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Diagnosis • Technology • Therapy • Prevention
DI EUROPE
AUG/SEPT 2017
Hybrid Imaging
F-NaF imaging of
18
vulnerable plaques and
EUROPE
myocardial scar tissue
using hybrid PET/CT and
PET/MR
ECR Symposium
Reports
Siemens Breast Care
Day: Dense Breasts
Bracco: CEUS
Workflow
Dichotomization and
the Radiologist’s
Workflow Environment
Radiation Exposure in
Prostatic Embolization
Point-of-Care
Cardiovascular
Ultrasound
MRI: Putting Patient
Imaging
Comfort First
Imaging News
Industry News
Technology Updates
DIEUROPE.com 
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DI EUROPE
BY Alan barclay, ph.d.
VOLUME 33, NUMBER 4
EDITORIAL ADVISORY BOARD
FROM THE EDITOR
Andreas Adam, London Richard P. Baum, Bad Berka
Frits H. Barneveld Binkhuysen,
Filipe Caseiro Alves, Coimbra
Maksim Cela, Tirana
Elias Brountzos, Athens Amersfoort
Carlo Catalano, Rome
Patrick Cozzone, Marseille
GBCAs — the Precautionary Principle
Katarzyna Gruszczynska,
Andrea Klauser, Innsbruck
Gabriele Krombach, Giessen
Anne Grethe Jurik, Arhus Katowice
Gabriel Krestin, Rotterdam
Christiane Kuhl, Bonn
behind the differences in attitude
between Europe and U.S. ?
Philippe Lefere, Roeselare Heinz U. Lemke, Kuessaberg
Thoralf Niendorf, Berlin Anne Paterson, Belfast
Anders Persson, Linköping Hans Ringertz,Stockholm
Gustav von Schulthess, Zurich Valentin E.Sinitsyn,Moscow
Patrick Veit-Haibach, Lucerne Thomas J.Vogl,Frankfurt The bureaucratic wheels of the European the brain and have come up so far with the
Medicine Agency grind inexorably on. A a “watch-and wait” policy. The FDA pointed
EDITORIAL STAFF review of gadolinium contrast agents was out that since to date there was no direct
Editor Alan Barclay, Ph.D.
E-mail: a.barclay@dieurope.com
first initiated more than a year ago at the evidence that gadolinium retention in the
Tel. +32 479 370 364 request of the European Commission in brain from any of the GBCAs is harmful,
US Consulting Editor Greg Freiherr
view of the increasing number of reports they considered that restricting GBCA use
E-mail: greg.freiherr@gmail.com
Publisher David Lansdowne that deposits of gadolinium were being iden- was not warranted at this time. The FDA
E-mail: d.lansdowne@dieurope.com tified in certain areas of the brains of patients will continue to assess the safety of GBCAs.
Associate Publisher Bob Warren
E-mail: b.warren@dieurope.com who had previously received Gadolinium- Many observers of the European regula-
Based Contrast agents (GBCAs) in MRI tory processes explain the difference in
examinations. attitude to GBCAs on either side of the
Following a clearly described procedure the Atlantic as being due to the application of
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Telephone: +852 2891 7117 Fax: +82 2 2273 4866
Fax: +852 2893 2101 Contact: Young J. Baek European law. to withdraw the marketing authorization
Contact: Adonis Mak To summarize, the result is that the market- for linear GBCAs, they share the same view
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DIAGNOSTIC IMAGING EUROPE is published eight times a year by DI Europe Ltd will be suspended in Europe, whereas the the brain. And there at least, if the steadily
Printed by Manson, St-Albans, UK. Annual subscriptions are available for €60
within Europe where it is also sent free of charge to physicians and radiology more stable macrocylic chelates will con- increasing number of papers published in
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of €110 for air mail. Single copy price is €10. Editorial Advisory Board members
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tinue to be authorized. the field is anything to go by, then the appeal
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Throughout the review process, the regula- is being heeded. It will be on the results of
Copyright © 2017 DI Europe Ltd. All rights reserved. Reproduction in any form
is forbidden without express permission of copyright owner. tory bodies were at pains to point out that such research that any future changes in the
although free gadolinium ions are known regulation of GBCAS will be based.
to be toxic in themselves, no evidence of In the meantime, one of the most danger-
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of the gadolinium ion from its chelate. which are still on the market and which so
far have not been shown to be associated
Meanwhile on the other side of the Atlantic, with gadolinium deposits in the brain, with
the redoubtable FDA have also been look- the great risk that the diagnostic utility of the
ing at the issue of gadolinium deposition in MRI exam may be seriously compromised.
DIEUROPE.com
AUG/SEPT 2017 D I E U R O P E 3
®
AUG/SEPT 2017 EUROPE
Cardiovascular Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24-39
According to World Health Organization statistics, Cardiovascular disease (CVD)
causes more than half of all deaths across the European Region. CVD causes 46
times the number of deaths and 11 times the disease burden caused by AIDS,
tuberculosis and malaria combined in Europe. 80% of premature heart disease
Each year cardiovascular disease (CVD) causes 3.9 million and stroke is preventable.
deaths in Europe and over 1.8 million deaths in the European Imaging has a vital role to play in prevention, diagnosis and monitoring of therapy
Union. CVD is the main cause of death in men in all but 12
countries of Europe and is the main cause of death in women
in all but two countries.
