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EFSUMB Newsletter

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

New Technology

Combined Use of 3D Contrast Enhanced Endoscopic Ultrasound Techniques Introduction ▼▼

While 3D sonography has become established in gynecology, abdominal applications have been mainly restricted to case reports and few studies. However, recent advances in computer technology have supported the development of new systems with motion detection methods and image registration algorithms – making it possible to acquire 3D data without position sensors, before and after administration of contrast enhancing agents. We reported on the first use of 3D imaging of the liver and spleen under real time conditions, using contrast enhanced phase inversion imaging with low mechanical index [1]. The advantages of 3D procedures are clearer visualization of anatomy and topography, visualization of the extension of changes into surrounding tissue with special emphasis on the reconstructed coronary plane, measurement of volumes (also non-symmetrical) or pathologic changes, improved diagnoses (quality of results) through analysis of the third plane, higher quality of results through imaging the surrounding structures with landmarks (quality management), improved examination quality through planning and performing an optimized image acquisition and image documentation, improved acceptance by the referring physician through clearer visualization and therefore fewer follow-up examinations, and demonstration of findings with reference to any desired scan plane (e.g. as part of the daily findings discussion). Compared to other tomographical imaging methods (e.g. computed tomogra-

phy, magnetic resonance imaging) ultrasound technology suffers from insufficiently clear documentation of the findings. The single images from real-time sonography resemble the pieces of a mosaic and are assembled into a complex threedimensional representation of the anatomy in its environmental context, and then recognized in space, solely through the powers of imagination of the investigator. However, an observer not directly participating in the examination will have difficulty sharing in this subjective visualization. Surgeons want a realistic and detailed survey image, where the change in relation to the environment can be evaluated (e.g. segment localization of liver tumors through visualization of the connections to the portal vein branches and hepatic veins). In recent years contrast enhanced endoscopic ultrasound has been introduced [2] and improved to push the boundries of conventional endoscopic ultrasound. Last year first systems of low mechanical index endoscopic ultrasound features became commercially available [3]. This was the starting point of the contrast enhanced low mechanical index endosonography (CELMI EUS) which allows to visualize contrast enhancing effects in microvessels. The technique developed first in clinical medicine as a method to discriminate chronic pancreatitis from pancreatic cancer [4] also using the contrast enhancing effect for Doppler spectrum analysis [5]. The investigation proved useful and is still performed in colour Doppler mode with high mechanical index endosonography (CEHMI EUS). In this method, the contrast

enhancer (usually Sonovue®) acts as a Doppler flow enhancer for analysis of macrovessels [6]. We report on the latest development in endoscopic ultrasound the combination of CEHMI EUS and CELMI EUS with a 3D reconstruction, which allows unique insights in the vessel structure of lesions.

Case Report ▼▼

A 68 year old woman was sent to clarify an unusual pancreatic mass, detected by CT scan. The woman’s medical history revealed renal cancer operation of the left kidney 15 years ago and hypertensive nephropathia. Therefore, computed tomography (CT) scan was performed without contrast enhancer. The suspected lesion was localized in the pancreatic tail with a size of 3 x 2.5 cm - not visible 5 years ago. Using endoscopic ultrasound, the lesion could be clearly shown with a sharp demarcation to the pancreatic tail (qFig. 1). Unenhanced color Doppler endosonography revealed a high vascularisation of the lesion. Using contrast enhanced low mechanical endoscopic ultrasound, a clear contrast enhancing effect of the neoplastic tissue could be observed (qFig. 2). The vessel structure of the unenhanced colour Doppler endosonography could be impressively shown in 3D endoscopic ultrasound (qFig. 3). Furthermore the whole tumor was visible using the combination of CELMI EUS with 3D reconstruction (qFig. 4). According to those results, the

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EFSUMB Newsletter

Fig. 1 Original unenhanced view of the lesion in the pancreatic tail using endoscopic Doppler ultrasound. The rich vascularisation of the tumour is not as impressive as in the 3D reconstruction due to longer scanning time in 3 D mode.

Fig. 2 Clearly hyperenhanced tumour after injection of contrast enhancer in low MI mode. The machine is already set up in 3D data acquiring mode.

Fig. 3 3D Color Doppler reconstruction of the rich vascularisation of a renal cancer metastasis in the pancreatic tail. The normal surrounding tissue is shown in gray colors.

Fig. 4 3D reconstruction of the metastatic lesion after demarcation with help of contrast enhanced low mechanical index endosonography. The normal surrounding pancreatic tissue does not take up the contrast enhancer and therefore remained not visible in the picture.

working diagnosis of a late onset of renal cancer metastasis in the pancreatic tail was made. No further lesions could be shown in further CT and MRI scans and the woman

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could be successfully operated on a second time with confirmation of the diagnosis.

