high selectiv-ity for the tumor as well as a temporary embolic effect.

The tumor selectivity is due to the surface tension properties of Lipiodol. These have the effect that when the emulsion reaches arterial branching points, it flows preferentially into the arteries of larger diameter [6]. This ten-dency to favor arteries of larger lumen diameter means that the concentration of Lipiodol is increased in the imme-diate tumor environment, since larger diameter arteries vascularize the tumor. Finally the fact that the injected mix-ture is a water-in-oil emulsion (Lipiodol contains drug droplets) further directs the drug towards the tumor. In addition Lipiodol is radio-opaque and so enables the distribution of the chemoembolizing agent to be directly visualized during the actual injection process [Figure 1].

Even though Lipiodol does have a temporary embolizing effect in its own right [7], it has been shown that a sim-ple injection of the emulsion of a che-motherapeutic agent in Lipiodol does not yield optimal results. To achieve this, a particulate embolization is also needed after the injection of the emul-

sion. It has been shown that patients receiving a particulate embolization have an overall increased survival rate [8]. Such complementary emboliza-tion enables an increase in the level of necrosis in the principal tumor [9]. Lipiodol has the unique property of being able to pass into the distal portal system [7]. This occurs via the peri-biliary plexus (the network of small, distal arterioles linking the arterial with the portal system) [10]. No par-ticulate embolization systems have this property of “double embolization” because their diameter is too large to enable passage through the peri-bili-ary plexus. It has been shown that the amount of emulsion passing through the peribiliary plexus correlates with a reduced level of local tumor recurrence [11,12].

LIpIOdOLManufactured and marketed by the French pharmaceutical group Guerbet, Lipiodol was recently approved by the French National Agency for Medicines and Health Products for “visualization, localization and vectorization of hepato-cellular carcinoma during trans-arterial chemoembolization”. The first two of these parameters, namely visualiza-tion and localization of HCC are based on the preferential Lipiodol uptake by tumor. Such uptake can be monitored by 3D cone beam CT imaging during the TACE procedure and is useful for evaluating the completeness of the treat-ment in nearly real time [Figure 1], [13].

However, even more useful and inter-esting is the fact that the fixation of Lipi-odol in the tumor is actually a biomarker predictive of the tumor response. There is an excellent correlation between the amount of Lipiodol in the tumor and the extent of necrosis, as determined by anatomo-pathological analysis whereas, in contrast, the measure of the decrease in the size of the tumor does not corre-late with the level of necrosis [14].

Other chemoembolization products have been analyzed and compared with the use of Lipiodol in the treatment of HCC. However, up until now, no alterna-tive product has been shown to be supe-

FigUre 2. (a) MRI of the arterial phase of a seg-ment IV biopsy-proven HCC shows a hypervascular tumor that demonstrates the same pattern of arterial enhancement as with CT (b) . Three months after two courses of TACE using doxorubicin/Lipiodol/Gelfoam MRI shows a complete devascularisation of the tumor (c). On CT 6 months later there is a clear uptake of Lipiodol by the tumor, and satellite nodules (arrows) without any remaining arterial enhancement. There is a complete mRECIST response. The patient has now been under surveillance for 2 years.


therAPeutIC IMAGINGrior to Lipiodol in randomized clinical trials designed to show the superiority of the challenger products over Lipiodol. Currently chemoembolization using Lipiodol is the reference method of choice for the treatment of intermediate stage hepatocellular carcinoma as speci-fied in the EASL and EORTC guidelines [Figure 2]

The recent approval by the French regulatory authorities of the Lipiodol procedure in fact reflects the use of the approach which has been widely prac-ticed over many years and is based on data published in a large number of papers – the current bibliography com-prises more than 1000 peer-reviewed papers, including two randomized con-trolled clinical trials. It is this compel-ling body of medical evidence that lies behind the decision of the EASL and EORTC to include the Lipiodol chemo-embolization technique in their guide-lines with a recommendation level of grade 1A.

CLINICAL TRIALsOne of the most recent large prospec-tive studies on Lipiodol TACE for HCC is a cooperative study between Japan and Korea and involved on 99 patients [15]. Interestingly the group used the same inclusion criteria as those used more than 10 years ago in the randomized study by Llovet et al. who showed the superiority of TACE over supportive care [16]. In the recent study, Ikeda et al showed a response rate to TACE of 73%, a 2-year overall survival rate of 75.0% (95% CI, 65.2%–82.8%) and a median overall survival of 3.1 years. These data contrast with the ear-lier study in which Llovet et al reported a 35% response rate to TACE, a 2-year over-all survival rate of 63.0% and a median overall survival of 2.1 years, although the response rates cannot be directly com-pared, since different criteria were used for the assessment of response (mRECIST vs. WHO). Nevertheless there is a clear improvement in survival. This is probably

due to several factors, including better patient selection and improved treatment techniques, microcatheter, 3D cone beam CT angiography, automatic recognition systems for tumor feeders [17].

fuTuRE pERspECTIvEsThere are several possible approaches which have the potential to further

improve the technique. In particular the identification of the optimal che-motherapeutic drug to incorporate in the Lipiodol emulsion could result in improvement in patient outcome (at the moment the EASL and EORTC guide-lines only specify the use of doxorubicin and cisplatin). Likewise, standardization and optimization of the actual method of preparation of the drug /Lipiodol emulsion has the potential to improve overall therapeutic benefit

REfERENCEs 1. llovet J, Ducreux M, lencioni r, di

Bisceglie A, Galle P, Dufour J, et al. EASl-EOrTc clinical practice guide-lines: management of hepatocellular carcinoma. Eur J cancer. 2012; 48(5): 599-641.

2. Yau T, Tang VY, Yao TJ, Fan ST, lo cM, Poon rT. Development of hong Kong liver cancer staging system with treatment stratification for patients with hepatocel-lular carcinoma. Gastroenterology. 2014; 146(7): 1691-700.e3.

3. llovet JM, real MI, Montana X, Planas r, coll S, Aponte J, et al. Arterial emboli-sation or chemoembolisation versus symptomatic treatment in patients with unresectable hepatocellular carcinoma: a randomised controlled trial. lancet 2002; 359(9319): 1734-39.

4. lo cM, ngan h, Tso WK, liu cl, lam cM, Poon rT, et al. randomized con-trolled trial of transarterial lipiodol chemoembolization for unresectable hepatocellular carcinoma. hepatology. 2002; 35(5): 1164-71.

5. raoul Jl, heresbach D, Bretagne JF, Ferrer DB, Duvauferrier r, Bourguet P, et al. chemoembolization of hepa-tocellular carcinomas. A study of the biodistribution and pharmacokinetics of doxorubicin. cancer. 1992; 70(3): 585-90.

6. de Baere T, Dufaux J, roche A, counnord J, Berthault M, Denys A, et al. circulatory alterations induced by intra-arterial injection of iodized oil and emulsions of iodized oil and

Doxorubicin: Experimental study. radiology. 1995; 194: 1 65-70.

7. de Baere T, Denys A, Briquet r, chevalier P, laurent A, roche A. Modification of arterial and portal hemodynamic after injection of iodized oil in the hepat-ic artery: experimental study. J Vasc Interv radiol. 1998; 9: 305-10.

8. Takayasu K, Arii S, Ikai I, Kudo M, Matsuyama Y, Kojiro M, et al. Overall sur-vival after transarterial lipiodol infusion chemotherapy with or without emboliza-tion for unresectable hepatocellular car-cinoma: propensity score analysis. AJr Am J roentgenol. 2010; 194(3): 830-7.

9. Takayasu K, Shima Y, Muramatsu Y, Moriyama n, Yamada T, Makuuchi M, et al. hepatocellular carcinoma : Treatment with intra arterial iodized oil with and without chemotherapeutic agents. radiology. 1987; 162: 345-51.

10. Kan Z, Wright K, Wallace S. Ethiodized oil emulsions in hepatic microcircula-tion: in vivo microscopy in animal mod-els. Acad radiol. 1997; 4(4): 275-82.

11. Miyayama S, Matsui O, Yamashiro M, ryu Y, Kaito K, Ozaki K, et al. Ultraselective transcatheter arte-rial chemoembolization with a 2-f tip microcatheter for small hepatocellular carcinomas: relationship between local tumor recurrence and visualization of the portal vein with iodized oil. J Vasc Interv radiol. 2007; 18(3): 365-76.

12. Miyayama S, Mitsui T, Zen Y, Sudo Y, Yamashiro M, Okuda M, et al. histopathological findings after ultraselective transcatheter arterial chemoembolization for hepatocellu-lar carcinoma. hepatol res. 2009; 39(4): 374-81.

13. chen r, Geschwind JF, Wang Z, Tacher V, lin M. Quantitative assessment of lipiodol deposition after chemo-embolization: comparison between cone-beam cT and multidetector cT. J Vasc Interv radiol. 2013; 24(12): 1837-44.

14. Takayasu K, Arii S, Matsuo n, Yoshikawa M, ryu M, Takasaki K, et al. comparison of cT findings with resected specimens after che-moembolization with iodized oil for hepatocellular carcinoma. AJr Am J roentgenol. 2000; 175(3): 699-704.

15. Ikeda M, Arai Y, Park SJ, Takeuchi Y, Anai h, Kim JK, Inaba Y, Aramaki T, Kwon Sh, Yamamoto S & Okusaka T. Prospective study of transcatheter arterial chemoembolization for unre-sectable hepatocellular carcinoma: an Asian cooperative study between Japan and Korea. J Vasc Interv radiol 2013; 24: 490-500.

16. llovet JM, real MI, Montana X, Planas r, coll S, Aponte J, Ayuso c, Sala M, Muchart J, Sola r, rodes J & Bruix J. Arterial embolisation or chemoemboli-sation versus symptomatic treatment in patients with unresectable hepa-tocellular carcinoma: a randomised controlled trial. lancet 2002; 359: 1734-1739.

17. Deschamps F, Solomon SB, Thornton rh, rao P, hakime A, Kuoch V & de Baere T. computed Analysis of Three-Dimensional cone-Beam computed Tomography Angiography for Determination of Tumor-Feeding Vessels During chemoembolization of liver Tumor: A Pilot Study. cardiovasc Intervent radiol 2010; 33: 1235–42.

“.....It has been shown that patients receiving a particulate embolization have an overall increased survival rate [8]. Such complementary embolization enables an increase

in the level of necrosis in the principal tumor [9].....”

eDuCAtIONRAdIOLOGY


By Dr M Moscova

Medical imaging in an integrated anatomy curriculumIn view of the fact that medical imaging skills play a central, and increasing role in the practice of nearly all clinical specialties, it is surprising that many medical schools do not have a curriculum formally integrating imaging in its own right.

This article describes the experience of Sydney Medical School who intro-duced an integrated imaging course into the anatomy curriculum in the first two years of a four-year graduate-entry program and summarizes the reactions of the students Incorporating imaging into the anatomy teaching early in the curriculum has the potential to improve students’ confidence in understanding imaging modalities and their relevance to clinical anatomy.

