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EvidEncE – basEd practicE of radiology in india : room for improvEmEnt

January 2002

The Newsmagazine of Imaging Innovation & Economicsautumn 2013 asia-pacific

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The contrast agent of choice for enhanced breast MRI P 10

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LIVENOW

By Dr Alan Barclay

Seen from the perspective of austerity-rid-den Western Europe the economic projections currently being made for India in general and the country’s healthcare sector in particular are the stuff of dreams, even if the growth rates have receded slightly over the last few months and the fall of the rupee could result in further (relative) cooling of the economy.

Healthcare in India is one of the country’s fastest growing industries being expected to grow at a compound annual growth rate of 15 per cent over the period 2011 – 2017. As the analyst Ravi Thomas has pointed out (Healthcare India: a billion opportunities by Ravi Thomas), India’s population growth and increased disposable income are expected to result in correspondingly increased healthcare awareness, raised expecta-tions of improved care and demands on behalf of the population. In addition India is witnessing a shift in disease patterns from communicable diseases to the high incidence of non-commu-nicable and lifestyle-related diseases, which is driving the need for tertiary and quaternary-care hospitals and clinics. The overall outcome of all this is that expenditure on healthcare is expected to rise dramatically. At the moment, the coun-try has something like half a million doctors, approximately one million nurses and around 1.37 million hospital beds Some analysts based on work carried out by reputable bodies such as Ernst & Young speculate that there is a need to add nearly 1.74 million beds by 2027 implying an investment of about 104 USD billion over the same period to fulfil the predicted needs. Various government programs such as those in the fields of tuberculosis, malaria and HIV/AIDS have been initiated but significant private sector investment and input is expected. Private players have already made significant investments in set-ting up state-of-the-art private hospitals in cities such as New Delhi, Chennai and Hyderabad. Significant in these developments is the relatively large amount of modern medical technology that has been and is planned to be installed.

Given the key role that radiology plays in any modern healthcare environment it is not surprising that dramatic rises in the installed bases of all of the most important radiology modalities are predicted over the coming years. To match this, a significant expansion is planned in the numbers of medically or technically qual-ified personnel, including radiologists. Certainly in one aspect India seems well equipped. With fewer than 300 medical colleges, an adequate

number of future doctors including radiologists seems assured.

Questions are beginning to be asked how-ever beyond the mere level of numbers of personnel and more about the actual quality of the personnel. A recent paper (Chandramohan et al. Evidence-based practice in radiology : knowledge , attitude and perceived barriers to practice among residents in radiology Eur J of Radioogy 2013 ;82: 894) describes a study carried out to find out what residents in the Department of Radiology, at Christian Medical College, Vellore, India, which is a 3000-bed tertiary care teaching hospital in South India, thought of the Evidence-based Practice of Radiology (EBPR). Using established meth-odologies such as McColl questionnaires and Barriers scale, the authors attempted to mea-sure whether EIBR was being implemented in practice. While there have been several similar studies done on general practitioners, surgeons, nursing staff, surgical nurses and radiogra-phers there has been no such study among radiology residents.

The results were sobering. Although the majority of residents had access to the Internet, fewer than half had access to Medline in the work place. Around 50–70% of residents were unaware of different evidence-based biblio-graphic databases; many others were aware but did not use these sources. Residents were aware of common terms used in evidence-based litera-ture, but unfamiliar with many although most of those who did not understand the terms were interested in learning them. However very few (14%) residents had received formal training in search strategies or even attended a course on EBM in general (11%). Even fewer (5%).had had some kind of training in critical appraisal of evidence based literature

In view of these results, the authors come to the inevitable recommendation that there is a great need for structured teaching of evidence based radiology in India. Ideally this should include statistical modules, critical appraisal modules and practical evidence based radiology exercises

Of course in a country as vast and diverse as India, the extrapolation of one study to the whole country can be dangerous. Nevertheless the fact that the profession is willing to ques-tion the quality of the training of the personnel who have such a key role to play in the future is already a positive sign. n

Evidence – based practice of radiology in India: room for improvement

FROM THE EDITOR

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COMING SOON IN ThE NExT ISSuE: Advances in ultrasound Computer-aided diagnosisOncology

EvidEncE – basEd practicE of radiology in india : room for improvEmEntIndia is set for a significant increase in healthcare spending over the next few years including in radiology. Questions are being raised as to whether the trainee radiologists needed for the future are proficient enough in evidence-based radiology. A recent study of interns in a south indian teaching hospital suggests that there is room for improvement

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INduSTRy NEWS

International day for medical physics. . . . . . . . . . . . . . . . . . . . . . . . . . 5

Hitachi Aloka opens new ultrasound R & D center. . . . . . . . . . . . . . . . 5

Global impact of breast cancer.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

New hybrid clinical operating theatre in CUHK — PWH. . . . . . . . . . . . . 6Panasonic transfers Ultrasonic Diagnostic Equipment business to Konica Minolta . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Philips opens new Asia-Pacific center in Singapore. . . . . . . . . . . . . . . . 6

Another successful RAD-AID conference. . . . . . . . . . . . . . . . . . . . . . . 9Molecular Imaging Centers in India : Making cancer detection more accessible. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Autumn 2013

REPORTS

an EnhancEd rolE for mri in radiation thErapy

page 13

thE contrast agEnt of choicE for EnhancEd brEast mri

page 10New hybrid clinical operating theatre in CUHK — PWH

Live 3D holographic imaging in interventional cardiology

06| INduSTRy NEWS

20| TEChNOLOGy uPdATE

accuratE assEssmEnt of livEr fibrosis

page 17

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NEWSIndustry

International day for medical physics

Hitachi Aloka opens new ultrasound R & D center

Global impact of breast cancer

On November 7th — the date was chosen deliberately since this is the date of birth in 1867 of Marie Curie, the pio-neering researcher on radioactivity — the International Organization for Medical Physics (IOMP) celebrated the Interna-tional Day for Medical Physics (IDMP). The plan is that IDMP should be an annual event in which 80 national organizations of IOMP and countries all over the world shall celebrate the impact of medical phys-ics on the daily lives of millions of humans worldwide, whether they be patients, workers or members of the public. The aim is to raise awareness of the important role medical physicists play in the clini-cal environment as well as in education, research and development of sophisticated medical technology. The theme chosen for

2013 is ‘Radiation Exposure from Medical Procedures: ask the Medical Physicist!’

As medical imaging technologies and radiotherapy techniques are fast develop-ing and becoming more intricate, medical physicists are playing an increasingly sig-nificant role in the clinical environment. They contribute to the safe and accurate use of radiation to achieve the best outcome of the prescribed medical diagnostic exami-nation or treatment. They assess radiation doses and associated risks to patients and personnel. Medical physicists optimize radiation procedures by performing accu-rate measurements and calculations, maxi-mizing the benefit against the potential risk in the use of radiation and contributing to the development and implementation of quality assurance programs. They are

highly qualified health professionals with postgraduate studies and clinical training. Most people needing radiation imaging and treatment procedures are not aware that there is a worldwide scientific commu-nity specializing in medical physics, ensur-ing the quality of these procedures while minimizing risks associated with radiation. Further information available at www.iomp.org Contact: Prof. John Damilakis, Chairman of the IOMP Education and Training Committee [email protected]

Hitachi Aloka Medical has set up a Medical System Development Center at Kokubunji-shi, Tokyo Japan. The facility will provide a consolidated base for the development of diagnos-tic ultrasound systems, probes, and software. Currently, the company’s activities for the development of diag-nostic ultrasound systems are divided between two plants, one in Tokyo and the other in Chiba Prefecture. The consolidation of these two groups at the newly opened Medical System Development Center has as objective the streamlining of product develop-ment by combining the development departments. Hitachi Aloka Medical have been working on development of the ProSound and HI VISION series of diagnostic ultrasound systems, in collaboration with Hitachi’s Central Research Laboratory (CRL), which is located right next to the new cen-ter. The relationship with the central research laboratory will continue and synergies are expected from the future collaboration with the CRL and other Hitachi’s research laboratories for early application of ground-breaking

technologies. A company spokesman indicated that the opening of the new center was a sign of the commitment of the company to the development of such new technologies and the provi-sion in a timely manner of products with significant value to customers throughout the world. HITACHI ALOKA MEDICAL ULTRASOUND R& D CENTERTOKYO JAPANwww.hitachi-aloka.com

GE Healthcare has commissioned new, independent, research into the global impact of breast cancer. Key findings include:

• As breast can-cer survival rates improve in the developed world, quality of life is becoming a growing issue. As a result, the report urges doctors to focus on measuring the impact of diagnosis and treatment on survivor’s quality of life, to identify what problems patients may have and how these can be mitigated

• 15 million years of ‘healthy life’ were lost worldwide in 2008, due to women dying early or being ill with the disease

• There is a direct link between survival rates in countries and the stage at which breast cancer is diagnosed, providing fur-ther evidence of the need for early detection and treatment

• Rising breast cancer incidence and mortality represent a significant and grow-ing threat for the developing world

• Consumer awareness and cultural bar-riers surrounding screening are putting lives at risk.www.gehealthcare.com


INduSTRy NEWS

Konica Minolta announced that the company has signed a business transfer agreement with Panasonic Healthcare under which the ultrasonic diagnos-tic equipment business of Panasonic Healthcare is to be transferred to Konica Minolta. The companies have up till now been jointly developing ultrasonic diag-nostic systems. To improve and expand the impact of this cooperation the companies have agreed that Panasonic Healthcare’s assets necessary for the plan-ning, development, manufacturing, sales, maintenance of ultrasonic diagnostic equipment will be transferred to Konica Minolta effective on January 1, 2014. The existing OEM-supply business relation-

ship between Panasonic Healthcare and its customers will also be transferred to Konica Minolta.

Konica Minolta continues to enhance its growth strategy in the healthcare busi-ness by expanding digital X-ray diag-nostic imaging systems, including the AeroDR, its current mainstream prod-ucts, fostering Healthcare IT services business and driving growth of business for new ultrasound diagnostic equipment with benefits based on Konica Minolta’s innovative strength acquired through the business deal with Panasonic Under the communication message “Giving Shape to Ideas,” Konica Minolta will make further efforts in facing challenges to develop state-of-the-art technologies in the medical imaging fields and create new values for the customers with high-quality products, services and solutionsKONICA MINOLTA TOKYO JAPANwww.konicaminolta.com

Funded by a generous donation of from an anonymous donor, the Chinese University of Hong Kong – Price of Wales Hospital (CUHK — PWH) in Hong Kong has been able to construct a brand new modern hybrid operating theatre. With this new cutting-edge facility, the hospital will be able to deliver higher quality sur-gical service benefiting not only patients with cardiovascular diseases, but also other disease types, such as neurosurgical and trauma cases. The extensive benefits of hybrid surgeries have been well proven. The new facility will further strengthen the hospital’s capability and role as a trauma and cardiothoracic surgery centre in the community.