REPORTS
Feature articles
ECR Symposium Reports
10-13|Global Insights for CEUS in
radiology: a Bracco spon-
sored symposium on contrast
enhanced ultrasound in the
fields of liver, macrovascular
and breast imaging
CEUS in liver imaging: Cardiac Imaging News Page The future of breast
40-43| Breast Care Day. A day-long the new ACR LI-RADS
Page 25 cancer screening —
symposium sponsored by classification where can it help the
Siemens Healthineers and dense breast ?
devoted solely to recent devel- Page 10
opments in breast imaging. Page 40
“Dealing with radiology’s prob-
lem child - dense breasts” imaging news
MRI reveals striking brain differences in people with genetic autism . 5
Cardiovascular Imaging Experimental PET tracer detects small blood clots . . . . . . . . . . . . . . 5
Optimal method for diagnosis of head injuries in children and
26-28| 18F-NaF imaging of vulnerable 6
minimization of use of CT scans .. . . . . . . . . . . . . . . . . . . . . . . . . . .
plaques and myocardial scar
tissue using hybrid PET/CT UK must do more to future-proof its MRI capacity, say imaging experts .. 9
and PET/MRI
First Alzheimer’s trial with focused ultrasound . . . . . . . . . . . . . . . . 9
30-32| Low-dose coronary computed
tomography angiography with RADIOLOGY WORK FLOW
prospective ECG triggering to
predict cardiac events in the Workflow Dichotomization and the Radiologist’s Workflow Environment. . . 14-16
long term.
RADIATION DOSE EXPOSURE
34-35| The role of cardiovascular
imaging modalities in the Radiation Exposure in Prostatic Embolization. . . . . . . . . . . . . . . 18-19
evaluation of IgG4-related car-
diovascular disease. POINT of CARE ULTRASOUND
POC US in regional anaesthesia and intesive care. . . . . . . . . . 44-45
36-38| Early Echocardiography has
a Low Yield in Patients with
Transient Ischemic Attack.
MRI
Putting Patient Comfort First: a New Perspective on
20-22|Industry News Improving Imaging Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . 46-47
48-50|Technology Update
Coming in the next issue:
Visit us at
DI EUROPE Breast Imaging
DIEUROPE.com
AUG/SEPT 2017 D I E U R O P E 4
IMA GI N G NEWS
MRI reveals striking brain differences in people with genetic autism
In the first major study of its kind, some striking differences in the brain
researchers using MRI have identified structures of deletion and duplication
structural abnormalities in the brains carriers compared with non-carriers.
of people with one of the most com- For instance, the corpus callosum, the
mon genetic causes of autism, accord- fiber bundle that connects the left and
ing to a new study (Owen JP et al Brain right sides of the brain, was abnor-
MR Imaging Findings and Associated mally shaped and thicker in the dele-
Outcomes in Carriers of the Reciprocal tion carriers but thinner in the dupli-
Copy Number Variation at 16p11.2. cation carriers, compared to the con-
Radiology. 2017 Aug :162934. doi: trol group and familial non-carriers.
10.1148/radiol.2017162934) Other stark differences were apparent.
The abnormalities visible on brain The deletion carriers displayed fea-
images corresponded to cognitive and tures of brain overgrowth, including
behavioral impairments in the study the extension of the cerebellum toward
group, suggesting a future role for the spinal cord. The duplication car-
imaging in identifying people with riers showed characteristics of brain
autism who are in most urgent need of undergrowth, such as decreased white
intervention. matter volume and larger ventricles.
Autism spectrum disorders are When the researchers compared
a group of developmental problem; cognitive assessments to imaging find-
symptoms typically appear early in life Example images for a control participant, a deletion ings, they found that the presence of
and frequently include communica- carrier, and a duplication carrier. In the sagittal image any imaging feature associated with the
tion problems and repetitive behav- of the deletion carrier, the thick corpus callosum, deletion carriers — such as a thicker
iors. Many people with autism have dens and craniocervical abnormality. Image Credits: corpus callosum — indicated worse
Radiological Society of North America
abnormalities at a specific site on the daily living, communication and social
16th chromosome known as 16p11.2. skills, compared to deletion carriers
Deletion or duplication of a small piece without any radiological abnormalities.
of chromosome at this site is one of the most common For the duplication carriers, the presence of decreased
genetic causes of autism spectrum disorder. white matter, corpus callosal volume and increased ven-
“People with deletions tend to have brain overgrowth, tricle size was associated with decreased full-scale and
developmental delays and a higher risk of obesity,” said verbal IQ scores, compared to duplication carriers without
study author Dr Julia P. Owen. “Those with duplications those findings.
are born with smaller brains and tend to have lower body Senior author Dr Elliott Sherr commented, “Often stud-
weight and developmental delays.” The researchers at UCSF ies like this focus on high-functioning individuals, but this
and four other sites performed structural MRI exams on 79 was an ‘all-comers’ group,” he said. “We didn’t do math-
deletion carriers, ranging in age from 1 to 48, and 79 dupli- ematical algorithms but rather used the trained eyes of
cation carriers, ages 1 to 63, along with 64 unaffected fam- neuroradiologists to evaluate the scans of a full range of
ily members and 109 participants in a control group. The individuals. When you look at a broad range of people like
participants completed a battery of cognitive and behav- this, from developmentally normal to more significantly
ioral tests, and neuroradiologists reviewed the brain images challenged, you’re better able to find these correlations.”
for development-related abnormalities. The results showed https://tinyurl.com/Owen-et-al-paper
Experimental PET tracer detects 58: 1094). Current imaging modalities rely on structural
characteristics, such as vascular flow impairment, and do not
small blood clots address the critical molecular components.
Blood clots in veins and arteries can lead to heart attack, “Currently available diagnostic techniques of thrombus
stroke, and pulmonary embolism, which are major causes of imaging rely on different modalities depending on the vas-
mortality. In the featured article of The Journal of Nuclear cular territory,” explains Dr Andrew W. Stephens, of Piramal
Medicine’s July 2017 issue, German researchers show that Imaging GmbH, Berlin, Germany. “A single imaging modality
targeting GPIIb/IIIa receptors, the key receptor involved in that could visualize thrombi from various sources in different
platelet clumping, with a fluorine-18 (18F) labeled ligand is anatomic regions would be very valuable.” For this preclinical
a promising approach for diagnostic imaging (Lohrke J et al study researchers successfully developed the novel small mol-
18
F-GP1, a Novel PET Tracer Designed for High-Sensitivity, ecule tracer 18F-GP1 for positron emission tomography (PET)
Low-Background Detection of Thrombi. J Nucl Med. 2017; imaging that binds with high affinity to GPIIb/IIIa receptors.
