{"paper_id":"b58092ed-3433-4963-a8a4-2671027b73ae","body_text":"S1\nAbstracts\nA\nB\nC\nD\nE\nF\nG\nPostgraduate Educational \nProgramme\nScientific Sessions \nScientific and Educational \nExhibits 323\n127\n325\n337\n373\n393\n3\nSatellite Symposia\nAuthors’ Index\nList of Authors & \nCo-Authors\nList of Moderators\nSession numbers are prefixed by CC, E3, EF, EM, HL, MC, MS, NH, OL, \nPC, RC, SF, SA, TF\nPresentation numbers are prefixed by the letter A\nSessions and abstracts are listed by days.\nPresentations for which the author(s) have submitted additional material and images to \nEPOS™ are marked with the  icon.\nSession numbers are prefixed by  SS\nPresentation numbers are prefixed by the letter B\nSessions and abstracts are listed by days.\nPresentations for which the author(s) have submitted additional material and images to \nEPOS™ are marked with the  icon.\nAbstracts and authors of EPOS™ presentations no longer appear in the Book of Abstracts. \nEach full EPOS™ presentation can instead be cited by a Digital Object Identifier (DOI) which \nappears with the presentation at www.myESR.org/EPOS\nPresentation numbers are prefixed by the letter D\nThis part lists all first authors (including co-authors) and presentation titles, followed by the \nsession number/topic header/identifyer in brackets and the presentation number. \nThis part lists all authors and co-authors followed by the presentation number in italic letters.\nThis part lists all moderators followed by the session number in italic letters.\nDOI 10.1007/s -0 0-0 1 -\nInsights Imaging\n13244 1 0 0 2\n\nThe ECR 2010 Book of Abstracts is a supplement to Insights into Imaging.\nISSN: 1869-4101\n© ESR – European Society of Radiology, 2010\nAll articles published herein are protected by copyright, which covers the exclusive rights to reproduce and distribute the articles, as well all translation rights. No material \npublished herein may be reproduced or stored electronically without first obtaining written permission from the publisher. The use of general descriptive names, trade names, \ntrademarks, etc., in this publication, even if not specifically identified, does not imply that these names are not protected by the relevant laws and regulations.\nWhile the advice and information in this publication is believed to be true and accurate at the date of publishing, neither the authors, the editors, nor the publisher can accept any \nlegal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein.\nESR accepts no responsibility for errors or misprints.\nThe Book of Abstracts is printed on environment-friendly paper.\nPrinted by Holzhausen, Vienna, February 2010\n\nS3\nA\nPostgraduate \nEducational Programme\nCategorical Courses (CC)\nEFOMP Workshop (EF)\nESR Audit Session\nESR meets Sessions (EM)\nEuropean Excellence in Education (E³)\nHonorary Lectures (HL)\nJoint Session of ESR and EC  \n(European Commission)\nMini Courses (MC)\nMultidisciplinary Sessions (MS)\nNew Horizons Sessions (NH)\nOpening Lecture (OL)\nProfessional Challenges Sessions (PC)\nRefresher Courses (RC)\nRTF - Radiology Trainees Forum (TF)\nSpecial Focus Sessions (SF)\nState of the Art Symposia (SA)\nThursday ...................... 5\nFriday ......................... 17\nSaturday ..................... 45\nSunday ....................... 71\nMonday .................... 103\n\nPostgraduate Educational Programme\nS4\n A B C D E F G\n\nThursday\nPostgraduate Educational Programme\nA\n S5\nCB D E F G\nThursday, March 4\n\nPostgraduate Educational Programme\nS6\n A B C D E F G\n14:00 - 15:30 Room E2 \nInteractive Teaching Session \nE³ 120 \nImaging in common clinical problems:  \nSoft tissue tumors \nModerator:\nR. Arkun; Izmir/TR \nA‑001 14:00 \nImaging in common clinical problems: Soft tissue tumors \nJ.L. Bloem1, A.M.A. de Schepper2; 1Leiden/NL, 2Antwerp/BE (j.l.bloem@lumc.nl) \nImaging is essential in diagnosis, grading, staging, and therapy monitoring of soft \ntissue tumors. Typically, a patient presents with a clinically detected soft tissue lump. \nIn a general practice, benign tumors and tumor-like lesions are 100 times more \nfrequent than malignant ones. This makes US a cost-effective first imaging method. \nNormal variants, non-neoplastic lumps (cysts, pos-traumatic lesions, muscle hernia-\ntion) and benign lesions (subcutaneous lipoma) can often be diagnosed. US is also \nused to guide needle sampling for cytology or histology. If the lesion does not allow \na specific US diagnosis, is larger than 3 cm, and/or is located deep to the fascia, \nlow threshold MR is indicated. Dynamic Gd-enhanced MR has the highest accuracy \n(80-90%) in differentiating (grading) benign from malignant lesions. Benign lesions \noften have specific signs allowing a tissue specific MR diagnosis with high sensitiv-\nity (75%). A tissue specific diagnosis often cannot be made in malignant lesions \n(sensitivity 37%). Criteria for malignancy are: no tissue specific benign diagnosis \ncan be made, size > 3 cm, located deep to fascia, liquefaction, early peripheral \nenhancement, inhomogeneous SI on T1 weighted images. Educational cases will \nbe staged during the session, addressing concerns of surgeons. Parameters that \nare useful or worthless in monitoring therapy and detecting recurrences will be \ndemonstrated in typical cases. \nLearning Objectives:\n1. To know when and how to use US and MR in making a tissue specific \ndiagnosis.\n2. To be able to use imaging criteria in differentiating benign from potentially \nmalignant soft tissue tumors with high accuracy (grading).\n3. To learn how to use MR in staging, monitoring therapy and detecting \nrecurrence.\n16:00 - 17:30 Room B \nRadiology of the Spine in 2010 \nCC 216 \nBack to basics: Protocols for the spine \nModerator:\nI. Cravo; Lisbon/PT \nA‑002 16:00 \nA. The role of the plain films \nJ.-L. Drapé; Paris/FR (jean‑luc.drape@cch.aphp.fr) \nPlain films of the spine remain widely performed. Radiologists must be aware of the \nquality criteria, diagnostic value and limitations of spinal plain films. Radiographs are \nmost often the first imaging examination in a patient with clinical symptoms (pain, \nradiculalgia) related to the spine. Radiographs still play an important and prelimi-\nnary role as an easy screening tool in degenerative disk disease. They are cheap, \nuniversally available, and offer a good panoramic view of the lumbar spine, adding \nmeaningful details on bone structures and the stability of the spine. Functional \ndynamic radiography remains the gold standard for the assessment of lumbar insta-\nbility. Because of its simplicity, low cost, and availability, functional flexion-extension \nradiography is the most thoroughly studied and the most widely used method in \nthe imaging diagnosis of lumbar intervertebral instability. Full spine radiographs are \nmandatory in patients with scoliosis. In seronegative spondyloarthropathies, spinal \nradiographs remain useful; however, they are unable to detect early inflammatory \nchanges of the spinal entheses, which are important for establishing a diagnosis \nand treatment without delay. In a patient with cervical spine trauma, plain films are \nof limited value and the analysis of the craniovertebral junction and upper cervical \nspine is often very difficult. For the diagnosis of myeloma, spinal metastases and \nspinal tumors plain films are complimentary to MRI and CT and basically play a \nmuch less significant role because of a lack of sensitivity. Radiographs are also of \nlimited value in the early diagnosis of a spinal infection. \nLearning Objectives:\n1. To be knowledgable about normal and abnormal findings on plain films of \nthe spine.\n2. To become familiar with the most common “pitfalls” in reading plain films of \nthe spine.\nA‑003 16:30  \nB. CT protocols for the spine \nB. Tins; Oswestry/UK (Bernhard.Tins@rjah.nhs.uk) \nCT is the examination of choice for the assessment of the bone structure of the \nspine. It is fast and tolerated by almost every patient. The choice of imaging pa-\nrameters and also the reconstruction algorithm and the mode of display can make \na significant difference to the perceived image quality and diagnostic accuracy. \nWhile generally a robust imaging method, artefacts can occur in CT imaging. In \nparticular, movement artefact and streak artefact can cause a problem for image \ninterpretation. Ways to minimize or limit these artefacts will be discussed. Generally \nimprovement in image quality results in an increased radiation dose and longer \nimaging times. Depending on the clinical question, the imaging parameters should \nbe varied accordingly. Usually, a common sense approach is all that needed to \nmake CT imaging of the spine a relatively simple and highly reliable examination. \nLearning Objectives:\n1. To describe state-of-the-art CT protocol for the spine.\n2. To become familiar with technical factors (acquisition, reconstruction) and \nparameters for CT examinations of the spine.\n3. To recognise artifacts and errors in analysing CT of the spine.\nA‑004 17:00 \nC. MR protocols for the spine \nJ. Hodler; Zurich/CH \nMR imaging of the spine is commonly performed with a number of different indi-\ncations. Accordingly, imaging protocols vary. Most protocols include T1- and T2-\nweighted spin-echo sequences in the sagittal plane, T2w (often also T1w) images \nin the transverse plane or a plane angled into the disk spaces. Coronal images may \nbe obtained for imaging of scoliosis, the atlanto-occipital and the sacral regions. \nAngled sagittal images may assist in the evaluation of the intervertebral foramen in \nthe cervical spine. STIR sequences are employed for sensitive detection of radio-\nlogically occult fractures, screening for metastasis and infection and for grading in \nsystemic inflammatory disease. Gradient-echo sequences are most commonly used \nin the cervical spine, often with T2*-weighting, in order to deal with flow artefacts \nand to obtain 3D data sets. Gadolinium-containing contrast is typically indicated \nin infection and neoplasm. Other types of contrast material such as USPIOs are \nnot commonly reported but may contribute to the diagnosis in equivocal cases. \nWhole-body MR imaging has become more easily available due to multichannel \nscanners and dedicated software. There is an increasing role for such imaging in \ndetection and staging of inflammatory diseases such as ankylosing spondylitis. \nDiffusion-weighted imaging appears to be promising in differentiating neoplastic \nfrom non-neoplastic fractures. Spectroscopy has rarely been employed for imaging \nof paraspinal muscles and may rather be of scientific interest. \nLearning Objectives:\n1. To become familiar with the latest MR techniques in MR imaging of the spine.\n2. To implement fast and robust clinical MR protocols for comprehensive \nassessment of the spine.\n3. To define the role of contrast media in evaluation of the spine.\n\nThursday\nPostgraduate Educational Programme\nA\n S7\nCB D E F G\n16:00 - 17:30 Room C \nSpecial Focus Session \nSF 2 \nOptimal imaging of muscle pathology \nModerator:\nC. Martinoli; Genoa/IT \nA‑005 16:00 \nChairman’s introduction \nC. Martinoli; Genoa/IT (carlo.martinoli@libero.it) \nMuscle imaging is inherently complex and presents unique morphologic challenges \nand continuing integration of dynamic, physiologic and functional capabilities as \nimaging technology progresses. After an overview of the most advanced techniques \nfor morphologic and functional imaging of the skeletal muscle, such as whole body \nMR imaging, 23Na MR imaging, metabolite quantification in MR spectroscopy and \ncontrast-enhanced ultrasound, this session will be focused on the optimal use of \nmodern imaging in a variety of muscle disorders, including sport-related condi-\ntions, tumours and non-neoplastic masses, ischemic and inflammatory diseases. \nSpeakers will present critical views on the various imaging modalities, to find the \nstrengths and the weaknesses of the techniques, and will embrace controversial \nissues regarding the diseases or the technology. In doing so, this session will help to \nunderstand the appropriate place of modern imaging in the clinical management of \npatients with muscle disease. At the end, a panel discussion will give the occasion \nto draw perspectives and expectations for muscle imaging between morphology \nand function, and to provide an outlook to the future in this field. \nSession Objectives:\n1. To provide an overview of the state-of-the-art imaging of muscle pathology.\n2. To learn about functional, dynamic, contrast-based and other new techniques \nimaging of muscles.\n3. To review the clinically relevant features of muscle imaging.\nA‑006 16:03 \nAdvanced techniques in MRI and functional imaging of muscle, dynamic \nultrasound and contrast agents \nM.-A. Weber; Heidelberg/DE (MarcAndre.Weber@med.uni‑heidelberg.de) \nImaging of skeletal muscles has seen considerable advances in recent years \nregarding both morphological as well as functional imaging techniques. Regarding \nmorphology, the advent of whole-body MRI has rendered the possibility to screen the \nwhole skeletal muscle system for muscles with oedematous changes in suspected \nmyositis to which a biopsy should be guided in order to reduce the sampling error. \nFunctional MR methods are available that can visualize different aspects of mus-\ncular (patho)physiology, such as muscular sodium (Na\n+) homeostasis using 23Na \nMRI, muscular energy and lipid metabolism using 31P and 1H MR spectroscopy. 31P \nMR spectroscopy also allows for quantification of the myocellular pH value. 23Na \nMRI has demonstrated its usefulness in the diagnostic work-up and management \nof patients with muscular Na+ channelopathies, where a myocellular Na+ overload \nthat causes muscle weakness can be quantified. Besides MRI, contrast-enhanced \nultrasound (CEUS) methods have also been introduced that can quantify muscular \nmicrocirculation at rest and even during exercise using a second generation contrast \nagent. Using this CEUS method, the influence of different exercise intensities on \nthe microcirculation of the exercising muscle becomes detectable. Also, CEUS \nis more efficient in the diagnostic work-up of suspected myositis than classic \ngreyscale ultrasonography, because CEUS can detect the inflammatory-induced \nmuscular hyperperfusion in acute myositis. It becomes obvious that modern mus-\ncular imaging techniques offer deeper insights in muscular (patho)physiology than \njust detecting unspecific myopathic manifestations like oedematous or lipomatous \nchanges, hyper- or atrophy. \nLearning Objectives:\n1. To learn about recent MRI and US methods for assessing skeletal muscles.\n2. To appreciate the abilities of these methods in normal and diseased skeletal \nmuscles.\n3. To understand the limitations of these methods.\nA‑007 16:23 \nSports-related muscle injuries: Temporal changes and when to return to play \nD. Connell; Stanmore/UK (davidconnellrad@gmail.com) \nA thorough understanding of muscle anatomy and basic pathophysiology is es-\nsential for imaging interpretation. Muscle fibres (myofibrils) usually tear away from \nconnective tissue elements, either the surrounding epimysial fascial covering or \nfrom the central tendon slip. This may result in a gap or defect within the muscle \nwith the formation of oedema and blood fluid products. Recognising muscle injury \nand discriminating central tendon injury from epimysial tears is important. It is also \nimportant to exclude tendon-bone avulsion from muscle strain. Temporal changes \nfollowing muscle injury follow an orderly pattern and can be observed with both MRI \nand ultrasound. Changes include the resolution of blood fluid products, decrease in \noedema and the formation of scar tissue. The superior contrast resolution of MRI \nmakes it a better modality for detecting the formation of granulation and maturing \nscar tissue. Despite the player becoming rapidly asymptomatic, pathologic changes \ncontinue for some time. Complications of muscle healing include chronic haematoma \nand myositis ossificans. A weak predictor of return to sporting activity is the amount \nof haematoma. More reliable predictors of return to play include the craniocaudal \nlength and cross-sectional area of the muscle tear. Muscles healing involves scar \nformation which in turn limits the ability for the muscle to passively stretch, and \nplaces additional stress on adjacent muscle fibres predisposing to further injury. \nRisk factors for recurrent injury have been identified and these include a previous \ntear greater than 60 mm in craniocaudal length and a past history of an ACL sprain. \nLearning Objectives:\n1. To understand the appearance of muscle injury in US and MR imaging.\n2. To provide information on how to assess severity and prognosis.\n3. To estimate the time it takes for an athlete to return to play and to modify the \nrehabilitation regimen based on imaging findings.\nA‑008 16:43 \nIschemic and inflammatory conditions: What we can see and what is \nimportant for the clinician \nA. Cotten; Lille/FR (acotten@chru‑lille.fr) \nInflammatory conditions of muscles are uncommon. These disorders include the \nthree main types of chronic, or persistent, inflammatory myopathy: polymyositis, \ndermatomyositis and inclusion body myositis. Myositis can also be found in other \nautoimmune, granulomatous, vasculitic, and systemic disorders. The diagnosis may \nbe highly suggested by the clinical and biological features and imaging is therefore \nused for the assessment of the extent and number of lesions, and for determining \nthe right site for biopsy. However, the clinical and biological presentation of these \ndisorders may be unusual. In these cases, ultrasound and MRI may represent a \nuseful complementary diagnostic tool. Other conditions can be associated with \nimaging features that may mimic the appearance of myositis; the usefulness of \nimaging for differentiating these disorders will be presented. Muscle infarction, which \nis a rare complication of diabetes mellitus, will also be described. \nLearning Objectives:\n1. To learn about the main ischemic and inflammatory conditions of the \nmuscles.\n2. To understand the potential and limitations of US and MRI in the assessment \nof such disorders.\n3. To consolidate knowledge of the clinically important imaging features.\nA‑009 17:03 \nMuscle tumors, non-neoplastic masses and mimickers: How to \ndifferentiate \nK. Wörtler; Munich/DE (woertler@roe.med.tum.de) \nIntramuscular tumors represent a large group of deep soft-tissue masses which \ncomprises benign neoplastic and non-neoplastic (tumor-like) lesions as well as \nmalignant neoplasms. Lipoma, hemangioma, myositis ossificans, myxoma, and \nintramuscular ganglion represent the most important benign muscle tumors. The dif-\nferential diagnosis of malignant intramuscular masses includes different soft tissue \nsarcomas (myxofibrosarcoma/MFH, fibrosarcoma, liposarcoma, leiomyosarcoma, \nrhabdomyosarcoma, Ewing sarcoma/PNET), metastases, and lymphoma. Hema-\ntomas, foreign bodies, parasites, and anatomic variants can mimic intramuscular \nneoplasms. The presentation of patients with a soft-tissue mass is often rather \nunspecific. Clinical features, like sex and history of the patient, previous trauma, \nduration of symptoms, and pain, have not proved to be useful in discrimination of \nbenign and malignant lesions. Imaging evaluation is therefore crucial for further \nmanagement. As a general guideline, biopsy should be performed in any mass \nlesion which cannot be specifically diagnosed by imaging. This course reviews the \n\nPostgraduate Educational Programme\nS8\n A B C D E F G\nradiologic appearance of important intramuscular masses with an emphasis on MR \nimaging. Findings which allow for a specific diagnosis will be highlighted on the \nbasis of pathologically confirmed cases. \nLearning Objectives:\n1. To become familiar with differential diagnosis of intramuscular soft tissue \nmasses.\n2. To learn about the radiologic approach to the diagnosis of tumors and tumor-\nlike lesions of muscles.\n3. To recognise typical morphologic features of important entities.\n4. To understand the importance of biopsy in cases with non-specific imaging \nfindings.\nPanel discussion:  \nAn outlook to the future: Muscle imaging between morphology and \nfunction \n17:23 \n16:00 - 17:30 Room D \nImaging in Lung Diseases \nCC 218 \nCOPD: A disorder of the respiratory and \ncardiovascular systems \nModerator:\nE.E.J.G. Coche; Brussels/BE \nA‑010 16:00 \nA. New facets of an old disease \nA.A. Bankier; Boston, MA/US (abankier@bidmc.harvard.edu) \nChronic Obstructive Pulmonary Disease (COPD) comprises a group of disorders \nwhose severity is graded along the decrease of the forced expiratory value in 1 second \n(FEV1), according to the Global Initiative for Obstructive Lung Disease (GOLD) clas-\nsification. Although they share this common albeit potentially artificial definition, the \ndiseases summarized under the umbrella COPD are heterogeneous in nature, have \ndifferent underlying causes, and require different approaches to diagnosis and therapy. \nThis presentation will summarize the historical background of terminology and clas-\nsification of COPD. It will further describe the individual diseases and emphasize their \ncommon and distinguishing factors. The presentation will present imaging algorithms \nfor the assessment of both individual diseases and the overall imaging assessment \nof COPD. Finally, the presentation will discuss the importance of phenotyping and \nobjective disease quantification in the imaging assessment of COPD. \nLearning Objectives:\n1. To learn about evolving comprehension of COPD over the past three \ndecades.\n2. To understand the lung parenchymal, bronchial, and vascular contributors to \npathophysiology, imaging and clinical presentation of COPD.\n3. To introduce novel integral diagnostic approaches to this complex disease, \nincluding the imaging contributions to phenotyping patients with COPD.\nA‑011 16:30 \nB. Morphology and function with CT: Myth or reality? \nM. Rémy-Jardin; Lille/FR (mremy‑jardin@chru‑lille.fr) \nChronic obstructive pulmonary disease (COPD) is a disease defined by irreversible \nairflow limitation with variable contributions of airway obstruction and parenchymal \ndestruction, both accurately evaluated with thin-section volume. The spectrum of \nmorphologic and functional evaluation of COPD with CT has recently been enlarged \nto the cardiovascular system, at the level of which specific lesions or functional \nalterations can be depicted, provided that CT examinations have been acquired \nwith ECG gating. New options have been recently introduced with dual energy CT \noffering the possibility to generate morphological and functional information from \nthe same examination. Because the severity of lung destruction and the distribu-\ntion of lung perfusion determine the functional consequences of emphysematous \nchanges, great attention has also been directed towards the analysis of lung \nperfusion alterations. As previously achievable with single-source CT, dual energy \nCT can provide thin-collimated high-resolution CT images that can be used to \ndetect and characterise emphysema as well as to quantify its severity. From the \nsame data set, it is also possible to provide information on the amount of iodine in \nthe most peripheral parts of the pulmonary arterial bed, often referred to as «lung \nperfusion imaging», from which it is possible to identify links between the severity \nof parenchymal destruction and the degree of lung perfusion alteration. Moreover, \ndual energy CT can also approach lung ventilation, as recently investigated with the \ninhalation of xenon. The purpose of this lecture is to review the practical approach \nof these combined evaluations in COPD patients, demonstrating the reality of their \nclinical implementations in 2010. \nLearning Objectives:\n1. To consolidate knowledge of clinicians’ expectations of functional information \nin the management of respiratory patients.\n2. To learn about the most recent technological developments in multidetector-\nrow CT (MDCT) enabling integration of morphology and function from the \nsame examination.\n3. To review the practical scanning protocols and the functional parameters that \ncan be derived from MDCT examinations.\nA‑012 17:00 \nC. Functional MRI \nH.-U. Kauczor; Heidelberg/DE (hans‑ulrich.kauczor@med.uni‑heidelberg.de) \nMRI of the lung has significant potential beyond the mere visualization of structure \nby providing comprehensive information about “function”, i.e. ventilation, respiratory \nmechanics, perfusion, and hemodynamics. Regional ventilation can be assessed \nby oxygen-enhanced proton MRI or in a more sophisticated way by the inhalation \nof hyperpolarized noble gases. Oxygen and 129Xe help to assess gas exchange, \nwhereas 3He and 129Xe will also address ventilation distribution (“alveolar fill -\ning time”) and pulmonary microstructure. Dynamic proton MRI during tidal and \nforced breathing is well suited to investigate hyperinflation, diaphragmatic and \nrib cage geometry as well as breathing pattern and mechanics. Even paradoxical \nmotion and effects of lung volume reduction surgery can be assessed. Dynamic \ncontrast-enhanced MR perfusion allows for a high diagnostic accuracy in detecting \nperfusion abnormalities as they occur in COPD due to hypoxic vasoconstriction. \nDelayed, collateral or systemic perfusion can be measured by the “capillary filling \ntime”. MR perfusion ratios correlate well with radionuclide perfusion scintigraphy \nratios and regional analysis can be achieved. Hypoxic vasoconstriction will lead to \npulmonary hypertension and cor pulmonale. MR-based assessment is important as \nCOPD patients with pulmonary hypertension have a poor prognosis and they need \nadequate treatment, including pulmonary vasodilators. MR will identify increased \nright ventricular volumes, decreased right ventricular function, and impaired left \nventricular diastolic function. The general availability of MRI of the lung for ad-\nvanced COPD is envisaged. The clinical impact will grow by increasing options \nfor interventional regional treatment. Functional MRI might be complemented by \nstructural CT -based phenotyping. \nLearning Objectives:\n1. To review the current MRI possibilities in lung functional imaging.\n2. To envisage the expected developments and their clinical impact.\n3. To describe the complementary roles of MRI and MDCT in providing \nfunctional information.\n16:00 - 17:30 Room E1 \nAbdominal and Gastrointestinal \nRC 201 \nGastroesophageal cancer: Is modern imaging \naccurate enough? \nModerator:\nF .‑T. Fork; Malmö/SE \nA‑013 16:00 \nA. Role of US, EUS and CEUS \nS. Roberts; Cardiff/UK (Ashley.Roberts@CardiffandVale.wales.nhs.uk) \nThe incidence of adenocarcinoma of the oesophagus and gastro-oesophageal \njunction (GOJ) has increased rapidly over the past 20 years, although squamous \ncell carcinoma (SCC) remains the commonest worldwide. Imaging has a major role \nin pre-treatment staging. We perform MDCT primarily to exclude distant metastases, \nthen local staging with endoscopic ultrasound (EUS) and PET/CT to further exclude \nmetastatic disease. This lecture will mainly focus on EUS with some discussion of the \nrole of transcutaneous (US) and contrast enhanced ultrasound (CEUS). T1 -invades \nlamina propria/submucosa; T2 -invades muscularis propria (MP); T3-through MP; T4 \n-invades adjacent structures; N0/N1-loco-regional lymph nodes; M1a-distant lymph \nnode metastases; M1b-distant metastases; GOJ tumours-Siewert I/II/III (Siewert \nIII -gastric TNM). EUS requires a dedicated endoscope, including a slim probe for \n\nThursday\nPostgraduate Educational Programme\nA\n S9\nCB D E F G\nstenoses. At 5-12 MHz, the five-layered gut wall correlates well with histology. The \n4th (hypoechoic) layer represents MP , and tumour relationship to this provides a \npre-operative T stage. Malignant nodes are defined by size, structure, margins and \nshape. EUS FNA improves specificity. Surgery has no impact on survival in EUS-\ndefined T4 disease. Patients who have non-curative surgery have poor quality of \nlife. EUS assists radiotherapy and surgical planning. US: Neck US ± FNA can be \nused in SCC. CT PET has diminished this practice, but FNA can confirm malig-\nnancy. CEUS: Occasional problem solver for equivocal liver lesions. CE EUS has \nbeen disappointing. Conclusion: Despite improvements in MDCT, MRI and PET/\nCT, EUS with EUS FNA retains a pivotal role in the management of oesophageal \nand gastrooesophageal cancer. \nLearning Objectives:\n1. To review the imaging modalities used in the staging of esophageal and \nesophagogastric junction cancer.\n2. To discuss pragmatic staging algorithms according to the availability of these \nmodalities.\n3. To explore the importance of imaging in planning the delivery of treatment.\nA‑014 16:30 \nB. Role of CT and MRI \nE.J. Rummeny; Munich/DE (rummeny@roe.med.tu‑muenchen.de) \nIn general, both multidetector row computed tomography (MDCT) and MR-imaging \n(MRI) may be used for detection and staging of gastroesophageal cancer. However, \nsince MDCT is faster and easier to perform it is still the preferred cross-sectional \nimaging technique. During this course, we will discuss the techniques used for \nMDCT and MRI to image patients with suspected cancer of the esophagus and/\nor the stomach. We will show how MDCT combined with air and water distension \nimproves the capability of local preoperative staging and we will also review data \nfor T - and N- staging. New techniques like MPRs may improve accuracy of staging \neven further as compared to transverse images. Furthermore, it can be shown that \nMDCT and MRI provide additional information on tumor depth and extragastric \ntumor spread. It will also be demonstrated how these techniques may be used for \nresponse evaluation after chemotherapy and radio-chemotherapy. As we could \nshow in the literature, volumetry based on MDCT data can help to predict early \nresponse to treatment 2 weeks after the initiation of neoadjuvant chemotherapy \nin patients with esophageal cancer, while the classic approach of tumor diameter \nmeasurement shows no correlation with histopathological tumor regression. In \ngeneral, we will discuss if MDCT and /or MRI can be used as primary tools for pre- \nand postoperative staging and follow-up in patients with gastroesophageal cancer. \nLearning Objectives:\n1. To describe how CT and MRI should be performed if esophageal and \nesophagogastric junction cancer is suspected.\n2. To discuss the accuracy of these imaging modalities for staging.\n3. To compare the use of CT and MRI in response evaluation after \nchemotherapy and radiation with other imaging modalities.\nA‑015 17:00  \nC. Role of PET/CT \nW.L. Wong; Northwood/UK (wailup.wong@stricklandscanner.org.uk) \nDrawing from a survey of the literature, the established role of FDG PET/CT in \nthe assessment of patients with gastroeosphageal cancer will be considered. The \nFDG PET/CT appearance of gastroesophageal cancer will be illustrated and the \nstrengths and limitations of FDG PET/CT for the evaluation of gastroeosophageal \ncancer will be highlighted. \nLearning Objectives:\n1. To demonstrate the typical imaging findings of PET/CT in GOJ cancer.\n2. To discuss the accuracy of PET/CT in imaging GOJ cancer.\n3. To describe the role of PET/CT in the management of GOJ cancer.\n16:00 - 17:30 Room E2 \nInteractive Teaching Session \nE³ 220a \nImaging in common clinical problems: Hematuria \nModerator:\nW. Szmigielski; Doha/QA \nA‑016 16:00 \nImaging in common clinical problems: Hematuria \nJ.J. Fütterer1, R.H. Oyen2; 1Nijmegen/NL, 2Leuven/BE (j.futterer@rad.umcn.nl) \nAt present, once it is established that haematuria is of non-glomerular origin, the imag-\ning modality of choice for imaging is Multi Detector-row Computerised T omographic \nUrography (MDCTU). MDCTU has replaced Intravenous Urography (IVU). IVU has a \nlimited role only (in young patients< 40 y - with hematuria) as has ultrasonography in \ninvestigating haematuria because of obvious limitations. MDCTU provides superior \ninformation on the renal parenchyma of the entire urinary tract in a single examination. \nAlthough MDCTU offers a unique tool for the investigation of haematuria, optimizing its \nrole is still under investigation, particularly as there are several variations of examination \ntechniques. These include combinations of phasic acquisitions (ranging from single to \nmultiple, as well as low radiation dose and higher dose techniques) and various other \nsupportive protocols: compression vs. no compression, saline infusion, administration \nof diuretics, supine and prone acquisitions, timing of acquisitions after intravenous \ncontrast administration and split bolus techniques. In addition, postprocessing algo-\nrhythms (including the use of maximum and average intensity projection, as well as \n3D-volume-rendered reconstructions), the methods used in analyzing the large number \nof images, and the radiation dose at the time of examination, all contribute to the final \nacceptance of this technique by radiologists, urologists and nephrologists. It is most \nlikely that the technique will be more refined and adjusted to the patient and suspected \nunderlying disease process (i.e. tailored MDCTU). Thus, the diagnostic accuracy will \nimprove at a reasonable patient dose. \nLearning Objectives:\n1. To learn about the indications for CTU.\n2. To understand the role of CTU in hematuria.\n3. To appreciate the decreasing role of IVU.\n4. To become familiar with CTU in routine clinical practice.\n16:00 - 17:30 Room F1 \nInteractive Teaching Session \nE³ 220b \nCommonly missed diagnosis in musculoskeletal \nconditions \nModerator:\nH. Imhof; Vienna/AT \nA‑017 16:00 \nCommonly missed diagnosis in musculoskeletal conditions \nF . Kainberger1, K. Bohndorf2; 1Vienna/AT, 2Augsburg/DE \n(franz.kainberger@meduniwien.ac.at) \nMany structures of the musculoskeletal system are prone to overuse and degen-\neration. Thus, stress-related injuries may mask the clinical appearance of many \nother entities. Indications for imaging: documentation of the patient’s history and \nthe knowledge of certain laboratory findings are of enormous help to differentiate \noveruse syndromes and arthritis from tumors, infections, vascular diseases, or \nothers. Investigation: with standardized imaging protocols all relevant anatomic \nareas have to be included for documenting the effects of biomechanical stress, the \nsymmetric manifestation of arthritis, the spread of tumors and infection, or trauma. \nInterpretation: the anatomic distribution of traumatic and stress-related injuries is \ninfluenced by “kinetic chains”. Bone marrow or soft tissue edema and many other \nimaging findings act as footprint patterns for the differential diagnosis. Likewise in \ninflammatory disorders, the distribution pattern is often characteristic for common \nand uncommon forms of rheumatic diseases or of infections. In tumors, the structure \n(“matrix”) and their borders are important features. Conclusion: a standardized \ndiagnostic process bases on the analysis of distinct clinical and anatomic patterns. \nIt also includes the recognition of patterns of misinterpretation. \n\nPostgraduate Educational Programme\nS10\n A B C D E F G\nLearning Objectives:\n1. To learn about the differential diagnosis between stress injuries, \ninflammatory processes, necrosis and tumors.\n2. To recognise the importance of insufficient consideration of clinical \ninformation and symptoms in the interpretation of imaging studies.\n3. To recognise the consequences of uncritical imaging requests.\n4. To stress the importance of a systematic approach to the interpretation of \nimaging, particularly radiographs.\n16:00 - 17:30 Room F2 \nBreast \nRC 202 \nBreast US \nModerator:\nG. Rizzatto; Gorizia/IT \nA‑018 16:00 \nA. Ultrasound and BI-RADS \nH.M. Zonderland; Amsterdam/NL (h.m.zonderland@hccnet.nl) \nThe BI-RADS lexicon for Ultrasound (US) dates from 2003. Adherence to its descrip-\ntors improves specificity. The descriptors shape, margin, boundary and surround-\ning tissue are most important, but also challenging, sometimes with considerable \nobserver variability. The identification of boundary and surrounding tissue effects \nis the result of the soft tissue resolution properties of US, in which it is superior to \nmammography. The effects of a mass on its surroundings such as an echogenic \nhalo, obliteration of the tissue planes and thickening of Cooper’s ligaments have a \nhigh predictive value of malignancy and can avoid false negative results in otherwise \nround, oval or well-defined masses. Recent studies suggest that when a lesion \nis palpable and the US descriptors suggests BI-RADS 3 (probably benign), the \nlikelihood is that it is benign and that the lesion may be managed without biopsy, \nsimilarly to non-palpable BI-RADS 3 lesions. The recommendation of follow-up \nby imaging alone is considered a laudable but difficult goal for many radiologists. \nOthers suggest a negative psychological impact for the patient and prefer biopsy. \nAlso, the guidance role of the multidisciplinary team cannot be denied. Therefore, \nsome choice in recommendations should be acceptable, provided that it is properly \nworded in the report. The use of BI-RADS based-CAD for US is still in its infancy. \nIt is a lesion analysis tool rather than a detection tool. Studies show mixed results, \nbut even the most experienced reader seems to benefit on occasion from having \nCAD input during the image interpretation process. \nLearning Objectives:\n1. To learn how to use BI-RADS lexicon in US.\n2. To review the most important pathologic signs.\n3. To evaluate the latest advances in US.\nA‑019 16:30 \nB. The role of ultrasound in premalignant and benign lesions \nI. Leconte; Brussels/BE (Isabelle.Leconte@rdgn.ucl.ac.be) \nBenign lesions can be divided into cystic and solid lesions. Simple cysts, complicated \ncysts are classified Bi-Rads 2. It has been reported that clustered microcysts in \npremenopausal women without any solid component can also be classified Bi-Rads \n2. Benign solid or indeterminate nodules may have specific US findings such as pure \nhyperechogenicity, parallel shape, well-defined margins, and few gentle lobulations. \nHowever, the predictive negative value of certain findings is less than 98%. The \nassociation of several findings is necessary as well as the absence of malignant \nfinding. Specific benign diagnosis will be reviewed. Frequent premalignant lesions \ninclude atypical ductal hyperplasia (ADH), lobular carcinoma in situ (LCIs), radial \nscar and papilloma. ADH and LCis are incidental findings; so, their US features \ndepend of the underlying lesion. Radial scars contain at least one suspicious \nfinding and are classified at least Bi-Rads 4a. Specific premalignant diagnosis will \nbe reviewed. To increase US specificity, it is necessary to improve US technique \nby following US guidelines published by ACR. Other technical artifices, like focal \ncompression, are useful. The characterization of the lesions is also improved by \nthe appropriate use of the compound imaging, tissue harmonic imaging and Color \nDoppler. Elastography seems really promising to reduce the false-positive rate, \nparticularly in case of complicated cyts. Finally, care must be taken to correlate \nUS findings with mammographic and physical examination findings. Furthermore, \nthe final management of the lesion depends on the context, the personal history \nand the anteriority, when available. \nLearning Objectives:\n1. To describe the US features.\n2. To differentiate between malignant, premalignant and benign lesions on US.\n3. To learn how to avoid unnecessary biopsies.\nA‑020 17:00 \nC. Axillary tail and US \nE.E. Deurloo; Amsterdam/NL (e.e.deurloo@amc.uva.nl) \nAxillary lymph node status is strongly correlated with prognosis in breast cancer \npatients: patients without axillary lymph node metastases have a significant better \nprognosis than patients with axillary lymph node metastases. Nowadays, breast \ncancer patients with a clinically-negative axilla undergo a sentinel lymph node \nbiopsy (SLNB) to sample the axillary lymph nodes. Ultrasonography of the axilla \ncan be used to detect lymph node metastases prior to surgery in patients with a \nclinically-negative axilla, thereby reducing the number of (time-consuming and \nexpensive) SLNBs. In ultrasonography of the axilla, the region that is examined is \nvery important: the sentinel node is often located in the lower part of the axilla and \ncan be found as low as the level of the nipple. A high frequency probe is required \nand ultrasonography should be combined with fine-needle aspiration (FNA). Charac-\nteristics of nodes that might differentiate between benign and malignant are: aspect \nof hilus and cortex, and with less accuracy size or shape. A more reproducible \ncharacteristic that can be used is cortex thickness. If a cortex thickness of e.g., \n2.3 mm is used as cut-off point to perform FNA, a sensitivity of FNA of 95% can be \nobtained with a specificity of 44%, meaning that most of the ultrasonographically \nvisible malignant nodes will be detected, and FNA will be performed in about 25% \nof all patients. Conclusion: Cortex thickness can be used to reduce the number of \nFNAs on benign nodes, while remaining a high sensitivity. \nLearning Objectives:\n1. To differentiate between normal and abnormal lymph nodes.\n2. To give criteria for abnormal lymph nodes.\n3. To describe the best biopsy technique.\n16:00 - 17:30 Room G/H \nNeuro \nRC 211 \nBasic MRI \nModerator:\nM.I. Argyropoulou; Ioannina/GR \nA‑021 16:00 \nA. Basic techniques and pattern recognition \nP .M. Parizel; Antwerp/BE (paul.parizel@uza.be) \nDiagnostic neuro-imaging procedures play an essential part in the diagnosis, \nmanagement, treatment and follow -up of patients with lesions of the central \nnervous system (CNS). The purpose of this presentation is to review basic imag-\ning techniques and to illustrate how pattern analysis contributes to the correct \n(differential) diagnosis for CNS lesions. The first step is to identify and outline the \nlesion and to establish its exact topography (anatomical location, intra/extra-axial, \nsupra/infra-tentorial). Changes in tissue density (CT) and signal intensity (MRI) \ncan provide clues to the histological nature (e.g. fat, fluid, gas, blood, etc). Central \nnecrosis and perilesional vasogenic edema are markers of aggressive behavior \nof lesions. Contrast agents can be used to assess lesion vascularity or to detect \nblood-brain-barrier breakdown. Perfusion-weighted imaging provides information \nregarding the microvasculature (angiogenesis) of tissues and tumors, as well capil-\nlary permeability. Diffusion-weighted imaging, including diffusion tensor imaging \nand tractrography, provides information about the ultra-structural organisation of \ntissues and lesions at a cellular level. Magnetic resonance spectroscopy yields an \ninsight into the biochemical composition of lesions and can be used in diagnosis \nand post-treatment follow-up. At the end of the lecture, we shall provide examples \nof typical disease patterns in CNS diseases, many of which can be associated with \nspecific symbols. In summary, thanks to improvements in equipment, both hardware \nand software, a comprehensive multimodal neuro-imaging protocol provides not \nonly anatomical images, but also gives information regarding tissue characteristics \nand contributes to the detection and biological characterization of CNS lesions. \nLearning Objectives:\n1. To present a comprehensive overview of basic MRI techniques in the \ndetection, characterisation and follow-up of CNS lesions.\n\nThursday\nPostgraduate Educational Programme\nA\n S11\nCB D E F G\n2. To illustrate how to correlate MRI signal intensity changes with biochemical \nand pathological findings.\n3. To demonstrate how to use anatomic location in CNS lesion characterisation \n(intra vs extra-axial, supra- vs infratentorial).\n4. To show how to use an analytic pattern recognition approach for differential \ndiagnosis of CNS lesions.\nA‑022 16:30 \nB. New MR sequences in daily practice \nR. Gasparotti; Brescia/IT (gasparo@med.unibs.it) \nMR imaging of the brain and spine is experiencing continuous progress in the \ndevelopment of new sequences, which have significantly improved the diagnostic \napproach in several diseases in daily practice. Demonstration of hemosiderin has \nrelied for a long time on T2* gradient echo images, which were characterized by \nlow spatial and contrast resolution. Susceptibility-weighted imaging (SWI) is a \nnew neuroimaging technique, based on high-spatial resolution 3D gradient-echo \nsequences with phase postprocessing, which uses tissue magnetic susceptibility \ndifferences to generate a unique contrast, different from that of T1, T2, and T2*. \nDue to its sensitivity in the detection of intravascular venous deoxygenated blood \nas well as extravascular blood products, 3D SWI has been successfully applied to \nstroke, head trauma, vascular malformations, cerebrovascular and neurodegenera-\ntive disorders. Diffusion tensor imaging (DTI) has become a research tool in almost \nany field of neurosciences. In daily practice, DTI can be applied to study brain and \nspinal cord tumors and cavernous malformations, where a thorough display of white \nmatter fibers is crucial for surgical planning. Conventional MR imaging has not been \nan effective method for imaging the brachial plexus, due to its complex anatomy \nand low contrast resolution between nerves and muscles. A new MR neurography \ntechnique has been recently developed, consisting of 3D T2 turbo-spin-echo (TSE) \nsequences with short-term inversion recovery (STIR) and variable flip angle RF \nexcitations (SPACE), with isotropic voxels, which allow multiplanar reconstructions \nalong roots, trunks and cords. Clinical applications are represented by traumatic \nand immune brachial plexopathies, thoracic outlet syndrome. \nLearning Objectives:\n1. To become familiar with the new MR sequences for the investigation of brain \nand spine lesions.\n2. To learn the essential features of the new MR sequences.\n3. To illustrate specific indications for the new MR sequences in brain and spine \nimaging.\n4. To discuss the impact of the new MR sequences on the clinical diagnosis.\nA‑023 17:00 \nC. Diffusion tensor imaging: Basic tool for radiologists? \nS. Lehéricy; Paris/FR (stephane.lehericy@psl.aphp.fr) \nDiffusion-weighted imaging (DWI) is sensitive to the random motion of water \nmolecules in the brain. Measures of water diffusivity from DWI provide estimates \nof the microstructural integrity of the brain parenchyma. Diffusion tensor imaging \n(DTI) can also detect the directionality of molecular diffusion in the white matter. The \ndirectionality dependence of diffusion is called anisotropy and is measured using \nindices such as fractional anisotropy. In the white matter, diffusivity predominates \nalong the direction of fiber bundles. By following the main direction of diffusion along \nthe tracts, tractography allows the reconstruction of fiber bundles in humans in vivo. \nDTI has several applications in brain pathology, such as preoperative localization \nof fiber bundles, the evaluation of brain damage in patients with traumatic brain \ninjury, and the detection of pathology in specific white matter fiber bundles. In this \npresentation, the basics of diffusion tensor imaging and fibre tracking and the main \nclinical applications of DTI in radiological practice will be presented as well as a \npractical guide on how to reconstruct major fibre bundles in the brain. \nLearning Objectives:\n1. To understand the basics of diffusion tensor imaging and fibre tracking.\n2. To know the main clinical applications of DTI in radiological practice.\n3. To learn how to reconstruct major fibre bundles in the brain.\n16:00 - 17:30 Room I \nVascular \nRC 215 \nDiseases of the visceral arteries \nModerator:\nM.I. Furmanek; Warsaw/PL \nA‑024 16:00 \nA. Renal vascular disease \nD. Vorwerk; Ingolstadt/DE (dierk.vorwerk@klinikum‑ingolstadt.de) \nRenal angioplasty meanwhile has developed into a standardized technique using \nprimary stenting in ostial lesions and angioplasty and or stenting in distal lesions. \nMiniaturization of instruments allows a less traumatic single side approach as well \nas transbrachial or transradial access depending on the renal arterial anatomy. \nTechnical success is high and acute complications relatively low. However, problems \nof cholesterol embolization following PTRA are still poorly understood. Patients \nwith fibromuscular dysplasia usually benefit from renal angioplasty concerning \ntheir blood pressure. Patients with atherosclerotic disease are not benefitting in the \nsame amount, some also will show deteriorated renal function. Actually, discussion \nis running high whether both patients with hypertension and/ or renal insufficiency \nmay undergo renal angioplasty as larger randomized studies did not show major \nimprovements compared to medication alone. Shortcomings of studies as well as \nintrinsic problems on looking on patients with renal artery disease will be discussed. \nLearning Objectives:\n1. To review the different causes of renal artery stenosis.\n2. To discuss the role of Doppler US, CTA and MRA in diagnosis of renal artery \nstenosis.\n3. T o become familiar with optimised treatment planning and treatment selection.\nA‑025 16:30 \nB. Acute and chronic mesenteric ischemia \nR. Uberoi; Oxford/UK (raman.uberoi@orh.nhs.uk) \nRapid and accurate diagnosis is vital in mesenteric ischemia and imaging has a major \nto play. Although, angiography remains the gold standard with the advantage that \nit also permits possible therapeutic intervention, include administering intra-arterial \nvasodilators and/or thrombolytic agents and angioplasty with or without stent place-\nment. Imaging has evolved to using non-invasive techniques. Duplex of mesenteric \narteries was developed in the late 1980s. Its primary application is to identify high-\ngrade stenoses in mesenteric vessels. A peak systolic velocity of > 275 cm/s in the \nSMA identifies a > 70% SMA stenosis with a sensitivity of 92%, a positive predictive \nvalue of 80% and a negative predictive value of 99%. CTA and contrast-enhanced \nMRA are excellent non-invasive screening techniques\n for patients suspected of having \nmesenteric ischemia. CTA has higher spatial resolution and faster acquisition times, \nallowing assessment of the peripheral visceral branches and the inferior mesenteric \nartery with greater accuracy than  contrast-enhanced MRA. In addition, in acute \nischemia CTA is more widely available with good accuracy for the findings of acute \nischemia including bowel wall thickening, portal venous gas, intramural pneumatosis, \nengorgement of mesenteric veins, loss or increase of bowel wall enhancement, \nand infarction of other abdominal organs. A sensitivity of 93%, specificity of 100%, \nand positive and negative predictive values of 100 and 94%, respectively, can be \nachieved for these CT findings. However, the lack of radiation\n and iodinated contrast \nagents make MRA the technique of choice for children and patients with azotemia. \nLearning Objectives:\n1. To describe the clinical manifestations of acute and chronic mesenteric \nischemia.\n2. To discuss the role of different imaging modalities in diagnosis of acute and \nchronic mesenteric ischemia.\n3. To demonstrate potential artifacts and pitfalls in non-invasive diagnosis of \nmesenteric ischemia.\nA‑026 17:00 \nC. Imaging before and after liver transplantation \nT. Schroeder; Essen/DE (Tobias.Schroeder@uni‑due.de) \nBackground: Orthotopic and living donor liver transplantation (OLT, LDLT) are \nroutinely used procedures in the treatment of irreversible end-stage liver disease. \nPreoperative imaging is important for exclusion of transplantation contraindications \nin the recipient, assessment of the operation anatomy in living liver donors, and to \n\nPostgraduate Educational Programme\nS12\n A B C D E F G\navoid donor-recipient mismatch. In particular, accurate preoperative knowledge of \nhepatic vascular anatomical variants contributes to reduce the incidence of com-\nplications during and following transplantation. The main purpose of postoperative \nimaging is the early detection and characterization of operation complications.\nProcedure Details: Earlier pre-harvest evaluation protocols included ultrasound, \ncomputed tomography (CT) or magnetic resonance imaging (MRI) for assessment \nof parenchymal lesions, tumor staging and liver planimetry, catheter angiography \n(DSA) for the display of the hepatic vascular system, ERCP for assessing the biliary \nanatomy and liver biopsy for the assessment of hepatic-cellular infiltration. To simplify \nand shorten such procedures to a minimum, comprehensive “all-in-one” MRI - and \nMultidetector-CT (MDCT) - protocols have been advocated. Both approaches combine \nthe advantage of minimal invasiveness with simultaneous assessment of the hepatic \nparenchymal morphology and a detailed analysis of the biliary and vascular anatomy.\nConclusion: The most versatile imaging modality both for the preoperative evalua-\ntion process and the postoperative diagnosis of complications is MDCT. Its specific \nadvantages lie in a wide availability and the possibility to evaluate all relevant ana-\ntomical components with high reliability within a single diagnostic step. If needed, it \nalso offers the possibility of direct CT -guided intervention (e.g., abscess drainage). \nLearning Objectives:\n1. To learn about the importance of visualisation of hepatic vasculature prior to \nliver transplantation.\n2. To become familiar with anatomical variants of the hepatic vasculature.\n3. To become familiar with typical and pathological findings after liver \ntransplantation.\n4. To learn about the treatment strategies before and after liver transplantation.\n16:00 - 17:30 Room K \nComputer Applications \nRC 205 \nImage sharing \nModerator:\nA. Abildgaard; Oslo/NO \nA‑027 16:00 \nA. Exchange of imaging data with portable media (CD, DVD, USB) \nN.H. Strickland; London/UK \nExchange of imaging data can be achieved with portable media, but is highly unsatisfac-\ntory because it is unreliable, cumbersome and slow. Imaging studies today are mostly \nvery large and should include an associated report as well as the images. Unless the \nimages are in DICOM format, they cannot be adequately manipulated. A self-launching \nDICOM viewer must be included on the portable media for the average recipient \n(with limited IT skills) to be able to view the images easily on an unsophisticated PC. \nScrolling through > 1000 images in a single study on portable media via a PC-based \nDICOM viewer is aggravatingly slow. Uploading imaging data from portable media to \nthe host P ACS and RIS is often fraught with difficulty, and is a labour-intensive manual \nprocess. Lack of adherence to universal standards for portable media leads to frequent \nincompatibility problems between the host P ACS and RIS and the portable media. \nIn countries such as England, government-imposed information governance rules \nenforce encryption of imaging studies (for more than four patients) on portable media. \nThe encryption and decryption processes, and the human errors often involved, for \nexample the loss of passwords or codes, further complicates the use of such portable \nmedia, and introduces significant clinical risk. The many technical and human problems \nassociated with using portable media to exchange imaging data relegate them to use \nas a last resort, best tolerated only for the exchange of low volumes of non-urgent \ndata when no more automated direct exchange mechanism is available or feasible. \nLearning Objectives:\n1. T o learn what are good portable media and how to create them within a P ACS.\n2. To know about workflow requirements integrating portable media in PACS \n(IHE PDI and IRWF).\n3. To implement quality improvement concepts.\nA‑028 16:30 \nB. Images crossing borders: What about administration and law? \nH.K. Pohjonen; Espoo/FI (hanna.pohjonen@rosalieco.fi) \neHealth community aims at creating a secure platform for the provision and consumption \nof clinical eServices by developing a new working environment for professionals and \nteams, a shared workspace for cross-border consultations and access to individual \nimages and patient records. In this lecture, practical examples of cross-border work-\nflow are shown. The cross-border availability and use of professionals as well as the \npossible technical, legal, organizational, semantic and quality assurance issues are \ndiscussed. Special attention is paid to emerging eMarket places for imaging: customers \nand providers for teleradiology meet via one connection node making the teleradiol-\nogy more controlled and accessible. With one integration to the central platform, the \nwhole market with several choices is opened up. The new generation cross-border \nteam working reduces waiting times and gives access to a wide professional pool for \nconsultations and second opinions increasing the quality of service. It also increases \nradiological effectiveness and gives financial savings. As an example, reporting of an \nextended MRI examination can be even five times less expensive. Cross-border eT eams \ncan offer an efficient way to share resources by identifying the need and extra capacity \nfor reporting and consultations. Clarifications regarding legal and financial matters and \nEU-level harmonization across different legal environments are still needed in order to \nboost cross-border teleradiology and maintaining the quality of the service. Linguistic \nissues are partly unsolved as well. \nLearning Objectives:\n1. To learn about European regulations in telemedicine.\n2. To learn concepts for improvement of services for patients.\n3. To be able to integrate quality assurance in teleradiology.\n4. To be aware of administrative and workflow aspects.\nA‑029 17:00 \nC. Image compression: Acceptable? Unacceptable? Any decision yet? \nE. Kotter; Freiburg/DE (elmar.kotter@uniklinik‑freiburg.de) \nDuring the past years, many clinical studies concerning radiological image data \ncompression have been published. They all show that loss image compression can \nbe used in radiology without loss of relevant image information. They disagree about \nthe compression ration that can be used safely. It medical purposes, it should be \ndistinguished between the technical loss of information (i.e. irreversible compression \nfrom a technical viewpoint) and the loss of medical relevant information. In some \ncountries (Canady, Germany and UK), official recommendations concerning image \ncompression in radiology have been published. These recommendations will be \npresented and compared. We will discuss practical aspects about consequences \nof different implementation models of image compression. \nLearning Objectives:\n1. To know that technical and medical lossy compression are different and why.\n2. To learn about experiences in clinical studies with compression.\n3. To know about legal aspects in different countries.\n4. To implement a medical based decision model using lossy compression.\n16:00 - 17:30 Room L/M \nMultidisciplinary Sessions: Managing Patients with Cancer \nMS 221 \nCarcinoma of the uterus and cervix \nA‑030 16:00 \nChairman’s introduction \nR.H. Reznek; London/UK (r.h.reznek@qmul.ac.uk) \nImaging has become pivotal in all aspects of the management of patients with can-\ncer. At the same time, it is acknowledged that optimal patient care is best achieved \nby a multidisciplinary team approach. The explosion of technological developments \nin imaging over the past years has meant that all members of the multidisciplinary \nteam should understand the potential applications, limitations and advantages of \nall the evolving and exciting imaging techniques. Equally, to understand the signifi-\ncance of the imaging findings and to contribute actively to management decisions \nand to the development of new clinical applications for imaging, it is critical that \nthe radiologist should have sufficient background knowledge of different tumours. \nThus, the radiologist should understand the pathology, the clinical background, \nthe therapeutic options and prognostic indicators of malignancy. This session will \naddress these principles in carcinoma of the uterus and cervix. \nLearning Objectives:\n1. To become familiar with the factors that influence the decision to operate \nand the nature of the procedure in patients with carcinoma of the uterus and \ncervix.\n2. To appreciate the information required from imaging by the oncologist in \nplanning radio and chemotherapy.\n3. To understand how the imaging has to be optimised and interpreted in order \nto provide the information needed by the surgeon and the oncologist.\n\nThursday\nPostgraduate Educational Programme\nA\n S13\nCB D E F G\nA‑031 16:05 \nWhat the surgeon needs to know \nC. Pomel; Clermont‑Ferrand/FR (christophe.pomel@cjp.fr) \nThe treatment of cervical cancer depends on the tumoral volume. Tumors of less \nthan 4 cm (FIGO stage 1 b1) are usually treated by surgery alone or followed by \nadjuvant radiotherapy. Tumors superior to 4 cm are actually treated by an association \nof radio-chemotherapy. A conservative treatment can be proposed to women with \nsmall cervical carcinoma wishing to preserve fertility. MRI allows measuring the \nendocervical extents of the tumor. The clinical examination can correctly predict the \ninvasion of parametria. This is well correlated with MRI imaging. The lymph node \nassessment is as crucial. It represents a major prognosis indicator. This assess-\nment has its greater interest in patients with advanced cervical cancer, in whom \nno lymph node assessment will be done. The management of endometrial cancer \nis pending on the infiltration of the myometrium. Stage Ia, Ib grade 1 and 2, there \nis no need for a lymphadenectomy. For all other stages, the lymphadenectomy is \nmandatory. Patients with pelvic recurrence of cervical or endometrial cancer with no \nevidence of metastatic disease may be eligible for pelvic exenteration. As the patient \npresents a clinical suspicious of pelvic relapse, MRI is the ideal tool to diagnose, \nmeasure the extent and afterwards planify a surgical treatment. The invasion of \nthe sciatic fossa as well of the external iliac vessells constitutes in our institution a \nmajor contra indication for surgery. On the other hand, patients with infiltration of \nthe ureter, or the internal iliac vessels may be eligible for surgery. \nLearning Objectives:\n1. To learn the factors that are considered in deciding whether or not to treat \npatients surgically in carcinoma of the cervix.\n2. To understand what considerations are taken into account in deciding \nwhether fertility-sparing surgery is feasible in patients with carcinoma of the \ncervix or endometrium.\n3. To appreciate how the decision is made as to whether or not a \nlymphadenectomy is performed in patients with carcinoma of the cervix.\n4. To become familiar with the criteria for surgical intervention in patients with \nrecurrent endometrial or cervical cancer.\nA‑032 16:25 \nWhat the clinical oncologist needs to know \nP .R. Blake; London/UK (peter.blake@rmh.nhs.uk) \nIn chemoradiation of cervical cancer, staging is vital to determine the correct treat-\nment protocol and radiotherapy volume. Imaging is now the mainstay of staging, \nrather than invasive investigations, and I will discuss this in terms of both direct \ninvasion of tissues and metastasis. The radiotherapy planning process in the UK \nis usually done by clinical oncologists (radiation oncologists who also supervise \nchemotherapy). This has become much more sophisticated and time-consuming \nthan was the case with conventional planning using orthogonal films. As a conse-\nquence, there are moves towards other groups of staff being used to define normal \ntissue volumes with only tumour volumes being defined by the clinical oncologist, \nwith or without radiologists’ help. Using multiple staff groups will require training \nand, possibly, audit by radiologists experienced in cervical cancer imaging. I will \nexplain what is meant by gross tumour volume (GTV), clinical tumour volume (CTV) \nand planning tumour volume (PTV) in radiotherapy planning. With image-guided \nbrachytherapy (IGBT), these same principles are being applied to the planning \nof brachytherapy. In the UK this is largely by specialist clinical oncologists, but in \nEurope this is often by radiologists. If the clinical oncologists are to do this, then \nthey need appropriate training, subspecialisation and continued experience in \norder to maintain their skills. Follow-up is often devolved to local hospitals that are \nnot cancer centres. The radiologists there need to be able to distinguish between \npost-radiotherapy effects and recurrent disease. \nLearning Objectives:\n1. To understand the basic principles of tumor staging in carcinoma of the \ncervix and uterus.\n2. To learn the meaning of the terms GTV, CTV, PTV, treatment volume and \norgans at risk.\n3. To appreciate how electronic portal imaging, cone-beam imaging and image-\nguided radiotherapy can be used to assure the quality of treatment delivered \nto the patient.\n4. To understand the importance and the protocols for the follow-up of patients \nwith carcinoma of the cervix and uterus.\nA‑033 16:40 \nImaging in carcinoma of the uterus and cervix \nR.H. Reznek; London/UK (r.h.reznek@qmul.ac.uk) \nThe purpose of imaging in endometrial cancer is to identify myometrial and cervi-\ncal invasion and extra-uterine disease to allow preoperative surgical planning in \npatients who often suffer serious co-morbidity. Overwhelming evidence exists that \nmagnetic resonance imaging (MRI) is the imaging technique of choice to provide \nthis information. Nevertheless, several pitfalls exist in interpretation of MRI and \ntechnique is crucial. In cervical cancer, imaging is used to provide answers to several \nclinical questions including detection of parametrial invasion, accurate assessment \nof tumour volume, its proximal extension, early detection of recurrence and nodal \ndisease. While computed tomography will accurately detect parametrial invasion, \nMRI has an established role in local staging. By assessing proximal extension of \ntumours in young women, MRI will determine the feasibility of fertility-preserving \nsurgery. By accurately showing the volume of tumour, it is used to plan and ad-\nminister conformal radiotherapy and for depiction of nodal disease in both cancers. \nFor endometrial and cervical cancer, MRI is used for surveillance, detection of \nrecurrence and evaluation of complications secondary to treatment. \nLearning Objectives:\n1. To understand how imaging is used to decide between surgery and \nchemoradiation in patients with cervical cancer.\n2. To learn how imaging is used to decide whether uterus-conserving surgery is \nfeasible in early stage cervical cancer.\n3. To understand how imaging is used to plan conformal radiotherapy in \ncervical cancer.\n4. To understand how imaging is used to determine the most appropriate \nsurgical technique in patients with endometrial cancer.\n5. To appreciate the pitfalls in the use of imaging to stage patients with \nendometrial and cervical cancer.\nPanel discussion and case presentation\n 17:10 \n16:00 - 17:30 Room N/O \nHead and Neck \nRC 208 \nSkull base \nModerator:\nK. Hrabak; Budapest/HU \nA‑034 16:00 \nA. Anatomical survival kit \nE. Steiner; St. Pölten/AT (erich.steiner@aon.at) \nUnderstanding anatomy is the basis for the interpretation of any imaging study. This \nanatomical survival kit aims to provide the anatomical principles of the skull base \nas a foundation for the evaluation of CT and MR imaging studies. On specimen \nphotographs and schematic drawings views of the complete skull base from above \nand below are shown. The anatomy of the osseous components such as the frontal, \nethmoid, sphenoid, temporal and occipital bone is discussed. The topographic \nrelationship of the anterior, middle and posterior cranial fossa to the adjacent ex-\ntracranial spaces such as the nasal cavity, paranasal sinuses, orbit, pterygopalatine \nfossa, middle ear, infracranial spaces and spinal canal is shown. The foramina and \nthe fissures of the skull base including the cribriform plate, optic canal, superior \norbital fissure, foramen rotundum, ovale and spinosum, foramen lacerum, Vidian \ncanal, carotid canal, internal auditory canal, jugular foramen, stylomastoid foramen, \nhypoglossal canal, and foramen magnum are discussed together with the passing \ncranial nerves and vessel. Their significance as pathways for spread of disease \nis emphasized. Special attention is paid to the cavernous sinus and its content. In \naddition, anatomical structures are reviewed on multiplanar CT and MR images. \nLearning Objectives:\n1. To review the anatomy of the skull base.\n2. To identify normal anatomical structures on CT and MRI studies of the skull \nbase.\n3. To understand anatomical fundamentals of the spread of disease.\n\nPostgraduate Educational Programme\nS14\n A B C D E F G\nA‑035 16:30 \nB. Cranial nerves in cancer imaging \nJ.W. Casselman; Bruges/BE (jan.casselman@azbrugge.be) \nDetection of nerve involvement by a head and neck tumor causes a dramatical \nincrease in tumor staging (T4). Adenoid cystic carcinoma arising from salivary \nglands, squamous cell carcinoma, basal cell carcinoma, melanoma, lymphoma \nand sarcoma are frequently associated with perineural tumor spread (PNS). This \nPNS can occur in the absence of clinical signs; hence, the radiologist routinely \nhas to exclude nerve involvement in all patients with head and neck cancer. Tumor \nspread is most frequent along the maxillary (V2) or mandibular (V3) branches of \nthe trigeminal nerve although tumor can less frequently also follow the ophthalmic \nbranch (V1). The mastoid segment of the facial nerve is another typical extension \nroute and tumors will also follow the connections between the facial and trigeminal \nnerve. Tumor spread along the hypoglossal nerve is less frequent. Involved nerves \nenhance, are thickened and cause enlargement of the foramina, fissures and canals \nthey pass through and eventually the tumor will extend intracranially and become \nmore difficult to treat or intreatable. PNS can be detected on axial and coronal high \nresolution gadolinium-enhanced T1-weighted images although more and more \nisotropic sub-millimetric gadolinium-enhanced fat suppressed 3D-FFE/VIBE images \nare used. In this refresher course, the typical routes of PNS will be illustrated and \nthe signs of PNS will be covered. Attention will be paid to the imaging techniques \nwhich should be used to detect tumor spread. An overview of the anatomical sites \nwhere it is easiest to pick up PNS and which should be checked will also be given. \nLearning Objectives:\n1. To learn the MR techniques used to depict cranial nerve involvement.\n2. To recognise the signs of nerve involvement by tumor.\n3. To understand the different routes of perineural tumor spread.\nA‑036 17:00 \nC. Depiction of dural invasion: How good is MRI? \nA. Borges; Lisbon/PT (borgalexandra@gmail.com) \nTransdural growth of head and neck malignancies has a major impact on treatment \nplanning and patient’s prognosis. Whereas tumours remaining extradural can be \nexcised through a facial approach, tumours that transgress the dura require a \ncombined craniofacial resection including dural resection to obtain free surgical \nmargins and often major reconstructive efforts to avoid post-surgical complications. \nSeveral studies have demonstrated the negative impact of dural invasion in patient’s \noutcome, together with the presence of positive margins and tumour histology. \nTherefore, all efforts should be made to recognize this feature pre-operatively. MR \nhas proven to be the most accurate image modality to depict dural invasion and \nperineural spread of tumour. Dural enhancement, although very sensitive for dural \ninvasion, has a low specificity as it may result not only from invasion by tumour but \nalso from reactive fibrovascular changes and meningeal inflammation. The pattern \nof dural enhancement, thicker than 5 mm or nodular, is more accurate, with higher \nspecificity. In addition, loss of the hypointense line which separates tumour from \nthe adjacent enhancing dura, (corresponding to the epidural space), and loss of \ncontinuity of the enhancing dura, best depicted on high resolution MR sequences, \nare helpful imaging signs of dural invasion. During surgery, efforts should be made \nto resect the surgical specimen en bloc with the adjacent dura and, when not at all \npossible, to correctly label the excised fragments of the dura to allow for adequate \npathologic staging. \nLearning Objectives:\n1. To recognise the most common routes of dural invasion by head and neck \ntumors.\n2. To understand the impact of transdural growth on treatment planning and \nprognosis.\n3. To become familiar with the MR criteria for dural invasion and their accuracy.\n4. To understand the limitations of pathology in assessing dural invasion.\n16:00 - 17:30 Room P \nCardiac \nRC 203 \nTips and tricks to improve your image quality \nModerator:\nT. Bader; Vienna/AT \nA‑037 16:00 \nA. Sharp CT images with little radiation \nL. Lehmkuhl; Leipzig/DE (lukas.lehmkuhl@med.uni‑leipzig.de) \nIn recent years the technological development of cardiac MSCT has increased the \nimportance of this procedure for the assessment of coronary heart disease in com-\nparison with cardiac catheterization. Computed tomography coronary angiography \n(CTCA) is increasingly performed in the clinical setting. However, successful use \nof CTCA depends on the radiologist‘s knowledge of potential pitfalls. Artifacts and \nsuboptimal contrast enhancement can degrade image quality and result in potential \nmisinterpretation. Artifacts can have multiple reasons, for example motion-related \nartifacts caused by cardiac, pulmonary or breathing movement, beam-hardening \neffects caused by metallic implants and calcifications, structural artifacts due to \nadjacent contrast enhanced structures and vessels and artifacts that result from \ntechnical limitations. An optimal contrast enhancement depends mainly from the \ncontrast injection protocol. Biphasic contrast injection protocols can be used for \nCTCA, while triphasic injection protocols are more suitable for functional analysis \nand for the assessment of the right ventricle. Furthermore, an optimal contrast \ndepends from an appropriate planning of the bolus tracking and from the venous \naccess chosen. Moreover, a successful cardiac CT depends on the radiation \nexposure applied. A high radiation dose results in high-resolution images, while a \nlower dose leads to increased image noise and results in unsharp images. There \nare several strategies to reduce the radiation dose during CT examinations without \ncompromising the diagnostic value of the examination, for example by the use of \na prospective gating or lowering the kV. \nLearning Objectives:\n1. To eliminate artifacts.\n2. To optimise contrast injection.\n3. To minimise radiation dose.\nA‑038 16:30 \nB. Clear MR images without artefacts \nJ. Bremerich; Basle/CH (jbremerich@uhbs.ch) \nIntroduction: Magnetic Resonance Imaging (MRI) of the heart is a powerful tool, \nbut it is also technically demanding. Images, however, can be substantially degraded \nby artefacts. Knowledge of origin, appearance and significance of such artefacts is \nessential to avoid misinterpretation and to improve image quality.\nMethods and Material: Cardiac imaging is typically performed on 1.5 or 3 Tesla \nmagnets equipped with surface coils using ECG gated sequences. Imaging tech-\nniques have evolved from traditional spin-echo and gradient-echo to turbo-spin-\necho, spoiled-gradient-echo, and balanced steady-state-free-precession sequences. \nMost recently developed techniques allow evaluation of morphology, function, \nperfusion, viability, coronary anatomy and flow; some advanced techniques are \nparticularly vulnerable to artefacts.\nResults: Gating related artefacts may be eliminated by repositioning of the leads, \nacquisition in end-expiration, optimization of sequence parameters or with periph-\neral pulse gating. Insufficient nulling of normal myocardium on late-enhancement \nsequences may be optimized by a dedicated TI scout. In balanced steady-state-\nfree-precession sequences, dark-band artefacts may occur particularly on 3 Tesla \nsystems. Such artefacts can be reduced by frequency shift technique. Some arte-\nfacts, however, may also be of diagnostic value. In cases when normal myocardium \ncannot be nulled even with long inversion times, amyloidosis may be suspected. \nMoreover, when gradient echo sequences provide low signal of myocardium, iron \noverload may be suspected.\nConclusion: Cardiac MRI is technically demanding and requires profound knowl-\nedge of MR physics as well as specific cardiac anatomy and physiology to identify \nartefacts, to avoid misinterpretation and to develop remedies for image improvement. \nLearning Objectives:\n1. To improve contrast, spatial and temporal resolution.\n2. To discuss usefulness of parallel imaging.\n3. To choose 1.5 or 3.0 Tesla: Is more always better?\n\nThursday\nPostgraduate Educational Programme\nA\n S15\nCB D E F G\nA‑039 17:00 \nC. Rescuing the examination with post-processing \nP .M.A. van Ooijen; Groningen/NL (p.m.a.van.ooyen@rad.umcg.nl) \nCardiac Computed Tomography (CT) has seen a very fast development over the \npast few years. Although the quality of the examinations has increased due to this \ndevelopment, problems such as trigger artefacts, suboptimal contrast bolus and \nrespiratory artefacts can still occur. For some of these problems, advanced post-\nprocessing techniques can be utilized to either reduce the resulting artefacts or to \nallow easy recognition of the artefacts. In this refresher course lecture, an overview \nof the current possibilities and impossibilities is given. \nLearning Objectives:\n1. To reduce ECG trigger artefacts on CT and MR.\n2. To compensate for suboptimal contrast enhancement.\n3. To choose appropriate visualisation techniques.\n16:00 - 17:30 Room Q \nInterventional Radiology \nRC 209 \nThe trauma patient \nModerator:\nA.A. Hatzidakis; Iraklion/GR \nA‑040 16:00 \nA. Imaging algorithms \nL.S. Fournier; Paris/FR (laure.fournier@egp.aphp.fr) \nInjured patients are considered as multi-trauma victims according to the mechanism \nof injury or the number of lesions, at least one being life-threatening. Initial imag-\ning evaluation of these patients will depend on the techniques available and the \nhaemodynamical state of the patient; determining one of two imaging work-ups. \nIn the haemodynamically unstable patient, chest and pelvis radiographs are per-\nformed as well as a US FAST (Focused Assessment with Sonography in Trauma) \nprotocol. This abdominal ultrasound examination provides a quick overview of the \nintraperitoneal cavity to detect free fluid, an indirect sign of acute haemorrhage, \nand injury to visceral organs requiring immediate surgery. It can be performed with \nmobile equipment and by emergency staff, including non-radiologists or surgeons. \nUS is highly sensitive (90%) for the detection of free intraperitoneal fluid but less \n(40%) for the identification of organ injuries. In the haemodynamically stable patient, \nwhole-body multidetector computed tomography (WBCT) is performed, providing \nrapid and complete assessment of head, cervical spine, chest, abdomen and \npelvis. WBCT has shown very high positive and negative predictive values > 90% \nfor each of the anatomical regions and for detection of active bleeding, with 30% \nof patients presenting lesions in one or more anatomic region than that suspected \nclinically. Lesions to solid organs may be divided in hematomas, lacerations, and \nvascular injuries. CT is the best technique to detect bowel injuries which may be \noccult initially and must be suspected in presence of bowel wall thickening, free \nfluid or air in the peritoneal cavity. \nLearning Objectives:\n1. To discuss appropriate triage of trauma patients to imaging.\n2. To learn the appropriate imaging techniques.\n3. To review imaging appearances.\nA‑041 16:30 \nB. Principles of embolisation \nJ.C. van den Berg; Lugano/CH (jos.vandenberg@eoc.ch) \nIn the management of trauma patients, the role of embolisation has become more \nand more important over the last years. With refinement of technique and avail-\nability of new embolic agents and catheters, more patients can be treated minimally \ninvasive nowadays. When performing transcatheter, knowledge of proper timing \nof the procedure and knowledge of material is essential. This paper will focus on \nthis, and will give an overview of all currently available embolic agents and devices, \ntheir use, indications and contraindications for their application. Potential pitfals will \nbe discussed, and complications will be dealt with. Finally, long-term outcome and \nresults will be discussed. \nLearning Objectives:\n1. To discuss the indications and timing of embolisation for trauma patients.\n2. To learn about principles and techniques of embolisation.\n3. To review endpoints and results of embolisation.\nA‑042 17:00 \nC. Iatrogenic trauma \nP . Haage; Wuppertal/DE (patrick.haage@helios‑kliniken.de) \nTraumatic injuries requiring prompt and effective treatment may in some instances \nbe a consequence of iatrogenic procedures. They may be as diverse and individual \nas the triggering trauma itself. Of particular interest to the radiologist regarding \ndiagnosis and treatment are vascular traumata. Iatrogenic trauma to the arterial \nand venous systems is quite frequent today, which may partly be attributed to \nthe increase in interventional procedure in recent years. Observed injuries to the \ncirculation may range from pseudoaneurysms, bleedings and dissections to arte-\nrial/deep vein thromboses, arteriovenous fistulae, embolism and occlusion. In this \npresentation, the necessary diagnostic imaging modalities in iatrogenic trauma \nand its interventional radiologic complication management will be presented and \ndelivered via “typical” examples. \nLearning Objectives:\n1. To review causes and imaging appearances of iatrogenic trauma.\n2. To review various IR methods of treatment.\n3. To review results and appropriate follow-up strategies.\n18:30 - 18:50 Room A \nPlenary Session \nOL \nPresiding:\nM. Szczerbo‑Trojanowska; Lublin/PL \nA‑043 18:30 \nThe two faces of HIV/AIDS in the brain: The face you know - And the one \nyou don’t \nA.G. Osborn; Salt Lake City, UT/US (anne.osborn@hsc.utah.edu) \nHIV-induced brain injury is a significant complication of AIDS. CNS symptoms \n(HIV encephalopathy or “HIVE”) are the first complaint in 5-10% of patients. More \nthan 25% eventually develop severe cognitive deficits (HIV-associated dementia \ncomplex). The face of HIV/AIDS that most of us know and recognize is that of \nthe disease as managed in a “resource-rich” environment. Questions such as \n“who should be imaged” and “how should they be imaged” presuppose a wealth \nof resources unimaginable in many parts of the world. With the advent of highly-\neffective antiviral regimens, HIV/AIDS has become for many infected patients a \nchronic, difficult but manageable disease. This presentation will briefly demonstrate \nthe pathology and imaging spectrum of HIV/AIDS as a chronic disorder, including \nexamples of the new immune reconstitution inflammatory syndrome (IRIS) in the \nbrain. The “other” face of HIV/AIDS, the one that most of us do not know, is that of \nthe disease in populations with “resource-poor” environments. AIDS in developing \ncountries often presents differently. While the virus is the same, its manifestations \nare quite different. Here AIDS can be an acute, often fulminant disease where co-\ninfections such as TB create a deadly intersection that magnifies the morbidity and \nlethality of both agents. Imaging in these patients, when available, may show a very \ndifferent disease spectrum from the more familiar patterns seen in resource-rich \nenvironments. With increased immigration and the rapid emergence of multi-drug \nresistant and extreme drug-resistant TB, this “second face” of HIV/AIDS may be \nthe one we will see in the very near future. \nLearning Objectives:\n1. To learn about the imaging spectrum of HIV/AIDS in the central nervous \nsystem in a resource-rich environment where highly effective antiviral \ntreatments and supportive therapy are widely available.\n2. To identify the imaging manifestations of immune reconstitution inflammatory \nsyndrome (IRIS) as seen in the brain.\n3. To understand the “deadly intersection” between HIV/AIDS and TB in \nresource-poor environment.\n4. To learn about the imaging manifestations of HIV/AIDS when it presents as \nacute, fulminant disease in a resource-poor environment.\n\nPostgraduate Educational Programme\nS16 A B C D E F G\n\nPostgraduate Educational Programme\nA S17CB D E F G\nPostgraduate Educational Programme\nA S17CB D E F G\nFriday, March 5\n\nPostgraduate Educational Programme\nS18\n A B C D E F G\n08:30 - 10:00 Room A \nSpecial Focus Session \nSF 3a \nDiffusion-weighted imaging of the abdomen: \nA new tool for oncologic imaging? \nModerator:\nF. Caseiro‑Alves; Coimbra/PT \nA‑044 08:30 \nChairman’s introduction \nF . Caseiro-Alves; Coimbra/PT (caseiroalves@gmail.com) \nExploitation of the microscopic movement of water molecules within biological \ntissues by DWI is a new tool for MRI, now becoming more available and wide-\nspread for a variety of abdominal applications. In oncology, its role as an imaging \nbiomarker is being progressively established for detection, characterization and \nmonitor response to therapy. Despite all these features, there are still many open \nissues to be solved such as standard definitions for measurement analysis, imag-\ning protocols for different anatomical locations, reproducibility among vendors, and \ninterpretation of the quantitative ADC values. Also, as a measure of diffusivity of \nthe extravascular extracellular space, complete understanding at the microscopic \nlevel is still incomplete and confounding factors may be present contributing to \nchange the final imaging appearance. Taking in account all the potential benefits \nof DWI, it is thus essential that radiologists master the technique, understanding \nits physical principles, clinical applications, limitations and pitfalls. It is the purpose \nof this session to provide a comprehensive overview of the technique ranging from \ntechnical definitions and parametrization options to specific applications in the liver, \npancreas and for lymph node mapping and/or characterization. \nSession Objectives:\n1. To introduce the imaging tools for evaluating tumor components.\n2. To address quantification issues and the role of DWI.\n3. To recall how to create imaging protocols.\n4. To stress the role of DWI in oncologic imaging and future developments.\nA‑045 08:34 \nDiffusion imaging: From theory to protocol development \nD.-M. Koh; Sutton/UK \nDiffusion-weighted MR imaging (DW-MRI) derives its image contrast from differ-\nences in the mobility of water between tissues. The signal attenuation observed \non DW-MRI reflects tissues cellularity, the tortuosity of the extracellular space, \nintegrity of cell membranes, as well as bulk flow phenomenon such as microcapillary \nperfusion. DW-MRI measurements can be acquired very quickly (typically several \nseconds to a few minutes) without the administration of exogenous contrast media, \nand provides unique qualitative and quantitative information that can aid disease \ndetection, disease characterisation and the evaluation of tumour response to treat-\nment. In the body, DW-MRI is most often performed using single-shot echo-plainer \nimaging (EPI) technique. Image acquisition can be performed in breath-hold or \nfree-breathing; the latter may be combined with respiratory and/or cardiac trigger-\ning. Each of these techniques has its advantages and disadvantages. DW-MRI in \nthe body using EPI technique is prone to a variety of artefacts and careful imaging \noptimisation is therefore critical to success. The DW-MRI acquisition sequences \nshould be optimised to maximise signal-to-noise and minimise potential artefacts. \nAdjustment of imaging parameters such as the echo-time, matrix size, partition \nthickness, parallel imaging, fat suppression scheme and the receiver band width are \nimportant to ensure that high quality DW-MR images can be consistently attained. \nA good apparent diffusion coefficient (ADC) measurement reproducibility can be \nachieve through meticulous technique. Evolving developments of DW-MRI in the \nbody include more sophisticated image acquisition and evaluation techniques to \ngain further insights into tissue structure and function. \nLearning Objectives:\n1. To describe the principles of DWI and its technical settings\n2. To discuss the influence of technical settings for imaging evaluation.\n3. To explain the role of quantification obtained by ADC maps and \nmeasurements and to comment on reproducibility issues.\n4. To discuss technique’s pros and cons, trends and future developments.\nA‑046 08:53 \nFocal liver lesions: What can we expect? \nM. Lewin; Paris/FR (maite.lewin@sat.aphp.fr) \nAs a result of rapid technological developments, DW-MRI is now a part of standard \nabdominal imaging practice. It is of special interest for detection and characteriza-\ntion of focal hepatic lesions because it improves tumor visualization and provides \nquantitative data (ADC map). This makes it possible to differentiate benign from \nmalignant lesions which display higher ADC values due to higher cellularity. How-\never, an overlap exists. The b value, characterizing the diffusion gradient’s strength, \nis a clue parameter. A minimal b value is needed to avoid perfusion effect but too \nhigh b values result in signal loss. A series of b values, usually from 200 to 800  \ns/mm\n2, are required to calculate ADC. Benign lesions have ADC values ranging \nfrom 2.04 to 2.89, HCC from 1.31 to 1.39 and metastasis 0.85 to 1.50 x 10-3 mm2/s. \nAn additional interest is the monitoring of treatment response and the prediction of \ntreatment outcome for vascular disruptive drugs and apoptosis-inducing therapies. \nSuccessful treatment is generally reflected by an increase in ADC values because \nof tumor size reduction or tumor necrosis. Correlatively, patients with tumors hav-\ning high ADC levels before treatment may be predicted to have a poor outcome. \nFurthermore, DW-MRI can be used as a pharmacodynamic biomarker that could \nsupport decision making in the drug development process, the aim being to increase \nthe likehood of success in later more coslty trials. However, the major challenge is \nstandardization of data acquisition and analysis for multicenter studies. \nLearning Objectives:\n1. To present DWI results for focal liver lesion detection and characterisation.\n2. To discuss shortcomings, pitfalls and technical details essential for obtaining \naccurate clinical results.\n3. To describe the current role of DWI in quantification and tumor response \nevaluation.\nA‑047 09:12 \nPancreatic neoplasms: Is DWI helpful? \nC. Matos; Brussels/BE (cmatos@ulb.ac.be) \nCompared to T1-weighted and T2-weighted strategies, diffusion-weighted imag-\ning (DWI) provides another mechanism for developing image contrast that may \nincrease the sensitivity and the specificity of MRI of the pancreas. In addition to \nthe information on tissue cellularity, on cell membrane integrity and on extracellular \nspace turtuosity, apparent diffusion coefficients (ADC) maps of tissue water can \nbe generated. For pancreatic DWI, parallel imaging, fat suppression, respiratory \ntriggering and multiple b-values (typically 0, 150 and 1000 s/mm\n2) are used. This \nstrategy presents the advantages of exploring a large FOV and has acceptable \nspatial resolution. Moreover, patient cooperation is minimized. Promising results \nhave been reported concerning the usefulness of DWI for investigating pancreatic \nadenocarcinoma and mass forming pancreatitis. It has been shown that mean ADC \nvalues of malignant lesions are significantly lower than those of benign lesions and \nthat DWI has similar accuracy to conventional MR imaging in diagnosing pancreatic \ncancer. Our results using DWI to explore the full range of pancreatic diseases did \nnot show statistically significant differences in mean ADC values between malignant \nand inflammatory diseases. Using DWI in addition to conventional MRI mainly \nincreased the sensitivity and the negative predictive value of the MR examination. \nDWI was a useful non-invasive tool for the follow-up of inflammatory diseases, \nand for detecting a lesion that may be suitable for biopsy in patients with chronic \npancreatitis or a cystic neoplasm. \nLearning Objectives:\n1. To present DWI results in cystic and solid pancreatic lesions, and explain its \nrole in detection, characterisation and staging.\n2. To discuss which sequence parameters should be used to get consistent \nclinical results.\n3. To address the role of quantification, potential shortcomings and pitfalls of \nthe technique for this application.\nA‑048 09:31 \nPelvic cancers and lymph node imaging: The PET competitor? \nS. Gourtsoyianni; Iraklion/GR (sgty76@gmail.com) \nIdentification of metastatic lymph nodes in pelvic malignancies is of paramount \nimportance since it modifies treatment strategy and prognosis. In order to avoid \nunnecessary extended lymphadenectomy, non-invasive imaging techniques are \ntried out. Cross-sectional imaging relying on nodal size and morphology and PET \non metabolic activity for lymph node characterization have not yet produced suf-\nficiently effective staging results due to considerable overlap in imaging features \nof benign and malignant lymph nodes. Lymphotropic nanoparticle enhanced MR \n\nFriday\nPostgraduate Educational Programme\nA\n S19\nCB D E F G\nimaging, however, has resulted in higher sensitivity in pelvic cancers lymph node \ncharacterization but requires long MR scanning time and is not available for routine \nclinical use. Diffusion weighted imaging has been tested with excellent results for \ndelineation and characterization of primary pelvic cancers and shows promise for \nlymph node staging. Diffusion weighted whole body imaging with background body \nsignal suppression (DWIBS) with inversion of gray scale producing images similar \nto PET and axial single shot EPI DWI with fat suppression demonstrate normal \nlymph nodes with a relative restricted diffusion, while both increase conspicuity \nof small (up to 2 mm) lymph nodes. ADC map produced from the latter sequence \nusing a wider range of b values is rendered necessary for quantification and thus \ncharacterization of lymph nodes. ADC is relatively independent of lesion size and \nvarious criteria, such as relative ADC value, have been proposed to increase sensi-\ntivity of DWI regarding differentiation between metastatic and non-metastatic pelvic \nlymph nodes, with the largest series being those of gynecological malignancies \ndue to extensive lymphadenectomy correlation data. \nLearning Objectives:\n1. To learn the technical settings (sequence characteristics, b values, necessity \nof ADC map or not, layout of images with or without 3D reconstruction) and \nthe optimal compromise for evaluating prostate, rectal and gynecological \ntumors.\n2. To review the literature on the Se and Sp of DWI, as compared with PET/CT \nand MRI with tissue-specific contrast media regarding local tumor staging.\nPanel discussion:  \nIs DWI ready for routine use in oncological practice? \n09:50 \n08:30 - 10:00 Room B \nRadiology of the Spine in 2010 \nCC 316 \nCommon spinal “problems” \nModerator:\nI.M. Björkman‑Burtscher; Lund/SE \nA‑049 08:30 \nA. “Myelopathy”: Easy way to the correct diagnosis \nM.M. Thurnher; Vienna/AT (majda.thurnher@meduniwien.ac.at) \nMyelopathy is a term that actually means “there is something wrong with the spinal \ncord” itself. Increased signal intensity in the spinal cord on T2-weighted magnetic \nresonance images (MR) has been reported in numerous diseases. Causes include \ntrauma, primary and secondary tumours, bacterial and viral myelitis, radiation my-\nelitis, spinal cord ischemia, compression myelopathy, etc. It is then not surprising \nthat the differentiation could be almost impossible based only on imaging findings. \nThis lecture will focus on MR imaging findings in the spinal cord diseases and its \npractical value in narrowing the differential diagnosis. The location, extent, multi-\nplicity, signal characteristics, and the degree of enhancement of abnormalities will \nbe described. A practical schematic approach with integration of imaging features \nand clinical data will be introduced. \nLearning Objectives:\n1. To define the term “myelopathy”.\n2. To discuss the differential diagnoses of spinal cord diseases.\n3. To introduce a “clinically useful” algorithm for myelopathy.\nA‑050 09:00 \nB. Congenital anomalies made \"easy\" \nA. Rossi; Genoa/IT (andrearossi@ospedale‑gaslini.ge.it) \nSpinal and spinal cord malformations are collectively named spinal dysraphisms. \nThey arise from defects occurring in the early embryological stages of gastrulation \n(weeks 2-3), primary neurulation (weeks 3-4), and secondary neurulation (weeks \n5-6). Spinal dysraphisms are categorized into open spinal dysraphisms, in which \nthere is exposure of abnormal nervous tissues through a skin defect, and closed \nspinal dysraphisms, in which there is a continuous skin coverage to the underlying \nmalformation. Open spinal dysraphisms basically include myelomeningocele and \nother rare abnormalities such as myelocele and hemimyelo (meningo)cele. Closed \nspinal dysraphisms are further categorized based on the association with low-back \nsubcutaneous masses. Closed spinal dysraphisms with mass are represented by \nlipomyelocele, lipomyelomeningocele, meningocele, and myelocystocele. Closed \nspinal dysraphisms without mass comprise simple dysraphic states (tight filum \nterminale, filar and intradural lipomas, persistent terminal ventricle, and dermal \nsinuses) and complex dysraphic states. The latter category further comprises de-\nfects of midline notochordal integration (basically represented by diastematomyelia) \nand defects of segmental notochordal formation (represented by caudal agenesis \nand spinal segmental dysgenesis). Magnetic resonance imaging is the preferred \nmodality for imaging these complex abnormalities. The use of the aforementioned \nclassification scheme is greatly helpful for making the diagnosis. \nLearning Objectives:\n1. To become familiar with normal and abnormal embryology of the spine.\n2. To review the most common spinal congenital anomalies and their \npathogenetic background.\n3. To describe imaging findings in various spinal anomalies that allow \ndifferentiation between entities.\nA‑051 09:30 \nC. Extradural spinal tumors \nP .C. Maly Sundgren; Lund/SE (Pia.Sundgren@med.lu.se) \nTumors of the spinal canal both the purely extradural tumors and those involving \nthe spinal cord are uncommon lesions but may result in significant morbidity. The \nmost important imaging tool for evaluating the spinal canal is magnetic resonance \nimaging (MRI). Conventional MRI has the capability to classify tumors of the spinal \ncanal in extradural, intradural-extramedullary or intradural intramedullary lesions. \nThe differential diagnosis for extradural and intradural-extramedullary spinal tu-\nmors are primarily based on location, but also the clinical presentation, age and \ngender of the patient are important factors in determining the diagnosis. The most \ncommon intradural extramedullary lesions are schwannomas, meningiomas, and \nneurofibromas. Less common lesions include paraganglioma, metastases, and \nrare tumors such as spinal nerve sheath myxoma (neurothekeoma), as well as \nlipoma, sarcomas and vascular tumors. These tumors occur far more commonly \nin the adult population than in children. Purely extradural lesions are rare, includ-\ning lymphoma, metastasis and benign lesions like arachnoid cyst, dermoid, and \nepidermoid. Among the differential diagnosis to primary and secondary tumors, \nwe have to consider epidural hematoma and abscesses. This short presentation \nwill focus on the current classification and the conventional MRI imaging features \nof the more common extradural and intradural extramedullary spine lesions. The \nrole of new MR imaging sequences such as diffusion weighted imaging (DWI) and \ndiffusion tensor imaging (DTI) and the use of measurements of apparent diffusion \ncoefficient (ADC) and fractional anisotropy (FA) to differentiate spinal neoplasms \nwill be discussed. \nLearning Objectives:\n1. To review the current classification of tumors in the spinal canal.\n2. To summarise key imaging findings in extradural spinal tumors.\n3. To become familiar with new techniques used in differentiation of spinal \nneoplasms.\n08:30 - 10:00 Room C \nState of the Art Symposium \nSA 3 \nMultiple sclerosis update \nModerator:\nA. Rovira‑Cañellas; Barcelona/ES\nA‑052 08:30 \nChairman’s introduction \nA. Rovira-Cañellas; Barcelona/ES (alex.rovira@idi‑cat.org) \nMultiple sclerosis (MS) is a chronic, persistent inflammatory-demyelinating dis-\nease of the CNS that typically presents as an acute clinically isolated syndrome \nattributable to a monofocal or multifocal demyelinating lesion. Conventional MRI \n(cMRI) techniques, such as T2W and gadolinium-enhanced T1W sequences, are \nhighly sensitive in detecting MS plaques and provide a quantitative assessment of \ninflammatory activity and lesion load. In fact, MRI is now integrated in the overall \ndiagnostic scheme of the disease because of its unique sensitivity to demonstrate \nthe spatial and temporal dissemination of demyelinating plaques in the brain and \nspinal cord. However, there is a persisting mismatch between clinical and cMRI \nefficacy of approved treatments, which underlies the fact that cMRI does not suffice \nto explain the entire spectrum of the disease process. In recent years, great effort \nhas been dedicated to overcoming this limitation by using non-conventional MR-\nderived metrics that can selectively measure the more destructive aspects of MS \npathology and monitor the reparative mechanisms. These metrics, which include \n\nPostgraduate Educational Programme\nS20\n A B C D E F G\nunenhanced T1-weighted imaging, measures of CNS atrophy, MT imaging, MR \nspectroscopy, DW imaging, and functional MRI, provide a better approximation of \nthe pathological substrate of the MS plaques, have increased our understanding \nof the pathogenesis of the disease, and have proven useful for studying the natural \nhistory of MS and monitoring the effects of new treatments. Therefore, MRI not \nonly plays an essential role in the diagnosis of MS, but can also serve as a true \nbiological marker of the severity of this disease. \nSession Objectives:\n1. To introduce the clinical aspects and pathophysiology of MS.\n2. To clarify the role of conventional and non-conventional MRI techniques in \nthe diagnosis and monitoring of MS.\n3. To stress the advantages and limitations of MRI as a biological marker in MS.\nA‑053 08:35 \nMRI and histopathological studies \nF . Barkhof; Amsterdam/NL (f.barkhof@vumc.nl) \nMRI is often used to diagnose multiple sclerosis (MS). This is due to the very \nhigh sensitivity of T2-weighted MRI for any alterations occurring in MS, including \ninflammation, demyelination, gliosis and axonal loss; even remyelinated lesion \nappear bright on T2-weighted images. For the same reason, it is hard to predict \nthe relationship between the extent of abnormalities on T2-weighted scans and \nrelapses or irreversible disability in MS - the so-called clinical-radiological paradox. \nBeyond the shortcomings of clinical scoring systems, MRI factors explaining this \ndiscrepancy include: a) location of lesions and spinal cord involvement, b) degree \nof tissue damage within lesions, c) abnormalities in the so-called normal appearing \nwhite matter, and d) grey matter involvement. Even newer techniques like double-\ninversion recovery (DIR) fail to identify the vast majority of cortical lesions, and \nonly cortical atrophy is a useful predictor of disability in advanced stages of MS. \nLearning Objectives:\n1. To understand the clinical-radiological paradox concept in MS.\n2. To comprehend the histopathological specificity of the various MR \nsequences based on radiological-pathological correlations.\n3. To be aware of the clinical importance of grey matter involvement in MS.\nA‑054 08:58 \nUpdate on MRI diagnostic criteria \nT.A. Y ousry; London/UK (t.yousry@ion.ucl.ac.uk) \nAn early and accurate diagnosis of MS in CIS patients is important to relieve \nuncertainty, provide prognosis counseling and consider MS disease modifying \ntreatments that have partial efficacy at this earliest clinical stage of the disease. \nAlthough, no single clinical feature or diagnostic test is sufficient for the diagnosis \nof MS, MRI has become the most useful investigation to support an MS diagnosis - \nand sometimes identifies alternative diagnoses. Diagnostic MRI criteria have been \ndeveloped based on the demonstration of lesions disseminated in space (DIS) and \ntime (DIT) and after exclusion of alternative causes. The most relevant are the \n“McDonald criteria” from 2001, and their revision in 2005. Whilst the new criteria \nare a logical step forward, they are complex. Increasing practical experience and \nthe study of different diagnostic approaches have shown potential ways to simplify \nMRI diagnostic prerequisites without relaxing their specificity. A new algorithm is \nproposed by the MAGNIMS group, which takes into consideration both image \ninterpretation and the timing of MRI. \nLearning Objectives:\n1. To be aware of the clinical importance of early diagnosis of MS.\n2. To become familiar with the McDonald MRI-based MS diagnostic criteria.\n3. To examine recent data that supports a revision of the McDonald MRI-based \ndiagnostic criteria in MS.\nA‑055 09:21 \nMRI as a biomarker \nM. Filippi; Milan/IT (massimo.filippi@hsr.it) \nMS is a very heterogenous disease, which usually takes several years before \ndisability accumulation can be measured clinically. This and the poor reliability of \nclinical scales, has led to the use of MR technology to monitor disease evolution. \nTraditionally, the extent of overall lesion burden, the frequency of occurrence of \n“active” lesions and their changes over time have been the most used MRI out-\ncomes. These MR metrics, however, lack of pathological specificity and are unable \nto quantify the extent of damage outside focal lesions. Modern, quantitative MR \ntechniques have the potential to overcome such limitations and have contributed \nto reshape the picture of MS as a condition which evolves through a balance \nbetween, on the one side, inflammatory-demyelination and degeneration and, on \nthe other, the effectiveness of tissue repair and cortical reorganization. Measures \nof atrophy are increasingly used to quantify the extent of irreversible tissue loss. \nMetrics derived from magnetization transfer and diffusion-weighted MRI enable \nus to quantify the extent of structural changes occurring within T2-visible lesions \nand normal-appearing tissues (including gray matter); proton MR spectroscopy \nadds valuable pieces of information on the biochemical nature of such changes; \nfunctional MRI discloses the role of cortical adaptive changes in limiting the clinical \nconsequences of tissue injury. This new picture of MS has important implications in \nthe context of monitoring, since it calls for a multiparametric MR approach, which \nshould be tailored according to the disease stage and the mode of action of the \ntested drug (e.g., anti-inflammatory vs. neuroproctective). \nLearning Objectives:\n1. To recognise the need for surrogate tools to monitor treatments in MS.\n2. To understand the advantages and disadvantages of conventional and non-\nconventional MR techniques that can be used as biomarkers of inflammation \nand neurodegeneration in MS.\n3. To introduce guidelines for the use of MR techniques in monitoring MS.\nPanel discussion:  \nHow should we use MRI in the diagnosis and monitoring of multiple \nsclerosis? \n09:44 \n08:30 - 10:00 Room D \nImaging in Lung Diseases \nCC 318 \nCardiothoracic CT: One-stop-shop procedure? \nModerator:\nP . Herzog; Munich/DE \nA‑056 08:30  \nA. How to assess cardiac function from a chest CT angiographic \nexamination \nG.W. Gladish; Houston, TX/US (ggladish@mdanderson.org) \nRight heart dysfunction can result from a variety of pathologic processes and can \nbe assessed both directly and indirectly using MDCT . Indirect assessment should \nbe performed on all contrast enhanced examinations. This includes morphologic \nevaluation of the right cardiac chambers and pulmonary arteries in comparison to \nanalogous left heart structures. The right ventricle diameter is normally less than the \nleft ventricle. Dilation of the right ventricle indicates pulmonary hypertension or right \nventricular volume overload and is a poor prognostic sign, particularly in patients with \nacute pulmonary emboli. Optimally performing this evaluation requires multiplanar \nreformatting capabilities, as the ratio of ventricular diameters is best demonstrated \non images in the short axis of the ventricles. Other morphologic findings include \nstraightening or reversal of the interventricular septum as an indication of elevated \nright ventricular pressure. Contrast enhancement patterns can also provide clues to \nright heart function. Significant reflux of contrast material into the inferior vena cava \nand hepatic veins indicates abnormal right heart blood flow due to pulmonary arterial \nhypertension, tricuspid regurgitation, or increased pericardial pressure. These conditions \nmay also result in heterogeneous hepatic enhancement due to hepatic congestion. \nDirect assessment of cardiac function requires cardiac gating and optimized contrast \nadministration. Right ventricle contrast enhancement must be maintained compared \nto standard coronary CT techniques. Right ventricle function can then be calculated \nusing tools developed for left ventricular assessment. The assessment of right heart \nfunction can add prognostic information to the assessment of diseases affecting the \npulmonary vasculature, including embolism and fibrosis. \nLearning Objectives:\n1. To review the different means of estimating right cardiac function with MDCT.\n2. To consolidate knowledge of CT features of right ventricular dysfunction.\n3. To understand the clinical usefulness of integrating cardiac functional \ninformation into the daily routine of a chest radiologist.\nA‑057 09:00 \nB. Impact in the management of acute pulmonary embolism \nI. Hartmann; Rotterdam/NL (i.hartmann@erasmusmc.nl) \nPulmonary embolism (PE) is a common and potentially fatal cardiovascular dis-\norder. Pressure overload of the right ventricle (RV) secondary to acute pulmonary \nhypertension is thought to play a significant role in PE-related mortality. Massive PE \nwith hemodynamic instability (e.g., hypotension and cardiac shock) is associated \n\nFriday\nPostgraduate Educational Programme\nA\n S21\nCB D E F G\nwith a poor prognosis and high mortality rates (> 50%). There is general agreement \nthat these patients should be treated aggressively (thrombolytic agents, surgery, \nor interventional procedures) whereas more aggressive therapy is generally not \nindicated in normotensive patients without RV dysfunction (RVD). However, up to \n7% of hemodynamically stable patients treated with anticoagulants also eventu-\nally die related to the PE event. Various diagnostic techniques or laboratory tests \nhave been proposed to classify patients with PE into groups with high risk and \nlow risk of fatal PE, with the ultimate aim of identifying those patients who may \nbenefit from more aggressive therapy. There are contradicting results regarding \nthe association between the extent of obstruction of the pulmonary arteries at CT \nand immediate outcome. Presence and severity of RV dilatation as assessed by \neither echocardiography or CT have been described as independent predictors of \nmortality within 3 months. Although thrombolytic therapy in normotensive patients \nwith RVD is currently controversial, they may also benefit from more aggressive \ntreatment. MDCT can be used to assess the degree of vascular obstruction and \ncardiac dysfunction, stratify the patient's risk of death, and, if thrombolytic therapy \nis indicated, can be used as a non-invasive tool for monitoring treatment. \nLearning Objectives:\n1. To learn about the current markers of cardiac dysfunction in acute pulmonary \nembolism.\n2. To review the prognostic role of MDCT in acute pulmonary embolism.\n3. To become familiar with the therapeutic impact in the management of acute \npulmonary embolism.\nA‑058 09:30 \nC. Clinical usefulness in chronic thoracic diseases \nG. Bastarrika\n1, T. Franquet2; 1Pamplona/ES, 2Barcelona/ES (bastarrika@unav.es) \nMDCT was initially limited to the depiction of morphologic changes at the level of \nthe thoracic organs. Actually, MDCT examinations offer the possibility of providing \ninformation on cardiac function by means of the availability of retrospective ECG-\ngating techniques and developments in dedicated cardiac analysis software. Chronic \nright ventricular (RV) hypertrophy and increased pulmonary resistance often go \non to cause RV dilatation and failure. Cor pulmonale is the syndrome of RV hy-\npertrophy, dilatation, and failure resulting from pulmonary hypertension secondary \nto lung disease. MDCT is an accurate and reliable noninvasive technique in the \nassessment of right ventricular (RV) function in the management of patients who \nhave a wide variety of acute or chronic respiratory disorders. \nLearning Objectives:\n1. To describe the cardiac consequences of chronic thoracic diseases.\n2. To discuss the concept of respiratory and cardiovascular disease in specific \nrespiratory disorders.\n3. To understand how the scanning protocols have to be modified to provide \nsuch information.\n08:30 - 10:00 Room E1 \nAbdominal and Gastrointestinal \nRC 301 \nQuantification of liver processes: Defining \nbiomarkers \nModerator:\nM.A. Bali; Brussels/BE \nA‑059 08:30 \nA. Steatosis \nP . Chevallier; Nice/FR (chevallier.p@chu‑nice.fr) \nHepatic steatosis is the most prevalent liver disorder in the developed world. Non-\nalcoholic fatty liver disease (NAFLD) is its most frequent manifestation and has \nbeen estimated to be as high as 35% in some populations. Currently, liver biopsy \nis still considered the gold standard for the assessment of liver fat, but there is a \nclear need for less invasive diagnostic techniques. Focus has been placed on non-\ninvasive imaging modalities for liver fat detection and quantification. The rationale, \nperformance characteristics, and limitations of these imaging modalities includ-\ning ultrasound, computed tomography, magnetic resonance imaging, magnetic \nresonance spectroscopy and magnetic resonance elastography will be discussed. \nThese techniques offer a wide range of anatomical and morphological informa-\ntion non-invasively even if none of them is able to assess all features visible using \nhistology such as the differentiation between microvesicular and macrovesicular \nsteatosis. Nevertheless, non-invasive imaging techniques and especially magnetic \nresonance are particularly useful to diagnose NAFLD in asymptomatic patients or \nto follow disease progression or response to treatment. \nLearning Objectives:\n1. To know the general features of the pathology and clinical issues.\n2. To know the general imaging findings.\n3. To identify the accuracy of each imaging modality to assess hepatic steatosis \nqualitatively and quantitatively.\nA‑060 09:00 \nB. Iron overload \nJ.M. Alústiza; San Sebastián/ES (jmalustiza@osatek.es) \nQuantification of Liver Iron Concentration (LIC) is the definitive parameter for \ndiagnosing hereditary hemochromatosis (HH). Values above 71 µmol Fe/g are \nhighly suggestive of the disease. In iron overload (IO) secondary to liver disease, \nalcohol abuse, etc. LIC levels are always lower. In secondary hemochromatosis, \nLIC is higher than in HH. Traditionally, LIC quantification requires a biopsy of the \nliver. MRI is considered as the preferred choice for non-invasive quantification \nof the LIC. IO causes a T2 shortening that results in a proportional decrease in \nliver signal. Calculation of relaxation time constants (T2/R2, T2*/R2*) requires \nsequences with multiple TEs and complex post-processing calculations. Results \nhave been reproducible in different machines and have shown a high correlation \nwith LIC measured on biopsies at all iron overload levels, including the high levels \nfound in secondary haemochromatosis. In fact, such calculations are still only \nperformed in highly specialised centres. Calculation of LIC from Signal Intensity \nratios between the liver and the paravertebral muscles is simpler to perform. Several \ndifferent gradient echo (GE) sequences are used to be able to evaluate different \niron overload levels and may be performed rapidly and easily in a vast majority of \nMRI machines. These calculations have shown a good correlation for LIC levels \ntypical of HH, lower than 300-400 µmol Fe/g. However, they saturate with the higher \noverload levels characteristic of secondary hemochromatosis. \nLearning Objectives:\n1. To learn the importance of quantifying the liver iron concentration in the \ndiagnosis of primary and secondary hemochromatosis.\n2. To describe quantification of LIC by MRI. Calculation of T2-R2 vs \nmeasurement of signal intensity ratio liver/muscle. Advantages and \ndisadvantages of each method. Reproducibility, standardisation, availability.\n3. To know the indication of the quantification of the LIC by MRI in the diagnosis \nof primary and secondary hemochromatosis.\nA‑061 09:30 \nC. Fibrosis \nB. Van Beers; Clichy/FR (bernard.van‑beers@bjn.aphp.fr) \nLiver fibrosis is a non-specific cicatrization process that occurs in all chronic insults \nof the liver. Hepatic fibrosis is reversible and can be treated, especially before \ncirrhosis occurs. The diagnosis of fibrosis relies on liver biopsy. However, hepatic \nbiopsy is invasive and there is a sampling variability related to the heterogeneity \nof fibrosis and the small size of the biopsies. Scoring systems based on serum \ntests have been developed. These biomarkers only enable differentiation between \nminimal and advanced fibrosis. Anatomical imaging is limited to the detection of \nadvanced fibrosis. Functional imaging can be used to stage liver fibrosis. Micro-\ncirculatory changes that can be detected with perfusion CT or MRI are observed \nin hepatic fibrosis. However, the correlation between the changes of the perfusion \nparameters and the stage of fibrosis is only moderate. At diffusion-weighted MRI, \nthere is a decrease of the apparent diffusion coefficient of the liver that correlates \nwith increased fibrosis. However, this decrease is mainly related to perfusion \nrather than true extracellular diffusion changes. Elastography is a new method that \nmeasures the visco-elastic parameters of the liver. Transient and acoustic radiation \nforce impulse elastography are ultrasound methods that are increasingly used to \nstage liver fibrosis. With MR elastography, a more accurate and precise assessment \nof the visco-elastic parameters of the liver can be obtained. These visco-elastic \nparameters are currently the most accurate biomarkers of liver fibrosis. However, \nother factors than fibrosis can influence the mechanical properties of the liver, \nincluding inflammation, bile duct obstruction and stellate cell activation. \nLearning Objectives:\n1. To understand the importance of detecting and assessing the severity of liver \nfibrosis.\n2. To learn about the value and limitations of different imaging methods for the \nquantification of liver fibrosis.\n3. To compare imaging and non-imaging biomarkers of liver fibrosis.\n\nPostgraduate Educational Programme\nS22\n A B C D E F G\n08:30 - 10:00 Room E2 \nFoundation Course: Head and Neck Radiology \nE³ 320a \nImaging techniques and common pitfalls \nModerator:\nB. Bobek‑Billewicz; Gliwice/PL \nA‑062 08:30 \nA. Computed tomography \nR. Maroldi; Brescia/IT (maroldi@med.unibs.it) \nThe main advantages of the current CT technology consist of its high spatial and \ntemporal resolution. A key issue of spatial resolution is the availability of isotropic \nvoxels below 0.30 mm to study very small bony structures as the ossicles in the \nmiddle ear, or the bony labyrinth. Improvements of temporal resolution permits to \nexamine the head and neck in most uncooperative patients, and to better separate \narterial and venous phases. The combination of high spatial and temporal resolu-\ntion enables a precise evaluation of complex structures, as the larynx, minimizing \nartifacts due to patient movement. However, the smaller are the voxels, the more \nthe SNR diminishes, thereby often resulting in a poor contrast resolution. The \nradiologist should be aware of this limitation. The choice of the proper slice thick-\nness in MPR or MIP may significantly increase the SNR and the detectability of \nthe vascular structures, respectively. In addition, MPR and MIP reconstructions \nprovide the power of high resolution in the coronal and the sagittal planes. Specific \nCT protocols have been tailored to achieve the necessary information in the vari-\nous areas of the head and neck and in different diseases (i.e. low mA in sinonasal \ninflammatory lesions, high mA in tumor assessment to maximize lesion detection). \nThough contrast agent administration usually enhances the pattern of the lesions \n(and the adjacent neck “key” vessels), on CT the contrast resolution of tissues is \npoor when compared to MR. \nLearning Objectives:\n1. To appreciate the possibilities and limitations of CT in head and neck \nradiology.