No.

16/June 2005
Stanford University’s 7th Annual International Symposium on Multidetector-Row CT June 15-18, 2005

www.siemens.com/medical

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Highlights
COVER STORY Think Clinical! Page 4 NEWS SOMATOM Sensation – 40-Slice Technology Page 12 BUINESS SOMATOM Spirit – “And it runs, and runs, and runs...“ Page 15 CLINICAL OUTCOMES syngo Body Perfusion CT – Differential Diagnosis of a Pancreas Page 20 SOMATOM Emotion 6 High Resolution Orthopedics Examination Page 24 SCIENCE Archaeology – High-tech Meets History Page 33 CUSTOMER CARE LIFE Educate – A Win-Win Situation Page 35

EDITOR’S LETTER

Bernd Ohnesorge, PhD, Vice President CT Marketing and Sales

Dear Reader,
It is Siemens’ goal to remain the trend-setter in Computed Tomography (CT) technology and clinical applications, and to provide innovative multislice CT and workflow solutions for all clinical needs – from the cost-optimized SOMATOM® Spirit up to the leading edge SOMATOM Sensation 64. More than 100 of our brand-new multislice SOMATOM Spirit CT scanners are in use all over the world, from the highlands of Tibet to Milwaukee, USA. Within one year, more than 250 SOMATOM Sensation 64-slice CT scanners have been installed in the world’s leading academic institutions and in busy hospitals and practices. First peer-reviewed reports in leading medical and scientific journals definitely substantiate the advantages of Siemens' proprietary z-SharpTM Technology in neuro, chest, vascular and cardiac CT applications. Moreover, the first SOMATOM Sensation 40 scanners, providing access to z-Sharp’s benefits at attractive investment levels, are running successfully in Europe and the USA. And our new SOMATOM Emotion 16, which was introduced at the ECR 2005 in Vienna, will bring advanced 16-slice CT performance to day-today clinical practice at even lower investment levels. And there is much, much more in the pipeline… As the amount of data acquired per study is increasing, high-performance workflow and application solutions gain importance. We have devoted most of this issue to discuss the challenges and solutions for the efficient management of large data sets. Find out about our latest innovations in clinical workflow design for cardio-vascular applications and for highly sensitive early diagnosis of cancer. Our authors and editors have put together another outstanding collection of useful information. Join us on a fascinating journey in space and time through the human body. We are looking forward to your comments, suggestions, and contributions. Sincerely,

Bernd Ohnesorge, PhD, Vice President CT Marketing and Sales

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CONTENT

COVER STORY
4 8 9 10 Think Clinical! The Fast Lane to Cardiac Diagnosis Benefits of Computer-Aided Detection Continuous Software Enhancements

NEWS
11 11 12 12 CT on its Way Beyond Slices? Advanced Performance at Low Cost 40-Slice Technology LEONARDO in Anatomy Teaching

BUSINESS
13 13 14 14 15 Cardiologists and Radiologists Unite Forces Free Trial Clinical Software Driving Initiatives against Colon Cancer Demo Poster “And it runs, and runs, and runs...“

CLINICAL OUTCOMES
16 18 20 22 24 26 SOMATOM Sensation 64: Low Dose Cardiac Scanning of a Neonate in one Second SOMATOM Sensation 40: Peripheral Runoff SOMATOM Sensation 16: Differential Diagnosis of a Pancreas SOMATOM Sensation Open: Paget Sarcoma Disease in the Tibia SOMATOM Emotion: High Resolution Orthopedics Examination SOMATOM Spirit: Pre-operative Neurosurgical Planning

SCIENCE
28 30 33 z-Ultra-High Resolution Mode Combining Forces to Improve Patient Care High-tech Meets History

CUSTOMER CARE
35 36 36 37 37 38 38 38 39 A Win-Win Situation Cross-country Postprocessing Events CT Imaging and Cherry Blossoms Exploring the Riches of Multislice CT Service: Frequently Asked Questions Service: CT Online Information and Services Available Directly at Your CT Scanner Service: Upcoming Events and Courses Imprint
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Think Clinical!
Siemens Computed Tomography is setting new trends in clinical workflow.
By Louise A. McKenna, PhD, Global Product and Marketing Manager CT-Workplaces, and Stefan Wünsch, PhD, Global Product and Marketing Manger Clinical Solutions, Siemens AG, Medical Solutions, CT Division

Think clinical! One of the hottest topics in medical imaging today is how to deliver a fast, confident diagnosis in an increasingly demanding clinical environment. Both physicians and patients have high clinical expectations, exam volumes are on the increase, scan times are faster than ever, datasets are large, plus there is demand for improved patient safety in terms of dose, without compromising result. Delivering excellent clinical outcomes in medical imaging today is no longer only about having thinnest slices, the most powerful tube and fastest rotation time. It is about having the most innovative Computed Tomography (CT) scanner in combination with well designed clinical workflow solutions. “From the clinicians’ viewpoint, achieving a fast, confident diagnosis relies on two key factors: the right CT technology in combination with the right clinical workflow,” says Elliot K. Fishman, MD, Professor of Radiology and Oncology at Johns

Hopkins Medical Center, Baltimore, USA. “In my opinion, Siemens is setting the trend in modern diagnostic imaging, combining the most innovative scanner technologies with intelligent workflow tools and new intuitive clinical software applications. Siemens is leading the way in seamlessly integrated CT solutions that help us to be fast in reaching the right clinical outcomes reliably and efficiently, everyday.”

Leadership in Workflow Solutions
The innovation explosion in Multislice CT technology and the introduction of 64-slice CT has revolutionized medical imaging, paving the way for a wealth of new and exciting clinical applications: fast cardiac CT in under eight seconds, whole body vascular CT with exquisite detail in under 20 seconds, highly sensitive virtual imaging of the colon and perfusion CT, to name but a few. And true to it’s tradition as an innova-

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Excellent image quality is only one step towards a confident physician’s diagnosis. Well designed clinical workflow solutions have become equally important.

tion leader, Siemens is setting new trends in clinically orientated diagnostic imaging. The unique portfolio of syngo® based workflow tools and software applications are intuitive and intelligent, designed to get clinicians to the right diagnosis as quickly and as efficiently as possible. The goal? Enhanced clinical outcomes for improved patient care. Improved Efficiency with CARE Solutions Scanning with speed and efficiency is prerequisite for improving throughput and enjoying all the clinical benefits of ultra-fast scan times. This can only be optimally achieved via more task automation within the scanning workflow. Dose and contrast management are key areas where automation can save precious time, improve reliability and enhance clinical outcomes, especially for interventional procedures. Automated real-time dose modulation and contrast media management offer two key benefits: they allow radiologists to offer more patient-friendly exams with no compromise in diagnostic image quality. Reliably improving efficiency through task-automation was one of the main drivers behind the development of Siemens unique portfolio of CARE solutions.

»CARE Dose4D helps us to reduce complexity… The software provides us with a fully automated, real-time anatomy based dose regulation, resulting in a simplified workflow without the need for individualized protocol optimization.«
Professor Werner Bautz, MD, University of Erlangen, Germany.

Siemens offers a solution that sets benchmarks for dose management: CARE Dose4DTM provides a fully automated dose modulation workflow designed to deliver the lowest possible dose with the best possible image quality. The automated protocol facilitates a fast workflow, because it is not necessary to adapt protocols manually for each new patient. For optimal cardiac studies, Siemens ECG-pulsing modulates dose so that maximum dose is given during expected diastole and only 20 percent dose during all other phases. For contrast media management, CARE Bolus CT and a new,

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CARE Dose4D

Scan with constant mA

Reduced dose Real-time level based on angular dose topogram modulation

X-ray dose

CARE Dose4D

Slice position

500 mA

30 mA
Instead of just taking into account the patient’s external dimensions and apparent size, CARE Dose4D analyzes the cross-sectional anatomy in real-time and adjusts the emitted X-ray dose accordingly – providing excellent image quality with minimized exposure.

Siemens exclusive CARE Contrast CT are the right answer to the increasing demand for fast, contrast enhanced CT scanning. State-of-the-art, 64-slice CT scanners such as the SOMATOM Sensation 64, image the entire chest, abdomen, and pelvis in less than ten seconds. These fast scan times raise unique challenges to the contrast media injector devices and the use of intravenous contrast media. Today’s Multislice CT scanners are so fast that if the injection parameters are not adjusted, the scan will be completed before the

entire volume of contrast is injected. These shorter scan times create an opportunity to reduce the total amount of intravenous contrast administered, decreasing costs and improving patient care. Siemens’ unique CARE Bolus CT software enables the improvement of planning procedures and diagnosis due to an optimized spiral scan start after contrast injection. As soon as a predefined contrast enhancement threshold is reached, the diagnostic scan is triggered and begins after a short, preset delay. In terms of workflow, CARE Bolus negates the need for a test bolus, facilitates contrast phase shaping, and the fully automated triggering protocol maximizes efficiency also for emergency exams. With the newest member of the CARE family, Siemens offers an industry first – CARE Contrast CT. CARE Contrast CT couples the CT with the injector. The fully automated workflow is initiated by a single click, which is especially useful for trauma and acute care patients. Data Management par Excellence – the WorkStream4D Way Data management plays a pivotal role in workflow efficiency. The typical number of images for a CT exam has risen from around 300 five years ago to well over 2000 with the SOMATOM Sensation 64. Such large data sets can only be managed electronically. In addition, the paradigm shift from 2D to volumetric 3D reading is driving medical imaging departments to adopt an efficient, filmless workflow where fast reconstruction and 3D volume rendering are essential for achieving an efficient diagnostic workflow. Siemens has been a pioneer of this paradigm shift and is the industry leader in innovative data management solutions. Managed the traditional way, multiple reconstruction and re-formatting steps not only reduce workflow efficiency, they also compromise image quality with a knock-on effect on diagnostic confidence. Siemens' innovative WorkStream4DTM is specifically designed to efficiently manage large data sets with fully automated reconstruction and reformatting of raw data – assuring the best possible image quality, which is good news for diagnostic confidence. With direct 3D reconstruction, all diagnostic information is captured in 3D slices, which economizes on data storage in daily workflow, as data volume can be reduced by up to a factor of ten. WorkStream4D also offers pre-programmed, multiphase 4D reconstruction protocols, enhancing the advanced clinical spectrum for dynamic evaluation in cardiac CT, for example. This deliberate optimization of the 2D, 3D and 4D workflow is designed to ensure that users can realize the full clinical benefit of Multislice CT. WorkStream4D is also designed to make workflow as flexible as possible, uniquely

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WorkStream4D
Conventional Workflow

Scan Time WorkStream4D

Reconstruct & Reformat

Read

Scan Time

Read

WorkStream4D virtually eliminates the need for time-consuming manual reconstruction steps – the software does this automatically.

enabling fully automated reconstruction in parallel to acquisition at both Navigator and Wizard CT-workplaces, offering users a high degree of workflow synergy.