AUG/SEPT 2017 D I E U R O P E 5
IMAGING NEWS
help inform the use of the clinical decision rules for head
injuries, which in turn could minimize CT scans, according to
Lead investigator, Dr F Babl. who said “The aim of this study
was to determine which children need CT scans to detect
brain injury,” said Dr Babl.”Most head injuries are mild and
don’t require neurosurgical management, however, a small
proportion of patients might present as having mild injuries,
but have clinically significant intracranial injuries,” he said.
“This can be a vexed issue because physicians need to bal-
ance the importance of diagnosing an injury with reducing
Strong signals are detected at the sites where inserted catheters had roughened surfaces. radiation exposure as much as possible.”
Almost no other background signal is visible. Only accumulation in the gallbladder becomes In these cases, clinicians can turn to clinical decision rules,
visible at the bottom. Image coutesy of Piramal Imaging GmbH, Berlin Germany which have been developed to identify children at high risk
of intracranial injuries, aiming to assist clinicians to minimize
F-GP1 showed a strong accumulation at the site of throm-
18
CT scans while still identifying all relevant injuries.
bus formation, and its binding ability was not affected by anti- In the prospective observational study, run across 10
coagulants such as aspirin and heparin. The tracer showed Australian and New Zealand tertiary hospitals and involving
rapid blood clearance, and PET imaging in a Cynomolgus 20,137 children with head injuries under the age of 18 years,
monkey model demonstrated the detection of small venous the research team compared three clinical decision rules
and arterial clots, endothelial damage and emboli in the brain. • The Pediatric Emergency Care Applied Research Network
Due to the favorable pre-clinical results, a first-in-human
study of 18F-GP1 is currently underway. Early results from an
interim analysis confirm the preclinical data and were pre-
sented at the 2017 Annual Meeting of the Society of Nuclear
Medicine and Molecular Imaging (SNMMI) in June.
“Although the current studies are preliminary, 18F-GP1 may
provide not only more accurate anatomic localization, but also
information of the risk of the clot growth or embolization,”
Stephens points out. “This may lead to changes in clinical
intervention to the individual patient.” Addressing the use
of anticoagulants to treat blood clots, he notes, “These drugs
can cause significant and life-threatening bleeding. There is
a critical need to balance the risk of bleeding against the risk
of clotting in each patient. 18F-GP1 may in the future assist in
this important decision.”
.https://tinyurl.com/Lohrke-et-al-paper (PECARN, USA) ;
• The Canadian Assessment of Tomography for Childhood
Head Injury (CATCH) rule
Optimal method for diagnosis of •The Children’s Head Injury Algorithm for the Prediction
of Important Clinical Events (CHALICE, UK).
head injuries in children and The goal was to determine which of these three decision
minimization of use of CT scans rules provided the best option when it came to identifying
children at very low risk of a traumatic brain injury.
Researchers hope to reduce unnecessary CT scans and The researchers found that all three rules were good
radiation exposure in children with head injuries, following options, but only one, the PECARN from the US, did not
the results from a large-scale, multicenter validation study miss a single patient requiring neurosurgery.
to assess the diagnostic accuracy of three clinical decision Internationally, the findings should provide a useful start-
rules used by emergency doctors (Babl FE et al. Accuracy of ing point for individual clinicians as well as hospitals or
PECARN, CATCH, and CHALICE head injury decision rules in regional bodies contemplating the introduction or modifica-
children: a prospective cohort study. Lancet. 2017 17; 389: 2393). tion of one of the clinical decision rules. Dr Babl pointed
Head injuries are one of the most common reasons chil- out : “However, it will be important to relate the findings to a
dren are taken to emergency departments. To rule out a seri- number of other factors before implementation, such as the
ous brain injury, a percentage of these children require a CT baseline CT use, the effect of the rules on the projected CT
scan and while this is obvious for serious head injuries, it’s rate, the baseline clinician diagnostic accuracy and experience,
more challenging to determine whether CT scans are neces- parental expectations, the medico-legal climate and economic
sary for children with milder injuries. considerations.”
The results from the recent Australasian clinical trial will https://tinyurl.com/Babl-et-al-paper
6 D I E U R O P E AUG/SEPT 2017
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The Annual Scientific
Meeting of the ESMRMB
19. – 21.
19 21 10.
10 2017 Barcelona / ES
S
A platform for physicians, engineers, radiograph
radiographers
hers /
research
technologists and scientists interested in MR res
search
and clinical practice.
HIGHLIGHTS WILL INCLUDE
∙ Sir Peter Mansfield Lecture by A. Heerschap, Nijmegen / NL
∙ Teaching Sessions on basic & advanced level
∙ Plenary Sessions by renowned speakers from Europe and the USA:
∙ Microstructure - from bench to bedside
∙ Big data from cohort and clinical studies
∙ MRI for neuroscience
COME AND JOIN OUR DISCUSSIONS
∙ Hot Topic Debate:
“Quantitative relaxation time measurement: boom or bust?”
∙ Roundtable Discussion:
“What is the future of contrast agents in MRI?”
Dedicated networking opportunities:
the opportunity to meet with experts, friends
and colleagues.
www.esmrmb.org
IMAGING NEWS
UK must do more to future-proof its MRI capacity, say imaging experts
Imaging experts in the UK are urging hospitals to for- • Only half of the organisations surveyed have plans to
mulate clear plans to replace outdated equipment, after replace scanners and there are no succession plans in place
a survey revealed that half of healthcare organisations for nearly 40% of MRI systems that are over seven years old
do not have any renewal plans, and more than a third of • While clinicians rated the vast majority of their MRI
older magnetic resonance imaging (MRI) scanners are scanners as state-of-the-art or adequate, 8% of systems were
not scheduled for replacement. While many hospitals are deemed “obsolete” The UK’s MRI capacity is stretched com-
operating newer equipment, 58% of MRI systems used pared to other countries. The UK has 6.1 MRI systems
by those surveyed are at least five per million people, fewer than coun-
years old, meaning they may not be tries including Estonia and Slovenia.
