CardiovasCular imaging

CardiovasCular imaging
Diagnosis • Technology • Therapy • Prevention
                                                                     AUG/SEPT 2017
  Hybrid Imaging

   F-NaF imaging of

  vulnerable plaques and

  myocardial scar tissue
  using hybrid PET/CT and

  ECR Symposium
  Siemens Breast Care
  Day: Dense Breasts
  Bracco: CEUS

  Dichotomization and
  the Radiologist’s
  Workflow Environment

  Radiation Exposure in
  Prostatic Embolization



  MRI: Putting Patient

  Comfort First

  Imaging News

  Industry News

  Technology Updates                                                     ­
CardiovasCular imaging
Each year, KLAS – an independent
healthcare research agency – interviews
thousands of healthcare professionals about
the products and services their organisations
use. This year’s 2017 KLAS ultrasound
report, shows that Fujifilm SonoSite is
the most adopted and widely considered
vendor for point-of-care ultrasound.


SONOSITE and the SONOSITE logo are trademarks and registered trademarks of FUJIFILM SonoSite, Inc. in various jurisdictions.
FUJIFILM is a trademark and registered trademark of FUJIFILM Corporation in various jurisdictions. All other trademarks are the property of their respective owners.
Copyright © 2017 FUJIFILM SonoSite, Inc. All rights reserved. Subject to change.                                                                             MKT02929 06/17
CardiovasCular imaging
                                                                                                                                               BY Alan barclay, ph.d.


                                                                                                                     FROM THE EDITOR
Andreas Adam, London                     Richard P. Baum, Bad Berka
Frits H. Barneveld Binkhuysen,
Filipe Caseiro Alves, Coimbra
Maksim Cela, Tirana
                                         Elias Brountzos, Athens Amersfoort
                                         Carlo Catalano, Rome
                                         Patrick Cozzone, Marseille
                                                                                    GBCAs — the Precautionary Principle
Katarzyna Gruszczynska,
Andrea Klauser, Innsbruck
Gabriele Krombach, Giessen
                                         Anne Grethe Jurik, Arhus Katowice
                                         Gabriel Krestin, Rotterdam
                                         Christiane Kuhl, Bonn
                                                                                    behind the differences in attitude
                                                                                    between Europe and U.S. ?
Philippe Lefere, Roeselare               Heinz U. Lemke, Kuessaberg
Thoralf Niendorf, Berlin                 Anne Paterson, Belfast
Anders Persson, Linköping                Hans Ringertz,Stockholm
Gustav von Schulthess, Zurich            Valentin E.Sinitsyn,Moscow
Patrick Veit-Haibach, Lucerne            Thomas J.Vogl,Frankfurt                   The bureaucratic wheels of the European             the brain and have come up so far with the
                                                                                   Medicine Agency grind inexorably on. A              a “watch-and wait” policy. The FDA pointed
EDITORIAL STAFF                                                                    review of gadolinium contrast agents was            out that since to date there was no direct
Editor                          Alan Barclay, Ph.D.
                                                                                   first initiated more than a year ago at the         evidence that gadolinium retention in the
		                              Tel. +32 479 370 364                               request of the European Commission in               brain from any of the GBCAs is harmful,
US Consulting Editor            Greg Freiherr
                                                                                   view of the increasing number of reports            they considered that restricting GBCA use
Publisher                       David Lansdowne                                    that deposits of gadolinium were being iden-        was not warranted at this time. The FDA
		                              E-mail:                   tified in certain areas of the brains of patients   will continue to assess the safety of GBCAs.
Associate Publisher             Bob Warren
		                              E-mail:                      who had previously received Gadolinium-             Many observers of the European regula-
                                                                                   Based Contrast agents (GBCAs) in MRI                tory processes explain the difference in
                                                                                   examinations.                                       attitude to GBCAs on either side of the
                                                                                   Following a clearly described procedure the         Atlantic as being due to the application of
Telephone: +44 1442 877777                                                         Pharmacovigilance and Risk Assessment               the (in)famous European “ Precautionary
                                                                                   Committee (PRAC) of the European                    Principle ” which has already caused much
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                                                                                   PRAC’s preliminary recommendations                  Basically the Precautionary Principle may
ROW €110.00                                                                        were then published in March this year.             be invoked when “a phenomenon, product
                                                                                   Following a request from the commercial             or process may have a dangerous effect, as
Europe, North America & Japan
                                                                                   companies who supplied the market, the              identified by a scientific and objective evalu-
DI Europe Ltd                                                                      PRAC re-examined its initial recommenda-            ation, if this evaluation does not allow the
Tel: + 44 (0)1442 877777                                                           tion to produce final recommendations,              risk to be determined with sufficient cer-
David Lansdowne
                                                                                   which were were then sent to the Committee          tainty”. The guidelines for its application are
Bob Warren
                                                                                   for Medicinal Products for Human Use                threefold : the fullest possible scientific eval-
E-mail:                                                      (CHMP), responsible for questions con-              uation, the determination, as far as possible,
Marika Cooper                                                                      cerning medicines for human use, which has          of the degree of scientific uncertainty; a risk
                                                                                   adopted the Agency’s final opinion. This is         evaluation and an evaluation of the potential
                                                                                   where we are now, with the last step in the         consequences of inaction; and finally the
China                                       Korea                                  bureaucratic chain still to be finalised —          participation of all interested parties in the
Adept Marketing                             Young Media Inc
                                                                                   namely the formality of the adoption by the         study of precautionary measures, once the
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                                                                                   European Commission of a legally binding            results of the scientific evaluation and/or the
Cheung Sha Wan, Kowloon                     Chung-Ku, Seoul, Korea 100-863         decision applicable in all EU Member States.        risk evaluation are available.
Hong Kong                                   E-mail:                Thus, it is now inevitable that the recom-          Despite the differences between the FDA
E-mail:             Telephone: +82 2 2273 4819
                                                                                   mendations of the PRAC will be enforced in          and the European authorities on the need
Telephone: +852 2891 7117                   Fax: +82 2 2273 4866
Fax: +852 2893 2101                         Contact: Young J. Baek                 European law.                                       to withdraw the marketing authorization
Contact: Adonis Mak                                                                To summarize, the result is that the market-        for linear GBCAs, they share the same view
                                                                                   ing authorization for linear GBCAs — the            as to the desirability of further research into
 Article Reprint Sales              DI Europe Ltd Tel: +44 1442 877777
                                                                                   chemical chelate which is known to be more          the mechanisms behind and characteris-
                                                                                   prone to leaching the Gadolinium ions —             tics of the deposition of the gadolinium in
DIAGNOSTIC IMAGING EUROPE is published eight times a year by DI Europe Ltd         will be suspended in Europe, whereas the            the brain. And there at least, if the steadily
Printed by Manson, St-Albans, UK. Annual subscriptions are available for €60
within Europe where it is also sent free of charge to physicians and radiology     more stable macrocylic chelates will con-           increasing number of papers published in
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                                                                                   tinue to be authorized.                             the field is anything to go by, then the appeal
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                                                                                   Throughout the review process, the regula-          is being heeded. It will be on the results of
Copyright © 2017 DI Europe Ltd. All rights reserved. Reproduction in any form
is forbidden without express permission of copyright owner.                        tory bodies were at pains to point out that         such research that any future changes in the
                                                                                   although free gadolinium ions are known             regulation of GBCAS will be based.
                                                                                   to be toxic in themselves, no evidence of           In the meantime, one of the most danger-
DI Europe Ltd
2 Claridge Court
                                                                                   adverse side effects had yet been found in          ous effects of the current situation is that, in
Lower Kings Road
Berkhamsted, Herts HP4 2AF
                                                                                   patients where deposits of gadolinium were          practice, radiologists may be scared off the
UK                                                                                 seen, presumably caused by the dissociation         use of all GBCAs, even the macrocyclic form
Telephone: +44 1442 877777
                                                                                   of the gadolinium ion from its chelate.             which are still on the market and which so
                                                                                                                                       far have not been shown to be associated
                                                                                   Meanwhile on the other side of the Atlantic,        with gadolinium deposits in the brain, with
                                                                                   the redoubtable FDA have also been look-            the great risk that the diagnostic utility of the
                                                                                   ing at the issue of gadolinium deposition in        MRI exam may be seriously compromised.
        AUG/SEPT 2017                                                                         D I    E U R O P E                                                                       3
CardiovasCular imaging

