key: cord-0006979-6g8p8hzw authors: nan title: Postgraduate Educational Programme date: 2009-03-14 journal: Eur Radiol DOI: 10.1007/s00330-009-1374-x sha: c5711a8c155950d4b102cba6255f36c52be944a1 doc_id: 6979 cord_uid: 6g8p8hzw nan Radiologists need to have a basic knowledge of the radiological anatomy of the organs imaged within the thorax, among which the pulmonary circulation plays an important role as it can provide not only morphologic, but also functional information useful for the management of numerous thoracic disorders. This new trends in evaluating the pulmonary circulation is driven by the technological developments of multidetector-row CT (MDCT) technology which offers the possibility to search for morphological abnormalities at the level of central and peripheral pulmonary vessels with single-source MDCT but also to integrate the evaluation of the capillary level by means of dual-energy CT. Detection of morphological abnormalities at the level of central and peripheral pulmonary vessels in congenital and acquired chest disorders requires the knowledge of the prevailing arterial and venous patterns whose analysis can now benefit from the development of computer-aided-diagnosis tools. The analysis of the most distal portion of the pulmonary circulation, sometime referred to as "pulmonary perfusion", is now available in routine clinical practice and requires, for proper interpretation of images, a basic knowledge of the anatomical relationships between the pulmonary and systemic circulations of the chest. CT can also participate in the noninvasive approach of pulmonary hypertension by means of the analysis of the degree of distensibility of central pulmonary arteries. All these pieces of information are accessible to radiologists providing the selection of the adequate scanning protocol. The purpose of this lecture is to review these anatomical and physiological perspectives offered by MDCT in 2009. Learning Objectives: 1. To understand the role of different imaging modalities for assessing the pulmonary circulation. 2. To learn strategies for achieving a reliable contrast enhancement of the pulmonary vessels. 3. To review the normal anatomy and normal variants of the pulmonary circulation. A-003 09:30 C. Cardiac chambers and coronary arteries F. Cademartiri, A. Palumbo, E. Maffei; Parma/ IT (filippocademartiri@hotmail.com) CT and MR are currently the most important emerging non invasive modalities for the assessment of the heart and coronary arteries. The Radiologist is not always confident with the requirements of cardiac and coronary artery anatomy. A good knowledge of normal and abnormal cardiac and coronary anatomy becomes very important when using very powerful imaging modalities such as CT and MRI. The intrinsic nature of heart with its small structures and constantly moving attitude becomes a real challenge both from the technical and interpretational standpoint. Cardiac anatomy is very important since normal, variants, and anomalies are extremely frequent in different configurations. Many cardiac conditions are associated with typical anatomical landmarks. These features should be part of the basic knowledge of cardiac radiologists. Spinal and spinal cord malformations are collectively named spinal dysraphisms. They arise from defects occurring in the early embryological stages of gastrulation (weeks 2-3), primary neurulation (weeks 3-4) and secondary neurulation (weeks 5-6). Spinal dysraphisms are categorized into open spinal dysraphisms, in which there is exposure of the abnormal nervous tissues through a skin defect, and closed spinal dysraphisms, in which there is a continuous skin coverage of the underlying malformation. Open spinal dysraphisms basically include myelomeningocele and other rare abnormalities such as myelocele and hemimyelo (meningo)cele. Closed spinal dysraphisms are further categorized based on the association with low-back subcutaneous masses. Closed spinal dysraphisms with mass are represented by lipomyelocele, lipomyelomeningocele, meningocele and myelocystocele. Closed spinal dysraphisms without mass comprise simple dysraphic states (tight filum terminale, filar and intradural lipomas, persistent terminal ventricle and dermal sinuses) and complex dysraphic states. The latter category further comprises defects of the midline notochordal integration (basically represented by diastematomyelia) and defects of the segmental notochordal formation (represented by caudal agenesis and spinal segmental dysgenesis). Magnetic resonance imaging is the preferred modality for imaging these complex abnormalities. The use of the aforementioned classification scheme is greatly helpful in making the diagnosis. The incidence of spinal tumors is more or less stable for primary spinal tumors (2.5/100,000/year), but increases continuously for secondary spinal tumors due to the relentless increase of cancer and improved survival rates of patients with malignant disease. Spinal tumors are traditionally classified by location into: intramedullary, intradural extramedullary and extradural tumors. The assignment of a lesion to one of these three locations is of major diagnostic importance as most types of spinal tumors or tumor-like lesions and cysts show a clear preference for one of the three locations. Besides the location of the lesion, key imaging findings, clinical presentation and knowledge of patterns of tumor spread provide valuable information to narrow the spectrum of differential diagnoses. Although routine MRI is the modality of choice, CT, Nuclear Medicine methods and advanced MR techniques such as DWI may be advantageous in diagnostics as well as in staging or post-treatment surveillance. In the past few years, there has been a marked increase in the use of imaging in monitoring patients undergoing treatment for cancer, both in the clinical setting and for clinical trials. There has been dramatic progress in understanding the information that can now be provided by imaging in the assessment of response, in the early prediction of the efficacy of treatment and in the detection of progressive disease. It has become vital for radiologists involved in the care of patients with cancer to be familiar with currently accepted criteria of tumor response and also to appreciate their limitations. It is essential that radiologists also appreciate the impact of these imaging measurements on the patient's care. Several modalities are now used in making this assessment, most widely CT, MRI and PET-CT. This session will deal not only with the fundamental issues involved in this process but also look at the additional information that can be extracted from the data on these imaging modalities, whether it be anatomical or functional. It is hoped that the session will stimulate a better understanding of this crucial role in the care of patients with cancer. A-008 08:35 Contemporary response assessment criteria L. Schwartz; New York, NY/US (schwartl@mskcc.org) Imaging has been used for decades to gauge the effectiveness of various oncologic interventions. One major benefit of imaging biomarkers in Oncology is that the findings may be evaluated and quantified for changes over time. Newer, functional imaging biomarkers are also playing a role as biomarkers for response assessment, such as FDG-PET and DCE-MRI scans. The complexity in imaging biomarkers is increasing not only with the number of available imaging and post-processing techniques, but perhaps even more importantly, with the number and diversity of relevant therapeutic options. Increasingly, it is becoming clear that a single imaging biomarker alone can be misleading, but is more robust when combined with other imaging or non-imaging biomarkers. Revisions of RECIST, tailored to specific cancers such as lymphoma or prostatic cancer, are already appearing in the literature With the increasing availability of combined CT/PET scanners it is feasible to combine volumetric information with metabolic data. Ultimately, the goal of imaging is to serve as a successful surrogate endpoint for a patient's response to therapy. Correlating and validating biomarkers is quite controversial, greatly debated, and undergoing intense research. Learning Objectives: 1. To understand the goals and modalities used to assess response to treatment in oncology. 2. To appreciate the current international standardised criteria for response assessment. 3 . To learn about revisions and updates to response assessment criteria. The use of PET/CT in the monitoring of tumor response W. Weber; Freiburg/DE PET imaging with the glucose analog fluorodeoxyglucose (FDG-PET) has been evaluated in numerous studies to monitor tumor response in patients undergoing chemo-and chemoradiotherapy. The clinical value of FDG-PET in the differentiation of residual or recurrent viable tumor and therapy-induced fibrosis or scar tissue has been documented for malignant lymphomas and various solid tumors. Furthermore, there are now several reports suggesting that quantitative assessment of therapyinduced changes in tumor FDG-uptake may allow prediction of tumor response and patient outcome very early in the course of therapy. In non-responding patients, treatment may be adjusted according to the individual chemo-and radiosensitivity of the tumor tissue. This indicates that FDG-PET has an enormous potential to "personalize" treatment and to reduce the side effects and costs of ineffective therapy. The use of PET/CT instead of stand-alone PET for treatment monitoring poses some methodological challenges for the quantitative analysis of PET scans and provides the opportunity to integrate morphological and functional information. This may allow definition of new parameters for assessment of tumor response and will facilitate the use of PET in clinical practice. In addition to FDG, several other imaging probes to monitor tumor response to therapy are in clinical studies. These include among others [18 F]fluorothymidine (FLT) for imaging of cellular proliferation, [18 F]fluoromisonidazole for assessment of tumor hypoxia and [18 F] Annexin V for apoptosis 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 identify basic anatomic and pathophysiologic principles as they apply to cancer treatment response assessment/prediction. 2. To describe the influence on therapy protocols. 3 . To identify which patients require PET/CT. A. Optimising CT C.C.A. Nolte-Ernsting; Mülheim a. d. Ruhr/DE (claus.nolte-ernsting@evkmh.de) CT urography (CTU) has undergone a very successful development during the past decade, increasingly obviating invasive procedures in the diagnostic management of urinary tract disorders. To date, a good uroradiologist is a radiologist who can produce a good CT urogram! Indeed, CTU has become a sophisticated imaging technique, but without having standardized guidelines. To achieve complete and uniform contrast enhancement of the urinary tract, Radiologists have the choice of numerous different measures and examination protocols: For example, the distention of the collecting system and ureters can be optimized with intravenous low-dose furosemide, whereas oral hydration or saline infusion alone has proved to be less efficient. Ureteral compression is actually out-dated. For optimal timing of the contrast enhancement during the excretory phase, the individual delay time in each patient may be determined exactly using single-slice test-images obtained at different intervals after injection of the contrast agent bolus. Besides the single bolus injection, there are diverse split-bolus techniques available. The advantage of split-bolus administration is to obtain a combined nephro-pyelographic phase instead of two separate phases. Test-images and split-bolus techniques are effective means for reducing the number of necessary acquisition phases. Anyway, radiation exposure is a critical issue and further optimization is achieved by using low-dose protocols and tube current modulation. CTU is easy to put into operation, but it seems impossible that we will ever have the one and only CTU technique. Especially the knowledge of the great variability of supplementary measures assists us in creating our individually optimized CTU protocols. Learning Objectives: 1. To understand that diverse examination techniques exist for imaging of the urinary tract by means of CT. 2. To become familiar with different methods of how to improve the contrast enhancement inside the urinary tract. 3. To appreciate measures for reducing the radiation exposure in unenhanced CT and in CT urography. A-012 09:15 B. Optimising MRI M.A. Cova; Trieste/ IT (cova@gnbts.univ.trieste.it) Magnetic Resonance (MR) urography has received a relatively lower attention than multidetector CT (MDCT) urography, being hampered by the low spatial resolution, which is crucial for calyceal evalution and by the requirement of updated MR units. Hovewer, excellent contrast resolution and lack of ionizing radiation make MR urography a useful technique for non-invasively evaluating the entire urinary tract, expecially when ionizing radiation is to be avoided, such as in pediatric or pregnant patients. The MR urographic techniques can be divided into two categories: static-fluid MR urography and excretory MR urography. The static-fluid MR urography utilizes unenhanced, heavily T2-weighted pulse sequences to image the urinary tract. On the heavily T2 weighted images, the urinary tract is hyperintense because of its long relaxation time, indipendent of the excretory renal function. This technique is ideally suited for patients with dilated or obstructed collecting system. In excretory MR urography, intravenous gadolinium is combined with a T1-weighted 3D gradient echo (GRE) sequence. The practicability of excretory MR urography depends on the ability of the kidneys to excrete the intravenously administered gadolinium agent. Administration of low-dose furosemide can improve the quality of excretory MR urography by enhancing urine flow and therefore providing a uniform distribution of the contrast material inside the entire urinary tract. Excretory MR urography provides high-quality images of both non-dilated and obstructed collecting systems. The static-fluid MR urography and the excretory MR urography techniques will be addressed in detail. BE (j.l.bloem@lumc.nl) Imaging is essential in diagnosis, grading, staging, and therapy monitoring of soft tissue tumors. Typically a patient presents with a clinically detected soft tissue lump. In a general practice, benign tumors and tumor-like lesions are 100 times more frequent than malignant ones. This makes US a cost-effective first imaging method. Normal variants, non-neoplastic lumps (cysts, post-traumatic lesions, muscle herniation), and benign lesions (subcutaneous lipoma) can often be diagnosed. US is also used to guide needle sampling for cytology or histology. If the lesion does not allow a specific US diagnosis, is larger than 3 cm, and/or is located deep to the fascia, low threshold MR is indicated. Dynamic Gd-enhanced MR has the highest accuracy (80-90%) in differentiating (grading) benign from malignant lesions. Benign lesions often have specific signs allowing a tissue-specific MR diagnosis with high sensitivity (75%). A tissue-specific diagnosis often cannot be made in malignant lesions (sensitivity 37%). Criteria for malignancy are: no tissue-specific benign diagnosis can be made, size > 3 cm, located deep to fascia, liquefaction, early peripheral enhancement, inhomogeneous SI on T1-weighted images. Educational cases will be staged during the session, addressing concerns of surgeons. Parameters that are useful, or worthless in monitoring therapy and detecting recurrences will be demonstrated in typical cases. Learning Objectives: 1. To know when and how to use US and MR in making a tissue specific diagnosis. 2. To be able to use imaging criteria in differentiating benign from potentially malignant soft tissue tumors with high accuracy (grading). 3. To learn how to use MR in staging, monitoring therapy and detecting recurrence. Diagnostic neuro-imaging procedures play an essential part in the in the diagnosis, management, treatment and follow-up of patients with lesions of the central nervous system (CNS) . The purpose of this presentation is to illustrate how pattern analysis contributes to the correct (differential) diagnosis for CNS lesions. The first step is to identify and outline the lesion, and to establish its exact anatomical location (intra-or extra-axial, supra-or infratentorial). The orientation and topography of the abnormality are equally important. Changes in tissue, tissue density on CT and signal intensity on MRI can provide clues to the histological nature (e.g. fat, fluid, gas, blood, etc). Central necrosis and perilesional vasogenic edema are markers of aggressive behavior of lesions. Contrast agents can be used to assess lesion vascularity or to detect blood-brain-barrier breakdown. Diffusion-weighted imaging, including diffusion-tensor imaging and tractography, provides a unique insight into the ultrastructural organization of tissues and lesions at a cellular level. Magnetic resonance spectroscopy yields information regarding the biochemical composition of lesions, and can be used in the diagnosis and post-treatment follow-up. Perfusion-weighted imaging provides information regarding the micro-vasculature (angiogenesis) of tissues and tumors, as well as capillary permeability and other parameters. In summary, thanks to improvements in equipment, both hardware and software, a comprehensive 'multimodal' neuro-imaging protocol provides not only anatomical images, but also gives information regarding tissue characteristics, and contributes to the detection and biological characterization CNS lesions. Learning Objectives: 1. To demonstrate how to use anatomic location in CNS lesion characterization (intra-versus extra-axial, supra-versus infratentorial). 2. To illustrate how to correlate MRI signal intensity changes with biochemical and pathological findings. 3. To understand how to select and tailor MRI sequence parameters in CNS lesions. 4. To show how to use a pattern analysis approach of CNS lesions to establish the (differential) diagnosis. A-020 09:30 C. Differential diagnosis of bright lesions on diffusion-weighted MRI M.M. Thurnher; Vienna/ AT (majda.thurnher@meduniwien.ac.at) As its first introduction, diffusion-weighted MR imaging (DWI) has become 'the technique' for the detection of the cerebral ischemia. The combination of diffusion and perfusion MR imaging has been increasingly used for the diagnosis and management of the individual patient with acute ischaemic stroke. This lecture attempts to elucidate and discuss how to use DWI in stroke, and also in non-infarct brain lesions (infections, metabolic diseases, tumours). On trace DWI untreated pyogenic abscesses typically present with high signal, and low ADC values, because of restricted diffusion in the high-viscosity pus within the abscess cavity. Some fungal abscesses show restricted diffusion; with usually more heterogeneous appearance. Tuberculous abscesses might have restricted diffusion and thus mimic pyogenic and fungal abscesses. Variable diffusion patterns have been described in cerebral toxoplasmosis, obviously dependent on the histological stage. Diffusion characteristics in brain tumours correlate strongly with the cellularity. High cellular tumours such as primary CNS lymphoma often exhibit restricted diffusion. Epidermoid cysts and cholesteatoma will also show restricted diffusion with high signal intensity on DWI. Necrotic neoplasms and metastases have elevated diffusion and show low signal on DWI with high ADC values. However, some lung cancer metastases can have restricted diffusion, simulating abscesses. Diffuse axonal injury (DAI) has been described to have high signal on DWI. Some hyperacute demyelinating lesions (MS plaques) will demonstrate high signal on DWI and could create problems in the differentiation from embolic infarcts. DWI provides images of unquestionable diagnostic value, with an established role in the neuroradiological examination protocols. Learning Objectives: 1. To recapitulate the basic principles of diffusion-weighted MR imaging (DWI). 2. To discuss the importance of DWI and ADC measurements in the diagnosis and differential diagnosis of brain lesions. 3. To report on uncommon causes of diffusion restriction. Imaging of the aortic arch can now be routinely performed with non-invasive imaging. In fact either CT or MR, thanks to their great spatial and temporal resolution, can provide excellent details that allow identification of vascular anomalies and different pathological entities either in the adults or in the paediatric population. In a single examination with both modalities, it is possible to evaluate the thoracic aorta and specifically the arch and supra-aortic vessels. CT is considered in most centres the method of choice for emergency cases, i.e. cases of dissection, trauma, etc, while MR imaging is generally preferred in other instances. During the presentation, details will be furnished on the different techniques of acquisition, contrast agent administration and importance of post-processing. In respect of MR imaging, it will also be shown the possible advantages of using blood pool contrast agents to perform, after first pass imaging, high resolution studies. Results will also be shown from different clinical studies in comparison with reference standards for the evaluation of the aortic arch and supra-aortic vessels and in particular for the assessment of the carotid arteries. Regarding the carotid arteries, current possibilities to evaluate not only the vascular lumen but also the walls and atherosclerotic plaque will be reviewed. Their importance will also be demonstrated for treatment planning and the choice between surgical, endovascular and conservative treatments. Explicative cases will be demonstrated for congenital and acquired diseases demonstrating the advantages and limitations of each imaging modality. Learning Objectives: 1. To understand the techniques of MRA and CTA in the evaluation of aortic arch and its branches. 2. To understand the techniques of Doppler ultrasound in the evaluation of aortic arch branches. 3. To understand the strengths and limitations of the various imaging modalities in the evaluation of aortic arch and its branches. of imaging in patients with aortic dissection. Visceral ischemia may be caused by dynamic or static obstruction. Dynamic obstruction is caused by true lumen compression and occurs when the visceral artery is supplied by the true lumen and the true lumen is compressed by the false lumen resulting in reduced blood flow in the involved visceral artery. Static obstruction refers to the situation when the dissection flap extends into the visceral artery itself and the blind-ending false lumen compresses the true lumen within the visceral artery branch. Learning Objectives: 1. To understand the diagnostic strategy with imaging techniques in aortic dissection. 2. To discuss the mechanisms of visceral ischemia in aortic dissection. 3. To learn how to differentiate between static and dynamic dissection. A-023 09:30 C. Inflammatory and infectious diseases T. Pfammatter; Zurich/CH (thomas.pfammatter@usz.ch) From an etiological point of view, aortitis can be subdivided into the inflammatory (non-infectious) and the infectious types. The vast majoritiy of aortitis belonged to the former group. This group includes mainly the large vessel vasculitides giant cell arteritis and Takayasu arteritis, next to the isolated aortitis of the ascending aorta or the abdominal aorta (inflammatory aneurysm, periaortitis). Infectious aortitis are caused by bacteria or fungi either by contiguous infection from adjacent stuctures or by hematogeneous seeding. In the latter instance, there is a predilection for diseased aortic wall segments such as aneurysms or atherosclerotic plaques. Keeping in mind that even histopathology can not discriminate between the types of inflammatory aortitis, the radiological approach is often limited to a description of anatomic disease extension, possibly the stage of inflammation, its evolution to stenosis, aneurysm or even dissection and the presence of atherosclerosis. Therefore, classification of inflammatory aortitis relies on a set of clinical, laboratory and radiological (Takayasu) or histological (giant cell arteritis) criteria. In early, untreated large vessel vasculitis with elevated inflammatory markers 18 F-FDG PET appears to be the most sensitive modality. Although CTA and MRA depict aortic and branch vessel wall changes, the correlation of these findings with disease activity is less than optimal as there is a delay of regression in wall edema or thickening when compared with clinical remission. Limited data suggest that PET is more useful in the evaluation of disease activity than CTA or MRA in inflammatory aortitis. PET-CTA or -MRA therefore seems promising to fine-tune anti-inflammatory therapies. Learning Objectives: 1. To get a basic knowledge of pathophysiology, classification and clinical presentation of aortitis. 2. To learn about imaging features of infectious and non-infectious aortitis. 3. To understand the role of imaging studies in the diagnosis and follow-up of aortitis. DE (christoph.trumm@med.uni-muenchen.de) Basic components of speech recognition systems (SRS) are the acoustic and the language model. The first provides statistical information on speaker-dependent variability of phoneme pronounciation, the latter contains empirically gathered probabilities of triplet word combinations. Requirements for sufficient performance of SRS within a multiuser PACS/RIS environment are a client-server architecture, a robust institution network and a high-end PACS/RIS hardware infrastructure. The client workstation is linked to the SR server and employs individual, continuously updated voice profiles, and the radiological context vocabulary. Department-wide RIS integration of the SR application is important for correct attribution, and timely and continuous processing of reports. Two operation modes of SRS can be used in a clinical setting: 1. Offline (batch) SR with transfer of the dictation to the SR server for subsequent processing. The preliminary report is corrected by a transcriptionist and finally proofread and authorized by the radiologist. (2) Online SR with real-time processing of the dictation and instant report correction, proofreading and authorization by the radiologist in one step. Offline SR can only be implemented given a supporting transcription service, and is comparable to conventional dictation with respect to the time effort. Online SR can decrease report turnaround times significantly, but also reduce radiologists´ throughput depending on the correction effort, and lead to clinically relevant homonym errors. State-ofthe-art SRS are characterized by recognition rates between 90-97% and extensive context vocabularies. Frequent update of the (product-dependent) personalized or department-wide, comprehensive context vocabulary is critical for maintaining recognition accuracy. Learning Objectives: 1. To be familiar with the principles of the computer basics behind the SR technology. 2. To understand and be able to critically appraise the potential clinical applications. 3. To be conversant with the organisational aspects of employing this technique in the clinical environment. 4. To appreciate the current state-of-the-art. A-025 09:00 B. PACS and beyond: Computer aided diagnosis as part of PACS workflow T.W. Vomweg; Koblenz/ DE (t.vomweg@dr-von-essen.de) The lecture will give a short introduction into the different understandings of the term "CAD". The term "CAD" covers a wide variety of software ranging between "Computer Aided Detection" up to full-automated "Computer Diagnosis". This will be followed by some broad overview of currently available CAD systems, especially in the field of breast and lung imaging. Output of such CAD systems is in part compatible to the DICOM standard and could therefore at least be stored in PACS. Historically most CAD systems started as standalone software running on the Radiologists' workstation or some special environment. Therefore Radiologists have to use a special hardware of a specific software client to obtain the results of the CAD system. Nowadays integration into an Integrated Health Environment (IHE) is beocoming more and more mandatory. Technologies used for integration differ and show a high amount of possible pitfalls. At least fully automated CAD software has a large potential to enrich information stored in the PACS without any user interaction. Learning Objectives: 1. To be familiar with the basic principles of computer aided diagnosis (CAD). 2. To be able to appraise the potential of clinical applications, especially lung and breast. 3. To be able to integrate usage of CAD as a part of image interpretation workflow in PACS workstation. 4. To understand the future possibilities of increased intelligence within PACS. The elbow is a complex hinge joint. The common flexor and extensor origins dominate the soft tissue supporting structures medially and laterally. Biceps and brachioradialis anteriorly and triceps posteriorly make up the other significant muscles. Rotation (pronation and supination) takes place at the radiocapitellar and proximal radioulnar joints. The pronator, supinator muscles and annular ligament support this movement. Several anatomical variants are important for MRI interpretation. Extraarticular variants are divided into abnormal signal changes and anatomical variation in normal structures. Magic angle signal phenomenon on short TE sequences account for a high proportion of 'normal' signal variation. The biceps tendon and the flexor and extensor entheses are particularly prone. Anatomical variations in ligaments are uncommon, though their anatomy is complex. Care must be taken to avoid misinterpreting the attachment of the radial collateral ligament into the annular ligament as a tear. Three important nerves cross the elbow and all may be compressed by anatomical variants. The ulnar nerve may also be compressed by an accessory anconeus epitrochlearis or be translocated anteriorly. The radial nerve may be compressed by fibrous bands, the vascular leash of Henry or between the two heads of supinator. The medial nerve may be compressed by an accessory supracondylar process or by the bicipital aponeurosis. Variants inside the elbow include joint surface pseudodefects, notably the capitellum and trochlea. Other normal intraarticular structures include synovial folds, the anterior and posterior fatpad and a radiocapitellar meniscus. Following MR arthrography, airbullbles and needle artefact should not be misconstrued as loose bodies. Learning Objectives: 1. To review in detail the MRI anatomy of the elbow joint and its relevance to disease processes. 2. To consider imaging protocols and techniques directed to the clinical problem. 3. To review the small number of anatomical variants that may be encountered. 09:30 C. Wrist A.H. Karantanas; Iraklion/GR (apolsen@yahoo.com) MRI has become an important diagnostic tool in the evaluation of wrist pain and functional impairment. MRI is able to depict various disorders such as avascular necrosis, occult fractures, inflammation, neoplasms, infections, and injuries of the triangular fibrocartilage (TFC) and interosseous ligaments. In terms of proper interpretation of images, normal anatomy demonstration by an optimized protocol is important. The increased SNR provided by high field MR systems (1.5-3.0 T) is a prerequisite for high-resolution images of the small joints and structures of the wrist. Patients should be placed in the prone position with the elbow extended overhead and the pronated hand in the center of a dedicated surface or phased array coil placed in the isocenter. The imaging protocol may include the following: sequences using FOV of 8-10 mm and slice thickness 2-3 mm: coronal and transverse T1-w SE and fat suppressed PD-w TSE, coronal STIR and 3D-GRE and sagittal T1 and T2-w. Contrast-enhanced fat suppressed T1-w SE images are acquired in cases with clinical indication of inflammation, infections and neoplasia. The MR arthrogram is studied with coronal fat suppressed T1-w SE (2 mm) and transverse 3D-T1-w-GRE (1 mm) after intraarticular injection of Gd solution (1:200). Pitfalls include inhomogenous fat suppression, magic angle effect often seen in the abductor pollicis longus and extensor pollicis brevis tendons, ligamentous attachments on hyaline cartilage, susceptibility artifacts from previous operations and partial volume effects. Variants in the wrist include variable ulnar length, accessory muscles and TFC age-related changes and tears in asymptomatic individuals. Learning Objectives: 1. To learn about a suggested updated MR technique for imaging the wrist. 2. To understand the normal imaging anatomy. 3. To become familiar with the most common pitfalls and variants that may simulate disease. Low-dose CT for early detection of lung cancer is widely used not only in research programs but also as a standard examination in daily clinical practice. When reading a low-dose scan, we have to face some potential problems in detection and interpretation. Peripheral nodules are rarely missed: MIP reconstruction and doublereading (together with experience and concentration) are recommended, while the role of CAD systems in nodules detection is questionable. The detection of small hilar lesions can be difficult and a careful evaluation of coronal view may be helpful. Changes in apical scar and pleural thickening may hide a cancer and all the examinations must be compared with the previous ones. The management of nodules is generally based on their size changes: growth is generally assessed at 3-month interval, but it can be misleading, because of the variability in measures or caused by the slow growth of some tumors or the changes of some benign lesions. Some problems arise from interpretation of small (< 4 or 5 mm) nodules, both prevalent and incidental, even if general consensus exists on long-term follow-up. Non-solid nodules need careful evaluation and dedicated management: The morphologic appearance is not reliable for diagnosis and they could grow slowly and increase in attenuation as sign of early-stage malignancy. Finally, we believe that collateral findings should be reported and attention in reading CTs must be paid not only to the lung, but also to thyroid, mediastinum and infradiaphragmatic images. Learning Objectives: 1. To disclose and share the difficulties encountered in reading low-dose CTs performed for lung cancer screening. 2. To analyse why some lesions may be missed or misinterpreted. 3. To learn how to distinguish parenchymal from pleural nodules and to face the problem of non-solid lesions. The strong rationale for staging is to select patients who will benefit from surgical resection. In the TNM 1997 classification, patients who are unlikely to benefit from surgical resection are those in stages IIIB and IV. These are distant metastases (M1), contralateral or supraclavicular node metastases (N3), or locally extensive tumor (T4). A revised edition of the TNM classification of lung cancer will be published in 2008. Standard radiography, CT and MRI have been used to stage lung cancer. Staging can be done non-invasively with imaging modalities alone, although in most instances, some surgical staging is also necessary. T4 disease can often be diagnosed on CT scanning if features such as destruction of a vertebral body adjacent to a tumor, encasement and distortion of mediastinal structures, or invasion of the heart is demonstrated. Multidetector CT scans allow thin-sections to be generated from volumetric data without the need for additional scanning through the area of interest. Computed tomography is the method of choice for the assessment of mediastinal nodes in lung cancer. Recent studies have shown relatively low sensitivity for CT in the detection of nodal metastases (41% -67%). Computed tomography also is associated with low specificity (79%-86%). The role of imaging in the determination of extrathoracic metastases from lung cancer is somewhat controversial. PET imaging with FDG is considered the most effective imaging modality. Detection of nerve involvement by a head and neck tumor can cause an important improvement in tumor staging (T4). Adenoid cystic, squamous cell and basal cell carcinoma, melanoma, lymphoma, and sarcoma are frequently assoiated with perineural tumor spread (PNS). This PNS can occur in the absence of clinical signs, hence the radiologist routinely has to exclude nerve involvement in all patients with head and neck cancer. Tumor spread is most frequent along the maxillary (V2) or mandibular (V3) branches of the trigeminal nerve although tumor can less frequently also follow the ophthalmic branch (V1). The mastoid segment of the facial nerve is another typical extension route and tumors will also follow the connections between the facial and trigeminal nerve. Tumor spread along the hypoglossal nerve is less frequent. Involved nerves enhance, are thickened and cause enlargement of the foramina, fissures and canals they pass through and eventually the tumor will extend intracranially and become more difficult to treat or intreatable. PNS can be detected on axial and coronal high resolution gadolinium-enhanced T1-weighted images although more and more isotropic sub-millimetric gadolinium-enhanced fat suppressed 3D-FFE or VIBE images are used. In this refresher course the typical routes of PNS will be illustrated and the signs of PNS will be covered. Special attention will be paid to the imaging techniques which should be used to detect tumor spread. An overview of the anatomical sites were it is easiest to pick up PNS and which should be checked will also be given. Transdural growth of head and neck malignancies has a major impact on treatment planning and patient's prognosis. Whereas tumours that remain extradural can be excised through a facial approach, tumours transgressing the dura require a combined craniofacial resection, dural resection to obtain free surgical margins and often, major reconstructive efforts to avoid post-surgical complications. Several studies have demonstrated the negative impact of dural invasion in patient's outcome, together with the presence of positive surgical margins and tumour histology. Therefore, all efforts should be made to recognize this feature pre-operatively. MR has proven to be the most accurate image modality to depict dural invasion and perineural spread of tumour. Dural enhancement, although very sensitive for dural invasion, has a low specificity as it may result both from invasion by tumour, from reactive fibrovascular changes, and from meningeal inflammation. The pattern of dural enhancement, thicker then 5 mm or nodular, is more accurate, showing higher specificity. In addition, loss of the hypointense line which separates tumour from the adjacent enhancing dura, (corresponding to the epidural space), and loss of continuity of the enhancing dura, best depicted on high resolution MR sequences, are helpful imaging signs of dural invasion. When considered together, MR criteria can offer an overall accuracy for dural invasion of 95%. During surgery efforts should be made to resect the tumour specimen en bloc along with the adjacent dura and, when not at all possible, to correctly label the excised fragments of the dura to allow for adequate pathologic staging. NL (c.y.nio@amc.uva.nl) Worldwide, esophageal cancer is the sixth leading cause of death. The incidence of esophageal cancer is rising in the western world, mainly as a result of an increase in the incidence of adenocarcinoma over the past few decades: 13,900 new cases in the United States when compared with 1,500 new cases in the Netherlands. Smoking is associated with an increased risk for both squamous cell-and adenocarcinoma. The other important etiologic factors are alcohol intake for squamous cell carcinoma and reflux disease for adenocarcinoma (the latter having eightfold increased risk). Because of the late onset of symptoms (mostly dysphagia), approximately 50% of patients have either unresectable tumors or metastasized disease. Work-up consists of endoscopy with biopsy followed by EUS for local staging. CT of the chest and abdomen combined with US of the cervical region is mandatory for detection of distant metastasis. PET-CT is increasingly being used to identify disease that has spread to sites undetectable by other imaging techniques (4-15%). Esophageal cancer is classified according to the TNM classification system. The A S17 C B D E F G H overall survival rate at 5 years has increased to 14% currently (95% for stage 0, less than 1 year for stage IV). Localized esophageal cancer is treated surgically with either a transthoracic or transhiatal approach, without significant differences in survival between the two techniques. Despite the widespread use of preoperative chemotherapy and radiotherapy, there remains no proof of principle that this strategy is effective in esophageal cancer. Non-surgical combination of chemo-and radiotherapy is able to prolong the long-term survival rate. Learning Objectives: 1. To describe the epidemiology and pathology of esophageal cancer. 2. To discuss the treatment options with their outcome. 3 . To describe the imaging information required for management of esophageal cancer. A-040 09:00 A.M. Riddell; Sutton/UK (Angela. Riddell@rmh.nhs.uk) Many patients with esophageal cancer present late, with disseminated disease. Computed Tomography (CT) forms the basis for initial staging and will identify metastases with 75% accuracy. Small volume metastatic disease, in particular peritoneal disease, may remain undetectable. CT is also used for local staging, particularly assessing resectability. Specific criteria determine mediastinal invasion (T4 disease) with reported accuracies on using these criteria ranging from 60% to 80%. As individual layers of the esophageal wall are not identifiable on CT, staging early tumours is less reliable. Nodal involvement is based on size criteria (> 10 mm). Specificity for N staging using CT varies as micrometastases can occur in small lymph nodes. Endoscopic Ultrasound (EUS) is able to delineate the esophageal wall layers and has 80% accuracy for T-staging. Using criteria based on morphology, the accuracy for nodal staging is also higher than CT at 79%. EUS-guided lymph node sampling can further improve diagnostic accuracy. After neoadjuvant therapy, however, the staging accuracy for both CT and EUS falls because of an inability to differentiate post-treatment fibrosis from residual tumour. MRI staging of esophageal cancer has previously shown accuracies similar to that of CT. Recent work using a high-resolution technique shows some potential for local staging. MRI and US can be used for characterisation of indeterminate liver lesions. Currently, the imaging algorithm for esophageal cancer staging would initially use CT to exclude metastatic disease, with EUS reserved for detailed staging of patients with localised disease appropriate for radical treatment and MRI being used for problem solving. Learning Objectives: 1. To define examination technique and accuracy of different imaging modalities (excluding PET/CT). 2. To demonstrate typical imaging findings in radiological imaging modalities of esophageal cancer. 3. To propose an imaging algorithm for esophageal cancer. A-041 09:30 C. The growing role of PET/CT V.J . Goh; Northwood/UK (gohmcglone@hotmail.com) Oesophageal cancer has one of the most rapidly increasing incidences of all cancers worldwide. Accurate staging is essential to ensure the most appropriate treatment is instigated. The conventional work-up of oesophageal cancer involves endoscopy, EUS, and CT but has its limitations. Whole body PET/CT has a growing role in the management of oesophageal cancer particularly for staging and the assessment of treatment response. In staging, its strength is in the detection of occult metastatic disease, preventing unnecessary surgery in up to 20% of the cases. PET/CT has an important role in early treatment response as metabolic changes precede morphological changes. PET/CT performed 14 days after instigation of neoadjuvant chemotherapy is a good marker of treatment response and eventual outcome. PET/CT also has an evolving role in the assessment of disease relapse. Limitations relate to low uptake in adenocarcinomas and uptake in oesophagitis. The advantages of PET/CT are such that it is fast becoming a standard imaging investigation for oesophageal cancer. Kidneys present a segmental anatomy, each segment being organized in two compartments: cortex and medulla. The medulla itself is segmented in inner and outer compartments. Each compartment corresponds to specific segments of nephrons. Visualisation of these different compartments, of cortico-medullary differentiation and cortico-medullary junction is highly variable, according to the each imaging technique and may require contrast agents. Volume of kidneys is adapted to body mass but volume of each segment is variable in each kidney. Morphological measurements which show best correlation with the degree of function are 3D cortical and parenchymal volumes. Reliable automatic softwares are still required for that purpose. Differences in degree of blood perfusion of both cortex and medulla (around 500 and 20 ml/mn/100 g respectively) are responsible for differences in contrast enhancement and in methods for quantification. Visualisation of the effect of concentration into medullary tubules depends on the degree of hydration. The best quantitative parameter of glomerular filtration is glomerular filtration rate (GFR), between 90 and 100 ml/min. However, filtration rate is variable from nephron to nephron. Therefore, dynamic studies must take into account this heterogeneity when attempting to quantify GFR. The level of renal oxygenation, assessable by MRI, is higher in cortex than in medulla: Medullary and cortical pO2 are 20 and 50 mmHg respectively. Medullary hypoxia is caused by active water and sodium reabsorption along the thick ascending limb of the Henle loop. Water movements are important in renal parenchyma and follow its tubular architecture with a high anisotropy level within medulla. Learning Objectives: 1. To describe the segmental and vascular anatomy of the kidney. 2. To provide appropriate information on main physiological renal parameters: Perfusion, filtration, concentration and oxygenation. 3. To understand the impact of these functional characteristics on imaging of normal kidneys. B. Congenital and pediatric diseases A. Paterson; Belfast/UK (anniep@csi.com) It is, of course, impossible to discuss the complete spectrum of congenital and paediatric renal disease in one 30-minute lecture. Rather, a 'guided tour' of some of the more commonly encountered conditions and their radiological features will be presented. The changing appearance of the normal kidney through childhood will be shown alongside those kidneys, which demonstrate anomalies of outline, rotation, position or size. Renal cystic disorders may be inherited or may occur sporadically, be diagnosed antenatally or during screening; they can remain silent until adulthood too. Large cysts can mimic obstructed pelvicalyceal systems or present as a renal mass. However, renal mass lesions may be solid as well as cystic, benign or malignant, and have a wide variation in their imaging characteristics. From US, through contrast studies, to CT, MR and scintigraphy, the study of congenital and paediatric renal disease utilises all imaging modalities. Learning Objectives: 1. To provide an overview of the common congenital renal anomalies encountered in clinical practice. 2. To learn about the spectrum of pediatric cystic renal disease. 3. To appreciate the possible differential diagnoses in a child with a renal mass lesion. The year 2009 is a special one for the biological sciences, as we celebrate the 200 th anniversary of the birth of Darwin, the visionary who gave us the theory of evolution. As Darwin showed, it is those who adapt to change who survive and thrive. By combining technology, biology and medicine, our specialty of radiology has evolved to be a guiding light in medicine as well as in the sciences on which medicine is based. Principal paradigms of imaging have shifted as a result of technological breakthroughs. We have gone from depicting organs to depicting cells, proteins and now even genes, how they function, and how they interact. It has become possible to unveil pictorially more and more of the basic biological processes that make life possible and, in going awry, result in cancer. What can possibly be next? Perhaps at this juncture, it is fitting to pause, step back, and consider how deeply interconnected imaging, medicine and the sciences have become and how much can be achieved by integrating them further. Advances in imaging and in fields such as genomics, proteomics and metabolomics are providing an extraordinary opportunity to unravel the complexity of the whole body. By learning, applying and sharing data and knowledge from multiple disciplines with a spirit of curiosity and generosity, we will open endless horizons for advances in cancer care. Renal artery stenosis (RAS) is a widely discussed and debated topic. Its incidence is 4% in hypertensive population, and 10-20% in patients with hypertension and coronary artery disease (CAD). Improved imaging methods suggest that RAS is more common than previously thought, and high prevalence of atheroslerotic RAS in patients with CAD and poor prognosis of these patients support a need for early detection of RAS. The relation of RAS to RVHT will be discussed, since the mere presence of RAS does not equal the presence of RVHT. In a 2-year period, about 30% of patients with ischemic renal disease will experience a cardiovascular event (death, heart failure, myocardial infarction, stroke) and the risk of mortality is directly related to the severity of atherosclerotic RAS. Also, ischemic nephropathy is responsible for up to 22% of advanced renal disease in patients older than 50 years. Most common is atherosclerotic, ostial RAS, while in younger patients fibromuscular dysplasia may cause RVHT, and other causes, like vasculitis, are quite rare. Doppler ultrasound, CT angiography, and MR angiography are widely used for the detection of RAS. The advantages and disadvantages of each method will be presented. Role of imaging, and in particular ultrasound, for the selection of patients and follow-up after endovascular intervention will be discussed. The value of angioplasty and stenting in RVHT is the source of great debate and data regarding treatment options are very conflicting. The overview of studies comparing angioplasty/stenting of atherosclerotic RAS with the best medical therapy will be presented. Most symptomatic upper urinary tract infections (UTI) in adults and children are ascending from the lower urinary tract, due to contamination from the fecal flora, mostly by E Coli. Other bacteria, such as Enterobacter, Klebsiella, Proteus, Pseudomonas and enterococci may also occur, but are more common in patients with recurrent or complicated UTI or as a result of antibiotic treatment. UTI involving the kidneys carries a risk for permanent renal damage and long-term complications such as hypertension, complications during pregnancy and renal failure. There is an ongoing debate whether children with first time UTI should be investigated by imaging or not. Opinions vary from performing extensive imaging with ultrasound, cystography and DMSA scintigraphy to no imaging at all. Adults with uncomplicated febrile UTI/acute pyelonephritis who respond promptly to antibacterial treatment need no radiological imaging. However, in patients with diabetes and those with growth of uncommon infecting bacteria imaging in UTI/acute pyelonephritis should be considered. Patients with repeated episodes of febrile UTI/pyelonephritis should have imaging of the urinary tract performed, in order to reveal any underlying cause. Multidetector-CT without and with i.v. contrast medium is the preferred method to demonstrate the extent of inflammation and any underlying cause of the UTI, such as ureteral stone and/or obstruction, and to reveal complications, such as abscess formation. Learning Objectives: 1. To provide an overview of most frequent urinary tract infections. 2. To become familiar with the work-up of a patient suspect of a urinary tract infection (when and how). 3. To understand how far we can get to the right diagnosis with imaging including differential diagnostic considerations. Merriam-Webster defines instability as the quality or state of being unstable, where unstable is lacking steadiness: apt to move, sway, not being in or able to maintain a state of balance. For some, this defines "macro-instability". It can be classified in axial rotational, translational, listhetic and postsurgical instability syndromes. Frymoyer defines spinal instability as the loss of spinal motion segment stiffness, such that force application to that motion segment produces greater displacements than would be seen in a normal structure, resulting in a painful condition and the potential for progressive deformity. This defines micro-instability and does not involve gross abnormal motion. Imaging in instability can either be anatomic or functional and/or dynamic. Dynamic examinations involve either flexion/extension or any other movement that provokes the patient's complaints. This is usually performed with X-rays, but can also be done on CT or MR either with an axial-loading device or on a stand-up MR machine. Anatomic (static) examinations can also be performed with plain film, CT or MR depending on the underlying pathology. According to some, micro-instability is equal to degenerative disc disease, internal disc disruption, and/or internal disc derangement. It is hypothesized that disc degeneration causes an increase in the neutral zone. This is defined as the zone within which the spine has minimal internal resistance to movement. An increased neutral zone is associated with micro-instability. In imaging of micro-instability, we will therefore focus on the intervertebral disc. NL (jwil@rdia.azm.nl) MRI is at present the imaging modality of choice for demonstrating degenerative disc disease and various types of narrowing of the spinal canal, which may be associated with radicular symptoms. Unfortunately, the abnormal MRI findings seen in patients with such symptoms can also be encountered frequently in individuals without any low back or leg complaints. This presentation attempts to correlate specific MR imaging features with the presence of radicular symptoms and also to use MRI findings to predict the natural history. MRI features are frequently associated with the presence of radicular symptoms. The following features are discussed: 1. Type of disc lesion: bulging, protruded, extruded. Extrusions most likely cause symptoms, but are occasionally asymptomatic. Protrusions and even bulges can be symptomatic, especially in combination with canal narrowing. 2. Presence of nerve root compression: MR myelography can be useful in identifying symptomatic lesions. 3. Presence of nerve root enhancement: This can be associated with radicular symptoms, but sensitivity and specificity are too low for routine use. Of the MRI features associated with good outcome, the following are discussed: 1. Patterns of MRI findings: "Classical" presentations with mediolateral disc extrusions causing nerve root compression have the best prognosis. 2. Contrast enhancement around an extruded disc: A marked inflammatory response predicts more rapid resolution. It is possible to identify MRI findings more frequently associated with radicular symptoms and a more favourable natural history, but exceptions are the rule. MRI findings should always be carefully correlated with clinical features. Facet joints are a major source of low back pain. Their synovial linings and joint capsules are richly innervated. Pain may arise from inflammatory processes in the facet joints and spread through the perifacetal soft tissues; alternatively, radicular pain may be the result of direct mechanical nerve root compression by hypertrophic facet joints. Osteoarthritis of the facet joints has been studied for many years using oblique conventional radiographs. Plain X-rays are useful in screening for facet joint osteoarthritis, but they lack sensitivity compared with CT. The introduction of CT in the 1970s made it possible to visualize directly the intervertebral disc and to demonstrate the compression of the dural sac and nerve roots by herniated disc material. MRI became more widely available in the late 1980s and is now considered the most sensitive imaging technique in degenerative disc disease and has therefore become the primary imaging modality for investigation of the spine. However, the role of the facet joints in the evaluation of patients with low back pain and sciatica has been underestimated. Facet joint degeneration has been described in morphological terms (osteophytic spurs, hypertrophy, erosions) on CT and conventional MR sequences. When using fat-suppressed techniques (both T2-and contrast-enhanced T1-weighted imaging), active inflammatory changes of the facet joints (facet synovitis) and perifacetal soft tissues can be clearly depicted. A prevalence of signal abnormalities on fat-suppressed T2-weighted imaging of 41% has been reported. A correlation between the side of facet synovitis and the side of patient's clinical symptoms has been demonstrated. The earliest attempts to assess the feasibility and usefulness of dual energy computed tomography (CT) for medical indications date back more than two decades. Two subsequent scans at different energy levels were performed with single-source CT systems. However, applications were hampered by the low photon output at low energy levels and by image co-registration problems resulting from even slight changes in patient position between the two consecutive scans. These challenges have now been resolved by the dual-source CT system. The design of the scanner is characterised by two X-ray tubes and corresponding detector elements that are mounted on the rotating gantry with an angular offset of 90 degrees. Owing to this scanner configuration, either high temporal resolution cardiac imaging can be performed, or -when running the two tubes at different energy levels -spectral information allowing material differentiation can be obtained. In the past two years, a considerable number of various DE applications have been developed and validated. These applications are based on a three-material decomposition algorithm and include the identification of iodine for perfusion studies; the differentiation of uric acid from other crystalloid substances; and the subtraction of iodine-containing structures from contrast-enhanced scans thus generating virtual non-enhanced images. This session will concentrate on the technical backgrounds of the technique and will highlight current and future applications of dual energy CT. We will try to demonstrate how this re-discovered technique may impact the clinical evaluation of patients. In CT imaging, materials having different elemental compositions can be represented by similar or the same CT numbers, making the differentiation and classification of different tissue types extremely challenging. The potential of dual energy CT lies in its ability to discriminate different materials based on differences in atomic number. Clinical examples where dual energy CT may play a role include: 1) CT angiography, where surrounding bone and iodinated vessels can have similar CT numbers, making fully automatic bone removal difficult in some locations, such as the skull base; and 2) material composition analysis of mineralized objects, such as in the identification of renal stone type where in vivo determination of stone type can direct medical management. In dual energy CT, an additional attenuation measurement is required at a second energy (tube potential setting, kV), allowing the differentiation of the two materials. The physical principles and potential clinical applications initially were described by Godfrey Hounsfield in 1973. Following additional research and algorithm development, it was commercially implemented in the 1980s by one manufacturer using a dual-kV approach. Dual-kV techniques are again available on clinical CT systems, accomplished with either slow or fast kV switching or dual-source methods. Alternatively, a dual-layer detector can be used to acquire dual energy data using a single kV. In the future, photon-counting detectors may allow multiple energy bins to be sampled using a single-kV, singlesource geometry, and single-layer detector. The fundamental principles of these techniques and their relative strengths and weaknesses will be reviewed. Dual-source CT has re-enlivened dual-energy (DE)CT. The scanner contains two X-ray tubes and corresponding detectors mounted in a perpendicular offset. Thus, simultaneous acquisition of two different spectra resolves image co-registration problems. Specific attenuation behaviours of different materials enable their differentiation, which is caused by material-dependent Compton and photo-electric effects. Various DE applications have been investigated: DECT of the abdomen and lung allows for the reconstruction of virtual non-enhanced images in which the iodine content is subtracted from contrast-enhanced images. The replacement of non-contrast-enhanced images by virtual non-contrast-enhanced images can reduce overall radiation exposure, through the possibility of skipping standard pre-contrast scans. Patients with flank pain planned for multiple data acquisitions before and after contrast-media injection profit from this strategy, without sacrificing the accuracy of diagnosis of urinary stone disease. DE strategies can valuably be used in liver or kidney imaging either by reducing radiation or quantifying iodine uptake in parenchymatous organs. In regard to urinary stones, the DE algorithm bases on the differentiation of uric acid (UA) from other crystalloid substances, which showed a high diagnostic efficiency. As UA stones can be treated medically, DECT may impact the clinical management. In pulmonary angiography, obstructive pulmonary diseases and pulmonary embolisms can be better delineated with DECT enabling the study of lung perfusion. In addition, xenon-enhanced DECT allows for the accurate assessment of dynamic and static regional ventilation with an exact match to thin-section CT but without any influence of lung volume. This presentation elucidates areas of current applications and ongoing research in abdominal and lung imaging with DECT. Learning Objectives: 1. To learn about the value of virtual non-enhanced CT of the urinary tract and liver. 2. To understand the role of dual energy CT for the differentiation of urinary stones. 3. To become familiar with the added value of dual energy CT of the lung. Cardiovascular and musculoskeletal dual-energy CT T.R.C. Johnson; Munich/ DE (thorsten.johnson@med.uni-muenchen.de) Dual-energy CT exploits the spectral properties of materials to differentiate them in CT datasets. An established application is the removal of bones from angiography datasets based on the differentiation of iodine and calcium. This offers the possibility to evaluate the entire angiography dataset in a single maximum intensity projection (MIP) showing all of the scanned vasculature instead of reading many thin slices. With the visualization of the vessels without bones or calcifications, stenoses are detected and graded more accurately. Also, small aneurysms in close vicinity to bone are identified more reliably, e.g. in the circle of Willis at the skull base. MIPs provide an excellent overview, which is important for surgical planning. An advanced algorithm additionally provides the option to add calcified atherosclerotic plaques back to the dataset after bone subtraction. Then, plaque distribution and morphology can be assessed, e.g. to plan bypass surgery. Another application of DECT is the assessment of myocardial perfusion based on the detection of iodine in the myocardium with an ECG-gated scan at dual tube voltages. Initial results show that pronounced perfusion defects can be identified. Thus, DECT offers the possibility to obtain both a coronary angiogram and a myocardial perfusion scan in a single exam. Dense collagen has some weak spectral properties, so that it is possible to identify tendons and ligaments and to color-code them in datasets. Thus, CT scans of trauma patients can be used not only to rule out fractures but also to evaluate tendons and ligaments for ruptures. Oslo/NO (torill.sauer@medisin.uio.no) (Micro-) calcification is a common finding in both opportunistic and organised mammography screening programmes. They occur in a wide range of lesions and represent diagnoses from the most innocent calcified secretion related to atrophy in menopause to high grade premalignant ductal carcinoma in situ (DCIS) and carcinomas. Calcification is a non-specific degenerative process and as such gives no indication as to being benign or malignant. It may be luminal, intraductal or stromal. Luminal calcification may be the result of atrophy with retention of secreted material without any histopathological abnormality or in benign, borderline or low grade premalignant lesions. Adenosis and sclerosing adenosis are examples of benign, non-tumoural disorders harbouring luminal microcalcs. 'Old', sclerosed fibroadenomas often have coarse stromal calcification. Columnar cell lesion/hyperplasia is an entity that seems to represent the far low grade spectrum of epithelial changes that may lead to a ductal or lobular carcinoma in situ or invasive carcinoma. These lesions regularly contain microcalcifications. Histologically they are often heterogeneous and may harbour benign epithelial changes as well as borderline/equivocal findings and carcinoma in situ. The radiological findings may reflect this heterogeneity. Most often they will be equivocal or suspicious on radiology and histologically benign. Ductal carcinoma in situ is likewise heterogeneous as to cellular atypia and growth pattern and this heterogeneity is also reflected in the radiological morphologic findings. Radiological calcifications mirror a wide spectrum of histopathological diagnoses from normal/atrophy to high grade DCIS. Heterogeneity of calcifications mirror histopathological heterogeneous or mixed lesions. Neoplastic lesions of the kidneys require imaging evaluation in all cases. The role of imaging -beyond detection of the lesion -is to properly characterize the mass, but also to provide reliable information regarding its stage, operability and prognosis. Radiology plays an important role in the follow-up of these cases as well. The spectrum of the available modalities extends from conventional plain radiography to PET-MR, but the major diagnostic task today is taken by the ultrasound-MDCT-MRI axis which is able to provide all relevant information in most cases. Ultrasound is the primary tool for the detection and differentiation; MDCT allows for more accurate characterization in the equivocal cases and provides the necessary information for local, regional and "distant" staging, while MRI is the problem-solving modality for those cases in which questions regarding the nature and the stage of the mass remains unclear. Beside the correct diagnostic algorithm, appropriate imaging technique is also essential for requiring valuable information, thus it is of utmost importance to learn how to perform these examinations. (pavlica@orsola-malpighi.med.unibo.it) Prostate cancer detection, diagnosis, staging and assessment of pre-and posttreatment are currently fraught with many unanswered questions and much controversy. Ultrasonography and MRI play the most important role to manage diagnosis, staging and follow-up for prostate cancer. Ultrasonographic guided biopsy is the most diffuse method to detect and charactarise prostate lesions. The combination of anatomical MR imaging with functional MR such as spectroscopy, diffusion and dynamic contrast-enhanced provides additional information in combination to the clinical data. Current indications for prostate MR imaging are: a) staging selected patients at risk for extracapsular extension with prostate cancer, who are uncertain to choose surgery or radiotherapy, b) patients with elevated or rising PSA levels but negative TRUS-guided biopsies and c) assessment of patients for suspected local recurrence after various therapies. The accuracy of MRI of the prostate to localize and target the biopsies will be outlined in order to minimize the false negative biopsy results whenever performed blindly. The session will define the patients who should be evaluated with MRI for detection, staging, response assessment and when relapse is suspected. Recent advances in breast interventional procedures have brought about not only a significant improvement in diagnostic accuracy, but also the possibility of stepping forward with 'minimally invasive' therapeutic indications under image guidance of benign and malignant lesions. Therapeutic percutaneous breast procedures can be divided into two categories: Techniques based on removal (Vacuum-assisted devices and percutaneous excisional biopsy) and based on 'tissue destruction' (ablation by radiofrequency, cryotherapy, high-intensity-focused ultrasound, laser therapy and focused microwave phased-array thermotherapy). Vacuum-assisted devices are playing an important role in percutaneous removal of benign lesions such as fibroadenomas, papillomas (whether or not in the context of nipple discharge) and inflammatory pathology. The procedure is safe with good results in terms of costs, cosmetic acceptance and removal of lesions, as has been reported in several recent publications. The main limitation is the size of the lesion; however, the introduction of large-bore needles (9G-7G), has made possible the removal of benign lesions up to 3 cm. Techniques based on 'tissue destruction', are mainly oriented to the treatment of malignant lesions and required a comprehensive diagnosis and staging prior to the procedure. An increasing number of series state the radiofrequency ablation to be a promising, minimally invasive technique for the treatment of infiltrating breast carcinomas under 2 cm, as compared with immediate surgery. Although most of these studies have been oriented on an experimental basis and small series, prospective randomized trials are to be carried out to comparatively analyze local recurrence and overall survival between patients treated by radioablation+RT and breast conserving-surgery+RT. Currently, the intervals for mammographic follow-up of patients with invasive breast cancer, ductal carcinoma in situ (DCIS) and high risk and precursor lesions vary widely from centre to centre, and country to country. Evidence for mammographic surveillance intervals for patients treated for invasive breast cancer and DCIS, and the length of time for which such patients should be followed up is lacking. National and international groups have produced guidelines, which differ in their recommendations. These will be reviewed, and suggestions made regarding an evidence-based regime for follow-up of these patients. High-risk and precursor lesions are a heterogeneous group with an increased risk of development of invasive breast cancer. Atypical ductal hyperplasia (ADH) carries a four-to fivefold increased risk rising to sixfold risk if premenopausal, and 10 times risk if there is a first-degree family history. Lobular neoplasia is a spectrum of lesions ranging from atypical lobular neoplasia (ALH) to lobular carcinoma in situ (LCIS). These lesions are not true precursor-lesions. With ALH, there is four-to fivefold risk of invasive disease; LCIS carries 8-10 times risk both in the ipsilateral and contralateral breast. Some 10-20% of patients with lobular neoplasia are likely to develop invasive disease 15-25 years after the initial diagnosis. The long-term evidence for increased surveillance in all these groups is lacking, but annual mammographic screening seems to be a pragmatic approach. The evidence for the role of MRI and other breast-imaging modalities in surveillance is emerging and will be discussed. (t.yousry@ion.ucl.ac.uk) Disease or degeneration of the basal ganglia, cerebral cortex and sometimes the thalamus gives rise to disorders of movements known as dyskinesias (Greek: difficult movement). The two main dyskinetic syndromes are (a) hypokinetic syndromes: Idiopathic Parkinson's disease (IPD), atypical PD (APD), multiple system atrophy (MSA), progressive supranuclear palsy (PSP) and cortico basal degeneration (CBD), and (b) hyperkinetic syndromes: chorea, tick, myoklonus, tremor, and dystonia. These movement disorders (MD) are often difficult to diagnose and to treat. Up to now the diagnosis is based on clinical criteria. However, despite the fact that imaging, is playing an increasing role in establishing and confirming the diagnosis of MD, many radiologists are not familiar with the role of the various imaging techniques in establishing the diagnosis, monitoring disease progression and furthering our understanding of the pathophysiology of MD. We will first review the role of "conventional" MRI in the workup of MD by presenting imaging signs that assist in the daily routine and that should be known by radiologists and neuroradiologists exposed to this disease entity. We will then review the contribution of specific imaging techniques such as fMRI, DTI, SPECT and PET in improving the diagnosis, providing biomarkers for the monitoring of the natural history and furthering our understanding of the pathophysiology of MD. We will conclude by addressing the central role of imaging in guiding surgical treatment, emphasizing the importance of detailed anatomical knowledge of the structures to be targeted and presenting the optimized techniques to image them. . MRI examination of the brain including T1 and T2 weighted images shows two types of findings in patients with movement disorders, namely regional atrophy and signal changes (increased or decreased T2 signal) with a distribution matching that of the neuropathological alterations typical of each disease. Accordingly, characteristic MRI features with variable sensitivity and specificity in movement disorders include the following: Signal changes of the corticospinal tracts in MND, atrophy of the midbrain in PSP, symmetric signal change of the basal ganglia in WD, "eye of the tiger" sign of the pallidum in HSD, atrophy of the caudate in HD, atrophy of the medulla and cervical spinal cord in FRDA, olivo-pontocerebellar atrophy or cortico-cerebellar atrophy in SCAs and ILOCAs, symmetric signal changes in the middle cerebellar peduncles combined with leukoaraiosis in FXTAS, and symmetric changes of the basal ganglia combined with olivopontocerebellar atrophy in MSA. The contribution to the diagnosis in the single patient of these findings is generally higher for sporadic conditions as compared to inherited diseases whose diagnosis now rests on molecular genetic tests. The clinical differentiation between Parkinson's disease (PD) and atypical parkinsonian disorders (APD) can be challenging for clinicians. There is therefore a need for diagnostic biomarkers that can reliably identify the pathology associated with these disorders and monitor the natural history. Advanced MRI techniques provide quantitative biomarkers that represent objective criteria in the differential diagnosis of neurodegenerative Parkinsonism. Advanced MRI techniques include magnetic resonance volumetry, diffusion imaging, proton magnetic resonance spectroscopy, MR relaxometry, and new computer-aided diagnostic approaches. Using these techniques, numerous abnormalities have been found in the basal ganglia, the cortex, the brainstem and the cerebellum in PD and APD. On the other hand, functional MRI helps understanding the effects of movement disorders and compensatory mechanisms. The aim of this presentation is to review the recent literature on the role of advanced MRI techniques, and particularly diffusion tensor imaging, in the diagnosis of PD and other parkinsonian disorders. Learning Objectives: 1. To understand the contribution of DTI in the diagnosis and in monitoring natural history. 