able to conduct state-of-the-art imag- By comparison, the US has 38.1 and
ing, such as that needed for certain Germany has 30.5 scanners per million.
types of heart and prostate cancer As well as assessing the state of their
scanning. Nearly a third (29%) of equipment, clinicians were also asked to
systems are over ten years old. The estimate future MRI workload. On aver-
Clinical Imaging Board (CIB) – a age, departments expect to see demand
collaboration between The Royal rise by 13% this year. In addition to
College of Radiologists (RCR), the upgrades and the replacement of old
Society and College of Radiographers systems, the radiology teams surveyed
(SCoR) and the Institute of Physics said they will need approximately 50
and Engineering in Medicine (IPEM) – surveyed NHS brand new scanners to meet escalating demand for imaging.
radiology departments across the UK to gauge the state “While many hospitals have MRI replacement plans in place,
of MRI equipment. it is concerning to see others do not appear to be planning
The survey findings in were issued in the report,“Magnetic for the future, especially when it comes to those working
Resonance Imaging (MRI) Equipment, Operations and with older machines. That nearly 40% of MRI scanners that
Planning in the NHS”. are seven or more years old are not destined for replacement
The CIB survey, which collected data relating to 171 scan- any time soon is a real worry.
ners used across the UK, revealed; “Radiology departments are already struggling with ever-
• 29% of MRI systems are at least ten years old – the growing workloads and not enough staff, and many now face
European Society of Radiology recommends scanners more working with outdated equipment.
than ten years old be replaced or risk becoming obsolete. https://tinyurl.com/UK-MRI-report
First Alzheimer’s trial with same patient will target a larger area of the
focused ultrasound right frontal lobe, and additional images
will again evaluate if the blood-brain bar-
Researchers at Sunnybrook Health rier is reopened. No drugs will be adminis-
Sciences Centre in Toronto, Canada have tered in the study.
begun the world’s first clinical trial evalu- “Our trial investigates, for the first time,
ating the feasibility and safety of opening the use of focused ultrasound to open the
the blood-brain barrier in patients with blood-brain barrier in patients with early-
Alzheimer’s disease using focused ultra- to-moderate Alzheimer’s disease, to deter-
sound. mine both its safety and technical feasibil-
For this trial, six Alzheimer’s patients, ity,” says Nir Lipsman, co-principal inves- provide an important method for more
ages 50–85 years, will undergo two non- tigator of the Sunnybrook study. “Results effectively delivering antibodies to the brain
invasive focused ultrasound procedures. from our study will help us plan future and may therefore one day be a treatment
For the first stage, the Exablate Neuro low- clinical trials to establish what role focused for Alzheimer’s—we just don’t yet know. It
frequency platform (Insightec) will apply ultrasound may play, whether alone or in is important to note that at this point we
focused ultrasound in a small area of the conjunction with medical treatments, in the are assessing only the feasibility and safety
right frontal lobe, and images will evaluate management of Alzheimer’s of opening the blood-brain barrier in these
if the blood-brain barrier was temporarily Sandra Black, senior scientist and co- patients.”
opened. In the second stage, approximately principal investigator at Sunnybrook adds, https://tinyurl.com/Sunnybrook-
one month later, a similar procedure to the “It is possible that focused ultrasound may alzheimer-s
AUG/SEPT 2017 D I E U R O P E 9
Symposium Report
Global Insights for CEUS in radiology
This article summarizes the proceedings of the recent symposium sponsored by
Bracco Imaging at ECR 2017 on Contrast Enhanced Ultrasound (CEUS) imaging.
Chaired by Prof. J. M. Correas, the symposium featured presentations by three dis-
tinguished clinicians experienced in CEUS in the respective fields of liver, macrovas-
cular and breast imaging.
CEUS in liver imaging: the new ACR influence subsequent management or therapy strategies
LI-RADS classification [Figure 1].
Prof. Fabio Piscaglia LR-1 (Definitely Benign). This is the category where
In 2013 the American College of Radi- imaging features are diagnostic of a definitely benign
ology (ACR) released their recom- entity. This category includes simple cysts, classic hem-
mended flowcharts for CT and MRI angioma, definite focal hepatic fat deposition or sparing.
characterization of the liver in patients
at risk of Hepatocellular Carcinoma LR-2 (Probably Benign). This category is relatively rare
(HCC) and introduced the Liver Imag- Dr. Fabio Piscaglia, and occurs when the nodule has imaging features sug-
ing Reporting and Data System (LI- is Professor of Internal gestive, but not diagnostic, of a benign entity. The criteria
RADS), the system of standardized ter- Medicine, at the for this category are: isoenhancement in all phases; of
minology and criteria to interpret and University of Bologna, very small distinct solid nodule (10 mm
community to apply consistent terminology; to reduce is iso-enhancing in all phases (ISO-ISO); a distinct solid
variability and errors in image interpretation; to facilitate nodule of any size with arterial phase hypoenhancement
integration with other imaging modalities and to improve without washout (HYPO-ISO); a solid noduleand mild and late washout CEUS in vascular imaging of pathol-
(very small HYPER-HYPO); a
distinct solid nodule ≥ 10 mm
ogies in the macrovascular system
with hyperhenancement in Prof D-A Clevert
arterial phase without washout As background, Prof Clevert
of any type (HYPER-ISO). reminded the audience that approxi-
mately 25-50% of all strokes (them-
LR-5 (definitely HCC). In LR-5 selves the third leading cause of
the nodules have imaging fea- death after ischemic heart disease
tures diagnostic of HCC. The and cancer) are caused by unstable
criteria for LR-5 are a nod- carotid artery plaque. It is also vitally Dr. D-A Clevert is
ule ≥ 10 mm showing arterial important to know whether a patient Professor of Radiology and
Head of the Interdisciplinary
phase enhancement (in whole is suffering or not from a high grade Ultrasound Center, Dept of
or in part, excluding rim and stenosis, which in turn can affect the Clinical Radiology, University
peripheral discontinuous globu- choice of treatment e.g. stenting, sur- of Munich, Grosshadern,
lar enhancement) followed by gery or no therapy. Germany
washout (late in onset and mild CT or MRI can already provide d i r k . c l e v e r t @ m e d . u n i -
munenchen.de
in degree (as observed by 120 clear and extensive information, e.g.
seconds after injection). This regarding stenosis of the carotid, so a valid question is what
pattern has an extremely high precise additional information does CEUS bring?
