ECR Today 2013 Sunday March 10 - myESR.org

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Sunday 10 March 2013Highlights ECR Today 2013 5Cruyff, Bergkamp, van Persie, et al. take secondplace behind interventional oncologyBy Philip WardBesides medicine, Prof. Jean-François Geschwind’s great passionin life is football in the Netherlands.“I would love to be asked to givea lecture about Dutch soccer, butunfortunately this has never happened,so I’m stuck giving lectureson interventional oncology andliver cancer therapy. Forgive me, butthat’s what I’ll talk about today!” hedisclosed at the start of yesterday’sWilhelm Conrad Roentgen HonoraryLecture.Interventional oncology is nowconsidered to be the fourth pillarof oncology, and has taken rootin many hospitals as a valid treatmentoption for cancer patients, saidGeschwind, who is director of thedivision of vascular and interventionalradiology at the Johns HopkinsUniversity School of Medicinein Baltimore, U.S., but originallycomes from Paris.“There has been a key paradigmshift towards molecular-based treatments,”he said. “To be successfulin this field, the true pioneers ininterventional oncology will needto understand the basic principlesof cancer biology and specificallythe hallmarks of the key signaturesof cancer.”Identifying so-called druggabletargets is a key notion here,Geschwind explained. Druggability,which involves the likelihood ofbeing able to modulate a target witha small-molecule drug, is essentialto determine whether a drug discoveryproject progresses in the developmentcycle. Predicting how druggablea novel target lies at the crux ofearly drug discovery. Because manyof these drugs are found serendipitously,it’s necessary to characterisethe drug effects and understand themechanism of action.The beauty of targeted therapy isthat it becomes realistic to developa biomarker, and he thinks radiologistsare particularly well placed todevelop imaging biomarkers. FDG-PET can be used as a biomarker oftumour metabolism, but many othersare now being developed, suchas those for hyperpolarised MRspectroscopy.“How can we integrate imageguidance, interventional techniquesthat are well known to all of us, andtargeted molecular therapy?” heasked. “If we can combine all that,we can make it a very happy marriage.For that again you have togo back to the principles of cancerbiology.”It’s important to build up anunderstanding of how healthy cellsat some stage undergo genetic mutationsthat will lead to an uncontrolledgrowth of a tumour, accordingto Geschwind. This in turn willlead to great disruptions of homeostasis,and homeostatic imbalancemay then lead to a state of disease.Honorary Lecturer Jean-François Geschwind from Baltimore, United States.South African radiology demonstrates itsdynamism and vibrancy on the big stageBy Becky McCallIt’s dynamic, exciting, and evolving.That’s how an engaging presenteropened her talk about the state ofacademic radiology training inSouth Africa. The reality, as displayedin the following lectures atSaturday’s ESR Meets session, certainlylived up to the promise.Prof. Zarina Lockhat, professor ofradiology at the University of Pretoria,spoke about radiology trainingin her country, and recognised thatthe pace of change was fast and furiousand that technological advancementwas driving the agenda.“Academic radiology has to bebalanced against a background ofscientific and technological advancement,”she said. “In 2002, Tom Cruisefascinated us in the film, MinorityReport, by using gesture recognitiontechnology and scrolling of images,but now surgeons manipulate imagesin a sterile environment by just movingtheir hands. It’s a reality.”Furthermore, so-called reasoningengines for radiologists arenot so far off, she added. “Patientobservations, signs and symptomsare punched in and deep reasoningsoftware systems give feedback onrecommendations for further investigationsand diagnoses.”Addressing a hot and recurringissue of the day, discussed in depthduring other sessions at this year’sECR, Lockhat suggested that radiologistswere emerging from thedark to interact with patients andclinicians. Referring to a recentEuropean survey, clinicians saidthey wanted old fashioned accessto radiologists, and straight forwardaccurate radiology reports,although she reported that in heropinion, reports are a work of art.Returning to the driving forceof technology, she highlighted thecurrent trend for computers to getsmaller. “First they were in rooms,then desktops, then in our laps, nowin our palms and soon they’ll be onour faces and possibly one day inour brains.”With a poignant nod to the valueof traditional academic radiology,and despite all the technologicaladvances, she read out an apt quotefor the radiologist in training: “Youonly seek what you look for and recogniseonly what you know. No matterwhat you have – smart phones,tablets, e-learning, e-resource – ifyou can’t see the abnormality youcannot make the call.”Lockhat acknowledged the contributionsof the College of Medicinein South Africa, the RadiologicalSociety of South Africa, andacademic institutions in providingacademic and clinical training. TheRSSA provides an academic platformwith webinars, conferences,workshops and the publication ofthe South African Journal of Radiology.Also, amongst today’s radiologytraining tools are a mixtureof didactic lectures, case-basedlearning, e-learning, and MedicalImaging Resource Center (MIRC)teaching files, she said.Another South African radiologistrecently performed exceptionallywell in the U.K. Royal Collegeof Radiologists’ examinations,illustrating how South Africanradiologists are carving a niche forthemselves on the internationalradiology scene. This was confirmedby other lectures during Saturday’ssession. Dr. Janse van Rensburg,from the University of Stellenbosch,explained a new concept about thepathogenesis of tuberculosis that hehad arrived at with his colleague,Dr. Richard Hewlett, from the sameinstitution.“The concept we propose is thatbasal cisternal meningitis in childrendue to tuberculosis is not aresult of the well-known Rich focustheory, but rather the result of directinfection of the choroid plexi, whichParticipants from Saturday’s ESR meets South Africa Session.leads to infection in the cerebrospinalfluid (CSF) and exposure of theantigen to the basal cisterns. Thisinvokes an inflammatory responseleading to CSF obstruction, whichin turn leads to the characteristicand predictable imaging findings inchildren,” he said, summarising thenew theory.The Rich theory has always beencontroversial over many years.Van Rensberg said South Africanresearchers had always been scepticalbecause of the discrepancybetween the MR images and thegross pathology and what the originalwork from the 1930s showed.“This showed a cortical lesionmeningitis that was not basal cisternalmeningitis, but nobody couldexplain how something high in thebrain caused meningitis at the base,”he explained. “People suggested thepatient was lying down, but they areusually walking around when diagnosed,or due to differences in bloodvessels in the brain.”Van Rensburg credits Hewlett forthe new explanation. “His explanationis just the logical theory afterdoing this for 20 years. He’s the onlyperson I know with the pathologyand neurology knowledge to bringit all together.”Radiology Trainees ForumMeet & Greet with your RTF RepresentativeToday, 13:15–13:45, Rising Stars Lounge, 2 nd LevelDr. Rüdiger Schernthaner, AustriaDr. Thierry Couvreur, BelgiumDr. Ana Sverko Peternac, CroatiaDr. Lasse Nørgaard, DenmarkDr. Peter Bannas, GermanyDr. Andrea Levai, HungaryDr. Shai Shrot, IsraelProf. Zhanar Abdrakhmanova, KazakhstanDr. Viola Koen, NetherlandsDr. Elisabeth Olstad, NorwayDr. Domen Plut, SloveniaDr. Yulia Mironova, UkraineDr. Marijana Basta Nikolic, SerbiaDr. Nadya Pyatigorskaya, FrancemyESR.org | #ECR2013 @myESR

6 ECR Today 2013 HighlightsSunday 10 March 2013Record participation for diplomaexamination at ECRBy Mélisande RougerThe increasingly popular EuropeanDiploma in Radiology (EDiR)attracted a record number of candidatesfrom all over the world to theECR. As many as 62 residents andradiologists travelled to Vienna tosit the examination, a 50% increasein participation from last year.This rise reflects the growing qualityand recognition of the diploma,according to Dr. Éamann Breatnachfrom Dublin, scientific director ofthe European Board of Radiology(EBR), which organises the examination.“People start to see that thediploma is a qualification agreed toby both the EBR and the EuropeanSociety of Radiology (ESR). There ismore recognition of the value of thediploma, which people see as usefulfor their individual career paths.Holding the diploma shows youremployer that you are enthusiasticand have a good knowledge base,and ultimately you can use it to lookfor employment elsewhere,” he said.The diploma is officially recognisedby the European Union ofMedical Specialists (UEMS), andits reputation extends well beyondEurope. Candidates from theGulf countries have come in largenumbers since the introductionof the diploma two years ago, andAmericans are beginning to showan interest as well. Furthermore,the Argentine Society of Radiologypaid for two young radiologists totake the diploma exam, and coveredtheir travel and accommodationcosts. Dr. Mariana Jakubowiczand Dr. Santiago Andrés, residentsat the Deutsches Hospital in BuenosAires, found it to be a great experienceand acknowledged the qualityof the examination.“The exam really covered everyaspect of general radiology. Thewritten part was tough. There werelots of questions and little time toanswer them. Cases were not thesimplest. The examination was challengingbecause of the language,but I know the examiners take thatinto account. I felt more comfortableduring the oral exam thoughand could comment on the images.Besides the examiners were veryfriendly and helpful,” Andrés said.“One difficulty is that we dothings differently back home. Forinstance I would never do an MRexamination for appendicitis butrather an ultrasound or abdominalCT scan, so I am not used to seeingthis pathology on MRI. Thatwas a bit confusing. But having amock exam beforehand could helpin this regard,” said Jakubowicz, whoconfirmed the huge interest amongyoung Argentinean radiologists inworking abroad.Andrés and Jakubowicz also presentedpapers through EPOS – onmammography, usual metastaticsites in PET, whole-body PET-CTexamination and on the selectionof biopsy sites with PET-CT. Part ofthe reason why they took the examin Vienna was so they could alsoattend the ECR, and diploma candidateswere given free access to thecongress this year. Conveniently,the examination started a daybefore the beginning of the ECR,to enable candidates to attend sessionsafterwards. Furthermore, theexamination was split over threedays, sparing candidates long waitingtimes between the written andoral tests.This time, diploma organisersinvited a panel of observers toattend the orals, in order to trainthem to become examiners nextyear. Organisers also announcedthat they would include a list ofrecommended literature for thenext examination, after candidatesrequested this option.“We would like to encouragepeople to be familiar with the ESRpublications, which include theMariana Jakubowicz and Santiago Andrés from Buenos Aires, Argentina, were amongst thecandidates at the European Diploma in Radiology exams which took place Wednesday to Fridayduring the ECR.publication on the revised trainingcharter and curriculum, thejournals European Radiology andInsights into Imaging, and the casematerial available on Eurorad. Butthis list is not exclusive and we areaware that there are very good booksin languages other than English,so I want to stress that point, andalso insist on the European natureof this examination, which is not alanguage test,” Breatnach said.In the future, organisers wouldlike to see the diploma becomeaccepted as equivalent to somenational qualifications, and negotiationsare currently underway.The examination will also be heldduring the annual meeting of theTurkish Society of Radiology inNovember. Candidates will have theoption of taking the oral test eitherin English or in the local language.Success in the examination willcertify a standard of radiologicalknowledge deemed appropriate bythe ESR for independent practise ingeneral radiology. The examinationis open to radiologists and radiologyresidents in their fifth year of training.Examination costs are €500 forESR full members and members intraining, and €1,100 for ESR correspondingmembers.Live discussions heat up EPOS AreaBy Mélisande RougerThe EPOS (Electronic PresentationOnline System) Area in Foyer A isan essential destination at the ECRand attendance was high betweenThursday and Saturday. Delegatestook part in live discussions onhot topics in radiology, which thistime focused on paediatric neuroimaging,MRI of the scrotum,plaque imaging and myocardialcharacterisation.During these live discussions,poster authors can personallyintroduce and comment on theirwork with the public. The chairwomanof the scientific exhibition,Professor Katrine Åhlström-Riklund,is particularly fond of thesedebates.“I think these presentations area good opportunity to start presenting,it’s a very friendly format.Previously there were just the posterson the wall and people went by,now these discussions invite themto share their views. There werelots of good questions today, lots ofexchanges going on,” she said.Furthermore, five posters, the bestones from a scientific, educationaland compositional point of view,received Magna Cum Laude awardson Friday.Now in its eleventh year, EPOSis one of the most popular featuresof the ECR. It provides radiologistswho cannot attend the congresswith the opportunity to presenttheir work, and many say it haschanged the way they interact withnew information in radiology.More than 16,000 poster presentationsare currently available onlineand authors can submit their workthroughout the year. For ECR 2013alone, 2,785 posters were submitted.“The posters cover everything.You can read about things you dealwith every day but also about thingsyou will never be confronted withexcept in the EPOS Area. There is ahuge amount of knowledge in there.This year is no exception, and youcan be sitting here in front of thecomputer during the whole ECRreading through all the posters,”said Åhlström-Riklund, obviouslypleased to be back in Vienna.A consultant doctor specialisingin movement disorders, dementiaand PET-CT in oncologic applications,Åhlström-Riklund works atthe University of Umeå, a small townin the North of Sweden. ”There areno old cities like Vienna in northernSweden. Our University is veryyoung for instance, it was foundedin 1959. Now we have 38,000 students,a pretty high population fora town of 160,000 inhabitants,” shesaid.Umeå will be the European Capitalof Culture in 2014 and manyactivities, concerts and performanceswill be offered throughoutthe year. Åhlström-Riklund is verymuch looking forward to next year,as Umeå Universty will offer eventsbased on seasonal themes.ECR delegates are welcome tojoin, listen, and discuss with theexperts again on Sunday.Professor Katrine Åhlström-Riklund, chairwoman of the scientific exhibition, awarded the MagnaCum Laude Awards on Friday to five best poster authors.From left to right: Carmen Ayuso, Manuel Recio, Ana Maria Quilles, Silvia Perugin Bernardi,Kristian Micallef, Shinichiro Kitao, Katrine Åhlström-RiklundLive discussion:Sunday, March 10, 12:30–13:00Vascular imaging: CT, MR – or something completely different?Challenges in imaging peripheral artery occlusive diseaseModerator: Christian Loewe; Vienna/AT#ECREPOS #ECR2013Eurasian collaborative project gets started at ECRA ground-breaking meeting washeld during ECR 2013 on Thursdayto discuss the extension of Eurasianradiology collaboration.The main organisers of the meetingwere Dr. Mansoor Fatehi (picturedon the left), General Secretaryof the Iranian Society of Radiologyand a member of the InternationalRelations Subcommittee of theEuropean Society of Radiology andDr. Ahmet Turgut (pictured on theleft), the General Secretary of theTurkish Society of Radiology. Atotal of 20 member societies wereidentified as potential participantsin the initiative.“We believe access to the state ofthe art radiology knowledge andimproving the standards of radiologypractice in this part of the worldare crucially important issues,” notedFatehi and Turgut in a joint statementthat was also signed by Dr. NevraElmas (President of the Turkish Societyof Radiology) and Dr. Jalal JalalShokouhi (President of the IranianSociety of Radiology). “We also thinkthat scientific collaboration betweenour societies and radiology communitiesin the region would creategreater opportunities for our colleaguesby sharing expertise. In thisregard, we are seeking your ideas onhow we can collaborate to achievethis ambition.”Dr. Mansoor Fatehi, General Secretary of the Iranian Society of Radiology andDr. Ahmet Turgut, the General Secretary of the Turkish Society of Radiology#ECR2013 @myESR | myESR.org

