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January 2002
Autumn 2013
asia-pacific
The Newsmagazine
of Imaging
Innovation &
Economics
A special region-specific
publication from the editors of
Diagnostic Imaging
An enhanced role
for MRI in Radiation
Therapy
P 13
Accurate assessment
of liver fibrosis P 17
The contrast agent of
choice for enhanced
breast MRI
P 10
asia-pacific
Evidence – based practice
of radiology in India :
room for improvement
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FROM THE EDITOR
EDITORIAL ADVISORY BOARD
Dr. Jennifer Cawson, Melbourne, Australia
Prof. Yi-Hong Chou, Taipei, Taiwan
Prof. Jiang-Ping Dai, Beijing, China
Prof. Hiroshi Fujita, Gifu, Japan
Mr. Robert George, Sturt, S. Australia
Dr. Julian He, Boston, USA
Prof. Jung-gi Im, Seoul, Korea
Dr. Bhavin Jankharia, Mumbia, India
Prof. Mikund S. Joshi, Mumbai, India
Dr. George Klempfner, Melbourne, Australia
Prof. Michio Kono, Kobe, Japan
Dr. K. Kulaveerasingam, Kuala Lumpur, Malaysia
Dr. Lillian L.Y. Leong, Hong Kong, China
Prof. Jae Hoon Lim, Seoul, Korea
Prof. Quanfei Meng, Guangzhou, China
Prof. Wilfred C. G. Peh, Singapore
Dr. Tauqir Ahmed Rana, Riyadh, Saudi Arabia
Dr. Zhonghua Sun, Curtin, Australia
Prof. Lenny K. A. Tan, Singapore
Dr. Chui-Mei Tui, Taipei, Taiwan
Prof Dr. John George, Kuala Lumpur, Malaysia
Evidence – based practice of radiology
in India: room for improvement
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Greg Freiherr
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Autumn 2013
By Dr Alan Barclay
Seen from the perspective of austerity-ridden Western Europe the economic projections
currently being made for India in general and
the country’s healthcare sector in particular are
the stuff of dreams, even if the growth rates have
receded slightly over the last few months and the
fall of the rupee could result in further (relative)
cooling of the economy.
Healthcare in India is one of the country’s
fastest growing industries being expected to
grow at a compound annual growth rate of 15 per
cent over the period 2011 – 2017. As the analyst
Ravi Thomas has pointed out (Healthcare India:
a billion opportunities by Ravi Thomas), India’s
population growth and increased disposable
income are expected to result in correspondingly
increased healthcare awareness, raised expectations of improved care and demands on behalf
of the population. In addition India is witnessing
a shift in disease patterns from communicable
diseases to the high incidence of non-communicable and lifestyle-related diseases, which is
driving the need for tertiary and quaternary-care
hospitals and clinics. The overall outcome of all
this is that expenditure on healthcare is expected
to rise dramatically. At the moment, the country has something like half a million doctors,
approximately one million nurses and around
1.37 million hospital beds Some analysts based
on work carried out by reputable bodies such as
Ernst & Young speculate that there is a need to
add nearly 1.74 million beds by 2027 implying
an investment of about 104 USD billion over the
same period to fulfil the predicted needs. Various
government programs such as those in the fields
of tuberculosis, malaria and HIV/AIDS have
been initiated but significant private sector
investment and input is expected. Private players
have already made significant investments in setting up state-of-the-art private hospitals in cities
such as New Delhi, Chennai and Hyderabad.
Significant in these developments is the relatively
large amount of modern medical technology
that has been and is planned to be installed.
Given the key role that radiology plays in
any modern healthcare environment it is not
surprising that dramatic rises in the installed
bases of all of the most important radiology
modalities are predicted over the coming years.
To match this, a significant expansion is planned
in the numbers of medically or technically qualified personnel, including radiologists. Certainly
in one aspect India seems well equipped. With
fewer than 300 medical colleges, an adequate
D I A G N O S T I C I M A G I N G
A S I A
number of future doctors including radiologists
seems assured.
Questions are beginning to be asked however beyond the mere level of numbers of
personnel and more about the actual quality of
the personnel. A recent paper (Chandramohan
et al. Evidence-based practice in radiology :
knowledge , attitude and perceived barriers to
practice among residents in radiology Eur J
of Radioogy 2013 ;82: 894) describes a study
carried out to find out what residents in the
Department of Radiology, at Christian Medical
College, Vellore, India, which is a 3000-bed
tertiary care teaching hospital in South India,
thought of the Evidence-based Practice of
Radiology (EBPR). Using established methodologies such as McColl questionnaires and
Barriers scale, the authors attempted to measure whether EIBR was being implemented in
practice. While there have been several similar
studies done on general practitioners, surgeons,
nursing staff, surgical nurses and radiographers there has been no such study among
radiology residents.
The results were sobering. Although the
majority of residents had access to the Internet,
fewer than half had access to Medline in the
work place. Around 50–70% of residents were
unaware of different evidence-based bibliographic databases; many others were aware but
did not use these sources. Residents were aware
of common terms used in evidence-based literature, but unfamiliar with many although most of
those who did not understand the terms were
interested in learning them. However very few
(14%) residents had received formal training
in search strategies or even attended a course
on EBM in general (11%). Even fewer (5%).had
had some kind of training in critical appraisal of
evidence based literature
In view of these results, the authors come to
the inevitable recommendation that there is a
great need for structured teaching of evidence
based radiology in India. Ideally this should
include statistical modules, critical appraisal
modules and practical evidence based radiology
exercises
Of course in a country as vast and diverse
as India, the extrapolation of one study to the
whole country can be dangerous. Nevertheless
the fact that the profession is willing to question the quality of the training of the personnel
who have such a key role to play in the future is
already a positive sign. n
P A C I F I C 3
Autumn 2013
asia-pacific
Evidence – based practice of radiology in India : room for improvement
India is set for a significant increase in healthcare spending over the next
few years including in radiology. Questions are being raised as to whether
the trainee radiologists needed for the future are proficient enough in
evidence-based radiology. A recent study of interns in a south indian
teaching hospital suggests that there is room for improvement
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REPORTS
06| Industry NEWS
New hybrid clinical operating
theatre in CUHK — PWH
20| TECHNOLOGY update
Live 3D holographic imaging in
interventional cardiology
Visit us at
DIEUROPE.com
Autumn 2013
The contrast agent of
choice for enhanced
breast MRI
An enhanced role
for MRI
in Radiation Therapy
Page 10
Page 13
Accurate assessment
of liver fibrosis
Page 17
Industry NEWS
International day for medical physics.. . . . . . . . . . . . . . . . . . . . . . . . . .
5
Hitachi Aloka opens new ultrasound R & D center. . . . . . . . . . . . . . . . .
5
Global impact of breast cancer.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
New hybrid clinical operating theatre in CUHK — PWH.. . . . . . . . . . . . .
6
Panasonic transfers Ultrasonic Diagnostic Equipment
business to Konica Minolta. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
Philips opens new Asia-Pacific center in Singapore.. . . . . . . . . . . . . . . .
6
Another successful RAD-AID conference. . . . . . . . . . . . . . . . . . . . . . . .
9
Molecular Imaging Centers in India : Making cancer detection
more accessible. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
asia-pacific
COMING SOON in the next issue:
Advances in ultrasound
Computer-aided diagnosis
Oncology
D I A G N O S T I C I M A G I N G
A S I A
P A C I F I C 4
Industry NEWS
International day for medical physics
On November 7th — the date was
chosen deliberately since this is the date
of birth in 1867 of Marie Curie, the pioneering researcher on radioactivity — the
International Organization for Medical
Physics (IOMP) celebrated the International Day for Medical Physics (IDMP).
The plan is that IDMP should be an annual
event in which 80 national organizations
of IOMP and countries all over the world
shall celebrate the impact of medical physics on the daily lives of millions of humans
worldwide, whether they be patients,
workers or members of the public. The
aim is to raise awareness of the important
role medical physicists play in the clinical environment as well as in education,
research and development of sophisticated
medical technology. The theme chosen for
2013 is ‘Radiation Exposure from Medical
Procedures: ask the Medical Physicist!’
As medical imaging technologies and
radiotherapy techniques are fast developing and becoming more intricate, medical
physicists are playing an increasingly significant role in the clinical environment.
They contribute to the safe and accurate use
of radiation to achieve the best outcome of
the prescribed medical diagnostic examination or treatment. They assess radiation
doses and associated risks to patients and
personnel. Medical physicists optimize
radiation procedures by performing accurate measurements and calculations, maximizing the benefit against the potential risk
in the use of radiation and contributing
to the development and implementation
of quality assurance programs. They are
Hitachi Aloka opens new ultrasound
R & D center
Hitachi Aloka Medical has set up a
Medical System Development Center
at Kokubunji-shi, Tokyo Japan. The
facility will provide a consolidated
base for the development of diagnostic ultrasound systems, probes, and
software. Currently, the company’s
activities for the development of diagnostic ultrasound systems are divided
between two plants, one in Tokyo and
the other in Chiba Prefecture. The
consolidation of these two groups at
the newly opened Medical System
Development Center has as objective
the streamlining of product development by combining the development
departments. Hitachi Aloka Medical
have been working on development of
the ProSound and HI VISION series
of diagnostic ultrasound systems, in
collaboration with Hitachi’s Central
Research Laboratory (CRL), which is
located right next to the new center. The relationship with the central
research laboratory will continue and
synergies are expected from the future
collaboration with the CRL and other
Hitachi’s research laboratories for
early application of ground-breaking
Autumn 2013
Global impact of
breast cancer
technologies. A company spokesman
indicated that the opening of the new
center was a sign of the commitment
of the company to the development of
such new technologies and the provision in a timely manner of products
with significant value to customers
throughout the world.
Hitachi Aloka Medical
Ultrasound R& D Center
Tokyo Japan
www.hitachi-aloka.com
D I A G N O S T I C I M A G I N G
highly qualified health professionals with
postgraduate studies and clinical training.
Most people needing radiation imaging
and treatment procedures are not aware
that there is a worldwide scientific community specializing in medical physics, ensuring the quality of these procedures while
minimizing risks associated with radiation.