Leadership in Clinical Applications
Siemens is also setting new standards in clinical CT through on-going innovation in integrated clinical software applications. The latest enhancements focus on improving speed and efficiency through simplifying workflow, increasing automation and integrating clinically orientated tasks into single software solutions. The current portfolio of syngo software offers the industry’s most comprehensive range of clinical solutions for cardiovascular CT, preventive care, oncology, neurology and routine imaging. The introduction of the SOMATOM Sensation 16 in 2001, closely followed by the SOMATOM Sensation 64, revolutionized cardiac and vascular CT. For the first time, CT was able to deliver the exceptional spatial and temporal resolution coupled with the exquisite image quality needed for non-invasive cardiac and vascular imaging. With a focus on automation, speed and simplicity, syngo Circulation* is the newest addition to the portfolio of advanced cardiac workflow tools designed to help clinicians realize the full diagnostic potential of cardiac CT imaging. Designed in close collaboration with Radiologists and Cardiologists, syngo Circulation provides the entire toolset for a comprehensive cardiac CT exam

based on a one-time loaded data-set. This includes an intelligently designed 1-click workflow for robust coronary vessel segmentation, automated stenosis quantification and optimized stent planning, automated quantification of ejection fraction, end-diastolic and systolic volume plus stroke volume, and 4D evaluation of up to 24 phases. Enhancing clinical workflow for vascular CT has been the focus in the further development of syngo InSpace4DTM. Concentrating on clinician’s requirements for more automated tools, particularly for removal of bony structures for faster vascular analysis, a fully automated advanced bone removal application is an integrated feature of the latest syngo InSpace4D. In combination with syngo Vessel View, users can really optimize diagnostic workflow for a broad range of vascular pathologies. For preventive care and oncology, syngo LungCARE CT and syngo Colonography are part of the new generation of intelligent clinical software solutions. They incorporate a number automated features such as measuring tools, synchronization for easy evaluation of follow-up studies or prone/supine reads and pre-filled reports, all designed to reduce the manual workflow of the clinicians so that they can focus on diagnosis. In combination with Siemens’ CT technology, a lung or colon exam, from scan to report, can be completed in less than 20 minutes – the clinician input representing about ten minutes for diagnosis and reporting.

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D E D I C AT E D S O L U T I O N S

The Fast Lane to Cardiac Diagnosis

syngo Circulation offers physicians the industry’s most comprehensive software solution for cardiac CT, setting a new benchmark for improving clinical outcomes through innovative software solutions. Computed Tomography (CT) fulfils many clinical needs – be it in neurology, oncology, angiography, in the emergency room or, increasingly, also in cardiology and preventive care. Siemens Medical Solutions offers specialized solutions for the specific needs of each of the respective clinical departments. “Supplying our customers with hardware dedicated to their needs is not enough”, says Bernd Montag, PhD, President of Siemens Medical Solutions’ CT division. “We also want to give applications and workflow tools to them that are explicitly designed to meet the needs of their specific clinical department – from patient registration to reporting.” syngo Circulation* is the first of Siemens’ new generation clinical software solutions. syngo Circulation is a dedicated solution for cardiac evaluation, uniquely designed to offer fast, robust morphological and functional analysis in one intuitive software application. ”An accurate but fast diagnosis is crucial in cardiovascular imaging in order to ensure the best quality of care for the patient. This is why the workflow must be extremely fast and well organized,“ states Lars Hofmann, MD, Global Product and Marketing Manager for Cardiac CT at Siemens. syngo Circulation was developed in close collaboration with leading cardiac experts. It features a unique user-friendly workflow that guides the clinician through cardiac evaluation from automated heart segmentation, through coronary vessel segmentation and stenosis quantification, fully automated functional analysis and reporting, in under 10 minutes. A typical workflow begins with fast loading of up to 24 phases, at highest image resolution. With a single click, the heart can be isolated from the rib cage facilitating rapid assessment of the overall cardiac anatomy. Fully automated segmentation and stenosis quantification tools provide for fast, confident evaluation of the coronary vessels and optimized stent planning. syngo Circulation also offers tools for full functional analysis including cine display for evaluation of wall motion defects, automated left ventricle segmentation and quantification of ejection fraction, stroke volume, end systolic and diastolic volumes. All qualitative and quantitative results are integrated in a single, customizable report. ”The new software helps to facilitate and increase workflow for physicians with a busy clinical practice by incorporating intuitive reporting functionality and integrating many time-saving, accurate and guided procedures for the rapid examination of cardiac CT studies”, says Michael Poon, MD, Director of Cardiology at the Cabrini Mecial Center and Associate Professor at the Mount Sinai School of Medicine, New York, USA.

*syngo Circulation is pending 510(k) review and is not yet commercially available in the U.S.

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COVER STORY

»Siemens’ syngo Neuro Perfusion CT provides a cutting-edge imaging technology that allows us to speed up patient diagnosis. The method allows us to differentiate definitively damaged brain tissue from penumbra in less than two minutes. «
Bernd Tomandl, MD, Assoc. Professor, Department of Interventional Radiology, Klinikum Süd, Nuremberg, Germany.

Siemens users are also in a unique position to benefit from state-of-the-art computer-assisted reading tools for lung nodules and colon lesions. syngo LungCARE CT with NEV (Nodule Enhanced Viewing) and syngo Colonography with PEV (Polyp Enhanced Viewing) represent an on-going commitment to development of automated tools that improve diagnostic confidence through the use of computer-assisted second readers, which may have real impact on treatment decisions. Centers that have already been working extensively with syngo LungCARE NEV have realized a significant improvement in daily workflow. Klinikum Rechts der Isar in

Munich, Germany has been able to reduce the number of reading physicians since introducing syngo LungCARE NEV: “With this tool, we reduced the need for the second read by a second physician screening all our chest datasets for lung nodules, and therefore improved our diagnostic work-up and follow-up findings,” says Christoph Engelke, MD, Department of Diagnostic Imaging, Technical University Munich, Germany. The innovation continues in software solutions for neurology, particularly for stroke and tumor perfusion. syngo Neuro Perfusion CT is an established tool for the fast assessment of

S ECO N D R EAD E R TOO L S

Benefits of Computer-Aided Detection
… in chest CT examinations
“In my opinion, reliable detection of early stages of lung cancer is a difficult but crucial task. There is no question that reading screening or diagnostic CT studies is susceptible to detection errors due to the huge amount of imaging data that has to be reviewed. In a recently published study, we demonstrated that the use of ‘second reader’ technology considerably increases the radiologist’s sensitivity for detection of pulmonary nodules. Therefore, to ensure the highest possible sensitivity for detection of early-stage lung cancer in the screening process, I am strongly in favor of double-checking the images with a Computer-Aided Detection (CAD) system. Preliminary results suggest that application of CAD might even be timeefficient. Finally, CAD is not only Dag Wormanns, MD, Department of Diagnos- valuable in lung cancer screentic Radiology, University ing, but also improves detection of lung metastases when staging Clinic Muenster, or re-staging oncology patients.“ Muenster, Germany

… in CT colonography
“Computer-Aided Detection (CAD) has been very successful in mammography and is being used for early detection of lung cancer. In my opinion, if CAD could accurately detect colon polyps in CT colonography (CTC), with a relatively low false positive rate, it might become another very important clinical application. Currently, most of the radiologists who are experienced in CTC would not want to interpret more than 3–5 studies per day. Reading CTC is a demanding, meticulous process, requiring focused and extremely attentive concentration. Given the fact that there are not enough radiologists to interpret the growing number of CT scans performed in the United States, any assistance in interpreting CTC will be Mark Baker, MD, Section embraced enthusiastically by of Abdominal Imaging, radiologists.“ Division of Radiology, The Cleveland Clinic Foundation, Cleveland, Ohio, USA

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stroke, with a complete exam requiring less than 15 minutes [1], which is critical for stroke patients. syngo Neuro Perfusion CT is also designed to be versatile and is ideal for the analysis of brain tumor perfusion for brain tumor angiogenesis or assessing treatment efficacy in oncology. Currently, Siemens offers around 30 workflow and clinical applications, providing solutions to meet a comprehensive

range of clinical needs from cardiac CT to oncology. With a keen eye on the future, Siemens will continue to set new trends for the next generation of clinical CT solutions…

[1] Tomandl B., et al. Comprehensive imaging of ischemic stroke with multislice CT. Radiographics 2003; 23: 565-592

syngo C T 2 0 0 6 A / G

Continuous Software Enhancements
In addition to new software developments, Siemens Medical Solutions continuously enhances existing clinical applications for Computed Tomography (CT). The latest developments provide various new features, such as improved workflow solutions, excellent image quality in the brain due to superior image optimization algorithms, as well as enhanced access to online information and services directly from the scanner console. This allows a faster download of scan protocols and – depending on the system configuration – facilitates innovative new clinical applications such as • syngo InSpace4D with integrated bone removal package for enhanced visualization of vascular structures • syngo Body Perfusion CT for quantitative evaluation of dynamic CT data of organs and tumors, following the injection of a compact bolus • CARE Contrast CT for a simplified contrast workflow, due to synchronized scanning and contrast media application. Newly shipped SOMATOM CT systems are pre-installed with the latest complimentary versions – and with the latest optional versions, if ordered. To increase clinical performance for already installed SOMATOM CT scanners, complimentary versions are included in the syngo Evolve contract as part of a Siemens Service Contract. The optional software applications can be ordered as upgrade packages, if desired. More information about the syngo Evolve Packages can be obtained online. For questions regarding the individual Evolve status of a CT scanner, the local Siemens representative should be contacted.

syngo InSpace4D with advanced bone removal facilitates fast segmentation and removal of bony structures for faster visualization of vessels.

k Further Information: www.siemens.com/ct-evolve

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NEWS

VISION OF THE FUTURE

CT on its Way Beyond Slices?
The number of slices acquired per rotation has doubled every 18 months in the last few years, and still the innovators at Siemens’ Computed Tomography (CT) Division continue to challenge the future limits of CT technology and applications. “To just continue the current slice race will not be the right path to open up new clinical possibilities”, says Bernd Ohnesorge, PhD, Vice President Marketing and Sales. “It’s time to explore totally new CT concepts, and to move beyond the simple adding of more detector rows." Last year’s RSNA visitors saw a visionary CT concept at the Siemens booth’s Innovation Pavilion that may redefine clinical CT in the future: a very slim gantry design with a wide gantry opening allowing for easy patient access and higher patient comfort. A large area detector with over 15 centimeter z-coverage per rotation enabling dynamic and volumetric imaging of entire organs and body regions, such as the heart, liver and brain. Several X-ray sources generate separate X-ray fan beams, while raw data is acquired by an arrangement of
S O M AT O M E m o t i o n 16

different detectors. A slim tube design similar to Siemens' STRATON® is a key prerequisite for such a concept. Sources and detector segments are combined differently in order to optimally adapt to the needs of each respective clinical application. Thus, this visionary concept offers numerous advantages for various clinical applications: 1. Examination of entire organs in one rotation, e.g. for brain, organ and tumor perfusion and for dynamic CTA examinations of the heart and other organs is made possible by utilizing the above mentioned area detector. 2.Simultaneously operating several source-detector subsystems may be a way to a temporal resolution below 100 milliseconds, eventually even below 50 milliseconds, independent of heart rate, with today’s rotation time of 0.33 seconds. Robust cardiac imaging at high and irregular heart rate may become feasible, without b-blockers and without drawbacks of multi-segment reconstruction algorithms – by using data from only one heart beat.

A future vision of CT, as shown at RSNA 2004 by Siemens’ Computed Tomography Division – a system combining several X-ray sources and detector domains 3.In the same way, more X-ray power is available for high quality imaging of obese patients at maximum volume coverage speed. More power is applied within shorter scan times, so that radiation exposure is not necessarily increased. High diagnostic quality can be achieved in obese patients where most X-ray energy is absorbed in the surrounding fat tissue. 4.Totally new opportunities can be explored with multiple source-detector subsystems operated with different X-ray energy levels, thus enabling spectral CT imaging. This may allow for raw-data based “built-in” separation of bone, vessel lumen and calcifications, or for characterization of liquids, such as blood and pus, in emergency diagnostics.

