2011 ISSUE 5 Newsletter

EFSUMB Newsletter

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

EFSUMB Newsletter Editor Adrian Săftoiu

Adrian Săftoiu

As the new editor of the EFSUMB Newsletter I want to personally welcome all the readers and contributors, especially from the very active EFSUMB community. Obviously, the letter will continue to go on in the same format in each number of the European Journal of Ultrasound, meaning that the six monthly basis will be a decent frequency to support an ongoing debate

about EFSUMB activities, including EUROSON congresses, schools and endorsed courses. The generous space provided by the European Journal of Ultrasound should represent an ongoing resource of new technology highlights in the ultrasound field, as well as recent article and book reviews. One of the hallmarks of the ultrasound community, namely interdisciplinarity, will be represented and especially envisioned in the content of the newsletter in the following period.

Being a gastroenterologist with experience in both transabdominal and endoscopic ultrasound, I will try to bring into attention of practitioners high quality research in ultrasound, but also hot topic educational issues, in order to provoke other challenging editorials and material for the newsletter. The objective would be to improve the current clinical practice of

International Course in Contrast Enhanced Ultrasound

Part II: Update: Liver & extra-hepatic use of US contrast agents, new developments Course Director: HP Weskott Pre-Course: 3rd November 2011 4th - 6th November 2011 Hannover - Germany Central Ultrasound Department Klinikum Region Hannover, Siloah Hospital

Contact Hans-Peter Weskott weskotthp@t-online.de for more information or www.efsumb.org

ultrasound at all levels, in the same time as building the EFSUMB reputation and taking the Newsletter to a broader audience. We would like to bring to your attention success stories in the field of ultrasound, either on the educational or research side, so I strongly encourage everybody to please send the material to us.

A warm thankful message is of course directed to the previous editor, Prof. Dr. Michael Bachmann Nielsen which had a profound contribution to the content of the newsletter in the past four years. Thus, a series of interviews with member countries of EFSUMB and also a series of new technology editorials was successfully introduced and carried on through his efforts which are deeply appreciated in the EFSUMB community and also the Publication Committee.

Through the sustained efforts of the EFSUMB commitees the initiative of an educational portal slowly developed, being launched during the WFUMB 2011 and 23rd EUROSON congress held in Vienna and already receiving a lot of individual visits. The Educational Portal represents an online collection of resources contributed by healthcare professionals, starting with the freely downloadable EFSUMB European Course book, clinical recommendations and guidelines (including for example the new EFSUMB Guidelines and Recommendations on the Clinical Practice of Contrast-Enhanced Ultrasound (CEUS):

EFSUMB Lynne Rudd 36 Portland Place, London W1B 1LS, United Kingdom Tel.: +44 (0) 20 7099 7140 Fax: +44 (0) 20 7436 7934 Email: efsumb@efsumb.org

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EFSUMB Newsletter Update 2011 on Non-hepatic Applications), examination techniques, case file presentations, etc.; most of them grouped under various system and organ categories. The Educational Portal should be entirely dynamic and consequently all ideas are welcome to be discussed in an academic, but certainly relaxed atmosphere. Intertwined links with the successful Case of the Month initiative of the EFSUMB website, will allow users to read interesting and illustrative cases, translated in several languages.

Dear colleagues, dear EFSUMB members, dear readers, A few weeks ago, during the WFUMB/EFSUMB congress in Vienna I took over the position of EFSUMB President. I have to confess that it is a greatest honour for me to act as officer for EFSUMB in such position and I’ll do my best, rest assured, to fulfill your expectations. Over the years a few ideas came to mind on how to serve the Federation, however, I do not feel this is the time to express my ideas and I’ll tell you why. EFSUMB will be really successful only if it will be able to act as a team, joining the forces and the experiences of all its players. Like in a team, not all players have the same role, but there is a high chance of achieving victory only if all players play united and in synergy. Thus, I’d like not my ideas to be presented, but only the ideas, strategies and plans that will be discussed and finally approved by the Executive Bureau, following also the sugges-

In the current issue we will also host a message from the new EFSUMB President, Dr. Fabio Piscaglia, which is taking his assignment with a lot of enthusiasm and of course responsibility. This was also boosted by the recent development of the new non-hepatic CEUS guidelines, which was successfully carried on in a very limited time. Being already available on the EFSUMB website and also as an electronic publication, this will surely represent a great help for all practitioners involved in the contrast-enhanced ultrasound community.

