2008-Issue04

435EFSUMB Newsletter

Ultraschall in Med 2008; 29

EFSUMB NewsletterEuropean Federation of Societies for Ultrasound in Medicine

and Biology

Welcome to Moldova

At the Board of Directors meeting in Ti-misoara in June the application for mem-bership from the Society of Ultrasound inMedicine and Biology of the Republic ofMoldova (SUMB) was approved and it is a

pleasure to welcome them as an EFSUMBmember. Moldova, bordering Romaniaand Ukraine, has a population of 4 million.The Ultrasound Society has 281 members.

Endoscopic ultrasonography (EUS)Routine method and new applications

EUS started in the early 1980s with radialmechanical scanners causing an imagingrevolution. For the first time, the visuali-zation of the gastrointestinal wall layersbecame possible and thus improved the

locoregional staging of gastrointestinaltumors. Nearly at the same time, the me-thod was extended to biliopancreaticdisease and further clinical applications.

The second revolution in connection withEUS was the introduction of longitudinalelectronic scanners in the 1990s enablingand establishing fine-needle aspirationbiopsy (FNAB) under realtime EUS con-trol. Electronic scanners have significant-ly improved the spatial resolution and thequality of imaging within the near field.Therefore, this technology is nowadaysalso implemented in radial scanners. EUSguided FNAB allows to obtain histologicspecimen from the surroundings of the

Comments on New Technology

gastrointestinal (GI) tract. Furthermore,FNAB proved to be the first step towardsEUS guided interventions like injectiontreatment (e.g. neurolysis of the celiacplexus) or drainage of pancreatic pseudo-cysts.

In the meantime, many indications for theuse of diagnostic and interventional EUShave been investigated and the readermay be interested to know which of themare currently accepted or have been drop-ped. The second focus may concern newEUS developments.

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Current applications of EUS

Before endoscopic mucosal or submuco-sal dissection of early gastrointestinalwall tumors, EUS is accepted to be the best

News from the web

One of the new ideas from the present Pu-blications Committee has been to includea Case of the Month at the EFSUMB web-site starting in March 2008. The most re-cent Case of the Month is always found atthe front page, and all cases can be foundusing the navigation list at the left. Casesinclude high quality ultrasound imagesand often video clips for download. Thenumber of hits on these pages is growingrapidly; in May 2008 there were morethan 300 hits.

Please remember that you can also alwaysfind the Newsletters at www.efsumb.orgeven if you do not receive them in print inthe EJU.

Michael Bachmann Nielsen

Representing the Society of Ultrasound in Medicine and Biology of the Republic of Moldova in June 2008:

Vasile Turcanu (President) and Sergiu Puiu (Secretary)

Jan Janssen and Lucas Greiner

436 EFSUMB Newsletter


non-invasive method to predict the stageand resectability of the lesion. Althoughone can argue that the pathologist is theone to definitely define the infiltrationdepth, it is favourable to know the EUS re-sult beforehand especially with respect tothe potential involvement of regionallymph nodes.

Neoadjuvant treatment for locally advan-ced cancer has to be based on the thorou-gh description of the tumor stage. This tre-atment policy nowadays is standard forstage T3/4 tumors of the esophagus andrectum which are usually defined by EUS.In esophageal cancer, the involvement ofceliac lymph nodes is no longer regardedto be crucial to decide about resectabilityand, therefore, EUS-FNAB of these lymphnodes has become less important.

The new efforts to improve the cure rate oflocally advanced gastric tumors - especi-ally of the cardia - by neoadjuvant chemo-therapy has resulted in the revival of EUSfor the staging of gastric cancer (althoughlaparoscopy might be very useful in thissetting, too). The choice of treatment ingastric lymphoma (MALTOM) depends onthe degree of malignancy and in low gradelymphoma on the local spread. Therefore,EUS is mandatory in the staging of gastriclymphoma.

After neoadjuvant treatment (chemo-therapy alone or radiochemotherapy), thequestion of tumor regression or even dis-appearance is of interest. In this respectEUS fails, because the echopoor inflam-matory reaction caused by these modali-ties cannot be differentiated from tumorinfiltration and, hence, the diagnostic ac-curacy proved not to surpass 50-60 %.

There is no doubt that EUS is the methodof choice to differentiate between submu-cosal GI tumors and external impressions.Furthermore, the echogeneity of submu-cosal lesions and the determination oftheir layer of origin significantly helps todetermine the therapeutic needs and ap-proach. Endoscopic resection can be donewith low complication rate, if the lesion islocated superficially to the proper musclelayer.