Advanced Performance at Low Cost
With the new SOMATOM Emotion 16, Siemens Medical Solutions again proves its cost-consciousness and clinical expertise. The SOMATOM Emotion 16 delivers the performance required for advanced clinical applications at low life-cycle costs. It is based on the successful SOMATOM Emotion product line with more than 3,500 installations worldwide. The new system enables hospitals and private practices with limited budgets and/or space allocations to install a 16-slice CT. Being air cooled, the SOMATOM Emotion 16 and all its components require only 18.5 square meter installation space. In addition to the economical purchase price, this minimal space requirement The SOMATOM Emotion 16 unites modern 16-slice technology with the cost-efficiency of the SOMATOM Emotion product line. and the overall low life cycle costs also contribute to it’s cost efficiency. From a clinical perspective, the new scanner offers every advantage of a modern 16-slice system: short breath hold times alowing image acquisition without movement artifacts, high diagnostic image quality due to a collimation of down to 16 x 0.6 millimeters, a minimum gantry rotation time of down to 0.5 seconds, and a comprehensive set of routine and advanced clinical applications.
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NEWS

S O M AT O M S e n s a t i o n P R O D U C T L I N E

40-Slice Technology
Two new Siemens Computed Tomography (CT) systems were recently introduced to the market. The world’s first SOMATOM Sensation 40 scanner was installed at the radiology department of Alamance Regional Medical Center, Burlington, NC., replacing the clinic’s SOMATOM Sensation 10. And Mayo Clinic in Rochester, MN., was one of the first clinics to install a SOMATOM Sensation Open with 40-slice technology. The system features an extra-large, 82 centimeter gantry bore and field of view. A new, optional high-capacity patient table, developed as part of the CT Clinical Innovation Center partnership between Mayo and Siemens, was installed with the system to permit advanced CT imaging of extremely heavy patients. The table allows the scanning of patients weighing up to 615 lbs, compared to 440 lbs for conventional patient tables. “With these features, the SOMATOM Sensation Open is ideally suited for very heavy patients and our Bariatric Surgery Program,” says Cynthia McCollough, PhD, Associate Professor of Radiological Physics at the Mayo Clinic College of Medicine. “In addition, the STRATON tube provides the X-ray output needed for high-quality images in very large patients. These are exactly the clinical and technical attributes we were seeking, especially for bariatric care and image guided interventions.” Both new systems feature Siemens revolutionary z-Sharp Technology, which utilizes an electron beam that is accurately and rapidly deflected, creating two alternating and overlapping X-ray projections reaching each detector element. This doubles the scan information without a corresponding increase in dose, and routinely enables acquisition of 40 slices per rotation with unprecedented image quality and the industry’s highest image resolution of below 0.4 millimeter. z-Sharp Technology firmly established a new benchmark for diagnostic excellence, as proven with almost 300 installations of z-Sharp powered systems worldwide.

With the SOMATOM Sensation 40, Siemens Medical Solutions rounds out its extensive high-end product portfolio in CT.

The large bore of the SOMATOM Sensation Open is ideal for examinations of bariatric and cancer patients.

LERNER COLLEGE OF MEDICINE

LEONARDO in Anatomy Teaching
Students in the anatomy classes at Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, OH., are enjoying very special insights into the human body. Each week starts with a session at the College’s LEONARDO Workstation. Faculty members demonstrate – with syngo InSpace and other applications – and explain multiple views of the body regions they will cover during the coming week. Students then return several times during the week to review images as they proceed on their weekly learning matter. New cases to demonstrate specific examples of anatomy are added onto the LEONARDO regularly. “The use of this technology has directly enhanced the students’ understanding of anatomy and their ability to visualize structures,” says Richard Drake, PhD, Director of Anatomy. He is also involved in preparing images on the LEONARDO for a publishing project of Gray’s Anatomy family of educational material. k Further Information:
www.clevelandclinic.org/cclcm

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BUSINESS

S O C I ET Y O F C AR D I OVAS C U L AR C T

Cardiologists and Radiologists Unite Forces
By Lars Hofmann, MD, Global Product and Marketing Manager Cardiac CT, Siemens AG, Medical Solutions, CT Division, Forchheim, Germany On March 7, 2005, the Society of Cardiovascular Computed Tomography (SCVCT) and the Society of Cardiac Computed Tomography (SCCT) merged to form a new society called “Society of Cardiovascular CT” (SCCT). Both former societies were relatively new, having just been formed in January 2005. They soon realized that they shared common goals and that a single, strong society would be more effective. The SCCT is represented by a 15-member Board of Directors and five executive officers. Four of them and the vast majority of the Board of Directors are long term Siemens Computed Tomography (CT) users. Executive officers of the SCCT are: Stephan Achenbach, MD, President, Erlangen, Germany; Michael Poon, MD, President-Elect, New York, NY; Daniel Berman, MD, Vice President, Los Angeles, CA; Gilbert Raff, MD, Secretary, Royal Oak, MI, and Joao Lima, MD, Treasurer, Baltimore, MD. “Computed Tomography has gone through rapid technical development in the past years, and is increasingly applicable to imaging of the heart, coronary arteries and vascular system. It is important that researchers and clinicians in this field work together to create a body of evidence strong enough to support recommendations as to which patients are most likely to benefit from the new diagnostic modalities and to assure that CT imaging performed by appropriately trained physicians will be available to these patients. I am confident that the newly formed Society of Cardiovascular CT will be very helpful in establishing the appropriate clinical role for cardiovascular CT,” said Dr. Achenbach, SCCT President. The SCCT is an international organization committed to the further development of cardiovascular CT through standards setting, advocacy, education, training, accreditation, quality control and research. Its members are physicians, scientists, technologists, and others who work in the field of cardiovascular CT. Siemens CT division strongly supports the new society and encourages users of cardiac CT to join the society to support this fascinating technology. k Further Information: www.scct.org

syn g o LU N G C AR E C T W ITH N EV

Free Trial Clinical Software
Siemens Computed Tomography (CT) now offers their latest computer assisted detection software syngo LungCARE CT with NEV (Nodule Enhanced Viewing), on a free, 90-day trial basis. This software is designed to enhance physicians’ diagnostic confidence as a second reader tool, confirming the presence or absence of lung lesions. Double reading with a second reader software offers a significantly increased sensitivity compared to conventional double reading. Thus, computer assisted detection is a valuable tool for the detection of pulmonary nodules, and should be used as second opinion.1 Trial licences are available • via LifeNet: Customers with SRS connectivity can order their trial software directly from their scanner. The software will then be automatically installed and ready for use. • via the local Siemens Representative: Customers can contact their local Siemens Representative. He/she will discuss the available trial options with them and schedule an appointment for the installation of the trial software. k Further Information:
www.siemens.com/SOMATOMExpand

syngo LungCARE CT with NEV identifies potential lung lesion that were overlooked during the radiologist’s first read.

1 Wormanns D, Beyer F, Diederich S, et al. Diagnostic performance of a commercially available CAD system for automatic detection of pulmonary nodules: Comparison with single and double reading. Röfo 2004 Jul; 176(7): 953-958

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BUSINESS

INVESTING IN PEOPLE

Driving Initiatives against Colon Cancer
Siemens Medical Solutions, Daimler Chrysler AG, Henkel KGaA, BASF AG and E.ON Ruhrgas AG, in cooperation with their respective occupational health centers, have all initiated screening programs for colon cancer. Siemens Medical Solutions in Germany invited employees aged 45 plus, together with those at risk (e.g. familial history) to undergo a Fecal Occult Blood Test (FOBT) as a primary screening tool. Employees with a positive test were offered two alternatives for further investigation: a traditional colonoscopy or – true to the tradition of innovating health care – the opportunity to undergo a CT-Colonography (CTC) on the University of Erlangen’s SOMATOM Sensation 64. The hugely successful take-up of this initiative reflects the increased awareness of the benefits of early detection: 1,110 employees signed up; of the 2.5 percent with a positive FOBT test, 60 percent chose to follow-up with a CTC. The success of the project had much to do with the close collaboration with Siemens Betriebskrankenkasse (SBK), and also with the department of radiology at the University of Erlangen. “This screening initiative represents a huge opportunity for us to gather more evidence for the use of virtual colonography as a highly sensitive and specific screening tool for colon cancer,” explains Rolf Janka, MD, Department of Radiology, University of Erlangen, Germany. “A virtual colonoscopy using CT is noninvasive, patient friendly, and relatively low cost. These are key pre-requisites for screening procedures. The more clinical data we can gather, the greater our chance of getting approval for CTC for colon cancer screening. In my opinion, that can only lead to one thing: better patient care!” The use of CT for early detection of colon cancer is a hotly debated topic. Several publications have demonstrated that with Multislice CT, radiologists can achieve a sensitivity and specificity to match conventional colonoscopy. Currently, experts across the globe are working hard on providing further data supporting the reliability of CTC for detection of clinically relevant polyps. One of the largest clinical trials will take place in the US, where the American College Imaging Network and the National Cancer Institute aim to accrue over 2,000 patients over the next 2.5 years.

C T C O LO N O G R A P H Y

Demo Poster
CT Colonography (CTC) is emerging as an attractive alternative to colonoscopy for the detection and evaluation of lesions of the colon in terms of excellent diagnostic outcomes, high patient acceptance and lower cost. It is ideally suited for patients who are unable or unfit to undergo conventional colonoscopy, as well as for asymptomatic and screening patients. Around 600 Siemens Multislice CT users are currently utilizing syngo Colonography for efficient evaluation of the colon. Thomas Mang, MD, and co-workers from the Medical University of Vienna, Austria, have performed around 280 CTC exams on their SOMATOM Sensation 16 Scanner over the last two years. Based on their experience with virtual colonoscopy, they have designed a poster demonstrating the spectrum of CTC findings in colon diseases. All diseases are briefly described and extensively demonstrated on 3D and 2D CT images, guiding and assisting users in the reporting of findings in CTC examinations. The poster has been produced together with Siemens Medical Solutions, Austria, and is available free of charge in either German or English. To obtain a free CT Colonography Poster, please send an e-mail with your postal address to med.somatomlife@siemens.com, subject “CTC Poster”.

Each disease is briefly described and demonstrated, based on CT images.

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BUSINESS

Interview
S O M AT O M S p i r i t

“And it runs, and runs, and runs...“
Fudan University – Zhongshan Hospital, Shanghai City, China, and WernerWicker-Klinik, Bad Wildungen, Germany, were among the first to install a SOMATOM Spirit. SOMATOM Sessions asked Professor Zeng MengShu, MD, and Carsten Figge, MD, about their experience with the new system. What types of examinations are you using the SOMATOM Spirit for? Dr. Figge: We use the SOMATOM Spirit for all exams in daily clinical routine. With our outpatients, there are more head, thoracic, and abdominal exams, while our inpatients mainly need examinations of the spine. We examine between 15 and 20 patients per day. Prof. MengShu: We do routine head and thoracic examinations, high resolution lung scans, abdominal contrast examinations, spine examinations, and other routine examinations. On average, we scan 60 patients per day with the SOMATOM Spirit. You have been working with the SOMATOM Spirit for over six months. What is your experience, compared to other CT scanners? Dr. Figge: Compared to our former SOMATOM AR.Star, the SOMATOM Spirit – as a dual-slice system – broadens our spectrum of examinations, to CT-Angiographies of the head, or multiphase exams of the abdomen, at thinner collimation. What is your opinion about the user guidance and simplicity of the user interface? Prof. MengShu: Our technologists are very satisfied with the user interface; it is easy to understand and to operate. Qualified technicians can do simple examinations after only five minutes of training. Dr. Figge: The SOMATOM Spirit is very easy to operate because of its syngo user interface. Many workflow steps can be automated, which reduces the workload for our technologists and shortens examination times. Secondary postprocessing like Multi-Planar Reformatting, Maximum Intensity Projection, or Volume Rendering Technique (VRT) are readily available for diagnosis. The ease of use surprises and pleases at the same time. Where do you use VRT? Dr. Figge: I use VRT for the visualization of complex diagnosis in meetings and demonstrations. This way, I can give surgeons an overview of complex anatomy; details can then be worked out in the primary slice images. Prof. MengShu: We use VRT for many kinds of examination, such as tracheal and bronchia examinations. Especially with CT-Angiography, we can see the abdominal artery after removing the bone and other organs. The value of VRT is well acknowledged, the doctors can see the area of interest directly in the 3D structure. What is your overall impression of the SOMATOM Spirit? Dr. Figge: And it runs, and runs, and runs ... To which customers would you recommend the SOMATOM Spirit? Dr. Figge: I would recommend it to any customer who needs an easy to use system for their daily clinical routine, and, at the same time, wants Carsten Figge, MD: “We experience up to 30 percent dose reduction, thanks to the SOMATOM Spirit’s CARE Dose functionality.” high cost efficiency. Particularly small, outlying clinics utilizing teleradiology can profit from the excellent handling concept. Prof. MengShu: The SOMATOM Spirit is the ideal system for hospitals with less than 500 beds that buy their first CT, and for large hospitals that buy an additional CT for routine examinations.

