Robert Lavayssiere, MD

Diffusion MRI came under the microscope in Dr. Denis Le Bihan's plenary lecture at the French national congress, les Journées Françaises de Radiologie (JFR), held in Paris in October.

Le Bihan is the founding director NeuroSpin, an institute of the French Commissariat à l'Energie Atomique, which develops and uses ultrahighfield MR to understand the brain. Over the past quarter century he has helped to introduce into research and clinical practice the concept of diffusion MRI.

Diffusion MRI is used to study normal and diseased brain anatomy and function, as well as brain wiring, from the measurement of molecular motion, in particular water molecules, in biological tissues. The technique has been adopted by MR vendors, and is now widely used for both basic research and clinical applications, especially in acute brain ischemia, white matter diseases, and connectivity disorders.

As mentioned by other speakers during the congress, Le Bihan's work has paved the way for diffusion to be used outside the brain. Diffusion imaging of the body (ear, nose, and throat; chest; abdomen; and pelvis) should eventually become a very powerful tool that is not yet fully understood or utilized.

The development of functional MRI has changed the way we study the human brain, giving access to the neural networks underlying complex cognitive functions such as language, mental imagery, and even consciousness, according to Le Bihan. He added that water, an apparently simple substance, keeps a lot of secrets.

La Société Française de Radiologie (SFR), now with Prof. Jean-Pierre Pruvo as general secretary, used its annual congress to unveil a new look LA SOCIETE FRANCAISE DE RADIOLOGIE LAUNCHES NEW WEBSITE TO COINCIDE WITH CENTENARY French congress celebrates 25 years of diffusion MRI's revolution in brain anatomic and functional imaging for its website (

). To mark SFR's centenary in 2009, it has redesigned the site in an attempt to make it more functional and better suited to respond to the challenges of tomorrow.

One element of SFR's strategy is to reach out more to the general public and to promote better understanding of the relationship between patients and radiologists. The society is currently conducting an online survey about patients' experiences and perceptions of imaging examinations, and is urging patients to take part in a “grand public consultation.” Via the SFR website, where patients are invited to answer a series of multiple choice questions on topics such as the general conduct and availability of the radiologist, the anxiety caused by the examination, and acceptability of the waiting time for the results.

For the first time at JFR, members of the public could attend an open session about the real benefits of interventional radiology. The 60-minute session was held at lunchtime on Saturday Oct. 17 in the grand amphitheatre of the Palais des Congrès; the objective was to promote greater understanding and awareness of interventional radiology.

The three honorary members of JFR '09 were Dr. Fred Avni from Brussels, Dr. Ricardo Garcia Monaco from Buenos Aires, and Dr. Michel Lafortune from Montreal. Prof. Georges Charpak, who received the Nobel Prize in Physics in 1992 for his invention and development of particle detectors at CERN (European Organization for Nuclear Research), received the gold medal at JFR '09, while Profs. Jean-Michel Bruel, Francis Joffre, and Alain Roche were honorary medalists. Medals were presented by SFR president Prof. Philippe Devred.

Some delegates expressed surprise that no government officials attended JFR '09. French radiology still appears to be under attack, and a new wave of fee reductions has been announced. Another concern is that the training system is now producing more public healthcare specialists than radiologists (about 85 a year, compared with 70), yet clinical workloads continue to increase. Shifting imaging into the hands of other specialists is a real threat. The next JFR will take place from 22 to 26 October 2010 at the Palais des Congrès, Porte Maillot, Paris.

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French congress celebrates 25 years of diffusion MRI’s revolution inbrain anatomic and functional imaging

For years, the world of breast imaging was quite simple. Screen-film mammography and ultrasound did not leap ahead, but they did a satisfactory job for most women. In the past few years, the armamentarium has exploded, with the introduction of modalities from MRI to vacuum biopsy. The management of breast disease has changed significantly.

Digital mammography has raised controversy in Europe and the U.S., especially in the screening field. Initial acceptance was quite slow, and the results of some papers were keenly contested, mainly because the gold standard, screen-film mammography, is far from perfect. Both techniques miss some cancers but not necessarily of the same type.

The American College of Radiology Imaging Network (ACRIN) study enrolled about 49,500 women and represents a milestone in digital mammography's history.