                                                               AUG/SEPT 2017                            EUROPE
                                                                Cardiovascular Imaging .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 24-39
                                                                According to World Health Organization statistics, Cardiovascular disease (CVD)
                                                                causes more than half of all deaths across the European Region. CVD causes 46
                                                                times the number of deaths and 11 times the disease burden caused by AIDS,
                                                                tuberculosis and malaria combined in Europe. 80% of premature heart disease
Each year cardiovascular disease (CVD) causes 3.9 million       and stroke is preventable.
deaths in Europe and over 1.8 million deaths in the European    Imaging has a vital role to play in prevention, diagnosis and monitoring of therapy
Union. CVD is the main cause of death in men in all but 12
countries of Europe and is the main cause of death in women
in all but two countries.
      Feature articles

      ECR Symposium Reports

      10-13|Global Insights for CEUS in
                  radiology: a Bracco spon-
                  sored symposium on contrast
                  enhanced ultrasound in the
                  fields of liver, macrovascular
                  and breast imaging
                                                                CEUS in liver imaging:                       Cardiac Imaging News Page                   The future of breast
      40-43| Breast Care Day. A day-long                       the new ACR LI-RADS
                                                                                                             Page 25                                     cancer screening —
                  symposium sponsored by                        classification                                                                           where can it help the
                  Siemens Healthineers and                                                                                                               dense breast ?
                  devoted solely to recent devel-               Page 10
                  opments in breast imaging.                                                                                                             Page 40
                  “Dealing with radiology’s prob-
                  lem child - dense breasts”                    imaging news
                                                                MRI reveals striking brain differences in people with genetic autism .  5
      Cardiovascular Imaging                                    Experimental PET tracer detects small blood clots . . . . . . . . . . . . . .                                              5
                                                                Optimal method for diagnosis of head injuries in children and
      26-28|	18F-NaF imaging of vulnerable                                                                                                     6
                                                                minimization of use of CT scans .. . . . . . . . . . . . . . . . . . . . . . . . . . .
                  plaques and myocardial scar
                  tissue using hybrid PET/CT                    UK must do more to future-proof its MRI capacity, say imaging experts .. 9
                  and PET/MRI
                                                                First Alzheimer’s trial with focused ultrasound . . . . . . . . . . . . . . . . 9
      30-32|	Low-dose coronary computed
                  tomography angiography with                   RADIOLOGY WORK FLOW
                  prospective ECG triggering to
                  predict cardiac events in the                 Workflow Dichotomization and the Radiologist’s Workflow Environment. . .                                        14-16
                  long term.
                                                                RADIATION DOSE EXPOSURE
      34-35|	The role of cardiovascular
                  imaging modalities in the                     Radiation Exposure in Prostatic Embolization. . . . . . . . . . . . . . .                                       18-19
                  evaluation of IgG4-related car-
                  diovascular disease.                          POINT of CARE ULTRASOUND
                                                                POC US in regional anaesthesia and intesive care. . . . . . . . . .  44-45
      36-38|	Early Echocardiography has
                  a Low Yield in Patients with
                  Transient Ischemic Attack.
                                                                Putting Patient Comfort First: a New Perspective on
      20-22|Industry News                                      Improving Imaging Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . .                                  46-47

      48-50|Technology Update
                                                                                                          Coming in the next issue:

      Visit us at
                                                               DI EUROPE                                  Breast Imaging
         AUG/SEPT 2017                                                 D I      E U R O P E                                                                                            4
CardiovasCular imaging
  MRI reveals striking brain differences in people with genetic autism
     In the first major study of its kind,                                                     some striking differences in the brain
 researchers using MRI have identified                                                         structures of deletion and duplication
 structural abnormalities in the brains                                                        carriers compared with non-carriers.
 of people with one of the most com-                                                           For instance, the corpus callosum, the
 mon genetic causes of autism, accord-                                                         fiber bundle that connects the left and
 ing to a new study (Owen JP et al Brain                                                       right sides of the brain, was abnor-
 MR Imaging Findings and Associated                                                            mally shaped and thicker in the dele-
 Outcomes in Carriers of the Reciprocal                                                        tion carriers but thinner in the dupli-
 Copy Number Variation at 16p11.2.                                                             cation carriers, compared to the con-
 Radiology. 2017 Aug :162934. doi:                                                             trol group and familial non-carriers.
 10.1148/radiol.2017162934)                                                                    Other stark differences were apparent.
     The abnormalities visible on brain                                                        The deletion carriers displayed fea-
 images corresponded to cognitive and                                                          tures of brain overgrowth, including
 behavioral impairments in the study                                                           the extension of the cerebellum toward
 group, suggesting a future role for                                                           the spinal cord. The duplication car-
 imaging in identifying people with                                                            riers showed characteristics of brain
 autism who are in most urgent need of                                                         undergrowth, such as decreased white
 intervention.                                                                                 matter volume and larger ventricles.
     Autism spectrum disorders are                                                                When the researchers compared
 a group of developmental problem;                                                             cognitive assessments to imaging find-
 symptoms typically appear early in life Example images for a control participant, a deletion ings, they found that the presence of
 and frequently include communica- carrier, and a duplication carrier. In the sagittal image any imaging feature associated with the
 tion problems and repetitive behav- of the deletion carrier, the thick corpus callosum, deletion carriers — such as a thicker
 iors. Many people with autism have dens and craniocervical abnormality. Image Credits: corpus callosum — indicated worse
                                            Radiological Society of North America
 abnormalities at a specific site on the                                                      daily living, communication and social
 16th chromosome known as 16p11.2.                                                            skills, compared to deletion carriers
 Deletion or duplication of a small piece                                                     without any radiological abnormalities.
 of chromosome at this site is one of the most common For the duplication carriers, the presence of decreased
 genetic causes of autism spectrum disorder.                             white matter, corpus callosal volume and increased ven-
     “People with deletions tend to have brain overgrowth, tricle size was associated with decreased full-scale and
 developmental delays and a higher risk of obesity,” said verbal IQ scores, compared to duplication carriers without
 study author Dr Julia P. Owen. “Those with duplications those findings.
 are born with smaller brains and tend to have lower body                   Senior author Dr Elliott Sherr commented, “Often stud-
 weight and developmental delays.” The researchers at UCSF ies like this focus on high-functioning individuals, but this
 and four other sites performed structural MRI exams on 79 was an ‘all-comers’ group,” he said. “We didn’t do math-
 deletion carriers, ranging in age from 1 to 48, and 79 dupli- ematical algorithms but rather used the trained eyes of
 cation carriers, ages 1 to 63, along with 64 unaffected fam- neuroradiologists to evaluate the scans of a full range of
 ily members and 109 participants in a control group. The individuals. When you look at a broad range of people like
 participants completed a battery of cognitive and behav- this, from developmentally normal to more significantly
 ioral tests, and neuroradiologists reviewed the brain images challenged, you’re better able to find these correlations.”
 for development-related abnormalities. The results showed