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Sunday 10 March 2013INSIDETODAYImaging providesimportantinformationabout traumaticbrain injurySee page 10Clinical CornerAdvances in forensicimaging bringnew opportunitiesfor radiologySee page 12Overuse injuriesin gymnasts andprofessional golfersSee page 16ECR Today 2013 9CT cardiothoracic imaging entersan exciting new phase of evolutionBy Frances Rylands-MonkThe rapid technical evolution ofCT scanners has made it possibleto acquire cardiac images with fewermotion artefacts, and studying theheart should be mandatory for radiologistswho are performing a routinechest CT examination to avoidoverlooking important findings,advocates a leading chest imagingspecialist.“It is essential for radiologiststo consider cardiac and thoracicassessment as a single imaging context,”said Prof. Lorenzo Bonomo,chairman of the department ofradiological sciences and bioimagingat Agostino Gemelli Hospital,Catholic University of Rome, whowill moderate this afternoon’s specialfocus session on comprehensiveCT cardiothoracic imaging.CT’s ever lower radiation dose,faster acquisition speed, highertemporal resolution and larger scanvolume per single rotation of thetube-detector system allows goodimage quality, even in patients withhigh heart rates. These advantagesalso help to reduce the incidence ofnon-assessable coronary segmentsdue to motion artefacts and increasethe modality’s capacity to assess theproximal extension of acute aorticdissection in surgical planning.“In the future, evaluation of theheart with CT imaging will be acommon procedure in the preoperativeassessment of patients, atleast for non-cardiac surgery, butthis requires a cultural change forradiologists, surgeons and physicians,”he said. “In addition, hybridimaging could offer the advantagesof different modalities in a singlediagnostic tool.”CT is currently the gold standardfor imaging the lungs and greatthoracic vessels, both in routineand emergency. Its role in coronaryimaging, on the other hand, is establishedin carefully selected patientswith proven high diagnostic accuracyand negative predictive value.In the emergency setting, CTangiography triple rule-out protocolcan help establish the causeProf. Lorenzo Bonomo, chairman of thedepartment of radiological sciences andbioimaging at Agostino Gemelli Hospital,Catholic University of Rome.of atypical acute chest pain relatedeither to the lungs (e.g., pneumothorax,pneumonitis) or cardiovascularstructures (e.g., acute aorticsyndrome, pulmonary embolism,coronary disease). Additionally,different imaging findings in noncontrastCT scans may reveal specificcardiothoracic problems, and ahyperdense aspect in a pre-contrastCT scan of the thoracic aorta wallin a patient with acute chest pain isa hallmark of an acute intramuralhaematoma, according to Bonomo.Expanding on the optimisationof CT techniques for diagnosisand assessment, his colleague Dr.Riccardo Marano, from the samehospital, will be covering coronaryartery imaging, while Prof. Edwinvan Beek, SINAPSE chair of clinicalradiology at the Queen’s MedicalResearch Institute, Universityof Edinburgh, U.K., will discussthe feasibility of cardiopulmonaryfunctional imaging.Prof. Uwe Joseph Schoepf, directorof cardiovascular imaging at theUniversity Hospital of South Carolina,Charleston, U.S., points outthat a comprehensive examinationrequires knowledge of a patient’smedical background and a tailoredapproach.“For investigating the complexpathologies of the heart-lungaxis, patients need more pre-scaninvolvement of the radiologist,” hesaid. “In many hospitals, there is stilla culture of standardised protocolsfor heart-lung imaging because it ismainly the technologist performingthe scan.”Interaction in CT on a routinebasis between the radiologist andthe technologist in European hospitalsmay be better than in the U.S.,but a greater exchange is alwaysdesirable, he elaborated. Furthermore,intense institutional dialoguewith referring physicians, such ascardiologists and pulmonologists,is crucial to truly understand theirclinical questions.In his talk today, Schoepf plansto outline powerful new CT toolsthat compensate for cardiac motion,while discussing best methods ofProf. Uwe Joseph Schoepf, director ofcardiovascular imaging at the UniversityHospital of South Carolina, Charleston, U.S.radiation dose reduction and thenew heart-lung dedicated softwareavailable for evaluating cardiacfunction, defining obstructive coronarystenosis and characterising andquantifying disease processes in thelung parenchyma.The session should appeal to allradiologists, as such diagnosticimaging will be increasingly askedof them in the general radiology setting,he said, pointing to the impossibilityfor subspecialists alone tomanage this expanding patientpopulation.For dealing with cardiac motion,ECG synchronisation for imagingstructures such as the heart, lungsand lung parenchyma has an ambivalenttrack record, and the radiationdose involved fluctuates withthe type of technology available overtime, according to Schoepf. FoursliceCT scans with retrospectiveECG gating meant higher radiationexposure. Latest generation scannersusing refined means of ECGsynchronisation deliver 1mSv or lessin cardiothoracic CT scans, betweenone third and one quarter of normalyearly background radiation dose,the latter being around 3.5mSv.However, 64-slice CT scanners arestill the most widely used platformand they typically deliver higherradiation doses, so radiologistsmust adapt protocols to the clinicalquestion to deliver the lowestpossible dose.“If we are only interested in theanatomy of the chest, then we shoulduse a clear-cut strategy of minimisingradiation dose and sacrificingfunctional information throughuse of prospective ECG triggeringwhich will allow clear evaluation ofthe lung parenchyma, thoracic vesselsand heart,” he pointed out.Using dual-source CT scanners isanother way to scan the entire chestwith 1mSv or less in less than 600milliseconds, he added. For otherpatients, functional informationmay be needed (e.g., cardiac chamberfunction and pumping abilityof the heart). Retrospectively ECGgated data acquisition gives anatomicaland functional informationfor assessing pump function,for example, but patients will typicallyreceive between 12 and 25 mSvof radiation exposure on a 64-slicescanner.“This is something we want toapply only if we have to. There arealternative techniques to obtainfunctional information at low radiationdose: ECG synchronised tubecurrent modulation, patient-specifickV selection, as well as hybrid strategiesbased on a mix of retrospectiveECG gating and prospectiveECG triggering help to minimiseradiation dose while still providingfunctional data,” Schoepf said.ECR delegates will hear how CTperfusion can assess pathologies likelung cancer or perfusion defects inthe heart muscle. It represents anexciting advance in terms of diagnosticyield, but also requires moreradiation.Ultra-high pitch CT acquisition using second generation dual-source CT in a woman with acutechest pain. A dose-length product of 40 mGy cm 2 was applied, which roughly translates to0.5mSv in effective radiation dose for the ECG-synchronised interrogation of the entire thorax.(Provided by Prof. Uwe Joseph Schoepf)“There is no such thing as a ‘freelunch’ in terms of diagnosis andradiation dose, with CT,” said Schoepf,adding that although carefulpatient selection is still paramountwhen using latest generation equipment,ECG synchronised acquisitionno longer involves an extrapenalty in radiation exposure, whilemaximising the diagnostic informationobtained from patients.As for the future outlook, continuousdevelopment of differenttechnologies to synchronise CTacquisitions with the patient’sheartbeat and the evolution of everrefined reconstruction techniquesmeans that the journey is far fromover.“We are now in an arena whereCT radiation exposure can competewith conventional x-ray,” heremarked. “In a few years, all CTimage reconstruction will be performedusing iterative reconstructiontechniques. We will also seean expansion of indications fordisease diagnosis, wider use of CTperfusion for monitoring and morequantification due to the increasingavailability of software solutionsfor determining disease extent andactivity.”Special Focus SessionSunday, March 10, 14:00–15:30,Room G/HSF 14b: Comprehensive CTcardiothoracic imaging:a new challenge forradiologists▶▶Chairman’s introductionL. Bonomo; Rome/IT▶▶How to optimise integratedcardiothoracic imaging with CTU.J. Schoepf; Charleston, SC/US▶▶Coronary artery imaging froma chest CT examination: whenand howR. Marano; Rome/IT▶▶Cardiopulmonary functionalimaging from a chest CTexamination: when and howE.J.R. van Beek; Edinburgh/UK▶▶Panel discussion: Is a singleCT scan technique andprotocol feasible for all thecardiothoracic problems?#SF14b #ECR2013GHmyESR.org | #ECR2013 @myESR

10 ECR Today 2013 Clinical CornerSunday 10 March 2013Imaging provides important informationabout traumatic brain injuryBy Mélisande RougerTraumatic brain injury (TBI) isa major cause of death and disabilityworldwide, causing about1.5 million deaths and leadingto millions of patients requiringemergency treatment every year.In severe cases, TBI is commonlyclassified according to morphologicalcriteria based on CT and MRIstudies. Experts will show how toimage TBI patients appropriately ina dedicated Special Focus Sessiontoday at the ECR.Although MRI may be better fordetecting traumatic lesions in laterphases following TBI, CT remainsthe examination technique of choicein the acute phase, according to Dr.Alex Rovira-Cañellas, director ofneuroradiology at Vall d’HebronHospital in Barcelona. “CT is themodality of choice for the emergencysetting. It is good at detectingfocal lesions that need to be operatedupon right away. We always doCT first,” he said.Although there is no questionregarding the use of brain CT insevere and moderate head trauma,there is still considerable uncertaintyabout the indications forbrain CT in patients with minorTBI. Recent data indicates that theliberal use of CT scanning in mildTBI is cost-effective and appearsjustified.MRI is more appropriate foridentifying diffuse lesions, whichbetter relate to the patient prognosis,and radiologists do T1, T2 anddiffusion-weighted sequences on aroutine basis to detect these in somepatients.However, both CT and conventionalMRI fall short in accurateprediction of outcome, becauseof their inability to depict the fullextent of brain injury, and becausethey offer qualitative rather thanquantitative information. Outcomeprediction is crucial because it hasan impact on the choice of specifictreatment methods, the decision ofwhether or not to alter treatment,and on advice given to patients andrelatives.Advanced MR techniques mayhelp determine outcome. “Diffusiontensor imaging (DTI) and protonMR spectroscopy (MRS) providequantitative assessment of the extentof brain damage and have been proposedas markers of axonal injuryand as indicators of long-term outcome,”said Rovira-Cañellas, whowill chair the session. With DTI orMRS, radiologists can better classifypatients and see what kind ofinjuries they have, but most importantly,radiologists can use them tocategorise the degree or extent oftissue injury. “From a clinical pointof view, it is very difficult to explorea patient with severe traumatic braininjury who is sedated in the intensiveunit, so the best way to assessthe extent of the injury is to use oneof these MR techniques. They arealso successfully applied in Alzheimer’s,stroke and multiple sclerosismanagement,” he said.DTI and MRS are also increasinglyused in research to monitortreatment. New drugs are currentlybeing tested and they must first beassessed in order to improve theirefficiency in selected patients,depending on the type of injurythey have.Radiologists must also rememberto image cerebrovascular injuries,which are very common aftertrauma. Quite frequently theseinjuries are not identified fromthe initial CT scan, and mortalityamong these patients (60 percent) ismuch higher than the rest of traumapatients. “You need to apply a seriesof protocols to look specifically forhead and neck injuries. It is veryimportant to do CT or x-ray angiographyto look for these injuries, asmany patients may require endovasculartreatment to stop or preventbleeding from vascular lesions,”Rovira-Cañellas said.These patients should be diagnosedas soon as possible. Becausethey often have injuries in otherparts of their body, it is easy toA35-year-old man with intracranial injuriessustained in a motor vehicle accident. BrainCT scan (A) performed six hours after theaccident was initially read as normal. BrainMR imaging performed six days later shows athin subdural haematoma in the left parietalregion on a T1-weighted image (B), and amild hyperintense lesion in the spleniumof the corpus callous on a T2-FLAIR image(C). This last finding is better identifiedas an area of high signal intensity on theisotropic diffusion-weighted image (D) witha decreased apparent diffusion coefficient(ADC) value (E). These features areconsistent with an area of cytotoxic oedemasecondary to diffuse axonal injury.(Provided by Dr. Alex Rovira-Cañellas)overlook cerebrovascular trauma,especially in the emergency settingwhere staff resources are strained.“Polytrauma patients usuallyundergo whole-body CT from brainto pelvis, but we don’t pay enoughattention to these lesions. We haveto look at hundreds of images in apatient in an acute setting, so it isnot easy for one person to read allof it in detail. In certain Europeancountries, this situation is becomingeven more unsustainable with theeconomic crisis, and the number ofpeople on call in hospitals has beenreduced. There are many experts inthe same hospital, but very rarely atthe same time,” he said.Experts will provide some helpfuladvice on how to face theserestrictions.BDSpecial Focus SessionSunday, March 10, 16:00–17:30, Room F1SF 15a: Traumatic brain injury▶▶Chairman’s introductionA. Rovira-Cañellas; Barcelona/ES▶▶Acute brain trauma: CT vs MRIM. Muto; Naples/IT▶▶New imaging techniques in the detectionand quantification of brain damageS. Sunaert; Leuven/BE▶▶Advanced imaging of brain trauma: outcome predictionD. Galanaud; Paris/FR▶▶Cerebrovascular trauma: diagnosis and therapyT. Krings; Toronto, ON/CA▶▶Panel discussion: Role of neuroimagingin traumatic brain injury in 2013#SF15a #ECR2013F1CEEuropeanRadiologynow at your fingertipsMore info at www.european-radiology.orgDownload at bit.ly/ER-app#ECR2013 @myESR | myESR.org