\n2. To become familiar with technical factors affecting image quality, including \ncontrast agent administration protocols.\n3. To learn how to fully exploit the possibilities of multidetector CT in head and \nneck imaging.\nA‑063 09:15 \nB. Magnetic resonance imaging \nM.G. Mack; Frankfurt a. Main/DE (m.mack@em.uni‑frankfurt.de) \nMagnetic resonance imaging is the state-of-the-art method for the evaluation of \nhead and neck disease. Especially in the head and neck area, the quality of the \nexamination depends on the correct selection and adjustment of the MR sequences. \nThe goal of this course is to learn how a MRI examination of the head and neck can \nbe optimized. The advantages and disadvantages of different MR sequences will \nbe discussed. Over the past few years, diffusion-weighted MRI has evolved from a \ntechnique that is primarily used to evaluate acute cerebral infarction to one that is \nemployed to study a variety of head and neck disease. The use of specific contrast \nagent will be evaluated further. This course will reduce the rate of diagnostic errors \nby helping radiologist distinguish pathology from MRI appearance that may simulate \ndisease. Tips and tricks of patient positioning and adaption of the sequences will \nbe presented. In addition, this course will demonstrate the different artefacts and \nthe most common pitfalls of magnetic resonance imaging in the head and neck \nand how to avoid them. \nLearning Objectives:\n1. To appreciate the possibilities and limitations of MRI in head and neck \nradiology.\n2. To become familiar with technical factors affecting image quality in head and \nneck MRI.\n3. To learn about new developments in MRI of head and neck pathology.\n08:30 - 10:00 Room F1 \nInteractive Teaching Session \nE³ 320b \nBreast cancer: Diagnosis, staging and follow-up \nModerator:\nA. Tardivon; Paris/FR \nA‑064 08:30 \nBreast cancer: Diagnosis, staging and follow-up \nK. Kinkel1, J. Camps Herrero2; 1Chêne‑Bougeries/CH, 2Valencia/ES \n(karen.kinkel‑trugli@wanadoo.fr) \nImaging guided biopsy has replaced surgical biopsy of suspicious breast lesions to \nreduce unnecessary surgery for benign disease and indicate the need for sentinel \nlymph node procedure. Biopsy guidance depends on lesion visibility at sonography, \nmammography or MRI. T o minimize false negative results, 9-14G needles and vacuum \nassisted systems are preferred sampling methods for most lesions. Image documenta-\ntion of non palpable lesion location and residual amount after biopsy is mandatory for \npreoperative lesion localization planning. A clip is positioned at the site of biopsy when-\never a suspicious lesion disappears during sampling or neoadjuvant chemotherapy. \nPreoperative lesion localization is usually guided by the imaging modality that has \nbeen used for biopsy. Specimen radiograph during surgery reduces surgical cancer \nremoval with positive tumor margins at postoperative pathology. Breast cancer staging \nencompasses a wide variety of anatomical and pathologic features that have a clear \nimpact on treatment: size, extensive intraductal component, extension to the nipple-\nareola complex, the pectoralis muscle or the skin and lymph node status. Compared \nto mammography and ultrasound, MRI is the most accurate imaging modality for \nlocal staging, except for lymph node assessment, where ultrasound and fine-needle \naspiration biopsy are the techniques of choice. The different follow-up strategies in \nthe breast cancer patient depend on the clinical scenario: assessment of response to \nneoadjuvant chemotherapy, follow-up of patients treated with conservative or recon-\nstructive surgery, confirmation of a suspected recurrence and evaluation of residual \ndisease after positive margins at pathology. The role of different imaging modalities \nwill be demonstrated in teaching cases. \nLearning Objectives:\n1. To obtain adequate lesion samples to allow histological proof prior to \ntreatment.\n2. To learn how to evaluate the extent of breast cancer.\n3. To learn the different follow-up strategies in patients with breast cancer.\n08:30 - 10:00 Room F2 \nMultidisciplinary Sessions: Managing Patients with Cancer \nMS 321 \nProstate gland \nA‑065 08:30 \nChairman’s introduction \nU.G. Mueller-Lisse; Munich/DE (ullrich.mueller‑lisse@med.uni‑muenchen.de) \nProstate cancer is now estimated to be the most frequently detected cancer in \nmen, with the exception of skin cancers (25% of all new cancers in male patients \nin the US). It is the second most common cause of cancer death among men (9% \nof all cancer deaths in male patients in the US). The debate over screening for \nprostate cancer has been active for years. While regional and multinational trials \ncontinue, there is as yet no nationwide screening project established. Prostate \nspecific antigen (PSA) has increased the number of prostate cancers detected \nat an early stage, with curative treatment options and increased post-therapeutic \nsurvival. With increased numbers of small cancers being detected, there are more \ntherapeutic modalities available, both in urological surgery and in radiation oncology. \nChoice demands for selection criteria, including radiological imaging, as an aid to \ndecisions. After therapy, patients with prostate cancer are being followed-up, to rule \nout both complications of the respective therapy selected and the development of \nrecurrence or metastasis. Findings at follow-up may have to be corroborated and \ntreatments planned based on radiological imaging. This multidisciplinary session \ndemonstrates and discusses current diagnostic and therapeutic options in prostate \ncancer and the respective role of radiological imaging, with emphasis on commu-\nnication, multidisciplinary interaction and decision-making. \n\nFriday\nPostgraduate Educational Programme\nA\n S23\nCB D E F G\nLearning Objectives:\n1. To know which clinical and imaging tests are available to detect and localise \nprostate cancer, and how they are currently being applied in clinical practice.\n2. To know which clinical and imaging tests are available to determine the \nextent of prostate cancer and its complications both before and after therapy.\n3. To know which therapeutic options are available to treat prostate cancer, and \nwhat factors influence the selection of treatment modality.\nA‑066 08:35 \nWhat the surgeon needs to know \nM. Seitz; Munich/DE (Michael.Seitz@med.uni‑muenchen.de) \nThe diagnosis of prostate cancer (PC) is based on a combination of digital rectal \nexamination (DRE), serum prostate specific antigen (PSA) testing, and transrectal \nultrasound (TRUS)-guided biopsy. In prostate cancer diagnosis or staging, neither \ncomputed tomography (CT) nor magnetic resonance imaging (MRI) are routinely rec-\nommended by European Association of Urology (EAU) guidelines. Nevertheless, MRI, \nPET/CT -scans and other modalities such as contrast-enhanced TRUS, MRI-guided \nbiopsy, MRI/TRUS-fusion guided biopsy and elastography are increasingly gaining \nrecognition as important tools for the detection and localization in patients suspected \nof prostate cancer. The aim of the lecture is to review the current and future clinical \nstatus of imaging procedures in the detection and localization of prostate cancer and \nwhat factors may influence the selection of treatment modality such as radical prosta-\ntectomy (RP), radiation (EBRT), hormonal therapy (HT), watchful waiting (WW) and \nactive surveillance (AS). Another main issue of the lecture, which is of high interest for \nclinicians, is the diagnostic value of imaging in patients with recurrent PC after definitive \ntherapy. We illuminate the advantages and drawbacks of TRUS, MRI and functional \nMRI-techniques as well as choline-based PET/CT -scanning. \nLearning Objectives:\n1. To know which tests can be performed to detect and localise prostate cancer, \nand the role diagnostic imaging plays.\n2. To know which urologic treatment options there are for prostate cancer, what \nfactors influence the selection of treatment modality, and if those factors can \nbe evaluated on a clinical basis.\n3. To know what information is necessary and what is useful for the surgical \ntreatment of prostate cancer.\n4. To know how surgical results are evaluated and how complications are \ndetected.\n5. To know how the patients are followed up.\n6. To know how recurrence is detected, analysed, and managed.\nA‑067 08:55 \nWhat the oncologist needs to know \nC. Belka; Munich/DE (Claus.Belka@med.uni‑muenchen.de) \nRadical surgery and radiation alone or in combination comprise highly effective \ntreatment modalities for prostate cancer. Up to now, only population based data \nindicate that in primary treatment settings surgery and radiation are equally ef-\nfective. Due to compliance problems and ethical consideration, no randomized \ntrial will address this question in the foreseeable future. In case of a biochemical \nrelapse or R1 resection, radiotherapy is the only curative approach currently known. \nDiagnosis and treatment monitoring is still based mainly on PSA determination. \nHowever, MRI and chlorine-PET may add important information in several clinical \nsituations. In this regard, the determination of an exact T stage and N stage is the \nmost important question to be addressed by imaging. \nLearning Objectives:\n1. To know about clinical staging of prostate cancer and what role there is for \ndiagnostic imaging.\n2. To know which radiation therapy options there are for prostate cancer, what \nfactors decide on the selection of treatment modality, and if those factors can \nbe evaluated on a clinical basis.\n3. To know how the response to the treatment is evaluated.\n4. T o know which complications may occur and how complications are detected.\n5. To know how the patients are followed up.\n6. To know how recurrence is detected, analysed, and managed.\nA‑068 09:15 \nImaging in prostate cancer \nU.G. Mueller-Lisse; Munich/DE (ullrich.mueller‑lisse@med.uni‑muenchen.de) \nDigital rectal examination (DRE) and prostate-specific-antigen testing (PSA) rep-\nresent the mainstay of prostate cancer (PCA) detection and are of limited use for \nstaging. Transrectal ultrasonography (TRUS) guides prostate biopsy when either \nDRE or PSA yields abnormal results. Magnetic resonance imaging (MRI) appears \nto be more accurate than either DRE or TRUS-guided biopsy and can help to detect \nand localize PCA and guide targeted biopsy in patients with suspicious PSA and \npreviously negative prostate biopsy results. Studies in small patient populations \nwith negative prostate biopsy results concordantly show moderate to high positive \npredictive values (approximately 40-90%) and high negative predictive values \n(approximately 87-100%) for combined MRI and MR spectroscopy. MRI can be \nhelpful for the local staging of PCA, including extracapsular extension (ECE) and \nseminal vesical invasion (SVI). MRI findings most indicative of ECE include oblit-\neration of the recto-prostatic angle and asymmetry of the neurovascular bundle. \nWhile accuracy of MRI varies widely, it appears to improve with maturation of MR \ntechnology (e.g., combined phased-array-endorectal-coil-systems, faster MRI \nsequences, more powerful gradient coils, and improved image post-processing), \nreader experience (e.g., almost 40% more sensitivity for ECE in experienced read-\ners), and combination of MRI with other MR techniques (e.g., combined dynamic, \ncontrast-enhanced MRI with sensitivity/specificity of 85/95% for ECE, respectively). \nFor SVI, sensitivity of MRI varies (approximately 25-80%), while specificity is high \n(approximately 80-99%). Data are limited for recurrent PCA, but one study reports \nsensitivity/specificity of 95/100% for local recurrence. PET/CT with choline-markers \naids in the detection of nodal and distant metastasis of PCA. \nLearning Objectives:\n1. To review different diagnostic imaging modalities and their respective \ncapabilities in the diagnosis.\n2. To summarise diagnostic imaging modalities and their respective test quality \nparameters in tumor detection and localisation.\n3. To learn about tumor staging.\n4. To learn about challenges in the detection of recurrences.\nPanel discussion and case presentation\n 09:35 \n08:30 - 10:00 Room G/H \nSpecial Focus Session \nSF 3b \nImaging the polytrauma patient \nModerator:\nA. Palkó; Szeged/HU \nA‑069 08:30 \nChairman’s introduction \nA. Palkó; Szeged/HU (palkoand@gmail.com) \nIn the modern trauma management environment, the role of imaging diagnostics is \nparamount. At the same time, the number of available modalities and the special ex-\npertise required for the appropriate treatment of the trauma patient makes it of utmost \nimportance to define the optimal, but at the same time sufficiently flexible, diagnostic \nalgorithm. The definition is supposed to extend not only to the sequence of available \nmodalities in different clinical settings but should also reflect the special attitude required \nfrom the radiologist in this special emergency environment. Thus, the goal of this session \nis to discuss rather the management and procedural details, the structured diagnostic \nalgorithm than the imaging symptoms and techniques, while of course these should \nstill play a role in the introduction and discussion of the topic. \nSession Objectives:\n1. To introduce the critical role of the radiologist in the care of polytrauma \npatients.\n2. To understand the role of imaging and image-guided intervention in reducing \nmorbidity and mortality.\n3. To explain appropriate diagnostic algorithms in different clinical settings\nA‑070 08:35 \nWho, when and where: The role of the radiologist in the trauma team \nG. Schueller; Vienna/AT (gerd.schueller@meduniwien.ac.at) \nTrauma induced mortality is approximately as high as of cardiovascular and onco-\nlogic disease together. During the last decade, the radiologist’s role in dedicated \ntrauma centres has been changing considerably. Most often, time is the major \ndeterminant for the prognosis of the traumatized patient. The radiologist’s expertise \nis needed to rapidly assess life-threatening conditions on the one hand and to pro-\nvide adequate information about the extent of organ lesions on the other, thereby \npredicting whether surgery would become necessary or wait and see strategies \nwould be of help. Hence, the radiologist is in the very middle of the trauma team, \n\nPostgraduate Educational Programme\nS24\n A B C D E F G\nalong with trauma surgeons and anesthesiologists. For that purpose, injury severity \nscores are of great help, and the radiologist must be familiar with these scores, as \nwell as with the therapeutic consequences associated with them. \nLearning Objectives:\n1. To learn about teamwork and evidence-based procedures in the \nmanagement of polytraumatised patients from the radiologist’s point of view.\n2. To understand CT -based injury severity scores, and the associated \ntherapeutic consequences.\n3. T o become familiar with the specific requirements regarding equipment, workflow \nand training of technicians and radiologists in an emergency unit environment.\nA‑071 08:45 \nFront line sonography \nE. Danse; Brussels/BE (danse@rdgn.ucl.ac.be) \nOur aim is to report on the current opinion about the role of US for the manage-\nment of polytraumatized patients. In this specific context, US is used for detection \nof intraperitoneal free fluid, pleural effusion, and indirect signs of pneumothorax. \nIn hemodynamically unstable patients, US is followed by an urgent exploratory \nlaparotomy or an angiographic procedure depending of US findings. In stable \npatients, negative or positive US is followed by a whole body CT evaluation. Based \non this presentation, the audience has to be informed to the current opinion about \nthe following items: 1. When to do this examination? At the time of accident, during \nthe resuscitation process, during the transport or at the initial time of admission \nin the emergency room? 2. Where to do this examination? On the scene of the \ntrauma, in the emergency department, in the operating room, in the radiological \ndepartment? 3. Who will do the examination? The more skilled and available opera-\ntor, a sonographer or a doctor, including an emergency physician, a surgeon, an \nanesthesiologist, and at the end, a radiologist? 4. Which device has to be used? \nMobile/portable sonographic machine, high tech device? 5. What do we have to \nlook for? a) ascitis and visceral lesions, chest and cardiac abdnormalities? b) which \nfindings can help for triage of the patients and definitions of priorities? Wait and see, \nCT without delay, CT with delay, early angiographic procedure or early laparotomy. \nLearning Objectives:\n1. To learn about the role and limitations of sonography in the management of \npolytraumatised patients.\n2. To be informed about the indications, timing, technical requirements and \noperator skill of US examination of the polytrauma patient.\n3. To understand the significance of different findings (visceral, chest and \ncardiac abnormalities, pathologic fluid accumulations, vascular injuries, etc). \ndetectable by US.\nA‑072 09:05 \nMDCT as the single best solution \nU. Linsenmaier; Munich/DE (ulrich.linsenmaier@med.uni‑muenchen.de) \nDiagnosis of trauma-related injuries is a key issue in modern emergency radiology. Fast, \nearly and comprehensive, as well as accurate depiction of potentially life-threatening \ninjury patterns is crucial. Conventional radiography (CR) and ultrasound (US) are well-\nestablished and still in use for a basic diagnostic work-up; however, many of studies \nhave shown a lower detection rate compared to CT . MDCT with its shorter scan time and \nincreased accuracy has become the gold standard for all patients after major trauma. \nThis lecture will cover the following issues: we will initially present current concepts \nof the so called „whole body CT (WBCT)“ or synonymously used „trauma pan scan“ \nprotocols for the initial radiological management of patients with major trauma (syn. \npolytrauma, multiple injured). We discuss also the use of MDCT for the primary patient \nsurvey (A TLS), integration of MDCT scanners in the emergency room and outcome of \npatients after MDCT . We then focus on comprehensive whole body MDCT scan pro-\ntocols for use in different scanner types, from 4, 16, 64 to 128 detector row scanners, \nincluding, technical aspects, slice and detector collimation, contrast medium injection, \nscan phases and image reconstruction parameters. MDCT delivers higher radiation \ndose, professional optimization of imaging parameters is recommended to minimize \nexposure and maximize diagnostic safety. We then present recent approaches for fast \nvolume image data reading (VIR), handling large data sets, as well as handling of a \nlarger number of patients as in mass casualties incidences. \nLearning Objectives:\n1. To understand the major role of MDCT in the early assessment of \npolytrauma patients and its influence on outcome.\n2. T o learn about comprehensive whole body protocols for patients with polytrauma \n(for 4-16-64 and > 64*MDCT scanners), technical aspects, contrast medium \ninjection, scan phases and image reconstruction parameters.\n3. To appreciate approaches for fast volume image data reading, logistics of an \nemergency radiology unit and factors affecting patient throughput.\nA‑073 09:25 \nThe growing importance of interventional radiology \nT. Jargiello; Lublin/PL (tojarg@interia.pl) \nCatheter-based, endovascular techniques had become an integral part of the trauma \nteam’s armamentarium. Although recognition of the role of interventional radiology \nin vascular trauma have a significant impact in decreasing morbidity and mortality, \nnot all hospitals have possibility to use it as 24-hour service. Transcatheter arte-\nrial embolization is the basic IR technique used to control bleeding in polytrauma \npatients. Each case of vascular or solid organ trauma is different, especially when \nit takes multi-organ injury. That is why specialized IR team must have at their own \ndisposal all possible catheter equipment (coaxial technique) and all available \nembolization materials. Injuries of main vascular trunks can also be managed with \ncovered stents (stentgrafts) - but it is really hard to have all its types and sizes on \nstock. Apart from TEA and stenting, percutaneous drainage procedures are also of \nsome importance especially, when there is a need to minimally invasive treatment \nof pathologic blood or other fluid collections. Sometimes, both methods are used \nin particular patient simultaneously. Good results of IR treatment of polytrauma \npatients are strictly depend on patients’ clinical status. Stable patients or those \nwith rapid response to fluid resuscitation (SBP > 80 mmHg) have better chance \nfor successful minimally-invasive intervention. Injury Severity Score (ISS) is very \nhelpful in predicting the final outcome (mortality rate). According statistics, patients \nwith ISS less than 50 are almost all to survive after non-surgical treatment and \nthose with ISS > 50 may not respond to this type of therapy. \nLearning Objectives:\n1. To discuss the role of interventional radiologists in the trauma team.\n2. To learn about the possibilities of interventional radiology.\n3. To recommend the appropriate methods depending on the clinical status of \nthe patient.\nPanel discussion:  \nImaging in polytrauma: How can we help most? \n09:45 \n08:30 - 10:00 Room K \nSpecial Focus Session \nSF 3c \nPediatric non-traumatic emergencies:  \nWhat we must know! \nModerator:\nM. Raissaki; Iraklion/GR \nA‑074 08:30 \nChairman’s introduction \nM. Raissaki; Iraklion/GR (mraissaki@yahoo.gr) \nPediatric non-traumatic emergencies represent a large proportion of all pediatric \nradiology cases and are ideally managed by experienced personnel, familiar with \nthe nature of the emergency. It is important to appreciate that certain signs and \nsymptoms are indicative of dangerous conditions with significant morbidity and \nmortality if left untreated or if there is delay in diagnosis and treatment. It is equally \nimportant to realise that conversely, in other cases, imaging could be delayed but \nis usually performed on an emergency basis to alleviate parent’s and/or doctor’s \nanxiety. In some life-threatening conditions, symptoms may be disturbing and \nalarming while in other situations with equally dangerous conditions, symptoms \nmay be mild. In all cases, the radiologist should play an active role by keeping a \nhigh index of suspicion for the devastating pediatric emergencies and by choosing \nthe most appropriate test taking under consideration the age of the patient, past \nmedical and present history, together with the signs and symptoms. Every test \nshould be performed appropriately with a dedicated technique, depending on the \nclinical question especially when considering aspirated foreign bodies and gastro-\nintestinal abnormalities. Experienced radiologists prove an invaluable assistance to \nclinicians for the management of these cases guiding towards medical or surgical \ntherapy and sometimes offering therapeutic intervention. Paediatric non-traumatic \nemergencies can be divided into four main categories, requiring imaging of the \nbrain, chest, abdomen and musculoskeletal system. \nSession Objectives:\n1. To discuss the most common non-traumatic pediatric emergencies.\n2. To understand the potentially devastating complications of delay in their \ndiagnosis and treatment.\n\nFriday\nPostgraduate Educational Programme\nA\n S25\nCB D E F G\n3. To recommend the most appropriate imaging test depending on age, history \nand symptoms.\n4. To understand the importance of appropriate technique when performing \ncertain tests on children.\nA‑075 08:33 \nNeurological emergencies \nC. Garel; Paris/FR (catherine.garel@trs.aphp.fr) \nSome conditions or symptoms may be highly suggestive of brain damage. In neo-\nnates, hypoxic-ischaemic encephalopathy, seizures with or without fever, marked \nhypotonia, apnea, marked thrombopenia or thrombophilic disorders prompt rapid \ninvestigation. In both neonates and older children, intracranial hypertension, con-\nsciousness disorders or infectious context with neurological findings require urgent \ncerebral imaging. In older children, acute onset or rapid evolution of neurological \nsymptoms or onset of neurological symptoms in a child suffering from sickle cell \ndisease, haematological malignancy or solid tumour are also an emergency. In all \nthese conditions, cerebral imaging may directly impact on therapeutic manage-\nment. Conversely, in other cases, cerebral imaging could be delayed but is usually \nperformed rapidly due to parental and/or medical anxiety. This is particularly true \nin neonates when brain abnormality was diagnosed by prenatal imaging and \npregnancy was not terminated or when facial malformation or syndrome with pos-\nsible brain involvement are discovered at birth and were not diagnosed by prenatal \nultrasound. Ultrasound is a good screening and monitoring imaging modality in \nneonates but lacks sensitivity and may overlook numerous cerebral lesions. Com-\nputed tomography can rapidly detect hydrocephalus or haemorrhage but it also \nlacks sensitivity. Magnetic resonance is the most sensitive current imaging modality \nand has better contrast resolution. Diffusion weighted imaging may be particularly \nuseful in the setting of cerebral emergency. \nLearning Objectives:\n1. To appreciate alarming symptoms requiring urgent investigation.\n2. To differentiate true emergencies for which cerebral imaging may directly \nimpact on therapeutic management and “delayed” emergencies related to \nparental and/or medical anxiety.\n3. To be aware of the main cerebral non-traumatic emergencies in neonates \nand older children.\n4. To learn about the respective contributions of US, CT and MRI.\nA‑076 08:51 \nThoracic emergencies \nC.E. de Lange; Oslo/NO (charlotte.eva.delange@rikshospitalet.no) \nIn children, non-traumatic thoracic emergencies are very frequent and usually \npresent with breathing difficulties. Sometimes, feeding or swallowing problems are \nassociated or presenting symptoms. In addition, less specific general symptoms \nlike fever, sepsis or chest pain may occur. The emergencies always require a rapid \ndiagnosis to establish a medical or surgical intervention plan, and radiological imag-\ning most often plays a key role. Correct interpretation of the radiological findings \nis of great importance to diagnose and monitor the illness and to avoid serious \ncomplications. Plain radiography with inspiratory and sometimes expiratory films or \nfluoroscopy still remains the most important and frequently used tool to gain informa-\ntion on acute pulmonary problems of all kinds. Ultrasonography is the first choice \nfor diagnosis and treatment of pleural effusions. Cross-sectional techniques like \nmultidetector computed tomography and magnetic resonance imaging are mainly \nused for investigating pulmonary/mediastinal masses and congenital abnormalities \nof the great vessels and the lungs. This lecture will review the imaging characteris-\ntics of acquired and congenital causes to non-traumatic thoracic emergencies; the \ncommon conditions involving the respiratory tract, chest wall and the esophagus, \nas well as the less frequent causes like tumours and manifestations of congenital \nmalformations. The choice of imaging modality and the urgency of radiological \nmanagement depending on the clinical presentation and the age of the child will \nbe discussed, with the main focus beyond the neonatal period. \nLearning Objectives:\n1. To learn about the spectrum of thoracic emergencies in children, including \nforeign bodies, mediastinal tumors, infection, asthma, air leaks and delayed \nmanifestations of congenital chest malformations.\n2. To consolidate knowledge of the essential role of radiology in making a rapid \ndiagnosis, planning treatment and avoiding devastating complications.\n3. To understand the different thoracic emergencies depending on age.\n4. To recommend the appropriate radiological technique depending on the \nclinical indication and the patient’s age.\nA‑077 09:09 \nAbdominal emergencies \nS.G.F . Robben; Maastricht/NL (srob@rdia.azm.nl) \nSeveral pediatric diseases are real abdominal emergencies. Any delay in diagnosis \nand treatment may result in death or severe morbidity. These diseases are highly \nage-dependent. Newborn infants may have congenital diseases as Hirschsprung’s \ndisease or meconium ileus or may develop necrotizing enterocolitis, incarcerated \ninguinal herniation and midgut volvulus. Infants and preschool children have \nintussusceptions, urinary tract infections and (rare) hemolytic uremic syndrome. \nChildren and adolescents have appendicitis, genito-urinary infections, ovarian tor-\nsion and Henoch Schonlein purpura. Considering radiation dose in children and the \nexcess value of ultrasonography (US) in small individuals, US plays an important \nrole as initial diagnostic modality in pediatric abdominal emergencies. Sensitivity \nand specificity for US in diagnosing intussuception, midgut volvulus, urinary tract \nabnormalities and appendicitis is over 90%. Conventional abdominal radiographs \nor fluoroscopy are valuable in Hirschsprung’s disease, meconium ileus, malrota-\ntion and necrotizing enterocolitis. I consider CT as an additional technique when \nthe initial techniques (US and conventional radiography) are inconclusive. MRI is \nseldom indicated in pediatric patients with abdominal emergencies because of \nmotion artifacts in anxious children and sometimes limited MR capacity. Delay \nin diagnosis of the above-mentioned diseases may be devastating, ranging from \nlife-long disability to death. Therefore, it is important to consider these diagnoses \nand to initiate prompt adequate diagnostic work-up. \nLearning Objectives:\n1. To discuss the most common and devastating pediatric abdominal \nemergencies.\n2. To discuss the appropriate imaging techniques in pediatric abdominal \nemergencies.\n3. To understand the consequences of any delay in diagnosis.\nA‑078 09:27 \nMusculoskeletal emergencies \nK.J. Johnson; Birmingham/UK (karl.johnson@bch.nhs.uk) \nThe common non-traumatic paediatric musculoskeletal emergencies which involve \nradiological evaluation in the order of priority are sepsis, slipped capital (upper) \nfemoral epiphysis (SCFE) and malignant tumours. This presentation will discuss \nthe clinical presentation of these conditions, the role and timing of imaging (and \nits limitations) and the appropriateness of specialist referral in these conditions. A \nseptic joint or limb can rapidly cause significant dysfunction and long-term morbidity. \nFortunately, appropriate rapid treatment will often lead to complete cure. Radiology \nis helpful in confirming the diagnosis, but the imaging features can be non-specific. \nImportantly, normal radiological findings, in particular radiographs and ultrasound, \ncannot exclude the diagnosis and clinical evaluation remains vitally important. The \nradiological features of osteomyelitis and septic arthritis will be demonstrated. \nThe value of magnetic resonance imaging in detecting occult infection, assessing \ncollections and planning appropriate surgical intervention will be illustrated. SCFE \ncan either present as an acute or an acute and chronic problem. It is important that \nboth AP and lateral radiographs are obtained to assess the hips. The important \ndiagnostic clues in assessing for SCFE will be discussed. The role of MR imaging \nas a complementary investigation will be highlighted. When there is a suspicious \nbone lesion, those features which suggest more rapid and aggressive growth will \nbe illustrated. The difficulties in excluding a malignant lesion along with the ap-\npropriate use of cross-sectional imaging and the importance of specialist referral \nwill be discussed. \nLearning Objectives:\n1. To learn about the three commonest musculoskeletal diseases that require \nurgent radiological evaluation and stress the complications of delay in \ndiagnosis and treatment.\n2. To discuss the complementary role of different imaging modalities in the \nevaluation of musculoskeletal infection, slipped capital femoral epiphysis and \nmalignancy.\n3. To recommend imaging algorithms.\nPanel discussion:  \nHow to manage the stressed pediatrician \n09:45 \n\nPostgraduate Educational Programme\nS26\n A B C D E F G\n08:30 - 10:00 Room L/M \nSpecial Focus Session \nSF 3d \nFetal body MRI \nModerator:\nM. Bekiesinska‑Figatowska; Warsaw/PL \nA‑079 08:30 \nChairman’s introduction \nM. Bekiesinska-Figatowska; Warsaw/PL (m.figatowska@mp.pl) \nOver the last 27 years, much has been written about fetal MRI, an adjunct technique \nto sonography in the detection of prenatal malformations, allowing for confirmation, \ncompletion and/or correction of sonographic findings. Most publications concerned \nfetal neuroradiology as the assessment of the central nervous system of the fetus \nwas the main indication for prenatal MRI. The spectrum of indications has grown \nhowever and MRI has emerged as a diagnostic tool for global assessment of the \nfetal body because new ultrafast MRI sequences have eliminated artifacts caused \nby fetal motion and provided very good quality of T2-weighted images acquired in \nless than one second. A high contrast between details of fetal body can be obtained \nthanks to the large amounts of water in most of fetal tissues. The purpose of this \nsession is to review practical aspects of MR imaging of fetal thorax, abdomen and \nmusculoskeletal system. The radiologists should know the normal anatomy of the \nfetal body and be able to recognize the pathologies characteristic for this develop-\nmental period. A discussion closing the session should answer the question whether \nthis concerns every radiologist or will remain a task for superspecialized radiologists. \nSession Objectives:\n1. To understand the role of prenatal body MRI.\n2. To learn about the added value of MRI compared to US in prenatal diagnosis \nof the thorax, abdomen and musculoskeletal system.\n3. To become familiar with imaging features of pathologies in these areas of the \nfetal body.\nA‑080 08:35 \nMRI of the thorax \nP . Eliás; Hradec Králové/CZ (elias@fnhk.cz) \nMagnetic resonance imaging (MRI) still suffers from limited temporal resolution and \nis rarely used for fetal cardiac studies. On the contrary, MRI has fewer physical and \nsubjective limitations than ultrasonography (US) and offers different information \nusing fast T2 and T1-weighted sequences. That is why it is becoming a valuable \nadjunct to US in evaluation of fetal thorax. MRI can aid in three categories: 1) to \nprovide more details on abnormalities seen on US, 2) to refine volumetry of the \nlungs, and 3) to provide the data on lung maturation. In congenital diaphragmatic \nhernia, two major prognostic factors can be accurately evaluated: presence of \nintrathoracic liver tissue (T2 hypo- and T1 hyperintense structure) and volume \nof the residual lungs. Estimation of total fetal lung volume on MRI seems to have \nbetter predictive value than traditionally used lung/head ratio based on US. Con-\ngenital cystic adenomatoid malformation and pulmonary sequestration present as \nT2 hyperintense and T1 hypointense expansile lesions. MRI is frequently used to \nconfirm the diagnosis and for follow-up of possible regression of these abnormali-\nties. Contrary to Doppler US, MRI is not able to differentiate between each other \nand is of limited predictive value. Developing fetal lung shows gradual increase of \nT2 and decrease of T1 signals due to increasing fluid content. Thus, the quantifica-\ntion of their relative values with liver serving as a reference organ can be used for \nassessment of pulmonary maturation. Diffusion weighted or spectroscopic MRI \nstudies do not seem to be of additional value at present. \nLearning Objectives:\n1. To become familiar with the standard US and MR examination techniques for \nimaging of the fetal thorax.\n2. To learn the basic aspects of normal imaging anatomy.\n3. T o cover the most important pathological entities affecting the fetal thorax and to \nshow the strengths and weaknesses of US and MR in diagnosing them.\n4. To point out currently accepted indications and future perspectives of MRI.\nA‑081 08:58 \nMRI of the abdomen \nT.A.G.M. Huisman; Baltimore, MD/US (thuisma1@jhmi.edu) \nFetal MRI has evolved to be a valuable second line imaging modality to confirm, \ncorrect or complete prenatal ultrasound (US) findings. Fetal MRI has proven to be \nespecially helpful for the central nervous system (CNS), but is however less well \nestablished for fetal abdominal pathologies. With growing fetal imaging expertise, \nincreasing acceptance of fetal MRI, and ongoing hard- and software developments, \nfetal MRI is progressively been used for abdominal indications. The fetal radiologist \nshould be familiar with the normal abdominal fetal anatomy and embryology to \nunderstand and identify fetal abdominal pathology. Based upon the normal devel-\nopment of the abdominal organs and gastrointestinal (GI) tract, we will review the \nvarious fetal pathologies that can be identified by fetal MRI. In particular, we will \nreview what the added value of fetal MRI is compared to prenatal US, which kind of \nimage contrasts should be used and what their respective value is in the examina-\ntion of fetal pathology. Many abdominal indications have already been established \nincluding pathologies of the GI-tract (atresia), the mesenterium (lymphangioma), \nthe solid organs (neuroblastoma) and urogenital tract (renal agenesis, cloacal \nmalformation). The list of abdominal indications is however continuously growing. \nThe importance of evaluating abdominal pathologies in the context of the entire \nfetal anatomy is obvious. Lesions within the abdomen may be related to adjacent \nor distant lesions but may also be part of a syndrome or even related to a possible \ntwin fetus. Consequently, a fetus with an abdominal pathology should always receive \na complete fetal MRI examination. \nLearning Objectives:\n1. To learn about fetal abdominal MRI and its current and future indications.\n2. To understand the strengths and weaknesses of fetal MRI of the abdomen.\n3. To appreciate the added value of fetal MRI compared to US in examining \nfetal abdominal pathologies.\n4. To become familiar with the different fetal MRI techniques for studying \nabdominal pathologies.\n5. To consolidate knowledge of abdominal pathologies that can be encountered \nintrauterine.\nA‑082 09:21 \nMRI of the skeleton \nD. Prayer, S.F . Nemec, G. Kasprian, D. Bettelheim, P .C. Brugger; Vienna/AT \n(daniela.prayer@meduniwien.ac.at) \nDiagnosis of pathologies of the fetal musculoskeletal system is regarded as a do-\nmain of ultrasound. Especially, 3D techniques allow detailed information on small \ndetails already in the early second trimester. Regarding these details, MRI is inferior \nto ultrasound even if the availability of echoplanar or gradient-echo sequences has \nimproved its ability to visualize bone. However, skeletal malformations and deformi-\nties may be parts of complex syndromes, the prognosis of which depends on the \npresence or absence of additional pathology. In such cases, for instance in Chiari \nII syndrome, MRI may provide information that allows to estimate the prognosis \nmore accurately. MRI can show the type of spinal dysraphism, and the extent of \ncerebral involvement. In syndromes like arthrogryposis that have a wide variety of \netiologies, some of them may be proved or excluded. In case of a single anomaly, \nas for instance, a club foot, the question of presence or absence of a complex \nmalformation or an underlying syndrome may be answered by MRI. Skeletal mal-\nformations are often associated with thoracic deformities leading to a reduction of \nlung volumina. Lung volumetry and assessment of lung signals help to conclude \non postnatal lung functionality. Malpositioned limbs may be the consequence of \nneuromuscular diseases. In such cases, MRI may find pathological signals in the \nmuscles. It has also been described that MRI can demonstrate the developmental \nchanges of the non-osseous parts of the metaphysis of the long bones. Whether \nthis information will be usable for diagnostic purposes will have to be proved. \nLearning Objectives:\n1. To understand which sequences demonstrate the fetal musculoskeletal \nsystem most adequately.\n2. To learn the contribution of MRI in the workup of musculoskeletal \npathologies.\n3. To recognise characteristic features of such pathologies on US and MRI.\nPanel discussion:  \nSuperspecialised examination or a task of the general radiologist? \n09:44 \n\nFriday\nPostgraduate Educational Programme\nA\n S27\nCB D E F G\n08:30 - 10:00 Room N/O \nProfessional Challenges Session \nPC 3 \nTeaching: Art, habit or science? \nModerator:\nJ.E. Wildberger; Maastricht/NL \nA‑083 08:30 \nChairman’s introduction: Teaching and education - help yourself: \nRequirements for the future of radiology \nJ.E. Wildberger; Maastricht/NL (j.wildberger@mumc.nl) \nTeaching and education in medicine is paid more and more attention, last but not \nleast for the evident shortage of young academics. If students and young profes-\nsionals are made enthusiastic by inspiring lectures and interactive seminars, it will \nbe more likely that they are interested in becoming e.g. a radiologist. This session \nwill provide different facets of lecturing and seminars. Standards, such as the \nEuropean Training Charter for Clinical Radiology, form a good basis for a local \nadaptation. Core competencies and clinical expertise will always be required to \npresent and communicate goals and objectives on a high level. In order to meet \nthe miscellaneous expectations, learning objectives and the current level of knowl-\nedge in the auditorium have to be considered. Improvements in teaching skills can \nbe trained and reflected, e.g. by changing the perspective (teacher-learners), by \nreceiving and providing feed-back, from independent evaluations, etc. to meet the \nultimate goal, a higher level of educational effectiveness. Different approaches and \nperspectives will be presented: active participation can be combined with traditional \ninteraction. Also, „new media“ such as e-learning will be discussed, which offer great \nopportunities for teaching and education, especially for our „visual“ and „digital“ \ndiscipline. These can also be incorporated into dedicated new teaching concepts, \nsuch as „problem-based learning“, where imaging is integrated rather than being \na stand-alone discipline. Finally, we are looking forward to a vivid panel discussion \non the different facets, opportunities and challenges in teaching and education. \nSession Objectives:\n1. To review the specific features of teaching and education in radiology.\n2. To understand the need of young radiologists in this context.\n3. To learn about the current and future concepts for improving teaching and \neducation.\nA‑084 08:35 \nClinical teaching: Avoid the yawn \nR. Greif; Berne/CH (robert.greif@insel.ch) \nWith a little effort, you, too, can deliver an exciting lecture or teaching session. \nAs an expert in the field, your job is not just to know your topic by heart - it is to \ninspire your students, igniting the fire of learning rather than inspiring yawns. Ef-\nfective clinical teaching requires involvement with your learners. Knowledge of their \nproblems, views and visions of the topic influences the learning climate. Exciting \nclinical teachers are not born, they are trained. Get involved in CME seminars about \nteaching, or formal medical education training programs. Spend your limited time in \nseminars focusing on teaching skills that you might transfer to your clinical teaching \nenvironment. Interaction and emotions initiate learning on the neurophysiologic level \nvia the hypothalamus. For this reason, inspiring your students intellectually will do \nmore than a brilliant Powerpoint slide show. Communicate meaningful learning \ngoals which are relevant for the students‘ clinical tasks and assignments. Give them \nexperience by involving them actively in planning, conducting and assessment of \nteaching. Interactive participation provides intellectual stimulation, fostering under-\nstanding and retention of the subject matter, and motivates further engagement \nin the topic. Y ou as a teacher modulate the learning climate by using a variety of \nteaching methods and learning materials and by adapting your teaching style to \nthe learners‘ needs. Finally, recognize that improvement comes through feedback. \nActively seek assessment of your performance from your peers and your students. \nStimulate yourself to take on new learning and teaching experiences - and stay \nawake throughout your career. \nLearning Objectives:\n1. To understand the need for intellectually inspiring lessons.\n2. To learn options for exciting teaching.\n3. To develop a practical approach to clinical teaching.\nA‑085 08:50 \nClinical teaching: The young doctor’s perspective \nC. Nyhsen; Sunderland/UK (nyhsenc@doctors.net.uk) \nWhen preparing a teaching program, one usually thinks of the contents first and \nhow to incorporate as much information as feasible into a relatively short period of \ntime. Much effort goes into layout, making the sessions appealing and giving valu-\nable advice. The learners‘ perspective is however often much different. Learning for \nthe greater good is frequently replaced by „surviving“ in real life, such as passing \nthe next exam or managing the next on-call successfully. It is, therefore, important \nthat educators consider the learners‘ point of view. The better they understand the \nstudents‘ situation, the better the sessions will be received and the more motivated \nthe students will become. Furthermore, considering the level of students one is \nteaching is important. Medical students vary greatly from junior medical doctors, \nand first year radiology trainees to more senior trainees. Therefore, a distinction has \nto be made between the very young, the young and the „more mature“ students, \nnot only with respect of contents but also with respect of teaching methods used. \nThis talk will introduce the Radiology Trainees Forum of the ESR with their role in \nrepresenting the trainees‘ perspective and it is going to address questions such as: \nWhat are a young doctor‘s expectations? How can I get and maintain the student‘s \ninterest? What are the worst mistakes to avoid? \nLearning Objectives:\n1. To be aware of the special needs of teaching in radiology.\n2. To provide an overview on current practical concepts: The young radiologist’s \nexpectations.\n3. To become familiar with the concept of the Radiology Trainees Forum (RTF).\nA‑086 09:05 \ne-Learning: Concept for the future? \nR. Fowler; Leeds/UK (richard.fowler@leedsth.nhs.uk) \nThis short presentation will address the potential benefits of e-learning in radiology \ntraining. It is best utilised as a complementary resource to traditional work-place train-\ning, but can substitute for many of the repetitive instructional tasks allowing a more \nproductive interface between learner and trainer. We will consider some of the current \noptions with reference to the RCR Radiology Integrated Training Initiative (R-ITI). We \nwill suggest how materials like these can best be integrated into radiology training. \nLearning Objectives:\n1. To learn the benefits of e-learning in radiology. Is it a complement or a \nsubstitute to conventional learning?\n2. To learn what the current e-options and models are.\n3. To become familiar with the e-learning programme of the Royal College of \nRadiology.\nA‑087 09:20 \nQuality and outcome for teaching in radiology \nS. Kolkman; Amsterdam/NL (s.kolkman@amc.uva.nl) \nA doctor of the future should have a natural ability to use radiology for optimizing \npatient care. This doctor knows which investigation is the best for assessing pathol-\nogy, is aware of the ranking of different imaging modalities, from simple to complex; \nknows the indications for the different investigations and knows how to provide a \nradiologist with relevant information. He/she has practical knowledge of the basics \nof the most commonly used radiologic techniques and knows the risks of ionizing \nradiation. This doctor can identify normal anatomy in different radiological investiga-\ntions and recognize pathology. At night, this doctor must recognize life-threatening \ndisorders immediately. In every situation he/she must be able to explain his/her \nrequest to the imaging specialist in a succinct way. To reach this goal, a perfect \neducational radiology program during the medical curriculum is needed. Before \ndeveloping an educational program, the final goal (s) must be clearly formulated. \nThe contents should be in accordance with clinical issues. And for optimal results, \nthe educational processes should be strictly controlled. In the AMC, Amsterdam, \nwe developed a radiology educational program. Starting in the first year of medi-\ncal school, different topics with increasing complexity are offered to the students \nthroughout all years of the curriculum. The contents are developed by a radiologist \nin close cooperation with anatomists, pathologists and different clinicians, according \nto the subjects. For each part of the program, all students have to pass an exam. \nThe programs are continuously evaluated and adapted when necessary, according \nto feed-back questionnaires. \nLearning Objectives:\n1. To understand the special needs of teaching in radiology.\n2. To be aware of quality criteria and standards in clinical education.\n3. To learn how to implement quality control in your teaching practice.\n\nPostgraduate Educational Programme\nS28\n A B C D E F G\nA‑088 09:35 \nTeach the teacher \nM. Hofer; Düsseldorf/DE (matthias.hofer@uni‑duesseldorf.de) \nThis presentation will present a short overview of three core competencies in \norder to provide effective lectures and seminars in radiology teaching sessions: \na) Methods to communicate goals and objectives effectively, b) adequate use of \nquestioning- and-answering techniques in interactions and c) effective slide design/\nuse of media to foster understanding and retention. The most common pitfalls in \nthe design of lectures and small group seminars, which we experienced in over \n75 train-the-teacher workshops at six medical schools over the last five years will \nbe demonstrated by short examples: • teacher-centered lecturing without active \ninvolvement of the learners; • to much content per time uncoupling of listeners; \n• unnecessary dark slide design fatiguing effects on learners; • inadequate use \nand dosage of animation in PowerPoint-presentations; and • inadequate use of \nassessment questioning. The influence of “psychological size” and the “threat of \nembarrassment”, especially in interactive teaching sessions on diagnostic imaging \nmodalities, will be elaborated. Thus, we intend to enhance the teachers’ aware-\nness of these aspects of our interaction between us and our learners in UGME \n(UnderGraduate Medical Education) as well as in PGME (PostGraduate Medical \nEducation). Finally, the predominant “blind spot” concerning our own teaching \nskills will be figured out and quantified, based upon previous and retrospective \nself-reflections of the trainees (colleagues) before and after their participation in \nteaching skills workshops. \nLearning Objectives:\n1. To learn about the need to educate educators.\n2. To understand the interaction between teachers and learners.\n3. To develop a structured path on how to teach effectively.\nPanel discussion:  \nTeaching and education in radiology: Well-prepared for the future? \n09:50 \n08:30 - 10:00 Room P \nCardiac \nRC 303 \nSystematic approach to congenital heart disease (CHD) \nModerator:\nA. de Roos; Leiden/NL \nA‑089 08:30 \nA. Echocardiography: The first line modality \nH. Abdul-Khaliq; Homburg a.d. Saar/DE (abdul‑khaliq@uks.eu) \nThe prevalence of congenital heart disease in infancy is nearly 8/1000 and represents \na heterogeneous spectrum of isolated or a combination of different malformations in \nthe heart of connected vessels. Depending on the severity of congenital heart disease, \nimmediate postnatal diagnosis is performed by transthoracal echocardiography in \nthe majority of infants. Prenatal diagnosis in the majority of cardiovascular malfor-\nmations or vessels is possible and may contribute to lower postnatal morbidity and \nmortality. Echocardiography is the first choice to diagnose structural and functional \nabnormalities in infants, children and adults before and after corrective surgery of \ncongenital heart disease. Using 2D echocardiography, the intra cardiac and extra \ncardiac anatomy can be visualized in the majority of patients. Colour Doppler can \nbe used to assess normal and abnormal intra- and extra-cardiac blood flow patterns. \nDoppler echocardiography provides quantitative information in blood velocity and \nthe calculated pressure gradient. The introduction of new imaging modalities such \nas the tissue Doppler and speckle tracking enables quantification of myocardial \nwall movements and deformations providing information on the regional myocardial \nfunction. 3D echocardiography is not routinely used in assessment of structural heart \nabnormalities. However, the novel real time 3D echocardiography presents a reliable \nmethod for volumetric assessment of left and right ventricular function. Using these \nparameters, LV ejection fraction and dyssynchroneous contractile function can be \nassessed easily. In conclusion, the conventional and novel echocardiography methods \nprovide a non-invasive and easy to perform method for evaluation of the morphology \nand function in the majority of congenital heart diseases. \nLearning Objectives:\n1. To discuss differential indications for echocardiography.\n2. To systematically analyse CHD.\n3. To review cases with complex CHD.\nA‑090 09:00 \nB. MRI: Getting more specific \nP . Beerbaum\n1, S. Sarikouch2; 1London/UK, 2Hannover/DE \nCardiac MR (CMR) has evolved as a diagnostic tool of key importance in the \nmanagement of patients of all age with congenital heart disease (CHD). In clinical \npractice, CMR is considered an ideal adjunct to echocardiography in older children, \nadolescents and adults as reflected by class I-II recommendations for the clinical \nuse of CMR by recent consensus panels. More recently, CMR is being increasingly \nused to image complex neonatal and infant CHD to plan surgical, interventional or \nhybrid repair, particularly during staged Fontan-type palliation of single ventricle \nphysiology. The main reasons for its attractiveness include the unique abilities of \nCMR to: (1) non-invasively quantify blood flows and ventricular function and (2) \nprovide detailed information on cardiovascular and airway morphology, particularly \nin complex CHD. Furthermore, hybrid systems of X-ray fluoroscopy combined with \nMRI scanners (“XMR systems”) allow for detailed investigation of pulmonary vas-\ncular resistance using MR flow and invasive pressure recordings. There is active \nresearch to proceed towards MR-guided cardiovascular interventions in CHD as \nrecent advances in the development of MR-safe guide wires and instrumentation \nallow for novel concepts of imaging during interventional procedures, using CMR as \nroad map and pre-/post intervention assessment of procedural results. Large-scale \nclinical trials have utilized CMR for quantification of ventricular function in CHD and \nhave much improved our understanding of prognostic factors for example in tetralogy \nof Fallot and Fontan circulation. Stress-CMR protocols using physical exercise or \npharmacological stimulation are currently being investigated with respect to their \npotential role in diagnosing early ventricular failure. \nLearning Objectives:\n1. To understand the advantages of MRI in CHD.\n2. To use dedicated MRI techniques (e.g. flow measurements) in CHD.\n3. To learn which MR parameters have a prognostic value in CHD.\nA‑091 09:30 \nC. MDCT: Filling the gap \nA. Küttner; Erlangen/DE \nIn recent years a multitude of different examining techniques for cardiac CT \nhave emerged. Retrospective gating, prospective triggering, Step and shoot and \nmost recently the ultra high pitch technique (FLASH) have become available. \nAll techniques have their distinctive advantage and disadvantages, which are to \nbe discussed when and how to use them properly and how the patient needs to \nbe prepared (beta-blocker, nitroglycerine). Furthermore different techniques for \ndelivering contrast media are discussed. A special section will also address the \nissue of radiation dose and how to practically implement these considerations in \ndaily examination routine. MRI and CT both can create images with high spatial \nand temporal resolution. In this course the advantages and disadvantages of both \ntechniques are discussed as well as when to use them in regard to CHD, e.g. plaque \nimaging vs. scar tissue imaging (late enhancement). Coronary Heart disease has a \nwide spectrum, ranging from early plaque detection (“vulnerable plaque”), stenosing \ncoronary heart disease (angina pectoris, chest pain protocol, triple-rule-out), acute \nphase imaging (vital myocardium vs. scar tissue), as well as follow up scan after \nstent placement or bypass surgery. The course is discussing different techniques \nhow to image specific features and when to apply cardiac CT best.\nLearning Objectives:\n1. To learn how to examine CHD with MDCT.\n2. To compare the advantages and limitations of MDCT in comparison to MRI.\n3. To understand the role of CT in differentiating various types of CHD.\n\nFriday\nPostgraduate Educational Programme\nA\n S29\nCB D E F G\n08:30 - 10:00 Room Q \nGenitourinary \nRC 307 \nFemale infertility \nModerator:\nE. Kuligowska; Boston, MA/US \nA‑092 08:30 \nA. “Functional imaging” of the ovary for everybody \nM. Weston; Leeds/UK (Michael.Weston@leedsth.nhs.uk) \nOvarian morphology, as seen on ultrasound, provides information on the functional \nstatus of the ovary. The appearance changes as a woman progresses from child-\nhood, through menarche and into her post-menopausal years. Furthermore, during \nher menstrual years, the ovary shows clear cyclical changes with each menstrual \ncycle. Intersex states can be suspected from the lack of normal ovarian morphol-\nogy, for example: androgen insensitivity may show a normal female phenotype \nbut have intra-pelvic testes rather than ovaries. Chromosome anomalies such as \nTurner’s syndrome may also demonstrate altered ovarian morphology, typically \n‘streak’ ovarian stroma with no follicles. Polycystic ovary syndrome is a complex \nand heterogeneous condition, the cardinal features of which are hyperandrogenism, \novulatory dysfunction and polycystic ovary appearance (though this is not essential \nto the diagnosis). The polycystic ovary appearance requires 12 or more follicles of \n2 to 9 mm in size or a volume of greater than 10 mls. If there is a follicle of 10 mm \nor greater, then the scan should be repeated at a later date when the ovary is \nquiescent. Other features of increased stroma or increased stromal echogenicity \nare specific but are not needed for diagnosis. It is recognised that a stromal area \nto total area ratio may be predictive of hyperandrogenism. Assisted conception \nuses ultrasound to track development of follicles and aid timing and dosage of \nmedication and egg retrieval. Hyperstimulated ovaries are a risk and need to be \nidentified. 3D scans may offer advantages over 2D in follicle counts and tracking. \nLearning Objectives:\n1. To review the different images associated with ovarian dysfunction such as \npolycystic disease, ovarian insufficiency, and chromosomic abnormalities.\n2. To understand the role of the radiologist in preparation and management of \novarian stimulations.\nA‑093 09:00 \nB. Pelvic endometriosis: Why is it commonly overlooked? \nG. Restaino; Campobasso/IT (gennares@hotmail.com) \nEndometriosis is defined as the presence of endometrial-like  tissue outside the \nuterus, which induces a chronic, inflammatory reaction. Subfertility is associated to \nendometriosis, with several proposed causal mechanisms: distorted pelvic anatomy, \naltered peritoneal, hormonal, and cell-mediated function, endocrine and ovulatory \nabnormalities, and impaired implantation. Imaging techniques currently used to \ndiagnose endometriosis are ultrasound and magnetic resonance imaging (MRI). \nSonographic features of endometriomas are low-level internal echos, multilocularity \nand parietal hyperchoic foci. At MRI, endometriomas appear hyperintense at T1- and \nT2-weighted sequences persisting at fat-suppressed T1-weighted images, often \nwith loss of intraluminal signal on T2-weighted images, due to high concentrations \nof iron and protein. Common sites of endometriosis are: Douglas’ pouch, utero-\nsacral ligaments, vagina, rectum and bladder. Rarer sites are: abdominal wall, fossa \nischio-rectalis, round ligament, lymphnodes, vulva, liver, and chest. Presentation of \nendometriosis is protean and aspecific, with diagnostic delay up to 12 years. This is \nbecause endometriosis is not an organ pathology, but an abdomino-pelvic disease, \nheterogeneous for genetic background, pathogenesis, location, extent, severity, \nclinical manifestations, treatment requirement and outcome. Differential diagnoses of \nendometrioma include corpus luteum, teratoma, cystadenoma, fibroma, tubo-ovarian \nabscess and carcinoma. Neoplasm must be ruled out particularly in pregnant patients \nwith decidualized endometriosis.A surgical procedure such as laparoscopy is required \nfor definitive diagnosis of endometriosis. T ransabdominal and transvaginal ultrasound \nrepresents the first-line imaging\n process for suspected endometriosis. MRI is the \nmodality of choice to diagnose all lesion sites of endometriosis, and is performed in \nselected patients according to the results of ultrasound and the severity of symptoms. \nLearning Objectives:\n1. To learn that pelvic endometriosis is a leading cause of infertility.\n2. To review the typical and atypical appearance of endometriosis, to explain \nthe diagnostic delay and potential differential diagnosis.\n3. To understand the role of imaging in establishing treatment strategies.\nA‑094 09:30 \nC. Understanding gynecologic malformations \nF .M. Danza, A.L. Valentini; Rome/IT (fmdanza@rm.unicatt.it) \nThe multiple embryologic steps of the urogenital system are reviewed to under-\nstand the numerous malformations of the ginecological organs that are possible to \nobserve during the radiological workup; pelvic or abdominal masses and infertility \nare usually the causes requiring a diagnostic study of these patients. Particular \nattention will be devoted to the diagnostic possibilities of radiological imaging in the \nanatomical demonstration of various clinical settings. Ultrasound and MRI are the \nmethods of choice, owing to the absence of radiation risks, while CT is reserved \nonly to particular case usually when the diagnostic orientation is confused or in \nemergency. Histerosalpingography is important when a fine anatomical detail of \ninner cavities are requested. Anyway, US and MRI, due to their capabilities to \ncreate series of multiplanar images and characterize tissues and liquids, are the \nmain tools radiologists can use. A wide pictorial assay of the common and rare \nmalformations of uterus, ovary and annexed bodies, in one with urologic associated \nconditions will be presented, as they appear on each imaging modalities, so that \na correct diagnosis can be achieved. The differential diagnosis with other pelvic \nmasses will be also displayed. \nLearning Objectives:\n1. To understand the most common uterine and vaginal malformations, with \nregard to embryology.\n2. To review the imaging appearance of uterine and vaginal malformations, with \na special emphasis on US and MRI.\n3. To be able to determine whether or not a malformation is the cause of \ninfertility.\n10:30 - 12:00 Room A \nESR meets Poland \nEM 1 \nEmergency radiology: The new frontiers, the old \nbarriers\nPresiding:\nC.J. Herold; Vienna/AT \nM. Sasiadek; Wroclaw/PL \nM. Szczerbo‑Trojanowska; Lublin/PL \nA‑095 10:30 \nIntroduction \nM. Sasiadek; Wroclaw/PL (mareks@rad.am.wroc.pl) \nThe history of Polish radiology started in 1896, just few months after Wilhelm \nRoentgen’s discovery, when the first X-ray image was performed in Cracow. Polish \nMedical Radiological Society (PMRS) was established in 1925. Currently, PMRS \nhas 15 subspecialty sections, each of them organizes annual meetings and courses. \nThe Congress of Polish Radiologists, which covers all fields of radiology, are held \nevery third year. PMRS organizes every year a lot of postgraduate courses e.g. \n“Polish School of Radiology”, School of MRI, School of Multidetector CT, as well as \nsubspecialty and regional courses. We also organize European Congresses and \nCourses, like European Society of Neuroradiology Congress (2008), European \nSchool of Radiology (ESOR) or Erasmus MRI Courses. The growing role of Polish \nradiology is reflected by fact, that the President of ECR 2010 is Prof. Malgorzata \nSzczerbo-Trojanowska from Lublin, Poland. Polish radiologists, especially those \nfrom academic centers, are active professionally and scientifically in all fields of \nmodern radiology. In this session, we decided to present the selected topics of \nemergency radiology. The lecturers represent the younger generation of Polish \nradiologists and are considered to be the “rising stars”. The particular topics we \nhave focused on are: stroke imaging, cardiac emergencies, management of aortic \ndissection and pulmonary embolism. The lecturers will present the updates in the \nfields mentioned above and propose the optimal management protocols in routine \nemergency setting. \nSession Objectives:\n1. To outline the activities of the Polish Medical Society of Radiology.\n2. To present the updates of the selected topics of emergency radiology.\n3. To present the achievements of the rising stars of Polish radiology.\n\nPostgraduate Educational Programme\nS30\n A B C D E F G\nA‑096 10:35 \nModern emergency stroke imaging \nK. Sklinda; Warsaw/PL (katarzyna.sklinda@gmail.com) \nStroke became one of the most common emergencies; however, very few patients \narrive at ER departments within “time-window” which deprives some of them of \nr-tPA administration only because the limit of time has been exceeded. Allocation \nof treatment is still dominated by the 3-hour time-window but rising availability of \nneuroimaging techniques would enable refining the indication for thrombolysis and \nset a new tissue-window basing on the determination of the extent of the salvageable \ntissue. Non-contrast CT in stroke imaging is dedicated to exclude contraindications \nsuch as cerebral hemorrhage or marked early infarct signs. However, MRI has \nbecome more available recently allowing delineation of ischemia in DWI within \nminutes after onset and depicting hypoperfusion in PWI. PWI/DWI mismatch can \nbe seen in about 80% of stroke patients in acute phase and quantitative PWI/TTP \nmaps reduce risk of its overestimation. In clinical practice MR examination may \nnot be available. Under such circumstances, CT could be the method of choice \nenabling fast quantitative evaluation of penumbra. In 256-detector row systems, it \nis possible to cover the whole brain and perform hemodynamic assessment at one \nbolus administration. It seems that CT can compete with MR in tissue - window \nimaging. The large number of patients arriving at ER-units with stroke-like symp-\ntoms and a relatively low sensitivity of CT in detection of cytotoxic/early vasogenic \nedema causes a need for developing a CAD system which would enable to exclude \ncertain groups of patients from further diagnostics. Initial experience with this kind \nof software would be presented. \nLearning Objectives:\n1. To consolidate knowledge of the methods already acknowledged.\n2. To learn about CAD in stroke imaging.\n3. To appreciate the value of CT.\nA‑097 10:53 \nCardiac emergency imaging: Crossing frontiers, meeting barriers \nK. Gruszczynska; Katowice/PL (KJgruszczynska@gmail.com) \nAcute myocardial infarction (AMI) affects approximately one million Polish inhabit-\nants per year. The diagnosis of acute coronary syndrome (ACS) is not always \nstraightforward, as the spectrum of clinical signs is wide. In Poland, ACSs account \nfor 2/3 of patients hospitalized in intensive care units. Cross-sectional imaging \nmay be most helpful in patients with atypical chest pain and non-diagnostic ECG. \nComputed tomography (CT) allows better definition of cardiovascular risk (coronary \ncalcium score). CT coronary angiography can rule out significant coronary stenosis \nand identify non-cardiac causes of chest pain (triple rule-out). Imaging patients \nwith acute ongoing chest pain may be challenging. Careful patient preparation \nand optimization of scan protocol are mandatory to optimize image quality and \nkeep radiation exposure to a minimum. Due to recently reduced radiation expo-\nsure cardiac CT become a viable option to study newborns with congenital heart \ndisease before cardiac surgery. Cardiovascular magnetic resonance (CMR) may \nimprove the triage of patients with ACS. It allows the diagnosis of several non-\ncoronary emergencies (myocarditis or cardiomiopathy). However, CMR requires \nprolonged patient cooperation. Moreover, coronary artery imaging by CMR is still \ntechnically challenging. Cardiac imaging with CT and CMR is established in a wide \nrange of clinical indications. Many radiologists in Poland underwent training in this \nsubspecialty and many practice it in elective, non-emergency settings. Cardiac \nemergency imaging represents ‚the next frontier’ for them. Proper training, an \nenthusiastic approach and tight cooperation with clinicians will hopefully allow \nyoung Polish radiologists to overcome the logistic barriers to non-invasive cardiac \nimaging in emergency settings. \nLearning Objectives:\n1. To outline the clinical needs for cross-sectional imaging techniques such as \nCT and MR in cardiac emergencies.\n2. To discuss the feasibility and the difficulties of performing CT and MR \nimaging in emergency cardiac clinical conditions.\n3. To review successes and failures achieved by cardiac radiologists in Poland \nwith CT and MR imaging in cardiac emergencies.\nA‑098 11:11 \nDissection of descending aorta: Diagnosis and management of aortic or \nend-organ complications \nK. Milczarek; Warsaw/PL (krzys‑km@wp.pl) \nAcute aortic dissection is a life-threatening disease with aortic rupture as a main \ncomplication followed by end-organ ischemic complications resulting with multiorgan \nfailure. Dissection of descending aorta is usually treated with aggressive medical \ntherapy. However, complications of aortic dissection should be early diagnosed \nand treated promptly emphasizing the role of imaging modalities. Indications for \nintervention in an acute setting include: impending or contained rupture, malperfu-\nsion syndrome, untreatable hypertension, persistent pain and early aneurysmal \nformation. The following treatment options are recognized: aortic stent-graft implan-\ntation, aortic branch stenting or fenestration as a solitary methods or combined with \nSG placement. The main goal of thoracic endografting is to seal the primary tear, \nre-establish the collapsed true lumen and resolve end-organ ischemia if present. \nSome patients receiving only BMT require intervention. Analyses from different \ngroups revealed several features that predict poor outcome including initial aortic \ndiameter > 4 cm or partial thrombosis of the perfused false lumen. A resent consen-\nsus statement considered following indications for endovascular repair in patients \nwith chronic aortic dissection: aortic diameter > 5.5 cm, annual aortic expansion \n> 1 cm, resistant hypertension, recurrent pain and chronic malperfusion syndrome. \nHowever, despite successful endografting of the thoracic aorta, in some cases the \nproblem of dissection remains on the abdominal level. To our knowledge, there is no \noverall clinical experience in endovascular repair of complicated aortic dissection \nin this region. We want to share experience of a leading center in Warsaw with the \nendovascular repair of descending aorta dissections, including the most challeng-\ning, abdominal region of aorta. \nLearning Objectives:\n1. To present the most frequent complications of descending aorta dissection.\n2. To define indications for intervention.\n3. To review possible therapeutic strategies.\nA‑099 11:29  \nWhat you see is what you diagnose: Staging the severity of acute \npulmonary embolism with computed tomography pulmonary angiography \nG. Staskiewicz; Lublin/PL (grzegorz.staskiewicz@gmail.com) \nAcute pulmonary embolism presents with a wide spectrum of clinical conditions, \nwhich range from clinically irrelevant isolated subsegmental embolism to a life-\nthreatening central embolism, resulting with hypotension and cardiogenic shock. \nRecent advances in the computed tomography have allowed a rapid progress in \nimaging of pulmonary embolism. Computed tomography pulmonary angiography \n(CTPA) makes it possible to visualize embolic material even in subsegmental \narteries, and to assess pulmonary parenchyma and mediastinal structures at the \nsame time. Furthermore, in large group of patients in whom PE has been excluded, \nCTPA allows for an alternative or additional diagnosis. CTPA allows an objective \nstaging of obstruction of pulmonary arteries. It may also suggest the right ventricular \ndysfunction in the course of acute pulmonary embolism, as well as visualize the \nbackground of thrombotic event. \nLearning Objectives:\n1. To summarise scoring systems used for objective staging of obstruction of \npulmonary arteries.\n2. To review CT signs of right ventricular dysfunction in the course of acute \npulmonary embolism.\n3. To become familiar with the range of alternative and additional diagnoses \nbased of CT findings.\nPanel discussion\n 11:47 \n10:30 - 12:00 Room E2 \nFoundation Course: Head and Neck Radiology \nE³ 420 \nTemporal bone \nModerator:\nB. De Foer; Antwerp/BE \nA‑100 10:30 \nA. External and middle ear \nA. Trojanowska; Lublin/PL (agnieszka30@yahoo.com) \nExternal and middle ear diseases are the second most frequent cause of visiting \nENT specialist. With the introduction of multislice CT imaging and new MRI tech-\nniques, excellent visualization of minute structures can be achieved. Therefore, \naccurate diagnosis of temporal bone diseases may be performed. In fact, the \npercentage of temporal bone imaging studies is growing fast. The critical condition \nfor depiction any external and middle ear pathology is the profound knowledge of \nanatomy. Since not all pathological conditions require imaging, it is very important \nto know exactly which diseases will require radiological evaluation. Detailed indica-\ntions for imaging and proper imaging techniques will be discussed. Although both \nCT and MRI can be applied, CT is the workhorse for the majority of pathological \n\nFriday\nPostgraduate Educational Programme\nA\n S31\nCB D E F G\nconditions. A detailed overview of common and most important external and \nmiddle ear diseases will be presented. These will include: EAC atresia, exostoses, \nosteoma, squamous cell carcinoma, congenital anomalies, post-traumatic changes, \nosteosclerosis, glomus tympanicum, middle ear schwannoma, inflammation and \ncholesteatoma. For each case, the most relevant clinical and radiological findings \nwill be discussed together with differential diagnosis. \nLearning Objectives:\n1. To review the relevant radiological anatomy of the external and middle ear.\n2. To learn about the indications of imaging in external and middle ear disease.\n3. To appreciate the relative value of CT and MRI in external and middle ear \ndisease.\n4. To become familiar with the imaging findings on CT and MRI in external and \nmiddle ear disease.\nA‑101 11:15 \nB. Inner ear and internal auditory canal \nB. Verbist; Leiden/NL (b.m.verbist@lumc.nl) \nOver the past years, there has been a growing interest in inner ear and cochlear \nnerve imaging due to advances in treatment of sensorineural hearing loss. Whereas \nin the past, hearing aids were the only option for amplification of sound, nowa-\ndays there is a possibility of direct stimulation of the cochlear nerve with cochlear \nimplantation. In those cases, careful assessment of the cochleovestibular system \nand nerve provides crucial information for the surgeon. Abnormal development \nof the inner ear or cochleovestibular nerve, pathologies influencing the cochlear \npatency - such as labyrinthitis ossificans or abnormalities of bone metabolism - or \nthe presence of retrocochlear pathology will influence patient management. Proper \nassessment of these structures requires high resolution CT or MR imaging. In this \nlecture, the normal anatomy of the inner ear and internal auditory canal will be \nillustrated and the imaging findings of congenital, infectious or inflammatory and \ntumoral pathology of the cochleovestibular system and nerve will be discussed. \nLearning Objectives:\n1. To review the normal radiological anatomy of the inner ear and internal \nauditory canal.\n2. To understand the importance of high-resolution imaging in evaluating inner \near and internal auditory canal pathology.\n3. To become familiar with the imaging findings in inner ear and internal \nauditory canal disease.\n12:15 - 12:45 Room A \nPlenary Session \nHL 1 \nWilhelm Conrad Röntgen - Honorary Lecture \nPresiding:\nM. Szczerbo‑Trojanowska; Lublin/PL \nA‑102 12:15 \nDiagnostic radiation and carcinogenesis: What do we know? \nM.N. Brant-Zawadzki; Newport Beach, CA/US (mbrant@hoaghospital.org) \nThe lay media and even most radiologists assume that exposure to diagnostic \nradiation is carcinogenic. However, a review of the literature demonstrates that the \nstate of knowledge of regarding carcinogenesis from diagnostic radiation is not at \nthe level of scientific fact; indeed, it is at most a theory, and more likely the level \nof knowledge is at the stage of hypothesis, with evidence both for and against the \nnull. This lecture will review that state of knowledge and provide a broad context \nfor the concern regarding cancer production by diagnostic levels used in everyday \nradiologic procedures. Comparison of risk to other industries and actuarial risk \nof detriment will be discussed. The controversial concepts about the theory of \nhormesis or potential benefits of minimal doses of radiation in stimulating defence \nmechanisms potentially mitigating carcinogenesis will be explored. The purpose \nof the lecture is to stimulate discussion in this very controversial, yet somewhat \nmisunderstood, area. All can agree that using the least amount of radiation nec-\nessary for appropriate diagnosis is the ideal state; however, unnecessary fear of \ndiagnostic radiation when it is appropriate should also be minimized. To these ends, \na transparent review of the topic is worthwhile. \nLearning Objectives:\n1. To comprehend the historical evidence for radiation induced carcinogenesis.\n2. To understand the state of knowledge regarding low-dose induction of \ncancer, and controversy surrounding the “no threshold hypothesis”.\n3. To become more familiar with the levels of risk posed by diagnostic radiation.\n14:00 - 15:30 Room E2 \nFoundation Course: Head and Neck Radiology \nE³ 520 \nNose and paranasal sinuses \nModerator:\nH. Eggesbø; Oslo/NO \nA‑103 14:00 \nA. Inflammatory disease \nD. Farina; Brescia/IT (nappaje@yahoo.it) \nAnatomy is the key for a conceptual understanding of inflammatory disease of the \nparanasal sinuses; in particular, the complex network of infundibula and recesses \nthat mark the pathway of mucus from the periphery (sinuses) to the centrum (nasal \ncavities). A vast number of variants complicate the interpretation of the anatomy: \nsome are clinically irrelevant, some may predispose to rhinosinusitis, and some \nare potential sources of iatrogenic damage. Acute rhinosinusitis generally requires \nno imaging. Only on the onset of ocular or neurological sign and symptoms, cross-\nsectional imaging (mainly MSCT) is urgently needed to identify complications. In \npatients affected by chronic rhinosinusitis, imaging must provide a roadmap for \nproper endoscopic surgery planning. In this setting, coronal MSCT is the standard \nfor evaluation and represents a shared language that allows mutual understand-\ning between head and neck radiologists and surgeons. According to the drainage \npathway (s) impaired, chronic rhinosinusitis can be classified in five patterns that, \nwhile simplifying the reporting process, also account for the pathophysiology of the \ndisease. Among these, nasal polyposis is the most extensive and requires careful \nobservation in order not to overlook benign or malignant neoplasms. Sagittal MPR \nreformations will be included in the protocol whenever the course and patency \nof the oblique frontal recess are to be demonstrated. MRI is inferior to MSCT in \ndemonstrating the labyrinth of sinuses and drainage pathways. This technique \nwill be used only in specific circumstances, such as when bone destruction (not \nnecessarily over the midline) and orbital or deep soft tissue lesions are found. \nLearning Objectives:\n1. To review the normal anatomical variants of the sinonasal cavities, and their \nimportance.\n2. To understand the indications for imaging in patients suffering sinusitis.\n3. To learn how to adapt the imaging technique according to the clinical \npresentation.\n4. To learn about the imaging findings in acute, chronic and complicated \nsinusitis.\nA‑104 14:45 \nB. Neoplastic disease \nT. Beale; London/UK (timothy.beale@royalfree.nhs.uk) \nThe lecture will review the role of imaging in the diagnosis of sinonasal tumours, \nillustrating the diversity of tumours affecting this region. The patterns of local and \ndistant spread of sinonasal neoplasia will be demonstrated and the respective \nroles of computed tomography and magnetic resonance imaging explained. Critical \nimaging review areas are discussed, in particular the assessment of orbital and \nintracranial involvement and perineural extension. The imaging features that aid in \ndistinguishing inflammatory from neoplastic and benign from malignant sinonasal \nconditions will be discussed. The imaging protocol and follow-up imaging strategy \nundertaken at our institution will be explained. \nLearning Objectives:\n1. To review the relevant anatomy in neoplastic disease of the sinonasal \ncavities.\n2. To learn about the imaging findings in benign and malignant tumors of the \nsinonasal cavities.\n3. To appreciate the relative value of CT and MRI in sinonasal tumors.\n4. To understand the importance of imaging in determining the extension \npattern of sinonasal tumors.\n\nPostgraduate Educational Programme\nS32\n A B C D E F G\n16:00 - 17:30 Room A \nNew Horizons Session \nNH 6 \nFunctional imaging in CT: Optional or built-in? \nModerator:\nH. Alkadhi; Zurich/CH \nA‑105 16:00 \nChairman’s introduction \nH. Alkadhi; Zurich/CH (halkadhi@partners.org) \nIn the past years, there has been a marked increase in attempts to image diseases \nwith CT not only on a morphological but also on a functional basis. The reasons \nfor these developments are manifold. One major reason is the known, inherent \nlimitation of morphological imaging alone that may lack important information on \nfunction being of prognostic value or being relevant to gauge treatment efficacy. \nAnother - simplistic though true - reason for these current attempts is a technical \none: current CT scanners have undergone such tremendous technical developments \nwith more and more gantry rotation speed and acquired slices as well as faster \nvolume coverage that functional imaging with CT became feasible at a reasonable \nradiation dose. Currently, functional imaging with CT is emerging in a number of \ndivergent fields, including the diagnosis and characterization of coronary heart \ndisease and myocardial function as well as for the early prediction of treatment \nefficacy and identification of progressive disease in patients with cancer. This ses-\nsion will deal with the technical requirements for functional imaging with CT and will \nintroduce the various concepts including perfusion, dual- or multi-energy imaging. \nIn addition, it will aim to highlight the added diagnostic value that can be extracted \nfrom this functional data for the ultimate goal to improve the care of our patients. \nSession Objectives:\n1. To provide an overview on the technological developments that enable \nfunctional imaging with CT.\n2. To learn the different types of algorithms for functional CT imaging.\n3. To understand the added value of functional imaging with CT.\nA‑106 16:03 \nWhat functional CT requires: Speed, coverage, and many slices \nP . Rogalla; Berlin/DE (rogalla@charite.de) \nFunctional CT is governed by many technical factors. Depending on the analytic \nmodel for data evaluation, fast sampling might represent the most important pa-\nrameter for accurate capture of density changes over time. In order to ensure \nhomogeneous sampling with time uniformity in the body area targeted for perfusion \nanalysis, mechanical motion of the patient for larger Z-axis coverage should be \napplied with due caution. Alternative models are based on extended time coverage \nnecessitating data sampling over more than 60 seconds. Longer scanning times \nresult in proportional increase in radiation dose raising the need to implement low-\ndose imaging techniques and data noise suppression. Motion correction poses an \nadditional challenge independent of subsequent analysis techniques. Longitudinal \ntracing the volume of interest with rigid or elastic data warping surfaces the necessity \nof evading patient motion during scanning by either breath holding or - alternatively \n- shallow free breathing. Additionally, thin slice isotropic volume reconstruction plays \na key role in data post-processing when elastic warping is deemed necessary for \nimage registration. Overall, functional imaging poses tremendous technical chal-\nlenges as to the optimal hardware selection, adequate scanning protocols, and \npost-processing algorithms. \nLearning Objectives:\n1. To explain the technical prerequisites for functional CT.\n2. To discuss the influence of reconstruction techniques, temporal resolution \nand temporal uniformity.\n3. To outline the role of functional CT in view of risks and benefits.\nA‑107 16:21 \nMulti-energy: An approach to functional imaging with CT \nP . Stolzmann; Zurich/CH (paul.stolzmann@usz.ch) \nThe ability of dual-source dual energy (DE) CT to simultaneously acquire two X-\nray spectra during the same phase of contrast enhancement excludes temporal \nchanges in enhancement between acquisitions and spatial misregistration. Specific \nattenuation behaviours of different materials enable their differentiation which is \ncaused by material-dependent Compton and photo-electric effects. DECT can \nthereby accurately measure elemental concentrations by using three-material \ndecomposition algorithms. These algorithms are used to identify and quantify \ncontrast materials allowing for the reconstruction of virtual non-enhanced (VNE) \nimages and the assessment of perfusion or ventilation volumes. VNE data sets \nare a reasonable approximation of true non-enhanced image allowing for the re-\nplacement of non-enhanced acquisitions in the assessment of vascular disorders \nor enhancing masses. Data on contrast material distribution provide information \nthat is complimentary to morphological CT. Regional alterations of lung perfusion \nare depicted by DECT in patients with predominant emphysema or pulmonary \nembolisms. Dynamic and static regional ventilation are displayed by ventilation \nDECT. Regarding cardiac imaging, DECT is promising for the integrative analysis \nof the coronary artery morphology and the myocardial blood supply. DE CT is an \nemerging technique that not only provides morphological but functional information. \nLearning Objectives:\n1. To understand the principle and potential benefit of multi-energy and spectral \nimaging.\n2. To learn how multi-energy CT may replace multi-phase imaging, giving rise \nto functional analyses.\n3. To understand how multi-energy CT may be used for monitoring treatment \nand for simultaneous visualisation of morphology and function.\nA‑108 16:39 \nFunctional cardiac imaging: The blessing of high spatial and temporal \nresolution \nC. Catalano, M. Francone; Rome/IT (Carlo.Catalano@uniroma1.it) \nAccurate and reproducible determination of cardiac function is essential for diagno-\nsis, therapeutic management and follow-up of cardiac diseases. A variety of imaging \ntechniques are used for the assessment of regional or global function however \ncardiac MRI has been widely adopted as the gold standard due to its unmatched \ntemporal resolution and superior tissue contrast. Conversely, because of the ra-\ndiation exposure and poor temporal resolution of previous scanners, MDCT has \nbeen seldom used for functional cardiac imaging. Limited temporal resolution of the \nmethod hampered evaluation of both regional wall motion, which generally requires \na resolution of 80 msec and the assessment of time-dependent parameters such \nas peak filling rate and peak ejection rate and led to systematic underestimation of \nventricular volumes. Recent technical improvements of CT systems allowed to reach \nhigh temporal resolution (up to 83 msec) minimizing motion artefacts and leading \nto widespread diffusion of cardiac MDCT; accordingly, because information on any \nheart phase could be obtained using a retrospective ECG-gating, use of CT for \nfunctional analysis has started to be accepted and clinically applied. Combination \nof high spatial and temporal resolution yields another advantage, which is accurate \ndepiction of cardiac valves and valvular leaflets motion can be analyzed, allowing \nto exclude stenoses or high-grade insufficiency and to quantify the orifice area. \nIn conclusion, while the evaluation of coronary arteries remains primary clinical \nindication, the improved performances of last MDCT scanners allow simultaneous \nand accurate assessment of global functional parameters, regional wall motion and \nvalvular function in a single scan. \nLearning Objectives:\n1. To understand the advantages of recent CT technological developments in \nterms of spatial and temporal resolution.\n2. To comprehend the importance of high spatial and temporal resolution in \ncardiac functional analysis, including assessment of regional and global wall \nmotion and valvular function.\n3. To emphasise the importance of quantitative and qualitative assessment of \ncardiac function for clinical diagnosis, risk stratification, patient management \nand prognosis.\nA‑109 16:57 \nCan CT perfusion monitor tumor therapy response? \nV.J. Goh; Northwood/UK (gohmcglone@hotmail.com) \nThe use of imaging to monitor tumor therapy response has increased in recent \nyears, both in the clinical setting and in clinical trials. With the increasing use of novel \ndrugs, many of which are cytostatic, in combination with standard chemotherapy or \nradiotherapy to improve progression free survival, there is an increasing need for \nfunctional evaluation. Anti-angiogenic agents and vascular disruptive agents target \nthe tumor vasculature, resulting in vascular pruning or vascular shutdown, and \nslowing of tumor growth. Kinetic modeling of tumor enhancement at Perfusion CT \nprovides valuable information of tumor vascular physiology. Quantitative Perfusion \nCT parameters reflect in vivo perfusion, blood volume and vascular leakage may \nprovide complementary information to standard assessment, and show promise as \na biomarker. In early phase clinical trials, Perfusion CT may provide evidence of an \n\nFriday\nPostgraduate Educational Programme\nA\n S33\nCB D E F G\nanti-vascular effect, be used to define a biologically active dose, may provide insight \ninto drug mechanism of action, and may aid treatment scheduling. The challenge for \nmulticentre implementation of Perfusion CT to monitor tumor therapy response is to \nimplement quality assurance, to standardize procedures and measurements, and to \nimprove scan reproducibility, within a framework for imaging biomarker development. \nLearning Objectives:\n1. To illustrate the methods that can be applied in clinical practice.\n2. To give clinical examples of the application of CT for monitoring tumor \ntherapy response.\n3. To discuss the challenges and limitations of CT for monitoring therapy \nresponse.\nPanel discussion:  \nFunctional imaging with CT: Ready for prime time? \n17:15 \n16:00 - 17:30 Room B \nRadiology of the Spine in 2010 \nCC 616 \nDiscs: Old problems and new solutions \nModerator:\nA. Gouliamos; Athens/GR \nA‑110 16:00 \nA. Spinal stenosis: How do you measure it? \nM. Gallucci; L ’Aquila/IT (massimo.gallucci@cc.univaq.it) \nA small canal diameter has been associated with an increased risk of injury; \nhowever, there is a lack of reliable normative data on spinal canal diameters and \nseveral different proposals have been reported by researchers. Stenosis can be \ndetermined by several causes. Classically, congenital, acquired (degenerative) or \nmixed forms are distinguished. Moreover, central stenosis is distinguished from \nlateral, foraminal or concentric ones. Cervical stenosis is usually defined as a canal \ndiameter of < 12 mm. An index often used on oplan X-ray film was the Torg ratio \n(canal vs body sagittal diameters. If less than 1= stenosis). A more modern concept \nis the SAC (space available for the cord). MRI permits to directly visualize the cord \nand the subarachnoid space. The mean diameter of the cervical cord is 7 mm and \nthe SAC is therefore reduced when less than a 1 mm CSF layer is present around \nthe cord, thus indicating a severe stenosis. At the lumbar level, congenital stenosis \nshows short pedicles, while acquired forms have their maximal expression at the \nlevel of the endplates. A mid sagittal diameter inferior to 14 mm is considered below \nnormal limits. If inferior to 10 mm, it is severely below. Following both radiological \nand post-mortem studies, narrow canal appears to be very common. Therefore, \nradiographic finding should be closely correlated with clinical signs to make the \ndiagnosis of stenosis and to make decision regarding treatment. Electromyography \nis strongly recommended to achieve the correct interpretation. \nLearning Objectives:\n1. To be knowledgable about the normal mechanisms responsible for spinal \nstability.\n2. To describe causes and imaging features of spinal stenosis.\n3. To learn about measurements for assessment of spinal stenosis.\nA‑111 16:30 \nB. Degenerative disc disease \nL. van den Hauwe\n1, C. Venstermans2, F . De Belder2, M.H.J. Voormolen2, \nJ.W.M. Van Goethem2, P .M. Parizel2; 1Brasschaat/BE, 2Antwerp/BE \n(lucvdhauwe@mac.com) \nThe functional unit of the vertebral column consists of two adjacent vertebral bodies, \nan intervertebral disc and two facet joints. This unit is called the motion segment. It \nconstitutes a three-joint-complex; degenerative changes of the intervertebral disc \nwill, therefore, affect the normal anatomy and function of the facet joints. Plain X-ray \nfilms are of limited use in the assessment of DDD since early signs of degeneration \ncannot be seen. Multi-detector row computed tomography (MDCT) provides excel-\nlent anatomic detail for the detection of disc herniation and nerve root compression. \nHowever, reporting disk contour changes has suffered greatly from incoherent and \nnon-uniform nomenclature. Therefore, the Nomenclature Committee of the American \nSociety of Spine Radiology has proposed a coherent and uniform nomenclature \nsystem, which has been widely accepted now among radiologists and physicians \ndealing with patients with DDD. Magnetic resonance imaging (MRI) is now con-\nsidered the most sensitive imaging technique in DDD. Due to its superb soft tissue \ncontrast discrimination, intrinsic disc changes may be observed early in DDD. MRI \nabnormalities in DDD include: disk height narrowing, T2 signal intensity changes, \ninternal disk disruption, disk contour changes, spinal canal narrowing, associated \nchanges in the vertebral endplates and posterior elements. Accurate interpretation \nof these findings remains a diagnostic challenge since not all imaging abnormalities \nare clinically relevant and may be encountered in the normal ageing population. \nThe value of newer MRI techniques (diffusion-weighted imaging, T2-relaxometry, \ndynamic imaging) in patients with DDD are under evaluation. \nLearning Objectives:\n1. To learn the current nomenclature for degenerative disc disease.\n2. To be knowledgable about morphologic changes of the degenerated discs.\n3. To introduce new MR imaging techniques for evaluation of the degenerative \ndisc disease.\nA‑112 17:00 \nC. Minimally invasive therapies for discogenic disease \nM. Muto; Naples/IT (mario.muto@ospedalecardarelli.it) \nIn the last 10 years, many types of percutaneous disk approach came out and have \nminimized the invasive nature of surgical techniques and avoid complications like \ninfection linked to surgery. All those techniques try to decompress the disk and/or re-\nduce the inflammatory reaction (oxygen-ozonetherapy) to improve clinical symptoms. \nThere are emergency surgery indications for HNP that include: progressive foot droop, \nhyperalgic paralazyng sciatica, cono-cauda syndrome. All the other clinical symptoms \ncan be treated by percutaneous disk treatment trying to avoid surgery. Nucleoptesis \nby oxygen-ozone mixture drying the nucleus with an oxygen-ozone mixture (O\n2-O3) \nuses a colourless irritant gas with a pungent odour which is unstable and has a \nstrong anti-oxidizing power. The O2-O3 gas mixture produced can be injected into \nthe intervertebral disc and root foramina, 3-4 ml into the disc and 15-20 ml into the \nneural foramen and root canal. The indications for O2-O3 treatment were extended to \nFBSS patients when it was understood that the ozone mechanisms of action could \nbe exploited to treat the chronic inflammation and venous stasis present in FBSS. On \nthe basis of our results and the assessment of our failures, we recommend selecting \npatients to avoid broadening the indications for treatment, thereby ensuring a high \nsuccess rate. Accurate diagnosis of the lesion and the spinal level to be treated, ac-\ncurate technical execution under CT or fluoroscopic guidance in expert hands and \npatient follow-up by the neuroradiologist after treatment are key factors in ensuring \nthe successful outcome of percutaneous treatment for this common condition. \nLearning Objectives:\n1. To review the indications/patient selection criteria for percutaneous \nnucleoplasty.\n2. To understand current nucleoplasty techniques.\n3. To become familiar with the techniques and safety considerations associated \nwith ozone therapy.\n16:00 - 17:30 Room C \nESR meets Neurologists \nEM 2 \nIschemic stroke: Diagnosis and treatment \nPresiding:\nJ.M. Ferro; Lisbon/PT \nC.J. Herold; Vienna/AT \nM. Szczerbo‑Trojanowska; Lublin/PL \nA‑113 16:00 \nIntroduction \nJ.M. Ferro; Lisboa/PT (jmferro@fm.ul.pt) \nIn a western population of 1 million inhabitants, 2,400 new strokes occur every year, \nof which 80% are ischemic in origin. One year later, less than 50% of patients will \nbe independent, and many survivors will have residual deficits. At the acute stage \nof cerebral ischemia, the treatment consists of: (i) keeping biological parameters \nwithin normal limits and preventing complications; (ii) admission in a stroke unit; (iii) \nintravenous administration of rt-PA as soon as possible after admission up to 4.5 \nhours; (iv) in patients who are not eligible for rt-PA, aspirin, and (v) decompressive \nsurgery in patients with or at high risk to develop malignant infarct, Other measures \nsuch as intra-arterial pharmacological or mechanical thrombolysis in basilar artery \nocclusions or T occlusion of the end part of the internal carotid artery, or hypothermia \nin malignant infarcts are possible at the acute stage but, in the absence of clear \nproof of efficacy should be restricted to randomized trials or life salvage. Diagnostic \n\nPostgraduate Educational Programme\nS34\n A B C D E F G\nimaging of ischemic stroke should rule out other pathologies such as intracerebral \nbleeding but provide positive evidence for the ischemic event. This helps in case of \nunclear clinical presentations, provides prognostic and etiologic clues and serves \nto appreciate the location and extent of parenchymal damage Information on tissue \nat risk and the state of the extra- and intracerebral vessels would also be desirable \nas it can heavily influence therapeutic decision making. All imaging data should \npossibly be collected on one machine and as fast as possible. \nSession Objectives:\n1. To define what information on stroke neurologists expect from radiologists.\n2. To become familiar with the neuroimaging of acute stroke.\n3. To be able to select the stroke patient for appropriate treatment.\nA‑114 16:05 \nWhat are the clinical requirements and expectations of diagnostic imaging \nF . Fazekas; Graz/AT (franz.fazekas@medunigraz.at) \nIschemic stroke is quite variable in its presentation and aetiology, and the increasing \npossibilities of acute treatment further add to the complexity of its management. \nIdeally, diagnostic imaging should not only rule out other pathologies such as in-\ntracerebral bleeding but also provide positive evidence for the ischemic event. This \nhelps in case of unclear clinical presentations, provides prognostic and etiologic \nclues and serves to appreciate the location and extent of parenchymal damage \nwhich may influence the risk/benefit ratio of therapeutic interventions. Informa-\ntion on tissue at risk and the state of the extra- and intracerebral vessels would \nalso be desirable as it can greatly influence therapeutic decision making. Time \nis a critical factor in all situations of ischemic stroke; therefore, all imaging data \nshould possibly be collected on one machine and as fast as possible. In addition \nto local options, it is always the patient’s clinical situation which ultimately defines \nthe trade-off between the amount of information that would be desirable and that \nwhich is absolutely needed. Furthermore, planning image acquisition for ischemic \nstroke must also consider the possible need for medical support and supervision \nof the patient and problems which may be encountered because of co-morbidities, \nimplants and inadequate patient collaboration. \nLearning Objectives:\n1. To define what neurologists expect from diagnostic imaging.\n2. To understand the importance of identifying the type and site of the lesion \ncausing stroke and the location and extent of parenchymal ischemia.\n3. To describe the minimal diagnostic imaging requirements for a stroke unit.\nA‑115 16:23 \nDiagnostic imaging of ischemic stroke \nM.M. Thurnher; Vienna/AT (majda.thurnher@meduniwien.ac.at) \nIschemic penumbra was first defined by Astrup in 1981 as perfused brain tissue \nwith the capacity to recover. Penumbra has become the focus of intense imaging \nresearch. Accurate detection of this ‘tissue at risk’ would identify patients who would \nbenefit from thrombolysis. However, new insights in the stroke pathophysiology have \nshown that the concept of penumbra has some serious limitations and raised doubts \non its clinical significance in acute stroke setting. It is now known that perfusion MR \ncannot identify tissue at risk, and signal abnormality on DWI does not represent \nonly infracted tissue, it can also contain penumbra. The debate on CT and MRI as \nimaging modalities for stroke is still ongoing and the question is not answered yet. \nWhat is the best imaging modality for thrombolysis triage inside of three hours of \nstroke, and what is the best modality after three hours of stroke onset? The purpose \nof this lecture will be to describe neuroimaging modalities capable of identifying \ninfarcted and penumbra tissue. Surrogate markers that could be used in ischemic \nstroke patients will be discussed also. \nLearning Objectives:\n1. To demonstrate advantages and disadvantages of CT and MRI in \nassessment of ischemic stroke.\n2. To explain DWI/PWI and CT perfusion “mismatch” and the concept of \npenumbra.\n3. To give an overview of the past, present and future of stroke imaging.\nA‑116 16:41 \nManagement of the acute stroke patient \nD. Leys; Lille/FR (DLEYS@CHRU‑LILLE.FR) \nDespite advances in prevention, the treatment of acute ischemic stroke remains \nessential to improve outcome and to lower mortality. At the acute stage of cerebral \nischemia, the treatment consists of: (i) general non-specific rules, such as treating \na vital emergency, keeping biological parameters within normal limits and prevent-\ning complications; (ii) admission in a stroke unit, to decrease mortality without \nincreasing dependence or recurrence risks; (iii) intravenous administration of rt-PA \nas soon as possible after admission, and within 3 hours of stroke onset in eligible \npatients, with a possible extension up to 4.5 hours although the benefit decreases \nrapidly over time; (iv) in patients who are not eligible for rt-PA, aspirin (160 to \n300 mg) to reduce early recurrence risks and death, even in atrial fibrillation, and \n(v) decompressive surgery in patients with raised intracranial pressure or at high \nrisk to develop malignant infarct because of a abnormality of more than 145 cm\n3 \non diffusion weighted images during the first 24 hours. Other measures are pos-\nsible at the acute stage but, in the absence of clear proof of efficacy, should be \nrestricted to randomized trials or tissue salvage: intra-arterial pharmacological or \nmechanical thrombolysis in basilar artery occlusions or T occlusion of the end part \nof the internal carotid artery, or hypothermia in malignant infarcts. Besides, early \nsecondary prevention measures should be started as soon as possible at least in \npatients who have no large infarct. \nLearning Objectives:\n1. To manage the flowchart of acute stroke treatment.\n2. To learn who are the candidates for IV and IA thrombolysis.\n3. To learn how to manage physiological parameters.\nA‑117 16:59 \nEndovascular treatment of the patient with ischemic stroke \nD. Vorwerk; Ingolstadt/DE (dierk.vorwerk@klinikum‑ingolstadt.de) \nRole of radiology in acute stroke was for a long time limited to imaging and exclu-\nsion of differential diagnoses. CT and MRA now allow noninvasive localization of \nthe occlusion level that may have rapid impact on the techniques of treatment. \nAlthough being used for only about 1% of all stroke patients, or of 10 % of all \npatients undergoing thrombolysis, intraarterial techniques further improved and \nplay a significant role in the treatment of patients with occlusions of the basilary \nartery, the carotid T and the M1 segment. Furthermore, acute recanalization of \nthe internal carotid artery in case of severe symptoms following thrombotic occlu-\nsions or dissections are available. More and more mechanical systems are used \nalone or in combination with intraarterial thrombolysis. Close cooperation between \nneurologists and radiologists is required to determine the best additive treatment. \nResults from literature show that under these particular circumstances, patients \nbenefit from an invasive approach in comparison to IV thrombolysis with/without \nultrasound enhancement. \nLearning Objectives:\n1. To learn about the role of interventional treatment in acute cerebral stroke.\n2. To understand techniques of thrombolytic therapy and mechanical \nthrombectomy.\n3. To understand parameters of acute success and long-tem outcome in \ninterventionally treated patients.\nPanel discussion 1\n7:17 \n16:00 - 17:30 Room D \nAbdominal and Gastrointestinal \nRC 601 \nTumor follow-up evaluation: Which modality for \nwhat? \nModerator:\nS. Terraz; Geneva/CH \nA‑118 16:00 \nA. US and CEUS \nT. Rettenbacher; Innsbruck/AT (thomas.rettenbacher@i‑med.ac.at) \nConventional US is the most frequently used liver imaging modality worldwide but \nhas a lower sensitivity and specificity than contrast-enhanced CT and contrast-\nenhanced MRI in the assessment of focal liver lesions. The introduction of US \ncontrast agents has opened new diagnostic possibilities and markedly reduced the \nsuperiority of CT and MRI. In most cases, hepatic lesions have typical perfusion \ncharacteristics and enhancement patterns that allow definite differentiation. Due to \nthe high spatial and time resolution of tumour vessel perfusion, contrast-enhanced \nultrasound (CEUS) is very appropriate in the differentiation of uncharacteristic focal \nliver lesions detected at conventional US and is superior to CT or MRI. Conventional \nUS and CEUS should also be used in cases of liver lesions appearing uncharacter-\nistic on CT or MRI scans. Under good US and CEUS examination conditions, the \ndetection rates of liver metastases are only slightly higher using contrast-enhanced \n\nFriday\nPostgraduate Educational Programme\nA\n S35\nCB D E F G\nCT or contrast-enhanced MRI. But in general, conventional US and CEUS cannot \nreplace the necessity of contrast-enhanced CT for tumour staging and tumour \nfollow-up. On the other hand, conventional US and CEUS applied percutaneously \nand especially intraoperatively are able to detect additional small metastases not \nvisible on CT or MRI. This is of impact for staging and follow-up of tumours in which \nthe liver is an important organ for metastases like gastrointestinal, liver, bile duct, \nand pancreatic malignancies. CEUS can also be helpful for guiding liver tumour \nablation. However, in the follow-up after tumour ablation, contrast-enhanced CT or \ncontrast-enhanced MRI is more sensitive. \nLearning Objectives:\n1. To learn about enhancement characteristics of the liver and the various focal \nliver lesions.\n2. To understand in which situations US and CEUS is expected to be \nappropriate.\n3. To discuss the role in comparison to CT and MRI.\nA‑119 16:30 \nB. CT and MRI perfusion \nF . Berger; Munich/DE (Frank.Berger@med.uni‑muenchen.de) \nAt initiation, tumors in a pre-vascular phase are supplied by oxygen and nutrients \nthat diffuse from pre-existing normal vessels. When the tumor reaches a critical \nsize of approximately 1-4 mm diameter, the resultant ischemia leads to secretion \nof angiogenic factors. These factors, such as vascular endothelial growth factor \n(VEGF), recruit and maintain tumor vessels. „New“ vessels (neovasculature) exhibit \nincreased blood volume and permeability compared with normal vessels. Various \nnew specific therapies in oncology target tumor vasculature or tumor neoangiogen-\nesis. It is not uncommon that these targeted therapies have pronounced cytostatic \nand not predominantly cytotoxic effects. This limits the usefulness of size based \nmorphological tumor response assessments utilizing RECIST or WHO criteria. Of \nnewer magnetic resonance imaging (MRI) modalities, perfusion MRI has emerged \nas a valid marker of tumor-induced blood vessels and their function. MRI perfusion \nmeasures the vascularity within a tumor, as well as its component heterogeneous \nparts. Of parameters which can be measured to date, blood volume and permeability \nare commonly applied in patient studies. Blood volume measures the aggregate size \nof the vascular space, while the permeability function informs about the integrity \nof vessels and their ‚leakiness‘ to contrast agents. We will describe the use of MR \nperfusion to monitor such new therapies and discuss its specific advantages and \nlimitations in comparison to CT perfusion protocols. PET based strategies for tar-\ngeted treatment-monitoring in oncology will be briefly mentioned, with prospect on \nthe significance of combined vascular and metabolic imaging for further optimizing \nnon-invasive response assessment in specific anticancer therapies. \nLearning Objectives:\n1. To learn about established morphological-based strategies for tumor \nresponse monitoring: RECIST and WHO criteria with its limitations in \ntargeted treatment surveillance.\n2. To learn about the latest antiangiogenic/antivascular treatment strategies in \noncology.\n3. To learn about perfusion imaging protocols, specific advantages and \ntechnical challenges when utilising CT or MRI.\n4. To learn about the significance of CT or MR perfusion imaging in oncology, \ntypical applications and future strategies for improvement of non-invasive \ntreatment monitoring in oncology.\nA‑120 17:00 \nC. MR diffusion \nC. Della Pina; Pisa/IT (mclotilde@virgilio.it) \nThe purpose of the lecture is to review the ability of diffusion-weighted magnetic \nresonance (MR) imaging in the assessment of loco-regional treatments of primary \nand secondary liver tumor. Guidance and monitoring local therapy, including radio-\nfrequency ablation (RFA) and transarterial chemoembolization (TACE), are crucial \nto evaluate the success and efficacy of therapy. A change in tumor size at computed \ntomography (CT) or MR imaging is the accepted criterion for assessing response \nafter chemotherapy, according to RECIST criteria. In the early post-treatment period \nafter loco-regional therapies, however, tumors may not change in size. Advances in \nMR imaging techniques, which include diffusion MR imaging and apparent diffusion \ncoefficient (ADC) maps, can provide in vivo metabolic information. Recent studies \ndemonstrated that water diffusion can be used to differentiate viable and cellular \nregions from necrotic area in the tumor. Viable tumors have intact cells that restrict \nthe motion of water molecules, reducing ADC value; on the other hand, necrotic \nregions allow free diffusion of water molecules and increase ADC value. This ad-\nditional information may enhance the morphologic findings of baseline and dynamic \nMR study. Moreover, new classes of antitumor therapy have been developed that \nhave an antiproliferative effect, inducing a delay in tumor shrinkage. Diffusion MR \nimaging can be promising in this clinical setting as a biomarker to predict early \nresponse to systemic chemotherapy. \nLearning Objectives:\n1. To describe physical and technical principles of diffusion-weighted imaging \nin tumors.\n2. To discuss the qualitative and quantitative information of the modality.\n3. To review imaging findings after percutaneous and intra-arterial treatments of \nliver malignancies.\n4. To address the clinical role of diffusion-weighted imaging in monitoring tumor \nresponse.\n16:00 - 17:30 Room E1 \nMusculoskeletal \nRC 610 \nMetabolic bone diseases \nModerator:\nG. Guglielmi; Foggia/IT \nA‑121 16:00 \nA. Latest advances in osteoporosis \nC.R. Krestan; Vienna/AT (christian.krestan@meduniwien.ac.at) \nOsteoporosis is of great socioeconomic impact, as approximately 30% of all \npostmenopausal women have osteoporosis in developed countries. Ageing of \npopulations worldwide will be responsible for a major increase of the incidence \nof osteoporosis in postmenopausal women. In 1994, the WHO Working Group \ndefined osteoporosis according to measurements of bone mineral density (BMD) \nusing dual energy X-ray absorptiometry (DXA) as a bone density T score at or \nbelow 2.5 standard deviations (T score) below normal peak values for young \nadults. The relative risk of a fracture is between 1.3 and 1.6 for each unit decline \nin spine or total hip T score. Due to limitations of the T -score concept, a 10-year \nrisk calculating tool has been developed by the WHO to determine intervention \nthresholds. Fragility fractures are however not only related to bone mineral density \n(BMD). Trabecular bone microarchitecture is a significant determinant of the bone’s \nmechanical properties and is thus of major clinical relevance in predicting fracture \nrisk. Trabecular bone structure analysis can be based on images from multidetector \ncomputed tomography, high-resolution peripheral computed tomography, high-\nresolution MRI and projection radiography. Advantages and disadvantages of the \ndifferent methods depend on radiation, costs, availability and a reasonable time \nfor in vivo scanning. Grading of vertebral fractures can be done by using a visual \nsemiquantitative scoring method. Vertebral morphometry is based on radiographs \nor scans from DXA-machines calculating ratios of vertebral heights with normal \nvalues to identify vertebral fractures. \nLearning Objectives:\n1. To describe what the radiologist ought to know about the WHO definition of \nosteoporosis and vertebral fracture risk.\n2. To describe the standard techniques and newer diagnostic techniques that \nprovide insights to the structure of trabecular bone.\n3. To analyse the pros and cons of these techniques.\n4. To describe methods of grading and quantitative morphometric assessment.\nA‑122 16:30 \nB. The many faces of Paget’s disease \nV.N. Cassar-Pullicino; Oswestry/UK (Victor.Pullicino@rjah.nhs.uk) \nPaget’s disease of bone can be monostotic or polyostotic in distribution. The pelvis, \nfemur, spine and the sacrum in particular are commonly involved sites but any bone \ncan be affected. The characteristic pathological process and its manifestation vary \non conventional radiographs. The coarse enlarged trabeculae and consolidation \nof bone are particularly prominent along the cortical contours of long bones. The \nappearances differ depending on the ratio of cortex to trabecular bone. The appear-\nances vary from a predominantly lytic to very sclerotic radiographic features with a \nvariable degree of expansion. In such instances, there is no need for further imag-\ning to make a diagnosis. Advanced imaging (scintigraphy, CT, MRI) is required in \ninstances of diagnostic uncertainty and to exclude the development of complications \nsecondary to Paget’s disease. In some instances, biopsy may also be necessary. \n\nPostgraduate Educational Programme\nS36\n A B C D E F G\nLearning Objectives:\n1. To highlight the pathological mechanisms of Paget’s disease.\n2. To discuss the radiological manifestations in the peripheral skeleton.\n3. To stress the imaging characteristics of spinal involvement.\n4. To review the benign and malignant complications that can arise in the \ndisease.\nA‑123 17:00 \nC. Rickets and osteomalacia \nJ.E. Adams; Manchester/UK (judith.adams@manchester.ac.uk) \nMetabolic diseases are caused by genetic, endocrine, nutritional or biochemical \nfactors. Rickets in children (osteomalacia [OM] in adults) is a qualitative abnormality \n(reduced mineral/osteoid ratio), in contrast to osteoporosis which is a quantitative \nabnormality (too little bone). Aetiology: vitamin D and normal phosphate, alkaline \nphosphatase and serum pH are important requirements for normal mineralisation \nof bone. Rickets/osteomalacia is caused by vitamin D deficiency, end-organ resis-\ntance to vitamin D, hypophosphataemia, hypophosphatasia and severe acidosis. \nVitamin D deficiency results from lack of sunlight, dietary deficiency, malabsorp-\ntion, chronic liver disease, chronic renal failure (CRF) and end-organ resistance \n(rare genetic disorders). Hypophosphataemia and phosphaturia result from renal \ntubular abnormalities including X-linked hypophosphataemic [XLH] and ‘oncogenic’ \nosteomalacia, in which a humoral factor is produced by the tumour (‘phosphatonin’). \nCandidates for phosphatonin include FGF-23 (fibroblast growth factor 23), PHEX \n(phosphate-regulating gene located on X-chromosome)\n and MEPE (matrix extracel-\nlular phosphoglycoprotein). A large variety of tumours can cause oncogenic OM, \nwhich are often small and vascular (haemangiopericytoma); imaging is important in \nidentification, as removal results in cure. Imaging: ricketic/osteomalacic bones are \nsoft and bend (Harrison sulcus, bowed legs, knock knees, varus deformity proximal \nfemur, tri-radiate pelvis). Abnormal endochondral ossification causes metaphyses \nto be cupped and poorly mineralized with widened growth plates. In adults, the \npathognomonic feature is the Looser’s zone composed of unmineralized osteoid, \ntypically found in medial femoral neck, pubic rami, lateral scapula and ribs. Some \nconditions (XLH) have other characteristic features (enthesopathy, extra-skeletal \nossification, dense bones with coarse trabecular pattern). \nLearning Objectives:\n1. To recognise the imaging features of rickets and osteomalacia.\n2. To learn the various causes of vitamin D deficiency and other disorders that \nresult in rickets and osteomalacia.\n3. To appreciate the role of imaging in oncogenic and x-linked \nhypophosphataemic osteomalacia.