Figure 2. An example of LR-5, positive predictive value for
i.e. definitely HCC, with character- HCC and can be considered Contrast Enhanced Ultrasound (CEUS)
istic mild and late Hyper to Hypo
enhancement.
definitively diagnostic [Figure A typical ultrasound examination of the carotid artery begins
Top Panel: base-line. Middle 2]. with standard grey-scale ultrasound, followed by color Dop-
Panel: arterial phase. Bottom pler, which however has some well-known limitations, such
Panel: portal phase LR-M (Definite or probable as scanning angle and blooming artefacts.
malignancy, but not specific CEUS can overcome these limitations. In practice CEUS
for HCC). The criteria for this final category are: a nod- examinationscan be performed using different image disply
ule with rim enhancement in the arterial phase on wash- techniques: e.g. overlay images including some tissue back-
out either early in onset (within 60 seconds of contrast ground information (which is advantageous if the anatomic
injection) and/or in intensity, regardless of the type of landmarks are visible) or contrast only images displaying the
arterial enhancement. This category includes cholangio- pure contrast signal.
carcinoma, mixed hepatocholangiocarcinoma, hepatocel-
lular carcinoma ( often of poor differnetaiation grade) or, Stenosis
more rarely lymphoma or metasdtatic lesions. Therefore Approximately 10-15% of all ischemic strokes and transi-
the management of LR-M can vary but frequently a biopsy tory ischemic attacks occur with a severely stenosed internal
is required. carotid artery (ICA). Prior to surgery it is important to be
able to differentiate between pre-occlusive stenosis and com-
Reasons for incorporating ACR CEUS LI-RADS category plete ICA occlusion [Figure 3[.
in reports
1) To establish a definitive diagnosis of HCC and to avoid
the possibility of misdiagnosis with cholangiocarcinoma
(CCC).
2) To convey clear information to the hepatologist, particularly
in non LR-5 cases or where the lesion cannot be biopsied
3) To allow monitoring of the progression of a lesion with
time, even in the absence of a change in the size of the lesion.
A complete selection of images representing all the CEUS LI-RADS
categories can be found in the recent article: F Piscaglia et al. American
College of Radiology Contrast Enhanced Ultrasound Liver Imaging
Reporting and Data System (CEUS LI-RADS) for the diagnosis of
Hepatocellular Carcinoma: a pictorial essay Ultraschall Med. 2017; Figure 3. In cases where standard ultrasound or even color Doppler are not clear,
38: 320 - 324. CEUS shows a definite occlusion in the Internal Carotid Artery
AUG/SEPT 2017 D I E U R O P E 11Symposium Report
Pseudo occlusions Carotid Body tumors
These can be a particular challenge. In some patients Depending on the size
color Doppler flow data can suggest a complete absence of a carotid body tumor
of flow (occlusion) — albeit without certainty — while decisions have to be
CEUS allows the demonstration of even small residual flow taken as to whether the
(pseudo occlusion). With only grey-scale and color doppler tumor should be oper-
images, it can be difficult to distinguish flow from pulsation ated on or not. To moni-
artefacts. The use of CEUS enables precise information to tor the success of any
be communicated to the surgeon regarding whether the intervention, it is useful
ICA is patent or not. to establish a basic pre-
In other patients, color Doppler shows flow only in the treatment evaluation Figure 4a. Carotid body tumor. Pre-operative
external carotid artery, with none in the ICA. Even the use of the perfusion of the CEUS shows a high degree of perfusion in the
tumor.
of power Doppler sometimes doesn’t help very much in tumor. Post-treatment
such situations. In such casesCEUS can directly show the reduction of the perfu-
actual flow situation. sion of the tumor indi-
cates successful treat-
Post-therapy follow-up ment [Figure 4a, 4b].
Traditionally, carotid endarterectomy (CEA) or open sur- Grey scale US and color
gery has been the treatment of choice, but carotid artery doppler can provide only
stenting (CAS) is an alternative, particularly in patients with orienting information
high surgical risk, e.g. patients undergoing neck radiation, but confirmative infor-
with high or low cervical lesions or those with significant mation on the tumor Figure 4b. Post-operative CEUS shows much
cardiopulmonary disease. In both CEA and CAS, re-steno- viability can be obtained reduced perfusion.
sis is a potential problem that should be monitored. In any only with CEUS.
case, whether an open surgery or stenting approach is used,
post-treatment monitoring is necessary. CEUS can precisely Indications.
show in-stent stenosis and the impact on blood flow, in In summary, the EFSUMB guidelines and recommendations
particular using cross-sectional views on the clinical practice of CEUS in non-hepatic applications
identify several indications for its use in the carotid artery:
Dissection • Ruling out stenosis
Classified either as traumatic or spontaneous, dissection • Follow-up after carotid stenting
of the cervical segments of the carotid and vertebral • Dissection
arteries is relatively rare, but when it does occur, the • Complications of vascular intervention
result can be blood flow in the false lumen, an increase • Plaque characterisation
in the risk of thrombosis resulting in complete occlu-
sion or peripheral embolization. Again, on grey scale
ultrasound it can sometimes be difficult to spot a dis-
CEUS in Breast Imaging: is it useful
section, and even with color Doppler the blood flow into for the characterisation and BI-RADS
the true and false lumen is difficult to understand. The
use of CEUS enables clear identification of dissection
classification of focal breast lesions?
and the demonstration of the entry of contrast into the Dr Jun Luo,
false lumen in realtime. Axial views in CEUS can show Introducing the subject by provid-
clearly the false and true lumenincluding the membrane ing background information on the
in between. advantages of current ultrasound
(US) approaches in breast imag-
Rare Cases ing, Dr Luo also pointed out that
Other cases where CEUS can be of use are challenges still remain to be faced.
