2007-Issue03

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EFSUMB Newsletter

EFSUMB Newsletter European Federation of Societies for Ultrasound in Medicine and Biology

Editorial delight to meet so many interested ultrasound practitioners. This years meeting was in the Royal Veterinary College in Copenhagen and the social event was a visit to the college's facilities including a view of their xray ultrasound and CT facilities. Though only a small society they are obviously very dynamic and I am sure there must be other similar Societies in Europe that have a similar ethos.

Looking back over a few previous editions I see that my editorial often starts with an account of my recent travels. Not wishing to break with the tradition I write this having just returned from a most excellent meeting of the Danish Ultrasound Society at the kind invitation of Michael Bachmann Nielsen. Once again it was a great

I am very lucky this month to have two contributions to the Newsletter one from Christoph Dietrich about endoscopic ultrasound and the other one from Lars Thorelius, a very provocative one about the future of ultrasound in radiology. I hope these will be of interest to you and may

stimulate others out there to write for the Newsletter. Unfortunately I cannot offer you any inducement apart from my grateful thanks and the hope that if you have a so called "bee in your bonnet" you can be almost certain someone else will share that enthusiasm/frustration.

The autumn and EUROSON 2007 still seems a long way away but now is definitely the time to be submitting papers to what promises to be a most interesting meeting in Autumn. I hope to see many of you there.

Dr David Pilling Editor EFSUMB Newsletter

Report of the Annual Scientific Meeting of the American Institute of Ultrasound in Medicine 16th - 18th March 2007 This major event in the American Institute's calendar was this year held in the Marriot Marquis Hotel in Times Square New York.

The scientific programme was very attractive with a pre convention programme on the Thursday and then three full days of science. The Meet „the Professor Sessions“ early in the morning and at lunch time were over subscribed. Most of the rest of programme was taken up with scientific sessions. Just Images Sessions, where the emphasis was on reviewing numbers of images, leading to a diagnosis together with categorical courses giving state of the art lectures on a wide variety of subjects. Most of the time there were four or five parallel sessions so that everyone was catered for. The Film Panel Sessions and some of the Just Images Sessions had audience participation with electronic voting which was very successful. Less

experienced delegates were able to enrol for Hands on Sessions gaining tuition from many experts particularly in 3 D ultrasound. The Oral Sessions were supplemented by an extensive scientific poster exhibit, Case of the Day challenges and a large technical exhibition.

As someone with fairly diverse interests both within ultrasound and using other modalities it is interesting how comparison with other techniques especially MRI in fetal work has become an important feature of these meetings recognising how many involved in ultrasound use this as only one of their tools amongst a whole range of available techniques. The widespread availability of 3D and 4 D ultrasound has produced a new dimension and now these machines are more widely available it is becoming clear what a great impact this technology can have in a number of areas.

To someone who is very used to the extensive social programme provided by BMUS, the rather limited social programme provided at AIUM is somewhat disappointing. However in a venue such as New York such a programme would perhaps be superfluous as there are many competing attractions in New York particularly the Broadway theatres, extensive choice of restaurants and the inevitable shopping!

Certainly for this delegate the meeting matched up to the high standards of previous AIUM Annual Meetings. The possibility of listening to and talking to some of the biggest names in ultrasound has always been one of the attractions of this meeting. Next years meeting is in San Diego California, the other side of the continent but with equally diverse attractions.

I am sure anyone going to the meeting cannot fail to be impressed.

Dr David Pilling Editor EFSUMB Newsletter Ultraschall in Med 2007; 28

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New and old ultrasound techniques contrast enhanced ultra-sound with respect to detection and characterisation of focal liver lesions.

Constantly evolving ultrasound techniques with the possibility for higher resolution using "harmonic imaging", elastography and contrast enhancement with contrast media are reasons for highlighting the situation.

After taking the patient history and physical examination, conventional B-mode and Colour Doppler imaging (CDI) are the imaging techniques of first choice in patients with suspected diseases of the liver and the gastrointestinal tract.

Unlike static CT scanning and magnetic resonance imaging (MRI) using contrast media, the ultrasound technique is realtime, fast, mobile and can easily be used to guide interventional procedures. In contrast to CT ultrasound uses no ionizing radiation, and is therefore also the technique of choice in pregnant women, and in patients with allergies against iodide based contrast media.