\n16:00 - 17:30 Room E2 \nFoundation Course: Head and Neck Radiology \nE³ 620 \nOral cavity, oropharynx and nasopharynx \nModerator:\nV. Chong; Singapore/SG \nA‑124 16:00 \nA. Oral cavity and oropharynx \nA. Borges; Lisbon/PT (borgalexandra@gmail.com) \nAlthough the oral cavity and oropharynx are in contiguity and affected by some of \nthe same pathologic processes, they are anatomically and embriologically distinct \nand diseases affecting these regions differ in prognosis. Therefore, it is mandatory to \nrecognize the boundaries between the two. The oral cavity is a space open anteriorly, \nvery accessible to clinical inspection. It is separated from the oropharynx by the \nboundary between the hard and soft palate superiorly, the anterior faucial arches \nlaterally and by the circunvallate papilla of the tongue, inferiorly. Lesions affecting \nthe oral cavity and oropharynx may originate from the mucosa, readily available to \nclinical inspection, or may be submucosal and more difficult to characterize only on \nclinical grounds. The most common disease affecting these anatomic compartments \nis infection. In this setting, imaging is used in cases refractory to conventional treat-\nment and on patients with a more serious clinical condition (airway compromise). \nSquamous cell cancer is the most common neoplasm occurring in the oral cavity \nand oropharynx. Incidence decreases from anterior to posterior while the prognosis \naggravates. Imaging is mandatory for tumor staging particularly in depicting deep \nextent. Tumors tend to grow along muscles and nerves and may invade bone. \nDisease extent dictates treatment modality and the extent of surgical resection, \nwhen surgery is the treatment option. Submucosal lesions span a wider gamut of \npathologies including pseudomasses, infection, benign and malignant neoplasm. \nIn this case, imaging is crucial to characterize the lesion and to provide a limited \nlist of differential diagnoses. \nLearning Objectives:\n1. To review the relevant anatomy of the oral cavity and oropharynx.\n2. To learn about the imaging features of benign lesions occuring in this region.\n3. To understand the extension patterns observed in malignant tumors of this \nregion.\n4. To appreciate the clinical impact of imaging findings in diseases of this \nregion.\nA‑125 16:45 \nB. Nasopharynx \nF . Dubrulle; Lille/FR (f‑dubrulle@chru‑lille.fr) \nThe nasopharynx represents an intersection between the nasal choanae, the \noropharynx, the deep facial spaces, the skull base and the intracranial cavity. \nMost nasopharyngeal neoplasms are malignant tumors showing aggressive local \ninfiltration along well-defined routes. The primary role of imaging is accurate tumor \nmapping and detection of possible tumor extension, especially to the skull base and \nthe deep facial spaces. The aim of this presentation is to illustrate these extension \npatterns of nasopharyngeal carcinomas on imaging and to show the particular \nimplication of imaging in the correct staging of the lesion. \nLearning Objectives:\n1. To review the relevant radiological anatomy of the nasopharynx and related \nspaces.\n2. To learn about the imaging features of benign lesions occuring in this region.\n3. To understand the extension patterns observed in malignant tumors of this \nregion.\n4. To appreciate the clinical impact of imaging findings in diseases of this \nregion.\n16:00 - 17:30 Room F1 \nGenitourinary \nRC 607 \nImaging of the scrotum and penis \nModerator:\nB. Brkljacic; Zagreb/HR \nA‑126 16:00 \nA. Acute scrotum \nL.E. Derchi; Genoa/IT (derchi@unige.it) \nUltrasonography is the technique best suited to evaluate the acute scrotum, since \nmodern transducers provide depiction of both fine anatomic details and intrates-\nticular vessels in all cases. It must be considered that causes of acute scrotum \nhave different frequencies according to patient age. Torsion is more common in the \npediatric age group; infections are more frequent in adults. In suspected testicular \ntorsion, color Doppler evaluation of intratesticulr flow allows diagnostic sensitivity \nof 86%. However, flow signals can be seen in low-grade torsions and identification \nof high-resistance flow at spectral analysis may help avoid false negatives. Torsion \nof the testicular appendages may be recognized when a small nodule, adjacent to \na normal-looking testis, with normal intratesticular flow, is encountered. Infection \nusually starts at the epidydimis and is diagnosed on clinical grounds; imaging is only \nrarely needed, but may be helpful in assessing testicular involvement. In patients \nwith trauma, imaging plays a key role in assessing testicular integrity, since surgery \nis needed when there is testicular rupture. Other, less common, causes of acute \nscrotum involve the scrotal skin, vessels and spermatic cord. Additionally, in rare \ncase, “non-scrotal” causes may produce acute scrotal symptoms. The most typical \nexample is extension of pain to the scrotum during a renal colic. Other causes may \nbe due to involvement of the scrotum from intrabdominal inflammatory or traumatic \npathologic changes due to patency of the processus vaginalis. \nLearning Objectives:\n1. To understand the role of imaging, especially US in testicular trauma.\n2. To learn whether imaging is required for testicular torsion and what the \nimaging signs are.\n3. To review the appearance of acute and subacute orchiepididymitis.\n\nFriday\nPostgraduate Educational Programme\nA\n S37\nCB D E F G\nA‑127 16:30 \nB. Incidentaloma in scrotal US \nL. Rocher; Le Kremlin‑Bicêtre/FR (laurence.rocher@bct.aphp.fr) \nThe most frequent pseudotumoral lesion is the tubular ectasia of the rete testis: it \nis characterized by a group of numerous tiny cysts and/or tubular configurations. \nMultinodular echotexture (similar nodules with diffuse regular distribution) involving \ntestis of normal size is usually bilateral and not malignant: it will be controlled. A \nmedical evaluation in search of a granulomatous disease like sarcoidosis is rec-\nommended, especially if the epididymis is also pathological. Multinodular aspect \n(hypo or hyperechoic nodes) involving very small testis (less than 3 ml) suggests a \nKlinefelter disease. Nodules are small benign leydig cell tumors or hyperplasia. The \nhypoechoic nodules greater than 5 mm, within vessels, identified by color Doppler \nwill generally be explored: Two main diagnoses are proposed: Seminoma and leydig \ncell tumor. Extemporaneous histologic analysis may be difficult. Hypoechoic areas, \nmicrolithiasis ou macrocalcification in the vincinity of the nodule, multifocal pattern, \nand very hypoechoic echotexture suggest malignity. A normal echotexture of the \nadjacent pulp, slight lobulate contours, a vascularity proportional to the size suggest \na Leydig cell tumor. In this case, a peroperative ultrasound may help the surgeon \nto perform a tumorectomy. MRI does not help us to distinguish these pathologies. \nSmall nodules of less than 5 mm incidentally found are generally controlled. We \nsuggest monitoring by ultrasound at 3, 6 and 12 months the first year, and then \nannually for two years. The announcement of a potentially malignant unexpected \nlesion should be very prudent and appropriate. \nLearning Objectives:\n1. To learn the various images that can be found incidentally on scrotal US, like \nmasses, calcifications, parenchymal heterogeneity and ductal ectasies.\n2. To determine which images may correspond to significant diseases and \nrequire follow-up or surgery.\nA‑128 17:00 \nC. Imaging of the penis \nM. Bertolotto; Trieste/IT (bertolot@univ.trieste.it) \nUltrasonography (US) is the first-line imaging modality in patients with penile dis-\nease. Using high-end equipment after pharmacologically induced erection penile \nanatomy is well defined and virtually all clinically significant penile vessels can be \nevaluated in normal and in impotent men. The superior soft-tissue contrast resolution \nafforded by MR imaging provides an opportunity to advance imaging evaluation of \nthe penis in selected cases. In the clinical practice, erectile dysfunction is the most \nfrequent penile abnormality which is investigated with Doppler US. The clinical role \nof this evaluation, however, reduced after the introduction of oral medications for \nimpotence. Differentiation among different forms of erectile dysfunction is mainly \nbased on evaluation of Doppler waveform changes in the cavernosal arteries. \nPeyronie’s disease is the most frequent cause of penile induration. Imaging is often \nrequired to evaluate the extension of the plaques, involvement of the penile septum, \nand relationship between the plaques and penile vasculature. In patients with penile \ntraumas, imaging allows accurate evaluation of albugineal tears, extra-albugineal \nand cavernosal hematomas, vascular lesions producing high flow priapism and \nother pathological changes. Compared with US, MR imaging has some advantages \nin identification of small albugineal tears, and is more accurate in identification of \nurethral or spongiosal involvement. Other situations in which penile imaging can \nbe required are circumscribed or diffuse cavernosal fibrosis, tumors, priapism, \nsevere inflammation, and evaluation of postsurgical complications. Most of these \nconditions are first investigated with US; MR imaging is optimal for tumor staging. \nLearning Objectives:\n1. To learn the most frequent penile diseases that can be diagnosed by \nimaging.\n2. To understand the respective roles of US and MRI and technical challenges \nof imaging.\n3. To know how imaging influences treatment and follow-up.\n16:00 - 17:30 Room F2 \nBreast \nRC 602 \nBreast MRI: Lesion characterisation \nModerator:\nK. Kinkel; Chêne‑Bougeries/CH \nA‑129 16:00 \nA. Morphology and kinetics at CE dynamic imaging \nG. Esen; Istanbul/TR (gulesenicten@gmail.com) \nMRI is the most sensitive imaging modality for the detection of invasive breast \ncarcinoma regardless of the fibroglandular composition of the breast. It is performed \nin prone position, in the axial, sagittal or coronal planes. Axial position is preferable \nbecause correlation with mammography and comparison with the opposite breast \nis possible. In order to detect small enhancing lesions reliably, fatty tissue signal is \nsuppressed, either by active fat suppression or subtraction. Examinations should \nbe performed in the second week of the menstrual cycle. Differential diagnosis \nis based on morphologic findings as well as contrast enhancement kinetics. It is \nimportant to have high resolution images while scanning as fast as possible so \nthat the temporal data is not lost. On MRI, benign lesions usually demonstrate \nminimal and slow enhancement, whereas malignancies are expected to show rapid \nenhancement and then washout. Morphologic findings are described according \nto the MR BI-RADS lexicon for the standardization of reports and interpretation \ncriteria. Masses with irregular or spiculated borders that show rim enhancement \nare highly suspicious for invasive tumors. Non-mass-like enhancement in the form \nof ductal or segmental clumped enhancement is also considered suspicious and \ncan be detected in DCIS. While interpreting breast MRI examinations, morphologi-\ncal and kinetic findings should be combined and correlated with mammographic \nand sonographic findings. Risk factors, if there are any, should also be taken into \nconsideration. In this lecture, appropriate imaging techniques as well as findings \nthat can be helpful in lesion characterization will be reviewed. \nLearning Objectives:\n1. To know the protocols used in breast MRI.\n2. To describe the different aspects of benign and malignant lesions.\n3. To review the basics of kinetic behaviour of breast lesions.\nA‑130 16:30 \nB. Overdiagnosis by breast MRI \nF . Sardanelli; Milan/IT (f.sardanelli@grupposandonato.it) \nOverdiagnosis should be considered for MRI indications in which lesions are diag-\nnosed which would have been undetected using only conventional imaging. This \nis intrinsically associated with screening MRI, recommended for high-risk women. \nHowever, high-risk cohort studies showed early stage of MRI-diagnosed cancers \nwith a high rate of negative nodal status, which plays in favor of an outcome effect \n(using assumptions derived from mammographic screening in the general female \npopulation). Conversely, the relatively higher probability of triple negative cancers \nin these women (in particular BRCA1 mutation carriers) should be taken also into \naccount. Meta-analyses showed that the risk of overdiagnosis is more important \nfor preoperative MRI (pMRI) which changes 16.6% of surgical treatments: 9.2% \nincrease of mastectomies due to 8.1% for true positives plus 1.1% for false positives; \n7.4% wider/additional excisions due to 3.0% plus 4.4%, respectively. Moreover, pMRI \nyields a 4.1% incremental detection rate of contralateral cancers (positive predic-\ntive value 48%); 35% DCIS and 65% invasive (mainly node negative). To reduce \novertreatment, we need needle sampling (including MRI guidance), reaching 13% \nof MRI-induced correct changes of surgical planning, to be compared with only \nabout 1% annual risk of recurrences (but also with 20-40% rate of positive surgical \nmargins). For contralateral cancers, needle biopsy can also reduce overtreatment, \nallowing excising contralateral cancers with simultaneous conservative surgery in \n4% of the women, to be compared with only 0.5-1% annual risk for contralateral \ncancer. pMRI has also been shown to detect extensive intraductal component, but \nwith 11-28% overestimate and 17-28% underestimate. \nLearning Objectives:\n1. To estimate overdiagnosis for preoperative MRI and for MRI screening of \nhigh risk women.\n2. To evaluate the potential impact of overdiagnosis.\n3. Possible ways to avoid overdiagnosis.\n\nPostgraduate Educational Programme\nS38\n A B C D E F G\nA‑131 17:00 \nC. How to improve specificity of breast MRI? \nJ. Veltman; Nijmegen/NL (j.veltman@rad.umcn.nl) \nBreast MRI has shown diagnostic sensitivities of 94-99% for invasive breast cancer; \nhowever, specificities have been reported significantly lower with values between \n37 and 86%. The specificity of breast MRI is mainly based on the evaluation of \nmorphologic features and relative “slow” dynamic characteristics of enhancing le-\nsions. The only moderate specificity that is achieved using these characteristics can \nresult in a significant number of false positive findings during for instance screening \nor pre-operative imaging. These findings will often require short term follow-up, \ntarget ultrasound with biopsy or even MRI guided biopsy. Fast dynamic imaging, \nspectroscopy and diffusion weighted imaging (DWI) have been described to have \npotential for improving the specificity of breast MRI. The use of fast dynamic imag-\ning sequences results in a more accurate evaluation of the initial enhancement of \nthe lesion. In combination with pharmacokinetic modeling, this can result in a more \nquantitative evaluation of enhancement. In proton-MR Spectroscopy (MRS), the \npresence of a choline signal, a cell-membrane precursor, in breast lesions can be \nused to differentiate benign from malignant lesions. The specificity of MRS varies \nbetween 67 and 100% in literature (average 87%). DWI has also shown potential \nin differentiating between benign and malignant lesions, but, like with other tech-\nniques, varying specificity values are reported ranging between 46 and 93%. In \nthis presentation, the value of these techniques for improving the performance of \nbreast MRI will be discussed. \nLearning Objectives:\n1. To discuss literature on MRI specificity.\n2. To discuss the value of ultrafast sequences.\n3. To discuss the value of spectroscopy and diffusion-weighted imaging.\n16:00 - 17:30 Room G/H \nState of the Art Symposium \nSA 6 \nAdrenals: Small glands, big problems … and \npractical solutions\nModerator:\nY . Menu; Paris/FR \nA‑132 16:00 \nChairman’s introduction: Five good reasons for the radiologist to image \nthe adrenals \nY . Menu; Paris/FR (yves.menu@sat.aphp.fr) \nThere are many reasons why adrenal imaging is meaningful. Five will summarize \nthe objectives of this session: 1. Adrenal lesions including tumours are extremely \ncommon. It is likely that any radiologist will face these questions almost every day. \n2. The problem of the so-called «incidentalomas» is especially common, and is \nsometimes a very difficult situation in patients with known or suspected cancer. 3. \nMany imaging modalities, including ultrasound, CT, MR and nuclear medicine are \nuseful in the detection, characterization, staging and follow-up of adrenal lesions. \n4. Imaging is powerful as long as precise protocols are applied, especially dynamic \nenhanced CT/MR and in-phase/opposed phase imaging. 5. Appropriate strategy, \nassociating imaging and biology are sometimes poorly understood and should be \nclarified, because the radiologist is in most cases the person who discovers adrenal \nlesions. Therefore, he/she should orientate the strategy according to the likelihood \nof specific diseases, advising either a simple follow-up or even no further examina-\ntion, or conversely prompting further clinical, biological or imaging investigations. \nThis session will answer these questions and provide the attendance with solid \nknowledge, useful for everyday’s practice. \nSession Objectives:\n1. It is a common clinical problem.\n2. It is the role of the radiologist.\n3. It is easy to manage.\n4. It is helpful for the patient.\n5. It saves anxiety and money.\nA‑133 16:05 \nWhat is normal, what is abnormal? \nM.-F . Bellin, S. Ferlicot, L. Rocher; Le Kremlin‑Bicêtre/FR \n(marie‑france.bellin@bct.aphp.fr) \nBecause of the increasing use of cross-sectional imaging, adrenal masses are \ncommonly detected, with reported frequency up to 5% at abdominal CT. Radiology \nplays a critical role in not only the detection of adrenal abnormalities but in charac-\nterizing them as benign or malignant. Computed tomography continues to be the \ncornerstone of adrenal imaging and has become the study of choice to differentiate \na benign adenoma from a metastasis in the oncology patient. An array of pulse \nsequences is now available that improves the image quality and diagnostic value \nof adrenal MR imaging. Adrenal masses can be classified into various groups on \nthe basis of the presence of intracellular lipid, macroscopic fat, haemorrhage, cystic \nchanges, vascularity and shape of the tumour. Recognition of the typical imaging \nfeatures of adrenal lesions is important for radiologists because it often changes \nthe treatment approach and may obviate surgery. \nLearning Objectives:\n1. To explain the optimal techniques of MRI and CT for the examination of the \nadrenals.\n2. To learn imaging landmarks of normal adrenal glands.\n3. To understand the concept of adrenal hyperplasia.\n4. To review the classification of adrenal tumours, benign and malignant, \nillustrated by radiopathological correlations.\n5. T o learn the clinical and radiological data in the most common diseases \nassociated with adrenal insufficiency like TB, histoplasmosis, haemorrhage, etc.\nA‑134 16:30 \nWhat is abnormal and not a problem? \nG. Heinz-Peer; Vienna/AT (gertraud.heinz@meduniwien.ac.at) \nThe widespread use of modern imaging techniques has significantly increased the \nnumber of incidentally detected adrenal masses. Adrenal incidentaloma is not so \nmuch a disease entity as a finding that may or may not represent a disease. Thus, \nincidental adrenal findings by their very nature pose a risk of over diagnosis and \novertreatment. Although most adrenal incidentalomas are of no significance beyond \nthe anxiety they produce indirectly. Some incidentalomas are clinically significant, \nand inadvertently leaving them alone might damage the patients´ health. Therefore, \ndetection of an incidentaloma necessitates a conscious decision regarding its man-\nagement. The past few years have seen an increasing reliance on semiquantitative \ntechniques in imaging and characterization of adrenal masses. Evaluation of the \nmean percentage washout for adrenal masses on delayed enhanced CT series \nallows differentiating benign and malignant incidentaloma with high sensitivity \nand specificity. On MRI, dynamic gadolinium enhanced - and chemical shift (CSI) \n- techniques have become well-accepted diagnostic methods in the characteriza-\ntion of adrenal masses. Additionally, nuclear medicine studies, and PET/CT have \nproved to be useful adjuncts in the whole assessment of adrenal lesions. All general \napproaches in managing adrenal incidentalomas involve hormonal screening. \nHowever, they vary both in extent and in the specific screening tests. In this lecture, \nan algorithm on the management of adrenal incidentalomas will be presented. \nLearning Objectives:\n1. To understand the prevalence of adrenal incidentalomas.\n2. To learn how radiology may help in differentiating benign and malignant \nincidentalomas.\n3. To be able to advise adequate examinations, both biological and radiological, \nfor the initial workup of adrenal incidentaloma.\n4. To understand how to organise follow-up.\nA‑135 16:55 \nWhat is abnormal and a problem, and what are the solutions? \nU.G. Mueller-Lisse; Munich/DE (ullrich.mueller‑lisse@med.uni‑muenchen.de) \nSince the advent of cross-sectional imaging in clinical medicine, adrenal lesions \nare frequently diagnosed even in asymptomatic patients. The term «incidentaloma» \nhas been coined for such lesions. However, while incidentalomas are frequently \nbenign, finding an adrenal lesion may constitute a diagnostic problem when the \npatient has previously been diagnosed with malignant disease. Following lung, \nliver, and bone, the adrenal is the 4\nth most common site of malignant metastasis. \nUnenhanced CT and MRI with in-phase and out-of-phase GRE-sequences may \nhelp to characterize adrenal lesions as (non-functioning) adenoma when the \nlesion measures less than 4 cm, appears round and homogenous, and there is \nsufficient intracellular fat. Contrast-dynamic imaging recognizes adrenal adenoma \nwith low contrast uptake and relatively fast wash-out (> 50% within 15 minutes). \n\nFriday\nPostgraduate Educational Programme\nA\n S39\nCB D E F G\nThe majority of metastases are bright on T2-weighted and iso- or hypo-intense in \nliver on T1-weighted MR images. Desmoplastic reaction may render a metastasis \ndark at MRI. Frequently, adrenal metastases demonstrate the same or similar \nimaging characteristics as the primary malignancy. In some tumor entities, e.g., \nNSCLC, lymphoma, or melanoma, PET/CT may demonstrate adrenal metastasis \nwith markedly increased specific-uptake-values for 18-FDG. However, tumors \nproducing catecholamines, e.g., benign or malignant phaeochromocytomas or their \nmetastases, may be characterized biochemically by means of MIBG- or octreotide \nszintigraphy (±SPECT), or Dota-Tate-PET/CT, and, in some instances, morphologi-\ncally by their inhomogeneity and contents of calcification and haemorrhage. Risks of \nneedle-tract-seeding, haemorrhage, and severe, acute hypertension are associated \nwith adrenal biopsy. Localization and characterization of functional adrenal tumors \nmay require adrenal venous blood sampling or orthostasis testing. \nLearning Objectives:\n1. To learn the natural history and the usual and unusual appearance of \nprimary cortical malignant tumors.\n2. To identify adrenal metastases, and the specific appearance according to the \nprimary site.\n3. To understand the role of PET/CT in adrenal malignancies.\n4. To be able to explain the advantages and limitations of percutaneous biopsy.\n5. To understand the radiological appearance and staging strategy in case of \nsymptomatic adenoma.\nEpilogue: \nThe practical role of the radiologist facing adrenal masses \n17:20 \n16:00 - 17:30 Room I \nVascular \nRC 615 \nPeripheral vascular malformations \nModerator:\nM. Sapoval; Paris/FR \nA‑136 16:00 \nA. Pathology, correct anatomical classification and clinical work-up \nH. Kubiena; Vienna/AT (harald.kubiena@meduniwien.ac.at) \nPatients presenting with vascular malformations mostly are nomadic and hopeless \nindividuals looking for help. Finally having reached a “multidisciplinary specialist-group” \nafter a sometimes long and misleading trip throughout the ocean of “single-players” \nof different specialities, these patients do not ask for any more diagnostics - they \nstrongly claim for therapy. Vascular malformations are congenital lesions, although \nmerely seen at birth they become evident throughout the individual’s growth. These \ndevelopmental errors can affect all components of the vascular tree in any area of \nthe body. The therapeutic goal must be defined rather as “control” than “cure” of \nthis disease. To make this point understandable for both patients and colleagues, \na fundamental understanding of the pathogenesis and natural course must be cre-\nated. In special cases of complex vascular malformations, the precise diagnosis and \nthe information about all potential side-effects as well as risk-factors of progression \nenables these patients to manage their daily life. Therefore, indications for treatment \nvary depending on the specific type of slow flow or high flow lesion, location, pain, \nfunctional and cosmetic impairments and general side-effects of each particular le-\nsion. Since no single specialist has enough knowledge to diagnose or treat vascular \nanomalies beyond the border of his/her distinct specialty, multidisciplinary working-\ngroups have emerged at these interdisciplinary interfaces. Their common language \nin classifying and their overall understanding of pathogenesis, prognosis offers \nthese mostly hopeless patients a costume-fit treatment addressing their symptoms. \nLearning Objectives:\n1. To understand the difference between AVMs and hemangiomas.\n2. To review the classification of arterio-venous malformations.\n3. To understand the influence of AVM types on treatment selection.\nA‑137 16:30 \nB. Diagnostic approaches to AVM: How to image the dynamic \nS. Frevert; Copenhagen/DK (susanne.frevert@rh.regionh.dk) \nAn arterio-venous malformation consists of a nidus made of micro- or macro fistulas \nand the feeding arteries and draining veins. The lesion is hemodynamically active \nwith fast-flow and early venous shunting. AVMs are considered congenital but most \nbecome evident later in life. The ideal examination to evaluate arterio-venous mal-\nformation must be safe, reliable and give answers to questions about the feeding \narteries and draining veins as well as the nidus. The vessel supply and involvement \nof bones, muscles, subcutaneous tissues and organs have to be determined and \nfinally the flow in the lesion must be addressed. Ultrasound combined with color \nDoppler examination is the primary diagnostic tool and documents the arterio-\nvenous shunting. The angioarchitecture of the lesion can be difficult to evaluate.\nContrast enhanced CT scanning is of limited value in arterio-venous malforma-\ntions except in lesions involving the internal organs and the visceral vessels. The \nsingle most useful examination is MRI. The scanning has the distinct advantage to \ndemonstrate the extent of the lesion. Contrast-enhanced MR angiography espe-\ncially with time resolved sequences allow the flow characteristics to be assessed. \nTypical findings of AVM are dilated tortuous vessels with flow void corresponding \nto the fast flow in the arteries and veins. The black round holes are visible in most \nsequences. There is little if any soft tissue mass. The hypertrophied arteries and \nenlarged draining veins are depicted on contrast-enhanced MR angiography. \nConventional angiography is indispensable for precise pre-therapeutic evaluation \nof the nidus and angioarchitecture. \nLearning Objectives:\n1. To learn about techniques for dynamic non-invasive vascular imaging.\n2. To demonstrate the imaging findings of different types of AVMs.\n3. To understand potential pitfalls of imaging modalities.\nA‑138 17:00 \nC. Treatment of AVMs: Image-guided interventions: When and when not \nJ.A. Reekers; Amsterdam/NL (J.A.Reekers@amc.uva.nl) \nManagement of arterio-venous malformations (AVM) is still one of the most chal-\nlenging interventional procedures. All AVMs are unique and need tailored treatment. \nThe typical medical history of an increasing tumour, often already diagnosed in \nchildhood, and the “trill” in a high-flow AVM already makes a diagnosis. The imag-\ning pathway is the same for all AVMs. MRI is the first choice diagnostic step. The \ntypical appearance on T1 and T2 makes the diagnosis. The most important feature \nof the MRI is that it will show the extent of the lesion. The latter is important for pos-\nsible treatment options. MRA does not contribute to the diagnosis and is therefore \nnot necessary. After the diagnosis of a high-flow AVM, a treatment plan can be \nmade. As an AVM is a benign disease, it is the patient’s complaints that lead to a \ntreatment. Just having an AVM is not an indication for treatment. Pain, bleeding, \nphysical constrain and sometimes cosmetic problems are the right indication for \ntreatment. In high-flow lesions, the aim is to close the direct A_V fistulae. This can \nbe done with several materials. Glue often gives the best results, but also coils or \nOnyx can be used. The outcome of treatment is not total cure (which is seldom \nreached) but improvement of QOL. \nLearning Objectives:\n1. To learn about optimised treatment strategies.\n2. To learn about risks and contraindications.\n3. To discuss pros and cons of percutaneous and/or endovascular treatment.\n16:00 - 17:30 Room K \nRTF - Radiology Trainees Forum \nTF 1 \nHighlighted Lectures \nModerators:\nD. Bulja; Sarajevo/BA \nP.R. Kornaat; Leiden/NL \nA‑139 16:00 \nCommon pitfalls in MR mammography \nD. Djilas-Ivanovic; Sremska Kamenica/RS (draganadji@hotmail.com) \nMagnetic resonance imaging (MRI) of the breast is emerging as the most sensi-\ntive modality available for the detection of primary or recurrent breast cancer. The \npublished sensitivity ranges between 89 and 100%, with more variable\n specificity \nranging between 20 and 100%. There are number of technical artifacts (motion \nartifacts, misregistration, magnetic susceptibility artifacts etc). and pitfalls (such as \ninadequate fat saturation at 3.0 T units) that can limit the interpretation of the images \nby masking or simulating disease. Both morphologic and kinetic features should \nbe considered in the image interpretation. However, many diagnostic pitfalls must \nbe considered. Both strong background enhancement and lack of enhancement \nof the lesion can lead to diagnostic mistakes. Lack of enhancement is strongly \n\nPostgraduate Educational Programme\nS40\n A B C D E F G\npredictive of benignity, with negative predictive value for invasive cancer of 94-\n96%, but the absence of observed enhancement does not necessarily exclude a \ncancer. Morphologic criteria, such as margin characteristics of a focal lesion or the \ndistribution of area enhancement, are considered the most important features for \nbreast lesion diagnosis. 1H MR spectroscopy is a promising tool in the detection of \nbreast malignancy, but there are many technical and interpretational pitfalls that \none should be aware of. Correlation of breast MRI with other imaging modalities \n(mammography and ultrasound) improves the diagnostic specificity. If breast MRI \nreveals a lesion that was not detected with previous, standard procedures, the \nradiologist should try to localize the lesion using second-look ultrasound. \nLearning Objectives:\n1. To learn about technical artifacts and pitfalls commonly encountered in \nbreast MRI.\n2. To become familiar with specific morphologic and kinetic features that should \nbe considered in the image interpretation.\n3. To appreciate the importance of correlation of breast MRI with other imaging \nmodalities.\nA‑140 16:30 \nAn easy approach to tackle neck imaging \nD. Farina; Brescia/IT (nappaje@yahoo.it) \nEssentially, two factors make neck imaging a demanding task: the challenge \nposed by motion artefacts and the understanding of the anatomy. First of all, neck \nimaging can be simplified if images of good quality are acquired. The routine use \nof multidetector CT equipments has noticeably decreased the impact of motion \nartefacts in CT imaging. Nonetheless, MRI should be preferred in the evaluation of \nsoft tissue masses of the neck. Tailoring of the protocol to both patient and lesion \nis thus essential to obtain a correct diagnosis, by combining time decreasing tricks \n(such as parallel imaging), contrast improving sequences (fat saturation, above all) \nand high resolution acquisition (such as 3d-VIBE). Secondly, neck imaging can be \nsimplified if the complex anatomy of this region is disassembled in spaces that are \neasily identified on cross-sectional scans, basically on axial plane (though also on \ncoronal and sagittal images). These spaces are defined by the splitting of the three \nlayers (superficial, middle, deep) of the deep cervical fascia. Nine spaces are thus \ndefined, 4 located in the suprahyoid neck (parapharyngeal, masticator, parotid, \npharyngeal mucosal), 1 in the infrahyoid neck (visceral) and 4 extending vertically \non both sides of the hyoid bone (carotid, retropharyngeal, perivertebral, posterior \ncervical). This schematic classification helps to assign each lesion to a space of \norigin, and consequently, to narrow the list of differential diagnoses to a minimum. \nMoreover, this classification accounts for the need to scrutinize the neck along all \nits length when acute inflammatory processes are under investigation. \nLearning Objectives:\n1. To become familiar with MSCT/MRI protocols for neck imaging.\n2. To learn the tricks to improve the quality of images.\n3. To understand the boundaries and vertical extension of the spaces of the \nneck.\n4. To become familiar with the space-specific differential diagnosis.\nA‑141 17:00 \nManagement in radiology \nL. Donoso; Barcelona/ES (ldonoso@clinic.ub.es) \nAs the importance of imaging studies in the diagnosis and treatment of all kinds of \npatients continues to grow, professionals from many different backgrounds are gaining \nfootholds in what was once the radiologist’s exclusive domain. Radiology departments \nneed to adopt a proactive approach to ensure that radiologists will continue to lead the \nimaging revolution. Innovative proposals focused on maximizing client satisfaction and \ncreating added value are the best way to keep a competitive edge. The management \nstrategy of creating added value through innovation has been effective in many differ-\nent branches of industry, and the basic principles of this approach can be applied in \nradiology. This presentation will focus on different ways to become more competitive by \ncreating added value in the services we provide. The future of radiology departments \nwill depend largely on our willingness and ability to manage innovatively to ensure that \nwe deliver added value to our clients. Innovative management begins with a critical \nevaluation of all the activities that make up the value chain. It is essential to review \nall the organization’s processes to determine which activities should be improved, \nreduced, or eliminated and to introduce new activities that create value for clients. Value \ncurves make it possible to examine these activities in detail and to compare traditional \napproaches with innovations. Information and communication technologies are key to \nthis strategy and this presentation will emphasize and illustrate their role in developing \nthe radiology department’s business strategy. \nLearning Objectives:\n1. To recognise the importance of innovative management in delivering \nradiological services.\n2. To understand how innovative management creates added value for clients.\n3. To appreciate the crucial role of information and communication \ntechnologies.\n16:00 - 17:30 Room L/M \nSpecial Focus Session \nSF 6 \nImaging of cardiomyopathies \nModerator:\nV.E. Sinitsyn; Moscow/RU \nA‑142 16:00 \nChairman’s introduction \nV.E. Sinitsyn; Moscow/RU (vsini@mail.ru) \nPrimary cardiomyopathies (CMP) are diseases of the myocardium of unknown \norigin, associated with cardiac dysfunction. There is a need for better detection and \ncharacterization of these diseases. Modern classification of CMP is quite complex. \nThanks to progress of cardiac imaging, new types of CMP have been discovered. \nThere is growing clinical interest in the use of cardiac MRI and MDCT in detection \nand characterization of CMP . Major tasks of cardiac imaging in CMP are: assess-\nment of cardiac morphology and function, quantification of blood flow and valve \nmotion and myocardial characterization, e.g. identification of foci of inflammation \nand fibrosis. Both MRI and MDCT may detect major diagnostic features of CMP \nwithout limitations of echocardiography. MR with late gadolinium enhancement \n(LGE) has turned into one of the best modalities for myocardial characterization, \ncompeting with nuclear imaging. Recent clinical studies have suggested that the \nextent and pattern of LGE may have prognostic and therapeutic value in patients \nwith CMP . CTA can reliably differentiate ischemic CMP from non-ischemic ones. New \ntechnologies of MDCT, such as dual energy CT, may be also used for myocardial \ncharacterization. It has been shown that MRI and MDCT can provide a valuable \ncontribution to the diagnosis of CMP and contribute substantially to proper manage-\nment and treatment of patients with CMP . Current clinical recommendations list CMP \nas one of the major indications for cardiac MRI or CT. Broad and growing scope of \nindications for cardiac imaging requires corresponding competence of radiologists \nin diagnosis of non-coronary cardiac diseases, including CMP . \nSession Objectives:\n1. To learn about the increasing incidence of cardiomyopathy, the various \netiologies and the terminology.\n2. To be aware of the natural history of cardiomyopathies.\n3. To understand why the radiologist has an added value in the diagnosis, \nwork-up and follow-up of cardiomyopathies, and how CT and MRI may play \nan important role in addition to echocardiography.\nA‑143 16:03 \nImaging of cardiomyopathies: What is important for the cardiologist? \nJ. Schulz-Menger; Berlin/DE (jeanette.schulz‑menger@charite.de) \nCardiac Magnetic Resonance (CMR) has the capability to assess cardiac function, \nto visualize small myocardial lesions and to differentiate myocardial tissue changes. \nOne of the most challenging tasks in cardiology is the differentiation of the underly-\ning cause of a wall motion abnormality, impaired myocardial function or causes for \nhypertrophy. In case of dilated cardiomyopathy, mainly the differentiation of ischemia \nand inflammatory reaction has to be elucidated. Beside characterization of tissue \nchanges, CMR has the potential to differentiate prospectively between reversible \nand irreversible myocardial injuries. The changes can be monitored during follow-up. \nThe broad clinical spectrum from subclinical disease to severe heart failure and \na course of the disease from complete convalescence to dilated cardiomyopathy \ndepends on the extent of the myocardial damage and its immediate detection. \nTherefore, an early non-invasive differentiation is warranted. Contrast-enhanced \nCMR and combined protocols has been used to detect myocardial inflammation \nfor several years and for follow-up. In case of hypertrophic cardiomyopathy, CMR \nis superior in comparison to echocardiography in detecting small and uncommon \nlocalized hypertrophied regions. The high spatial resolution allows the visualiza-\ntion of small abnormalities including findings affecting the papillary muscle. The \napplication of contrast-enhanced CMR may be helpful to differentiate the cause \n\nFriday\nPostgraduate Educational Programme\nA\n S41\nCB D E F G\nand provides some information regarding risk-assessment. Detection of myocardial \ntissue changes offers the opportunity to understand the development of disease \nand therefore the potential to optimize therapy. \nLearning Objectives:\n1. To become familiar with classification and manifestations of \ncardiomyopathies.\n2. To understand the major needs for imaging in cardiomyopathies.\n3. To indicate the modern role of cardiac CT and MRI in the work-up of a \npatient with cardiomyopathy.\nA‑144 16:15 \nMRI and MDCT in dilated cardiomyopathy \nJ. Bogaert; Leuven/BE (Jan.Bogaert@uz.kuleuven.ac.be) \nThe role of non-invasive imaging techniques, in particular computed tomography \n(CT) and magnetic resonance imaging (MRI), is rapidly expanding in investigating \npatients with dilated ventricles. The etiology of uni- or biventricular enlargement is \nwidely variable (e.g. idiopathic dilated, ischemic, toxic, metabolic, arrhythmogenic \nRV dysplasia, non-compaction cardiomyopathy), making straightforward diagnosis \nand treatment often challenging. Both CT and MRI provide volumetric data, and in \ncombination with ECG triggering, ventricular volumes and volume changes of both \nventricles throughout the cardiac cycle can be accurately quantified. The MRI, and \nCT to a lesser extent, can provide valuable information on the underlying cause and \ndetect associated pathology (e.g. thrombus formation, valvular regurgitation). The \npresence and pattern of myocardial enhancement is informative about the type of myo-\ncardial insult (e.g., ischemic versus inflammatory) and helpful in predicting response \nin cardiac resynchronization therapy (CRT). Angiographic CT/MRI techniques can \nbe used to visualize the cardiac venous system, facilitating CRT lead placement. To \nconclude, the novel, not infrequently unique, information obtained by both techniques \nhas been extremely helpful in better understanding the “dilated” heart. \nLearning Objectives:\n1. To understand how to perform cardiac MRI and MDCT in order to assess \ncardiac morphology and function in patients with dilated cardiomyopathy.\n2. To learn how imaging helps to differentiate dilated cardiomyopathy from \nischemic cardiomyopathy and chronic myocarditis.\n3. To compare MRI and MDCT with other imaging modalities in diagnosis of \ndilated cardiomyopathy and to show their contribution to treatment selection \nand patient outcome.\nA‑145 16:35 \nMRI and MDCT in hypertrophic cardiomyopathy \nM. Gutberlet; Leipzig/DE (matthias.gutberlet@herzzentrum‑leipzig.de) \nHypertrophic cardiomyopathy (HCM) is a cardiomyopathy, which is characterized by an \ninappropriate myocardial hypertrophy in the absence of an obvious cause and is geneti-\ncally transmitted in the majority of patients. It can occur with an obstruction (HOCM) \nof the left ventricular outflow tract (LVOT) and without (HCM). Magnetic Resonance \nimaging (MRI) as well as Multi Detector Computed T omography (MDCT), i.e. in patients \nwith contraindications for MRI, can assess left and right ventricular function and muscle \nmass. MRI with its possibilities of tissue characterization has improved the knowledge \nabout different cardiomyopathies in the recent years so much. Especially, for the risk \nstratification of patients suffering from hypertrophic cardiomyopathy (HCM), MRI with \nthe use of „late gadolinium enhancement“ (LGE) as a surrogate parameter for fibrosis \nor scar tissue seems to be of an additional value, because the areas of LGE can be \nseen as a potential arrhythmogenic region. Furthermore, MRI provides the unique \npossibility to quantify the LVOT -obstruction by the use of MR-flow measurements. \nLearning Objectives:\n1. To become familiar with major forms of hypertrophic cardiomyopathy, clinical \nmanifestations and complications of the disease.\n2. To show the role of cardiac MRI and MDCT in the assessment of myocardial \nhypertrophy, flow and valvular disturbances in this form of cardiomyopathy.\n3. To consolidate knowledge about possible links between imaging features of \nthe disease, its complications and patient’s prognosis.\nA‑146 16:55 \nUncharted waters: Unclassified and rare cardiomyopathies \nJ.D. Dodd; Dublin/IE (J.Dodd@st‑vincents.ie) \nCardiomyopathies are an important and heterogeneous group of diseases. They may \nbe classified into primary and secondary etiologies. Primary cardiomyopathies are \nthose solely/predominantly confined to heart muscle, whilst secondary cardiomyopa-\nthies demonstrate myocardial involvement as part of a more generalized systemic \nmulti-organ disease. The number of entities in both categories continues to rise as \nour definition and understanding of cardiomyopathies continues to evolve. In each \nbroad category, what was once considered rare is becoming increasingly commonly \nrecognized as our appreciation of the importance of genetic factors in combination \nwith environmental influences continues to grow. The increasing availability of non-\ninvasive imaging modalities such as cardiac magnetic resonance imaging (CMRI) and \nechocardiography is playing an increasingly central role in the evaluation of patients \nsuspected of cardiomyopathy. Rare primary cardiomyopathies include morphological \nand genetic variations of ARVD, non-compaction syndrome and glycogen storage \ndisorders. Of the mixed cardiomyopathies, unusual infectious and toxic causes \nare being increasingly recognized. The evolving role of cardiomyopathies in the \nautoimmune and neuromuscular disease categories is of burgeoning interest. Our \nunderstanding of the acquired cardiomyopathies such as T ako-tsubo and peri-partum \ncardiomyopathies continue to develop. A number of secondary cardiomyopathies are \nnow being characterized, such as those occurring as part of the connective tissue \ndisorders. An overview of the clinical characteristics and potential etiologies of some \nof these rare cardiomyopathies and examples illustrated on CMRI will be provided. \nLearning Objectives:\n1. To review the etiologies of the various unclassified/rare cardiomyopathies.\n2. To learn about the clinical features and pathophysiology of the unclassified/\nrare cardiomyopathies.\n3. To acquire the latest knowledge of the appearances of the unclassified/rare \ncardiomyopathies on cardiac MRI.\nPanel discussion:  \nImaging of cardiomyopathies: A wake-up call for the general \nradiologis \n17:15 \n16:00 - 17:30 Room N/O \nContrast Media \nRC 606 \nOrgan-specific and future contrast media in MRI \nModerator:\nA.J. van der Molen; Leiden/NL \nA‑147 16:00 \nA. Real added value of liver-specific contrast media \nO. Clément; Paris/FR (olivier.clement@inserm.fr) \nLiver specific contrast agents have been developed by pharmaceutical companies for \nalmost 20 years, but what remains in 2010? A few specific indications. There are two \nmajor mechanisms for liver specific uptake: 1. A specific hepatobiliary uptake through a \nmembrane transporter at the sinusoidal face of the hepatocyte (Multihance\n®, Primovist®) \nor through a non-specific mechanism for manganese (T eslascan®). 2. An uptake by the \ncells of the reticulo endothelial system for iron oxide particles (Resovist®, Endorem®). \nThe resulting liver parenchymal enhancement will be a bright with gadolinium and \nmanganese chelates (T1 effect) and dark with iron particles (T2 effect). On clinical \nroutine for liver imaging, the initial dynamic arterial and portal phases are of paramount \nimportance to detect and more to characterize lesions. With liver specific agents, another \nphase is added, the delayed parenchymal phase which adds information, especially \nfor lesion detection. Clinical trials and marketing authorizations for liver specific agents \nconcern either detection of metastasis or characterization of liver tumors. After so many \nyears of market release, only few liver examinations are performed routinely, mainly \nin centers specialized in liver surgery. This can be explained because none of these \nagents offer both possibilities to have dynamic and delayed phases, and a good dynamic \nphase with a non-specific gadolinium chelate already answers a majority of the clinical \nquestions. This course will detail the different clinical situations where a specific liver \ncontrast agent is needed in routine liver imaging. \nLearning Objectives:\n1. To know which liver-specific contrast media can be used in clinical practice.\n2. To understand the respective working mechanisms.\n3. To know the evidence for clinical applications and indications.\nA‑148 16:30 \nB. Contrast for atherosclerosis imaging \nJ.H. Gillard; Cambridge/UK (jhg21@cam.ac.uk) \nDespite tremendous advances in the recognition and management of risk factors for \natheromatous disease, it remains responsible for substantial morbidity and mortality \nin the Western world. Until recently, the risk of carotid disease in symptomatic pa-\ntients was determined by simple luminal measurements. We are now able to image \n\nPostgraduate Educational Programme\nS42\n A B C D E F G\nindividual plaque components including the fibrous cap, lipid core and haemorrhage. \nThe current goal is to be better able to characterise plaque risk, whether it is in the \ncarotid, coronary or peripheral vasculature. Our understanding of the natural history \nof atheroma development continues to grow. Whilst the assessment of risk is aided by \nthe quantification of individual morphological components in plaque viewed with MR, \nit has been difficult to image true plaque function. Enticing studies of plaque activity \ndemonstrated using FDG PET showed that it is possible to image inflammatory activ-\nity in humans. We now have MR contrast agents that are taken up by macrophages \nand are visible with high-resolution MR. We are also able to image not only individual \nplaque structure, but also function, allowing an improved understanding of why two \npatients will identical degrees of luminal stenosis may have completely different \ndegrees of vulnerability. There have been tremendous advances in our ability to ac-\ncess plaque instability using MR over the last few years, the most exciting being the \nability to use cell specific markers of inflammation. The challenge is to validate these \ntechniques in the carotid and assess their utility and effectiveness in clinical practice. \nLearning Objectives:\n1. To understand the pathophysiology of the formation of the atherosclerotic \nplaque.\n2. To understand how contrast agents can visualise plaques.\n3. To know what the clinical applications and indications are.\nA‑149 17:00 \nC. CEST-type contrast media in MRI \nM.T. McMahon, A.A. Gilad, G. Liu, P .C.M. van Zijl, J.W.M. Bulte;\nBaltimore, MD/US (jwmbulte@MRI.jhu.edu) \nA novel approach to generate MRI contrast without the use of metal-based contrast \nagents is to perform Chemical Exchange Saturation Transfer (CEST) imaging in \nthe presence of agents with multiple exchangeable protons that are off-resonance. \nWhen irradiated with a saturation pulse at the specific off-resonance frequency, \nthe protons lose their capability to create signal, with the signal loss transferred to \nbulk water (the source of MRI signal) through chemical exchange. Several types \nof CEST contrast agents have now been described, containing amide, amine, \nor hydroxyl protons as off-resonance exchangeable protons. By virtue of their \nfrequency-specific resonance, it is possible to selectively saturate the proton group \nof choice, permitting a distinction of different polypeptides by assigning multiple \ncolors. Some biological applications of CEST contrast agents include the cloning \nand expression of an amide-rich reporter gene for MRI cell tracking, their use as pH \nsensor, and lipoCEST agents for imaging of lymph nodes. As they are bio-organic \nand consist of naturally occurring compounds, the future clinical use of CEST \nagents may be facilitated. A closely related type of contrast media, PARACEST \nagents, works using a similar principle but uses metal ions to shift away the proton \nresonance from the water peak. Some examples of other groups developing these \nPARACEST agents will also be highlighted. \nLearning Objectives:\n1. To understand the working mechanism of CEST -type imaging.\n2. To introduce the potential clinical indications and applications.\n16:00 - 17:30 Room P \nChest \nRC 604 \nHot CT issues in clinical practice \nModerator:\nC. Schaefer‑Prokop; Amsterdam/NL \nA‑150 16:00 \nA. How to manage incidentally found pulmonary nodules \nL. Bonomo; Rome/IT (lbonomo@rm.unicatt.it) \nPulmonary nodules are small, focal, radiographic opacities that may be solitary or \nmultiple. Solitary pulmonary nodule (SPN) is a single, round, well circumscribed \nradiographic opacity that measures < 3 cm in diameter and is surrounded completely \nby aerated lung. Small subcentimeter nodules measure < 8 to 10 mm in diameter and \ncan be solitary or multiple. The improved technology in CT scanners has resulted in \nthe detection of large number of small noncalcified pulmonary nodules (< 10 mm) \non CT scans. In reported studies the frequency of detecting one or more SPN on \na screening CT scan ranges from 5 to 60%. The clinical significance is unknown. \nCharacterization of small pulmonary nodules is very difficult because detailed \nmorphologic features often cannot be perceived. For small pulmonary nodules, \nCT morphology is quite non-specific, no typical feature of malignancy is defined, \nand considerable error is associated in the density measurement. The likelihood of \nmalignancy depends on patient risk factors, nodule size and morphologic character-\nistics; it is highest in current smokers and increases with age. A strong association \nbetween nodule diameter and the likelihood of malignancy has been reported. \nRegarding the morphology, the nodules may be characterized as solid, partly \nsolid or pure ground glass opacities. In some studies, the likelihood of malignancy \nwas high in ground glass opacities and in partly solid lesions but much lower in \nsolid nodules. The optimal approach to the management of subcentimeter nodules \nremains problematic and the current guidelines are not in complete agreement. \nLearning Objectives:\n1. To review the different risk situations for patients with pulmonary nodules.\n2. To describe the rationale for choosing different management options in \ndifferent patient populations.\n3. To recommend management strategies for the individual patient.\nA‑151 16:30 \nB. Optimising and minimising radiation dose \nD. Tack; Baudour/BE (denis.tack@skynet.be) \nThe radiation dose delivered by MDCT for a standard chest volumetric acquisition \nranges between 10 and 100 times the one delivered for a chest radiograph. Nu-\nmerous recent technical improvements help limit the dose of volumetric CT. Using \nappropriate parameters, optimized MDCT of the chest delivers less than 10 times \nthe dose of a chest radiograph while providing excellent diagnostic image quality. \nLow-dose chest MDCT with slightly reduced image quality may deliver a radiation \ndose in the range of that delivered for a radiographic examination. In this presenta-\ntion, we will review the available reference diagnostic levels, and compare them to \noptimized dose and to low-dose levels. The reasons for inappropriate use of higher \ndoses will be reviewed in addition to the most recent technological advances and \nresearch enabling further radiation dose reductions. \nLearning Objectives:\n1. To review the latest technological advances for dose optimisation and \nminimisation.\n2. To provide CTDIvol, DLP and effective dose values for state-of-the-art chest \nMDCT scanning.\n3. To review radiation risks and benefits from perfusion and triple-rule-out \nMDCT studies of the chest.\nA‑152 17:00 \nC. Phenotyping and interventions in COPD \nP .A. Grenier; Paris/FR (philippe.grenier@psl.aphp.fr) \nChronic obstructive pulmonary disease (COPD) is a slowly progressive airway \nobstructive disorder resulting from an exaggerated inflammatory response that \nultimately destroys the lung parenchyma (emphysema) and induces irreversible \nreduction in the caliber of small airways (airway wall remodeling). Bronchial wall \nthickness and the extent of emphysema at CT in COPD patients have proven to \nbe both the strongest independent determinants of the degree of airflow obstruc-\ntion at pulmonary function tests. Using CT to define phenotypic abnormalities in \nCOPD patients may serve to optimize treatment and assess response to potential \ntherapeutic interventions. Although the different morphologic abnormalities seen \non CT scans of COPD patients often overlap, two separate groups of patients can \nbe identified, those with emphysema predominant disease and those with airway \npredominant disease due to chronic inflammation resulting in airway remodelling \nand narrowing. The former category can be further subdivided based on the type of \nemphysema present and further characterized by anatomic distribution and sever-\nity using visual assessment and volumetric quantitative CT techniques. Patients \nin the airway predominant category can also be characterized by CT as showing \nbronchial wall thickening, small airway inflammation, mosaic perfusion and air \ntrapping expressing small airway narrowing, and expiratory bronchial collapse due \nto cartilage deficiency. Recent advances in automated airway segmentation and \nquantitative analysis have made measurements of airway dimensions feasible. In \nlongitudinal studies, standardization of procedures and quality control are needed, \nparticularly if quantitative CT outcomes are used as endpoint in clinical trials and \nultimately in the clinical management of individual patients. \nLearning Objectives:\n1. To know the classification of COPD phenotypes, and the key role of CT in \ndetermining the predominant phenotype in any given COPD patient.\n2. To understand the methods used for CT quantitative assessment of \nemphysema and airway wall remodelling, and their limits.\n3. To know the role of imaging in selecting candidates for interventions, and in \nfollow-up of longitudinal studies.\n\nFriday\nPostgraduate Educational Programme\nA\n S43\nCB D E F G\n16:00 - 17:30 Room Q \nInterventional Radiology \nRC 609 \nRF ablation beyond the liver \nModerator:\nR.D. García Mónaco; Buenos Aires/AR \nA‑153 16:00  \nA. RF ablation in bone \nA.D. Kelekis; Athens/GR (akelekis@cc.uoa.gr) \nThe purpose of this refresher course is to demonstrate techniques used in bone \nablation in the spine and the appendicular skeleton. There is an active dilemma on \nwhich lesions to use thermal ablation and on which stabilization by bone augmentation \ntechniques. We will review differences between lytic and blastic lesions and charac-\nteristics of various ablation devices (such as monopolar, bipolar, single and multitined \nelectrodes). Imaging techniques, including fluoroscopy, computed tomography and \nmagnetic resonance will be addressed. Analgesia is being discussed. Complications \nare analyzed. By the end of this presentation, users of ablation techniques should be \naware of the possible anatomical and positional landmarks, as well as the possible \nadvantages and disadvantages of each device. Results of ablation will be discussed. \nCombination of the ablation technique with other methods will be presented. We will \nexplore the possible advantages to standard osteoplasty. In conclusion, bone ablation \nis a valid technique, standing alone or in combination with other procedures. The \npurpose of this presentation is to allow the interventional radiologist to perform the \nablation in a safe and efficient way. Knowing the limitations of the material at hand \nseems to be important for avoiding technical complications. \nLearning Objectives:\n1. To discuss indications, patient selection and preprocedural imaging.\n2. To descibe the technique.\n3. To review the results and complications.\nA‑154 16:30 \nB. RF ablation in the kidney \nM.A. Farrell; Waterford/IE (michaela.farrell@hse.ie) \nOver the last two decades, open nephron sparing surgery has become the preferred \nsurgical alternative to nephrectomy for treatment of patients with a single, small (< 5 cm) \nclearly localized renal mass and a normal contralateral kidney. Because 25-49% of newly \ndiagnosed small renal masses are identified incidentally on cross sectional imaging, \noften in elderly patients, less invasive surgical nephron sparing alternatives have been \nadvocated, including laproscopic partial nephrectomy and laproscopic cryoablation, \nfor select tumors in an effort to reduce surgical mortality and morbidity while preserv-\ning renal function. Percutaneous image-guided ablation offers potential advantages \nover surgical methods including the minimally invasive nature of the procedure, less \nmortality and morbidity than surgery, shorter hospital stay, and quicker recovery. Local \ntumor control rates of up to 95% have been reported for small tumors. Central tumors \nand tumors greater than 3 cm in diameter are more difficult to successfully treat with \nlocal tumor progression occurring 25% of central tumors. T umors larger than 3 cm in \ndiameter typically require overlapping ablations and incomplete treatment can result \nfrom residual tumor at the ablation interfaces. While in some reports, local tumor pro-\ngression occurred in up to 20% of tumors larger than 3 cm, in contrast, others have \nshown that all exophytic tumors, despite their size, can successfully be treated using \nmultiple overlapping ablations and complete treatment may require more than one \nablation session. The most clinically relevant and potentially avoidable complication is \nureteral injury with resultant obstruction of the intrarenal collecting system. \nLearning Objectives:\n1. To discuss indications and patient selection.\n2. To describe currently available therapeutic alternatives.\n3. To review the results of RF ablation compared with other treatments.\nA‑155 17:00 \nC. RF ablation in the chest \nI. Bargellini; Pisa/IT (irenebargellini@hotmail.com) \nIn the past decade, percutaneous image-guided radiofrequency ablation (RFA) has \nbeen proposed as a safe and effective minimally invasive procedure in selected \npatients with unresectable or medically inoperable lung malignancies. When ad-\nequately performed by experienced operators, the procedure is associated with \nup to 99% immediate technical success rate and low incidence of major (8-15%) \nand minor complications (20-40%). The most frequent complications are alveolar \nhaemorrhage, pleural effusion and pneumothorax (9-52%), the latter requiring chest \ntube placement in a relatively low number of cases (3-5% of ablation sessions). \nSome studies have pointed out that, although these complications are unpredict-\nable, there are some significant risks factors for pneumothorax, some of them being \ninevitable (such as patients’ age, emphysema, and tumor diameter and location), \nsome others being avoidable, particularly when planning the needle access and \ntrack through the lung parenchyma. After RFA, sustained complete tumor response \nhas been demonstrated in about 85-90% of the target lesions. These favourable \nfigures are associated with promising survival rates. According to the RAPTURE \nstudy, the 2-year cancer-specific survival was 73% in patients with NSCLC, 68% \nin patients with colorectal metastases, and 67% in patients with other metastases, \nwith corresponding overall survival rates of 48, 66 and 64%, respectively. These \nresults can be obtained after proper patient selection by a multidisciplinary team. In \nparticular, RFA can be useful in nodules smaller than 3 cm and in peripheral loca-\ntion (possibly > 1 cm from the hilum). The association between RFA and chemo-/\nradioteraphy should also be considered in selected patients. \nLearning Objectives:\n1. To discuss indications and patient selection.\n2. To describe the technique and complications.\n3. To review the results of RF ablation to date.\n\nPostgraduate Educational Programme\nS44 A B C D E F G\n\nPostgraduate Educational Programme\nA S45CB D E F G\nSaturday, March 6\n\nPostgraduate Educational Programme\nS46\n A B C D E F G\n08:30 - 10:00 Room A \nSpecial Focus Session \nSF 7a \nCardiac CT: Imaging beyond the coronaries \nModerator:\nK. Nikolaou; Munich/DE \nA‑156 08:30 \nChairman’s introduction \nK. Nikolaou; Munich/DE (konstantin.nikolaou@med.uni‑muenchen.de) \nWhile multislice CT (MSCT) has so far mainly been tested to detect obstructive coro-\nnary artery disease (CAD), ongoing developments of scanner technology open up \nnew diagnostic options and indications. With the improvement of temporal resolution, \nan accurate assessment of regional and global ventricular function, as well as of the \ncardiac valves, is becoming feasible. Regarding the assessment of the myocardium, new \ntechniques such as myocardial perfusion imaging with CT or dual/multi energy imaging \nopen up new horizons, depicting areas of ischemia and non-viable tissue. Finally, the \nease and speed of CT - in conjunction with an improved radiation dose efficiency - have \nincreased the number of CT acquisitions in cases of congenital heart disease, even in \nyounger patients. While the evaluation of coronary artery stenoses will for now most \nprobably remain the primary clinical indication for cardiac CT , these new applications \nare steadily under development and widening the options for cardiac CT imaging. \nSession Objectives:\n1. To become familiar with the potential use and viability of CT for imaging of \nheart function.\n2. To learn about indications and protocols for the use of CT in congenital heart \ndisease.\n3. To review dose reduction strategies for various protocols.\nA‑157 08:36 \nMyocardial and valvular function \nT.R.C. Johnson; Munich/DE (thorsten.johnson@med.uni‑muenchen.de) \nDynamic CT with a muliphase coverage of the heart throughout the cardiac cycle \nrequires restrictions in tube current modulation and implies a comparatively high ra-\ndiation exposure. Thus, the indication is restricted to elderly patients or individuals in \nwhom echocardiography and MRI are not available as alternatives. However, dynamic \ninformation is also available as side information if the coronary arteries are of primary \ndiagnostic interest. Practically it is easiest to perform a multiphase reconstruction of \nthe entire data volume, e.g. in non-overlapping thin axial slices at 10% steps over the \ncardiac cycle. The evaluation of cardiac motion is best visualized in standard planes \nknown from MRI and echocardiography, i.e. in long and short axis slices aligned parallel \nand perpendicular to the interventricular septum. New software tools also provide the \noption to automatically quantify parameters of global and regional volume, wall motion \nand ejection. These parameters can help to identify cardiomyopathy or areas of infarc-\ntion. Dynamic reconstructions also make it possible to assess valvular function. The \nleft ventricular valves are normally well visualized, while a long bolus or preferentially \na mixed chaser bolus is necessary to opacify right atrial and ventricular volume suf-\nficiently to depict the pulmonary and especially the tricuspid valve. Aortic stenoses are \nusually quite obvious due to extensive calcification and lack of motion with small residual \nopening area. CT is far less sensitive to insufficiencies because a tiny gap between \nthe leaflets can cause clinically relevant regurgitation, especially at the mitral valve. \nLearning Objectives:\n1. To understand the technique and become acquainted with the practical \nevaluation of dynamic CT.\n2. To become familiar with changes in myocardial wall motion and their \ndiagnostic relevance. \n3. To recognise valvular disease and know the diagnostic accuracy in \nestimating the degree of changes.\nA‑158 09:04 \nMyocardial viability and perfusion \nJ.-F . Paul; Le Plessis Robinson/FR (pauljf@ccml.fr) \nAfter an acute myocardial infarction (MI), myocardial damage varies within the \nventricle wall. At first pass, myocardial ischemia is seen as a subendocardial \nhypodensity, more or less transmural and more or less persistent over time after \ninjection of contrast medium. However, first pass imaging of cardiac muscle may \nbe not accurate enough to assess ischemia. Additional delayed enhanced images \nmay be also very useful to assess inflammatory changes within the cardiac muscle, \neither in case of myocardial infarction or myocarditis. Some clinical examples will \nbe provided in case of unexplained severe chest pain, illustrating the great clini-\ncal interest of MDCT based on delayed enhancement imaging. A comprehensive \nprotocol in acute setting (including arterial phase and delayed acquisition) will be \nproposed for quick diagnosis of myocardial infarction. Very recently, MDCT delayed \nimaging has shown to be also useful for assessment of myocardial viability. MDCT \nmay be then performed just after PCI, using intracoronary contrast injection required \nfor stent placement. These histological changes are more or less severe resulting \nin a functional point of view from complete non-viability to complete recovery of the \nsegmental contractility: transmural late enhancement is associated with non-viability. \nA dual-phase MDCT will be also detailed for assessment of viability in the first week \nafter myocardial infarction. In summary, beyond coronary arteries, CT provides \nrelevant information about cardiac perfusion and viability after myocardial infarction. \nLearning Objectives:\n1. To understand the potential of CT for evaluating viability and perfusion.\n2. To describe appropriate protocols for optimisation of late enhancement \nimaging.\n3. To know how to use myocardial information in emergency settings.\nA‑159 09:32 \nCongenital heart disease \nS. Leschka; Zurich/CH (sebastian.leschka@kssg.ch) \nVarious imaging modalities contribute diagnostic information in patients with \ncongenital heart disease (CHD). Although echocardiography is the diagnostic \nmethod of choice, the development of multi-detector row computed tomography \n(CT) has increased its clinical application in evaluating patients with CHD. Because \nof increased scan speed, high spatial resolution, and simultaneous evaluation \nof cardiovascular structures and lung parenchyma, CT has become a helpful \ncomplementary imaging modality in pre- and post-surgical evaluation of patients \nwith CHD. When coupled with electrocardiography-gating, CT can provide data on \nventricular function and cardiac valves, and allows for accurate assessment of the \ncoronary arteries. Expertise in morphology and terminology, profound knowledge \nin wide spectrum of surgical procedures, and dedicated imaging protocols for \nCT are required to comply with the altered flow conditions in patients with CHD. \nThe sequential, segmental approach will be described for accurate morphologic \ninterpretation of several CHD conditions. \nLearning Objectives:\n1. To determine appropriate CT protocols for evaluating congenital\n heart \ndisease (CHD).\n2. To describe a sequential approach that may be used in interpreting CT \nimages of CHD.\n3. To provide typical case studies of congenital heart disease.\n08:30 - 10:00 Room B \nRadiology of the Spine in 2010 \nCC 716 \nSpinal cord: Difficult but devastating diagnoses \nModerator:\nD. Balériaux; Brussels/BE \nA‑160 08:30 \nA. Demyelinating diseases of the spinal cord \nA. Rovira-Cañellas; Barcelona/ES (alex.rovira@idi‑cat.org) \nThe spinal cord is commonly affected in multiple sclerosis (MS) and other idiopathic \ninflammatory demyelinating diseases, such as acute demyelinating encephalomy-\nelitis and neuromyelitis optica. The prevalence of cord abnormalities is as high as \n74 to 85% in established MS. In clinically isolated syndromes (CIS), the prevalence \nof asymptomatic cord lesions is lower, although they can be found in 30 to 40% of \npatients with this condition. MRI of the spinal cord can provide important diagnostic \ninformation in several clinical settings. Patients initially diagnosed with MS, but \nshowing signs or symptoms of myelopathy, are typically evaluated by spinal cord \nMRI to exclude treatable lesions. Moreover, the presence of cord lesions may help \nto determine dissemination in space according to the 2005 McDonald diagnostic \ncriteria, and can strengthen the diagnosis of MS in patients fitting the clinical criteria \nfor MS, but with negative or inconclusive brain MRI findings. Similarly, diagnostic \ncertainty can be increased in patients with non-specific brain findings, particularly \nthose > 50 years old, because asymptomatic cord lesions are relatively frequent \n\nSaturday\nPostgraduate Educational Programme\nA\n S47\nCB D E F G\nin MS, but are rare in other white matter diseases. Spinal cord abnormalities, as \nseen on conventional MRI scans, mainly reflect demyelination, but underestimate \naxonal damage, which is likely the reason why the relationship with disability is \npoor. The progressive refinement of modern quantitative techniques (e.g., diffu-\nsion tensor imaging, MR spectroscopy, and magnetization transfer) should result \nin a more complete in vivo picture of spinal cord pathology in MS and, ultimately, \na better relationship with the clinical picture. \nLearning Objectives:\n1. To explain the mechanisms of demyelination.\n2. To review the most common demyelinating diseases and their key imaging \nfindings.\n3. To comprehend the clinical criteria for diagnosing demyelinating diseases of \nthe spinal cord.\nA‑161 09:00 \nB. Spinal cord tumors \nC. Mueller-Mang; Vienna/AT (christina.mueller‑mang@meduniwien.ac.at) \nSpinal cord tumors are uncommon, accounting for  about 4 to 10% of all central \nnervous system tumors. Despite their rarity, these neoplasms are important to the \nradiologist because MR imaging provides essential information about the extent, \nlocation, and internal structure of spinal cord tumors, thus critically narrowing the \ndifferential diagnosis and guiding surgery. Most spinal cord tumors are malignant, \nand 90-95% are classified  as gliomas. Astrocytoma is the most common spinal \ncord glioma in the pediatric age group, whereas spinal cord ependymoma is the \nmost common type in adults. Both entities constitute up to 70%\n of all intramedullary \nneoplasms. Nonglial neoplasms are much less common and include hemangioblas-\ntomas, paragangliomas, metastases, lymphoma, and primitive neuroectodermal \ntumors (PNETs). On MR imaging, intramedullary neoplasms cause enlargement \nof the spinal cord caused and almost always show contrast enhancement. They \nmay be solid or associated with neoplastic cysts that are located within the tumor \nand result from necrosis and degeneration, or non-neoplastic cysts that are located \nat the cranial and caudal pole of the tumor and most probably represent reactive \ndilatation of the spinal canal. An optimal MR imaging study not only enables the \ncorrect differential diagnosis in the majority of spinal cord tumors preoperatively, but \nalso allows the discrimination of tumor from these non-neoplastic cysts and edema, \nwhich is crucial for surgical planning. New MR techniques, such as diffusion tensor \nimaging (DTI) and fiber tracking (FT), may be helpful with further characterization \nof some spinal cord tumors and in better delineation of their margins. \nLearning Objectives:\n1. To review the most common spinal cord tumors.\n2. To summarise key imaging findings in different spinal cord neoplasms.\n3. To discuss how to create the optimal MR imaging protocol for preoperative \nplanning of spinal cord tumors.\nA‑162 09:30 \nC. Vascular disorders of the spinal cord \nT. Krings; Toronto, ON/CA (timo.krings@uhn.on.ca) \nSpinal vascular diseases are rare and constitute only 1-2% of all vascular neu-\nrological pathologies. Since their clinical diagnosis is based mainly on magnetic \nresonance imaging (MRI) and digital subtraction angiography, the radiologist plays a \nmajor role in the diagnostic workup. In the lecture, the following vascular pathologies \nof the spine are described: spinal arterial infarcts, spinal cavernomas, and spinal \narteriovenous shunting lesions and an overview about their imaging features both \non MRI, MR angiography and digital subtraction angiography is given. Clinical dif-\nferential diagnoses, the neurological symptomatology and the potential therapeutic \napproaches of these diseases which might vary depending on the underlying \npathology are presented. Although MRI including MRA constitutes the diagnostic \nmodality of first choice in suspected spinal vascular malformation, a definite diag-\nnosis of the disease and therefore the choice of suited therapeutic approach rests \non selective spinal angiography, which should be performed at a specialized center. \nLearning Objectives:\n1. To understand the pathophysiology of spinal vascular anomalies.\n2. To describe imaging findings in different spinal vascular diseases.\n3. To comprehend the concepts of CTA, MRA and angiography in evaluation of \nspinal vascular disorders.\n08:30 - 10:00 Room C \nNew Horizons Session \nNH 7 \nBiomarkers: New word, new world, new work? \nModerator:\nA.R. Padhani; Northwood/UK \nA‑163 08:30 \nChairman’s introduction \nA.R. Padhani; Northwood/UK \nThis introductory 90 min symposium focuses on clinical imaging biomarker develop-\nment with a view to meeting current challenges in clinical diagnosis and manage-\nment and of drug development. The lecturers will discuss via didactic talks the key \nbiological hallmarks of cancers that are assessable by imaging techniques that \nare ready for clinical translation. For each imaging biomarker chosen, the biologi-\ncal basis, quantification methods, validation and clinical use will be described by \nexperts involved biomarker development. Emphasis will be placed on biomarker \nqualification processes. The approaches demonstrated will be relevant to other \nbiomarkers and will be adaptable for diagnosing, assessment of tumour aggres-\nsiveness, therapy response and resistance and be relevant to the development of \nnovel anti-cancer therapeutics. \nSession Objectives:\n1. To understand the challenges of clinical diagnosis and management and of \ndrug development.\n2. To understand that cancers have unique hallmarks including cellular \nproliferation, tissue hypoxia and angiogenesis, many of which can be imaged \nand used for diagnosis, to assess therapy response and its outcome, as well \nas for drug development.\n3. To review the biological basis and evidence for MRI and PET biomarkers that \nare ready for clinical translation.\n4. To consider methods for predictive biomarker qualification.\nA‑164 08:33 \nBiomarkers: What are they? \nB. Van Beers; Clichy/FR (bernard.van‑beers@bjn.aphp.fr) \nBiomarkers are characteristics that are objectively measured as indicators of normal \nbiological processes, pathological processes, or pharmaceutical responses to a \ntherapeutic intervention. Compared with biochemical and histological biomarkers, \nimaging biomarkers have the advantage of remaining non-invasive and being \nspatially and temporally resolved. They are thus ideally suited for assessing the \nresponse to treatment. In new drug development, assessment of benefit and risk \nhas to be done. The most reliable way to assess the clinical impact of a thera-\npeutic intervention is through its effect on a clinical endpoint such as survival or \ndisease-free survival. These standards may be impractical because long periods \nare required for these clinical endpoints to be achieved and trials with large number \nof patients are needed for their evaluation. Surrogate endpoints are biomarkers \nthat are intended to substitute for a clinical endpoint. Anatomical, molecular, and \nfunctional characteristics can be used as imaging biomarkers. The RECIST crite-\nria are anatomical imaging biomarkers that are accepted surrogate endpoints in \ncancer treatment, but are limited in the assessment of some tumors. The use of \nmolecular imaging biomarkers is limited by their narrow target specificity. Functional \nbiomarkers are increasingly used with PET, contrast-enhanced CT, perfusion CT \nand MRI, diffusion-weighted MRI, MR elastography and spectroscopy. They have an \nimportant potential to help in selecting the patients and assessing the response to \nnew treatments. However, important efforts of validation and standardization remain \nto be done before the wide use of functional biomarkers and their acceptance as \nsurrogate endpoints. \nLearning Objectives:\n1. To be able to distinguish biomarkers from surrogate markers.\n2. To be able to give examples of the major classes of biomarkers (preclinical \nand clinical examples).\n3. To know generally what needs to be done for any biomarkers to be useful in \nthe clinic and for drug development.\n\nPostgraduate Educational Programme\nS48\n A B C D E F G\nA‑165 08:51 \nMRI biomarkers: Ready in abdomen? \nD.J. Lomas; Cambridge/UK (djl15@radiol.cam.ac.uk) \nFour quantitative MR biomarker examples will be presented including the basis for \nthe observations, biological mechanisms, clinical context, analysis and evidence \nfor their validation. These aspects will be discussed briefly along with what further \ndevelopment is required for their routine use in clinical practice. 1. Hepatic and cardiac \niron measurements using R2 (*) methods, 2. Liver and spleen stiffness with elastog-\nraphy, 3. Hepatic steatosis using MRI and MRS, and 4. Tumour response with DWI. \nLearning Objectives:\n1. To be able to cite examples of MRI biomarkers that can be used to \ninvestigate abdominal disease.\n2. To get to know the clinical context, biological basis, measurement and \nanalysis methods of biomarkers of angiogenesis, hypoxia and fibrosis.\n3. To become familiar with the clinical evidence for biomarker usage and \nlimitations for each biomarker.\nA‑166 09:09 \nPET cancer biomarkers at the starting line \nE.O. Aboagye; London/UK (eric.aboagye@imperial.ac.uk) \nPositron emission tomography (PET) permits detection of molecular interactions and path-\nways non-invasively in living subjects. Of interest to cancer, PET molecular biomarkers are \nbeing adopted into the clinical research arena for studying tumour biology . Regional distribu-\ntion and levels of both extracellular and intracellular targets can be measured. Presently , \nthere are molecular probes for measuring the biochemistry of tumours including glucose \nmetabolism proliferation, apoptosis, multi-drug resistance phenotype, hypoxia and angio-\ngenesis. With PET , unique information is present in both the spatial (limited) and temporal \ndomains. Fusion of such molecular information with other imaging platforms that provide \nhigh anatomical resolution such as computed tomography (CT) provides improved detection \nand definition of lesions; improved quantification of ‘change’ results from this. A number of \nPET biomarkers including [\n18F]fluorodeoxyglucose and [18F]fluorothymidine have ‘matured’ \nare being used in drug development as pharmacodynamic and response markers. New \nimaging biomarkers have to be qualified/validated to enable their use for drug development \nand ultimately for patient management. This lecture will discuss the evidence for biomarker \nusage together with the potential and limitations of the methodologies. \nLearning Objectives:\n1. To be able to provide examples of PET tracers that can be used to \ninvestigate tumor biology.\n2. To get to know the clinical context, biological basis, measurement and \nanalysis methods of PET biomarkers of angiogenesis, hypoxia, proliferation, \napoptosis and multi-drug resistance of angiogenesis.\n3. To become familiar with the clinical evidence for biomarker usage and \nlimitations for each biomarker.\nA‑167 09:27 \nBiomarkers: An illustrated framework for development \nA.R. Padhani; Northwood/UK \nDevelopment frameworks outlining the practical steps for the qualification of functional \nimaging as biomarkers for pharmaceutical drug development and clinical therapeutic \nefficacy assessments are urgently needed. The process is iterative involving several \nkey steps which include: 1. Defining the key clinical/drug issues with reference to the \ntumour and therapy in question. 2. Biomarker selection process - linking the imaging \nbiomarker to underlying pathophysiological processes or to changes induced by thera-\npies. 3. Initial feasibility studies - demonstrating in principle the link between the chosen \nbiomarkers and therapy response. 4. Biomarker optimization before implementation \nof the biomarker into a generalised clinical trial setting. 5. Early efficacy studies docu-\nmenting test performance and for estimating group predictive values. 6. Determining \nthe level of change of a biomarker that predicts response to therapy on an individual \nbasis via measurement of error determinations. 7. Definitive clinical studies with efficacy \nendpoints beginning with demonstration of multisite working. \nLearning Objectives:\n1. To understand how dynamic MRI has progressed as a method for \npersonalised assessment of therapy response in breast cancer.\n2. To be able to assess for any other biomarker the extent of development and \nso to be able define the next steps in development.\n3. To discuss whether imaging biomarkers can realistically be developed for \ntheir intended purpose.\nPanel discussion:  \nHow should we implement biomarkers in clinical practice? \n09:45 \n08:30 - 10:00 Room D \nAbdominal and Gastrointestinal \nRC 701 \nAbdominal MRI: Protocols that work \nModerator:\nL. Grazioli; Brescia/IT \nA‑168 08:30 \nA. Liver \nW. Schima; Vienna/AT (Wolfgang.Schima@khgh.at) \nLiver MRI is undertaken to study the liver parenchyma, vasculature, and biliary system. \nIt is necessary to employ a variety of different MR pulse sequences to achieve lesion \ndetection and characterization. A set of T1- and T2-w pulse sequences is standard for \nevaluation of fat and iron content and for lesion delineation. In-phase and opposed-\nphase, T1-w GRE images show focal or diffuse fatty infiltration and focal sparing. \nFor T2-w imaging, a TSE sequence with fat suppression (either breath-hold or with \nfree breathing) is robust and provides high tumor contrast. The quite popular T2-w \nhalf-Fourier single-shot TSE (e.g., HASTE) pulse sequences show anatomic detail \n(including bile ducts), but lack lesion contrast because of the long echo train. In case \nof suspected iron overload (i.e., hemosiderosis and hemochromatosis), an additional \nT2*-w GRE is recommended because of the susceptibility. Administration of a contrast \nagent is mandatory in liver MRI because many focal lesions are only highlighted by \nenhanced pulse sequences. Dynamic gadolinium chelate-enhanced T1-w GRE pulse \n(preferably 3D interpolated) sequences are versatile and useful for lesion detection and \ncharacterization as well assessment of the vasculature (i.e., hepatic artery aneurysms, \nBudd-Chiari-S., portal vein thrombosis, etc). Both hepato-biliary and reticuloendothelial \nliver-specific contrast agents render excellent results for detection and differentiation \nbetween metastases and hemangiomas or FNH. Manganese- or superparamagnetic \niron oxide liver-specific contrast agents can be administered in patients with renal insuf-\nficiency. The choice of contrast material should be based on availability, the specific \nclinical question, and the renal function of the patient. \nLearning Objectives:\n1. To learn about the standard pulse sequences for liver imaging and the critical \ntechnical parameters.\n2. To discuss the diagnostic value of non-specific gadolinium chelates and \ndifferent liver-specific contrast agents depending on the clinical question.\n3. To learn how to optimise pulse sequences and imaging protocols according \nto the scanner’s and the patient’s performance.\nA‑169 09:00 \nB. Small bowel and colon \nN. Papanikolaou; Iraklion/GR (npapan@med.uoc.gr) \nThe advent of powerful gradient systems resulted in substantial improvement of im-\nage quality in ultrafast magnetic resonance (MR) imaging and therefore novel clinical \napplications emerged including gastrointestinal tract imaging. Within this context, MR \nenteroclysis and MR colonography were developed, providing luminal, transmural and \nextramural diagnostic information at the same imaging session. T wo different protocols \nhave been developed for imaging the small bowel with MR. These include MR follow-\nthrough and MR enteroclysis. MR follow-through is based on the oral ingestion of an \nadequate amount of contrast agent and acquisition of consecutive sequences. In a \nclinical setting, sufficient luminal distention that guarantees accurate individual lesion de-\ntection can be achieved by MR enteroclysis. T wo MR colonography protocols have been \nproposed. According to the first, termed as ‚bright lumen MRC’, a gadolinium-spiked \nwater solution is administered endorectally to the patient who has previously undergone \ncolonic cleansing to distend the colon, resulting in a homogeneous high-signal intensity \non heavily T1-weighted 3D gradient echo images. Polyps are demonstrated as filling \ndefects while air bubbles can be differentiated by performing the examination in both \nsupine and prone positions. According to the second approach, termed as ‚dark lumen \nMRC’, dense barium or tapped water is used to distend the colon in conjunction with \npost-gadolinium 3D gradient echo with fat-saturation sequences. The colonic wall and \nthe corresponding polyps exhibit high signal intensity as a result of gadolinium uptake \nwhile the colonic lumen presents with low signal intensity. \nLearning Objectives:\n1. To review technical aspects of MR enteroclysis and MR colonography.\n2. To review MR enteroclysis imaging features of Crohn’s disease.\n3. To address the current clinical role of MR enteroclysis in patients with \nCrohn’s disease.\n4. To address the potential of MR colonography in the era of CT colonography.\n\nSaturday\nPostgraduate Educational Programme\nA\n S49\nCB D E F G\nA‑170 09:30 \nC. Pancreas and bile ducts \nC. Matos; Brussels/BE (cmatos@ulb.ac.be) \nMR imaging of the pancreas and bile ducts relies upon a combination of T2-w and \nT1-w strategies in order to safely acquire anatomic, cross-sectional and functional \ninformation.Tissue-imaging strategies include free breathing T2-w imaging (obtained \nwith echo-train spin-echo sequences with or without fat saturation) and breath-hold \n3D-gradient echo T1-w imaging (obtained with fat saturation) without gadolinium and \nin the capillary phase and in the interstitial phase post-gadolinium. This combination is \nvaluable in the assessment of the full spectrum of pancreatic diseases and malignant \nbile duct obstruction. Hardware improvements (gradients) and the advent of more so-\nphisticated phased-array coils and parallel imaging capabilities in modern MR scanners \nallowed increasing the spatial and temporal resolution of “conventional” T2-w and T1-w \nsequences. Furthermore, it provided the possibility of adding high-b-value diffusion \nweighted imaging (DWI) to our routine protocol in order to increase the sensitivity of \nMRI. T o obtain conventional MRCP imaging, thick-slab heavily T2-w TSE sequences \nor 3D heavily T2-w TSE sequences may be used. Advantages and limitations of both \nsequences will be underlined. Functional bile duct imaging is obtained using contrast \nagents that are taken up by hepatocytes and excreted through the biliary system in \ncombination with volumetric T1-w sequences. We use this technique in postoperative \ncomplications and to elucidate complex biliary anatomy. Functional imaging of the \npancreas is obtained by combining MRCP along with hormonal stimulation with secretin. \nIn addition, secretin improves anatomic delineation and allows MRI quantification of \nfluid production by the exocrine pancreas. \nLearning Objectives:\n1. To describe the preferred imaging sequences for MRI/MRCP of the pancreas \nand bile ducts.\n2. To describe the use of techniques/methods to improve image quality.\n3. To propose imaging protocols for MRI/MRCP of the pancreas and bile ducts \nin different clinical settings.\n08:30 - 10:00 Room E1 \nMusculoskeletal \nRC 710 \nArthritis: Back to basics \nModerator:\nV. Jevtic; Ljubljana/SI \nA‑171 08:30 \nA. Radiographic diagnosis \nA.J. Grainger; Leeds/UK (andrew.grainger@leedsth.nhs.uk) \nDespite the increasing availability of modern imaging techniques such as ultra-\nsound (US) and MRI, conventional radiographs (CR) continue to be fundamental to \nrheumatological imaging, playing an important role in diagnosis and monitoring of \nthe arthritides. Evaluation of plain films includes an assessment of the soft tissues \nfor swelling and calcification. Soft tissue swelling can be extremely subtle but may \nbe the first CR sign of joint disease. Joint space on CR reflects the thickness of \narticular cartilage and is typically lost as a result of arthropathy either symmetrically, \nas seen in the inflammatory arthritides, or asymmetrically as in osteoarthritis. In \nsome arthritides, such as gout, joint space is preserved until subsequent stages in \nthe disease process, while in other conditions bony ankylosis may occur. Evaluation \nof the periarticular bone usually reveals the presence of erosions, osteophytes, \nsubchondral bone changes, such as cysts and sclerosis, and changes in bone den-\nsity. Finally, plain films allow an assessment of joint alignment and also, in the case \nof hand and foot films, give an indication as to the distribution of disease. Despite \nthe wide use of CR in the evaluation of the arthritides, it has the disadvantage in \nthat it is relatively insensitive to the early changes of disease and changes occur \nrelatively slowly. In the early stages of arthritis, when therapy may have the greatest \nrole and where structural abnormalities may be reversible, radiographically defined \njoint damage is not a prominent feature. \nLearning Objectives:\n1. To be able to recognise the range of the radiographic changes seen in \narthropathy.\n2. To be able to identify features on the radiograph that allow a specific \ndiagnosis to be made.\n3. To understand the role of radiographs in monitoring the progression of \narthritis.\nA‑172 09:00 \nB. Imaging crystal arthritis \nA. Cotten; Lille/FR (acotten@chru‑lille.fr) \nGouty arthritis, calcium pyrophosphate dihydrate crystal deposition disease and \ncalcium apatite crystal deposition disease represent the three main crystal deposi-\ntion disorders encountered in the clinical practice. If the clinical and radiological \nfeatures are usually straightforward, some presentations may be misleading. This \npresentation will focus on the typical and atypical or unusual radiological features \nof these crystal deposition disorders. It will also present the potential usefulness \nand limitations of US, CT and MR imaging in the diagnosis of these diseases. \nLearning Objectives:\n1. To present the main radiographic features of crystal deposition disorders.\n2. To show the potential of US, CT and MRI in the diagnosis of these disorders.\n3. To present some unusual radiological presentations of these disorders.\nA‑173 09:30  \nC. Imaging the spine in arthritis \nA. Jurik; Århus/DK (anne.jurik@aarhus.rm.dk) \nThe spine can be involved as part of most inflammatory disorders, but most fre-\nquent in rheumatoid arthritis (RA) and seronegative spondyloarthropathies (SpA). \nInvolvement in RA is usually located to the cervical spine where erosive changes \nare predominantly seen in the atlanto-axial region. The diagnosis of cervical RA \nchanges is important as they can cause instability potentially risking spinal cord \ninjury. In RA patients with neck pain, radiography of the cervical spine including a \nlateral view during flexion is mandatory. Supplementary MRI or CT may be needed \nbefore treatment of instability and can sometimes reveal inflammatory changes in \npatients with normal radiography. According to the European classification criteria, \nseronegative spondyloarthropathies are divided into ankylosing spondylitis (AS), \npsoriatic arthropathy, reactive arthritis, arthritis associated with inflammatory bowel \ndisorders (enteropatic arthropathy) and undifferentated spondyloarthropathy. Inflam-\nmatory changes at the sacroiliac joints always occur in AS and is part of most other \nforms of SpA. Spinal changes are also a feature of SpA, especially in late stages \nof AS. Manifest structural changes can be diagnosed at radiography. Vertebral \nsquaring, syndesmophytes and ankylosis of apophyseal joints are characteristic of \nAS whereas more voluminous paravertebral new bone formation occur in psoriatic \narthropathy and reactive arthritis. The features of enteropatic arthropathy often re-\nsemble those of AS. Detection of early inflammatory changes of the sacroiliac joint \nor the spine demands an MRI. MRI is also valuable for estimating and monitoring \npost-diagnostic disease activity. CT predominantly plays a role in the diagnosis of \ncomplicating fractures. \nLearning Objectives:\n1. To become familiar with the radiographic features of spinal involvement in \nrheumatoid arthritis (RA) and seronegative spondyloarthropathy (SpA).\n2. To know the MRI and CT features in RA and SpA.\n3. To know the diagnostic advantages of MRI and CT.\n08:30 - 10:00 Room E2 \nFoundation Course: Head and Neck Radiology \nE³ 720a \nLarynx and hypopharynx \nModerator:\nM. Gödeny‑Polony; Budapest/HU \nA‑174 08:30 \nA. Benign lesions \nR. Hermans; Leuven/BE (Robert.Hermans@uz.kuleuven.ac.be) \nThe larynx and hypopharynx are anatomically very closely related. Essentially, the \nlarynx consists of a supporting skeleton (made up of cartilages and fibrous bands), \na mucosal surface, and in between a soft tissue layer containing fat, some ligaments \nand muscular structures. The larynx is divided into three regions: glottis (correspond-\ning to the level of the true vocal cords), subglottis and supraglottis. The hypopharynx \nis the portion of the pharynx that extends from the oropharynx to the esophageal \nverge. The larynx forms the anterior wall of the hypopharynx. The border between \nthe hypopharynx and the oropharynx is at the level of the pharyngo-epiglottic folds, \nwhile the border with the esophagus is at the level of the inferior rim of the cricoid \ncartilage. The hypopharynx is divided into three regions: pyriform sinus (one on each \nside), post-cricoid region and posterior hypopharyngeal wall. On imaging studies, \n\nPostgraduate Educational Programme\nS50\n A B C D E F G\nthe appearance of the laryngeal cartilages varies considerably, depending on the \ndegree of ossification and the amount of fatty marrow in the ossified medullar space. \nThe assessment of the intralaryngeal and intramural hypopharyngeal fat planes \nis essential in the workup of patients: obliteration of these fat planes may be the \nonly sign of underlying pathology. Benign pathology of the larynx and hypopharynx \nrequiring radiologic evaluation is uncommon. Laryngocele, traumatic pathology and \nvocal cord paralysis are the most frequent conditions imaged. Among the congenital \nlesions, thyroglossal duct cyst is most commonly seen. \nLearning Objectives:\n1. To review the relevant anatomy of the larynx and hypopharynx.\n2. To become familiar with some anatomical variants that may mimic disease.\n3. To learn about the imaging findings in benign lesions of the larynx and \nhypopharynx.\nA‑175 09:15 \nB. Malignant lesions \nF .A. Pameijer; Utrecht/NL (f.a.pameijer@umcutrecht.nl) \nImaging of the larynx is essentially the same as imaging of the hypopharynx because \nthese structures are anatomically and functionally closely integrated. The presen-\ntation will focus on squamous cell carcinoma, which is by far the most prevalent \nhistology in laryngeal and hypopharyngeal cancer. The nature of malignancies in \nthis region will be discussed with some epidemiological data. CT or MRI has become \nessential for the correct pretherapeutic staging of laryngeal and hypopharyngeal \ntumors. In this era of cost concern, it seems to be a good principle to do one cross-\nsectional study that accurately answers the clinical questions. The relative value \nof CT and MRI in this aspect will be discussed. While the otolaryngologist uses \nendoscopy to evaluate the mucosal surface, it is the radiologist’s role to show the \ndeep extent of a lesion. This effort becomes more effective if the radiologist is aware \nof the spread patterns observed in laryngeal and hypopharyngeal cancer. These \ntypical spread patterns will be shown, using clinical examples from daily practice, \nin relation to the T -staging criteria for these tumors. \nLearning Objectives:\n1. To learn about the nature of malignant lesions occuring in this region.\n2. To understand the relative value of CT and MRI in evaluating malignant \ndisease in this region.\n3. To become familiar with the extension patterns observed in laryngeal and \nhypopharyngeal cancer.\n08:30 - 10:00 Room F1 \nInteractive Teaching Session \nE³ 720b \nCancer of the uterus: Diagnosis, staging and \nfollow-up \nModerator:\nH. Hricak; New Y ork, NY/US \nA‑176 08:30 \nCancer of the uterus: Diagnosis, staging and follow-up \nB. Hamm1, P . Petrow2; 1Berlin/DE, 2Paris/FR (bernd.hamm@charite.de) \nMR imaging is the method of first choice for staging uterine malignancies. The main \ncriterion for staging endometrial cancer is the depth of myometrial invasion. The \ndiagnostic accuracy can be improved by performing a dynamic contrast-enhanced \nstudy in addition to T2-weighted imaging. The backbone of staging cervical cancer \nis T2-weighted imaging with a high spatial resolution performed in sagittal and \ntransverse slice orientation. Invasion of the parametrium can thus be assessed with \na high degree of accuracy. Especially in staging cervical cancer, MR imaging can \nreplace numerous other diagnostic tests and thus improve pretherapeutic staging \nwhile at the same time reduce costs. In addition, MR imaging is used in planning \nradiotherapy and following-up patients having undergone irradiation. Lymph node \nstaging still remains to be improved, for example, by a combination of MR lym-\nphography and diffusion-weighted imaging. \nLearning Objectives:\n1. To become familiar with imaging features in staging cervical and uterine \ncancer.\n2. To understand the impact of imaging on modern patient treatment.\n3. To understand the imaging findings on follow-up.\n08:30 - 10:00 Room F2 \nMultidisciplinary Sessions: Managing Patients with Cancer \nMS 721 \nLung cancer \nA‑177 08:30 \nChairman’s introduction \nJ. Cáceres; Barcelona/ES (josecac@gmail.com) \nBronchogenic carcinoma is one of the main causes of mortality from cancer in \nthe western world. Lung cancers are either suspected clinically or by the chest \nradiograph and confirmed with computed tomography. Lung biopsy corroborates \nthe diagnosis and establishes the histological type. The cooperation with other \nclinical disciplines is crucial to obtain an adequate evaluation of the patient and to \ninstitute adequate therapy. \nLearning Objectives:\n1. To optimise the use of diagnostic techniques in lung cancer.\n2. To promote cooperation with other clinical disciplines in the management of \nlung cancer.\n3. To emphasise the help of clinicians in image interpretation.\nA‑178 08:35 \nWhat the surgeon needs to know \nW. Weder; Zurich/CH (walter.weder@usz.ch) \nWith increasing multidisciplinary efforts, accurate diagnostics and staging remains \ncrucial in decision making for an individualized therapy at different stages of lung \ncancer patients. Radiologists are indispensably involved in each step of this pro-\ncess. Using the TNM staging system CT scans, especially high resolution CTs, \nare still the gold standard of morphologic tumor assessment concerning primary \ntumor extension, signs of malignancy or relation to surrounding structures, which \nis essential for planning the surgical procedure. Furthermore, radiologists can help \nus to gather the initial diagnosis of undetermined pulmonary nodules by using CT \nguided fine needle aspiration techniques. For determining the N stage, contrast \nenhanced CT helps the surgeon to detect suspicious mediastinal lymphnodes and \ndecide whether to go for primary surgery or further diagnostic with neoadjuvant \ntherapy. In terms of mediastinal lymphnode and especially extrathoracic metastases, \nthe combination of PET/CT has added a lot more value to the pure morphologic \nassessment of staging; the high negative predictive value has changed the ‚pre-\nsurgical‘ management of patients and has become a standard staging procedure \nfor all stages in many institutions. For planning oncological resections, modern \nthree-dimensional techniques are used more frequently. Also for evaluating the \npatients‘ response to neoadjuvant therapy or as postoperative control of recurrency \nor late metastatic disease, CT scans (or PET/CTs) are performed routinely. Finally, \ntreatment regimens should be discussed in a multidisciplinary tumor board in the \npresence of an experienced radiologist in order to get the best information on the \nmorphologic extent of the disease. \nLearning Objectives:\n1. To know the local extension of the lesion as well as loco-regional metastasis.\n2. To know the presence or absence of extrathoracic disease.\n3. To determine the severity of co-morbidities on chest imaging such as \nemphysema, PH and others.\nA‑179 08:55 \nWhat the oncologist needs to know \nR. Pirker; Vienna/AT (robert.pirker@meduniwien.ac.at) \nPatients with lung cancer are treated based on histology and initial tumor stage. Clini-\ncal tumor stage is crucial for both prognosis and optimal treatment. Staging should \nfocus on size and location of primary tumor, mediastinal lymph node involvement \nand potential presence of distant metastasis. Other important information refers \nto tumor tissue accessible for diagnostic biopsies, tumor invasion of major vessels \nand tumor cavitation. CT of the lungs and upper abdomen is recommended for all \npatients but imaging of brain and bones depends on the clinical situation. Patients \nwith resectable NSCLC will undergo surgery. Patients with pathological tumor stages \nII and III and selected patients with stage IB will receive adjuvant chemotherapy. \nPatients with incomplete tumor resection will receive adjuvant radiotherapy. With \nregard to stage III NSCLC, information on mediastinal lymph node involvement \n(single versus multiple levels, bulky) is required. Patients planned for curative \ntreatment should also undergo brain imaging. Most patients with clinical stage III \n\nSaturday\nPostgraduate Educational Programme\nA\n S51\nCB D E F G\nNSCLC are treated with chemoradiotherapy. Re-staging after chemoradiotherapy \nshould particularly characterize patients with mediastinal down-staging who might \nbenefit from additional surgery. Patients with advanced NSCLC receive palliative \nchemotherapy and, in case of progression, second-line therapy. Patients undergo \nradiological imaging usually every other cycle according to RECIST criteria and in \ncase of clinical signs of progression. Patients with small cell lung cancer receive \nchemotherapy and, in case of limited disease, also local radiotherapy. Follow-up \nexaminations in patients with lung cancer should focus on signs of progression and \nside effects of treatment such as infections and pneumonitis. \nLearning Objectives:\n1. To present clinical guidelines for staging, prognosis and therapy in carcinoma \nof the lung.\n2. To describe the criteria for adjuvant therapy in NSCLC.\n3. To evaluate patients with NSCLC stage III.\n4. To differentiate progression vs infection in advanced NSCLC.\nA‑180 09:15 \nImaging in lung cancer \nJ. Cáceres; Barcelona/ES (josecac@gmail.com) \nThe initial examination in patients with lung carcinoma is the chest radiograph. Once \nthe diagnosis is made, it is important to perform the proper radiological work-up \nto establish the stage and the adequate treatment. Staging is a key factor in lung \ncancer management and is important to select the proper imaging technique in \nindividual cases. In treated patients, imaging is a main aspect of the follow-up. \nThe radiologist must know how to evaluate signs of recurrence, which should be \ndistinguished from related processes and post-radiotherapy changes. \nLearning Objectives:\n1. To select appropriate imaging techniques in lung cancer.\n2. To describe current tumor staging.\n3. To learn to discover recurrences and complications post-treatment.\nPanel discussion and case presentation\n 09:35 \n08:30 - 10:00 Room G/H \nEFOMP Workshop\nNew technology in diagnostic radiology: Risk management, \ntechnology assessment and improved diagnosis \nEF 1 \nTechnology assessment for imaging equipment \nModerators: \nA. Del Guerra; Pisa/IT \nK. Faulkner; Wallsend/UK \nWelcome address 08:30  \nS. Christofides; Nicosia/CY \nM. Szczerbo‑Trojanowska; Lublin/PL\nA‑181 08:40 \nIntroduction to EC initiatives in acceptability criteria for imaging \nequipment \nK. Faulkner1, J. Malone2, S. Christofides3, S. Lillicrap4; 1 Wallsend/UK, 2Dublin/IE, \n3Nicosia/CY, 4Bath/UK (keith.faulkner@nhs.net) \nIn 1997, the European Commission published Radiation Protection 91: Criteria for \nacceptability of radiological (including radiotherapy) and nuclear medicine installa-\ntions. This document specified minimum criteria for acceptability. It has been used \nto this effect in legislation, codes of practice and by individual professionals. Since \nthe original publication, development of new radiological systems and technologies, \nas well as improvements in traditional technologies, has created circumstances \nwhere the acceptability criteria have been reviewed. In this lecture, the background \nto the development of the publication, and the implications on change in radiation \nprotection/quality assurance philosophy for acceptability criteria and minimum \nperformance standards for radiological, nuclear medicine and radiotherapy equip-\nment are described. Acceptability criteria have been produced consistent with the \nEuropean Commission’s Medical Exposures Directive which requires that patient \nexposures are justified. Criteria were developed by a team drawn from a broad \nrange of backgrounds including hospitals, industry, government bodies, regulators \nand standardisation organisations. Representatives were mainly from Europe, but \nindividuals from the American Association of Medical Physics and International \nAtomic Energy Agency were included in the drafting process. \nLearning Objectives:\n1. To understand the philosophy behind acceptability criteria.\n2. To be aware of the implications of new acceptability criteria.\n3. To discover the consensus based approach used in their development.\nA‑182 09:05  \nTechnology assessment and radiological imaging \nS. Christofides; Nicosia/CY (cstelios@cytanet.com.cy) \nTechnology Assessment (TA) in health care is a multidisciplinary field of policy \nanalysis. It involves the study of the medical, social, ethical, and economic implica-\ntions of development, diffusion, and use of health technology. Health Technology \nAssessment (HTA) is a multidisciplinary process that summarises information about \nthe medical, social, economic and ethical issues related to the use of a health \ntechnology in a systematic, transparent, unbiased and robust manner. Its aim is to \ninform the formulation of safe, effective, health policies which are patient focused \nand seek to achieve best value. Despite its policy goals, HTA must always be firmly \nrooted in research and the scientific method. HTA is an approach to meet those \nchallenges and apply the cost effectiveness in the selection of new technologies \nthat are advancing rapidly and becoming highly sophisticated with time. It can help \nto meet the ever-increasing demands on competence, specialization and cost \neffectiveness that modern health care services are faced in today’s economically \nconscious world. The methodology developed by the EUnetHTA project will be \nused to demonstrate the value of HTA with particular emphasis in the evaluation \nof radiological imaging technologies. \nLearning Objectives:\n1. To become familiar with the concepts of health technology assessment.\n2. To understand the multidisciplinary nature of health technology assessment.\n3. To appreciate the value of health technology assessment in providing cost \neffective and evidence based procedures for the benefit of the patient.\nA‑183 09:30 \nAcceptability criteria: A perspective from standards and equipment \nmanufacturers \nR. Klausz; Buc/FR (remy.klausz@med.ge.com) \nIn Europe, different systems exist to rule the design and performance of medical \ndevices, in particular when they use ionising radiation. From one side, the European \nCouncil Directive 93/42/EEC (MDD) requires that medical devices are designed \nand manufactured so as to meet specified essential requirements. They should \nthen be placed on the market or put into service within the territory of member \nstates without any obstacle. The compliance with the Essential requirements can \nbe reached by complying with harmonized standards, in particular, the EN60601 \nseries ruling Basic Safety and Essential Performances of Medical Devices. From \nanother side, the Council Directive 97/43/Euratom requires that member states \nadopt specific criteria of acceptability for radiological installations in order to indicate \nwhen appropriate remedial action is necessary, including, if appropriate, taking the \nequipment out of service. The transposition of this directive in the regulation of the \nmember states has resulted in methods and values for these criteria of acceptability, \ndiffering from country to country as well as from those driven by the MDD. It can, \ntherefore, happen that a medical device is installed and put into service according \nto the MDD, and not authorized to be used following the national criteria of accept-\nability. To respect the policy set by the MDD which allows complying equipment to \nmove freely within the Community and to be put into service in accordance with \ntheir intended purpose, the acceptability criteria throughout European Union should \nbe harmonized, and fully compatible with the standardized criteria for design and \nmanufacturing. \nLearning Objectives:\n1. To identify the different standards and regulations applicable.\n2. To understand the consequences of the acceptability criteria on the \nmanufacturing and service of medical devices.\n3. To understand the benefits for a standardisation of the acceptability criteria.\n\nPostgraduate Educational Programme\nS52\n A B C D E F G\n08:30 - 10:00 Room I \nVascular \nRC 715 \nVascular imaging: The diabetic patient \nModerator:\nJ.H. Peregrin; Prague/CZ \nA‑184 08:30 \nA. What the radiologist needs to know about the diabetic patient \nA. Raptis; Athens/GR (atraptis@med.uoa.gr) \nDiabetes mellitus (DM) is recognized as a major health - economic problem in the \n2 1st century. Ninety percent of the diabetic population is suffering from type 2 and \nthe remaining 10% from type 1 and other types of DM. An epidemic of type 2 DM \nis occurring across the world and the number may increase from 100 to 200 mil-\nlion over the next 15 years. As rates of childhood obesity escalate, type 2 DM has \nincreasingly been diagnosed in children and adolescents. Duration of diabetes is \nan important factor in the pathogenesis of complications, but other risk factors - \nfor example, hypertension, cigarette smoking, and hyperlipidaemia - interact with \ndiabetes to affect the clinical course of microangiopathy and macroangiopathy. \nCardiovascular disease (CVD) accounts for a great majority of deaths in patients \nwith type 2 DM. According to the WHO, the prevalence of CVD in diabetic patients \nranges from 26 to 36%. Fatality rate after myocardial infarction is greater in dia-\nbetic patients, and overall prognosis after coronary heart disease is worse. Based \non these observations, it has been proposed that DM should be considered as a \ncoronary heart disease risk equivalent. Atheromatous disease in the legs, as in the \nheart, tends to affect more distal vessels producing multiple, diffuse lesions that are \nless straightforward to bypass or dilate by angioplasty. The serious complications \nassociated with DM make it essential for physicians to be aware of the risk factors \nand the screening guidelines, allowing for earlier patient diagnosis and treatment. \nLearning Objectives:\n1. To learn about the prevalence, risk factors and prognosis of diabetic patients \nin the 2 1\nst century.\n2. To understand the multimorbidity of diabetic patients.\n3. To learn about the vascular manifestations of diabetes.\nA‑185 09:00 \nB. Imaging of the diabetic patient \nL.P . Lawler; Dublin/IE (llawler@mater.ie) \nDiabetes is a systemic disease with potential multi-organ dysfunction. Significant \ndiabetic pathophysiology is linked to vasculopathy which can have distinctive features \nand patterns. We shall discuss how these vessels and territories may be optimally \nimaged, assessed and interpreted using current non-invasive and invasive imaging \nmodalities. The particular challenges and limits to imaging diabetic vascular disease \nwill be discussed. The latest changes in contrast/medication guidelines will be dis-\ncussed. The particular patient risks from diabetes-related disease and medication \nand their management will be reviewed. Key elements of image acquisition and \nprocessing will be covered for 3D CTA, PET/CTA, MRA and DSA. The major arterial \nvascular territories including carotid-cerebral, coronary, aortic, mesenteric, renal and \nperipheral systems will be covered. Modern screening, diagnostic and therapeutic \nimaging strategies will be addressed. Novel imaging developments such as disease \nbiomarkers, plaque imaging, and stem cell research will be considered. This lecture \nwill provide the elements for comprehensive clinical assessment and problem solv-\ning as well as research potential in imaging the diabetic patient and vasculopathy. \nLearning Objectives:\n1. To become familiar with the specific diagnostic requirements in diabetic \nvasculopathy.\n2. To learn about specific risk factors for imaging and treatment in diabetic \npatients.\n3. To discuss optimised imaging strategies in diabetic patients.\nA‑186 09:30 \nC. Cost-effective selection of the appropriate imaging technique \nR. Ouwendijk; Rotterdam/NL (r.ouwendijk@erasmusmc.nl) \nWith the current constraints on health care resources and the emphasis on value for \nmoney, it is important to assess new technologies and demonstrate their value prior \nto their widespread use in day-to-day practice. To determine the optimal diagnostic \nimaging work-up for patients with peripheral arterial disease, we need to take into \naccount not only the diagnostic accuracy of each test, but also the related effects \nof diagnostic imaging tests on treatment planning, functional improvement, qual -\nity of life and costs. Digital subtraction angiography is an invasive technique that \nrequires post-procedural observation and, sometimes, hospitalization of the patient. \nDSA is associated with a higher complication rate and higher costs as compared \nwith less invasive imaging techniques such as duplex ultrasound (DUS), computed \ntomographic angiography (CTA) and magnetic resonance angiography (MRA). DUS \nis an inexpensive non-invasive technique providing both anatomical and functional \ninformation. DUS, however, results in lower therapeutic confidence and more addi-\ntional imaging compared to CTA and MRA. CTA and MRA are minimal invasive and \ncan be performed as an outpatient procedure. Disadvantages of CTA are the use of \nradiation and impaired image interpretation in the presence of vessel wall calcifica-\ntions. Disadvantages of MRA include the higher investment cost for equipment and \nvenous overlay in the calf. Venous overlay and vessel wall calcifications are especially \na problem in diabetic patients. During this presentation, the cost and effects of the \ndifferent imaging techniques for peripheral arterial disease will be discussed including \nclinical utility, quality of life, functional patient outcomes and actual costs. \nLearning Objectives:\n1. To understand the pros and cons of different diagnostic modalities with \nregard to cost effectiveness.\n2. To provide cost-effective diagnostic algorithms in diabetic vasculopathy.\n08:30 - 10:00 Room K \nPediatric \nRC 712 \nImaging the GI/GU tracts \nModerator:\nG. del Pozo; Madrid/ES \nA‑187 08:30 \nA. Is ultrasound enough for a comprehensive diagnosis? \nM. Riccabona; Graz/AT \nPaediatric US has emerged to a sophisticated technique allowing definite diagnosis \nof many paediatric GI and GU conditions. Restrictions have to be considered then \nindicating fluoroscopy or sectional imaging. The common GI queries where US has \npractically replaced other imaging are HPSt, volvolus, intussusception, IBD/appendicitis. \nIn these, complementary imaging (usually fluoroscopy, sometimes MRI/CT) is rarely \nneeded. Other queries need fluoroscopy (malrotation) or MRI/CT (tumours), some only \nradiographs (atresia, NEC), although US may offer some information. And US helps \nas a therapeutic option (US-guided hydrostatic reduction). GU tract US is even more \nimportant; indication for other studies (VCUG, MRU) heavily relies on US. A skilled \nand experienced technique by knowledgeable investigators applying age-adapted \ntransducers is mandatory to exploit the vast US potential reducing/optimising additional \nimaging in many conditions. US is the primary imaging tool in HN, obstructive uropathy, \nurolithiasis, cyst and masses, and genital conditions (malformations, torsion). In signifi-\ncant HN, additional reflux assessment and grading of obstructions is needed (VCUG, \nscintigarphy or MR-Urography). Childhood urolithiasis can usually be diagnosed by US, \nsometimes complemented by KUB, hardly adapted IVU or stone CT is necessary. In \ntumours, additional sectional imaging serves for imaging work-up/staging. In conclusion, \nmodern US allows a comprehensive diagnosis in many paediatric GI and GU conditions \nobviating the need for additional, more invasive or radiating imaging. However, one \nneeds to know US restrictions to then choose appropriate complementing imaging. \nLearning Objectives:\n1. To learn about the technical requirements and potential of US in the GI/GU \ntracts.