MEdICAL IMAGING – wHY, wHEN ANd HOw sHOuLd wE TEACH IT TO MEdICAL sTudENTs?Increasingly, medical practitioners are expected to be profi-cient in the basic interpretation of medical images, includ-ing X-rays, CT and ultrasound scans. Medical students are expected to gain basic imaging skills before entry into resi-dency programs. A survey of 99 residency program direc-tors in the United States found the vast majority considered basic radiology skills to be essential for medical graduates [1]. Specifically, skills considered essential by over 90% of respondents included a systematic approach to interpreting chest and abdominal X-rays, the ability to recognise com-mon abnormal findings on chest and abdominal X-rays and the ability to choose the most appropriate radiologic study.

These essential skills should be taught in the undergrad-uate/preclinical setting in order for the medical graduates to meet these expectations.

Despite basic medical imaging skills being considered essential in almost every clinical specialty, many medical schools do not have a defined, longitudinally integrated medical imaging curriculum. Medical imaging is often integrated with other core clinical disciplines. As medical imaging relies heavily on knowledge of anatomical struc-

tures, anatomy is considered to be an appropriate discipline to teach these skills.

Integrating medical imaging into anatomy teaching has many benefits. Students exposed to radiology early in a medical curriculum are more likely to report an interest in radiology disciplines and to consider radiology as a career[2]. Students exposed to imaging also show improved understanding of relationships between anatomical struc-tures, an ability to recognise anatomical structures on med-ical images and confidence in interpreting X-rays, MRI, CT and ultrasound images. Including radiology and ultrasound into the anatomy curriculum has been shown to improve student performance in anatomy and/or imaging [3-5].

Medical imaging components, including ultrasound, CT, MRI and online radiology modules, have been successfully integrated into anatomy curricula by a number of medical schools.

Some schools developed programs that over several weeks integrated a combination of cadaveric specimens, X-rays, ultrasound, CT and MRI scans into anatomy [6, 7]. However, there is a substantial difference between medical schools in the amount and type of imaging taught. A recent review described considerable variation in how medical imaging is integrated into anatomy. Some schools only pro-vide medical imaging materials to students on request [8]. A more uniform approach is needed to achieve consistent educational outcomes, as many medical students still find interpretation of medical images challenging.

sYdNEY MEdICAL sCHOOL – CAsE sTudY ON INTEGRAT-ING MEdICAL IMAGING INTO ANATOMY CuRRICuLuMSydney Medical School made a decision to integrate medi-cal imaging into the anatomy curriculum following a pro-gram review. Detailed descriptions of the program and its new imaging component have been published previ-

The author :

dr Michelle Moscova

Senior lecturer,

Educational Development

Graduate School of Medicine

School of Medicine

Faculty of Science, Medicine & health

University of Wollongong | nSW | 2522

Australia



ously [9]. The program focused on intro-ducing imaging techniques, developing understanding of basic interpretation of medical images and improving student confidence in their ability to understand three-dimensional anatomy. X-rays, MRI, CT, ultrasound images, endoscopy and laparoscopy videos were introduced to the program.

Medical imaging was integrated into the first two years of the four-year gradu-ate-entry program. Because the program was based around problem-based learn-ing (PBL), all teaching of clinical sciences was arranged around PBL cases. Medi-cal imaging components were mapped to PBL cases within the new anatomy curriculum. Students were taught all rel-evant regional anatomy before medical imaging components were introduced for the same region.

MEdICAL IMAGING COMpONENTsThe imaging curriculum consisted of:

1. Nine specialist radiology lectures delivered at the end of each relevant anat-omy block by radiologists and a vascular surgeon.

2. Normal radiologic anatomy deliv-ered by anatomy staff. Each anatomy practical session included a station where students identified anatomical structures on X-rays, MRI and CT scans. This pro-vided a basic introduction to imaging.

3. Radiologists and radiology reg-istrars delivered four cross-sectional imaging practical sessions. These ses-sions aimed to improve understanding of imaging modalities and student confi-dence in basic interpretation of MRI and CT scans.

4. Sonographers and a vascular sur-geon delivered three ultrasound practi-cal sessions. These sessions included one hands-on ultrasound session using a human volunteer.

5. Annotated endoscopy and lapa-roscopy videos were developed with a gastrointestinal surgeon. They included directional labels and a voice-over description of anatomical structures.

6. Medical imaging assessment was included into the anatomy practical sum-mative assessment.

sTudENT ExpERIENCE wITH THE NEw MEdICAL IMAGING CuRRICuLuM – HOw CAN IT BE IMpROvEd?We prioritized evaluating student experi-ence with the new curriculum because it affects motivation to learn and student engagement. We were also interested if the students’ experience with the new curriculum was affected by the their prior exposure to anatomy. We evaluated three consecutive cohorts to ensure the find-ings were not cohort-specific.

In practice, to assess student experi-ence, we conducted surveys consisting of a combination of 5-point Likert scale and open response questions. The sur-veys also asked students to rate their level of prior exposure to anatomy based on the description provided. A detailed description of the method and statisti-cal analysis was published previously [9]. We reviewed components of the medi-cal imaging curriculum that were poorly received by the students. As student opin-ion is not always in line with best teaching practice that supports learning, changes to the curriculum were only made if they were evidence-based.

Over three quarters of students who responded to the survey classified them-selves either as beginners or near beginners in anatomy. Between 90%-92% of students were satisfied with the overall quality of teaching. This suggested a good overall stu-dent experience with the new curriculum.

The students rated cross-sectional imaging practical sessions consistently higher than imaging lectures. The main lecture criticisms included repetition/overlap, including less content or making lectures slower paced and less complex. Students with less prior anatomy expe-rience wanted to focus more on basics: “…teaching us the basics of a systematic approach to interpreting X-rays before delving into clinical cases…”. Students with high prior anatomy experience wanted more complex and interactive material included in lectures: “More interactive learning, more case scenar-ios and real clinical studies”. A review of imaging lecture content in response to students’ comments revealed the need to simplify and scaffold content to reduce its complexity. In response, interactive introductory radiology sessions were

Most students thought practical sessions were good and wanted more of them. Overwhelmingly, tutors were named as the most useful resource.Students with high prior anatomy experience wanted ultrasound to be taught as part of clinical skills rather than anatomy: To improve ultrasound sessions, a series of notes and questions were developed to support ultrasound activities, which were made available to students online.


rADIOLOGY eDuCAtIONdeveloped. These sessions were taught by a radiographer and focused on basic concepts, for example systematic inter-pretation of X-rays.

Between 72-77% of students believed cross-sectional imaging sessions helped them better understand the imaging modalities of CT, MRI and ultrasound. Between 76-84% of students thought these practical sessions helped them understand spatial relationships between the struc-tures of thorax, head and neck and 71-77% believed they helped reinforce the location and relationships of abdominal viscera. Between 69-80% of students agreed ultra-sound sessions were helpful in understand-ing abdominal and vascular ultrasound. 72% of students thought endoscopy and laparoscopy movies were useful in relating practical session material to clinical prac-tice. Most students thought radiology and ultrasound practical sessions were good and wanted more of them. Overwhelm-ingly, tutors were named as the most useful resource. Students with low prior anatomy experience wanted more imaging quizzes: “the imaging [practical] sessions – should have had quizzes”. Students with high prior anatomy experience wanted ultrasound to be taught as part of clinical skills rather than anatomy: “Ultrasound might be bet-ter taught as patient doctor tutorials on clinical days”. To improve ultrasound ses-

sions, we developed a series of notes and questions to support ultrasound activities, which were made available to students online. Use of an ultrasound dummy with pathological organs was also introduced to ultrasound sessions in addition to using volunteer models.

LIKELY fuTuRE dEvELOpMENTsMore and more medical schools are incor-porating imaging into their anatomy cur-riculum. More of them, including our program, introduce medical students to multiple imaging modalities during their anatomy studies. Given the increased reli-ance on imaging for diagnosis and treat-ment and its relevance to anatomy, it is likely that use of imaging in anatomy labo-ratories will continue to increase. A big challenge will be to work on development of a standardised curriculum for medi-cal imaging. This curriculum will need to begin in pre-clinical years and continue into more advanced clinical stages of medical programs. While developing such a curriculum will be a challenge, it will provide consistency in imaging training. It will also provide medical students with an opportunity to build on the imaging skills acquired in pre-clinical years and apply these skills in clinical practice.

CONCLusIONThe longitudinal integration of medical imaging into the anatomy teaching early

in the curriculum may improve students’ confidence in understanding imaging modalities and their relevance to clini-cal anatomy. Medical imaging is likely to remain in the medical curriculum, given its increased use in medical practice and expectations that students graduate with basic radiology skills.

REfERENCEs1. Kondo Kl, Swerdlow M: Medical student radiology

curriculum: what skills do residency program direc-tors believe are essential for medical students to attain? Acad radiol 2013; 20(3): 263-271.

2. Branstetter BFt, Faix lE, humphrey Al, Schumann JB: Preclinical medical student training in radiology: the effect of early exposure. AJr Am J roentgenol 2007; 188(1): W9-14.

3. Dreher SM, DePhilip r, Bahner D: Ultrasound expo-sure during gross anatomy. J Emerg Med 2014; 46(2): 231-240.

4. Feigin DS, Magid D, Smirniotopoulos JG, carbognin SJ: learning and retaining normal radiographic chest anatomy: does preclinical exposure improve student performance? Acad radiol 2007; 14(9): 1137-1142.

5. Magid D, hudson DW, Feigin DS: chest radiographic anatomy retention: the impact of preclinical ground-work on clinical recall in two schools. Acad radiol 2009; 16(11): 1443-1447.

6. Benninger B, Kloenne J, horn Jl: clinical anatomy of the lingual nerve and identification with ultraso-nography. Br J Oral Maxillofac Surg 2013; 51(6): 541-544.

7. Schober A, Pieper cc, Schmidt r, Wittkowski W: “Anatomy and Imaging”: 10 Years of Experience with an Interdisciplinary Teaching Project in Preclinical Medical Education - From an Elective to a curricular course. rofo 2014; 186(5): 458-465.

8. Phillips AW, Smith SG, Straus cM: The role of radiology in preclinical anatomy: a critical review of the past, present, and future. Acad radiol 2013; 20(3): 297-304 e291.

9. Moscova M, Bryce DA, Sindhusake D, Young n: Integration of medical imaging including ultrasound into a new clinical anatomy curriculum. Anat Sci Educ 2014: Aug 6. doi: 10.1002/ase.1481.

Vascular Imaging of the Central Nervous System: Physical Principles, Clinical Applications and Emerging TechniquesBy Joana Ramalho, Mauricio Castillo Published by Springer 2014 432 pp € 133.30 hardbook; € 109.99 e-book

book review

The first book-length reference to thor-oughly describe diagnostic and therapeutic advances in the development of vascular radi-ology over the last decade

The last ten years has seen vascular imag-ing of the central nervous system (CNS) evolve from fairly crude, invasive procedures to more advanced imaging methods that are safer, faster, and more precise—with computed tomographic (CT) and magnetic resonance (MR) imaging methods playing a special role in these advances.

