key: cord-0001022-e1bn79ui
authors: nan
title: ECR 2011 Book of Abstracts - A - Postgraduate Educational Programme
date: 2011-03-01
journal: Insights Imaging
DOI: 10.1007/s13244-011-0078-3
sha: c99c13a7fd862340808414143b4a04893a7ecc0f
doc_id: 1022
cord_uid: e1bn79ui

nan

For PET-CT, the CT exam is generally performed as standard whole-body exam from the base of the skull to the upper thighs. Standard parameters are non-ionic iodinated intravenous contrast material at 0.5 g/kg bodyweight with a venous delay of 70 seconds after injection and 3-5 mm thick continuous axial reconstructions with medium soft convolution kernels. CT images frequently contain important diagnostic information beyond mere 'anatomic landmarking', so generally a diagnostic, contrast enhanced normal-dose CT should be performed except if a recent diagnostic CT scan is available for fusion. Then, a low-dose CT is sufficient for attenuation correction. A difference from routine CT protocols is the expiratory position to match the respiratory position of PET acquisition. Also, negative oral contrast material should be applied and the whole body should be included in the field of view to allow effective attenuation correction of PET images. Diagnostic reading has to include lung, soft tissue and bone windows. Optimally, the assessment should be performed by one reader evaluating CT and PET images simultaneously on multiplanar reformats. Learning Objectives:

1. To get acquainted with standard CT examination parameters for oncological imaging including the requirements for an effective attenuation correction. 2. To see the diagnostic value of CT beyond 'anatomical landmarking'. 3 . To learn effective ways to interpret PET-CT examinations.

Nuclear medicine perspective T. Beyer; Zurich/CH Combined PET/CT images were first proposed as early 1984. Since 1998 PET/ CT became available for broader clinical testing. Since its commercial introduction in 2001 more than 5'000 PET/CT systems were installed worldwide. PET/CT is a logical and technical consequence of early, manual or semi-automatic efforts to align functional and anatomical images for easier and improved diagnosis. PET, or positron emission tomography, is an emission tomographic imaging method based on the application of radioactively labelled biomolecules in order to measure and quantitate signalling or metabolic pathways. CT, computed tomography, on the other hand, uses an external ionising radiation transmission source to generate projection data of the transmitted radiation, thus helping to generate high spatial resolution images of the anatomy of the subject. Both sets of information can be combined easily in a PET/CT, whereby both the PET and CT components can be operated in close spatial proximity within a single gantry without cross-talk effects. Through the combination of CT and PET overall examination times of oncology PET studies are reduced by 30%. In addition, PET instrumentation has been advanced to include time-of-flight measurements for improved signal-to-noise ratio, extended axial field-of-view-coverage for higher sensitivity and novel image reconstruction for improved contrast. Today, high-quality one-stop shop staging with PET/CT is possible in 10 min, or less. Learning Objectives:

1. To illustrate the origin of combined PET/CT imaging. 2. To motivate the strength of PET: high spatial sensitivity, quantification and functional information. 3. To appreciate the difference between "contrast" and "tracer" imaging. 4. To highlight novel developments in PET imaging: time of flight (TOF), extended axial field-of-view. Computed tomography is the main contribution to diagnostic medial radiation exposure to the public. In the year 2001, CT accounted for only 6% of all radiationassociated examinations; however, at the same time it accounted for 47% of the total radiation exposure. Since the beginning of this century numerous international surveys had been performed with the aim to define diagnostic reference levels in European countries. Radiation exposure by CT has increased particularly by cardiac CT examination, what has caused awareness to utilise all strategies for radiation protection in CT. Modern CT scanners are equipped with automated anatomical or organ sparing exposure control. It is the CT investigators responsibility to check the clinical indication, limit the scan range and decide for the appropriate scan protocol with the least radiation exposure. Newer technical developments in CT scanner hard and software will enable to further reduce the dose from CT. All these strategies are essentially necessary since the number of CT investigations and the scope of clinical indications are expanding with advancing medical progress.

Learning Objectives: 1. To understand the meaning of diagnostic reference values. 2. To become aware of dose intense CT protocols. 3 . To learn about strategies for radiation protection in CT.

Nuclear medicine perspective S.P. Mueller; Essen/DE Different radiopharmaceuticals labelled with positron emitting radioisotopes are used to study a multitude of molecular processes using a positron-emissiontomography (PET) scanner which nowadays is typically integrated with a CT scanner (PET/CT). This lecture will enable the attendee to comprehend that the radiation exposure from PET depends on the biodistribution and kinetics of the radiopharmaceutical, the physical half-life of the positron emitting radioisotope used for labelling, and the injected activity, leading to an understanding that there is no generic "radiation exposure from PET or PET/CT". Learning Objectives: 1. To learn that the comparison of doses for different radiopharmaceuticals is based on the concept of the effective dose which expresses the total stochastic risk from the non-uniform radiation exposure to individual radiosensitive organs in terms of a uniform whole body radiation dose. 2. To understand that the effective dose from certain radiopharmaceuticals may be reduced by simple means, e.g. if it is renally eliminated by frequently voiding the bladder, and that the effective doses for the most prevalent radiopharmaceuticals lie within the typical range of other diagnostic nuclear medicine tests and compare favourably to the radiation exposure from the CT portion of a whole-body PET/CT scan.

PET and PET/CT are non-invasive, 3-dimensional imaging modalities which have become standard of care in patients with malignant lymphomas. These modalities have been extensively studied for staging, restaging, monitoring response to therapy, surveillance after definite treatment, and assessment of transformation. More recently, PET tracers have been suggested as surrogate markers for cancer drug development.

Learning Objectives: 1. To understand in which clinical scenarios PET and PET/CT imaging are superior to standard imaging modalities or other diagnostic tests. 2. To learn the diagnostic accuracy and predictive potential of PET and PET/CT for staging/restaging Hodgkin's disease and non-Hodgkin's lymphoma.

of the examination. Therefore, for oncologic applications, PET-CT has already gained widespread acceptance for the initial staging of cancer, the management of recurrent cancer, and for monitoring the response to therapy. The development of a large variety of radiotracers is an evolving procedure. The most frequent used radiotracer in clinical practice, 18 F FDG, is based on the identification of the fundamental aspects of tumour glucose metabolism. New radiotracers, with promising potential for PET-CT, are also currently available to visualise specific cellular and molecular tumour pathway and more being developed.

Learning Objectives: 1. To appreciate the advantage of a combined PET-CT technique. 2. To consolidate our knowledge of optimal examination protocols and to be aware of the pitfalls that may be encountered using this technique. 3. To understand the indications for PET-CT in the diagnosis, staging, and therapy monitoring of a large variety of GI tumours. 4. To become familiar with the different radiotracers to obtain a tailored and personalized diagnosis for the large variety of GI tumours.

A-013 13 Integrated positron emission tomography (PET)/CT provides combined metabolic and anatomic information of malignancies. The addition of CT to PET for urogenital purposes is very useful. CT should be performed with oral and intravenous contrast agent administration as a full diagnostic technique. If performed under these conditions, this technique can help to avoid PET pitfalls including focal retained activity in ureters and urinary bladder, and increased uptake in physiologic and benign pelvic processes such as endometrial uptake in the menstrual phase, leiomyomatosis, endometriosis or infection. We will describe the use of PET/CT in the characterisation, staging and surveillance of urogenital malignancies including kidney, prostate, bladder, uterine cervix, endometrium and ovaries. PET/CT is internationally accepted as the most useful surveillance imaging tool in patients with ovarian cancer, and its use as a problem-solving modality has also rapidly grown in the rest of urogenital malignancies.

Learning Objectives: 1. To learn the appropriate protocols and settings of a diagnostic CT in PET/CT for urogenital purposes. Computed tomography remains the workhorse of clinical cross sectional imaging due to its good availability, enormous speed, high spatial resolution and sufficient tissue contrast to evaluate most diseases based on morphology. Compared to PET and SPECT, room for improvement remains in sensitivity and specificity for certain diseases and, compared to ultrasound and MRI, in dynamic imaging. However, already today there are new CT techniques which can provide diagnostically equivalent information as SPECT or PET but with higher spatial resolution, in shorter acquisition time and without radioactive tracers. One of these techniques is CT perfusion imaging with repeated low-dose acquisitions of the same organ.

With this method, a detailed evaluation of brain perfusion is feasible e.g, for stroke assessment, or of tumour perfusion, e.g. to assess early therapy response. Another option is Dual Energy CT which does not require additional dose but can provide additional important diagnostic information similar to PET or SPECT. Examples are the evaluation of lung ventilation und perfusion with xenon gas and iodine contrast. For oncological imaging, the evaluation of tumour perfusion based on spectral identification of iodine is an attractive option to increase specificity without additional dose or radioactivity. Similarly, it is feasible to assess myocardial perfusion along with coronary CT angiography. For some diseases, even the molecular substrate can be identified with this technique, e.g. uric acid in gout patients. These new techniques provide significant advantages in oncological imaging and may further add to disease characterisation if combined in PET-CT. Learning Objectives: 1. To understand the strengths of current CT technology in oncological imaging based on morphology. 2. To learn about the diagnostic value of CT beyond anatomical referencing.

Energy CT as options to improve disease characterisation.

Tracers beyond FDG in daily routine M. Beheshti; Linz/AT

The ability of positron emission tomography (PET) to study different biological processes opens up new windows for both researches and daily clinical use. Addition of computed tomography (CT) to PET improves detection efficiency and results in better localization of the lesions. The aim of this review is to consolidate knowledge of oncological applications of PET tracers other than [(18)F]fluoro-2-deoxy-D -glucose] (FDG) in the daily clinical practice. FDG, as a non -specific tracer, has limited value in the assessment of different cancers such as prostate cancer, neuroendocrine tumours (NET), brain tumours, hepatocellular Carcinoma (HCC), and some types of breast cancers. Hence, due to high sensitivity of PET in performing non-invasive functional studies, further investigations and developments are warranted for defining specific PET radiotracers and theirs clinical applications regarding different tumour entities. Oncological non-FDG PET tracers can be generally categorized into 3 groups: those labeled with F-18, C-11 and other non-FDG tracers. Fluorine-18 and C-11 are labeled with different amino acids, substrates involved in fatty acid synthesis, protein synthesis, amino acid transport substrate and tracers linked to nucleic acid synthesis. These tracers are also labeled with specific ligands for receptor imaging. The other non-FDG A-024 16 With the increasing use of abdominal cross-sectional imaging, incidental adrenal masses are being detected more often. The important clinical question is whether these lesions are benign adenomas or malignant primary or secondary masses. Benign adrenal masses such as lipid-rich adenomas, phaeochromocytomas, myelolipomas, adrenal cysts and adrenal haemorrhage have pathognomonic cross-sectional imaging appearances. However, there remains a significant overlap between imaging features of some lipid-poor adenomas and malignant lesions. The nature of incidentally detected adrenal masses can be determined with a high degree of accuracy using computed tomography and magnetic resonance imaging alone. Positron emission tomography is also increasingly used in clinical practice in characterising incidentally detected lesions in patients with cancer. The performance of the established and new techniques in CT, MRI and to a lesser extent PET, that can be used to distinguish benign adenomas and malignant lesions of the adrenal gland will be reviewed. With the increasing use of imaging, incidentally detected renal masses are very common. While masses detected by CT or MR usually can be properly classified, renal masses detected by ultrasound frequently require further workup. The following considerations determine the diagnostic workup: simple cysts are very common but may present atypically. Renal cell carcinomas may be cystic but usually display at least a small solid component. Renal cell carcinomas have a bad prognosis when metastasized but metastases hardly every develop before the tumour has reached 3 cm in diameter. Differentiation between solid tumours by imaging alone is exceedingly difficult, save for the identification of angiomyolipomas in adults. This course will discuss suitable diagnostic algorithms based on the initial presentation of the mass. Typical imaging findings of various benign and malignant renal masses will be presented. The role of the Bosniak classification will be illustrated. Newer developments such as a waitand-see approach or primary biopsy for small solid renal masses will be discussed. Learning Objectives: 1. To learn how to detect and characterise a renal mass. 2. To understand how to apply adequate protocols according to the clinical situation.

The wrist and hand are characterised by variability of bones, fibrocartilage, ligaments, muscles and neurovascular structures. Coalitions (most commonly lunotriquetral, prevalence of 0.1%), ulnar impaction positive variance of the ulna, carpe bossu and an accessory medial lunate facet associated with osteoarthritis are typical variants of bone. The triangular fibrocartilage complex (TFCC) and the interosseous ligaments often present with small defects. Radial TFCC defects are present in 64% of symptomatic but also in 46% asymptomatic wrists. In addition, their prevalence increases with age, apparently without increasing symptoms. Accessory muscles are common and may clinically mimick a neoplasm. Disease may also be mimicked by imaging artifacts. Magic angle effects cause increased tendon signal and may thus lead to the incorrect diagnosis of tendinopathy. The lunate appears to be more dorsally tilted on sagittal MR images than on standard radiographs (radiolunate angle ~20° larger on MR images). This value increases to ~37° if the wrist is positioned in ulnar deviated as is commonly the case when the wrist is examined in the "superman position", with the arm above the head. Magic angle artefacts are commonly encountered in the wrist. The extensor and flexor pollicis longus are especially prone to such artefacts, due to their oblique course approaching the critical 55° with regard to the B 0 field. In conclusion, variability is rather the rule than the exception in the hand and wrist. Only part of the findings have clinical meaning. Technical aspects add another dimension of variability.

Learning Objectives: 1. To become familiar with the normal anatomy. 2. To be able to identify normal variants. 3 . To appreciate the range of pitfalls that may simulate pathology.

The imaging of the trauma stratifies the severity and the treatment strategy. The leading modalities in low-energy trauma are x-ray and ultrasound. The different approach has to be used in high-energy trauma -the silent life-threatening injury must be actively searched. Although the first examination on the site of the accident could estimate whether the severe trauma is present, the imaging must confirm or exclude it. Besides fast transport to the trauma centre has the extraordinary impact on survival the diagnostic algorithm. The installation of CT, ultrasound and x-ray directly within the emergency department is extremely important for the trauma management. If the focused assessment sonography for trauma (FAST) is replaced by whole body CT, the life-threatening injury is detected at fastest. Protocol includes imaging of non-enhanced CT head and cervical spine followed by the contrast-enhanced CT of the entire thorax, abdomen and pelvis, in cases of lower extremities trauma covering whole body. CT could be performed also under resuscitation, because whole imaging takes about three to five minutes. Following findings listed recently according to their impact on survival must be confirmed or excluded: intracranial injury, cervical spine trauma, aortic injury, overpressure pneumothorax, severe bleeding in the abdominal cavity, organs injury, peripheral vascular trauma, bone trauma; the trauma team including anaesthesiologist, surgeon and radiologist discusses the findings and plans of the treatment. Over the last two decades, spiral-CT has become a highly reliable imaging modality to diagnose haemorrhage in trauma, while the role of catheter angiography has changed from a diagnostic to a therapeutic modality. Traumatic injuries of the heart and aorta lead to sudden death occurring at the accident site, whereas uncontrollable haemorrhage from larger arteries and parenchymal organs is the most frequent cause of mortality during the first 4 h following severe trauma. In patients with ruptured aorta or major arteries, stenting and temporary balloon occlusion may contribute to saving lives, while transcatheter embolisation may prevent exsanguination in haemorrhage from visceral organs, arteriovenous fistulas, and secondary onset haemorrhage. However, a haemodynamically stable patient is a prerequisite for all angiographic interventions. Definite haemostasis using the above-mentioned techniques can be obtained in 80-100% (major and periphery arteries) and 82-100% (visceral organs), respectively. Possible complications following angiographic haemostatic interventions depend very much on the treated vessel bed but are, in general, as low as 5%.

Learning Objectives: 1. To understand potential treatment options and when to treat and when not to treat. 

A S15 C B D E F G H to current best practice, restriction of opinions to one's own expertise, expression of opinions that take into consideration all of the material facts, and the readiness to change that opinion if additional information becomes available. Any unusual, contradictory or inconsistent features of the case should be highlighted. The expert should highlight whether a proposition is a hypothesis (in particular a controversial hypothesis) or an opinion deduced in accordance with peer-reviewed technique, research and experience accepted as a consensus in the scientific community. He/she should indicate whether the opinion is provisional (or qualified), stating the qualification and the reason for it, and identify what further information is required to give an opinion without qualification. When there is a range of opinion on any question to be answered by the expert, (a) the range of opinion should be summarised, (b) highlight whether that range of opinion includes an 'unknown cause' (because of limited facts of the case or limited research/peer-reviewed publications), and (c) give reasons for the opinion expressed. Reprints of scientific publications will assist the court, but will also enable the attorneys to undertake a more robust cross examination! Learning Objectives:

1. To learn about imaging findings in relation to whether or not abuse has occurred. 2. To understand in which cases the diagnosis of child abuse should be raised in the radiology report. 3. To become familiar with the terms that should be used when highly specific imaging indicators are identified in an otherwise normal infant.

The radiologist at the eye of the storm 17:14

Imaging plays a central role in the diagnosis of child abuse. Is there any risk of the radiologist having a detrimental impact on either the welfare of the patient or the judicial process by either under-diagnosing or over-diagnosing child abuse? Ovarian cancer continues to be a challenge to radiologists and clinicians, as it is one of the most lethal female tumours. This is mainly due to its diagnosis in an advanced stage in the majority of patients. However, new developments can be observed: new insights in tumour biology, advances in imaging and new concepts of ovarian cancer treatment and surveillance. Furthermore, a multidisciplinary expert team approach has also substantially changed the management of patients with suspected ovarian cancer. The findings of radiology are becoming pivotal in a more individualised patient care. The role of radiology includes (a) characterisation of sonographically indeterminate adnexal masses, (b) staging as guidance for surgery and treatment planning (including identification of sites of non optimal resectabilty) in suspected ovarian cancer, (c) assessment of recurrent disease, and (d) in selected cases image-guided biopsy. In this session we provide an update on the aetiology and current concepts of treatment of ovarian cancer and on the contribution of radiology in characterisation and staging in patients with the working diagnosis of ovarian cancer. The panel discussion will focus on the role of radiology in multidisciplinary conferences in suspected ovarian cancer. Session Objectives:

1. To learn about new concepts in etiology and treatment of ovarian cancer. 2. To become familiar with optimised imaging protocols to diagnose ovarian cancer. 3 . To learn about the value of CT and PET/CT as a basis for treatment planning in ovarian cancer. 4. To appreciate the role of the radiologist in multidisciplinary consensus conferences.

Session Objectives: 1 . To learn about current imaging practices in the evaluation of suspected child abuse. 2. To learn about imaging changes which permit a firm diagnosis of child abuse. 3. To become familiar how to construct a comprehensive report providing evidence of child abuse.

How to image and detect patterns of skeletal injury indicating child abuse P.K. Kleinman; Boston, MA/US (Paul. Kleinman@childrens.harvard.edu) In infants, skeletal injury may form the basis for the diagnosis of abuse. The first step is the acquisition of a skeletal survey utilising meticulous technique adhering to a rigorous imaging protocol. A proper interpretation is ensured when the radiologist is familiar with the various patterns of skeletal injury, their specificity for abuse and those entities which may simulate inflicted injury. Appreciation of the lesion morphology, the fundamental pathologic alterations and mechanism of injury are essential in assessing the significance of the findings and placing them in the clinical context. Dating fractures poses a significant challenge, but in most cases, injuries can be placed in a certain time frame, especially if a follow-up skeletal survey is obtained. Although radiography forms the basis of skeletal imaging, ultrasound, CT, scintigraphy and MRI may clarify findings and optimise diagnosis and management. The radiology report must be constructed with care and the language should be crafted with the expectation that the radiologist may be called to testify in court, a daunting challenge in an often highly adversarial environment.

Learning Objectives:

1. To learn about the appropriate imaging protocols and quality for skeletal survey in suspected child abuse. 2. To learn about patterns of skeletal injury typical of child abuse. 3 . To become familiar with findings that point to alternative diagnoses.

Imaging strategies to fully determine intracranial injury resulting from child abuse C. Adamsbaum, C. Rey-Salmon; Paris/FR (c.adamsbaum@svp.ap-hop-paris.fr)

Radiologists play a key role in the early diagnosis of abusive head trauma (AHT). Symptoms are various and may range from coma to asymptomatic children. Changing elements of the history provided previous injuries, bruising in non-ambulatory children and delay in seeking care raise a high index of suspicion. The most common finding in AHT is of multifocal subdural haematomas over the cerebral hemispheres, the convexity, the posterior interhemispheric fissure and the posterior fossa. The haematomas are often associated with hypoxic-ischaemic injury and retinal haemorrhages. CT is the first diagnostic examination to be used for patients with acute injury. It can reveal intracranial haemorrhage, fracture and soft tissue swelling with a high degree of sensitivity. CT should be repeated after a time interval if the findings are doubtful or if there is a discrepancy with the neurological picture. MRI (including T1, T2, T2*, diffusion sequences and cervical spine examination) is required to fully determine intracranial injury as it can exquisitely demonstrate hypoxic-ischaemic injuries by showing areas of cytotoxic oedema. It is impossible to date precisely a haematoma whose pattern is influenced by numerous factors. However, the main point is to determine the presence of 'age-different' lesions. This not only provides a strong argument for the diagnosis but also suggest repetitive violence and thereby, a high risk for further injury unless protective action is undertaken. Brain imaging must be performed in all siblings younger than 2 years, living in the same conditions as the index case. Learning Objectives:

1. To learn about imaging protocols designed to: a) detect acute treatable conditions b) depict fully and determine the timing of all injuries. 2. To become familiar with imaging findings that are highly suggestive of child abuse. 3 . To learn about head trauma that may simulate child abuse.

What is the information required by any court and how the radiological reports should be phrased S. Chapman; Birmingham/UK (stevechapman@doctors.org.uk) This presentation will describe the role of a paediatric radiologist as an expert witness (as opposed to a witness to fact). The expert has an overriding duty to the court that takes precedence over any obligation from whom the expert has received instructions or by whom the expert is paid. Particular duties include advice that conforms A-040 16:05 Ovarian cancer: update and role of radiology J.A. Spencer; Leeds/UK (johnaspencer50@hotmail.com)

Ovarian cancer is known as the 'silent killer'. It is usually diagnosed late and most women have disease disseminated to the peritoneum (and/or pleura) at presentation. Standard treatment comprises cytoreductive surgery followed by platinumbased chemotherapy. An alternative is neoadjuvant chemotherapy followed by interval debulking surgery (IDS) then completion chemotherapy. Data from the EORTC 55971 trial show this to be as effective as the standard of care. There are strong genetic predispositions to ovarian, fallopian tube and primary peritoneal cancers. There is linkage with breast cancer in women with BRCA gene mutations and with colon cancer with the HNPCC gene. Ongoing trials are screening women in the general population and at high risk of the disease. These use the serum tumour marker CA125 followed by US as screening tools. MR imaging is an effective tool to assess sonographically indeterminate adnexal masses and offers an earlier diagnosis of cancer than interval reassessment with US. CT is the most commonly used modality for assessment of disease extent prior to surgery. Image-guided biopsy is necessary prior to starting neoadjuvant chemotherapy. The EORTC 55955 and MRC (UK) OV05 trials of women with treated ovarian cancer have shown no outcome advantage for women treated early at 'CA125 relapse' of disease versus later with clinical or CT evidence of relapse. This questions the role of CA125 in follow-up and argues against investigation of the 'CA125 +ve, CT -ve' woman with more expensive and scarce imaging resources such as CT-PET and DCEMR. Learning Objectives:

1. To become familiar with clinical features of ovarian cancer.

2. To learn about the etiology of ovarian cancer, including genetic predisposition and the current research into screening. 3. To become familiar with new concepts of treatment ovarian cancer and surveillance of the treated patient and their impact for the use and choice of imaging modalities.

Imaging of adnexal masses: is it feasible to diagnose ovarian cancer? I. Thomassin-Naggara; Paris/FR (isabelle.thomassin@tnn.aphp.fr)

Adnexal masses can be depicted by many imaging modalities (US, CT, MR and PET-FDG). However, the characterisation of adnexal tumours is mainly based on two techniques: US and MRI. For complex adnexal masses, MR imaging add to conventional criteria of malignancy common to all imaging modalities (bilaterality, tumour diameter larger than 4 cm, predominantly solid mass, cystic tumour with vegetations, and secondary malignant features, such as ascites, peritoneal involvement, and enlarged lymph nodes) specific features based on the characterisation of the solid tissue (including vegetation, thickened irregular septa, and solid portion) of the adnexal tumour. Signal intensity of solid tissue on T2 sequence (fibrous tissue), perfusion (neoangiogenesis), and diffusion (cellularity) are combined to make a decision tree analysis. Low T2 signal, absence of high b1000 signal, and time intensity curve type 1 are predictive of benignity whereas high T2 signal and time intensity curve type 3 are predictive of malignancy. Combining common classical features and specific MR features for predicting malignancy, MR imaging has a high degree of accuracy (96%) for characterising complex adnexal tumours. This high diagnostic confidence rate may help young women wishing to preserve childbearing potential to opt for conservative surgery and avoid the systematic removal of benign complex adnexal masses in menopausal women. Learning Objectives: 1. To understand the role of ultrasonography in assessing and managing complex adnexal lesions. 2. To learn how to optimise the MRI protocol and how to improve the characterisation of indeterminate complex adnexal masses. 3. To understand the added value of functional sequences (DCE MRI and DWI) in diagnosing adnexal masses.

The European and American guidelines include breast ultrasound in a restricted diagnostic scenario for breast cancer diagnosis. The fourth edition of the European guidelines (2006) reviewed in 2008 refers to US in only twice. ACR in its 2007 ACR Practice guideline reduces breast ultrasound examination to seven situations. Evaluation of the axilla and ultrasound as a screening tool on high risk women is considered an area of research. The progression of US makes guidelines become obsolete very fast. Its application still remains pending on the results of clinical trials. Image smoothing on sono-CT or multiple frequency transducers will produce images, eventually with more diagnostic information. Second tissue harmonics will produce sharper and more clear images. CAD systems, Doppler and contrast Doppler will help in diagnosis. 3D with the new software and automatic probes constitute a very promising work in progress. They will make a dramatic change in our workload. The radiologist will be released of performing the exam, to review the images in the workstation. Sonoelastography has evolved from the manual to the actual automatic shearwave. This system measures the transversal transmission of sound in biologic tissues. It is a new and promising technology, probably more objective and non-operator dependant, that is able to differentiate benign from malignant conditions. All of these systems will be reviewed and evaluated for its actual situation. The problem now is how to introduce new terms, new descriptors, and new technologies in the BI-RADS system, once clinical evidence is demonstrated. Diffusion-weighted MRI (DWI) is a promising technique in oncology. It can be used for in vivo quantification of the combined effects of capillary perfusion and diffusion. Using echoplanar imaging (EPI), DWI is possible with fast imaging times minimising the effect of gross physiologic motion from respiration and cardiac movement.

In this lecture, we will discuss the acquisition, post-processing and quantification methods and results of DWI in abdominal and pelvis tumours. We will also review the mechanisms associated with diffusion changes in tumours. MRI-pathologic correlation will be shown. Finally, limitations and future directions of the technique will be reviewed. Diagnostic potentials -as well as limitations -associated with morphological cross-sectional imaging on the one hand and functional imaging on the other are increasingly well understood. It has become obvious that in many cases both kinds of imaging complement one another. Hence, hybrid PET/CT imaging must be considered one of the most promising new developments in medical imaging. However, some questions have to be raised and challenges have to be met to avoid overrating PET/CT in oncology. PET/CT with [18 F]-2-fluoro-2-deoxy-D-glucose (FDG) as a radioactive tracer has been reported to be more accurate than either imaging modality alone and sometimes even more accurate than CT and PET read side by side. However, the clinically important question should rather be the following: Does this higher accuracy have an impact on patient management? Furthermore, some tumours do not have an increased glucose metabolism making them FDG-PET negative. The most recently launched line of PET/CT scanners combines high-definition PET with high-end multislice CT. These imaging systems not only provide a higher diagnostic accuracy based on detection of smaller lesions with CT and PET, but also offer integration of complex CT protocols into the PET/CT scan. These protocols include CT perfusion, three-dimensional CT image reconstruction or virtual fly-through. The aim of this talk is to give an overview concerning PET/CT in oncology. The mechanism of radionuclide uptake, different tracers, the indications of PET/CT in oncology and its accuracy will be addressed. Learning Objectives: 1. To understand why uptake of the tracer provides information on the viability of solid tumours. 2. To learn whether PET/CT is able to give reliable quantitative information. 3 . To know whether PET/CT is a valuable tool for tumour response to treatment.

to gain additional functional information. Functional imaging techniques such as diffusion tensor imaging and tractography as well as fMRI are increasingly used and relied on in clinical practice. With diffusion tensor imaging and tractography the location, course and integrity of the major white matter tracts can be depicted, while with fMRI the brain's cortical function is visualised. Despite major technical advances, these techniques are still time consuming, labour intensive and have several limitations. They therefore need to be used and interpreted with care. The purpose of this lecture is to review the functional anatomy of the brain in a clinically relevant context and to illustrate when additional functional imaging techniques may be indicated. The most important eloquent brain areas are addressed and include the motor, visual and language systems. Routine clinical cardiac MRI requires speed and efficiency as a result of physical motion. Consequently, the challenges and benefits of rapid MRI are nowhere more apparent than in the field of cardiovascular MR imaging. To meet these challenges, one must balance the competing constraints of signal-to-noise ratio (SNR), contrastto-noise ratio (CNR), spatial resolution, temporal resolution, scan time, and image quality. One of the main determinants of SNR is the static magnetic field strength. Hence, cardiovascular MRI at 3.0 T or more holds the promise to overcome some of the SNR limitations and to extend the capabilities of cardiac MRI. All studies in cardiac MRI at higher field strength have proven the feasibility of cardiac MRI for the comprehensive assessment of cardiac morphology and function. The studies demonstrated a significant SNR increase, but also outlined image-quality problems associated with B 1 -field inhomogeneities and specific absorption rate (SAR) constraints. With regard to acquisition speed, parallel imaging MRI capabilities form an important enabling factor, especially if enough SNR is available. Therefore, the combination of higher field strength and parallel imaging strategies may help to overcome several of the present limitations in cardiac MRI like cardiac perfusion and coronary artery imaging. The present indications, advantages and limitations of cardiac MRI at 3.0 T will be discussed. The risks associated with the exposure of ionising radiation has raised increasing concerns in the radiological community. The recent years have shown an overall increase in the use of CT for the imaging of the heart and the coronary arteries. The downside of this increased use of cardiac CT is the increase in the collective radiation dose with cardiac CT which have been reported to be associated with an effective radiation dose of 20 mSv or more. Increased awareness of the radiation dose with cardiac CT led to the development of several effective radiation dose reduction strategies including prospective ECG gating technique, anatomy and ECG-based tube current modulation, high pitch acquisition, and adaptation of the CT scanning parameters to the body habitus. However, the dose reduction strategies should be selected carefully on an individual patient basis in order to avoid serious image quality impairment by noise and artefacts. The lecture outlines the different radiation dose saving techniques currently used in clinical practice, The anatomy of the brain is often perceived as being complicated. Especially the cortex is seen as an irregular arrangement of variable structures, which are difficult to differentiate and to identify. We will review the overall subdivision of the brain into lobes and describe their boundaries and their major gyri and sulci. We will then describe the location of specific functions. 1. Primary sensorimotor cortex: motor is located in the precentral gyrus, sensory in the postcentral gyrus around the central sulcus (CS), hence the importance of always correctly identifying the CS. We will present 4 interlocked methods to identify the CS in the axial plane (a) knob, (b) lateral axial, (c) medial axial, (d) gyral/cortical thickness and 3 to identify it in the sagittal plane (a) lateral sagittal, (b) hook, (c) medial sagittal. 2. Primary auditory cortex (A1): centred at the postero-medial part of Heschl's gyrus (HG), we will present simple landmarks in each of the 3 planes: (a) axial: adhaesio interthalamica, (b) sagittal: omega/heart shape of HG, (c) coronal: omega shape of HG. 3 . Primary visual cortex (V1): Centred on the calcarine sulcus, we will discuss the characteristic shape that allows the identification of this structure in all 3 planes. At the end of this lecture, you will know the subdivision of the cortex; the methods and landmarks necessary to identify the primary sensorimotor, speech, auditory, and visual areas. Magnetic resonance imaging (MRI) has undergone a rapid development in the last decade with numerous new techniques. Nevertheless, pattern recognition of brain lesions based on signal intensities on conventional MR sequences (T1-and T2-weighted, FLAIR) is the first step in diagnostic "work up". Good examples for pattern recognition are lesions with T1-shortening ("bright" on T1WI) such as: fat containing lesions (lipoma), melanoma, lesions with colloid content, calcifications, and haemorrhagic metastatic lesions. T2-shortening ("dark" on T2WI) in enhancing lesions is suggestive of lymphoma and certain infections (tuberculosis, fungal abscesses). Flow void (absence of signal) reflects high velocity flowing blood or CSF, and will help in diagnosing vessel abnormalities and related pathologies. The purpose of this lecture is to refresh knowledge on patterns and normal variants useful for clinical practice. A simplified "pipeline" consisting of easy consecutive steps will be introduced. Learning Objectives: 1. To learn important normal variants of different structures and lesions in the brain. 2. To learn about recognition patterns that might be helpful in suggesting the most likely etiology of common brain lesions. 3. To consolidate the key imaging findings in different types of lesions and normal variants.

A-051 17:00 C. Clinical symptoms correlated to brain anatomy M. Smits; Rotterdam/NL (marion.smits@erasmusmc.nl)

Diagnostic neuro-imaging heavily depends on a thorough understanding of brain anatomy in relation to the brain's function. Clinical neurological symptoms and deficits not only give us an indication of the brain area(s) involved but may also direct us towards the use of specific imaging techniques, such as diffusion tensor imaging and tractography, as well as functional magnetic resonance imaging (fMRI). Specific imaging findings, on the other hand, may direct clinical management in a neurologically intact patient, such as the decision to resect a brain tumour in or near an eloquent brain area. Again, specific imaging techniques may be used Evaluation of response to treatment allows an early assessment of tumour response typically after 2-4 cycles of chemotherapy. This evaluation is most commonly performed with PET/CT during therapy for high grade non-Hodgkin's lymphoma. This review presentation looks at the potential roles that CT, regional MRI and whole body MRI do and could play in response evaluation from a radiology perspective. The presenter is a radiologist who is clinical director of a medium volume PET/ CT centre. The talk focuses on discrepancies between CT and PET findings in tumour response and on tumours or situations where CT is the primary modality to determine tumour response. Potential roles for whole body MRI in response evaluation and assessment of solid tumours by MRI are examined. At a general level, the role of the radiologist as part of the multidisciplinary oncology meeting (MDM), including when and where to use image-guided biopsy in response evaluation and the use of RECIST versus PRECIST criteria is discussed. The aim of the presentation is to outline the role of CT in tumour response evaluation in the era of PET/CT and to explore potential roles particularly for whole body MRI in tumour assessment. The presenter hopes to encourage radiologists to get fully involved in MDM discussions regarding CT, MRI and PET/CT evaluation. Learning Objectives: 1. To learn the standard method (tumour measurements) for the evaluation of tumour response to treatment. 2. To understand the limits of international standard. 3. To become familiar with methods that provide functional or structural information, like perfusion CTMR or DW-MRI.

Evaluation of tumour response to therapy: the role of nuclear medicine A. Chiti; Milan/IT (arturo.chiti@humanitas.it)

The high costs and possible side effects of chemotherapy and radiation therapy treatments favour the use of effective ways to monitor the treatment efficacy in oncology. Molecular imaging demonstrated to be effective in evaluating the response after and during the course of therapy, in order to assess chemo-sensitivity and chemo-resistance of a particular neoplasm. The use of PET-CT in this setting can vary from very sophisticated and complex quantitative evaluation to simple qualitative analyses. In malignant lymphoma, international criteria for monitoring response to therapy have recently been revised, and FDG now plays a central role in defining tumour response. In a variety of solid tumours, studies have indicated that FDG PET-CT may provide early and accurate assessment of tumour response, suggesting that it could play a significant role in personalising the treatment of malignant tumours. Performed during and after therapy for HL and aggressive NHL, FDG PET results have a high prognostic value and correlate with survival. FDG PET has been incorporated into revised response criteria for aggressive lymphomas, and several ongoing trials are under way to investigate the value of treatment adaptation based on early FDG PET results for HL and aggressive NHL. Many technical aspects must be taken in consideration to avoid critical errors in evaluating response. From patient preparation to image acquisition a series of possible pitfalls must be avoided. In the clinical practice, the most widely used parameter is the SUV, which can improve the accuracy of qualitative image assessment in many clinical settings. Learning Objectives: 1. To understand why PET-CT can be used to assess tumour viability. 2. To become familiar with the principles of signal quantification and to discuss its advantages and limits. 3 . To learn about the incoming tracers that might enhance the role of PET-CT in the evaluation of tumour response.

Alzheimer's disease: the role of radiology J. Alvarez-Linera; Madrid/ES (jalinera@ruberinternacional.es)

Neurobiological changes in Alzheimer's disease (AD) occur in an stereotypical pattern that begins in the medial temporal lobe (MTL) years before the clinical manifestation (brain reserve). Brain atrophy is a marker of neurodegeneration that reflects the neurobiological disorder and is correlated with the neuropsychological changes at all stages of the disease. Other imaging markers may reflect changes in microstructural (diffusion), functional (perfusion) or metabolic (MRS) domains that would provide additional information but are awaiting wider validation. In the early stages of AD, the most effective MRI markers are those that reveal atrophy in MTL, particularly the measures of the hippocampus. The MTL atrophy mea-the required conditions in whom they may be successfully used, and how these techniques could be implemented in the daily clinical practice. Proper linking of the data acquisition to the patients ECG is among the crucial prerequisites for successful cardiac imaging. While cardiac CT data acquisition itself does not impose any effect on the patients' ECG, inherent physical effects in the MR environment does show impact on the ECG trace and may hamper proper R-peak delineation. In addition, patient-related factors such as arrhythmia might affect image quality (IQ). Dose saving strategies in cardiac CT limit the possibilities of retrospective IQ optimisation and as such more emphasis is recommended prior to data acquisition which is mainly related to patient selection/heart rate control. In cardiac MR a high amplitude ECG without influence of magnetic or scanning effects is of outmost importance. Arrhythmia also remains a challenge that might be overcome by arrhythmia-rejection algorithms or real-time imaging. Suboptimal contrast enhancement ought to be avoided by proper planning and timing as the majority of post-processing algorithms is based on signal behaviour. In the unfortunate situation of suboptimal contrast enhancement often only the use of standard post-processing tools is possible while semi-automated tools for cardiac post-processing may fail or necessitate substantial user interaction. The use of straight forward visualisation techniques is recommended for diagnosis while complex visualisation tools may add on confidentiality but are mainly suited for case presentations. Coronary evaluation is typically performed using centerline tools allowing for the easy assessment of CAD. While these tools potentially allow for estimation of the degree of diameter and area stenosis, accuracy though may still be limited. This is the second session between ESR and EANM at each Society's Annual Congress. Few would argue but that patient's interests are best served by crossfertilisation and open communication between specialties. This is particularly true for radiology and nuclear medicine. This session elaborates on clinical scenarios where cross-fertilisation between both specialties is particularly important. The session will elaborate the radiologist and nuclear medicine perspectives on two common clinical scenarios, i.e. tumour response to therapy and evaluation of Alzheimers disease. Session Objectives: 1. To appreciate how nuclear medicine and radiology provide complementary information. 2. To learn how each method can enhance the mutual performance of the radiologist and nuclear medicine physician. 3 . To learn about recent advances in the field of tumour evaluation and early detection of Alzheimer's disease.

shown on MDCT-images in the axial, coronal, and sagittal plane. Variants of the normal anatomy, which are important to describe and to know are also shown. Some of these variants are also delineated on MR images. In the second part of the lecture, the different expressions of congenital malformations of the external and middle ear will be explained. The different findings of the severity of the malformations will be shown and their importance for further clinical-therapeutical procedures will be explained. Imaging investigation of cholesteatoma is required before surgery. If no surgery has been performed previously, CT will provide information about the location of the lesion (epi, pro, meso, retro, hypotympanum), the partial or total destruction of the ossicles, and possible extension to the inner ear. If there is no doubt about any of these factors CT is sufficient. In doubtful cases an MRI examination is performed to confirm or refute the presence of cholesteatoma using T1 sequences without IV contrast medium, and diffusion weighted imaging with or without high resolution T2, depending on the age of the patient. In postoperative recurrent cholesteatoma, MRI is becoming the modality of first choice for detecting cholesteatomas, appearing : low in signal on T1 sequences, high in signal on diffusion weighted imaging. However, care is required since performing diffusion weighted imaging without T1 may lead to false positives. A granuloma with a slightly or markedly increased T1 signal is often associated with a high signal on diffusion. Measurement of ADC is useful for detecting cholesteatomas, infected cholesteatomas or abscess. Finally whilst MRI is the first examination in the follow-up of postoperative patients, the use of contrast medium is not necessary in most of the cases. A-062 17:00 C. Implants and postoperative findings in the middle ear B. Verbist; Leiden and Nijmegen/NL Many conditions which affect the function of the middle ear may require surgical intervention. Postoperative imaging will be requested either to evaluate complete removal of diseases (eg in cholesteatoma) or because of new, persisting or recurrent complaints of the patient (e.g. vertigo after stapes replacement). In this presentation, different surgical procedures will be reviewed including the indications for a certain surgical approach as well as the different types of prosthesis. The normal postoperative imaging appearance of the most common surgical techniques will be shown. It will be discussed whether CT or MRI should be performed to answer the clinical questions. An overview of possible failures and complications will be given. The management of patients with vascular malformations is often suboptimal. The reasons for this are many but include confusion regarding classification, uncertainty about the most appropriate imaging of the various forms of malformation and a sures are helping to propose new diagnostic criteria for AD, allowing a diagnosis of probable AD in predementia stages, when memory loss criteria are attached to Imaging criteria (MRI or PET) or measures of amyloid/tau in CSF. The use of atrophy markers (global or MTL) increases the effectiveness in clinical trials (both by reducing the size of the sample and increasing the statistical power) and is therefore contributing significantly to the development of new treatments. The association of multiple markers of structural and functional imaging (MRI and PET) and the use of advanced computational analysis techniques will allow better management of AD but it needs a broader validation and know the most efficient combination of biomarkers at each stage of the disease, including the preclinical period. Scientists, researchers and clinicians all benefit from molecular imaging in dementia providing exciting new insights into their basic biology and pathophysiology. Targeting specific aspects of neurotransmission, metabolism, inflammation or plaque formation -just to mention some of the current molecular approaches -increasingly gains impact on establishing the correct diagnosis, following the course of dementia or developing CNS drugs. This talk will highlight the molecular targets and major PET and SPECT tracers for application in dementia, and will update on the results of the clinical imaging studies published in recent years. Typical imaging patterns of Alzheimer's disease (AD) will be discussed, including also the diagnostic discrimination from other types of neurodegenerative dementias such as frontotemporal dementias, Lewy body dementia, and others. Assessment of MCI patients and the probability of transition in manifest dementia (predominantly AD) will be addressed together with its prognostic relevance. Furthermore, recent advances in analysing tools which further improved the high diagnostic accuracy already reached by visual assessments will be presented. Even though in competition with other modalities, ‚standard FDG' PET has shown to be a robust and both, sensitive and specific marker in the diagnostic work-up of dementia. FDG information will be markedly extended in clinical practice by specific amyloid imaging in the near future when these tracers are approved and thus generally available.

Learning Objectives: 1. To become familiar with the nuclear medicine method that enables detection and evaluation of Alzheimer's disease. 2. To learn about the potential development of functional studies using nuclear medicine. 3. To understand how nuclear medicine and radiology can provide complementary information.

symptoms may require explanation and reassurance only. Lesions with a mainly cutaneous element may be treated with laser. Deeper lesions are usually treated with several episodes of sclerotherapy. Agents such as alcohol, polidocanol and STD will be discussed and the relative advantages and issues explained. Informed consent is vital, and the approach to this will be outlined. High flow lesions are frequently associated with severe cosmetic changes, invasion of surrounding tissues, haemorrhage, and high output cardiac failure. Lesions may be life threatening. In the extremities peripheral ischaemia and ulceration due to steal of blood by the arteriovenous malformation is common. Informed consent will again be discussed, as potential for major complications is high. Key to endovascular management of these lesions is an understanding of the nidus, arterial inflow and venous outflow. The role of liquid and solid embolic agents and specifics of transarterial, venous and direct approaches will be discussed. AVMs pose a major problem regarding classification and treatment. A case report discussed by the panellists demonstrates how these patients should be approached. The importance of establishing an interdisciplinary outpatient clinic is also presented. The most important organisational steps for providing an efficient clinical service are given. In addition, the most common pitfalls and complications of treatment are illustrated. Computer-aided detection/diagnosis (CAD) is recognised as a workstation or a system developed in order to assist the radiologists (clinicians) in performing their daily diagnostic tasks. Clinically implemented CADs are available at workstations and (if DICOM compliant) may serve as a plug-in to PACS. The three-layer CAD system includes: (1) image analysis procedures whose development requires a medical and technical knowledge, (2) a database module that is managed by experienced radiologists and IT professionals, and (3) graphical user interface (GUI) that enables a user-friendly access to the data, the processing tools, and the results. A modern CAD development involves a multidisciplinary team whose members are experts in medical and technical fields. A close collaboration of all experts is required at all stages of system life-cycle. At each stage the physicians knowledge and experience are indispensable. It includes medical analysis of the diagnostic problem, data collection, image analysis evaluation, and clinical verification. Design, testing, and evaluation have to be successful in order to ensure CAD implementation in a daily clinical routine. In this session three experts will share their experiences in the area of the overall CAD architecture, its evaluation, validation and acceptance by clinicians, advantages and restrictions of solutions and clinical implementation in lung, breast and colon cancer. Reading paradigm (primary, concurrent, second) in oncology as well as results of CAD clinical implementation will be presented. Perspectives in clinical CAD implementation in diagnosis and treatment will be discussed. Patients presenting with vascular malformations mostly are nomadic and hopeless individuals looking for help. Finally having reached a "multidisciplinary specialistgroup" after a sometimes long and misleading trip throughout the ocean of "singleplayers" of different specialities these patients do not ask for any more diagnostics -they strongly claim for therapy. Vascular malformations are congenital lesions, although merely seen at birth they become evident throughout the individuals growth. These developmental errors can affect all components of the vascular tree in any area of the body. The therapeutic goal must be defined rather as "control" than "cure" of this disease. To make this point understandable for both patients and collegues a fundamental understanding of the pathogenesis and natural course must be created. In special cases of complex vascular malformations the precise diagnosis and the information about all potential side-effects as well as risk-factors of progression enables these patients to manage their daily life. Therefore, indications for treatment vary depending on the specific type of slow flow or high flow lesion, location, pain, functional and cosmetic impairments and general side-effects of each particular lesion, since no single specialist has enough knowledge to diagnose or treat vascular anomalies beyond the border of his distinct speciality multidisciplinary working-groups emerged at these interdisciplinary interfaces. Their common language in classifying and their overall understanding of pathogenesis, prognosis offer these mostly hopeless patients a custom-fit treatment addressing their symptoms. Imaging of vascular malformations should be directed by clinical assessment of the type of malformation to be expected, clinical symptoms and need for treatment. In order to make the proper decision of the required imaging modality or treatment, it is essential that the (interventional) radiologist is a member of a dedicated vascular malformation team. Imaging needs to be tailored to the individual patient although general rules can be applied. Duplex ultrasound together with a clinical assessment is often sufficient to make a proper diagnosis. This is especially true for the paediatric population. If more information about the extent of the lesion is needed, MR is often used in case of low flow lesions (venous/lymphatic), and MRA or CTA in case of high flow lesions. Angiography is mandatory if an AVM is diagnosed and treatment is planned. High frame rate imaging and selective injections are the only options for a proper evaluation of the nidus architecture of the AVM. There are exceptions that warrant deviating from the above general rules. In this lecture, both the general rules and the exceptions will be discussed. At the onset of the 21 st century humankind is focusing its attention on a very small molecule, as controlling CO 2 in the atmosphere is becoming a major goal, economically, socially and politically. Yet, there is another small molecule which is going to play a more prominent role in the near future. H 2 O, especially in its liquid form, the 'Blue Gold', is just indispensable to our lives. Water makes 60 to 70% of the human body weight and is crucial to the working of the biological machinery. Still, how such a tiny molecule with its 105° 'magic' angle could have been at the origin of life remains largely a mystery. Different organisms have adopted different strategies in the way they get the most out of water, depending on their environment, and water contributes to the biodiversity. Faulty mechanisms in the use of water by tissues may lead to severe diseases or death. Clearly, water deserves to be seen as the prime 'biological molecule', and radiologists have long recognised its importance from the days of 'dry' (bone and air) radiology to the advent of CT which allowed contrast from 'wet' tissues to be explored. With MRI one went one step further, as magnetisation of water is the sole source of contrast. Life has led to intelligence, and recent MRI studies have suggested that water may also actively contribute to the mechanisms underlying brain function. Could the 'molecule of life' also be the 'molecule of the mind'? Clearly, water must be radiologists' best friend. Learning Objectives:

1. To comprehend how the structure of the water molecule makes it important to life. 2. To understand the importance of water in biological and cellular processes. 3. To become familiar with the different ways water is responsible for image contrast in radiology.

A. The role of CAD in modern-day imaging A. Todd-Pokropek; London/UK (A.Todd@ucl.ac.uk)

The use of CAD in medicine is an important and growing area of research. Firstly good data must be acquired including not just images but associated information. The first step in that of preprocessing, notably (but not only) noise reduction. The data are then passed onto the segmentation step. Often this step is semi-automatic requiring some manual intervention. Conventional edge detection methods are not often of value, but Active Shape and Appearance Models, the use of Markov Random Fields etc are commonly used. The next step is that of feature extraction both of shape and texture. These data are then submitted to one of several classifiers such as Artificial Neural Networks (including MTANNs) Support Vector Machines (SVM) and data reduction using Principle and Independent Component Analysis, and Multiple voting techniques such as ADABoost are also of value. The output may simply be returned to the observer (clinician) or as further input for a decision support system. Examples considered will be in breast imaging (mammography), lung nodule detection, virtual colonoscopy and lumber spine. The use of the CAD system as a simultaneous assistant or as a second reader is important. The use of CAD in therapy is of increasing important. The assessment of such CAD system (evaluation and validation) is still controversial. The difficulty of bringing systems both instrumentation and software for use in clinical practice in often underestimated and there have been some notable failures. Some example of 'failures' will be given. CT colonography has evolved rapidly and disseminated widely over the last decade. The ability to provide an accurate whole colon examination with near perfect completion rates, use of reduced laxative bowel preparations and extra-colonic organ review has attracted very considerable interest amongst the wider radiological and gastroenterological community. Inclusion of CT colonography in several core radiological training programmes confirms its evolution from super-specialist technique (performed in only a few centres) to mainstream. However, evidence supports highly variable performance, which is perhaps unsurprising given the complexity of both technique and interpretation methods -both which require specific training. Notably, attendance at a training workshop generally represents the beginning of a radiologist's experience of CT colonography. Indeed, most delegates rapidly progress from unconscious to conscious incompetence, acknowledging the need for a planned implementation strategy prior to offering CT colonography in their routine clinical practice. Thankfully a decade of intensive research and large volume clinical experience has equipped the radiological community with knowledge and experience to inform successful CT colonography implementation strategies. By combining this experience with training and accreditation practices developed for colonoscopy, the prospect of a robust quality assurance framework is realistic and necessary to reassure both service commissioners and the general public alike.

