www.siemens.com/medical
Sessions
Picture
Highlights
COVER STORY
SOMATOM Sensation 64 –
Unprecedented Detail,
Speed and Image Quality
Page 4
NEWS
PROCAM Calculator plus
CT-Examination Support
Treatment of Coronary
Events
Page 14
CLINICAL OUTCOMES
SOMATOM Sensation 64:
First Case Studies
Page 18
SCIENCE
CARE Dose4D: Clinical
Evaluation on a SOMATOM
Emotion 6
Page 32
CUSTOMER CARE
Clinical Training for Cutting-
Edge CT Expertise
Page 36
EDITOR’S LETTER
Dear Reader,
Advances in patient- and user-friendliness as well as clinical excellence have always been our
goals at Siemens Medical Solutions’ Computed Tomography Division. With the development of
the SOMATOM® Sensation 64, we responded directly to the needs of our clinical users, and
have established new benchmarks in image quality, resolution and speed. The SOMATOM
Sensation 64’s unmatched resolution provides a level of detail that we expect will open up
entirely new applications for CT technology, proving that Siemens is once again pushing for-
ward the boundaries and capabilities of medical imaging.
The first clinical results, which we are introducing in this issue of SOMATOM Sessions, are
impressive. The new system delivers optimal image quality in cardiac, neurology and body
imaging applications with a spatial resolution of 0.4 millimeter – within a few seconds. Read
our Cover Story and the medical examples in our Clinical Outcomes section to learn more
about the SOMATOM Sensation 64’s outstanding technology and clinical capabilities.
With the last issue, we changed the SOMATOM Sessions into a news magazine on the world of
computed tomography. Your resounding positive response is encouraging to our
authors and Editorial Board. We are looking forward to more comments and feedback on
this issue – and for your contributions and topic suggestions for future issues.
Enjoy reading.
Yours sincerly,
2 SOMATOM Sessions 14
CONTENT
COVER STORY
4 SOMATOM Sensation 64 – Unprecedented Detail, Speed and Image Quality
8 “Now We Can see the Smallest of Details“
10 How Ceramic and Electronics become Medical Technology
NEWS
14 Introducing the Latest Technology
14 PROCAM Calculator plus CT-Examination Support Treatment of Coronary Events
15 World’s First 20-Slice Open CT System
15 syngo® InSpace: New Features
15 syngo Colonography: Hot Topic – Affordable for Everyone
BUSINESS
16 Efficient Workflow and Intelligent Post-Processing with syngo-Speaking Workplaces
17 Optimizing Workflow for Outpatient Imaging Center
17 Exclusive Agreement for further Development of Medical Imaging Software
CLINICAL OUTCOMES
18 SOMATOM Sensation 64: Multi-slice CT after Inferior Myocardial Infarction
21 SOMATOM Sensation 64: Whole Body Arterial Run-off
24 SOMATOM Volume Zoom: Perfusion CT of Intra-axial Brain Tumors:
Intracerebral Lymphoma
26 SOMATOM Emotion 6: Postosteosynthetic Vertebroplasty for a Burst Fracture of L1
SCIENCE
29 Computer Assisted Diagnosis (CAD): Current Status and Future Applications
32 CARE Dose4D™: Clinical Evaluation on a SOMATOM Emotion 6
35 SARS – Correlation of Follow-up Methods
CUSTOMER CARE
36 Clinical Training for Cutting-Edge CT Expertise
37 Introducing the Latest Technology
37 Service: Frequently Asked Questions
38 Hands-on the LEONARDO
38 Service: CT Online
38 Service: Upcoming Events
39 Imprint
SOMATOM Sessions 14 3
COVER STORY
Unprecedented Detail,
Speed and Image Quality
With the SOMATOM Sensation 64 Siemens Medical Solutions,
the leader in computed tomography innovation for 30 years, once
again sets the industry’s benchmark for diagnostic excellence.
By Alexander Zimmermann, Global Product and Marketing Manager SOMATOM Sensation, & Doris Pischitz,
Media and Public Relations, Siemens AG, Medical Solutions, CT Division
The requirements of clinical users were decisive for the system concept of the SOMATOM Sensation 64.
4 SOMATOM Sessions 14
COVER STORY
Today’s physicians expect the latest CT technology to signifi- of storing high amounts of heat. Instead of increasing the
cantly increase the visualization of finest details while out- size of the tube’s anode to compensate for the problem of
performing the highest volume coverage and acquisition inefficient heat transfer, the unique STRATON uses a directly
speed already known with 16-slice scanners. The new cooled anode. The tube’s – especially the anode’s – direct
SOMATOM Sensation 64 and its Siemens’ exclusive leading- contact with the cooling oil enables an extremely high, pre-
edge technology perfectly meets – and often exceeds – these viously unmatched cooling rate of five Million Heat Units
expectations. It accomplishes acquisition of 64 sub-millime- (MHU) per minute. Cooling delays experienced with con-
ter slices per rotation and allows physicians to routinely ventional X-ray tubes during multiple long-range scans are
achieve unprecedented diagnostic detail with the industry’s eliminated, even for large patients. The revolutionary, high
best isotropic resolution of 0.4 millimeter. Combined with cooling rate eliminates the need for anode heat storage
the industry’s fastest rotation speed of 0.33 seconds, the capacity – leading to 0 MHU. In addition, it allows for a com-
SOMATOM Sensation 64 routinely provides unmatched pact anode design which is the key to the industry’s fastest
image quality through unprecedented temporal and spatial CT rotation time of 0.33 seconds. This enables, for instance,
resolution. This image quality allows the display of the small- superb cardiac image quality without motion artifacts even
est intracranial, pulmonary, mesenteric, renal and peripheral at higher heart rates.
vessels, as well as the detailed visualization of the entire
coronary artery tree. In addition, it redefines CT plaque Revolutionary z-Sharp Technology
analysis and in-stent evaluation. Acquisition of 64 slices per rotation is possible through the
new STRATON X-ray tube’s Double z-Sampling Technology,
“Siemens has consistently taken the lead in the development and the new Siemens proprietary detector technology. The
of the most advanced CT innovations. Specifically, customer STRATON’s electron beam is accurately and rapidly deflected
demands for more accurate and faster CT imaging have been by an electromagnetic field, similar to a cathode-ray tube.
