Drs García ,Vega and Graells, excellent radiologists at Hospital Universitario Dr Peset, musculo-skeletal section
Dear friends,
Today, I am going to show you a case provided to me by Dr Luis García ( A European Diploma holder).
This is not a very complicated case, but may underline a not very well known clinical scenario.
Professor Paul Sidhu is Professor of Imaging Sciences at King’s College London and consultant radiologist at King’s College Hospital, where he helped pioneer contrast-enhanced ultrasound (CEUS), a technique that can potentially be used to image children just as well as adults, in reduced time, and without the downsides of radiation and toxicity. Professor Sidhu will make the case for CEUS use in paediatric radiology today during the Luigi Oliva Honorary Lecture.
There is no question that ultrasound is the most child-friendly imaging technique. The modality has countless benefits for young patients: no ionising radiation, no sedation or anaesthesia, and ease of use, to name a few. “Ultrasound is the most suitable modality for imaging children, as they don’t have to stay still. Parents can be present during the examination to support their child. The radiologist can stop and start the examination without losing information, plus children have low body fat and are better suited to ultrasound,” Sidhu said.
Professor Paul Sidhu from King’s College London will argue for CEUS use in paediatric radiology in today’s Luigi Oliva Honorary Lecture.
Adding a contrast agent to ultrasound has been shown to improve diagnosis tremendously in applications where vascularity or haemo-dynamics must be assessed in real time. With CEUS, in the case of focal liver lesions, which are often difficult to characterise in adults and children on B-mode ultrasound alone, essential information from the arterial and portal venous phases aids diagnosis in minutes without needing CT or MR imaging. This alone should be a decisive argument for widespread CEUS use in the paediatric population, Sidhu explained.
“The combination of contrast with ultrasound allows for a more detailed assessment of the pattern of vascularity and dynamics in a continuous fashion for three to five minutes in real time, and it can be repeated as many times as necessary. The child does not need to keep still, and all the same focal liver characteristics seen in the adult are seen in the child. The ability to come to a clear diagnosis, with a single imaging examination is a great relief for the parents, often present with the child during the examination, rather than remote as with CT or MR imaging,” he said.
With CEUS, radiologists can obtain a lot of information in the first five minutes following the injection, the time window that the contrast agent lasts in the blood pool. This is more than enough to carry out the examination and make a conclusion. The technique can be used in every possible scenario from trauma to disease imaging, with great results. “Imaging with ultrasound in children is the most useful and informative procedure,” Sidhu concluded. Read more…
African radiologists will share their knowledge and experience of medical imaging practice in their respective countries, today during the ‘ESR meets Africa’ session. Examples of cooperation with the European Society of Radiology will be presented, notably in radiation protection, a field where efforts between Europe and Africa are starting to pay off.
Africa is big, diverse and full of possibilities. Its myriad of countries (54), languages, cultures and economic scenarios offers unmatched potential, but it can also complicate the organisation of radiology.
Prof. Dina Husseiny Salama and Prof. Hassen Gharbi, together with ESR President Prof. Lorenzo E. Derchi and Prof. Guy Frija, Chair of EuroSafe Imaging, surrounded by delegates at the 5th African Society of Radiology conference in January 2019, in Cairo, Egypt.
Equipment and workforce tend to vary considerably from one country to another. For example, the radiologists’ ratio ranges from 1 to 80 per million population, depending on the country.
“Our main challenges are in training and the implementation of national legislation that can help organise the field, especially regarding radiation protection,” said Prof. Hassen Gharbi from Tunis, Tunisia, who will co-chair the session with ESR President Lorenzo Derchi from Genoa, Italy.
Technological advances have opened new horizons for the application of ionising radiation in healthcare all around the world and this has led to an increase in medical imaging procedures using radiation, also in Africa.
Unlike most of the continent, Tunisia, Algeria and Morocco have dedicated guidelines on ionising radiation use. But even there, rules must be implemented to help healthcare professionals prescribe examinations adequately.
“There is a growing need for structured strategies and a holistic approach towards the full integration of radiation safety and clinical imaging guidelines in Africa,” said Prof. Dina Husseiny Salama from Cairo, Egypt. Read more…
Michael Grace Kawooya is a Professor of Radiology at the Ernest Cook Ultrasound Research and Education Institute and Professor Emeritus at the Makerere University College of Health Sciences in Kampala, Uganda. He has done much for the development of radiology in his country and the rest of Africa, but says efforts must continue to increase the number of radiologists and range of equipment, and to raise awareness of radiation safety. Kawooya believes Africa can learn a lot from European advances. His contributions to improving bilateral cooperation will be rewarded today as he receives ESR Honorary Membership.
Professor Michael G. Kawooya’s contributions to improving bilateral cooperation between Africa and Europe will be rewarded today as he receives ESR Honorary Membership.