Step one: the publication of international CT colonography standards, co-authored by eminent radiologists from across Europe and beyond has been achieved. This talk will review the likely next steps. Computer-assisted detection (CAD) for CT colonography is now widely available in Europe from a number of different vendors. This presentation will detail factors that potential users will need to know in order to properly evaluate CAD systems, use them in clinical practice, and evaluate their likely impact. The different ways in which the performance of CAD systems can be assessed will be discussed and the difference between weak methodologies (e.g. internal validation) and more valid assessments (e.g. external validation) will be explained. Now that the diagnostic performance of CT colonography has been well-established, this state-of-the-art symposium will deal with issues related to the implementation CT colonography in day to day clinical practice. The lecturers will deal with the diagnostic performance of CT colonography, the technical requirements necessary to obtain high quality diagnostic data, the factors that underpin a high-quality service (including reader training), how implementation differs across different countries, and the possible impact of new developments, including computer-assisted detection (CAD). Two decades ago spiral CT technology initiated a new era in diagnostic imaging with virtual colonoscopy or CT colonography (CTC) as a major innovation. Introduced by David Vining in 1994, CTC was rapidly endorsed as a potential tool for colorectal cancer screening. After an initial pioneering period defining the basic CTC principles, the advent of multi-slice CT significantly improved spatial and temporal resolution, allowing for isotropic image reconstruction with detailed 3D rendering of the colonic wall and very short acquisition times, reducing motion artefacts. Furthermore, application and refinement of (ultra-) low dose technique almost completely tackled the issue of radiation dose. These improvements have resulted in the perfect optical colonoscopy imitator with reliable fly through of the colon in a timely manner. Consecutively, the primary 3D reading paradigm with 2D problem-solving is getting more and more adepts, although in experienced hands primary 2D-read with 3D-problem solving is a solid contender. To improve depiction of the colonic wall new 3D visualisation methods were developed. These technical improvements with the application of state-of-the-art CTC technique have resulted in a very good performance of polyp detection. In three multi-centre studies, totalising 3775 patients, sensitivity ranged between 78-91% and 90-92% and specificity between 84-93% and 84-98% for lesions > 6 mm and > 10 mm, respectively. Finally, it may be expected that further refinements of CAD, laxative-free CTC with electronic cleansing and dual energy CT will bring CTC to the next level and will enhance it as the reliable and cost-effective tool for colorectal cancer screening. Learning Objectives:

1. To review the evolution of CT colonography since its introduction, with a focus on data acquisition and methods of data visualisation and interpretation. 2. To review the currently achievable test characteristics of CTC (sensitivity, specificity, accuracy) via reference to current trial data. 3. To become familiar with imminent developments that may further enhance CTC test characteristics.

astinitis and extension of infection from adjacent spaces (neck, pharynx, pleura or retroperitoneum). Typical cases including the role of radiologic findings with respect to sensitivity and specificity, and important differential diagnosis will be discussed. The distinction between a parapneumonic pleural effusion and an empyema based on radiologic findings is often impossible. Features suggesting a "complicated" course requiring interventional or even surgical treatment at some point will be discussed. Features of empyema and lung abscess at CT will be illustrated as well as CT indices of severity of empyema and its effect on the underlying lung that allow some prediction of functional outcome after surgical decortication. An empyema necessitatis describes a chronic empyema that attempts to decompress through the chest wall. Infectious agents include tuberculosis, actinomyces, staphylococcus and various types of fungi. It has to be differentiated from other mostly neoplastic diseases that cross fascial planes such as lymphoma or Pancoast tumour. Most lymphomas arise in lymph nodes or other lymphatic tissues. Extranodal lymphomas arise in tissues normally devoid of lymphoid tissue. Involvement of so-called extranodal organs is a common finding after staging investigation, however, and a substantial part of NHL even arises in these sites. The latter form is often referred to as primary extranodal NHL. Splenic lymphoma is common in both Hodgkin disease and non-Hodgkin lymphomas but it may be difficult to detect by imaging techniques because lymphoma nodules in the spleen are often smaller than 1 cm. Splenic enlargement alone is not a good indicator of lymphomatous involvement. Primary hepatic lymphoma is rare compared with disseminated diseases at both nodal and extranodal sites. Several forms of hepatic involvement can be seen including mass lesions/nodules, diffuse infiltrative form and extrahepatic involvement of the hepatic ligament. Lymphomatous involvement of liver hilum nodes often infiltrates along the hepatic artery and portal vein toward the head of the pancreas and produces an infiltrative bulky mass that involves the liver, pancreas and duodenum. Primary pancreatic lymphoma is very rare and can be difficult to differentiate from pancreatic adenocarcinoma. Definitive pathological diagnosis of lymphomas is often obtained using image-guided biopsy. This noninvasive procedure is important as the prognosis and management of lymphomas differ greatly from that of adenocarcinoma or metastatic diseases. Staging (Ann Arbor classification or modifications) and response to therapy is primarily by CT. Community acquired pneumonia (CAP) is a major health care problem because of their high morbidity and mortality rates. Patients exposed to non-hospital risks who develop pneumonia have been traditionally categorised as having communityacquired pneumonia (CAP). Healthcare-associated pneumonia (HCAP) is a new designation for pneumonias affecting individuals residing in non-hospital health care facilities, patients undergoing outpatient procedures or therapies, and patients who have been recently discharged from the hospital setting. When the diagnosis of CAP or HCAP is suspected, imaging studies are mandatory for the evaluation of affected patients. A nosocomial pneumonia is defined as one not acquired in a hospital or a long-term care facility. It occurs most commonly among ICU patients, predominately in individuals requiring mechanical ventilation. Pulmonary infection is a major cause of morbidity and mortality in patients with impaired immune function. Increasing numbers of patients are becoming immunosuppressed, because of solid organ and hematopoietic stem cell transplantation, the use of immunosuppressive agents for treating a host of inflammatory diseases, or congenital and acquired diseases such as acquired immune deficiency syndrome (AIDS). Mildy impaired host immunity as it occurs in chronic debilitating illness, diabetes mellitus, malnutrition, alcoholism, advanced age, prolonged corticosteroid administration and chronic obstructive lung disease have also been regarded as predisposing factors of pulmonary infections. The rapid diagnosis and treatment of pulmonary infections are essential. Combination of pattern recognition with knowledge of the clinical setting is the best approach to pulmonary infectious processes. Acute mediastinitis is a potentially life threatening but fortunately rare condition that requires prompt diagnosis and treatment. Spontaneous or iatrogenic oesophageal rupture is the by far most common cause. Other causes include post-surgical medi-ask the patient for those information. At the time of MR imaging plain films and/ or results of an ultrasound exam of the shoulder, if possible, should be available. However, only such prerequisites allow to run a tailored examination protocol and to support the orthopaedic colleague with the needed answers for further adequate therapy. The patient has to be placed in the magnet in a pleasant situation to avoid artefacts due to patients movement, which usually cause motion artefacts. It is very important to explain to patients to keep quiet during the whole examination, because artefacts may need repetitions of sequences, and lead so to prolongation of total examination time. Furthermore, they make diagnosis more difficult and eventually more or less inaccurate. Lastly, sequence repetitions decrease patient throughput and therefore cost effectiveness. Imaging in three orientations (axial, paracoronalparallel to the supraspinatus tendon, and parasagittal -parallel to the glenoid cavity) using T1W (PDW) and/or T2W sequences have to be performed. In case of specific questions regarding lesions of the labrum intraarticular administration of contrast agent (MR arthrography) should be considered, which is sometimes (different from country to country) possible after discussion with referring orthopaedic surgeon only. MR imaging (MRI) and MR arthrography are the primary diagnostic imaging modalities applied to patients with degenerative, traumatic and sports-related shoulder lesions. In this categorical course the characteristic MR imaging and MR arthrographic features of articular pathologies of the shoulder, in particular, instability-associated injuries, rotator cuff tears and biceps tendon lesions are discussed. Beside lesion detection the radiological analysis comprises the understanding of the underlying pathomechanism and recognition of possible interrelations between different type of lesions (for example, secondary impingement and associated lesions of the posterosuperior labrum). The use of classification systems for specific lesions is introduced in order to improve the radiological report. A reasonable structure for written reports is discussed comprising a brief and clear description of pathological findings with subsequent interpretation and categorisation of findings with a view of therapeutic decision making. Tissue changes in the treated neck by surgery and/or radiotherapy (RT) make the detection of residual or recurrent tumour more difficult. Clinical evaluation of the neck is also hampered by these changes. Therefore, any (non-invasive) method helping in the detection of recurrence is welcome. In order to evaluate the treated neck, radiologists should be familiar with expected post-RT findings. Histological changes post-RT will be discussed in combination with imaging examples. This knowledge will enable radiologists to recognise non-expected findings post-RT. Non-expected post-RT findings can be caused either by tumour recurrence, or by complications of treatment (e.g. chondro-radionecrosis). Imaging examples will be shown. Especially after surgery, including various types of neck dissection, lymphatic drainage patterns of the head and neck are altered. It is important that radiologists are aware of these changes. Imaging examples will be shown. CT and/or MR-findings in the treated neck may be inconclusive. In these cases, there may be an additional role for metabolic (PET) imaging. At present, the position of metabolic imaging in the imaging protocol for the treated neck is unclear. Information from the recent literature will be discussed. Also, examples from daily practice will be shown, with emphasis on the importance of base-line imaging after treatment and the timing of such base-line scans. This knowledge will help in understanding the current indications and limitations of post-treatment metabolic (PET) imaging of the head and neck. An increasing number of functional and metabolic imaging options reflecting relevant aspects of tumour biology have rapidly been incorporated into clinical trials and, progressively, into clinical practice. While tumour staging according to the TNM system still rules most decisions regarding treatment choice in head and neck cancer, biological information from the tumour and its microenvironment has proven to have important predictive and prognostic value heading for a tailored and individualised patient's management. CT, MR and PET are the mainstay imaging modalities to access tumour extent, both of the primary tumour, lymphatic and distant metastases and for early depiction of recurrence during patient's follow-up. Hypoxia and angiogenesis, the major driving forces for tumour aggressiveness, long linked to chemo and irradiation treatment failure, can now be imaged both by PET (18 F-MISO or 60Cu ATSM) or MRI (BOLD and PWI, respectively). This information is being used to define biological tumour volumes, to tailor conformational and intensity modulated radiation treatments and to select patients for specific treatments such as radiosensitizers, hypoxia selective cytotoxic and antiangiogenic drugs. Overexpression/amplification of EGFR (epidermal growth factor receptor) are common genetic abnormalities in SCC linked to increased cell proliferation and worse prognosis. Imaging techniques reflecting cell proliferation/ density (18 F-FLT -desoxyfluorothymidine-and diffusion-weighted MRI) can be used to select patients for treatment with EGFR inhibitors. This special focus session will review the use of these imaging modalities both prior, during and after treatment of head and neck cancer focusing on their specific advantages and accuracies in these different settings. Contrast-enhanced CT and MRI are routinely used in order to determine the precise localisation, size and anatomic extent of the primary lesion. On the other hand, positron emission tomography (PET) is the most sensitive and specific technique for in vivo imaging of metabolic pathways and receptor-ligand interactions in the tissues. A common question is which of these techniques should be used in a particular patient. The most widely used technique is CT, as it has a number of important advantages over MRI, like wide availability, relative low cost and short examination time. However, CT also has a number of disadvantages compared to MRI: relative low soft tissue contrast resolution, severe image quality degradation by dental fillings or other metallic foreign objects, and radiation exposure. PET in combination with CT and/or MRI has a good sensitivity and specificity for the detection of primary tumour and for nodal staging as well as for detection in a single examination distant metastases, occult tumours, second synchronous tumours, and for radiotherapy planning. By combining PET with CT and MRI studies, either sequentially or synchronous performed, the diagnostic accuracy is significantly higher. In those situations, it has been proven that magnetic resonance (MR) imaging is a valuable adjunct to delineate the pathology. In non-pregnant woman the radiological evaluation is less difficult. Still, a multimodality approach may be needed in certain cases. In this lecture, radiological features of non-gynaecologic emergencies such as acute appendicitis, diverticulitis, renal calculi and pyelonephritis will be discussed. The purpose is to discuss the role of imaging and the potential of different methods applicable in childhood UTI -with a focus on US. The imaging task in UTI has changed, and new questions arouse for radiology. In addition, growing economical demands pressurise radiology to restrict imaging to those conditions where an evident benefit has been demonstrated. This efficacy-oriented approach is difficult in children due to the lack of evidence-based data. Thus, controversies exist on if, when and how to investigate childhood UTI, trying to minimise procedures and reduce burden on children and health budgets without missing important conditions that may pose a threat to the kidney. Furthermore, modern imaging with new methods, applications and potential (e.g. contrast-enhanced voiding urosonography = ce-VUS) may influence the imaging algorithm. The in utero and post-natal follow-up of foetuses with urinary tract dilatation has provided lots of information about the proper management of urinary tract malformations. Nowadays, affected neonates are evaluated following standardised charts Panel discussion:

The three musketeers were actually FOUR 09:44 CT, MR and PET: how to choose between modalities in head and neck cancer patients. An increasing number of imaging modalities reflecting functional and metabolic aspects of tumours have rapidly been incorporated into clinical practice. These modalities provide additional information on tumour vascularisation/ angiogenesis (CT and MR perfusion); on tumour metabolism, hypoxia and proliferation (PET using different radioactively labelled substances) and on tumour architecture and cellular density (DWI). Hybrid imaging, PET-CT and, in the near future PET-MR, can provide morphologic, metabolic and functional information in a one-stop-shop examination. The choice of the best modality (ies) to answer specific questions in the diagnosis, follow-up and in the prediction of response to treatment and prognosis will be addressed. Acute abdominal and pelvic pain in pregnant women may be the manifestation of various gynaecological and non-gynaecological conditions. The correct diagnosis of the causes of acute pain during pregnancy is critical to minimise maternal-foetal morbidity and mortality. Although ultrasound (US) is the primary imaging investigation in the diagnostic evaluation of the pregnant patient, the role of magnetic resonance (MR) imaging in the evaluation of foetal and maternal diseases in pregnant patients continues to expand. MR imaging offers different potential advantages in comparison to US for evaluating acute abdominal and pelvic pain; these include multiplanar imaging capabilities, a higher soft tissue contrast and the ability to detect and distinguish blood from other fluid collections. When US is equivocal or nondiagnostic, MR imaging is a valuable complement to determine the exact aetiology of acute abdominal pain. The intrinsic safety and the accuracy of MRI in diagnosing abdominal and pelvic disease make it an excellent choice for triage of pregnant patients with acute abdominal and pelvic pain. MR imaging provides important information that influences patient management, and it is important for the radiologist to recognise the MR imaging appearance of the common causes of acute abdominal and pelvic pain during pregnancy. This lecture will discuss the use of MR imaging for maternal diseases that cause acute abdominal and pelvic pain during pregnancy. Moreover, this lecture will discuss the different MR imaging techniques to use, and will show how to detect and to differentiate the gynaecologic and non-gynaecologic causes of pain during pregnancy. In this lecture, the role of imaging in the evaluation of gynaecologic emergencies will be presented. A combined approach using both clinical findings and imaging features is necessary. Accurate evaluation is important as failure to make a diagnosis may lead to serious consequences. Presenting symptoms, such as pelvic pain or vaginal bleeding or discharge, may overlap with pregnancy-related emergencies and with non-gynaecologic abdominal emergencies. The range of conditions to be considered include ovarian cyst emergencies (cyst rupture, haemorrhage or torsion), infective conditions (Bartholins' or vulval abscess, pelvic inflammatory disease or tubo-ovarian abcess) and acute bleeding (from inflammation, neoplasm, or trauma). Pain may be related to the menstrual cycle, as in endometriosis or ruptured corpus luteum, or may be unrelated, such as in fibroid or ovarian torsion or pelvic inflammatory disease. The imaging features of these acute abnormalities will be reviewed and discussed in the context of the differential diagnoses. The major functional imaging tools for tumour management are obtained with dynamic contrast-enhanced imaging, diffusion-weighted MR imaging, and MR elastography. These acquisitions allow understanding of tumour angiogenesis and perfusion, and tumour architecture. Dynamic contrast material-enhanced imaging allows assessment of perfusion parameters. Diffusion-weighted MR imaging provides information that reflects tissue cellularity and the integrity of cellular membranes. MR elastography evaluates the mechanical properties of tissue such as stiffness and viscosity. To date, tumour detection is mainly based on morphologic features. However, changes in perfusion parameters have been shown as early parameters of liver metastases detection in patient with colorectal carcinoma or breast carcinoma. Tumour characterisation is usually based on morphologic features. Yet, perfusion parameters have been shown to correlate with microvascular density and tumour differentiation helping tumour characterisation. Furthermore, apparent coefficient diffusion (diffusion-weighted MR imaging) and stiffness and viscosity (MR elastography) are significantly different in benign and malignant tumours. Despite these differences, these last parameters usually do not allow definitive subtyping. Functional imaging starts playing a major role in non-surgical treatment follow-up especially with targeted cancer therapy. Changes in perfusion parameters, apparent coefficient diffusion, and stiffness and viscosity are observed in responders. Interestingly, these changes appear promptly after treatment initiation. These functional variables are not included in RECIST 1.1 but might be part of response criteria in the next future. Many examples of functional imaging for tumour management will be provided. Learning Objectives: 1. To understand the potential of functional imaging in tumour detection. 2. To understand the potential of functional imaging in tumour characterisation. 3 . To learn about the future use of functional imaging in treatment planning and follow-up.

(among others, thanks to the ESUR-ESPR working group). At birth, a confirmatory ultrasound is performed in order to evaluate the type and degree of the malformation. Urinary tract dilatation are separated into mild, moderate and marked. Mild and moderate dilatation will be followed by US. Voiding cystogram and functional studies will be performed only if the dilatation is significant or persists. The prognosis is usually good. Patients with marked dilatation would be managed more "aggressively". Their work-up would be initiated as soon as diagnosed in order to diagnose cases that need therapeutic manoeuvre. For them voiding cystogram, anatomical and functional studies cannot be skipped and are important for the prognosis. Long-term follow-up are needed to prevent further damage.

Learning Objectives: 1. To learn which infants with antenatal diagnosis of urinary tract dilatation require imaging and when. 2. To become familiar with the most important differential diagnosis. 3 . To learn about the imaging strategies in these infants.

C. Renal and pararenal masses: basic rules P. Tomà; Rome/IT (paolo.toma@opbg.net)

The differential diagnosis of renal and pararenal masses firstly depends on the age of the child. Wilms tumour (nephroblastoma) is the most common abdominal tumour in 1-8 years old (80% of cases in children less than 5 years old -peak age 3.6 years). Renal non-Wilms tumours represent a significant proportion of renal tumours in children, especially in children aged less than 6 months or greater than 12 years. Neuroblastoma most commonly arises from the adrenal gland but can arise anywhere along sympathetic chain; it is the most common tumour in children under 2 years of age (90% of cases in children less than 5 years -mean age < 2 years). Adrenal adenomas and carcinomas also occur in childhood. US is the initial imaging modality to investigate an abdominal mass in children. CT or MRI is used to confirm the US findings and not uncommonly add new, valuable information. Concerning Wilms tumour there is a very diverse approach to treatment according to geographical location. This variation in therapeutic attitude has consequences for the choice of imaging modality at diagnosis. Neuroblastoma staging includes also 123I-MIBG, and laboratory investigations (bilateral bone marrow aspirates with histochemical tests and urine catecholamine level measurements). We focus on the points under discussion: revision to the staging of neuroblastoma, the problems inherent in distinguishing nephrogenic rests from Wilms tumour and the approach regarding small lung nodules in children with Wilms tumour. The principle of BI-RADS 3 imaging finding should be that of "quasi-benign" type, i.e. with a very low associated risk of malignancy (< 2%), opening the possibility of a short-term imaging follow-up as an alternative to imaging-guided needle biopsy. However, a number of issues should be regarded as relevant to radiologists and patients. 2) radiologists' differences in classification. 2. When needle biopsy is optioned, vacuum-assisted biopsy under stereotactical guidance for mammographic only findings (typically, microcalcifications) and core-biopsy for sonographic findings should be used; fine needle aspiration cytology should be avoided due to the high probability of benign lesions which need larger tissue samples. 3. When short-term follow-up (typically, 6 months) is optioned, the same technique on which the BI-RADS 3 lesions was initially detected should be used. 4. In the screening setting, short-term follow-up option is commonly not considered and the reader is forced to give a dichotomic reading (recall/not recall). 5. The choice between the two options should be clearly discussed with the patient, including the psychological cost of waiting six months to get a conclusive report, and a really informed consent should be obtained. 6. Till now, there is insufficient evidence for using tomosynthesis or MRI for evaluating mammographic or sonographic BI-RADS 3 findings. The premise behind the BI-RADS 3 classification is to identify a group of low risk lesions that can be safely placed on follow-up rather than biopsy. In practice this can be very difficult and is anachronistic to the principles of the European population screening programmes where the radiology objective is to diagnose or discharge. The panel will discuss these dilemmas. Starting in the late 1980s an American College of Radiologists task force developed the concept of guidelines to standardise mammography reporting: breast imaging reporting and data system (BI-RADS). There is evidence that over time there have been improvements in consistency of use, sensitivity, specificity and positive predictive value. However, BI-RADS 3 'probably benign; short interval follow-up recommended; less than 2% risk of malignancy' has always been the most difficult and controversial, with the highest levels of discordance between classification and recommendation, wide variation in both intra-and inter-observer agreement and a 2007 literature review demonstrating PPV for malignancy of between 0 and 8%. Management of breast disease has moved on a great deal since the 1990s. In the main driven by increasing specialisation associated with population screening programmes. Nowadays a specialist breast radiologist works with a wide variety of needle options at his hip to such an extent that the breast Multi-Disciplinary Team increasingly feels that failure to obtain a non-operative diagnosis of discrete lesions is unacceptable. In this setting, and mindful of the medico legal consequences of 'delayed diagnosis', is there still room to allow a patient to leave the one stop clinic without a definitive diagnosis? As the leaders of the diagnostic team we also have to take account of the emotional and psycho-social consequences for our patients as well as the financial costs to patient and the healthcare economy. Breast imaging reporting and data system (BI-RADS) was developed for standardising reporting and include mammography, ultrasound, and MRI. BI-RADS category 3 "probably benign finding -short-interval follow-up suggested" should have less than 2% risk of malignancy. Category 4 has been subgrouped into 4 A, 4B, and 4C, and this influence the classification of BI-RADS 3. Mammographic BI-RADS 3: three nonpalpable findings in this category include clusters of punctate microcalcifications, well-circumscribed and noncalcified solitary masses, and benign-appearing asymmetric density. Digital mammography will increase detection of amorphous microcalcifications and the number of BI-RADS 3 (or 4 A) lesions. Intramammary lymph nodes and calcified fibroadenomas are BI-RADS 2 lesions. Ultrasonographic BI-RADS 3: a most important BI-RADS 3 lesion is a solid oval mass ("tumour") with gently lobulations, circumscribed margins, and parallel orientation. Using strict criteria, the negative predictive value is approaching 99%. Two other lesions are nonpalpable "complicated cyst" and clustered microcysts. The "complex" cyst, i.e., a mass with cystic and solid components, should be classified as BI-RADS 4. MRI BI-RADS 3: there is lack of evidence which MRI findings should be categorised BI-RADS 3. Nonmass-like enhancement (NMLE) and enhancement kinetics are unique to MRI. Lesions less than 5 mm ("foci") need no assessment. A challenge is MRI-detected tumours < 10 mm as morphologic analysis is of limited value. Benign kinetic curves may justify short-term follow-up. In high-risk women, MRI-guided vacuum-assisted biopsy should be considered. In conclusion, BI-RADS 3 is justified in diagnostic settings but should be avoided or kept at a minimum in screening. 

What will be the standard machine and field of the future? L. Darrasse; Orsay/FR (luc.darrasse@u-psud.fr)

Improving the sensitivity has still been an essential issue in MRI, because the signal from nuclear spins relies on extremely weak magnetic interactions dominated by thermal fluctuation. To push the signal-to-noise ratio upward, the basic routes have been (i) to increase the field strength, (ii) to improve the signal detection with radiofrequency coils and (iii) to enhance the signal dynamically with contrast agents or alternative preparation techniques. The first route is the most obvious one, driven by the trends in analytical MR spectroscopy and small-animal MRI. Going up to or even above 7 T represents a considerable challenge, both technically and in view to renew the MR equipment market. However, this way is limited by safety issues, radiofrequency penetration concerns and susceptibility artefacts. Alternatively, improving the radiofrequency system relies on a complex electrodynamics background, where tissue conductivity and different sources of noise have to be considered. During the last half-period of MRI development, radiofrequency coil arrays have appeared as a powerful mean to improve the signalto-noise and to accelerate the spatial encoding process, even able to overcome some pitfalls with high-field MRI. Finally, the topics of an optimal field strength has always been highly controversial because the contrast mechanisms, on which the diagnostic information is mainly founded, are essentially field-dependent. Basically, the contrast mechanisms tend to be dominated, respectively, by macromolecular cross-relaxation at low field, and by susceptibility-weighted diffusion at high field. An emerging question is then to address different pathologies or organs with either general-purpose or dedicated MRI systems. Learning Objectives:

1. To learn about the possibilities of gaining a jump in signal. 2. To understand the respective strategies of field increase and coil improvements. 3. To consider the probable system in 2020.

Will new technologies allow a jump in sensitivity? J. Hennig; Freiburg/DE (Juergen.Hennig@uniklinik-freiburg.de) Imaging technologies have made breathtaking progress for several decades and in all aspects of medical imaging -MR, CT, US and PET. Amongst the current developments in MRI there are several areas which hold promise to redefine the boundaries of sensitivity. Ultrahighfield MRI with field strengths of 7 T and more starts to reveal insights into tissue microstructure so far inaccessible to MR (or any other technique). This is still under intense technological development with some key issues to resolve notably safety issues related to the high radiofrequency power. The unique contrast and resolution does hold promise for highly relevant applications such as neurodegenerative disease, small vessel disease, MS and others -although definite clinical studies for a ‚killer application' are still lacking. 13C-Hyperpolarisation of metabolites such as pyruvate, succinate, bicarbonate, etc. lead to an increase in detection sensitivity by factors of 10-100,000. Finally, the development of targeted probes is progressing extremely rapidly and for all imaging modalities. Most of this work is aimed at preclinical research, but the tremendous impact of the new insight in translational research promises to be of high impact for clinical application. Will these technologies allow a jump in sensitivity? Yes and no. Image quality, contrast and sensitivity will grow significantly. The biggest impact will, however, lie in the combination of the new possibilities with other data -imaging as well as non-imaging. A true change in paradigm will only be achieved if the current parcellated knowledge about various aspects of the disease is unified into a comprehensive picture. Learning Objectives:

1. To review the recent developments in RF-coils and gradients.

2. To learn about the new measurements technologies. 3. To envision how these new tools will allow a huge gain in sensitivity.

Will new MR contrast probes compete with PET? S. Aime; Turin/IT (silvio.aime@unito.it)

Purpose: Molecular imaging is a new science that will have a tremendous impact in the development of innovative diagnostic tools. In the first stage of its enrolment, it has relied massively on PET/SPECT and optical imaging technologies because of the superior sensitivity of their probes. In the long-term, MRI/MRS approaches may recover a central role, provided that further sensitivity improvements will be attained.

High sensitivity MRI probes have been designed and tested for molecular imaging applications. In the case of paramagnetic based systems they rely on improved design of the coordination cage as well as on the encapsulation/incorporation in proper nanocarriers. For multiple detection studies, CEST as well Hyperpolarized C-13 containing molecules have been considered. Results: As molecular imaging is the evolution of biologists' in vitro work that has revolutionized the way living cells and intact tissues were investigated, MRI multiplex-visualization of biological processes appears to be a key task for the forthcoming years for an efficient translation of such outstanding achievements. The search for frequency-encoding MRI contrast agents represented by CESTand Hyperpolarized C-13 containing molecules have opened the interesting perspective of detecting more than one agent in the same anatomical region. This task is largely precluded to nuclear probes. Moreover merging MRI and nanotechnology allows the attainment of high sensitivity systems also with the classical relaxation agents. Conclusion: Recent achievements in amplification procedures allow to tackle the intrinsic insensitivity of MRI probes to make them more competitive in the arena of molecular imaging applications. The use of imaging to monitor response to treatment has become central in the care of patients with cancer. It is crucial therefore that radiologists involved in the management of patients with cancer understand the place of imaging within the clinical context of the management of patients with cancer; that they are aware of the criteria of the accepted current criteria for assessing response and are familiar not only with new developments in imaging that act as a surrogate end-point for evaluating the success of treatment but are also aware of how imaging is used to predict the likely response early in the patient's pathway. This session will concentrate on all these aspects on the use of cancer imaging in monitoring response to treatment in patients with cancer. We are in the era of targeted cancer therapy, whether by small molecules derived from knowledge of the molecular pathogenesis of tumours, or from biological therapies emerging from our understanding of immunology and cell biology. These approaches convey new challenges for the monitoring of response. Small molecule therapeutics often stabilise tumours for significant periods without producing clear reduction of masses, and for these the assessment of surrogate endpoints takes on increasing importance. The measurement of pharmacodynamics is central to early phase trials in which confirmation of on-target effects is required to determine the biologically effective dose, and in many cases this is best done by functional imaging. Biological therapeutics such as monoclonal antibodies and cellular immunotherapy also need novel approaches for the determination of their actions in vivo, particularly as they are frequently tested in the setting of low level disease. Randomised trials are underway to assess the contribution of functional imaging, in particular CT-PET as a means to guide therapy. The emerging data suggest that there are broad variations in accuracy, both according to the disease in question and the context in which studies are performed, even before factors such as imaging quality control and standardised reporting are included. For the future, standardisation of techniques and common quality control will play a vital part in advancing our understanding in this rapidly evolving field. tas. There is regression of portions of these arches, but several remnants normally persist. Any failure in this process can result in congenital anomalies of the aorta or pulmonary vessels. These anomalies can be categorised into aortopulmonary anomalies, systemic arterial anomalies, and pulmonary artery anomalies. The aortopulmonary anomalies comprise truncus arteriosus, hemitruncus arteriosus, aorticopulmonary window, patent ductus arteriosus, and transposition of the great arteries. The systemic arterial anomalies include the anomalies of the aortic arch, of which the most common is a left aortic arch with aberrant right subclavian artery. Double aortic arch is the most common cause of a vascular ring and is characterised by left and right aortic arches arising from the ascending aorta and encircling the trachea and oesophagus. A right aortic arch can have three "subtypes": aberrant left subclavian artery, mirror image branching, or isolated subclavian artery. The first type is the most common one and is the second most common cause of vascular ring. Aortic coarctation, pseudocoarctation and interruption of the aortic arch are other systemic arterial anomalies. The most important pulmonary artery anomalies are idiopathic dilatation of the pulmonary trunk, absence or proximal interruption of a pulmonary artery, pulmonary arterial stenosis, and pulmonary sling. Cardiovascular magnetic resonance (CMR) imaging has become integrated into the assessment pathways for congenital heart disease in both paediatric and adult patients. CMR provides a powerful tool, giving anatomical and haemodynamic information that echocardiography and catheterisation alone do not provide. Extracardiac anatomy, including the great arteries, systemic and pulmonary veins, can be delineated with high spatial resolution. Vascular and valvular flow can be assessed, shunts can be quantified, and myocardial function can be measured accurately and with high reproducibility, regardless of ventricular morphology. Finally, CMR surpasses both catheterisation and echocardiography in providing high resolution, isotropic, three-dimensional (3D) datasets. This allows for reconstruction of data in any anatomical imaging plane, giving complete visualisation of complex congenital cardiac anomalies, without the use of ionising radiation. In the congenital heart disease, CMR can be justified for any patient in whom clinical or echocardiographic data are insufficient for monitoring, decision-making or surgical planning. Due to the complexity of both the anatomy and physiology of congenital heart disease, it is essential to have a systematic approach for CMR when assessing these patients. With the development of novel CT scanners, especially the Dual Source CT, novel strategies of examining congenital heart disease became possible. Especially newborns and infants younger 3 years of age are difficult to examine, since compliance cannot be expected. Also young children are especially susceptible to ionizing radiation and should be exposed as little as possible. In a first step the course will illustrate the underlying technical principle how to examine children in < 1 sec with sub mSv exposure. Also the course will teach how to avoid sedation in children of any age. In a second step the course will show how to apply contrast media in children of all ages and what strategy to use. In a third step the course will show how to appropriately choose scanning parameters for the CT scan since the size and weight varies considerable in children as there are small to date newborns with < 2 kg body weight up to adolescents with a body weight > 60 kg. Since little comprehensive data is available how to examine with an optimal compromise between sufficient image quality and unnecessary radiation overexposure the data of the Erlangen study will be presented and discussed. In a forth part typical indications for the exam are shown and how to interpret the exam. Also limits for the exams are shown. In a final step a comparison with MRI is shown which method is used for which pathology. In this session contrast-induced nephropathy and nephrogenic systemic fibrosis will be discussed. Measures to reduce the incidence these adverse effects will also be presented. The pathophysiology of CIN is complex and not well understood. Basically, a misbalance between vasodilatation and vasoconstriction takes place inside the kidney after intra-arterial or intravenous CM administration. Furthermore, increased oxygen demand of tubular cells due to increased reabsorbtion of sodium and water is a second mechanism, leading to transient medullar ischaemia. Identifying the patient at risk is the first step in prevention. Knowledge of the patient's medical record and a recent basic kidney function are mandatory. High-risk patients should receive prevention. Two major topics in CIN prevention are the questions whether iso-osmolar CM cause significantly less CIN than low-osmolar CM and whether hydration schedules with NaHCO 3 give significantly less CIN than hydration schedules with NaCl 0.9%. Currently up to 50% of all MRI examinations worldwide are performed using contrast agents, either an extracellular agent or an organ-specific agent. The extracellular MRI contrast agents are chelates that contain the paramagnetic ion gadolinium which strongly affects the relaxation properties of water protons, leading to changes in tissue contrast. Gd-DTPA was the first extracellular agent to be introduced in clinical practice. Since the introduction of Gd-DTPA in 1988, various gadolinium chelates with different chemical properties became available for clinical use. For many years, it was believed that gadolinium-based contrast agents (GBCA)

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Principles in the use of conventional/anatomic imaging for response assessment L. Schwartz; New York, NY/US (lschwartz@columbia.edu)

The standard way to assess a patient's response to chemotherapy is to use computed tomography (CT) to measure tumour size using uni-dimensional (RECIST) or bi-dimensional (WHO) criteria. This methodology has changed little in the past 30 years despite the emergence of new therapies and advances in imaging technology. Measuring the changes in the size of tumours in one or two dimensions does not always capture the effects of novel therapies on primary tumours and metastases. Radiographic changes in the size of tumours treated, for instance, with epidermal growth factor receptor tyrosine kinase inhibitors such as gefitinib or erlotinib or inhibitors of angiogenesis such as bevacizumab do not necessarily occur at the same magnitude or speed as observed in those individuals treated with standard cytotoxic therapies. With these newer agents, tumours respond by undergoing cystic change, central necrosis, and density changes that may not be captured by conventional measurements of the largest lesion diameter.

Learning Objectives: 1. To understand and appreciate the use of conventional/anatomic imaging for response assessment in clinical practice as well as in clinical trials. 2. To understand general and disease-specific challenges associated with response assessment at imaging. 3. To recognise potential improvement in imaging and image post-processing for response assessment.

PET in monitoring response W. Weber; Freiburg/DE PET imaging and specifically PET/CT with the glucose analogue fluorodeoxyglucose (FDG) has been evaluated in a significant number of studies to monitor tumour response in patients undergoing chemotherapy, radiotherapy or targeted therapies. The clinical value of for differentiation of residual or recurrent viable tumour and therapy-induced fibrosis or scar tissue has been established for malignant lymphomas and various solid tumours. Furthermore, there are now several reports suggesting that quantitative assessment of therapy-induced changes in tumour FDG-uptake may allow prediction of tumour response to chemotherapy and targeted drugs very early in the course of therapy. In non-responding patients treatment may be adjusted according to the individual phenotype of the tumour tissue. Current studies investigate whether FDG-PET can be used to "personalise" treatment and to reduce the side effects and costs of ineffective therapy. In addition to FDG, several other imaging probes are in clinical studies to monitor tumour response to therapy. These include among others [ 18 F]fluorothymidine (FLT) for imaging of cellular proliferation, [ 18 F]fluoromisonidazole for assessment of tumour hypoxia and radio-labelled RGD-peptides for angiogenesis imaging. Preclinical and early clinical trials with these imaging probes are encouraging, but need to be confirmed in larger clinical trials. Learning Objectives: 1. To understand how image acquisition and reconstruction influence visual and quantitative analysis of PET studies. 2. To describe current criteria for assessing tumour response in lymphoma and solid tumours and recognise the limitations of these criteria. 3. To understand how differences between scanner models can influence response assessment by PET.

Panel discussion: Why does the radiologist need to understand the importance of monitoring response and how it is done? 09:45

Monitoring the response to treatment has become a critical part of the management of patients with cancer. The markedly improved diagnostic performance of crosssectional imaging in delineating the extent of malignancy has meant that imaging has become increasingly important as a surrogate end-point. These two factors have resulted in an increasing need for a standardisation of the criteria of response both in therapeutic trials and in clinical practice. It is vital that all radiologists imaging patients with cancer are familiar with the limitations, pitfalls and strengths of these changing criteria and also are aware of the possibility of using imaging to evaluate the changing molecular make-up of the cancer. stent-grafts is steadily increasing. Therefore, knowledge of this treatment option is fundamental to provide basis for procedure planning and a meaningful radiological reporting. Imaging plays a crucial role in the assessment of patients with aortic aneurysms. Eligibility for endovascular treatment depends very much on detailed anatomical knowledge of the aorta, its branches and vascular access through the iliac arteries. We will review the role of imaging modalities: US, CT, MR for detection and evaluation of anatomy of thoracic and abdominal aneurysms. The strength and weakness of each modality will be reviewed and inclusion criteria for endovascular aortic aneurysm repair will be presented. The precise sizing of the stentgraft obtained from the images is certainly one of the most critical points of the endovascular procedure and a condition of its success. Although it is a minimally invasive treatment it is associated with complications. There is a strong need for general radiologists to know about the most prevalent normal and abnormal findings of the post-treatment aorta. The session will end with discussion addressing the central role of imaging in pre-and post-treatment evaluation of the patients with aortic aneurysms. Indications for and experience with placement of endovascular stent grafts in the thoracic aorta are still evolving. Recent advances in imaging technologies have drastically boosted the role of pre-procedural imaging. The accepted diagnostic gold standard, digital subtraction angiography, is now being challenged by the state-ofthe-art computed tomography angiography (CTA), magnetic resonance angiography (MRA) and trans-oesophageal echocardiography (TEE). Among these, technological advancements of multidetector computed tomography (MDCT) have propelled it to being the default modality used, optimising the balance between spatial and temporal resolutions and invasiveness. MDCT angiography allows the comprehensive evaluation of thoracic lesions in terms of morphological features and extent, presence of thrombus, relationship with adjacent structures and branches as well as signs of impending or acute rupture, and is routinely used in these settings. In this presentation, we review the current state-of-the-art radiological imaging for thoracic endovascular aneurysm repair (TEVAR), especially focusing on the role of MDCT angiography. After analysing the technical aspects for optimised imaging protocols for thoracic aortic diseases, we will discuss pre-procedural determinants of candidacy, and how to formulate interventional plans based on cross-sectional imaging. The purpose is to present the essential principles of endovascular repair of abdominal aortic aneurysms (EVAR). Abdominal aortic aneurysms (AAA) larger than 5.5 cm should be treated. Inclusion criteria for EVAR include satisfactory aneurysm neck morphology and suitable access vessels. Preprocedural imaging involves CTA from the diaphragm to the femoral arteries. Several devices may be used to cover a wide range of anatomy. EVAR procedures are generally performed as combined procedures by teams of vasculr surgeons and interventional radiologists. Patients are followed up indefinitely by CTA (or ultrasound) and plain radiography. The periprocedural mortality is three times lower compared with surgery. Late mortality rates are similar between surgery and EVAR. Quality of life issues favour EVAR in the short and medium term. Early published series reported high complication and reintervention rates for EVAR, although these have reduced with increased experience and improved device technology. Gene-reporter imaging has been used to monitor cell-based therapies in neurology. One of the most promising applications of molecular imaging principles is the targeting of amyloid deposition in the patients with Alzheimer's disease. It is hoped that early diagnosis of the neurodegeneration may lead to better therapies. The advent of hybrid-imaging will be associated with the need for multimodal contrast agents exploiting the imaging characteristics of the involved instrumentation for more differentiated visualisation of structure, physiology, and biology. Learning Objectives: 1. To understand the working mechanism and radiation of current clinical tracers. 2. To become familiar with the potential clinical indications and applications. 3 . To learn about potential new tracers.

Panel discussion: What specific precautions are mandatory in order to guarantee contrast media safety to patients and healthcare professionals? 09:44 Current contrast agents are safer than previous products. However there are still safety aspects to consider, including patient's kidney function, thyroid metabolism, allergy, radiation exposure, or specific medical history, and there is no such thing as total or complete safety. While these simple precautions may appear obsolete in the era of sophisticated technical approaches, these issues are still quite complex and crucial in maintaining a high safety level. The discussion will give guidelines and tips for achieving a high level of safety when using contrast agents.

Room Q

The ABC of EVAR Magnetic resonance imaging (MRI) is the best tool to explore white matter disorders (WMD), including the most common demyelinating disease: multiple sclerosis (MS). The formation of demyelinating lesions is related to an "inflammatory attack". New techniques as diffusion tensor imaging (DTI), perfusion weighted imaging and USPIO enhancing can explore earlier and more specifically lesions formation. Acute demyelinating lesions may resolve (remyelination) or persist as "chronic black holes". Chronic demyelinating lesions lead to axonal injury and Wallerian degeneration. A diffuse neurodegenerative process leading to cerebral atrophy is actually a major landmark in MS. Conventional MRI sequences allows visualisation of white matter lesions (seen as hyper T2/FLAIR lesions, low signal T1 lesions and possible gadolinium contrast enhancement), presently the basis of MS diagnosis. MS follow-up is usually clinic but imaging could provide prognosis and therapeutic parameters ("surrogate markers") even if disease progression and axonal loss are independent from "lesion load". MR spectroscopy, DTI or magnetization transfer imaging (MTI) provide measurement of diffuse tissue damage in clinical research, and may correlate to disease progression, as well as brain volume measurement. After exclusion of alternative diagnosis (MRI "red flags" as other WMD), MRI lesions dissemination in space and time criteria are the main points in MS diagnosis. The widely used revised McDonald criteria may be replaced by more simple and efficient MAGNIMS criteria. Such criteria could allow starting "modifying disease treatments" as soon as the first "clinical isolated syndrome". Since blood oxygenation level-dependent (BOLD) signal changes have been observed using MRI and modulated using neuronal stimuli, functional MRI (fMRI) has quickly become the most popular non-invasive functional neuroimaging technique in clinical practice and cognitive neuroscience. Indeed, high-field MR scanners and BOLD-sensitive sequences are now widely accessible in both clinical and research settings. BOLD signal that relies on deoxyhaemoglin concentration is detectable without injection of external contrast media. The colourful activation maps combined with three-dimensional brain anatomy may have also made this imaging method as much attractive as controversial. Numerous applications of fMRI have been suggested in medicine. After a 15-year long history in clinical practice and thousands of scientific papers even in prestigious journals, the role of fMRI remains mostly dedicated to map eloquent cortex before a neurosurgical procedure. In fact, BOLD fMRI is challenging because the relationship between the neuronal response to a stimulus and the activation blobs relies on neurovascular coupling, haemodynamic response, MR signal detection, and complex time-series analyses. Besides an obvious and partially elucidated complexity, and several concerns on the interpretation of experimental paradigms in cognitive neuroscience, fMRI is based on a robust physiological and physical framework. BOLD signal is reproducible across subjects and MR scanners. fMRI requires a rigorous methodology to acquire and analyse data, an advanced knowledge in sulcogyral and functional neuroanatomy to estimate spatial displacement and reorganisation in patient with focal lesion, and a solid experience in BOLD imaging to distinguish artefacts and potential confounds from appropriate results. Learning Objectives:

1. To know the key points of quality in fMRI. 2. To know the main pitfalls in fMRI interpretation. 3 . To learn more about advances in fMRI of brain perfusion.

A-120 09:21

The role of imaging in follow-up K.A. Hausegger; Klagenfurt/AT (klaus.hausegger@lkh-klu.at)

The goal of surveillance after EVAR is to prevent late rupture eurysm. High pressure ELs (type I and type III EL) are risk factors for late rupture therefore have to be treated. Type-II, IV and type V (endotension) ELs are low pressure ELs with a low rupture risk. Thus, it is essential not only to detect ELs but also to classify ELs correctly. Until recently stent graft surveillance has been performed with contrast enhanced multislice CT (MSCT), typically 1, 3, 6 and 12 months after EVAR and thereafter in yearly intervals. However, although MSCT proved to be a very effective in FU cumulative radiation exposure, repetitive contrast medium load and increasing work load have to be seen critically. Therefore, alternative surveillance protocols especially including ultrasound have been evaluated. Several studies have shown that a risk-adjusted follow-up regime might be most efficient. Patients with low risk of aneurysm-related mortality after EVAR have a normal 1-and 6-month MSCT scan and sack shrinkage at 12 months. In these patients regular contrast enhanced US in yearly intervals have been proven to be safe for further FU. A one yearly non-enhanced low-dose CT or a plain film may be recommended to detect distortion or migration of the stent-graft. Patients with a persistent type II EL after one year need to be followed more closely and imaging modality is chosen depending on the character of the EL. In most cases EL classification can be made correctly by MSCT or US; however, sometimes DSA may be needed. Panel discussion:

The key role of imaging in endovascular aortic aneurysm repair 09:44

Many patients with aortic aneurysms are currently treated endovascularly. Therefore the number of patients imaged pre and post-procedurally is increasing. Radiologists evaluating aortic aneurysms with different modalities should know the key imaging features to look for in pre-treatment as well as follow-up examinations.

J.-P. Pruvo; Lille/FR (jppruvo@chru-lille.fr)

Neuroimaging is one of the fields of radiology with the most exciting recent advances. Moreover, these advances show dramatically important clinical applications. Some are useful for the specialised neuroradiologist, but most are critical for the general radiologist as well. In this session, we will try to address some of the most relevant issues: white matter disorders are common diseases. Expertise of the radiologist is important in detecting the disease, and in the evaluation of the activity after treatment. With this respect, standardisation of criteria is desirable for appropriate medical decisions. Functional Imaging is a fascinating insight into the human brain. It opens new horizons and has found many applications in the evaluation of psychiatric diseases, and in the planning before treatment of brain lesions, among other potential applications. Although it is obvious that we ignore much more than we know, this field is already one of the most exciting topics in neuroradiology. Although these methods are still in the field of specialists, everybody should be aware of the possibilities of functional imaging of the brain and its recent developments. Stroke is by excellence a clinically relevant problem. Because it is an emergency situation, time really matters, and we have more than one imaging tool to explore these patients, it is mandatory to provide strong recommendations and guidelines for the radiologist, in accordance with the clinical situation and with the treatment options. At the end of this session, the attendees will be aware of important advances in the domain of neuroradiology, and will take home very important landmarks for their own clinical practice. Jaundice is rare in children but imaging has a major role to establish the cause which differs according to age. In the neonatal period the leading cause is biliary atresia (BA) which consists of the obliteration of the extrahaepatic bile duct (BD) without dilatation of intrahaepatic BD and requires urgent surgical treatment to reduce the need for liver transplantation. BA must be considered when there are persistent white acholic stools and firm hepatomegaly. US shows the absence of dilated BD and in a few cases a cyst at the porta hepatis or findings of the splenic malformation syndrome, but often it is not conclusive. MRCP has not yet proved to be reliable for the diagnosis of BA. Other neonatal cholestases include medical intrahepatic causes which can be identified by biological tests or histological findings and rare causes of extrahepatic obstruction with dilated BD such as lithiasis, choledochal cyst or spontaneous perforation of BD. In childhood, US easily identifies all causes of extrahepatic obstruction by showing dilated BD; the main causes include choledochal cyst (the most frequent congenital malformation, defined by an abnormally long common bilio-pancreatic channel), cholelithiasis, tumoural compression, sclerosing cholangitis, portal vein obstruction, postsurgical or posttraumatic stenosis… In all these cases, in our experience, MRCP has become the modality of choice and has replaced invasive procedures which are nowadays reserved for treatment. MDCT may be useful in rare instances, for example, to differentiate calculi and aerobilia after surgery. Imaging protocols and illustrative cases will be presented. Neonatal bowel obstruction generally presents within hours of birth. The diagnosis of bowel obstruction is clinical but imaging is vital to determine the cause. The plain radiograph will distinguish upper from lower intestinal obstruction. The radiograph alone is diagnostic in duodenal atresia and jejunal atresia and the baby may be taken directly to surgery. If the radiograph shows multiple dilated loops of bowel, more than 4 loops, then the obstruction is distal ileal or colonic. The radiograph may give some clues as to the possible cause, such as a large fluid level in the dilated loop proximal to an atresia. Contrast enema, usually with low osmolar water soluble contrast, is used in most cases, however, to determine the cause of lower intestinal obstruction because the management of this is different for different causes of obstruction. Meconium ileus and ileal atresia are the commonest ileal causes of obstruction and Hirschprung's disease and meconium plug syndrome are the commonest colonic causes of obstruction. Colonic atresia is rare and imperforate anus is a clinical diagnosis. Radiologically guided reduction is used to treat meconium ileus. Intestinal obstruction in the older neonate may be due to volvulous, pyloric stenosis, duodenal stenosis or omphalomesenteric band. In the baby born prematurely, obstruction may be caused by stricture secondary to necrotising enterocolitis. Radiographs and contrast studies are also used to evaluate these conditions. Learning Objectives:

1. To learn about the most common causes of neonatal obstruction. 2. To understand the role of plain radiography in establishing the diagnosis. 3. To know when upper and lower GI contrast studies are indicated and the contrast medium used.

Stroke around the clock: will the challenger (CT perfusion) beat the champion (diffusion MRI)?

In patients admitted for a suspected stroke, time management is the most important criterion for therapeutic decisions. Less than four hours and a half, all patients admitted in emergency for an acute neurological deficit without impairment of consciousness (NIH < 25) and presented with a brain ischaemia of less than one third of the territory of the middle cerebral artery should receive IV thrombolysis. Brain imaging must exclude bleeding and quantify the extent of ischaemic damages. Between 4.5 and 6 hours after onset of symptoms, intravenous thrombolysis and/ or intraarterial mechanical or chemical thrombolysis may be indicated in selected cases. The assessment of ischaemic penumbra and vessel permeability is particularly important for the therapeutic decision. This may be evaluated either by MRI or CT. MRI is the technique of choice that should be used whenever possible because of the absence of irradiation and iodine-related side effects, the optimal anatomical coverage, the detection of lacunar infarct and its sensitivity for evaluating ischaemic brain damages of the posterior fossa. Imaging protocol should include FLAIR (fluid attenuated inversion recovery), T2*, diffusion/perfusion and MR angiographic sequences. In case of unstable patient or if MRI is not available, a non-contrast CT scan must be performed and completed by perfusion CT and CT angiography. The main advantages of this technique are the short time of data acquisition and the absolute quantification of perfusion due to the linear relation between attenuation and concentration. Pneumonia is a common cause of attendance to hospital. Chest infections in children are usually viral and self limiting, but sometimes chest infections can be prolonged or repeated. There are many underlying causes for this, for example, congenital anatomical causes, underlying patient susceptibility, inhaled foreign bodies and unusual organisms. One of the more common causes seen in hospital is when pneumonia has become complicated by empyema. Very rarely other conditions such as Kawasaki's disease or tumours can masquerade as pneumonia. This session will review these conditions together with the benefits and limitations of plain radiography. It will also consider times when other imaging modalities such as CT and ultrasound can help to guide diagnosis and treatment. In children, congenital heart disease (CHD) is more frequent than acquired heart disease. Diagnosis and subsequent management of patients with CHD relies heavily on different and often multiple complementary imaging modalities. Serial assessment of the morphology and function of the heart and thoracic vessels is needed at various stages of care. Although chest radiography is frequently used for monitoring the cardiorespiratory status and complications that may arise during clinical care or intervention, it rarely provides a complete diagnosis. Echocardiography, as first line imaging modality, often provides all information required for diagnosis and follow-up, especially in small children with good acoustic windows. Contrastenhanced computed tomography (CT) and magnetic resonance (MR) imaging are valuable for detailed three-dimensional evaluation of the extracardiac vasculature and cardiac anatomy. In addition to being radiation free, MR has the advantage to provide both morphologic and functional information with the use of different techniques including ECG gated gradient-echo cine imaging, gadolinium-enhanced angiography and velocity-encoded phase-contrast imaging. A comprehensive MR evaluation including quantitative measurements of ventricular volumes and function as well as blood flow in vessels and across valves can give important information on long-term sequelae of the underlying cardiac defect, the significance of residual lesions, and potential complications of surgery. It is also valuable for planning and timing of future interventions. Today, CT and MR have become the next line of investigation when echocardiography does not provide sufficient information, while catheter angiography is reserved for the assessment of coronary arteries, measurements of pulmonary vascular resistance and interventional procedures. Over the past years, diagnostic imaging has witnessed a veritable explosion in the modalities available for studying patients. When applied to the study of the thorax, they contribute to earlier detection of abnormalities and greater diagnostic accuracy. Yet, the conventional radiographic examination of the chest continues to be the most commonly performed imaging study and, when properly interpreted, continues to demonstrate a wealth of information. For a correct interpretation of the chest radiograph, several premises should be met by the radiologist: a proper knowledge of the anatomy and semiology of the thorax, stressing the need for a lateral projection, understand the importance of reviewing previous studies and try to avoid unnecessary cross-sectional studies. This lecture will address the radiological approach to imaging children of all age groups presenting with cough. This is a common symptom with very diverse causes, from acute viral infection to complex vascular and intrinsic congenital tracheal anomalies and can be the presenting symptom of acute (rapidly fatal if not managed adequately) and chronic effects of foreign body aspiration. The various causes of cough vary with age and whether cough is acute, sub-acute or chronic. This has effects on radiological investigations deployed, and thence on subsequent clinical management. We will present a pragmatic approach to radiological investigations in this diverse set of patients, using simple algorithms and illustrate the more important (and often rarer) causes of cough with discussion around deployment of examinations that are fit for purpose using ALARA principles. Guidance on imaging algorithms and CT technique will be given to children with this important presenting symptom of myriad diverse pathological processes. The attendee will learn the value and optimal use of imaging with tips on optimising CT technique as fit for purpose. Learning Objectives:

1. To learn about the differential diagnoses in the very young child and in older children. 2. To learn which imaging modalities best help to determine the final diagnosis in the various age groups. 3. To understand radiation protection requirements in chest CT examinations.

Clinical examples of dual energy CT L.S. Guimarães; Viseu/PT (luis.s.guimaraes@gmail.com) Dual energy (DE) computed tomography (CT) allows the discrimination of different materials, which has several clinical applications. The ability to differentiate calcium from uric acid renal stones allows the identification of patients that will benefit from drugs that alkalinise urine. A musculoskeletal application of the same technique is in tophaceous gout, where the crystals can be differentiated from bone. Postprocessing of CT angiography images can be facilitated using DE techniques to identify and remove the calcium signal. Such an approach removes both bones and calcified plaques. "Virtual non-contrast" images can be obtained by identifying and removing the iodine-containing voxels of contrast-enhanced CT images, simulating non-contrast images and potentially eliminating the need for some non-contrast acquisitions, but it should be realised that small misclassifications could result in missing tiny caliceal tip stones, for example. DECT also allows the utilisation of low energies without the prejudice of unacceptable noise. Since iodine signal is significantly higher at low energies, disease conspicuity can be improved. This is particularly beneficial in the liver (for hepatocellular carcinoma identification), in the pancreas (for visualisation of hypo-and hypervascular lesions), and in enterography (to increase the identification of hyperenhancement). The approach for displaying the enhanced iodine signal may be one of blending information from the two energies (into a single grey-scale image), or via an iodine-only view. Further validation of dual energy techniques and their limitations is needed to understand the patient populations in which such techniques can be utilised and where conclusions based on dual energy data can be trusted. CT perfusion imaging is a quantitative technique that employs rapid sequences of CT images after bolus administration of intravenous contrast material to measure a range of physiological processes related to the microvasculature of tissues. CT perfusion parameters can provide surrogates for tissue hypoxia as well as the physiological processes such as vasodilatation that represent vascular responses to hypoxia. Although the basic techniques for DCE-CT have been available for decades, more recently a range of technological advances have contributed to the greater applicability of perfusion CT in the clinical environment including wider CT detectors, shorter gantry rotation times, 'table-toggling', radiation dose reduction and software corrections for image mis-registration due to respiratory or other patient motion. Consensus guidelines are now available for the acquisition and processing of CT perfusion studies for the brain and body. To date, the main applications of CT perfusion imaging in stroke have been the confirmation of stroke diagnosis and extent, identification of penumbra and selection of patients for thrombolysis. The main applications in oncology have been in lesion characterisation, risk-stratification and assessment of treatment response. Computed tomography (CT) systems have provided three-dimensional (x, y, z) data since their clinical introduction in the 1970s. This session will address the extension of CT imaging into the fourth and fifth dimensions. The rapid acquisition capabilities of modern CT scanners open the door to the fourth dimension -time -where a time-course CT scan can provide clinical information about blood flow, perfusion and other physiological measures regarding organ function. The door to the fifth dimension -energy -is opened by dual energy image acquisition techniques, which are made possible by dual source CT scanners or rapidly switching x-ray source CT scanners. Dual energy CT images can be manipulated to provide quantitative information with regard to the elemental composition of tissues, which, in turn, can be used to differentiate between bone and iodine contrast, with many other applications possible as well. Modern CT scanners now provide multidimensional data sets characterised as I (x, y, z, t, E), and the additional information provided by these five-dimensional data sets provide genuinely useful clinical information which add to the diagnostic potential of computed tomography. X-ray computed tomography (CT) usually measures the attenuation of the patient or object cross-section in question at a fixed chosen voltage value; the result is presented as the linear attenuation coefficient µ expressed in Hounsfield units (HU). Dual energy CT (DECT) acquires data at two different mean energies and evaluates the differences in attenuation. Dual energy CT imaging has been a topic since the 1970s. The acquisition modes have changed over the years from two separate scans at different voltages to single scans with rapid kV-switching, and dual source CT operating with different voltages and pre-filtrations. These concepts will be explained in detail including future options of energy-discriminating detectors. The basic physics principles remain the same for all acquisition schemes. The two independent measurements allow separating two tissue characteristics contributing to attenuation. For example, low and high effective atomic number material densities can be determined in the so-called basis material decomposition. Arbitrary combinations such as monoenergetic or electron density and effective atomic number images can then be provided. These will be illustrated and explained by examples such as differentiation between plaque and contrast agent or virtual unenhanced abdominal organ imaging. DECT meanwhile offers quite a number of accepted clinical applications which will be covered in a separate talk. 

ous lesions (adenomas) and curable early-stage cancer, screening for CRC has high potential for reducing incidence and mortality of the disease. Nevertheless, the benefit of population-based CRC screening needs to be weighed against potential risks, psychological distress and required resources since only a minority of the population develops the disease and may thus benefit from screening. Several industrialised countries offer faecal occult blood testing as a primary screening tool, with positive test results being followed up by colonoscopy. Some countries, such as the United States and Germany, also offer colonoscopy as a primary screening tool. While the results of randomised controlled trials regarding screening colonoscopy are still outstanding, there is evidence from observational studies that support its effectiveness in population-based CRC screening. Recent evidence suggests that colonoscopy, when performed in the community setting, is more effective in protecting from neoplasms in the left colon and rectum than in the right colon. Decision-analytic models support the (cost)-effectiveness of screening colonoscopy but results vary, among others, according to compliance, (country-specific) cost estimates and screening schedules.

Learning Objectives:

1. To learn about the incidence and prevalence of colorectal cancer and its precursors in the target population of screening. 2. To understand the rationale for colorectal cancer screening. 3. To become familiar with estimated (cost) effectiveness of colorectal cancer screening when using optical colonoscopy as a primary screening tool.

Facts from the statistician (true for once?): how accurate is CT colonography

The issue of diagnostic accuracy of CTC for CRC and polyps has been debated for a long time, because of the conflicting results published in the literature. Those results led researchers to design three important studies: two large, multicenter trials testing the performance of CTC in comparison with CC in asymptomatic individuals (ACRIN and IMPACT) and one randomised, double-arm trial (SIGGAR) conducted on symptomatic patients with the aim to detect CRC. Both the ACRIN and IMPACT reported per-patient sensitivity of 90% for polyps > 10 mm and 78-84% for polyps larger than 6 mm; per-patient specificity was extremely high, over 85%, independent of lesion size. The major drawback of the ACRIN was represented by the poor positive predictive value (PPV) (23% for polyps ≥10 mm); a definitely better PPV was documented in the IMPACT trial (62% for lesions larger than 6 mm) as well as in studies obtained in high-experienced centers. However, the negative predictive value in both the ACRIN and the IMPACT was rather high, approaching 100%; this is extremely important in order to reassure negative patients about the significance of the examination. Excellent results were also obtained in the Munich Colorectal Cancer Prevention Trial, a single-center study where around 300 asymptomatic subjects underwent low-dose CTC in comparison with other screening tests (CC, sigmoidoscopy and FOBT). Despite the good results there are still some open issues: the significance of diminutive (< 6 mm) polyps, the management of intermediate (6-9 mm) lesions and the detection rate for non-polypoid, flat lesions. Colonoscopy is a very useful and important method to examine the colon. In recent years virtual colonoscopy has become a popular alternative to optical colonoscopy. Disorder of the colon includes colorectal cancer, which is one of the most common cancers worldwide and presents a threat to life since the mortality is almost 50%. Colorectal cancer screening has been shown to be an efficient method to find early forms of colorectal cancer and also to reduce mortality in this disease. In this session we will discuss the various methods used to examine the colon, how useful they are and the economy behind using them. Facts from the epidemiologist: Incidence, prevalence, rationale for screening, standard results of optical colonoscopy. Colorectal cancer (CRC) is the third most common cancer in the world, with about 1 million new cases and more than 500.000 deaths per year. Incidence of CRC strongly increases by age and is higher in men than in women. The lifetime risk differs between countries and is about 7% in the United States. Because most cases of CRC develop from removable precancer-stabilisation complex system a dual echo T2/DP sequence could be performed in a sagittal-oblique plane drawing an imaginary line which on an axial image used as reference plane, is done perpendicular to popliteous tendon. Gradient echo (GE) sequences are useful in cartilage and traumatic pathology. T2-weighted sequences understimate cartilage thickness since cortex and cartilage have the same signal. PD sequences may have the similar signal for cartilage and adjacent joint fluid, obscuring defects; fat suppression solves this. If available, acquisitions performed in orthostatism could give further information in the assessment of meniscal and patello-femural pathology. Learning Objectives:

1. To understand the influences of patient positioning, scan parameters and magnet/coil technology on image quality. 2. To learn how to optimise scan protocols to maximise patient throughput without compromising diagnostic quality. 3. To recognise how and when to modify scan protocols to answer specific clinical questions. This talk will review appearances of normal anatomic variants identified at MRI of the knee including discoid meniscus, transverse meniscal ligaments meniscal flounce, ossicles, and pseudotears. Subsequently the talk will focus on diagnostic pitfalls reflecting both imaging technique and variations in anatomy such as the effect of motion, imaging plane and anatomic variations in patella shape. MRI of the knee is one of the most frequent performed investigations, thus indicating that common abnormalities need to be familiar to the general radiologist. A simple and straightforward method of enabling assessment of clinically relevant anatomical entities is based upon a (pre)structured radiology report. Use of speech recognition facilitates implementation of pre-structured reporting in a KISS manner. Since one now is enabled to structure the report, using digital tools, terminology used should be discussed between the reporting radiology department and the clinical partners. It is mandatory that the important message, the clinical relevance of the information that radiologists put in their report, is understood by the referring clinician in the same manner as it was meant to be. We should consider the background of our referring physician, and tailor our report, both in chosen terminology as well as detailed information. When working in a centre in which both specialised orthopaedic surgeons as well as general practitioners (GPs) or sports physicians are referring for MRI, each of the three needs a tailored report, especially considering advise for secondary referral: GPs and sports physicians will need different approach, compared to medical specialists. Also, the knowledge of terminology used should be considered. The presentation focuses on common encountered pathologies, considering common abnormalities. Emphasis is given to common abnormalities, and pitfalls that should be dealt with. Some sports specific entities are discussed. Implication of clinical correlation is stressed. The presentation will include casebased clinical illustrations. Learning Objectives: 1. To review the imaging appearances of common abnormalities. 2. To understand the use of terminology to describe pathological findings. 3. To learn how to structure a radiological report to ensure clarity and brevity.

of view and the "Third Eye" colonoscope are under investigation. At the moment, however, the combination of both, exact diagnostic and sufficient therapeutic action at the same time, is the reason why optical beats virtual in this particular indication. Since its evolution CT colonography has been advocated as a safe well tolerated alternative to colonoscopy, particularly in the context of colorectal cancer screening. Notably perforation rates are lower than those of colonoscopy and cardiovascular effects are less. However, patient preference studies have produced mixed results and it is not clear if standard CTC will increase compliance with screening. Furthermore, issues over apparent inferior sensitivity for polyp detection compared to colonoscopy, need for prolonged radiologist education and radiation dose exposure have been cited as barriers to widespread implementation in a screening context. Technical developments in recent years are beginning to address these issues. Use of reduced laxative regimes supplemented with faecal tagging have shown good results with superior patient acceptability. Software developments have also speeded up dataset analysis -notably panoramic or "virtual pathology" 3D views reducing or eliminating hidden areas within the colon. Furthermore, computer-aided detection software is increasingly fit for purpose and good data show a positive effect on radiologist performance both in the research setting and day to day clinical practice. This presentation will review the data on patient preference and safety and highlight developments in those areas in which CTC holds advantages over conventional endoscopic techniques. Discussion will focus not only on colon cancer screening but also the on data supporting CTC in older symptomatic patients who are at higher risk of adverse events during colonoscopy. Learning Objectives:

1. To review the patient safety of CT colonography and conventional colonoscopy. 2. To review advanced computer techniques for maximising visualisation of the colon during CT colongraphy including 3D visualisation methods and computer aided detection. 3. To review the data on CT performance with particular emphasis on patientfriendly reduced laxative regimens. 4. To consider patient preference data. Osteoporosis, osteomalacia, hyperparathyroidism and Paget's disease have conventionally been considered the disease entities that comprise metabolic bone disease. The lecture will follow this convention and discuss the imaging characteristics that suggest osteoporosis in the elderly or anorexia nervosa in younger patients by the distribution of fractures and marrow changes as well as the role of bone mineral density evaluations in osteoporosis. Oncogenic osteomalacia will be discussed in the context of appropriate imaging for detecting the tumour and emphasise the basic biochemical abnormality that most radiologists should be familiar with that leads to the diagnosis. Radiologists most frequently encounter hyperparathyroidism in renal osteodystrophy with over a million patients worldwide kept alive by dialysis. Dialysis-induced imaging changes such as amyloid and the spectrum of findings from long-term dialysis will be shown and demonstrated. Paget's disease is on the decline. Its distinctive MRI signal characteristics in uncomplicated cases, in contrary to most bone lesions encountered in clinical practice, will be explained. Learning Objectives: 1. To get an overview of the entities that are considered in the realm of metabolic bone disease. 2. To understand common, less common and rare findings. 3 . To learn about some imaging findings that occur as a consequence of treatment. Osteoporosis is of great socioeconomic impact, as approximately 30% of all postmenopausal women have osteoporosis in developed countries. Ageing of populations worldwide will be responsible for a major increase of the incidence of osteoporosis in postmenopausal women. In 1994, the WHO Working Group defined osteoporosis according to measurements of bone mineral density (BMD) using dual energy x-ray absorptiometry (DXA) as a bone density T score at or below 2.5 standard deviations (T score) below normal peak values for young adults. The relative risk of a fracture is between 1.3 and 1.6 for each unit decline in spine or total hip T score. Due to limitations of the T-score concept a 10-year risk calculating tool has been developed by the WHO to determine intervention thresholds. Fragility fractures are, however, not only related to bone mineral density (BMD). Trabecular bone microarchitecture is a significant determinant of the bone's mechanical properties and is thus of major clinical relevance in predicting fracture risk. Trabecular bone structure analysis can be based on images from multidetector computed tomography, high-resolution peripheral computed tomography, highresolution MRI and projection radiography. Advantages and disadvantages of the different methods depend on radiation, costs, availability and a reasonable time for in vivo scanning. The purpose of this refresher course is to demonstrate bone ablation. The main aim of thermal tumour ablation is to destroy the tumour using ionic movement to kill the malignant cells without damaging adjacent vital structures. Multiple sources of energy have been used to induce cell death. RF energy is an electromagnetic one. Radio waves emanate from the non-insulated distal portion of the electrode. Heat is produced by resistive forces (i.e., ionic agitation) surrounding the electrode as the radio waves attempt to find their ground. Other type of ablations (using different wave lengths) include microwave, electoporosis, laser and radiofrequency ablation is still seeking its place among bone interventional techniques. This presentation is an overview, in an area of non-vascular interventions in the spine and the appendicular skeleton. It will explain the patient selection, indication and possible approaches to a bone lesion. Available material will be discussed, as well as possible combinations of them in order to yield maximum results, while reducing possible drawbacks. Over the last two decades, open nephron sparing surgery has become the preferred surgical alternative to nephrectomy for treatment of patients with a single, small (< 5 cm) localised renal mass and a normal contralateral kidney. Because 25-49% of newly diagnosed small renal masses are identified incidentally on crosssectional imaging, often in elderly patients, less invasive surgical nephron sparing alternatives have been advocated, including laproscopic partial nephrectomy and laproscopic cryoablation, for select tumours in an effort to reduce surgical mortality and morbidity while preserving renal function. Percutaneous image-guided ablation offers potential advantages over surgical methods including the minimally invasive nature of the procedure, less mortality and morbidity than surgery, shorter hospital stay, and quicker recovery. Local tumour control rates of up to 95% have been reported for small tumours. Central tumours and tumours greater than 3 cm in diameter are more difficult to successfully treat with local tumour progression occurring 25% of central tumours. Tumours larger than 3 cm in diameter typically require overlapping ablations and incomplete treatment can result from residual tumour at the ablation interfaces. While in some reports, local tumour progression occurred in up to 20% of tumours larger than 3 cm, in contrast, others have shown that all exophytic tumours, despite their size, can successfully be treated using multiple overlapping ablations and complete treatment may require more than one ablation session. The most clinically relevant and potentially avoidable complication is ureteral injury with resultant obstruction of the intrarenal collecting system. Percutaneous image-guided radiofrequency ablation (RFA) represents as a safe and effective minimally invasive procedure in selected patients with unresectable or medically inoperable lung malignancies. When adequately performed, in selected patients, the procedure is associated with over 95% immediate technical success rate and relatively low incidence of major (8-15%) and minor complications (20-40%). Pneumothorax represents the most frequent complication (up to 60%) but presentation, the worse the outcome in adulthood. AVN is a significant complication. CT/MR assists orthopaedic planning. Imaging strategy: plain radiographs. Small children localise pain poorly. Whole limb radiographs may be needed. US detects hip effusions but cannot differentiate pus from effusion. Nuclear medicine may need sedation for scanning phase. A full bladder may obscure the pelvis. MR is sensitive for soft tissue pathology and marrow disease included in the area imaged. Radiographs are needed before MR, which is insensitive for bone detail.