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For registration and preliminary programme visit www.euroson2012.com

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Fabio Piscaglia, EFSUMB President.

tions of the Board of Directors, which represent each National Society. Accordingly in the next Newsletter, in the first issue of Ultraschall 2012, the EFSUMB Executive Bureau will present the past, ongoing and future activities of the Federation.

This will symbolize the synergistic work of the EFSUMB officers, starting from the Executive Bureau. The high scientific level of the Executive Bureau (which can be easily noticed from the curricula of their members including their scientific publications of which I am proud) also well symbolizes the very vital and productive scientific life of the whole Federation. The Young Investigator session is for this reason one of the best moment(s) of each Euroson Congress and EFSUMB strongly supports it.

I’d like, however, to take the occasion also to solicit all of you to be more active part of the life of Federation. The Federation is becoming more open and accessible than ever, thanks to the modern facilities travelling through internet and english is becoming familiar for most doctors. Education and science are certainly the two solid pillars on which our Federation stands and all of you can now easily and directly contribute to both of them on an international level, through our web portal. Any member can now contribute to produce the material for the Edu Portal and to set up scientific activities and concurrently benefitting from the contributions of other members. As you will have noticed, EFSUMB strives to bring you practically all material for free in internet, trying to provide maximal yield from the limited fee each member provide to EFSUMB. So please visit the website (www.efsumb.org)

EFSUMB Newsletter and take advantage from it. This might be particularly relevant in the current times of financial difficulties and we hope will be appreciated.

Any further enquiry you might have about the activities of the Federation or those to which you could participate can be addressed to Mrs Lynne Rudd, our General Secretary (efsumb@efsumb.org). She is really very efficient, hard working, kind and cooperative and will answer you or help you to connect with to the appropriate EFSUMB officer.

To conclude with a personal touch, the recent meeting in Vienna, which was perfectly organized by Prof. Mostbeck and his staff, was for me emotional for several reasons. Not only I took over the position of President from my predecessor Christian Nolsøe, whose friendship I could appreciate more and more over time, but the ceremony was attended by the pioneers in ultrasound, invited for a congress session devoted to them. These scientists, coming from all over the world, like Prof. Weill from France, Prof. Watanabe from Japan or Prof. Ziskin from USA, created innovations in medicine with the capability of imagining a new future, when often most of their colleagues were greatly skeptical about any possible future for that strange equipment making only dot and lines (not to mention that the eqiupment was occasionally even despised!). It was touching sitting next to these pioneers to which we all owe a large part of our daily practice.

Moreover, the congress took place in the same country, Austria, in which I attended my first Euroson Congress, in Innsbruck in 1993. Nearly 20 years have gone by, but those memories are still fresh in my mind: comparing that Congress to the present one, it was impressive for me to realize what great steps forward our Federation did! And lastly, on this occasion, I’d like to express my gratitude to my mentor, Prof.

Luigi Bolondi, a pioneer in clinical abdominal ultrasound and former EFSUMB President, who introduced me to the greatly exciting field of scientific research in medicine and with whom I still have the good fortune to work.

Yours sincerely Fabio Piscaglia EFSUMB President Division of Internal Medicine University of Bologna, Italy fabio.piscaglia@unibo.it

Hybrid Imaging Techniques Caroline Ewertsen1, Adrian Săftoiu2

Introduction ▼▼

Hybrid imaging is most commonly known as the combination of functional images from Positron Emission Tomography (PET) or Single Photon Emission Computed Tomography (SPECT) with anatomical images from Computed Tomography (CT) or Magnetic Resonance Imaging (MRI).

These techniques have gained widespread use within the last decade, while systems obtaining both radionuclide images and anatomical images are commercially available [1].