ECR Today: How much has radiology advanced in Uganda?
Michael Grace Kawooya: Back in the late 1980s, radiology was very new to medical practice in Uganda, and its contribution to healthcare was not well understood. It was not given priority and was underfunded. There were only two radiologists in the country when I finished my residency and we were overwhelmed with work. Doctors were not willing to undertake radiology residency, fearing that radiologists didn’t earn much. Equipment was scanty and often malfunctioning. Many of these challenges still exist today, but to a lesser extent. Radiology is better understood and its role is now evident. The number or radiologists has increased to almost 70. This year alone, 20 doctors took up radiology residency. The number and range of equipment has also increased.
ECRT: Are there any regional trends in radiology in Africa?
MGK: The same challenges facing radiology in Uganda bedevil most of Africa, but North Africa, which is largely Arabic, and South Africa, which is wealthier, face fewer challenges. In these parts of Africa, radiology has flourished more compared to Central, East, and West Africa. The radiologist-to-population ratio is approximately 1:67,000 in Egypt, 1:1,600,000 in Uganda and 1: 8,000,000 in Malawi. The more affluent regions have higher numbers and range as well as sophistication of imaging equipment. They have more radiology training institutions and undertake more research. Read more…
Professor Federico G. Lubinus is full professor of radiology and director of the radiology residency programme at the autonomous university of Bucaramanga (UNAB) in Colombia. He is one of the leaders in South American radiology and he believes that bringing back ultrasound to the heart of radiological practice is key to the future growth of the specialty. His efforts will be acknowledged today as he receives ESR Honorary Membership.
When it comes to radiology, South America has very similar challenges to the rest of the world and a number of regional trends, Lubinus explained. “Big workloads, turf battles with other medical specialties, and challenges imposed by teleradiology and artificial intelligence are some of the many difficulties we have to deal with, not only as radiological societies but also as radiologists wondering about the role of the specialty in the near future,” he said.
Professor Federico G. Lubinus, who will receive ESR Honorary Membership at today’s Grand Opening, is one of the leaders in South American radiology.
But radiology practice in the continent is uneven and a major difference concerns radiology training, according to Lubinus, who currently heads the Latin American Educational Forum, a group that brings together radiological societies of South America to develop and advance educational issues in the region. “Training is dependent on the regulations of each country. There is great diversity both in the number of years of study required to be a specialist and in the minimum requirements demanded in each country, which makes it difficult to standardise programmes and perform appropriate evaluation of knowledge,” said Lubinus.
Lubinus is also director of the scientific committee of the Asociación Colombiana de Radiología (ACR), a society he served twice as president. Under his aegis, the ACR worked to have a standardised training programme, a tool that is now recognised by the Colombian ministry of education as the basis for evaluation and certification of radiology graduates, and radiologists who have received their certification abroad.
For the past four years, the Latin American Education Forum has also engaged in developing a standardised academic residency programme as a reference instrument for the validation of qualifications of Latin American radiologists, to improve the much needed certification and recertification in radiology.
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.
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.
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.
Read more…
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.
Dr. Ilse Vejborg, head of radiology at the University Hospital of Copenhagen, Rigshospitalet and head of the Capital Mammography Screening programme in Denmark.
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.
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.
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.
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.
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.
Dr. Sophie Dellas, assistant professor of radiology and division head of breast imaging and diagnostics at the University Hospital Basel, Switzerland.
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.
Watch this session on ECR Live: Friday, March 8, 16:00–17:30, Room F1
The global demand for medical imaging examinations has been growing rapidly over the past decade. Sustaining a workforce to match demand is becoming a challenge, as an increasing number of hospitals are facing a shortage of radiologists. Some countries have filled the gap by allowing radiographers to perform and interpret ultrasound examinations independently, to relieve the pressure on staff. This option continues to divide the European radiological community, and many seem to be against delegating a medical act to non-doctors. However, new educational opportunities and radiographers’ growing interest in medical science are challenging this concept, a panel of radiographers will show during a Special Focus Session chaired by a radiologist and a radiographer at ECR 2013.
Dean Pekarovic from the University Hospital of Ljubljana, Slovenia.
Ultrasound is a widely available modality and many medical specialists are using it without the help of radiologists, sometimes without sufficient knowledge and to the detriment of patients. However, radiographers who have received proper theoretical and clinical training know how to best use the modality and read images correctly, according to Dean Pekarovic, a radiographer at the University Hospital of Ljubljana, Slovenia, and member of the advisory board of the European Federation of Radiographer Societies (EFRS). “Ultrasound is a very competitive field, everybody wants to use it. But not everyone has the ability to perform an examination and interpret images appropriately. Radiographers with specific training are able to carry out such examinations and can even write reports on their own,” he said.
