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Diagnosis • Technology • Therapy • Prevention MAY/june 2018

Radiology Education

Virtual world software found to be highly useful in teaching radiology

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Breast Imaging Special Combination of 3D automated breast ultrasound and DBT Optimising mammographic compression protocols for Asian women A multimodal system for the diagnosis of breast cancer: the SOLUS project

Myocardial perfusion imaging in the detection of coronary artery disease :

Breast Imaging News

Radiation dose reduction The NEXO [Dose] Radiation Dose Index Monitoring software enables multi-modality, enterprise-wide radiation dose data aggregation and reporting.

Workloads in Radiology The effect of shift length, schedule and volume on diagnostic errors

Imaging News

Technology Updates

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PET more sensitive than spect ­

Industry News


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BY Alan barclay, ph.d.

FROM THE EDITOR

VOLUME 34, NUMBER 3 EDITORIAL ADVISORY BOARD Andreas Adam, London Frits H. Barneveld Binkhuysen, Filipe Caseiro Alves, Coimbra Maksim Cela, Tirana Katarzyna Gruszczynska, Andrea Klauser, Innsbruck Gabriele Krombach, Giessen Philippe Lefere, Roeselare Thoralf Niendorf, Berlin Anders Persson, Linköping Gustav von Schulthess, Zurich Patrick Veit-Haibach, Lucerne

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GDPR — is radiology ready? With everyone’s email inboxes currently being swamped by requests from all sorts of organisations for confirmation to authorize acceptance of their emails and to “keep in contact”, nobody can really claim to be unaware that the latest EU legislation on the protection of personal data, the General Data Protection Regulation (GDPR) is finally legally applicable (it came into force 25th May) Apart from the most assiduous followers of European bureaucracy, very few people will have actually read the 90 page document describing the basic principles of GDPR, which are nevertheless relatively straightforward. Organisations that collect or use personal data must ask for the consent of the individual concerned and disclose their reason for doing so. The data should be only used for a stated purpose. If an individual wants to see what data have been collected, they should be able to do so. If personal data are lost or hacked, that should be disclosed. And so on. Thus, leaving aside for the moment the nagging doubt that policing or otherwise verifying compliance to the new rules could involve a huge, expensive layer of additional bureaucracy, the rules themselves seem to be based on common-sense, particularly when looked at in the context of the recent debate on the apparent misuse of Facebook data. However things get less straightforward when it comes to applying the new GDPR rules to healthcare and in particular to radiology, where uncluttered exchange of personal data and images is at the core of the proper functioning of imaging services. It is true that many studies have shown that the vast majority of hospital patients have absolutely no problem with the sharing of their medical data and images between appropriate healthcare personnel, especially if such data sharing is likely to result in increased diagnostic accuracy. However these same studies show an understandably high level of unease on the part of patients at the idea of their data being unnecessarily made available to irrelevant, non-involved or nonmedical personnel. Even less acceptable would be the idea that their medical data aren’t secure and that they could be corrupted, either accidentally or — perish the thought — deliberately. So it should not at all be imagined that D I

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the radiology world is somehow magically exempt from the application of GDPR conditions. To reflect the special situation of health data, specific GDPR derogations have however been defined for data concerning health, but still with the overall aim of protecting the rights of data subjects (in the new bureaucratic language, a “data subject” means a patient) and confidentiality of personal health data, whilst preserving the benefits of processing data such as digital images for research and public health. Thus radiologists cannot ignore the new rules. On the contrary, as explained in recent ESR guidelines radiology departments should be ready to comply with several new health-specific GDPR rules. These include: • obtaining explicit consent from the patient • to apply appropriate technical and organisational safeguards such as anonymization, pseudonymisation and encryption for data use in public health projects • to provide access for the patient to his/her personal medical records •to provide digital copies of personal data free of charge, including images in a structured commonly-used and machine –readable format upon patients’ request • to rectify inaccurate data • to notify the national supervisory authority within 72 h in case of breach of personal data • to designate a data protection officer (DPO) in larger hospitals and institutions. And while it is expected that initially at least the regulators charged with monitoring compliance will do so with a light touch, nevertheless the new GDPR also specifies sanctions, such as penalties and fines that are applicable to all organisations in both the public and private sectors who fail to comply with the rules for data protection. It thus behoves healthcare organisation to acquaint themselves with and implement the regulations: several organisations such as the NHS European Office and the Wellcome Trust provide indepth analyses of the new regulations but a more digestible starting point is the ESR guidelines (European Society of Radiology. the new EU General Data Protection Regulation: what the radiologist should know. Insights Imaging 2017; 8: 295). Required reading for radiologists in the brave new GDPR world. 3


®

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Front Cover Story PET myocardial perfusion imaging more accurate than SPECT scans in detecting coronary artery disease A large cohort comparative study of PET vs SPECT for the diagnosis of Coronary Artery Disease (CAD) has confirmed the advantages of PET. Overall, PET more successfully identified patients with severe obstructive CAD and need for revascularization; compared to SPECT, PET scans increased true positives and reduced false positives for severe coronary artery disease������ 31 Front cover image There was a significant increase in the detection of severe obstructive coronary artery disease in patients who receive cardiac positron emission testing (PET) imaging instead of single photon emission computed tomography (SPECT) scan, according to researchers at the Intermountain Medical Center Heart Institute in Salt Lake City, UT, USA Image credit Intermountain Medical Center Heart Institute. Reproduced courtesy of JCI Insight, © 2018 Am Soc Clin Invest.

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The FUSION-X-US prototype has been developed for the combined performance of automated breast volume scan (ABVS) and tomosynthesis in one workflow.

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24 -27| Symposium Report The Bracco-sponsored symposium on Advances in X-ray imaging at ECR 2018 featured presentations on: •Current status and future prospects

in mammography: •K  ey principles in improving the use of iodinated contrast media in modern CT system • Optimal management of patient safety and economic aspects in a modern CT unit.

40-41| Radiology

Workloads Diagnostic errors: the effect of shift length, schedule and volume

29-32 | Industry News 33-37 | Imaging News 48-50 | Technology Update

Visit us at

A virtual world is a three-dimensional space reproduced on a computer through a specific viewer, in which the user, can move, interact with different objects, or communicate with others. Virtual worlds are very useful for radiology teaching

NEXO[Dose] from Bracco is a vendor-neutral Radiation Dose Index Monitoring (RDIM) software which enables multi-modality, enterprise-wide radiation dose data aggregation and reporting.

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Page 43 Breast Imaging Articles

10 Optimising mammographic compression protocols for Asian women .. . . . . . . . . . . 14 A multimodal system for the diagnosis of breast cancer: the SOLUS project . . . . . 20 Combination of 3D automated breast ultrasound and digital breast tomosynthesis. .

Breast Imaging News Contrast–enhanced cone–beam breast CT compared to mammography and MRI . . . . .

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Preoperative breast MRI shows no mortality benefit in older women with breast cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Contrast-enhanced digital mammography comparable to breast MRI after endocrine or chemotherapy .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Breast cancers detected at smaller size in women with implants . . . . . . . . . .

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Long-term accuracy of breast cancer risk assessment combining classic risk factors and breast density . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Breast cancer screening MRI results in higher biopsy rates but lower cancer yields . . .

Software found to equal radiologists in assessing breast density and associated cancer risk. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Incidence and outcome of breast biopsy procedures during follow-up after treatment for breast cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8 Study shows that tomosynthesis actually costs less than digital mammography. 9

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BREAS T IMAGING NEWS Contrast–enhanced cone–beam breast CT compared to mammography and MRI Mammography is currently the only breast imaging method proven to affect breast cancer mortality, but nevertheless has disadvantages, such as a reduced contrast between non-calcifying breast tunors and fat-free parenchyma. Advanced three dimensional breast imaging modalities such as MRI and cone-beam breast CT (CBBCT) could overcome such limitations of mammography. Although MRI is generally considered to be the most sensitive modality, it has higher costs and limited accessibility; it may also have lower specificity. Cone-beam breast computed tomography (CBBCT) is a novel technique providing truly isotropic images of the breast with high spatial resolution and high contrast resolution. Preliminary research suggested that the technique had the potential to further characterize high-risk breast lesions that have been identified in screening by mammography or ultrasound T h e additional application of intravenous iodinated contrast agents to give the te chnique k n o w n as contrast-enhanced cone beam breast CT (CE-CBBCT) opens up the possibility of even further advances. Previous studies have shown a superior cancer detection rate for CE-CBBCT over mammography but so far there have been no studies comparing it with breast MRI. Now, a recently published study (Wienbeck et al. Contrast-enhanced cone-beam breast-CT (CBBCT): clinical performance compared to mammography and MRI. Eur Radiol. 2018 Mar 28.) describes the diagnostic accuracy of CE-CBBCT in dense breast tissue MAY / JUNE 2018

compared to mammography and MRI as well as with non-contrast enhance CBBCT. The study involved two independent and blinded readers and included 41 patients. The results showed a higher overall area under the curve (AUC) and sensitivity for the two contrast-based techniques (i.e. CE-CBBCT and MRI) compared to mammography and noncontrast enhanced CBBCT. The authors concluded that CE-CBBCT could serve as an imaging alternative for patients with contraindications for MRI. They found additional benefits for CE-CBBCT, namely a shortened examination time and a more comfortable examination for the patients in that there was no claustrophobia nor the noise associated with MRI. The authors envision future advances in CE-CBBCT such as use of iterative reconstruction technology to reduce radiation exposure and the implementation of dual-energy technology. https://tinyurl.com/Wienbeck-et-alpaper

Preoperative breast MRI shows no mortality benefit in older women with breast cancer

While it is generally recognised that breast MRI is the most sensitive imaging modality for the detection of cancerous breast lesions, the survival benefit from detecting additional breast cancers by preoperative magnetic resonance imaging (MRI) continues to be controversial. To investigate this paradox, a

multi-centred team of US researchers followed a cohort of 4454 women diagnosed with non-metastatic breast cancer (stage I-III) in five registries of the United States breast cancer surveillance consortium (BCSC). The results of their study have now been published (Onega T et al. Preoperative breast MRI and mortality in older women with breast cancer. Breast Cancer Res Treat. 2018. doi: 10.1007/s10549-018-4732-z) The researchers estimated the cumulative probability of breast cancerspecific and all-cause mortality and tested the association of preoperative MRI with all-cause mortality using a Cox proportional hazards model. They found that 917 (20.6%) women underwent preoperative MRI, but that there was no significant difference in the cumulative probability of breast cancer-specific mortality. No significant difference was found in the hazard of all-cause mortality during the followup period after adjusting for sociodemographic and clinical factors among women with MRI compared to those without MRI. The authors conclude that their findings of no breast cancer-specific or all-cause mortality benefit agree with previous results that indicate a lack of improvement in surgical outcomes associated with use of preoperative MRI. In combination with other reports, the authors suggest that the results of their analysis highlight the importance of exploring further the benefit of preoperative MRI in patient-reported outcomes such as women’s decision quality and confidence levels with decisions involving treatment choices. https://tinyurl.com/Onega-et-al-paper

Contrast-enhanced digital mammography comparable to breast MRI after endocrine or chemotherapy Contrast-enhanced digital mammography is comparable to breast MRI in evaluating residual breast cancer

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BREAST IMAGING NEWS

Typical example of the different contrast-enhanced digital mammography images. First, a low-energy image is acquired (A), immediately followed by the high-energy image (B), which is used in post-processing to create the recombined image (C), in which the invasive breast cancer is clearly visible (arrow).

after neoadjuvant endocrine therapy or chemotherapy, according to the results of a study carried out by Mayo Clinic researchers. “Our study aimed to compare contrast-enhanced mammography with breast MRI in evaluating residual breast cancer in patients undergoing presurgical systemic treatment to shrink their tumor size,” said Dr Bhavika Patel, radiologist at Mayo Clinic’s Arizona campus. “We identified patients who had both contrast-enhanced digital mammography and MRI after treatment to shrink their tumors and before additional therapy or a mastectomy.” Dr. Patel and her colleagues conducted a retrospective review of contrast-enhanced digital mammography cases at Mayo Clinic’s Arizona campus between September 2014 and June 2016. Forty female patients met the inclusion criteria. The mean age of study participants was 52.3 years. Thirty-four patients received chemotherapy, and six patients received endocrine therapy. The researchers interpreted the radiographic images in a blinded fashion and compared residual size on imaging to pathology from surgical samples. Their results indicated that both imaging modalities demonstrate comparable accuracy in assessing residual cancer. “These findings, if validated in larger studies, could potentially support the use of contrast-enhanced mammography as an alternative approach for evaluating residual cancer in the preoperative setting.” said Dr. Patel “Contrast-enhanced mammography is a potentially easier, faster, more accessible and more cost-effective option 6

than breast MRI”. She added that the Mayo Clinic’s Arizona campus is one of the first sites in the U.S. to implement contrast-enhanced digital mammography. “Patients find contrastenhanced digital mammography less anxiety-provoking than MRI, which can cause some patients to feel claustrophobic,” said Dr. Patel. https://tinyurl.com/Patel-CEDM-Mayo

Breast cancer screening MRI results in higher biopsy rates but lower cancer yields

Given that there is currently little evidence on the population-based harms and benefits of screening breast magnetic resonance imaging (MRI) in women with and without a personal history of breast cancer (PHBC), a US based team of researchers set out to determine the biopsy rates and yield in the 90 days following screening (mammography vs MRI with or without mammography) among women with and without a personal history of breast cancer (PHBC) (Buist DSM et

al Breast Biopsy Intensity and Findings Following Breast Cancer Screening in Women With and Without a Personal History of Breast Cancer JAMA Intern Med. 2018; 178(4):458-468) The main outcomes and measures of the study were: biopsy intensity (surgical greater than core greater than fine-needle aspiration) and yield (invasive cancer greater than ductal carcinoma in situ greater than high-risk benign greater than  benign) within 90 days of a screening episode. Age-adjusted rates of biopsy intensity (per 1000 screening episodes) and biopsy yield (per 1000 screening episodes with biopsies) were compared. D I

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The researchers found that In a population-based cohort including 812 164 women undergoing screening (mammography vs MRI with or without mammography), there were 2-fold higher and 5-fold higher core and surgical biopsy rates following MRI compared with mammography among women with and without a PHBC, respectively, resulting in lower invasive cancer and ductal carcinoma in situ yield for both groups. It was thus concluded that women with and without PHBC who undergo screening MRI experience higher biopsy rates coupled with significantly lower cancer yield findings following biopsy compared to screening mammography alone. The authors point out that further work is needed to identify women who will benefit from screening MRI to ensure an acceptable benefit-to-harm ratio. https://tinyurl.com/Buist-et-al-paper

Breast cancers detected at smaller size in women with implants

Studies have clearly shown that breast implants do not increase the risk of breast cancer, but there are continued concerns that implants might lead to delayed diagnosis of breast cancer. According to a recently published study (Sosin, M, et al. Breast Cancer following Augmentation Mammaplasty: A Case-Control Study Plastic and Reconstructive Surgery: April 2018; 141: 833), breast augmentation with implants does not interfere with the ability to detect later breast cancers — in fact, cancers may be detected at a

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smaller size in breasts with implants, The study also shows some differences in breast cancer diagnosis and treatment in women who have had breast augmentation, including a higher rate of mastectomy. The researchers studied 48 patients with breast cancer developing after breast augmentation, along with a group of 302 women with breast cancer who did not have breast implants. Data on the two groups of patients were analyzed to determine whether and how breast augmentation and the presence of implants affected the detection, staging, and treatment of breast cancer. At diagnosis, the cancers were significantly smaller in women with breast implants: average size 1.4 centimeter, compared to 1.9 centimeter in women without implants. In patients whose cancers were detected by the finding of a palpable mass--by either breast self-exam or clinical exam--the average tumor size was 1.6 cm in the breast augmentation group versus 2.33 cm in the comparison group. However, the rate of cancer detection by screening mammograms was lower for women with implants: 77.8 percent, compared to 90.7 percent in breasts without implants. Cancers tended to be diagnosed at an earlier stage in the breast augmentation group, although the difference was not statistically significant. The study also found some differences in subsequent breast cancer diagnosis and treatment. Women with implants were more likely to undergo excisional biopsy and less likely to undergo imaging-guided core needle biopsy. Women in the breast augmentation group were more likely to be treated with mastectomy, (73 versus 57 percent); and less likely to undergo breast-conserving treatment, (27 versus 43 percent). However screening mammography may be more likely to miss cancers in women with implants, despite the use of modern mammographic techniques designed to increase detection. Dr. Sosin comments, “Our findings may have important implications for patient counseling regarding breast augmentation and breast cancer detection.” https://tinyurl.com/M-Sosin-et-alpaper MAY / JUNE 2018

Long-term accuracy of breast cancer risk assessment combining classic risk factors and breast density Risk-based breast cancer screening is not commonly adopted in the United States or elsewhere, but it has the potential to increase the benefits and decrease the harms of screening and increase the number of women eligible for preventive therapy. Breast cancer risk models have been used to guide entry criteria in prevention trials and to determine the eligibility of women

“... breast cancer risk assessment combining classic risk factors and mammographic density may be valid for many years after evaluation....” for preventive therapy and supplemental screening by magnetic resonance imaging. For example in women at an elevated risk of breast cancer, selective estrogen receptor modulator therapy for 5 years has been shown to reduce the risk of breast cancer by about 40%, and the effect persists for at least 20 years. A prerequisite for the implementation of risk-adapted screening intervals and use of preventive therapies in precision medicine is accurate risk assessment and, in this context, an important question for risk assessment is the follow- up time over which a model is accurate. Short-term predictions are useful for decisions such as additional screening modalities at the time of mammography, whereas longer term risk predictions are important for deciding a risk-adapted screening regimen and eligibility for preventive therapy. Although several risk models provide the residual lifetime risk for a woman by year, studies to validate their performance have mostly considered cases within 5 years of risk assessment. D I

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A newly published paper presents the result of a study whose main aim was to evaluate the Tyrer- Cuzick risk assessment model to 19 years after risk assessment or 75 years of age in a screening cohort. (Brentnall AR et al. Long-term Accuracy of Breast Cancer Risk Assessment Combining Classic Risk Factors and Breast Density. JAMA Oncol. 2018 Apr 5:e180174.) The Tyrer-Cuzick model incorporates classic breast cancer risk factors, including information on affected second- and third-degree relatives, body mass index, menopause, and hormone therapy. The researchers assessed the performance of the model at different followup times and determined how much the accuracy of the model improves by adding a Breast Imaging and Reporting Data System (BI-RADS) measure of breast density. The researchers found that in a cohort study of 132 139 women attending screening from 1996 to 2014, the Tyrer-Cuzick model with mammographic density included was well calibrated (2699 cases observed; 2757 cases expected), with no significant loss in calibration to 19 years after assessment. A high-risk group suitable for preventive therapy included 4645 women (3.5%) and 273 cancers (10.1%). The authors concluded that accurate risk assessment for breast cancer is needed for risk-adapted screening and prevention strategies; risk assessment combining classic risk factors and mammographic density may be valid for many years after evaluation. The researchers found that risk models combining classic risk factors with mammographic density were informative to 19 years after risk assessment. Mammographic density helped to identify a greater number of women at the extremes of the risk distribution where preventive measures or different screening intervals might be considered to minimize intervention-associated harms and the public health burden of breast cancer. https://tinyurl.com/brentnall-et-al paper 7