Sunday 10 March 2013Clinical CornerECR Today 2013 11Intervention gives hope to patients withpleural effusion and lytic bone metastasesBy Becky McCallProf. Afshin Gangi is passionateabout cementoplasty, and believesit must be considered in the contextof the whole patient. “Patients needto be seen before and after the proceduresand interventional radiologistsneed to be responsible for thepatient from A to Z,” he emphasises.“The patient is not just a metastasis.”Gangi, an interventional radiologistfrom Strasbourg Hospital,France, explained that with cementoplasty,interventional radiologistscan only control pain and consolidatebone, and not treat the tumour. Theprocedure involves injecting acryliccement or glue into lytic bone metastasis.It is usually indicated for painful,lytic bone metastasis especiallywhen there is a risk of compressionfracture in the spine, condyles andacetabulum. Large bones for example,the femoral shaft, are not agood indication for cementoplasty.Also, non-lytic, hard metastases areunsuitable for cementoplasty becausethere is no space within the tumour.Cementoplasty must always beconsidered alongside other anticancertherapies and techniqueswhen planning a patient’s diseasemanagement, and an ablation mayneed to be performed initially, followedby cementoplasty, he noted.At this afternoon’s special focussession addressing the need for palliativeinterventional techniques incancer, Gangi will advise on how andwhen to use cementoplasty and onthe broader aspects of disease management.He stressed that the coremessage of his talk would be on theneed for interventional radiologiststo be more than a technician. Theyneed to be a complete clinician, andthis is currently a weakness of interventionalradiology, he believes.Patients referred for cementoplastyare usually under the care ofa chain of clinicians and sometimescertain treatment options can beoverlooked due to a lack of communicationbetween the links inthe chain. “Everyone needs to worktogether; there is one conductor, andwe are the musicians who need toplay at the right time and with theright note otherwise it will be acatastrophe,” stated Gangi.Patients with renal cell carcinomaand bone metastases exemplify thisscenario. The pain and fragility ofthese metastases can be treated withAA: Painful lytic L4 spinal metastasis. B: Vertebroplasty with injection of 3.5 ml of acrylic cement can provide excellent pain relief.cement but they continue to growvery quickly inside the spinal canalcausing paraplegia. “Here you needto consolidate the vertebral body totreat pain and then use therapy tocontrol the tumour too.”At today’s session, Prof. FergusGleeson, from the department ofradiology at Churchill Hospital,Headington, Oxford, U.K., will discussissues around the managementof pleural effusions, highlightingways of managing pleural effusionin patients as palliation in cancerpatients. He explained that a cancer,whether inside or outside the chest,can be associated with pleural fluideither by direct invasion or by seedingalong the surface that creates fluid.“Palliative care aims to treat symptoms,most notably breathlessness.Patients can also present with pleuraleffusion when a cancer has notbeen diagnosed in the patient,” heremarked. “Often the first symptomof cancer in these patients is breathlessnesscaused by pleural effusion.Symptoms are the same whetherthe patient presents de novo or hasa known cancer.”Diagnosis of pleural effusions canbe conducted by sampling pleuralfluid. According to Gleeson, thismethod usually provides a diagnosisof malignancy in 60% of patients. Inthe other 40%, and also in patientswith mesothelioma, the fluid is lessforthcoming and diagnosis of thecause of the pleural effusion maybe as low as 30%.Gleeson advocates a simple chestx-ray to diagnose pleural effusion,and then an ultrasound scan tolocate the fluid and remove it, followedby a CT scan to determine ifthe effusion is due to cancer includingits extent and primary source.“In our work, we have shown thatultrasound can be used for more thanjust taking the fluid off, but it can beused for diagnosis of malignancyby looking at the pleural surface,”reported Gleeson. “Also we haveshown that it is possible to teach physiciansand others who use ultrasoundto do this procedure in outpatientsand the emergency department.”Addressing an ongoing debate,Gleeson will discuss the number offluid removals required for a reliablediagnosis, and whether medicalthoracoscopy should be used todetermine malignancy in additionto tissue biopsy.“You can do tests related to thepleura using PET scanning to providea prognosis on how aggressivethe tumour is and the locations itmight have spread to. In the caseof mesothelioma, it is possible tomeasure the total glycolytic volumewhich provides a measure ofhow well a patient will respond tochemotherapy,” he said.In addition to his clinical work,Gleeson will present his researchthat highlights a common misunderstandingof lung anatomy. He hasfound that the intercostal artery isnot necessarily where people thinkit is located. “Most people are taughtthat the intercostal artery lies inthe flange of the rib on the undersurface where it is protected fromBtrauma, but actually it does not liein the flange of the rib in the posteriorregion, and is not protectedfrom interventional procedures performedmedial to the angle of therib. With age, vessels become kinkedand the flange may not protect theintercostal artery as well if at all,”he explained.He will also use the session topresent insights from his experienceof conducting pleurodesis as a palliativemeasure. He will discuss howto train, who to drain and whether apleurodesis or chest drain is necessary,as well as the risks associatedwith these procedures.Pleural effusions in patients withmalignancy are common and notwell managed, according to Gleeson.He points out that it would be helpfulif all hospital healthcare providersand GPs understood a commoncare pathway so patients do not getmissed under GP or emergency care.The vast majority (around 75%)of large pleural effusions are dueto malignancies. In the U.K., witha population of 60 million, therewould be about 100,000 malignantpleural effusions. It is common, andthe difficulty is that imaging is sogood that tiny amounts of pleuralfluid can be detected in patients withheart failure, he added.Understanding the cause ofpleural effusions is a huge issueworldwide, which Gleeson fears ismanaged very badly. He stressedthat there was a need for greaterunderstanding of different ways ofmanaging the patient. For example,after diagnosis of malignancyis confirmed, a physician needs todecide if the patient is suitable forchemotherapy and to provide themost minimally invasive procedurepossible so the patient can leave hospitalpromptly.“The vast majority of radiologistsand physicians don’t knowabout how best to manage pleuraleffusions. Advice should be soughtfrom experienced radiologists andrespiratory physicians on the managementof symptomatic relief ofpleural effusions,” he concluded.Special Focus SessionSunday, March 10, 14:00–15:30,Room F1SF 14a: Palliative interventionaltechniques in cancer▶▶Chairman’s introductionK.A. Hausegger; Klagenfurt/AT▶▶Cementoplasty of lytic bonemetastasisA. Gangi; Strasbourg/FR▶▶Pleural drainage, pleurodesisF. Gleeson; Oxford/UK▶▶Percutaneous nephrostomy(PCN) and ureteral stentingF. Orsi; Milan/IT▶▶Biliary proceduresM. Krokidis; Cambridge/UK▶▶Panel discussion: How invasivecan palliation be? When to sayno to palliative treatment?#SF14a #ECR2013F1AA B CBA: Painful lytic rib metastasis.B: Cementoplasty of the rib, again givingexcellent pain relief.A: Large painful lytic metastasis of the iliac bone with extension to the acetabulum. Pain resisting radiotherapy. The iliac metastasis doesn’t need consolidation (not weight-bearing bone) and istreated by cryoablation with two cryoprobes. Cementoplasty needle positioned in the acetabulum.B: Visualisation of the ice ball during cryoabaltion of the iliac metastasis.C: Cementoplasty of the acetabulum for consolidation and pain management.(All images provided by Prof. Afshin Gangi)myESR.org | #ECR2013 @myESR

12 ECR Today 2013 Clinical CornerSunday 10 March 2013Advances in forensic imaging bringnew opportunities for radiologyBy Simon LeeThe ability to spot pathologicalimaging findings among normalpost-mortem signs of degenerationmay not be a universal skill amongradiologists, but it could prove tobe a useful, if not essential one. Asthe reliability of modern forensicimaging rapidly improves, forensicpathologists are increasinglyseeking the help of radiologists toexamine bodies non-invasively, sothey should be prepared to answerthat call, according to experts whowill speak in a Special Focus Sessionon ‘Advances in forensic imaging’today. The development of techniquessuch as spiral volumetricCT and, more recently, MRI, havedramatically improved the abilityof radiologists to determine causesof death and detect other crucialpost-mortem signs, providing aninvaluable service that can supplement,and in some cases replace,traditional autopsy.However, training and regulationhave not kept up with the paceof technological progress, meaningthere is still plenty of roomfor improvement in this growingbranch of radiology. This afternoon’ssession will see established forensicradiologists review the current stateof the field and discuss the most usefulimaging techniques available.Due to its strengths in the visualisationof bone structure and thedetection of embolisms and grossabnormalities in soft tissue, CT hasbeen widely used in forensic pathologyfor some time. Its advantagesover MR in terms of the availabilityof equipment, relative simplicity,and the time constraints inherentin examining corpses, have made itthe dominant modality in forensicimaging. The recent development ofvolumetric measurement has giventhis lead a further boost by introducingthe ability to obtain imagesin different ways and focus morespecifically on areas of interest.“Spiral volumetric computedtomography is largely responsiblefor the incredible recent developmentof the role of diagnostic imagingin forensic medicine. If you arelooking for specific details in thePost-mortem whole-body CT angiography. Pulmonary embolism: coronal multi planarreconstruction (MPR) showing the filling defect in the right descending branch of thepulmonary artery. (Provided by Prof. Giuseppe Guglielmi)ABone and metal maximum intensity projection (MIP) reconstruction (A) and volume-rendered (VR) 3D-CT reconstruction (B). Homicidal death: characteristic bony and metallic fragmentson the exit side of the skull, where the bullet caused a large loss of brain, leading to shattering of the skull. (Provided by Prof. Giuseppe Guglielmi)skin you can make a reconstructionof the skin; if your investigation centreson the skeleton, you can reconstructbones; and if you are lookingat organs, you can reconstruct thesoft tissue. You can manipulate theimages to find the exact answer youare looking for,” said session chairmanProf. Giuseppe Guglielmi,from the University of Foggia, Italy.“This doesn’t always remove thenecessity of conducting a regularautopsy, but it helps a great dealwith the diagnosis and sometimesit proves to be enough to excludethe need for further analysis. Thereare many exciting developments inthis field that can provide informationabout causes of death, includingthose originating from the vascularsystem, time of death, identity,anthropological information likethe age, sex and stature of unidentifiedhuman remains, and, just asimportantly, details of an attack on,or abuse of, a living person,” saidGuglielmi.Thanks to the development ofspecially created contrast techniques,CT can also be used toinvestigate the post-mortem vascularsystem. Multiphase post-mortemCT-angiography (MPMCTA),which involves the performance ofone native CT scan and three angiographicphases (arterial, venousand dynamic), allows the vascularsystem to be imaged in a similarway to standard clinical CT angiography.A mixture of paraffin oiland a specially created oily contrastagent is injected via a device whichBreproduces the conditions of perfusionin a living body, enabling theradiologist to capture highly accurateimages of any abnormalities inthe vascular bed of the viscera, orlesions of the vascular system.Based on post-mortem MDCTstudies, a new approach calledvirtual anthropology has beendeveloped. In cases of unidentifiedremains, positive identification ofthe deceased can be made by usingcomparative or reconstructive techniquesto determine importantanthropological information suchas racial phenotype, age at death,sex and stature. More recently, MRIhas been used to augment forensicinvestigations, particularly in musculoskeletal,cardiovascular andangiographic fields and in forensicimaging of the living, such as casesof child abuse, survived strangulationand age estimation, accordingto Guglielmi.“At the moment, MRI is used forvery few cases because it is moredifficult to use on corpses than CT,but I am sure that forensic imagingwill increasingly turn to MRI toanswer certain questions. It is vitalthat we share more knowledge aboutforensic imaging in general, becausethere is a serious lack of awarenessabout it,” said Guglielmi.“Very few radiologists are wellinformed about this subject and itis vital that the national and Europeansocieties bring more attentionto the topic, because it represents avery real opportunity to extend ourdiscipline. If we are not training inthis area, providing personnel andtaking charge of forensic imaging,then we run the risk that pathologistswill move into this area andmake reports by themselves withoutasking radiologists. With the excellenttechnological resources availableand such an obvious opportunityfor the growth of radiology, wehave to make sure we don’t miss thechance, because this belongs to ourfield,” he added.Special Focus SessionSunday, March 10, 14:00–15:30,Room ZSF 14c: Advances in forensicradiology▶▶Chairman’s introductionG. Guglielmi; Foggia/IT▶▶Imaging in forensic medicineM. Thali; Zurich/CH▶▶Advances in post-mortem CTangiographyS. Grabherr; Lausanne/CH▶▶Virtual anthropology andforensic identificationusing MDCTF. Dedouit; Toulouse/FR▶▶Forensic MR imagingT. Ruder; Zurich/CH▶▶Panel discussion:Which imaging technique forwhich forensic scenario?#SF14c #ECR2013ZEPOS DiscussionsTo enhance interaction, discussions on hot topics in radiology have beenarranged, where authors of the selected and best-scored posters in each fieldwill discuss them with a moderator.All discussions take place in the EPOS Area in Foyer A (2 nd level) and ECRdelegates are welcome to join, listen, and discuss with the experts. Today‘sdiscussion round will be:Sunday, March 10, 12:30–13:00Vascular imaging: CT, MR – or something completely different?Challenges in imaging peripheral artery occlusive diseaseModerator: Christian Loewe; Vienna/AT#ECR2013 @myESR | myESR.org

Sunday 10 March 2013Clinical CornerECR Today 2013 13Excitement builds over digital breasttomosynthesis, but debate surroundsits screening roleBy Rebekah MoanWill digital breast tomosynthesis(DBT) replace mammography forbreast cancer screening? The answeris ‘maybe’, and it depends on howwell the modality performs in someforthcoming clinical trials, say twoexperts who will share their viewswith ECR attendees at this afternoon’sspecial focus session.The sensitivity of mammographyfor the detection of breast cancer isless than optimal, primarily becausethe breast is a 3D structure that isprojected on to a 2D radiographicimage. This means normal breasttissue can conceal a tumour. DBTis a 3D radiographic technique thatreduces the effect of overlapping tissuesin breast cancer detection.DBT appears to be gaining inpopularity. The technique improvesthe accuracy of finding cancers, aswell as reducing the recall rate ofwomen with suspicious findings,especially in younger women andthose with dense breasts, accordingto Dr. Martin Yaffe, a senior scientistof imaging research at SunnybrookResearch Institute and a professorin the departments of medicalbiophysics and medical imaging atthe University of Toronto, Canada.“That’s what the excitement is allabout,” he said in an interview withECR Today.DBT is exciting because it’s thenewest and most realistic competitorto digital mammography thathas come up in years, according tofellow speaker Dr. Sophia Zackrisson,an associate professor of diagnosticradiology at Lund University,Skåne University Hospital inMalmö.“It is a similar technique to digitalmammography, with images that arelike digital mammography, so theradiologists can easily adapt theirreading of this new technique,” shesaid. “It is also easily integrated inthe clinical setting. This is in contrastto MRI, for instance, which is moreexpensive, time-consuming, andmore challenging in interpretation.”In tomosynthesis, the x-ray tubemoves over a range of angles about apivot point located above the digitaldetector to obtain a series of lowdosedigital projection radiographs,Yaffe explained. The detector maybe stationary or also rotate aboutthe pivot point. The x-ray tube mayIn this screening case, an asyptomatic woman has a tumour that is not discernible on digital mammography (left), but appears as a clearly visiblespiculated lesion on digital breast tomosynthesis (white arrow), which shows the slice where the lesion is in focus. The lesion is a 13 mm invasiveductal carcinoma, grade 2. (Provided by Dr. Sophia Zackrisson)temporarily halt as each projectionis acquired or may move continuouslyduring acquisition.A computer algorithm reconstructsa 3D image. The images areusually viewed as a ‘movie-loop’where adjacent x-y planes are displayedsequentially. Imagers are ableto see structures within the breastwithout overlap. The tumour isclearer, easier to see, and separatefrom structures in the breast.“Tomosynthesis from what we’veseen is promising in the NorthAmerican context, where a highpercentage of women get calledback,” he said. “We can reduce thatrate by 30% or more as well as findsome cancers that have not beendetected.”Tomosynthesis’ most likely applicationis in breast cancer screening,but its precise role will only be determinedafter a study that is comparingfull-field digital mammographywith DBT, the T-MIST trial, a multivendor,multisite trial. The trial isonly for sites in North America, butwill have implications for countrieson other continents as well.“Personally, I do not think it(DBT) should be used in screeningbefore we have evidence from trialsshowing that we gain in detectionand not lose too much on the falsepositiveside,” Zackrisson said.During his presentation, Yaffe willexplain how tomosynthesis works,point to preliminary results of theT-MIST trial, show images, andexplain why tomosynthesis is betterthan conventional projection. InZackrisson’s lecture, ECR delegateswill get a good overview of DBTand hear results from recent studieswith updates on the accuracy ofthe technique.“Aspects of reading time andimage presentation will be discussed,which is important sincethis is one of the major obstaclesat least in screening,” she said.“What views should be used? Howshould the image stacks in digitalThe T-MIST trial should answer the questionas to whether digital breast tomosynthesiscan replace digital mammography, accordingto Dr. Martin Yaffe, from the University ofToronto, Canada.breast tomosynthesis be presented?Can we find a presentation modewhich is acceptable in the screeningworkflow?”DBT is a promising tool in breastimaging, she concluded. However,further evidence from the ongoingtrials is needed to establishits place in breast cancer diagnosisand screening.Special Focus SessionSunday, March 10, 16:00–17:30,Room F2SF 15b: Digital breasttomosynthesis▶ ▶ Chairman’s introductionG. Gennaro; Padua/IT▶▶Optimisation of imageacquisition and reconstructionin DBTM.J. Yaffe; Toronto, ON/CA▶▶Current role of DBT indiagnostic imagingS. Zackrisson; Malmö/SE▶▶Clinical aspects of computeraided detection and diagnosisin DBTH.-P. Chan; Ann Arbor, MI/US▶▶Panel discussion: Digitalbreast tomosynthesis:replacing or just supportingstandard mammography?#SF15b #ECR2013F2Reduceenergy usein your hotel.Even turning down the heatingand reusing towelsby one degreecan make a difference!myESR.org | #ECR2013 @myESR