Werner-Wicker-Klinik specializes in acute care for spinal marrow injuries, congenital and acquired spine diseases (German Center for Scoliosis), neuro-urology, and neuro-surgery. Its Radiological Institute collaborates closely with the Radiology Institute Bad Zwesten, Practice of Drs. Mariß/ Aref/Figge. Together, they attend not only to the outpatients of all hospitals of the Wicker-Group, but also serve as a teleradiology center for 14 acute-care hospitals. As a polyclinic, Zhongshan Hospital focuses on the diagnosis and treatment of liver, kidney and lung cancer. The clinic has 1,272 beds, 1.2 million outpatients and 25 thousand inpatients per year. There are 2,300 employees working in the hospital, including 360 professors and associate professors, plus three CAS (Chinese Academy of Science) and CAE (Chinese Academy of Engineering) academicians.

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CLINICAL OUTCOMES

SOMATOM Sensation

SOMATOM Emotion

SOMATOM Spirit

Case 1: Low Dose Cardiac Scanning of a Neonate in one Second
By Jean-François Paul, MD, Anne Sigal-Cinqualbre MD, Department of Radiology, and V. Lambert, MD, Department of Cardiopediatry, Marie Lannelongue Hospital, Le Plessis-Robinson, France

HISTORY
An 1 day old infant was referred for cardiac CT for differential diagnosis prior to surgical intervention for severe aortic coarctation from total interruption of aortic arch. Previous foetal echocardiography had revealed asymmetry of ventricles associated with an enlarged right ventricle, and there was suspicion of coarctation of the aortic arch. At birth, echocardiography was not able to assess whether the baby was suffering from severe aortic coarctation or if the aortic arch was totally interrupted.

DIAGNOSIS
CT revealed atypical coarctation, associated with very large patent ductus arteriosus, supplying descending aorta with blood. On the first acquisition [Fig. 1 and 2], only patent ductus arteriosus, descending aorta and left subclavian artery were opacified, due to the right to left shunt between ductus arteriosus and descending aorta. The aortic arch was not visualized. A second acquisition was performed with a longer start delay to accommodate this unusual anatomical configuration. The aortic arch was opacified, and MIP images clearly showed

SCANNING PROCEDURE
Due to the high rotation speed (0.33 s) of the SOMATOM Sensation 64 gantry, the entire thorax could be captured in only 1 second and hence it was not necessary to sedate the infant. Five cc of contrast medium were injected at a flow rate of 0.6 cc/s in a small cubital vein. After the analysis of the first acquisition data set, an additional acquisition was necessary to visualize the aortic arch. Indeed, the aortic arch was not visualized at first-pass because most of the contrast flow was going from the pulmonary artery directly to the descending aorta (via patent ductus arteriosus), bypassing the aortic arch. A second acquisition 10 seconds later was necessary to get the aortic arch opacified [Fig. 3]. CARE Dose4D was applied, enabling us to perform the exam with an exposure that was as low as reasonably achievable, in this case at 80 kV and 20 mAs. Total DLP for 2 acquisitions was 15, and the estimated exposure for the exam was very low at 0.6 mSv. Images were reconstructed at 1 mm using MIP and VRT reconstructions for a complete description of anatomical disorders. [ 1 ] Left lateral view using VRT display. First acquisition showed very large patent ductus arteriosus in connection with descending aorta. Left subclavian artery is originating from the junction of the two vessels. Aortic arch is not opacified. PDA: patent ductus arteriosus; DA: descending aorta; LSCA: left subclavian artery; LPA: left pulmonary artery

[ 2 ] Same acquisition in a more posterior view

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[ 3 ] Second acquisition (10 seconds after first pass): MIP view showed opacified aortic arch with severe coarctation (arrow). AA: Aortic arch; DA: descending aorta

[ 4 ] VRT display of the aortic arch, in a left lateral view. Note that the aortic narrowing is hidden by the patent ductus arteriosus.PDA: patent ductus arteriosus; DA: descending aorta; LSCA: left subclavian artery; IA: innominate artery; LCA: left carotid artery; LPA: left pulmonary artery

[ 5 ] VRT display in a posterior view shows the complex anatomy associated with the aortic coarctation. PDA: patent ductus arteriosus; DA: descending aorta; LSCA: left subclavian artery; LCA: left carotid artery; AA: aortic arch

EXAMINATION PROTOCOL
that the aorta was severely narrowed, but not totally interrupted [Fig. 3]. Additional VRT images depicted this complex configuration [Fig. 4 and 5]. Surgical intervention by lateral thoracotomy was successful. The baby was discharged from our institution at day 10, without complication.
Scanner Scan area Scan length Scan time Scan direction Heart rate ACV kV Effective mAs Rotation time Slice collimation Slice width Table feed Reconstruction increment CTDI Kernel SOMATOM Sensation Cardiac 64 thorax 64 mm 1s caudo-cranial 140 no ECG gating 80 kV 20 mAs 0.33 s 0.6 mm 1 mm 46 mm / s 0.7 mm 0.49 mGy B30

COMMENTS
This is an exemplary case for the application of 64-slice CT scanning for congenital heart disease patients, especially in newborns. Very short acquisition times, associated with thin collimation, provide very high quality images in non-interventional procedures, associated with low radiation exposure. These data may be crucial in such critical conditions. In case of interrupted arch, the surgical approach would have required sternototomy with bypass circulation instead of lateral thoracotomy. In case of doubt at echocardiography, a conventional aortography may be indicated, but angiography is a very risky examination, especially in neonates. Multislice CT is the ideal alternative to avoid such an invasive imaging technique. Here, CT was preferred to MR due to superior spatial resolution, speed of acquisition (and thus absence of respiratory artefacts), and no need for sedation. Radiation dose delivered by CT was below 1 mSv.

Contrast Volume Flow rate Start delay 5 ml 0.6 ml / s 10 s (central venous access)

Postprocessing

MIP, VRT

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SOMATOM Sensation

SOMATOM Emotion

SOMATOM Spirit

Case 2: Peripheral Runoff
Geoffrey Browne, MD, Chris DeAngelo RT ( R ), ( CT ), Alamance Regional Medical Center, Burlington, USA

HISTORY
A 56 year old male patient was presented with pain in the muscle of the left leg after slight exercise. A CTA runoff with the latest 40-slice CT technology was scheduled to rule out claudication.

DIAGNOSIS
CTA revealed an occlusion of the left common iliac artery just distal to its origin. Occlusion of the proximal two thirds of the left external iliac artery is present. Collateral reconstitution of the distal left external iliac artery/common femoral artery is noted. Distal vessels are not affected due to collateral blood supply.

COMMENT
The case demonstrates the clinical impact of CT for non-invasive assessment of vascular structures with the SOMATOM Sensation 40. Due to the excellent speed and an isotropic resolution below 0.4 mm, even finest structures can be resolved without venous overlap.

[ 1 ] VRT showing occlusion of the left iliac artery after bone removal performed with syngo InSpace4D

EXAMINATION PROTOCOL
Scanner Scan area Scan length Scan time Scan direction kV Effective mAs Rotation time Slice collimation Slice width Pitch Reconstruction increment Contrast Volume Flow rate Start delay SOMATOM Sensation 40 Lower extremity runoff upper leg: 545.5 mm; feet: 238 mm upper leg: 19 s; feet: 8 s craniocaudal 120 kV 170 mAs (CARE Dose4D) 0.37 s 0.6 mm 0.75 mm 1 0.5 mm 370 Isovue 100 ml 3 ml / s Care Bolus CT triggered at 100 HU with the reference ROI on the aorta Postprocessing syngo InSpace4D with bone removal

[ 2 ] MIP image showing occluded femoral artery from the origin, filling by collateral circulation from the peripheral part

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[ 3 ] Curved MPR shows calcified and non-calcified plaques as well as the thrombus responsible for the occlusion.

[ 4 ] VRT of the collateral vessels

A

B

[ 5A and 5B ] VRT images show the normal blood supply through the collaterals of the tibial vessels and supply of the feet.

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CLINICAL OUTCOMES

SOMATOM Sensation

SOMATOM Emotion

SOMATOM Spirit

NEW: syngo Body Perfusion CT Functional Diagnosis of Organs and Tumors
The syngo Body Perfusion CT option* allows for the quantitative evaluation of dynamic CT data of organs and tumors, following the injection of a compact bolus. By providing images of blood flow, blood volume and permeability from one set of dynamic CT data, syngo Body Perfusion CT permits the assessment of irregular perfusion and of perfusion changes during therapy. Using specific evaluation protocols for different organs and motion correction for improved accurate anatomical object alignment, it can be particularly helpful for differential diagnosis and monitoring of tumors.

Case 3: Differential Diagnosis of a Pancreas
By Xue Hua Dan, MD, and Jin Zheng Yu, MD, Department of Radiology, Peking Union Medical College Hospital, Beijing, China

HISTORY
The patient was a 65 year old man, who had suffered from hypoglycemia for 5 years, aggravated by vertigo and spells of unconsciousness during the past 2 years. Due to the severe symptoms, an insulinoma, a tumor of the pancreas, was suspected. A previous enhanced CT scan (one month earlier) indicated no abnormalities. The surgeon asked for an additional CT scan that revealed a pancreatic tumor.

EXAMINATION PROTOCOL
Scanner SOMATOM Sensation 16 Non-contrast phase Scan area From diaphragm to iliac crest Arterial phase From horizontal part of duodenum to diaphragm 11.52 cm 3.22 s caudal-cranial 120 kV 160 mAs 0.5 s 1.5 mm 2.0 mm 24.0 mm 1.0 mm B20f omnipaque (350 mg iodine / ml) +saline 70 ml + 20 ml 5 ml / s 5s MPR/MIP/VRT Dynamic scan Pancreas level

Scan length

25 cm 11.77 s cranial-caudal 120 kV 160 mAs 0.5 s 0.75 mm 1.0 mm 12.0 mm 0.7 mm B10f –

2.4 cm 35 s – 80 kV 140 mAs 1.0 s 1.5 mm 3.0 mm 0 mm – H30f omnipaque (350 mg iodine / ml) +saline 50 ml + 20 ml 5 ml / s 5s syngo Body Perfusion CT

DIAGNOSIS UND COMMENTS
Only a decade ago, the sensitivity of finding insulinomas with CT was rather low. Today, using high resolution MSCT in the early arterial phase, we can quite easily detect these small pancreatic lesions. Arterial spiral CT showed a small, but strongly enhancing lesion of 1.3 cm at the tail of the pancreas. Tumor feeding arteries originating from the splenic artery were also delineated using MIP and MPR. Additional dynamic scanning confirmed the diagnosis of insulinoma. With syngo Body Perfusion CT, it was possible to further characterize the lesion. It showed the typical behavior of a benign tumor with significantly increased flow and blood volume, but normal permeability. The patient was referred for tumor resection. Pathological findings confirmed the CT results.

