• medical physics summary talk...35:08 shkodra 6/10/2014 - y. lemoigne / ifmp – ambilly –...

Shkodra 6/10/2014 - Y. LEMOIGNE / IFMP – Ambilly – France & CERN-Geneva-Switzerland35:08

• MEDICAL PHYSICS SUMMARY TALK

Y. Lemoigne

P. Altieri

K. Theodorou

C. Cachard

H. Liebgott

D. Miladinova

S. Petkovska

MEDICAL PHYSICS in SHKODRAMEDICAL PHYSICS in SHKODRAMEDICAL PHYSICS in SHKODRAMEDICAL PHYSICS in SHKODRADefinitively Oriented !

What did we learned of What did we learned of What did we learned of What did we learned of Important (Important (Important (Important (…………my opinion!)my opinion!)my opinion!)my opinion!)


Yves LEMOIGNE,Yves LEMOIGNE,Yves LEMOIGNE,Yves LEMOIGNE, PhD IFMP, PhD IFMP, PhD IFMP, PhD IFMP, TERA & CERN, GenevaTERA & CERN, GenevaTERA & CERN, GenevaTERA & CERN, Geneva

1. Ultrasound (C. Cachard, H. Liebgott)

2. CT-scanner (with X-Rays)

3. SPECT

4. PET, PET-CT

5. MRI (Cf. Kyriaki Theodorou)

7. Med. Imaging in Hospital (D. Miladinova, S. Petkosvska)

8. Innovative Therapy with Ultrasound (H. Liebgott)

9. Innovation in Radiotherapy (P. Altieri, K. Theodorou)

MEDICAL PHYSICS was mainly,

MEDICAL IMAGING

with also innovative Therapy (US, Hadrons)

PETCT

Short review of Medical Imaging techniques

Innovative Therapy


1. ULTRASOUND

Christian Cachard & Hervé Liebgott

Lyon, France


Real time imaging

• 10 to 60 frames/s

IN L

IVE

ULTRASOUND (C.Cachard)ULTRASOUND (C.Cachard)ULTRASOUND (C.Cachard)ULTRASOUND (C.Cachard)


ULTRASOUND (C.Cachard)

Longitudinal motion of the carotid artery

wall as a new marker of cardiovascular risk

1

2


Longitudinal motion of the carotid artery wall as a

new marker of cardiovascular risk

(cont’d video)

3

4


Doppler systems building blocks: Doppler systems building blocks: Doppler systems building blocks: Doppler systems building blocks: Doppler systems building blocks: Doppler systems building blocks: Doppler systems building blocks: Doppler systems building blocks:

Pulsed wave (PW) systemsPulsed wave (PW) systemsPulsed wave (PW) systemsPulsed wave (PW) systemsPulsed wave (PW) systemsPulsed wave (PW) systemsPulsed wave (PW) systemsPulsed wave (PW) systems

Transmitter

Flow

·A single transduceracts as transmitter and receiver

Bursts of US energy are transmitted into the body at rate PRF

GateReceiver

Processing

Display

Audiooutput


C. Cachard : EchoC. Cachard : EchoC. Cachard : EchoC. Cachard : EchoC. Cachard : EchoC. Cachard : EchoC. Cachard : EchoC. Cachard : Echo--------Doppler (Duplex) Doppler (Duplex) Doppler (Duplex) Doppler (Duplex) Doppler (Duplex) Doppler (Duplex) Doppler (Duplex) Doppler (Duplex)

examplesexamplesexamplesexamplesexamplesexamplesexamplesexamples

Healthy Common Carotid Artery Stenotic Internal Carotid Artery


10

Example 3D: fetus (movie)

Hervé Liebgott : 3 D Imaging


*

Hervé Liebgott : 3 D Imaging

<=Transesophageal imaging

Transthoracic imaging =>

Courtesy of Lasse Lovstakken (NTNU Trondheim)


12http://keckmedicine.adam.com/

H. Liebgott: Example: insertion of a

catheter for the studies of the coronary

arteries


13

Example: insertion of a catheter

for the studies of the coronary

arteries

Hervé Liebgott:


14

Stent in water(CREATIS) illustration of geometrical artefacts

Stent in a vessel with stenosis (www.vasculardiseasemanagement.com)

Hervé Liebgott:

media4.mp4


15

1) Complex motion visualization: blood flow1) Complex motion visualization: blood flow1) Complex motion visualization: blood flow1) Complex motion visualization: blood flow

Ultrafast

vector flow in the carotid

bifurcation of

a healthy subject

Courtesy of Alfred Yu, Hong Kong University

Hervé Liebgott:

Here reversed or turning flow


16

1) Complex motion visualization: blood flow

Ultrafast vector flow in the carotid bifurcation of a subject with 50% eccentric stenosis

Courtesy of Alfred Yu, Hong Kong University


• Perimembranous ventricular septal defect (significant shunt)

• 36 days old, 4259 gr.

VectorVector--flow imagingflow imagingColorColor--Doppler + vectorDoppler + vector--flowflowColorColor--DopplerDopplerBB--modemode

Image source: Wikipedia, Pat Lynch

LV

LA

RV

1) Complex motion

visualization:

cardiac flow

Courtesy of Lasse Lovstakken, NTNU Trondheim, Norway

Hervé Liebgott:


• Perimembranous ventricular septal defect (significant shunt)

• 36 days old, 4259 gr.

VectorVector--flow imagingflow imagingColorColor--Doppler + vectorDoppler + vector--flowflowColorColor--DopplerDopplerBB--modemode

Image source: Wikipedia, Pat Lynch

LV

LA

RV

Complex motion visualization: cardiac flow

Courtesy of Lasse Lovstakken, NTNU Trondheim, Norway


Photo-acoustic imaging

Optical

imaging

Ultrasound

imaging

Contrast

Resolution > ~ 1 mm

Investigation depth < ~ 5 cm

Functional information

Contrast

Resolution > ~ 100 µm

Investigation depth ~ 10 cm

No Functional information

Contrast (optical abosption)

Resolution of Ultrasound

Depth of investigation

Functional information due to optical absorption

Non invasive, non inonizing

WHY Photo-acoustic imaging?


H. LiebgottH. LiebgottH. LiebgottH. Liebgott: Physical principle: Physical principle: Physical principle: Physical principle

Ultrasound generation with lightUltrasound generation with light

Laser pulseLaser pulseLocal

absorption by

tissues

Local

absorption by

tissues

Thermal

expansion

Thermal

expansionAcoustic

wave

Acoustic

wave

LASER

Optical

absorber


Vascularization

Cancer � abnormal vascularization

In vivo PA image of the hand

vascularization. UCL PA Imaging

Group

H. Liebgott:H. Liebgott:H. Liebgott:H. Liebgott: ApplicationsApplicationsApplicationsApplications

3D photoacoustic imaging of

melanoma in vivo. Zhang

et.al. Nature Biotechnology

2006


OTHER DEVICESOTHER DEVICESOTHER DEVICESOTHER DEVICES


From Craig S Levin. Eur J Nucl Med & Mol Imag. 2005, 32(14), S-325-45

Add the best capabilities of two cameras

Spatial resolution (CT)+ Sensitivity (PET)

Imaging

Modality

Spatial

Resolution (mm)

Acquisition

time per

frame(s)

Molecular

probe mass

required (ng)

Molecular

sensitivity

(mol/L)

Tissue

penetration

depth (mm)

Signal

quantification

capabilities

US 0.05-0.5 (animal)

0.1-1 (clinical)

0.1-100 103-106 Not well characterized

1-300 Low

CT 0.03-0.4 (animal)

0.5-1 (clinical)

1-300 NA Not well

characterized>300 Medium-

High

SPECT 0.5-2 (animal)

7-15 (clinical)60-2000 1-100 10-10-10-11 >300 Medium-

High

PET 1-2 (animal)

6-10 (clinical)1-300 1-100 10-11-10-12 >300 High

PET-CT 0.03-0.4 (animal)

0.5-1 (clinical))

1-300 1-100 10-11-10-12 >300 High

MRI 0.025-0.1 (animal)

0.2 (clinical)0.1-100 103-106 10-3-10-5 >300 High

23(PET-CT from myself)

Next: PET-MRI ?