Many papers have been published
Arteriovenous fistula on the value of US in breast can-
Fistulae between carotid artery and the jugular vein, caused for cer screening, e.g. Shen et al Br J Dr Jun Luo, is Head of Ultrasound
example by dislocated central catheter line placement can be Cancer. 2015; 112: 998. which com- Department, Sichuan Provincial
identified by color doppler, but CEUS provides a clearer image pared modalities used for screening People’s Hospital, Chengdu,
Sichuan, China
of the problem. for breast cancer in Chinese women Milton-lj@hotmail.com
and concluded that US was superior
Aneurysm of the external extracranial ICA is also rare, but to mammography from the point of
requires characterisation prior to surgery. Color Doppler has view of cancer detection. The J-Start study from Japan (Ohu-
limitations, whereas the use of CEUS can clearly identify and chi et al, Lancet. 2016 23; 387: 341) also showed a significant
measure the size of the aneurysm and identify whether there increase in sensitivity in the detection of early cancers when
are soft plaques or not. US was used as an adjunct to mammography. On the basis
12 D I E U R O P E AUG/SEPT 2017Predictive Models
The overall objective of the use of CEUS predictive models is the
maximal reduction of unnecessary biopsies, while minimizing
the possibility of missing invasive breast cancer. In addition,
the models should be easy to use and have good inter-observer
agreement. The predictive model includes 3 defined enhance-
ment pattern indicating malignancy [Figure 5a] and three pat-
terns indicating a benign lesion [Figure 5b]. An example of the
application of these criteria is shown in Figure 6 where the use of
CEUS with an apparently benign lesion on 2D US was identified
as malignant by application of the model. The altered diagnosis
was confirmed by biopsy.
Figure 5a. Malignant Predictive Models
Refining BI-RADS
In Dr Luo’s clinic in Chengdu, China, all (100%) patients
who are BI-RADS 4 on the basis of mammography and
2D US, are biopsied, with an overall cancer-to-biopsy yield
of only 40%. Implementing the CEUS-based classification,
the biopsy rate falls to 25 % and the cancer-to-biopsy ratio
increases to 73% with only 2.98% of missed malignant
lesions. These lesions would be picked up at the 6 month fol-
low-up examination, suggested for all patient downgraded
from BI-RADS 4 based on the CEUS examination. These
promising results have led to the initiation of a large multi-
Figure 5b. Benign Predictive Models center trial in China to confirm the findings and suggested
diagnostic algorithm.
of these results, US appears beneficial when screening Asian
women but one question is whether similar results can be
obtained in Caucasian women. Another multi-centre trial
carried out in the USA, Canada and Argentina (Berg et al,
J Natl Cancer Inst. 2015;108:367) concluded that the cancer
detection rate with US was comparable to that of mammog-
raphy, with US identifying a greater proportion of invasive
and node-negative cancers. However the remaining prob-
lem is the substantial increase in the rate of false positives,
which are accumulating in the BI-RADS 4 category lesions.
Characterising all BI-RADS 4 lesions with biopsy (acc. to the
current guidelines) creates a huge number of biopsies with
the related patient discomfort and costs.
Figure 6. The above CEUS image shows hyperenhancement, a larger lesion, that
is regular-shaped and with clear margins. The model would predict malignancy, and
Overdiagnosis.
this was confirmed to be IDC on biopsy
Although overdiagnosis is recognised as being a major challenge
in breast cancer screening, methods for estimating its precise
rates have not been standardized. Reported rates range from Risk of malignancy transformation from apparently benign
5 – 50 % or more (e.g. Hamashima et al. J Clin Oncol. 2016; 46: lesions
48, McCarthy et al Breast Cancer Res. 2015;17: 1); 7% to 9% of The use of the malignant or benign CEUS enhancement pat-
women will have a negative biopsy. tern has been shown to be able to confirm benign lesions
The magnitude of these figures shows how big the problem is from apparently benign US images, and identify potentially
and suggests that the BI-RADS combination of US and mam- malignant lesions in patients. An analogy of such development
mography (which do not provide any microvascular informa- of breast lesions is that of geological volcanoes, which can be
tion) needs to be improved. classified as “Dead”, “Silent” or “Active”.
In addressing overdiagnosis, the key question is how to assess
the risk of malignant transformation in benign lesions. CEUS Conclusions
has an important role to play in this context, but in turn also • BI-RADS classifications of breast cancer can be refined if
raises certain questions regarding how CEUS should be used, CEUS is incorporated into the screening protocol.
which CEUS patterns are useful, how to analyse such patterns • CEUS can help predict the risk of malignant transfor-
and whether qualitative or quantitative analyses are more use- mation of benign lesions since such transformations are
ful. The concept of predictive models was developed to address accompanied by micro-vascular proliferation which can be
these issues. detected by CEUS.
AUG/SEPT 2017 D I E U R O P E 13Radiology WorkFlow
Workflow dichotomization
and the radiologist’s workflow
environment
By Dr John-Paul J. Yu
W orkflow disruptions are ubiquitous within cog-
nitively demanding and complex work environ-
ments and are associated with errors, workflow inef-
be broadly categorized into image-interpretive (IITs)
and non-image interpretive tasks (NITs). In a prospec-
tive, randomized, observational investigation at our
ficiency, and task prolongation. The healthcare work institution, we observed that individuals spent nearly
environment is one such example of an intrinsically 40% of their total time throughout the day performing
complex work environment that often finds individuals NITs including answering phone calls, returning pages,
engaging in rapid task switching and task shortening providing in-room consultative services for referring
with concomitant deleterious effects on patient safety, clinicians, technologists, and other radiologists, exam
workflow efficiency, and other quality outcomes [1]. protocoling, and teaching [5]. Moreover, previous work
Not surprisingly, these phenomena have garnered sig- at our institution demonstrated that the reading room
nificant interest throughout clinical medicine where work environment is highly fragmented with an average
the implications of workplace interruptions can include of 14.9 task-switching events (TSEs) per hour, yielding
physical, emotional, economic harm, and even loss of a rate of approximately one interruption every four
life. By virtue of a dynamic and complex work environ- minutes. The significant time and effort commitment
ment and the myriad of responsibilities incumbent on to NITs – in addition to the inherent disruptive nature
radiologists, the radiology work environment is par- of these tasks – spurred efforts to better organize and
ticularly susceptible to the effects of workplace disrup- handle these NITs in both an efficient and thoughtful
tions [2] with radiologists often experiencing significant manner.
strain in maintaining a streamlined, efficient workflow
[3, 4].
