EFSUMB Newsletter
EFSUMB Newsletter European Federation of Societies for Ultrasound in Medicine and Biology
Welcome to Moldova At the Board of Directors meeting in Timisoara in June the application for membership from the Society of Ultrasound in Medicine and Biology of the Republic of Moldova (SUMB) was approved and it is a
pleasure to welcome them as an EFSUMB member. Moldova, bordering Romania and Ukraine, has a population of 4 million. The Ultrasound Society has 281 members.
News from the web One of the new ideas from the present Publications Committee has been to include a Case of the Month at the EFSUMB website starting in March 2008. The most recent Case of the Month is always found at the front page, and all cases can be found using the navigation list at the left. Cases include high quality ultrasound images and often video clips for download. The number of hits on these pages is growing rapidly; in May 2008 there were more than 300 hits.
Representing the Society of Ultrasound in Medicine and Biology of the Republic of Moldova in June 2008: Vasile Turcanu (President) and Sergiu Puiu (Secretary)
Please remember that you can also always find the Newsletters at www.efsumb.org even if you do not receive them in print in the EJU. Michael Bachmann Nielsen
Comments on New Technology
Endoscopic ultrasonography (EUS) Routine method and new applications locoregional staging of gastrointestinal tumors. Nearly at the same time, the method was extended to biliopancreatic disease and further clinical applications.
Jan Janssen and Lucas Greiner
EUS started in the early 1980s with radial mechanical scanners causing an imaging revolution. For the first time, the visualization of the gastrointestinal wall layers became possible and thus improved the
The second revolution in connection with EUS was the introduction of longitudinal electronic scanners in the 1990s enabling and establishing fine-needle aspiration biopsy (FNAB) under realtime EUS control. Electronic scanners have significantly improved the spatial resolution and the quality of imaging within the near field. Therefore, this technology is nowadays also implemented in radial scanners. EUS guided FNAB allows to obtain histologic specimen from the surroundings of the
gastrointestinal (GI) tract. Furthermore, FNAB proved to be the first step towards EUS guided interventions like injection treatment (e.g. neurolysis of the celiac plexus) or drainage of pancreatic pseudocysts. In the meantime, many indications for the use of diagnostic and interventional EUS have been investigated and the reader may be interested to know which of them are currently accepted or have been dropped. The second focus may concern new EUS developments.
Current applications of EUS 5 Before endoscopic mucosal or submucosal dissection of early gastrointestinal wall tumors, EUS is accepted to be the best Ultraschall in Med 2008; 29
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non-invasive method to predict the stage and resectability of the lesion. Although one can argue that the pathologist is the one to definitely define the infiltration depth, it is favourable to know the EUS result beforehand especially with respect to the potential involvement of regional lymph nodes. Neoadjuvant treatment for locally advanced cancer has to be based on the thorough description of the tumor stage. This treatment policy nowadays is standard for stage T3/4 tumors of the esophagus and rectum which are usually defined by EUS. In esophageal cancer, the involvement of celiac lymph nodes is no longer regarded to be crucial to decide about resectability and, therefore, EUS-FNAB of these lymph nodes has become less important. The new efforts to improve the cure rate of locally advanced gastric tumors - especially of the cardia - by neoadjuvant chemotherapy has resulted in the revival of EUS for the staging of gastric cancer (although laparoscopy might be very useful in this setting, too). The choice of treatment in gastric lymphoma (MALTOM) depends on the degree of malignancy and in low grade lymphoma on the local spread. Therefore, EUS is mandatory in the staging of gastric lymphoma. After neoadjuvant treatment (chemotherapy alone or radiochemotherapy), the question of tumor regression or even disappearance is of interest. In this respect EUS fails, because the echopoor inflammatory reaction caused by these modalities cannot be differentiated from tumor infiltration and, hence, the diagnostic accuracy proved not to surpass 50-60 %. There is no doubt that EUS is the method of choice to differentiate between submucosal GI tumors and external impressions. Furthermore, the echogeneity of submucosal lesions and the determination of their layer of origin significantly helps to determine the therapeutic needs and approach. Endoscopic resection can be done with low complication rate, if the lesion is located superficially to the proper muscle layer. Pancreatic tumors are a further target of EUS which is able to reveal very small lesions in otherwise healthy organs. The ability is of clinical value looking for endocrine tumors that are suspected due to their endocrine activity. The early detecUltraschall in Med 2008; 29
tion of ductal carcinomas will usually fail, since EUS is no screening method. The staging of pancreatic tumors can be helpful, although data as to the prediction of vessel infiltration are conflicting. EUS-FNAB can reliably be performed to define pancreatic lesions histo- or cytologically. Like all competitve diagnostic methods, EUS even in addition with elastography or FNAB is not suitable to detect early stage pancreatic cancer in chronic pancreatitis. Studies have shown that EUS is a valuable tool to diagnose early pancreatitis before ERC criteria become visible. The diagnostic accuracy for biliary stones or other reasons of biliary obstruction is at least as good as on ERCP. Therefore, diagnostic ERCP, which is affected by more and potentially severe complications, is nowadays substituted by EUS. MRCP might be an even less invasive alternative. Although the spatial resolution of MRCP is inferior, most comparative studies estimate MRCP and EUS to be equivalent. Therefore, the choice of method may depend on the local setting.