2. To appreciate the contribution of fMRI to understanding the effects of movement disorders and role in differential diagnosis. Diagnosis: Role of nuclear medicine K. Tatsch; Munich/ DE (Klaus.Tatsch@med.uni-muenchen.de) Among neurodegenerative movement disorders Parkinson's disease (PD) and atypical parkinsonism (aPS) such as multiple system atrophy (MSA), progressive supranuclear palsy (PSP), and corticobasal degeneration (CBD) are the clinical most relevant diagnoses. Dementia with Lewy bodies (DLB) also plays an increasing role. In those illnesses establishment of an early and accurate diagnosis impacts on management, helps to avoid wrong treatment decisions and may aid in the selection of patients for therapeutic trials. The well established involvement of the dopaminergic system in movement disorders is readily assessable with PET and SPECT. Compromised presynaptic nigrostriatal functions allow to accurately distinguish neurodegenerative parkinsonism from those illnesses which may mimic it such as essential tremor, drug induced or psychogenic parkinsonism, NPH, or dopa-responsive dystonia. Furthermore involvement of presynaptic functions allow to distinguish highly reliably between DLB and Alzheimer dementia. The domain of postsynaptic D2 receptor imaging is the differential diagnosis of PD versus aPS. Whereas in PD postsynaptic D2 receptor binding is primarily intact, the latter is markedly reduced in aPS, where neurodegeneration affects both pre-and postsynaptic nerve fibers. Although D2 receptor studies aid to establish the diagnosis of aPS they are less helpful to distinguish among MSA, PSP, and CBD. Here specific patterns in FDG PET may further clarify diagnoses. Another nuclear medicine based principle is the assessment of cardiac sympathetic denervation which also allows to discriminate between PD and MSA or PSP. Beyond the mentioned applications nuclear medicine techniques are used to assess disease severity, measure disease progression, and target drug action. (t.yousry@ion.ucl.ac.uk) Functional stereotactic neurosurgery is an established method in treating patients with PD. There are two possible approaches: (1). Ablative surgery; (2) . deep brain stimulation (DBS). The main established anatomic targets are the internal globus pallidum (GPi) and the subthalamic nucleus (STN); the value of other targets, such as the pedunculopontine nucleus (PPN) are under evaluation. These targets are reached using coordinates derived from a stereotactic atlas or from the MR images of the individual patient. For the latter approach it is important to know the targets' anatomic characteristics. We will concentrate on the STN and GPi. The STN is a small lens-shaped structure, obliquely oriented in all three planes. Its close proximity to the substantia nigra adds to the challenges in visualising it directly. Several anatomic methods and landmarks have been established to assist in its identification, such as the red nucleus, the mamillary bodies or the mamillothalamic tract. The GPi is located between the internal medullary lamina laterally and the internal capsule medially. For the GPi's accurate identification it is vital to identify these two white matter tracts. We will review the anatomy and the related controversial literature with the published mistakes. Pre-and postoperative imaging protocols must enable the visualisation of all these structures in a timely manner. The GPi is best visualised on PD sequences, and the STN on T2 sequences (acquisition time 3-7 min). After DBS implantation, however, it is crucial to use sequences with a low SAR, to avoid complications from energy deposition. Renal hypertension is relatively rare compared to other causes of hypertension and usually is due to renal artery stenosis. Imaging may be done by different means. Noninvasive radiological techniques are preferred in screening for renal artery stenosis and includes color-coded duplex sonography, MR angiography and CT angiography. For central renal artery stenoses, cross-sectional imaging are relatively reliable in detection of RAS, but CT-angiography may be limited due to heavy calcifications as MR angiography tends to overscore a lesion detected. Ultrasound depends on the investigator's skills and patient-related factors. Thus, direct aortography or selective angiography are still the method of choice to verify the diagnosis, but should be then carried out in order to perform a simultaneous intervention. Angiography is the method of choice especially for segmental arterial stenosis. Interventional treatment for ostial or proximal RAS is stent-supported renal angioplasty, while distal renal ertery stenosis, fibromuscular dysplasia and segmental renal artery stenosis are treated by balloon angioplasty alone and may undergo stenting only in case of complications. Stent graft insetion or renal emboplization are rare events to treat renal hypertension or insufficiency. Percutaneous revascularisation of renal artery stenoses has been under discussion for a couple of years as randomized trials did not show major advantage of invasive treatment compared to medical treatment. Actually, new randomized trilas did not show advantage of interventional treatement for renal insuffiency and RAS. These trials will be presented and discussed. The rational analysis of the masses and pathologies arising in the supra-and infrahyoid neck necessitates an exact localization according to the anatomical spaces. There is a certain overlap, sometimes resulting in confusion, between the anatomic and surgical borders and definitions of the neck spaces. It is necessary for the clinical radiologist to elucidate the complex anatomical relationships from a radiological point of view and to present the critical contents of each space. Thus, a space-orientated differential diagnosis may be facilitated and according to the location and the typical CT and MR imaging appearance of various lesions the differential diagnosis may be narrowed down to specific pathologies. Common pathologies in the vicinity of the critical contents as well as pathologies extending beyond one anatomical space are also of major interest for the radiologist and crucial for the patient's treatment. Therefore, CT and MR surveys should be meticulously read for such imaging findings. There are, however, many potential pitfalls that may ruin a neck study. This lecture focuses on the differentiation of primary parapharyngeal masses arising from the pre-styloid parapharyngeal space, the retro-styloid parapharyngeal space (carotid space), and the deep lobe of the parotid gland. In this respect, it is important to observe whether the styloid process is displaced and the direction of displacement. Pre-styloid parapharyngeal lesions displace the styloid process laterally, deep lobe parotid lesions displace it posteriorly while retro-styloid parapharyngeal masses displace it anteriorly. This lecture will also examine the pitfalls related to signal changes in denervation atrophy and diagnosing lesions in the carotid space. Denervation often produces high signal intensity on T2-weighted images or demonstrates contrast enhancement. These changes may be mistaken for tumour involvement. It is important to note signals generated by flow in the carotid sheath may mimic non-existent lesions. The purpose of this lecture is to familiarize the radiologist with parapharyngeal space diseases and its clinical significance. First, a brief overwiew of parapharyngeal space anatomy will be presented, followed by discussion of different imaging modalities, including functional imaging techniques. Next, a systematic review will include key radiologic features of (a) congenital or developmental lesions including branchial cleft cyst and cystic hygroma, (b)neoplastic lesions, such as minor salivary gland tumors, neurogenic tumors and tumors from other surrounding spaces, and (c)infectious or inflammatory lesions, like odontogenic and tonsillar infections. Emphasis will be placed on what the surgeon needs to know in order to plan the treatment and how to report imaging findings in a comprehensive way. Finally, all steps including clinical examination, imaging studies, treatment options and follow-up, with particular attention paid to the role of radiologist, will be reviewed. As an endpoint, tips and tricks of some parapharyngeal space diseases will be discussed with appropriate examples. Image quality (IQ) in coronary CT angiography is still a challenging issue. IQ depends mainly on three parameters: 1. Heart motion artefacts with a strong inverse correlation of IQ and velocity of the moving heart. Heart motion varies with heart rate. Below 65-70 beats per minute, best images are reconstructed in the diastolic phase. Over this range, the best phase is rather found in the end-systolic phase, but good image quality may then be difficult to reach. 2. Contrast enhancement in the coronary tree: contrast enhancement should be in the range of 300-500 Hounsfield Units for a good depiction of coronary lesions. Contrast enhancement depends on body size, heart rate, concentration of iodinated contrast medium and rate of injec-tion. 3. Little radiation dose requires appropriate adjustment of kV and mAs for each individual. The new prospective acquisition mode is promising to reduce drastically the radiation dose. However using prospective mode safely is limited to patients with low and stable heart rate at the present time. In conclusion, obtaining sharp images with little radiation requires individually adapted cardiac CT protocols. DE (Bernd.Wintersperger@med.uni-muenchen.de) Compared to other organ regions, MR imaging of the heart faces substantially more challenges as it represents a constantly fast moving organ that is also exposed to additional motion based on its position within the chest. Therefore MR users have to deal with various sources of artifacts, which may be differentiated into patientand organ-related artifacts and technical, hard-and software related artifacts. As the heart represents a rapid moving structure, for high image quality it is of utmost importance to freeze cardiac motion. This is being addressed by limiting the data acquisition window within the individual heart cycle. Exceeding certain thresholds might result in substantial blurring of the images or inaccurate results. Segmented data acquisitions allow tailoring the temporal resolution and data sampling window. Although sampling window could be shortened to almost arbitrary values, this might result in acquisition times exceeding the patient's breath-hold capabilities. In case of arrhythmias dedicated techniques may be of benefit to still allow for a diagnostic image quality. Also respiratory motion may result in substantial artifacts affecting image quality whereas the use of breath-hold techniques is the easiest way to avoid these artifacts. Alternatively real-time techniques, navigating techniques or the use of data averaging techniques may be used to eliminate/substantially reduce breathing artifacts. Artifacts may also arise from the hard-and software being used. This is mainly related to field-strength and accelerated data acquisitions. Although these techniques may also reduce artifacts, they may by themselves be a source of additional artifacts. Cardiac Computed Tomography (CT) has seen a very fast development over the past few years. Although the quality of the examinations has increased due to this development, problems such as trigger artefacts, suboptimal contrast bolus and respiratory artefacts can still occur. For some of these problems, advanced postprocessing techniques can be utilized to either reduce the resulting artefacts or to allow easy recognition of the artefacts. In this refresher course lecture, an overview of the current possibilities and impossibilities is given. (o.m.vandelden@amc.uva.nl) The imaging assessment of trauma patients and the sequence of imaging studies performed during the initial evaluation and stabilization by the trauma team according to the ABC-principles are dictated by ATLS guidelines and are highly protocolized. The role of imaging in the C (Circulation) is to assess site (s) of hemorrhage and if possible to quantify hemorrhage from these sites as well as to assess whether bleeding is predominantly arterial or venous in nature. The first essential images obtained usually are a lateral C-spine, chest film, and pelvic X-ray. The chest film contains information about pulmonary or pleural hemorrhage and potential traumatic aortic injury (TAI). Suspicion for potential TAI should always be followed by CTA of the thoracic aorta. A pelvic fracture as seen on a plain film of the pelvis should always raise the suspicion of retroperitoneal hemorrhage. High grade or unstable pelvic injuries are associated with significant arterial hemorrhage and pelvic fractures are often associated with the presence of significant intra-abdominal trauma. In patients with pelvic fracture and/or significant abdominal trauma US (FAST) should be performed immediately during the initial imaging evaluation. Depending on initial imaging findings and the clinical condition of the patient further assessment is preferably performed with CT. During the session imaging algorithms for different injury types (chest-pelvis-abdomen) and different clinical scenarios (hemodynamically stable-hemodynamically unstable) are discussed, with emphasis on detecting hemorrhage and selecting patients for endovascular intervention. Vascular intervention can be lifesaving in the early management of trauma. Balloon occlusion of the aorta or iliac arteries can be performed without screening and will stabilize a patient buying time to allow injury assessment and imaging. Embolization is performed as the definitive procedure to stop arterial haemorrhage. The precise timing of embolization depends on other life threatening problems, but it is essential to realize that arterial bleeding should be stopped as quickly as possible. The simplest way to ensure this is to perform immediate contrast-enhanced CT scanning to identify all significant injuries and the site/s of bleeding. Management should then follow a robust algorithm which defines the order of interventions. Trauma embolization must be performed in a pragmatic manner; stopping life threatening bleeding takes precedence. The angiographer must understand the following: (1) Use of a variety of embolic agents including: coils, particles and glue. (2) Crohn's disease is more likely a systemic disease governed by a shift in the immune response, thus affecting the whole MALT system. Its treatment should be as conservative as possible and surgery is resorted to only after complications like indolent fistulations, stenoses, bleeding, or bowel perforation developed. Bowel ultrasound is a quick, simple and effective method and therefore it could be, according to our experiences, the first choice with respect to both the treatment and follow-up in patients with Crohn's disease. The ultrasound examination (US) is performed without any bowel preparation; it is not necessary to be empty. The patients are examined in supine position. We examine first whole small bowel, mesentery and large bowel, than the terminal ileum and cecum or the areas of anastomoses. We assess folds, hastrum, wall thickness, vascularity, and echogenity of the surrounding fat, presence of nodes and course of peristalsis. The examination is completed by the measuring of the flows in AMS. Finally, we use the intravenous contrast. Concerning the transducer, we use both -convex as well as linear. Bowel US is a simply inexpensive and easily available method. Bowel US in patients with Crohn´s disease is useful as differential diagnostic method as well as in the follow-up of these patients. The principal problem is subjectivity of this method. Therefore, we record whole examination to our digital archive. The aim of this lecture is to give an overview of the techniques and typical findings for imaging Crohn's disease (CD) with either multirow detector 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 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 is 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 proved to be good tools for evaluating the extent, activity of the disease and presence of extraluminal complications. Both are also able to identify the type of the disease, as being either the active / inflammatory, the fistulizing /perforating, the fibrostenosing or the reparative / regenerative type. Comparing the two modalities for imaging, CD is difficult: CT has a high in-plane resolution but the exam lacks the high soft tissue contrast of MR and there is the problem of radiation dose. "More is better", seems to be the philosophy behind multislice CT (MSCT) technology today. Already sixty-four slice CT is becoming the gold standard across radiology and that trend might only multiply once 256-slice CT system will become widely available. The dual source technology generates the high speed required for cardiac imaging by adding a second X-ray source and a second detector. It is the cardiovascular applications that are driving more slices and more tubes. However, is more always better? Providing wider coverage by increasing the number of CT slices does not necessarily provide solutions to immediate clinical needs, such as improved characterization of plaque, greater visual details in stents and dose reduction. Temporal resolution is one of the most critical parameters for cardiac CT imaging. Single source CT scanners have only limited temporal resolution of ca. 160 ms, still far away from 15 ms of conventional angiography. Dual-source CT made a significant step forward reaching a temporal resolution of 83 milliseconds. A 256-slice CT system on the other hand might overcome 64-slice CT's limitation in capturing an entire image in a single rotation for full integration of functional data and anatomical data. In 64-slice CT systems, helical scanning must be employed, and datasets acquired over several cardiac cycles to cover the entire heart. Thus, varying degrees of discontinuity in the body-axis direction are observed between the datasets acquired in different cardiac cycles. Routine clinical cardiac MRI requires speed and efficiency as a result of physiological motion. Consequently, the challenges and the 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), contrast-to-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. Biomarkers comprise anatomic, physiologic, metabolic, biochemical, biophysical, and molecular parameters which can be used to determine the presence and state of disease. Conventional biomarkers are commonly assessed by laboratory tests or physical examination. Owing to the advancement of imaging technology, the role of imaging biomarkers is rapidly increasing in medicine. Imaging biomarkers are expected to have a large impact in medicine, e.g. for better understanding the mechanisms of disease, for drug discovery and development, screening, improved diagnosis, and monitoring of treatment. Whereas most conventional biomarkers (laboratory tests) are quantitative, a processing step is required to extract quantitative parameters from imaging data. Therefore, there is an important role for quantitative image analysis in the development of imaging biomarkers, and in their application in medical decision making and treatment monitoring. In this talk we will focus on medical image analysis techniques aimed at the development of quantitative imaging biomarkers for cardiovascular disease. Imaging biomarkers that are discussed include quantitative descriptors of vessel morphology (stenosis grade, aneurysm size and shape), atherosclerotic plaque burden (plaque volume, plaque composition, calcium scoring) and cardiac function (LV ejection fraction, LV perfusion, LV wall motion). We also address the essential role of evaluation, validation and standardization in the successful implementation of quantitative cardiovascular imaging biomarkers. Skeletal manifestations of TB remain a major problem in the world. The incidence is rising with increasing AIDS, immunosuppressive drugs or substance abuse. WHO declared TB a global health emergency in 1993. Drug-resistant TB infections are classified into: multi-drug resistant TB (MDR-TB), which is defined as resistance to the two most effective first-line TB drugs; extensively drug-resistant TB (XDR-TB) has also resistance to three or more of the six classes of second-line drugs; extremely drug-resistant TB (XXDR-TB) has resistance to every anti-TB drug. Thes are significant public health issues in many countries. TB of the spine accounts for 1% of all TB infections and 25-60 of all bone and joint infections caused by TB. It generally affects adults in the fourth and fifth decades, and lower thoracic and lumbar vertebrae are the most common sites. TB spondylitis is more indolent with a more gradual onset of symptoms over months to years. Neuroradiology has an important role in the diagnosis, treatment planning, treatment and treatment monitoring of spinal TB. Multiple vertebral body involvement is the rule and skip lesions occur. Despite the advent of advanced diagnostic technology, neither clinical examination nor radiological findings may be reliable in differentiating atypical forms of spinal TB from other infections or from neoplasms. Generally, longer treatment with expensive drugs, with or without percutaneous spinal interventional procedures or surgical interventions is required. A wide range of infective organism may affect the spine with increasing incidence due to AIDS, bone marrow and organ transplantations, and use of immunosuppressive therapies and vascular devices. Spinal infections can be classified based on the anatomic location involved: Osteomyelitis (vertebral bodies), discitis (intervertebral discs), epidural phlegmon/abscess (epidural space), arachnoiditis/leptomeningitis (meninges and nerve roots), and myelitis/ intramedullary abscess (spinal cord). MR imaging plays a key role in early diagnosis of spinal infections and provides crucial information regarding the extent, location and internal structure of these severe and potentially life-threatening diseases. Even though many imaging signs of spinal infections are nonspecific, careful analysis of MR features critically helps narrowing the differential diagnosis, and for some infections allows a specific diagnosis in the correct clinical context. Follow-up MR imaging examinations are increasingly used to monitor response to treatment in patients with spinal infections and guide clinical decisions, whether to continue antimicrobial therapy or to proceed with surgery. Cellular imaging has long been a term dedicated to cellular biology with the use of optical techniques at a microscopic level. With the development of advanced cellular therapies for organ regeneration, gene transfer or anti-cancer vaccines, the need to monitor cell transplantation non-invasively with imaging has become clear and cellular imaging now comprises the macroscopic level. In the future, the radiologist will be asked to visualize the site of implantation, and the fate of transplanted cells in the organ or in the whole body. MRI seems well suited for this purpose, because it combines an excellent spatial resolution and a good contrast resolution when cells are labelled with iron oxide nanoparticles. The aim of this session is to explore the state of the art of cellular imaging with optical and MRI techniques for the visualisation of cells at both micro-and macroscopic scales. Technical developments for cell labelling and detection will be detailed, and in vivo examples will be shown. Labelling and manipulating the cell with USPIO F. Gazeau; Paris/FR (florence.gazeau@univ-paris-diderot.fr) Magnetic labelling of living cells creates opportunities for numerous biomedical applications as individual cell manipulation, magnetic control of cell migration, intracellular heating or MRI cell tracking. The unique advantage of magnetic-based methods is to activate or monitor cell behaviour by a remote stimulus, namely the magnetic field. Cell labelling methods using superparamagnetic nanoparticles have been developed, showing no adverse effect on cell proliferation and functionalities, while conferring magnetic properties to various cell types. We will describe a nonspecific labelling technique based on anionic magnetic nanoparticles (AMNP) and the subsequent magnetic properties of cells. We will review the effects of different magnetic fields on the labelled cells: -non-invasive MRI detection at the single cell level (in vitro and in vivo), -intracellular manipulation by rotating field, -cell targeting by magnetic attraction, -intracellular hyperthermia under high frequency field. These approaches will be discussed in the context of their applications for cell therapy and tissue engineering (non-invasive tracking of cell implants, cell delivery assisted by magnetic forces). Imaging cell transplants with MRI M. Modo; London/UK (mike.modo@iop.kcl.ac.uk) Cell therapy is emerging as a viable option for organ repair. However, to date little is known about how the stem cells perform beneficial functions, how they migrate, integrate and differentiate in the living animal. The use of magnetic resonance imaging and related approaches that allow the non-invasive monitoring of the organ systems can provide novel insights into the process of stem-cell-mediated repair. Especially the use of bimodal MRI contrast agents is of great value in establishing this technique as it allows the independent corroboration of MRI observations by fluorescent histology. This allows a rapid development of in vitro assays that assess cellular uptake, but also affords validation of in vivo MRI of the migration of transplanted stem cells. However, long-term in vivo experiments including functional assessments are needed to ensure that contrast agents do not interfere with the recovery process. This thorough pre-clinical testing will ensure that this approach can be used in experimental studies to understand the fundamentals of stem cell-mediated repair and that these can be efficiently translated into clinical applications. Learning Objectives: 1. To gain an understanding of the need to use non-invasive imaging to advance stem cell therapy. 2. To critically evaluate the pros and cons of various cell labelling techniques. 3. To be able to evaluate the in vivo assessment of cell therapy using magnetic resonance imaging. Dynamic cell imaging of cancer invasion with optics P. Friedl; Nijmegen/NL (P.Friedl@ncmls.ru.nl) Multiphoton microscopy (MPM) has defined standards for 3D fluorescence and higher harmonic generation analysis of cells and tissue structures in vitro and in vivo. Using a tunable optical parametric oscillator (OPO), we show that infrared-excited two-photon microscopy above 1 microm allows multifold enhanced detection of red fluorophores and second harmonic generation at sub-micron resolution, supports 80-100% deeper tissue penetration and reduces phototoxicity and photobleaching by 80-95%, as compared with the commonly used excitation range (750 to 950 nm). Because of the enhanced tissue penetration, deep-tumor microenvironments become accessible by intravital microscopy, revealing subregions of collective cancer cell invasion of several hundred cells co-opting and moving along preexisting blood vessels and extracellular matrix tracks at velocities of 150 µm/day. These zones of invasive growth comprise cells that retain cell-cell junctions moving in a coordinated fashion yet retain their proliferation capability and show striking survival advantage during experimental irradiation therapy. Thus, deep-tumor imaging by infrared-excited MPM identifies stage-resolved reconstruction of invasive growth and disease progression, the cooption of blood vessel, and radio-resistant niches. The mammographic features of small cancers and the work-up and diagnosis of mammographic lesions are presented from the authors' experiences of population screening -20-30,000 women per annum for 20 years. BIRADS, one of several systems developed to provide a standardised classification for mammographic lesions, will be discussed. Results: Detection of subtle soft tissue lesions requires systematic examination of both the glandular tissue and the review areas -the area between the margin of pectoralis and the glandular tissue on the MLO, the inferior and medial aspects of the breast and the retro-areola area. Work-up of mammographic lesions using the triple assessment method and a standard image classification system enables a specific diagnosis to be made in 95-100% of cases recalled for assessment, and the number of soft tissue abnormalities requiring diagnostic surgical excision should be minimised. The key mammographic features to be assessed for mass lesions are density, outline, solitary or multiple and interval change. Distortion is seen as numerous converging lines with no central mass. The detection and accurate assessment of mammographic mass lesions and architectural distortion is essential for the effective use of X-ray mammography in both screening and diagnostic practice. Breast calcifications are very frequent findings, especially in elderly women. Not all calcifications represent malignancy, but a lot of attention has to be paid to them, because of their varied appearances. Artefacts may be present because of technical reasons -at analogue and digital mammography as well -radiologists must be familiar with them. Macrocalcifications mostly represent benign lesions; however, microcalcifications may indicate malignancy. Characterization is mainly performed by targeted mammography examination, sometimes completed by ultrasound and MRI. Recognition of typically benign microcalcifications is quite easy and secure, but distinction among the rest of microcalcifications is based on the reader's experience, and statistical probability -these methods are rarely conclusive, but fail to reveal malignant tumours of the breast. Very early cancers may be considered as benign lesions because of their small extension and atypical, benign-looking morphology. Following the Breast Imaging -Reporting and Data Systems (BI-RADS TM ) lexicon, it is mandatory to categorize these lesions, to standardize therapy planning, but biopsy is always recommended when the probability of cancer is over 2%. Stereotactic approach is recommended as the targeting method, while identification of calcifications by ultrasound is not secure. Vacuum core biopsy or traditional core biopsy are the sampling methods of choice. If multiple clusters are present, the two most distant groups are the subjects of biopsy. The use of breast ultrasound (US) has multiple roles. The initial application was to distinguish liquid from solid lesions, followed by the possibility of guiding biopsies. Nowadays, we know a series of descriptors that can be used to analyse breast lesions. The usefulness of descriptors has been emphasized with the introduction of the Breast Imaging Reporting and Data. System (BI-RADS) for US developed by the American College of Radiology in 2004. Many aspects of the lesions are evaluated on conventional B-mode imaging, together with the morphology of the surrounding area and the analysis at color Doppler imaging of the vascular pattern. A strict observation of different signs can reduce the rate of avoidable biopsies and concurrently increase the identification of malignant pathology. Technological development offers better image quality and produces also additional signs like the introduction of elasticity imaging. Age, personal constitution, hormonal status, and physiological changes like pregnancy, lactation and menopause affect the anatomy and composition of the breast. For identifying pathological findings and distinguishing them from artifacts, it is important to appreciate the wide range of variability of the normal breast. Specific conditions and personal history of the patient should be considered as well in the management of the lesions. They should help answer the clinical questions raised concerning the presence, level, and cause of obstruction as well as assessing the potential for recovery. In order to become familiar with urinary obstruction, cases will be presented for interactive expertise; the audience will be presented with CT and CT urography (CTU), MR urography (MRU) and functional MR, ultrasonographic, isotopic and X-ray images. The recent technological advances of CT and MR imaging have had an exceptional impact on the study of urinary tract obstruction. CT, CTU and MRU are gradually becoming the mainstay of imaging urinary obstruction. In this session, the recommended techniques of CTU and MRU will be described and their relative merits and limitations reviewed. The methods as to how to perform these examinations, clinical indications, advantages and limitations will be presented. We will also demonstrate several interpretation pitfalls and limitations of axial and 3D imaging. Attendees will have the opportunity to better identify simple or tougher cases. At the end of the lecture, attendees will become familiar with moderate or severe urinary obstruction, acute or chronic urinary obstruction, their various features and causes. Carcinoma of the bladder is the most common neoplasm of the urinary tract. More than 90% of the cases are transitional cell carcinomas (TCCs). Tumors arising in the urothelium of the renal pelvis and ureter are relatively rare. However, over 85-90% of these tumors are TCCs. The renal pelvis is more commonly involved than the ureter. Hematuria is the most frequent symptom of TCC, followed by dull flank pain and acute renal colic. Rarely, TCC may be discovered incidentally. An essential role for traditional imaging modalities, such as excretory urography, retrograde pyelography and ultrasonography, is still reserved in the diagnosis of upper tract TCC. Staging is usually performed with CT or MRI. However, the emerging technique of CT urography allows detection of urinary tract tumors and calculi, assessment of perirenal tissues and staging of lesions. Excellent sensitivity (96%) and specificity (99%) rates are now reported with regard to the diagnosis of upper tract TCCs with CT urography in the work-up of hematuria. Cystoscopy is still the method of choice for the evaluation of the urinary bladder, since sensitivity for detecting lower tract lesions with CT urography remains low (40% or less). Nonetheless, CT urography may offer the opportunity for one-stop evaluation in the initial assessment of hematuria and in follow-up of TCC. In this teaching session, the attendees will have the opportunity to discuss, through selected clinical cases, the distinctive role, the advantages and limitations of each one of the imaging modalities in assessing the presence of ureter and bladder neoplasms. This lecture will be devoted to technical issues regarding nerve imaging by ultrasound (US) and magnetic resonance imaging (MRI). The main objectives of the lecture will be to (1) To consolidate knowledge of the normal macroscopic and microscopic anatomy of peripheral nerves, (2) To learn how to perform a successful US and MRI examination of peripheral nerves, and (3) To become familiar with normal US and MRI appearance of peripheral nerves. State-of-the-art imaging techniques will be presented, including diffusion tensor imaging (DTI) for peripheral nerves imaging. A direct comparison of US and MRI in their ability to depict nerve fascicule will be done. Finally, advantages and disadvantages of each technique will also be discussed. The nerves of the appendicular skeleton may be affected by inflammatory and neoplastic conditions. The clinical features are frequently misleading and the nerve conduction studies may be negative or non specific. Radiographs are usually normal and CT scan is neither sensitive or specific. All these features emphasize the fundamental role of US and MRI in the assessment of these disorders. This lecture will present the main inflammatory and neoplastic conditions that may affect the peripheral nerves. The US and MRI features of these disorders will be presented, the usefulness and limitations of these techniques will be discussed. act as T2-susceptibility agents, whose contrasting abilities increase by increasing the magnetic field strength. In the case of Gd(III)-complexes, the systems mainly act as T1-relaxation agents, whose efficiency is eventually enhanced by the long reorientational time of the supramolecular aggregate. In addition to tackle sensitivity issues, such systems may also be designed in order to become responsive to a specific physical or biochemical parameter of the microenvironment in which they distribute. Finally, liposomes have been exploited to generate a novel class of highly sensitive CEST (Chemical Exchange Saturation Transfer) agents dubbed LIPOCEST. Such systems are characterized by a shifted resonance for the large pool of water molecules entrapped in the liposomal cavity that can be selectively irradiated in order to transfer saturated magnetization to the bulk water signal. Autofluorescent proteins are being employed to visualize fundamental cellular processes. When applied to virus research, this strategy allows to study dynamic events in the life cycle of a virus. For example, fusion of autofluorescent proteins with structural components of the virus particle allows monitoring of adsorption, penetration, intracellular transport and virus assembly. Herpes simplex virus type 1 (HSV-1) is composed of three different compartments, capsid, tegument and envelope. The simultaneous fusion of multiple virion proteins from the different virion compartments to autofluorescent proteins is a potent strategy to investigate the dynamics of compartmentalization and interaction among HSV-1 proteins. Autofluorescent proteins can also be applied to visualize the spatial and temporal organization of virus genome replication in live cells; for example, the replication of adeno-associated virus (AAV) and HSV-1 in co-infected cells. The molecular mechanisms of AAV and HSV-1 interaction are not only of fundamental virological interest, but have also practical implications for the design of chimeric HSV/AAV hybrid gene therapy vectors. These vectors combine the large transgene capacity of HSV-1 with the potential for site-specific integration of AAV and therefore support the safe and stable expression of therapeutic transgenes. We have been developing methods for detecting the early responses of tumours to therapy. This has included methods for detecting tumour cell death, since this has been shown to be a good prognostic indicator for treatment outcome. Thus, by monitoring tumour cell death, an oncologist may get an indication of whether a drug is working very early during treatment, possibly within 24-48 hours, and long before there is any evidence of tumour shrinkage. Sensitivity in the NMR experiment can be increased dramatically using nuclear spin hyperpolarization (> 10,000x). We showed that exchange of hyperpolarized 13 C label between lactate and pyruvate, in the reaction catalyzed by the lactate dehydrogenase, can be imaged in tumours and that this flux was decreased in treated tumours undergoing drug-induced cell death. The technique could be used in the future for response monitoring in the clinic, in the same way as 18 FDG has been used with PET. Since alterations in tissue pH underlie many disease processes, the capability to image tissue pH in the clinic could offer new ways of detecting disease and response to treatment. Tissue pH can be imaged in vivo from the ratio of the signal intensities of hyperpolarized H 13 CO 3 -and 13 CO 2 following intravenous injection of hyperpolarized H 13 CO 3 -. The technique was demonstrated with a study on a mouse tumour model, which showed that the average tumour pH was significantly lower than the surrounding tissue. Since bicarbonate is already used intravenously in humans, we propose that this technique could be used clinically to image disease. The early diagnosis of rheumatoid arthritis (RA) is essential for modern therapy to be effective. Research shows that ultrasound and MRI may have important roles to play in this process. In addition these imaging techniques are now being shown to detect changes in disease progression or response to treatment before such changes become clinically apparent, providing objective evidence of a drug's efficacy. While these roles currently mainly exist in the research environment their translation into clinical practice seems inevitable. In this session four experts have been invited to review and summarise the current status of these two modalities for the early diagnosis of RA and to look at the techniques available for monitoring disease progression. While three of the speakers are radiologists the fourth will provide an insight from the point of view of the rheumatologist. Diagnostic ultrasound has the ability to image body's soft tissues, cartilage and bone surface at high resolution. It can distinguish fluid from solid tissue, either in terms of appearance alone or by guiding accurate aspiration. Combining this with its real-time dynamic imaging capability and inherent close clinical correlation (you have to be with the patient to perform an ultrasound) gives us a symptom-based, anatomical and functional assessment, ideal for the evaluation of articular and periarticular disorders. Developments in probe technology are improving near-field resolution with 3D and 4D techniques, now becoming feasible clinical tools. High frequency matrix probes allow this form of ultrasound imaging without movement of the probe. This is of great value when assessing vascularity of lesions or conditions. The artefacts produced by probe motion previously hampered reproducibility and prevented widespread use as a biomarker development. The increased usability of these techniques will reduce the major drawback of reproducibility of ultrasound and when combined with power Doppler and contrast imaging, these probe developments will be a major step forward in the development of vascularity outcome measures. Fusion imaging is the use of 3D MR data sets registered with position censors on the US probe to allow overlay of MR and US images in real time. This is of great value in terms of targeting areas identified on MR for injection or biopsy and in validating US abnormalities such as synovitis and erosion using MR Datasets. Despite a lower prevalence when compared to e.g. osteoarthritis, RA has a very high medical and socio-economic impact due to its often rapidly progressive and destructive course and an increased mortality rate. With the advent of new very promising therapeutic concepts, e.g. anti-TNF-alpha blocking agents, and a more wide spread availability of MRI early diagnosis and early onset of treatment has become an important focus in the management of RA patients. Bony erosions as a marker of -mostly irreversible -structural damage may occur as early as 4 months after onset of symptoms and may progress to joint destruction, ankylosis and loss of function within 2 years. Bone marrow edema like signal alterations/patterns (BMEP) may be seen even earlier in MRI and are believed to be a precursor of bony destruction, a recent study suggesting it to reflect inflammatory cellular infiltrations rather than "edema" alone. Synovitis may be detected with MRI as early as 2 months after onset of symptoms and often is taken as a marker of disease activity. Statistical associations have been demonstrated between the amount of synovitis and subsequent erosions and -especially -between BMEP and erosions in follow-up. Several MRI-based studies have demonstrated earlier visualisation and visualisation of more erosions using MRI as compared to projection radiography as well as the value of MRI in early clinical diagnosis of RA based on synovitis. MRI protocols rely on T1-w sequences, (moderately) T2-w / STIR sequences covering at least 2 imaging planes and post-CM sequences. The latter may contribute to differentiate active erosions from mere cystic change and clearly contribute to assess synovial inflammatory disease activity. Dynamic Contrast Enhanced MRI (DCE-MRI) of rheumatoid arthritis has been shown to correlate with histological markers of inflammation, predict erosive progression and respond to treatment. Various imaging parameters and analysis techniques have been described. Some of these are discussed in this presentation together with the choice of timing of imaging. In general, the entire volume of inflamed synovium should be assessed in the joint or joints of interest. The optimal MRI parameters are a compromise between the spatial and temporal resolution technically achievable; the signal-to-noise ratio may not be a major limitation. A spatial resolution of less than 1 mm in all three planes and temporal resolution of around 10s typically provides acceptable reproducibility of simple measurements of early enhancement rates. Pharmacokinetic modeling of the DCE-MRI data characterizes underlying physiological parameters; however, the early enhancement rate may be a more appropriate marker of response to treatment as it represents a combination of several synergistic effects. DCE-MRI offers the potential to measure changes after 1 week of TNF blocking treatment and is sufficiently responsive to show an early improvement followed by relapse in some patients. In conclusion, early enhancement rates calculated from 3D DCE-MRI datasets provide reproducible measures which sensitively track the time-course of inflammatory changes in rheumatoid arthritis. However, care must be taken when interpreting a response to biologic therapy in the first few weeks as the initial improvement may not be maintained. Trauma is the third leading cause of death in the USA, and the leading cause of death for those under 40 years of age. Thoracic injuries are responsible for 25% of trauma deaths. Each year more than 300,000 patients are hospitalized in the USA and 25,000 people die as a result of thoracic trauma. Today, multi-detector computer tomography (MDCT) can quickly and accurately diagnose and display a wide variety of thoracic injuries. In the multiple trauma patient, thoracic CT can be included as part of a single acquisition 'total body' trauma scan, which also includes the patient's head, face, cervical spine, abdomen and pelvis. CT scans for suspected thoracic trauma should be performed with intravenous contrast material to opacify the aorta, heart and vascular structures. Routine coronal and sagittal reformations are performed in all cases. Volumetric (3D) and CTAs (CT arteriograms) are performed for displaced fractures of the thoracic skeleton and vascular injuries. CT can quickly and accurately diagnose and display a wide spectrum of thoracic injuries. In the pleural space, CT can show occult pneumothoraces, tension pneumothorax and hemothorax. Lung contusion, lung laceration and lung herniation are clearly displayed. Aortic injuries are accurately diagnosed, and CTA images can show the relationship between the injury and left subclavian artery, for treatment planning. In cardiac trauma, CT may show hemopericardium from cardiac contusion, pneumopericardium from pericardial laceration and IV contrast extravasation from cardiac laceration. Airway injuries of the trachea and bronchi are accurately diagnosed as are large and small diaphragmatic injuries and skeletal trauma. This lecture will cover majority of the splenic and bowel injuries seen on multidetector computed tomography (MDCT) following blunt trauma. The appearances of blunt liver and splenic injuries will be compared and contrasted. The lecture will also emphasize the relevance of the MDCT findings of these three injuries to their subsequent management. Blunt injuries of the extraperitoneal organs and structures include a great spectrum of injuries and may represent a difficult challenge for their diagnostic and management implications. Renal injuries can be classified into four large categories based on imaging findings. The vast majority of blunt renal injuries include minor injuries and therefore are managed non-operatively. Serious renal injuries are frequently associated with injuries to other organs. MDCT can help differentiate trivial renal injuries from those requiring intervention. Injuries of the pancreas resulting from blunt trauma are relatively uncommon and difficult to detect. However, these injuries are associated with high morbidity and mortality, especially if the diagnosis is delayed. MDCT can demonstrate pancreatic parenchymal injuries and complications such as abscess, fistula, pancreatitis and pseudocyst. MDCT also suggests disruption of the pancreatic duct, depending on the degree of parenchymal injury, whereas MR cholangiopancreatography allows direct imaging of the pancreatic duct and sites of disruption. Early recognition of this finding is of critical importance as disruption of the main pancreatic duct is the main cause of delayed complications. Duodenal injuries may be very subtle. Extraperitoneal fluid after complete laceration of the duodenum may require definitive confirmation using oral contast. Injuries of the retroperitoneal vessels are relatively uncommon. Early identification of these injuries is imperative because hemorrhagic shock remains a primary cause of death. MDCT is the modality of choice in the identification of retroperitoneal vessels injuries in stable and semi-stable patients and can direct optimal management decisions. Dyspnea, an uncomfortable sensation of breathing or an awareness of respiratory distress, can result from a range of conditions with various clinical presentations (acute,subacute and chronic)and with many possible associated signs and symptoms.A number of disorders cause dyspnea including congestive heart failure, COPD,asthma, metabolic acidosis, anxiety, upper airway obstruction and neuromuscular diseases.The majority of cases are caused by either a cardiac or respiratory disorder. Acute dyspnea represents a challenge for physicians and needs accurate and rapid diagnosis.An integrated diagnostic strategy is mandatory to achieve a correct diagnosis.Some of the causes can be identified by clinical examination but other causes can be insidious requiring further diagnostic exams that comprehend evaluation of some biomarkers and radiological tests such as chest X-ray and multidetector computed tomography pulmonary angiography (MDCT PA). MDCT is able to provide detailed information on pulmonary arteries, aorta, coronary arteries, heart and lung parenchyma at the same time giving a comprehensive assessment of cardiac and non-cardiac causes of dyspnea in stable emergency department patients with a good overall sensitivity and specificity. In this context, pulmonary embolism remains a diagnostic challenge and dyspnea is a common presentation symptom; an accurate assessment of pre-test probability that involves clinical evaluation, laboratory tests and, in some cases, even chest X-ray has a key role in the diagnostic algorithm. When pre-test probability is intermediate or high, MDCT is the method of choice to achieve the definite diagnosis with a high sensitivity and negative predictive value and with a high percentage of alternative diagnosis identification. Multidetector-row computed tomographic (CT) angiography of the pulmonary arteries is the first-line imaging technique in patients suspected of having pulmonary embolism (PE). Patient risk stratification is important because optimal management, monitoring and therapeutic strategies depend on the patient's prognosis. The relation between morphological extent of PE with clinical outcome will be treated by several additional scientific papers at ECR 2009. Acute right-sided heart failure is known to be responsible for circulatory collapse and death in patients with severe PE, and can be assessed on CT pulmonary angiography by measuring the dimensions of the right-sided heart cavities or systemic veins. The magnitude of PE can be calculated on CT pulmonary angiography by applying dedicated CT scores or adapted angiographic scores. This information can be combined with clinical data such as the Wells score. However, small pulmonary emboli may go undetected in patients who do not present typical clinical signs or whose symptoms are not attributed to PE. To date, there is limited knowledge about such incidental undetected cases of acute PE in patients who undergo multidetector-row CT of the chest, and how the severity of PE in combination with other morbidity factors influences the natural course of the disease in patients treated for PE in comparison with those receiving no treatment. This refresher course reviews CT-based scoring methods for assessment of patients with acute PE. The various CT-based methods for risk stratification and their potential value for a combination with clinical scoring system such as the Wells score are discussed. A comprehensive review of imaging strategies for patients with incidental and minor subsegmental PE is given. Learning Objectives: 1. To learn about the frequency and prognostic significance of mild pulmonary embolism with one-year outcomes in high-risk patient cohorts. 2. To improve the diagnostic skills in detection and severity assessment of acute pulmonary embolism using CTA. 3. To stratify patients with acute PE according to high and low mortality risk using combined clinical and CT-based scoring techniques. Pulmonary hypertension (PHT) remains a disease difficult to diagnose because the clinical findings are non-specific, often leading to a delayed diagnosis. Once recognized, 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, particularly well exemplified in the specific context of chronic thromboembolic pulmonary hypertension. 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 microcirculation, the latter being 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. The major clinical impact of these new scanning protocols is that morphology and function can be obtained from the same data set, with no restriction on the diagnostic performance of highresolution CT angiographic images. The purpose of this lecture is to review these new trends in imaging of PHT through practical clinical situations, including the most common causes of PHT. An improved diagnostic accuracy of the state-of-the-art imaging modalities (US, CT, MR) has resulted in an increased detection of small renal masses. First of all, the superb spatial resolution of MSCT contributes to higher detection rate of these lesions although their confident characterization (benign vs. malignant) is often challenging. Ultrasound allows accurate discrimination of majority of cystic lesions, including simple renal cysts; however, many of other masses cannot be characterized with this modality. The other, not infrequent problem encountered on US, are pseudotumors, which are most often due to normal anatomical variants (i.e. column of Bertin, dromedary hump). True nature of these lesions can be clarified by CT and MR imaging. According to Bosniak's classification, cystic lesions can be divided into four types: (I) simple cysts, (II) cysts with minimal risk of malignancy, (III)possibly malignant cysts, and (IV) definite cystic neoplasms. MR imaging, due to a very good contrast resolution, enables best characterization of fluid structures, allowing distinction of hyperdense cysts (> 40 HU on CT, due to hemorrhage or high protein content) from solid tumors. The diagnosis of angiomyolipoma is based on detection of fatty tissue and relies on CT and MR imaging. On the contrary, adenoma cannot be readily distinguished from RCC by either technique. Oncocytoma in many cases may also mimic RCC and only a small percentage of these lesions demonstrate characteristic appearance suggesting correct diagnosis. In the diagnosis of focal inflammatory lesions, clinical history along with imaging findings may be useful in lesion characterization. Advances in our understanding of the natural history and limited aggressive potential of many small renal masses, expanding treatment options and the integration of molecular factors into prognostic and therapeutic algorithms have stimulated renewed interest in percutaneous renal mass biopsy. Today, biopsy plays a fundamental role in the care of patients with a renal mass. Biopsy results are used to confirm the diagnosis of renal cancers, metastases, and infections, and there is increasing evidence to suggest that biopsy can help subtype and grade many primary renal cancers. Reported techniques of renal mass biopsy vary widely with different modes of radiographic guidance, needle size, number of cores and pathological analyses. Percutaneous biopsy of renal masses is now most often guided by using CT, US, and rarely MR imaging. Until now, there are no data to support the use of one modality for all masses. Percutaneous biopsy of renal masses can be performed with a wide range of needle sizes. However, percutaneous renal mass biopsy with two or three cores using 18-gauge needles may improve diagnostic accuracy without increasing morbidity. Both increased incidence and improved survival in renal cancer are considerably attributable to the incidental radiologic detection of early stage disease and the advent of safe nephrecotmy in the 1970s. Small kidney cancers should not, however, be dismissed as unimportant indolent cancers in an ageing population. Whilst, the 5-year survival has improved dramatically since the 1950s, there has been a rise in the overall age-standardised mortality from kidney cancer from 3 to 4.5 per 100,000 population between 1971 and 2005 in the UK, for example. The available natural history papers for small renal tumours indicate that there is a cohort of 15 -20% which grow much more aggressively and as yet we have no simple method for identifying this subset. Urologic outcome data have clearly shown that partial nephrectomy can achieve identical oncological outcomes to standard/radical nephrectomy. Preservation of background renal function is an important consideration in this population and ablative procedures are increasingly being shown to have equally effective oncologic outcomes at 3 -4 year follow-up. A number of different thermal energies including radiofrequency and cryoablation have been shown to be effective in the ablation of sub-4 cm (T1a) tumours. With careful image guidance and other interventional manoeuvres almost all sub-4 cm renal tumours are amenable to image-guided ablation with very low morbidity. These techniques will be discussed. The lecture provides an overview of the imaging characteristics of the common benign focal liver lesions namely cysts, haemagiomata, focal nodular hyperplasia and hepatic adenomata. The appearances of regenerative liver nodules, abscesses and focal fatty change or sparing are also described. Particular attention is given to the enhancement characteristics and appearance of these lesions with contrastenhanced ultrasound and MRI. Atypical presentations of these lesions and pitfalls will also be discussed and several case examples are provided where the different imaging modalities help in problem-solving. More of benign focal liver lesions are detected nowadays with the routine use of cross-sectional imaging modalities. Differentiation between benign liver tumours from malignant and pre-malignant lesions is accepted as the most important diagnostic problem. Although differential diagnosis is easily obtained by the help of advanced imaging modalities in some of the patients with presumed benign focal liver lesions, final diagnosis sometimes becomes possible only after getting by percutaneous biopsy for the differential diagnosis between benign and malig- nant lesions or the confirmation of presumed benign focal liver lesions. Although percutaneous biopsy is performed under US guidance in most of the patients with presumed benign focal liver lesions, CT or MRI are also used in some instances. After having standard sterile conditions, the procedure is carried out by using generally free-hand technique besides the others. Generally, a cutting needle biopsy is indicated to achieve the correct diagnosis in patients with presumed benign focal liver lesions. Diagnostic accuracy is associated with up to 99% of the patients in this group of patients. Although complication rates of guided biopsy have been reported between 0-6%, most authors report rates less than 2%. The mortality rate has been estimated at 0.1% or less. Therefore, imaging-guided biopsy is a highly accurate procedure in patients with presumed benign focal liver lesions if indicated. Benign focal liver lesions are a common finding in clinical imaging, whereas lesions such as, e.g. hemangiomas and cysts of the liver may be found in up to 20 % of the cases. Furthermore, the permanent technical improvement of almost every imaging modality leads to the detection of an increasing number of small (benign) lesions. In this setting, benign lesions can be found incidentally or -even more crucially -in patients with suspected or known underlying malignant disease with and without the simultaneous presence of malignant liver lesions. In consequence, it is of ample impact to differentiate these lesions for further adequate treatment-planning. As benign liver lesions are in general not necessitating surgical resection or any other therapy with some rare exceptions, it is essential to confirm the benign nature of a lesion to prevent the patient from potential harm by an undesired therapy. The integration of clinical information and modern imaging techniques such as mainly contrast-enhanced ultrasound, multi-phasic contrast-enhanced computed tomography and magnetic resonance tomography will allow a correct characterization of benign lesions with a very high prevalence. Depending on the clinical situation, also a wait-and-see tactic can be suitable, while in ambiguous cases a percutaneous biopsy may speed up the diagnostic decision-process. Typical clinical scenarios regarding different focal liver lesions with and without concomitant (malignant) disease will be discussed considering appropriate diagnostic strategies, taking in account also technical and economical issues. Learning Objectives: 1. To discuss contribution of current imaging modalities to the diagnosis of benign focal liver lesions. 2. To discuss the influence of imaging diagnosis on therapeutic decisions: Surgery vs follow-up. 3. To define clinically focused diagnostic strategies for the assessment of these lesions. ECR 2009 is an important date in the history of European-Swiss radiology. With Prof. Borut Marincek as the President of congress, Switzerland is one of the hosted countries in the "ESR meets programme". It is an honour and privilege to present four Swiss speakers in this session addressing the use of high-field MRI in academical research and clinical practice in Switzerland. Topics are heart-imaging, stroke management, abdominal and pelvic MRI-imaging well as Sports imaging. Swiss academic and clinical radiology has always had its place at the forefront of European radiology. It is our aim to share with the audience the use of high-field MRI as another sphere, where Switzerland contributes to considerable advances in European radiology. Perfusion imaging in the heart of Europe: 1.5 Tesla and more J. Bremerich; Basle/CH (jbremerich@uhbs.ch) Myocardial perfusion imaging with MR is an attractive alternative to nuclear techniques since it provides more information, is better available, less expensive, and does not require radiation. Gadolinium-enhanced-first-pass perfusion imaging, however, requires cutting-edge hardware components allowing for very rapid imaging of the whole heart with excellent spatial and contrast resolution. Saturation-recoverygradient-recalled-echo sequences are typically used to acquire up to eight slices with every heart beat. Hardware improvements such as dedicated multichannel coils, strong gradient systems and higher field scanners can improve perfusion imaging. In recent years, multiple 3 Tesla scanners have been installed in Switzerland and throughout Europe. Recent studies showed that perfusion imaging benefits from such 3 Tesla systems with respect to signal/noise-ratio, contrast/enhancement-ratio and maximum signal-upslope. First generation 3 Tesla systems were hampered by substantial artefacts. Most of these problems, however, are now solved with the latest generation scanners. Today many radiologists are still reluctant to pharmacological stress testing, although the vasodilator adenosine has an excellent safety profile and has been used for decades in nuclear medicine. Recent studies showed safety and high diagnostic accuracy of MR perfusion imaging. Most interesting is the excellent negative predictive value of a normal perfusion scan which has also been reported from nuclear imaging. In conclusion, cardiac perfusion MR is an attractive alternative to nuclear techniques. Perfusion MR benefits from cuttingedge hardware such as dedicated multichannel coils, strong gradient-systems, and 3 Tesla field. Larger studies, however, are still required to define the place of perfusion MR in management of coronary artery disease. The impact of high field MRI on stroke management Neuroradiology plays a central role in the diagnosis and management of acute stroke in Switzerland. Due to progressive developments in both software and hardware, Magnetic Resonance Imaging techniques play an increasingly important role in the management of patients with acute stroke. Techniques such as diffusion and perfusion have shown to be of importance in depicting the early lesion and perfusion deficit. Diffusion tensor imaging and functional MRI play an important role in the follow-up of stroke patients in order to assess neuronal regeneration and cortical reorganization. These techniques have been improved even further by the advent of high-field MR systems (> 3 T). New perfusion techniques such as arterial spin labelling should be able to demonstrate revascularization and collaterals and susceptibility-weighted imaging (SWI) can demonstrate hemorrhages better than standard T2* imaging. The use of 3 T machines is, however, associated with the occurrence of increased artifacts that require sequence impèrovements. We discuss how this has impacted patient management in Switzerland and how to this day MRI remains both an indispensable clinical tool and a research method. Indeed both pathophysiologically and from an imaging point of view some controversies still need to be resolved regarding its use. Learning Objectives: 1. To understand the advantages and disadvantages of 3 T neuro-imaging. 2. To understand how to best implement 3 T protocols for stroke. 3. To understand the impact of high-field MR on patient management in Switzerland. Abdominal and pelvic MRI: From 1.5 to 3.0 Tesla D. Weishaupt; Zurich/CH (dominik.weishaupt@usz.ch) Over the last decade, MR imaging has gained wide acceptance as a potent tool for evaluation of the abdomen and pelvis. Several hard-and software refinements such as the introduction of phased-array coils, parallel imaging as well as the availability of fast high-resolution 3D gradient echo sequences for dynamic breath-hold contrast-enhanced imaging have turned MR into a robust technique for imaging of the abdomen and pelvis. In addition tissue-specific contrast agents, diffusionweighted imaging as well spectroscopy allow for metabolic or functional information. With the advent of whole-body 3.0 T MR systems further improvement in image quality is expected. Although the advantages of high-field-strength systems with regard to improvement of signal-to-noise ratio are obvious, 3.0 T systems do not always live up to user expectations for imaging of the abdomen and pelvis. Imaging at 3.0 T requires several protocol adaptations in order to compensate for the increased chemical shift and susceptibility artifacts at 3.0 T. In addition, the radiologist has to deal with standing wave and conductivity effects which are usually not seen at field strength of 1.5 T. Coping with these artifacts and SAR issues is crucial and determines to which extent high-field strength MR will succeed clinically. Nevertheless clinical experience and first results of published evidence has shown that 3.0 T seems to improve imaging of the abdomen and pelvis at least for some applications. Learning Objectives: 1. To appreciate the role of abdominal and pelvic MRI in Switzerland. 2. To discuss opportunities and challenges of high field imaging in the abdomen and pelvis. 3. To review current status of high field abdominal and pelvic imaging. Does sports imaging need 3.0 Tesla? T. Treumann 1 , H. Bonel 2 ; 1 Lucerne/CH, 2 Berne/CH MRI is the most flexible of all imaging modalities, and 3 T is the latest and greatest technology to be introduced to the MR imaging community. In the past years, we have observed a widespread shift from 1.5 T to 3 T imaging in Switzerland. An increasing number of smaller hospitals and outpatient facilities are adopting 3 T today, as opposed to academic hospitals and research facilities -the primary users of 3 T just a few years ago. In sports medicine, MRI has become a vital part for diagnosis, treatment, and postoperative evaluation. If the patient happens to be an athlete, as in many instances, it will be possible to determine the status of an injury without surgery and without keeping the player off the field until he or she recovers from the diagnostic procedure. One of the primary benefits of imaging with a 3 T magnet is that it allows users to either acquire images faster, by using less signal to obtain a diagnostic image, or to go to higher spatial resolution and acquire finer detailed images. Different to spinal or abdominal imaging, the approach of plugging into 3 T, what you do at 1.5 T, works fairly well for musculoskeletal (MSK) imaging, but emphasis lies on finer detail and higher resolution. A number of orthopedic and sports traumatologists are no longer satisfied with 1.5 T images, but insist on 3 T MR imaging for their patients. For the radiologist, the main benefit of 3 T seems to be the heightened diagnostic confidence level to diagnose lesions. Learning Objectives: 1. To appreciate the role of 3 T imaging in athletes. 2. To discuss the advantage of 3 T over 1.5 T in musculoskeletal imaging. 3. To review the current status of musculoskeletal imaging. Interventional uroradiology has been evolving over the last two decades with the aid of advances in the fields of computer-assisted imaging modalities as well as image-guided minimally invasive techniques. Percutaneous procedures are replacing open surgical methods as they often provide equal or more benefit to the patient without general anaesthesia, with less pain, faster recovery and better end-results. The importance of diagnostic radiology and a team approach with urologists and nephrologists in planning and executing the interventions is paramount. Optimal image-guidance, indications, techniques and complications of the most common interventional uroradiology procedures such as drainage, urine diversion, and antegrade ureter stenting are discussed. Kidney transplantation has become a routine procedure for the treatment of endstage renal disease. In the preoperative period, the task of the radiologist is to rule out diseases (systemic malignancy, active infection, severe arteriosclerosis) contraindicating transplantation. In living related donors, one has to confirm that two structurally normal and functioning kidneys are present. The anatomy of renal vessels can be mapped by CT angiography prior to harvesting. It is important to know precisely the applied surgical technique. Ultrasound is the principal imaging technique used in the evaluation of the transplanted kidney. The normal renal transplant can be easily visualized in the iliac fossa. Assessment of the renal graft includes evaluation of the a) size of the kidney (length, parenchyma width), b) parenchymal echogenicity, c) definition of the cortico-medullary junction, d) collecting system, e) surrounding soft tissues, f) vascularization, resistive index (RI). During evaluation renal graft failure, the radiologist has to consider the time of its occurrence. Parenchymal complications are acute tubular necrosis (ATN), rejection (hyperacute, accelerated acute, acute or chronic), cyclosporine toxicity, disease recurrence, or infection. Possible vascular complications are renal vein thrombosis, renal artery thrombosis and renal artery stenosis. Urologic problems can be ureteral oedema, urinary fistulae, urinoma and subsequent ureteral strictures. In the differential diagnosis of fluid collections one has to take into account haematoma, abscess, urinoma and lymphocele. The occurrence of neoplastic diseases in transplanted patients are more common. Iatrogenic complications such as haemorrhage, renal AV fistula and pseudoaneurysm can occur after taking a biopsy. Morpho-functional imaging for personalised cancer therapy S. del Vecchio; Naples/IT (delvecc@unina.it) Current knowledge of the genetic alterations underlying tumor growth and progression indicates that individual tumors, despite shared pathological features, may have specific molecular signatures that can determine their differential aggressiveness, sensitivity or resistance to therapy and ultimately the susceptibility of the patient to be cured. Tumor microenvironment and host factors are additional important sources of variability in tumor response to therapy. Therefore, many efforts are currently made to identify and use the optimal drug regimen that will benefit an individual patient. Imaging technologies provide tools to visualize molecular characteristics of tumors, local microenvironment properties and several host factors affecting tumor response. On the basis of imaging findings, patients can be selected for a given drug regimen, drug effects can be monitored in real time, sensitivity or resistance can be predicted and identified, and relapse or progression can be early detected. In particular, the appropriate selection of patients for molecularly targeted therapies would promote an enrichment of patient population that can potentiate clinical trials. Early monitoring of tumor response to therapy would allow continuing or changing therapy on the basis of individual tumor sensitivity or resistance. Tumor microenvironment and host factors may be evaluated and eventually modified to favour drug action. Here, we report prominent examples of non-invasive imaging techniques that may guide the adoption and monitor the effects of specific drug regimens in individual patients, thus contributing to personalised cancer therapy. Learning Objectives: 1. To comprehend the rationale of personalised cancer therapy. 2. To understand the contribution of non-invasive imaging techniques to personalised cancer therapy. 