\n2. To revisit important conditions that can be comprehensively assessed and \npartially treated by US.\n3. To understand the limitations of US in the GI/GU tracts.\n4. To learn about complementary imaging techniques when US is not enough.\nA‑188 09:00 \nB. Role of plain film, fluoroscopy, nuclear medicine and CT \nV. Donoghue; Dublin/IE (veronica.donoghue@cuh.ie) \nThere have been many advances in cross-sectional imaging over the past years. \nDespite this, plain radiography still plays a significant role in the diagnosis of many \nabdominal conditions, particularly abnormalities of the gastrointestinal tract. Its \nrole is particularly important in newborn infants in assessing the many causes \nof bowel obstruction. The indications for fluoroscopy in children have decreased \n\nSaturday\nPostgraduate Educational Programme\nA\n S53\nCB D E F G\nsignificantly in recent years; for example, many patients with inflammatory bowel \ndisease are investigated using ultrasonography, MRI and CT and urocystosonog-\nraphy has replaced the voiding cystourethrogram in many departments. However, \nfluoroscopy is still required for the diagnosis of many conditions, such as newborn \nbowel disorders and the assessment of feeding problems and is frequently used to \nguide the reduction of intussusception. In the paediatric population, it is important \nto keep the radiation dose to a minimum and some methods of fluoroscopic dose \nreduction will be addressed. Ultrasonography is the first choice in the investigation \nof most GI and GU disorders. However, CT is required in many instances such \nas in the assessment of abdominal tumours, the investigation of major trauma \nand occasionally in patients with acute appendicitis. The role played by nuclear \nmedicine examinations will also be discussed particularly the role of Tc99m Mag3 \nrenography and Tc99m DMSA scans in assessing the many frequently encountered \nrenal disorders in children. \nLearning Objectives:\n1. To illustrate the continued usefulness of plain film radiography in children of \nall ages, in particular in the neonatal period.\n2. To describe the current status of fluoroscopy and issues relating to dose \nreduction.\n3. To discuss the uses and benefits of CT and the role played by nuclear \nmedicine studies in specific GI and GU conditions.\nA‑189 09:30 \nC. MRI: Current state and new options \nW. Hirsch; Leipzig/DE (hirw@medizin.uni‑leipzig.de) \nBesides ultrasound, MRI is the imaging modality of choice of the abdomen in \nchildren and is equally important in paediatric radiology. Especially for children, \n3.0 Tesla MRI is gradually established in the daily routine alongside using 1.5 T. \nFortunately, the shorter wave length of 3.0 T avoids typical artefacts especially in \nchildren because of their smaller body sizes in comparison to the higher incidence \nof these artefacts in adults with larger body sizes. The current state of paediatric \nabdominal imaging will be discussed by means of typical imaging examples us-\ning 1.5 T as well as 3.0 T MRI. MRCP has gained a new quality using higher field \nstrength and contrast enhanced MRA has also improved significantly. Increasingly, \npaediatric radiology makes use of perfusion studies to characterise lesions of the \nliver as well as other parenchymatous organs. MR spectroscopy has not yet been \nestablished in abdominal examinations of children. An exception is the spectro-\nscopic estimation of liver fat in children, which is however in an experimental stage. \nLearning Objectives:\n1. To learn about typical indications and findings of abdominal MRI and how it \ncompares with other imaging modalities.\n2. To show the possibilities, advantages and disadvantages of standard and \nhigh field strength.\n3. To show how we do it and how we try to avoid artefacts in imaging abdominal \nsolid organs.\n08:30 - 10:00 Room L/M \nRadiographers \nRC 714 \nMRI \nModerators: \nH. Ringertz; Linköping/SE \nC. Vandulek; Kaposvár/HU \nA‑190 08:30 \nA. Investigation of occlusive peripheral arterial diseases: Role of CT, MR, \nUS and DSA \nG. Pavlikovics; Miskolc/HU (gpavlikovics@gmail.com) \nAtherosclerosis is a generalized disease and contributes to cardiac death, stroke, \nlimb loss and a range of other illnesses. Disease in the major arteries, including \nthe infrarenal abdominal aorta, renal and internal iliac arteries, and peripheral \nvasculature, remains a major cause of morbidity and mortality. Traditional catheter-\nbased angiographic techniques are invasive and require arterial puncture. They \nalso rely upon potentially nephrotoxic iodinated contrast agents; however, less \ninvasive imaging techniques as US, CT and MRI have been developed. The ac-\ncuracy of these might approach the accepted standard of diagnostic X-ray based \nangiography. In this lecture: First, the clinical basics of peripheral arterial occlusive \ndiseases (PAOD) with the anatomical fundamentals will be summarized; Second, an \noverview of the angiographic modalities will be presented; Finally, the methodology \nof peripheral MR angiography will be discussed with emphasis on: •Image quality \n(Signal optimization, Contrast optimization, linear k-space reordering); •Timing (test \nbolus, bolus trigger); •Contrast agent (extracellular (role of concentration!), and \nblood-pool agents); •Instruments and patient preparation; •Contrast agent (Injection \nprotocols for different agents, minimizing the dose, role of renal function - NSF!!!, \nblood-pool agents: steady-state imaging (perfusion?), pitfalls of blood-pool agents); \n•Sequences (first pass and steady-state). \nLearning Objectives:\n1. To consolidate knowledge about occlusive peripheral arterial diseases.\n2. To appreciate the role of imaging modalities (CT, MR, DSA, US) in \ninvestigation and therapy planning with emphasis on bolus-chasing \nperipheral MRA and CTA.\n3. To summarise the basics of contrast-enhanced MRA and CTA.\n4. To learn about two kinds of MR contrast agents (extracellular and blood pool).\nA‑191 09:15 \nB. Practical approach to fMRI: Methods and cases \nP . Bogorodzki; Warsaw/PL (piotr@ire.pw.edu.pl) \nMagnetic resonance imaging (MRI) provides anatomic images of the human brain. \nBesides anatomy, recent scanners can provide physiological information, which is \nbased on the blood oxygen level dependency (BOLD) effect. A technique called \nfunctional MRI (fMRI) allows us to detect the functional brain areas involved in \nvarious tasks: motor, hearing, language, etc. FMRI methodology involves several \naspects: scanner settings, stimulation paradigm programming, subject preparation, \nsubject’s performance monitoring and post processing software pipeline settings. \nAlthough not equally important, all these determine the final quality of fMRI. \nMoreover, fMRI studies require from clinical staff additional skills and knowledge \nabout application of dedicated software for stimulating paradigms, application and \nmaintenance of MR-compatible devices (headphones, display, response buttons) \nused for fMRI stimuli presentation, and application of statistical tools used for brain \nactivations localization. All these aspects will be explored and illustrated with clinical \nand experimental examples from Bioimaging Research Center and collaborating \ninstitutions. Despite a large number of publications in medical imaging science, \nmost of the recent developments in neuroimaging are not used in clinical routine. \nMany clinical radiologists consider these techniques as research tools and are not \naware of their clinical applications. The main goal of this talk is therefore to promote \nthis technique and translate fMRI imaging from bench to bedside. \nLearning Objectives:\n1. To learn about the practical application of functional magnetic resonance \nimaging (fMRI) technique in terms of physics, instrumentation and \nexperimental design.\n2. To learn about critical factors determining repeatability and quality of fMRI, \nwhich will be illustrated using clinical examples.\n3. To learn about the clinical use of fMRI.\n08:30 - 10:00 Room N/O \nSpecial Focus Session \nSF 7b \nPresent and future direction of ultrasound\nModerator:\nL.E. Derchi; Genoa/IT \nA‑192 08:30 \nChairman’s introduction \nL.E. Derchi; Genoa/IT (derchi@unige.it) \nUS is the most widely used and rapidly growing of all sectional imaging methods \nand constitutes a large part of the workload of many radiological departments. \nHowever, many radiologists seem to perceive it as a “mature” specialty, in which \nthere are only few possibilities to advance and little chance to publish or present \ninnovative studies. On the contrary, recent advances have significantly boosted \nthe research horizons of US. This session will discuss the clinical applications and \nresearch relevance of three of the most important innovations in diagnostic US: \ncontrast enhanced studies, volume US and elastography. Integration of these new \nUS techniques into the activities of a busy radiological department needs efforts. It \nmay be difficult to invest money into the new technologies, to have time to acquire \n\nPostgraduate Educational Programme\nS54\n A B C D E F G\nthe necessary expertise and to maintain high patient throughput. The entire work-\nflow of US studies should be adapted, possibly with shorter acquisition times and \nsome marked time for the post-processing phases. Furthermore, the provocative \ntitle of the panel discussion will lead to evaluate the role of radiologists in US and, \neven in a situation in which many clinicians are using US as a “new stethoscope”, \nto maintain a strong position of our discipline in this field. \nSession Objectives:\n1. To learn about technical advances in US.\n2. To understand how new US techniques integrate into the activities of the \nradiology department.\n3. To discuss the role of radiology in the future of US.\nA‑193 08:35 \nClinical applications of US contrast media: Present guidelines \nM. Claudon; Vandoeuvre‑les‑Nancy/FR (m.claudon@chu‑nancy.fr) \nUltrasound contrast agents (UCAs), in conjunction with contrast specific imaging \ntechniques, are increasingly accepted in clinical use for diagnostic imaging and \npost-interventional workup in several organs. A first consensus document focused \non focal liver lesions detection, characterization and follow-up was published by \nEFSUMB (European Federation of Societies for Ultrasound in Medicine and Biology; \nwebsite: www.efsumb.org) in 2004. The first paper was updated and expanded in \n2008 to include recommendations for applications in the kidney, in vesico-ureteric \nreflux, in the pancreas, in trauma and in the cerebral circulation. Both papers were \nwell received and are within the top 1%, according to their citation index. These \nguidelines and recommendations are based on comprehensive literature surveys \nincluding results from prospective clinical trials. On issues where no significant \nstudy data were available, evidence was obtained from expert committee reports \nor was based on the actual consensus of experts in the field of US and contrast \nenhanced ultrasound during consensus conferences. They provide general advice \nfor the use of UCAs and are intended to create standard protocols for the use and \nadministration of UCAs, and improve the management of patients. Beyond general \nrecommendations, individual cases must be managed on the basis of all clinical \ndata available for that specific case. These guidelines will be subject to change \nto reflect future advances in scientific knowledge and the rapidly evolving field of \nUS technology. \nLearning Objectives:\n1. To understand the basic principles of contrast enhanced US (CEUS).\n2. To discuss appropriate technical settings and examination protocols.\n3. To illustrate various examples of the main clinical applications of CEUS in \nadults and children.\nA‑194 08:58 \nElastography: Clinical tool or toy? \nG. Rizzatto; Gorizia/IT (grizzatto@libero.it) \nThe mechanical properties of biologic tissues depend on their constituents and \ntheir structural organization. Usually, tumors are stiffer than normal soft tissues and \nbenign lesions. Sonoelastography is an ultrasound (US) technique that allows to \nestimate in vivo the mechanical properties of tissues; it mostly uses conventional \nultrasound systems and customized software. The principle of elastography is \nbased on slight tissue compression on the structures examined. It produces strain \n(displacement) within the tissue. Calculation of the strain profile along the axis of \ncompression is converted into a real-time elastic modulus image. Basically, tissue \nelasticity US methods fall into two main groups: methods where a quasi-static \nexternal compression is applied to the tissue and the resulting components of \ndisplacement or of the strain tensor are estimated; transient elastography which \nrelies on the observation of the propagation of a transient shear wave generated \ndirectly by the transducer to determine the viscoelastic properties of the tissues. \nShear propagation imaging requires dedicated ultrafast scanners. A large number \nof reports show that US elastography is already a clinical tool in breast imaging. It \nmainly increases the specificity for benignity. Other proposed clinical applications \ninclude liver (diffuse and focal diseases), prostate (cancer detection), thyroid (benign \nnodules vs. carcinoma), lymph nodes (normal or reactive vs. metastatic), muscles \nand tendons (inflammations, traumas and tumors), and skin (abscesses). US \nelastography may be also part of more sophisticated applications (US endoscopy \nof pancreatic lesions, MRI and US fusion imaging of breast lesions, and monitoring \nof the efficacy of US guided therapies). \nLearning Objectives:\n1. To describe the biomechanics that are the basis of tissue elastography.\n2. To review the different methods of US tissue strain analysis.\n3. To review the clinical and research results obtained in different areas.\nA‑195 09:21 \nVolume US in clinical practice for the radiologist \nS.T. Elliott; Newcastle upon Tyne/UK (simon.elliott@nuth.nhs.uk) \nThe common perception of 3D ultrasound is of surface-rendered images, espe-\ncially of the fetus. While these images are fascinating and appealing, they have \nlittle clinical application in the non-obstetric environment. However, the same \nequipment, enhanced by new transducer technology and software, can be used \nto take ultrasonography to another level, providing different image presentations, \nand working practices similar to those of CT and MR. This talk will describe the \nlatest volume ultrasound technology and show new clinical applications, multi-\nplanar reconstruction, multislice imaging, and volumetric analysis. The proven \nand potential benefits, in terms of clinical accuracy, training, workflow and overall \nefficiency, will be discussed. \nLearning Objectives:\n1. To learn about the indications and applications for volume US in non-\nobstetric imaging.\n2. To understand the technology involved in acquisition, manipulation and \ninterpretation for volume US datasets.\n3. To learn the benefits that can be gained by using volume US in terms of \ndiagnosis and workflow efficiency.\nPanel discussion:  \nWill ultrasound remain only the stethoscope of the clinician? \n09:44 \n08:30 - 10:00 Room P \nChest \nRC 704 \n\"Known\" conditions revisited \nModerator:\nM.‑L. Storto; Chieti/IT \nA‑196 08:30 \nA. An approach to cystic lung disease on HRCT \nA. Devaraj; Cambridge/UK \nLung cysts are rounded areas of reduced attenuation usually surrounded by a \nthin wall and should be distinguished from lung cavities. The pathogenesis of \nmultiple cysts in lung disease is mostly poorly understood. Offered explanations \ninclude focal necrosis, partial bronchiolar obstruction causing bronchial dilatation \nor retractile interstitial fibrosis. Disorders characterised by multiple lung cysts are, \nwith the exception of centrilobular emphysema, rare conditions. In diseases such \nas lymphangioleiomyomatosis, LIP and langerhans cell histiocytosis, HRCT can \nprovide useful diagnostic information by illustrating the distribution of disease and \ndemonstrating other ancillary signs. In other instances (e.g. the rare disorder Birt-\nHogg-Dube syndrome), lung cysts are distributed randomly and CT does not show \ncharacteristic features. In this setting, a confident diagnosis requires lung biopsy. \nA more common occurrence is the identification of an occasional lung cyst on \nCT, with aetiologies including focal emphysema, pneumatocoeles, squamous cell \nmetastatic disease and also as part of a normal phenomenon in elderly patients. \nWhere possible, an explanation should always be sought when isolated lung cysts \nare identified, because simple lung cysts (equivalent to simple cysts in the kidney \nfor example) are not typically seen in the lung. \nLearning Objectives:\n1. To become familiar with a basic classification of cystic lung diseases.\n2. To understand the pathogenesis of cystic air spaces in the lungs.\n3. To learn about the spectrum of diseases characterised by pulmonary cysts.\n4. To appreciate ancillary signs on HRCT that may refine the differential \ndiagnosis.\nA‑197 09:00 \nB. Under-recognised infections in immune competent individuals \nT. Franquet; Barcelona/ES (tfranquet@santpau.cat) \nThere have been increasing numbers of underdiagnosed emergent pulmonary infec-\ntions in immunocompetent and immunocompromised adults. Necrotizing pneumoc-\ncocal pneumonia, community-acquired methicillin-resistant Staphylococcus aureus \n(CA-MRSA), non-tuberculous mycobacterial infections and community-acquired \nrespiratory viral infections are emerging pathogens that can cause severe infections \nin healthy individuals and/or immunocompromised patients. Combination of pattern \n\nSaturday\nPostgraduate Educational Programme\nA\n S55\nCB D E F G\nrecognition with knowledge of the clinical setting is the best diagnostic approach to \npulmonary infectious processes. When pulmonary infection is suspected, knowledge \nof the varied radiographic manifestations will narrow the differential diagnosis. \nLearning Objectives:\n1. To understand the different clinical settings in patients with pulmonary \ninfections.\n2. To discuss the role of imaging methods in the management of patients with \nsuspected pneumonia.\n3. To become familiar with uncommon, but not rare, pulmonary infections.\n4. To be aware of under-recognised pneumonias with unusual radiological \nfeatures.\nA‑198 09:30 \nC. Imaging of thoracic tuberculosis \nI.E. Tyurin; Moscow/RU (igortyurin@gmail.com) \nApproximately 1.7 billion people worldwide are infected with Mycobacterium tu-\nberculosis, of which 20 million are active cases. The reasons for resurgence of TB \ninfection include the HIV epidemic, a rise in reactivation disease in the elderly, a \ngrowing migrant population and spread of drug resistant strains. In AIDS patients, \nthe imaging features depend on the degree of immune suppression, TB is more \noften disseminated and more than half of patients have at least one extrapulmonary \nsite of the disease. A pattern of postprimary TB is also usually seen among patients \nwith decreased immunity due to alcoholism, renal failure, diabetes mellitus, ageing, \nmalignancy, renal and cardiac transplantation. The development of the disease is a \ncomplex process closely related to the patents immunity and hypersensitivity. The \npathologic form of the pulmonary infection depends on the sensitivity of the infected \nhost and is classified as primary or postprimary. Primary TB pattern represents \ninfection resulting from recent contact with the pathogen. Postprimary TB pattern \nresults from reactivation of a dormant focus within the lungs or exogenous infection. \nThoracic tuberculosis produces a broad spectrum of radiographic abnormalities. The \nradiological patterns had been described as parenchymal, airway, vascular, medi-\nastinal, pleural, and chest wall lesions. Common causes of a missed diagnosis of \nthoracic tuberculosis are failure to recognize hilar and mediastinal lymphadenopathy \nas a manifestation of primary disease in adults, overlooking of minimal productive \nlesions or reporting them as inactive, and failure to recognize that an upper-lobe \nor superior segment of lower lobe mass might be tuberculosis. \nLearning Objectives:\n1. To understand the radiologist’s role in diagnosis and management of thoracic \ntuberculosis.\n2. To illustrate imaging features of thoracic tuberculosis and typical patterns of \nprimary and post-primary infection, both at presentation and on follow-up.\n3. To become familiar with the radiological patterns of multidrug-resistant \ntuberculosis and imaging features of thoracic tuberculosis in immune \ncompromised patients.\n08:30 - 10:00 Room Q \nGenitourinary \nRC 707 \nCTU and MRU: Urinary tract imaging \nModerator:\nH.J. Michaely; Mannheim/DE \nA‑199 08:30 \nA. CTU/MRU in acute obstruction \nT. Meindl, U.L. Mueller-Lisse, U.G. Mueller-Lisse; Munich/DE \n(thomas.meindl@med.uni‑muenchen.de) \nA variety of pathological processes that involve the upper urinary tract (UUT) may \ncause acute urinary obstruction: impacted calculi, neoplasms, intra- and extraluminal \nureter compression, coagulopathy, fibrosis and surgery. Clinically acute obstruction \nleads to significant flanc pain and renal colic that urges the clinician to immediate \ndiagnostic work-up and appropriate treatment. Radiological imaging procedures \ninclude ultrasonography, intravenous urography, computed tomography (CT) and \nmagnetic resonance (MR) imaging. Among the cross-sectional examinations, multi-\ndetector CT is the modality of choice for clarifying the underlying cause of acute \nobstruction. Unenhanced (low-dose) CT is the new imaging standard for detec-\ntion of calculi. Contrast-enhanced CT allows diagnosis of virtually all pathologies \nleading to obstructive nephropathy. After intravenous contrast media application, \nseveral contrast-phases can be imaged including the excretory phase for depiction \nof the UUT. Since radiation dose is a major drawback, imaging protocols have to \nbe optimized and must be tailored to the clinical question. Magnetic resonance \nurography reveals the possibility of imaging the urinary tract without the need for \ncontrast media by means of heavily T2-weighted sequences. These static urograms \nprovide information about the grade and site of obstruction, independent of the \nexcretory function of the kidneys. After injection of Gadolinium chelates, one or more \nurograms can be acquired during contrast media excretion. In the context of acute \nobstruction, MR urography is preferred in pediatric, young and pregnant patients. \nPatients with renal impairment are examined with T2-weighted sequences without \nthe need for contrast media. Magnetic resonance urography is complementary to \nCT in challenging cases. \nLearning Objectives:\n1. To learn the technical tips for MRU and CTU in acute obstruction.\n2. To discuss the value of cross-sectional urography compared to IVP .\n3. To review the appearance of major diseases like urinary stones, clots, etc.\n4. To understand the drawbacks of each method and which one should be \nused first.\nA‑200 09:00 \nB. Chronic/intermittent obstruction \nM.-F . Bellin\n1, M. Claudon2, J. Ifergan1; 1Le Kremlin‑Bicêtre/FR, \n2Vandoeuvre les Nancy/FR (marie‑france.bellin@bct.aphp.fr) \nThe recent technological advances of CTU and MRU have had an exceptional \nimpact on the assessment of chronic/intermittent obstruction. Imaging studies \nshould help answer the clinical questions raised concerning the presence, level, \nand cause of obstruction. In this session, the recommended techniques of CTU \nand MRU will be described and their relative merits and limitations reviewed. 3D \nCT images should be used as an adjunct to the transverse images, instead of a \nreplacement, because volume-rendered images best depict the lumen and not the \nwall of the urinary tract. Thin-section reformatted CT images likely are as sensitive \nas transverse images in the detection of urinary tract abnormalities. MRU is being \nincreasingly used because it provides excellent anatomic and functional imaging \nin a single setting. The relative advantages of static-fluid MRU and excretory MRU \nwill be discussed. The main etiologies of chronic/intermittent obstruction will be \nillustrated. Bladder cancer, cervical cancer, and prostate cancer are relatively\n \ncommon causes of malignant ureteral obstruction. UPJ is the most common site \nof urinary tract obstruction in children. Vessels crossing a ureteropelvic junction \nobstruction contribute\n to the degree of hydronephrosis in up to 46% of these pa-\ntients. Demonstration of these vessels and their location anterior or posterior to the \nobstruction facilitates surgical planning and limits potentially serious complications. \nBenign strictures of the ureter may complicate abdominal and pelvic inflammatory \nprocesses, infection, surgical or interventional procedures. At the end of the lecture, \nattendees will become familiar with moderate or severe urinary obstruction and \ntheir various features and causes. \nLearning Objectives:\n1. To learn the technical tips for MRU and CTU in chronic obstruction.\n2. To review the appearance of major diseases like PU junction, prostate \nmasses, chronic inflammation and extrinsic compression.\n3. To understand the advantages and disadvantages of each method.\nA‑201 09:30 \nC. Tumors: CTU/MRU \nN.C. Cowan; Oxford/UK (nccowan@gmail.com) \n1. Technological advances in both computed tomography (CT) and magnetic \nresonance (MR) imaging have improved diagnostic imaging of the urinary tract, \nsurpassing ultrasound and the intravenous urogram. Multidetector computed to-\nmography urography (CTU) is defined as CT examination of the kidneys, ureters \nand bladder with at least one imaging series acquired during the excretory phase \nof contrast enhancement. MR urography (MRU) can be performed by using heavily \nT2-weighted sequences without contrast material or T1 spoiled gradient- recalled \necho sequences during the excretory phase after administration of gadolinium-\nbased contrast material. In adults, CTU or MRU is now the preferred examination. \nTechnical aspects of image acquisition and processing will be explored and technical \ntips relating to protocol design given. 2. The typical and atypical appearances of \nupper urinary tract urothelial tumours and bladder cancers will be demonstrated. \nA method of fluoroscopic biopsy of upper tract tumours is described for validation \nof the imaging diagnosis. 3. Early and accurate diagnosis of urinary tract tumours \nhelps optimise prognosis but conventional investigative pathways are complicated \nand lengthy, utilising multiple imaging tests and many diagnostic algorithms exist \nwithout rigorous evaluation. CTU offers a single imaging test of high diagnostic \naccuracy with the potential to replace multiple alternative imaging tests in the diag-\n\nPostgraduate Educational Programme\nS56\n A B C D E F G\nnostic pathway, improve patient experience, improve diagnostic performance and \naccelerate diagnosis. MRU is a promising technique that may be used for the initial \nevaluation of patients at high risk for developing upper-tract urothelial carcinoma \nwhen CTU or intravenous urography is contraindicated. \nLearning Objectives:\n1. To learn the technical tips for MRU and CTU in the detection of urothelial \ntumors.\n2. To review the typical and atypical appearance of urothelial tumors.\n3. To understand why CTU/MRU are complementary tools to other imaging \nmethods.\n10:30 - 12:00 Room B \nESR meets Argentina \nEM 3 \nArgentine radiology: Past, present and future \nPresiding:\nA.E. Buzzi; Buenos Aires/AR \nC.J. Herold; Vienna/AT \nM. Szczerbo‑Trojanowska; Lublin/PL \nA‑202 10:30 \nIntroduction \nA.E. Buzzi; Buenos Aires/AR (alfredo.buzzi@diagnosticomedico.com) \nThe Sociedad Argentina de Radiología (SAR) was founded on May 14 th, 1917, \nin Buenos Aires, and has been the core of academic and social activity of the \nArgentinean radiological community. Many pioneers made original contributions to \nboth diagnostic and therapeutic radiology that deserve a universal repercussion, \nas we will show. Since its origins, the SAR has carried out numerous activities \namong which we can highlight the publication of the “Revista Argentina de Radio-\nlogia” (edited since 1937), the dictation of the Course of Specialist in Diagnostic \nImaging for more than 30 years (now in a virtual format), the organization of the \nArgentine Congress of Radiology for 55 years (with more than 2000 attendees), the \norganization of the Council of Professional Certification, and many services to its \nmembers. Since 2000, the SAR has the purpose of placing Argentinean radiology \nin the international radiological community, having signed scientific agreements with \nmany radiological societies both in America and Europe that are very active. To keep \nthe high academic level reached throughout the years, the SAR has maintained the \never-growing scientific, cultural and social activities, and has strongly worked in the \nformation of professionals. Despite the economic situation that Argentina and other \nLatin American are facing (that makes difficult for all our radiological community to \naccede to the top technology), there are many institutions with both medical level \nand equipment of the first level, as the speakers will demonstrate. \nSession Objectives:\n1. To describe the original Argentinean contributions to clinical and \ntechnological radiology.\n2. To describe the actual status of radiological practice in Argentina.\n3. To share our vision of Argentinean radiology.\nA‑203 10:35 \nPneumo esophageal MDCT: Its role in cancer presurgical characterisation \nand staging \nM. Ulla; Buenos Aires/AR (marina.ulla@hospitalitaliano.org.ar) \nPre-surgical characterisation and staging of esophageal and gastro esophagic junc-\ntion (GEJ) cancer with a sole imaging method could be useful for the therapeutic \nstrategy since gastric invasion determines the scope of resection to be performed. \nConventional CT scans have some limitations for hollow organ assessment in the \nabsence of lumen distension, since the organ wall may be collapsed. Indeed, it \nis sometimes difficult to define wall thickening or to guarantee the presence of \nesophageal tumors with endoluminal growth. For these reasons, optimal esophageal \ndistension has been considered useful to overcome these limitations. Although \nesophageal and gastric lumen distension has been performed with oral contrast \nagents, it is often suboptimal due to contrast rapid transit. Moreover, oral contrast \nenhancement may generate confusing images, with the same density as the tumor. \nThis potential drawback is crucial at the level of the GEJ, a typically difficult region \nto evaluate, where depiction of the tumor anatomic location conditions the surgi-\ncal strategy. To better evaluate the GEJ while staging the esophageal cancer, we \ndevelop a novel technique under MDCT in which CO\n2 is instilled into the esophagus \nto achieve maximum lumen distension. With this study, called pneumo esophageal \nMDCT, the thickened areas are highlighted in relation to the normal esophageal \nwall. The aim of this communication is to describe this technique, showing its results \nand imaging in correlation with surgical findings. \nLearning Objectives:\n1. To learn about pneumo esophageal MDCT technique.\n2. To understand its role in esophageal cancer presurgical characterisation and \nstaging.\n3. To appreciate the typical imaging findings.\n4. To become familiar with the technique and interpretation.\n5. To consolidate knowledge of esophagus tumor evaluation.\nA‑204 10:53 \nCystic echinococcosis: Our experience in Patagonia \nS. Moguillansky; Cipolletti Rio Negro/AR (smoguil@speedy.com.ar) \nHuman cystic echinococcosis (CE) or hydatidosis is a zoonotic infection caused \nby the larval stages of Echinococcus granulosus and its genetic variants. It is still \nendemic in Mediterranean countries, the Middle and Far East, and South America. \nOne of the major endemic regions in Argentina is Patagonia, where the dominant \nstrain of E. granulosus is the sheep-dog strain or G1. Humans become infected \nthrough accidental ingestion of contaminated water or vegetables or through \ncontact with a definitive host. Imaging techniques represented a breakthrough in \nthe diagnosis, treatment, and follow-up of patients with CE. Ultrasonography (US) \nis considered the gold standard for the diagnosis of hepatic hydatidosis (HH). \nUS field surveys have been useful to reveal the natural history in asymptomatic \nindividuals and allow improved epidemiologic evaluation. US is the method of \nchoice to monitor response to treatment and guide surgical intervention. Its high \nsensitivity and specificity relegates immunodiagnosis as a complementary tool. Two \nclassifications are widely used: the Gharbi and the WHO classification; however, \ncontroversy exists as to which better reflects the natural history and post-therapy \nchanges. Different imaging signs have been described and are well known. This \npresentation emphasizes key features in differential diagnosis with other space-\noccupying lesions of the liver. CT and MRI studies in the face of complications of \nHH will be reviewed. Therapeutic options are varied and far from uniform among \ndifferent centers. They will be briefly mentioned and include: “watch and wait”, \nchemotherapy, surgery, and PAIR. \nLearning Objectives:\n1. To illustrate national experience in mass screening approach.\n2. To become familiar with the common imaging findings.\n3. To understand how current classifications correlate with the natural history or \ntreatment-induced changes of the cysts.\n4. To appreciate how the imaging workup aids selection of optimal treatment.\nA‑205 11:11  \nRadioanatomy of the lower uterine arterial anastomoses \nR.D. García Mónaco; Buenos Aires/AR \n(ricardo.garciamonaco@hospitalitaliano.org.ar) \nThe utero-ovarian anastomosis (upper or proximal uterine arterial anastomosis) are \nwell described in the literature and have been related to hormonal alterations as a \nconsequence of ovarian ischemia after uterine embolization (UAE).On the contrary, \neven though complications after UAE have been reported, the utero-vesical-vaginal \nanastomosis (lower or distal uterine arterial anastomosis) are less known and \ndescriptions are scanty. Indeed, non-target embolizations (bladder,vaginal and \nvulvar) were reported after UAE. It has been often speculated that arterial reflux of \nthe embolic agents might have been the cause. A better possible explanation could \nbe the undesired passage of the embolic material from the uterine artery towards \nthe vaginal or vesical arteries through the lower anastomotic plexus. Surgical or \nendovascular occlusion of both uterine arteries have proved to be inefficient in \ncertain types of obstetric bleeding, probably due to collateral arterial supply from \nthe lower uterine arterial anastomosis. These utero-vesical-vaginal anastomosis \nare constant, although hard to observe in normal clinical situations. They become \nangiographically evident in some hipervascular conditions such as pregnancy or \nplacental infiltration, otherwise by forceful contrast injection in wedge catheter \nposition. The lower uterine anastomotic system should be well recognized by \ninterventional radiologists to avoid iatrogenic extrauterine ischemic complications \nor prevent symptomatic recurrence after embolization of obstetric hemorrhage. \nIn this communication, we shall describe and illustrate the lower uterine arterial \nanastomosis, its angiographic and anatomical characteristics, with the aim of \nincreasing the efficacy and safety of UAE. \n\nSaturday\nPostgraduate Educational Programme\nA\n S57\nCB D E F G\nLearning Objectives:\n1. To learn about the uterine-vesical-vaginal arterial anastomoses.\n2. To become familiar with arterial lower vascular supply.\n3. To understand its clinical role in UAE and obstetric hemorrhage.\n4. To appreciate its relation in placenta accreta diagnosis and management.\n5. To avoid iatrogenic non-target UAE complications.\nA‑206 11:29 \nHigh-resolution MRI in rectal cancer \nA. Dieguez; Buenos Aires/AR (amdieguez@speedy.com.ar) \nHigh-resolution magnetic resonance has become an important tool in the staging of \nrectal cancer, directing the therapeutic strategy in the preoperative multidisciplinary \nteam. MRI can clearly show the relevant anatomy for Total Mesorectal Excision, in \nparticular the mesorectal fascia, assessing resectability. It can also identify patients \nwith prognostic risk factors such as depth of invasion and status of the surgical \ncircumferential resection margin. In this way, patients at highest risk can undergo \npreoperative adjuvant treatment, which has a better outcome and less toxicity than \npostoperative treatment. The report should include the T and N staging, the status \nof the circumferential resection margin, and the presence or absence of extramural \nvascular invasion. Knowing that the prognosis for low rectal cancer is different from \nthat for upper and middle third level tumors, the analysis in this location deserves \nspecial attention. High-resolution magnetic resonance is reproducible and accurate \nin the selection of the proper preoperative treatment. We will describe the pertinent \nanatomy, the MRI technique, and the prognostic risk factors, and show our 5-year \nexperience with a multidisciplinary team for the assessment of these patients. \nLearning Objectives:\n1. To describe the high-resolution MRI state-of-the art technique and the data-\nreporting form in patients with rectal cancer.\n2. To describe the anatomic landmarks of relevance in Total Mesorectal \nExcision of the rectum.\n3. To illustrate the use of high-resolution MRI in the identification of poor \nprognostic factors in rectal cancer.\n4. To understand its role in selecting patients for preoperative neoadjuvant \ntherapy.\nPanel discussion \n11:47 \n10:30 - 12:00 Room E2 \nFoundation Course: Head and Neck Radiology \nE³ 820 \nNeck lymph nodes and glands \nModerator:\nS. Robinson; Vienna/AT \nA‑207 10:30 \nA. Neck lymph nodes and salivary glands \nH.C. Thoeny; Berne/CH (harriet.thoeny@insel.ch) \nInvolvement of lymph nodes in various pathologies of the head and neck is frequent \nnot only in malignant diseases but also in inflammatory conditions. As size criteria \nare not sufficient to define a lymph node as malignant, other criteria such as shape, \ncentral necrosis and extracapsular spread are other helpful signs. However, micro-\nmetastases are still an unresolved problem although new imaging methods have \nalready shown promising results. Typical imaging features of CT and MRI indicating \nextracapsular spread and carotid artery invasion will be discussed as these have \ntherapeutic and prognostic implications. Although salivary gland pathologies are \nrelatively rare, its large variety of differential diagnoses makes it challenging. In \nchildren and pregnant women, sonography is the first step, and CT is the method of \nchoice in inflammatory disease. MRI is the first line examination in palpable salivary \ngland masses to assess the exact extent of tumours, the invasion of neighbouring \nstructures, perineural spread and bone invasion. Differential diagnoses and imaging \nfeatures of the most frequent tumour types will be discussed and an approach to \ndifferentiate between benign and malignant lesions will be provided. \nLearning Objectives:\n1. To become familiar with the normal appearance of lymph nodes and salivary \nglands on imaging studies.\n2. To review the imaging findings in common diseases affecting the neck lymph \nnodes.\n3. To review the imaging findings in benign and malignant diseases of the \nsalivary glands.\n4. To appreciate the relative value of different imaging techniques in the \nevaluation of neck nodal and salivary gland disease.\nA‑208 11:15 \nB. Thyroid and parathyroid glands \nA.D. King; Hong Kong/CN (king2015@cuhk.edu.hk) \nThyroid Gland: The normal appearance and developmental abnormalities of the \nthyroid are covered briefly, followed by a discussion of some of the more impor-\ntant malignant and benign diseases of the thyroid. Imaging thyroid cancer will be \nillustrated with an emphasis on papillary carcinoma, which is the most common \nthyroid cancer. Diagnosis is obtained from ultrasound guided biopsy. Ultrasound \nis often sufficient to also stage early thyroid cancer in the neck, but MRI/(CT) is \nrequired for more advanced disease where there is extra-thyroidal primary tumour \nspread or extensive nodal disease. The impact of imaging on thyroid cancer man-\nagement will be discussed. Benign thyroid nodules are common and ultrasound \nis used to distinguish these nodules from cancer; however, some nodules remain \nindeterminate on ultrasound and in these cases selection of criteria for biopsy is \ncontroversial. Finally, the imaging appearances in Graves’s thyrotoxoicosis and \nthyroiditis (Hashimoto’s, subacute and suppurative) will be illustrated. Parathyroid \nGlands: Imaging is used to localise the abnormal parathyroid gland (parathyroid \nadenoma, hyperplasia or rarely carcinoma) in hyperparathyroidism. There are \nusually four parathyroid glands located in the neck but supernumerary or ectopic \nglands may occur in the neck and mediastinum. Pre-operative localisation reduces \noperative time and allows minimally invasive forms of surgery to be performed. In \nthis context, \n99mTc- sestamibi scintigraphy and ultrasound are usually the first choice \nfor localisation, while additional techniques such as MRI or CT are reserved for \ncases where the abnormal gland cannot be localised or there is persistent/recur-\nrent disease after surgery. \nLearning Objectives:\n1. To review the normal anatomy and imaging appearance of the thyroid and \nparathyroid glands.\n2. To learn about the imaging findings in benign and malignant disease of these \nstructures.\n3. To understand the relative value of different imaging techniques to evaluate \npathology of these structures.\n4. To appreciate the impact of imaging findings on patient management.\n10:30 - 12:00 Room G/H \nEFOMP Workshop\nNew technology in diagnostic radiology: Risk management, \ntechnology assessment and improved diagnosis \nEF 2 \nRisk management and technology assessment \nModerators: \nS. Christofides; Nicosia/CY \nA. Torresin; Milan/IT \nA‑209 10:30 \nAcceptability criteria and radiography equipment, digital imaging and CT \nJ. Malone; Dublin/IE (jifmal@gmail.com) \nIn 2007, the EC commissioned a group of experts to undertake the revision of \nReport RP91 on “Criteria for Acceptability of Radiological (including Radiotherapy) \nand Nuclear Medicine Installations”. This paper introduces some of the concerns \nencountered in the diagnostic radiology section of the report and the approach \nadopted to establishing the criteria. It is expected that after a period of consultation, \nthe report will be finalised by the European Commission and published. The group \nwas particularly concerned to devise a set of criteria that applied to contemporary \nradiological equipment. Thus, all modalities including general film screen radiogra-\nphy, CR, DR, fluoroscopy, interventional radiology, CT, dental radiography and DXA \nwere reviewed. The group concentrated on identifying performance criteria which, if \nnot met, would require equipment to be removed from service immediately. These \nwere defined as suspension levels. The methodologies for assessing performance \nand the performance levels were, where possible, based on literature that com-\nmanded a high level of consensus. Where this was not available, the judgment \n\nPostgraduate Educational Programme\nS58\n A B C D E F G\nof the expert group, followed by peer review was employed. Where possible, the \napproach used has been consistent with the approach in international standards \nsuch as those issued by IEC. The paper will present the approach employed and \nsome examples of the values recommended. \nLearning Objectives:\n1. To comprehend the different meanings associated with terms like \nacceptance test, criteria for acceptability, and commissioning, as used with \ndiagnostic imaging equipment.\n2. To understand the status that will be afforded to criteria for acceptability \nfor radiological equipment under the EU Medical Exposures Directive, and \nhow this may influence the end users of equipment in hospitals/clinics and \nmanufacturers/suppliers of equipment and services.\n3. To become familiar with the bodies involved in the creation of standards and \ncriteria for acceptability for diagnostic radiology imaging equipment.\n4. To become familiar with the consultation process presently open with respect \nto the new draft criteria for the acceptability of equipment.\n5. To examine examples of criteria for acceptability from the draft report.\nA‑210 11:00 \nAcceptability criteria and equipment for fluoroscopy and interventional \nradiology \nS. Balter; New Y ork, NY/US \nFluoroscopic systems can be highly flexible and are open to a wide range of ap-\nplications. They may offer a multiplicity of modes (and sub-modes) of operation. \nCommissioning of newly installed equipment includes optimizing the equipment \nsettings for its intended use. A representative subset of the most probable intended \nuses of the equipment should be identified for acceptability testing. For example, \nthe main “cardiac mode (s)” and associated sub-modes might be tested in a unit \nwhose intended application will be in the area of cardiac imaging. If the unit is later \ndeployed for different purposes, the need for new commissioning and a new accept-\nability test will have to be considered by the practitioner and the MPE. Fluoroscopes \nintended for interventional use ought to have dose measurement capabilities such \nas Air Kerma Area Product and/or Accumulated Air Kerma at a reference point. \nAcceptability testing includes evaluating the accuracy of these instruments. In many \ncases, fluoroscopic systems are supplied as dedicated units suitable for cardiac, \nvascular, gastrointestinal or other specific applications. Powerful mobile units are \navailable and are generally flexible. In all cases, the MPE will have to consider the \nintended application of the unit and the environment in which it will be installed and \nused. With respect to the X-Ray generator, many of the criteria of acceptability are \nsimilar to those prevailing for general radiographic systems. \nLearning Objectives:\n1. To become familiar with the process of testing fluoroscopes for clinical \nacceptability.\n2. To be aware of the need for optimizing the setting of a fluoroscope \ncorresponding to its intended use.\nA‑211 11:30 \nAcceptability criteria and equipment for nuclear medicine \nS. Christofides1, L. Malone2, P . Horton3, S. Mattsson4; 1Nicosia/CY, 2Dublin/IE, \n3Newcastle upon Tyne/UK, 4Malmö/SE (soren.mattsson@med.lu.se) \nPurpose: To specify acceptable performance tolerance levels (suspension levels) \nfor gamma camera and positron emission based procedures. Instruments needed \nfor therapeutic procedures and intra-operative probes are also covered.\nMethods and Materials: As shown in the preceding papers describing the revision \nof the EC RP91 criteria.\nResults: This section considers equipment for: 1. Nuclear medicine therapeutic \nprocedures. 2. Radiopharmacy quality assurance programme. 3. Gamma camera \nbased diagnostic procedures. 4. Positron emission diagnostic procedures. 5. \nHybrid diagnostic systems. 6. Intra-operative probes. Each part is comprised of \na brief introduction and a list of equipment for which suspension levels are given. \nFor each equipment, a table is given with the performance parameters and the \nsuspension levels.\nConclusion: It is evident that there are few publications that give hard values for \nsuspension levels, especially for new and evolving technologies in nuclear medi-\ncine. Therefore, it was necessary to quote acceptable tolerance levels, which are \nrelated to the value used for acceptance testing/commissioning of the equipment \nand on values quoted by the manufacturer. It was also evident that case studies \ndescribing the suspension of equipment based on the characteristic parameters \nfalling outside defined tolerance levels or hard parameter values were not identified \nin the published literature. It is recommended that such case studies should be \npublished for future use in defining more solid suspension levels. Since technology \nis evolving continuously and new equipment is placed on the market with a rapid \ntempo, it is necessary with a regular review and updating of the recommended \nsuspension levels. \nLearning Objectives:\n1. To comprehend the background for and rational of the revised RP91 \nacceptability criteria for nuclear medicine installations.\n2. To understand when equipment no longer meets the required performance \ntolerance levels (suspension levels) and has to be withdrawn from use.\n3. To become familiar with the revision of the EU RP91 document and \nwith documents from IAEA, IEC and NEMA related to performance \nmeasurements and quality assurance for nuclear medicine equipment.\n10:30 - 12:00 Room Z \nESR Audit Session \nClinical audit for radiologists: Why it is worth doing, \nand how to make it work \nModerator:\nE.J. Adam; London/UK \nA‑212 10:30 \nClinical audit: What is it and who should do it? \nE.J. Adam; London/UK (Jane.Adam@stgeorges.nhs.uk) \nThis talk will focus on how radiologists can become involved in and carry out clinical \naudit, and what benefits it can bring. There are many definitions of clinical audit, \nsome of which imply regulation or outside scrutiny, but clinical audit should be viewed \nas a professionally led method of improving patient care through the systematic \nexamination of systems, processes and outcomes against chosen and agreed \nstandards. It is a process that can readily be carried out by individuals, groups or \nwhole departments. If properly conducted, with appropriate confidentiality and in a \nno-blame environment, clinical audit can be a professionally satisfying, productive \nand effective way of examining what we do to provide reassurance that all is well, or \nwhere necessary, find ways to improve and enhance the care we offer to patients. \nLearning Objectives:\n1. To comprehend the definition of clinical audit.\n2. To understand the methodology and scope of clinical audit.\n3. To become familiar with the benefits of audit and how it can become part of \nour normal professional practice.\nA‑213 10:50 \nClinical audit and accreditation: Intimidating or encouraging? \nExperience in Germany \nB. Ertl-Wagner; Munich/DE (Birgit.Ertl‑Wagner@med.uni‑muenchen.de) \nIn Germany, quality management (QM) has been obtaining increasing attention in \nthe medical arena, as the legislature now demands the introduction of a QM system \nboth in the in- and out-patient settings. This has led to a steep increase in accredita-\ntions in recent years, also in the field of radiology. A commonly used QM system in \nGerman hospitals is KTQ, a genuinely German system that can only be applied for \nentire hospitals and not for departments. In addition, ISO 9001:2008 is a prevalent \nsystem both for the in- and out-patient settings. Other QM and accreditation models \ninclude EFQM, Joint Commission International, proCum cert, and several models \nspecifically designed for the out-patient practice setting. The introduction of QM to \nGerman medicine has caused a pronounced increase in both internal and external \naudits. These mechanisms have to be incorporated into the management system \nand organisational structure in order to ascertain continuous improvement of the \ndepartment. Even though audit is oftentimes initially perceived as threatening, it \ncan be an extremely rewarding and educational experience if conducted properly. \nAudit has the capability to identify potential weaknesses and to devise mechanisms \nto ameliorate or eradicate these. In a blame-free environment, this can lead to an \nimproved and more content situation for patients, staff and referring physicians. \nLearning Objectives:\n1. To become familiar with the various QM models commonly used in German \nmedicine and radiology.\n2. To become acquainted with the common processes of introducing a QM \nsystem to a radiological department.\n3. To explore the mechanisms and benefits of both internal and external audits.\n\nSaturday\nPostgraduate Educational Programme\nA\n S59\nCB D E F G\nA‑214 11:10  \nClinical audit: Getting everyone involved! UK experience and the role of \nnational audit projects \nS. Barter; Cambridge/UK (suebarter@btinternet.com) \nThe Clinical Radiology Audit Sub-Committee (CRASC) of the Royal College of \nRadiologists (RCR) was established to co-ordinate national radiology audit activity. \nIts function is to promote and facilitate audit through nominated audit leads in each \nhospital trust, who act as a link between the RCR and their department, encouraging \naudit locally and participating in relevant RCR national audits. At least one national \naudit is carried out annually, with data collected via electronic submission and the \nanonymised results presented to audit leads at an annual Audit Forum. Individual \ndepartmental results are analysed using statistical process control (SPC) methodol-\nogy. This enables identification of departments underperforming against the national \nmean, and recommending corrective action, by redesigning the process being \naudited, or by identifying and eliminating specific root causes locally. Past National \nAudits include: 2006 - Audit of outcomes of Nephrostomy, 2007 - Audit of Effective \nCommunication and 2008 - Audit of Accuracy of Staging of Uterine Cancer. The \nCommittee has developed a web-based tool for facilitating local audit, “AuditLive”, a \nfully searchable collection of templates or “recipes” which can be downloaded and \nadapted. Fellows are also able to submit their own templates for audit for publica-\ntion hence sharing best practice nationally. We encourage radiologists in training \nto participate in audit by holding Audit Poster competitions at National Radiology \nScientific Meetings, and produce an audit newsletter, distributed to every member \nand Fellow of the RCR. Our experience leads us to believe that audit succeeds \nwhen relevant, locally owned and properly structured, and multi-professional, and \nour model encourages this. \nLearning Objectives:\n1. To comprehend the role of clinical audit in radiology practice.\n2. To understand how to facilitate clinical audit locally and nationally.\n3. To become familiar with some of the systems developed in the UK by the \nRoyal College of Radiologists.\nA‑215 11:30 \nImplementation of the EC guideline in practice \nS. Soimakallio; Tampere/FI (seppo.soimakallio@pshp.fi) \nPurpose: To introduce the new EC guideline of Clinical Audit (CA) and how it is to \nbe implemented in practice of radiological department.\nMethods and Materials: Guideline contains the terminology and practical matters \nof INTERNAL (annually) and EXTERNAL (within 5 years) AUDIT. Every radiological \nunit must have some kind of quality system with documented practice in quality \nmanual. Motivation of staff is necessary to achieve the good quality of work and \nto prepare for the external inspection. Enough resources (time, costs, etc). must \nbe reserved for updating of quality manual. Auditing organization can use only \nindependent, experienced and educated auditors. The audited unit should change \nits own practice according to the recommendations given by auditors. National Ad-\nvisory Committee is useful to coordinate and to develop the national audit practice. \nCriteria of good practice should be developed in cooperation with national societies.\nResults: The new guideline is supposed to give advice to every question concern-\ning clinical audit. In Finland, the most difficult thing was how to start the process. \nWith two runs of CA, we will notice improved quality of diagnostics, reduced dose \nof radiation, effective use of resources and professional education. The number of \nrecommendations has strongly diminished during two runs.\nConclusion: Guideline is the necessary tool to implement clinical audit in practice \nof radiology. National legislation and regulations should be taken into account in \nthis process. \nLearning Objectives:\n1. To comprehend the EC guideline.\n2. To understand the whole process of clinical audit.\n3. To become familiar with implementation of the guideline in radiology practice.\nDiscussion\n 11:50 \n12:15 - 12:45 Room A \nPlenary Session \nHL 2 \nJosef Lissner - Honorary Lecture \nPresiding:\nM. Szczerbo‑Trojanowska; Lublin/PL \nA‑216 12:15 \nThe advance of musculoskeletal radiology and creating defining moments \nS.E. Anderson; Sydney/AU (andersonsembach@yahoo.com.au) \nMusculoskeletal radiology has experienced significant progress in clinical expertise, \nresearch and teaching. Technology has been, among others, a very positive driving \nforce. However, medicine and radiology are still human centric disciplines. Teach-\ners, students and patients are important stakeholder groups. Their daily interaction \non different levels sometimes blurs the key moments that might otherwise impact \non individual choices in the long term. How do we leverage the human aspect in \na more defined way? The speaker will discuss this topic and some ideas with the \nfocus on teaching and cross-generational influence. \nLearning Objectives:\n1. To have an appreciation of the advance of musculoskeletal radiology.\n2. To appreciate the specific potential role of “defining moments” influencing \neducation, teaching and to developing musculoskeletal radiology further.\n12:30 - 13:30 Room I \nJoint Session of ESR and EC (European Commission)\neHealth: Legal and technical challenges for \nradiology \nModerator:\nI.W. McCall; Oswestry/UK \nA‑217 12:30 \nIntroduction on eHealth \nC. Dima; Brussels/BE \nEuropean health systems are faced with challenges like citizens’ expectations for \nhigh-quality care, staff shortages, unequal territorial distribution and rising healthcare \ncosts. eHealth and telemedicine in particular are tools which can help to address \nchallenges, like contributing to deliver better quality of care, to increase accessibility \nto healthcare in remote geographical locations or to overcome shortages of health \nprofessionals in given situations. Recognising the potential benefits of ICT tools in \nthis context, the European Commission has been supporting efforts in the field of ICT \nfor Health for the last 20 years. EC instruments used for making eHealth a reality are \na mix of research, policy and support to deployment activities. Research activities \nin three main areas (Personal Health Systems, Patient Safety, Virtual Physiological \nHuman) are being financed under the Seventh Framework Programme for Research \n(FP7). Several policy actions have been adopted in order to support eHealth devel-\nopment: Action Plan for a European eHealth Area (April 2004); Communication on \nlead markets (December 2007); Recommendation on cross border interoperability \nof EHR systems (July 2008); Proposal for a Directive on patient’s rights for cross \nborder care (July 2008); Communication on “telemedicine and the benefit for patients, \nhealthcare systems and society” (November 2008). Implementation, support to poli-\ncies: Competitiveness Innovation Programme (CIP ICT PSP): Large Scale Pilot on \nInteroperability and Telemedicine + Thematic Networks. \nA‑218 12:40 \nLegal aspects of eHealth related to medical imaging \nC. Dima; Brussels/BE \nThe best illustration of an eHealth service in the field of medical imaging is tele-\nradiology. Teleradiology is a telemedicine service which involves the electronic \ntransmission of radiographic images from one geographical location to another \nfor the purposes of interpretation and consultation. The Communication from the \nCommission to the European Parliament, the Council, the European Economic \nand Social Committee and the Committee of the Regions on telemedicine for \nthe benefit of patients, healthcare systems and society [COM (2008) 0689 final] \nacknowledges the fact that teleradiology is currently the telemedicine service in \n\nPostgraduate Educational Programme\nS60\n A B C D E F G\nthe most advanced stage of deployment. It is a way to optimize management of \nscarce resources. In the Communication the Commission undertook to publish, in \ncooperation with Member States, an analysis of the Community legal framework \napplicable to telemedicine services, including teleradiology. This was listed in the \nCommunication as an action aimed to bring legal clarity to telemedicine. Several EU \nlegal acts have been identified as being applicable to teleradiology. The challenge \nis to determine and clearly specify the scope, depth and borders of applicability \nof existing Community legal framework to teleradiology. It is both important and \nuseful to analyse the case of teleradiology services by cross-reference to the \nrelevant Community legislation in the main problematic areas, such as: freedom \nto provide telemedicine services, license/authorisation of health professionals \nproviding telemedicine services, liability, personal data protection and jurisdiction. \nA‑219 12:55 \nRadiology’s view on telemedicine communication \nL. Donoso; Barcelona/ES \nThe European Society of Radiology (ESR) is closely monitoring EU legislation and \nEU affairs with a potential impact on medical imaging and has started to successfully \nbuild relations with relevant EU institutions and EU consulting and public affairs \nagencies. The ESR very much welcomes the Communication on Telemedicine \nissued by the European Commission as a document that brings to the attention of \ndifferent stakeholders several important issues concerning telemedicine.\nThe ESR wants to make sure that: 1. Although staff shortages are expected in the \nfuture, a radiological act must always be defined as a medical act. 2. Standardised \nEuropean training curricula and structures for all radiologists are established. 3. \nReporting radiologists are registered, including adequate monitoring and accredita-\ntion mechanisms. 4. Special attention is given to the challenges new technologies \npose for the radiologist profession.\nThe ESR demands that a future legislation on Telemedicine shall provide the \nfollowing: 1. Teleradiology has to be defined as medical act in its own right. 2. \nEstablishment of accreditation criteria for teleradiology providers that are homog-\nenous throughout the EU. 3. Emphasis on the importance of delivering high-quality \nhealthcare to the patient. 4. International quality standards and careful monitoring \nof service providers. 5. Regulation of telemedicine and teleradiology should be the \nresponsibility of the member state where the patient undergoes the imaging proce-\ndure or telemedical referral. 6. Full information of patients and informed consent. \nA‑220 13:05 \neHealth: Technical aspects \nD. Caramella; Pisa/IT \nBroadband access and the ability of providers to enable full connectivity is a \nprerequisite for the deployment of teleradiology. However, the geographical areas \nthat may be more in need of teleradiology (scarcely populated areas) usually \nhave more difficult or limited access to the high-performance connections that are \nneeded. Moreover, it is hard to underestimate the importance of interoperability and \nstandardisation. In Radiology there has been formidable progress in this field with \nthe development of DICOM and IHE. However, fine tuning of existing standards is \nstill needed to cope with the specific issues that are relevant to teleradiology. For \nexample, an EU wide consensus on specifications for transfer protocols, encryp-\ntion, digital signatures and providing a Public Key Infrastructure service would \nimprove the practical access to teleradiology and the interoperability between \ndifferent partners in healthcare. Another important aspect is that interoperability \nhas to include all information systems in which the remote radiologist may find the \ncomplete clinical information (images and data) that is necessary for the diagnosis. \nTherefore, access to prior imaging examinations as well as to the Electronic Patient \nRecord must be available in teleradiology applications in order to ensure the same \nquality of radiological diagnosis that is obtainable in the HIS-PACS environment at \nthe hospital level. Even if current state-of-the-art technology has reached a mature \nstage when it can really help to fulfil the aim of realising teleradiology, a serious \ndeployment programme will never be possible unless other development points \n(namely legal and organizational issues) are tackled and fixed as well. \nDiscussion \n13:15 \n16:00 - 17:30 Room A \nRadiology in Abdominal Emergencies \nCC 1017 \nMissing perfusion: Abdominal ischemic disease \nModerator:\nN. Gourtsoyiannis; Iraklion/GR \nA‑221 16:00 \nA. Mesenteric angiography: Diagnostic and therapeutic approach \nJ. Lammer; Vienna/AT (johannes.lammer@akhwien.at) \nAcute abdominal organ ischemia may be caused by hypovolaemic shock, spasm \n(ergotism), embolization and aortic dissection. Embolization is the most common \ncause. It occurs typically in elderly patients with atrial fibrillation, after myocardial \ninfarction or due to a thoracic aortic aneurysm (TAA). The primary diagnosis is made \nby CT with contrast enhancement which also can demonstrate cardiac thrombi or a \nTAA. Interventional treatment can be performed with a thrombectomy device or fibri-\nnolysis with recombinant tissue plasminogen activator (rt-PA; 10 mg loading dose, \n5 mg/hr infusion dose). Acute aortic dissection may cause dynamic compression of \nthe true lumen with occlusion of the ostium of the visceral arteries (floating visceral \nsign). The primary diagnosis is made by CT. Occlusion of the primary entry tear \nwith a thoracic aortic stentgraft may decompress the true aortic lumen followed by \nreperfusion of the visceral arteries. Chronic abdominal ischemia in younger patients \nmay be due to fibromuscular dysplasia, Takayasu arteritis or neurofibromatosis. \nIn the elderly, it is usually caused by arteriosclerosis. The patient may have post \nprandial abdominal pain (angina abdominalis), diarrhea and/or weight loss. Due \nto the collateral circulation, symptoms usually occur only if more than one of the \nmajor arteries (celiac trunk, superior and inferior mesenteric artery) is narrowed. \nThe diagnosis can be made by color Doppler ultrasound (CDUS), CT and MR with \ncontrast enhancement. Endovascular treatment is done by PTA and stent placement. \nLearning Objectives:\n1. To learn the different causes of ischemic abdominal emergencies and \nprinciples for treatment by interventional radiology.\n2. To learn the causes and the optimal imaging strategy for preparing treatment.\n3. To understand the principles, techniques and results of interventional \nradiology for the treatment of acute abdominal bleeding.\nA‑222 16:30 \nB. The black bowel \nP . Rogalla; Berlin/DE (rogalla@charite.de) \nIschemic bowel disease represents a live threatening disease that requires immediate \nclinical attention once diagnosed. Expansion of cardiac surgery, surgical interven-\ntions in elderly and high-risk patients have created an increasing demand for early \ndiagnostic workup if bowel ischemia is clinically suspected. Multi-row detector CT with \nmultiplanar refomations including further projection techniques plays a leading role in \nearly detection of bowel ischemia if blood work and clinical presentation are equivocal \nor contradictory. Optimal sequencing of intravenous contrast media injection and the \nscanning delay represents a prerequisite for reliable diagnostic outcomes. Knowledge \nof typical patterns of the disease, early and late signs of ischemic bowel disease is \nmandatory for radiologist in charge. The course will help to understand physiological \nprinciples and causes of ischemic bowel disease. Diagnostic performance of cur-\nrent imaging tests and how to integrate them into clinical practice will be discussed. \nLearning Objectives:\n1. To understand the underlying physiological principles and causes of ischemic \nbowel disease.\n2. To become familiar with typical signs of bowel ischemia and how to use \nthem.\n3. To discuss the diagnostic performance of current imaging tests and how to \nintegrate them into clinical practice.\nA‑223 17:00 \nC. Clinical management: What you need to know \nD.E. Malone; Dublin/IE (dmalone@ucd.ie) \nAcute mesenteric insufficiency (AMI) is due to arterial or venous occlusion. Arterial \nAMI is an emergency. The typical patient is elderly, may have atrial fibrillation and has \nrecent onset intense visceral pain disproportionate to clinical signs. CT is the mainstay \nof diagnosis and may be supplemented by CT angiography (CT A). Waste no time if \narterial AMI is suspected. Average mortality rates of 71% (59-93%) have been reported \n\nSaturday\nPostgraduate Educational Programme\nA\n S61\nCB D E F G\nand symptom duration before therapy is an independent predictor of mortality. Age > 70 \nyears, metabolic acidosis and renal failure are other danger signs. Interrupt routine CT \nlists; ensure that these patients are scanned as soon as possible - neutral oral contrast \nand high-dose IV contrast are essential. CT appearances should be correlated with \nserum lactate as acute arterial occlusion without reperfusion may produce falsely \n'normal' bowel wall thickness. Early diagnosis and aggressive surgical intervention \ncombining bowel resection with revascularisation offer the best prognosis. Venous AMI \nmay present with a more chronic, intermittent course of pain, fever, abdominal tender-\nness and ascites. Therapy is bowel resection and anticoagulation. Ischaemic colitis \noccurs in elderly patients with atherosclerosis spontaneously or after aortic aneurysm \nrepair. There are fewer systemic manifestations, bloody diarrhoea predominates; it may \nspontaneously resolve. CT or contrast enema is established imaging options. Chronic \nmesenteric ischaemia presents with 'intestinal angina' and weight loss. Doppler US, \nCT A/MRA are diagnostic. Surgical or interventional therapy is feasible; the correct choice \nvaries with individual patient anatomic and comorbidity considerations. Endovascular \ntherapy may have higher re-intervention rates, reducing cost-effectiveness. \nLearning Objectives:\n1. To discuss the clinical signs of ischemic bowel disease.\n2. To analyse the clinical management of patients with suspected bowel \nischemia with focus on workflow.\n3. To analyse cost-effectiveness and clinical outcome of early diagnosis and \ninterventional treatment options.\n16:00 - 17:30 Room B \nRadiology of the Spine in 2010 \nCC 1016 \nBones: What you should know! \nModerator:\nV.G. Hadjidekov; Sofia/BG \nA‑224 16:00 \nA. Primary and secondary tumors of the bony spine \nJ.W.M. Van Goethem, L. van den Hauwe, C. Venstermans, F . De Belder, \nP .M. Parizel; Antwerp/BE (johan.vangoethem@ua.ac.be) \nSpinal tumors are uncommon lesions and affect only a minority of the population. \nHowever, these lesions can cause significant morbidity in terms of limb dysfunc-\ntion and can be associated with mortality as well. In establishing the differential \ndiagnosis for a spinal lesion, location is the most important feature. In general, \nextradural lesions are the most common (60% of all spinal tumors), with the major-\nity of lesions originating from the vertebrae. The most frequent extradural tumor is \nmetastasis, while primary bone tumors are much less common. Solitary vertebral \nlesions are less common than tumors with multiple locations. Benign lesions are \nusually asymptomatic, incidentals findings, malignant vertebral tumors give back \npain and sometimes manifest neurologic symptoms, especially in children. MR \nimaging is the best imaging modality, but bone scintigraphy is useful in detecting \nmultiple lesions and distant metastases. CT is also important in imaging these \nlesions and sometimes shows typical patterns of bone destruction, sclerosis and/\nor remodeling. The most frequent malignant extradural tumor is metastasis. Other \nmalignant tumors include lymphoma - multiple myeloma, chordoma, Ewing sar-\ncoma and chondrosarcoma. The most frequent benign lesions are hemangioma, \nenostosis (simple bone island), osteoid osteoma - osteoblastoma, aneurismal bone \ncyst, giant cell tumor, eosinophilic granuloma (histiocytosis) and osteochondroma. \nBesides imaging findings, the age of the patient and the multiplicity and location of \nthe lesion (s) are most important in the differential diagnosis. \nLearning Objectives:\n1. To review the most common primary tumors of the bony spine.\n2. T o learn how to analyse imaging patterns of neoplastic bone lesions in the spine.\n3. To re-evaluate the necessity of CT and/or MR in evaluation of tumors of the \nbony spine.\nA‑225 16:30 \nB. Traumatic bone injury \nM. Stajgis; Poznan/PL (stajgis@o2.pl) \nTraumatic bone injury of the spine presents a great clinical and social problem as \nit often affects young and previously healthy patients. The role of radiologist is to \ndetect and precisely indicate the areas of the spine which have been affected by \nthe trauma. The knowledge of normal anatomy of the spine and the most common \nanatomical variants are absolutely necessary to make the correct diagnosis. Also, \nthe mechanism of injury is important - its understanding helps and simplifies the \ndiagnostic pathwork. Crucial for the patient is to distinguish between stable and \nunstable fractures; this enables the optimal treatment (surgical vs. nonsurgical) - \nDenis concept of three columns of the spine is one of examples of common language \nbetween radiologist and neurosurgeon. Spinal injuries are divided into minor and \nmajor ones. Minor injuries include fractures of transverse and spinous processes, \nfacets and interarticular parts. The most common major injuries are compression \nand burst fractures with anatomic dislocations. The role of radiograms will be \npresented. Without doubt, MDCT with reformats is the ‘gold standard’ method in \nevaluation of traumatic bone injury and must be implemented in routine protocol \nin every patient with neurological or other clinical symptoms. Also, MRI plays a \nvery important role - it can detect the subtle injury symptoms like posttraumatic \nbone marrow oedema, evaluate the degree of spinal cord compression with its \nconsequences and determine the injury of soft tissues (e.g. ligaments). Finally, \nthe disadvantages and traps of different imaging modalities will be presented. \nLearning Objectives:\n1. To understand the mechanisms of traumatic bone injury.\n2. To learn about MR imaging findings in different traumatic abnormalities of \nthe spine.\n3. To become familiar with the advantages and disadvantages of different \nimaging techniques in spinal trauma.\nA‑226 17:00 \nC. Spinal infections: More common than expected? \nE.T. Tali; Ankara/TR (turgut.tali@gmail.com) \nSkeletal manifestations of TB remain a major problem in the world. The incidence is \nrising with increasing AIDS, immunosuppressive drugs or substance abuse. WHO de-\nclared TB a global health emergency. Drug-resistant TB infections (multi-drug resistant \nTB (MDR-TB), which is defined as resistance to the two most effective first-line TB drugs: \nextensively drug-resistant TB (XDR-TB) and extremely drug-resistant TB (XXDR-TB) \nthat have resistance to every anti-TB drug are also increasing recently. TB of the spine \naccounts for 1% of all TB infections and 25-60 of all bone and joint TB infections. It \ngenerally affects adults in the fourth and fifth decades. TB spondylitis is more indolent \nwith a more gradual onset of symptoms over months to years. Lower thoracic and up-\nper lumbar vertebrae are the most common sites. Multiple vertebral body involvement \nis the rule and skip lesions occur. Vertebral body is eventually destroyed with loss of \ncortical definition and fragmentation, large paravertebral abscess and epidural infection \nare frequently seen. Reactive sclerosis, vertebral body collapse, gibbous deformity and \nvertebral body fusion are findings of advanced cases. The incidence of TB meningitis \nwith meningeal enhancement, adhesions, loculations and TB myelitis with focal cord \nswelling, edema, nodular lesions are low. Despite the advent of advanced diagnostic \ntechnology, neither clinical examination nor radiological findings may be reliable in \ndifferentiating atypical forms of spinal TB from other infections or from neoplasms. \nGenerally, longer treatment with expensive drugs, with or without percutaneous spinal \ninterventional procedures or surgical interventions, is required. \nLearning Objectives:\n1. To review different forms of spinal infection.\n2. To understand pathophysiology and imaging features of tuberculous \nspondylodiscitis.\n3. To know about imaging findings in leptomeningeal and intramedullary \ninfections.\n16:00 - 17:30 Room C \nSpecial Focus Session \nSF 10a \nNew insights in breast imaging \nModerator:\nE. Azavedo; Stockholm/SE \nA‑227 16:00 \nChairman’s introduction \nE. Azavedo; Stockholm/SE (edward.azavedo@ki.se) \nThis Special Focus session will bring to you updated information in the field of breast \nimaging. During the last few decades, breast imaging has been the single most important \ncontributor to decrease in breast cancer mortality. This, in turn, has been much due \nto our increased knowledge of image interpretation but also due to the tremendous \nimprovements in the technology of breast imaging. In this session, we will learn about \nmost of the new developments in the field of breast ultrasound, nuclear medicine, \n\nPostgraduate Educational Programme\nS62\n A B C D E F G\nphysics behind the new technology etc. Each of the presenters will provide a thorough \ninsight in their fields of expertise and time will be made available to discuss things that \nneed clarification. We look forward to welcome you all to get an updated information \nabout radiological information that could directly be implied in your clinical services. \nSession Objectives:\n1. To update knowledge of new technologies.\n2. To understand the physics and radiation dose of the new methods.\n3. To understand the possible role of new techniques in clinical practice.\nA‑228 16:05 \nTomosynthesis in breast imaging: Tomorrow’s mammography? \nK.C. Y oung; Guildford/UK (ken.young@nhs.net) \nThe introduction of high quality digital full-field detectors for mammography has \nfacilitated the development of digital breast tomosynthesis (DBT). Currently, a num-\nber of manufacturers have DBT systems either available for purchase or in clinical \nevaluation. However, there are significant variations in the approach adopted by each \nmanufacturer. This presentation will review the underlying physics of tomosynthesis \nas well as discussing the differences between the approaches favoured by different \nmanufacturers. A method of extending the current European dosimetry protocol \nfor mammography to include DBT systems will be described and the current dose \nlevels for DBT systems reviewed. While there is evidence that DBT may improve \nthe detection of breast lesions, and particularly masses, some unresolved ques-\ntions about how to use this new technology are discussed. These include whether \nDBT can replace 2D imaging or whether both are a needed. Does one still need \ntwo views with DBT? Is a narrow or wide tomo angle preferable? Are movement \nartefacts a significant problem? Is micro-calcification detection adequate in DBT? \nLearning Objectives:\n1. To understand the physics of the method.\n2. To appreciate its capabilities and limitations.\n3. To learn about the radiation dose levels.\n4. To become familiar with image interpretation.\nA‑229 16:28 \nAdvances in breast ultrasound \nT.J. Popiela; Krakow/PL (msjpopie@cyf‑kr.edu.pl) \nBreast ultrasound (US) is a diagnostic tool complementary to mammography that \nincreases the detection of malignant breast lesions. B-mode US is a method of choice \nfor differentiating solid from cystic lesions. To make the examination more objective, \nthe set of individual sonographic features used for US breast diagnosis together with \nUS-BIRADS lexicon were implemented. Recent results of computer-aided diagnosis \n(CAD) are encouraging even though they can be used only to static images. Real-time \ncompound imaging is the best technique for evaluation of the margin and internal \nechotexture of nodules, while tissue harmonic imaging has a significant role in the vi-\nsualization of a lesion against a fatty background. Both techniques are complementary \nto B-mode imaging. To reliably evaluate tumor vascularization, a Doppler technique \nwas implemented into breast US. Contrast agents with microbubbles used with this \ntechnique enhance signal from tumoral vessels in breast lesions. It helps to evalu-\nate benign and malignant breast masses and tumor response especially in patients \nreceiving neoadjuvant chemotherapy. Three-dimensional real time US allows more \nreliable evaluation of breast lesion than standard 2D mode. It accurately assesses \ncontours and interaction with surrounding tissue. It is helpful in guiding the biopsy \nneedle, especially in small-size lesion. Breast cancer tissue is harder than surrounding \nhealthy stroma, and this criterion is used in the analysis of US elasticity images that \nconsist mainly of an image of strain in response to force. Breast mass elastography \nis another method with potential for enhancing the specificity of US cancer detection. \nLearning Objectives:\n1. To be informed of the latest innovations including elastography, 3D and \ncontrast enhanced US.\n2. To understand how high resolution and “functional” US impacts on clinical \npractice.\n3. To learn techniques that may improve users skill.\nA‑230 16:51 \nBreast specific gamma imaging: A novel, physiologic approach to breast \ncancer diagnosis \nR.F . Brem; Washington, DC/US (rbrem@mfa.gwu.edu) \nBreast specific gamma imaging is a novel, physiologic approach to molecular \nimaging of the breast which uses Tc sestamibi and a dedicated high resolution \nbreast specific gamma camera for the diagnosis of breast cancer. This discussion \nwill discuss the scientific basis for breast specific gamma imaging and will review \nthe literature regarding the use of breast specific gamma imaging. Comparison of \nbreast specific gamma imaging to other physiologic approaches to breast imag-\ning including MRI will be discussed. Approaches to integration of breast specific \ngamma imaging in clinical practice as well as proper use in clinical practice will \nbe reviewed. Finally, ongoing research and developments using breast specific \ngamma imaging will be discussed including dedicated gamma guided minimally \ninvasive breast biopsy. \nLearning Objectives:\n1. To understand a new scintimammography method.\n2. To learn to appreciate diagnostic information.\n3. To learn about its position in relation to competing methods.\n4. To learn about its possibilities and limitations.\nPanel discussion:  \nHow should we integrate modern technology into our clinical diagnostic \nroutines \n17:14 \n16:00 - 17:30 Room D \nImaging in Lung Diseases \nCC 1018 \nBeyond morphological analysis of lung tumors \nModerator:\nC. Beigelman; Paris/FR \nA‑231 16:00 \nA. New therapeutic horizons: What do radiologists need to know? \nE.F . Patz, Jr.; Durham, NC/US (patz0002@mc.duke.edu) \nRadiology plays a fundamental role in every aspect of clinical oncology. Imaging \ntumors provides invaluable information in establishing a diagnosis and directing \npatient management. It is also used to suggest appropriate treatment, determine \nprognosis, assess disease status following therapy, and guide interventional \nprocedures. The conventional imaging appearance of lung cancer has been well \ndescribed, but does not correlate with the ultimate phenotype. Lung cancer cells \nresult from abnormal genes, which generate a complex host response. This creates \na primary mass consisting of a spectrum of cells including tumor cells, inflammatory \ncells, fibroblasts, macrophage, and hematopoietic progenitor cells. Therefore, if di-\nagnostic imaging is to reflect tumor biology it must learn to incorporate fundamental \nmolecular properties of the disease and move beyond traditional anatomic and \nmorphologic descriptions. The genesis of a molecular imaging initiative occurred \nin the early 1990s, with the use of positron emission tomography (PET) imaging \nand the glucose analog probe, 18 F 2-fluoro-2-deoxy-D-glucose (FDG). FDG-PET \nimaging has become one of the most important tools to evaluate cancer patients. \nAs a move toward molecular imaging continues, the development of new targets, \ntechniques, and tumor-specific imaging probes should provide more accurate di-\nagnostic information. In the future, imaging may be able to address many current, \nunresolved diagnostic issues in oncology. Imaging studies that elucidate basic \nmolecular events would increase our understanding of malignancies, and ultimately \ninfluence clinical practice and outcomes. \nLearning Objectives:\n1. To understand fundamental limitations in anatomical/morphological imaging \nof tumors.\n2. To describe biological features of lung tumors.\n3. To describe new approaches to imaging lung tumors.\nA‑232 16:30 \nB. Tumoral angiogenesis with CT \nN. Tacelli; Lille/FR (n‑tacelli@chru‑lille.fr) \nHighly vascularised tumours have been shown to be associated with a poor out-\ncome for many types of cancers, including lung carcinomas. In this latter group, \nthe prognosis remains poor with a 5-year survival rate of only 15%. The necessity \nfor new approaches in the assessment of this type of cancer has triggered major \ninterest in biologic parameters among which angiogenesis factors that are known \nto play an important role in the process of tumor growth and metastasis dissemina-\ntion. An in-vivo marker of angiogenesis, obtained through non-invasive imaging, \ncan provide an independent indicator of prognosis, enabling risk stratification for \npatients with cancer. Following the advent of fast scanning technology, there has \nbeen a resurgence of interest in tumour perfusion analysis with CT, initially focused \non the degree of contrast enhancement during dynamic contrast material-enhanced \n\nSaturday\nPostgraduate Educational Programme\nA\n S63\nCB D E F G\nexaminations over a limited volume-of-interest. However, tumour vasculature exhibits \nboth spatial and temporal heterogeneity that does not make perfusion assessment \nstraightforward. Recent technological advances of perfusion analysis now allow \nquantifying spatial changes in blood flow but also in capillary permeability throughout \nthe entire tumour height. The purpose of this lecture is to review the new trends in \nevaluating tumoral perfusion and to investigate the potential of functional MDCT \ntechnology to monitor the efficacy of newly introduced antiangiogenesis drugs. \nLearning Objectives:\n1. To describe the CT parameters that enable characterisation of tumoral \nangiogenesis.\n2. T o learn about the current results of tumoral angiogenesis assessment with MDCT .\n3. To describe the clinical impact of this novel evaluation of oncologic patients.\nA‑233 17:00 \nC. Nuclear imaging \nN. Howarth; Chêne‑Bougeries/CH (nigel.howarth@grangettes.ch) \nIntegrated PET/CT imaging has an established role in the management of cancer \npatients and is now recommended for all patients with curative non-small cell \nlung cancer. PET/CT provides information essential for staging and prognosis, \nfor choice of management and monitoring of treatment and for the detection of \nrecurrence. Recent technical developments in PET/CT permit rapid examinations \nwith improved resolution. Compared with standard CT or stand-alone PET, the \nadded value of fused imaging is uncontested. The clinical influence of preoperative \nPET/CT is currently undergoing extensive evaluation. Radiologists should benefit \nfrom an understanding of important aspects of molecular imaging to improve their \ncontribution to patient management. With the increasing use of PET/CT in the \nmanagement of cancer patients, imaging pitfalls must be recognized to avoid both \nfalse-positive and false-negative interpretation. The principles and good practices \nof PET/CT will be explained. Normal distribution of FDG, pitfalls and normal vari-\nants will be presented. Specific examples will be discussed to demonstrate how \nthe combined information of images of human anatomy upon which biological \ninformation within body structures is added improves delineation of disease, can \nguide surgical and radiation planning and biopsy. Advances in technology result in \nnew training requirements for radiologists who should promote close collaboration \nwith nuclear medicine specialists. \nLearning Objectives:\n1. To understand how the combination of functional and morphologic data \nprovides added value, helping patient management.\n2. To learn the common pitfalls in PET/CT interpretation of lung cancer.\n3. To emphasise the importance of a strong collaboration between nuclear \nmedicine specialists and radiologists.\n16:00 - 17:30 Room E1 \nMusculoskeletal \nRC 1010 \nHip through the ages \nModerator:\nM. Padrón; Madrid/ES \nA‑234 16:00 \nA. The pediatric hip \nD.J. Wilson; Oxford/UK (david.wilson@noc.anglox.nhs.uk) \nDepending on the age of the child, hip symptoms may predict a variety of diseases. \nIn the infant, developmental dysplasia and infection should be considered. After \nthe age of 4, irritable hip most commonly due to transient synovitis is the common-\nest disease but infection is the more worrying condition. Perthes disease affects \nsome and this condition overlaps into those over 8 who may have a slipped upper \nfemoral epiphysis. Fractures and rare cases of osteonecrosis and chondrolysis are \na concern in the adolescent. In the young and indeed in most cases, ultrasound \nprovides a useful first line test. Aspiration of effusion may be both diagnostic and \ntherapeutic. In the older child and, especially when SUFE is a risk, conventional \nradiographs with an external rotated “frog leg” view is very important. Despite \nthe logistics problems in children, there is an important role for MRI especially in \ncases where the initial imaging does not explain the symptoms. I will review the \nimaging pathways and provide examples of common diseases. I will also discuss \nhow to manage the difficult case and show recent audit data on detection rates \nand clinical management. \nLearning Objectives:\n1. To understand the age-specific diseases of the hip in children.\n2. To appreciate the strengths and weaknesses of each imaging method.\n3. To understand how imaging is used in the management of children’s hip \nproblems.\nA‑235 16:30 \nB. The hip in the young athlete \nC.W.A. Pfirrmann; Zurich/CH \nFemoroacetabular impingement (FAI) is a common condition in the young athlete. \nFAI refers to a conflict between the proximal femur and the acetabulum. Both an \nabnormal shape of the proximal femur (FAI of the „Cam-Type“: Aspheric femoral \nhead and/or a waist deficiency of the femoral neck) and the acetabulum (FAI of \nthe „Pincer-Type“: Acetabular retroversion or a deep acetabulum) or a combination \nof the two may be present. For a long period, the FAI may be asymptomatic and \nthe only clinical finding will be an impaired internal rotation of the hip joint. Later \ncartilage damage (outside-in abrasion of acetabular cartilage/delamination) and \nlabral tears occur. Labral tears are most common in the anterosuperior aspect of \nthe acetabulum. Anatomic variants like a sulcus may be present and should be \ndistinguished from tears. A sulcus is common at the junction of the labrum with the \ntransverse ligament and is generally located beyond the equator of the hip joint. \nInsufficiency fractures about the hip commonly occur in the region of the femoral \nneck. Another site vulnerable to overuse is the symphysis pubis. Often, a bone \nmarrow edema pattern around the symphysis pubis is observed. This reflects the \nstress reaction of bone. Injury to tendon attachments in the young athlete occurs \nfrequently about the adductor tendons. A characteristic finding is the „secondary \ncleft sign“, which reflects a partial tear of the adductor tendon aponeurosis. Injury \nto other tendon attachments such as the abductor tendons may occur, but tend \nto be less common. \nLearning Objectives:\n1. To understand the mechanisms of injury of the hip.\n2. To recognise the imaging pattern of abnormalities of the hip.\n3. To become familiar with femoroacetabular impingement.\n4. To learn about the typical injuries to tendon attachments around the hip.\nA‑236 17:00 \nC. The ageing hip \nA.H. Karantanas; Iraklion/GR (akarantanas@gmail.com) \nUnderstanding age-related changes is essential for interpretation of imaging stud-\nies. Age is a risk factor strongly correlated with osteoarthritis (OA), which is the \nmost common hip joint disease seen in adults. The diagnosis of OA is based on \na combination of radiographic findings and characteristic subjective symptoms. \nThe lack of a radiographic consensus definition has resulted in a variation of the \npublished incidences and prevalence of OA. The progression of OA traditionally \nhas been measured using radiographic joint space width (JSW). Weight-bearing \nradiographs centered on the hip are the most reproducible and reliable ones. The \nsequence of degeneration includes the following radiographic findings: joint space \nnarrowing, osteophyte formation, subchondral sclerosis, and cyst formation. Cur-\nrent definitions of radiological OA based on reduced JSW and osteophytes display \npredictive validity for clinical hip OA. Radiographs are also useful for assessing \ndevelopmental dysplasia and other congenital disorders which may lead to early \nOA. There are cases though that radiographs show minor changes and the clini-\ncal suspicion of early disease can be confirmed with more sophisticated imaging \nmethods, such as CT and MRI. CT is helpful for additional measurements such as \nfemoral and acetabular abnormal version which might lead to OA. Femoroacetabular \nimpingement has been shown to cause labral and chondral lesions and leads to \nOA. Prompt recognition of abnormal head-neck junction on radiographs enables \nproper conservative or surgical treatment planning. MR arthrography is the method \nof choice for assessing the labra whereas CT arthrography might be used as an \nalternative for articular cartilage assessment. \nLearning Objectives:\n1. To become familiar with the radiographic assessment of the ageing hip.\n2. To discuss the MRI findings of degenerative hip disease.\n3. To review the various disorders which predispose for early osteoarthritis.\n4. To recognise the advantages and disadvantages of CT and MR arthrography \nof the ageing hip.\n\nPostgraduate Educational Programme\nS64\n A B C D E F G\n16:00 - 17:30 Room E2 \nExtremity Joint MRI \nMC 1025 \nLower extremity: Anatomy, variants and pitfalls \nModerator:\nM. Shahabpour; Brussels/BE \nA‑237 16:00 \nA. Hip \nE. Llopis; Valencia/ES (ellopis@hospital‑ribera.com) \nHip joint is designed for stability, supports the body weight and shifts mechanical loads \nduring ambulation and activity to the lower extremities. Surrounded structures of the \nhip can be divided into static and dynamic and help to stability. The hip capsule, labrum \nand ligament, and primary iliofemoral ligament act as static stabilizers. The dynamic \nstabilizers are the surrounding muscles and their tendinous attachments, with the most \nsignificant group being the abductors. Hip musculature can be divided by anatomic \nlocation, quadrants (anterior, lateral, and posterior) or by functional groups (flexors, \nabductors, external rotators, and adductors). The hip has a ball and socket configu-\nration, where the sphere of the femoral head moves free in the round cavity of the \nacetabulum. When there is abnormal contact between the femur and the acetabulum, \npremature degenerative changes might develop. There are some anatomic normal \nstructures that should not be confused with injuries, the acetabular notch, transverse \nligament, ligament teres normal variants of the labrum absence or partial deficiency \nof the labrum, normal perilabral recess between the attachment of the capsule and \nthe labrum and sublabral sulcus. Also, communication between the joint and ileopsoas \nbursa or less frequently to the obturador bursa is present in a small percentage of the \nnormal population. However, there are other anatomical variants that have increased \nincidence on symptomatic patients or early degenerative disease, such as cystic \nchanges in the femoral neck, os acetabuli or inverted labrum; these findings should \nbe carefully correlated with other injuries and with patient’s symptoms. \nLearning Objectives:\n1. To describe normal hip anatomy, bone, labral, and musculotendinous \nstructures.\n2. To understand pelvis alignment and basic hip biomechanics.\n3. To provide helpful clues to distinguish pitfalls from pathological conditions.\n4. To review normal anatomy variants and their relationships with symptoms \nand syndromes: Causes or consequences?\nA‑238 16:30 \nB. Knee \nB. Vande Berg; Brussels/BE (bruno.vandeberg@uclouvain.be) \nKnee MR imaging represents an everyday challenge to many radiologists: What is the \nimportance of MR imaging in patient management? How can we avoid false positive \ndiagnoses? How can we optimise lesion characterization? This lecture will focus on \nnormal anatomy of the meniscus and on variants that may simulate surgical lesions. \nThe importance of displaced meniscal fragment will be demonstrated and several le-\nsions that may mimic fragments will be displayed. Common ligament variant will also be \ndescribed. We will also provide in-depth analysis of incidental bone and marrow changes \nfrequently observed on knee MR images (red marrow hyperplasia, bone islands, en-\nchondroma); although they have less diagnostic importance, over-diagnosis may cause \nunnecessary anxiety to the patients. Finally, we will demonstrate the venous anatomy \nof the knee with implications on knee imaging. We will not describe muscle variants. \nLearning Objectives:\n1. To provide an overview of the anatomy of the meniscus and ligaments with \nemphasis on variants that may simulate lesions.\n2. To provide in-depth analysis of incidental bone and marrow changes \nfrequently observed in knee MR images.\n3. To demonstrate the venous anatomy of the knee with implications for knee \nimaging.\nA‑239 17:00 \nC. Foot and ankle \nN. Saupe; Zurich/CH (nadja.saupe@balgrist.ch) \nThe purpose of this talk is to highlight anatomical variants of foot and ankle in the \nasymptomatic population as well as borderlands of normal and early pathological \nfindings and also to discuss technical pitfalls in magnetic resonance imaging of foot \nand ankle. Special attention should be drawn to the complex ligament anatomy of \nthe medial collateral ligaments (superficial tibionavicular ligament, tibiospring liga-\nment, tibicalcaneal ligament and the deep anterior and posterior tibiotalar ligaments) \nand the tendon insertion of anterior and posterior tibial tendons. Technical pitfalls \nsuch as the influence of foot positioning on prevalence of the magic angle artifact \n(MAE) in ankle tendons and inhomogeneous fat suppression will be discussed. Ad-\nditionally, various features of anatomic variants that are potentially associated with \nperoneal tendon disorders such as peroneus quartus muscle, low lying peroneus \nbrevis muscle belly, size of peroneal tubercle and size of retrotrochlear eminentia \nas well as the shape of the fibular groove will be explained. The prevalence, pattern \nand size of bone marrow changes on short-tau inversion recovery (STIR) magnetic \nresonance images in asymptomatic feet and ankles such as cysts just inferior to the \nangle of Gissane and tiny bone marrow spots (vascular remnants) will be highlighted \nas well as plantar fat pad (PFP) signal intensity alterations under the metatarsal \nheads and their histological correspondence to fibrosis and adventitious bursae. \nThis knowledge should prevent inaccurate interpretations and prevent unnecessary \ndiagnostic work-up and treatment. \nLearning Objectives:\n1. To become familiar with the anatomy of foot and ankle.\n2. To know the prevalence of anatomic variants that can be associated with \npathologic conditions in the foot and ankle.\n3. To understand the influence of foot positioning on prevalence and site of the \nmagic angle effect in ankle tendons.\n16:00 - 17:30 Room F1 \nGenitourinary \nRC 1007 \nKidney: Imaging and intervention \nModerator:\nR. Stern Padovan; Zagreb/HR \nA‑240 16:00 \nA. Angiomyolipoma: A review \nN. Grenier; Bordeaux/FR (nicolas.grenier@chu‑bordeaux.fr) \nAngiomyolipomas (AML) are benign tumors derived from the perivascular epithelioid \ncell (PEC) characterized at pathological examination by expression of melanocytic \nmarker HBM-45. They contain various proportions of the three components: vascular, \nfatty and muscular. An epithelioïd variant with a malignant potential is exceptional. \n80% are sporadic and 20% integrated to tuberous sclerosis. The association with a \nlymphangioleiomyomatosis is always possible: chest CT will be performed in TS and \nsporadic AML if large or associated with respiratory troubles. Characterization of AML is \npossible, based on identification of its fatty content mainly using CT . When microscopic, \nthis component may be missed and biopsy is required with immunostaining. MR imag-\ning may be helpful using chemical-shift sequences but thresholds, to rule-out clear cell \ncarcinoma, have to be better defined. Presence of necrosis or calcifications rules-out \ndiagnosis of AML. AMLs must be treated if hemorrhagic, painful or if diameter exceeds \n4 cm. Embolization is the main nonsurgical method, using microparticles, alcool and/or \ncoils but postembolization syndrome must be prevented. Volume regression may require \nall agents whereas aneurysm occlusion requires coiling. The effect on volume and on \nhemorrhagic risk is substantial making surgery as an alternative method for nephron \nsparing purposes. Secondary surgery is required in less than 10% of embolization. \nRF ablation is also possible but its efficacy is still under evaluation. \nLearning Objectives:\n1. To learn the high frequency of angiomyolipoma, and the possibility of \ncomplication.\n2. To review the imaging appearance of typical and atypical angiomyolipoma.\n3. To understand the higher incidence of angiomyolipoma in certain \nphakomatoses.\n4. To learn about the possibilities of intervention and to discuss the indications \nand results.\nA‑241 16:30 \nB. The (not so) rare malignant tumors of the kidney \nP . Hallscheidt; Heidelberg/DE (Peter.Hallscheidt@med.uni‑heidelberg.de) \nCaused by the hugh amount of ultrasound studies, by CT and MR scans many renal \ntumors are detected without symptoms. The radiologist has the duty to differentiate \nrenal lesion and to diagnose malign tumours in adults and children. Modern imaging \nmodalities like CT and MRI have the capability to differentiate renal tumours because \nof different attributes. Besides the benign tumors, the malign tumors like renal cell \n\nSaturday\nPostgraduate Educational Programme\nA\n S65\nCB D E F G\ncarcinoma, complex cysts, metastasis of other malignomas and lymphomas of the \nkidneys have to be differentiated. Whereas CT has very high spatial resolution and \nthe capability to detect calcifications, MRI with its high soft tissue contrast showed \nto be superior in detection of complex cysts and delineation of tumor thrombus. \nThe most common and not so common renal tumours are demonstrated and typi-\ncal findings are discussed. \nLearning Objectives:\n1. To review the malignant tumors of the kidney beyond renal cell carcinoma: \nBellini duct carcinoma, chromophobe renal cell carcinoma, lymphoma, \nsarcoma, renal medullary carcinoma and metastases.\n2. To learn how imaging can provide some clues for the diagnosis.\nA‑242 17:00 \nC. Radiofrequency and cryotherapy of renal tumors: Techniques, results \nand complications \nJ.-M. Correas, M.-O. Timsit, A. Méjean, O. Hélénon; Paris/FR\n(jean‑michel.correas@nck.aphp.fr) \nConservative treatment is increasingly used for the treatment of small renal tumours \nin order to limit the renal function deterioration. The surgical procedure remains \nstandard but minimally invasive therapy has been developed particularly for pa-\ntients with multiple comorbidity factors (including age), hereditary renal cancer, \nchronic renal failure, and solitary functioning kidney. Multiple techniques can be \napplied including radiofrequency ablation, cryotherapy, microwave ablation and \nhigh-intensity focused ultrasound. Renal tumour ablation is facing some specific \nissues compared to the liver tumour ablation due to the high blood flow of both \nrenal lesion and normal parenchyma, the limited amount of normal parenchyma for \nboth preservation of the renal function and for the stabilization of the electrodes, \nand the sensitivity to heat of the collecting tubes in the renal sinus. The tumor size \n(over 4 cm) and the central position of the renal tumor seem to be the major limiting \nfactors. The principles, indications and results of each technique will be discussed. \nLearning Objectives:\n1. To learn the technique and results of radiofrequency ablation of renal tumors.\n2. To learn principles, indications and results of cryotherapy, microwave ablation \nand high-intensity focused US (HIFU).\n16:00 - 17:30 Room F2 \nSpecial Focus Session \nSF 10b \nBreast cancer: How to evaluate response to \ntreatment\nModerator:\nT.H. Helbich; Vienna/AT \nA‑243 16:00 \nChairman’s introduction \nT.H. Helbich; Vienna/AT (Thomas.Helbich@meduniwien.ac.at) \nNeoadjuvant treatment has become a standard of care in locally advanced as well \nas in operable breast cancer. Response rates are high. There is, however, a lack \nof information on which modality is the best to evaluate response to treatment. \nSeveral modalities are offered such as imaging, blood probes, biological markers \nor a combination of all. The goal of this session is to discuss the value of imag-\ning techniques like mammography, ultrasound, MRI, PET and other non imaging \nmodalities, which evaluate response to treatment in breast cancer. Participants \nwill learn to apply these different modalities; in addition, they will get an overview \nabout limitations as well as success rate with respect to the response rates during \nneoadjuvant treatment. We look forward to welcome you all to get updated informa-\ntion, which could directly be implied in your clinical services. \nSession Objectives:\n1. To give a basic understanding of how breast cancer responds to treatment.\n2. To explain how to evaluate response to treatment from an oncologic/surgical \nperspective.\n3. To show how response to treatment is assessed with imaging techniques.\nA‑244 16:03 \nFrom genes to surgical outcome \nM. Gnant; Vienna/AT (michael.gnant@meduniwien.ac.at) \nSurgical strategy in breast cancer treatment greatly depends on tumor size, patient’s \nanatomy, and breast tumor biology. Neoadjuvant treatment has become in standard \nof care in locally advanced cancer, but also in operable breast cancer where breast \nconservation may not be achievable without oncological or cosmetic compromises. \nPre-treatment confirmation of malignancy is mandatory. Response rates are high, \nand overall response rates are usually reported between 60 and 90%. Complete \npathological remission is optimal, and occurs between 3 and 60% of cases, greatly \ndepending on tumor biology. Multimodality approaches require intense interaction \nbetween surgeons and diagnostic specialists. Both planning as well as definitive \nsurgical strategy depend heavily on accurate response monitoring and assessment \nas well as localisation procedures. Breast conservation rates of 90% and more can \nbe achieved in experienced interdisciplinary teams. \nLearning Objectives:\n1. To stress the multidisciplinary approach to therapy.\n2. To report the response rate to neoadjuvant therapy.\n3. To demonstrate whether surgical strategy is affected by radiological \nmonitoring of neoadjuvant treatment.\nA‑245 16:21 \nMammography and ultrasound \nS. Delorme; Heidelberg/DE (s.delorme@dkfz‑heidelberg.de) \nUltrasound and mammography are frequently used tools to follow-up breast cancer \nduring neo-adjuvant chemotherapy. Although non-invasive and cost-effective, the \nresults obtained with either method must be viewed with caution for several reasons: \n• Since necrotic cell death, rather than apoptosis, is the predominant mechanism \nof tumour response, an early shrinkage of a lesion is unlikely, even in responders. \nFurthermore, persistent stroma may be difficult to discriminate from vital tumour. \nThis is of particular concern with mammography, since the stromal reaction, which \nis often marked, contributes greatly to the imaging features of breast cancer.  \n• Ultrasound is examiner-dependent and so are all measurements. Even with a \nsingle examiner, the probe position may be impossible to be exactly reproduced. \n• With most probes being approximately 5 cm long, large or multicentric tumours \nmay be difficult to measure in toto. • After a tumour has partially responded to \nchemotherapy, its overall size may be underestimated if isolated, small residual \nislets or intraductal components at its extremes are missed. Its size may be over-\nestimated due to inflammatory changes or persistent stromal components. • In \nstudies comparing ultrasound, X-ray mammography, and contrast-enhanced MRI \nwith the results of the histopathological workup, the sizes measured on MRI scans \nwere best correlated with the diameter of the pathologic specimen. In summary, \nultrasound or mammography may be used to identify early those patients whose \ndisease progresses despite treatment, but for planning of breast-conserving surgery, \nan additional contrast-enhanced MRI should be considered. \nLearning Objectives:\n1. To recognise treatment-induced changes.\n2. To recognise the limitations of each method in assessing treatment \nresponse.\n3. To understand the predictive value of US and mammography for the \nresponse to treatment.\nA‑246 16:39 \nMRI and more \nF . Sardanelli; Milan/IT (f.sardanelli@grupposandonato.it) \nA PubMed/Medline search found 59 original articles published from 06/1996 to \n06/2009 reporting MRI in the neoadjuvant chemotherapy (NAC) setting in 2,355 \npatients. Of 40 studies (1,513 patients) on prediction of pathological response, \n36 (1,385 patients) concluded in favor of MRI with a good-to-excellent correlation \nbetween size of residual disease (RD) at MRI and pathology (r=0.65-0.98). However, \nMRI underestimation/overestimation of RD and false negatives were highlighted. \nPatients with mass lesions presenting concentric shrinkage are good candidates to \nconserving surgery while multifocal/multicentric cancers or unique masses present-\ning dendritic shrinkage or fragmentation should undergo mastectomy. For non-mass \nlesions, the probability of underestimating RD is higher than for mass-lesions. NAC \ntype should be considered: RD was frequently underestimated in patients treated \nwith taxanes and in HER-2 negative patients treated with bevacizumab. MRI early \nprediction of treatment efficacy was reported by studies resting on MRI volumetric \nchanges and/or kinetic analysis. Importantly, initial experience was retrospectively \ndescribed that when NAC is switched if the reduction in the largest diameter is \n\nPostgraduate Educational Programme\nS66\n A B C D E F G\n< 25% at MRI, > 70% of nonresponders show a favorable clinical response, increas-\ning the rate of conserving surgery. MRI is cost-effective if an early shift from an \nineffective to a more effective NAC has a measurable benefit in the cure rate. MRI \nwas also shown to predict disease-free and/or overall survival. Initial but promising \nresults were shown using proton MR spectroscopy or diffusion weighted imaging. \nThe ultimate benefit on survival in patients monitored with breast MRI in the NAC \nsetting is not yet established. \nLearning Objectives:\n1. To demonstrate the potential of CE-MRI for evaluating response to treatment.\n2. To understand the predictive value of CE-MRI for the response to treatment.\n3. To introduce non-contrast MR techniques for evaluating response to \ntreatment: DWI and spectroscopy.\nA‑247 16:57 \nPET, PET/CT and more \nB. Sharma; Sutton/UK (bhuey.sharma@rmh.nhs.uk) \nAnatomical techniques including CT and MRI, together with bone scan are gener-\nally used for breast cancer metastatic disease evaluation and treatment response \nassessment. Functional imaging, particularly PET/CT, is a powerful modality in \nbreast cancer, indeed being useful for early response evaluation, prognostication, \nresponse assessment at ‘difficult to image sites’ and bone response. This talk will \ndetail the strengths and weaknesses of 18 FDG PET/CT compared with all other \nconventional and new (including MRI Diffusion) imaging techniques with regard to \nassessing all different body systems/organs. Bone response is an especially dif-\nficult and exciting area for functional imaging techniques; SUV analysis will also be \ndiscussed as will the relative sensitivities of PET compared to other techniques - this \nbeing an important aspect for clinicians to understand. Hormone, chemotherapy, \nradiotherapy, the new entities of both ‘pre and post liver Radiofrequency Ablation’ \nand ‘intracranial Gamma Knife’ response evaluation will all be discussed, with \npractical guidance regarding appropriate imaging in patients in order to enable \noptimal patient management. PET/CT providing patient prognostication regarding \ntreatment regimens will be detailed. The use of novel targeted radiotracers, such \nas ER PET imaging, will also be addressed. \nLearning Objectives:\n1. To understand the role of PET/CT relative to other modalities in staging \nprimary and metastatic breast cancer.\n2. To show the role of PET/CT in response evaluation (hormone and other \ntreatments).\n3. To focus on the strengths and weaknesses of PET/CT or other techniques \n(such as MRI/PET or optical imaging).\nPanel discussion:  \nCan we still trust oncologists‘ fingers? \n17:15 \n16:00 - 17:30 Room G/H \nNeuro \nRC 1011 \nFocal brain lesions \nModerator:\nJ. Walecki; Warsaw/PL \nA‑248 16:00 \nA. Differential diagnosis of T2 hyperintense lesions \nA. Rovira-Cañellas; Barcelona/ES (alex.rovira@idi‑cat.org) \nFocal white matter T2 hyperintense lesions (THL) are commonly observed MRI \nabnormalities not only in the elderly, but also in middle age and young patients. In \naddition to physiological ageing brain changes, a large list of different disorders \nshould be considered in patients presenting with THLs such as hypoxic-ischemic \nvasculopathies (atherosclerotic and hypertensive small vessel disease, CADASIL, \nFabry’s disease, Susac’s syndrome), multiple sclerosis and variants, primary and \nsystemic vasculitis, sarcoidosis, adult forms of leukoencephalopathies (meta -\nchromatic leukodystrophy, globoid cell leukodystrophy, adrenomyeloneuropathy, \nmitochondrial disorders, vanishing white matter, and cerebrotendinous xanthoma-\ntosis), trauma and radiochemotherapy, and acquired metabolic conditions (hepatic \nencephalopathy, alcoholism), among others. While it is recognized that a combi-\nnation of findings from clinical history, physical examination, and laboratory tests \nis commonly required to correctly establish a firm and clear etiological diagnosis \nof THLs, a detailed analysis of different MRI features should also be considered \nessential: e.g. lesions shape, size, and distribution; contrast-uptake; associated \nstructural lesions (microbleeds, infarcts, spinal cord, brainstem and cerebellar \ninvolvement, large-vessel disease). In addition to these conventional MRI-based \nfeatures, non-conventional MR techniques (diffusion, MR spectroscopy, perfusion) \nmay also provide in some cases useful diagnostic information. Knowledge of these \nfeatures will assist the diagnostic work-up of patients presenting with THLs, and \nshould be considered a first step to take full advantage of the potential of MRI, and \nin doing so should result in a reduced chance of misdiagnoses and facilitate the \ncorrect diagnosis of sometimes treatable disorders. \nLearning Objectives:\n1. To be aware of the limited specificity of brain multifocal T2 abnormalities.\n2. To learn about recognition patterns that might be helpful in suggesting the \nmost likely etiology of brain multifocal T2 lesions.\n3. To learn about the role of spinal cord imaging and advanced neuroimaging \ntechniques in the differential diagnosis of brain T2 hyperintense lesions.\n4. To be able to establish a neuroimaging diagnostic strategy in patients with \nmultiple brain T2 lesions of unknown origin.\nA‑249 16:30 \nB. Neoplasm or not? Decision making in focal mass lesions of the brain \nZ. Rumboldt; Charleston, SC/US (rumbolz@musc.edu) \nA variety of diseases including neoplasms, but also infectious, inflammatory, \nvascular and traumatic processes, may present as focal intracranial mass lesions. \nModern neuroimaging, primarily with MRI, enables differentiation of these entities \nallowing for accurate diagnosis in almost all cases. The requirements are appropriate \nimage acquisition and detailed analysis of imaging findings, while pertinent clini-\ncal information may be very helpful in certain cases. The distinction is frequently \nbroad, between different disease processes, such as with tumefactive demyelin-\nation versus neoplasm, which is often sufficient for clinical decision making and \npatient management; at times this may be more specific, approaching histological \ndiagnosis, such as with pilocytic astrocytoma versus medulloblastoma. This presen-\ntation will go briefly over the imaging techniques and various disease processes, \nwhile heavily concentrating on the differentiating imaging features and decision \nmaking process. Helpful clinical information will also be mentioned and emergent \nconditions stressed. The emphasis will be on the key distinguishing features, such \nas presence or absence of vasogenic edema, intra or extra axial location, signal \nintensity characteristics, presence and pattern of contrast enhancement, as well \nas diffusion and perfusion features. A number of cases with intracranial masses \nwill then be reviewed and analyzed, using a step by step approach, accentuating \nthe most reliable distinguishing findings. \nLearning Objectives:\n1. To list various pathologic processes that present as focal brain masses.\n2. To define the differentiating imaging and clinical features of those processes.\n3. To recapitulate the role of imaging techniques for differentiation of brain \nmass lesions.\nA‑250 17:00 \nC. Adult glioma: Advanced neuroimaging for treatment planning \nC. Calli; Izmir/TR (cemcalli@superonline.com) \nThe role of MR imaging in gliomas consists of many steps. 1. Is there a lesion in \nthe brain? 2. Is the lesion a tumor? 3. Is the tumor a glioma? 4. Is it a high- or low-\ngrade glioma? 5. If there is a suspicion and a biopsy is planned, which part of the \ntumor should be targeted at biopsy? 6. How should the surgery be performed to \navoid injury to functional areas of the brain (e.g., motor cortex)? 7. If there is need \nfor adjunctive radiotherapy, how should the extent of the tumor be defined to be \ntargeted for radiation? 8. After radiotherapy, if a new enhancing lesion occurs, is it \na recurrent glioma or radiation necrosis? Conventional anatomical MR imaging is \nnot always powerful enough to answer these questions. However, with advanced \nMR imaging techniques like diffusion MR (including tractography), perfusion MR, \nMR spectroscopy and functional MRI (fMRI), we can answer the above questions \nreliably in most cases. \nLearning Objectives:\n1. To emphasise different treatment protocols for different types of adult \ngliomas.\n2. To give brief information about the advanced neuroimaging techniques, \nwhich may aid further pre-operative characterisation of adult gliomas.\n3. To discuss the roles of various advanced neuroimaging techniques for glioma \ntreatment planning.