Pancreatic tumors are a further target ofEUS which is able to reveal very small le-sions in otherwise healthy organs. Theability is of clinical value looking for en-docrine tumors that are suspected due totheir endocrine activity. The early detec-

tion of ductal carcinomas will usually fail,since EUS is no screening method. The sta-ging of pancreatic tumors can be helpful,although data as to the prediction of vesselinfiltration are conflicting. EUS-FNAB canreliably be performed to define pancreaticlesions histo- or cytologically. Like allcompetitve diagnostic methods, EUS evenin addition with elastography or FNAB isnot suitable to detect early stage pancrea-tic cancer in chronic pancreatitis.

Studies have shown that EUS is a valuabletool to diagnose early pancreatitis beforeERC criteria become visible. The diagno-stic accuracy for biliary stones or other re-asons of biliary obstruction is at least asgood as on ERCP. Therefore, diagnosticERCP, which is affected by more and po-tentially severe complications, is nowa-days substituted by EUS. MRCP might bean even less invasive alternative. Althoughthe spatial resolution of MRCP is inferior,most comparative studies estimate MRCPand EUS to be equivalent. Therefore, thechoice of method may depend on the localsetting.

The endosonographic access to the left ad-renal is very comfortable and FNAB withthe question of M1 metastasis can be re-liably performed, if necessary.

EUS guided interventions and per-

5

spectives

EUS guided interventions are well esta-blished for the drainage of pseudocysts orabscesses. In EUS centers, the drainage ofdilated hepatic ducts into the GI tract isperformed with promising success rates.Celiac plexus neurolysis can easily be per-formed, but the sustainability of the pro-cedure is insufficient for pain in the courseof chronic pancreatitis and still in discus-sion for pain caused by tumorous infiltra-tion. Several efforts to treat tumors by EUSguided injection have been made, but theyhave not yet overcome the experimentalstage. Interesting studies in porcine mo-dels have tested surgical techniques likeEUS guided gastroenterostomy or fundo-plicatio.

New non-invasive technologies imple-mented in EUS are elastography, which isdescribed in EFSUMB Newsletter issue 3this year, and contrast enhanced EUSwhich is becoming available in the nearfuture.

5

Conclusion

In summary, EUS combining imaging(q Fig. 1) and the options of FNAB and in-tervention (q Fig. 2) nowadays is a valua-ble and indispensable diagnostic and the-rapeutic tool in gastroenterology and as-sociated fields. New EUS technologies pro-mise to expand or specify the panel of ap-plications.

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: [email protected]

[email protected]

Fig. 1 EUS imaging of the normal left adrenal.

Fig. 2a,b Process (a) and result (b) of EUS guided

drainage of a pancreatic pseudosyst



EFSUMB Newsletter meets Spain.

5

Facts:

3 Population: 45 million3 Capital and largest city: Madrid (3.2

million)3 Area: 504.030 km23 EFSUMB members: 180

Spain was one of the thirteen foundingmembers of EFSUMB in 1972. The currentinterview between the president and de-legate of the Spanish Ultrasound SocietySEECO (SOCIEDAD ESPAÑOLA DEECOGRAFIA) Dr Eugenio Cerezo and Editorof the EFSUMB Newsletter, Professor Mi-chael Bachmann Nielsen, took place inApril 2008.

Eugenio Cerezo is now running a privateclinic in Madrid. He has been the delegateof the Spanish Society for a number ofyears now. "I'm a specialist in internal me-dicine and gastroenterology", Eugenio Ce-rezo says, "and I started doing ultrasoundin the seventies. Nowadays I only do ultra-sound examinations".

"Spain is only listed as having 177 mem-bers; this seems small compared to thesize of the country". "It is", Eugenio Cerezosays," it should be closer to six thousand.The reason is that ultrasound is performedby doctors within many different socie-ties: radiology, internal medicine, vascu-lar medicine, gynaecology and obstetrics,rheumatology, gastroenterology, general

practitioners to mention a few. This me-ans that the Spanish Ultrasound Society,SEECO, is not a huge but multi disciplinarysociety that integrates different specia-lists that practice ultrasound exams, evenveterinarians, and also there are a numberof other societies which integrates exclu-sively some special ultrasound doctors, asfor example UROLOGY SOCIETY integratesonly UROLOGIST, GYNAECOLOGY SOCIE-TY (SEGO) only GYNECOLOGY AND OBST-RECTICS DOCTORS, not as an independentsociety but as section groups".