3. To become familiar with applications of non-invasive imaging techniques to guide and monitor cancer therapy. Funding for imaging science: Where do we stand now in FP7 P. Jehenson; Brussels/BE (philippe.jehenson@ec.europa.eu) The aim will be to learn about the European Union's 7 th framework programme for research and technological development (FP7), which is managed by the European Commission and has a budget of about 50 billion euro over 7 years (2007) (2008) (2009) (2010) (2011) (2012) (2013) , and to understand its structure and the opportunities for research funding, including for young researchers. Dramatic advances in molecular biology have sifted into radiology generating the concept of "molecular imaging". Molecular biology has now expanded and migrated to "systems biology". This presages a similar migration in imaging. Radiology is in the information business. The questions being asked of it will necessarily change, as diagnostic and therapeutic decisions under a molecular medicine paradigm are increasingly based on systems biology. Radiology has sophisticated techniques that reveal and reflect the histopathology of diseases. Histopathology, however, is being supplanted by "molecular signatures". Imaging will need to navigate toward providing information about molecular signatures, which reflect important biologic processes. The body's systems are nested and operate on many scales. But the basic system resides within the cell, having evolved over approximately 2 billion years to form a scale-free network, which is both fast and robust, but in which causality may not be easily determined. This system and its subsystems control basic biologic processes such as growth, death, energy metabolism, cell motility, angiogenesis, etc., which collectively produce cell and tissue phenotypes. It will become the goal of "systems radiology" to develop analytic imaging techniques to parse the state of biologic processes that determine prognosis, drug selection and therapeutic response. For radiology to answer questions in the new molecular age of medicine, imaging will need to be closely tied to the burgeoning techniques of measuring system behavior within cells, within tissues and between organs. The questions asked of radiology are changing and its answers will need to be "systems" oriented. Imaging-guided biopsy has replaced surgical biopsy of suspicious breast lesions to reduce unnecessary surgery for benign disease and indicate the need for sentinel lymph node procedure. Biopsy guidance depends on lesion visibility at sonography, mammography or MRI. For minimizing the false negative results, 9-14G needles and vacuum-assisted systems are the preferred sampling methods for G H most lesions. Image documentation of non-palpable lesion location and residual amount after biopsy is mandatory for preoperative lesion localization planning. A clip is positioned at the site of biopsy whenever a suspicious lesion disappears during sampling or neoadjuvant chemotherapy. Preoperative lesion localization is usually guided by the imaging modality that has been used for biopsy. Specimen radiograph during surgery reduces surgical cancer removal with positive tumor margins at postoperative pathology. Breast cancer staging encompasses a wide variety of anatomical and pathologic features that have a clear impact on treatment: size, extensive intraductal component, extension to the nipple-areola complex, the pectoralis muscle or the skin and lymph node status. Compared with mammography and ultrasound, MRI is the most accurate imaging modality for local staging, except for lymph node assessment, where ultrasound and fine-needle aspiration biopsy are the techniques of choice. The different follow-up strategies in the breast cancer patient depend on the clinical scenario: assessment of response to neoadjuvant chemotherapy, follow-up of patients treated with conservative or reconstructive surgery, confirmation of a suspected recurrence and evaluation of residual disease after positive margins at pathology. The role of different imaging modalities will be demonstrated in teaching cases. The objective of stress imaging are to assess perfusion, synchronicity, viability or functional reserve. Adenosine stress enables assessment of cardiac perfusion reserve which is an early indicator of significant coronary artery disease. During infusion of Adenosine for 3 minutes (140 µg/kg/min) gadolinium-chelates are injected (0.1 mmol/kg) at 4 ml/s and the first-pass of gadolinium is assessed with a saturation-recovery-gradient-recalled-echo sequence. Relevant coronary artery disease is characterized by hypoperfusion at stress which is not present at rest. Adenosine has a favourable safety profile. Dobutamine stress enables assessment of perfusion, synchronicity, viability and functional reserve. Wall motion is imaged with cine-gradient-recalled-echo sequences at rest and incremental doses of dobutamine (5/10/20/30/40 µg/kg/min). Significant coronary artery disease and restricted functional reserve is identified by declining systolic myocardial thickening with increasing doses, viability by improving function with increasing doses, and severe dyssynchrony by increasing wall motion abnormalities with increasing doses. Pharmacologic stress requires monitoring of ECG and blood pressure. Adenosine stress perfusion imaging has matured to a widely used and robust tool. Sensitivity/specificity for detection of coronary artery disease are 91%/62%, which exceed that of scintigraphy. Moreover, adenosine MR allows for risk stratification in patients with suspected coronary artery disease and is an excellent predictor of major adverse cardiac events. Dobutamine stress MR identifies viability with sensitivity/specificity of 73/83%. Moreover, Dobutamine has been used to assess functional reserve after repair of tetralogy of fallot. In conclusion, stress MR provides important information on cardiac function and perfusion and is a strong predictor of major adverse cardiac events. (srunderwood@imperial.ac.uk) This presentation will review the basic patho-physiology underlying SPECT and PET imaging of the myocardium including mechanisms of tracer uptake and retention and also pharmacological stress techniques. It will review current clinical indications for both techniques together with the evidence that underlies current guidelines. There will be an emphasis on the assessment of viable and hibernating myocardium in patients with heart failure and a consideration of the relative strengths and weaknesses of each technique. Implications for future routine practice of nuclear cardiology will also be considered. Hibernating myocardium is defined as chronic but potentially reversible myocardial dysfunction at rest due to persistently impaired coronary blood flow. In patients with ischaemic cardiomyopathy, hibernating myocardium will recover when revascularised, infarcted myocardium will not. It's estimated that 20-50% of patients with ischaemic cardiomyopathy have a component of hibernating myocardium and could benefit from revascularisation. Revascularisation, however, is not without risk and revascularising infarcted myocardium represents risk for no benefit. The role of imaging is to distinguish hibernating myocardium from infarction and thereby identify those patients needing revascularisation. There are multiple modalities that can fulfill this role (stress echocardiography, nuclear SPECT & PET, first pass MR perfusion & delayed enhancement). Each has its own strengths and weaknesses. How should they best be used and how should we deal with 'turf' issues raised by different techniques being managed by competing clinical groups? This presentation will examine the principals behind each modality and will suggest a rationale for their use. The Leicester approach to combining these techniques under one clinical umbrella, i.e. 'non-invasive cardiac imaging', will also be described. Trauma to the spine is not an uncommon injury affecting predominantly the young and healthy individuals. The socioeconomic costs for those suffering additional injuries to the spinal cord are astronomic. Incorrect or delayed diagnosis of unstable and therefore threatening fractures increases poor outcome with severe disability. The primary goal of initial imaging workup of patients with spinal trauma is to identify those with unstable fractures and therefore allow fast and precise surgical repair. This workup follows quiet simple rules taking into consideration the functional architecture of the spine (i.e. the three columns of the spine), the mechanism of injury (e.g. flexion or distraction) and possible pre-existing diseases, such as ankylosing spondylitis. Knowledge of the normal appearance of the spine and of possible pitfalls together with these previously addressed rules and appropriate use of available imaging modalities should enable every radiologist to distinguish the stable from the unstable spinal fractures. Acute traumatic spinal cord injury (SCI), in majority of the cases, results in devastating medical and social consequences. Magnetic resonance (MR) examination is the imaging method of choice in assessment of lesion morphology, extent and severity of trauma. As the intramedullary lesions like hemorrhage and edema are dynamic -the time interval between injury and MR examination should be not longer than 72 hours. For interpreting the performed MR images correctly, one has to understand the mechanisms of SCI, which are similar to brain diffuse axonal injury in large number of patients. For optimal characterization of SCI, one has to start with an estimation of maximum canal compromise and the degree of spinal cord compression at the beginning. Then qualitative intramedullary changes should be evaluated: Cord swelling, edema, contusive hemorrhage, hematomyelia, partial or complete laceration. Patients with minimal cord changes at MR imaging usually have the best outcome, then the group of patients with cord edema is the next. On the other hand, intramedullary hemorrhage is a single predictor of the bad outcome. It is also accepted that the level of injury has influence on the eventual prognosis. Protocol for routine MRI of patients with SCI, which consists of SE and GRE sequences, is proposed. Additional and new imaging techniques like MRA, DWI and DTI are discussed, they should be implemented in complicated cases or for prognostic purposes. One has to also reckon with non-mechanical acute SCI conditions like iatrogenic complications after vertebral radiofrequency ablations, high voltage electrical injury etc. Spinal injuries are generally less common in children when compared with adults. Of all the spine injuries, cervical spine injuries are the most frequently reported spine trauma accounting for 40-60%; of all pediatric spine injuries, however, cervical spinal injuries are relatively rare in children and accounts for only 10% of all such injuries. The etiology varies depending on the age of the child with motor vehicle accidents being the most common cause of pediatric cervical spine injury, but obstetric complications, fall, child abuse sports, and diving accidents also account for many injuries as well. The specific biomechanics of the pediatric cervical spine leads to a different distribution of stresses in injuries and distinct radiological features and represent a distinct clinical entity when compared with those seen in adults. Young children more commonly have upper cervical injuries, seldom below C3, whereas older children are prone to lower cervical injuries. The pediatric cervical injuries in children less then 8 years of age demonstrates a high incidence of subluxations without fractures and they are more prone to spinal cord injury with normal radiographs compared with adults, seen in up to 6% the cases because of the ligamanetous laxity. In addition, physial injuries are specific for children. The methods of choice for imaging the suspected spinal injuries in children are the same as for adults; multi-slice CT with reformatted images, and, if indicated, MRI. This lecture will focus on typical spinal injuries seen in the pediatric population with special focus on injuries of the cervical spine. Radiology plays a significant role in helping to properly diagnose and treat emergency patients. Ensuring an efficient, clinical and cost-effective emergency radiology service requires close collaboration with emergency physicians and other critical care colleagues. This session aims to exchange views and experiences with the European Society for Emergency Medicine in order to further enhance the medical treatment of emergency patients. In many hospitals, the percentage of emergency radiological examinations is 30% or more. In order to cope with this challenge, the radiology department has to integrate a satellite unit in the emergency department or adjacent to it. The minimum requirements of equipment for this unit consist of state-of-the-art general radiography, ultrasound and CT rooms. Ultrasound is recognised as a primary screening tool for more expedient diagnoses in potentially life-threatening emergencies. Requests for radiology via RIS and reporting with the aid of PACS will secure a "time-critical" workflow, especially while the emergency department is overcrowded. Teleradiology allows a continuous urgent reporting offside. The permanent availability of a dedicated group of highly trained radiologists and radiographers is a prerequisite for an efficient patient care. Evidence-based algorithms providing immediate optimal service to emergency patients will be presented in this session. Session Objectives: 1. To remind the audience that radiology is an integral part of an emergency department. 2. To emphasise the importance of a first-hand dialogue between the radiologist and the emergency physician in order to ensure a high quality patient care. 3. To review the role of ultrasound as a primary, symptom-directed diagnostic tool in the triage of emergency patients. 4. To appreciate and explore the contribution of the different imaging modalities in the emergency department for securing a "time critical" workflow in any circumstance, especially overcrowding. Ultrasound as a time critical diagnostic tool for the emergency department P.K. Thompson; Rockhampton, QLD/AU (pkthompson@mac.com) Emergency and other critical care clinicians increasingly use ultrasound as a point of care tool to aid clinical assessment at the patient's bedside. It is important to appreciate how ultrasound can be used to benefit patient and clinician, at the bedside, in such a focused assessment, in comparison to a more formal imaging assessment by ultrasound within the imaging department. A brief review of literature and worldwide experience in relation to the clinician use of ultrasound is provided. This focuses on the role in resuscitation and the impact on critical clinical decisions at the patient's bedside. The role of ultrasound in assisting in interventional procedures such as central venous cannulation is crucial. The benefit of this for patient care, as well as the utility of focused ultrasound in assisting the prioritisation and use of other imaging modalities, is discussed. The role of training and the need for competency-based assessments are also considered in light of recent experiences within the UK and other developed emergency care training programmes. Ultrasound is of particular benefit in the assessment of a patient's circulation when there is a possibility of free intra-peritoneal, pleural or pericardial fluid secondary to trauma. It is also of significant benefit in the assessment of patients presenting to the emergency departments with abdominal or back pain or other symptoms suggestive of an abdominal aortic aneurysm. Similarly, it has a significant role in providing a focused cardiac assessment in numerous peri-arrest scenarios when clinical intervention is required and shock is anticipated. The use of US in the patent with acute trauma is a controversial issue. From a radiologist's view, items of concern are the precise role that US (including contrastenhanced US) should play in the imaging of acute trauma in the setting of MD-CT close to the emergency room, the amount of training and appropriate level of expertise of the sonographer and/or the physician (as in my country) performing the examination, required to obtain high accuracy, the limitations (and advantages) of focused US examinations (FAST) and the utility of the results for decisions regarding optimal patient management. The FAST approach focuses on the presence or absence of hemoperitoneum for further management and additional imaging, but US has an additional high impact to the diagnosis of pleural and pericardial fluid and pneumothorax in the acute trauma setting. However, MD-CT is more sensitive and specific than US for the vast majority of abdominal, retroperitoneal and thoracic trauma injuries and can provide relevant information on injuries of the head, face and spine that are not accessible by US. If MD-CT is not immediately available, US performed by experienced hands and an experienced brain can confirm or rule out intraabdominal and, with less accuracy, retroperitoneal injury. However, after severe trauma I would prefer my admission into a trauma center provided with state-of-the-art MD-CT. A major programme of reform in England has resulted in a massive decrease in overcrowding of emergency departments (EDs) and most patients now spend less than 4 hours in the department. This was achieved by redesign work, both within the emergency department and outside. Patient flows were analysed and lean thinking approaches were used to determine the value adding steps in the processes and to remove waste. The relationship between the ED and the imaging department can have a major influence on the flow of emergency care patients. The flows between the ED and imaging can be improved by various tools including process mapping, spaghetti diagrams, resource utilisation and demand analysis. An understanding of variation in flow is key, as is the realisation that much of the variation in demand is predictable (and a lot is created by the system). Traditional ways of working have often been convenient for the staff, but not efficient for the organisation or convenient for the patient. New technologies including PACS can contribute to improvements, but only if part of a redesign. The imaging department also has a major impact on the length of stay of all patients, which influences bed occupancy, which in turn improves outflow from the ED. By understanding where we can all add value and where we create waste, we can produce a system that is better for the patient, easier for staff and better for the hospital. In the emergency room, it is essential to assess critically injured patients quickly and adequately. This implies making a judicious choice of the most efficient and effective imaging modalities, taking into account recent technological developments. Several factors should be considered in selecting the optimal imaging modality, including the quality and completeness of the information provided, speed, availability, reliability and safety of the procedure. Unfortunately, in many hospitals, severely injured patients are still referred first for pointless plain X-ray films, and valuable time is lost before the patient is referred for a multi-detector CT scan examination. The purpose of this presentation is to familiarize the audience with the various imaging technologies (mainly ultrasound (US), multi-detector computed tomography (MDCT), and magnetic resonance imaging (MRI)) and their appropriate application in the accident and emergency department. The issue of 'focussed assessment with sonography for trauma' (FAST) will be addressed, and compared with MDCT in early triage of emergency room patients. We shall point to the increasingly important role of MRI in acute neurological diseases and trauma. Our problem-based approach will focus on imaging strategies for patients with trauma of the craniocerebral region, spine, chest, abdomen and pelvis, and musculoskeletal system. We shall propose diagnostic algorithms which can stand the test of being efficient, reliable, reproducible and cost-effective. In summary, this presentation will focus on showing how the appropriate application of radiological technologies facilitates patient flow through the triage and fast-track areas of an emergency department and contributes to the overall quality of patient care. Learning Objectives: 1. To stress that radiologists must become familiar with the clinical issues involved in the care and management of acutely ill and traumatised patients, and that they should understand the specific questions to be answered. 2. To select the most effective and appropriate diagnostic imaging techniques in a given clinical setting. 3. To highlight the increasingly important role of radiologists for advising emergency medicine physicians, and thereby contribute to quality of patient care. 4. To offer a problem-based guide for the imaging evaluation of emergency room patients and present algorithms for common pathologic entities seen in emergency radiology. Osteoporosis is a healthcare-social problem of increasing relevance in developed countries, especially because of the rapid increase of the incidence of fragility fractures in postmenopausal women. More than 10 years ago the diagnosis of osteoporosis has been defined by WHO on the basis of the assessment of bone mineral density (BMD). Osteoporosis is defined as a BMD of 2.5 SD or more below the average value for premenopausal women (T-score <-2.5 SD). Severe osteoporosis denotes osteoporosis in the presence of one or more fragility fractures. Even if in the first years all measurable sites were equally considered valid for diagnosis, recently it was recognised that the most effective site for diagnosis is the proximal femur with dual energy X-ray absorptiometry (DXA). Several other skeletal sites (axial and appendicular) could also be evaluated by other validated densitometric techniques (QCT, QUS) for fracture prediction. Other clinical risk factors contribute to fracture risk independently of densitometric techniques. These include age, previous fragility fracture, premature menopause, a family history of hip fracture, and the use of oral corticosteroids. Because of the many techniques available for fracture risk assessment, the T-score approach to determine the risk of fracture appears to be lacking because of discrepancies among sites and techniques. The 10-year probability of fracture is the most effective approach to determine intervention thresholds. Many cost-effective treatments can be provided to women if on the basis of the10 year-probability of fracture. Insufficiency fractures are defined as stress fractures that occur due to normal biomechanical loading in abnormally weak bone. They are commonly observed in patients with osteoporosis, but may also be found after radiation therapy or chemotherapy. Typical locations are the pelvis, sacrum and the spine. At the spine MRI is very sensitive to differentiate acute and old vertebral insufficiency fractures; also these fractures have typical morphologic features that frequently allow their differentiation from neoplastic fractures. At the pelvis insufficiency fractures are located frequently in more than one location, which affects imaging protocols and coverage of the whole pelvis is generally recommended. Given frequent concurrent osteopenia in the patients fractures are very difficult to diagnose on radiographs and more than 40% of pelvis insufficiency fractures, sacral fractures in particular, are negative on radiographs. It should also be noted that CT detects only approximately 70% of the insufficiency fractures diagnosed with MRI. Typical combinations of insufficiency fractures are found, for example pubic insufficiency fractures, approximately 90%, associated with fractures in another location, in particular the sacrum. At the knee it now has been generally accepted that lesions previously described as spontaneous osteonecrosis of the knee are actually insufficiency fractures occurring typically in elderly patients (> 60 years). In summary, insufficiency fractures are a frequent pathology that needs to be correctly diagnosed and MRI currently is the most accurate imaging test to arrive at this diagnosis. However, the radiologists have to be familiar with the typical features of these fractures. In a general hospital, acute abdomen accounts for 30% to 40% of all emergency surgical admissions, and the abdomen is involved in approximately 25% of multitrauma patients. Recent technological advancements have brought to the forefront the importance of imaging in the initial assessment and subsequent management of patients admitted with acute abdominal conditions. Thus, the role of clinical examination, laboratory data and imaging is constantly redefined in new management algorithms, in the endeavor for achieving the highest level of efficiency and to optimize the use of medical resources. Abdominal organ injuries, either isolated or part of more extensive trauma, require immediate and reliable imaging evaluation after stabilization of the patient's condition in order to make fast therapeutic decision to reduce mortality to a minimal level. In both traumatic and non-traumatic acute abdominal conditions, the routine diagnostic work-up scheme (plain abdominal X-ray + ultrasound) is more and more frequently replaced by abdominal multidetector CT examination, extended to other regions as necessary. It is of utmost importance for an emergency radiologist to get familiar with the classical signs and pitfalls encountered in common traumatic and non-traumatic acute situations, as also to understand the current role and diagnostic efficacy of the different imaging modalities. The initial investigation of a pelvic mass is invariably with ultrasound. Analysis is based on the following criteria: Size; calcifications; septa; wall thickness; papillarities; mixed cystic and solid state; blood flow; contrast enhancement; and abnormalities outside the presenting lesion. Certain benign lesions such as haemorrhagic cysts and dermoid tumours can present characteristic features. Clot retraction and the change of blood with time can accurately define a haemorrhagic cyst. Likewise, a fat/ fluid level, echogenic plug or dermoid mesh indicate a dermoid tumour. Appropriate clinical features help too; for instance, fever points towards an abscess and pregnancy and pain in someone known to have a fibroid suggests fibroid degeneration. Papillarities, a mixed cystic and solid pattern and evidence of disease outside the G H presenting lesion are strong pointers to a malignant lesion. When an adnexal mass is found, the operator must take into account the age, menstrual status, prior and presenting history as well as the ultrasound appearances in deciding the nature of the lesion. Possible decisions are: a) benign, no follow-up needed; b) benign, but needs removal or other treatment; c) most likely benign, follow-up with ultrasound after an interval; d) possibly benign but level of uncertainty high, proceed to MR to characterise the lesion; e) malignant, proceed to CT scan for staging. Finally, in patients unfit or unsuitable for surgery, biopsy may be needed to confirm the nature of a tumour. Transabdominal omental biopsy or transvaginal biopsy of a pelvic mass are well tolerated and provide reliable results. Ultrasound is the first line imaging modality to assess a suspected adnexal mass. However, overall approximately 20% of masses on US are considered as indeterminate. MRI has been established as powerful modality to further investigate these lesions. The latter include complex masses, such as dermoids, endometrioma or other benign hemorrhagic lesions, leiomyomas, fibrothecomas, hydrosalpinx and ovarian cancer. The purpose of further imaging these lesions includes: a) identification of the origin, b) differentiation of benign from malignant tumors and c) differentiation of benign lesions that warrant intervention from those that do not. Characterisation of an adnexal mass by MRI is based upon morphologic features, signal characteristics and perfusion. A diagnostic algorithm to further assess indeterminate adnexal masses will be presented. It is based on the findings using standard MRI with T1 and T2WI. Such lesions are then divided into the three following categories: a mass bright on T1WI, a mass dark on T2WI and a cystic solid mass. Depending on these features further characterisation is possible by using additional sequences including fat saturation, chemical shift imaging or contrast enhanced imaging. CT staging, especially multislice CT, is the modality of choice for staging ovarian cancer. The prognosis of patients with ovarian cancer is still related to the tumor stage at laparoscopy and residual tumor after cytoreductive surgery. Nevertheless, tumor debulking is not always possible because of the tumor extent and planning surgery might be difficult. Thus, the roles of imaging are triple: to select the candidates for primary chemotherapy if the lesions are non resectable, to determine the best sites for biopsies in case of peritoneal carcinomatosis, and to help to define the therapeutic strategies in a multidisciplinary approach. Resectability on imaging depends on two major factors: lesion size and location. The following imaging criteria for predicting non resectable disease must be known : abdominal wall invasion, retroperitoneal presacral disease, lymph node involvement above renal hilum, peritoneal implants > 2 cm (porta hepatis, intersegmental fissure, gastrosplenic and gastrohepatic ligaments, diaphragm) and invasion of small bowel mesentery. CT staging must include chest, abdominal and pelvic images to detect also distant metastasis. In case of non-resectable lesion, the treatment must begin with primary chemotherapy in order to allow the debulking surgery. Nevertheless, sensitivity of CT is still low to detect small peritoneal implants (< 2 cm). Magnetic resonance imaging (MRI) is the most sensitive imaging modality for the detection of invasive breast carcinoma regardless of the fibroglandular composition of the breast. It is performed in prone position, in the axial, sagittal or coronal planes. Axial position is preferrable because correlation with mammography and comparison with the opposite breast is possible. For detecting small enhancing lesions reliably, fatty tissue signal is suppressed, either by active fat-suppression or subtraction. Examinations should be performed in the second week of the menstrual cycle. Differential diagnosis is based on morphologic findings as well as contrast-enhancement kinetics. It is important to have high-resolution images while scanning as fast as possible so that the temporal data is not lost. On MRI, benign lesions usually demonstrate minimal and slow enhancement, whereas malignancies are expected to show rapid enhancement and then washout. Morphologic findings are described according to the MR BI-RADS lexicon for the standardization of reports and interpretation criteria. Masses with irregular or spiculated borders that show rim enhancement are highly suspicious for invasive tumors. On the other hand, non mass-like enhancement in the form of ductal or segmental clumped enhancement is also considered suspicious and can be detected in DCIS. While interpreting breast MRI examinations, morphological and kinetic findings should be combined and correlated with mammographic and sonographic findings. Risk factors, if there are any, should also be taken into consideration. In this lecture, appropriate imaging techniques as well as findings that can be helpful in lesion characterization will be reviewed. Magnetic resonance mammography (MRM) is opening new avenues in the diagnosis of breast cancer. It has been known for over 25 years that MRM can accurately detect breast cancers larger than 3 millimeters. The problem in recent years has been an international debate concerning methods, techniques and the interpretation of the myriad images. For years, the phrase "high sensitivity but low specificity" has been used like a mantra to characterize MRM. But results in recent decades suggest that we can greatly increase this limited specificity by extracting and analyzing all of the morphologic and kinetic signs contained in the 1000-plus images from an MRM examination. In this refresher course I will explore the currently known signs in MRM and they will be discussed and demonstrated using examples so that this information can be applied in the practical interpretation of MR mammograms. Local staging is of importance in the treatment decision of patients with breast cancer. MRI at the moment is superior to mammography and ultrasound in tumorsize estimation as well as the detection of multifocality and multicentricity. In about 20% of the cases, MRI shows additional malignant lesions in the affected breast when compared with mammography and ultrasound. Although in the case of breastsaving surgery a patient will always be treated with irradiation and dependent on the size of the tumor, the grading and the lymph-node staging with hormonal and or chemotherapy, so small additional tumorfoci around the primary tumor, not removed by surgery, will be adequately treated with these therapies. Multicentricity, that means a second tumor more than 4 cm from the primary tumor, detected only by MRI is an indication for mastectomy. This has to be proven by biopsy. Another advantage of preoperative MRI is the better evaluation of the contralateral breast. In the literature, between 3% and 20% synchronous contralateral cancers are detected only by MRI. The fear of overtreatment by performing preoperative MRI is not realistic. The first results of the impact of preoperative breast MRI show that in patients who underwent preoperative MRI, the local recurrence was lower (1.2%) compared with women who did not undergo a preoperative MRI (6.8%). In conclusion, it can be stated that preoperative MRI has a positive impact on treatment and outcome. The aims of the lecture are the following: to present the regular brain vascularity, to present variations of the brain vessels, to present the neuroradiological correlates of occlusion of the brain vessels, and to present the influence of variations of the brain vessels on the extent and the neuroradiological appearance of a cerebral infarction. Perfusion Comutertomography (CT) and Magnetic Resonance Imaging (MRI) are increasingly utilized as the primary imaging modalities in major stroke centers. The ability to depict several aspects of individual pathophysiology makes the use of those techniques in stroke both attractive and complex. However, profound knowledge of the pathophysiology of the imaging findings is the major prerequisite for a rational diagnostic workup. The penumbra in acute stroke patients has been defined as brain tissue with loss of electric activity and potential recovery after timely recanalization of the occluded artery. It is widely accepted that extension of the lesion in acute stroke as delimited in perfusion weighted MRI (PWI) beyond the corresponding lesion boundary in diffusion weighted imaging (DWI) is indicative of tissue at risk of infarction. This "mismatch-concept" has been challenged recently on the grounds that the PWI lesion cannot discriminate reliably between benign oligaemia and true penumbra, and because of noted overestimation of the extent of infarction seen at follow-up. A likely factor in these shortcomings is that the same degree of perfusion impairment might have a different impact on the tissue depending on patient age, the anatomic location and time from stroke onset. However, the determination of the size of the ischemic penumbra may help predict potential response to therapy. In the presentation, basic imaging principles of diffusion and perfusion imaging as well as further perspectives like application of T2'-imaging and the use of multiparametric prediction maps will be discussed. Adequate visualisation of lower limb arteries is essential before arterial reconstruction. Digital subtraction contrast arteriography (DSA) has long been considered the diagnostic standard for imaging of peripheral arterial disease and is used routinely in most centres. MRA and CTA are now replacing DSA as standard imaging methods. Also, replacing diagnostic DSA with duplex ultrasound (DUS) is finding wide acceptance because of its non-invasive nature, lower risks and costs. By tradition, lower limb DUS has been considered to be imprecise, operator-dependent and difficult to learn. However, when imaging peripheral arterial disease, there is a good agreement between DUS and DSA in the supra-and infragenicular segments. DUS is highly reproducible, with an overall interobserver variation comparable with DSA. After the first 15 supervised DUS examinations, proficiency can be obtained in the supragenicular segment. The infragenicular arteries are more demanding, requiring 100 supervised DUS examinations. Infragenicular vessels distal to multiple occlusive lesions are also difficult to visualize using DSA. In some of these cases, patent vessels can be demonstrated using DUS, thus offering possibility for limb salvage. In conclusion, DUS and DSA are valuable tools in the diagnostic workup of peripheral arterial disease and both should be mandatory in the diagnostic armamentarium in all vascular units. DUS has the potential to increase limb salvage rate, reduce patient discomfort and procedure-related complications in selected cases. Since its introduction, contrast-enhanced (ce-) MRA has experienced an exciting evolution and now plays a dominant and outstanding role in state-of-the-art vascular imaging. The availability of highly diagnostic, non-invasive MRA techniques has more or less replaced diagnostic, invasive intra-arterial DSA. After the introduction of bolus-chase or moving-bed techniques, ce-MRA has become the leading MRA technique, even for the peripheral arteries. However, acquisition time is relatively long; also, imaging of the complete peripheral vasculature with homogeneous accuracy at all levels is still challenging. As the visualization of the arteries of the calf can be hampered by venous overlay or limited spatial resolution, different techniques to reduce the acquisition time, to increase the spatial resolution, and to reduce the venous overlay, especially in diabetic patients, have been reported. Hybrid techniques that combine fast 2D acquisitions of the arteries of the pelvis and the thigh with high-resolution scans of the crural and pedal arteries during a second contrast injection provide high spatial resolution with no venous overlay in the third field-of-view. Recently, continuous MRA was introduced with promising results. With the recently launched intravascular (blood-pool) agents, significantly increased spatial resolution can be obtained. However, complex discrimination between arteries and veins is mandatory using such agents, which might be timeconsuming. During this presentation, the different techniques for peripheral MRA, including single-station, multi-station -multi-injection, moving-bed, or bolus-chase protocols, as well as hybrid protocols, will be described and demonstrated on clinical examples. Sequences, contrast-injection protocols, and visualization techniques, will be explained and exemplified. Peripheral arterial disease (PAD) is one of the major manifestations of systemic atherosclerosis estimated to be present in 3% of the people in the age range 40-59 years and in 20% of the people over 70 years. Approximately 5% of the patients with PAD will progress from intermittent claudication to critical limb ischaemia (CLI) in the due course of their disease. CLI is associated with an extremely poor prognosis with a mortality rate of 25% per year and an additional amputation rate of 25% in the same time. Anatomically in CLI patients, approximately 70% of the arterial lesions are located both in the in the femoro-popliteal and tibial tract. Only 30% of the patients present with below-the-knee artery lesions. Because of the coincidence of diabetes mellitus in most of the patients, these arteries are very often heavily calcified. This has to be taken in consideration when selecting an imaging method for the vascular tree of CLI patients. Therefore imaging of the vessels of CLI patients has to be fast, non-invasive and be sufficient as a tool for the treatment-planning. Multirow-detector CT has a potent role in this field characterized by advantages and limitations compared with other imaging modalities. In the refresher course, the CT-protocols together with the post-processing modalities will be reviewed. One major demand is the number of images which are produced in these patients. In addition, further limitations like severe calcifications and the delayed contrast of the arteries because of pre-existing stenosis or occlusions will be addressed. This presentation is for the enthusiastic, intellectually curious, hard-working young investigator/teacher who has little first-hand experience with the scientific writing and publication process. You will learn about common mistakes and pitfalls in the manuscript writing and submission process and how to avoid them. You will learn new insights into the how and why of the editorial decision making process through the use of real-world examples, from the International Consulting Editor of the American Journal of Roentgenology (AJR). In particular for patients up to 40 years of age, trauma is the most common cause of death. In order to reduce mortality, a rapid radiologic diagnosis is essential. Today, sonography plays a role only in the evaluation of minor trauma and as ´Focused Assessment with Sonography for Trauma (FAST)' in major trauma. However, computed tomography has proven to be a potent tool for the triage of traumatized patients, because, based on the results of the CT scan, patients can be referred for operation or safely be classified for "wait and see" treatment. For that purpose, injury severity scores are of great help, and the radiologist must be familiar with these scores, as well as with the therapeutic consequences associated with them. In particular for you as radiologists in training, it will often be a challenge to provide accurate reports when numerous surgeons are standing behind you. This presentation will focus on online radiology resources that are available for training purposes. Information will be given about the different types of online resources that currently can be found. Several methods to search the Internet effectively for these resources will be explained and demonstrated. Tips and tricks will be given to make optimal use of the Web for this matter. Finally a selection of websites that can be used for training and also for clinical practice will be shown and discussed in more detail. (t.vogl@em.uni-frankfurt.de) In the present session on radiofrequency ablation beyond the liver the various indications for RFA, such as lung, kidney and musculoskeletal lesions will be discussed. The presenters of this session will provide an overview on the different techniques. They will inform about indications, contraindications, complications and results in the various organs. Moreover, the role of RFA in the competitive field of thermal ablation with special focus on microwave ablation and laser ablation will be discussed to define the future role of RFA. Another question is whether RFA will also be used outside the radiology department. The current role of radiofrequency is based on the experience in the clinical outcome of radiofrequency-guided thermal ablation in focal liver lesions. Different instrumentation in technology nowadays also allows a variety of indications beyond the liver. The techniques of radiofrequency ablation (RFA) are mainly based on different technologies like mono-and bipolar RFA, cooled systems and a huge variety of radiofrequency probes which can be individually adapted to size, neighbourhood and position of the intrahepatic position of the lesions. For monitoring RFA, ultrasound and MR-guided placement of the radiofrequency probe is performed via percutaneous access, especially for evaluation of possible side effects and complications. The clinical strategies are based on the organs involved. Thus, RFA has been established in the treatment of primary and secondary lung neoplasms with new advances regarding the design of the RFA probes. The second most frequent indication is the treatment of kidney neoplasms. Here especially the therapeutic role of radiofrequency in the management of small intra-renal lesions will be documented and discussed. In musculoskeletal lesions RFA has been fully integrated both in the osteoid osteoma and in other bone tumors and metastases. Radiofrequency ablation has been applied to lung tumors for almost a decade and has managed to become an established minimally invasive therapy option for a selected patient population. RFA is applied both for primary lung cancer and for pulmonary metastases, both with a curative and palliative intent. Early stage NSCLC (T1N0M0, T2N0M0) have successfully been treated by percutaneous RFA with 5-year overall survival rates of 27% and 47% progression-free survival for tumors < 3 cm, with a median time to progression of 45 months. These figures are clearly more favourable than those for conventional external beam radiation. Promising results have been achieved with ablating lung metastases, provided the patients were carefully chosen with respect to number, size and site of the metastases. Control of the primary tumor site is mandatory for curative intent. Five year survival rates for lung metastases from colorectal cancer are as high as 57%. Combination of RFA with radiotherapy for NSCLC, especially in N1 and N2 disease with the option to irradiate hilar and local mediastinal lymph nodes not amenable to RFA should be a viable consideration with available data showing convincing 5-year cumulative survival rates of 39% and no additional toxicity. The role of palliative thoracic RFA should not be underestimated, indications being pain, cough and hemoptysis not otherwise controllable. Cytoreduction through RFA prior to chemo-/radiotherapy is also worth considering, taking into account that the centre of a large tumor, often hypoxic, is more resistant to ionizing radiation and chemotherapeutic drugs and prone to recur locally after treatment. The need for therapy in bone tumors is triggered by the typical clinical signs as pain, local destruction and destabilization, immobilization, neurologic deficits, and finally functional impairment; whereas pain relief and stabilization is the primary goal of every therapy in bone tumors. Beyond osteoid-osteoma, representing an incidence of 1:2000, primary benign and malignant bone tumours are rare entities accounting for only about 0.2% of all malignancies. The therapy of first choice in these entities is surgical resection if necessary and possible. Therefore, only few anecdotal data on radiofrequency ablation of such tumors exist. In contrast, secondary osseous malignancies may occur in about 30 to 70% of all malignant diseases and are mostly found within the spine (69%), in the pelvis (41%), in the femoral (25%), and in the skull bones (14%). In the majority of cases where surgery cannot be applied anymore radio-and/or chemotherapy inclusively hormonal therapy, depending on the primary tumour, will be administered. Unfortunately, the response to these therapies is limited with a high risk of recurrence. This stimulated the utilization of more targeted, minimal-invasive techniques as RFA already known for excellent results in the treatment of solid organ tumors. Local RFA will remain mainly a symptomatic, supportive (palliative) therapy, which can also be applied in conjunction with other therapies as resection, radio-or chemotherapy, or augmentation procedures. At present, the limited data on RFA in skeletal tumors indicate a high success rate regarding symptomatic pain relief; nevertheless, the final role of RFA in the treatment algorithms of bone tumors seems to be promising, but has still to be defined. The hypopharynx, or laryngopharynx, is the most caudal portion of the pharynx that extends from the laryngeal surface of the epiglottis to the cricopharyngeus. Most authors divide the hypopharynx into the piriform sinuses, the posterior wall, and the postcricoid region. Occasionally, within the literature, a fourth area of the hypopharynx is described as the marginal area, represented by the lateral surface of the aryepiglottic folds. However, the larynx itself presents one of the true challenges of head and neck imaging. Consequently, the diagnostic approach to the hypopharyngeal neck is based on a brief understanding of the complex anatomy and function of the larynx. Congenital, inflammatory, neoplastic, and traumatic abnormalities all affect the larynx. Based on endoscopy, the clinician mainly has a certain predisposed idea of the clinical problem, eventhough the endoscopist is limited in his ability to define the acuteness of certain pathology relative to precise landmarks. These landmarks determine whether the patient is a candidate for a pharyngolaryngectomy, a laryngectomy, a speech conservation therapy, or a radioand/or chemotherapy. The exact knowledge of the different surgical approaches is mandatory for the radiologist to ascertain the necessary and most appropriate therapeutic approach and to obtain the best result for the patient. Anatomic landmarks and the radiologic appearance in a non-pathologic neck and a pathologic involvement of these landmarks will be reviewed extensively in a coherent manner. Post-treatment imaging is done when a recurrent tumour is clinically suspected, for confirmation and determining its extent. After radiation therapy, tumour recurrence appears on CT or MRI as a soft tissue mass at the primary site. After surgery, it appears as a mass along the resection margins. Imaging may also be used as a surveillance tool, to try to detect recurrent tumour before it becomes clinically evident, possibly with a better chance for successful salvage. Early tumour recurrence may be difficult to distinguish from treatment-induced tissue changes. An early follow-up CT or MR study, best obtained about 3-6 months after the end of treatment, documents treatment-caused tissue changes. By comparing subsequent studies with this baseline study, tumour recurrences can be detected with more confidence, and often earlier than that obtained by clinical follow-up alone. Some authors recommend FDG-PET as the initial baseline study. If performed 3-4 months after treatment, FDG-PET has a high negative predictive value, but a relatively low positive predictive value. A positive post-treatment FDG-PET study should be correlated with clinical findings and results from other imaging modalities, and histological confirmation is desirable. Diffusion-weighted MRI provides information about cell density and integrity, and vascularity, and is feasible in the head and neck. This technique is very sensitive to structural tissue changes, even during their very early stages of development. Initial results suggest that this non-invasive technique, not requiring an external contrast agent, may be more specific than FDG-PET in the post-treatment evaluation of head and neck cancer. With the exception of distant metastases, the presence of cervical lymph node metastases is the single most adverse independent prognostic factor in patients with head and neck squamous cell carcinoma (HNSCC). This implies that staging of neck metastasis is a crucial step in treatment planning. As the sensitivity of ultrasonography, CT and MRI in identifying small lymphatic metastases is inadequate, many of the patients with no detectable metastases will receive elective treatment of the neck. Nor PET-CT presently fully addresses this clinical question. In fact, its sensitivity is strictly dictated by the size of the metastasis: excellent when size is 8-9 mm or more, very low when diameter is less than 5 mm. Should 'focused techniques', like FNAC (or functional MR, ADC-based), be applied to the most probable nodal site (s), according to primary tumor location? Unfortunately, this strategy does not appear practical, as lymphatic drainage patterns from HNSCC are not highly predictable. Nuclear medicine techniques such as the sentinel lymph node biopsy may improve the detection rate of the lymph-borne target-node. Its role in staging and management of HNSCC is yet to be fully established. A second critical issue is the detection of tumor spreading beyond the lymphnode capsule (ECS). Its presence reduces survival to 25 to 30%, and it is a significant predictor of the development of distant metastasis. The imaging features of ultrasonography, CT and MRI indicating extracapsular tumor spread, carotid and vertebral invasion should be well known to the radiologist because they have therapeutic and prognostic implications. This course will focus on diffuse, frequently bilateral processes characterized by 'alveolar filling-in'. The differential diagnosis of 'airspace shadows' is long and includes a broad variety of diseases in terms of diagnosis, therapeutic management and prognosis. The radiographic and CT appearances depend on the intra-alveolar material (cellular vs. fluid) that resulted in a replacement of the air within the distal airways, the temporal evolution (acute vs. chronic) and reactive or associated changes of interstitium and vessels. Pieces of useful information towards the differential diagnosis include a) analysis of the features of the shadowing such as its density, distribution and borders; b) analysis of accessory findings such as signs of volume increase or decrease, vascularity, the presence of air bronchogram or the presence of overlying reticular or septal densities and c) correlation with clinical symptoms such as hemoptysis, fever, history of cardiac insufficiency, immune-status or a history of known or suspected malignancy. The goal of the course is to review common causes of alveolar shadowing such as pneumonia, atelectasis, edema, hemorrhage, alveolar proteinosis or neoplastic diseases; to describe important morphological and clinical features leading to the diagnosis and to provide the radiologist with helpful visual and clinical tools for differential diagnosis. Learning Objectives: 1. To become familiar with an alveolar pattern in CXR and CT. 2. To understand the underlying radiologic-pathologic correlations of alveolar opacities. 3. To review the spectrum of the common and unusual conditions presenting with an alveolar pattern. 4. To discuss an approach to the differential diagnosis based on clinical information, distribution of disease and additional morphological findings. Septal, reticular, nodular, reticulonodular and ground-glass patterns characterize interstitial lung disease. Each of these HRCT patterns characterizes some predominant entities, and in combination with clinical findings often helps to make a specific diagnosis. Occasionally different entities may mimic each other tremendously on radiologic terms, either because they share identical HRCT findings or because of superimposition of HRCT patterns. Idiopathic pulmonary fibrosis, fibrosis associated with connective tissue disease, asbestosis, chronic sarcoidosis, chronic hypersensitivity pneumonitis and drug-induced fibrosis may present on HRCT with lower zone, subpleural reticular pattern associated with honeycombing. Cystic pattern also results in a reticular pattern. Occasionally lymphangiomyomatosis may be indistinguishable from tuberous sclerosis or langerhans cell histiocytosis (LCH), while end-stage LCH may mimic end-stage fibrosis or extensive emphysema. Both pulmonary edema and lymphangitic carcinomatosis may be characterized by a septal pattern resulting from thickened interlobular septa. Micronodular pattern with ill-defined centrilobular nodules may be identically present in hypersensitivity pneumonitis and respiratory bronchiolitis. Sarcoidosis may occasionally mimic miliary tuberculosis or hematogenous metastases presenting with a miliary nodular pattern, while bronchogenic spread of tuberculosis may be indistinguishble from panbronchiolitis, both presenting with tree-in-bud pattern. Atypical infection presenting with ground-glass pattern may mimic hemorrhage. Ground-glass pattern associated with minimal reticulation may be seen in desquamative interstitial pneumonia, respiratory bronchilitis associated intestitial lung disease and nonspecific interstitial pneumonia. Various mimics in interstitial lung disease exist and differential diagnosis could be narrowed when possible, based on the integration of the correct HRCT pattern together with any additional imaging clues in the appropriate clinical context. Learning Objectives: 1. To learn about the different HRCT patterns, which are related to interstitial lung diseases and to understand the underlying pathologic-radiologic correlations that cause each HRCT pattern. 2. To be familiar with the more "classical" entities presenting with each HRCT pattern and to discuss the possible overlap of different HRCT patterns and the more common diagnostic mimics in each case. 3. To familiarise with potential pitfalls in diagnosing interstitial opacities on HRCT and learn about some clues that help differentiate the various diagnostic mimics. Uterine artery embolization is indicated in the treatment of symptomatic fibroids in women who wish to retain their uterus and/or avoid surgery. Patients are currently selected on the basis that menorrhagia is their main complaint and their family complete. Contra-indications include infection, refusal to consent for hysterectomy under any circumstances, pregnancy and suspected malignancy. All patients should have a gynaecological assessment and be provided with information about all treatment options. A diagnosis of uterine fibroids should be made by ultrasound or MR. Patient preparation protocols should be in place which may include prophylactic antibiotics, analgesia protocols etc. Operators will develop their own technique, but common to all is the need for selective catheterisation of both uterine arteries, which are embolized with particulate matter. It is important to understand the difference between various particulate agents and how the end points for embolization differs between them. For non spherical agents, virtual stasis in the uterine artery is required whilst for spherical agents, flow in the parent artery is maintained with a "pruned tree" appearance. Patients should be informed of the expected course of events following embolization, and how to recognise complications. They should also be given the names and contact details in case of emergency. They should be reviewed early in their post embolization period and then again at 6 months and beyond to assess outcomes. Either US or MR are used to image the uterus. MR has the advantage of allowing easy comparison and assessment of any residual fibroid vascularity. There is an increased demand for uterine sparing procedures in fibroid treatment. The significant innovation has been the uterine artery embolization as non-surgical management. Myomectomy is the standard of surgical care for women who wish to retain their uterus. It can be carried out laparoscopically, vaginally and abdominally. The aim of this workshop is to compare uterine artery embolization with myomectomy. So far four studies have been performed in which clinical outcomes of UAE were compared with abdominal myomectomy, two retrospective (Broder et al., Razavi et al). and two prospective. One of them non-randomized (Goodwin et al)., compares myomectomy with embolization using non-spherical PVA particles and the other one, randomized prospective study, compares UAE and myomectomy in pregnancy planning women (Mara et al). Overall results give evidence that UAE offers an advantage over conventional surgery in terms of shorter hospital stay and quicker return to daily activities. Clinical outcome appears to be similar to that of surgery as well as complication rate. Two studies report higher re-intervention rate in embolization group compared to surgery. Myomectomy appears to have superior reproductive outcomes in the first 2 years after treatment. The economic analysis indicated that UAE is less expensive than myomectomy even after further treatments for unresolved or recurrent symptoms are taken into account. There are no studies comparing embolization with other than abdominal myomectomy. There is a continued need for further longer term and larger randomised controlled trials of UAE versus medical or surgical treatments for managing symptomatic fibroids. One of the important issues of treatment of uterine fibroids is to preserve fertility in patients seeking pregnancy. Recent studies confirmed the feasibility of Uterine Artery Embolization (UAE) in complex therapy of these patients. Although a lot of issues are still equivocal and need further research, on the basis of 7-year experience in UAE and more than 1800 interventions performed, we discuss indications and contraindications, choice on embolic agent, specific technical maneuvers intended to prevent inadvertent embolization of ovarian arteries which is the important issue in patients desiring pregnancy. Specific attention is paid to combination of UAE with other methods such as myomectomy and hysteroresectoscopy depending on clinical situation and outcome of UAE. We discuss this aspect of the problem from the interventional radiologist's point of view and offer the algorithm of complex treatment of patients with uterine fibroids desiring pregnancy. In conclusion, the results of complex treatment are analyzed: the rate of pregnancies, deliveries and their complications. Also directions for further studies are described. MRI of the liver has to evaluate the liver parenchyma, vasculature, and biliary system. It is necessary to employ a variety of different magnetic resonance (MR) pulse sequences to achieve lesion detection and characterization. A set of T1-and T2-w pulse sequences is standard for evaluation of fat and iron content and for lesion delineation. In-phase and opposed-phase T1-w GRE images show focal or diffuse fatty infiltration and focal sparing. For T2-w imaging, a TSE sequence with fat-suppression (either breath-held or with free breathing) is robust and provides high tumor contrast. 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 because of the long echo-train. In case of suspected iron overload (i.e., hemosiderosis and hemochromatosis) an additional T2*-w GRE is recommended. Administration of a contrast agent is mandatory in liver MRI, because many focal lesions will only be highlighted by enhanced pulse sequences. Dynamic gadolinium chelate-enhanced T1-w GRE pulse (preferably 3-D interpolated) sequences are versatile and useful for lesion detection and characterization as well assessment of the vasculature (i.e., Budd-Chiari syndrome, portal vein thrombosis, etc). Both the hepatobiliary and reticuloendothelial liver-specific contrast agents render excellent results for detection and differentiation between metastases and hemangiomas or FNH. Some liver-specific contrast agents are not gadolinium-based and can be administered in patients with renal insufficiency. The choice of contrast material should be based on availability, the specific clinical question, and the renal function of the patient. The advent of powerful gradient systems resulted in substantial improvement of image quality in ultrafast magnetic resonance (MR) imaging and therefore novel clinical applications emerged including gastrointestinal tract imaging. Within this context, MR enteroclysis and MR colonography were developed, providing luminal, transmural and extramural diagnostic information at the same imaging session. Two different protocols have been developed for imaging the small bowel with MR. These include MR follow-through and MR enteroclysis. MR follow-through is based on the oral ingestion of an adequate amount of contrast agent and acquisition of consecutive sequences. In a clinical setting, sufficient luminal distention that guarantees accurate individual lesion detection can be achieved by MR enteroclysis. Two MR colonography protocols have been proposed. According to the first, termed as 'bright lumen MRC', a gadolinium-spiked water solution is administered endorectally to the patient who has previously undergone colonic cleansing to distend the colon, resulting in a homogeneous high-signal intensity on heavily T 1 -weighted 3D gradient echo images. Polyps are demonstrated as filling defects while air bubbles can be differentiated by performing the examination in both supine and prone positions. 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. MRI of the pancreas and bile ducts relies upon a combination of T2-w and T1-w strategies to acquire anatomic and functional information. Tissue-imaging strategies include free-breathing T2-w imaging (obtained with echo-train SE sequences with or without fat-saturation) and breath-hold 3D-GRE 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 and the advent of more sophisticated phased-array coils and parallel imaging capabilities 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 for increasing the sensitivity of MRI. 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 biliary imaging is obtained 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 secretin challenge with the objective of improving anatomic delineation and quantifying fluid production by the exocrine pancreas. The need for a non-invasive modality for coronary artery imaging has triggered substantial improvements of CT technology in the preceding decades. CT has rapidly evolved from a research tool to a valuable non-invasive modality used in daily clinical practice. Using most recent CT technology, robust imaging of coronary arteries has become feasible. Several trials have demonstrated a high diagnostic accuracy and robustness of coronary CT angiography to assess coronary stenoses in selected patients. Based on clinical considerations, coronary CT angiography is beneficial in symptomatic patients having no high risk for coronary disease. Moreover, coronary CT angiography is considered appropriate for the comprehensive assessment of coronary artery anomalies. Further indications include the evaluation of aorto-coronary bypass grafts, and the planning of minimally invasive heart surgery. Another important -yet not entirely accepted indication -includes the use of coronary CT angiography in patients with acute chest pain having normal initial biomarkers and a normal or inconclusive ECG. While the evaluation of coronary stenoses and anatomy is the major clinical indication for coronary CT angiography, a simultaneous and accurate assessment of ventricular functional parameters, regional wall motion, and valve morphology as well as function have been proven by several studies. Despite these developments in CT technology, coronary CT angiography still suffers from limitations including the evaluation of patients with severe coronary calcifications, coronary stents, and complex arrhythmia. Further improvements in technology are expected to allow an expansion of indications for coronary CT angiography in the near future. The parameter used in CT to indicate radiation output is the Computed Tomography Dose Index (CTDI). This index is not the patient-dose, but rather an internationally standardized method for expressing the amount of radiation delivered to a standardsized phantom for a given scan protocol. It is displayed on the scanner console to assist the user in scan optimization. It can also be used to estimate effective dose (E), which is of interest in assessing potential biologic risk. E is a 'risk-equivalent dose' and can not be directly measured; rather, it is calculated using risk estimates averaged over age and gender. It can not be used for epidemiological purposes or for any single patient. The range of E values reported for cardiac CTA is comparable or less than that from other cardiac imaging exams. Specific estimates of E for various exams will be presented. Modulation of the mA throughout the cardiac cycle has been shown to reduce dose in cardiac CT by as much as 50%. The dose reduction depends on the time spent at minimum mA and maximum mA per cycle. A limitation of ECG-based modulation occurs when patient heart rate is not stable, as the optimal reconstruction window might occur during mA min . Algorithms that automatically increase the mA to mA max when the scanner senses an R-R interval that is significantly different from the previous rhythm provides increased clinical robustness, such that ECG-based modulation is used more consistently. This and other dose reduction tools will be described. Low-back pain is a major burden for the health-care system, $100 billion worldwide being the annual estimated cost. MRI is the major diagnostic tool in lumbar spine diseases. Nevertheless, conventional MRI is often unable to give a correct explanation of local and radicular pain. More recently, devices called "axial loader" had been proposed to simulate the gravitational load in conventional CT or MRI equipments. These devices, usually mechanical or hydraulic compressors, are in fact able to enhance the visibility of segmental instability or disc disease; however, they do not reproduce physiological load. On the other hand, dedicated MRI equipments had been proposed by some industries, which are able to examine the spine in the upright position or under flexion-extension or lateral bending, thus reproducing the normal physiological movements. Upright exams open new perspectives in studying biomechanics in normal individuals as well as enhance the diagnostic range in low back pain and sciatica. Changes in lumbo-sacral lordosis angle, sac dimensions and ligament distensions are easily seen in normal subjects. In pathology, morphological changes between recumbent and upright position are seen in 48-65% of cases, while therapeutically relevant findings vary from 12% in case of disc disease, 15 % in case of spondylolistesis and 30 % in case of stenosis. Finally, dynamic MRI opens the possibility of studying the subject in the painful position, sometimes different from the standard recumbent or upright ones. Major limits are represented by costs, examination time and motion artifacts due to difficulty in maintaining the upright position, mostly when it is painful. Image quality in spine MR imaging is dependent on five major factors: 1. Spatial resolution 2. Signal to noise (SNR) 3. Contrast to noise (CNR) 4. Temporal resolution 5. Artifacts. Artifacts: Susceptibility artifact and geometric distortion; chemical shift artifact, from the existence of multiple resonance frequencies; CSF partial volume effects; truncation artifact, insufficient phase-encoding sampling; B 0 -inhomogeneity of surrounding neck/airway structures; physiologic motion: vascular/CSF pulsation, respiratory, swallowing motion; nonphysiologic motion: gross neck motion; dielectric artifact; increased specific absorption rate (SAR). Most of these artifacts are in part dependent on magnetic field strength. There is substantial susceptibility and signal loss in the spine from signal dephasing at the tissue-bone and tissue-air interfaces. Similarly, increasing the TE to increase T2-weighting for the cord will result in increased CSF signal dephasing from pulsatile motion. These susceptibility effects can be decreased by using thinner sections as well as using multiple receiver coils with parallel imaging techniques. By the same token, combining phase array coil technology with higher field strengths can have a beneficial effect on other artifacts such as the dielectric effect and reducing the SAR. Modifying the shape of the RF pulse using a variable rate selective excitation (VERSE) pulse will also reduce SAR and improve image quality. Chemical shift effects are inversely proportional to the received bandwidth. Hence increasing the receiver bandwidth will decrease chemical shift; however, this comes at the cost of reducing SNR. Complications of cardiovascular disease, including stroke, myocardial infarction, and sudden cardiac death, are the most common causes of death in the western world. Atherosclerotic disease accounts for approximately 50% of ischemic strokes and for the majority of myocardial infarctions and sudden cardiac deaths. Despite major advances in the treatment of atherosclerosis, a larger percentage of individuals with the disease who are apparently healthy, die without prior symptoms. The challenge for screening and diagnostic methods is to identify patients at high risk who have lesions that are vulnerable to thrombosis, so called vulnerable plaques, before the event occurs. Imaging methods have the potential to not only be used as a screening tool for the presence of atherosclerosis but also to help distinguish stable from unstable plaques and ultimately patients with low versus those with high risk of cardiovascular complications. Furthermore, imaging methods can be used to further improve our understanding of the pathophysiology of the disease and to monitor anti-atherosclerotic treatment effects. The limitations and the potential of the different imaging techniques currently used in atherosclerosis imaging, such as magnetic resonance imaging, computed tomography, intravascular ultrasound and PET/SPECT imaging will be discussed in this session. Applications of these imaging techniques in animals and in humans will be shown and the potential of new imaging markers and new contrast agents will be discussed. Atherosclerotic disease of the carotid bifurcation is a major source of thromboembolism and subsequent stroke. Non-invasive in vivo investigations of the relationship between atherosclerotic plaque tissue composition/morphology and the development of neurological symptoms may provide critical information for detection of vulnerable plaque. Histological studies suggest that vulnerable plaque is characterized by thinning and rupture of the fibrous cap that overlies the necrotic core. Exposure of the thrombogenic core following cap rupture is thought to lead to ischemic complications from thrombotic occlusion of the vessel or distal embolization of athero-thrombotic debris. Carotid atherosclerosis, especially in advanced stages, tends to be complicated in both morphology and composition. The required imaging technique must be able to identify these features with reasonable spatial resolution and acquisition time. Magnetic resonance imaging (MRI), including the use of contrast agents, has been shown to be able to identify important features associated with vulnerable or culprit plaques. These include fibrous cap, lipid rich necrotic core, intraplaque hemorrhage, calcification, neovasculature, and inflammation. MRI can also be used to assess lesion types and provide quantitative measurement of plaque composition and lesion morphology. These abilities make MRI a unique technique for understanding atherosclerosis development, monitor atherosclerosis progression or regression, and study lesion features that can predict future clinical events. This lecture will highlight the following key points: (1) Technical considerations for atherosclerotic plaque characterization by carotid MRI; (2) Carotid MRI application in clinical diagnosis; and (3) Carotid MRI application in monitoring progression and regression of atherosclerosis. Future directions will also be discussed. Cardiovascular diseases are the most common cause of death in industrialised countries. Most of the morbidity and mortality is due to atherosclerosis of the coronary arteries, resulting in coronary heart disease and its principal manifestations, angina pectoris, myocardial infarction, sudden cardiac death and heart failure. Atherosclerotic lesions develop in a course of a series of highly specific cellular and molecular responses of the vessel wall to injury. The potentially most dangerous lesions are unstable and prone to rupture. These plaques are often of lesser stenosis severity and thus would sometimes not impair blood flow at rest or during exercise. Unstable plaques are characterized by activated macrophages, mast cells and other cells being localized in the plaque shoulder which secret a variety of matrix-degrading enzymes such as metalloproteinases. Therefore, there is a great need for non-invasive diagnostic techniques that characterize vascular lesions to early identify patients at high risk of major acute cardiovascular events. SPECT and PET provide the most sensitive and selective means for imaging molecular interactions non-invasively in the living body and could therefore prove a potent approach to the identification of the metabolically active plaque that is vulnerable to rupture. Targets for PET/SPECT imaging are among enzymes (e.g. matrixmetalloproteinases, caspases) and receptors, whose expression and activation destabilizes the plaque and increase the risk for plaque rupture and subsequent life-threatening events. New radiopharmaceuticals addressing relevant targets in plaques and their future use in hybrid imaging approaches (e.g. PET/CT) should improve the clinical characterization of atherosclerotic plaques. Learning Objectives: 1. To learn about the application of tracers and markers in animals and in humans and their advantages and disadvantages. 