14 ECR Today 2013 Clinical CornerSunday 10 March 2013Keep aware of looming difficulties inassessment of MR-compatible devicesBy Edna Astbury-WardMost radiologists have a basicunderstanding of which implanteddevices are contraindicated for anMRI scan, but due to the rapiddevelopment in MR-compatibledevices, it is very difficult to staycompletely up-to-date with the widearray of new devices and implants.Help is now on hand at thismorning’s risk assessment and riskcommunication refresher course,at which ECR attendees will learnabout the importance of being awareof the latest trends and developmentsin MR-compatible devicesand where to go for the best adviceon this important topic. They willalso learn about the best ways toexplain about risk to patients.“In the near future it will bemore and more difficult to assessthe safety of different patients enteringthe MR suite because there is atrend towards the use of more powerfulMRI machines, higher mainfield strength, stronger gradients,and more and more ‘MR compatible’devices are coming to market,which makes it particularly difficultto assess compatibility,” said Dr.Ronald Peeters, from the MedicalImaging Research Center, LeuvenCatholic University, Belgium.Although the advent of MR-compatibledevices such as pacemakers,defibrillators and neurostimulators,should increase the possibility ofpatients undergoing MRI, it is nota green light to scan all patientswithout checking, he added.“Previously it was quite straightforward:patients with pacemakersor neurostimulators were notallowed on the MR scanner. Nowone has to check on an individualbasis for compatibility of a certainimplanted device in the patient,and also take into account the conditionof the implanted device,”Peeters commented. “If in anydoubt, radiologists should contactexperts such as specialist radiologistsor MR physicists to check forcompatibility.”Many patients do not understandthe difference between CT, PET andMRI, and few patients understandthe risk associated with these proceduresand implantable devices,according to Peeters. Therefore, it isalways very important that referringclinicians check for any possibleimplanted devices in their patientsprior to MRI procedures. If radiologistsrequire further compatibilitydetails, most of the latest informationis available on the internet andin online product manuals, he noted.Manufacturers also provide an ID/product card that patients carrieswith them, stating the devices type/number and possible compatibilityissues and conditions of use.Many compatible devices areactually conditionally compatible,like maximum main field strengthallowed, maximum gradientstrength allowed, maximum specificabsorption rate allowed, whichscanning protocols are allowed, etc.,and therefore the correct literatureand correct type of device must beknown before proceeding to MRscan.“Before a patient enters the radiologydepartment, the importanceof procedural adherence cannot beunderestimated, and when a clinicianrequests an MR examination,a checklist must be completed. Ifpatients answer ‘yes’ to certain questions,they must contact the radiologydepartment immediately toallow the MR personnel (or specialiststaff) time to check for contraindicationsor compatibility issues ofthe device,” said Peeters.Responsibility can differ, dependingon what is filled in on the checklistand if the checklist is correctlycompleted and the presence of anincompatible device has been stated,but if the patient still enters the MRIsystem, the healthcare professionalwho carries out the procedure isresponsible. If the problematicdevice was not mentioned on thechecklist, then the responsibilitymay lie with the clinician whoordered the scan, or the patientwho may not have properly filledin the questionnaire, he explained.On the other hand, if the manufacturerstates wrongly that the deviceis compatible and an adverse incidentoccurs and the manufacturer’sconditions for scanning havebeen followed, the manufacturer isresponsible.The task of communicating riskvaries from case to case, as individuals’levels of knowledge and expertiseabout specific subjects vary, saidDr. Gaya Gamhewage, from thedepartment of communications inthe Office of the Director-Generalat the World Health Organization,Geneva, Switzerland.“As experts, our perception ofrisk from a radiological procedureis vastly different to patients’understanding of the concept ofrisk from undertaking such a procedure.Communicating risk topatients is complex and requirestime,” she said. “Voluntary risktakingamongst people is completelydifferent from enforcing aperson to take a risk against theirwill – for example, voluntary riskmay include such things as cigarettesmoking or engaging in riskysexual behaviour – whereas forcinga person to do this against theirwishes may increase their perceptionof the riskiness.”Gamhewage advises that for somepatients, the emotional response tothe risk is disproportionate to theactual risk involved, so interpersonalskills and levels of sensitivityand intelligence are importantwhen communicating actual andperceived risk to patients. Staff mayneed to engage on an emotional levelto gain the trust and co-operation ofthe patient initially and then providethe facts – a process referred to asDr. Ronald Peeters discusses a complex case with his colleague.precautionary advocacy. Outragemanagement, on the other hand, isabout getting people to calm downso they will listen.“It’s no good just telling people tocalm down, when clearly they areangry about something. It’s aboutexplanation and being on their side;for example, ‘I can see you are angryabout that, let me explain why weare doing this’. You need to validatewhat they feel. Unless you understandon an emotional level abouttheir anxieties, people will let youspeak but they won’t heed youradvice,” she said.Looking to the future of risk management,Gamhewage commentedthat the area of risk managementis competing with the internet,which is a source of both reliableand unreliable information. Doctorswere once the only trusted source ofhealth information for patients, butthat’s no longer the case.“Ignore social media at yourperil! If you say that the internetonly has rubbish on it, then it isyour job to direct patients to reliablesites. You need to give peopleinformation on the channels thatthey want,” she noted. “I feel it’svital to incorporate risk communicationstraining into continuingmedical education. We can’t beegotistic and say ‘well I told them’,because that’s not how the worldis any more.”Refresher Course:Physics in RadiologySunday, March 10, 08:30–10:00,Room L/MRC 1213: Risk assessment andrisk communication▶▶Chairmen’s introductionM.M. Rehani; Vienna/ATP. Vock; Berne/CHA. Radiation risks for patientsand staffE. Vaño; Madrid/ESB. Risk in MRIR. Peeters; Leuven/BEC. Communication of risk topatients and publicG. Gamhewage; Geneva/CH▶▶Panel discussion:How to communicate risk topatients and the public?#RC1213 #ECR2013LMESOR ASKLEPIOS Courses, 2013The established ASKLEPIOS project is tailored toward serving professional development byaddressing recognised needs in the context of continuous radiological education. Its programmesinclude multithematic, organ-oriented, multimodality and multidisciplinary advanced courses, aimedat senior residents, general radiologists, private practitioners in radiology, and allied specialists.Urogenital Cross-Sectional ImagingApril 10–11, Cairo/EgyptContrast Enhanced Ultrasound (CEUS)May 9–10, London/United KingdomMultimodality CourseSeptember 27–28, Warsaw/PolandEmergency RadiologyOctober 4–5, Rostov-on-don/RussiaCardiovascular ImagingNovember 1–2, Beirut/LebanonMultidisciplinary Approach of Cancer ImagingNovember 7–9, Rome/ItalyPick up the complete ESOR 2013 Programme Brochure from the ESOR Booth.#ECR2013 @myESR | myESR.org

Sunday 10 March 2013INSIDETODAYDedicated workstationscrucial forsuccess of lowdoseCT lung cancerscreeningSee page 19Technology FocusTowards instantcomputationalsupport for interactivediagnosisSee page 20CT colonography:Accurate registrationof prone and supineendoluminal surfacesof colonSee page 21ECR Today 2013 17PACS developers put renewed emphasison patient empowerment and safetyBy John BonnerPACS is now a mature technology inEurope, but who has benefitted fromits introduction? Certainly, radiologistsand radiographers have gainedbecause they now have a reliable toolfor storing and accessing vital diagnosticdata. Also, hospital administratorstend to feel reassured thatmedical staff in all departments canwork more efficiently and provide ahigher quality of service.Yet what about the patients themselves?In truth, it is unlikely thatmany of them will have even heardabout the huge changes in workingpractices that have occurred overthe past two decades as a result ofthe digital revolution, but that situationis changing rapidly, as visitorsto the commercial exhibition at ECR2013 can see.Companies in the healthcare ITsector are developing PACS applicationsthat don’t just passively supportthe diagnostic process by providingkey information. Instead, thereis increasing evidence that thesetechnologies can actively direct thedecisions made by medical staff andalso help patients to have a say intreatments they are given.Sectra, for instance, has developedits DoseTrack software toautomatically monitor the radiationdose received by patients inthe course of their treatment andto help physicians to keep the doseas low as possible. The product hasbeen in use since 2008 in a networkof 10 hospitals in the Skåne regionof southern Sweden, where it hasanalysed data from more than 2million examinations in a range ofdifferent radiology modalities. Theoriginal project was set up by MatsNilsson, a professor in the departmentof medical radiation physics atSkåne University Hospital, Malmö,and developed as a collaborativeproject between the academic andindustry partners.DoseTrack can access and storeinformation from any imagingmodality that can transfer doseinformation using a DICOMradiation dose structured reportor DICOM modality performedprocedure step, according to thecompany. For older technology, itmay also be possible to acquire theinformation manually. DoseTrackcan manage information from CT,fluoro/angio, conventional x-rayand mammography.“Patient safety is obviously themain driver for this technology, butthere are other reasons. It is helpfulfor different clinics to determine thedoses given to patients in the variousmodalities and it will also alertthe technicians if there is somethingwrong with the equipment used,”explained Marie Ekström, vicepresidentof Sectra’s radiology ITbusiness. “Clearly, different modalitieswill create different exposureto radiation, so this helps staff tosteer their investigations towardsthe modality which will provide theoptimal results in terms of radiationexposure and the clinical informationobtainable.”She noted that the system can alsobe used to set thresholds for dosealerts, and it creates a way of integratingreports with national registries.But at the local level, it willalso put the radiology departmentback where it belongs at the centreof all activity within the hospitaland empower individual patients,she claims.“It is important in cases such asthose individuals who may haveto be given chest examinations asneonates. Later in life, they willknow to avoid unnecessary examinations.So this helps the patient totake control over their own healthcare,which is something that is happeningall over the world,” Ekströmsaid.Carestream Healthcare is awareof this trend, and is making itscontribution through the MyVuepatient portal that it is showingfor the first time at ECR 2013.This application allows patients tosecurely access, manage and sharetheir medical images and radiologyreports with their own physicianand other healthcare providers. Thehospital creates a unique and securelog-in that is emailed to the patientafter an examination. Through this,the patient can download informa-continued on page 18The Vue Cloud service from Carestream offers the flexibility of a monthly fee and canaccommodate growth without the need for hospitals to fund and manage network expansions.Siemens’ syngo.Breast Care Reading is the client-server application for state-of-the-artmammography and unique tomosynthesis reading.Part of the screen image for Sectra’s DoseTrack comparing radiation levels in differenthospitals and modalities.Fuji’s Synapse Enterprise suite of products aims to provide improved image visualisation,enhanced ease-of-use and increased efficiency.The syngo.via WebViewer from Siemens enables fast reading and viewing of images within thehospital. Connection is possible from anywhere within reach of the hospital network through asecure VPN connection.myESR.org | #ECR2013 @myESR