BREAST IMAGING NEWS

Software found to equal radiologists in assessing breast density and associated cancer risk It is important to establish the density VolparaDensity from the Volpara company Another important result of the study of a woman’s breast. Dense breasts, that is those with a high level fibroglandular tissue, was that both automated and clinical breast can not only “mask” the detection by mam- density assessment methods were equally mography of any suspicious lesions but can accurate at predicting both screen-detected also increase the aggressiveness of any tumor. and interval cancers when breast density was Traditionally, breast density is assessed sub- assessed within 5 years of cancer diagnosis. “These findings have implications for jectively by a radiologist, but now software breast cancer risk modhas been developed to els, in particular those automatically quantithat predict risk of the tate breast density. more aggressive interval The results of cancer,” added Prof C a large multicenter Vachon, of the Mayo trial to compare these Clinic, the paper’s methods of density senior author. “Breast assessment and involvdensity measures can be ing more than 1600 used to inform a womwomen have just been an’s risk of screen and/ published (Kerlikowske or interval detected K et al. Automated and Clinical Breast Imaging Breast density is the ratio of volume of dense cancers up to five years Reporting and Data tissue to the total volume of the breast: High after assessment.” In the United System Density Measures breast density means there is a greater volume Predict Risk of Screen- of fibroglandular breast tissue compared to fat. States, thirty states Low breast density means there is a greater Detected and Interval volume of fat compared to fibroglandular breast have laws requiring that women receive Cancers. Ann Intern tissue.. Image courtsey of Volpara notification of their Med. 2018 May 1). breast density, which It was found that both assessment methods were equally accu- is graded on the standard four-category rate in predicting both the risk of cancer Breast Imaging Reporting and Data System detected through mammography screening (BI-RADS) scale: a. almost entirely fatty; b. and the risk of interval invasive cancer – that scattered fibroglandular densities; c. heterois, cancer diagnosed within a year of a nega- geneously dense; and d. extremely dense. The researchers found that women tive mammography result. Both methods predicted interval cancer more strongly than with an automated BI-RADS assessment of extremely dense breasts had a 5.65 times screen-detected cancer. UCSF Professor of Medicine Karla higher risk of interval cancer and a 1.43 times Kerlikowske, said “Women with dense breasts higher risk of screen-detected cancer than are more likely to be diagnosed with advanced- women with scattered fibroglandular densistage breast cancers, especially those that are ties, the most common density category in interval cancers, because their cancers are average-risk women. “There have been concerns raised about more likely to remain undetected for longer. These findings demonstrate that breast-density the reliability of BI-RADS breast density evaluation can be done with equal accuracy measures, since an assessment might vary by either a radiologist or an automated sys- for an individual woman depending on the tem. They also show the potential value of a radiologist and the mammogram,” observed reproducible automated evaluation in helping Kerlikowske, “Automated assessments, which identify women with dense breasts who are are produced by computer algorithm, are more at higher risk of aggressive tumors, and thus reproducible and less subjective. Therefore, they more likely to be candidates for supplemental could alleviate the sense of subjectivity and inconsistency.” screening.” The automated breast density mea- Kerlikowske et al paper : surement system used in the study was www.ncbi.nlm.nih.gov/pubmed/29710124

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Incidence and outcome of breast biopsies during follow-up after treatment for breast cancer

When discussing initial surgical options for breast cancer, patients frequently cite the fear of having to endure the process of repeated breast biopsies and the associated stress related to the potential of another cancer diagnosis during follow-up for breast cancer as the reason for choosing mastectomy or bilateral mastectomy. However, it remains unclear how often patients treated for invasive breast cancer will actually require breast biopsies during follow-up. To address this knowledge gap, a team of researchers from the MD Anderson Cancer Center in Houston, Texas, set up a study to determine how often biopsies are performed in follow-up after previous breast cancer treatment in 2 large complementary databases. The results of the study were recently published. (van la Parra RFD et al. Incidence and Outcome of Breast Biopsy Procedures During Follow-up After Treatment for Breast Cancer. JAMA Surg. 2018. doi: 10.1001). The population-based cohort study included 41 510 patients 64 years or younger in a commercial insurance database and 80 369 patients 66 years or older in the SEER-Medicare database. Patients were diagnosed with incident invasive breast cancer (stages I-III) from January 1, 2000, through December 31, 2011. Diagnosis and procedural codes were used to identify biopsy rates during follow-up. It was found that of 121 879 patients, an estimated 14.9% to 23.4% of patients underwent breast biopsy by 10-year follow-up; breast biopsy was significantly associated with age at initial treatment, type of initial surgery or radiotherapy, and administration of chemotherapy. After biopsy, approximately 20% to 30% of women underwent additional cancer treatment. The authors conclude that their data on the need for breast biopsies during follow-up and subsequent treatments can be used in the context of therapy-planning discussions and survivorship expectations for patients with breast cancer. https://tinyurl.com/van-la-Parra-et-al-paper MAY / JUNE 2018


Study shows that tomosynthesis actually costs less than mammography Although digital breast tomosynthesis (DBT) costs more than a digital mammography (DM) screening, it actually may help rein in cancer screening costs, according to preliminary findings presented by researchers from the Perelman School of Medicine at the University of Pennsylvania at the latest San Antonio Breast Cancer Symposium. The group analyzed 46,483 screening episodes — a single screening mammogram and all subsequent breast diagnosis related costs for the following year — in two hospitals within the University of Pennsylvania Health System. Senior author Dr E Conant, chief of Breast Imaging at Penn Medicine said “Breast imaging is more precise than ever thanks to DBT. Despite its higher initial cost, DBT is increasingly being embraced by radiologists everywhere. If you look at expenses associated with breast diagnosis in the following year after initial screening, DBT is more cost effective in terms of health system or population level screening.” Previous studies modeling outcomes have demonstrated that DBT can be cost effective. In this study, the authors analyzed actual costs and patient outcomes within a single health system where both DM and DBT screening occurred. Fifty three percent of the women studied received DM and 47 percent received DBT. They tested DBT and DM according to four outcomes - true positive (TP), true negative (TN), false positive (FP), and false negative (FN) rates. DBT was a more effective screening method. Compared to DM episodes, DBT episodes had lower FP and higher TN rates. It was found that DM and DBT episodes had roughly the same average episode costs per woman screened for FP, FN and TP outcomes despite the higher cost per individual DBT study. San Antonio Breast Cancer symposium: www.sabcs.org/2017-SABCS MAY / JUNE 2018

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Breast Imaging

Recent developments in breast cancer imaging: combination of 3D automated breast ultrasound and digital breast tomosynthesis in the FUSION-X-US prototype By Dr Benedikt Schaefgen, Marija Juskic & Dr Michael Golatta

In this article we present a novel approach to breast cancer imaging. In response to the growing importance of breast sonography and digital tomosynthesis, the FUSIONX-US prototype has been developed to enable the carrying out of both automated breast volume scan (ABVS) and tomosynthesis in one, combined workflow. There is a pressing need for improvement in current methodologies of breast cancer screening, since it is well establsihed that mammography alone does not provide sufficient diagnostic accuracy for all patients. The management of patients with dense breast tissue is particularly challenging, not only because the risk of developing breast cancer is significantly higher in such patients but also because in women with dense breasts, lesions are more likely to be missed in breast cancer screening [1]. Mammography and breast ultrasound are currently the basic imaging modalities used in routine breast cancer

One such developement is tomosynthesis, the 3D-procedure using low-dose digital x-ray projections. Compared to 2D-mammography, tomosynthesis has been shown to increase the sensitivity and specificity of breast cancer detection, especially in high risk patient groups with dense breast tissue [3-5]. Hand held ultrasound (HHUS) is able to detect additional malignancies compared to mammography alone, but is a procedure that is both time-consuming and highly examiner-dependent [6]. Automated 3D-ultrasound imaging of the whole breast (ABVS) has been shown to not only reduce the examination and interpretation time compared to HHUS, but also to yield higher inter-observer reliability [7-11]. Both ABVS and tomosynthesis are thus playing an increasingly important role in modern breast cancer diagnostics [12-14]. It is against this background that recently research and development efforts have been undertaken with the aim of combining tomosynthesis and ABVS in one device for the improved detection and classification of breast lesions [15-21]. THE FUSION-X-US PROTOTYPE

This is one of the first devices combining tomosynthesis and ABVS that has been developed to the level of testing on patients in a clinical setting. Based on the well-established ACUSON S2000 ultrasound system and the Mammomat Inspiration mammography/tomosynthesis system (both from Siemens Healthineers), the new FUSION-X-US system allows both ABVS und tomosynthesis to be carried out in only a few minutes, in one single workflow procedure without decompression of the breast or change of position In the procedure, the breast compression involves the use of a flexible gauze, which is transparent to X-rays

The Authors Benedikt Schaefgen, MD, Marija Juskic, Michael Golatta MD Department of Gynaecology and Obstetrics, Universitäts-Frauenklinik Heidelberg, Heidelberg, Germany. Corresponding author Dr M Golatta

email michael.golatta@med.uni-heidelberg.de

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screening and have undergone continued development over the last few years [2].

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images acquired using the FUSIONX-US prototype alone were sufficient for the detection of malignant lesions. RESULTS

Figure 1: Schematic view of the X-US prototype. An ultrasound transducer is incoporated into a prototype compression plate of a standard MAMMOMAT Inspiration system. During normal x-ray imaging (mammography or tomosynthesis) the transducer is “parked” outside the x-ray field at the edge of the compression plate. Directly after acquisition of the x-ray images, the transducer then moves automatically from right to left to perform the ultrasound scan.

and also allows the full functioning of the ultrasound transducer head. In the first step of the procedure, tomosynthesis is carried out as usual in mediolateral (ML), mediolateraloblique (MLO) or craniocaudal (CC) views. While the breast remains under compression and without any change of position, the ultrasound transducer then moves over the gauze to acquire the ultrasound scans. The data are processed in separate computer software systems; the regions of interest can be analyzed side-by-side by matching the 3D image position data from tomosynthesis and ABVS [Figures 1,2]. A feasibility study of the new system was performed in 2015 with 23 nonselectively recruited patients who had been referred to our breast unit with an indication for tomosynthesis. All patients underwent the standard diagnostic work-up according to current guidelines, namely physician-performed clinical examination, 2D-digital mammography and hand held 2D-ultrasound [22]. This procedure was then complemented with tomosynthesis and ABVS examinations, which were carried out using the FUSION-X-US prototype system and interpreted in conjunction with the other examinations. MAY / JUNE 2018

In this study, two radiologists, both of whom were blinded to the results of the standard workup, were presented with only the ABVS and tomosynthesis images from the FUSION-X-US prototype. The examining radiologists were instructed to classify any lesions according to the Breast Imaging-Reporting and Data System (BIRADS®) [23]. The objective of this separate evaluation of the tomosynthesis and ABVS data, was to determine whether the

The scanning process was well tolerated by all patients. and worked flawlessly, taking 25 sec for the tomosynthesis scan and 80 sec for ABVS. The 3D reconstruction allowed direct correlation of ABVS and tomosynthesis slides in all cases. The investigators spent approximately two minutes interpreting the tomosynthesis image and another two to three minutes on the ABVS interpretation. There was no significant difference between the interpretation time spent by both investigators [Table 1]. In the whole patient cohort in this evaluation [see Supplementary Table for patient details], a total of 29 lesions were found (23 benign lesions, including three with microcalcifications, and six malignant lesions). All six malignant lesions were identified by both investigators in tomosynthesis and were classified as either unclear (BIRADS® 0) or suspicious (BI-RADS® 4-5) [see Table 2], so no malignant lesion was missed [see Table 3]. However, only in a few cases (3/6, 50.0%, investigator 1; 4/6, 66.6%, investigator

Figure 2: Close up of the transducer unit and compression plate

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Breast Imaging

Figure 3: Screenshots showing a benign solid lesion on corresponding images of tomosyntesis in mediolateral orientation (upper left), 3D-ABVS reconstruction (upper right-hand side) and 2D-ABVS ultrasound image (note: the bottom of the image is oriented towards the ultrasound transducer)

2), was the lesion also seen in ABVS. No lesion was detected only in ABVS. In six cases, the ABVS image of a lesion that was classified in tomosynthesis as unclear or suspicious (BI-RADS® 0, 4b or 5) was identified as benign (BIRADS® 2). Figure 3 shows a screenshot of one of these cases in which the ABVS image led to the correct identification of a benign lesion as a fibroadenoma (BI-RADS® 2), which had been

classified as suspicious (BI-RADS® 4b) by tomosynthesis. The average area of the breast covered in ABVS (99.7 cm², SD 25.4) was significantly smaller than in tomosynthesis (150.3 cm²; SD 37.9; p<0.001). An improved ABVS coverage is one of the major development priorities for future systems. CONCLUSION

Our descriptive feasibility study showed that the FUSION-X-US system

Table 1: Time spent by both investigators for the interpretation of ABVS and tomosynthesis images produced by the FUSION-X-US-prototype

can perform tomosynthesis and ABVS in a single, one-time and efficient workflow procedure with direct correlation of imaging findings from both modalities. Suspicious findings were reliably detected by two independent investigators. Since no additional lesions were detected in ABVS, there was no increase in sensitivity compared to tomosynthesis alone. Thus, our analysis of this relatively small cohort of patients did not show any clear benefit of the additional ABVS. A larger study with higher patient numbers is needed to test the potential benefit of the additional ABVS. The main technical challenges of the integrated ABVS/tomosynthesis system are breast coverage and image quality. Against these criteria, the FUSION-X-US prototype currently does not come up to the performance of a stand-alone ABVS device. On average, only 66.0% of the area covered by tomosynthesis was covered by ABVS, so not all regions of interest could be examined in both modalities. One reason for the limited coverage of ABVS is the fact that the ultrasound transducer was embedded in a housing with a thickness of about 1 cm on each side, thus limiting coverage of peripheral regions. Development efforts to produce ultrasound transducers with a thinner housing that are better adapted to the specifications of the prototype should help to overcome this issue. The quality of the tomosynthesis images of the prototype device was

Table 2: Malignant lesions case-by-case

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Table 3: Detection of lesions

Supplementary Table . Description of patient cohort

comparable to those of standard tomosynthesis, but the ABVS image quality was lower than in a stand-alone ABVS system. This limitation probably contributed to the relatively high rate of unclear (BI-RADS® 0) cases in ABVS. Also, the software for the ultrasound measurements was optimized for standard ABVS measurements and not for the special case of the prototype, resulting in suboptimal image quality. In future studies, a parameter optimization for the interpretation of the ABVS data produced by the prototype device will be performed. 3D tomosynthesis and additional ultrasound examinations have a growing diagnostic importance, especially in highrisk patient groups with dense breast tissue. With further technical improvements, combined ABVS and tomosynthesis systems could be valuable tools for improved breast cancer diagnostics. REFERENCES 1. Duffy SW, Morrish OWE, Allgood PC et al. Mammographic density and breast cancer risk in breast screening assessment cases and women with a family history of breast cancer. Eur J Cancer 2018; 88: 48-56 2. Gotzsche PC & Jorgensen KJ. Screening for breast cancer with mammography. Cochrane Database Syst Rev. 2013. 10.1002/14651858.CD001877. pub5:CD001877 3. Carney PA, Miglioretti DL, Yankaskas BC et al. Individual and combined effects of age, breast density, and hormone replacement therapy use on the accuracy of screening mammography. Ann Intern Med 2003; 138:168-175 4. Buist DS, Porter PL, Lehman C, Taplin SH & White E. Factors contributing to mammography failure in women aged 40-49 years. J Natl Cancer Inst 2004; 96:1432-1440 5. Skaane P. Breast cancer screening with digital breast tomosynthesis. Breast Cancer 2017; 24:32-41

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6. Berg WA, Blume JD, Cormack JB et al. Combined screening with ultrasound and mammography vs mammography alone in women at elevated risk of breast cancer. JAMA 2008; 299: 2151-2163 7. Giger ML, Inciardi MF, Edwards A et al. Automated Breast Ultrasound in Breast Cancer Screening of Women With Dense Breasts: Reader Study of Mammography-Negative and Mammography-Positive Cancers. AJR Am J Roentgenol 2016; 206: 1341-1350 8. Wilczek B, Wilczek HE, Rasouliyan L & Leifland K. Adding 3D automated breast ultrasound to mammography screening in women with heterogeneously and extremely dense breasts: Report from a hospital-based, high-volume, single-center breast cancer screening program. Eur J Radiol 2016; 85: 1554-1563 9. Brem RF, Tabar L, Duffy SW et al. Assessing improvement in detection of breast cancer with three-dimensional automated breast US in women with dense breast tissue: the SomoInsight Study. Radiology 2015; 274: 663-673 10. Golatta M, Franz D, Harcos A et al. Interobserver reliability of automated breast volume scanner (ABVS) interpretation and agreement of ABVS findings with hand held breast ultrasound (HHUS), mammography and pathology results. Eur J Radiol 2013; 82: e332-336 11. Golatta M, Baggs C, Schweitzer-Martin M et al. Evaluation of an automated breast 3D-ultrasound system by comparing it with hand-held ultrasound (HHUS) and mammography. Arch Gynecol Obstet 2015; 291: 889-895 12. Ciatto S, Houssami N, Bernardi D et al. Integration of 3D digital mammography with tomosynthesis for population breast-cancer screening (STORM): a prospective comparison study. Lancet Oncol 2013; 14: 583-589 13. Skaane P, Bandos AI, Gullien R et al. Comparison of digital mammography alone and digital mammography plus tomosynthesis in a population-based screening program. Radiology 2013; 267: 47-56 14. Wojcinski S, Gyapong S, Farrokh A, Soergel P, Hillemanns P, Degenhardt F . Diagnostic performance and inter-observer concordance in lesion detection with the automated breast volume scanner (ABVS). BMC Med Imaging 2013; 13:36 15. Kapur A, Carson PL, Eberhard J et al. Combination of digital mammography with semi-automated 3D breast ultrasound. Technol Cancer Res Treat 2004; 3: 325-334 16. Padilla F, Roubidoux MA, Paramagul C et al. Breast mass characterization using 3-dimensional automated ultrasound as an adjunct to digital breast tomosynthesis: a pilot study. J Ultrasound Med 2013; 32: 93-104 17. Richter K, Winzer KJ, Frohberg HD et al. [Combination of mammography with automated ultrasound (Sono-X) in routine diagnosis?]. Zentralbl Chir 1998 123 Suppl 5:37-41 18. Sinha SP, Roubidoux MA, Helvie MA et al. Multi-modality 3D breast imaging with X-Ray tomosynthesis and automated ultrasound. Conf Proc IEEE Eng Med Biol Soc 2007: 1335-1338 19. Schulz-Wendtland R, Jud SM, Fasching PA et al. A Standard Mammography Unit - Standard 3D Ultrasound Probe Fusion Prototype: First Results. Geburtshilfe Frauenheilkd 2017; 77: 679-685 20. Vaughan CL, Douglas TS, Said-Hartley Q et al. Testing a dual-modality system that combines full-field digital mammography and automated breast ultrasound. Clin Imaging 2016; 40: 498-505 21. Schaefgen B, Heil J, Barr RG et al. Initial results of the FUSION-X-US prototype combining 3D automated breast ultrasound and digital breast tomosynthesis. Eur Radiol. 2018; 10.1007/s00330-017-5235-8 22. Wockel A & Kreienberg R. First Revision of the German S3 Guideline ‘Diagnosis, Therapy, and Follow-Up of Breast Cancer’. Breast Care (Basel) 2008; 3: 82-86 23. D’Orsi CJ SE, Mendelson EB, Morris EA,et al. (2013) ACR BI-RADS® Atlas, Breast Imaging Reporting and Data System. Reston, VA, American College of Radiology