2. To understand the differences between PET, PET/CT and SPECT and the potential advantages and disadvantages. 3. To get acquainted with the potential molecular targets in the atherosclerotic disease process. Plaque imaging in animal models: New MRI contrast agents M. Sirol; Paris/FR (marc.sirol@gmail.com) Despite advances in our understanding of the pathogenesis of atherosclerosis and new therapeutic modalities, atherosclerosis and its thrombotic complications remain the leading cause of morbi/mortality in Western societies. The lack of an adequate imaging modality for early atherosclerotic plaque detection limits the prevention and treatment of the disease. Therefore, identification of high-risk atherosclerotic lesions prone to rupture and thrombosis may greatly decrease complications associated with atherosclerosis. High-resolution magnetic resonance imaging (MRI) has recently emerged as one of the most promising techniques for the non-invasive study of atherothrombotic disease. It can characterize plaque composition and monitor its progression. The development of MRI contrast agents that specifically target components of atherosclerotic plaques may enable non-invasive detection of high-risk lesions. This lecture focuses on the use of molecular imaging for the identification of high risk or vulnerable plaques in vivo. It clearly pictures the technical requirements for MR plaque imaging in animal models. Promising and newer MR contrast agents that are currently under development for plaque imaging are synthesized according to variety of molecules present in atherosclerotic plaques. Such agents may enable treatment of "high-risk" patients prior to lesion progression and occurrence of complications, and may allow for better stratification of "high-risk" plaque and "high-risk" patients. Despite the increasing availability of modern imaging techniques such as ultrasound (US) and MRI, conventional radiographs (CR) continue to be fundamental to rheumatological imaging, playing an important role in diagnosis and monitoring of the arthritides. Evaluation of plain films includes an assessment of the soft tissues for swelling and calcification. Soft tissue swelling can be extremely subtle but may be the first CR sign of joint disease. Joint space on CR reflects the thickness of articular cartilage and is typically lost as a result of arthropathy either symmetrically, as seen in the inflammatory arthritides, or asymmetrically as in osteoarthritis. In some arthritides, such as gtout, joint space is preserved until subsequent stages in the disease process, while in other conditions bony ankylosis may occur. Evaluation of the periarticular bone usually reveals the presence of erosions, osteophytes, subchondral bone changes such as cysts and sclerosis and changes in bone density. Finally, plain films allow an assessment of joint alignment and also, in the case of hand and foot films, give an indication as to the distribution of disease. Despite the wide use of CR in the evaluation of the arthritides, it has the disadvantage that it is relatively insensitive to the early changes of disease and changes occur relatively slowly. In the early stages of arthritis, when therapy may have the greatest role and where structural abnormalities may be reversible, radiographically defined joint damage is not a prominent feature. Gouty arthritis, calcium pyrophosphate dihydrate crystal deposition disease and calcium apatite crystal deposition disease represent the three main crystal deposition disorders encountered in the clinical practice. If the clinical and radiological features are usually straightforward, some presentations may be misleading. This presentation will focus on the typical and atypical or unusual radiological features of these crystal deposition disorders. It will also present the potential usefulness and limitations of US, CT and MR imaging in the diagnosis of these diseases. Involvement of the spine can occur as part of most inflammatory disorders, but it is most frequent in rheumatoid arthritis (RA) and seronegative spondyloarthropathies (SpA). Involvement in RA is usually located to the cervical spine where erosive changes in the atlanto-axial region predominate. The diagnosis of cervical RA changes is important as they can cause instability with a potential risk for spinal cord injury. In RA patients with neck pain, radiography of the cervical spine including a lateral view during flexion is mandatory. Supplementary MRI or CT may be needed before treatment of instability and can sometimes reveal inflammatory changes in patients with normal radiography. Seronegative spondyloarthropathies are, according to the European classification criteria, divided into ankylosing spondylitis (AS), psoriatic arthropathy, reactive arthritis, arthritis associated with inflammatory bowel disorders (enteropathic arthropathy) and unclassifiable spondylarthropathy. Inflammatory changes at the sacroiliac joints always occur in AS and is part of most other forms of SpA. Spinal changes are also a feature of SpA, especially in later stages and in AS. Manifest structural changes can be diagnosed at radiography. Vertebral squaring, syndesmophytes and ankylosis of apophyseal joints are characteristic of AS whereas more voluminous paravertebral new bone formation occur in psoriatic arthropathy and reactive arthritis. The features of enteropathic arthropathy are often similar to that for AS. The detection of early inflammatory changes of the sacroiliac joint or the spine demands MRI. MRI is also valuable for estimating and monitoring the degree of disease activity subsequently. CT predominantly plays a role in the diagnosis of complicating fracture. Colorectal cancer is common. The European Union with a population of 500 million will experience approximately 280,000 new cases of colorectal cancer each year. 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 programmes. Typical diagnostic tools include the barium enema, 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 accurate staging of the primary tumour, 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. Lung infections are a common cause of morbidity and mortality in immunocompetent and immunocompromised individuals. This session is dedicated to recognise and understand the importance of guidelines in the management of respiratory infections. We will discuss the diagnostic utility of CT and show how it might contribute to improve the diagnosis in a selected group of processes. Respiratory infections (RI) are a very common problem The present and the future of the management and the prevention of these infections is the purpose of this review talk. Guidelines to manage RI have been released by several societies. It has been demonstrated that implementation of these guidelines is followed by a better outcome. Consequently, this is an important issue for managing these patients. Avoiding the consumption of antibiotics is a crucial step to avoid antibiotic resistances. The great part of antibiotic consumption is in primary care (80%). The European network GRACE combats antimicrobial resistances. The main objective is to develop platforms dedicated to investigated rapid tests and biomarkers helping to distinguish bacterial from viral infections in primary care. The same issue of resistances is a major problem in intra-hospital resistances. The network MOSAR supported by the EU as well aims to rapidly diagnose and decrease antibiotic resistances. New antibiotics are mainly targeted against Gram-positive cocci. Among these new lipoglycopeptides such as telavancin, oritavancin and dalvavacin are effective to treat MRSA infection wich is of the most intra-hospital disturbing microorganisms. Another new field is the coadjuvant treatment of severe infections to decrease mortality. This includes antinflammatory drugs (corticosteroids) and molecules that modulate cogaulation (tifacogin). Therapy with antibodies is also a promising field to treat pseudomonal infections. This is still under investigation for humans. In summary in the field of respiratory infection there some clear directions to be followed in order to better diagnose, decrease mortality and decrease microbial resistances. The widespread use of Highly Active Anti-Retroviral Therapy (HAART) has changed the nature of the clinical challenges related to HIV in the past decade. Whilst the number of patients in Europe living with HIV continues to climb, largely as the result of migration of HIV positive patients from sub-Saharan Africa, the number of patients developing AIDS or dying as a direct result of HIV has stabilised. New challenges have arisen related to intolerance to HAART and an increase in incidence of a range of neoplasms. Whilst some of these tumours are particularly associated with HIV, there has also been a general increase in many more commonplace neoplasms in this patient group. Community-acquired and nosocomial pneumonia C.J. Herold; Vienna/AT (Christian.Herold@meduniwien.ac.at) Pneumonia is one of the leading causes of morbidity, hospitalization, and mortality in both industrialized and developing countries. In particular, pulmonary infections acquired in the community, and pneumonias arising in the hospital setting, represent a major medical and economic problem and thus a continuous challenge to health care. For the radiologist, it is important to understand that community-acquired pneumonia (CAP) and nosocomial pneumonia (NP) share a number of characteristics, but should, in many respects be regarded as separate entities. CAP and NP arise in different populations, host different spectra of causative pathogens, and pose different challenges to both the clinician and the radiologist. CAP is generally seen in outpatients, is most frequently caused by typical bacteria, atypical bacteria and viruses, and its radiologic diagnosis is relatively straightforward. NP, in contrast, develops in the hospital setting, is commonly caused by gram-negative bacteria, and may generate substantial problems for the radiologist. Overall, both for CAP and NP, imaging is an integral component of the diagnosis, important for classification and differential diagnosis, and helpful for follow-up. Within the last years, we have observed a changing pattern of causative microorganisms, -and to a certain extent, also unusual radiologic appearances of CAP and NP. Therefore, this course will focus both on well-known and new presentations of CAP and NP, and will elucidate those trends which may be important for imaging diagnosis. Learning Objectives: 1. To help understand the epidemiology and the causative factors of community and hospital acquired pneumonia. 2. To elucidate the spectrum of causative micro-organisms in both forms of pneumonia. 3. To present the radiologic features and patterns of different pneumonias. 4. To discuss the role of imaging methods in the investigation of patients with suspected pneumonia. Tuberculosis and nontuberculous mycobacterial infections G.R. Ferretti; Grenoble/FR (gferretti@chu-grenoble.fr) Tuberculosis (TB) remains a common infection in the world. Clinical presentations of TB have changed in the past 20 years due to the occurrence of HIV infection and multidrug resistant bacilli. The radiological patterns of thoracic TB have also changed; classical patterns of primary and post primary TB are still described along with increasing atypical presentations, particularly in immunocompromised patients. In Western Europe, individuals at high risk include HIV-infected patients, the homeless, and migrants from countries with high prevalence of TB. Imaging plays a key role for identifying pulmonary TB; chest X ray is the first modality; HRCT shows higher sensitivity and specificity than CXR for demonstrating thoracic abnormalities due to TB, complications, and disease activity. Pulmonary diseases due to nontuberculous mycobacteria (N TM ) are less frequent than TB; host and mycobacterial factors are responsible for one of three prototypical forms of pulmonary N TM : tuberculosis-like pattern; nodular bronchiectasis, and hypersensitivity pneumonitis. The purpose of this presentation is to describe the new faces of thoracic TB, to emphasize to role of CT in assessing the activity of TB, and to show the differences between pulmonary TB and pulmonary diseases due to NTB. Low-flow and high-flow vascular malformation: Is angiography always necessary? Vascular malformations (VMs) can be classified on hemodynamics as low-flow and high-flow malformations and on predominant abnormal vascular channels. Ultrasound (US) is useful to evaluate margins of the malformations, but does not determine the full extent of VM. Doppler US permits real-time analysis of the arterial and venous flow and measurement of flow velocities, differentiating low-from high-flow VMs. Contrast-enhanced ultrasound (CEUS) can be helpful in evaluating low-flow VMs and during percutaneous sclerotheraphy to depict the ablation area. Multi-detector row CT can evaluate enhancement, presence of calcification or thrombus and the distal run-off. Because of its high temporal resolution, CT is a good tool to evaluate VMs, but has the disadvantage of exposure to ionizing radiation. Magnetic resonance depicts the full extent of VMs and the relation between VMs and adjacent structures. Spin-echo T1-weighted images are useful to evaluate the basic anatomy. STIR and T2-weighted images can assess the extent of malformations. Dynamic contrast-enhanced MRI is useful to distinguish high-flow from low-flow VMs. Time-resolved MR angiography could be a reliable tool for the characterization of VMs with respect to arterial feeders, nidus size and venous drainage; its limit is in the depiction of the small terminal branch of the affluxion artery. Direct percutaneous phlebography and peripheral phlebography can be helpful in case of atypical VMs or in the presence of composed or dysmorphic veins. Angiography is not relevant for the diagnosis but important as a precursor to interventional procedures. Patients presenting with vascular malformations mostly are nomadic and hopeless individuals looking for help. Finally, having reached a "multidisciplinary specialist group" after a sometimes long and misleading trip throughout the ocean of "single players" of different specialities, these patients do not ask for any more diagnostics, but strongly claim for therapy. Vascular malformations are congenital lesions, although merely seen at birth they become evident throughout the individual's growth. These developmental errors can affect all the 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 to 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 on all potential side effects as well as risk factors of progression enable 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 specialst 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 classifiying and their overall understanding of the pathogenesis and prognosis offer these mostly hopeless patients a costume-fit treatment that addresses their symptoms. The need for more advanced and accurate methods for guiding and controlling minimally invasive procedures continues to grow as these procedures become increasingly important in medicine. MR imaging has many advantages that make it an exciting tool for guiding endoluminal and endovascular procedures. The rationale for using MRI as a guidance tool is not primarily to avoid radiation exposure but to add therapeutically relevant information to an interventional procedure. MRI can provide functional and morphologic information in tumor bearing bile ducts as well as in atherosclerotic arteries where it visualizes not only the lumen of the vessel, as does conventional angiography, but also the vessel wall, different plaque components and the surrounding tissues. In the past basic MRI-guided catheter-based endoluminal and endovascular interventions were performed in animal models to test device visibility and procedure feasibility. More recently, complex procedures, such as endovascular repair of aortic aneurysm, arterial recanalization and stenting, embolization, septal occluder placement, and transjugular intrahepatic portosystemic shunt have been performed in pre-clinical settings. There are only a limited number of reports on patient applications. Most of these clinical applications are feasibility studies copying X-ray fluoroscopy guided procedures that have not yet demonstrated the clear additional benefit of MRI guidance. Few studies showed that MRI is able to replace the combined utilization of other imaging modalities to guide devices during a procedure. Although MRI does not involve ionizing radiation exposure, there are some hazards that must be known before utilizing interventional MRI in a clinical setting. In this presentation, after a brief overview of the devices used in the MRI-guided cardiovascular interventions, some investigational procedures will be explained. Common problems with these procedures are the inability to visualize the interventional devices' safety and accuracy. On the other hand, Magnetic Resonance Imaging (MRI) can be an excellent tool for the guiding interventions since heart and the surrounding structures are visualized in great precision with this modality. In addition, the mechanical function of the heart and the infarct size and location can be determined. Currently, multiple research groups are working on MRI-guided electrophysiological measurements and cardiac ablation in response to poor management of atrial fibrilation using current technologies. MRI-guided stem cell injection is a very exciting area of development since injected cells can be tracked not only during the procedure but also after the procedure. Some very difficult interventional procedures such as cardiac valve placement and recanalization of the cronic total occlusion can be rather trivial in MRI-guided procedures. In short, in this presentation, the emerging field of MRI-guided cardiac interventions will be introduced. Like many other fields of modern imaging, pediatric imaging has evolved markedly over the last years. First, the frontiers of the speciality have been extended and nowadays, it includes fetal imaging. This, not only through the use of ultrasound, bu also, in selected applications, through fetal MR imaging and even low dose CT. These techniques have an important impact on the management of the pregnancies and on the postnatal work-up. Second, applications of CT and MR imaging have increased in children. As prescribed by the ALARA principles, pediatric radiology faces the challenge of performing the best examination for the best diagnosis. It is not only CT versus MR imaging; it is also what is the best technique and how to optimize its use. These various aspects of modern pediatric imaging will be illustrated and discussed throughout the session. including antenatal diagnosis and post natal follow-up. Meanwhile, the main role of antenatal imaging is to differentiate a lethal from a non-lethal affection. This mostly determines the management of the pregnancy and may lead to termination in lethal cases (ex: cerebral tumors, lethal squelettal dysplasia). Fetal medical or surgical therapies can be proposed in some non-lethal pathologies (ex: maternal corticotherapy in cases of fetal adreno-genital syndrome or fetal tracheal obstruction in diaphragmatic hernias…). The neonatal management of the newborns is often modified according to the antenatal diagnosis. In cases of abdominal tumors, digestive tract anomalies (ex: atresia, perforation…), or uro-genital malformations (ex: uretral valves) the delivery and neonatal management can be better organised and neonatal surgery promptly performed. In cases requiring neonatal medical therapy (ex: complicated renal duplication), adequate treatment can be initiated immediately in the post natal period preventing urinary tract infections. In complex cases, MR imaging and CT are complementary techniques that help in precising the diagnosis and establishing a prognosis. Therefore, in daily practice, fetal imaging plays a significant role on the outcome of the pregnancies and newborns. How to adapt CT for use in children Computed tomography (CT) in children poses unique problems, which are not encountered in adults. The relative lack of visceral fat combined with patient motion results in degradation of image quality making the recognition of normal anatomical structures and some pathologies more difficult to visualize. Mistakes in interpreting CT images in children are related mainly to artefacts induced by the scanning technique or to misinterpretation of a normal anatomical variant as pathological. The recent major advances in technology in conjunction with meticulous attention paid to CT techniques have combined together to improve the sensitivity and specificity of paediatric CT imaging and have resulted in more precise diagnostic possibilities. Many of the significant changes in current diagnostic practice are related to the introduction of helical CT technology and especially multidetector CT, which allow the study of airways and vascular structures (with the development of CT angiography). The improvement in the quality of multiplanar reconstructions has also been very important when analyzing specific diseases in children. High resolution CT of the chest is a useful technique capable of imaging the lung with excellent spatial resolution and precise anatomic detail, while delivering little radiation to the patient. The introduction of new CT technologies has several potential benefits for paediatric patients. The use of IV contrast agents can be optimized, sedation rates reduced, image quality improved, CT indications increased, and radiation exposure decreased by using customised protocols for children. The main clinical indication for CT examination will be discussed. Learning Objectives: 1. To discuss the necessary modifications in scanning techniques to optimise pediatric scanning. 2. To present special tricks to optimise scan accuracy in children. Body MRI for use in children O.E. Olsen; London/UK (olseno@gosh.nhs.uk) 1. There is hardly any empirical evidence to support an academic race between CT and MRI. Rationalising from accepted facts, however, MRI is the modality of choice for most clinical applications in children. Advantages over CT include: 1) no ionising radiation, 2) a wide range of image contrasts, 3) a wide range of quantitative opportunities, and 4) potential for temporal information. Equal performance to CT would be expected for 3D-imageing. A priori disadvantages include 1) poorer signal-to-noise ratio (SNR) at high resolutions, 2) longer acquisition times often requiring sedation or general anaesthesia in order to minimise motion artefact, and 3) relative inability to visualise cortical bone, calcium, lung tissue. 2. The underlying physics as well as practical impact of some key technical parameters will be discussed. The following workflow is suggested when adjusting a pulse sequence: 1) Choose a coil with appropriate size for the anatomy/abnormaltiy of interest, and prefer a transmit-receive coil; 2) adjust the field-of-view; 3) adjust the base resolution to approximately 0.8 mm in infants, 1 mm in children, 1.2 mm in adolescents; 4) correct the SNR by altering the acquisition time -knowing that SNR is proportional to voxel size times square root of acquisition time -by changing the number of excitations, number of phase encoding steps, bandwidth; 5) ensure multiple contrasts are used, and consider intravenous contrast as standard; 6) use motion correction if possible: respiratory gating, cardiac gating, anti peristaltic agent, targeted fat suppression, special k space techniques e.g. propeller. This was investigated through a questionnaire sent out to 12 European countries and answered by around 750 radiographers. Starting the following project -HENRE II -we proceeded on this basis and were asking all European Radiography Societies about the national regulations of CPD. To provide evidence regarding the persons who had undertaken CPD there are various accreditation systems available, either income-or outcome-based, which will be shown by selected models. The presentation will also show the difference between CPD and Lifelong Learning LLL. By all participants in the questionnaire CPD is seen as extremely important. Many countries within Europe do provide CPD for Radiographers, some do not. Many of the latter are planning or would wish to have regular CPD available. The network of Nordic Masters in Radiography/Radiotherapy (NOMAR) is a network of partners from higher education and radiography societies in Finland, Denmark, Iceland, Norway and Sweden. NOMAR was started in November 2004, at the initiative of the Nordic Society of Radiographers (NSR) with the purpose of working towards establishing a joint Masters Degree program (MSc) to make the best use of the expertise of the several higher education institutions in the Nordic countries involved in the subjects. There is a demand on further education and life-long learning to provide high quality healthcare. In addition, an environment of research and innovation is crucial for the professional development required to fulfill the demands of society regarding development and welfare. The radiographers' profession is young and the extent restricted in the Nordic counties. Both the number of professionals and scientific activity in the educational institutions are limited. A joint Nordic MSc would provide the radiographers with the opportunity to engage in higher education with more alternatives than would be possible were each country to offer their own program. A joint MSc program would also make it possible to highlight the Nordic perspective in Radiography/Radiotherapy, while emphasising on a holistic approach, and giving patient care high priority in the examinations and treatment. Hence it is important to develop an ongoing masters program of high quality in Radiography/Radiotherapy and to assimilate the best from every country and strengthen the collaboration among the Nordic countries regarding the profession and radiography as a science. Curricula of higher education in the European Higher Education Area, including radiography education and training, should be outcome-based in nature by the year 2010. Each country is performing curriculum development within its social, historical and cultural context as well as considering its human and financial resources. Radiography education and training in Estonia has lasted less than 10 years and about 70 graduates have qualified during that period. So far, the radiographer education has been teacher-centred, subject-based and very often carried out by teachers who are not radiographers themselves due to the accepted traditions and principles in the society. Transition from a subject-based and teacher-centred curriculum to an outcome-based and learner-centred curriculum in the conditions of limited resources and teaching experience can be carried out under the conditions of good cooperation between practising radiographers and teachers who are often non-radiographers but have sufficient pedagogical competence. Practising radiographers who have learned according to the subject-based and teachers-centred educational framework provide radiographic content of the curriculum, and non-radiographer teachers with pedagogical competence translate this content into the language of outcome-based curriculum. As a result of this kind of cooperation the role and importance of clinical training supervised by practising radiographers becomes more clearly understandable to both parties. To ensure the comparability and wider acceptance of the qualification provided with a national curriculum, the essential role and functions of international networks (HENRE) and partner organisations have to be considered, and the opportunities offered by them, taken into account. Traumatic injuries to the thoracolumbar spine encompass a variety of frequently occurring injuries as well as some rare injuries involving the anterior and dorsal parts of the bony structures, the discs and the ligamenteous structures. As a peculiarity the spine protects the cord as well as the nerve roots and traumatic involvement of these structures is of particular importance with regard to the therapeutic outcome of the patient. Thoracic and lumbar spinal injuries affect approximately 2% to 3% of blunt trauma victims and are associated with approximately 40% to 50% incidence of neurologic deficit. The spectrum of thoracolumbar injuries is broad and includes benign myofascial strains, fractures and bony instability, ligamentous instability, and neurologic compromise. Evaluation of thoracolumbar injuries requires a rapid and focused evaluation at the time of injury to rule out neurologically threatening injuries. However, the complexity of the spine and the associated injuries lead to classification of various types of thoracolumbar spine fractures. In Europe, the most commonly used classification system for thoracolumbar spine fractures is the AO classification system. MDCT is the most important imaging modality for classification of thoracolumbar injuries according to the AO classification system. Learning Objectives: 1. To learn the relationship between the mechanism of injury and the resultant injury classifications. 2. To appreciate the role of CT and MRI in imaging thoracolumbar injuries. 3. To understand how imaging is used to direct clinical management. Pelvic injuries are usually the result of high-energy mechanisms such as road traffic accidents and falls from a height. The forces generated by these mechanisms put the patient at very high risk of concurrent torso injuries. It is a sad fact that trauma teams following the strict ATLS guidelines may assume that the major pelvic injury demonstrated on the pelvic radiograph completely explains the patient's condition. The patient may well then follow ATLS guidelines and be subjected to difficult unnecssary interventions such as diagnostic peritoneal lavage and diagnostic laparotomy, neither of which will identify plevic and retroperitoneal bleeding points. Pelvic injuries themselves have a high association with vascular injuries, most commonly to the superior gluteal artery although other vessels are implicated. If external fixation of the pelvis fails to stabilse the patient then vascular intervention is essential. Surgical exploration of the retroperitoneum/pelvis is extremely difficult and invasive. By contrast it is possible that a vascular radiologist will be able to isolate the bleeeding source and embolise it within 10 minutes of their first diagnostic run. Fractured femoral neck is usually a straightforward diagnosis to make, but approximately 1% are radiographically occult at first presentation. This can falsely reassure clinicans into discharging the patient who returns weeks later with a displaced fracture and the inevitable complaint. Therefore this injury should never be excluded by plain radioghraphs alone and if the patient fails to mobilse as expected, then further imaging either by MRI or bone scintigraphy is mandatory. Learning Objectives: 1. To show that pelvic injuries are high energy injuries and imaging should therefore be targeted at the torso rather than just the pelvis. 2. To emphasise the high risk of associated vascular injuries necessitating early CT scanning even when the patients are haemodynamically unstable. 3. To explain the key role of the vascular radiologist in these injuries. 4. To demonstrate the importance of further imaging for a clinically suspected fractured neck of femur with a normal radiograph. Major trauma of the extremities are often comminuted fractures with intra-articular involvement. The aim of fracture treatment is accurate anatomical repositioning of the fragments, and the recovery of the proper angulatory deformity. Different studies demonstrate that the inter-and intraindividual reproducibility of the AO/ASIF classification on the basis of conventional radiographs resulted in only moderate agreement. However, MDCT is extremely sensitive in the detection of fractures, and source images together with rendered reconstructions can display the spatial relatitionship of fracture fragments. In patients with suspected vascular involvement, MDCT permits immediate evaluation of the involved extremity concerning osseous and vascular pathologies as well as rapid examination of other body regions that may be injured and to include the diagnostics of the extremity into the whole body examination of polytraumatised patients. In most cases, this strategy is reliable in the detection of fractures and vascular injuries, but it is considerably less suitable for assessment of lesions of cartilage, ligaments, nerves, and other soft tissue injuries. A suitable imaging modality for such soft-tissue lesion is MR-imaging. The value of these techniques, including qualitative and quantitative post-processing techniques, will be discussed. Guidelines for optimal pretherapeutic evaluation management will be proposed. Additionally, virtual 3D planning of corrective osteotomy will be introduced. By providing virtual perspectives that simulate the anatomical and pathological reality and by allowing interactive control on rendering parameters, computer-assisted three-dimensional reconstruction of imaging data enables the creation of virtual reality environment, the utilization of which assists the determination of diagnosis and preoperative planning. The substantial advances in the medical and surgical treatment of congenital heart diseases have dramatically improved patients' life-expectancy, as well as increased the number of those needing life-long monitoring to identify complications and residual issues. While echocardiography continues to be the mainstay of non-invasive imaging, cardiac MRI (cMRI) and multi-slices computed tomography (MSCT) have taken on increasing roles in the diagnosis of congenital heart disease in infants, children, and adults, especially if post-operative. The two modalities may be complementary, even though MRI is preferable in young patients because of the absence of ionizing radiations. Intracardiac anatomy is well depicted by MRI, but CT may provide exquisite images of the great vessels. In adult patients, MR and CT are helpful in demonstrating and quantifying physiologic changes superimposed on the underlying congenital malformations. Gadolinium-enhanced cMRI or three-dimensional reconstructed images from MSCT angiography allow excellent delineation of vascular structures in complex heart disease. Coronary imaging, while possible with both modalities, appears more defined with MSCT. Similarly, post-interventional imaging, such as in aortic coarctation, might be better analysed with MSCT, especially in case of metallic stent. Post-operative imaging of CHD is especially enhanced by the spin echo MRI techniques, while gradient cine echo MRI imaging allows functional information that is not encumbered by geometric assumptions. In these patients, MRI is the recognized gold standard in the evaluation of right ventricular function. Moreover, phase-contrast cardiac MRI data can provide information about flow, allowing accurate determination of regurgitation and shunt volume. Imaging has a central role in the diagnostic work-up of cardiac masses and pericardial diseases. From a radiological point of view, computed tomography (CT) and magnetic resonance imaging (MRI) are the most important techniques, although echocardiography is most often used as primary imaging modality. Cardiac masses, in general, can be non-tumoral or tumoral. The presentation, localization and tissue characterization in combination with clinical history are usually very helpful to differentiate between tumoral and non-tumoral masses, and between benign and malignant tumors. In this presentation the work-up will be discussed, as well as an overview of the most frequent cardiac masses encountered in daily routine practice will be discussed. Pericardial diseases may severely affect cardiac function (i.e. constriction / tamponade). MRI and to a lesser extent CT provide valuable information about the pericardial abnormalities as well as the impact on the cardiac structures and cardiac function. The presentation of most important pericardial diseases (effusion, inflammation, constriction) on CT and MRI will be highlighted. Many stones in the collecting system have a complex 3D structure, e.g. staghorn calculus. When planning a percutaneous stone extraction of such a stone from an IVP or a standard CT, it is often impossible to decide the optimal track. Often, these patients end up with multiple tracks, but with remaining stones. Our goal has been to make the patient stone-free using one track. The question is how to minimize the risk, but optimize the result? The goal has been reached by extended radiological planning with 3D-CT, creating the track under CT guidance and with a radiologist assisting the endourologist during surgery. The CT examination is performed with thin slices (< 1 mm) in two phases, native and excretory phase. 3D-images of the stone and the collecting system are produced in a workstation. On these 3D images, it is then possible to choose an optimal and safe track. In the most complicated cases, a biomodel of the collecting system with the stone is produced. When a high puncture, above the 12 th rib is chosen, the puncture is performed under CT guidance. Using CT guidance will minimize the risk. Finally, we have found that a radiologist attending in OR, supplying the endourologist with 3-D information from the two-dimensional fluoroscopic image, is of great help. Besides watchful waiting ,there are four major techniques for the treatment of stones in the urinary tract, namely ureteroscopic stone extraction, extracorporeal shock wave lithotripsy (ESWL), laser lithotripsy through a flexible pyeloscop, and percutaneous stone extraction. It is up to the endourologist to choose the best technique for each individual stone. In this decision, it is not only the effectiveness in stone removal, which has to be considered, but also patient safety and discomfort. Indications for percutaneous stone extraction are large stones (> 20 mm), ESWL-resistant stones and patients with anatomical difficulties. The majority of renal stones, which are treated with percutaneous technique are large and with a complex 3-dimensional structure. To avoid complications, when performing percutaneous stone extraction, the ideal way is to create a track to a lower or middle calyx and with a puncture below the 12 th rib. However, the problem is that in some cases the whole stone cannot be reached by a lower calyx puncture and in other cases the stone cannot be reached at all by a lower calyx puncture. Often these patients end up with multiple tracks, but with the stones remaining. In these cases, a high puncture could solve the problem. But a high puncture means an increased risk, as the track may pass the pleura, lung, liver, or spleen. Steatosis and non-alcoholic steatohepatitis (NASH) (together: NAFLD for non alcoholic fatty liver disease) are histopathological entities. The metabolic syndrome (MS) is a cluster of clinical or laboratory anomalies. Pure steatosis is a frequent and benign condition characterized by the mere accumulation of triglycerides as droplets within hepatocytes. NASH is a much less common condition characterized by hepatocellular damage (ballooning, Mallory bodies), inflammation, and fibrosis, in addition to steatosis. MS is a cluster of several features associated with an increased risk of cardiovascular disease (high blood pressure, increased abdominal fat, hyperglycemia, hypertriglyceridemia, and decreased HDL cholesterol). MS is strongly related to insulin resistance. MS is most commonly associated with NAFLD, although which is the cause or the consequence is debated. Factors determining transition from steatosis to NASH are unclear. Deposition of fibrous tissue, and eventually cirrhosis, occurs with NASH, not with pure steatosis. NASH is a cofactor aggravating chronic viral hepatitis or alcoholic liver disease. Increasing age and diabetes are predictors for fibrosis stage. Hepatocellular carcinoma is as frequent as with other causes of cirrhosis. Many patients with NAFLD die from cardiovascular causes rather than from liver-related conditions. There is no current recommendation to screen for pure steatosis. Validated means to screen for NASH non-invasively will hopefully become available in a near future. Such NASH patients might then be proposed therapeutic trials. However, besides diet and exercise to control excess weight and MS, treatments with a proven efficacy in slowing the course toward cirrhosis and hepatocellular carcinoma are still lacking. Learning Objectives: 1. To present demographic and pathologic background of steatosis, NASH and metabolic syndrome. 2. To discuss the process of steatosis, NASH and cirrhosis. 3. To present current knowledge to screen and treat patients with steatosis or NASH. Imaging fatty liver is a major issue in abdominal radiology. Diagnosis and characterization of focal liver lesions in patients with diffuse liver esteatosis might be challenging because the sensitivity of standard techniques such as US and CT is substantially decreased in that setting. In addition both focal fatty change and focal fatty sparing may be difficult to differentiate from tumoral lesions, especially in patients with a known primary cancer. The aim of this presentation is to provide an update on imaging techniques that can be used to diagnose focal liver lesions in the setting of steatosis with a special emphasis on MRI. Frequent pitfalls will be reviewed and the importance of chemical-shift MR imaging will be stressed. In adddition the imaging appearance with US, CT and MR of other fat containing lesions in the liver such as CHC and adenoma will be reviewed. The association of steatosis of the liver with inflammatory changes and fibrosis in obese subjects and with excessive alcohol consumption is established. The potential of histological progression to cirrhosis, liver failure and hepatocellular carcinoma is recognised and the future burden these patients will place on liver services is an epidemiological challenge. A diagnosis of fatty liver disease should define the histology and grade of the disease and risk stratify the subjects according to the aetiology of their steatosis. Pathological grading systems can define the at risk group by distinguishing between patients with necroinflammatory activity and fibrosis from those with benign steatosis. Age, biochemical profile and potential aetiological or demographic factors do not stratify these patients and biopsy may be necessary. The challenge for imaging is to use non-invasive techniques to diagnose FLD, quantify macrosteatosis and grade the disease.Qualitative and quantitative measures with USS, CT and MR are used and have been validated against histological findings. To date these provide valuable adjunctive data to patient management in defined groups, e.g., potential donors for living related liver transplantation. However, there are diagnostic pitfalls in both the qualitative and quantitative techniques. For example the techniques do not differentiate accurately between macro and microsteatosis or between NASH and non-progressive NAFLD. Furthermore, patterns of geograhical focal steatosis present difficulties for standardising ROIs. Fibrosis and iron deposition also limit techniques dependant on chemical shift sampling and elasticity. This presentation will summarise the currrent status of these techniques and their applicability to this disease. Croatian Society of Radiology (CSR) is the professional society of Croatian radiologists, and one of the most active societies within the Croatian Medical Association. CSR has 380 members, and cares about all aspects of professional of issues in Croatian radiology. Over the last 2-3 years the quality of radiological equipment has increased considerably, and new equipment was installed in hospitals in all Croatian regions, including eight new 1.5 T MRI units and one 3 T MRI scanner. Through the private-public partnership first CT-PET systems were installed. Regarding the number of CT and MRI units and the number of radiologists per number of inhabitants, Croatia has better indicators than most of transitional countries. CSR initiated the reform of the residency curriculum in accordance with the UEMS guidelines, proposing prolongation of residency from four to five-years system, as well as introduction of new subspecialties (currently only three exist officially). CSR oversees with the Medical Faculty of University of Zagreb compulsory professional education for residents. The board exam is still practical and oral, but the CSR is planning to introduce the written exam, as well. CSR was very active in introducing and is overseeing the national breast cancer mammographic screening program, that commenced in October 2006, and has promising initial results. Experts from three university centers (Zagreb, Split and Rijeka) will present the current status of breast imaging and interventional radiology in Croatia, with four presentations about national mammographic breast cancer screening program, image guided breast biopsies, endovascular intracranial procedures and endovascular aortic repair. Osijek/HR (mmarotti@kbsm.hr) The goal of screening mammography is to detect malignant breast lesions in asymptomatic women. Randomised trials have demonstrated that screening mammography reduces breast cancer mortality from 25 to 35% among women aged 50-69 years. In October 2006, the national MBC screening program officially commenced in Croatia (population 4.3 millions), financed and coordinated by the Ministry of Health. Women in the age group of 50-69 years (570,000 women) are included and invited for mammography on a biannual basis. Invitations and statistical evaluation of findings are managed by regional and central institutes for public health. BI-RADS lexicon was translated in Croatian language with permission of ACR. All radiologists participating in the program received the lexicon. BI-RADS categorization is exclusively used for the assessment of findings and statistical follow-up. Double reading is mandatory. The program is coordinated centrally, with radiologists being responsible for monitoring and quality control of screening units in four geographic regions. The mammographic equipment must be less than 10 years old, with regular maintenance and quality control. Centers for management of women with suspicious BI-RADS findings were designated for various regions. The overall attendance rate in the first year is 55%, with wide geographical variations between counties (41-83%). Distribution of BI-RADS finding is: BI-RADS 0 9.2%; BI-RADS 1 41.8%; BI-RADS 2 40.0%; BI-RADS 3 8.0%; BI-RADS IV 0.9%, BI-RADS V 0.16 %. So far, 793 breast cancers have been confirmed. Learning Objectives: 1. To appreciate the efficacy of mammographic screening. 2. To illustrate the spectrum of problems and difficulties in the national mammographic screening programme. 3. To learn the role of various performance indicators, such as participation rate, rate of screen-detected cancers, rate of advanced cancers, and benignmalignant biopsy ratio. 4. To appreciate that mammographic screening should be conducted based on cancer registry data in order to assess the rates of interval and advanced cancers. 5. To compare the results of the Croatian mammographic screening programme with those in other countries. Image-guided breast biopsies D. Miletic; Rijeka/HR (damir.miletic@medri.hr) Different imaging modalities including ultrasonography (US), mammography and magnetic resonance imaging (MRI) are used to guide breast biopsy devices. Croatian achievements will be presented. Image-guided breast biopsy is mandatory to characterize detected breast lesions. Stereotactic guidance applying add-on units or dedicated prone biopsy devices is optimal for suspicious microcalcifications. US guidance is preferable whenever the lesion is evident. MR imaging can reveal lesions that are both sonographically and mammographically occult, and the ability to perform MR imaging-guided biopsy or wire localization is essential. Outcomes of various techniques in terms of missed cancers, underestimation, complications or the need for second biopsy are in the focus of radiological interest. Core biopsies are performed with an automated gun or vacuum-assisted device. More than three specimens, preferably those that are nonfragmented and that sink, are obtained with a 14-gauge breast biopsy needle. Because all or most of the lesion may be removed during vacuum-assisted biopsy, a marking device is frequently needed to assist in subsequent needle localization procedures. MR imaging-guided biopsy combines an MR-compatible coaxial needle to target the lesion and a stainless steel core biopsy needle or vacuum-assisted probe to sample the lesion. Bleeding and vasovagal attack are rare and harmless complications of breast biopsies. Sonographic guidance is a frequent and available method in all Croatian hospitals and many private practices. Stereotactic guidance using add-on units is a routine procedure in several Croatian clinical hospitals. MRI-guided breast biopsy implementation is a challenge for dedicated centres. Endovascular intracranial procedures M. Rados; Zagreb/HR For ruptured and unruptured intracranial aneurysms, two major treatment modalities are endovascular embolization or "coiling" and neurosurgical repair or "clipping." Nowadays, endovascular embolization of ruptured and unruptured intracranial aneurysms is method of choice in many hospitals worldwide due to the advance in manufacturing of new types of coils, microcatheters and microwires. Intracranial aneurysms with the narrow and wide neck have a different technical approach. Emoblization by simple coiling is possible at the most of aneurysms with narrow neck (dome/neck ratio >2). Choice of the appropriate first coil and subsequent complete fulfillment of the aneurysm with coils is the key element for successful procedure. For aneurysms of wide neck, additional endovascular methods like balloon remodeling or embolization with stent-assisted coiling can be applied. For ruptured aneurysms, the data show an improved survival with coiling compared to surgical clipping. A total of 242 patients harboring 256 intracranial aneurysms were treated by endovascular coil embolization at our institution during the period between September 2004 and November 2008. Among them, 196 patients presenting with aneurysmal subarachnoidal hemorrhage were successfully treated by coil embolization within 20 days of hemorrhage. Coil embolisation of intracranial aneurysms is a very feasible treatment method associated with a small risk of permanent morbidity-mortality. In period between May 2006 and November 2008 we also treated 48 patients with arterio-venous malformation (AVM). Before choosing appropriate method of treatment it is necessary to estimate many morphological and hemodynamic characteristic of AVM. Neuroradiological analysis should evaluate morphological localization, size of nidus, number and hemodynamic properties of feeders and also type of drainage. Learning Objectives: 1. To discuss the indications for endovascular management of intracranial aneurysms and to understand the various endovascular techniques available. 2. To define which intracranial arteriovenous malformations can be treated with endovascular procedures. 3. To understand the role of the interventional neuroradiologist in defining the optimal treatment for intracranial AVMs and AVF in comparison with surgery and radiosurgery. 4. To analyse the treatment results in ruptured intracranial aneurysms after endovascular procedures. Endovascular aortic repair L. Cambj-Sapunar; Split/HR (lianacambj@hotmail.com) Abdominal aortic aneurysm (AAA) is a disease of considerable importance since its rupture represents the 10-13 Th cause of death in men over 65 years of age. The primary goal in management of AAA is prevention of rupture, but the decision between open surgical and endovascular repair (EVAR) is still under debate. With careful choice of patients, improved skills and new improved devices, we can prevent most of the early and late complications of EVAR. The main disadvantage of EVAR compared to surgery is a high rate of re-interventions due to continuing aortic expansion. Important advances have been made in the understanding of the pathophysiological mechanisms of AAA, but there are still no effective strategies to reduce aneurysmal growth. Further investigations of biomechanics and development of specific drug therapy targeted at AAA growth are needed. Croatia is one of the European countries that is most strongly affected with population aging. An increasing number of people over 65 years of age along with a high number of smokers have a strong impact on continuously rising incidence of AAA in Croatian population. We will present our 9 years experience with EVAR for the treatment of unruptured AAA. Our study of aneurysmal growth at follow-ups and stent graft migration rate do not differ from those that have already been reported in publications. We will highlight the role of experimental research in the field of atherosclerotic disease with the emphasis on AAA growth. Importance of the involvement of interventional radiologists in research will be discussed. Bronchogenic carcinoma is a main cause of mortality from cancer in the western world. Lung cancers are commonly diagnosed in chest radiographs, while some are detected, many others are missed. Common and uncommon manifestations in the chest radiograph that suggest the diagnosis of lung cancer are thus important. and must be recognized. Once the diagnosis is made, it is important to perform the proper radiological work-up to establish the stage and the adequate treatment. Staging is a key factor in lung cancer management and is important for selecting the proper imaging technique in individual cases. Finally, in treated patients, imaging is a main aspect of the follow-up. The radiologist must know how to evaluate signs of recurrence, which should be distinguished from subclinical diseases and post-radiotherapy changes. Why an 'ode' to the liver? Thanks to this extraordinary organ, our discipline has been able to impressively grow in the last decades. From the simple vision of a shadow in the plain film of the abdomen, the continuous development and application of new tools, has brought us to the current multimodal exploration of liver anatomy and function. Indeed, nowadays we are able to display the unique structure of this organ, with its complex vascular architecture and high polarised cellular activity. Moreover, the wide range of pathological conditions that may affect the liver can be characterised and quantified exploiting the developments of modern imaging techniques: Actually, the liver should be considered the 'litmus test' for the maturity of any imaging method! All the techniques have upgraded their performances to address liver-specific issues. The microbubbles in US, perfusion imaging in MSCT, tissue-specific contrast media, MR elastography, diffusion and many other tools that are still works-in-progress will soon be in clinical use. However, for our discipline, the liver is no longer only diagnosis: In this domain, images are essential for orienting the decision-making among several currently available therapeutic options. In particular, there is no other organ in which interventional procedures play a larger role, using images for treatment guidance and for evaluating the Myocardial diseases can be ischemic or non-ischemic. Ischemic myocardial diseases are usually attributable to underlying coronary artery disease. In contrast, non-ischemic myocardial diseases cover a wide range of diseases, making the diagnosis and appropriate treatment often challenging. Imaging has turned out to be of utmost importance as it provides accurate information on the myocardial morphology as well as the impact on regional and global myocardial function. Non-ischemic cardiomyopathies can be classified as diseases primarily affecting the heart (cardiomyopathies, myocarditis) or systemic diseases affecting the myocardium (eg sarcoidosis, amyloidosis). In this presentation, we will discuss how the use the imaging modalities, in particular magnetic resonance imaging (MRI), in the diagnosis of these diseases. We will highlight the MRI sequences needed to obtain the most valuable information, as well as the presentation of non-ischemic myocardial diseases on MRI. Moreover, we will discuss the use of this technique in the differential diagnosis and provide approaches for use in daily clinical practice. After an acute myocardial infarction (MI), myocardial damage varies within the ventricle wall. These histological changes are more or less severe resulting in a functional point of view from complete non-viability to complete recovery of the segmental contractility. Using MRI and CT, viability assessment relies on first-pass and late-enhancement imaging, due to abnormal uptake and wash-out in damaged myocardium. Early prediction of recovery is of great importance for prognosis and adaptation of the treatment. Different imaging techniques are available for viability assessment, such as low-dose dobutamine echocardiography and MRI. Very recently, CT has been proposed also for this purpose including evaluation of viability at a very early stage, just after percutaneous angioplasty, without reinjection. The potential of the CT will be presented in comparison to the two other established methods. Magnetic resonance imaging (MRI) and computed tomography (CT) are useful non-invasive methods for evaluating cardiac tumors. They are well-suited modalities offering excellent resolution and delineation of the cardiac anatomy and characterization of various tumoral and non-tumoral masses including myxomas and thrombi. Imaging of cardiac tumors with CT and MRI involves advantages and disadvantages compared with each other and also comparing with echocardiography, which is the clinical mainstay for evaluating cardiac masses. MRI is particularly useful when ultrasound imaging does not provide adequate diagnostic information or requires further characterisation. CT has the advantage of being able to detect calcifications. Furthermore, CT allows with the same examination the assessment of the coronary arteries that represents a considerable benefit. Both modalities provide a large field of view compared with echocardiography. This allows examination of the entire chest and detection of associated pathologies in the mediastinum and lungs. Although cardiac tumors have a relatively low prevalence, some have a characteristic appearance at CT and MRI, which allows their reliable identification prior to sugery. Bearing in mind the world-wide increase in the use of CT and MRI for the evaluation of the heart, radiologists should be familiar with the imaging features of various common and distinguishing cardiac masses at CT and MRI. and was found to be effective in the treatment of pain associated with vertebral fractures due to benign and malignant tumors. PV was adopted for the repair of osteoporotic vertebral fractures in the USA in 1993, and the first US case series was reported in 1997. The idea of attempting to restore lost vertebral body height and reduce the associated kyphotic deformity while stabilizing a vertebral compression fracture was conceived in the early 1990s by a US orthopedic surgeon, Dr. Mark Reiley. KP relies on the same stabilization principle used in PV: the introduction of bone cement into a compromised vertebra. KP is sometimes even referred to as "balloon-assisted vertebroplasty." A randomized clinical trial that compared KP to conservative medical management was attempted, but patient entry was slow; this initiative was ultimately abandoned in favor of a clinical registry. Like PV, KP has not been tested in a comparison trial against conservative therapy. The phrase "vertebroplasty vs. kyphoplasty" evokes images of competitive procedures and battling groups of entrenched physicians. Both procedures, however, offer potential benefit with an acceptable safety profile when used by properly trained physicians in appropriately selected patients. Both relieve the pain associated with vertebral compression fractures. Biomechanical data comparing the mechanical stabilization by PV and KP show similar results. The goal now should be to refine the indications for each procedure so that we may select the appropriate therapy to maximally benefit our patients. A-248 17:00 Sacral insufficiency fracture is related to physiological calcium loss in elderly patients or pathological osteopenic condition in patients treated with chronic corticosteroid therapy. Searching for more common cause of low back pain, such as lumbar fractures, sacral insufficiency fractures are frequently underestimated on conventional X-ray plain film or CT study (19) . Moreover, as well as for the rest of the spine, the sacrum can be affected by primitive or secondary malignancies. Patients affected by sacral insufficiency fractures or sacral malignancies experience disappearing or significant reduction of low back pain when percutaneous sacroplasty treatment is performed, and the clinical results remain stable even in the late follow-up. Multiple fractionated PMMA injections under a CT guide allow precise sacral bone reconstruction and prevent PMMA foraminal leakage. Moreover, almost every area of the vertebra can be remodeled using an appropriate CT-guided technique, as for the trasverse process, the articular process or the pedicle. Finally, we tested a new water suspension of osteoinductive bioceramics, easily injectable through conventional vertebroplastic needles in non-fractured VB of severely osteopenic patients affected by multiple non-adjacent VCF and in patients with vertebral large osteolitic defects with the aim of activating focal osteogenesis (percutaneous osteoinduction, PO). The purpose of this session is to highlight the increasingly important role of diagnostic imaging procedures and image-guided therapeutic interventions in the diagnosis, management, treatment, and follow-up of stroke patients. Stroke is defined as a sudden or rapid onset of a neurologic deficit (in a vascular territory) due to a cerebrovascular disease lasting longer than 24 hours. It is the most common non-traumatic neurological emergency, especially in elderly patients. An estimated 10-15% of patients die following acute stroke, while 30-60% survives with permanent disabilities. Two different types of acute stroke can be discerned: hemorrhagic (15-20% of strokes) or ischemic (80 % of strokes). Recent advances in CT and MRI provide exciting new opportunities for performing 'multi-parametric' examinations in acute stroke patients, combining anatomical images with diffusion, perfusion and angiography. These imaging procedures contribute to our understanding of the pathophysiology of ischemic stroke, and may help us to develop an adequate triage protocol that takes into account the type and extent of stroke, time of onset, and the site of vessel occlusion. An important goal of imaging in the acute phase is to identify the ischemic penumbra, an area of potentially salvageable tissue surrounding the core infarct. In summary (1) Multimodal imaging techniques help to guide stroke therapy and to predict patient outcome. (2) New treatment options (such as thrombolytic therapy or interventional endovascular methods, e.g., mechanical recanalisation) should be considered in the management of stroke patients. What happens in acute stroke? R.G. Gonzalez; Boston, MA/US (rggonzalez@partners.org) The occlusion of an artery to the brain sets into motion a complex series of physiological events that may result in a range of clinical outcomes ranging from little or no deficit to major disability or death. The outcome depends on a variety of factors including the artery that is occluded and the collateral circulation. The occlusion of a major artery or branch results in the rapid irreversible injury to a portion of brain (ischemic core), and the establishment of a region that is hypoperfused by collaterals that are dysfunctional, but viable, which is called the ischemic penumbra. Modern neuroimaging is capable of depicting with precision the site of occlusion, the presence of collaterals, the ischemic core and the penumbra. The outcome of the patient can be modified by therapy. Specifically, the recanalization of a major artery occlusion can convert a potentially devastating outcome to situation where the patient has little or no deficit. Neuroimaging through its capacity to depict the relevant stroke anatomy and physiology is becoming increasingly valuable in therapeutic decisions. With the advent of MRI at the end of the last century, the question came up whether CT is still necessary for the management of acute stroke. Manufacturers stopped the development of CT technology and concentrated on MRI with view to the advantages of MRI: early detection of ischemic lesions on DWI, combination with MRA and perfusion imaging (MRP), no radiation. Nevertheless, MRI had problems to show: its feasibility in severely ill patients and its cost effectiveness. There is no randomized controlled trial that proves that specific information provided by MRI can enhance the benefit of stroke treatment in comparison with CT. Moreover, three pivotal positive trials showing the benefit from IV and IA thrombolysis were based on CT. In the meanwhile, CT replaced widely conventional radiography and became the working horse in emergency facilities. The development of multislice technology reduced scantime to the range of seconds. The combination of non-enhanced CT with CTA and CT perfusion imaging (CTP) now allows a similar ‚one-stop-shopping' like MRI, but in shorter time and with less contraindications. Besides its feasibility, the main advantages of CT in acute stroke today are its specificity for ionic edema that means irreversible tissue injury, the accuracy of CTA, and the quality of CTP. Disadvantages of CT are its insensitivity for cytotoxic edema and old brain hemorrhages and its lower contrast resolution compared to MRI. CT will remain the diagnostic workhorse for acute stroke patients, whereas MRI is required in single cases when stroke is a differential diagnosis. Patients outcome after ischemic stroke depends on the time between onset of symptoms and revascularisation, the recanalisation rate and the occurrence of intracranial hemorrhage. Fast and sufficient reperfusion in combination with a low rate of intracranial hemorrhage is the key to successful stroke treatment. The NINDS study was able to demonstrate the efficacy of systemic intravenous thrombolysis therapy (IVT) when initiated within 3 hours from onset of stroke. This narrow time window and various exclusion criteria limits the number of stroke victims who can be treated intravenously. The rate of recanalisation after IVT is about 44 %. The Prolyse in Acute Cerebral Thrombembolism (PROACT) study evaluated the safety and efficiency of local, intraarterial administration (LIT) of the thrombolytic drug in a time window of 6 hours and confirmed a significant higher rate of recanalisation of 66% compared to 18% in the heparin only group. Good clinical outcome was achieved in 40% of the treated patients compared to 25% in the control group. Recent developments, using mechanical recanalisation in addition with IVT (bridging therapy) or LIT achieved recanalisation rates of about 70% in addition with improved clinical outcome even in patients treated in a time window of 8 hours and suffering from proximal, large vessel occlussion. Based on the experience of more tha 500 stroke patients treated by endovascular approach we will discuss the indication and techniques of LIT, thrombaspiration, mechanical thrombectomy and PTA/stenting to reduce the time and increase the rate of revascularisation. Bone marrow edema is a generic term used to describe a common finding at MR imaging of the bone marrow. We will first define and illustrate the MR features that are characteristic of this syndrome as seen in the femoral head. We will also emphasize additional imaging findings on MR imaging or on conventional radiographs that can help to make a more specific diagnosis because femoral head edema can be observed in a spectrum of diagnoses including hip osteoarthritis, femoral head osteonecrosis, transient osteoporosis, femoral head fracture (post-traumatic, insufficiency or stress-related), and in the idiopathic bone marrow edema syndrome. We will stress the value of features that are helpful in clinical practice to offer the patients and the referring physicians a prognostic information. Hip joint is designed for stability, for supporting the weight and shifting the mechanical loads during ambulation and activity to the lower extremities. Sorrounding structures can be divided into static and dynamic stabilizers. Hip capsule and ligaments, primarily iliofemoral ligament act as a static syabilizer. Dynamic stabilizers are the sorrounding muscles and tendinous attachements. Several lesions and injuries can mimic a hip pain. Sport injuries to the hip and pelvis generally account for 5-6% of athletic injuries in adults. Soccer players, runners and ballet dancers are particularly prone to such injuries. Athletes presented with hip or groin pain can have its origin in the femoral head, labrum, muscles or pubis.The differential diagnosis of groin pain is wide and includes muscle tear, tendinosis or tears,apophysis avulsion, stress fracture, osteitis pubis, bursitis, hernia, entrapment neuropathy and referred pain from spine or sacroiliac joints. A systematic approach with different imaging modalities, specially MRI provide a valuable tool and permit an accurate diagnosis. Lymphomas may be of nodal or extra-nodal origin and are broadly classified into Hodgkin's disease (HD) and Non-Hodgkin's lymphoma (NHL). Notwithstanding a sophisticated subclassification, the key issue for the radiologist is differentiating indolent and aggressive lymphomas. Protean imaging manifestations reflect the varied pathology of lymphomas. HD tends to progress contiguously and is limited to nodes and spleen until advanced. NHL often presents as disseminated extranodal disease. Consequently, localized HD is often treated by a combination of chemotherapy and radiotherapy, whereas disseminated HD or NHLs are treated by intensive chemotherapy alone. Distinguishing localized and non-localized disease is therefore critical in HD. Examples of lymphoma in various organ systems will be demonstrated, with emphasis on gastrointestinal lymphomas. Imaging has roles in diagnosis, staging, and assessing treatment response. Advantages and limitations of various modalities will be discussed. Imaging-directed core biopsy including specimen immunohistochemistry should obviate surgery. Relapse requires repeat biopsy to assess possible transformation. Staging, usually by the Ann Arbor classification (or modifications), is primarily by CT, which can also monitor therapeutic response. Carcinoma of the uterine cervix occurs predominantly in women aged between 30 and 44 years. The diagnosis of cervical carcinoma is obtained by means of the Papanicolaou smear; in fact its widespread use has led to a decreased incidence of squamous cell carcinoma. The role of diagnostic imaging in cervical carcinoma is staging. Tumor spread can occur by direct extension or through lymphatics; hematogenous spread is rare. Cervical carcinoma staging should be performed according to the FIGO staging system, which is an important determinant of prognosis and choice of treatment. Clinical FIGO staging has a high error rate compared with surgical staging; an important role of MR imaging is to increase pretreatment staging accuracy in patients with cervical carcinoma. Sagittal and axial T2w sequences provide good contrast between the tumor and normal cervix. It was reported that overall, MR imaging is more cost effective than other imaging modalities. Carcinoma of the endometrium is the most common invasive gynecologic malignancy of the female genital tract. Clinically, patients with endometrial carcinoma present abnormal uterine bleeding. The role of MR imaging in endometrial carcinoma is disease staging and treatment planning. MR imaging has been shown to be the most valuable imaging modality in this task, because of its intrinsic contrast resolution and multiplanar capability. The appearance of noninvasive endometrial carcinoma on MR imaging is characterized by a normal or thickened endometrium, with intact junctional zone and sharp tumor-myometrium interface. Invasive endometrial carcinoma is characterized disruption or irregularity of the junctional zone by an intermediate signal intensity mass, on T2-weighted images. Uterine artery embolisation (UAE) is a non-surgical intervention for treating symptomatic uterine leiomyomas and represents an alternative to surgical removal (Hysterectomy, moymectomy, hysteroscopic resection). The indication for uterine artery embolisation crucially relies on the pre-interventional assessment of symptomology and burden of disease. Especially the location, size, and number of leiomyomas are important to determine treatment options of patients. As a rule, both single and multiple fibroids can be treated by UAE. The number and location of the individual tumors (subserosal, intramural, transmural, submucosal) does not affect the approach, technique or outcome of UAE. MR guided high-intensity focused ultrasound (HIFUS) is a non-invasive treatment option for symptomatic leiomyomata. In contrast to UAE and surgery it lacks the invasiveness of these procedures since the targeted leiomyoma are ablated by energy transmitted through the skin by focused ultrasound while exact delivery is monitored online by MR Imaging. Size, location and number of fibroids are limiting factors for the application of HIFUS. Magnetic resonance imaging (MRI) is superior compared to ultrasound in delineating the extent of fibroid disease and excluding other pathologies or disease processes that may mimick fibroid-related complaints. Further advantages of MRI result from the use of MR angiography and contrast-enhanced imaging in assessing outcome and complications following UAE. This presentation summarizes the current role of UAE and ultrasound ablation (HIFUS) for uterine leiomyomata as well as the role of imaging before and after the procedure. Learning Objectives: 1. To understand the basic principles of MR-guided high-intensity focused ultrasound (HIFUS) and uterine artery embolisation for the treatment of leiomyomas of the uterus. Occupational lung diseases (OLD) are a major health problem. Imaging plays a crucial role in the assessment of the patient with a suspicion of OLD. Hence, diagnosis is not always straightforward. As an example: Is a singular pleural plaque in a patient with a history of asbestos exposure asbestos-related pleural disease? This session will give triple information on this topic. We will learn about clinical needs of the occupational health practitioner, and get familiar with modern quantitative imaging techniques and the ILO-2000 and ICOERD-HRCT classifications. The chairman's introduction will guide into the topic. Radiological imaging of occupational lung disease is an ongoing interdisciplinary challenge. This is true both for mass screening by conventional chest radiography or CT-scans as well as for individual work-up of "complicated cases" with CT-scans. From the occupational clinician's point of view, the following issues are in the spotlight: 1. Screening for occupational lung cancer in high risk groups: Despite the lack of studies showing an overall increase in survival, there are cohorts (mainly, with an exposure history to asbestos and silica) which are regularly screened with CT-scans mainly in study settings. Therefore, the question arises regarding the optimum balance of time intervals, resolution/quality of CT-scans in terms of diagnostic sensitivity and specificity, and radiation protection for the individual patient. 