18 ECR Today 2013 Technology FocusSunday 10 March 2013continued from page 17tion to a PC, laptop, or tablet. It iseasier to use and more convenientthan managing DVDs, CDs or otherphysical storage formats for medicalrecords.“The healthcare industry is movingto embrace new technologiesthat allow patients to play agreater role in their medical care,”said Saskia Groeneveld, Europeanregional marketing manager for thecompany’s healthcare informationsolutions business. “With MyVue,healthcare providers can also benefitbecause they can use the patientportal to boost referral volumeswhile simultaneously reducing thetime and cost of outputting medicalexams on to DVD/CDs or radiographicfilm.”MyVue is currently available asan option for the Vue PACS andVue Archive (which uses third-partyPACS) users and is now availableas part of the Vue Cloud Service.Launched in February 2013, theservice reportedly offers the flexibilityof a monthly fee and canaccommodate growth without theneed for healthcare facilities to fundand manage network expansion interms of additional patient users.Meanwhile, Siemens Healthcareis striving to improve diagnosticdecision-making and speed workflowthroughout the hospital andbeyond with new applications forits 3D routine and advanced readingsoftware syngo.via, as well as anupdate for its syngo.plaza system.“The latest version of syngo.viadoesn’t just give our customers theopportunity to view images, it givesthem the full picture, allowing themto dig deeper into that image andextract more clinical information,”said Dr. Marc Lauterbach, directorof global marketing with Siemens’syngo business unit. “A good exampleof this is our new bone applicationfor CT images. When lookingfor fractures or metastases in a rib,radiologists would normally have toscroll through the image and examinemultiple planes. This applicationautomatically ‘unfolds the ribs’ andpresents the different bones in anunobstructed view. It also labels eachbone so that the site of the lesion canbe rapidly identified in the report.”Syngo.via is still a relatively newproduct, and researchers from Siemensare busy developing softwareto incorporate new imaging modalities.The current version allows staff inclient hospitals to access and displaymaterial from CT, MRI, nuclear medicineand angiography, and the newversion launched at ECR 2013 alsoincludes a mammography function.For users of mobile devices, Siemenswill also show how productslike the iPad can be used for diagnosticreading when the physician ison the move. The latest version of thesyngo Web Viewer provides access toimages from CT, MRI, computed anddigital radiography, PET and PET-CT devices. It features new layoutsthat allow the display of multiplanarreconstructions on one screen.At the Philips booth, the companyis demonstrating the fruitsof its efforts to extend the abilityof teleradiology users to influenceclinical decisions by including newmodalities. It has broadened the visualisationcapabilities available onits web portal, IntelliSpace, with theintroduction of advanced MR cardiacand neuro processing features.First launched in 2010, IntelliSpaceis a thin-client applications serverand ‘virtually access-anywheresolution’ for multimodality clinicalreview, analysis and diagnosis,with key applications for CT, nuclearmedicine, and MRI.The underlying technology issimilar to the advanced capabilitiesavailable today on the dedicated MRworkstation in Philips’ portfolio.However, optimised workflow andtask guidance have been introducedto create an easy to use and moreeffective system, according to thevendor. It will enhance the abilityof customers to perform their workwithout the need to move betweenlocations or systems. Furthermore,by allowing physicians to reviewdata without the need to install dedicatedworkstations, it will enhancethe ability of different hospitals tocollaborate more easily in makingthe final diagnosis, the companyexplained.GE Healthcare is heading in asimilar direction with the launchof its Universal Viewer, which bringstogether advanced visualisation,intelligent productivity tools, andmultimodality workflow for oncologyand breast imaging, all withinone intuitive workspace that can beaccessed anywhere, anytime. Thesystem is compatible with CentricityPACS, Centricity PACS-IW, andthe Centricity Clinical Archive.Based on independent research,GE said Universal Viewer has thepotential to provide a 5% productivityimprovement in departmentsusing the system. It has a unified userinterface with a look and feel that iseasy to learn and able to adapt toradiologists’ preferences, automatingexamination setup. Referringphysicians can access the viewerfrom anywhere, and patients canget from the examination to theirresults in less time, GE explained.Fujifilm is promoting ‘clinicalvalue’ products at ECR 2013.Synapse 3D aids clinical decisionsupport by providing a comprehensivesuite of advanced visualisationapplications aimed at improvingdiagnosis and surgical outcomes,the company states. SYNAPSE ERmis a specialist mobile application foracute stroke and emergency treatment.It supports fast and easy communicationswhile also providingimages and related clinical data onmobile devices, enabling specialistsoutside of a hospital to supportemergency diagnosis and treatment.Finally, Agfa HealthCare is demonstratingits IMPAX RadiationExposure Monitoring (REM) solution,which provides an automatedway to collect, organise and analysea patient’s radiation exposuredata. It tracks radiation exposureinformation across multiple modalities,departments and institutions,according to Agfa.Visit the Technical Exhibition!And learn all about the most recent developments in healthcare technology.Opening hours:EXPO Halls and EXPO Foyer DFriday, March 8 to Sunday, March 10: 10:00–18:00Monday, March 11: 10:00–14:00First Level (Gallery)Thursday, March 7: 14:00–18:00Friday, March 8 to Monday, March 11: 10:00–18:00PACS in 2013: back to the future of radiologyBy Theo AhadomeAfter focusing on enterprise IT(vendor-neutral archiving, EMRintegration,cloud storage andadvanced analytics) over the lastthree years with limited success,there are renewed calls for PACS toreturn to a focus on radiology. Inparticular there is a need for PACSproduct development to be realignedwith the current and future requirementsof radiologists, including theneed for improved productivity andenhanced diagnostic capabilities.Over the past three years,PACS has provided, or at least hasattempted to provide, enterprisefunctionality including enterprisearchiving, universal access and analytics.However, the failings of PACSenterprise functions were exposedas workflow became more complex,requiring true application interoperability.In addition, new data sharingprotocols and economic pressurescould not cope with rising storagevolumes and the subsequently largedata handling costs.Today’s PACS challenge is tochoose which enterprise and analyticscomponent, if any, can bereliably delivered by PACS, andensuring PACS works well withthe third-party systems that arebetter able to deliver on certainfunctions. Indeed, there is a strongcase for PACS to withdraw allproprietary enterprise access andanalytics functions, allowing middlewarespecialities to tackle thesewhile the PACS provides a strongerfront-end. In other words, there isno need for any PACS to try to bea VNA and advanced visualisationtool, as well an enterprise analyticsengine. Moreover, these are not themajor requirements of their coreusers – radiologists. However, asIT purchasing power increasinglygoes towards the enterprise, PACSsuppliers stand the risk of neglectingtheir core users by trying to appeasetheir new partners.Rather, there is a need for PACS tocome back to radiology by reducingthe time radiologists have to spendanalysing images, improving andstreamlining the user interface andenhancing diagnostics. Productivitygains, for example, are achieved viasophisticated hanging protocols thatpre-determine optimal image presentation,and intelligent systems thatlearn and help repeat a user’s preferredworkflow per study type. Researchand development efforts should focuson introducing such features thatimprove radiologist’s productivityand make PACS easier to use.In the advanced diagnostics field,technology barriers continue to bebroken – techniques which werepreviously considered advancedvisualisation (AV), including maximumintensity projection (MiP) andmultiplanar reconstruction (MPR),are now increasingly being incorporatedinto imaging systems asstandard. This has proven valuableto both clinicians and radiologistsas a diagnostic aid, to improve confidenceand for pre-operative planning.Where a third-party systemis available, and PACS in itself doesnot provide advanced visualisationtools, then the key is integration –the ability to seamlessly access andapply AV from PACS as though theywere one complete solution. However,third-party AV is not necessarilythe answer, and as radiologistsincreasingly use advanced visualisationtools some AV functionswill be delivered by PACS. The keyis to define the threshold betweentools required routinely and thoseonly needed for advanced analysisin a smaller number of cases.Increasingly, radiologists are performing3D cross-referencing andpost-processing for CT, PET-CT,MPR and MiP. It is those tools thatPACS should increasingly incorporate,while leaving more advancedKey strengths of different imaging informatics software. Overlap indicates required combinationof products to achieve combined benefits.diagnostic analysis to third-partysystems.The combinations of PACS andthird-party systems achieve radiologyand enterprise benefits througha best-of-breed, application neutralenvironment (Figure). Best-ofbreedhere refers to systems, notvendors – there is a whole differentdebate as to whether any one vendorcan provide more than one bestof-breedsystem. It is this author’sopinion that it can be achieved – solong as application independenceand interoperability can be clearlyproven. That, however, distractsfrom the core of the argument – forPACS to refocus on what it is goodat: helping radiologists performtheir work better.Theo Ahadome is a senior marketanalyst at the healthcare IT researchgroup at InMedica, a division of IHS(NYSE:IHS). InMedica is a providerof market research and consultancyin the medical electronics industry(www.in-medica.com).#ECR2013 @myESR | myESR.org

Sunday 10 March 2013Technology FocusECR Today 2013 19EIBIR presents IMAGINEAfter last year’s success, EIBIR is again hosting the IMAGINE Workshop, under the heading ‘Novel technology thatshapes radiology’. IMAGINE aims to stimulate interaction between imaging researchers and radiologists. Leadinginternational academic and industrial research groups present their latest developments in medical imageanalysis and image-guided interventions. During the interactive software demonstration sessions the visitorsget hands-on experience with developed techniques and tools. The presenters of the workshops were invitedto introduce their work in ECR Today.Dedicated workstations crucial for successof low-dose CT lung cancer screeningBy Colin Jacobs,Eva M. van Rikxoort,Jan-Martin Kuhnigk,Thorsten Twellmann,Pim A. de Jong,Ernst T. Scholten,Cornelia M.M. Schaefer-Prokop,Mathias Prokop,Bram van GinnekenAt present, lung cancer is the mostcommon and most deadly cancerin men and women worldwide.The five-year survival rate for allstages combined is only 16 percent.If the disease is still localised whendetected, the five-year survival rateis substantially increased (52 percent).Therefore, screening has beenproposed as a means to detect lungcancer at an early stage. The recentpositive results from the NationalLung Screening Trial (NLST) in theUnited States have provided scientificevidence that screening with lowdosechest CT reduces lung cancermortality. The National ComprehensiveCancer Network has revised itsrecommendations for screening andnow strongly recommends the use oflow-dose CT screening for individualsat high risk of lung cancer.In its current form, however, thelarge scale introduction of CT lungscreening would put an enormousburden on radiologists. Therefore, itis crucial to develop dedicated chestreading workstations with a numberof innovations that allow for an optimisedhigh throughput workflowfor reporting on low-dose chest CTscans. Building upon our clinicaland technical experience in reading,image analysis and data processingfor large screening trials in Europe(over 30,000 CT scans from 10,000participants) and a careful review ofthe existing commercially availablelung workstations, we have developeda prototype for a dedicatedchest reading workstation.An important component of theworkstation is computer-aideddetection (CAD) of pulmonarynodules. We have developed twoCAD systems for detecting solidnodules and subsolid nodules, bothof which have been extensively evaluatedusing data from the Dutch-Belgian lung cancer screening trial(NELSON). Both CAD systemshave been integrated in the workstationand the user can adjust thenumber of marks that are displayedby the CAD systems. Presentedmarks can quickly be accepted orrejected. High throughput readingwith CAD, as a first reader operatingat high sensitivity, is supported.In this reading mode, the user canreject incorrect CAD marks, butdoes not have to inspect the entirescan section by section.Furthermore, a completely automaticelastic registration between thecurrent and prior scans is performedto allow linked scrolling. Prior scansof the same patient are presented on asecond screen and the radiologist caneasily switch between various priorscans to compare lesions over time.Importantly, the elastic registrationis also used to add annotated lesionsfrom prior scans to the current scans,which have to be accepted or rejectedby the radiologist.Advanced segmentation algorithmshave been included, whichhave been designed to handle complexvascular and pleural attachments,and subsolid nodules canbe delineated automatically in 3D.Volumetric segmentations of thesame lesion in prior scans are displayedto allow the user to checkfor consistency of the segmentationsover time. Important characteristicsof the lesion are calculatedautomatically, such as volume, mass,average density, equivalent diameter,volume doubling time (VDT),and mass doubling time (MDT).Mass has been shown to be a moreimportant predictor of growth forsubsolid nodules. Lesions with suspiciousvalues for VDT or MDT areautomatically flagged.Finally, findings have been summarisedin a structured report inHTML and PDF format in a database,and can be sent to physiciansand PACS upon request. Followuprecommendations according tovarious screening algorithms andguidelines from leading societies,including the upcoming revisedFleischner Society guidelines for themanagement of pulmonary nodules,can be included in the reports.The application is currently availableas a research prototype andis in use at five sites. The currentprototype will be presented at theIMAGINE Workshop presented bythe European Institute for BiomedicalImaging Research (EIBIR).More information about theproject can be found atwww.diagnijmegen.nl,www.mevis.fraunhofer.deC. Jacobs, E. M. van Rikxoort,M. Prokop, and B. van Ginnekenbelong to the Fraunhofer MEVIS,Diagnostic Image Analysis Group,The Image Interpretation sessions, two traditional highlightsof every ECR, provide both education and entertainment. Twopanels of distinguished radiologists will share their knowledgeand diagnosis strategies with you.Sunday, March 10, 13:00–14:00, Room AJunior Image Interpretation Quiz: Golden EyeModerator: A. Alguersuari; Sabadell/ESCo-Moderator: E. Belmonte; Barcelona/ESPanellists:G. Gherarducci; Pisa/ITC. Sayer; Brighton/UKC.M. Sommer; Heidelberg/DEL. Tzarouchi; Ioannina/GRA. Vanrossomme; Brussels/BEComputer-aided detection (CAD): marks for both solid and subsolid nodules are precomputed for each case to be accepted or rejected by the user(Case courtesy of the NELSON screening programme).Side-by-side comparison of segmentations of the same lesion, from current and prior scans, in three orthogonal directions is supported, allowingsegmentation consistency and lesion growth to be checked. Each column shows a time point. The rows show axial, sagittal and coronal views,respectively (Case courtesy of the NELSON screening programme).Radboud University NijmegenMedical Centre; J.-M. Kuhnigkfrom Bremen/DE is associated clinicianat the same institute; C.M.M.Schaefer-Prokop from Amersfoort/NL is chair at the same institute.T. Twellmann works at MeVis MedicalSolutions AG in Bremen/DE;P. A. de Jong works at the UniversityMedical Center Utrecht/NL; andE. T. Scholten is from Haarlemmerliede/NL.STAFF BOXEditorsJulia Patuzzi, Vienna/ATPhilip Ward, Chester/UKEditorial TeamMichael Crean, Vienna/ATSimon Lee, Vienna/ATContributing WritersEdna Astbury-Ward, Chester/UKJohn Bonner, London/UKMichael Crean, Vienna/ATJaveni Hemetsberger, Vienna/ATSimon Lee, Vienna/ATBecky McCall, London/UKRebekah Moan, San Francisco, CA/USAlena Morrison, Vienna/ATMélisande Rouger, Vienna/ATFrances Rylands-Monk, St. Meen Le Grand/FrancePhilip Ward, Chester/UKDavid Zizka, Vienna/ATLayoutPhilipp Stöhr, Vienna/ATMarketing & AdvertisementsKonrad FriedrichE-mail: marketing@myESR.orgContact the Editorial OfficeESR OfficeNeutorgasse 91010 Vienna, AustriaPhone: (+43-1) 533 40 64-0Fax: (+43-1) 533 40 64-441E-mail: communications@myESR.orgECR Today is published 6x duringECR 2013.Circulation: 22,000Printed by Holzhausen, Vienna 2013myESR.orgmyESR.org | #ECR2013 @myESR

20 ECR Today 2013 Technology FocusSunday 10 March 2013Towards instant computational supportfor interactive diagnosisBy Katja Bühler, David Major,Jiří Hladůvka and Rainer WegenkittlFully automated computer-aideddetection (CAD) systems are used,even today, in only a few specialcases. Imaging methods and diagnosticquestions are constantlyevolving and demand a paradigmshift from previously envisionedstatic CAD systems towards moreflexible interactive support systemsintegrating, rather than replacing,the diagnostic abilities of the radiologist.The majority of readings indaily clinical routine are still donein an interactive manner and oftenwith just basic computational support.Although sophisticated imageanalysis, quantification and annotationmethods have been proposedby the research community, manyof them have not been integratedinto common radiological workflowsyet. Their hardware and timerequirements are often incompatiblewith real world settings in a clinicalenvironment, where results haveto be delivered within seconds onstandard hardware.Our research aims at bridging thegap between academic research inmedical image analysis and realworld applications. We investigatemethods amalgamating sophisticated,fully automated server-sideimage processing with the cognitiveskills of the radiologist by enablingA method that automatically labels the spine on CT scans, based on a combination of a machine learning-based classification approach anditerative matching of local models, captures the appearance and morphometry around two subsequent vertebrae, presented by researchers fromthe VRVis centre in Vienna.them to enhance the automaticresults through online interactionwithin seconds, allowing them toreach a final diagnostic decision.The goal of our research is to minimisethe user interaction and timerequired for expensive server-sideimage processing tasks by exploitingthe time from scanner to workstation.The major challenge we face inthis context is splitting the processingpipeline into parts, which canbe robustly implemented in a fullyautomated manner and react interactivelyand semi-automatically,almost in real time; even under realworld conditions.During the IMAGINE session wewill showcase two solutions followingthis paradigm: The spine providesan internal frame of referenceto describe positions in the superiorpart of the human body. Its usagerequires the semantic annotationof vertebrae and disks, which is,especially in 3D data sets, an inconvenienttask. We present a methodthat automatically labels the spineon CT scans based on a combinationof a machine learning-basedclassification approach and iterativematching of local models, capturingthe appearance and morphometryaround two subsequent vertebrae.The algorithm showed robust handlingof full and partial scans of thespine. Our tests report high recall(95.5 percent) and precision (99percent) rates. Nevertheless, themethod might deliver shifted results,or even fail completely, in certaincases like the presence of extremepathologies. For these cases we haveincluded the ability to interactivelymanipulate the result delivered asan offline pre-processing step onthe server. For cases of completefailure it is possible to initialise anew labelling sequence by placinga single label that delivers almostinstantaneous results.Computer-aided tracking ofblood vessels in CTA images isthe basis for many higher leveldiagnostic tasks in the context ofvascular diseases. The high morphologicalvariability of vesselsystems and high variations incontrast agent saturation hamperthe development of completelyautomatic methods. We presenta hybrid solution that performsthe time consuming model-basedtracking of possible vessel segmentsas a preprocessing step onthe server. Vessel tree growing, i.e.the selection and connection ofrelevant vessels, can be performedsemi-automatically on the clientwithin seconds. The integration ofanatomical region dependent rulesleads to a highly robust solutiondelivering, in most cases, the wholetree of relevant vessels with just oneclick, even in the presence of vesselgaps caused by small or mediumsize stenosis or soft plaque. Ourmethod has been tuned and testedfor CTA datasets of peripheralvessels of the lower limbs. Futurework includes the extension of themethod to other vascular systems.We would like to invite you toshare your opinion and ideas onour approaches and solutions in apersonal discussion with us. Oursoftware is on display at the VRVisbooth at IMAGINE.Katja Bühler, David Major and JiříHladůvka work at VRVis Zentrumfür Virtual Reality und VisualisierungForschungs-GmbH in Vienna/AT. Rainer Wegenkittl works atAGFA Healthcare, Vienna/AT.VRVis is Austria’s leading centre forapplied research in the field of visualcomputing and acts as a bridge betweenacademia and industry. The presentedprojects are results of a joint technologytransfer project with AGFA Healthcareand are supported by FFG as part ofthe Austrian COMET initiative..artundwork designbüroEmbracing lifethrough better medicalimaging solutions.Better medical imaging solutions for the needs of our customersWe have been committed to delivering outstanding medical imaging solutions over decades. Original solutions, that havegrown out of the groups' expertise and technical know-how, providing innovations that meet equally the Zeitgeist and theneeds of our customers and their patients.Visit us at booth 320 in Expo Cand discover “solution stars in radiology”Hitachi Medical Systems Europe Holding AG · Sumpfstrasse 13 · CH-6300 Zugwww.hitachi-medical-systems.eu#ECR2013 @myESR | myESR.org