Vascular Imaging of the Central Nervous Sys-tem is the first full-length reference text that shows

radiologists—especially neuroradiologists—how to optimize the use of the many techniques avail-able in order to increase the sensitivity and speci-ficity of vascular imaging, thereby improving the diagnosis and treatment of individual patients. Each chapter is formatted carefully and divided into two essential parts: The first part describes the physical principles underlying each imaging technique, along potential associated artifacts and pitfalls; the second part addresses clinical applica-tions and novel applications of each method.

There is a strong focus on the clinical appli-cation of each modality or technique in CNS radiology.

NeWSINdusTRY


Siemens sells its hospi-tal information systems business to focus on imaging and therapy

Siemens Healthcare plans to divest its hospital information system busi-ness (HS) for US$ 1.3 billion (around €963 million) in cash to the US-based company Cerner Corp. The HS busi-ness is focused on administrative hos-pital IT and electronic patient records, and is thus different from the infor-mation technology that enhances the capabilities of imaging modalities and laboratory equipment. The HS division is headquartered in Malvern, Pennsyl-vania, United States and employs some 6,000 employees worldwide with opera-tions in the US, in Europe (particularly Germany), and in Asia. The transac-tion is subject to applicable regulatory approvals and planned to close during the first quarter of calendar year 2015. The transaction is fully aligned with the overall strategy of Siemens – Vision 2020. “In recent years, we have continu-ously invested in our HS-portfolio and achieved significant progress on the technology side. At the same time, we realized that the business success of our hospital information systems could not always keep pace with our competition”, says Hermann Requardt, CEO Siemens Healthcare. “Additionally an increasing number of country-specific require-ments, such as those resulting from US healthcare reform, make it increasingly challenging to achieve sufficient scale effects. Going forward we will focus on the development of information systems

that support our businesses in labora-tory diagnostics as well as imaging and therapy.” The takeover of the business by Cerner provides a positive perspective for customers and employees, as Cerner has a proven expertise and is one of the leading players in the market. At

the same time with the divestment, Sie-mens Healthcare and Cerner are engag-ing in a strategic alliance in the field of Next Generation Healthcare IT. Next Generation Healthcare IT is one of the future focus fields of action for Siemens Healthcare.

SIEMEnSErlAnGEn, GErMAnY www.siemens.com

varian acquires radiation simulation Software company

Varian Medical Systems, announced it has acquired certain assets of Tran-spire, Inc., including the Acuros dose calculation software that has been inte-grated into Varian’s market-leading BrachyVision and Eclipse treatment planning software products.

“Acuros software makes it possible to implement highly precise forms of treat-ment in heterogeneous tissues such as the lung—something other algorithms do not do as well,” says Jeff Amacker, Var-ian’s senior director of clinical solutions. “Acuros can accomplish this in a work-able timeframe, compared with more cumbersome Monte Carlo approaches that are just not used because they take too long.” “Varian and Transpire have enjoyed an OEM relationship since 2008, when we first incorporated the Acuros algorithm into our systems for planning and delivering high-precision radiotherapy for the treatment of can-cer,” says Kolleen Kennedy, president of Varian’s Oncology Systems business. “This acquisition will enable us to con-tinue leveraging the Acuros solution for use in proton therapy, and for improving

our image guidance tools on other Var-ian treatment systems. We look forward to working directly with Transpire’s accomplished team of engineers and scientists, who have now joined Varian, to further refine and enhance our treat-ment planning software systems.”

The acquisition also covers Tran-spire’s Attila software, which is in use worldwide in a diverse range of indus-tries where radiation effects play an inte-gral role in product performance, safety, and reliability.

VArIAn MEDIcAl SYSTEMS, PAlO AlTO, cA USA www.varian.com

ge’s digital tomosyn-thesis mammogra-phy system gets FDa approval

A digital mammography system — developed from concepts originally tested at Massachusetts General Hospital (MGH) in the United States — has been approved by the U.S. Food and Drug Administration. GE Healthcare received approval to market the SenoClaire Digi-tal Breast Tomosynthesis system, based on patented technology licensed from the MGH and developed under the lead-ership of Daniel B. Kopans, MD, founder and senior radiologist in the

INDuStrY NeWS


Breast Imaging Division of the MGH Department of Radiology.

Kopans notes that soon after wide-spread screening mammography was introduced in the mid-1980s, U.S. death rates from breast cancer — which had remained unchanged for more than 40 years — began to decline. But the limi-tations of conventional mammography reduce its ability to find all tumors while avoiding false positive readings.

Kopans originally proposed in 1978 applying a then theoretical technique called tomosynthesis — namely the construction of a 3D image from digital readings taken at many different tissue depths — to the problem of superim-position, but the digital image detec-tors and powerful computers required to construct such images were not avail-able until the 1990s. Clinical trials have shown this elimination of tissue super-imposition can reveal tumors that are hidden on conventional mammograms and reduce false positive readings.

“This is an exciting time in breast imaging,” says Kopans, who is also a professor of Radiology at Harvard Medical School. “Conventional mam-mography, even with its limitations, has helped to dramatically reduce deaths from breast cancer. The availability of digital breast tomosynthesis should help to drive breast cancer deaths down even further, and this FDA approval should make the technology available to more and more women. We all hope for ways to totally prevent or cure breast cancer, but until such methods are available, we will continue working to find more ways to detect breast cancer earlier to save the lives of patients with breast cancer.”

GE hEAlThcArE AMErShAM UnITED KInGDOM www3.gehealthcare.com

claron partners with italian Telehealth systems provider

Claron Technology has announces a partnership with Medishare, an innova-tive Italian telehealth system provider, for the integration of its family of Nil zero-footprint viewers in the Medishare PACS and RIS solutions, which are pro-vided throughout Italy.

“We selected Nil because the technol-ogy is robust, easy-to-use, reliable and affordable,” comments Stefano Fait Dalla Nese, CEO of Medishare. “NilRead is CE marked for diagnostic review and is very efficient in the primary and second reading settings. NilShare is an easy-to-

use, flexible solution for non-diagnos-tic viewing. Together they provide an excellent complement to our portfolio of enabling technologies.”

Claron’s NilRead zero-footprint diagnostic viewer provides offsite authorized radiologists with real time access to any digital imaging exam in the system for viewing and interpreta-tion. It supports display of DICOM modalities and related medical infor-mation on a multi-monitor diagnostic workstation. It also supports diagnos-tic image viewing on a laptop, tablet and smartphone whenever a diag-nostic workstation is not available. The innovative viewer family enables remote physicians to access high-res-olution, diagnostic quality display of both DICOM and non-DICOM for-mats, as well as referral quality images.

“We recently showcased the family of Nil zero-footprint medical viewers at the National Congress of SIRM (Società Italiana di Radiologia Medica), Italy’s leading radiology show in Florence,” says Fait. “The Nil family of viewers impressed the many health profession-als attending. NilRead and NilShare can be integrated into any DICOM network and are available as turn-key solutions for hospitals, imaging groups and radiol-ogy practices.”

Medishare is a provider of radiologi-cal tele-consultation services to both public and private health facilities. The company has received several awards for its innovative solutions in the medi-cal field. Medishare has its operational headquarters in Bologna, and one office in Gorizia at the TechnoAREA, the larg-est technology park in Italy.

clArOn TEchnOlOGYTOrOnTO, cAnADA, www.clarontech.com

Medaphor floats on aiMMedaPhor, the UK-based global pro-

vider of advanced ultrasound education and training systems for medical pro-fessionals, has raised £4.7 million in its flotation on the AIM market of the Lon-don Stock Exchange. MedaPhor’s lead product is ScanTrainer, a virtual reality-based ‘real feel’ ultrasound training sim-ulator that enables trainees, of any level, to literally feel what they see on the computer screen in order to develop the complex mix of cognitive skills and eye-hand movement coordination required to learn all the key ultrasound scanning skills. MedaPhor, a Cardiff University spin-out company, is based in Cardiff in the UK and San Diego in the USA. The simulator uses real patient scans, within an educationally driven training pro-gramme, to teach the core and advanced ultrasound scanning skills without the need for an ultrasound machine or a patient and with considerably reduced expert supervision.

MedaPhor’s ScanTrainer range of simulators includes advanced haptic simulators for teaching internal and external obstetric and gynecology scan-ning and a new general medical upper abdomen training simulator, aimed at the large radiology ultrasound training market, that was launched in San Fran-cisco, USA in January this year.

Stuart Gall, CEO of MedaPhor Group plc, said: “This is a landmark event for the Company and we are grateful to our existing investors, especially IP Group, Finance Wales and our founder Profes-sor Nazar Amso, for their support, as well as welcoming new investors, who include the Welsh Arthurian Life Sci-ences Fund. Medical simulation services continue to grow rapidly and we believe our products have the potential to make us a major player in the ultrasound sector of this exciting market. Moving to AIM provides us with the backing and vis-ibility to deliver on our growth strategy.”

MEDAPhOrcArDIFF, UK ww.medaphor.com

INDuStrY NeWS


agfa healthcare wins a digital imaging con-tract in lebanon

The newly opened “Beirut Medical Imaging — Saint Antoine de Padoue — Center” in the Achrafieh district of the Lebanon capital Beirut, has cho-sen Agfa HealthCare systems to supply imaging equipment. The reasons for

the choice of Agfa products were pri-marily the image quality, dose reduc-tion and after-sales service. “We needed a solution that would give us very high image and detector quality, with the potential for patient X-ray dose reduc-tion, at the right price-quality ratio,” commented Dr. Tanios Habis of Bei-rut Medical Centre - Saint Antoine de Padoue. The equipment includes a floor mounted scalable direct radiog-raphy system and CR 10-X tabletop digitizer with full leg/full spine option. Agfa HealthCare’s direct radiography (DR) system is a scalable, robust, floor-mounted radiography system offering flexible configurations and options, including the highest quality CsI DR detectors.

Like all of Agfa HealthCare’s digital radiography solutions, its floor mounted DR system and CR 10-X come with Agfa HealthCare’s gold-standard MUSICA workstation and image processing soft-ware. The workstation provides very fast image acquisition and a smooth work-flow, while the image processing software analyzes each image and automatically applies the appropriate image enhance-ment parameters independent of the exam type, so providing consistently high image quality.