2. Differential diagnosis in imaging of interstitial lung disease: In 2002, the ATS and ERS published a joint statement detailing a revised classification of the idiopathic interstitial pneumonias, and this provided an integrated clinical, radiological and pathological classification with broad agreement. Nevertheless, occupational interstitial lung disease due to, e.g., asbestos, silica, or other agents such as glass fibers, beryllium, graphite, or inducers of extrinsic alveolitis and others, have to be considered in many of these patients, and an internationally standardized and transparent approach is clearly warranted. Since for aspects of workers' compensation the diagnosis has to be proven beyond doubt, specificity of radiological imaging is the crucial point, particularly in the absence of a pathological diagnosis. 3. The situation is particularly complicated when different clinical diseases are present simultaneously, such as pleural plaques and UIP, or extrinsic alveolitis and emphysema. 4. Radiological and functional correlation in occupational lung disease: For reasons both of early diagnosis and workers' compensation, the clinician needs to know to which extent certain functional changes in, e.g., spirometry or cardiopulmonary exercise capacity can be causally attributed to specific parenchymal changes. Interdisciplinary approaches are clearly warranted both regarding international "state of the art consensus" as well as on the local level serving the patient. The assessment of imaging changes associated with OLD has been historically based on fully subjective or on semi-quantitative template-based evaluations. This presentation will document the shift to quantiative imaging approaches of OLD, warranting increased sensitivity and specificity of results, improved reproducibility of findings and decreased interobserver variability. Illustrations of the shift in practice will be based on both diseases and on technical modalities such as digital radiograph, computed tomography and magnetic resonance imaging. An outlook will draft the potential position of these emerging techniques in future diagnostic algorithms and in OLD-related clinical scenarios. Learning Objectives: 1. To describe quantitative imaging techniques used in the assessment of OLD. 2. To discuss the epidemiological and clinical implications of these techniques. 3. To detail the future challenges in the imaging assessment of OLD. Team teaching: All you ever wanted to know about ILO-2000 and ICOERD-HRCT classifications and never dared to ask K.G. Hering 1 , K. Hofmann-Preiß 2 ; 1 Dortmund/DE, The International Labour Office (ILO) has promoted discussion and published a series of guidelines on how to classify chest radiographs of persons with pneumoconioses. Based on this system, the type and degree of lung abnormality could be readily assessed in a population of exposed subjects, and correlations made with exposure severity or duration, morbidity and mortality. The development of high-resolution computed tomography (HRCT) has revealed the weakness of chest radiographs, especially for the diagnosis of early abnormalities produced by pneumoconioses. In 2005, a group of international experts from Belgium, Finland, France, Germany, Great Britain, Japan and the USA agreed on a principal coding system, along with reference films and imaging parameters, the International Clas-G H sification for Occupational and Environmental Respiratory Diseases (ICOERD). The system has been tested by eight experienced NIOSH-B-readers. The reading trial included 114 lung zones selected from 19 CT films of dust-exposed workers to assess the reliability of the classification system by weighted k. Inter-and intra-reader agreements were evaluated and the system has been categorized as an acceptable tool to obtain reliable semi-quantification of HRCT for dust-related lung diseases. Both classification systems are purely descriptive (rather than diagnostic), so that all aspects of thoracic abnormalities may be recorded. Take-home messages: 1. ILO-and ICOERD-classification systems are semi-quantitative tools to standardize classification methods and facilitate international comparisons of data on pneumoconioses and epidemiological investigations. 2. The classification systems are purely descriptive, so that all aspects of parenchymal and pleural abnormalities may be recorded, independent of the cause. This presentation will be focused on the most frequent pituitary tumors, i.e. pituitary adenomas. With amenorrhea-galactorrhea syndrome, the suspected lesion is usually an intrasellar microprolactinoma, the MRI technique has to be adapted for this search, pitfalls represented by artefacts have to be ruled out. Hyperprolactinemia in man, on the other hand, is frequently correlated with a macroadenoma, in this particular case, the radiologists have to look for signs of invasiveness. Cushing's disease is quite always present in relation with a small or very small pituitary adenoma, the MRI technique must include sophisticated sequences such as dynamic studies or delayed images after gadolinium injection to detect subtle signal changes. In acromegaly, pituitary adenoma can be small or large, or partially masked by an empty sella, the signal of growth hormone (GH)-pituitary adenoma is hypointense on T2 sequence in two-thirds of the cases. Gonadotrophic adenomas are usually large and responsible for hypopituitarism and/or visual symptoms. The recurrence rate is high after surgery and serial MRI must detect early signs of recurrence. The spectrum of non-adenomatous pituitary lesions will be also discussed. Primary brain tumors are associated with the third highest cancer-related mortality rate and a disproportionally high level of disability and mortality. Therefore, early and accurate diagnosis is critical for determining prognosis and therapy. Brain tumors consist of a group of neoplasms with wide variations in malignancy phenotype and heterogeneous imaging findings. A radiologist, by using well-established traditional criteria such as a) the age of the patient, b) the location of the lesion (intra-or extraaxial, supra-or infra-tentorial), and c) imaging characteristics (margins, edema, necrosis, hemorrhage, calcifications, cellularity, pattern of enhancement), in the majority of the patients, is able to provide an adequate differential diagnosis, as different types of tumors occur in different age groups, in certain intracranial locations and with various imaging features. Although MRI is the imaging modality of choice for the evaluation of intracranial masses, it suffers from a number of limitations including: a) difficulties in demarcating the exact margins of infiltrative tumors. b) limitations in distinguishing high-grade from low-grade neoplasms, c) difficulties in differentiating a primary intra-axial tumor from a solitary metastasis, d) difficulties in discriminating between recurrent tumor and post-radiation necrosis, e) difficulties in distinguishing neoplastic from non-neoplastic intracranial lesions. Advanced, non-conventional MR techniques such as Diffusion-weighted Imaging and Diffusion Tensor Imaging (DWI-DTI), Perfusion Imaging (PWI), MR Spectroscopy (MRS) and Functional MRI (fMRI), can be used to improve the diagnostic accuracy and evolve brain imaging from a strictly morphologic diagnosis, to one that combines anatomy, metabolism, physiology, biochemistry and function. Learning Objectives: 1. To learn the incidence and neuropathology of primary brain tumors. 2. To learn the typical imaging features of primary brain tumors. 3. To report on the limitations of conventional contrast-enhanced MR imaging in the diagnosis and differential diagnosis of brain tumors. C. Pseudo-tumors, cysts and cyst-like lesions P. Demaerel; Leuven/BE (philippe.demaerel@uz.kuleuven.ac.be) A wide variety of non-neoplastic intracranial lesions can mimic brain neoplasms. For initiating the appropriate therapy, it is important to differentiate these lesions from neoplasms. Clinical elements play an important role. The WHO classification contains a separate category of tumour-like lesions, which will briefly be reviewed. But most attention will be paid to vascular and infectious brain pathology simulating neoplasms. Both CT and MR play a role in this diagnostic challenge and more advanced techniques such as diffusion-and perfusion-imaging may contribute to the final diagnosis. Hemorrhagic lesions can be neoplastic but can also be a cavernous angioma or an infarct. Brain abscess can look like a malignant necrotic brain tumour. Toxoplasmosis can be difficult to differentiate from lymphoma. A large number of infectious pathogens (e.g. Behçet, Listeria, tuberculosis, sarcoidosis,…) can present with multiple brain lesions which need to be differentiated from metastases. Tumefactive multiple sclerosis and inflammatory pseudotumours can mimic brain tumours. Cyst-like intracranial lesions and cysts can be neoplastic as well as non-neoplastic. Congenital and tumoral cysts will be discussed. One should be careful not to diagnose a space-occupying lesion too readily as a neoplasm. As a rule, it is wise to take into consideration congenital, traumatic, vascular, infectious/ inflammatory and neoplastic pathology when confronted with a space-occupying intracranial lesion. Follow-up imaging is important both for reaching the final diagnosis and for following up a lesion during therapy. Learning Objectives: 1. To discuss the most frequent brain lesions that can simulate a brain tumor. 2. To learn possible differential diagnostic signs on conventional neuroradiological examinations. 3. To discuss the impact of advanced techniques in the differential diagnosis of pseudo-tumoral lesions. tion (e.g. metabolic activity or degree of hypoxia) to the conventional anatomical approach. In practice, PET and CT scans are not acquired simultaneously. Rather, the patient bed moves from CT to adjacent PET gantry. As the patient remains in the same position, there is no need for fusing images, provided that there has been no patient movement. For many PET studies quantification is essential. Consequently, a PET/CT scanner can only be used optimally if it still allows for such quantitative studies. In this respect the main difference between PET/CT and stand alone PET is the way in which attenuation correction is performed. Therefore, attention should be given to the following issues: 1. Mismatch between CT and PET data, leading to attenuation correction artefacts, e.g. due to patient movement (between scans) or inappropriate bed design (bending between gantries). 2. Accuracy of attenuation correction, especially when using contrast material for CT or with metal implants. Learning Objectives: 1. To provide an overview of the principles of PET and the potential benefits and limitations of a combined PET-CT system. 2. To understand the issues related to the use of CT for attenuation correction of PET images. 3. To learn about (the need for) quantification of PET data. 4. To provide an overview of potential clinical applications of a PET-CT system. Registration of image data from different modalities has attracted considerable interest in the past years. In particular, also imaging devices integrating a CT scanner with a dual-headed SPECT camera have been developed. Furthermore, considerable progress has been made also in the field of software-based image registration since data compatibility between different modalities has been much improved. However, evidence on the anatomical accuracy of software-based registration between SPECT and CT is still scarce; most authors report the anatomical inaccuracy of that technique to be in the order of 1 cm. With SPECT/CT hybrid imaging, the accuracy of image fusion is expected to be much better. First own data show that the anatomical mismatch between skeletal SPECT and CT is well below pixel width, averaging 1 mm. In SPECT/CT datasets, CT may be used for attenuation correction of the SPECT images. Applying this technique to skeletal scintigrams, the deeper structures of the body will gain in counts compared to the more superficially located parts of the skeleton. However, misalignments between SPECT and CT will lead to considerable artefacts when attenuation correction is used. Therefore, for the clinical application of that technology, an exact data match is mandatory, and it should be employed cautiously. The high anatomical accuracy of image registration by SPECT/CT offers the potential to exactly relate SPECT abnormalities to an anatomical region and elucidate unclear SPECT findings by obtaining a CT in the same imaging session. This potential greatly enhances diagnostic accuracy, which will also be demonstrated in this lecture. MRI and PET are imaging modalities that complement each other in several respects. The simultaneous acquisition moreover has got the potential to be faster, more precise and much simpler than sequential imaging. The combination of MRI and PET poses big challenges mainly due to the fact that the photomultiplier tubes (PMT) used in today's PET/CT scanners cannot be operated in high magnetic fields. In addition, the mutual electromagnetic compatibility, and space as well as other constraints have to be considered. Various groups pursued different concepts to overcome these issues; however, the first prototype systems allowing simultaneous human imaging of the same volume were built using avalanche photodiodes (APD) instead of PMTs to assemble a MR-compatible PET camera. Multiple groups have published preclinical MR-PET images, providing the proof of principle for the different simultaneous approaches. However, first simultaneously acquired human brain images have been generated following the APD approach with a PET Head Insert inside a 3 T MR system. Many academic groups as well as the industry are working on solving the technical challenges of a MR-PET integration. The availability of fully functional demonstrators for rodent and human imaging will pave the way for clinical MR-PET applications. Ultrasound (US) is considered the best imaging modality for GI pathology in children because there are no issues of radiation, high spatial resolution, real-time visualisation, portability, interventional guides, and interactivity (image-symptom correlation). The usefulness of plain abdominal film in GI pathology is in question, and may be avoided or postponed except in trauma situations, neonatal period and critical care units. There is a tendency to replace US by multidetector computed tomography (MDCT) as primary diagnostic tool. A carefully review of the literature shows that the use of CT is not justified, especially in case of acute abdomen. In most cases, this diagnosis can be accomplished by US. In some specific situations, like polytraumatized children and oncologic pathologies, CT can be superior and could be used as a primary tool. MR does not use ionizing radiation, but is an expensive and time-consuming procedure. Also, in many cases it is necessary to use sedation or anesthesic procedures, as well as contrasts with additional risks. However, it is very useful in oncology framework. Description of US images and characteristic signs with a precise pathologic correlation offers objective US features that facilitates the diagnosis and minimize the operator-dependent disadvantage of this technique. US is particularly useful in the acute abdomen confidently ruling out intussusception and appendicitis. Beside, It is an ideal method to guide in real-time interventional procedures (intussusception reduction, biopsies and fine-needle aspirations. The aim of this course is to deal with GI pathologies susceptible to diagnosis by US and to discourse its advantage and limitations. AT (michael.riccabona@meduni-graz.at) (Pediatric) CT applications have been boosted with the advent of spiral multi-detector scanners, reducing sedation needs and enabling multiplanar reconstructions. Thus CT as the most widespread and tested sectional modality not only remains the pediatric emergency imaging tool, but is also used for tumor assessment and in complicated abdominal disease (as also in situations where there is no MRI available). However, CT-inherent restrictions need to be addressed: 1. CT's considerable radiation is the most important disadvantage for pediatric application obviating dynamic-functional imaging, or a 'second try'. 2. Discrimination of (small) structures may be poor, and intravenous (or peroral/rectal) contrast administration is often necessary. 3. The specific pediatric pathologies cause adapted imaging (e.g. poorly calcified urolithiasis -infectious, oxaluric, cystinuric, potentially missed by non-enhanced ultra-low-dose 'stone-CT'). 4. Immature or impaired renal function restricts contrast application. 5. It is mandatory to adapt adult CT protocols to the various child-specific needs and queries. Thus dedicated (low-dose) pediatric CT protocols are advisable designed to meet individual queries and considering age-specific needs (slice thickness, increment, pitch, rotation time, delay) as well as equipment-associated variations. Some basic rules for establishing pediatric abdominal CT protocols, besides questioning its need, are: 1. Accept some image noise maintaining diagnostic image quality and reduce radiation dose. 2. Do not use large detectors for spiral-or sequence mode. 3. Consider focused CT. In conclu-G H sion, given a valid CT indication, pre-established pediatric abdominal (low-dose) CT protocols should grant its optimal use allowing a diagnostic examination at the first attempt with lowest possible radiation burden. The place of MRI in the evaluation of the paediatric population is growing, as it has the ability to provide both anatomical and functional information within large fields of view, and without any radiation. Recent technical advances concerning field strength, gradients, coils and sequences are to be used for imaging children, as they allow higher spatial and / or temporal resolution and better contrast. A few techniques may also contribute to obtain better control of motion artefacts. In the GI domain, the main indication concerns bowel inflammatory diseases but the technique can be occasionally used for specific entities such as duplication cysts, lymphangioma and anorectal anomalies. Nowadays, MR urography is a well established technique in many institutions, providing rich morphological information while post-gadolinium dynamic sequences allow complementary assessment of the split renal function and upper urinary tract drainage. The main indication is the evaluation of obstructive pathology, most often in a context of malformation. Actual limits of the practice of MRI in children include the need for sedation in young children, cost, and potential risk of Nephrogenic Systemic Fibrosis although its occurrence is rare. MRI should be nowadays the method of choice to be performed after an initial ultrasound in the diagnosis and / or follow-up of certain GI and most GU diseases in children. Purpose: To review the role of radiology in the examination of skeletal remains. Since 1896, radiology has been a tool of forensic medicine. Its non-invasive procedure allows skeletal and soft tissues to be examined to determine mechanisms of injury, cause of death and identity. Durability of skeletal and dental structures enables their survival from destructive forces of fire and decomposition, outlasting soft tissues by tens, hundreds and thousands of years. In many cases, the surviving material represents the only information about the individual, their life and events surrounding their death. In such circumstances, radiology is a valuable tool for the investigator. Results: A series of case studies covering archaeological studies, investigation of suspicious death, determination of identity and investigation of war crimes and human rights abuses demonstrate that radiology is an important and often essential tool. However, it is clear from the literature reviewed that utilisation is variable and often dependent upon the experience of the investigator, availability of suitable equipment and trained and interested practitioners. Little research in the field of physical anthropology and forensic science has recognised the opportunities offered by radiographic examination and there appears to be a lack of awareness of the rapidly developing field of medical imaging and the opportunities offered by modern imaging techniques. Conclusion: Radiographers and radiologists can play a pivotal role in forensic and archaeological investigation of skeletal material in conjunction with archaeologists, anthropologists, pathologists and odontologists. Modern Imaging techniques have enormous potential and greater collaboration among the sciences needs to be encouraged. Learning Objectives: 1. To learn about the use of radiology in the examination of human remains. 2. To understand the importance of the role of radiographers and radiologists in the forensic and archaeological investigation of skeletal remains. 3. To give an overview on cases studied. 4. To become familiar with the role of the forensic team of radiographers and the use of modern imaging modalities in this field. B. The role of forensic imaging in the aftermath of the London tube and bus bombings C. Rock; Huddersfield/UK (catherine.rock@ge.com) On 7 th July 2005, 56 people were killed and over 700 injured when bombers staged four simultaneous attacks upon the London Transport system. The London Mass Fatality Plan was invoked, an emergency mortuary was established in the City of London and was operational within 48 hours of the attacks. The Association of Forensic Radiographers initiated their planned response. Over a 17-day period, 56 bodies and 1162 body parts were examined. Primary surveys of whole bodies were undertaken using fluoroscopy by teams of two radiographers and a pathologist. This method of imaging facilitated rapid location of personal effects, documentation of injuries sustained by the victims and also aided the retrieval of foreign bodies. In the case of body parts, the primary survey was undertaken using digital and computed radiography. Secondary surveys were undertaken following removal of clothing and external examination by the pathologist. They were mainly limited to intra-oral dental radiography in conjunction with odontological examination and enabled rapid, non-invasive acquisition of post-mortem data for comparison with available ante-mortem records. Tertiary examinations of both bodies and body parts were undertaken at the request of the pathologist in a number of cases. Use of modern radiographic imaging technologies contributed greatly to the speed of the pathology examination and identification process. Fluoroscopy and digital radiography enabled items of forensic evidence to be located and recovered very rapidly whilst minimising the need for invasive procedures. Although conventional X-rays have found their way into daily forensic practice, newer, clinically established methods, such as CT and MRI, seem to lag behind in their forensic implementation. Nevertheless, many different forensic institutions have started implementing CT, and even occasionally MRI in post-mortem forensic investigations with success. One of the main tasks of forensic medicine and pathology is the reconstruction of a case based on findings. In addition to conventional methods such as autopsy and photography, three main tools are available for the documentation of findings: 3D surface scanning for body surfaces, and CT and MRI for internal findings. Photogrammetry-based optical 3D surface scanning permits the 3D documentation of patterned injuries of living and deceased victims as well as tools, weapons and even whole crime scenes. Using MSCT and/or magnetic resonance imaging (MRI), the internal findings of corpses can be visualised. Additional findings become accessible with post-mortem angiography using a modified heart-lung machine and CT-guided post-mortem biopsy. The internal injuries of surviving victims of assault, especially regarding choking and other forms of blunt trauma not necessarily seen at external inspection, can be visualised using MRI. These techniques provide an accuracy and three-dimensionality conventional documentations lack and allow for the re-examination of the corpse and the crime scene even decades later, after burial of the corpse and vacation of the crime scene. This non-invasive or minimally invasive approach can offer alternatives to conventional examination techniques and will, according to our opinion, improve forensic medicine and pathology in the near future. Microbubble contrast agents for ultrasound (US) have gained an increasing interest in the recent years as a result of the safe profile and the increased stability in the bloodstream for several minutes. The contrast-specific US techniques, dedicated to the selective registration of the signals produced by microbubble insonation, allow a definite improvement in the contrast resolution and suppression of signal from stationary tissues. Microbubbles contain gases and are covered by a shell of biocompatible materials and respond to the pressure changes due to insonation by changing their diameter according to a resonance phenomenon with production of harmonics. Microbubbles present a pure intravascular distribution even though some agents present a post-vascular hepato-spleno-specific phase 2-5 minutes after intravenous injection. From 10 to 15 minutes after injection the microbubble gas content is exhaled via the lungs. The echo-signal quantification after microbubble injection may be performed by specialized softwares which have access to the raw data before application of non-linear modifications and are able to anti-log the grayscale signals which are log-compressed for video presentation. The echo-signal intensity, linearized or log-compressed, may be quantified by positioning manually defined ROIs. The determination of the degree of tissue contrast enhancement relies on the accurate distinction between backscatterer signals originating from microbubbles and the intrinsic signal emanating from tissues. The principal field of application of echo-signal quantification is the organ perfusion analysis which may be assessed through the off-site analysis of destruction-replenishment curves. Different mathematical functions have been proposed to fit echo-signal intensity raw data versus time. Contrast-enhanced US (CEUS) applications are growing with the improvement of US systems and specific imaging sequences. Applications have been extended in a recent consensus conference. Detection and characterisation of focal liver lesions remains the major indication. Liver CEUS is performed after a conventional US study performed with high standards. Characterization relies on the presence or absence of microbubbles within the lesion during late phase of the contrast transit and the pattern and timing of enhancement. Based on reported criteria, high sensitivity, specificity and diagnostic accuracy can be reached, with a very significant improvement compared to conventional sonography. Kidney vascular disorders are a more recent promising application area. CEUS improves the detection of abnormal micro and macro vascular disorders, particularly for the detection of renal ischemic diseases. It is a promising technique for the characterization of complex cystic masses and monitoring ablation of solid masses. However, the performance appears limited for the detection and characterization of solid masses. Among the remaining indications in the genito-urinary field, the detection of vesico-ureteric reflux, testis torsion and prostate cancer are the most promising. Other applications include pancreas, low energy blunt abdominal trauma, transcranial US Doppler. The quantification of USCA effect is leaving now the research lab to become more and more used in clinical practise. However, they are many issues including the heterogeneous distribution of acoustic energy. Future applications include new areas, such as 3D/ 4D imaging, strokes, thyroid, neo angiogenesis, and quantitative assessment of perfusion particularly for tumour response evaluation. Learning Objectives: 1. To become familiar with clinical applications to date. 2. To learn in-vivo experimental application of US contrast agents. 3. To discuss factors that influence quantitative assessments. Ultrasound is the most popular imaging modality, providing inexpensive real-time imaging with portable (including handheld) equipment. Targeted contrast agents (microbubbles) can make ultrasound imaging even more helpful: molecular imaging can provide information on the vascular endothelium molecular markers of disease. This could be useful for diagnostics, image-guided biopsies, and evaluation of therapy efficacy. Gas-filled microbubbles can be prepared from water-insoluble fluorinated gas and stabilized with a monolayer of lipid, surfactant and/or polymer. Targeting ligands directed towards endothelial targets (E-and P-selectin, ICAM-1, VCAM-1, alphaVbeta3, VEGF receptors) can be attached to microbubble shell. Many monoclonal antibodies achieve microbubble targeting only in the relatively slow flow conditions (wall shear stress ~1 dyn/cm2). To achieve microbubble targeting in fast flow, specialized glycosulfopeptides or sialyl Lewis carbohydrates can be used. Combination of two (or more) ligands on the contrast agent particles further improves targeting. Excellent microbubble detection sensitivity has already been achieved by ultrasound imaging. Multipulse techniques (phase inversion or power modulation), allow detection of individual microbubble particles (size of ~1-2 um and picogram mass). Therefore, detection of microbubbles selectively targeted to the disease area vasculature is feasible, even if a small fraction of the injected ultrasound contrast accumulates at the target. Ultrasound imaging of vascular targets has been successfully demonstrated in a wide range of animal models, from inflammation, ischemia and ischemia-reperfusion injury to atherosclerosis and to cancer. Translation of early research proof-of-concept studies to the clinically useful, safe and efficient practical applications will be the next challenge for ultrasound contrast agents. This presentation will give an overview of computer algorithms that are available for chest radiographs and chest CT, to detect abnormalities (nodules, pulmonary embolism, interstitial abnormalities), to obtain a diagnosis (interstitial lung disease, tuberculosis, probability of malignancy of lung nodules), to visualize disease progression (temporal and contralateral subtraction) and to quantify the extent of disease (emphysema scoring, airway analysis, COPD). The focus will be on explaining how CAD algorithms work internally. Knowledge about what goes on under the hood will help to identify key weaknesses of current technology. Methods as to how to overcome these limitations will be discussed. For nearly one decade, computer-aided diagnosis of lung nodules, especially automated detection on chest CT scans (computer-aided detection [CAD]), was an issue for only few experts in academic radiology. Five years ago, the medical industry discovered that area and started a large-scale development of CAD software. This development was triggered by the special interest in early detection of lung cancer with low-dose CT and the related issue of limited sensitivity of radiologists to detect small lung cancers on CT scans. During the past few years, a second population of patients turned into the focus of interest: Patients with a known malignant disease and the risk to develop lung metastases, or with known lung metastases. Algorithms developed to detect early lung cancer proved to be useful also for detection of lung metastases. So, CAD applications are now suitable for ruling out lung metastases more reliably as well as to track known lung metastases under treatment. Up-to-date CAD systems are able to provide radiologists not only with results of the automated nodule detection but also with support in image viewing (e.g. MIP or VRT mode, automatic synchronisation of current and previous CT scan, automated matching of nodules in different scans). The talk will present the following: a) Current applications of CAD for lung nodules. What can you expect when using CAD? b) Discuss how to integrate CAD into the reporting workflow. c) Discuss integration problems of CAD systems in the existent RIS/PACS environment and possible solutions. Learning Objectives: 1. To learn about the limited sensitivity of radiologists for detection of pulmonary lesions like early stages of lung cancer and pulmonary metastases. 2. To appreciate the benefit of software assistance to detect lung lesions. (hans-ulrich.kauczor@med.uni-heidelberg.de) Quantification of disease severity is important for management, stratification, prediction of response and prognosis as well as treatment monitoring in obstructive and vascular lung disease. Obstructive lung disease, such as chronic bronchitis, asthma, cystic fibrosis and emphysema, may present with two major components, namely airway and parenchymal disease. In airway disease, CAD tools focus on measurements of airway diameter and wall thickness. Skeletonization of the airways allows generating planes perpendicular to the centre line and thus improving accuracy. Small airway disease is associated with air-trapping, which is amenable to quantification by CAD. Loss and destruction of lung parenchyma in emphysema is easily quantified by lung segmentation and calculation of mean lung density, emphysema index, and percentiles. This can be complemented by a more sophisticated cluster analysis or texture classification in 3D. Such results show good correlations with pulmonary function tests and can be applied as imagebased surrogates for lung function. CAD tools are also available for quantification of thrombus load in pulmonary embolism and as surrogates for right heart strain. They might serve as an important parameter to escalate treatment. 4D-imaging of respiratory motion or blood flow poses new challenges to image post processing and quantification. Novel approaches are able to visualize 4D information and dedicated vector maps of respiratory motion or blood flow can be generated. As MRI is one of the mainstays in 4D imaging there is an increasing demand for CAD tools handling MR images. Interventional instruments as used for X-ray-guided procedures greatly relies on metallic materials, which cause a potential safety hazard, when used in the MR environment. Safety conditions and new instrument developments will be presented during the next talks aiming at the introduction of MR guidance into clinical practice. Most challenging among the interventional procedures are endovascular interventions. The image quality of today's real-time imaging allows a broad range of cardiovascular applications, which will be demonstrated in preclinical studies, where the need for absolutely safe instruments is less demanding. Besides the feasibility of MR guidance for cardiovascular procedures, the indications and possible advantages of MRI over other imaging modalities will be discussed. One quite unique imaging ability of MRI is being used in the clinical setting already: Temperature measurement or at least demonstration of temperature changes. MRI will be demonstrated to exploit this feature in clinical settings using it for guidance of ablation procedures. Some clinical indications are already established and a special focus will be the use of focussed ultrasound guided by MRI. Over the recent decade, an ever-increasing number of interventional procedures have been performed in MRI systems. To perform MR-guided interventions, not only the MR systems needed to be optimized -also the interventional instruments had to be adapted to fulfill the special requirements of the MR environment. To avoid potentially dangerous attractive forces (missile effect) all parts of the instruments need to be designed of non-magnetic materials, and only under certain well-defined circumstances weakly magnetic materials may be used. Instruments containing electronic components must be carefully shielded to avoid artifacts from RF interferences, and long-conducting structures such as cables must not be used to reduce the danger of RF-induced tissue-heating. In many interventions, major parts of the instruments are introduced into the patient's body, so that a direct observation of the instrument position is not possible. Dedicated markers have been attached to the instruments, which are later identified in the MR images. As positive markers, reservoirs filled with contrast agent have been utilized, whereas negative markers creating a strong signal void have been constructed from materials with a strong susceptibility difference to tissue. A second class of markers makes use of the signal enhancement inductively coupled radio-frequency coils. Small marker coils which were directly connected to the MR receiver system have been designed, that can be attached to various instruments. Both coil systems can be detected within the human body by MR techniques, so that an automatic re-alignment of the imaging slice with the instrument becomes possible. The possibility of measuring physiologic parameters and the potential of high resolution imaging of the vessel wall are features of MRI that can be advantageously employed for cardiovascular interventions. Interventional MRI overcomes the drawbacks of other guiding techniques, such as conventional angiography, which can delineate only the vessel lumen and exposes the patient and the interventionalist to ionizing radiation, or ultrasound, which can not delineate catheters and devices over their entire length. In animal experiments, almost all cardiovascular interventions, including catheterization and stenting of coronary arteries have been proved to be feasible. Beyond selecting appropriate devices, adapting the different steps of the usually fluoroscopic-guided interventions to the requirements of cross-sectional imaging, namely selection of suitable landmarks in the anatomy and adapting the imaging planes accordingly, have contributed to the success of these approaches. In special centers, MR-guided right heart catheterization is already performed in patients. A huge obstacle for a broader use of MR-guided intervention is the lack of commercially available devices. MR guidance of focused ultrasound allows this destructive noninvasive technology to be applied to many difficult areas in the body provided a suitable acoustic window can be achieved. Online real-time thermal mapping allows assessment of heat deposition as it is carried out so that titration of response against input indices may be carried out to provide the safest most accurate and reliable tissue ablation. To date there is extensive experience in the treatment of uterine fibroids around the world and applications are slowly developing in other soft tissue areas. Within the next year projects involving ablation of prostate, liver, kidney will be developed together with existing areas of work in bone metastases, breast carcinoma and other similar areas. This talk will discuss these new emerging areas and will describe the advantages and problems associated with applying this new technology to these sites. For breast magnetic resonance (MR) imaging, a high spatial resolution is important for resolving morphologic and architectural details of even small tumors. At the same time, fast imaging is required to account for the transient enhancement of breast cancers: Cancers start to wash-out the contrast already after 1-2 minutes after reaching the peak enhancement in the early post-contrast period. This washout, combined with the progressive enhancement in the adjacent fibroglandular tissue, may cancel out the contrast with which a cancer is depicted against its background. As in contrast-enhanced MR angiography, also in breast MRI, it is therefore mandatory to use combination of a high spatial resolution with fast, dynamic acquisitions -this is the temporal versus spatial dilemma that all current breast MRI protocols face. Breast MRI technique comes in two different versions: As bilateral axial dynamic subtracted technique and as (mostly) unilateral semi-or non-dynamic, sagittal, actively fat-suppressed technique. Meanwhile, these two different 'camps' are less strictly separated -mainly as a result of the technical progress that has taken place. This lecture will present the many different approaches to breast MRI and will discuss the advantages and disadvantages of the respective pulse sequences. The discussion will include: Axial or sagittal or coronal orientation? 2-D or 3-D acquisition? Active fat-suppression or not? What comes first: Spatial or temporal resolution? CAD reading or not? 3.0 T or 1.5 T? Aim is to enable a balanced and informed decision-making regarding the choice of pulse sequence parameters for the breast MRI. Magnetic resonance imaging (MRI) of the breast identifies glandular tissue regardless of the amount of underlying fat tissue and demonstrates skin, nipple and chest wall components adequately. Motion artifacts are minimized in prone patientpositioning in a breast coil, hands against legs and head positioned on a front holder allowing breathing with a relaxed neck. Because the detection of breast lesions relies on visualization of abnormal contrast enhancement during T1-weighted imaging, the suppression of white fatty signal intensity is mandatory. Subtraction of pre-contrast images from post-contrast images is a technique used in both 2-D and 3-D sequences; spectral fat-suppression and water excitation are the other fat-suppression techniques. Abnormal enhancement is close to vessel enhancement but exhibits unusual morphology (spiculated borders, rim enhancement, segmental enhancement, irregular linear enhancement, etc). and may display wash-out kinetics. The description of both morphological and kinetic enhancement characteristics follows the Breast Imaging -Reporting and Data Systems (BI-RADS TM ) lexicon to allow standardization and clinical acceptance of results. The interpretation of enhancing elements within a breast into a risk category of malignancy takes into account several factors: The patient's age, phase of the menstrual cycle, personal risk of breast cancer and history of and/or current medical, surgical and radiation therapy. According to the clinical situation, an abnormal finding may be read differently. Knowledge of tumor histology to stage breast cancer is also important as invasive lobular cancers, medullary breast cancers or ductal carcinoma in situ often do not exhibit wash-out kinetics. A comparison with prior mammography and ultrasound is crucial to integrate findings of MRI in the final diagnosis. The major goal for breast-cancer imaging in the next decade is about more accurate disease characterization through the synthesis of anatomic, functional, and molecular imaging information. No consensus exists regarding the use of imaging for evaluating primary breast cancers. Besides other imaging methods, magnetic resonance imaging (MRI) has emerged as one of the major modalities for non-invasive functional imaging. Functional MRI will thus play a key role in the detection and characterization of breast tumors and in the assessment of treatment response. MRI produces already high-resolution three-dimensional images delineating morphological features of the breast. Functional MR images of breast tissues depend on endogenous differences in water content, metabolites and/or diffusion characteristics of the tissue of interest. By applying different MR methods, these endogenous differences can be measured and can help in increasing the specificity of MRI of the breast. Amongst others, these methods include: (a) imaging of hemodynamic parameters, including blood perfusion and vascular permeability with MMCE-MRI; (b) imaging of metabolites to assess the relative concentrations of chemical compounds like choline and citrate with MR spectroscopy; and (c) imaging of thermally random molecular displacement with diffusion MRI. Each technique is promising but is hampered by one or more limitations. Thus the fusion of all functional MR methods to one image is a challenging but promising way [called the fifth dimension (5D) of imaging] to achieve the goal. Echocardiography is the gold standard examination to evaluate valvular heart disease. The aim of the lecture is to review how to diagnose, quantitate and manage the most common acquired manifestations: aortic and mitral stenosis as well as aortic, mitral and tricupid regurgitation. New pathophysiological concepts will be discussed, such as the relationship between atherosclerosis and aortic stenosis and the different forms of mitral regurgitation (functional versus structural etiologies). Another goal is to introduce new imaging modalities such as 3D echocardiography and to discuss which information is needed for adequate preoperative planning. As a noninvasive, accurate and reproducible modality for the assessment of structural and functional parameters, MR imaging offers diagnostic options in patients with valvular heart disease that are unique in some regard: the severity of valvular regurgitation can be qualitatively evaluated with cine gradient-echo MR imaging and quantified using flow velocity mapping. In complex valvular heart disease, ventricular volumetric measurements combined with MR flow measurements can be used to accurately assess the contribution of each valve to cardiac dysfunction including the transvalvular pressure gradient and valve area in valvular stenosis. MR angiography can be used as a diagnostic adjunct in cases of combined disease of the aortic root. As modern techniques in cardiac surgery increasingly rely on MR imaging data for the planning of innovative procedures good interstudy reproducibility suggests a role for peri-operative MR imaging in determining the effects of therapeutic interventions. Furthermore, follow-up studies of functional and morphological parameters including delayed contrast enhancement are useful to gain prognostic information and predict patient outcome. This fact, improving costeffectiveness and increasing availability of state-of-the art scanners and software tools will promote MR imaging as a more frequently used routine procedure in valvular heart disease. AT (Gudrun.Feuchtner@i-med.ac.at) Lastest multislice computed tomography scanners allow 4D-cine imaging of cardiac valve function, through improvements in temporal resolution, complementary to coronary CT angiography from the same CT data set. Following potential implementations will be discussed: (1) Aortic stenosis: Planimetric measurement of the anatomic aortic valve orifice area (AVA) during mid-systole provides a reliable criterion to identify patients with aortic stenosis, if less than < 2 cm², which is reasonable in patients undergoing cardiac CT and having valve calcification, or if other modalities provide limited, or equivocal results. Besides, CT may qualify as valuable modality before percutaneous valve replacement. (2) Aortic regurgitation: based on the visiblity of a central valvular leakage area during diastole, aortic regurgitation can be identified. (3) Mitral stenosis/regurgitation: The more complex and 'saddle' shape makes the evaluation difficult, and clinical application cannot be recommended to date. An exception may be mitral valve prolapse. (4) Infective endocarditis: the key to diagnosis are the following characteristic imaging find-ings: (a) Vegetations, (b) Abscess/pseudoaneurysms, (c) Leaflet perforation, (d) Fistula, and (e) Dehiscence. A main advantage of CT in the pre-operative triage is the complementary ruling-out of coronary artery disease, and the avoidance of invasive angiography and associated risks. Notably, CT is reliable for exclusion of coronary artery disease before any valve surgery in general. Left ventricular (LV)function is an important parameter to define clinical management, and to predict outcome. CT has recently shown promising results to assess global and regional LV-function, and myocardial viability. Learning Objectives: 1. To learn about the potential of CT for assessing morphologic valvular abnormalities. 2. To appreciate the potential and limitations of CT for evaluating valvular function. 3. To understand the role of CT for a comprehensive cardiac evaluation including the valves, ventricles, and coronaries. Neck and back pain represent one of the most common and costly medical problems affecting developed nations. For example, low back pain currently affects up to 40% of adults in western Europe, resulting in massive medical costs and lost productivity. Evaluating and treating these patients is challenging, due to the variable pain generators in the spine, multiple levels that can be responsible for pain and the overlap of clinical symptoms that result from the various structures in the spine. Minimally invasive spine procedures provide an important contribution to the management of patients with neck, back or radicular pain symptoms. Percutaneous interventions for the treatment of disc disorders are being utilized with increased frequency and provide a viable alternative to the long-term use of oral analgesics or surgery. Both of these alternatives have associated morbidity and potential for very negative outcomes. Spinal interventions may be performed safely on an outpatient basis by proceduralists who are familiar with fluoroscopic anatomy, radiation safety and the technical components of interventional procedures. A high resolution multidirectional C-arm fluoroscopy device and a tilting fluoroscopic table provide the ideal combination for patient comfort and access to the spine. In this session, we will review techniques for evaluating and treating spine-origin pain. Several techniques for the assessment and treatment of specific pathologic conditions affecting the spine will be reviewed as an introduction to dedicated lectures on the treatment of disc pathology. The benefits and disadvantages of these procedures will also be reviewed. The dilemma on how to treat acute herniated discs remains unresolved. Discogenic pain, due to its favorable spontaneous regression, is mainly treated conservatively. Nevertheless, in some selected cases, pain is resistant to medical treatment. Surgical discectomy has the risk for recurrent radicular pain known as "failed back surgery syndrome", which is a disabling condition, very difficult to manage. In a selected group of patients, percutaneous treatment can be very useful, minimizing the risk of a possible complication. The purpose of this course is to demonstrate the techniques used in percutaneous disc treatment. We will address patient selection, indication and possible approaches. Imaging techniques, including fluoroscopy, computed tomography and magnetic resonance, will be shown. Analgesia is being discussed, as well as mobilization and drugs. Anatomic and positional landmarks A S87 C B D E F G H will be presented. The attending physician will have an overview of the material and methods available, such as discography, disc biopsy, coblation and decompressor technique, and steroid and alcohol gel injection. We will discuss pre-clinical and clinical data focusing on the safety of the technique and its effects on disc biochemistry. Complications are analyzed, as well as techniques to minimize potential risk of neurological damage. In conclusion, this presentation for percutaneous disc treatment will hopefully allow the interventional radiologist to perform these techniques in a safe and efficient way, minimizing the risk for his patient, while yielding all possible potential advantages. Knowing the limitations of the material at hand seems to be important for avoiding technical complications. Disc therapy is a wide challenge that seeks to reduce spine pain and neurological deficit of the upper and lower limb in patients with herniated disc. The first key point is to understand exactly the origin of spine and radicular pain, which is very important in the clinical evaluation of the patient. Clinical evaluation must confirm imaging findings. The second key point is to consider the absolute indications for surgery, such as progressive foot droop, cono-cauda syndrome and hyperalgic sciatica resistant to any type of medical therapy. The third point is to perform the percutaneous treatment after at least 6-8 weeks of medical and/or physical therapy. The natural history of herniated disc has been studied and we know that after 12 months the success rate is not really different between medical-physical therapy and any other type of therapy. The real problem lies in the management of pain in these patients. At this point, we have many arrows to use, some of them at the cervical and lumbar level, while others can be used only at the lumbar level. All the systems try to reduce disc volume and intradiscal pressure. Only the oxygen-ozone therapy associates an anti-inflammatory action as well. A success rate of 70-85% is reported in literature of patients with correct indications. All the treatments are minimally invasive and performed with local anesthesia, with very few cases of complications (inflammatory) reported in literature. Overindications related to the minimal invasivity of these treatments is a mistake that must be avoided. Efforts to screen for lung cancer have been undertaken since the 1970s, initially using chest readiography and sputum cytology. Recently, low-radiation dose unenhanced CT and more advanced analysis of sputum, blood and exhaled air have been applied with promising results. However, the diagnosis of an abnormal finding in an asymptomatic screening population may have a completely different significance compared to the same finding in a symptomatic patient. The following presentations will describe the motivation for screening for lung cancer, its potential advantages and disadvantages. Session Objectives: 1. To describe the current data on lung cancer screening. 2. To be able to understand the potential of screening. 3. To be able to understand the limitations of screening. Rationale for screening S. Diederich; Düsseldorf/ DE (s.diederich@marien-hospital.de) Lung cancer is the leading cause of death from malignancy with an estimated 1.3 million deaths per year worldwide. More than 85% of cancers occur in active or former cigarette smokers; other risk factors include occupational exposure to asbestos, chromium, arsenic and other substances. At early stages (i.e. tumor without infiltation of adjacent structures, lymph node or distant metastases) lung cancer causes no symptoms. Therefore, in symptomatic patients the cancer is usually advanced at the time of diagnosis. The overall five-year survival is, thus, poor and less than 15% worldwide. Cure, however, is much more likely if lung cancer is treated at the early asymptomatic stages. It is hoped that the detection of lung cancer at the early stages using diagnostic tests will allow more effective treatment and ultimately cure. It is, however, important to understand that screening asymptomatic individuals, as in any other screening programme, will have completely different aspects from those of examining symptomatic patients. The proportion of cancer, even in high-risk populations such as heavy smokers, will be low. False-positve findings will cause concern, unneccessary morbidity and potentially even mortality in healthy subjects. False-negative findings may falsely reassure individuals to continue smoking and neglect new symptoms. If cure is not achieved, early diagnosis of lung cancer will only prolong the period of life of the person as a cancer patient. Finally, a screening programme including diagnostic procedures and follow-up should be cost-effective to justify the expenditure, compared to other fields of preventive and curative medicine. Learning Objectives: 1. To describe to epidemiology of lung cancer. 2. To understand the therapy and prognosis when lung cancer is detected by symptoms. 3. To understand the concept of stage shift through early diagnosis. 4. To understand the potential biases in the recent studies on lung cancer screening. Interim results from the NELSON trial M. Oudkerk; Groningen/NL (m.oudkerk@rad.umcg.nl) The NELSON study (the Dutch-Belgian Lung cancer screening trial) started in 2004 and is Europe's leading population-based randomised lung cancer screening trial in which 20,000 high risk smokers and ex-smokers between 50-75 years of age have been randomised between MDCT screening in year 1, 2 and 4, or no screening. From 6.100 participants in the screen arm, DNA, plasma, and serum have been collected at baseline and lung function tests have been done. Sequential serum and plasma samples are being collected in lung cancer positive cases before and after surgical resection and in all 8.000 participants of the screen arm a second blood sampling for plasma, serum and DNA will be performed in the last screening round (2008) (2009) . Detailed history on smoking habits, alcohol consumption, body weight, and lung cancer among first and second degree relatives, duration and intensity of asbestos exposure, presence of COPD or emphysema and all demographic data are available for all participants.In 2009 we expect to have > 300 lung cancer cases identified in the screening and the control arm. The central radiological database in which already more than 20,000 low-dose MDCT images are stored is located in UMCG Groningen. It is expected that by the end of the screening phase of the NELSON trial, it will contain almost 30.000 CT scans with at least 2,000 different types of pulmonary nodules. The CT scans will not only be used for lung cancer screening but also for quantification of coronary calcifications. Our experience is based on two cohorts of high-risk volunteers enrolled in 2000 (1035 subjects, now undergoing 8 th annual low-dose CT) and in 2004-2005 (5202 subjects) for a total of over 27,000 low-dose CTs. Problems in detection are rare and may arise from small hilar lesions, nodules attached to pleural surface or hidden in apical scar. The main causes of errors leading to a wrong decision on patient management are the false-positive or false-negative results from PET or from follow-up in measuring size changes. The under-or over-estimation of growth G H of a nodule may be because of variability in automatic volume measures or in subjective diameter evaluation, or to too short a time between the two CTs, or to the growth of some benign nodules, or to a period of quiescence of some tumours. PET, although extremely useful in defining the nature of undetermined nodules, gives positive results in some benign lesions, while on the other hand, is often ineffective regarding slow-growing tumours and non-solid lesions. Non-solid nodules need careful evaluation and dedicated management: The morphologic appearance is not reliable for diagnosis and they could grow slowly and increase in attenuation as a sign of early-stage malignancy. Multidisciplinary discussion of the low-dose CT-positive cases and careful evaluation of imaging results with a complete evaluation of the patient can reduce the number of unnecessary biopsies. The knowledge of MR imaging findings of a normal shoulder joint, its variants, and pathologic alterations is crucial for an exact diagnosis. There are several forms of impingement: 'Primary external impingement' is caused by subacromial or subcoracoid impingement (spurs, unstable or acromiale, variations of the acromial morphology, degeneration of the acromioclavicular joint or abnormalities of the coracoid process). Chronic or long-standing glenohumeral instability, mostly observed in athletes who participate in sports that require repetitive overhead or throwing motions, may lead to 'secondary external impingement'. In those cases clinical symptoms may mask signs of underlying glenohumeral instability and point directly to rotator cuff lesions. 'Internal impingement' is a separate category of impingement and is caused by abnormalities due to friction between the posterosuperior or anterosuperior labrum and glenoid, and rotator cuff. Almost always long-standing impingements cause rotator cuff lesions (degeneration/fraying of tendons, partial or full thicknes tears). In this presentation, the different forms of impingement and MR imaging findings of rotator cuff pathology are demonstrated. Learning Objectives: 1. To become familiar with MR imaging of the normal rotator cuff. 2. To understand aetiology and MR findings of rotator cuff lesions caused by or leading to subacromial impingement. 3. To recognise tendinosis vs partial and full thickness rotator cuff tears. A-300 09:00 B. Glenohumeral instability P. Hughes; Plymouth/UK (philhughes_uk@yahoo.com) The term "shoulder instability", embraces those patients with both subluxation and dislocation of the joint, and investigation is indicated predominantly for recurrent dislocation or for apprehension when the arm is held in certain positions. Accurate pre-operative assessment is essential and likely to become increasingly necessary with the increased use of arthroscopic repair. The primary diagnostic modality applied to the pre-operative investigation of instability is MR arthrography. Its sensitivity and specificity in identifying abnormalities related to instability will be discussed and contrasted with alternative imaging techniques. The injection technique, imaging protocols and optimal orientation of scans will be considered along with the potential benefits of ABER positioning. Common appearances of labral, glenoid and ligamentous abnormalities associated with instability will be demonstrated. The importance of identifying the less common posterior and multidirectional instability and rotator cuff tears will be emphasized. Common post-operative appearances and causes of recurrent instability will be discussed. (ellopis@hospital-ribera.com) There is a growing evidence of the importance of the long head of the biceps tendon as stabilizers of the anterosuperior aspect of the shoulder, especially with the arm in abduction and external rotation. Long head of the biceps tendon enters shoulder joint though the rotator interval, triangular structure between the subscapularis, supraspinatus tendon, superior glenohumeral ligament, and coracohumeral ligament. Long head of the biceps tendon changes from vertical to horizontal orientation and this is stabilized by a complex tendoligamentous sling called the biceps pulley. Biceps tendon is a well known common source of shoulder pain in combination with labral or rotator cuff abnormities. However, isolated injuries of the biceps tendon and rotator interval are more frequent than previously thought and its evaluation might be difficult with subtle clinical, radiological and Arthoscopical findings. Moreover, injuries of the biceps tendon or biceps tendon attachment changes load points of glenohumeral joint and increases the torsion forces to the superior labrum and might start a cascade of anterior shoulder structures. Understanding of anatomy and biomechanics is essential to achieve an accurate diagnosis and plan adequate treatment. Neuroradiological assessment of acute stroke patients is mandatory, not only to confirm the clinical diagnosis and exclude a non-vascular origin of the symptoms, but also to accurately classify the condition based on the type (ischemic or hemorrhagic), topography, extension, and causative mechanism. Several neuroradiological techniques such as CT, CT angiography, CT perfusion, multimodal MRI and DSA can be used for this purpose, and the results of these studies will influence selection of the most appropriate treatment. Knowledge of the advantages and drawbacks of these techniques for proper assessment of acute stroke is essential to establish the most cost-effective diagnostic strategy, which should be based on reported evidence-based data, personal experience, and equipment availability. In the last few years, special efforts have been made to improve the approach for selecting patients who will benefit from thrombolytic therapy, and extend the therapeutic window in which this treatment can be safely used. The use of advanced neuroradiological techniques, which can estimate the presence of potentially salvageable ischemic brain tissue (ischemic penumbra) and accurately identify the location of the arterial occlusion, seems to better achieve these goals than unenhanced CT. In addition to their role in diagnostic assessment of acute stroke patients, various endovascular techniques, including recanalization (superselective intra-arterial thrombolysis, mechanical clot retraction, stenting, and angioplasty) and occlusive (embolization) procedures, are considered treatment options for both ischemic and hemorrhagic A S89 C B D E F G H (intraparenchymal and subarachnoid) stroke. These diagnostic and therapeutic neuroradiological techniques and procedures will be described, critically reviewed, and discussed interactively through the presentation of clinical cases. (l.brocklebank@dental.gla.ac.uk) Background: Panoramic radiography has been widely available for demonstrating the teeth and jaws since the 1970s. However, interpretation is often left to the 'dentist', rather than being undertaken by radiologists. Imaging Findings: Panoramic radiography produces a sectional image, determined by the synchronised movement of a) a vertical narrow X-ray beam around the patient and b) the imaging receptor, film or digital, through the beam; ghost images from the opposite side are an inherent feature of this technique. Accurate patient positioning is important for high quality images. Many anatomical features are demonstrated and their recognition, together with knowledge of dental development and structure, assist in recognising abnormalities. Both the sectional and two-dimensional nature of this image limit its value; reference to the recent availability of cone-beam CT will assist in emphasising the limitations. Conclusion: Panoramic radiography will continue to be useful in imaging the teeth and jaws. The value of this image is enhanced by an understanding of its production. However, the development occurring in cone-beam CT of the jaws, and the relatively low radiation dose, as compared with conventional CT, will have an increasing impact on the technique of choice in certain clinical situations. The imaging algorithm employs the orthopantomogram as first line examination delineating a lesions location, extent, relation to teeth, mandibular canal and status of dentition. CT is more accurate defining a lesions morphology, delineating the bucco-lingual/ mesio-distal extent and relationship to specific dental structures. In early infection and malignancy, CT and MR are complementary. Cystic lesions may be odontogenic in origin like follicular cyst, keratocystic odontogenic tumour and radicular cyst, which differ in location and appearance from non-odontogenic fissural cysts. Osseous pseudocystic lesions comprise hemorrhagic bone cyst, aneurysmatic bone and stafne cyst. CT is more accurate to define the probable diagnosis in odontogenic tumours (ameloblastoma, myxoma, odontoma), non-odontogenic tumours (osteoma, osteochondroma, exostoses) and fibro-osseous lesions (cemental lesions, fibrous dysplasia and ossifying fibroma). The type of osteolysis and periosteal reaction on CT is indicative of malignancy like osteosarcoma, lymphoma, multiple myeloma and metastases. In acute osteomyelitis (< 4 weeks) imaging depicts focal osteolysis and periosteal reaction and predisposing conditions. Chronic osteomyelitis (> 4 weeks) is distinguished into secondary chronic osteomyelitis with sequestra, calcified periosteum, osteosclerosis, fistulae and pathologic fracture as typical features. Primary chronic osteomyelitis displays sclerosis of a hemimandible and may be associated with seronegative spondyloarthropathy (CRMO and SAPHO`s syndrome). Bisphosphonate-induced osteonecrosis is a complication after treatment of bone metastases, hypercalcemia and rarely of osteoporosis. Marked sclerosis and increase in jaw size, thickening of periodontal ligament are signs of inhibition of bone remodelling; sequestra, fistulae and periosteal reaction indicate common presence of concomitant infection. US-NCB has become the most widespread system of percutaneous biopsy, because of the excellent control of the needle in real time and its ability to reach lesions located in difficult places as axylla or near the nipple. This is a safe, comfortable and economical technique, but it requires a notable level of experience. The length of needle and core will be selected according to lesion size, location, depth and other circumstances. Under local anaesthesia, the needle is orientated parallel to chest wall, so the skin access point must be separated from the US probe. Three to five specimens are recommended to get maximum accuracy and the lowest grade of infra-estimation. The number of samples should be greater for lesions with complex radiological features. The colour, consistence and grade of immersion of the cylinders in formaldehide are useful criteria to know their suitability for diagnosis. This is the elective technique for BI-RADS-4-5 lesions properly identified by US. In particular situations, BI-RADS-3 lesions can be managed similarly. Only lesions not clearly seen by US must be sampled under stereotaxic or MR control. FNA-Citology is usually reserved for special situations such as some BI-RADS-3 nodules or cases when the objective is evacuation. The extensive use of US-NCB A S91 C B D E F G H proton spectrum metabolites, notably N-acetylaspartate (NAA), a neuronal marker, choline-containing compounds (Cho), a marker of membrane turnover, and creatinephosphocreatine (Cr), and on the presence of lipids and lactate. Brain tumors typically present with a loss of NAA and an increase in the Cho content. MRS has also been used to differentiate non-tumoral lesions like hamartomas from gliomas and to assess the grade and agressiveness of a tumor. In several studies, it has been reported that hamartomas did not differ significantly from the normal brain, while gliomas had lower NAA/Cr, Cr/Cho, and NAA/Cho ratios. Follow-up assessment of cerebral tumors is another promising field for MRS and CSI. Increase in size and enhancement are typical findings for progression but also reflect therapy-induced changes. Both techniques provide supplementary information about the possible extent and nature of changes on a routine MRI scan by analyzing the presence and/or ratio of the tissue metabolites NAA, creatine, choline, and lactate. The ratio of choline to normal creatine level usually is significantly elevated in those areas consistent with tumor compared with those containing predominantly treatmenteffect. In fact, treatment-effect is generally indicated by a marked depression of all the intracellular metabolites. CSI proved to be helpful in mixed histologic findings comprised of necrosis and tumor. In diagnostic radiology there has been a substantial increase in both the frequency and range of medical exposures. In addition, high-dose techniques such as CT scanning and interventional radiology/cardiology have become commonplace. Equipment design has led to higher patient throughput. All of these factors have contributed to a large increase in the frequency of procedures and the collective dose to the population. Worldwide, diagnostic radiology represents the largest manmade contribution to population dose. In this refresher course, patient dosimetry measurement methods for diagnostic radiology examinations will be described. This will include an introduction to various patient dose quantities and their relevance to patient dose surveys. The published literature on patient dose levels for various diagnostic procedures and their frequency will be reviewed. Proposed strategies for identifying and dealing with practices where doses are higher than the norm will be described. This will include a description of, as well as practical examples of, optimisation and justification. Case studies of practical approaches to patient dose reduction will be described. Specific examples drawn from paediatrics and radiology of pregnant women will be provided. Interventional radiology, and mainly fluoroscopy-guided procedures, is a growing sphere of activity in all developed countries and, today represents an important contributor to optimising the radiation dose exposure to the patient population. Several studies have evidenced a large variability of patient and staff exposures, equipment performance and level of justification of the practice in cardiology, neuroradiology and peripheral interventional areas. In some procedures the skin dose can be, for a substantial number of patients, higher than the threshold for deterministic effects of radiation. The use of complex radiological equipment to perform potentially high-dose procedures outside radiology departments by personnel not trained in radiological imaging and radiation protection is another important factor explaining non optimised procedures. The presentation provides an overview of the level of exposures, both for patient and staff operating in different interventional area. Example of non-optimised set-up of angiographic equipment, differences in technical protocols, differences in staff dosimetry and staff exposure will introduce to the need of training and optimisation of procedures. The results of some studies on the introduction of reference levels (RL) in interventional practice, taking into account the complexity of procedures, the proposal of dose constraints for staff exposure and reference values for the entrance dose rates of equipment will introduce to the available optimisation tools. Quality criteria of clinical images, together with the evaluation of test phantom images, is another important part of the optimisation process.The importance of training of interventional staff, the follow-up of some training events and the training material available will be finally presented and discussed. (2) of the directive, shall be kept as low as reasonably achievable consistent with obtaining the required diagnostic information taking into account economic and social factors. This Clause implies that every establishment using ionising radiation for diagnostic procedures or therapeutic interventional techniques need to establish a patient dose management system in order to keep these doses as low as reasonably achievable. In Nuclear Medicine, due to the use of unsealed radioactive sources, there is a need to establish two distinct management systems, one for diagnostic procedures and one for therapeutic procedures. The use of hybrid systems such as PET/CT and SPECT/CT for diagnostic purposes makes the management of patient doses even more difficult, since additional to the dose to the patient form the radiopharmaceuticals used, the dose from the CT in acquiring the anatomic images or from the image attenuation correction need to be taken into account. The aim of this presentation is to give a birds eye view of the peculiarities of these management systems with the objective to present a review of radiopharmaceutical administrative practices involved, to present the challenges of optimisation and justification of the procedures and to provide specific data for comparison with other diagnostic techniques using ionising radiation. Magnetic resonance (MR) imaging has become a clinically important modality for advanced morphological and functional assessment of the heart and great vessels in children with congenital cardiac disease. Contrast-enhanced threedimensional MR angiography is replacing catheter-angiography for delineation of the thoracic vasculature when echocardiographic imaging is insufficient. Cine MR imaging with fast-gradient echo or steady-state free-precession sequences can characterise complex cardiac or vascular anatomy, and is considered the most accurate non-invasive technique for assessing ventricular volumes, function and mass. Hemodynamic information is provided by velocity-encoded phase-contrast MR imaging allowing quantification of differential blood flow to the lungs, valvular insufficiency, shunts, and gradients across stenoses. Although the basic imaging sequences for the different MR techniques are available on current scanners, and are the same as for adult imaging, successful paediatric cardiovascular MR imaging requires adjustments of imaging strategies and technical settings. The smaller structures and higher heart rates in children demand greater spatial and temporal resolutions. Suitably sized coils providing high signal-to-noise ratios need to be used in order to maintain sufficient signal from the smaller voxels. Small children have to be immobilised for an MR study; we prefer anaesthesia with controlled ventilation over sedation so that the best possible image quality without respiratory motion artefacts can be achieved. MR imaging is routinely used for pre-and postoperative assessment of aortic anomalies, pulmonary artery anatomy and right ventricular function in patients with tetralogy of Fallot or pulmonary atresia, and of complex congenital heart disease in neonates and infants. (a.taylor@ich.ucl.ac.uk) Over the last 5 years, the development of non-surgical methods for the treatment of heart valve disease has become a reality. The increased use of these devices improves patient comfort, avoids prolonged hospital care and stay, and enables patients to return to normal daily activities in a shorter time, ultimately reducing healthcare costs. Magnetic resonance (MR) imaging has played a crucial role in the success of this our percutaneous pulmonary valve implantation (PPVI) programme by: 1. Accurately defining the anatomy of the implantation site for improved patient selection, 2. Assisting in accurate device positioning at the time of implantation under cardiac catheterisation, and 3. Demonstrating the technical and physiological success of the treatment. The imaging technologies and techniques (including tips, tricks and pitfalls) necessary to carry out the pre-, peri-and post-valve implantation assessment will be described in detail in this presentation. The use of cardiovascular CT in the assessment of stents in heart and great vessels will also be described. Despite the success of percutaneous valve implantations, only a limited number of patients can benefit from these procedures because of variations in individual patient anatomy and loading conditions. The use of imaging methodologies to construct models both virtual and real will be discussed to show how imaging can aid in the expanding the number of patients (with both pulmonary and aortic disease) who can benefit from these new minimally invasive treatments. The ability of radiographers to interpret radiographs when working in the trauma environment is an increasingly important skill in assisting junior doctors and nurse practitioners who may not have the necessary radiological experience and expertise. This presentation is intended to demonstrate some of the basic methods that radiographers should use when evaluating and interpreting trauma images of the upper and lower limb, and so increase their knowledge and confidence. At the end of the presentation, it is hoped that delegates will feel confident enough to begin writing brief comments on image appearances. This method of image comment has been employed at Poole and many other hospitals throughout the UK and has been shown to improve accuracy of diagnosis and subsequently the service to patients. Oslo/NO (borgny.ween@rikshospitalet.no) Purpose: Lung cancer is the most frequently encountered cancer worldwide. Survival rates of lung cancer are low. The earliest possible diagnosis is of great importance. High-quality radiography of any clinical question, especially when it comes to lung cancer, is a prerequisite for a correct diagnosis. Standardization of techniques is the cornerstone of measuring quality of radiography, as used in the PGMI (perfect-good-moderate-inadequate) model for scaling of image evaluation in mammography. The optimal techniques for chest radiography are known from textbooks; however, suboptimal images are often produced. Missed cancers on chest radiographs will be illustrated, and potential ways to ensure the radiographic quality by using an image evaluation method will be discussed. Methods and Materials: A questionnaire study was performed among radiographers and radiologists working in a number of hospitals and clinics, representing a variation of work-cultures in Norway. The study measured radiographers' and radiologists' subjective diagnostic importance regarding the properties of image evaluation, in relation to image identification, positioning, visualization of technical quality, post-processing and artefacts. Results: Questionnaires were returned by 21 radiographers and 13 radiologists, who had worked for 5-41 and 2-40 years respectively in chest imaging. A range of results were collected, and some of them will be illustrated with images and the professionals' respective comments. The results can be useful to create a grading scale for radiographic chest image quality evaluation. This can be implemented in a peer practice model, which can act as a link between image evaluation and practical work. The medical impact of CT and PET/CT has grown at an unexpected pace over the last 8 years, and it has been followed by an increasing number of examinations, often for new medical indications, often with more than one scanning phase and including larger volumes of the body. In this session, we will not focus on the excellent, decisive information obtained, nor will we review all new technical features. We will rather analyze the impact of the development on radiation exposure at the individual and the population level and try to help the clinical radiologist to improve the daily patient service. Justification is the first step in a wise use of this powerful diagnostic tool; quantitatively, its contribution to individual exposure is even more important than the following steps of optimization. Once justified, every CT or PET/ CT examination must be optimized; protocol adaptation to the specific patient includes the choice of parameters according to the size, age, gender and clinical question. In PET/CT, the CT part can serve different purposes, and the CT protocol and exposure will vary greatly depending on the purpose; the different scenarios will be shown. Last but not least, the tool of dose reference levels (DRLs) uses retrospective data to prospectively optimize exposure. The different speakers all are top experts of their subject and will do their best to give the audience simple, practical and useful hints. Introduction of spiral CT and multi detector computed tomography (MDCT) has expanded the applications of CT, leading to a substantial increase in the number of CT examinations and collective patient dose. Today, in industrialised countries CT scans account for 4-13% of X-ray examinations with increasing frequency. The isotropic submillimeter resolution and fast scan speed of 10-20 seconds for most examinations are some of the reasons why MDCT is used for more and more clinical indications like CT angiography, polytrauma, virtual endoscopy, cardiac imaging and screening. Today CT amounts to 40-70% of the medical dose contribution of all X-ray examinations with a wide variation between different countries. In Germany the annual growth rate between 1996 and 2003 was 8% per year. New technical developments like dose modulation and more efficient detectors enable a significant dose reduction of a single slice, but the dose per study seems to be constant as an increasing scan length and/or number of phases is observed. The collective dose is continuously growing as more and more CT examinations are performed. The appropriate use of CT relative to patient care involves two components: a correct justification of the scheduled procedure and minimization of the radiation dose without compromising diagnostic quality. In this context, referral or appropriateness criteria, which have been published in most European countries, are very helpful. Prior to every CT examination a justification should compare the risk of an existing or assumed disease with the radiation related risk. Learning Objectives: 1. To realise the impact of CT development on population exposure. 