This year, the main theme of the International Day of Radiology is breast imaging. To get some insight into the field, we spoke to Prof. Boris Brkljačić, professor of radiology and Vice-Dean at the University of Zagreb School of Medicine, Croatia, and Chairman of the ESR Communications and External Affairs Committee.

European Society of Radiology: Breast imaging is widely known for its role in the detection of breast cancer. Could you please briefly outline the advantages and disadvantages of the various modalities used in this regard?
Boris Brkljačić: Mammography, ultrasound and MRI are three modalities used for the detection of breast cancer. Mammography has been used for many decades, and the introduction of full flat panel digital mammography has enabled image acquisition with a lower radiation dose, and other advantages in image processing and biopsies. Mammography is used widely in breast cancer screening and has been validated through decades of screening. It is also the initial imaging method in women older than 40 and it enables the detection of microcalcifications, the early signs of ductal cancer in situ, and the majority of breast cancers, depending on the radiographic density of the breast. It can also be used to guide biopsy of microcalcifications. The denser the breasts are, the lower the sensitivity of mammography in detecting breast lesions, which is the disadvantage of mammography. The new mammographic method, digital tomosynthesis, improves the detection rate of cancer in dense breasts. Mammography exposes patients to radiation and is therefore not recommended in young women because their breasts are very radiosensitive.

Ultrasound is an imaging method that provides images based on the acoustic properties of tissues. The blood flow in lesions can be analysed by colour Doppler ultrasound, and elasticity of lesions can be analysed and quantified by sonoelastography. The advantage of ultrasound is that it is completely harmless; it does not expose patients to radiation, and is an excellent method for the guidance of biopsies of all sonographically visible lesions. Ultrasound can demonstrate cancers that are not visible in mammographically dense breasts, and is the complementary imaging modality to mammography, both in diagnosis and in screening. Some U.S. states legally oblige physicians to inform women about mammographic density and advise them of additional methods of examination in dense breasts. Among many advantages in ultrasound technology are the automated whole-breast ultrasound systems that have recently been introduced to the market. The disadvantage of ultrasound is that it increases the number of false-positive findings.

Magnetic resonance imaging (MRI) of the breast has gained considerable importance over the last two decades and is used more and more in breast imaging. It is used in high-risk screening, in the detection of occult cancer with positive lymph nodes, and in the evaluation of implants, and it is the best method for detecting the presence of and assessing the distribution and extent of cancer. It can also be used to monitor the success of neoadjuvant chemotherapy, and is an excellent method for looking for residual cancer or recurrence after treatment. MRI is relatively expensive and time consuming, although abbreviated MRI protocols have recently been introduced.

For treatment planning and monitoring it is very important to know the exact type and grade of cancer, and its immunohistochemical profile. Image guided biopsy is crucial in relation to that, and all imaging methods enable precise, image-guided biopsy to obtain an adequate sample from the breast cancer and other breast lesions.
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This year, the main theme of the International Day of Radiology is breast imaging. To get some insight into the field, we spoke to Dr. Ilse Vejborg, head of radiology at the University Hospital of Copenhagen, Rigshospitalet and head of the Capital Mammography Screening programme in Denmark.

European Society of Radiology: Breast imaging is widely known for its role in the detection of breast cancer. Could you please briefly outline the advantages and disadvantages of the various modalities used in this regard?
Ilse Vejborg: Mammography is a fast examination, showing the whole breast, if performed properly. Mammography has a high sensitivity to fatty tissue but the sensitivity can be compromised in dense breasts. Ultrasonography is an important supplementary examination which should be used in diagnostic examinations of women with palpable lumps or other symptoms in the breast. In experienced hands, ultrasound is the best examination for distinguishing a solid from cystic palpable lump but often also for evaluating whether the lump looks benign or malignant. Ultrasonography offers the possibility of evaluating the blood flow (Doppler) and stiffness (elastography) in a process and can be used to perform ultrasound-guided interventions.

MR Mammography has the highest sensitivity of all the imaging modalities but a more varying specificity; the latter is probably partly explained by the fact that in contrast to mammography screening, where high volume readers reading more than 5,000 examinations a year are mandatory, high volume readers of MR mammography are rarer.