Conclusion 5 In summary, EUS combining imaging (q Fig. 1) and the options of FNAB and intervention (q Fig. 2) nowadays is a valuable and indispensable diagnostic and therapeutic tool in gastroenterology and associated fields. New EUS technologies promise to expand or specify the panel of applications.
Fig. 1 EUS imaging of the normal left adrenal.
The endosonographic access to the left adrenal is very comfortable and FNAB with the question of M1 metastasis can be reliably performed, if necessary.
EUS guided interventions and perspectives 5 EUS guided interventions are well established for the drainage of pseudocysts or abscesses. In EUS centers, the drainage of dilated hepatic ducts into the GI tract is performed with promising success rates. Celiac plexus neurolysis can easily be performed, but the sustainability of the procedure is insufficient for pain in the course of chronic pancreatitis and still in discussion for pain caused by tumorous infiltration. Several efforts to treat tumors by EUS guided injection have been made, but they have not yet overcome the experimental stage. Interesting studies in porcine models have tested surgical techniques like EUS guided gastroenterostomy or fundoplicatio. New non-invasive technologies implemented in EUS are elastography, which is described in EFSUMB Newsletter issue 3 this year, and contrast enhanced EUS which is becoming available in the near future.
Fig. 2a,b Process (a) and result (b) of EUS guided drainage of a pancreatic pseudosyst
Jan Janssen and Lucas Greiner Medizinische Klinik 2 HELIOS Klinikum Wuppertal Heusnerstrasse 40 D-42283 Wuppertal phone: +49 202 896 2288 fax: +49 202 896 2740 Email: jan.janssen@helios-kliniken.de lucas.greiner@helios-kliniken.de
EFSUMB Newsletter
EFSUMB Newsletter meets Spain. Facts: 5 3 Population: 45 million 3 Capital and largest city: Madrid (3.2 million) 3 Area: 504.030 km2 3 EFSUMB members: 180 Spain was one of the thirteen founding members of EFSUMB in 1972. The current interview between the president and delegate of the Spanish Ultrasound Society SEECO (SOCIEDAD ESPAﾃ前LA DE ECOGRAFIA) Dr Eugenio Cerezo and Editor of the EFSUMB Newsletter, Professor Michael Bachmann Nielsen, took place in April 2008.