AGFA hEAlThcArE MOrTSEl, BElGIUM www.agfa.com

Bracco launches ultrasound contrast agent in russia

Bracco Imaging has announced the launch of its ultrasound con-

trast agent SonoVue (sulphur hexa-fluoride microbubbles) in Russia. SonoVue is a second generation of ultrasound contrast agent approved and used for the diagnosis of car-diac, liver, breast and vascular dis-eases. Russia is a market with a long tradition in diagnostic imag-ing and with extensive experience in ultrasonography both in cardiol-ogy and in radiology as well as in other specialties. The availability of SonoVu in Russia allows healthcare professionals to perform dynamic imaging of contrast distribution and flow dynamics in echocardiography, vascular imaging and microvascu-lar imaging for characterization of focal lesions in liver and breast. Bracco will launch a series of edu-cational activities to train interested centers in the proper use of con-trast-enhanced ultrasound (CEUS)

and share the more than 12 years’ experience obtained with CEUS in Europe and Asia. SonoVue is approved in more than 35 countries and has been used in over 3 million patients worldwide. Its safety profile has been proven to be satisfactory even in critically ill patients, to the point that the Committee on Human Medicinal Products (CHMP) of the European Medicines Agency (EMA) decided to remove contraindica-tions for use of the product in this special population. The first sales of SonoVue in Russia took place at the beginning of July, and the product is now being promoted in principal centers.

BrAccO IMAGInGMIlAnO, ITAlY www.braccoimaging.com

Mindray and Zonare’s fusion bears sales fruits

Mindray and ZONARErecently teamed together to provide 17 ultra-sound systems to Hennepin County Medical Center (HCMC) in Minne-apolis, Minnesota, USA – a nationally

recognized regional healthcare pro-vider. The purchase contract includes 11 Mindray portable and six ZONARE ZS3 units. “HCMC is a pioneer in the use of point-of-care ultrasound,” said Andrew Laudenbach, MD, emergency physician at HCMC. “Having state-of-the-art ultrasound technology imme-diately accessible in our emergency department is a standard for provid-ing excellence in patient care.” HCMC is a Level I Adult and Pediatric Trauma Center and nationally US recognized medical education center with innova-tive programs and specialties. In addi-tion to its emergency and trauma ser-vices, HCMC provides care through several primary care clinics with various locations throughout the county includ-ing a retail clinic in a local Walmart store. Its emergency department alone has more than 100,000 patient visits each year. “Because of our high volume and the demand for rapid results, we rely on imaging solutions that provide outstanding diagnostic quality and user-friendly interfaces,” said Lauden-bach. “We are pleased that the synergy between Mindray and ZONARE could offer a comprehensive solution for HCMC,” said Glen Mclaughlin, PhD, president of ZONARE. “These are the type of results we had anticipated when the two companies joined together.”

MInDrAY, ShEnZhEn, chInA, www.mindray.comZOnArE, MOUnTAIn VIEW, cA, USAwww.zonare.com

reGGIO eMILIA, ItALY HOspITAL fOCus:


Optimizing It infrastructure in a provincial hub hospital and active oncology research centreThe Reggio Emilia hospital is a highly prestigious clini-cal research centre located in the North of Italy. Not only with 900 beds in the central research unit, the institute is also linked to five additional rural satellites so, as a whole the group deals with a total of over 530 000 peo-ple from throughout the surrounding area.

The IT infrastructure required to maintain this complex establishment running smoothly and at maximum effi-ciency has itself to be of utmost efficiency. We spoke to Dr Marco Foracchia IT Medical systems manager who is the “chef d’orchestre” of a system generally considered to be a top example of leading edge advanced IT management

Q Before we get into the details of the IT systems, first a word about the Reggio Emilia Hospital itself. It is classified as IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico) or Institutes of Hospitalization and Scientific Care, which is a title awarded to only a few hospitals that have gained spe-cial “recognition of the scientific nature in clinical areas of expertise” . What are the hospital’s main areas of expertise?

In fact, our “Santa Maria Nuova” hospitial in Reggio Emilia is a reference hub for the whole province of Reggio Emilia which is located in the north of Italy between Parma and Bologna. As a reference hub the hospital covers all disci-plines. The provincial healthcare system also comprises five smaller general hospitals.

In addition, our hospital has always been very active in cancer treatment and research, and in recent years has com-

mited to develop and institutionalize its focus on Oncology. It has now been officially recognized as a research institution (IRCCS) and is in the process of being accredited by the Organization of European Cancer Institutes.

Organized in 53 units, the hospital currently has around 900 beds. We have around 51 000 patient admissions per year, one fourth of which are related to oncological pathologies.

Q What’s the role of IT in your hospital, and how is it managed?

We spend around 3% of the total hospital budget in IT, which is very high by Italian standards (the Italian national average is 1% of total hospital budget allocated to IT).

This strong commitment to, and recognition of, the importance of IT in our hospital has led over the years to the setting up of a comprehensive IT infrastructure that encom-passes not only our main Reggio Emilia hospital, but also the satellite hospitals throughout the province. This structure enables every hospital and every public healthcare facility in the province to share the same network, the same IT systems, the same PACS, the same Clinical Repository, etc., etc.

Right from the beginning, that is at the procurement stage, all systems are designed to be properly integrated into the general IT environment. The outcome is a scenario where a fully data-integrated province-wide healthcare sys-tem provides in real time all information to any healthcare professional..

We are now in the progress of being evaluated by HIMSS for the Level 6 classification of the European EMR Adop-tion Model (EMRAM). We are proud of this since this is the

Dr Marco Foracchia is Medical iT sytems Manager at reggio emilia hospital, whose iT budget, as a pro-portion of the total hospital budget is three times the Italian average

The “Santa Maria Nuova” hospitial in Reggio Emilia is a reference hub for the whole province of Reggio Emilia which is located in the north of Italy between Parma and Bologna..


penultimate grade of the EMRAM grad-ing system. Of course this is the result of all the work and the effort put into sys-tems and data integration, which go well beyond the simple acquisition of IT sys-tems or individual diagnostic equipment.

And we’re dealing with much more than straightforward radiology applica-tions.The management of “exotic” imag-ing, such as non-radiology has to be gov-erned by the same underlying principles of data integration and sharing.

Q Now a word about the radiology and other imaging services. What imaging modalities do you have? What about the satellite hospitals? How do you cur-rently deal with non-DICOM imaging ?

The hospital Radiology and Nuclear Medicine services cover almost all types of traditional radiological imaging. We currently have 6 CTs, 3 MRIs, 9 DRs, one PET-CT, one SPECT-CT, 2 X-Ray Angi-ography devices and 6 radiological ultra-sound devices. Our Medical Physics unit supports the Radiology and Nuclear Med-icine services by managing the modalities, leading the procurement processes, and, together and in co-operation with the IT department, in designing, implementing and managing the IT infrastructure.

The provincial hospitals are also well equipped, with 5 CTs, 24 Digital Radiog-raphy devices, 3 MRIs and several Ultra-sound devices. These devices are also managed by the same central Medical Physics unit and IT department.

All these devices are networked to a single PACS system (Carestream); the radiology services thoughout the whole

province have been completely filmless since 2003, and have been completely paperless since 2010.

Many more ultrasound devices are used in other non-radiology units, and even if they can be technically categorized as being within the structured DICOM wworld, in parctice it is difficult to assimi-late them with the devices used in the radi-ology services since their use is very often far outside the traditional workflow.

Their management is a completely dif-ferent issue… traditionally they have been ostracized from the PACS and have not therefore been able to be managed at all.

Non-DICOM imaging can be a pretty “wild” field, comprising several different devices and data types. The field ranges from well known, common systems such as endoscopy imaging, up to the handling of data from EEGs or spirometry exami-nations which are even difficult to classify as “imaging”. Of course, they can always be thought of as images, in the sense that they involve the storage of recorded traces, but the actual information needed for fur-ther processing by specific software is both graphical and numerical (i.e. a signal).

Some manufacturers of such non-DICOM devices and data types plan future migration of their devices to com-ply with DICOM standards. However, in practice this trend is limited to data types that can be easily assimilated with existing DICOM standards (e.g. endoscopy images can be “dicomized”) and to other fields that have a sufficient “mass”, in terms of economic interest, to justify the necessary investments.

Many different “niche” devices man-age data types that can neither be eas-ily assimilated into any existing DICOM entity, nor, because of the limited number of devices existing worldwide, can they justify the investment needed for develop-ing DICOM conversion software and the necessary PACS integration systems.

All the data generated by these “exotic” devices has either been managed by local, proprietary systems (also known as “local silos”), or — in many cases — not man-aged at all.

In a recent study sponsored by Car-estream, we tried to take a census of all these extra-radiology devices, classify them, and estimate the amount of data generated by each one. We estimated that 36 different types of extra-Radiology modalities are currently generating data that “would be worth storing”. Of these 36, only 7 sources are natively DICOM or could be converted. They account for only 24% of the total amount of data generated. The remaining device types can in some cases be connected to XDS repositories, but in most cases are not designed to be integrated at all.

This situation is common to most hos-pitals that have reached a sufficiently high level of specialization and have therefore acquired many different highly specialized technologies.

It is of course possible simply to “sur-vive” with a silo-based management or by just giving up the storage and manage-ment of most of these types of data. But, in Reggio Emilia the context is changing....

Q What is changing with respect to the management of extra-radiology infor-mation ?

There are three driving forces which are becoming more and more relevant and are moving beyond radiology into extra-radiology imaging. These drivers are: regulatory issues, multidisciplinary care paths;and research activities.

Regulatory issues. Italian, and to some extent European

regulations require us to properly store data and, upon request, be able to give it back to the actual owner: the patient. This has always been normal practice

Carestream Vue Archive was the selected solution for the multiple data inputs. “Having a true vendor-neutral clinical image repository means my facility can ingest all data formats without interrupting data flow” says Dr Marco Foracchia..


hOSPItAL FOCuS: reGGIO eMILIA, ItALY

for the most traditional pieces of clinical information, namely Medical Records, Radiology and Laboratory results. Now-adays patients are becoming more and more demanding. They want to have the video of their endoscopy, they want to have the images taken by the pathology department of the biopsy specimens, they might even want to have the video of the surgery performed. Basically the bottom line is: if you acquire data, you have to be ready to give it back to the patient at some time or another… and in reality, more and more often the patient will ask for it.

Recently our hospital region has undergone a detailed inspection of all our IT systems by government authori-ties, during which the biggest focus and most relevant issue was “privacy”, in terms of “proper management of data”. The clear statements was: “if you store data, it has to be properly managed”.

Multidisciplinary Care PathsThe second driver is Care Paths. They

have of course always existed in a very basic form… For example, when neces-sary, a GP would send the patient to several specialists one after the other. The GP would then gather their reports and share them with other specialists to acquire more reports that finally gave the necessary overview to reach a defini-tive diagnosis and to define the appro-priate and necessary treatment.

This process has evolved and is gradually being restructured, now going under the name of “integrated care”. Information shared by all the healthcare professionals involved in the path cannot be limited to reports any more: information has to include all data generated in the process. This implies both the need to store the information appropriately and the need to share it among professionals (and the patient!).

Sharing information in Care Paths becomes even more relevant when they involve peripheral points of care for initial assessments and follow-up and when the central acute-oriented hospital is limited to highly specialized diagnos-tic procedures and the main therapeutic processes.