Experimental PET tracer detects                                     58: 1094). Current imaging modalities rely on structural
                                                                    characteristics, such as vascular flow impairment, and do not
small blood clots                                                   address the critical molecular components.
Blood clots in veins and arteries can lead to heart attack,            “Currently available diagnostic techniques of thrombus
stroke, and pulmonary embolism, which are major causes of           imaging rely on different modalities depending on the vas-
mortality. In the featured article of The Journal of Nuclear        cular territory,” explains Dr Andrew W. Stephens, of Piramal
Medicine’s July 2017 issue, German researchers show that            Imaging GmbH, Berlin, Germany. “A single imaging modality
targeting GPIIb/IIIa receptors, the key receptor involved in        that could visualize thrombi from various sources in different
platelet clumping, with a fluorine-18 (18F) labeled ligand is       anatomic regions would be very valuable.” For this preclinical
a promising approach for diagnostic imaging (Lohrke J et al         study researchers successfully developed the novel small mol-
  F-GP1, a Novel PET Tracer Designed for High-Sensitivity,          ecule tracer 18F-GP1 for positron emission tomography (PET)
Low-Background Detection of Thrombi. J Nucl Med. 2017;              imaging that binds with high affinity to GPIIb/IIIa receptors.

AUG/SEPT 2017                                           D I    E U R O P E                                                           5
CardiovasCular imaging

                                                                                             help inform the use of the clinical decision rules for head
                                                                                             injuries, which in turn could minimize CT scans, according to
                                                                                             Lead investigator, Dr F Babl. who said “The aim of this study
                                                                                             was to determine which children need CT scans to detect
                                                                                             brain injury,” said Dr Babl.”Most head injuries are mild and
                                                                                             don’t require neurosurgical management, however, a small
                                                                                             proportion of patients might present as having mild injuries,
                                                                                             but have clinically significant intracranial injuries,” he said.
                                                                                                 “This can be a vexed issue because physicians need to bal-
                                                                                             ance the importance of diagnosing an injury with reducing
Strong signals are detected at the sites where inserted catheters had roughened surfaces.    radiation exposure as much as possible.”
Almost no other background signal is visible. Only accumulation in the gallbladder becomes       In these cases, clinicians can turn to clinical decision rules,
visible at the bottom. Image coutesy of Piramal Imaging GmbH, Berlin Germany                 which have been developed to identify children at high risk
                                                                                             of intracranial injuries, aiming to assist clinicians to minimize
     F-GP1 showed a strong accumulation at the site of throm-
                                                                                             CT scans while still identifying all relevant injuries.
bus formation, and its binding ability was not affected by anti-                                 In the prospective observational study, run across 10
coagulants such as aspirin and heparin. The tracer showed                                    Australian and New Zealand tertiary hospitals and involving
rapid blood clearance, and PET imaging in a Cynomolgus                                       20,137 children with head injuries under the age of 18 years,
monkey model demonstrated the detection of small venous                                      the research team compared three clinical decision rules
and arterial clots, endothelial damage and emboli in the brain.                                  • The Pediatric Emergency Care Applied Research Network
Due to the favorable pre-clinical results, a first-in-human
study of 18F-GP1 is currently underway. Early results from an
interim analysis confirm the preclinical data and were pre-
sented at the 2017 Annual Meeting of the Society of Nuclear
Medicine and Molecular Imaging (SNMMI) in June.
    “Although the current studies are preliminary, 18F-GP1 may
provide not only more accurate anatomic localization, but also
information of the risk of the clot growth or embolization,”
Stephens points out. “This may lead to changes in clinical
intervention to the individual patient.” Addressing the use
of anticoagulants to treat blood clots, he notes, “These drugs
can cause significant and life-threatening bleeding. There is
a critical need to balance the risk of bleeding against the risk
of clotting in each patient. 18F-GP1 may in the future assist in
this important decision.”
.                                                      (PECARN, USA) ;
                                                                                                • The Canadian Assessment of Tomography for Childhood
                                                                                             Head Injury (CATCH) rule
Optimal method for diagnosis of                                                                 •The Children’s Head Injury Algorithm for the Prediction
                                                                                             of Important Clinical Events (CHALICE, UK).
head injuries in children and                                                                   The goal was to determine which of these three decision
minimization of use of CT scans                                                              rules provided the best option when it came to identifying
                                                                                             children at very low risk of a traumatic brain injury.
   Researchers hope to reduce unnecessary CT scans and                                          The researchers found that all three rules were good
radiation exposure in children with head injuries, following                                 options, but only one, the PECARN from the US, did not
the results from a large-scale, multicenter validation study                                 miss a single patient requiring neurosurgery.
to assess the diagnostic accuracy of three clinical decision                                    Internationally, the findings should provide a useful start-
rules used by emergency doctors (Babl FE et al. Accuracy of                                  ing point for individual clinicians as well as hospitals or
PECARN, CATCH, and CHALICE head injury decision rules in                                     regional bodies contemplating the introduction or modifica-
children: a prospective cohort study. Lancet. 2017 17; 389: 2393).                           tion of one of the clinical decision rules. Dr Babl pointed
   Head injuries are one of the most common reasons chil-                                    out : “However, it will be important to relate the findings to a
dren are taken to emergency departments. To rule out a seri-                                 number of other factors before implementation, such as the
ous brain injury, a percentage of these children require a CT                                baseline CT use, the effect of the rules on the projected CT
scan and while this is obvious for serious head injuries, it’s                               rate, the baseline clinician diagnostic accuracy and experience,
more challenging to determine whether CT scans are neces-                                    parental expectations, the medico-legal climate and economic
sary for children with milder injuries.                                                      considerations.”
   The results from the recent Australasian clinical trial will                    

 6                                                                              D I      E U R O P E                                                  AUG/SEPT 2017
CardiovasCular imaging


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CardiovasCular imaging
The Annual Scientific
 Meeting of the ESMRMB
 19. – 21.
 19    21 10.
           10 2017 Barcelona / ES

 A platform for physicians, engineers, radiograph
                                                hers /
 technologists and scientists interested in MR res
 and clinical practice.