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Optimising mammographic compression protocols for Asian women By Prof. Kwan Hoong Ng & Dr Susie Lau

In this article, we summarise our recent study in which we investigated the variability of mammographic compression parameters amongst Asian women, and also the effects of reducing compression force on image quality and mean glandular dose (MGD) in Asian women. We found that force-standardized protocols led to widely varying compression parameters, but that it is feasible to reduce mammographic compression force with minimal effects on image quality and MGD in Asian women. BREAST COMPRESSION DURING MAMMOGRAPHY

Breast compression is used in mammography both for optimizing image quality and reducing radiation dose [1-3]. When compressed, the breast deforms, giving rise to a breast contact area between the breast and compression paddle. The extent of breast deformation depends on the elasticity of breast tissue and size. [1]. One obvious disadvantage of breast compression is of course the pain and discomfort experienced by many women, particularly those who have undergone conservative treatment for breast cancer [1, 4-7]. During mammography, radiographers normally compress the breast according to established compression protocols [8-10], and also according to their own experience and judgment based on the tautness of the breast, its size and the pain tolerance of the women. Currently available mammographic compression protocols are force-standardized, subjective, and The Authors Prof. Kwan Hoong Ng, PhD. DABMP & Susie Lau, PhD Department of Biomedical Imaging, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia. Corresponding Author

It was observed in recent studies that force-standardized compression protocols result in women with smaller breasts being subjected to higher compression pressures and possibly experiencing more pain during mammography compared to women with larger breasts [4, 11, 14, 15]. Moreover, studies also revealed that although there was a tendency to apply greater compression forces to women with greater breast volumes, large variations still existed even between women with similar breast volumes [4, 16]. In addition, over-compression of the breast has also been reported in several studies, in which the compressed breast thickness (CBT) was not reduced even when additional compression force was applied. This causes unnecessary increase in pain and discomfort to the women without any benefits in image quality and radiation dose [11, 13, 14, 17]. Variations in compression force result largely from differences in the experience of the radiographers. One aim of the compression technique used should be to minimize variability as this could affect the consistency of the imaging procedure [1, 4, 12, 16]. Likewise, the level, and variability, of the pain and discomfort experienced by women during mammography should also be minimized as this could affect future participation in screening mammography [1, 4, 12, 18, 19]. Recent studies have suggested using pressure (applied force divided by the breast contact area) instead of force to standardize mammographic compression [1, 4, 11]. Pressurebased standardization inherently takes breast elasticity and size into account, and provides an objective and consistent mammographic compression for each individual breast [1, 4, 11]. These studies also proposed standardizing compression pressure at 10 kPa (about 75 mmHg), on the basis that this pressure corresponds to the normal diastolic pressure in the breast, and so results in constant venous blood outflow from the breast, regardless of breast size and the view in which the mammography is carried out [craniocaudal (CC) or mediolateral-obl ique (MLO)] [1, 4, 6, 11, 15]. However the currently available compression protocols [8-10] have largely been optimized for Caucasian women and thus Asian women (who generally have smaller breasts)

Dr K H Ng. email: ngkh@ummc.edu.my

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do not take breast size and elasticity into account [1, 4, 6, 11]. This lack of consistent and objective guidelines in mammographic compression has led to large variations in both the force and pressure applied by radiographers during mammography [1, 4, 12, 13].

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1. Data on file and from public sources, 2017. 2. Results from Friedewald, SM, et al. “Breast cancer screening using tomosynthesis in combination with digital mammography.” JAMA 311.24 (2014): 2499-2507; a multi-site (13), non-randomized, historical control study of 454,000 screening mammograms investigating the initial impact of the introduction of the Hologic Selenia® Dimensions® on screening outcomes. Individual results may vary. The study found an average 41% increase and that 1.2 (95% CI: 0.8-1.6) additional invasive breast cancers per 1000 screening exams were found in women receiving combined 2D FFDM and 3D™ mammograms acquired with the Hologic 3D™ Mammography System versus women receiving 2D FFDM mammograms only. 3. In an internal study comparing Hologic’s standard compression technology to the SmartCurve™ system (18 x 24cm). ADS-01949-EUR-EN Rev 001 © 2017 Hologic, Inc. All rights reserved. Hologic, 3D, 3Dimensions, 3D Mammography, Dimensions, Selenia, The Science of Sure, and associated logos are trademarks and/or registered trademarks of Hologic, Inc. and/or its subsidiaries in the US and/or other countries. All other trademarks, registered trademarks, and product names are the property of their respective owners.


Breast Imaging compression force and in compression pressure applied. The compression force applied in MLO views was found to be significantly higher than that in CC view, whereas the compression pressure applied in CC view was significantly higher than that of MLO.

Figure 1. (a) Scatter plot showing compression force against contact area. (b) Box plot showing compression force for the left CC, left MLO, right CC and right MLO views [20].

are examined using protocols that might not be optimal for them. Previous studies of compression have mainly been carried out in Caucasian women — little is known about mammographic compression in Asian women. For this reason, we recently investigated the mammographic compression practices used with the Asian women attending our center by analyzing the variability of compression parameters and other relevant imaging parameters. We also evaluated the possible impact of reducing compression force on image quality and mean glandular dose (MGD) in a phantom-based study [20]. MAMMOGRAPHIC COMPRESSION PARAMETERS IN ASIAN WOMEN

In the first part of our study, we collected 15818 “For Processing” raw digital mammograms (CC and MLO views) from 3772 Asian women aged 35-80 years (mean: 57±9 years) who underwent screening or diagnostic mammography at our center. The mammograms were processed using an automated volumetric breast density (VBD) measurement system (Volpara Version 1.5.1) to extract compression parameters during mammography, including the compression force applied and the compressed breast thickness (CBT) from the DICOM header of the images. The breast contact area between the breast and the compression paddle was computed by the Volpara software, based on the total breast area segmented from the background in the images. Compression pressure was estimated by dividing the applied compression force by the breast contact area. Other parameters including breast 16

volume, volumetric breast density (VBD) and MGD were also computed from the images by the Volpara software. We then investigated the relationships between these parameters (i.e. compression force, compression pressure, CBT, breast volume, VBD and MGD) with the breast contact area. As expected, compression pressure and breast volume were observed to correlate strongly and statistically significantly with breast contact area as these two parameters were derived from breast contact area [Figures 1 and 2]. Compression force, CBT and VBD showed moderately significant correlation with breast contact area, whereas MGD showed weak, but still significant, correlation with breast contact area [Figure 3]. We also found that the force-standardized protocol as currently practiced in our center with our Asian women and patients resulted in large variations in both

The overall median compression force for our study population was approximately 12.0 daN. Based on our data and the proposed pressure-standardized protocol, the optimal median compression force should be approximately 8.1 daN. In a previous film-screen mammography study, it was reported that many women experienced breast pain with compression forces of 12.0 daN; reducing the compression force to 9.0 daN was found to be more acceptable and tolerable to the women in the study [21]. Consequently, we carried out a study using phantoms to investigate the potential impact on image quality and MGD of reducing the compression force from 12.0 daN to 9.0 daN in digital mammography in Asian women. Analysis of data from 105 Asian women aged 24-78 years (mean: 52±11 years) who underwent screening or diagnostic mammography at our center revealed that the CBT increased by 3.3±1.4 mm when the compression force was reduced from 12.0 daN to 9.0 daN. PHANTOM STUDY FOR ASSESSING IMAGE QUALITY AND MEAN GLANDULAR DOSE

In this part of our study, we used the RMI156 Mammographic Accreditation Phantom to simulate a typical 4.2 cm of compressed human breast (composed of

Figure 2. (a) Scatter plot showing compression pressure against contact area. (b) Box plot showing compression pressure for the left CC, left MLO, right CC and right MLO views [20].

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1. Data on file and from public sources, 2017. ADS-01950-EUR-EN Rev 001 © 2017 Hologic, Inc. All rights reserved. Hologic, 3D, 3Dimensions, 3D Mammography, Clarity HD, Dimensions, Selenia, The Science of Sure, and associated logos are trademarks and/or registered trademarks of Hologic, Inc. and/or its subsidiaries in the US and/or other countries. All other trademarks, registered trademarks, and product names are the property of their respective owners.


Breast Imaging

Figure 3. (a) Scatter plot showing mean glandular dose against contact area. (b) Box plot showing mean glandular dose for the left CC, left MLO, right CC and right MLO views [20]. .

50% adipose tissue and 50% glandular tissue). To simulate different thicknesses of breast tissue, 10.2 cm X 10.8 cm slabs of polymethyl methacrylate (PMMA) were used. Images of the RMI156 phantom were first acquired using the two most frequent anode/filter combinations and tube voltages (kVp), namely tungsten/rhodium combination (W/Rh) at 28 kVp, and tungsten/silver combination (W/Ag) at 30 kVp. The phantom was then imaged with increasing numbers of PMMA slabs of different thicknesses (1-6 mm, with 1 mm increments) added between the phantom and compression paddle to simulate the increase in CBT. Four professionally trained observers were then asked to score the phantom image quality from no PMMA slabs added up to a total of 6 mm PMMA slabs added. The images, displayed on a diagnostic monitor, were scored according to test features, such as fibers, masses and calcifications in the images. Statistical analysis revealed that there were no significant differences in the fiber, mass, calcification and total scores when the phantom was imaged without any added slabs and with 5 mm of PMMA slabs added, using both W/Rh at 28 kVp and W/Ag at 30 kVp, so indicating that the image quality was similar under these conditions. From these findings, we expect that the increase of 3.3Âą1.4 mm in CBT which would result from lowering the compression force would have limited impact on image quality. Estimates of MGD in the phantom study showed that an increase in CBT caused by the decrease 18

in compression force from 12.0 daN to 9.0 daN would also have limited effects on MGD. CONCLUSION

Currently available force-standardized protocols do not take breast elasticity and size into account, and led to widely varying compression parameters, particularly compression force and compression pressure. This has already been shown in Caucasian women but has now been confirmed also in Asian women. These force-standardized protocols have largely been optimized for Caucasian women, thus Asian women who generally have smaller breasts are subjected to protocols that might not be suitable for them. We also showed that it is feasible to reduce compression force in Asian women with limited impact on image quality and MGD in digital mammography. In view of the limitations of force-standardized protocols, pressure-based standardization as promoted by some researchers [1, 4, 6, 11, 15], would appear to be superior for mammographic compression protocols. In the light of all this, we trust that manufacturers will take steps to improve the compression mechanism and measurement, with the overall aim of providing women with a more comfortable experience during mammography, while of course maintaining image quality. REFERENCES 1. Branderhorst W, de Groot JE, Highnam R, Chan A, Bohm-Velez M, Broeders MJ, et al. Mammographic compression--a need for mechanical standardization. Eur J

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Radiol. 2015; 84: 596. 2. Yaffe MJ. AAPM tutorial. Physics of mammography: image recording process. Radiographics : a review publication of the Radiological Society of North America, Inc. 1990; 10: 341. 3. Chen B, Wang Y, Sun X, Guo W, Zhao M, Cui G, et al. Analysis of patient dose in full field digital mammography. Eur J Radiol. 2012; 81: 868. 4. de Groot JE, Broeders MJ, Branderhorst W, den Heeten GJ, Grimbergen CA. A novel approach to mammographic breast compression: Improved standardization and reduced discomfort by controlling pressure instead of force. Med Phys. 2013; 40: 081901. 5. Broeders MJ, Ten Voorde M, Veldkamp WJ, van Engen RE, van Landsveld-Verhoeven C, t Jong-Gunneman MN, et al. Comparison of a flexible versus a rigid breast compression paddle: pain experience, projected breast area, radiation dose and technical image quality. Eur Radiol. 2015; 25: 821. 6. de Groot JE, Broeders MJ, Branderhorst W, den Heeten GJ & Grimbergen CA. Mammographic compression after breast conserving therapy: controlling pressure instead of force. Med Phys. 2014; 41: 023501. 7. Kornguth PJ, Keefe FJ, Wright KR & Delong DM. Mammography pain in women treated conservatively for breast cancer. J Pain. 2000; 1: 268.. 8. International Atomic Energy Agency. Quality assurance programme for digital mammography Vienna2011 [May 16, 2015]. Available from: http://www-pub.iaea.org/ MTCD/publications/PDF/Pub1482_web.pdf. 9. European Commission. European guidelines for quality assurance in breast cancer screening and diagnosis 2006 [May 16, 2015]. Available from: http://euref.org/ european-guidelines/4th-edition. 10. US Food and Drug Administration. Mammography Quality Standards Act and Program 2013 [updated June 03, 2013 June 05, 2013]. Available from: http://www.fda.gov/Radiation-EmittingProducts/ MammographyQualityStandardsActandProgram/default. htm. 11. de Groot JE, Branderhorst W, Grimbergen CA, den Heeten GJ, Broeders MJ. Towards personalized compression in mammography: a comparison study between pressure- and force-standardization. Eur J Radiol. 2015; 84: 384. 12. Mercer CE, Szczepura K, Kelly J, Millington SR, Denton ERE, Borgen R, et al. A 6-year study of mammographic compression force: Practitioner variability within and between screening sites. Radiography. 2015; 21: 68. 13. Poulos A & McLean D. The application of breast compression in mammography: a new perspective. Radiography. 2004; 10: 131. 14. Dustler M, Andersson I, Brorson H, Frojd P, Mattsson S, Tingberg A, et al. Breast compression in mammography: pressure distribution patterns. Acta Radiol. 2012; 53: 973. 15. de Groot JE, Broeders MJ, Grimbergen CA & den Heeten GJ. Pain-preventing strategies in mammography: an observational study of simultaneously recorded pain and breast mechanics throughout the entire breast compression cycle. BMC Womens Health. 2015; 15: 26. 16. Mercer CE, Hogg P, Szczepura K & Denton ERE. Practitioner compression force variation in mammography: A 6-year study. Radiography. 2013; 19: 200. 17. Poulos A, McLean D, Rickard M & Heard R. Breast compression in mammography: how much is enough? Australas Radiol. 2003; 47: 121. 18. Whelehan P, Evans A, Wells M & Macgillivray S. The effect of mammography pain on repeat participation in breast cancer screening: a systematic review. Breast. 2013; 22: 389. 19. Elwood M, McNoe B, Smith T, Bandaranayake M & Doyle TC. Once is enough--why some women do not continue to participate in a breast cancer screening programme. N Z Med J. 1998; 111:180. 20. Lau S, Abdul Aziz YF & Ng KH. Mammographic compression in Asian women. PLoS ONE. 2017; 12(4): e0175781. 21. Chida K, Komatsu Y, Sai M, Nakagami A, Yamada T, Yamashita T, et al. Reduced compression mammography to reduce breast pain. Clinical imaging. 2009; 33: 7.

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1. Results from Friedewald, SM, et al. “Breast cancer screening using tomosynthesis in combination with digital mammography.” JAMA 311.24 (2014): 2499-2507; a multi-site (13), non-randomized, historical control study of 454,000 screening mammograms investigating the initial impact of the introduction of the Hologic Selenia® Dimensions® on screening outcomes. Individual results may vary. The study found an average 41% increase and that 1.2 (95% CI: 0.8-1.6) additional invasive breast cancers per 1000 screening exams were found in women receiving combined 2D FFDM and 3D™ mammograms acquired with the Hologic 3D™ Mammography System versus women receiving 2D FFDM mammograms only. 2. Hologic data on file, 2017. ADS-01951-EUR-EN Rev 001 © 2017 Hologic, Inc. All rights reserved. Hologic, 3D, 3Dimensions, 3D Mammography, Intelligent 2D, Dimensions, Selenia, The Science of Sure, and associated logos are trademarks and/or registered trademarks of Hologic, Inc. and/or its subsidiaries in the US and/or other countries. All other trademarks, registered trademarks, and product names are the property of their respective owners.


Breast Imaging

A multimodal system for the diagnosis of breast cancer: the SOLUS project By Paola Taroni, Peter Gordebeke, Alberto Dalla Mora, Alberto Tosi, Antonio Pifferi, Jean-Marc Dinten, Mathieu Perriollat, David Savery, Hélène Sportouche, Bogdan Rosinski, Simon Arridge, Andrea Giudice, Simone Tisa, Elena Venturini, Pietro Panizza, Pamela Zolda, Alexander Flocke”

Breast cancer is the most common cancer in Europe; it is estimated that about one in eight women in Europe will develop breast cancer before the age of 85 [1, 2]. Early diagnosis of breast cancer maximizes the chances of survival so the availability of diagnostic tools with a high sensitivity for early cancer detection and with high specificity to minimize false positive results is vital. The International Agency for Research on Cancer has confirmed the effectiveness of mammographic screening in reducing breast cancer mortality [3]. However, screening programs also result in the detection of a significant number of false positive cases [4], which lead to unnecessary additional imaging and invasive procedures such as fine needle aspirations or biopsies. On average about 50% of positive breast screening outcomes turn out to be false positives meaning that further invasive examination could have been avoided. These not only have a negative impact on patients’ quality of life but also are a high economic burden on healthcare systems. There is thus a clear need for an affordable and highly specific point-of-care system to substantially improve in-depth diagnosis of breast lesions detected by ammography. Several imaging modalities are currently being used or evaluated or as an adjunct to mammography. This article summarizes the rationale behind the Solus project whose aims are the development of a multimodal breast imaging system involving diffuse optics, ultrasound and shear wave elastography. Ultrasound

Ultrasonography (US) is the first choice technique to assess both non-palpable lesions visible at mammography and

The Authors Paola Taroni, Peter Gordebeke, Alberto Dalla Mora, Alberto Tosi, Antonio Pifferi, Jean-Marc Dinten, Mathieu Perriollat, David Savery, Hélène Sportouche, Bogdan Rosinski, Simon Arridge, Andrea Giudice, Simone Tisa, Elena Venturini, Pietro Panizza, Pamela Zolda, Alexander Flocke” Corresponding Author Peter Gordebeke, European Institute for Biomedical Imaging Research, Vienna, Austria. email: pgordebeke@eibir.org

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also palpable lesions, as well as to guide breast biopsy. For routine clinical applications, grey scale B-mode US is generally used. Morphologic features identified on US can be categorized to enable distinction between malignant and benign lesions. Thus, ellipsoid shapes, thin capsules and gentle lobulations are typically characteristic of benign lesions whereas spiculation, taller-than-wide orientation, angular margins and microcalcifications are generally associated with malignant lesions. The Breast Imaging Reporting and Data System (BI-RADS) with US [5] provides standardized terminology to describe and assess masses found in breast tissue, as well as recommendations for further follow-up. BI-RADS category 3 are considered probable benign lesions, with a very low rate of malignancy (<2%). However BIRADS category 4 covers a wide range of lesions whose malignancy status is less predictable. Thus currently, the diagnostic results of conventional B-mode US are frequently unsatisfactory. Improved characterization of lesions might allow better BIRADS categorization which could lead to more non-invasive follow-ups rather than biopsies. Shear wave elastography

Recently, the more advanced US technique known as shear wave elastography (SWE) has been introduced and provides a quantitative and reproducible measurement of tissue stiffness. This can reflect the increased deposition of extracellular matrix in neoplastic tissue and serve as a marker of malignancy. A recent meta-analysis has evaluated the performance of SWE for the diagnosis of breast cancer [6]. The specificity of conventional US alone was 55%, but the addition of SWE to conventional US increased the specificity to 80%, while maintaining sensitivity essentially unaltered at 95%. However, even further improvement in specificity is desirable to achieve a significant reduction in the false positive rate and so generate a real impact on both patients and healthcare systems. Diffuse optical imaging

