VIENNA, Austria – The little things mattered the most at this year's European Congress of Radiology (ECR), held here this week.

The heavy hardware of medical imaging seemed to fade into the background as cells and molecules took center stage in papers presented in scientific sessions and products displayed in the exhibition.

Even where the spotlight returned to a machine, the focus was on the bits and bytes of its software rather than the mechanics of its transducers, generators or sensors.

This year's event drew a record 18,000 delegates from 100 countries and the sponsoring European Society of Radiology (ESR; Vienna) announced that the 280,000-square-foot exhibition space was officially sold out, with 285 companies participating.

ESR accepted 1,684 abstracts from the 5,363 submitted this year, with 840 presented in 84 sessions.

Germany was the top contributor of papers and posters with 248 submissions, followed by Italy with 232, the UK with 129, Spain with 122 and the U.S. with 98.

A significant number of presentations were dedicated to research with micro bubbles to enhance visualization of disease, molecular tracers to illuminate disease processes and nanoparticles to observe the metabolic processes.

In her opening keynote address, Hedvig Hricak, chairman of the department of radiology at Memorial Sloan-Kettering Cancer Center (New York) noted that molecular imaging was ranked by Fortune magazine as one of the five technologies expected to have the greatest impact on society over the next 10 years.

"Imaging is just one element in an integrated diagnostic approach," she said. "We have no choice but to learn serum screening, proteomics and molecular pathways. We need to embrace physics, chemistry and biology."

The chairman of the board for the Radiological Society of North America (RSNA; Oak Brook, Illinois) and the incoming president of RSNA for 2010, Hricak also expressed a sentiment that was echoed in sessions throughout this year's congress when she said that with today's chemical contrast agents and tracers illuminating the detailed processes of disease, "it is sometimes frightening to see how little we have known."

Hricak suggested the emerging concept of theranostics, where an immunoassay lab-on-a-chip is developed as a companion diagnostic for ongoing measurement of the effectiveness of a pharmaceutical therapy, could be applied to imaging diagnostics as well.

In the field of oncology, she said it is increasingly important to use highly targeted imaging modalities in combination with a specific tracer to monitor treatment directed at a specific type of tumor

Lab-on-chip test for biomarkers can be an excellent tool in some therapeutic applications, she told Diagnostics & Imaging Week, but because these tests work with micro droplets drawn from the patient, "we don't know where the marker is coming from, so they do not tell us about a specific cancer.

"Metastatic disease is different from the primary cancer, so while immunoassays help, targeted imaging is essential for targeted therapies," she said. "The tracers being developed for medical imaging today are fantastic compared to five years ago," she told D&IW.

Working at a major research center, Hricak said she has special access to these new molecular agents for investigational purposes, but said it is frustrating that they are not yet available for widespread use.

Radiology meets the ER physician

Emergency medicine is the guest of honor at ECR and a Special Focus session highlighted the current debate between advocates of ultrasound and computed tomography (CT) as the best modality for triage and diagnosis of trauma patients.

Michael Rieger, a radiologist, and Wolfgang Voelckel, a trauma physician, collaborate on enhancing workflow for the emergency room at University Hospital Innsbruck in Austria that features a dedicated dual-source CT scanner.

They advocate the abandoning all other modalities in favor of whole body, high resolution, 64-slice evaluation of polytraumatized patients

"The use of ultrasound is just a waste of time," during the golden first hour of trauma treatment, according to Rieger, who said "CT phase acquisition and evaluation has brought a revolution in trauma care."

Describing the Innsbruck workflow, the physicians said that once and anesthesiologist validates stable hemodynamics, the patient is sent for the CT scan.

They reported the average elapsed time from admission to creation of the first CT image is 31 minutes and the time to evaluation of the images is 19 minutes.

Voelckel said scans provide a head-to-toe evaluation with two meters of coverage showing "the whole head, the entire skeletal system, the thoracic cage, the pelvis and any organ injuries in the abdomen. "

"We include molecular diagnosis CT angiography of cervical arteries to detect carotid injury, of the thoracic aorta to detect traumatic aneurysm, and we can see arterial injuries of the extremities with high resolution that will show finger artery ruptures," said Rieger.

A study of 500 injuries in Innsbruck showed that "we missed 10 injuries, of which three were considered serious.

Moderating the ardent Austrians, the chair of radiology at Antwerp University Hospital (Edegem, Belgium), Paul Parizel, said ultrasound may not be as sensitive as CT but that it is more readily available and will provide a certain amount of critical diagnostic information immediately.

"A number of papers from emergency or surgical departments claim that focused ultrasound is the way to go in triage of patients," he said, while papers coming out of radiology groups are more cautious, saying that is CT scan is not available or not practical, the ultrasound is the best choice.

Gerhard Mostbeck of the Wilhelminenspital and Otto Wagner Hospital and Medical Centers (Vienna) tightly explained the dilemma in this ongoing debate between CT and ultrasound by underlining the practical issue of whether an emergency department is able to afford afford a dedicated CT scanner.

"In my experience the role for ultrasound is quite small in the case of polytrauma patients if you have a dedicated CT unit in the emergency department," Mostbeck said.

"But if it is going to take 20minutes to take the patient to the CT scanner in another building, then things look quite different," he said.

Taking early detection to the extreme

Prenatal ultrasound is considered a routine clinical procedure today but a professor of radiology at the University of Vienna asks if that is good enough.

Daniela Prayer, a leading advocate of in utero magnetic resonance imaging (MRI) suggests such advanced scans should not be considered a luxury but a necessity for the unborn.

Improvements in technology have made MRI not only safer for the fetus but faster as well.

"Today we have ultrafast sequencing requiring 15 to 30 seconds for rendering dynamic images," she said.

Where there were once only two contrast agents, "today we have so many more that we can characterize olfactory bulbs in the fetus," Prayer said.

In her presentation she showed high resolution imaging that allows monitoring of the child's behavior in the womb, revealing esophageal atrosia, a swallowing problem indicating the child will aspirate into its lungs the first feeding of the mother's milk.

She showed diagnoses of unborn infants at 16 to 18 weeks gestation with damaged kidneys and one with a blocked rectum, problems that can be corrected with a surgical intervention.

Prayer said the University of Vienna was the first to image brain fiber tracking proving a diagnosis of cortical spinal connectors.

The benefit of pre-natal MRI is that the whole child can be viewed and if a surgery is indicated, in utero is safer, as the child is contained in a natural life-support system.

"There are no lines or tubes or needles as there would be for a child born with a life-threatening defect," she said.

"In response to the question whether prenatal MRI is a luxury or a necessity, I would pose the question, 'Do we have the right to withhold the diagnostic?'" Prayer said.

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