Other causes: spinal problems -discitis, avulsions of muscle origins, trauma -toddler's fracture, diffuse bone disease, localised bone disease; blind areas: spine, pelvis/sacroiliac joints. Learning Objectives:

1. To learn about the imaging approach to the child with suspected developmental hip dysplasia. 2. To become familiar with the differential diagnosis in the older child with a limp. 3. To learn which imaging modalities best help to arrive at a diagnosis. Skeletal injuries are the most common findings noted on imaging studies in cases of child abuse. In infants, certain lesions, such as the classic metaphyseal lesion and posteromedial rib fractures are sufficiently characteristic to point strongly to the diagnosis of inflicted trauma. Other fractures are less specific for abuse, but when correlated with other imaging findings and clinical information, their presence may add strong support for the diagnosis. Many of the most specific injuries produce subtle radiographic alterations, and meticulous technique, adhering to a strict imaging protocol, is vital in providing optimal detection of the fractures. In recent years, increasing attention has been given to those conditions that may simulate inflicted injury. A variety of normal variants, naturally occurring diseases and accidental injuries may be confused with the findings of child abuse. Other conditions, real or hypothetical, may be suggested by consultants in medico-legal proceedings. To be credible, a witness must be prepared to counter reckless and irresponsible testimony given by uninformed or biased medical "experts". To ensure that investigators and finders of fact are provided with testimony that is clear, concise and accurate, the radiologist must be fully informed and prepared to address the radiologic alterations and their significance to a reasonable medical certainty. Learning Objectives:

1. To learn in detail the investigation of a child with suspected non-accidental injury. 2. To learn about the typical skeletal injuries seen on plain radiography and the differential diagnosis. 3. To understand when further imaging is required and which imaging modality is best. Acute osteomyelitis and septic arthritis are diagnostic and therapeutic emergency in children. Diagnosis remains challenging because of their variable expression (acute, subacute, chronic stages, causative agents and hosts). Imaging strategy relies on a multimodality approach including radiographs and ultrasonography as first line examinations with a complementary role for bone scintigraphy and MRI. MRI is especially useful for misleading challenging presentations (such as axial skeleton, pelvis and calcaneus osteomyelitis) and for detection of reversible osteocartilaginous ischaemia requiring urgent surgical drainage. Juvenile idiopathic arthritis (JIA) is an heterogeneous group of chronic inflammatory disorders that are classified on their mode of onset (systematic, pauci and polyarticular diseases). It is a diagnosis of exclusion and imaging plays a major role in the differential diagnosis. Radiographic scoring systems of JIA are different from adult scoring systems with less emphasis on joint space narrowing. Doppler-ultrasonography and MRI play an increasing role in a the assessment of disease activity and response to treatment.

Learning Objectives:

1. To learn about the imaging approach to a child with suspected osteomyelitis and septic arthritis and to outline the classical features. 2. To learn how best to investigate a child with suspected arthropathy and the specific findings. 3. To understand the differential diagnoses of bone and joint infections. semiquantitative scoring method. Vertebral morphometry is based on radiographs or scans from DXA-machines calculating ratios of vertebral heights with normal values to identify vertebral fractures. 

great need for early, accurate and reliable imaging indicators of tumour response to anti-angiogenic drugs which is ultimately defined by overall survival rate, but is mostly based on changes in number and size of measurable tumour "targets", i.e. blood vessels. Thanks to its characteristics of high temporal and spatial resolution in limited fields and lack of ionising radiation and side effects (i.e. easy repeatability), contrast-enhanced US (CEUS) is currently the simplest and also most reliable imaging modality for detection, analysis and quantification of intratumoural macro-and microvascularity (up to 40 μm in diameter). Even minimal changes can be easily detected and quantified with CEUS during anti-angiogenic treatments: early disappearance (or severe reduction) of tumoural vascularisation is highly predictive of complete (or significant) response even before tumour volume decreases. Initial clinical studies were conducted on hypervascular hepatic metastases (e.g. metastases from GISTs), but recently also hypovascular hepatic metastases and primary cancers of different organs are being assessed. For the quantitative analysis of tumour vascularity changes several parameters (peak intensity, time-to-peak intensity, area under the curve, etc). are currently being investigated and specific perfusion software connected to working stations are being developed and clinically tested. The clinical application of MR-mammography (MRM) in the last 26 years has shown that this imaging tool has had significant diagnostic advantages in the field of breast diagnosis, e.g. the proof of small breast cancers, the differentiation between scar and recurrent tumours, the detection of multifocality/multicentricity, the search for primary tumours, the delineation of implants, etc. The clinical use of MR-mammography is steadily increasing. However, many still describe a "high sensitivity but a low specificity", which is wrong. Achieving a high quality is not an easy task; a lot of teachers have to be learned and considered. This refresher course is focussing on high quality concerning technical and diagnostic aspects, especially focussing the question of improving specificity. Dynamic contrast enhanced computed tomography (DCE-CT) is a noninvasive method showing haemodynamic changes in living tissue in various oncologic and non-oncologic applications. Recently, it has gained an increased popularity for studying malignant tumour blood supply and formation of new vessels, also known as angiogenesis, that plays a critical role in the growth of cancer. Technical remarks: Repeated rapid CT scans are acquired at the same location to allow determination of time-attenuation curves (TAC). Several quantitative parameters are assessed: tumour blood flow (TBF) (ml/min/100 g), tumour blood volume (TBV) (ml/100 g), permeability surface product (PSP) (ml/min/100 g) and mean transit time (MTT) (s) are calculated using dedicated perfusion software. Indication: Perfusion CT may be used by the distinction of benign from malignant lesions when conventional methods are unreliable, may improve staging by demonstrating occult hepatic metastases, may guide biopsy to the tumour region most likely to be of highest grade. Several tumours with higher perfusion are more sensitive to the chemoradiation than that with lower perfusion. Findings at DCE-CT images after chemoradiotherapy are a significant predictor of early tumour response and overall survival. Its applications have been stimulated by the development of anti-angiogenesis therapy for monitoring the effects of therapy and additionally may be used as a noninvasive tool in detection of hepatic toxicity of chemotherapy. In the future, new prognostic information could impact clinical management. Studying the response of cancers by measuring changes in their blood flow may provide useful information on oncologic patients for managing cancers in the future. Advanced imaging is now widely utilised in the research and clinical settings. In the clinical setting, qualitative, semi-quantitative and quantitative approaches such as review of colour-coded maps to ROI analysis and analysis of signal intensity curves are being applied in practice. We will also compare the relative advantages for T1 DCE MRI with T2* DSC MRI in the estimation of perfusion and permeability metrics in the clinic as well as some more automated histogram analysis methods. The role of advanced imaging in the characterisation of tumour biology and different pathologies will be reviewed. Differentiating between recurrent tumour and therapeutic necrosis is often a challenge. We will review the role of advanced imaging and also the effects of anti-angiogenic therapies on tumour microvasculature/microenvironment resulting in changes in diffusion, perfusion and MRS. Pseudophenomenon has made conventional imaging with gadolinium contrast agent almost obsolete necessitating mechanistic techniques to differentiate entities such as pseudoprogression which is seen more commonly as a result of therapy with temozolomide and radiation for high grade gliomas as well as pseudo-response and pseudo-pseudoprogression. Lastly to combine and apply these different imaging techniques in a multi-parametric algorithmic fashion in the clinical setting can be shown to increase our diagnostic specificity and confidence.

Learning Objectives: 1. To become familiar with different advanced MR techniques used in brain tumour imaging. 2. To learn the role of permeability, perfusion, diffusion imaging and MR spectroscopy in characterising brain tumour biology and differential diagnostics. 3. To become familiar with a complete imaging protocol, which can be implemented in a multi-parametric algorithm fashion in brain tumour diagnosis.

Monitoring and prediction of treatment response P.C. Maly Sundgren; Lund/SE (Pia.Sundgren@med.lu.se)

High-grade gliomas have a poor survival rate despite improvements in surgery, radiation and chemotherapy. A contributing factor to the poor survival is the inability of currently available imaging techniques to accurately delineate the tumour which results that targeted focal treatment my not be effective. Conventional imaging is not able to give an early assessment of the effectiveness of radiation and/or chemotherapy. Early identification of patients with a poor treatment response or who suffer from tumour recurrence can be of great advantage: it provides the opportunity to adjust individual more rapidly, and sparing patients unnecessary morbidity, and Breast MRI has shown diagnostic sensitivities of 94-99% for invasive breast cancer; however, specificities have been reported significantly lower with values between 37% and 86%. The specificity of breast MRI is in a routine clinical setting based on the evaluation of morphologic features and relative "slow" dynamic characteristics of enhancing lesions. The only moderate specificity that is achieved using these characteristics can result in a significant number of false positive findings during, for instance, screening or pre-operative imaging. These findings will often require short-term follow-up, target ultrasound with biopsy or even MRI-guided biopsy. Fast dynamic imaging, spectroscopy and diffusion weighted imaging (DWI) have been described to have potential for improving the specificity of breast MRI. The use of fast dynamic imaging sequences result in a more accurate evaluation of the initial enhancement of the lesion. In combination with pharmacokinetic modelling this can result in a more quantitative evaluation of enhancement. In proton-MR spectroscopy (MRS) the presence of a choline signal, a cell-membrane precursor, in breast lesions can be used to differentiate benign from malignant lesions. The specificity of MRS varies between 67 and 100% in literature (average 87%). DWI has also shown potential in differentiating between benign an malignant lesions, but, like with other techniques, varying specificity values are reported ranging between 46% and 93%. In this presentation the value of these techniques for improving the performance of breast MRI will be discussed. Although bedside chest radiograph is one of the less elaborate imaging examinations in our diagnostic armamentarium, it remains the most frequent radiologic procedure performed in intensive care patients. Despite its limitations chest imaging is an important tool in the management of the critically ill patient. Though the advent of digital radiography has vastly contributed to improved image quality of the bedside radiographs, optimal positioning and technique remain a real challenge for the performing technologist. In addition, the interpretation of chest radiography in the critically ill patient poses a challenge for the radiologist, because findings are frequently unspecific and lung opacifications have similar appearances in a variety of different cardiopulmonary pathologies. Clinical information and an interdisciplinary approach are therefore crucial for optimal interpretation of these chest radiographs.

The American College of Radiology has established expert recommendations for the use of bedside chest radiography. Current recommendations suggest that routine daily chest radiographs should be reserved for patients with acute cardiopulmonary problems and in patients receiving mechanical ventilation. Acquisition of a portable chest radiograph is recommended after insertion of endotracheal tubes, central venous catheters, pulmonary artery catheters, chest tubes, and nasogastric tubes. Therefore, knowledge of correct positioning of catheters, tubes, and monitoring devices and of various malpositions and associated complications is essential for the interpreting radiologist. Chest ultrasonography (CHUS) is a useful imaging tool in patients at intensive care units, because of its simplicity and reproducibility. However, there are some limitations such as low specificity of some crucial sonographic signs and limited searching area (soft tissues, pleural cavity and lung consolidations). The ICU patient can be examined in supine or sometimes in lateral or partly lateral position using intercostal spaces as an acoustic window. Supine analysis of the anterior chest wall rules out pneumothorax, while lateral approach detects clinically relevant pleural effusion and parenchymal consolidations. CHUS is a method of choice in detection as well as in characterisation and volume estimation of free and/or loculated pleural fluid. With CHUS we can explore and characterise lung consolidations from the moment they reach the visceral pleura. They can be in contact with pleural line or can be observed through an effusion. However, in case of subcutaneous emphysema and/or diffuse oedema of soft tissues the lung parenchyma can not be reliably assessed. Also, in the question of pulmonary embolisms in critically ill patient, CHUS could be contributive. Sometimes small pleural effusion can be visible with some peripheral lung tissue consolidations indicating minute pulmonary infarction. Typical pulmonary infarction is triangular tissue consolidation with air bronchogram and absence of Doppler blood flow signals within consolidated lungs but CECT for confirmation is mandatory. CHUS exploration of the diaphragm can reliably evaluate respiratory movements since pleural effusion even substantial does not affect the amplitude of diaphragmatic excursion.

Learning Objectives: 1. To understand the advantages and limitations of bedside thoracic ultrasonography. 2. To learn about the US findings of pleural and parenchymal diseases suitable for bedside ultrasonography. 3. To review current guidelines for estimation of pleural effusion volume. delay in initiation of other maybe more effective treatment. In recent years, different functional imaging approaches such as dynamic contrast-enhanced (DCE) and dynamic susceptibility-weighted contrast (DSC) MRI, diffusion-weighted imaging and spectroscopy have been complementary used for diagnosis and treatment response. In this lecture different advance MR and CT imaging methods as well as the traditional way of monitoring to assess treatment response will be discussed. In addition, a novel recently published promising technique will be described -the parametric response mapping (PRM), a novel voxel-wise analytical method of monitoring physiological and environmental changes in a tumour volume during treatment will be presented and compared to the traditional methods used. Finally, the aim of the lecture is to consolidate the present knowledge and novel ideas in brain tumour imaging for future monitoring of treatment response and the possibility and limitations for future individualisation of cancer therapy. Learning Objectives:

1. To gain an understanding of the present traditional model for the treatment cycle for brain tumours and how they are monitored. 2. To learn about different imaging biomarkers for early assessment of brain tumour treatment response that might result in individualisation of cancer therapy. 3. To consolidate present knowledge and ideas in brain tumour imaging for future brain tumour therapy and monitoring of response.

Radiation necrosis and pseudo-progression vs recurrent tumour

Pseudophenomenon has made conventional imaging with gadolinium contrast agent almost obsolete necessitating mechanistic techniques to differentiate entities such as pseudoprogression which is seen more commonly as a result of advanced multimodal therapeutic concepts. Advanced, non-enhanced and contrast enhanced MR imaging techniques include MR-spectroscopy, perfusion MR imaging, dynamic contrast enhanced MRI and diffusion tensor MR. In the presentation we will analyse the application of those techniques in brain tumour assessment with focus on the post-therapeutic brain to differentiate therapy induced from tumourinduced changes. The results of the available studies in literature, all with relatively limited patient numbers, indicate that the combination of functional MRI proved to be useful in the post-therapeutic workup of gliomas, lymphomas and metastatic disesease. The typical patterns of tumour recurrence and the different therapyinduced effects will be presented. In perfusion (DSC-MRI) and dynamic contrast enhanced magnetic resonance imaging (DCE-MRI) the signal intensity measurements of the tumour reflect a composite of tumour perfusion, vessel permeability, and the extravascular-extracellular space. In contrast to conventional enhanced MRI, which simply presents a snapshot of enhancement at one time point, both techniques permits a fuller depiction of the wash-in and wash-out contrast kinetics within tumours, and this provides insight into the nature of the bulk tissue properties on its microvascular level. With the strong demand in drug development the identification of biomarkers that can assess tumour microvascular properties noninvasive dynamic MRI is the method of choice to assess tumour response and to identify atypical tumour response findings. 

Indications and spectrum of pathological findings

Functional abnormalities of the pelvic floor represent a significant health-care problem, as they affect approximately 15% of older multiparous women. Moreover, nearly 300.000 surgeries in United States are annually performed to correct those disorders. The success of medical and surgical therapies relies on the correct classification of dysfunction and identification of the pelvic compartments involved. Clinical classifications of pelvic floor abnormalities are primarily topographic, rather than functional. However, as the pelvic floor muscles tend to act as a unique functional entity, their dysfunction usually leads to dysfunction of more than one organ system (genitourinary or gastrointestinal), resulting in a wide spectrum of symptoms variably associated, including dysuria, urinary incontinence, uterine prolapse, anal or pelvic pain, obstructed defaecation, rectal prolapse or faecal incontinence. Because of the variability of symptoms and complexity of physio-pathological mechanisms, diagnosis of pelvic floor disorders is usually achieved by combining different diagnostic tools. Dynamic MRI of the pelvic floor has emerged as an alternative and effective modality for assessing and understanding of these disorders. It currently offers a complete morphological and functional evaluation of all three compartments at the same time. Constipation and pelvic organ prolapse are the most common indications for a dynamic MRI. The physio-pathological features of the main pelvic floor disorders and their MRI findings will be shown in detail. MR images and movies, with particular regard to posterior pelvic floor abnormalities, such as rectocele, rectal invagination and prolapse, enterocele, descending perineal syndrome and spastic pelvic floor syndrome, will be illustrated and discussed. The ability to perform and interpret dynamic pelvic floor imaging is essential for the modern gastrointestinal (and indeed urogynaecological) radiologist. The other speakers in this session will be reviewing indications, pathologic findings, clinical relevance, and MR technique. Although I will detail the MR and fluoroscopic techniques used at my institution, I will focus on the specific technical and diagnostic advantages and disadvantages of both dynamic pelvic MR and conventional fluoroscopic evacuation proctography (defecography). Many practitioners wising to initiate this type of imaging will wish to know what modality to chose and existing practitioners using fluoroscopy will possibly be interested in migrating their practice to MR. I will illustrate what imaging findings are best imaged by each technique, continually referencing this to whether the finding is ultimately important to the referring clinician or not. Using examples from our own research programme and clinical practice, I will illustrate why we have migrated our practice exclusively to dynamic MR. Although dynamic pelvic MR imaging is increasingly used for imaging pelvic floor disorders, the crucial question is whether the technique can completely replace conventional techniques. Although MR imaging provides excellent soft-tissue contrast which is a particular advantage when imaging the pelvis, it has to be acknowledged, that the examination is performed in supine position and not in physiological sitting position.

This presentation will review the ultrasound appearances of pleural disease in ward and ITU-based patients, and will discuss the indications for pleural procedures and the complications associated with them. The use of colour Doppler to aid the diagnosis of effusions will be discussed, as will the identification of septations and the need for intrapleural fibrinolytic therapy. The advantages of guided versus blind drain insertion will be presented, and the benefits of large versus small bore drains will also be discussed. Pelvic floor function and structure is complex. Imaging has a key role in guiding the clinician in managing patients with incontinence, constipation, difficult rectal evacuation and pelvic organ prolapse. Dynamic imaging is of particular interest for assessment of the pelvic floor since this kind of imaging gives a near physiological data set of what is happening and gives us a better understanding of the multifactorial causes of pelvic floor dysfunction. Whereas conventional evacuation proctography was over years standard of reference for dynamic imaging of the pelvic floor, dynamic MR imaging of the pelvic floor is gaining increasing acceptance among radiologists and clinicians. However, dynamic MR imaging of the pelvic floor is (due to the architecture of most the clinically MR magnets) usually performed in supine position which does exclude the axial load on the pelvic floor. The lack of a physiological patient positioning during dynamic pelvic floor MR imaging is still brought into discussion if dynamic MR imaging of the pelvic floor can replace conventional techniques or not. 

The pelvic floor is a complex anatomic and functional unit. In clinical routine a simple anatomic concept of the female pelvic floor has gained acceptance. Especially for treatment planning, the female pelvic floor may be separated into three functional compartments: the anterior compartment (bladder and urethra), the middle compartment (vagina, cervix, uterus, and adnexa), and the posterior compartment (anus and rectum). Intact structure of the pelvic floor is a basic prerequisite for a normal mechanism of defecation and continence. Over the last years, MR imaging has gained increasing acceptance as imaging modality for evaluation of the pelvic floor, which enables a global and integrated approach to the pelvic floor. Using static T2weighted sequences the morphology of the pelvic floor can be visualised in great detail. A rapid half-Fourier T2-weighted, balanced steady state free precession (bSSFP), or gradient-recalled echo (GRE) sequence are used to obtain sagittal images while the patient is at rest, during pelvic squeeze, during pelvic strain and to document the evacuation process. On these images the radiologist identifies the pubococcygeal line (PCL) (which represents the level of the pelvic floor). In normal findings, the base of the anterior and the middle compartment are above the PCL at rest, and the pelvic floor elevates during contraction. During straining, Although most clinical diagnostic imaging studies employ anatomic techniques such as computed tomography (CT) and magnetic resonance (MR) imaging, much of radiology research currently focuses on adapting these conventional methods to physiologic imaging as well as on introducing new techniques and agents for studying processes at the cellular and molecular levels in vivo, i.e. molecular imaging. Molecular imaging promises to provide new methods for the detection of minimal changes in diseased tissue and support for personalised therapy.

Although molecular imaging has been practiced for over 20 years in the context of nuclear medicine, other imaging modalities have only recently been applied to the noninvasive assessment of physiology and molecular events. Nevertheless, there has been sufficient experience with specifically targeted contrast agents and high-resolution techniques for MR imaging and other modalities that we must begin moving these new technologies from the laboratory to the clinic. Several projects relevant to oncology will be discussed with emphasis on how they were/will be moved from the bench to the clinic. Aortic dissection is increasingly managed by endovascular means. It is important for all radiologists to understand the benefits and disadvantages of varying imaging modalities in the differential diagnosis and the fundamental anatomical requirements for assessing suitability for endovascular repair. The causes, detection, classification and complications of aortic dissection will be discussed followed by a panel discussion of imaging strategies which give the best information for diagnostic work-up, endograft planning and monitoring of patients during and after treatment. With the introduction of targeted therapeutics and personalised therapy regimen there is increasing need to improve diagnosis of diseases in a way that insight into pathophysiological and molecular regulation is provided. In this context, molecular imaging can be of tremendous help in basic research, drug development and the clinics. Many interesting approaches of molecular imaging have been tried in small animal models. New methods and tools have been identified, which are easy enough to handle, aceptable in its costs and, most importantly, reliable enough to be translated to clinical practice. Unfortunatenly, as soon as they have entered the clinics they are often not classified as molecular imaging anymore. Among those are MR-spectroscopy, SPIO/USPIO enhanced liver and RES imaging but also contrast agents like Gd-EOB-DTPA and most applications for PET/SPECT. Other interesting applications such as targeted ultrasound imaging are already established tools in preclinical research and very close to first clinical use. Near infrared optical imaging is another example of a rapidly developing technology and first clinical devices and dyes (e.g. to detect arthritic lesions) are availibe now. It can be expected that with the availability of targeted and activatable probes the acceptance and the use of optical imaging methods will further rise. Most proably, this will initially happen in context with intraoperative diagnosis and endoscopy. In summary, it is the aim of this talk to give a realistic overview on the available molecular imaging tools and on their potential for preclinical research and patient use. Cardiovascular diseases remain the number one cause of morbidity and mortality, both in the developed and developing countries, and in men and women alike. It is expected that these numbers will continue to increase in the coming decades due to escalating proportions of obesity and the aging population. Atherosclerosis is the major cause for cardiovascular disease. Since in about 50% of cases a stroke or acute myocardial infarction is the first symptom of atherosclerosis, it is of paramount importance to identify patient at high risk. A first step in the identification is the use of clinical risk profiling, such as the Framingham Risk score, which has an area under the curve (AUC) of about 0.8 using ROC analysis. However, clinical risk profiling alone is not sufficient to identify individual patients at imminent risk to develop a cardiovascular event in the near future. A next step in a more precise identification of the patient at risk is the development of serum biomarkers for atherosclerotic disease. However, so far serum biomarkers have failed to contribute substantially to improve the AUC in the prediction of cardiovascular events using ROC analysis. A major step forward in risk stratification is provided by the rapid development of cardiac computed tomography, which offers a rapid visual access to the coronary tree, at low radiation dose and in a patient friendly manner. However, for the identification of the vulnerable plaque we need to go beyond anatomical imaging, and use molecular imaging tools. In the lecture I will discuss the different targets for molecular imaging within the vulnerable plaque, such as inflammation, apoptosis and angionenesis. Imaging of these substrates of plaque vulnerability may offer opportunities for a precise identification of the patient at risk, at the individual level. The aim of the lecture is to familiarise the audience with the specific paediatric conditions in trauma radiology. It will be described the major pathophysiologic differences in childhood and the consecutive altered injury pattern. The standard radiological imaging protocol for various involved body regions and different trauma settings/varying queries will be described, with suggestion for standardised diagnostic algorithams in some typical settings. Special regard will be given to radiation protection and the potential of imaging modalities such as ultrasound, multi-detector CT as well as MRI in paediatric trauma patients. The roll of the lecture is to provide some basic guidelines for young radiologists and general radiologists who less often have to deal with paediatric patients.

Learning Objectives: 1. To become familiar with the major pathophysiologic differences in childhood trauma 2. To standardised diagnostic algorithm in some typical settings in field of pediatric trauma.

Basic principles in the interpretation of signal intensities on T1-and T2weighted images G. Wilms; Leuven/BE (Guido.Wilms@uz.kuleuven.ac.be)

The signal intensities of normal structures and pathological findings on conventional T1-and T2-weighted MR images depend on many factors. The amount of water, proton density, chemical structure and/or binding, presence or absence of flow (of blood or CSF), calcification, fat, blood degradation products, melanin, mucine and even air are all factors that influence the signal characteristics. T1-and T2-lenghtening is the rule in most tumoural, vascular and infectious lesions and therefore is rather unspecific. T1-and T2-shortening can be due to the presence of fat (lipoma), melanin (melanoma and metastasis of melanoma), mucine (metastasis of sigmoid carcinoma), colloid material (colloid cyst, Rathke cleft cyst) and even calcification (falx!). T1-shortening with T2-lengthening can be due to cholesterine (cholesterol granuloma, craniopharyngioma), high protein content (tumoural cysts), and methaemoglobin (late haemorrhage, thrombus). T1-lengthening and T2-shortening is almost exclusively due to deoxyhaemoglobin. Acute haemorrhage and meningioma can be iso-intense on T1-weighted images, while some meningiomas and micrometastases can be iso-intense on T2-weighted images. Absence of signal can be due to high-velocity flowing blood (aneurysm, AVM, hypervascular tumours), high velocity flowing CSF (normal pressure hydrocephalus, cortical bone or extensive calcification, air and a large amount of iron (coils, clips). It is concluded that the simple use of a combination of T1-and T2-signal intensities on conventional MR images can be used to arrive at the diagnosis and differential diagnosis of brain lesions. Complications occurring after acute aortic dissections should be separated into those related to the disease per se and those related to post-treatment conditions. Life-threatening complications related to the disease should be familiar as immediate consequences for treatment may ensue. Most of these are either located in the aortic root or related to mal-perfusion syndromes. The aortic root with very thin walled structures of the sinus of valsalva is located within the pericardial sac. The structure is prone to rupture and may produce life-threatening pericardial tamponade or present clinically as sudden onset of severe aortic regurgitation. All imaging modalities suitable for diagnostic workup in such conditions have to be rapidly accessible and performable. This precludes lengthy MR imaging procedures and renders ultrasound and CT as the mostly used modalities. The condition that has to be recognised as the most important inductor of malperfusion syndromes in the descending aorta is the progression of dissection into aortic branches and the true lumen collapse. Both conditions are easily discernible with CT imaging. Complications related to treatment should be sub-classified into those after pure surgical treatment and those related to endograft repair. The acute surgical complication with most deleterious effects is related to spinal cord ischaemia. The condition also applies to endograft repair. It is therefore beneficial for the radiologist involved either in pre-surgical imaging or interventional treatment to acquire thorough knowledge of the spinal cord blood supply. Endograft complications of interest encompass endoleak formations, stent migrations and endoluminal stent collapse.

Learning Objectives: 1. To learn the most common complications. 2. To learn the most appropriate imaging strategy for diagnosis. 3. To understand the clinical significance of the most common complications.

Which imaging modality is best for endovascular management? 17:14

The various imaging modalities for establishing the diagnosis of acute non-traumatic dissections will be discussed. The panellists will present recommendations for diagnostic work-up with special respect to differential diagnosis such as acute myocardial infarction and acute pulmonary embolism. Also, the problem of sizing the endograft and planning the procedure will be addressed. The panellists will discuss strategies for detection of complications and for monitoring patients following treatment. The quality of radiographs is determined by many parameters from both technical and clinical origin. During the presentation, we will make an overview of the particular features of x-ray tubes and plain films that affect the quality of the radiological image. The training session will start from very simple x-ray tubes and film, and gradually introduce more sophisticated, state-of-the-art technology. We will briefly explain concepts such as focal spot, heel effect, beam quality, filters, grid, film sensitivity, automatic exposure control, etc. from a practical point of view. The European Commission and selected research groups have developed criteria to judge the quality of the images and we will show how they can be used to improve the daily practice. A more technical evaluation of quality is possible with images of test objects, some of which are very straightforward and interesting if problems have to be retrieved. X-ray quality should be at a high level every day. Therefore quality control procedures have a role. One example evaluates the stability of the imaging chain by means of acquisitions of homogeneous blocks of PMMA. We will illustrate typical findings with repercussions on the radiological practice, and show that the fight against artefacts is a never ending process. Both with film and digital detectors, radiologists should be aware that quality management and quality control procedures are needed. Quality has to be organized, and quality control procedures have to be automated and included in the routine practice. There are diverse underlying causes for "diagnostic mistakes". Missed lesions due to inadequate technique, "satisfaction of search" or lack of perception have to be differentiated from interpretative mistakes of lesions that have well been seen but erroneously interpreted due to the lack of experience, misconception or overlap of findings that complicates the differential diagnosis. Each of these underlying reasons require a different approach to avoid them or reduce their risk of occurrence. The first type of mistake arises more often when interpreting chest radiographs and refers to the detection of mostly small focal parenchymal densities but also to the interpretation of mediastinal and hilar contours. By analysing typical cases, visual "tricks", helpful display techniques and strategies for systematic review and analysis will be outlined that are thought to be helpful in reducing the risk of "missing" a lesion. The second type of mistake mostly represents a problem of interpreting parenchymal abnormalities seen on CT. Since the lung has limited means to "react" against an injury, many radiologic findings are aspecific. Interpretation of pathology of parenchymal changes is based on pattern analysis, the knowledge of disease distribution and additional findings of pleura and mediastinum. In many cases, an interdisciplinary approach of radiologists and clinicians is essential for correct interpretation. Cases will be analysed to illustrate difficult differential diagnosis occuring in daily routine (e.g., infectious pneumonia versus organising pneumonia) and key features helping in going into the right interpretative direction will be outlined. Emphasis will lie on focal lung disease rather on the interpretation of diffuse interstitial lung diseases.

Learning Objectives:

1. To learn about visual tricks and strategies to overcome typical perception errors in chest radiography. 2. To become familiar with overlaps of morphologic findings of focal parenchymal lesions frequently occuring in daily routine when interpreting thoracic CT. 3. To recognise those additional findings that represent the "helpful clue" for correctly narrowing the differential diagnosis.

Panel discussion:

What have we learned from our mistakes? 09:44

Interpreting the results of imaging studies is more and more challenging and time consuming due to the large volume of data to evaluate, compare and post-process. Moreover, errors in the interpretation of imaging studies can have significant effects on patient care, particularly in acute medicine and oncology. So the question is how to be aware of the potential pitfalls that may be encountered in the realisation and the interpretation of imaging studies and how to avoid them or to learn from them. Acute pancreatitis remains a potentially life threatening condition with an overall mortality rate of 5%. Its outcome is strongly related to a precise and timely diagnosis, a correct estimate of severity and subsequent appropriate treatment. Radiologic imaging, particularly CT, plays a key role in staging the severity and therefore helps guiding therapeutic decisions. Management of interstitial or edematous pancreatitis is supportive while severe or necrotising pancreatitis requires intense monitoring and specific therapies. The latter has a higher mortality and guarded prognosis, since it may lead to organ failure, infection, pseudocyst formation and extrapancreatic parenchymal and vascular complications. A number of severity indices have been established to determine the prognosis of acute pancreatitis, based both on clinical and imaging criteria. A CT-based severity index has become the main prognostic method to predict outcomes. This course reviews relevant imaging findings of various stages of acute pancreatitis and its complications by CT, including special conditions such as groove pancreatitis and autoimmune pancreatitis. Currently established and modified severity indices are reviewed to learn how to estimate prognosis and guide therapy. Interpreting the results of imaging studies is more and more challenging and time consuming due to the large volume of data to evaluate, compare and post-process. Radiology errors are inevitable, affect all radiologists and may be defined as a mistake that has management implications for the patient. Errors can be broadly classified into technical errors, active errors (errors in perception, judgment or knowledge) and errors of communication. The majority of errors are false-negative interpretations and occur during interpretation of CT examinations. Good communication between the referring physician and the radiologist is essential. Unfortunately, only a small minority of radiologists keep a personal record of their errors. Patient safety should benefit from the repeat organisation of "error meetings" through the act of collective learning. Radiologists and radiology departments must continue to improve the process of recording and addressing errors. A-185 08:58

Radiologists do make mistakes, diagnostic errors can be the cause of severe consequences to patients or, luckily, in many cases, they can be corrected. Learning from mistakes is quite important since understanding why a mistake has been made help to avoid it in the future. During this lecture a series of mistakes made in the field of GU will be presented and causes which have lead to each of them will be analysed. Dyspnoea is a common symptom in patients presenting to the emergency room.

In almost two-thirds of all cases, dyspnoea is caused by either a pulmonary or a cardiovascular disorder. Imaging in patients with dyspnoea depends mainly on the clinical presentation and the medical history of the patient. Chest radiographs are a cost-effective and rapid test for the evaluation of patients with dyspnoea, with a fair sensitivity and specificity. For this reason, chest radiographs are usually performed early in the diagnostic evaluation of patients with acute and chronic dyspnoea. Chest radiographs enable the diagnosis of frequent causes of dyspnoea of pulmonary origin, such as pneumonia, pneumothorax, pleural effusions, interstitial lung diseases, and emphysema. The diagnosis of cardiovascular disorders, such as pulmonary venous hypertension, cardiomyopathy, as well as valvular diseases, is also facilitated by chest radiographs. If chest radiographs, clinical studies, and laboratory tests, however, are non-diagnostic or equivocal, CT is indicated. CT offers high sensitivity and specificity for the evaluation of pulmonary embolism and for diseases of the pulmonary parenchyma and the airways. High-resolution CT represents the method of choice for the evaluation of suspected diffuse lung disease. Additional expiratory scans are useful for the evaluation of mosaic perfusion and air-trapping. Chronic pancreatitis (CP) is an inflammatory disease of the pancreas, with irreversible morphologic changes and fibrotic replacement of the gland, which progressively result in loss of exocrine and endocrine function. CP is morphologically characterised by irregular sclerosis associated with destruction and permanent loss of the exocrine parenchyma which may be either focal, segmental or diffuse. The primary symptoms of CP are abdominal pain and maldigestion, which may be physically and socially debilitating, although it is acknowledged that chronic pancreatitis can occasionally be painless. A classification based on the causes of CP is useful in order to better define the therapeutic interventions. However, morphological changes of the pancreatic ducts are the main rule of thumb for the classification in order to better compare the results of the treatment. Imaging techniques have a role both on the diagnosis -especially in the early phases of the disease -and on the classification of CP, either for the grading of the disease, to explain the aetiology -even for rare forms -and to differentiate the focal mass from ductal adenocarcinoma. CT, MRI and ERCP have a specific role in the assessment of CP, due to the different capacity of the techniques to explore the pancreatic gland. However, thanks to heavily T2w sequences, MRI has a competitive role with ERCP, which actually has more an interventional role in case of obstructive CP. Finally, MRI thanks to secretin test and DWI sequences is able to give a non-invasive assessment of pancreatic exocrine function. Complications of pancreatitis may include fluid collections and pseudocysts, vascular complications such as arterial pseudoaneurysm or thrombosis of the portal venous system, and stenosis of common bile duct and pancreatic duct. Inflammatory fluid collections in the context of acute pancreatitis often resolve spontaneously. Drainage may become necessary in the presence of clinical complications such as abdominal pain, compression of adjacent organs by large pseudocysts, or if superinfection of a pseudocyst occurs. Depending on clinical, morphologic, or technical factors, drainage may be accomplished with image-guided external catheter placement, by endoscopic internal (transgastric) drainage or by internal surgical drainage. Arterial pseudoaneurysm carries the risk of acute intra-or extraperitoneal bleeding, and transarterial embolisation is usually indicated when pseudoaneurym is detected. Strictures of the common bile duct secondary to chronic pancreatitis may require percutaneous or endoscopic retrograde intervention. Learning Objectives:

1. To review interventional techniques that are used to manage fluid collections in the setting of pancreatitis. 2. To compare the results with those obtained by surgical and/or endoscopic approach. 3. To learn about algorithms used for clinical decision making, and for treatment evaluation and follow-up. 4. To understand major shortcomings and complications and how to avoid them.

Discussion 09:45 ants include the presence of accessory muscles, a low-lying peroneus brevis muscle belly, pseudosubluxation of the peroneus brevis tendon, and a bifurcated or mildly crescentic peroneus brevis tendon. Accessory muscles in the ankle area include in the lateral aspect the peroneal tertius and peroneal quartus, in the medial aspect the flexor digitorum accessorius longus, and posteriorly the peroneocalcaneus internus, tibiocalcaneus internus and accessory soleus. As variations are commonly seen in asymptomatic ankles, matching with clinical symptoms is important. Pitfalls include pseudoloose bodies in the ankle joint, pseudolipomas, and artefacts such as the "magic angle" effect, chemical shift, susceptibility, motion, "ghost" and partial volume averaging. Knowledge of normal anatomy, pitfalls and variants, aids radiologists in making the precise diagnosis of various disorders. The aetiology of dyspnoea is varied. It may be due to pulmonary or pleural disease, cardiac pathology or extrathoracic causes. Imaging is an useful adjunct in the diagnosis of majority of cases of dyspnoea. In this lecture we will present selected cases which will demonstrate the usefulness of different imaging modalities, emphasising when cross-sectional imaging is indicated.

Learning Objectives: 1. To review typical cases illustrating the role of imaging modalities in the differential diagnosis of dyspnea cases. 2. To motivate the audience by the use of voting pads to be involved in the diagnostic process. 3. To highlight the conclusion that may be drawn on the basis of the discussed cases. The term bone marrow oedema was introduced to describe ill-defined bone marrow hypointensity on T1Wi and hyperintensity on T2Wi and water sensitive sequences. Bone marrow edema can be found in many similar unrelated disorders, such as bone contusions, osteonecrosis, inflammatory or degenerative disease, being a non-specific MRI abnormality representing a diagnostic challenge for radiologist.

Recently has been demonstrated that bone marrow oedema might be a prognosis marker for OA (osteoarthritis) and inflammatory disease, and could be used as a powerful predictive tool for treatment options. Therefore our role as radiologist is to try to increase specificity to help patient management and decrease progression. Subchondral bone marrow lesions (BMLs) are a hallmark of osteoarthritis (OA) on MRI. Radiologically, BMLs in OA are understood as non-cystic subchondral areas of ill-defined hyperintensity on T2w images and of hypointensity on T1w images, but only water-sensitive fat-suppressed sequences depict the lesions to their maximum extent. BMLs are observed regularly in conjunction with adjacent cartilage alterations. Higher grades of cartilage loss are associated with higher prevalence and greater volume of concomitant BMLs. As the disease progresses, an increase in BML volume is seen in the same region subchondrally in many patients, which is positively correlated with an increase in cartilage loss and radiographic joint space narrowing. Cysts are strongly associated with BMLs in the same subregion and develop within non-cystic BMLs. The published data on the natural history of BMLs are ambiguous but recent reports showed that the majority of subchondral BMLs may regress or resolve completely. Note that progression and regression of BMLs may be observed within the same knee simultaneously. Histologic correlation studies showed that the lesions consisted of a mixture of different tissue patterns with only little oedema. Specific changes in bone mineralisation and remodelling in areas of BMLs have been shown, and they appear sclerotic compared to unaffected regions from the same individual. Differential diagnoses of OA-related BMLs include traumatic bone contusions and fractures with or without disruption of the articular surface. Osteonecrosis, inflammation, idiopathic BMLs, red marrow and post-surgical alterations should also be considered.

Learning Objectives:

1. To learn about the basic physiopathology of OA and its relation with BME. 2. To analyse the distribution and natural history of BME in OA. 3. To understand the differential diagnosis and relevance of BME in staging OA and as a marker of prognosis.

B. BME and early inflammatory disease A.J. Grainger; Leeds/UK (andrew.grainger@leedsth.nhs.uk)

Marrow oedema is identified as a feature of many forms of inflammatory and mechanical arthritis, but has been most studied in the inflammatory arthritides and particular in rheumatoid arthritis. It was first reported as a feature of RA as far back as 1986. Work has been undertaken both using human specimens and specimens from animal models which suggest that marrow oedema seen on MRI in RA corresponds to areas of inflammation been associated with invading pannus, lymphocytic aggregates and hypervascularity. There is also evidence that the marrow lesions seen on MRI in ankylosing spondylitis correspond to histopathological inflammatory change. Marrow oedema has been shown to be an important predictor The recent technological advances of CTU and MRU have had an exceptional impact on the assessment of chronic/intermittent obstruction. Imaging studies should help answer the clinical questions raised concerning the presence, level, and cause of obstruction. In this session, the recommended techniques of CTU and MRU will be described and their relative merits and limitations reviewed. 3D CT images should be used as an adjunct to the transverse images, instead of a replacement, because volume-rendered images best depict the lumen and not the wall of the urinary tract. Thin-section reformatted CT images likely are as sensitive as transverse images in the detection of urinary tract abnormalities. MRU is being increasingly used because it provides excellent anatomic and functional imaging in a single setting. It has proved particularly valuable in pregnant women and children. The relative advantages of static-fluid MRU and excretory MRU will be discussed. The main aetiologies of chronic/intermittent obstruction will be illustrated, including intraluminal diseases (stones, clots, etc.), wall abnormalities (transitional cell carcinomas, tuberculosis, etc.) and extraluminal diseases (pelvic and retroperitoneal tumours, retroperitoneal fibrosis, GI tract diseases, etc.) UPJ syndrome is the most common site of urinary tract obstruction in children. Vessels crossing a ureteropelvic junction obstruction contribute to the degree of hydronephrosis in up to 46% of these patients. Demonstration of these vessels and their location anterior or posterior to the obstruction facilitates surgical planning. At the end of the lecture, attendees will become familiar with moderate or severe urinary obstruction and their various features and causes. 1. Technological advances in both computed tomography (CT) and magnetic resonance (MR) imaging have improved the diagnostic imaging of the urinary tract, surpassing ultrasound and the intravenous urogram. Multidetector computed tomography urography (CTU) is defined as CT examination of the kidneys, ureters and bladder with at least one imaging series acquired during the excretory phase of contrast enhancement. MR urography (MRU) can be performed using heavily T2-weighted sequences without contrast material or T1 spoiled gradient -recalled echo sequences during the excretory phase after administration of gadoliniumbased contrast material. In adults, CTU or MRU is now the preferred examination. Technical aspects of image acquisition and processing will be explored and technical tips relating to protocol design given. 2. The typical and atypical appearances of upper urinary tract urothelial tumours and bladder cancers will be demonstrated. A method of fluoroscopic biopsy of upper tract tumours is described for validation of the imaging diagnosis. 3. Early and accurate diagnosis of urinary tract tumours helps optimise prognosis but conventional investigative pathways are complicated and lengthy, utilising multiple imaging tests and many diagnostic algorithms exist without rigorous evaluation. CTU offers a single imaging test of high diagnostic accuracy with the potential to replace multiple alternative imaging tests in the diagnostic pathway, improve patient experience, improve diagnostic performance and accelerate diagnosis. MRU is a promising technique that may be used for the initial evaluation of patients at high risk for developing upper-tract urothelial carcinoma when CTU or intravenous urography is contraindicated. rhage and periventricular echodensities. The posterior fontanelle approach improves the detection of grade II haemorrhage in 30% more cases than the anterior fontanelle, and the mastoid fontanelle approach is essential for diagnosing cerebellar haemorrhage. Ventricular dilatation is the main complication of intraventricular haemorrhage and resolves spontaneously in approximately 65% of cases. The main challenge with periventricular echodensities is to differentiate them from classical periventricular leukomalacia. When cysts appear during follow-up, the diagnosis is straightforward. MRI is considered to be more sensitive than US for evaluating white-matter damage. Congenital brain malformations including ventricular dilatation of diverse aetiologies, corpus callosus agenesis and posterior fossa malformations are usually diagnosed prenatally. MRI complements US for this purpose. Acquired abnormalities arise mainly from infections and hypoxic-ischaemic injury. Although MR is considered the gold standard, US still plays an important role in the study of hypoxic-ischaemic lesions when used to its full capacity. Depending on the duration and severity of the hypoxic insult, patterns different from those seen in premature infants may be observed. Brain malformations are conditions where the brain has not formed properly during pregnancy. These problems in brain structure are almost often (with some exceptions) associated with neurological and developmental problems. Often, brain malformations are part of syndromic complexes that require a multidisciplinary approach. Malformations may be caused by inherited genetic defects, spontaneous mutations within the genes of the embryo, or effects on the embryo due to the mother's infection, trauma, or drug use. Classification schemes are currently shifting from a morphological to a genetic approach. The most frequent congenital brain abnormalities may be categorised into anomalies of the corpus callosum and telencephalic commissures, holoprosencephalies and related entities, malformations of the cerebral cortex, and malformations of the cerebellum. These congenital brain defects are diagnosed either from direct physical examination or from imaging studies including CT and MRI. Prenatal MRI offers a viable method to improve detection and characterisation of these entities in utero.

Learning Objectives:

1. To learn about the common supra-and infratentorial congenital abnormalities. 2. To learn when MRI is required and the appropriate imaging protocol. 3. To learn if and when CT is still useful in the investigation of congenital anomalies. In addition to predicting bone destruction for erosion, marrow oedema is independently predictive of joint space loss and therefore cartilage destruction. It also correlates well with other measures of disease activity. We have applied dynamic contrast enhancement techniques to show that treatment with anti-TNF therapy brings about a reduction in contrast uptake in areas of marrow oedema in patients with RA. In the seronegative arthritides marrow oedema in the spine in ankylosing spondylitis has been shown to be predictive of future changes and of response to treatment. Diffusion weighted imaging of marrow lesions in ankylosing spondylitis can also be used to show a treatment response, seen as a change in the apparent diffusion coefficient. Bone marrow oedema, also referred as bone contusion or bone bruise, is frequently identified at magnetic resonance imaging after an injury to the musculoskeletal system. It may result from a direct blow to the bone, compressive forces from adjacent bones impacting one another, or from traction forces that occur during an avulsion injury. Its location reflects the mechanism of injury, which allows for a focused search for predictable patterns of associated internal derangements. It is seen in any joint but are particularly common in the knee reflecting mechanisms such as pivot shift, hyperextension, contrecoup or dashboard injuries, as well as lateral patellar dislocation. In a context of trauma, bone marrow oedema, identified at MR imaging as areas of poorly marginated signal intensity alteration (best seen on fat-suppressed sequences) in the cancellous bone and marrow, represents areas of oedema and haemorrhage secondary to trabecular injury. It can be seen as soon as one hour after trauma and usually resolves in the following six to eight months, except in case of subsequent chondral lesion.

Learning Objectives:

1. To learn about BHE physiopathology in trauma scenario, direct and indirect mechanism. 2. To recognise BME as a footprint that allows other soft tissue injuries to be ruled out. 3. To analyse whether BME can be a value tool for follow-up.

Can we still use the term BME or should we be more specific? 09:44

The term bone marrow oedema was introduced to describe ill-defined bone marrow hyperintensity on T2 weighted images. Since then many studies have demonstrated that it can be found in many similar unrelated disorders, such as bone contusions, osteonecrosis, inflammatory or degenerative disease, and that it is a non-specific MRI abnormality. It has been demonstrated that bone marrow oedema might be a prognosis marker for OA (osteoarthritis) and inflammatory disease, and could be used as a powerful predictive tool for treatment options. Therefore our role is to increase specificity to help patient management and decrease progression.

Room E2 Sonography is an essential tool for studying the neonatal brain. Brain scans are usually performed via the anterior fontanelle; however, a more complete assessment of the brain can be achieved using the posterior and mastoid fontanelles, high-resolution linear array transducers and colour or power Doppler. The most common lesions in premature infants are intraventricular/periventricular haemor- At initiation, tumours in a pre-vascular phase are supplied by oxygen and nutrients that diffuse from pre-existing normal vessels. When the tumour reaches a critical size of approximately 1-4 mm diameter, the resultant ischaemia leads to secretion of angiogenic factors. These factors, such as vascular endothelial growth factor (VEGF), recruit and maintain tumour vessels. "New" vessels (neovasculature) exhibit increased blood volume and permeability compared with normal vessels.

Various new specific therapies in oncology target tumour vasculature or tumour neoangiogenesis. It is not uncommon that these targeted therapies have pronounced cytostatic and not predominantly cytotoxic effects. This limits the usefulness of size-based morphological tumour response assessments. Of newer magnetic resonance imaging (MRI) modalities, perfusion MRI has emerged as a valid marker of tumour-induced blood vessels and their function. MRI perfusion measures the vascularity within a tumour, as well as its component heterogeneous parts. Of parameters which can be measured to date, blood volume and permeability are commonly applied in patient studies. Blood volume measures the aggregate size of the vascular space, while the permeability function informs about the integrity of vessels and their ‚leakiness' to contrast agents. We will describe the use of MR perfusion to monitor such new therapies and discuss its specific advantages and limitations in comparison to CT perfusion protocols. PET-based strategies for targeted treatment-monitoring in oncology will be briefly mentioned, with prospect on the significance of combined vascular and metabolic imaging for further optimising non-invasive response assessment in specific anticancer therapies. After a brief review of physical and technical principles of diffusion-weighted MR imaging and PET-CT, the lecture describes the ability of these techniques in evaluating functional parameters in tumour tissue. Diffusion-weighted sequences have been used in an attempt to further increase the diagnostic capability of baseline and dynamic MR study by providing functional information. Diffusion-weighted MR imaging is based on the random microscopic movement of molecules that can be quantified by means of apparent diffusion coefficient (ADC). In the early post-treatment period after loco-regional therapies, tumours may not change in size. Recent studies demonstrated that water diffusion can be used to differentiate viable and cellular regions from necrotic area in the tumour, regardless morphologic or dimensional changes. Moreover, new classes of antitumour therapy have been developed that have an antiproliferative effect, inducing a delay in tumour shrinkage. Diffusion MR imaging can be promising in this clinical setting as a biomarker to predict early response to systemic chemotherapy. On the other hand, PET/CT, combining the functional and the structural imaging approach, was shown to be superior regarding conventional imaging modalities in the identification of intrahepatic and extrahepatic metastases. Less experience and less publications are available for PET-CT in monitoring tumour response after interventional therapies, but the ability of PET-CT to measure early metabolic changes could make this technique useful in the development of novel anticancer drugs. Until now, in oncology, only the RECIST criteria based on anatomical measurement of the tumour size are used for drug trials or in clinical practice because this is a standardised way to assess the tumour response that allows the calculation of the progression-free survival (PFS) or the time to progression (Ttp) that are usually accepted as surrogate end point for overall survival. However, tumour follow-up evaluation using only morphology is usually delayed and with the emergence of new numerous and very expensive targeted therapies there is now a need to move beyond morphology to find new ways to assess tumour responses or progression not only for clinical trials but also in clinical practice to maintain or to change quickly a treatment. This is the aim of the functional imaging using ultrasound, CT, MRI or PET. The ultimate goal of these technique is to find biomarkers able to predict the likely course of disease, irrespective of treatment (prognostic biomarkers) or able to forecast the likely response to treatment (predictive biomarkers); before (baseline values of a parameter) or during the treatment (dynamic variation of the parameter during the follow-up). During this session the presenters will discuss the technical issues and the results obtained today using ultrasound with share-waves or microbubbles, functional CT, dynamic contrast enhanced MRI, diffusion weighted MRI and PET-CT. The candidate biomarkers will be presented as well as the limits and the problems that are still to be overcome.

