Annual Meeting of the Belgian Society of Radiology (BSR) November 19, 2016

Editorial on the Annual Meeting of the Belgian Society of Radiology (BSR) 19 November 2016.


Reto Sutter
The first invited speaker is Doctor Reto Sutter, radiologist and PD, Deputy Head of the Radiology Department at the well-known Orthopedic University Hospital Balgrist in Zurich/Switzerland. Dr. Sutter graduated from medical school at the University of Zurich and trained in radiology and pathology in the University Hospital Zurich and the Cantonal Hospital in Winterthur as well as in the Royal London Hospital/Queen Mary University in London, United Kingdom. During his training, his research focus was on MRI of the abdomen and the cardiovascular system. He further investigated neural stem cells and their role in the development of medulloblastoma during his stay in the UK.
His main research interests are imaging of the joints, imaging of metal hardware and reduction of metal artifacts on CT and MR imaging. Dr Sutter published several widely read studies on femoroacetabular impingement and further published several studies on metal artifact reduction at MRI, e.g. in patients with total hip and total knee arthroplasty, both from a technical and a clinical view point. At Balgrist Hospital, more than 90% of his work is focused on musculoskeletal radiology. As such, he performs many CT and MR arthrography examinations, e.g. in shoulder instability, but also examines a lot of high-level athletes from different sports activities. He has published 48 peer-reviewed papers (on PubMed) since 2007 (17 as the first author). Dr Sutter received several awards for his work, including the 2012 Jubilee Award of the Swiss Society of Radiology. In 2014, he received his habilitation (formal initiation as senior lecturer in the medical faculty at the University of Zurich). He is a member of the assistant editorial board for the Journal Investigative Radiology and is acting as reviewer for a number of prestigious journals, including Skeletal Radiology and Radiology. He is a member of the International Skeletal Society and holds the Diploma of the European Society of Musculoskeletal Radiology (ESSR), where he is also a member of the ESSR Sports Imaging Subcommittee (chaired by Maryam Shahabpour since 2013).
Reto Sutter approaches "Sports Injuries" through the radiological misinterpretations that the radiologists should learn to recognize and to avoid. Athletes can present a variety of common and specific injuries. Some of the sports injuries are initially misdiagnosed, leading to possible mid-and long-term secondary complications that may delay return to sports or prevent the athlete from competing at an elite level. Furthermore, normal physiological and mechanical phenomenons in athletes could be interpreted as abnormal imaging findings, especially in young athletes. As an example, an athlete with acute tear of the anterior cruciate ligament of the knee could present associated injuries to the joint capsule and the posterolateral or posteromedial stabilizing structures. If those lesions are missed and left untreated, the athlete could develop a posterolateral or posteromedial instability of the knee joint. Additionally, there are more typical injury patterns and locations diagnosed in specific sports, such as subtalar fracture of the lateral process of the talus, the so-called snowboarder's ankle,that could be missed on plain radiographs and sometimes on MR imaging. On the other hand, there are seemingly abnormal findings in athletes detected on radiographs, CT or MR imaging that are commonly encountered but completely asymptomatic. Professor Sutter concludes that a good communication between the referring sports physician and the radiologist is paramount to provide a fast and correct diagnosis, seeing the patient history and clinical examination helps to avoid misinterpretation of the imaging findings.