addressed,“ said Richard Hausmann, PhD, President, CT Divi- Two focal spots are created on the anode plate that alternate
sion, Siemens Medical Solutions. “The SOMATOM Sensation precisely 4,640 times per second in the z-direction. This Dou-
64 establishes the new benchmark for diagnostic excellence ble z-Sampling enables two X-ray beams to pass through the
and clinical workflow.” body in two different angles, virtually simultaneously. This
Recently introduced conventional 40- and 64-slice CT scan-
ners simply increase the number of detector elements,
resulting in higher scan speed without any increase in reso- Cathode Anode
lution. The SOMATOM Sensation 64 utilizes Siemens’ lastest,
exclusive technologies: the unique STRATON® X-ray tube,
the revolutionary z-SharpTM Technology and the cutting-edge Heat
UltraFastCeramic (UFCTM) detector system. These leading-
edge technologies enable both, increasing the number of
detector elements necessary for high volume coverage and
attaining previously unachieved 0.4 millimeter spatial reso-
lution. 1
SOMATOM Sessions 14 5
COVER STORY
6 SOMATOM Sessions 14
COVER STORY
A B [ A ] Conventional 64 x 0.6 mm
(0.5 s, pitch 0.7, 150mAs,
table feed 27 mm/rotation).
[ B ] Siemens 64 x 0.6 mm
with z-Sharp Technology
(0.5 s, pitch 1.5, 150 mAs,
table feed 28 mm/rotation).
High speed plus high resolution also leads to benefits in of chest pain. The increased speed also facilitates data acqui-
emergency situations. “The SOMATOM Sensation 64 has the sition for other patients who have difficulty holding their
potential to change the way chest pain of unclear origin is breath, such as elderly or pediatric patients.
examined in the emergency room,” says Bernd Ohnesorge,
PhD, Vice President Marketing and Sales, CT Division, Siemens Together, all these innovations allow physicians to take
Medical Solutions. It is now possible to examine heart and full advantage of unprecedented image detail, quality and
lung in one scan for exclusion of, for example, pulmonary speed with the SOMATOM Sensation 64. After a comprehen-
embolism or aortic dissection, and coronary artery stenosis. sive clinical testing phase, the system will be available as
A few seconds are sufficient for a ECG-gated scan of the Siemens Medical Solutions’ new CT flagship model
complete thorax. The physician with this one scan receives beginning in the fall of 2004.
image data that can be analyzed for several possible causes
A B [ A ] The SOMATOM
Sensation 64 redefines
follow-up of stent
patency.
[ B ] New areas of
unprecedented
3 mm Coronary Stent anatomical details can
be monitored.
Courtesy Institute of
Diagnostic Radiology/Institute
of Medical Physics,
Friedrich-Alexander-University
Erlangen-Nuremberg,
Germany
3 mm Coronary Stent
SOMATOM Sessions 14 7
COVER STORY
Interview
What did you expect from the SOMATOM Sensation 64? tions show a lot more detail, and this is true for cranial,
BAUTZ: Actually we were very satisfied with our cardiac, thorax, and abdominal studies. We can run true
SOMATOM Sensation 16. For example, we would not have arterial phases, for example of the carotis, without run-
needed faster volume coverage, as today's 16-slice scan- ning into the venous phase. Also, we experience a signifi-
ners already need a very refined bolus tracking in order cant reduction of spiral artifacts in the head, so the SO-
not to overtake it. But to achieve a confident diagnosis, MATOM Sensation 64 greatly improves brain and neuro
you always look for the highest isotropic resolution to vi- exams. We do not examine a lot of inner or middle ears,
sualize anatomical details. Here, the SOMATOM Sensation but from what we have reconstructed so far – based on
64 offers true clinical advantages, particularly in resolu- cranial CT angio scans – the high isotropic resolution will
tion along the z-axis. Also, due to it’s fast gantry rotation, it also improve diagnosis there.
eliminates any motion artifacts. KALENDER: I would also expect improvements in bone
structure exams for osteoporosis, and in examinations of
How satisfied are you with the image quality of the the joints.
SOMATOM Sensation 64?
BAUTZ: It is excellent. The system pushes temporal and With the SOMATOM Sensation 64, Siemens introduces
spatial resolution to a new level , achieving previously im- the new z-Sharp Technology: a focal spot that alter-
possible image quality. Besides this impressive image nates along the patient’s axis, which is the key for 0.4
quality, casual spiral artifacts known from any CT I have millimeter isotropic resolution. What are the advan-
seen so far are also gone. tages, compared to a conventional 64 slice CT?
KALENDER: I think that the introduction of the new
Which clinical advantages, compared to a 16-slice CT, z-Sharp Technology is comparable to the invention of
does the SOMATOM Sensation 64 offer? Which appli- multi-slice CT. Conventional 64-slice solutions increase
cations profit primarily from 0.4 millimeter isotropic the number of detector elements, resulting in a larger
resolution and 0.33 seconds gantry rotation speed? z-coverage without any improvements in image quality.
BAUTZ: The SOMATOM Sensation 64’s imaging quality, Instead, z-Sharp Technology's two overlapping X-ray
sharpness and speed gives us the opportunity to study beams improve the sampling rate, resulting in a signifi-
the human anatomy at a level that has only been dreamt cantly increased resolution and elimination of CT typical
about. Through the eyes of the scanner, we now can im- spiral artifacts. This innovative concept guarantees excel-
age smallest pathology which may, for example, improve lent image quality independent of the pitch value and
early diagnosis and treatment options. CT angio examina- without any increase in dose.