Further information available at
www.iomp.org
Contact: Prof. John Damilakis,
Chairman of the IOMP Education and
Training Committee
[email protected]
GE Healthcare
has commissioned
new, independent,
research into the
global impact of
breast cancer. Key
findings include:
• As breast cancer survival rates improve in the developed
world, quality of life is becoming a growing
issue. As a result, the report urges doctors to
focus on measuring the impact of diagnosis
and treatment on survivor’s quality of life, to
identify what problems patients may have
and how these can be mitigated
• 15 million years of ‘healthy life’ were
lost worldwide in 2008, due to women dying
early or being ill with the disease
• There is a direct link between survival
rates in countries and the stage at which
breast cancer is diagnosed, providing further evidence of the need for early detection
and treatment
• Rising breast cancer incidence and
mortality represent a significant and growing threat for the developing world
• Consumer awareness and cultural barriers surrounding screening are putting lives
at risk.
www.gehealthcare.com
A S I A
P A C I F I C 5
Industry NEWS
New hybrid clinical operating theatre
in CUHK — PWH
Funded by a generous donation of
from an anonymous donor, the Chinese
University of Hong Kong – Price of Wales
Hospital (CUHK — PWH) in Hong Kong
has been able to construct a brand new
modern hybrid operating theatre. With
this new cutting-edge facility, the hospital
will be able to deliver higher quality surgical service benefiting not only patients
with cardiovascular diseases, but also
other disease types, such as neurosurgical
and trauma cases. The extensive benefits
of hybrid surgeries have been well proven.
The new facility will further strengthen
the hospital’s capability and role as a
trauma and cardiothoracic surgery centre
in the community.
Traditionally, patients with cardiovascular diseases undergoing operations like
coronary artery bypass, valve repair and
abdominal aneurysm stent may have to be
examined and treated in multiple points
of care in the hospital, including the
radiology department for pre-operative
imaging and the catheterization laboratory for percutaneous procedures before
undergoing the surgery. Re-explorations
are sometimes necessary after patients
have been transferred to the intensive care
unit. The new hybrid operating theatre
integrates different technologies, offering real-time intra-operative imaging and
computer-assisted instrument control to
allow surgeons, physicians and interventional radiologists to perform all necessary procedures in one location. It can
reduce healthcare cost and shorten hospital stay, while on the other hand enhance
treatment efficiency and minimize the
risk of patient transfer.
Prof. Francis K L Chan, Dean of Medicine, CUHK added, ‘The new hybrid
operating theatre has strengthened our
competitiveness in teaching, research and
clinical service. Our medical students and
surgical trainees will have the opportunity
to learn and master the state-of-the-art
surgical technology.”
Prof. Paul B.S. Lai, Chairman of the
Department of Surgery at CUHK added
that surgeons can now perform more
advanced cardiovascular surgeries with
Panasonic transfers Ultrasonic Diagnostic
Equipment business to Konica Minolta
Konica Minolta announced that the
company has signed a business transfer
agreement with Panasonic Healthcare
under which the ultrasonic diagnostic equipment business of Panasonic
Healthcare is to be transferred to Konica
Minolta. The companies have up till now
been jointly developing ultrasonic diagnostic systems. To improve and expand
the impact of this cooperation the
companies have agreed that Panasonic
Healthcare’s assets necessary for the planning, development, manufacturing, sales,
maintenance of ultrasonic diagnostic
equipment will be transferred to Konica
Minolta effective on January 1, 2014. The
existing OEM-supply business relation6
ship between Panasonic Healthcare and
its customers will also be transferred to
Konica Minolta.
Konica Minolta continues to enhance
its growth strategy in the healthcare business by expanding digital X-ray diagnostic imaging systems, including the
AeroDR, its current mainstream products, fostering Healthcare IT services
business and driving growth of business
for new ultrasound diagnostic equipment
with benefits based on Konica Minolta’s
innovative strength acquired through
the business deal with Panasonic Under
the communication message “Giving
Shape to Ideas,” Konica Minolta will
make further efforts in facing challenges
to develop state-of-the-art technologies
in the medical imaging fields and create
new values for the customers with highquality products, services and solutions
Konica Minolta
Tokyo Japan
www.konicaminolta.com
D I A G N O S T I C I M A G I N G
A S I A
critical patients who might otherwise not
be operated on at all.‘The minimally invasive and hybrid procedures have resulted
in remarkably lower morbidity and mortality of elderly patients or patients with
complex pathologies.”
With the synergies between CUHK
and PWH, the dedicated clinical teams
have been committed to developing the
best surgical care for patients and advance
research of minimally-invasive surgery.
They will continue to serve the community with the highest professional standards on education and caring practice,
contributing to the advancement of health
sciences.
CUHK—PWH
Hong Kong SAR China
www.cpr.cuhk.edu.hk/en
Philips opens new
Asia-Pacific center in
Singapore
Philips announced that it is introducing healthcare innovations that will
help health systems in Asia to address
the growing challenges linked to a fast
growing and aging population. Philips’
new Hospital to Home business in Asia
Pacific will seek to improve care transitions by offering re-admission management consulting, telehealth solutions for
greater care continuity, and a personal
health portal to engage patients and their
families in their own health. Its head-
P A C I F I C continued on page 09
Autumn 2013
ABCD
CARS
2014 springer.com
COmPuter Assisted
rAdiOlOgy
And surgery
International
Journal
th
28 International
Congress and
Exhibition
of Computer
Assisted
Radiology
and Surgery
A journal for interdisciplinary research, development
and applications
A journal for interdisciplinary research, development
andof image guided
diagnosis and therapy
applications of image guided diagnosis and therapy
main themes
 Medical Imaging
 Computed Maxillofacial
Imaging
Editors-in-Chief:
Heinzand
U. Lemke
 Image Processing
Visualization
Michael W. Vannier
 PACS and IHE
Organ of
 TelemedicineThe
andOfficial
E-Health
CARS, ISCAS, EuroPACS
 Computer Aided Diagnosis
and CURAC
 Computer Assisted Radiation Therapy
 Image and Model Guided Therapy
 Personalized Medicine
 Surgical Navigation
 Surgical Robotics and Instrumentation
 Surgical Simulation and Education
IJCARS website: www.springer.com/11548
Manuscript Submissions:
www.editorialmanager.com/jcars
 Computer Assisted Orthopaedic and Spinal Surgery
Please submit
www.editorialmanager.com/jcars
 Computer Assisted
Head your
and manuscript
Neck, andatENT
Surgery
 Image Guided Neurosurgery
 Minimally Invasive Cardiovascular and Thoracoabdominal Surgery
 Digital Operating Room
Deadline for abstract/paper
submission: 10th January 2014
June 25–28, 2014
Fukuoka International Convention Center
Fukuoka, Japan
President
Makoto Hashizume, MD, PhD, FACS (J)
Honorary Presidents
Masaki Kitajima, MD, FACS (J)
Hironobu Nakamura, MD, PhD (J)
Congress Organizing Committee
Stanley Baum, MD (USA)
Elizabeth Beckmann, BSc (UK)
Leonard Berliner, MD (USA)
Silvio Diego Bianchi, MD (I)
Ulrich Bick, MD (D)
Davide Caramella, MD (I)
Kevin Cleary, PhD (USA)
Takeyoshi Dohi, PhD (J)
Kunio Doi, PhD (USA)
Volkmar Falk, MD (CH)
Allan G. Farman, PhD, DSc (USA)
Hubertus Feussner, MD (D)
Guy Frija, MD (F)
Stephen Golding, FRCR, MD (UK)
Olga Golubnitschaja, MD (D)
Makoto Hashizume, MD, PhD, FACS (J)
Javier Herrero Jover, MD, PhD (E)
Kiyonari Inamura, PhD (J)
Pierre Jannin, PhD (F)
Leo Joskowicz, PhD (IL)
Heinz U. Lemke, PhD (D) (Chair)
Hans-Peter Meinzer, PhD (D)
Hironobu Nakamura, MD, PhD (J)
Nassir Navab, PhD (D)
Emanuele Neri, MD (I)
Terry M. Peters, PhD (CDN)
Osman M. Ratib, MD, PhD (CH)
Jarmo Reponen, MD (FIN)
Hans G. Ringertz, MD, PhD (S)
Ramin Shahidi, PhD (USA)
Gero Strauss, MD (D)
Michael W. Vannier, MD (USA)
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Industry NEWS
Another successful RAD-AID
conference
The Fifth Annual 2013 RAD-AID
Conference was held on Saturday, October 26th at the Johns Hopkins Hospital
in Baltimore, Maryland.USA
RAD-AID International is a nonprofit organization founded by a team
of radiologists trained at Johns Hopkins. The organization is a global network assisting developing countries to
implement and optimize radiology and
health imaging services while improving the role of radiology in global public
health initiatives. RAD-AID also aims to
improve the provision of radiology and
health care services in the developing
world through a sustained longitudinal
legacy of dialog, education, resources,
and collaboration.
Philips opens new Asia-Pacific center
in Singapore
continued from page 06
In addition to specific projects,
RAD-AID International runs training programs so that individuals in
developing countries can learn how to
perform and interpret medical imaging to make patient care decisions. To
make sure that these efforts are optimized for areas with limited resources,
RAD-AID have developed a Radiology Readiness package. In the field of
Public Health, RAD-AID International
provides education on public health
issues such as maternal infant mortality, breast cancer screening, and
tuberculosis control, all of which have
important roles for radiology such as
ultrasound, mammography, and radiography. These public health issues
have been identified by the World
Health Organization as international
priorities in which health personnel
need to be educated on ways to better
screen for breast cancer, treat tuberculosis, and prevent maternal-infant
mortality at child birth.
RAD-AID
Chevy Chase, MD, USA
www.rad-aid.org
Molecular Imaging Centers in India:
making cancer detection
more accessible
Representing the first of a network of
molecular imaging centers around the
country with GE Healthcare as technology
provider, Nueclear Healthcare Ltd (NHL)
and GE have opened their first molecuAutumn 2013
lar imaging center in Navi Mumbai. The
partnership is the result of a growing need
for more affordable access to advanced
molecular imaging technologies such as
PET/CT. Cancer rates have become one of
the leading causes of death in India, with
about 2.5 million cancer patients.
GE Healthcare and NHL aim/have a
goal to establish 120 molecular imaging
centers around the country to provide
more affordable access to PET/CT imaging. Following the inaugural opening of
Navi Mumbai’s center, five more centers
will be commissioned in 2013. NHL is
expected to offer PET/CT imaging at just
Rs.10,000/- compared to the Rs.18,00025,000 patients pay today for same services.
The goal is for the NHL network of
D I A G N O S T I C I M A G I N G
quarters and competence center for
the region will be located in Singapore.