Filip Vanhoenacker
The second speaker of the first session is Doctor Filip Vanhoenacker, Belgian radiologist who studied at the Catholic University of Leuven. He is staff radiologist at the General Hospital of St-Maarten, Mechelen-Duffel since 1991 and consultant radiologist at the University of Antwerp since 1995, as well as guest lecturer since 2007 and guest professor since 2013. He is also guest professor at the University of Ghent since 2011. In 2003, he obtained a PhD based on "congenital abnormalities of the skeleton", one of his numerous fields of interest. He has published 296 peer-reviewed papers referenced on Pub-Med and is the author or co-author of 61 book chapters and monographs. He is the editor and co-editor of "Imaging of Soft Tissue Tumors" by AM De Schepper, PM Parizel, L De Beuckeleer, F Vanhoenacker 2001, 2006, and a forthcoming 2017 edition (Springer-Verlag) and "Imaging of Orthopedic Sports Injuries" by FM Vanhoenacker, M Maas, JL Gielen, 2007 (Springer-Verlag). He is a referee for European Radiology, JBR-BTR/JBSR, European Journal of Radiology, Skeletal Radiology, Singapore Medical Journal, British Journal of Sports Medicine, Eurorad, and Insights into Imaging.
The impact of his research topics on the present and future practice of radiology is mainly educational, launching the careers of young radiologists and residents.
Filip Vanhoenacker presents the "Common Pitfalls in MR Imaging of the Knee Joint", an overview of common interpretation errors and pitfalls encountered by young residents or less-experienced radiologists. MRI of the knee joint is one of the most commonly requested examinations and belongs to the core clinical practice in most MRI clinical units (together with spinal and brain MRI). Therefore, these examinations are often reported by general radiologists in most private institutions and are an important part of routine education of radiology residents. Professor Vanhoenacker emphasizes pitfalls due to insufficient knowledge of anatomic variants from osseous origin (as bipartite patella or dorsal defect of the patella) that should not be confused with osteochondritis dissecans, Brodie abscess or bone tumors. Cortical avulsive irregularity, another benign bone defect located at the posteromedial femoral condyle should not be misinterpreted as an aggressive neoplastic lesion. He recommends the following to avoid common mistakes: • Consider age and clinical findings as well as previous medical history and symptoms before interpreting the images. • Use standardized questionnaires to indicate the precise location of the pain, duration of the complaints, history of trauma, aggravating activities, underlying diseases and previous surgery. • Look at previous imaging studies and other imaging modalities, such as plain films or CT scan (namely for identification of calcifications) or ultrasound, since the comparison with these examinations can be extremely helpful for the correct diagnosis. • Analyze all imaging planes systematically for all structures and compare the T1 and T2 weighted pulse sequences. • Look for other clinically atypical abnormalities (as pigmented villonodular synovitis, gout, other crystal deposition diseases, bone marrow abnormalities, ganglion cyst of the anterior cruciate ligament) apart from common intra-and peri-articular pathologies (like menisci, anterior cruciate ligament, cartilage). • Keep technical artifacts in mind as a cause of interpretation errors.
• Overcome the phenomenon of satisfaction of search, where detection of one abnormality may reduce the detectability of another abnormality.
Filip Vanhoenacker recommends a systematic approach in the analysis of all intra-and extra-articular structures of the knee joint.

Christian Glaser
The When asked what teaching means to him, Christian replies that first of all, teaching is fun and very instructive. It is also a way to give back some of what he had the luck to learn from the teachers he came across. For Christian Glaser, a key feature of radiology as a medical specialty is that the radiologist and his team work at the interface between a more and more subspecialized clinical environment, our patients and a highly sophisticated imaging technique. This comes with the responsibility to continuously and carefully evolve and adapt our position between the poles of a diagnostic service provider, of being active in therapy, and of taking responsibility in patient management. For Professor Glaser it is important to bring to life the interfacing characteristics of our profession, radiology, in day-to-day practice. This implies to combine and integrate at least three aspects: a sound image quality, scrupulous reading and the clinical context.
Christian Glaser develops some of the important errors in imaging of the ankle. His lecture is focused on "Tarsal Coalitions, a Practical Approach to a Not-so-rare Entity".
He explains that the term coalition refers to a connection between two normally separate bones, presumably due to a disturbance in mesenchymal segmentation. A coalition may be bony, fibrous, cartilaginous or a mixture of these tissues and may be partial or complete, i.e. it may affect a complete joint (facet) surface area or a fraction of it.
According to Professor Glaser and the scientific literature, imaging should be based on radiographs followed by MRI and -if relevant for therapy -by CT. The role of imaging is to corroborate the suspicion of a coalition, to bring up a coalition as a potential differential diagnosis to explain unclear or prolonged pain, to determine the nature, extent and location of one or more coalitions as well as potential accompanying changes (degenerative or stress reactions, e.g. bone marrow edema pattern), in order to help guide therapy.
The technical evolution of MRI enables this modality to depict and accurately describe any coalition and its morphologic features, reducing the need for CT in the workup of coalitions. Both CT and MRI have greatly facilitated the diagnosis of tarsal coalitions compared to radiography; this is also reflected by the higher incidence of coalitions in cross-sectional imaging studies. MRI shows bone marrow edema pattern around a non-osseous coalition or around adjacent joints. And of course, MRI may demonstrate associated soft tissue changes such as tendon pathologies in foot deformity or sinus tarsi syndrome. In terms of MR image analysis it is helpful to systematically look for the presence or absence/disturbance of the typical sequence of linear patterns reflecting a joint: trabecular bone, subchondral bone plate, articular cartilage and joint space. This approach may help to avoid overlooking subtle coalitions. CT is useful in specific situations, such as preoperatively, to decide whether a resection or arthrodesis is feasible, to specifically plan a procedure, to assess fine bony details of a coalition, or to assess secondary subtle degenerative change. It may also be especially helpful to detect small bony bridges outside/at the very periphery of the main joints of the foot, so-called extra-articular coalitions.
The last speakers of the first MSK session are from the Young Radiologist Section (YRS), a subdivision of the Belgian Society of Radiology (BSR) dedicated to residents and also recently (less than five years) graduated radiologists. Doctor Solenne Lanotte (current YRS French speaking Chair from UCL) and Doctor Cédric Bohyn (YRS Secretary from KUL) have prepared an original casebased presentation: "The Hips Don't Lie: A Case-based Quiz".