Scan time Scan direction kV Effective mAs Rotation time Slice collimation Slice width Table feed / rotation Reconstruction increment Kernel Contrast

Volume Flow rate Start delay/ Bolus tracking

– – – –

*syngo Body Perfusion CT is available for SOMATOM Emotion Duo, 6, and 16, and SOMATOM Sensation scanners with syngo CT 2006 A/G.

Postprocessing

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A

B

[ 1A and 1B ] MPR and MIP images show the small endocrine tumor as a highly enhanced nodule (arrow), located at the tail of the pancreas, with the nutritional artery visible.

[ 2 ] Functional parameter maps calculated in two adjacent 3 mm slices (upper and lower row) using syngo Body Perfusion CT. The maps show increased blood flow (left, red color) and blood volume (middle, red color), but normal permeability (right, green color). Note the excellent spatial delineation of this small tumor made possible by robust modeling of data from thin slices and acquired in only 35 s (one breath hold).

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CLINICAL OUTCOMES

SOMATOM Sensation

SOMATOM Emotion

SOMATOM Spirit

Case 4: Paget Sarcoma Disease in the Tibia
By J. Dinkel, MD, U. Mende, MD, PhD, Department of Radiation Oncology, and J. Debus, MD, PhD, Director, Department of Radiation Oncology, University of Heidelberg, Germany

HISTORY
An 80 year old female with monostotic Paget’s disease of the right tibia presents with progressive pain and soft tissue swelling of the right leg. A biopsy was taken that confirmed the exact pathologic diagnosis of the lesion arising from Paget’s disease and a sarcomatous transformation to osteosarcoma. appear superimposed on osteoclastic activity and eventually predominate; and finally, the blastic phase (late-inactive), in which osteoblastic activity gradually declines. Monostotic disease (10–35% of cases) is more often seen in the axial view of the skeleton, although any site can be the sole region of involvement. Polyostotic disease (65–90 %) is more frequent than monostotic disease. The patient presented here had monostotic disease localized in the right tibia only. VRT and MPR images of the tibia show the radiological characteristic manifestations of Paget’s disease: a diffuse cortical and trabecular thickening involving the entire bone. The combination of progressive osteoclastic and osteoblastic activity leads to the dichotomy of osseous enlargement but weakening of the bone. Sequelae of this osseous weakening are the most common complication of Paget’s disease. An anterior bowing of the tibia is seen in the VRT reconstruction.

DIAGNOSIS
Paget’s disease of the bone is a common disorder affecting approximately 3–4% of the population over 40 years old. The pathologic abnormality in Paget’s disease is excessive and abnormal remodeling of the bone. Three phases have classically been described as discrete and distinctive, although in reality they represent a continuum: the lytic phase (incipient-active), in which osteoclasts predominate; the mixed phase (active), in which osteoblasts begin to

1A

1B

[ 1A and 1B ] Osteoblastic tumor mass (arrow) extending into the soft tissue with infiltration of the skin and skin metastases

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Disorganized areas are seen in the cortex of the distal tibia. The fractured fibula was not affected by Paget’s disease. Since the patient refused the recommended surgical treatment, radiation therapy was performed.

COMMENTS
Neoplastic complications of Paget’s disease are relatively rare. Sarcomatous degeneration is estimated to occur in 1% of patients with longstanding disease. In case of severe polyostotic disease, the relative risk of sarcomatous transformation is up to 5–10%. A Paget sarcoma can have different appearances depending on the matrix produced (osteolytic, osteoblastic, mixed). In this case, the CT scan shows the osteoblastic tumor mass extending into the soft tissue with infiltration of the skin and skin metastases. Moreover, the CT scan of the popliteal region reveals nodular mineralizations of metastatic lymph nodes. The high isotropic resolution provided by the SOMATOM Sensation Open with 40 x 0.6 mm slices produced during each rotation, allows for the detection of small changes after the radiation therapy. Spiral artifacts e.g. aliasing artifacts that manifest as streaks emerging from high contrast objects, and windmill artifacts, are almost completely eliminated with z-Sharp Technology, even at higher pitch values. In addition, z-Sharp Technology reduces image noise when the reconstructed slice width is the same thickness as the collimation.

[ 2 ] Arteriosclerosis of posterior tibial artery (thin arrow); diffuse cortical and trabecular thickening involving the entire bone with anterior bowing (thick arrow)

[ 3 ] Nodular mineralizations of metastatic lymph nodes (arrow)

EXAMINATION PROTOCOL
Scanner Scan area Scan length Scan time Scan direction kV Effective mAs Rotation time Slice collimation Slice width Pitch Reconstruction increment CTDI Kernel SOMATOM Sensation Open, 40 slices extremity 451 mm 41.5 s cranio-caudal 120 kV 66 mAs (CARE Dose4D) 90 mAs ref. 1s 0.6 mm 0.6 mm 0.9 0.4 mm 7.24 mGy B20 / B60

[ 4 ] Disorganized areas are seen in the distal cortex of the distal tibia

Postprocessing

syngo InSpace

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CLINICAL OUTCOMES

SOMATOM Sensation

SOMATOM Emotion

SOMATOM Spirit

Case 5: High Resolution Orthopedics Examination
Ly Thai Bach, MD, Chief of Radiology Unite, & Eric Devilaine, Chief of X-ray Technician Team, Centre Hospitalier Robert Morlevat, Semur en Auxois, France

HISTORY
A 75 year old woman was referred for a detailed evaluation of her left ankle because of degenerative arthropathy, which also entails mechanical pain. She benefited from a local infiltration of anaesthetics some time ago, with good results. Prior standard x-rays confirmed a subastragalar arthropathy of the talus (astragalus) and probably also astragalo-scaphoid and tibio-tarsal. A high resolution CT scan was requested in order to examine the different injuries of the region. heel bone, but also at the level of the anterior-inferior part of the talus and at the level of the anterior part of the extremity distal of the tibia. Furthermore, calcifications, probably of cartilagenous origin, were also visible on both sides of the talus in the frontal view, confirming the evidence of a chondrocalcinosis (deposition of multiple small calcified islands of bone within the synovium of the joint). Also, edema of the soft tissue around the ankle at the subcutaneous level could be observed.

DIAGNOSIS
Using the high resolution mode of our SOMATOM Emotion 6 with a collimation of 6 x 0.5 millimeter, we were able to view the degenerative processes in the tibio-astragalus region with posterior constriction. We identified the presence of several subchondral geodes-like formations (sphere shaped structure which contains a hollow cavity), some 17 mm diameter, mainly visible at the level of the anterior part of the

COMMENTS
Especially for examinations of bone joints and the inner ear, we primarily use the high resolution mode in order to detect smallest details, such as micro calcification. This feature allows us to provide an improved differential diagnosis compared to normal scan modes.

The SOMATOM Emotion scanners from the singleslice SOMATOM Emotion to the new, 16-slice SOMATOM Emotion 16 – reliably perform routine and advanced applications.

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EXAMINATION PROTOCOL
Scanner Scan area Scan length Scan time Scan direction kV Effective mAs SOMATOM Emotion 6, high resolution mode extremity 80 mm 32 s craniocaudal 130 kV 90 mAs (CARE Dose4D) Rotation time Slice collimation Slice width Table feed / rotation Reconstruction increment Kernel 1.0 s 6 x 0.5 mm 0.6 mm 2.5 mm 0.3 mm U90s

[ 1 ] The axial view shows irregular, roughly spherical, bodies (arrowhead) in the anterior part of the heel bone as well as the presence of micro calcifications (arrow).

[ 2 ] Sagital view of degenerative processes of the tibio-astralagus part of the talus (arrows) with posterior constriction

[ 3 ] The coronal view shows the presence of micro calcifications, probably of cartilagenous origin (arrowhead), and edema of the soft tissue (arrow).

[ 4 ] VRT of the tibia shows the geodes-like structures of the anterior part of extremity distal of the tibia (arrow).

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SOMATOM Sensation

SOMATOM Emotion

SOMATOM Spirit

New Multisclice CT – SOMATOM Spirit

The attractive design of the SOMATOM Spirit helps alleviate patients’ inhibitions.

The SOMATOM Spirit is a subsecond, dual-slice CT scanner for day-to-day clinical routine. It is ideally suited for outlying satellite clinics utilizing teleradiology as well as medical fields other than radiology, such as ENT, dental surgeons, and general practitioners. By adding CT to their medical services, virtually any practice or facility can improve the quality of patient care and increase patient volume.

Case 6: Pre-operative Neurosurgical Planning
By Carsten Figge, MD, Radiology Institute/Practice Drs. Mariß/Aref/Figge, Bad Zwesten, Germany

HISTORY
A 36 year old female with a suspected tumor was admitted for neurosurgical evaluation after increasingly frequent headaches during the last months, anosmia and emotional labililty. The patient refused to undergo MR scanning due to high grade claustrophobia. Pre-operative CT scanning was requested by the neurosurgeons to provide more information of possible tumor proliferation, infiltration into the sinuses and dislocations of vessels. like enhancement. A peritumoral edema with compression of the ventricles was also noted. CTA revealed a dislocation of the arteriae cerebri anteriores and identified the feeding arteries of the tumor. Additionally, a hyperosteosis in the lamina cribrossa can be seen. Tumor growth in the sinuses can be excluded. In this specific case, having a patient with claustrophobia, the combination of CTA, MIP and MPR reconstructions allowed for successful surgical planning. This case demonstrates the beneficial value of CT scanning as an alternative to MR scanning in the preparation for surgical interventions.

DIAGNOSIS UND COMMENTS
The CT scan showed an inhomogeneous frontobasal enhancing mass, a suspected meningioma of the olfactory groove due to related symptoms with heterogeneous rim-

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[ 1A ] Axial image showing a subfrontal extra-axial enhancing mass, with compression of the frontal lobes

[ 2 ] CTA of tumor feeding vessels

[ 3 ] Sagital MPR of the tumor

[ 4 ] VRT of the menigeoma

EXAMINATION PROTOCOL
Scanner Scan area Scan length Scan time Scan direction kV Effective mAs Rotation time Slice collimation Slice width SOMATOM Spirit cerebrum 110 mm 25 s caudo-cranial 130 kV 50 mAs 0.8 s 2 x 1 mm 1.25 mm Postprocessing MIP, MPR, VRT Contrast Volume Flow rate Start delay Non ionic contrast media 120 ml 3 ml / s 25 s Pitch Reconstruction increment Kernel 1.8 0.6 mm H21