ResearchLast, but not least, research in the

medical field is changing. It is no longer based on simple data being gathered off-line in paper or electronic forms. More and more research projects involve the acquisition, storage and exchange among researchers of image or numeri-cal data, very often acquired by highly specialized devices. Pharmaceutical companies increasingly carry out clini-cal trials which require the availability of raw imaging or numerical data directly acquired from devices.

Analysis of impact In order to try to assess objectively

the first two “trends”, we involved a set of clinicians to participate in two studies where they were asked to fill out forms for every clinical case they treated over a chosen time interval (some months) and a specific care path. They were asked to assess the relevance of the potential availability of specific data sources for each case.

The results confirmed that informa-tion that was once considered not to be extremely important — and thus not stored — is now becoming relevant for the care path, and if it were made avail-able could have a significant clinical impact.

Q Finally you went for the Carestream Vue Archive as the integrated extra-radiology images and media reposi-tory. What were the key reasons behind your choice? How has it panned out in practice?

Given the drivers/needs described above, we realized that, if we wanted to

provide a unique, enterprise level solu-tion the first thing to do was to assess quantitatively what the “extra-radiol-ogy” field was, and especially the “non-DICOM” part.

Carestream, having been our valuable partner in the radiology IT systems for almost a decade, agreed to support us in performing a one year study on this subject.

The study led to a complete census of all potential devices, their classification and the estimation of the data throughput. (Of course in situations where data was not actually stored, we could only make estimations).

The most challenging result coming for this study was that only a limited portion (roughly 30%) of data could be managed by a system offering only DICOM and XDS standards.

At the time Carestream was not planning to go beyond these two stan-dards. In order to successfully imple-ment VNA, Carestream supported us by developing a third layer for sim-plified data acquisition to the system. This allowed us to potentially integrate 100% of data sources available at the hospital.

The system has now passed through the commissioning phase and has been connected experimen-tally to several data sources spanning the spectrum of complexity: from “good old” DICOM (Endocrinology ultrasound) to non-DICOM, non-XDS data sources (e.g endoscopy video sources).

Q What are the plans for the next stages? The system will be put into full clini-

cal use by continuing the “full spectrum” approach described above.

On the DICOM side, we are connecting all non-radiology ultrasound devices. At the same time, on the non-DICOM side, we will connect all Video Endoscopies, Surgery Videos and Surgical Microscopy videos.

We then plan to continue connecting all data sources, and plan to complete all the ones classified as “clinically relevant” within the next three years.

All in all it has been an exciting and productive IT time at Reggio Emilia — and it looks like continuing for some time yet.

“.... the bottom line is: if you acquire data you have to be ready to give it back to the patient at

some time or another....”

“.... information cannot be limited to reports... it

has to include all the data generated in the process ....”

DISPLAYSRAdIOLOGY


redefining the reading room with a revolutionary diagnostic display designed to meet the challenges that radiologists face every day

Barco has just announced the release of Coronis Uniti, the first diagnostic display explicitly designed for both PACS and breast imaging. With its unparalleled image quality, inventive productivity features, and commitment to ergonomics, Coronis Uniti is Barco’s latest response to some of the challenges in modern radiology: increasing image volumes, growing complexity, and ergonomic stress.

“With nearly 30 years of experience in healthcare imag-ing, we understand the radiology market and the challenges that the industry is facing today. It’s this experience that led to the development of Coronis Uniti, a diagnostic dis-play system that unifies the workflow for radiologists,” says Lynda Domogalla, Vice President of product marketing for Barco’s Healthcare division.

The most important issues facing radiologists were brought to light a few weeks ago, when healthcare research agency The MarkeTech Group revealed the results of its most recent radiology survey. The study, which interviewed over 200 radiologists from Europe and North America, also offered clear insights into possible solutions. For example, the majority of respondents indicated that higher image quality, a more efficient workflow, and increased comfort would significantly increase reading performance.

uNIfIEd pERfORMANCEThe features of the new Coronis Uniti display are a tes-

tament to Barco’s commitment to improve reading per-formance. By supporting both PACS and breast imaging, calibrated color and grayscale, 2D and 3D, and static as well as dynamic images, Coronis Uniti eliminates the need for multi-head display setups or moving to another workstation, thus increasing workflow efficiency. Focused on driving pro-ductivity, Coronis Uniti is loaded with ingenious features that improve the reading experience. These include RapidFrame technology to ensure crisp and in-focus moving images and an innovative multi-touch pad for fast control.

uNsEEN IN THE MARKETThe 12MP color screen offers the highest resolution avail-

able on the medical imaging market today. Furthermore, to meet the DICOM standard for grayscale images and to guarantee consistent behavior, the display is equipped with Barco’s industry-changing SteadyColor calibration technol-ogy. Additional special features such as Color PPU and Ambient Light Compensation ensure that image quality is flawless, in any lighting environment. The MediCal QAWeb software for automated calibration and Quality Assurance guarantees top performance without interruptions.

ERGONOMIC ExpERIENCEAccording to the MarkeTech study, no fewer than 87 per-

cent of radiologists experience physical discomfort when read-ing images, ranging from eye fatigue to back pain. In the light of this, Barco has paid extensive attention to ergonomic aspects in the development of the new product. The display optimizes the reading experience by mirroring the natural field of vision of humans. Its carefully designed format minimizes the need for head and eye movements, while also creating the perfect canvas for side-by-side comparison of multiple images.

To reduce eye fatigue, the SoftGlow wall light adds ambi-ent light to the reading room, while the SoftGlow task light shines a light on papers and film folders. Barco’s Opti-cal Glass technology is also incorporated into the display, which reduces reflection and enhances image sharpness for greater viewing comfort. Additionally, Coronis Uniti can be turned into a virtual lightbox to compare films – using a handy film clip – with current digital exams.

A NEw vIEw ON RAdIOLOGY“With advances in image quality, productivity, and ergo-

nomics, Barco hopes that the Coronis Uniti display sys-tem will change the radiology reading room,” says Lynda Domogalla. “By simplifying and standardizing the image reading technology platform, it becomes easier to manage and control the entire display network. Furthermore, by replacing the multiple-head display setup, Coronis Uniti offers unique opportunities to reduce display cost, real estate, and operational expenditure. In short, this is a one-time investment that will last a lifetime.”

The new Coronis Uniti system from Barco was specifically designed to maximise ergonomic efficiency. A recent survey of radiologists revealed that no fewer than 87 per cent of radiologists experience physical discomfort when reading images, a statistic which looks as though it will increase in the future as radi-ology workloads continue to grow and become more complex. The system’s 12MP color screen offers the highest resolution available on the medical imag-ing market today. The system is designed for both PACS and breast imaging.

uLTRAsOuNd


by Dr Richard G. Barr

Improving Prostate Cancer Screening with ShearWave elastographyShearWave Elastography has been shown to have higher sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) than existing modalities for the screening of prostate cancer

The current screening protocol for diagnosing pros-tate cancer consists of a screening test of prostate-specific antigen (PSA) measured in serum, typically combined with a digital rectal examination. When ele-vated levels of PSA are detected, the protocol calls for a transrectal ultrasound (TRUS)-guided prostate biopsy. Serious review of the two-step screening process has revealed major drawbacks, including over diagnosis in the early stage and missed cancers in the second[1, 2]. For instance, these drawbacks have led the United States Preventative Task Force to give the PSA test a “D” grade and to recommend against it, commenting that the “expected harms of PSA screening are greater than the potential benefit” [3].

A portion of the risk in the risk/benefit ratio for PSA screening comes from the performance of unnecessary biopsies in response to false positives. A recent study of the use of ShearWave Elastography (SWE) for exam-ining the prostate, however, suggests that adding this imaging modality to the early stage of PC screening could reduce false positives, thus avoiding unnecessary invasive procedures for men who are not at risk of PC [4].

In this study, SWE was shown to have higher sensi-tivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) than existing modali-ties—making it a potentially game-changing tool for the responsible detection of PC [4].

pROsTATE CANCER According to The European Randomized Study of Screening for Prostate Cancer (ERSPC), “Prostate can-cer is the second leading cause of cancer death in men in Western Europe and the United States. Worldwide, more than 670,000 men are diagnosed with prostate cancer every year, accounting for one in nine of all new cancers in males. It is the second most common cancer in men

after lung cancer. Around 225,000 cases are diagnosed each year in Europe alone and 240,000 in the USA.”[5].

Not all of those diagnoses are of fast-growing can-cers; Cancer Research UK reports that “of all those with prostate cancer, about 94 out of every 100 men (94%) live for at least a year after they are diagnosed. About 85 out of every 100 men (85%) live for at least 5 years. And about 84 out of every 100 men (84%) live for at least 10 years [6]. Using SWE to prevent unnecessary biopsies by distinguishing between benign and malignant lesions would improve the cost benefit ratio of PSA screening. An imaging test that could assess tumor aggressiveness would be helpful in determining treatment strategies. Preliminary work suggests this may be possible with SWE [7].

sHEARwAvE ELAsTOGRApHYThere are two forms of elastography used currently: strain elastography and shearwave. Because strain elas-tography requires the user to apply pressure to the body to deform the tissue in order to make its calculation, problems with reproducibility and issues of consistency across users are common. SWE differs from strain elas-tography in several ways: it is performed more quickly, is largely user-independent, and yields quantitative infor-mation about the tissue being imaged.

SWE creates a shear wave that passes through the tissue being imaged; because the stiffness of this tissue affects the wave’s velocity (the stiffer the tissue, the faster the shearwave travels), this method generates quantita-tive diagnostic information about the tissue elasticity. In the equipment used for this study, the Aixplorer™ from SuperSonic Imagine, the velocity for each pixel is expressed in kilopascals (kPa), and coded by color which is then overlaid on the appropriate B-mode image.

The anatomy of the prostate and its risk map are actu-ally aligned with SWE as a modality for screening: SWE is best suited to imaging the largest of the four zones of

The author :

Richard G. Barr Md, phd, fACR, fsRu

Professor of radiology,

northeastern Ohio Medical University,

Southwoods Imaging,

USA


“...Perhaps — especially in the current anti-screening climate — a modality with the

attributes of SWE.... could even tip the balance back in favor of prostate screening ...”


the prostate, the peripheral zone. This is also the zone where up to 80% of cancers occur, and is thus the first place to look in detecting PC.

swE fOR pROsTATE EvALuATIONOne prospective study undertaken in Ohio, USA, drew its participants from patients scheduled for TRUS-guided biopsy after an initial screening had indicated an elevated PSA level and/or abnormal digital rectal examination result. A total of 53 patients joined the study. At the end, 26 foci of cancer were

detected in 11 of the participants, 5 of whom eventually had total prostatecto-mies. The result of those surgeries were then made available for comparison to the physicians performing the research.

SWE readings were taken on the Aixplorer, measuring the Young modu-lus (a measure of elasticity) in kPa for every nodule and area of suspicion with SWE velocity above the baseline pros-tate tissue. A radiologist then exam-ined those same patients, identifying nodules and any other suspicious areas.