Traditionally, patients with cardiovas-cular diseases undergoing operations like coronary artery bypass, valve repair and abdominal aneurysm stent may have to be examined and treated in multiple points of care in the hospital, including the radiology department for pre-operative imaging and the catheterization labora-tory for percutaneous procedures before

undergoing the surgery. Re-explorations are sometimes necessary after patients have been transferred to the intensive care unit. The new hybrid operating theatre integrates different technologies, offer-ing real-time intra-operative imaging and computer-assisted instrument control to allow surgeons, physicians and interven-tional radiologists to perform all neces-sary procedures in one location. It can reduce healthcare cost and shorten hospi-tal stay, while on the other hand enhance treatment efficiency and minimize the risk of patient transfer.

Prof. Francis K L Chan, Dean of Medi-cine, CUHK added, ‘The new hybrid operating theatre has strengthened our competitiveness in teaching, research and clinical service. Our medical students and surgical trainees will have the opportunity to learn and master the state-of-the-art surgical technology.”

Prof. Paul B.S. Lai, Chairman of the Department of Surgery at CUHK added that surgeons can now perform more advanced cardiovascular surgeries with

critical patients who might otherwise not be operated on at all. ‘The minimally inva-sive and hybrid procedures have resulted in remarkably lower morbidity and mor-tality of elderly patients or patients with complex pathologies.”

With the synergies between CUHK and PWH, the dedicated clinical teams have been committed to developing the best surgical care for patients and advance research of minimally-invasive surgery. They will continue to serve the commu-nity with the highest professional stan-dards on education and caring practice, contributing to the advancement of health sciences.CUHK—PWHHONG KONG SAR CHINAwww.cpr.cuhk.edu.hk/en

Panasonic transfers Ultrasonic Diagnostic Equipment business to Konica Minolta

New hybrid clinical operating theatre in CUHK — PWH

6 D I A G n O S t I C I m A G I n G A S I A P A C I F I C Autumn 2013

Philips opens new Asia-Pacific center in Singapore

Philips announced that it is intro-ducing healthcare innovations that will help health systems in Asia to address the growing challenges linked to a fast growing and aging population. Philips’ new Hospital to Home business in Asia Pacific will seek to improve care transi-tions by offering re-admission manage-ment consulting, telehealth solutions for greater care continuity, and a personal health portal to engage patients and their families in their own health. Its head-

continued on page 09

PresidentMakoto Hashizume, MD, PhD, FACS (J) Honorary PresidentsMasaki Kitajima, MD, FACS (J)Hironobu Nakamura, MD, PhD (J) Congress Organizing Committee Stanley Baum, MD (USA)Elizabeth Beckmann, BSc (UK)Leonard Berliner, MD (USA)Silvio Diego Bianchi, MD (I)Ulrich Bick, MD (D)Davide Caramella, MD (I)Kevin Cleary, PhD (USA)Takeyoshi Dohi, PhD (J)Kunio Doi, PhD (USA)Volkmar Falk, MD (CH)Allan G. Farman, PhD, DSc (USA)Hubertus Feussner, MD (D)Guy Frija, MD (F)Stephen Golding, FRCR, MD (UK)Olga Golubnitschaja, MD (D)Makoto Hashizume, MD, PhD, FACS (J)Javier Herrero Jover, MD, PhD (E)Kiyonari Inamura, PhD (J)Pierre Jannin, PhD (F)Leo Joskowicz, PhD (IL)Heinz U. Lemke, PhD (D) (Chair)Hans-Peter Meinzer, PhD (D)Hironobu Nakamura, MD, PhD (J)Nassir Navab, PhD (D)Emanuele Neri, MD (I)Terry M. Peters, PhD (CDN)Osman M. Ratib, MD, PhD (CH)Jarmo Reponen, MD (FIN)Hans G. Ringertz, MD, PhD (S)Ramin Shahidi, PhD (USA)Gero Strauss, MD (D)Michael W. Vannier, MD (USA)

www.cars-int.org

COmPuter Assisted rAdiOlOgy And surgery

CARS 2014

28th International Congress and Exhibition

main themes Medical Imaging

Computed Maxillofacial Imaging

Image Processing and Visualization

PACS and IHE

Telemedicine and E-Health

Computer Aided Diagnosis

Computer Assisted Radiation Therapy

Image and Model Guided Therapy

Personalized Medicine

Surgical Navigation

Surgical Robotics and Instrumentation

Surgical Simulation and Education

Computer Assisted Orthopaedic and Spinal Surgery

Computer Assisted Head and Neck, and ENT Surgery

Image Guided Neurosurgery

Minimally Invasive Cardiovascular and Thoracoabdominal Surgery

Digital Operating Room

A journal for interdisciplinary research, development and applications of image guided

diagnosis and therapy

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Please submit your manuscript at www.editorialmanager.com/jcars

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International Journal of Computer Assisted Radiology and Surgery A journal for interdisciplinary research, development and applications of image guided diagnosis and therapy

Deadline for abstract/paper submission: 10th January 2014

IJCARS website: www.springer.com/11548Manuscript Submissions:

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June 25–28, 2014Fukuoka International Convention Center

Fukuoka, Japan

Supported by: Organised by:

www.arabhealthonline.com [email protected] +971 4 3367334

27 - 30 January 2014Dubai International Convention & Exhibition Centre

If you are not at Arab Health, you are not in healthcare. Arab Health is the place to be.Sobhi A.Batterjee, President & CEO, Saudi German Hospitals Group

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3,427

INduSTRy NEWS

quarters and competence center for the region will be located in Singapore. Chronic illnesses are rising faster in Asia than globally and the sheer number of people requiring care is staggering. Asia will be home to half of the world’s elderly population and half of the global burden of chronic conditions by 2030. Asians increasing life expectancy and growing economic affluence will add tremendous pressure on the region’s already-stretched healthcare systems and create ever higher demand for quality care.

“By realizing Hospital to Home solu-tions that are relevant to the local care ecosystem, we will bridge the hospital and the home for a truly patient-cen-tered care model,” said Frans van Houten, CEO Philips. “In the Asia Pacific region, Singapore is seen as a reference site for its healthcare system and therefore an ideal location to establish the regional headquarters for this new business. Together with the local stakeholders, we will develop patient care models for the region that will enhance patient out-comes beyond hospital.”PHILIPS SINGAPORETOA PAYOH W, SINGAPOREwww.philips.com.sg


Supported by: Organised by:

www.arabhealthonline.com [email protected] +971 4 3367334

27 - 30 January 2014Dubai International Convention & Exhibition Centre

If you are not at Arab Health, you are not in healthcare. Arab Health is the place to be.Sobhi A.Batterjee, President & CEO, Saudi German Hospitals Group

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Philips opens new Asia-Pacific center in Singapore continued from page 06

Another successful RAD-AID conference

The Fifth Annual 2013 RAD-AID Conference was held on Saturday, Octo-ber 26th at the Johns Hopkins Hospital in Baltimore, Maryland.USA

RAD-AID International is a non-profit organization founded by a team of radiologists trained at Johns Hop-kins. The organization is a global net-work assisting developing countries to implement and optimize radiology and health imaging services while improv-ing the role of radiology in global public health initiatives. RAD-AID also aims to improve the provision of radiology and health care services in the developing world through a sustained longitudinal legacy of dialog, education, resources, and collaboration.

In addition to specific projects, RAD-AID International runs train-ing programs so that individuals in developing countries can learn how to perform and interpret medical imag-ing to make patient care decisions. To make sure that these efforts are opti-mized for areas with limited resources, RAD-AID have developed a Radiol-ogy Readiness package. In the field of Public Health, RAD-AID International provides education on public health issues such as maternal infant mor-tality, breast cancer screening, and tuberculosis control, all of which have important roles for radiology such as ultrasound, mammography, and radi-ography. These public health issues have been identified by the World Health Organization as international priorities in which health personnel need to be educated on ways to better screen for breast cancer, treat tuber-culosis, and prevent maternal-infant mortality at child birth.RAD-AID CHEvY CHASE, MD, USAwww.rad-aid.org

Representing the first of a network of molecular imaging centers around the country with GE Healthcare as technology provider, Nueclear Healthcare Ltd (NHL) and GE have opened their first molecu-

lar imaging center in Navi Mumbai. The partnership is the result of a growing need for more affordable access to advanced molecular imaging technologies such as PET/CT. Cancer rates have become one of the leading causes of death in India, with about 2.5 million cancer patients.

GE Healthcare and NHL aim/have a goal to establish 120 molecular imaging centers around the country to provide more affordable access to PET/CT imag-ing. Following the inaugural opening of Navi Mumbai’s center, five more centers will be commissioned in 2013. NHL is expected to offer PET/CT imaging at just Rs.10,000/- compared to the Rs.18,000- 25,000 patients pay today for same services.

The goal is for the NHL network of

molecular imaging centers to ultimately have twelve cyclotrons for production of bio-markers required for cancer imaging and 120 GE Discovery PET/CT imaging scanners. The PET/CT systems will help enable doctors to determine whether a sus-picious growth is cancerous or benign in a single exam. Previously, doctors had to put patients through two separate scans to get similar information – with limited success.

“India has cancer rates that are com-parable to the majority of developing countries,” said Dr A Velumani, Founder & Managing Director of NHL i.

“Cost has been one of the biggest bar-riers in advancing early cancer detection. Our goal is to remove the barrier of cost by reducing the cost to patients by half. If we make detection and treatment affordable, more people will come forward and the sheer volume will take care of our capital investments,” he added.GE HEALTHCARE CHALFONT ST GILES, UKwww3.gehealthcare.com

Molecular Imaging Centers in India:making cancer detection more accessible

advertorIal

Multihance : the contrast agent of choice for enhanced breast MRIMagnetic Resonance (MR) Imaging is widely considered the diagnostic imaging modality of choice for the evaluation of abnormalities associated with the breast. Numerous studies have shown that contrast-enhanced breast MRI is significantly more sensitive and accurate for the detection and characterization of breast cancer than conventional techniques such as mammography and ultrasound.