Chronic illnesses are rising faster in Asia
than globally and the sheer number of
people requiring care is staggering. Asia
will be home to half of the world’s elderly
population and half of the global burden
of chronic conditions by 2030. Asians
increasing life expectancy and growing
economic affluence will add tremendous
pressure on the region’s already-stretched
healthcare systems and create ever higher
demand for quality care.
“By realizing Hospital to Home solutions that are relevant to the local care
ecosystem, we will bridge the hospital
and the home for a truly patient-centered care model,” said Frans van Houten,
CEO Philips. “In the Asia Pacific region,
Singapore is seen as a reference site for
its healthcare system and therefore an
ideal location to establish the regional
headquarters for this new business.
Together with the local stakeholders,
we will develop patient care models for
the region that will enhance patient outcomes beyond hospital.”
Philips Singapore
Toa Payoh W, Singapore
www.philips.com.sg
molecular imaging centers to ultimately
have twelve cyclotrons for production of
bio-markers required for cancer imaging
and 120 GE Discovery PET/CT imaging
scanners. The PET/CT systems will help
enable doctors to determine whether a suspicious growth is cancerous or benign in a
single exam. Previously, doctors had to put
patients through two separate scans to get
similar information – with limited success.
“India has cancer rates that are comparable to the majority of developing
countries,” said Dr A Velumani, Founder
& Managing Director of NHL i.
“Cost has been one of the biggest barriers in advancing early cancer detection.
Our goal is to remove the barrier of cost by
reducing the cost to patients by half. If we
make detection and treatment affordable,
more people will come forward and the
sheer volume will take care of our capital
investments,” he added.
GE Healthcare
Chalfont St Giles, UK
www3.gehealthcare.com
A S I A
P A C I F I C 9
Advertorial
Multihance : the contrast agent of
choice for enhanced breast MRI
Magnetic Resonance (MR) Imaging is widely considered the diagnostic imaging modality of choice for
the evaluation of abnormalities associated with the breast. Numerous studies have shown that contrastenhanced breast MRI is significantly more sensitive and accurate for the detection and characterization of
breast cancer than conventional techniques such as mammography and ultrasound.
D
efinite indications for which contrastenhanced MRI is strongly recommended
include screening of women at high risk of
developing breast cancer, the evaluation
of tumor response to neoadjuvant chemotherapy
(NAC), the detection of occult primary breast cancer, and the detection of suspected local cancer
recurrence [1]. Numerous studies have also highlighted the benefit of contrast-enhanced MRI for
additional indications such as preoperative breast
evaluation [2, 3]. However, as with all imaging modalities, optimized diagnostic performance
depends on optimized image acquisition. On
the one hand, this implies appropriate sequence
parameters to allow image acquisition with optimal
spatial and temporal resolution and, on the other,
appropriate contrast enhancement to better detect
and characterize suspicious lesions.
Of the numerous contrast agents available, MultiHance (Gadobenate dimeglumine, Bracco Imaging SpA, Milan, Italy) is the only one specifically
approved by European regulatory authorities for
breast MRI applications.
This specific approval, which is for “MRI of the
breast, for the detection of malignant lesions in
patients where breast cancer is known or suspected
on the basis of previous mammography or ultrasound results” [4], reflects the proven superiority of
MultiHance for the detection and characterization
of breast cancer not only compared with conventional imaging techniques [5, 6] but also compared
with breast MRI enhanced with other MR contrast
agents [6-9]. This latter evidence comes directly
from three prospective, intra-individual crossover
comparisons of MultiHance with Magnevist in
which all evaluated patients received both contrast
agents at equivalent doses of 0.1 mmol/kg bodyweight in randomized fashion in two separate but
otherwise identical MRI examinations separated by
no more than 7 days (7-9).
The most recent of these studies was a large double-blind, multicenter, randomized, intra-individual
crossover comparison of MultiHance and Magnevist in which three highly experienced, independent
Autumn 2013
and fully blinded readers assessed comparative MR
images from 162 women with abnormalities at mammography or ultrasound which were considered suspicious for malignancy (BI-RADS 3, 4 or 5).
The study revealed highly significant superiority for
MultiHance over Magnevist not only for the detection of malignant lesions (91.7-94.4% vs. 79.983.3%; p≤0.0003), but also in terms of diagnostic
performance for the identification of breast cancer (sensitivity: 95.2% vs. 81.2-84.6%; specificity:
91.1-96.9-99.0% vs. 93.8-97.8%; accuracy: 96.798.2% vs. 92.8-96.1%; PPV: 77.2-91.1% vs. 60.980.7%; and NPV: 99.0-99.4% vs. 97.8-98.1%;
p≤0.0094 across all readers and assessments).
As for other MR applications for which contrast
agent use is mandatory, the superior performance of
MultiHance is due to the greater r1 relaxivity of this
agent relative to other gadolinium-based contrast
agents. Specifically, the Gd-BOPTA contrast-effective
FIGURE 1. 45-year-old woman referred for breast MRI for breast cancer
staging after unequivocal mammography/ultrasound before histology/pathology. A) Subtracted image acquired after administration of 0.1 mmol/kg BW
Magnevist. B) Subtracted image acquired after administration of 0.1 mmol/
kg BW MultiHance. Note the greater lesion conspicuity and better definition
of lesion margins on B. Histology confirmed an invasive lobular carcinoma.
D I A G N O S T I C I M A G I N G
A S I A
P A C I F I C 10
molecule of MultiHance, unlike the Gd-DTPA contrasteffective molecule of Magnevist, possesses a hydrophobic benzyloxymethyl side-chain which fits into specific
sites on the albumin molecule leading to a slowing of
the tumbling rate of the Gd-BOPTA complex in blood
and thus an increase in its relaxivity [10]. This in turn
leads to greater signal intensity (SI) enhancement on
T1-weighted images and thus improved conspicuity not
only of the lesion itself but also of characteristic malignant features such as spiculated lesion margins [Figure
1]. To date, the greater r1 relaxivity and resulting
greater SI enhancement achievable with MultiHance
has been shown to be of benefit for the improved detection and diagnosis of malignant lesions [6-9], for better predicting malignancy in the case of histologically
borderline lesions diagnosed at core needle biopsy
[11], for improved detection of malignant contralateral
lesions in patients with diagnosed unilateral breast cancer [12] and for improved malignant lesion detection/
exclusion and surgical decision making in patients with
breast cancer detected at conventional imaging [13].
Although implementation of breast MRI into routine
clinical practice has been hampered by factors such
as cost, perceived high frequency of false positive
diagnoses, lack of availability of minimally invasive
biopsy capabilities, and fear of overtreatment, findings
suggest that many of these apparent drawbacks may
be overcome with the use of MultiHance.
ing.
CK.
detection and characterization at contrast-enhanced MR mammography: gadobenate dimeglumine versus gadopentetate
dimeglumine. Radiology 2005; 237: 45-56.
8. Pediconi F, Catalano C, Padula S, et al. Contrast-Enhanced
MR Mammography: Improved lesion detection and differentiation with gadobenate dimeglumine. AJR Am J Roentgenol.
2008; 191: 1339-1346.
9. Martincich L, Faivre-Pierret M, Zechmann CM, et al. Multicenter,
Double-Blind,
Randomized,
Intraindividual
Crossover
Comparison of Gadobenate Dimeglumine and Gadopentetate
Dimeglumine for Breast MR Imaging (DETECT Trial).
Radiology. 2011; 258:396-408.
10.Giesel FL, von Tengg-Kobligk H, Wilkinson ID, et al. Influence
of human serum albumin on longitudinal and transverse
relaxation rates (R1 and R2) of magnetic resonance contrast
agents. Invest Radiol 2006; 41: 222–228.
11. Pediconi F, Padula S, Dominelli V, et al. Role of Breast
MR Imaging for Predicting Malignancy of Histologically
Borderline Lesions Diagnosed at Core Needle Biopsy:
Prospective Evaluation. Radiology. 2010; 257: 653-661.
12. Pediconi F, Catalano C, Roselli A, et al. Contrast-enhanced
MR Mammography for Evaluation of the Contralateral Breast
in Patients with Diagnosed Unilateral Breast Cancer or HighRisk Lesions. Radiology 2007; 243: 670-680.
References
1. Kuhl
7. Pediconi F, Catalano C, Occhiato R, et al. Breast lesion
Current
Part
2.
status
of
breast
Clinical
MR
imag-
applications.
Radiology. 2007; 244: 672-91.
2. Braun M, Pölcher M, Schrading S, et al. Influence of pre-
13. Pediconi F, Catalano C, Padula S, et al. Contrast-enhanced
magnetic resonance mammography: does it affect surgical decision-making in patients with breast cancer? Breast
Cancer Res Treat. 2007; 106: 65-74.
operative MRI on the surgical management of patients with
operable breast cancer. Breast Cancer Res Treat. 2008;
111:179-87.
3. Kuhl C, Kuhn W, Braun M, Schild H. Pre-operative staging of
breast cancer with breast MRI: one step forward, two steps
back? Breast. 2007;16 Suppl 2: S34-44.
4. Available at: http://www.medicines.org.uk/emc/medicine/6132/SPC/MultiHance/
5. Pediconi F, Catalano C, Roselli A, et al. The challenge of
imaging dense breast parenchyma: is magnetic resonance
mammography the technique of choice? A comparative
study with x-ray mammography and whole-breast ultrasound.
Invest Radiol. 2009; 44: 412-421.
6. Gilbert FJ, van den Bosch HCM, Petrillo A, et al. Comparison
of gadobenate dimeglumine-enhanced breast MRI and
gadopentetate dimeglumine-enhanced breast MRI with mammography and ultrasound for the detection of breast cancer.
J Magn Reson Imaging. 2013; In press.
11
D I A G N O S T I C I M A G I N G
A S I A
P A C I F I C Autumn 2013
Relaxivity matters…
also in Breast MRI
Superior diagnostic
performance*
vs. gadopentetate dimeglumine
at equivalent dose1
*At equivalent dose of 0.1 mmol/kg, MultiHance provides significantly superior detection of cancer lesions and significantly superior sensitivity, specificity and predictive values for detection/
exclusion of breast regions with cancer lesions than gadopentetate dimeglumine(1)
(1) Martincich et al. Radiology 2011; 258(2):396-408
Please see full Prescribing Information. Before use, please consult the locally approved Summary of Product Characteristics, which will be made available upon request.