Restaging gastric cancer

Scan duration: 15 min

5 beds; 3 min/bed; 8s/3i/6F

10.6 mCi; 90 min post-injection

A 52 year-old male patient with history of gastric cancer imaged pre- and post-therapy (after ½ year)

Scan duration: 15 min



Pre-therapy

Post-therapy

Pre-therapy (4/06) Post-therapy (10/06)With Biograph

½½½½ year Post / Pre treatment Surveyyear Post / Pre treatment Surveyyear Post / Pre treatment Surveyyear Post / Pre treatment Survey

6 monthslater

* *

Example in help for PostExample in help for PostExample in help for PostExample in help for Post----treatment surveytreatment surveytreatment surveytreatment survey


SURVEY : Vaginal cancer

A 50 year-old female patient restaged for vulvar cancer with history of NHL (Non-

Hodgkin lymphoma),. The PET/CT scan shows focal uptake in right aspect of the vulva (SUV: 10.3). Adjacent focal anorectal uptake (SUV: 5.5). CT is negative with no abnormality seen. Only combination of CT and PET can show that!

Biograph Scan duration: 15 min



CT only

PET+CT

PET only

PETPETPETPET----CT is more powerful than PET aloneCT is more powerful than PET aloneCT is more powerful than PET aloneCT is more powerful than PET alone…………....

*


EVOLUTION in MEDICAL IMAGINGEVOLUTION in MEDICAL IMAGINGEVOLUTION in MEDICAL IMAGINGEVOLUTION in MEDICAL IMAGING(combination of existing equipment)(combination of existing equipment)(combination of existing equipment)(combination of existing equipment)

ToToToTo

REVOLUTIONREVOLUTIONREVOLUTIONREVOLUTION in MEDICAL IMAGING in MEDICAL IMAGING in MEDICAL IMAGING in MEDICAL IMAGING @Hospital @Hospital @Hospital @Hospital !!!!

(Integrated devices only possible from (Integrated devices only possible from (Integrated devices only possible from (Integrated devices only possible from recent technical developments)recent technical developments)recent technical developments)recent technical developments)


Combined whole-body PET/CT to PET/MR..

PET/CT

PETPETPETPET CTCTCTCT

PET

MDCT

PET

PET/MR

PET MR

(S.R. Cherry,

Magnet

Magnet

PET

PET

MRMRMRMRPETPETPETPET

=> Patient is moved

=> No patient movement

High Field Magnet

High Field Magnet


EVOLUTION in MEDICAL IMAGING(combination of existing equipment)

Data taken at different time / in different configuration / in different places…

Fusion only by software

Data taken at sequential time / with minimal movement of patient

Fusion by software

CT PETExample:

movement


(same hardware)

REVOLUTION in MEDICAL IMAGING !(Integrated devices from technical developments)

Example: MRT PET

No movement !

REVOLUTION is simultaneous Acquisitions without patient deplacement !!


MAGNETIC RESONANCE IMAGING

Cf. Talk of Kyriaki TheodorouInside the exceptional performance of this method:

- Excellent spatial resolution (ok for anatomy)

- No Radiation (only Noise unfortunatly…)

- Any type of contrast availlable

- Functional imaging : Two exemples:• Diffusion Weighted Imaging (DWI), Diffusion Diffusion Weighted Imaging (DWI), Diffusion Diffusion Weighted Imaging (DWI), Diffusion Diffusion Weighted Imaging (DWI), Diffusion Tensor Imaging (DTI)Tensor Imaging (DTI)Tensor Imaging (DTI)Tensor Imaging (DTI)=> Fiber Tracking=> Fiber Tracking=> Fiber Tracking=> Fiber Tracking

• Spectroscopy capability:Spectroscopy capability:Spectroscopy capability:Spectroscopy capability:With MRS, MR has impressive results to ANALYSE IN-VIVO what molecules are present inside the body (Only MR can do that so well…)=> Powerful tool for diagnostic


6/10/2014 Kiki Theodorou 31

MRI – Advanced Techniques

Diffusion Weighted Imaging (DWI)

The measurement of the degree of diffusion anisotropy can yield useful biological information on the tissue’s microstructure, e.g. degree of myelination.