The diagnostic process, differential diagnosis and continuous routine follow-up of patients with for example focal liver lesions require an easily available, reliable and cost-effective diagnostic method. Ultrasound is a widely used method for the detection of liver lesions, but it was generally regarded as inferior to contrast-enhanced computed tomography and magnetic resonance imaging. Recent advances in contrast-enhanced ultrasound techniques (CEUS) have improved the detection rate to a level similar to that attained using CT and MRI. Owing to the high spatial resolution of sonography, CEUS may also detect subcentimetre metastases. This is clear from several single centre studies and recently also a European multicentre study. Recently published reviews focus on the amazing advances of

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In recent years, also the use of endoscopic ultrasound has increased rapidly incorporating many new techniques and options, for example elastography, contrast enhanced techniques and new interventional options which will be standard procedures in the near future.

Endoscopic ultrasound, regarded as the "king discipline" of endoscopy, has been developed not only into an efficient and accurate diagnostic tool decisive in many clinical circumstances but also as a therapeutic option facilitating minimally invasive approaches to many organ systems.

Guidance on the successful handling of needling and catheters has been esta-

blished and other new EUS techniques are on the horizon showing the high potential of this method.

Published reviews and new textbooks which gather all current innovative methods and techniques suggest the possibility of incorporating this method into daily routine in a broader way than established so far. Insightful assessments of the evolving techniques and their uses and limitations are offered including comparison of methods.

There is also a need for teaching, such as step-by-step instructions for all current procedures and techniques including strategies for selecting patients and procedures including hygiene requirements, informed consent, patient positioning and monitoring. Logical, didactic tools including the necessary anatomy and pathology are mandatory including valuable tips and techniques for diagnosis and treatment to promote this method.

Prof Christoph F. Dietrich

Ultrasound in Radiology – is there a future?

Throughout the world there is an increasing demand for ultrasound (US) exams.

This is true also for US in radiology. However, there is no evidence that ultrasound is relieving the burdens of CT or MRI - on the contrary, there is an ever increasing demand also for the services provided by those modalities. It seems that ultrasound is merely being added to the plethora of other exams rather than being a true and dependable cornerstone within radiology.

Anybody working in an average radiology department is well aware of the fact that there has been a remarkable development in their CT and MRI departments in the past ten years. But what has happened to their US departments? Apart from better US scanners, don't the procedures and indications look very similar to those back in the early 90's, except for the fact that CT has taken over virtually all cases of acute abdomen as well as most planned examinations where the diagnostic results are really important? Has the overwhelming impact of PACS systems in radiology had any substantial impact on the documen-

tation of ultrasound exams, or are we all still depending on the written report as concluded bedside? Have we reached the possibility to draw new conclusions from the images of an old US exam? Unfortunately most radiologists will find the answers to those questions discouraging on behalf of US, to say the least.

In my view there will be an inevitable downward spiral for advanced US in radiology in the overwhelming competition against other PACS-dependent modalities, if the US community does not acknowledge that drastic measures are necessary in order to reduce the gap between the modern PACS image documentation of CT and MRI on the one hand, and the prevailing limited still image documentation of US on the other. Clinicians become increasingly accustomed to the conspicuous images that are produced by CT and MRI, and will generally not continue to settle for the non-documentation of US in cases where imaging really matter. In hospitals where there is a fruitful cooperation between US and the clinicians, the sonolo-

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gists are personally well known by the clinicians. This trust in a few sonologists is of course a very fragile basis for enduring and dependable US services. And regardless of the skills of the sonologist, his judgement on a piece of paper will never outweigh the ruthless truth of retrievable CT or MRI images that say something else.

And his still images are no good for comparison when the patient comes back for a check-up, since new pathology can never be proven not to have been there on the first occasion.

Is there no way that US can approach the dependability and consistency of other modalities in radiology? Can US retrieve lost turf, and again become a cornerstone within radiology? Chances are that it can, but it will require a whole new way of thinking by radiologists and all other involved. Without learning from radiology's built-in quality assurance mechanisms and applying them to US, it will never happen. We simply can not afford to have top notch diagnosticians at each transducer for the large bulk of US exams in order to find rare pathology. We need to be able to capture exams in a way that they can be read and diagnosed by experts at workstations, even if the examiners are not fully trained diagnosticians but good scanners who capture pre-defined cine loops of the regions of interest.