ESR: Early detection of breast cancer is the most important issue for reducing mortality, which is one reason for large-scale screening programmes. What kind of programmes are in place in your country and where do you see the advantages and possible disadvantages?
IV: In Denmark we have nationwide, organised, population-based mammography screening. Mammography screening is offered every second year free of charge in the target age group of women aged 50–69 years. Mammography screening is the only imaging modality proven to reduce breast cancer mortality. It is a fast and inexpensive examination which can be performed without the presence of the physicians. In Denmark, all screening centres have digital mammography equipment and RIS and PACS systems.

Nationwide mammography screening in Denmark was implemented rather late compared to our Nordic neighbours and Denmark has had a higher mortality of breast cancer than the other Nordic countries. Mammography screening started in Copenhagen municipality in 1991, in the county of Fyn in 1993 and in the municipality of Frederiksberg (close to Copenhagen) in 1994. These programmes offering screening only to around 20% of the target population were for many years the only screening programmes in Denmark. Not until 2010 did we have a nationwide roll out of mammography screening.

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This year, the main theme of the International Day of Radiology is breast imaging. To get some insight into the field, we spoke to Dr. Viera Lehotská, Associate Professor and Head of the 2nd Radiology Department of the Faculty of Medicine Comenius University and St. Elizabeth’s Cancer Institute, Bratislava, Slovakia.

European Society of Radiology: Breast imaging is widely known for its role in the detection of breast cancer. Could you please briefly outline the advantages and disadvantages of the various modalities used in this regard?
Viera Lehotská: Mammography, including recent trends (e.g. tomosynthesis), is considered to be an essential, highly sensitive and representative method in the diagnostics of non-palpable breast lesions, especially those with the presence of microcalcifications. Based on this fact, mammography is generally accepted as the only proper method for active detection of breast cancer in the screening process. One disadvantage is the use of ionising radiation, and some patients might also consider the need for breast compression during imaging another disadvantage. But its contribution to the diagnosis of early stages of breast cancer significantly outweighs these limitations.

Ultrasound examination of the breast and the axilla serves as the main complementary method to mammography: for differentiation between cystic and solid lesions as well as for the elimination of occult lesions in dense breast glands. For younger women (under 40), pregnant women, or women during lactation, as well as for women with inflammatory breast disease or impaired mammary implants, ultrasound is used as the first choice examination method. Its benefit is not only its low cost but also its repeatability and non-risk character. Together with newer trends such as US-elastography and contrast-enhanced ultrasound (CEUS), it contributes to the assessment of lesions dignity (whether it is benign or malignant). It is very helpful in the follow-up of operated and irradiated breast and is therefore an important part of the monitoring of patients after surgery for breast cancer.

MR-mammography has strictly defined indications, which, if they are kept to, makes it a robust method. It has high sensitivity in the diagnosis of invasive breast carcinoma. Its specificity can be increased by using functional MRI methods such as diffusion-weighted imaging (DWI) and dynamic contrast-enhanced (DCE) MRI, and MR-spectroscopy. In addition, its potential is not only in the assessment of the extent of breast cancer (multiplicity, etc.) or in the assessment of early response to neoadjuvant chemotherapy, but also in its high sensitivity in high risk groups.

Interventional methods also play a very important role, whether under the MG-stereotactic, ultrasound or MR-navigation. Preoperative histologisation of breast lesions by standard vacuum-assisted biopsy or by the Intact BLES (Breast Lesion Excision System) is an indispensable part of the exact diagnosis of the character of breast lesions. Similarly, image-guided localisation techniques enable effective surgical treatment of breast cancer.

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This year, the main theme of the International Day of Radiology is breast imaging. To get some insight into the field, we spoke to Dr. Sophie Dellas, assistant professor of radiology and division head of breast imaging and diagnostics at the University Hospital Basel, Switzerland, and a core team member of the certified breast centre at the same institution.