An ordered structure has

predominantly a left–right orientation.

These inferences are entirely consistent

with the fibers of the corpus callosum,

which passes through this region.

�ADC is rotational variable

�A single ADC is inadequate for characterizing diffusion

Apparent Diffusion

Coefficient (ADC)



MRI – Advanced Techniques

Diffusion Tensor Imaging (DTI)

Xue R., et.al., Magn. Reson. Med. 42 (1999), 1123–1127

=> Fiber Tracking



ANALYSE IN-VIVO what molecules are presentinside the body (Only MR can do that so well…)

=> Powerful tool for diagnostic (cf. LL, or 3.8 peaks.)


For about 10% of severe cases which cannot For about 10% of severe cases which cannot For about 10% of severe cases which cannot For about 10% of severe cases which cannot

be treated by gamma Photons:be treated by gamma Photons:be treated by gamma Photons:be treated by gamma Photons:

• Radioresistive cellsRadioresistive cellsRadioresistive cellsRadioresistive cells

• Pediatric cancerPediatric cancerPediatric cancerPediatric cancer

• Very difficult configuration of tumor Very difficult configuration of tumor Very difficult configuration of tumor Very difficult configuration of tumor

Example: Proximity of Cave vein in leaverExample: Proximity of Cave vein in leaverExample: Proximity of Cave vein in leaverExample: Proximity of Cave vein in leaver

INNOVATIVE RADIOTHERAPY =INNOVATIVE RADIOTHERAPY =INNOVATIVE RADIOTHERAPY =INNOVATIVE RADIOTHERAPY =

HADRONTHERAPYHADRONTHERAPYHADRONTHERAPYHADRONTHERAPY

Talks from : Palma Altieri, Kiki Theodorou


35

P. Altieri: PHYSICAL BASICS Hadron TherapyHadron TherapyHadron TherapyHadron Therapy

Treatment of tumors through external irradiation by means of

accelerated hadronic particles:

neutrons, protons, pions, antiprotons, helium, lithium, boron,

carbon and oxygen ions. Protons and heavy ions (particles with mass greater than helium)

have physical properties, and so radiobiological effects, such that:

1.high and conformal dose is delivered to the tumor target;

2.minimazing the irradiation of healthy tissue.

HadronsPhotons

Ionization density Effect on cellular DNA

Double strands that make up the DNA helix


P. Altieri:BIOLOGICAL BASICS

36

DX-rays

Dparticle

RBE =

Relative Biological Effectiveness (RBE)

RBE depens on many factors:

• energy;

• particle type;

• organ dimensions;

• tissue type;

• presence of oxygen.

hadrons more biologically effective than

photons: lower dose is required to cause the

same biological effect


37

Physical advantages :

� finite range and high

ionization density;

� lower integral dose;

� small lateral scattering

(larger flexibility).

TC image: dose distribution calculated for

proton beams and X-rays.

Protons vs photons P. Altieri: BIOLOGICAL BASICS

Clinical advantages :

� treatment of deep-seated, irregular

shaped and radioresistant tumors;

� small probability of side effects in

normal tissue (critical structrure);

� proton therapy suitable for

pediatric diseases (reduced toxicity).


Greek Hadrontherapy project

Kiki TheodorouKiki TheodorouKiki TheodorouKiki Theodorou



Cancer Facts – Epidemiological Data in EU

Efficiency of detection

95%

80%

70%

30%

Or less ?