What gives me the right to make such statements? Being a radiologist myself I dare expose these ideas, but they would be worthless without clinical experience of an alternative way of organizing a US department. Being head of the US section of the Radiology Department, LinkÜping University Hospital, Sweden, I and my colleagues reorganized ultrasound completely in June 2002. We installed a US dedicated PACS system and abandoned still images completely. Instead, we replace still images with 5–10 seconds long cineloops. We developed organ- and structure-specific standardized scanning patterns, capturing the entire organs or targets of interest on such cineloops, scanning at a steady pace in one direction. All involved - senior sonologists, radiologists and residents - began scanning all exams according to such standardized patterns, so that the organs were displayed equally on the US workstations regardless of who performed the exams. The US workflow essentially became equivalent to that of

the rest of the radiology department, with capturing of full organ volumes, workstation readability, double checks and finally storage in PACS for later retrieval. Following a short period of time during which everyone got accustomed to this new practice, we found out that it was much easier to discuss pathology at the workstations when the scanning patterns were obvious and natural to all. For the first time it was possible to compare old and new exams side by side and actually show to us and the clinicians that there was new pathology in areas that were normal on the first exam. Our younger colleagues experienced a steeper learning curve, since they had the possibility to see the entire production of the US section on our workstations, all scanned in a way they were familiar with. They were very pleased with the competent feedback they could be given at the workstations. And, as a routine, all out of hours work was re-read by a senior sonologist the following regular working day for feedback and corrections.

Now, almost five years and more than 30.000 exams later, I dare say that the outcome of this reorganization in the direction toward a "radiological workflow" has exceeded all expectations. Now we know for certain that all examiners, regardless of skills, are biased by various parameters bedside, and often oversee information that is actually captured in the cine loops.

The dependability of the reports has become better since the examiner can reassess his exam at a workstation while reporting, thus finding details that were overlooked bedside. It is also quite easy to discuss details of our exams when we want a second opinion. No reports by residents leave the US section without previous reading of the examination by a sonologist at the workstation. The accuracy and security of the standardized scanning patterns reached such a level that we trained two radiographers to become "sonotechnicians", who learned how to scan the bulk of average US exams for later reporting by the sonologists at the workstations. Despite the fact that the sonotechnicians are not pathology trained, their exam technique is excellent and their exams are presented on the monitors just like those of the experienced sonologist. Their exams are read at an average rate of 12 per hour by the sonologists, which proves that the technique is very time efficient for the sonologists.

However, of course there also are advanced US exams that require the skills of a sonologist or sonographer bedside for the understanding of the pathology, but documentation according to the basic principles of standardized cine loops, and reviewing them at the workstation, provides an increased understanding of the findings in many cases. This is especially true for structures with a complex anatomy, which can be better understood by slowly reviewing the scans back and forth at the workstation before the final decision. To date there has been no 3D- or 4D technique presented that allows for volumeor multiplanar rendering of such scans without loss of subtle parenchymal pathology, but considering the fast technical development, such volume rendering may soon be a helpful adjunct to the basic scans.

The conclusion drawn by our clinicians as well as ourselves is that our procedures including standardized cineloop scanning, workstation reading and PACS storage - which we call "Sonodynamics" - has a very positive continuous impact on the reliability and consistency of the US section's services. We feel that Sonodynamics is unparalleled when it comes to US education and training. A large percentage of advanced diagnostic challenges are resolved without the use of other modalities, and the employment of sonotechnicians provides time efficient workstation reading of the bulk of common US requests. I am sure that US in radiology would benefit very much if all of us in the US community would reconsider old habits and unite to work for standardization and full documentation. If we don't, I am afraid it will not be long before US looses all examinations of importance to other radiological modalities.

For further information on the background of Sonodynamics, and for details regarding our standardized Sonoexams, you are most welcome to visit the Sonodynamics website www.sonodynamics.com Prof Lars Thorelius - Denmark

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