A. US and CEUS M. Claudon; Vandoeuvre-les-Nancy/FR (m.claudon@chu-nancy.fr)

For tumour evaluation, the main advantages of ultrasound (US) associate a high frame rate and a large range of data and parameters potentially extracted from the signal backscattered from tissues. Beyond morphology, elastography is a first modality, based on in vivo estimation of the mechanical properties of tissues. Data on displacement or strain of tissues and lesions can be obtained by manual external compression, but shear wave generation techniques allow for a quantitative and more precise estimation of their visco-elastic properties. In oncology, clinical evaluation included first breast. Contrast-enhanced US (CEUS) is obtained after intravenous administration of microbubbles which are pure blood pool contrast agents. CEUS is capable for detection, characterisation and follow-up of tumour lesions, based on enhancement profiles during bolus, destruction-replenishment, or contrast burst depletion imaging. Quantification of perfusion in normal tissues and lesions may be obtained by extracting various blood flow and blood volumerelated parameters from time-intensity curves. Protocols have entered validation processes to improve reproducibility. As a predictive technique, CEUS is a promising tool for monitoring changes of haemodynamic parameters and evaluating the early response during chemotherapy or antiangiogenic treatment. It is helpful in the guidance and follow-up of lesions treated by radiofrequency or cryoablation. Recent advances of US and CEUS include 3D/4D real-time imaging with matrix technology, and the evaluation of targeted agents, to be released on site after bubble destruction by the US beam. Interventional radiology (IR) is the part of clinical radiology based on the percutaneous or endoluminal treatment of widespread conditions. The procedures performed by the interventional radiologists require a deep level of knowledge of clinical imaging and specific training in patient management and care. Technical skills are also needed because complex devices and materials are used in some procedures. Therefore, specific training programmes are required to address the training needs for the interventional radiologist. A multidisciplinary approach is required (based on team work) with defined levels in patient care. IR procedures have become the treatment of choice for many conditions as an alternative for some surgical procedures. Even for some conditions without a defined treatment are now being treated by IR. Thus, it is a discipline with a great deal of interaction with other clinical specialities that requires a clear definition. IR specialists have to receive recognition in the patient care process and their activity has to be known by the medical community. The recognition of IR as a subspecialty of clinical radiology by the UEMS will contribute to the development of specific training programmes in the European community and will promote training centres with certified specialists. Interventional radiology (IR) procedures are complex and require specific training to ensure good results. In the UK, a curriculum for subspecialty training was established in 1998 specifying the required knowledge, training and core procedures expected of trainees. This curriculum has undergone several reforms since that time. However, training is not uniform throughout Europe and this stimulated the development of a Europe wide IR training document to ensure similar training in all countries as a way of ensuring good medical practice. Radiology training is based on 3 years of common radiology training and 2 years of subspecialty training with an option for further specialist training in the 6 th year. Regular appraisals and assessments of trainees' performance should guide progress at local training institutions with the aim that competence is assessed formally at the end of training by a European Board examination. This qualification will be recognised thoughout Europe and ensures that the required proficiency in IR procedures has been attained. Competence in the core skills for IR occurs during the first 3 years of training. In the next 2 years, trainees undertake modular training depending on their areas of interest and ultimate goals. The majority of this training is practical, supervised training in interventional suites and theatres, with clinical exposure. Simulators play a role alongside the more traditional training methods and allow early training in a more forgiving environment away from the patient. Development and validation of such simulation models is progressing.

discrimination of individual x-ray quanta, i.e. the detectors can 'see' the colour of the x-rays. Different materials attenuate the energy spectrum in their own characteristic way. By comparing the measured spectra with the spectrum emitted from the x-ray tube the penetrated material can be characterised. Colour x-ray imaging can be used in breast imaging to detect, for example the uptake of an iodinated contrast agent to show the vasculature of a tumour while reducing the impact of the structures from the surrounding tissue. It can also be used to estimate the breast density and as a material decomposition technique to separate the digital mammogram into compositional images, showing different material types separately. Colour x-ray imaging can, for example be realised with pulse height discrimination in a photon counting detector, multiple exposures with different x-ray tube settings or filtering the x-ray beam before or after the object. The most simple form of colour x-ray is dual energy where two images are acquired at different x-ray energies. Lung cancer staging is based on imaging techniques in combination with tissue diagnosis and surgical exploration. The TNM staging system describes the local tumour extent (T1-T4), presence or absence of lymph node metastases (N0-N3) and distant metastases (M0/M1). Different combinations of T-, N-and M-factors translate into tumour stages (stages IA-IV). Therapeutic decisions and assessment of prognosis are based on these tumour stages. Recently, the TNM system has been modified: tumour size is now used more precisely for T staging: tumours <= 2 cm: T1a, > 2-3 cm: T1b, > 3-5 cm: T2a, > 5-7 cm: T2b, > 7 cm: T3. Satellite tumour nodules in the same lobe are now classified as T3 (previously T4) and in a different lobe of the ipsilateral lung as T4 (previously M1). Satellite nodules in the contralateral lung (previously M1) and pleural or pericardial metastases (previously T4) are now classified as M1a, whereas distant metastases outside the chest are classified as M1b (previously M1). Also, the TNM staging system should now be applied not only to non-small cell lung cancer (NSCLC) but also to small cell lung cancer (SCLC). During this refresher course the different T-, N-and M-stages will be presented including the recent changes and examples will be presented and discussed with the audience. Therapeutic strategies in different tumour stages will be described and key decisions highlighted. The accuracy of different imaging procedures and findings will be presented and the role of biopsy in specific clinical scenarios will be discussed. X-ray computed tomography (CT) has been proposed and evaluated recently as a potential alternative method for breast imaging. Efforts so far showed success with respect to contrast-enhanced dynamic imaging, but suffered from limited spatial resolution. Respective efforts and clinical results will be reviewed. The new concept presented here builds upon micro-CT scanning approaches and aims at providing both high spatial resolution at around 100 µm for micro-calcification imaging and advanced dynamic scan capabilities with continuous acquisition and scan times of about 10 seconds for differential diagnosis of lesions. To achieve this, spiral scan modes, slipring technology, high-resolution detectors and high-power micro-focus x-ray tubes are demanded. The concept has been evaluated and confirmed by simulations and basic experiments; feasibility studies are expected by the end of 2011. Colour x-ray imaging can best be described as the x-ray analogy to optical colour imaging. In optical imaging the wavelength -the energy -of the light gives the different colours that we see. Emerging x-ray detector technologies enable energy maintenance of confidentiality of patient information. In contrast, more hierarchical cultures often defer to elders for decision-making whereas communal cultures may involve community leaders in a shared decision-making process. Gender and religious issues can also affect the provision of high-quality procedures with same gender care being a requirement within some cultural groups and gowning procedures that maintain cultural values frequently being an expectation. In addition, in many countries in the developing world, radiation still has mystique and fear associated with it, affecting participation in screening programs and recruitment to medical radiation technology educational programs. This presentation will present findings from a variety of countries and cultures that will help to contextualise these issues through a cross-cultural imaging lens. First line image interpretation is now commonly used in the United Kingdom. For many years radiographers have used a system commonly known as "Red Dot" in order to identify to the referring clinician that an abnormality has been recognised on a radiographic image. This has more recently evolved into radiographer comment where the radiographers' experience in recognising abnormalities can help referring clinicians. Junior doctors are often inexperienced at image interpretation, thus this system can assist in ensuring that a higher percentage of fractures and injuries are observed and the appropriate treatment obtained. This presentation will demonstrate the fundamentals of basic image interpretation of the cervical, thoracic and lumbar spine in a trauma situation. It will include basic anatomy, mechanism of injury, common fractures and soft tissue signs. Using these principles this will encourage radiographers to use the comment system, both developing the radiographer's role and helping to improve patient care. Two fasciae cross the suprahyoid neck: the superficial cervical fascia (SCF) and the deep cervical fascia (DCF). The latter can be divided into three parts and these layers define different fascial spaces or compartments. The descriptions of these compartiments in the literature vary almost as much as those of the fasciae themselves. In addition, the names of the formed compartiments vary within the literature. Despite these controversies, the knowledge of these compartiments is inestimable for correct differential diagnosis of pathologies that arise in the suprahyoid neck. With the utilisation of cross-sectional imaging, it has been noticed that growth of some tumours appears restricted by fasciae and knowledge of the anatomy of these fasciae allows not only prediction of growth patterns. By allocation of a tumour to a certain compartiment the number of differential diagnosis drop dramatically due to the fact that in different compartiments different types of tissue occur. In addition, the exact localisation of infectious disease of the suprahyoid neck may predict further intracranial or mediastinal spread. Even though the number management of cancer patients, imaging pitfalls must be recognised to avoid both false-positive and false-negative interpretation. The principles and good practices of PET/CT will be explained. Normal distribution of FDG, pitfalls and normal variants will be presented. Specific examples will be discussed to demonstrate how the combined information of images of human anatomy upon which biological information within body structures is added improves delineation of disease, can guide surgical and radiation planning and biopsy. Advances in technology result in new training requirements for radiologists who should promote close collaboration with nuclear medicine specialists. The metabolic syndrome refers to the clustering of cardiovascular risk factors including diabetes, obesity, dyslipidaemia and hypertension. The association between metabolic syndrome and cardiovascular diseases raises important questions about the underlying pathological processes. Insulin resistance and visceral obesity have been recognised as the most important pathogenic factors. Metabolic syndrome generally precedes and is often associated with type 2 diabetes. Cardiovascular risk reduction in individuals with metabolic syndrome should include (1) control of obesity, diet and physical activity and (2) control of the individual components of metabolic syndrome, especially atherogenic dyslipidaemia, hypertension, hyperglycaemia and prothrombotic state. Appropriate management of metabolic syndrome should be able to prevent the progression from impaired glucose tolerance to frank diabetes and thus to prevent the increasing prevalence of type 2 diabetes and vascular diseases. Each 1% increase in HbA1c is associated with a 28% increase in risk of incident PAD. Diabetes is also highly associated with progression of PAD and especially with the development of critical limb ischemia. Rigorous control of blood glucose prevents the microvascular complications of diabetes, although similar benefits on the macrocirculation have not been ascertained. Patients with diabetes and PAD should have an aggressive control of blood glucose levels with a HbA1c goal of < 7.0% or as close to 6% as possible. In the new TASC paper this recommendation is graded as C, meaning that it is based on evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities, while there are no applicable studies of good quality. Peripheral arterial disease (PAD) is a common cardiovascular complication in patients with diabetes. In contrast to non-diabetic PAD, it is more prevalent and, because of the distal territory of vessel involvement and its association with peripheral neuropathy, it is more commonly asymptomatic. Diabetic PAD thus may present later with more severe disease and have a greater risk of amputation. The pervasive influence of diabetes on the atherothrombotic milieu of the peripheral vasculature is unique. The abnormal metabolic state accompanying diabetes results in changes in the arterial structure and function. The proatherogenic changes include increases in vascular inflammation and derangements in the vascular cellular components, alterations in blood cells and haemostatic factors. These changes are associated with an increased risk for accelerated atherogenesis as well as poor outcomes. In contrast to the focal and proximal atherosclerotic lesions of non-diabetic PAD, in diabetic patients the lesions are more likely to be more heavily calcified, diffuse, and distal, sparing the proximal vessels and mainly affecting the more distal arteries in the calf and, in a later stage, the foot. By identifying a patient with subclinical disease and instituting preventative measures, it may be possible to avoid acute, limb-threatening ischaemia. The primary imaging modality to be used should be duplex ultrasound, due to its non-invasive nature, lower risks and costs. CT-angiography and MR-angiography are now replacing DSA as standard imaging methods, providing a non-invasive assessment of the localisation and extension of a vascular lesion and allowing an accurate planning of endovascular and/or surgical treatment. of spaces in the literature varies from seven to fourteen, the use of seven spaces or compartiments seems to be helpful for a sufficient diagnostic approach using cross-sectional imaging. Anatomic landmarks and the radiologic appearance in a non-pathologic suprahyoid neck and a pathologic involvement of the suprahyoid compartiments will be reviewed extensively in a coherent manner. The anatomy of the suprahyoid neck is complex and the spectrum of diseases is wide. To improve studies of the neck, radiologists should become increasingly more familiar with the anatomy and expected pathology in the various spaces. This familiarity provides crucial information required for the selection of treatment options and therapeutic planning. In addition, radiologists should be aware of situations when diagnostic inaccuracies may lead to serious consequences and complications. For example, surgical approach to a deep lobe parotid tumour as though it is a parapharyngeal lesion will in all likelihood result in facial nerve injury. MRI artefacts such as complex flow-induced increase in signals may be mistaken as a lesion prompting an unnecessary operation. An awareness of such pitfalls helps to improve the quality of imaging studies. This presentation highlights some pertinent anatomical knowledge that may help to improve the diagnostic accuracy of neck studies and at the same time explain the existence of pitfalls that may ruin imaging studies. Three layers of the deep cervical fascia define the suprahyoid neck compartments, which include: prevertebral, retropharyngeal, carotid, masticator, parapharyngeal and pharyngeal mucosal space. Knowledge of the structures inherent to these spaces will provide the radiologist with an accurate basis for differential diagnosis. Also, expanding lesions will distort or displace adjacent structures and fascia in predictable fashion, which is crucial in defining the site of origin. Both MRI and CT are frequently used in the imaging of suprahyoid neck lesions. The introduction of functional imaging has also given some benefits. Primary and secondary, benign and malignant processes occupying major suprahyoid neck spaces will be discussed, with regard to crucial findings necessary for appropriate treatment selection and treatment planning. Since correct diagnosis requires close collaboration with ENT surgeons, clinical findings will also be discussed, together with practical information needed for surgery. In vivo proton MR spectroscopy is a non-invasive MR technique that is routinely used to assess a number of paediatric neurologic conditions. It is based on the fact that protons belonging to different metabolites resonate at slightly different frequencies (chemical shift). Using water suppression and volume localisation techniques we can obtain a spectrum (single voxel) or spectra (SI) containing metabolite peaks corresponding to predetermined anatomical site(s). In paediatrics the majority of spectroscopy is performed in the brain and the metabolites detected usually are: N-acetyl aspartate, N-acetyl aspartyl glutamate, creatine and phosphocreatine, Choline containing compounds (free choline, acetylcholine, phosphocholine, cytidine diphosphate choline and glycerophosphocholine), myoinositol, myoinositol monophosphate and glycine, aminoacids (glutamine, glutamate and GABA), lactate, lipids and macromolecules. These metabolites participate in fundamental metabolic pathways and their levels are being disturbed by various pathologies. Thus, MR spectroscopy has a vast field of application including paediatric tumours, infarction, hypoxia, ischaemia, infection, inflammation, metabolic disorders neurological disorders and trauma. In many cases, it can redirect or narrow differential diagnoses; in selected instances, it may provide the key finding that points to a final diagnosis. However, MR spectroscopy alone is usually not specific, but can be very helpful especially in combination with other clinical, diagnostic and other MR methods. Finally, particular caution is needed in data evaluation because spectral appearance and concentrations of the most prominent metabolites are affected by (a) experimental and preprocessing factors and (b) brain development. Stroke in children is most often of ischaemic origin and thrombophlebitis is the second cause of stroke in children. Stroke is considered as rare compared to the adult population. However, numerous aetiologies impose to look for a cause through series biological investigations. The goal of brain imaging is to confirm the diagnosis of stroke, to evaluate the extension of ischaemia and mostly to participate in the search of a cause for the stroke. Prognostic is mostly related to the aetiology. A lot of cases are performed under general anaesthesia leading to limited indications of MRA in the acute phase compared to adult. The role of CTA at the acute phase is mostly to confirm thrombophlebitis and is the primary method to assess intracranial vessels at the acute phase of haemorrhage of arterial or venous origin. It is also the primary method to assess arterial vessels at the neck level (especially when dissection is suspected). CTA permits to confirm or rule out arterial lesion that was suspected on MR: indeed, cases with pitfalls are numerous with MR angiography. The role of MRA, also always performed in the acute phase or follow-up of vascular diseases, is not as clear as CTA role because of artefacts especially in young children. The role of angiography (DSA) is finally limited to prove vasculitis when the other methods are not contributive and in cases of arterial or arterio-venous malformation to plan the treatment (endovascular procedure versus surgery or radiosurgery). Diffusion tensor imaging (DTI) studies demonstrate progressive apparent diffusion coefficient (ADC) decrease within grey and white matter areas starting from foetal life as sign of brain maturation; meanwhile, fractional anisotropy (FA) increases in some white matter structures. Changes in FA and ADC, together with radial and axial diffusivity values, during cell proliferation-migration and during myelination, well correlate with modifications known from developmental histologic studies. Acute ADC decrease (i.e. ischaemia) can be detected already in foetal stroke and its measure is pivotal in monitoring neonatal hypoxic-ischaemic encephalopathy. ADC calculation allows also to assess acute osmotic and metabolic anomalies in neonate (i.e. hypernatremia, hypoglycaemia, etc.). Early FA decrease, with radial and axial diffusivity changes, is observed in white matter areas as sign or early wallerian degeneration after acute brain damage. Chronic regional white matter FA reduction is detectable in sequelae of periventricular leukomalacia or adjacent to malformative cortex. Also, in children with neurodevelopmental delay (autism, ADHD, dyslexia, etc.). FA reduction and radial or axial diffusivity changes have been demonstrated, but in these conditions not on a single case basis rather in cohort quantitative studies. Finally, building fiber tracking and colour coded (RGB) maps from DTI data may help in better characterising suspected structural anomalies on a single case basis (i.e. corpus callosum, hippocampal fornix, optic radiation, cerebellar peduncles malformations, etc.). However, the potentials of fiber tracking applications still need to be fully exploited, especially in view of future higher spatial resolution image acquisitions.

Learning Objectives: 1. To understand the relationship of ADC-FA values with the structural characteristics of the normal developing brain. 2. To understand ADC-FA value changes in paediatric CNS diseases. 3 . To learn about the potential impact of fibre tracking in clinical paediatric neuroradiological practice. Congenital pulmonary malformations may involve the lung parenchyma, bronchi, arterial supply, and venous drainage. The pulmonary developmental abnormalities that most commonly result in clinically significant complications in neonates and children are hypogenetic lung syndrome, bronchopulmonary sequestration (BPS), congenital lobar emphysema (CLE), bronchial atresia, congenital cystic adenomatoid malformation (CCAM), and bronchopulmonary foregut cysts. It should be noted that there is often considerable overlap between these conditions and that multiple lesions may be identified in the same patient either separately or as hybrid lesions. The aim of this presentation is to illustrate the characteristic imaging manifestations of the most important congenital lung diseases and their main differential diagnosis. Emphasis will be given to pre-natal diagnosis using ultrasound or magnetic resonance imaging (MRI) and post-natal diagnosis using MRI or low dose CT in multidetector scanners. Ultrasonography (US) is the primary screening modality in prenatal imaging. Its diagnostic accuracy is usually very high so that the indications for foetal MRI should be very rare. In some countries, because US is considered of secondary importance and is not exploited as much as it could be, there is a progressive shift from US to MRI as a prenatal imaging modality. Consequently, there are many discrepancies regarding the relative contributions of foetal US and MRI in the prenatal literature. The main indications for foetal MRI will be discussed, with emphasis on the central nervous system, which remains the main field of application. In daily practice, the technique of foetal MRI has not changed during the last decade and most diagnoses can be assessed using T1, T2 and T2* sequences. The basic technique and patient preparation will be described. New techniques, based on a functional or a metabolic approach, have been developing during the past few years but their impact on daily practice is still very limited. Many studies have underlined the high diagnostic contribution of foetal MRI compared with US. However, the diagnostic accuracy of MRI has not been studied in large series. Comparison between pre-and postnatal data or between foetal MRI and pathological findings make it possible to define the main limits of foetal MRI. Regarding the brain, migration or cortical development disorders are often overlooked or underdiagnosed. A tight collaboration between colleagues practicing prenatal US and MRI should increase diagnostic accuracy, both modalities being complementary. Founded on September 15, 1948, the Brazilian College of Radiology comprises 23 Regional Societies and ten thousand associates. The college is a branch of the Brazilian Medical Association (AMB) acting as its Scientific Department of Radiology, Imaging Diagnosis and Radiotherapy. It collects, under the same umbrella medical professionals and legal entities in the field of diagnosis and treatment using imaging methods and/or ionising radiation. Session Objectives:

1. To get an introduction to the practice of radiology in Brazil. 2. To understand the importance of radiology as a method for diagnosing diseases in Brazil.

Granulomatous interstitial lung disease: HRCT path correlation C.I.S. Silva; Salvador/BR (c.isabela.silva@gmail.com)

Granulomatous interstitial lung diseases are a group of lung diseases in which granulomas are an important component of the histologic findings. The most common conditions are hypersensitivity pneumonitis and sarcoidosis. Hypersensitivity pneumonitis is very common in Brazil because of the warm and humid climate in most regions and a large number of birds. The prevalence of sarcoidosis in Brazil seems to be lower than that in North America and Europe. Other ubiquitous causes of granulomatous interstitial lung disease include intravenous talcosis, drug reactions, and some forms of vasculitis (e.g. Churg-Strauss syndrome). The aim of this presentation is to illustrate the characteristic high-resolution CT and histologic manifestations of the most common granulomatous interstitial lung diseases and to summarise the main differential diagnosis based on the pattern and distribution of abnormalities seen on high-resolution CT.

Learning Objectives: 1. To become familiar with the characteristic high-resolution CT and histologic findings of the most common granulomatous interstitial lung diseases (hypersensitivity pneumonitis and sarcoidosis). 2. To learn about the most helpful features in distinguishing the granulomatous interstitial diseases from other parenchymal lung diseases.

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The most common granulomatous lung diseases are fungal infections and tuberculosis. These infections are particularly prevalent in Brazil, the most common fungal infection being paracoccidioidomycosis (South American blastomycosis). Histoplasmosis and coccidioidomycosis may occur but they are uncommon. Paracoccidioidomycosis is the most frequent endemic systemic mycosis in Latin America, being seen particularly in Brazil, Argentina, Colombia, and Venezuela. The lungs are the main target organ of P. Brasiliensis organisms, and infection of the lungs is the leading cause of morbidity and mortality in these patients. Fungal infections need to be considered not only in patients living in endemic regions but also in patients who have travelled to these areas. Although the prevalence of pulmonary tuberculosis has decreased in Brazil in recent years it remains one of the most important causes of pulmonary morbidity and mortality. The aim of this presentation is to discuss the radiologic manifestations of the granulomatous pulmonary infections with emphasis in paracoccidioidomycosis and tuberculosis and to summarise the main differential diagnosis. Magnetic resonance imaging (MRI) is a highly sensitive technique that provides complementary information to conventional breast imaging (i.e. mammography and ultrasonography) for the detection of multinodular disease and for the assessment of primary tumour extent. The use of MR breast imaging has increased considerably in the past decade. Although its use is well established for some indications, e.g. detection of unknown primary and assessment of uncertain disease extent, breast MRI is still under investigation for other applications such as preoperative assessment in patients eligible for breast conserving therapy on the basis of conventional imaging and clinical examination. Despite its superior ability to visualise disease spread, recent studies have shown increased rates of mastectomy without reduction in positive surgical margins or local recurrence rates. Nonetheless, a shift in paradigm is occurring, focusing on the use of breast MRI to reduce involvement of healthy tissue in breast-conserving therapy. This paradigm involves new methodology to optimise the transfer of information to the surgeons and radiation oncologists. New technological developments, such as diffusion-weighted imaging (DWI) and magnetic resonance spectroscopy (MRS) provide new insights to establish a link with underlying biology of the tumour. Contrast-enhanced MRI, DWI and MRS are examined for their ability to extract prognostically relevant information to individualise therapy to individual patients and tumours. This overview aims to summarise the current status of breast MR imaging and new developments geared towards providing therapists with patient-tailored information for treatment decision, treatment guidance and therapy response.

This talk will review the current literature and clinical use of foetal MRI in cases with ventriculomegaly. The initial part will discuss antenatal ultrasound in the detection, categorisation and diagnosis at the 20-week anomaly scan. The role of foetal MRI will be discussed including which cases may benefit most from foetal MRI when the resource is limited. The timing of the foetal MR with relation to gestational age and the value of further foetal MR scans at a later gestational age will also be discussed. This is still a controversial and debated area especially when the resource is limited or there are financial constraints. The current literature will be discussed on the issues around foetal MRI in cases with ventriculomegaly both isolated ventriculomegaly and ventriculomegaly associated with other abnormalities. Finally, this section will conclude by looking at the common associated abnormalities seen in cases referred with ventriculomegaly. The final section will discuss the role of foetal MR in imaging the posterior fossa, an area often difficult with ultrasound especially in the later stages of pregnancy. Again the current literature will be discussed and the use of foetal MR in clinical practice. The concluding time will be used to summarise the referral pathway used by local centre in the UK. This will differ with other UK centres and centres worldwide. Hopefully, time will allow an open discussion on this at the end of the session. Learning Objectives:

1. To learn about the differential diagnoses of ventriculomegaly identified on foetal ultrasonography. 2. To learn when MR should be performed and its value when compared to ultrasonography. 3. To understand the value of MRI in assessing posterior fossa abnormalities.

Prenatal diagnosis involves obtaining genetic, anatomic, biochemical and physiological information about the foetus and analysing whether there are any alterations that might have repercussions during the foetal period or after birth. Magnetic resonance imaging (MRI) has been useful in the diagnosis of foetal anomalies for many years. Thoracic abnormalities play an important role in infant morbidity and mortality. Survival after birth depends largely on adequate lung development during gestation, and various pulmonary problems can affect foetuses. Heart defects are present in 8 of 1000 live births, and up to 25% of these are associated with other malformations. Other thoracic anomalies (tracheoesophageal malformations, chest wall defects, and tumours, amongst others) can also cause morbimortality. Congenital abdominal anomalies can affect many organs. It is essential to determine the location and morphological characteristics of the lesion to ensure an accurate diagnosis. MRI's excellent contrast resolution between tissues is very useful in the diagnosis of these conditions. Prenatal diagnosis also makes it possible to detect anomalies that can be difficult to recognise clinically in newborns but require early treatment to minimise possible complications.This presentation stresses the importance of diagnosing chest and abdominal problems before birth and analyses the usefulness of MRI in this context. Learning Objectives:

1. To learn about the MR protocol when investigating the foetal chest. 2. To recognise the situations in which MRI is helpful in assessing chest abnormalities. 3. To understand the value of MRI when compared to ultrasonography in assessing congenital renal and gastrointestinal abnormalities.

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Structured reporting: improving the quality of radiology reports C.E. Kahn; Milwaukee, WI/US (kahn@mcw.edu)

The radiology report communicates the results of an imaging procedure and provides the enduring legal record of the procedure. Structured reporting uses standardised language and predefined formats to create reports. Structured reports can integrate information collected during the imaging procedure, such as clinical data, technical parameters, measurements, annotations, and key images. In this presentation, well defined structured reporting describes its advantages and disadvantages, and identifies the motivations for its adoption. This session will discuss how structured reporting can make it easier to retrieve reported information, evaluate the appropriateness of exams, and aggregate data across health care enterprises. Structured reporting can support radiology quality improvement, research, and education, and has the potential to improve the quality of communication between radiologists and their referring colleagues. 

Beyond Air-space disease is secondary to occupation of the acini and alveoli by oedema, exudates or malignant cells. It presents in the chest radiograph as ill-defined densities which tend to coalesce. The presence of an air bronchogram is pathognomonic. When the disease is widespread it shows the typical "butterfly" appearance. Air- The pixel data set of modern imaging is transformed into a life altering insight for the individual patient through the radiologic report. A good report is patient and service centred, and forms the basis of the reciprocal relationship between radiologist and referring clinician. It is a creative process with serious scientific purpose and becomes part of the permanent record in a person's life. Its primary role is communication of diagnostic and procedure-related imaging information but it has many vital adjunct roles in quality service delivery. In current practice of multidisciplinary care the report content must be of value to all the stakeholders beyond radiology. Structured reports must have uniformity where possible to permit data-mining and audit whilst preserving the individual radiologist practice and style and the individual nature of each patient's health. Report design has a particular role in modern alerting and safety-net systems when unexpected or critical imaging findings are discovered. The properly written report can be vital in medico-legal defence to reflect good practice. Ultimately guidelines and standards on reporting must be meaningful to the users and appropriate to local resources, systems and needs. Learning Objectives: 1. To comprehend the role of the modern radiological report. 2. To understand the role of the report in communication and patient safety. 3. To become familiar with structured report formulations.

Structured reporting: European perspective R. Silverio; Grosseto/IT (rsilverio@sirm.org)

In the last decade, we observe an increasing interest in structured report (SR). This is a part of the DICOM standard, where the technical and clinical information are organised in a standard format so that it can be retrieved and reused for clinical, statistical and research scopes. Structured reports have three important features: a "structured" format, with fixed paragraphs, heading and subheading in which to describe technical data and clinical findings, impressions and conclusions; a consistent, "itemised" organisation, leading to a better way of reporting, even with automated speech recognition systems; and the possibility, or rather the need, of a common, shared language. When defined terms from a standard lexicon are associated with imaging reports, the information in the report becomes more accessible and reusable. Moreover, SR allows the interoperability between the DICOM world and the complex sphere of the e-health (electronic patient record, patient care, etc). It is possible to convert a radiological report created as SR in a CDA2 (Clinical Document Architecture) document. This clinical document will be used in every computerised healthcare application, as well in the several regional e-health projects (EPSOS, ELGA, Calliope, Renewing Health, etc). promoted by European Community. Integrating the Healthcare Enterprise (IHE) initiative is as a key partner in fostering the adoption of structured report. In short, question of whether SR will be adopted by radiologists is now a question of "when", not "if." Learning Objectives: 1. To become familiar with structured report. 2. To keep up to date on the developments of e-health projects in Europe. Acute mesenteric insufficiency (AMI) is due to arterial or venous occlusion. Arterial AMI is an emergency. The typical patient is elderly, may have atrial fibrillation and has recent onset intense visceral pain disproportionate to clinical signs. CT is the mainstay of diagnosis and may be supplemented by CT angiography (CTA). Waste no time if arterial AMI is suspected. Average mortality rates of 71% (59-93%) have been reported and symptom duration before therapy is an independent predictor of mortality. Age > 70 years, metabolic acidosis and renal failure are other danger signs. Interrupt routine CT lists; ensure that these patients are scanned as soon as possible -neutral oral contrast and high-dose IV contrast are essential. CT appearances should be correlated with serum lactate as acute arterial occlusion without reperfusion may produce falsely 'normal' bowel wall thickness. Early diagnosis and aggressive surgical intervention combining bowel resection with revascularisation offer the best prognosis. Venous AMI may present with a more chronic, intermittent course of pain, fever, abdominal tenderness and ascites. Therapy is bowel resection and anticoagulation. Ischaemic colitis occurs in elderly patients with atherosclerosis spontaneously or after aortic aneurysm repair. This invited lecture explores the groundbreaking use of CT for studying antiquities and artworks from a wide range of cultures, irrespective of their age or material. Dr. Marc Ghysels, a former interventional radiologist, comes from a family of artists and collectors. About ten years ago he set up a private radiology practice in Brussels where he analyses antiquities and artworks. Over the years he has built an international reputation among collectors and art dealers as well as museum curators and experts working in auction rooms. Art specialists call on his radiological skills and knowledge to authenticate antiquities, and more specifically to show: what methods were used to make the works, what damage they have suffered over the years, how much restoration has been done, and to expose the many tricks used by forgers to deceive not only the discerning eye of the collector but also the methods of scientific analysis more commonly used than CT scans. His presentation will highlight the prominent role of CT as a nondestructive test to explore selected artworks made in wood, terracotta, stone, and ivory. Acute abdominal organ ischaemia may be caused by hypovolaemic shock, spasm (ergotism), embolisation and aortic dissection. Embolisation is the most common cause. It occurs typically in elderly patients with atrial fibrillation, after myocardial infarction or due to a thoracic aortic aneurysm (TAA). The primary diagnosis is made by CT with contrast enhancement which can also demonstrate cardiac thrombi or a TAA. Interventional treatment can be performed with a thrombectomy device or fibrinolysis with recombinant tissue plasminogen activator (rt-PA; 10 mg loading dose, 5 mg/hr infusion dose). Acute aortic dissection may cause dynamic compression of the true lumen with occlusion of the ostium of the visceral arteries (floating visceral sign). The primary diagnosis is made by CT. Occlusion of the primary entry tear with a thoracic aortic stentgraft may decompress the false lumen followed by reexpansion of the true aortic lumen followed by reperfusion of the visceral arteries. Chronic abdominal ischaemia in younger patients may be due to fibromuscular dysplasia, Takayasu arteritis or neurofibromatosis. In the elderly it is usually caused by arteriosclerosis. The patient may have post-prandial abdominal pain (angina abdominalis), diarrhoea and/or weight loss. Due to the collateral circulation, symptoms usually occur only if more than one of the major arteries (celiac trunk, superior and inferior mesenteric artery) is narrowed. The diagnosis can be made by color Doppler ultrasound (CDUS), CT and MR with contrast enhancement. Endovascular treatment is done by PTA and stent placement.

To learn what to include in the report of CNS infections for the treatment planning. 4. To learn how to report follow-ups and treatment monitoring of CNS infections. Finding of a palpable mass in the abdomen always raises the possibility of an important clinical problem. A potentially life-threatening process, especially malignancy is the major concern. The list of differential diagnosis of "abdominal mass" is a very long one. In the process of differential diagnosis the most common approach is to evaluate the patient according to the gender, age, patient history and co-existing clinical and laboratory findings. The accompanying symptoms and signs and the location of the abdominal mass are the key indicators in the clinician's way of thinking in the process of differential diagnosis. For instance, a palpable mass with acute abdomen or intestinal obstruction will be assessed differently than a mass found incidentally. Imaging is commonly required to confirm or ascertain the diagnosis. Cross-sectional imaging is required to accurately evaluate a palpable abdominal mass in most situations. Ultrasound and computed tomography have each been used successfully in evaluating patients with palpable abdominal mass. Although each modality is appropriate in most situations, the advantages and disadvantages of each modality in certain situations will be addressed and the appropriateness criteria will be reviewed in this lecture. Knowledge of a detailed clinical history is as important to the radiologist as to the clinician. Its impact on the diagnostic accuracy in the interpretation of the images will also be addressed. 

A palpable abdominal mass has a long list of benign and malignant differential diagnoses. These diagnoses may be as different as a hydatid cyst of the liver, a volvolus, an aneurysm, or a giant renal cell carcinoma. The diagnostic approach is based on two major steps: first, the affected organ must be indentified. Second, the differential diagnosis must be established based on imaging characteristics. The choice of ultrasound, CT or MRI should be based on location and size of the mass. Despite the fact that ultrasound is frequently used as a first step, the overview and anatomic orientation in large masses may be hampered, making ultrasound a better technique for image-guided biopsy than for primary diagnosis. In the vast majority of cases, multidetector CT is the first technique of choice. A thin-section protocol should be used to allow for high-quality multiplanar imaging. A pre-contrast scan is usually not required but can be helpful in suspected hemorrhage. For most upper and middle abdominal masses, biphasic imaging in the arterial and portal phase is recommended in order to establish the relation of the mass to the vasculature and to assess vascularity. In the small pelvis, MR is the superior imaging technique. Otherwise, MRI is mainly used for problem-solving. This course will discuss how to use the various imaging tool efficiently to narrow the differential diagnosis, decide about the need for biopsy and establish a suitable therapy. The most common viral infection of the brain is herpes encephalitis (HSV1). It is a necrotising encephalitis with a a mortality of more than 50%. On imaging studies lesions will be seen in the "limbic system", i.e. the temporal lobes, hippocampi, insular cortex and cingulate gyrus. They appear as hypodensity on CT, T2-and FLAIR hyperintensity on MRI, possibly with haemorrhagic transformation. Diffusion is restricted in the early phase. Enhancement occurs at a later stage. Human immunodeficiency virus (HIV) infection is a multifocal giant-cell encephalitis eventually leading to a progressive leuco-encephalopathy. On MR atypical focal or diffuse symmetrical signal abnormalities are seen neither with mass-effect nor with enhancement and typically sparing the U-fibers. Spectroscopy can show an increase of myo-inositol. Progressive multifocal leuco-encephalopathy (PML) is due to reactivation of the JC polyomavirus in immunocompromised patients, 10% of which are HIV positive. On MRI "scalloped" multifocal asymmetrical lesions are seen with minimal mass-effect and without enhancement. New treatments of HIV, especially highly active antiretroviral therapy (HAART) can lead to a paradoxical worsening of patients due to the immune reconstitution inflammatory syndrome (IRIS). On MRI mass lesions are seen with diffuse patchy enhancement. Cerebral toxoplamosis appears as multiple enhancing lesions with marked perilesional oedema. Calcification is possible. Prion diseases are caused by a proteinaceous infectious particle leading to Creutzfeld-Jacob disease in humans. Diffusion weighted MR-images show high signal intensities in the cortex and the basal ganglia. Abnormalities on T2-weighted images and FLAIR occur at a later stage where atrophy is mostly prominent. To learn how to assist clinicians for the diagnosis and differential diagnosis of bacterial and parasitic CNS infections.

susceptibility effects, increased radiofrequency (RF) field inhomogeneity and more pronounced magnetic shielding effects. In the mean time, many investigators have proposed strategies to optimise imaging protocols and to decrease SAR levels and to reduce artefacts including optimised coil and hardware design, in combination with parallel imaging and modulation of refocusing flip angles. Many clinical applications in neurology and angiography for high field MRI that were recently being investigated showed benefits over 1.5 T. However, as of to date, virtually no prospective comparative studies have been performed and published that could help to estimate whether or not there would be any clinical benefit of 3.0 T MSK over 1.5 T. Although many authors described the improved SNR of MSK imaging at 3.0 T allowing for higher spatial resolution this has not been prospectively investigated with comparison to 1.5 T. Further studies have to show whether the improvement in speed and resolution will also translate into increased patient throughput and earlier depiction of disease in MSK applications at 3.0 T. Ultrasound is the best imaging modality for evaluation of acute scrotal conditions. MRI is used only rarely, when US findings are equivocal and in cases of suspected infarction. CT is used exceptionally, for example, to detect air in the scrotal wall.

High-frequency transducers with modern software like compound imaging and native harmonic, and very good colour sensitivity for low flow in small vessels provide excellent insight into testicular morphology and vascularisation. It is very important to distinguish testicular torsion from the acute inflammation, as it has important therapeutic and even medicolegal consequences. In testicular torsion rapid diagnosis is vital, and salvage rate is directly related to timely operation. Torsion is more common in younger patients and orchiepididymitis is more common in adults. Infection usually starts at the epididymis and then spreads to testis The patient presenting with an abdominal mass represents a common clinical problem. Clearly, the differential diagnosis is large and obviously will depend on the age and sex of the patient as well as location of the mass. Of course history and clinical examination are mandatory, but formal diagnosis will usually rest on radiological interpretation. Contrast examinations have now been replaced by cross-sectional imaging and endoscopy and it behoves the clinical radiologist to be aware of the advantages and limitations of these methods in order to reach a diagnosis. Particular difficulty may be encountered when the mass is so large that it is difficult to determine the organ of origin. The purpose of this interactive case discussion is to explore the relative merits of ultrasound, CT, MR and endoscopy in establishing a diagnosis in two different cases. The cases concerned are: 1.

A 21-year-old man who presents with a right iliac fossa mass, but is otherwise asymptomatic. 2. A 54-year-old woman who presents with anaemia and a large upper abdominal mass. Active audience participation will be encouraged by means of key pads in order to respond to issues raised during the debate. The most straightforward expectation from 3 T MRI scanners is a gain in SNR that could be translated in improving spatial resolution and/or reducing imaging time at an at least constant CNR. Together with field strength, susceptibility effects, chemical shift and T1 increase and T2 and T2* decrease. Also, relaxation properties of contrast agents are modulated. RF power deposition is higher at 3 T and is often a limiting factor in sequence parameter optimisation. Hence, the need to optimise MRI sequence protocol parameters at 3 T. For cartilage, muscle, synovial fluid and fat, T1 increases by between 14% and 22%, T2 decreases by between 10% and 37% and R1 of Gd Chelates decrease by 5% to 10% when B0 increases from 1.5 T to 3 T. In most applications reduced T2 and increased T1 work synergistically towards a reduced SNR. Since the change in relaxation times is not linear for the different tissues, CNR varies with field strength, too. A relatively straight forward approach is to lengthen TR in order to compensate for longer T1 and to shorten TE to compensate for shorter T2 (*). In non-fat-sat images bandwidth needs to be increased to control chemical shift effects. Because of the better fat and water peak separation, 3 T often helps improve frequency-based fat saturation but may also be greatly impaired by field inhomogeneities in the presence of metallic materials. Field strength (B0) and appropriate dedicated multi-element coils are the hardware prerequisites to bring high resolution (HR) isotropic imaging into clinical routine. Depending on the age of the child, hip symptoms may predict a variety of diseases.

In the infant, developmental dysplasia and infection should be considered. After the age of 4, irritable hip most commonly due to transient synovitis is the commonest disease but infection is the more worrying condition. Perthes disease affects some and this condition overlaps into those over 8 who may have a slipped upper femoral epiphysis. Fractures and rare cases of osteonecrosis and chondrolysis are a concern in the adolescent. In the young and indeed in most cases, ultrasound provides a useful first line test. Aspiration of effusion may be both diagnostic and therapeutic. In the older child and, especially when SUFE is a risk, conventional radiographs with an external rotated "frog leg" view is very important. Despite the logistics problems in children, there is an important role for MRI especially in cases where the initial imaging does not explain the symptoms. I will review the imaging pathways and provide examples of common diseases. I will also discuss how to manage the difficult case and show recent audit data on detection rates and clinical management. FAI refers to a conflict between the proximal femur and the acetabulum. Both an abnormal shape of the proximal femur (FAI of the "Cam-Type": Aspheric femoral head with a laterally increasing radius and/or a waist deficiency of the femoral neck) and the acetabulum (FAI of the "Pincer-Type": Acetabular retroversion or a deep acetabulum) or a combination of the two may be present. For a long period the FAI may be asymptomatic and the only clinical finding will be an impaired internal rotation of the hip joint. Later as the disease progresses, cartilage damage (outside-in abrasion of the acetabular cartilage/cartilage delamination) and labral tears occur. Labral tears are most common in the anterosuperior aspect of the acetabulum. A typical labral tear is an incomplete detachment with a tear located at the base of the labrum. Anatomic variants such as a sulcus may be present and should be distinguished from tears. A sulcus is common at the junction of the labrum with the transverse ligament and is generally located beyond the equator of the hip joint. Insufficiency fractures about the hip commonly occur in the region of the femoral neck. Another site vulnerable to overuse is the symphysis pubis. Often, a bone marrow oedema pattern around the symphysis pubis is observed. A characteristic finding is the "Secondary cleft sign", which reflects a partial tear of the adductor tendon aponeurosis at the symphysis pubis. Understanding age-related changes is essential for interpretation of imaging studies. Age is a risk factor strongly correlated with osteoarthritis (OA) which is the most common hip joint disease seen in adults. The diagnosis of OA is based on a combination of radiographic findings and characteristic subjective symptoms. The lack of a radiographic consensus definition has resulted in a variation of the that is painful and hypervascularised on colour Doppler imaging. In cases of torsion B-mode findings are non-specific, while on colour Doppler flow is absent in complete torsion, but may be present and diminished in incomplete torsion, or increased in intermittent torsion. In cases of trauma ultrasound is important to diagnose haematoma, haematocele to evaluate integrity of testis and assess whether the testicular fracture is present or if the surgery is needed in cases of testicular rupture. Imaging is helpful in cases of rare causes of the acute scrotum, such as Fournier gangrene, testicular appendage torsion, vasculitis, and also in evaluation non-scrotal causes of symptoms, like in cases of renal colic, abdominal inflammatory and traumatic conditions, etc. A scrotal mass is an important clinical problem and a source of anxiety to the patient. Radiologists play an important role in the management of these cases, since imaging is required to provide information about precise anatomical location of the lesion, its size and extension and, possibly, to elucidate the nature of the disease. The US and MRI findings of the many different scrotal tumours will be presented in this lecture. Special attention will be given to two topics. The first are the possibilities offered by imaging to differentiate among the different pathologies, especially to differentiate between benign and malignant lesions. The second will be the problem of the small, non-palpable, indeterminate testicular mass. Such lesions have been shown to be relatively frequent. Prevalence of malignancy varies widely in the literature, and orchidectomy seems not justified in all cases. The use of contrast-enhanced MRI and of advanced US techniques (contrast-enhanced US and elastography) may help to narrow the differential. Furthermore, the use of intraoperative US to guide removal of non-palpable testicular nodules can help to perform conservative surgery in lesions with no malignant potential. Learning Objectives: 1. To understand the typical imaging appearance of benign and malignant scrotal tumours. 2. To review differential diagnosis of intra and extratesticular scrotal tumours and the impact of imaging.

C. Imaging of the penis M. Bertolotto; Trieste/IT (bertolot@univ.trieste.it) Ultrasonography (US) is the first-line imaging modality in patients with penile disease. Using high-end equipment after pharmacologically induced erection penile anatomy is well defined and virtually all clinically significant penile vessels can be evaluated in normal and in impotent men. The superior soft-tissue contrast resolution afforded by MR imaging provides an opportunity to advance imaging evaluation of the penis in selected cases. In the clinical practice, erectile dysfunction is the most frequent penile abnormality which is investigated with Doppler US. The clinical role of this evaluation, however, reduced after the introduction of oral medications for impotence. Differentiation among different forms of erectile dysfunction is mainly based on evaluation of Doppler waveform changes in the cavernosal arteries. Peyronie's disease is the most frequent cause of penile induration. Imaging is often required to evaluate the extension of the plaques, involvement of the penile septum, and relationship between the plaques and penile vasculature. In patients with penile traumas, imaging allows accurate evaluation of albugineal tears, extra-albugineal and cavernosal haematomas, vascular lesions producing high flow priapism and other pathological changes. Compared with US, MR imaging has some advantages in identification of small albugineal tears, and is more accurate in identification of urethral or spongiosal involvement. Other situations in which penile imaging can be required are circumscribed or diffuse cavernosal fibrosis, tumours, priapism, severe inflammation, and evaluation of postsurgical complications. Most of these conditions are first investigated with US; MR imaging is optimal for tumour staging. Endocrine tumours of the pancreas are derived form the APUD cell system. They often show early clinical sign related to the hormones produced by these tumours. The usually very specific symptoms raise the suspicion of an endocrine tumour of the gastro-entero-pancreactic tract and initiate imaging studies for tumour detection. In this setting usually the pancreas is among the most frequent tumour sites. Since endocrine active tumours of the pancreas usually show a strong vascularisation, they can be differentiated from other solid tumours of the pancreas -including adenocarcinoma of the pancreas. Metastases in the pancreas are very rare -however, they represent a potential differential diagnosis either for non-functioning neuroendocrine tumours or for adenocarcinoma of the pancreas. Since the evaluation of the whole pancreas is crucial, transabdominal ultrasound plays an only limited role for the detection of endocrine pancreatic tumours. Usually MRI and CT -alone or in combination with specific nuclear medicine tracers in PET -are needed for accurate diagnosis and staging of these tumours. published incidences and prevalence of OA. The progression of OA traditionally has been measured using radiographic joint space width (JSW). Weight-bearing radiographs centered on the hip are the most reproducible and reliable ones. The sequence of degeneration includes the following radiographic findings: joint space narrowing, osteophyte formation, subchondral sclerosis, and cyst formation. Current definitions of radiological OA based on reduced JSW and osteophytes display predictive validity for clinical hip OA. Radiographs are also useful for assessing developmental dysplasia and other congenital disorders which may lead to early OA. There are cases though, that radiographs show minor changes and the clinical suspicion of early disease can be confirmed with more sophisticated imaging methods, such as CT and MRI. CT is helpful for additional measurements such as femoral and acetabular abnormal version which might lead to OA. Femoroacetabular impingement has been shown to cause labral and chondral lesions and leads to OA. Prompt recognition of abnormal head-neck junction on radiographs enables proper conservative or surgical treatment planning. MR arthrography is the method of choice for assessing the labra whereas CT arthrography might be used as an alternative for articular cartilage assessment. Cystic tumours of the pancreas include a variety of masses which can be classified into cystic tumours of the exocrine pancreas, cystic tumours of the endocrine pancreas, cystic tumour-like lesions of the exocrine pancreas. In order to simplify the approach only the relatively common cystic tumours -the intrapapillary mucinous tumours (IPMT), the serous cystoadenoma (SC) and the mucinous cystoadenoma (MC) -will be considered. IPMT are characterised by ductal dilatation. Imaging characteristics of IPMT are best displayed at MR-cholangiopancreatography. On the basis of the extent, these tumours can be divided into IPMT of the main duct (or central), IPMT of the secondary ducts (or peripheral) and mixed IPMT. Central and mixed IPMT have a malignant behaviour and therefore need to be treated surgically, while peripheral IPMT have a benign behaviour and, in general, need only follow-up. SC are characterised by a microcystic architecture in most cases. Imaging features are typical in cases of microcystic appearance and consist of small amounts of fluids interspersed within multiple septae of a "sponge like" mass. The differential diagnosis with a mucinous cystoadenoma is difficult in cases with a oligo-macrocystic appearance. MC appears as a uni-oligolocular cystic mass, with a simil-ovaric stroma in the tail of the pancreas. Imaging features include a cystic mass with a definite wall and inner septae. When calcifications and enhancing nodules are present, a mucinous cystoadenocarcinoma has to be suspected. Therefore, a careful evaluation of imaging features of pancreatic cystic tumours is needed to differentiate benign form malignant masses. Learning Objectives: 1. To understand the classification and management of cystic pancreatic tumours using rad/path correlation. 2. To learn how to provide a differential diagnosis and how, when and why imaging techniques should be used. 3. To review pathological and imaging findings of intra-ductal cystic tumours. 4. To learn how to deal with the incidental pancreatic cyst. 

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The evolving role of the radiologist P. Brader; Vienna/AT (peter@brader.md)

In the past two decades, enormous strides have been made in medical imaging and many new technologies and agents are now available for breast cancer research, clinical trials and patient care. Advances in experimental and clinical breast imaging are likely to improve our knowledge of how breast cancer arises at the cellular level, which will help not only to identify and locate tumours but also to assess the activity of biological processes within these tumours. This recent and concomitant progress, in imaging in general, and in breast imaging in particular, has been facilitated by the convergence of molecular cell biology, pathology, chemistry, physics and engineering in a multimodality and multidisciplinary way. The challenge for radiology is to begin thinking at the molecular level. It is, therefore, important that the next generation of radiologists become more involved in multidisciplinary research and clinical work, and that younger radiologists receive special training in diagnostic imaging and nuclear medicine, as well as a solid understanding of physics, radiochemistry, pathology and biology. Applying this approach to breast cancer patients should allow earlier detection, stratification of patients for treatment, and objective evaluation of new therapies. The outcome will be considerably better management and care of those with breast cancer. Breast cancer is the leading cause of cancer death among women worldwide. Imaging plays a key role in the early detection of breast cancer. Mammography is an accepted screening modality with some limitations such as over-treatment. To overcome these limitations research is going on to characterise breast cancer more accurately. Currently researchers are working on different strategies spanning the spectrum from tomography-based systems to MRI and even molecular imaging. This panel discussion will focus on these different strategies. The auditorium will learn if in 2025 imaging still plays a major role in breast cancer detection or whether a simple blood test will eventually solve the problem. Breast cancer is the leading cause of cancer death among women world wide. Imaging plays a key role in the early detection of breast cancer. Mammography is an accepted screening modality with some limitations such as over treatment. To overcome this limitations, research is going on to characterise breast cancer more accurately. Currently researchers are working on different strategies spanning the spectrum from tomography-based systems to MRI and even more molecular imaging. This panel discussion will focus on these different strategies. The auditorium will learn if in 2025 imaging still plays a major role in breast cancer detection or a simple blood test will eventually solve the problem. 

Is mammography still an accepted modality for breast cancer imaging in 2025? M.J. Yaffe; Toronto, ON/CA (martin.yaffe@sunnybrook.ca) X-ray mammography is currently the only imaging modality that when used in routine screening has been demonstrated to contribute to reduced mortality in women in the age range 40-74. But, the accuracy of mammography is limited with respect to both sensitivity and specificity. Digital mammography has provided increased sensitivity in women with dense breasts and three-dimensional methods such as digital breast tomosynthesis or dedicated breast CT promise to yield further improvement. However, these techniques are dependent on detecting rather gross physical changes as masses, microcalcifications or architectural distortions develop and, therefore, their ultimate potential is limited. It is likely that before 2025, detection tools that are more specifically targeted to molecular characteristics or early functional changes associated with cancer will be clinically available. These may be either in the form of an imaging test, based on a specific biomarker for the cancer or possibly an innocuous test designed to sense a circulating biomarker in the blood or urine. In the latter case, a positive test would be followed by an imaging study to provide localisation for therapy. Such tests could not only detect the presence of disease but would also provide prognostic information to guide the type and aggressiveness of therapy so that overtreatment could be avoided. Promising imaging techniques based on targeted imaging with ultrasound, x-ray contrast agents, MR and radio-labelled agents are already under investigation. By exploiting new molecular or functional signals one of these is almost certain to replace mammography before 2025. 

Can we assess cell density of tumours with imaging techniques? D.-M. Koh; Sutton/UK Imaging is increasingly used to define endpoints of clinical trials in oncology. Tumour cellular density may be inferred by diffusion-weighted MR imaging (DW-MRI) and measurement of the T2 relaxation time. DW-MRI is unique as the mechanism of contrast is based on differences in the mobility of water between tissues, which can be quantified by the apparent diffusion co-efficient (ADC). Tumours are frequently more cellular compared with their tissue of origin which impedes water diffusion, resulting in increased conspicuity on DW-MRI and lower ADC values. Studies have shown negative correlations between histopathologically determined cell density and ADC in several tumour types, including prostate cancer, soft tissue sarcomas and cerebral tumours. DW-MRI is sensitive for tumour detection, especially for disseminated peritoneal disease, liver and bone metastases. Whole body DW-MRI with background suppression (DWIBS) is an emerging technique that has shown substantial promising for staging of lung cancer, prostate cancer, lymphoma and multiple myeloma. Effective treatment results in reduction in cell density due to cell lysis, apoptosis and necrosis, leading to a rise in ADC value. ADC increase has been observed within 30 days of anti-tumour treatment (including chemotherapy and radiotherapy); and as early as one to two weeks after treatment. Quantitative ADC measurements may also be prognostic as tumours with higher pre-treatment ADC have been shown to respond poorer to chemotherapy and radiotherapy. Nevertheless, a number of challenges still have to be overcome to qualify ADC as a response and prognostic biomarkers in a multi-centre setting across different imaging platforms. Angiogenesis is an essential process whereby tumours derive vascular supply from adjacent tissue, to sustain tumour growth and metastatic spread. Newer targeted antiangiogenic therapies differ significantly from current cytotoxic therapies for cancer. The methods of dose selection are either invasive, such as biopsy and histology, or time consuming, such as tumour shrinkage and time to disease progression, both of which take months to assess and fraught with other limitations. Moreover, cancer is a very variable disease, which means that some patients will respond to a particular therapy while others will not. There is, therefore, a great need to establish surrogate markers for drug response that are both rapid and reliable, not only for clinical trials of new drugs but also to aid in the selection of optimal treatment for individual patients. Multiparametric imaging techniques provide a non-invasive insight into tumour cell density, vascularisation, and biochemistry. Imaging data have the potential to provide information on disease profiling pertaining to diagnosis, prognosis, selection of therapy, monitoring of response to therapy, and pharmacokinetic information of drugs. Undoubtedly, these methods hold great promise, but how can we standardise these techniques, in terms of acquisition parameters and image analysis (post-processing), and validate imaging parameters as biomarkers in multicenter international cancer trials. Beginning with a review of the frequently used response evaluation criteria in solid tumours (RECIST), the development and optimisation of new imaging parameters as biomarkers of treatment response and optimised monitoring of tumour therapy in multicenter EORTC clinical trials will be presented. DW-MRI is sensitive for tumour detection; ADC is affected by the different cellular density of a tumour. Still, a number of challenges need to be overcome to qualify ADC as a response and prognostic biomarker in a multicenter setting. The large variety in primary tumours and imaging methods, as well as the large variety and continual evolution of imaging equipment, point towards the need for a concerted design of imaging protocols in order to assure that these protocols are applicable to multicenter trials. Furthermore, reliable evaluation of imaging data requires imagers experienced in the area of the definite cancer targeted in this trial and in the use of imaging tools for lesion quantification. From this session, a roadmap for future collaboration between EORTC and ESR combining different imaging modalities will emerge. Session Objectives: 1. To prove that advanced multiparametric imaging techniques play a crucial role in the diagnosis, staging, treatment monitoring and follow-up of oncological patients. 2. To explore avenues for future collaboration between EORTC and ECR. 3. To suggest input of radiologists in the design and implementation of multicenter trials.

The EORTC Imaging Group: vision and strategy on cancer imaging S. Stroobants; Antwerp/BE (Sigrid.Stroobants@ua.ac.be)

Response to cancer treatment is evaluated by subsequent assessments of target lesions and is defined as a significant decrease in measurable tumour dimensions (WHO, RECIST). The new targeted therapeutics which cause cytostasis rather than cytotoxicity have challenged volume-based response criteria and tumour regression is increasingly recognised as an unreliable end point. New imaging modalities looking at tumour biology, like positron emission tomography (PET) or diffusion weighted (DW) and dynamic contrast enhanced (DCE) magnetic resonance imaging (MRI) or increasingly used to identify subpopulation of patients most likely to respond. Recently, new response criteria were introduced that incorporate FDG-PET (RECIST 1.1 for solid tumours and new Cheson criteria for lymphomas).

Since imaging is becoming increasingly important in novel trial design, the EORTC decided to invest in an imaging platform. EORTC has established a medical imaging exchange infrastructure allowing to store imaging data linked to the clinical databases. A functional imaging expert group is set up to review protocols, organise central review and develop specific initiatives for imaging biomarker validation. EORTC is part of the QuicCONCEPT consortium that within the EU innovative medicine initiative (IMI) will try to validate the use of novel PET probes and DW-MRI as biomarkers for apoptosis and proliferation. Functional imaging techniques can only evolve successfully into biomarkers that are clinically valuable and important for drug development, when there is agreement on the standards for measurement and analysis and working groups are set up in collaboration with the different professional organisations (ESR, EIBIR, EANM) to set up imaging guidelines.

conditions such as TTTS in twin pregnancies and foetal demise. The living foetus can also suffer from abnormal blood supply to the CNS, and thus showing small or even large hemispheric infarcts. Other diffusion technique, DTI is also used to demonstrate the white matter formation of the foetal brain. MRS is also used in the evaluation of the foetal brain. The values of the NAA, Choline and the existence of lactate are different than the values in the paediatric and adult brain. Learning Objectives: 1. To explore the new imaging techniques for the study of the foetal brain.

2. To understand the use of diffusion-weighted imaging in the foetal brain. 3. To become familiar with the accurate use of T1-weighted sequences in the foetal brain. 4. To understand the possibilities of tractography in the fetal brain.

The paediatric central nervous system is a complex structure undergoing rapid development. As such, there is a rapid, continuous modification of what is "normal" in relation with age and the stage of development. Knowledge of the normal patterns of brain development in the clinically relevant ages from 0 to 18 years is necessary to interpret neuroimaging findings correctly. Knowledge of embryology and normal variants is also greatly helpful. MR imaging equipment and parameters need to be adjusted and optimisation for paediatric studies. Pitfalls often occur from the misunderstanding of normal conditions that are perceived as abnormal based on a comparison with the appearance of the normal brain in adults. This includes, for instance, the evaluation of the brain in the first 2-3 years of life during the course of the process of myelination. A summary of the most frequent conditions that may lead to misinterpretation of findings will be provided here. Learning Objectives:

1. To understand a different approach to neuroimaging in the developing paediatric brain and spine. 2. To appreciate that, despite the wide and potentially complex spectrum of diseases seen in neuropaediatrics, most interpretations can be made through the thoughtful application of basic neuroradiological analytical techniques. 3. To be aware of certain areas where common pitfalls, myths and misunderstandings occur.

The ability to develop more aggressive treatments of acute neurological disorders in children is nowadays improving; however, infants and children are often uncooperative, clinical signs are not always easily localised, and diagnosis and therapy may be both delayed. Effective imaging of the central nervous system assumes an increasingly important role in the evaluation of these critically ill children. This lecture will review the main indications to perform a neuroimaging procedure in children with a neurological emergency. With didactic purposes, acute conditions will be classified in traumatic and non-traumatic (ischaemic and haemorrhagic stroke, infection and acute metabolic disorders). Differential diagnosis will be discussed based on representative cases selected from the daily routine in a paediatric tertiary hospital. The varied neurological complications that can occur in the child admitted at the intensive care unit will also be presented in a didactic manner, including PRES (posterior reversible encephalopathy syndrome), acute liver failure, osmotic demyelination syndrome, hypoglycaemic encephalopathy or induced neurotoxicity. Eventually, some peculiarities in oncologic and immunosupressed children, particularly opportunistic infections, will be highlighted. Practical algorithms with the preferential use of either CT or MRI will be developed for each section. CT continues being the primary modality for trauma, although it should be better used in cases of non-available MRI in the other acute conditions to save radiation in children. MR imaging is nowadays better for imaging these children owing to the new techniques that can be used, such as diffusion imaging (DI), spectroscopy, arterial spin labelling (ASL) or susceptibility-weighted imaging (SWI).