Cédric Bohyn
To complete the musculoskeletal contributions of this special November issue of the Journal of the BSR, Anagha Parkar, radiologist from Bergen, Norway (presenting a lecture at the chest session) was asked to write a paper on her field of interest in musculoskeletal imaging, in particular the role of CT imaging after reconstruction of the anterior cruciate ligament, part of her future PhD thesis.
1.2 The purpose of the second session on Musculoskeletal Imaging is to try to answer to the questions arised in managing patients with Shoulder Instability: How to Do or Not to Do? and How to Help the Surgeon? It is organized by the Musculoskeletal Section, chaired by Maryam Shahabpour from the Vrije Universiteit Brussel (VUB). She has invited experts in shoulder imaging from Switzerland (Reto Sutter and Patrick Omoumi) and Bruno Vande Berg from UCL as well as Nicole Pouliart, a skilled shoulder surgeon from VUB Brussels.

Bruno Vande Berg
The first speaker, Doctor Bruno Vande Berg, is staff radiologist at the Department of Medical Imaging of the University Hospital UCL St Luc since 1994. He obtained a PhD in 1997 on "sequential quantitative analysis and mapping of the bone marrow with MR", and started in 1998 as a clinical teacher at the Université Catholique de Louvain; in 2004 he became clinical professor responsible for the osteoarticular radiology unit and Chief of the Radiology Department of the Cliniques Universitaires St Luc -UCL. Since 2014, he has been Associated Chief of the Radiology Department, responsible for education and the osteoarticular radiology unit, Chairman of the interuniversity DES (Diploma of specialized studies). He is also Chair of the French Accreditation Committee in Radiodiagnosis.
He obtained research funds from FNRS (Fonds de la Recherche Scientifique) and was scientific collaborator and promotor of the "Télévie" operation from 1990 to 1997 working on "Integration of MRI for evaluation and therapeutic monitoring of leukemia and myeloma". He obtained the President's Medal of the International Skeletal Society in 2004 (as did Christian Glaser in 2012). He published about 158 peer-reviewed papers referenced on PubMed, many of them with his mentors Jacques Malghem (212 on PubMed) and Baudouin Maldague (164). Bruno Vande Berg also wrote more than 75 book chapters.
Professor Bruno Vande Berg presents "Radiographic Analysis of Osseous Injuries after Dislocation of the Shoulder Joint". He states that radiography remains pivotal to the workup of instability lesions of the shoulder, both in the acute as well as the chronic settings. The goal of radiography is to detect osseous abnormalities and locate them in order to determine the direction of instability. In anteroinferior instability, Hill-Sachs lesions are often visible at radiography and should not be confused with various differential diagnoses, which are usually more laterally located (as synovial inclusion cysts and marginal inflammatory erosions). Bankart lesions are more difficult to detect at conventional radiography, but there are less false positives than for Hill-Sachs lesions. The Garth view represents an excellent radiographic view to detect anteroinferior instability impaction fractures at both the humeral and glenoid sides. According to Bruno Vande Berg and many MSK experts, conventional radiography is the first step of the diagnostic workup since it allows the detection of osseous abnormalities following dislocations. However, advanced cross-sectional imaging techniques (MR, CT and US) will be required to accurately quantify these bone abnormalities and to detect associated lesions of soft tissue stabilizers of the shoulder (chondrolabral, capsuloligamentous structures) as well as rotator cuff lesions.