Optical methods can give insight into tissue physiology and alterations, thus providing information complementary to US. Diffuse optics can probe tissue to a depth of a few centimetres, which makes it an appealing potential candidate for the non-invasive diagnosis of breast cancer, either as E U R O P E

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At the heart of the system is a multimodal probe capable of carrying out diffuse optical tomography, by means of a newly designed small device known as a smart optode, as well as US and SWE measurements

a stand-alone modality or in combination with other imaging modalities. With diffuse optics, it is possible to measure the light absorption and scattering properties of breast tissue. Tissue composition and functional blood parameters, such as hemoglobin and oxygen saturation, as well as water and lipid content, are derived from the knowledge of the absorption properties at multiple wavelengths, while scattering provides information on tissue structure. Cancerous breast tissue is typically characterized by high hemoglobin and water content, while lipid content is correspondingly low. High light scattering has also often been detected in malignant lesions [7, 8]. Cancerous breast tissue is typically characterized by high hemoglobin and water content, while lipid content is correspondingly low. High light scattering has also often been detected in malignant lesions [7, 8]. These observations have a solid basis in tumor biology, as they all correlate with tissue changes associated with tumor development, such as neoangiogenesis, alterations of stromal components and increased extracellular matrix deposition among others. Collagen â&#x20AC;&#x201D; the structural element of the extracellular matrix which provides tissue with its mechanical strength and elasticity â&#x20AC;&#x201D; can also be measured using diffuse optics. Alterations in stromal architecture and composition are well-known aspects of pathological breast conditions and a causal link between stromal collagen and tumor formation and progression has been established [9]. Thus, information on the collagen content in breast tissue could provide useful information for breast lesion classification. A pioneering research team in the Politecnico di Milano, Italy, has been investigating the non-invasive optical characterization of biological tissues for more than two decades [12, 13] and has recently obtained encouraging preliminary clinical data, showing that collagen may be even more crucial than hemoglobin in the differentiation between malignant and benign breast lesions [10, 11]. Up till now collagen, as quantified by optical means has never been exploited in clinical practice for breast diagnostics. MAY / JUNE 2018

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Diffuse optics operating in the so-called time-domain, i.e. with short light pulses of the order of picoseconds, allow complete optical characterization of tissue in a single measurement. However diffuse optical imaging has a well-known limitation, namely its limited spatial resolution, which is inherently due to the highly diffusive nature of biological tissues. To better exploit the information from diffuse optics, and to overcome its limited spatial resolution, morphologic data obtained from other imaging modalities, such as mammography, MRI, PET or US, have been used to provide prior information in diffuse optical tomography reconstruction procedures, or fused with optical images to provide anatomical landmarks [14]. Contrary to mammography or PET, US does not involve the use of ionizing radiation and does not have many of the disadvantages of these modalities (complexity, cost, long examination times, use of contrast agents, limited patient acceptance). This makes US an ideal method from which to derive anatomical information and to complement diffuse optics. The SOLUS project

The SOLUS project aims to develop an innovative, multimodal tomographic system, combining diffuse optics, US and SWE, to support the in vivo diagnosis of breast cancer. Specifically, our multimodal system hopes to improve the classification of breast lesions after a positive result on mammographic screening, and specifically at improving the discrimination of lesions that are borderline between benign and malignant (BI-RADS 3 vs. 4a) and which presently result in screening studies having high false positive rates. Combining diffuse optics with US can be achieved via the development of a portable, cost-effective, non-invasive, point-of-care diagnostic tool. We aim to attain the projectâ&#x20AC;&#x2122;s overall objectives by exploiting innovative photonics concepts and developing new components. By employing time-domain diffuse optics with a small sourcedetector distance, and a high dynamic range time-gated approach, the SOLUS system should achieve unprecedented sensitivity, spatial resolution, and depth penetration, thereby providing effective, diagnostic information on tissue composition and functional blood parameters to complement the anatomical information and characteristics of tissue stiffness provided by conventional US and SWE, respectively. To reach our general goal, we are developing an innovative photonic module, called a smart optode to perform diffuse optical tomography to a depth of a few centimeters. The smart optode includes a novel laser driver and a newly developed fast-gated detector and acquisition electronics. The smart optode itself will be small in size (about 1x1x4 cm) and will be combined with a US transducer into a multimodal probe capable of carrying out diffuse optical tomography, as well as US and SWE measurements. This multimodal probe is at the heart of the SOLUS system for high-specificity, multi-parametric breast imaging and diagnosis of breast cancer. From the point of view of the patient and clinical user, the breast examination procedure will be very similar to current standard US practices. This should facilitate acceptance by the patient

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Breast Imaging and the clinician. A more comprehensive characterization of breast tissue, a higher diagnostic specificity, and a reduction in the number of further invasive examinations are expected. After assessment of the sensitivity and spatial resolution of the system in laboratory trials, we plan to validate the SOLUS system in real clinical settings. A pilot clinical study on patients with benign and malignant breast lesions (20 each) has been designed to demonstrate the overall feasibility of the proposed approach, the practical usability of the multi-modal instrument, and at the same time to provide insights into the real diagnostic advantages that can be achieved.

The Solus system will be incorporated into a commercially available ultrasound system (the Aixplorer system from Supersonic Imagine).

Impact of SOLUS

The SOLUS system should achieve substantially improved breast cancer diagnosis and reduction in unnecessary biopsies. The improvement in the characterisation of breast lesions also leads to higher specificity in non-invasive breast cancer diagnosis. Women receiving a negative report after their examination will be spared unnecessary additional examinations. The system will also allow more effective treatment and therapy management. New and improved therapy response prediction and monitoring enable personalized decision-making, therapy planning and optimization for each patient. This also contributes to a significant decrease in the total cost of breast cancer diagnosis. 22

First results and achievements

The project members are currently designing and developing the components for the system. Ultimately, these will be incorporated into an existing, commercially available ultrasound system (the Aixplorer system from the French company SuperSonic Imagine). In the first 18 months of the project, we’ve already developed a fast, compact laser driver and a new time-gated single-photon detector for the diffuse optics. These will be integrated into the smart optode, for which the overall design has been completed. We’re also working on the integration of the optode into the multimodal probe. The practical ergonomics of the probe are very important, so special attention is being paid to feedback from our collaborating clinicians on this aspect. Highly automated image processing and reconstruction algorithms are being developed, whereby anatomical information from US will be used as priors for the reconstruction of the diffuse optics measurements. We’ve also recently designed multimodal phantoms for optical tomography and ultrasound, necessary to assess the performance of the smart optode, multimodal probe and the overall system. The protocol for the clinical pilot study has also been designed. Facts and figures

SOLUS is a four-year project that started in November 2016, and so will conclude in October 2020. The project is coordinated by Prof. Paola Taroni from the Politecnico di Milano, Italy. The consortium brings together physicists, engineers, clinicians and four industry partners to develop the SOLUS system for improved breast cancer diagnosis. The consortium consists of nine partners from five European countries: • Politecnico di Milano, Milan, Italy • CEA-Leti, Grenoble, France • SuperSonic Imagine, Aix-en-Provence, France • Vermon, Tours, France • University College London, London, UK • Micro Photon Devices, Bolzano, Italy • Ospedale San Raffaele, Milan, Italy • European Institute for Biomedical Imaging Research, Vienna, Austria •iC-Haus, Bodenheim, Germany D I

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Acknowledgement

The SOLUS project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 731877. The SOLUS project is an initiative of the Photonics Public Private Partnership. References 1. International Agency for Research on Cancer, “Global Cancer Observatory,” 2018. [Online]. Available: http://gco.iarc.fr. 2. Curado M, Edwards B, Shin H, Storm H, Ferlay J, Heanue M & Boyle P. Cancer Incidence in Five Continents, Vol. IX. IARC Press, Lyon, 2007. 3. Lauby-Secretan B, Scoccianti C, Loomis D, Benbrahim-Tallaa L, Bouvard V, Bianchini F & Straif K. Breast Cancer Screening — Viewpoint of the IARC Working Group,. New England Journal of Medicine. 2015; 372: 2353 4. Independent UK Panel on Breast Cancer Screening. The benefits and harms of breast cancer screening: an independent review. Lancet 2012; 380: 1778 5. Mendelson E, Baum J, Berg W, Merritt C & Rubin E, Breast imaging, Reporting and Data System, BI-RADS: ultrasound. in American College of Radiology, Reston, VA, US, 2003. 6. Liu B, Zheng Y, Huang G, Lin M, Shan Q, Lu Y, Tian W, & Xie X. Breast Lesions: Quantitative Diagnosis Using Ultrasound Shear Wave Elastography—A Systematic Review and Meta-Analysis. Ultrasound in Medicine and Biology, 2016 ; 42: 835 7. Durduran T, Choe R, Baker W & Yodh A. Diffuse optics for tissue monitoring and tomography,. Reports on Progress in Physics. 2010; 73: 1 8. Leff D, Warren O, Enfield L, Gibson A, Athanasiou T, Patten D, Hebden J, Yang G & Darzi A. A diffuse optical imaging of the healthy and diseases breast: a systematic review. Breast Cancer Research and Treatment, 2008; 108: 9. 9. Luparello C. Aspects of Collagen Changes in Breast Cancer J of Carcinogenesis & Mutagenesis, p. S13, 2013. 10. Quarto G, Spinelli L, Pifferi A, Torricelli A, Cubeddu R, Abbate F, Balestreri N, Menna S, Cassano E & Taroni P. Estimate of tissue composition in malignant and benign breast lesions by time-domain optical mammography, Biomedical Optics Express, 2014; 5: 3684. 11. Taroni P, Pifferi A, Salvagnini E, Spinelli L, Teoricelli A & Cubeddu R. Seven-wavelength time-resolved optical mammography extending beyond 1000 nm for breast collagen quantification. Optics Express, 2009; 17: 15932 12. Dalla Mora A, Contini D, Arridge S, Martelli F, Tosi A, Boso G, Farina A, Durduran T, Martinenghi E, Torricelli A & Pifferi A. Towards next-generation timedomain diffuse optics for extreme depth penetration and sensitivity. Biomedical Optics Express, 2015; 6: 1749. 13. Konugolu Venkata Sekar S, Beh JS, Farina A, Dalla Mora A, Pifferi A & Taroni P. Broadband diffuse optical characterization of elastin for biomedical applications. Biophys Chem. 2017; 229: 130 14. Pearlman PC, Adams A, Elias SG, Mali WP, Viergever MA, Pluim JP. Mono- and multimodal registration of optical breast images. J Biomed Opt. 2012; 17: 080901

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Symposium Report Advances in X-Ray Imaging This article summarizes the proceedings of the recent symposium sponsored by Bracco Imaging at ECR 2018 on X-Ray imaging. Chaired by Prof. M Prokop, the symposium featured presentations by three experienced clinicians describing respectively the current status and future prospects in mammography; the key principles in improving the use of iodinated contrast media in modern CT systems and the optimal management of patient safety and economic aspects in a modern CT unit.

X-ray Mammography: today and tomorrow Prof T. Helbich Prof Helbich began his presentation by showing several mammography images Prof Thomas Helbich in which the high level of extremely Dept of Bionedical Imaging and Image-guided therapy, dense fibroglandular tissue makes iden- Division of Molecular and tification of cancerous lesions very dif- Gender Imaging Medical University of ficult. This highlights one of the major Vienna. challenges of conventional mammogra- thomas.helbich@meduniwien.ac.at phy, particularly for screening purposes. Having set the scene for his presentation, Prof Helbich then briefly described some of the recent technological innovations developed to meet this challenge and which are dramatically improving breast imaging practices. Tomosynthesis Although first described in 1998, tomosynthesis only entered routine practice much later, with the advent of digital mammography. Now, digital breast tomosynthesis (DBT) is a wellestablished, powerful technique, in which “sliced” images of the breast enables identification of lesions that would otherwise be missed at conventional mammography [Figure1]. Although a drawback of DBT when used together with conventional mammography is an increased radiation dose, this can be overcome by using synthetic reconstructions of a two-dimensional mammogram from the reconstructed tomosynthesis slices, thereby avoiding the need for a

Figure 1. Digital Breast Tomosynthesis is increasingly replacing 2D Mammography principally because DBT can detect significantly more cancerous lesions than 2D MG, Left Panels: DM, digital mammography. Central Panels: SM,synthetic 2 D mammogram. Right Panels: DBT, digital breast tomosynthesis.

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separate conventional digital mammogram. The combination of tomosynthesis plus synthetic 2D mammography allows lower overall radiation dose, shorter compression time and superior performance in terms of lesion detection. Advantages of DBT include improved cancer detection, increased accuracy and reduced patient recall rate. This has led to the question as to whether DBT could replace conventional mammography in screening applications. Several studies, using systems from several vendors and involving large numbers of women, have shown that the use of DBT allows a significant increase (between 27% to 54%) in cancer detection rate. A consequence of these findings has been an explosion in the numbers of sales of tomosynthesis systems. Contrast enhanced dual energy mammography (CEDEM). Contrast-enhanced MRI is the imaging modality with the highest sensitivity for breast cancer detection. Studies using “abbreviated” contrast enhanced MRI screening protocols have shown that this approach results in a cancer detection rate of 18/1000 women screened (compared to 7 - 9/1000 with DBT and 3 - 4 /1000 for mammography). The question is whether similar benefits are attainable in mammography with the use of appropriate iodinated contrast media. Such contrast enhancement is already established for standard non-breast CT examinations. In practice, CEDEM involves modification of the X-ray spectrum of a standard mammography system through the use of filters and modified software. The procedure involves the acquisition of a low energy image as in normal mammography, followed by a high energy image and subtraction of the two images, with the final subtracted image revealing cancer lesions that have taken up contrast [Figure 2]. For a successful CEDEM examination, appropriate contrast agents and an efficient contrast injector are essential. A review of the literature shows that contrast injection flow rates of 3-5 mL/sec are used in CEDEM, at 1-1.5 mL/ Kg body weight. While a range of iodine contrast concentrations have been used, higher iodine concentrations (e.g. 400 mg/mL) are advantageous in increasing lesion conspicuity and facilitating reductions in radiation dose. In short, CEDEM has proven feasible and easy to perform, with a cancer detection rate similar to that of MRI across all densities of breast tissue.

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Contrast enhanced tomosynthesis (CE tomo) The above two innovations in mammography, namely DBT and CEDEM have each been shown to have their own advantages, so a logical followup is to evaluate whether they can be combined into one combined imaging modality, CE-tomo. Initial studies on a prototype system suggest that the performance characteristics of CE â&#x20AC;&#x201C; tomo are similar to those of MRI. Contrast enhanced CT (CECT) Other workers consider that contrastenhanced tomosynthesis is just one step on the way to the ultimate goal which would be contrast- enhanced CT in which images are taken right around the breast, instead of a limited number of slice images as in DBT. Two CECT breast systems have been developed so far, one of which uses a photon counting detector and has been shown to detect not just masses but also microcalcifications with high sensitivity. Yet another very recent innovation is gating-based phase contrast CT .

total iodine dose. [Figure 3]. Iodine delivery rate is the amount of Iodine in g/sec that is administered to the patient. An appropriate IDR is particularly important for vascular (CTA) and perfusion examinations involving the first pass of iodine through the scanning window. The total iodine dose, on the other hand, is of greater importance for organ or tissue parenchymal studies in which a higher total iodine dose results in greater enhancement thereby improving the accuracy for cancer detection and characterization. Of course these contrast media aspects have to be considered together with factors relating to the CT scanner itself, e.g. tube voltage (kV) and current (mA), scan duration, scan delay, type of scan, etc., as well as those relating to the patient, such as the organ being examined, the patientâ&#x20AC;&#x2122;s age, weight, cardiovascular status, renal function etc. The radiologistâ&#x20AC;&#x2122;s responsibility is to manage protocols to optimize the various scanner and injection parameters for each individual patient.

Figure 2. The sensitivity of Contrast-Enhanced Dual Energy Mammography (CEDEM) has been shown to be equivalent to that of breast MRI. Images a & c: CEDEM; images b & d: MRI.

Conclusion. With the possible exception of screening in high-risk women where MRI still remains the optimal modality, the recently developed technologies of CE mammography, CE tomo or even CE CT have the potential to cover all applications in the field of breast imaging.

How to improve the use of iodinated contrast media in modern CT systems: key principles Prof Luis Marti-Bonmati Prof Bonmati reminded the audience of the basic rationale for the use of contrast media in CT, namely to improve the intrinsically poor soft tissue contrast of CT, to give improved conspicuity of any pathological soft Prof Luis Marti-Bonmati tissue alterations. The most impor- Department of Medical Imaging tant parameters that should be con- La Fe University and Polytechnic sidered when selecting a protocol are hospital, Valencia, Spain. the iodine delivery rate (IDR) and the marti_lui@gva.es MAY / JUNE 2018

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Figure 3. The most important parameters that should be considered when selecting a protocol are the iodine delivery rate and the total iodine dose. Images reproduced from Bae KT. Intravenous contrast medium administration and scan timing at CT: considerations and approaches. Radiology. 2010; 256: 32-61.

Prof Bonmati thereafter focused on the benefit of high concentration contrast media (HCCM) in CE CT Radiation exposure. Nowadays a major focus is on reducing the radiation exposure in CT examinations. HCCM (e.g. CM containing 400 mg Iodine/mL) have the potential to permit reductions of radiation beyond those routinely attainable using automated dose modulation systems. Such approaches are in keeping with the ALARA principle which aims to reduce radiation exposure to a minimum. Reducing radiation dose with HCCM. The higher iodine content in HCCM gives an increased signal for a given injection rate. This means that more noise can be accepted during image acquisition for a given contant signal to noise ratio (SNR). This in turn means that the tube current (mA), which is directly proportional to radiation dose, can be reduced while maintaining identical SNR. This reduction in radiation dose can be as much as 40% if a 400 mg/mL concentration of contrast is used instead of 300 mg/mL. In addition, lesion conspicuity is increased due to the tighter bolus during contrast injection

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Symposium Report Arterial enhancement in CE-CT. Early and late phase enhancement, i.e. arterial and capillary phases, respectively, is affected by the iodine delivery rate (IDR). Thus, for the same concentration of contrast agent, the higher the speed of administration the higher (and earlier) the peak of arterial enhancement. Conversely, a higher volume of CM would lead to a higher (and later) peak enhancement. Use of a lower concentration CM would necessitate administration of a higher volume at a faster injection rate to match that achievable with HCCM. This may not always be feasible or desirable, for example in the case of young pediatric patients or older more frail patients with poor venous access. A higher IDR produces a sharper bolus which results in a higher peak enhancement and a lower waste of contrast media with fast scanners. The use of a saline flush increases the arterial enhancement and the time to peak. In general use of HCCM at a relatively fast injection rate is optimal for improving first pass image quality at low radiation dose. Parenchymal enhancement. The degree of parenchymal enhancement reflects the Total Iodine Dose (TID) administered and is independent of the IDR. Parenchymal enhancement is inversely proportional to body weight and is improved with a saline flush. A total iodine dose of 600 mg iodine/kG body weight is usually adequate. However a better result can be achieved if the lean body weight (LBW) can be measured, in which case a TID of 800 mg/kG LBW is routinely used. Using HCCM, this means the TID can be achieved with 2 mL of 400 mg/mL HCCM Timing. Patient factors need to be taken into account when estimating the time necessary for the CM to reach the tissues being imaged. Thus, a fixed delay between contrast injection and the start of scanning is not optimal because of patient variability. A test bolus is time-consuming so bolus tracking is the preferred method. In bolus tracking, a trigger threshold (typically 100 Hounsfield Units) is fixed, after which typical delays are set, e.g. 6 sec for the early arterial phase, 12 sec for the late arterial phase, 48 sec for the portal phase and even 180 second for the interstitial delayed phase. HCCM summary • High concentration contrast media gives a higher signal. For a constant SNR, more noise can be accepted so radiation dose (mAs) can be reduced : “ High iodine concentration — low mAs” •The constant SNR approach can be further optimized through the

Figure 4.