Learning Objectives: 1. To learn the characteristic neuroimaging findings that may be useful in establishing differential diagnoses. 2. To understand the various neurological complications that can occur in the intensive care unit and to become familiar with their most typical imaging patterns. 3. To consolidate knowledge of the best neuroimaging protocols for the acutely ill child and establish the main indications for the use of MR imaging, particularly diffusion and spectroscopy. 

Challenges for morphologic imaging in oncology trials: reproducibility and reading F.E. Lecouvet; Brussels/BE (frederic.lecouvet@uclouvain.be)

Beside clinical endpoints and biological or molecular parameters, beside emerging perfusion or diffusion imaging techniques, morphologic imaging remains the cornerstone of the evaluation of treatment response in the majority of primary or metastatic tumours. The large variety in cancers and imaging methods, as well as the large variety and permanent evolution in imaging equipments, raises the need for a concerted design of imaging protocols to guarantee transposability of these protocols to multiple centers. The reliable evaluation of imaging studies obtained in trials requires readers experienced in the area of the definite cancer targeted in this trial, and in the use of imaging tools for lesion quantification. The imaging group of the EORTC targets this optimisation of imaging protocols. First, the different "organ groups" of the EORTC will benefit from the availability of expert radiologists in the different fields of oncology, involved in the choice and tuning of adequate and generalisable imaging tools from the beginning of trials design. The design of CT or MRI studies should target acquisition parameters transposable in a large number of centers; there is no need for "cutting edge" protocols for a reliable assessment of response in a majority of cancer patients. Second, the central review of imaging studies will be possible based on the involvement of expert radiologists, and on a robust imaging platform that guarantees availability, quality control, and "side by side" evaluation of baseline and follow-up examinations. Principles and limits of response evaluation by morphologic imaging in oncology will be illustrated. A practical approach to HRCT of the chest for diagnosis of diffuse lung diseases includes: recognition of the abnormalities, definition of their distribution within the secondary lobule or the lung, identification of associated findings. When combined with the patient clinical history, these 3 steps allow to shorten the list of differential diagnoses and may sometimes lead to a specific diagnosis. A reticular pattern consists of multiple lines as the result of interlobular septal thickening, intralobular lines or cystic walls of honeycombing. When present as a predominant abnormality, thickening of interlobular septa has a limited differential diagnosis which includes pulmonary oedema/haemorrhage, lymphangitic spread of cancer, sarcoidosis and alveolar proteinosis. Honeycombing represents destroyed and fibrotic lung tissue containing numerous cystic airspaces with fibrous walls and is considered a CT feature of established pulmonary fibrosis. When honeycombing is present, UIP is likely the histologic pattern and IPF is the most likely diagnosis, in the absence of a known disease. A nodular pattern consists of multiple rounded opacities 2-10 mm in size. The distribution of nodules is the most important factor in making an accurate diagnosis. A centrilobular predominance of nodules that typically spare pleural surfaces is a frequent sign of bronchiolitis and airway disease. A perilymphatic distribution is most frequently seen in patients with sarcoidosis, silicosis and lymphangitic spread of cancer. A random distribution with nodules diffusely and uniformly distributed can be the result of infection, haematogenous metastases and other rare diseases such as Langerhans cell histiocytosis. 

The diffuse interstitial lung diseases (DILDs) are a heterogeneous group of disorders which principally affect the lung parenchyma. Basic HRCT patterns are common to many disease processes and are usually non-specific. However, their distribution and their temporal evolution are often characteristic enough for diagnostic purposes. Increased lung opacity: air-space consolidation, by definition, occurs when alveolar air is replaced by fluid, cells, or other material. On HRCT, consolidation results in an increase in lung opacity associated with obscuration of underlying vessels. Conversely, ground-glass opacity is defined as: "... hazy increased attenuation of lung with preservation of bronchial and vascular margins". The significance of ground-glass opacity depends on the clinical scenario. Cysts and decreased lung opacity: a cyst appears as a round parenchymal lucency or low-attenuating area with a well-defined interface with normal lung. Lung diseases characterised by cysts include Langerhan´s cell histiocytosis, lymphangioleiomyomatosis, LIP, postinfectious pneumatoceles, and amyloidosis. Recently, lung cysts have been reported in association with extrinsic allergic alveolitis. Honeycombing is a process characterised by the presence of cystic spaces.The determination of the presence or absence of honeycombing on HRCT in patients with idiopathic interstitial pneumonia is of great importance. Honeycombing may have an atypical distribution particularly in asbestosis, sarcoidosis, non-specific interstitial pneumonia (NSIP), drug-related fibrosis and hypersensitivity pneumonitis. HRCT is now an integral component of the clinical investigation of patients with suspected and established interstitial lung disease. A knowledge of the close relationship between histopathological changes and CT appearances. Learning Objectives:

1. To understand the different patterns on HRCT scans of the chest.

2. To learn about a systematic approach to differential diagnosis of diffuse lung diseases. 3. To review key imaging findings.

How do we report CT of the chest? 17:14

The radiology report is often the primary method of communicating imaging findings to the referring physician. Practical guidelines on how to report CT scans of the chest for diffuse infiltrative lung diseases will be provided by the panel. Emphasis will be placed on both report content and style in order to provide the clinician a tool for good patient care. With the advent of volumetric data acquisition and with increasing knowledge of patho-radiological correlations, HRCT has further matured over the last decade and provides the radiologist with an excellent tool for accurately demonstrating gross lung anatomy and precisely analysing abnormal findings. The radiologic diagnosis of many pulmonary abnormalities is based on an assessment of their pattern and distribution. While the pathologist has the advantage of being able to evaluate specimens microscopically, the radiologist is confined to the assessment of more gross disease. However, the radiologist is able to examine the entire lung providing him with information about the distribution of disease and about additional diagnostic clues in mediastinum and pleura. Both together, characterisation of the gross findings and knowledge of their distribution represent the key features for arriving at a confident diagnosis. Session Objectives: 1. To become familiar with the standardized and internationally accepted terminology for describing and analysing HRCT findings. 2. To learn how a structured analysis of the predominant pattern and its distribution represent the key for making a specific diagnosis in the best case scenario or to understand how it helps to narrow the differential diagnosis. 3. To promote the understanding how the variability of manifestations of some diseases can cause an overlap of findings being responsible for difficulties the radiologist encounters when categorizing diffuse diseases of the lung parenchyma.

A. Most radiological reports consist of a ‚descriptive part' in which the radiologist describes the findings and a short ‚conclusion part' containing the interpretation of what is seen. Both parts are filled with ‚jargon'. Some terms are typical radiological ‚language' while others refer to terminology also used by clinicians and pathologists. Some terms are purely descriptive but others may contain already some interpretation of what is seen and hence narrow the differential diagnosis. The meaning of a term may also change over time. It is very important that both radiologists and the readers of their reports speak the same language and know and understand the meaning and full content of each term. This is especially important when radiological findings in patients with diffuse lung diseases are described and interpreted. Diagnosis of diffuse lung disease is indeed largely based on the recognition and description of the appearance pattern of the disease because this often allows developing an appropriate list of differential diagnosis. Members of the Fleischner Society have introduced a glossary of terms for thoracic imaging. This presentation will emphasise on the importance of such a glossary for both describing and interpreting chest images. Special attention will be given to the terms used to describe the different patterns in diffuse lung diseases: (1) reticular and short linear opacities, (2) nodular opacities, (3) increased lung opacity and (4) cysts and decreased lung opacity. 

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The purpose is to describe ethical dilemmas related to the use of radiation in Finnish radiographer's work in diagnostic imaging. The data were collected during the spring and summer of 2008, and it consisted of thematic interviews of diagnostic radiographers (N=8) whose working experience varied from 4 to 31 years. The data were analysed by the method of data-oriented qualitative inductive content analysis.

Ethical dilemmas related to the use of radiation were found to concern justification and optimisation principles, which were found to be inadequately implemented by radiographers. The background factors of these dilemmas were found to be both dependent on and independent of the employee, resulting in worsened well-being at work and in seeking for change. The current processing methods of dilemmas were found to be insufficient, and suggestions for better processing methods were made.

The results suggest that there may be shortcomings in radiographers' knowledge of radiation usage. Attitudinal problems within the work community seem to maintain ethical shortcomings. Instead of ethically inadequate routines and passing the baton to other professionals, radiographers should be encouraged in committing themselves into responsibility and safety culture. Respondents repeatedly described powerlessness and inability to intervene in ethical problems. The common cold is one of the most frequent illnesses in Europe and the United States. Although most cold are mild and resolve within a short time period, colds cost billions of dollars per year, mostly due to lost time at work and school. The common cold is a group of symptoms caused by one of a large number of viruses. Rhinoviruses cause the greatest number of colds; there are more than 100 different varieties of rhinovirus. The average adult experiences two to three colds per year, while children average 8-12 colds per year. In most cases, colds do not cause serious illness. Most colds last for 3-7 days, although many people continue to have symptoms (coughing, sneezing and congestion) for up to 2 weeks. Some viruses that cause the common cold can also depress the immune system or cause swelling in the lining of the nose or airways; this can lead to bacterial infection. One of the more common complications is sinusitis, which is usually caused by viruses and rarely (about 2% of the time) by bacteria. However, it can be difficult to distinguish bacterial sinusitis from sinusitis caused by a cold because the signs and symptoms can be similar. However, due to the fact that a runny nose can also result from inflammation, trauma, foreign body and other abnormal processes, including tumours, an excellent diagnostic workup is necessary. The purpose is to examine the relationship between man and technology within radiography without considering man and technology as separate entities. The study is designed as an observational study which took place in a Danish radiological department. It involved 20 examinations followed up by three semi-structured interviews. Through emergent narratives radiographers construct a practice in which the relationship between man and technology is marked by a struggle of domination of one over the other. The struggle expresses itself through two competing plots: a diagnostic plot with a prevailing, but not merely chronological structure mostly composed of events tied to pathology. The life story, in opposition, plots the examination as a significant experience in the patient's life, transforming it into events stretching towards a future yet unknown. Most often the radiographers contributed to the domination of man over technology through active engagement of their narrative alertness. Errors and failure to keep the time schedule can, however, lead the radiographers to a change of perspective that makes them displace man from the scene of radiography by playing on the premises of technology. In several stories technology can be labelled ‚setting' while the patient plays the main role. The radiographers act with the patient as point of origin, but they reason with technological arguments. Hence, the human aspects of radiography constitutes an underground practice, which is not explicitly articulated valuable. This creates a field of tension between man and technology, with risk of technological dominance. The private life of everyone of us as well as the everyday practice of our profession is deeply embedded in ethical/deontological aspects which play a critical role into: our profession, the relationship with our patients, with our colleagues, with the health care team we work with, and with ourselves. The radiographer's everyday practice has to take this aspects into account. Ethics finds its origins in the fusion of three different sources, as if it were a compromise between: the species we belong to, the society we live in, and ourselves. Yet, we are not obliged to abide to these three elements. It is through our actions that we decide how to behave in certain situations. And this is the reason why every single action towards the others gathers importance, the simple rites when individuals meet play a pivotal role in the creation of a relationship with the others. Shaking hands, greeting and using polite forms of speech, all these actions are ethically important, they allow us to catch the benevolence of our interlocutor and to discourage any possible hostility. What would happen if our professional identity were perceived and acknowledged through the way we can interact and relate to others? In this case, the work no longer ennobles the man, but it is the man, through his actions, who ennobles his profession. Behaving ethically towards one's own profession, towards the others and towards ourselves, is it, or could this be the common ground of European professional ethics? Whenever a diagnostic x-ray examination of a pregnant patient is considered to be necessary, conceptus dose estimation is an important step in assessing the risks to the unborn child. Accurate estimation of conceptus dose is also needed after inadvertent irradiation of a pregnant patient from a diagnostic x-ray procedure. Several methods have been developed to estimate conceptus dose from radiologic examinations. When the uterus is remote from the directly exposed tissues, the conceptus is exposed to scattered radiation and its dose is negligible (< 1 mGy). Examinations involving the abdomen-pelvis may deliver higher dose to the child. Variations in maternal body size and uterus position should be taken into account to obtain accurate conceptus dose estimation. Multidetector CT (MDCT) scanners have replaced conventional CT technology. Conceptus doses from abdominal MDCT range from about 13 to about 31 mGy during the first post-conception weeks for a scan acquired at 120 kVp, 200 mAs with a pitch of 1.0, depending on maternal body size and uterine position. Multi-phase abdominal CT examinations may deliver relatively high doses to the unborn child. Doses to the conceptus below 100 mGy should not be considered a reason for termination of pregnancy. The risk to the embryo/foetus for stochastic effects is assessed on the basis of dose using appropriate risk factors. Although these risks from a single diagnostic procedure are low for the majority of diagnostic x-ray examinations, it is important to ensure that doses are kept as low as reasonably achievable.

Learning Objectives: 1. To learn how to manage and counsel pregnant patients in case of (a) intentional and (b) accidental exposure. 2. To learn how to estimate conceptus radiation dose from diagnostic x-ray examinations. 3. To learn how to assess the radiogenic risks to the embryo/foetus from diagnostic x-ray examinations.

epithelial cells. The mucociliary transport drains each sinus in a specific pattern through its ostium to the nasal cavity and ensures a constant flow of mucus containing bacteria and particulate matter. Functional endoscopic sinus surgery (FESS) aims to enlarge the preformed ostia to allow physiologic drainage. Preoperatively, anatomic variants have to be ruled out or shown by CT to avoid injury. Special emphasis lies on the ostiomeatal unit, a complex anatomic region at crossroads of mucociliary drainage from frontal, anterior ethmoid and maxillary sinuses (uncinate process, Haller, Agger and frontoethmoidal cells, inverse turbinate). Description of the level of the cribriforme plate in relation to the roof of the ethmoid is another key element in a report to avoid skull base injury (Keros I-III). Preoperative identification of variations in the location of the optic nerve and the cavernous portion of the internal carotid artery is also mandatory. Furthermore, the close proximity of the sinuses to neighbouring structures and their thin bony walls predispose to certain pathways of spread. Runny and stuffy noses may be due to a long list of pathologic conditions, which require distinct imaging strategies and treatment options. Acute rhinosinusitis, for example, is normally managed by GPs without any imaging study. Occasionally, signs and symptoms suggest orbital or intracranial complications: in such cases MSCT allows a prompt diagnosis and is preferred to MRI for wider availability and faster acquisition. Persistence of signs/symptoms for longer than 12 weeks classifies rhinosinusitis as chronic (CRS); the condition may or may not be associated with the presence of nasal polyps. In patients affected by CRS cross-sectional imaging aims at precisely depicting bone structures and air conduits. In detail, imaging shows the anatomic arrangement of sinus drainage pathways and their patency, maps anatomic variants that may facilitate CRS or increase surgical risk, depicts bone changes induced by CRS or by the mechanical pressure exerted by polyps. These tasks are better accomplished by CT, even more so after the advent of multislice technology allowed multiplanar reconstructions along oblique planes. After surgery, imaging is required when signs/symptoms recur -to asses presence and extension of CRS or nasal polyps -or when late complications are suspected -such as mucosal synechiae impairing mucus drainage or mucocele. MRI plays a limited role in sinusitis because it fails to demonstrate thin bone structures; nonetheless, its use is advocated in aggressive inflammatory diseases (such as invasive mycoses and Wegener's granulomatosis) to demonstrate the involvement of deep spaces of the face and of the skull base. Sinonasal tumours are rare and comprise only 1% of all malignancies. The clinical and radiological challenge is to differentiate malignancy from benign or inflammatory changes. Most malignant tumours present at advanced stages. Malignant tumours are most common in the 5 th -7 th decades and have a male preponderance. Squamous cell carcinomas are the most prevalent (80%) followed by adenocarcinomas. Squamous cell carcinomas are most common in the maxillary sinus, next the nasal cavity and ethmoid sinuses, while adenocarcinomas are most often seen in the ethmoid sinuses, and commonly caused by occupational exposures, e.g. nickel and hardwood workers. Inverting papilloma is one of the most common benign tumours and have been associated with human papillomavirus. CT should be the first modality in paranasal sinus imaging, while complementary MRI before and after gadolinium i.v. is mandatory to differentiate tumour from inflammatory disease. A general rule is that tumours more often have unilateral extension and that malignant tumours usually erode the bone. However, malignancy may mimic benign tumours with thickening or remodelling of the adjacent bone. While CT is superior to demonstrate changes in the bone, MRI can differentiate tumour from inflammatory changes and demonstrate tumour invasion and perineural spread. Malignant tumours are: squamous cell carcinoma, adenocarcinoma, adenoid

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B. X-ray imaging and pregnancy: justification and optimisation of exposure P. Vock; Berne/CH (peter.vock@insel.ch)

As outside pregnancy, justification and optimisation are the main steps to be done when an imaging examination using ionising radiation is considered during pregnancy. However, the risk concerns the embryo/foetus in addition to the mother which means that justification has to be more critical whenever the uterine dose is not neglectable. The practical approach to an examination in any woman of child-bearing age starts by ruling out pregnancy, whether by taking history or by a laboratory test. When pregnancy cannot be ruled out, further steps will depend on the type of examination needed and the urgency of diagnostic clarification. Ultrasound is the alternative to be preferred when it can answer the clinical question. But even among x-ray examinations, the uterine dose is varying widely which asks for a careful selection, optimisation and, maybe, for postponing the test. Once pregnancy is confirmed, the major question is whether the specific type of diagnostic examination will include the uterus in the primary radiation field. Examinations not involving the uterus by direct radiation -despite a potentially significant exposure by scattered radiation -can usually be performed without a relevant risk to the embryo/ foetus. The situation is more critical when the uterus is within the examination field and when therapeutic interventions are considered. The presentation will discuss the practical approach to these different situations, the influence of the stage of pregnancy, optimisation methods and the choice between alternative methods in some frequent clinical situations. This paper explores the risks to the foetus when magnetic resonance imaging (MRI) is used. MRI uses three main components to produce images from inside the body: a static magnetic field; a pulsed radio-frequency (RF) fields and time-varying gradient electromagnetic fields. The exact frequencies of these fields depend on the MRI system purchased, for example; a 0.5T scanner uses 21 MHz RF, a 1.5 T system uses 63 MHz and a 3 T system uses 127 MHz RF. There is also a wide range of options for gradient strengths and slew rates to be considered as well. The overall exposure for the foetus depends ultimately on the imaging sequence used and the area being scanned. This paper will discuss particular hazards that need to be addressed for pregnant women including biological effects of the static and time-varying magnetic fields, heating effects of the RF pulses and acoustic noise generated by the spatial encoding gradients. The circumstances for foetal exposure in MRI will also be discussed including the following situations: the patient may not be aware that she is pregnant, likely to be in the first trimester; the mother is referred for direct foetal imaging after ultrasound (normally second or third trimester); the expectant mother may need diagnosis; research on pregnant volunteers. The exposure for pregnant staff working in MRI is also an essential consideration. Finally, how to minimise the exposure for the foetus during MR imaging will be discussed. A B C D E F G H in terms of cerebral perfusion (rCBF, rCBV, MTT and TTP) and cell metabolism (cytotoxic versus vasogenic oedema, diffusion restriction). The fundamental goals of stroke imaging in the acute phase are: 1. to rule out intracranial haemorrhage, and other non-stroke causes of the patient's symptoms; 2. to show occlusion of a major blood vessel, e.g. by CT or MR angiography; 3. to demonstrate ischaemic brain tissue (cytotoxic oedema), e.g. by diffusion-weighted MRI; 4. to reveal tissue blood flow and to identify areas of salvageable brain tissue ("penumbra"), e.g. by perfusion CT or MRI; 5. to select candidates for thrombolytic therapy within the critical 3 to 6 hour time window. The purpose of this presentation is to review how new developments in neuroimaging improve our understanding of the pathophysiology of acute stroke and to demonstrate that multiparametric techniques now play a crucial role in the rapid diagnosis, clinical management, therapy and outcome prediction of patients with an acute stroke. Organisation is crucial to the practice of dethrombosis. The first step is to grasp the fact that ischaemic stroke is an emergency. Stroke victims require an organisation similar to that provided for heart attack patients. Patients must be taken to hospital in an ambulance manned by a specifically trained crew. Ideally equipped with a mini CT scanner recently made available. This device provides an immediate morphological scan and CT angiogram to be sent by satellite to the reference hospital so that the problem will be clear and the medical team ready on the patient's arrival. Clinical and neurological assessment of the patient must be undertaken immediately along the lines of UK practice implementing a simple, clear and rapid procedure. If the clinical, CT and CT angiography findings indicate intra-arterial treatment, responsibility shifts to the neuroradiology team, organised to work a 24 hour shift, at the hospital or at least on call. Dedicated imaging systems must be available: a multi-layer CT device (CT angiography and perfusion studies). Dedicated angiography suite is essential. A flat panel system would be ideal. There is growing evidence supporting the availability of an MR system. This device would certainly enhance the possibilities of a stroke unit but it is not essential in the initial stages. A stroke unit should be based on a dedicated facility, with emergency access separate from the general emergency room, dedicated equipment, dedicated ambulances and appropriate links including a dedicated ward and a rehabilitation unit essential to the success of the project. Learning Objectives:

1. To learn about the benefits and risks in stroke intervention. 2. To consolidate knowledge of different methods of intervention in stroke therapy. 3. To learn about the different imaging methods used to decide on and perform stroke intervention.

Where do we stand in stroke therapy today? 09:44

Stroke is a common health problem with high socio-economic costs. In recent years much effort has been focused on finding ways to ensure early intervention as well as new methods not only for early detection but for early treatment. The discussion will focus on where we stand today and whether we think stroke imaging and treatment will advance further. During the last decade imaging of stroke has developed from a minor field dealing with a barely treatable disease to one of the most dynamic parts of neuroradiology. The routinely treatment with intra-venous thrombolysis within the 4.5 hour time window and the continuously expanding treatment of severe strokes with intra-arterial thrombectomy have lead to increasing requests from clinicians and interventional neuroradiologists to provide imaging information for treatment guidance. All radiologists involved in the management of stroke are facing mainly three demands: first, to have good knowledge of the causes and the pathophysiology of ischaemic stroke and a proper understanding of the current models for infarct development, as a prerequisite for rational decision making and efficient communication with the clinicians. Second, to be able to choose and to use appropriate imaging modalities for the acute work up of patients with stroke and to be aware of the benefits and drawbacks of CT and MRI. Finally, is good knowledge about the therapy options mandatory in order to be able to support the clinicians in the time critical treatment decision. This session will try to cover these three demands in order to give an overview on the current status and the opportunity to discus future perspectives.

A. Aetiology and pathophysiology of stroke R. von Kummer; Dresden/DE (ruediger.vonkummer@uniklinikum-dresden.de)

"Stroke" is the commonly used diagnosis for disturbances of brain blood supply due to ischaemia, haemorrhage, or venous obstruction. It is evident that "disturbances of blood supply" in stroke patients do not represent a useful concept in order to develop effective treatment. It is the radiologist's task to describe the acute brain pathology, its conditions (pathophysiology), and its aetiology to give directions for specific treatment and prophylaxis. The approach is vascular and brain tissue imaging. Brain ischaemia is the cause of stroke in about 85% of patients, intracranial haemorrhage in 15% of patients. Arterial obstruction causing brain ischaemia is thrombotic or embolic. It can as well be caused by arterial wall dissection or inflammation. Arterial wall diseases and heart diseases including a patent foramen ovale are sources for brain embolism. The obstruction of a brain supplying artery causes brain tissue ischaemia of various degrees depending on the capacity of collaterals supplying the same arterial territory. The chances for collateral compensation depend on the site of obstruction and the development of collateral vessels. Neurons cannot tolerate low cerebral blood flow (CBF) below 10 ml/100 g x min for more than 20 minutes and develop first cellular then irreversible ionic oedema. They survive, but do not function with low CBF between 10 and 20 ml/100 g x min. Enhancement of CBF in such regions, e.g. by arterial recanalisation can mean functional recovery. The imaging diagnosis of damaged brain is therefore the first aim in acute ischaemic stroke patients. Focal liver lesions are part of our everyday practice because radiologists performing various types of examinations may encounter them without being aware of any clinical condition rising the suspicion of these changes. In a situation like this several important decisions are to be made by the radiologists, like: is the lesion clinically significant, is the lesion benign or malignant, are additional imaging examinations necessary, does it require medical, surgical or interventional radiological action, should it be, and if yes, how frequently followed up, etc. For providing a well-established answer to these questions the reporting radiologist has to be familiar with medical history and results of former examinations (physical, laboratory, imaging, etc.); consider the age, gender, physical condition, eating and drinking habits, potential drug abuse of the patient; bearing in mind the prevalence and statistical probabilities of different pathologic conditions. With all this information at hand the thorough analysis of images obtained by different modalities will allow a rather reliable differential diagnosis and a well-established planning of therapy of the incidentally detected lesions.

Learning Objectives:

To learn more about the clinical conditions that may result in the appearance of focal liver lesions. 2. To be informed about the clinician's way of thinking in the process of differential diagnosis. The spectrum of differential diagnoses is broad in the liver. Therefore, incidentally discovered liver lesions represent a challenging clinical situation. Fortunately, there are specific imaging features for the most common benign and malignant liver lesions (such as, e.g. hemangioma, FNH, cysts, vascular pseudolesions, HCC and metastases) so that a minimal-invasive diagnosis with a biopsy is not needed in a lot of cases. In ultrasound, the echogenity and recently also the contrast agent behaviour are used for liver lesions characterisation. In CT, attenuation and also contrast agent behaviour are used for characterisation. MR imaging offers several options including T1-and T2-weighted images, use of chemical shift imaging, GRE sequences with long echos and diffusion weighted images, so that tissue components such as fat, water, glycogen, iron, etc. can be evaluated already in the pre-contrast examination. Beside the evaluation of dynamic signal characteristics in the early dynamic phase after contrast agent application, MR can utilize also tissue-specific contrast agents dedicated to the RES or to the hepatocytes. Other modalities such as angiography, PET or other nuclear medicine methods usually only play a minor role nowadays in the evaluation of incidental liver lesions in nononcological patients. In oncological patients the clinical consequences and also the range of diagnoses and pre-test probabilities are different from the non-oncological group; therefore, the demands to imaging are even higher. In case of atypical presentation of otherwise benign liver lesions such as sclerosed hemangioma close follow-up or even biopsy can be necessary in such a setting. Thyroid nodules are common. In 4-8% of adults nodules can be palpated and at ultrasonographic examination nodules are seen in 10-41%. Most nodules are benign, the eventual diagnosis in patients with a palpable nodule is carcinoma in only 5% of cases. The incidence of thyroid carcinoma is low. Papillary carcinoma is the most common type and is found in 75-80% of thyroid cancer. Lymph node metastases in thyroid carcinoma are primary to the paratracheal and prelaryngeal nodes (Level VI), and the upper (Level III) and lower (Level IV) jugular nodes. Malignancy should be suspected when there is rapid growth, a firm or fixated mass, when enlarged lymph nodes are present or in case of vocal cord paralysis.

In patients with multiple thyroid nodules the cancer risk per patient is not altered. Ultrasound is the primary imaging technique in patients with a palpable thyroid nodule. It is best performed with the patient supine, the neck slightly extended and using a high frequency linear-array transducer. Several ultrasonographic features are more often associated with benign or malignant nodules. However, while some ultrasonographic features may strongly suggest malignancy it may be very difficult to rule out malignancy by means of these features alone. Ultrasound-guided fine needle biopsy can be performed in an attempt to differentiate between benign and malignant nodules. Unfortunately, even with ultrasound guidance, an important number of cytological examinations will be non-diagnostic. In addition, in follicular lesions it is usually impossible to differentiate cytologically between benign and malignant follicular nodules.

Learning Objectives:

1. To learn about the optimal settings for US examination of the thyroid. The neck is host to a large variety of benign and malignant diseases ranging from simple cysts to acute inflammation with complications to highly malignant sarcomas and imaging plays an important role to assess the nature and the extention of disease. Patient history and clinical findings will decide which imaging technique is best suited to resolve the diagnostic dilemma. Ultrasound is recommended to differentiate between a cystic or solid lesion, to guide FNA, being quick and accurate. Pathologic flow within or around a lesion can be assessed adding Doppler technique. In acute illnesses with anticipated complications, such as a deep neck abscess, contrast-enhanced CT is required to evaluate local extention and demonstrate spread from the neck deep to the mediastinum. MRI is indicated to assess non-inflammatory, subacute or chronic diseases, such as vascular malformations, branchial cleft cysts, benign and malignant soft tissue tumours, brachial plexus pathology and neurologic diseases. Vascular malformations are easily depicted with MRI using T2 sequences in different image planes. Persistent fistulas of the branchial system can also be depicted by MRI running from the anterior border of the sternocleidomastoid muscle to the lateral pharyngeal wall. Assessing the origin of a soft tissue tumour has major implications for surgery. Staging a malignant soft tissue tumour must comprise the skull base and upper mediastinum including local extention, pathologic neck nodes and perineural spread. Follow-up during chemotherapy and postoperative monitoring of malignant disease are important indications for (MR) imaging, the more so in young patients, diminishing ionising radiation. Learning Objectives: 1. To identify different compartments in the neck. 2. To be able to choose the optimal imaging technique relating to request. 3. To become familiar with the most common pathology in adults and children. 4. To be able to address a short list of differential diagnoses.

patients (92%) and by ultrasound in 95 patients (93%). The activity of the disease was assessed correctly in 91% patients by ultrasound, compared to 74% patients by enteroclysis. There was no statistically significant difference. Bowel US is a useful investigation for the diagnosis and follow-up of patients with Crohn´s disease. Learning Objectives:

1. To learn about US techniques used in the assessment of patients with inflammatory bowel disease. 2. To learn tips for interpretation of US in the diagnosis and follow-up of patients with inflammatory bowel disease. 3. To understand the pros and cons of using US, including CEUS, in the diagnosis and follow-up of patients with inflammatory bowel disease, including assessment of disease activity. 4. To appreciate the accuracy, reproducibility and usefulness of US compared with other imaging techniques in assessing patients with inflammatory bowel disease.

A-304 08:58

The use of computed tomography (CT) in the diagnostic imaging of patients affected by inflammatory bowel disease (IBD) has a long standing history. CT techniques such as CT-enteroclysis and CT-enterography have been reported as efficient tools for a radiological assessment of disease. The state-of-the art methods will be reported and their potentialities in diagnostic accuracy discussed in different clinical type of IBD. The acute setting of unknown IBD could be demanded as well to CT examination performed in emergency without endoluminal contrast medium administration. The CT appearance of the intestinal wall of the segments involved by an active disease could be not correctly interpreted if the knowledge of basic and classic typical findings of IBD is not combined to consider different pathologic entities that could affect the intestine, offering similar but not even equal signs. The entire abdominal background needs to be evaluated according to the clinical symptoms, signs, laboratory parameters and history of the patient. CT examination could be an efficient tool to determine the degree of disease activity in patient with known IBD as well as to assess the presence of an acute inflammatory disease of the intestine in patients with unknown IBD affection. The actual role of CT in the early diagnosis of IBD, in disease staging and detection of complications as well as monitoring therapy in follow-up will also be considered and discussed. Learning Objectives:

1. To learn about state-of-the-art CT techniques for the assessment of patients with inflammatory bowel disease. 2. To learn tips for interpretation in terms of diagnosis and differential diagnosis of inflammatory bowel disease. 3. To discuss the value of CT in determining disease activity and monitoring therapy. The aim of this lecture is to give an overview of the techniques and typical findings for imaging Crohn's disease (CD) with either multidetector row computed tomography (MDCT) or with magnetic resonance imaging (MRI) and compare the two different modalities. Optimal imaging of CD begins with the preparation phase. The small bowel has to be distended for a concise examination. This can be done either invasively, i.e. enteroclysis or orally, which is named enterography. There is much debate on which of these two preparation methods is better. For the administered intraluminal contrast, best is water with some additives, which are neutral in CT and biphasic in MR. Imaging in MDCT is done 40 sec and 70 sec after IV administration of iodinated contrast with a thin collimation. All image data are reconstructed in axial, coronal and sagittal planes. The aim of imaging in CD should be to establish the following: (1) presence, severity, and extent of the disease; (2) its activity; and 3) extra-intestinal complications. Both modalities have proven to be a good tool to evaluate the extent, the activity of the disease and the presence of extraluminal complications. Both are also able to identify the type of the disease, being either the active/inflammatory, the fistulising/perforating, the fibrostenosing or the reparative/regenerative type. The challenge for MRI is mostly the in-plane resolution of the image data whereas radiation dose is for CT. Incidental lesions are frequently discovered during routine radiographic evaluations. Correlation with clinical history and additional confirmatory imaging is essential to the development of an accurate, focused differential diagnosis and for appropriate management. The objective of this presentation is to describe the imaging findings associated with incidentally found liver lesions and to review those clinical and radiologic features, which should be considered in development of an ordered and accurate differential diagnosis.

Learning Objectives: 1. To introduce typical cases illustrating the role of imaging modalities in the differential diagnosis of unexpected liver lesion cases. 2. To motivate the audience by the use of voting pads to be involved in the diagnostic process. 3. To highlight the conclusion that may be drawn on the basis of the discussed cases. The diagnosis of IBD is based on complex evaluation of clinical signs, endoscopic appearance, radiological imaging, laboratory tests and histology. Besides Crohn's disease (CD) and ulcerative colitis (UC) the modern classification advises to use the term IBDU (IBD unclassified) colitis to those 10% of cases, where the distinction between CD and UC is impossible based on the results of multiple exams. These cases are usually clinically more severe, with humbler therapeutic results. The new classification of CD types includes besides the phenotype (B1: inflammatory non stenosing non penetrating, B2: stenosing, B3: penetrating) the age (A1: ≤16 y, A2: 17-40 y, A3: > 40 y) the location (L1: ileum, L2: colon, L3: ileocolic, L4: upper GI tract) and P perianal involvement. In UC the most important clinical factors are extent, type and severity. The classification includes length and clinical types as acute, relapse-remission and chronic continuum. The radiological imaging in CD is needed for lesions not reachable by the endoscope, for categorising, for follow-up and detecting complications. Different modalities fit best for these different tasks.

The goal of imaging in UC is rather to help differential diagnosis and detection of complications. While in UC there are good correlation between laboratory and endoscopic signs of activity and severity so there is not much need for radiological activity indices, in CD the clinical activity does not correlate with the histological changes. Although CDAI is widely used for clinical studies, it includes several subjective factors, thus radiological activity indices may be of help.

Crohn's disease is more likely a systemic disease governed by a shift in the immune response, thus affecting the whole MALT system. Bowel ultrasound is a quick, simple and effective investigation. The method is simple and requires no bowel preparation. We use both -convex (C 5-1 -overview, anatomical orientation) as well as linear transducer (L 12-5 -preferred, incl. CEUS, L 17-5 -children and very slim patients, L 9-3 -TDPs, deep structures). We examine patients in supine position, first small bowel, than mesentery and large bowel. Finally, we examine the terminal ileum and cecum or the areas of anastomoses. We assess folds, hastrum, wall thickness, vascularity, echogenity of the surrounding fat, the presence of nodes and peristalsis. In some cases we use intravenous contrast (CEUS). At least four studies have prospectively compared the diagnostic accuracy of US with radiological studies, endoscopy or surgery in those with suspected Crohn's disease. In these studies, the sensitivity of US ranged between 84% and 90% and its specificity reached 98% and 100%. In our prospective study we investigated patients by ultrasound and enteroclysis. We established the diagnosis by enteroclysis in 94 The central venous vasculature and particularly the upper venous system may be obstructed by either benign or malignant lesions. Malignant central venous obstructions are mainly due to bronchial carcinoma, mediastinal metastasis, mesothelioma or lymphoma. The most common cause for benign central venous obstruction is haemodialysis related; other benign reasons are rather uncommon but increasing due to the omnipresent use of permanent central venous access catheters as well as implantable cardiac rhythm management devices. The incidence of haemodialysis-related central venous obstruction resulting in angioplasty is described to be more than 10 times higher compared to, for example, pace-makerinduced stenosis. In any case, early detection and treatment of complications are essential to provide adequate care. Contrast venography for many years has been the standard of reference; yet this procedure has its shortcomings. Sonography is not consistently reliable for detection of central pathologies, owing to difficult access to these vessels. Today contrast enhanced CT is employed to define the site of the obstruction and the presence of possible thrombosis and reveal surrounding soft tissue alterations. MRI is of comparative or even higher sensitivity and specificity in evaluating the patency of the central veins. The efficacy and safety of stent placement in central venous occlusion of benign and malignant origin lead to rapid relief. Stenting provides fast symptomatic help. Repetitive percutaneous intervention can prolong the cumulative patency. Thrombolysis may be required to improve the final result, should, however, not be employed as a sole means for revascularisation. US and MR are excellent imaging techniques for studying tendons and muscles. During this integrated session we will review the advantages and disadvantages of US and MR for the diagnosis and follow-up of sports injuries. Tricks of both techniques will be addressed, together with some useful guidelines for specific sports injuries. Ultrasound is being used at the pitch side and in sports medicine practice as an adjunct to clinical practice. With this in mind there are a number of questions that will be answered in these talks. 1. When US and MRI are the primary imaging and when they are complimentary. 2. What advances have there been in US and MRI imaging to help advance our use of these techniques in tendon and muscle injury. 3. Should we be aspirating haematomas and using autologous blood injections or PRP to treat tendon or muscle disease. 4. Can we predict the athletes return to sport?

A-310 08:35

Muscle imaging is inherently complex and presents unique morphologic challenges and continuing integration of dynamic, physiologic and functional capabilities. In sports medicine, ultrasound (US) has proved to be an excellent tool to evaluate muscle strain and contusion injuries in athletes providing good correlation with clinical findings. In the acute phase, US has nearly equal sensitivity to MR imaging to diagnose muscle strains, except in the first few hours after the injury, when fresh haemorrhage and oedema have similar echogenicity to normal muscle and strains may go unnoticed. Later in the process, US has been shown to be a useful tool in assessing the sequential stages of muscle repair, showing progressive resolution of blood fluid products, decrease in oedema and formation of scar tissue, thus aiding rehabilitation planning. Dynamic US during muscle contraction can be valu-3. To compare the diagnostic accuracy of CT versus MRI in Crohn's disease. 4. To learn about a strategy for the use of CT and MRI in the radiological workup of patients with inflammatory bowel disease.

Five good reasons for the radiologist to be at the forefront 09:44

The chairman and speakers will debate the optimum imaging paradigms according to (1) the clinical indication, (2) assessment of those with suspected but as-yetundiagnosed disease, (3) staging of the small bowel in those with newly diagnosed Crohn disease, (4) evaluation of response to therapy and (5) assessment of those with long standing disease. The optimum approach to assessing and monitoring disease activity will be discussed. Deep vein thrombosis (DVT) is a common condition which can lead to possible lifethreatening pulmonary embolism (PE). The primary imaging modality nowadays is Duplex ultrasound. In cases where the pelvic veins and/or the vena cava is involved, a venous-phase CT is helpful to determine the exact extend of the clot burden. Standard therapy for DVT is anticoagulation. However, if there is a contraindication or a complication (bleeding) to anticoagulation a vena cava filter is a good option to prevent PE. A filter should also be considered if a catheter directed thrombolysis is performed. With the new optional filters the filtration can be terminated either by removing the filter or by converting the filter into a stent. One problem which was observed with these optional filters is that (too) many of them are left in place. Despite a low complication rate of filters, a filter may cause an increased risk of further DVT, or a caval occlusion and in rare cases even a migration or penetration is possible. Therefore, patients with optional filters should be followed and filters should be retrieved when clinically no longer needed. Varicose veins are an early manifestation of venous insufficiency of the lower limbs which can also lead to skin changes including extensive ulceration. It is a very common problem affecting up to 30% of adults in Europe. Patients presenting with venous insufficiency must first be assessed by a history and clinical examination to determine the presence and extent of the disease. A duplex ultrasound examination is essential to determine the cause from which an appropriate treatment plan can be decided. Depending on the patients wishes and their funding options it is perfectly reasonable to treat all stages of the disease even if just cosmetic. Treatment aims to eliminate the reflux in all contributing veins starting proximally and moving distally. Surgery used to be the commonest treatment offered to patients but this has been largely superceded by endovenous methods which have significant advantages including: no general anaesthesia, outpatient based, no cuts, no scars, low recurrence, rapid convalesence. There are several endovenous methods using laser, RF, foam sclerotherapy and most recently steam heating and a combined mechanical/sclerosant system (ClariVein (R)). Laser and RF give almost identical results and 95% permanent truncal vein closure is to be expected. Foam sclerotherapy is cheaper and quicker but long-term results are poorer and patients often have to return for repeat procedures. Having ablated the main truncal veins using laser or RF at least 50% of patients require additional treatments for residual varicosities, e.g. microavulsions or foam sclerotherapy. Adenocarcinoma is the most common pancreatic malignancy, affecting the head in 60-70%. MDCT is very effective in detection and staging of adenocarcinoma, with a sensitivity of up to 90% for detection and accuracy of 80-90% for staging, but it has limitations (detection of small cancers, characterisation). MRI is a problem-solving tool in equivocal CT to depict small cancers. MRI with MRCP helps to differentiate between adenocarcinoma and focal pancreatitis. The "duct penetrating sign" at MRCP is indicative of an inflammatory mass. Examination protocols for MDCT include oral administration of 1-1.5 l of water ("hydro-CT"), IV contrast administration of 2 ml/kg b.w. (app. 140-150 ml), a flow rate of 4-5 ml/s, and a biphasic scan in parenchyma and venous phases. MRI protocol should include non-fatsat and fat-sat T1w GRE, T2w TSE, DWI, MRCP, and contrast-enhanced sequences. Gadoliniumenhanced T1w 3D-GRE are helpful for assessment of vessel infiltration and cystic tumours, whereas mangafodipir-enhanced sequences improve delineation of small tumours. In patients with locally advanced tumours, neoadjuvant chemoradiation may be used for tumour downsizing to make it amenable to radical surgery. However, pancreatic cancer often does not shrink after tumour response, which renders MDCT or MRI unreliable for tumour assessment in this setting. PET/CT may play a role in this indication. In conclusion, CE hydro-MDCT is an excellent and robust tool for pancreatic cancer detection and staging. MDCT in combination with MRI or EUS provides high accuracy for characterisation of tumours. Further improvement is needed to assess tumour response after neoadjuvant chemoradiation. CT is the established imaging technique for evaluation of pancreatic adenocarcinoma. MRI, however, can play a major role in this disease. Technical advances of MRI including parallel imaging techniques, multichannel receive coils of the abdomen, dynamic gadolinium-enhanced T1-weighted fat sat 3D GRE sequences, 3D MRCP sequences, mangafodipir-enhanced MRI and diffusion weighted imaging (DWI) have greatly improved the results of MRI in the assessment of pancreatic tumours. Standard imaging sequences include T1-weighted GRE with fat saturation, in-phase and opposed phased T1-weighted, axial single-shot turbo spin-echo (TSE) and coronal/oblique 2D and/or 3D MR cholangio-pancreatography (MRCP) pulse sequences, post-gadolinium-enhanced 3D T1-weighted fat sat sequence and DWI with multiple b values. MR imaging may be useful as subsequent examination for: (1) detection of small non-contour-deforming tumours with isoattenuated appearance at CT, (2) evaluation of local extension and vascular encasement, (3) detection of the presence of lymph node and peritoneal metastases, and (4) detection and characterisation of associated liver lesions and liver metastases. Diffusion-weighted imaging may be helpful as a complementary imaging method in the differentiation between mass-forming focal pancreatitis and pancreatic adenocarcinoma. Due to its superior soft-tissue contrast compared with CT, MRI ap-able to monitor the healing process. Local complications, such as vein thrombosis, irritation of adjacent neurovascular bundles, chronic haematoma and myositic ossificans can be demonstrated with this technique as well. However, US tends to underestimate the extent of injury and the abnormalities seen disappear more quickly when compared with MR imaging. At least in elite athletes, MR imaging seems, therefore, to play a more significant role in management of muscle injury, particularly when decisions regarding the time at which the patient can return to play are needed. By contrast, US is more accessible, and cheaper than MR imaging. In most clinical settings, US should be regarded as the first-line imaging choice for assessing skeletal muscle injury.

Learning Objectives: 1. To understand the mechanism of injury of muscles in athletes. Sports activity can affect tendons due to chronic overuse or acute injury. Both can result in complete tendon rupture. US is helpful in precise assessment of rupture severity and extend, but enables alsofor assessment of tendon degeneration, where rupture of individual collagen fibres stimulates a chronic cycle of reparative response caused due to repetitive microtrauma. In chronic tendinopathy histopathological changes, such as hypoxic, mucoid, calcifying, or lipoid degenerations are present. US enables for differentiation of partial tears, tendinosis, tenosynovitis or paratendinosis, because of active and passive dynamic examination possibilities, and high-resolution capability when using high frequency probes. US developments as power Doppler US, sonoelastography and contrast enhanced US allow further for new insights into tendinopathy. With the use of US, tendon changes can be diagnosed before they become symptomatic and a reduction of tendon load and initiation of treatment before the condition becomes chronic seem to gain important place in therapeutic regimes. Furthermore, US-guided therapies are advisable over blinded-guided injections to minimise side effects and to allow an accurate targeted therapeutic approach. Although diagnosis of acute muscle injuries in athletes is usually clinical, magnetic resonance imaging (MRI) is a very helpful adjunct tool in this setting, showing the location, extent and severity of the injury and thereby streamlining the management of the patient. Portability of ultrasonography (US) on the playfield in the acute setting is not matched by MRI, which nevertheless has distinct patterns of grade 1-3 muscle strains; however, it is usually with nonacute and deeper injuries of the muscles that MRI is especially helpful. Presence of bone contusion, stress reaction, or stress fracture is readily displayed by MRI and this is practically beyond the limits of US. Evolving haematomas, fibrosis, scarring, and myositis ossificans are sequelae of direct or indirect muscle injury which are usually outlined in a single field of view by MRI. Delayed onset muscle soreness and chronic exertional compartment syndrome, as well as acute and chronic stages of muscle denervation changes, are readily diagnosed with MRI. By providing an understanding of distinct muscular denervation changes, MRI may actually noninvasively point to the entrapped or involved nerve and guide medical or surgical intervention. Foci of mucoid degeneration within the muscle, myotendinous junction, or tendon itself are readily shown by MRI, which thereby displays potential sites of failure during sport activities. Diffusion tensor imaging may have a role in displaying the subtle architectural disruptions of directly or indirectly injured muscles. Learning Objectives: 1. To understand the specific role of MRI in the evaluation of muscle and tendon injuries in athletes. 2. To recognise imaging patterns of tendon abnormalities in athletes: acute and over-use injuries. 3. To review different mechanisms of muscle injuries: direct and indirect. 4. To understand how MRI might be used in the management of athletes. When a defect occurs in the bowel wall, air will appear within the peritoneal cavity, most frequently due to perforated peptic ulcer and perforated sigmoid diverticulitis.

In most perforating gastrointestinal conditions however, the -imminent-perforation is walled-off by neighbouring bowel loops, mesentery and especially by the omentum, nick-named "policeman of the belly". If this walling-off process occurs timely and effectively, no or only minimal free air will appear. The most important causes of walled-off gastrointestinal perforation are appendicitis, peptic ulcer disease, sigmoid diverticulitis, bowel malignancy, Crohn disease and -often underdiagnosed-accidently ingested sharp foreign bodies, as toothpicks, fish bones, chicken bones, etc. The extent to which the perforation is walled-off, determines the eventual course of the disease. The US hallmark of -imminent-perforation is inflamed fat around the involved bowel structure. Inflamed fat on US corresponds to what is often called "dirty fat" on CT scan: hypodense fat is interspersed with hyperdense streaks. This represents oedema or cellular infiltration of the fatty mesentery and omentum, which have migrated towards the site of the imminent perforation in an attempt to seal it off. On US inflamed fat is recognised as hyperechoic, non-compressible fatty tissue often interspersed with hypoechoic streaks. If fluid collections occur within the inflamed fat, this implies abscess formation. Inflamed fat is an important and valuable sign in perforating gastrointestinal conditions. If found in the absence of bowel pathology, the diagnosis is usually epiploic appendagitis or omental infarction. MDCT is an extremely powerful tool when the search for a GI perforation is required. The high spatial and contrast resolutions make MDCT the most accurate imaging method to identify even small amount of free intraperitoneal air. There is general consensus about the acquisition of a contrast-enhanced scan acquired during the portal venous phase of enhancement (delay of around 60-70 sec). Controversies are still present in the literature about the utility of a pre-contrast scan as well as the need for a preliminary administration of an oral soluble iodinated CM or for an enema or gaseous distention of the distal GI tract. Image reviewing needs the use of a workstation because multiplanar reformations have been demonstrated to improve the detection of small amount of free air. An appropriate window setting is mandatory and it makes MDCT 100% accurate for identification of free air and almost 90% accurate in the identification of the precise site of perforation. The aim of the examination is not only to assess the presence of free air but also to detect the site of perforation: this is an extremely useful clinical information especially if surgeons decide to perform a laparoscopic repair. Several CT signs have been described, able to guide the diagnosis and to differentiate between a perforation originating in the upper GI tract (stomach and duodenum), in the small bowel or in the colon. Evidence-based radiology' (EBR) is based on best current evidence, traditionally acquired radiological expertise, the ALARA principle and the values of referring doctors and patients. Any appropriately trained radiologist can formulate an answerable question, search the literature, appraise the retrieved evidence, apply their findings to local practice and evaluate the results. This presentation will describe and illustrate the 'EBR' process. Patients with chronic pancreatitis (CP) may present with features resembling pancreatic carcinoma, for which CP is a risk factor with an incidence of 5.9% after 20 yrs. EBR methods were applied to the problem of differentiating mass-forming CP from pancreatic adenocarcinoma. A focused question and literature search found no secondary literature or imaging guidelines. Primary literature searching found 53 relevant papers, 9 comprised current best evidence. For CT, time-attenuation curve characteristics had a sensitivity of 94% and a specificity of 83% for carcinoma. For MR, dynamic time intensity curve characteristics were only reported in a descriptive study but the Duct Penetrating Sign (MRCP) had a sensitivity of 85% and a specificity of 96%. For PET/CT, 18 F-FDG had a sensitivity for carcinoma between 86% and 96% with specificity of 87%-100%. For EUS/FNA, the sensitivity for carcinoma in pre-existing CP was consistently low (54-74%), but the specificity was 100%. Simple Bayesian analysis was used to establish the best order in which to apply these studies in practice. An algorithmic approach will be presented. The presentation will also consider other 'grey areas' in the field of pancreatic adenocarcinoma imaging using EBR methods. Learning Objectives:

1. To learn about evidence-based methods of literature searching and appraisal. 2. To understand how these methods can be used to produce diagnostic algorithms using the differentiation of pancreatic adenocarcinoma from mass-forming chronic pancreatitis as an example. 3. To learn about diagnostic algorithms based on different clinical scenarios (local and distant staging, advance versus early disease) involving multiple imaging techniques.

08:30 -10:00 Room F1

The hole in the guts In recent years, continuing trends in radiology have diminished the importance of plain films of the abdomen significantly. Ultrasonography and MDCT are applied with enormous success to the investigation of many abdominal conditions in the emergency setting. In the eyes of the radiologist, plain films, therefore, seem irrelevant in the presence of such powerful imaging procedures. Surprisingly, referring physicians, mostly surgeons, gastroenterologists and urologists, still request plain films although the potential of MDCT is obvious to them as well. In their perception, the plain film is either a definitive examination before initiation of treatment (e.g. stone at the ureteropelvic junction in US proven hydronephrosis) or a preliminary study prior to MDCT or surgery (exclusion of pneumoperitoneum or ileus). In the present climate of cost and radiation consciousness this trend may continue. Moreover, many surgeons, gastroenterologists, urologists, etc. have greater skills in reading plain films than in understanding MDCT. Therefore, the radiologist should poration. All these techniques remain investigational at this time for the treatment of breast cancer. The limitations of and challenges associated with each ablation technique and the issues raised by early pilot studies, which have so far prevented these techniques from replacing standard surgical techniques, will be discussed. In the elderly the co-existence of several diseases, the prevalence of involutional and degenerative aspects, together with physical and cognitive problems represent 'the norm'. It is therefore important to know how to distinguish the healthy elderly from those in need of treatment to avoid overdiagnosis and overtreatment. So the question is how to be aware of the potential and limits of diagnostic imaging and its applications in geriatric patients. Brain development occurs rapidly during the last trimester of pregnancy and continues at a rapid pace in the first two years of life. More subtle maturation, for example in the white mater, occurs well into the third decade of life, as evidenced by diffusion tensor imaging (DTI). Evidence of brain degeneration is occurring soon afterwards and includes mild brain volume los, reductions in white mater integrity on DTI, widening of Virchow-Robin spaces and accumulation of incidental white matter lesions (WML). Severe WML and incidental cerebral microbleeds (MBs) are associated with know cardiovascular risk factors and while the concurrent impact may be subtle in terms of cognition, they carry a poor prognosis in the long run. The same is true for silent cerebral infarcts, which increase the risk of dementia. Neurodegenerative (general brain volume loss, ventricular dilatation and hippocampal atrophy) changes also occur well before the onset of clinical signs of dementia. In genetically predisposed subjects (e.g. APOE4 carriers) abnormal (compensatory) brain activity on functional MRI and increased (compensatory) cerebral metabolism on FDG-PET have been observed that predict subsequent cognitive decline. More recently, PET studies employing amyloid tracers have shown abnormal binding in a significant proportion of cognitively elderly, suggesting that these subjects are at risk to develop Alzheimer's disease -the pace of which is currently undetermined. The objective of percutaneous needle biopsy of the breast is to obtain an accurate preoperative diagnosis with a low upgrade rate post-surgery. Indications arise in both symptomatic and screen-detected lesions. A range of biopsy needle designs are available and their selection depends on being aware of the range of needle design types, their advantages and limitations. Cutting needles, guns, vacuum systems and MR compatible devices will be discussed. Guidance technique for ultrasound, x-ray stereotaxis and MR-guided procedures is extremely important, beginning with patient positioning and anaesthesia prior to commencing the procedure. Accurate needle placement under direct vision using high frequency ultrasound probes, x-ray stereotaxis with digital systems and MR guided -with the option of using a CAD system for distance calculation -will be presented. Typical imaging signs and potential pitfalls of each technique, both anatomical and technical, will be highlighted. Methods to increase accuracy including the use of meticulous technique, adequate sampling and correlation of specimen pathology with imaging findings at multidisciplinary meetings are essential. There is always the possibility of a false negative biopsy results in any type of percutaneous image-guided needle biopsy (FNAC, core biopsy, vacuum-assisted biopsy). The risk depends upon the quality of the harvested cytologic or histologic material. The quality is closely related to the amount of material collected and the accurate targeting of a lesion. Some lesions are at a higher risk of underestimation (sizes < 5 mm, architectural distortions, microcalcifications, stellate lesions) than others (i.e. focal lesions). The false-negative rates for microcalfications using vacuum-assisted biopsy were reported to be 1.2%, for mass lesions 0.8%. Using ultrasound-guided 14 g-core needle biopsy the false-negative rates were reported to be in the range of 2.5%. Radiologic-histologic correlation plays a key role in the definite and correct judgement of the diagnostic result. In case of imaging-histologic discordance re-biopsy, possibly using larger needle diameters, or even open biopsy should be considered. The European Guidelines for Quality Assurance of Breast Cancer Screening and Diagnosis define outcome parameter for breast biopsies. Guidelines from the European Society of Breast Imaging published in 2007 define the standards and skills necessary to perform these procedures. Documentation standards should be used (B1-B5) to allow continuous yearly evaluation of the individual institution results and quality improvement. The aim of any needle biopsy is to get as much, i.e. representative material as possible. Nevertheless, a certain amount of underestimation, caused by lesion type (ADH, DCIS, LIN, papilloma, for example) will remain and has to be reflected. The presentation will discuss the role of large vessel arteritis within the spectrum of thoracic vascular diseases. It will detail the pathological entities and their morphological, functional, and clinical characteristics. It will present typical CT and MRI findings and discuss key elements to the differential diagnosis. It will finally discuss the clinical relevance of this diseases, with a special emphasis on overall evolving importance of thoracic vascular disorders. Severe haemoptysis can occur in about 5% of patients. It is associated with high mortality due to asphyxiation, if not treated, and needs urgent and comprehensive evaluation of the lung parenchyma, airways, and thoracic vasculature. Multidetector row CT angiography is a very useful noninvasive imaging modality for initial assessment of haemoptysis in stable patients. It can accurately identify the source and the most common predisposing causes of haemoptysis (bronchiectasis, chronic bronchitis, lung malignancy, tuberculosis and fungal infection) and the effects of haemorrhage on the lungs and airways. Moreover, the combined use of thin-section axial and complex reformatted images allows clear depiction of the origins and trajectories of abnormally dilated systemic arteries that may be responsible for the bleeding in over 90% of cases requiring intervention with arterial embolisation or surgery. Nonbronchial arteries may also represent an important cause of haemoptysis. The road maps of dilated bronchial and nonbronchial arteries provided by CT angiography represent a useful guide for endovascular treatment. CT angiography is a quick and noninvasive tool that is helpful in the diagnosis and management of haemoptysis. disorders that affect the elderly population. Some misleading radiological presentations typically occurring in this population will be also presented. In the elderly the coexistence of several diseases, the prevalence of involutional and degenerative aspects, together with physical and cognitive problems represent 'the norm'. It is therefore important to know how to distinguish the healthy elderly from those in need of treatment to avoid overdiagnosis and overtreatment. So the question is how to be aware of the potential and limits of diagnostic imaging and its applications in geriatric patients.

Fast development in the area of imagining modalities demands a lot of work in dose and image quality optimisation and management. Deterministic harms have been reported both in interventional and diagnostic radiology. There are also some special groups (e.g. children) which need a lot of attention and especially tight indications for x-ray examinations. Radiation dose and image quality optimisation can be applied with small steps in everyday clinical work as a part of self assessment, if the safety culture is agreed by all professionals. The vendors put the settings high in order to reach the best image quality. After installation the settings must be re-evaluated before starting clinical use of the equipment. Also, the sensitivity of AEC (automatic exposure control) must be turned according the detector. Using the air gap (30 cm) instead of grid, e.g. in hip axio-lateral project or scoliosis, dose decrease can be even two thirds. The role of radiographer is expanding to new areas. Quality assurance and dose and image optimisation could be parts of the expanded role. The new technical solutions in imaging offer a lot of possibilities for dose reduction, if we want, but there is also danger of dose creeping if the doses are not followed up frequently. The management and legislation offer the basics but the work must be done among those who are working in radiological departments. Commitment to the safety culture on all levels in medical radiation offers better care and procedures with lower doses to the patients. Radiological procedures are performed because of medical benefits to patients, but they also cause some harm because of the dose. If medical benefit overweighs detriment the procedure is justified. The purpose of the optimisation is then to adjust the procedure in a way to maximise the ratio of benefit over harm. Question is who is responsible to do it and how it can be done. Who should participate: we believe there is a major role of radiographer as she/he is present at each and every radiological procedure performed. But it is absolutely mandatory for them to understand benefits of the procedure and understand harm (dose). Radiographer's position is the connection between radiologist, medical physicist and vendor's engineers.