 ∙   Sir Peter Mansfield Lecture by A. Heerschap, Nijmegen / NL
 ∙   Teaching Sessions on basic & advanced level
 ∙   Plenary Sessions by renowned speakers from Europe and the USA:
       ∙   Microstructure - from bench to bedside
       ∙   Big data from cohort and clinical studies
       ∙   MRI for neuroscience


 ∙   Hot Topic Debate:
     “Quantitative relaxation time measurement: boom or bust?”
 ∙   Roundtable Discussion:
     “What is the future of contrast agents in MRI?”

Dedicated networking opportunities:
the opportunity to meet with experts, friends
and colleagues.
CardiovasCular imaging

         UK must do more to future-proof its MRI capacity, say imaging experts
     Imaging experts in the UK are urging hospitals to for-                   • Only half of the organisations surveyed have plans to
  mulate clear plans to replace outdated equipment, after                 replace scanners and there are no succession plans in place
  a survey revealed that half of healthcare organisations                 for nearly 40% of MRI systems that are over seven years old
  do not have any renewal plans, and more than a third of                     • While clinicians rated the vast majority of their MRI
  older magnetic resonance imaging (MRI) scanners are                     scanners as state-of-the-art or adequate, 8% of systems were
  not scheduled for replacement. While many hospitals are                 deemed “obsolete” The UK’s MRI capacity is stretched com-
  operating newer equipment, 58% of MRI systems used                      pared to other countries. The UK has 6.1 MRI systems
  by those surveyed are at least five                                                          per million people, fewer than coun-
  years old, meaning they may not be                                                           tries including Estonia and Slovenia.
  able to conduct state-of-the-art imag-                                                       By comparison, the US has 38.1 and
  ing, such as that needed for certain                                                         Germany has 30.5 scanners per million.
  types of heart and prostate cancer                                                               As well as assessing the state of their
  scanning. Nearly a third (29%) of                                                            equipment, clinicians were also asked to
  systems are over ten years old. The                                                          estimate future MRI workload. On aver-
  Clinical Imaging Board (CIB) – a                                                             age, departments expect to see demand
  collaboration between The Royal                                                              rise by 13% this year. In addition to
  College of Radiologists (RCR), the                                                           upgrades and the replacement of old
  Society and College of Radiographers                                                         systems, the radiology teams surveyed
  (SCoR) and the Institute of Physics                                                          said they will need approximately 50
  and Engineering in Medicine (IPEM) – surveyed NHS                       brand new scanners to meet escalating demand for imaging.
  radiology departments across the UK to gauge the state                  “While many hospitals have MRI replacement plans in place,
  of MRI equipment.                                                       it is concerning to see others do not appear to be planning
     The survey findings in were issued in the report,“Magnetic           for the future, especially when it comes to those working
  Resonance Imaging (MRI) Equipment, Operations and                       with older machines. That nearly 40% of MRI scanners that
  Planning in the NHS”.                                                   are seven or more years old are not destined for replacement
     The CIB survey, which collected data relating to 171 scan-           any time soon is a real worry.
  ners used across the UK, revealed;                                          “Radiology departments are already struggling with ever-
     • 29% of MRI systems are at least ten years old – the                growing workloads and not enough staff, and many now face
  European Society of Radiology recommends scanners more                  working with outdated equipment.
  than ten years old be replaced or risk becoming obsolete.     

First Alzheimer’s trial with                    same patient will target a larger area of the
focused ultrasound                              right frontal lobe, and additional images
                                                will again evaluate if the blood-brain bar-
    Researchers at Sunnybrook Health            rier is reopened. No drugs will be adminis-
Sciences Centre in Toronto, Canada have         tered in the study.
begun the world’s first clinical trial evalu-        “Our trial investigates, for the first time,
ating the feasibility and safety of opening     the use of focused ultrasound to open the
the blood-brain barrier in patients with        blood-brain barrier in patients with early-
Alzheimer’s disease using focused ultra-        to-moderate Alzheimer’s disease, to deter-
sound.                                          mine both its safety and technical feasibil-
    For this trial, six Alzheimer’s patients,   ity,” says Nir Lipsman, co-principal inves-         provide an important method for more
ages 50–85 years, will undergo two non-         tigator of the Sunnybrook study. “Results           effectively delivering antibodies to the brain
invasive focused ultrasound procedures.         from our study will help us plan future             and may therefore one day be a treatment
For the first stage, the Exablate Neuro low-    clinical trials to establish what role focused      for Alzheimer’s—we just don’t yet know. It
frequency platform (Insightec) will apply       ultrasound may play, whether alone or in            is important to note that at this point we
focused ultrasound in a small area of the       conjunction with medical treatments, in the         are assessing only the feasibility and safety
right frontal lobe, and images will evaluate    management of Alzheimer’s                           of opening the blood-brain barrier in these
if the blood-brain barrier was temporarily           Sandra Black, senior scientist and co-         patients.”
opened. In the second stage, approximately      principal investigator at Sunnybrook adds,
one month later, a similar procedure to the     “It is possible that focused ultrasound may         alzheimer-s

AUG/SEPT 2017                                               D I    E U R O P E                                                                  9
CardiovasCular imaging
Symposium Report
     Global Insights for CEUS in radiology
     This article summarizes the proceedings of the recent symposium sponsored by
     Bracco Imaging at ECR 2017 on Contrast Enhanced Ultrasound (CEUS) imaging.
     Chaired by Prof. J. M. Correas, the symposium featured presentations by three dis-
     tinguished clinicians experienced in CEUS in the respective fields of liver, macrovas-
     cular and breast imaging.

     CEUS in liver imaging: the new ACR                                  influence subsequent management or therapy strategies
     LI-RADS classification                                              [Figure 1].