European Society of Radiology: Breast imaging is widely known for its role in the detection of breast cancer. Could you please briefly outline the advantages and disadvantages of the various modalities used in this regard?
Sophie Dellas: Mammography is the imaging modality of choice for breast cancer screening, but also for diagnosis, evaluation, and follow-up of people who have had breast cancer. Long-term results of randomised controlled trials of mammography screening on average show a decrease in breast cancer mortality of 22% in women aged 50 to 74 years. The main problem of mammography is that it is not a perfect method. Mammography generates 2D images based on the density of tissue for penetrating x-rays. The compression of the breast that is required during a mammogram can be uncomfortable. The compression is necessary to reduce overlapping of the breast tissue. A breast cancer can be hidden in the overlapping tissue and not visible on the mammogram. This is called a false negative mammogram. Mammography is associated with a false negative rate in the order of 10% to 20%. On the other hand, mammography can identify an abnormality that looks like a cancer, but turns out to be normal. This is called a false positive mammogram. Besides worrying about being diagnosed with breast cancer, a false positive means more tests and follow-up examinations. Furthermore, at least some of the cancers found with screening mammography would never otherwise be diagnosed in a patient’s lifetime. The magnitude of such overdiagnosis is a topic of much debate. It is likely to represent up to 10% of breast cancers found on screening mammography and results in potentially unnecessary treatments.

Breast ultrasound is complementary to both mammography and magnetic resonance imaging (MRI) of the breast. It does not use radiation. It is therefore the initial diagnostic method of choice if breast imaging is required below the age of 40. It allows the confident characterisation of not only benign cysts but also benign and malignant solid masses and the characterisation of palpable abnormalities. The high spatial and contrast resolution of modern breast ultrasound equipment allows the detection of subtle lesions at the size of terminal duct lobular units such as DCIS and small invasive cancers. In women with dense breasts and a negative mammogram, ultrasound therefore is increasingly used as a supplemental screening tool. The major disadvantage of ultrasound as a screening tool is the high risk of false positive findings resulting in unnecessary biopsies. The rate of false positives is much higher with screening ultrasound than with mammography or screening MRI.

Unlike mammography, MRI of the breast does not use radiation. It is safe even though it does require an intravenous injection of a contrast medium. It has a sensitivity exceeding 90% for detecting breast cancer and is superior to mammography and ultrasound. Annual MRI screening is recommended for women with a high lifetime risk of getting breast cancer. Although breast MR imaging is extremely sensitive, its specificity is limited, leading to additional workups and benign biopsies. Good quality breast MR imaging is expensive, time-consuming, and not universally available. Patients with pacemakers, certain aneurysm clips or other metallic hardware, an allergy to contrast agents, or severe claustrophobia are unable to undergo MR imaging.

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An interview with Joanna Fairhurst, consultant paediatric radiologist at the children’s radiology department of the University Hospitals of Southampton.

European Society of Radiology: What is paediatric imaging? What age are the patients, and how is it different from regular imaging?
Joanna Fairhurst: Paediatric imaging covers all imaging modalities – plain films, ultrasound, fluoroscopy, computed tomography (CT), nuclear medicine, magnetic resonance (MRI) – undertaken in children ranging from new-born infants to those who are sixteen, or in some centres eighteen, years old. Imaging patients in this age range poses some very specific challenges. First, coming to the hospital can be a very frightening experience for young children, and we need to adapt our techniques to help children feel as secure and comfortable as possible, and we often employ distraction and play therapy to reduce their anxiety and help them cooperate with their examinations. We also try to create a child-friendly environment, by decorating our department and providing toys, but the best way to make our young patients feel at ease is to have radiographers and radiologists who are experienced in, and enjoy working with children.

The next main difference between paediatric and adult radiology is that we have to be familiar with the imaging appearances of the developing patient – from pre-term infant to adolescent – including many normal developmental variants. We also have to deal with many diseases and pathologies that are specific to children. Unlike other subspecialties within imaging, although some do specialise, most paediatric radiologists are involved with all modalities and all body systems.
Finally, when we image children, we not only have to communicate with young people: very often we also have to interact with their parents and carers, so we must learn to respond to their concerns and needs as well.

ESR: Since when has paediatric imaging been a specialty in its own right?
JF: It could be argued that paediatric radiology is the oldest imaging specialty, dating back to the use of x-rays and the interpretation of the images produced in children’s hospitals in the early 1900s. Many people, however, consider Dr. John Caffey (1985–1978) as the ‘founder’ of paediatric radiology after he published his book Pediatric X-Ray Diagnosis in 1945. Paediatric imaging gained broader recognition in the United States with the founding of the Society for Pediatric Radiology in 1958, and came of age in Europe with the creation of the European Society of Paediatric Radiology in 1963.