Radiologists usually do not have in depth knowledge of technology and dose and physicists and engineers on the other hand do not understand in depth the medical aspects of procedure. Radiographers must also understand operational possibilities of every x-ray machine. To get to know them they should be there at the acceptance of the x-ray machine and talk to service engineers and applicators. They should also talk to physicist when he/she is doing tests. And finally simulation of procedure(s) using different phantoms is the best way to understand how machine parameters are affecting image quality and dose. In presentation, some examples for different modalities will be given.

Learning Objectives:

To gain knowledge about how to start with optimisation of radiological procedures. 2. To understand the basics of quality control (QA) for radiographic modalities and how to use experience acquired from QA in daily work. 3. To become familiar with guidelines and applications for good radiological practice and how to implement them in the optimisation process. 4. To consolidate knowledge of technology of radiographic modalities and the use of materials in daily practice according to guidelines, and to be familiar with the radiographers responsibility in the field of radiation protection. The availability of magnetic resonance (MR) scanners operating at 7 T and above has already proved beneficial for MR imaging and spectroscopy of the human brain and promises similar benefits in the human body. These advantages result from the increases with the magnetic field of the intrinsic signal-to-noise ratio, blood oxygenation level dependent (BOLD) contrast, which forms the basis of the vast majority of functional MR imaging (MRI) experiments, and chemical shift dispersion. These gains can be exploited in improving the spatial and/or temporal resolution of anatomical and functional MRI experiments and in increasing the spectral resolution in volume selective spectroscopy or chemical shift imaging. Operation at the increased magnetic field also offers easier access to T 2 * -contrast and improved implementation of susceptibility-weighted imaging (SWI) in which the phase of gradient echo images provides information about local variation of magnetic susceptibility. In the brain, such variation appears to be dominated by differences in iron concentration and myelin content, so that high-field SWI may provide useful information about the progression of neurodegenerative disease. The elevated T 1 relaxation times at 7 T also offer benefits for arterial spin labelling and time of flight angiography. Current and potential future applications of high-field MRI in clinical and pre-clinical studies in a number of areas and will be discussed in this presentation, along with the barriers to wider usage of 7 T systems for clinical studies. The purpose is to present and discuss the role of imaging in non-traumatic acute abdomen, with particular focus on ultrasound (US). The neonatal GI tract emergencies, associated with specific disorders and imaging strategies, are excluded. Acute abdomen in children refers to a wide variety of conditions ranging from benign disorders, such as gastroenteritis, to threatening disease, such as midgut volvulus or intussusception. The recognition of a surgical emergency requires usually, after a competent clinical evaluation, an imaging investigation in order to avoid negative or unnecessary surgery. Abdominal plain film is known as poorly sensitive in most situations, except bowel occlusion. Ultrasound requires experience and a thorough examination but has demonstrated a high sensitivity and specificity for diagnosing bowel obstruction, midgut volvulus, intussusception, acute appendicitis, Over the recent years the clinical MRI field strengths have gradually been increased to 3 Tesla; however, whole body MRI systems with higher fields of up to 9.4 Tesla have become available in experimental settings. Compared to clinical field strengths, MRI at very high magnetic fields has several advantages but also some unique challenges. With increasing field strength the signal-to-noise ratio increases, which can be used to either increase the spatial resolution in the images, or to acquire the images more rapidly. Unfortunately, the energy deposited in the human body via the RF excitation scales quadratically with the field strength. Thus, the specific absorption rate (SAR) is a critical factor in all rapid imaging protocols, and requires the design of RF pulses with low SAR, (e.g. VERSE pulses). Inhomogeneities of the RF field which are induced by standing wave phenomena have to be compensated, and make the design of efficient spin echo pulse sequences very difficult. At higher field also the field inhomogeneities become larger and stronger imaging gradients are required to overcome the susceptibility-induced image distortion. Stronger gradient systems are difficult to manufacture, and the usable gradient slew rate is limited by peripheral nerve stimulation thresholds. Furthermore, stronger and faster gradients become very loud at high fields, and special measures for sound protection are required. Despite these limitations, high-field MRI offers image with very high resolution, it provides unique contrasts, a better spectral separation of the resonance lines and high signal for non-proton applications. Clinical MRI usually aims to depict anatomic regions of interest with uniform coverage and contrast behaviour. To this end it is essential to use suitably homogeneous radiofrequency (RF) magnetic fields for spin excitation, refocusing, and saturation. Traditionally, such uniform transmit fields are generated by volume resonators based on quasi-stationary electrodynamics, which, however, gradually cease to apply as clinical MRI explores high field strengths of 3 T and beyond. The concomitant increase in operating frequency entails shorter RF wavelength and increasing tissue interactions, which render the tailoring of RF fields substantially more complex and patient-dependent. One promising response to this challenge is to depart from volume resonators and perform RF transmission by multiple, individually fed transmitter elements. With such transmit arrays the effective RF field can be tailored on a per-patient and per-scan basis by adjusting the relative magnitude and phase of driving the elements (RF shimming). In advanced imple-08:30 -10:00 Room Z 

Neural stem cells are in the process of finding their translation into the clinic. However, it is well-known that the cells by themselves do not regrow lost tissue. To this end, neural stem cells need further support and guidance. Tissue engineering is using biomaterials to provide a structural support for cells, but can also incorporate the release of factors that guide the fate of transplanted cells. Ideally, an in vivo imaging approach would encompass all these processes. We here demonstratethe use of a 19 F MRI contrast agent to detect clinical-grade human neural stem cells non-invasively over 7 days within a tissue cavity formed by stroke. To provide structural support for these transplanted cells within the tissue cavity, cells were mixed with an engineered de-cellularisedextracellular matrix (ECM). Using diffusion MRI, we were able to detect the presence of the ECM within the stroke cavity. This approach hence provides a novel approach as to how we can study transplanted cells and tissue regeneration in vivo by MRI. Our lab has been among the first to exploit dendritic cell (DC) therapy to treat melanoma patients. Over the past years, immunological responses are increasingly reported and clinical responses have consistently been observed. Moreover, DC therapy often has much milder side effects than standard chemotherapy. A key hurdle in the development of the DC therapy is accurate delivery of the cells to lymph nodes (LNs), or their successful migration from the site of injection to LNs. In particular, tools for measuring cell migration in vivo are necessary. Ideally, we would be able to quantify the number of DCs at the relevant site, with high resolution anatomical context to allow differentiation of LNs and the possibility of longitudinal data acquisition. Furthermore, functional data on the ensuing immune response is also required. Towards these ends, we have been working on developing imaging techniques to study DCs in vivo, for example with scintigraphy on 111 In-labeled DCs, and magnetic resonance imaging (MRI) on iron-labelled DCs. Scintigraphy is quantitative, but it is restricted to the relatively short half-life of the radioisotope and is unable to resolve individual LNs. MRI allows high resolution anatomic localisation, but the use of contrast agents such as iron oxide is not quantitative. Our recent work has focused on imaging the functionality of these DCs using positron emission tomography (PET) to study LN activation. Finally, we have also developed in vitro assays that closely mimic in vivo DC migration in 3D scaffolds imaged using quantitative 19 F MRI, as a substitute for in vivo optimization. We plan on applying 19 F MRI to the tracking of DCs in vivo, as the technique allows both quantification and high-resolution anatomic detail.

hypertrophic pyloric stenosis, etc. It enables some differential diagnosis such as infectious ileocolitis, ischaemic colitis, Henoch Schonlein purpura, complicated Meckel diverticulum or duplication, etc. or even pyelonephritis. It can provide some findings suggesting mesenteric adenolymphitis, viral gastroenteritis, etc. The US findings will be described as well as the potentialities and limitations of US in each of these conditions. The accurate knowledge of the clinical findings together with the results of US will guide the need for another imaging modality: enhanced CT in case of suspected appendicitis with inconclusive US, upper GI series in an infant with bilious vomiting and impossibility to display the mesenteric vessels, etc. At last, some aspects of pancreatic and biliary tract emergencies will be shown. The purpose is to discuss the role of emergency imaging in acute paediatric GU conditions, with particular focus on the potential of ultrasound (US). Besides GU tract trauma conditions such as urosepsis, renal failure, renal colics, ovarian or testicular torsion with all the respective relevant differential diagnoses have to be considered and urgently addressed adequately. Particularly with respect to radiation protection (ALARA-principle) and due to the superb US potential in childhood, US is often used as the primary imaging tool. In many conditions US will reveal all treatment relevant information and no additional imaging is necessary in the acute setting. However, in other conditions such as severe (multiple) trauma CT remains the best primary imaging tool, however, only by using age-adapted CT protocols. The work-up and follow-up may also require imaging, usually achievable by US and partially by MRI, scintigraphy and/or cystography. All these lead to imaging algorithms that differ from adults. The most important conditions, their imaging appearance, the potential pitfalls and some important methodical details will be presented, also discussing the recommended dedicated paediatric imaging algorithms. In most paediatric acute GU conditions US is adequate as the first and often sufficient imaging modality. Rarely other imaging is necessary particularly in the acute setting -except for CT in severe (multiple) trauma. All imaging should be indicated with respect to therapeutic consequences and the ALARA principle, and proper paediatric protocols as well as methododical skills (e.g., dedicated paediatric US) should be provided 24 hours throughout the year. Learning Objectives:

1. To learn about the diagnostic imaging approach in acute urinary tract disease. Computed tomography (CT) is the imaging method of choice in the evaluation of abdominal injury after blunt trauma in haemodynamically stable children. An unstable patient needs to be stabilised prior to CT or to proceed directly to surgery. Evaluation with CT allows for accurate detection and quantification of injury to solid and hollow viscera, and can also identifies an active haemorrhage. CT can help prioritise optimal management by diagnosing the major or most life-threatening site of haemorrhage or injury. CT can also demonstrate associated bony injury to ribs, spine, and pelvis. A normal CT examination may prevent other unnecessary explorations. The decision for operative intervention in the small percentage of children who require surgical haemostasis is primary made based on clinical criteria and not on CT findings. Interventional techniques deeply changed approach to treatment of diseases. In each country, interventional radiology practice establishment varies according to local factors, but following a standard strategy seems better to set up this facility. According to above-mentioned points, I decided to establish this specialty in our hospital since 1996 as the pioneer center in interventional radiology Iran. At first the procedures included percutaneous laser disc decompensation (PLDD), and vertebroplasty followed by vascular procedures such as UAE in later years. Now, we are performing all interventional procedures in our country including aortic stent and all neurointervention procedures. The following items will be discussed: 1. Prepare step by step strategies for establishing intervention. 2. Solving issues regarding interventions procedures. 3.

Modified techniques for lowering costs to cover interventions in poor people. 4. Setting of fellowship courses. 5. Co-operation with dedicated and pioneer international centers such as using neocrylate for treatment of brain aneurysms in conjunction with UCSD for the first time on human. When presenting our experience we want to review how we should start interventional radiology in developing countries. Fibroids are the most common benign tumours of the uterus during female reproductive age. Uterine artery embolisation (UAE) is a procedure in which using embolic particles (PVA, Gelfoam, etc.) we block blood supply to uterine fibroids. It has been reported as a relatively safe, effective, and durable nonsurgical alternative method diminishing fibroid-related symptoms. UAE is typically performed in both uterine arteries by an experienced interventional radiologist. After UAE, reduction in menorrhagia has been reported as 80-93% and the mean decrease in fibroid size varies from 50% to 78% in the literature. Complications including amenorrhoea are frequency ranging from 1% to 7% in the literature. UAE may be followed by menopause in 1% of the cases. Nevertheless, it is usually encountered in women in their late 40s. It seems that the future of UAE depends on optimal selection of patients based on the prediction of volume-shrinkage, the outcome of fertility, and the long-term efficacy. Although pregnancy is possible after embolisation, neither fertility preservation nor its improvement can be definitely guaranteed. Women who desire to become pregnant should definitely be cautioned about potential complications during pregnancy. In this presentation we are going to review the position of UAE in Iran and to present our experience about the efficacy, and safety of UAE. Besides, we will discuss some methods of dose reduction during UAE and the effects of UAE on fertility and pregnancy outcome. Purpose: Labelling pancreatic islets (PI) with superparamagnetic markers enables their detection as hypointense spots on magnetic resonance (MR) images. We tracked PI transplanted into the liver and quantified their signal loss in liver tissue using MR imaging over a six-month period. Methods and Materials: PI were labelled with ferucarbotran 5 μl/ml for 6-44 hours and transplanted into the portal vein in 8 C-peptide negative recipients (12 infusions). The liver was examined prior to transplantation and subsequently 1 day and 1, 2, 4 and 24 weeks after transplantation using a 3 T MR scanner. Results: In all recipients significant C-peptide levels and near-normal HbA1c values were achieved with 50-80% insulin dose reduction. No side-effects related to the labelling procedure were documented. A significant decrease in the number of islet spots was detected at 1 week post-transplantation (on average 60%) with a subsequent only slight decrease for up to 24 weeks. In two subjects with a labelling period of less than 6 and 10 hours respectively only a few islet spots were detected corresponding to poor islet visualization in phantoms labelled for the same period of time. Conclusion: PI visualization was successful in all recipients but was less efficient if the labelling period was less than 16 hours. A significant decrease in islet spots occurred at 1 week post-transplantation suggesting early islet destruction or impaired engraftment. Then, the decrease in islet spot numbers slowed and islets were still detected at 24 weeks post-transplantation. Data shows that MR detection of ferucarbotran-labelled islets correlates with sustained C-peptide production. areolar complex), the presence of other imaging findings (extension to the skin, inflammatory cancers) and the status of regional lymph nodes. This information influences the type of treatment given to the patient and it is very important to gather as much information as possible in order to obtain a one-step surgical excision with free margins at pathology. On the basis of this information and on discussions held in multidisciplinary meetings, markers will be placed wherever needed in order to locate the exact distribution of the tumour(s). The different parts of a structured report (clinical data relevant to the report, technical description of the diagnostic or the interventional modality, pitfalls during the exam, description of breast composition, description of lesions, categories and overall assessment) should always be included in order to guarantee that all the important information is there. Breast imaging, like other subspecialties in radiology, is a multimodality area of knowledge where it is vital to integrate the information obtained through diagnostic and interventional procedures in order to supply the clinician with a body of data that is useful and straightforward. Liver metastases are of the most difficult therapeutic challenges in oncologic managements. Surgery is frequently impossible due to disease extent and systemic chemotherapy usually fails. In other body parts, the combination of radiotherapy and systemic chemotherapy is used for several types of malignancies. We successfully adopted a novel image-guided form of this combination for such masses referred to as radiochemoembolisation, which substantially intensifies the treatment locally. Patients underwent transarterial radiochemoembolisation with chemotherapy protocol of mitomycin, doxorubicin, and cisplatin and embolisation with radioisotope particles of 32 P. The effectiveness of method was determined by comparing contrast-enhanced CT images, pre-and post-intervention. Treatment response was evaluated using RECIST criteria. We also used some arbitrary criteria such as tumoural mean density and enhancement pattern. For stable and partial-response cases, the procedure was repeated. We did not repeat the treatment for progressive diseases. Complete-response cases were only followed. After completing treatment sessions, regardless of the tumour source, considerable amount of patients showed substantial response. In terms of RECIST criteria, a significant portion of patients gained at least a "Partial Response". But the decrease in tumour density and the appearance of non-enhancing tissues were more promising. Radiochemoembolisation is an effective method for the treatment of patients with unresectable hepatic metastases. Although this study lacks a control group, it shows the effectiveness of the treatment. Literature review showed the response to treatment with regard to RECIST criteria had been better in our study comparing with studies only used chemoembolisation or radioembolisation. , which showed the superiority of digital mammography for younger and perimenopausal women, as well as those with dense breasts; the National CT Colonography Trial (NCTCT), demonstrating the equivalence of CTC with colonoscopy; and the National Lung Screening Trial (NLST) which has preliminarily reported a 20% decrease in lung cancer-specific mortality associated with annual CT screening. ACRIN's current focuses include the assessment of emerging imaging biomarkers for the prediction of and monitoring of response to treatment and the extension of its activities to disease processes beyond cancer. According to the second approach, termed as ‚dark lumen MRC', dense barium or tapped water is used to distend the colon in conjunction with post-gadolinium 3D gradient echo with fat-saturation sequences. The colonic wall and the corresponding polyps exhibit high signal intensity as a result of gadolinium uptake while the colonic lumen presents with low signal intensity. MR imaging of the pancreas and bile ducts relies upon a combination of T2-w and T1-w strategies in order to safely acquire anatomic, cross-sectional and functional information. Tissue-imaging strategies include free breathing T2-w imaging (obtained with echo-train spin-echo sequences with or without fat saturation) and breath-hold 3D-gradient echo T1-w imaging (obtained with fat saturation) without gadolinium and in the capillary phase and in the interstitial phase post-gadolinium. This combination is valuable in the assessment of the full spectrum of pancreatic diseases and malignant bile duct obstruction.

Hardware improvements (gradients) and the advent of more sophisticated phased-array coils and parallel imaging capabilities in modern MR scanners allowed to increase the spatial and temporal resolution of "conventional" T2-w and T1-w sequences. Furthermore, it provided the possibility of adding high-b-value diffusion weighted imaging (DWI) to our routine protocol in order to increase the sensitivity of MRI in detecting malignant and inflammatory diseases. To obtain conventional MRCP imaging thick-slab heavily T2-w TSE sequences or 3D heavily T2-w TSE sequences may be used. Advantages and limitations of both sequences will be underlined. Functional bile duct imaging is obtained imaging modality or technique for this problem. Increasing technological capabilities and knowledge of how to optimise CT/MR contrast utilisation provides better ways to characterise tumours than ever before such that key clinical specialties outside of radiology now recommend nonbiopsy imaging diagnosis of HCC to triage patient treatment. Radiologists must work extra diligently to learn the clinical issues, triage points and implications that are associated with specific clinical presentations and imaging findings. The perfect test that does not require cognitive interpretation of the constellation of imaging findings with integration of the patient clinical presentation to optimise patient care is not in our near future. This lecture emphasises historical advances in liver imaging and how data in the literature impacted patient care decisions in ways that may be different than expected from radiologists. An emphasis on pathologic-imaging correlation will be used to put apparent disparate published results in proper perspective to allow radiologists to meaningfully interact with clinical colleagues in determining optimal patient treatment. Liver MRI is undertaken to assess the liver parenchyma, vasculature, and biliary system. It is necessary to use a variety of unenhanced and contrast-enhanced MR pulse sequences to achieve lesion detection and characterisation. A set of T1-, T2-w and DWI sequences is now standard for lesion delineation and assessment of liver fat and iron content. In-phase and opposed-phase T1-w GRE images show focal or diffuse fatty infiltration and focal sparing. A fat-suppressed T2-w TSE sequence is robust and provides high tumour contrast, with 3.0 T units now allowing acquisition of isotropic 3D-TSE sequences. The quite popular T2-w half-Fourier single-shot TSE (e.g., HASTE) pulse sequences show anatomic detail (including bile ducts), but lack lesion contrast. In case of suspected iron overload (i.e., haemosiderosis and haemochromatosis) an additional T2*-w GRE is recommended. Acquisition of DWI Patient transport into the radiology department, contact to other potentially infectious persons, and things such as breath-holding are reasonable burdens and dangers to immunocompromised patients. When searching the focus of fever, imaging should help to identify an affected organ system in order to eventually guide invasive procedures to identify underlying micro-organism or non-infectious disease. Equally relevant is the exclusion of its involvement with a reasonable specificity. Depending on local epidemiology, organ system, and the clinical signs and symptoms, suspected differential diagnosis can be derived from image patterns. Some of these diagnoses might be exclusion diagnosis, others might require invasive procedures including time consuming and costly analysis to be verified. Invasive procedures, however, require adequate hemostasis, which is usually not available for a substantial duration due to pancytopenia in patients who underwent chemotherapy. If imaging fails to derive the underlying disease confident and conclusively in a fast way, clinicians might need to treat on an empirical basis. Empirical treatment plays a major role in immunocompromised or severely ill patients at risk, because mortality rises within hours of untreated disease. On the other hand, empiric treatment causes relevant toxicity and substantial costs, while imaging might become cost-effective. using contrast agents that are taken up by hepatocytes and excreted through the biliary system in combination with volumetric T1-w sequences. We use this technique in postoperative complications and to elucidate complex biliary anatomy. Functional imaging of the pancreas is obtained by combining MRCP along with hormonal stimulation with secretin. In addition, secretin improves anatomic delineation and allows MRI quantification of fluid production by the exocrine pancreas. Despite the advance of cross-sectional techniques, the chest radiograph remains a basic tool for the initial approach to heart diseases. In this lecture we will present our current approach to evaluate cardiac pathology in conventional radiography illustrating it with selected cases. The basic approach consists of seven steps, evaluating the size and shape of the cardiac silhouette, cardiac calcifications, pulmonary circulation and lung changes, great vessels and implanted devices, all of them correlated with the clinical findings. Looking at the heart on a chest film may be considered at a first glance as wasting time since, today, many other techniques are available today to offer an impressive luxury details of the morphological and functional evaluation of heart. Nevertheless, the chest film remains often the first modality performed in many situations in which symptoms can be both from pulmonary or cardiac origin and then, careful analysis of heart may avoid rough mistakes in patient management. Acquired and congenital pericardial or cardiac abnormalities may be responsible for a deformity of the cardiac silhouette and lead to explore the patient by a chest CT. CT with fast scanning capabilities can acquire images of the thorax with reduced cardiac motion artefacts, improving the evaluation of the heart in the course of a thoracic CT. Unexpected findings of cardiac structures on both unenhanced and enhanced acquisition can dramatically influence the patient's clinical management. In many situations, a chest CT is performed without cardiac gating and it may be necessary to complement the initial examination by a gated acquisition to provide a more dedicated analysis. The normal appearance of cardiac structures and the most common cardiac abnormalities should be known by all the radiologists. Various conditions such as idiopathic and acquired cardiomyopathy, ischaemic heart disease, valvular dysfunction can be identified even on non-gated scans. Pulmonary diseases may also involve pericardium and cardiac structures and this should be clearly identified. Learning Objectives:

1. To learn how to detect and characterise cardiac abnormalities in the chest radiograph. 2. To learn how to detect and characterise cardiac abnormalities on chest CT. 3. To learn the limitations of the interpretation of cardiac abnormalities on ungated chest CT. 4. To learn when further evaluation is required. nal in discs and vertebrae to the adult shape and signal pattern will be reviewed. The normal pattern of unfused bony segments and apophyses in the child and fusion to the mature adult form will be reviewed. Normal variants such as persistent segmentation/non-union leading to limbus vertebrae and dysraphism will be reviewed. Intervertebral discs, vertebral body endplates, posterior elements and bone marrow show a wide degree of variation and the borderland of normal variant versus pathological abnormality is often difficult to navigate. Common borderland findings such as Schmorl's nodes versus Scheuermann's disease will be discussed. Transitional vertebrae as such are normal but incomplete transitional changes are associated with clinical symptoms. Even without associated pathological changes the terminology of transitional vertebrae is a common pitfall. Simple coping strategies will be reviewed. Various imaging artefacts can have an influence on image interpretation though lumbar spine MR imaging is more resistant to these than imaging of the cervical and thoracic spine. This talk will review an approach to imaging complications of total hip replacements. The talk will briefly review surgical techniques and types of prostheses. The talk will subsequently review early and late complications of prostheses and focus on the integrated use of all modalities including radiographs, aspiration arthrography, scintigraphy and MRI in achieving a diagnosis. There are many surgical techniques to repair meniscal tear, focal cartilage defect, cruciate ligament tear, malalignment, fracture, osteoarthrosis, etc. Conventional radiography, CT-scan, CT-arthrography and MRI play an important role in evaluation of the knee after surgery or arthroscopy. Indications for postoperative imaging are infection, persistent pain and dysfunction. Every radiologist should be familiar with "normal" imaging findings after arthroscopy, osteosynthesis, ligament reconstruction, osteotomy, knee prosthesis and meniscal or (osteo)chondral repair, but also recognise the main complications after knee surgery or arthroscopy. Orthopaedic hardware is usually evaluated on plain radiography or CT, and only a relative contraindication for MRI. Microscopic metal artefacts and fibrotic scarring are frequently seen along the course of the instrumentation tract. After partial meniscectomy, an obtuse angle at the apex of the meniscus and increased signal intensity of the remnant part of the meniscus are normal findings, whereas fibrillation and recurrent tear may explain the complaints of the patient. Various intra-and extra-articular reconstructive procedures exist for anterior and posterior cruciate ligament reconstruction. Besides the neoligament, an osseous tunnel, screws and metal artefacts are also visible. Postoperative findings of the extensor apparatus include a thickened patellar tendon, focal myxoid degeneration, fibrosis and focal defects, e.g. after harvesting tendon tissue for ACL reconstruction or after release of the lateral patellar retinaculum for 'unstable' patella. Accelerated osteoarthritis may be a late postoperative finding. MRI very well depicts incorporation and alignment of osteochondral auto-or allografts, and the position, morphology and integrity of the meniscus after repair or transplantation. To evaluate postsurgical patients it is important to know the primary clinical diagnosis, the surgical treatment, the interval since surgery, and patients' current clinical symptoms. Radiography is the most common imaging modality to evaluate the postoperative ankle, particularly in traumatic cases; after reduction and fixation of a fracture or dislocation it is generally carried out as routine. Ultrasonography is highly sensitive and specific in postoperative tendon assessment, thanks to the superb resolution, and the opportunity for dynamic evaluation of tendon integrity. chest drains (28-30 Fr) with underwater seals achieved decompression of pleural fluid collections. Recent literature suggests small bore drains may be adequate, with image guidance playing an important role. Pleural space anatomy, including fissural locations will be revised. Aetiology of transudates, exudates and empyemas, along with typical clinical presenting features are outlined. Various examples of plain film, ultrasound, multi-detector computed tomography and MRI appearances of pleural collections and their aetiologies are presented. Selection of patients, image guidance methods, catheter size, insertion technique, pitfalls and procedure complications are discussed. Importance of physician-radiologist liaison with respect to catheter management and catheter dwell times is emphasised. Pleural space fluid collections are common clinical entities that radiologists can accurately diagnose as well as successfully treat. Overview of aetiology, radiological appearances and method of image-guided drainage of infected pleural fluid collections is provided. Pelvic abscess drainage may employ more difficult access routes due to anatomic restrictions. The procedure may carry a higher risk of complications compared to simple abdominal drainage. To optimise patient preparation, correction of coagulation deficits, optimisation of antibiotic treatment, and sedation or anesthesia may be needed. The usual access routes for deep pelvic abscesses are the anterolateral and the posterior transgluteal approach. In selected cases, a transvaginal or transrectal approach may be the safer and more efficient option. Depending on the viscosity of the drained fluid, the presence of necrotic solid tissue and gas, different sizes of drainage material may be needed. Do not hesitate to employ large drainage catheters if indicated. An overview of the available material will be given. Intestinal laceration is a major complication which can be managed percutaneously in selected circumstances. Often, the weakest part of percutaneous drainage is the postinterventional management. It is advocated that the management is actively guided by the interventionalist who ensures that the drainage is properly handled, rinsed, and cleaned, that follow-up imaging is performed at the right intervals, and who is also responsible for indicating drain removal. Chest CT and MRI are commonly performed to evaluate patients with acute chest pain. A number of imaging techniques are available that may cover the entire chest, including the cardiovascular system. The radiologist will encounter more and more cardiovascular disease that was not visible with ungated CT and MRI techniques. The differential diagnosis of acute chest pain may include over 30 possible diagnoses, a substantial number related to cardiovascular disease. It is important to recognise chronic and acute coronary disease, myocardial infarction and its complications, left ventricular function, pericardial disease, atrial disease and large vessel disease. Case material will be presented and discussed using both CT and MRI techniques to illustrate the spectrum of usual and more unusual cardiovascular pathology that should be considered in the differential diagnosis of unexplained chest pain. Pulmonary hypertension (PHT) remains a disease difficult to diagnose because the clinical findings are nonspecific, often leading to a delayed diagnosis. Once recognised, it is necessary to determine the underlying cause and to estimate the severity of pulmonary hypertension. Among the noninvasive methods of assessment of PHT, CT angiography (CTA) now plays an important role in the diagnosis and post-therapeutic management of PHT. Numerous recent technological advances of multidetector-row CT technology (MDCT) have reinforced the clinical impact of this technology by introducing new tools for the morphological evaluation of small-sized pulmonary arteries and pulmonary capillaries, the latter being accessible with dual energy CT and often referred to as pulmonary "perfusion". The role of CT now also includes the possibility to investigate the presence of PHT on the basis of functional parameters, such as the distensibility of the pulmonary arterial wall, and to integrate cardiac functional information, with great interest towards right ventricular function. The major clinical impact of these new scanning modes is that morphology and function can be obtained from the same data set, with no restriction on the diagnostic performance of high-resolution CT angiographic images. The purpose of this lecture is to review these new trends in imaging of PHT and estimating right ventricular function through practical clinical situations, including the most common causes of PHT. CT scans of the chest are usually performed and reported as if the lungs were the only organs in the thoracic cage. However, the heart and pulmonary arteries can show significant abnormalities either as associated findings of the parenchymal disease or as incidental findings. So the recommendation is: do not forget the heart and pulmonary vessels when reporting a CT scan of the chest.

MRI has rapidly become important in post-operative assessment of the ankle, because it provides high soft-tissue contrast, multiplanar capability and osseous structures visualisation. It shows signal changes of ligaments and tendons, hypointense subchondral sclerosis, subchondral bone marrow oedema, joint effusion, capsular thickening, fibrosis, and synovitis. MRI has also an important role in the evaluation of post-surgery ankle pain due to impingement syndrome and in the hindfoot chronic instability related to postoperated sinus tarsi syndrome; it demonstrates the anatomy of sinus tarsi, chronic synovitis and nonspecific inflammatory changes, synovial cysts, fibrosis and subtalar joint effusion. It is important also in the follow-up of tumours and tumour-like conditions of bone and soft tissues after surgery. Computed tomography is the most valuable method to define the osseous anatomy of the postoperative ankle, so it is important in the follow-up of the operated osteochondral lesions of the talus. CT allows the evaluation of irregularities or degenerative changes, and progressive degenerative arthritis; however, CT usually fails to evaluate soft tissue's ankle lesion. The development of subsecond MDCT scanners with high temporal and spatial resolution has significantly reduced scanning times and now it is possible to have very good quality images of the heart during routine chest CT examinations. Therefore, the importance of looking at the heart and pulmonary vessels on a CT scan performed for non-cardiac reasons will be emphasised. Anatomic cardiac details that every radiologist should know will be discussed in the first talk; the presentation is aimed mainly at the non-cardiac radiologist. It will review normal cardiac anatomic details, as routinely encountered on modern multi-detector CT studies. It is now possible to delineate much of the intracardiac anatomy on a contrast enhanced study and significant pathology may also be evident on non-enhanced CT examinations. Important incidental findings and their clinical relevance will be discussed in the second talk. Unexpectedly, cardiac abnormalities may be diagnosed when lung disease is clinically suspected and vice versa; the focus of this presentation will be the comprehensive evaluation of lung and heart/large vessels diseases.The strong correlation existing between pressure in the pulmonary artery system and dilatation of the pulmonary trunk and central branches will be discussed in the last talk. CT is considered more useful than echocardiography because it can depict the cardiac structures in all patients including those with extensive parenchymal abnormalities. At the end of the presentations we should try to answer the question about the routine reporting of cardiovascular findings on CT scan of the chest.

A. Anatomic cardiac details that every radiologist should know S.P.G. Padley; London/UK (s.padley@ic.ac.uk)

This presentation is aimed at the non-cardiac radiologist. It will review normal cardiac anatomic detail, as routinely encountered on modern multi-detector CT studies.

It is now possible to delineate much of the intracardiac anatomy on a contrast enhanced study, and significant pathology may also be evident on non-enhanced CT examinations. This study will primarily review normal cardiac anatomy, including cardiac chambers, valves and coronary vessels. The typical radiological appearances of innocent incidental intra-pericardial abnormalities will then be reviewed. Important incidental pathology will be discussed in the next talk. Liver fat, inflammation, and fibrosis are important pathological features in patients with diffuse liver disease. The clinical gold standard for assessing these features is liver biopsy. Due to its invasiveness and sampling variability, however, liver biopsy is suboptimal for screening, monitoring, and clinical research. There is, therefore, a need to develop biomarkers to assess liver fat, inflammation, and fibrosis non-invasively. In recent years, many quantitative imaging techniques have been developed, refined, tested, and made available. The question becomes: are these techniques ready for routine clinical use or are they most appropriate for research? In this special focus question, we will begin with a brief overview of diffuse liver disease and discuss basic concepts of biomarker validation and qualification. Dr. Reeder then will discuss conventional and state-of-the-art imaging-based biomarkers of liver fat. Dr. Cobbold will discuss the current status of non-invasive biomarkers for liver inflammation. Dr. Van Beers will discuss ultrasound-and MR-based biomarkers of liver fibrosis, with emphasis on techniques such as transient elastography and MR elastography that measure visco-elastic properties of liver tissue. We will conclude with a panel discussion asking the question: are the repeatability, reproducibility, and robustness of the non-invasive biomarkers presented in this session adequate for routine clinical implementation? Session Objectives: 1. To review the clinical importance of diffuse liver disease. 2. To understand that key features of diffuse liver disease include fat accumulation, inflammation, and fibrosis. 3. To understand the need for non-invasive biomarkers to assess fat, inflammation, and fibrosis. 4. To review basic concepts in biomarker validation and qualification.

Quantification of liver fat S.B. Reeder; Madison, WI/US (sreeder@wisc.edu) Intracellular deposition of fat within hepatocytes (steatosis) is a common condition of the liver. Fat is the histological hallmark of non-alcoholic fatty liver disease (NAFLD) but also may occur with alcohol abuse, viral hepatitis, HIV and genetic lipodystrophies, and chemotherapy. NAFLD alone afflicts an estimated 20-80 million in the US and is a rapidly growing condition in other Western societies, paralleling the expanding epidemics of obesity and diabetes type II. This talk will review the clinical, pathogenic and histological features of liver fat, including an overview of fatty liver disease and diseases where fat is an important disease feature. Next, it will review the current use and limitations of non-targeted biopsy in diffuse liver disease, and why quantitative non-invasive biomarkers of liver fat and iron would be beneficial. Currently available conventional magnetic resonance imaging techniques that attempt to detect and quantify liver fat will then be discussed, as well as known confounding factors that corrupt the ability of conventional methods to quantify fat. This lecture will then describe emerging quantitative imaging methods for accurate and precise quantification of liver fat, and the advantages offered by these methods address in comparison with conventional methods. Finally, remaining challenges and unsolved problems for quantifying liver fat will be discussed. Conventional MRI techniques, such as T2W and gadolinium-enhanced T1W sequences, which are highly sensitive for detecting demyelinating plaques, are recognised as the most important paraclinical tool for diagnosing multiple sclerosis (MS). However, the changes seen on MRI in patients with MS are not diseasespecific, as focal white matter T2 hyperintense lesions (THL) are also commonly observed not only in the elderly but also in middle age and young patients, and in a large list of different disorders such as hypoxic-ischaemic vasculopathies (atherosclerotic and hypertensive small vessel disease, CADASIL, Fabry's disease and Susac's syndrome), CNS vasculitis, sarcoidosis, adult forms of leucoencephalopathies, trauma and radio chemotherapy, and acquired metabolic conditions (hepatic encephalopathy, alcoholism), among others. While it is recognised that a combination of findings from clinical history, physical examination and laboratory tests is commonly required to correctly establish a firm and clear aetiological diagnosis of THLs, a detailed analysis of different MRI features should also be considered essential, e.g. lesions shape, size, and distribution; contrast-uptake; and associated structural lesions (microbleeds, infarcts, spinal cord, brainstem and cerebellar involvement, …). In addition to these conventional MRI-based features, non-conventional MR techniques (diffusion, MRS and perfusion) may also provide in some cases useful diagnostic information. Knowledge of these features will assist the diagnostic work-up of patients presenting with THLs, and should be considered a first step to take full advantage of the potential of MRI, and in doing so should result in a reduced chance of misdiagnoses and facilitate the correct diagnosis of sometimes treatable disorders. Learning Objectives: 1. To be aware of the limited specificity of brain multifocal T2 abnormalities.

2. To learn about recognition patterns that might be helpful in suggesting the most likely etiology of brain multifocal T2 lesions. 3 . To learn about the role of spinal cord imaging and advanced neuroimaging techniques for the differential diagnosis of brain T2 hyperintense lesions. 4. To be able to establish a neuroimaging diagnostic strategy in patients with multiple brain T2 lesions of unknown origin. Breast imaging reporting and data system (BI-RADS) was developed by American College of Radiology in order to set standards for mammography reporting, common terminology and data collection. BI-RADS is being used widely for over a decade and many studies have assessed the validity of the system. An important component of BI-RADS is the lexicon which gives descriptors of specific imaging features that facilitate image interpretation and unify the reports. Two main titles for these descriptors are about masses and calcifications. An asymmetry is called a mass when it is seen in two projections. A mass is defined with its shape, margin and density. Definition of a mass with these three modifiers would help the radiologist to determine the type of the mass and probability of its malignancy. Calcifications are divided into three categories by their shapes and another descriptor is defined for their distribution. The first category is for typically benign calcifications. The other two are for probably malign calcifications where biopsy should be suggested. The distribution modifiers for calcifications can also play an important role in assessing the probability of malignancy. BI-RADS defines 7 assessment categories from 0 to 6 for the final report that facilitate data management for yearly audits. Category 3 is the transition zone between malignant and benign lesions where the suspicion for malignancy should be less than 2% and requires short-term follow-up. BI-RADS morphology and distribution descriptors are effective in assessing the risk of malignancy with a reasonable positive predictive value. The breast imaging reporting and data system (BI-RADS ® ) for ultrasound (US) was developed by the American College of Radiology (ACR) and published in 2003. Although this lexicon was created to achieve a consensus among radiologists when describing breast abnormalities, clinical practice shows substantial intraobserver agreement but only moderate interobserver agreement. Most problems are reported for descriptors related to shape (when trying to classify abnormalities containing lobulations and/or elliptical with not-parallel orientation), echo pattern and margin. Especially mass margin is a critical feature for determining whether a lesion should be biopsied or not. Other problems are related to the final assessment, including difficulties in applying the subcategories and the relatively high percentage of false negative cases for lesions interpreted as category 3. Many computer-aided diagnosis software have shown the potential to improve performance amongst less experienced readers and decrease interobserver variability; still they do not solve all the problems. The BI-RADS ® lexicon is actually under advanced revision by an international panel and Ellen B. Mendelson chairs the US subcommittee. Revision is reviewing both descriptors and categories; it will include also new parameters linked to the evolution of US technology as colour flow mapping and elastography.

troubles. Characterisation of AML is possible, based on identification of its fatty content mainly using CT. When microscopic, this component may be missed and biopsy is required with immunostaining. MR imaging may be helpful using chemicalshift sequences but thresholds, to rule-out clear cell carcinoma, have to be better defined. Presence of necrosis or calcifications rules-out diagnosis of AML. AMLs must be treated if haemorrhagic, painful or if diameter exceeds 4cm. Embolisation is the main nonsurgical method, using microparticles, alcohol and/or coils but postembolisation syndrome must be prevented. Volume regression may require all agents whereas aneurysm occlusion requires coiling. The effect on volume and on haemorrhagic risk is substantial making surgery as an alternative method for nephron sparing purposes. Secondary surgery is required in less than 10% of embolisation. RF ablation is also possible but its efficacy is still under evaluation. The number of small renal tumours is increasing due to the large amount of imaging examinations of the kidneys performed with various modalities and the true increasing incidence of renal cancer. Conservative therapy of small renal tumours is now widely recognised as the reference technique for the treatment of these small lesions. The increasing rate of chronic renal failure in the elderly and the efficacy of conservative therapy to treat cancer as demonstrated by the urologists performing partial nephrectomy and tumourectomy emphasise the role of percutanaeous minimally invasive ablative procedures, particularly in patients with surgical contraindications. Radiofrequency ablation and cryotherapy are the two most developed techniques, but new technical approaches are under development such as microwave ablation, electroporation, etc. The evaluation of the success of the procedure relies on imaging techniques showing the lack of enhancement within the lesion and the size and shape of the necrotic covering the entire tumour area. The techniques, indications, results, and complications of both radiofrequency ablation and cryotherapy will be discussed. A variety of diseases including neoplasms, but also infectious, inflammatory, vascular and traumatic processes, may present as focal intracranial mass lesions. Modern neuroimaging, primarily with MRI, enables differentiation of these entities allowing for accurate diagnosis in almost all cases. The requirements are appropriate image acquisition and detailed analysis of imaging findings, while pertinent clinical information may be very helpful in certain cases. The distinction is frequently broad, between different disease processes, such as with tumefactive demyelination versus neoplasm, which is often sufficient for clinical decision making and patient management; at times this may be more specific, approaching histological diagnosis, such as with pilocytic astrocytoma versus medulloblastoma. This presentation will go briefly over the imaging techniques and various disease processes, while heavily concentrating on the differentiating features of intraaxial primarily non-haemorrhagic mass lesions. The emphasis will be on the key distinguishing imaging features, such as presence or absence of mass effect or vasogenic oedema, signal intensity characteristics, presence and pattern of contrast enhancement, as well as diffusion and perfusion features. Decision making process will be discussed. A number of cases with intracranial masses will then be reviewed and analysed, using a step by step approach, accentuating the most reliable distinguishing findings. The role of MR imaging in adult gliomas consists of many steps. (1) Is there a lesion in the brain? (2) Is the lesion a tumour? (3) Is the tumour a glioma? (4) Is it a high-or low-grade glioma? (5) If there is a suspicion and a biopsy is planned, which part of the tumour should be targeted at biopsy. (6) How the surgery should be performed to avoid injury to functional areas of the brain (e.g. motor cortex). (7) If there is need for adjunctive radiotherapy, how the extent of the tumour should be defined? (8) After radiotherapy, if a new enhancing lesion occurs, is it a recurrent neoplasm or radiation necrosis? Conventional anatomical MR imaging is not always powerful enough to answer these questions. However, with advanced MR imaging techniques such as diffusion MR (including tractography), perfusion MR, MR spectroscopy and functional MRI (fMRI) we can answer the above questions reliably in most cases. The purpose is to gain numerical information of accuracy in the treatment of localised prostate cancer and calculate the necessary size of the safety margin around the clinical target volume (CTV-PTV). In addition, the purpose was to evaluate the accuracy in treatment set up with patients with high BMI to find out whether patients with high BMI need a larger safety margin. Portal imaging was used to measure off-line random set-up error from bony structure. The sample size was 40, i.e. all the patients who received radiation treatment for localised prostate cancer in Landspítali -University Hospital (LSH) 2006. A total of 3032 portal images were acquired. In 2010, the task was repeated for 38 patients having gold fiducial markers in the prostate. The calculated 3-D IMRT safety margins in LSH 2006 was to be 15.8 mm. Correlation is with high BMI and set-up errors in medio lateralis (M-L) direction (r=0.21). This indicates that a patient with an increased pelvic circumference has a tendency to have more set-up errors. Reformed procedural workflow resulted in more acceptable calculated margins in 2010. When corrected on line 3 times per week the margin is to be 7.2 mm and 3.0 mm if corrected 5 times per week. In conclusion, for delivery of 76-78 Gy to the prostate with IMRT and spare surrounding healthy tissue effort is needed to secure the accuracy in the overall procedure of treatment planning and delivery.

Learning Objectives:

1. To gain knowledge on how to improve the target accuracy in treating prostate cancer with radiation therapy using Electronic Portal Imaging. 2. To understand the importance of gaining numerical information of accuracy in the treatment of clinically localised prostate cancer and how to use the information to calculate the necessary size of the safety margin around the clinical target volume. 3. To become familiar with the preparation needed before starting treatment with IMRT and be aware that there is a need to look at all the treatment elements including the technical side, quality, education, staff and patients. 4. To consolidate knowledge of radiation therapy for prostate cancer and the meaning of giving high dose to the target while minimising radiation dose to healthy tissue.

B. Image-guided radiation therapy: when imaging meets therapy A. Sarchosoglou; Athens/GR (anastasia71@hotmail.com)

The aim of this presentation is: to understand the necessity of imaging in the delivery of external radiotherapy; to be familiar with the technology of image-guided radiation therapy and to to gain knowledge about the implementation of 3D IGRT. The aim of radiotherapy is to deliver high dose to target volume while minimising the dose to surrounding healthy tissues. However, during treatment delivery many uncertainties may arise that can result in higher toxicity and poor local control. Thus, it is crucial to monitor and adjust if necessary, the actual treatment. Image-guided radiation therapy is the process where images are taken immediately prior or during a course of radiation treatment, to assess and improve the accuracy of therapy. Manufactures have developed a number of systems to perform IGRT providing the options of ionising radiation images/non-ionising imaging technology and gantry mounted/room mounted equipment. 3D IGRT can be performed by acquiring computed tomography images on the treatment unit. These images are matched with reference images from planning CT and potential discrepancies are recognised, calculated and corrected by couch shifts giving optimal results. Such advanced technologies require quality assurance systems to be in place and high trained personnel. When properly implemented, IGRT meets the aim of radiation therapy. Imaging provides confidence to radiation therapy to be aggressive, to fight cancer. Imaging promises radiation therapy a great future with improvements in clinical outcomes and patient survival! Multicentre trials have shown that CT colonography is ready for widespread clinical use. However, these studies have also highlighted the inconsistent performances of CT colonography, with divergent results being recorded in different centres and between readers. Inter-observer and inter-centre variability may be related to reader experience but it is also affected by how CT colonography is performed. While faecal tagging has been accepted universally as the proper way to prepare patients for CT colonography, there is no consensus on which tagging agent is better, on the timing of contrast agent administration and on whether laxatives should be administered and in what dosage. In a similar way it is not yet clear which is the best way to obtain colon distension, whether by administering spasmolytic agents routinely or by changing patient's decubitus. Standardising bowel preparation and technique is one of the most important goals that need to be achieved for CT colonography to be universally accepted and this presentation will attempt to deal with the issue using an evidence-based approach. The evaluation of CT colonography (CTC) studies is based on detection, interpretation and reporting of colonic findings. It is performed on a computer workstation equipped with dedicated CTC software by a primary 2D or a primary 3D approach. In either case, the alternative viewing technique must be available for rapid correlation and characterisation of suspicious findings. Primary 2D evaluation is based on "lumen tracking" by interactively scrolling through the axial slices and multiplanar reformatted images, focusing only on the air-distended colonic lumen from one end to the other one. Primary 2D evaluation provides information about the attenuation of findings during the search process and is time-efficient. Primary 3D evaluation is based on 3D virtual endoscopy in an antegrade and retrograde fashion and increases both, the conspicuity, especially of small and medium-sized polyps, and the duration of visualisation. The use of advanced 3D displays like virtual dissection or unfolding techniques may reduce the interpretation time for primary 3D evaluation. Computer-aided detection (CAD) algorithms used as a 2 nd reader were shown to reduce the number of perceptual errors by pointing out possible abnormalities that might otherwise be missed. Colonic findings are characterised by their morphology, their attenuation characteristics, and by their mobility. Knowledge of CTC imaging features of common colonic lesions and artefacts is necessary for characterisation of findings and differentiation between definite colonic lesions and pseudo-lesions. Standardisation of CTC reporting facilitates classification and communication of findings and the comparison with previous studies, thereby better assisting physicians in making appropriate management decisions. The revolutionary development in multidetector CT (MDCT) technology during the past decade has contributed to a substantial increase in its diagnostic applications and accuracy in children. A major drawback of MDCT is the use of ionising radiation with the risks of radiation-induced side effects, of which the induction of secondary cancer is the most important. Therefore, justification and optimisation of paediatric MDCT is of great importance in order to reduce these risks as much as possible (‚as low as reasonably achievable' principle). Optimisation of paediatric MDCT starts with a solid understanding of all technical aspects of CT, including the most relevant scan parameters, dose reduction techniques and technique of IV contrast material administration. Furthermore, due to the smaller size and lack of visceral fat in young children the interaction and absorption of radiation will be different which will influence the choice of the various technique and scan parameters. Although all these issues are pivotal for a successful CT examination, it may become worthless if the importance of pre-scan issues such as justification and patient preparation are ignored. After a short overview concerning the current knowledge on radiationrelated risks in children, this lecture will focus on several aspects relevant for MDCT optimisation in children. Issues such as justification, patient preparation, technique and scan parameters will be addressed. Finally, some guidelines for radiation dose level-based CT protocols will be given. The purpose is to present an overview of the safety hazards and safety protocols related to infants undergoing MRI examinations. MRI infrastructure-dependent safety hazards originating from: (a) static and fringe magnetic fields, (b) gradient subsystems, (c) radiofrequency subsystems and (d) acoustic noise sound pressure will be reviewed and discussed. Safety hazards related to upcoming technological issues and future trends concerning MRI will be presented. The current status of the organisations responsible to the problems of MR safety will be reviewed. Which authority is responsible and where the responsibility is addressed to (Directives, Legislation policies, etc). An optimised protocol related to a variety of clinical MR sequences in reference to temperature measurements, EMF measurements, SAR and acoustic noise figures using basic commercially available infrastructure will be presented. 2D/3D TSE sequences with different ETL's, 2D/3D GRE, 2D/3D SSFP and SE/GRE EPI sequences with multi-(b) diffusion gradients and 3D TOF MR angiography sequences will be examined. In vitro measurements of SNR, spatial resolution and scan times will be performed for each clinical MR sequence. A comprehensive MRI equipment operational policy (optima: (ETL, TR, TE, b-value, EPI factor etc).) for a safety protocol for infants undergoing MRI is proposed. Recommendations for safe infant MRI examinations will be summarised and presented. Conclusion: MRI equipment can operate safely for infant imaging but require policies and procedures beyond those required for standard diagnostic MRI examinations. Learning Objectives:

1. To get an overview of the three basic safety hazards related to infants undergoing MRI examinations. 2. To become familiar with safety hazards related to upcoming technological issues and future trends. 3. To learn about a safety protocol that could be applied in MRI examinations for infants.

A S105 C B D E F G H perfusion imaging. New possibilities arise in MRI almost every day. Imaging algorithms are to provide the correct diagnosis in the shortest time with the lowest expenses and harm to the patient. MRI is the first method of choice in neurological diseases with two exceptions: acute stroke and acute trauma, CT providing the necessary information, more available and with easier patient care. Adequate imaging protocols optimally visualise the anatomical region of interest and pathological processes, optimise the comparison between serial examinations and provide the information in reasonable examination time. Appropriate and well understood clinical information is indispensable (neuroradiology means good clinical knowledge combined with expertise in imaging methods and their evaluation). Complicated protocols are superfluous without competent clinical background but adequate information must be provided to experienced clinicians. Basic protocols help to gather important information but do not exclude additional necessary methods. Examples to be demonstrated are MRI protocol for the pituitary, epilepsy, multiple sclerosis and spine. The up-to-date concepts of image evaluation and interpretation will be demonstrated for brain CT, brain MRI and spinal MRI, including the importance of follow-up. The body and conclusion part of the structured neuroradiological report will be discussed. Consultation with other neuroradiologists and with clinicians is the final tool to reach the goal: to help in recovering the patients' health. Ten authentic and original typical clinical cases illustrating the importance of imaging modalities in the differential diagnosis of focal neurological symptoms from headache to epilepsy will be presented while respecting the privacy of the patient. The spectrum of pathologies includes vascular, inflammation, metabolic, degenerative diseases, congenital malformations and neoplasms of the central nervous system. Each case story will be described shortly in a standard form followed by demonstration of typical CT and/or MRI images. In some cases, conventional MRI will be supplemented by multi-voxel MR spectroscopy, DTI, MR tractography images, and morphological pictures. Follow-up images will be presented where appropriate. Several diagnostic options will be offered for attendants. The audience will be asked to participate in the diagnostic process by the use of voting pads. After highlighting of final diagnosis the basic differential diagnostic considerations will be briefly summarised and emphasised from the clinical and imaging point of view for each presented case. Learning Objectives:

1. To introduce typical cases illustrating the role of imaging modalities in the differential diagnosis of focal neurological symptoms. 2. To motivate the audience by the use of voting pads to be involved in the diagnostic process. 3. To highlight the conclusion that may be drawn on the basis of the discussed cases. Diagnostic quality MRI of soft tissue masses can be performed using a variety of magnetic equipments and a variety of field strengths. Regardless of system design, efforts should be made to maximise signal-to-noise ratios (SNR) using the most appropriate coil to include the lesion and associated oedema. FOV should be tailored to the size of the patient and the size of the mass. It is important to obtain images in at least two planes through the lesion. Slice thickness vary depending on the size of the lesion and interslice should be not more than one-half of the slice width. Imaging matrix should be balanced to in-plane spatial resolution. Parallel While CTC has achieved excellent results in average risk individuals with regard to detection of clinically relevant polyps, it has not yet been implemented on a large scale in colorectal cancer (CRC) screening programmes. This is mainly due to the fact that it uses ionising radiation. There is uncertainty about adequate screening strategies and the risk of radiation-induced malignancy. This presentation will summarise recent results of CTC in a screening setting, will look at the dose associated with CTC, and summarise calculations of radiation-associated risk of malignancy.

The key question is whether low doses from CTC will cause relevant negative effects in the screening population. The lecture will also feature a comparison between CT and MR colonography, an imaging test that might be able to provide high sensitivity CRC screening without ionising radiation. From headache to epilepsy… or from "normal", physiological "headache" to life threatening pathological conditions. When do we need "neuroimaging" and what is the optimal diagnostic work-up? The radiologist must and should remain first of all a Medical Doctor: he/she should keep close contact with the clinical world and always keep an active dialogue with the referring clinician. Indeed, medical Imaging has become more and more sophisticated but also more expensive. Imaging is not a "screening procedure" in brain pathology but should be performed in order to confirm a clinical, suspected diagnosis keeping still in mind that differential diagnosis must be considered as well. Imaging plays also a unique role in lesion evaluation and treatment monitoring. The radiologist must answer precise questions about the patient's suspected pathological condition and if necessary, discuss the Imaging findings with the clinician in order to narrow the differential diagnosis. Each MRI or CT must be performed with a clear knowledge of the clinical question and the suspected pathology. Therefore, the radiologist will make the proper choices of imaging techniques especially with MRI where imaging sequences have become numerous. Headaches and seizures are symptoms only and may be present in multiple and very diverse pathological conditions as infectious, neoplastic, haemorrhagic, vascular diseases: by knowing the clinical history a good "clinically conscious" radiologist will undoubtedly be of greater "added value"! Learning Objectives: 1. To learn more about the clinical conditions causing focal neurological symptoms. 2. To be informed about the clinician's way of thinking in the process of differential diagnosis. Neuroradiology has a continuously changing and developing array of modalities. Conventional radiography has lost its importance. Angiographic practice has shifted from diagnostics to therapy. MS-MD CT scanners provide high-quality CT angiography and

A S107 C B D E F G H T2W-MRI to localise PZ-Zone PCa. In the T-Zone, stromal nodules commonly have a low ADC value simulating PCa. Significant differences in tumour ADC values existed between patients with low-risk, and those with higher risk localised P-Zone PCa. With S-MRI, the best accuracy for diagnosing PCa is obtained by combining a positive T2W-MRI and a choline+creatine/citrate ratio > 0.75. In the T-Zone, S-MRI has the same limitations than DCE and DW-MRI. Multiparametric functional MRI accuracy of MRI to detect PCa can be improved by combining different functional sequences. At the moment, it seems that the most widespread used protocol is a combination of DW and DCE-MRI for detection of P-Zone tumours. Performance of functional MRI to detect T-Zone PCa is less well established. Multiparametric MRI can now be used to perform stereotaxic TRUS-guided biopsies after TRUS-MRI image fusion. The role of imaging in patients with increased PSA level after radical prostatectomy or radiation therapy is to aid in differentiating locally recurrent disease which can be managed with local therapy from distant metastatic disease requiring systemic therapy. Although the majority of local recurrences in post-surgical patients can be detected by MRI in the perianastomotic region which can also be evaluated with TRUS and TRUS-guided biopsy, some recurrences can occur at pelvic sites that are beyond the range of TRUS; MRI has a role of labelling these sites for TRUSguided biopsy. The combination of an external phased-array coil and endorectal coil is recommended for detecting local recurrent cancer. Current protocols involve T2-weighted MRI combined with functional techniques such as dynamic contrastenhanced MRI (DCE-MRI), magnetic resonance spectroscopy and diffusionweighted MRI. In the post-prostatectomy bed, recurrences present as lobulated masses having low to intermediate signal intensity on T2-weighted images and showing early, nodular enhancement with early washout of gadolinium on DCE-MRI. The predominant finding after radiotherapy is a diffusely low signal intensity with an indistinct zonal anatomy where the contrast between a hypointense recurrence and benign irradiated tissue decreases. On DCE-MRI, peripheral zone enhancement is lower after radiotherapy and any focal enhancement should be regarded as suspicious. The overall diagnostic efficacy of DCE-MRI for detecting recurrent prostate cancer is better than T2-weighted MRI alone. On MRI, bone metastases have low and high signal intensity on T1-and T2-weighted images, respectively, and enhance after intravenous gadolinium administration. Learning Objectives: 1. To understand the role of MRI in the follow-up of the patients with prostate cancer after radical prostatectomy or radiotherapy. In this presentation new techniques with potential clinical value will be described with a focus on prostate cancer multi-modality MR imaging. Techniques such as T2W, DWI, DCE and MRSI will be addressed, and their role in screening, determination of tumour aggression and localisation, MR-guided biopsy, MR-guided minimal invasive focal therapy (laser, cryo, HiFu), and MR-guided radiotherapy will be discussed. Examples will be shown. The major area of debate is how to approach patients with increased PSA levels. The discussion has two parts: one is the patient who has not had a prior cancer diagnosis and the other one is the patient who has already been treated for prostate cancer. What is the role of MR (as well as MRS, DW MR and dynamic MR) in precluding the need for multiple biopsies? When should we stop in cases with high or increasing levels of PSA despite consecutive negative biopsy outcomes?

A S109 C B D E F G H and that radiation therapy and systemic treatments play a major role for curing minimal residual disease. For evaluating and predicting response to neo-adjuvant treatments, the major question is the debate between morphology (size and volume) and function (perfusion, spectroscopy and diffusion). For follow-up after treatment, considering the number of women concerned, cost benefit analyses are mandatory to offer the most efficient imaging strategies based not only on defined subgroups (risk factors of local relapse) but also over time. One of the first take home messages of this course is the multidisciplinary approach of this disease or in another way: we do not treat images but patients!