8 SOMATOM Sessions 14
COVER STORY
SOMATOM Sessions 14 9
COVER STORY
C T D ETEC TO R KN OW- H OW
Computed Tomography (CT) systems are one of the pillars of criteria in the CT market. Developments that carry far into
modern medicine, providing reliable diagnostic images with- the future assure Siemens’ market position of innovation
in a few seconds. Siemens alone has nearly 10,000 systems leader in CT. One of the objectives is to further enhance
installed worldwide and the demand continues. Multi-slice Siemens’ top-level competence in the development and
CT technology introduces a host of new clinical applications, manufacturing of detector arrays in order to be able to offer
for example, for cardiac imaging or CT colonography. X-ray Siemens-own, innovative, and cost-effective solutions.
tubes as well as detector systems are key differentiation The important core components of a CT system, the X-ray
10 SOMATOM Sessions 14
COVER STORY
Transforming X-rays
SOMATOM Sessions 14 11
COVER STORY
the shorter the afterglow, the sharper the image. This is the tomography system, UFC, especially optimized for CT, cre-
only way to achieve gantry rotation times of 0.33 seconds. ates considerable competitive advantages for Siemens Med-
ical Solutions – one of the reasons for the in-house UFC
UFC is almost as valuable as gold development.
The afterglow of the detector material developed in Forch- In addition to its minimal afterglow, UFC shows additional
heim decays 400 times faster than yttrium gadolinium oxide advantages: it can be processed with saws and tools from
(YGO) used for some time now by competitors in the CT the silicon industry and cut into small, stamp-sized plates –
field. This is the reason why the Siemens developer called approximately the size of a detector element. Needless to
their ceramic UFC – UltraFastCeramic. How to produce it, say, highest precision is required for processing. The toler-
remains the secret of Siemens’ scientists. “It’s the same as ance range does not exceed a few micrometer. Not without
with Coca Cola”, says Thomas von der Haar, PhD, Head of CT reason: after all, the resolution of a CT system depends on it.
Detector Development at Siemens Medical Solutions. “The The small UFC plates are structured into a millimeter fine,
ingredients are known, but aside from the manufacturer, chessboard-like pattern. The number of detector lines in the
nobody really knows the full recipe.” One thing is known for chessboard pattern is important. Until a few years ago, com-
sure: aside from the rare earth element gadolinium, the UFC puted tomography systems had only one single detector
ceramic also includes sulfur and other additives. The ceramic line, which meant that only a single slice could be acquired
material is the result of a process that involves mixing, chem- per rotation. These systems were followed by so-called mul-
ical reduction, sintering and pressing. The end product is a ti-slice systems. They featured several detector lines located
hard, yellow substance that resembles plastic more than it next to each other. During one rotation, several adjoining
does ceramic and weighs about as much as gold – and is just slices are acquired. As a result, a wider body region can be
about as valuable. Only a few tons of this expensive basic displayed within the same time period and with improved
material are needed annually. Since the scintillator material image quality. This provides the patient with the additional
has a significant effect on the characteristics of a computed advantage of drastically reduced examination times, an
The detector manufacturing in Forchheim also Highest precision in structuring the UFC-plates is of
delivers the detector systems for the production of utmost importance because this process significantly
the SOMATOM Smile in China. affects the resolution of a CT system.
12 SOMATOM Sessions 14
COVER STORY
An interdisciplinary team of experts is working in the The SOMATOM Sensation 16 has a total
Detector Center in the area of research, development of more than 10,000 pixels on its 42 detector
and manufacturing for detector and data electronics, elements – therefore providing also more
production process development and management. than 10,000 transmission channels.
important improvement, considering that, for thorax or heart tition by more than one-upmanship and maintain its position
examinations, the patient has to hold his or her breath to as a trendsetter in CT development, a role that has been
ensure that the image quality is not compromised by move- exclusively Siemens’ since the seventies.
ments of the thorax. Breath holding became considerably In its unique CT system design, the new SOMATOM Sensa-
shorter with multi-slice systems. tion 64 combines a 40-row multi-slice detector array (32 x
One example: the SOMATOM Sensation 16, a 16-slice com- 0.6 millimeter detector rows, eight x 1.2 millimeter detector
puted tomography system. Its detector array consists of a rows) with a special mobile focus – the so-called Double
total of 42 detector modules. These are located next to each z-Sampling Technology – of the new STRATON X-ray tube.
other over a distance of approximately one meter in the Having developed this detector for the SOMATOM Sensation
gantry. This is wide enough to image a patient from shoulder 64, are there any remaining challenges? Stefan Pflaum, Head
to shoulder. Each detector module comprises a single of the Detector Center in Forchheim, explains: “Sure there
16-row detector plate, including the photodiode layer locat- are. The ultimate goal is to create even larger area detector
ed underneath it as well as the signal processing electronics. elements with an acquisition width of approximately 12 cm.”
Since the UFC detector layers are divided not only by rows This would allow to completely image the human heart with
but also by columns, a multitude of single pixels measuring just one single rotation of the gantry. While the UFC technol-
between one to two square millimeters in size result per ogy could handle this easily, the challenge is to integrate and
plate. The 16-row system has a total of more than 10,000 pix- process the growing amount of pixel channels and image
els on its 42 detector elements. The signals of these pixels information within a small area at reasonable costs. It is clear
are routed over their own electronic channel. that CT technology has not reached its limits by far. For
Pflaum it is just a matter of time until area detectors become
64-Slice CT a commercial reality.
This know-how created the basis for the development of the
detector array for the world’s first 64-slice computed tomog-
raphy system – a giant step forward. For one, the z-coverage
Author: Tim Schroeder is a biologist and former editor of the science
that can be scanned per rotation is larger. For the other, res-
section of the Berliner Zeitung. He is now a freelance writer in Oldenburg
olution is increased because the detector chessboard has an and publishes his work regularly in scientific journals such as Spektrum
even finer grid. Siemens is going to outdistance the compe- der Wissenschaft, Max Planck Forschung and Fraunhofer Magazine.
SOMATOM Sessions 14 13
NEWS
ECR 2004
C T I N C A R D I O LO GY
14 SOMATOM Sessions 14
S O M AT O M S e n s a t i o n O p e n
syngo InSpace
New Features
A wealth of exciting new features will be What’s more, a number of workflow en- the zoom factor, improved handling of
available with the latest version of syngo hancing tools and features have been regions of interest (ROI) and the possi-
InSpace, including syngo InSpace4D. implemented. Two studies can be loaded, bility to perform 2D measurements in
With the 4th – temporal – dimension, it is viewed and compared in parallel. For the 3D volume.
possible to display the beating heart by quick and easy display of data, a broad
playing multiple reconstruction phases selection of presets is provided, together k Further Information:
as a movie. Anatomy can be examined with the possibility to define individual www.siemens.com/
interactively. default settings, numeric adjustment of computed-tomography
s y n g o C O LO N O G R A P H Y
SOMATOM Sessions 14 15
BUSINESS
Wor k St r eam
16 SOMATOM Sessions 14
S O M AT O M E m o t i o n 6
Ralph Wolkewitz, MD, and his colleague
Optimizing Workflow Thomas Krambrich, MD, are convinced of
the economical and clinical benefits of
for Outpatient Imaging Center their new SOMATOM Emotion 6.