Fusion of images obtained from different anatomical imaging modalities and combinations of cross-sectional images and endoscopical or surgical images has also become available within recent years.

Thus for some years, ultrasound (US) images and endoscopical ultrasound (EUS) images have been included in hybrid imaging systems with CT, MRI, PET/CT, endoscopical and intraoperative images resulting in new perspectives for diagnosis and therapy benefitting from the strengths of each method. US or EUS may add specific benefit to hybrid imaging because of the live images, the lack of radiation exposure

Fig. 1a Normal image of the right liver lobe.

Left: fusion of US and CT. Right: corresponding CT image b. Hybrid US and CT image, oblique section showing the right liver lobe and right kidney. The green box corresponds to the US image. The CT image can be zoomed in or out.

and the ease of image-guided interventions, but in some of the newer techniques also for intraoperative navigation.

Within recent years, several commercially available US/EUS systems with incorporated software for hybrid imaging have become available. To our knowledge, all are based on a magnetic positioning system including software in the US system, a magnetic transmitter placed close to the patient and magnetic sensor(s) attached to the transducer. The magnetic positioning system spatially tracks the transducer, and the previously recorded CT/MRI data set can be reformatted to fit the actual US scan plane. The commercially available systems do not yet provide fusion with endoscopical or surgical images.

Thus, pre-procedure CT/MRI images are uploaded into the US scanner and 3D reconstructions are performed from the 3D dataset, followed by co-registration with US/EUS images in real-time based on the magnetic positioning tracking of the US or EUS probe. Different co-registration methods using external markers or internal anatomical landmarks, or even automatic co-registration, have been proposed and are still under development.

Due to the magnetic positioning system, it is possible to mark target lesions on one image and the marker will be shown on the corresponding image from the other modality. While moving away from the target lesion, colored boxes indicate the distance from the target lesion. This is an advantage when more than one lesion is present, for e.g. in the liver, and differentiation between them is necessary. It may also be helpful in combination with realtime elastography to distinguish between multiple lymph nodes for instance in esophageal, gastric or lung cancer.

Transabdominal Ultrasound ▼▼

Hybrid imaging involving real-time US has been evaluated in different anatomical areas.

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EFSUMB Newsletter lesions suspect of cancer [10]. Further studies are needed to evaluate whether the method will be an advantage for instance in combination with real-time elastography, which has been established as an useful method for depiction of prostate lesions.

Fig. 2a Longitudinal section of the right kidney. Left: CT image. Right: US image revealing missing color Doppler signals in the upper pole. b A kidney infarction was confirmed in hybrid imaging of contrast-enhanced CT (left) and CEUS (right).

The commercially available systems have mainly been tested in the abdominal setting in animal/phantom models and humans, mostly for imaging of the liver (q Fig. 1) or kidney (q Fig. 2). The method has a high accuracy in phantoms and bovine livers [2, 3] and was regarded useful for detection of small, difficult to visualize lesions in the liver and for evaluation of hepatocellular carcinoma (HCC) ablation, especially in combination with contrastenhanced US (CEUS). The advantage of hybrid imaging in the liver was the possibility of better overview in areas normally considered difficult to visualize sonographically (the liver dome and anterior thoracic wall) (q Fig. 3); furthermore, it enabled visualization of lesions that could not be seen in conventional B-mode [4–6].

Recently, the method has also been evaluated for musculoskeletal and breast applications showing promising results. It enabled US-guided needle insertion in the sacroiliac joint and it aided in the imaging of osteoarthritis and rheumatoid arthritis by correlating the MRI and US images (q Fig. 4) [7, 8]. In breast cancer, guidance for US detection of lesions seen on MRI was possible [9].

Fusion of US and MRI images of the prostate has been evaluated in several studies.

One study successfully demonstrated a better detection rate for prostate cancer using MRI targeted US-guided biopsy of

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Generally, the diagnostic accuracy and image-guided intervention are improved by adding several imaging modalities. By involving real-time US in hybrid imaging it may become possible to visualize areas, which are otherwise difficult to visualize sonographically. Thus, US-guided intervention may become possible for instance in areas hidden behind bone or in air-containing lesions. Furthermore, biopsy or follow-up on PET-positive lesions lying among PET-negative lesions could result in earlier detection of tumors and possibly improved treatment.