Patrick Omoumi
The second speaker of the shoulder session is Doctor Patrick Omoumi, a radiologist from Persian origin. He graduated from La Pitié-Salpêtrière School of Medicine, Paris, France (2003) He published over 65 papers in peer-reviewed journals, over 100 abstracts/presentations at international conferences, including several awards and 22 book chapters and monographs. He has presented over 50 invited lectures at national and international conferences and has organized the annual symposium on MSK radiology in Lausanne University since 2014. He co-organized the bi-annual joint meeting of the University Hospitals of Brussels (UCL) and Lille on Musculoskeletal Imaging from 2010 to 2014. He is faculty member of some of the MSK Erasmus Courses on Magnetic Resonance Imaging and the European School of Radiology courses.
Professor Omoumi presents "MR Arthrography in Glenohumeral Instability: It May Not Be as Complicated as It Seems". Glenohumeral joint instability is usually an intimidating topic for most radiologists, due to both the complexity of related anatomical and biomechanical considerations, as well as the increasing number of classifications and acronyms reported in the literature. Patrick Omoumi aims to demystify glenohumeral instability by focusing on the relevant anatomy and pathophysiology and reviewing the important imaging findings, and he explains how to describe them for the clinician in a relevant and simple way. The role of the radiologist in assessing glenohumeral instability lesions is to properly describe the stabilizing structures involved (bone, soft tissue stabilizers and their periosteal insertion), to localize them and to attempt to characterize them as acute or chronic. It is less important to find the acronym associated to a lesion. Impaction fractures on the glenoid and humeral sides are important to specify, locate and quantify. Any associated cartilaginous or rotator cuff tendon lesion should be reported to the clinician.
As do most authors, Patrick Omoumi agrees that proper assessment of glenohumeral labroligamentous structures requires the intra-articular injection of contrast material, either with MR-or CT-arthrography, in order to distend the joint cavity. MR and CT arthrography have shown similar (or slightly superior performance for CT arthrography, depending on the studies) for the detection of labral and/or ligamentous lesions, as well as for associated lesions, including cartilage and rotator cuff tendon lesions. For the assessment of bony structures (for which CT remains superior, despite recent progress made at MRI thanks to 3D sequences). However, whenever possible, MR arthrography should be preferred due to the exposure of patients to ionizing radiation with CT, and the proximity of radiosensitive organs such as the thyroid. It has been suggested that additional acquisitions with the shoulder placed in different positions, such as the ABER position, may be useful to improve the detection of antero-inferior labro-ligamentous lesions. For Dr Omoumi and others, the systematic use of the additional positions in the general population may not be required in practice due the low diagnostic yield, the additional examination time and patient discomfort.
The third speaker on shoulder imaging is Doctor Reto Sutter (from Balgrist University Hospital, Zurich) who was introduced in the beginning of the editorial.
Professor Sutter shares his experience on "The Role of CT Arthrography in Shoulder Instability". Plain CT and CT arthrography are useful tools in evaluating both the osseous structures and the soft tissues in patients with shoulder instability.
In patients with classic anteroinferior shoulder instability, CT can easily diagnose and quantify the common Hill-Sachs defect and glenoid rim fractures. It is the most accurate modality to assess the glenoid bone. Whereas the amount of osseous defects and glenoid bone loss at the anterior part of the glenoid may be underestimated at MRI in patients with anteroinferior shoulder instability, CT allows a precise visualization of this part of the glenoid, both in acute glenoid fracture and in chronic instability. In cases with only minor glenoid bone loss a labral repair and capsular surgery may be performed, while in cases with substantial glenoid bone loss, usually an osseous corrective surgery is preferred. Further, Reto Sutter reports that CT is a simple modality for performing anatomical measurements in the shoulder, such as glenoid version, or for the assessment and quantification of the amount of osseous deficiencies of the posterior glenoid in patients with suspected posterior shoulder instability. CT is also often used to assess atrophy and fatty infiltration of the rotator cuff muscle. Finally, CT is also beneficial for assessing patients in the postoperative situation, e.g. after a Latarjet procedure, where the distal part of the coracoid process is transferred to the anterior portion of the glenoid in order to prevent re-dislocation of the shoulder joint. CT allows for accurate assessment of the position of the osseous block and detection of a possible non-union. In patients with a suspected dislocation of anchors after rotator cuff repair, CT allows the identification and localization of the anchors and surgical wires.
The injection for CT arthrography can be performed under fluoroscopy guidance, under sonography, or even directly on the CT examination table with a low-dose CT protocol for the injection itself, followed by the standard diagnostic CT. With its inherent high spatial resolution, CT arthrography allows a precise evaluation of labral and chondral defects and is useful for the assessment of the biceps anchor and capsule-labrum complex.
The speakers of the last presentation on shoulder instability are Drs Nicole Pouliart and Maryam Shahabpour. The collaboration between the shoulder surgeon Nicole Pouliart and the MSK staff radiologists of UZ Brussel, Maryam Shahabpour, Michel de Maeseneer, Cedric Boulet and more recently Seema Doering started with a comparative study of CTA, MRA and arthroscopy in a large series of young patients with shoulder instability (supported by a research fund). Seeing the benefits of the regular radiosurgical confrontations, we came to the topic of today: "What Can the Radiologist Do to Help the Surgeon Manage Shoulder Instability?" Nicole and Maryam emphasize in a duo presentation why identification of abnormalities, whether variants or pathologic, is important to the surgeon facing a treatment decision and how important it is to collaborate with the clinician and to use the same language as the surgeon in our reports.
The typical lesions related with classic anterior and anteroinferior shoulder dislocation are an anteroinferior labral avulsion with or without bony fragment of bone loss (Bankart and Hill-Sachs lesions). These are relatively straightforward to identify on imaging, although normal variants of the inferior labrum and variants of labral damage may cause confusion. Other capsuloligamentous lesions, often associated with less typical types of instability, are much more difficult to correctly identify on imaging, as they occur in the anterosuperior part of the glenohumeral joint with its many normal variants or because they result in more subtle, and therefore easily overlooked changes in morphology or signal intensity.
They try to answer to questions as: What does a normal labrum look like? Can we differentiate normal wear from pathology? Is the labrum always firmly attached to and flush with the glenoid rim? What are the signs of normal superior variants (11 to 1 o'clock)? or normal anterosuperior variants (1 to 3 o'clock)? How can we differentiate from pathology? Are there variants in the other areas: anterior, anteroinferior, and posterosuperior labrum? What shouldn't we miss in patients with recurrent anterior dislocations, with capsulolabral and other lesions, with anterosuperior instability and rotator interval, MGHL and SGHL pathology, with biceps instability.
2. The Chest Radiology sessions are organized by Walter De Wever (Chair of the Chest Radiology Section of BSR) and the Young Radiologist Section (YRS).