Definite indications for which contrast-enhanced MRI is strongly recommended include screening of women at high risk of developing breast cancer, the evaluation

of tumor response to neoadjuvant chemotherapy (NAC), the detection of occult primary breast can-cer, and the detection of suspected local cancer recurrence [1]. Numerous studies have also high-lighted the benefit of contrast-enhanced MRI for additional indications such as preoperative breast evaluation [2, 3]. However, as with all imag-ing modalities, optimized diagnostic performance depends on optimized image acquisition. On the one hand, this implies appropriate sequence parameters to allow image acquisition with optimal spatial and temporal resolution and, on the other, appropriate contrast enhancement to better detect and characterize suspicious lesions. Of the numerous contrast agents available, Mul-tiHance (Gadobenate dimeglumine, Bracco Imag-ing SpA, Milan, Italy) is the only one specifically approved by European regulatory authorities for breast MRI applications. This specific approval, which is for “MRI of the breast, for the detection of malignant lesions in patients where breast cancer is known or suspected on the basis of previous mammography or ultra-sound results” [4], reflects the proven superiority of MultiHance for the detection and characterization of breast cancer not only compared with conven-tional imaging techniques [5, 6] but also compared with breast MRI enhanced with other MR contrast agents [6-9]. This latter evidence comes directly from three prospective, intra-individual crossover comparisons of MultiHance with Magnevist in which all evaluated patients received both contrast agents at equivalent doses of 0.1 mmol/kg body-weight in randomized fashion in two separate but otherwise identical MRI examinations separated by no more than 7 days (7-9). The most recent of these studies was a large dou-ble-blind, multicenter, randomized, intra-individual crossover comparison of MultiHance and Magnev-ist in which three highly experienced, independent

and fully blinded readers assessed comparative MR images from 162 women with abnormalities at mam-mography or ultrasound which were considered sus-picious for malignancy (BI-RADS 3, 4 or 5). The study revealed highly significant superiority for MultiHance over Magnevist not only for the detec-tion of malignant lesions (91.7-94.4% vs. 79.9-83.3%; p≤0.0003), but also in terms of diagnostic performance for the identification of breast can-cer (sensitivity: 95.2% vs. 81.2-84.6%; specificity: 91.1-96.9-99.0% vs. 93.8-97.8%; accuracy: 96.7-98.2% vs. 92.8-96.1%; PPV: 77.2-91.1% vs. 60.9-80.7%; and NPV: 99.0-99.4% vs. 97.8-98.1%; p≤0.0094 across all readers and assessments). As for other MR applications for which contrast agent use is mandatory, the superior performance of MultiHance is due to the greater r1 relaxivity of this agent relative to other gadolinium-based contrast agents. Specifically, the Gd-BOPTA contrast-effective

FIGURE 1. 45-year-old woman referred for breast MRI for breast cancer staging after unequivocal mammography/ultrasound before histology/pathol-ogy. A) Subtracted image acquired after administration of 0.1 mmol/kg BW Magnevist. B) Subtracted image acquired after administration of 0.1 mmol/kg BW MultiHance. Note the greater lesion conspicuity and better definition of lesion margins on B. Histology confirmed an invasive lobular carcinoma.


molecule of MultiHance, unlike the Gd-DTPA contrast-effective molecule of Magnevist, possesses a hydropho-bic benzyloxymethyl side-chain which fits into specific sites on the albumin molecule leading to a slowing of the tumbling rate of the Gd-BOPTA complex in blood and thus an increase in its relaxivity [10]. This in turn leads to greater signal intensity (SI) enhancement on T1-weighted images and thus improved conspicuity not only of the lesion itself but also of characteristic malig-nant features such as spiculated lesion margins [Figure 1]. To date, the greater r1 relaxivity and resulting greater SI enhancement achievable with MultiHance has been shown to be of benefit for the improved detec-tion and diagnosis of malignant lesions [6-9], for bet-ter predicting malignancy in the case of histologically borderline lesions diagnosed at core needle biopsy [11], for improved detection of malignant contralateral lesions in patients with diagnosed unilateral breast can-cer [12] and for improved malignant lesion detection/exclusion and surgical decision making in patients with breast cancer detected at conventional imaging [13].Although implementation of breast MRI into routine clinical practice has been hampered by factors such as cost, perceived high frequency of false positive diagnoses, lack of availability of minimally invasive biopsy capabilities, and fear of overtreatment, findings suggest that many of these apparent drawbacks may be overcome with the use of MultiHance.

RefeRences1. Kuhl CK. Current status of breast MR imag-

ing. Part 2. Clinical applications. Radiology. 2007; 244: 672-91.

2. Braun M, Pölcher M, Schrading S, et al. Influence of pre-operative MRI on the surgical management of patients with operable breast cancer. Breast Cancer Res Treat. 2008; 111:179-87.

3. Kuhl C, Kuhn W, Braun M, Schild H. Pre-operative staging of breast cancer with breast MRI: one step forward, two steps back? Breast. 2007;16 Suppl 2: S34-44.

4. Available at: http://www.medicines.org.uk/emc/medi-cine/6132/SPC/MultiHance/

5. Pediconi F, Catalano C, Roselli A, et al. The challenge of imaging dense breast parenchyma: is magnetic resonance mammography the technique of choice? A comparative study with x-ray mammography and whole-breast ultrasound. Invest Radiol. 2009; 44: 412-421.

6. Gilbert FJ, van den Bosch HCM, Petrillo A, et al. Comparison of gadobenate dimeglumine-enhanced breast MRI and gadopentetate dimeglumine-enhanced breast MRI with mam-mography and ultrasound for the detection of breast cancer. J Magn Reson Imaging. 2013; In press.

7. Pediconi F, Catalano C, Occhiato R, et al. Breast lesion detection and characterization at contrast-enhanced MR mam-mography: gadobenate dimeglumine versus gadopentetate dimeglumine. Radiology 2005; 237: 45-56.

8. Pediconi F, Catalano C, Padula S, et al. Contrast-Enhanced MR Mammography: Improved lesion detection and differen-tiation with gadobenate dimeglumine. AJR Am J Roentgenol. 2008; 191: 1339-1346.

9. Martincich L, Faivre-Pierret M, Zechmann CM, et al. Multicenter, Double-Blind, Randomized, Intraindividual Crossover Comparison of Gadobenate Dimeglumine and Gadopentetate Dimeglumine for Breast MR Imaging (DETECT Trial). Radiology. 2011; 258:396-408.

10. Giesel FL, von Tengg-Kobligk H, Wilkinson ID, et al. Influence of human serum albumin on longitudinal and transverse relaxation rates (R1 and R2) of magnetic resonance contrast agents. Invest Radiol 2006; 41: 222–228.

11. Pediconi F, Padula S, Dominelli V, et al. Role of Breast MR Imaging for Predicting Malignancy of Histologically Borderline Lesions Diagnosed at Core Needle Biopsy: Prospective Evaluation. Radiology. 2010; 257: 653-661.

12. Pediconi F, Catalano C, Roselli A, et al. Contrast-enhanced MR Mammography for Evaluation of the Contralateral Breast in Patients with Diagnosed Unilateral Breast Cancer or High-Risk Lesions. Radiology 2007; 243: 670-680.

13. Pediconi F, Catalano C, Padula S, et al. Contrast-enhanced magnetic resonance mammography: does it affect surgi-cal decision-making in patients with breast cancer? Breast Cancer Res Treat. 2007; 106: 65-74.


Relaxivity matters…also in Breast MRI

MULTIHANCE - SUMMARY OF PRODUCT CHARACTERISTICS MultiHance, 0.5 M solution for injection Composition 1 ml of solution for injection contains: gadobenic acid 334 mg (0.5 M) as the dimeglumine salt. [Gadobenate dimeglu-mine 529 mg = gadobenic acid 334 mg + meglumine 195 mg]. Excipients Water for injections. Therapeutic indications and dosage This medicinal product is for diagnostic use only. MultiHance is a paramagnetic contrast agent for use in diagnostic magnetic resonance imaging (MRI) indicated for: MRI of the brain and spine for patients 2 years and older where it improves the detection of lesions and provides diagnostic information additional to that obtained with unenhanced MRI (0.2 mL/kg); Contrast-enhanced MR-angiography for adult patients where it improves the diagnostic accuracy for detecting clinically significant steno-occlusive vascular disease in patients with suspected or known vascular disease of the abdominal or peripheral arteries (0.2 mL/kg); MRI of the liver for the detection of focal liver lesions in adult patients with known or suspected primary liver cancer (e.g. hepatocellular carcinoma) or metastatic disease (0.1 mL/kg); MRI of the breast, for the detection of malignant lesions in patients where breast cancer is known or suspected on the basis of previous mammography or ultrasound results (0.2 mL/kg) Contra-indications MultiHance is contra-indicated in: patients with hypersensitivity to any of the ingredients; in patients with a history of allergic or adverse reactions to other gadolinium chelates. Special warnings and special precaution for use MultiHance should not be admixed with any other drug; the product should not be frozen, and it should be used immediately after drawing into the syringe. Patients should be kept under close supervision for 15 minutes following the injection as the majority of severe reactions occur at this time. The patient should remain in the hospital environment for one hour after the time of injection. The accepted general safety procedures for Magnetic Resonance Imaging, in particular the exclusion of ferromagnetic objects, for example cardiac pace-makers or aneurysm clips, are also applicable when MultiHance is used. Caution is advised in patients with cardiovascular disease. The use of diagnostic contrast media, such as MultiHance, should be restricted to hospitals or clinics staffed for intensive care emergencies and where cardiopulmonary resuscitation equipment is readily available. Small quantities of benzyl alcohol (< 0.2%) may be released by gado-benate dimeglumine during storage. Thus MultiHance should not be used in patients with a history of sensitivity to benzyl alcohol. As with other gadolinium-chelates, a contrast-enhanced MRI should not be performed within 7 hours of a MultiHance-enhanced MRI examination to allow for clearance of MultiHance from the body. Impaired renal function Prior to administration of MultiHance, it is recommended that all patients are screened for renal dysfunction by obtaining laboratory tests. There have been reports of nephrogenic systemic fibrosis (NSF) associated with use of some gadolinium containing contrast agents in patients with acute or chronic severe renal impairment (GFR < 30 ml/min/1.73 m2).Patients undergoing liver transplantation are at particular risk since the incidence of acute renal failure is high in this group. As there is a possibility that NSF may occur with MultiHance, it should therefore be avoided in patients with severe renal impairment and in patients in the perioperative liver transplantation period unless the diagnostic information is essential and not available with non-contrast enhanced MRI. Haemodialysis shortly after MultiHance administration may be useful at removing MultiHance from the body. There is no evidence to support the initiation of haemodialysis for prevention or treatment of NSF in patients not already undergoing haemodialysis. Elderly As the renal clearance of gadoben-ate dimeglumine may be impaired in the elderly, it is particularly important to screen patients aged 65 years and older for renal dysfunction. Undesirable effects The following adverse events were seen during the clinical development of MultiHance among 2637 adult subjects. There were no adverse reactions with a frequency greater than 2%. Common (≥ 1/100, < 1/10): Nervous system disorders; Headache. Gastrointestinal disorders; Nausea. General disorders and administration site conditions; Injection site reaction, feeling hot. Uncommon (≥ 1/1,000, < 1/100): Infections and infestations; Nasopharyngitis. Nervous system disorders; Paraesthesia, dizziness, syncope, parosmia. Cardiac disorders; Tachycardia, atrial fibrillation, first-degree atrioventricular block, ventricular extrasystoles, sinus bradycardia. Vascular disorders; Hypertension, hypotension. Respiratory, thoracic and mediastinal disorders; Rhinitis. Gastrointestinal disor-ders; Dry mouth, taste perversion, diarrhoea, vomiting, dyspepsia, salivation, abdominal pain. Skin & subcutaneous tissue disorders; Pruritus, rash, face oedema, urticaria, sweating. Musculoskeletal, connective tissue and bone disorders; Back pain, myalgia. General disorders and administration site conditions; Asthenia, fever, chills, chest pain, pain, injection site pain, injection site extravasation. Investigations; Abnormal laboratory tests, abnormal ECG, prolonged QT. Rare (≥ 1/10,000, < 1/1,000): Nervous system disorders; Hyperaesthesia, tremor, intracranial hypertension, hemiplegia. Eye disorders; Conjunctivitis. Ear and labyrinth disorders; Tinnitus. Cardiac disorders; Arrhythmia, myocardial ischaemia, prolonged PR interval. Respiratory, thoracic and mediastinal disorders; Dyspnoea N.O.S., laryngospasm, wheezing, pulmonary congestion, pulmonary oedema. Gastrointestinal disorders; Constipation, faecal incontinence, necrotising pancreatitis. Renal and urinary disorders; Urinary incontinence, urinary urgency. General disorders and administration site conditions; Injection site inflammation. Additional safety information Laboratory abnormalities cited above include hypochromic anaemia, leukocytosis, leukopenia, basophilia, hypoproteinaemia, hypocalcaemia, hyperkalaemia, hyperglycaemia or hypoglycaemia, albuminuria, glycosuria, haematuria, hyperlipidaemia, hyperbilirubinaemia, serum iron increased, and increases in serum transaminases, alkaline phosphatase, lactic dehydrogenase, and in serum creatinine and were reported in equal or less than 0.4% of patients following the administration of MultiHance. However these findings were mostly seen in patients with evidence of pre-existing impairment of hepatic function or pre-existing metabolic disease. The majority of these events were non-serious, transient and spontaneously resolved without residual effects. There was no evidence of any correlation with age, gender or dose administered. Paediatric In paediatric patients enrolled in clinical trials the most commonly reported adverse reactions included vomiting (1.4%), pyrexia (0.9%) and hyperhydrosis (0.9%). The frequency and nature of adverse reactions was similar to that in adults. In marketed use, adverse reactions were reported in fewer than 0.1% of patients. Most commonly reported were: nausea, vomiting, Signs and symptoms of hypersensitivity reactions including anaphylactic shock, anaphylactoid reactions, angioedema, laryngeal spasm and rash. Injection site reactions due to extravasation of the contrast medium leading to local pain or burning sensations, swelling and blistering have been reported. Isolated cases of nephrogenic systemic fibrosis (NSF) have been reported with MultiHance in patients co-administered other gadolinium-containing contrast agents. Please note The peel-off tracking label on the vials should be stuck onto the patient records to enable accurate recording of the gadolinium contrast agent used. The dose used should also be recorded. Consult the locally approved package insert. The Marketing Authorisation Holder, the Marketing Authorisation number and the date of approval may be different in different countries. Date of revision of this text March 2013.