Eugenio Cerezo is now running a private clinic in Madrid. He has been the delegate of the Spanish Society for a number of years now. "I'm a specialist in internal medicine and gastroenterology", Eugenio Cerezo says, "and I started doing ultrasound in the seventies. Nowadays I only do ultrasound examinations". "Spain is only listed as having 177 members; this seems small compared to the size of the country". "It is", Eugenio Cerezo says," it should be closer to six thousand. The reason is that ultrasound is performed by doctors within many different societies: radiology, internal medicine, vascular medicine, gynaecology and obstetrics, rheumatology, gastroenterology, general
Training during Doppler course dedicated to the carotids
SEECO officers Dr Eugenio Cerezo, President
Dr Antonio Diaz, Vicepresident
practitioners to mention a few. This means that the Spanish Ultrasound Society, SEECO, is not a huge but multi disciplinary society that integrates different specialists that practice ultrasound exams, even veterinarians, and also there are a number of other societies which integrates exclusively some special ultrasound doctors, as for example UROLOGY SOCIETY integrates only UROLOGIST, GYNAECOLOGY SOCIETY (SEGO) only GYNECOLOGY AND OBSTRECTICS DOCTORS, not as an independent society but as section groups". In Spain there are three independent ultrasound societies, one "SOCIEDAD ESPAﾃ前LA DE ULTRASONOGRAFIA" formed exclusively by radiologists, other "ASOCIACION DE ECOGRAFIA DIGESTIVA" integrated by gastroenterologists and finally SEECO "SOCIEDAD ESPAﾃ前LA DE ECOGRAFIA" multidisciplinary and integrated for different types of specialities, the latter being associated with EFSUMB. For someone outside Spain one wonders why these societies do not join in one large federation. "The problem is complex", Cerezo says, "of the societies listed above the Gastroenterological one and SEECO, as truly independent societies, are trying to integrate in a federation, the problem is not the will to form the federation rather it is a legal problem because in Spain we need three societies to form a federation, and the other groups which want integrate, the gynaecologist, very numerous, are
Dr Christina Martinez, Honorary Treasurer Dr Conception Millana, Honorary Secretary
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not a truly independent society. Radiologist do not can afford the fee for the federation and that is the reason they give for not integrate. We are currently working on a way to get around that issue and also to attract more doctors and hopefully it will succeed, it takes time and patience." SEECO has a newsletter every second month; the information goes on the Internet. Their new website was launched recently, www.seeco.es and is entirely in Spanish.
king to launch a web based journal, hopefully at the end of the year; it will be a bilanguage journal." Spanish is one of the major languages of the world, it is estimated that it is the first language of more than 400 million people. "When we study at the university all our books are in Spanish", Cerezo says, "and I would guess that between 60 and 70 % of common doctors in Spain do not read easily English. This is also one of the reasons why it is difficult to join an English language journal. But this is changing, in young doctors".
"Being a delegate in EFSUMB I am sure you have considered joining the Ultraschall in der Medizin - family", says Michael Bachmann Nielsen. "The journal is certainly a very attractive journal and if we succeed in making one united ultrasound society in Spain I hope we can consider this for our official journal. We are currently wor-
Because of the mix of societies involved in ultrasound in Spain there are also a large numbers of courses. "I am involved in courses in vascular Doppler, musculoskeletal ultrasound courses etc., even we do a special abdomen ultrasound course " Cerezo says, "which is a combination of lectures, clinical practice and finally an exam
A letter to ECMUS
Ultrasound safety - the dotty old aunt is at it again ! There are two ways to evacuate a crowded lecture hall at an ultrasound conference in a very short time: 3 1. shout "fire" 3 2. put a slide on the screen with the message "the scheduled lecture on 3D imaging of fetal genitalia has been cancelled and is replaced by a lecture on ultrasound safety" However, ultrasound safety, particularly safety of ultrasound performed during pregnancy has received a boost in recent months. Not, as one might think, because of an increasing awareness that the ever more widespread use of pulsed-wave and color Doppler in the first trimester of pregnancy might potentially harm embryos and fetuses who have to undergo this sound energy impact for screening purposes. The sudden resurgence of interest in ultrasound safety particularly in the US is entirely the consequence of a new turf
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war: Commercial 3-D ultrasound studios promising cute golden 3-D images of cuddly fetuses are springing up in shopping malls all over North America and, increasingly, in Europe. Tom Cruise got unexpected additional fame when he acquired a top of the range 3-D ultrasound machine to look at the development of his wife's pregnancy, and to visualize his unborn baby at home. A lot of people, representatives of the medical profession and lawmakers have spoken up and declared they are worried about the potential harm these non-medical uses might cause. But let's face it - in which situation is more sound energy being delivered onto the fetus: during a 28 week "facing" scan with 3 D ultrasound or an 11 week scan where Doppler of the fetal ductus venosus and the tricuspidal valve has to be performed in order to screen the fetus for its potential to have trisomy 21?
corresponding to EFSUMB level 1 which we are going to extend to other ultrasound applications". "What are your hopes for ultrasound and EFSUMB in the future?" "Ultrasound in Spain is actually doing well, diversity is good, and a large number of doctors are now performing ultrasound in almost every medical speciality", Eugenio Cerezo says. "My hope is that EFSUMB will be the one who will organize a common European test corresponding to the levels they have described. There should be tests involving abdominal US, vascular US, musculoskeletal, gynaecology and obstetric ultrasound etc. and it would be an excellent thing to insure that we have the same standard throughout Europe".