\n\nSaturday\nPostgraduate Educational Programme\nA\n S67\nCB D E F G\n16:00 - 17:30 Room I \nPhysics in Radiology \nRC 1013 \nHigh field MRI: Beyond 3 T \nModerators: \nE. Atalar; Ankara/TR \nH. Köstler; Würzburg/DE \nA‑251 16:00 \nA. Challenges of high field MR \nM. Bock; Heidelberg/DE (m.bock@dkfz.de) \nOver the recent years the clinical MRI field strengths have gradually been increased \nto 3 T esla; however, whole body MRI systems with higher fields of up to 9.4 T esla have \nbecome available in experimental settings. Compared to clinical field strengths, MRI at \nvery high magnetic fields has several advantages but also some unique challenges. \nWith increasing field strength, the signal-to-noise ratio increases, which can be used \nto either increase the spatial resolution in the images, or to acquire the images more \nrapidly. Unfortunately, the energy deposited in the human body via the RF excitation \nscales quadratically with the field strength. Thus, the specific absorption rate (SAR) \nis a critical factor in all rapid imaging protocols and requires the design of RF pulses \nwith low SAR, (e.g. VERSE pulses). Inhomogeneities of the RF field which are induced \nby standing wave phenomena have to be compensated, and make the design of \nefficient spin echo pulse sequences very difficult. At higher field also, the field inho-\nmogeneities become larger and stronger imaging gradients are required to overcome \nthe susceptibility-induced image distortion. Stronger gradient systems are difficult to \nmanufacture, and the usable gradient slew rate is limited by peripheral nerve stimulation \nthresholds. Furthermore, stronger and faster gradients become very loud at high fields, \nand special measures for sound protection are required. Despite these limitations, high \nfield MRI offers image with very high resolution, it provides unique contrasts, a better \nspectral separation of the resonance lines and high signal for non-proton applications. \nLearning Objectives:\n1. To explain how the increased field strength affects exposure and image \nquality characteristics.\n2. To describe MR imaging protocols developed for ultra-high field MRI.\n3. To become familiar with technology for specific absorption rate reduction.\nA‑252 16:30 \nB. A complicated solution to a complicated problem: Transmit array \nK.P . Pruessmann; Zurich/CH (pruessmann@biomed.ee.ethz.ch)\nClinical MRI usually aims to depict anatomic regions of interest with uniform \ncoverage and contrast behavior. To this end it is essential to use suitably homo-\ngeneous radiofrequency (RF) magnetic fields for spin excitation, refocusing, and \nsaturation. Traditionally, such uniform transmit fields are generated by volume \nresonators based on quasi-stationary electrodynamics, which, however, gradually \ncease to apply as clinical MRI explores high field strengths of 3T and beyond. The \nconcomitant increase in operating frequency entails shorter RF wavelength and \nincreasing tissue interactions, which render the tayloring of RF fields substantially \nmore complex and patient-dependent. One promising response to this challenge \nis to depart from volume resonators and perform RF transmission by multiple, \nindividually fed transmitter elements. With such transmit arrays the effective RF \nfield can be taylored on a per-patient and per-scan basis by adjusting the relative \nmagnitude and phase of driving the elements (RF shimming). In advanced imple-\nmentations the phase and magnitude relations are even varied during RF pulses. \nIn combination with equally dynamic gradient waveforms such fully individual \ncontrol permits particularly fast spatially taylored RF pulses (Transmit SENSE). \nArray transmission entails a generalization of RF pulse design, for which a range \nof efficient mathematical mehods have been developed. One important challenge \nthat remains, however, is the need to calibrate array transmitters in terms of the \nindividual channels’ RF field contributions, both magnetic and electric. The latter, \nin particular, underlie power deposition in the tissue and hence need to be closely \ncontrolled to enforce strict SAR limits. \nLearning Objectives:\n1. T o learn about the need to control radio-frequency fields, particularly at high B0.\n2. To understand the principles of doing so by multiple-channel transmission.\n3. To get acquainted with the methods of obtaining uniform and tailored \nexcitation within SAR limits.\nA‑253 17:00 \nC. Is 7T ready for clinical use? \nR.W. Bowtell; Nottingham/UK (richard.bowtell@nottingham.ac.uk) \nThe availability of magnetic resonance (MR) scanners operating at 7T and above \nhas already proved beneficial for MR imaging and spectroscopy of the human \nbrain and promises similar benefits in the human body. These advantages result \nfrom the increases with the magnetic field of the intrinsic signal-to-noise ratio, \nblood oxygenation level dependent (BOLD) contrast, which forms the basis of \nthe vast majority of functional MR imaging (MRI) experiments, and chemical shift \ndispersion. These gains can be exploited in improving the spatial and/or temporal \nresolution of anatomical and functional MRI experiments and in increasing the \nspectral resolution in volume selective spectroscopy or chemical shift imaging. \nOperation at the increased magnetic field also offers easier access to T\n2\n*-contrast \nand improved implementation of susceptibility-weighted imaging (SWI) in which \nthe phase of gradient echo images provides information about local variation of \nmagnetic susceptibility. In the brain, such variation appears to be dominated by \ndifferences in iron concentration and myelin content, so that high-field SWI may \nprovide useful information about the progression of neurodegenerative disease. \nThe elevated T1- relaxation times at 7 T also offer benefits for arterial spin labelling \nand time of flight angiography. Current and potential future applications of high-field \nMRI in clinical and pre-clinical studies in a number of areas will be discussed in this \npresentation, along with the barriers to wider usage of 7 T systems in clinical studies. \nLearning Objectives:\n1. To categorise the advantages that 7T provides for magnetic resonance \nimaging and spectroscopy.\n2. To identify the areas of clinical application where 7T already offers significant \nbenefits over lower fields.\n3. To highlight the barriers to clinical usage of 7T.\n4. To recognise the technical developments that will help to overcome these \nbarriers and allow wider clinical usage of 7T.\n16:00 - 17:30 Room L/M \nRadiographers \nRC 1014 \nAdministrative issues \nModerators: \nK. Åhlström Riklund; Umeå/SE \nS. Braico; Rome/IT \nA‑254 16:00 \nA. Lean project at OUH \nL. Tarp; Odense/DK (lene.tarp@ouh.regionsyddanmark.dk) \nPurpose: We will illuminate how lean can be used in a Department of Radiology \nand how we can optimize patient journey and decrease non-value-added waste with \nexisting resources. The main goal is to create a high quality system by eliminate waste \nand increase patient safety and worker satisfaction in order to make a lean culture. \nThe first goal is to comply with the department’s targets for waiting time for the patient \njourney within our whole working process. The second goal is to optimize the daily \nproduction to reduce the wasting time and waiting time for every patient journey. A \nthird goal is to get the staff involved and make better working environment for them.\nMethods and Materials: We have meetings in every team on a weekly basis to \ndiscuss measurement and development in the team. We made analysis of patient \njourney in every team and we made analysis of working - to reduce/eliminate waste \nand increase efficiency.\nResults:\n 1. Optimization of patient journey; Waiting time can now be met on the examination. \n2. Optimization of production, better workflow gives organized and more efficient rooms. \n3. Working environment for staff, time for training and development of staff was found.\nConclusion: Creating a lean culture will increase production, improve the patient \njourney and make better working environment for staff. It will change the organiza-\ntion by allowing the basis staff to get involved in organizing their part of the work \nwithin the team and also to put the focus on the patient’s expectation for service. \nLearning Objectives:\n1. To learn about lean thinking and how lean tools can be used in a radiology \ndepartment.\n2. To understand how different lean tools can improve the patient journey.\n3. To learn about improving the working environment for staff.\n4. To understand how a lean culture can increase job satisfaction.\n5. To understand the challenges of how to get people involved.\n\nPostgraduate Educational Programme\nS68\n A B C D E F G\nA‑255 16:45 \nB. Lean project at the NHS Lothian Edinburgh \nL. Hudson; Edinburgh/UK (lorraine.hudson@luht.scot.nhs.uk) \nNHS Lothian required improvement in its capacity and capability by significant \nservice redesign. A Lean programme was implemented in 2006.The initial project \nwas to reduce CT waiting times for cancer patients. The CT service consisted of 6 \nscanners spread across 4 sites in Lothian. Each department worked as a stand-\nalone service with little collaboration. Administration processes and waiting times \nvaried in each department. The longest wait for an appointment was 21 weeks. \nA large, multidisciplinary staff group worked together during a ‘Kaizen’ (Japanese \nfor change for the better) week. A two month period of intense preparatory work \ngathering information and data from key staff was necessary prior to the event. Good \ncommunication with staff was essential through introductory meetings to alleviate \nfears and suspicion of change. Work practices were analysed through process \nmapping with an aim to reduce waste and increase value for patients and staff. \nReferral pathways were streamlined, reducing delays and inappropriate referrals. \nInformation was improved increasing the effectiveness of patient understanding of \nexamination procedure and preparation. Waiting lists were pooled across Lothian \nwith agreed protocols and scheduling. At the end of the Kaizen week, the booking \nturnaround time was reduced from 31 days to 24 hrs and the maximum waiting \ntime reduced from 21 to 6 weeks, the average being 2-3 weeks. The commitment \nof time and support from senior management empowered staff to take ownership \nof the service they provided. Staff identified areas for improvement and found their \nown solutions, achieving dramatic and sustained benefits for patients. \nLearning Objectives:\n1. To learn how we identified diverse practices across the 4 CT sites within \nLothian.\n2. To gain knowledge on how we improved waiting times, communication and \nidentified and removed waste in our systems by using 5 Sigma, Kaizen, and \nWork Out.\n3. To understand the obstacles to the implementation of change due to diverse \npersonalities and processes across our radiology departments.\n4. To appreciate the importance of communication and support of our Health \nBoard and Executive management team and the requirement to involve the \nwhole multidisciplinary team.\n16:00 - 17:30 Room N/O \nHead and Neck \nRC 1008 \nSuprahyoid neck \nModerator:\nC. Czerny; Vienna/AT \nA‑256 16:00 \nA. Neck spaces: What you need to know \nS. Bisdas; Tübingen/DE (sotirios.bisdas@med.uni‑tuebingen.de) \nThe rational analysis of the masses and pathologies arising in the suprahyoidal \nneck necessitates an exact localization. There is a certain overlap, sometimes \nresulting in confusion, between the anatomical and surgical borders and defini-\ntions of the neck spaces. It is necessary for the clinical radiologist to elucidate the \ncomplex anatomical relationships from a radiological point of view and to present \nthe critical contents of each space. Thus, a space-orientated differential diagnosis \nmay be facilitated. According to the localization and the typical CT and MR imaging \nappearance of various lesions, the differential diagnosis may be narrowed down \nto specific pathologies. Common pathologies in the vicinity of the critical contents \nas well as pathologies extending beyond one anatomical space are also of major \ninterest for the radiologist and crucial for the patient‘s treatment. Therefore, CT and \nMR surveys should be meticulously read for such imaging findings. \nLearning Objectives:\n1. To identify the CT and MR imaging landmarks of the suprahyoid neck \nspaces.\n2. To identify the common diseases and their typical appearance in each \nsuprahyoid neck space.\n3. To use the neck spaces as a basis for differential diagnosis in the suprahyoid \nneck.\nA‑257 16:30 \nB. How to ruin or improve your head and neck study \nV. Chong; Singapore/SG (dnrcfhv@nus.edu.sg) \nThe anatomy of the suprahyoid neck is complex and the spectrum of diseases \nis wide. To improve studies of the neck, radiologists should become increasingly \nmore familiar with the anatomy and expected pathology in the various spaces. \nThis familiarity provides crucial information required for the selection of treatment \noptions and therapeutic planning. In addition, radiologists should be aware of \nsituations when diagnostic inaccuracies may lead to serious consequences and \ncomplications. For example, surgical approach to a deep lobe parotid tumour as \nthough it is a parapharyngeal lesion will in all likelihood result in facial nerve injury. \nMRI artifacts such as complex flow-induced increase in signals may be mistaken \nas a lesion prompting an unnecessary operation. An awareness of such pitfalls \nhelps to improve the quality of imaging studies. This presentation highlights some \npertinent anatomical knowledge that may help improve the diagnostic accuracy of \nneck studies and at the same time explain the existence of pitfalls that may ruin \nimaging studies. \nLearning Objectives:\n1. To learn the anatomic basis of imaging abnormalities.\n2. To understand the pathologic basis of image interpretation.\n3. To learn the potential pitfalls of radiologic diagnosis.\nA‑258 17:00 \nC. Tips and tricks in the parapharyngeal space \nA. Trojanowska; Lublin/PL (agnieszka30@yahoo.com) \nParapharyngeal space (PPS) belongs to the deep spaces of the neck and it has a \nshape of inverted pyramid. The base of the pyramid is attached to the skull base and \nthe apex reaches the level of hyoid bone. Primary neoplasms arising in this space \nare very rare, and parapharyngeal space becomes the most frequently invaded or \ndisplaced by processes growing in adjacent spaces. Based on the direction and \npattern of PPS and its vessels’ displacement, a detailed differential diagnosis can \nbe made. Both MRI and CT are frequently used for imaging of PPS pathological \nconditions, and the introduction of functional imaging has given also some benefits. \nPrimary and secondary, benign and malignant processes of PPS will be discussed \nin detail. These will include: cysts, salivary gland tumors, schwannomas, paragan-\ngliomas, squamous cell carcinomas, enlarged lymph nodes, lymphomas, vascular \nmalformations, and inflammatory diseases. Since correct diagnosis requires close \ncollaboration with ENT surgeons; clinical findings will be also discussed, together \nwith principal information which should be included into report. \nLearning Objectives:\n1. To become familiar with the anatomy and pathology of the parapharyngeal \nspace.\n2. To review the proper imaging technique to examine parapharyngeal space \nlesions.\n3. To learn how to differentiate between benign and malignant lesions.\n4. To provide a template of the ‘perfect’ report.\n16:00 - 17:30 Room P \nChest \nRC 1004 \nChest in the emergency room \nModerator:\nA.P . Parkar; Bergen/NO \nA‑259 16:00 \nA. Can chest radiography tell you the whole truth? \nK. Malagari; Athens/GR (kmalag@otenet.gr) \nChest radiography is the most frequently performed imaging examination performed \nin the emergency room. It allows a first assessment of the bony cage and lungs. \nMediastinal emergencies are not feasible to appreciate; however, a normal chest \nX-ray has a high negative prognostic accuracy. Entities that may be missed will be \ndiscussed in this session. Positive intrathoracic findings include pleural effusion, \ndiffuse or focused alveolar opacities, and signs of extraalveolar air. Fractures and \ndislocations are also feasible to recognise on the chest radiogram - but further \nevaluation is only possible with CT imaging. The signs of pleural effusion and ex-\ntraalveolar air in the supine and erect position are going to be discussed in detail. \nThe various causes of local «alveolar» opacities in the emergency setting most \n\nSaturday\nPostgraduate Educational Programme\nA\n S69\nCB D E F G\nfrequently include aspiration, infection, atelectasis, contusion, and laceration. The \ndifferential diagnosis of these findings is going to be discussed thoroughly. At the \nend of the session, the audience will be able to take full advantage of the findings \nof chest X-ray and appreciate what is the best imaging algorithm to further proceed \nwith the diagnosis. \nLearning Objectives:\n1. To describe potential pitfalls of plain film in the emergency department.\n2. To present the negative and positive predictive value of chest films in the \nemergency setting.\n3. To become familiar with imaging features of the spectrum of emergency \nconditions.\nA‑260 16:30 \nB. Triple rule-out CT in atypical chest pain: Must or luxury? \nG. Savino; Rome/IT (gsavino@sirm.org) \nA variety of pathologies such as pneumonia, pneumothorax, pericarditis or more \nlife-threatening conditions such as acute coronary syndrome, acute aortic syndrome \nor pulmonary emobolism may present with the same clinical condition: chest pain. \nIt has been estimated that each year in the United States, approximately 5 million \npatients present to emergency department (ED) with acute chest pain and over \nmore than 1.5 million are admitted after the standard diagnostic work-up. For most \nof these patients, no cardiac pathology is detected. Hospitalization is mandatory \nfor patients with typical signs of myocardial ischemia, whereas those without risk \nfactors for coronary heart disease, without typical cardiac chest pain and with a \nnormal electrocardiogram, are usually discharged. Diagnostic uncertainty arises, \nhowever, for a substantial number of subjects who are usually subjected to further \ninvestigations, with the result of longer hospitalization and higher costs. The advent \nof 64-slice MDCT scanners has made it possible to perform a non-invasive high-\nresolution study of the thorax, allowing evaluation of the coronary arteries, aorta \nand pulmonary arteries. The aim of this lecture is to discuss the utility of MDCT \nangiography of the thorax as triage tool in patients with acute chest pain and to \nexamine the impact of this modality on patient and hospital management as well \nas in the clinical-decision making. The technical principles and the diagnostic \nalgorithms for using a single ECG-gated 64-slice CT scan in ED for triple-rule-out \nof acute pulmonary embolism, aortic dissection, acute coronary syndromes and \nother diseases of the chest are discussed. \nLearning Objectives:\n1. To learn how to perform a triple-rule-out scan by MDCT.\n2. To understand how to select patients with typical chest pain.\n3. To present clinical cases and to review the evidence data.\nA‑261 17:00 \nC. Imaging of chest trauma \nA. Oikonomou; Alexandroupolis/GR (aoikonom@med.duth.gr) \nThoracic injury overall is the third most common cause of trauma following injury to \nthe head and extremities. More specifically, penetrating thoracic injury is the cause \nof 4-15% of admission to major trauma centres. Blunt and penetrating thoracic \ntrauma has a high morbidity and mortality accounting for approximately 25% of \ntrauma-related deaths, second only to head trauma. More than 70% of cases of \nblunt thoracic trauma are due to motor vehicle collisions with the remaining caused \nby falls or blows from blunt objects. Penetrating thoracic injury is mainly caused by \nknives and handgun bullets. Mechanisms of injury are discussed and spectrum of \nabnormalities and radiologic findings encountered in blunt and penetrating thoracic \ntrauma are categorized in injuries of pleural space (pneumothorax, hemothorax), \nlungs (pulmonary contusion, laceration, herniation), airways (tracheobronchial \nlacerations, Macklin effect), esophagus, heart, aorta and great vessels (injury to \nthoracic aorta, internal mammary artery and aortic arch branches), diaphragm and \nchest wall (rib, scapular, sternal fractures and sternoclavicular dislocations). The \npossible coexistence of multiple types of injury in a single patient is stressed and \ntherefore systematic exclusion after thorough investigation of all types of injury is \nwarranted. The superiority of CT over chest radiograph in diagnosing chest trauma \nis well documented. Moreover, with the advent of MDCT the time of scanning the \ntrauma patient has significantly reduced to several seconds allowing more time \nfor post-diagnosis appropriate care. Finally, high-quality multiplanar and volumetric \nreformatted CT images greatly improve detection of injury and enhance the under-\nstanding of mechanisms of trauma-related abnormalities. \nLearning Objectives:\n1. To discuss epidemiology, mortality - morbidity, significance, pathophysiologic \nfeatures and mechanisms of injury in blunt chest trauma.\n2. To discuss the typical radiologic findings as well as pitfalls associated with \nthe wide spectrum of types of injury in the thorax, including injury of the \nlung parenchyma, trachea and airways, aorta (and aortic vessels), heart \nand pericardium, esophagus, pleura, diaphragm and thoracic wall. Possible \ncoexistence of multiple types of injury is stressed.\n3. To review the advantages and diagnostic impact of CT/MDCT for selected \ninjuries over other modalities and discuss recommended imaging protocols \nand algorithms.\n16:00 - 17:30 Room Q \nProfessional Challenges Session \nPC 10 \nPET/CT in oncologic imaging \nModerators:\nE. Breatnach; Dublin/IE\nA. Chiti; Milan/IT \nA‑262 16:00 \nChairmen’s introduction \nE. Breatnach1, A. Chiti2; 1Dublin/IE, 2Milan/IT \nThis combined session from European Society of Radiology (ESR) and European \nAssociation of Nuclear Medicine (EANM) representatives is intended to illustrate \nthe complementary role of techniques from both specialties in patient investigation, \nfocussing on specific topics in oncologic PET/CT. The session will highight areas of \nknowledge which are necessary for good quality reporting of PET/CT, and where \nthe benefits of knowledge of principles in the complementary specialty are illus-\ntrated. For the radiologist, updates on newer tracer elements and their application \nwill be presented, and for the Nuclear Medicine physician and radiologist the CT \ncorrelates of benign processes which may mimic abnormality in oncologic patients \non PET/CT will be illustrated. \nSession Objectives:\n1. To familiarise radiologists and nuclear medicine physicians with the causes \nand imaging features of common false positive and false negative PET/CT \nfindings.\n2. To describe new possibilities to increase specificity and sensitivity of PET/CT.\n3. To give a practical update on the development of newer tracers in PET/CT.\nA‑263 16:05 \nNew probes to increase specificity and sensitivity of PET/CT in oncology \nW. Weber; Freiburg/DE \nPET is currently almost exclusively performed with the glucose analog fluorodeoxy-\nglucose (FDG). While FDG allows a surprisingly sensitive and specific diagnosis \nof many human cancers, there is a clear need for a further characterization of \nmalignant tumors and for even more sensitive and specific detection of metastases. \nRadiolabeled ligands binding to specific receptors on the surface of cancer cells \noffer the opportunity to improve the diagnostic accuracy of PET for these applica-\ntions. PET with such radioligands can also identify patients who will benefit from \nradionuclide therapy targeting these receptors. The use of receptor PET is most \nadvanced in the area of for neuroendocrine tumors (NETs) which frequently express \nsomatostatin receptors (SSTRS). This receptor class can be targeted by a variety \nof radiolabeled octreotide derivatives such as tetraazacyclododecane-tetraacetic \nacid tyrosine octreotid (DOTATOC). PET with these radioligands allows highly \naccurate diagnosis of NETs, but is also used to select patients for treatment with \nYttrium-90 DOTATOC. Ligands for the integrin alpha-v beta-3 can be used to as-\nsess the expression and function of this integrin. These ligands (RGD peptides) are \nbeing tested in clinical studies for planning and monitoring of therapies targeting \nangiogenesis or tumor cell invasiveness. Another target being investigated is the \nGRP (gastrin releasing peptide) receptor, which is expressed on the majority of \nbreast and prostate cancer cells. In conclusion, PET with receptor ligands provides \na unique opportunity to improve the sensitivity and specificity of PET/CT. \nLearning Objectives:\n1. To learn about receptors that are being studied as targets for PET imaging \nprobes.\n2. To understand the strengths and limitations of receptor PET imaging.\n3. To appreciate the potential clinical applications of receptor PET.\n4. To become familiar with the current status of research on PET ligands for \nsomatostatin receptors, gastrin releasing peptide receptors and integrins.\n\nPostgraduate Educational Programme\nS70 A B C D E F G\nA‑264 16:23 \nThe added value of contrast-enhanced PET/CT \nT.F . Hany; Zurich/CH \nAnatomical information is an additional benefit in co-registered PET/CT imag -\ning and improves localization of pathological FDG uptake. Different CT systems \n(single or multi-slice spiral CT scanner) are used in hybrid PET/CT system. Since \nthe application of contrast media is a standard procedure in CT, application of \ncontrast has been also mandated in co-registered imaging. The beneficial use of \nintravenous contrast is dependent on tumor type, e.g. for certain indications like \nmelanoma or lymphoma, intravenous contrast is not needed. For other malignan-\ncies, especially abdominal malignancies, single - up to triple phase intravenous \ncontrast enhanced CT protocols including arterial, portal venous and late phase \nimaging are implemented depending on the tumor type. Especially in the evalua-\ntion of the liver in primary liver tumors like hepatocellular carcinoma or metastases \nfrom neuroendocrine carcinoma of the gastrointestinal tract (GIT) as well as in the \nevaluation of pancreatic cancer, arterial phase imaging is a standard procedure. \nAlso in the ENT -tract, intravenous enhanced CT helps to delineate the primary \ntumor and especially necrotic, cystic lymph node metastases. Positive as well as \nnegative oral contrast agents are used for delineation of the gastro-intestinal tract \n(GIT) from adjacent structures. Recently, liquid low density oral contrast agents as \na mixture of locust bean gum and mannitol for CT have been demonstrated to be \nfavorable in the use for PET/CT. Technical issues, indications and implications in \nthe use of positive as well as negative oral contrast agents and intravenous contrast \nenhancement in PET/CT imaging are discussed. \nLearning Objectives:\n1. To understand the technical application of contrast agents in PET/CT.\n2. To know the indications and limitations for intravenous contrast enhanced \nPET/CT.\n3. To learn new combined functional applications from CT imaging like CT -\nperfusion imaging integrated into a PET/CT protocol.\nA‑265 16:41 \nCauses and imaging features of false positives/false negatives on PET/CT \nin oncologic imaging \nC. Smith; Dublin/IE\nF18-FDG is a glucose analogue that is taken up and retained by a wide range of \nmalignancies. F18-FDG PET/CT is now firmly established as an accurate method \nfor the staging and restaging of various cancers. It is however well recognised that \nmany false positive and false negative results can occur when interpreting oncology \nPET/CT scans. F18-FDG accumulates in normal tissue and other non-malignant \nconditions and some malignancies do not take up F18-FDG or have a low affinity \nfor the tracer. PET/CT allows for the correlation of two separate imaging modalities, \ncombining both morphological and metabolic information. The CT component is \nroutinely used for attenuation purposes and to accurately locate the FDG uptake. \nWe should however also use the CT to help interpret the PET findings. In this talk \nwe will highlight specific false negative and false positive findings that would one \nshould be aware of when interpreting staging scans for individual cancers. One \nsuch example is osteoblastic breast metastases, which can be PET negative. We \naim to highlight specific conditions such as radiation changes, drug toxicities, thymic \nhyperplasia, flare response that are encountered routinely on restaging scans that \ncan lead to false positive interpretations. We will emphasise the importance of using \nthe CT component to help recognise these entities to allow improved diagnostic \naccuracy. In light of the increased use of PET/CT, it is important that nuclear \nmedicine physicians and radiologists be aware of these conditions and correlate \nthe PET and CT components to avoid misdiagnosis, over staging of disease and \nunnecessary biopsies. \nLearning Objectives:\n1. T o describe and discuss the common false positives and false negatives \nencountered by interpreting physicians on routine oncologic F18-FDG PET/CT .\n2. To identify the pitfalls of F18-FDG PET/CT in imaging specific cancers.\n3. To emphasise the importance of interpreting the PET images in conjunction \nwith the CT images to give an accurate diagnosis.\nA‑266 16:59 \nNew tracers in oncologic PET/CT \nH. Schoder; New Y ork, NY/US \nNew PET tracers in oncology can be characterized by their chemical structure, their \nmechanism of uptake and retention, and the “hallmark of cancer” they visualize. \nThis presentation discusses some agents currently used in clinical trials. Choline \n(\n11C or 18F) uptake reflects choline kinase activity (enzyme up-regulated in cancer) \nand membrane synthesis. Accumulating data show promise for the imaging of brain \ntumors and recurrent prostate cancer (PSA relapse). \n18F FLT is a marker of cellular \nproliferation. Its cellular uptake is proportional to thymidine kinase 1 activity. Since \nFLT uptake in most primary malignancies is low (lower than FDG uptake), it is not a \nsuitable tracer for tumor staging. Instead, FLT may provide prognostic information, \nserve for treatment monitoring, and possibly differentiate radiation necrosis from \nrecurrence in treated gliomas. Many current clinical trials incorporate FLT PET as an \nexploratory response measure. Antigens and receptors, expressed on the surface \nof tumor cells, can be targets for PET. Imaging of estrogen and Her2 receptors \nin breast cancer (\n18F FES; 68Ga/ 64Cu herceptin) may be useful in predicting and \nmonitoring the response to hormonal therapy or trastuzumab. In prostate cancer, \nimaging of the androgen receptor (AR) with 18F FDHT provides insights into tumor \nbiology. In contrast to widespread believe, AR is expressed and important for tumor \ngrowth and survival in all clinical states, including castrate-resistant metastatic \ndisease. AR imaging appears useful in predicting and monitoring the response to \nnovel anti prostate cancer drugs. \nLearning Objectives:\n1. To briefly discuss new PET tracers already in clinical use and other tracers \nwith likely clinical utility in the next 3-5 years for selected disease settings.\n2. To discuss how new PET tracers can aid in moving the field of oncologic \nimaging from merely visualising the extent of disease to an improved \nunderstanding of tumor biology.\n3. To provide examples of how new PET tracers can impact the clinical \nmanagement of cancer patients.\nPanel discussion \n17:17 \n\nPostgraduate Educational Programme\nA S71CB D E F G\nPostgraduate Educational Programme\nA S71CB D E F G\nSunday, March 7\n\nPostgraduate Educational Programme\nS72 A B C D E F G\n08:30 - 10:00 Room A \nRadiology in Abdominal Emergencies \nCC 1117 \nThe hole in the guts \nModerator:\nS.K. Puri; New Delhi/IN \nA‑267 08:30 \nA. Wasting time with plain radiography? \nM. Laniado; Dresden/DE \nIn recent years, continuing trends in radiology have diminished the importance of \nplain films of the abdomen significantly. Ultrasonography and MDCT are applied with \nenormous success to the investigation of many abdominal conditions in the emer-\ngency setting. In the eyes of the radiologist, plain films, therefore, seem irrelevant in \nthe presence of such powerful imaging procedures. Surprisingly, referring physicians, \nmostly surgeons, gastroenterologists and urologists, still request plain films although \nthe potential of MDCT is obvious to them as well. In their perception, the plain film is \neither a definitive examination before initiation of treatment (e.g. stone at the uretero-\npelvic junction in US proven hydronephrosis) or a preliminary study prior to MDCT \nor surgery (exclusion of pneumoperitoneum or ileus). In the present climate of cost \nand radiation consciousness this trend may continue. Moreover, many surgeons, \ngastroenterologists, urologists, etc. have greater skills in reading plain films than in \nunderstanding MDCT. Therefore, the radiologist should be as much familiar as the \nreferring physician with plain film appearances of many types of abdominal pathol-\nogy and established roentgen signs. The purpose of the presentation is to review \nremaining indications for abdominal plain films and to revisit common imaging findings. \nLearning Objectives:\n1. To review the most common causes of hollow organ perforation.\n2. To know the optimal technique for plain film of the abdomen in the \nemergency setting, signs of perforation.\n3. To discuss if there are still indications for plain film of the abdomen in the era \nof US and CT.\nA‑268 09:00 \nB. Defining the role of US \nJ.B.C.M. Puylaert; The Hague/NL (dr.jbcmpuylaert@wxs.nl) \nWhen a defect occurs in the bowel wall, air will appear within the peritoneal cavity, most \nfrequently due to perforated peptic ulcer and perforated sigmoid diverticulitis. In most \nperforating gastrointestinal conditions, however, the -imminent- perforation is walled-off \nby neighboring bowel loops, mesentery and especially by the omentum, nick-named \n“policeman of the belly”. If this walling-off process occurs timely and effectively, no or \nonly minimal free air will appear. The most important causes of walled-off gastrointestinal \nperforation are appendicitis, peptic ulcer disease, sigmoid diverticulitis, bowel malignancy , \nCrohn’s disease and - often underdiagnosed - accidently ingested sharp foreign bodies, as \ntoothpicks, fish bones, chicken bones, etc. The extent to which the perforation is walled-off, \ndetermines the eventual course of the disease. The US hallmark of - imminent - perforation \nis inflamed fat around the involved bowel structure. Inflamed fat on US corresponds to \nwhat is often called “dirty fat” on CT scan: hypodense fat is interspersed with hyperdense \nstreaks. This represents edema or cellular infiltration of the fatty mesentery and omentum, \nwhich have migrated towards the site of the imminent perforation in an attempt to seal it \noff. On US, inflamed fat is recognized as hyperechoic, non-compressible fatty tissue often \ninterspersed with hypoechoic streaks. If fluid collections occur within the inflamed fat, this \nimplies abscess formation. Inflamed fat is an important and valuable sign in perforating \ngastrointestinal conditions. If found in the absence of bowel pathology, the diagnosis is \nusually epiploic appendagitis or omental infarction. \nLearning Objectives:\n1. To understand the strength of US as the primary imaging modality.\n2. To know typical signs of bowel perforation.\n3. To be aware of the limitations and pitfalls of US.\nA‑269 09:30 \nC. In search of the hole: CT \nA. Laghi; Latina/IT (andrea.laghi@uniroma1.it) \nMDCT is an extremely powerful tool when the search for a GI perforation is required. \nIn fact, the high spatial and contrast resolutions, much higher than conventional X-\nray, make MDCT the most accurate imaging method to identify even small amount \nof free intraperitoneal air. There is general consensus about the acquisition of a \ncontrast-enhanced scan acquired during the portal venous phase of enhancement \n(delay of around 60-70 sec). Controversies are still present in the literature about \nthe utility of a pre-contrast scan as well as the need for a preliminary administra-\ntion of an oral soluble iodinated cm or for an enema or gaseous distention of the \ndistal GI tract. Image reviewing needs the use of a workstation since multiplanar \nreformations have been demonstrated to improve the detection of small amount \nof free air. An appropriate window setting (in particular the use of wide windows, \ni.e. lung window) is mandatory and it makes MDCT 100% accurate for identifica-\ntion of free air and almost 90% accurate in the identification of the precise site of \nperforation. In fact, the aim of the examination is not only to assess the presence \nof free air, but also to detect the site of perforation: this is extremely useful clinical \ninformation especially if surgeons decide to perform a laparoscopic repair. Several \nCT signs have been described, able to guide the diagnosis and to differentiate \nbetween a perforation originating in the upper GI tract (stomach and duodenum), \nin the small bowel or in the colon. \nLearning Objectives:\n1. To learn the appropriate imaging protocols in patients with suspected bowel \nperforation.\n2. To learn useful signs for the detection and localisation of perforation.\n3. To discuss imaging strategies in case of clinical suspicion of bowel \nperforation.\n08:30 - 10:00 Room B \nRadiology of the Spine in 2010 \nCC 1116 \nAdvanced imaging techniques in the spine \nModerator:\nM. Leonardi; Bologna/IT \nA‑270 08:30 \nA. Benign vs malignant fracture in the spine \nA. Baur-Melnyk; Munich/DE (Andrea.Baur@med.uni‑muenchen.de) \nVertebral collapse is common in the elderly population. The underlying condition \nis osteoporosis or metastases. Signal characteristics are the same for benign \nas well as for neoplastic disease, e.g. hypointense on T1 and hyperintense on \nSTIR. Both show contrast uptake. Therefore, the knowledge of morphological \nsigns are important to know to better discriminate these entities. New imaging \ntechniques, such as diffusion and perfusion of the spine, can help in differential \ndiagnosis. Diffusion-weighted imaging has been especially used for the differentia-\ntion of benign and neoplastic vertebral collapse. Different sequences have been \nexplored. Qualitative analysis can be done reliably with steady state free preces-\nsion sequences (SSFP-Siemens, Erlangen). Hypointense or isointense signal is \nassociated with benign edema, whereas tumor shows hyperintensity in contrast \nto normal surrounding marrow. Several studies applied quantitative DWI to normal \nand pathological vertebral bone marrow. Pathological bone marrow exhibits much \nhigher diffusivities, ranging from about 0.7 to 1.0×10\n-3 mm2/s in metastases as well \nas malignant fractures. In acute osteoporotic and traumatic fractures ADCs of 1.0 \nto 2.0×10\n-3 mm2/s were found. Although a certain overlap of ADC ranges can be \nseen, ADC measurements can be useful for the differentiation of benign vertebral \nfractures and metastatic lesions. Perfusion of vertebral fractures might also be a \npotential for the discrimination of acute benign and neoplastic fractures. In first \nstudies, FDG PET/CT can help for the differentiation of benign and malignant \nconditions of spinal fractures. Increased FDG uptake (> 3-4 SUV) usually is seen \nin malignant fractures. \nLearning Objectives:\n1. To understand the pathophysiological principles of vertebral body fractures.\n2. To describe the use of diffusion-weighted MR imaging in differentiation of \nbenign and malignant fractures.\n3. To set up an optimal clinical MR protocol for evaluation of vertebral body \nfractures.\nA‑271 09:00 \nB. Imaging in low back pain \nA. Stäbler; Munich/DE (info@radiologie‑muenchen‑harlaching.de) \nDegenerative diseases of the spine include degeneration of the intervertebral discs \nand endplates as well as degenerations of the intervertebral joints. Degeneration \nof the intervertebral disc can result in anular tears and in disc herniation with com-\npromise or compression of nerve roots. Disc herniation (disc prolapse) is defined \n\nSunday\nPostgraduate Educational Programme\nA S73CB D E F G\nas dislocation of nucleus pulposus material through a defect of the anulus fibrous \n(anular tear) bejond the outer part of the anulus fibrosus (non-contained disc) or \nas a dislocation of nucleus pulposus material inside the disc in areas of the anulus \nfibrosus with dislocation of the outer part of the anulus fibrous (contained disc). \nThe location and morphology of the anular tear pedicts the direction of migration/\nsequestration of a disc hernia. Dehydration and disintegration of the disc tissue \nleads to increased segmental mobility. Instability with symptomatic osteochondrosis \nnamed activated erosive intervertebral osteochondrosis can develop, character-\nized by bone marrow edema, disc vascularity and hyaline cartilage proliferations in \nerosions on MRI. Activated intervertebral or facet joint osteoarthrosis may become \nsymptomatic due to synovitis and fibrovascular tissue. Facet joint osteoarthrosis \ncan also be responsible for central spinal canal stenosis, stenosis of the recess \nor narrowing of the neuroforamen. Signs of symptomatic spinal stenosis on MRI \nare root redundancy and root edema with swelling. There exist mechanisms to \nrecognize dynamic worsening of spinal canal stenosis by weight bearing on MRI \nin prone position. \nLearning Objectives:\n1. To understand the aetiology and pathomechanisms of low back pain.\n2. To identify key imaging findings in low back pain.\n3. To describe the imaging protocol and strategy in patients with failed back \nsurgery syndrome.\nA‑272 09:30 \nC. 3 T spinal imaging \nM. Law; Los Angeles, CA/US (meng.law@usc.edu) \nImage quality in spine MR imaging is dependent on five major factors: 1. Spatial \nResolution, 2. Signal to Noise (SNR), 3. Contrast to Noise (CNR), 4. Temporal \nResolution, and 5. Artifacts.\nArtifacts: a) Susceptibility artifact and geometric distortion, b) Chemical shift \nartifact-from the existence of multiple resonance frequencies, c) CSF partial volume \neffects, d) Truncation artifact - insufficient phase-encoding sampling, e) B0- inho-\nmogeneity of surrounding neck/airway structures, f) Physiologic motion- vascular/\nCSF pulsation, respiratory, swallowing motion, g) Non physiologic motion - gross \nneck motion, h) Dielectric artifact, and i) Increased specific absorption rate (SAR). \nMost of these artifacts are in part dependent on magnetic field strength. There is \nsubstantial susceptibility and signal loss in the spine from signal dephasing at the \ntissue-bone and tissue-air interfaces. Similarly, increasing the TE to increase T2-\nweighting for the cord, will result in increased CSF signal dephasing from pulsatile \nmotion. These susceptibility effects can be decreased by using thinner sections as \nwell as using multiple receiver coils with parallel imaging techniques. By the same \ntoken, combining phase array coil technology with higher field strengths can have \na beneficial effect on other artifacts such as the dielectric effect and reducing the \nSAR. Modifying the shape of the RF pulse using a VariablE Rate Selective Excita-\ntion (VERSE) pulse will also reduce SAR and improve image quality. Chemical \nshift effects are inversely proportional to received bandwidth. Hence, increasing \nthe receiver bandwidth will decrease chemical shift; however, this comes at a cost \nof reducing SNR. \nLearning Objectives:\n1. To learn about the factors affecting image quality for spine imaging at 3 T.\n2. To become familiar with sequence and parameter choices for spine imaging \nat 3 T.\n3. To understand artifacts and solutions in spine imaging at high field.\n08:30 - 10:00 Room C \nNeuro \nRC 1111 \nStroke \nModerator:\nR. Siemund; Lund/SE \nA‑273 08:30  \nA. CT or MRI in the acute ischemic stroke? \nG. Krumina; Riga/LV (gaida.krumina@apollo.lv) \nEarly signs of hyperacute stroke on native CT are hypoattenuation of gray mat-\nter structures, hyperdense arteries, and mass effect. Insular ribbon sign reflects \ncytotoxic edema and relates to specificity of arterial anatomy. Two types of insular \nstroke with different functional outcomes have been distinguished: the minor and the \nmajor insular stroke. ASPECTS is a standardised quantitative CT grading system \nin acute anterior circulation ischemic stroke. Baseline ASPECTS value predicts \nresponse to intraarterial and intravenous thrombolysis functional outcome and \nincidence of secondary hemorrage within 3 and 6 hours of stroke onset. Hyperdense \nartery sign represents stasis\n of flow due to arterial thrombus. Proximal hyperdense \nMCA sign is associated with poor short and long-term prognosis; intravenous \nthrombolysis is ineffective. Distal hyperdense MCA sign does not implicate poor \noutcome; patients are applicable to thrombolytic therapy. Hyperdense PCA sign \nis associated with thalamic infarction, large PCA territory ischemia, more severe \nneurology and higher risk of hemorrhagic transformation. Hyperattenuating artery \nsign correlates positively with angiographic finding of occlusion. CTA is essential \nfor evaluating of intra- and extracranial dissections, and intravascular thrombi. \nMRI protocol in acute stroke includes DWI, T1 SE,\n T2 FSE, FLAIR, T2* GE, PWI, \nMRA. DWI is most sensitive tool for detection of hyperacute stroke at first 6 hours. \nIn patients with TIA, DWI has discriminative value in predicting risk of new TIA or \nfuture stroke. To correctly estimate the infarct age, it is important to examine DWI \nin comparison with ADC maps. \nLearning Objectives:\n1. To learn how to recognise the early CT signs of hyperacute stroke.\n2. To compare the sensitivity and specificity of CT and MRI for the diagnosis of \nacute stroke.\n3. To discuss the practical aspects of the use of CT and MRI in the \nmanagement of acute stroke patients.\nA‑274 09:00 \nB. DWI, CT/MR PWI, and/or CTA/MRA: What is necessary? \nA. Dörfler; Erlangen/DE (arnd.doerfler@uk‑erlangen.de) \nThe goals of stroke imaging are to establish a diagnosis as early as possible to \nobtain accurate information about intracranial vasculature\n and brain perfusion to \nselect the appropriate therapy. Comprehensive evaluation may be performed with a \ncombination of CT or MRI. Unenhanced CT helps to rule out hemorrhage and may \nidentify early signs of ischemic stroke, respectively. In addition, CT angiography and \nCT perfusion imaging may depict major vessel occlusion and perfusion disturbances \nindicating tissue at risk. Diffusion-weighted MR imaging is more sensitive in the \ndetection\n of hyperacute ischemia. MR angiography reveals the status of extra- and \nintracranial vessels, and a mismatch between findings on diffusion and perfusion \nMR images may be pragmatically  used to predict the presence of a penumbra. \nRegarding our own experience, “multimodal MR imaging” provides substantially \ngreater information about brain ischemic pathophysiology and overall a more sensi-\ntive diagnosis for acute stroke, especially in patients with an uncertain time window \nof symptom onset and vertebrobasilar ischemia.\n Thus, combining various imaging \ntechniques may help to differentiate  patients who may profit from intravenous or \ninterventional therapy in an even extended time window  from those who do not.  \nThus, we think that MRI should replace CT as the primary neuroimaging technique, \nat least in patients suspicious for vertebrobasilar ischemia or presenting in an \nextended time window. In our institution, we use a multimodal CT protocol when \nacute stroke patients present within 4.5 hours (ECASS III time window); patients \npresenting beyond this time window are examined with a multimodal MRI protocol. \nLearning Objectives:\n1. To delineate the objectives of stroke imaging in the context of available \nstroke therapies.\n2. To introduce the basic concepts of DWI, PWI, and MRA.\n3. To discuss the strategies of multimodal CT and MR stroke imaging.\n4. To discuss the differential diagnosis of stroke.\nA‑275 09:30 \nC. Nontraumatic intracranial hemorrhage \nL. van den Hauwe1, M.H.J. Voormolen2, C. Venstermans2, F . De Belder2, \nJ.W.M. Van Goethem2, P .M. Parizel2; 1Brasschaat/BE, 2Antwerp/BE \n(lucvdhauwe@mac.com) \nNon-traumatic intracranial hemorrhage is a common cause of an acute neurologi-\ncal deficit and represents up to 20% of patients presenting with stroke. Stroke is \na medical emergency and CT should be performed as soon as possible to rule \nout intracranial hemorrhage and to exclude other intracranial pathology such as \nbrain tumors. Once intracranial bleeding is ruled out, thrombolytic therapy may be \nconsidered. CT also allows to look for potential complications such as increased \nintracranial pressure and brain herniation. Intraparenchymal hemorrhage at the level \nof the basal ganglia is typically seen in older patients with hypertension, but may also \nbe observed in younger patients with sinus thrombosis. Extra-axial hemorrhages \nmay be found in the subarachnoid space as well as in the epidural and subdural \ncompartments. Subdural hematomas are frequently observed in elderly people \nwith brain atrophy and typically occur in patients taking anticoagulant medication \n\nPostgraduate Educational Programme\nS74 A B C D E F G\nsuffering a minor trauma. When CT demonstrates the presence of subarachnoid \nhemorrhage, CT angiography should be performed to rule out a cerebral aneurysm \nor vascular malformation, before going into catheter angiography. MRI, including T2* \nand Susceptibility Weighted Imaging (SWI), may be used to look for more subtle \ncauses of bleeding such as cerebral amyloid angiopathy. \nLearning Objectives:\n1. To review the different types of nontraumatic intracranial hemorrhage in \npatients presenting with stroke.\n2. To discuss imaging strategies in the diagnostic work-up of hemorrhagic \nstroke.\n3. To illustrate the optimal imaging techniques for the detection of nontraumatic \nintracranial hemorrhage.\n08:30 - 10:00 Room D \nAbdominal and Gastrointestinal \nRC 1101 \nRectal cancer \nModerator:\nH. Trillaud; Bordeaux/FR \nA‑276 08:30 \nA. Staging with US and CT \nA. Maier; Vienna/AT (andrea.maier@meduniwien.ac.at) \nFor rectal cancer surgery, a variety of alternative operations are currently possible, \nincluding low anterior resection, total mesorectal excision and local, transanal \nresection. Furthermore, there is an increasing trend toward treating patients with \nradiotherapy before surgery to improve local control. The choice of operation and \nthe decision whether to employ radiotherapy is based on preoperative staging. In \npatients with primary rectal cancer, accurate assessment of tumour extent within \nand beyond the rectal wall and the presence or absence of lymph node invasion \nare factors for determining prognosis and risk of tumour recurrence. Endorectal \nultrasound (EUS) is effective for T -staging, although it is least accurate for T2 and \nT4 tumours. It has been recommended as the investigation of choice in the selection \nof potentially curative local excision. Distinguishing between T1 and T2 tumours \nmay be a problem. Lymph node staging by this method is less precise than tumour \nstaging. Initial reports of the use of CT for tumour staging were encouraging. How-\never, studies which compare CT with EUS staging consistently show the latter to be \nmore accurate for both tumour stage and lymph node stage. Thus, the usefulness \nof CT for rectal cancer is disappointing. Tumours within the rectal wall and slight \ninvasion through the wall cannot be assessed. Accurate assessment of local spread \ncan only be achieved in advanced tumours. The value of CT as an investigation \ntool for staging rectal cancer has to be seen in the detection of distant metastases. \nLearning Objectives:\n1. To learn exam technique of endorectal US.\n2. To describe morphology and staging of rectal cancer.\n3. To understand the role of CT for local and distant staging.\nA‑277 09:00 \nB. Staging with MRI \nC. Hoeffel; Reims/FR (choeffel‑fornes@chu‑reims.fr) \nAdvancements have been made in multiple aspects of diagnostic and therapeutic \napproaches to rectal cancer. Therapeutic advances include total mesorectal \nexcision, transanal excision, and adjuvant treatments such as chemotherapeutic \nagents and refined radiotherapy techniques. The accurate identification of patients \nwho are candidates for combined modality treatment depends on multidisciplinary \napproach and is particularly essential to optimize outcomes. The ability of MRI to \naccurately image the relevant structures of the mesorectum in rectal cancer has \nbecome increasingly evident. Advances in the method and technique for obtain-\ning these scans have resulted in improved image acquisition. Interpretation of \npreoperative MR images in patients with rectal cancer allows the identification \nof several prognostic factors that will enable better selection of patients who may \nbenefit from more intensive treatment without subjecting those who will not to un-\nnecessary treatment. We will describe the MRI staging of rectal tumors, and how \nthis information can be used to optimize management of these cancers, and will \noutline the added values of new techniques. \nLearning Objectives:\n1. To demonstrate the techniques for accurate magnetic resonance imaging \nassessment of rectal tumors.\n2. To understand the anatomy of the mesorectal margin in relation to total \nmesorectal excision surgery and the anatomy of the lower third of the \nrectum.\n3. To understand the role of the radiologist in identifying prognostic factors \npreoperatively and preventing margin positive disease.\n4. To discuss the impact of modern MR imaging (3 Tesla, diffusion-weighted \nMRI, ...).\nA‑278 09:30 \nC. Follow-up \nG. Brown; Sutton/UK (gina.brown@rmh.nhs.uk) \nDefining patterns of recurrence is crucial in the overall assessment of efficacy of \ntreatment strategies. In particular, patterns of local recurrence can identify areas \nfor locally directed therapy and the early detection of distant relapse is also es-\nsential in enabling early and effective treatment of relapse. For the radiologist, \nknowledge of the patterns and outcomes from recurrence is essential for effective \nsurveillance strategies and in this lecture the patterns of local relapse based on \nan understanding of their aetiology will be covered. At present, CT scanning of the \nthorax abdomen and pelvis remains the most common method of surveillance of \npatients following colorectal surgery. The majority of patients develop metastatic \ndisease within the first two years of surgery and therefore six monthly post opera-\ntive surveillance is common place for patients who are at a high risk of developing \nmetastatic disease. In approximately 10% of cases, a cause for a rising CEA will \nnot be found on conventional CT; in these circumstances, PET/CT can be helpful. \nEarly detection of metastatic disease or recurrent disease in colorectal cancer \nhas been shown to benefit patients and in up to 40% of patients resection of local \nor distant recurrence can result in long term cure. The following patterns of local \nrecurrence will be discussed: • Marginal; • Pelvic side wall; • Peritoneal; • Perineal; \n• Anastamotic; • Krukenberg; and Knowledge of the compartmental distribution of \nrecurrent disease will also enable planning for radical pelvic exenteration. \nLearning Objectives:\n1. To understand the evidence base for follow-up of primary rectal cancer.\n2. To understand the patterns of recurrent disease.\n3. To review the guidelines for imaging of local and distant recurrent disease.\n08:30 - 10:00 Room E1 \nMusculoskeletal \nRC 1110 \nShoulder \nModerator:\nC. Masciocchi; L ’Aquila/IT \nA‑279 08:30 \nA. Rotator cuff and impingement \nJ. Kramer; Linz/AT (kramer@ctmri.at) \nMR imaging findings of a normal shoulder joint, its variants and pathologic altera-\ntions have to be known for enabling an exact diagnosis. Mostly rotator cuff lesions \nare observed in patients with more or less degenerated tendinous structures who \nhad suffered not rarely a minor trauma only. In case the tendons basically are not \ndegenerated, osseous lesions occur more likely. Especially long-standing impinge-\nment may cause rotator cuff lesions (degeneration/fraying of tendons, partial or \nfull thickness tears). There are several forms of impingement: “Primary external \nimpingement” is caused by subacromial or subcoracoid impingement (e.g. spurs, \nvariations of the acromial morphology, etc). Chronic or long standing glenohumeral \ninstability, mostly observed in athletes who participate in sports that require repeti-\ntive overhead or throwing motions, may lead to “secondary external impingement”. \nIn these cases, clinical symptoms may mask signs of underlying glenohumeral \ninstability and point directly to rotator cuff lesions. “Internal impingement” is caused \nby abnormalities due to friction between the posterosuperior or anterosuperior \nlabrum and glenoid, and rotator cuff. In this presentation, the different forms of \nimpingement and MR imaging findings of rotator cuff pathology are demonstrated. \nLearning Objectives:\n1. To become familiar with MRI of normal rotator cuff structures.\n2. To understand the etiology of impingement.\n3. To recognise imaging findings in different forms of impingement.\n4. To become familiar with MR findings in rotator cuff lesions.\n\nSunday\nPostgraduate Educational Programme\nA S75CB D E F G\nA‑280 09:00 \nB. Instability \nM. Reijnierse; Leiden/NL (m.reijnierse@lumc.nl) \nStability of the glenohumeral joint is based on multiple factors. These include the \nrotator cuff, the glenoid labrum, the coracoacromial arch and the glenohumeral liga-\nments. Instability of the glenohumeral joint can be divided in two major categories: \ntraumatic and atraumatic. Acute anterior dislocation is most frequently seen and \noften results in unidirectional instability of a shoulder. Atraumatic instability can \nbe congenital or the result of repetitive microtrauma e.g. swimming and throwing. \nThis instability is often multidirectional and may be bilateral. Three glenohumeral \nligaments (GHL) have been described, the superior GHL, the middle GHL and \nthe inferior GHL complex, formed by an anterior band, a posterior band and an \naxillary recess of the joint. The number of ligaments is variable in any person and \ntheir size varies considerably. The SGHL is present in 90-97% of shoulder studies \nand is variable in origin. The MGHL is present in 73-92% and the IGHL is pres-\nent almost 100% of shoulder studies. Ligamentous abnormalities can be seen in \nisolation; however, since stability is based on multiple factors, coexisting structural \nabnormalities are frequently found. For accurate assessment of the glenohumeral \nligaments, the use of MR arthrography is essential. With joint distension, these \nintra-articular ligaments can be evaluated. MR arthrography is indicated to find \nadditional abnormalities in case of clinical significant glenohumeral instability and \nis an essential part of presurgical planning. \nLearning Objectives:\n1. To appreciate the role of MR imaging in glenohumeral instability.\n2. To understand the anatomy and normal variations of the glenohumeral \nligaments.\n3. To recognise pathology due to instability.\nA‑281 09:30 \nC. The post-operative shoulder \nM. Zanetti; Zurich/CH (marco.zanetti@balgrist.ch) \nStandard radiographs are essential in the evaluation of the postoperative shoulder. \nRadiographs allow giving an overview of the position of humeral head and glenoid \n(acromiohumeral distance, anterior or posterior dislocation) in a physiologic upright \nstanding position. Dislocation of metallic implants can be recognized on CT images. \nCT has its advantages in the assessment of extraanatomical glenoid reconstruc-\ntions (Latarjet or Bristol procedures). Hidden fractures after shoulder prosthesis \nsurgery at the coracoid process or acromion are often visible only on CT images. \nMR imaging after shoulder surgery is used to assess muscles and tendons. The \ndirect MR arthrography is used to assess labrum or cartilage lesions. However, \nthe diagnostic value of direct MR arthrography after rotator cuff reconstruction \nis limited by the fact that the rotator cuff is not watertight after surgery. Partial \nthickness rotator cuff tears cannot be discriminated from a normal postoperative \nscar. Therefore, standard MR imaging provides similar results. Ultrasound can be \nused alternatively for the postoperative assessment of the rotator cuff. Subacro-\nmial bursitis diagnosed on MR STIR images is most commonly (98%) a normal \npostoperative finding. The postoperative MR protocol differs minimally (no gradient \necho sequences, susceptibility artefact along the frequency direction, turbo spin \necho instead spin-echo, short TE, large bandwidth, large echo train length, STIR \ninstead fat sat) from the preoperative MR protocol. \nLearning Objectives:\n1. To become familiar with surgical techniques in patients with impingement, \ninstability-related disorders, and osteoarthritis.\n2. To differentiate between normal and abnormal findings after shoulder \nsurgery.\n3. To learn about MRI after shoulder surgery.\n08:30 - 10:00 Room E2 \nInteractive Teaching Session \nE³ 1120 \nColorectal cancer: Diagnosis, staging and follow-up \nModerator:\nM. Marotti; Zagreb/HR \nA‑282 08:30 \nColorectal cancer: Diagnosis, staging and follow-up \nR.G.H. Beets-Tan1, A.H. Freeman2; 1Maastricht/NL, 2Cambridge/UK \n(r.beets.tan@mumc.nl) \nColorectal cancer is common. Approximately 280,000 new cases occur each year \nin the 500 million population of the 27 states which comprise the EU. After lung, \nit is the second commonest cause of cancer death resulting in approximately \n140,000 deaths per annum. These relatively high mortality figures are a reflection \nof the fact that the disease is often advanced at the time of presentation. Efforts to \nreduce mortality, therefore, centre on early detection as well as accurate staging. \nThe latter is particularly important in rectal cancer-the commonest site for colonic \ncancer. Detection depends on presentation, which is often protean or non-existent; \nhence, the introduction of screening programs. Typical diagnostic tools include the \nbarium enema, optical colonoscopy and CT colonography. The limitations of the \nbarium enema have been exposed by optical colonoscopy and it can no longer be \nadvocated in this role. CT colonography, however, rivals optical colonoscopy in the \ndetection of polyps and tumours, although of course has no therapeutic potential. \nMajor advances in the treatment of rectal cancer include total mesorectal excision \n(TME) of the rectum as well as neo-adjuvant therapies such as chemo-radiation. \nTheir use depends on highly accurate staging of the primary disease, which can \nonly be achieved by MR examination, although of course CT or PET/CT is required \nfor the assessment of more distant metastatic disease. Finally, once treated, it is \nessential that these patients are followed-up; usually by a regime of colonoscopy \nand CT. These issues will be discussed in an interactive lecture. \nLearning Objectives:\n1. To review the genetic and environmental factors predisposing to colorectal \ncancer and to consider the significance of colorectal cancer in overall health \nterms.\n2. To understand the rationale of screening and to discuss the role of CT \ncolonography and its relation to other screening tests such as FOB test and \ncolonoscopy.\n3. To learn the principles and rationale for accurate preoperative imaging of \nrectal cancer.\n08:30 - 10:00 Room F1 \nOrgans from A to Z: Liver \nMC 1119 \nAnatomy and techniques \nModerator:\nS.C. Efremidis; Ioannina/GR \nA‑283 08:30 \nA. Essentials of liver anatomy and multimodality display \nW. Schima; Vienna/AT (Wolfgang.Schima@khgh.at) \nKnowledge of the normal anatomy and of the most frequent variants and anoma-\nlies of liver segments, vascular, and biliary anatomy is of major importance for \nhepato-biliary surgery and interventional procedures. Radiologic studies to evaluate \nanatomy include color Doppler ultrasound and contrast-enhanced MDCT and MRI. \nAnalysis of 3D data sets obtained with MDCT or MRI is most helpful for evalua-\ntion of complex anatomy. Radiologic classification of liver segments according to \nCouinaud can be reliably achieved with MDCT and MRI data sets with vascular \nopacification. Arterial-phase MDCT imaging is the best non-invasive technique \nto demonstrate variants of the hepatic artery, including accessory and replaced \nright and left hepatic arteries. For preoperative demonstration of biliary ductal \nvariations and anomalies, MRCP has become the standard imaging technique. \nIt reliably shows dystopic biliary radicles, which are at risk of inadvertently being \nclamped during surgery. The development of MRCP with liver-specific MR contrast \nagents has further increased the diagnostic yield to show normal-sized bile ducts. \n\nPostgraduate Educational Programme\nS76 A B C D E F G\nRecently, multi-phasic MDCT with intravenous and biliary contrast agent has been \nshown to be a reliable tool for demonstration all aspects of surgically relevant liver \nanatomy in one-stop-shopping. Accurate assessment of liver segmental anatomy \nand vascular and biliary variants and anomalies is crucial to help pre-therapeutic \nplanning and to avoid surgical complications. \nLearning Objectives:\n1. To understand the segmental anatomy of the liver as seen with \nUS, CT, and MRI.\n2. To become familiar with vascular and biliary anatomy including anatomic \nvariations.\n3. To understand why US, CT and MRI are complementary and to learn the \nadvantages of multimodality display.\nA‑284 09:00 \nB. The correct protocols for CT and MR \nB. Marincek; Zurich/CH (Borut.Marincek@bluewin.ch) \nLiver MDCT protocols are adapted to the clinical situation. Routine abdomen-pelvis \nscans are acquired during a portal-venous phase only and visualize hypovascular \nliver parenchyma lesions. In target-oriented liver scans, early arterial phase im-\nages provide a purely arterial road map. Dedicated triphasic protocols include \na late arterial phase for the detection of hypervascular lesions, a portal-venous \nphase and an anytime between 2 and 5 minutes delayed phase for improving the \ndemonstration of cholangiocarcinoma and cysts. Non-enhanced scans are help-\nful to depict intrahepatic biliary stones or to differentiate retained chemo-infused \nmaterial from contrast enhancement. Tube current modulation techniques should \nbe applied for dose reduction. In obese patients, 140 kV tube voltage is recom-\nmended (standard: 120 kV). Liver MRI is mostly performed to evaluate focal disease. \nThe protocol should include as a minimum precontrast T1w gradient echo (GE) \nin- and opposed-phase images to identify intracellular fat and T2w fat-suppressed \nspin echo sequences for the characterization of fluid-containing lesions (e.g. cyst, \nhemangioma). Non-specific extracellular Gd-chelates are routinely used for dynamic \nmultiphase (late arterial, portal-venous, delayed phase) T1w fat-suppressed GE \nsequences. They are adequate for detection and characterization of the majority \nof focal lesions. Contrast agents with combined extracellular dynamic enhancing \nand hepatocyte-selective properties (hepatobiliary imaging window duration of \n60-120 minutes) are excreted into blind-ending bile ducts typical of FNH, but do \nnot accumulate within an adenoma, HCC, or hypervascular metastases, facilitating \ndifferentiation. Reticuloendothelial system-specific contrast agents are taken up by \nfunctioning Kupffer cells, but lack dynamic enhancement information, reducing the \nability to characterize lesions. \nLearning Objectives:\n1. To learn about the MDCT protocols for detecting and characterising liver \nlesions.\n2. To consolidate knowledge of standard MRI protocols for lesion detection and \ncharacterisation.\n3. To become familiar with the use of contrast media for MRI, including liver-\nspecific agents.\nA‑285 09:30 \nC. Imaging the function and structure in clinical practice \nY . Menu; Paris/FR (yves.menu@sat.aphp.fr) \nBeyond the traditional role of anatomical display, imaging extends now to functional \nand structural imaging. Because liver tumours, both primary and secondary, are so \nfrequent, and because chronic liver disease is a real public health problem, liver \nimaging is a natural target for advances in organ evaluation. Perfusion studies can \nbe made using US, CT and MRI after intra venous tracer injection. Bio-distribution \nof the tracer, either intra vascular or intra and extra vascular, should be understood, \nas well as main methods for extraction of parametric images anq quantitative pa-\nrameters. The main role of perfusion studies is to evaluate angiogenesis and more \nover its evolution after administration of chemotherapy or targeted therapy in case \nof tumour. Hepatocyte uptake can be evaluated using specific tracers, providing \nfunctional information useful for tumour characterization. Structural analysis can \nbe done using Diffusion Weighted MRI (DW-MRI). Advantages (fast acquisition, \nintra observer reproducibility, feasibility on virtually all installed machines) and \ndrawbacks (absence of standardization, inter observer variability) should be fully \nunderstood. DW-MRI can be helpful in predicting and evaluating tumour response \nto treatment, as well as grading the severity of liver fibrosis. Other methods, like \nelastography, may play an increasing role in the evaluation of diffuse liver disease, \nand possibly of tumours. Spectroscopy is unlikely to become a routine clinical tool \nin the very near future. In this lecture, protocols for functional and structural ex-\naminations will be provided, and a tentative synthesis of their practical or potential \nrole will be presented. \nLearning Objectives:\n1. To understand how imaging can approach structure and function.\n2. To learn the CT and MRI protocols for the exploration of liver structure and \nfunction.\n3. To understand how diseases can impair structure and function and to learn \nthe consequences on imaging.\n08:30 - 10:00 Room F2 \nBreast \nRC 1102 \nInterventional techniques \nModerator:\nR. Schulz‑Wendtland; Erlangen/DE \nA‑286 08:30 \nA. US-guided core biopsy \nL. Apesteguía, L.J. Pina Insausti; Pamplona/ES \nUS-NCB under local anaesthesia is nowadays the most widespread system of per-\ncutaneous biopsy, because of the excellent control we can achieve with the needle \nand the ability to reach lesions located in difficult places such as axylla or near the \nnipple. It is a safe, comfortable and economical technique although it requires a no-\ntable level of experience. The length of needle and core can be selected according to \nlesion size, location, depth and other circumstances. The skin access point must be \nseparated from the US probe because the needle must be orientated parallel to the \nchest wall. Three to five specimens are recommended to get the maximum accuracy \nand the lowest grade of infra-estimation. The number of samples should be greater \nfor lesions with complex radiological features. The colour, consistence and grade of \nimmersion of the cylinders in formaldehyde are useful criteria to know their suitability \nfor diagnosis. This is the elective technique for BI-RADS-4-5 lesions properly identified \nby US. In particular situations, BI-RADS-3 lesions can be managed similarly. Only \nlesions not clearly seen by US should be punctured under stereotaxic or MR control. \nFNA-Cytology is reserved for special situations such as some BI-RADS-3 nodules \nor when the objective is evacuation. The extensive use of US-NCB has drastically \nreduced the number of surgical procedures due to false positive radiological findings. \nCorrelating histological and radiological features is extremely important. In cases of \ndisagreement, vacuum-assisted systems or surgical biopsy are recommended. All \nbreast radiologists should be encouraged to get experience in US-NCB. \nLearning Objectives:\n1. To review the principles of biopsy techniques.\n2. To learn pros and cons of these interventions.\n3. To update the indications in order to reduce false positives.\nA‑287 09:00 \nB. Stereotactic large core biopsy \nP .D. Britton; Cambridge/UK (peter.britton@addenbrookes.nhs.uk) \nStereotactic breast biopsy has a long-established role in breast diagnosis for \nidentifying lesions not detectable by ultrasound. Technical advances in ultrasound \nhave meant that stereotactic biopsy is now almost exclusively performed on screen-\ndetected microcalcification and small parenchymal deformities. Such lesions present \nthe greatest diagnostic challenges confronting the breast radiologist. Abnormalities \nare frequently small, hard to target and encompass most borderline and in-situ \npathologies encountered. Compared with lesions targeted by ultrasound, diagnostic \nperformance has lower sensitivity, higher false negative and cancer upgrade rates. \nTo tackle these challenges, digital equipment is essential whether prone biopsy or \nupright. Fine needle aspiration cytology (FNAC) has been superseded by devices \nharvesting larger amounts of tissue such as core biopsy (CB) and vacuum-assisted \nbiopsy (VAB). Are better results achieved with VAB, and if so, does it justify the \nconsiderable extra expense? Whatever targeting method or biopsy device is used, a \nmeticulous approach to technique, adequate sampling and correlation with pathol-\nogy at multidisciplinary team meetings are essential for best and safe patient-care. \nLearning Objectives:\n1. To understand the indications for stereotactic intervention.\n2. To discuss different available systems.\n3. To learn tricks and tips for needle and clip placement.\n4. To understand the pros and cons of stereotactic core and vacuum-assisted \nbiopsy.\n\nSunday\nPostgraduate Educational Programme\nA S77CB D E F G\nA‑288 09:30 \nC. An update on MR-guided wide excision biopsy \nS.H. Heywang-Köbrunner; Munich/DE \nBreast MRI is capable of visualizing lesions not visible by other methods. Depending \non patient preselection, 20-30% of these lesions may be malignant. Indications: \nLesions classified as BIRADS 4 or 5 which are visualized by MRI alone (as counter-\nchecked by retrospective ultrasound) need to be biopsied under MR guidance. Even \nthough MR-guided percutaneous breast biopsy is the more demanding procedure, \nit should be preferred to wire localisation and surgery; among percutaneous breast \nbiopsy methods, MR-guided vacuum-assisted breast biopsy appears the method of \nchoice with proven accuracy and reporducibility (1). Techniques: Meanwhile, coils \nand software for MR-guided targerting are commercially available. An overview will \nbe given of the procedure, available equipments and oneway material for MR-guided \nbiopsy. Usefulness: MR guided interventions are indispensable to correctly assess \nlesions visible by MR alone. Following the European guidelines, minimal invasive \nbreast biopsy should be performed for imaging detected lesions whenever possible \n(> 70%, optimum > 90% of the lesions). In case of benign lesions, unnecessary \nsurgery can be avoided. In case of malignancy, treatment planning is optimized. \nAn overview of existing literature data will be given. \nLearning Objectives:\n1. To update the indications for this approach.\n2. To learn basic techniques of present systems.\n3. To explain its usefulness in multicentric cancers.\n08:30 - 10:00 Room G/H \nNew Horizons Session \nNH 11 \nMRI of the lungs: Light at the end of the tunnel?\nModerator:\nH.‑U. Kauczor; Heidelberg/DE \nA‑289 08:30 \nChairman’s introduction \nH.-U. Kauczor; Heidelberg/DE (hans‑ulrich.kauczor@med.uni‑heidelberg.de) \nMRI of the lung has experienced an impressive series of ground-breaking techno-\nlogical developments. Almost all of them are related to imaging speed, gating and \nsignal enhancement. The potential of visualizing pulmonary vasculature, patho-\nlogical structures and probing pulmonary microstructure rivals CT. However, the \ncapability of MRI to assess “function” in a broader sense is its biggest advantage \nover CT beyond the mere lack of ionizing radiation. Functional MRI of the lung \nincludes: perfusion, ventilation, gas exchange, vascular permeability, flow, shunt, \nhemodynamics, right heart function, lung volumes and mechanics, motion. As such, \nthe broad spectrum of functional MRI of the lung is capable to replace a series of \ndifferent diagnostic procedures, such as pulmonary function tests, ventilation and \nperfusion scintigraphy, echocardiography, and fluoroscopy. Clinical indications for \nMRI of the lung are congenital cardiovascular and cardiopulmonary abnormalities; \ncystic fibrosis; pulmonary hypertension; lung cancer: differentiation between T3 \nand T4 tumors; mediastinal tumors; and malignant pleural mesothelioma. Current \nrecommendations for a standard protocol are focused on quality, workflow and \nspeed, and allow for completing a MRI of the lung within less than 30 minutes. The \nstructural and functional components of MRI of the lung can also be regarded as \na part of whole body MRI, which gains more and more attention in diagnosis of \ncongenital anomalies and diseases; thromboembolic disease; staging in oncology, \nand systemic inflammatory diseases, such as tuberculosis or COPD. \nSession Objectives:\n1. To learn about indications of when to use MRI of the lung.\n2. To understand the rationale of using MRI of the lung, especially with regard \nto CT.\n3. To focus understanding of MRI techniques towards a clinical protocol.\nA‑290 08:33 \nChallenges for MRI of the lung \nJ.M. Wild; Sheffield/UK (j.m.wild@sheffield.ac.uk) \nThe talk will be primarily from a technical perspective, focusing on how best to \nimage the lungs with MRI at present an how the speaker envisages improvements \nin the years to come. It will cover state-of-the-art imaging methods for 1H MRI of \nlung morphology including the role of parallel imaging. Review of current functional \nimaging methodology with 1H MRI will be given with an overview of pulse sequences \nfor ventilation, oxygen enhancement, perfusion (CE and endogeneous) and lung \ndynamics. Discussion includes the role of hyperpolarised gas MRI - technical \nmethods and functional sensitivity of 3He and 129Xe MRI in respiratory research. \nThe talk will be illustrated with images from Sheffield and other leading lung MRI \nresearch groups. \nLearning Objectives:\n1. To learn about state-of-the-art imaging methods for 1H MRI of lung \nmorphology.\n2. To understand functional imaging methodology with 1H MRI (ventilation, O2 \nenhancement, perfusion (CE and endogeneous), lung dynamics).\n3. To appreciate functional lung imaging methodology with hyperpolarised \ngases (3He, 129Xe).\nA‑291 08:51 \nMRI of neoplastic and inflammatory lung disease \nJ. Biederer; Kiel/DE (juergen.biederer@rad.uni‑kiel.de) \nCombining fast breath-hold acquisitions with parallel imaging, shared echo-\ntechnique and rotating phase encoding, MRI of the lung has overcome its former \nwell-known limitations. Comprehensive protocols with fast sequences can be \nrecommended for a number of indications including neoplastic and inflammatory \nlung disease. The non-contrast-enhanced basic protocol (in-room time 15 min). \ncomprises a coronal T2w single-shot half-Fourier TSE (HASTE) sequence with \na high sensitivity for infiltrates and a transversal T1w 3D-GRE (VIBE) sequence \nwith a high sensitivity for small nodular lesions. A motion compensated T2w TSE \nimproves depiction of masses with chest wall invasion. This is followed by a coronal \nsteady-state free precession sequence (TrueFISP) in free breathing, which is highly \nsensitive for central pulmonary embolism and gross cardiac or respiratory dysfunc-\ntion. A final multi-breath-hold transversal fat-saturated T2w-TSE visualizes enlarged \nlymph nodes and skeletal lesions. Unclear masses, consolidation or pleural effusion \ndetected in the basic protocol warrant an additional contrast-enhanced fat-saturated \n3D-GRE (VIBE) sequence (plus 5 min). Detection rates for pulmonary infiltrates \nwith the basic protocol match CT making it a valuable alternative in particular for \nchildren, young patients and pregnant women. The sensitivity for lung nodules \nreaches 80-90% for lesions > 4 mm (100% for > 8 mm). Both capacities are ap-\npreciated in cystic fibrosis patients for follow-up using dedicated scores of the extent \nof disease. In lung cancer patients, MRI contributes to staging and radiotherapy \nplanning by superior soft tissue contrast, e.g. to separate tumour from atelectasis. \nAdministration of contrast material contributes to detect tumour necrosis, chest \nwall or mediastinal invasion and pleural reaction/carcinosis. \nLearning Objectives:\n1. To outline a basic push-button protocol for 1H MRI of the lung with clinical \n1.5 T scanners.\n2. To learn about the scope of MRI for solid and infiltrative lung disease using a \nstandard protocol.\n3. To become familiar with potential clinical applications and particular \nadvantages compared to CT.\n4. To observe limitations and pitfalls of 1H MRI.\nA‑292 09:09 \nMRI of pulmonary vascular disease \nS. Ley; Heidelberg/DE (ley@gmx.de) \nVisualization of the pulmonary arteries can be performed using steady-state free \nprecession (SSFP) or contrast-enhanced 3D-GRE sequences (ce-MRA). SSFP \ntechniques allow for evaluation of the main and lobar pulmonary arteries. Sensitivity \non a lobar level was 79% in patients suffering from PE. As these sequences are \nperformed in less than a minute, they should be used by default as initial sequences \nof a thoracic examination. High spatial resolution ce-MRA can be acquired in a \nbreath-hold of less than 20 s with a spatial resolution in the range of 1.2-1.4 mm\n3. \nThis allows for evaluation of the pulmonary arteries down to a segmental level. Even \npatients with mild to moderate shortness-of-breath are capable of breath-holding \nfor this period of time. Therefore, this technique is well suited to rule out central PE \nor any other obstructive disease. One approach to reduce the breath-hold time is \nto acquire two sagittal image slabs (each 10-12 s), one for each lung. In patients \nwith chronic thromboembolic disease, this technique showed more pathological \nfindings than one coronal acquisition. Reducing the acquisition time to 1-1.5 s, a 3D \nperfusion-weighted (ce-perfusion) dataset can be acquired. Analysis can be done \nvisually i.e. by image subtraction revealing perfusion deficits. Obvious perfusion \ndefects, either focal or wedge-shaped, can be differentiated from a heterogeneous \nreduction. This basic analysis already allows for characterization of different vascular \npathologies or diseases of parenchymal origin. Detailed functional information can \n\nPostgraduate Educational Programme\nS78 A B C D E F G\nbe gained from quantitative analysis of pulmonary blood flow, pulmonary blood \nvolume and mean transit time. \nLearning Objectives:\n1. To consolidate knowledge of state-of-the-art imaging methods for high-\nspatial and temporal resolution, contrast-enhanced and non-contrast-\nenhanced MR agiography of the pulmonary vasculature.\n2. To become familiar with the clinical application of MRA of the pulmonary \nvasculature and its comparison to CTA.\n3. To appreciate functional imaging of the pulmonary circulation using time-\nresolved MRA.\nA‑293 09:27 \nMRI of ventilation and gas exchange in airway disease \nF . Molinari; Rome/IT (fmolinari@rm.unicatt.it) \nThe management of patients with chronic airway disorders, such as asthma and \nCOPD, is generally based on the assessment of clinical data and pulmonary func-\ntion tests (PFTs). Although PFTs are recommended for diagnosing airway disease \nand grading airflow limitation, their use as a comprehensive tool for evaluating \nlung function has been debated. An individual susceptibility of airway response \n(i.e. inflammation) to external noxae is thought to influence the natural history of \nboth asthma and COPD, leading to a considerable heterogeneity of clinical expres-\nsion and patient outcome. Different pathogenetic and clinical phenotypes may be \nincluded in one single category of global lung function damage as determined by \nPFTs. CT and MRI show the regional pulmonary anatomy three-dimensionally. \nQuantitative data regarding lung structure and function can also be obtained \nfrom both modalities. The high spatial resolution of CT and intrinsic contrast dif-\nference between lung structures and air guarantees excellent definition of small \nchanges of airways and lung parenchyma, such as bronchial wall thickening and \nobstruction, air-trapping and centrilobular emphysema. While limited in the ability \nto visualize small-scale lung anatomy, MRI has been used with gaseous contrasts \nto depict pulmonary airspaces and provide information on alveolar gas exchange. \nThe possibility to perform longitudinal and interventional studies without radiation \nexposure has added to the understanding of the pathogenesis of asthma. Pulmo-\nnary vasculature changes and respiratory muscle dysfunction have been studied \nin COPD using dynamic MRI techniques. All these imaging tools are available to \nidentify new morphologic and functional patterns of alterations in airway diseases. \nLearning Objectives:\n1. To summarise the clinical needs for imaging lung ventilation and gas \nexchange in airway disease.\n2. To appreciate advantages and limitations of MRI in assessing changes of \nlung function related to airway obstruction.\n3. To understand how CT and MRI can provide clinically relevant information in \npatients with airway disease.\nPanel discussion:  \nMRI of the lung: Can it beat CT? \n09:45 \n08:30 - 10:00 Room I \nPhysics in Radiology \nRC 1113 \nDiagnostic radiology and pregnancy \nModerators: \nH. Bosmans; Leuven/BE \nE. Vaño; Madrid/ES \nA‑294 08:30 \nA. Conceptus doses and risks from maternal diagnostic X-ray \nexaminations \nJ. Damilakis; Iraklion/GR (damilaki@med.uoc.gr) \nWhenever a diagnostic X-ray examination of a pregnant patient is considered to be \nnecessary, conceptus dose estimation is an important step in assessing the risks \nto the unborn child. Accurate estimation of conceptus dose is also needed after \ninadvertent irradiation of a pregnant patient from a diagnostic X-ray procedure. \nSeveral methods have been developed to estimate conceptus dose from radiologic \nexaminations. When the uterus is remote from the directly exposed tissues, the \nconceptus is exposed to scattered radiation and its dose is negligible (< 1 mGy). \nExaminations involving the abdomen-pelvis may deliver higher dose to the child. \nVariations in maternal body size and uterus position should be taken into account \nto obtain accurate conceptus dose estimation. Multidetector CT (MDCT) scanners \nhave replaced conventional CT technology. Conceptus doses from abdominal MDCT \nrange from about 11.0 mGy to about 27.0 mGy during the first post-conception \nweeks for a scan acquired at 120 kVp, 200 mAs with a pitch of 1.0, depending on \nmaternal body size and uterine position. Multi-phase abdominal MDCT examinations \nmay deliver relatively high doses to the unborn child. Doses to the conceptus below \n100 mGy should not be considered a reason for termination of pregnancy. The risk \nto the embryo/fetus for stochastic effects is assessed on the basis of dose using \nappropriate risk factors. Although these risks from a single diagnostic procedure \nare low for the majority of diagnostic X-ray examinations, it is important to ensure \nthat doses are kept as low as reasonably achievable. \nLearning Objectives:\n1. To learn how to manage and counsel pregnant patients in case of (a) \nintentional and (b) accidental exposure.\n2. To learn how to estimate conceptus radiation dose from diagnostic X-ray \nexaminations.\n3. To learn how to assess the radiogenic risks to the embryo/fetus from \ndiagnostic X-ray examinations.\nA‑295 09:00 \nB. X-ray imaging and pregnancy: Justification and optimisation of \nexposure\nP . Vock; Berne/CH (peter.vock@insel.ch) \nAs outside pregnancy, justification and optimisation are the main steps to be \ndone when an imaging examination using ionising radiation is considered during \npregnancy. However, the risk concerns the embryo/fetus in addition to the mother \nwhich means that justification has to be more critical whenever the uterine dose \nis not neglectable. The practical approach to an examination in any woman of \nchild-bearing age starts by ruling out pregnancy, whether by history taking or by \na laboratory test. When pregnancy cannot be ruled out, further steps will depend \non the type of examination needed and the urgency of diagnostic clarification. \nUltrasound is the alternative to be preferred when it can answer the clinical ques-\ntion. But even among X-ray examinations, the uterine dose is varying widely which \nasks for a careful selection, optimisation and, maybe, for postponing the test. Once \npregnancy is confirmed, the major question is whether the specific type of diagnostic \nexamination will include the uterus in the primary radiation field. Examinations not \ninvolving the uterus by direct radiation, despite a potentially significant exposure by \nscattered radiation, can usually be performed without a relevant risk to the embryo/\nfetus. The situation is more critical when the uterus is within the examination field \nand when therapeutic interventions are considered. The presentation will discuss \nthe practical approach to these different situations, the influence of the stage of \npregnancy, optimisation methods and the choice between alternative methods in \nsome frequent clinical situations. \nLearning Objectives:\n1. To become familiar with the radiologist’s practical approach to justification \nduring pregnancy.\n2. To learn how to optimise imaging protocols for X-ray examinations performed \non pregnant patients.\n3. To present the role of imaging modalities in the evaluation of pregnant \npatients.\nA‑296 09:30  \nC. Pregnancy and MRI: Risks to the unborn child \nJ. De Wilde; Edinburgh/UK (jdewilde@staffmail.ed.ac.uk) \nThis paper explores the risks to the fetus when Magnetic Resonance Imaging (MRI) \nis used. MRI uses three main components to produce images from inside the body, \n1. A static magnetic field, 2. Pulsed radio-frequency (RF) fields and 3. Time-varying \ngradient electromagnetic fields. The exact frequencies of these fields depend on \nthe MRI system purchased, for example; a 0.5T scanner uses 21 MHz RF , a 1.5 T \nsystem uses 63 MHz and a 3 T system uses 127 MHz RF . There are a wide range \nof options for gradient strengths and slew rates to be considered as well. The \noverall exposure for the fetus depends ultimately on the imaging sequence used. \nThis paper will discuss particular hazards that need to be addressed for pregnant \nwomen including biological effects of the static and time-varying magnetic fields, \nheating effects of the RF pulses and acoustic noise generated by the spatial encod-\ning gradients. The circumstances for fetal exposure in MRI will also be discussed \nincluding the following situations: the patient may not be aware she is pregnant, \nlikely to be in the first trimester; the mother is referred for direct fetal imaging after \nultrasound (normally 2\nnd or 3rd Trimester); the expectant mother may need diagnosis; \nresearch on pregnant volunteers. The exposure for pregnant staff working in MRI \nis also an essential consideration. Finally, how to minimise the exposure for the \nfetus during MR imaging will be discussed. \n\nSunday\nPostgraduate Educational Programme\nA S79CB D E F G\nLearning Objectives:\n1. To understand the risks to the fetus in MRI from static and time-varying \nmagnetic fields, with particular reference to the radiofrequency field.\n2. To consider the exposure of the fetus to noise during MRI.\n3. To understand how to minimise the exposure for the fetus during MR \nimaging.\n08:30 - 10:00 Room K \nPediatric \nRC 1112 \nAdvanced brain MR imaging: Why and when \nModerator:\nJ.‑F . Chateil; Bordeaux/FR \nA‑297 08:30 \nA. Diffusion tensor imaging \nA. Righini; Milan/IT (neurorad@icp.mi.it) \nDiffusion Tensor Imaging (DTI) studies demonstrate progressive Apparent Diffu-\nsion Coefficient (ADC) decrease within gray and white matter areas starting from \nfetal life as sign of brain maturation; at the same time, Fractional Anisotropy (FA) \nincreases in some white matter structures. Changes in FA and ADC, together with \nradial and axial diffusivity values, during cell proliferation-migration and during \nmyelination, well correlate with modifications known from developmental histology \nstudies. Acute ADC decrease (i.e. ischemia) can be detected already in fetal stroke \nand its measure is pivotal in monitoring neonatal hypoxic-ischemic encephalopathy. \nADC calculation allows also to assess acute osmotic and metabolic anomalies in \nneonate (i.e. hypernatremia, hypoglycaemia, etc). Early FA decrease, with radial \nand axial diffusivity changes, is observed in white matter areas as sign or early \nwallerian degeneration after acute brain damage. Chronic regional white matter \nFA reduction is detectable in sequelae of periventricular leukomalacya or adjacent \nto malformative cortex, but also in older children with neurodevelopmental delay \n(mostly in statistical quantitative studies on autism, ADHD, dyslexia, etc). Finally, \nthe building of Fiber Tracking and Color coded (RGB) maps from DTI data may \nhelp in better characterizing suspected structural anomalies on a single case basis \n(i.e., corpus callosum, hippocampal fornix, optic radiation, cerebellar peduncles \nmalformations, etc). However, the potential of Fiber Tracking applications still needs \nto be fully exploited, especially in view of future higher spatial resolution acquisitions. \nLearning Objectives:\n1. To learn about the correlation between ADC-FA values and structural \ncharacteristics of a normal developing brain.\n2. To learn about pathology-tissular correlations with ADC-FA value changes in \nCNS pediatric diseases.\n3. To learn about the potential impact of fiber tracking in clinical pediatric \nneuroradiological practice.\nA‑298 09:00 \nB. Spectroscopy \nL. Astrakas; Ioannina/GR (astrakas@cs.uoi.gr) \nIn vivo proton MR spectroscopy (MRS) is a non-invasive MR technique that is \nroutinely used to assess a number of pediatric neurologic conditions. It is based \non the fact that protons belonging to different metabolites have slightly different \nresonance frequencies (chemical shift). Using water suppression and volume \nlocalization techniques, we can obtain either one spectrum (single voxel) or mul-\ntiple spectra (SI) containing metabolite peaks corresponding to predetermined \nanatomical site  (s). In pediatrics, the majority of spectroscopy is performed in \nthe brain and the metabolites detected usually are: N-acetyl aspartate, N-acetyl \naspartyl glutamate, creatine and phosphocreatine, choline containing compounds \n(free choline, acetylcholine, phosphocholine, cytidine diphosphate choline, and \nglycerophosphocholine), Myoinositol, myoinositol monophosphate, and glycine, \naminoacids (glutamine, glutamate, GABA), lactate, lipids and macromolecules. \nThese metabolites participate in important metabolic pathways and their levels are \nbeing disturbed by various pathologies. Thus, MRS has a vast field of applications \nincluding tumors, infarction, hypoxia, ischemia, infection, inflammation, metabolic \ndisorders, neurological disorders and trauma. In many cases, it can redirect or \nnarrow differential diagnoses; in selected instances, it may provide the key finding \nthat points to a final diagnosis. MR spectroscopy alone is usually not specific, but \ncan be very helpful especially in combination with other clinical, diagnostic and \nother MR methods. Particular caution is needed in data evaluation because spec-\ntral appearance and concentrations of the metabolites are affected by: a) proper \nselection of experimental and preprocessing factors and b) brain development. \nLearning Objectives:\n1. To become familiar with the basic principles of proton MR spectroscopy.\n2. To learn what proton MR spectroscopy can offer to the diagnosis and \nmonitoring of various pediatric diseases.\n3. To learn how MR spectroscopy combines with other MR techniques.\nA‑299 09:30 \nC. Functional MRI \nL. Hertz-Pannier; Gif sur Yvette/FR (lucie.hertz‑pannier@cea.fr) \nFunctional MRI (fMRI) has become the tool of choice for studying the cerebral \norganization of children, due to its non-invasiveness allowing repeat unsuccessful \nstudies in patients, and the study of healthy children (by contrast to radionuclide \nstudies). However, several technical and physiological issues must be considered \nin order to use fMRI in the pediatric population, pertaining to the developing brain \n(cortical immaturity, ongoing myelination) and to the developmental age (adapted \ntasks, control of performance, reference state). The main difficulty remains to obtain \nthe child’s cooperation and avoid head motion. When cooperation cannot be fully \nobtained, «passive» tasks can be used to test perceptual functions and receptive \nlanguage. A comprehensive assessment of brain organization can thus be achieved \nthrough the combination of neuropsychology and MR techniques (anatomical MRI, \ndiffusion tensor imaging and fMRI). Motor, language and visual fMRI paradigms are \nnow being used successfully in children, which show activation patterns comparable \nto adults, with a trend toward more diffuse and scattered activation. The main clinical \napplication is the assessment of reorganization (plasticity) of eloquent cortices in the \npresurgical workup of epileptic foci or brain tumors near the central or perisylvian \nregions and to tailor resections to avoid postoperative deficits. Nowadays, fMRI can \nreplace the invasive Wada test in about 85% of epilepsy surgery patients and shows \ngood colocalization of activated cortices when compared with electrical cortical \nstimulation. Further research is needed to outline the clinical contribution of fMRI \nto the management of developmental disorders with specific cognitive impairment. \nLearning Objectives:\n1. To understand the basic mechanisms, advantages and limitations of fMRI in \nchildren.\n2. To describe the anatomo-functional organisation and plasticity of the \ndeveloping brain.\n3. To describe the main clinical applications of fMRI in children.\n08:30 - 10:00 Room L/M \nRadiographers \nRC 1114 \nPatient interaction \nModerators: \nP. Blackburn Andersen; Kolding/DK \nC. Garvey; Liverpool/UK \nA‑300 08:30 \nA. Interaction between patient and radiographer during radiological \nexaminations \nB.T. Andersson; Lund/SE (Bodil‑T.Andersson@med.lu.se) \nAim: To examine the interaction in encounters in the course of radiographic \nexaminations and to be able to understand advantages and difficulties involved.\nBackground: When a patient attends the hospital in order to undergo a radiographic \nexamination he/she is in a need of professional care and support. For many patients \nwithin the context of diagnostic radiology, concern about the result and insecurity \npertaining to what will come next can be a major issue. The radiographer has a \ncentral role as he/she meets the patient before, during and after the radiographic \nexamination. It is of paramount importance that the radiographer is familiar with the \nproblems involved and can give support during the entire radiographic procedure. \nMethod: A descriptive design with a qualitative approach was chosen. Data were \ncollected through interviews with radiographers and female patients.\nResults: Four different types of encounters were expressed; the empowering, the \nempathetic, the mechanical and the neglectful. The empowering and the empathetic \nencounter gave rise to positive feelings within the patient while the mechanical \nand the neglectful engendered negative feelings. Radiographers’ competence was \nmanifested by openness, active listening and by being present in the very short \nand intensive encounter with the patient.\n\nPostgraduate Educational Programme\nS80 A B C D E F G\nConclusion: The quality of the interaction is of great importance to the whole \nradiographic procedure. The challenge for a radiographer in a diagnostic radiology \ndepartment is to have knowledge of when the technology should be in focus and \nhow to devote time to the patient and deal with the ambiguity and inseparability \nbetween them. \nLearning Objectives:\n1. To gain knowledge about the interaction in the encounter.\n2. To learn more about different types of encounters in the course of \nradiographic examinations.\n3. To be able to understand advantages and difficulties involved in the \ninteraction in the encounter.\nA‑301 09:00 \nB. The role of the radiographer in patient advocacy \nV. Challen; Lancaster/UK (val.challen@cumbria.ac.uk) \nPatient advocacy can be seen to be primarily concerned with both promoting and \nprotecting the interests of patients; yet there is no single consistent definition of the \nterm. A wide variety of patient advocacy models have been developed for the nursing \nprofession and more recently five elements of advocacy have been identified as a \nguide for the radiography profession in the UK. Some radiographer job descriptions \nand quality benchmarks often refer to the requirement of the radiographer to act as \npatient advocate; yet often the reality is that the radiographer is not empowered to \ntake on such a role either by the employing authority or through self motivation. A \nrecent study has shown that advocacy is seen by the majority of radiographers as \na professional requirement particularly in relation to radiation safety; however, most \nare unwilling to discuss potential radiation doses with patients despite requests \nfrom patients and carers. Championing ethical and social justice in the healthcare \nenvironment plus support for patients’ autonomy appears to be underdeveloped \nin many radiographers. These factors could be addressed through appropriate \neducation and training in addition to the further development of assertiveness and \ncommunication skills. Advantages for both patient and radiographer in the undertak-\ning of such roles must be tempered by any perceived limitations whilst at the same \ntime acknowledging the changing public expectations of healthcare professionals. \nLearning Objectives:\n1. To understand the meaning of patient advocacy in its broadest term.\n2. To appreciate the ethical and social factors involved in supporting the \nindividual’s autonomy and championing patients’ rights.\n3. To identify those factors that may influence and motivate radiographers in \nundertaking patient advocacy.\n4. To analyse a number of scenarios involving an advocacy role and \ninvestigating the feelings and perceptions of radiographers undertaking such \na role.\nA‑302 09:30 \nC. Measuring short and long-term consequences of a false-positive \nmammography among women attending breast cancer screening \nprogrammes \nA. Bolejko; Malmö/SE (anetta.bolejko@skane.se) \nNumerous studies have shown significant short-term negative psychological con-\nsequences of a false-positive screening mammography. The consequences may \nfor instance appear as increased anxiety, fear, and feeling certain about heaving \nbreast cancer. The results regarding long-term psychological effects are, however, \ncontradictory. The psychological consequences of a false-positive screening mam-\nmography are difficult to measure. Up to now, generic instruments with additional ad \nhoc scales have been used. The generic questionnaires, although with established \npsychometric properties, are developed in general settings or patient populations, \nand as such they may not be sensitive enough to capture all psychological impact of \na false-positive screening mammography. Results from studies using such measures \ncan therefore be viewed as incomplete and remain tentative. Results from ad hoc \nscales are even more ambiguous, as these have not been tested regarding validity \nand reliability at all. The outcome measures conducted must be based on a model \nof the construct being measured, have high content validity, and the psychometric \nproperties should be determined in the target population. Recently, a condition \nspecific self-report instrument measuring consequences of a false-positive screen-\ning mammography has been established in Denmark. Initial evidence supports its \nreliability and validity, which provides an opportunity to measure such consequences \nin a more accurate and sensitive way. The questionnaire has just been adapted to a \nSwedish context and its content validity in a target population has been determined \nsince the equivalence of content relevance and content coverage to the original \nversion should be shown prior to use in another culture. \nLearning Objectives:\n1. To learn about what is known so far from the literature about short and long-\nterm consequences of false-positive mammographic screening - truths and \npitfalls.\n2. To be aware of how to test, use and interpret available instruments \nfor measuring short and long-term consequences of false-positive \nmammographic screening.\n3. To be familiar with the field through examples from Sweden and Denmark.\n08:30 - 10:00 Room N/O \nHead and Neck \nRC 1108 \nInfrahyoid neck \nModerator:\nA.A.A. Abdel Razek; Mansoura/EG \nA‑303 08:30 \nA. Hypopharyngeal cancer: What you need to know \nC.R. Habermann; Hamburg/DE (c.habermann@uke.uni‑hamburg.de) \nThe hypopharynx, or laryngopharynx, is the most caudal portion of the pharynx that \nextent from the laryngeal surface of the epiglottis to the cricopharyngeus. Most authors \ndivide the hypopharynx into the piriform sinuses, the posterior wall, and the postcricoid \nregion. Occasionally, within the literature, a fourth area of the hypopharynx is described \nas the marginal area, represented by the lateral surface of the aryepiglottic folds. \nHowever, the larynx itself presents one of the true challenges of head and neck imag-\ning. Consequently, the diagnostic approach to the hypopharyngeal neck is based on \na brief understanding of the complex anatomy and function of the larynx. Congenital, \ninflammatory, neoplastic, and traumatic abnormalities all affect the larynx. Due to \nendoscopy the clinician mainly has a decided idea of the clinical problem. Although, \nthe endoscopist is limited in the ability to define the deep extent of a certain pathol-\nogy relative to precise landmarks. These landmarks determine whether the patient \nis a candidate for a pharyngolaryngectomy, a laryngectomy, a speech conservation \ntherapy, or a radio- and/or chemotherapy. The exact knowledge of the different surgical \napproaches is mandatory for the radiologist to ascertain the necessary and most ap-\npropriate therapeutic approach and to obtain the best result for the patient. Anatomic \nlandmarks and the radiologic appearance in a non-pathologic neck and a pathologic \ninvolvement of these landmarks will be reviewed extensively in a coherent manner. \nLearning Objectives:\n1. To understand the complex anatomy and function of the hypopharynx.\n2. To become familiar with the TNM staging of hypopharyngeal neoplasm.\n3. To recognise what the clinician needs to know for preoperative planning.\n4. To provide a template for a valuable imaging report.\nA‑304 09:00 \nB. The suspected recurrence: How to deal with it \nR. Hermans; Leuven/BE (Robert.Hermans@uz.kuleuven.ac.be) \nPosttreatment imaging is done when a recurrent tumour is clinically suspected, \nand for confirmation and determining its extent. After radiation therapy, tumour \nrecurrence appears on CT or MRI as a soft tissue mass at the primary site. After \nsurgery, it appears as a mass along the resection margins. Imaging may also be \nused as a surveillance tool to try to detect recurrent tumour before it becomes clini-\ncally evident, possibly with a better chance for successful salvage. Early tumour \nrecurrence may be difficult to distinguish from treatment-induced tissue changes. An \nearly follow-up CT or MR study, best obtained about 3-6 months after end of treat-\nment, documents treatment-caused changes. By comparing subsequent studies \nwith this baseline study, tumour recurrences can be detected with more confidence, \nand often earlier than by clinical follow-up alone. Some authors recommend FDG-\nPET as the initial baseline study. If performed 3-4 months after treatment, PET \nhas a high negative predictive value, but relatively low positive predictive value. A \npositive posttreatment PET study should be correlated with clinical findings and \nresults from other imaging modalities, and histological confirmation is desirable. \nDiffusion-weighted MRI provides information about cell density, cell integrity and \nvascularity, and is applicable in the head and neck region. This technique is very \nsensitive to structural changes in pathologic tissue, even during their very early \nstages of development. Ongoing research suggests that this non-invasive technique, \nnot requiring an external contrast agent, may be more specific than FDG-PET in \nthe posttreatment evaluation of head and neck cancer. \n\nSunday\nPostgraduate Educational Programme\nA S81CB D E F G\nLearning Objectives:\n1. To review the expected tissue changes after therapy.\n2. To learn the early signs of tumor recurrence.\n3. To understand the value of post-treatment surveillance imaging.\n4. To appreciate the relative value of different imaging modalities after therapy.\nA‑305 09:30 \nC. Lymph node imaging from A to Z \nR. Maroldi; Brescia/IT (maroldi@med.unibs.it) \nWith the exception of distant metastases, the presence of cervical lymph node me-\ntastases is the single most adverse independent prognostic factor in patients with \nhead and neck squamous cell carcinoma (HNSCC). This implies that staging of neck \nmetastasis is a crucial step in treatment planning. As the sensitivity of ultrasonography, \nCT and MRI in identifying small lymphatic metastases is inadequate, many of the \npatients with no detectable metastases will receive elective treatment of the neck. \nNor PET/CT presently fully addresses this clinical question. In fact, its sensitivity is \nstrictly dictated by the size of the metastasis: excellent when size is 8-9 mm or more, \nvery low when diameter is less than 5 mm. Should ‘focused techniques’, like FNAC (or \nfunctional MR, ADC-based), be applied to the most probable nodal site (s), according \nto primary tumor location? Unfortunately, this strategy does not appear practical, as \nlymphatic drainage patterns from HNSCC are not highly predictable. Nuclear medicine \ntechniques such as the sentinel lymph node biopsy may improve the detection rate \nof the lymph-borne target-node. Its role in staging and management of HNSCC is \nyet to be fully established. A second critical issue is the detection of tumor spreading \nbeyond the lymphnode capsule (ECS). Its presence reduces survival to 25 to 30%, \nand it is a significant predictor of the development of distant metastasis. The imag-\ning features of ultrasonography, CT and MRI indicating extracapsular tumor spread, \ncarotid and vertebral invasion should be well known to the radiologist because they \nhave therapeutic and prognostic implications. \nLearning Objectives:\n1. To understand the patterns of nodal spread.\n2. To review the role of morphological imaging techniques.\n3. To review the role of PET/CT.\n08:30 - 10:00 Room P \nChest \nRC 1104 \nBedside chest imaging \nModerator:\nJ. Neuwirth; Prague/CZ \nA‑306 08:30 \nA. Bedside chest radiography: Technical aspects and main results \nE. Eisenhuber; Vienna/AT (eisenhuber@gmail.com) \nAlthough bedside chest radiograph is one of the less elaborate imaging examina-\ntions in our diagnostic armamentarium, it remains the most frequent radiologic \nprocedure performed in intensive care patients. Despite its limitations, chest imag-\ning is an important tool in the management of the critically ill patient. Though the \nadvent of digital radiography has vastly contributed to improved image quality of the \nbedside radiographs, optimal positioning and technique remain a real challenge for \nthe performing technologist. Additionally, the interpretation of chest radiography in \nthe critically ill patient poses a challenge for the radiologist, because findings are \nfrequently unspecific and lung opacifications have similar appearances in a variety \nof different cardiopulmonary pathologies. Clinical information and an interdisciplinary \napproach are therefore crucial for optimal interpretation of these chest radiographs.\nThe American College of Radiology has established expert recommendations for the \nuse of bedside chest radiography. Current recommendations suggest that routine \ndaily chest radiographs should be reserved for patients with acute cardiopulmonary \nproblems and in patients receiving mechanical ventilation. Acquisition of a portable \nchest radiograph is recommended after insertion of endotracheal tubes, central \nvenous catheters, pulmonary artery catheters, chest tubes, and nasogastric tubes.\nTherefore, knowledge of correct positioning of catheters, tubes, and monitoring \ndevices and of various malpositions and associated complications is essential for \nthe interpreting radiologist. \nLearning Objectives:\n1. To review the technical requirements of portable chest units.\n2. To recognise the main patterns of acute pulmonary diseases.\n3. To be aware of the limitations of bedside chest radiography.\nA‑307 09:00 \nB. Role of bedside ultrasonography of the thorax \nK. Vidmar Kocijancic; Ljubljana/SI (ksenija.kocijancic@kclj.si) \nChest ultrasonography (CHUS) is a useful imaging tool, but limited (because of \nultrasound physics) to the thoracic soft tissues, pleural space and adjacent pro-\ncesses in the lung parenchyma. This non-ionizing imaging method is unlike the \nradiography, CT or MRI, operator created and is very useful in patients at intensive \ncare units because of its simplicity, reproducibility and being very useful for the clini-\ncians, especially when performed by experts. The ICU patient can be examined in \nsupine or sometimes in lateral or partly lateral position with the convex ultrasound \n(US) small radius probes using intercostal spaces as an acoustic window. Supine \nanalysis of the anterior chest wall rules out pneumothorax, while lateral approach \ndetects clinically relevant pleural effusion and parenchimal consolidations. CHUS is \na method of choice in detection as well as in characterization and volume estimation \nof free and/or loculated pleural fluid. With CHUS, we can explore and characterize \nlung consolidations from the moment they reach the visceral pleura. They can be in \ncontact with pleural line or can be observed through an effusion. Also, in the ques-\ntion of pulmonary embolisms in critically ill patients, CHUS could be contributive. \nSometimes, small pleural effusion can be visible with some peripheral lung tissue \nconsolidations indicating minute pulmonary infarction. Typical pulmonary infarction \nis triangular tissue consolidation with air bronchogram and absence of Doppler \nblood flow signals within consolidated lungs. CHUS exploration of the diaphragm \ncan reliably evaluate respiratory movements since pleural effusion, even substantial, \ndoes not affect the amplitude of diaphragmatic excursion. \nLearning Objectives:\n1. To understand the role of US as a diagnostic tool in pleural and parenchymal \ndiseases in critically ill patients.\n2. To review the guidelines for estimation of pleural fluid volume.\n3 To discuss the role of US as a guiding modality for bedside pleural/chest \nintervention.\nA‑308 09:30 \nC. Radiologic-guided bedside interventions of the thorax \nF . Gleeson; Oxford/UK (fergus.gleeson@nds.ox.ac.uk) \nThis presentation will review the ultrasound appearances of pleural disease in ward \nand ITU based patients, and will discuss the indications for pleural procedures \nand the complications associated with them. The use of colour Doppler to aid the \ndiagnosis of effusions will be discussed, as will the identification of septations \nand the need for intrapleural fibrinolytic therapy. The advantages of guided versus \nblind drain insertion will be presented, and the benefits of large versus small bore \ndrains will also be discussed. \nLearning Objectives:\n1. To learn when ultrasound-guided thoracic intervention should be performed.\n2. To understand how intervention should be performed.\n3. To be aware of the complications that may arise from ultrasound-guided \nthoracic intervention.\n08:30 - 10:00 Room Q \nInterventional Radiology \nRC 1109 \nVenous thromboembolism \nModerator:\nO.M. van Delden; Amsterdam/NL \nA‑309 08:30 \nA. Which IVC filter? \nD.K. Tsetis; Iraklion/GR (tsetis@med.uoc.gr) \nInferior vena caval (IVC) filters are effective devices for preventing pulmonary embo-\nlism (PE). The incidence of fatal recurrent PE is 20%, despite adequate anticoagula-\ntion, and typically occurs within the first 3 months after the initiation of anticoagulation \ntherapy. The indications for IVC filtration are categorized as absolute, relative and \nprophylactic (absence of venous thromboembolism). Application of IVC filters has \nbeen expanded to include patients needing short-term IVC filtration. For this purpose, \nseveral types of optional, retrieval filters have been developed offering protection from \nlong-term complications of permant filtratin such as IVC occlusion, caval penetration, \nfilter migration or fracture. Conical type IVC filters are attractive designs, due to their \nability able to trap large clots into the central part of the cava, allowing flow around \n\nPostgraduate Educational Programme\nS82 A B C D E F G\nthe periphery and thereby decreasing the chances of caval occlusion. In order to \nextend the retrieval window much longer than the initial recommendation of 10-14 \ndays, new filters have been designed to minimise effects of endothelialisation on their \nelements which contact the wall of the cava. The majority of these modern devices \nare designed with linear longitudinal struts which are able to slide out from under-\nneath caval wall endothelium covering them. Unfortunately, there is little opportunity \nto compare efficacy and complication rates of different filter types, as new designs \nreplacing older ones are continuously brought onto the market. \nLearning Objectives:\n1. To know the principles of treatment and discuss the indications.\n2. To learn about the different types of filters and their imaging appearances.\n3. To discuss efficacy of different filters.\nA‑310 09:00 \nB. Complications of IVC filters and their management \nA. Nicholson; Leeds/UK (tonynick@tonynick.karoo.co.uk) \nInferior vena cava (IVC) filtration devices were developed in the 1970s as an alter-\nnative to open caval ligation in patients perceived to be at high risk of pulmonary \nembolism (PE) where anticoagulation was contraindicated or ineffective. Despite \nover three decades of experience, the evidence for their efficacy is lacking, and \nis principally based on case control or observational studies; to date, there is only \none randomized, controlled trial. Reported immediate complication rates for percu-\ntaneous filter insertion (and retrieval) are consistently low (in the region of 1%) but \nconcerns relating to long-term IVC filtration persist, with reported IVC thrombosis \nrates of between 1 and 28%. There is evidence from the USA of increasing rates \nof IVC filter insertion over the last two decades, despite relatively stable rates of \nthromboembolic disease. Data from the US National Hospital Discharge Survey \ndemonstrate increased filter use from 2000 insertions in 1979 to 49,000 in 1999. \nThe development of smaller introduction systems and filters, which are potentially \nretrievable, has occurred contemporaneously with this increase. It is likely that the \nease of insertion of percutaneous devices has reduced the perception of risk, driving \nincreasing rates of filter insertion and a broadening of the categories of patients \nfor whom a caval filter is considered. The development of retrievable devices may \nhave reduced concerns relating to long term IVC filter safety and is likely to have \ncontributed to increased rates of filter insertion in a similar manner. This has occurred \ndespite evidence that only a proportion of retrievable filters are actually removed. \nLearning Objectives:\n1. To review reported complications of filters.\n2. To learn strategies to deal with the various complications.\n3. To discuss how these may be avoided.