*At equivalent dose of 0.1 mmol/kg, MultiHance provides significantly superior detection of cancer lesions and significantly superior sensitivity, specificity and predictive values for detection/exclusion of breast regions with cancer lesions than gadopentetate dimeglumine(1)

(1) Martincich et al. Radiology 2011; 258(2):396-408Please see full Prescribing Information. Before use, please consult the locally approved Summary of Product Characteristics, which will be made available upon request.

Superior diagnostic performance*

vs. gadopentetate dimeglumineat equivalent dose1

AD MH Breast 0513.indd 1 15/05/13 08:55

Relaxivity matters…also in Breast MRI

MULTIHANCE - SUMMARY OF PRODUCT CHARACTERISTICS MultiHance, 0.5 M solution for injection Composition 1 ml of solution for injection contains: gadobenic acid 334 mg (0.5 M) as the dimeglumine salt. [Gadobenate dimeglu-mine 529 mg = gadobenic acid 334 mg + meglumine 195 mg]. Excipients Water for injections. Therapeutic indications and dosage This medicinal product is for diagnostic use only. MultiHance is a paramagnetic contrast agent for use in diagnostic magnetic resonance imaging (MRI) indicated for: MRI of the brain and spine for patients 2 years and older where it improves the detection of lesions and provides diagnostic information additional to that obtained with unenhanced MRI (0.2 mL/kg); Contrast-enhanced MR-angiography for adult patients where it improves the diagnostic accuracy for detecting clinically significant steno-occlusive vascular disease in patients with suspected or known vascular disease of the abdominal or peripheral arteries (0.2 mL/kg); MRI of the liver for the detection of focal liver lesions in adult patients with known or suspected primary liver cancer (e.g. hepatocellular carcinoma) or metastatic disease (0.1 mL/kg); MRI of the breast, for the detection of malignant lesions in patients where breast cancer is known or suspected on the basis of previous mammography or ultrasound results (0.2 mL/kg) Contra-indications MultiHance is contra-indicated in: patients with hypersensitivity to any of the ingredients; in patients with a history of allergic or adverse reactions to other gadolinium chelates. Special warnings and special precaution for use MultiHance should not be admixed with any other drug; the product should not be frozen, and it should be used immediately after drawing into the syringe. Patients should be kept under close supervision for 15 minutes following the injection as the majority of severe reactions occur at this time. The patient should remain in the hospital environment for one hour after the time of injection. The accepted general safety procedures for Magnetic Resonance Imaging, in particular the exclusion of ferromagnetic objects, for example cardiac pace-makers or aneurysm clips, are also applicable when MultiHance is used. Caution is advised in patients with cardiovascular disease. The use of diagnostic contrast media, such as MultiHance, should be restricted to hospitals or clinics staffed for intensive care emergencies and where cardiopulmonary resuscitation equipment is readily available. Small quantities of benzyl alcohol (< 0.2%) may be released by gado-benate dimeglumine during storage. Thus MultiHance should not be used in patients with a history of sensitivity to benzyl alcohol. As with other gadolinium-chelates, a contrast-enhanced MRI should not be performed within 7 hours of a MultiHance-enhanced MRI examination to allow for clearance of MultiHance from the body. Impaired renal function Prior to administration of MultiHance, it is recommended that all patients are screened for renal dysfunction by obtaining laboratory tests. There have been reports of nephrogenic systemic fibrosis (NSF) associated with use of some gadolinium containing contrast agents in patients with acute or chronic severe renal impairment (GFR < 30 ml/min/1.73 m2).Patients undergoing liver transplantation are at particular risk since the incidence of acute renal failure is high in this group. As there is a possibility that NSF may occur with MultiHance, it should therefore be avoided in patients with severe renal impairment and in patients in the perioperative liver transplantation period unless the diagnostic information is essential and not available with non-contrast enhanced MRI. Haemodialysis shortly after MultiHance administration may be useful at removing MultiHance from the body. There is no evidence to support the initiation of haemodialysis for prevention or treatment of NSF in patients not already undergoing haemodialysis. Elderly As the renal clearance of gadoben-ate dimeglumine may be impaired in the elderly, it is particularly important to screen patients aged 65 years and older for renal dysfunction. Undesirable effects The following adverse events were seen during the clinical development of MultiHance among 2637 adult subjects. There were no adverse reactions with a frequency greater than 2%. Common (≥ 1/100, < 1/10): Nervous system disorders; Headache. Gastrointestinal disorders; Nausea. General disorders and administration site conditions; Injection site reaction, feeling hot. Uncommon (≥ 1/1,000, < 1/100): Infections and infestations; Nasopharyngitis. Nervous system disorders; Paraesthesia, dizziness, syncope, parosmia. Cardiac disorders; Tachycardia, atrial fibrillation, first-degree atrioventricular block, ventricular extrasystoles, sinus bradycardia. Vascular disorders; Hypertension, hypotension. Respiratory, thoracic and mediastinal disorders; Rhinitis. Gastrointestinal disor-ders; Dry mouth, taste perversion, diarrhoea, vomiting, dyspepsia, salivation, abdominal pain. Skin & subcutaneous tissue disorders; Pruritus, rash, face oedema, urticaria, sweating. Musculoskeletal, connective tissue and bone disorders; Back pain, myalgia. General disorders and administration site conditions; Asthenia, fever, chills, chest pain, pain, injection site pain, injection site extravasation. Investigations; Abnormal laboratory tests, abnormal ECG, prolonged QT. Rare (≥ 1/10,000, < 1/1,000): Nervous system disorders; Hyperaesthesia, tremor, intracranial hypertension, hemiplegia. Eye disorders; Conjunctivitis. Ear and labyrinth disorders; Tinnitus. Cardiac disorders; Arrhythmia, myocardial ischaemia, prolonged PR interval. Respiratory, thoracic and mediastinal disorders; Dyspnoea N.O.S., laryngospasm, wheezing, pulmonary congestion, pulmonary oedema. Gastrointestinal disorders; Constipation, faecal incontinence, necrotising pancreatitis. Renal and urinary disorders; Urinary incontinence, urinary urgency. General disorders and administration site conditions; Injection site inflammation. Additional safety information Laboratory abnormalities cited above include hypochromic anaemia, leukocytosis, leukopenia, basophilia, hypoproteinaemia, hypocalcaemia, hyperkalaemia, hyperglycaemia or hypoglycaemia, albuminuria, glycosuria, haematuria, hyperlipidaemia, hyperbilirubinaemia, serum iron increased, and increases in serum transaminases, alkaline phosphatase, lactic dehydrogenase, and in serum creatinine and were reported in equal or less than 0.4% of patients following the administration of MultiHance. However these findings were mostly seen in patients with evidence of pre-existing impairment of hepatic function or pre-existing metabolic disease. The majority of these events were non-serious, transient and spontaneously resolved without residual effects. There was no evidence of any correlation with age, gender or dose administered. Paediatric In paediatric patients enrolled in clinical trials the most commonly reported adverse reactions included vomiting (1.4%), pyrexia (0.9%) and hyperhydrosis (0.9%). The frequency and nature of adverse reactions was similar to that in adults. In marketed use, adverse reactions were reported in fewer than 0.1% of patients. Most commonly reported were: nausea, vomiting, Signs and symptoms of hypersensitivity reactions including anaphylactic shock, anaphylactoid reactions, angioedema, laryngeal spasm and rash. Injection site reactions due to extravasation of the contrast medium leading to local pain or burning sensations, swelling and blistering have been reported. Isolated cases of nephrogenic systemic fibrosis (NSF) have been reported with MultiHance in patients co-administered other gadolinium-containing contrast agents. Please note The peel-off tracking label on the vials should be stuck onto the patient records to enable accurate recording of the gadolinium contrast agent used. The dose used should also be recorded. Consult the locally approved package insert. The Marketing Authorisation Holder, the Marketing Authorisation number and the date of approval may be different in different countries. Date of revision of this text March 2013.