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guest post by Benjamin Taragin

I have always been fascinated by LEGO®. There is something soothing about raking the pile with your hands, trying to find the perfect piece to complete your next build. It was with this mindset that I was helping my son, Yoni, build one of his projects (clearly there is no pleasure in this for me ;)). As we were working with the LEGO pieces, I came across a curved semicircular piece and realised that it reminded me of the bore opening of an MRI. With that thought in my head, my son and I began to build our initial LEGO MRI model. After building it, I realised that this might actually be useful for our child life division at the Children’s Hospital at Montefiore, spearheaded by Susan Frank and Meghan Kelly, to use when prepping patients for MRI. While many simulators exist on the market, some large and some small, none are built with the basic blocks of childhood. Additionally, its small size and portability allows it to be carried around the hospital in a regular work bag.

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Dear Friends,

To mark the International Day of Radiology, which this year is focusing on paediatric imaging, we are presenting chest radiographs of a 5-year-old boy with an abdominal mass and mild fever. A Wilm’s tumour was suspected. Check the images below, leave your thoughts in the comments section and come back for the answer on Friday.

Diagnosis.

1. Pleural tumour in fissure
2. Pneumonia
3. Metastases
4. None of the above

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The ESR spoke with Manuela Messmer-Wullen, president of the Austrian Stroke Self-Help Association (SHÖ) and liaison officer for the Stroke Alliance for Europe (SAFE), about the long-term effects of stroke, how it can be prevented and how imaging can help provide a crucial time-saving diagnosis.

ESR: What is the overall aim of your organisation in Austria and what exactly do you do to achieve this goal?

Manuela Messmer-Wullen: Our mission is to inform the public about the burden of stroke, inform them on how to prevent stroke and support those who have been affected by stroke with information regarding their rehabilitation. We also provide support for carers, as well as information on where to find the right rehabilitation facilities, medical support, access to treatments, etc. We lobby, in general, for a better situation for stroke patients and their carers, to give them all a voice in the Austrian healthcare system. I do this work on a voluntary basis, without financial support from the state; projects are financed by individual funders. My personal investment of knowledge, time, energy and power is made in an effort to give stroke patients and their carers a better quality of life in Austria.

ESR: How many members do you have? Who are they?

MMW: In several Austrian states there are different groups run by individuals, therapeutic staff and medical professionals. SHÖ is the umbrella organisation for stroke patients and its membership is made up from many different patient groups who support their members across the country and within different fields.

ESR: Stroke affects an increasing number of people worldwide. Do you think current Austrian health policies are well suited to tackling the issue?

MMW: Not at all, there is no special information pointing out that stroke itself is a brain attack. Stroke is often obscured by the term ‘cardiovascular disease’. This term is used by the media for simplicity and much of the public is unaware that it includes stroke. It would be more helpful to use the individual terms, stroke and heart attack more often. The public has to be informed about the danger of stroke and its possible consequences, like disability. Stroke affects the brain and can damage a lot of functions. Most people have no idea about these facts. Once they have this basic information about stroke, we can start educating them on how to prevent it. Stroke is the only brain disease that can, in certain circumstances, be prevented. People need to be informed of the necessary lifestyle changes.

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The ESR spoke with Donna Walsh, executive director of the European Federation of Neurological Associations (EFNA) about how her organisation supports patients with brain disorders and how well patients are informed about the role of radiology in neurology.

European Society of Radiology: What is the overall aim of your organisation and what exactly do you do to achieve this goal?

Donna Walsh: The European Federation of Neurological Associations (EFNA) is an umbrella group representing pan-European neurology patient groups. Our slogan, ‘empowering patient neurology groups,’ encapsulates our goals as an association. We strive to add capacity to our members, allowing them to be the most effective advocates possible in their own disease-specific areas. EFNA embraces the concept of partnership for progress: working at a high level with relevant stakeholders from the fields of policy, medical, scientific/research, industry, patient partners and other key opinion leaders.