MULTIHANCE - SUMMARY OF PRODUCT CHARACTERISTICS MultiHance, 0.5 M solution for injection Composition 1 ml of solution for injection contains: gadobenic acid 334 mg (0.5 M) as the dimeglumine salt. [Gadobenate dimeglumine 529 mg = gadobenic acid 334 mg + meglumine 195 mg]. Excipients Water for injections. Therapeutic indications and dosage This medicinal product is for diagnostic use only. MultiHance is a paramagnetic contrast agent for
use in diagnostic magnetic resonance imaging (MRI) indicated for: MRI of the brain and spine for patients 2 years and older where it improves the detection of lesions and provides diagnostic information additional to that obtained with
unenhanced MRI (0.2 mL/kg); Contrast-enhanced MR-angiography for adult patients where it improves the diagnostic accuracy for detecting clinically significant steno-occlusive vascular disease in patients with suspected or known
vascular disease of the abdominal or peripheral arteries (0.2 mL/kg); MRI of the liver for the detection of focal liver lesions in adult patients with known or suspected primary liver cancer (e.g. hepatocellular carcinoma) or metastatic disease
(0.1 mL/kg); MRI of the breast, for the detection of malignant lesions in patients where breast cancer is known or suspected on the basis of previous mammography or ultrasound results (0.2 mL/kg) Contra-indications MultiHance is
contra-indicated in: patients with hypersensitivity to any of the ingredients; in patients with a history of allergic or adverse reactions to other gadolinium chelates. Special warnings and special precaution for use MultiHance should not
be admixed with any other drug; the product should not be frozen, and it should be used immediately after drawing into the syringe. Patients should be kept under close supervision for 15 minutes following the injection as the majority
of severe reactions occur at this time. The patient should remain in the hospital environment for one hour after the time of injection. The accepted general safety procedures for Magnetic Resonance Imaging, in particular the exclusion
of ferromagnetic objects, for example cardiac pace-makers or aneurysm clips, are also applicable when MultiHance is used. Caution is advised in patients with cardiovascular disease. The use of diagnostic contrast media, such as
MultiHance, should be restricted to hospitals or clinics staffed for intensive care emergencies and where cardiopulmonary resuscitation equipment is readily available. Small quantities of benzyl alcohol (< 0.2%) may be released by gadobenate dimeglumine during storage. Thus MultiHance should not be used in patients with a history of sensitivity to benzyl alcohol. As with other gadolinium-chelates, a contrast-enhanced MRI should not be performed within 7 hours of a
MultiHance-enhanced MRI examination to allow for clearance of MultiHance from the body. Impaired renal function Prior to administration of MultiHance, it is recommended that all patients are screened for renal dysfunction by obtaining
laboratory tests. There have been reports of nephrogenic systemic fibrosis (NSF) associated with use of some gadolinium containing contrast agents in patients with acute or chronic severe renal impairment (GFR < 30 ml/min/1.73 m2).
Patients undergoing liver transplantation are at particular risk since the incidence of acute renal failure is high in this group. As there is a possibility that NSF may occur with MultiHance, it should therefore be avoided in patients with severe
renal impairment and in patients in the perioperative liver transplantation period unless the diagnostic information is essential and not available with non-contrast enhanced MRI. Haemodialysis shortly after MultiHance administration may
be useful at removing MultiHance from the body. There is no evidence to support the initiation of haemodialysis for prevention or treatment of NSF in patients not already undergoing haemodialysis. Elderly As the renal clearance of gadobenate dimeglumine may be impaired in the elderly, it is particularly important to screen patients aged 65 years and older for renal dysfunction. Undesirable effects The following adverse events were seen during the clinical development of
MultiHance among 2637 adult subjects. There were no adverse reactions with a frequency greater than 2%. Common (≥ 1/100, < 1/10): Nervous system disorders; Headache. Gastrointestinal disorders; Nausea. General disorders and
administration site conditions; Injection site reaction, feeling hot. Uncommon (≥ 1/1,000, < 1/100): Infections and infestations; Nasopharyngitis. Nervous system disorders; Paraesthesia, dizziness, syncope, parosmia. Cardiac disorders;
Tachycardia, atrial fibrillation, first-degree atrioventricular block, ventricular extrasystoles, sinus bradycardia. Vascular disorders; Hypertension, hypotension. Respiratory, thoracic and mediastinal disorders; Rhinitis. Gastrointestinal disorders; Dry mouth, taste perversion, diarrhoea, vomiting, dyspepsia, salivation, abdominal pain. Skin & subcutaneous tissue disorders; Pruritus, rash, face oedema, urticaria, sweating. Musculoskeletal, connective tissue and bone disorders;
Back pain, myalgia. General disorders and administration site conditions; Asthenia, fever, chills, chest pain, pain, injection site pain, injection site extravasation. Investigations; Abnormal laboratory tests, abnormal ECG, prolonged QT. Rare
(≥ 1/10,000, < 1/1,000): Nervous system disorders; Hyperaesthesia, tremor, intracranial hypertension, hemiplegia. Eye disorders; Conjunctivitis. Ear and labyrinth disorders; Tinnitus. Cardiac disorders; Arrhythmia, myocardial ischaemia,
prolonged PR interval. Respiratory, thoracic and mediastinal disorders; Dyspnoea N.O.S., laryngospasm, wheezing, pulmonary congestion, pulmonary oedema. Gastrointestinal disorders; Constipation, faecal incontinence, necrotising
pancreatitis. Renal and urinary disorders; Urinary incontinence, urinary urgency. General disorders and administration site conditions; Injection site inflammation. Additional safety information Laboratory abnormalities cited above include
hypochromic anaemia, leukocytosis, leukopenia, basophilia, hypoproteinaemia, hypocalcaemia, hyperkalaemia, hyperglycaemia or hypoglycaemia, albuminuria, glycosuria, haematuria, hyperlipidaemia, hyperbilirubinaemia, serum iron
increased, and increases in serum transaminases, alkaline phosphatase, lactic dehydrogenase, and in serum creatinine and were reported in equal or less than 0.4% of patients following the administration of MultiHance. However these
findings were mostly seen in patients with evidence of pre-existing impairment of hepatic function or pre-existing metabolic disease. The majority of these events were non-serious, transient and spontaneously resolved without residual
effects. There was no evidence of any correlation with age, gender or dose administered. Paediatric In paediatric patients enrolled in clinical trials the most commonly reported adverse reactions included vomiting (1.4%), pyrexia (0.9%)
and hyperhydrosis (0.9%). The frequency and nature of adverse reactions was similar to that in adults. In marketed use, adverse reactions were reported in fewer than 0.1% of patients. Most commonly reported were: nausea, vomiting,
Signs and symptoms of hypersensitivity reactions including anaphylactic shock, anaphylactoid reactions, angioedema, laryngeal spasm and rash. Injection site reactions due to extravasation of the contrast medium leading to local pain or
burning sensations, swelling and blistering have been reported. Isolated cases of nephrogenic systemic fibrosis (NSF) have been reported with MultiHance in patients co-administered other gadolinium-containing contrast agents. Please
note The peel-off tracking label on the vials should be stuck onto the patient records to enable accurate recording of the gadolinium contrast agent used. The dose used should also be recorded. Consult the locally approved package
insert. The Marketing Authorisation Holder, the Marketing Authorisation number and the date of approval may be different in different countries. Date of revision of this text March 2013.
therapy
By Prof. Peter Metcalfe
An enhanced role for MRI
in Radiation Therapy
MRI provides unrivalled detail about tumor location extent and biological status. This article explores the hypothesis that enhanced use of MRI will enable
improved radiation therapy treatment regimens for cancer patients. MRI provides important image information to better enable radiation therapy treatment planning, treatment response monitoring and image guidance.
RADIATION TREATMENT PLANNING
Developments in external beam radiation therapy using
medical linear accelerators (linacs) and internal brachytherapy sources have enabled a precise match of radiation
dose to the tumor volume. If we use computed tomography
(CT) imaging alone, two fundamental questions remain.
Exactly where is the tumor and how far does it extend?
Hence wide margins (typically 10mm) are included that
encompass normal tissue and thus increase toxicity of the
radiation treatment.
Prior to patient treatment the radiation dose is calculated
on a computerised radiation therapy treatment planning
system (TPS). For visualization the radiation dose is presented as a series of isodose levels painted onto each CT slice.
CT images provide geometric integrity and electron density
information that ensure accurately predicted radiation dose.
Unfortunately CT images are devoid of detailed soft tissue
information.
What does Magnetic resonance imaging (MRI) bring to the
party?
MRI provides high-resolution anatomical information with
excellent soft-tissue contrast. The most commonly used of
the MR-visible nuclei is the hydrogen proton, which produces the strongest signal and is abundant in the body (primarily as water and fat). MR images exploit the differences
in either “longitudinal” (T1) or “transverse” (T2) relaxation
times of fat and water, producing large variations in contrast.
T1-weighted images are considered best for gross structural
information (anatomy) and T2-weighted images for biological characteristics (pathology). A multitude of sequences
can be applied to provide unlimited potential in the assessment of soft tissue anatomy and surrogates for pathologic
tumor properties. Beyond this, new MRI techniques, broadly
termed “functional MRI” can provide information about
tumor perfusion vascular permeability, extracellular space
tortuosity, metabolic status and hypoxia. A recent article
by this author and colleagues in “Technology in Cancer
Research and Treatment” discusses these techniques in more
detail [1].
Advanced tools exist for registering and overlaying MRI on
CT data sets. The fused image combines a geometrically
sound electron density map for dose calculation from CT
and better soft tissue contrast from the MRI. This provides
more accurate visualization of position, volume and shape
of the tumor, hence smaller treatment margins are possible.
The brain was the first site where MRI was routinely used in
TPS applications. MRI images are routinely used to identify
and locate brain tumors such as gliomas. Figure 1 shows a
typical CT and MRI image set for brain (Courtesy [1]). The
T1-weighted high-resolution 3D spoiled gradient method is
used to define the gross visible disease, which is the region
of the blood-brain barrier breakdown, while the clinical
target volume is defined using the T2-weighted image series
on which the extent of the edema thought to harbor microscopic disease is delineated. In the treatment of arteriovenous
malformations (AVMs), magnetic resonance angiography
is employed for the definition of the nidus. These can then
be treated with a Gamma Knife or stereotactic radiosurgery
on a linac.
Dynamic MRI can be used to image patient-specific tumors for planning of lung cancers for
radiotherapy at frame rates of ~4 images per second.