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A typical abdominal protocol in use at La Fe Hospital,

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use of iterative reconstruction, • Heating the Contrast Media to 30 -35° C decreases its viscosity and peak pressure. Together with smaller volumes, such heating reduces adverse events and facilitates contrast distribution • In both early and late arterial phases a high IDR (2gI/s at high concentration, fast injection rate with a sharper bolus) yields a higher signal • Enhancement of arterial and hypervascular lesions (early and late phases) depends on the IDR (1.5gI/s) and the injection duration which should be as short as possible (4mL/s) — shorter and faster bolus. • Parenchymal enhancement, is proportional to TID. The volume should be adjusted in accordance with the LBW to reduce interpatient variability. • Monophasic protocols give more consistent enhancements. A typical abdominal protocol in routine use at La Fe Hospital is shown in Figure 4.

How to best manage safety compliance and economics in a modern CT unit. Prof Mathias Prokop There are many factors which have to be taken into account for optimal management of a modern CT unit but they can be classified into two main categories. The first covers quality, safety and compliance aspects, which include : • Individual optimization of contrast and radiation dose; Prof Mathias Prokop • Traceability of contrast and radia- Dept of Radiology and Nuclear Medicin, Radboud University Medical tion dose delivery Center, Nijmegen, The Netherlands. • Compliance with DRLs mathias.prokop@radboudumc.nl • Protocol management The other main category deals with economic aspects and covers subjects such as: • Ensuring high scan throughput; • Minimising waste of contrast media; • Ensuring that the cost of disposables is acceptable. A key component which helps to attain these objectives is the use of high concentration contrast media HCCM (e.g. Bracco’s HCCM provides 400 mg I/mL), which not only gives high enhancement when required, but can also be utilized to reduce radiation dose (of special importance in young patients). Individualization of radiation dose. For this, xyz tube current modulation is now current practice in modern scanners where the tube current is modulated to local x-ray attenuation, to give a more homogeneous detector signal and ultimately provide similar image quality, independent of the body region. Closely connected with xyz modulation, automated exposure control (AEC) is now also standard on modern CT systems and adjusts the tube current to the global x-ray attenuation, so that similar image quality is produced, independently of patient size. Individualization of contrast dose. For this, the injection time is kept constant, but the contrast volume and flow rate are varied as a function of the size of the patient, The overall effect is that similar enhancement can

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Figure 5. Example of group data presented by Bracco’s NEXO [Dose] system

be achieved for all patients, with smaller patients receiving less contrast and better enhancement being achieved in larger patients. High contrast concentration In Nijmegen, high contrast concentrations (Iomeron 400) are used to maximise Contrast to Noise Ratio (CNR) for CTA in young individuals, for cardiac CT and for perfusion imaging, where the contrast media is pre-warmed to 38 ° C to reduce viscosity. Interaction between individualized radiation and contrast dose It is well established that for a constant iodine concentration the use of lower kV provides more enhancement. There is an inverse square relationship between noise and radiation dose, so to reduce noise by a factor of two, i.e. increase the CNR by a factor of two, the dose would have to be increased by a factor of four. On the other hand, a two-fold increase in CNR can also be achieved by increasing the amount of contrast by a factor of two. Thus increasing the contrast can be a powerful adjunct to mA reduction alone. Where low radiation exposure protocols are indicated, e.g. for CTA, cardiac patients, slim patients or children, the selected parameters should be high contrast concentration, high flow, low kV (but a wide window setting is required). Iterative reconstruction should always be used. Such protocols are particularly suitable for young patients, who frequently have a high cardiac output, especially when they are nervous. Their renal function is generally good so total iodine dose is usually not a limiting factor and they are generally not obese, so low kV settings are more often possible. With young patients, the radiation risk is higher so it is important that the radiation exposure be

reduced. However if low contrast volume protocols are required, e.g. for renal failure or elderly patients, the parameters should be low volume, low flow, low kV with normal window setting and iterative reconstruction. Monitoring software. An integral contrast/ dose management tool is highly useful for tasks such as centralizing protocol management; giving safe web access; uploading data to HIS/ RIS/PACS; monitoring protocol use and compliance and for creating performance reports. Bracco’s NEXO [Dose] system carries out all these functions. An advantage of the system is that data can be presented from groups of patients. For example, Figure 5 shows a scatterplot of radiation dose as a function of patient body weight, from which it can be seen that there are a couple of outliers, namely two low bodyweight patients who received too large a radiation dose. Likewise the performance of different scanners can be examined through use of aggregated data. However it is not just group data that are presented; it is possible to evaluate individual patients/ protocols. The system also detects any suboptimal protocol design, errors in AEC settings or operator errors. Contrast injection Ideally, contrast dose should be personalized on the basis of standardized protocols in order to ensure safety of the administration procedures, to comply with best practices and guidelines as well as to minimize contrast wastage. In practice this is not so easy. For example there are differences in regulations between various European countries. In addition, often contrast medium is supplied in fixed bottle sizes so that a considerable amount of contrast may be unnecessarily discarded — home-made solutions to overcome this run the risk of sterility problems, backflow of blood etc. Bracco’s CT Exprès contrast injector solves such problems [Figure 6].Approved by the FDA, the multidosing system is syringeless and feeds from an NaCl bag and from two contrast bottles of up to 500 mL. A click system allows safe exchange of patient lines. In Nijmegen this system has now been adapted in routine use and has been found to be very flexible, with enough contrast from one bottle for 8 – 12 patients and with pre-warming of the contrast media to 38 °C. Patients can be changed rapidly and the contrast bottle can be changed at leisure. The system is safe with no backflow, air detection and is clean, with no leaks. Take-home messages for optimal management Safety and compliance. • Individualized contrast and radiation dose Less radiation/ more contrast in young patients More radiation, less contrast in patients with renal impairment • Protocol management • Monitoring software for compliance, dose reporting and performance bench-marking Economics • High throughput injector allows more patients per day with minimal waste of contrast • The correct amount of contrast is always injected

Figure 6. Bracco’s CT Exprès contrast injector

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Cardiovascular and Interventional Radiological Society of Europe


INDUSTRY NEWS After successful IPO, Siemens Healthineers “on track” to meet business targets Following its successful initial public offering in March, Siemens Healthineers has posted good business figures for the first quarter of 2018. Year-over-year revenue was up four percent at EUR 3.2 billion. The profit margin increased by 90 basis points to 17.4 percent. “With a strong performance the team of Siemens Healthineers has once again demonstrated the operational strength of our businesses, while preparing for our successful IPO”, said Bernd Montag, CEO Siemens Healthineers. “Based on the good quarterly figures, we confirm our outlook for the full year.” The Imaging Segment generated revenue of EUR 1.9 billion, corresponding to a year-on-year increase of six percent on a comparable basis. Comparable revenue growth in all three regions with significant growth in the U.S., China and Latin America was driven by an increase in equipment sales and services with strong increase in MR, CT and Ultrasound.

Following the initial public offering on March 16, the Siemens Healthineers share price has developed positively. The reorganization of the operating units and the reduction of decision-making levels is intended to make the company leaner, more efficient and more agile. At the recent European Radiology Congress, the newly spun-off company introduced many new products including the particularly lightweight and adaptable Acuson Juniper ultrasound system and the new Magnetom Sola2 magnetic resonance scanner. The new systems are planned to support healthcare providers in expanding precision medicine, transforming care delivery and improving patient experience. Siemens Healthineers Erlangen, Germany www.healthcare.siemens

Guerbet strengthens position in interventional procedures Guerbet, the French global specialist in contrast agents and solutions for medical imaging, has announced that it will acquire technology developed by Occlugel, a French company specialized in the R&D of microspheres used in embolization. The technology will be used in several ranges of microspheres for vascular embolization of benign tumors, for example uterine fibroma and prostate adenoma, and for vascular chemoembolization of malignant tumors, including in some liver, lung and kidney cancers. This technology will complete the existing range of Guerbet’s Interventional Imaging solutions, and above all create strong synergies with the Accurate range of antireflux microcatheters, acquired recently by the company . This news follows an earlier separate announcement from Guerbet that they have entered into a partnership with the Department of Radiodiagnosis and Interventional Radiology of the University Hospital of Lausanne in Switzerland and the Lausanne Center for Experimental Therapies (CTE) to evaluate the effects of Lipiodol-based conventional transarterial

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chemoembolization (cTACE) on the immunity of patients with hepatocellular carcinoma (HCC), the primary liver cancer tumor that causes over 700,000 deaths annually throughout the world and has one of the highest incidence rates in Western countries. cTACE is the reference treatment for patients with intermediatestage HCC and has been demonstrated

to significantly improve patient survival compared to supportive palliative therapy. Nevertheless, and despite progress brought by new medical practices, there is an urgent need to develop new therapies to fight this pathology which has a poor prognosis. Recent innovations include immunotherapy, aimed at stimulating or restoring the immune responses that specifically fight the tumor. This approach has elicited much interest and is the subject of several clinical trials for HCC treatment. Modern cancer treatment of most types of tumor involves

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a combination of several therapies used either sequentially or simultaneously, with the aim of obtaining an additive and sometimes even synergistic therapeutic effect. Combining local treatments, such as cTACE, with systemic immunotherapy promises to improve the tolerance and individual effectiveness of treatments. “It is essential that we improve our understanding and characterization of the anti-tumor effects of cTACE and that we study its ability to convert poorly immunogenic tumors, also called ‘immune deserts’, into immunogenic tumors. By reprogramming the tumor microenvironment, we could combine cTACE with immunotherapy,” said Dr. Rafael Duran from the CHUV Department of Radiodiagnosis and Interventional Radiology. The partners will work together to clarify the immunomodulatory and activating mechanisms induced by a cTACE procedure in patients with HCC, by measuring variations in the expression of different families of genes and of proteins involved in the anti-tumor immune response. Guerbet Villepinte, France www.guerbet.com

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INDUSTRY NEWS

Philips and Hologic announce global partnership agreement to provide integrated imaging solutions for women’s health At the recent ECR meeting Philips and Hologic announced a partnership, Hologic can join Philips when engaging with customers global partnership agreement to offer care professionals integrated on projects that were not previously possible for the two companies solutions comprising diagnostic imaging modalities, advanced alone. It’s a win for everyone involved, including the customers and informatics and services for screening, diagnosis and treatment patients we serve.” of women across the world. The collaboration combines Hologic’s In breast care, Philips offers advanced imaging for ultrainnovative mammography sound (e.g. Philips Affinity with technologies and Philips’ Anatomical Intelligence for “...The new partnership will allow hospitals eas- Breast), MRI (e.g. Philips Ingenia leading portfolio of ultrasound, MRI, CT, and X-ray ier access to integrated suites of diagnostic imaging digital MRI with Compressed systems, advanced infor- modalities, advanced informatics and services for SENSE to speed up exam times), matics and broad range of and PET/CT (e.g. Philips Vereos comprehensive breast screening and diagnosis...” fully digital PET/CT), supported services, including maintenance, upgrade, training by intelligent image analysis, and operational perforquantification, information manmance management services. agement and workflow tools. Under the agreement, Philips will be “No two women are alike, and we are teaming up with care able to offer select products from Hologic’s breast health portfolio providers and leading industry partners to supas part of multi-modality deals for hospiport the delivery of a tailored, seamless breast tals and health systems. This will include care experience for women,” said Rob Cascella, Hologic’s new 3Dimensions mammograCEO Diagnosis & Treatment businesses for phy system, the fastest, highest resolution Philips. “That is why I am very pleased to breast tomosynthesis system in the indusannounce our new partnership with Hologic try, as well as other technologies for breast for mammography. This partnership allows us screening and interventional radiology. to offer a complete set of innovative diagnostic The multi-year, non-exclusive global imaging systems, software and services to our partnership agreement allows for customcustomers, including Hologic’s market-leading ized regional implementation to best meet mammography solutions for breast screening the individual needs of each customer. and diagnosis of women in need of care.” “Hologic believes in enabling doctors with superior technology Philips Healthcare that improves women’s health through early detection and treatment,” Amsterdam, The Netherlands said Pete Valenti, Hologic’s Division President, Breast and Skeletal www.philips.com Health Solutions.“Our market-leading mammography solutions per- Hologic fectly complement Philips’ portfolio, making Hologic the right indus- Marlborough, MA, USA. try partner for this first-of-its-kind collaboration. Now, through the www.hologic.com

Carestream installs imaging system on Mount Everest Delivering medical imaging equipment to the top of the world is not for the faint of heart. Capital Enterprises, a Carestream distributor, transported and installed a CARESTREAM Vita Flex CR System that provides imaging services to 8,000 local residents as well as mountaineers, sherpas and others who support Mount Everest climbers. The Vita Flex was installed in the Kunde hospital located 24.6 kilometers from Mount Everest Base Camp. The imaging system was transported by plane to Lukla, Nepal, which is ranked as the world’s deadliest airport due to its high elevation and unforgiving terrain. From there 30

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porters carried the X-ray equipment on their backs for 30 kilometers to the Kunde hospital. The Vita Flex CR system is used by medical staff to acquire digital X-ray images of shoulders and extremities that have been broken or sprained; the head and neck area to diagnose sprains or concussions; as well as chest exams that may indicate a patient has pneumonia, altitude sickness, or evidence of a heart attack or other serious medical conditions. “The images are available in minutes and physicians can then decide if a patient can be treated at the hospital or must be transported to Kathmandu by helicopter,” said Charlie Hicks, Carestream’s General Manager of Global X-ray Solutions. Carestream, Rochester, NY, USA www.carestream.com.

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F ro nt Cov e r Story PET myocardial perfusion imaging more accurate than SPECT scans in detecting coronary artery disease Myocardial perfusion imagCenter Heart Institute, and lead ing (MPI) is utilized to deterauthor of the study. mine the presence and extent of The researchers looked at ischemic coronary artery disease pharmacologic SPECT so the (CAD). For over 30 years SPECT comparison with PET scans was has been the primary modality more accurate. for MPI. PET has replaced or The researchers found that supplemented SPECT imaging •Using PET scans instead in some centers but has not yet of SPECT scans resulted in been used as broadly as SPECT. increased rates of diagnosis of However more centers are now severe obstructive coronary considering switching to PET artery disease from 70 percent MPI. In addition to not requirto 79 percent. ing an onsite cyclotron, PET MPI • PET scans were associinvolves a lower radiation dose ated with a lower incidence of for the patient and needs shorter invasive catheterization withttime to obtain the images. PET out identification of severe also has improved resolution coronary artery disease (43% vs and has the ability to quantify 55%). myocardial blood flow. These There was a significant increase in the detection of severe obstructive • Overall, PET more sucadvantages have prompted the coronary artery disease in patients who receive cardiac positron emission cessfully identified patients testing (PET) imaging instead of single photon emission computed tomogAmerican Society of Nuclear raphy (SPECT) scan, according to researchers at the Intermountain Medical with severe obstructive CAD Cardiology and Society of Center Heart Institute in Salt Lake City, UT, USA and need for revascularization; Nuclear Medicine and Molecular Image credit Intermountain Medical Center Heart Institute. Reproduced compared to SPECT, PET scans Imaging to release a joint posi- courtesy of JCI Insight, © 2018 Am Soc Clin Invest. increased true positives and tion paper highlighting the propreduced false positives for severe erties of PET that make it most useful in screening for coronary artery disease. obstructive CAD. “Intermountain Medical Center made the switch from In 2013, the Intermountain Medical Center, Salt Lake SPECT to PET in 2013, so we thought it would be valuable City, UT, USA began to implement a PET-based program to look at the differences in clinical outcomes since then,” said for MPI. To understand the differences between the 2-year Dr Kirk Knowlton, director of cardiovascular research at period of SPECT utilization just before the PET program the Intermountain Medical Center Heart Institute. “In order began, and the 2 years after PET was fully implemented, to understand the differences between the two-year period of a group of researchers conducted a retrospective analysis SPECT utilization immediately before the PET program began of prospectively collected catheterization outcomes 60 days and the two years after PET was fully implemented, we conafter MPI and also assessed 1-year clinical outcomes to ducted a retrospective analysis of catheterization outcomes 60 determine major adverse cardiovascular events (MACE) in days after heart patients received various treatments.” the 2 periods. This represents one of the largest cohorts of “This study involves one of the largest number of PET PET-imaged patients reported to date. patients studied to date,” Dr. Min added. “What we now know The results of the study have now been published (Knight is that PET more successfully identifies patient who have highS et al Implementation of a cardiac PET stress program: com- grade coronary artery disease and may benefit from revascuparison of outcomes to the preceding SPECT era. JCI Insight. larization. Similarly, PET better identified patients who did 2018; 3(9). pii: 12094). not need an invasive procedure. This has broad implications For the study, researchers examined Intermountain as physicians consider what test best serves their individual Healthcare’s Enterprise Data Warehouse, which is one of the patients and institutions consider the advantages and disadlargest depositories of clinical data in the US , and identified vantages of SPECT and PET as well as downstream resource 3,394 patients who underwent a pharmacologic SPECT from utilization.” 2011-2012 and 7,478 patients who underwent PET in 20142015 at Intermountain Medical Center. Corresponding Author: “The benefit of the study is that it helps us better identify Dr KU Knowlton, a patient’s risk for adverse events affecting the heart and their Director of Cardiovascular Research. need for further care,” said Dr David Min, a cardiologist spe- email: kirk.knowlton @imail.org cializing in cardiac imaging at the Intermountain Medical https://tinyurl.com/Knight-et-al-paper MAY / JUNE 2018

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INDUSTRY NEWS

GE in collaboration on body composition analysis software for sports and fitness markets GE Healthcare has announced a joint marketing collaboration agreement with FitTrace, a leading cloud-based body composition analysis and reporting software company based in USA. GE is a global leader in dual energy X-ray absorptiometry (DXA) and quantitative ultrasound (QUS) technology, and the collaboration integrates the reliability and versatility of these technologies with the cloud-based reporting, sharing and advanced analytics capabilities from FitTrace to equip sports and fitness communities with information to help their athletes. “The sports performance and metabolic health industries are on a mission to improve human peak health and performance through better understanding of body composition, metabolic disorders, nutrition and genetics,” said Claudio Mejia, General Manager of GE Healthcare’s Bone and Metabolic Health business. DXA technology is the gold standard for measuring accurate and reliable body composition and a convenient method