2. To get an idea of the relative and absolute contribution. 3. To better understand risk assessment and justification. Impact of protocols and CT scanner types on dose J. Damilakis; Iraklion/ GR (damilaki@med.uoc.gr) A substantial increase in the use of multirow-detector CT (MDCT) imaging has been observed over the last few years. Radiation dose optimization, therefore, remains a major issue in CT imaging. For designing and optimizing a scanning protocol, deep knowledge of the parameters that affect dose from MDCT examinations is needed. Among the important factors that affect dose are the number of scans, the exposure parameters, the scanning length and the body size of the patient. Efforts should be undertaken to optimize CT examinations using imaging protocols that take into account the body characteristics of the patient. Automatic exposure control (AEC) systems adapt tube current based on the attenuation of the body region being scanned to achieve a specified image quality level with a lower dose. However, familiarization with the operational characteristics of AEC mechanisms is a pre-requisite for efficient dose optimization. Every type of MDCT scanner has its own dosimetric characteristics. Dose-effective use of modern CT systems can be established only with on-site dose measurements and deep knowledge of the rapidly changing technology. Overbeaming and z-overscanning are technical features that affect patient dose. Overbeaming refers to the primary exposure of a body section that is wider than the active detector array extent and depends mainly on the geometric characteristics of the X-ray beam. If helical scanning is used, additional dose will result from z-overscanning. The relative contribution of the extra exposure resulting from z-overscanning may be considerable, especially when the planned image volume is limited, for example in paediatric studies. Combined PET/CT has become an integral part in the state-of-the-art cancer patient management. Today more than 3,000 PET/CT have been installed worldwide. PET/CT imaging exams include a scout scan followed by a spiral-CT and a multi-step PET emission scan. Although the PET/CT scans have led to increased diagnostic accuracy/confidence in cancer diagnosis, the sobering fact is that this benefit frequently comes at the expense of unreasonably higher patient/staff exposure to radiation. Patient exposure from combined FDG-PET/CT ranges from 8-25 mSv. This exposure varies with the CT protocol chosen, the number of CT scans (say, without and with CT contrast) and, to a lesser degree, with the amount of PET activity injected. Staff exposure can increase as compared with standard PET-only because of longer occupation times in the scanner room (eg, attach the CT contrast-injector, position patients with a thermoplastic mask). In almost all cases, however, additional patient set-up times lead to an increased value of PET/CT data for diagnosis and therapy planning. We will review clinical PET/CT protocols for oncology and related patient exposure levels and present a judicious decision scheme for PET/CT indications to avoid patient overexposure from repeated CT scanning. Reasons for unnecessary patient exposure include also the use of separate CT scans for PET-attenuation correction and diagnosis. Both can be combined at no, or little cost. Finally, we present technology advances in PET and CT that help reduce standard dose levels. In summary, clinical PET/CT is needed for state-of-the-art oncology diagnosis. Imaging protocol standards can be employed to ensure maximum diagnostic accuracy without increasing patient exposure levels unnecessarily. The introduction of 64-section CT has resulted in the implementation of coronary CT angiography into daily clinical practice. Increasing robustness for non-invasive coronary artery imaging could be achieved through the implementation of the dualsource CT system providing a two-fold increase in the temporal resolution. The technique is particularly useful in patients having an intermediate pre-test likelihood of coronary artery disease, i.e., in patients where the history, cardiovascular risk profile, symptoms, and the results of ECG or stress tests will mandate the rule-out coronary stenoses. In these situations, CT is a clinically useful tool and may obviate the need for invasive diagnostic procedures. Beyond the luminographic assessment of stenoses, CT also allows for the quantification of the coronary calcium burden (i.e., calcium scoring) in a low-dose non-enhanced scan. A huge number of trials have shown that the calcium burden is associated with the risk of suffering a heart attack, which may be clinically useful in patients having an intermediate risk. The contrast-enhanced CT scan for coronary angiography also includes qualitative information about the composition of coronary plaques. These can be accurately characterized by CT into calcified, non-calcified or mixed plaques. Particularly noncalcified plaques represent an early stage of atherosclerosis and mixed plaques carry some risk for rupture which makes their identification an important adjunct to a purely luminographic coronary artery asessment. In the past few years, magnetic resonance (MR) myocardial perfusion imaging has become a routinely used tool in the diagnosis of coronary artery disease, cardiomyopathies and cardiac masses. Also witnessed is the growing interest in the use of MR perfusion to assess microvascular obstruction after myocardial infarction. Perfusion protocol demands a high field MR scanner equipped with dedicated phased-array cardiac coil and dedicated pulse sequences. MR compatible contrast injector and monitoring system are desirable. Various techniques including first pass, BOLD and spin labelling were used to assess myocardial perfusion. First pass perfusion during hyperemia (Adenosine, Dypiridamol) is the most widely used method. The occurrence of myocardial perfusion deficit consistent of coronary territory is a very reliable indicator of coronary artery stenosis. It is important to realize diagnostic pitfalls associated with image interpretation. Many useful tricks could help to differentiate between real perfusion defects and artifact. Adenosine is the preferable vasodilatator. Contraindications include advanced atrioventricular block and obstructive pulmonary disease. In general, adenosine side-effects are mild and well-tolerated by most patients but resuscitation equipment and CPR-trained staff are required during the stress test. MDCT perfusion is a recently investigated technique to evaluate perfusion deficit in animal models and patients. MDCT might be, in the future, an alternative modality for patients with contraindication to magnetic resonance. Viable myocardium is defined by the presence of living myocytes, irrespective of their contractile function. The goal of assessing viability is to identify patients with ischemic left ventricular dysfunction that may improve their function after coronary revascularization. Several imaging techniques can be used for the assessment of myocardial viability. Nuclear medicine techniques such as sestamibi-and thallium-SPECT have been extensively used. FDG-PET is a more recent technique with greater diagnostic accuracy than the former. Low-dose dobutamine stress echocardiography (DSE) has greater specificity but lower sensitivity than thallium-SPECT. CT can detect areas of delayed enhancement, but the need for an additional acquisition with greater radiation exposure, use of iodinated contrast, and smaller contrast resolution between infarcted and non-infarcted myocardium are important drawbacks. MR is now one of the most important imaging tools in viability imaging. Myocardial wall thickness greater than 5 mm in areas of chronic transmural myocardial infarction (MI) was initially proposed as a marker of viability. However, there are segments with a thickness smaller than 5 mm that improve function after revascularization and others with a thickness greater than 5 mm that do not. Delayed-enhancement MR (DE-MR) is a very robust technique as it is the only imaging technique that can quantify the transmural extent of infarction (TEI). DE-MR predicts functional improvement after reperfusion and the likelihood of improvement is inversely related with the TEI. Dobutamine-stress MR also has an excellent sensitivity and specificity in the detection of viable myocardium, greater than DSE. Strategies in the diagnostic pathway for suspected venous thromboembolism include the use of ultrasound imaging, clinical pretest probability assessment, Ddimer testing, and CT and MR pulmonary angiography. The decrease in mortality from pulmonary embolism may partially be on account of more exact diagnoses. Requirements of PE assessment are that it is feasible in most patients and leads to the proper diagnosis and appropriate therapy. In this regard, angiography has long been recognized to the reference modality, where all techniques had to be measured against. However, angiography is not possible in up to 20% of patients and due to its associated invasiveness and complications it has been replaced by CTA and more recently MRA, both of which are faster, less invasive, less operatordependent and have less complications. For CTA, dedicated imaging procedures and protocols which may be combined with a CT phlebography are necessary. MRA does offer advantages over spiral CT, because it does not involve ionizing radiation and it makes use of smaller amounts of gadolinium chelates. Key aspects that restrict MRA application are non-diagnostic quality of images and alterations that prevent a patient from entering a magnetic field, which are in the order of 15%. In summary, every patient with clinically suspected VTE must be risk stratified, in This lecture will encompass 10 years of personal DVT treatment experience. Evolution of treatment methods will be addressed as this provides an insight into the rationale behind the current methods. Methods of diagnosis, indications for treatment and patient selection will be discussed. The different techniques -catheter directed and pharmaco-mechanical thrombectomy-will be be gone into in varying detail. The importance of choosing a correct access site, and having a detailed pre-treatment plan will be stressed. Methods of administering thrombolysis will be detailed. The most common procedural errors will be listed so you can hopefully avoid them; along with the importance of good longuitudinal follow-up. Finally a discussion of the financial implications of various treatments will take place. Today, there is a clear clinical need for accurate depiction of the liver vasculature both in its extra and intra-hepatic components (macro and microvasculature) because of new clinical demands such as the living related liver donor for transplantation or to define the anatomical segmentation prior to endovascular interventional procedures. More than providing a simple vascular roadmap, cross-sectional imaging of the liver has been proving to be the preferred technique for liver vessel display, both in its arterial and venous components. Multidetector CT and high-resolution MRI using parallel imaging strategies are able to provide a unique, morphologically driven information, resolving very small vessels, resulting from isotropic capabilities. Apart from a brief revision of cross-sectional methodology used in this clinical context, the presentation will focus on the normal vascular anatomy of the liver and main variants, emphasizing its implications for clinical decision making. Going down to the microvasculature, the normal vascular pathways of the unique dual circulation of the liver will be addressed as well as possible aspects of parenchymal enhancement observed on dynamic MDCT/MR studies. Portal hypertension (PHT) is a common clinical syndrome resulting mainly from chronic liver diseases and is characterized by a pathological increase in portal pressure. The definition is based on a pressure measurement and is usually determined indirectly by subtracting the free hepatic venous pressure [or the inferior vena cava (IVC) pressure] from the wedged hepatic venous pressure, the so-called hepatic venous pressure gradient. Values above the normal upper limit of 5 mm Hg define portal hypertension; however, portal pressure measurement is not performed routinely and requires investigation in highly specialized centers. This is why noninvasive imaging modalities play a crucial role in the diagnosis and management of portal hypertension. Doppler sonography is the current imaging modality to diagnose PTH, but recently MDCT with reconstructed images and MR imaging have shown to be helpful. Most of the imaging findings are qualitative (presence of portosystemic collaterals, portal flow direction, spleen enlargement). Evaluation of quantitative variables such as mean portal velocity and portal venous flow are are not used in daily reoutine and usually limited to longitudinal pharmacological studies. We will stress the role of imaging in patients with PTH. Briefly, we will consider the most important questions in clinical practice: a) are there signs of PHT?, b) is it a PHT secondary to cirrhosis or should we think to less common disorders, c) is encephalopathy related to large collateral pathways? and d) what are the reliable imaging findings for patient-monitoring after portal hypertension decompression. Australia is the sixth largest country in the world but with a population of only 21 million. New Zealand while approximately of the size of Italy has a population of only 4.2 million. Two-thirds of Australia is desert or semi arid and New Zealand has large areas of rugged and inaccessible land. While the populations of both countries are concentrated in major urban centres, providing diagnostic imaging (DI) services to those in regional, rural and remote areas (which cannot support the infrastructure or personnel to justify establishing hospitals or practices) and to meet the needs of indigenous and diverse cultural groups presents serious patient access and politically sensitive issues which require creative solutions, such as teleradiology. Service delivery is complicated in Australia by a complex political system involving the federal and seven state/territory governments, each with responsibilities for different parts of the health system. The tax-payer funded health insurance scheme in Australia involves close monitoring of national expenditure and strict control over funding of new technologies and procedures, which, for example, has impacted adversely on access to MRI. The current ratio of 1 Radiologist per 15,000 population (in both countries) is barely adequate to meet increasing growth in diagnostic imaging services of approx 7% p.a. The shortage of Radiologists and Radiographers and increasing workload pressures present challenges in satisfying demand while ensuring safe and quality services. Governments and private sector practices need to be persuaded to support new training positions and education is required to reduce unnecessary and inappropriate demand. Learning Objective: 1. To appreciate the issues and challenges facing radiologists in Australia and New Zealand. The 'Quality Use of Diagnostic Imaging' (QUDI) program and changing practice at a local level S. Goergen; Port Melbourne, VIC/AU (stacy.goergen@southernhealth.org.au) The Quality Use of Diagnostic Imaging Program was established in 2003 under a funding agreement with the Commonwealth. It is unique in Australia with regard to its breadth and depth of experience in quality improvement in diagnostic imaging and in its multidisciplinary approach to this issue. The first 5 year funding cycle concluded in June 2008 with over 20 projects concerned with quality, safety, consumers and providers of diagnostic imaging services now completed. As we enter a new 12 month funding cycle, the work program will focus on implementation of many of the key project outcomes from the first five years. During the first 5 year funding cycle, three projects focussed on practice -level quality improvement. Two of these projects were co-sponsored by QUDI and the National Institute of Clinical Studies, Australia's peak body for implementation of evidence into practice. These projects focussed on 1. Implementation of the Ottawa ankle rules in two emergency departments; 2. Implementation of a decision tool for risk assessment of patients with suspected pulmonary embolism regarding their need for diagnostic imaging. The third project aimed to achieve reduction in the dose of radiation delivered by CT scanning at 6 paediatric hospitals in five of Australia's six states. The baseline audit found wide variation in delivered dose. A combination of audit, feedback on results in comparison to other sites, dose optimization strategies workshop, and re audit six months later achieved an average of > 30% reduction in dose (measured as DRLs). Accreditation of radiology practices in Australia and New Zealand D. Swinbourne; Sydney, NSW/AU (ceo@ranzcr.edu.au) Providing quality radiology services requires a focus on the performance of both individual team members and on the department/practice providing the service. The Royal Australian and New Zealand College of Radiologists (RANZCR) is supporting Radiologists in their individual performance improvement and through programs which accredit diagnostic imaging (DI) practices, aimed at ensuring high-quality care for patients, safe working environments with a continuous quality improvement focus. In New Zealand a peer review voluntary program driven by Radiologists in collaboration with a reputable accreditation organisation has achieved high participation and compliance, and with minimal involvement of government. In Australia, RANZCR has developed comprehensive standards and a voluntary accreditation program which is recognised as the "gold standard". However, its uptake has been diluted by the Government's problematic efforts to also introduce a regulated 'mandatory' program. This program requires all DI practices to be accredited under a government run scheme in order for services provided by those practices to be eligible for patient rebates under Australia's national health insurance scheme, Medicare. While well intentioned, the complicated political and regulatory environment and the need for acceptance by all providers, has compromised its value and limited its applicability in the overall DI marketplace. The standards initially underpinning this scheme are no more than existing requirements for professional registration, radiation safety and Medicare compliance. Over time, it is hoped that quality and patient focussed standards will be adopted. This has raised important questions about the appropriateness and pitfalls of governments' involvement in quality programs. Many noninvasive imaging techniques are available for the evaluation of patients with known or suspected coronary artery disease. Among these, computed tomography (CT) based techniques allow the quantification of coronary atherosclerotic calcium and noninvasive imaging of coronary arteries, whereas nuclear cardiology is the most widely used noninvasive approach for the assessment of myocardial perfusion. The available single-photon emission computed tomography (SPECT) flow agents are characterised by a cardiac uptake proportional to myocardial blood flow. In addition, different positron emission tomography (PET) tracers may be used for the quantitative measurement of myocardial blood flow and coronary flow reserve. Extensive research is currently being performed in the development noninvasive coronary angiography and myocardial perfusion imaging using cardiac magnetic resonance (MR). In addition, new multimodality imaging systems have been recently developed bringing together anatomical and functional information. The major advantage of the integrated approach to the diagnosis of coronary artery disease is the added sensitivity of PET or SPECT and CT angiography. PET or SPECT stress perfusion imaging complements the anatomical CT data by providing functional information on the hemodynamic significance of coronary artery stenoses, thus allowing more appropriate selection of patients who may benefit from revascularization procedures. This process of integration of imaging systems has progressed to MR. While the principle may be the same, each modality has its specific benefits. This session sought to provide a description of the relative merits of different noninvasive imaging techniques in the assessment of myocardial perfusion, viability and left ventricular function in coronary artery disease. When choosing an imaging test for a cardiovascular patient, different tests are available of which each has its appropriate indication. When speaking about cardiac CT, it is usual to first think about the ability of the technique to image coronary morphology. When acquiring data with retrospective ECG-gating in the spiral mode, however, it is also possible to assess additionally cardiac anatomy in various phases throughout the cardiac cycle. Thus, cardiac CT depicts the moving heart chambers and cardiac valves with good quality during both systole and diastole using the same CT data set that has been acquired for the evaluation of the coronary arteries. Along with this, it is possible with cardiac CT to assess the global and regional ventricular function with an accuracy that is comparable with that of the current reference standard modality, magnetic resonance imaging (MRI). Moreover, measurements of the valve opening and of potential regurgitant orifice areas allow to some degree the quantification of valvular heart disease using CT, with similar results as compared to the clinical mainstay echocardiography. Furthermore, recent data both in animals and in humans have shown that cardiac CT is able to assess myocardial viability with an accuracy that is similar to the reference standard MRI and comparable to histopathology. Finally, dual-energy data acquisition with cardiac CT allows quantification of myocardial perfusion, making the "morphological" modality CT a competitor to the "functional" imaging tools SPECT and MRI. Technetium-labeled tracers, sestamibi and tetrofosmine, are progressively substituting thallium-201 as the preferred MPI tracer for the better physical characteristics and lower radiation burden. Images are usually acquired 40-60 min after the injection. Recently, however, the feasibility of acquiring gated-SPECT with tetrofosmine as early as 15 min after the tracer injection was documented. In addition, preliminary results reported on the possibility that 99 mTc-tetrofosmine could have some differential wash-out in normal as well ischemic regions, faster in the normal regions and slower in the ischemic regions, leading to the possibility of an underestimation of the ischemic burden when gated-SPECT images are acquired at conventional delay after the injection. This allows a faster stress-rest evaluation, with resources optimization and improved patient convenience. In order to speed up the time required to complete a stress-rest evaluation, new iterative algorithms were recently proposed, which allow the reconstruction of images acquired with half the time/frame usually employed for a gated-SPECT study. These algorithms, however, could be also employed with the study obtained after injection of a reduced amount of tracer. The former allows an increased patient throughput and optimization of resources. The latter modalities would allow a significant reduction in both patients' and operators' exposure. Finally, a new PET tracer for the assessment of stress-rest myocardial perfusion, labelled with F18 and thus not requiring an onsite production, is under development. Hybrid imaging in cardiology with SPECT/CT and PET/CT integrates the principles of cell biology, molecular biology and molecular genetics to conventional structural cardiovascular imaging. PET and SPECT techniques, by virtue of its inherent sensitivity to detect processes that take place at a micromolar level, and of the flexibility of radiochemistry approaches, are ideally suited for cardiac molecular imaging. Modern CT systems offer detailed anatomy of the heart and coronary vessels. Fused PET/CT and SPECT/CT imaging systems now provide metabolic and functional information from PET or SPECT combined with the high spatial resolution and anatomic information of CT. CT angiography and PET or SPECT can be performed in a single diagnostic test interval to simultaneously assess the extent of coronary artery disease and its hemodynamic significance. Current topics and areas of development in hybrid cardiac imaging include: new strategies and protocols for more effective assessment of myocardial perfusion and viability, new approaches to ischemic and necrotic myocardium, myocyte characterization and integrity, gene therapy and gene product imaging, new approaches to evaluate hibernating and stunned myocardium, angiogenesis, receptor occupancy, vascular integrity, and imaging of unstable plaque and imaging for early atherosclerosis. Glucose metabolic activity is increased in active atherosclerotic plaque and can be assessed in vivo with PET/CT to identify vulnerable plaques. With the current advances in genomics and proteomics, hybrid cardiac imaging will identify new markers of disease activity and will play a central role in screening of patients, diagnosis, prognosis and patient management. The widespread development of digital imaging modalities have led to an increasing number of analysis techniques assisting radiologists and physicians in the diagnostic interpretation and quantitative analysis of image data. These techniques provide more objective and reproducible results and ensure more consistent interpretation of images between observers and better diagnostic performance overall. Every technique, however, can be subject to errors and mistakes due to inappropriate data provided by artifacts in the images or by misuse of the tools in conditions that are not ideal for accurate measurements. Simple measurements such as volumes or densities can be influenced by several parameters that can be overlooked or even unknown to the user. It is important to understand and carefully control the validity of data extracted by quantitative analysis and not to blindly trust the numerical results provided by the computer program. This course will review several domains where quantitative analysis tools are being applied in clinical routine, such as quantitative measurement of tissue metabolism wit PET, functional analysis of cardiac function from dynamic images such as MRI, CT or ultrasound, and many other applications. The goal is to draw the attention to the importance of proper usage of quantitative analysis tools and understanding of the underlying algorithms and imaging parameters that can influence the results. The objective being to provide the participants with some basic knowledge on the techniques used in quantitative measurements and how they can be influenced by different factors from image acquisition protocols to the way users are applying them. As the boundaries between radiation therapy, interventional radiology and surgery are becoming less well-defined, appropriate patient models will become the greatest common denominator for all therapeutic disciplines. To outline possible solutions for interdisciplinary approaches, the concept of workflow modelling, therapy imaging and model management system (TIMMS), and multi-entity Bayesian network methods will be introduced. Appropriate use of information and communication technology and mechatronic systems is considered by many experts as significant contribution to improve therapeutic workflow and patient model creation and management. This requires a suitable IT infrastructure as well as communication and interface standards, such as DICOM and suitable extensions, to allow data interchange between imaging systems outside and surgical system components within the operating room (OR). A conceptual design and realization of such an infrastructure, i.e. a TIMMS, will be presented. Standards for creating and integrating information about patients, equipment, and procedures are vitally needed when planning for an efficient OR. The DICOM Working Group 24 (WG24) has been established to develop DICOM objects and services related to the TIMMS architecture for image and model-guided surgery. Some examples of modelling tools for workflow and patient information management relating to interventional radiology and surgery will be presented. A well-defined workflow and a high-fidelity patient model will be the base of activities for therapeutic disciplines. Radiology combined with imaging informatics can play a significant role to assist in defining the patient-specific models for a variety of therapeutic workflows. The increased use of imaging modalities such as ultrasound, computed tomography, and magnetic resonance imaging has increased the number of incidentally detected adrenal masses. Up to 5% of abdominal CT-examinations performed for reasons unrelated to adrenal dysfunction or suspected dysfunction will demonstrate an adrenal mass. This percentage could be even increased, since we know from autopsy studies that the prevalence of adrenal masses is about 7% in those 70 years of age or older. In the absence of extraadrenal malignancies the majority of these lesions will turn out to be nonhypersecretory and benign. However, this is not true for a patient with a known malignancy. In this special case it is difficult to assess the relative likelihood of an adenoma and a malignant lesion. Until few years ago, adrenal biopsy, resection, or clinical follow-up were the only methods of distinguishing benign adenomas from malignancies. Improvements of both, CT and MRI techniques have increased the reliability of these imaging methods in differentiating benign and malignant adrenal masses. Additionally, nuclear medicine studies using specific radiopharmaceuticals have the advantage of providing functional metabolic information for adrenal lesion characterization. PET-CT using 18-FDG allows malignant adrenal lesions to be characterized and gives detailed morphological information. In this talk strengths and limitations of the various imaging techniques in adrenal mass imaging and characterization of adrenal masses will be addressed. An imaging algorithm and the clinical management of an incidental mass will be considered. Full-field digital mammography (FFDM) offers several advantages in mammography screening as compared with screen-film mammography (SFM). FFDM has a higher diagnostic accuracy in women with dense breast, and a higher detection rate for DCIS has been reported. The true flexibility of digital technology is primarily realized in soft-copy reading. Soft-copy reading is not straightforward with a high workload. Proper hanging protocol and optimal reading environment is essential, especially for soft-copy interpretation using batch reading. A hanging protocol may include a total of 16 single images for one examination. Interpreting 75 women every hour means that the reader has to look at 1200 images per hour in the soft-copy batch reading. This is a great challenge, and subtle malignancies may easily be overlooked by less experienced readers. The technology of digital mammography represents a platform for advanced applications including computer-aided detection (CAD), which is also possible with SFM but made much easier with FFDM. CAD has been used for several years in SFM, but it is time-consuming to scan the analoge films. Using digital mammography and soft-copy reading, the CAD output is shown directly on the workstation. Use of CAD has the potential for preventing perception errors in soft-copy batch reading with a high work-flow, and consequently increases the cancer detection rate. Studies have shown that by using CAD more cancers and smaller cancers can be detected. Furthermore, CAD has the potential for increasing the cancer detection rate even in breast cancer screening programs using independent double reading. The entire field of medicine is moving towards more individualized or "personalized" approaches. This holds true not only for therapeutic strategies -where more refined, stage-adapted procedures are in use to meet the individual needs of a given patient -but also for the field of early diagnosis and prevention. Adequate risk stratification and risk-adapted, individualized screening policies are advocated. Regarding the early diagnosis of breast cancer, population-based mammographic screening has been shown to help reduce breast cancer mortality. Mammographic screening, reduced post-menopausal hormone intake and the development of new, targeted therapies all contributed to the reduction of breast cancer mortality that has been observed in the last couple of years. Still -breast cancer is one of the most frequent cancers overall, and it continues to be the leading cause of cancer death in women, indicating that there is room -and need! -for improvement. Magnetic resonance imaging (MRI) of the breast has been introduced a decade ago. Over recent years, it has become increasingly evident that breast MRI by far is the most powerful breast imaging technique that is currently available. Across all different clinical and screening scenarios, MRI has been shown to be superior to mammography -be it for diagnosing primary or recurrent, invasive or intraductal, familial or sporadic breast cancer, irrespective of a woman's breast density. And yet is the technique only slowly adopted in clinical practice. Arguments against the use of breast MRI include costs, frequency of false-positive diagnoses, lack of trained radiologists, lack of minimally invasive biopsy capabilities, lack of evidence by randomized controlled clinical trials, and, last, fear of overtreatment. In this lecture, these concerns are reviewed, discussed and weighted against the advantages of screening and diagnostic applications of breast MRI. The Breast Imaging Reporting and Data System (BI-RADS) was developed in 1993 by the American College of Radiology (ACR) to standardize mammographic reporting, to improve communication, and to reduce confusion regarding mammographic findings. In the meantime the BI-RADS is applied for ultrasound (US) and magnetic resonance imaging (MRI) of the breast as well. The BI-RADS lexicon offers a number of strengths, including the application of a standardized common language to facilitate communication between radiologists, referring physicians, and patients. The system also clarifies the reporting of all three imaging modalities and will support the completion of quality improvement activities and clinical research. However, there is one exception, the BI-RADS 3 category, which is used with less enthusiasm than the remaining five categories. The reason for this development is unclear as the imaging criteria of BI-RADS 3 lesions have been well assessed in several studies. The use of BI-RADS category 3 (probably benign) is reserved for findings that are almost certainly benign. BI-RADS 3 is not an indeterminate category for malignancy, but one that, for mammography, US, and MRI, has a less than 2% chance of malignancy (i.e. is almost certainly benign Congenital lesions of the brain is a vast topic including: -congenital malformations, -congenital infections, -inborn error of metabolism, -destructive brain acquired in utero. Malformations are described following embryological timing and include neural tube defects, disorders of diverticulation (holoprosencephaly spectrum, cystic malformations of the posterior fossa), commissural agenesis, malformations of cortical development that can involve cellular multiplication, differentiation, migration and organization. Malformations also include extracerebral cysts and vascular malformations. Although brain malformations are characterized by specific anatomical features, MRI features can change across time along with brain maturational changes, especially in cases of malformation of cortical development, but also in midline lipomas. The most common congenital infections are CMV and toxoplasmosis which result in brain malformations and destructive lesions of the brain. Neonatal herpes encephalitis is less frequent and highly destructive. Inborn error of metabolism can be encountered in utero and in neonates, the most frequent seen being mitochondrial cytopathies that rarely display basal ganglia involvement (until the first year of life) compared to older children. Some metabolic disease are also known to give brain malformations (i.e. corpus callosum agenenis in pyruvate deshydrogenase deficiency). Other metabolic disease are known to lead to brain damage similar to cerebral lesions of hypoxic-ischemic origin.Destructive brain acquired in utero of hypoxic origin can be encountered postnatally especially in the neonatal period as stroke, necrosis. Acute events one to several days before birth also happen leading to brain damage sometimes difficult to differentiate from cerebral damages that have taken place pernatally. Infratentorial neoplasms prevail between years 3 and 11. Patients with infratentorial tumors present with nausea, vomiting, cranial nerve palsies, truncal or cerebellar ataxia, and head tilt. Medulloblastoma (MB) is a grade IV, homogeneous tumor, frequently abutting the fourth ventricle, hyperdense on CT, hypointense in T1weighted images, and iso-to hypointense in T2-weighted images. Classical MB accounts for about 75% of cases. Histological variants include desmoplastic MB, MB with extensive nodularity, anaplastic, and large cell MB. Pilocytic astrocytoma is a grade I tumor that may originate either from the vermis or lateral into a cerebellar hemisphere. The typical appearance is that of a large cyst with a solid mural nodule. The solid portion is hypodense on baseline CT, T1 hypointense, and T2 hyperintense consistent with low cellularity and nuclear-to-cytoplasmatic ratio. Ependymomas commonly arise from the floor of the fourth ventricle and may invade the subarachnoid spaces via the outlet foramina of the fourth ventricle. Calcifications are detected in 25-50% of cases. Brainstem gliomas most commonly involve the pons (54% of cases), followed by the midbrain (32%) and the medulla (14%). Diffuse pontine tumors carry the poorest prognosis, with 11 to 17% survival at 3 years and often produce diffuse infiltrations so that frequently the whole brainstem is affected. Exophytic tumors grow extrinsically anterolaterally into the cerebellopontine angle cistern, posterolaterally through the middle cerebellar peduncle into the cerebellar hemisphere, or posteriorly into the fourth ventricle. Histologically, the vast majority of cases is represented by low grade astrocytomas. 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 for improving 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 had a special project to prepare European Guideline on clinical audits. 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 applications. 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 organizations and regulatory bodies. It is important to recognize that the guideline is not a legal requirement. Through addressing technical, financial and clinical provision for high quality RADIOLOGICAL procedures, the main beneficiary is eventually the patient. 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. 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 audits by a number of entities. These include: 1. National bodies concerned with improving radiation safety for staff and patients particularly under the EU 97/43 directive. 2. Hospital-wide accreditation surveys from state and independent accrediting organisations. 3. Auditing of standards from within professional bodies. 4. Investigation of specific incidents within radiology departments 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 in an operating hospital are generally similar. Mechanisms such as outcomes, quality cycles, performance indices are critical to the success of any hospital-based accreditation 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 an Irish hospital highlighted the critical need for clear communication of roles and responsibilities to those who are carrying out audit and those who are being audited in hospitals. caused by the intravascular spread of angio-invasive fungi. Several granulomatous diseases may involve the sinonasal tract mucosa. Wegener granulomatosis is the most frequent, but other vasculitides, as Churg-Strauss disease, or non-vasculitides granulomatous disease (as sarcoidosis) may be observed. These lesions tend to present a chronic clinical course. Nevertheless, the chronic ischemia of the mucosa frequently leads to bacterial superinfection and inflammatory changes of the bony framework. Similar findings are observed in cocaine abuser in which extensive destruction of the nasal septum and the palate may be observed. Though imaging plays a major role in confirming the clinical suspect of invasive fungal rhinosinusitis, it is the accurate extent of the process provided by MR or CT which influences treatment planning, particularly the involvement of the dura and the orbit content. In chronic aggressive granulomatous diseases, the diagnosis is usually provided by endoscopy and histology. MR is useful in monitoring the submucosal lesions after drug treatment, for example in Wegener granulomatosis, in which the potential involvement of the orbit or the temporal bone has to be assessed. Transthoracic echo can be used in the office setting and is supported by the increasing portability of machines. This type of echo is not limited by heart rate or rhythm. The 'echo window' can be limited by body type and by the co-existence of conditions, particularly respiratory diseases such as emphysema or paralysis of the diaphragm. Among the diagnostic limitations of transthoracic echocardiography are, diagnosis of the thickened, some types of cardiomyopathy and diseases of the cardiac apex which is often not well seen. Details of valve morphology and tranoesophageal echo is an invasive investigation where the patient has to swallow the echo probe. The patient often requires sedation for this but the investigation can be carried out as a day case. Trans-oesophageal echo provide greater detail of cardiac anatomy and function and is used frequently as an adjunct to cardiac surgery as an intra-operative procedure. Stress echo-cardiography is used for the diagnosis of myocardial ischaemia when accompanied by increasing doses of intravenous Dobutamine and for the diagnosis of myocardial viability. The principle of this test is that a low dose of Dobutamine will excite function in a non-functional area of myocardium which is viable. All types of echo can utilize the additional facilities of Doppler examination (pulsed and continuous wave) colour and echo contras to make physiological diagnoses. These tests remain more subjective than other competing image tests because of the need for operator experience and skill, patient-based factors and the more subjective nature of interpretation. Cardiac MRI has evolved into an alternative and complementary modality to ultrasonography in assessing patients with valvular heart disease. MRI on state-of-theart scanners using cine and velocity-encoded gradient echo sequences provides reliable qualitative and quantitative assessment of valvular dysfunction including stenosis and insufficiency. It can also quantify flow through the atrioventricular and ventriculoarterial valves, as well as virtually any vascular structure. MRI provides moreover morphological and functional assessment of both ventricles with objective volumetric measurements throughout the cardiac cycle. With the combination of the above volumetric and flow data it can quantify stenosis and/or insufficiency in patients with simple or complex valvular disease, as well as Qp/Qs ratio and shunts. MRI is the only modality able to quantify the regurgitant volume, which is of importance in patients with aortic regurgitation or pulmonary insufficiency as in surgically corrected tetralogy of Fallot. The mathematical combination of pulmonary regurgitant and tricuspid flow reflects the diastolic function of the right ventricle. MRI is superior to ultrasonography in situations with poor acoustic windows such as postoperative or obese patients, conduits calcified or not, always providing objective anatomic and functional data. It is, however, a time-consuming and expensive modality and inferior to ultrasonography in the assessment of valve leaflets and small vegetations. Future perspectives include improved anatomic imaging at 3 T, efforts to adequately visualize valve leaflets, real-time velocity-encoded sequences, and whole-heart scanning with flow sequences encoded in the three directions. In 30-50% of oncologic patients the liver is a preferred site of primary or secondary malignant tumours. Surgery still remains the only curative treatment option for liver tumours. RFA offers chance extent number of candidates for surgery and/or it is also alternative to other curative treatment in some cases. In our hospital all indications for RFA are done by the committee (oncologist, onco-surgeon, interventional radiologist and gastroenterologist), which works once a week. The written conclusion is obligatory for everyone (included in medical report). For RFA we use the following criteria: Patients with fewer than four lesions measuring 5 cm or less (including safety rim!!!)are not candidates for liver resection. Evidence of extrahepatic tumor is not contraindication. Patients with active infection or uncorrectable coagulopathy are excluded. The size of the tumors must be initially measured (US, CEUS, CT or MR). The extent of infiltration of tumors must be estimated exactly. We planned a safety margin to cover the tumor and at least 1 cm of the surrounding tissue. In cases of tumor with poorly defined borders the goal is an ablation margin of 1.5 cm. A S107 C B D E F G H Tumors larger than 3.5 cm in diameter must be ablated with multiple overlapping spheres or with special protocol or electrode. The ablation border is determined by the relationship between the tumor and adjacent structures and the blood supply. After RFA, 1-day observation is mandatory. Follow-up is done by contrast ultrasound (during procedure an after procedure) and by CT and/or MR every 6 months. Imaging report is the main column of communication between radiologist, patient and clinician. Therefore, a perfect structure is essential to easily draw the attention of the reader to the necessary information. The main parts of the report are indication for this particular breast imaging study, patient and family history, clinical findings, composition of breast parenchyma, detailed description of significant findings (lesion features and localization) using adequate, unequivocal and internationally established terminology, and comparison with previous imaging studies. Specifications of the examination have to be given especially in MR imaging reports (equipment, sequences and contrast media used) as well as reports of interventional procedures (i.e. equipment, local anesthesia). In the conclusion of the report a final assessment category according to the BI-RADS ® -classification has to be included. The significance and the practical use of each final assessment category and the reasons for the specific course of action will be explained and demonstrated by respective examples of all imaging modalities. Emphasis will be laid on potential errors and how to avoid them as well as on a clear red thread for stringent report organization to definitely avoid misunderstandings by patients and clinicians. Associated findings may be associated with the different categories of lesions (BI-RADS lexicon) or stand alone as findings when no other abnormality is present. They concern the skin (retraction, thickening, invasion, skin lesion), the nipple (retraction), the fibrous stroma (thickening related to edema) and lymphadenopathies. At MRI, other associated findings are described such as pre-contrast high duct signals, cysts, blood, abnormal signal voids, and pectoralis muscle or chest wall invasion. Special cases on mammograms described specific entities that may be considered as normal structures or normal variants in most of patients such as solitary dilated ducts, intramammary lymph nodes, global or focal asymmetries. Asymmetries may require additional workup (spot compression, ultrasound), especially when abnormal clinical findings are present, to search for pejorative signs: Convex margins, gradient of density, associated architectural distortion or calcifications, comparison with previous studies. Additional special cases related to ultrasound are complicated cysts and clustered microcysts. All these entities will be defined and illustrated through different cases to understand how to recognize them and how to differentiate a normal variant from a true lesion. Purpose: Multimodality workup has the real potential to improve the situation of patients with breast diseases. Breast cancer is currently the most frequently diagnosed cancer and the most frequent cause of cancer-induced death in women in Europe. Demographic trends indicate a continuing increase in this substantive public health problem. Early detection through systemaric screening, effective diagnostic pathways and optional treatment have the potentiality to substantially lower the current breast cancer mortality rates and reduce the burden of this disease on the population. For ensuring these benefits, high-quality services are essential. These may be achieved through the underlying basic principles of learning, training, specialisation, volume levels, multidisciplinary team-working, the use of set targets and performance indicators and audit. Ethically these principles should be regarded as applying to symptomatic diagnostic services and screening. Unnecessary workup of lesions which show clearly benign features should be avoided for minimising the anxiety of the patients and maintaining a streamlined cost-effective service. Results: The best way for a multimodality workup for breast diseases are the European guidelines for quality assurance in breast cancer screening and diagnosis (Fourth Edition, 2006) with its coverage on: Radiographical and Radiological Guidelines. The aim of a multimodality workup is to summarise all pertinent data on the basis of the European Guidelines. The cornerstone in the triage of patients with acute chest pain is based on a sound evaluation of character of the pain, location, radiation, onset and duration of the chest pain.The pain might be influenced by breathing, coughing, swallowing, a change in body position, movement, emotional or physical exertion or climatic conditions. Accompanying symptoms may add valuable information as well. The physical examination is focused on heart rate and rhythm, blood pressure, auscultation and percussion of lungs and heart, palpation of the abdomen and peripheral pulses and respiratory rate. An ECG at rest is readily available as well as laboratory markers like troponin test, d-Dimer, blood gas analysis and brain natriuretic peptide. A simple chest X-ray may give valuable clues to the underlying diagnosis. Appropriately equipped emergency rooms may have access to an echocardiographic examination. However, the clinical evaluation often reveals ambiguous findings. Especially in aortic dissection and pulmonary embolism, they can rarely be proved or excluded with the above-mentioned diagnostic tools and a CT scan is regularly mandated in this situation. Learning Objectives: 1. To provide an overview of the most important differential diagnosis in patients with acute chest pain. 2. To review the current clinical standard to triage and risk stratify patients with acute chest pain. 3. To understand the value and limitations of using the clinical presentation to triage those patients. B. CT principles, protocols and findings T. Schertler; Zurich/CH (Thomas.Schertler@usz.ch) Early triage of patients with acute chest pain presents one of the most difficult diagnostic challenges. Patient's history, initial cardiac enzyme levels and electrocardiography (ECG) often do not allow a safe discharge of patients. Furthermore, symptoms of different life-threatening and non-life-threatening chest pathologies are non-specific and clinical presentations can overlap. Recent advances in diagnostic imaging such as multi-detector computed tomography (MDCT) technology have the potential to improve patient triage decisions. CT angiography is widely accepted and routinely used as a primary diagnostic tool in the assessment of pulmonary embolism and aortic dissection. Several studies performed with 64-slice CT in patients suffering from acute chest pain have shown the capability to diagnose or to rule out coronary artery disease (CAD). The newest CT scanner generation, the Dual-source CT (DSCT) enables ECG-gated imaging with an increased temporal resolution. Imaging of the entire chest with ECG-gating is now feasible and allows an evaluation of the pulmonary arteries, the thoracic aorta, and the coronary arteries with diagnostic image quality within a single examination. This so called triple rule-out protocol also requires an adjustment of the contrast material application protocol for the simultaneous attenuation of the three vascular territories, i.e., the aorta, the pulmonary, and the coronary arteries. Recent studies have shown that a triple rule-out protocol yields promising results as a modality for evaluating chest pain patients. However, the precise indication and the appropriate patient population benefiting from a triple rule-out CT protocol has not yet been defined. Learning Objectives: 1. To learn about the CT scanner requirements for imaging the patient with acute chest pain. 2. To introduce CT protocols for imaging the heart and the entire chest in those patients. 3. To review the typical CT imaging findings of patients with acute chest pain. A-387 17:00 C. CT for triage and prognosis U. Hoffmann; Boston, MA/US (uhoffman@partners.org) Patients with Acute Chest Pain represent a global challenge for the healthcare system. Among the patients who are admitted for presumed acute coronary syndrome (ACS), less than 20% will ultimately have a primary or a secondary diagnosis of ACS. While a large number of patients are admitted and investigated extensively for what ultimately turns out to be non-cardiac chest pain, 2-8% of ACS patients are discharged inadvertently leading to significant morbidity and mortality. Contrastenhanced cardiac CT is a newly available diagnostic tool, which is unique in that it allows the non-invasive assessment of the presence and extent coronary artery disease and regional left ventricular dysfunction. Recent data suggest that cardiac CT may enable guidance of triage, management, and therapy of patients with acute chest pain and low-to-intermediate risk patients. Comparison with competing non-invasive diagnostic tests and discussion of the risk benefit aspects of using cardiac CT for evaluating patients with acute chest pain are necessary to define how cardiac CT could be implemented in a cost-effective manner into the triage and management of patients with acute chest pain. Learning Objectives: 1. To review the accuracy and reproducibility of CT for the diagnosis of coronary artery disease. 2. To appreciate the role of CT in the emergency evaluation of patients with acute chest pain. 3. To understand the benefit of CT in the acute chest pain patient with regard to triage, risk stratification and prognosis. Development of radiology as a medical speciality depends to a great extent on the workforce volume in the field and its engagement in the professional career. In radiology, women constitute an increasing part of the workforce, limited by social, cultural and economic factors. In the majority of contemporary societies, those factors have lost their former meaning and power, leading to increasing participation of women in research and clinical radiology. The spread of new imaging technologies without use of ionizing radiation and increasing safety of radiological equipment further promote this trend. Women are more often holding leading and influential positions, but still far below their potential. In the time of equal rights and everincreasing career opportunities for women in radiology, the issues of combining social roles and ambitions with those related to work in radiology call for analysis and finding new solutions. This session shall explore those challenges and give a prognosis about the future. A S109 C B D E F G H AT (majda.thurnher@meduniwien.ac.at) The American Association for Women Radiologists (AAMC) statistics for 2005-2006 report the following numbers: women represent 50% of applicants to medical school, 48% of first-year medical students, 49% of all medical students, 42% of residents and fellows, 32% of medical faculty members, 38% of assistant professors, 28% of associate professors, 16% of full professors, 19% of division or section chiefs, 10% of department chairs, 43% of assistant deans, 31% of associate and senior associate or vice deans, and 11% of medical school deans (Angtuaco et al., Radio-Graphics 2008) . In most European medical universities, the percentage of women medical students, as well as those who finish medical school, is around 50% or even above 50%. Over the past decade, the percentage of women in diagnostic radiology residencies has remained remarkably constant at or slightly above 25%. However, women continue to be underrepresented in radiology chair positions. Back in 1983, women radiologists were underrepresented in the editorial boards of major radiology journals (1.7%) and in the upper echelons of radiologic societies. Today, two of the world's top general medical journals, the BMJ and JAMA, have female editors, clearly reflecting what is happening in medicine as a whole. Learning Objectives: 1. To provide information about the number of women radiologists in Europe, their present status and achievements, changes during last 20 years and future perspectives. 2. To explore relationship between work and family life from radiology training to retirement. 3. To highlight the impact the European working time directive will have on how we work. Can you be a good parent and a good academic radiologist? I.M. Björkman-Burtscher; Lund/SE (isabella.bjorkman-burtscher@med.lu.se) A significant upsurge of women in medical school enrolment and diagnostic radiology training has been encountered throughout the last decade in many European countries. However, women still lag behind with regard to the percentage of leading clinical and academic positions held. A reason often quoted for this phenomenon is women's unwillingness or incapability to share not only financial family responsibilities with their spouse, but also to hand over nursing and traditional female family responsibilities. This unwillingness or incapability may not primarily be intrinsic for an individual, but dictated by the cultural and social environment. It leaves parents in a situation where two full-time jobs have to be combined with family life, which generally gets more and more complex. To add to such a list of duties, the commitment linked to an academic career is obviously a huge task. The combination of good parenthood and a reasonable career as an academic radiologist demands family-friendly work patterns, cultural and social environments supporting this rather common, but complex, family design, and last but not least well-structured and efficient academic career plans. Strict guidelines for academic education, academic promotion and academic resources contribute to an effective commitment to an academic career along with family life. Furthermore, elimination or outsourcing of time-consuming administrative duties promotes a deeper engagement in academic research and university teaching. Learning Objectives: 1. To identify key conflicts in combining parenthood with academic work. 2. To relate different working conditions and lifestyles to these conflicts. 3. To reflect on possible problem solving strategies. Combining life as a radiologist with bringing up children C. Lopez; Bedford/UK (carolina1202@aol.com) Combining a professional career with bringing up children is a challenge that, today, many women undertake successfully in most professions. Opportunities for jobs in medicine and certainly in radiology are now equal, regardless of gender. But maternity and motherhood have implications on the working life of women; invariably, there will be a break in their career. Many will choose to reduce working hours and instinctively their priorities will shift towards the welfare of their children. This is a difficult period, but temporary, and therefore the better the workplace recognises the difficulties and adjusts to the demands, the greater the success in ensuring that the skills of those women are not lost and that they progress and continue to develop in the workplace as well as live a happy and fruitful family life. My experience in the UK as a Radiology trainee and as a Consultant Radiologist has been compatible with bringing up three children and very positive indeed. Access to flexible working patterns, support by colleagues and a variety of childcare options have all contributed to this satisfactory outcome, though it has not been without difficulties or the occasional old-fashioned prejudice. During my talk, my experience as well as a compilation of those of my female colleagues, common strategies to cope and a view of the future will be presented. Family friendly work patterns: How to integrate them in radiology departments C. Roche; Galway/IE (clareroche@hotmail.com) Peoples' lives are getting busier all the time. Radiologists today are often juggling work and family responsibilities, demands on their time for education, exercise or leisure and may, at times, feel dissatisfied with the quality of both their work and personal lives. Organisations that work with their employees to find and implement solutions to this dilemma will find that providing a workplace that fosters work-life balance is not without clear benefits. This is a real issue for men as well as women. The catalyst for change in work practices will be the increasing number of female radiologists. There is a growing upward trend in the percentage of female medical graduates across the world. This is mirrored in radiology. In general, family-friendly policies are associated with improvements in productivity and performance. This is contrary to the widely held view that the costs of family-friendly policies outweigh the benefits. Radiologists will be attracted to those jobs that offer flexibility in an environment where they can have an interesting career. Departments that promote family-friendly workplaces have an edge when it comes to recruitment and retention of skilled employees. Family-friendly policies are a way to support and recognize the changing needs of employees at different points in their lives and careers. They are good for business. They are good for radiologists and they are good for families. Learning Objectives: 1. To explain how radiological work patterns will change over the next 10 years with an increasing proportion of female radiologists. 2. To understand the challenges facing radiology departments as they try to balance demands for flexible working hours with provision of service. 