*At equivalent dose of 0.1 mmol/kg, MultiHance provides significantly superior detection of cancer lesions and significantly superior sensitivity, specificity and predictive values for detection/exclusion of breast regions with cancer lesions than gadopentetate dimeglumine(1)

(1) Martincich et al. Radiology 2011; 258(2):396-408Please see full Prescribing Information. Before use, please consult the locally approved Summary of Product Characteristics, which will be made available upon request.

Superior diagnostic performance*

vs. gadopentetate dimeglumineat equivalent dose1

AD MH Breast 0513.indd 1 15/05/13 08:55

THERAPY


By Prof. Peter Metcalfe

An enhanced role for MRI in Radiation TherapyMRI provides unrivalled detail about tumor location extent and biological sta-tus. This article explores the hypothesis that enhanced use of MRI will enable improved radiation therapy treatment regimens for cancer patients. MRI pro-vides important image information to better enable radiation therapy treat-ment planning, treatment response monitoring and image guidance.

radIatIon treatment PlannInGDevelopments in external beam radiation therapy using medical linear accelerators (linacs) and internal brachy-therapy sources have enabled a precise match of radiation dose to the tumor volume. If we use computed tomography (CT) imaging alone, two fundamental questions remain. Exactly where is the tumor and how far does it extend? Hence wide margins (typically 10mm) are included that encompass normal tissue and thus increase toxicity of the radiation treatment.Prior to patient treatment the radiation dose is calculated on a computerised radiation therapy treatment planning system (TPS). For visualization the radiation dose is pre-sented as a series of isodose levels painted onto each CT slice. CT images provide geometric integrity and electron density information that ensure accurately predicted radiation dose. Unfortunately CT images are devoid of detailed soft tissue information.What does Magnetic resonance imaging (MRI) bring to the party? MRI provides high-resolution anatomical information with excellent soft-tissue contrast. The most commonly used of the MR-visible nuclei is the hydrogen proton, which pro-duces the strongest signal and is abundant in the body (pri-marily as water and fat). MR images exploit the differences in either “longitudinal” (T1) or “transverse” (T2) relaxation times of fat and water, producing large variations in contrast. T1-weighted images are considered best for gross structural information (anatomy) and T2-weighted images for bio-logical characteristics (pathology). A multitude of sequences can be applied to provide unlimited potential in the assess-ment of soft tissue anatomy and surrogates for pathologic tumor properties. Beyond this, new MRI techniques, broadly termed “functional MRI” can provide information about tumor perfusion vascular permeability, extracellular space

tortuosity, metabolic status and hypoxia. A recent article by this author and colleagues in “Technology in Cancer Research and Treatment” discusses these techniques in more detail [1]. Advanced tools exist for registering and overlaying MRI on CT data sets. The fused image combines a geometrically sound electron density map for dose calculation from CT and better soft tissue contrast from the MRI. This provides more accurate visualization of position, volume and shape of the tumor, hence smaller treatment margins are possible. The brain was the first site where MRI was routinely used in TPS applications. MRI images are routinely used to identify and locate brain tumors such as gliomas. Figure 1 shows a typical CT and MRI image set for brain (Courtesy [1]). The T1-weighted high-resolution 3D spoiled gradient method is used to define the gross visible disease, which is the region of the blood-brain barrier breakdown, while the clinical target volume is defined using the T2-weighted image series on which the extent of the edema thought to harbor micro-scopic disease is delineated. In the treatment of arteriovenous malformations (AVMs), magnetic resonance angiography is employed for the definition of the nidus. These can then be treated with a Gamma Knife or stereotactic radiosurgery on a linac.Dynamic MRI can be used to image patient-spe-cific tumors for planning of lung cancers for radiotherapy at frame rates of ~4 images per second. This allows the lung to be imaged fast enough to analyze

the author:

Prof Peter metcalfe holds the Chair in Radiation Oncology Physics at the Centre for Medical Radiation Physics, University of Wollongong, Australia. The Chair is supported by the Cancer Institute of New South Wales. He is also a member of the Ingham Institute of Applied Medical Research, Liverpool, Sydney, Australia.

FIGURE 1. CT (left panel) co-registered with a T1-3D-SPGR MRI image set (right panel). The difference in tumor visualization can be clearly appreciated between the between the two panel. (Image reproduced with permission from Technology in Cancer Research and Treatment, Adenine Press. Reference [1]).

true motion and deformation over the breathing cycle. 4DCT can also image lung however not all tumors are visible and they suffer from motion artifacts. Tumor extent is clearly visible on MRI as shown in Figure 2. This is a typical lung image obtained in three planes using MRI (courtesy [1]).Various structures in the prostate such as the apex and penile bulb are more clearly visible using MRI [2]. There is also clear indication for MRI in cases with prosthetic hip replacements where CT is adversely effected by artifacts from the high density and high atomic number prostheses [3].MRI is well established as the optimum imaging modality for cervical-cancer diagnosis in comparison to CT and clinical examination. MRI is considered the imaging modality of choice for cer-vix contouring in TPS, with significant

improvement in contrast between the target volume and normal tissues [4. Breast patients present an interesting challenge for use of MRI in TPS. While MRI is ideal for tumor extent [5] the set ups are contradictory, prone breast coils are used for imaging while most patients are treated in the supine posi-tion. Research into breast coils that are effective in the supine position is continuing.Most MRI machines are housed in diag-nostic imaging departments. Currently only about 10% of radiation therapy patients receive an MRI image specifi-cally for RTP. A contributing factor may be accessibility. Hence a new trend is developing. Radiation therapy depart-ments are installing MRIs in-house. Some specialized requirements for MRI devices for radiation therapy treatment planning applications include:

i) large bore (at least 70cm) to fit in patient positioning devices, ii) flat table top to mimic patient position-ing on linaciii) patient skin off set surface coils to avoid patient contour distortion iv) MR compatible immobilization devices (not carbon fibre) v) The jury is still out on 1.5 T (geometry) or 3 T (signal to noise) For historical reasons CTs in Radiotherapy departments are called “CT-simulators” hence MR devices in radiation therapy departments are likely to be identified as “MR-simulators”.

treatment resPonse monItorInGNormal tissue is best spared when radia-tion therapy is fractionated. Fraction-ation means the dose is given in small, equal amounts. One fraction is typically 2 Gray of radiation dose per day. One fraction of dose is given per day over several weeks of treatment. The ready access to MR-simulators in radiation therapy departments may enable more repeat scans during the course of treat-ment. The hope is that this may lead to individual patient treatment response monitoring. Tracking the likelihood of local recur-rence during the course of a radiation therapy treatment is in its infancy. While there are several other promising func-tional MR methods we will restrict dis-cussion here to one in particular that shows promise for treatment response monitoring. Diffusion weighted (DW)-MRI scan sequences produce image contrast that depends on differences in tissue-water mobility. Two equally large, opposing gradient pulses in the diffu-sion sequence make the signal intensity dependent on the movement of water


FIGURE 2. Axial, Coronal and Sagittal plane of a T2 weighted Single Shot Fast Spin Echo image (SSFSE) of a Small Cell Lung Cancer for a 64 year old male with T4 N2 M0 disease. T2 images generally used to define pathology, fat tends to appear black on T2 images. Shows excellent differentiation noted between mediastinum and tumor mass (Image reproduced with permission from Technology in Cancer Research and Treatment, Adenine Press. Reference [1]).

FIGURE 3. MRI images and ADC maps at various stages of radiotherapy (a) before radiotherapy (b) mid treatment (c) Post-treatment. Green no change in ADC, red ADC increased, blue ADC has decreased at the assessment time. (Image reproduced with permission from Technology in Cancer Research and Treatment, Adenine Press. Reference [1]).

molecules. The apparent diffusion coefficient (ADC), in units mm2/s, is the metric used for the assessment of water diffusion through tissue. To explore the potential to reliably compare intra- and post-treat-ment images with pre-treatment images, i.e. using voxel-based ADC maps at various time points to predict the response of brain metastases to whole-brain radiotherapy, diffusion-mapping tech-niques have been developed that allow the reliable comparison of intra- and post-treatment images with pre-treatment images [ ].An example is shown in Figure 3 (courtesy [1]). An increase in ADC (red points) in a voxel indicates increased diffusion distance of the water molecules, and hence a decrease in cell density, which could indicate that the volume is responding to therapy. In the same way, no change in ADC (green points) could indicate no response to therapy, and a decrease in ADC (blue points) indicates a decreased diffusion distance of water molecules, and hence an increase in cell density, which could indicate a proliferating volume of cells during therapy. The technique is also being tested with head and neck, breast and prostate patient cohorts although lymphatic structures may be a confounding factor for ADC analysis at typical clinical voxel resolutions [7].

ImaGe GuIdanCe usInG mrI-lInaC: tHe Future?The common scenario for daily alignment of patients prior to treat-ment with the linac is to use an X-ray tube with flat panel detector combination mounted on the linac gantry at an angle off-set to the linac treatment head. The device is rotated prior to treatment and a Cone Beam CT image is produced. Then the patient is relocated by a couch shift to a position that best registers the Cone beam image with the original planned CT. We call this image guided radiation therapy.In such scenarios repeat image guidance scans using these devices in the radiotherapy setting increase the small prob-ability of secondary primary tumor induction. Because MRI does not rely on ionizing radiation for imaging, there is no increased potential induction of secondary primary malig-nancies associated with its use in image guidance. Hence the development of MRI machines for image guidance becomes a favorable proposition. The ability to image mobile tumors in particular lung or liver using MRI is even more compelling.

Building a combination MRI-linac is not a trivial technical exercise. Apart from the engineering challenges of RF per-turbation from the linac, there is the requirement to account for various electron-beam perturbation effects that affect the paths of electrons generated by x-rays and hence the dose at regions such as the patient skin and lung-tissue interfaces [8].Despite these developmental difficulties two groups (located at Utrecht and Edmonton) have developed prototype MRI-linac devices [9, 10 ]. Figure 4 shows a schematic of an MRI-linac prototype design concept that is about to be installed at the Ingham Institute in Sydney [11]. It is envisaged these devices will enable MRI to be used for on-line real time image-guided radiation therapy. In other words tracking moving tumors with MRI while treating them in parallel with a linear accelerator in real time.MR-simulators used off line at various time points within the treatment cycle will ensure we have an accessible imaging tool for cancer patient tumor volume definition and treatment response monitoring. MRI-linacs may also provide viable on-line image guidance solutions in the near future.

aCknowledGement:I would like to acknowledge information included in the manuscript from Gary Liney, Lois Holloway, Wolfgang Tomé and Paul Keall who is directing the MRI-linac project at Ingham.

reFerenCes1. Metcalfe P., Liney G., Holloway L., Walker A., Barton M., Delaney G., vinod S., Tomé

W., The Potential for an Enhanced Role For MRI in Radiation Therapy Treatment Planning Technology in Cancer Research and Treatment ISSN 1533-0346 2013 April 24. Epub ahead of print. © Adenine Press (2013)

2. McLaughlin, P., Narayana, v., Meirowitz, A., Troyer, S., Roberson, P., Gonda, R., Sandler, H., Marsh, L., Lawrence, T., Kessler, M. vessel-sparing prostate radio-therapy: dose limitation to critical erectile vascular structures (internal pudendal artery and corpus cavernosum) defined by MRI. International Journal of Radiation Oncology Biology Physics 2005; 61, 20-31.