The first session on Chest imaging is focused on Pulmonary Embolism and Chest Pain and moderated by Professor Walter De Wever (KUL-UZ Leuven).
He reports that pulmonary embolism is the third most common cause of cardiovascular death among Americans, behind myocardial infarction and stroke. The diagnosis or exclusion of pulmonary embolism as a cause of chest pain remains challenging for emergency physicians. Symptoms can be vague or non-existent, and the clinical presentation shares features with many other common diagnoses. Pulmonary embolism occurs when clots formed in the deep venous system dislodge or break loose, travel through the heart, and become lodged in the pulmonary vascular bed. The microvascular pulmonary bed has also the property to filter other tissue or substance like fat, air, tumor, septic material, organ fragments and foreign material. Also this can result in obstruction to blood flow.

Cornelia Schaefer-Prokop
The first topic on pulmonary embolism and chest pain is presented by Professor Cornelia Schaefer-Prokop (from Amersfoort, the Netherlands). She is radiologist at Meander Medical Centre, Amersfoort, and part-time researcher at DIAG. She has worked as radiologist in Hannover, Germany (1993-1998), AKH Vienna, Austria (1998-2004), AMC Amsterdam (2005-2009, and since 2009 in Meander Medical Centre Amersfoort. Her main research interests are in digital radiography, computeraided detection, pulmonary embolism and interstitial lung diseases. She is editorial board member of European Radiology, Journal of Thoracic Imaging and Insights into Imaging and she is also a member of the Fleischner Society. She is the author of 110 peer reviewed publications (82 referred on PubMed) and editor of two books. She presents a lecture on "Pulmonary Embolism, Subsegmental PE, Incidental PE: Diagnosis and Management".