     Prof. Fabio Piscaglia                                               LR-1 (Definitely Benign). This is the category where
     In 2013 the American College of Radi-                               imaging features are diagnostic of a definitely benign
     ology (ACR) released their recom-                                   entity. This category includes simple cysts, classic hem-
     mended flowcharts for CT and MRI                                    angioma, definite focal hepatic fat deposition or sparing.
     characterization of the liver in patients
     at risk of Hepatocellular Carcinoma                                 LR-2 (Probably Benign). This category is relatively rare
     (HCC) and introduced the Liver Imag- Dr. Fabio Piscaglia,           and occurs when the nodule has imaging features sug-
     ing Reporting and Data System (LI- is Professor of Internal         gestive, but not diagnostic, of a benign entity. The criteria
     RADS), the system of standardized ter- Medicine, at the             for this category are: isoenhancement in all phases; of
     minology and criteria to interpret and University of Bologna,       very small distinct solid nodule (10 mm
     community to apply consistent terminology; to reduce                is iso-enhancing in all phases (ISO-ISO); a distinct solid
     variability and errors in image interpretation; to facilitate       nodule of any size with arterial phase hypoenhancement
     integration with other imaging modalities and to improve            without washout (HYPO-ISO); a solid nodule
and mild and late washout             CEUS in vascular imaging of pathol-
                                       (very small HYPER-HYPO); a
                                       distinct solid nodule ≥ 10 mm
                                                                             ogies in the macrovascular system
                                       with hyperhenancement in              Prof D-A Clevert
                                       arterial phase without washout        As background, Prof Clevert
                                       of any type (HYPER-ISO).              reminded the audience that approxi-
                                                                             mately 25-50% of all strokes (them-
                                       LR-5 (definitely HCC). In LR-5        selves the third leading cause of
                                       the nodules have imaging fea-         death after ischemic heart disease
                                       tures diagnostic of HCC. The          and cancer) are caused by unstable
                                       criteria for LR-5 are a nod-          carotid artery plaque. It is also vitally Dr. D-A Clevert is
                                       ule ≥ 10 mm showing arterial          important to know whether a patient Professor of Radiology and
                                                                                                                       Head of the Interdisciplinary
                                       phase enhancement (in whole           is suffering or not from a high grade Ultrasound Center, Dept of
                                       or in part, excluding rim and         stenosis, which in turn can affect the Clinical Radiology, University
                                       peripheral discontinuous globu-       choice of treatment e.g. stenting, sur- of Munich, Grosshadern,
                                       lar enhancement) followed by          gery or no therapy.                       Germany
                                       washout (late in onset and mild       CT or MRI can already provide d i r k . c l e v e r t @ m e d . u n i -
                                       in degree (as observed by 120         clear and extensive information, e.g.
                                       seconds after injection). This        regarding stenosis of the carotid, so a valid question is what
                                       pattern has an extremely high         precise additional information does CEUS bring?
Figure 2. An example of LR-5,          positive predictive value for
i.e. definitely HCC, with character-   HCC and can be considered             Contrast Enhanced Ultrasound (CEUS)
istic mild and late Hyper to Hypo
                                       definitively diagnostic [Figure       A typical ultrasound examination of the carotid artery begins
Top Panel: base-line. Middle           2].                                   with standard grey-scale ultrasound, followed by color Dop-
Panel: arterial phase. Bottom                                                pler, which however has some well-known limitations, such
Panel: portal phase        LR-M (Definite or probable                        as scanning angle and blooming artefacts.
                           malignancy, but not specific                      CEUS can overcome these limitations. In practice CEUS
for HCC). The criteria for this final category are: a nod-                   examinationscan be performed using different image disply
ule with rim enhancement in the arterial phase on wash-                      techniques: e.g. overlay images including some tissue back-
out either early in onset (within 60 seconds of contrast                     ground information (which is advantageous if the anatomic
injection) and/or in intensity, regardless of the type of                    landmarks are visible) or contrast only images displaying the
arterial enhancement. This category includes cholangio-                      pure contrast signal.
carcinoma, mixed hepatocholangiocarcinoma, hepatocel-
lular carcinoma ( often of poor differnetaiation grade) or,                  Stenosis
more rarely lymphoma or metasdtatic lesions. Therefore                       Approximately 10-15% of all ischemic strokes and transi-
the management of LR-M can vary but frequently a biopsy                      tory ischemic attacks occur with a severely stenosed internal
is required.                                                                 carotid artery (ICA). Prior to surgery it is important to be
                                                                             able to differentiate between pre-occlusive stenosis and com-
Reasons for incorporating ACR CEUS LI-RADS category                          plete ICA occlusion [Figure 3[.
in reports
1) To establish a definitive diagnosis of HCC and to avoid
the possibility of misdiagnosis with cholangiocarcinoma

2) To convey clear information to the hepatologist, particularly
in non LR-5 cases or where the lesion cannot be biopsied

3) To allow monitoring of the progression of a lesion with
time, even in the absence of a change in the size of the lesion.

A complete selection of images representing all the CEUS LI-RADS
categories can be found in the recent article: F Piscaglia et al. American
College of Radiology Contrast Enhanced Ultrasound Liver Imaging
Reporting and Data System (CEUS LI-RADS) for the diagnosis of
Hepatocellular Carcinoma: a pictorial essay Ultraschall Med. 2017;           Figure 3. In cases where standard ultrasound or even color Doppler are not clear,
38: 320 - 324.                                                               CEUS shows a definite occlusion in the Internal Carotid Artery

AUG/SEPT 2017                                                  D I    E U R O P E                                                                         11
Symposium Report