\nA‑311 09:30 \nC. Central venous occlusions in the chest \nA. Basile; Catania/IT (antodoc@yahoo.com) \nRadiological approaches in the diagnostic pathway for central venous occlusion disease \ncomprise mainly CT/MR pulmonary angiography and flebography for superior caval \nsystem. Looking at imaging modalities, angiography has long been considered the \nreference standard that all other techniques have to be measured against. Advantages \ninclude the option of inducing a therapy, local fibrinolysis-therapy via the angiographic \ncatheter in place, angioplasty and stenting etc. Pulmonary embolism leads to right \nventricular dysfunction and compromised hemodynamics of the cardiopulmonary \nsystem requires more aggressive treatment than anticoagulation because survival \ndepends on rapid recanalization of the pulmonary arterial obstruction and reduction of \nthe right ventricular afterload. Percutaneous catheter based treatment is an alternative \nto surgical embolectomy in high-risk patients or in patients with contraindications to \nthrombolytic drugs. Catheter-based thrombolysis accelerates clot lysis and hastens \nthe rees-tablishment of normal pulmonary artery circulation, furthermore combined \ntechniques with percutaneous thrombectomy including thrombus removal with aspira-\ntion, extraction, or fragmentation, may enhance the efficacy. Symptomatic obstruction of \nthe superior vena cava and innominate vein of the chest is a debilitating and potentially \nlife-threatening condition. Conventional surgery and radiation therapy have a historical \nrole in the management of patients with malignant superior vena cava obstruction. \nSVC stenting has become widely accepted in the management of SVCO and has \nalso recently been advocated as the first line treatment option in patients with malig-\nnant obstruction. Outcomes and complications compare very favorably with standard \ntherapies such as chemotherapy and radiotherapy, and although recurrent obstruction \nmay occur, most patients can be treated by re-intervention. \nLearning Objectives:\n1. To review imaging modalities.\n2. To discuss interventional radiological treatment options.\n3. To learn about different indications and routes of treatment.\n10:30 - 12:00 Room E2 \nInteractive Teaching Session \nE³ 1220 \nLung cancer: From plain film to sectional imaging \nModerator:\nG.H. Mostbeck; Vienna/AT \nA‑312 10:30 \nLung cancer: From plain film to sectional imaging \nJ. Cáceres1, J. Vilar2; 1Barcelona/ES, 2Valencia/ES (josecac@gmail.com) \nBronchogenic carcinoma is a main cause of mortality from cancer in the western \nworld. Lung cancers are commonly diagnosed in chest radiographs; while some \nare detected, many others are missed. Common and uncommon manifestations in \nthe chest radiograph that suggest the diagnosis of lung cancer are thus important \nand must be recognized. Once the diagnosis is made, it is important to perform \nthe proper radiological work-up to establish the stage and the adequate treatment. \nStaging is a key factor in lung cancer management and is important for selecting \nthe proper imaging technique in individual cases. Finally, in treated patients, imag-\ning is a main aspect of the follow-up. The radiologist must know how to evaluate \nsigns of recurrence, which should be distinguished from subclinical diseases and \npost-radiotherapy changes. \nLearning Objectives:\n1. To optimise imaging procedures in diagnosing lung cancer.\n2. To learn basic facts in staging lung cancer.\n3. To detect complications and/or recurrence in treated lung cancer.\n12:15 - 12:45 Room A \nPlenary Session \nHL 3 \nMaria Sklodowska-Curie - Honorary Lecture\nPresiding:\nM. Szczerbo-Trojanowska; Lublin/PL \nA‑313 12:15 \nFemale urinary incontinence: \nIs there still a place for radiology/radiologists? \nA.P . Wieczorek; Lublin/PL (rtg@dsk.lublin.pl) \nUrinary incontinence is an involuntary leakage of the urine. This simple definition \ndescribes medical condition concerning more than 30% of female population, \nwith the incidence increasing with age and parity. This embarrassing complaint \nsignificantly worsens the quality of life becoming a major society problem. Introduc-\ntion of new surgical achievements such as implanting plastic tapes and meshes \nhas opened new therapeutic opportunities. However, still between 15 and 30% \nof surgeries do not bring expected outcome. Among the causes of unsuccessful \nsurgeries, multifactor background of the condition must be mentioned, as well as \nimproper qualification for the operation, which often is based on patient history, \nclinical examination and urodynamics and sometimes additionally on insufficient \nimaging studies. Percentage of failures in surgical treatment of urinary incontinence \ncould be decreased involving in the diagnostic process modern imaging tools such \nas MR or high frequency ultrasonography, which are not even mentioned in any \nurogynaecological and proctological guidelines for the management of urinary dys-\nfunctions. Precise assessment of pelvic floor organs is nowadays possible despite \ntheir complex anatomy and function. This, however, requires close cooperation be-\ntween radiologists and clinicians to define the role and place of imaging techniques \nin modern urogynaecology in order to better understand incontinence and provide \nclinically useful information for treatment of women with urinary incontinence. \nLearning Objectives:\n1. To comprehend urinary incontinence in women as increasing social problem.\n2. To understand the function of pelvic floor organs and modern imaging \nmethods allowing their precise visualisation.\n3. To become familiar with currently available imaging techniques in diagnostics \nand monitoring of treatment of urinary incontinence.\n\nSunday\nPostgraduate Educational Programme\nA S83CB D E F G\n14:00 - 15:30 Room A \nExtremity Joint MRI \nMC 1325 \nUpper extremity: Anatomy, variants and pitfalls \nModerator:\nM. Rupreht; Maribor/SI \nA‑314 14:00 \nA. Shoulder \nK. Wörtler; Munich/DE (woertler@roe.med.tum.de) \nThe anatomy of the glenohumeral joint is not only complex but also highly variable. \nAnatomic variants are most frequently observed at the labral-bicipital complex \n(sublabral recess), the superior portion of the anterior glenoid labrum (sublabral \nhole, Buford complex), and the superior and middle glenohumeral ligaments (mor-\nphologic variations, absence). On cross-sectional imaging, these variants might be \nmisdiagnosed as sequels of previous trauma, such as SLAP lesions, injuries of the \nanteroinferior labro-ligamentous complex, or pulley lesions. Other anatomic variants, \nparticularly those of the bony elements of the shoulder (abnormal glenoid version, \nglenoid dysplasia, os acromiale) and the long head of biceps tendon, might how-\never be associated with shoulder pathology, such as glenohumeral instability and \nsubacromial impingement. This course reviews the normal cross-sectional anatomy \nof the shoulder, important anatomic variants and typical pitfalls in interpretation. \nPractical guidelines that might prove useful in distinguishing morphologic variants \nand pathologic conditions on the basis of imaging features will be presented. \nLearning Objectives:\n1. To become familiar with the anatomy of the shoulder joint.\n2. To learn about anatomic variants of the labroligamentous complex, labral-\nbicipital complex, and bony elements of the shoulder.\n3. To avoid misinterpretations of anatomic variants as pathologic conditions.\n4. To learn about useful imaging features in order to distinguish variants from \nlabral tears, SLAP lesions and other shoulder pathologies.\nA‑315 14:30 \nB. Elbow \nM. Zanetti; Zurich/CH (marco.zanetti@balgrist.ch) \nThe anatomy of the elbow joint is complex. The common flexor (associated with Golfer \nelbow) and extensor origins (T ennis elbow) dominate the soft tissue supporting struc-\ntures medially and laterally. Biceps and brachioradialis anteriorly and triceps posteriorly \nmake up the other significant muscles. Several anatomical variants are important for \nMRI interpretation. Extraarticular variants are divided into abnormal signal changes and \nanatomical variation in normal structures. Magic angle signal phenomenon on short \nTE sequences account for a high proportion of ‚normal’ signal variation. The biceps \ntendon and the flexor and extensor entheses are particularly prone. An increased sig-\nnal in the ulnar nerve on fluid sensitive MR images is visible in 60% of asymptomatic \nelbows. The distal biceps tendon is commonly seen with two separate splits (-25%). \nAnatomical variations in ligaments are uncommon, though their anatomy is complex. \nThe lateral collateral ligament is visible only in 85% of asymptomatic elbows but the \nother elbow ligaments are all visible. Three important nerves cross the elbow and all \nmay be compressed by anatomical variants. The ulnar nerve may be compressed \nby an accessory anconeus epitrochlearis. The radial nerve may be compressed by \nfibrous bands, the vascular leash of Henry or between the two heads of supinator. The \nmedial nerve may be compressed by an accessory supracondylar process or by the \nbicipital aponeurosis. Variants inside the elbow include joint surface pseudodefects, \nnotably the capitellum and trochlea. Synovial folds (not thicker than 2 mm) are normal \nintraarticular structures. The posterolateral plica is seen in 98% asymptomatic elbows. \nLearning Objectives:\n1. To review in detail the MRI anatomy of the elbow joint and its relevance to \ndisease processes.\n2. To consider imaging protocols and techniques directed to the clinical problem.\n3. To review the small number of anatomical variants that may be encountered.\nA‑316 15:00 \nC. Wrist \nA.H. Karantanas; Iraklion/GR (akarantanas@gmail.com) \nMRI has become an important diagnostic tool in the evaluation of wrist pain and \nfunctional impairment. MRI is able to depict various disorders such as avascular \nnecrosis, occult fractures, inflammation, neoplasms, infections, and injuries of the \ntriangular fibrocartilage (TFC) and interosseous ligaments. Normal anatomy dem-\nonstration by an optimized protocol is a prerequisite for depicting abnormalities. \nThe increased SNR provided by high field MR systems (1.5-3.0 T) is important for \nobtaining high-resolution images. Patients should be placed in the prone position \nwith the elbow extended overhead and the pronated hand in the center of a dedi-\ncated surface or phased array coil placed in the isocenter. The imaging protocol may \ninclude the following sequences using FOV of 8-10 mm and slice thickness 2-3 mm: \ncoronal and transverse T1-w SE and fat suppressed PD-w TSE, coronal STIR and \n3D-GRE and sagittal T1 and T2-w. Contrast-enhanced fat suppressed T1-w SE im-\nages are acquired in cases with clinical indication of inflammation, infections and \nneoplasia. The MR arthrogram is performed with fat suppressed T1-w SE (2 mm) \nin all three planes or with a transverse 3D-T1-w-GRE (1 mm) after intra-articular \ninjection of Gd solution (1:200). Pitfalls of wrist MRI include inhomogenous fat sup-\npression, magic angle effect often seen in the abductor pollicis longus and extensor \npollicis brevis tendons, high signal of ligamentous attachments on hyaline cartilage, \nsusceptibility artifacts from previous operations and partial volume effects. Variants \nin the wrist include variable ulnar length, presence of accessory muscles and TFC \nage-related changes and tears in asymptomatic individuals. \nLearning Objectives:\n1. To learn about a suggested updated MR technique for imaging the wrist.\n2. To understand the normal imaging anatomy.\n3. To become familiar with the most common pitfalls and variants that may \nsimulate disease.\n14:00 - 15:30 Room B \nChest \nRC 1304 \nAirways evaluation \nModerator:\nS. Matthews; Sheffield/UK \nA‑317 14:00 \nA. Volume CT assessment of diffuse diseases of the airways \nG.R. Ferretti; Grenoble/FR (GFerretti@chu‑grenoble.fr) \nThe diagnosis of airway disease is challenging for the clinician as it has no specific \nclinical or functional features. Volume CT has become the preeminent imaging \nmodality for the assessment of the airways and is at the present time the radio-\nlogical method of choice for investigating a patient suspected of airway disease. \nVolumetric HRCT of the entire lung combining end inspiratory, end expiratory, and \ndynamic expiratory acquisitions demonstrates localized functional information. \nThe addition of postprocessing techniques such as maximum intensity projection, \nminimum intensity projection, and multiplanar reformations enhance the diagnostic \ncapabilities of CT in showing characteristic findings of airway diseases. Moreover, \nvolumetric HRCT assesses the extent and severity of disease. It may be repeated \nfor assessing the response to therapy, and often avoid the need for histological \nevaluations. In the presentation, we will review the role of volume CT in patients \nsuspected of bronchiectasis, chronic bronchitis, asthma, tracheobronchomalacia, \nand small airway diseases. \nLearning Objectives:\n1. To review the advantages of VCT for the diagnosis and characterisation of \nairway abnormalities.\n2. To emphasise the post-processing techniques that may contribute to \nimproving the visualisation of airway diseases.\n3. To recognise the main patterns of small airway diseases on VHRCT.\nA‑318 14:30 \nB. Quantitative assessment of the airways \nF . Laurent; Pessac/FR (francois.laurent@chu‑bordeaux.fr) \nMethods for noninvasively measuring airway dimensions have been a challenge \nsince the site and nature of airway obstruction in chronic airway diseases have been \nrecognized. In this respect, the role of Computed Tomography has been essential \nand this course will focus on both the technical aspects and major results obtained \nusing this technique. Taking the advantages of the three-dimensional evaluation of \nairways using multidetector CT, recent advances in computer algorithms have made \npossible to measure airway wall and lumen of any visible bronchus on CT images at \neach bronchial generation. Various methods of segmentation of airways have been \nproposed and developed. They will be presented with their respective advantages \nand drawbacks as well as the potential effects of CT technical and visualisation \n\nPostgraduate Educational Programme\nS84 A B C D E F G\nparameters and cardiovascular pulsations. So far, no consensus, however, has been \nfound for establishing the most appropriate method for measuring airways. In addition, \nthe limited spatial resolution of CT does not allow visualising and measuring small \nairways. Nevertheless, many investigators have compared morphometric bronchial \nparameters assessed by CT with functional and histological indexes in various \nchronic airway diseases, i.e. COPD, asthma and cystic fibrosis. Potential applications \nof these results are the definition of phenotypes, non-invasive assessment of airway \nremodeling and inflammation, evaluation of pharmacotherapy. During this course, \nthese major features will be reviewed and their significance commented as well as \ndiscrepancies and contradictions amongst investigations. Finally, conditions of further \ndevelopments including dynamic changes in airway caliber, a likely more appropriate \nmethod for assessing functional abnormalities, will be presented. \nLearning Objectives:\n1. To know the technical requirements of MDCT for a quantitative evaluation of \nlarge and small airways.\n2. To comprehend the various post-processing methods that are useful in \nquantitative evaluation of large and small airways.\n3. To understand the potential applications in airway diseases.\nA‑319 15:00 \nC. CT quantification of pulmonary emphysema \nP .A. Gevenois; Brussels/BE (pierre.alain.gevenois@ulb.ac.be) \nMulti-Detector Row CT (MDCT) provides information on the overall lung structure as \nit relates to diffuse pulmonary diseases such as pulmonary emphysema, which is \ncharacterized by lung destruction and reduced tissue mass. These changes are as-\nsociated with a shift of the attenuation distribution curve toward negative values. As a \nconsequence, indexes derived from this distribution - such as the relative area of lung \noccupied by attenuation coefficients lower than a particular threshold and percentile \nof this distribution - can be used as measurements of the extent of pulmonary emphy-\nsema. With MDCT , morphometrical comparisons have shown that the relative area \nof lung occupied by attenuation coefficients lower than -960 HU and the 1\nst percentile \nof the distribution curve are appropriate indexes to reflect both the macroscopic and \nmicroscopic extents of pulmonary emphysema but that indexes characterizing the size \ndistribution of lung areas with attenuation lower than -960 and 1\nst percentile were not \nappropriate. In order to reduce radiation dose, the tube current-time product can be \nreduced (down to 20 mAs) but as the radiation dose has an effect on CT quantification, \nit should be kept constant in follow-up examination. For the same reason, slice thickness \nshould also be kept constant. Based on quantification of pulmonary emphysema as \npart of COPD, MDCT makes now possible its phenotyping. \nLearning Objectives:\n1. To understand the morphological features of pulmonary emphysema and the \nbasis of CT quantification of pulmonary emphysema.\n2. To become familiar with the different CT quantitative indexes and the \ninfluences of CT parameters on these indexes.\n3. To understand the potential role of CT in phenotyping chronic obstructive \npulmonary disease.\n14:00 - 15:30 Room C \nState of the Art Symposium \nSA 13 \nLymph node imaging: Imaging is back! \nModerator:\nJ.O. Barentsz; Nijmegen/NL \nA‑320 14:00 \nChairman’s introduction: Can US, CT and MRI challenge PET/CT? \nJ.O. Barentsz; Nijmegen/NL (J.Barentsz@rad.umcn.nl) \nThe proposed coursed will discuss the various aspects of nodal imaging pertinent to \ncancer staging in the abdomen and pelvis. The anatomical distribution of lymph nodes \nalong with the imaging appearance of normal lymph nodes will be discussed along with \npathways of metastatic nodal spread in various abdominal tumors. The use of state-of-the-\nart imaging including US, MDCT , MRI, and PET -scanning for lymph nodes will be outlined. \nRecommendations for optimal imaging planes, optimal spatial resolution, appropriate \nuse of contrast agents, and pitfalls will be made. The changing clinical role of imaging \ntechniques in relation to nodal dissection will be assessed. Guidelines will be provided \nin which patient group nodal imaging should be performed and in the patients in whom \nimaging is less relevant. Finally, the increasing role of new techniques like multi detector \nhigh resolution CT , USPIO-MRI, advanced US, PET -scanning and 3D segmentation will \nbe presented and discussed. Practical problems general radiologists may encounter using \nthese new techniques will be addressed. After this course, the attendees will know where \nthe various abdominal anatomical lymph nodes are located, how they can be found on \ncross-sectional images and, more in general, what the criteria are for metastatic nodes. \nThey will be able to appropriately use cross-sectional techniques and will be aware of \nnew developments and how they can potentially apply them. \nSession Objectives:\n1. To appreciate the importance of nodal staging in cancer.\n2. To understand the advantages and disadvantages of the various imaging \ntechniques.\n3. To show which imaging modality should be used for different cancers.\nA‑321 14:05 \nHow and where to use US for nodal diagnosis \nL. Solbiati; Busto Arsizio/IT \nNodal staging is of crucial importance in the diagnostic work-up and in the follow-up \nof the majority of neoplastic diseases. Sonography (US) plays a fundamental role in \nnodal staging when superficial nodal chains (neck, axilla, groin) are involved, while \nfor deep abdominal and retroperitoneal nodal chains CT or MRI provide much higher \ndetection rate. US allows to detect superficial adenopathies as small as 2-3 mm, with \na detection rate higher than that of cross-sectional modalities, but, particularly for very \nsmall lymph nodes, the critical issue is the differentiation between immunoreactive and \npathologic (either inflammatory or metastatic) nodes. For this purpose, morphological \ncriteria - such as size, shape, echogenicity of the cortex, presence of the hyperechoic \nhilum, calcifications and intranodal necrotic or cystic changes - and vascular patterns \nassessed by color-power Doppler (hilar or peripheral vessel distribution, focal absence of \nperfusion, presence of subcapsular, displaced and/or burnt vessels, etc ..) are generally \nused, with reported sensitivity range of 80-85% and specificity of 85-90%. Recently, \ncontrast-enhanced US (CEUS) has been applied to superficial lymph nodes and further \nfindings have been described, particularly for the characterization of metastatic nodes, \ni.e. disruption of hilar vascularity, replaced by cortical hypervascularity with tortuous and \naberrant feeding vessels and intranodal focal areas with early wash-out, representing \ndeposits of neoplastic cells or necrotic changes. However, significant limitations in the \ncharacterization of small metastases in normal-sized or slightly enlarged nodes are still \nencountered, and fine-needle aspiration biopsy (FNAB) remains the main diagnostic \nmodality for the final diagnosis in doubtful cases. US can enable more accurate selec-\ntion of nodes to submit to FNAB, reducing the number of pathologic assessments and \nis the modality of choice for the guidance of FNAB in all cases. \nLearning Objectives:\n1. To appreciate the importance of nodal staging in cancers.\n2. To understand the potential and limitations of US in detecting lymph node \nmetastases.\n3. To show how nodes can be biopsied by US guidance.\nA‑322 14:28 \nAbdominal and pelvic nodes: Is morphological assessment using CT and \nMR useful? \nD.-M. Koh; Sutton/UK \nNodal disease is an independent adverse prognostic factor in many cancers. \nAccurate nodal staging is important for treatment planning. Although nodal size \nmeasurement is still most frequently applied to distinguish between malignant and \nbenign lymph nodes, there can be substantial overlap. As such, morphological \nassessment of lymph nodes using CT and/ or MR imaging can help to improve \nnodal staging. Morphological evaluation of nodal shape, nodal contour, presence of \nnecrosis, nodal calcifications, nodal clustering, internal nodal heterogeneity, loss of \nfatty nodal hilum and nodal enhancement may improve the detection of malignant \nlymph nodes in patients with cancers prior to treatment. Nevertheless, the limitations \nand pitfalls of using these features for nodal assessment should be understood. Fol-\nlowing chemotherapy, a change in nodal morphology may also suggest a response \nto treatment. Nodal assessment using nodal size and morphological appearances \nshould be interpreted with the relevant clinical details, laboratory findings, as well \nas history of prior treatment. This combined approach can help to optimise nodal \nassessment using conventional CT and MR imaging. \nLearning Objectives:\n1. To appreciate the importance of nodal staging in cancers.\n2. To understand the criteria used to assess lymph nodes for malignancy on CT \nand MR.\n3. To learn how knowledge of tumor markers, the pathological features of the \nprimary malignancy and the pathways of nodal spread can contribute to \nnodal assessment.\n4. To identify pitfalls in nodal assessment by conventional CT and MR imaging.\n\nSunday\nPostgraduate Educational Programme\nA S85CB D E F G\nA‑323 14:51 \nNodal staging: MR and beyond? \nJ.O. Barentsz; Nijmegen/NL (J.Barentsz@rad.umcn.nl) \nA macrophage-specific magnetic resonance (MR) contrast agent allows the detec-\ntion of small and otherwise undetectable lymph node metastases in patients with \ncancer. This has an important clinical impact as the diagnosis will be more precise \nand less invasive to obtain. Subsequently, this will reduce morbidity and health \ncare costs. However, thorough knowledge of sequence parameters and planes, \nlymph node anatomy, appearance of normal and abnormal nodes, patterns of \nspread, and pitfalls is essential when using this novel MR-technique. This will be \nelaborated in this presentation. \nLearning Objectives:\n1. To show the value of MR imaging in detecting lymph node metastases.\n2. To understand which new developments improve the recognition of \npathologic nodes.\n3. To compare the clinical prospects of these novel MRI techniques in relation \nto PET/CT.\nPanel discussion:  \nChoosing the right modality: Clinical cases \n15:14 \n14:00 - 15:30 Room D \nImaging in Lung Diseases \nCC 1318 \nLung perfusion imaging: CT or MR? \nModerator:\nA. Larici; Rome/IT \nA‑324 14:00 \nA. Technological basis for lung perfusion with CT \nB. Ghaye; Liège/BE (bghaye@chu.ulg.ac.be) \nAssessment of pulmonary perfusion could be useful in various clinical settings, i.e. \npulmonary embolism. In this setting, CT pulmonary angiography (CTPA) is able to \nidentify clots within distal pulmonary arteries with 95% specificity. The clinical impact \nof PE depends not only on the embolus size but also on the underlying factors, \nincluding vasoactive agents, vasoconstriction reflex, systemic arterial hypoxemia, \nsequelae of previous episodes of PE, or associated disorders, such as chronic \nobstructive pulmonary disease. Assessment of the impaired microcirculation may \nprovide additional information that may be more important for patient treatment \nthan the direct visualization of emboli. CT assessment of pulmonary perfusion has \nbeen attempted by various techniques, including dynamic CM enhancement or a \ndual-phase subtraction technique. Radiation dose is one of the main drawbacks \nprecluding the use of repeating acquisitions with CT. With the introduction of dual \nenergy CT (DECT), the pulmonary microcirculation can be assessed in a single \nacquisition at acceptable radiation dose. Nevertheless, DECT does not allow a \ntrue perfusion assessment as vascular iodine content can only be assessed at \none time-point. However, compared to scintigraphy and MRI, it is the only imaging \nmodality able to provide high-quality morphological and functional information on \nthe pulmonary circulation from the same data set, justifying the moderate increase \nin the overall radiation dose compared to single-source CT. The aim of this lecture \nis to review the CT techniques to evaluate lung perfusion with special emphasis on \nDECT and to provide the technological basis to understand, perform and optimize \nmulti-energy CT scanning. \nLearning Objectives:\n1. To understand the technological basis of lung perfusion imaging with MDCT.\n2. To describe the current protocols that enable lung perfusion imaging in \nroutine clinical practice.\n3. To review the various means of optimising image quality.\nA‑325 14:30 \nB. Clinical experience with CT \nF . Pontana; Lille/FR (fpontana@yahoo.fr) \nThe assessment of the pulmonary microcirculation is clinically relevant in numerous \nthoracic disorders and is now accessible to CT . This new trend in evaluating the lung \nperfusion is driven by the technological developments of dual-source multidetector-row \nCT technology which offers the possibility to integrate the evaluation of the capillary \nlevel by means of dual energy CT (DECT). The analysis of the most distal portion of \nthe pulmonary circulation is now available in routine clinical practice and requires, for \nproper interpretation of images, a basic knowledge of the lung perfusion physiology. \nWith regard to the diagnosis of acute pulmonary embolism, DECT can detect perfu-\nsion defects, well known from scintigraphic perfusion studies. It can also contribute \nto recognize ground glass opacities of vascular origin when a nonspecific pattern of \nground glass attenuation is depicted on diagnostic images. Alterations in pulmonary \nperfusion can also be integrated in the CT assessment of small airways diseases like \nasthma or COPD. Lung perfusion quantification by DECT can also be considered in \nthe preoperative assessment of postoperative pulmonary function in patients with \nsevere emphysema or lung cancer. The major clinical impact of these new scanning \nprotocols is that morphology and function can be obtained from the same data set, \nwith no restriction on the diagnostic performance of high-resolution CT angiographic \nimages and with radiation doses below the legally required levels. The purpose of this \nlecture is to review these physiological perspectives offered by DECT in 2010. \nLearning Objectives:\n1. To learn about lung perfusion in normal subjects.\n2. To describe the basic patterns of abnormal perfusion in clinically relevant \nsituations.\n3. To become familiar with the most frequently encountered interpretive pitfalls.\nA‑326 15:00 \nC. MR perfusion imaging \nS. Ley; Heidelberg/DE (ley@gmx.de) \nMRI of the chest is getting more and more accepted for the assessment of diseases of \nthe lung parenchyma. Contrast enhanced pulmonary perfusion (ce-perfusion) is a key \ncomponent of recommended MR examination protocols. Image acquisition is easy and \ncan be rapidly performed. In principle volumetric datasets with a high-spatial resolution \nare acquired over time during a rapid injection of a contrast agent. These datasets can \nbe reformatted as needed allowing for a good delineation of the lobar and segmental \npulmonary anatomy. Analysis can be done visually i.e. by image subtraction revealing \nperfusion deficits. Obvious perfusion defects, either focal or wedge-shaped can be \ndifferentiated from a heterogeneous reduction. This basic analysis already allows for \ncharacterization of different vascular pathologies or diseases of parenchymal origin. \nDetailed functional information can be gained from quantitative analysis of pulmonary \nblood flow, pulmonary blood volume and mean transit time. These parameters show \nexcellent agreement with perfusion scintigraphy and H (2)15O positron emission \ntomography (PET). Quantitative perfusion analysis should be applied in patients with \npulmonary hypertension. Here, a good agreement with pressure measurements could \nbe established. MRI of pulmonary perfusion is also well suited for follow-up examinations \nas this technique allows for regional and quantitative therapy monitoring. \nLearning Objectives:\n1. To review the practical approach of perfusion imaging with MRI.\n2. To become familiar with the functional parameters evaluated with MRI.\n3. To describe the advantages and limitations of MRI in comparison with MDCT \nin evaluating lung perfusion.\n14:00 - 15:30 Room E1 \nMusculoskeletal \nRC 1310 \nKnee \nModerator:\nM. Maas; Amsterdam/NL \nA‑327 14:00 \nA. Menisci: Latest advances \nS.J. Eustace; Dublin/IE (seustace@iol.ie) \nThis talk will review basic anatomy and function of meniscii and optimum imaging \ntechniques using MRI. The talk will then review patterns of meniscal injury, types \nof meniscal tear, and review the concept of medical versus surgical meniscal injury. \nThe talk will outline the role of radiology in the management of meniscal cysts and \nfinally address current concepts in meniscal transplantation. \nLearning Objectives:\n1. To review imaging protocols and anatomy of the menisci.\n2. To review MR appearances of commonly encountered meniscal tears.\n3. To review implications of imaging appearances on patient outcome and \nmanagement.\n\nPostgraduate Educational Programme\nS86 A B C D E F G\nA‑328 14:30 \nB. The posterior corners \nJ. Hodler; Zurich/CH \nThe posterolateral and posteromedial corners of the knee both consist of several \nstructures which are important for stabilization. Unfortunately, they are not con-\nsistently defined in the literature. Many descriptions of the posterolateral corner \ninclude the lateral collateral ligament, the popliteal tendon, the popliteofibular liga-\nment and the posterolateral capsule, which is reinforced by the arcuate ligament \nand the fabellofibular ligament. Descriptions of the posteromedial corner also vary. \nThe superficial and deep medial collateral ligament as well as the posteromedial \ncapsule serve as passive restraining structures. The popliteal oblique ligament may \nnot be consistently found as an individual structure. If present, it has a close rela-\ntionship with the posteromedial meniscus. The posteromedial corner has also been \ndescribed as the “semimembranosus corner” because of the functional significance \nof the semimembranosus muscle. Up to five semimembranosus expansions have \nbeen described. Corner lesions are typically associated with injuries of the cruci-\nate ligaments and the menisci. In the acute phase, clinical findings can be difficult \nto interpret due to pain and swelling. Missed injuries of the posterior corners may \nlead to chronic instability, chronic pain, and, eventually, to secondary osteoarthritis. \nThey may also adversely affect the outcome of knee surgery such as cruciate liga-\nment repair. MR imaging is the best diagnostic test in suspected corner lesions. It \ndemonstrates corner injuries and associated lesions, including those that may be \noverlooked during clinical examination or arthroscopy. \nLearning Objectives:\n1. To learn about the anatomy of the posterior corners.\n2. To consolidate knowledge about injuries to the posterior corners.\n3. To appreciate the role of imaging methods in the diagnosis of posterior \nabnormalities.\nA‑329 15:00 \nC. The post-operative knee \nC. Glaser; Munich/DE \nAs meniscal, ligament and cartilage repair procedures are more and more commonly \napplied there is also a need for post-OP MRI in the knee. This requires knowledge \nfrom the radiologist regarding the basic principles of repair procedures, what are \nto be considered regular anatomy and normal imaging findings post-OP , how to \ndifferentiate these from pathologic post-OP evolution. Technically, the MR imaging \napproach has to cope with artifacts arising mostly from magnetic foreign particles \nintroducing local field inhomogeneities. The overarching goal of repair procedures \nis to prevent future premature osteoarthritis. Principally, ligament repair aims at \nrestoring a stable joint and at providing a quick return to activity. Meniscal surgery \ntries to preserve as much of a stable meniscal substance as possible because of \nthe significant meniscal contribution to load bearing. Cartilage repair procedures \ntarget joint surface congruity. Technically, relaxation time dependent inversion \nrecovery sequences provide a much more robust fat suppression than frequency \nbased saturation techniques. As simple as it is, careful selection of frequency and \nphase encoding directions with respect to the location of foreign metallic objects \nversus the area of interest are indispensable to help avoid or at least greatly reduce \nartifacts. In addition, use of turbospinecho sequences with short echo spacing, \nshort echo times in general, high spatial resolution, high bandwidth contribute to \nartifact suppression. Direct and indirect MR arthrography may be useful to detect \nrecurrent/residual meniscal tears and fragmentation/early loosening after menis-\ncal/cartilage surgery. \nLearning Objectives:\n1. To review principles of repair procedures in the knee.\n2. To appreciate technical aspects of imaging the post-operative knee.\n3. T o discuss normal and pathologic findings when imaging the post-operative knee.\n14:00 - 15:30 Room E2 \nInteractive Teaching Session \nE³ 1320 \nImaging in common clinical problems: \nAcute abdomen\nModerator:\nF . Takis; Keratea/GR \nA‑330 14:00 \nImaging in common clinical problems: Acute abdomen \nA. Palkó1, P .-A. Poletti2; 1Szeged/HU, 2Geneva/CH (palkoand@gmail.com) \nIn a general hospital, acute abdomen accounts for 30 to 40% of all emergency surgical \nadmissions, and the abdomen is involved in approximately 25% of multi-trauma patients. \nRecent technological advancements have brought to the forefront the importance of \nimaging in the initial assessment and subsequent management of patients admitted \nwith acute abdominal conditions. Thus, the role of clinical examination, laboratory \ndata and imaging is constantly redefined in new management algorithms, in the strive \nto achieve the highest level of efficiency and to spare medical resources. Abdominal \ntraumatic injuries, either isolated or part of more extensive trauma, require immediate \nand reliable imaging evaluation after stabilization of the patient’s condition in order to \nmake fast therapeutic decision to reduce mortality to a minimal level. In both traumatic \nand non traumatic acute abdominal conditions, the routine diagnostic work-up scheme \n(plain abdominal X-ray + ultrasound) is more and more frequently replaced by abdominal \nmultidetector CT examination extended to other regions if necessary. It is of utmost \nimportance for an emergency radiologist to get familiar with the classical signs and \npitfalls encountered in common traumatic and non-traumatic acute situations, as well as \nto understand the current role and diagnostic efficacy of the different imaging modalities. \nLearning Objectives:\n1. To highlight the role of different imaging methods in the radiological work-up \nof patients with acute abdominal pain.\n2. To discuss the radiological signs of the most frequently encountered acute \nabdominal pathologies.\n3. To present pitfalls in imaging patients with acute abdominal pain.\n14:00 - 15:30 Room F1 \nOrgans from A to Z: Liver \nMC 1319 \nDiffuse liver diseases \nModerator:\nA. Besim; Ankara/TR \nA‑331 14:00  \nA. Assessment of diffuse liver disease (including cirrhosis) \nL. Martí-Bonmatí; Valencia/ES (marti_lui@gva.es) \nThe different MR approaches used to make a clear initial qualitative evaluation in \ndiffuse liver disorders will be commented on and complemented with the implemen-\ntation of imaging biomarkers to accurately quantify the degree of liver abnormalities. \nMR is unique in its ability to extract information on tissue components and functional \nstatus. This information has transformed the way imaging interacts in clinical sce-\nnarios of liver disorders. MR can accurate evaluate the degree of liver steatosis with \nthe use of chemical shift and TSE fat suppression imaging. New tools (separation \nof water and fat signals with gradient asymmetric echo and spectroscopy) may be \neven more precise. Also, non-invasiveness iron concentration can be now calculated \nwith multiecho T2* relaxometry techniques and even with simple monoexponential \nT2 decay signal intensity calculations. The degree of water in the parenchyma can \nbe also inferred with the use of STIR images, thereby, allowing the diagnosis of \nsteatohepatitis and grading the necroinflammatory infiltrate in cirrhosis. The pres-\nence of liver fibrosis directly affects the isotropy conditions of the water molecules, \nsuffering from a higher restriction to movement. With IVIM, a restricted diffusion in \npatients with cirrhosis is mainly related to variations in the perfusion component \nas well as alterations in pure molecular water diffusion in cirrhotic livers. The liver \nperfusion characteristics may be also of interest in the evaluation of fibrosis and \ninflammation. MR Elastography and MR Spectroscopy with metabololomic quantita-\ntion will also play a role in the grading of chronic liver diseases. \n\nSunday\nPostgraduate Educational Programme\nA S87CB D E F G\nLearning Objectives:\n1. To learn the imaging features of cirrhotic diffuse liver disease.\n2. To learn the imaging features of non-cirrhotic diffuse liver disease.\n3. To learn how imaging can help in the quantification and follow-up of diffuse \nliver disease.\nA‑332 14:30 \nB. Infectious diseases of the liver \nO. Akhan; Ankara/TR (akhano@tr.net) \nInfectious diseases of the liver include pyogenic and amoebic abscesses, parasitic \ndiseases such as hydatid diseases and schistosomiasis, fungal, viral and granulmat-\nous diseases such as tuberculosis. Infectious organisms may enter into the liver \nby hematogenous spread via the hepatic artery or portal vein, ascension of the \ninfection from biliary tract or direct extension from penetrating trauma. The number \nof the patients with liver infections is increasing in the daily practice because of \nthe increases in immigration and travel worldwide besides higher rate of immu-\nnocompromised patients. Imaging modalities such as ultrasonography, computed \ntomography and Magnetic resonance imaging play important roles in the detection \nand differential diagnosis of liver infections. Features of imaging modalities with \nappropriate clinical information are needed to obtain the most likely diagnosis in \nmost of the cases with liver infections. However, percutaneous biopsy is indicated \nto achieve the correct diagnosis in the others. Characteristic imaging features \ndemonstrated in different liver infectious diseases may lead to early diagnosis, so \nthat appropriate treatment can be performed accordingly. Besides the advances of \nthe diagnosis, percutaneous treatment techniques under imaging guidance have \nalready gained a major role in the treatment of liver abscesses and liver hydatid \ndiseases. Percutaneous approach has already become the first choice in the treat-\nment of liver pyogenic abscesses and hydatid cysts. \nLearning Objectives:\n1. To learn relevant epidemiology of infectious diseases of the liver.\n2. To appreciate imaging findings of infectious disease in both \nimmunocompromised and non-immunocompromised patients.\n3. To understand the technique, indications and results of image-guided \nprocedures in the management of infectious diseases of the liver.\nA‑333 15:00 \nC. Vascular diseases of the liver: Detection and role of transplantation \nV. Vilgrain; Clichy/FR (valerie.vilgrain@bjn.aphp.fr) \nThere are three different vascular systems in the liver. Arterial diseases are uncom-\nmon and mostly observed after transarterial chemo-embolisation or liver transplanta-\ntion. These abnormalities will not be covered it this lecture. Portal venous obstruction \nmay be due to tumoral obstruction mostly related to hepatocellular carcinoma or \nclotting (portal venous thrombosis). Risk factors for portal vein thrombosis (PVT) \nare liver cirrhosis, intra-abdominal infection, and thrombophilic disorders including \nmyeloproliferative diseases. Diagnosis of PVT is based on imaging-studies and \namong them computed tomography plays an important role. Imaging is also helpful \nto differentiate acute stage from chronic stage and to evaluate the complications \nrelated to PVT including portal hypertension. Anticoagulation is strongly indicated \nin acute PVT as complete or partial repermeation can be achieved in most patients. \nOther treatments are exceptional. On the other hand, if extrahepatic PVT is pres-\nent, liver transplantation is much more complicated. The hepatic venous system \nextends from the central veins of the hepatic lobule, up to the hepatic vein ostia into \nthe inferior vena cava. Most of the other disorders of the hepatic venous system \neventually cause its obstruction. The so-called Budd-Chiari syndrome is the liver \ndisease resulting from the hepatic venous outflow block. Primary BCS relates to \nthe primary venous lesions including phlebitis, thrombosis or fibrosis. Diagnosis \nof PVT is based on imaging-studies and among them Doppler ultrasound and MR \nimaging play an important role. Anticoagulation and therapy for underlying disease \nare crucial. Portosystemic shunting and liver transplantation are discussed in \nsymptomatic patients after anticoagulation. \nLearning Objectives:\n1. To understand the imaging findings associated with vascular abnormalities \nwithin the liver.\n2. To learn the indications of liver transplantation in vascular diseases.\n3. To learn the importance of vascular assessment before liver transplantation \nand to recognise vascular abnormalities that may render difficult or even \ncontra-indicate liver transplantation.\n14:00 - 15:30 Room F2 \nBreast \nRC 1302 \nScreening programmes: New challenges \nModerator:\nS.B.G. Grover; New Delhi/IN \nA‑334 14:00 \nA. Digital mammography screening \nM.J. Y affe, R.A. Jong; Toronto, ON/CA (martin.yaffe@swri.ca) \nIn the DMIST trial of mammography screening, conducted in North America, \ndigital mammography was demonstrated to provide superior accuracy to screen \nfilm mammography, but only for certain overlapping subgroups, women with dense \nbreasts and women under the age of 50. The performance of digital mammography \nis achieved through an interplay of new technology and image processing software, \ninterfaced to a digital archiving system (PACS). The hardware consists of the X-ray \ndetector system and the high-resolution computer image display. The software \nincludes several types of image processing designed to facilitate interpretation \nof the examination and to improve performance at detection and characterization \nof lesions. Interestingly, unlike screen-film mammography, where the technology \nis fairly homogeneous, in digital mammography there is considerable diversity in \nthe designs of the detector systems and variation in their physical performance \ncharacteristics including spatial resolution and noise. Most mammographic signs \nof cancer provide subtle contrast and in general digital mammography systems are \ndesigned to amplify these contrasts at the expense of spatial resolution. Depend-\ning on the technology used, they may also provide advantages in terms of dose \nreduction and improved throughput of imaging. In this presentation, some of the \ntechnical factors (detector, display, software and PACS) and their influence on the \ndiagnostic performance and practicality of digital mammography in the context of \nscreening will be discussed. \nLearning Objectives:\n1. To describe conditions for digital screening.\n2. To describe different systems.\n3. To discuss the influence of digital screening on outcomes.\nA‑335 14:30 \nB. Are CAD systems of any help in screening? \nP .A.T. Baltzer; Jena/DE (pascal.baltzer@med.uni‑jena.de) \nThe basic concept of “Computer Assisted Diagnosis” (CAD) in radiology is to \nsimplify data analysis by use of computer techniques. The reader of a study is as-\nsisted by semiautomated analyses, which can be detection or characterization of \nsuspicious areas. Prospective use of statistical models derived from a previously \nanalyzed representative case database or implementation of machine learning \nmethods lead to the more sophisticated concept of “Computer Diagnosis”. In such \na setting, the computer is able to detect lesions and calculate their respective \nprobability of malignancy, acting as a second reader opinion. Up to now, only CAD \nsystems are available commercially. The use of CAD in X-ray mammography is \nquite well analyzed. Most of these systems assist the reader by detecting suspi-\ncious lesions or microcalcifications. A high computer sensitivity is controlled for \nspecificity by a human reader. In MR-mammography, CAD systems so far focused \non semiquantitative analysis of dynamic enhancement features. A threshold for \ninitial enhancement is used to segment dynamic volume data. All image voxels \npassing the initial enhancement threshold are further differentiated by their en-\nhancement characteristics. Parametric maps visualize results as a color-coded \noverlay. Furthermore, enhancement characteristics as well as lesion volumes can \nbe assessed quantitatively. Results can be integrated into a BIRADS based report \nmask. The idea is to standardize and simplify reporting of MR-mammography and \nthus to improve the diagnostic workflow. This talk will discuss possibilities of CAD \nin clinical workflow considering different CAD concepts and critically evaluate the \npossible value of CAD in screening with MR-mammography. \nLearning Objectives:\n1. To discuss CAD in clinical workflow.\n2. To discuss different types of CAD in MRI.\n3. To evaluate the value of CAD in screening with breast MRI.\n\nPostgraduate Educational Programme\nS88 A B C D E F G\nA‑336 15:00 \nC. Screening with MRI: The future? \nH. Dobson; Glasgow/UK (hilary.dobson@ggc.scot.nhs.uk) \nPopulation base screening for breast cancer with mammography has a strong evi-\ndence base and is used widely throughout the world. Since its inception, refinements \nof the mammographic process e.g. with the introduction of digital mammography \nand extension of policy to include younger and older women from the initial cohort of \n50-74, have been introduced. In the U.K., recent mortality evaluations have shown \ngeneralised improvement, in part due to the contribution by screening as a result \nof the detection of “earlier” disease. More recently, MRI has an established role in \nimproving cancer detection in populations deemed to be at high risk as a result of \nfamilial history/genetic mutation. This evidence base has resulted in a revision to \nthe surveillance guidelines in the U.K. Conflicting evidence, however, exists with \nregard to the use of MRI “screening” of women recently diagnosed with breast \ncancer but being assessed for surgical conservation and a review of the literature \n(including ACRIN6667 and COMICE) will be presented. Evidence fails to show a \ncost effectiveness basis for the use of MRI as a “screening” modality undergoing \nfollow-up following treatment for breast cancer. A recent study evaluating the use \nof MRI as a screening tool in young women have identified a potential increase in \ndetection rate of ductal carcinoma in situ (DCIS) but further work is required. MRI \nscreening of general population will be discussed in a cost effectiveness context. \nLearning Objectives:\n1. To give an overview of where we are now.\n2. To discuss the role of conventional imaging in screening together with MRI.\n3. To discuss the future role of screening with MRI.\n14:00 - 15:30 Room G/H \nNeuro \nRC 1311 \nNeurodegenerative disorders \nModerator:\nN.N.\nA‑337 14:00 \nA. The new MS diagnostic criteria \nB. Góraj; Nijmegen/NL (B.Goraj@rad.umcn.nl) \nMultiple sclerosis (MS) is the most common demyelinating disease. It can affect relatively \nyoung people and progressively lead to a serious invalidation and even death. It has \nbeen first recognized and described as the clinical entity together with its histopathologi-\ncal substrate in the end of the 19\nth century. From this time on, diverse variants and forms \nof the disease have been identified besides the classical MS. The clinical course of MS \ndoes not follow the uniform pattern; several possible forms have been distinguished. \nThe diagnosis of MS relied for many years on the clinical assessment and then also on \nthe presence of the CSF findings. Unfortunately, due to the frequently not unequivocal \nclinical manifestation, mimicking other disorders and to the low specificity of the CSF \nabnormalities, the diagnosis of MS remained difficult. The advent of MRI has changed \nthis situation dramatically; the new tool has been found, able to depict directly the le-\nsions in the brain. Visualisation of the demyelinated “plaques” has made it possible to \ndiagnose MS on the basis of the presence and typical configuration of the lesions as \nseen on MRI scans of the brain and spinal cord. MRI techniques enable to document \nthe dissemination of the lesions in space and time - essential for the definition of MS. \nThe combination of clinical, laboratory and imaging parameters are being designed and \nconstantly updated to serve as diagnostic criteria for the diagnosis of MS. \nLearning Objectives:\n1. To understand the pathomechanisms which lead to different MRI \nmanifestations of MS.\n2. To become familiar with diverse forms and variants of MS.\n3. To review the current diagnostic criteria for MS.\nA‑338 14:30 \nB. Early diagnosis and differential neuroimaging issues in dementia \nM.P . Wattjes; Amsterdam/NL (m.wattjes@vumc.nl) \nThe diagnosis of dementia is based on clinical findings within a multidisciplinary \ndiagnostic setting. Clinical neuroimaging is increasingly being used and has become \none of the most important paraclinical tools in the diagnosis of dementia. According \nto current guidelines, neuroimaging should be performed at least once during the \ndiagnostic work-up of patients with suspected or definite dementia. Initially, neuro-\nimaging was used to identify or exclude potentially treatable causes of dementia \nwhich accounts only for a small proportion of all causes of dementia. Currently, the \nrole of neuroimaging goes far beyond these purposes. Computed tomography (CT) \nand magnetic resonance imaging (MRI) are able to identify and quantify the amount \nregional/global cortical atrophy, hippocampus atrophy as well as detect vascular \ndamage. On structural MRI or CT, we are able to identify certain atrophy patterns \nwhich can substantially aid diagnosis in dementia. Particularly in early disease \nstages, advanced imaging techniques such as positron emission tomography (PET) \nand single photon emission computed tomography (SPECT) can be valuable tools \nto further improve the ability to differentiate among different neurodegenerative dis-\neases. Using special tracers such as the Pittsburgh Compound -B (PIB) ligand, we \nare able to directly detect amyloid depositions in the brain which is helpful to narrow \nthe differential diagnosis and to differentiate between Alzheimer pathology and other \nneurodegenerative diseases causing dementia. In addition to the role of neuroimaging \nfor diagnostic purposes, MRI and other advanced imaging modalities have already \nbecome indispensable tools for treatment and safety monitoring in clinical trials. \nLearning Objectives:\n1. To learn the additional value of clinical neuroimaging in dementia in terms of \nthe exclusion of curable causes.\n2. To discuss the key features of an imaging protocol for patients with dementia \non MRI and MDCT.\n3. To learn typical atrophy patterns and other imaging findings of \nneurodegenerative diseases.\n4. To learn the diagnostic criteria and imaging findings in vascular dementia.\nA‑339 15:00 \nC. Neuroimaging in abnormal movement diseases \nB. Gómez-Ansón, E. Granell Moreno; Barcelona/ES (bgomeza@santpau.cat) \nMovement diseases including Parkinson´s disease, atypical Parkinsonisms, \nHuntington´s disease, Fragile X Chromosome T remor Associated Ataxia Syndrome \n(FXT AS), essential tremor, and spinocerebellar ataxias, among others, have been tra-\nditionally described and classified on phenotypical (clinical) features. Recent advances \non their underlying genetic, biochemical, pathological and neuroimaging features have \nproduced the necessity for their reclassification. The association of cognitive decline to \nsome of these conditions has produced the emergence of new concepts/entities, such \nas Parkinson´s Disease Dementia or cognitive decline associated to taupathies. Ad-\nditionally, novel treatment options, both pharmacological and in functional neurosurgery, \nhave produced the necessity for improving early and precise diagnosis. Although neu-\nroimaging features have been described in groups of patients having various abnormal \nmovement disorders, a challenge still remains for neuroimaging to precisely characterize \na single subject´s pathological condition. Neuroimaging methods, including modern \npostprocessing/anaylysis approaches, such as Voxel based Morphometry (VBM) or \npattern recognition, may provide further insights in this regards in the very near future. \nFor this, multicentric, large-scale efforts to create large databanks of multidisciplinary \ninformation, aiming at linking the different types, are needed. \nLearning Objectives:\n1. To give an overview of the current classification of abnormal movement \ndiseases, including clinical, biochemical, and genetic data.\n2. To summarise the imaging findings described in these conditions.\n3. To present the challenges for neuroimaging in the field for the very near \nfuture.\n14:00 - 15:30 Room I \nPhysics in Radiology \nRC 1313 \nRadiation dose management \nModerators: \nM. Koutalonis; London/UK \nJ.N. Vassileva; Sofia/BG \nA‑340 14:00 \nA. Justification in clinical practice \nJ.R. Mayo; Vancouver, BC/CA (jmayo@vanhosp.bc.ca) \nJustification and dose optimization form the foundation of medical radiation dose \nmanagement. Justification ensures that the benefit derived from the radiologic \nexamination exceeds the risk imparted by: administered radiation, derived infor-\nmation and societal cost. The justification decision can only be completed using \ndata regarding: patient’s age, sex, medical condition, psychosocial state; referring \n\nSunday\nPostgraduate Educational Programme\nA S89CB D E F G\nclinician’s differential diagnosis, experience, tolerance for diagnostic certainty; \nradiologist’s expertise, experience, tolerance for diagnostic certainty, knowledge \nof radiation risk; society’s provision of equipment, resource balancing perceived \nneed. The weighting of any one factor may determine the final imaging decision. In \nmajority of cases, the information available for the calculation of risk benefit is either; \nignored, unrecognized, irrelevant, or nonexistent. Therefore, majority of imaging \ndecisions are arbitrary. The increased utilization of expensive, high radiation dose \nimaging examinations is forcing the radiologic community to address this problem, \nwith the poster child modality being CT. This review will provide an overview of the \nestimated extent of unjustified examinations and outline the currently implemented \nsolution, clinical practice guidelines supported by clinical outcome data. The ultimate \ngoal of justification is to provide all parties relevant risk and benefit information at \nthe time of radiologic consultation. \nLearning Objectives:\n1. To illustrate benefit-to-risk ratios for common CT examinations.\n2. To review the evidence that suggests harm may be caused by the radiation \ndose delivered in medical imaging.\n3. To outline a simple method of dose calculation for CT, the conversion of dose \nlength product to effective dose.\nA‑341 14:30 \nB. Practical CT dose reduction strategies \nW.A. Kalender; Erlangen/DE (willi.kalender@imp.uni‑erlangen.de) \nIt is generally known that dose depends on scan parameters such as tube voltage \n(kV) and time-current product (mAs); the basic relationships will be reviewed briefly. \nIt is less well known and actually a very complex question how a desired image qual-\nity level, in particular a specific contrast-to-noise-ratio, can be achieved at minimal \ndose. Respective optimization efforts also have to take the imaging task into ac-\ncount, i.e. the question if soft tissue, contrast medium or bone is to be imaged. Tube \ncurrent modulation and especially automatic exposure control which are available \non modern CT scanners try and help the user with this task; respective concepts \nand technical implementations will be reviewed in detail. They allow working at a \ndesired noise and resolution level by adapting the scan parameters automatically. \nTechnical approaches, e.g. new image reconstruction approaches or detector \nmaterials, which may help to reduce dose further and which will likely become \navailable routinely in the future, will be covered briefly to indicate their potential. \nLearning Objectives:\n1. To understand how patient dose relates to the choices of standard scan \nparameters.\n2. To understand the concepts of tube current modulation and automatic \nexposure control for CT.\n3. To learn about new technical approaches to dose reduction.\nA‑342 15:00 \nC. Digital vs conventional radiography: What about the dose? \nJ.R.G. Persliden; Örebro/SE (Jan.Persliden@orebroll.se) \nDigital radiography gives new possibilities to optimise the radiographic images. \nThe radiation dose in digital radiography can often be substantially reduced. This, \nhowever, depends among other factors on the radiation detector used. Using CR \n(computed radiography), the doses have been shown in several studies to be ap-\nproximately of the same magnitude as those in film screen radiography. Using flat \npanel detectors, the dose in some examinations have been reduced by up to 70% \ncompared to the film screen dose. The new detectors dynamic range means that \nwe no longer need to expose the image to the same density as before to avoid over \nor under exposure. We can now expose the image to the level where the noise no \nlonger is disturbing the interpretation and let the computer adjust the grey scale \nlevel. Examples will be given on how to reduce the dose down to an acceptable \nnoise level in lumbar spine and urography examinations. On the other hand, it is also \npossible to increase the dose without over exposing the image. An example will be \ngiven where the use of a digital fluoroscopy system substantially increased the dose. \nUsing digital techniques, it is also possible to process the image, reduce the noise, \nenhance edges, etc. Factorial experiments have been performed to find optimal \nexposure and processing settings in, as an example, lumbar spine examinations. \nLearning Objectives:\n1. To present radiation dose levels associated with digital radiography.\n2. To become familiar with practical dose reduction methods in digital \nradiography.\n3. To compare doses of conventional and digital radiography.\n14:00 - 15:30 Room K \nPediatric \nRC 1312 \nSafety first \nModerator:\nS. Ryan; Dublin/IE \nA‑343 14:00 \nA. CT in children: Dose reduction strategies \nR.A.J. Nievelstein; Utrecht/NL (R.A.J.Nievelstein@umcutrecht.nl) \nThe revolutionary development in multidetector CT (MDCT) technology during the \npast decade has contributed to a substantial increase in its diagnostic applications \nand accuracy in children. A major drawback of MDCT is the use of ionizing radiation \nwith the risks of radiation induced side effects, of which the induction of secondary \ncancer is the most important. Therefore, justification and optimization of paediatric \nMDCT is of great importance in order to reduce these risks as much as possible \n(„As low as reasonably achievable“ principle). Optimization of paediatric MDCT \nstarts with a solid understanding of all technical aspects of CT, including the most \nrelevant scan parameters, dose reduction techniques and technique of IV contrast \nmaterial administration. Furthermore, due to the smaller size and lack of visceral fat \nin young children, the interaction and absorption of radiation will be different which \nwill influence the choice of the various technique and scan parameters. Although all \nthese issues are pivotal for a successful CT examination, it may become worthless \nif the importance of pre-scan issues such as justification and patient preparation \nare ignored. After a short overview concerning the current knowledge on radiation \nrelated risks in children, this lecture will focus on several aspects relevant for MDCT \noptimization in children. Issues like justification, patient preparation, technique \nand scan parameters and contrast administration will be addressed. Finally, some \nguidelines for radiation dose level based CT protocols will be given. \nLearning Objectives:\n1. To outline the current knowledge on radiation risks in children.\n2. To discuss the CT scan and technique parameters that influence radiation \ndose.\n3. To discuss dose reducing strategies in order to optimise CT in children.\nA‑344 14:30 \nB. Ensuring safety for infants undergoing MRI \nT.G. Maris; Iraklion/GR (tmaris@med.uoc.gr) \nPurpose: To present an overview of the safety hazards and safety protocols related \nto infants undergoing MRI examinations.\nMethods and Materials: MRI infrastructure dependent safety hazards originating \nfrom: (a) static and fringe magnetic fields, (b) gradient subsystems, (c) radiofre-\nquency subsystems and (d) acoustic noise sound pressure will be reviewed and \ndiscussed. Safety hazards related to upcoming technological issues and future \ntrends concerning MRI will be presented. The current status of the organizations \nresponsible to the problems of MR safety will be reviewed. An optimized protocol \nrelated to a variety of clinical MR sequences in reference to temperature measure-\nments, EMF measurements, SAR and acoustic noise figures using basic com-\nmercially available infrastructure will be presented. 2D/3D TSE sequences with \ndifferent ETLs, 2D/3D GRE, 2D/3D SSFP , SE/GRE EPI sequences with multi-(b) \ndiffusion gradients and 3D TOF MR angiography sequences will be examined. In \nvitro measurements of SNR, spatial resolution and scan times will be performed \nfor each clinical MR sequence.\nResults: A comprehensive MRI equipment operational policy (optima: (ETL, TR, \nTE, b-value, EPI factor, SAR, SNR, Spatial Resolution, Scan time etc)) for a safety \nprotocol for infants undergoing MRI is proposed. Recommendations for safe infant \nMRI examinations will be summarized and presented.\nConclusion: MRI equipment can operate safely for infant imaging but require \npolicies and procedures beyond those required for standard diagnostic MRI \nexaminations. \nLearning Objectives:\n1. To present an overview of the three basic safety hazards related to infants \nundergoing MRI examinations.\n2. To present safety hazards related to upcoming technological issues and \nfuture trends.\n3. To present a safety protocol that could be applied in MRI examinations for \ninfants.\n\nPostgraduate Educational Programme\nS90 A B C D E F G\nA‑345 15:00 \nC. Fetal MRI: Attitudes towards safety \nD. Price; London/UK (david.price@uclh.nhs.uk) \nWith the development of ultra-fast imaging techniques such as EPI and HASTE, \nMRI has become a very important tool in the assessment of fetal abnormalities \nparticularly in the brain. However, there a number of potential hazards associated \nwith the use of this technique. The developing fetus will be exposed to both static \nand time-varying magnetic fields. There is also the potential for raised fetal tem-\nperatures due to RF power deposition. Ultra fast MRI scans may also have high \nacoustic noise levels. Current evidence suggests that RF heating and acoustic noise \nare the most concerning issues. However, there is a great deal of uncertainty over \nany possible effects. At present, published follow-up studies of children exposed to \nMRI in-utero have not shown any strong evidence of detrimental effects. However, \nthese studies have been on a small scale. Various national and international regu-\nlatory and advisory bodies have published guidance on MRI safety which include \nconsiderations of the pregnant patient and the fetus. Commercial MRI systems also \noperate to an IEC safety standard. In particular, this aims to restrict temperature \nrises within the patient through the use of specific absorption rate (SAR) limits. On \nthe basis of our present knowledge, it is prudent to remain within the ‘normal’ mode \nof operation with regard to SAR exposure. It is also important, so far as possible, \nto reduce the maternal stress induced by the examination; for instance, through \nthe provision of adequate hearing protection. \nLearning Objectives:\n1. To understand the possible hazards to the fetus from MRI including RF \npower deposition and acoustic noise.\n2. To achieve an awareness of the current evidence in the literature as to the \nextent of the hazards.\n3. To achieve an awareness of the current guidance from safety advisory bodies.\n4. To understand protective measures that may be considered as part of a risk-\nbenefit analysis for fetal imaging.\n14:00 - 15:30 Room L/M \nRadiographers \nRC 1314 \nCT imaging \nModerators: \nM. Golebiowski; Warsaw/PL \nD. Pekarovic; Ljubljana/SI \nA‑346 14:00 \nA. CT of the GI system \nM. Leidner; Stockholm/SE (Madeleine@Leidner.se) \nCT of the small bowel and the colon is done in our department for many years now. \nAs the technique gets better with the possibility to have thinner slices and shorter \nscan time, the exams are of course better today than when we started with CT of \nthe GI tract. We started with a 4 slice scanner, then a 16 slice scanner and now \nwith a 64 slice scanner we can really see the difference in images quality. The new \ntechnique also gives us nice reformatted images in other plans like coronal and \nsagital. At first, we used air for the colon and there had to be a doctor to insufflate \nthe air; now we use carbon dioxide and with automated insufflations. This means that \nwe get a much better colonic distention and it is easier for the patient. Now, we have \nsome radiographers doing the examinations. For the small bowel we use negative \ncontrast media, either Guaran (through a tube) or VoLumen to drink. The best is \nto administrate the contrast trough a nasogastric tube, but that means that there \nhas to be a doctor to insert the tube. Both examinations need intravenous contrast \nmedia and we give 500 mg Iodine based on body weight. The delay for the colon \nis 70 seconds (venous phase) and for the small bowel 50 seconds (enteric phase) \nto see the enhancement in the bowel wall. We always scan the whole abdomen. \nLearning Objectives:\n1. To learn about CT of the GI tract, especially the small bowel and colon.\n2. To understand the MDCT technique and how to improve image quality using \nexamples from 4, 16 and 64 slice scanners.\n3. To become familiar with how to prepare the patient, the use of different \ncontrast media, protocols for scanning and how to present the images for \nthe doctor.\nA‑347 14:45 \nB. Introduction to PET/CT: Modalities and patient care \nK.J. Thomsen; Odense/DK \nIn this presentation, the basics behind PET/CT will be presented giving an insight in the \nconfiguration of the scanner hardware and how the images are made. The technique \nis not as far away from X-rays as one should think. It is just turned a little upside down. \nThe patient is the part emitting the radiation instead of the X-ray tube, and the PET \ncrystal detects the radiation and converts it into useable images. The challenge in this \nprocess is the patient who becomes more or less radioactive. Rule number one: keeping \ndistance very much applies here. And, of course, as little patient contact as possible. \nLead is also used in protecting the staff but unfortunately the patient emits 511 KeV \nand so protective clothing made of lead is not an option. PET is a functional examina-\ntion much like ultrasound and urography. PET shows metabolic active cells. However, \nit can be difficult to say exactly which organ is affected. This is where the CT comes in. \nWhen the two types of images are fused, it is easier to see which organs are involved \nand thereby making a more exact diagnosis which will be illustrated. \nLearning Objectives:\n1. T o understand the basics behind PET/CT scanning, hardware configuration etc.\n2. To learn about the special problems/challenges when the patient is \nradioactive.\n3. To learn about the advantages in diagnosing diseases with PET/CT.\n14:00 - 15:30 Room N/O \nGenitourinary \nRC 1307 \nUterus: Imaging and intervention \nModerator:\nR. Forstner; Salzburg/AT \nA‑348 14:00 \nA. Benign diseases \nT.M. Cunha; Lisbon/PT (tmargarida@netcabo.pt) \nBenign diseases of the uterus can be evaluated by US, MRI, hysterography, hystero-\nsonography and hysteroscopy. Combined transabdominal and transvaginal US is the \nstudy of choice for the initial evaluation. The use of MRI appears to be cost-effective in \nthe diagnosis of endometrial thickening following treatment by tamoxifen, selection of \ncandidates for selective myomectomy and the follow-up of medically treated adenomyo-\nsis. MRI is helpful in unexplained uterine bleeding with normal ultrasound, before and \nafter embolization and in guiding focused ultrasound. CT has no role in the detection \nand characterization of benign uterine diseases. The most common diseases of the \nuterus are leiomyomas, adenomyosis and endometrial polyps. Leiomyomas may be \nsolitary or multiple, and over 90% arise from the uterine corpus. Leiomyomas can be \nsubmucosal, intramural, subserosal, or pedunculated. Subserosal leiomyoma can grow \nto a large size indistinguishable from an adnexal lesion on US. On MRI, leiomyomas \ncan be divided into two categories based on their histological characteristics: nonde-\ngenerative and degenerative. Degenerative changes correspond to hyaline, myxoid, \nhemorrhagic and cystic degeneration, and calcification. Adenomyosis is characterized \nby the presence of ectopic endometrial glands and stroma within the myometrium, \nat least 2.5 mm from the endometrial basalis layer and is associated with reactive \nhypertrophy of the surrounding myometrial smooth muscle. T wo forms of adenomyosis \nare known: a diffuse and a focal type, also known as adenomyoma. MRI is the most \naccurate noninvasive imaging test for differentiation of leiomyoma from adenomyosis. \nAfter imaging, detection of endometrial polyps should be always confirmed by hyster-\noscopy and pathological evaluation. \nLearning Objectives:\n1. To recognise US and MRI findings and imaging pitfalls in benign uterine \ndiseases.\n2. To understand the indications for MRI.\n3. To discuss the different types of uterine leiomyoma degeneration.\nA‑349 14:30 \nB. Malignant tumors \nJ.A. Spencer; Leeds/UK (johnaspencer50@hotmail.com) \nA recent modification to the FIGO staging system for uterine cancer has been agreed \nand this will be discussed with emphasis on its implications for imaging. A staging \nsystem has been proposed for uterine sarcoma which has previously been staged \naccording to that for uterine carcinoma. This divides sarcomas into leimyosarcoma \n\nSunday\nPostgraduate Educational Programme\nA S91CB D E F G\nwhere size is an important local staging discriminator from endometrial stromal \nsarcoma and adenosarcoma where depth invasion is more relevant. Carcinosar-\ncoma is staged as for uterine carcinoma where now local stage is simply stage IA, \ninner half, all tumour grades vs outer half, stage IB. \nLearning Objectives:\n1. To review MR imaging protocols and appearance of malignant uterine \ntumors.\n2. To understand the role of MR imaging in staging malignant uterine tumors.\n3. To understand current therapeutic strategies for malignant uterine tumors.\nA‑350 15:00 \nC. Ultrasound ablation and uterine artery embolisation for treatment of \nuterine leiomyomas \nT. Kroencke; Berlin/DE (thomas.kroencke@charite.de) \nUterine artery embolisation (UAE) is a non-surgical intervention for treating \nsymptomatic uterine leiomyomas and represents an alternative to surgical re -\nmoval (hysterectomy, moymectomy, hysteroscopic resection). The indication for \nuterine artery embolisation crucially relies on the pre-interventional assessment \nof symptomology and burden of disease. Especially the location, size, and number \nof leiomyomas are important to determine treatment options of patients. As a rule, \nboth single and multiple fibroids can be treated by UAE. The number and location \nof the individual tumors (subserosal, intramural, transmural, submucosal) do not \naffect the approach, technique or outcome of UAE. MR guided high-intensity focused \nultrasound (HIFUS) is a non-invasive treatment option for symptomatic leiomyomata. \nIn contrast to UAE and surgery, it lacks the invasiveness of these procedures since \nthe targeted leiomyoma are ablated by energy transmitted through the skin by \nfocused ultrasound while exact delivery is monitored online by MR imaging. Size, \nlocation and number of fibroids are limiting factors for the application of HIFUS. \nMagnetic resonance imaging (MRI) is superior compared to ultrasound in delineating \nthe extent of fibroid disease and excluding other pathologies or disease processes \nthat may mimic fibroid-related complaints. Further advantages of MRI result from \nthe use of MR angiography and contrast-enhanced imaging in assessing outcome \nand complications following UAE. This presentation summarizes the current role of \nUAE and ultrasound ablation (HIFUS) for uterine leiomyomata as well as the role \nof imaging before and after the procedure. \nLearning Objectives:\n1. To understand basic principles, indications and contraindications of MR-\nguided high-intensity focused US (HIFU) and uterine artery embolisation.\n2. To understand the role of imaging in patient selection and follow-up.\n3. To learn about the role of these treatment options and alternative surgical \ntherapies in light of the current literature.\n14:00 - 15:30 Room P \nProfessional Challenges Session \nPC 13 \nThe radiologist of the future: \nChallenges and changes \nModerator:\nP.A. Grenier; Paris/FR \nA‑351 14:00 \nChairman’s introduction \nP .A. Grenier; Paris/FR (philippe.grenier@psl.ap‑hop‑paris.fr) \nFrom training to management, numerous challenges await radiologists in the future. \nIt is necessary to update the curriculum for training in radiology, bearing in mind \nalarming demographic projections and the need for better representation of some \nsubspecialties. In the face of constant evolution in medicine, the role that radiologists \nwill play in innovative multidisciplinary fields, such as molecular imaging, needs to \nbe discussed now. Although probably involved in the future translational and clini-\ncal phases of development, radiologists must absolutely secure their place in the \nresearch teams as of today. Radiology could defend itself better in turf battles and \nto the authorities if it communicated more effectively and efficiently. Although numer-\nous challenges face imaging, there are reasons to be optimistic. Three international \nrenowned experts will address their visions on training perspectives, investment in \ntechnologic innovations, and the role of management and communication to reinforce \nthe position of radiology in healthcare systems. Different solutions will be debated \nduring the session, and participants are extremely welcome to present their ideas. \nSession Objectives:\n1. To become fully aware of the most important strategic issues for the future \nof radiology.\n2. To know the visions of three renowned and highly estimated leaders to take \nup our professional challenges.\n3. To be prepared to develop strategic plans in order to adapt our training \nprogrammes, develop new emerging areas of imaging, and improve our \nability in management and communication.\nA‑352 14:05 \nHow to train the radiologists of the 2 1st century \nI.W. McCall; Oswestry/UK (iainwmcc@aol.com) \nThe quality of training is a key factor for the future of European radiology. The \nnumbers of radiologists per national population varies across European, often \nwith insufficient trainees to replace let alone expand the specialist work force. The \nincreased percentage of female radiologists influences the available workforce and \nthe working time directive increase the radiologist requirement for a 24/7 service. \nThe training curriculum provides structure for all European training programmes \nand it must be regularly revised taking into account these demographic factors and \nfuture clinical demands reflecting future not past requirements. Developments that \nare limited to specialist centres or in advanced state of research will become main-\nstream and new techniques incorporated. Trainees must understand both principles \nand practice. Techniques that are no longer required are removed. The curriculum \nmust include an understanding of physiology and cell biology for molecular level \nimaging and function. Imaging is now too extensive for radiologists to be experts \nin all areas. Subspecialisation is therefore essential, but this must build on a core \nknowledge and ability to use all available equipment and to deal satisfactorily with all \ncommon diseases. The subsequent degree of subspecialisation will depend on the \nfuture role of the trainee. Subspecialisation curricula are also essential. Changing \nmethods of delivering training will provide greater European uniformity. The use of \ncomputer based teaching programmes and internet access to quality interactive \nradiological case collections will also bring overall improvements and harmonisation \ncombined with apprentice based experience monitored by a European organisation. \nLearning Objectives:\n1. To review the demographic perspectives in radiology for the next 10 years.\n2. To understand why and how the curriculum for training in radiology has to be \nupdated regularly.\n3. To know how to develop professional skills in subspecialties of radiology \nwithout leaving the common trunk.\nA‑353 14:28 \nMolecular imaging and therapy: Turf battle to lose or to win \nG.P . Krestin; Rotterdam/NL (g.p.krestin@erasmusmc.nl) \nMolecular imaging is expected to be pivotal to early diagnoses, patient stratifica-\ntion, and early response assessment. Although at a first glance it may seem to \nbe of little concern to radiologists, when looking beyond the pretty pictures and \nsometimes complex vocabulary of molecular imaging publications, it becomes clear \nthat radiologists need to get involved in this emerging field, if they want to maintain \ntheir central role in health care. While molecular imaging used to be primarily linked \nto imaging modalities not commonly associated with radiology departments, i.e. \noptical imaging, PET and SPECT, technologies such as CT, MRI and ultrasound \nare becoming essential tools in the field, either as a single modality or in hybrid \nimaging approaches. It is the role of academic and research institutions to gather \nknowledge and dedicate resources in this field. The radiological community needs to \ninvest in this future by education and participation in the molecular sciences and by \ncreating relevant research facilities. But it is not only research. Clinical radiologists \nhave to be aware of the ongoing innovations in our profession and support training \nand education of our next generations. Clearly, molecular imaging is the new frontier \nin diagnostic imaging, and therefore European radiologists have to be part in this \ndevelopment. But molecular imaging is and will remain a multidisciplinary effort for \nthe years to come. Not only imaging specialists a related basic scientists but also \nother disciplines are and should be involved in the complex process of translation \nof fundamental innovation into the clinical environment. \nLearning Objectives:\n1. To understand molecular imaging is a multidisciplinary field in medicine and \nscience.\n2. To make clear that radiologists must be involved in the development of \nmolecular imaging.\n3. To know the different steps and constraints in developing a molecular \nimaging programme in an academic centre.\n\nPostgraduate Educational Programme\nS92 A B C D E F G\nA‑354 14:51 \nMarketing in radiology: Evil or guardian angel \nM. Goyen; Hamburg/DE (goyen@uke.de) \nMarketing, public relations, customer communication - until recently the meaning \nof these concepts was unknown in European hospitals. With the incipient predatory \ncompetition and the increasing rivalry within the health market, a change of mind \nhas resulted: the hospital on its way to becoming a patient-, quality- and employee-\noriented service provider. The process of informing and, not least, specifically \naddressing internal and external customers plays an important role in this change. \nThis contribution offers an overview over health marketing as a marketing concept \nfor the planning, coordination and control of market-oriented healthcare activities \nwith the focus on radiology. \nLearning Objectives:\n1. To understand why and how the crucial role of radiology in patient \nmanagement and clinical outcomes must be more visible.\n2. To know how to convince the authorities and healthcare decision makers \nabout the strategic importance of investing in medical imaging innovations.\n3. To acquire basic knowledge to improve our communication abilities with our \npartners and patients.\nPanel discussion:  \nCan we be optimistic? … Yes we can! \n17:14 \n14:00 - 15:30 Room Q \nInterventional Radiology \nRC 1309 \nInfection and percutaneous drainage \nModerator:\nM. Bezzi; Rome/IT \nA‑355 14:00  \nA. Empyema \nA.G. Ryan; Waterford/IE (jackoriain@yahoo.ca) \nGuided by the surgical axiom of: “Choose well, Cut well, Get well”, I will discuss: a) \nthe diagnosis of empyema using radiographs, ultrasound and CT, b) the treatment \noptions, including the use of adjunctive pharmaceuticals, c) the evidence supporting \nthe optimal catheter and lytic and d) patient-related outcomes evidence for both \ninterventional radiology and surgical techniques. \nLearning Objectives:\n1. To discuss imaging and indications for drainage.\n2. To review technical aspects of catheter drainage.\n3. To discuss the use of urokinase.\n4. To discuss results of percutaneous drainage.\nA‑356 14:30 \nB. Abdominal abscess \nV. Válek; Brno/CZ (vlvalek@med.muni.cz) \nWith the new antimicrobial agents and advances in diagnostic imaging and imaging-\nguided percutaneous procedures has been significantly improved management of \npyogenic liver abscess. The advantages of the percutaneous approach include a \nmarked\n decrease in the invasiveness and cost of abscess drainage. The classic triad \nof fever, upper right quadrant pain or fullness, and jaundice is rarely seen nowadays. \nPossible image-based exclusionary criteria for drainage included abscess size of \nless than 3 cm in diameter, fluid attenuation of more than 40 HU, absence of contrast \nmaterial-enhanced margins, absence of trapped air in a fluid collection, absence of \nfree intraperitoneal air, and presence of air without fluid in the abscess cavity. The \nmost important is size of less than 3 cm. Possible clinical exclusionary criteria included \nnormal white blood cell count, normal temperature, normal blood pressure, absence of \nperitoneal signs, lack of relevant medical history and do-not-resuscitate code status. \nIndications for percutaneous approach to abdominal abscess drainage are a clinical \nsign of inflammation and fluid collection (abscess) large than 3 cm. Contraindications \nare today only relative. Percutaneous needle aspiration or catheter drainage guided by \nCT of sonography, therefore, has become the therapy of choice for abdominal abscess. \nLearning Objectives:\n1. To discuss common indications for drainage and appropriate imaging work-up.\n2. To discuss image guidance, route planning and catheter placement.\n3. To review follow-up strategies and results.\nA‑357 15:00 \nC. Pelvic abscess \nM.A. Funovics; Vienna/AT (martin.funovics@univie.ac.at) \nPelvic abscess drainage may employ more difficult acces routes due to amatomic \nrestrictions. The procedure may carry a higher risk of complications compared to \nsimple abdominal drainage. To optimize patient preparation, correction of coagula-\ntion deficits, optimization of antibiotic treatment, and sedation or anesthesia may be \nneeded. The usual access routes for deep pelvic abscesses are the anterolateral and \nthe posterior transgluteal approach. In selected cases, a transvaginal or transrectal \napproach may be the safer and more efficient option. Depending on the viscosity \nof the drained fluid, the presence of necrotic solid tissue and gas, different sizes of \ndrainage material may be needed. Do not hesitate to employ large drainage catheters \nif indicated. An overview of the available material will be given. Intestinal laceration is a \nmajor complication which can be managed percutaneously in selected circumstances. \nThe postinterventional management after percutaneous drainage is among the most \nimportant predictors of success, and most often neglected. It is advocated that the \nmanagement is actively guided by the interventionalist who ensures that the drainage \nis properly handled, rinsed, and cleaned, that follow-up imaging is performed at the \nright intervals, and who ultimately indicates drain removal. \nLearning Objectives:\n1. To discuss indications and imaging work-up.\n2. To learn about transgluteal, endocavitary and other routes of drainage.\n3. To review results and follow-up strategies.\n16:00 - 17:30 Room A \nRadiology in Abdominal Emergencies \nCC 1417 \nInflammation and oedema \nModerator:\nJ.‑M. Bruel; Montpellier/FR \nA‑358 16:00 \nA. The three musketeers: Appendicitis, diverticulitis, colitis \nJ. Stoker; Amsterdam/NL (j.stoker@amc.uva.nl) \nAppendicitis, diverticulitis and colitis are frequent causes of acute inflammatory bowel \nemergencies. In many patients, suspected for these conditions the diagnosis is not \nclear upfront. Imaging plays an important role in identifying the underlying cause. \nUltrasound (US) and computed tomography (CT) are readily available and widely used \nimaging techniques for this work up. US comprises an examination of the abdomen \nwith the graded compression technique. A transducer should be used optimized for \nthe visualization of the bowel. The CT protocol includes the use of intravenous contrast \nmedium, while oral contrast medium will not be routine in many institutions. Findings \nare bowel wall thickening (or enlarged appendiceal diameter), fat infiltration, free air \nand fluid collections. The present evidence on the role of imaging in appendicitis and \ndiverticulitis is substantial and has been summarized in systematic reviews. Although \nUS is accurate in diagnosing appendicitis and diverticulitis, CT is more accurate than \nUS. Further advantages of CT are better identification of alternative diagnoses and \nbetter comparison between consecutive examinations. Thereby, CT is more helpful \nin communicating the diagnosis to the referring physician. Cost effectiveness of \nCT in acute appendicitis has been demonstrated as well as the positive impact on \nmanagement. For colitis, the evidence is more limited and imaging has here more \nlimitations. Drawback of CT is ionizing radiation exposure. An imaging strategy with \ninitial US and CT only in inconclusive of negative US cases results in the highest \nsensitivity, reduces ionizing radiation exposure and is cost effective. \nLearning Objectives:\n1. To know the pros and cons of ultrasound and computer tomography in \nappendicitis, diverticulitis and colitis.\n2. To understand the imaging findings and results in appendicitis, diverticulitis \nand colitis.\n3. To learn the role of imaging in acute inflammatory bowel emergencies.\nA‑359 16:30 \nB. Liver and biliary tree \nJ.A. Soto; Boston, MA/US (jorgeasoto@aol.com) \nAcute inflammatory and infectious diseases of the liver and biliary tract are often \nsuspected to be the cause of symptoms that require emergent attention. Thus, \nthe hepato-biliary system is frequently the target of imaging studies performed on \n\nSunday\nPostgraduate Educational Programme\nA S93CB D E F G\npatients presenting acutely. Additionally, the gallbladder and bile ducts are com-\nmonly found to be the unsuspected source of non-specific complaints, such as \nfever/malaise or alterations of laboratory tests, such as leukocytosis or elevated \nacute phase reactant levels. Acute hepato-biliary conditions encountered regularly \ninclude acute cholecystitis and its complications, acute biliary obstruction with \nascending cholangitis and hepatic abscess. Although these diagnoses can be \nstraightforward in patients with the classic combinations of specific symptoms, \nsigns and abnormal test results, the clinical situation can be atypical, leading to \ndelays in diagnosis with devastating consequences. Ultrasonography has been (and \ncontinues to be) the first imaging test used to evaluate the liver and biliary tract in \nthe emergency setting. When sonographic findings confirm the clinically suspected \ndisease, the diagnosis is established and specific therapy can be administered. \nHowever, due to the inherent limitations of ultrasonography in some instances and \nthe non-specific clinical presentation of many patients, additional examinations are \noften acquired during the diagnostic investigation. These include CT, MR/MRCP , \nscintigraphy (HIDA scan), ERCP and EUS. This course reviews the imaging find-\nings on multiple modalities of these acute hepato-biliary inflammatory processes \nwith reference to the various clinical contexts. Strengths and weaknesses of each \nmodality are emphasized, with special attention placed on causes of false-negative \nand false-positive results. \nLearning Objectives:\n1. To learn the etiology and clinical presentation of acute inflammatory liver \ndiseases.\n2. To understand imaging strategies using US, CT and MRI.\n3. To know typical findings and the spectrum of differential diagnoses.\nA‑360 17:00 \nC. Pancreatitis: Common and critical \nP .R. Ros; Boston, MA/US (Pablo.Ros@UHhospitals.org) \nPancreatitis is an abdominal condition potentially life threatening. Imaging plays a \nkey role not only in the diagnosis but also in the staging and patient management of \nacute and chronic pancreatitis. Management of interstitial or edematous pancreatitis \nis supportive. On the other hand, severe or necrotizing pancreatitis requires intense \nmonitoring, specific therapies and has a guarded prognosis, since it may lead to \norgan failure, infection, pseudocyst formation and extrapancreatic parenchymal and \nvascular complications. Pancreatic inflammation and necrosis can be easily identi-\nfied by imaging methods and has prognostic implications. The clinical prognostic \ncriteria in acute pancreatitis have been modified and are currently coupled with \nimaging criteria. CT plays a central role in the evaluation of patients with known or \nsuspected pancreatitis. A CT based severity index is the main prognostic method \nto predict outcomes. In addition, MRI and MRCP play increasingly important roles \nin pancreatitis evaluation. Integrity of the pancreatic duct can be easily evaluated \nby this last method, particularly if coupled with the use of secretin. We discuss the \nmodern imaging criteria for the diagnoses, staging and patient management in acute \npancreatitis and review subtypes such as immunologic and groove pancreatitis. We \nadditionally review the evidence based imaging utilization parameters and published \nappropriateness criteria for the use of CT and MRI in the setting of pancreatitis. \nLearning Objectives:\n1. To learn epidemiology and clinical outcome of patients with pancreatitis.\n2. To understand typical findings and diagnostic pitfalls.\n3. To know the role of radiology in patients with acute and chronic pancreatitis.\n16:00 - 17:30 Room B \nSpecial Focus Session \nSF 14 \nImaging in ENT emergencies \nModerator:\nB. Verbist; Leiden/NL \nA‑361 16:00 \nChairman‘s introduction \nB. Verbist; Leiden/NL (b.m.verbist@lumc.nl) \nMany ENT and craniofacial pathologies can be handled electively; however, there \nare otolaryngological emergencies, both traumatic and non-traumatic, for which \nproper initial assessment and management are crucial in preserving life and \nminimizing disabling or disfiguring sequelae. This session will highlight the diag-\nnostic approach and critical imaging findings in patients with facial and temporal \nbone trauma and infectious or inflammatory disease of the paranasal sinus, neck, \nmastoid, middle and inner ear. \nSession Objectives:\n1. To review indications for urgent imaging in head and neck radiology.\n2. To provide appropriate imaging protocols for ENT emergencies.\n3. To become familiar with imaging findings in acute head and neck pathology.\nA‑362 16:05 \nEmergencies of the sinonasal cavities and the anterior skull base \nJ.W. Casselman; Bruges/BE (jan.casselman@azbrugge.be) \nLife-threatening emergencies are rare in the anterior skull base and sinonasal \nand orbital region. In trauma, even the most severe fractures or soft tissue lesions \nrarely require immediate life saving intervention. However, intracranial bleeding, \nbrain concussion with swelling etc. require immediate care. Therefore, imaging \nshould always include the intracranial structures. A major soft tissue bleeding can \nalso put the patient’s life at risk and prompt action by the surgeon is then needed. \nSevere bleeding can also occur after surgery performed for other reasons (e.g. \ntumor surgery). Traumatic involvement of the eye and especially the optic nerve \nshould be checked as fast decompression of the nerve is needed to preserve \nvision. Both CT and MR can play a role here. Infection, especially fungal sinus \ninfection, can reach the orbital intra-conal structures or intracranial structures. This, \nthen, becomes a real emergency and can have a fatal outcome in the absence \nof adequate treatment. Many other lesions present as “sub-acute” emergencies. \nImaging is required to save normal function (e.g. vision, mastication, prevention or \nreparation of CSF leaks which often make normal daily life impossible etc). In most \nof the traumatic and bleeding emergencies, CT will be the technique of choice in the \nearly post-traumatic period because of its availability, speed and access (monitoring \netc). However, in some cases (e.g. optic nerve compression/edema), MR might be \nneeded in an immediate second stage. Most of the above mentioned emergencies \nwill be illustrated and discussed. \nLearning Objectives:\n1. To know the traumatic and non-traumatic emergencies in the anterior skull \nbase and orbit.\n2. To learn which imaging techniques should be used in the different \nemergency situations.\n3. To learn which information is most important for the clinician and must be \nreported.\nA‑363 16:28 \nEmergencies of the ear \nF . Veillon; Strasbourg/FR (Francis.Veillon@chru‑strasbourg.fr) \nThe emergencies of the ear are represented by the acute infection of the middle \near with mastoiditis whose extension must be described by the radiologist to the \notologist: peripheral abcess, osteitis, fistula of the otic capsule, thrombosis of the \nlateral sinus, extradural abcess, unique or multiple cerebral abcesses. Infections \nof the inner ear leading to ossifying labyrinthitis are regarded as an emergency in \ncases where cochlear implantation is considered. The traumatisms of the round \nand/or oval windows with or without fracture with a leakage of perilabyrinthine fluid \nare also discussed with the results of imaging leading, in most of the cases, to an \nimmediate surgery. The fistulas of the inner ear with an important vertigo due to \nsecondary or primitive cholesteatomas, histiocytosis, agranulocytosis, tuberculosis \nmust be operated immediately. Finally, a precise knowledge of anatomy, a good \ntechnique of imaging and a close collaboration with the otologist are necessary. \nLearning Objectives:\n1. To understand what the otologist wants to know from the radiologist in acute \nmastoiditis.\n2. T o learn about the different techniques of CT and MRI in emergencies of the ear.\n3. To describe a practical approach to reading the images in emergencies of \nthe ear.\nA‑364 16:51 \nEmergencies of the neck \nM. Becker; Geneva/CH (minerva.becker@hcuge.ch) \nThe purpose of this lecture is to familiarize the radiologist with the most common \ntypes of traumatic and non- traumatic emergencies in the neck. A systematic review \nwill include key radiologic features of laryngeal fractures, pharyngeal perforation, \ntraumatic vascular injuries (dissection, occulusion, pseudoaneurysm, perforation \nand acute bleeding) and trauma of the brachial plexus (streching, avulsion, compres-\nsion). The review will also focus on non-traumatic neck emergencies with a special \nemphasis on infectious lesions including suppurative lymphadenitis, cellulitis, neck \n\nPostgraduate Educational Programme\nS94 A B C D E F G\nabscess, necrotizing fasciitis, pyolaryngoceles, osteomyelitis, septic thrombosis \nof the internal jugular vein and infected branchial cleft cysts. Typical associated \ninfectious complications of the mediastinum and chest will be discussed with an \nemphasis on the early detection of lesions. The detection of foreign bodies as a \ncause of secondary infection will also be briefly addressed. Major emphasis will \nbe put on what the clinician needs to know and on how to report the findings in a \ncomprehensive way. \nLearning Objectives:\n1. To become familiar with common presentations of traumatic and non-\ntraumatic emergencies of the neck.\n2. To describe the pertinent radiologic findings and to identify related \ncomplications.\n3. To be able to adapt the examination protocol depending on the type of lesion \nsuspected.\n4. To learn how to report the pertinent findings to the clinician.\nPanel discussion:  \nGood reasons for performing CT and MRI in emergencies 1\n7:14 \n16:00 - 17:30 Room C \nNew Horizons Session \nNH 14 \nHybrid imaging: The radiologic/nuclear sandwich\nModerator:\nT.F . Hany; Zurich/CH \nA‑365 16:00 \nChairman’s introduction \nT.F . Hany; Zurich/CH (thomas.hany@usz.ch) \nThe science of medical imaging has various facets, especially function and morphol-\nogy, play a major role in oncology as well as non-oncological disease. Even though \ncapable of detecting various functional impairments, radiology is regarded as the \nmain diagnostic field in the detection of morphological pathologies, especially by \ncross-sectional imaging. Nuclear medicine, on the other hand, has been limited \nto a certain kind of pure functional studies. The introduction of positron-emission-\ntomography (PET) at the end of the last decade by using different tracers, among \nwhich F-18 Fluorodeoxyglucose proved the most reliable substance for metabolic \nimaging, has rejuvenated nuclear medicine especially in the field of oncological \nimaging. Hampered by the lack of a morphological reference frame, addition of \nmorphological cross-sectional image information of computed tomography (CT) \nto the so-called PET/CT has proved to be one of the most successful stories in \nmedical imaging. This success has carried on further developments to combine \ndifferent imaging modalities as well as nuclear medicine tracers/technologies like \nPET/MR or SPECT/CT in oncological imaging and other fields like cardiology or \nmusculo-skeletal disease. This development has been driven by experts of each \nfield; however, further efforts have to be invested to determine how/where to embed \nthis technology and how to train our future users to satiate our ongoing hunger of \nknowledge, which a sandwich just cannot do. \nSession Objectives:\n1. To learn technique and daily use of hybrid imaging technology.\n2. To enhance the knowledge of new tracers used in hybrid imaging.\n3. To have further insight in possible other hybrid imaging technology beyond \nPET/CT.\nA‑366 16:05 \nPET/CT: Lessons learned from a decade \nG. Antoch; Essen/DE (gerald.antoch@uni‑essen.de) \nDiagnostic potentials - as well as limitations - associated with morphological \ncross-sectional imaging on the one hand, and functional imaging on the other, are \nincreasingly well understood. It has become obvious that in many cases both kinds \nof imaging complement one another. Therefore, hybrid PET/CT imaging must be \nconsidered one of the most important new developments in medical imaging in the \npast decade. However, some questions have to be raised and challenges have to \nbe met to avoid overrating PET/CT in oncology and cardiology. In oncology, PET/\nCT with [18 F]-2-Fluoro-2-deoxy-D-glucose (FDG) as a radioactive tracer has been \nreported to be more accurate than either imaging modality alone and sometimes \neven more accurate than CT and PET read side by side. However, the clinically \nimportant question after one decade of PET/CT imaging should rather be the fol-\nlowing: Does this higher accuracy have an impact on patient management? Only \nrecently have cardiac PET/CT applications have become feasible with integra-\ntion of high-end CT systems within the PET/CT scanner. A „one-stop shopping \napproach“ when imaging a coronary artery stenosis with CT -angiography (CTA) \nand, simultaneously, imaging the corresponding functional effects of the affected \nmyocardium must be considered desirable. However, visual correlation of CTA \nwith PET or SPECT data sets acquired on separate scanners has been performed \nsuccessfully for years. To address the topic „lessons learned from a decade“, this \ntalk will provide an overview on current indications as well as limitations of PET/\nCT in oncology and cardiology. \nLearning Objectives:\n1. To become familiar with indications of PET/CT utilizing FDG and other \nradionuclides.\n2. To understand the limitations of PET/CT as currently available in clinical \nroutine.\n3. To learn about tumor-specific PET/CT examination protocols.\nA‑367 16:28 \nNew tracers in hybrid imaging \nS. Fanti; Bologna/IT (stefano.fanti@aosp.bo.it) \nAmong molecular imaging procedures, Positron Emission Tomography (PET) is \nthe most diffuse and rapidly growing, and at present it is routinely used in patients \naffected by a large variety of malignant neoplastic diseases. Many papers in the \nliterature have already demonstrated the utility of this imaging technique whose \ncapabilities have been furthermore developed by the introduction of hybrid scan-\nners, particularly PET/CT. The combination of functional data (given by PET) and \nanatomic details (by CT) allows to significantly increase diagnostic accuracy, es-\nsentially due to a better specificity. The usefulness of PET relies on its capability \nof investigating molecular processes by means of specific radiotracers, with the \nmost employed being 18 F-DeoxyGlucose (FDG). FDG PET scans give important \ninformation about tissues glucose consuption, usually very increased in the great \nmajority of solid malignancies. Despite FDG scans representing more than 90% \nof all PET scans, other positron emitter tracers are available and each one may be \nspecific for different neoplastic diseases. In fact, some malignancies do not show \nincrease in glucose consumption and are almost invisible with FDG. Tracers already \nin clinical use include Choline (labelled with 11C or 18 F), a marker of cell membrane \nmetabolism particularly useful for prostate cancer detection; 18 F-Tyrosine and \n11C-Methionine, which enable to study proteic metabolism and are successfully \nemployed for CNS neoplastic diseases; 11C-Acetate, used for prostate cancer, \nhepatocellular carcinoma and other liver lesions; and 18 F-DOPA and 68Ga-DOTA-\nNOC, useful in neuroendocrine tumors. Other PET tracers are currently undergoing \ntrials to evaluate their potential usefulness in oncology and other fields. \nLearning Objectives:\n1. To become familiar with new PET tracers beyond FDG recently introduced in \nhybrid imaging.\n2. To understand the potential clinical applications of PET/CT using these new \ntracers.\n3. To speculate on further development of hybrid imaging related to new tracers.\nA‑368 16:51 \nHybrid imaging in 10 years \nT. Beyer; Essen/DE (thomas2@gmx.net) \nSince the 1990s, combinations of imaging systems have become available that \nallow the intrinsic combination of functional and anatomical imaging within a single \nexam. With the latest PET/MRI technology, this information can even be acquired \nsimultaneously, thus opening the door to new insight into molecular pathways and to \nexaminations that are affected less by motion artifacts. Though PET/MR is unlikely \nto replace PET/CT, or any other imaging technology as such in clinical routine, \nit has nonetheless aroused the interest of many researchers. PET/MR appears \nparticularly appealing in neurology research and some oncology applications. \nIn 10 years from now, we will see all existing dual-modality imaging systems in \nclinical routine, including PET/MR. These systems will offer patients a maximum \naccuracy in diagnosis, staging and follow-up. Research on PET/MR together with \nnew advances in therapy strategies for neurodegenerative diseases may help \npush the importance of PET/MRI. We will witness ultra-fast, whole-body PET/CT \nstaging becoming a modality-of-choice in oncology. SPECT/CT could evolve into \na whole-body imaging modality with supplementary use in dosimetry applications. \nAlthough desirable, other combinations of imaging systems, such as SPECT and \nMRI, may have to wait another 10 years to turn into prototype systems for clinical \napplications. In the interim, a combination of PET and US is lingering around waiting \n\nSunday\nPostgraduate Educational Programme\nA S95CB D E F G\nfor first prototype adopters. As exciting as these new hybrid imaging systems, even \ntriple-modality systems, sound we need to remember that these imaging systems \nneed to be technologically feasible, applicable in clinical routine and cost-effective. \nLearning Objectives:\n1. To review existing hybrid imaging technology in clinical practice \n(e.g. SPECT/CT, PET/CT, PET/MR).\n2. To appreciate the potential of truly combined imaging technology \n(e.g. anatomical guidance of image reconstruction).\n3. To speculate on hybrid imaging technology and applications in the near and \ndistant future.\nPanel discussion:  \nWill all imaging become hybrid? \n17:14 \n16:00 - 17:30 Room D \nImaging in Lung Diseases \nCC 1418 \nIs volumetric CT the only way of scanning lung \ndiseases? \nModerator:\nJ. Rémy; Lille/FR \nA‑369 16:00 \nA. Radiation dose and chest CT imaging \nD. Tack; Baudour/BE (denis.tack@skynet.be) \nX-rays delivered by diagnostic and interventional radiology are lower than 100 to 200 \nmSv and belong to the low level radiation. As no direct carcinogenic effect of low level \nradiation has been definitely proven, the carcinogenic risk in the range of low-level \nradiation is calculated by linear extrapolation of the risk observed among atomic bomb \nsurvivors. CT is responsible for more than 50% of patient exposure for diagnostic imag-\ning because the number of examination and the dose per examination are both high. \nChest is an anatomical region of high risk for radiation induced carcinogenesis because \nthe radio sensitivity of its content is high, in particular in women because of the breast. \nLearning Objectives:\n1. To understand the current debates on the radiation risks of medical imaging.\n2. To describe the relative contribution of CT to radiation dose.\n3. To review the relative radiosensitivity of chest organs and the subsequent \npractical considerations for chest CT imaging.\nA‑370 16:30 \nB. Optimisation of volumetric CT protocols \nM. Prokop; Nijmegen/NL (mathias.prokop@gmail.com) \nVolumetric CT protocols have become the de-facto standard for most body CT \napplications. The „scan thin-read thick“ paradigm is also valid for pulmonary CT: \ndata are acquired with thin collimation (0.5 - 1 mm, depending on scanner type), \nreconstructed with slightly thicker overlapping sections (0.75 - 1.25 mm) to yield \na „secondary raw data set“ from which, depending on the clinical question, thick \naxial, coronal and sagittal sections can be reconstructed using multiplanar reforma-\ntions. For most clinical application, 5 mm thick sections reconstructed every 4 mm \nsuffice. For lung embolism and high-resolution imaging of the lung parenchyma, \nhowever, thinner sections (1 - 2 mm) yield better results. For the lung parenchyma, \nin particular, special adaptations have to be considered: by using a 768\n2 or 10242 \nmatrix and a high-resolution kernel spatial resolution can be improved. By choos-\ning the reconstruction increment close to the relation “field of view/matrix size”, \nan isotropic data grid is produced that provides excellent quality in all imaging \ndirections. Higher speed will reduce breathing artifacts. Minimum scan durations \nfor the chest vary between 0.7 and 4 s, depending on the manufacturer. Without \nECG-triggering, ultrafast scans may cover the heart in systole and suffer from severe \ncardiac motion artifacts also in the lung parenchyma. Prospective ECG-triggering \nof ultrafast spiral scans (“flash scanning”) is therefore advisable so that the heart is \nalways covered in diastole. Retrospective gating is only useful in patients with lung \ndisease if cardiac function or pulmonary artery pulsatility is to be evaluated as well. \nLearning Objectives:\n1. To understand the “scan thin-read thick” paradigm of volumetric scanning.\n2. To become familiar with the various techniques to optimise volumetric \nresolution.\n3. To understand the effect of motion and learn about techniques to reduce \nmotion artifacts.\nA‑371 17:00 \nC. Alternatives to volumetric CT \nS.R. Desai; London/UK (sujal.desai@kch.nhs.uk) \nMultidetector computed tomography (MDCT) of the lungs offers many advantages: \nthe rapid acquisition significantly reduces or eliminates the movement artefacts \nthat have plagued earlier generations of CT machines. Multiplanar images, once \nthe ambit of magnetic resonance imaging, are now routinely available from MDCT \nacquisitions. Sophisticated post-processing techniques (including internal/external \nrendering and maximum/minimum intensity projections) and the ability to generate \n“high-resolution” images, that simulate conventional high-resolution CT (HRCT), \nare the other perceived benefits of MDCT technology. Nevertheless, advances in \nimaging often come at a price and must never be viewed uncritically: aside from \nthe increased radiation burden, the real clinical impact of MDCT images has never \nbeen rigorously tested. Indeed, in specific clinical scenarios (for example, in the \ndiagnosis of acute pulmonary embolism), MDCT images appear to offer no clinical \nor prognostic advantage over CT images acquired using single-slice technology. In \nmany air space diseases, MDCT probably adds little to the diagnostic evaluation \nparticularly after the findings on serial chest radiographs and the key clinical data \nhave been considered. In diffuse interstitial lung diseases (DILD), it is noteworthy \nthat the image quality of a “high-resolution” MDCT study may be inferior to con-\nventional HRCT. Furthermore, the added influence of the larger number of images \ngenerated in an MDCT examination on observer confidence and accuracy in DILD \nhas been questioned. In this presentation, the value of volumetric MDCT in thoracic \nimaging will be critically evaluated. \nLearning Objectives:\n1. To review the clinical situations in which alternatives to volumetric CT can be \nreasonably considered.\n2. To describe the practical alternatives to volumetric CT.\n3. To discuss the necessary collaboration between radiologists and clinicians to \nimplement alternatives to volumetric CT in routine clinical practice.\n16:00 - 17:30 Room E1 \nMusculoskeletal \nRC 1410 \nBone tumors \nModerator:\nK. Verstraete; Gent/BE \nA‑372 16:00 \nA. Diagnosis: From radiographs to MRI \nK. Wörtler; Munich/DE (woertler@roe.med.tum.de) \nThe diagnosis of a bone tumor is based on clinical findings, the age of the patient, \nthe location of the lesion, its radiologic appearance, and, if imaging does not al-\nlow for a specific diagnosis, its histopathologic features. Radiography remains the \ninitial imaging modality for evaluation of the localization of the lesion with respect \nto the longitudinal and axial planes of the involved bone, for the depiction of matrix \nmineralizations, and for estimation of biologic activity by analyzing the patterns of \nbone destruction and periosteal response. CT can add „radiographic“ information \nparticularly in regions of complex skeletal anatomy such as the spine, pelvis and \nshoulder girdle. MR imaging has classically been used to determine the local ex-\ntent of a bone tumor (local staging). In addition to radiography and/or CT, it can at \ntimes also be valuable in establishing the differential diagnosis, especially in cystic \nbone lesions and cartilaginous tumors. Whole-body applications have recently \ngained importance in demonstrating the presence and extent of bone (marrow) \ninvolvement in benign and malignant systemic/polyostotic tumorous diseases. This \ncourse reviews the basic principles of diagnosing bone tumors in a multimodality \napproach (with an emphasis on conventional radiography). The different steps of \nmorphologic analysis as well as the advantages and disadvantages of the individual \nimaging techniques are illustrated on the basis of pathologically confirmed cases. \nLearning Objectives:\n1. To become familiar with the basic principles of diagnosing bone tumors.\n2. To learn how to determine the biologic activity of bone neoplasms and tumor-\nlike lesions on the basis of radiographic findings.\n3. To understand the role of CT and MRI in the diagnosis of bone tumors.\n4. To recognise imaging patterns on the basis of radiologic-pathologic \ncorrelation.\n\nPostgraduate Educational Programme\nS96 A B C D E F G\nA‑373 16:30 \nB. Staging and intervention \nS. James; Birmingham/UK (steven.james@roh.nhs.uk) \nPrimary bone tumours require both local staging and the identification of distant \nmetastases to guide management. MR imaging is the modality of choice to determine \nlocal disease extent and allows excellent depiction of intra and extra-osseous disease. \nChest CT enables pulmonary metastases to be identified and bone scintigraphy al-\nlows evaluation of the presence of bone metastases. The roles of whole body MRI \nand PET/CT in the staging of bone tumours will also be discussed. Whilst imaging \nmay allow a narrow differential diagnosis to be reached, histological confirmation \nof the nature of the lesion is required pre-operatively to plan appropriate treatment. \nImage guided biopsy may be performed using fluoroscopy, CT, MRI and occasionally \nultrasound guidance. The relative values of each of these techniques will be covered. \nPercutaneous therapies are increasingly being utilised in the treatment of a number \nof primary bone tumours. Radiofrequency ablation is the method of choice for osteoid \nosteoma and is now used in the treatment of chondroblastoma. Alternatives include \nmicrowave therapy, cryotherapy and sclerotherapy. These percutaneous techniques \nmay also be used for local disease control where disease recurrence is encountered. \nLearning Objectives:\n1. To understand the role of radiographs, MRI, CT and bone scintigraphy in the \nstaging of primary bone tumours.\n2. To appreciate the principles and techniques of percutaneous bone biopsy.\n3. To be aware of the indications, technique and outcome of percutaneous \ntherapies in the treatment of bone tumors.\nA‑374 17:00 \nC. New techniques (including DWI) \nS. Pans; Leuven/BE (Steven.Pans@uz.kuleuven.ac.be) \nMagnetic resonance imaging (MRI) has evolved to become the most important diag-\nnostic method for local staging of primary bone tumors and for detecting postoperative \ntumor relapse. It allows accurate preoperative staging of local tumor extent and helps \nto obtain adequate safety margins. MRI is a noninvasive technique that can be used to \nobtain information regarding tumor vascularization, metabolism, and pathophysiology, \nand allows early assessment of therapeutic effects of cancer drugs. One approach is \ndynamic contrast-enhanced (DCE) MRI, which measures tumor vascular characteristics \nafter administration of a contrast medium. MRI enhanced with small-molecular-weight \ncontrast agents is extensively used in the clinic to differentiate benign from malignant \nlesions, as well as to monitor tumor microvascular characteristics during treatment. \nDiffusion-weighted MRI (DWI) is a more recent technique and it allows noninvasive \ncharacterization of biologic tissues based on the random microscopic motion of water \nproton measurement. Several studies have shown that DWI allows early detection of \ntumor response to chemotherapy. The use of water diffusion is a surrogate marker used \nto distinguish highly cellular regions of tumor from acellular and necrotic regions. Whole \nbody diffusion-weighted sequence (WB DWI) is a new promising technique feasible \nto evaluate multifocal disease. DWI has revealed great potential in the evaluation of \npatients with cancer or benign disease, as it supplies both quantitative and qualitative \ninformation of the whole body. This presentation will focus on the potential role of DWI \nin combination of DCE MRI in bone tumors as well as on the possibilities of WB DWI. \nLearning Objectives:\n1. To learn about new techniques in diagnosis and follow-up of bone tumors.\n2. To appreciate the integration of DWI in whole-body MRI.\n3. To become familiar with diffusion-weighted imaging in bone tumors.\n16:00 - 17:30 Room E2 \nInteractive Teaching Session \nE³ 1420 \nLymphomas: Diagnosis, staging and follow-up \nModerator:\nJ.A. Verschakelen; Leuven/BE \nA‑375 16:00 \nLymphomas: Diagnosis, staging and follow-up \nE. de Kerviler1, R.M. Mendelson2; 1Paris/FR, 2Perth/AU\n(richard.mendelson@health.wa.gov.au) \nLymphomas may be of nodal or extra-nodal origin and are broadly classified into \nHodgkin‘s disease (HD) and Non-Hodgkin‘s lymphoma (NHL). Notwithstanding a \nsophisticated subclassification, the key issue for the radiologist is differentiating \nindolent and aggressive lymphomas. Protean imaging manifestations reflect the \nvaried pathology of lymphomas. HD tends to progress contiguously and is limited \nto nodes and spleen until advanced. NHL often presents as disseminated extra-\nnodal disease. Consequently, localized HD is often treated by a combination of \nchemotherapy and radiotherapy, whereas disseminated HD or NHLs are treated by \nintensive chemotherapy alone. Distinguishing localized and non-localized disease \nis therefore critical in HD. Examples of lymphoma in various organ systems will be \ndemonstrated, with emphasis on gastrointestinal lymphomas. Imaging has roles in \ndiagnosis, staging, and assessing treatment response. The advantages and limita-\ntions of various modalities will be discussed. Imaging-directed core biopsy including \nspecimen immunohistochemistry should obviate surgery. Relapse requires repeat \nbiopsy to assess possible transformation. Staging, usually by the Ann Arbor clas-\nsification (or modifications), is primarily by CT, which can also monitor therapeutic \nresponse. Other, organ-specific, imaging is performed when clinically indicated \n- for example, bone scintigraphy or MRI for bone pain; gastrointestinal studies for \nappropriate symptoms; MRI for suspected CNS lymphoma. \n18F -PET or PET/CT \nare useful for showing occult advanced disease, assessing therapeutic response \n(by the International Harmonization Project revised response criteria), detecting \nrelapse, and differentiating fibrosis/necrosis from viable tumour. Follow-up imag-\ning for Burkitt’s and aggressive lymphoma should be early to assess therapeutic \nefficiency, or after several chemotherapy courses for more indolent lymphomas. \nLearning Objectives:\n1. To learn the protean appearances of lymphoma in relation to the organ \nsystems involved.