With more than 300 systems sold since In Wolkewitz’s practice, five physicians that, with the SOMATOM Emotion 6, we
the start of production one year ago, the and 50 employees examine and treat will easily be able to handle another ten
SOMATOM Emotion 6 is one of the most up to 400 patients a day with a wide percent increase in patient throughput
successful CT systems in the world. The range of imaging and radiology equip- which we expect from the radiation
cost-effective system was developed ment, from X-ray, CT, Angiography and therapy center that is currently being
especially for customers with limited Mammography to Magnetic Resonance built.” The SOMATOM Emotion 6 will
budgets and space availability, making it Imaging and Nuclear Medicine. The then additionally be used for radiation
a high performance-oriented CT scanner SOMATOM Emotion 6, installed last No- therapy planning, as well as preventive
for daily routine examinations. vember, is mainly employed for thorax and follow-up care.
This works smoothly, according to Ralph scans, abdominal and neurological stud- To further enhance it’s capabilities and
Wolkewitz, MD at the multidisciplinary ies, and calcium scoring. Wolkewitz and cost effectiveness, Siemens Medical So-
joint practice of the Marienhospital in his team also plan to start using CT lutions recently introduced new clinical
Soest, Germany: “We are scanning up to colonography soon. application software – syngo LungCARE
60 patients within an eight-hour work But it is not just the speed of the scanner CT, CARE Dose4D, and CARE Vision – as
day without problems. Most patients get itself that enables this workload. “To- well as the durable new Dura 422 liquid
an appointment for the day they call.” gether with the intuitive user interface bearing X-ray tube for the SOMATOM
This is one reason that the SOMATOM syngo, and the fast 3D reconstructions Emotion 6.
Emotion 6 is patient friendly. The other, on the LEONARDO workstation, we can
of course, is its fast acquisition and also speed up workflow and physicians’ k Further Information:
therefore, short breathhold time. diagnosis,” says Wolkewitz. “We are sure www.arzt-radiologie-soest.de
syngo InSpace
Case 1:
Multi-slice CT after Inferior Myocardial Infarction
By S. Achenbach, MD, W. G. Daniel, MD, D. K. Pohle, MD, D. Ropers, MD, Department of Internal Medicine II,
K. Anders, MD, U. Baum, MD, W. Bautz, MD, Institute of Diagnostic Radiology,
W. A. Kalender, MD, Institute of Medical Physics, University of Erlangen, Germany
18 SOMATOM Sessions 14
CLINICAL OUTCOMES
A B [ 2A and 2B ]
Pronounced
right ventricular
enlargement in
RV the MSCT scan
performed two
weeks after the
acute event [2A:
RV axial image; 2B:
„short axis“ refor-
mat] as evidence
of right ventricu-
lar involvement in
inferior myocar-
dial infarction
A B
➘
➘
➘
SOMATOM Sessions 14 19
CLINICAL OUTCOMES SOMATOM SOMATOM
Sensation Emotion
A B
A B
20 SOMATOM Sessions 14
CLINICAL OUTCOMES
Case 2:
Whole Body Arterial Run-off
By A. Küttner, MD, Department of Radiology, Eberhard-Karls-University, Tuebingen,
J. E. Wildberger, Assc. Professor, Department of Diagnostic Radiology, University Hospital Aachen,
M. Lell, MD, Department of Diagnostic Radiology, University of Erlangen,
A. Blaha, Siemens Medical Solutions, Forchheim, Germany
SOMATOM Sessions 14 21
CLINICAL OUTCOMES SOMATOM SOMATOM
Sensation Emotion
[ 3 ] Sagittal VRT-
zoom of the right
carotid bifurcation.
No relevant stenosis
is seen; note the
detailed depiction of
the right vertebral
artery.
[ 4 ] VRT of the
ungated aortic
arch.
[ 5 ] VRT-zoom at the
proximal thigh: The distal
common femoral artery,
the superficial femoral
artery, as well as the deep
femoral artery are homo-
geneously contrasted.
22 SOMATOM Sessions 14
CLINICAL OUTCOMES
[ 6 ] VRT-zoom at the level of the renal arteries. [ 7 ] MPR of the soft plaque (arrow) in the right com-
Normal single vascular supply is demonstrated for both mon iliac artery.
kidneys. Note the homogeneous opacification of the
urinary tract down to the iliac decussation due to the
previous contrast application.
[ 8 ] MIP of the renal arteries. [ 9 ] VRT-zoom at the proximal calf: The popliteal
artery, with the soleus arteries, as well as the proximal
portion of the anterior and posterior tibial artery, and
the fibular artery are depicted clearly.
SOMATOM Sessions 14 23
CLINICAL OUTCOMES SOMATOM SOMATOM
Sensation Emotion
Case 3:
Perfusion CT of Intra-axial Brain Tumors:
Intracerebral Lymphoma
By Peter Schramm, MD, Department of Neuroradiology, University Heidelberg Medical Center, Heidelberg, Germany
In the past decades, incidence rates for primary central EXAMINATION PROTOCOLS
nervous system lymphomas have been increasing, especially
in elderly patients and patients with immune compromise Scanner SOMATOM Sensation 4
[1]. Since the specific therapy of these tumors completely Scan Area through the tumor (in this case
differs from those of glioma, it is absolutely necessary to basal ganglia)
identify these tumors and to separate them from other Scan length 20 mm
Scan time 40 s
intracranial masses.