Canon Medical Systems in consortium to develop deep learning technology in MRI Canon Medical Systems has initiated a collaborative research program on the application of Deep Learning Reconstruction (DLR), an Artificial Intelligence (AI)-based technology in magnetic resonance (MR) imaging,. The collab-

oration partners are Kumamoto University in Japan and the University of Bordeaux, France. DLR is a reconstruction technology that eliminates noise from images utilizing deep learning technology. Within this technology, the relationship between noisy and less noisy images is analyzed using a computer generated model, which makes it possible to eliminate noise from newly acquired images. DLR is not only capable of acquiring high resolution images, it also allows ultra-high-resolution images to be acquired more quickly than conventional imaging methods. DLR is considered to be a major technological advance that will dramatically change how MRI examinations 32

adopted by top researchers and professionals in the sports performance and metabolic health industries. DXA can be used to measure the distribution of fat and lean mass throughout the body or to analyze changes in body composition over time to help sports medicine professionals monitor the impact of training and dietary programs of their athletes. FitTrace is an easy to use cloud-based app that provides unique visualization and analysis of DXA-based body composition measurements. Athletes can be tracked, compared and benchmarked with other professional athletes. The “Team Edition” provides advanced analytics to help trainers, strength coaches and sports dietitians gain insights regarding training, nutrition and their athletes’ body compositions on any laptop or mobile device. GE Healthcare Little Chalfont, UK www3.gehealthcare.com

are performed in the future. Professor Yasuyuki Yamashita of the Department of Diagnostic Radiology, Kumamoto University, commented “DLR has the potential to transform the conventional concept of MR imaging and is expected to allow the acquisition of super-high-resolution images in a shorter time and contribute to more accurate quantitative analysis.” Professor Vincent Dousset, Chef de Service Neuro-Imagerie CHU de Bordeaux, said,“When DLR is used, the ultra-high-resolution images acquired from Canon’s 3-T MRI system that we have in our institute are comparable to images acquired using a 7-T MRI system. This suggests that DLR may be able to take the place of some high-field conventional MRI studies.” Overall, the combination of the latest AI technology with next-generation MRI scanners is expected to be useful not only for eliminating noise and improving image quality, but also in a wide variety of MR related fields. Canon Medical systems EUrope Zoetermeer , The Netherlands https://eu.medical.canon

Kromek to develop Molecular Breast Imaging Device Kromek, a UK-based radiation detection technology company has announced that D I

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it has been awarded funding from the UK’s Innovation agency for a three-year programme to deliver a Low Dose Molecular Breast Imaging (“LDMBI”) technology based on Kromek’s CZT-based SPECT detectors. The project is in partnership with one of the UK’s few ‘Outstanding’ NHS Trusts, namely Newcastleupon-Tyne Hospitals NHS Foundation Trust

In the first phase of the project, Kromek will utilise new developments in the company’s CZT-based SPECT detector technology to reduce the required dose of radiation in molecular breast imaging, the cuttingedge technology which uses a radioactive tracer to identify tumors. By partnering with breast cancer experts at the Newcastle Hospitals during the development, the team will ensure that the technology is tuned to clinical and patient needs. The LDMBI device will subsequently be used in a pilot study with the Newcastle Hospitals to demonstrate the clinical benefits of incorporating Kromek’s SPECT detectors. Kromek Sedgefield, UK www.kromek.com MAY / JUNE 2018


I MA GING NEWS Japan updates recommendations on use of Gadolinium-Based Contrast Agents Ever since the first report in 2014 that high MRI signal intensity in the dentate nucleus in the brain on T1-weighted images correlated with the number of previous gadolinium-based contrast agent (GBCA) administrations — subsequently found to be attributable to the deposition of free gadolinium released from GBCAs — there has been an intense debate on the significance of the findings. Although no direct pathological consequences have (so far) been reported, the concern over even-

children, and patients with inflammatory conditions. Japan has now revised the package inserts of GBCAs, with the addition of two recommendations, namely 1) careful consideration as to restricting GBCA use to clinical circumstances in which the information provided by the contrast is absolutely necessary, and 2) the use of macrocyclic GBCA as a primary choice and the use of linear GBCAs only when the use of a macrocyclic GBCA is not indicated because of a history of adverse effects. (Kanda T. The New Restrictions on the Use of Linear Gadolinium-based Contrast Agents in Japan. Magn Reson Med Sci. 2018 Mar 16.) In Japan, linear GBCA use has already drastically decreased from 64.7% in 2014 to 24.7% in 2016, and it is predicted that usage will show a further decrease because of the latest revision in the package insert. https://tinyurl.com/Kanda-GBCApaper

Study shows emergency CT for head trauma may be overused

tual toxicological effects has prompted regulatory authorities to take action. In Europe, the European Medicines Agency withdrew market authorisation for certain linear GBCAs (linear GBCAs have been shown to release free gadolinium ions more easily than macrocyclic GBCAs which remain on the market). In the USA, the FDA did not go quite as far but recommended that health care professionals should consider the retention characteristics of each agent when choosing a GBCA for patients who may be at higher risk for gadolinium retention. In practice this will most often mean that macrocyclic agents should be used preferentially, particularly for patients such as those requiring multiple lifetime doses, pregnant women, MAY / JUNE 2018

Emergency patients are too often given head CT to check for skull fractures and brain hemorrhage, leading to unnecessary heath care costs and patient exposure to radiation, according to a study presented at the ARRS 2018 Annual Meeting. The study presented by Michaela Cellina, of the Radiology Department of Fatebenefratelli-Sacco Hospital in Milan, Italy, evaluated head

CT scans carried out for minor head injury (MHI) in patients aged 18-45 who presented to the hospital’s emergency department between January 1 and June 30, 2016. (Cellina M et al. Overuse of computed tomography for minor head injury in young patients: an analysis of promoting factors. Radiol Med. 2018 Mar 7) For each CT scan, the researchers determined whether the CT referral met the criteria indicated by the UK’s National Institute for Health and Care Excellence (NICE) and the Canadian CT Head Rule (CCHR). Of 492 cases reviewed, 260 (52.8%) and 376 (76.4%) of the CT examinations were not indicated according to the NICE and CCHR, respectively. The researchers noted no statistically significant difference between the specialty and seniority of the referring physician and over-referral, or between the patient’s age and unwarranted CT studies. Motor vehicle accidents, however, were associated with a higher rate of non-indicated CT examinations for both NICE and CCHR criteria, and two-wheel vehicle driver accidents were associated with a higher rate of appropriated CT exams for both NICE and CCHR. Only 15 of the 260 CT examinations were positive for brain hemorrhage, subarachnoid hemorrhage, or skull fracture. https://tinyurl.com/Cellina-et-al-paper

MRI “glove” provides new look at hand anatomy A recent study has found that a new kind of MRI component in the shape of a glove can deliver the first clear images of bones, tendons and ligaments moving together (Zhang B, Sodickson DK & Cloos MA. A high-impedance detector-array glove for magnetic resonance imaging of the hand. Nature Biomedical Engineering, 2018; Mar 1–8) The study authors, from the Center for Advanced Imaging Innovation and Research (CAI2R), within the

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ESC Congress Munich 2018 25-29 August Where the world of cardiology comes together

Spotlight: Valvular Heart Disease

SAVE ON REGISTRATION Early registration deadline - 31 July Become an ESC Professional Member & save more

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IMAGING NEWS Department of Radiology at NYU Langone Health say that their MRI glove prototype promises to become useful in the future diagnosis of repetitive strain injuries such as carpal tunnel syndrome in office workers, athletes, and musicians. Because the new system shows how different tissue types impinge on each other as they move, the authors say it could also enable the construction of a more versatile atlas of hand anatomy, guide surgery with hand images in more realistic positions, or aid in the design of better prosthetics. “Our results represent the first demonstration of an MRI technology that is both flexible and sensitive enough to capture the complexity of soft-tissue mechanics in the hand,” said lead author Dr B Zhang, As all current MRI scanners measure signals that create currents in receiver coils (detectors), such coils have always been designed as “low impedance” structures that let the current flow easily. The leap made by the study authors was to design a “high impedance” structure that blocks current, and then measures how hard the force in magnetic waves “pushes” (the voltage) as it attempts to establish a current in the coil. With no electric current created by the MR signal, the new receiver coils no longer create magnetic fields that could interfere with neighboring receivers, thus removing the need for rigid structures. The researchers found that their system, with the new coils stitched into a cotton glove, generated “exquisite” images of freely moving muscles, tendons and ligaments in a hand as it played piano and grabbed objects.

In a first for MRI, a glove-shaped detector proved capable of capturing images of moving fingers. The technology showed how tissue types moved in concert, which could be useful in cataloging differences seen in injury. Image courtesy of NYU School of Medicine

“We wanted to try our new elements in an application that could never be done with traditional coils, and settled on an attempt to capture images with a glove,” says senior author Dr Martijn

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Cloos,. “We hope that this result ushers in a new era of MRI design, perhaps including flexible sleeve arrays around injured knees, or comfy beanies to study the developing brains of newborns.” https://tinyurl.com/MRI-glove-paper

Major study shows prostate MRI reveals more cancers which need treatment, and reduces overdiagnosis compared to standard biopsy A large international study has shown that an MRI scan can reduce the number of invasive prostate biopsies by up to 28%. The recently publiched results of the PRECISION trial shows that using

MRI to target prostate biopsies leads to more of the harmful prostate cancers, and fewer harmless cancers, being diagnosed (Kasivisvanathan V et al. MRI-Targeted or Standard Biopsy for Prostate-Cancer Diagnosis N Engl J Med. 2018; 378: 1767). Given that more than a million men in Europe undergo a prostate biopsy every year, the authors believe that this work could change clinical practice. Dr Veeru Kasivisvanathan of University College London and first author of the study, said: “PRECISION is the first international multi-centre randomised trial to show the benefits of using MRI at the start of the prostate cancer diagnosis process. In men who need to have investigation for prostate cancer for the first time, PRECISION shows that using an MRI to identify suspected cancer in the prostate and performing a prostate biopsy targeted to the

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MRI information, leads to more cancers being diagnosed than the standard way that we have been performing prostate biopsy for the last 25 years”. Dr Caroline Moore, Reader in Urology at University College London and senior author of the study commented: ‘We compared standard prostate biopsy to the use of MRI, offering targeted biopsies to only those men who had a suspicious MRI. The MRI pathway detected more harmful cancers that needed treatment, and it reduced the overdiagnosis of harmless cancers, even though fewer men had a biopsy in the MRI arm. ’ Professor Mark Emberton of University College London commented: ‘This study was the first to allow men to avoid a biopsy. If high quality MRI can be achieved across Europe, then over a quarter of the 1 million men who currently undergo a biopsy could safely avoid it’. Prostate cancer is currently diagnosed by examining biopsy samples taken from the prostate via the procedure called TRUS (TRansrectal UltraSound guided prostate biopsy). This means taking around 10-12 samples from the prostate using a probe with a special needle. The ultrasound-guided procedure means inserting a probe into the anus under local anaesthetic. It is uncomfortable, costly, and carries a slight risk of infection, but because it involves estimating the position of a possible tumour, it also means that tumours are often missed. The PRECISION study investigates whether an MRI scan can avoid the need for biopsy in some patients, or give better diagnostic information where a biopsy is necessary. Researchers from 23 centres randomly allocated 500 men to be examined either with a standard 10-12 core TRUS biopsy, or with an initial MRI scan followed by a targeted biopsy if the MRI showed an abnormality. The main aim was to assess what proportion of men were diagnosed with clinically significant prostate cancer (Gleason Grade of ≥3+4) which is harmful cancer that is desirable to find. It also aimed to assess the proportion of men who were diagnosed with clinically insignificant cancer (Gleason Grade 3+3) which is desirable to avoid as it doesn’t benefit from treatment. The researchers found that 71 (28%)

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IMAGING NEWS of the 252 men in the MRI arm of the study avoided the need for a subsequent biopsy. Of those who needed a biopsy, the researchers detected clinically significant cancer in 95 (38%) of the 252 men, compared with 64 (26%) of the 248 men who received only the TRUS biopsy. “This shows that a diagnostic pathway with initial MRI assessment followed by biopsy when required, can not only reduce the overall number of biopsies performed, but can give more accurate results than TRUS-biopsy alone. We also found that patients who had MRI had fewer side effects than those who just had the standard TRUS biopsy. This is because the MRI allows some men to avoid biopsy and in those who need one, is able to better indicate which area of the prostate needs to be investigated, so you don’t need to randomly sample the whole prostate and can use fewer biopsy cores”, said Dr Kasivisvanathan. “The ability to perform good quality MRI and the ability to interpret the MRI information are specialist skills. We will therefore need appropriate training for clinicians to use the technology and changes in health services to increase availability and capacity to perform prostate MRI. In the long-term, this new diagnostic pathway can be cost-effective. Costs can be saved by the reduction in the number of men undergoing biopsy in the first place, by the earlier diagnosis of harmful cancers and in the avoidance of the diagnosis of harmless cancers” https://tinyurl.com/Kasivisvanathan-et-al

scans of over 1000 older Australian women for the presence of calcium deposits in the large artery in the abdomen called the aorta. They graded the severity of these calcium deposits using scans carried out for osteoporosis screening. They then followed the women for almost 15 years to determine the occurrence of cardiovascu-

lar disease within the cohort. “We found that that the presence of calcifications increased the likelihood of having cardiovascular disease such as heart attacks, and even the likelihood of cardiovascular deaths and mortality in general.” said co-author Dr Douglas P. Kiel, Director, Musculoskeletal Research Center at Hebrew SeniorLife’s Institute for Aging Research. “Our study highlights the fact that having a bone density test not only tells women about their risk of fracture, but also their long term risk for cardiovascular disease. This makes bone density testing even more useful in screening.” https://tinyurl.com/Lews-et-al-paper

Researchers find bone 3-D mapping babies’ density scans can also brains During the third trimester, a baby’s help identify cardiobrain undergoes rapid development in vascular disease utero. The cerebral cortex dramatically In a recently published study, researchers from Hebrew SeniorLife’s Institute for Aging Research, University of Western Australia, and the University of Sydney, have discovered that bone density scans, typically used to determine fracture risk, could also be an aid in identifying cardiovascular disease. (Lewis et al. LongTerm Atherosclerotic Vascular Disease Risk and Prognosis in Elderly Women With Abdominal Aortic Calcification on Lateral Spine Images Captured During Bone Density Testing: A Prospective Study J Bone Miner Res. 2018. doi: 10.1002/jbmr.3405). The researchers analyzed the bone density

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expands its surface area and begins to fold. Previous work suggests that this quick and very vital growth is an individualized process, with details varying from infant to infant. Research from a collaborative team at Washington University in St. Louis tested a new, 3-D method that could lead to new diagnostic tools that will precisely measure the third-trimester growth and folding patterns of a baby’s brain. (Garcia et al. Dynamic patterns of cortical expansion during folding of the preterm human brain. Proc Natl Acad Sci U S A. 2018; 115: 3156). The findings could help to sound an early alarm on developmental disorders in D I

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premature infants that could affect them later in life. “One of the things that’s really interesting about people’s brains is that they are so different, yet so similar,” said Dr Philip Bayly. “We all have the same components, but our brain folds are like fingerprints: Everyone has a different pattern. Understanding the mechanical process of folding -- when it occurs -- might be a way to detect problems for brain development down the road.” The researchers accessed MR 3-D brain images from 30 pre-term infants. The babies were scanned two to four times each during the period of rapid brain expansion, which typically happens at 28 to 30 weeks. Using a new computer algorithm, the researchers obtained accurate point-topoint correspondence between younger and older cortical reconstructions of the same infant. From each pair of surfaces, the team calculated precise maps of cortical expansion. Then, using a minimum energy approach to compare brain surfaces at different times, researchers picked up on subtle differences in the babies’ brain folding patterns. “The minimum energy approach is

A team of scientists at Washington University in St. Louis has developed a new way to track folding patterns in the brains of premature babies. It’s hoped this new process could someday be used for diagnosing a host of diseases, including autism and schizophrenia. Image courtesy of Washington University in St. Louis

the one that’s most likely from a physical standpoint,” Bayly said. “When we obtain surfaces from MR images, we don’t know which points on the older surface correspond with which points on the younger surface. We reasoned, that since nature is efficient, the most likely correspondence is the one that produces the best match between surface landmarks, while at the same time, minimizing how much the brain would have to distort while it is growing. “When you use this minimum energy approach, you get rid of a lot of noise in the analysis, and what emerged were these subtle MAY / JUNE 2018


IMAGING NEWS patterns of growth that were previously hidden in the data. Not only do we have a better picture of these developmental processes in general, but doctors should hopefully be able to assess individual patients, take a look at their pattern of brain development, and figure out how it’s tracking.” https://tinyurl.com/Garcia-et-al-paper

Heart doctors from the European Society of Cardiology (ESC) Council on Stroke are calling on national health authorities for permission to provide stroke patients with mechanical thrombectomy, a life-saving treatment for acute ischaemic stroke, in regions where there is a lack of trained specialists. “We have evidence that after a short period of training on the procedure, interventional cardiologists treating acute ischaemic stroke achieve the same results as traditional interventional neuroradiologists,” said Professor Petr Widimsky, Chair of the ESC Council on Stroke. Acute ischaemic stroke is a severe form of the condition where a blood vessel to the brain becomes blocked. It accounts for up to four in five strokes, or over one million cases in Europe each year.

function normally. If performed within two to three hours of symptom onset, the rate of survival with normal neurological function rises to more than 70% of patients. In Europe, mechanical thrombectomy is currently provided by interventional neuroradiologists, but there is a severe shortage of these specialists. Even countries with the most specialists, such as Germany, the Netherlands and the Czech Republic, only have sufficient numbers to treat around one-third of acute ischaemic stroke patients. In some other countries, fewer than 1% of acute ischaemic stroke patients can be treated. Professor Widimsky said: “There are interventional cardiology units in all countries in Europe and the Americas, and in most other continents. The equipment for mechanical thrombectomy is available; it’s the trained specialists to perform the procedure that are lacking. This situation could be solved by training cardiologists to perform mechanical thrombectomy.” The ESC Council on Stroke is proposing that interventional cardiologists receive three months of training on how to do mechanical thrombectomy, rather than the typical two years required for other physicians. “Many interventional cardiologists routinely perform stenting of the carotid arteries so three months of training is sufficient to learn intracranial mechanical thrombectomy,” said Professor Widimsky. “It is up to health authorities in each country to decide if

Without treatment most patients die or are severely disabled and permanently bedridden. Even with clot-busting drugs, 75% of patients die or are severely disabled. With mechanical thrombectomy, the procedure to physically remove the clot and restore blood flow to the brain, about half of patients survive and

they will allow this.” The proposals are being put forward by the ESC Council on Stroke and the European Association of Percutaneous Cardiovascular Interventions, a branch of the ESC. www.escardio.org/Councils/Councilon-Stroke

Shortage of interventional neuroradiologists lead heart doctors to call for permission to provide therapy to stroke patients

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Majority of U.S. heavy smokers still not screened for lung cancer despite recommendations An analysis of 1,800 lung cancer screening sites in the United States found that only 1.9% of more than 7 million current and former heavy smokers were screened for lung cancer in 2016, despite United States Preventive Services Task Force (USPSTF) and ASCO screening recommendations. This study, the first assessment of lung cancer screening rates since those recommendations were issued in 2013, was presented at the recent 2018 ASCO Annual Meeting in Chicago.

“Lung cancer screening rates are much lower than screening rates for breast and colorectal cancers, which is unfortunate,” said lead study author Dr Danh Pham, medical oncologist. “It is unclear if the screening deficit is due to low provider referral or perhaps patient psychological barriers from fear of diagnosis. Lung cancer is unique in that there may be stigma associated with screening, as some smokers think that if cancer is detected, it would confirm they’ve made a bad lifestyle choice.” The USPSTF recommends that people ages 55 to 80 years who are current or former heavy smokers (have smoked at least 30 cigarette pack-years) be screened for lung cancer using low-dose computed tomography (LDCT). The study’s researchers gathered data from the 2016 American College of Radiology’s Lung Cancer Screening Registry on people who received LDCT at nearly 1,800 accredited screening sites. They compared that data to 2015 National Health Interview Survey estimates of eligible smokers who could be screened based on the USPSTF recommendations. The screening rate was calculated by dividing the number of LDCT scans by the number of smokers eligible for screening per USPSTF recommendations. Nationwide, a total of 1,796 accredited screening centers could have screened 7,612,965 eligible current and former heavy smokers, but only 141,260 people received LDCT screenings (the nationwide screening rate was 1.9%). (By comparison, about 65% of women age 40 or older had a mammogram in 2015). https://tinyurl.com/Asco-paper 37


IMAGING NEWS

Improved pediatric appendicitis care with judicious ultrasound and fewer CT scans Researchers from Children’s Minnesota and HealthPartners Institute have developed a new pediatric appendicitis risk calculator (pARC) to aid in the diagnosis of appendicitis (Kharbanda AB et al. Development and Validation of a Novel Pediatric Appendicitis Risk Calculator (pARC). Pediatrics. 2018; 141(4). pii: e20172699).