The impact of radiologist workflow
dichotomization
“... the radiology work environment is Imaging interpretation is one of many components that
particularly susceptible to the effects of constitute the full scope of responsibilities in a modern
workplace disruptions...” radiology practice. Even as image interpretation remains
our most tangible clinical deliverable, it reflects one
of many links in the imaging value chain. Additional
The complexity of the radiologist’s workflow environ- links in the imaging value chain include consultative
ment is largely a consequence of the multiple roles services provided to our referring clinical colleagues,
the modern radiologist balances as an imaging expert exam protocoling, patient scanning, and other activities
and diagnostician, physician consultant, educator, and previously identified as NITs; however, in spite of the
interventionalist. While these responsibilities concep- disruptive nature of NITs, they are an essential com-
tually span a wide-range of clinical activities, they can ponent of providing value in today’s clinical environ-
ment. The intrinsic value and importance of NITs belies
The Author the frustration encountered with NITs throughout the
John-Paul J. Yu, MD, PhD workday where NITs – with their stochastic and disrup-
Assistant Professor of Radiology, Psychiatry, and Biomedical tive nature – often occur as unanticipated interruptions
Engineering, Associate Program Director, Neuroradiology to the radiologist’s primary duty of high-quality image
Fellowship Program Division of Neuroradiology, Department of interpretation. At our institution (and anecdotally at
Radiology. numerous other academic institutions), the sheer num-
Director, Laboratory for Behavioral Systems Neuroscience ber of NITs and frequency of associated task switching
Member, Neuroscience Training Program served as an impetus for a more thoughtful approach
Member, Clinical Neuroengineering Training Program to reading room workflows, with the goal of a more
UW | University of Wisconsin School of Medicine and Public Health efficient, streamlined practice that leverages existing
E3/366 Clinical Science Center opportunities for imaging value chain optimization.
600 Highland Avenue | Madison, WI | 53792-3252 United States Towards these ends, we separated our reading room
email: jpyu@uwhealth.org tasks into two discrete workflows — IIT and NIT — to
14 D I E U R O P E AUG/SEPT 2017Table 1. Interruptions
facilitate the division of responsibility in the range of 3.2-4.7 minutes [8], Resources [10]. Identified risk factors
for these tasks [6]. workflow dichotomization would now for burnout often manifest as descrip-
conceivably and comfortably allow tions of job dissatisfaction that include
After the implementation of IIT and for the interpretation of a standard work overload, difficult shifts, lack of
NIT workflows in our reading room, head CT without interruption and by control, and severe time constraints for
an evaluation of our results clearly extension, would reduce the number work output (e.g, exam turn-around
demonstrate that workflow dichoto- of interruptions our radiologists could times). We postulate that a highly dis-
mization yields successful outcomes expect when interpreting more time- rupted radiology work environment is
along multiple dimensions of analysis. intensive, complex imaging. a key culprit underpinning many of
Implementing discrete IIT and NIT these sources of job dissatisfaction,
workflows resulted in a precipitous which may in turn lead to radiolo-
decrease in time spent on NITs by our “... Radiology has experi- gist burnout. Workflow optimization
image interpreting radiologists, falling enced diminishing levels efforts, such work dichotomization,
to less than 25% of pre-intervention of professional satisfaction to improve reading room efficiencies
level furthermore and moreover, repre- over time and excessive may also have the added benefit of
senting less than 5% of the radiologists workload is among the most decreased mental burden, workload,
overall time in the post-intervention commonly reported reasons related improved provider career satis-
period. Perhaps more importantly, the for provider dissatisfaction faction. The analysis of and subsequent
decrease in time spent on NITs was ...” improvements to the radiologist’s
nearly equally matched with a concom- workflow environment also requires
itant increase in time spent on image Workflow dichotomization a careful analysis of individual work-
interpretation (up to a total of 73.2% improves workplace satisfaction loads and the impact individual work-
post-intervention from 53.8% pre- Beyond the aforementioned posi- loads have on the overall efficiency of a
intervention) suggesting a nearly-com- tive quantitative impact of workflow workflow process. These examinations
plete direct transfer of NIT-time to IIT- dichotomization, there are less tangible also afford a more nuanced exploration
time. The delineation of a discrete NIT but no less important perceptive ben- of the impact workflow design has on
workflow also resulted in a 40% reduc- efits derived from separating reading individual operators. Whereas work-
tion in TSEs experienced by the pri- room tasks into IIT and NIT work- flow represents the sequence of pro-
mary radiologist. The marked reduc- flows. As with other medical special- cesses through which a piece of work
tion in TSEs is particularly important ties, radiology has experienced dimin- passes from start to finish, workload
and encouraging as numerous previ- ishing levels of professional satisfaction represents the actual amount of work
ous studies have demonstrated the over time and excessive workload is to be done. Workload, on the individ-
deleterious effects of interruption on among the most commonly reported ual level, is not an absolute quantity
the quality of image interpretation [7]. reasons for provider dissatisfaction [9]. and is variably dependent on numer-
The reduction in TSEs and increase in The intrinsic and extrinsic risk factors ous intrinsic factors (such as individ-
image interpretive time was reflected associated with career-related burn- ual experience and skill) and extrin-
throughout our data with the mean out specifically amongst radiologists is sic factors (such as interruptions and
time between TSEs more than dou- summarized in a recent report released system failures), which all contribute
bling from 05:44 to 11:01. With average by the American College of Radiol- to the overall perception of individual
head CT interpretations times reported ogy (ACR) Commission on Human workload.