This allows the lung to be imaged fast enough to analyze
The Author:
Prof Peter Metcalfe holds the Chair in Radiation Oncology
Physics at the Centre for Medical Radiation Physics, University
of Wollongong, Australia. The Chair is supported by the Cancer
Institute of New South Wales. He is also a member of the Ingham
Institute of Applied Medical Research, Liverpool, Sydney, Australia.
13
D I A G N O S T I C I M A G I N G
FIGURE 1. CT (left panel) co-registered with a T1-3D-SPGR MRI image set
(right panel). The difference in tumor visualization can be clearly appreciated
between the between the two panel. (Image reproduced with permission from
Technology in Cancer Research and Treatment, Adenine Press. Reference [1]).
A S I A
P A C I F I C Autumn 2013
FIGURE 2. Axial, Coronal and Sagittal plane of a T2 weighted Single Shot Fast Spin Echo image (SSFSE) of a Small Cell Lung Cancer for a 64 year old male with T4 N2
M0 disease. T2 images generally used to define pathology, fat tends to appear black on T2 images. Shows excellent differentiation noted between mediastinum and tumor
mass (Image reproduced with permission from Technology in Cancer Research and Treatment, Adenine Press. Reference [1]).
true motion and deformation over the
breathing cycle. 4DCT can also image
lung however not all tumors are visible
and they suffer from motion artifacts.
Tumor extent is clearly visible on MRI as
shown in Figure 2. This is a typical lung
image obtained in three planes using
MRI (courtesy [1]).
Various structures in the prostate such
as the apex and penile bulb are more
clearly visible using MRI [2]. There is
also clear indication for MRI in cases
with prosthetic hip replacements where
CT is adversely effected by artifacts
from the high density and high atomic
number prostheses [3].
MRI is well established as the optimum
imaging modality for cervical-cancer
diagnosis in comparison to CT and
clinical examination. MRI is considered
the imaging modality of choice for cervix contouring in TPS, with significant
improvement in contrast between the
target volume and normal tissues [4.
Breast patients present an interesting
challenge for use of MRI in TPS. While
MRI is ideal for tumor extent [5] the
set ups are contradictory, prone breast
coils are used for imaging while most
patients are treated in the supine position. Research into breast coils that
are effective in the supine position is
continuing.
Most MRI machines are housed in diagnostic imaging departments. Currently
only about 10% of radiation therapy
patients receive an MRI image specifically for RTP. A contributing factor may
be accessibility. Hence a new trend is
developing. Radiation therapy departments are installing MRIs in-house. Some
specialized requirements for MRI devices
for radiation therapy treatment planning
applications include:
FIGURE 3. MRI images and ADC maps at various stages of radiotherapy (a) before radiotherapy (b) mid
treatment (c) Post-treatment. Green no change in ADC, red ADC increased, blue ADC has decreased at the
assessment time. (Image reproduced with permission from Technology in Cancer Research and Treatment,
Adenine Press. Reference [1]).
14
D I A G N O S T I C I M A G I N G
A S I A
i) large bore (at least 70cm) to fit in patient
positioning devices,
ii) flat table top to mimic patient positioning on linac
iii) patient skin off set surface coils to
avoid patient contour distortion
iv) MR compatible immobilization devices
(not carbon fibre)
v) The jury is still out on 1.5 T (geometry)
or 3 T (signal to noise)
For historical reasons CTs in Radiotherapy
departments are called “CT-simulators”
hence MR devices in radiation therapy
departments are likely to be identified as
“MR-simulators”.
TREATMENT RESPONSE MONITORING
Normal tissue is best spared when radiation therapy is fractionated. Fractionation means the dose is given in small,
equal amounts. One fraction is typically
2 Gray of radiation dose per day. One
fraction of dose is given per day over
several weeks of treatment. The ready
access to MR-simulators in radiation
therapy departments may enable more
repeat scans during the course of treatment. The hope is that this may lead to
individual patient treatment response
monitoring.
Tracking the likelihood of local recurrence during the course of a radiation
therapy treatment is in its infancy. While
there are several other promising functional MR methods we will restrict discussion here to one in particular that
shows promise for treatment response
monitoring. Diffusion weighted (DW)MRI scan sequences produce image
contrast that depends on differences in
tissue-water mobility. Two equally large,
opposing gradient pulses in the diffusion sequence make the signal intensity
dependent on the movement of water
P A C I F I C Autumn 2013
FIGURE 4. Schematic of the MRI-linac design being installed at the Ingham Institute
of Applied Medical Research in Sydney this December. The magnet is a split bore
1T design. Two linac orientations are being tested to explore impact on dose at
interfaces (adapted with permission from reference [11]).
molecules. The apparent diffusion coefficient (ADC), in units
mm2/s, is the metric used for the assessment of water diffusion
through tissue.
To explore the potential to reliably compare intra- and post-treatment images with pre-treatment images, i.e. using voxel-based
ADC maps at various time points to predict the response of brain
metastases to whole-brain radiotherapy, diffusion-mapping techniques have been developed that allow the reliable comparison of
intra- and post-treatment images with pre-treatment images [ ].
An example is shown in Figure 3 (courtesy [1]). An increase
in ADC (red points) in a voxel indicates increased diffusion
distance of the water molecules, and hence a decrease in cell
density, which could indicate that the volume is responding
to therapy. In the same way, no change in ADC (green points)
could indicate no response to therapy, and a decrease in ADC
(blue points) indicates a decreased diffusion distance of water
molecules, and hence an increase in cell density, which could
indicate a proliferating volume of cells during therapy. The
technique is also being tested with head and neck, breast and
prostate patient cohorts although lymphatic structures may
be a confounding factor for ADC analysis at typical clinical
voxel resolutions [7].
IMAGE GUIDANCE USING MRI-LINAC: THE FUTURE?
The common scenario for daily alignment of patients prior to treatment with the linac is to use an X-ray tube with flat panel detector
combination mounted on the linac gantry at an angle off-set to the
linac treatment head. The device is rotated prior to treatment and
a Cone Beam CT image is produced. Then the patient is relocated
by a couch shift to a position that best registers the Cone beam
image with the original planned CT. We call this image guided
radiation therapy.
In such scenarios repeat image guidance scans using these
devices in the radiotherapy setting increase the small probability of secondary primary tumor induction. Because MRI
does not rely on ionizing radiation for imaging, there is no
increased potential induction of secondary primary malignancies associated with its use in image guidance. Hence the
development of MRI machines for image guidance becomes a
favorable proposition. The ability to image mobile tumors in
particular lung or liver using MRI is even more compelling.
Autumn 2013
Building a combination MRI-linac is not a trivial technical
exercise. Apart from the engineering challenges of RF perturbation from the linac, there is the requirement to account
for various electron-beam perturbation effects that affect the
paths of electrons generated by x-rays and hence the dose at
regions such as the patient skin and lung-tissue interfaces [8].
Despite these developmental difficulties two groups (located
at Utrecht and Edmonton) have developed prototype MRIlinac devices [9, 10 ]. Figure 4 shows a schematic of an MRIlinac prototype design concept that is about to be installed
at the Ingham Institute in Sydney [11]. It is envisaged these
devices will enable MRI to be used for on-line real time imageguided radiation therapy. In other words tracking moving
tumors with MRI while treating them in parallel with a linear
accelerator in real time.
MR-simulators used off line at various time points within the
treatment cycle will ensure we have an accessible imaging tool
for cancer patient tumor volume definition and treatment
response monitoring. MRI-linacs may also provide viable online image guidance solutions in the near future.
Acknowledgement:
I would like to acknowledge information included in the
manuscript from Gary Liney, Lois Holloway, Wolfgang
Tomé and Paul Keall who is directing the MRI-linac project
at Ingham.
References
1. Metcalfe P., Liney G., Holloway L., Walker A., Barton M., Delaney G., Vinod S., Tomé
W., The Potential for an Enhanced Role For MRI in Radiation Therapy Treatment
Planning Technology in Cancer Research and Treatment ISSN 1533-0346
2013 April 24. Epub ahead of print. © Adenine Press (2013)
2. McLaughlin, P., Narayana, V., Meirowitz, A., Troyer, S., Roberson, P., Gonda, R.,
Sandler, H., Marsh, L., Lawrence, T., Kessler, M. Vessel-sparing prostate radiotherapy: dose limitation to critical erectile vascular structures (internal pudendal
artery and corpus cavernosum) defined by MRI. International Journal of Radiation
Oncology Biology Physics 2005; 61, 20-31.
3.Rosewall, T., Kong, V., Vesprini, D., Catton, C., Chung, P., Ménard, C., Bayley, A.
Prostate delineation using CT and MRI for radiotherapy patients with bilateral hip
prostheses. Radiotherapy and Oncology 2009; 90: 325-330.
4. Lim, K., Small, W., Portelance, L., Ceutzbrg, C. et al. Consensus Guidelines for
delineation of clinical target volume for intensity-modulated pelvic radiotherapy
for the definitive treatment of cervix cancer. International Journal of Radiation
Oncology Biology Physics 2011; 79, 348-355.
5. Schmitz., A., van den Bosch, M., Loo, C., Mali, W., Bartelink, H., Gertenbach M.,
Holland R., Peterse J., Rutgers E., Gilhuijs K., Precise correlation between MRI and
histopathology-Exploring treatment margins for MRI-guided localized breast cancer
therapy, Radiotherapy and oncology, 2010; 97: 225-232.
6. Hamstra, D. A., Galbán, C. J., Meyer, C. R., Johnson, T. D., Sund- gren, P. C., Tsien,
C., Lawrence, T. S., Junck, L., Ross, D. J., Rehem- tulla, A. Functional diffusion
map as an early imaging biomarker for high-grade glioma: correlation with conventional radiologic response and overall survival. Journal of Clinical Oncology
2008; 26:3387-3394.
7. Bourne, R., Kurniawan, N., Cowin, G., Sved, P., Watson, G. 16 T Diffusion microimaging of fixed prostate tissue: preliminary findings. Magnetic Resonance in Medicine
2011; 66: 244-247.
8. Oborn, B. M., Metcalfe, P., Butson, M., Rosenfeld, Keall P. A. Monte Carlo characterization of skin doses in 6MV transverse field MRI-linac systems: effect of
field size, surface orientation, magnetic field strength, and exit bolus. Medical
Physics 2010; 37: 5208 -5217. Raaijmakers, A., Raaymakers, B., Van der Meer,
S., Lagendijk, J. Integrating a MRI scanner with a 6MV radiotherapy accelerator: impact of the surface orientation on the entrance and exit dose due to
the transverse magnetic field. Physics in Medicine and Biology 2007; 52:
929-939.