Parents love the reassuring thumpthump-thump and the complex waveform patterns we produce at these cardiac Doppler examinations in the first trimester and we reassure them that ultrasound is harmless in our hands. However, most first-trimester ultrasound operators have no idea what MI and TI mean, concern for ultrasound safety is considered thoroughly un-cool as is attendance at sessions dedicated to this boring subject. Ultrasound safety is treated like a slightly deranged dotty old aunt who is confined to her crammed garret and only once in a while is dressed up, taken out, told to bash the babyview-studios with her rolled-up umbrella and then taken up to her garret and locked up again. Prof Christoph Brezinka MD PhD, Innbruck, Austria Chairman Perinatal Doppler Focus Group of ISUOG Christoph.brezinka@i-med.ac.at
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News from the Education & Professional Standards Committee voted in favour of a change in the Euroson School bylaws to make it more attractive to plan and run these courses.
Euroson Schools 5
It was nice to meet with many of you at the EUROSON congress in Timisoara. The congress was a great opportunity for enhanced education in ultrasonography and the organisers did a splendid job to include many postgraduate courses and state-ofthe art lectures in the programme.
The EPS Committee has as one of its main tasks to promote more Euroson Schools to be arranged throughout Europe. The first Euroson School of EFSUMB was arranged in 1992 and since then over 40 courses has been held. We will stimulate all the National Societies and ultrasound groups all over Europe to consider establishing a post-graduate course under the umbrella of a Euroson School. The EFSUMB secretariat and EPSC have made a dedicated "start package" to help the organisers of Euroson Schools. For more information, look at www.efsumb.org.
At the last meeting of the Education & Professional Standards Committee (EPSC) in Timisoara, I had the great pleasure to welcome Prof Boris Brkljacic as co-opted member of the Committee. At this meeting we were also happy to acknowledge that the EFSUMB Board of Directors had
As Europe is the definite leader in clinical applications of CEUS, we have started an initiative to arrange regular Euroson Schools on the subject of CEUS. In cooperation with Bracco, the first Euroson School on CEUS is taking place 6. – 9. of November in Hanover under the auspices
Dear ultrasound friend
of Dr. Hans Peter Weskott. For more information about programme and registration, go to the website: www.CEUS-course.eu. Following Hanover, the next Euroson School on CEUS is scheduled for January 2009 in Nice, France. The overall plan is to arrange 3-5 Euroson Schools each year around Europe, thus ensuring that our members have access to high quality post-graduate courses on this very important topic.
Status and Progress of the Guidelines 5 Two more minimum training recommendations are intended to be published this year: Infant cranial and Thoracic ultrasound. Work is also in progress regarding the Critical/Intensive Care and Focused Emergency. The different guidelines and recommendations can be viewed online at the EFSUMB website. The EPS Committee also wants to promote production of educational material for publication and dissemination on the Web. EPSC would like to see the EFSUMB website being an instructive educational portal for colleagues in the ultrasound community. Prof. Odd Helge Gilja Chairman EPSC odd.gilja@helse-bergen.no
First international course on contrast enhanced ultrasound November 2008 6th – 9th Hanover, Germany Like no other technique before, US contrast agents have revolutionized diagnostic ultrasound. In 2004, the European ultrasound societies developed guidelines on the use of US contrast agents in liver diseases. Although the main focus is still on liver diseases, it is accepted that US contrast agents can also add a great deal of diagnostic value in extra hepatic organ diseases, such as in renal diseases, which is now covered by the EFSUMB guidelines. These were updated in 2008 (www.efsumb.org).
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I would very much like to encourage you to attend the first international course on contrast enhanced ultrasound (CEUS) in Hanover. It takes place November 6th–9th 2008 and is supported by the EFSUMB (Euroson School).
will be followed by the CEUS lectures. In the 'hands on' workshops the participants will be trained in small groups. Many well known experts in their diagnostic field both from inside and outside Europe have agreed to join the team.
On the first day, the US manufactures and Bracco Company will present their current technology and give a lecture on their plans for the near future. Over the next three days the attendees will have the opportunity to learn about focal liver and renal diseases: each entity will first be reviewed by a pathologist and then CT, MRI and PET findings will be presented. This
CME credits can also be earned. You can find out more about this educational course as well as how to register by visiting our website: www.CEUS-course.eu. Dr. HP Weskott, MD On behalf of the International Faculty Board
EFSUMB Newsletter
www.thieme.de Noch mehr Auswahl. Noch mehr Neues. Noch mehr Infos.
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