In Spain there are three independent ul-trasound societies, one "SOCIEDAD ES-PAÑOLA DE ULTRASONOGRAFIA" formedexclusively by radiologists, other "ASO-CIACION DE ECOGRAFIA DIGESTIVA" inte-grated by gastroenterologists and finallySEECO "SOCIEDAD ESPAÑOLA DEECOGRAFIA" multidisciplinary and inte-grated for different types of specialities,the latter being associated with EFSUMB.For someone outside Spain one wonderswhy these societies do not join in one lar-ge federation. "The problem is complex",Cerezo says, "of the societies listed abovethe Gastroenterological one and SEECO, astruly independent societies, are trying tointegrate in a federation, the problem isnot the will to form the federation ratherit is a legal problem because in Spain weneed three societies to form a federation,and the other groups which want integra-te, the gynaecologist, very numerous, are

Training during Doppler course dedicated to the carotids

SEECO officers Dr Antonio Diaz, Vicepresident Dr Christina Martinez, Honorary Treasurer

Dr Eugenio Cerezo, President Dr Conception Millana, Honorary Secretary



not a truly independent society. Radiolo-gist do not can afford the fee for the feder-ation and that is the reason they give fornot integrate. We are currently workingon a way to get around that issue and alsoto attract more doctors and hopefully itwill succeed, it takes time and patience."

SEECO has a newsletter every secondmonth; the information goes on the Inter-net. Their new website was launched re-cently, www.seeco.es and is entirely inSpanish.

"Being a delegate in EFSUMB I am sure youhave considered joining the Ultraschall inder Medizin - family", says Michael Bach-mann Nielsen. "The journal is certainly avery attractive journal and if we succeedin making one united ultrasound societyin Spain I hope we can consider this forour official journal. We are currently wor-

king to launch a web based journal, hope-fully at the end of the year; it will be a bi-language journal." Spanish is one of themajor languages of the world, it is estima-ted that it is the first language of morethan 400 million people. "When we studyat the university all our books are in Spa-nish", Cerezo says, "and I would guess thatbetween 60 and 70 % of common doctorsin Spain do not read easily English. This isalso one of the reasons why it is difficult tojoin an English language journal. But thisis changing, in young doctors".

Because of the mix of societies involved inultrasound in Spain there are also a largenumbers of courses. "I am involved incourses in vascular Doppler, musculoske-letal ultrasound courses etc., even we do aspecial abdomen ultrasound course " Ce-rezo says, "which is a combination of lec-tures, clinical practice and finally an exam

corresponding to EFSUMB level 1 whichwe are going to extend to other ultrasoundapplications".

"What are your hopes for ultrasound andEFSUMB in the future?" "Ultrasound inSpain is actually doing well, diversity isgood, and a large number of doctors arenow performing ultrasound in almostevery medical speciality", Eugenio Cerezosays. "My hope is that EFSUMB will be theone who will organize a common Euro-pean test corresponding to the levels theyhave described. There should be tests in-volving abdominal US, vascular US, mus-culoskeletal, gynaecology and obstetricultrasound etc. and it would be an excel-lent thing to insure that we have the samestandard throughout Europe".

Ultrasound safety - the dotty old aunt is at it again !

There are two ways to evacuate a crowdedlecture hall at an ultrasound conferencein 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 can-celled and is replaced by a lecture on ul-trasound safety"

However, ultrasound safety, particularlysafety of ultrasound performed duringpregnancy has received a boost in recentmonths. Not, as one might think, becauseof an increasing awareness that the evermore widespread use of pulsed-wave andcolor Doppler in the first trimester of pre-gnancy might potentially harm embryosand fetuses who have to undergo thissound energy impact for screening purpo-ses.

The sudden resurgence of interest in ul-trasound safety particularly in the US isentirely the consequence of a new turf

war: Commercial 3-D ultrasound studiospromising cute golden 3-D images ofcuddly fetuses are springing up in shop-ping malls all over North America and,increasingly, in Europe. Tom Cruise gotunexpected additional fame when he ac-quired a top of the range 3-D ultrasoundmachine to look at the development of hiswife's pregnancy, and to visualize his un-born baby at home.

A lot of people, representatives of the me-dical profession and lawmakers have spo-ken up and declared they are worriedabout the potential harm these non-me-dical uses might cause.

But let's face it - in which situation is moresound energy being delivered onto the fe-tus: during a 28 week "facing" scan with3 D ultrasound or an 11 week scan whereDoppler of the fetal ductus venosus andthe tricuspidal valve has to be performedin order to screen the fetus for its potentialto have trisomy 21?

A letter to ECMUS Parents love the reassuring thump-thump-thump and the complex waveformpatterns we produce at these cardiacDoppler examinations in the first trime-ster and we reassure them that ultrasoundis harmless in our hands.