kV 80 kV
Effective mAs 250 mAs
HISTORY Rotation time 1.0 s
Slice collimation 4 x 5 mm
A 72 year old male presented to the Department of Neurolo- Slice width 2 x 10 mm
gy suffering from diplopic images for eight weeks. The Table feed / rotation 0 mm
patient also noticed an increasing shakiness when walking. Reconstruction increment 1 image/s
He was fully orientated. Kernel H40s
24 SOMATOM Sessions 14
CLINICAL OUTCOMES
Maps of PCT revealed a massive disruption of the blood- tial diagnosis with the syngo Perfusion CT software, enabling
brain-barrier within the tumor. drug therapy in this case. Therefore, our patient was treated
Obviously the contrast enhancement is not due to hypervas- with corticosteroids which led to a significant reduction of
cularization or neoangiogenesis of the tumor but to contrast the tumor volume and to clinical restitutio ad integrum.
leakage through the disrupted blood-brain-barrier. This com-
bination is typical for lymphoma. This case illustrates that
contrast enhancement within brain tumors allows differen-
1 2
➘
➘
➘
1 Cote TR, MannsA, Hardy CR, Yellin FJ, Hartge P. Epidemiology of brain
lymphoma among people with or without acquired immunodeficiency
syndrome. AIDS/Cancer Study Group. J Natl Cancer Inst. 1996 May 15;
88(10): 675-9
SOMATOM Sessions 14 25
CLINICAL OUTCOMES SOMATOM SOMATOM
Sensation Emotion
Case 4:
Postosteosynthetic Vertebroplasty
for a Burst Fracture of L1
By T. Bouziane, MD, & J. Kirsch, MD, Head of Radiology Department, Radiology Department,
Clinique Notre-Dame, Tournai, Belgium
26 SOMATOM Sessions 14
CLINICAL OUTCOMES
COMMENTS [ 1 ] Radiographic
profile of the
Vertebroplasty is an interventional radiological technique dorsolumbar hinge :
consisting of the injection of an acrylic cement into a patho- Burst fracture of
logical vertebra by a percutaneous path in order to obtain an L1 with recoil of the
antalgic effect and a consolidation of the vertebra [1, 2, 3]. posterosuperior
The procedure consists, on the one hand, of stabilizing the marginal angle,
vertebral body and, on the other, of the antalgesic effect and responsible for
canal stenosis.
the consolidation of the fractures, as well as the destruction
of the intracorporeal nerve ends, resulting from the toxic
effect and the thermal release of the cement during the
solidification phase.
The puncture required for the injection of the cement was
performed under tomodensitometric guidance in order to
avoid the known classical complications, above all, with the
epidural escape of cement. In this case, given the multifrag-
mentation of the vertebral body, we preferred to use a single
transpedicular path [4].
EXAMINATION PROTOCOLS
SOMATOM Sessions 14 27
CLINICAL OUTCOMES SOMATOM SOMATOM
Sensation Emotion
4 5 6
28 SOMATOM Sessions 14
SCIENCE
With the introduction, and now widespread availability of In addition to these applications, CAD also offers the oppor-
multidetector CT (MDCT) scanners, the need for advanced tunity as a “second reader,” providing automatic detection of
imaging tools for detecting and characterizing lung nodules otherwise overlooked lung nodules. As recently documented
has become imperative. Faced with the daunting task of by Swensen et al, in an evaluation of annual incidence screen-
evaluating between 250 and 350 high resolution 1.5 mm ing CT scans, up to 26% of nodules may be missed [5]. As
images now routinely provided by 4- and especially 16-slice reported by Armato et al, CAD allowed detection of 78% of 18
CT scanners, radiologists already are clearly in need of more overlooked nodules in studies in which contiguous 10 mm
sophisticated methods of image evaluation than simple thick sections only were obtained [6]. Similarly, Wormanns et
perusal of 5 to 7 mm axial CT images [1]. al, using a CAD system specifically designed to detect nodules
Although usually interpreted to be limited to lung nodule larger than 5 mm, found that up to 15% of nodules were iden-
detection, CAD is best defined for radiologists as any of a tified solely by computer [7]. As importantly, Novak et al, in an
number of methods of assisting interpretation by means of evaluation of 13 studies using MDCT screening with 1.25 mm
computerized image analysis. Broadly interpreted, this contiguous sections initially interpreted as negative, showed
includes both methods of detection and of characterization that use of CAD allowed identification of an additional 10
[2]. In fact, many of these computer tools are already avail- actionable nodules – defined as larger than 3 mm – in 46% of
able. These include: rapid real time transitions between cine cases. As important, CAD also offers the potential to markedly
displays of thick and thin (1-1.5 mm) sections, multi-planar diminish interobserver variability [8]. It should be emphasized
reconstructions (MPR) and sliding maximum intensity pro- that, with ever expanding data sets providing greater and
jection images (MIP), all in a variety of user defined imaging greater numbers of high resolution thin CT sections, the appli-
planes. Once identified, additional tools to further character- cability of CAD for detecting lung nodules will only expand.
ize lesions are also now available, including: 180 degree cart- The introduction of a new Siemens software tool named NEV
wheel projections (allowing rapid differentiation between (Nodule Enhanced Viewing) represents a big step in this
lung nodules and similar sized blood vessels), as well as real direction. NEV in conjunction with the other tools provided
time 3D segmentation, providing automatic assessment of by syngo LungCARE CT is designed to support the physician
nodule diameters and volumes. These data are critical for in confirming the presence or absence of identified lung
accurate assessment of interval growth, especially for small- lesions (e.g., nodules).
er lung nodules that are notoriously difficult to reproducibly It is apparent that, in this era of MSCT, the the future is espe-
measure even with the use of electronic calipers [3]. cially bright for the continued development and utilization of
In cases in which nodule densitometry is required following computer methods for assessing the thorax. In addition to
administration of intravenous contrast media, it is now also already established uses such as nodule detection and char-
possible to automatically acquire average density measure- acterization, CAD offers considerable promise for automatic
ments of an entire nodule at various timed intervals, replac- detection of subtle sub-segmental pulmonary emboli. Of
ing the need for obtaining user defined single axial sections. particular interest is the potential for CAD to provide CT eval-
It is also now possible to automatically register the location uation of both global and regional lung morphology and
of nodules on follow-up scans once identified on prior stud- function, including such diverse indications as measuring
ies – a major improvement in time utilization. As document- pulmonary ventilation as a measure of likely success of lung
ed by Novak et al, in a study of 16 patients, an automated volume reduction surgery [9].
nodule detection system provided exact correspondence
between nodules on scans performed at two separate times
within three contiguous 1 mm high resolution axial sections
in 99% of cases [4].