ESR: How many patient organisations do you represent? How many members do you have? Who are they?

DW: EFNA is an umbrella organisation comprising 19 predominantly pan-European disease-specific neurology patient organisations. These are Dystonia Europe, Euro-Ataxia, European Alliance for Restless Legs Syndrome (EARLS), European Alliance of Neuromuscular Disorders Associations (EAMDA), European Headache Alliance (EHA), European Huntington’s Federation (EHF), European Multiple Sclerosis Platform (EMSP), European Myasthenia Gravis Association (EuMGA), European Network for Research in Alternating Hemiplegia in Childhood (ENRAH), European Polio Union, European Sexual Health Alliance (ESHA), Guillain-Barre & Associated Inflammatory Neuropathies (GAIN), International Brain Tumour Alliance (IBTA), International Bureau for Epilepsy (IBE), Motor Neurone Disease Association (MND) – Europe, Pain Alliance Europe (PAE), Progressive Supranuclear Palsy Association – Europe (PSP-Europe), Stroke Alliance for Europe (SAFE) , Trigeminal Neuralgia Association UK. As you can see, there are also some national organisations who are associate members and some international groups, in the absence of a pan-European association.

ESR: What are the most common brain diseases in Europe?

DW: Brain disorders are very common and will affect one in three of us during our lifetime. They range from very prevalent disorders such as migraine (affecting up to 15% of the population) to very rare disorders. Most people will have heard of multiple sclerosis, dementia, Parkinson’s disease, epilepsy, stroke, etc. But people often forget that sleep, mood, anxiety, addiction and eating disorders are also disorders of the brain. So brain disorders range from the genetic to the degenerative to the muscular and beyond!

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Nicola Bedlington is executive director of the European Patients’ Forum (EPF) and chairperson of the ESR’s Patient Advisory Group for Medical Imaging (PAGMI). The goal of PAGMI is to bring together patients, the public and imaging professionals in order to positively influence advances in the field of medical imaging to the benefit of European patients. The group has contributed to the International Day of Radiology, which aims to raise public awareness of the benefits of medical imaging and has promoted the ESR’s patient information website. We asked Ms. Bedlington for her views on healthcare in the EU and why she chose to participate in the International Day of Radiology.

What is the overall aim of your organisation?
Nicola Bedlington: Our vision is high quality, patient-centred and equitable healthcare for all patients throughout the European Union. The European Patients’ Forum is an umbrella organisation that works with patient groups in public health and health advocacy across Europe. Our members represent specific chronic disease groups at EU level, or are national coalitions of patients. We currently represent almost 60 such organisations. Our mission is to be the collective patients’ voice at EU level, manifesting the solidarity, power and unity of the EU patients’ movement, and to provide a strong and united voice in order to put patients at the centre of EU health policy and programmes. In this regard we are the key interlocutor with EU institutions on cross-cutting issues affecting all patients.

What exactly does your organisation do to meet this aim?
Nicola Bedlington: The EPF helps to empower patient organisations through educational seminars, policy initiatives and projects. We coordinate best practice exchanges between patient organisations at European and national levels. Our programmes also help to strengthen organisational and advocacy capacity.

Your organisation has experience working with various chronic disease groups. Do many patients suffer from chronic diseases in the EU?
Nicola Bedlington: Following consultation with our members we estimate there are at least 150 million patients with chronic conditions across the European Union. This figure is likely to increase given the ageing population.

Many EU countries face significant health budget cuts, leading to shorter hospital stays and less access to modern equipment (i.e. long waiting lists for MRI exams). How can better patient care be promoted?
Nicola Bedlington: The EPF is working with its member organisations to ensure health is seen as an investment, and patients are not perceived as purely cost drivers. Major health inequalities exist across the EU which impact enormously on patient access to care. Building on the three pillars of quality information, health literacy and empowerment, patients can be agents of change and sources of innovation, particularly in terms of equity and sustainability of care. There need to be meaningful opportunities for patient involvement throughout the healthcare sector. We promote meaningful patient involvement in all forms of innovation, whether it is in high or low technology, pharmaceuticals, information technology, social change or systems change. The patient community seeks partnerships with researchers, policy-makers and industry in order to achieve greater impact in this arena.
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