The researchers used data collected from ten pediatric emergency departments to develop the risk calculator and then independently validated the score using data from a single children’s hospital. Potential benefits of using the new risk calculator include a reduction in the use of computed tomography (CT), more judicious utilization of ultrasound and a reduction in healthcare expenditures. “This method is of great benefit to our patients and the health care system overall,” said Dr. Anupam Kharbanda, co-Principal Investigator “In addition to being able to target our care specifically to each patient, we’re also reducing the use of unnecessary medical tests and expenses. We’re thrilled to have developed a new way to standardize care for children and adolescents with abdominal pain.” Abdominal pain is one of the most common reasons children visit the emergency department and appendicitis is the most frequent surgical emergency in pediatrics. CT is one of the most common ways clinicians diagnose appendicitis. However CT 38

scans are not only costly, but they can also put pediatric patients at risk of radiation-induced injuries, The same researchers, along with colleagues from Kaiser Permanente Northern California, are conducting a 17-center trial to improve the care of pediatric patients who seek care in general emergency departments This study will utilize the appendicitis risk calculator to guide care in the community setting. https://tinyurl.com/Kharbanda-et-alpaper

Artificial intelligence improves stroke and dementia diagnosis in most common brain scan New software, created by scientists at Imperial College London and the University of Edinburgh in the UK, has been shown to be able to identify and measure the severity of small vessel disease (SVD), one of the commonest causes of stroke and dementia (Chen L et al

Rapid Automated Quantification of Cerebral Leukoaraiosis on CT Images: A Multicenter Validation Study. Radiology. 2018; 15:171567). SVD is a very common neurological disease in older people that reduces blood flow to the deep white matter connections of the brain, damaging and eventually killing the brain cells. It causes stroke and dementia as well as mood disturbance. SVD increases with D I

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age and is accelerated by hypertension and diabetes. At the moment, doctors diagnose SVD by looking for changes to white matter in the brain during MRI or CT scans. However, in CT scans it is often difficult to decide where the edges of the SVD are, thus making it difficult to estimate the severity of the disease. To develop the software, the study used historical data of 1082 CT scans of stroke patients across 70 hospitals in the UK between 2000-2014. The software identified and measured a marker of SVD, and then gave a score indicating how severe the disease was ranging from mild to severe. The researchers then compared the results to a panel of expert doctors who estimated SVD severity from the same scans. The level of agreement of the software with the experts was as good as agreements between one expert with another. Additionally, in 60 cases they obtained MRI and CT in the same subjects, and used the MRI to estimate the exact amount of SVD. This showed that the software is 85 per cent accurate at predicting how severe is SVD. The UK researchers say that the new technology can help clinicians to administer the best treatment to patients more quickly in emergency settings - and predict a person’s likelihood of developing dementia. Professor J Wardlaw said: “This is a first step in making a scan reading tool that could be useful in mining large routine scan datasets and, after more testing, might aid patient assessment at hospital admission with stroke.” The software could help influence doctors decision-making in emergency neurological conditions and lead to more personalised medicine. For example, in stroke, treatments such as ‘clot busting medications’ can be quickly administered to unblock an artery. However, these treatments can be hazardous by causing bleeding, which becomes more likely as the amount of SVD increases. The software could be applied in future to estimate the likely risk of haemorrhage in patients and doctors can decide on a personal basis, along with other factors, whether to treat or not with clot busters. MAY / JUNE 2018


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Radiology Workload

Diagnostic errors: the effect of shift length, schedule and volume By Dr C Lamouruex, Dr TN Hanna & Dr JO Johnson

With the increased utilization of medical imaging over the past several decades, efforts to optimize patient care through improving diagnostic imaging accuracy are more relevant than ever. More than 85 million CT examinations were performed in the United States in 2011 alone [1], meaning that even a 0.01% improvement in diagnostic accuracy could affect 8500 patients. The diagnostic radiologist is thus faced with not only the challenge of interpreting increased numbers of imaging exams per hour and per day but also of meeting the demand for coverage 24 hours a day, seven days a week. The reality is that increased interpretive volumes per radiologist are needed [2,3] as well as variable schedules and shift lengths. This article summarizes the results of a recent study of the effect of exam volumes, shift length and schedule on radiologist performance and diagnostic accuracy. Studies evaluating the effect of interpretive volume on diagnostic accuracy of residents and attending physicians The Authors Dr C Lamoureux1, Dr TN Hanna2 & Dr JO Johnson2 1. Virtual Radiologic, Eden Prairie, Minn. U.S.A. 2. Division of Emergency Radiology, Department of Radiology and Imaging Sciences, Emory University Midtown Hospital, Emory University, 550 Peachtree Rd, Atlanta, GA, USA Communicating Author : Dr Christine Lamoureux. email: Christine.Lamoureux@vrad.com

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have shown a relationship between diagnostic errors and increased volume. In one such study by Fitzgerald [4] there were increased errors in CT interpretation when more than 20 were read per day. Increased speed of interpretation was also linked to a 26.6% increase in errors in 80% of radiologists [5]. Shift length has previously been shown to affect diagnostic errors toward the end of a shift. For example, Ruutiainen et al. [6] showed a relationship between resident diagnostic errors in the last 2 hours of an overnight shift. Studies of interns, residents and nurses have demonstrated a relationship between errors and shift schedule, with increased errors associated with overnight shifts [7], and with shifts longer than 12-12.5 hours [8,9]. Most prior work to examine these factors in radiology was compiled through resident data [10]. However, data regarding the prevalence of diagnostic errors by attending-level radiologists in general is limited. Notable exceptions include the American College of Radiology (ACR) RADPEER program launched in 2002 which reports important diagnostic errors in 0.39% of exams interpreted by participating radiologists through 2007 [11].

â&#x20AC;&#x153; ... the most errors occurred in the last 10% of the shift...â&#x20AC;? Design and Methodology

The major goal of our retrospective study was to determine whether there was an association between attending level radiologist performance and effects of volume, shift length and schedule in a large teleradiology practice, Virtual Radiologic Professionals, LLC (vRad) [12] At the time of the study (calendar year 2015), there were 370 ABR-certified radiologists in the practice providing interpretations 24 hours a day/7 days a week. Teleradiologists provided preliminary interpretations. A second radiologist, from a client practice, subsequently rendered a final interpretation. Through a rigorous quality assurance process between the client and teleradiology practices, 4294 major discrepancies out of a total pool of 2,922,377 imaging exams were identified. Major discrepancies are defined as a significant diagnostic interpretive error with implication or possible implication on patient care. Each major discrepancy was vetted through a formal vRad QA Committee and the severity of the discrepancy was determined. Examinations with major discrepancies were categorized as acute or chronic with an urgency description. Data collection included shift start and end time and date of shift, shift type (regularly scheduled, holiday, weekend, extra, backup) and shift volume. Extra shifts

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were defined as shifts of variable lengths worked before or after a regular shift or at times on days when a regular shift was not scheduled. A backup shift was defined as a shift for which the radiologist was scheduled to interpret a variable number of exams only if needed during the shift period,. Results

Overall Error Rate: The overall rate of major diagnostic errors was 0.15%. Out of a total of 2,922,377 examinations interpreted, there were 4294 major diagnostic discrepancies were identified (0.15%). Given the differences in study and practice mix, this 0.15% error rate is comparable to the reported RADPEER rate of 0.39%. CT examinations made up 79.9% of these exams and had the highest number of discrepancies (86.6%). Effects of Shift Length on Error Rate: The mean length of a radiologist shift where a major discrepancy occurred was 8.97 +/-2.28 hours, and on average, errors occurred 9 hours into a shift, with the peak incidence between 10-12 hours. Significantly more errors occurred late in shifts than occurred early (P<.0001). When shifts were divided into tenths, the fewest errors occurred in the first 10% of the shift, and the most errors occurred in the last 10% of the shift. Effect of Diagnostic Volume on Error Rate: The mean volume of studies was higher in those shifts with major discrepancies then those without major discrepancies (P <0001). The mean study volume for all shifts for the year was 67.60 +/- 60.20, with a mean studies per hour of 10.95+/6.81. The mean study volume for shifts in which major discrepancies occurred was 118.96 +/- 66.89 exams, with a mean studies per hour of 13.06 +/-6.10. Moreover, the mean number of studies per hour significantly differed for shifts with a major discrepancy compared with the mean per-hour read rate for the year (P<.0001), and the incidence of multiple errors in given shift increased with study volume in those shifts where an error occurred (P<.001). MAY / JUNE 2018

Effect of Number of Days Worked and Shift Type: The mean number of prior consecutive days in which a radiologist worked was 3.38 days +/-3.23 days (range 0-14 days). The number of errors did not differ as a function of the number of days worked consecutively (P<.0893), however, there was a significant difference in error rate as a function of shift type, with more errors occurring during regular shifts (which were often longer than the other types of shifts). For shifts with at least one error, there was no significant difference in errors as a function of modality, whether the discrepancy was acute or chronic or had a critical finding. Regarding urgency description, exams with trauma protocols resulted in more multi-error shifts than other types of studies.

study gives us some tools to optimize shift, schedule, and volume parameters in our own practices: Practical Advice

• Read slower: closer to 11 studies an hour then 13 (particularly when there is a high proportion of CT and trauma protocols) and closer to 70 studies a shift then 120. • Shorten shifts: diagnostic errors peak between 10-12 hours into a shift. • Be vigilant late in shifts: the last 10% of the shift had more errors then any other 10% shift period. • Take a break: although not statistically significant, the study shows that consecutive days work trended toward worsening interpretive performance.

Limitations

The practice setting for our study introduced some limitations. Because the data was from a teleradiology practice, there was an over-representation of night shifts compared with conventional practices impacting the modality mix (fewer x-rays and MRIs at night). An increase in the acuteness of the exam may also be more prevalent at night, altering the distribution and types of interpreted pathologies. Fewer distractions from phone calls, consultations and lack of performance of procedures likely increased the concentrated reading time and increased volumes read by the teleradiologist. The nature of the preliminary interpretation versus a final interpretation may also be a limitation of this study, as the second radiologist generating the final read had access to but may or may not have referenced the preliminary interpretation which could lead to decreased discrepancy rates because of alliterative cognitive bias. Other potential contributing factors include more clinical data available to the second radiologist and the benefit of time. Study Implications

Interpretive errors are a rare but real occurrence in diagnostic radiology. As radiologists we are continuously seeking ways to improve performance. This D I

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References: 1. IMV Medical Information Division. IMV CT Market Outlook Report. IMV Medical Information Division; Des Plaines, IL;2012. 2. Sunshine JH, Burkhardt JH. Radiology groups’ workload in relative value units and factors affecting it. Radiology 2000; 214(3): 815-822. 3. McDonald RJ, Schwartz KM, Eckel LJ, et al. The effects of changes in utilization and technological advancements of cross-sectional imaging on radiologist workload. Acad Radiol 2015 22(9): 1191-1198. 4. Folkard S, Lombardi DA. Modeling the impact of the components of long work hours on injuries and “accidents.” Am J Ind Med 2006: 49(11): 953-963. 5. Fitzgerald R. Error in radiology. Clin Radiol 2001;561(12)938-946 6. Sokolovskaya E, Shinde T, Ruchman RB, et al. The effect of faster reporting speed for imaging studies on the number of misses and interpretation errors: a pilot study. J Am Coll Radiol 2015; 12(7): 683-688. 7. Ruutiainen AT, Durand DJ, Scanlon MH, Itri JN. Increased error rates in preliminary reports issued by radiology residents working more than 10 consecutive hours overnight. Acad radiol 2013; 20(3): 305-311. 8. Olds DM & Clarke SP. The effect of work hours on adverse events and errors in health care. J Safety Res 2010; 41(2): 153-162. 9. Scott LD, Rogers AE, Hwang WT, Zhang Y. Effects of critical care nurses’ work hours on vigilance and patient’s safety. Am J Crit Care 2006; 15(1): 30-37 10. Hanna TN, Loehfelm T*, Khosa F, Rohatgi S, Johnson JO. Overnight shift work: factors contributing to diagnostic discrepancies. Emer Radio. 2015; 23(1): 41-47. 11. Jackson VP, Cushing T. Abujudeh HH, et al. RADPEER scoring white paper. J Am Coll Radiol 2009; 6(1): 21-25. 12. Hanna TN, Lamoureux C, Krupinski EA, Weber S, Johnson JO. Effect of shift, schedule, and volume on interpretive accuracy: a retrospective analysis of 2.9 million radiologic examinations. Radiology 2018; 287(1): 205-212.

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Radiology Education

Teaching radiology in the “Second Life” virtual world By Francisco Sendra-Portero MD, PhD, Rocio Lorenzo-Alvarez MD, and Jose Pavia-Molina MD, PhD.

Virtual worlds and Second Life in educational activities

A virtual world is a three-dimensional space reproduced on a computer through a specific viewer, in which the user, represented by an avatar, can move, interact with different objects, or communicate with others in a real time environment [1,2]. Due to their potential use by multiple users, virtual worlds are also known as multiuser virtual environments [2,3] or multiuser virtual worlds (MUVWs) [4]. Virtual worlds can promote the learning of real-world knowledge and skills by imitating real-world environments and practices. They are an emerging method used both in traditional classrooms and in distance education, and have been used in disciplines such as teacher training [5], language development [6] and health education [1]. Second Life, created in 2003 by Linden Research Inc. (San Francisco), is one of the most well-known virtual worlds used in healthcare education [4]. Second Life is a virtual world with more than 1500 million square meters, where recreational, social, cultural and educational activities are developed by the users themselves. There are many activities in Second Life dedicated to the training of health professionals [4], and interesting experiences in training areas such as emergencies [7], nursing [8], primary care [9] or medical undergraduate [3,10]. Technical capabilities of Second Life for learning radiology

Second Life is organized in multiple virtual regions. Most of them are square plots of 256m X 256m that reproduce the real world, with water, earth and sky, so resembling an island. In 2011 we developed such an island, named “The Medical Master Island”, which had the appearance of a university campus, and included several academic buildings and other more imaginative spaces such as underwater stages (caves, palaces and submerged basements)

A simulated case presentation by medical students

or aerial locations (floating platforms and auditoriums, etc.) [11,12]. The whole island is dedicated mainly to the development of educational innovation projects in radiology, and can be visited at: https://maps.secondlife.com/secondlife/Medical%20Master%20 Island/119/90/22.

Communication between avatars can be done through voice chat, written chat and note cards. Voice chat gives an important sensation of presence, facilitates activities such as conferences, debates or discussion groups. Voice chat also makes it possible to put questions to the speaker or to someone else in the audience and is thus very versatile in enabling opinions to be expressed. The written chat option is more suitable for putting “short answer” questions (such as yes/no, true/false, etc.) to the audience and allows attendees to communicate with the presenter without interrupting the presentation. Note cards are messages that are sent in Second Life and are stored in the inventory of the avatar that receives it, with the date, time of sending and avatar of origin being registered. Note cards are very useful for collecting information from students, for example, recording who is attending the session or collecting the results of a task or

The Authors Francisco Sendra-Portero MD, PhD. , Rocio Lorenzo-Alvarez MD1, and Jose Pavia-Molina MD, PhD2.

1

1. Department of Radiology and Medical Physics, University of Malaga, Malaga, Spain. 2. Department of Pharmacology , University of Malaga, Malag , Spain,

Corresponding author: F Sendra Portero. email : sendra @uma.es

MAY / JUNE 2018

A radiological workshop on radiological anatomy

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Radiology Education and performed 4 asynchronous tasks, sending the results to the teacher by means of a note card. The student attendance level was 83% in the sessions; and 92% of them completed the tasks. The students rated the organization, the contents, the usefulness for their training and the teacher as having more than 9 on a scale of 1 to 10. This initial experience thus demonstrated that the teaching of radiology using Second Life was feasible and well perceived by medical students [11]. This motivated us to further investigate the possibilities of Second Life for radiolUsers feel more comfortable speaking in public and asking questions in Second Life than in face-to-face ogy training. situations, perhaps because of the “protective effect” of the anonymity of their avatar. Thus, we later carried out various training activities in radiology, some of which had an exam, with the note card being sent to objectives, methodology and content, an academic format, such as lectures on the teacher’s avatar. involving a total of more than 800 users, advances in radiology for master students, All objects in Second Life are composed of who all completed individual satisfac- radiological interpretation workshops for primary objects or “prims”, whose faces are tion questionnaires after carrying out medical students and primary care physicovered by textures that give them a partic- the respective activities. The question- cians, or bibliographical search workshops ular appearance (metal, wood, brick, grass, naires were designed to determine the on Google and PubMed for doctoral stuetc.). The prims can have images associated users’ evaluation of the environment, the dents. Other experiences, such as meetings with one or several of their faces, which is teaching contents or the usefulness for of clinical sessions for residents in radiolvery helpful to show radiographic images their training, and other aspects. ogy, or exposure sessions and discussion in a permanent way. Objects can perform We began in October 2011, with a of radiology topics presented by students functions through internal proof biomedical engineering, were grams in Linden Scripting Lanfocused on improving oral com“... The quality of the images shown in guage, when the user interacts with munication skills. More recently, them. They can also play videos or Second Life is excellent, which is a major we have developed a competitive web pages on one of their faces. advantage for radiology education, since the multi-user game for third-year medical students on the island We have used this last effect to create presentation panels, through contrast and details of medical images can named “The League of Rays”, divided into 6 weekly blocks on PowerPoint presentations saved as be optimally displayed ...” images and integrated into a simple anatomy and radiological semiology. In this, participants had to Web page with forward and backward buttons. They can be used as pro- 4-week voluntary course on the funda- study the educational content on their own jection screens in a conference or to host mentals of radiology (for 20 students for the first 4 days and sit a test involvcontent that the user can view on-demand. in 1st to 3rd year medical school) and ing 15 questions over the remaining 3 The quality of the images shown in Sec- on the interpretation of radiographs in days. Students who obtained lower scores ond Life is excellent, which is a major the second cycle (for 26 students in 4th were eliminated and the remaining paradvantage for radiology education, since to 6th year). All of them attended four ticipants were classified into five categories the contrast and details of medical images 2 hours real-time synchronous sessions depending on their results. (In a reference can be optimally displayed for teaching purposes. The designing and setup of asynchronous tasks, as well as the design and implementation of synchronous sessions are easy. All that is needed is the creation PowerPoint presentations, a skill in which all modern university professors and teachers are highly experienced. The presentations are then saved as images and simple Web pages created. practical experience of radiology education with Second Life

Since 2011 we have carried out various training activities with different 44

Lecture presentation by a team of bioengineering students

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to radiological densities, the categories were air, fat, water, calcium and metal). A voluntary session involving 91 students was held in 2015, and two compulsory sessions, with 191 and 182 students were held in 2016 and 2017, respectively. The game was highly appreciated by the students (average scores ≥7.9 out of 10 points), although in the compulsory experiences there were somewhat lower ratings, probably due to the participation of a less motivated student sector. These experiences have been summarized in a recent paper in Spanish [12]; full results are pending publication. the future of radiology education in virtual worlds