\n2. To understand the radiologic-pathologic correlations of the different cell types \nof lymphoma.\n3. To discuss the role of image-guided core needle biopsies in the definitive \ndiagnosis of lymphoma at diagnosis and follow-up.\n4. To discuss the roles of imaging in radiological and nuclear medicine \ntechniques in staging, treatment and follow-up of lymphoma with emphasis \non the new response criteria.\n16:00 - 17:30 Room F1 \nMolecular Imaging \nRC 1406 \nMolecular imaging probes on your doorstep \nModerator:\nJ.Å. Jakobsen; Oslo/NO \nA‑376 16:00 \nA. SPIO and USPIO probes for inflammatory diseases \nN. Grenier; Bordeaux/FR (nicolas.grenier@chu‑bordeaux.fr) \nSuperparamagnetic iron oxide particles will probably play a major role in future clini-\ncal applications of imaging of inflammatory processes. Cardiovascular, neurological, \nrenal and osseous inflammatory diseases are mainly concerned. First generation \nparticles with a short circulating time (SPIO) will have limited applications because \nrapidly cleared from blood by phagocytosis. However, their incorporation ex vivo into \ncells is the most efficient for cell labeling and tracking, for example of macrophages. \nFollowing generations are smaller particles with longer circulating time (USPIO, \nMION, CLIO), better devoted to target inflammatory cells in vivo and to be used as \nmolecular probes. Non-specific targeting of phagocytic cells as macrophages has \nbeen demonstrated in many experimental inflammatory models and, in humans, \nfor characterizing vulnerable atherosclerotic plaques, active inflammatory renal \ndiseases, and active plaques in multiple sclerosis. Mechanism of cell uptake is \ncomplex and its degree and speed depend on many factors as particle size and type \nof coating. Small particles can be targeted more specifically by attaching specific \nligands of biological targets such as integrins overexpressed on surface of cells \ninvolved during inflammatory process as macrophages, leucocytes, smooth muscle \ncells, endothelial cells or activated platelets. Ex vivo labeling of macrophages has \nrecently developed and incorporation of particles also depends on their physical \ncharacteristics. This method will make possible to track the macrophages to inflam-\nmatory sites and, in the future, could serve as cellular vectors for gene therapy. \nLearning Objectives:\n1. To understand the working mechanism of SPIO and USPIO probes.\n2. To understand how these probes can be used in visualisation of \ninflammatory diseases.\n3. To show the clinical value of these probes.\n\nSunday\nPostgraduate Educational Programme\nA S97CB D E F G\nA‑377 16:30 \nB. Multi-functional MRI for assessing novel therapies: Decision tools or \ndecorations? \nA.R. Padhani; Northwood/UK \nThere is an increased opportunity to perform MR imaging using functional imag-\ning techniques at a variety of organ sites in a relatively short examination time \nacceptable to patients. These techniques yield quantitative information which \nreflects on specific aspects of the underlying tumour or tissue biology. Many of \nthese techniques are used to provide unique information as surrogate biomark-\ners for tumour behaviour, including response of tumours to novel treatments. The \nmulti-parametric approach combines the information from different function imaging \ntechniques, which goes beyond what can be achieved using any single functional \ntechnique, thus allowing an improved understanding of the biological processes and \nthe biological responses to therapeutic interventions. Multiparametric MR imaging \nhas many potential clinical roles and is useful for pharmaceutical drug development \nand for predicting therapeutic efficacy. \nLearning Objectives:\n1. To know that functional MRI bridges the gap between animal and humans in \nearly drug development.\n2. To realise that pharmacodynamic information has direct a influence on early \ndrug development.\n3. To know the biophysical basis and quantification of multifunctional MRI \ntechniques that probe tumor processes of proliferation, hypoxia and \nangiogenesis.\n4. To learn that imaging findings differ in their onset, duration and magnitude \nthus reflecting underlying pathophysiological changes and heterogeneity \nrelated to therapeutic effects.\nA‑378 17:00 \nC. MRI cell tracking \nJ.W.M. Bulte; Baltimore, MD/US (jwmbulte@MRI.jhu.edu) \nThe clinical development of novel immune and stem cell therapies calls for suitable \nmethods that can follow the fate of cells non-invasively in humans at high resolu-\ntion. Our lab has developed several methods to label cells magnetically (using tiny \nsuperparamagnetic iron oxide nanoparticles) in order to make them visible by MR \nimaging. Following years of extensive animal research, in 2005, this technology \nwas introduced in the clinic using dendritic cell cancer vaccines. MRI cell tracking \nis further pursued in animal models of de- and dys-myelination, multiple sclerosis, \nbrain tumors, spinal cord injury, stroke, and cardiovascular disease. Novel reporter \ngenes are also being developed that can provide contrast on MRI scans. Artificial \nproteins are being designed, cloned, and expressed in mammalian cells that contain \nspecific proton exchangable groups of which the proton signal can be manipulated. \nInstead of directly labeling cells, we have also shown that semi-permeable algi-\nnate microcapsules can be loaded with multimodal contrast agents while offering \nsimultaneous immunoprotection of cellular therapeutics. \nLearning Objectives:\n1. To understand how cells can be labelled and thus tracked.\n2. To introduce the potential clinical indications and applications.\n16:00 - 17:30 Room F2 \nBreast \nRC 1402 \nDetection of ductal carcinoma in situ \nModerator:\nG. Forrai; Budapest/HU \nA‑379 16:00  \nA. Mammography \nB. Brancato, R. Taschini; Florence/IT (b.brancato@ispo.toscana.it) \nMammography is the leading method for the diagnosis of DCIS. As mammographic \nsigns are sometimes rather subtle, their detection requires optimal technique and \nskilled radiologists. DCIS very often exhibit microcalcifications, due to either tumoral \nnecrosis (typically, comedocarcinoma) or active cellular secretion; DCIS can also \nappear as a mass, due to epithelial proliferation, periductal fibrosis and elastosis. \nMicrocalcifications are very often isolated (47% in our series). Less frequently, they \nare associated with mass (39%). Isolated masses are uncommon (4%). Digital \nmammography, as it betters conspicuity of microcalcifications, notably improves \ndetection of DCIS. Although mammography is very powerful in detecting early \nsigns of DCIS, it is less effective in differential diagnosis with benign lesions. Fine, \nlinear, branching (casting) calcifications (BI-RADS 5) have the highest positive \npredictive value (PPV) for malignancy; amorphous, pleomorphic, and granular \ncalcifications (BI-RADS 4) are of intermediate concern and needle core biopsy is \nalways mandatory. Among masses, opacities with high density, irregular shape, \nspiculate margins have the highest PPV for malignancy, although DCIS usually \nexhibit low density masses, elongated, with indistinct margins. The PPV increases \nwhen a mass is associated with microcalcifications. The distinction is between \nDCIS and invasive carcinoma is very difficult as the signs are often similar and \nthe two pathologies frequently associated (e.g. microinvasive carcinoma; invasive \ncarcinoma with extensive intraductal component); DCIS is more likely in case of \nisolated microcalcifications without mass. \nLearning Objectives:\n1. To review the signs in depicting DCIS.\n2. To learn how we can reach this diagnosis with a low PPV.\n3. To classify microcalcifications using BI-RADS categories.\nA‑380 16:30 \nB. Ultrasound \nC.F . Weismann; Salzburg/AT (christian.weismann@inode.at) \nWhat can US learn from mammography (MG) in DCIS? In up to 90%, DCIS is \ndiagnosed by MG detecting pleomorphic and irregular clustered microcalcifications \n(MCs). The US investigator learns from MG the localisation and the distribution \n(group, linear, segmental, regional) of the MCs in the breast. Depending on mam-\nmographical breast tissue density and on morphology of the DCIS, MG may show \nthe combination of MCs embedded in a mass or in an enlarged tubular structure.\nWhat are the US criteria of mammographically proven microcalcifications? US-\nvisualisation of the MCs depends on tissue contrast. The tissue contrast is influenced \nby the US-frequency used. The higher the frequency, the better the spatial resolution, \nalthough the tissue contrast may be reduced. Modern US technology permits to alter \nthe frequency during the investigation to optimize the tissue contrast. The individual \nMC appears as a tiny echogenic dot or spot. It may show reverberations. Usually, \nacoustic shadowing is not produced by a single MC. Morphologic determination \ncomparable to MG-features is currently beyond resolution. What are the US signs \nof calcified and non-calcified DCIS? Low echo lesions, well circumscribed with \nechogenic dots and spots (MCs) are the common type. Low echo lesions with an \nill defined margin with or without echogenic dots, irregularly enlarged ducts filled \nwith hypoechogenic structures with or without MCs, lesions in combination with a \nduct and intracystic solid lesions raise the suspicion of DCIS.\nWhat helps to realize the problem? According to the above questions, some tips \nconclude the lecture. \nLearning Objectives:\n1. To compare its value with mammography in DCIS.\n2. To discuss diagnostic criteria for DCIS with and without microcalcifications.\n3. To learn practical tips in problem solving.\nA‑381 17:00 \nC. MR imaging \nR.A. Kubik-Huch; Baden/CH (rahel.kubik@ksb.ch) \nPatients with ductal carcinoma in situ (DCIS) may develop invasive carcinoma in \nabout 60% of cases over a period of 10 years. Therefore, it is important to diagnose \nand evaluate cases of DCIS properly for better patient management. Dynamic \ncontrast-enhanced MRI of the breast has become a well established method for \ndetecting and evaluating invasive breast carcinoma. There are less scientific data \nregarding the accuracy of MRI as compared to mammography for in situ carcinoma. \nIn contrast to invasive carcinoma, DCIS usually displays linear of ductal clumped \nenhancement and focal branching pattern on dynamic contrast-enhanced se -\nquences and delayed, persistent (i.e. benign) dynamics. Therefore, morphology is \nmore reliable than kinetics. Overlap with benign disease, e.g. fibrocystic changes, \ndoes exist. MRI was shown to be significantly more sensitive than mammography \nor ultrasound for the detection of DCIS. The wide range of sensitivities for detection \nof DCIS published in the literature is in part likely to reflect variations in interpreta-\ntions, imaging parameters and selections bias. DCIS are a highly heterogeneous \ngroup of tumors. Preliminary data indicate that the enhancement patterns may \npartly also depend on the grading and a normal MRI scan may potentially allow to \nexclude high grade DCIS. The role of MRI in DCIS is currently not fully established. \nMRI may play an increasing role in assessing the extent of disease in the breast \nin women with known or suspected DCIS in the future. \n\nPostgraduate Educational Programme\nS98 A B C D E F G\nLearning Objectives:\n1. To learn about the morphological pattern and signal enhancement \ncharacteristics of ductal carcinoma in situ.\n2. To discuss whether in situ carcinoma can be differentiated from invasive \ndisease on MRI.\n3. To review the current literature on MRI in ductal carcinoma in situ.\n4. To discuss the potential impact of breast MRI on the treatment of DCIS.\n16:00 - 17:30 Room G/H \nNeuro \nRC 1411 \nCommon disorders of the pediatric brain \nModerator:\nP. Eliás; Hradec Králové/CZ \nA‑382 16:00 \nA. Fetal MR imaging: More than just T2-weighted images \nC. Hoffmann; Tel Hashomer/IL (chen.hoffmann@sheba.health.gov.il) \nThe objective of this talk is to introduce other techniques than SS FSE T2 in use when \nscanning the fetal brain. The most frequent indications for MRI are ventriculomegaly, \nasymmetry of the ventricular system, brain malformations, infection and others. Most \nof the MR scan is done with Single Shot FSE T2 (SSFSET2); this is a sequence al-\nlowing the acquisition of slice by slice of the brain, and thus minimizing the effect of \nfetal movement on the scan. T oday, fast FRFSET2 are available; this is a very short \nT2 sequence in which the white and gray matter junction is visualized very well. T1 or \nFSPGR are used with limitations due to the fetal movements. It is necessary to perform \nT1 to demonstrate the myelination. DWI is a very important tool in the understanding the \nischemic changes in the adult brain, allowing the diagnosis of acute infarcts. Ischemic \ninsult can occur in fetuses with conditions such as TTTS in twin pregnancies and fetal \ndemise. The living fetus can also suffer from abnormal blood supply to the CNS, and \nthus showing small or even large hemispheric infarcts. Other diffusion technique, DTI is \nalso used to demonstrate the white matter formation of the fetal brain. MRS is also used \nin the evaluation of the fetal brain. The values of the NAA, choline and the existence of \nlactate are different than the values in the pediatric and adult brain. \nLearning Objectives:\n1. To explore the new imaging techniques for the study of the fetal brain.\n2. To study the use of diffusion-weighted imaging in the fetal brain.\n3. To focus on an accurate use of T1-weighted sequences in the fetal brain.\n4. To explore the possibilities of tractography in the fetal brain.\nA‑383 16:30 \nB. Normal findings and pitfalls in pediatric neuroimaging \nW. Chong; London/UK (ChongK@gosh.nhs.uk) \nNeuroimaging of the developing pediatric brain and spine requires the optimisation of \nimaging equipment and parameters. The radiologist is assisted by a good knowledge \nof embryology and normal variants as well as an understanding of pediatric disorders. \nHowever, even without a thorough knowledge of pediatrics, the application of sound \nradiological principles, including physics and anatomy, applied logically and rigorously, \nwill allow the radiologist to provide clinically useful interpretations of the images. Pitfall \nmay still occur, and the common ones are usually based on common misunderstand-\nings or even myths about pediatric normal anatomy or the presentation of disease as \nseen in adults. In a famous quote, ‘the child is not simply a small adult’. \nLearning Objectives:\n1. To understand a different approach to neuroimaging in the developing \npediatric brain and spine.\n2. To appreciate that, despite the wide and potentially complex spectrum of \ndiseases seen in neuropediatrics, most interpretations can be made through \nthe thoughtful application of basic neuroradiological analytical techniques.\n3. To be aware of certain areas where common pitfalls, myths and \nmisunderstandings occur.\nA‑384 17:00 \nC. Neuroimaging in the acutely ill child \nE. Vázquez; Barcelona/ES (evazquez@vhebron.net) \nThe ability to develop more aggressive treatments of acute neurological disorders \nin children is nowadays improving; however, infants and children are often uncoop-\nerative, clinical signs are not always easily localized, and so diagnosis and therapy \nmay be both delayed. Effective imaging of the central nervous system has assumed \nan increasingly important role in the evaluation of children with acute neurological \ndisorders. This lecture will review the main indications to perform a neuroimaging \nprocedure in children with a neurological emergency. With didactic purposes, these \nacute conditions will be classified in traumatic and non-traumatic conditions. In \nthe no traumatic acute setting we will consider children presenting with headache \n(particularly with those symptoms and signs suggesting underlying neoplasm or \nhaemorrhage), seizures (particular relevance to those cases that need urgent \nneuroimaging), coma, acute neurological deficits, or acute spinal cord syndrome. \nPractical algorithms with the preferential use of either CT or MRI (including diffu-\nsion and spectroscopy) in each group of pathologies, such as cranial trauma, acute \nhypoxia, cerebral infarction, venous thrombosis, haemorrhage, shunt malfunction \nor encephalitis, will be presented following representative didactic cases selected \nfrom the daily routine in a paediatric tertiary hospital. \nLearning Objectives:\n1. To learn the characteristic neuroimaging findings that may be useful in \nestablishing differential diagnoses.\n2. To understand the various neurological complications that can occur in the \nintensive care unit and to become familiar with their most typical imaging \npatterns.\n3. To consolidate the best neuroimaging protocols for the acutely ill child \nand establish the main indications for the use of MR imaging, particularly \ndiffusion and spectroscopy.\n16:00 - 17:30 Room I \nPhysics in Radiology \nRC 1413 \nClinical audit, accreditation and the role of the \nmedical physicist \nModerators: \nA. Del Guerra; Pisa/IT \nJ. Geleijns; Leiden/NL \nA‑385 16:00 \nA. European-wide perspective on clinical audit \nH. Jarvinen; Helsinki/FI (hannu.jarvinen@stuk.fi) \nThe Council Directive 97/43/EURATOM introduced the concept of clinical audit to \nmedical RADIOLOGICAL (diagnostic radiology, nuclear medicine and radiotherapy) \nprocedures. Clinical audit is a systematic review of the procedures in order to im-\nprove the quality and the outcome of patient care. According to the directive, clinical \naudits shall be implemented in accordance with national procedures. The review of \nits implementation in Europe has revealed a high variation of approaches and many \npractical problems. Therefore, the European Commission has published further guid-\nance on clinical audits in its Radiation Protection series. The purpose is to improve the \nimplementation of clinical audits and to enable the member states to adopt the model \nof clinical audit with respect to their national legislation and administrative provisions. \nThe guideline points out the importance of both internal and external assessments \nfor clinical audit. It deals with all types and levels of clinical audit and gives practical \nguidance for application. It defines the list of topics which should be covered, while the \nactual criteria of good practice are discussed on generic levels only. The borderline \nbetween clinical audit and other quality assessments (accreditations, certifications, \npeer reviews) and regulatory inspections is also discussed. The guideline is ad -\ndressed to all professional groups, hospital management, auditing organizations \nand regulatory bodies. It is important to recognize that the guideline is not a legal \nrequirement. Through addressing technical, financial and clinical provision for high \nquality RADIOLOGICAL procedures, the main beneficiary is eventually the patient. \nLearning Objectives:\n1. To describe the purpose and essential contents of the European commission \nguideline on clinical audit.\n2. To describe a review of clinical audits in Europe.\nA‑386 16:30 \nB. National perspective: Clinical audit inspections \nS. Ebdon-Jackson; Didcot/UK (steve.ebdon‑jackson@hpa.org.uk) \nEuropean Council Directive 97/43/Euratom requires under Article 6 (4) that “clinical \naudits are carried out in accordance with national procedures”. Implementation \nof this requirement across Europe has been varied. This paper will reflect on the \nexperience in the UK and will consider examples of the various initiatives under-\n\nSunday\nPostgraduate Educational Programme\nA S99CB D E F G\ntaken in the UK by professional bodies and organisations. This will be contrasted \nwith the role of the regulator and the aims of the inspection process with regard to \ncompliance with the specific regulation addressing clinical audit and the remaining \nregulations addressing justification, optimisation etc. Examples will be provided of \nthe type of audits undertaken within UK hospitals. A UK perspective of EC and \nIAEA initiatives in clinical audit will be provided. \nLearning Objectives:\n1. To describe the approach taken by a national body to perform clinical audit.\n2. To describe practical aspects of clinical audit inspections.\n3. To describe lessons learned from inspection and suggestions for \nimprovement.\nA‑387 17:00 \nC. Hospital perspective on clinical audit \nP . Gilligan; Dublin/IE (PGilligan@materprivate.ie) \nThe demand from the public for greater accountability and standards has increased \nthe importance of audit and accreditation in modern healthcare delivery. Success may \ndetermine whether the hospital can secure funding or even continue to offer certain \nservices. Specifically, radiology departments participate in audits by a number of enti-\nties: 1. National bodies concerned with improving radiation safety particularly under \nEU 97/43 directives. 2. Hospital wide accreditation surveys from state and private \naccrediting organisations such as Joint Commission International and ISO. 3. Audit-\ning of standards from within professional bodies. 4. Investigation of specific incidents \nwithin radiology departments such as misdiagnosis or radiation concerns. 5. Modality \nspecific standards. Although the specific requirements of the accrediting or auditing \nbody may differ, the processes and practical aspects in demonstrating compliance with \nstandards and quality improvement are similar. In addition to fulfilling basic regulatory \nrequirements, the medical physicist is playing a role in developing performance indices \nparticularly in radiation safety, clinical image quality and equipment management. \nThe medical physicists experience in developing quality assurance programs has \nalso proved useful throughout the whole hospital. The increasing role of the medical \nphysicist in audit underpins the requirement for inclusion of audit and accreditation as \npart of their education. Recent experience of setting up and participating in EU 97/43 \ndirective based clinical audit in Ireland highlighted the critical need for clarity of roles \nand ownerships of processes to be communicated to those who are carrying out audit \nand those who are being audited in hospitals. \nLearning Objectives:\n1. T o describe practical aspects of complying with standards and undergoing audit.\n2. To describe the outcomes of the audit.\n3. To describe how to implement the results of the clinical audit.\n16:00 - 17:30 Room K \nPediatric \nRC 1412 \nImaging in non-accidental injury \nModerator:\nR.R. van Rijn; Amsterdam/NL \nA‑388 16:00 \nA. CNS trauma \nP . Demaerel; Leuven/BE (philippe.demaerel@uz.kuleuven.ac.be) \nThe presentation will focus on the role of the radiologist in non-accidental head \ninjury. The common acute findings will be discussed as well as the long term imaging \nfeatures on brain CT and MRI. An optimal imaging strategy will be defined. Particular \nattention will be paid to the role of skull X-ray and ultrasound, to the assessment of \ngeneralised brain edema on CT, to the estimation of timing hematoma on CT and \nMRI, to the role of diffusion weighted MRI, to the differential diagnosis with other \nentities and to the interaction with the forensic sciences in medico-legal situations. \nNon-accidental head injury is regularly encountered in large community hospitals \nand the role of the radiologist is crucial because the clinical presentation is often \nmisleading. Therefore, all radiologists should be aware of the, sometimes subtle, \nimaging appearances. \nLearning Objectives:\n1. To stress the role of CT in the assessment of non-accidental cranial injury.\n2. To emphasise the contribution of MRI, including diffusion-weighted imaging, \nin the acute setting.\n3. To describe controversies regarding the age of a subdural hematoma.\n4. To give advice on how to report on a CNS non-accidental injury.\nA‑389 16:30 \nB. Skeletal trauma \nM. Alison, R. Azoulay, B. Tilea, G.-H. Sebag; Paris/FR\n(guy.sebag@rdb.ap‑hop‑paris.fr) \nImaging plays an important role in the detection and documentation of abuse, and \nfailure to make a correct diagnosis may have serious consequences. Fractures are \nthe second most common finding in child abuse after cutaneous findings and the \nskeletal survey is the cornerstone radiological examination in suspected physical \nabuse. The skeletal survey protocol should be performed according to the pub-\nlished pediatric radiology guidelines and standards. Careful attention is needed \nwith regard to the quality of the radiographs. Equivocal fractures at all sites should \nbe evaluated with additional projections. The follow-up skeletal survey increases \nthe sensitivity of initial radiographic examination and should be considered in all \ncases where abuse is strongly suspected. Bone scintigraphy may complement the \nskeletal survey notably in infants. Although estimation of fracture age should be \napproached with caution, it is important to differentiate recent from old fractures \nand when multiple fractures are present to state if the fractures are of similar or \ndifferent ages. Careful interpretation by radiologists with experience in pediatric \nimaging is mandatory in order to distinguish abuse from accidental trauma, normal \nvariants, metabolic bone diseases and skeletal dysplasias. \nLearning Objectives:\n1. To describe the imaging strategy in skeletal non-accidental injury.\n2. To determine the technical considerations including quality insurance.\n3. To show the imaging features of inflicted skeletal injury.\n4. To discuss the differential diagnosis.\nA‑390 17:00 \nC. Abdominal trauma \nM. Raissaki; Iraklion/GR (mraissaki@yahoo.gr) \nChild abuse accounts for 10% of all blunt abdominal traumas in patients younger than \n5 years. Abuse-related abdominal injuries carry a worse prognosis, with a mortality \nof up to 50%, due to the severity of injuries, the delay in seeking help and occasion-\nally the misleading provided history. A high index of suspicion should exist for any \npatient less than 3 years of age with a traumatised hollow or solid viscous especially \nwhen the history is not consistent with the clinical presentation or extent of injury. Any \nabdominal injury pattern may occur in child abuse, the commonest being duodenal \nor other hollow viscera’s hematoma and/or rupture, mesenteric trauma, pancreatic \nlaceration, liver laceration, and adrenal hematomas. Multiple injured organs, combina-\ntion of solid and hollow viscus injuries may also occur. Rib, pelvis and spinal fractures \nshould be actively looked for. Indications for imaging the abdomen in suspected child \nabuse include elevated hepatic transaminases and amylase, abdominal bruising, \ndistension, tenderness, bilious vomiting and hematuria. Abused children who have \nsuffered massive trauma should be imaged with the same protocols as the ones fol-\nlowing extensive accidental trauma. Following stabilization, CT is considered the test \nof choice for the identification and documentation of abdominal trauma in suspected \nchild abuse. Ultrasonography is considered a reasonable preliminary study in stable \nchildren less than 1 year of age and extremely useful for the follow-up. An upper GI \nseries is indicated for occult or resolving duodenal hematomas. \nLearning Objectives:\n1. To understand differences between accidental and non-accidental abdominal \ntrauma.\n2. To describe the type of abdominal injuries that may indicate child abuse.\n3. To discuss the appropriateness of imaging in suspected abdominal non-\naccidental trauma.\n\nPostgraduate Educational Programme\nS100 A B C D E F G\n16:00 - 17:30 Room L/M \nRadiographers \nRC 1414 \nPediatric imaging \nModerators: \nC. Balassy; Toronto, ON/CA \nP. Gerson; Paris/FR \nA‑391 16:00 \nA. DR system: How to find the best hardware and software to achieve \nmininum dose and best images \nH. Precht, O. Gerke; Odense/DK (hepr@ucl.dk) \nPurpose: To develop knowledge for informed consideration of dose reduction \nand image quality in paediatric radiography and to reduce patient dose based on \nprocess heat algorithms in Canon’s DR system. Options for software optimiza-\ntion were studied in relation to optimal image quality and follow-up examinations, \nto investigate when it may be possible to accept inferior image quality and thus \ncomply with ALARA.\nMethods and Materials: A quantitative experimental study based on experiments \nwith technical and human phantoms. A technical CDRad phantom was used and \nthe pictures were analyzed using CDRad software, giving results as objective IQF \nvalues. The human phantom was replaced with a lamb pelvis with femur, which \noffers absorption comparable to a 5-year-old child according to the report by NRPB. \nThe human pictures were analyzed by 3 radiologists specializing in paediatric bone \nexaminations using the relative VGA scale and the absolute VGA scale.\nResults: Software impact on image quality was great, but the dose effect will \nalways influence the experienced quality. CDRad analysis of the software base \ncaused image quality factors, which are important in human images, to be impos-\nsible to assess.\nConclusion: Optimal image quality is maintained at a dose reduction of 70%, \nbut the images were diagnostically approved at a reduction of 97% on the basis \nof the reference value. Control recordings were possible at 0.5 mAs, all based on \nMLT (S)-optimized images. \nLearning Objectives:\n1. To learn about possibilities for software processing optimisation in DR \nsystems.\n2. To become familiar with possibilities to grade dose and image quality in \nrelation to the indication for the examination.\n3. To report a study on the possibilities of improving image quality using \ndifferent dose levels in pediatric femur examinations using Canons MLT (S) \nalgorithm.\nA‑392 16:45 \nB. CT: Cardiac examinations in children \nT. Bock-Pedersen; Copenhagen/DK (tina.bock‑pedersen@toshscan.dk) \nWe, at the University Hospital in Copenhagen, Denmark - Rigshospital, have gained \nexperience with Cardiac CT, since 2005. We have a 64MSCT and a 320MSCT. We \nwould like to share our considerations and show how we have set up our protocols \nfor Cardiac CT imaging of the pediatric patient. One of the advantages with CT is \nexamination speed, which allows us to perform most all pediatric CT scans without \nsedation or general anesthesia. Outpatient examination is possible, as it is a non-\ninvasive examination. Dose is a limiting factor, as children are much more sensitive \nto radiation. Therefore, when possible, non-ionizing modalities should be used \n(MRI or ECHO). What is essential when imaging a pediatric patient, especially in \nregards to heart imaging with congenital abnormalities? Triggering can be an issue \nand we prefer to trigger visually/manually. Continues bolus is made possible with \nthe auto injector.Teamwork and preparation are the key factors! Before the patient \narrives, the radiologist/cardiologist and radiographer have to decide what is to be \ndiagnosed, how to reach the diagnose and at what dose i.e. decide on the quality \nof the scan - can we do a ‚low dose‘ scan‘, arteriel phase, with ECG triggering? etc. \nLearning Objectives:\n1. To learn how to perform a successful diagnostic CT on a pediatric patient.\n2. To become familiar with the technical aspects of cardiac CT.\n3. To learn about the difference between children and adults.\n4. To learn about the importance of teamwork.\n16:00 - 17:30 Room N/O \nProfessional Challenges Session \nPC 14 \nRadiology and the law \nModerator:\nE. Breatnach; Dublin/IE \nA‑393 16:00 \nChairman’s introduction \nE. Breatnach; Dublin/IE (ebreatnach@mater.ie) \nThe modern radiologist needs to deal increasingly with European regulations \nwhich more and more impacts on every facet of his/her professional life. In addi-\ntion, malpractice litigation is an increasing force. Many technologies have specific \nattendant legal issues, e.g. teleradiology, and the increasing workload of radiolo-\ngists increases their vulnerability to individual malpractice claims. This session \nwill address these topics and will highlight the extent of the problem both in the \ncontext of general regulations and individual risk areas. Three speakers represent-\ning North America, mainland Europe and the U.K. will present papers outlining the \nmajor issues involved. A final question and answer session will deal with specific \nmedicolegal case scenarios and will be audience interactive. \nSession Objectives:\nUsing ‘real case’ material:\n1. To familiarise radiologists with their vulnerability to litigation.\n2. Steps to avoid being successfully sued.\n3. Items of new European regulations and how they increasingly affect your \nradiology practice.\nA‑394 16:05 \nRadiologic communications: Dilemmas and pitfalls \nL. Berlin; Skokie, IL/US (lberlin@northshore.org) \nCommunication is a two-way street. There is often a dispute between the radiologist, \nwho argues that a report was transmitted, and the referring physician, who argues \nthat the report was never received. Radiologists claim that a written report was \nsent and should have been sufficient. If the ordering physicians did not notice or \nread the report, then should not the radiologist be free of blame? Unfortunately, the \nanswer is no. It is true that if the referring physician would promptly review written \nradiology reports, injuries to patients would not occur. Nevertheless, it is the radi-\nologist’s breach of the standard of radiologic care - failure to directly communicate \nsignificant unexpected findings to the referring physician - that initiates the chain of \nevents that often leads to a patient’s injury or death. The radiologist is not relieved of \nliability. Communicating the results of radiologic examinations has become just as \nmuch the duty of radiologists as is the rendering of interpretations. The American \ncourts and the American College of Radiology have clearly stated that radiologists \nmust verbally communicate urgent or significant unexpected findings to referring \nphysicians. There is now evolving in the American judicial system an expansion \nof the radiologist’s duty to include direct communication to patients as well as to \nreferring physicians. Several companies now market direct communication products \nwhich may satisfy the requirements for direct communication. Radiologists may \nwish to investigate them to determine whether or not they would satisfy local needs. \nLearning Objectives:\n1. To understand the radiologist’s responsibility in communication of acute and \npossibly life threatening radiologic abnormalities.\n2. To recognise the radiologist’s responsibility in prompt communication of less \nacute findings.\n3. To outline the principles of direct communication of radiological findings to \npatients.\nA‑395 16:28 \nMedical negligence: The lawyer’s perspective \nG. Loibner; Vienna/AT (anwalt@ra‑loibner.at) \nThe basis of treatment of patients is the contract of treatment. Under such contract, \nthe patient is not entitled to a specific result of the treatment but to treatment with \ndue care. Due care is measured by the standard of medical skills and science. \nIn case of damages suffered by the patient from lack of due care, the patient is \nentitled to compensation. The burden to prove the damage, the malpractice and \nthe causality between malpractice and damage rests with the patient. The burden \nto prove that due care has been applied rests with the physician. A case example \n\nSunday\nPostgraduate Educational Programme\nA S101CB D E F G\nconcerning the missed finding of a malignant breast tumor will be presented. Beside \nmalpractice, the lack of patient’s informed consent becomes an increasing source \nof physicians’ liability. Apart from treatment with due care, patients are entitled \nto information about the risks and consequences of treatment and alternatives \nthereto. Failure to adequately inform the patient can result in physician’s liability \nfor damages resulting from treatment performed lege artis in case risks materialize \nthe patient has not been duly informed of. Information by form sheet only is not \nconsidered sufficient. Extent and intensity of information depend on the urgency \nof treatment. The less urgent the treatment, the more intense information has to \nbe. Proper documentation of information is essential for the avoidance of liability. \nLearning Objectives:\n1. To learn about the general principles of liability for medical malpractice.\n2. To understand the increasing risk of liability despite of lege artis treatment for \nlack of patient’s informed consent.\n3. To appreciate the importance of proper documentation of patient’s \ninformation in order to minimise the risk of liability.\nA‑396 16:51 \nEuropean legislation big brother: What the practitioner should know to \navoid being sued and what to do if you are \nR. FitzGerald; Wolverhampton/UK (richard.fitzgerald@rwh‑tr.nhs.uk) \n1. European Working Time Directive (EWTD): The EWTD was passed in 1993. \nHowever there have been many delays in its full implementation by medical prac-\ntitioners, due to problems of staffing and service provision. Full implementation of \nEWTD is expected of all doctors in the EU from August 1\nst 2009. The legal climate \nwill be more hostile for those doctors accused of negligence, with respect of a period \nof time when they have been in breach of the EWTD. There is increasing literature \non the effect of fatigue on safe medical performance. 2. Patient Confidentiality: The \nEuropean Court of Human Right ruled in 2008 that the Government of Finland \nhad breached Article 8 of the European Convention on Human Rights (the right \nto privacy) by not securing the patient confidentiality of the plaintiff, a nurse. The \nFinnish Hospital had only been able to identify the five most recent individuals \nto access the patient’s electronic record and this was considered inadequate by \nthe Court. The I versus Finland case alters the legal context for inadequate audit \nprocesses to assure patient confidentiality from inappropriate access to electronic \npatient records. 3. Medical Regulatory Requirements for Teleradiology Reporting \nfor Patients in the EU: The Directive on the Application of Patient Rights in Cross-\nBorder Healthcare had a comfortable majority in its First Reading in the European \nParliament in April 2009. It is now with EU Health Ministers and will go to the new \nMEPs in the autumn for a second reading. The current wording of Article 16 on \ne-Health includes provision to regulate telemedicine practitioners. \nLearning Objectives:\n1. To appreciate the medico-legal consequences of failure to comply with the \nEuropean Working Time Directive.\n2. To understand the precedent set in I versus Finland for patient confidentiality \nwith electronic patient records and PACS.\n3. To be familiar with the current medical regulatory requirements for \nteleradiology reporting E.U./Worldwide.\nPanel discussion:  \nIllustrative cases on: 1. Medico-legal consequences of poor radiology \ncommunication. 2. What is an ‚acceptable‘ error rate for radiologists?  \n3. Panel advice on how to reduce one‘s medico-legal vulnerability.\n 17:14 \n16:00 - 17:30 Room P \nCardiac \nRC 1403 \nValvular heart disease \nModerator:\nF. Cademartiri; Parma/IT \nA‑397 16:00 \nA. Echocardiography: Clinical standard with limitations \nM.R. Rees; Gwynedd/UK (m.rees@bangor.ac.uk) \nTransthoracic echocardiography is routinely used in the office setting and acts \nas a first line diagnostic technique in cardiology. It is a portable, readily available \nmodality but has its limitations. Among the diagnostic limitations of transthoracic \nechocardiography are diagnosis of the thickened, some types of cardiomyopathy \nand diseases of the cardiac apex, which is often not well seen. Details of valve mor-\nphology and tranoesophageal echo are an invasive investigation where the patient \nhas to swallow the echo probe. The patient often requires sedation for this but the \ninvestigation can be carried out as a day case. Trans-oesophageal echo provide \ngreater detail of cardiac anatomy and function and is used frequently as an adjunct \nto cardiac surgery as an intra-operative procedure. Stress echo-cardiography is \nused for the diagnosis of myocardial ischaemia when accompanied by increasing \ndoses of intravenous Dobutamine and for the diagnosis of myocardial viability. \nThe principle of this test is that a low dose of Dobutamine will excite function in a \nnon-functional area of myocardium which is viable. All types of echo can utilize the \nadditional facilities of Doppler examination (pulsed and continuous wave) colour and \necho contras to make physiological diagnoses. These tests remain more subjective \nthan other competing image tests because of the need for operator experience \nand skill, patient-based factors and the more subjective nature of interpretation. \nLearning Objectives:\n1. To discuss anatomy and clinical background.\n2. To identify strengths and limitations.\n3. To compare a transthoracic vs a transesophageal approach.\nA‑398 16:30 \nB. Computed tomography: More than calcification! \nA. Lembcke; Berlin/DE (Alexander.Lembcke@gmx.de) \nIn cardiac surgery, heart valve diseases represent the second most common reason \nfor an operation. Different modalities, (i.e. echocardiography, cardiac magnetic \nresonance imaging and cardiac catheterisation) are currently in use to assess \npatients with suspected heart valve disease. However, all examination techniques \nhave their own strengths and limitations. Multislice computed tomography (MSCT) \nhas recently emerged as an additional modality that permits functional 4D imaging \nof the cardiac valves. Beyond the quantification of calcifications, MSCT may allow \nfor the detailed 3D visualisation of the valve morphology. This includes the detec-\ntion of valvular vegetations and local complications (e.g. paravalvular abscess) \nin infective endocarditis. Furthermore, MSCT may provide useful information \nregarding disease severity in valve stenosis and insufficiency by planimetry of \nthe valvular opening and regurgitant orifice area. The ability of MSCT to describe \nthe 3D geometry of the entire aortic root is particularly helpful to plan aortic valve \nsurgery and interventions (e.g. minimally invasive aortic valve replacement using \neither the transapical or transfemoral approach). Moreover, MSCT may allow for \nthe simultaneous evaluation of the coronary arteries and myocardial function. This \npresentation will discuss the potential clinical role of MSCT for the evaluation of \npatients with heart valve disease, the advantages and disadvantages of current \nMSCT techniques and the differences between MSCT and established modalities \nused for evaluating heart valve disease (i.e. echocardiography, cardiac magnetic \nresonance imaging and cardiac catheterisation). \nLearning Objectives:\n1. To optimise functional 4D-imaging.\n2. To quantify valve insufficiency and stenosis with CT.\n3. To plan surgery and percutaneous valve replacement, and to map \ncalcification.\n\nPostgraduate Educational Programme\nS102 A B C D E F G\nA‑399 17:00 \nC. Magnetic resonance: Value of flow measurements \nN.L. Kelekis; Athens/GR (kelnik@med.uoa.gr) \nCardiac MRI has evolved into an alternative and complementary modality to ultra-\nsonography in assessing patients with valvular heart disease. MRI on state-of-the-\nart scanners using cine and velocity-encoded gradient echo sequences provides \nreliable qualitative and quantitative assessment of valvular dysfunction including \nstenosis and insufficiency. It can also quantify flow through the atrioventricular and \nventriculoarterial valves, as well as virtually any vascular structure. MRI provides \nmoreover morphological and functional assessment of both ventricles with objec-\ntive volumetric measurements throughout the cardiac cycle. With the combination \nof the above volumetric and flow data, it can quantify stenosis and/or insufficiency \nin patients with simple or complex valvular disease, as well as Qp/Qs ratio and \nshunts. MRI is the only modality able to quantify the regurgitant volume, which is \nof importance in patients with aortic regurgitation or pulmonary insufficiency as in \nsurgically corrected tetralogy of Fallot. The mathematical combination of pulmonary \nregurgitant and tricuspid flow reflects the diastolic function of the right ventricle. MRI \nis superior to ultrasonography in situations with poor acoustic windows such as \npostoperative or obese patients, conduits calcified or not, always providing objec-\ntive anatomic and functional data. It is, however, a time-consuming and expensive \nmodality and inferior to ultrasonography in the assessment of valve leaflets and \nsmall vegetations. Future perspectives include improved anatomic imaging at 3 T, \nefforts to adequately visualize valve leaflets, real-time velocity-encoded sequences, \nand whole-heart scanning with flow sequences encoded in the three directions. \nLearning Objectives:\n1. To optimise imaging protocol.\n2. To quantify valve insufficiency and stenosis with MRI.\n3. To learn about pitfalls in MR flow measurements.\n16:00 - 17:30 Room Q \nInterventional Radiology \nRC 1409 \nOncologic interventions in the liver \nModerator:\nJ.‑I. Bilbao; Pamplona/ES \nA‑400 16:00 \nA. RF ablation \nF . Deschamps; Villejuif/FR (Frederic.Deschamps@igr.fr) \nPercutaneous radiofrequency ablation (RFA) is a safe and effective treatment for \nwell-selected patients with hepatic tumors such as hepatocellular carcinoma (HCC) \nand liver colorectal metastase (LCM). An appropriate selection is crucial. It is based \non clinical and technical arguments. Clinically, surgical resection of the hepatic \ntumors remains the gold standard. Indeed, the survival data following RFA are not \nas good as surgical resection. The only exception seems to be the RFA of the very \nearly HCC (≤2.0 cm) in cirrhosis that is not candidate for liver transplantation. Most \noften, the RFA offers an alternative for patients with medical comorbidities, poor \nliver function or prior hepatectomy. Technically, there are three decisive points for \ncomplete ablation. The first point is the good visualization of the tumor either under \nultrasound or un-enhanced computed-tomography (CT) examination. Metallic coil \nplacement, lipiodol tattoo and virtual CT sonography with magnetic navigation are \ntechnical tricks that allow the RFA of \"invisible\" tumors. The second point is the \ntumor size: in most series, a diameter less than 25-35 mm is commonly admitted \nas a prognostic factor. This is probably because the maximal ablation diameter is \nslightly larger than 40 mm with the electrode needles available now. RFA combined \nwith trans-arterial chemo-embolization might improve the local control by increas-\ning the ablation diameter. The last point is the \"heat-sink effect\" that requires a \ntemporary occlusion of a large vessel close to the tumor. The quality of follow-up \nimaging is a key factor for evaluation of the tumor destruction. \nLearning Objectives:\n1. To discuss indications for RF ablation.\n2. To learn about the technique and devices for RF ablation.\n3. To discuss results and follow-up strategies.\nA‑401 16:30 \nB. New embolisation techniques \nF . Orsi; Milan/IT (franco.orsi@ieo.it) \nWhile liver resection is still the gold-standard for curative local treatment of liver \nlesions, several promising local approaches have been developed in the past three \ndecades, such as intra-arterial treatments, percutaneous thermal ablation, stereo-\ntactic radiotherapy and more recently high intensity focused ultrasound. There is no \nconsensus on the best local therapy. However, intra-arterial therapies offer great \npromise based upon the premise that hepatic tumors are fed mainly, if not exclu-\nsively, by arteries. Bland embolization, chemoembolization and radio-embolization \nare some of the most commonly performed local treatments for patients with liver \ncancers and several embolic agents have been specifically developed for that \npurpose. Both TACE and TAE may shut-down the arterial blood flow to the tumor, \nleading for tumor ischemia and, eventually, tumor cell death, if anoxia is induced. \nAssociation of local chemotherapy to the embolic effect represents the rationale for \nTACE. For this purpose, new embolic particles, which may precisely elute drugs, \nhave been introduced. For radioembolization, micro-particles are injected into the \nfeeding arteries as vehicles for delivering interstitial sources of radiation therapy. \nSmall and precisely calibrated micro-particles have been introduced for a deeper \na more effective TAE. Because hepatic tumors are supplied by several arterial \nfeeders, complete tumor death may be obtained only if the entire vascular network \nsupplying the tumor will be treated. If even small feeding arteries will be missed, \ntumor mass will be not completely treated and it will relapse. For this reason, the \nknowledge of possible vascular abnormality is mandatory for a better outcome. \nLearning Objectives:\n1. To discuss the uses of drug eluting beads.\n2. To review experience with selective internal radiation \n(yttrium-90, and others).\n3. To review the role of hepaspheres in hepatic embolisation.\nA‑402 17:00 \nC. Future directions \nJ. Kettenbach1, A. Melzer2; 1Berne/CH, 2Dundee/UK (joachim.kettenbach@insel.ch) \nImage-guidance and imaging fusion techniques represent an integral element in \noncologic liver surgery. In addition, several liver planning techniques such as the \nVirtual Liver Surgery Planer enhance simulation of a proposed liver resection. Using \nroboter-assistance or navigational guidance, combined with classic tumor ablation \ntechniques such as radiofrequency ablation, significantly enhances accuracy of ablation \nprobe placement and efficacy of ablation necrosis. It has further shown that the local \nrecurrence rate was considerable lower, and the amount of complete tumor ablation \nwas significantly more likely as compared to other studies. Most recent, a European \nUnion-funded project, lead by IMSaT , at the University of Dundee, collaborating with \nInSightec, Ltd and CapsuT ech Ltd will integrate magnetic resonance imaging, focused \nultrasound to deliver and activate nano-capsules carrying anti-cancer drugs to effectively \ntarget tumors. This project involves drugs being injected into the body in the form of \ntiny capsules, which are harmless until they are activated by a concentrated focused \nultrasound `blast‘, using devices developed in IMSaT‘s medical ultrasound laboratories \nas well as commercial systems. The MRI scanner will be used to track the passage of \nthe drugs, visualize the target and monitor the delivery of the drug treatment. InSightec \ndevelops unique commercial MR-guided focused ultrasound systems, and CapsuT ech \ndeals with different aspects of a drug delivery platform based on targeted nano-capsules. \nAll this innovative developments may contribute to improved patient outcome, less side \neffects, and reduced pain medication for patients, with otherwise unresectable tumors. \nLearning Objectives:\n1. To review new ablation modalities.\n2. To review research on targeted embolotherapy.\n3. To discuss the use of combined therapies.\n\nPostgraduate Educational Programme\nA S103CB D E F G\nPostgraduate Educational Programme\nA S103CB D E F G\nMonday, March 8\n\nPostgraduate Educational Programme\nS104 A B C D E F G\nPostgraduate Educational Programme\nS104 A B C D E F G\n08:30 - 10:00 Room A \nRadiology in Abdominal Emergencies \nCC 1517 \nThe acute abdomen \nModerator:\nN.N.\nA‑403 08:30 \nA. The wrong twist: Mesenteric and omental torsion \nM. Macari; New Y ork, NY/US (michael.macari@nyumc.org) \nThere are numerous causes of acute abdominal pain. While the clinical history, \nphysical examination, and laboratory results may be helpful in triaging patients with \nabdominal pain, MDCT has become one of the most important tools in the evaluation \nof these patients. Twisting of the mesentery is a relatively common cause of acute \nabdominal pain. This may be due to a primary volvulous, internal hernias through \nmesenteric rents, or around adhesions. Mesenteric torsion with small bowel volvu-\nlous is most often caused by adhesions. Recognizing the CT findings of mesenteric \nvolvulous with resultant closed loop intestinal obstruction and subsequent ischemic \nbowel are of utmost importance. Omental torsion is not as common as mesenteric \ntorsion and the bowel is usually not affected. This lecture will review the imaging \nfindings and clinical aspects of mesenteric and omental torsion. \nLearning Objectives:\n1. To understand the pathophysiology of mesenteric and omental torsion.\n2. To know the typical presentation on cross-sectional imaging modalities.\n3. To learn imaging strategies with focus on MDCT.\nA‑404 09:00 \nB. Abdominal hernias \nG. Brancatelli; Palermo/IT (gbranca@yahoo.com) \nAbdominal hernias are common in daily practice and can be divided into: external or \nabdominal wall hernias, internal hernias; diaphragmatic hernias. External hernias typi-\ncally involve protrusion of abdominal contents through a defect in the abdominal wall. \nInternal hernias involve protrusion of viscera through congenital or acquired defects in \nthe mesentery or the peritoneum. Diaphragmatic hernias involve protrusion of abdominal \ncontents into the chest. Among these conditions, the diagnosis of internal hernia is the \nmost challenging. Bariatric surgery and liver transplantation with biliary-enteric anastomo-\nsis, with the Roux-en-Y loop placed in a retrocolic position, are recognized predisposing \nfactors for internal hernia development. Symptoms of hernia are nonspecific and vague, \nand clinical and radiologic diagnosis can sometimes be challenging. Immediate diagnosis \nis mandatory because misdiagnosis can be complicated by bowel obstruction, volvulus, \nstrangulation, incarceration, or trauma. MDCT with its multiplanar capabilities is widely \nbelieved to facilitate this diagnosis, because it is able to delineate hernia type, location, \nsize, and shape and is particularly useful to diagnose unsuspected hernias. It also allows \ndistinguishing hernias from masses of the abdominal wall, such as tumors, hematomas, \nabscesses. As a result, knowledge of the CT findings of abdominal hernias may allow \nearly and more accurate diagnosis, with a resultant decrease in the mortality rate. \nLearning Objectives:\n1. To understand the predisposing factors, clinical presentation and \ncomplications of abdominal hernias.\n2. To be able to recognise abdominal hernias on imaging through multiple \nexamples with an emphasis on MDCT.\n3. To illustrate the postsurgical anatomy underlying internal hernias.\nA‑405 09:30 \nC. Acute stages in neoplastic diseases \nJ.A. Guthrie; Leeds/UK (Ashley.Guthrie@leedsth.nhs.uk) \nAfter the initial presentation, a patient with cancer enters a phase of active treatment \n(surgery, chemotherapy, or radiotherapy), and then remission/cure or palliative phases. \nAn „acute abdomen“ may complicate any phase. The principle causes are obstruction, \nperforation, haemorrhage, ischaemia and sepsis. Tumours arising from the GI tract \nare leading causes but any tumour involving the abdominal cavity or haematological \nmalignancy may be implicated. During treatment with chemotherapy or radiotherapy \nacute abdominal symptoms are common as a consequence of direct toxicity. Im-\naging must be used as an adjunct to clinical assessment. Patterns of abdominal \ninvolvement are often modified in the later phases of disease. GI tract obstruction \nmay be due to progression or the mechanical consequences of prior surgery and \nis more commonly at multiple levels. Perforation or fistulation may occur with either \nprogressive disease or tumour lysis in response to therapy. Cancer does not protect \nagainst the common inflammatory conditions but poor host response and the use of \nsteroids may mask signs leading to extensive abnormality at diagnosis. Bone marrow \nsuppression increases susceptibility to infection including neutropenic enterocolitis, \nand haemorrhage. Bone marrow transplantation and consequent graft versus host \ndisease is a potent cause of acute abdominal symptoms. CT is the major imaging \ntechnique although MR has an increasing role particularly in the assessment of the \nfemale pelvis. Major determinants when considering the differential diagnosis include \nthe nature and initial stage of the primary, any prior anatomical modification (surgery), \nthe nature and relationship to current treatment and the bone marrow status. \nLearning Objectives:\n1. To be able to list neoplastic diseases that may potentially lead to acute \nabdominal symptoms.\n2. To appreciate the differences in causes and findings of the acute abdomen \nbetween the initial presentation with neoplasia and when undergoing \ntreatment.\n3. To understand typical CT findings and pitfalls, and the potential role of MRI.\n08:30 - 10:00 Room B \nSpecial Focus Session \nSF 15a \nAcute aortic syndrome \nModerator:\nJ. Lammer; Vienna/AT \nA‑406 08:30 \nChairman’s introduction \nJ. Lammer; Vienna/AT (johannes.lammer@akhwien.at) \nThe acute aortic syndrome is a life-threatening disease. Aortic dissection type A \nand B, intramural hematoma, penetrating aortic ulcer, traumatic transsection and \nthe rupture of an aortic aneurysm may cause an acute aortic syndrome. Clinically, \nit usually causes severe chest pain. It can mimic myocardial infarction, pulmonary \nembolization and it may be followed by neurological symptoms such as hemiplegia \nor paraplegia. Rupture into the mediastinum and pleural space may cause shock \nor death. The primary diagnosis is made by contrast enhanced CT. ECG gated \nCT is mandatory for a detailed diagnosis. A triple rule out protocol is required in \nclinically unclear cases. The radiologist is the first to make the diagnosis and an \nimportant decision maker for the emergency treatment. Acute surgical treatment in \ntype A dissections and endovascular treatment in complicated type B dissections, \npenetrating ulcers and traumatic dissections is the treatment of choice. Ruptured \naortic aneurysms can be treated by open surgery and endovascular techniques. \nSession Objectives:\n1. To learn about the clinical aspects of acute aortic syndrome.\n2. To learn about imaging of acute aortic syndrome.\n3. To learn about endovascular therapy of acute aortic syndrome.\nA‑407 08:33 \nTechnique, advantages and limitations of CTA and MRA \nV. Bérczi; Budapest/HU (Berczi@hotmail.com) \nT echnique, advantages, disadvantages of CT A and MRA will be explained. A brief com-\nparison (indications, limitation, advantages, disadvantages) with other diagnostic tech-\nniques, like X-ray, transesophageal echocardiography, and catheter angiography, will be \npresented. Preoperative and follow-up imaging of aortic dissection, intramural thrombus, \nand penetrating atherosclerotic aortic ulcer as well as aortic dissection, ruptured thoracic \naortic aneurysms, and aortic injuries will be discussed. The triple rule-out CT A protocol \nto prove or exclude acute coronary syndrome, aortic dissection, or pulmonary embolism \nis crucial, since each year, approximately 6 million patients in the United States alone \npresent to the emergency department with acute chest pain. CT A is considerably faster \nthan MRA in this acute setting. It may exclude deadly causes of chest pain; the higher \nradiation dose delivered with current techniques is a valid clinical concern. Compared with \nthe usual radiation dose of a standard 64-slice CCT A (10-23 mSv), the effective radia-\ntion dose of a „triple rule-out” scan is often increased by 50% (25-40 mSv). However, a \nrecent study demonstrates that the radiation can be a lot less (< 9 mSv) when using tube \ncurrent modulation. Artery of Adamkiewicz is the largest anterior segmental medullary \nartery. It typically arises from a left posterior intercostal artery, which branches from the \naorta, and supplies the lower two-thirds of the spinal cord via the anterior spinal artery. It \ncan be important to identify the location of the artery before treating aorta diseases with \nstent-grafts to prevent paraplegia. Its location can be identified with both CT A and MRA. \n\nMonday\nPostgraduate Educational Programme\nA S105CB D E F G\nPostgraduate Educational Programme\nA S105CB D E F G\nLearning Objectives:\n1. To learn about the technique of CTA and MRA of the thoracic aorta.\n2. To understand when to use CTA and when MRA is preferable.\n3. To understand when not to use CTA and/or MRA.\nA‑408 08:51 \nKey imaging findings that allow distinction among the various aortic \npathologies \nF . Fanelli; Rome/IT (fabrizio.fanelli@uniroma1.it) \nDifferent non-invasive imaging modalities: plain X-ray radiography, multidetector \nCT -angiography (MDCT A), MR-angiography (MRA), conventional digital subtraction \nangiography (DSA) and transesophageal echocardiography (TEE) are nowadays \navailable for the evaluation of the acute aortic disease. At the level of the thoracic \naorta also, a plain X-ray examination permits to evaluate abnormal findings in 88% of \ncases: widened mediastinum, abnormal aortic knob contour, tracheal or esophageal \ndeviation, and ring sign with displacement of the aortic margin > 5 cm beyond the \ncalcified aortic intima. An initial non-contrast MDCT scan should be performed to rule \nout intramural hematoma because intravenous contrast may obscure this diagnosis \nas a consequence of uniform opacification of luminal structures. Intramural hematoma \nmay appear as a localized thickening of the aortic wall with internal displacement of \nintimal calcifications. MDCT enables clear visualization of the aortic wall to assess \nthe presence of an inflammatory aortic aneurysm. Additionally, it facilitates accurate \ndetection of aneurysm rupture or contained leakage. In patients with suspected acute \naortic dissection, contrast-enhanced MDCT scanning of both the chest and abdomen \nshould be performed because it is particularly useful in detecting intimal flap, the extent \nof aortic dissection, branch vessel involvement, patency of true and false lumens, \npotential pericardial effusion, and even the patency of the coronary arteries. MRA with \naxial images, acquired with \"black-blood\" sequences, allows a better evaluation of the \naortic wall and of any dissection, ulcer or thrombus accumulation. This sequence takes \nadvantage of the lack of signal from blood flowing perpendicular to the imaging plane. \nLearning Objectives:\n1. To learn about the distinction between type A and type B dissection.\n2. To understand the key imaging findings and the correct imaging protocol to \ndiagnose an intramural hematoma.\n3. To learn when an aortic ulcer is dangerous for the patient.\nA‑409 09:09 \nEndovascular management of acute type B dissection \nH. Rousseau; Toulouse/FR (rousseau.h@chu‑toulouse.fr) \nThe life-threatening nature of aortic dissection requires that diagnosis and treat-\nment be rapid with the most reliable and least invasive technique possible. Imaging \nmethods are essential with several objectives; accurate description of the lesions, \ntopographical classification, investigation of the extent of the lesions to the supra-\naortic and visceral arteries or of involvement of adjacent structures. These extensive \ninvestigations provide an evaluation of the severity and potential for progression of \nthe lesions and a guide to treatment. The CT scan is the best method of investigation \nin an emergency. Treatment and surveillance in the intensive care unit are essential \nin all cases. Besides medical therapy, schematically, in type B aortic dissection, \nsurgery and endovascular procedures are reserved for complications, principally \nrupture and visceral ischaemia. In these cases, endovascular techniques have \nprogressed because of their better tolerance. Exclusion of the proximal intimal tear \nby a stent-graft depressurises the false lumen and predisposes to its thrombosis. \nRemodelling with reduction of the aortic diameter is observed with reperfusion of \nthe distal vessels. Endovascular fenestration is reserved for problems of perfusion \ndue to a dynamic mechanism. The principle is to create a wide orifice between \nthe true and false lumens in order to reduce pressure in the false lumen. The \nimplantation of bare stents may be useful in the arteries of viscera with ischaemia \nby a static mechanism. In conclusion, aortic dissection may be treated effectively \nby endovascular techniques, either alone or as a complement to surgery of the \nascending aorta. \nLearning Objectives:\n1. To understand the indications for treatment of acute type B dissection.\n2. To appreciate the difference between complicated and uncomplicated \ndissection.\n3. To understand that the diagnosis of critical organ perfusion is important.\n4. To learn about the technique of endovascular management of type B \ndissection.\nA‑410 09:27 \nEndovascular management of thoracic aortic rupture \nR. Morgan; London/UK (robert.morgan@stgeorges.nhs.uk) \nRupture of the thoracic aorta is a catastrophic event leading to rapid death in the \nmajority of cases. Standard therapy is by open surgical repair. However, many \npatients can be treated by the insertion of endografts into the aorta across the \nlocation of the rupture. Patients who survive initial resuscitation and the journey to \nhospital should undergo immediate imaging assessment for potential treatment. \nThe optimal imaging strategy is a contrast enhanced CT scan with coverage from \nthe neck to the groins. Suitability for treatment by endografts involves assessment \nof the images for satisfactory proximal and distal landing zones and iliac arteries \nof adequate calibre. If patients are deemed suitable for endografting, an endograft \nof suitable size is inserted across the site of the aortic tear. Generally, only a single \nendograft is required to cover the tear unless there is coexistent additional pathology \n(e.g. aneurysm, dissection). It is sensible to keep a supply of devices of appropri-\nate size in stock which may be used in emergency situations. Complications of \nendografting particular to trauma mainly relate to poor conformability of endografts \nin the aortic arch. Many patients presenting with aortic trauma are young. Current \ndevices may not adequately conform around the curve of the aorta at the junc-\ntion of the aortic arch and descending aorta, which is a common site of rupture. \nIn extreme cases, poor endograft conformability may lead to device collapse and \nsevere aortic pseudocoarctation, which may require open removal of the device. \nLearning Objectives:\n1. To learn about the correct management of patients with aortic rupture.\n2. To learn about imaging protocols of aortic rupture.\n3. To learn about the technique of endovascular management of ruptured \nthoracic aortic aneurysms.\n4. To become familiar with post-treatment complications in patients with aortic \nruptures.\nPanel discussion:  \nWhen is it time for the diagnostic radiologist to call the interventionalist or \nsurgeon urgently? \n09:45 \n08:30 - 10:00 Room C \nAbdominal and Gastrointestinal \nRC 1501 \nCT colonography: All the relevant aspects \nModerator:\nA.K. Dixon; Cambridge/UK \nA‑411 08:30 \nA. State-of-the-art technique \nF . Iafrate; Rome/IT (francoiafrate@gmail.com) \nIn this lecture, the most important different technical aspects of CT colonography \nexamination will be discussed. Bowel preparation represents a crucial point of a \ncorrect CTC study, necessary to cleanse the bowel of residual stool, which might \nsimulate colonic lesions. Usually, the same preparation scheme as conventional \ncolonoscopy or barium enema (i.e. polyethylene glycol 4000 electrolyte solution) is \nused. Different preparations (i.e. phospho-soda) have been investigated showing a \nsignificant reduction of residual fluids. However, due to patient discomfort, the goal \nfor the next future is the avoidance of any bowel preparation, using a “fecal or fluid \ntagging” technique. Different approaches of tagging will be discussed. Choice of \ndestending agent (Co\n2 versus room air) represents another crucial point of exam and \nwill be discussed. Spasmolytics agents are routinely used by most investigators using \nCT colonography. The use of these drugs is still controversial as it was showed that \nglucagon administration does not improve colonic distention. The use of i.v. contrast \nagents is still questionable. Although it has been demonstrated a mild improvement \nin polyp detection if i.v. contrast agent is administered, its routine use strictly depends \non clinical indications and using fecal or fluid tagging is still questionable. In fact, it is \nnot feasible in a screening population due to higher costs as well as major complexity \nof the exam, whereas it is mandatory in case of staging neoplastic lesions and in \npatients undergoing follow-up for colo-rectal cancer. Finally, different formats used for \nimage interpretation (primary 2D versus primary 3D) will be discussed. \nLearning Objectives:\n1. To review current bowel preparation techniques for CTC from cathartic to \n“fecal/fluid tagging”.\n\nPostgraduate Educational Programme\nS106\n A B C D E F G\nPostgraduate Educational Programme\nS106 A B C D E F G\n2. To review options for practical aspects and protocols used (distention, \nspasmolytic agents, use of I.V. contrast material…).\n3. To describe principles of data acquisition at CTC.\n4. To describe options for 2D and 3D image interpretation of CTC.\nA‑412 09:00 \nB. Avoiding traps or pitfalls \nP . Lefere, S. Gryspeerdt; Roeselare/BE (radiologie@skynet.be) \nAdequate interpretation of CT colonography (CTC) is directly related to the level \nof experience of the reporting radiologist. To reduce false negative and positive \nfindings to a minimum, awareness and good knowledge of traps and pitfalls is \ninvaluable. Pitfalls in CTC imaging may be related to the CTC technique used, the \nanatomy of colonic and pericolonic structures and the two- and three-dimensional \nimaging features. Technique related pitfalls are caused by the different steps of \nthe CTC procedure: preparation, colonic distension and image acquisition. Diag-\nnostic problems are frequently caused by retained stool, spasm, collapse, motion \nartefacts, and image noise. Anatomy related pitfalls are caused by prominent \nsemi-lunar folds, deep haustrations with hidden zones, tortuosity with flexural \npseudotumors, diverticulosis, the valves of Houston, the ileo-cecal valve. Pitfalls \nrelated to two- and three-dimensional imaging are caused by thickened folds, polyps \nclose to a fold, polyps mimicking stool, flat lesions and by tagged or non-tagged \nretained colonic residue, diverticulosis, wall thickening, luminal narrowing, deep \nhaustral folds, spasm v tumor, flat lesions, polyps v stool, flat lesions, respectively. \nTechnique related pitfalls can be overcome by the application of state-of-the-art \nCTC technique performed by an experienced CTC-team. Anatomy related pitfalls \ncan be avoided by detailed comparison between 2D and 3D images. Special \ncare should be taken when inspecting blind ending structures as the cecum and \nthe rectum. Experience with both two- and three-dimensional imaging aspects is \nrequired to adequately interpret CTC. Finally, ongoing quality assurance and¼ a \ngood exam avoid a lot of errors. \nLearning Objectives:\n1. To describe pitfalls in imaging related to CTC technique and colonic anatomy.\n2. To describe typical pitfalls in imaging related to 2D and 3D imaging \nrespectively.\n3. To propose a flowchart for avoiding traps and pitfalls in imaging.\nA‑413 09:30 \nC. Evidence based results? \nS.A. Taylor; London/UK (csytaylor@yahoo.co.uk) \nIt is over 15 years since the technique of CT colonography (“virtual colonoscopy”) \nwas first described. Initial single center studies produced very promising results but \nearly multi-center trials produced very mixed data. Sensitivity for 1 cm adenomas \nranged from less than 60% to over 90% in these studies. Research then focused on \nidentifying the reasons for this variability in diagnostic performance of CT colonogra-\nphy. In particular, attention focused on optimum data acquisition parameters, bowel \npreparation, use of faecal tagging, reader training requirements and competence \ntesting, and optimised visualisation techniques (notably primary 2D vs. primary 3D). \nRecent innovations now include computer assisted detection (CAD). Implementation \nof the findings from this body of research by the VC community has led to recent \nsuccessful mutlicenter trial data from both the US and Europe. This presentation \nwill summarise the main trial data reporting the diagnostic performance of CT \ncolonography and highlight potential reasons for discrepancies between studies. \nIn particular, reader training and data analysis methods will be reviewed and the \npotential role of CAD discussed. Based on the evidence to data, recommendations \nwill be made to optimise CTC dissemination amongst the radiology community. \nLearning Objectives:\n1. To review the latest CTC performance trial data.\n2. To highlight inconsistencies in trial results and explore underlying reasons.\n3. To review the evidence for optimised reader performance, focusing on \nreading technique and training.\n08:30 - 10:00 Room D \nImaging in Lung Diseases \nCC 1518 \nNew interactions between radiologists and \nendoscopists \nModerator:\nM. Boijsen; Gothenburg/SE \nA‑414 08:30 \nA. Imaging of lymph nodes: We can do better \nC. Mueller-Mang; Vienna/AT (christina.mueller‑mang@meduniwien.ac.at) \nThe accurate assessment of lymph node status is essential in selecting the optimal \ntreatment strategy in patients with thoracic malignancies. To date, MDCT is still \nwidely used for this purpose because it provides excellent anatomic information \nabout the lymph nodes of the mediastinum. However, CT evaluation of the lymph \nnodes is limited by the fact that it yields only presumptive evidence of metastatic \ndisease that is mainly based on size criteria, and studies have shown that it has a \nrelatively low sensitivity for the detection of mediastinal nodal metastases between \n64 and 74%. PET imaging with FDG has been shown to be more accurate than \nCT in mediastinal nodal staging, but the highest accuracy for the differentiation \nof benign and malignant lymph nodes has been reported with integrated PET/CT \n(93%). Therefore, MDCT as a stand-alone imaging modality in mediastinal lymph \nnode staging is declining in favor of integrated PET/CT. MR imaging of the chest \nis being performed more often, and recent studies have shown promising results \nin the detection of mediastinal nodal metastasis, based on signal intensity and \nmorphologic characteristics, with an efficacy comparable to that of PET/CT. To \nassess the clinical utility of new MR techniques, such as diffusion-weighted MR \nimaging and MR imaging with ultrasmall iron oxide particles (USPIO), further stud-\nies are required. Considering the increasing concerns about radiation exposure, \nMR imaging could be a valuable alternative for PET/CT, especially in patients who \nrequire long-term follow-up imaging. \nLearning Objectives:\n1. To consolidate knowledge on the various means of imaging lymph nodes.\n2. To describe the current limitations of MDCT in lymph node evaluation.\n3. To learn about recent developments in MR imaging of lymph nodes and their \nclinical impact.\nA‑415 09:00 \nB. Direct nodal sampling by echoendoscopy: The clinician’s expectations \nF .J.F . Herth; Heidelberg/DE (Felix.Herth@thoraxklinik‑heidelberg.de) \nPurpose: There is increasing awareness of minimally invasive endoscopic tech-\nniques for mediastinal staging in lung cancer. Traditionally, cervical mediastinoscopy \nhas been utilized. Endobronchial ultrasound-guided fine needle aspiration (EBUS) \nhas recently emerged as a potential alternative.\nMethods and Material: EBUS has sensitivity for lung cancer which is at least \nequivalent (if not superior) to cervical mediastinoscopy. The efficacy and technical \naspects of endobronchial ultrasound (EBUS) are reviewed because this technol-\nogy promises to revolutionise bronchoscopy. Guided biopsies and real-time TBNA \nhave been shown to increase the diagnostic yield over conventional bronchoscopic \ntechniques.\nResults: The pooled sensitivity of real-time EBUS-TBNA in lung cancer is 90% \nbut the false negative rate is 20%. However, negative results need either further \nconfirmatory testing or adequate clinical follow-up. Complications are rare with either \nEBUS modality and are usually related to the underlying biopsy procedure rather \nthan the use of ultrasound. Procedure duration is short enough to be incorporated \ninto an outpatient setting and can be performed under moderate sedation.\nSummary: Currently, EBUS can be recommended for initial staging as a minimally \ninvasive option provided negative results are followed by cervical mediastinoscopy. \nThis would also allow cervical mediastinoscopy to be reserved for restaging. \nConventional transbronchial needle aspiration has a limited role only as a firstline \nstaging procedure but may aid diagnosis. In the future, EBUS may have a role in \npresurgical staging of the radiologically normal mediastinum and re-staging if prior \nstaging is done by cervical mediastinoscopy. \nLearning Objectives:\n1. To describe technological developments that enable direct nodal sampling by \nechoendoscopy.\n\nMonday\nPostgraduate Educational Programme\nA\n S107\nCB D E F G\nPostgraduate Educational Programme\nA S107CB D E F G\n2. To review the lymph node sites accessible by echoendoscopy.\n3. To learn about the tumoral and non-tumoral disorders that can benefit from \nthis minimally invasive procedure.\nA‑416 09:30 \nC. Image-guided endoscopy and biopsy of lung nodules \nC.-H. Marquette; Nice/FR (marquette.ch@chu‑nice.fr) \nTransthoracic needle aspiration (TTNA) is the gold standard technique for peripheral \nlung lesions < 2 cm but the technique is associated with increased pneumothorax \nrates that range from 23 to 44%. The high diagnostic yield of this method (85%) \nderives from selected populations that fulfilled in advance clinical and radiologic \ncriteria to undergo TTNA. Thus, in real life, many patients hardly can undergo TTNA \ndue to medical comorbidities such as respiratory insufficiency. These reservations \nalso apply to diagnostic surgery (via video-assisted thoracoscopic surgery or \nthoracotomy.). Diagnostic yield of blind transbronchial biopsies (TBB) via flexible \nbronchoscopy (FB) in this situation is very low (<20%) but novel technologies includ-\ning endobronchial ultrasound (EBUS) and electromagnetic navigation (EN) have \nbeen shown to be safe and effective imaging tool for TBB via FB. Not only will EN \nguidance improve the diagnostic yield of FB but one envision potential therapeutic \napproach to targeted lung lesions such as placement of fiducial markers for ste-\nreotactic radiotherapy or placement flexible radiofrequency probes. \nLearning Objectives:\n1. To review the principles of image-guided endoscopy and biopsy of lung \nnodules.\n2. To describe the necessary interaction between radiologists and endoscopists \nfor successful tissue sampling.\n3. To learn about the advantages and limitations of this approach in comparison \nwith alternative diagnostic tools.\n08:30 - 10:00 Room E1 \nMusculoskeletal \nRC 1510 \nElbow and wrist \nModerator:\nJ.‑L. Drapé; Paris/FR \nA‑417 08:30 \nA. Elbow and wrist trauma \nM.C. De Jonge; Amsterdam/NL (M.C.deJonge@amc.uva.nl) \nTrauma to the upper extremity is amongst the most common entities encountered \nin daily practice conventional radiography and should always be the first step to \nevaluate the patient followed by HRCT (High Resolution CT) for osseous lesions \nand MRI/US for the evaluation of soft tissues. Elbow: The supracondylar distal \nhumerus fracture is one of the commonest and most feared fractures in children. \nAdults more often sustain an olecranon or radial head or neck fracture. Children often \ndislocate the radial head without fracture. Both adults and children can dislocate their \nelbow, which is almost always a posterior displacement of the ulna and radius. Soft \ntissue injuries around the elbow can be muscular, tendinous or ligamentous. The \ndistal biceps tendon rupture is in adults probably the most common injury. Lower arm: \nFractures of the mid lower arm are common in children but not in adults. The Galeazzi \nand Monteggia fracture-dislocation injuries are classic but in fact uncommon. Often \nin children, it is a ‘simple’ diaphyseal fracture of the radius and ulna whilst in adults \nwe mostly see isolated injuries to the ulna (“nightstick” fracture). Wrist: Injuries to the \nwrist are ubiquitous in children, adolescents and adults. Usually, it involves the distal \nradius. Injuries to the carpal bones (scaphoid - triquetrum) are often seen in adults, \nbut are uncommon in children. Fracture dislocations are not very uncommon but easily \nmissed. T raumatic soft tissue injuries to the wrist usually involve ligamentous structures \nlike the SL ligament or the TFCC. \nLearning Objectives:\n1. To discuss the relevant anatomy.\n2. To provide an overview of common acute injuries and relevant imaging.\n3. To review the medicolegal implications of missed injuries.\nA‑418 09:00 \nB. Overuse of elbow and wrist \nE. Llopis; Valencia/ES (ellopis@hospital‑ribera.com) \n“Overuse may be defined as a level of repetitive microtrauma sufficient to overwhelm \nthe tissues ability to adapt”. The purpose of this talk is to highlight the influence of \nrepetive microtrauma causing injuries on the elbow and wrist. We will review the role \nof the different imaging techniques on diagnosis and management of these lesions. \nThe lecture will be divided into: 1. Overuse tendon injuries of the elbow and wrist: a) \nlateral epicondylitis, extensor tendinosis, b) medial epicondylitis, flexor tendinosis, \nc) De Quervain tenosynovitis, d) intersection syndrome, e) extensor cubitus ulnaris \ntenosynovitis, f) tenosynovitis of the flexor carpi radialis; 2. Posterolateral elbow \nimpingement, posterolateral plica and 3. Ulnar side impaction syndromes. Ulnar \nside impaction syndrome is a common source of pain and limitation of motion that \nresults from repetitive forced impingement between the distal ulna and the carpal \nrow and the surrounding structures. Depending on the impaction side can be divided \ninto: Ulnar impaction syndrome, carpal-ulnar impaction; Ulnar impingement syn-\ndrome, ulna against distal radius; Ulnar styloid impaction syndrome, stylotriquetrum \nimpaction; Hamato-lunate impaction syndrome or combined impaction syndrome. \nLearning Objectives:\n1. To define the concept of overuse syndrome.\n2. To understand anatomical and biomechanical influence on the development \nof overuse injuries.\n3. To review the role of different imaging modalities, with emphasis on MRI and \nimaging-guided percutaneous treatments.\n4. To describe characteristic imaging findings of specific overuse injuries.\nA‑419 09:30 \nC. Neuropathy \nC. Martinoli; Genoa/IT (carlo.martinoli@libero.it) \nA variety of peripheral neuropathies can be encountered about the elbow and wrist \naffecting the median, the radial and the ulnar nerve. Most are entrapment syndromes \nand include the supracondylar process syndrome, the pronator syndrome, the \nanterior interosseous neuropathy (Kiloh-Nevin syndrome) and the carpal tunnel \nsyndrome for the median nerve; the posterior interosseous neuropathy and the \nWartenberg syndrome for the radial nerve; the cubital tunnel and the Guyon tunnel \nsyndrome for the ulnar nerve. Although clinical examination and nerve conduction \nstudies are the mainstays of the diagnostic work-up of peripheral neuropathies, \nultrasound (US) and magnetic resonance (MR) imaging may provide key informa-\ntion about the exact anatomic location of a lesion and the nature of the constricting \nfinding or may help narrow the differential diagnosis. In patients with peripheral \nneuropathies around the elbow and wrist, US and MR imaging may provide critical \ninformation for planning an adequate treatment strategy. A deep knowledge of the \nnormal anatomy and of the possible causes, typical clinical findings, and imaging \nfeatures of peripheral neuropathies that affect the median, radial, and ulnar nerves \nallows greater confidence in the diagnosis. Although US and MR imaging have fol-\nlowed parallel paths for nerve imaging with little comparison of the two modalities, \nUS seems to have some advantages over MR imaging, including higher spatial \nresolution, time effectiveness, the ability to explore long nerve segments in a single \nstudy and to examine tissues in both static and dynamic states. \nLearning Objectives:\n1. To describe the spectrum of US and MR imaging findings of neuropathies \naround the elbow and wrist.\n2. To emphasise the role of imaging in the management of entrapment \nneuropathies to delineate the nature and extent of the process.\n3. To learn to recognise the main clinical picture of entrapment neuropathies.\n\nPostgraduate Educational Programme\nS108\n A B C D E F G\nPostgraduate Educational Programme\nS108 A B C D E F G\n08:30 - 10:00 Room E2 \nInteractive Teaching Session \nE³ 1520 \nCommon clinical problems: Cognitive decline  \nand dementia \nModerator:\nA. Platkajis; Riga/LV \nA‑420 08:30 \nCommon clinical problems: Cognitive decline and dementia \nB. Gómez-Ansón1, F . Barkhof2; 1Barcelona/ES, 2Amsterdam/NL \n(bgomeza@santpau.cat) \nWith advances in healthcare and age, the prevalence of dementia increases ex-\nponentially, with ~ 20% of subjects over 85 years becoming demented. While the \nguidelines differ by country, many recommend imaging at least once during the \nwork-up of patients suspected of dementia. Beyond exclusion of surgically treatable \ndisorders (e.g. tumour, subdural hematoma or hydrocephalus), imaging can now \nbe used to positively determine the underlying disorder (e.g. hippocampal atrophy \nin Alzheimer’s disease). While MRI is the modality of choice, multislice CT with \nmultiplanar reformats provides a robust and quick alternative to assess general \ncortical atrophy, hippocampal atrophy and vascular pathology. SPECT and PET \nshould be reserved for second line investigation, e.g. suspicion of frontotemporal \nlobar degeneration (FLTD) lacking characteristic atrophy on structural imaging. The \nadvent of amyloid imaging using PIB-PET provides a future tool to secure a diag-\nnosis of Alzheimer through molecular imaging, but its value over CSF examination \nneeds to be determined. Increasing insights are being gained into the aetiology, \nclinical features and imaging findings in other neurodegenerative diseases, e.g. \nLewy-body dementia. Structural imaging plays an essential role in establishing the \ndiagnosis of vascular dementia (VaD), and cases of mixed dementia. Serial MRI is \nvery sensitive to the degenerative process underlying neurodegenerative disorders, \nproviding insights into their pathogenesis and offers a possibility to determine the \neffects of putative new treatments in randomized clinical trials. \nLearning Objectives:\n1. To learn about the usefulness of imaging in patients with dementia.\n2. To be able to approach conventional CT and MRI examinations for patients \nwith cognitive decline and dementia.\n3. To become familiar with the most common types of dementia and their \ncharacteristic imaging findings.\n4. To appreciate the role of imaging in early diagnosis of dementia and in \ndifferentiating the vascular and neurodegenerative disease dementia.\n5. To become more familiar with the applications of imaging in research in \ndementia, especially in providing surrogate markers.\n08:30 - 10:00 Room F1 \nOrgans from A to Z: Liver \nMC 1519 \nPrimary liver tumors \nModerator:\nB.I. Choi; Seoul/KR \nA‑421 08:30 \nA. Benign liver tumors \nF . Caseiro-Alves; Coimbra/PT (caseiroalves@gmail.com) \nImaging evaluation of focal liver lesions may be currently addressed by multiple \ntechniques that may provide complementary diagnostic information in order to ac-\ncurately detect and characterize benign liver tumors. The ultimate goal of imaging \nis thus to be able to separate the “don’t touch me” lesion from those that should be \nmanaged more aggressively or by more or less close follow-up. The usual clinical \ncontext of benign liver tumors is the fortuitous discovery of a FLL especially by the \nwidespread b-mode US scans. More in-depth analysis becomes necessary when \nclassical radiological criteria are not entirely met or when we are dealing with a \nnew or previously non-reported finding in an oncologic patient. Despite the vast \narray of benign liver tumors, we will discuss in more detail the imaging findings of \ncystic lesions, hemangioma, FNH and liver adenoma using current state-of-the-\nart techniques such as CE sonography, cell-directed contrast agents for MRI and \ndiffusion-weighted imaging. The new classification of liver cell adenoma as well \nits clinical implications will be also addressed. Finally, a strategy for the charac-\nterization of the incidental liver lesion will be provided based on the concurrent or \ncomplementary information delivered by the different imaging techniques, focusing \non their pros, cons and also, when applicable, the role of biopsy in order to secure \nthe proper diagnosis. \nLearning Objectives:\n1. To learn the classification and natural history of benign liver tumors.\n2. To become familiar with the imaging findings with reference to tissue \ncharacterisation.\n3. To learn about the imaging strategy in the assessment of an incidental focal \nliver lesion.\nA‑422 09:00 \nB. Imaging of hepatocellular carcinoma \nC. Bartolozzi; Pisa/IT \nIn the setting of a cirrhotic patient, a solid nodular lesion found during ultrasound (US) \nsurveillance has a high likelihood of being a hepatocelluar carcinoma (HCC). However, \nhystology demonstrates that many small nodules detected by US in cirrhotic livers \ndo not necessary correspond to HCC. The differential diagnosis between small HCC \nand non-malignant hepatocellular lesions may be very challenging. Actually, nodules \ndetected during US surveillance are further investigated with dynamic imaging tech-\nniques, such as contrast enhanced US, contrast-enhanced multidetector computed \ntomography (MDCT), and contrast-enhanced magnetic resonance imaging (MRI). \nDynamic imaging allows in fact detecting the major clue for suspecting malignant \ndegeneration that is represented by the peculiar vascular supply. Through the progres-\nsion from regenerative nodule, to low-grade up to high grade dysplastic nodule (DN), \nand finally to overt HCC, new arterial vessels, termed nontriadal arteries develops, \nand become the dominant nodular blood supply, with the decrease of portal venous \nflow. However, two further parallel processes take place during the carcinogenetic \npathway: a) the progressive loss of biliary polarization of the hepatocyte and the \nderangement of the microscopic secretory structure, and b) the progressive nodular \ndepletion of Kupffer cells. MRI, performed with hepatobiliary contrast media, may \ngive an insight on this “grey area”, in which significant hystological changes already \noccurred, without an evident arterial supply: whereas moderately/poorly differenti-\nated lesions fail to take up the agents, appearing hypointense to liver on T1-weighted \nimages, well-differentiated tumor may show as hyperintense, because of the uptake \nand trapping of the agent within neoplastic cells. \nLearning Objectives:\n1. To understand the process of hepatocarcinogenesis.\n2. To know how to differentiate dysplastic nodules and early-stage \nhepatocellular carcinoma, by means of different imaging modalities.\n3. To learn the appropriate strategy in case of small nodules detected in a \ncirrhotic patient.\nA‑423 09:30 \nC. Other primary malignant liver tumors \nR. Manfredi; Verona/IT (rmanfredi@univr.it) \nCholangiocarcinoma is a malignant tumor arising from the epithelium of the bile \nducts. The relative incidence of cholangiocarcinoma among primary liver cancer \nreported in autopsy series ranges from 5 to 30%; it is, however, the most common \nprimary malignancy of the biliary tree. Most of these tumors are adenocarcinomas. \nThe Liver Cancer Study Group of Japan has proposed a new classification based \non growth characteristics, with tumors being identified as mass-forming, periductal-\ninfiltrating, and intraductal- growing types. This classification is considered to be \nthe most reasonable because it describes the gross appearance, growing char-\nacteristics, biologic behavior, and prognostic implication for patients and because \nit is helpful for radiologic interpretation. The imaging evaluation of patients with \nhilar cholangiocarcinoma has traditionally included computed tomography and \nsonography or a combination of the two techniques for diagnosis and preoperative \nassessment of resectability. In recent years, MR imaging in conjunction with MR \ncholangiopancreatography (MRCP), has proved to be helpful in diagnosing hilar \ncholangiocarcinoma and in determining resectability. Cholangiocarcinoma appears \nas a moderately irregular thickening of the bile duct wall (> 5 mm), with symmetrical \nupstream dilation of the intrahepatic bile ducts. Sometimes, it may be difficult to \ndifferentiate the periductal-infiltrating type of cholangiocarcinoma, encompassing \nthe bile duct confluence and the proximal segment of the common bile duct, from \nthe intraductal-growing type, especially when the lesion is small. Less frequent \nprimary liver neoplasms are represented by hepatoblastoma, fibrolamellar car-\ncinoma, transitional cell tumor, embryonal sarcoma, angiosarcoma, hepithelioid \nhemangioendothelioma, and germ cell tumor. \n\nMonday\nPostgraduate Educational Programme\nA\n S109\nCB D E F G\nPostgraduate Educational Programme\nA S109CB D E F G\nLearning Objectives:\n1. To learn the spectrum of primary liver tumors, excluding HCC.\n2. To learn about imaging findings in cholangiocarcinoma, and clues for staging \nand deciding treatment.\n3. To become familiar with imaging findings of other less frequent, primary \nmalignant tumors of the liver.\n08:30 - 10:00 Room F2 \nSpecial Focus Session \nSF 15b \nDiffusion-weighted imaging of the CNS  \nbeyond stroke\nModerator:\nS. Sunaert; Leuven/BE \nA‑424 08:30 \nChairman’s introduction \nS. Sunaert; Leuven/BE (Stefan.Sunaert@uz.kuleuven.ac.be) \nWithin this session, state-of-the-art diffusion-weighted MRI applications other than \nstroke will be reviewed. New developments, such as diffusion tensor imaging, will \nbe covered. The benefits and challenges of DWI in the diagnosis of CNS pathol-\nogy will be compared to other imaging techniques. Finally, we will debate whether \ndiffusion-weighted imaging provides a window on histology and pathophysiology. \nSession Objectives:\n1. To review state-of-the-art diffusion-weighted MRI applications beyond stroke.\n2. To evaluate the benefits and challenges of DWI in the diagnosis of CNS \npathology in comparison to other imaging techniques.\n3. To debate whether diffusion-weighted imaging provides a window on \nhistology and pathophysiology.\nA‑425 08:35 \nDWI in focal non-ischemic brain lesions \nM. Law; Los Angeles, CA/US (meng.law@usc.edu) \nDiffusion weighted and diffusion tensor imaging is now widely utilized in the research and \nclinical settings beyond its clinical applications in stroke. In the clinical setting, qualitative, \nsemi-quantitative and quantitative methods are being utilized to evaluate DWI and DTI \ndata. There are a number of pitfalls with all of these approaches. The role of diffusion \nweighted and diffusion tensor imaging characterization of tumor biology and different \npathologies will be reviewed. Differentiating between recurrent tumor and therapeutic \nnecrosis is often a challenge. We will review the role of advanced imaging and also \nthe effects of anti-angiogenic therapies on tumor microvasculature/microenvironment \nresulting in changes in diffusion, perfusion and MRS. As patients are being treated \nwith new anti-angiogenic agents such as Bevacizumab (an anti-VEGF antibody), an \nentity called “pseudo-response” has also been described where patients demonstrate \nan MRI response. Lastly, to combine and apply these different imaging techniques in \na complete imaging protocol and a multi-parametric algorithmic fashion in the clinical \nsetting can be shown to increase our diagnostic specificity and confidence. \nLearning Objectives:\n1. To apply diffusion-weighted imaging in the characterisation of focal non-\nischemic brain lesions.\n2. To differentiate between tumoral and non-tumoral disease such as glioma, \nmetastases, lymphoma, infection and demyelinating disease.\n3. To differentiate recurrent tumor from therapeutic necrosis in the post-\ntherapeutic brain.\n4. To combine DWI in a multi-parametric algorithmic fashion with other \nadvanced MRI tools such as MR spectroscopy and perfusion/permeability \nimaging in the characterisation of focal brain lesions.\nA‑426 08:58 \nDWI in diffuse non-ischemic brain and spine pathology \nM. Mascalchi; Florence/IT (m.mascalchi@dfc.unifi.it) \nHardware and software developments have determined an explosion of the clini-\ncal applications of diffusion weighted (DW) and diffusion tensor (DT) MR imaging \nfor assessment of diffuse diseases of the brain and spine. These applications are \nbased on either simple visual assessment of tissue signal intensity in DW images \nor sophisticated quantitative analyses performed using ROI, histogram, tractogra-\nphy or voxel-wise techniques on the maps of apparent diffusion coefficient, mean \ndiffusivity or fractional anisotropy. Due to the sensitivity to extracellular edema or \nmicrostructural changes both determining increased proton diffusion, DWI and DTI \nare the techniques of choice for assessment of the diffuse white matter involve-\nment in inherited or acquired metabolic diseases and in age-related small vessel \nleukoencephalopathy. In particular, they enable detection of significant changes \nalso in the normal appearing white matter which are closely correlated to the \nclinical and laboratory findings and can be used to monitor brain involvement or \nto serve as a surrogate marker of these diseases. DWI demonstration of areas of \nrestricted diffusion in the cortical grey matter is a sensitive diagnostic feature of \nherpes encephalitis and Creutzfeld-Jakob disease. Finally, DWI and DTI have been \nincreasingly used to map WM tract damage in neurodegenerative diseases of the \ngray matter such as movement disorders and dementias. The application of DWI \nand DTI to spinal pathology and, in particular, their potential contribution in the \ndifferential diagnosis between benign bone marrow edema and metastatic involve-\nment has been controversial. The adoption of lower b values (typically b=300-600 \ns/mm\n2) are recommended for such a purpose. \nLearning Objectives:\n1. To show the main results obtained in diffuse white matter and grey matter \ndiseases of the CNS using DWI and DTI.\n2. To illustrate the possible integration of DWI and DTI with other MR \ntechniques providing structural and functional evaluation of the brain.\n3. To appreciate the main results obtained with spinal DWI and DTI in spinal \npathology.\nA‑427 09:21 \nDWI: Use of advanced diffusion markers in non-infarct lesions \nW. Van Hecke; Antwerp/BE (wim.vanhecke@ua.ac.be) \nDiffusion weighted imaging (DWI) is a relatively new method in which the image \ncontrast is produced by the random microscopic motion of water molecules in dif-\nferent tissues. DWI consists of a DW image and an apparent diffusion coefficient \n(ADC) map. By acquiring at least 6 DW images in different spatial directions, a \ndiffusion tensor (DT) can be estimated in every voxel. This DT describes the three \ndimensional diffusion process in that voxel can give an insight into the white matter \nfiber architecture. Local quantitative measures are derived from the diffusion ten-\nsor, such as the fractional anisotropy (FA), which is a normalized measure for the \ndegree of anisotropy, and the mean diffusivity (MD), i.e., the averaged diffusion. \nRecent DTI studies of different pathologies are starting to use these quantitative \nmeasurements, demonstrating the potential of this in vivo and noninvasive imaging \ntechnique for detecting microstructural pathological alterations. Quantitative DW \nand DT measures can give an insight into different non-infarct lesions of the brain, \nsuch as for example infectious, neoplastic and demyelinating diseases. \nLearning Objectives:\n1. To become familiar with the different types of advanced diffusion markers \ncalculated from DWI and DTI.\n2. To become familiar with the visualisation and interpretation of diffusion \ntensor images.\n3. To apply advanced diffusion (tensor) markers in non-infarct lesions.\nPanel discussion:  \nDWI: A window on histology and physiopathology? \n09:44 \n08:30 - 10:00 Room G/H \nNeuro \nRC 1511 \nInterventional neuroradiology \nModerator:\nM. Forsting; Essen/DE \nA‑428 08:30 \nA. Endovascular management of intracranial aneurysms \nA. Krajina; Hradec Králové/CZ (krajina@fnhk.cz) \nEndovascular therapy of intracranial aneurysms has become the first line treatment \noption, whenever this option is available. The neurointerventionalist performing the \nprocedure should have appropriate radiographic equipment, training and regular \nworkload of patients. This can be better accomplished in a high-volume neurovas-\ncular center where appropriate neurosurgical care can be instituted promptly. There \nare two endovascular strategies to treat cerebral aneurysms. The first is occlusion \n\nPostgraduate Educational Programme\nS110\n A B C D E F G\nPostgraduate Educational Programme\nS110 A B C D E F G\nof the aneurysmal sac with metallic coils preserving the parent artery, and second \nis occlusion of the parent artery in order to exclude the otherwise untreatable \naneurysms from the blood circulation. Controlled coil intrasaccular delivery is \nthe prerequisite for their widespread and safe use. The technology allows for the \nwithdrawal and exchange of incorrectly sized or unstable coils prior to deployment. \nThe International Subarachnoid Aneurysms Trial was a large randomized, prospec-\ntive study of endovascular coiling versus surgical clipping for a selected group of \npatients with bleeding aneurysms deemed suitable for both types of therapy. The \nstudy revealed an absolute risk of death or independency reduction 8.7% for coil-\ning over clipping in one year after treatment. Coiling is followed by annual delayed \nrebleeding rate of 1%. Permanent procedural complications occurred in 3.7%. \nThe most frequent procedural complication was cerebral ischemia. Unruptured \naneurysms are a heterogeneous entity with extreme variation in reported rupture \nrisk. The critical size of the aneurysm is more than 7 mm. Posterior circulation \nlocation, multilobularity and aneurysms in young, hypertensive, smoking patients \nwere found to be in increased risk of hemorrhage. \nLearning Objectives:\n1. To review the principles and technique of endovascular management of \nintracranial aneurysms.\n2. To review the results of endovascular treatment.\n3. To learn about the management of treatment complications.\n4. To discuss ruptured and unruptured aneurysm treatment strategies and \nfollow-up.\nA‑429 09:00 \nB. Endovascular treatment of acute ischemic stroke \nL. Castellan; Genoa/IT (lucio.castellan@hsanmartino.it) \nIn Europe, stroke represents the third cause of death and the first cause of disability, \nwith an enormous social and economic impact. Prompt treatment with thrombolytic \ndrugs can restore blood flow in occluded intracranial arteries before major brain \ndamage has occurred. Over the past 2 decades, the management of stroke has \nprogressed significantly due to intravenous and intraarterial trhombolysis. The ef-\nficacy of intravenous approach with tissue plasminogen activator within 4.5 hours \nsince symptoms onset has been proven in large, well-designed studies. Intraarterial \nthrombolysis was first studied as an alternative to intravenous thrombolysis, with \nthe particular intent to increase the time window, to rapidly deliver the thrombolytic \nagent with high concentration at the site of occlusion and to obtain mechanical clot \ndisruption. The interventional treatment options available today are the intraarte-\nrial administration of tissue plasminogen activator and newer antiplatelet agents, \nmechanical thrombectomy by means several different intravascular systems, and \nintracranial angioplasty and stent placement. These techniques should lead to \nimproved recanalization and reduced hemorrhagic complications. Moreover, all the \nmechanical procedures could allow to bring the time window up to 8 hours or to \ntry the recanalization also after unsuccessful intravenous thrombolysis. Neverthe-\nless, because of the differences in stroke severity, time to treatment and occlusion \nlocations, direct comparisons among different thrombolytic therapies have been \ndifficult and currently many of these approaches have yet to prove their benefits in \ncontrolled clinical trials, although they offer new hope for a very large population \nof patients with stroke. \nLearning Objectives:\n1. To point out patient selection criteria for new mechanical thrombectomy and \nother endovascular procedures of intracranial revascularisation.\n2. To investigate the efficacy of intravenous thrombolysis.\n3. To become familiar with the practical applications of mechanical \nembolectomy devices in the treatment of acute ischemic stroke.\n4. To discuss integration of stroke centres of different levels in a territorial \nnetwork of emergency care systems as well as the potential impact of well-\norganised systems for stroke care.\nA‑430 09:30 \nC. Stent-based technologies in the treatment of intracranial aneurysms \nand atherosclerotic disease \nI. Szikora; Budapest/HU (h13424szi@helka.iif.hu) \nStent technology is presently applied in the endovascular treatment of atheroscle-\nrotic stenosis and that of aneurysms. For intracranial atherosclerotic disease, self \nand balloon expandable stents are used to decrease the incidence of procedural \ncomplications and to improve the long term results by reducing the incidence of \nrestenosis. Recent studies demonstrate that the complication rate of intracranial \nangioplasty has been reduced from 15 to 3%. Up to now, significant restenosis \nrate remains as high as 28% and is symptomatic in 4.1%. For aneurysms, self-\nexpandable stents deployed across the aneurysm neck are used to make intrasac-\ncular packing feasible or support tighter packing and to improve long-term results \nby promoting endothelial growth over the aneurysm orifice. More recently, high \nmesh density flow diverting devices became available that are capable of inducing \naneurysm thrombosis without intrasaccular packing by significantly reducing flow \nacross the orifice. Published results demonstrate that using coil supporting stents \nrecanalization of completely occluded aneurysms can be reduced to 4.3% and \nprogressive thrombosis in incompletely occluded lesions can be achieved in 14% \nof the cases. Using new generation flow diverting stents, complete, lasting occlusion \nof large, giant and broad neck aneurysms can be achieved in over 90% of cases. \nAt present, stent angioplasty is an inherent part of the treatment of intracranial \natherosclerotic disease. Intracranial stent implantation is an important adjunctive \ntechnique for some aneurysms and offers an entirely new avenue for the primary \ntreatment of some previously difficult or impossible to treat lesions. \nLearning Objectives:\n1. To understand the technical possibilities, limitations, potential complications, \nmid-term results and current indications of using stent-assisted angioplasty \nin atherosclerotic intracranial arterial stenosis and acute ischaemic stroke.\n2. To understand the technical possibilities, limitations, potential complications \nmid-term results and current indications of using stent-assisted coil \npacking and stent-based flow modification in the treatment of ruptured and \nunruptured intracranial aneurysms.\n08:30 - 10:00 Room I \nPhysics in Radiology \nRC 1513 \nVisualisation, perception and image processing \nModerators: \nL. Donoso; Barcelona/ES \nW.J.M. van der Putten; Galway/IE \nA‑431 08:30 \nA. Visualisation and perception \nA.G. Gale; Loughborough/UK (a.g.gale@lboro.ac.uk) \nRadiological interpretation always incurs some degree of error due to the nature \nof disease presentation coupled with the difficulty in diagnosis, especially where \nearly signs of disease need to be identified such as in medical screening. Early \nresearch studies of radiologists’ performance concentrated upon the chest radio-\ngraph but more recent work has studied breast screening extensively, as well as \nMRI and CT. As radiology is now almost fully digital, research has also examined \nobserver behaviour with a range of digital images, viewing conditions, and image \ndisplay presentations. It is possible that radiological interpretation will never be \naccomplished without some errors occurring; however, it is important that steps \nare taken to minimise any causes of errors as far as possible. The reported error \nrates found in numerous investigations across different radiological domains will \nbe reviewed and the reasons for these elucidated. Appropriate reporting conditions \nwill be highlighted for different image viewing scenarios. A theoretical framework for \nunderstanding error causation, especially where abnormalities are missed, will be \ndetailed. Furthermore, the underlying visual, perceptual and cognitive processes \nwhich lead to errors will be detailed and approaches to minimise error occurrence \nwill then be proposed. The relationship between human perceptual and cognitive \nskills and computer imaging processing will be discussed and the usefulness of \nCAD systems outlined as how they can best aid the radiologist from the human \nperformance viewpoint. \nLearning Objectives:\n1. To review the basic principles of perception, detection and detectability.\n2. To learn about specifics of perception in medical imaging.\n3. To learn how image processing can help us with the perception process.\nA‑432 09:00  \nB. Image processing and perception \nB.M. ter Haar Romeny; Eindhoven/NL (B.M.terHaarRomeny@tue.nl) \nThe need for quantitative image analysis in radiology is universal: computer-aided \ndetection, segmentation for 3D volume visualization, image enhancement, pattern \nrecognition etc. All need effective, robust and preferably generic (not ‘ad hoc’) algo-\nrithms for the computer. How to design such algorithms? A good inspiration source \nis the functionality of the visual system; the best investigated brain structure today. \nIn this talk, we will explain how we think the brain calculates features in images, \nwhy the retina measures at a wide range of resolutions and how we can exploit \n\nMonday\nPostgraduate Educational Programme\nA\n S111\nCB D E F G\nPostgraduate Educational Programme\nA S111CB D E F G\nthis in multi-scale analysis, and how we can learn to understand and exploit the \nGestalt Laws. The visual system is strongly adaptive and self-learning. New optical \nrecording techniques have given new insight in how the cells in the visual cortex \nare functioning. We will go through these functionalities step-by-step. What we \ndiscover is quite amazing. We recognize huge amounts of filter banks in the first \nstages of vision: many filters analyse each pixel of the incoming image at a range \nof scales, orientations, derivative order, for each colour, and also as a function of \ntime. We programmed these filters into the computer and were able to build many \ninteresting applications for (bio-) medical imaging: detection of catheters at seriously \nreduced levels of fluoroscopy X-ray radiation dose, automatic detection of polyps \nin the colon, quantitative analysis of ischemic heart ventricle deformation, breast \ncancer CAD, pulmonary emboli CAD and analysis of in-vivo microscopy images \nnow so abundant in modern life-sciences research. \nLearning Objectives:\n1. To gain insight into modern computer vision techniques for computer-aided \ndiagnosis.\n2. To learn how the first stages of human visual perception process information.\n3. To learn a range of application areas of image processing techniques for \nmedical imaging.\nA‑433 09:30 \nC. Clinical application of image processing \nA. Persson; Linköping/SE (anders.persson@cmiv.liu.se) \nThe practice of medical image diagnosis is currently undergoing a fast transforma-\ntion. Vast amounts of data can be generated in standard examination and focus is \nshifting from improving the collection of relevant data for diagnosis to development \nof effective methods to analyze, visualize, navigate, and interact with medical \ninformation. It is now becoming generally accepted in the medical community that \none of the most important keys to manage the increasing information flow is the \nuse of 3D and 4D applications. This talk will take its starting point in state-of-the-\nart medical visualization and then discuss the need for a research agenda that \nfocuses on the development of the next generation of medical visualization tools, \nemphasizing the fact that these tools must be based on medical user requirement \nand work flow studies as well as on new technical developments. \nLearning Objectives:\n1. To learn how to use adequate reconstructions/image sequences in CT/MR.\n2. To learn when to use transverse, sagittal and coronal displays.\n3. To learn when to use 3D displays.\n08:30 - 10:00 Room K \nPediatric \nRC 1512 \nChest imaging: What to use and when to use it \nModerator:\nA.E. Healey; Liverpool/UK \nA‑434 08:30 \nA. US: When and how? \nI. Gassner; Innsbruck/AT (i.gassner@i‑med.ac.at) \nDiseases of the chest are commonly evaluated by means of the three dominant \nimaging modalities: conventional chest radiographs, CT and MR. Thorax ultrasound \nis not often performed mainly because bone and air are traditionally considered \nnatural barriers for the ultrasound beam. However, the unique thoracic anatomy \nof neonates and children as well as certain pathologic conditions provides many \nacoustic windows into the chest. Only little effort is needed to evaluate and diagnose \na wide range of clinical problems in the thorax without the radiation exposure from \nfrequent chest radiographs and CT, or the need for sedation often required for MR \nimaging. In particular, ultrasound is quickly implemented in the remote intensive \ncare situation where patients can be examined in any given position and location \nminimising the need to move or transfer patients, who are on life support devices. \nUltrasound is particularly useful in differentiating between pulmonary and pleural \nlesion, in visualising diseased parenchyma hidden by pleural effusion in chest radio-\ngraphs, to detect and characterise pleural fluid collections, to delineate anomalies \nof mediastinum and great vessels, and last but not least, to assess malposition \nand complications of central vein catheters. \nLearning Objectives:\n1. To demonstrate imaging approaches to the mediastinum, pleura, diaphragm, \nand lung.\n2. To review sonographic features of thoracic disorders.\n3. To illustrate the use of chest US in neonatal intensive care.\nA‑435 09:00 \nB. CT: What you really need to know \nC. Owens; London/UK (owensc@gosh.nhs.uk) \nThis presentation will discuss applications of CT in the evaluation of chest dis-\nease in children. The advent of fast acquisition thin collimation volumetric CT has \nrevolutionized thoracic CT imaging in children. The majority of children requiring \nthoracic CT fall in to three basic categories; hence, three basic protocols suffice for \nmost chest CT examinations in children. Metastatic disease, focal lung pathology \nor mediastinal mass/adenopathy allows scanning with thicker beam collimation \nand lower pitch factors preserving risk from inappropriate over dosage. Vascular \nor airways disease may require thinner collimation and higher pitches. MRI may, \ntherefore, be more appropriate in these patients. In Diffuse lung disease, sequen-\ntial scans with thin collimation and high spatial frequency reconstructions are the \nestablished optimal technique. Tube current (MA) and kilo voltage KV should be \nkept to the lowest allowing diagnostic quality images and depend on patient size \nand weight. Enabling automated dose modulation will override set parameters \nand so understanding of manufacturers’ settings is imperative. There are many \ncontroversial issues within applications of paediatric chest CT and it is vital that the \nradiologist is constantly questioning the added diagnostic role of CT over the other \nalternative non-ionizing examinations (e.g. MRI) when available and appropriate. \nThe presentation will discuss areas of potential controversy within the assessment \nof children undergoing thoracic CT. \nLearning Objectives:\n1. To discuss specific customised protocols used in pediatric chest CT imaging.\n2. To discuss strategies for pediatric CT dose reduction.\n3. To illustrate the strength of chest CT using case-based illustrations.\nA‑436 09:30 \nC. MRI: The icing on the cake. Are we really there yet? \nM.U. Puderbach; Heidelberg/DE (m.puderbach@dkfz.de) \nDiseases of the respiratory system are of great importance in paediatrics. Early \ndetection and follow-up of infectious, congenital and environmental diseases in \nyoung patients is crucial for adequate treatment and improved outcome. Here, \nimaging techniques play an indispensable role. In the past, the interest was focused \non morphological aspects of pulmonary tissue. Here, computed tomography (CT) \nserves as the gold standard. In the course of the development of MRI, MR imaging of \nthe lung played a subordinate role. This was caused by several technical problems: \n1. low signal to noise ratio because of low proton density of the lung, 2. artefacts \nbecause of cardiac and breathing motion, 3. susceptibility artefacts because of air-\nsoft tissue transition. Despite these inherent difficulties of MRI of the lung, significant \nprogress has been made recently. Although spatial resolution is lower than at CT, \nMRI allows for the visualisation of the lung parenchyma by using ultra short echo \ntime (TE). Furthermore, MRI has the advantages to evaluate different tissue aspects \n(T1w, T2w, fat suppression) and to improve lesion characterization. Additionally, \nMRI is capable to assess lung function, e.g. perfusion, angiography, ventilation \nand respiratory mechanics. Using up to date scanner systems, a complete study \nof the chest including morphological and functional imaging can be performed in \nless than 30 minutes. Especially, diseases that go along with pulmonary structure \naugmentation and/or involve vascular structures can be studied by MRI. \nLearning Objectives:\n1. To describe the various techniques available for MRI of the chest in children.\n2. To illustrate specific clinical scenarios where MRI is helpful.\n3. To illustrate the strengths and weaknesses of chest MRI with case-based \nillustrations.\n\nPostgraduate Educational Programme\nS112\n A B C D E F G\nPostgraduate Educational Programme\nS112 A B C D E F G\n08:30 - 10:00 Room L/M \nSpecial Focus Session \nSF 15c \nVascular ultrasound imaging: When and how\nModerator:\nB. Brkljacic; Zagreb/HR \nA‑437 08:30 \nChairman’s introduction \nB. Brkljacic; Zagreb/HR (boris.brkljacic@zg.htnet.hr) \nUltrasound has fundamentally transformed vascular medicine. It offered new \nand profound insight into vascular physiology, early detection became possible, \nand its high diagnostic accuracy permits optimal therapeutic management. US is \nunfortunately underused among radiologists; often, CTA and MRA are preferred \neven when they do not offer real advantages. Ultrasound is noninvasive, cheap, \neasily and widely available, provides morphologic and physiologic information, \nwith direct hemodynamic data obtained at the site of pathologic lesion, and proxi-\nmally and distally, and is highly accurate. It is also useful during many vascular \ninterventional procedures. It requires experience, manual dexterity and is highly \noperator-dependent. In the session the role of US in the quantification of vascular \ndisease will be described, with the emphasis on physiological measurements. \nState-of-the art performance and interpretation of carotid US examinations and \nthe role of US and US contrast media for the characterization of plaque will be \npresented. The role and advantages of US over other imaging methods in planning \nof endovascular procedures and follow-up will be emphasized. Finally, deep venous \nthrombosis is a common and important condition potentially resulting in pulmonary \nembolism. US is the major imaging modality used for accurate diagnosis and to \nprevent thromboembolic complications; major aspects of US diagnosis of DVT will \nbe presented. Additionally, alternative conditions that clinically mimic DVT and their \nUS findings will be presented. Vascular ultrasound should be utilized by radiologists \nto complement CTA and MRA, since it provides a quick, inexpensive and accurate \nway to diagnose major arterial and venous diseases. \nSession Objectives:\n1. To present the role of US in the evaluation of hemodynamics and \nquantification of vascular disease.