A. Evaluation of residual disease after excisional biopsy C. Boetes; Maastricht/NL (c.boetes@mumc.nl)

Mammography can have an additional value in evaluating if microcalcifications are left behind in the case of DCIS and irradical operation. Ultrasonography has proven to have no additional value in evaluating the postoperative breast, because of haematoma and scar tissue. MR imaging of the breast can of all imaging techniques predict residual disease in the most accurate way. However, false positive results can exist because of enhancing scar tissue. Also, false-negative results exist, especially owing to residual low and intermediate grade DCIS. It is recommended to perform postoperative breast MRI in premenopausal women in the right time of the menstrual cycle, that means between the 5 th and 12 th day after the start of the menstrual cycle. Unclear is how soon after the operation one should perform breast MRI. If a large mass of residual disease is suspected, MRI is an excellent tool to confirm this fact. But, if a mastectomy is considered, pathological confirmation before the re-operation is recommended. Another imaging technique is TC-99m-MIBI scintimammography. This seems a promising technique with a high sensitivity and specificity. Neoadjuvant chemotherapy is regularly used for downstaging of locally advanced breast cancer. While it is equivalent to adjuvant therapy regarding overall survival and occurrence of distant metastasis, more patients are eligible for surgical treatment by less aggressive breast conservative therapy. Neoplastic growth depends on blood supply with nutrients and oxygen. Hypoxia-induced angiogenesis is an early step in tumour progression. MRI is the imaging modality providing highest sensitivity for detection of breast cancer, highlighting tumour vascularisation by injection of T1-shortening contrast agents. Characteristic differences between benign and malignant lesions are cause. Ultrasound (US) and computed tomography (CT) are readily available and widely used imaging techniques for this work up. US comprises an examination of the abdomen with the graded compression technique. A transducer should be used optimised for the visualisation of the bowel. The CT protocol includes the use of intravenous contrast medium, while oral contrast medium will not be routine in many institutions. Findings are bowel wall thickening (or enlarged appendiceal diameter), fat infiltration, free air and fluid collections. The present evidence on the role of imaging in appendicitis and diverticulitis is substantial and has been summarised in systematic reviews. Although US is accurate in diagnosing appendicitis and diverticulitis, CT is more accurate than US. Further advantages of CT are better identification of alternative diagnoses and better comparison between consecutive examinations. Thereby, CT is more helpful in communicating the diagnosis to the referring physician. Cost effectiveness of CT in acute appendicitis has been demonstrated as well as the positive impact on management. For colitis, the evidence is more limited and imaging has more limitations here. Drawback of CT is ionising radiation exposure. An imaging strategy with initial US and CT only in inconclusive of negative US cases results in the highest sensitivity, reduces ionising radiation exposure and is cost effective. Accurate and rapid diagnostic imaging is essential for the appropriate management of acute biliary tract disorders. Ultrasonography (US) continues to be the first and often the only test needed to confirm suspected diagnoses affecting the ducts and gallbladder. However, there has been an increase in the overall use of computed tomography (CT) in the emergency room setting, mostly because for its widespread availability and the relative speed, ease and uniformity with which evaluations can be performed. Thus, CT may be the first imaging examination performed on patients presenting with signs and symptoms that are less specific for biliary diseases. Magnetic resonance (MR) imaging has similarly robust potential as CT, although its integration into the acute care setting requires greater technical and logistical effort. Improved MR imaging sequences, advances in coil technology, streamlined imaging protocols, and increased technical and professional familiarity with the modality make it an increasingly attractive option when there is concern about patient radiation exposure or allergy to iodinated contrast material, as in pregnant patients with acute abdominal symptoms. MR can also be used as a problem-solving modality. In this presentation, the common and uncommon imaging appearances on US, CT and MR of acute diseases of the biliary tract and gallbladder will be reviewed. Potential pitfalls to be avoided with the three modalities are also illustrated. Learning Objectives:

1. To learn the etiology and clinical presentation of acute inflammatory liver diseases. 2. To understand imaging strategies using US, CT and MRI. 3. To know typical findings and the spectrum of differential diagnoses. Pancreatitis is an abdominal condition potentially life threatening. Imaging plays a key role not only in the diagnosis but also in the staging and patient management of acute and chronic pancreatitis. Pancreatic inflammation and necrosis can be easily identified by imaging methods and has prognostic implications. The clinical prognostic criteria in acute pancreatitis are currently coupled with imaging criteria. CT plays a central role in the evaluation of patients with known or suspected pancreatitis. A CT-based severity index is the main prognostic method to predict outcomes. In addition, MRI and MRCP play increasingly important roles in pancreatitis evaluation. Integrity of the pancreatic duct can be easily evaluated by this last method, particularly if enhanced with the use of secretin. Imaging appropriateness criteria determine the value of distinct imaging modalities with regard to the stage of disease. We review the modern imaging criteria for the diagnoses, staging and patient management in acute and chronic pancreatitis. We also discuss current severity indices and imaging appropriateness criteria. Advancements in CT and MRI technology have lead to an increasing use of these modalities in the non-invasive assessment of coronary arteries, myocardial perfusion, and cardiac function. While their role in detecting coronary artery disease and functional disorders has been widely accepted, it is still unclear whether they could be adopted in triaging patients for the best therapeutic approach. Large studies have already suggested that indication for surgery and percutaneous interventions cannot be solely based on the demonstration of morphologic alterations and that such "cosmetic" interventions are not always leading to the expected outcomes. Therefore, non-invasive imaging techniques have to offer more then just the detection of grades of coronary artery stenosis, of areas of infarcted myocardium, or of valvular alterations. Adjustment of imaging protocols for additional evaluation of coronary flow reserve, of myocardial perfusion and contractility and of valve size, position and damage with subsequent quantification of degree of stenosis and/ or regurgitation are necessary in order to allow to choose the most appropriate therapeutic approach and thus become the "gold standard" for prognosis and pretherapeutic diagnosis of cardiac diseases.

A. Can CT predict the outcome of percutaneous intervention? C. Loewe; Vienna/AT (christian.loewe@meduniwien.ac.at)

The outcome of coronary revascularisation is not only defined by primary technical success but also by improvement of symptoms and quality of life. Thus, despite the individual comorbidities, the outcome and thus the potential benefit of coronary revascularisation depends on many different factors, including morphology, distribution and severity of coronary lesions, myocardial viability, and ventricular function. Consequently, the detection of coronary stenosis is not sufficient for planning an optimised treatment. It should be evaluated if the myocardial territory supported by the diseased artery is still vital. In addition, lesions at risk for plaque rupture (culprit lesions) should be identified and treated to avoid major coronary events. Cardiac CT allows for the exact assessment of coronary morphology including length, calcification and severity of lesions. Based on this morphological information, success of a percutaneous revascularisation procedure can be anticipated with high prognostic accuracy. In addition, the possibility of identification of culprit lesion by means of coronary CT has been described recently. By this, dedicated treatment of only the relevant stenosis should become possible avoiding multiple, potentially unneeded, stents. Finally, even the assessment of myocardial viability by means of CT becomes possible. Using all the possibilities of cardiac CT optimised treatment plan can be established, and outcome can be estimated. Radiological interpretation always incurs some degree of error due to the nature of disease presentation coupled with the difficulty in diagnosis, especially where early signs of disease need to be identified such as in medical screening. Early research studies of radiologists' performance concentrated upon the chest radiograph but more recent work has studied breast screening extensively, as well as MRI and CT. As radiology is now almost fully digital then research has also examined observer behaviour with a range of digital images, viewing conditions, and image display presentations. It is possible that radiological interpretation will never be accomplished without some errors occurring; however, it is important that steps are taken to minimise any causes of errors as far as possible. The reported error rates found in numerous investigations across different radiological domains will be reviewed and the reasons for these will be elucidated. Appropriate reporting conditions will be highlighted for different image viewing scenarios. A theoretical framework for understanding error causation, especially where abnormalities are missed will be detailed. Furthermore, the underlying visual, perceptual and cognitive processes which lead to errors will be detailed and approaches to minimise error occurrence will then be proposed. The relationship between human perceptual and cognitive skills and computer imaging processing will be discussed and the usefulness of CAD systems outlined as how they can best aid the radiologist from the human performance viewpoint.

Learning Objectives: 1. To review the basic principles of perception, detection and detectability.

2. To learn about specifics of perception in medical imaging. 3. To learn how image processing can help us with the perception process.

ing using Graf's method led to higher treatment and follow-up rates than that based on NHI alone, i.e. 3-5% vs. 0.4-1.5% and 10-20% vs. 6-7%, respectively. However, improved examination techniques and a better understanding of the findings have led to a more tailored approach, and an extensive meta-analysis performed in 2000, including 534 papers, could not find any differences in treatment rates due to different ultrasound techniques. In this lecture I will present a crude status for US techniques used and also give recommendations for a worth while screening strategy based on present knowledge, and on work performed within the ESPR's DDH Task Force group. With technological advances in recent years, paediatric whole body imaging is now a clinically feasible and increasingly accessible technique. The two principle modalities available are PET, with or without co-registered CT images, and whole body MRI (WB-MRI), both of which can be utilised to evaluate widespread disease states efficiently. The main application of these techniques has hitherto been oncological; however, as these techniques become more accepted, their use is becoming more varied. PET provides functional assessment, utilising a radiotracer, most commonly FDG-18, to assess metabolic activity within tissues, with areas of greater metabolic activity depicted as increased tracer uptake. The use of combined CT-PET enables accurate specific uptake values (SUV) to be determined, via attenuation correction, and anatomical co-registration which reduces perceptual errors. WB-MRI primarily provides an anatomical assessment, using tissue contrast to identify pathology. This typically uses water sensitive sequences to provide high sensitivity. "Physiologic" MRI sequences, such as diffusion weighted imaging (DWI) can also be employed to obtain functional MRI data, either qualitatively or quantitatively. There are advantages and disadvantages to both techniques, including ionising radiation exposure, acquisition times, movement and other artefacts, and reproducibility, which all need to be considered when choosing a particular technique for whole body assessment in any given paediatric patient, with the disease process being investigated also influencing the technique used. The relative merits, clinical applications and evidence base for the use of PET/CT and WB-MRI in paediatrics will be discussed. Near future developments, such as PET-MRI will be touched upon. The practice of medical image diagnosis is currently undergoing a fast transformation. Vast amounts of data can be generated in standard examinations and focus is shifting from improving the collection of relevant data for diagnosis to development of effective methods to analyse, visualise, navigate and interact with medical information. It is now becoming generally accepted in the medical community that one of the most important keys to manage the increasing information work load is the use of 3D and 4D applications. This talk will take its starting point in state-ofthe-art medical visualisation and then discuss the need for a research agenda that focuses on the development of the next generation of medical visualisation tools, emphasising the fact that these tools must be based on medical user requirement and work flow studies as well as on new technical developments. Childhood osteomyelitis is a relatively rare finding in childhood with an estimated annual incidence of 1 per 5000 and is predominantly seen in young children (< 5 years). It can be caused by via haematogenous spread, contiguously from local areas of infection or from penetrating trauma or surgery. Usually it is caused by bacterial infections, but occasionally fungi, viruses or parasites are causative agents. Clinical findings can range from mild to severe and depends on many factors such as age, site of infection, acute versus chronic osteomyelitis, and causative agent. The CRP and sedimentation rate are usually elevated; however, this is not always the case. Given the variability in clinical presentation radiology plays a crucial role in the detection of osteomyelitis.

Although conventional radiography (CR) has a limited sensitivity and specificity for the diagnosis of osteomyelitis, its wide availability makes it the first diagnostic technique of choice in children. For further analysis both MRI and radionuclide bone scintigraphy (RBS) have shown to have a high sensitivity for the detection of osteomyelitis. The advantages and disadvantages of both the techniques will be addressed. CT mostly plays a role in the diagnosis of chronic osteomyelitis or in the pre-surgical work-up. The use of radiology also allows for a differential diagnosis of osteomyelitis, based on clinical cases, an overview of this differential diagnosis will be given. The aim of this lecture is to present an evidence-based diagnostic strategy for childhood osteomyelitis. Developmental dysplasia of the hip (DDH) is the most common musculoskeletal disorder in childhood, with a reported prevalence of 1-4% according to method of ascertainment and definitions used. Ultrasound has enabled a detailed view of both neonatal hip stability (NHI) and morphology, and two different schools have developed; one arguing that NHI alone is the major pathology warranting splinting, the other including acetabular dysplasia as an important feature. Both static (Graf, Morin) and dynamic (Harcke) ultrasound techniques, as well as a combination of the two (modified Graf (Rosendahl)), have been described and are currently used. In Europe, Graf's ultrasound technique or a modification of this is commonly used within the German speaking countries and areas, in parts of Scandinavia, the UK, Italy, France, Hungary and the Netherlands. Others use a modified Morin's method while Harcke's method is used only occasionally. Initially, universal ultrasound screen-(helium or xenon), oxygen-enhancement or other technologies. All of these might also provide quantitative read-outs for disease and/or therapy monitoring. Learning Objectives: 1. To learn how CT and other imaging methods can be used to examine the structure-function relationship in SAD. 2. To review the state-of-the-art imaging methods that can provide information about disease extent, disease activity and global and regional lung function in patients with SAD. 3. To become familiar with the current use and the future developments of these techniques.

Panel discussion: Signs of small airways disease can be seen on CT but when and why do they really matter? 09:44

Signs of small airways disease are a frequent finding on CT especially when expiratory scans are performed in addition to inspiratory scans. When should we report these changes? Are they always important, do they perhaps predict the development of more severe disease, or are there cases where they have little influence on diagnosis and therapy? When should an expiratory scan be performed? Careful preoperative staging and preoperative using high-resolution MRI together with preoperative multidisciplinary team discussion has been shown to reduce margin involvement by tumour from 30% to < 5% by identification of patients that require more radical preoperative therapy and surgery. The detailed demonstration of preoperative prognostic factors also recognises patients on imaging that are not at risk of local recurrence and therefore the avoidance of unnecessary preoperative therapy in a proportion of patients. The use of EUS can help in the assessment of early stage flat lesions suitable for local excision and is a powerful complementary tool. PET-CT is crucial for the preoperative work up of patients undergoing radical procedures such as metastatectomy. Follow-up for colorectal cancer patients at high risk for developing recurrent disease is now well established, and the emergence of specialised multidisciplinary teams, combined with a range of treatment options for recurrent disease has improved curative resection rates following metastatectomy and pelvic recurrence surgery. Radiologists with a solid understanding of not only the pathological manifestations of primary and recurrent rectal cancer but also the treatment options available play a key role in enabling the appropriate selection of patients -increasing overall cure rates and reducing treatment-related morbidity. This refresher course aims to provide radiologists with an understanding of local staging of rectal cancer, the assessment of recurrent disease, and assessing response to treatment. The course will highlight how imaging underpins the key preoperative decisions for surgical and oncological treatment planning in rectal cancer.

A. Staging with US and CT A. Maier; Vienna/AT (andrea.maier@meduniwien.ac.at)

For rectal cancer surgery a variety of alternative operations are currently possible. Furthermore, there is an increasing trend towards treating patients with radiotherapy before surgery. The choice of operation and the decision whether to employ radiotherapy is based on preoperative staging. In patients with primary rectal cancer accurate assessment of tumour extent and the presence or absence of lymph node invasion are factors for determining prognosis and risk of tumour recurrence. Endorectal ultrasound (EUS) is effective for T-staging. It has been recommended as the investigation of choice in the selection of potentially curative local excision. Lymph node staging by this method is less precise than tumour staging. Initial reports of the use of CT for tumour staging were encouraging. Studies which compare CT with EUS staging consistently show the latter to be more accurate for both tumour stage and lymph node stage. Thus, the usefulness by the speakers at the end of the session. At the other end of the clinical and imaging spectrum to obliterative bronchiolitis is exudative small airways disease, typified by (Japanese) diffuse panbronchiolitis. The exudative bronchiolitides are characterised by direct signs on HRCT, notably a tree-in-bud pattern. While this is a readily appreciated and specific sign, other diseases that mimic this HRCT finding will be discussed. Bronchiectasis of variable severity is a usual accompaniment to both obliterative and exudative bronchiolitis and the relationship between large and small airways disease will be explored. The instances in which HRCT findings of obliterative and exudative bronchiolitis co-exist are relatively few, and the differential diagnosis for this situation will be considered. In practice, HRCT will often show signs of bronchiolitis (whether obliterative or exudative) limited to a segment or even subsegment, and the interpretation of the clinical significance of such a chance finding is sometimes a difficult judgement.

Learning Objectives: 1. To become familiar with the direct and indirect signs of small airway involvement on CT. 2. To know how to correlate these signs with the pathological changes. 3. To understand the differential diagnosis with other diseases that can show similar CT findings.

From pattern to diagnosis C. Beigelman; Paris/FR Various schemes of classification of SAD have been proposed according to clinical, pathologic or imaging criteria that are confusing. An optimal approach, mainly based on CT analysis of direct and indirect features, usually allows the recognition of the two main types of SAD, namely inflammatory/exudative and fibrotic/constrictive/ obliterative bronchiolitis. A miscellaneous group that corresponds to bronchiolar involvement in diverse diffuse lung diseases may also be individualised. Direct signs of SAD that refer to direct visualisation of diseased bronchioles strongly suggest inflammatory bronchiolitis. They mainly consist in centrilobular nodules with tree in bud appearance. Conversely, indirect signs mainly represented by mosaic attenuation, air trapping, bronchial wall thickening and dilation characterise fibrotic bronchiolitis. Volumetric acquisition, performed a dose reaching that obtained with classical HRCT protocols, may be of interest in several ways. Particularly, maximum intensity projection tool may facilitate the recognition of the tree in bud pattern. The minimum intensity projection mode may optimise the recognition of the mosaic attenuation pattern requiring an appropriate contrast resolution, as well as the analysis of proximal airways. Expiratory CT, optimally performed on a dynamic mode, may be useful in some conditions at a dose equivalent to around 2 chest x-rays. A combination of post-processing tools from a volumetric acquisition performed with carefully chosen parameters might therefore appear useful in the evaluation of SAD. Furthermore, additional co-existing findings such as ground glass opacity or other features of interstitial pneumonias may be detected. Their analysis may help to recognise the cause of SAD in addition to clinical data. Structural changes associated with SAD are difficult to depict directly on CT. Indirect signs of SAD, such as mosaic attenuation on an inspiratory scan and/or air trapping on an expiratory scan, are common findings. They nicely illustrate the structure-function relationship between obstruction or expiratory collapse of the small airways and the subsequent effects on ventilation (local hyperinflation) and perfusion (hypoxic vasoconstriction). These "functional" signs are thought to be more sensitive than the direct visualisation of the underlying structural changes. Careful interpretation and software tools help to generate data about disease extent as well as global and regional lung function. Beyond paired inspiratory-expiratory CT scanning, dynamic expiratory cine as well as perfusion and ventilation imaging on the basis of both, CT and MRI, can be applied to increase sensitivity, specificity and accuracy of the diagnosis of SAD. Some of them are ready for routine clinical use, such as dynamic expiratory cine CT, cine MRI during continuous breathing as well as gadolinium-enhanced perfusion MRI. Future developments in the fields of CT and MRI will provide novel technical approaches for functional imaging of SAD. These will include novel applications of dual energy/spectral CT using iodine-enhancement for perfusion and xenon-enhancement for ventilation enhancement as well as ventilation MRI using hyperpolarised gases

To understand the advantages and limitations of BI-RADS in clinical practice

To appreciate the potential of an automated analysis of the descriptors

To trace continuous modifications required by technological advancements. 4. To review BI-RADS categorisation with case illustrations

A. How I do it P. Richards; Stoke-on-Trent/UK (paula.richards@uhns.nhs.uk) 1 . Always report in the same logical manner for each examination, which imprints normal pathology 'jumps out at one'. 2. Evaluate all images before looking at the clinical information to prevent bias and satisfaction of search. 3. Review every scout image. Scoliosis transitional vertebrae and pseudoarthrosis become more obvious on coronals. Single kidneys, hydronephrosis and renal tumours may explain 'back pain', especially if there are mets. 4. Review any x-rays or old IVUs, remembering that abdominal x-rays show the spine. 5. Indications; summarise the reason for the scan. Think of the differential diagnosis to exclude. 6. Technique; allows one to check the levels scanned. Be sure there has been no area missed between 2 studies. 7. Report vertebral alignment and disc height. 8. MRI just like an x-ray, i.e. there is normal alignment from D10 to S3. 9. Start at the far sagittals and look at the nerve roots in the 'key hole', the pars and facets. 10. Determine the worst abnormality on the axials and report the most significant findings first. Check the facets at each level. 11. Have a checklist of normals at the end; 'the bone marrow, cord and CSF return normal signal. The conus ends normally with no pars or metastasis'. 12.Opinion: explain what you think is causing the patient's symptoms. Assume this is the only part read, so if there is only one kidney reiterate here. The lecture will illustrate additional information on scout images and benefits of coronal images. Learning Objectives:1. To understand the influences of patient positioning, scan parameters and magnet/coil technology on image quality. 2. To learn how to optimise scan protocols to maximise patient throughput without compromising diagnostic quality. 3. To recognise how and when to modify scan protocols to answer specific clinical questions.A-371 14 The lumbar spine undergoes morphological changes with age. Normal appearances and relevant normal variants will be discussed. In particular, the morphological change from an almost round intervertebral disc in newborns with high water sig-Postgraduate.Educational.Programme S102 A B C D E F G H Radiotherapy is an area with a rapidly improving development of new techniques and improved possibilities for accuracy. This lecture aims to illustrate and discuss points of contact and the need for collaboration between radiotherapy and radiography. European educational programmes and working fields for radiotherapy nurses and radiotherapy technicians are compared. Radiotherapy nurses and radiotherapy technicians are responsible for the administration of radiotherapy to cancer patients and for the clinical care related to the treatment. Apart from prevention and treatment of side effects and psychosocial support during the treatment, it encompasses preparations, delivery and verification of the radiation dose. Educational programmes differ in terms of academical level and target groups, whether it is nurses or technicians in radiology or radiotherapy exclusively. Areas in the radiotherapy process where competences from radiography are needed are discussed, considering both technical development and research progresses. Learning Objectives:1. To gain knowledge about the differences and similarities between the areas of education and profession in radiography and radiotherapy from a historical perspective. The demand from the public for greater accountability and standards has increased the importance of audit and accreditation in modern healthcare delivery. Specifically radiology departments participate in audit and accreditation by a number of entities. These include: 1. National bodies concerned with improving radiation safety particularly originating from EU 97/43 directives. 2. Hospital wide accreditation surveys from state and private accrediting organisations. 3. Auditing of standards from within professional bodies. 4. Following from investigation of specific incidents such as misdiagnosis or radiation concerns. 5. Modality-specific standards.Although the specific requirements of the accrediting or auditing body may differ, the processes and practical aspects in demonstrating compliance with standards and quality improvement are generally similar. Mechanisms such as outcomes, quality cycles, and performance indicators are critical in the success of any accreditation or audit program. In addition to fulfilling basic regulatory requirements, the medical physicist is playing an increasing role in developing performance indices particularly in radiation safety, clinical image quality and equipment management. The increasing role of the medical physicist in audit underpins the requirement for inclusion of audit and accreditation as part of their education. Recent experience of setting up and participating in EU 97/43 directive-based clinical audit in Ireland highlighted the critical need for clarity of roles and ownerships of processes to be communicated to those who are carrying out audit and those who are being audited in hospitals and dental practices. Performing imaging studies in a child requires basic knowledge. The first point is to reassure and to avoid stressful/painful procedure. Training of radiographer and radiologist is fundamental. Explanations, presence of a parent (if not pregnant…), are preferable. Specific devices may be useful for immobilisation and to avoid repeated exposures. Antalgic drugs (traumatic circumstances) or sedative nitrous oxide inhalation (MCUG) may be useful. X-rays exposition in relation with conventional radiology is lower than the one encountered with CT. But dose depends on type of examination and also on imaging equipment. New devices, such digital fluoroscopy with x-rays pulsed emission, flat-panel detector, slot-scanning x-ray imager need less ionising radiation than conventional screen-films devices or even photostimulable phosphor imaging plates. The scale between the higher and the lower dose for the same examination can be from ten to one. Common principles of protection that apply to all x-ray imaging procedures, known as ALARA concept (as low as reasonably achievable), have to be used daily. Act in accordance of the medical justification of the examination, without any non-ionising alternative method, remains the first step. The second one is the optimisation of each procedure, the limitation of expositions, with control of the x-ray beam adjusted to optimise the critical balance between image quality and exposure to the child. Measure of the dose is mandatory to demonstrate appropriate levels on child exposure and to be sure in the future that very low radiation doses received during conventional imaging procedures will not produce adverse effects. The Council Directive 97/43/EURATOM introduced the concept of clinical audit to medical radiological (diagnostic radiology, nuclear medicine and radiotherapy) procedures. Clinical audit is a systematic review of the procedures in order to improve the quality and the outcome of patient care. According to the directive, clinical audits shall be implemented in accordance with national procedures. The review of its implementation in Europe has revealed a high variation of approaches and many practical problems. Therefore, the European Commission has published further guidelines on clinical audits in its report Radiation Protection No. 159 (2009). The purpose is to improve the implementation of clinical audits and to enable the Member States to adopt the model of clinical audit with respect to their national legislation and administrative provisions. The guideline points out the importance of both internal and external assessments for clinical audit. It deals with all types and levels of clinical audit and gives practical guidance for application. It defines the list of topics which should be covered, while the actual criteria of good practice are discussed on generic levels only. The borderline between clinical audit and other quality assessments (accreditations, certifications, peer reviews) and regulatory inspections is also discussed. The guideline is addressed to all professional groups, hospital management, auditing organisations and regulatory bodies. It is important to recognise that the guideline is not a legal requirement. This refresher course lecture will give a summary of the EC guidelines and discuss briefly the implementation of clinical audits in Europe.Learning Objectives: 1. To understand the purpose and essential contents of the European commission guideline on clinical audit.

B. National perspective: clinical audit inspections S. Ebdon-Jackson; Didcot/UK (steve.ebdon-jackson@hpa.org.uk) European Council Directive 97/43/Euratom requires under Article 6 (4) that "clinical audits are carried out in accordance with national procedures". Implementation of this requirement across Europe has been varied. This paper will reflect on the experience in the UK and will consider examples of the various initiatives undertaken in the UK by professional bodies and organisations. This will be contrasted with the role of the regulator and the aims of the inspection process with regard to compliance with the specific regulation addressing clinical audit and the remaining regulations addressing justification, optimisation, etc. Examples will be provided of the type of audits undertaken within UK hospitals. A UK perspective of EC and IAEA initiatives in clinical audit will be provided. Percutaneous radiofrequency ablation (RFA) is a safe and effective treatment for well selected patient with hepatic tumours such as hepatocellular carcinoma (HCC) and liver colorectal metastases (LCM). An appropriate selection is crucial. It is based on clinical and technical arguments. Clinically, surgical resection of the haepatic tumours remains the gold standard. Indeed, survival data following RFA are not as good as surgical resection. The only exception seems to be the RFA of the very early HCC (≤3.0 cm) in cirrhosis that is not candidate for liver transplantation. Most often, the RFA offers an alternative for patients with medical comorbidities, poor liver function or prior hepatectomy. Technically, there are three decisive points for complete ablation. The first point is the good visualisation of the tumour either under ultrasound or un-enhanced computed-tomography (CT) examination. Metallic coil placement, lipiodol tattoo and virtual CT sonography with magnetic navigation are technical tricks that allow the RF ablation of "invisible" tumour. The second point is the tumour size: in most series, a diameter less than 25-35 mm is commonly admitted as a prognostic factor. This is probably because the maximal ablation diameter is slightly larger than 40 mm with the electrode needles available now. Micro-waves ablation might improve the local control by increasing the ablation diameter. The last point is the "heat-sink effect" that requires a temporary occlusion of a large vessel close to the tumour. The quality of follow-up imaging is a key factor for evaluation of tumour destruction. Partial hepatectomy for liver metastases or primary liver tumours can only be performed when the future remnant liver volume (FRLV) is considered large enough to avoid the risk of post-operative liver failure. In normal livers a FRLV of 25-30% is considered safe whereas in compromised livers a FRLV of at least 40% is required. In patients whom the FLRV is considered to small, PVE may be performed pre-operatively to increase the FRLV. PVE involves percutaneous selective embolisation of the portal venous (PV) system, usually of the right liver lobe, which leads to atrophy of the embolised lobe. This, in turn, leads to hypertrophy of the FRLV. Because of the dual vascular supply to the liver (arterial and portal venous), necrosis of the embolised lobe does not occur. This compensatory hypertrophy of the left lobe facilitates resection in patients in whom the FRLV would otherwise have been to small to allow resection. PVE is most often performed percutaneously under conscious sedation and local anaesthesia through an ipsilateral approach, using a combination of particles, such as polyvinyl-alcohol (PVA) and embolisation coils. Potential complications of PVE include thrombosis of the contralateral PV, liver abscess formation or cholangitis and are rare. Most of the hypertrophy occurs in the first 3-4 weeks after PVE and increase in volume of the FRLV averages 12% after this time period. CT-volumetry should be performed both before PVE and after 3-4 weeks to measure increase in FRLV. Accurate identification and reporting on soft tissue extremity masses is essential for correct diagnosis and optimal treatment planning. This lecture focuses on the MRI signs to stage and grade-characterise soft tissue mass lesions. These two objectives are the major structural components of the MRI report and fit the request of the referring clinician. This implies an accurate description of these signs with appropriate terminology in the report. Local staging is essential for the preoperative work up. Important staging parameters are size, compartmental location, skip lesions and relationship to neurovascular structures and joints, as well as distance to the nearest joint space. Grading and characterisation is complex and multifactorial and classifies the lesions as "certainly benign" (no biopsy needed) and "possibly " or "certainly malignant" (biopsy needed). Grading parameters are homogeneity, (changing) signal intensities in multiple acquisition techniques and static and dynamic gadolinium enhancement pattern. These are used to define the composition of the lesion, i.e. fat, met-Hb, hemosiderin, myxoid tissue, collagen, viable, cystic or necrotic components. Other important grading and parameters are lesion margin, shape, perilesional invasion or destruction, multiplicity, specific location and associated findings but also age and gender of the patient. Image guidance and imaging fusion techniques represent an integral element in oncologic interventions and liver surgery. In addition, several liver planning techniques such as the virtual liver surgery planer enhance simulation of a proposed liver resection. Using roboter-assistance or navigational guidance combined with thermal ablation techniques such as radiofrequency ablation, significantly enhances accuracy of ablation probe placement and efficacy of ablation necrosis. Furthermore, the local recurrence rate can be considerably reduced, and the amount of complete tumour ablation is significantly more likely. Integrating magnetic resonance imaging, and focused ultrasound to deliver and activate nano-capsules carrying anti-cancer drugs to effectively target tumours will be another task. This will involve drugs being injected into the body in the form of tiny capsules, which are harmless until they are activated by a concentrated focused ultrasound `blast'.The MRI scanner will then be used to track the passage of the drugs, visualise the target and monitor the delivery of the drug treatment. The risks associated with radiation exposure in CT is of concern to radiologists, medical physicists, government regulators, and the media. Thoracic CT is a technically robust, non-invasive imaging technique for the evaluation of several traumatic and non-traumatic thoracic emergencies. Technical advances in the past years have resulted in improvements in image acquisition speed, spatial resolution, and the temporal resolution. Consequently, thoracic CT can now be performed rapidly in emergency conditions without substantial delay in treatment. State-of-the-art CT systems are now capable of imaging the entire thorax within a few seconds. However, radiation exposure associated with thoracic CT have been increased with the advantages of modern CT systems particularly in the evaluation of chest pain syndrome. Thoracic aortic CT angiography with cardiac gating may now be considered the preferred technique for the evaluation of chest pain syndrome in selected patients but is associated with a substantial higher radiation dose than routine non-gated thoracic CT. Several effective strategies have been developed to limit the radiation exposure in cardiac gated thoracic CT including prospective ECG gating techniques, anatomy and ECG-based tube current modulation, high pitch acquisition, and adaptation of the CT scanning parameters to the body habitus. In addition, several techniques are available to reduce the radiation exposure in nongated thoracic CT depending on the patient's body habitus and the clinical indication. Because of advancing technical developments and increasing diagnostic utility of MDCT in emergency care, its use has expanded significantly and has changed patient care, especially in chest emergencies. However, MDCT has important drawbacks in cost and radiation exposure. The first presentation will discuss MDCT in acute chest pain (ACP). Scan techniques in different scanners will be addressed. The reasons why CTA/CTCA can be a viable application for ACP and the current evidence for CTA in ACP will be discussed followed by an update on indications. The next presentation will address MDCT in chest trauma. Its significance, the utility of this imaging method and its advantage compared to other modalities will be discussed. The examination protocol and the role of post-processing methods will be addressed. The interpretation of MDCT, findings, benefits, limitations and pitfalls will be shown. The utility of chest x-ray and ultrasound as primary examinations and the indication for MDCT, routine or selective, will be discussed. Our last speaker will familiarise us with procedures to measure radiation dose in thoracic MDCT, followed by an update of radiation exposure associated with the protocols for the different clinical indications. Finally, available techniques for radiation dose reduction in ECG-gated and non-gated MDCT and their effectiveness in radiation dose reduction will be demonstrated. However, the best way to reduce radiation is to perform MDCT only when there is an appropriate indication and this will be the focus of the concluding panel discussion of this session. Chest trauma is, particularly in younger population, a significant cause of morbidity and mortality. It is directly responsible for 20-25% of trauma-related deaths and in other 50% of deaths it is an important contributing factor. Imaging methods play the key role in management of this group of patients. Introduction of MDCT in the last decade of the 20 th century markedly changed the diagnostic approach to the thoracic trauma. Fast data acquisition and increased resolution in the z-axis enabled reliable assessment of all chest anatomical components (often together with other parts of the body) in one examination. Compared to x-ray MDCT defines more accurately the extent and severity of traumatic changes and may detect serious In 85% of nontraumatic cases, subarachnoid haemorrhage (SAH) is the result of aneurysmal rupture. Other causes of SAH include perimesencephalic SAH (10%) and other disorders (5%) such as arteriovenous malformation (AVM), vertebrobasilar artery dissection, dural AV-fistula, cortical vein thrombosis, amyloid angiopathy, … SAH represents an emergency situation and diagnosis should be established ASAP.Plane computed tomography (CT) is the initial diagnostic test of choice (wide availability, easy accessibility, high sensitivity and specificity). If CT is negative, lumbar puncture and/or MRI of the brain (including FLAIR images) and spine should be performed. 3D TOF MR angiography (MRA) sequences have high sensitivity and specificity in detecting cerebral aneurysms; but because of their lower spatial resolution are insufficient to analyse in detail aneurysm morphology. This in contrast with CTA. Both CTA and MRA may be proposed as a first-choice, noninvasive examination, but the negative predictive value is poor, and therefore digital subtraction angiography (DSA) is mandatory for all SAH cases with negative CTA or MRA. Catheter angiography remains the golden standard in the detection and evaluation of cerebral aneurysms (size, relationship between neck and adjacent vessels, etc). Increased attenuation (CT) and hyperintense signal (FLAIR) within the basal cisterns and sulci are a characteristic finding of SAH; however, it is aspecific. Pattern and location of the blood may help to locate the ruptured aneurysm; sometimes helpful when multiple aneurysms are found. Pseudo-SAH may be a potential imaging pitfall because it may be observed in other acute neurological conditions (cerebral edema, bacterial meningitis, etc). Recurrent disease following treatment for primary breast cancer can occur in the same breast following conservation surgery, ipsilateral breast tumour recurrence (IBTR) or in the contralateral breast, metachronous contralateral breast cancer (MCBC). Estimations for the rate of recurrence are between 04 and 0.8% each year. The rate of recurrence is higher than breast cancer incidence in the general population. Risk factors for recurrence are young age (< 50), high grade disease, incomplete tumour excision and no radiotherapy. Due to the large numbers of women who develop and survive breast cancer the cost and resource required to follow-up these women is considerable. There are variable guidelines in Europe for the surveillance of women but most regimes include clinical follow-up and mammography. Variations concern the frequency of mammography, the length of follow-up required, and whether clinical examination is required. The clinical effectiveness and cost-effectiveness of different surveillance mammography regimens after the treatment of primary breast cancer will be reviewed together with the results of systematic reviews. Modelling of two data registries was undertaken to ascertain the survival benefit. Alternative methods of surveillance will be considered such as MRI with the diagnostic accuracy of the various imaging techniques considered. A summary of the economic evaluation will be presented to demonstrate the assumptions that require to be made in this complex area where there is a paucity of evidence.Learning Objectives: 1. To understand the risk of recurrent disease and second primary following the treatment of breast cancer. 2. To review literature on surveillance mammography and other imaging methods for detection. 3. To appreciate the range of recommendations for surveillance mammography and clinical follow-up with cost benefit analysis.

The new challenge in breast cancer: evaluation of response 17:14Evaluation of the treated breast is one of the major challenges in breast imaging.There is especially much debate on the evaluation of response to therapy. The best imaging modality, the best imaging criteria, timing, accuracy and limitations of imaging are currently being investigated. Whether it is time to reach conclusions regarding these aspects is the issue of this panel discussion. Intracranial aneurysms are abnormal dilatations of the arteries, and will be found in 1% to 14% in general population. In 90% cerebral aneurysms are saccular and develop from the arteries of the circle of Willis or its major branches. Aneurysms typically become symptomatic between the age of 40 and 60 years, with subarachnoid haemorrhage (SAH) or intracerebral haematomas. Less common are giant aneurysms usually found in middle-aged women presenting with signs more indicative of a mass lesion. CT angiography (CTA) has been proven to be an excellent tool to visualise intracranial arteries. The average sensitivity of CTA for the detection of intracranial aneurysms reaches 90%. Post-processing allows assessment of the aneurysm with maximum intensity projections (MIP) and surface-rendered 3D projections in multiple plains. MR angiography (MRA) is a practical and noninvasive tool for screening of high-risk individuals for aneurysms. DSA is diagnostic method of choice for assessment of intracranial aneurysms and was considered to be a 'gold standard' for evaluation of cerebral vessels. A clear shift from invasive to noninvasive imaging of cerebral vessels has been noticed in the last decade. This lecture will discuss advantages and disadvantages of CTA, MRA and DSA in detection, assessment, and post-treatment evaluation of intracranial aneurysms. Intracranial aneurysms have a multifactorial origin. A heterogeneous and complex group of pathogenic mechanisms including luminal, mural and extramural factors interact for the development and growth of aneurysms. There are several types of intracranial aneurysms, being the saccular the most common type. The aneurismal treatment is dependent on its type and needs a multidisciplinary approach including endovascular and microsurgical teams. Endovascular treatment is recognised as the first-line treatment for most of the ruptured saccular intracranial aneurysms. There has been an enormous improvement in the endovascular technology and techniques offering a wide spectrum of treatment possibilities that broadened the variety of aneurysms that can be treated. The treatment options include the use of coils with/without the help of balloon-remodelling and/or stenting. Other options include the use of covered stents, of "flow-diverter" stents, of liquid embolics, or the parent vessel occlusion. The multislice computer tomography angiography (MSCTA) is a reliable method for pretreatment evaluation of intracranial aneurysms. For the posttreatment evaluation, magnetic resonance angiography (MRA) can be used for the follow-up of embolised aneurysms; and MSCTA may be used for the follow-up of surgically treated aneurysms. There are several challenges remaining in aneurysm management. In the diagnostic field, improvement of the non-invasive techniques for the diagnosis, for the morphological and haemodynamic characterisation and for the posttreatment follow-up of aneurysms is expected. In the endovascular field, technological breakthroughs to improve the occlusion rate, to increase the treatment durability, and to promote the vessel wall healing are desired. Learning Objectives:1. To learn about present treatment of brain aneurysms. 2. To understand the strategies for multimodal CT and MR aneurysm imaging pre and post-treatment. 3. To present the challenges for neuroimaging in the field in the near future.

Where do we stand in brain aneurysm treatment today? 17:14There is a significant difference in the management of patients with ruptured versus un-ruptured brain aneurysms. This panel discussion will focus on the management of patients with brain aneurysms and will with simple case presentations show the management in ruptured and un-ruptured aneurysms and discuss the involvement of the neurosurgeon in more complex cases.Cone beam CT (CBCT) is a method for obtaining CT-like images using a C-arm system. Our aim was to investigate the accuracy of these images compared with multi-detector CT (MDCT) as a gold standard in radiological imaging of abdominal aortic aneurysms (AAA). 40 patients with AAA referred for elective EVAR were included in a pre-therapy protocol (20 patients) and in a post-therapy protocol (20 patients). All were exposed to standard MDCT and one additional CBCT. Image data were evaluated by two radiologists and statistically compared using a linear mixed model. First, 6 predefined arterial measurements were performed, then 9 predefined anatomical areas were assessed and scored for visibility on a scale from 1 to 4. All measurements were chosen to be relevant for evaluating of AAA before and after EVAR. For the arterial measurements no significant differences were found between MDCT and CBCT. Visibility for the anatomical areas was significantly better for MDCT; however, most of the CBCT readings were above lowest acceptable level. Visualisation of the iliac arteries was suboptimal. We think that our results support the start of clinical trials that scientifically can test the outcome without the use of MDCT immediately before and after EVAR. The problem with poor visualisation of the distal iliac arteries might be solved with newer technology. In conclusion, the result indicates that CBCT in the operation room gives sufficient image-based information to support EVAR in a pre-and post-therapy setting. Undertaking theatre radiography can appear a daunting task for the radiographers lacking in confidence in their ability but others (like all expert practitioners) make it look easy and uncomplicated. Theatre radiography requires all the knowledge, skills and abilities of a competent radiographer together with assertiveness, reflection and the ability to modify your technique at a moment's notice. There are a multitude of 'traits' which distinguish the expert from the novice. These include production of optimum images, effective use of the equipment, radiation protection, infection control, effective communication and teamworking. There is also a clear depth of knowledge together with a multitude of skills and abilities. The key to a stress-free experience is preparation. It is essential that there is a mechanism for theatre staff and the radiology department to communicate effectively and give the radiographer prior notice of all cases requiring their attendance. It is also desirable to be in the theatre when the patient arrives for their examination to enable you to check the patient's identity, pregnancy status and ensure the patient is positioned correctly to facilitate screening. There are few excuses to give the surgeon if you cannot screen the area of interest because of poor positioning of the patient and equipment. This paper will discuss the knowledge, skills and abilities required to undertake theatre radiography in a safe and proficient manner without feeling threatened by the experience. Learning Objectives: 1. To understand the key skills required to undertake radiographic procedures in the operating theatre. 2. To gain an insight into the interpersonal skill required for effective radiographic practice in the operating theatre. Prediction of coronary revascularisation outcome represents a major clinical question because a large number of medical and surgical options have become available for ischaemic cardiomyopathy with need to identify more rigorous criteria for patient's selection. The combination in a single examination of function, stress-perfusion and tissue characterisation with T2-weighted 'oedema-sensitive' and late-gadolinium enhancement (LGE) techniques supported the role of cardiac MR (CMR) as an important technique for the evaluation of patients candidates to revascularisation. Besides more "traditional" indicators such as ejection fraction, end-diastolic wall thickness or endsystolic volumes, extent and distribution of myocardial scar depicted with LGE has been identified as one of the most important predictors of post-revascularisation outcome with direct influence on functional recovery and on major adverse cardiovascular events (MACE) due to the potential induction of arrhythmias from the scar.LGE technique has been shown to be superior to nuclear medicine for the assessment of myocardial viability due to the higher spatial resolution (up to 60-fold greater than SPECT) and an intrinsic high contrast resolution. A further technique that could be adopted before revascularisation is stress imaging. Myocardial ischaemia detected by either CMR adenosine first-pass perfusion or dobutamine-induced wall motion abnormalities has been shown to predict subsequent cardiac death whereas normal stress perfusion showed a high negative predictive value for MACE. In conclusions, although as a relatively new diagnostic modality prognostic evidence is predominantly derived from singlecenter studies, CMR is increasingly becoming an important tool for risk stratification of patients before revascularisation, offering indications about outcome and mortality. Cardiac valve diseases are an important public health problem, strongly linked to the general increasing age of the Western population. The most frequent valve disease is aortic stenosis, for which percutaneous aortic valve replacement (PAVR) is currently evolving to a feasible alternative therapy for the classical surgical approach in high-risk patients. Nevertheless, careful evaluation of all aspects of this new approach is still required to avoid uncontrolled diffusion. Imaging plays a key role in selecting patients who may be eligible for PAVR, focusing on the evaluation of leaflet anatomy, severity of valve dysfunction, haemodynamic consequences and potential problems in the access route. While echocardiography is commonly used for both the anatomical and functional evaluation, multidetector CT (MDCT) has important intrinsic advantages providing state-of-the-art 3D imaging with a high spatial resolution over a large anatomic coverage. During this course, we will discuss the advantages and disadvantages of MDCT compared to other imaging modalities. The relevant anatomy of the aortic valve and annulus will be reviewed, with emphasis on correct alignment of the imaging planes, and its implications for correct reporting of the necessary measurements targeted at the clinicians need. Furthermore, MDCT scan protocol design will be reviewed, focusing not only on optimal implementation of common scan parameters but also on the need of ECG-triggering and its consequences. Finally, we will present the current status of evidence on using MDCT in PAVR procedures, and discuss future challenges and perspectives. Learning Objectives: 1. To understand how to optimise the imaging protocol for aortic valve imaging. 2. To learn how to report the findings and what to include in the report. 3. To understand the impact of this approach on patient management. The need for quantitative image analysis in radiology is universal: computer-aided detection, segmentation for 3D volume visualisation, image enhancement, pattern recognition, etc. All need effective, robust and preferably generic (not 'ad hoc') algorithms for the computer. How to design such algorithms? A good inspiration source is the functionality of the visual system, the best investigated brain structure today. In this talk we will explain how we think the brain calculates features in images, why the retina measures at a wide range of resolutions and how we can exploit this. The visual system is strongly adaptive and self-learning. New optical recording techniques have given new insight in how the cells in the visual cortex are functioning. We will go through these functionalities step-by-step. What we discover is quite amazing. We recognise huge amounts of filter banks in the first stages of vision: many filters analyse each pixel of the incoming image at a range of scales, orientations, derivative order, for each colour, and also as a function of time. Extensive feedback loops take care of optimal settings locally. We programmed these filters into the computer, and were able to build many interesting applications for computer-aided diagnosis: detection of catheters at seriously reduced levels of x-ray radiation dose, automatic polyp detection, quantitative analysis of ischaemic heart ventricle deformation, breast cancer CAD, pulmonary emboli CAD and analysis of in vivo microscopy images now so abundant in modern life-sciences research. Postgraduate.Educational.Programmethe GI tract are leading causes but any tumour involving the abdominal cavity or haematological malignancy may be implicated. During treatment with chemotherapy or radiotherapy acute abdominal symptoms are common as a consequence of direct toxicity. Imaging must be used as an adjunct to clinical assessment. Patterns of abdominal involvement are often modified in the later phases of disease. GI tract obstruction may be due to progression or the mechanical consequences of prior surgery and is more commonly at multiple levels. Perforation or fistulation may occur with either progressive disease or tumour lysis in response to therapy. Cancer does not protect against the common inflammatory conditions but poor host response and the use of steroids may mask signs leading to extensive abnormality at diagnosis. Bone marrow suppression increases susceptibility to infection including neutropenic enterocolitis and haemorrhage. Bone marrow transplantation and consequent graft versus host disease is a potent cause of acute abdominal symptoms. CT is the major imaging technique although MR has an increasing role particularly in the assessment of the female pelvis. Major determinants when considering the differential diagnosis include; the nature and initial stage of the primary, any prior anatomical modification (surgery), the nature and relationship to current treatment and the bone marrow status. This workshop will begin by describing the current limitations of MRI in evaluating prostate cancer patients and will show how to overcome these with advanced imaging techniques including diffusion weighted MRI (DW-MRI), MR spectroscopic imaging (1H-MRSI) and dynamic contrast enhanced MRI (DCE-MRI). The emphasis will be on the use of processing tools that are readily available for clinical practice. We will describe how to analyse images and provide a scheme for reporting findings back to surgeons/oncologists. We will show that using more than one MRI tool improves imaging performance and that the relative importance of each technique remains unresolved. We will demonstrate new indications for advanced MRI in prostate cancer patients. Abdominal hernias are common in daily practice and can be divided into: external or abdominal wall hernias, internal hernias and diaphragmatic hernias. External hernias typically involve protrusion of abdominal contents through a defect in the abdominal wall. Internal hernias involve protrusion of viscera through congenital or acquired defects in the mesentery or the peritoneum. Diaphragmatic hernias involve protrusion of abdominal contents into the chest. Among these conditions, the diagnosis of internal hernia is the most challenging. Bariatric surgery and liver transplantation with biliary-enteric anastomosis, with the Roux-en-Y loop placed in a retrocolic position, are recognised predisposing factors for internal hernia development. Symptoms of hernia are nonspecific and vague, and clinical and radiologic diagnosis can sometimes be challenging. Immediate diagnosis is mandatory because misdiagnosis can be complicated by bowel obstruction, volvulus, strangulation, incarceration, or trauma. MDCT with its multiplanar capabilities is widely believed to facilitate this diagnosis, because it is able to delineate hernia type, location, size, and shape and is particularly useful to diagnose unsuspected hernias. It also allows distinguishing hernias from masses of the abdominal wall, such as tumours, haematomas and abscesses. As a result, knowledge of the CT findings of abdominal hernias may allow early and more accurate diagnosis, with a resultant decrease in the mortality rate. The title of this talk limits the discussion of torsion to the mesentery and omentum. It has to be mentioned, however, that an abnormal twist (torsion) can involve any peritoneal reflection of those suspending and fixating hollow viscera, (e.g. stomach, small bowel, cecum, sigmoid and gallbladder), solid organs, (e.g. spleen, ovaries), or even extraperitonel (extraabdominal) organs such as the testicles, leading to the pathologic entity of volvulus or torsion of the corresponding viscous with its associated (different) imaging findings, prognosis and treatment. Moreover, twisting of the mesentery and volvulus can occur secondary to a variety of conditions including congenital anomalies of intestinal rotation with variable prognosis. Finally, torsion of the omentum can be either primary or secondary, also associated with different pathology, imaging findings and treatment. Consequently, a broad spectrum of abnormalities ensues related to the pathophysiology of torsion which requires a detailed classification, an accurate description and the use of correct terminology making it impossible to be covered within the time limits of a presentation. Therefore, focusing the discussion on to abnormal twist of small bowel mesentery and omentum will simplify the approach to avoid overlaps and confusion. This case-based lecture will present typical clinical cases of pelvic pain as well as some unusual but important causes. Cases of acute and of chronic pelvic pain, and benign as well as malignant disease will be included. The audience will have the opportunity to participate in case discussion by the use of interactive voting pads. The selection of imaging modality for each clinical presentation and the importance of knowing the clinical findings at the time of the radiological interpretation will be discussed. For each case, the key radiological features will be illustrated. The essential elements of the radiology report and the key information required by the clinician will be discussed. In each case, the differential diagnosis and the need for follow-up imaging will be considered. The key teaching points for each diagnosis will be reviewed. This lecture provides a practical approach to the fundamentals of normal cross-sectional anatomy of the hip. Basic knowledge necessary to identify the different portions and contents of the joint anatomy is provided. A special emphasis is on cartilaginous structures, the acetabular fossa, and capsular fibers and ligaments. Functional anatomy of muscles and tendons about the hip is reviewed. The location of bursae and their association with adjacent structures is discussed. In the second part of the lecture attendees will learn how to avoid commonly seen pitfalls about the hip. A special focus on anatomic variants of the acetabular labrum simulating disease is given. Osseous variants including acetabular ossicles and the superior acetabular notch will be explained and explored. Debates about the role of herniation pits referred to as a normal variant are reviewed. The lecture offers an overview of muscular and tendinous variations around the hip joint. Pelvic pain is an important part of clinical practice for any clinician who provides health care for women. Pelvic pain may be acute, recurrent or chronic. Acute pelvic pain (APP) rarely lasts more than one month without crisis, resolution, or cure. Pain of more than 1 or 3 or 6 months of duration is considered as chronic pelvic pain (CPP) and in many settings may be considered and treated as an illness itself. Women who present with APP frequently exhibit nonspecific signs and symptoms. Diagnostic considerations encompass multiple organ systems, including obstetric, gynaecologic, urologic, gastrointestinal, and vascular aetiologies. As the first priority, urgent life-threatening conditions (e.g. ectopic pregnancy, appendicitis and ruptured ovarian cyst) and fertility-threatening conditions (e.g. pelvic inflammatory disease and ovarian torsion) must be considered. Adolescents and pregnant and postpartum women require unique considerations. CCP is a common and significant disorder of women, with a prevalence of 3.8-12%. Many disorders of the reproductive tract, gastrointestinal system, urological organs, musculoskeletal system, and psychoneurological system may be associated with CCP, the most common being endometriosis, adhesions, irritable bowel syndrome and interstitial cystitis. Ultrasonography should be the initial imaging test because of its sensitivities across most aetiologies and its lack of radiation exposure. Computed tomography (CT) serves an important role in patients with nonlocalizing symptoms, an indeterminate US evaluation, or in patients who require a wider search beyond the field of view available with US. Magnetic resonance imaging is an extremely useful second-line modality for problem solving after US or CT. Fat-suppression sequences help to establish fat-containing lesions and increase the conspicuity of inflammatory lesions. Different sequences will be discussed. MR is rated below US and CT for evaluation of acute pelvic conditions, but is excellent alternative when administration of iodinated contrast media or radiation exposure is undesirable, especially in young or pregnant patients. Long imaging times, limited access and cost are major drawbacks of MRI. Imaging findings of various gynaecologic and nongynaecologic conditions causing female pelvic pain will be presented. An overview of the interventional radiology management of painful osseus metastases will be presented. Consideration will be given to patient, lesion and treatment modality selection (including radiofrequency ablation, cryoablation, microwave ablation, laser ablation, ethanol ablation, MR focused ultrasound ablation, cement osteoplasty, transarterial embolisation and combinations therein, e.g. combined radiofrequency ablation and cement osteoplasty). The evidence supporting these techniques and patient outcomes will be reviewed. Molecular imaging -defined as the non-invasive assessment of biological mechanisms at molecular and cellular level -will play a major role in future disease diagnosis and treatment planning. In this context, the aim of this session is to introduce in simple terms several major research areas in molecular imaging and to discuss their future potential for clinical radiology. The differential diagnosis of hip pain is broad and includes intra-articular pathology, extra-articular pathology including referred pain from the spine, and mimickers including groin pain and pain from the joints of the pelvic ring. The diagnosis of all causes of hip pain/pathology has improved with greater use of magnetic resonance imaging (MRI) to complement traditional investigations. In this session pathology involving the hip and groin will be reviewed in a systematic way which will outline an approach to the hip that will allow the reader to maximise their diagnostic ability. The review will include evaluation of bone marrow disorders such as avascular necrosis and transient osteoporosis and intra-articular pathology including labral tears and femoroacetabular impingement (arthritis and traumatic fractures will not be reviewed). Extra-articular diagnoses such as bursitis, groin pain (osteitis pubis and adductor/ gracilis dysfunction) and common muscle and tendon injuries will then be reviewed. Today, many procedures of bone and joint are performed under imaging control. Minimally invasive procedures require less resources, time, recovery, and cost, and often offer reduced morbidity and mortality, compared to other modalities. Many percutaneous techniques are available. Some aim to treat pain and consolidate bone (cementoplasty). Others ablate or reduce the tumour (chemical and thermal ablation techniques). The interventional radiologist with an efficient imaging-guided technique (flat panel fluoroscopy, CT, and MRI) can increase the precision of the above-described procedures allowing an improvement of the results and reduction of the complications. Furthermore, the presented interventions are carried out either on an outpatient basis or with 24 hours hospitalisation which contributes to the reduction of overall costs and presents a major advantage for patients of working age. Some of these minimally invasive procedures can be considered as alternatives to surgery without excluding further surgical options if necessary.