YL comment : These figures have to be weighted by efficiency of detection by each National Health Service:

it is only my guess

to be verified. (YL)



Hadron Facility in Greece - Feasibility

Existing Infrastructure

� 1.5 M people immediate health coverage

� 3ry care University Hospital

� Medical School

� Institute for Research & Technology



CERN

Medical

School

I.R.E.TH

NTUA

Industry

Funding

agencies

Biologists

Engineers

DoctorsPolicy

makers

Physicists

& Medical

physicists

Epidemiologists

Need Multidisciplinary / Collaboration


MEDICAL PHYSICS IN MEDICAL EDUCATION AND

HOSPITAL SETTINGS

Daniela Miladinova, MD PhD

Nikola Jankulovski, MD PhD

Faculty of Medicine, University Ss Cyril and Methodius

International Conference on LHC, Astrophysicis, Medical and Environmental Physics

Shkoder, 8th October 2014

Med Phys @ University & HospitalMed Phys @ University & HospitalMed Phys @ University & HospitalMed Phys @ University & Hospital


Nowadays, UKIM through figures is: around Nowadays, UKIM through figures is: around 60.000 enrolled students 60.000 enrolled students from Republic of from Republic of Macedonia in first and second cycle of studies, as well as over Macedonia in first and second cycle of studies, as well as over 700 foreign students700 foreign students. The . The third cycle doctoral studies is realized within the School of third cycle doctoral studies is realized within the School of doctoral studies with more doctoral studies with more than 600 studentsthan 600 students..

More than 3100 teaching, research, associate as well as administMore than 3100 teaching, research, associate as well as administrative staffrative staff


FACULTY OF MEDICINEFACULTY OF MEDICINEFACULTY OF MEDICINEFACULTY OF MEDICINEFACULTY OF MEDICINEFACULTY OF MEDICINEFACULTY OF MEDICINEFACULTY OF MEDICINE

ORGANIZATIONAL STRUCTUREORGANIZATIONAL STRUCTUREORGANIZATIONAL STRUCTUREORGANIZATIONAL STRUCTUREORGANIZATIONAL STRUCTUREORGANIZATIONAL STRUCTUREORGANIZATIONAL STRUCTUREORGANIZATIONAL STRUCTURE

•• 34 Departments/Cathedras34 Departments/Cathedras

•• 12 Institutes12 Institutes--full time full time employeedemployeed at the Faculty of at the Faculty of MedicineMedicine

•• 24 University Clinics 24 University Clinics –– part time part time employeedemployeed at the at the Faculty of Medicine Faculty of Medicine

•• 10 Affiliated Educational Institutions (10 Affiliated Educational Institutions (--Institute of Institute of public health)public health)

•• 2 Centers (Center for public health and Center for 2 Centers (Center for public health and Center for family medicine) family medicine)



FACULTY OF MEDICINEFACULTY OF MEDICINEFACULTY OF MEDICINEFACULTY OF MEDICINEFIRST YEAR OF STUDIESFIRST YEAR OF STUDIESFIRST YEAR OF STUDIESFIRST YEAR OF STUDIES

• Anatomy 1 & 2

• Biophysics

• Hospital care

• Medical chemistry

• Medical psychology

• Histology and

embriology 1 & 2

• Introduction to

medicine and medical

professions

• Social medicine

• Cell morphology and

physiology

• Medical ethics

• Basics in human

genetics

• First aidDaniela Miladinova, MD PhD


-NUCLEAR MEDICINE (mandatory in 3rd y. with 1.5ECTS)