Finally, the urologist—without learn-ing the results of the SWE imaging—performed a sextant biopsy accord-ing to standard clinical procedure. (Any abnormalities on B-mode alone were also examined by biopsy. When SWE-recorded abnormalities were not among the original biopsied tissue, additional samples were obtained after the completion of standard biopsy.)

The receiver operating characteris-tic (ROC) curve was generated using the Young modulus and the patho-logic result (benign/malignant). In the peripheral zone of the prostate, nodules were identified on B-mode and docu-mented and correlated with SWE val-ues; the SWE and biopsy results were compared in each zone.

fINdINGsThe study calculated a value of 37 kPa as the cutoff between benign and malignant tissue on the basis of the receiver operating characteris-tic (ROC) curve. With this cutoff, the authors reported, the SWE had a sen-sitivity of 96.2% (25/26), a specificity of 96.2% (281/292), a PPV of 69.4% (25/36), and a NPV of 99.6% (281/282). This finding is in line with other pre-liminary studies employing shear wave elastography, which have compared it to current modalities and found it to possess sensitivity, specificity, and NPV all greater than 90% [8]. There were significant differences between the stiffness values of prostate cancer and benign etiologies (normal pros-tate tissue, acute inflammation, chronic

FigUre 1. Comparison of ultrasound and SWE. This patient presented with a hypoechoic nodule on ultra-sound (black lesion. with arrow). Shear wave elastography was preformed, and the nodule was found to be of low stiffness (G20 kPa). Note the blue area with a yellow arrow. However, another lesion was found with a high stiffness (75 kPa) and was found on biopsy to be PC with Gleason grade 7. Note the red lesion with a red arrow. (Reproduced with permission from Ultrasound Quarterly March 2012).

n Pathologic Result Minimum kPa

Maximum kPa

Mean kPa SD

242 Benign 9 107 21.2 11.8

21 Atypia 14 38 20.6 5.3

26 Cancer 30 110 58.0 20.7

13 Acute inflammation 9 28 19.5 5.5

16 Chronic inflammation 13 63 27.3 15.5

TaBle 1. Summary of results (Reproduced with permission from Ultrasound Quarterly March 2012).


uLtrASOuND

inflammation and atypia).False positives are a major problem

in prostate screening, of course. With SWE, of the 11 false-positive samples in the study, over half were secondary to calcifications noted on B-mode in benign tissue. This suggests that false positives could be further minimized with the eliminations of calcifica-tions from biopsy—a possibility that deserves additional research.

CONCLusIONWhile this study calls for more research reproducing and expanding on its results, it demonstrates the promise of using SWE for prostate screening. Fur-ther study could determine whether eliminating calcifications from biopsy is appropriate—a change that could reduce the overall number of biopsies and increase the percentage of positive biopsies.

Perhaps especially in the current anti-screening climate, a modality with the attributes of SWE constitutes a more responsible, more discerning form of PC detection, one that could even tip the balance back in favor of prostate screening.

REfERENCEs1. http://www.cancer.gov/cancertopics/

factsheet/detection/PSA.2. http://www.erspc-media.org/erspc-

background/#risks.3. http://www.uspreventiveservicestask-

force.org/Page/Topic/recommenda-tion-summary/prostate-cancer-screen-ing.

4. richard G. Barr, richard Memo, and carl r. Schaub. “Shear Wave Ultrasound Elastography of the Prostate: Initial results.” Ultrasound Quarterly Volume 28.1 (March 2012).

5. http://www.erspc-media.org/erspc-background/.

6. http://www.cancerresearchuk.org/about-cancer/type/prostate-cancer/treatment/statistics-and-outlook-for-prostate-cancer.

7. rSnA 2013 Scientific Program “Quantitative Shear Wave Ultrasound Elastography for Prostate cancer Imaging: correlation to Pathology” JM correas, A Khairoune, A Tissier, O helenon, rG Barr

8. correas J-M, Khairoune A, Tissier A-M, et al. Trans-rectal quantitative shear wave elastography: application to prostate cancerVa feasibility study. Poster presented at the European congress of radiology; March 3Y7, 2011; Vienna, Austria. Abstract c-17480.

FigUre 2. True positive for Gleason 6 carcinoma. This patient presented with a low PSA but firm left side on digital rectal exam. B-mode imaging and color Doppler produced no findings. Shear wave elastography presented this image. Note the posterior high stiffness lesion on the left side. This lesion read at a high stiffness (119 kPa) and was confirmed on biopsy to be a Gleason 6 carcinoma.(Reproduced with permission from Ultrasound Quarterly March 2012).

Anatomy in Diagnostic Imaging, 3rd EditionBy Peter Fleckenstein & Jørgen Tranum-Jensen Pub by Wiley-Blackwell, October 2014, 520 p, €70.40 paperback; €56.99

book review

Now in its third edition, Anatomy in Diagnostic Imaging is an unrivalled atlas of anatomy applied to diagnostic imaging. The book covers the entire human body and employs all the imaging modalities used in clinical practice; x-ray, CT, MR, PET, ultrasound and scintigraphy. An intro-ductory chapter explains succinctly the essentials of the imaging and examination techniques drawing on the latest technical developments.

In view of the great strides that have been made in this area recently, all chapters have been thoroughly revised in this third edi-

tion. The book’s original and didactically convincing presentation has been enhanced with over 250 new images. There are now more than 900 images, all carefully selected in order to be user-friendly and easy-to-read, due to their high quality and the comprehensive anatomical interpretation directly placed alongside every one.

Both for medical students and practising doctors, Anatomy in Diagnostic Imaging, Third edition will serve as the go-to all-round reference collection linking anatomy and modern diagnostic imaging

34 D I E U R O P E JUNE/JULY 2012

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rADIOLOGYMusCuLOsKELETAL


By Drs G-C Lee, V. Khoury, D.R. Steinberg, W. Kim, M. Dalinka & M.E. Steinberg

evaluation of Osteonecrosis by radiologistsManagement of patients with osteonecrosis of the femoral head (ONFH) remains controver-sial and challenging. Because prognosis and treatment are determined by both the stage and the extent of involvement, it is important that an effective method of evaluation be used that includes both of these factors. Skeletal radiologists clearly recognize this and most do use some method to indicate the extent of involvement. However, fewer than one half use a specific classification system and most of these use the Ficat and Arlet classification which indicates only the stage. The evaluation and treatment of patients with ONFH could be improved considerably if both radiologists and orthopaedists routinely used an effective classification which indicates the extent of involvement as well as the stage.

INTROduCTION The evaluation and management of patients with osteo-necrosis of the femoral head (ONFH) remains one of our more controversial and challenging problems. Cur-rently we do not have a completely satisfactory method of treatment, and there is little agreement as to the rela-tive effectiveness of the various forms of management which are available. The prognosis and treatment are determined by both the stage and extent of involvement. It is therefore essential that we use an effective method of evaluation and classification which indicates not only the stage or type of pathology present, but also the size of the necrotic lesion and the extent of joint involvement [1-4]. Failure to do this has made it difficult to compare different methods of management and has led to much of the current confusion. Radiologists and orthopedists are the two medical specialties most concerned with the diagnosis and evaluation of patients with osteonecrosis. We therefore sought to determine how these two groups evaluate patients with this condition.

METHODSInitially, articles describing the treatment of patients

with ONFH published in the orthopedic literature between 1985 and 2011 were reviewed to determine the methods used to indicate the type and extent of

pathology present. Specific classification systems were identified and categorized between those which indi-cated only the stage, and those which indicated both the stage and extent of involvement.

Next, a twelve-part questionnaire designed to deter-mine how radiologists evaluate patients with ONFH was sent to the 888 members of the Society of Skeletal Radiology (SSR).

REsuLTs Literature Review

In 208 studies published in the orthopedic litera-ture between 1985 and 2011, patients were evaluated using specific classification systems which were cited 237 times. Systems which indicated only the stage were cited 139 times (59%), and systems which also indicated the extent of involvement were cited 77 times (32%). During the most recent five-year period, 2006 to 2011, in 56 studies the stage only was indicated 30 times (48%), and both stage and extent of involvement were indicated 27 times (44%) [4,5]. Radiologist Survey One hundred and twenty one musculoskeletal radiologists responded to our questionnaire, each answering all questions. Patients were evaluated using plain radiographs and magnetic resonance imaging (MRI). All respondents agreed that it was clinically important to determine the extent of necrosis and joint involvement, and 115 of them (95%) stated that this should be part of the radi-ologists’ evaluation. However, only 55 respondents (46%) said that in practice they used a specific classification system, and most of these used the Ficat and Arlet classification which does not indi-cate the extent of the necrosis. Of the respondents, 107 (88%) did include a simple visual estimate of lesion size, whereas 41 (34%) used angular measure-ments on X-Ray or MRI, and 31 (26%) made three

The authors :

Gwo-Chin Lee, M.d. 1; v. Khoury, M.d. 2; david R. steinberg, M.d. 1; w. Kim, M.d2 .; Murray dalinka, M.d 2 & Marvin E. steinberg, M.d.1

1. Penn Musculoskeletal center Penn Medicine University city 3737 Market Street, Sixth Floor Philadelphia, Pennsylvania 19104 USA

2. Department of radiology Perelman School of Medicine The University of Pennsylvania Philadelphia, Pennsylvania 19104 USA

contact:

Dr M.E. Steinberg. email : [email protected]

dimensional measurements on MRI. The majority of respondents indicated that they were seldom consulted by the treating physicians about which imaging studies should be obtained [6].

dIsCussIONAdult hips with non-traumatic ON undergo a relatively well defined sequence of events following the ini-tial vascular insult. These pathologic changes form the basis for most clas-sification systems, which give a con-cise description of the type of pathol-ogy present, referred to as the “stage”. However, this provides only a partial description of the status of the hip, as

it is important to indicate the extent or severity of the pathology as well. The prognosis and hence the treatment of hips in both early and later stages of ON are determined to a large extent by the size of the initial infarct and the subse-quent amount of joint pathology [1-4].

For example, Stage II hips with a small area of necrosis do so well follow-ing joint preserving surgery, that many will probably heal spontaneously even without surgical intervention. How-ever, hips with a large area of necrosis, greater than 50%, will often do poorly, and therefore some clinicians feel it best to treat them symptomatically until total hip replacement is needed. Accordingly, determination of lesion size must be

included in an effective classification system. This will also allow us to fol-low improvement or progression and thereby evaluate and compare differ-ent methods of treatment. Ultimately, this will allow us to determine the best method of management for each spe-cific patient with ONFH.

The four part classification of Ficat and Arlet [7] is still the one most fre-quently used by both orthopedic sur-geons and radiologists. [Table 1]. This is understandable since it is well estab-lished, having been in use since 1960, is relatively simple, and is clinically useful. However, it has significant limitations, due primarily to its failure to indicate the size of the infarct or the extent of joint involvement.