Fig. 3 Difficult visualization of the liver dome due to the presence of air.

Endoscopic Ultrasound ▼▼

Endoscopic ultrasound (EUS) has also been used in combination with CT/MRI images, based on electromagnetic tracking of the tip of the endoscope by using special magnetic positioning sensors placed nearby the small US transducer on the tip of the echoendoscope [11–13]. The hybrid EUS-CT procedures were tested in a limited number of patients, showing an accurate positioning of the US transducer (echoendoscope tip), enhanced diagnostic confidence based on multimodality imaging visualization, as well as faster location of the lesions [14]. This could have significant consequences for the followup of the patients during chemotherapy and/or antiangiogenic treatment based on fusion of power Doppler or low mechanical index harmonic contrast-enhanced EUS with dynamic contrast-enhanced CT or MRI [15].

Perspectives ▼▼

Fig. 4 Hybrid imaging of anterior part of trochlea of the humerus using US (left) and MRI (right).

Future perspectives of hybrid imaging would include better ways of displaying the information with multiple modes visible on the same screen (e. g. fly through capabilities on the 3D reconstructed images), but also more reliable and faster computer algorithms for the co-registration (e. g. automatic co-registration without external or internal position markers).

The possibility of fusing a previously recorded 3D US dataset may allow side-byside evaluation of tumor response to antiangiogenic treatment, for instance with CEUS and time intensity curves. Real-time co-registration of 4D ultrasound images with corresponding multiplanar segmented reconstructions of CT or MRI imaging may be available in the near future, allowing a better follow-up of oncological patients or better preoperative planning in complex surgical situations.

In conclusion, hybrid imaging may be superior to individual imaging techniques both for the accuracy of transducer orientation, but also in terms of image interpretation and real-time guidance of therapeutic procedures. The technique may significantly decrease the learning curve of difficult ultrasound procedures, as well as broaden the use of imaging as a clinical extension through combination of both anatomical and functional characteristics of the displayed images. More importantly, multimodality registration allows the reduction of radiation exposure caused by CT-guided procedures, which can be safely carried out using ultrasound guidance in real-time hybrid imaging systems. Furthermore, multiple modes can be used simultaneously in the same system, e. g. coregistration between PET-CT and real-

EFSUMB Newsletter time US elastography or CEUS. However, clinical impact of these technological advances should be established by further prospective randomized trials.

References 1 Townsend DW. Positron emission tomography/computed tomography. Semin Nucl Med 2008; 38: 152–166 2 Crocetti L, Lencioni R, Debeni S, et al. Targeting liver lesions for radiofrequency ablation: an experimental feasibility study using a CT-US fusion imaging system. Invest Radiol 2008; 43: 33–39 3 Ewertsen C, Grossjohann HS, Nielsen KR, Torp-Pedersen S, Nielsen MB. Biopsy guided by real-time sonography fused with MRI: a phantom study. AJR Am J Roentgenol 2008; 190: 1671–1674 4 Ewertsen C, Henriksen BM, Torp-Pedersen S, Bachmann Nielsen M. Characterization by biopsy or CEUS of liver lesions guided by image fusion between ultrasonography and CT, PET/CT or MRI. Ultraschall Med 2011; 32: 191–197 5 Liu FY, Yu XL, Liang P, et al. Microwave ablation assisted by a real-time virtual navigation system for hepatocellular carcinoma undetectable by conventional ultrasonography. Eur J Radiol 2011 6 Sandulescu L, Săftoiu A, Dumitrescu D, Ciurea T. The role of real-time contrast-enhanced and real-time virtual sonography in the assessment of malignant liver lesions. J Gastrointestin Liver Dis 2009; 18: 103–108 7 Iagnocco A, Perella C, D‘Agostino MA, et al.