Pseudo occlusions                                                  Carotid Body tumors
These can be a particular challenge. In some patients              Depending on the size
color Doppler flow data can suggest a complete absence             of a carotid body tumor
of flow (occlusion) — albeit without certainty — while             decisions have to be
CEUS allows the demonstration of even small residual flow          taken as to whether the
(pseudo occlusion). With only grey-scale and color doppler         tumor should be oper-
images, it can be difficult to distinguish flow from pulsation     ated on or not. To moni-
artefacts. The use of CEUS enables precise information to          tor the success of any
be communicated to the surgeon regarding whether the               intervention, it is useful
ICA is patent or not.                                              to establish a basic pre-
In other patients, color Doppler shows flow only in the            treatment      evaluation     Figure 4a. Carotid body tumor. Pre-operative
external carotid artery, with none in the ICA. Even the use        of the perfusion of the       CEUS shows a high degree of perfusion in the
of power Doppler sometimes doesn’t help very much in               tumor. Post-treatment
such situations. In such casesCEUS can directly show the           reduction of the perfu-
actual flow situation.                                             sion of the tumor indi-
                                                                   cates successful treat-
Post-therapy follow-up                                             ment [Figure 4a, 4b].
Traditionally, carotid endarterectomy (CEA) or open sur-           Grey scale US and color
gery has been the treatment of choice, but carotid artery          doppler can provide only
stenting (CAS) is an alternative, particularly in patients with    orienting information
high surgical risk, e.g. patients undergoing neck radiation,       but confirmative infor-
with high or low cervical lesions or those with significant        mation on the tumor           Figure 4b. Post-operative CEUS shows much
cardiopulmonary disease. In both CEA and CAS, re-steno-            viability can be obtained     reduced perfusion.
sis is a potential problem that should be monitored. In any        only with CEUS.
case, whether an open surgery or stenting approach is used,
post-treatment monitoring is necessary. CEUS can precisely         Indications.
show in-stent stenosis and the impact on blood flow, in            In summary, the EFSUMB guidelines and recommendations
particular using cross-sectional views                             on the clinical practice of CEUS in non-hepatic applications
                                                                   identify several indications for its use in the carotid artery:
Dissection                                                         • Ruling out stenosis
Classified either as traumatic or spontaneous, dissection          • Follow-up after carotid stenting
of the cervical segments of the carotid and vertebral              • Dissection
arteries is relatively rare, but when it does occur, the           • Complications of vascular intervention
result can be blood flow in the false lumen, an increase           • Plaque characterisation
in the risk of thrombosis resulting in complete occlu-
sion or peripheral embolization. Again, on grey scale
ultrasound it can sometimes be difficult to spot a dis-
                                                                   CEUS in Breast Imaging: is it useful
section, and even with color Doppler the blood flow into           for the characterisation and BI-RADS
the true and false lumen is difficult to understand. The
use of CEUS enables clear identification of dissection
                                                                   classification of focal breast lesions?
and the demonstration of the entry of contrast into the            Dr Jun Luo,
false lumen in realtime. Axial views in CEUS can show              Introducing the subject by provid-
clearly the false and true lumenincluding the membrane             ing background information on the
in between.                                                        advantages of current ultrasound
                                                                   (US) approaches in breast imag-
Rare Cases                                                         ing, Dr Luo also pointed out that
Other cases where CEUS can be of use are                           challenges still remain to be faced.
                                                                   Many papers have been published
Arteriovenous fistula                                              on the value of US in breast can-
Fistulae between carotid artery and the jugular vein, caused for   cer screening, e.g. Shen et al Br J Dr Jun Luo, is Head of Ultrasound
example by dislocated central catheter line placement can be       Cancer. 2015; 112: 998. which com- Department, Sichuan Provincial
identified by color doppler, but CEUS provides a clearer image     pared modalities used for screening People’s Hospital, Chengdu,
                                                                                                            Sichuan, China
of the problem.                                                    for breast cancer in Chinese women
                                                                   and concluded that US was superior
Aneurysm of the external extracranial ICA is also rare, but        to mammography from the point of
requires characterisation prior to surgery. Color Doppler has      view of cancer detection. The J-Start study from Japan (Ohu-
limitations, whereas the use of CEUS can clearly identify and      chi et al, Lancet. 2016 23; 387: 341) also showed a significant
measure the size of the aneurysm and identify whether there        increase in sensitivity in the detection of early cancers when
are soft plaques or not.                                           US was used as an adjunct to mammography. On the basis

12                                                      D I   E U R O P E                                                      AUG/SEPT 2017
Predictive Models
                                                                  The overall objective of the use of CEUS predictive models is the
                                                                  maximal reduction of unnecessary biopsies, while minimizing
                                                                  the possibility of missing invasive breast cancer. In addition,
                                                                  the models should be easy to use and have good inter-observer
                                                                  agreement. The predictive model includes 3 defined enhance-
                                                                  ment pattern indicating malignancy [Figure 5a] and three pat-
                                                                  terns indicating a benign lesion [Figure 5b]. An example of the
                                                                  application of these criteria is shown in Figure 6 where the use of
                                                                  CEUS with an apparently benign lesion on 2D US was identified
                                                                  as malignant by application of the model. The altered diagnosis
                                                                  was confirmed by biopsy.
Figure 5a. Malignant Predictive Models

                                                                  Refining BI-RADS
                                                                  In Dr Luo’s clinic in Chengdu, China, all (100%) patients
                                                                  who are BI-RADS 4 on the basis of mammography and
                                                                  2D US, are biopsied, with an overall cancer-to-biopsy yield
                                                                  of only 40%. Implementing the CEUS-based classification,
                                                                  the biopsy rate falls to 25 % and the cancer-to-biopsy ratio
                                                                  increases to 73% with only 2.98% of missed malignant
                                                                  lesions. These lesions would be picked up at the 6 month fol-
                                                                  low-up examination, suggested for all patient downgraded
                                                                  from BI-RADS 4 based on the CEUS examination. These
                                                                  promising results have led to the initiation of a large multi-
Figure 5b. Benign Predictive Models                               center trial in China to confirm the findings and suggested
                                                                  diagnostic algorithm.
of these results, US appears beneficial when screening Asian
women but one question is whether similar results can be
obtained in Caucasian women. Another multi-centre trial
carried out in the USA, Canada and Argentina (Berg et al,
J Natl Cancer Inst. 2015;108:367) concluded that the cancer
detection rate with US was comparable to that of mammog-
raphy, with US identifying a greater proportion of invasive
and node-negative cancers. However the remaining prob-
lem is the substantial increase in the rate of false positives,
which are accumulating in the BI-RADS 4 category lesions.
Characterising all BI-RADS 4 lesions with biopsy (acc. to the
current guidelines) creates a huge number of biopsies with
the related patient discomfort and costs.
                                                                  Figure 6. The above CEUS image shows hyperenhancement, a larger lesion, that
                                                                  is regular-shaped and with clear margins. The model would predict malignancy, and
                                                                  this was confirmed to be IDC on biopsy
Although overdiagnosis is recognised as being a major challenge
in breast cancer screening, methods for estimating its precise
rates have not been standardized. Reported rates range from       Risk of malignancy transformation from apparently benign
5 – 50 % or more (e.g. Hamashima et al. J Clin Oncol. 2016; 46:   lesions
48, McCarthy et al Breast Cancer Res. 2015;17: 1); 7% to 9% of    The use of the malignant or benign CEUS enhancement pat-
women will have a negative biopsy.                                tern has been shown to be able to confirm benign lesions
The magnitude of these figures shows how big the problem is       from apparently benign US images, and identify potentially
and suggests that the BI-RADS combination of US and mam-          malignant lesions in patients. An analogy of such development
mography (which do not provide any microvascular informa-         of breast lesions is that of geological volcanoes, which can be
tion) needs to be improved.                                       classified as “Dead”, “Silent” or “Active”.
In addressing overdiagnosis, the key question is how to assess
the risk of malignant transformation in benign lesions. CEUS      Conclusions
has an important role to play in this context, but in turn also   • BI-RADS classifications of breast cancer can be refined if
raises certain questions regarding how CEUS should be used,       CEUS is incorporated into the screening protocol.
which CEUS patterns are useful, how to analyse such patterns      • CEUS can help predict the risk of malignant transfor-
and whether qualitative or quantitative analyses are more use-    mation of benign lesions since such transformations are
ful. The concept of predictive models was developed to address    accompanied by micro-vascular proliferation which can be
these issues.                                                     detected by CEUS.