Second Life allows synchronous remote participation of students and teachers, thus avoiding the need to travel and offering a versatile and attractive environment for younger generations. The excellent graphic representation of the images is ideal for carrying out training activities in diagnostic imaging. The sensation of being present allows the development of synchronous activities such as conferences or practical workshops, with active and enthusiastic participation of the assistants. Second Life is also an ideal tool for the development of effective oral communication skills [13], although it does not include non-verbal communication or visual contact with the audience. It is a very efficient tool for training and improving the ability to communicate in public or to participate actively in debates, as users feel more comfortable speaking in public and asking questions in Second Life than in face-to-face situations [9], perhaps because of the “protective effect” of the anonymity of their avatar. Second Life also allows the development of asynchronous activities. In this context, we have used panels with radiological cases for asynchronous tasks in several courses, or with educational contents for “The League of Rays” game, that the students had to use during a given period. The training contents can also be permanently housed in Second Life, so that the users can review them on-demand, as in a 3D multimedia virtual library. We are currently exploring radiology team-based learning for medical students, and interpretive skills training for radiology residents, but the possibilities of Second Life for radiology education also include other, more elaborate formats, such as the simulation of virtual patients,which can develop learning based on role-playing in clinical situations, emulating radiology OSCE stations. These kinds of projects however require a considerable work in editing objects to give enough plausibility to virtual scenarios to engage participants. Other possibilities that we are currently studying are: the development of automated multiuser learning games, where the events that happen in-world are

Medical students in the game “League of Rays”

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Residents in a clinical discussion session

controlled from a server located outside, in real life; the configuration of virtual X-ray, CT or MRI equipment with which the users could interact by performing virtual explorations to their avatars explaining how such equipment works. Both projects require a deep knowledge of programming and many hours for development and testing, but could lead to highly interesting results in radiology education. References

1. Boulos MN, Hetherington L, Wheeler S: Second life: an overview of

the potential of 3-D virtual worlds in medical and health education. Health Info Libr J. 2007; 24: 233-45. 2. Veltman M, Connor K, Honey M, Diener, S, Bodily D. Collaborative practice through simulations in a multiuser virtual environment. Comput Inform Nurs. 2012; 30: 63-67. 3. Richardson A, Hazzard M, Challman SD, Morgenstein AM, Brueckner JK. A “Second Life” for gross anatomy: applications for multiuser virtual environments in teaching the anatomical sciences. Anat Sci Educ. 2011;4: 39-43. 4. Liaw SY, Carpio GAC, Lau Y, Tan SC, Lim WS, Goh PS. Multiuser virtual worlds in healthcare education: A systematic review. Nurse Educ Today. 2018; 65: 136-149. 5. Oh K, Nussl N. Teacher training in the use of a three-dimensional immersive virtual world: Building understanding through first-hand experiences. J Teach Learn Technol. 2014; 3: 33-58. 6. Knutzen B, Kennedy D. The Global Classroom Project: Learning a Second Language in a Virtual Environment. Electron J E-Learn. 2010; 10: 90-106. 7. Conradi E, Kavia S, Burden D, Rice A, Woodham L, Beaumont C, Savin-Baden M, Poulton T. Virtual patients in a virtual world: Training paramedic students for practice. Med Teach. 2009; 31: 713-20. 8. Patel V, Lee H, Taylor D, Aggarwal R, Kinross J, Darzi A. Virtual worlds are an innovative tool for medical device training in a simulated environment. Stud Health Technol Inform. 2012; 173: 338-43. 9. Melus-Palazon E, Bartolome-Moreno C, Palacin-Arbues JC, Lafuente-Lafuente A, Garcia IG, Guillen S, Esteban AB, Clemente S, Marco AM, Gargallo PM, Lopez C, Magallon-Botaya R. Experience with using second life for medical education in a family and community medicine education unit. BMC Med Educ. 2012; 12: 30. 10. Gazave CM, HatcherER. Evaluating the Use of Second Life for Virtual Team-Based Learning in an Online Undergraduate Anatomy Cours. Med Sci Educ. 2017; 27: 217-27. 11. Lorenzo-Alvarez R, Pavia-Molina J, Sendra-Portero F. Exploring the Potential of Undergraduate Radiology Education in the Virtual World Second Life with First-cycle and Second-cycle Medical Students. Acad Radiol. 2018. Accepted, in press. doi: 10.1016/j. acra.2018.02.026. 12. Lorenzo-Alvarez R, Pavia-Molina J, Sendra-Portero F. Possibilities of the three-dimensional virtual environment tridimensional Second Life® for training in radiology. Radiologia. 2018. Accepted, in press. doi: 10.1016/j.rx.2018.02.006. 13. Mitchell S, Heyden R, Heyden N, Schroy P, Andrew S, Sadikova E, Wiecha J. A pilot study of motivational interviewing training in a virtual world. J Med Internet Res. 2011; 13: e77. 1.

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From Compliance to Efficiency: NEXO[DOSE] from BRACCO Radiation Dose Monitoring Systems – Optimization Tools

The EURATOM 59/2013 Directive laid down basic safety standards for protection against the dangers of patient exposure to ionizing radiation and introduced changes to previous directives. The latest directive has a direct impact on the workflow of radiology departments. The latest changes include the management and communication of the exposure patient to ionizing radiation, which will now become part of the patient’s clinical history. The Radiation Dose Index Monitoring (RDIM) systems currently available from several vendors vary widely in their capabilities, the degree of difficulty to implement, the ease of customizing data analyses, and the ability of the system to grow with the evolution in clinical practice, imaging equipment, or regulatory requirements. The exposure data to be inserted in the radiological report should be the most timely and accurate as possible, and should reflect the collaboration among the various healthcare professionals involved (e.g. radiologist, radiographer, medical physicist, RIS/PACS administrator, vendor, etc.) As the appropriate management of good data is the basis for creating reliable information upon which to take action, close attention must be paid to the validation of methods used to measure exposure data. Radiation Dose Monitoring and Management Systems provide valid tools which, in the hands of a multi-disciplinary team, can allow healthcare professionals to implement the optimization measures (processes, protocols and results) required by the Euratom Directive.

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software which enables multi-modality, enterprise-wide radiation dose data aggregation and reporting. Easy to install, implement and use, NEXO[DOSE] minimizes the efforts required of hospital IT departments and allows radiology healthcare professionals to gain general procedure awareness and to identify any malpractices, thus facilitating the implementation of training programs and optimization policies. Based on customer-provided thresholds and guidelines, NEXO[DOSE] identifies patients who may be at risk of overexposure to ionizing radiation. By managing radiation dose effectively, facilities can adapt to new technologies and meet evolving regulatory standards and compliance requirements for procedures operations. NEXO[DOSE] offers a complete features set, including two validated methods for Organ Dose estimation. In addition, NEXO[DOSE] allows a standardized approach to calculating Peak Skin Dose across multiple vendors’ systems in a consistent manner. NEXO[DOSE] monitoring also covers non-ionizing radiation, including MRI. The current version adds a vast array of improved tools and analytics, including tracking of SAR (Specific Absorption Rate, SAR Max W/kg), slew rates (dB/dt Max T/s), operating modes (normal, first level, etc.) and all other MR parameters. Although MR images are of course not acquired through use of ionizing radiation, the MR environment involves a strong magnetic field that changes with time and radiofrequency energy. There are thus potential safety concerns and so the MRI process should be monitored closely. Additional new features include data acquisition and display of injectable contrast media parameters from any “smart” injector in CT, MR and Cardiac Cath labs. This information is directly incorporated into the patient folder of NEXO[DOSE], thus allowing providers to track all imaging-related data for all modalities. This ensures a wider holistic view for radiology departments, and equips facilities with an expanded range of tools and data handling to provide more reliable reports and generally improve imaging practices, image quality, and overall patient safety.

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NEXO[DOSE] — An easy to use solution for accurate and efficient radiation exposure monitoring and management.

Bracco Imaging S.p.A., a leading global company in the diagnostic imaging business, announced in April 2017 that it had made a strategic investment in PHS Technologies Group, a division of PACSHealth, LLC, to further expand its portfolio of Informatics Solutions for Radiology. The agreement further strengthened Bracco’s partnership with PHS Technologies, and allows Bracco to enhance distribution efforts of NEXO[DOSE], a vendor-neutral Radiation Dose Index Monitoring (RDIM) MAY / JUNE 2018

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TEC H NOLOG Y update Forty new and unique applications in MRI post-processing

Olea Medical has created a software upgrade for Canon’s MRI Systems that will enable faster, more accurate and costeffective diagnoses with less stress on patients. The upgrade is available for all of Canon’s current MRI-systems as well as their new systems

Canon Medical is a key player in the MRI market, while Olea Medical — part of Canon Medical since 2015 — is renowned for providing the most advanced post-processing solutions for MRI. Olea is a leader in developing clinical applications for advanced MRI post-processing, and its innovative solutions allow for image viewing, analysis and processing of even the most complex MRI sequences. The systems standardize both viewing and analysis capabilities of functional and dynamic imaging datasets acquired with MRI. The new Olea Vision provides the basis for 40 completely new and unique applications. Olea Medical La Ciotat, France www.olea-medical.com

Training videos designed to make mammography positioning better

The U.S.-based organization Mammography Educators has partnered with Volpara to enhance the VolparaEnterprise software with embedded training modules. Designed to improve the quality of breast imaging using proven techniques in mammography positioning, the videos will provide multiple levels of technologist training, with positioning overviews for the CC and MLO projections as well as for common positioning performance issues. Topics include: excessive exaggeration, nipple in profile, assuring adequate length for the posterior nipple line, inframammar y fold, and the length and shape of pectoralis muscle. “Proper breast positioning is critical for optimal cancer detection, but difficult to assess manually. We are excited to partner with Volpara to make these targeted training videos for more than a dozen common positioning performance 48

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issues that can be routinely identified using VolparaEnterprise software,” said Louise Miller, co-founder of Mammography Educators. “These videos are designed to help improve image quality in a way that is consistent, reproducible and ergonomically sound.” VolparaEnterprise software features a Technologist dashboard, which enables each mammography technologist to monitor her own performance and selftrain. In addition, the lead technologist now sees a Quality Quadrant diagram that summarizes patient positioning and compression performance by each technologist, helping to identify training opportunities. VolparaEnterprise software delivers key performance indicators for hundreds of performance and quality metrics, including patient positioning and compression, which are widely viewed as the causes of most clinical image deficiencies, and associated with delayed detection of breast cancer. VolparaEnterprise software enables breast centers to perform rapid quality control checks that help optimize the productivity and efficiency of imaging resources. This in turn helps decrease costs through the reduction of retakes, increase employee effectiveness, and enhance the patient experience. “We have been using VolparaEnterprise to redefine how to track and trend our technologist’s quality and facility workflow. VolparaEnterprise has provided our Institute with amazing objective, analytic capability which has allowed us to applaud the team’s strengths and use them to facilitate collaborative growth, while identifying opportunities that we individualize by technologist. We have seen continued and sustained improvements as a result of this program,” said Maureen Mann, Executive Director of Boca Raton Regional Hospital’s Christine E. Lynn Women’s Health & Wellness Institute in Florida. Volpara, Wellington, New Zealand www.volparasolutions.com

Next-generation ultrasound system

Siemens Healthineers has launched the Acuson Juniper, a new ultrasound system with advanced applications and imaging performance while featuring a lightweight, ergonomic design and complete maneuverability for use across a wide variety of clinical segments. Though small in size, the Acuson Juniper does not compromise in performance, offering providers a system that is not only powerful, but nimble in design. Siemens incorporated feedback from 365 participants in its largest-ever ultrasound co-creation project to ensure that the Acuson Juniper meets the needs of today’s changing healthcare landscape. The system’s versatility and adaptability makes it ideal for diverse patient anatomies and physiologies. Users can customize the Acuson Juniper based on patient interactions for improved clinical workflow The smallest, most lightweight system in its class, the Acuson Juniper adapts to virtually any exam environment and maneuvers easily with no trade-offs in performance. Sleep and boot-up times of mere seconds allow clinical users to transfer the system within a hospital without

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MAY / JUNE 2018


sacrificing time with patients. Designed to address the needs of differing clinical departments, the system has flexible, intuitive, and customizable tilt settings. Five active transducer ports allow for the system’s quick and easy readiness after transfer from department to department. The system’s LED monitor and touch panel are the largest in its segment. The system’s two standard USB ports enable quick transfer of images to patients, eliminating the need for printout documentation. Further improving the patient experience, the Acuson Juniper is 40 percent quieter than other ultrasound systems in its class. A new signal processor reduces probe and patient motion artifacts, and enables

fast image acquisition. A new back-end engine allows advanced elastography imaging and has a new measurement package. For use across departments, the Acuson Juniper is equipped with 16 transducers and is customizable with advanced imaging applications for use in radiology and interventional radiology, urology, cardiovascular, orthopedic, and obstetrics/gynecological imaging. Siemens Healthineers Erlangen, Germany, www.healthcare.siemens.com MAY / JUNE 2018

Canon enters premium 1.5T MRI market

Canon Medical Systems Corporation has announced the release of its new premium 1.5T MRI system, the Vantage Orian, which is one of the company’s first major product releases since officially changing the company name from Toshiba Medical on January 4, 2018. The new product is a major foray into the premium wide-bore 1.5T market and features new technology designed to boost productivity, enhance patient comfort and deliver diagnostic clinical confidence to users and patients alike. With a new slim gradient that delivers a gradient performance with a maximum amplitude of 45 mT/m, combined with a slew rate of 200 T/m/s that enhances high resolution and diffusion imaging, Vantage Orian offers high performance imaging capability previously not available on 1.5T systems from Canon. Utilizing migrated high end 3T technology, Vantage Orian offers referring physicians and patients diagnostic MRI imaging services with complete clinical confidence. Canon’s PURERF and Saturn Gradient technology means that stable and consistent imaging performance is ensured, increasing signal to noise ratio (SNR) by up to 38%. The Vantage Orian offers a range of new Rapid Scan and Easy Tech technology that reduces scan time and helps improve workflow. A redesigned gantry interface and dockable table ensure seamless patient handling. New applications like Multiband SPEEDER, that shortens acquisitions such as high angular resolution diffusion imaging (HARDI), and an eight-fold accelerated k-t SPEEDER allows high frame D I

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rate cardiac cine and perfusion imaging with free breathing. Vantage Orian also offers one of the smallest footprints in the 1.5T widebore class and low power consumption eco features that reduce energy use by up to 21%. The reliable system is equipped with excellent maintenance programs to satisfy the needs of hospital administrators. A relaxed patient is key in MRI, and Vantage Orian takes care of this with industry leading quiet scan sequences that reduce ambient noise using Pianissimo Zen technology. The 71 cm wide bore and immersive virtual MR theater are designed to put patients at ease. Vantage Orian also facilitates the examination of challenging patients with Pediatric SPEEDER coils, contrast free applications and ForeSee View for simplified scan planning. Canon Medical Systems Europe Zoetermeer, The Netherlands https://eu.medical.canon

Mammography phantom

The Mammo 156 phantom was created to provide a mammography repeatability and reproducibility standard. Simulating the radiographic characteristics of 4.2 cm compressed breast tissue, the phantom mimics breast tissue and is a feedback mechanism that provides a framework for constant improvement in early detection and mortality reduction. Embedded objects mimic breast diseases, micro calcifications, fibrous structures and tumor masses.

With the phantom, any technologist or radiographer on any machine can provide the same image set to help detect breast cancer. Sun Nuclear Melbourne, FL, USA www.sunnuclear.com 49


TECHNOLOGY update Fujifilm gets into CT

The new FCT Speedia and FCT Speedia HD CT systems from Fujifilm represent the finalization of the company’s maturation process in the medical systems field and brings CT technology to accompany Fujifilm’s well-established room and mobile digital X-ray solutions. The compact size, powerful applications, and optimized workflow of the new Speedia systems provide the solution to multiple routine examinations without compromise. The system features a 75cm wide gantry bore, a class leading bore size which reduces patient anxiety, The wide bore allows easier access to the patient even when the patient’s arms are raised and the patient cannot lie flat on their back, improving both technologist and patent experience A compact foot-print is maintained to facilitate installation into existing rooms.

Speedia has advanced noise reduction processing using iterative reconstruction technology to reduce image noise and artifacts while maintaining a high quality image. Seven levels of dose reduction can be selected to optimize dose and image quality per examination. In addition, the Intelli IP Quick system reduce the image reconstruction time of Intelli IP. Fujifilm Tokyo, Japan www.fujifilmhealthcare.com/ 50

Portable X-ray unit has with reduced size and weight

This new DRX-Revolution Nano portable X-ray system from Carestream uses Carbon Nano Tube technology to deliver significantly reduced size and weight compared to existing mobile X-ray systems. The new system is a lighter

weight, non-motorized system that is easy to manoeuver and position for patient imaging. It complements the Carestream DRX-Revolution Mobile X-ray System, which is designed to capture inpatient, outpatient and ER exams at facilities of all sizes. Among the features of the new system are : •Fully integrated digital workflow; • Carbon Nano Tube technology and an advanced lithium iron phosphate battery that contributes to longer life; • a sleek design with enhanced visibility both over and around the system • a compact footprint and total weight of about 100 kg that makes it easy to maneuver and position in tight spaces; and • a choice of Carestream wireless detectors including DRX-1, DRX Core, DRX Plus and DRX 2530C. Carestream Rochester, NY, USA www.carestream. com

Improved diagnostic quality and speed in MR

The new Philips Ingenia Elition X solution offers a revolutionary breakthrough in diagnostic quality and speed, while setting new standards for clinical research in 3.0T D I

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imaging based on new gradient- and RF designs. Ingenia Elition X’s speed and productivity stem from Philips’ commitment to not only reach for a best informed and compliant patient but also accelerate MRI exams. Furthermore, the Ingenia Elition X offers an immersive audio-visual experience to calm patients and guide them through MR exams. VitalEye, a revolution in patient sensing, keeps a caring eye on the patient thanks to touchless patient sensing. The quality of the physiology signal is significantly better than a belt-based approach. The operator receives a continuous and robust respiratory signal without any interaction.

Exams accelerated by up to 50%

Ingenia Elition not only accelerates sequences, but the entire patient exam. Compressed SENSE accelerates scans by up to 50% with virtually equal image quality. This feature can be applied to all anatomies and anatomical contrasts in both 3D and 2D scans. Up to 60% higher resolution

Fully redesigned gradients combined with Compressed SENSE acceleration technology allow up to 60% higher spatial resolution in the same scan time, revealing more details for greater precision. For example this allows speeding up of isotropic 3D MSK imaging. Philips Healthcare Amsterdam, The Netherlands www.philips.com MAY / JUNE 2018


EuroEcho 2 0 Imaging 1 8 exercise and sport | valvular heart disease

5/8

December

Milan ITALY

22nd Annual Congress of the European Association of Cardiovascular Imaging (EACVI), a registered branch of the ESC. www.escardio.org/EACVI

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Dieurope mayjune 2018  

The leading pan-European resource for news, analysis and trends in diagnostic and interventional radiology. Reaches 25,000 EMEA radiologists...

Dieurope mayjune 2018  

The leading pan-European resource for news, analysis and trends in diagnostic and interventional radiology. Reaches 25,000 EMEA radiologists...