Back pain is one of the most common complaints, it is estimated that almost 50% of working adults will experience it in any given year. Diseases of peripheral skeleton may produce painful symptomatology as well. Some of the algogenic structures of the spine and peripheral skeleton are lumbar intervertebral discs, facet joints and atlanto-axial/occipital joints, sacroiliac joints, nerve root dura, periosteum, ligaments, fascia. Among several aetiologies which can involve these structures, spine degenerative pathology plays the leading role. Nowadays, several different interventional techniques are available, each one with its specific target of action. With the right indication each of them has been proved to be effective as painkilling modality. Herein, we present an up to date comprehensive overview on the interventional techniques available with their own indications. Small airways and small airways diseases (SAD) have attracted a lot of interest that has resulted in a large number of publications since the early 1970s. Despite the several histopathological and clinical subtypes that have been described diagnosis is not always obvious. The introduction of thin section CT and the fact that this CT technique is able to depict signs of SAD has not only renewed interest but has also improved insights in these disorders. In this session the direct and indirect CT signs of SAD will be presented and the CT techniques that can improve their detection will be explained. Correlations between pathological findings and the presence of these CT signs will be made and diseases that can mimic these CT findings will be discussed. Schemes of classification of SAD based on clinical and pathological findings will be discussed briefly, but most attention will be given to the radiological classification, which is based on the recognition of the direct and indirect signs of SAD. Algorithms that help to identify the cause of SAD will be presented. Finally, the use of CT and also of MR as a tool to examine the structure-function relationship in SAD will be discussed. It will be shown how careful interpretation and software tools can help to generate data about disease extent and global and regional lung function. The ability to recognise direct and indirect signs of small airways disease on HRCT has led to renewed interest in these elusive disorders. The "purest" of these diseases is constrictive obliterative bronchiolitis which is manifested on HRCT by the indirect sign of a mosaic attenuation pattern; the differential diagnosis for mosaicism and an algorithm that helps to identify the correct cause of small airways disease will be presented. The necessity for routine expiratory HRCT to make the diagnosis of obliterative bronchiolitis is controversial and will be discussed jointly Whole body fluorescent imaging and bioluminescent imaging are now widely applied in small animals to study all kinds of biological and molecular processes like i.e. gene expression, tumour progression and metastasis, apoptosis, inflammation, angiogenesis, proteolysis and to follow trafficking, differentiation and fate of cells (i.e. stem-, immune-and tumour cells). This has been done mainly by using gene reporters expressing fluorescent proteins or luciferases. Recently new mutated red shifted fluorescent proteins (with better light penetration and less absorption and autofluorescence) and codon optimized and mutated luciferases have been developed making optical imaging more sensitive and offering the possibility to use dual gene reporters. Apart from new "smart gene reporters" there has also been a great development in injectable near infrared fluorescent (NIRF) probes, especially for tumour detection. These NIRF probes can either be targeted or enzyme-cleavable. These new developments has opened up the possibility to apply NIRF imaging in the clinic especially to image tumour tissue and to identify sentinel lymph nodes during operation. The assessment of the tumour-free margin during cancer surgery is critical to completely remove the tumour and improve the prognosis of the patient. By injecting a tumour specific NIRF probe, tumour tissue and local metastases can be visualised in real-time during operation using a dedicated NIRF camera system. We now already use NIRF imaging in the clinic to detect the sentinel lymph node (SLN) in several types of cancers. In the current presentation preclinical and clinical applications of NIRF imaging in image-guided surgery will be discussed. Targeted ultrasound contrast agents have opened up the door for molecular imaging with sonography. These contrast agents, which consist of encapsulated gas microbubbles, are coated with antibodies or specific ligands. Injected into the circulation, microbubbles are retained in diseased tissue where they can be detected and quantified by different approaches such as "semiquantitative 2-D" or "quantitative 3-D" imaging techniques. Due to their size, microbubbles behave similar to red blood cells and remain within the intravascular space. Therefore, the disease process must be characterised by specific molecular changes on the surface of the endothelial cells to be assessable by ultrasound. Several angiogenic markers such as VEGFR2, α v β 3 -integrins, ICAM-1 and VCAM are known to be overexpressed by the endothelium in neoplastic, inflammatory and vascular diseases. Thus, molecular ultrasound imaging seems perfectly suited to detect these markers and monitor changes which might occur during treatment response or disease progression. Today, targeted ultrasound contrast agents are becoming a routinely used preclinical tool and the first application of specific microbubbles in a clinical scenario is expected for the near future. This talk will introduce into the principles of molecular imaging with ultrasound. Based on recent studies, basics of tumour biology, potential endovascular targets, synthesis of molecular probes and different imaging approaches for a preclinical and clinical application of molecular ultrasound will be discussed. In this RC, a general insight of imaging in epilepsy, including indications, protocols, and the most common neuroradiological conditions to be identified, will be covered. Particular interest will be given to tumours as a cause of epilepsy, and to their more relevant neuroradiological aspects. Finally, the contributions of different imaging techniques in the specific context of epilepsy surgery will be reviewed. Brain tumours are a common cause of epilepsy more often in adults, less in children.Tumours detected in patients with chronic epilepsy are predominantly located in the brain cortex area, affecting the temporal lobe most often. Any benign or malignant brain tumour can be responsible for seizures, but some are more frequently associated with epileptic symptoms. Low-grade astrocytomas, oligodendrogliomas, gangliomas, dysembryoplastic neuroepithelial tumours (DNETs) and glioblastomas multiforme are the tumours significantly often presenting with seizures in adult population. Brain tumour-related epileptogenesis in not fully understood yet, but one can list a number of factors playing an important role in this process, including: disruption of physiological neuronal structure, tumour affection on the release of neurotransmitters and abnormal electrical activity of the brain. Different imaging techniques are widely used for evaluation for neoplasms in epileptic patients. CT is reserved for acute conditions, one must remember to exclude other possible aetiologies of seizures like haemorrhage, trauma or inherited malformations. MRI remains the gold standard in imaging investigation of patients with epilepsy. Conventional pre-and post-contrast SE sequences are mandatory to perform in every subject. Newer and more sophisticated techniques such as diffusion-weighted imaging (DWI), functional studies (fMRI), spectroscopy (MRS) and PET are helpful in qualification for surgery and preoperative functional mapping. MRI has become established as the modality of choice for preoperative local staging of rectal cancer. The most important general advantages of MRI compared to other crosssectional imaging modalities are the soft tissue contrast resolution between the propria muscle layer of the rectum and the perirectal fat, the ability to visualise the different pelvic compartments including the visceral pelvic (mesorectal) fascia and the surrounding tissues in the pelvis. High resolution T2-weighted sequences sagittal, transaxial and perpendicular to the tumour is the basic standard for morphological evaluation of the tumour, the distance of the tumour to the anal verge and for evaluation of extramural extension and the distance to the circumferential resection margin. Presence of other adverse features such as extramural venous invasion and local lymph node metastases is also noted. The MR-images are ideally demonstrated by the radiologist in a local multidisciplinary conference to make sure that the information is used to select the best possible treatment for the patient. When neo-adjuvant treatment is administered, MRI is usually performed both before and after treatment to assess treatment response. When planning surgery, both the pre-as well as the post-treatment images should be available for surgical planning. Finally in this lecture, the potential benefits of 3 T compared to 1.5 T for pre-operative imaging of rectal cancer as well as the present role of additional techniques, such as diffusion-weighted imaging (DWI) and specific contrast agents that have been evaluated for assessment of rectal cancer will be addressed. Locally recurrent rectal cancer is the main concern after rectal cancer surgery and has long been regarded as a rarely curable disease. Patients were treated palliatively, and subsequent median survival was 14 months and the 5-year survival rate was 5%. However, during the past 20-30 years, more patients were considered candidates for curative treatment due to better treatment options. Patients with distant recurrences from colorectal cancer, especially those in the liver or lung, have improved chances for cure with better imaging, better surgery and alternative minimal invasive treatment. In the follow-up after colorectal cancer surgery it is thus important to detect recurrences at an early stage. Besides CEA, imaging is often used as a surveillance tool. It is still unclear which is the most cost-efficient (imaging) tool for monitoring distant and local recurrences. This lecture aims at providing the evidence for surveillance by imaging and reviewing the guidelines for the detection of recurrences after colorectal cancer surgery. It will also discuss the role of MRI for establishing resectability of locally recurrent rectal cancer and the imaging patterns and features of recurrent disease. Its strength comprises a high sensitivity in detecting coronary stenosis > 50% and an excellent negative predictive value. The stringent limitation of CTA lies in its confinement to anatomic grading of coronary stenosis and a lack of information regarding whether a stenosis causes reversible myocardial ischaemia indicating the need for coronary revascularisation. Recently published data in animals and humans indicate that myocardial computed tomography perfusion (CTP) imaging is feasible, promising and accurate. The advantage of CTA is the comprehensive evaluation of coronary arteries and myocardial perfusion defects from the same datasets, which permits both visualisation of coronary anatomy and physiology.Further, CT provides information about regional and global myocardial function. The aim of this course is to understand basic principles of CT perfusion and functional imaging, to learn "how-to" perform CTP and comprehensive CTA/CTP scans, to review current scientific evidence and to discuss potential clinical applications. Nuclear medicine tests (SPECT and PET), MRI and more recently MDCT have been involved in myocardial perfusion imaging. In clinical practice, perfusion analysis is routinely performed with qualitative or semiquantitative assessment, both based on relative evaluation of uptake or enhancement of myocardium, considering a remote region as normal. However, the assumption of part of myocardium as normal can be wrong and cause false negatives. Absolute quantification has been introduced mostly with PET perfusion imaging (water, ammonia and rubidium), but its incremental value for the clinical decision making has not been widely investigated. More recently, MR perfusion imaging has been used for quantitative analysis with different technical approach. There are some clinical scenarios where quantification can change the clinical interpretation: 1. multivessel coronary artery disease (CAD), 2. balanced multivessel CAD, 3. exclusion of CAD in symptomatic patients, 4. microvascular disease, 5. revascularised patients. However, there are still some limitations in the use of absolute quantification: first, the setting of cutoff value for normal or abnormal perfusion; second, some clinical situations, such as heart failure patients, where perfusion is reduced and heterogeneous. Finally, studies concerning the prognostic value and the cost-effectiveness are needed. Epilepsy is a common disorder with a prevalence of up to 1% in the general population. Epilepsies are broadly classified into generalized and focal. Though most generalised seizures are controlled pharmaceutically, 30% of focal seizures are medically intractable. In this subset of patients, the overall sensitivity of MRI in identifying responsible substrates is approximately 80%. The purpose of neuroimaging in epilepsy patients is to identify underlying structural abnormalities that require specific treatment (usually surgical) and to aid in formulating a syndromic or aetiologic diagnosis. In this presentation imaging findings of the most common non-neoplastic lesions responsible for focal epilepsy, namely: a. hippocampal sclerosis, b. malformations of cortical development, c. vascular abnormalities and e. gliosis, will be discussed along with their differential diagnosis and pertinent imaging pitfalls. Since routine MR imaging is suboptimal in identifying epileptogenic substrates, imaging should be tailored accordingly. Hippocampal sclerosis, the most common cause of mesial temporal lobe epilepsy, is best demonstrated when the temporal lobes are imaged with thin sections in coronal plane perpendicular to the longitudinal axis of the hippocampus. Inversion recovery sequences best demonstrate morphology and volume loss in the hippocampus, mammilary body and fornix. T2 and FLAIR images best demonstrate the increased signal due to gliosis. For malformations of cortical development FLAIR is useful in assessing hyperintense signal. T1 gradient volume sequences can demonstrate subtle developmental malformations. Finally, because many epileptogenic lesions are subtle and easily overlooked, a systematic diagnostic approach to MRI interpretation in the clinical setting of epilepsy is helpful and will be discussed. Epilepsy surgery is an effective and safe therapy for selected patients with intractable localisation-related epilepsy. When morphological MRI fails to reveal focal, structural pathology (e.g. tumour, dysplasia, etc). as the putative aetiology for the seizures, other modalities may be taken into account. In the absence of structural pathology it is essential to identify the epileptogenic zone as exactly as possible in order to (a) increase the chance of a good outcome (reduction or termination of seizures) and (b) limit post-surgical sequelae. This lecture will cover some modalities that may add valuable information in this process. The need to individualise the pre-surgical evaluation and the concept of a multimodality epilepsy protocol will be discussed. The main focus will be on SPECT (single-photon-emission computed tomography), functional MRI, PET (positron-emission tomography) and the added value of co-registration on morphological MRI (e.g. SISCOM). Briefly, ictal SPECT may help to identify focal areas of hyperperfusion (ictal zones). Functional MRI is used for several reasons. One is to determine language laterality (dominant hemisphere); another is to localise eloquent cortical structures to aid the planning of the surgical approach. PET may detect hypometabolic areas corresponding to areas involved in epilepsy. MRS (magnetic resonance spectroscopy), MEG (magnetoencephalography) and intradural EEG-registration and stimulation will be mentioned. The term epilepsy covers a wide spectrum of symptoms and underlying etiologies. An essential part of the work-up of patients with epilepsy includes the radiological examination. In recent years more sophisticated methods radiological methods have emerged and the discussion will focus on how these new advanced techniques may help finding underlying causes and be of help in the pre-surgical work-up.

Excellence in teleradiology: key issues in workflow management J. Schillebeeckx; Bonheiden/BE (jan.schillebeeckx@imelda.be)The healthcare market is undergoing significant change. The market is evolving from a provider centric to a patient centric model, requiring relevant data to converge at patient level in a timely and structured fashion. The push towards setting up collaborative networks for radiology is strong in most European countries. The most important challenge for teleradiology is to ensure that it develops in a manner that benefits patient care and ensures overall patient safety, and does not in any way reduce the quality of radiology services provided to the citizen. Therefore, these collaborative networks require more than just IT infrastructure with IT support. But as important is case management, workflow management and the administrative and management support that provides all the stakeholders with operational, analytical and statistical QA reports. Through a centrally operated hub, the radiology workflow is optimised to ensure throughput of cases, involving radiologists in the network, with the difference that only the services are provided by the Hub to the network, not the medical acts, which remain in the hands of the radiologists. Learning Objectives:1. To learn about the technical needs of a teleradiology infrastructure adapted to a distributed environment. 2. To understand that teleradiology involves much more than just technology.Optimising the workflow and time management are also important. 3. To appreciate how creating collaborative networks can improve the efficiency of radiology procedures and bring improved work/life balance to radiologists.

To make teleradiology an integrated part of clinical radiology, it must change from being a provider of radiology reports into a close collaboration with the client radiology department. There are many different aspects on workflow in a clinical setting and the teleradiology service should adapt to these specific needs in order to make a seamless collaboration. However, there are advantages with the global aspects of teleradiology that could improve diagnostic accuracy and efficiency in the clinical setting that should be woven into the collaboration. Teleradiology services have developed substantially over the last few years from limited use between hospitals and tertiary care centres for second opinions and patient transfer to the international provision of reporting services. There is no doubt that teleradiology provides a valuable service in some circumstances, but it also has a number of inherent limitations regarding the proper provision of imaging services to the patient and therefore may increase risks for the patient. We will highlight the problems that have arisen and reiterate key parts of the guidelines which were developed for the benefit of patient care. This lecture will demonstrate a multimodality approach to the imaging of salivary colic. The relevant US and MRI salivary anatomy will be highlighted and the ultrasound, computed tomography and magnetic resonance appearances of salivary grafts. respectively. Graft sclerosis develops in 38% of nonoccluded venous bypass vessels after 5 years and in 75% after 10 years. This sclerosis causes more than 50% luminal narrowing in approximately half of the affected vessels. Non-invasive imaging of coronary bypass grafts by MD-CT require information about the operative procedure. With the increasing implementation of 64slice CT scanners and beyond, it is possible to scan the heart and the full anatomic extent of grafts with sub-millimeter slice-thickness within a single breath-hold. When analysing the grafts, three graft segments should be assessed: the origin or proximal anastomosis, the body of the graft and the cardiac anastomosis, either single or sequential. Recent studies have shown that graft patency and the presence of significant graft stenosis can be assessed with an accuracy of 100% using most recent MD-CT technology (256/320 slice CT or dual source CT). The assessment of native coronaries with respect to the progression of CAD may still be problematic in cases with severe calcifications of the native coronary arteries. In these cases, MR perfusion imaging in combination with Cine and late gadolinium enhancement (LGE) imaging may be helpful in detecting newly developed, stress-induced myocardial ischaemia. Teleradiology services have developed substantially over the last few years from limited use between hospitals and tertiary care centres for second opinions and patient transfer to the international provision of reporting services There is no doubt that teleradiology provides a valuable service in some circumstances, but it also has a number of inherent limitations regarding the proper provision of imaging services to the patient and therefore may increase risks for the patient. We will highlight the problems that have arisen and to reiterate key parts of the guidelines which were developed for the benefit of patient care. It is now well understood that teleradiology cannot be considered just as 'telereporting', i.e. the simple interpretations of images remotely acquired and sent as a message in the bottle. Teleradiology procedures, being medical acts, must ensure the full involvement of the interpreting radiologist in all phases of the well established practice of diagnostic imaging: appropriateness check, personalised acquisition protocols, access to clinical history and prior imaging examinations, communication with referring physician and patient. Any obstacle that teleradiology causes to these activities may put our patients at risk (and therefore may expose us at liability suits). The presentation will describe the organisational as well as technological remedies for reducing such risk. For several decades, Monte Carlo simulation has been recognised as a powerful technique to simulate the transport of radiation in media, as well as to provide solutions for calculations too complex for classical approaches. Several general purpose codes and databases providing particle interaction cross-sections have been developed, and with the increase in computing power, simulation has become more and more popular within the field of medical imaging. Using Monte Carlo simulation methods, the different steps involved in the formation of a medical image can be analysed in detail, and the whole system optimised. A topic that has deserved particular attention in the past is the simulation of x-ray tubes and x-ray spectra, which is the first step in the simulation of a medical imaging system. When simulating an x-ray tube, various complex phenomena need to be taken into account, such as the electron multiple scattering, bremsstrahlung interactions, characteristic x-rays emitted from the K-shell and Auger electrons emitted during a photon interaction. Together with the simulation of the target material and the filtration of the x-ray beam through permanent (e.g. a Be window) and added filtration (e.g. Al, Mo, Rh, Ag, etc)., this technique can lead to a good estimation of the emitted x-ray spectrum, a task which is hard to achieve with experimental methods. This review will provide an overview of the basic knowledge necessary to start the simulation of an x-ray tube as well as of how to accelerate the calculations. Emphasis will be given to mammographic x-ray tubes. Breast cancer screening and diagnostic imaging, as all clinical imaging, are increasingly multimodality. A number of new imaging modalities have been developed, including digital breast tomosynthesis and dedicated breast CT. They have shown promise in early studies; however, their technological complexity present obstacle for optimisation. The ultimate technology tests are clinical trials, which are, however, challenging, particularly for breast cancer screening, as large studies are needed due to the small number of detected lesions. Clinical trials are costly, long, and they involve repeated exposure of women to radiation. As an alternative, we have been developing virtual clinical trials, based upon our virtual breast phantoms and simulation of phantom images. This talk will describe the development of anthropomorphic computer breast phantoms, and illustrate their use in the analysis of phantom digital mammography and digital breast tomosynthesis images. Different currently used phantom designs will be compared in terms of their flexibility and realism. Specific phantom requirements related to different imaging modalities will be emphasised. The role of phantoms in tissue-specific analysis of the radiation dose during mammography will be discussed. In addition to the anthropomorphic phantoms for breast imaging, the use of virtual patients in various clinical imaging disciplines will also be illustrated. Learning Objectives:1. To learn about requirements for anthropomorphic phantoms (virtual patients). 2. To understand the value of anthropomorphic phantoms for breast imaging. 3. To compare advantages and disadvantages of several types of anthropomorphic phantoms. 4. To learn how to estimate typical patient doses from simulations with virtual phantoms.colic will be shown and techniques for optimising the imaging of salivary colic given. The use of US, CT, MRI, and both MRI and conventional sialography in the imaging of salivary colic will be discussed. The role of interventional sialography and minimally invasive techniques in benign salivary gland obstruction will be demonstrated. Trigeminal neuralgia is defined as recurrent episodes of lancinating pain most common in the second (V 2 ) or third division (V 3 ) of the trigeminal nerve. The pathogenesis is a neurovascular conflict by an artery or vein associated with focal demyelination of sensory fibers at the glia-Schwann cell junction. Apposition of demyelinated fibers induces abnormal generation and transmission of impulses. MR Imaging is based on high-resolution 3D sequences: CISS/Fiesta/3D T2Space with coronal and sagittal oblique MPR and a 3D TOF intracranial sequence with axial and coronal thin MIP reconstruction to delineate the course of vessels along the trigeminal nerve form the pons, and glia Schwann cell junction to the Gasserian ganglion. The brainstem and brain are assessed by T2, Flair and 3D isotropic Gd-enhanced T1 sequences; the viscerocranium is examined by a noncontrast and coronal T1 Gd fat suppressed sequence. Analysis of images is focussed on recognition of displacement and distortion of the proximal trigeminal nerve by the SCA, rarely by the AICA, BA or petrosal, pontomesencephalic or peduncular vein. Correlation of the circumferential site of distortion at the root entry zone with the somatopic representation of fibres increases the, in general, low specificity of the neurovascular contact. Ruling our compressive tumours, neoplastic infiltration, inflammation or demyelination and delineating a neurovascular conflict stratifies patients for potential microvascular decompression in case of failure of medication. The purpose of this lecture is to provide an overview of the key imaging features of painful swallowing with or without associated mucosal pathology. In the presence of a mucosal lesion, painful swallowing is most often caused by infectious, neoplastic or traumatic lesions of the pharynx itself, whereas in the absence of mucosal alterations, painful swallowing is the result of functional disorders (dysfunction of the cricopharyngeus muscle), infectious, inflammatory or neoplastic diseases affecting adjacent neck spaces (retropharyngeal and paraphyrngeal space), neurologic impairment (glossopharyngeal neuralgia), carotidodynia and Eagle's syndrome. The indications for CT, MRI, US and videofluoroscopy will be reviewed and their respective role in the detection and precise description of the underlying cause. Major emphasis will be put on how to report the findings in a comprehensive way. Learning Objectives:1. To recognise the most common causes of painful swallowing in patients with a normal pharynx at clinical examination. 2. To review the role of different imaging techniques in the diagnosis and treatment of painful swallowing. 3. To review the key imaging techniques in the diagnosis and treatment of painful swallowing. 4. To review the key imaging features of the most common causes of painful swallowing as seen with the respective imaging techniques.The typical HRCT features of interstitial lung disease are ground-glass opacity, consolidation, pulmonary nodules, tree-in but sign, bronchiolar wall thickening, mucoid impaction, air trapping, septal thickening, mosaic perfusion and honey combing. Most frequent diseases in children to be dealt with are bronchiectasis, cystic fibrosis, asthma, constrictive bronchiolitis, bronchiolitis obliterans and extrinsic allergic alveolitis and they will be demonstrated with use of a systematic approach. During the lecture we will present and validate methods to simulate radiographic images with the Monte Carlo software MCNP/MCNPX in a time efficient way. We will start the lecture by introducing three image detector models that can be used in MCNP/MCNPX. The first detector model that will be presented is the standard semideterministic radiography tally, which has been used in previous image simulation studies. Furthermore, we will present two alternative stochastic detector models: a perfect energy integrating detector and a detector based on the energy absorbed in the detector material. The image detector models will be validated by comparing calculated scatter-to-primary ratios (SPRs) with published and experimentally acquired SPR values. Subsequently, we will introduce a method to modify the images, generated with the MCNP/MCNPX image detector models, for the physical characteristics of a computed radiography (CR) imaging systems. The method presented in this lecture takes into account the signal intensity variations due to the heel effect along the anode-cathode axis, the spatial resolution characteristics of the imaging system and the various sources of image noise. To demonstrate the accuracy of our model we will compare the threshold-contrast detectability in simulated and experimentally acquired images of a contrast-detail phantom. Thoracic trauma in children is most commonly seen in a polytrauma context, and is associated with significant morbidity and mortality. Blunt trauma accounts for the majority of cases, often resultant from motor vehicle accident and pedestrian crash. Common thoracic injuries include pulmonary contusion, rib fractures, pneumothorax and haemothorax. Diaphragmatic and mediastinal injuries, such as aortic rupture and tracheobrocheal tear, are rare but potentially life threatening. Different patterns of injury are seen in children due to anatomical and physiological differences, and these should be recognised. Chest radiography is the first and most important imaging modality. MDCT allows accurate diagnosis for most traumatic injuries, and is usually performed for severe chest and/or polytrauma. Adapted paediatric protocols are essential. Foreign body inhalation is a common paediatric domestic accident, with potential serious or even fatal consequences. Clinical history is the key for the diagnosis. With a definite history, bronchoscopy is the modality of choice for both diagnosis and treatment. However, in many cases the aspiration event is not witnessed and the diagnosis is often delayed or overlooked. The majority of aspirated foreign bodies are non-opaque and imaging findings largely result from complete or incomplete airway obstruction. Chest radiography is the first imaging modality. Expiratory films (or lateral decubitus or fluoroscopy) are very useful to demonstrate air-trapping. Chest MDCT offer excellent details of the tracheobronchial tree and pulmonary parenchyma, and is usually reserved for more complex cases and/or long-standing foreign bodies. High-resolution CT of the chest is the imaging technique of choice for the evaluation of most infiltrative diseases of the chest. In children dose-adapted protocols should be used and recommendations for suitable protocols will be given in the course.

The mediastinum is a region of the thorax that separates both lungs and communicates with the neck and the abdomen. These two anatomic features are very important to understand the behaviour of some diseases and their radiological manifestations. Most asymptomatic mediastinal masses are benign, while clinical symptoms might raise the possibility of a malignant lesion. Imaging plays a very important role, especially CT and MRI. In the presence of a mediastinal mass we must ask ourselves two questions: 1. Where is the mass located? The classic divisions of the mediastinum in compartments remains very useful, because it narrows the differential diagnosis. 2. Is the lesion cystic or solid? Pure mediastinal cysts are benign and their characterisation depends on their location. Thymic cyst (anterior mediastinum), bronchogenic and duplication cysts (middle mediastinum) and menyngoceles (posterior mediastinum). Solid lesions may be benign or malignant while some lesions may have a cystic component. Solid lesions of the anterior mediastinum are usually thymomas, germ cell tumours or lymphomas. In the middle mediastinum most masses are of lymphatic origin but we should also include aortic or oesophageal pathology. Intrathoracic thyroid usually follows the trachea and thus is situated in the upper-middle mediastinum although posterior and anterior extensions may occur. In the posterior mediastinum most masses are of neural origin. There are some locations that will typically indicate specific diagnosis or a narrow differential. Such is the case of the cardiophrenic angle masses, juxtadiaphragmatic lesions and thoracic inlet pathology. Colorectal cancer is common. Approximately 280,000 new cases occur each year in the 500 million population of the 27 states which comprise the EU. After lung, it is the second commonest cause of cancer death resulting in approximately 140,000 deaths per annum. These relatively high mortality figures are a reflection of the fact that the disease is often advanced at the time of presentation. Efforts to reduce mortality, therefore centre on early detection as well as accurate staging. The latter is particularly important in rectal cancer-the commonest site for colonic cancer. Detection depends on presentation, which is often protean or non-existent; hence, the introduction of screening programs. Typical diagnostic tools include the barium oenema, optical colonoscopy and CT colonography. The limitations of the barium enema have been exposed by optical colonoscopy and it can no longer be advocated in this role. CT colonography, however, rivals optical colonoscopy in the detection of polyps and tumours, although of course has no therapeutic potential. Major advances in the treatment of rectal cancer include total mesorectal excision (TME) of the rectum as well as neo-adjuvant therapies such as chemo-radiation. Their use depends on highly accurate staging of the primary disease, which can only be achieved by MR examination, although of course CT or PET/CT is required for the assessment of more distant metastatic disease. Finally, once treated, it is essential that these patients are followed-up; usually by a regime of colonoscopy and CT. These issues will be discussed in an interactive lecture. Decreased opacity of the lung may be a bilateral or unilateral process. If unilateral, it may involve an entire lung, a lobe or a segment. Faulty radiological technique must always be excluded. The most common cause of unilateral decreased opacity is a previous mastectomy. Bilateral decreased opacity occurs in COPD and asthma. It is also caused by decreased blood flow in the lung/s. Expiratory films separate the true lung causes from all the others, by demonstrating air trapping. Pulmonary nodules are spherical radiographic opacities (solid and subsolid) that measure up to 30 mm in diameter. Extremely common in clinical practice, pulmonary nodules, especially small ones under 1 cm in diameter, are a challenge to manage. It is important to identify malignant nodules because they are potentially curable. The first step in assessing a pulmonary nodule on a chest radiograph is to determine that it is indeed a lung nodule rather than a pleural or chest wall abnormality. It is essential to review images from previous examinations, because a solid nodule that remains stable for at least 2 years is probably benign. Topics discussed in this talk include the importance of nodule size, growth rate, margin morphology, density (solid, ground-glass and part solid), calcifications or fatty components within the nodules, the significance of cavitations or bubble-like densities, enhancement patterns at dynamic contrast-enhanced CT, and findings on positron emission tomography (PET). The talk also covers the current guidelines for the management of incidentally detected nodules (solid and subsolid). This presentation has the purpose to familiarise radiologists with the spectrum of mesenteric and omental cystic masses, demonstrating the additional correlation with the underlying pathology. Cystic masses of the mesentery or omentum are not common lesions; however, radiologists should be aware of these entities as well as with other cystic lesion of the abdomen. Important tool for the diagnosis is to determine the organ from which the mass originates. Common types of mesenteric and cystic masses include lymphangioma, enteric duplication cyst, enteric cyst, mesothelial cyst and non-pancreatic pseudocyst. Other entities such as cystic mesothelioma, cystic spindle cell tumour and cystic teratoma could be located in the mesentery also. Due to the overlap in the imaging features, not always the final diagnosis could be reached by imaging only and therefore histologic examination is necessary to establish the diagnosis. However, it is important for the radiologist to define the cystic nature of the mass and demonstrate the potential mesenteric or omental origin, targeting to the correct differential diagnosis of the cystic lesion. Cancer cells from intraabdominal neoplasms, carried by peritoneal fluid throughout the abdominal cavity, result in widespread metastases in the form of implants, the socalled peritoneal carcinomatosis. The location of implants development is governed mostly by peritoneal fluid circulation and by specific anatomic pathways formed by peritoneal reflections. The most common sites where the peritoneal fluid may temporarily arrested facilitating implantation of cancer cells include cul-de-sac, distal small bowel mesentery, right paracolic gutter, posterior sub-hepatic space, greater omentum and sub-phrenic spaces. The role of imaging is to disclose the presence and extent of the disease -i.e. fundamental in candidates for cytoreductive surgery -to monitor response to treatment and to reveal recurrences. MDCT with thin collimation and i.v. contrast material supplemented by multiplanar reconstructions is the primary imaging modality for the investigation of peritoneal carcinomatosis. Ascitis, contrast enhanced smooth, nodular, or plaque-like peritoneal thickening, peritoneal nodules, plaques or masses, rounded, ill-defined soft-tissue or cystic mesenteric masses, mesenteric fixation with increased attenuation values and thickening, irregular soft-tissue permeation of omental fat or confluent solid omental masses are the most frequent CT findings of peritoneal carcinomatosis. CT has a sensitivity and specificity between 85 and 95%, depending on the size/location of implants and examination protocol used. MR imaging employing a post-gadolinium-enhanced 3d FLASH sequence with fat saturation may alternatively be used and it is advantageous in cases of diffused layered type of peritoneal/mesenteric involvement. Diffusion MRI may be of value in post-treatment imaging evaluation. Primary solid tumours of the peritoneum and mesentery occur much less frequently than metastatic disease in the same location. However, these rare primary neoplasms (peritoneal mesothelioma, primary peritoneal serous carcinoma, desmoplastic small round cell tumour, mesenchymal tumours, mesenteric fibromatosis or mesenteric desmoid tumour, mesenteric sarcoma, etc.) are often first detected at CT and should be considered in the absence of a known primary organ-based malignancy. CT appearance combined with patient's relevant clinical and demographic data can help narrow the differential diagnosis for a primary peritoneal or mesenteric tumour in many cases; Diffuse sheetlike thickening of the peritoneum and stellate appearance of the mesentery at CT or MRI are suggestive of primary malignant mesothelioma in older men with high level of asbestos exposure. Absence of an ovarian mass is mandatory in suggesting the diagnosis of primary peritoneal serous carcinoma in a post-menopausal woman. Desmoplastic small round cell tumour occurs in young men and often presents with a large primary peritoneal mass with calcification. A solid mesenteric mass at CT or MRI, regardless of its pre-and post-contrast appearance, occurring in a patient with familial Postgraduate.Educational.Programme 

Embolisation of HCC with drug eluting beads K. Malagari; Athens/GR (kmalag@otenet.gr)Drug eluting beads have proved predictable pharmacokinetics and achievement of higher doses of the chemotherapeutic, prolonged contact time with cancer cells.In addition, research data today have shown response, and tolerance benefit of drug eluting beads compared to conventional chemoembolisation for the more advanced subgroup of BCLC -class B patients. For diameters larger than 100 μm DC Bead loaded with doxorubicin have proven to be more effective with respect to local response, recurrence rates and time to progression (TTP) compared to bland embolisation with similar diameters. In this session results of studies on DC Bead loaded with doxorubicin for the treatment of HCC will be discussed, and guidelines for optimal clinical use will be presented. 

Selective internal radiotherapy J.I. Bilbao; Pamplona/ES (jibilbao@unav.es)Selective internal radiotherapy, also called radioembolisation (RE), consists in the delivery of beta-radiation to liver tumours using microspheres loaded with yttrium-90 (Y90) that are injected into the hepatic artery or its branches. Y90 is a pure beta-emitting radioisotope, with a limited tissue penetration (average: 2.5 mm and maximal: 11 mm) and a half life of 64 hours. Y90 can be either incorporated or labelled into glass or resin microspheres (25 µm). Once the particles are infused into the hepatic artery, they travel to the distal tumoural arterioles, from where the beta-emissions from the isotope irradiate the tumour. With traditional external beam radiation, doses are limited to 30-40 Gray (Gy) due to the risk of radiation-induced liver disease that may occur with higher doses. With RE, tumours can receive a higher dose of radiation due to their preferentially arterial vascularisation and a higher tolerance of the non-tumoural liver parenchyma to this form of radiation. RE has shown an encouraging antitumoural activity with a good safety profile in patients with hepatocellular carcinoma, even in the presence of portal vein thrombosis or invasion. Local tumour growth control is achieved in the majority of patients although response rates using volumetric criteria are achieved in only 20-40% of patients. In liver-predominant unresectable metastases, there is promising evidence that RE combined with systemic chemotherapy significantly extends the time to progression of liver metastases and increases objective response rates as well as enabling patients to receive systemic chemotherapy for a longer period of time. Learning Objectives:1. To learn about the technique, legal and safety requirements in the cathlab. 2. To understand the diagnostic and interventional procedures before radioembolisation.

Combined therapies before and after ablation R. Lencioni; Pisa/IT (lencioni@med.unipi.it) Image-guided RFA is currently established as the standard of care for patients with early-stage HCC when transplantation or resection is precluded. However, histologic data from liver specimens of patients who underwent RFA as bridge treatment for transplantation showed that the rate of complete tumour eradication is highly dependent on the size and the presence of large abutting vessels. Combined percutaneous-transcatheter approaches that aim at increasing the ablation volume by minimising heat loss due to perfusion-mediated tissue cooling have been developed, using either a balloon catheter occlusion of the tumour arterial supply at the time of the RFA or by performing a prior TACE. Experimental studies in animal tumour models have shown that lowering the temperature threshold at which cell death occurs by combining sublethal heating with cell exposure to Trans-arterial chemoembolisation takes advantage of the largely portal vascularisation of liver tissue, while metastatic tissue is supplied almost exclusively by hepatic arteries. The benefit of intra-arterial application of chemotherapeutic drugs is proportional to the first pass extraction of the drug by the target tissue and inversely proportional to the body clearance of the drug. These figures vary greatly with different chemical properties of the drug. Intratumoural drug concentration after transarterial application (compared to intravenous application) is approximately 20x for THP-adriamycine, 5x -10x for 5 FU, 6x -8x for mitomycine, 4x for cisplatin or oxaliplatin, and 2x for doxorubicin. Several trials support superiority of intraarterial 5 FU over i.v. application in response rate, and partly with a moderate survival benefit. However, with the advent of novel chemotherapeutics (mainly oxalyplatin, irinotecan), response rates of i.v. chemotherapy approached the results after i.a. 5 FU. More recently, i.a. oxaliplatin has shown a 45% response rate in a multicenter trial on non-responders to i.v. oxalyplatin. Also, combinations of i.a. oxalyplatin and i.v. 5 FU and cetuximab have achieved promising response rates as first line therapy. Even though intraarterial chemoembolisation alone can achieve promising response rates, the actual survival benefits are limited to date. Also, the beneficial effect of additional embolization (over conventional arterial injection) remains largely unproven for a large number of different embolisation agents in hepatic metastases. In an attempt to further increase tumour uptake, chemotherapeutic agents (anthracyclines and irinotecan) have been electrostatically coupled to microspheres. Irinotecan-eluting microspheres have been untilized in the treatment of CRC metastases in smaller case series. Due to the high parenchymal drug uptake, appropriate medications to mitigate postembolization side effects need to be emphasised. While the initial response rates were over 60% (according to EASL), tumour progression was observed within 6 months in the majority of responders, suggesting potential stimulation of angiogenesis at the tumour boarders. Potentially, adjuvant antiangiogenic treatment can provide an overadditive effect in these patients.Primary bone tumours require both local staging and the identification of distant metastases to guide management. MR imaging is the modality of choice to determine local disease extent and allows excellent depiction of intra-and extraosseous disease. Chest CT enables pulmonary metastases to be identified and bone scintigraphy allows evaluation of the presence of bone metastases. The roles of whole body MRI and PET/CT in the staging of bone tumours will also be discussed. Whilst imaging may allow a narrow differential diagnosis to be reached, histological confirmation of the nature of the lesion is required pre-operatively to plan appropriate treatment. Image-guided biopsy may be performed using fluoroscopy, CT, MRI and occasionally ultrasound guidance. The relative values of each of these techniques will be covered. Percutaneous therapies are increasingly being utilised in the treatment of a number of primary bone tumours. Radiofrequency ablation is the method of choice for osteoid osteoma and is now used in the treatment of chondroblastoma. Alternatives include microwave therapy, cryotherapy and sclerotherapy. These percutaneous techniques may also be used for local disease control where disease recurrence is encountered. Magnetic resonance imaging (MRI) has evolved to become the most important diagnostic method for local staging of primary bone tumours and for detecting postoperative tumour relapse. It allows accurate preoperative staging of local tumour extent and helps to obtain adequate safety margins. MRI is a noninvasive technique that can be used to obtain information regarding tumour vascularisation, metabolism, and pathophysiology, and allows early assessment of therapeutic effects of cancer drugs. One approach is dynamic contrast-enhanced (DCE) MRI, which measures tumour vascular characteristics after administration of a contrast medium. MRI enhanced with small-molecular-weight contrast agents is extensively used in the clinic to differentiate benign from malignant lesions, as well as to monitor tumour microvascular characteristics during treatment. Diffusion-weighted MRI (DWI) is a more recent technique and it allows noninvasive characterisation of biologic tissues based on the random microscopic motion of water proton measurement. Several studies have shown that DWI allows early detection of tumour response to chemotherapy. The use of water diffusion is a surrogate marker used to distinguish highly cellular regions of tumour from acellular and necrotic regions. Whole body diffusion-weighted sequence (WB DWI) is a new promising technique feasible to evaluate multifocal disease. DWI has revealed great potential in the evaluation of patients with cancer or benign disease, as it supplies both quantitative and qualitative information of the whole body. This presentation will focus on the potential role of DWI in combination of DCE MRI in bone tumours as well as on the possibilities of WB DWI. In this integrated refresher course, the impact of basic and advanced imaging on the entire process, from diagnosis to treatment of bone tumours, will be addressed. Diagnosis is based on understanding the imaging features from a histopathologic chemotherapeutic agents is an attractive alternate strategy to increase tumour necrosis. The efficacy of a combination therapy, including RFA plus the intraarterial administration of drug-eluting beads has been recently demonstrated, while the use of intravenously administered, thermally sensitive drug carriers is currently being explored. Despite the advances in local treatment, the long-term outcome of treated patients remains unsatisfactory because new tumours emerge in about 80% of the cases within 5 years. Clinical trials evaluating the usefulness of adjuvant molecular targeted therapies with anti-angiogenic and anti-proliferative activity in preventing early recurrence after successful ablation are ongoing. In this integrated refresher course, the impact of basic and advanced imaging on the entire process from diagnosis to treatment of bone tumours will be addressed. Diagnosis is based on understanding the imaging features from a histopathologic perspective. Staging, biopsy and image-guided treatment require an integration of imaging findings with basic knowledge of surgical-oncological principles, as well as skills. Can technically driven development of advanced MR techniques change how we diagnose, monitor therapy and determine prognosis. Techniques and procedures that improve patient outcome in a cost-effective way will be identified based on 3 presentations and a panel discussion.

A. Diagnosis: from radiographs to MRI K. Wörtler; Munich/DE (woertler@roe.med.tum.de)The diagnosis of a bone tumour is based on clinical findings, the age of the patient, the location of the lesion, its radiologic appearance, and, if imaging does not allow for a specific diagnosis, its histopathologic features. Radiography remains the initial imaging modality for evaluation of the localisation of the lesion with respect to the longitudinal and axial planes of the involved bone, for the depiction of matrix mineralisations, and for estimation of biologic activity by analysing the patterns of bone destruction and periosteal response. CT can add "radiographic" information particularly in regions of complex skeletal anatomy such as the spine, pelvis and shoulder girdle. MR imaging has classically been used to determine the local extent of a bone tumour (local staging). In addition to radiography and/or CT, it can at times also be valuable in establishing the differential diagnosis, especially in cystic bone lesions and cartilaginous tumours. Whole-body applications have recently gained importance in demonstrating the presence and extent of bone (marrow) involvement in benign and malignant systemic/polyostotic tumourous diseases. This course reviews the basic principles of diagnosing bone tumours in a multimodality approach (with an emphasis on conventional radiography). The different steps of morphologic analysis as well as the advantages and disadvantages of the individual imaging techniques are illustrated on the basis of pathologically confirmed cases.

S130 A B C D E F G H review: (1) the biological rationale for using perfusion imaging in brain tumours, (2) methods available for the imaging of microvascular structure and function in brain tumours. We will discuss the relevant advantages and disadvantages of T1 versus T2 weighted acquisition strategies. Early diagnosis and treatment of acute stroke is crucial for a favourable prognosis. While non-contrast MRI is much more sensitive to ischaemia in comparison with non-contrast CT, perfusion studies make both techniques comparable. Ultrafast CT scanners cover most of the brain with perfusion imaging; the scanning is faster and quality imaging results depend less on patient co-operation than in MRI. However, MRI enables diffusion imaging adding more specific information to the diagnostic process. Because of the short time window to eventual vascular intervention, in many institutions CT is the technique of choice. Besides depiction of hyperacute stroke by means of diffusion weighted imaging, MRI has the advantage of performing a contrast agent-free perfusion study using a promising new technique called arterial spin labelling (ASL). Thus, an MRI perfusion study can be performed even in patients with impaired renal functions where iodine and gadolinium-based contrast agents may be dangerous. Perfusion imaging is an emerging non-invasive tool that enables evaluation of brain function via assessment of various hemodynamic measurements such as cerebral blood volume, cerebral blood flow, and mean transit time. These techniques have become important clinical tools in the diagnosis and treatment of patients with CNS disorders via evaluation of brain tissue during cerebrovascular diseases, noninvasive histopathologic assessment of tumours, evaluation of neurodegenerative conditions and assessment of the effects of drugs. Perfusion imaging is helpful to analyse and assist in judging the biological behaviour (especially haemodynamic features) of central nervous system diseases. Qualitative and quantitative information can be obtained to evaluate pathoanatomical structures and pathophysiological changes of the lesions. Cerebral blood flow (CBF), cerebral blood volume (CBV), mean transient time (MTT), permeability surface (PS), regional blood volume, microvascular permeability measurements and more information can be obtained for the diagnosis and differential diagnosis of the diseases. Advantages and disadvantages of the CT perfusion imaging (CTP) and magnetic resonance perfusion imaging (MRP) in the different diseases will be evaluated in detail. Hints and tips for the better applications and postprocessing will also be discussed. 

Techniques for CT and MR, post-processing, radiation R.A. Meuli; Lausanne/CH (reto.meuli@chuv.ch)Brain perfusion can be assessed by CT and MR. For CT, two major techniques are used. First, Xenon CT is an equilibrium technique based on a freely diffusible tracer. First pass of iodinated contrast injected intravenously is a second method, more widely available. Both methods are proven to be robust and quantitative, thanks to the linear relationship between contrast concentration and x-ray attenuation. For the CT methods, concern regarding x-ray doses delivered to the patients need to be addressed. MR is also able to assess brain perfusion using the first pass of gadolinium based contrast agent injected intravenously. This method has to be considered as a semi-quantitative because of the non linear relationship between contrast concentration and MR signal changes. Arterial spin labeling is another MR method assessing brain perfusion without injection of contrast. In such case, the blood flow in the carotids is magnetically labelled by an external radiofrequency pulse and observed during its first pass through the brain. Each of this various CT and MR techniques have advantages and limits that will be illustrated and summarised. Learning Objectives: 1. To understand and compare the different techniques for brain perfusion imaging. 2. To learn about the methods of acquisition and post-processing of brain perfusion by first pass of contrast agent for CT and MR. 3. To learn about non contrast MR methods (arterial spin labelling).

Brain tumours A. Jackson; Manchester/UK (Alan.Jackson@manchester.ac.uk) This presentation will discuss the current 'state of the art' in the use of perfusion imaging techniques in neuro-oncology. The term "perfusion imaging" is commonly used but is in fact a misnomer since perfusion and blood flow are not the only imaging biomarkers of microvascular structure and function in common use. Indeed, in oncological applications measurements of proportional blood volume, endothelial capillary permeability or vessel size can be of equal or greater importance. We will Reproduction is by spore formation which is prolific and therefore human respiratory tract exposure is almost constant. The spectrum of aspergillus infection includes aspergilloma (mycetoma), chronic pulmonary aspergillosis, chronic necrotising pulmonary aspergillosis (subacute invasive, chronic airway invasive), invasive pulmonary aspergillosis (angioinvasive, non-angioinvasive including acute tracheobronchitis, exudative bronchiolitis and bronchopneumonia), and allergic disease (allergic bronchopulmonary aspergillosis (ABPA) and bronchocentric granulomatosis). Immunocompromised individuals are particularly susceptible to invasive aspergillosis. The risk factors for invasive aspergillosis include: profound neutropenia, haematopoietic stem cell transplant recipients, solid organ transplantation, potent immunosupressive therapy, prolonged corticosteroid use and AIDS. Invasive aspergillosis can be further subdivided into angioinvasive and non-angioinvasive forms. The imaging features of angioinvasive aspergillosis are characterised on CT by nodules with a 'halo' of surrounding ground glass opacity due to alveolar haemorrhage. In the context of neutrophil recovery, nodules may demonstrate cavitation. Airway invasive aspergillosis may manifest as areas of consolidation (bronchopneumonia), nodular 'tree-in-bud' densities on CT (exudative bronchiolitis), or an acute tracheobronchitis with large airway thickening. Falling rates are stabilising in Europe. Tuberculosis is developing new faces due to changes in host cellular immunity, such as HIV infection, immunosuppressive therapy, malignancy and due to multi-drug resistance. Chest radiography plays a major role in screening, diagnosis, and response to treatment of patients with TB; however, radiographs may be normal or show only mild or nonspecific findings in active disease. CT and high-resolution CT (HRCT) are more sensitive than chest radiography in the detection and characterisation of parenchymal disease, small foci of cavitation, mediastinal lymphadenopathy, and pleural complications. Based on these findings, HRCT is useful in determining disease activity and plays also an important role in the management of TB. Radiological manifestations of primary tuberculosis are lymph node enlargement, airspace consolidation and pleural effusion. The most common findings of post-primary tuberculosis are centrilobular nodules, branching linear and nodular opacities, patchy or lobular areas of consolidation, and cavitation. Miliary tuberculosis results from acute haematogenous dissemination of TB bacilli in lungs and other organs and CT-findings consist of innumerable small nodules randomly distributed throughout both lungs. Airway tuberculosis is characterised by circumferential wall thickening and luminal narrowing, with involvement of a long segment of the bronchi.sensitive diagnostic tool. Radiological semiotics are always useful and often very specific in addressing the diagnosis: some fundamental concepts include the peculiar pattern of vasogenic oedema, which, in opposition to what happens in the brain, tends to involve the central grey more than the peripheral white matter. Distribution pattern of the lesion can also often address to aetiological diagnosis. In fact, lesions selectively involving posterior or lateral columns, asymmetrically, and sparing the central grey matter, are more typical expression of demyelinatinginflammatory diseases (multiple sclerosis, ADEM, Devic's disease, LES, Behcet's disease), while selective and symmetrical involvement of both posterior columns, extended for more than 2 myelomers, and possibly associated with involvement of lateral columns, is typical expression of combined sclerosis (B12 vitamin deficit). Ischaemic lesions are also usually symmetrical, but they involve both grey and white matter, extending to the anterior two-third of the cord, or, sometimes, remain limited to the central grey matter. On the other hand, selective involvement of the anterior horns is typical of poliomyelitis. Early stage head and neck cancer can be cured by surgery or radiotherapy. The choice depends on the functional and cosmetic result to be expected, tumour histology, patient's condition and preference, and institutional policy. In advanced lesions, nowadays concomitant chemoradiotherapy is offered, with surgery reserved for salvage. A relatively high locoregional control rate can be obtained, at the expense of acute and late toxic side effects, and a higher incidence of treatment complications. On post-therapeutic imaging studies, treatment-induced tissue changes are often visible; these changes should not be misinterpreted as evidence of persistent or recurrent tumour, or treatment complication. After radiotherapy, the visible changes depend on the radiation dose and rate, the irradiated tissue volume, and the time elapsed since the end of treatment. Basically, thickening of the laryngeal and pharyngeal walls, increased attenuation of fat planes, postirradiation sialadenitis, lymphatic tissue atrophy, and retropharyngeal oedema will be seen. These irradiation-induced tissue changes usually appear symmetrical. The acute effects of radiotherapy occur during or immediately after treatment, and usually settle spontaneously. Complications of radiotherapy are usually seen months to years after the end of treatment. There is no clear consensus regarding optimal time points for surveillance, but clinical assessments are more frequent in year 1 and are performed over at least 2-3 years, during which time most locoregional failures and second primary tumours are detected. Ideally for imaging surveillance at least one post-treatment baseline head and neck scan (MRI/CT) should be performed at 3-6 months, and often closer surveillance is desirable. Candidates for salvage surgery after (chemo) radiotherapy undergo a post-treatment scan at 6-8 weeks, followed by regular scans (4-6 months in year 1; 6-12 months thereafter, the exact time period being tailored to the patient The most recent advances of radiotherapy techniques are characterised by the increased precision with which the radiation energy is released to the target, the reduced collateral damage to adjacent non-neoplastic tissues, and the synergic Viral agents are part of the spectrum of organisms which cause community acquired pneumonias. Furthermore, they are thought to function as a trigger for bacterial infections in the hospital or health care setting. In addition, viruses play a significant role as causative agents for infections in the immunocompromized host. Within the last years, outbreaks of viral infections have challenged regional, national and even global health care systems, have effected thousands of individuals and have resulted in significant morbidity and mortality. Most of the involved viral agents represented emerging organisms with an unpredictable impact on individual and society health. The radiologic community has learned several lessons from the documented outbreaks, and radiologists around the world have contributed to the early diagnosis of the disease, the monitoring of its course, and the documentation of complications as well as of response to therapy. Thus, imaging plays an important role in the diagnosis and management of these patients. In this course, epidemiologic aspects, patho-physiology and clinical features of emerging viral infections will be presented. In addition, their radiologic features and the role of radiology in diagnosis and management will be discussed. Attendees will learn how to understand, recognize, report and follow patients with emerging viral infections. Major changes in the treatment of head and neck neoplasms encompass the advances of endoscopic-based surgical techniques, mainly for nasosinusal and laryngeal tumours, and the application of sophisticated radiation therapy techniques, combined with chemotherapy. As most tumours arise from the mucosa of the upper aero-digestive tract, clinical surveillance is necessary to detect superficial recurrences, while morphological and 'functional' imaging techniques are indispensable to detect subclinical extra-mucosal and nodal recurrences. How can imaging techniques discriminate recurrence, inflammation, necrosis or scar? Key points include the knowledge of the normal appearance of tissues (morphology and signals) on CT, MRI, and PET-CT after surgery and chemo-radiotherapy. Specifically, when non-surgical treatment has been used, that means to become familiar with the expected changes both of tumour and adjacent tissues. Morphology-based imaging techniques are often inadequate to discriminate small recurrences from vascularised scar tissue (enhancing). CT or MRI do require to be integrated by information provided by functional-based imaging techniques, FDG-PET-CT being the most established. Recently, a great interest among radiologists is focused on the application of DCE-CT or DCE-MRI and DWI-MRI in the follow-up of head and neck neoplasms. In fact, several studies have credited these techniques for providing functional information about tissues (perfusion, water exchange) that help to discriminate scar from recurrences. Obviously, the horizon pursued is to combine morphology and functional data in a single examination. Though clearly promising, these new techniques share significant limitations, like the reproducibility of CT and MR-based functional results, their introduction and feasibility in the day practice. Today, CT angiography (CTA) is considered as a safe, non-invasive and wellestablished procedure for vascular imaging. Modern multi-slice CT technology allows for coverage of larger vascular territories -even the whole body -in just several seconds. Further technical improvements such as wide detectors of up to 16 cm width or moving table techniques are making new applications possible, such as perfusion imaging, or time-resolved CT angiography. Especially with the moving table technique (the so-called "shuttle-mode"), vascular territories of up to 50 cm can be covered in a dynamic fashion, which can be helpful in the diagnosis of aortic dissections or peripheral vascular occlusive disease. On the other side, radiation exposure has to be maintained within a reasonable range applying these repeated acquisition modes. Another interesting field opening new options in CTA is dual energy CT (DECT). A number of technical setups may allow for spectral CT imaging, such as systems with two tubes (dual source CT), CT systems with switching kV modes or with special detectors. In vascular applications, DECT is especially helpful for automated bone removal, plaque removal, and potentially for "perfusion" imaging (iodine mapping). In this course, the basics of modern CT angiography will be highlighted, with a special focus on new applications such as time-resolved CTA and dual energy CTA. Angio-3D with digital flat-panel detector has recently been adapted for use with C-arm systems and provides a higher detector quantum efficiency (DQE) than conventional detectors based on II camera. This configuration represents the next generation of imaging technology available in the interventional radiology suite and is predicted to be the platform for many of the three-dimensional (3D) roadmapping and navigational tools that will emerge in parallel with its integration. It provides projection radiography, fluoroscopy, digital subtraction angiography, and volumetric computed tomography (CT) capabilities with the ability for immediate multiplanar post-treatment assessment in a single patient setup, within the interventional suite. Such capabilities allow the interventionalist to perform intraprocedural volumetric imaging without the need for patient transportation. The clinical benefits of 2D angiography with these new systems have been assessed in the fields of cardiology and interventional radiology. These key features alone may translate to a reduction in the use of iodinated contrast media, a decrease in the radiation dose to the patient and operator, and an increase in the safety and performance of interventional procedures. Proper use of this new technology requires an understanding of both its capabilities and limitations. This article provides an overview of the potential of this new technology. Learning Objectives: 1. To learn the basic principles of flat panel CT. 2. To review imaging protocols, results and radiation exposure aspects. 3. To become familiar with the most common applications.effect of chemo-radiotherapy. As the treatment planning becomes progressively 'tailored', strong predictive factors for the individual tumour arising in a specific patient have to be identified. These factors would ideally provide a quantitative assessment of the risks of both relapsing (in the primary, nodal or distant sites) and developing treatment-related (early or late) complications. Predictors are related to tumour's characteristics (biology, metabolism, site, volume and spread) and to patient's overall clinical conditions. Imaging-based predictive factors have been founded upon morphological findings (2D, volume) until the development of new techniques, which analyse 'functional' parameters like FDG-PET-CT, the most established, and perfusion-CT or DWI-MRI. Evidence of level A has been provided on the impact of negative predictive value of FDG-PET-CT in ruling out residual disease, whilst there is no clear data regarding the role of pre-treatment intensity of glucose metabolism (SUV) in predicting the outcome after radiotherapy. This limitation can be addressed to the enrolment of tumours arising in various sites in the head and neck. A major disadvantage common not only in PET studies but also in most DCE and DWI-MRI studies. Perfusion-CT and DWI-MR are promising techniques, as they provide information about neo-angiogenesis and water-flow in submicroscopic tissue compartments. However, these techniques still require randomised trials and confirmation studies about the reproducibility of their interesting results. In the follow-up after minimal invasive surgical techniques or chemo-radiation, a major limitation of standard morphological imaging is the differentiation of the highly vascularised scar tissue (enhancing, with mass effect) from persistent or recurrent neoplasm. Is it time for integrating standard imaging with the functional information provided by DWI and/or CT or MR perfusion techniques? Which evidence level are we at presently? Is it now feasible in daily practice? Three-Tesla MRI scanners offer an increased signal and contrast for MR-angiography (MRA) compared to 1.5-Tesla machines. MRA can be performed within a shorter time enabling the acquisition of temporally resolved three-dimensional datasets with high spatial resolution. Due to high signal and contrast the dose of gadolinium may be reduced. Furthermore, novel imaging protocols for MRA at 3.0-Tesla with intravasal contrast agents and prolonged enhancement during high-spatial-resolution steady-state enable new possibilities for angiography of the upper and lower extremities including veins and vessels below the knee, spinal arteries, vascular malformations, and double-gated angiography of coronary arteries and bypass vessels to compensate for the complex cardiac motion pattern. A 3.0-Tesla MRI system equipped with a matrix coil system allows for whole body MRA with continuous table movement, which is an applicable technique for imaging peripheral vessels without the need for planning different steps and field of view positioning, thereby considerably reducing the examination time. Phase contrast magnetic resonance angiography may develop into an important, noninvasive method for obtaining quantitative information on blood flow. In addition, non-enhanced three-dimensional MR angiography using turbo spin echo (TSE) imaging with non-selective refocusing pulses may be a promising imaging technique for vascular imaging in patients with renal insufficiency. The advent of minimally invasive surgery has made even more important the place of preoperative imaging assessment of patients selected for this type of surgery. In fact, the loss of tactile feed-back and the bi-dimensional intraoperative vision have limited the capability of surgeons to assess extent and anatomic relationship of a given disease, particularly cancer. Preoperative planning can be further enhanced by the use of 3D models of the target anatomy, derived from CT scan dataset. In addition, dedicated technology can be implemented to introduce mixed reality environments in the operative room. Using 3D helmets with built-in microcameras, the surgeons' view of the operative field can be fused with the preoperative 3D anatomy of the patient. Localiser should be used, either infrared based or electromagnetic. The last step would be intraoperative navigation. This offers special problems to be addressed, due to organ shifting and soft tissue in the setting of abdominal surgery. The appropriate use of information and communication technology (ICT) and associated systems is considered by many experts as a significant contribution to improve workflow and quality of care in clinical settings. A conceptual design and prototypical implementation of such an infrastructure, i.e. a therapy Imaging and model management system (TIMMS) will be introduced as a solution to a patientspecific medicine. A TIMMS is an information technology concept and framework for the collection, organisation, and utilisation of medical information from sources such as the electronic medical record, PACS, etc. TIMMS was originally designed as a surgical assist system, but has many general medical uses as well, including all forms of model-guided medicine and may therefore be generalised to a medical information and model management system. The architectural framework and a number of individual ICT components of a TIMMS have been realised. These include standardised interfaces for communication of patient-specific and workflow models, thereby creating a unified environment for the input and output of data, including the representation and display of information and images, as well as the electromechanical control of interventional and navigational devices. In conclusion, the patient-specific model (PSM) is the central construct for a patient within a personalised medicine environment in order to provide a clinician with a real-time representation of critical information about the patient. The required information concerning the patient for model-guided therapy is extracted by TIMMS agents and assembled within the framework of an active PSM and workflow management system. The introduction of picture archiving and communication systems (PACS), through a much more effective image sharing, has dramatically changed the role of radiology both within the hospital and on a geographic perspective. Historically, the latter has become apparent first with the early implementation of teleradiology applications. Physicians and the general public have understood that digital images can be read, processed, and stored independently on the site of production. Therefore, teleconsultation and telereporting activities have been carried out among medical users, and generic users have learnt to include radiological images in their own on-line personal health records. Only later the full potentialities of multidisciplinary image sharing within the hospital have been discovered, and now it is increasingly common to see advanced integration between radiologists and surgeons for planning and guiding surgical interventions. During this session, the lecturers -exceptionally expert in their respective fields -will give insights into image sharing: from the geographical applications (teleradiology) to the hospital-based applications, with specific reference to the support to surgeons (intraoperative guidance and model-guided surgery). Medical imaging is part of a changing medical environment, a changing patient environment and consequently a new medical world. In the recent decennium one of the most important changes in radiology is the conversion from analogue to digital. In no time medical images have become interchangeable through the digital highway and could be post-processed in a different location. Teleradiology has become a reality since then. We have seen the maturation of commercial international teleradiology companies offering a wide portfolio of services. Another aspect is the availability of image data for all medical specialties beyond radiology and beyond the regular medical disciplines. An increasing number of surgical or oncological specialties and even pharmaceutical companies increasingly use image data to prepare a strategy for operative procedures, to choose the right therapy, to decide which prosthesis to the best to use, for follow-up or for post-processing purposes. They are supported by many new techniques and software. An increasing number of medical computer applications such as complex navigation and visualisation tools based upon digital images is already in clinical use or under development. Another trend is the increasing interest in E-health and telemedicine in Europe, also among European policy makers. Now we see mobile health that brings care directly into the patient environment. The purpose of this presentation is to give a comprehensive overview of and insight into these new developments and to create awareness among radiologists of the increasing importance of integration of medical imaging in a multidisciplinary environment.