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SCIENCE

SOMATOM Sensation 64 z-Ultra-High Resolution Mode
By Thomas Flohr, PhD, Head of Physics and Application Development, and Karl Stierstorfer, PhD, Physics and Application Development, Siemens AG, Medical Solutions, CT Division A special ultra-high resolution mode, called z-UHR, providing considerably enhanced spatial resolution, will be introduced for new SOMATOM Sensation 64 scanners, starting in summer 2005: up to 0.24 millimeter isotropic resolution can then be achieved in clinical routine. With z-UHR, the SOMATOM Sensation 64 has reached a level of resolution previously known only from non-clinical research CT systems using CsI-aSi flat-panel detectors. “The combination of the revolutionary z-Sharp Technology and the unique z-UHR functionality offers our users, in daily clinical routine, an isotropic detail in the range of MicroCT technology,” says Alexander Zimmermann, Global Product and Marketing Manager SOMATOM Sensation. The new mode is intended for ultra-high resolution boneimaging, in particular for wrists, joints, and inner ear studies. Pre-requisite for z-UHR ultra-high resolution mode is the unique z-Sharp Technology enabled by the Siemens proprietary STRATON X-ray tube. A moveable tantalum comb (grid) is positioned in front of the detector elements, covering the outer detector rows and effectively reducing the z-aperture of the inner six detector rows from 0.6 millimeter to 0.35 millimeter at iso-center [Fig. 1]. Without z-Sharp Technology, collimated 0.35 millimeter slices would be acquired with this set-up – but unfortunately with a sampling distance of 0.6 millimeter and a corresponding “dead zone” of 0.25 millimeter, so that the slices would not be adjacent in the z-direction and volume coverage would be incomplete. However, z-Sharp Technology provides measurement data in these dead zones as well. Using z-Sharp Technology, rays of subsequent readings are shifted by 0.3 millimeter at iso-center in the longitudinal (z-) direction. Two subsequent six-slice readings are interleaved and result in one twelve-slice projection with 0.3 millimeter z-sampling distance and 0.35 millimeter detector z-aperture – without gaps in the longitudinal direction. The data acquired with z-UHR correspond to those obtained with a conventional detector with 0.3 millimeter detector elements. The grid covers six adjacent 0.6 millimeter central detector elements, and thus provides the data of 12 x 0.3 millimeter collimated slices with z-UHR. Well defined slices with 0.4 millimeter slice-width are reconstructed in a spiral mode. Both in the scan plane and along the z-axis, an isotropic resolution of 0.24 millimeter (240 micron) is achieved. This can be demonstrated using the CATPHAN (The Phantom Laboratories, Salem, NY). Turning the high resolution insert by 90°, the bar patterns become roughly oriented along the z-direction. Fig. 2 shows an MPR of this phantom in the longitudinal direction, proving that 21 lp/cm, corresponding to 0.24 millimeter object size, can be resolved. Early clinical experience demonstrates that both inner ear and wrist studies show significantly improved z-axis resolution with increased clarity of sub-millimeter anatomic structures [Fig. 3].

Detector set-up

X-ray focus

Scanfield

z-axis

Grid

0.35 mm

[ 1 ] Schematic illustration of the detector set-up used for z-UHR. A moveable tantalum grid is positioned in front of the detector elements, reducing their z-aperture to 0.35 millimeter at iso-center. z-Sharp technology is used to acquire readings with a z-shift of 0.3 millimeter at isocenter. Two subsequent readings are interleaved and result in projection data with 0.3 millimeter z-sampling distance and 0.35 millimeter detector z-aperture.

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2

z-axis (mm) 0.24

0.25

0.26

[ 2 ] MPR of the high resolution insert of the CATPHAN, demonstrating 0.24 millimeter isotropic resolution with z-UHR available for the SOMATOM Sensation 64. [ 3 ] MPR of a wrist fracture acquired with 0.24 millimeter isotropic resolution. The image demonstrates a level of resolution previously known only from research CT systems with flat-panel detectors.
(Image courtesy of Klinikum Großhadern, Munich, Germany).

0.27

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SCIENCE

Symbia TruePoint SPECT·CT Combining Forces to Improve Patient Care
Single Photon Emission Computed Tomography (SPECT) and Computed Tomography (CT) come together to revolutionize medical imaging
By Claudette Yasell, Nuclear Medicine Division, Siemens Medical Solutions, Hoffmann Estates, IL, USA

The 2004 introduction of Symbia with TruePoint SPECT·CT technology definitely created new momentum in medical imaging. A breakthrough in healthcare and medical imaging, it provides a new tool to improve workflow efficiency and accelerate patient diagnoses. Building on the foundation of Siemens’ history of innovation and technology, Symbia is the perfect merger of two equal modalities, single photon emission computed tomography (SPECT) and computed tomography (CT), into one hybrid imager that will make a difference in the way medical imaging is delivered. SPECT imaging is predominantly used to reveal a patient’s functional or vital processes, such as blood circulation and the metabolism and vitality of organs and tumors. The addition of CT to this imaging technique provides the anatomical map for pinpointing the exact location of disease in the body, in order match metabolic or “functional” information.

A New Concept
Symbia’s imaging modalities, SPECT, SPECT·CT and Multislice CT, can be used independently or together. Used in combination, TruePoint SPECT·CT provides contemporaneously acquired, coregistered SPECT and diagnostic CT images, an advance with immediate benefits for oncology and cardiology, experts say. “Experience from PET/CT tells us that there is an advantage to having a diagnostic CT along with the nuclear medicine study to aid in tumor localization and surgical planning,” says Homer Macapinlac, MD, Deputy Chairman, Department of Nuclear Medicine, M. D. Anderson Cancer Center, who is planning for the installation of 5 Symbia TruePoint SPECT·CT imagers in 2005. “M. D. Anderson Cancer Center’s mission is to eliminate cancer, and our goal specifically in the Division of Diagnostic Imaging is to provide the best imaging possible to empower our physicians to help cancer patients,” Macapinlac said, “Because the anatomical detail is essential to have in combination with the functional information, TruePoint

SPECT·CT is going to help us in the diagnostic interpretation of clinical exams. Ultimately, the person who benefits from this new technology will be the patient.” Experts believe that Symbia will also have a profound effect on cardiac imaging. “I’m pretty excited,” says Edward Ficaro, Ph.D., an assistant research scientist in the Department of Radiology at the University of Michigan Health System, the very first clinical installation of Symbia. Ficaro has spent more than a decade working to improve the accuracy of SPECT imaging, from acquisition through physician review. He works closely with cardiac specialists and expects that with Symbia, they will be able to register SPECT and CT images of the heart with increased precision and accuracy. “Registering these images isn’t being done routinely because it's so difficult,‘ says Ficaro. The problem is that the thorax isn't a rigid structure. So registration is not just a fixed point rigid transformation, it’s often an actual morphing of the body based upon known landmarks.“ With TruePoint SPECT·CT technology, Symbia enables the examination of function and perfusion of the right ventricle of the heart, that, at just 1 to 4 mm thickness, is usually obscured in traditional SPECT studies.

Thinking Ahead
Innovations in technology have been the backbone of Siemens' success. Innovations such as TruePoint SPECT·CT were facilitated through an integrated team of engineers and scientists from nuclear medicine and CT working together to create new possibilities in the care of cardiac and cancer patients. After the incredible growth of PET/CT, customers and engineers alike began to imagine the possibilities of SPECT and CT together. Extensive customer surveys led to an initial concept involving basic CT capabilities added to the powerful SPECT capabilities of the e.cam Signature Series. The success of PET/CT systems involving high-end CT technology and the

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SPECT and CT imaging come together in Symbia TruePoint SPECT·CT technology.

Fusing the two technologies was not simply a matter of shoehorning the components of two existing systems into a slightly larger housing. The system is highly integrated, mechanically and electronically. While striving to make use of existing components wherever possible, the team often had to reconfigure and redesign components from each technology in the interest of meeting their compactness goals. The SPECT drive system was pushed to the outside, which allowed the CT components to be brought closer to the SPECT heads. The CT gantry was essentially redesigned, allowing the components to be as close as possible. With the SPECT and CT components tightly integrated, the resulting system offers many possible modes of operation.

Meeting the Integration Challenge
The push for tight integration extended to the software as well. The team aimed at keeping the individual user interfaces the same as those employed in the component systems. The software operation of the Symbia TruePoint SPECT·CT system is based on Siemens' exclusive syngo common medical imaging software platform that provides multimodality connectivity using the DICOM standard. At the heart of the software lies the Flash 3D SPECT image reconstruction software, based on an iterative maximumlikelihood algorithm that allows for modeling and correction of data degradations such as attenuation, collimator blurring, and scatter. Obviously, the CT images can be used to estimate the attenuation experienced by the SPECT photons, but not directly. CT X-ray sources produce photons with a broad range of energies, typically centered around 70 keV, while SPECT radionuclides most commonly emit photons of 140 keV. To convert a CT image into a SPECT attenuation map, it is necessary first to determine the effective average energy of the photons contributing to the CT image, and then to apply appropriate conversion factors to each pixel. The conversion has to be accurate for all isotopes and SPECT acquisition parameters. Moreover, the great difference in resolution between CT and SPECT images must be bridged in order for the CT images to be registered with SPECT for attenuation correction.

explosive growth in Multislice CT studies, however, ultimately led the company to design the current line-up of Symbia scanners, the T, T2 and T6 systems, involving single-, dual-, or six-slice CT technology drawn directly from Siemens CT Division.

Designing a Hybrid Success
Having already designed the best in SPECT, the design team gave Symbia everything the e.cam has to offer, including HD detectors, and unparalleled image quality and speed in nuclear imaging. The team decided early-on to avoid the “washer-dryer” approach of simply coupling two existing systems with a common patient bed, in favor of a more tightly integrated design, using as many existing components as possible. The goal was to achieve a 200-cm scan range through both systems’ fields of view without requiring an impractically long patient motion range. An excessively long patient motion range would have made it difficult to site the system in standard nuclear medicine and radiology rooms. Minimizing the patient motion range meant minimizing the distance between the CT and SPECT fields of view. One possible solution, of course, would have been to mount the CT and SPECT components on the same rotation gantry so that they shared a field of view. However, the team rejected this design because the weight of the SPECT heads would have severely limited the gantry rotation speed and thus the imaging speed achievable by the CT components. If state-ofthe-art Multislice CT components were to be used, the system needed to be capable of the sub-second gantry rotation speeds expected in modern Siemens' CT scanners. So the team opted for maintaining distinct but closely spaced subsystems.

Securing Clinical Success
To date, the intuitive interfaces of Symbia have been successful in creating workflow efficiencies since the very first national and international clinical installations were completed. The very first user, University of Michigan Health System, in Ann Arbor, MI, completed installation prior to the 2004 RSNA and the very first clinical images from Symbia with TruePoint SPECT·CT were presented there. “The Symbia

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with TruePoint SPECT·CT technology will allow us to take nuclear cardiac imaging to the next level. We expect that within the next year, we’ll be doing 80 to 90 percent of our cardiac studies on these systems,” said James Corbett, MD, professor of Radiology and Internal Medicine, Director of Cardiovascular Nuclear Medicine, UMMC. “As we integrate this new system into our clinical practice, we expect diagnostic accuracy to be improved significantly, as the amount of information gathered will be considerably increased. This should make the Nuclear Medicine SPECT images more accurate, and the information from the spatially registered CT scan will provide additional correlative data. We expect this will prove to be important for patient care and significantly enhance the diagnostic and prognostic value to the combined imaging procedure, compared to conventional SPECT imaging alone.”The University of Erlangen in Germany was recently the first European recipient of Symbia. Professor

Torsten Kuwert, MD, Chairman of the Department of Nuclear Medicine is confident that the addition of this hybrid imager will ultimately achieve the same success as PET/CT. “By combining SPECT and CT, it is possible to combine high biochemical resolution with high anatomical resolution to really localize neoplastic lesions, which should be expected to add to the quality of diagnosis. Hybrid PET/CT systems have already proven the diagnostic benefit, and most believe it’s not too much of a stretch to expect the same from SPECT·CT.” Siemens expects the Symbia hybrid imaging system to appeal to a number of different medical specialists, including radiologists, cardiologists and, of course, nuclear medicine specialists. Fittingly for a system born of cooperation and integration, it may actually realize its full potential when used in concert across departmental lines, with interpretation of the diagnostic-quality CT scans and SPECT data ultimately improving patient care.