22 ECR Today 2013 Technology FocusSunday 10 March 2013Present and future trendsin imaging informaticsBy Osman RatibWith the evolution towards fullydigital imaging departments, imaginginformatics have become anintegral part of our daily practiceand have fundamentally changedthe daily workflow of many radiologists.The rapid evolution ofinformation technology (IT) andthe wide accessibility of moderncommunication tools have driventhe industry to adopt many consumer-marketsolutions into theirproducts. From the adoption ofportable tablets to the seamlessstorage of data in the ‘cloud’, innovationsin technology have broughtus many convenient solutions forwider access to information, addingflexibility and mobility for a moreefficient workflow.Acquiring knowledge in this fieldcan help radiologists better understandrecent developments in informationtechnology, and keep upwith the latest trends. It is not necessaryto become an IT expert, but tohave an idea of current concepts andIT tools that could help radiologistsimprove their daily work.To help the radiology communitykeep up with some of the recentdevelopments and technical evolutions,the ESR’s eHealth and InformaticsSubcommittee has preparedsome informative posters on differentrelevant topics in informationtechnology:• Introduction and overview onDICOM and IHE• Workstation development andmultimodality viewing• Structured reporting• Image access on tablets and portabledevices• Image compression• Radiation exposure monitoring• eLearning: overview of ESRactivities• Integrating teaching files intoPACS using IHE/TCE• eHealth: developments and initiativesin EuropeThese topics should provide ECRparticipants with a wide scope ofeducation exhibits and up-to-dateinformation on:• The principles of DICOM, whichhas become the standard in medicalimaging, and IHE, which isan initiative to enhance interoperabilityof modalities andinformation• The development of the reportingworkflow, which has changedcompletely over the past decade,now including 3D imaging, CADand new concepts in reporting• Technical developments toenhance the documentation andtracking of radiation exposure;new recommendations on the useof image compression or imagesharing with portable media (e.g.CD, DVD, USB Memory)• How to use digital infrastructureto improve activities in researchand education• The development of eHealth andthe influence of radiology• An international high-levelexpert panel on ‘image compression’initiated by the ESR• New developments in image managementand image processingThere will also be a chance tomeet experts in this area. Interestedvisitors are welcome to sharetheir experience and expertisewith the eHealth and InformaticsSubcommittee.Visit the eHealth and InformaticsInformation Booth in Foyer A onthe 2 nd Level.Professor Osman Ratib fromGeneva, Switzerland, is Chairmanof the ESR eHealth and InformaticsSubcommittee.Professor Osman Ratibfrom Geneva, Switzerland.#ECR2013 @myESR | myESR.org

Sunday 10 March 2013Technology FocusECR Today 2013 23Cardiac radiology society has anothersuccessful yearBy Valentin SinitsynCardiac radiology represents one ofthe most dynamic fields in modernradiology. This is evident from theconstant growth of cardiac radiologypapers submitted to the ECR– up to 21 percent in 2013.The Annual Scientific Meetingof the European Society of CardiacRadiology is the most remarkableand visible of its activities. EveryESCR annual meeting is a perfectcombination of tradition andinnovation.The ESCR Annual Scientific Meeting2012 continued the society’sfocus on the most important scientificand practical issues in cardiacradiology. In 2012, the ESCR annualProfessor Valentin Sinitsynfrom Moscow, Russia.meeting took place in the splendidcity of Barcelona. This vibrantmulticultural city is a very popularlocation for all kinds of medical congressesand conferences, making it anideal location for the ESCR AnnualMeeting. This meeting was a repeatof the success seen at the ESCR 2011Congress in Amsterdam. The meetingin Barcelona attracted 466 participantsfrom 44 countries. The topfive countries, by number of participants,were Spain, the Netherlands,Germany, Russia and Italy. Congresspresident, Dr. Teresa de Caralt contributedimmensely to the success ofthe meeting.The meeting in Barcelona hadmany memorable events. One ofthem was the opening ceremony:the famous Spanish-American cardiologistProfessor Josep Brugada(everybody knows about the geneticcardiac disease called Brugada syndrome)delivered a brilliant lecture,‘New concepts in cardiac imagingapplications for arrhythmias evaluation’,which was complemented by apresentation from ESCR vice-president,Professor Matthias Gutberlet.In Barcelona, the Society presentedand launched its longawaitedpan-European project,the ‘MR/CT Registry’ (www.mrctregistry.org).We invite you to join;details can be found on the website.Another major event at everyESCR annual congress, since 2009,has been the Cardiac Imaging Examination,which is now an essentialpart of the ESR-endorsed EuropeanBoard of Cardiac Radiology(EBCR) Diploma. During the lastcongress, top European and internationalexperts delivered state-ofthe-artlectures and presentationson major fields of cardiac radiology.The meeting’s educationalprogramme gave all the informationnecessary to pass the cardiacimaging examination and get theDiploma in Cardiac Radiology.There were also live teaching casepresentations during ESCR 2012.An Electronic poster (EPOS) areawith free internet access providedan excellent opportunity to becomeacquainted with electronic postersfrom current and previous meetings.The Asian Society of CardiacRadiology (ASCI) held a scientificsession during the Barcelona meeting,presenting lectures from ourfriends and colleagues in Asia.Long-standing industry partnersof the ESCR (Bayer HealthCareMedical Care, Bracco, Circle CardiovascularImaging, Covidien, GEHealthcare, RAPID Biomedical,Siemens, TeraRecon, Toshiba andWisepress) offered participants theopportunity to visit their booths atthe exhibition area, and they hadinteresting and well-attended companysymposia, which highlightedthe latest in imaging equipment andcontrast media.The ESCR continued supportingyoung radiologists through its YoungAbstract Presenter ProgrammeProfessor Josep Brugada delivered a brilliant lecture at theESCR 2012 Opening Ceremony in Barcelona.(YAPP), helping them attend annualmeetings and present their papersand posters. In 2014, the ESCR isgoing to expand this project, offeringmore grants and holding specialsessions for medical students. Eightyoung radiologists, with the eightbest posters, received ESCR MagnaCum Laude, Cum Laude and Certificateof Merit diplomas.In 2013, the ESCR Annual ScientificMeeting will be held at BMAHouse, London/UK; headquartersof the British Medical Association.The president of this congress willbe Professor Michael Rees, who ispast-president of the ESCR.We are going to offer you an interestingprogramme and some surprisesand look forward to seeingyou in London.More information about the ESCRcan be found at www.escr.orgProfessor Valentin Sinitsyn fromMoscow, Russia, is President of theESCR.Croatian Society of Radiology bringsbalance to research and educationBy Damir MiletićThe Croatian Society of Radiologyhas approximately 400 radiologistsand residents among its members.There is a very long tradition ofradiology practice in our country.Our society was founded in 1928as the Roentgenology Society,and after several changes in namebecame known as the Croatian Societyof Radiology, after independencein 1991. Our regular activitiesinclude nine professional meetingsper year and a national congressevery four years. We also continuallyparticipate in the organisationof international and regional meetings,as well as symposia such as theAlpe-Adria radiological meeting orthe Hungarian-Slovenian-Croatianmeeting.Education, professional issuesand science are all within the scopeof our activity. The Croatian Societyof Radiology also acts within professionalfields including neuro, interventional,and thoracopulmonaryradiology. Our main challenge isto find the ideal balance betweenthe narrow subspecialty approach,with the risk of handing over traditionalradiological disciplines toother clinical specialties, and thegeneral radiology approach, whichrecognises the exponential growthof radiological knowledge and thenecessity for the radiologist tounderstand not only imaging, butalso clinical data and basic medicaldisciplines. As a relatively smallsociety we are still very coherent andare traditionally known as one ofthe most active societies within theCroatian medical community.The Croatian Society of Radiologyendeavours to harmonise the educationof residents at the nationallevel, insisting on regular structuredlectures and continual knowledgetests. National level written examsare our next goal for residents’ education.Another important task isto develop an academic radiologynetwork, as well as coordinate educationand research in clinical andinterventional radiology. A lack ofinterest among young radiologistsin interventional radiology has beennoticed in previous years. Problemswith equipment and budgeting forinterventional radiology, and theproliferation of cardiac catheterisationlabs in many Croatian hospitalshave probably contributed to thissituation. We have tried to stimulateinterest in interventional radiologythrough enhanced activity by thesection for interventional radiology,with a focus on education andtraining.Professional relations and understandingbetween radiologists andradiological technologists (radiographers)is our next importantconcern. Therefore, we haveundertaken several initiatives todefine teamwork and the roles ofeach profession in the interests ofpatient safety. The quality control ofimaging services is becoming morecommon in recent years, but qualityassessment structures still need tobe better defined.Balancing radiological equipmentprocurement with the actualrequirements of radiology departmentsin our hospitals, as well asimproving the utilisation of existingequipment and radiological expertise,remain major challenges. Thegrowing volume and complexity ofthe radiological workload in clinicalhospitals has to be matched withan increase in equipment and staff.Teleradiology is a recent challengefor our radiological community. Webelieve that it could strongly influencethe radiologist’s motivationand yield substantial benefits forour patients. This process has begunwith clinical radiology in Croatianhospitals, aiming to incorporate allradiological facilities into this network.Alongside IT technology, asignificant improvement in teleradiologyrequires compatible imagingprotocols and guidelines. We alsoexpect teleradiology to balancethe workload of radiology teamsacross the country. However, thereimbursement model for radiologyservices needs to be refined. Bearingin mind our past experiences inimplementing teleradiology, expertsin particular fields of radiology wereadditionally burdened by the factthat they received no actual compensation,and it is not surprisingthat they are not eager to contributeto this initiative again.As a professional society we promotethe idea of the clinical radiologistas an advisory physician,involved not only in patient diagnosisbut also in multidisciplinaryteams responsible for follow-up andtreatment of patients. Due to theabundance of imaging modalitiesavailable to referring clinicians,radiologists actually have to performdiagnostic imaging proceduresfor a referred patient, whilealso allowing for the diagnostic reliabilityand availability of differentmodalities, cost-benefit ratio, andtotal patient radiation exposure.These demanding tasks increase theamount of clinical time dedicatedto multidisciplinary team meetingsand decrease the amount of timeavailable for traditional image interpretationand intervention. This isa great challenge which makes theradiologist an important and indispensablepart of the clinical setting.More information about theCroatian Society of Radiology canbe found at www.radiologija.orgProfessor Damir Miletić is Presidentof the Croatian Society of Radiology.ECR 2013 Smartphone AppThe ECR 2013 App gives iPhone and Android users a new way to experience the congress. The app is packed with features,including general congress information, scientific and educational programme details, news on arts & culture in Vienna,full abstracts, and even floor plans of the Austria Center. You can download the app from iTunes or via the QR code to the right ▶▶▶myESR.org | #ECR2013 @myESR