3. Rosewall, T., Kong, v., vesprini, D., Catton, C., Chung, P., Ménard, C., Bayley, A. Prostate delineation using CT and MRI for radiotherapy patients with bilateral hip prostheses. Radiotherapy and Oncology 2009; 90: 325-330.

4. Lim, K., Small, W., Portelance, L., Ceutzbrg, C. et al. Consensus Guidelines for delineation of clinical target volume for intensity-modulated pelvic radiotherapy for the definitive treatment of cervix cancer. International Journal of Radiation Oncology Biology Physics 2011; 79, 348-355.

5. Schmitz., A., van den Bosch, M., Loo, C., Mali, W., Bartelink, H., Gertenbach M., Holland R., Peterse J., Rutgers E., Gilhuijs K., Precise correlation between MRI and histopathology-Exploring treatment margins for MRI-guided localized breast cancer therapy, Radiotherapy and oncology, 2010; 97: 225-232.

6. Hamstra, D. A., Galbán, C. J., Meyer, C. R., Johnson, T. D., Sund- gren, P. C., Tsien, C., Lawrence, T. S., Junck, L., Ross, D. J., Rehem- tulla, A. Functional diffusion map as an early imaging biomarker for high-grade glioma: correlation with con-ventional radiologic response and overall survival. Journal of Clinical Oncology 2008; 26:3387-3394.

7. Bourne, R., Kurniawan, N., Cowin, G., Sved, P., Watson, G. 16 T Diffusion microimag-ing of fixed prostate tissue: preliminary findings. Magnetic Resonance in Medicine 2011; 66: 244-247.

8. Oborn, B. M., Metcalfe, P., Butson, M., Rosenfeld, Keall P. A. Monte Carlo char-acterization of skin doses in 6Mv transverse field MRI-linac systems: effect of field size, surface orientation, magnetic field strength, and exit bolus. Medical Physics 2010; 37: 5208 -5217. Raaijmakers, A., Raaymakers, B., van der Meer, S., Lagendijk, J. Integrating a MRI scanner with a 6Mv radiotherapy accelera-tor: impact of the surface orientation on the entrance and exit dose due to the transverse magnetic field. Physics in Medicine and Biology 2007; 52: 929-939.

10. Fallone, B., Carlone, M., Murray, B., Rathee, S., Stanescu, T., Steciw, S., Wachowicz, K, Kirkby, C. TU-C-M100F-01: Develop- ment of a linac-MRI sys-tem for real-time ART. Medical Physics 2007; 34: 2547.

11. Constantine D., Fahrig R., Keall P. A study of the effect of in-line and perpen-dicular magnetic fields on beam characteristics of electron guns in medical linear accelerators. Medical Physics 2011; 38: 4174-4184.


FIGURE 4. Schematic of the MRI-linac design being installed at the Ingham Institute of Applied Medical Research in Sydney this December. The magnet is a split bore 1T design. Two linac orientations are being tested to explore impact on dose at interfaces (adapted with permission from reference [11]).

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Accurate assessment of liver fibrosisPatients with chronic hepatitis B are at increased risk of cirrhosis. Assessment of fibrosis has important prognostic implications that can guide clinical therapy.

This article describes the results of a recent study, carried out in a large group of normal subjects and chronic hepatitis B patients, to evalu-ate the utility of ShearWave Elastography (SWE) for assessment of liver fibrosis. The results were correlated with those of biopsies.

The study established clear benefits from the use of SWE in HBV-infected patients and showed that the measured liver elasticity was cor-related with the stage of liver fibrosis. Measurement of the stiffness of the spleen by SWE may also be useful, especially in cases where SWE of the liver is difficult

tHe need For Better assessmentConventional ultrasound already helps radiolo-gists detect and manage liver nodules, hepato-cellular carcinomas, and also guide minimally invasive treatments of liver lesions. However, for patients with chronic liver diseases, and espe-cially Hepatitis B infection, conventional ultra-sound has some distinct limitations. To effectively treat patients affected by chronic Hepatitis B virus (HBV), physicians need an accurate quantification of liver fibrosis—and that is one function conven-tional ultrasound does not perform well. ShearWave Elastography (SWE) may fill this gap. Not only does SWE acquire images 200 times faster than conventional ultrasound, it yields quantita-tive information about tissue elasticity. Integrated

into the Aixplorer ultrasound system (from the French-based company Supersonic Imagine), SWE displays this quantitative information (measured in kilopascals) in an easily interpretable color-coded display, and can also superimpose the data over B-mode images. The ability of Shear Wave Elas-tography to quantify tissue stiffness could prove useful in assessing and managing chronic Hepatitis B infection.

studyInG sHearwave elastoGraPHy In lIver PatIentsBasing ourselves on previously published research which showed the benefits of the technology for managing chronic liver disease due to Hepatitis C [1,2], we set out to evaluate SWE on patients with chronic Hepatitis B. We used SWE to study liver and spleen stiffness in a large group of normal subjects and proven chronic Hepatitis B carriers, and correlated the results with those of biopsies [3]. Not only did we find that SWE measurements correlated more accurately with liver fibrosis than another non-invasive methods, we discovered that SWE measurements of the spleen might also help

the authors:

vivian y. F. leung Ph.d. & winnie C. w. Chu, m.d. are at:

Department of Imaging and Interventional Radiology

The Chinese University of Hong Kong,

Prince of Wales Hospital, Shatin, New Territories, Hong Kong SAR, China

e-mail: [email protected]

By Dr Vivian Y. F. Leung & Prof Winnie C. W. Chu,

ULTRASOUND ELASTOGRAPHY

Autumn 2013 2013 D I A G n O S t I C I m A G I n G A S I A P A C I F I C 17

uLTRASOuNd ELASTOGRAPhy

assess advanced fibrosis. Broadly, the study established clear benefits from the use of SWE with HBV-infected patients and indi-cated that further benefits could also be achievable. Of these, the most exciting is the possibility that SWE could improve the indications for biopsy, although this would of course need further confirmation by large prospective studies of

HBV-infected patients. More immediately, however, the study determined optimal cut-off values (in kilopascals) for distinguishing cirrhosis, severe fibrosis, and significant moder-ate fibrosis. Especially in cases of significant moderate fibrosis, in which conventional ultrasound is insensitive, the demonstrated accuracy of SWE measurements

could be crucial in indicating the appropriate treatment. SWE is particularly useful for assess-ing early fibrotic stage META-VIR F2.

Case studIes

a. swe assessment oF severe lIver FIBrosIsThis 55 year-old male HBV carrier was an ex-smoker, non-drinker, and presented with colonic polyp. His liver function was impaired, with fluctuating alanine aminotransfer-ase (ALT) levels up to 91 IU/L. Gray scale ultrasound of the liver showed only mild coarsening of the echotex-ture. SWE of the liver was performed [Figure 1]. and liver stiffness was measured at 9.7 kPa (1.8 m/s), which was graded as F≥3 Biopsy proved a METAVIR score F3.

B. moderate lIver FIBrosIs assessed By BotH lIver and sPleen stIFFness This 63 year-old male HBV car-rier ceased smoking and alcohol consumption in 2000. He pre-sented with reflux esophagitis. On the ultrasound examina-tion, the liver showed a nor-mal echotexture and a spleen of normal size with homogenous echotexture. A SWE analysis of the liver parenchyma and spleen was performed [Figure 2]. Liver elasticity was measured to be 7.3 kPa (1.6 m/s). that is correspond-ing to F≥2, while spleen elastic-ity was measured at 19.7 kPa (2.6 m/s) which was approaching the F≥2 splenic cut-off value found to be 19.8 kPa (2.6 m/s) in our experience. Liver biopsy proved a METAVIR F2 score, thus con-firming that SWE was able to correctly assess liver fibrosis in this case.

Can tHe sPleen BrInG InsIGHt to lIver FIBrosIs staGInG?Due to its relationship with the liver, the spleen may offer new insights into liver fibrosis stag-ing. The progression of liver

18 D I A G n O S t I C I m A G I n G A S I A P A C I F I C Autumn 2013 2013

FIGURE 2. Case B. 63 year old Male HBV carrier. The SWE measurement results were 7.3 kPa for liver elasticity (corresponding to F≥2) and 19.7 kPa for the spleen elasticity F≥2 cut-off value. The liver biopsy showed a Metavir score of F2, a direct correlation with the SWE measurement.

FIGURE 1. Case A. A 55 year old male HBV carrier in whom liver stiffness was measured at 9.7 kPa with SWE, which was suggestive of a severe fibrsosis level (F≥3). Liver biopsy confirmed a Metavir F3 score.

fibrosis often prompts architec-tural changes to the spleen as well, probably due to hemodynamic alterations. The increase in spleen stiffness does not follow the same progression curve as the liver and we found that using SWE on the spleen did not yield as accurate a result as using SWE directly on the liver.

Nevertheless, in cases where the liver is too small for an appropri-ate reading to be made or where there is some other impediment to liver measurement, the spleen can be considered as an organ which can yield ancillary param-eters to support the diagnosis of severe fibrosis and cirrhosis in suspicious cases.

ConClusIonThrough the use of better-honed cut-off values for the staging of liver fibrosis and accurate,

quantitative assessment of liver stiffness as measured by Shear-Wave Elastography, physicians can provide earlier and higher quality care to HBV-infected patients. The additional use of SWE for splenic measurements may also improve diagnosis and treatment, especially in patients whose liver disease is already so severe that their livers can-not be measured adequately. The shear wave technology can also be helpful in monitoring the response to treatment in patients who have contraindications to invasive techniques.

reFerenCes1. Bavu E, Gennisson JL, Couade

M, Bercoff J, Mallet v, Fink M, Badel A, vallet-Pichard A, Nalpas B, Tanter M, Pol S. Noninvasive in vivo liver fibrosis evaluation using

supersonic shear imaging: a clini-cal study on 113 hepatitis C virus patients. Ultrasound Med Biol. 2011 Sep;37(9):1361-73.

2. Ferraioli G, Tinelli C, Dal Bello B, Zicchetti M, Filice G, Filice C; Liver Fibrosis Study Group. Accuracy of real-time shear wave elastogra-phy for assesing liver fibrosis in chronic hepatitis C: a pilot study. Hepatology. 2012 Dec;56(6):2125-33.

3. Leung vY, Shen J, Wong vW, Abrigo J, Wong GL, Chim AM, Chu SH, Chan AW, Choi PC, Ahuja AT, Chan HL, Chu WC. Quantitative Elastography of Liver Fibrosis and Spleen Stiffness in Chronic Hepatitis B Carriers: Comparison of Shear-Wave Elastography and Transient Elastography with liver biopsy cor-relation. Radiology. 2013 Aug 2. [Epub ahead of print]


EXPERT EDITIONAs ShearWave™ Elastography is a real-time, quantitative, non-invasive and reproducible method, it will be helpful in validating the absence of fibrosis in order to reduce the number of unnecessary liver biopsies as well as to confirm cirrhosis to avoid dangerous biopsies and the possibility of hemorrhage.