SOMATOM Sessions 14 29
SCIENCE
Case Study
NEV in the Evaluation of Recurrent Lung Cancer
By David P. Naidich, MD, FACCP, Department of Radiology, New York University Medical Center, Tisch Hospital, New York, USA
HISTORY
A 67 year old man was evaluated with routine follow-up low- adjacent central vascular structures [Fig. 2A]. Re-evaluation
dose surveillance CT scans since 1997. Before initial presenta- of this study using Nodule Enhanced Viewing (NEV) facilitat-
tion, the patient had previously undergone a right upper ed identification of this lesion a [Fig. 2B]. This lesion could
lobe resection for non-small cell lung cancer, followed by have been further characterized by the physician using the
adjuvant chemotherapy. In our institution, periodic six to variety of tools available on syngo LungCARE CT, including
twelve month follow-up CT examinations are obtained to 180 degree cartwheel projections allowing small nodules to
identify potential tumor recurrence. Given an increased risk be easily differentiated from similar sized blood vessels, as
of second lung primaries, we also scan to identify potential well as real-time 3D segmentation providing accurate cross-
new lung neoplasms. sectional diameters and precise determination of nodule vol-
ume and overall density [Fig. 3].
DIAGNOSIS
EXAMINATION PROTOCOLS
In this case, follow-up CT studies over the course of several
years periodically failed to identify the presence of new nod- Scanner SOMATOM Volume Zoom
ules requiring additional chemotherapy. On the most recent Scan Area from thoracic inlet to
CT examination, performed in March, 2004, a 3 x 2.5 cm the hemidiaphragms
lobular mass is clearly identifiable in the medial aspect of the Scan length 320 mm
left upper lobe extending to the left hilum associated with Scan time 22 s
Scan direction cephalo-caudal
enlarged peri-carinal and aorticopulmonary lymph nodes
kV 120 kV
[Fig. 1]. These findings proved consistent with advanced dis-
Effective mAs 33 mAs with CARE Dose4D
ease recurrence. Rotation time 0.5 s
Slice collimation 4 x 1 mm
COMMENTS Slice width 1.25 and 7 mm
Pitch 1.8
Retrospective evaluation of the previous CT examination, Reconstruction increment 1 and 6 mm, respectively
performed six months prior, showed that a subtle sub-cen- Kernel B60f
30 SOMATOM Sessions 14
SCIENCE
If NEV had been used during the initial review of the prior both early recurrences as well as new primary lung cancers
exam, this lesion, which subsequently proved to represent represent an important addition to our imaging armamen-
recurrent tumor, might not have been missed. Software tarium. This case example demonstrates the potential future
tools which enhance the ability of the physician to detect value of lung CAD.
A B
[ 2A ] Axial CT section using syngo LungCARE CT at the [ 2B ] The same section now is marked with
same level as shown in [1], obtained six months earlier. a red circle identifying a central nodular density.
Although a subtle lesion is present in the medial aspect of Re-evaluation with NEV successfully outlined
the left upper lobe, this was not identified prospectively. this previously overlooked potential abnormality.
1 Ko, JP, Naidich, DP. Lung nodule detection and characterization with mul-
tislice CT. Radiol Clin N Amer, 2003; 41: 575–597
2 Giger, ML. Computer-aided diagnosis in radiology. Acad Radiol, 2002;
9(1): 1–3
3 Erasmus, JJ, et al. Interobserver and intraobserver variability in measure-
ment of non-small-cell carcinoma lung lesions: implications for assessment
of tumor response. J Clin Oncol, 2003; 21(13): 2574–82
4 Novak, CL, et al. Performance of an automatic system for nodule corre-
spondence in follow-up CT studies of the lung. Radiology, 2002; 225 (P):
476–476
5 Swensen, SJ, et al. Screening for lung cancer with low-dose spiral com-
puted tomography. Am J Respir Crit Care Med, 2002; 165(4): 508–513
6 Armato, SG, 3rd, et al. Lung cancer: performance of automated lung
nodule detection applied to cancers missed in a CT screening program.
Radiology, 2002; 225(3): 685–92
7 Wormanns, D, et al. Automatic detection of pulmonary nodules at spiral
CT: clinical application of a computer-aided diagnosis system. Eur Radiol,
2002; 12(5): 1052–7
8 Novak, CL, et al. Identification of missed pulmonary nodules on low-dose
CT lung cancer screening studies using an automatic detection system. in
[ 3 ] Images obtained using syngo LungCARE CT to SPIE. 2003; Proc SPIE
retrospectively assess questionable nodule identified in 9 Hoffman, EA, et al. Characterization of the interstitial lung diseases via
Figure 2B by NEV. In this case, a subtle nodule is clearly density-based and texture-based analysis of computed tomography images
present adjacent to central pulmonary vessels, most of lung structure and function. Acad Radiol, 2003; 10: 1104–1118
*syngo LungCARE CT including the NEV software is available on a 90-day
easily identified using 3D segmentation. In this image
free trial basis. For more information please contact your local Siemens
the lung nodule is outlined in yellow to facilitate identi- Representative. If you have Siemens Remote Service connectivity, you can
fication. Note that syngo LungCARE CT provides auto- order your free trial software directly via SOMATOM Life @ Your Scanner
matic assessment of this nodule’s diameter, volume from your Navigator or Wizard console. syngo LungCARE CT NEV is available
and density. for the SOMATOM Emotion 6, SOMATOM Sensation Scanners and for the
LEONARDO workstation.
SOMATOM Sessions 14 31
NEWS SECTION
SCIENCE
CARE Dose4D
Clinical Evaluation on a SOMATOM Emotion 6
CARE Dose4D and its real-time mA adjustment ensures good image
quality at the lowest dose. Based on experience with more than 400 patients,
the authors achieved 20 to 72% dose reduction in comparison with fixed
mA level, while maintaining good diagnostic image quality.