10. Fallone, B., Carlone, M., Murray, B., Rathee, S., Stanescu, T., Steciw, S.,
Wachowicz, K, Kirkby, C. TU-C-M100F-01: Develop- ment of a linac-MRI system for real-time ART. Medical Physics 2007; 34: 2547.
11. Constantine D., Fahrig R., Keall P. A study of the effect of in-line and perpendicular magnetic fields on beam characteristics of electron guns in medical
linear accelerators. Medical Physics 2011; 38: 4174-4184.
D I A G N O S T I C I M A G I N G
A S I A
P A C I F I C 15
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Ultrasound elastography
By Dr Vivian Y. F. Leung & Prof Winnie C. W. Chu,
Accurate assessment
of liver fibrosis
Patients with chronic hepatitis B are at increased risk of cirrhosis.
Assessment of fibrosis has important prognostic implications that can
guide clinical therapy.
This article describes the results of a recent study, carried out in a large
group of normal subjects and chronic hepatitis B patients, to evaluate the utility of ShearWave Elastography (SWE) for assessment of liver
fibrosis. The results were correlated with those of biopsies.
The study established clear benefits from the use of SWE in HBVinfected patients and showed that the measured liver elasticity was correlated with the stage of liver fibrosis. Measurement of the stiffness of
the spleen by SWE may also be useful, especially in cases where SWE
of the liver is difficult
The Need for Better Assessment
Conventional ultrasound already helps radiologists detect and manage liver nodules, hepatocellular carcinomas, and also guide minimally
invasive treatments of liver lesions. However, for
patients with chronic liver diseases, and especially Hepatitis B infection, conventional ultrasound has some distinct limitations. To effectively
treat patients affected by chronic Hepatitis B virus
(HBV), physicians need an accurate quantification
of liver fibrosis—and that is one function conventional ultrasound does not perform well.
ShearWave Elastography (SWE) may fill this gap.
Not only does SWE acquire images 200 times faster
than conventional ultrasound, it yields quantitative information about tissue elasticity. Integrated
The authors:
Vivian Y. F. Leung Ph.D. & Winnie C. W. Chu, M.D. are at:
Department of Imaging and Interventional Radiology
The Chinese University of Hong Kong,
Prince of Wales Hospital, Shatin, New Territories, Hong Kong
SAR, China
e-mail: [email protected]
AUTUMN 2013 2013 into the Aixplorer ultrasound system (from the
French-based company Supersonic Imagine), SWE
displays this quantitative information (measured in
kilopascals) in an easily interpretable color-coded
display, and can also superimpose the data over
B-mode images. The ability of Shear Wave Elastography to quantify tissue stiffness could prove
useful in assessing and managing chronic Hepatitis
B infection.
Studying ShearWave Elastography in Liver Patients
Basing ourselves on previously published research
which showed the benefits of the technology for
managing chronic liver disease due to Hepatitis C
[1,2], we set out to evaluate SWE on patients with
chronic Hepatitis B. We used SWE to study liver
and spleen stiffness in a large group of normal
subjects and proven chronic Hepatitis B carriers,
and correlated the results with those of biopsies
[3].
Not only did we find that SWE measurements
correlated more accurately with liver fibrosis than
another non-invasive methods, we discovered that
SWE measurements of the spleen might also help
D I A G N O S T I C I M A G I N G
A S I A
P A C I F I C 17
Ultrasound elastography
assess advanced fibrosis.
Broadly, the study established clear
benefits from the use of SWE with
HBV-infected patients and indicated that further benefits could
also be achievable. Of these, the
most exciting is the possibility that
SWE could improve the indications
for biopsy, although this would of
course need further confirmation
by large prospective studies of
HBV-infected patients.
More immediately, however, the
study determined optimal cutoff values (in kilopascals) for
distinguishing cirrhosis, severe
fibrosis, and significant moderate fibrosis. Especially in cases of
significant moderate fibrosis, in
which conventional ultrasound
is insensitive, the demonstrated
accuracy of SWE measurements
could be crucial in indicating
the appropriate treatment. SWE
is particularly useful for assessing early fibrotic stage METAVIR F2.
Case studies
A. SWE assessment of
severe liver fibrosis
This 55 year-old male HBV carrier
was an ex-smoker, non-drinker, and
presented with colonic polyp. His
liver function was impaired, with
fluctuating alanine aminotransferase (ALT) levels up to 91 IU/L. Gray
scale ultrasound of the liver showed
only mild coarsening of the echotexture. SWE of the liver was performed
[Figure 1]. and liver stiffness was
measured at 9.7 kPa (1.8 m/s), which
was graded as F≥3 Biopsy proved a
METAVIR score F3.
B. Moderate liver fibrosis
assessed by both liver and
spleen stiffness
FIGURE 1. Case A. A 55 year old male HBV carrier in whom liver stiffness was measured at 9.7 kPa with SWE,
which was suggestive of a severe fibrsosis level (F≥3). Liver biopsy confirmed a Metavir F3 score.
This 63 year-old male HBV carrier ceased smoking and alcohol
consumption in 2000. He presented with reflux esophagitis.
On the ultrasound examination, the liver showed a normal echotexture and a spleen of
normal size with homogenous
echotexture. A SWE analysis of
the liver parenchyma and spleen
was performed [Figure 2]. Liver
elasticity was measured to be 7.3
kPa (1.6 m/s). that is corresponding to F≥2, while spleen elasticity was measured at 19.7 kPa (2.6
m/s) which was approaching the
F≥2 splenic cut-off value found
to be 19.8 kPa (2.6 m/s) in our
experience. Liver biopsy proved
a METAVIR F2 score, thus confirming that SWE was able to
correctly assess liver fibrosis in
this case.
Can the Spleen Bring Insight
to Liver Fibrosis Staging?
FIGURE 2. Case B. 63 year old Male HBV carrier. The SWE measurement results were 7.3 kPa for liver elasticity
(corresponding to F≥2) and 19.7 kPa for the spleen elasticity F≥2 cut-off value. The liver biopsy showed a
Metavir score of F2, a direct correlation with the SWE measurement.
18
D I A G N O S T I C I M A G I N G
A S I A
Due to its relationship with the
liver, the spleen may offer new
insights into liver fibrosis staging. The progression of liver
P A C I F I C AUTUMN 2013 2013
fibrosis often prompts architectural changes to the spleen as well,
probably due to hemodynamic
alterations. The increase in spleen
stiffness does not follow the same
progression curve as the liver and
we found that using SWE on the
spleen did not yield as accurate a
result as using SWE directly on the
liver.
Nevertheless, in cases where the
liver is too small for an appropriate reading to be made or where
there is some other impediment
to liver measurement, the spleen
can be considered as an organ
which can yield ancillary parameters to support the diagnosis of
severe fibrosis and cirrhosis in
suspicious cases.
Conclusion
Through the use of better-honed
cut-off values for the staging
of liver fibrosis and accurate,
quantitative assessment of liver
stiffness as measured by ShearWave Elastography, physicians
can provide earlier and higher
quality care to HBV-infected
patients. The additional use of
SWE for splenic measurements
may also improve diagnosis and
treatment, especially in patients
whose liver disease is already
so severe that their livers cannot be measured adequately. The
shear wave technology can also
be helpful in monitoring the
response to treatment in patients
who have contraindications to
invasive techniques.
References
1. B
avu E, Gennisson JL, Couade
M, Bercoff J, Mallet V, Fink M,
Badel A, Vallet-Pichard A, Nalpas
B, Tanter M, Pol S. Noninvasive in
vivo liver fibrosis evaluation using
supersonic shear imaging: a clinical study on 113 hepatitis C virus
patients. Ultrasound Med Biol.
2011 Sep;37(9):1361-73.
2. Ferraioli G, Tinelli C, Dal Bello B,
Zicchetti M, Filice G, Filice C; Liver
Fibrosis Study Group. Accuracy of
real-time shear wave elastography for assesing liver fibrosis in
chronic hepatitis C: a pilot study.
Hepatology. 2012 Dec;56(6):212533.
3. L eung VY, Shen J, Wong VW, Abrigo
J, Wong GL, Chim AM, Chu SH, Chan
AW, Choi PC, Ahuja AT, Chan HL,
Chu WC. Quantitative Elastography
of Liver Fibrosis and Spleen
Stiffness in Chronic Hepatitis B
Carriers: Comparison of ShearWave Elastography and Transient
Elastography with liver biopsy correlation. Radiology. 2013 Aug 2.
[Epub ahead of print]
EXPERT EDITION
As ShearWave™ Elastography is a real-time,
quantitative, non-invasive and reproducible method,
it will be helpful in validating the absence of fibrosis
in order to reduce the number of unnecessary liver
biopsies as well as to confirm cirrhosis to avoid
dangerous biopsies and the possibility of
hemorrhage.
Aymeric Guibal MD, PhD
Hôpital de Perpignan, France
Liver / Prostate / Thyroid / Vascular / Musculoskeletal / Abdomen / Gynecology / Obstetrics / Breast / Breast 3D / Pediatrics
AUTUMN 2013 2013 D I A G N O S T I C I M A G I N G
A S I A
P A C I F I C 19
TEC H NOLOGY update
Compact Ultrasound
Endoscopic system
The recently launched EU-ME2
endoscopic ultrasound center from
Olympus delivers higher resolution images than previous models
in the range while maintaining the
same compact size of the previous models. The new system also
features a variety of new functions
such as the Tissue Harmonic Echo
mode which reduces artifacts by
image signal processing to achieve
a clearer image, The Elastography
mode displays the relative stiffness of tissue. The Pulse Wave
Doppler mode measures the speed
and amount of blood flow and the
H-FLOW (High Resolution Flow)
mode can display small vessels Last
but not least, thanks to its compact
size it fits on Olympus’ endoscopy
system trolley, and ensures the
compatibility with other Olympus’
endoscopy systems for efficient
examinations.
Olympus
tokyo, jAPAN
WWW.OLYMPUS.COM
2MP color diagnostic display
Featuring LED backlights and a
unique front-of-screen sensor for
on-demand image quality checks,
the new Nio Color 2MP LED diagnostic display from Barco provides
an effective solution for a multitude of applications and modalities, including 3D PACS, 3D echo,
ultrasound, orthopedic imaging,
CAD, image fusion, nuclear medicine and PET. The new system has
a high-bright LCD panel with a display resolution of 1600 x 1200 pixels. Featuring a DICOM calibrated
luminance of 400 cd/m² throughout its entire lifetime, the new dis-
20
play system is perfectly adapted for
multi-modality diagnostic imaging. With unrivaled color accuracy,
accurate grayscales, a high contrast
ratio (1400:1) and a 178° viewing
angle to ensure confident image
reading the new display comes with
integrated Backlight Output Stabilization technology, ensuring fast
power-up and long-term luminance
stability. The on-demand image
quality checks ensure maximum
uptime of the display. Additionally,
the LED backlights produce less
heat, require less cooling and thus
reduce overall operational costs for
the hospital.