Benoît Ghaye
The second speaker of this Chest Session is Professor Benoît Ghaye, Head of Clinics in the Radiology Department of the University Hospital Saint Luc (UCL) in Brussels since 2009. His main topic of interest is cardio-thoracic imaging. The topic of his PhD is "acute thrombo-embolic pulmonary disease". He is a member of different scientific societies: ESTI, SIT, SRBR, SFR, RSNA, ESR and he is author of 28 peer-reviewed papers (referenced on Pub-Med and published in international journals as Radiology, Radiographics, AJR, European Radiology, Lancet, etc. He shares his experience on "Non-thrombotic Pulmonary Emboli: Diagnosis and Management" (see abstract).

Rodrigo Salgado
The third speaker is Professor Rodrigo Salgado, senior staff member at the Cardiovascular Imaging Unit of Antwerp University Hospital. He is former president of the Cardiac Imaging Section of the Belgian Society of Radiology and subcommittee board member of the European Society of Cardiac Radiology. He is reviewer for several international cardiovascular journals and member of the Scientific Council of the Belgian Society of Radiology. His current scientific research is focused on CT dose-reduction techniques, time-resolved MRA of vascular malformations and CT imaging of transcatheter heart valves. He has published more than 20 peer-reviewed papers (21 on PubMed) in international journals as Radiographics, AJR, JCAT, Cardiac and Thoracic Journals, etc.
He presents a lecture on "Acute, Not PE-related Chest Pain: Diagnosis and Management" (see abstract).

2.2
The Young Radiologist Section has also prepared a session on Chest Imaging: A Practical Approach, chaired by Astrid Van Hoyweghen and Anne-Sophie Vanhoenacker (YRS members from respectively UZ Antwerp and KU Leuven).
Anagha P. Parkar (from Bergen, Norway) the first speaker of this session is invited by the YRS to present "Differential Diagnosis of Cavitary Lung Lesions".

Anagha Parkar
It is a topic that may be challenging in clinical settings, as there are many differential diagnoses (see paper). Since Anagha is working in the smaller hospital (of two) in Bergen, her presentation will be aimed at the level of trainees and general radiologists. She loves thoracic radiology, but as a "generalist", she has to report on the whole body. Since 2008, she has been consultant radiologist at Haraldsplass Deaconess Hospital, Bergen, Norway. She graduated in 1999 at Ruhr Universität Bochum, Germany, and was certi- He works as an expert one day a week for the 'Fund for occupational diseases', which entitles victims of occupational disease to a financial compensation. These diseases are often characterised by pleural pathologies and thus correspond well to the topic that he presents: "Diseases of the Pleura and Chest Wall", with comparative interpretation of CT and standard radiography of the pleura. Many diseases affect the pleural space in both adults and children, including common diseases such as pneumonia, cancer and heart failure. Pleural effusion is the most common manifestation of pleural disease and it is often a secondary effect of another disease process. Doctor Ilsen emphasizes the crucial role of imaging in the management of pleural disease. Chest radiography remains often the first examination in the assessment of these patients. Depending on the clinical context, the optimal imaging technique for further evaluation might be computed tomography (CT), ultrasound (US) or magnetic resonance imaging (MRI).
The last speakers of this session are Dr Laurent Van Camp and Dr Ward Vander Mijnsbrugge, YRS members. They present an original case-based lecture on "TB or Not TB: A Case-based Quiz".

Laurent Van Camp
Ward Vander Mijnsbrugge

Plenary Session
"The BSR in 2016" An overview of the most important activities is provided by BSR President Professor Geert Villeirs.
Geert Villeirs "Keynote lecture" by Maggie De Block, Federal Minister of Social Affairs and Public Health.
Maggie De Block will deliver a keynote address to all residents and radiologists at the BSR Annual Meeting 2016.
4. In the afternoon an Image Interpretation Session so-called 'Clash of the Titans' is organized by the Young Radiologist Section with the help of the Thorax and MSK Belgian experts and is moderated by Laurens Topff and Naïm Jerjir (YRS/KUL).