 The initial results suggest there is a slight benefit for women with dense breasts and no clear advantage against screen-film mammography in others, digital mammography being at least equal to SFM. The open Oslo studies enrolled more than 30,000 women and showed some other advantages-lower recall rate, better specificity in certain cases, and lower dose exposure-with marginal overall superiority for digital mammography.

Meanwhile, the debate over screening continues. A survey presented at the SOFMIS (La Societe Francaise de Mastologie et d'Imagerie du Sein) conference in June showed that screening was not uniform in the world.

 Only nine national screening programs exist in 25 EU countries, with wide differences in terms of age at screening, periodicity, second reading, and quality control. In some federally organized countries, screening may or may not exist, and it can differ from a linguistic or regional point of view (county/lander/canton). Variations also occur in heavily centralized countries. The age at which screening begins ranges from 40 to 50, and the age at which it ends differs from 69 to 74.

Kopans has shown how information can be manipulated, even by highly respected peer-reviewed journals.

 This leads to biases in the analysis of the results of screening campaigns and inaccurate information, notably about starting screening at the arbitrary age of 50. In France, the age for initial screening is 50, but we find nearly as many cancers in a population aged 45 to 50 as in the 50 to 55 range, and no age is specified for women with dense breasts, even without hormonal replacement therapy.

In the U.S., digital mammography accounts for 8% to 10% of the installed base. In May 2006, 865 of the 8879 accredited breast centers had 1210 digital systems. The results of the Mammography Quality Standards Act published by the Food and Drug Administration show a clear trend toward digital mammography, with a steep decline of SFM accreditation and a clear increase of digital mammography accreditation. Digital mammography was approved in 2000. Medicare has accepted some extra payment for digital mammography ($135.29 versus $85.65), as well as for computer-aided detection ($19.17), but the market remains quite sluggish as buyers wait for more evidence. The ACRIN trial triggered a great deal of interest from the general public, and coverage appeared in numerous newspapers. Many Web sites, including those of the National Cancer Institute and the Susan G. Komen Breast Cancer Foundation, are warning women not to defer their screening exams by waiting for digital mammography.

In Europe, the situation is complex because some countries are still conducting investigational studies. Some have closed pilot studies and are moving toward digital screening, and in most countries, except France, both techniques are now allowed for screening. According to some experts in the SOFMIS survey, Pisano's paper has prompted a strong tendency toward digital screening in Europe,

 but there are no national digital screening programs. In the Netherlands, the digital program has been postponed until 2007.

Controversy about economics also persists, but very few papers are available on this topic. There are many ways of conducting a screening mammography program, and uniformity is lacking. A Swedish pilot study showed it was possible to screen 20,000 women a year and conduct 4500 diagnostic studies with a single digital full-field mammography unit staffed by two radiologists with five radiographers.

 A U.K. study that was conducted in 2004 that was performed with two different FFDM systems concluded that digital mammography was nearly as cost-effective as SFM when using soft-copy reading only with digital archiving.

Like it or not, breast screening mammography is going digital. Many factors account for this trend, including increased pressure from industry and growing scientific evidence and public awareness. The digital equipment market is expected to grow annually by 10% to 12% for the next five years. The financial benefits still must be proven, and the organizational approach has to be modified greatly to take advantage of innovations such as digital mass storage and image distribution, as well as data-mining (eDiamond project) and the National Digital Mammography Archive. Some issues remain unresolved, but the move toward digital mammography screening looks set to change screening practice.

DR. LAVAYSSIERE is a private-practice radiologist in Sarcelles, France.

 Pisano E, Gatsonis C, and Hendrick E. Diagnostic performance of digital versus film mammography for breast-cancer screening. NEJM 2005;353(17):1773-1783.


 Skaane P and Skjennald A. Screen-film mammography versus full-field digital mammography with soft-copy reading: randomized trial in a population-based screening program-the Oslo II Study. Radiology 2004;232:197-204.


 Lavayssiere R. Revue des experiences etrangeres de depistage numerique. SOFMIS, Clermont-Ferrand, France, 2-3 June 2006.


 Kopans DB. Informed decision making: age 50 is arbitrary and has no demonstrated influence on breast cancer screening in women. AJR 2005;185:177-82.