To overcome these limitations, sub-sequent classification systems specifi-cally include these measurements. The University of Pennsylvania classifica-tion was first published in 1984 [8,9] [Table 2]. In 1991 it was endorsed by the Association for Research on Bone Cir-culation (ARCO), although it was later modified [10,11]. In 1992 it was also endorsed by the Committee on the Hip of the American Association of Ortho-pedic Surgeons (AAOS).

The literature we reviewed confirmed that during the past twenty-five years the Ficat and Arlet classification was the one cited most often. However the next most frequently cited were the Uni-versity of Pennsylvania and the ARCO classifications, which are quantitative. Although there has been a steady trend towards the use of more comprehen-sive and effective methods of evaluating patients with ONFH, during the most recent five year period, namely 2006 through 2011, approximately one half of the published studies on the treatment of ONFH continued to use non-quanti-tative methods of evaluation [4,5].

Table 1. Ficat And Arlet Four-Stage Radiological Classification of Osteonecrosis of the Femoral Head.

TaBle 2. University of Pennsylvania Classification of Osteonecrosis.


MuSCuLOSkeLetAL rADIOLOGYThe recent survey of skeletal radi-

ologists [6] found that they also clearly recognized the importance of indicat-ing the extent of involvement in hips with ON, and 113 of the 121 respon-dents did use some method to indicate this. Most used simple visual estimates, although many used angular or three-dimensional measurements. However, fewer than one half used a specific clas-sification system and most of those who did used the non-quantitative Ficat and Arlet classification. It is gratifying that the large majority of radiologists do make an attempt to indicate the extent of the necrosis, however both visual estimates and angular measurements are approximations rather than true measurements of the volumetric size of the necrotic lesion or the amount of joint involvement. It is important that the most accurate available methods of measurement be used when possible, and that they be an integral part of a comprehensive classification system rather than being presented as a sepa-rate parameter of evaluation [12].

Some concern has been expressed that the methods originally described for measuring lesion size are too complicated for routine use [3]. However, since the introduction of the University of Penn-sylvania classification approximately thirty years ago, our imaging technology has improved considerably and it is now

much easier to make these measurements. In addition, it has been pointed out that a simple visual estimate of lesion size made on radiographs by an experienced evalu-ator is reasonably accurate and satisfac-tory for clinical purposes, and it can be included as part of a comprehensive clas-sification system [1,3].

suMMARY ANd CONCLusIONsManagement of patients with osteone-crosis of the femoral head remains both challenging and controversial. It is now well recognized that the evaluation and treatment of this condition could be improved if an effective and comprehen-sive classification system were in general use by radiologists and orthopedists. This classification must indicate not only the stage but also the size of the necrotic segment, and the extent of femoral head and joint involvement. During the past several years there has been a trend in this direction, and both groups should be urged to continue this trend. Orthope-dic surgeons should also communicate routinely with their radiology colleagues when determining which imaging stud-ies to obtain and how to interpret them. This will provide us radiologists with more accurate information regarding the effectiveness of various methods of management, and ultimately will enable us to improve the treatment of patients with osteonecrosis of the femoral head.

REfERENCEs1. Steinberg ME, Bands rE, Parry S, hoffman E,

chan T, hartman KM. Does lesion size affect the outcome in avascular necrosis? clin Orthop. 1999; 367: 262.

2. Theodorou DJ, Malizos Kn, Beris AE, Theodorou SF, Soucacos Pn. Multi modal imaging quantita-tion of the lesion size in osteonecrosis of the femoral head. clin Orthop. 2001; 386: 54.

3. cherian SF, laorr A, Saleh KJ et al. Quantifying the extent of femoral head involvement in osteonecro-sis. J bone Joint Surg 2003; 85-A: 309 .

4. lee G-c, Steinberg ME. Are we evaluating osteo-necrosis adequately? International Orthopaedics (SIcOT) 2012; 36: 2433.

5. Mont MA, et al. Systematic analysis of classifi-cation systems for osteonecrosis of the femoral head. J Bone Joint Surg. 2006. 88-A, Supp 3: 16.

6. lee G-c, Khoury V, Steinberg D, Kim W, Dalinka M, Steinberg M. how do radiologists evaluate osteonecrosis? Skeletal radiology. 43: p. 607-614. 2014.

7. Ficat rP, Arlet J. necrosis of the Femoral head. In: hungerford DS Ed. Ischemia and necrosis of Bone. Williams & Wilkins. Baltimore, MD. p. 53-74. 1980.

8. Steinberg ME, hayken GD, Steinberg Dr. A new method for evaluation and staging of avascular necrosis of the femoral head. In: Arlet J, Ficat rP, hungerford DS (Eds). Bone circulation. Williams & Wilkins. Baltimore, MD. p. 398-403. 1984.

9. Steinberg ME, hayken GD, Steinberg Dr. A quan-titative system for staging avascular necrosis. J Bone Joint Surg (Br) 77: p. 34-41. 1995.

10. Gardeniers JWM. ArcO committee on Terminology and Staging. A new proposition of terminology and an international classification of osteonecrosis. ArcO newsletter 3: p. 153-9. 1991.

11. Gardeniers JWM, ArcO committee on Terminology and Staging. report on the committee Meeting at Santiago de compostella. ArcO newsletter 5: p. 79-82. 1993.

12. hernigou P, lambotte Sc. Volumetric analysis of osteonecrosis of the femur: anatomical correla-tion using MrI. J Bone Joint Surg (Br). 83-B. p. 672-5. 2001.

Whole-body MRI ScreeningEdited by Ralf Puls & Norbert Hosten Published by Springer 2014 374 pp € 83.29

book review

The advent of dedicated whole-body MRI scanners has made it possible to image the human body from head to toe with excellent spatial resolution and with the sensitivity and specificity of conventional MR systems. A comprehensive screening examination by MRI relies on fast image acquisition, and this is now feasible owing to several very recent developments, includ-ing multichannel techniques, new surface coil systems, and automatic table movement.

The daily analysis of whole-body MRI datasets uncovers many incidental findings, which are discussed by an interdisciplin-ary advisory board of physicians from all

specialties. This book provides a systematic overview of these incidental findings with the aid of approximately 240 high-quality images. The radiologists involved in the project have written chapters on each organ system, presenting a structured compilation of the most common findings, their mor-phologic appearances on whole-body MRI, and guidance on their clinical management. Chapters on technical and ethical issues are also included.

It is hoped that this book will assist other diagnosticians in deciding how to handle the most common incidental findings encountered when performing whole-body MRI.

High performance ultrasound Imaging at value pricing

The new Z.One PRO u l t r a s o u n d system from Zonare has been designed to provide an eco-nomical, high p e r f o r m a n c e imaging sys-tem for a wide variety of appli-cations. The new system is

based on the company’s proprietary ZONE Sonograph Technology (ZST) originally introduced a decade ago. Unlike conventional beamformer, line-by-line imaging, ZST uses soft-ware-driven, large zone acquisitions, providing an entirely new and dif-ferent approach to ultrasound data acquisition and image formation. The result is more detail with con-sistent, high resolution and uniform imaging at depth from the smallest to the largest of patients through-out the field of view. As an afford-able high performance system, the Z.One PRO offers image quality in a durable, small footprint unit. The one-touch easy image optimization and customizable capabilities are part of an intuitive user interface, supporting a seamless workflow. The high speed boot-up, optional battery pack and wireless features allow for easy transport when needed. ZOnArE MEDIcAl SYSTEMS, IncMOUnTAIn VIEW, cA, USA.www.zonare.com

New Ceiling-Mounted Tube Option for Carestream Imaging system

A ceiling-mounted tube option has been introduced by Carestream for its high-end DR system, the DRX-Ascend to provide versatile positioning for a variety of imag-ing exams. The system also offers a floor-mounted tube stand, wall stand and a choice of an elevat-ing float-top table or non-elevating table. “The DRX-Ascend delivers cost-effective, fully featured imag-ing that allows hospitals, imaging

centres, orthopedic practices and urgent care clinics to select a con-figuration that satisfies their imag-ing workflow and budget,” said Heidi McIntosh, Global Market-ing Manager for X-ray Solutions. “DRX-Ascend users and other healthcare providers are interested in a ceiling-mounted tube because it can deliver flexible patient posi-tioning that helps radiographers perform imaging exams in less time, which can lead to greater productivity.”

The DRX-Ascend System can be

configured with DRX-1 and DRX-1C detectors. Both detectors fit into the standard Bucky used in X-ray wall stands and tables. In addition, Carestream’s small-format 25 x 30 cm detector, the DRX 2530C, can be used for orthopedic and tabletop exams. Customers can also opt to install a fixed 43 x 43 cm detector for the wall stand. Carestream’s multi-color touch panel screen mounted at the tube stand gives radiogra-phers remote generator control, displays image previews and allows review of previous images for the current patient. The DRX-Ascend system offers several detector hold-ers to help radiographers perform cross-table lateral exams as well as other specialty views. Facilities can use a single DRX detector with the system or opt for two or more detectors to maximise productivity and efficiency. The DRX-Ascend

also offers users the benefits of Carestream’s advanced image pro-cessing software and a consistent user interface across Carestream’s computed radiography (CR) and digital radiography (DR) systems facilitates a smooth transition from CR to DR technology.

cArESTrEAM rOchESTEr, nY, USA www.carestream.com

High performance CT with improved iterative recon-struction and high work rate

The new Revolution EVO from GE Healthcare has been designed to support the widest variety of patients and applications, from complex trauma or cardiac cases, to large patient backlogs in busy emergency departments that strain workflows and resources.

With Revolution EVO, high res-olution is guaranteed and low dose is routine. The new Clarity Imag-ing System provides up to 100% better spatial resolution compared to previous GE CT scanners. The innovative ASiR-V iterative recon-struction method lowers dose up to 82% for patients of all ages –- while still enabling work processes to be maintained. With more intelligence and automation from patient prep-aration through post processing, there is a 40% increase in workflow efficiency.

The entire imaging chain has been re-designed centred on the new Clarity detector inherited from the breakthrough technology introduced on Revolution CT.

At the beginning of the imaging chain, the Performix 40 Plus tube delivers exceptional performance. Its stable dual focal spot improves precision and its 0.35-second rou-tine rotation speed enables faster scan times. The iterative recon-struction algorithm comes stan-dard and focuses primarily on more advanced noise- and object -mod-eling with added physics modeling to help reduce noise, improve low-contrast detectability and reduce artifacts. Combining the speed of ASiR with added capabilities from Veo full model-based itera-

uPDAteTECHNOLOGY



teChNOLOGY uPDAte

tive reconstruction, the novel ASiR-V iterative reconstruction algorithm brings low dose and improved quality to routine imaging, with up to 100% better spatial resolution. ASiR-V has the capability to improve spatial reso-lution compared to FBP by allowing the reconstruction of higher-resolu-tion images with no increase in image noise. ASiR-V improves the detect-ability of low-contrast objects by up to 135% when compared to corre-sponding FBP reconstructions at the same dose. Depending upon the scan technique and reconstruction param-eters, ASiR-V can significantly reduce electronic image noise.