Aymeric Guibal MD, PhDHôpital de Perpignan, France

Liver / Prostate / Thyroid / Vascular / Musculoskeletal / Abdomen / Gynecology / Obstetrics / Breast / Breast 3D / Pediatrics

Compact ultrasound endoscopic system

The recently launched EU-ME2 endoscopic ultrasound center from Olympus delivers higher resolu-tion images than previous models in the range while maintaining the same compact size of the previ-ous models. The new system also features a variety of new functions such as the Tissue Harmonic Echo mode which reduces artifacts by image signal processing to achieve a clearer image, The Elastography mode displays the relative stiff-ness of tissue. The Pulse Wave Doppler mode measures the speed and amount of blood flow and the H-FLOW (High Resolution Flow) mode can display small vessels Last but not least, thanks to its compact size it fits on Olympus’ endoscopy system trolley, and ensures the compatibility with other Olympus’ endoscopy systems for efficient examinations.OLYMPUSTOKYO, JAPANWWW.OLYMPUS.COM

2mP color diagnostic display Featuring LED backlights and a

unique front-of-screen sensor for on-demand image quality checks, the new Nio Color 2MP LED diag-nostic display from Barco provides an effective solution for a multi-tude of applications and modali-ties, including 3D PACS, 3D echo, ultrasound, orthopedic imaging, CAD, image fusion, nuclear medi-cine and PET. The new system has a high-bright LCD panel with a dis-play resolution of 1600 x 1200 pix-els. Featuring a DICOM calibrated luminance of 400 cd/m² through-out its entire lifetime, the new dis-

play system is perfectly adapted for multi-modality diagnostic imag-ing. With unrivaled color accuracy, accurate grayscales, a high contrast ratio (1400:1) and a 178° viewing angle to ensure confident image reading the new display comes with integrated Backlight Output Stabi-lization technology, ensuring fast power-up and long-term luminance

stability. The on-demand image quality checks ensure maximum uptime of the display. Additionally, the LED backlights produce less heat, require less cooling and thus reduce overall operational costs for the hospital.BARCO KORTRIJK, BELGIUM www.barco.com

smaller, smarter, simpler ultrasound

The new Xario 200 and Xario 100 models from Toshiba have been positioned to address the higher-mid range segment of the market, that is just below the premium-high segment of the company’s established Aplio series. The new models are designed to provide top perfor-mance in a small package, pro-viding top image quality, versatil-ity and flexible workflow and are highly mobile for easy movement between departments throughout the hospital. The Xario 100 model covers a wide range of basic appli-cations including cardiovascular and 3D/4D imaging, with excel-lent image quality, whereas the Xario 200 model can be equipped

for advanced applications such as the Contrast Enhanced Ultra-sound (CEUS) imaging package and the Elastography package

The Xario is built on high den-sity imaging architecture and so Toshiba could transfer almost all imaging enhancement technolo-gies previously developed for the Aplio class onto the new Xario platform These include Precision Imaging, ApliPur+, Advanced Dynamic Flow (ADF), and even Differential Tissue Harmonic Imaging, a Toshiba proprietary wideband technology that pro-vides deep penetration capabil-ity and excellent resolution at the same time. High quality trans-ducers are particularly important for a “workhorse” like the Xario which comes with a range of a new type of wide bandwidth transducers, from standard mod-els to specialty The transducers are lightweight and designed to

be easy to handle. The image quality for fetal diagnostics is high and comes very close to that of the Aplio. TOSHIBA, TOKYO, JAPAN www.toshiba.com.

uPdATEteCHnoloGy


C-arm with high operability and image quality

The new Opescope Acteno C-Arm system from Shimadzu enables free

and easy positioning and optimal per-formance to meet the demands of the operation room and emergency room. The total system guarantees both high image quality and ease of use. The fully counter-balanced C-arm provides extra-light and quick C-arm movements and positioning and the exclusive manual C-arm vertical movements enables much quicker height adjustments in routine operation. Shimadzu’s unique C-arm lock/release button at the image intensifier enables the C-arm to be posi-tioned from the clinician’s side without going back to the cart-unit. The enlarged

78cm wide opening of the C-arm makes approaches to the patient easy, minimiz-ing the chance of contact with the oper-ating table. On the other hand, the small width of the system of just 80cm makes it much easier to move through narrow doors or to position it in busy opera-tion rooms which are frequently already encumbered with many surgical devices. The absence of levers and cables on the C-arm makes it easy to wipe and keep clean. SHIMADZU, TOKYO, JAPAN www.shimadzu.com


The newly introduced Somatom Force CT system from Siemens is a Dual Source high-end CT capable of offer-ing individualized diagnoses especially for challenging patients, e.g. for very young patients, the seriously ill, and obese patients. Patients suffering from renal insuf-ficiency will benefit from the significant reduction in contrast medium. Up to 20 percent of patients suffer from renal insufficiency and contrast medium contain-ing iodine can place extra burden on the kidneys of older patients and those with chronic illnesses in particular. Initial examinations show that the average quantity of contrast medium administered in thoracic examinations can be lowered from between 90 and 110 mL to between 25 and 35 mL. This is made possible by the two Vectron X-ray tubes in Somatom Force, which enable routine examinations at particularly low tube voltages of 70 to 100 kilovolts. As the contrast-to-noise ratio rises, the amount of contrast medium can be lowered accordingly.

The new system can also deliver considerable added value in treatment control. 4D imaging, which shows the function of organs and vessels next to their morphology, is particularly important here because it allows addi-

tional information to be gleaned about primary tumors and metastases. A disadvantage of this dynamic perfu-sion is that – up to now – high dose values of more than 50 mSv were required in certain cases. This dose can now be more than halved with Somatom Force. In some pre-liminary cases, just 14.7 mSv was required. Such values enable the procedure to be used routinely, thus enabling quicker and more well-founded decisions to be made about which treatment is most suitable for an individual patient “

The NLST lung cancer screening study conducted in the U.S. has prompted a realignment of priorities in can-cer prevention: the study showed that mortality rates can be reduced by 20 percent if early lung cancer detection is performed with lowdose CT rather than conventional chest X-rays. The new Somatom Force is particularly suitable for such early detection examinations thanks to its previously unattained low dose values. Up to 50 per-cent lower than that of previous high-end CTs, this low dose is a result of the “Turbo Flash Mode” of the system and the use of two special spectral filters – Selective Photon Shields – which optimize the X-ray spectrum and thus significantly improve the air/soft-tissue contrast. It has been shown that lung scans can be acquired at dose values of 0.1 mSv.

Another advantage in pulmonary diagnostics is the enlarged field of view (50 cm) of the “Turbo Flash Mode”. With an acquisition rate of almost 400 mm per second this allows the entire thorax to be scanned in around one second With the fastest acquisition rate on the market (737 mm/s) entire thoracic-abdominal examinations can even be performed in just one second, thus removing the need for breath-hold. Even high heart rates do not lead to disruptive motion artefacts in clinical images.

SIEMENSERLANGEN, GERMANY www.siemens.com

World launch of High-end Dual Source CT

TEChNOLOGy uPdATE

30-inch color lCd monitor for multi-modality applications.

The 6 megapixel screen of the RadiForce RX650 provides enough space to display numerous applica-tions at once, making it an effective replacement for a dual 3 megapixel monitor setup. In addition, medi-cal professionals can conveniently view images side-by-side without the obtrusive bezels typically found in a multi-monitor environment. The monitor gives users full control of the layout on screen to streamline the radiology workflow. The moni-tors new design saves more space than a typical multi-monitor setup to make the work area more efficient. In addition, the narrow space between the bezels and the screen also make cleaning easy.

To meet DICOM Part 14* inter-national standards, EIZO carefully measures and sets each grayscale tone on the production line for the most consistent shadings possible. With the RadiForce RX650, both monochrome and color images can be viewed at individually optimized brightness levels and tones using EIZO’s Hybrid Gamma feature to expand the usabil-ity of multi-modality applications. An Integrated Front Sensor (IFS) housed within the front bezel performs con-venient, hands-free quality control calibration. While in use, the sensor does not interfere with the viewing area to dramatically cut the workload and maintenance costs associated with maintaining monitor quality control.EIZO CORPORATION ISHIKAWA, JAPANwww.eizo.com


The Dutch-based giant Philips and the Israeli company RealView Imaging have announced the completion of a clinical study that has successfully dem-onstrated the feasibility of using live 3D holographic visualization and interac-tion technology to guide minimally-invasive structural heart disease proce-dures. In the pilot study that involved eight patients and was conducted in collaboration with the Schneider Chil-dren’s Medical Center in Petach Tikva, Israel, RealView’s visualization technol-ogy was used to display interactive, real-time 3D holographic images acquired by Philips’ interventional X-ray and cardiac ultrasound systems.

In addition to viewing the patient’s heart on a 2D screen, clinicians in the interventional team were able to view detailed dynamic 3D holographic images of the heart ’floating in free space’ during a minimally-invasive structural heart disease procedure, without using special eyewear. The doc-tors were also able to manipulate the projected 3D heart structures by liter-ally touching the holographic volumes in front of them.“The holographic projections enabled me to intuitively understand and interrogate the 3D spatial anatomy of the patient’s heart, as well as to navigate and appreciate the device-tissue interaction during the procedure,” said Dr. Einat Birk, pediatric cardiologist and Director of the Institute of Pediatric Cardiology at Schneider Children’s Medical Center.

The ability to reach into the image and apply markings on the soft tissue

anatomy in the X-ray and 3D ultra-sound images could be extremely useful for guidance of these complex procedures. Progress in image-guided therapies for heart diseases — from the opening of obstructed coronary arteries to catheter ablation therapy for heart arrhythmias and catheter-based structural heart repairs — have greatly increased the need for live 3D image guidance, to supplement today’s live 2D image guidance. Live X-ray and live 3D cardiac ultrasound imaging are typically used simulta-neously to guide minimally invasive structural heart repair procedures, with the ultrasound images providing detailed insights into the heart’s soft tissue anatomy, and the X-ray imag-ing providing visualization of cath-eters and heart implants. The techno-logical advancements in the acquisi-tion of live 3D images to guide mini-mally invasive procedures have also triggered the development of novel ways to visualize the data. Following the promising results produced by this pilot study, Philips and RealView Imaging will continue to explore the clinical value of combining live 3D imaging and medical holography, both in interventional cardiology and in other clinical areas. PHILIPS EINDHOvEN, THE NETHERLANDSwww.philips.com/newscenter.

REALvIEW IMAGING YOKNEAM, ISRAEL www.realviewimaging.com.