AUG/SEPT 2017                                         D I   E U R O P E                                                                        13
Radiology WorkFlow
     Workflow dichotomization
     and the radiologist’s workflow
     By Dr John-Paul J. Yu

     W       orkflow disruptions are ubiquitous within cog-
             nitively demanding and complex work environ-
     ments and are associated with errors, workflow inef-
                                                                           be broadly categorized into image-interpretive (IITs)
                                                                           and non-image interpretive tasks (NITs). In a prospec-
                                                                           tive, randomized, observational investigation at our
     ficiency, and task prolongation. The healthcare work                  institution, we observed that individuals spent nearly
     environment is one such example of an intrinsically                   40% of their total time throughout the day performing
     complex work environment that often finds individuals                 NITs including answering phone calls, returning pages,
     engaging in rapid task switching and task shortening                  providing in-room consultative services for referring
     with concomitant deleterious effects on patient safety,               clinicians, technologists, and other radiologists, exam
     workflow efficiency, and other quality outcomes [1].                  protocoling, and teaching [5]. Moreover, previous work
     Not surprisingly, these phenomena have garnered sig-                  at our institution demonstrated that the reading room
     nificant interest throughout clinical medicine where                  work environment is highly fragmented with an average
     the implications of workplace interruptions can include               of 14.9 task-switching events (TSEs) per hour, yielding
     physical, emotional, economic harm, and even loss of                  a rate of approximately one interruption every four
     life. By virtue of a dynamic and complex work environ-                minutes. The significant time and effort commitment
     ment and the myriad of responsibilities incumbent on                  to NITs – in addition to the inherent disruptive nature
     radiologists, the radiology work environment is par-                  of these tasks – spurred efforts to better organize and
     ticularly susceptible to the effects of workplace disrup-             handle these NITs in both an efficient and thoughtful
     tions [2] with radiologists often experiencing significant            manner.
     strain in maintaining a streamlined, efficient workflow
     [3, 4].
                                                                           The impact of radiologist workflow
         “... the radiology work environment is                            Imaging interpretation is one of many components that
        particularly susceptible to the effects of                         constitute the full scope of responsibilities in a modern
                  workplace disruptions...”                                radiology practice. Even as image interpretation remains
                                                                           our most tangible clinical deliverable, it reflects one
                                                                           of many links in the imaging value chain. Additional
     The complexity of the radiologist’s workflow environ-                 links in the imaging value chain include consultative
     ment is largely a consequence of the multiple roles                   services provided to our referring clinical colleagues,
     the modern radiologist balances as an imaging expert                  exam protocoling, patient scanning, and other activities
     and diagnostician, physician consultant, educator, and                previously identified as NITs; however, in spite of the
     interventionalist. While these responsibilities concep-               disruptive nature of NITs, they are an essential com-
     tually span a wide-range of clinical activities, they can             ponent of providing value in today’s clinical environ-
                                                                           ment. The intrinsic value and importance of NITs belies
     The Author                                                            the frustration encountered with NITs throughout the
     John-Paul J. Yu, MD, PhD                                              workday where NITs – with their stochastic and disrup-
     Assistant Professor of Radiology, Psychiatry, and Biomedical          tive nature – often occur as unanticipated interruptions
     Engineering, Associate Program Director, Neuroradiology               to the radiologist’s primary duty of high-quality image
     Fellowship Program Division of Neuroradiology, Department of          interpretation. At our institution (and anecdotally at
     Radiology.                                                            numerous other academic institutions), the sheer num-
     Director, Laboratory for Behavioral Systems Neuroscience              ber of NITs and frequency of associated task switching
     Member, Neuroscience Training Program                                 served as an impetus for a more thoughtful approach
     Member, Clinical Neuroengineering Training Program                    to reading room workflows, with the goal of a more
     UW | University of Wisconsin School of Medicine and Public Health     efficient, streamlined practice that leverages existing
     E3/366 Clinical Science Center                                        opportunities for imaging value chain optimization.
     600 Highland Avenue | Madison, WI | 53792-3252 United States          Towards these ends, we separated our reading room
     email:                                              tasks into two discrete workflows — IIT and NIT — to

14                                                                       D I   E U R O P E                               AUG/SEPT 2017
Table 1. Interruptions

facilitate the division of responsibility   in the range of 3.2-4.7 minutes [8],         Resources [10]. Identified risk factors
for these tasks [6].                        workflow dichotomization would now           for burnout often manifest as descrip-
                                            conceivably and comfortably allow            tions of job dissatisfaction that include
After the implementation of IIT and         for the interpretation of a standard         work overload, difficult shifts, lack of
NIT workflows in our reading room,          head CT without interruption and by          control, and severe time constraints for
an evaluation of our results clearly        extension, would reduce the number           work output (e.g, exam turn-around
demonstrate that workflow dichoto-          of interruptions our radiologists could      times). We postulate that a highly dis-
mization yields successful outcomes         expect when interpreting more time-          rupted radiology work environment is
along multiple dimensions of analysis.      intensive, complex imaging.                  a key culprit underpinning many of
Implementing discrete IIT and NIT                                                        these sources of job dissatisfaction,
workflows resulted in a precipitous                                                      which may in turn lead to radiolo-
decrease in time spent on NITs by our          “... Radiology has experi-                gist burnout. Workflow optimization
image interpreting radiologists, falling       enced diminishing levels                  efforts, such work dichotomization,
to less than 25% of pre-intervention          of professional satisfaction               to improve reading room efficiencies
level furthermore and moreover, repre-          over time and excessive                  may also have the added benefit of
senting less than 5% of the radiologists      workload is among the most                 decreased mental burden, workload,
overall time in the post-intervention         commonly reported reasons                  related improved provider career satis-
period. Perhaps more importantly, the         for provider dissatisfaction               faction. The analysis of and subsequent
decrease in time spent on NITs was                         ...”                          improvements to the radiologist’s
nearly equally matched with a concom-                                                    workflow environment also requires
itant increase in time spent on image       Workflow dichotomization                     a careful analysis of individual work-
interpretation (up to a total of 73.2%      improves workplace satisfaction              loads and the impact individual work-
post-intervention from 53.8% pre-           Beyond the aforementioned posi-              loads have on the overall efficiency of a
intervention) suggesting a nearly-com-      tive quantitative impact of workflow         workflow process. These examinations
plete direct transfer of NIT-time to IIT-   dichotomization, there are less tangible     also afford a more nuanced exploration
time. The delineation of a discrete NIT     but no less important perceptive ben-        of the impact workflow design has on
workflow also resulted in a 40% reduc-      efits derived from separating reading        individual operators. Whereas work-
tion in TSEs experienced by the pri-        room tasks into IIT and NIT work-            flow represents the sequence of pro-
mary radiologist. The marked reduc-         flows. As with other medical special-        cesses through which a piece of work
tion in TSEs is particularly important      ties, radiology has experienced dimin-       passes from start to finish, workload
and encouraging as numerous previ-          ishing levels of professional satisfaction   represents the actual amount of work
ous studies have demonstrated the           over time and excessive workload is          to be done. Workload, on the individ-
deleterious effects of interruption on      among the most commonly reported             ual level, is not an absolute quantity
the quality of image interpretation [7].    reasons for provider dissatisfaction [9].    and is variably dependent on numer-
The reduction in TSEs and increase in       The intrinsic and extrinsic risk factors     ous intrinsic factors (such as individ-
image interpretive time was reflected       associated with career-related burn-         ual experience and skill) and extrin-
throughout our data with the mean           out specifically amongst radiologists is     sic factors (such as interruptions and
time between TSEs more than dou-            summarized in a recent report released       system failures), which all contribute
bling from 05:44 to 11:01. With average     by the American College of Radiol-           to the overall perception of individual
head CT interpretations times reported      ogy (ACR) Commission on Human                workload.