Sunday 10 March 2013Community NewsECR Today 2013 25INSIDETODAYTen years of EPOS:A decade of digitalinnovationSee page 26Horizon 2020:EU’s FrameworkProgramme forResearch andInnovationSee page 26The Metamorphosesof Egon SchieleSee page 30Accomplished professor to becomeeditor-in-chief of European RadiologyBy Mélisande RougerECR Today spoke with ProfessorMaximilian Reiser from Munich,Germany, about his ambitions andthe challenges he expects to face ashead of European Radiology.ECR Today: You will become editor-in-chiefof European Radiologyin 2014. What are your plansand ambitions regarding this newposition?Maximilian Reiser: Professors Lissner,Baert and Dixon, together withtheir deputy editors, the advisoryeditorial board, editorial staff, sectioneditors and the scientific editorialboard, have worked hard andshown impressive dedication, as wellas admirable and generous commitment,in making European Radiologywhat it is today – the flagshipof radiology in Europe. I am awarethat it will not be easy to follow intheir footsteps, but Prof. Dixon hasoffered to give me an in-depth introductionto my new task – an offerwhich I have gladly accepted. Myambition is to consolidate and furtherdevelop the scientific impact ofEuropean Radiology, which is a journalof international repute. To thisend, innovative thoughts and ideaswill certainly be required, which Iwould like to develop, discuss andimplement together with the ESRleadership.ECRT: Could you please tell usabout your experience in journalediting? How many publicationshave you authored?MR: I have been editor-in-chief ofthe German journal Der Radiologefor many years, serial editor ofthe book series Medical Radiology– Diagnostic Imaging (Springer),member of the advisory editorialboard of European Radiology andreviewer for several radiologicaljournals. I have authored or coauthored502 publications since2002, which owes to the fact thatwe have a very active scientific teamat our institute.ECRT: Do you have any advicefor aspiring authors? What is thebest way for them to present theirwork?MR: It is important that authorspresent significant topics withvalid methods and use adequatebiostatic methods. Wherever possible,authors should not only demonstratethe diagnostic significanceof a radiological method but alsothe outcome for the patient. It goeswithout saying that clearly definedreference methods need to be usedin every article.ECRT: Where do you see scientificpublishing in ten years? Will therebe any print journals at all? If not,do you think this will reduce thescientific quality of publications?MR: Electronic media offer manyvery interesting possibilities foreditors, authors and readers. Alongwith the increase in online material,however, more guidance is needed toallow the reader to find valuable andtrustworthy information. Therefore,I am absolutely convinced that peerreviewedjournals will continue toplay a very important role in thefuture – regardless of their form ofdistribution (online or printed). Inboth cases, of course, the ethics ofpublishing and handling scientificdata will have to be strictly followedand clearly laid out.Professor Maximilian Reiserfrom Munich, GermanyResearch is best way to turn resources intoknowledge, states today’s Honorary LecturerBy Michael CreanIn recognition of his dedicationto scientific research and development,Professor Luis Martí-Bonmatí from Valencia, Spain,has been invited by the EuropeanSociety of Radiology to present theSantiago Ramón y Cajal HonoraryLecture, ‘Research and Science:from Individuals to Societies –the Ramón y Cajal background,’at ECR 2013.Luis Martí Bonmatí is director ofMedical Imaging at La Fe Universityand Polytechnic University Hospital,and chief of radiology at QuirónHospital, Valencia, Spain. He is alsoprofessor of radiology at ValenciaUniversity.After completing his undergraduatemedical training at the Universityof Valencia in 1983, Prof. Martí-Bonmatí worked as a resident at LaFe University Hospital Valenciauntil 1987. He then began work onhis Ph.D. thesis, ‘MRI in the studyand characterisation of focal liverlesions’, earning him a doctoratewith excellence from the Universityof Valencia in 1990.As a researcher, Prof. Martí-Bonmatí’s interests lie mainly inthe fields of liver MR and CT,abdominal and pelvic MRI, contrastagents, image processing, andimaging biomarkers. With morethan 200 articles listed in PubMedand 55 book chapters to his name,he is an established scientific author.As an editor he has contributed toeight books. He has also supervisedmore than 25 Ph.D. students, andhas delivered hundreds of presentationsat scientific meetings, symposia,and international conferences.“In my position as director ofmedical imaging, my work focuseson the paradigm change; fromimproving diagnostic performancesto taking care of the patient, andits particular clinical conditions inan integrated and individualisedmanner. In this way, we executethe necessary diagnostic and therapeuticprocedures that are betterfor integral patient care, using thewhole technological potential andbiological knowledge of the disease.To do this requires the help of everystaff member and an increase inresearch activity and technologicaltransfer to the clinical innovation,”Prof. Martí-Bonmatí explained.On top of his work as a clinicianand academic, Prof. Martí-Bonmatíhas also been engaged in strengtheninginternational ties within thefield of radiology. He is an activemember of many European scientificsocieties and has served aspresident of the Spanish Society ofRadiology, the European Society forMagnetic Resonance in Medicineand Biology and the Spanish Societyof Abdominal Imaging. In additionto these presidencies, he has servedas vice-president of the EuropeanSociety of Gastrointestinal andAbdominal Radiology.He is a long-time member of theEuropean Society of Radiology andcurrently serves as chairman of thesociety’s Research Committee.“Research is also at the forefrontof my career. Both in Valenciaand as chairman of the ESR’sResearch Committee, I recognisethat research is the best way to turnresources into knowledge across thescientific world and that innovationconsists of developing,” Prof. Martí-Bonmatí stated.Professor Luis Martí-Bonmatífrom Valencia, SpainSunday, March 10, 12:15–12:45, Room ASantiago Ramón y Cajal Honorary LectureResearch and science: from individuals to societies –the Ramón y Cajal backgroundLuis Martí-Bonmatí; Valencia/ESmyESR.org | #ECR2013 @myESR

26 ECR Today 2013 Community NewsSunday 10 March 2013Ten years of EPOS:A decade of digital innovationECR Today spoke with ProfessorNicholas Gourtsoyiannis, founderof EPOS, on the platform’s tenthanniversary.ECR Today: This year the ElectronicPresentation Online System(EPOS) is celebrating its 10thbirthday. How far has it come inten years? How would you gaugethe success of this enterprise?Nicholas Gourtsoyiannis: A timelesschange, productive, useful and creative,the first of its kind, which hasliterally transformed the way majorradiological congresses function, bygoing completely digital. ECR 2003was of course the first big meetingever to introduce and stage EPOS,presenting all its posters electronically.The immediate major benefitswere that it stimulated the wholeworld of digital natives, and itopened up new horizons for thousandsof radiologists who could notattend or present at the ECR. Posterpresentations are essential for everyyoung radiologist’s career, as it givesthem a platform to prove their excellenceand professionalism, even ifthey are not yet advanced enoughto become an oral lecturer. Thereare thousands of radiologists in theworld that want to present theirwork, but as we all know, space andtime are limited.Starting with 870 posters at ECR2003, EPOS today includes morethan 2,500 posters per congress,in essence an eLearning library initself, and is the connecting platformfor around 1,500 presenters – it hasdeveloped into a very powerful toolfor the ECR.ECRT: How was the idea of EPOSborn?NG: The idea was to move forwardwith time – how could a very modern,advanced and technical specialtylike radiology, working withhigh quality images, stick to paperprintouts? Considering the manyimportant features of digital posters(ability to zoom into images and playvideos), the answer was obvious.There was a need for a revolution, toenhance the quality and attractivenessof the congress, for authors aswell as for participants. We felt theneed for an effective change, allowingscientific dialogue to expand andcontinue after the ECR, as well as aneed to offer the corpus of the wholecongress digitally.A positive result was that therewas room for more posters, whichcame with the growth of the ECR.Poster panels need space, which cannow be used for other projects, suchas special exhibitions, lounges, ormore lecture rooms.ECRT: What has EPOS brought tothe world of radiology?NG: It has brought internationalcongresses to another level – noton its own, but as part of the ongoingrevolution that the ECR has begun:it is beautiful, modern and developsnew trends, and therefore drives theradiological meeting scene.EPOS was also a revolution interms of sustainability, as all postersare stored electronically and canbe accessed online, not only duringthe congress, hence making scienceavailable all year long.ECRT: The EPOS Lounge is alwaysa popular destination at the ECR.Have you used it yourself? Haveyou noticed any developmentsover time (more visitors, locationexpansion, etc.)?NG: Due to my many commitments,I unfortunately have notused the EPOS Area as often as Iwould have liked. What I can see isthat over the years, it has become acentral location within the AustriaCenter, which is always crowdedwith many different people, tellingme that the concept of havinga lounge in front of the EPOSroom to sit, relax and chat, is goodand enjoyed by the congress participants.I have the impressionthat EPOS has become a centralelement of ESR’s online activitiesand, especially at the congress,consolidates many projects, suchas self-assessment, Eurorad andCases of the Day.ECRT: Do you have a personalwish or message for EPOS on its10th anniversary?NG: Being Greek, I would say τάπάντα ῥεῖ (ta panta rhei), whichmeans everything is in constantchange – I am confident that therewill be a lot of new things in theProfessor Nicholas Gourtsoyiannis from Athens, Greece,founder of EPOSfuture for EPOS and the ECR, andI am very excited to see these futuredevelopments.I am proud that the ECR ElectronicPoster Online System hasbeen called EPOS, a four-thousandyear-oldGreek word, which refers toa narrative celebrating heroic deeds.Our vibrant scientific community isembracing it as their platform fordialogue and integration. Inevitablyit will prosper even more in lightof the growing popularity of socialmedia and other electronic tools foreLearning. There should not be anycongress without e-posters, so thattheir contents are accessible to allradiologists, and so young radiologistswill no longer be excluded fromcontributing towards the progress ofour specialty.Last but not least, I hope thatno radiologist will be excludedfrom our scientific community justbecause they cannot attend a meetingfor financial reasons or any otherreason – EPOS should always complementpersonal interaction.Browse through thousandsof electronic posters fromECR 2003–2013 and other congresseswww.myESR.org/eposT R A D E M A R K O FHorizon 2020: European Union’s FrameworkProgramme for Research and InnovationBy Javeni HemetsbergerThe framework programme forresearch and innovation, horizon2020 is going to run from 2014–2020 and will integrate the Europeanframework programme, theprogramme for the competitivenessof enterprises and SMEs (COSME),as well as the European Institute ofInnovation and Technology (EIT).The overall budget, which the EuropeanCommission has put forward,will amount to €80 billion, of which€8bn will be dedicated to healthresearch.Tense negotiations betweenEuropean Parliament andMember States over theEU budget 2014–2020The Horizon 2020 package, whichprovides research funding for the2014–2020 period, has been caughtup in the tense negotiations betweenthe European Parliament and MemberStates over the EU budget.Due to a lack of progress on theEU budget, the chairs of the EuropeanPeople’s Party (EPP) and theProgressive Alliance of Socialistsand Democrats (S&D) have signeda letter, along with Horizon 2020Rapporteurs Christian Ehler, TeresaRiera Madurell and Maria da GracaCarvalho, asking Herman VanRompuy (president of the EuropeanCouncil) to support an increase inthe Horizon 2020 budget in the EUbudget discussions.At a meeting of the EuropeanCouncil on November 22 in Brussels,no agreement could be reachedbetween the Member States on the2014–2020 EU budget. However,disproportionate cuts to researchhave been proposed, which are disturbingas they call for a six percentcut to the total EU budget and a 12percent cut to the research, innovationand education budget comparedto the Commission’s proposedbudget.An agreement on Horizon 2020will not be reached before spring2013. It is still unclear how this willimpact preparatory work for thecall for proposals, or whether theEuropean Commission will be ableto launch the first calls in January2014 as planned.On November28, the EuropeanParliament’s Industry and ResearchCommittee (ITRE) adopted its positionon Horizon 2020, voting toincrease the total budget from €80billion to €100 billion. The ITRECommittee is also seeking to strikea balance in the attribution of fundsbetween fundamental researchprojects and projects closer to theindustry.Given that the Parliament andthe Council could still amend proceduresproposed in the Horizon2020 programme, the Commissionhas not yet defined the 2014work programme and subsequentproject calls. The Irish Presidencyis expected to push for a deal withthe European Parliament ahead ofa meeting of research ministers inMay 2013.The adoption of legislation by theParliament and Council on Horizon2020 is slated for the end of 2013.Horizon 2020 will be launched onJanuary 1, 2014.The ESR has issued a statement onHorizon 2020, outlining the ESR’sview on the future of EU scientificresearch. This view is in line withHorizon 2020’s three main objectives:maintaining and promotingexcellence in research, developingcompetitive industries and,most importantly, building a bettersociety.More information on Horizon2020 can be found atec.europa.eu/research/horizon2020Please contacteu-affairs@myESR.orgif you have any questions.#ECR2013 @myESR | myESR.org

Sunday 10 March 2013Community NewsECR Today 2013 27Turkish radiologists delighted by growinginternational influenceBy Nevra ElmasThe Board of the Turkish Society of Radiology.The Turkish Society of Radiologyis one of the foremost medical specialtyorganisations in Turkey. It wasformed in 2000, from the merger ofthe two main radiology societies inTurkey, one of which was foundedas early as 1924 (the other, theTurkish Society of Medical Imagingand Interventional Radiology,was founded in 1991). The society’smain office is in Ankara (capital ofTurkey) and has 1,930 members ingood standing. It aims to promoteradiological education and cooperationamong its members withregard to professional, social andlegal issues.The Turkish Society of Radiology,which is a member of the TurkishMedical Specialist Board, an officialbody of the Ministry of Healthin Turkey, is a non-governmentalorganisation, dedicated to promotingradiological education andcooperation among its memberswith regard to professional, socialand legal issues. Accordingly, themain radiological issues that oursociety handles are related to education.Radiology education inTurkey is mostly provided by universityhospitals, as well as teachinghospitals run by the TurkishMinistry of Health. There are 50state-run university hospitals, nineprivate university hospitals and 29government teaching hospitals inTurkey. Radiology residency trainingprogrammes are under the legalauthority of the Ministry of Health.Unfortunately, the training periodwas reduced to four years, from fiveyears, by the Ministry of Health lastyear. The Turkish Society of Radiologyis actively trying to have thetraining period restored to fiveyears; a five-year residency trainingprogramme has been preparedby the Turkish Society of Radiologyfor educational centres around thecountry.The Turkish Society of Radiologyhas initiated two important educationalprogrammes for residents andyoung radiologists in 2010. Withthese two projects, we expect radiologiststo become the best educatedphysicians in the country.The Turkish Society of Radiologyhas established the Winter School forthe training of residents. In this programme,each resident undergoes atwo-week training programme oncethey begin their residency period.Every year, approximately 200 residentsare trained in the fundamentalsof radiology by distinguishedlecturers (there are 800 residents intraining in educational hospitals).The first Winter School programmewas in December 2010, 180 residentstook part, while the secondone was in January 2011 with 175residents, and the third one, in January2012, had 357 participants. Allcosts were covered by the TurkishSociety of Radiology and residentsparticipated free of charge.The Turkish Society of Radiologyhas also established a ScholarshipProgramme to support youngradiologists in furthering theireducation. This programme wasintroduced to support our youngcolleagues who want to get a bettereducation in the field of radiology,in either Turkey or abroad, for 6to 12 months. The Turkish Societyof Radiology supports candidateswith a stipend of $1,200 per monthfor training abroad and $750 permonth for training within Turkey.In 2011, seven young colleagueswere awarded scholarships by theprogramme. With this programme,The next Turkish Congress of Radiology is going to be held on November 6–10, 2013 in Antalya.we aim to support 30 colleagues peryear.Radiology board exams havebeen administered by the educationcouncil of the Turkish Societyof Radiology since 2004. The boardexams are composed of two parts:one theory exam and one practicalexam. Only participants who passthe theoretical exam can take thepractical exam. We encourage ourresidents, who go through the WinterSchool training programme, totake the theoretical exam before thefinal exam of the residency period.The Society holds an annualnational congress of radiology, aswell as symposia and other smallscalemeetings. Attendance atannual congresses is in the range of1,500 to 2,000 radiologists. Impressivenumbers of world-renownedradiologists, from many subspecialtiesof radiology, attend these meetingsto present lectures.The 33 rd Turkish Congress ofRadiology was held on November7–11, 2012 in Antalya, and 1,736radiologists attended. Every year thenumber of participants grows. Atthe Turkish Congress of Radiology2012, there were 19 lecturers fromEurope and the United States; a totalof 149 oral presentations and 897electronic exhibits were presented.There were three main topics:‘Women Imaging’, ‘How to do it?’and ‘Radiologic Physics’.Our next National RadiologyCongress is going to be held onNovember 6–10, 2013 in Antalya.The Turkish Society of Radiologypublishes the quarterly peerreviewedjournal Diagnostic andInterventional Radiology. This journal,which has been published since1994, has the highest standards ofpeer-review, editorial content andpublication quality. In 2007, Diagnosticand Interventional Radiologywas accepted for indexing in IndexMedicus and SCIE (Science CitationIndex-Expended). The Impact Factorof Diagnostic and InterventionalRadiology in 2011 was 1.1. This journalis also available free to all readerson the web (www.dirjournal.org). Itis one of the best medical journalspublished in Turkey, south-easternEurope and the Middle East.The number of scientific articlesby Turkish authors in radiologyjournals has increased substantiallyover the last 15 years, and Turkeyconsistently ranks among the topfive countries submitting articles tothe most respected radiology journalssuch as the American Journal ofRoentgenology, Cardiovascular andInterventional Radiology, EuropeanJournal of Radiology, AmericanJournal of Neuroradiology, PediatricRadiology and European Radiology.I think growth in the numberof articles published in radiologyjournals from Turkey will continuein the future.The Turkish Society of Radiologyis an ESR Institutional MemberSociety, which develops infrastructureand human resources,implements high quality trainingprogrammes for residents andyoung colleagues, and shares invaluablescientific knowledge with theinternational community. I hopethat these endeavours will graduallyincrease in the future.More information about theTurkish Society of Radiology canbe found at www.turkrad.org.trProfessor Nevra Elmas from Izmir,Turkey, is President of the TurkishSociety of Radiology.Customise your congress!Plan and personalise your ECR 2013 experiencewith the Interactive Programme Planner.ipp.myesr.orgmyESR.org | #ECR2013 @myESR