 Heddson B. A complete digital workflow at the breast unit, Helsinborg Hospital, Sweden. EUSOBI, Vienna, 1-2 March 2006.


 Legood R, Gray AM. A cost comparison of full field digital mammography (FFDM) with film screen mammography in breast cancer screening. NHS Breast Screening Programme Equipment Report 0403. February 2004. Sheffield, NHS Cancer Screening Programmes.

Digital mammography begins to deliver hope

I entered private practice on a full-time basis in 1984, having quit my position in a state-run general hospital following a disagreement over lack of funding for continuing medical education. The imaging center that I joined had just been granted permission to buy a CT scanner. This would not be news today. But 20 years ago, establishment of a private CT center in Sarcelles, a suburban town 15 km north of Paris, was news indeed. CT scanners were scarce in France, and procedures required users to attain a certificate of need, which was a very cumbersome process.

We initially received CT referrals from eight districts in the greater Paris area, covering 10 million inhabitants. Some patients we scanned on our "medium range" system had been referred from university hospitals. Our catchment area today is much more local, and patients are examined on a 16-slice scanner.

Our center also became the first private practice outside of Marseilles, and the third in France, to install an MR imaging unit. The 0.5T scanner arrived in July 1987. When we came to upgrade the system a few years later, we faced problems with our request to purchase a higher field system. French health authorities, it seemed, wanted to limit the availability of 1T (and higher field strength) scanners to university hospitals. Our appeal eventually brought the necessary permission, and we were able to buy a 1T scanner.

We currently work with a 1.5T scanner and would like to buy a second MR system. Permission will be granted only if we can satisfy a regional committee, comprising administrators and union representatives, of our need. Making a strong case for medical matters in such a somber courtlike environment is not always easy. We can only hope that the decision has not already been made before we begin our plea.

The number of mammography and breast workup procedures we perform at Sarcelles has increased markedly as well over the past two decades. This higher workload prompted creation of a full senology department, equipped with digital and screen-film mammography systems, ultrasound, and a stereotactic vacuum biopsy unit. Unfortunately, digitalmammography is not reimbursed by the state in France, although reimbursement of stereotactic biopsies was introduced in February 2005.

The switch to soft-copy workflow has been a memorable adventure. We have worked with four different RIS purveyors over the past 18 years. The first supplier went out of business, the second maintained our installed base but did not develop the software, and the third lasted a little longer but was killed by the development of PC-based networks. Our current supplier appears to be on solid ground, but we shall wait and see. We are on our second PACS. Budgetary limitations prevent further upgrades at present, though prices continue to fall and performance is improving. The French government provides no financial incentives to purchasing a RIS or PACS, despite its stated objective of achieving nationwide electronic medical records in 2006/2007.

The latest addition to our center's imaging armamentarium is a hybrid PET/CT scanner. We received permission to acquire PET/CT in April 2002, and the system arrived four months later and was installed next to an in situ cyclotron. Radiologists receive no reimbursement for reporting PET/CT procedures at present, so the CT images are read by a nuclear medicine specialist with no explicit radiological training.

Our medical imaging center has thrived over the past 20 years and kept up with advances in technology. Of course, the center would be nothing without its patients, who are drawn from the diverse, multiracial population of Sarcelles. Today's average patient is much more demanding and informed than ever before but is still unwilling to pay for even the most state-of-the-art imaging studies. The number of plaintiffs is also increasing.

I confess that I never envisioned all the administrative work and financial issues that form part of private practice radiology. The apparent war between public and private healthcare sectors is needless. Figures showing the wealth earned by French private radiologists are usually misleading. Prejudice against private practitioners using top-end equipment is also nonsense.

Debates about economics and medical imaging are likely to go on. It can sometimes seem as if we radiologists have been struggling against the same problems for the past 20 years. The battle will continue, regardless of new rules or reforms that make it increasingly difficult to retain technical and financial control of our specialty. But whatever the future brings, the prospect of further innovations suggests that a career in radiology will remain as exciting as ever.

DR. LAVAYSSIERE is a private-practice radiologist in Sarcelles, France. He has been a member of DI Europe's Editorial Advisory Board since 1987.

Robert Lavayssiere, MD

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