Live 3D holographic imaging in interventional cardiology

TEChNOLOGy uPdATE

Cone Beam Ct system with large Fov for Head and neck imaging

Particularly suitable for in-office use the new Scanora 3Dx cone beam CT system from Soredex has a large field of view (FOV) and is designed for head and neck imaging. The system is intended for wide application areas ranging from single dental implant planning with small FOV up to whole skull imaging with extra large FOV. The system is thus ideal for ENT, dento-maxillofacial and cranial examinations in imaging centers, ENT offices, total care oral and maxillofacial clinics and hospitals.

The new system is the latest mem-ber of the company’s SCANORA CBCT product family. Compared to its prede-cessors, however, the SCANORA 3Dx has a larger flat panel detector that now enables a wider range of imaging fields-of-view. The new highly accurate system has the same smooth workflow as in other models in the range and fea-tures a clear control screen and motor-ized patient positioning movements. The optional dental panoramic sensor is available as before.

A total of eight user selectable FOVs are available, each with their own typi-cal applications. For example the small-est cylindrical FOV 50 x 50 mm with the highest resolution of 0.1 mm voxel size is intended for localized problems, such as detailed imaging of single tooth endodontic structures or ossicular chain of the inner ear, whereas sev-

eral medium-size FOVs are suitable for imaging for example both temporal bones in one volume. The most suit-able FOV for sinus and ENT imaging is the 140 x 165 mm (HxD) with 0.2 mm voxel size and finally the largest FOV 240 x 165 mm (HxD) with 0.5 mm voxel size is intended for whole skull examinations, such as in the fol-low-up of facial surgery operations. The voxel volume is isotropic, ensuring that measurements in any direction are accurate. Scanora 3Dx incorporates the latest imaging technology. For example, the 3D detector is a large amorphous

Silicon flat panel for high resolution projection image acquisition and the SARA (SOREDEX Advanced Recon-struction Algorithm) reconstruction method produces 3D volumes out of these projection images. Thanks to the wide adjustment ranges of parameters the overall radiation dose for specific diagnostic indications can be opti-mized by selecting the smallest FOV for each task and adjusting the mA and resolution accordingly. SOREDEx, TUUSULA, FINLAND www.soredex.com


A new version of the latest image enhancement software (US PLUS-View) from the Swedish company Context Vision has been designed for the Digital Signal Processor (DSP), a processing platform which is particularly suited for portable and handheld ultrasound devices. (DSPs are microprocessors spe-cifically designed to handle digital signal and image processing tasks). These devices provide a smaller, lower-cost solution, with excellent performance, low latency, and no requirements for specialized cool-ing or large batteries. DSPs have seen tremendous growth in the last decade, finding use in everything from cellular phones to advanced scientific instruments.)

As Point of Care is driving today’s health care market, ultra-sound manufacturers are invest-ing in the development of por-table ultrasound equipment to meet increased demand. Experts

predict this to be one of the fast-est growing segments in medical imaging. “We are very pleased to release another product for the mid-end segment. The continued growth of our ultrasound family demonstrates the flexibility of our latest technology,” said Anita Toll-stadius, CEO, ContextVision. “We are focusing our product develop-ment on growing segments and therefore expect solutions for the DSP platform to become impor-tant over the coming years.” Con-text Vision has optimized its flex-ible image enhancement software for implementation into the small and cost-effective DSP. Product development has concentrated on achieving as much functionality as possible despite constraints of the DSP and the end result is a product with a very high standard. CONTExT vISION, STOCKHOLM, SWEDENwww.contextvision.com.

Image enhancement software for Point of Care ultrasound

Original. Enhanced

A Well-Balanced Contrast Medium

With a right mix of osmolality, viscosity and iodine concentration, Ultravist® delivers contrast for high-quality imaging results.1

www.bayer.co.ukEnquiries: 01635 563000Calls to and from Bayer HealthCare may be recordedDate of preparation: October 2012. L.GB.10.2012.0951All rights reserved. © Bayer plc 2012

Ultravist® (iopromide) Prescribing Information (Refer to Summary of Product Characteristics (SmPC) before prescribing) Presentation: Intravascular injections of non-ionic iopromide in strengths of 150mg, 240mg, 300mg and 370mg of iodine/ml. Indications: For diagnostic use only. Delineation of the vascular and renal systems and of body cavities. Posology and administration: Adults Intravenous urography: minimum doses: Ultravist 370: 0.8ml/kg body weight; Ultravist 300: 1ml/kg body weight; Ultravist 240: 1.3ml/kg body weight. Children Intravenous urography: see SmPC. Adults Computed tomography: Cranial CT: Ultravist 240: 1.5-2.5ml/kg body weight; Ultravist 300: 1-2ml/kg body weight; Ultravist 370: 1-1.5ml/kg body weight. Whole-body CT: Dosage and administration rate depend on investigation and scanner. Adults Angiography: depends on age, weight, cardiac output, general condition, clinical problem, examination technique and the nature and volume of the vascular region to be investigated. (see SmPC). Adults Checking function of dialysis shunt: Ultravist 150: 10ml. Paediatric population: young infants (age < 1 year) and especially newborns are susceptible to electrolyte imbalance and haemodynamic alterations. Care should be taken regarding the dose of contrast medium to be given, the technical performance of the radiological procedure and the patient status. Renal impairment: to reduce the risk of additional contrast media-induced renal impairment in patients with pre-existing renal impairment, the minimum possible dose should be used. Hepatic impairment: no dosage adjustment is necessary. Elderly: possibility of reduced renal function should be considered. Contra-indications: Uncontrolled thyrotoxicosis. Warnings and precautions: Can be associated with anaphylactoid/hypersensitivity reactions, ensure preparedness for institution of emergency measures. Allergy-like reactions from mild to severe possible, mostly within 30 min, but delayed reactions (hours to days) may occur. Particularly careful risk/benefit judgement required for patients with: known hypersensitivity to Ultravist or its excipients; previous reaction to any contrast medium or; history of bronchial asthma or allergic disorders (increased risk). Pre-medicate with corticosteroids if necessary. To minimise risk: administer Ultravist to recumbent patients; observe patients closely for 15 minutes and keep them in hospital for at least one hour after the last injection. Patients on beta-blockers may be resistant to the effects of beta agonists. If severe reaction occurs, patients with cardiovascular disease are more susceptible to serious or fatal outcomes. Caution in patients with: known/suspected hyperthyroidism or goitre, monitor thyroid function in neonates exposed via mother or during neonatal period. Caution in patients with cerebral arteriosclerosis, pulmonary emphysema, poor general health, renal insufficiency, dehydration, diabetes mellitus, multiple myeloma/ paraproteinaemia, repetitive and / or large doses of Ultravist. Nephrotoxicity may occur or rarely acute renal failure. Ensure adequate hydration of patients; correct water or electrolyte imbalances before administration. With cardiac or severe coronary artery disease, increased risk of haemodynamic changes or arrhythmia. Intravascular injection may precipitate pulmonary oedema in patients with heart failure. Increased risk of neurological complications in patients with seizure history or CNS disorders. Caution in patients with reduced seizure threshold. May aggravate the symptoms of myasthenia gravis. Flush intravascular catheters frequently with physiological saline (if possible with addition of heparin) and minimise procedure length to minimise procedure-related thromboembolism risk. Patients with phaeochromocytoma may be at increased risk of developing a hypertensive crisis. Minimise excitement, anxiety and pain. Do not use in myelography. Sensitivity testing is not recommended. Interactions: Consider interruption of biguanides treatment prior to Ultravist administration as a precaution against development of lactic acidosis. Prevalence of delayed reactions higher in patients who have received interleukin-2. Diagnosis and treatment of thyroid disorders with thyrotropic radioisotopes may be impeded for up to several weeks due to reduced radioisotope uptake. Pregnancy and lactation: Adequate and well-controlled studies in pregnant women have not been conducted. Safety for nursed infants has not been investigated. Effects on ability to drive and use machines: Driving or operating machinery is not advisable for 30 minutes after the last injection. Undesirable effects: Common: dizziness, headache, dysgeusia, blurred/disturbed vision, chest pain/discomfort, hypertension, vasodilatation, vomiting, nausea, pain, injection site reactions (e.g. oedema, soft tissue injury post extravasation), feeling hot. Serious side effects: cf – Warnings and Precautions – in addition: Hypersensitivity/anaphylactoid reactions (anaphylactoid shock§*, respiratory arrest§*, bronchospasm*, laryngeal*/pharyngeal* or mucosal oedema, laryngeal/pharyngeal spasm§, asthma§*, angioedema), vasovagal reactions, arrhythmia*, dyspnoea*, cardiac arrest*, myocardial ischaemia*/infarction*, thyrotoxic crisis, thyroid disorder, coma*, cerebral ischaemia/infarction*, stroke*, brain oedema*, convulsion*, transient cortical blindness (IV use only), loss of consciousness, amnesia, paresis/paralysis, hearing disorders, cardiac failure*, bradycardia*, tachycardia, cyanosis*, hypotension*, shock*, thromboembolic events (IV use), pulmonary oedema*, respiratory insufficiency*, aspiration*, bullous conditions (e.g. Stevens-Johnson syndrome or Lyell syndrome), compartment syndrome due to extravasation (IV use), renal impairment/acute renal failure (IV use). § Reactions identified only during post-marketing surveillance (frequency not known). *These adverse reactions may have a fatal or life-threatening outcome and are considered the most serious adverse drug reactions. Prescribers should consult the SmPC in relation to other side effects. Overdose: Symptoms may include fluid and electrolyte imbalance, renal failure, cardiovascular and pulmonary complications. Monitoring of fluids, electrolytes and renal function recommended in case of intravascular overdosage. Treatment of overdose should be directed towards the support of vital functions. Ultravist is dialysable. Incompatibilities: Because of possible precipitation, X-ray contrast media and prophylactic agents must not be injected as mixed solutions. Special Precautions for Storage: Protect from light and X-rays. Legal Classification: POM Package Quantities and Basic NHS Price: Ultravist 150 10 x 50ml bottles £101.57 Ultravist 240 10 x 50ml £145.86 Ultravist 300 10 x 20ml £124.63 10 x 50ml £182.03 1 x 100ml £36.16 1 x 200ml £71.98 Ultravist 370 10 x 50ml £224.94 1 x 100ml £44.68 1 x 200ml £88.78 MA Numbers: Ultravist 150: 00010/0564 Ultravist 240: 00010/0565 Ultravist 300: 00010/0566 Ultravist 370: 00010/0567 Further information available from: Bayer plc, Bayer House, Strawberry Hill, Newbury, Berkshire, RG14 1JA, Telephone: (01635) 563000 Date of preparation: August 2012 Ultravist® is a trademark of the Bayer Group.

Adverse events should be reported. Reporting forms and information can be found

at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Bayer plc.

Tel.: 01635 563500, Fax.: 01635 563703, Email: [email protected]

References1. For details and full range of indications please refer to the

Summary of Product Characteristics.

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