BOOSTYOURCAREER.TAKE THE EUROPEANDIPLOMA IN RADIOLOGY (EDiR)EXAM DATES:June 6–8, 2013, Wroclaw/PL(Congress of the Polish Medical Society of Radiology)October 18–22, 2013, Paris/FR (JFR)October 28 – November 2, Antalya/TR (TURKRAD 2013)www.myESR.org/diploma

Sunday 10 March 2013Community NewsECR Today 2013 29Eventful year for Serbian radiologyBy Milos A. LucicThe Radiological Society of Serbia(RSS) is an association representingradiology specialists, radiologistsin training, and other professionalsworking in the field of diagnosticand interventional radiology,as well as diagnostic medical andfunctional-molecular imaging inSerbia. The RSS is an institutionalmember of the European Societyof Radiology (ESR) and the InternationalSociety of Radiology (ISR).Last year, the city of Novi Sadhosted two important radiologicalevents: the first European School ofRadiology Galen Foundation Coursein Neuroradiology in April, and aEuropean School of InterventionalRadiology course on tumour ablationin May, which attracted manyprominent international speakers,including Professor Paul M. Parizel,ESNR past-president, and ProfessorNicholas Gourtsoyiannis, directorof ESOR, as well as participantsfrom numerous countries aroundthe world.The Serbian Society of Neuroradiologists,headed by ProfessorTatjana Stosic-Opincal held thethird Serbian Congress of Neuroradiologistsand Advanced Coursein Interventional Neuroradiology,which took place in Belgrade fromMay 31 to June 2, 2012, with participationfrom the vast majority ofSerbian diagnostic and interventionalneuroradiologists along witha large number of very prominentEuropean neuroradiologists. It wasa successful demonstration of whatto expect from the upcoming ESNRAnnual Meeting in 2016.November 8, 2012 is an importantdate for the RSS, and it stronglysupported the celebration of thefirst International Day of Radiology(IDoR) 2012. Numerousnewspapers, radio and TV newsprogrammes informed the publicin our country of the InternationalDay of Radiology 2012 andthe importance of radiologists inmedical care. It did so by raisingawareness of our profession andthe process of establishing the diagnosisand the treatment decisionmakingprocess.The RSS strongly supported andencouraged the establishment ofthe new subspecialty society: theSerbian Society of InterventionalRadiology, founded in September2012 and led by elected presidentProfessor Petar Bosnjakovic.Another important task forProf. Bosnjakovic this year, andalso for the RSS, will be the SerbianCongress of Radiology 2013,which will be held in Nis, October24–27, 2013. The national biennialcongress will be held for a secondtime, in close cooperation withthe Radiological Society of Serbiaand the Section for RadiologicalDiagnostics of Serbian MedicalDoctors Society. We expect thelast extremely successful congressESOR Galen Foundation Course in Neuroradiology, held in Novi Sad, University School of Medicine, April 26–28, 2012. Pictured from left:Prof. Dr. Nicholas Gourtsoyiannis, ESOR Director; Prof. Dr. Tatjana Stosic-Opincal, Serbian Society of Neuroradiologists president; Prof. Dr. Paul M.Parizel, ESNR past president. Standing from left: Assoc. Prof. Dr. Katarina Koprivsek, faculty and Prof. Dr. Milos Lucic, RSS president.to be surpassed by the upcomingone. Numerous programme topicsselected by the scientific committeewill be presented at the SerbianCongress of Radiology 2013, notonly by foreign academics but alsoby our local lecturers, in a unitedeffort to raise the quality of the scientificprogramme.In addition, the RSS runs manyradiological and multidisciplinarycourses in collaboration withnumerous other professional organisations,offering a wide spectrum ofcore and advanced state-of-the-artradiological knowledge in variousfields of radiology and subspecialtydisciplines.More information about theRadiological Society of Serbiacan be found atwww.udruzenjeradiologasrbije.orgProfessor Milos A. Lucic from SremskaKamenica, Serbia, is Chairmanof the Radiological Society of Serbia.Meet & Greet atthe Rising StarsLoungeMeet & Greet with yourRTF RepresentativeDon’t miss the opportunity to get in touchwith your national RTF representative duringthe ECR! Visit the RTF Meeting Point inthe Rising Stars Lounge (Foyer B,2 nd Level) where resident representativesfrom various countries will be availabledaily from 13:15 to 13:45 to provide youwith first-hand information.ESR President in the Rising StarsLoungeTake the unique chance to meet andgreet the ESR President in the Rising StarsLounge during the ECR.Sunday, March 10, 12:45–13:05Prof. Gabriel P. Krestin(Netherlands)ESR PresidentRTF HighlightedLectures andthe RTF GeneralAssemblyMake sure you catch the RTF HighlightedLectures and the RTF General AssemblySunday, March 10, 10:30–12:00, Room QRadiology Trainees ForumRTF Highlighted LecturesModerators: D. Bulja; Sarajevo/BAV.H. Koen; Harleem/NL▶▶Emergency radiologymanagement in patients withpolytraumaU. Linsenmaier; Munich/DE▶▶Imaging of non-traumaticintracranial haemorrhageZ. Merhemic; Sarajevo/BA▶▶Case-based learning inradiologyP. Pokieser; Vienna/ATRTF General AssemblySunday, March 10, 14:30–16:00Meeting Room 9, 3 rd LevelRising Stars ProgrammeBasic SessionsSunday, March 10, 08:30–10:00, Studio 2013Basic Session on Interventional Radiology‣‣Management of aortic aneurysm and dissectionR. Morgan; London/UK‣‣Overview of the development of interventional radiology techniquesB. Ganai; Newcastle/UK‣‣Embolisation of liver malignanciesM.A.A.J. van den Bosch; Utrecht/NLStudent SessionsSunday, March 10, 14:00–15:00, Studio 2013Final Student SessionThe four best student presenters will be awarded by the ESR during this session.Student Hands-on Workshops on UltrasoundIn cooperation with Sono4YouAfter last year’s success, hands-on workshops exclusively for students will again be held atECR 2013.An expert team of tutors will lead the students through the workshops, which will includesix different workstations to give every participant the chance to familiarise themselveswith the wide range of possibilities with ultrasound.‣‣Workshop Advanced:Sunday, March 10, 16:00–18:00Suitable for advanced students and residents.All workshops take place in Room X(1 st level).Registration:This workshop is fully booked. Places may become available at short notice onsite.PIN toWINGameThe final draw for thePin to Win gametakes place today inExtension Expo Aat the SamsungBooth, between5:00 and 5:30 p.m.myESR.org | #ECR2013 @myESR

30 ECR Today 2013 Arts & CultureSunday 10 March 2013The Metamorphoses of Egon SchieleThe Leopold Museum reveals theExpressionist’s ability to transformEgon Schiele, Self-portrait with winter cherries, 1912© Leopold Museum, Vienna, Inv. 454Egon Schiele, Sinking Sun, 1913© Leopold Museum, Vienna, Inv. 625Egon Schiele, The Hermits, 1912© Leopold Museum, Vienna, Inv. 466Following the huge success of theexhibition ‘Melancholy and Provocation’,which highlighted the antithesesin the œuvre of Egon Schiele(1890–1918) – the profound sadnessand world weariness on the one handand the provocative, stirring aspecton the other – the Leopold Museumnow presents Schiele masterpiecesfrom the Leopold Collection in anew context. The exhibition, curatedby Elisabeth Leopold, is dedicated toSchiele’s ability to transform.Metamorphoses: Schieletransformed his own figureinto various shapesThe main focus of the exhibition,which comprises some 20 paintingsas well as documents andautographs, is on the artist’s selfportraits.Since the Renaissancethe self-portrait has been a centraltheme for many artists, includingAlbrecht Dürer, Anthonis vanDyck and Rembrandt. Schiele, however,transformed himself in hisself-portraits. “Schiele often usedhimself as a model, changing andtransforming his body into variousshapes,” explains Elisabeth Leopold.These transformations could best bedescribed as ‘metamorphoses’. Theintensity with which Egon Schieleused body language as a medium ofexpression is largely unprecedented.According to Elisabeth Leopold “thedepicted becomes a symbol of thedying man who becomes a hermit,naked and levitating”.Hermits and Levitation:transformation of life into deathRight at the start of the exhibitionvisitors encounter three large-scalefigural depictions which are amongEgon Schiele’s most important paintings.The 1912 work ‘The Hermits’sees Egon Schiele and Gustav Klimtmelting into a double-figure undera black cloak. The two figures alsoappear as generalised types of men.In a letter to the industrialist and eminentart collector Carl ReininghausSchiele explained, “They are the bodiesof sensitive beings”. In his impressiveearly masterpiece ‘Seated MaleNude (Self-Portrait)’ of 1910 the artistrendered himself as a highly expressive,gesticulative figure. A few yearslater Schiele showed the transformationof life into death in his two-figuredepiction ‘Levitation’ (1915).Oneiric images andforbidden loveThese three chief works are framedby the surreal oneiric images thatSchiele presented in his 1911 exhibitionat the reputable GalerieMiethke under artistic directorCarl Moll: ‘Lyricist’, ‘Self-Seer II’and ‘Revelation’. The same room alsohosts numerous significant worksfrom 1912, most importantly ‘Self-Portrait with Physalis’ and ‘Portraitof Wally Neuzil’ which depict EgonSchiele and his great love Wally andare among the most famous pairsof paintings in art history. Muchin keeping with the theme of theiramour fou, Elisabeth Leopold alsopresents the work ‘Cardinal andNun’, symbolising a ‘forbidden’ butnevertheless inescapable attractionbetween man and woman. The ‘Self-Portrait with Raised Bare Shoulder’shows a face full of panic and horror.Seemingly forced into a corner, theartist screams open-mouthed andwide-eyed in protest of a hostileworld that refuses to understandhis message.Farewell paintings andanthropomorphic housesAnother part of the exhibition isdedicated to Schiele’s landscapes.The work ‘Sinking Sun’ (1913) is afarewell painting. The foregroundis dark and infused with an infinitesense of cold, the sea is grey. Thesky glows in a faint shade of carminered. The horizontal lines arebroken up by two young, almostbare trees whose dry leaves are stiffenedby the cold. The sun is sinkingalmost imperceptibly as a smallball into the sea. It is taking its leave,and perhaps it will never return.This section also includes Schiele’santhropomorphic houses inspiredby the Bohemian city of ČeskýKrumlov on the Moldova River,with its Gothic and Renaissancebuildings set in narrow lanes andsurrounded by the black river.‘No-man’s-land and the endof the world’:Schiele’s Houses by the SeaAccording to Elisabeth Leopold“these houses are expressions of theartist’s spiritual world”. She pointsout the slightly animated contoursand the subdued colours, whichare occasionally shot through withbright objects such as gutters, windowframes and hung up laundry. ToElisabeth Leopold these renderingsrepresent “landscapes of the soul”which are “permeated by a senseof melancholy and transience”. Thehighlight of this part of the exhibitionis the rarely exhibited work‘Houses by the Sea’ (1914). A partialsettlement could be reached last yearconcerning this painting with thesole heir of the work’s original ownerJenny Steiner. Elisabeth Leopoldsays of it: “Each house resemblesa human face. A sharp, horizontalboundary line behind the buildingsmarks the transition to the light greysea from which rocks emerge in thedistance that stand out against thedark grey sky. Rudolf Leopold calledthis horizon ‘the eternal line of theno-man’s-land and the end of theworld’.”Egon Schiele, ‘Self-Seer’ II (Death and Man)© Leopold Museum, Vienna, Inv. 451Leopold Museumat the MuseumsQuartier | Museumsplatz 1, 1070 ViennaOpening Hours:The Museum is open daily:10am to 6pmThursdays: 10am to 9pmClosed on Tuesdayswww.leopoldmuseum.org#ECR2013 @myESR | myESR.org

Egon Schiele, Self-portrait with raised naked shoulder, 1912© Leopold Museum, Vienna, Inv. 653

32 ECR Today 2013 Arts & CultureSunday 10 March 2013What’s on today in Vienna?Theatre & DancePlease note that all performances are in German!Akademietheater1030 Vienna, Lisztstraße 1Phone: +43 1 51444 4145www.burgtheater.at19:00 Einige Nachrichten an das Allby Wolfram LotzBurgtheater1010 Vienna, Dr. Karl-Lueger-Ring 2Phone: +43 1 51444 4145www.burgtheater.at19:00 Der Ignorant und der Wahnsinnigeby Thomas BernhardTheater in der Josefstadt1080 Vienna, Josefstädter Straße 26Phone: +43 1 42 700 300www.josefstadt.org15:00 Forever Young by Franz Wittenbrink19:30 Forever Young by Franz WittenbrinkVolkstheater1070 Vienna, Neustiftgasse 1Phone: 43 1 52111 400www.volkstheater.at15:00 Ratgeber für den intelligentenHomosexuellen zu Kapitalismusund Sozialismus mit Schlüsselzur Heiligen Schriftby Tony KushnerDer Ignorant und der Wahnsinnige by Thomas Bernhard © Reinhard Werner / BurgtheaterConcerts & SoundsMusikverein (Classical Music)1010 Vienna, Bösendorferstrasse 12www.musikverein.at11:00 Wiener Philharmoniker,conductor Zubin MehtaA. BrucknerArena (Alternative Music)1030 Vienna, Baumgasse 80www.arena.co.at20:00 Long Distance Calling (Germany) +Sólstafir (Iceland)Porgy & Bess (Jazz)1010 Vienna, Riemergasse 11www.porgy.at20:30 David Friesen Trio (US)Wiener Philharmoniker at the Musikverein © Richard SchusterOpera & Musical TheatreVolksoper1090 Vienna, Währingerstraße 78www.volksoper.at18:00 Die verkaufte Braut by Bedrich SmetanaWiener Staatsoper – Vienna State Opera1010 Vienna, Opernring 2www.wiener-staatsoper.at16:00 Don Giovanni by Wolfgang Amadeus Mozart,conducted by Louis LangréeWith Ildar Abdrazakov, Marina Rebeka, TobySpence, Véronique Gens, Erwin SchrottRaimundtheater1060 Vienna, Wallgasse 18–20www.musicalvienna.at18:00 Elisabeth by Michael Kunze & Sylvester LevayRonacher1010 Vienna, Seilerstätte 9www.musicalvienna.at18:00 Natürlich Blond by Laurence O’Keefe, NellBenjamin & Heather HachElisabeth © VBW/Brinkoff/Mögenburg#ECR2013 @myESR | myESR.org