Magnetic resonance and ultrasonography real-time fusion imaging of the hand and wrist in osteoarthritis and rheumatoid arthritis. Rheumatology (Oxford) 2011; 50: 1409–1413 8 Klauser AS, De Zordo T, Feuchtner GM, et al.

Fusion of real-time US with CT images to guide sacroiliac joint injection in vitro and in vivo. Radiology 2010; 256: 547–553 9 Nakano S, Yoshida M, Fujii K, et al. Fusion of MRI and sonography image for breast cancer evaluation using real-time virtual sonography with magnetic navigation: first experience. Jpn J Clin Oncol 2009; 39: 552–559 10 Pinto PA, Chung PH, Rastinehad AR, et al. Magnetic Resonance Imaging/Ultrasound Fusion Guided Prostate Biopsy Improves Cancer Detection Following Transrectal Ultrasound Biopsy and Correlates With Multiparametric Magnetic Resonance Imaging. J Urol 2011 [Epub ahead of print] 11 Estépar RS, Westin CF, Vosburgh KG. Towards real time 2D to 3D registration for ultrasound-guided endoscopic and laparoscopic procedures. Int J Comput Assist Radiol Surg 2009: 549–560 12 Hummel J, Figl M, Bax M, Bergmann H, Birkfellner W. 2D/3D registration of endoscopic ultrasound to CT volume data. Phys Med Biol 2008; 53: 4303–4316 13 Vosburgh KG, Stylopoulos N, Estepar RS, et al. EUS with CT improves efficiency and structure identification over conventional EUS. Gastrointest Endosc 2007; 65: 866–870

14 Obstein KL, Estepar RS, Jayender J, et al.

Image Registered Gastroscopic Ultrasound (IRGUS) in human subjects: a pilot study to assess feasibility. Endoscopy 2011; 43: 394– 399 15 Gruionu L, Săftoiu A, Iordache A, Ioncică AM, Burtea D, Dumitrescu D. Feasibility study of tridimensional co-registration of endoscopic ultrasound and dynamic spiral computer tomography procedures for real-time evaluation of tumor angiogenesis. Gastrointest

1

Department of Radiology, Copenhagen University Hospital, Roskilde Sygehus, Roskilde,Denmark

2

Department of Gastroenterology, Research Center of Gastroenterology and Hepatology, University of Medicine and Pharmacy Craiova, Romania

Endosc 2011 [Abstract]

Euroson-school Refresher Ultrasound Course: Abdominal, Doppler and CEUS 03. – 05. November 2011 University Hospital Košice

Congress Fee

Information/Contact:

210 € including lunches and «Slovak evening dinner» on 4th November 2011

PD Dr. med. Jan Tuma Seilerweg 1

Registration Participians from Switzerland: Flight, Hotel, Congress Fee incl. lunches and «Slovak evening dinner»: 2 000 CHF, www.sgum.ch Participians from other countries: kuchta@lf.upjs.sk

CH - 8610 Uster Switzerland Jan.Tuma@hin.ch PD Dr. Milan Kuchta, CSc.: LF UPJŠ v Košiciach Trieda Snp c. 1 Košice, Slovakia kuchta@lf.upjs.sk

Contact Jan Tuma praxisdrtuma@bluewin.ch for more information or www.efsumb.org

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EFSUMB Newsletter

The EFSUMB and WFUMB Guidelines and Recommendations on the Clinical Practice of Contrast Enhanced Ultrasound (CEUS).

Update 2011 on Hepatic (EFSUMB and WFUMB) and Non-hepatic Applications (EFSUMB) CEUS Guidelines Update 2011 Authors in Frankfurt.

Contrast-enhanced ultrasound (CEUS) was originally introduced to enhance Doppler signals of macrovessels. With the introduction of sulphur hexafluoride (SonoVue®), real time low mechanical index (MI) contrast-enhanced ultrasound was introduced to analyse the microvascularity. Because of their physical size (at or smaller than red blood cells), ultrasound contrast agents (UCAs) act as pure blood pool agents which explains some of the advantages of CEUS. The European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) introduced the first Guidelines on the use of CEUS in 2004. This document mainly focused on liver applications. New applications, in addition to the liver, were developed in the following years. Therefore, in the update of the clinical recommendations on the use of CEUS by the EFSUMB, published in 2008, applications to other organs were described as well. In the following years an increasing interest in the clinical applications of CEUS technique and new fields has been investigated, so that up to now nearly all organ systems have been subject to CEUS studies.