However, most first-trimester ultrasoundoperators have no idea what MI and TI me-an, concern for ultrasound safety is consi-dered thoroughly un-cool as is attendanceat sessions dedicated to this boring sub-ject.

Ultrasound safety is treated like a slightlyderanged dotty old aunt who is confinedto her crammed garret and only once in awhile is dressed up, taken out, told to bashthe babyview-studios with her rolled-upumbrella and then taken up to her garretand locked up again.

Prof Christoph Brezinka MD PhD,

Innbruck, Austria

Chairman Perinatal Doppler Focus Group of

ISUOG

[email protected]



News from the Education & Professional Standards Committee

Dear ultrasound friend

It was nice to meet with many of you at theEUROSON congress in Timisoara. The con-gress was a great opportunity for enhan-ced education in ultrasonography and theorganisers did a splendid job to includemany postgraduate courses and state-of-the art lectures in the programme.

At the last meeting of the Education & Pro-fessional Standards Committee (EPSC) inTimisoara, I had the great pleasure to wel-come Prof Boris Brkljacic as co-optedmember of the Committee. At this mee-ting we were also happy to acknowledgethat the EFSUMB Board of Directors had

voted in favour of a change in the EurosonSchool bylaws to make it more attractiveto plan and run these courses.

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Euroson Schools

The EPS Committee has as one of its maintasks to promote more Euroson Schools tobe arranged throughout Europe. The firstEuroson School of EFSUMB was arrangedin 1992 and since then over 40 courses hasbeen held. We will stimulate all the Natio-nal Societies and ultrasound groups allover Europe to consider establishing apost-graduate course under the umbrellaof a Euroson School. The EFSUMB secreta-riat and EPSC have made a dedicated "startpackage" to help the organisers of EurosonSchools. For more information, look atwww.efsumb.org.

As Europe is the definite leader in clinicalapplications of CEUS, we have started aninitiative to arrange regular EurosonSchools on the subject of CEUS. In coope-ration with Bracco, the first EurosonSchool on CEUS is taking place 6. – 9. ofNovember in Hanover under the auspices

of Dr. Hans Peter Weskott. For more infor-mation about programme and registrati-on, go to the website: www.CEUS-cour-se.eu. Following Hanover, the next Euro-son School on CEUS is scheduled for Janu-ary 2009 in Nice, France. The overall planis to arrange 3-5 Euroson Schools eachyear around Europe, thus ensuring thatour members have access to high qualitypost-graduate courses on this very im-portant topic.

Status and Progress of the Guideli-

5

nes

Two more minimum training recommen-dations are intended to be published thisyear: Infant cranial and Thoracic ultra-sound. Work is also in progress regardingthe Critical/Intensive Care and FocusedEmergency. The different guidelines andrecommendations can be viewed online atthe EFSUMB website.

The EPS Committee also wants to promoteproduction of educational material for pu-blication and dissemination on the Web.EPSC would like to see the EFSUMB web-site being an instructive educational por-tal for colleagues in the ultrasound com-munity.

Prof. Odd Helge Gilja

Chairman EPSC

[email protected]

First international course on contrast enhanced ultrasound

November 2008 6th – 9thHanover, Germany

Like no other technique before, US con-trast agents have revolutionized diagno-stic ultrasound. In 2004, the European ul-trasound societies developed guidelineson the use of US contrast agents in liverdiseases. Although the main focus is stillon liver diseases, it is accepted that UScontrast agents can also add a great deal ofdiagnostic value in extra hepatic organdiseases, such as in renal diseases, whichis now covered by the EFSUMB guidelines.These were updated in 2008 (www.efs-umb.org).

I would very much like to encourage youto attend the first international course oncontrast enhanced ultrasound (CEUS) inHanover. It takes place November 6th–9th2008 and is supported by the EFSUMB(Euroson School).

On the first day, the US manufactures andBracco Company will present their cur-rent technology and give a lecture on theirplans for the near future. Over the nextthree days the attendees will have the op-portunity to learn about focal liver and re-nal diseases: each entity will first be re-viewed by a pathologist and then CT, MRIand PET findings will be presented. This

will be followed by the CEUS lectures. Inthe 'hands on' workshops the participantswill be trained in small groups. Many wellknown experts in their diagnostic fieldboth from inside and outside Europe haveagreed to join the team.

CME credits can also be earned. You canfind out more about this educational cour-se as well as how to register by visiting ourwebsite: www.CEUS-course.eu.

Dr. HP Weskott, MD

On behalf of the International Faculty

Board



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