AUG/SEPT 2017                                         D I   E U R O P E                                                        15
Radiology WorkFlow

Table 2. Workload

Table 3. Satisfaction

Evaluation of the impact of
                                           measurements (and improvements) in           radiologists an opportunity to engage
workflow Dichomotization
                                           workflow dichotomization.                    in a rewarding clinical practice.
To evaluate the impact of workflow         As clinical imaging volumes continue
dichotomization on perceptions of          to increase, an understanding of work-       References:
workload, workplace interruptions,         place disruptions and their impact of        1. Westbrook J I et al. The impact of interruptions
                                                                                        on clinical task completion. Qual. Saf. Health Care.
and workplace satisfaction, survey data    radiologist productivity and global          2010; 19: 284.
were collected before and after work-      measures of radiologist workload and         2. Yu J-PJ et al. The radiologist’s workflow environ-
flow dichotomization at our institution;   workplace satisfaction have become           ment: evaluation of disruptors and potential implica-
                                                                                        tions. J Am Coll Radiol 2014; 11: 589.
data are summarized in Tables 1-3 [11].    increasingly salient. Implementation         3. Kansagra AP et al. Disruption of Radiologist
Following implementation of separate       of separate dedicated image-interpre-        Workflow. Curr Probl Diagn Radiol 2016; 45: 101.
dedicated image-interpretive and non-      tive and non-image interpretive work-        4. Larson DB et al. Communication in Diagnostic
                                                                                        Radiology: Meeting the Challenges of Complexity. Am
                                                                                        J Roentgenol. 2014; 203: 957.
                                                                                        5. Schemmel A et al. Radiology Workflow Disruptors:
   “....Implementing discrete Image Interprteive Tasks (IIT) and                        A Detailed Analysis. J Am Coll Radiol 2016; 13:
  Non-Image Interpretive Tasks (NIT) workflows resulted in a pre-                       6. Lee M H et al. Workflow Dynamics and the Imaging
  cipitous decrease in time spent on NITs by our image interpret-                       Value Chain: Quantifying the Effect of Designating
                          ing radiologists,                                             a Nonimage-Interpretive Task Workflow. Curr Probl
                                                                                        Diagn Radiol. 2016, doi:10.1067/
                                                                                        7. Balint B J et al. Do Telephone Call Interruptions
image interpretive workflows, our work     flows resulted in improved radiologist       Have an ImPact on Radiology Resident Diagnostic
                                                                                        Accuracy? Acad. Radiol. 2014; 21: 1623.
demonstrated a measurable uniform          perceptions of workplace disruptors
                                                                                        8. Reiner BI et al., Radiologists’ productivity in the
improvement in workplace satisfaction      and mental effort with a concomitant         interpretation of CT scans: A comparison of PACS
with a concomitant decrease in percep-     improvement in overall workplace             with conventional film. Am J Roentgenol. 2001;
                                                                                        176: 861.
tions of the workplace disruptions and     satisfaction. These and other similar
                                                                                        9. Zafar HM et al. Satisfaction of radiologists in the
effort required to complete workplace      efforts highlight the importance of          United States: A comparison between 2003 and
tasks. Beyond the quantitative impact      workflow design not only on workplace        1995. Radiology. 2007; 244: 223.
of workflow dichotomization, these         efficiencies but also in the positive sec-   10. Harolds JA et al. Burnout of Radiologists:
                                                                                        Frequency, Risk Factors, and Remedies: A Report of
data reflect the perceptive changes        ondary gains observed in individual          the ACR Commission on Human Resources. J Am
that occur in the workplace and cap-       workload levels and offers a potential       Coll Radiol. 2016; 13: 411.
                                                                                        11. Lee MH et al. Radiology Workflow Dynamics: How
ture important benchmarks that might       practice model that offers outstand-         Workflow Patterns Impact Radiologist Perceptions of
otherwise go unnoticed in quantitative     ing patient care while also providing        Workplace Satisfaction. Acad Radiol. 2017; 24: 483

16                                                    D I   E U R O P E                                                         AUG/SEPT 2017
International Cancer Imaging
                                             Society Meeting & 17th Annual
                                             Teaching Course
                                             Cancer Imaging and Intervention:
                                             a Multidisciplinary Approach

2nd - 4th October 2017                            • 2 Keynote lectures ‘Cancer Imaging in the era of precision
                                                    medicine’ and ‘Immunotherapy: Imaging challenges’

Langenbeck-Virchow                                • 8 Computer hands-on workshops using Siemens
                                                    workstations on evaluation of cancer of prostate, breast,
                                                    lung, liver, lung, ovary, uterus and whole-body imaging
Haus, Berlin, Germany                             • 25 sessions addressing structured reporting, response
                                                    evaluation, complications of medical and radiation therapy,
ICIS 2017 will focus on quantitative                metastatic disease, joint sessions with radiation and medical
                                                    oncologists, precision medicine, radiogenomics, prostate, female
and functional oncologic imaging and                pelvis, liver, pancreas, lung, lymphoma, CEUS and many more
the multidisciplinary management of
oncology patients. There will be a spectrum       • 4 Scientific Sessions dedicated to proffered papers, and a poster
                                                    exhibition with prizes for the best overall paper and poster
of sessions ranging from innovative and
state-of-the-art imaging, practical hands-on-     • 4 live-case workshops Transarterial chemoembolization
                                                    (TACE) in HCC / liver metastases, Radioembolization (SIRT),
workshops, essential refresher courses and          Microwave ablation of a pulmonary tumour in metastasis or
live-case workshops.                                small lung cancer, Radiofrequency ablation of liver metastasis

                                                  Delegates will received 17 CPD points from the Royal College
                                                  of Radiologists (Monday - 6, Tuesday - 6, Wednesday - 5). CME
                                                  accreditation will be sought from the European Accreditation Council
                                                  Continuing Medical Education (EACCME).
In association with:
Call for abstracts: Deadline 29th May 2017        Programme planning committee: Stefan Diederich ICIS President (DE),
Submit online at          Bernhard Gebauer (DE), Dow-Mu Koh (UK), Beth McCarville (US),
                                                  Anwar Padhani (UK), Andrea Rockall (UK), Heinz-Peter Schlemmer (DE),
                                                  Harriet Thoeny (CH).

For further information please contact:
ICIS, 140-148 Borough High Street, London, SE1 1LB    E:
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