Conclusions ▼▼

The combination of 3D reconstruction with enhanced and unenhancend endoscopic ultrasound seems to be a feasible method to give the investigator and the referring doctor new insights into the anatomy and outer borders of a neoplastic lesion. The advantage of the new method is the small learning curve and the possible combination with any endoscopic ultrasound technique. The disadvantage seems to be the interrupted investigation due to the data aquiring period (in total between 15 and 20 sec.). This means that the advantage of real time contrast enhanced ultrasound has to be compromised. So far using this tool we have to inject two contrast vials, the first time for the dynamic analysis of the lesion and the second time for requiring data for the 3D reconstruction. Developing the low mechanical index endosonography into better scanning quality might outcast the disadvantages and lower the costs. Real time 3D scanner, as already in use in gynecological ultrasound, could improve the method even further. References   1 Dietrich CF. [3D real time contrast enhanced ultrasonography,a new technique]. Rofo 2002; 174(2):160-163.   2 Dietrich CF, Ignee A, Frey H. Contrast-enhanced endoscopic ultrasound with low mechanical index: a new technique. Z Gastroenterol 2005; 43(11):1219-1223.   3 Dietrich CF. Contrast-enhanced low mechanical index endoscopic ultrasound (CELMIEUS). Endoscopy 2009; 41 Suppl 2:E43-E44.   4 Hocke M, Schulze E, Gottschalk P, Topalidis T, Dietrich CF. Contrast-enhanced endoscopic ultrasound in discrimination between focal pancreatitis and pancreatic cancer. World J Gastroenterol 2006; 12(2):246-250.   5 Hocke M, Ignee A, Topalidis T, Stallmach A, Dietrich CF. Contrast-enhanced endosonographic Doppler spectrum analysis is helpful in discrimination between focal chronic pancreatitis and pancreatic cancer. Pancreas 2007; 35(3):286-288.   6 Hocke M, Schmidt C, Zimmer B, Topalidis T, Dietrich CF, Stallmach A. [Contrast enhanced endosonography for improving differential diagnosis between chronic pancreatitis and pancreatic cancer]. Dtsch Med Wochenschr 2008; 133(38):1888-1892.

Michael Hocke, Christoph F Dietrich

EFSUMB Newsletter

Message from Dr Caroline Hong to all EFSUMB Members and Friends of ASUM Caroline Hong

session at the Opera House, and I was given the privilege to give the speech at the Mayor’s reception on behalf of all the international guests at the Copenhagen City Hall. ASUM was represented by 8 speakers, Prof Rob Gibson, Prof Ron Benzie, A/ Prof Amar Trevedi, Dr Talat Uppal, Penny Koh, Vanessa Pincham and Dr Sue Westerway at this congress.

By the time you read this message, I would have said goodbye to many friends of ASUM, including those of EFSUMB, who have supported and worked with me on various common goals for promoting excellence in ultrasound. My first introduction to EFSUMB was through Prof Soren Hanke when I was involved in the bidding for the WFUMB 2009 world ultrasound congress in 2001. Later in 2004, I met a tall handsome charismatic Dane, Dr Christian Nolsøe, who together with another tall handsome charismatic Dane, Prof Michael Bachmann Neilsen, introduced me to the Danish Society for Diagnostic Ultrasound (DSDU). My President at that time was Dr Glenn McNally and we initiated discussions for collaboration between the two societies, (inspired by Princess Mary and Prince Federik). Then in 2005, the ASUM President, Dr David Rogers and I signed a Memorandum of Understanding called CADUCEUS, which is an acronym coined by the well known Prof Ron Benzie, also my former President. CADUCEUS stands for Collaborative Australasian Danish Undertaking of Continuing Education in UltraSound. This program has been running successfully since 2005, with exchange speakers at each other’s annual meetings in Australia, New Zealand and Denmark. Furthermore, we have had several placements of doctors from Denmark in Australia to learn and experience ultrasound practice in our region. The profile of Denmark and EFSUMB is very high in Australia and New Zealand.

My last day at ASUM as Chief Executive Officer is 11 May 2011. I have had 10 wonderful years as ASUM’s inaugural CEO, a career that I will remember fondly with pride and joy. To all EFSUMB members, friends of ASUM, I want to say a big thank you for your friendship and support. The world is small and technology allows us to remain in contact no matter what paths we choose to move on to. There is LinkedIn, Facebook and email. Some are already connected to me in that way. I will continue to advocate for excellence in ultrasound globally in my professional life. My mantra in life is “Passionate to be the difference to make a difference”. I hope I have in some way, being Asian born, Australian educated, being different, have contributed to being a strong ambassador for the goals of ASUM working with DSDU and EFSUMB in the ultrasound world. My successor is Mrs Annie Gibbins, who comes from a strong background in education and nursing. She was National Education Manager for the Orthopaedic Society for nearly 3 years in her most recent role. I wish her every success and I have done my best to ensure that ASUM continues to remain friends of EFSUMB and that the CADUCEUS continues into the future generations. That, I feel, would be a legacy that I would feel proud to have played a part in advocating, nurturing and fostering for DSDU, EFSUMB and ASUM. With warm regards, Dr Caroline Hong ASUM CEO (2001 to 11 May 2011)

It was my proudest moment to be an invited guest speaker at the EFSUMB 2010 congress in Denmark, and where there was a dedicated EUROSON Meet ASUM

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