3. To illustrate how evolving technologies can help to create a better work-life balance. Across the gender divide: The male radiologist's perspective M. Laniado; Dresden/ DE (michael.laniado@uniklinikum-dresden.de) Females have started to take over radiology training positions in Germany. This trend is not surprising since more than 50% of medical students are females today. To some extent, male radiologists are concerned about the changing gender balance. Most importantly, they are concerned that their female colleagues drop out from night shifts and weekend duties at the time of pregnancy and it is often the group of skilled lady doctors in their 3 rd to 5 th year of training, if not the board-certified female radiologists, who go for a minimum of 1-year maternity leave. Replacement is difficult because a well-trained radiologist never accepts a position on a 1-year contract and newcomers in radiology cannot fill up the gap. Another potential fear of male radiologists is the demanding situation after maternity leave, because a mother of a child is usually less flexible than a male radiologist with a child. These challenges can be turned into opportunities if radiology successfully recruits the brightest and most motivated female minds. This may be done by promoting the unique features of our specialty such as continuous technical innovation, high-level interdisciplinary clinical work, excellent training conditions with only a minor percentage of administrative duties, combination of imaging and intervention, etc. If these ladies return after maternity leave, they often show a high level of organization, i.e. work is done efficiently and fast, and home-based film reading may also be done. However, the concept of having an increasing percentage of female radiologists can only be successful in benefitting all if hospital administration agrees to have more training positions and staff positions than the traditional number. Peliosis, sinusoidal dilatation and sinusoidal obstruction syndrome are characterized by involvement of the smallest hepatic vessels. They are common vascular diseases, but they are uncommonly identified on imaging methods. The main reason is that cross-sectional imaging features of these conditions are not specific and only partially known, and this is reflected by the low number of reports published in the radiology literature. Along with these conditions, the occurrence of small, incidentally detected, hypervascular lesions in the arterial phase of enhancement at both CT and MR imaging is a relatively frequent event when imaging the liver for other reasons. Capillary angiomas, small focal nodular hyperplasia lesions, hyperplasic nodules and arteriovenous shunts account for the majority of these events, but metastatic disease must be ruled out when a primary neoplasm is present. Most benign hypervascular masses demonstrate persistent enhancement beyond the arterial phase and this proves to be a useful criterion to suggest benignity. Conversely, malignant hypervascular masses are known to demonstrate "washout" or loss of enhancement on hepatic venous and delayed-phase imaging. When a confident diagnosis cannot be reached with a single technique, it might prove useful to perform an additional imaging study choosing among MDCT, MR with hepatospecific contrast media or contrast-enhanced US. In doubtful cases, imaging follow-up is a valid alternative to biopsy when the likelihood of a malignant lesion is low. However, in most cases, improved knowledge of these diseases is a valuable guide to a confident diagnosis by the radiologist. A S111 C B D E F G H With the advent of and increasing experience with minimally invasive therapies for injured cartilage there is a need for sensitive and specific depiction and follow-up of cartilage abnormalities and repair procedures. Accordingly, there is more and more experience in clinical imaging comprising lesion detection and grading as well as post-OP evaluation of the status of repair and depiction of complications. However, technically, imaging articular cartilage is challenging due to the small anatomic size and high degrees of curvature of cartilage layers requiring high resolution and due to its short T2 relaxation times limiting the available MR signal. The recent advent of 3 T MR scanners and dedicated multi-channel coils may be very helpful in order to improve the trade off between resolution, SNR, and CNR at tolerable imaging times. Going beyond clinical imaging, quantitative approaches are required to assess the natural course of OA and the efficacy of the various treatment strategies. Ideally, such imaging should be able to discriminate irreversible from potentially reversible changes within the cartilage matrix before open loss of cartilage substance occurs. Today, most experience is available from volumetric approaches based on high-resolution 3D FS GRE sequences, aiming at cartilage volume / thickness loss. Among the techniques addressing composition and organisation of the cartilage matrix, the two techniques closest to (pre) clinical use are T1-mapping after Gadolinium (dGEMRIC: proteoglycan content) and T2-mapping (collagenous fibre anisotropy, water content). These techniques should be understood as producing complimentary rather than competitive data in view of a comprehensive assessment of cartilage. Diffusion magnetic resonance (MR) imaging techniques have attracted much attention in the past decade, providing information not available from conventional MR imaging sequences. They monitor, in vivo, random microscopic motion of water protons. Diffusion-weighted imaging (DWI) is the simplest form of diffusion imaging. It allows tissue characterization at a sub-millimetric level. Diffusion tensor imaging (DTI) is an evolution of this technique. It is a quantitative method based on diffusion anisotropy that allows further assessment of tissue microstructure. Microstructural parameters, such as fractional anisotropy (FA) and apparent diffusion coefficient (ADC), can be calculated with these techniques. MR tractography is a rendering method that allows 3-D visualization of anisotropic structures. These techniques have encountered a growing interest in the evaluation of musculoskeletal disorders. Promising applications are the evaluation of bone marrow cellularity, bone and soft tissue tumors, muscular disorders, cartilage imaging, and peripheral and spinal nerves lesions. Technical requirements are a limitation to the widespread use of these techniques, but recent advances in hardware and imaging techniques offer encouraging perspectives. Learning Objectives: 1. To understand the basic principles of diffusion imaging. 2. To discuss the potential applications of these techniques in musculoskeletal diseases. 3. To discuss their limitations and how improvements may be made. A-400 17:00 C. MR contrast media D. Weishaupt; Zurich/CH (dominik.weishaupt@usz.ch) Currently, extracellular gadolinium-based Mr contrast agents are most commonly used for imaging of muskuloskeletal (MSK) disorders. For MSK imaging, extracellular contrast agents are injected intravenously or intraarticularly (MR arthrography). Although the use of extracellular contrast agents provide mostly morphologic information, some functional information can also be obtained. Over the past years, there has been increasing interest in cellular imaging. Cellular imaging can be defined as the non-invasive and repetitive imaging of targeted cells and cellular processes in living organisms. A key requirement for cellular imaging is the availability of high-relaxivity MRI contrast agents and secondarily to link them to surrogate markers. Another important challenge is the trade-off between image resolution and detectable contrast agent concentration, which has to be overcome in case of cellular imaging. In general, gadolinium chelates may be used for cellular imaging, but most gadolinium complexes exhibit too low relaxivities. Superparamagnetic iron oxide (SPIO) and ultrasmall superparamagnetic iron oxide particles (USPIO) are the preferred MR contrast agents for cellular imaging. Depending on their size, surface charge and coating, they are engulfed by different cells of the macrophage/monocyte phagocytotic system. Another approach to depict in vivo distribution of macrophages is direct labelling of hematopoetic (progenitor) cells. Dedicated labelling techniques using SPIO or USPIO have been described, which allow tracking of the in vivo distribution on injected human hematopoietic progenitor cells to various target organs. Learning Objectives: 1. To discuss the current role and applications of contrast agents with special focus on cellular imaging in musculoskeletal diseases. 2. To review the results obtained in cellular imaging of musculoskeletal diseases and to discuss their impact on therapies. 3. To provide an outlook of future developments in cellular MR imaging in the assessment of musculoskeletal diseases. The face and neck offer some of the most complicated anatomy with which the radiologist has to deal, and also a particularly wide range of pathology, making cervicofacial imaging a complex area of clinical practice. Further, imaging signs in the face and neck can frequently be difficult to elicit. Many general radiologists prefer to avoid practising in this area, if possible; but a basic knowledge of neck masses is fundamental to general radiology practice. A simple approach to the complexity of the suprahyoid neck may be taken on the basis of anatomical compartments. Knowledge of and ability to analyse these is fundamental to perform differential diagnosis and provide the radiologist with a useful guide in establishing the pathological basis of imaging signs. In this area, it is also important to correlate imaging with clinical examination, as lesions may have identical imaging signs but radically different pathophysiology. Imaging signs are rarely specific but provide a good guide to further clinical management, including local staging of both benign and malignant disease. In radiology generally, knowledge of the clinical treatment options is fundamental to providing a meaningful radiological report. This is particularly true of cervicofacial disease where therapeutic options are generally not well understood by radiologists, and where clinicoradiological liaison becomes paramount. With the increasing value of imaging -both in diagnosis, intervention, follow-up of treatment and understanding of pathogenesis of diseases -the use of contrast media has also increased heavily during the last few decades. Especially in CT, MRI and intervention, both iodine and gadolinium contrast media are used in higher doses in sicker patients. Accordingly, in spite of the fact that modern contrast media are less toxic than contrast agents used 10-20 years ago, the sheer increase in number of patients at-risk receiving contrast media contributes to a risk of increased number of adverse events. The adverse events can be divided into two groups, the acute and late-allergic (allergoid-like reactions) and renal. The renal reactions are contrastmedia-induced nephropathy, which may happen with both iodine and gadolinium contrast media. Nephrogenic systemic fibrosis is an adverse event that only occurs following gadolinium contrast-media injections. This session will elucidate who are the at-risk patients for the different types of reactions, how common they are, how they can be prevented generally and on an individual patient basis. Lastly, the session will also include situations where prevention has failed, and discuss suggestions as to how the different types of adverse events should be treated. This is a report on the different clinical and biochemical arguments available to prove or rule out an immune mechanism in patients experiencing an immediate reaction following iodinated contrast media (ICM) as their treatment and prevention. Immediate clinical signs resembling allergy are called hypersensitivity reactions and are subdivided into allergic (when an immune mechanism can be demonstrated) and non-allergic hypersensitivity reactions, when an immune mechanism is ruled out (non-specific histamine release). The diagnosis of an immediate hypersensitivity reaction relies on a triad associating the precise description of the initial clinical signs (according to the Ring and Messmer severity scale), their onset delay, the results of the biological assessment and the results of skin testing with the culprit agent. Analysis of these data allows identifying the pathophysiology of the reaction and the allergen involved in case of an allergic mechanism. Biochemical tests include plasma histamine and tryptase measurements. Skin tests should be performed according strict criteria. Reactors with positive skin tests should not receive the same ICM again. Other commercially available ICM should also be skin-tested and cross-reacting ICM avoided. ICM yielding a negative skin test may be proposed for subsequent radiological procedures. The same diagnostic scheme is used in case of an immediate reaction following gadolinium-based CM. Treatment of severe reactions (cardiovascular collapse, cardiac arrest) relies on epinephrine and vascular loading. The diagnosis of a proven immediate allergy to a given ICM (and to cross-reacting ICM) imposes their definitive avoidance but not of all iodinated drugs. Contrast-induced nephropathy (CIN) is a serious adverse event associated with the use of contrast media (CM). Patients who develop this complication can have increased morbidity, higher rates of mortality, lengthy hospital stays, and poor longterm outcomes. Although CIN cannot be eliminated, the chances of developing this condition can be reduced by using appropriate prevention strategies. An important first step to reduce the chance of CIN is to identify risk factors associated with this condition. Patients with a previously elevated serum creatinine level, especially when secondary to diabetic nephropathy, are at great risk for developing CIN. Other patient-related risk factors include concurrent use of nephrotoxic medications, dehydration, congestive heart failure, age greater than 70 years, and probably the presence of diabetes mellitus even if serum creatinine is normal. Adequate hydration is widely accepted as an important prophylactic measure for preventing CIN, but the optimal hydration regimen is still debatable. Other strategies for reducing the risk of CIN include pharmacological manipulation, haemodialysis and haemofiltration, withdrawal of nephrotoxic drugs. The risk of CIN increases with greater doses of CM, is related to the route of administration (intrarterial injection entails a greater risk) and to the choice of CM. Controversies still exist on this topic. A number of studies published over the last few years support the use of iso-osmolar CM (non-ionic dimer) versus some low-osmolar agents for intra-arterial administration in at-risk patients. However, other data show that there is no difference between iso-osmolar agents and some low-osmolar CM. 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 the 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 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. The need for quantitative image analysis in radiology is universal: computer-aided detection, segmentation for 3D volume visualization, 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 inspirational 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 in multi-scale analysis, and how we can learn to understand and exploit the Gestalt Laws. The visual system is strongly adaptive and self-learning. New optical recording techniques have given new insight into how the cells in the visual cortex are functioning. We will go through these functionalities step-by-step. We recognize 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. The application areas for (bio-) medical imaging that we will discuss are broad: detection of catheters at much reduced levels of fluoroscopy dose, quantitative analysis of ischemic heart ventricle deformation, breast cancer CAD, pulmonary emboli CAD and analysis of in-vivo microscopy images now so abundant in modern life-sciences research. The practice of medical image diagnosis is currently undergoing a fast transformation. Vast amounts of data can be generated in standard examination and focus is shifting from improving the collection of relevant data for diagnosis to development of effective methods to analyze, visualize, 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 flow is the use of 3D and 4D applications. This talk will take its starting point in state-of-theart medical visualization and then discuss the need for a research agenda that focuses on the development of the next generation of medical visualization tools, emphasizing the fact that these tools must be based on medical user requirement and workflow studies as well as on new technical developments. Abdominal trauma is common in children and accounts for significant morbidity and mortality. Children may be injured during motor vehicle crashes, pedestrian accidents, falls while playing or because of physical abuse. The spleen is the most frequently injured intraabdominal organ, followed by the liver, intestine and pancreas. The management of abdominal trauma in children has changed over the past decade due to advances in imaging techniques and a more conservative treatment approach. Optimal evaluation of the injured child may require the use of multiple diagnostic modalities. Focused abdominal sonography for trauma (FAST) is indicated as a screening method for abdominal injuries in children, but FAST revealed limitations in identifying specific organ injuries, especially when free fluid was absent. Computed tomography (CT) of the abdomen can depict abdominal injuries accurately, but requires patient transport, injection of contrast material and significant radiation exposure. Multidetector-row spiral computed tomography (MDCT) is excellent for imaging trauma patients, but should not be performed routinely in children. Appropriate low-dose MDCT protocols are available, which minimize radiation exposure and still allow reliable identification of typical injury patterns in pediatric abdominal trauma. Evaluating a child who sustained abdominal injury is daily practice in a department of pediatric radiology. Blunt abdominal traumas are much more frequent than penetrating ones. Various mechanisms may be involved, but discrepancy between deceleration and the grade of renal trauma can be encountered. Minor trauma can induce a severe renal fracture especially in cases of underlying kidney/urinary tract malformation or tumor. The most severe lesions are usually observed following motor vehicle accidents, pedestrian crashes or sport injuries. On the other hand, minor traumatisms represent the most frequent situation and include fall while playing in toddlers, and bathroom accidents in neonates and young children. An inflicted injury should be remembered as the potential cause. In this lecture, emphasis will be placed on the pediatric particularities of renal injuries and the different imaging strategies. Renal trauma cannot be individualized from associated lesions with regard to imaging strategy, which mainly depends on the local organization, available A S119 C B D E F G H be used as an adjunct to US. The PAD technique depends on case-specifics and personal preference. PAD is usually performed using standard aseptic Seldinger technique with local anesthesia. Alternatively, the trocar technique may be used. Small and simple abscesses may also be treated with aspiration and lavage. Details about specific intra-abdominal PAD procedures are discussed. Clinical follow-up care may be assisted with CT, US and contrast studies if the infection is not resolving. Patients usually receive antibiotic therapy and additional interventional manipulation is based on clinical and radiological results. PAD endpoints include signs of patient recovery, reduction in white blood cell count and daily catheter output less than 10 mL. Simple abdominal abscess treatment is usually complete within days but complex abscesses or abscesses associated with enteric fistulas may require weeks to months. Success rates for PAD are high (almost 90%) for most of the abdominal abscesses. However lower success rates are reported for pancreatic abscesses and enteric fistulas. Significant PAD complications are rare (0% to 10%) and might be avoided by careful planning and patient preparation. Based on morphologic criteria in X-ray and CT, skeletal metastases are classified into osteolytic (50%), osteoblastic (35%) and mixed type (15%). The clinical algorithm for clarification of bone metastases includes X-ray studies, skeletal scintigraphy, CT and MRI. Yet, only pronounced destructions (> 50%) of bone mineral content are readily visible in radiographic studies. CT is more sensitive than radiography and modality of choice to evaluate the extent of bone destruction and assess fracture risk. MRI allows visualization of bone marrow with high spatial resolution, is more sensitive than X-ray, CT or scintigraphy and provides precise assessment of marrow infiltration into adjacent paraosseous structures. Non-contrasted T1-w-TSE-and Turbo-STIR-sequences proved most sensitive for discrimination of the benign from malignant marrow disorders. Osteolytic lesions are iso-/hypointense on T1-w-TSE-and hyperintense on STIR-sequences. Osteoblastic metastases may often show isointense signal patterns on STIR. Diagnostic problems in MRI may arise in younger patients with highly cellular hematopoietic marrow, where knowledge of age-dependent conversion patterns is required. Furthermore, avital bone metastases after therapy can remain virtually unchanged in morphology/ signal, thus complicating evaluation of response. Technological improvements have introduced whole-body MRI (WB-MRI) as new tool for bone marrow screening. Parallel imaging (PAT) and matrix coil concepts significantly reduced acquisition times without compromises in spatial resolution. High diagnostic accuracy for WB-MRI bone marrow screening has been reported with relevant additional findings outside the axial skeleton or within parenchymal organs. The proposed protocol at 1.5 T consists of coronal whole-body T1-w-TSE/STIR-imaging including sagittal imaging of the spine with 42 minutes total imaging time. Metastases represent the commonest malignant tumours of the skeleton. In the majority of cases, the characterisation of bone metastases is straightforward, since they appear as multifocal, aggressive lytic, sclerotic or mixed lytic/sclerotic lesions in a patient with known primary malignancy. However, certain clinical situations exist where the diagnosis becomes less clear. First, a patient with known malignancy may present with a focal or multifocal bone lesions which do not appear typical for metastases. Such lesions include a variety of non-neoplastic conditions, benign neoplastic and primary bone malignancies. Second, the differentiation between benign and pathological vertebral collapse must be determined. In the majority of cases, this can be achieved by attention to a number of signs which are demonstrated by conventional MRI. Third, a patient with no known history of primary malignancy may present with a single or multifocal bones lesions and the diagnosis of bone metastases must always be considered, particularly over the age of 40 years. It is important to note that metastases have no characteristic imaging features that differentiate them from myeloma or high-grade primary bone sarcomas and that in the majority of cases, further imaging with MRI will not aid in characterisation. The requirement for diagnostic needle biopsy is stressed in this situation. In conclusion, the characterisation of an individual skeletal lesion as a bone metastasis is not always easy, and consideration must be given to a large number of potential differential diagnoses before management is undertaken. Whereas the role of different imaging modalities (bone scan, CT, MRI…) in the workup of symptoms and systematic screening for bone metastases is well established, their role to assess treatment response of bone metastases remains limited and unclear. Bone metastases differ from those seen in other organs such as the lung or liver, in that they are presumed to be "non measurable" and are thus not "targets" for treatment monitoring. However, more rent imaging techniques, especially MRI, can detect "morphologic" changes in bone metastases during treatment in a significant proportion of patients. Signs of disease progression are quite evident. More subtle signs suggestive of response can be highlighted. More recent quantification tools such as dynamic contrast-enhanced (DCE) MRI and diffusion-weighted imaging (DWI) open new perspectives. Finally, the role of "metabolic" imaging modalities, especially of PET-scan, to assess the response of bone metastases to treatment will be illustrated. Existing minimally invasive techniques for the treatment of primary and secondary bone tumors include: ethanol ablation, cementoplasty, radiofrequency-ablation, cryo-ablation, laser photocoagulation and radiofrequency cavitation. Aspects of each ablation technique including mechanism of action, equipment, patient selection, treatment technique, and recent patient outcome are presented. A review is presented of the current status of image-guided tumor ablation therapy. The benefits and limitations of each technique are discussed. Interventional Percutaneous injection of methylmethacrylate (Cementoplasty) is a palliative technique usually indicated when osteolysis involves the weight-bearing bone (i.e., vertebral body, acetabular roof). The main advantage of thermal ablation is the ability to create a well-controlled focal thermal injury with minimal morbidity and mortality to date. Unlike alcoholization (ethanol ablation), thermal ablation creates a well-demarcated lesion. RF and Cryo are particularly useful in the indication of ablation technique as a tumor therapy and, in palliative bone metastases pain management when consolidation is not mandatory. However, in specific cases, bone metastases ablation should be associated with cementoplasty to avoid compression fracture. The management of patients with bone metastases requires consideration of many factors: a) careful evaluation of the patient's general condition, b) an understanding of the disease process: Curative or palliative treatment? c) an appreciation of the degree of bone destruction (consolidation) or decompression (Coblation). And a working knowledge of available treatment options is required. A multidisciplinary approach is essential to determine the course of treatment that best alleviates the pain, preserves function, and optimizes the quality of life remaining in the patient with malignant and metastatic disease. To provide nationwide access to all radiological imaging data within Austria, a concept for a virtual nationwide PACS, based on the IHE definitions for image interchange, has been developed. A project was started to evaluate the possibilities of implementing shared, multi-user repositories. Every authorised person within the healthcare system will be granted access to all image data of an individual patient. To achieve this goal all existing archives, be they in hospitals or in private radiology practices, must be connected. The current status of the project, its challenges and possible pitfalls will be presented. Radiologists will love the APPC F. Frühwald; St. Pölten/AT (franz.fruehwald@fruehwald.at) Austria is the first country to try to connect all existing but currently isolated PACS and to grant radiologists access to all imaging data stored (fully obeying the Austrian Medical Data Privacy Act). For radiologists a system of shared multi-user repositories promises several benefits, such as improved diagnostic quality when using prior studies for comparison, and reduced costs. Unstructured repositories multiply unnecessary workloads by providing irrelevant old imaging information instead of relevant prior imaging studies. While working on this project, a common interface between different PACS from different vendors proved to be necessary as a 'search & exchange code'. A new coding system called APPC (Austrian PACS Procedure Code) was developed, which allows automatic location and selection of relevant prior imaging studies in the so-far unstructured ocean of imaging data. Therefore, it will be possible to integrate the numerous existing extensive medical IT installations in Austria into a nationwide system without major hardware or software replacements. The concept and structure of the APPC will be presented. Initial MDCT coupled with follow-up sonographies is the imaging method of choice, but US can be sufficient in many cases, especially when a high standard examination is absolutely normal. IV urography should no longer be employed. Rarely, angiography can be used to take care of children with intractable bleeding. Posttraumatic renal sequelae can be evaluated by DMSA scintigraphy: MR urography which provides analysis of both anatomy and function can be an efficient alternative. Learning Objectives: 1. To describe imaging findings in cases of renal trauma Pathology of the external and middle ear F. Veillon; Strasbourg/FR (Francis.Veillon@chru-strasbourg.fr) External auditory meatus: Malformations: Stenosis and absence (CT), traumatisms (50 %; CT) Middle ear pathology: Vascular abnormality (CT), aberrant internal carotid artery, persistence of stapedial artery, procidence of the jugular bulb. Malformations (CT): Small middle ear, fixed, deformed or absent ossicles, narrow or absent windows with or without abnormal facial nerves. Traumatisms (CT): Most of the fractures follow the middle ear with or without ossicular dislocations. Inflammation (CT and MRI): In emergency mastoiditis with or without abcess. In cold conditions, imaging allows to separate the tympanosclerosis, granuloma, fibrosis, hyperplasia and secondary cholesteatoma. Benign and malignant lesions: Primitive cholesteatoma, meningioma, neuroma (eighth, seventh), adenoma, paraganglioma, histiocytosis, tuberculosis, external malignant otitis, carcinoma, lymphoma, metastasis. To conclude, CT and MRI allow usually a precise final diagnosis of the extension of external and middle ear pathology To know optimisation of imaging techniques used for assessment of external auditory canal and middle ear To familiarise with imaging findings within external auditory canal and middle ear in patients with conductive hearing loss cancers, targeting, evaluation in difficult breasts, response to neoadjuvant treatments. It is important to underline that for the final assessment of lesions, both anatomical and elastographic information should be considered. Learning Objectives: 1. To understand the role of elastography in diagnosing breast lesions. 2. To become familiar with the complementary role of elastography in the differentiation of benign and malignant breast lesions To learn about the different methods of breast elastography has drastically reduced the number of surgical procedures due to false positive radiological findings. Correlating histological and radiological features is extremely important. In cases of disagreement, vacuum-assisted systems or surgical biopsy are usually recommended. All breast radiologists should be encouraged to get plenty of experience in US-NCB. Learning Objectives:1. To review the technique basic principles. 2. To know pros and cons of this approach to breast conditions diagnosis. 3 . To update the indications in order to reduce false positive.A-307 09:00 B. Stereotactic large core biopsy P. D . Britton; Cambridge/UK (peter.britton@addenbrookes.nhs.uk) Stereotactic breast biopsy has a long-established role in breast diagnosis for identifying lesions not detectable by ultrasound. Technical advances in ultrasound has meant that stereotactic biopsy is now almost exclusively performed on screen-detected microcalcification and small parenchymal deformities. Such lesions present the greatest diagnostic challenges confronting the breast radiologist. Abnormalities are frequently small, hard to target and encompass most borderline and in-situ pathologies encountered. Compared with lesions targeted by ultrasound diagnostic performance has lower sensitivity, higher false negative and cancer upgrade rates. To tackle these challenges digital equipment is essential whether prone biopsy or upright. Fine needle aspiration cytology (FNAC) has been superseded by devices harvesting larger amounts of tissue such as core biopsy (CB) and vacuum-assisted biopsy (VAB). Are better results achieved with VAB, and if so, does it justify the considerable extra expense? Whatever targeting method or biopsy device is used, a meticulous approach to technique, adequate sampling and correlation with pathology at multidisciplinary team meetings are essential for best and safe patient-care. A-308 09:30 C. An update on MR-guided wide excision biopsy Breast MRI is capable of visualizing lesions not detected by other methods. Depending on patient preselection, 20-30% of these lesions may be malignant. For histopathological assessment of suspicious or indeterminate lesions (BIRADS 4 or 5) visualized by MRI alone, MR-guidance is needed. Whenever MR-guided percutaneous biopsy can be performed, it should be preferred to MR-guided wire localisation. Unfortunately, because of the limitations of part of the biopsy coils, because of the limited availability of experienced teams, and because of the restrictions on re-imbursement, MR-guided percutaneous biopsy is offered in only few institutions. MR-guided wire localisation unfortunately requires subsequent open biopsy and thus does not allow conformity to European guidelines for minimal invasive assessement of imaging-detected lesions. However, when performed by a sufficiently experienced team, it does allow histopathological clarification of MR-detected lesions. Indications for MR-guided wire localisation thus include histopathological assessment of MR-detected lesions that are sufficiently suspicious (usually > BIRADS 4) that cannot be visualized by other methods prospectively or in retrospect and that cannot be assessed by MR-guided percutaneous biopsy. In this course, the standard procedure, an overview of available equipemnt and results pubished in the literature for the assessment of multicentric disease or other indications are summarized. Magnetic resonance spectroscopy (MRS) provides metabolic information and enables tissue characterization on biochemical level. However, MRS does not replace MRI, but in fact works as an adjunct tool. A multifunctional approach including patient evaluation and imaging together with MRS is accepted to be the most beneficial approach. Different methods can be used to sample the given voxel/volume with different echo times in MRS. Appropriate shimming to homogenize the magnetic field, adequate water signal and fat-suppression should be done for high quality spectra. Care should also be taken to avoid blood, blood degradation products, air, CSF, fat, necrotic areas, metal, calcification and bone in voxel positioning. MRS has found its main area of use in neuroradiology as a tool in gathering additional information in differentiating various diseases, evaluating tumors and diagnosing metabolic disorders. Nowadays, neurodegenerative diseases including Alzheimer's disease and ALS, epilepsy, ischemic diseases, demyelinating processes including MS, trauma and infection are other neuropatholigical entities in which MRS is increasingly involved. MRS may also be used as a prognostic indicator in following the progression of the disease and evaluating treatment response. Neuroimaging might play an important role in the timely diagnosis of metabolic disorders and in some disease be helpful in therapeutic decision-making as for example in children with adrenoleukodystrophy (ALD). Combined with conventional MRI, newer MRI techniques such as magnetic resonance spectroscopy (MRS) add additional information and are considered helpful for the final diagnosis of certain types of metabolic disorders. In respect of interpretation of MR spectroscopy in children, the same must be done cautiously with judgment. A range of factors can influence the profile of 1H-MR spectrum including magnetic field uniformity, poor shimming that may result in reduced resolution, broadening of resonances and distorting metabolic ratios to interpatient variability because of age and developmental stage. Relative ratios of detectable metabolites and the detection of metabolites normally not present in the pediatric spectral profile have shown to be valuable in the evaluation and work-up of metabolic disorders in children. For example, an abnormal elevation of NAA is classically seen in Canavan's disease, the absence or significant reduction of creatine peak is the hallmark for creatine deficiency diseases and detectable presence of lactate in the basal ganglia supports a clinical and laboratory diagnosis of a mitochondrial disorder. The purpose of the present lecture is to describe the current applications of MR spectroscopy techniques for the diagnosis of metabolic disorders, emphasizing key pathological metabolic spectra that can help in the diagnosis of some metabolic diseases, and to outline the strengths, weakness and applications of MR spectroscopy in the work-up and diagnosis of metabolic disorders. Learning Objectives: 1. To learn the protocol. 2. To discuss the clinical and MRS features. 3. To discuss the differential diagnosis.A-311 09:30 C. MRS in brain tumors M. Essig; Heidelberg/ DE (m.essig@dkfz-heidelberg.de) Proton magnetic resonance spectroscopy (MRS) and spectroscopic imaging (CSI) are becoming common clinical tools in neurooncology as they assist in the acquisition of functional tissue information. Spectroscopic characterization of brain abnormalities has relied mostly on the calculations of ratios between the main Parenchymal disorders of vascular origin can present as focal or diffuse changes in morphology and attenuation of the liver. In case of focal changes, differentiation from focal liver lesions e.g. metastases or hepatocellular carcinomas is implicated, and in case of diffuse changes the level of vascular obstruction (pre-or post-sinusoidal, gross hepatic veins) has to be evaluated. The most common parenchymal disorders of vascular origin are transient hepatic attenuation differences (THAD), which typically present in areas with aberrant venous supply and/or drainage e.g. adjacent to the falciform ligament or in the gallbladder bed. They usually present as wedge-shaped areas with fatty changes of the liver parenchyma and signs of hyperperfusion. Other causes of THAD include changes in hepatic perfusion caused by extrinsic compression (e.g. by ribs) or arterio-portal shunting resulting from liver cirrhosis or as a complication of invasive procedures (e.g. liver biopsy). Changes in hepatic perfusion and venous outflow can be related to typical parenchymal pattern, which differentiate depending whether there is pre-sinusoidal blood flow impairment (e.g. nodular regenerative hyperplasia, NRH), sinusoidal dilatation or peliosis, post-sinusoidal obstruction (veno-occlusive disease) or acute or chronic obstruction of the hepatic veins (Budd-Chiari-Syndrome). As a result of vascular disorders lobar or segmental hyperplasia or atrophy can be found, e.g. segmental hyperplasia of the caudated lobe in case of Budd-Chiari-Syndrome as a result from aberrant venous drainage. Lobar or segmental atrophy can be related to either vascular causes e.g. liver infarction after arterial occlusion or non-vascular causes e.g. atrophy caused by segmental bile duct obstruction. The role of CT and MRI for the assessment of acute cardiac and paracardiac disease is still evolving. Coronary CTA may be used as a gatekeeper for excluding coronary artery disease in patients presenting with acute coronary syndrome. CT is also well suited to assess acute aortic syndromes and acute pulmonary embolism. 'Triple rule out' CT protocols may play an increasing role in acute chest pain patients. The main value of MRI is direct infarct imaging and myocardial perfusion imaging in patients with acute chest pain of presumed cardiac origin. The selection of the most appropriate technique depends on clinical indication, availability, speed of examination and local expertise. Acute chest pain, whether traumatic or non-traumatic, involves multiple organ systems including the thorax, the pleura, the lung, the mediastinum, the pulmonary vessels, and the upper abdomen. Interactive cases will stress the radiographic diagnosis of many of these diseases: how to determine whether additional imaging is needed, and if so, which images? As time is often the essence in these patients, imaging efficiency will be stressed. Basic clinical parameters, such as onset of pain, duration of pain, distribution of pain, etc. will be integrated into the diagnostic approach. The primary emphasis will be emergency room and outpatient problems but inpatient problems will also be included. Since its beginnings in the fifth century B.C., rational medicine has been influenced in an alternating manner by two very different and opposing medico-philosophical systems, i.e. the cardiocentric, invented and represented by Aristotle (384 -322 B.C). and the encephalocentric, invented and represented by Hippocrates (460 -c. 377 B.C). and his school. The aristotelian cardiocentric system postulates that the heart is the seat of the soul and of the intellect, while the hippocratic encephalocentric system places these fundamental human qualities in the brain. Although the issue of localization of the soul and intellect has been resolved, the implications of these two systems for the clinical practice and for research persisted until today. With its advanced neuroimgaging tools and its sophisticated interventional techniques, modern neuroradiology is intimately involved and plays a critical role in the diagnostic evaluation and treatment of patients with central nervous system diseases. As such, and like all other neuroscience disciplines, it is fully exposed to the centuries old cardio-encephalocentric conflict of medicine. In this presentation, the author will analyze how these two different medico-philosophical systems influence the way diagnostic neuroimaging and neurointerventional techniques are being applied in the clinical and research settings and propose ways of how this dilemma of modern neuroscience can be resolved. Learning Objectives: 1. To become familiar with the evolution of fundamental concepts, underlying clinical neurosciences. 2. To understand how these concepts influence the clinical practice and the research of modern neuroradiology in both, its diagnostic and interventional parts.The role of imaging in the accurate detection and diagnosis of tumours of the spine is dependent on the inherent sensitivity and specificity of the imaging modalities, the interpretative and processing skills of the reporting radiologist and a sound knowledge of the biological behaviour of the different tumoral pathological entities. This short talk will therefore focus on the strengths and weaknesses of the imaging modalities, the imaging signs used in the detection of spinal pathology and the differentiating imaging features related to the specific tumoral conditions. Tumour-like conditions will also be included in the differential diagnosis as well as coverage of the interventional radiological techniques used in the diagnosis and treatment of tumours of the spine. SI (vladimir.jevtic@mf.uni-lj.si) Infective spondylitis represents 2-4% of all cases of osteomyelitis and is increasing in prevalence. The most common causative pyogenic organisms are gram-positive bacteria, mainly Staphylococcus aures. Rarely spondylitis is the result of infection with gram-negative bacteria or nonpyogenic micro-organisms (Mycobacterium tuberculosis). Typically lumbar spine is involved, followed in frequency by the thoracic, sacral and cervical spine infections. The hematogenous spread of infection via arterial or venous system is the most common route of contamination. It may be also the result of different spinal operations, the extension of infection per continutatem from a contiguous focus or direct implantation of micro-organisms following diagnostic or therapeutic disc punctures. Vertebral infections, pyogenic as well as granulomatous represent serious disease entities which unrecognised may cause neurological compromise and late spinal deformities. Therefore an early diagnosis with prompt treatment are of utmost clinical importance and are mainly based on the use of different imaging modalities. In practice, bone scintigraphy, conventional radiography, CT and MRI are utilised. Due to its high sensitivity and specificity MRI is the method of choice for an early diagnosis and follow-up of vertebral infection and is frequently used as the only imaging modality. Pathoanatomic changes in spinal infection are nonspecific. Similar MRI features may be seen in etiologically different spinal diseases, which may be misleading, especially at the beginning of infection. Correct diagnosis of vertebral infection is based on understanding of the pathogenesis of the disease and of the complex consecutive morphological and signal intensity MRI changes. The postoperative imaging of the spine is performed for routine assessment of patients with a good clinical outcome or for investigating recurrent pain. The routine assessment is performed to evaluate the degree of spinal fusion, the development of pseudarthrosis, the integrity of the devices and the result of vertebroplasty. Plain radiographs are usually sufficient to evaluate these patients with regard to the initiation of physiotherapy and the elimination of restrictive bracing. The failed back surgery syndrome is found in 10-40% of patients either shortly or long after surgery which failed to correct the initial clinical problem. The most common causes of this syndrome include the following: recurrent or persistent disc herniation, spinal stenosis, arachnoiditis, epidural fibrosis, incorrect placement or fracture of metal hardware, failure of fusion with development of a pseudarthrosis, haemorrhage, and infection. These patients often require cross-sectional imaging to determine the cause of the problem and to plan the next treatment or intervention. The evaluation of the spine in patients with metal orthopedic hardware is currently performed with MDCT. Various techniques including thin sections, high X-ray tube current and KVp, narrow collimation and soft tissue reconstruction algorithm with thick sections, allowing better penetration of metal hardware and reduction of artifacts. In patients without metal devices, MRI with contrast enhancement is the method of choice.For an accurate postoperative assessment of spine, it is important that radiologists be familiar with normal imaging findings after surgery with various techniques and devices as well as with the capabilities of advanced imaging techniques. Haemoptysis may be caused by different abnormalities including infection, other inflammatory conditions as well as malignancy. Imaging is a critical component of diagnostic assessment of patients with haemoptysis in addition to bronchoscopic evaluation. Depending on the clinical situation, chest radiography is usually the first imaging examination. Thin-section spiral CT with intravenous application of contrast medium is usually required. Modern postprocessing such as multiplanar reformation (MPR), maximum intensity projections (MIP) and volume rendering techniques (VRT) may be useful in identifying the abnormality and demonstrating the pathology to clinical colleagues for treatment planning. Rarely, MRI can be helpful for the diagnosis. Therapy includes medical treatment, surgery, bronchoscopic procedures and angiographic interventions. In this interactive session an introduction will be given on the diagnostic value of imaging techniques in haemoptysis. Typical scenarios of patients presenting with haemoptysis will be presented, radiological work-up and interpretation of findings will be discussed. In a second part, the interventional therapy of hemoptysis will be discussed including typical clinical settings, bronchial arterial anatomy, technique and results of embolization. a wide range of clinical problems in the thorax without the radiation exposure from frequent chest radiographs and CT, or the need for sedation often required for MR imaging. In particular, ultrasound is quickly implemented in the remote intensive care situation where patients can be examined in any given position and location minimising the need to move or transfer patients, who are on life-support devices. Ultrasound is particularly useful in differentiating between pulmonary and pleural lesions, in visualising diseased parenchyma hidden by pleural effusion in chest radiographs, to detect and characterise pleural fluid collections, to delineate anomalies of mediastinum and great vessels, and last but not least, assess malposition and complications of central vein catheters. (hubert.ducou-le-pointe@trs.ap-hop-paris.fr) Following chest radiography, CT remains the most widely used technique for chest evaluation, even in pediatric population. By combining both helical volumetric acquisition and thin slice thickness, multidetector-row CT (MDCT) allows the performance of both helical and high resolution CT (HRCT) of the chest. The aim of this lecture is to give a practical approach to how and why we perform pediatric chest CT. Children are up to 10 times more radiosensitive than adults. Therefore, first we must answer the question: Is this exam necessary and could I answer the question without using ionizing radiation? Then, we must choose the most appropriate protocol to answer to the clinical questions posed. Pediatric protocols minimize the use of multiple scans (pre-and post-contrast scan) and adjust individual settings based on the size or the weight of the patient. Thin collimation is applied when partial volume must be reduced (e.g. HRCT of the lung, CT angiography or for 3-D post-processing). In our practice, MDCT is performed without sedation in children aged over 3 years or under 6 months. Up to 6 years of age, quiet breathing is better than attempting breath-holding. When contrast injection is needed, a non-ionic contrast media is administered at a dose of 1 ml/kg via a cannula using a power injector (hand injection is used for patients under 2 years of age). Post-processing techniques (MPR, 3-D volume rendering and virtual bronchoscopy) are commonly used. Diseases of the respiratory system are of great importance in paediatrics. Early detection and follow-up of infectious, congenital and environmental diseases in young patients is crucial for adequate treatment and improved outcome. Concerning the same, imaging techniques play an indispensable role. In the past, the interest was focused on morphological aspects of pulmonary tissue. Here computed tomography (CT) serves as the gold standard. In the course of the development of MRI, MR imaging of the lungs played a subordinate role. This was caused by several technical problems: 1. low signal-to-noise ratio because of low proton density of the lung, 2. artefacts because of cardiac and breathing motion, 3. susceptibility artefacts because of air-soft tissue transition. Despite these inherent difficulties of MRI of the lung, significant progress has been made recently. Although spatial resolution is lower than that with CT, MRI allows for the visualisation of the lung parenchyma by using ultra-short echo-time (TE). Furthermore, MRI has the advantages to evaluate different tissue aspects (T1w, T2w, fat-suppression) and to improve lesion characterization. Additionally, MRI is capable of assessing lung function, e.g. perfusion, angiography, ventilation and respiratory mechanics. Using up-to-date scanner systems, a complete study of the chest including morphological and functional imaging can be performed in less than 30 minutes. Especially, diseases that go along with pulmonary structure augmentation and/or tbat involve vascular structures can be studied by MRI. Patient exposure, which has been the largest exposure to the human population from man-made radiation sources, has become still larger during the past decade. Unlike regular monitoring of staff exposure, there is, by and large, lack of patient dose monitoring in radiological examinations. Knowing radiation dose becomes essential for optimization of protection. One might expect that improved technology would have reduced absorbed doses from almost all medical procedures over the last several decades. This is true for most low-dose examinations (such as radiography), but not so for relatively high-dose procedures (such as CT scans), primarily due to changes in practice, covering larger body areas in CT examinations and lack of justification. An International Action Plan on radiological protection of patients, as developed by the IAEA in cooperation with other international organizations such as WHO, PAHO, EC, ISO, IEC, ICRP, UNSCEAR, ISR, ISRRT, IOMP to name a few, has provided momentum to patient dose management. Actions include the development of a new public website on radiation protection of patients (http://rpop.iaea. org), training material for specific target audiences, free dissemination of training material, projects on patient dose management in radiography, interventional procedures, mammography and CT and programme impact assessment. The results from large number of countries (> 20) show that significant dose reduction to patients is possible without compromising on clinical benefit of diagnostic and interventional procedure. Learning Objectives:1. To learn about actions at international level that are directed at radiological protection of patients. 2. To understand that there is need to measure or assess patient doses in radiological procedures and optimise the doses without compromising on image quality. Imaging of rhinosinusitis: Why should I bother? Because the prevalence of rhinosinusitis (principally of chronic rhinosinusitis) is rather high, implying that this condition may be frequently encountered in the daily routine of a radiologist. Because surgery has been revolutionized (few decades ago) by the introduction endoscopic surgery. This demands a detailed knowledge of the anatomy of the region, particularly focused on the structures that serve as landmarks during surgery. Because the term rhinosinusitis encompasses several conditions with different clinical implications, knowledge of their patterns at CT or MRI is crucial, not only for surgical planning of chronic inflammation, but above all to allow prompt diagnosis of potentially lifethreatening forms. Finally, because knowledge of the anatomy and of the disease allows proper selection and optimization of the imaging technique. This is essential in order to exploit the potential of cross-sectional Imaging, while decreasing -as far as possible -its invasiveness. Session Objectives: 1. To review anatomy and physiology of the paranasal sinuses. 2. To provide clues for prompt identification of acute complications. 3. To provide a checklist for CT interpretation in patients with chronic rhinosinusitis. 4. To highlight the role of interactive navigation of CT images for the identification of key anatomic landmarks. The basics: Techniques and functional anatomy H.B. Eggesbø; Oslo/ NO (h.b.eggesbo@medisin.uio.no) CT is the "gold standard" in imaging sinonasal disease. Low-dose CT (20 mAs) with limited scans outside the lens area is to be preferred for screening. CT offers excellent delineation of bony anatomy and extent of sinus disease and serves as a "road map" during functional endoscopic sinus surgery (FESS). MR imaging may be useful to differentiate soft tissue masses. Coronal T1 and T2 or STIR may be sufficient in "simple" sinusitis. If neoplasms or complications to sinusitis must be ruled out, additional imaging planes and intravenous Gadolinium are mandatory. By the age of 12 years the four-paired sinuses attain adult shape. Excessive aeration of surrounding bone is referred to as pneumatisation variants and the three most common are concha bullosa, infraorbital, and agger cells. If sphenoid sinus pneumatisation is retarded the posterior ethmoid cells may proceed superior or lateral to the sphenoid sinus and named sphenoethmoid or Onodi cells. The sinuses are lined with respiratory-type ciliated cells that beat in a specific direction and each sinus has its own specific mucociliary drainage route. Interruption of these routes causes mucus stagnation and sinusitis. The daily routine: Chronic rhinosinusitis and endoscopic surgery R. Hermans; Leuven/BE (Robert.Hermans@uz.kuleuven.ac.be)Chronic rhinosinusitis is a common medical problem. It is defined as rhinosinusal inflammation, with duration of more than 12 consecutive weeks. The etiology is multifactorial, including allergy, recurrent infection, predisposing sinonasal anatomical variants, mucociliary abnormalities, and others. Poliposis nasi is commonly seen in patients suffering chronic rhinosinusitis. Although histologically similar, antrochoanal polyps occur isolated and are not associated with chronic inflammation. Chronic rhinosinusitis often causes nasal obstruction, but also postnasal drip, nasal discharge, and pain, which are common symptoms. In a minority of patients, the presenting symptoms are because of atelectasis of the maxillary sinus, leading to enophtalmos and sometimes facial asymmetry ('silent sinus syndrome'). Highresolution CT is the modality for evaluation of chronic rhinosinusitis. The role of imaging is to show the extent of disease and the presence of anatomical variants, predisposing to chronic inflammation and/or surgical complications. Based on the obstruction of different drainage pathways, several patterns of disease distribution can be described. Posttreatment imaging is done when recurrent inflammatory disease is suspected. The CT study should include a description of the type of surgery performed, an assessment of the critical wall structures and anatomical variants unaffected by previous surgery, and an evaluation of the extent of persistent or recurrent inflammatory disease. Complications after endoscopic surgery are rare, but potentially severe and life-threatening. The most common complication is an osteo-meningeal breach in the roof of the naso-ethmoidal cavity, causing cerebrospinal fluid leakage. Imaging is indicated to search for the site of traumatic bony disruption and possible associated injuries. The infrequent ones: Aggressive inflammatory diseases R. Maroldi; Brescia/ IT (maroldi@med.unibs.it) "Aggressive" inflammatory diseases of the sinonasal cavities encompass lesions which tend to destroy the soft tissues lining the cavities, may involve the bony framework, and have the potential to spread into the surrounding spaces, as the orbit and the cranial cavity. Fungal infections in immunodeficient patients are associated with a high mortality. A very aggressive and rapid progression is frequently observed. The infections are characterized by ischemic necrosis of both soft and bony tissues, Liver CT and MRI have dramatically improved lesion detection in the liver. However, when sensitivity increases, specificity may decrease, with an increasingly reported number of lesions that are "too small to characterize". It has been said that any hypervascular tumour of the liver in a patient with chronic liver disease was hepatocellular carcinoma until proved unequivocally to be benign. Since, many authors have reported that some benign conditions were actually commonly discovered, even in patients with chronic liver disease. European and American guidelines have been published, all advising to refrain from invasive examinations or treatments in such patients, as long as the lesions measured less than 1 cm in diameter. Follow-up examination should rather be organized. In patients without any history of liver disease, CT and MRI examinations may incidentally find such lesions, giving the radiologists hesitation and patients anxiety, even if the most likely final diagnosis is a benign lesion. Because vascular abnormalities are responsible for many troublesome images detected on CT and MRI, a good understanding of the normal anatomy, physiology and variants is required. Because small benign tumours are very common in a patient with normal liver, careful analysis of lesion appearance provides some clues for the final diagnosis. Because hepatocellular carcinoma should be detected as early as possible, a standardized strategy should be implemented for patients with chronic liver disease. Finally, adapted communication should be found with the patient, in order to make him understand the medical strategy. The advent of multi-slice CT and dramatically reduced scan acquisition times have permitted radiologists the opportunity to visualize temporal perfusion phenomena in the liver. 'Cleaner' late arterial and portal venous phases have not only improved lesion characterisation but also demonstrated commonplace late arterial perfusion phenomena within the liver parenchyma. Brisker contrast administration and scan acquisition has highlighted the frequency of these phenomena. Optimisation of contrast delivery is important if late arterial and portal venous phase perfusion abnormalities are to be appreciated. This involves correctly timed late arterial phase triggering and the delivery of a 'tight' iodine load. The real benefit of brisker, optimised contrast delivery is a cleaner late arterial phase imaging without portal venous admixture. These aspects of optimised contrast delivery will be discussed. These perfusion phenomena exist because of the complex reciprocation of arterial and portal perfusion of subsegments of the liver. This presentation will look at the vascular inflow of the liver and how it is influenced by arterioportal communications at the portal triad (transsinusoidal), around tumours (transtumoural) and via potential peribiliary vascular channels (transplexal) and periportal vessels (transvasal). An understanding of these mechanisms and their clinical manifestations helps in the appreciation of evolving disease processes within the liver. Small hypervascular lesions in a cirrhotic liver: Who is the good, the bad or the ugly? F. Caseiro-Alves; Coimbra/PT (caseiroalves@gmail.com)Liver carcinogenesis is a stepwise multifactorial process where major players are cell differentiation, proliferation and angiogenesis. Currently the best way to assess the earlier stages of oncogenesis is to assess the neoangiogenetic process by means of dynamic imaging on US, CT or MRI. The imaging goal is to detect hypervascular liver nodules in the arterial dominant phase of liver enhancement, separating the portal fed benign regenerative nodules of the progressively arterially fed dysplastic and, further on, overt hepatocellular carcinoma. Clinical criteria for early HCC detection (< 2 cm) currently in use worldwide rely on imaging techniques in order to assess angiogenesis but one must recognize its relatively low sensitivity and specificity per se, since similar findings (and not tumors) may be caused by perfusion abnormalities, such as arterio-portal fistulas, third inflow tracts, flash-filling hemangiomas, etc. Furthermore, a significant proportion of small hypervascular liver foci are stable or even disappear on subsequent imaging studies. Thus, whenever possible, the diagnosis of small HCC foci must combine other signs of malignancy such as delayed hypodensity/intensity or washout, T2-w hyperintensity, delayed enhancing tumor capsule and interval growth.Iidentification of a simple hypervascular foci in a cirrhotic patient must be interpreted with caution, and it will possibly trigger the performance of other imaging techniques and/or a more frequent follow-up studies in order to assess interval growth.Learning Objectives: 1. To recognise the small hypervascular foci in cirrhotic liver. 2. To understand why hypervascularisation helps in the characterisation between regeneration nodules (the good), dysplastic nodules (the bad), and early HCC (the ugly). 3. To know that a significant proportion of these lesions are not HCC's and to understand some possible reasons. 4. To learn the medical/radiological decision, based on the application of the EASL criteria. Non-cirrhotic liver: The TDTU ("too difficult to understand") hypervascular lesions G. Brancatelli; Palermo/IT (gbranca@yahoo.com)Learning Objectives: 1. To understand how to elicit correctly diagnostic signs in the suprahyoid neck. 2. To appreciate the importance of the anatomical localisation of disease and in particular the contribution of understanding anatomical compartments to differential diagnosis. 3. To understand the strengths and weaknesses of characterising suprahyoid lesions on the basis of imaging signals and characteristics. 4. To understand the importance to surgical management of precise evaluation and staging by imaging.A-402 16:45The infrahyoid neck is an anatomical area between the oral cavity, the submandibular space and the entrance of the thoracic cage, which may serve as a highway, connecting different areas. It contains mainly longitudinal structures: muscles, blood vessels, nerves, esophagus and only a few horizontal structures e.g. the hyoid bone, the thyroid gland, the vocal cords. When examining this region at a digital workstation, it is important to use a rigid systematic analysis to avoid diagnostic failures: larynx -upper airways, hypopharynx -esophagus -blood vessels -lymph nodes -muscles -thyroid gland -spine -skin. Few clinical issues regarding the infrahyoid neck will involve this anatomic area only. For example esophageal cancer of the cervical esophagus needs to be staged before treatment planning, including the neck nodes, chest and upper abdomen. Extension of a deep parapharyngeal neck abscess beyond the hyoid bone may involve the infrahyoid neck before extending into the mediastinum. But a lateral neck cyst is usually in an infrahyoid location. The choice of imaging depends on clinical information: should we use US, CT, MRI, PET-CT or shall the patient immediately be transported to the radiology intervention department? The radiologist should be aware of the acute (trauma, haemorrhage, vascular occlusion), semi-acute (infection) or non-acute situation (staging cancer, analysis slowly growing mass lesion). Pathology differs between children and adults and to know the incidence of the most common diseases in the infrahyoid neck is extremely rewarding in daily practice. Individualised risk assessment and dosing of iodine contrast media U. Nyman; Trelleborg/SE (ulf.nyman@skane.se)Many organizations recommend equations based on serum-creatinine (SCr), anthropometric (weight/height) and/or demographic data (age/gender/ethnicity) to estimate GFR. Although only 80-90% of GFR-estimates are within ±30% of the measured GFR, they are better than using SCr alone. Glomerular filtration rate values may be directly related to contrast medium (CM) dose in gram-iodine; 10-120 gram-iodine are within the same numerical range as GFR (10-120 mL/min). The 'area under the plasma concentration-time curve' (AUC) is directly related to CM-dose/GFR. AUC is an estimate of systemic drug exposure and often well correlated with drug toxicity. Thus, gram-iodine/GFR ratio may be the best measure to predict the risk of contrast-induced nephropathy (CIN). Preliminary coronary angiography/angioplasty and CT data indicate that a 1:1 gram-iodine/GFR ratio may be a relatively safe upper limit to avoid CIN providing GFR is not < 30 mL/ min (severe azotemia) and/or multiple risk factors are present. CM-dose may be substantially reduced in many patients at risk of CIN by dosing per kg body weight, using a saline chaser, and specifically for CT-angiography and arterial phase tumour-scanning: 1) adapt injection duration to scan time, 2) use bolus tracking instead of test bolus, 3) reduce tube potential to 80 kVp (mAs-compensation for constant signal-to-noise ratio), and 4) decrease CM-dose with decreasing cardiac output. OmniVis (Scandinavian distribution by GE Healthcare) calculates GFR, gives the CM-volume/-concentration=gram-iodine dose numerically corresponding to GFR, and allow set up of CT-protocols based on body weight and constant injection duration (CT-angiography) resulting in a constant dose-rate in mg I/kg/ second in all patients.Learning Objectives: 1. To learn the different methods to estimate renal function (GFR).2. To understand how to adapt the gram-iodine dose to minimise the risk of contrast induced nephropathy. 3. To learn how to optimise the CT protocols to minimise the dose of contrast media. Gadolinium contrast media and nephrogenic systemic fibrosis G. Heinz-Peer; Vienna/AT (gertraud.heinz@meduniwien.ac.at)Unlike the known risk of contrast-induced nephropathy with iodinated contrast agents, early investigations did not find evidence for renal function deterioration after administration of gadolinium-based contrast agents (GBCAs). Radiologists believed that GBCAs were safe to deliver at any creatinine or estimated glomerular filtration (GFR) level. Because of the confidence in the apparent safety of GBCAs, preferably contrast-enhanced magnetic resonance imaging (MRI) studies were used in patients with renal dysfunction. Additionally, bold off-label applications were performed especially in MR angiography and myocardial viability studies. Nine years passed from the first observation of NSF in 1997 and the linkage of nephrogenic stystemic fibrosis (NSF) cases to recent GBCA administration in 2006. Since then, NSF has been surrounded by extensive publicity which has led to much information on this still not fully understood disease. Radiologists became aware of different physicochemical properties of the various GBCAs, which may play a causative role in the pathogenesis of NSF. The etiology of NSF is likely to be multifactorial. The most common factor identified in patients is the presence of some form of acute or chronic renal failure. The majority of such cases are associated with the administration of high doses of GBCAs. Alerted by an increased knowledge on possible deleterious effects, radiologists have become much more critical regarding the use of GBCAs. Mammography is the leading method for the diagnosis of ductal carcinoma in situ (DCIS). As mammographic signs are sometimes rather subtle, their detection requires optimal technique and skilled radiologists. Ductal carcinomas in situ very often exhibit microcalcifications, resulting from either tumoral necrosis (typically, comedocarcinoma) or active cellular secretion; DCIS can also appear as a mass, because of epithelial proliferation, periductal fibrosis and elastosis. Microcalcifications are very often isolated (47% in our series). Less frequently, they are associated with mass (39%). Isolated masses are uncommon (4%). Digital mammography, as it betters conspicuity of microcalcifications, notably improves detection of DCIS.Although mammography is very powerful in detecting early signs of DCIS, it is less effective in differential diagnosis with benign lesions. Fine, linear, branching (casting) calcifications (BI-RADS 5) have the highest positive predictive value (PPV) for malignancy; amorphous, pleomorphic, granular calcifications (BI-RADS 4) are of intermediate concern and needle core biopsy is always mandatory. Among masses, opacities with high density, irregular shape, spiculated margins have the highest PPV for malignancy, although DCIS usually exhibit low-density masses, elongated, with indistinct margins. The PPV increases when a mass is associated with microcalcifications. The distinction between DCIS and invasive carcinoma is very difficult as the signs are often similar and the two pathologies are frequently associated (e.g. microinvasive carcinoma; invasive carcinoma with extensive intraductal component); DCIS is more likely with occurrence of isolated microcalcifications without mass. Patients with ductal carcinoma in situ (DCIS) may develop invasive carcinoma in about 60% of the cases over a period of 10 years. Therefore, it is important to diagnose and evaluate cases of DCIS properly for better patient management. Whereas DCIS is not listed as an indication for breast MRI in the American College of Radiology Practice Guidelines, technology is rapidly improving and recent studies indicate an increasing role for MRI in specific settings. In contrast to invasive carcinoma, DCIS usually displays linear or ductal clumped enhancement and focal branching pattern on dynamic contrast-enhanced sequences and delayed, persistent (i.e. benign) dynamics. Therefore, morphology is more reliable than kinetics.Overlap with benign disease, e.g. fibrocystic changes, does exist. MRI was shown to be significantly more sensitive than mammography or ultrasound for the detection of DCIS. The wide range of sensitivities for detection of DCIS published in the literature is in part likely to reflect variations in interpretations, imaging parameters and selections bias. DCISs are a highly heterogeneous group of tumors. Preliminary data indicate that the enhancement patterns may partly also depend on the grading and a normal MRI scan may potentially allow exclusion of high-grade DCIS. The role of MRI in DCIS is currently not fully established. In the future, MRI may play an increasing role in assessing the extent of disease in the breast in women with known or suspected DCIS. Epilepsy is a common disorder with a prevalence of up to 1% in the general population. Epilepsies are classified into generalized and focal. Though most generalized 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 etiologic diagnosis. In this presentation, imaging findings of the most common lesions responsible for focal epilepsy, namely a.hippocampal sclerosis, b.malformations of cortical development, c.epilepsy-associated neoplasms, d.vascular abnormalities and e. gliosis, will be discussed along with their differential diagnosis and pertinent imaging pitfalls. As 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 increased signal resulting from 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. Cognitive decline is an important socio-economic problem in Europe nowadays. Neurodegenerative diseases and their associated changes in brain function and structure are the underlying pathology in many cases. These include Alzheimer´s disease (AD) and their preclinical stages (Mild Cognitive Impairment (MCI), and prodromal AD), Fronto-Temporal-Lobar Degeneration (FTLD), Vascular Dementia, Parkinson´s Disease Dementia, Lewy Body Dementia, and more rare diseases such as Huntington´s disease or Fragile-X-associated-Tremor Syndrome (FX-TAS). Neuroimaging features of all these neurodegenerative diseases have been described in groups of patients. Functional and morphological changes have also been described on brain imaging associated to healthy aging. Two main challenges still remain open for brain imaging in the field of cognitive decline: 1) Differentiating healthy from pathological aging; 2) Characterizing a single subject´s underlying pathological condition as precisely and as early as possible. Imaging findings in the brain of normal aging and the most frequent causes of cognitive decline will be presented. An emphasis will be placed upon recent advances in Neuroimaging methods that may help in the individual patient´s approach in the near future, such as Voxel-based Morphometry, Cortical thickness measurements, or Pattern recognition analysis. A-419 17:00The type of traumatic head injuries depends not only on the mode of injury but also on the age of the child as young children have anatomical and physiological particularities. Young infants have for example a relatively large head, weak neck muscles, thin compressible skull, large subarachnoid spaces, poor myelination, inadequate vasomotor reactivity and different regional metabolism activities. Primary injuries are direct consequences of the forces associated with the traumatic event.They include intra-axial lesions (cortical contusions, diffuse axonal injuries, brain hematomas) and extra-axial lesions (subarachnoid hemorrhage, subdural hematoma, epidural hematoma and intraventricular hemorrhage). Secondary injuries are considered as reactive brain processes. They include cytotoxic and vasogenic edema with possible malignant cerebral swelling, and cellular necrosis from hypoxia, possible associated seizures, arterial infarction and pressure necrosis. Diagnosis of infantile inflicted injury remains very challenging as most abused infants present with non-specific clinical findings. Craniocerebral involvement is not uncommon and has a worse outcome than in accidental injuries. Non-accidental injury is indeed the leading cause of traumatic death in infancy, of neurodevelopmental disabilities and permanent neurological deficits. Cranial lesions in non-accidental injury are produced by violent shaking without impact (shaken-baby syndrome) or with impact (shaking-impact syndrome) generating high translational but also rotational forces that accompany rapid acceleration-deceleration movements. MRI is required to detect non-hemorrhagic intraparenchymal involvement. Several studies have proved the sensitivity and the prognostic value of early diffusion-weighted (DW) imaging in non-accidental brain injury. The purpose of this study was to familiarize the technician with: a) the most important diagnostic features in order to adequately prepare the procedure and support the radiologist during the procedure, b) the most widely performed image-guided interventional procedures, c) the most important devices and medicaments. As precedures become more standardized and more complex, the technician should familiarize himself with the topics in order to actively support the radiologist. Spine interventions are performed under CT or X ray fluoroscopy. The role of the technician is to adecuately prepare the interventional set and to provide excellent images in order to follow the procedure. The importance of lowering the doses has to be emphasized to the patient and to the operator. Ultrasound has widely replaced X-ray fluoroscopy in interventional procedures on articulations, muscles and tendons. This has changed the procedure from a two-hand to a three-to four-hand procedure! The importance of adequate image documentation of the procedure is mandatory in order to provide proper information to the referred clinician and to the patient, and for didactic and forensic reasons. The role of the technician is either to hold the probe or to store the best images while choosing the most significant picture of the loop. Image-guided interventions in pain are a growing field of musculoskeletal imaging. Because of increasing complexity of the procedures, a more active role for the technician required. Background: Diffusion MRI measures the molecular mobility of water in tissue and has become a useful tool in daily clinical MR-examinations of the brain. Almost all modern MR scanners have the capability to perform diffusion scans and many sites have a mandatory diffusion sequence in all brain protocols. Different methods are used in MRI diffusion measurements of the brain and it is important to know how different techniques are used clinically today and may continue to be used perhaps in the future. It is also of great importance to outline the advantages and limits of the technique. Procedure and Imaging Findings: MR diffusion is an important tool for correct diagnosis in many diseases especially acute stroke, bacterial abscesses and some tumors and it is important to have knowledge about different kinds of calculated diffusion images. Many abbreviations are being used in diffusion MRI and most of these will be explained and presented along with clinical examples. Conclusion: MRI diffusion of the brain is a technique frequently used today. It is important for the radiographer to become more familiar with the underlying theory, pitfalls and artifacts. The role of the Radiographer, in relation to professional competencies, is in continuous growth and evolution. In this presentation will be demonstrated a particular background, where the Radiographer, with experience gained in cardiac-CT unit in Southern Switzerland, based on 1,200 examinations per year, assumes a central role in management. Not only the Radiologist represents an important reference for the Cardiologist on the level of post-processing and diagnostic valuation. Overcoming the patients' fears, managing stress, adapting the protocol to the physiological parameters of the patient, considering the impact of dose to the patient in relation to the clinical question, assessing/evaluating the quality of the results, preparing the images for valuation by the Cardiologist in the post-processing site, cooperating with the Cardiologist in the evaluation and diagnosis, growing within the team: These are the challenges with which a Radiographer is daily confronted in our environment.Learning Objectives: 1. To learn about different protocols and procedures. 