-RADIOLOGY RADIOLOGY RADIOLOGY RADIOLOGY

(mandatory in 3rd y. with 3.5 ECTS)(mandatory in 3rd y. with 3.5 ECTS)(mandatory in 3rd y. with 3.5 ECTS)(mandatory in 3rd y. with 3.5 ECTS)---- RADIOTHERAPY AND ONCOLOGYRADIOTHERAPY AND ONCOLOGYRADIOTHERAPY AND ONCOLOGYRADIOTHERAPY AND ONCOLOGY---- GRADUATE MEDICAL NURSE/TECHNICIANGRADUATE MEDICAL NURSE/TECHNICIANGRADUATE MEDICAL NURSE/TECHNICIANGRADUATE MEDICAL NURSE/TECHNICIAN---- SPEECH AND LANGUAGE THERAPISTS SPEECH AND LANGUAGE THERAPISTS SPEECH AND LANGUAGE THERAPISTS SPEECH AND LANGUAGE THERAPISTS ---- PHYSIOTHERAPISTS PHYSIOTHERAPISTS PHYSIOTHERAPISTS PHYSIOTHERAPISTS ---- RADIOLOGICAL TECHNOLOGISTS RADIOLOGICAL TECHNOLOGISTS RADIOLOGICAL TECHNOLOGISTS RADIOLOGICAL TECHNOLOGISTS -------- POSTGRADUATE STUDIES (in medical nuclear POSTGRADUATE STUDIES (in medical nuclear POSTGRADUATE STUDIES (in medical nuclear POSTGRADUATE STUDIES (in medical nuclear physics) physics) physics) physics) ---- APPLICATIVE PHYSICS IN CLINICAL PRACTICE (in APPLICATIVE PHYSICS IN CLINICAL PRACTICE (in APPLICATIVE PHYSICS IN CLINICAL PRACTICE (in APPLICATIVE PHYSICS IN CLINICAL PRACTICE (in nuclear medicine) nuclear medicine) nuclear medicine) nuclear medicine) ---- APPLICATIVE PHYSICS IN CLINICAL PRACTICE (in APPLICATIVE PHYSICS IN CLINICAL PRACTICE (in APPLICATIVE PHYSICS IN CLINICAL PRACTICE (in APPLICATIVE PHYSICS IN CLINICAL PRACTICE (in radiotherapy)radiotherapy)radiotherapy)radiotherapy)



Institute of Institute of Institute of Institute of PathophysiologyPathophysiologyPathophysiologyPathophysiologyandandandand Nuclear MedicineNuclear MedicineNuclear MedicineNuclear Medicine

• 2 experienced

physicists,

spec.

in medical

nuclear physics

6 grad.radiologic

technologies



University Clinic of Radiotherapy and University Clinic of Radiotherapy and University Clinic of Radiotherapy and University Clinic of Radiotherapy and OncologyOncologyOncologyOncology

• 4 specialists

• 1 on

specialization

• 5 physicists



M E D I C A L P H Y S I C S M E D I C A L P H Y S I C S

inininininininin private clinical practiceprivate clinical practice

Sonja Petkovska

ACIBADEM SISTINA Clinical Center

Shkoder 2014

What does it take to become a Medical Physicist?What does it take to become a Medical Physicist?

To be a medical physicist, you should:

have a high level of ability and interest in physical sciences and computing

have an interest in medicine and in the development of new methods of

patient care and treatment be accurate, able to concentrate for long

periods, and have a high level of attention to detail


have high ethical standards and the ability to take responsibility for making

Decisions have an enquiring mind and good problem solving skills to lead

a research and development teamhave excellent oral and written

communication skills be able to reassure nervous patients.

Sonja Petkovska


25-Oct-14

What does a Medical Physicist doWhat does a Medical Physicist doWhat does a Medical Physicist doWhat does a Medical Physicist doWhat does a Medical Physicist doWhat does a Medical Physicist doWhat does a Medical Physicist doWhat does a Medical Physicist do??

• apply the principles of physics to patient care

• work closely with doctors and other professionals to assess and treat

ill health

• research, design and develop techniques and equipment used by

medical staff to diagnose and treat patients (alongside other specialist

physicists, clinical engineers and technical staff.

Shkoder 2014 Slide 50


To be a medical physicist, you should:

have a high level of ability and interest in physical sciences and Computing

have an interest in medicine and in the development of new methods of

patient care and treatment be accurate, able to concentrate for long periods,

and have a high level of attention to detail.

have high ethical standards and the ability to take responsibility for making

decisionshave an enquiring mind and good problem solving skills to lead a

research and development team have excellent oral and written communi-

cation skills be able to reassure nervous patients

Sonja Petkovska


FAREWELL

• medical physics summary talk...35:08 shkodra 6/10/2014 - y. lemoigne / ifmp – ambilly –...

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