By T. H. Mulkens, MD, P. Bellinck, MD, & J. L. Termote, MD, Department of Radiology, H.-Hart Ziekenhuis, Lier, Belgium
Recent technological advances have markedly enhanced the based examinations in the United States, it delivers over
clinical applications of CT. While the benefits of CT exceed two-thirds of the total radiation dose associated with med-
the harmful effects of radiation exposure in patients, increas- ical imaging and about one-third of the collective population
ing radiation dose to the population has raised a compelling dose [1, 2].
case for reduction of radiation exposure from CT [1, 2]. Vari- Recent articles have focused on the estimated risk of cancer
ous methods and strategies based on individual patient development due to the use of diagnostic X-rays in adults [3]
attributes and CT technology have been explored for dose and children [4]. The radiation dose from CT can approach,
optimization [1]. and sometimes exceed, the level known to increase the
Owing to the ongoing technological boom during the past probability of cancer and can add a small, but statistically sig-
ten years, there has been a corresponding, notable increase nificant, risk to the lifetime cancer mortality risk of the natu-
in the number of CT examinations being performed around ral background cancer rate.
the world: surveys performed in the United States reveal that The broadened use of CT in clinical practice has thereby
the annual number of CT examinations has increased almost raised concerns about mounting radiation exposure, thus
tenfold in less than two decades – from 3.6 million in 1980 to emphasizing the need for appropriate strategies to optimize
33 million in 1998 [2, 3]. An estimated 2.7 million CT studies CT and, if possible, reduce radiation dose due to CT, while
were performed in children under the age of 15 years in preserving the required image quality and medical benefit.
2000 [4]. While CT accounts for only 11 to 13% of X-ray- In this paper, we will present our clinical data about the use
[ 1 ] 45-year-old female (165 cm, 66 kg, BMI=24.24 ). CT multiphase examination of the abdomen superior for
clinical history of recurrent pancreatitis. Mean effective mAs of 70 (CTDIvol = 8.0 mGy) which means 33% reduction
compared to the reference mAs level of 105. Calculated effective dose for the whole multiphase examination is
14.3 mSv. CT images in the arterial phase show multiple pancreas pseudocysts and pancreatic calcifications.
32 SOMATOM Sessions 14
SCIENCE
NEWS SECTION
[ 2 ] 35-year-old-man (150 cm, 54 kg, BMI=24.02). CT examination of C-spine for evaluation of cervical pain
without irradiation. Mean effective mAs of 45 which is a dose reduction of nearly 75 % in comparison with the
reference level of 175 mAs. CT shows disk protrusion at disk level C5-C6. Calculated effective dose for the
whole examination is only 0.54 mSv.
of CARE Dose4D, a fully automated, real-time and anatomy- Angular (x-y-axis) modulation has a different objective than
based dose regulation program to optimize CT dose and z-modulation [5, 6, 7]. In angular modulation, the tube cur-
image quality. rent is adjusted to minimize X-rays in projections (angles)
that have less importance for the reduction of overall image
Automatic Modulation of Tube noise content. In anatomy that is highly asymmetric (e.g. the
Current in CT shoulders), X-rays are much less attenuated in the anterior-
The modulation of X-ray tube current is a technical innova- posterior direction than in the lateral direction [5]. Thus, the
tion that substantially reduces radiation dose. By adjusting overwhelming abundance of anterior-posterior X-rays can
the tube current to follow the changing patient anatomy, often be reduced dramatically without a marked effect on
dose efficiency will be improved [1, 5, 6, 7]. overall image noise. Angular tube current modulation has
There are two methods used on CT scanners today: z-axis been introduced on multi-detector row CT scanners by
modulation and angular (x- and y-axis) modulation. Both meth- Siemens with the CARE Dose program. In this implementa-
ods have a complementary role in minimizing patient dose tion, the modulation is determined in real time by using pro-
and are both incorporated in the CARE Dose4D mechanism. jection data that lag 180° from the X-ray generation angle. In
In z-axis modulation, tube current is adjusted to maintain a clinical studies, CARE Dose gives dose reduction of typically
user-selected level in the image data. Noise is regulated on 10 to 50%, with mean reduction of 10% for head region, 53%
the final image to a level desired by the user. In this sense, for shoulder region, 22% for thorax region, 15% for abdomen
z-axis modulation is the CT equivalent of the auto-exposure region and 25% for pelvis region [7]. A recent investigation
control systems used for many years with conventional X-ray of 100 helical CT imaging studies in children in whose angu-
systems. Z-Axis modulation is an attempt to render all lar modulation was used, showed a 10 to 60% decrease in
images with similar noise, independent of patient size and dose, with a mean reduction of 22.3% (neck, 20%; thorax,
anatomy. The dose savings with z-axis modulation are 23%; abdomen, 23%; thorax and abdomen, 22%) without
expected to be greater than those with fixed-tube current loss of image quality [8].
methods, since the tube current will be automatically The ideal CT scanner will employ both z-axis and angular
reduced for smaller patients and anatomic regions [1]. modulation techniques. When available in all commercial CT
Z-Axis modulation has been introduced for multi-detector scanners, use of manual techniques, whereby a tube current
row CT scanners in the new CARE Dose4D mechanism. Tube value is selected on the basis of some simple measure of the
current modulation is determined from the attenuation val- patient (e.g. weight or cross-sectional dimensions), will be
ues and shape obtained by refined data analysis of one sin- replaced with this computerized objective approach [1].
gle projection radiogram (Topogram) of the patient just prior With these developments, tube current modulation in CT
to the CT scans. Clinical results of this technique have not yet scanners is comparable to photographic timing or automatic
been published [1]. brightness controls currently used in conventional radiogra-
SOMATOM Sessions 14 33
SCIENCE
[ Table 1 ]
Examples of dose reduction compared to a standard reference level using CARE Dose4D.