2. To understand the role of the radiographer/radiological technologist before, during and after the procedure. 3. To appreciate the importance of obtaining excellent quality images, the importance of involving the patient in the procedure, importance of radiation protection. 4. To become familiar with material, method and procedure. 5. To consolidate knowledge of correct application of protocols in cardiac-CT and available material. D. CT/MRI post processing B. Merlino; Rome/ IT (bmerlino@rm.unicatt.it) In the last two decades, CT and MR have been more and more evolving as volume techniques and, correspondingly, the need of tools that are able to process large image sets for rearranging voxel data on planes different from those of acquisition has been increasing. Several post-processing techniques have been introduced and proved their efficacy in extracting more information from the acquired data and a new class of diagnostic examinations have been made possible (e.i. CT and MR angiography, colonography). Similarly, the roles of radiologists and radiographers have been rapidly changing. as a result of modification of the instruments used in their routine work. Especially, radiographers are moving from the acquisition of the imaging data on the scanners to a more evolutionary concept, in which they are responsible of the production of exams inclusive of originally acquired and post-processed images according to standard protocols and quality assessment. The present lecture is first focused on the description of the main post-processing techniques (MultiPlanar Reformatting, Maximum and Minimum Intensity Projection, Volume Rendering Techniques), with special emphasis on the needs for radiographers in terms of basic principles, correctness criteria, advantages and disadvantages. As a second point, particular attention is paid to the use of those techiques within and just after the procedures, as a major involvement step from radiographers, which implies knowledge of the principles and protocols of post-processing in relation to anatomical or clinical issuer, for both CT and MR. Finally, the role of radiographers for digital documentation and storage tasks is discussed. Background: PET/CT is the most widely used technique for clinical molecular imaging and allows for true clinically metabolic imaging. PET and its combination with CT has revolutionized onclologic imaging. The most widely used tracer is 18 Ffluoro-deoxy-D-glucose (FDG), accounting for more than 90% of all PET studies. Newer PET radiotracers allow imaging of a whole variety of pathways, targets and functions and are already explored in clinical trials. Details: The combination of PET with CT delivers combined structural and functional information. For many clinical questions, this combination gives more accurate results than either modality alone. Localization of abnormal tracer activity is easier and abnormal structural elements can be assessed more accurately. However, the combination can also result in some pitfalls that the clinical user has to be aware of. FDG PET/CT studies have an established impact on staging, follow-up and therapy monitoring, e.g. in lymphomas, lung cancers, cervical carcinoma, breast cancer, head-and-neck cancers, and GI tumors. Novel tracers will further broaden our capability to image biological processes and will add additional information. FLT can visualize cell proliferation. Methionine has been shown to be superior to FDG in imaging brain tumors; FDHT has been used to image androgen receptors in prostate cancer. Many labeled antibodies have been explored and even marker genes for gene expression are under clinical evaluation to be applied e.g. in celltracking studies. Conclusion: PET/CT has already changed oncologic imaging and future tracers and combinations will broaden even further its significant impact. DE (bernd.pichler@med.uni-tuebingen.de) With the introduction of combined positron emission tomography (PET) and computed tomography (CT), hybrid imaging also entered the clinic as a diagnostic tool. The combination of functional and high-resolution morphological data with a high spatial fusion accuracy improved in oncologic applications, the diagnostic specificity and sensitivity for many tumor entities. However, PET/CT bears limitations: CT adds a significant radiation dose, which might be a limiting factor for follow-up studies, the soft-tissue contrast provided by CT is very limited and finally, technical hurdles prevent a simultaneous PET and CT data acquisition. The sequential imaging, first the CT and then PET data, restricts the correction of motion artefacts caused by breathing, cardiac or patient motion. Thus, PET/CT data are often not perfectly matched. Furthermore, sequential imaging does not allow accurate temporal correlation of the data. These limitations initiated research projects which concentrate on the development of combined PET and magnetic resonance imaging (MRI). While the technical realization of PET/CT is quite straight-forward by hard-wiring the two scanners back-to-back and using a common patient bed and acquisition software platform, the combination of PET and MRI is technically more challenging. The standard PET detector technology, which is based on photomultiplier tubes (PMTs) can not be used in magnetic fields. Also, MRI bores are very limited in space, requiring compact PET detectors. However, several groups have recently shown that the full integration of PET detectors into a MRI scanner is feasible. This allows a simultaneous acquisition of multi-functional PET and MRI data along with morphology. Optical imaging is unequivocally the most versatile and widely used visualization modality in clinical practice and life sciences research. In recent years, advances in photonic technologies and image formation methods have received particular attention in biological research and the drug discovery process for non-invasively revealing information on the molecular basis of disease and treatment. An increasing availability of endogenous reporters such as fluorescent proteins and probes with physiological and molecular specificity enable insights to cellular and sub-cellular processes through the entire range of small animals, embryos, fish and insects and have revolutionized the role of imaging on the laboratory bench, well beyond the capability of conventional microscopy. This talk describes current progress with instruments and methods for in-vivo photonic tomography of whole intact animals and model biological organisms. We show how new tomographic concepts are necessary for accurate and quantitative molecular investigations in tissues and why it could be potentially a valuable tool for accelerated investigations of therapeutic efficacy and outcome. We further demonstrate that cellular function and bio-chemical changes can be detected in-vivo, through intact tissues at high sensitivity and molecular specificity. Examples of imaging enzyme up-regulation, carcinogenesis and gene-expression are given. The potential for clinical translation is further outlined. Limitations of the method and future directions are also discussed. In other systems of the human body, the identification of cysts, usually fluid-filled, may be a chance finding of little clinical importance, e.g. incidental 'simple' renal cysts on a staging CT for lung cancer. By contrast, cystic air spaces in the lungs demand an explanation because they almost invariably denote significant disease. An exception to this rule, recently described, is the high prevalence of scattered small cystic air spaces in elderly individuals (they are found in over half of the elderly population aged over 75 years). Apart from centrilobular emphysema, in which thin-walled cystic air spaces are occasionally prominent, diffuse lung diseases characterised by cysts are relatively rare. These diseases can be considered as belonging to either a) conditions with a recognisable distribution and/or ancillary features (e.g. Langerhans cell histiocytosis, or LIP with amyloid) in which the CT appearances may be diagnostic or b) conditions with no characteristic features on CT in which lung biopsy is mandatory for diagnosis; such diseases tend to be very rare (e.g. cystic mesenchymomas, Birt-Hogg-Dubé syndrome). The pathogenesis of cystic airspaces in the lung is usually disease-specific; for example, post-staphylococcal infection pneumatoceles are the consequence of tissue lysis. The process (es) responsible for more numerous and diffuse cystic air spaces is less well understood: A 'check valve' mechanism is commonly cited in the literature; but this probably only applies to a few conditions. Learning Objectives: 1. To become familiar with a basic classification of cystic lung diseases. 2. To understand the pathogenesis of cystic air spaces in the lungs. 3 . To learn about the spectrum of diseases characterised by pulmonary cysts. 4. To appreciate ancillary signs on HRCT that may refine the differential diagnosis. There have been increasing numbers of underdiagnosed emergent pulmonary infections in immunocompetent adults. Necrotizing pneumoccocal pneumonia, community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infections, non-tuberculous mycobacterial infections and community-acquired respiratory viral infections are emerging pathologies that can cause severe infections in healthy individuals. Combination of pattern recognition with knowledge of the clinical setting is the best diagnostic approach to pulmonary infectious processes. When pulmonary infection is suspected, knowledge of the varied radiographic manifestations will narrow the differential diagnosis. resulting from recent contact with the pathogen. Post-primary TB pattern results from reactivation of a dormant focus within the lungs. Thoracic tuberculosis produces a broad spectrum of radiographic abnormalities. The radiological patterns had been described as parenchymal, airway, vascular, mediastinal, pleural, and chest wall lesions. Common causes of a missed diagnosis of thoracic tuberculosis are failure to recognize hilar and mediastinal lymphadenopathy as a manifestation of primary disease in adults, overlooking of minimal productive lesions or reporting them as inactive, failure to recognize that an upper-lobe or superior segment of lower lobe mass might be tuberculosis. In AIDS patients, the imaging features depend on the degree of immunosuppression. A pattern of post-primary TB is also usually seen among patients with decreased immunity caused by alcoholism, renal failure, diabetes mellitus, ageing, malignancy, and transplantation to organs -renal as also cardiac. Percutaneous abscess drainage is the standard of care in pelvic abscesses in the absence of indications for immediate surgery. For most patients, percutaneous abscess drainage offers a safe surgical alternative or a temporizing measure for the surgery, with a subsequent surgical option depending on the nature and extent of underlying disease. A variety of disorders can produce fluid collections in the lower abdomen and pelvis and the differential diagnosis is often based on imaging findings. Pelvic fluid collections can be drained in several ways, with the success and safety of percutaneous therapy depending on safe access route planning. Deep pelvic abscesses may present a unique challenge for percutaneous drainage. Although the transabdominal approach is the simplest, it may not always be feasible because of interposed structures that include the pelvic bones, intestine, bladder, iliac vessels, and gynecologic organs. Use of the transgluteal, perineal or endovaginal approach to drain these abscesses can circumvent these obstacles and provide a useful surgical alternative or a temporizing measure. These alternative routes of access to the pelvies require a thorough understanding of the anatomy of the perineum, the cul-de-sac and the sciatic foramen region. The results of percutaneous drainage and the follow-up strategies will be reviewed in this workshop. Ultrasound-guided interventional techniques play an increasingly significant role in the management of breast disease. Common indications are diverse and include: Biopsy of solid masses or microcalcifications, symptomatic cyst drainage, lymphnode staging in patients with breast cancer, tumour mapping with preoperative radiotracer injection or hookwires and mapping with metallic markers in patients undergoing neoadjuvant chemotherapy, as well as breast abscess drainage. Less frequent indications are: ablation of benign lesions with vacuum biopsy devices, cryoablation of fibroadenomas and radiofrequency ablation of small breast cancers. Techical aspects of ultrasound (US) interventional procedures should take into account circumstances related to the patient (patient positioning an preparation), state-of-the-art US hardware and software, all the different types of biopsy devices available and the insertion technique. The appropiate choice of the biopsy needle to be used (FNAB, automated core biopsy, vacuum-assisted biopsy) is one of the most important aspects of US interventional procedures for the breast, because the needle conditions to a great extent the correct sampling of the lesion. Potential pitfalls to be considered are: false negative results because of technical failure, or failure to choose the right type of needle, failure to recognize a radiologicalpathological discordance, and lack of imaging follow-up. Also to be taken into account are the lesions that should not be biopsied and should undergo surgical biopsy (radial scar, complex cysts) and the management of complications (bleeding, pseudoaneurysm formation). In summary, interventional US is a continuously expanding field that successfully avoids more invasive surgical procedures with a high level of accuracy. For the mammographic guidanc the stereotactic guidance, the guidance by the use of an alphanumeric fenestrated paddle and the free-hand localisation are available. Stereotactic guidance is the most accurate technique for the biopsy of breast lesions. Preoperative localisation of lesions can be done stereotactically by the use of an alphanumeric fenestrated paddle or by the free hand method. Stereotactic guidance uses off-angled views for computer-assisted targeting of mammographically visible lesions. It can be done in prone position on dedicated tables or in upright position on the mammography system itself. Although both approaches proved their value in practice, prone tables have more advantages. The indications for stereotactically guided biopsy are ACR 4 and 5 lesions as well as some ACR 3 lesions, for which biopsy under ultrasound guidance is not possible. The most frequent indication is a cluster of microcalcifications. Before starting the biopsy, it is important to select the appropriate needle. Fine needle aspiration cytology and core biopsy can be performed via stereotactic guidance, but the use of a vacuum-assisted procedure is advised because of its higher accuracy in the diagnosis of breast lesions and especially of microcalcifications. The execution of an accurate procedure requires different technical and medical specifications, such as a correct mammographical documentation and an experienced medical and technical staff. Contrast-enhanced magnetic resonance imaging (MRI) has proved to be more sensitive for the detection of breast lesions compared with mammography and/ or ultrasound. However, one of the continuing challenges of breast MRI is the differentiation between benign and malignant lesions. This combination of a high sensitivity in combination with only a moderate specificity focusses on lesions that are occult on other modalities and cannot be classified as benign based on morphology and enhancement dynamics. For these lesions, MRI-guided interventions are unavoidable. The indication to perform an interventional procedure on MRI should be based on the aspect and size of the lesion, the primary MRI indication and the personal and family history of the patient. Any radiologist who performs breast MRI must be familiar with the possibilities and limitations of MRI-guided breast interventions and be able to facilitate them in his own or a related radiology department. MRI-guided interventional procedures can be performed either by a free-hand technique or with the use of a stereotactic needle-guidance system. The stereotactic needle-guidance almost ensures an accurate needle placement at the first attempt. However, the biopsy system cannot correct for tissue movement during the procedure. Another limitation is that lesions can be out of reach for some devices, this applies especially for lesions near the chest wall or the axilla. Although MRI-guided interventional procedures are accurate, it is important to discuss the results with the pathologist to check whether the findings are explanatory for the enhancement found on the MRI. As a result of the exciting technical advances made over the last several years, CT imaging of the heart has gained more and more importance. The possibility to provide angiography-like images of the coronary arteries, as well as functional and morphological information about the heart non-invasively, has resulted in a continuing increase of accepted and established indications for cardiac imaging with CT, including the imaging after coronary bypass graft placement. Indication for imaging after bypass graft surgery is recurrent or persistent angina, a positive stress testing, or follow-up to detect early bypass graft complications. All different types of bypass grafts can be visualized with CTA, including arterial in situ grafts, free arterial grafts, and aorto-coronary (venous) bypass grafts. Bypass stenosis or occlusion can be delineated with a high diagnostic accuracy. To ensure the complete delineation of all bypass grafts, including arterial in situ grafts, enlargement of the scanning field is recommended in all patients after bypass graft placement. Thus, the subclavian arteries should be included in the scan to demonstrate the branching of the internal mammarian arteries and to visualize potentially relevant stenoses of the subclavian artery that could cause the coronary steal syndrome. Within this presentation, an overview over the different types of coronary artery bypass grafts will be provided, together with examples of their typical appearance at CTA. Furthermore, imaging protocols, as well as tips and tricks for bypass graft imaging, will be presented. Finally, typical findings and pathologies after bypass graft surgery will be discussed based on clinical examples. Considering the high number of percutaneous coronary interventions that involve stent implantation, the development of relatively inexpensive and non-invasive methods for assessing stent patency is an issue of growing interest. Computed tomography angiography is a non-invasive diagnostic tool to visualise coronary arteries. The evaluation of stents is, however, hampered by the occurrence of high-density artefacts ('blooming effect') caused by the stent struts. These artefacts cause an apparent enlargement of the stent and preclude appropriate assessment of the in-stent lumen. In particular, the lumen of small stents, overlapping stents and bifurcation stents is difficult to assess. The type of metal also plays a role. The presence of motion artefacts in the dataset, or image noise in very large patients, may further hinder the evaluation of stents. Stent diameter is an important predictor of in-stent lumen visibility, therefore it should be considered as a criterion to select patients before referral to computed tomography angiography. In stents with diameter < 3 mm, computed tomography may not be a good gate-keeper before conventional angiography. In patients with stents ≥3 mm, the metal-related high-density artefacts can be compensated for by proper patient preparation (e.g., accurate heart rate control by use of beta-blockers), optimization of the scan parameters and contrast injection rate (e.g., in obese patients), and use of dedicated post-processing (e.g., sharp convolution kernels). Learning Objectives:1. To learn about the need for non-invasive imaging of coronary stents. 2. To appreciate the current clinical role and diagnostic performance of CT for coronary stent imaging. 3. To recognise the problems and possible solutions of stent imaging with CT. Aortic valve repair has been introduced more than 45 years ago. Nowadays aortic valve surgery represents the second most frequent group of procedures in cardiac surgery. These include the treatment of aortic stenosis and less frequently aortic insufficiency. Multiple techniques have been described for aortic valve repair, with aortic valve replacement being the most commonly performed procedure. This procedure may be combined with the repair of ascending aortic aneurysms, using composite aortic valve graft. Only recently transfemoral and transapical procedures became available for aortic valve replacement. Because of the steadily increasing age of the patients undergoing aortic surgery and the increasing frequency of comorbid conditions, there is an increasing need for post-operative imaging. While transesophageal and transthoracic echocardiography are most commonly used for assessing the post-operative aortic root, MSCT with sub-second gantry rotation time with or without ECG-synchronization provides valuable information in the postoperative assessment of the aortic root, particularly in complex procedures or if the aorta is involved. With the increasing number of aortic valve procedures there also are more and more postoperative patients undergoing CT for other reasons. Consequently, there is a strong need for radiologists to know about the most prevalent normal and abnormal findings of the post-operative aortic root. Bone metastases represent an everyday challenge for the radiologists: How can we optimise their detection? How can we increase our confidence in making a specific diagnosis? What should we observe during treatment? Can we contribute to a better management of patients with bones metastases? This course will provide an overview of available screening algorithms for bone metastases detection with emphasis on recent MRI protocols and whole-body imaging strategies. Typical and unusual MR and CT patterns will be reviewed with illustration of commonly misdiagnosed lesions. The role of the different imaging modalities (Bone scan [BS], CT, MRI) in the assessment of treatment response remains limited and unclear. Changes in lesion dimension and lesion signal intensity have to be emphasized and we will illustrate the potential role of 'morphologic' imaging techniques, especially MRI, which can display treatment-related changes in bone metastases in a significant proportion of patients. We will also indicate signs of progressive disease. The potential value of more recent quantification tools such as dynamic contrast-enhanced (DCE) MRI and diffusion-weighted imaging (DWI) will be discussed, in comparison with the role of 'metabolic' imaging modalities, especially of PET-scan. Finally, we will describe the fundamentals of the available techniques used in oncologic patients with symptomatic bone lesions, to identify valuable indications and recognized complications. The AGA defines occult bleeding as initial presentation of iron-deficiency anemia (IDA) and/or positive fecal occult blood testing (FOBT) with no visible blood in feces, while obscure bleeding is defined as recurrent or persistent IDA, positive FOBT, or visible bleeding with no bleeding source found at original endoscopy. ‚Obscure' therefore indicates that the cause of the bleeding has not been determined after initial colonoscopy and upper endoscopy. Frequently the bleeding stops without treatment. Further workup is required when persistent bleeding necessitates transfusions. A bleeding source in the small bowel is the most common cause for obscure anemia. Potential pathologies responsible for occult small bowel bleeding may be vascular (e.g. angiodyplasia), inflammatory ulceration or erosion as in Crohn's disease, neoplastic, Meckel's diverticula, or radiation-induced, or celiac sprue. Enteroclysis is accurate in detecting small bowel tumors or Crohn's disease but is of limited use in diagnosing vascular ectasia. Newer concepts combining enteroclysis with CT or MRI are researched in the context of obscure anemia, but no general agreement on its usefulness has been achieved. Invasive angiography is rarely indicated because the bleeding rate is usually below the required threshold. Endoscopic techniques used to evaluate the small bowel include capsule endoscopy, push enteroscopy and intraoperative enteroscopy. Capsule endoscopy is considered gold standard by many gastroenterologists for obscure anemia and has been shown to be cost-effective in several studies. Even after thorough testing, the bleeding source may not be identified in a significant number of patients, who then have to undergo empirical treatment. Interventional radiology techniques are commonly used for the control of acute bleeding from the gastroduodenal tract. The techniques differ according to the site of bleeding (upper GI vs lower GI) and according to the type of bleeding vessel (arteries or veins in case of portal hypertension). Angiography and embolization are used after the failure of endoscopy either to control bleeding and/or to localize the site of bleeding. Angiography is used when an embolization is no longer used as a diagnostic tool, and it replaces an endoscopic technique including capsule endoscopy or computed tomography. Embolization techniques are different in the gastroduodenal territory where aggressive embolization can be achieved with a low rate of complication than in the lower GI where attention must be paid to ischemia. Distal embolization with microcoils are recommended in the colorectal territory. In case of cirrhosis, interventional radiology techniques have a different aim. Since portal hypertension is the first cause, transjugular porto-systemic shunt or variceal embolization can be discussed. The severity of cirrhosis, as well as the severity of portal hypertension, must be taken into consideration. In this session, basic extra-spinal interventional procedures are defined as rapid procedures that use a needle for aspiration, injection of fluids, or biopsy. The procedures are commonly guided with the use of different imaging modalities. Both fluoroscopy and ultrasound are cheap and the needle can be visualized in real-time. CT-guidance is more expensive and might be more time consuming than fluoroscopy, but gives more information of the trajectory and the nature of the target. Today, CT-guidance could be facilitated with the use of needle tandem technique, plastic grids, external and internal needle holders and CT-fluoroscopy. US-and MR-guidance will not be covered in this presentation. The most common basic procedures are injections of corticosteroids or contrast agents (arthrograms) into joints. Different techniques and approaches will be described. Less common are treatment of calcifying tendinitis, tenographies and therapeutic nerve injections to the pelvic and suprascapular region. Indications and approaches for musculoskeletal biopsy, different biopsy needles and techniques will be shown. A biopsy obtained from the soft part or the area with the most aggressive appearances is often favourable. Important for a successful biopsy is the specimen handling. The understanding of the clinician's request and knowledge of what the pathologist has to do with the specimen facilitate the decision whether the specimen should be sent fresh, in formalin or frozen. Most diagnostics can today be performed on formalin-fixed material; however, the increased demand for banking of specimens and some specific analyses favour fresh and/or frozen material. Few options are available for pain relief in patients with bone metastases, who fail standard treatments such as percutaneous cementoplasty and RF ablation (RFA). Percutaneous cementoplasty can provide immediate pain relief and can restore mechanical stability for patients with pelvic bone metastases (often extending to the weight-bearing part of the acetabulum). Improvement in pain and walking ability is demonstrated within the first 48 h of treatment in 80% of the cases. Osteolytic bone metastases may be also treated with image-guided RFA using a multi-tip needle. For bulky tumors extending to extraosseous regions, percutaneous RFA therapy combined with cementoplasty or percutaneous image-guided cryoablation may be effective. Adverse events include skin burns, transient bowel and bladder incontinence, fracture of the acetabulum or femur and hematoma.The CT-guided RFA of osteoid osteoma has the advantage of exact localization of the nidus intraoperatively and exact documentation of its ablation with poor invasive approach. After needle biopsy, percutaneous RFA is performed with general or spinal anesthesia. RFA is applied for a period of 4-12-min with the use of a rigid, non-cooled or cooled RF electrode with 1-mm diameter size. For procedures performed as the initial treatment, the success rate is 79-97%. For recurrent lesions, the success rate is lower. Local complications may be cellulitis and sympathetic dystrophy. MR imaging demonstrates subsequent changes of treated areas partially correlated with the clinical outcome. Multi-tined expandable RF electrode system is more dedicated to larger chondroblastomas. Because of their epiphyseal locations, complications are cartilage-and bone damages, particularly in the weight-bearing joints. Ultrasound (US) is an excellent modality for guiding interventional procedures in the musculoskeletal system. This lecture will discuss the indications, the rationale and the techniques used to carry out the most commonly performed interventional procedures guided by US in the musculoskeletal system. Among the technical points, we will make a focus on target identification, puncture point location and tricks of the trade for aspiration and injection. Then, common US-guided procedures including arthrocentesis and drainage of soft-tissue collections, steroid injection in joint cavities, para-articular bursae and tendon sheaths, tumor biopsies, removal of foreign bodies, dry needling and autologous blood injection in tendinopathies, regional anesthesia and percutaneous treatment of calcifying tendinitis and painful neuromas will be discussed with regard to individual sites of the upper and the lower extremity. With appropriate preparation and attention to sterility, US-guided procedures have a relatively low complication profile. Imaging tests should be used according to the patient's clinical condition associated with jaundice. Indeed to a large extent the diagnostic approach depends on the pre-imaging probability that jaundice is obstructive rather than non-obstructive, the cause is benign rather than malignant. Additional considerations should include the therapeutic options available (high level of expertise in endoscopy and hepatobiliary surgery). Finally the availability of each possible modality has also to be considered. In this interactive session, these different clinical scenarios will be presented and corresponding appropriateness criteria of US, CT, MRI and ERCP will be discussed. Detecting pathology of the inner ear requires a robust MRI protocol for the examination of sensorineural hearing loss. A state-of-the-art MRI protocol should include -apart from a total brain study-a 3D submillimeter heavily T2-weighted sequence together with a thin slice T1-weighted sequence after gadolinium administration. Isotropic voxels are to be preferred. One should be able to discern all details of normal inner ear anatomy on both sequences. Pathology of the inner ear can be subdivided in enhancing pathology and non-enhancing -most frequently congenital-pathology. The largest subgroup of enhancing pathology is formed by the intralabyrinthine schwannomas. Most intralabyrinthine schwannomas start in the scala tympanic of the basal turn of the cochlea and gradually fill up the entire membranous labyrinth. Major differential diagnosis should be done with labyrinthitis in which enhancement is more diffuse without abnormalities on the heavily T2weighted sequence in the acute phase. There are various other more rare causes of labyrinthine enhancement such as amongst others otosclerosis and metastatic disease. Most frequently encountered congenital abnormalities are cochlear malformations such as the Mondini malformation and the enlarged vestibular aqueduct.In the workup of cochlear implantation other congenital malformations such as the aplasia or hypoplasia of the cochlear nerve should be excluded. Portal hypertension (PH) is an end result of many diseases in which whatever the cause portal pressure irreversibly and continuously increases. From the practical point of view, it is classified into three groups as prehepatic (infrahepatic), intrahepatic and post hepatic (suprahepatic). Intrahepatic group still could be subdivided in three; presinusoidal, sinusoidal and post sinusoidal. Today radiologists are playing major role not only in the diagnosis of PH but also in the palliation and/treatment of PH. Modern noninvasive procedures such as colour Doppler ultrasound, CT and MRI are giving detailed information about portal system and have almost replaced the old, mostly invasive procedures such as spleno or arterial portography. On the other hand TIPS is an important procedure as an alternative to surgical shunt operations and mostly now is used as a bridge to hepatic transplantation for the radical treatment of PH. Today effective treatment of PH secondary to arterio-portal fistulas is done in angio suits by interventional radiologists using various embolization techniques with absolutely no need for anymore surgery. In this Special Focus Session three experts, Professors Akata, Menu and Bilbao will share their experience and discuss some problems with the audience in the current diagnosis and treatment of PH. Intra and supra hepatic diseases explain the majority of cases of portal hypertension (PH). Both share the same pathophysiology. For different reasons (endoluminal obstruction of small or large hepatic veins vs centrolobular vein compression), both tend to obstruct hepatic outflow and therefore increase sinusoidal pressure. The consequences on imaging are arterialization, development of portocaval collaterals and reversed portal flow. These are the major signs for PH detection. The aetiology is usually obvious considering clinical background. In some cases, this may be challenging. The main initial question is about the patency of hepatic veins, in order to detect Budd-Chiari syndrome, which may require a specific emergency treatment. US is the modality of choice, and MRI might be useful, while CT is not recommended. Evaluation of portal flow with imaging have been slightly disappointing. Although measurements, especially using US, are reliable and reproducible, there is a major overlap between individuals, not allowing a useful evaluation of disease severity for the practionner. Considering staging and treatment options, imaging is part of the decision. The major portocaval collaterals have different potential risks. Some are at high risk for bleeding like gastro-esopahageal varices and indirect splenorenal collaterals, and others for encephalopathy like direct spleno renal collaterals. Considering anatomical and clinical risks, some patients might be selected for a specific treatment under imaging guidance. Prehepatic causes: CT or MRI? D. Akata; Ankara/TR (fdakata@hotmail.com) Prehepatic (extrahepatic) portal hypertension may be caused by portal vein occlusion or thrombosis. In neonatal patients portal vein occlusion is almost always related to infection, usually omphalitis or a complicated umbilical vein catheterization. In adults, the cause of portal vein occlusion varies, but is mostly caused by inflammatory visceral organ disease such as ulcerative colitis, pancreatitis, appendicitis. Pancreas cancer, trauma, blood dyscrasias, and oral contraceptive use also obstruct portal vein. Therefore, pretherapeutic evaluation using imaging is mandatory to detect the level of narrowing or occlusion, to demonstrate the collateral pathways or shunts, and also to understand the cause of portal hypertension. Improvements in noninvasive imaging have significantly increased their efficiency in delineating the extrahepatic portal hypertension and its cause. Although color flow Doppler sonography is the primary examination, CT and MR portography too are widely used. The choice of the modality depends on the clinical status and on the availability. Detailed abdominal CT or MR exam should also be performed. Learning Objectives:1. To recognise the normal anatomy, variants and congenital anomalies of the portal venous system. A comparative study, performed in 1997, between TIPS and H-graft portocaval shunts showed that both presented similar clinical results; however, the initial lower cost of TIPS was offset by higher rates of subsequent occlusion and rehemorrhage. More recent studies (prevention of recurrent bleeding) that compare TIPS and distal splenorenal shunts demonstrate equal results according survival. However, the rate of encephalopathy and rebleeding was higher in the TIPS group. The most probable reason for these unfovarable results for TIPS is that many percutaneous shunts were performed with non-covered prostheses. PTFE-covered prostheses offer excellent results with minimal rates of restenosis.There is a controversy, once TIPS has been performed, regarding the need to embolize a collateral-varicose vein.In general, after an effective decrease in the portosistemic gradient, the possibility of rebleeding is very low and there should be no need to occlude the bleding vessel. Some authors have demonstrated that, in patients with TIPS restenosis, the possibility of rebleeding is lower if collaterals were effectively embolized during the initial procedure. Several reports, however, demonstrate that associated venous embolization should be performed in cases with portal hypertension and bleeding from varices localized in colostomies. Many Japanesse reports have presented the use of direct transvenous embolization of gastric varices by using a transcaval approach (BRTO). These authors conclude that after an effective embolization of the bleeding varicose vein there is no need to perform a portocaval shunt. Brain arteriovenous malformations (bAVMs) are the most common cerebrovascular malformations. They consist in different numbers and types of abnormal arteriovenous shunts, resulting from congenital errors of the vasculature development that are modelled by local hemodynamic and angiogenic factors. Brain hemorrhage is the most severe clinical presentation of bAVMs. Other common presentations include neurological deficits, seizures and headaches. It is widely accepted that ruptured bAVMs have a higher risk of rebleeding. Other risks for bleeding include increasing patient age, deep location, deep venous drainage, larger bAVMs size, venous stenosis and associated aneurysms. The bAVMs treatment is multidisciplinary and includes three different treatment options, namely neurosurgery, radiosurgery and endovascular treatment, that may be used alone or in different combinations to achieve the cure of bAVMs. The choice of the treatment strategy is individual based on clinical features and on bAVM angioarchitecture, but also depending on the local expertise in the different treatment modalities. It is accepted that small-sized and superficial bAVMs can be treated by surgery, but endovascular treatment can also be helpful, especially in lesions located on eloquent areas and with special angioarchitecture features. Small-sized and deeply located bAVMs may be treated by radiosurgery or by endovascular treatment. Medium-size bAVMs can be treated by initial endovascular treatment aiming size reduction, followed by surgery or radiosurgery. Large-size bAVMs are extremely difficult to cure and the indication for treatment is debatable. Post-treatment imaging follow-up is useful for early depiction of treatment complications, like venous thrombosis, oedema, hemorrhage and radiation effects. Neurovascular stenting can be simply reviewed in two parts: for revascularization in ischemia and for artery reconstruction in endovascular cerebral aneurysm treatment. The first part of this presentation provides basic techniques, indications and rationale for stent assisted revascularization in extracranial and intracranial vessels discussing the results of current clinical trials and tricks to minimize the risks of the procedure. The second part will summarize the basics and different indications of neurovascular stenting in endovascular cerebral aneurysm treatment.The use of stents deployed across the aneurysm neck in the parent artery for the reconstruc-tive endovascular treatment of challenging aneurysms created an important impact combined with various intrasaccular occlusion materials such as metallic coils and liquid embolics. This improvement let us achieve very satisfactory results in the endovascular management of very large or giant aneurysms which otherwise have no effective treatment alternatives. As a last contribution of evolving endovascular techniques/technology in our field, stents have been developing with specific designs or have been used in telescopic fashion (stent in stent) or Y fashioned in bifurcations to create a substantial flow diversion accross the aneurysm neck inducing spontaneous aneurysm thrombosis without putting any material into the aneuryms sac. This can also be achieved with intracranial placement of artificial vessel grafts in the parent artery to exclude aneurysms from the circulation that will be finally demonstrated. The management of intracranial aneurysms depends on whether they are symptomatic or caused by a subarachnoid haemorrhage (SAH) or whether they have been discovered incidentally on imaging studies. In patients with SAH, provided the patient has survived and is not in very poor clinical condition active treatment of the aneurysm must be instituted to prevent re-bleeding, which is nearly always catastrophic. There is now strong evidence (Grade 1) from randomised trials that in patients with anatomically suitable aneurysms coiling with detachable platinum coils results in better clinical outcome in respect of death or disability at 1 year than clipping. The medium-term follow-up data indicate that this benefit continues over at least 5 years. In patients found on imaging to have small incidental aneurysms (< 7 mm in the anterior circulation) the risk of bleeding, on the best available evidence, is extremely low. The widespread tendency to recommend treating these aneurysm, particularly in middle-aged and elderly patients, may be putting patients at greater risk from procedural complications than the natural history. A randomised trial comparing observation with treatment (TEAM) is underway in an effort to answer some of these questions. But all radiologists should avoid disseminating the misleading impression that such aneurysms constitute 'a bomb in their head'. They occur in about 3-5% of the adult population and most will never rupture. This talk will describe the evidence in respect of the treatment of ruptured and unruptured cerebral aneurysms. Venous diseases are among the most frequent in the general population of industrialized countries. The venous system anatomy of the lower limbs and especially its functionality still presents half-lighted areas, a fact easily qualified as incredible for the third millennium. The twenty-first century has opened the door to a better understanding of the pathophysiology of venous disease based on the Doppler duplex findings of the late twentieth century. The correct functioning of the venous system depends on a complex series of valves and pumps that are individually frail and prone to malfunction, yet the system as a whole performs remarkably well under extremely adverse conditions. The Doppler mode gives functional information about spontaneous and phasic venous flow and about the function of the venous valves. The B-mode offers real-time anatomic information and images of the vein wall and lumen and it can visualize intraluminal thrombus. Duplex is now used for diagnosis of both deep and superficial systems, intraoperative imaging and guidance and post-treatment assessment of therapeutic success as well as diagnosis of the reason for treatment failure. Diagnostic quality from ultrasound relies on the proper education of the ultrasonographer, as well as diligent study and practice. Clearly, the complexity of venous disease is not to be taken lightly; thus an accurate preliminary evaluation of each phlebology patient including duplex ultrasound examination will contribute to the best outcome in each situation. Duplex Doppler ultrasonography (DDUS) is nowadays the initial modality of choice for diagnosing lower limb venous pathologies, mainly DVT and chronic venous insufficiency, because of the high accuracy of the method as well as its low cost, portability, availability and lack of ionizing radiation. DDUS is the only non-invasive modality that combines real-time visualization of vein morphology and the map of flow velocity and direction. In patients suspected with DVT, DDUS is done right after D-dimer test which has 99% sensitivity in detecting thrombus, but only 50% specificity. This means that negative D-dimer test excludes DVT but positive one does not confirm the diagnosis. That is why DDUS is to show the presence and location of thrombus -its sensitivity and specificity according most authors reaches 100% in scope of iliofemoral and popliteal region. Calf vein thrombosis is properly diagnosed only in 40-50% of cases. DDUS is a "gold standard" examination of chronic venous insufficiency (DVT follow-up). It shows thrombus organization (recanalization) and valvular incompetence. However, it provides relatively little quantitative hemodynamic information on venous hypertension. DDUS has also drawbacks -the major one is high equipment and examiner dependency -preparation and position of a patient is also important. Among recent technical developments, harmonic imaging and "x-beam", which improves standard B-mode compression examination, are very useful. Also the more sensitive colour Doppler technique is helpful in detecting venous flow in deeper-lying veins (Hunter's channel, iliocaval). Doppler enhancing agents and 3-D technique have little influence in improving diagnosis of peripheral venous pathology. As a low flow, high capacitance system the studies differ from the arterial counterparts. In disease states with obstructive change, the large and variable anatomy of the collateral development can also be challenging for imaging analysis. CT and MR angiography have a role in evaluating the iliocaval and lower extremity veins. In this presentation we shall discuss the acquisition parameters and techniques to optimise CT/MR imaging of the venous system. Venous imaging can be more challenging in terms of capturing the bolus and dealing with unopacified in-flow. High spatial and contrast resolution is required for optimal imaging assessment. Near isotropic multidetector CT venography can provide high-quality imaging data-sets where 3D volume rendered post-processing can provide imaging perspectives independent of the plane of acquisition. It can also provide important adjunct information on the viscera and bowel involved. Similarly, the flow sensitivity of MRA can provide valuable functional information on the venous flow and flow direction. We shall discuss a series of case examples and illustrate how CTA and MRA can be used in the context of existing imaging tools to provide comprehensive diagnostic evaluation and guidance for interventional and surgical therapies. The spectrum of high-resolution computed tomography (HRCT) appearances of normal lung in the paediatric age range is not, by contrast to those documented in adults and the elderly, well documented. For example, the rate at which the overall attenuation of lung parenchyma diminishes from birth through childhood is unknown, and the basic issue of knowing what this normal range of lung density is, has a bearing on the interpretation of HRCT. Nevertheless, for practical purposes, the healthy adolescent lung is indistinguishable, in CT terms, from adult lung. The incidence of some lung diseases is highly age-dependent. For example, sarcoidosis is extremely rare before adolescence, whereas surfactant deficiency disorders of varying severity are increasingly being recognised in younger children; how these disorders develop over time and manifest themselves in adolescence and later life has not yet been established. Another condition which has an age-dependent CT pattern is bronchopulmonary dysplasia. The appearances of this condition in later life in some ways resemble those seen in ARDS survivors. There are some lung diseases (e.g. constrictive obliterative bronchiolitis and alveolar proteinosis) in which the parenchymal pattern on CT is the same irrespective of age. Because of the continuing development of the classification of diffuse lung diseases in paediatric practice (with some entities being abandoned and others renamed), as well as issues of rarity and observer variation between pathologists, it may be sometimes difficult to decide whether a particular diffuse lung disease shows change with age or transforms altogether into another entity. Sports injuries occurred in around 10% of the pediatric population. Because of their relative weakness, the specific sites of trauma include the epiphysis, the physis and the apophysis. A thorough clinical exam may guide the choice of the most appropriate radiological imaging exam (s). Knowledge of the muscles involved in dedicated sport activities, of their insertion sites and the normal development of the secondary ossification centers will greatly help to identify the suspected area. Plain X-rays are always necessary and often sufficient. Growth development lead to numerous tracks and the use of dedicated text books is mandatory. Ultrasounds exam is occasionally realized (ankle sprain, elbow hemarthrosis, avulsion fractures) but never without X-rays. Use of Computed Tomography is limited to complex fractures or suspicion of myositis ossificans. MR imaging is mostly performed to look for intra-articular foreign body, viability of osteochondral fragment in osteochondrosis, associated lesions (i.e.; meniscus, cruciate ligaments) or epiphysiodesis. As compared with MR, Bone Scan has no application in those situations because of its low specificity, its cost and its radiation exposure-risk. Based on each clinical situation, an appropriate decisional imaging algorithm will lead to an accurate clinical treatment and will prevent unnecessary time-and cost-consuming exams. Dynamic elastography is based on assessing the transmission of shear waves in tissues to measure the elasticity (stiffness) and viscosity of organs or lesions. This assessment can be done with ultrasound-or magnetic resonance imaging. These methods have complementary roles. Transient ultrasound elastography is easy to perform and inexpensive. However, it analyzes only the elasticity of a small volume of tissue and has a lower accuracy than three-dimensional MR elastography. As we will hear during this session, elastography is an emerging imaging modality for characterizing and grading diffuse and focal lesions, including fibrosis and tumors, in various organs such as the liver, breast, brain, skeletal muscle, and heart. Palpation has been an integral and important part in the diagnostic procedures of for instance breast cancer detection or liver disease assessment. Unfortunately, until now, it was not possible to measure elasticity non-invasively. Elastography is overcoming the former technical limitations and fills an important gap: the noninvasive assessment of tissue's mechanical parameters via MRI or ultrasound. Thus, former manual palpation turns now into a technique providing absolute physical numbers which can be used, for instance, to determine the grade of liver fibrosis or characterize the malignancy of a breast lesion. Elastography uses the fact that the propagation of low-frequency mechanical waves is tightly linked to the underlying mechanical properties. Mechanical waves will propagate fast in stiff regions and slow in soft regions. Since MRI and ultrasound are techniques sensitive to motion, it is possible to image the propagation of these waves inside the body. The waves are typically generated via dedicated transducers on the surface and propagate deep into the body. In a second step it is now necessary to "convert" these waves into values of elasticity and viscosity. Furthermore, Elastography provides insight into the micro-architecture of tissue. The corresponding physical effect is very similar to the one of anomalous diffusion. In our case, mechanical waves traverse a maze of obstacles when propagating in tissue due to the presence of the vasculature. The resulting effective wave propagation seen at the macroscopic level is actually affected by the spatial arrangement of the obstacles at the microscopic level.Learning Objectives: 1. To understand the general principles of ultrasound and MR elastography. 2. To become familiar with the methods of wave generation, image acquisition and signal processing in elastography. 3. To appreciate the potential role of elastography in assessing tissue microstructure. Liver fibrosis M.R. Brunetto; Pisa/IT (brunetto@med-club.com)The staging of fibrosis in chronic liver disease helps to define the risk of disease progression in candidates to antiviral therapy. However, liver biopsy is invasive and unsuitable for tight monitoring and several factors affect its accuracy to quantify fibrosis. Serum assays and use of algorithms were proposed as surrogate markers of fibrosis, but the lack of standardization hampers their use in clinical practice.Recently liver stiffness (LS), measured by the speed of transmission of an elastic wave across the liver (transient elastography, TE), showed high accuracy to assess liver fibrosis. AUROCs for fibrosis ≥ F2 and cirrhosis range from 0.79-0.93 and 0.95-0.97, respectively. LS cut-offs range from 4-8.7 KPascal for fibrosis ≥ F2 (sensitivity 66-94%, specificity 17.9-90.7%, PPV 65 -93.8%, NPV 50-92%) and 10. 3-17.6 KPascal for cirrhosis (sensitivity 77-100%, specificity 87-97%, PPV 48-100%, NPV 82-97%). Larger studies are needed to identify consensus cut-off values. However, we have to consider that LS correlates primarily with fibrosis, but it is significantly influenced also by other factors: inflammation, oedema and vascular congestion. Accordingly, we showed as LS varies parallelling the kinetics of transaminases during hepatitis exacerbations and decreases to much lower values than expected by histological stage alone in patients with long-lasting clinical remissions and transaminases normalization. In conclusion TE is a new, non invasive tool, useful to identify and monitor liver disease in clinical practice, provided that the clinical background of the patient and the concurrent biochemical activity of liver disease are taken into account. The mechanical behavior of biological tissue is determined by rigidity and compliance of tissue-building cells as well as their geometrical organization and intercellular connectivity. These tissue microstructural properties are important diagnostic markers and thus it is desirable to have medical imaging techniques based on tissue mechanics. Traditionally, tissue mechanics has always been assessed by palpation in order to 'feel' suspicious elasticity changes associated with disease. A technical 'palpation', known as magnetic resonance elastography (MRE), combines shear waves with MRI, which uniquely allows measuring the viscoelasticity of brain tissue in its intact physiological environment. First MRE studies performed on humans and animal models show the effect of Alzheimer's disease, multiple sclerosis and aging on the biomechanical properties of the brain. MRE has also been applied on skeletal muscle to measure stiffness as a synonym of muscle function in various muscle-related diseases. Moreover, new experiments demonstrate the feasibility of MRE to detect myocardial elasticity changes between diastole and systole, which are related to intraventricular pressure changes. This allows for the first time the non-invasive measurement of cardiac work in the human heart, which is potentially useful for assessing pathologies associated with increased myocardial stiffness such as diastolic dysfunction. Recent success in cardiac and brain MRE was enabled by a significant acceleration of MRE using steady-state MRE sequences or spin echo EPI-MRE.Learning Objectives: 1. To become familiar with the methods to perform elastography on brain, skeletal muscle and heart. 2. To understand emerging clinical applications of elastography in the brain. 3 . To learn about some potential applications of elastography in skeletal muscle and myocardium. Current data have shown that drug-eluting stents (DES) can safely be implanted in the coronaries as well as femoral and renal arteries. For the peripheral vascular territory, DES however have not shown to be superior to state-of-the-art bare stents. Although the percentage of stenosis tended to be lower with femoral sirolimuseluting stents in SIROCCO I & II, there were no statistically significant differences as compared with bare stents. The mean late loss values were 0.38 mm ± 0.64 and 0.68 mm ± 0.97 for the sirolimus-eluting stent group and the bare-stent group, respectively (P =.20). The binary restenosis rates, with a cutoff of 50% at 6 months, were zero in the sirolimus-eluting stent group and 7.7% in the bare-stent group (P =.49). There was no significant difference between treatments in terms of adverse events. Recent studies with everolimus and paclitaxel will try to elucidate the potential of DES outside the coronaries. Also, drug-eluting balloon data are emerging that are showing great promise in the lower leg (THUNDER trial). Patients with pulmonary nodules are not a homogenous group of individuals. Lung nodules in smokers have a different significance as compared with those detected in oncologic patients, or those seen in young non-smokers with no risk factors for malignant disease. There is increasing evidence that apart from traditional morphologic criteria, clinical pretest probability, patient age and nodule size are important factors in the construction of a management model for patients with pulmonary nodules. Many published management strategies for indeterminant small pulmonary nodules have raised serious concerns, because they recommend too many CT scans and consequently, expose individuals to a high amount of radiation. For example, existing recommendations involve several follow-up CT examinations for every indeterminant nodule, regardless of its size. Such elaborate follow-up protocols are not required for very small nodules, particularly, not when such nodules are found incidentally in young non-smokers without a history of cancer. Furthermore, in young patients, the risk from radiation must be weighted against the risk of missing a malignant disorder, or the risk arising from an invasive diagnostic approach. As the risk of malignancy increases with nodule size, focal abnormalities with a diameter of more than 8 mm require a more aggressive and potentially invasive diagnostic approach to confirm or rule out cancer. The aim of this presentation is to provide the audience with a practical approach to the management of incidentally detected pulmonary nodules of various sizes in patients with different risk profiles for lung cancer. Multi-row detector computed tomography (MDCT) is responsible for the largest part of the radiation dose delivered for medical diagnosis, and this dose is in constant increase, because of the progression in the number of procedures, of inappropriateness in prescription, and of new clinical indications. Inappropriate setup of CT parameters is responsible for useless radiation, particularly when high kilovoltage settings are used. AEC developed by manufacturers enable to adapt the tube current to the patients' morphology but not the tube potential. In order to reduce and or optimize the MDCT radiation dose, the radiologist can act at various levels such as check for correct indication, chose appropriate KV and mAs or image quality level, reduce the number of acquisitions and the Z coverage. Low-dose settings may also be chosen as they provide diagnostic image quality with a dose not higher than two to four chest X-ray examinations. The sequential HRCT technique is an alternate to helical MDCT as it reduces the dose by a factor of four and can be pursued for follow-up examinations for ILD. Radiation dose should preferably be reduced in young and in female patients with benign disorders and long life-expectancy. Chronic obstructive pulmonary disease (COPD) is a slowly progressive airway obstructive disorder resulting from an exaggerated inflammatory response that ultimately destroys the lung parenchyma (emphysema) and induces irreversible reduction in the caliber of small airways (airway wall remodeling). Bronchial wall thickness and the extent of emphysema at CT in COPD patients have proven to be both the strongest and independent determinants of the degree of airflow obstruction at pulmonary function tests. Computed tomography (CT) has been the best imaging technique to assess in vivo the presence, type (centrilobular, panlobular, paraseptal), distribution and extent of emphysema. Recommendations in CT protocols for adequate reproducibility have been made in order to use CT for quantitative assessment of emphysema in longitudinal studies. Introduction of the multi-row detector CT technique has tremendously improved the ability to assess the proximal airways in three dimensions. Different image analysis techniques have been developed to make measurements of airway dimensions on CT scans. Use of CT in evaluation of patients with COPD has made it clear that individuals with this condition may have different morphologic appearances. Some have extensive emphysema, while others with equal functional impairment have little or no emphysema. These morphologic differences may reflect important differences in the underlying pathophysiology and genomic profile of COPD. Even if the phenotypic abnormalities which may be recognized on CT images in patients with COPD often overlap, it is hoped that identification and quantification of the predominant morphologic findings in individuals with COPD will help optimize treatment. Learning Objectives:1. To know the classification of COPD phenotypes, and the key role of CT in determining the predominant phenotype in any given COPD patient. 2. To understand the methods and their limits used for CT quantitative assessment of emphysema and airway wall remodelling. 3. To know the role of imaging in selecting candidates for interventions, and in follow-up for longitudinal studies. Aortic aneurysm is an important cause of cardiovascular mortality in Occidental countries, and as the population is aging, the incidence of aneurysm is on the rise. Because of the risks and complications associated with aortic surgery, stentgrafting of the aorta is emerging as a new technique in aneurysms of various etiologies. The theoretical advantages are multiple: a simple arteriotomy under mild anticoagulation is performed without aortic clamping, which, theoretically, lessens the risk of major complications. The precise sizing of the device obtained from MD-CT with 3D-reconstructions is certainly one of the most critical points of these endovascular procedures. A number of prospective studies using a variety of devices have now been published in the literature, but so far no randomized studies are available. Actually, short-term morbidity and mortality rates, of large series, compare favorably with those from surgery, and stent graft placement is proving to be a safe, minimally invasive, and effective treatment for thoracic aortic diseases. But, although endoluminal interventions are minimally invasive, they are associated with complications, as are surgical methods. In this talk, indications, technical aspects and results of endovascular TAA repairs will be reviewed. We will also examine the advantages and limitations of stent graft treatment. Learning Objectives:1. To review patient selection and preprocedural imaging for endovascular treatment. Aortic dissection is one of the most serious and dramatically acute pathologies with a frequency ranging annually from 10 to 20 cases per million people. Dissection is generally secondary to degeneration of the collagen and elastin matrix within the aortic media layer. The formation of a tear in the aortic intima allows pulsatile blood to enter and propagate into the aortic media. The blood-filled space between the dissected layers becomes the false lumen. Diagnosis is based on modern noninvasive imaging modalities, such as multidetector-row CT angiography. Medical therapy is considered the treatment of choice in case of uncomplicated type B dissection, while in case of lower or visceral ischemia or renal failure, an immediate operative treatment is necessary. However, in those patients treated with medical therapy, mortality rate remains greater than 20%, with a high incidence (14-20%) of aneurysm formation in the first 5 years. A 30-day mortality rate of 10% is reported for uncomplicated type B dissection, while in case of complicated dissection, mortality rate becomes higher, 20% at 2 days and 25% at 30-day. In the last few years, the endovascular stent-graft therapy has progressed from the placement of home-made devices to the routine use of commercially manufactured endoprosthesis, which are deployed within the true lumen across the primary entry tear for its complete obliteration. The initial results of these feasibility studies suggested that stent-grafts offer an attractive alternative to open surgical repair, since this treatment can potentially reduce operative risks, hospitalization times and procedural costs. Positron emission tomography (PET) is a major advance in molecular imaging. Coincidence imaging enhances its sensitivity, while the uptake of metabolic or receptor-binding tracers characterize the aggressiveness of the tumors. FDG PET is indicated for the evaluation of advanced breast cancer, for the staging of patients with large or distant initial disease, for the restaging of patients with loco-regional recurrence or metastases and for monitoring therapy. The resolution of PET does not allow detection of small tumor or micrometastatic nodes, making it unsuitable for screening and for defining the axillary status. PET is specific in detecting metastatic disease early-on, in patients with involvement of numerous lymph nodes, loco-regional recurrence or increasing tumor markers and in characterizing the extent of the disease. PET is also useful in evaluating response to therapy and subsequent prognosis. It can predict on lack of pathologic response but cannot assess the extent of residual disease in responding patients. Progress will result from increased resolution and sensitivity. The availability of specialized detectors for positron emission mammography (PEM) should allow resolutions down to 1.5 mm. This should allow screening of most tumors with high SUV, but well-differentiated and lobular tumors have lower uptake and could still be missed. PEM appears to be capable of detecting multicentric tumors and the extent of DCIS, leading to a potential reduction in reintervention. Newer tracers are needed to enhance detection and provide biologic information on the tumor. F-thymidine for proliferation, F-miso for hypoxia, F-RGD for angiogenesis and FES for estrogen receptors have the potential to increase the role of PET in the future. Digital mammography offers new opportunities that are not provided by conventional film-screen for the detection of breast carcinomas. Two recent promising advanced application of digital mammography are the Contrast-Enhanced Digital Mammography (CEDM) and tomosynthesis. The CEDM allows the assessment of angiogenesis of breast carcinomas. This new technique is based on a full-field digital mammography used in conjunction with the injection of an iodinated contrast medium. Two techniques of CEDM have been developed: The dual-energy subtraction imaging that exploits the energy dependence of the X-ray attenuation components in the image and the temporal subtraction technique producing highenergy digital mammography images before and after contrast medium injection. Both techniques have been successful in detecting breast carcinomas. We will present and illustrate first clinical experiences of both of these techniques and their potential for future clinical applications. The second part will be on tomosynthesis.One of the most important limitations of mammography is the combination of structures in two-dimensional views than can obscure a cancer or create a false positive lesion. Breast tomosynthesis provides three-dimensional information on the breast by the acquisition of multiple projected views with different angles processed into a series of 1-mm slices. We will describe the acquisition technique and The detection of optical signatures can potentially enhance the diagnosis and surgical management of breast cancer. Particularly, light in the near-infrared (NIR) range can traverse breast tissue efficiently and thus provide coverage of deep-tissue sections. Surface-weighted imaging techniques (fluorescence reflectance imaging, FRI; optical coherence tomography, OCT) as well as tomographic techniques (e.g. diffuse optical tomography, DOT) have been applied both for preclinical and clinical applications. Besides imaging intrinsic absorbers such as hemoglobin, fat and water, the introduction of fluorescence-enhanced optical imaging has significantly expanded the capabilities of optical imaging. Contrasting strategies in this context range from non-specific, perfusion type-to targeted-and 'smart'-fluorochromes. The feasibility of resolving 3-D fluorochrome distribution in a clinical setting has been shown. More recent studies suggest that combining high resolution imaging methodologies such as MRI or Ultrasound (opto-acoustics) may help to partially overcome the inherent limitations of this technology. The subjective interpretation of breast lesions with mammography, ultrasound, and MR-imaging is difficult to evaluate and therefore difficult to improve. The medical audit is the only way to measure breast imaging performance in a manner that includes not only technical, but also interpretive capabilities of the system. The 'Breast Imaging Reporting and Data System' (BI-RADS) is a quality assurance tool, designed to standardise breast-imaging reporting, reduce confusion in breastimaging interpretations, and facilitate outcome monitoring. Through a medical audit and outcome monitoring, the system provides important peer review and quality assurance data to improve the quality of patient care. The BI-RADS is the product of a cooperative effort between members of various committees of the American College of Radiology. The BI-RADS was first introduced in 1992 in the United States and has become a widely accepted tool all over the world. However, there is a need for continuous teaching of the BI-RADS classification because it is intended for use in everyday practice and should make it possible to issue meaningful, unambiguous breast-imaging reports. This BI-RADS session has been organised to provide participants with an introduction to the most important sections of this system. These are the breast-imaging lexicon for mammography-, ultrasound-, and MR-imaging. Beside the theoretical background, participants will be trained and tested on how to apply the BI-RADS. The material will be presented in an interactive way with audience participation and self assessment by use of an electronic voting system (key-pads). At the end of the session, the participant with the most accurate answers, will be awarded a prize. Learning Objectives: 1. To know more about BI-RADS, particular about the breast imaging lexicon, the reporting system, and follow-up and outcome monitoring. 2. To know how to apply BI-RADS for mammography, ultrasound, and MR imaging. 3. To use BI-RADS in everyday practice and issue meaningful, unambiguous breast imaging reports.