Barco
Kortrijk, Belgium
www.barco.com
for advanced applications such
as the Contrast Enhanced Ultrasound (CEUS) imaging package
and the Elastography package
The Xario is built on high density imaging architecture and so
Toshiba could transfer almost all
imaging enhancement technologies previously developed for the
Aplio class onto the new Xario
platform These include Precision
Imaging, ApliPur+, Advanced
Dynamic Flow (ADF), and even
Differential Tissue Harmonic
Imaging, a Toshiba proprietary
wideband technology that provides deep penetration capability and excellent resolution at the
same time. High quality transducers are particularly important
for a “workhorse” like the Xario
which comes with a range of
a new type of wide bandwidth
transducers, from standard models to specialty The transducers
are lightweight and designed to
Smaller, smarter, simpler
Ultrasound
The new Xario 200 and Xario
100 models from Toshiba have
been positioned to address the
higher-mid range segment of
the market, that is just below
the premium-high segment of
the company’s established Aplio
series. The new models are
designed to provide top performance in a small package, providing top image quality, versatility and flexible workflow and are
highly mobile for easy movement
between departments throughout
the hospital. The Xario 100 model
covers a wide range of basic applications including cardiovascular
and 3D/4D imaging, with excellent image quality, whereas the
Xario 200 model can be equipped
D I A G N O S T I C I M A G I N G
A S I A
be easy to handle. The image
quality for fetal diagnostics is
high and comes very close to that
of the Aplio.
Toshiba,
Tokyo, Japan
www.toshiba.com.
P A C I F I C AUTUMN 2013 2013
World launch of High-end Dual Source CT
The newly introduced Somatom Force CT system from
Siemens is a Dual Source high-end CT capable of offering individualized diagnoses especially for challenging
patients, e.g. for very young patients, the seriously ill,
and obese patients. Patients suffering from renal insufficiency will benefit from the significant reduction in
contrast medium. Up to 20 percent of patients suffer
from renal insufficiency and contrast medium containing iodine can place extra burden on the kidneys of older
patients and those with chronic illnesses in particular.
Initial examinations show that the average quantity of
contrast medium administered in thoracic examinations
can be lowered from between 90 and 110 mL to between
25 and 35 mL. This is made possible by the two Vectron
X-ray tubes in Somatom Force, which enable routine
examinations at particularly low tube voltages of 70 to
100 kilovolts. As the contrast-to-noise ratio rises, the
amount of contrast medium can be lowered accordingly.
The new system can also deliver considerable added
value in treatment control. 4D imaging, which shows the
function of organs and vessels next to their morphology,
is particularly important here because it allows addi-
C-arm with high operability and
image quality
The new Opescope Acteno C-Arm
system from Shimadzu enables free
AUTUMN 2013 2013 tional information to be gleaned about primary tumors
and metastases. A disadvantage of this dynamic perfusion is that – up to now – high dose values of more than
50 mSv were required in certain cases. This dose can now
be more than halved with Somatom Force. In some preliminary cases, just 14.7 mSv was required. Such values
enable the procedure to be used routinely, thus enabling
quicker and more well-founded decisions to be made
about which treatment is most suitable for an individual
patient “
The NLST lung cancer screening study conducted in
the U.S. has prompted a realignment of priorities in cancer prevention: the study showed that mortality rates can
be reduced by 20 percent if early lung cancer detection
is performed with lowdose CT rather than conventional
chest X-rays. The new Somatom Force is particularly
suitable for such early detection examinations thanks to
its previously unattained low dose values. Up to 50 percent lower than that of previous high-end CTs, this low
dose is a result of the “Turbo Flash Mode” of the system
and the use of two special spectral filters – Selective
Photon Shields – which optimize the X-ray spectrum and
thus significantly improve the air/soft-tissue contrast. It
has been shown that lung scans can be acquired at dose
values of 0.1 mSv.
Another advantage in pulmonary diagnostics is the
enlarged field of view (50 cm) of the “Turbo Flash Mode”.
With an acquisition rate of almost 400 mm per second
this allows the entire thorax to be scanned in around one
second With the fastest acquisition rate on the market
(737 mm/s) entire thoracic-abdominal examinations can
even be performed in just one second, thus removing the
need for breath-hold. Even high heart rates do not lead to
disruptive motion artefacts in clinical images.
Siemens
Erlangen, Germany
www.siemens.com
and easy positioning and optimal performance to meet the demands of the
operation room and emergency room.
The total system guarantees both high
image quality and ease of use. The fully
counter-balanced C-arm provides extralight and quick C-arm movements and
positioning and the exclusive manual
C-arm vertical movements enables
much quicker height adjustments in
routine operation. Shimadzu’s unique
C-arm lock/release button at the image
intensifier enables the C-arm to be positioned from the clinician’s side without
going back to the cart-unit. The enlarged
D I A G N O S T I C I M A G I N G
78cm wide opening of the C-arm makes
approaches to the patient easy, minimizing the chance of contact with the operating table. On the other hand, the small
width of the system of just 80cm makes
it much easier to move through narrow
doors or to position it in busy operation rooms which are frequently already
encumbered with many surgical devices.
The absence of levers and cables on the
C-arm makes it easy to wipe and keep
clean.
Shimadzu,
Tokyo, Japan
www.shimadzu.com
A S I A
P A C I F I C 21
TECHNOLOGY update
30-inch color LCD monitor for
multi-modality applications.
The 6 megapixel screen of the
RadiForce RX650 provides enough
space to display numerous applications at once, making it an effective
replacement for a dual 3 megapixel
monitor setup. In addition, medical professionals can conveniently
view images side-by-side without
the obtrusive bezels typically found
in a multi-monitor environment.
The monitor gives users full control
of the layout on screen to streamline
the radiology workflow. The monitors new design saves more space
than a typical multi-monitor setup to
make the work area more efficient. In
addition, the narrow space between
the bezels and the screen also make
cleaning easy.
To meet DICOM Part 14* international standards, EIZO carefully
measures and sets each grayscale tone
on the production line for the most
consistent shadings possible. With the
RadiForce RX650, both monochrome
and color images can be viewed at
individually optimized brightness
levels and tones using EIZO’s Hybrid
Gamma feature to expand the usability of multi-modality applications. An
Integrated Front Sensor (IFS) housed
within the front bezel performs convenient, hands-free quality control
calibration. While in use, the sensor
does not interfere with the viewing
area to dramatically cut the workload
and maintenance costs associated with
maintaining monitor quality control.
EIZO Corporation
Ishikawa, Japan
www.eizo.com
22
Live 3D holographic imaging in interventional cardiology
The Dutch-based giant Philips and
the Israeli company RealView Imaging
have announced the completion of a
clinical study that has successfully demonstrated the feasibility of using live 3D
holographic visualization and interaction technology to guide minimallyinvasive structural heart disease procedures. In the pilot study that involved
eight patients and was conducted in
collaboration with the Schneider Children’s Medical Center in Petach Tikva,
Israel, RealView’s visualization technology was used to display interactive, realtime 3D holographic images acquired
by Philips’ interventional X-ray and
cardiac ultrasound systems.
In addition to viewing the patient’s
heart on a 2D screen, clinicians in the
interventional team were able to view
detailed dynamic 3D holographic
images of the heart ’floating in free
space’ during a minimally-invasive
structural heart disease procedure,
without using special eyewear. The doctors were also able to manipulate the
projected 3D heart structures by literally touching the holographic volumes
in front of them.“The holographic
projections enabled me to intuitively
understand and interrogate the 3D
spatial anatomy of the patient’s heart,
as well as to navigate and appreciate
the device-tissue interaction during
the procedure,” said Dr. Einat Birk,
pediatric cardiologist and Director of
the Institute of Pediatric Cardiology at
Schneider Children’s Medical Center.
The ability to reach into the image
and apply markings on the soft tissue
D I A G N O S T I C I M A G I N G
A S I A
anatomy in the X-ray and 3D ultrasound images could be extremely
useful for guidance of these complex
procedures. Progress in image-guided
therapies for heart diseases — from
the opening of obstructed coronary
arteries to catheter ablation therapy
for heart arrhythmias and catheterbased structural heart repairs — have
greatly increased the need for live
3D image guidance, to supplement
today’s live 2D image guidance. Live
X-ray and live 3D cardiac ultrasound
imaging are typically used simultaneously to guide minimally invasive
structural heart repair procedures,
with the ultrasound images providing
detailed insights into the heart’s soft
tissue anatomy, and the X-ray imaging providing visualization of catheters and heart implants. The technological advancements in the acquisition of live 3D images to guide minimally invasive procedures have also
triggered the development of novel
ways to visualize the data. Following
the promising results produced by
this pilot study, Philips and RealView
Imaging will continue to explore the
clinical value of combining live 3D
imaging and medical holography,
both in interventional cardiology and
in other clinical areas.
Philips
Eindhoven, The Netherlands
www.philips.com/newscenter.
RealView Imaging
Yokneam, Israel
www.realviewimaging.com.
P A C I F I C AUTUMN 2013 2013
TECHNOLOGY update
Cone Beam CT system with
large FOV for Head and Neck
imaging
Image enhancement software for Point of Care ultrasound
Original.
Particularly suitable for in-office
use the new Scanora 3Dx cone beam
CT system from Soredex has a large
field of view (FOV) and is designed
for head and neck imaging. The system
is intended for wide application areas
ranging from single dental implant
planning with small FOV up to whole
skull imaging with extra large FOV. The
system is thus ideal for ENT, dentomaxillofacial and cranial examinations
in imaging centers, ENT offices, total
care oral and maxillofacial clinics and
hospitals.
The new system is the latest member of the company’s SCANORA CBCT
product family. Compared to its predecessors, however, the SCANORA 3Dx
has a larger flat panel detector that
now enables a wider range of imaging
fields-of-view. The new highly accurate
system has the same smooth workflow
as in other models in the range and features a clear control screen and motorized patient positioning movements.
The optional dental panoramic sensor
is available as before.