reference mAs effective mAs dose reduction effective mAs number of
mean mean % range patients
Abdomen - Pelvis 105 71,6 32 39–121 53
Abdomen - Liver 95 51,57 46 41–99 23
L-spine medium 200 129,6 35 92–200 42
C-spine 175 52,12 70 43–70 26
phy. Indeed, automatic tube current modulation promises to 35% with CARE Dose4D in comparison with 10 to 20% for
be an important optimization of scanning parameters that CARE DOSE. The most spectacular mAs reduction we got in
will help eliminate the guesswork involved in parameter C-spine spiral examinations: mean reduction of 70%, consis-
selection. tent in more than 25 patients (15 to 20% for CARE DOSE):
mAs reduction from 175 reference mAs level to about 50–55
Evaluation of CARE Dose4D effective mAs, or reduction of CTDIvol from 23.3 mGy to
A preliminary test version of the new Siemens software was 7.4 mGy!
implemented on our SOMATOM Emotion 6 multi-detector The quality of the images is good and consistent. In very slim
CT in December, 2003. Among the new features included in patients the system gives very low mAs settings, so that the
this newest software version is CARE Dose4D. images are quite noisy, compared to the previous scan tech-
We started to evaluate CARE Dose4D, beginning with a limit- nique. But the system permits fine-tuning of the settings of
ed number of scan protocols that we used most and which the CARE Dose4D program, so that for very slim patients the
constitute the majority of our daily CT work, described for power of the program is adjusted properly.
the following regions: thorax spiral exams: routine and ‘lung Our conclusion: The use of CARE Dose4D is very simple and
embolism’ protocol; abdomen spiral exams: abdomen-pelvis clear. Once the standard reference level of mAs is adapted
protocol (whole abdomen), abdomen multiphase liver and for each scan protocol to a level of good image quality for a
kidney protocol and abdomen low dose protocol for urolithi- standard normal sized patient, and once it is activated in the
asis search; spine exams: L-spine spirals, in medium and scan protocol, it really works as an “automatic exposure con-
large size patients and C-spine spirals [table 1]. In the initial trol” mechanism and adapts the dose to the individual
period, we looked for the best ‘reference mAs level’ for each patient size (including large or bariatric patients) without
scan protocol: this is the preset mAs level from which the need for further modifications.
CARE Dose4D program starts and which gives good image
1 Kalra MK, Maher MM, Toth TL et al. Strategies for CT radiation Dose opti-
quality for a mean, normal-sized patient. After trying differ-
misation. Radiology, 2004; 230: 619–628
ent reference ‘mAs’ levels for each scan protocol, we agreed, 2 Nickoloff EL and Alderson PO. Radiation exposures to patients from CT:
based on subjective impression of good image quality, about reality, public perception and policy. AJR, 2001; 177: 285–287
the reference mAs levels of our different scan protocols. 3 Berrington de Gonzalez A and Darby S. Risk of cancer from diagnostic
X-rays: estimates for the United Kingdom and 14 other countries. Lancet,
Since beginning in December 2003, we have done about 2004; 363: 345–351
450 CT examinations with CARE Dose4D. We collected 4 Brenner D, Elliston C, Hall E et al. Estimated risk of radiation-induced fatal
patient data and examination data for 325 patients. We can cancer from paediatric CT. AJR, 2001; 176: 289–296
5 Kalender WA, Wolf H, Suess C, Gies M, Greess H, Bautz WA. Dose reduc-
say that the software program of CARE Dose4D is stable and
tion in CT by online tube current control: principles and validation on phan-
that for each scan region/protocol the results are consistent. toms and cadavers. Eur Radiol 1999; 9: 555–562
When we compare with the level of mAs reduction/dose gain 6 Kalender WA. Possibilities for reducing the dose in CT. In: Computed
with the previous CARE DOSE system, what we know from Tomography, Publicis MCD Verlag, Munich, 2000; 139–142.
7 Greess H, Wolf H, Baum U, Lell M, Pirkl M, Kalender WA, Bautz WA. Dose
our data and from the literature, we have a greater mean reduction in computed tomography by attenuation-based online modula-
dose gain in CT abdomen and CT pelvis : 32 to 45% for CARE tion of tube current: evaluation of six anatomical regions. Eur Radiol 2000;
Dose4D (mean 38%) and 15 to 25% for CARE DOSE, respec- 10: 391–394
8 Greess H, Nomayr A, Wolf H et al. Dose reduction in CT examination of
tively. We have comparable mAs reduction in CT thorax:
children by an attenuation-based on-line modulation of tube current (CARE
about 20% with CARE Dose4D and CARE DOSE, and obvious- Dose). Eur Radiol 2002; 12: 1571–1576
ly more in the L-spine examinations: mean mAs reduction of Results may vary. Data on File.
34 SOMATOM Sessions 14
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SOMATOM Sessions 14 35
CUSTOMER CARE
L I F E – S O M AT O M E D U C AT E
36 SOMATOM Sessions 14
CUSTOMER CARE
CU STO M E R EVE NT
SERVICE
SOMATOM Sessions 14 37
CUSTOMER CARE
CLINIC AL TR AINING
Baltimore, 7 a.m.: each of the 13 hands-on
Hands-on the LEONARDO sessions at both meetings was oversubscribed.
The Johns Hopkins Medical Centre is well known for its con- hugely popular hands-on sessions. Each 90 minute session
tinuing medical education courses, not least Professor Elliot began with a “how-to” demo lead by both the Hopkins
Fishman, MD, for his popular multi-detector CT (MDCT) course faculty and Siemens applications specialists, which
workshops. In March and April, Siemens Medical Solutions highlighted the principles of the techniques and their clinical
hosted hands-on workstation training sessions at his applications. Participants then dived in to a wealth of spe-
“Advanced Topics in CT Scanning” courses in Los Angeles and cially chosen clinical cases, supported by a team of Siemens
Baltimore. At both meetings, more than 300 radiologists and applications specialists who made sure that, by the end of
technologists took advantage of the opportunity for hands- the session, everyone walked away with a good grasp of the
on training in the principles of 3D and virtual imaging with principles and clinical application of 3D and virtual post-pro-
syngo InSpace, CT angiography, cardiac CT, virtual colonog- cessing techniques.
raphy and lung imaging. Siemens provided 20 LEONARDO k Further Information:
workplaces, enabling participants to work individually in the www.CTisus.com, www.siemens.com/SOMATOMEducate
C T ONLINE
In addition, you can always find the latest CT courses offered by Siemens Medical Solutions at www.siemens.com/SOMATOMEducate.
38 SOMATOM Sessions 14
CUSTOMER CARE
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