Designed to help improve produc-tivity by streamlining workflow and access to information, Smart Flow technologies enable fast, hands-free patient positioning, exam prescrip-tion from the patient’s side, integrated injections, up to 55 IPS real-time reconstruction during the scan and access to advanced applications right on the console. With the IQ Enhance pitch booster, it is possible to scan a chest as fast as two seconds with 175 mm per second acquisition speed to help shorten patient breath-holds while maintaining image quality.

Dual-energy imaging allows easy configuration of back-to-back axial or helical scans of the same anatomy at two different X-ray energies (kVs). The dual-energy data can be quickly post-processed right on the console or on the Advantage Workstation with easy image registration and one-click ROI ratio for simple analysis.

GE hEAlThcArE AMErShAM , UK www3gehalthcare.com

Mindray Releases New Generation ultrasound system Good image quality is at the heart of clinically relevant ultra-

sound. The new DC-70 system from Mindray pro-vides such high image quality and its unique touch ges-

tures enables extremely easy and fast examinations. High image clarity is the result of high-end inherent technologies. The quality exams and optimized user expe-rience are unprecedented and have already established DC-70 as a true workhorse in cardiac practices.

MInDrAY ShEnZhEn , chInAwww.mindray.com

The new Prime edition of Siemens’ Acuson SC2000 ultrasound system is a premium cardiovascular imaging sys-tem which offers live full-volume color Doppler imaging of heart valve anat-omy and blood-flow using a new true volume transesophageal echo (TEE) probe. With the technology, physicians can obtain a more anatomically authen-tic view of the heart and dynamic blood flow in one view during interventional valve procedures, even in patients with ECG abnormalities. This helps to make faster and more accurate critical deci-sions. During 3D TEE imaging, the physician guides a flexible probe into the esophagus to acquire close-range, detailed pictures of the heart to assess valve function. When a dysfunctional valve regurgitates blood back into the heart chambers or does not open prop-erly to let through sufficient blood, a valve procedure may be necessary to repair or replace the valve with an arti-ficial one. TEE is used to guide place-ment of devices such as mitraclips and artificial valves during cardiac interven-tions to correct valve dysfunction. Cur-rent methods of imaging with 3D TEE require stitching – the fusion of mul-tiple heartbeats – to form a complete image of heart function and blood flow. This gated acquisition eliminates almost all patients with any ECG abnormali-ties and often results in image artifacts, which may skew results. The new Z6Ms true volume TEE probe is the first Sie-mens transducer to use true volume 3D TEE with 90° x 90° real-time acquisition and volume color Doppler, enabling full

3D images of the heart, in every heart-beat without stitching. By eliminating the need for multiple beats to form an image and adding volume color Dop-pler capabilities, the Z6Ms true volume TEE probe allows the surgeon to visu-alize and assess blood flow in real-time during a procedure to make sure that the repaired or replaced valve is work-ing properly, potentially reducing the

need for a secondary intervention to correct any remaining regurgitation. Also introduced for the first time on the Acuson SC2000 Prime is the eSie Valves advanced analysis package, an automated software to measure heart valves during cardiac procedures. While standard quantification software takes several minutes to provide measure-ments of heart valves, eSie Valves pro-vides automated measurements for the aortic and mitral valves in seconds. SIEMEnS ErlAnGEn, GErMAnY www.siemens.com

Ultrasound system visualizes entire blood flow during heart valve procedures


teChNOLOGY uPDAte

Core specimen radiography systemThe Faxitron CoreVision increases the standard of care for patients by eliminating delays waiting for veri-fication of core samples. With one touch of the button a successful biopsy procedure can be confirmed and images can be instantly sent to multiple destinations without the need to interrupt mammography workflow. Thus the system — which

requires no additional X-ray shield-ing required , nor does it need any specialized X-ray knowledge to operate — allows instant confirma-tion of a successful biopsy proce-dure. A one button operation uses Automatic Exposure Control (AEC) for optimal image quality. The AEC optimizes the detection of micro-calcifications. DICOM compliant software is provided with efficient access to modality work list and PACS Store & Print options. The system has the ability to send mul-tiple annotated images to PACS at a touch of a button.

The small footprint mini-mizes intrusion in point of care environments FAXITrOn BIOPTIcSTUcSOn, ArIZOnA USAwww.faxitron.com

premium ultrasound from samsung Samsung Medison, has announced the launch of ‘RS80A’, a premium ultrasound system designed Sam-sung Electronics’ high-tech IT and imaging function. The RS80A model

Esaote has just launched two new ultra-sound sys-tems. MyLab-Gamma, a best in class, highly-p o r t a b l e “green” ultra-sound system is based on the company’s

productivity-oriented operating platform. The super-light, feature packed portable system enables ultrasound to be used in any environment - at a moment’s notice.Highly portable and battery-operated, the MyLabGamma offers fast boot times and a rapid resume from standby mode that means the system is ready to use within seconds. Integration of wireless connec-tivity, a class -leading feature for a system of its size and price, facilitates easy, one-click networking with other systems and local networks as required.

The system has been engineered to meet the rigorous demands of the sonog-rapher’s working environment, particu-larly those using ultrasound systems for many hours a day. Esaote’s simple-to-use, eTouch screen-based interface guides the operator through set-up and image cap-ture, enabling faster workflow. A high res-olution widescreen monitor can be rotated through +90/-90 degrees to increase comfort, and allows an examination to be shared with the patient or colleague. An almost silent cooling system improves the quality of the working environment and reduces operator disturbance.

Two transducer connectors allow two probes to be connected to the system. Switching the probe selection during an examination is simple, further increas-ing efficiency and workflow. An optional multi-connector is available, allowing up to four transducers to be connected and selected via the intuitive software inter-face. The system can be recovered in the shortest time possible by simply connect-ing it to the network.

For cardiovascular applications, MyLabGamma is equipped with compre-hensive cardiac and vascular ultrasound packages with advanced tools (QIMT, XStrain, TEE Probe, Post Processing,

Wireless connectivity. Customizable measurements and flexible configuration make MyLabGamma the complete solu-tion for cardiovascular scanning. MyLab-Gamma’s is also well-suited for other applications, including general imaging, women’s health, anaesthesiology, emer-gency and critical care.

The second new system just intro-duced by Esaote is MyLabSix, a fast, accu-rate and highly flexible enhanced ultra-sound system. Configured for an extensive range of applications, MyLabSix delivers a premium quality, yet affordable solution for shared ultrasound services across any busy clinical setting. MyLabSix is a complete cart-based system that can be used across a broad range of applications, from cardiovascular to general imaging and women’s health. It comes with highly advanced CV features, including Compass M-Mode, Tissue Velocity Mapping, Stress Echo, XStrain and QIMT - combining to ensure complete confidence in any diag-nosis. MyLabSix has been ergonomically conceived with the comfort of the user as a key priority. The rotating keyboard can easily be made higher or lower according to user prefer-ence. Similarly, an articu-lated arm for the screen increases com-fort, as well as enabling the sharing of results with a patient or colleague quickly and easily. Ergonomic features include appleprobes – transducers that are specially shaped to keep the hand and wrist in their natu-ral grip, helping to prevent tension in the hand from building up.

In keeping with its aim of maximising workflow and performance for a multitude of purposes and individual users, MyLab-Six has a simplified control panel including a high resolution touchscreen display. ESAOTE GEnOA, ITAlY www.esaote.com

Two new ultrasound systems from Esaote

MyLab Gamma is suitable for cardiovascular and many other applications..

MyLabSix has been ergo-nomically designed with the uiesr’s comfort in mind


teChNOLOGY uPDAte

offers greater diagnostic confidence and accuracy through the latest innovations in imaging and usabil-ity. The new system provides superb image quality and uses the standard-ized Breast Imaging-Reporting and Data System (BI-RADS) score for analysis and classification of tar-geted regions. S-Detect results in more effective diagnosis by reduc-ing unnecessary biopsies and saving time through simplified procedures. The S-Vue Transducer gives broader bandwidth and higher sensitivity to enable exquisite image quality at depth. (Samsung Medison has expanded its probe line-up to sup-port diagnosis over various areas such as thorax, abdomen, carotid and thyroid) Equipped with a 3D

Navigator and fewer keys on the control panel the system’s intui-tive design allows for ease of use and greater examination through-put. Users are given more operat-ing space as keyboard is embedded into the touch screen. The device can remember each user’s custom-ized position and height of the con-trol panel every time they run the system.“Samsung is finally putting its feet into the radiology market thanks to the launch of RS80A. We are confident that this premium sys-tem will provide users a new level of diagnostic quality and convenience,” said Soo-in Cho, CEO of Samsung

Medison. “Samsung will continue to put its best efforts towards devel-oping medical devices that deliver true-to-life images and features that provide faster diagnosis.”

SAMSUnG MEDISOnSEOUl, KOrEAwww.samsungmedison.com

Kubtec has just introduced its ground-breaking tomosynthesis technology for digital specimen radiography of excised breast tis-sue. The patent-pending technology allows for multi-planar x-ray imag-ing for thorough margin analysis of excised breast tissue and is the core foundation on which Kubtec’s new system, MOZART, is based.

By incorporating the TomoV-iew technology, MOZART offers a comprehensive solution for imaging excised breast tissue while increas-ing accuracy, saving time, and reduc-ing re-excision rates in the operat-ing room. The new system is the only specimen radiography system to offer both 2D and 3D imaging for comprehensive analysis of excised breast tissue.

Using the power of tomosynthesis , the new technology offers an unprecedented depth of view for 3D margin confirmation— including fields of view that can not be detected with conventional 2D imaging. The need for continually turning and repositioning of the specimen container at varying angles for margin confirmation is eliminated. . The acquisition of 3D data set takes about the same time as it takes to acquire 2D images. With superior 2D/3D imaging capabilities and rapid image acquisition the new system is the most powerful X-ray imaging tool for margin analysis.

In addition to the 3D imaging of excised breast tissue the new sys-tem gives the ability to examine specimens at varying slice depths “The TomoView technology in MOZART allows for comprehensive intraopera-tive margin analysis in a single step, without turning and repositioning the specimen container multiple times to obtain additional views,” said Kubtec’s Director of Research and Development, Chester Lowe, PhD, FACR. “Using TomoView’s multi-dimensional imaging technology with-out requiring repositioning of specimens, MOZART will provide a faster, more efficient specimen radiography solution for radiology, surgery, and pathology departments.”

“The system offers radiologists, surgeons and pathologists an elegant synthesis of digital technologies for the most advanced specimen imaging available.”

KUBTEc MIlFOrD cT USA http://kubtec.com

Tomosynthesis Technology for Breast Cancer Specimen Radiography

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Imagine reviewing any image on a single display. One that brings the best image quality

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The only display explicitly designed for both PACS and breast imaging. Unique in its

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