Case Study Myocardial Perfusion Using TruePoint SPECT·CT
By James Corbett, MD, Professor of Radiology and Internal Medicine, Director of Cardiovascular Nuclear Medicine, University of Michigan, Ann Arbor, MI, USA

HISTORY
An 82 year old male, 77 kg (169.2 lbs), with known coronary artery disease, poorly controlled hypertension, insomnia and other problems, came in for a routine follow-up after experiencing minor bouts of chest pain. His resting EKG was abnormal. During exercise, he experienced greater than 1 to 2 mm ST depression, but did not experience chest pain at that time.

Images show an apical and anterior defect that’s mostly reversible and an inferior and inferior-septal defect that is significantly reversible. CT attenuated corrected (AC) images show greater reversibility of inferior defect than uncorrected images. Also noted is post-stress LV dilatation.

DIAGNOSIS
A TruePoint SPECT·CT study was performed with the Symbia hybrid imager using standard SPECT protocol in combination with a 6-slice CT scan. The SPECT portion of the examination revealed an apical and anterior defect that is mostly reversible and an inferior and inferior-septal defect that is significantly reversible. The scan also detected post-stress LV dilatation.

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Archaeology High-tech Meets History
Siemens Computed Tomography (CT) scanners help unravel the past: In January 2005, the ancient Egyptian mummy Tutankhamen was examined by an Egyptian team utilizing a SOMATOM Emotion 6 to explore how old he was at death, if he had suffered from any diseases, what he died of, and to determine the condition of the mummy itself. The following results were announced in Cairo in March 2005.
Was King Tutankhamen killed? Zahi Hawass, PhD, Secretary General of Egypt’s Supreme Council of Antiquities, stated that there is no evidence that the young king was actually murdered. This murder theory is based upon an X-ray examination of the pharaoh’s head in 1968 which revealed a cloudy area at the back of the skull. The project’s scientists have now agreed that there is no evidence of murder. There is nothing that indicates a blow to the rear of the skull. There are two bone fragments loose in the skull, but these cannot possibly have been from an injury causing death – they would have become stuck in the embalming resin. The scientists have matched these pieces to the fractured cervical vertebra and foramen magnum, and believe these were broken either during the embalming process or in 1925 by the mummy’s discoverers, who were trying to get access to the gold artifacts wrapped with the mummy.

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Careful Mummification
Based on the identification of at least five different types of resin and the many episodes of its introduction to the body and cranial cavity, the scientists concluded that great care was taken in the mummification of the pharaoh. This counters previous arguments that the body was prepared hurriedly and carelessly, perhaps to cover up a crime. However, the remains of Tutankhamen are in very poor shape, primarily due to the damage done by the Howard Carter team that discovered the tomb in 1922. The body is in several pieces. Bones and skin are broken in numerous places. The king’s arms, originally folded across his chest, are now by his sides. Many parts are missing, although fragments remain loose in the sand tray where the mummy is resting. The scientists noted a fracture of the left lower femur, at the level of the epiphyseal plate. This fracture appears different from the breaks caused by Carter’s team: it has ragged

[ 1 ] One of Tutankhamen’s wisdom teeth is still impacted. [ 2 ] The king had a small cleft in his hard palate. [ 3 ] Whole body of pharaoh Tutankhamen
Clinical images courtesy of Supreme Council of Antiquities

edges, and there are two layers of resin inside. Some scientists believe that the resin indicates that this can only have occurred during Tutankhamen’s life or the embalming process. They note that this type of fracture, unlike many others, is possible in young men. There is no obvious evidence of healing, but such indications may be masked by the resin. Since the associated skin wound would still have been open, this fracture would have had to occur shortly before death. Carter’s team had noted that the patella on his left leg was

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[ 4 ] Zahi Hawass, PhD, Secretary General of the Supreme Council of Antiquities, takes a close look at the mummy of Tutankhamen.
Photo courtesy of Brando Quilici

loose, possibly suggesting further damage to his body. Now the patella is completely separated, and has been wrapped with the left hand. Scientists also noted a fracture of the right patella and right lower leg. Based on this evidence, they suggested the king may have suffered an accident in which he broke his leg, leaving an open wound. Although the break itself would not have been life-threatening, infection could have set in. However, it is also possible, although less likely, that this fracture was caused by the embalmers. Other scientists maintain that the fracture can only have been inflicted by Carter’s team during extraction of the body from the coffin. They argue that if such a fracture had been suffered in life, there would have been evidence of hemorrhage or hematoma in the CT scan. They believe the resin was pushed into the fracture by Carter’s team. The examination confirmed that Tutankhamen had died at about the age of 19. The fusion of the epiphyseal plates matches the development of a young man of 18 or more, and 20 or less. The wisdom teeth are not completely grown. One of them [Fig. 1] is impacted, and there is a slight thinning of the sinus cavity above. The king had a small cleft in his hard palate [Fig. 2], not associated with an external expression such as a hare-lip. His lower teeth were slightly misaligned. He had large front incisors and the overbite characteristic of other kings from his family. Tutankhamen had a dolichocephalic skull. As the cranial sutures are not prematurely fused, this is most likely a normal anthropological variation rather than any pathology. There is a slight bend in his spine; the scientists agreed that this is not scoliosis, since there is no rotation and no associated deformation of the vertebrae. The bend thus most likely reflects the way the mummy was positioned by the embalmers. The sternum and a large percentage of the front ribs of the mummy are missing. Their ends appear to have been cleanly cut by a sharp instrument. The scientists agree that this cannot mirror extensive trauma to the chest, as such trauma would have left marks elsewhere in the body. Opinion is

divided as to whether the ribs and sternum had been removed by the embalmers or by Carter’s team. Archaeological investigation will continue in an attempt to resolve this issue. Tutankhamen was approximately 170 centimeters tall [Fig. 4], as extrapolated from the measurement of the tibia. Judging from his bones, which indicate a slight build, he had been well-fed and healthy, and had not suffered major childhood malnutrition or infectious diseases. His internal organs, as is usual for Egyptian mummies, are not present in the body, and thus could not be analyzed. The Egyptian scientific team, headed by Dr. Hawass, consisted of radiologists, pathologists, and anatomists from the Faculty of Medicine at Cairo University. The team later invited three foreign consultants to work with them. The examination was part of a research project being conducted by Egypt’s Supreme Council of Antiquities. The project also includes meticulous CT scans of a large number of other Egyptian mummies. To support the project, Siemens Medical Solutions and the National Geographic Society have provided a SOMATOM Emotion 6 installed in a trailer – making it transportable to wherever it is needed. With this device, the fragile remains of Egypt’s ancient people can be studied with a minimum of movement and disturbance with the ultimate view of prolonging preservation. k Further Information:
www.ngs.org; www.guardians.net/hawass/

The Great Art Detective
Using CT for ancient relics is not only restricted to human remains. At RSNA 2004, a group of Belgian scientists led by Marc Ghysels, MD, illustrated the spectrum of CT findings in wooden, ivory, pottery and stone sculptures. Using a SOMATOM Volume Zoom, these experts are able to disclose manufacturing techniques, natural damage, repairs, restoration and fakes. When a collector is interested in an art work, one of his primary concerns is to establish its authenticity. This is based on both subjective factors and scientific analysis such as stylistic analysis, thermoluminescence or carbon-14 analysis, dendrochronological study, spectroscopic or microscopic analysis etc. Unlike these tests, which focus mainly on the visible parts of the work or on a few samples, CT has the advantage of describing the inner state of the object, without damaging it in any way.

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L i f e : E D U C AT E

A Win-Win Situation
With the SOMATOM Sensation Cardiac 64 taking cardiac CT to the next level, the need for dedicated customer training increases. Siemens Medical Solutions supports its customers, providing firsthand know-how, and the possibility to exchange experience with well-versed medical colleagues.
Siemens’ Life customer care solutions offer an array of measures to customers to get the most value out of their systems by maximizing their clinical know-how. In addition to a full range of continuous learning programs – from extensive start-up and technical training to applications support and web-based courses – customers can attend workshops, fellowships, and symposiums held in close cooperation with renowned clinical partners. Workshops on cardiac computed tomography (CT) are being held at Erasmus Medical Center, Rotterdam, The Netherlands; Friedrich-Alexander University Clinic, Erlangen, Germany; University Hospital Muenster, Germany and other distinguished institutions. In co-operation with Siemens, these partners offer regular courses for both radiologists and cardiologists, combining lectures and hands-on training on the SOMATOM Sensation Cardiac 64. Participants have the chance to observe patient exams, attend lectures and participate in case studies review sessions. Some physicians just starting with cardiac CT and with no experience in radiology, appreciate an even deeper insight. Frans Santosa, MD, from the cardiovascular Waringin Medika clinic in Jakarta, Indonesia, is a German-trained internist, cardiologist and angiologist, who was not very familiar with radiology. However, he saw the advantages of cardiac CT and purchased two

Frans Santosa, MD (2nd from right): “Thanks to Siemens’ Life Program, I’ve been able to optimally utilize my new SOMATOM Sensation Cardiac 64 right from installation.” SOMATOM Sensation Cardiac 64s in late 2004, one for his clinic, one for a private practice he started with some colleagues. Just before installation, he spent quite some time at the FriedrichAlexander University Clinic in a fellowship program. “I really appreciate the chance to learn from my experienced German colleagues. Everyone has been very generous sharing their knowledge, and I now see even more clinical capabilities of the SOMATOM Sensation Cardiac 64 than I thought before,” he resumes. Not only do the trainees profit from the fellowship program, but the hosting clinics as well. Says Stefan Martinoff, MD, Director of the Clinic for Radiology and Nuclear Medicine at the German Heart Center in Munich (DHM), “We

Stefan Martinoff, MD: "Not only do our guests profit from us, we also profit from them. It is a win-win situation."

have made some excellent international connections during the past years. We are very proud of our worldwide network of physicians and scientists. Our joint objective is to steadily increase the quality of medical care.” Radiologists and cardiologists at the DHM diagnose CT images together. “Coronary CT is at its best and optimal patient care is ensured only when both specialties sit together at the same table,” emphasizes Martinoff. “A physician can not be both a radiologist and a highly trained cardiologist at the same time,” he offers with conviction. “This is why cooperation is a must, although it is not practiced everywhere due to frequent competition between the two specialties.”

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E D U C AT E

Cross-country Postprocessing Events
Following last year’s success, Siemens Medical Solutions again supported hands-on training sessions at Professor Elliot Fishman’s popular “Advanced Topics in Computed Tomography (CT) Scanning” CME accredited courses in Los Angeles (April 1–3rd, 2005) and Baltimore (April 8–10th, 2005). Over 300 radiologists and technologists took advantage of the opportunity to learn more about the principles of 3D and virtual imaging with syngo InSpace4D, CT-Angiography, cardiac CT, virtual colonography and lung imaging. Siemens provided 20 LEONARDO workplaces enabling participants to work individually during each of the clinical hands-on sessions. Sessions, lead by both experienced Hopkins faculty and Siemens applications spe-

Both, the courses at “Advanced Topics in CT Scanning“ (left), and the Hands-on Workshop “CT-Colonography” at ESGAR (right), were met with enthusiasm. cialists, gave attendees the opportunity to work through a wealth of specially selected clinical cases. Everyone walked away with a firm grasp of the principles and clinical application of 3D and virtual post-processing techniques. ESGAR’s 3rd CME accredited Hands-on Workshop, “CT-Colonography” (April 26– 28th, 2005) was hosted by Phillipe Lefere, MD, and Stefaan Gryspeerdt, MD, from Stedelijk Ziekenhuis, Roeselare, Belgium. Places were limited to 40 for each of the two concurrent workshops, and a total of 80 radiologists joined the invited faculty in the beautiful ancient city of Bruges, Belgium, for a packed two day program. The first day of each workshop was comprehensive with lectures and hands-on demos on the essentials of CTColonography (CTC) from leading CTC experts including Johannes Wessling, MD, (Munster, Germany) and Andrea Laghi, MD, (Rome, Italy). Day two was dedicated to tutored hands-on sessions with faculty members present to guide the participants through over 100 specially selected cases. Siemens Medical Solutions supported the workshop with six LEONARDO workplaces running syngo Colonography software. “The workshop ideally balanced between lectures and plenty of time for hands-on training. Having a clinical expert guiding us through the more challenging test cases was very helpful. I came away with useful tips that will certainly enhance my CTC workflow,“ says Christian Lauer, MD, O.L.V.V. Lourdes-Ziekenhuis, Belgium.