A total of eight user selectable FOVs
are available, each with their own typical applications. For example the smallest cylindrical FOV 50 x 50 mm with
the highest resolution of 0.1 mm voxel
size is intended for localized problems,
such as detailed imaging of single tooth
endodontic structures or ossicular
chain of the inner ear, whereas sevAUTUMN 2013 2013 Enhanced
A new version of the latest image
enhancement software (US PLUSView) from the Swedish company
Context Vision has been designed
for the Digital Signal Processor
(DSP), a processing platform which
is particularly suited for portable
and handheld ultrasound devices.
(DSPs are microprocessors specifically designed to handle digital
signal and image processing tasks).
These devices provide a smaller,
lower-cost solution, with excellent
performance, low latency, and no
requirements for specialized cooling or large batteries. DSPs have
seen tremendous growth in the last
decade, finding use in everything
from cellular phones to advanced
scientific instruments.)
As Point of Care is driving
today’s health care market, ultrasound manufacturers are investing in the development of portable ultrasound equipment to
meet increased demand. Experts
eral medium-size FOVs are suitable
for imaging for example both temporal
bones in one volume. The most suitable FOV for sinus and ENT imaging
is the 140 x 165 mm (HxD) with 0.2
mm voxel size and finally the largest
FOV 240 x 165 mm (HxD) with 0.5
mm voxel size is intended for whole
skull examinations, such as in the follow-up of facial surgery operations.
The voxel volume is isotropic, ensuring
that measurements in any direction are
accurate. Scanora 3Dx incorporates the
latest imaging technology. For example,
the 3D detector is a large amorphous
D I A G N O S T I C I M A G I N G
predict this to be one of the fastest growing segments in medical
imaging. “We are very pleased to
release another product for the
mid-end segment. The continued
growth of our ultrasound family
demonstrates the flexibility of our
latest technology,” said Anita Tollstadius, CEO, ContextVision. “We
are focusing our product development on growing segments and
therefore expect solutions for the
DSP platform to become important over the coming years.” Context Vision has optimized its flexible image enhancement software
for implementation into the small
and cost-effective DSP. Product
development has concentrated on
achieving as much functionality as
possible despite constraints of the
DSP and the end result is a product
with a very high standard.
Context Vision,
Stockholm, Sweden
www.contextvision.com.
Silicon flat panel for high resolution
projection image acquisition and the
SARA (SOREDEX Advanced Reconstruction Algorithm) reconstruction
method produces 3D volumes out of
these projection images. Thanks to the
wide adjustment ranges of parameters
the overall radiation dose for specific
diagnostic indications can be optimized by selecting the smallest FOV
for each task and adjusting the mA and
resolution accordingly.
Soredex,
Tuusula, Finland
www.soredex.com
A S I A
P A C I F I C 23
A Well-Balanced Contrast Medium
With a right mix of osmolality, viscosity
and iodine concentration, Ultravist® delivers
contrast for high-quality imaging results.1
www.bayer.co.uk
Enquiries: 01635 563000
Calls to and from Bayer HealthCare may be recorded
Date of preparation: October 2012. L.GB.10.2012.0951
All rights reserved. © Bayer plc 2012
Ultravist ® (iopromide) Prescribing Information (Refer
to Summary of Product Characteristics (SmPC) before
prescribing) Presentation: Intravascular injections of nonionic iopromide in strengths of 150mg, 240mg, 300mg and
370mg of iodine/ml. Indications: For diagnostic use only.
Delineation of the vascular and renal systems and of body
cavities. Posology and administration: Adults Intravenous
urography: minimum doses: Ultravist 370: 0.8ml/kg body
weight; Ultravist 300: 1ml/kg body weight; Ultravist 240:
1.3ml/kg body weight. Children Intravenous urography:
see SmPC. Adults Computed tomography: Cranial CT:
Ultravist 240: 1.5-2.5ml/kg body weight; Ultravist 300:
1-2ml/kg body weight; Ultravist 370: 1-1.5ml/kg body
weight. Whole-body CT: Dosage and administration rate
depend on investigation and scanner. Adults Angiography:
depends on age, weight, cardiac output, general condition,
clinical problem, examination technique and the nature and
volume of the vascular region to be investigated. (see SmPC).
Adults Checking function of dialysis shunt: Ultravist 150:
10ml. Paediatric population: young infants (age < 1 year)
and especially newborns are susceptible to electrolyte
imbalance and haemodynamic alterations. Care should be
taken regarding the dose of contrast medium to be given,
the technical performance of the radiological procedure and
the patient status. Renal impairment: to reduce the risk
of additional contrast media-induced renal impairment in
patients with pre-existing renal impairment, the minimum
possible dose should be used. Hepatic impairment: no dosage
adjustment is necessary. Elderly: possibility of reduced
renal function should be considered. Contra-indications:
Uncontrolled thyrotoxicosis. Warnings and precautions: Can
be associated with anaphylactoid/hypersensitivity reactions,
ensure preparedness for institution of emergency measures.
Allergy-like reactions from mild to severe possible, mostly
within 30 min, but delayed reactions (hours to days) may
occur. Particularly careful risk/benefit judgement required
for patients with: known hypersensitivity to Ultravist or its
excipients; previous reaction to any contrast medium or;
history of bronchial asthma or allergic disorders (increased
risk). Pre-medicate with corticosteroids if necessary. To
minimise risk: administer Ultravist to recumbent patients;
observe patients closely for 15 minutes and keep them in
hospital for at least one hour after the last injection. Patients on
beta-blockers may be resistant to the effects of beta agonists.
If severe reaction occurs, patients with cardiovascular disease
are more susceptible to serious or fatal outcomes. Caution
in patients with: known/suspected hyperthyroidism or goitre,
monitor thyroid function in neonates exposed via mother or
during neonatal period. Caution in patients with cerebral
arteriosclerosis, pulmonary emphysema, poor general health,
renal insufficiency, dehydration, diabetes mellitus, multiple
myeloma/ paraproteinaemia, repetitive and / or large doses
of Ultravist. Nephrotoxicity may occur or rarely acute renal
failure. Ensure adequate hydration of patients; correct
water or electrolyte imbalances before administration. With
cardiac or severe coronary artery disease, increased risk of
haemodynamic changes or arrhythmia. Intravascular
injection may precipitate pulmonary oedema in patients with
heart failure. Increased risk of neurological complications
in patients with seizure history or CNS disorders. Caution
in patients with reduced seizure threshold. May aggravate
the symptoms of myasthenia gravis. Flush intravascular
catheters frequently with physiological saline (if possible
with addition of heparin) and minimise procedure length to
minimise procedure-related thromboembolism risk. Patients
with phaeochromocytoma may be at increased risk of
developing a hypertensive crisis. Minimise excitement, anxiety
and pain. Do not use in myelography. Sensitivity testing
is not recommended. Interactions: Consider interruption
of biguanides treatment prior to Ultravist administration
as a precaution against development of lactic acidosis.
Prevalence of delayed reactions higher in patients who have
received interleukin-2. Diagnosis and treatment of thyroid
disorders with thyrotropic radioisotopes may be impeded
for up to several weeks due to reduced radioisotope uptake.
Pregnancy and lactation: Adequate and well-controlled
studies in pregnant women have not been conducted.
Safety for nursed infants has not been investigated.
Effects on ability to drive and use machines: Driving or
operating machinery is not advisable for 30 minutes after
the last injection. Undesirable effects: Common: dizziness,
headache, dysgeusia, blurred/disturbed vision, chest pain/
discomfort, hypertension, vasodilatation, vomiting, nausea,
pain, injection site reactions (e.g. oedema, soft tissue injury
post extravasation), feeling hot. Serious side effects: cf –
Warnings and Precautions – in addition: Hypersensitivity/
anaphylactoid reactions (anaphylactoid shock§*, respiratory
arrest§*, bronchospasm*, laryngeal*/pharyngeal* or
mucosal oedema, laryngeal/pharyngeal spasm§, asthma§*,
angioedema), vasovagal reactions, arrhythmia*, dyspnoea*,
cardiac arrest*, myocardial ischaemia*/infarction*, thyrotoxic
crisis, thyroid disorder, coma*, cerebral ischaemia/infarction*,
stroke*, brain oedema*, convulsion*, transient cortical
blindness (IV use only), loss of consciousness, amnesia,
paresis/paralysis, hearing disorders, cardiac failure*,
bradycardia*, tachycardia, cyanosis*, hypotension*, shock*,
thromboembolic events (IV use), pulmonary oedema*,
respiratory insufficiency*, aspiration*, bullous conditions (e.g.
Stevens-Johnson syndrome or Lyell syndrome), compartment
syndrome due to extravasation (IV use), renal impairment/
acute renal failure (IV use). § Reactions identified only during
post-marketing surveillance (frequency not known). *These
adverse reactions may have a fatal or life-threatening
outcome and are considered the most serious adverse drug
reactions. Prescribers should consult the SmPC in relation
to other side effects. Overdose: Symptoms may include fluid
and electrolyte imbalance, renal failure, cardiovascular and
pulmonary complications. Monitoring of fluids, electrolytes
and renal function recommended in case of intravascular
overdosage. Treatment of overdose should be directed
towards the support of vital functions. Ultravist is dialysable.
Incompatibilities: Because of possible precipitation, X-ray
contrast media and prophylactic agents must not be injected
as mixed solutions. Special Precautions for Storage: Protect
from light and X-rays. Legal Classification: POM Package
Quantities and Basic NHS Price: Ultravist 150 10 x 50ml
bottles £101.57 Ultravist 240 10 x 50ml £145.86 Ultravist
300 10 x 20ml £124.63 10 x 50ml £182.03 1 x 100ml £36.16
1 x 200ml £71.98 Ultravist 370 10 x 50ml £224.94 1 x 100ml
£44.68 1 x 200ml £88.78 MA Numbers: Ultravist 150:
00010/0564 Ultravist 240: 00010/0565 Ultravist 300:
00010/0566 Ultravist 370: 00010/0567 Further information
available from: Bayer plc, Bayer House, Strawberry Hill,
Newbury, Berkshire, RG14 1JA, Telephone: (01635) 563000
Date of preparation: August 2012 Ultravist® is a trademark
of the Bayer Group.
Adverse events should be reported.
Reporting forms and information can be found
at www.mhra.gov.uk/yellowcard.
Adverse events should also be reported to Bayer plc.
Tel.: 01635 563500, Fax.: 01635 563703,
Email: [email protected]
References
1. For details and full range of indications please refer to the
Summary of Product Characteristics.