Therefore, in 2010 EFSUMB initiated a new update of guidelines.

Also regarding future perspectives of CEUS, it was felt that a new update on CEUS liver applications should be prepared and published on a worldwide basis

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since liver indications are the most common used applications so far. Therefore, an agreement was concluded with the World Federation of Societies for Ultrasound in Medicine and Biology (WFUMB) to prepare joint guidelines exclusively on liver applications, taking advantage of the experience of EFSUMB and of the previously published documents. This new article will be issued as a simultaneous publication in Ultraschall in der Medizin/European Journal of Ultrasound and in Ultrasound in Medicine and Biology also to reflect the world wide use of CEUS and the effective collaboration of the societies.

The content include general considerations (technical aspects), characterization of focal liver lesions (FLL) in the non cirrhotic liver, characterization of FLL in the cirrhotic liver, characterization of portal vein thrombosis and biopsy related description. Detection of FLL with the transabdominal approach, intraoperative CEUS, monitoring ablative treatment, liver transplantation, contrast quantification and monitoring of systemic treatment, safety aspects and technical appendices.

At the same time EFSUMB decided to explore the published literature for evidence of established but also of additional indications. Reports on numerous offlabel extravascular or intracavitary administration of SonoVue have been also published in recent years. In the tradition of earlier EFSUMB recommendations these clinical re-

commendations on the use of CEUS are based on comprehensive literature surveys particularly including results from prospective clinical trials. They are intended to create standard protocols for the use and administration of UCA and improve the management of patients. Recommendations are based on the literature and the experts’ consensus to provide a categorization of the level of evidence and a level (strength) of recommendation for each indication. Thematic sections of the manuscript include description of equipment, investigators’ training, terminology, safety aspects, pediatric indications, pancreas including endoscopic contrast-enhanced ultrasound, extrahepatic biliary system, gastrointestinal tract and perineum, spleen, kidney, use of CEUS in patients with renal failure, transplanted kidney, adrenals, urinary bladder, vesi-coureteral reflux, prostate, scrotum, abdominal trauma, lung and pleural lesions, vascular applications including aorto-caval fistulae and cerebral vessels, rheumatology (inflammatory joint disease), extravascular (intracavitary) applications, analysis of lymph nodes, tumor response assessment and free tissue transplants. Breast and other gynecological indications are included in the manuscript as well. Some of the indications are established whereas others are not which are categorized as emergent CEUS applications since evidence is insufficient for general recommendation. The manuscript also discusses safety aspects and includes a technical appendix and selected references.

Reference: F. Piscaglia, C. Nolsøe, C. F. Dietrich, D. O. Cosgrove, O. H. Gilja, M. Bachmann Nielsen, T. Albrecht, L. Barozzi, M. Bertolotto, O. Catalano, M. Claudon, D. A. Clevert, J. M. Correas, M. D’Onofrio, F. M. Drudi, J. Eyding, M. Giovannini, M. Hocke, A. Ignee, E. M. Jung, A. S. Klauser, N. Lassau, E. Leen, G. Mathis, A. Saftoiu, G. Seidel, P. S. Sidhu, G. ter. Haar, D. Timmerman, H. P.Weskott. The EFSUMB Guidelines and Recommendations on the Clinical Practice of Contrast Enhanced Ultrasound (CEUS): Update 2011 on non-hepatic applications.

Ultraschall Med 2011 Correspondence: Prof. Dr. med. Christoph F. Dietrich Caritas-Krankenhaus Bad Mergentheim Uhlandstr. 7 D-97980 Bad Mergentheim Tel.: 49 (0)7931–58–2201 Fax: 49 (0)7931–58–2290 E-Mail: Christoph.dietrich@ckbm.de