AUG/SEPT 2017 D I E U R O P E 15Radiology WorkFlow
Table 2. Workload
Table 3. Satisfaction
Evaluation of the impact of
measurements (and improvements) in radiologists an opportunity to engage
workflow Dichomotization
workflow dichotomization. in a rewarding clinical practice.
To evaluate the impact of workflow As clinical imaging volumes continue
dichotomization on perceptions of to increase, an understanding of work- References:
workload, workplace interruptions, place disruptions and their impact of 1. Westbrook J I et al. The impact of interruptions
on clinical task completion. Qual. Saf. Health Care.
and workplace satisfaction, survey data radiologist productivity and global 2010; 19: 284.
were collected before and after work- measures of radiologist workload and 2. Yu J-PJ et al. The radiologist’s workflow environ-
flow dichotomization at our institution; workplace satisfaction have become ment: evaluation of disruptors and potential implica-
tions. J Am Coll Radiol 2014; 11: 589.
data are summarized in Tables 1-3 [11]. increasingly salient. Implementation 3. Kansagra AP et al. Disruption of Radiologist
Following implementation of separate of separate dedicated image-interpre- Workflow. Curr Probl Diagn Radiol 2016; 45: 101.
dedicated image-interpretive and non- tive and non-image interpretive work- 4. Larson DB et al. Communication in Diagnostic
Radiology: Meeting the Challenges of Complexity. Am
J Roentgenol. 2014; 203: 957.
5. Schemmel A et al. Radiology Workflow Disruptors:
“....Implementing discrete Image Interprteive Tasks (IIT) and A Detailed Analysis. J Am Coll Radiol 2016; 13:
1210
Non-Image Interpretive Tasks (NIT) workflows resulted in a pre- 6. Lee M H et al. Workflow Dynamics and the Imaging
cipitous decrease in time spent on NITs by our image interpret- Value Chain: Quantifying the Effect of Designating
ing radiologists, a Nonimage-Interpretive Task Workflow. Curr Probl
Diagn Radiol. 2016, doi:10.1067/
7. Balint B J et al. Do Telephone Call Interruptions
image interpretive workflows, our work flows resulted in improved radiologist Have an ImPact on Radiology Resident Diagnostic
Accuracy? Acad. Radiol. 2014; 21: 1623.
demonstrated a measurable uniform perceptions of workplace disruptors
8. Reiner BI et al., Radiologists’ productivity in the
improvement in workplace satisfaction and mental effort with a concomitant interpretation of CT scans: A comparison of PACS
with a concomitant decrease in percep- improvement in overall workplace with conventional film. Am J Roentgenol. 2001;
176: 861.
tions of the workplace disruptions and satisfaction. These and other similar
9. Zafar HM et al. Satisfaction of radiologists in the
effort required to complete workplace efforts highlight the importance of United States: A comparison between 2003 and
tasks. Beyond the quantitative impact workflow design not only on workplace 1995. Radiology. 2007; 244: 223.
of workflow dichotomization, these efficiencies but also in the positive sec- 10. Harolds JA et al. Burnout of Radiologists:
Frequency, Risk Factors, and Remedies: A Report of
data reflect the perceptive changes ondary gains observed in individual the ACR Commission on Human Resources. J Am
that occur in the workplace and cap- workload levels and offers a potential Coll Radiol. 2016; 13: 411.
11. Lee MH et al. Radiology Workflow Dynamics: How
ture important benchmarks that might practice model that offers outstand- Workflow Patterns Impact Radiologist Perceptions of
otherwise go unnoticed in quantitative ing patient care while also providing Workplace Satisfaction. Acad Radiol. 2017; 24: 483
16 D I E U R O P E AUG/SEPT 2017International Cancer Imaging
Society Meeting & 17th Annual
Teaching Course
Cancer Imaging and Intervention:
a Multidisciplinary Approach
2nd - 4th October 2017 • 2 Keynote lectures ‘Cancer Imaging in the era of precision
medicine’ and ‘Immunotherapy: Imaging challenges’
Langenbeck-Virchow • 8 Computer hands-on workshops using Siemens
workstations on evaluation of cancer of prostate, breast,
lung, liver, lung, ovary, uterus and whole-body imaging
Haus, Berlin, Germany • 25 sessions addressing structured reporting, response
evaluation, complications of medical and radiation therapy,
ICIS 2017 will focus on quantitative metastatic disease, joint sessions with radiation and medical
oncologists, precision medicine, radiogenomics, prostate, female
and functional oncologic imaging and pelvis, liver, pancreas, lung, lymphoma, CEUS and many more
the multidisciplinary management of
oncology patients. There will be a spectrum • 4 Scientific Sessions dedicated to proffered papers, and a poster
exhibition with prizes for the best overall paper and poster
of sessions ranging from innovative and
state-of-the-art imaging, practical hands-on- • 4 live-case workshops Transarterial chemoembolization
(TACE) in HCC / liver metastases, Radioembolization (SIRT),
workshops, essential refresher courses and Microwave ablation of a pulmonary tumour in metastasis or
live-case workshops. small lung cancer, Radiofrequency ablation of liver metastasis
Delegates will received 17 CPD points from the Royal College
of Radiologists (Monday - 6, Tuesday - 6, Wednesday - 5). CME
accreditation will be sought from the European Accreditation Council
Continuing Medical Education (EACCME).
In association with:
Call for abstracts: Deadline 29th May 2017 Programme planning committee: Stefan Diederich ICIS President (DE),
Submit online at icimagingsociety.org.uk Bernhard Gebauer (DE), Dow-Mu Koh (UK), Beth McCarville (US),
Anwar Padhani (UK), Andrea Rockall (UK), Heinz-Peter Schlemmer (DE),
Harriet Thoeny (CH).
For further information please contact:
ICIS, 140-148 Borough High Street, London, SE1 1LB E: louise.mustoe@cancerimagingsociety.org.uk
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