T E C H N O LO G I S T E D U C AT I O N S Y M P O S I U M

CT Imaging and Cherry Blossoms
Many customers took advantage of the outstanding possibility to benefit from the integrated approach across modalities that Siemens offers for radiology, cardiology, and oncology solutions. This year's Technologist Education Symposium took place in Washington DC, USA from April 17th to 19th and offered sessions related to cardiac and vascular angiography, diagnostic radiology, computed tomography (CT), magnetic resonance (MR), nuclear medicine/PET, oncology, and ultrasound, including various lectures and hands-on training. Once again this was a successful event for everyone who came to learn about clinical routine and topics encompassing the cutting edge of medical imaging technology. The first day, all participants met for a for a general preview of the educational symposium, reviewing case studies and overall topics concerning the different healthcare sectors. The evening ended with a welcome reception. During the following two days, all participants had the chance to attend lectures for cardiac & vascular angiography, diagnostic radiology, CT, MR, or breakout sessions, according to their own fields of interest. For CT, there were speakers from Siemens as well as from well known institutions, like Andy Trovinger from Radiology Imaging Associates and Williams Jonathan, MD, from Shands Jacksonville. Several companies exhibited their filming products, injector systems and MRI accessories. But even with such an exciting program, all participants still had enough time to enjoy Washington’s cherry blossoms and socialize at the dinner buffet.

During the LEONARDO hands-on session, participants worked with the latest applications.

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7 T H I N T E R N AT I O N A L S O M AT O M C T U S E R C O N F E R E N C E

Exploring the Riches of Multislice CT
High-end clinical applications were at the center of the 7th International SOMATOM Computed Tomography (CT) User Conference, held in conjunction with the University Hospital La Sapienza, in Rome, Italy, in May 2005. The “Eternal City” alone, with its impressive art and architecture, the Forum and Coliseum, the baroque churches and the Vatican, would have been enough to fill everybody’s senses. But there have been remarkable achievements in CT technology and applications since the last Siemens User Conference in 2002, and all participants were eagerly awaiting the latest information from research groups from around the world. Renowned speakers presented a wealth of outstanding clinical results in the various fields of CT imaging. The 17th century Teatro Capranica provided beautiful surroundings for 60 luminary speakers, lecturing on topics such as “Technology Principles of Multislice CT”, “Head and Neck“, “Chest“, “Cardiac“, “Abdominal“, and “Vascular CT“, and “New Frontiers in CT”. The lectures were supplemented by panel discussions, case demonstrations, hands-on workstation sessions, and a poster exhibition. Professor Roberto Passariello, MD, head of the Department of Radiologic Sciences, was chairman of the conference, supported by Carlo Catalano, MD, Associate Professor at the same department (both University Hospital La Sapienza, Rome,

The more than 150 participants also enjoyed the view over Rome’s ancient roofs at an exclusive social event.

Italy). Professor Elliot Fishman, MD, Johns Hopkins Hospital, Baltimore, MD. USA, and Professor Yutaka Imai, MD, Tokai University, Tokyo, Japan, were co-chairmen. A CD of the conference will be available soon.

SERVICE

Frequently Asked Questions
Via the SOMATOM World User Lounges, Siemens applications specialists answer your questions on “how to …” easily use Siemens Computed Tomography scanners and applications in daily clinical practice. Additionally, SOMATOM Sessions offers a regular column with frequently asked questions for offline reference. Why can’t I remove patient protection to delete studies from the browser? Reload the study back into the exam card, check for open recon jobs and delete the open recon jobs, if present. Take note of the position of the chronicle bars: if any are indented, patient protection is applied. Once the chronicle bars are all to the left, the study is no longer protected. Patient information is incorrect. Can I change it after scanning is completed? After reconstructions are complete, select the patient in the browser. Be sure that the study is not open in any platform, no open recon jobs exist and the study is not delete protected. On the browser drop down menu, select ’Edit and Correct‘. A warning box will appear that this is an external document; select ’Continue‘. The correct platform will then open. The major topics are on the left side of the vertical tabs and the right side has the details for each section. Make the necessary changes and sign off with your initials (minimum of 3 letters) in the upper right hand corner of the platform and then click ‘OK‘ in the bottom left corner. Why are the images that I sent to filming in reverse order? The order of the images depends on the configuration of your browser. The sort functions on the browser vary with each level of the patient study. The selections for the patients name are alphabetical, chronological, work status or reverse order. On the series level, multiple and modality specific selections are also available. Simply select the local database heading and sort for ’DB Date and Time‘, for the study level select ’Study Date and Time‘, and the series level should be set to ’Instance Number‘. Also make sure to deselect any level with reverse order activated.

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C T ONLINE

S I E M E N S R E M OTE S E RVI C E

CT on the World Wide Web
k www.insideinspace.com Inside InSpace introduces technicians and physicians to syngo InSpace, the volume imaging application for interactive display of volume datasets from Computed Tomography and 3D Angiography. The website offers complete information on all software features and specifications. Hints and tips, plus an 'Ask the Experts' button support users in getting the most out of syngo InSpace4D in their daily clinical work. A selection of feature articles and lectures is available for reference. The latest syngo InSpace4D presets are offered for download. A video and image gallery introduces interesting cases. The information is supplemented by CME course dates for syngo InSpace.

Information and Services Available Directly at Your CT Scanner
Working efficiently in a radiology department becomes more and more dependent on information. How about finding the latest application guide online? Or easily receiving information about new software that might simplify daily workflow? Or trying new applications before purchasing? This and much more is possible with SOMATOM LifeNet, the information and service portal available free of charge directly at your Computed Tomography (CT) scanner consoles. As a Siemens customer, you can even download the latest scan protocols to make sure they are always up to date. To find out how SOMATOM LifeNet can help you with your daily work, simply go to SOMATOM LifeNet under Options in your syngo menu bar. The only prerequisite is Siemens Remote LifeNet offeres easy access to the Service, a feature provided at no addilatest information – directly at the tional cost in the Siemens service CT scanner console. agreement.

Upcoming Events & Courses
Title 6th International Conference on Cardiac CT ESC ASTRO Location Boston, USA Short Description International Meeting Date July 21–23, 2005 Contact cme.med.harvard.edu

Stockholm, Sweden Denver, USA

European Society of Cardiology Congress American Society for Therapeutic Radiology and Oncology Congress Transcatheter Cardiovascular Therapeutics Sympoisium European Society for Therapeutic Radiology and Oncology Congress American Heart Association Scientific Sessions Radiological Society of North America Congress

Sept. 3–7, 2005 Oct. 16–20, 2005

www.escardio.org www.astro.org

TCT ESTRO

Washington, USA Paris, France

Oct. 17–21, 2005 Oct. 30–Nov. 3, 2005

www.tct2005.com www.estroweb.org

AHA RSNA CME Courses

Dallas, USA Chicago, USA

Nov. 13–16, 2005 Nov. 27–Dec. 2, 2005 Regular events, please see website

www.americanheart.org www.scientificsessions.org www.rsna.org www.CTisus.com

Johns Hopkins University, Focus on multislice CT University, Baltimore, USA; scanning and and other US locations post-processing

In addition, you can always find the latest CT courses offered by Siemens Medical Solutions at www.siemens.com/SOMATOMEducate.

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SOMATOM SESSIONS – IMPRINT
© 2005 by Siemens AG, Berlin and Munich, All rights reserved

Publisher Siemens AG Medical Solutions Computed Tomography Division Siemensstraße 1 D-91301 Forchheim Responsible for Contents: Bernd Ohnesorge, PhD Editors Doris Pischitz, M.A. (doris.pischitz@siemens.com) Stefan Wuensch, PhD (stefan.wuensch@siemens.com) Editorial Board Jessica Amberg Joachim Buck, PhD Thomas Flohr, PhD Chad DeGraaff André Hartung Sandra Jeleazcov Matthew Manuel Louise McKenna, PhD Axel Lorz Jens Scharnagl Authors of this Issue Geoffrey Browne, MD, Alamance Regional Medical Center, Burlington, USA Chris DeAngelo RT (R), (CT), Alamance Regional Medical Center, Burlington, USA J. Debus, MD, PhD, Department of Radiation Oncology, University of Heidelberg, Germany

Eric Devilaine, Chief of X-ray Technician Team, Centre Hospitalier Robert Morlevat, Semur en Auxois, France J. Dinkel, MD, Department of Radiation Oncology, University of Heidelberg, Germany Carsten Figge, MD, Radiology Institute/Practice Drs. Mariß/Aref/Figge, Bad Zwesten, Germany V. Lambert, MD, Department of Cardiopediatry, Marie Lannelongue Hospital, Le Plessis-Robinson, France U. Mende, MD, PhD, Department of Radiation Oncology, University of Heidelberg, Germany Jean-François Paul, MD, Department of Radiology, Marie Lannelongue Hospital, Le Plessis-Robinson, France Jin Zheng Yu, MD, Department of Radiology, Peking Union Medical College Hospital, Beijing, China Anne Sigal-Cinqualbre MD, Department of Radiology, Marie Lannelongue Hospital, Le Plessis-Robinson, France Ly Thai Bach, MD, Chief of Radiology Unite, Centre Hospitalier Robert Morlevat, Semur en Auxois, France

Xue Hua Dan, MD, Department of Radiology Peking Union Medical College Hospital, Beijing, China Tony De Lisa, freelance writer Jessica Amberg; Chad DeGraaff; Thomas Flohr, PhD; Lars Hofmann, MD; Louise McKenna, PhD; Per Anselm Mahr; Bernd Ohnesorge, PhD; Rainer Raupach, PhD; Gitta Schulz; Karl Stierstorfer, PhD; Heiko Tuttas; Claudette Yasell; all Siemens Medical Solutions

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Note in accordance with § 33 Para.1 of the German Federal Data Protection Law: Despatch is made using an address file which is maintained with the aid of an automated data processing system. SOMATOM Sessions with a total circulation of 35,000 copies is sent free of charge to Siemens Computed Tomography customers, qualified physicians and radiology departments throughout the world. It includes reports in the English language on Computed Tomography: diagnostic and therapeutic methods and their application as well as results and experience gained with corresponding systems and solutions. It introduces from case to case new principles and procedures and discusses their clinical potential. The statements and views of the authors in the individual contributions do not necessarily reflect the opinion of the publisher. The information presented in these articles and case reports is for illustration only and is not intended to be relied upon by the reader for instruction as to the practice of medicine. Any health care practitioner reading this information is reminded that they must use their own learning, training and expertise in dealing with their individual patients. This material does not substitute for that duty and is not intended by Siemens Medical Solutions to be used for any purpose in that regard. The drugs and doses mentioned herein are consistent with the approval labeling for uses and/or indications

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No. 16/June 2005
Stanford University’s 7th Annual International Symposium on Multidetector-Row CT June 15-18, 2005

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