\n2. To describe the role of US in the planning and follow-up of endovascular \nprocedures.\n3. To discuss the role of US in the diagnosis of DVT and its mimics.\nA‑438 08:33 \nNot only imaging: A window on physiology\nC. Deane; London/UK (colin.deane@kch.nhs.uk) \nUltrasound is established in the diagnosis of arterial disease. The morphological \ninformation from B-mode, together with colour flow imaging of the residual arterial \nlumen, is complemented by Doppler measurement of arterial velocity and the flow \nwaveform. This not only gives a measure of the geometrical severity of the lesion \nbut is also indicative of the pressure changes through the stenosis and its effect \non the local circulation. Changes to flow waveform show the effects proximal and \ndistal vascular changes. The combination of local changes through a renal artery \nstenosis with flow waveform changes within the kidney is, for example, arguably \nvaluable in assessing both the artery stenosis level and the intrarenal circulation. \nUltrasound has an important role to play in the evaluation of early disease. It provides \ninexpensive screening for aortic aneurysm. Measurement of intimal thickening in the \ncarotid arteries has been used as a predictor of increased cardiovascular disease. \nUltrasound can also be used in the measurement of arterial stiffness which has \nshown to be an early indication of arterial disease. Lastly, transcranial Doppler is \nan inexpensive technique for examining cerebral haemodynamics. Clinically ef-\nfective in, for example, screening children with sickle cell disease, it has extensive \nresearch applications. The use of TCD techniques to measure small microemboli \nhas been shown to offer possibilities to identify patients at risk from stroke from \ncarotid stenoses with the potential to enable refinement of treatment options. \nLearning Objectives:\n1. To present the role of US in the quantification of vascular disease.\n2. To provide an overview of US measurement techniques in vascular \ndisease and flow measurement, the role of US in vascular physiological \nmeasurement including arterial compliance, and the use of transcranial \nDoppler techniques for cerebral hemodynamics and embolus detection.\nA‑439 08:53  \nCarotid stenosis and vulnerable plaque \nD. Gaitini; Haifa/IL (d_gaitini@rambam.health.gov.il) \nIdentification of carotid stenosis and differentiation stenosis from occlusion may \nenable selection of the most appropriate candidates for endarterectomy or stent \nimplantation. Carotid ultrasound (CUS) has become an important means to reach \nthese goals thanks to advances in CUS performance and interpretation driven by \ntechnological improvements in gray scale, color and spectral Doppler. Intima-media \nthickness, plaque location and characterization, flow disturbance and flow velocities \nfor the diagnosis of carotid stenosis are obtained by CUS. The degree of diameter \nstenosis of internal carotid artery is the main parameter used for therapeutic ap-\nproaches. Plaque rupture is the most common type of plaque complications, ac-\ncounting for almost 70% of fatal acute myocardial infarctions and cerebral strokes. \nMicrobubbles contrast media (CMUS) injection may demonstrate neovessels in the \natherosclerotic plaque. A high density of neovascularization diagnosed by CMUS \ncorresponds to a vulnerable plaque, with higher propensity to rupture and clinical \nmanifestations. CUS is a unique imaging method for the investigation of carotid \nstenosis. Non-invasive, accurate and cost-effective, it provides morphological and \nfunctional information. It is increasingly becoming the first and often the sole im-\naging study before treatment, where costly and invasive procedures are reserved \nfor special cases. State-of-the-art in the performance and interpretation of CUS \nexaminations and the role of CMUS for plaque characterization are presented. \nLearning Objectives:\n1. To describe the technique of US Doppler examination, correlation of US \nDoppler results with stenosis degree, and advantages and limitations \ncompared to other imaging tests.\n2. To present the patterns of atheroslcerotic plaques and the role of US \ncontrast media in the characterisation of the vulnerable plaque.\nA‑440 09:13  \nPlanning and follow-up of endovascular procedures \nZ. Morvay; Szeged/HU (mzita@radio.szote.u‑szeged.hu) \nUltrasound is effective in imaging and measuring disease in large arteries although \nthe skill and equipment required varies. For example, the abdominal aorta can easily \nbe visualized but renal arteries require more skill and high specification equipment. \nCarotid, femoral, popliteal, brachial arteries are easily accessed and criteria for \ndetermining the severity of steno-occlusive disease are well-established. Small \narteries in the arm and leg can be imaged although those in the leg may present \ndifficulties, especially in diabetic patients with high prevalence of multiple lesions in \ntibioperoneal arteries. In this case, other image modalities are often required. Suc-\ncessful imaging requires careful manipulation of colour flow and Doppler controls, \ngain, transmit frequency, PRF , beam steering and angle correction. It is important \nto be confident of flow direction and measures velocities; good scanning techniques \ncan limit errors. Velocity criteria can be used to grade stenoses into categories. \nAbsolute values are helpful although velocity ratios are useful to compensate for \nphysiological variables; for example, in the peripheral circulation. Ultrasound is ef-\nfective in determining the presence and extent of aneurysms, pseudoaneurysms, \nfistulas, dissections and has in important role in follow-up of surgical and radio-\nlogical vascular interventions. Fortunately, stents and grafts placed into vessel are \n“transparent” for ultrasound; after such procedures, the same measurements can \nbe performed in vessels as for native vessels. Diagnostic criteria will be presented \ntogether with limitations as to their use in clinical scanning. \nLearning Objectives:\n1. To describe indications, technique, pitfalls and general yield of Doppler US \nfor the diagnosis of arterial stenosis.\n2. To present the role and advantages of US over other diagnostic procedures \nin the diagnosis and therapy of post-procedural complications.\nA‑441 09:33 \nDVT diagnosis and mimics \nG. Ivanac; Zagreb/HR (gordana.augustan@zg.htnet.hr) \nDeep venous thrombosis (DVT) is extremely common and pulmonary embolism \nremains major killer of inpatients. Although the risk factors for DVT are known, \nprophylaxis is not universal. False diagnosis results in unnecessary anticoagulant \ntherapy and the risk of bleeding. Clinical diagnosis of DVT alone is unreliable; only \n20-30% of those with symptoms have DVT and 90% of patients with fatal PE are \nasymptomatic for DVT. Accurate diagnosis and prompt therapy are essential to \nreduce risk of thromboembolic complications. Ultrasound is the major imaging \nmethod to diagnose DVT and follow-up the patient during and after the therapy. The \ngoals of venous ultrasound are: to diagnose the presence or absence of thrombus, \n\nMonday\nPostgraduate Educational Programme\nA\n S113\nCB D E F G\nPostgraduate Educational Programme\nA S113CB D E F G\nto evaluate the thrombus extent and characterize whether it is fresh or organized, \nfree-floating or attached, partially or totally occlusive, and finally to establish \nthe alternative diagnose to DVT in patients with similar symptoms. Examination \ntechnique and criteria to diagnose acute and chronic DVT will be presented. The \nrole of US in the follow-up of patients will be discussed. Controversial and difficult \nissues will be discussed, regarding the selection of patients for imaging, screening \nof asymptomatic high-risk patients, imaging of isolated calf DVT, and the need to \nprovide permanent hospital US service for suspected DVT. Clinical diagnosis of \nDVT is difficult, and the majority of thrombi are clinically silent; ultrasound enables \nrecognition of alternative pathology with similar clinical symptoms in more than 15% \nof patients; many examples of alternative pathologic conditions will be presented. \nLearning Objectives:\n1. To describe goals, technique, pitfalls and accuracy of Doppler US in \ndiagnosis of DVT and post-thrombotic syndrome.\n2. To discuss controversial issues and strategies to refine the selection of \npatients for imaging.\n3. To present the advantages of US in diagnosing alternative conditions that \nclinically mimic DVT.\nPanel discussion:  \nWhy is vascular US underutilised in radiology departments \n09:53 \n08:30 - 10:00 Room N/O \nHead and Neck \nRC 1508 \nCommon pains in the head and neck \nModerator:\nL. Akesson; Lund/SE \nA‑442 08:30 \nA. Salivary colic \nT. Beale; London/UK (timothy.beale@royalfree.nhs.uk) \nThis lecture will demonstrate a multimodality approach to the imaging of salivary \ncolic. The relevant US and MRI salivary anatomy will be highlighted and the ultra-\nsound, computed tomography and magnetic resonance appearances of salivary \ncolic will be shown and techniques for optimising the imaging of salivary colic given. \nThe use of US, CT, MRI, and both MRI and conventional sialography in the imaging \nof salivary colic will be discussed. The role of interventional sialography and mini-\nmally invasive techniques in benign salivary gland obstruction will be demonstrated. \nLearning Objectives:\n1. To review the role of imaging in the evaluation of salivary colic.\n2. To understand the advantages and limitations of the different available \nimaging techniques.\n3. To become familiar with MR sialography technique and how it compares with \nconventional sialography.\n4. To learn the indications and limitations of interventional sialography.\nA‑443 09:00 \nB. Trigeminal neuralgia \nB.F . Schuknecht; Zurich/CH (image‑solution@ggaweb.ch) \nTrigeminal neuralgia is defined as recurrent episodes of intense lancinating pain \nmost common in the second (V\n2) or third division (V3) of the trigeminal nerve. The \npathogenesis is a neurovascular conflict by an artery or vein associated with fo-\ncal demyelination of sensory fibers at the glia schwanncell junction. Apposition of \ndemyelinated fibers induces abnormal generation and transmission of impulses. \nMR Imaging is based on high resolution sequences: CISS with coronal and sagittal \noblique MPR and 3D TOF sequences with a thin MIP reconstruction to delineate \nthe cisternal course of the trigmenial nerve, the root entry and glia schwanncell \njunction and the course of vessels along the trigeminal nerve. The brainstem and \nbrain are assessed by T2, Flair and 3D isotropic Gd enhanced sequences, and the \nviscerocranium is examined by a noncontrast and coronal T1 Gd fat suppressed \nsequence. Analysis of images is focused on recognition of displacement and distor-\ntion of the proximal trigeminal nerve by the SCA, rarely by the AICA, BA or petrosal \nvein. Inflammatory CNS disorders and peritrigeminal tumours are scrutinized as \nwell as neoplastic or inflammatory lesions along the course of the V\n1 - V3 division \nfrom the root entry to the exit foramina. Correlation of the circumferential site of \ndistortion at the root entry zone with the somatopic representation of fibers increases \nthe in general low specificity of the neurovascular contact. Ruling our compressive \ntumours and delineating a marked neurovascular conflict may stratify patients in \ncase of failure of antiepileptic medication to microvascular decompressive surgery. \nLearning Objectives:\n1. To review the clinical diagnostic criteria and pathophysiology of trigeminal \nneuralgia.\n2. To learn how to tailor MR imaging technique.\n3. To become familiar with the most common causes.\n4. To understand the value of imaging in patient management.\nA‑444 09:30 \nC. Painful swallowing \nM. Becker; Geneva/CH (minerva.becker@hcuge.ch) \nThe purpose of this lecture is to provide an overview of the key imaging features of \npainful swallowing with or without associated mucosal pathology. In the presence of \na mucosal lesion, painful swallowing is most often caused by infectious, neoplastic \nor traumatic lesions of the pharynx itself, whereas in the absence of mucosal al-\nterations, painful swallowing is the result of functional disorders (dysfunction of the \ncricopharyngeus muscle), infectious, inflammatory or neoplastic diseases affecting \nadjacent neck spaces (retropharyngeal and paraphyrngeal space), neurologic \nimpairment (glossopharyngeal neuralgia), carotidodynia and Eagle’s syndrome. \nThe indications for CT, MRI, US and videofluoroscopy will be reviewed and their \nrespective role in the detection and precise description of the underlying cause. \nMajor emphasis will be placed on how to report the findings in a comprehensive way. \nLearning Objectives:\n1. To recognise the most common causes of painful swallowing in patients with \nan abnormal pharynx at clinical examination.\n2. To recognise the most common causes of painful swallowing in patients with \na normal pharynx at clinical examination.\n3. To review the role of different imaging techniques in the diagnosis and \ntreatment of painful swallowing.\n4. To review the key imaging features of the most common causes of painful \nswallowing as seen on the respective imaging techniques.\n08:30 - 10:00 Room P \nCardiac \nRC 1503 \nImaging coronary artery disease (CAD) \nModerator:\nG.H. Roditi; Glasgow/UK \nA‑445 08:30 \nA. CT of coronary arteries: Luminography and beyond \nH. Alkadhi; Zurich/CH (halkadhi@partners.org) \nCoronary CT angiography has entered daily clinical practice. Increasing robustness \nfor non-invasive coronary artery imaging could be achieved through the implemen-\ntation of CT systems equipped with dual-source technology and/or providing a \nwider Z-axis coverage (128 slices and more). In addition, an increase in temporal \nresolution has diminished the dependency of image quality on the patients‘ heart \nrate. Cardiac CT is particularly useful in patients having an intermediate pre-test \nlikelihood of coronary artery disease based on their history, cardiovascular risk \nfactors, symptoms, and the results of ECG or stress tests. In these patients, CT is \na clinically useful tool and may obviate the need for invasive diagnostic procedures. \nThe contrast-enhanced CT scan for coronary angiography also includes qualitative \ninformation about the extent and composition of coronary plaques. These can be \ncharacterized by CT into calcified, non-calcified or mixed. Particularly, non-calcified \nplaques represent an early stage of atherosclerosis and mixed plaques carry some \nrisk for rupture which makes their identification an important adjunct to a purely \nluminographic coronary artery assessment. Whereas MR continues to fall short of \nimaging the cororary arteries in a clinically robust manner, it has recently shown \ngreat promise in the detection and characterization of coronary artery plaques. \nThis is mainly achieved through its excellent soft-tissue resolution that generally \noutperforms that obtained from CT. \nLearning Objectives:\n1. To review the performance of CT for diagnosing CAD.\n2. To highlight the importance of non-invasive imaging of coronary plaques.\n3. To define the current and future role of CT for plaque imaging.\n\nPostgraduate Educational Programme\nS114\n A B C D E F G\nPostgraduate Educational Programme\nS114 A B C D E F G\nA‑446 09:00 \nB. MRI: What can it provide in CAD? \nL. Natale; Rome/IT (lnatale@rm.unicatt.it) \nMRI is a powerful tool in cardiac imaging, because of its morphological, functional \nand perfusion information, due to its high spatial, contrast and temporal resolu-\ntions. In CAD, MRI has very strong clinical indications in ischemia detection, acute \nand chronic myocardial infarction assessment, and viability assessment. Many \ntechniques can be employed: Fat sat T2 imaging is very useful in edema detection, \nfirst pass sequences can be used at rest and stress to detect perfusion defects \nand ischemia, delayed enhancement sequences are considered gold standard \nfor necrosis and/or scar recognition and quantification and viability assessment. \nFurthermore, other information can be obtained by MRI; in treated and untreated \nacute myocardial infarction, microvascular obstruction presence represents a major \nprognostic factor. Different approaches can be used: Rest first pass imaging, so-\ncalled early late enhancement, conventional late enhancement. Risk stratification is \nanother important field where MRI can be employed. Ischemia presence/absence \nstill remains a major prognostic factor in patients with suspected CAD. Rest and \nstress perfusion MRI is more feasible than rest and stress cine-MRI for ischemia \nrecognition, with many advantages compared to nuclear perfusion imaging. More \nthan important technical development, future of cardiac MRI can be represented \nby emergency room applications, such as T2 imaging in acute chest pain and \nperfusion imaging in atypical chest pain. \nLearning Objectives:\n1. To review the scientific evidence of MRI in CAD.\n2. To discuss various techniques for assessing function, perfusion and viability \nin CAD.\n3. To define the current and future role of MRI in risk stratification of patients \nwith CAD.\nA‑447 09:30 \nC. MRI and MDCT: Complementary or competitive? \nK. Nikolaou; Munich/DE (konstantin.nikolaou@med.uni‑muenchen.de) \nHigh-field-strength clinical magnets, high-performance gradient hardware, and ultra-\nfast pulse sequence technology are rapidly making the vision of a comprehensive \ncardiac MR imaging examination a reality. This examination is poised to have a \nsignificant effect on the management of coronary artery disease by means of assess-\nment of myocardial function and regional wall motion with tagging and pharmacologic \nstress testing, evaluation of the coronary microvasculature with perfusion imaging, \nand with MRI having been established as the gold standard of myocardial viability \nanalysis. On the other hand, the direct visualization of the coronary arteries has been \nthe main clinical application for multislice CT. With ever faster multislice-CT scanners \nat hand and with growing indications for cardiac imaging and imaging in ischemic \nheart disease also using CT , the appropriate use of each imaging modality in patients \nwith suspected and known coronary artery disease is under ongoing discussion. \nLearning Objectives:\n1. To understand the strengths and weaknesses of MRI and MDCT.\n2. To discuss clinical indications for both modalities.\n3. To review CAD cases.\n08:30 - 10:00 Room Q \nInterventional Radiology \nRC 1509 \nMinimally invasive treatment of uterine fibroids \nModerator:\nR. Pietura; Lublin/PL \nA‑448 08:30 \nA. Choice of embolic agent \nN. Hacking; Southampton/UK (nigel.hacking@virgin.net) \n1. To learn which embolic particles may be used for uterine fibroid embolisation \n(UFE): p-PVA, s-PVA: the longest use of any product for UFE, relatively cheap \nand effective in RCTs. Most commonly used embolic in UK and Canada. s-PVA \nintroduced to allow deeper penetration and less clumping. Gelfoam: the cheapest \nembolic and effective, with long term studies showing safety and efficacy. Widely \nused in the Far East, UK, India and the Caribbean. Embospheres (ES), Beadblock \n(BB), Embozenes (EZ): three further spherical agents. Available in a wide range of \nsizes, colours and with different physical characteristics. Less catheter occlusions \nthan with PVA. Easier to deliver through a micro-catheter. Agents of choice in the \nUSA and much of Europe.\n2. To discuss criteria for selection of particles: The ease of use, volume of embolic \nrequired, complication rates and cost all vary between embolic agents. Depth of \npenetration into the fibroid, the inflammatory response, uterine artery occlusion \nrates and fibroid infarction rates also show some variation. All the above agents have \nbeen used effectively and safely in UFE. The costs of the embolics vary significantly.\n3. To review evidence for and against available embolic particles: Fibroid re-growth \nand recurrence of symptoms have been shown to be related to fibroid infarction \nrates and this is the most accurate way of predicting long term outcomes following \nUFE with differing embolic agents. Comparative fibroid infarction rates with these \ndifferent agents will be presented. \nLearning Objectives:\n1. To learn which embolic particles may be used for uterine fibroid \nembolisation (UFE).\n2. To discuss criteria for selection of particles.\n3. To review the evidence for and against available embolic particles.\nA‑449 09:00 \nB. Recurrence of fibroids after embolisation \nC. Binkert; Winterthur/CH (christoph.binkert@ksw.ch) \nUterine fibroid embolisation (UFE) has shown a similar clinical outcome after two \nyears compared to hysterectomy in the EMMY trial. However, there is a higher \nreported rate of re-intervention after UFE compared to hysterectomy. In the REST \ntrial, the re-intervention rate was 20% for UFE vs. 2% for the hysterectomy population \nduring a median follow-up of 32 months. MRI has become the modality of choice \nto assess the outcome after UFE. Y ouselfi et al. (JVIR 2006) showed that the large \nmajority of recurrent fibroids occurs from re-growth after incomplete fibroid infarction \nand only a minority (12%) are new fibroids. Therefore, the key question is: what \nare the factors to prevent complete embolisation. Basically, the problem is that not \nenough particles get to the fibroids. One reason is an arterial supply other than \nthe uterine arteries. The most common additional supply is the ovarian arteries. If \nparts of the fibroid are only supplied by the ovarian artery, a complete embolisation \nthrough the uterine arteries is not possible. Another reason is either the inability \nto catheterise the uterine artery or the impairment of flow before or during particu-\nlate embolisation such as spasms or dissection. In order to minimize incomplete \nfibroid infarction, the ovarian arteries should be assessed during UFE and in case \nof substantial supply to the fibroids embolised. Also, subtle catheter technique \nshould be applied with the use of small catheters (4 F or microcatheters). Overall, \nit should not be forgotten that only symptomatic recurrences need further treatment. \nLearning Objectives:\n1. To discuss factors affecting the incidence of fibroid recurrence.\n2. To discuss methods of avoiding recurrence.\n3. To review the current evidence regarding recurrence.\nA‑450 09:30 \nC. UAE and HIFUS: What the radiologist needs to know \nT. Kroencke; Berlin/DE (thomas.kroencke@charite.de) \nUterine artery embolisation (UAE) and MR guided high-intensity focused ultrasound \n(HIFUS) are minimal-invasive therapies for treating symptomatic uterine leiomyo-\nmas (fibroids) and represent alternatives to surgery (hysterectomy, moymectomy, \nhysteroscopic resection). The indication for treatment of uterine leiomyoma de-\npends heavily on symptomatology and burden of disease. Chronic fibroid related \nsymptoms fall into three major categories: bleeding symptoms (hypermenorhea, \ndysmenorrhea), bulk-related symptoms (urinary frequency, obstipation, bloating, \npelvic pain), and infertility. With the exception of infertility, patient expectations are \ncentered on the efficacy of currently available treatment options regarding freedom \nof symptoms, quality-of-life and invasiveness of therapy. Validated questionnaires \nare available to assess symptom severity and impairment of quality-of-life in a \nstandardized manner. The burden of disease is dependent on the location, size, and \nnumber of leiomyoma. However, as opposed to many malignant tumors, no unique \nclassification system is available to date to determine the extent of disease and help \nto stratify treatment options. Non-invasive imaging such as transvaginal ultrasound \n(TVUS) and magnetic resonance imaging (MRI) play a crucial rule in detection of \nuterine leiomyoma and differentiation from other uterine and ovarian pathologies. \nThis presentation summarizes current treatment options in the light of the current \nliterature. Especially, the role of interventional radiological treatments like HIFUS \nand UAE for uterine leiomyoma is discussed in a case-based approach. The role \nof imaging with a focus on key information requested by the treating interventional \nradiologist, typical imaging features before and after these procedures as well as \na common differential diagnoses will be discussed. \n\nMonday\nPostgraduate Educational Programme\nA\n S115\nCB D E F G\nPostgraduate Educational Programme\nA S115CB D E F G\nLearning Objectives:\n1. To discuss the role of HIFUS and UAE as an alternative to surgery.\n2. To learn about the role of MR imaging prior to UAE and HIFUS.\n3. To differentiate typical versus atypical findings after UAE and HIFUS.\n10:30 - 12:00 Room E2 \nInteractive Teaching Session \nE³ 1620 \nImaging in common clinical problems: Neck mass \nModerator:\nM.G. Mack; Frankfurt a. Main/DE \nA‑451 10:30 \nA. Above hyoid \nS.J. Golding; Oxford/UK (stephen.golding@nds.ox.ac.uk) \nThe face and neck offer some of the most complicated anatomy with which the \nradiologist has to deal, and also a particularly wide range of pathology, making \ncervicofacial imaging a complex area of clinical practice. Further, imaging signs in \nthe face and neck can frequently be difficult to elicit. Many general radiologists prefer \nto avoid practicing in this area if possible but a basic knowledge of neck masses \nis fundamental to general radiology practice. A simple approach to the complexity \nof the suprahyoid neck may be taken on the basis of anatomical compartments. \nKnowledge of and ability to analyse these is fundamental to differential diagnosis \nand provide the radiologist with a useful guide to establishing the pathological basis \nof imaging signs. In this area, it is also important to correlate imaging with clinical \nexamination, as lesions may have identical imaging signs but radically different \npathophysiology. Imaging signs are rarely specific but provide a good guide to further \nclinical management, including local staging of both benign and malignant disease. \nIn radiology generally, knowledge of the clinical treatment options is fundamental to \nproviding a meaningful radiological report. This is particularly true of cervicofacial \ndisease where therapeutic options are generally not well understood by radiologists, \nand where clinicoradiological liaison becomes paramount. \nLearning Objectives:\n1. To learn about diagnostic imaging signs in the suprahyoid neck.\n2. To appreciate the importance of correctly localising disease and how this \nhelps in the differential diagnosis.\n3. To understand the strengths and weaknesses of characterising suprahyoid \nlesions on the basis of imaging signals and characteristics.\n4. To understand the importance to patient management of precise evaluation \nand staging by imaging.\nA‑452 11:15  \nB. Below hyoid \nN.J.M. Freling; Amsterdam/NL (n.j.freling@amc.uva.nl) \nThe infrahyoid neck is an anatomical area between the oral cavity, the submandibular \nspace and the entrance of the thoracic cage, which may serve as a highway, con-\nnecting different areas. It contains mainly longitudinal structures: muscles, blood \nvessels, nerves, esophagus and only a few horizontal structures, e.g. the hyoid \nbone, the thyroid gland, and the vocal cords. When examining this region at a digital \nworkstation, it is important to use a rigid systematic analysis to avoid diagnostic \nfailures: larynx - upper airways, hypopharynx - esophagus - blood vessels - lymph \nnodes - muscles - thyroid gland - spine - skin. Few clinical issues regarding the \ninfrahyoid neck will involve this anatomic area only. For example, esophageal cancer \nof the cervical esophagus needs to be staged before treatment planning, including \nthe neck nodes, chest and upper abdomen. Extension of a deep parapharyngeal \nneck abscess beyond the hyoid bone may involve the infrahyoid neck before \nextending into the mediastinum. But a lateral neck cyst is usually in an infrahyoid \nlocation. The choice of imaging depends on clinical information: should we use US, \nCT, MRI, PET/CT or shall the patient immediately be transported to the radiology \nintervention department? The radiologist should be aware of the acute (trauma, \nhaemorrhage, vascular occlusion), semi-acute (infection) or non-acute situation \n(staging cancer, analysis slowly growing mass lesion). Pathology differs between \nchildren and adults and to know the incidence of the most common diseases in \nthe infrahyoid neck is extremely rewarding in daily practice. \nLearning Objectives:\n1. To learn what structures are located in the infrahyoid neck (excl. the larynx).\n2. To know what a cystic lesion might represent in children and in adults.\n3. To know how to diagnose a solid lesion and what its nature could be.\n4. To learn how to recognise vascular lesions.\n5. To understand how to use the best of different imaging modalities to obtain \na diagnosis.\n12:15 - 13:45 Room B \nESR meets Saudi Arabia \nEM 4 \nSaudi radiology\nPresiding:\nC.J. Herold; Vienna/AT \nS.S.A. Lingawi; Jeddah/SA \nM. Szczerbo‑Trojanowska; Lublin/PL \nA‑453 12:15 \nIntroduction \nS.S.A. Lingawi; Jeddah/SA (dr_lingawi@yahoo.ca) \nThe Radiological Society of Saudi Arabia (RSSA) is a young society. It was es-\ntablished in January 2004 and is now in its 6\nth year. About 400 radiologists work \nin Saudi Arabia, a third of whom are Saudi nationals and the rest are expatriates \nfrom different nationalities including North America, Europe, North Africa, East \nMediterranean counties and the Indian subcontinent. The ratio of women to men \nis almost 1:6. RSSA also servers radiographers, whose number is triple that of \nradiologists. As the field of radiology is evolving and the recognition of its importance \nis becoming a fact in all physicians’ minds, it is expected that the number of physi-\ncians seeking radiology certification will increase. In our local training program, this \nhas been noticed over the past five years with equal number of applicants among \nmen and women. As the rest of the word, radiology in Saudi Arabia is met with \nthe following main challenges: 1. High medical demand and shortage of enough \nqualified radiologists. 2. Need for high quality RIS/PACS systems at a national level. \n3. Need for reliable national and international Teleradiology systems. 4. Need for \nphysician education to improve appropriate radiological investigation referral pattern. \nCertain endemic diseases are present in Saudi Arabia such as: tuberculosis and \nbrucellosis, and parasitic infestations. Similarly, due to various genetic and social \nfactors other diseases are prevalent such as congenital anomalies, diabetes mel-\nlitus, and sickle cell anaemia. Among the various oncological diseases, lymphoma \nseems to be prevalent. \nSession Objectives:\n1. To introduce the practice of radiology in Saudi Arabia.\n2. To highlight the role of the Radiological Society of Saudi Arabia.\n3. To demonstrate some of the common health issues in Saudi Arabia.\nA‑454 12:23  \nPeculiar musculoskeletal infections and infestations \nM.E. Abd El Bagi; Riyadh/SA (drm_bagi@hotmail.com) \nSaudi Arabia emphatically surpassed hardship days, which left behind residual \npeculiar infections, to prosperity which provided accurate imaging facilities for \ndiagnosing those infections. The most peculiar and most sinister is mycetoma. It \nis a mimicker of all bone diseases which may be misdiagnosed. Mycetoma can \nlook like osteomyelitis, simple or aneurysmal bone cysts, fibrous dysplasia, en-\nchondroma, osteosarcoma, Ewing’s tumour, osteoid osteoma or neurofibromatosis. \nMycetoma is painless. It burrows deeply before it becomes clinically manifest and \nmay require amputation or re-amputation. The bidirectional travel between tropical \nand temperate countries and the global warming may cause spreading of human \nparasites. No country is exempt. The musculoskeletal system could be the transit \nroute or the graveyard of certain parasites. These include cysticercosis, hydatid \ndisease, guinea worms and filariasis. Such parasites may be discovered acciden-\ntally on radiographs as calcifications and may present with rheumatism or bizarre \nsymptoms. Acute bone pain in sickle cell diseases patients is a common clinical \ndilemma with great morbidity. It could be due to an infection, an established infarct \nor a transient vasculopathy. Differentiation is difficult clinically and management is \ndiverse. Plain films are usually negative. Ultrasound is neither sensitive nor specific. \nRadioisotopes may require multiple studies with technetium scan, WBC scan or \ncolloid bone marrow scan with a significant radiation dose. MRI is the modality of \nchoice but is expensive and may require heavy sedation for children. Future use of \nMR perfusion studies may help to differentiate among infection, infarct and transient \nvasculopathy to avoid invasive procedures. \n\nPostgraduate Educational Programme\nS116\n A B C D E F G\nPostgraduate Educational Programme\nS116 A B C D E F G\nLearning Objectives:\n1. To summarise the peculiar infections of the musculoskeletal system.\n2. To demonstrate the spectrum of the radiologic signs of peculiar \nmusculoskeletal infections.\n3. To describe how can these peculiar musculoskeletal infections mimic other \nbone diseases.\nA‑455 12:46  \nBrucellosis in Saudi Arabia from head to toe \nN.A. Al-Nakshabandi; Riyadh/SA (nizar.nakshabandi@ksu.edu.sa) \nHuman brucellosis is notoriously a multisystem disease. Brucellosis is endemic in \nSaudi Arabia. Morbidity in humans in the Saudi population continues to be reported \nwith increasing frequency from various regions of the country, particularly from the \nrural areas, and human infection is in the range of 1.6 - 2.6%. The disease presents \nin both sexes and in all ages with varied manifestations. It can involve any part \nof the body. In the brain, it can present with meningitis, encephalitis, MRI can be \nnormal, abnormal enhancement of the meninges, from inflammation, white matter \nchanges and vascular changes. Involvement of the spine can be diffuse or focal \nwith most cases seen in the lumbar spine region. Erosions as well as sclerosis \nare in the endplates of the vertebra. Changes of inflammation can be seen on \nMRI. Osteomyelitis of adjacent vertebra is with or without involvement of the disc \nspace and an epidural mass in diffuse spondolitic brucellosis. Sacroiliac joint is a \nfavorite location for the disease. Most bone/joint involvement was normal on plain \nradiographs but evidence of osteomyelitis and septic arthritis was seen on MRI. \nIn the body, there is hepatosplenomegaly and lymphadenopathy along with ileitis \nin rare cases. Colitis and spontaneous peritonitis have can be seen on CT scan. \nSacular mycotic pseuoaneurysms of the aorta from direct extension of vertebral \nbody osteomylitis can be seen on CT. Epididymo-orchitis is the most common \ngenitourinary complication visualized on ultrasound. \nLearning Objectives:\n1. To summarise the full extent of Brucella infection in various body systems.\n2. To demonstrate the spectrum of the radiologic signs of Brucella infection.\n3. To understand the importance of imaging in the diagnosis of Brucellosis.\nA‑456 13:09 \nRole of imaging in discovery and characterisation of genetic diseases \nI.A. Alorainy; Riyadh/SA (alorainy@ksu.edu.sa) \nHistorically, imaging has significantly contributed in the discovery and understanding \nof many genetic diseases. With the recent imaging advances, the role of radiology \nand medical imaging is not any more limited to the study of gross alteration in \nstructure, but rather extends to the study of microstructure and function of body \norgans, tissues, and cells. Today, there is a great opportunity for imaging to have \nstronger impact on knowledge about genetic diseases. In Saudi Arabia, genetic \ndiseases are prevalent partly due to high percentage of consanguineous mar-\nriages resulting in high frequency of autosomal recessive disorders and increased \nfrequencies of homozygosity for autosomal dominant traits. Such genetic diseases \nare either rare by Western standards or are unknown. This presentation will address \nthe role of imaging in the discovery and characterization of genetic diseases in \nSaudi Arabia with emphasis on neurological diseases. Examples of such diseases \nand syndromes include: HOXA1 mutation in Bosley-Salih-Alorainy syndrome, \nROBO3 mutation in horizontal gaze palsy with progressive scoliosis (HGPPS), \nC2orf37 mutation in Woodhouse-Sakati syndrome, RELN mutations in autosomal \nrecessive lissencephaly with cerebellar hypoplasia, CC2D2 A mutation in Joubert \nsyndrome, intragenic deletion in the LARGE gene causes Walker-Warburg syn-\ndrome, TDP1 mutation in spinocerebellar ataxia with axonal neuropathy, MRE11 \nmutation in ataxia telangiectasia-like disorder, and Dincsoy-Salih-Patel syndrome. \nFrom a local Saudi perspective, imaging had a pivotal role in the discovery and/\nor characterization of these disorders, and with the advent of imaging techniques, \nincluding functional and molecular imaging, we expect to experience a further role \nof imaging in understanding genetic diseases. \nLearning Objectives:\n1. To learn how imaging has contributed to the discovery and understanding of \ngenetic diseases.\n2. To appreciate the great opportunities for advanced imaging techniques \nto play a fundamental role in discovering new genetic diseases and \ncharacterising the existing ones.\n3. To understand the importance of taking a lead position in multidisciplinary \ngenetic research.\n4. To recognise the importance of observation of structural or functional \nderangement in discovering and understanding diseases.\nPanel discussion \n13:32\n14:00 - 15:30 Room E2 \nInteractive Teaching Session \nE³ 1720 \nImaging in common clinical problems: Hemoptysis \nModerator:\nE. Castaner; Sabadell/ES \nA‑458 14:00 \nImaging in common clinical problems: Hemoptysis \nS. Diederich1, M.-L. Storto2; 1Düsseldorf/DE, 2Chieti/IT \n(s.diederich@marien‑hospital.de) \nHemoptysis is a potentially life-threatening condition requiring an urgent and com-\nprehensive evaluation of the lung parenchyma, airways, and vessels. Bronchiectasis, \nchronic bronchitis, malignancy, and chronic infections (particularly tuberculosis and \naspergillosis) are well-known causes of hemoptysis. Less common causes include \npulmonary embolism with infarct, vascular anomalies such as pulmonary arterio-\nvenous malformations and bronchial artery aneurysms, vasculitis, and iatrogenic \nconditions. “Cryptogenic” hemoptysis, a diagnosis of exclusion, should also be \nconsidered since it is responsible for 3-42.2% of episodes of hemoptysis, particularly \nin smokers. Standard diagnostic algorithms have been based on a combination of \nconventional radiography, bronchoscopy, CT, and thoracic angiography. In recent \nyears, the development of multi-detector CT has introduced a comprehensive, \nnoninvasive method of evaluating the entire thorax. Moreover, multi-detector CT \ncan be used to detect bronchial arteries and, less frequently, nonbronchial systemic \narteries causing hemoptysis. In this session, we will review different causes of he-\nmoptysis and illustrate typical cases using an interactive modality of presentation. \nWe will also discuss the role of multi-detector CT and other imaging modalities \nin the evaluation and management of patients with hemoptysis together with a \nproposal of a diagnostic algorithm. \nLearning Objectives:\n1. To describe the potential etiology of hemoptysis.\n2. To understand the information provided by different imaging modalities in \nhemoptysis.\n3. To demonstrate typical imaging findings in patients with hemoptysis from \ndifferent etiologies.\n16:00 - 17:30 Room A \nRadiology in Abdominal Emergencies \nCC 1817 \nWhen time matters \nModerator:\nR.A. Novelline; Boston, MA/US \nA‑459 16:00 \nA. Emergency room: When radiologists can save lives \nO. Chan; London/UK (zaideotto@blueyonder.co.uk) \nThe advent of major new technological advances in radiology has dramatically \nchanged the role of the ER radiologist. ER radiologists should now play a central role \nin delivering a comprehensive 24/7 service. ER radiologists should be key figures \nin The Emergency Team and have the opportunity to save lives - “stop imaging \npatients to death” and “stop examining patients to death”. In effect, the combination \nof early imaging, accurate and fast diagnosis and therefore avoiding unnecessary \ndelays, will almost certainly lead to a reduction in the rate of unnecessary compli-\ncations and deaths. In order to be able to effect change, ER radiologists will have \nto be central in the design of new Emergency departments, help to decide on new \nimaging strategies and protocols for different clinical scenarios and help to draw \nup the response to a major incident. \nLearning Objectives:\n1. To know the radiologist’s task in the emergency room.\n2. To understand examples of diseases in which fast-track imaging plays a role.\n3. To learn how radiologists can be part of the emergency team.\n\nMonday\nPostgraduate Educational Programme\nA\n S117\nCB D E F G\nPostgraduate Educational Programme\nA S117CB D E F G\nA‑460 16:30 \nB. Rupture of solid organs \nJ. Cazejust; Paris/FR (julien.cazejust@sat.aphp.fr) \nIn abdominal trauma, spleen and liver are the most frequently affected organs. Initial \nUltrasonography is helpful in providing an overview of potential lesions, as proposed \nwith the FAST -US. This is especially dedicated to patient with hemodynamic instabil-\nity, in which the presence of a massive hemoperitoneum prompts for surgery without \nany further examination. In other cases, the management of the patient is more \nand more conservative, associating supportive care and interventional radiology, \nwhile surgery is seldom performed. The severity of the injury is best assessed by \nmultidetector CT. Hepatic or splenic lesions range from simple contusion or minor \nlaceration to organ fracture (linear lesion> 3 cm) and vascular avulsion, according \nto the AAST classification. Grade V splenic lesion is \"completely shattered spleen\" \nor \"hilar vascular injury which devascularized spleen\", whereas \"hepatic avulsion\" \nis the most severe lesion (grade VI). MDCT can only be performed in a patient \nwith controlled hemodynamic parameters. MDCT protocol should adapt to the \nPurpose: thin slices allow multiplanar reconstruction, especially dedicated to bone \ntrauma, iodine injection provides detection of bleeding, as well as road mapping \nwhen intervention is necessary. Arterial phase is mandatory, although bleeding can \nsometimes be more conspicuous on venous phase. Intervention might be necessary \nshortly after CT when active bleeding is seen, and if the patient is hemodynamically \nunstable. However, detection of active bleeding does not mean that intervention \nis systematically done because some lesions may resolve spontaneously. In that \ncase, a close follow-up is necessary, as well as multidisciplinary concertation with \nregard to potential recurrence. \nLearning Objectives:\n1. To know organs at risk in typical trauma situations and to be able to quantify \nlesions and hierarchise the potential risk.\n2. To learn imaging features and their diagnostic importance.\n3. To understand potential pitfalls and limitations of US, CT and MRI.\nA‑461 17:00 \nC. Intestinal haemorrhage \nN. Elmas; Izmir/TR (nevraelmas@gmail.com) \nGastrointestinal haemorrhage has been accepted as an important admission cause \nto emergency departments. Mortality and morbidity ranges due to gastrointestinal \nhaemorhage point out high incidence potentially. Diagnostic and therapeutic ap-\nproaches are different in upper and lower intestinal tract bleeding. Type of haemor-\nrhage depends on the origin of the bleeding. Clinical examination with history is \nessential for the selection of investigation. Etiologic causes can be encountered \nas gastric ulcer, diverticulosis, inflammatory and ischemic bowel diseases, varices \ndue to the portal hypertension, arteriovenous malformation, neoplastic changes \netc. Endoscopic procedures have been used as primary examination modality in \nintestinal bleeding especially upper intestinal tract. However, endoscopic techniques \nmay result with negative or failed examination in detection of bleeding source. \nUnder these circumstances, additional examination techniques are necessary \nsuch as catheter angiography, radionuclide red cell labeling technique. These \ntechniques have some disadvantages such as time-consuming, invasive and \nlow sensitivity or specificity ranges. In recent years, computed tomography has \nbecome the first imaging technique with advances in speed, multiphasic imaging \ncapacity, multiplanar visualization, angiographic ability and high spatial resolution \nin gastrointestinal bleeding. \nLearning Objectives:\n1. To know the classification of intestinal haemorrhage types according to their \nlocation and causes.\n2. To understand how to perform and interpret imaging in patients with acute \nand chronic intestinal bleeding.\n3. To know the factors affecting therapeutic alternatives.\n16:00 - 17:30 Room B \nMultidisciplinary Sessions: Managing Patients with Cancer \nMS 1821 \nColorectal cancer \nA‑462 16:00 \nChairman’s introduction \nR.G.H. Beets-Tan; Maastricht/NL (r.beets.tan@mumc.nl) \nThis course is relevant for all radiologists who are dealing with CRC staging. The \nimpact of imaging on treatment-stratification is significant. It is important to have \nin-depth knowledge of what clinicians want to know from imaging and how radi-\nologists can provide these answers. With the worldwide adoption of preoperative \nradiotherapy in rectal cancer surgery, primary-staging is necessary to accurately \nselect patients who only need surgery from those who will have an unacceptably \nhigh risk for local failure unless aggressive neoadjuvant treatment is given. CT and \nMRI are being more widely used in local and distant staging, respectively. Their roles \nin primary staging will be discussed. The relevant surgical anatomy of the pelvis that \nwill be useful for radiologists to better report MR pathology will be provided as well \nas the relevant biology of rectal cancer to understand local and distant recurrences \nand its prognostic-risk-factors. Imaging also influences tailoring of the radiotherapy \nfields that uses planar imaging for planning. To understand how your imaging find-\nings on tumor extent determine the radiation-treatment-volumes will be dealt with in \nthis course. New treatment options like local excision or even wait and see to those \nwho achieve a pathological good response (ypT1-2) or complete response (ypCR) \nfollowing preoperative chemoradiotherapy have improved long-term outcomes in \nlocal control rates, independent of their initial TN-stage. Restaging with imaging \nmay contribute in selecting these good responders. To understand how treatment \ndecisions can be tailored according to the tumor responses after completion of \nradiotherapy, what conservative surgical treatments exist and what is the role of \nimaging in restaging are other important goals of this course. \nLearning Objectives:\n1. To understand the increasingly important role of the radiologist in the \nmultidisciplinary management of rectal cancer patients.\n2. To understand the clinical background of different treatment options and its \nimpact of imaging on treatment outcome.\nA‑463 16:05 \nWhat the surgeon needs to know \nG.L. Beets; Maastricht/NL (g.beets@ah.unimaas.nl) \nRectal cancer treatment has changed from a monodisciplinary surgical disease \nto a disease that often requires a multidisciplinary approach. In different countries \nand institutions, different approaches are used, but the common theme is that in \nearly disease surgery only is the preferred treatment, and in more advanced cases \nneoadjuvant radiotherapy or chemoradiation. Prognostic factors that can be used \nin these choices are: the T stage, the N stage, the distance of the tumour to the \nmesorectal fascia, and the distance of the tumour to the anorectal ring. The informa-\ntion required in a particular institution is dictated by the treatment strategies that are \nused, and radiologists should be aware of this through a good communication and \ncollaboration with the clinicians. Specific surgical questions that imaging can address \nare: the exact relation of the tumour to: 1) the mesorectal fascia 2) the surrounding \norgans and 3) the anal sphincter. Repeated staging after chemoradiation is not yet \nstandardised, and the clinical relevance is again related to the change in strategy \nthe clinicians are willing to make, such as: sphincter or organ saving surgery after \na good response where this was not feasible before the chemoradiation or a local \nexcision instead of a standard rectal resection in a good responder. This field is \nevolving, and no standard recommendations can be made. \nLearning Objectives:\n1. To understand the anatomy that is relevant in treating patients with rectal \ncancer.\n2. To understand the treatment options used in your institution, and how \npatients are selected.\n3. To understand what surgeons will do with the images and information.\n\nPostgraduate Educational Programme\nS118\n A B C D E F G\nPostgraduate Educational Programme\nS118 A B C D E F G\nA‑464 16:25  \nWhat the radiation oncologist needs to know \nV. Valentini; Rome/IT (vvalentini@rm.unicatt.it) \nWith the worldwide adoption of preoperative radiotherapy in rectal cancer for pa-\ntients who will have an unacceptably high risk for local failure, images contribute \nto tailor radiotherapy fields and treatment decisions according to tumor responses \nduring and after completion of radiotherapy. Nowadays, innovative techniques \nusing 3D conformal treatment planning are recommended for radiotherapy treat-\nment. The most important contribution of 3-D treatment planning was the ability \nto plan and localize tumour target and normal tissues at all levels of the treatment \nvolume. Based on the predominant locations of local recurrences and the lymph \nnode involvement, guidelines for definition and delineation of the pelvic volumes \nto irradiate in rectal cancer are proposed. The choice of pelvic volumes to irradiate \ntake also into account the height of the tumour, the definition of the local tumour \nextent and the nodal status at clinical stage by imaging. Many series report that \npatients who achieve a pathological complete response (pCR) following preopera-\ntive radiotherapy + concurrent chemotherapy have improved long-term outcomes \nin terms of excellent local control rates, independently of their initial clinical T and \nN stage. After treatment, imaging contributes to detect favourable patients who \ncould be cured with less surgery. Sequential PET/CT data (before, during and after \nradiochemotherapy) in combination with clinical variables seem to increase the \nperformance of prediction models for pathologic complete response significantly. \nBased on these imaging modalities, new early response modulated treatments can \nbe tested in the following years. \nLearning Objectives:\n1. To understand how your imaging findings on tumor extent determine the \nradiotherapy treatment volumes.\n2. To understand how treatment decisions can be tailored according to the \ntumor responses during and after completion of preoperative radiotherapy.\nA‑465 16:45 \nImaging in colorectal cancer \nR.G.H. Beets-Tan; Maastricht/NL (r.beets.tan@mumc.nl) \nThe assessment of the local spread of the tumor includes the determination of the \ndepth of tumor growth in the rectal wall, the circumferential resection margin at \nTME, the depth of tumor invasion in surrounding pelvic structures, and the nodal \nstatus. For superficial rectal cancer, that can be treated with surgery only (transanal \nresection or TME), endoluminal ultrasound is the most accurate staging method \nto assess tumor ingrowth in the muscular rectal wall. For the remaining mobile \nand fixed rectal cancer a high resolution MRI with a dedicated phased array coil \nis at present the most reliable technique to evaluate the mesorectal fascia and the \ncircumferential resection margins. Despite the identification of lymph nodes even as \nsmall as 2-3 mm on high resolution imaging, reliable detection of nodal metastases \nis presently not possible, because planar imaging only rely on morphological criteria. \nHowever promising results have been reported with the use of LN MR contrast in \nMRI and new functional MRI techniques. State of the art imaging and the role of \nMRI as well as the relevant role of the radiologists in the multidisciplinary decision \nmaking team will be discussed. After preoperative chemoradiation most advanced \ntumors shows phenomenal response so new treatment dilemmas and new ques-\ntions arises for MR of rectal cancer. The lecture will not only provides evidence in \nstaging but also in restaging with imaging and will discuss the role of MRI as well \nas other modalities such as EUS and PET/CT. \nLearning Objectives:\n1. To understand how imaging can identify low and high risk groups of rectal \ncancer patients and how it may influence the treatment choice.\n2. To understand the evidence for the use of EUS, CT, MRI and PET/CT in local \nand distant staging of rectal cancer.\n3. To know the right MR protocol, typical MR features and pitfalls when \ninterpreting MRI.\nPanel discussion and case presentation 1\n7:05 \n16:00 - 17:30 Room D \nAbdominal and Gastrointestinal \nRC 1801 \nCrohn’s disease: Techniques and results \nModerator:\nF. Maccioni; Rome/IT \nA‑466 16:00 \nA. Role of US \nV. Válek; Brno/CZ (vlvalek@med.muni.cz) \nThe ultrasound examination (US) we do without any preparation; it is not neces-\nsary to be empty. We examine patients in supine position, first small bowel, then \nmesentery and large bowel. We complete the examination in some cases with \nthe application of the intravenous contrast (CEUS). CEUS is a useful method to \nassess the therapeutic effectiveness of specific medical anti-inflammatory treat-\nment in patients with Crohn’s disease. Using high-resolution linear transducer \nmural perfusion, changes in active Crohn’s disease can be appreciated applying \ncontrast harmonic imaging with quantitative time intensity curve analysis. This \ntechnique could be an effective dynamic imaging modality for diagnosis and espe-\ncially follow-up examination to monitor treatment in CD. At least four studies have \nprospectively compared the diagnostic accuracy of US with radiological studies, \nendoscopy or surgery in suspected Crohn’s disease at diagnosis. In these studies, \nthe sensitivity of US ranged between 84 and 90% and its specificity reached 98 and \n100%. In our prospective study, we compared 102 patients with Crohn´s disease. \nThe activity of the disease was assessed correctly in 91% patients by ultrasound. \nIn the largest series, the overall sensitivity of US was 93% and the specificity was \n97%. US reach highest sensitivity (95%) when the disease involved the terminal \nileum. US compares very well with radiological techniques and surgery, mainly in \nthe detection of strictures and abscesses, while for fistulas data are more conflicting \nand less satisfactory, with sensitivity values ranging from 50 to 87% and specificity \nvalues from 90 to 95%. \nLearning Objectives:\n1. To describe the strategy of small bowel US in Crohn’s disease.\n2. To present keys for diagnosis and follow-up of US in Crohn’s disease.\n3. To discuss the pros and cons of US including CEUS in Crohn’s disease.\n4. To discuss the accuracy, objectivity and usefulness of US in Crohn’s disease.\nA‑467 16:30 \nB. MRI and MR-related tools \nS. Gourtsoyianni; Iraklion/GR (sgty76@gmail.com) \nOver the years, several different oral contrast agents have been tested for luminal \ndistention of small bowel when assessing Crohn‘s disease with MRI. For consis-\ntency of imaging findings, accurate wall thickness measurements and depiction of \neven subtle changes of bowel mucosa, MR Enteroclysis (MRE) performed after \nduodenal intubation and administration of a maximum amount of 2 lt of contrast \nagent, while the patient is lying prone inside the MR scanner were performed with \nexcellent results. MRI examination protocol should include true FISP and HASTE \nsequences for anatomical delineation of mesenteries and bowel as well as post \ngadolinium 2D/3D T1 weighted fat saturated sequences for lesion characterization, \nlymph node enhancement measurements and evaluation of bowel wall enhance-\nment pattern. Normal intestinal wall exhibits moderate homogeneous enhancement \nwhile abnormal wall presents either with multilayered, in case of active Crohn‘s \ndisease, inhomogeneous-diffuse, in case of chronic inflammation and fibrosis, or \nhomogeneous marked, enhancement pattern in case of moderate inflammation. \nWith the utilization of various MR-related tools such as multiple contrast mechanisms \nand cine true FISP sequences, accurate disease subtype classification may be \nachieved based on morphology and motility imaging features. MRI not only allows \ndemonstration of transmural nature of disease but also „sees“ beyond obstructed \nbowel loops in contrast to direct examination methods such as capsule endoscopy. \nStenotic lesions may be further characterized since differentiation between edema \nand fibrosis is possible with T2 weighted images in which fibrosis presents with \na typical low signal intensity appearance, while inflammation or edema presents \nwith high signal intensity. \nLearning Objectives:\n1. To describe an advanced comprehensive MR examination protocol for \ndiagnosis and differential diagnosis of Crohn’s disease.\n\nMonday\nPostgraduate Educational Programme\nA\n S119\nCB D E F G\nPostgraduate Educational Programme\nA S119CB D E F G\n2. To discuss the potential of MR enteroclysis in characterising and \ndifferentiating inflammation from fibrosis in assessing Crohn’s disease \nactivity and in defining different disease subtypes.\n3. To review strengths and weaknesses of the application of MRE in view of \nother direct and indirect sensitive techniques available.\nA‑468 17:00 \nC. CT vs MRI \nM.A. Patak; Berne/CH (michael.patak@insel.ch) \nThe aim of this lecture is to give an overview of the techniques and typical findings \nfor imaging Crohn’s disease (CD) with either multirow detector computed tomog-\nraphy (MDCT) or with magnetic resonance imaging (MRI) and compare the two \ndifferent modalities. Optimal imaging of CD begins with the preparation phase. The \nsmall bowel has to be distended for a concise examination. This can be done either \ninvasively, i.e. enteroclysis or orally, which is named enterography. There is much \ndebate on which of these two preparation methods is better. For the administered \nintraluminal contrast, the best is water with some additives, which are neutral in CT \nand biphasic in MR. Imaging in MDCT is done 40 and 70 sec after IV administration \nof iodinated contrast with a thin collimation. All image data are reconstructed in \naxial, coronal and sagittal planes. The aim of imaging in CD should be to establish \nthe following: 1) presence, severity, and extent of the disease; 2) its activity; and \n3) extra-intestinal complications. Both modalities have proven to be a good tool to \nevaluate the extent, the activity of the disease and the presence of extraluminal \ncomplications. Both are also able to identify the type of the disease, being the ac-\ntive/inflammatory, the fistulizing /perforating, the fibrostenosing or the reparative/\nregenerative type. The challenge for MRI is mostly the in-plane resolution of the \nimage data whereas radiation dose is for CT. \nLearning Objectives:\n1. To describe the possible techniques of CT in Crohn’s disease.\n2. To consider the pros and cons of CT and MRI in Crohn’s disease.\n3. To compare the diagnostic accuracy of CT versus MRI in Crohn’s disease.\n4. To determine the role of CT and MRI in the radiological work-up for Crohn’s \ndisease.\n16:00 - 17:30 Room E1 \nSpecial Focus Session \nSF 18 \nRenal cancer: Old problems, new solutions\nModerator:\nA. Magnusson; Uppsala/SE \nA‑469 16:00 \nChairman’s introduction \nA. Magnusson; Uppsala/SE (anders.magnusson@radiol.uu.se) \nNot many years ago, renal cancer was detected on excretory urography as a \nspace occupying lesion. The further diagnostic work up included a few tools, fluo-\nroscopically guided biopsies and renal angiography. Most tumours were large and \nsymptomatic; often patients presented with the classic triad, including haematuria, \nflank pain and a palpable mass. The only tool, which was available for treatment, \nwas radical nephrectomy. Today, a majority of renal tumours detected are incidental \ntumours. This is due to the increasing use of modern imaging techniques, CT, MRI \nand ultrasound. An incidental tumour is, by definition, discovered when the patient \nis investigated for symptoms not related to a renal tumour, it is asymptomatic and \ngenerally small in size and localized. In parallel, the tools which are available for \ndiagnosis and treatment has expanded, CT - or ultrasound guided biopsy, nephron-\nsparing surgery, either open, laparoscopic or robotic and ablative therapies, cryo- or \nradiofrequency ablation. The incidence of renal cell cancer, especially small renal \ntumours, is increasing and survival is improving. With an increasing number of small \nrenal tumours, many of them benign lesions, a number of questions are raised: \nWhen to biopsy and can we trust the result? Which therapeutic strategy should be \nchosen, surgery or ablation? Are we overtreating some patients, or maybe a larger \nnumber should simply be followed? \nSession Objectives:\n1. To review the imaging of renal cancer and the impact of new imaging \nmethods.\n2. To learn about the new developments in the staging of renal cancer on both \nCT and MRI.\n3. To review the role of RF ablation in comparison with other treatments.\nA‑470 16:05 \nMDCT of renal cancer \nA. Cieszanowski; Warsaw/PL (andrzej.cieszanowski@wum.edu.pl) \nThe superb spatial resolution of MDCT has resulted in higher detection rate of renal \nmasses and better visualization of their morphology. MDCT allows discrimination \nbetween most of benign and malignant renal tumors, although its ability for correct \ncharacterization of some lesions is still limited (i.e. oncocytoma, low-fat angiomyo-\nlipoma, fat-containing RCC, solitary renal lymphoma, focal inflammation). Accord-\ning to a revised Bosniak classification, cystic lesions can be divided into 5 types: \nsimple cysts (I), minimally complicated cysts (II), minimally complicated cysts that \nneed follow-up (IIF), possibly malignant cysts (III), and definite cystic neoplasms \n(IV). MDCT allows depiction of detailed morphology of cystic lesions (i.e. density, \ncontrast enhancement, septa, calcification), allowing correct classification in majority \nof the cases. Recent classification of renal cell carcinoma includes the following \nhistological subtypes: conventional (clear cell), papillary, chromophobe and collect-\ning duct carcinoma (with renal medullary carcinoma variant). Hypovascular tumors \n(i.e. papillary RCC) have better prognosis than hypervascular lesions (i.e. clear cell \nRCC). Involvement of collecting system, along with infiltrative growth, suggests the \ndiagnosis of collecting duct carcinoma, which carries the worst prognosis of all RCC \nsubtypes. MDCT also enables accurate staging of RCC, which has consequences \nfor prognosis and therapy. Evaluation includes tumor relation to perinephric tissues, \nvenous structures, adrenal s, Gerota’s fascia, as well as, involvement of regional \nlymph nodes and distant metastases. \nLearning Objectives:\n1. To discuss the characterisation of cystic renal masses by CT.\n2. To learn about pathologic subtypes of renal cell carcinoma and correlate \nthem with CT findings.\n3. To review the staging of renal cell carcinoma with CT.\nA‑471 16:30 \nUS and MRI \nN. Grenier; Bordeaux/FR (nicolas.grenier@chu‑bordeaux.fr) \nUS and MRI are useful tools to help in characterizing solid and cystic renal tumors. \nThe main advantage of these techniques is their sensitivity to light contrast enhance-\nment when subtle or localized. Papillary carcinomas are often hypoperfused requir-\ning contrast-enhanced MRI or US, with delayed images, to detect their enhancement \nmaking it possible to separate solid and cystic tumors. Diffusion-weighted MR \nsequences can also help for that purpose. In cystic masses, the same is true for \ndetection of enhancement of small areas as septas, capsule and small nodules, \nwith an impact on Bosniak classification. The main indications of these techniques \nin that field are 2 F and non-classified cystic lesions. MRI may also show the fat \nand lipid contents of solid tumors by using chemical shift-weighted sequences \n(in-phase and opposed-phase), mainly to separate angiomyolipomas with small \nfat content and renal cell carcinoma. Unfortunately, no reliable threshold is able to \naccurately separate these two entities yet. Renal staging can also be performed \nwith MRI, but with little advantages, when compared to CT. \nLearning Objectives:\n1. To learn how to distinguish benign and solid lesions.\n2. To review the Bosniak classification as it pertains to US and MRI.\n3. To review the staging of renal cancer with MRI.\nA‑472 16:55 \nTumor ablation \nA. Adam; London/UK (andy.adam@kcl.ac.uk) \nRadiofrequency ablation (RFA) is increasingly being used to treat small renal tu-\nmours in patients who are not candidates for surgery. The main indications are renal \ninsufficiency, a single kidney, multiple tumours and hereditary conditions associated \nwith renal neoplasms. The procedure is usually guided by CT or ultrasound imaging \nand is tolerated well in most patients. Follow-up is mainly by imaging, the immediate \ngoal of which is to assess whether complete necrosis has been achieved. Ultra-\nsound does not usually provide useful information, as the echogenicity of fibrosis \nand neoplastic tissue overlap. Contrast enhanced-MRI and contrast enhanced-CT \nare capable of demonstrating residual viable tumour requiring treatment. Effective \nablation is achieved in approximately 90% of patients in a single session of therapy. \nHowever, tumours larger than 3 cm in diameter are more difficult to eradicate at the \nfirst attempt, often requiring a second RFA session. Combining RFA with percutane-\nous ethanol injection (PEI) increases the area of coagulation. RFA is particularly \nhelpful in patients with solitary kidneys and impairment of renal function. In such \npatients, partial nephrectomy can lead to renal failure and the need for dialysis in \nup to 10% of patients. RFA enables most patients to be treated with minimal loss \n\nPostgraduate Educational Programme\nS120\n A B C D E F G\nPostgraduate Educational Programme\nS120 A B C D E F G\nof function and avoids the need for dialysis in the vast majority. Combined PEI and \nRFA is a safe and effective alternative treatment for patients with renal tumours \nand is likely to replace partial nephrectomy in many patients with small neoplasms. \nLearning Objectives:\n1. To review technical challenges and criteria for patient selection.\n2. To discuss methods and results of tumor ablation as well as various imaging \nproblems that may be encountered in patients previously treated either by \npercutaneous methods or by partial surgery.\n3. To describe and compare tumor ablation and nephron sparing surgery and \ndiscuss how best to follow-up patients.\nPanel discussion:  \n1. How should we image and stage the patient with suspected renal \ncancer? 2. Is tumor ablation here to stay? \n17:20 \n16:00 - 17:30 Room E2 \nInteractive Teaching Session \nE³ 1820a \nImaging in common clinical problems: Acute chest pain \nModerator:\nG.A. Krombach; Aachen/DE \nA‑473 16:00 \nA. Cardiac \nA. de Roos; Leiden/NL (A.de_Roos@lumc.nl) \nCardiac and pericardiac causes for acute chest pain will be reviewed as shown \nby MDCT and MRI. MDCT is well suited to evaluate coronary artery disease by \ndemonstrating stenoses and plaques. The utility of MDCT for assessing myocardial \nperfusion is currently under development. MRI is well accepted for imaging of isch-\nemia and infarction. Pericardial disease can be depicted by both MDCT and MRI. \nMDCT is the preferred first-line technique for evaluation of large vessel disease, \nespecially in the acute setting. Gated MDCT is advocated for imaging aortic dissec-\ntion, especially when the ascending aorta is involved. There is a broad differential \ndiagnosis in the setting of acute chest pain. Many of the possible diagnoses can \nbe assessed by cross-sectional imaging. The capabilities of MDCT and MRI are \ngetting more and more similar. The indications for MDCT and MRI are dependent \non diagnostic performance, availability, expertise and local preference. \nLearning Objectives:\n1. To learn CT and MRI methods for cardiac imaging.\n2. To learn indications for acute cardiac disease evaluation.\n3. To review acute cardiac disease presentations.\nA‑474 16:45 \nB. Non-cardiac \nL.R. Goodman; Milwaukee, WI/US (lgoodman@mcw.edu) \nAcute chest pain, whether traumatic or non-traumatic, involves multiple organ \nsystems including the thorax, the pleura, the lung, the mediastinum, the pulmonary \nvessels, and the upper abdomen. Interactive cases will stress the radiographic \ndiagnosis of many of these diseases: how to determine whether additional imaging \nis needed, and if so, which images? As time is often the essence in these patients, \nimaging efficiency will be stressed. Basic clinical parameters, such as onset of \npain, duration of pain, distribution of pain, etc. will be integrated into the diagnostic \napproach. The primary emphasis will be emergency room and outpatient problems \nbut inpatient problems will also be included. \nLearning Objectives:\n1. To learn CT and MRI methods for evaluating acute chest pain.\n2. To understand the appropriate indications for CT and MRI.\n3. To review the most common pathologies in acute chest pain.\n16:00 - 17:30 Room F1 \nInteractive Teaching Session \nE³ 1820b \nImaging in common clinical problems: Jaundice \nModerator:\nC. Roche; Galway/IE \nA‑475 16:00 \nImaging in common clinical problems: Jaundice \nC. Matos1, C. Becker2; 1Brussels/BE, 2Geneva/CH (cmatos@ulb.ac.be) \nIn this interactive session, the authors will conduct the audience through the differ-\nent questions a radiologist needs to answer to choose the appropriate combination \nof imaging techniques when evaluating a patient with jaundice. Different clinical \nscenarios will be illustrated emphasizing the different steps to make a differential \ndiagnosis between benign and malignant causes of jaundice. Guidelines for a \nmultidisciplinary approach will be provided according to the likelihood of bile duct \nobstruction, to the accuracy of non-invasive and of invasive imaging modalities and \nto the therapeutic options available. \nLearning Objectives:\n1. To describe the imaging techniques used for investigating a patient with \njaundice.\n2. To discuss key points of interpretation of benign and malignant causes of \njaundice.\n3. To provide imaging guidelines for investigating a patient with jaundice.\n16:00 - 17:30 Room F2 \nProfessional Challenges Session \nPC 18 \nRadiation protection\nModerator:\nE. Vaño; Madrid/ES \nA‑476 16:00 \nChairman’s introduction \nE. Vaño; Madrid/ES (eliseov@med.ucm.es) \nRadiological Protection (RP) is a key topic in the modern radiology. Ionizing \nradiations are used for most of the diagnostic and interventional procedures and \nradiologists and other health professionals involved in these techniques should \nknow the radiological risks to be able to make a good balance between benefit \nand risk when deciding the appropriateness of the examinations (justification) and \nthe best way to perform the procedure (optimization). Several European Directives \ndeal with RP , but two of them have significant regulatory impact in radiology: 97/43/\nEuratom (on RP of patients) and Directive 96/29/Euratom (on RP of professionals). \nThese directives (together with others) are now in a process of simplification and \nupdating by the European Commission (EC) (“recast” process) to follow the 2007 \nRecommendations of the International Commission on Radiological Protection \n(ICRP) and other International Organizations. It is expected that the new directive \non “Basic Safety Standards” will improve the RP aspects in medical exposures and \nthis will mean a professional challenge for the European radiologists and allied \nprofessionals. During the last three years, the EC has promoted many meetings \nand workshops to discuss and receive inputs from the scientific societies and from \nthe Member States on the benefits and inconveniences of the existing Directives, \nto have the opportunity to improve the legislation. Several research programmes \nin the area of radiology and contracts (including networking) to help in the applica-\ntions of the Directives have been funded by the EC. Contacts with the ESR are \nconsidered relevant in this process. \nSession Objectives:\n1. To underline the importance of radiation protection in diagnostic and \ninterventional radiology.\n2. To inform on the work made by the European Commission and other \nInternational Organisations to improve radiation safety in medical exposure.\n3. To introduce the networking work on radiation protection promoted in Europe \nand the role of the ESR.\n\nMonday\nPostgraduate Educational Programme\nA\n S121\nCB D E F G\nPostgraduate Educational Programme\nA S121CB D E F G\nA‑477 16:05 \nNew European Directive on basic safety standards \nE. Vaño; Madrid/ES (eliseov@med.ucm.es) \nSeveral European Directives dealing with radiation protection (RP) are in a process \nof simplification and updating by the European Commission. The new Directive \ncalled “Basic Safety Standards” will improve the RP aspects in medical exposures \nnow regulated by the Directives 97/43/Euratom (for patients) and 96/29/Euratom \n(for public and workers). “Protection of patients and other individuals submitted \nto medical exposure” will be Title VIII of the new Directive. The “medico-legal” \nexposures, now called “Non Medical Imaging Exposure” will not be considered \na medical exposure. The course on radiation protection in medical and dental \nschools will be mandatory. Procedures on asymptomatic individuals, for early \ndetection of disease but not as part of a health screening programme, will require \nspecific justification. The radiation detriment of the medical radiological staff will \nbe considered during justification and optimization of medical exposures. The use \nof Diagnostic Reference Levels will be also required for interventional procedures. \nPatient dose information for practitioner will be mandatory for interventional and \nCT procedures. Other radiodiagnostic equipment shall also have this information \nafter the publication of the directive. Patient radiation dose will be part of the clinical \nreport on the examinations. A registration and analysis system of events involv-\ning or potentially involving accidental or unintended exposures will be mandatory. \nAll these changes will require member states, the radiology community and the \nindustry, to adapt national regulations, quality assurance programmes and X-ray \nsystems, to the new requirements. The goal will be a high standard of radiation \nsafety in the European radiology. \nLearning Objectives:\n1. To know that a new European Directive including aspects of radiation safety \nin medical exposures is in progress.\n2. To become familiar with the changes in the new Directive in comparison to \nthe 97/43/EURATOM.\n3. To appreciate the potential impact of the new Directive on radiation safety \naspects for patients and professionals in diagnostic and interventional \nradiology.\nA‑478 16:28  \nEMAN - The European Medical ALARA Network \nP . Vock; Berne/CH (peter.vock@insel.ch) \nNew ICRP recommendations, basic safety standards, European Directives and \nnational regulations, in order to become effective for the patient, have to be applied \nby the medical practitioners (radiographers, radiologists, and other medical doc-\ntors) during their daily work. Building up a sustainable network among the different \nstakeholders is, therefore, an important step for an open discussion and exchange \nbetween different professionals trying to apply the ALARA principle in medicine. \nSeven partner organizations - among them the European Society of Radiology \n(ESR) and the European Federation of Radiographer Societies (EFRS) - have \njointly founded the EMAN consortium to support the EC in promoting radiation \nsafety in medical diagnostics and intervention. During the 3-year project, two \nworking groups will concentrate on CT and interventional radiology, respectively, \nthe most critical sources of individual patient and occupational exposure. One \nworking group will specifically analyze and act on X-ray applications outside the \ndepartment of radiology where training has historically been less well established. \nDissemination of information and coordination will be enhanced by the EMAN \nwebsite and a steering committee. Towards the end of the project, a European \nEMAN workshop will summarize the results and present them to the profession, \nand in parallel measures will be taken to maintain a sustainable EMAN rendering \nservices to the medical practitioners and bringing feedback and suggestions to the \nEC regarding radiation protection in medicine. \nLearning Objectives:\n1. To understand the importance of building a network on radiation protection \nfor radiologists and radiographers.\n2. To know the effort made by the European Commission to promote radiation \nsafety in diagnostic and interventional radiology.\n3. To recognise the objectives and workplan of the medical ALARA network.\nA‑479 16:51 \nRadiation protection training and practice: Bridging the gap \nM.M. Rehani; Vienna/AT (m.rehani@iaea.org) \nNot even a week passes without a paper getting published in peer reviewed jour-\nnals on radiation protection in imaging technologies. Few years ago, the change in \ntechnology was faster than adoption of radiation dose management but currently \neven the development of dose reduction techniques is faster than its adoption. \nInternational organizations are seized with this issue and are working to cope \nwith this challenge. Conventional training methodologies that deal with principles \nare inadequate as people are looking for specific information delivered to them at \ntheir desk or home on periodic basis. The amount of information currently avail-\nable through internet is leading to “information pollution” and professionals look for \ninformation from authentic sources. International organizations such as International \nCommission on Radiological Protection (ICRP) and International Atomic Energy \nAgency (IAEA) are rising to the occasion to attend to the need and fill the gap. ICRP \nis an independent body that provides recommendations on radiological protection. \nIAEA develops safety standards and applies them in member states. The talk, while \npresenting the need, is going to create awareness about information that is avail-\nable from ICRP and IAEA, the experience gained in making vast training material \ndeveloped in collaboration with International Society of Radiology (ISR), Interna-\ntional Society of Radiographers & Radiological Technologists (ISRRT), International \nOrganization of medical Physics (IOMP) and WHO available free through website \n(http://rpop.iaea.org) and through CDs containing power point slides, conventional \ntraining courses and sending focused and condensed information from professional \nsocieties and academic publications through monthly emails. \nLearning Objectives:\n1. To understand the need for good knowledge of radiation protection (RP) \nprinciples in the practice of diagnostic and interventional radiology.\n2. To know the existence of recommendations issued by the International \nCommission on Radiological Protection.\n3. To highlight the role and the existence of websites and training material for \nRP produced by different scientific societies and international organisations.\nPanel discussion:  \nWhat do radiologists need to know about the new recommendations of the \nICRP and the new European Directive? \n17:14 \n16:00 - 17:30 Room G/H \nNeuro \nRC 1811 \nBasic MR spectroscopy \nModerator:\nK.‑O. Løvblad; Geneva/CH \nA‑480 16:00 \nA. MRS in daily practice made easy \nA. Urbanik; Krakow/PL (aurbanik@mp.pl) \nThe presentation includes a discussion of magnetic resonance proton spectroscopy \n(HMRS). It shows the methods for MR signal acquisition and its processing. It \npresents technical as well as clinical factors which impact the quality of. An analysis \nincludes a normal brain spectrum, as well as the function of specific metabolites. \nIt lists examples of HMRS application in clinical procedures. \nLearning Objectives:\n1. To present normal spectrum of the brain and meaning of the particular \nmetabolites.\n2. To explain the technical requirements and possibilities of MR spectroscopy \nof the brain.\n3. To present the most common applications of MR spectroscopy of the brain.\nA‑481 16:30 \nB. MRS in metabolic CNS disorders \nP .C. Maly Sundgren; Lund/SE (pia.sundgren@med.lu.se) \nNeuroimaging might play an important role in the timely diagnosis of metabolic \ndisorders and in some disease be helpful in therapeutic decision making such as ad-\nrenoleukodystrophy (ALD). Combined with conventional MRI, magnetic resonance \nspectroscopy (MRS) adds additional information and is considered helpful for the \nfinal diagnosis of some metabolic disorders. The interpretation of MR spectroscopy \nin children must be done with judgment. A range of factors can influence the profile of \n1H-MR spectrum including magnetic field uniformity, poor shimming that may result \nin reduced resolution, broadening of resonances and distorting metabolic ratios to \ninter-patient variability due to age and development. Relative ratios of detectable \nmetabolites and the detection of metabolites normally not present in the pediatric \nspectral profile have shown to be valuable in the evaluation and work-up of metabolic \ndisorders in children. For example, an abnormal elevation of NAA is classically seen \n\nPostgraduate Educational Programme\nS122\n A B C D E F G\nTherefore, electrocardiogram (ECG)-gated CT acquisitions are recommended for \nevaluation of AD, to eliminate the influence of motion artifact by cardiac pulsation. \nFurthermore, in ECG-gated CT acquisition, it is possible to obtain volume data at \nany cardiac phase and in four-dimensional images and, therefore, it is possible to \ndifferentiate between pulsating type and static type dissection; this evaluation is \nimportant because allows to show aortic motion and reduction of elasticity. Both \nof the phenomena lead to an increase of vessel wall shear stress, which is in turn \nconsidered to be the underlying biomechanical factor for intimal detachment and \nchronic aortic expansion. \nLearning Objectives:\n1. To review the current classification of aortic dissections and their variants.\n2. To learn about the respective roles of MRA and CTA.\n3. To learn how to differentiate between dynamic and static dissection.\nA‑484 16:30 \nB. Imaging requirements prior to endovascular aneurysm repair \nT. Pfammatter; Zurich/CH \nWhile ten years ago endovascular aortic treatment planning relied on a combina-\ntion of measuring catheter angiography and axial CT - or MR- images, nowadays \nmulti-detector CT angiography (MDCT) is the default modality before treatment of \nboth acute and chronic aortic conditions. MRA is a valuable alternative particularly \nfor younger patients in order to reduce the cumulative radiation exposure as a fair \nnumber of these patients will require long-term postoperative imaging follow-up. \nAs associated aortic pathologies occur in up to 25% of patients therefore the entire \naorta, in addition to the iliac and femoral access arteries have to be included in \nthe imaging volume. For diseases affecting the thoracic aorta the brachiocephalic \nbranches (internal carotid disease, vertebral arteries before over-stentgrafting of \nleft subclavian artery) have also to be imaged. Preoperative protocol generally \ninclude nonenhanced and first-pass arterial scans. 2D and 3D post processing \nalgorithms such as multiplanar reformation (MPR), maximum intensity projections \n(MIP) and semi-automated center-line measurements on curved planar reforma-\ntions allow anatomical patient selection for endovascular treatment and the choice \nof the appropriate stent-graft. Due to accordion and bow redundancy the in-situ \nlength of the stentgraft tends to be underestimated on center-line measurements \nparticularly in tortuous aortas or large aneurysms. Diameters, tortuosity and extent \nof calcification determine the choice of the insertion access. Evaluation of length, \nconfiguration and morphology of the stentgraft landing zones is very important as \nstent-graft fixation is crucial for short- and long-term exclusion of an aneurysm. \nClinical relevance of time-resolved data acquisition (dynamic imaging, 4D-imaging) \nfor endovascular treatment planning has not been proven yet. Automated mathemati-\ncal analysis of CT data has been shown to be reliable for complex endovascular \nreconstructions (side-branched stent-grafts) and is likely to be adopted for these \ncases in the near future. \nLearning Objectives:\n1. To learn about optimised imaging strategies prior to endovascular aortic \naneurysm repair.\n2. To become familiar with specific diagnostic requirements for treatment \nplanning.\n3. To discuss prognostic factors for successful endovascular aortic aneurysm \nrepair.\nA‑485 17:00 \nC. Detection of complications after aortic stent grafting \nE. Brountzos; Athens/GR (ebrountz@med.uoa.gr) \nLifelong surveillance after EVAR is recommended using imaging, focusing on \nthree parameters: aortic diameter, endoleaks, and endograft’s integrity. The ideal \nfollow-up modality should be inexpensive, widely available, reproducible, accurate, \nand without radiation exposure. Contrast medium-enhanced multidetector computer \ntomography angiography (MDCTA) is the most established follow-up modality for \nEVAR patients. The AAA diameter can be measured with 100% sensitivity and \nspecificity, while MDCTA has a 92% sensitivity and 90% specificity for endoleak \ndetection. Biphasic CTA is the most widely used technique, but there is no universal \nagreement on the ideal protocol. Magnetic resonance angiography (MRA) has \na role in young patients. Aortic diameter measurement and endoleak detection \nare very accurate using MRA. MRA however, is not applicable for stainless steel \nendografts. Radiographs can detect structural abnormalities of the endograft. \nHowever, CTA can also provide sufficient information regarding the integrity of the \nendograft. Color Doppler ultrasonography (CDUS) performs poorly in the detec-\ntion of endoleaks: pooled sensitivity rates were 66-69%. The recent introduction of \ncontrast enhanced US (CEUS) significantly improved the detection of endoleaks: \nsensitivity (97.5 vs 62.5%), and specificity (81.8 vs 63.6%). Investigators have \nin Canavan’s disease, the absence or significant reduction of the creatine peak is \nthe hallmark for different creatine deficiency diseases and a detectable presence \nof lactate in the basal ganglia supports the clinical and laboratory diagnosis of a \nmitochondrial disorder. The purpose of the present lecture is to describe the current \nMR spectroscopy techniques for evaluation of metabolic disorders, emphasizing \nkey pathological metabolic spectra and typical brain MRI findings that can help \nin the diagnosis of some of the more common metabolic diseases, and to outline \nthe strengths, weakness and applications of MR spectroscopy in the work-up and \ndiagnosis of metabolic disorders. \nLearning Objectives:\n1. To learn the imaging protocol for MRS in the study of metabolic disorders.\n2. To discuss the clinical features of neurometabolic disease.\n3. To discuss the MRS features of these disorders.\n4. To discuss the differential diagnosis.\nA‑482 17:00 \nC. MRS in brain tumors \nM. Essig; Heidelberg/DE (m.essig@dkfz‑heidelberg.de) \nProton magnetic resonance spectroscopy (MRS) and spectroscopic imaging (CSI) \nare becoming common clinical tools in neurooncology since they allow for functional \ntissue information. Spectroscopic characterization of brain abnormalities has relied \nmostly on the calculations of ratios between the main proton spectrum metabolites, \nnotably N-acetylaspartate (NAA), a neuronal marker, choline-containing compounds \n(Cho), a marker of membrane turnover, and creatine-phosphocreatine (Cr), and \non the presence of lipids and lactate. Brain tumors typically present with a loss of \nNAA and an increase in the Cho content. MRS has also been used to differentiate \nnon-tumoral lesions like hamartomas from gliomas and to assess the grade and \naggressiveness of a tumor. In several studies, it has been reported that hamartomas \ndid not differ significantly from the normal brain, while gliomas had lower NAA/Cr, \nCr/Cho, and NAA/Cho ratios. Follow-up assessment of cerebral tumors is another \npromising field for MRS and CSI. Increase in size and enhancement are typical \nfindings for progression but also reflect therapy induced changes. Both techniques \nprovide supplementary information about the possible extent and nature of changes \non a routine MRI scan by analyzing the presence and/or ratio of the tissue metabo-\nlites NAA, creatine, choline, and lactate. The ratio of choline to normal creatine \nlevel usually is significantly elevated in those areas consistent with tumor compared \nwith those containing predominantly treatment effect. In fact, treatment effect is \ngenerally indicated by a marked depression of all the intracellular metabolites. CSI \nproved to be helpful in mixed histologic findings comprised of necrosis and tumor. \nLearning Objectives:\n1. To present normal and tumorous spectra of the brain.\n2. To learn how to use MR spectroscopy in the differential diagnostics of brain \ntumors.\n3. To learn how MR spectroscopy can help to distinguish tumor progression or \nrecurrence from therapy induced changes.\n16:00 - 17:30 Room I \nVascular \nRC 1815 \nAortic imaging \nModerator:\nW. Cwikiel; Ann Arbor, MI/US \nA‑483 16:00 \nA. Aortic dissections: New insights into an old disease \nF . De Cobelli; Milan/IT (francesco.decobelli@hsr.it) \nAortic dissection (AD) is an emergency, critical and life-threatening disease. The \nmortality of this condition is high, with major complications including rupture and \nend-organ ischemia. The estimated mortality increases at the rate of 1% per \nhour once the diagnosis of aortic dissection is made. The DeBakey and Stanford \nclassifications are usually adopted by radiologists to accurately classify AD using \ncomputed tomography (CT) or magnetic resonance imaging and angiography \n(MRI and MRA) and to indicate the appropriate therapeutic treatment. Both im-\naging techniques have different advantages and drawbacks in the evaluation of \naortic dissection: usually, multidetector-CT is the preferable imaging technique in \nemergency condition such as in case of ascending aorta dissection. However, CT, \nusually involve acquisition of static images. Motion artifacts of ascending aorta itself \nor of an intimal flap, which causes cardiac pulsation, impair image quality in AD. \n\nMonday\nPostgraduate Educational Programme\nA\n S123\nCB D E F G\nLearning Objectives:\n1. To learn how to integrate teaching files into PACS (e.g. IHE TCE).\n2. To know about differences in eLearning tools.\n3. To know why structured reporting is important regarding eLearning.\nA‑488 17:00 \nC. What radiologists should know about the use of PACS in surgical \nprocedures \nE. Neri; Pisa/IT (neri@med.unipi.it) \nSurgical procedures are more and more dependent on a deep pre-operative imaging \nassessment, and it is particularly evident in the planning of a minimally invasive \nsurgical interventions. PACS (Picture Archiving and Communication System), de-\nveloped in the Radiology Department, represents the natural working environment \nof the radiologist, but the strong demand of surgeons to access images for treat-\nment planning is pushing radiology to develop the proper image sharing strategies. \nRadiologists should be aware about which images are required to plan the surgical \nprocedure (non-contrast, contrast-enhanced, arterial, portal phase or both), how \nmany images (full datasets or only those obtained at the level of the surgical field?), \nhow to provide the datasets (CDs, network) and finally they should know how to \nstructure the report in the prevision of a surgical procedure. Do radiologists have \nenough knowledge about the above issues to be effective in the surgical planning? \nProbably most of them know the surgical demand, but are not yet aware about how \nto provide the information required. The presentation is aimed to cover these issues \nand provide to the radiologist an update on the surgical planning tools. \nLearning Objectives:\n1. To learn about developments in planning therapy with imaging.\n2. To know how these developments change PACS evolution.\n3. To learn about consequences for diagnostic imaging.\n4. To be familiar with the different therapeutic applications (e.g. planning, \nvolumetry, registration, guidance, robotics, ...).\n16:00 - 17:30 Room L/M \nRadiology of the Spine in 2010 \nCC 1816 \nSpinal intervention: A new level of success \nModerator:\nM. Serrallonga; Barcelona/ES \nA‑489 16:00 \nA. Image-guided pain management \nB.A. Johnson; Minneapolis, MN/US (bjohnson@cdirad.com) \nNeck and back pain represents one of the most common and costly medical \nproblems affecting developed nations. For example, low back pain currently affects \nup to 40% of adults in Western Europe, resulting in massive medical costs and \nlost productivity. Evaluating and treating these patients is challenging, due to the \npresence of a number of potential pain generators in the spine, multiple levels that \ncan be responsible for pain, and the overlap of clinical symptoms that result from \nthe various structures in the spine. The facet joints, vertebral bodies, nerve roots \nand local nociceptors represent potential sources of pain. The clinical evaluation of \npotential pain generators is mostly using physiologic tests to selectively anesthetize \nspecific structures. A comprehensive history, targeted physical exam, and imaging \nstudies help determine which structures are the best candidates for testing. In this \nsession, we will review techniques for evaluating and treating spine-origin pain. \nSeveral techniques for the assessment and treatment of specific pathologic condi-\ntions affecting the spine will be reviewed as an introduction to dedicated lectures \non cement augmentation and other interventions. The benefits and disadvantages \nof these procedures will also be reviewed, in addition to the expanding role of \nneuroradiologists in pain management. \nLearning Objectives:\n1. To understand the etiology and pathophysiology of spine-origin pain.\n2. To review indications for image-guided, minimally invasive spine procedures.\n3. To learn about equipment, materials and techniques utilised for spine \nprocedures.\nalready suggested substituting CTA with CEUS for patients with low likelihood for \ncomplications. Current strategies and modalities for the follow-up of the patients \nafter EVAR are far from satisfactory. The medical community is still on an ongoing \nquest for the ideal follow-up method. \nLearning Objectives:\n1. To learn about typical findings after aortic stent grafting.\n2. To become familiar with typical imaging pitfalls.\n3. To learn about the most common complications.\n16:00 - 17:30 Room K \nComputer Applications \nRC 1805 \nPACS: Evolution \nModerator:\nJ. Chabriais; Aurillac/FR \nA‑486 16:00  \nA. How to improve PACS with open source software \nO. Ratib; Geneva/CH \nOpen source software is a new paradigm in software development that has proven \nto be cost effective and successful in many general applications (Linux, Firefox, \nJoomla, etc). It is now penetrating vertical markets such as medical applications, \nand that is changing all the rules. It is particularly promising in advanced image \ndisplay and analysis applications where the rapid increase in demand cannot be \nmatched by traditional expensive commercial solutions. The evolution of radiology \nimaging modalities from 2D sectional acquisition to a 3D volumetric acquisition and \neven higher dimensions with functional data and the emergence of multimodality \nscanners such as PET/CT scanners calls for new and innovative display and visu-\nalization tools. By combining multiple new technologies and open-source projects, \nit is today possible to develop a new generation of high-performance 3D DICOM \nviewers for personal computers. These 3D visualization tools were traditionally \nonly accessible on expensive 3D workstations restricting their use to specialist \nradiologists. An example of such an Open Source project is the OSIRIX software \nfor multimodality image analysis and processing. It provides the necessary tools for \nnavigating and processing very large datasets of multimodality imaging. It can be \nimplemented outside radiology departments and provide a solution for increasing \nneeds and requirements of clinicians, surgeons and other specialists. It can also \nbe easily integrated with existing PACS and RIS legacy systems. Open source \ncomponent can provide cost effective and efficient ways for deploying advanced \nPACS workstations outside radiology in specialized clinical wards and conference \nrooms in large academic hospitals. \nLearning Objectives:\n1. To learn why proprietary PACS solutions have advantages and restrictions.\n2. To know how open source solutions could be implemented in PACS \nenvironment.\n3. To learn about specific open source tools.\n4. To understand legal aspects in clinical applications of open source software.\nA‑487 16:30  \nB. How PACS is useful for eLearning \nP . Pokieser; Vienna/AT (peter.pokieser@meduniwien.ac.at) \nThe term “eLearning” includes all forms of learning, where digital media or com-\nmunication tools are involved in the presentation, distribution or communication of \nlearning content. To be familiar with the spectrum of eLearning strategies enhanc-\ning radiological education with PACS, didactic basics of modern eLearning will \nbe presented. A modern PACS without any additional tools can be used for many \nexcellent eLearning strategies. Although, there are many different tools available, \nproviding useful features for dedicated use. The lecture will focus on the integration \nof teaching files into PACS, explaining the use of IHE related tools (TCE), promising \ninteroperability for sharing cases with other institutions. An overview of other useful \nfeatures and some representative tools as examples will be discussed. One of the \nmost important tasks of clinical radiology is the written report of a study. The various \nimages and series of a study combined with a written report are the most fruitful \nbasis for cultivating case based radiological eLearning. Structured reporting does \nnot only facilitate communication of reports in daily routine; furthermore, it helps \nto transform routine work into teaching files easily. An example of a pertinent work \nflow will be presented; a demonstration of case series can be tested by participants \nof the ECR 2010 at the ePACS booth. \n\nPostgraduate Educational Programme\nS124\n A B C D E F G\n16:00 - 17:30 Room N/O \nHead and Neck \nRC 1808 \nReporting and staging head and neck tumors \nModerator:\nS.J. Golding; Oxford/UK \nA‑492 16:00 \nA. Paranasal sinuses \nD. Farina; Brescia/IT (nappaje@yahoo.it) \nSinonasal neoplasms encompass a large number of different histotypes, thus, \naccounting for the peculiar density of anatomical structures and tissues present \nin this restricted area. Adenocarcinoma, squamous cell carcinoma and olfactory \nneuroblastoma are more frequent, with the maxillary sinus (about 80%) largely \nprevailing on the ethmoid as the site of origin. MRI is generally regarded as the best \nimaging modality for its high contrast resolution. Characterization of the lesion is \nbeyond the scope of imaging as substantial overlapping between different histotypes \nexists; yet, MRI proves helpful in separating the lesion from retained inflammatory \nsecretions in blocked sinus cavities. Different TNM classifications are applied to \nmaxillary sinus and nasal cavity/ethmoid tumors. Beyond TNM, correct treatment \nplanning requires precise assessment of tumor spread towards three crucial areas, \ni.e. orbit, anterior cranial fossa and pterygopalatine fossa/masticator space. More-\nover, detection of perineural spread is essential as this pattern of tumor growth can \nbe clinically unsuspected whilst it conveys the tumor cells beyond the surgical and \nradiation fields of treatment. Thus, the FOV of any MRI study should encompass \nthe cavernous sinus and Meckel’s cave and, if necessary - as may be the case in \nadenoid cystic carcinoma - follow perineural spread even further. Neck nodes are \nnot routinely studied in sinonasal tumors although this issue needs thorough care \nwhen tumor extends to the skin or posteriorly to the pharynx. \nLearning Objectives:\n1. To review the most common sinonasal malignancies.\n2. To become familiar with the TNM staging of sinonasal neoplasms.\n3. To understand the role of imaging in treatment planning.\n4. To learn how to issue a valuable report.\nA‑493 16:30 \nB. Oral cavity \nF .A. Pameijer; Utrecht/NL (f.a.pameijer@umcutrecht.nl) \nHead and neck cancer commonly originates from the oral cavity as well as from \nthe oropharynx. As in most head and neck sites, squamous cell carcinoma is by far \nthe most prevalent histology. Correct pretherapeutic TNM-staging is an important \nfactor in the treatment planning of oropharyngeal neoplasms. This is a multidisci-\nplinary effort. While the otolaryngologist uses endoscopy to evaluate the mucosal \nsurface, it is the radiologist’s role to show the deep extent of a lesion. CT or MRI \nhas become essential for pre-therapeutic staging of oropharyngeal tumors. In this \nera of cost concern, it seems to be a good principle to do one cross-sectional study \nthat accurately answers the clinical questions. The relative value of CT and MRI in \nthis aspect will be discussed. To be an effective consultant, the radiologist’s report \nshould contain information needed by the surgeon. To supply this information, it is \nhelpful if the radiologist is aware of the spread patterns observed in oral cancer. The \ntypical spread patterns from the various subsites in the oral cavity will be shown. \nBased on the imaging finding, it is (usually) possible to conclude the report with \na ‘radiological’ TN (M)-stage. This approach will be demonstrated using clinical \nexamples from daily practice. \nLearning Objectives:\n1. To become familiar with the TNM staging of SCC.\n2. To understand the advantages and limitations of available imaging \ntechniques.\n3. To learn what the surgeon needs to know for preoperative planning.\n4. To provide a template for a valuable imaging report.\nA‑494 17:00 \nC. Larynx \nA.D. King; Hong Kong/CN (king2015@cuhk.edu.hk) \nPrimary tumour (T Stage): MRI or CT is used to stage the primary; in general, MRI \nis slightly more sensitive to tumour spread but less specific and more likely to be \ndegraded by motion. Mucosal tumour extent in the supraglottis, glottis and subglottis \nA‑490 16:30 \nB. Cement augmentation: Patient and treatment selection \nG.H. Zoarski; Baltimore, MD/US (gzoarski@umm.edu) \nAppropriate patient selection is essential in achieving clinical success in perform-\ning any type of percutaneous vertebral augmentation. The primary indication for \ntreatment is pain associated with a vertebral compression fracture caused by \nosteoporosis, hemangioma, or tumor invasion. Some argue that there may be a \nrole for prophylactic treatment in patients at extremely high risk for compression \nfracture (e.g. patients with kyphosis due to prior osteoporotic compression fractures, \nor patients on chronic steroid treatment with sentinel pain or imaging findings). \nProphylaxis, however, is not a generally accepted indication for vertebroplasty, and \nno controlled studies have been undertaken to substantiate the utility of performing \nvertebroplasty for prophylaxis. Best success is generally achieved with patients in \nwhom pain and tenderness on palpation is localized to the level of radiographic \ncompression fracture. In early published and unpublished treatment series, most \npatients had been allowed to fail conventional medical therapy of analgesics and \nbed rest prior to treatment. More recent series have advocated treatment as early \nas a few weeks, and even within days of the acute event. Late treatment (greater \nthan six months) is less likely to be successful in relieving pain; however, numerous \ninvestigators have anecdotally reported symptomatic improvement with vertebral \naugmentation performed even years after the initial injury. \nLearning Objectives:\n1. To learn about the benefits and risks of spinal height restoration.\n2. To review the experience with cement augmentation.\n3. To describe a safe approach for cement delivery systems into vertebral \nbodies.\nA‑491 17:00 \nC. Spinal interventions beyond vertebroplasty \nA. Gangi; Strasbourg/FR (gangi@rad6.u‑strasbg.fr) \nInterventional procedures of spine are performed under fluoroscopic, CT and MRI \nguidance. A combination of CT and fluoroscopy has been established in difficult \nspinal procedures. The MR imaging is used more and more in spinal interventions \nwith the great advantage of absence of radiation, capacity of thermal monitoring, \nreal time imaging, and multiplan capability. Spinal biopsy: biopsy of spinal lesions \nis one of the major indications in skeletal interventional radiology. Therapeutic joint \ninjection: facet-joint injection in lumbar spine is a simple and safe procedure. Perira-\ndicular infiltration consists of an injection of steroids and anaesthetic into the epidural \nspace at the level of the pathological disk. Percutaneous laser and radiofrequency \n(RF) disk decompression: percutaneous laser and RF disk decompression are \nused to treat patients with radiculalgia caused by disk herniations. Percutaneous \nmanagement of bone tumours: percutaneous thermal ablation of spinal tumours \nwith radiofrequency, laser, and cryoablation is an efficient technique for ablation. \nThe major indication is palliative treatment of spinal metastases and pain manage-\nment. Curative ablation is performed in some selected cases. Thermal ablation of \nbone metastases is promising in pain management. Osteoid osteoma is a benign \nneoplasm of bone. Curative treatment of these tumours by thermal ablation is well \nestablished and considered as standard treatment of this tumour. The interventional \nradiologist with an efficient imaging guided technique can increase the precision \nof the above described procedures allowing an improvement of the results and \nreduction of the complications. A multidisciplinary team work is mandatory for a \nsuccessful practice. \nLearning Objectives:\n1. To present an update of spinal interventions.\n2. To understand the technique and the mechanism of action of percutaneous \nspinal tumor management.\n3. To learn about risks and benefits of spinal interventions.\n\nMonday\nPostgraduate Educational Programme\nA\n S125\nCB D E F G\nmanagement of cancer patients, imaging pitfalls must be recognized to avoid both \nfalse-positive and false-negative interpretation. The principles and good practices \nof PET/CT will be explained. Normal distribution of FDG, pitfalls and normal vari-\nants will be presented. Specific examples will be discussed to demonstrate how \nthe combined information of images of human anatomy upon which biological \ninformation within body structures is added improves delineation of disease, can \nguide surgical and radiation planning and biopsy. Advances in technology result in \nnew training requirements for radiologists who should promote close collaboration \nwith nuclear medicine specialists. \nLearning Objectives:\n1. To understand how the combination of functional and morphologic data \nprovides added-value, helping patient management.\n2. To learn the common pitfalls important for PET/CT interpretation in lung \ncancer.\n3. To emphasise the importance of a strong collaboration between nuclear \nmedicine specialists and radiologists.\nA‑497 17:00 \nC. Radiofrequency ablation of NSCLC: Current status \nT. de Baère; Villejuif/FR (debaere@igr.fr) \nRFA provides 70 - 90% of complete ablation in small size lung tumors. The rate of \ncomplete ablation at 2 years for tumors less than 2 cm is 80 to 90% in most reports. \nThe rate of complete ablation is highly dependent on the volume of ablation relative \nto the tumor. In 75 primary stage I NSCLC median survival was 29 months, with \n78, 36, and 27% at 1, 3, and 5 years, respectively. Better survival was reported \nfor tumors 3 cm or smaller with a survival rate close to 50% at 5 years. Radiation \ntherapy combined with RFA in 41 NSCLCC patients improved with 57% survival \nat 3 years. The survival was 34.6 ± 7 months for tumors > 3 cm and 44.4 ± 5.4 \nmonths when ≤3 cm. CT follow-up induced some delayed discovery of incomplete \ntreatment, 4 to 12 months (mean±SD = 7.66 ±2.77) after RFA in our experience. \nPET/CT appears promising to provide early evaluation of treatment response but \ntiming of PET after ablation is a key factor because G6PD uptake is highly increased \n1 to 3 weeks after ablation with an SUV ratio of 5 and higher between RF ablation \nzone to muscle. After RFA, there is no changes in post-ablation respiratory test \nand, consequently, a major benefit of lung RFA to treatment of NSCLC is that it \nallows curative treatment in non-surgical early NSCLC. Moreover, this excellent \ntolerance allows safe treatment of single lung patients. \nLearning Objectives:\n1. To be able to define the best candidates for lung radiofrequency ablation.\n2. To know the results of radiofrequency ablation for primary tumours and lung \nmetastases.\n3. To know different imaging patterns of a radiofrequency ablated tumor.\n16:00 - 17:30 Room Q \nOrgans from A to Z: Liver \nMC 1819 \nLiver tumors and management \nModerator:\nP.L. Pereira; Heilbronn/DE \nA‑498 16:00 \nA. Liver metastases \nA. Palkó; Szeged/HU (palkoand@gmail.com) \nMetastasis is the spread of tumor cells via the lymph, blood, or body cavities to near \nor distant sites where new secondary tumors are formed. Most patients succumb to \ntheir metastatic disease; therefore, controlling the spread and growth of malignant \ncells at metastatic sites is an important challenge. Liver is the parenchymal organ \nmost often affected by metastases, not only because of its rich, dual blood sup-\nply but also because of humoral factors that promote cell growth. Most common \nprimary tumor sites are the colon, stomach, pancreas, breast and lung. 90% of the \nmetastases are multifocal and can occur anywhere in the liver, their size ranges \nfrom macromorphologically undetectable seeds to several centimeters. Beyond this, \nthe appearance of metastases depends on their homogeneity, vascularity, shape, \ncontour, age of the filiae (presence and age of degenerative changes: necrosis, \nbleeding, calcification, scars) and tumour border (liver tissue surrounding the \nmetastasis with compression, desmoplastic reaction, inflammatory changes). The \nrole and responsibility of imaging diagnosis in detecting and characterizing these \nlesions is paramount. The task of this presentation is to summarize the techniques \nis assessed endoscopically (T1 and T2), aided by imaging in the subglottis. Deep \ntumour invasion into the pre and para-epiglottic spaces (T3), Extralaryngeal sites \n(T4) and cartilage (T3 or T4) is assessed by imaging. Treatment options vary widely \nand so the lecture will highlight some of the more important clinical implications of \ntumour spread into these (SPEC) sites. Nodal metastases (N Stage): Nodes are \nimaged by MRI or CT (according to modality for the primary) and may be supple-\nmented by ultrasound. The sites of nodal spread are dependent on the primary \ntumour, being more common in supraglottic or deeply invasive tumours, and rare \nin early glottic tumours. Imaging identifies metastatic nodes and then stages the \ndisease (single node ≤ 3 cm = N1, any node > 6 cm = N3, other combinations = \nN2). Patients without nodes (N0) who are candidates for surgery may undergo less \nextensive neck dissection or, in very selective cases, a conservative management \napproach. Distant metastases (M Stage). Distant metastases (M1) are uncommon \nin laryngeal cancer, patients being at greater risk from second primaries (espe-\ncially lung). Chest radiograph is performed in all patients and thoracic CT in those \nat high risk. The role of FDG PET in distant metastases and second primaries is \nunder investigation. \nLearning Objectives:\n1. To become familiar with the TNM staging of laryngeal SCC.\n2. To recognise the best imaging modality for staging.\n3. To understand the required information to decide upon the best treatment \noption.\n4. To provide a template for a valuable imaging report.\n16:00 - 17:30 Room P \nChest \nRC 1804 \nNon-small cell lung cancer \nModerator:\nC.K. Atasoy; Ankara/TR \nA‑495 16:00 \nA. Update in TNM classification \nS. Diederich; Düsseldorf/DE (s.diederich@marien‑hospital.de) \nThe aim of precisely staging lung cancer with imaging techniques is to allow se-\nlection of the optimum therapeutic strategy and avoid unnecessary therapies that \ncause harm to the patient or cost to the health system. As many other malignancies, \nlung cancer staging is performed using the T (Tumor)-, N (Node)- and M (Metas-\ntasis)- classification to describe local tumor extent and the presence or absence \nof lymphatic or haematogenous metastases. According to potential therapeutic \nstrategies, different combinations of TNM-categories are grouped in stages (stage \nI -IV). Radical surgery - if possible - is most likely to result in cure of the disease. \nTherefore, separation of resectable versus unresectable tumor manifestations by \nmeans of imaging studies is of utmost importance in order not to deny a potentially \nlifesaving operation to a resectable patient and simultaneously avoid unnecessary \nsurgery in an unresectable patient. Using analysis of outcome in patients with dif-\nferent T -, N- and M-stages, the previous staging system has been modified recently. \nThe aim of this course is to present the current staging system and give examples \nof different stages at imaging. \nLearning Objectives:\n1. To understand the principles of T -, N- and M-classification in lung cancer.\n2. To understand the effect on therapeutic strategies and prognosis of different \ntumor stages.\n3. To understand the recent changes in the TNM-staging system in lung cancer.\nA‑496 16:30 \nB. PET/CT in lung cancer \nN. Howarth; Chêne‑Bougeries/CH (nigel.howarth@grangettes.ch) \nIntegrated PET/CT imaging has an established role in the management of cancer \npatients and is now recommended for all patients with curative non-small cell \nlung cancer. PET/CT provides information essential for staging and prognosis, \nfor choice of management and monitoring of treatment and for the detection of \nrecurrence. Recent technical developments in PET/CT permit rapid examinations \nwith improved resolution. Compared with standard CT or stand-alone PET, the \nadded value of fused imaging is uncontested. The clinical influence of preoperative \nPET/CT is currently undergoing extensive evaluation. Radiologists should benefit \nfrom an understanding of important aspects of molecular imaging to improve their \ncontribution to patient management. With the increasing use of PET/CT in the \n\nPostgraduate Educational Programme\nS126\n A B C D E F G\nLearning Objectives:\n1. To understand why tumor response evaluation is critical for the treatment \nstrategy and to learn the different imaging criteria provided by international \nrecommendations.\n2. To understand which criteria are adapted for the evaluation of tumor \nresponse after ablation.\n3. To learn about the latest developments in imaging assessment of tumor \nresponse.\nand diagnostic algorithm of imaging modalities (with particular emphasize on the \nuse of special MRI techniques), and to identify the typical imaging findings, but \nalso the differential diagnostic difficulties encountered during the everyday activity \nof radiologists. \nLearning Objectives:\n1. To understand the different consequences of the onset of liver metastases \naccording to cancer type and clinical situations.\n2. To appreciate the role of different imaging modalities and their respective \naccuracy for detection and characterisation.\n3. To learn about the imaging criteria for assessing the response to systemic \nchemotherapies.\nA‑499 16:30 \nB. Staging of liver tumors and treatment planning: When and how to treat \nA.R. Gillams; London/UK (alliesorting@googlemail.com) \nThe choice of therapy depends on tumour type, the number, size, location and \ndistribution of liver tumours, the status of the background liver parenchyma, the \npatients overall status and the extent of disease elsewhere. Percutaneous ablation \nis indicated in patients with limited numbers of small-moderate sized tumours typi-\ncally < 5 metastases, < 5 cm in diameter or in cirrhosis, 3 HCC nodules, < 3 cm \nor < 5 cm solitary HCC. In indolent neuroendocrine tumours, larger numbers of \nsmaller tumours can be treated at sequential sessions. Ablation can be used in \nmost parts of the liver, if appropriate imaging guidance is available. Vulnerable \nstructures must be displaced away from the ablation to prevent collateral damage. \nLesions next to the common bile duct should only be treated during intraductal \ncooling. Radiofrequency ablation is superior to percutaneous ethanol injection with \nthe exception of exophytic HCC. In breast cancer, it is acceptable to treat patients \nwith controlled extra-hepatic disease but generally, the best results are achieved \nin patients with liver-only disease. Percutaneous ablation is minimally invasive \nand well tolerated even in patients who are not sufficiently fit to undergo surgery. \nPercutaneous ablation is readily combined with other treatments e.g. resection \nor cyberknife. Chemoembolisation has a long track record in HCC and has been \nshown to improve survival in meta-analyses. Generally, chemoembolisation is used \nin conjunction with ablation or in patients who cannot undergo ablation. Chemo-\ntherapy is used to downsize patients who are not initially suitable for ablation or \nas an adjunctive treatment. \nLearning Objectives:\n1. To learn about the spectrum of treatment options in liver tumors.\n2. To appreciate the importance of tumor characteristics and spread for \nselecting the suitable treatment.\n3. To understand indications, contraindications, and complications of intra-\narterial and percutaneous interventions in the treatment of primary and \nmetastatic liver tumors.\nA‑500 17:00 \nC. Evaluation of tumor response to treatment \nT.K. Helmberger; Munich/DE (thomas.helmberger@kh‑bogenhausen.de) \nStaging and re-staging before and after therapy in malignancies are integral and \ncrucial components of the comprehensive diagnostic and therapeutical concept \nof tumour treatment. For assessing tumor response to treatment, the WHO had \nestablished guidelines which were transformed in a more simplified evaluation \nsystem, the Response Evaluation Criteria in Solid Tumours (RECIST) now avail-\nable in the even more simplified version 1.1. These criteria, which are primarily \nbased on gathering data of presence and size of malignant lesions, are applied \nwidely in oncology, and maybe reasonably meet the needs in follow-up of chemo-\ntherapy. However, with the advent and increasingly widespread use of multimodal \ntherapy regimens including the huge variety of minimal invasive procedures and \nbiologicals RECIST alone is not sufficient for evaluating treatment response. The \noften more complex tissue reaction to local or targeted treatment necessitates \na more comprehensive assessment of response to cope with a specific therapy \nsuccess. Therefore, extended criteria as type of perfusion of the index tumour (s), \nseemingly increased size of an ablation zone and its change over time, degree of \nuniformity or potential irregularity in the shape of an ablation zone, and changes \nin vascularisation, but also complications (e.g. bleeding, damage to biliary ducts) \nthat might alter subsequent image interpretation) have to be incorporated into \nthe response assessment. Modern cross-sectional imaging mainly by contrast-\nenhanced CT and MRI, but also by ultrasound and PET/CT, offers beyond pure \nmorphological evaluation a deep insight into changes of vascularization, fibrotic \nregression, residual or new tumor growth and complex concomitant phenomena.","source_license":"CC-BY-4.0","license_restricted":false}