RSNA in Review: Mammography, Radiation Dose & iPhones

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© Apple, RadiForce GS521
If the organizers of the 95th Scientific Assembly and Annual Meeting of the Radiological Society of North America even considered the idea of putting together a conference that could skim along quietly underneath the radar, those thoughts ended Nov. 17 when the U.S. Preventive Services Task Force released its controversial revised mammography guidelines.

Radiologists were suddenly front and center of a national controversy just days before the annual meeting began—and the impact of the mammography brouhaha went on to impact the meeting itself. On Wednesday, Dec. 2, the RSNA put together a panel of breast imaging experts, who, in front of the media including crews from several national television networks, harshly panned the recommendations. Grumblings heard throughout the exhibit floor, educational sessions and Chicago nightspots were similar.

Following the task force’s recommendations might save money, said Stephen Feig, MD, a professor of radiology at the University of California Irvine School of Medicine and president-elect of the American Society of Breast Disease, but “we will lose more lives.”

The controversy spilled over into the educational sessions as well. Attendees would have been hard-pressed to find a session on breast imaging in which the mammography recommendations weren’t mentioned.

But, even as this controversy simmered, the rest of the conference rolled along. Altogether, some 1,750 scientific papers in 16 subspecialties were offered, as well as 1,735 education exhibits and 712 scientific papers. And those concerns about attendance that were so apparent last year, dissipated this year as pre-registration for professionals and guests was up by 1 percent.

As far as radiology’s future is concerned, the pressure is on, according to RSNA president Gary Becker, MD. The demand for physician transparency and accountability from patients and their families, insurers, hospitals, quality groups, accrediting organizations, regulators and government is bound to grow. So, Becker told attendees during the opening address of the RSNA scientific sessions, quality improvement will have to be a priority for radiologists.

“If radiologists and all physicians wish to avoid ceding all medical regulations to government and other external stakeholders, we must earn the public’s trust. To maintain a portion of our privilege to self regulate, we will have to deliver quality, affordable care; engage in physician performance assessment and improvement; and demonstrate our outcomes through public reporting,” Becker said.

On the exhibition show floor, the attitude seemed to be one of genuine optimism. Both the booths and floors were crowded and, while there were fewer vendors on the floor this year than in the past, many of them suggested that they were getting solid leads at RSNA 2009 and seeing fewer tire-kickers.

Read on for a synopsis of some key educational sessions.


RSNA Educational Sessions in Review


Radiation revelations revisited
The issue of radiation dose exposure continued to be a top concern at RSNA 2009, as it has the last two years, particularly with the revelation in October that over an 18-month period some 250 patients at Cedars-Sinai Medical Center in Los Angeles had received excessive doses of radiation while undergoing CT brain perfusion scans.

The FDA is investigating whether the radiation exposure problems came from human error or involved problems with CT equipment, and since then has extended its inquiry into two other hospitals in the Los Angeles area, as well as hospitals in other parts of the country.

Researchers at the University of Wisconsin certainly had Cedars-Sinai on their minds as they presented the results of a study they carried out on unnecessary abdominal/pelvic CT imaging. “Radiation exposure has been a hot topic, particularly focusing on unnecessary radiation and over-exposure in patients during CT exams,” said Kristie Guite, MD, a radiation resident at the University of Wisconsin (UW) in Madison, and one of the authors of the study. “I think the recent events at Cedars-Sinai [in Los Angeles] reminds us that we are not doing everything we can to minimize radiation exposure to patients.”

In their study, the University of Wisconsin researchers reviewed a total of 978 imaging series. They found, using the American College of Radiology Appropriateness Criteria, that 345 of those CT series (35.3 percent) were not indicated. According to the researchers, the most common unnecessary exam was delayed-phase imaging (through which several images of the same part of the body are taken within a short period of time after a contrast injection in order to detect changes). This accounted for 268 of the 345 unnecessary exams.

“If we could eliminate these unindicated phases, we could reduce overall radiation dose by 63 percent,” said Guite.

iPhone for diagnosis?
In the hands of a radiologist—and with the installation of the right kind of software—an iPhone can be more than a portable telephone, internet and multimedia device.

According to the results of a study carried out by researchers at Johns Hopkins University, an iPhone equipped with OsiriX mobile software can be used to accurately diagnose acute appendicitis from remote locations. While this wouldn’t be advisable for “formal interpretations,” said Asim F. Choudhri, MD, the study’s principal investigator, the use of a mobile device such as the iPhone could suffice in an emergency.

Five senior radiology residents who were blinded to the diagnosis retrospectively reviewed 25 abdominal and pelvis CT studies performed on patients with right lower quadrant pain. All patients had either surgical confirmation of the diagnosis of acute appendicitis or follow-up clinical evaluation confirming no acute appendicitis. The residents correctly identified 15 cases of acute appendicitis on 74 of 75 interpretations (99 percent), with one false negative. They correctly identified appendicoliths on 35 of 40 interpretations (88 percent).

“We recommend that any diagnosis that is made over the iPhone is confirmed as soon as possible through conventional methods,” Choudhri said. “Currently, it is not used for final diagnosis, but our goal is to expedite the process and assist the surgeon.”

Can mammograms increase cancer odds for high-risk young women?
Could the use of mammography on young women with a familial or genetic predisposition for breast cancer actually increase their chances of getting breast cancer? Marijke Jansen-van der Weide, PhD, from the University Medical Center Groningen in the Netherlands, analyzed peer-reviewed, published medical research and determined that among high-risk women the average risk of breast cancer due to low-dose radiation exposure was 1.5 times greater than that of high-risk women not exposed to low-dose radiation. She suggested that young women with risk factors consider alternative screening methods, such as MRI.

Lowering the need for biopsy in women under 40
Targeting suspicious areas of the breast with ultrasound could reduce the need for biopsies in young women, according to Constance Lehman, MD, PhD, of the University of Washington and the Seattle Cancer Care Alliance. She said the data on the use of ultrasound on women under the age of 40 indicates that “we can be much more reassuring to patients on the very low likelihood of malignancy” in what are most likely benign lesions.

“Because cancer does occur in this age group, ultrasound is a valuable tool in evaluating these regions of focal signs or symptoms in women under 40, because the high sensitivity supports the use of ultrasound over surgical excision of lumps in young women, which is currently a common practice in the United States,” Lehman said. “Ultrasound is a tool that can be used to decrease the harm associated with unnecessary surgery and also decrease the cost associated with unnecessary surgery.”

Elastography goes skin deep
High-frequency ultrasound used with elastography—a technique widely associated with imaging areas like the breast and thyroid—also can be used evaluate skin cancer.

According to study author and presenter Eliot L. Siegel, MD, of the University of Maryland in Baltimore, the rising incidence of skin cancer—about 1 million Americans develop basal cell carcinoma every year—makes this technique particularly relevant. Researchers prospectively imaged 40 patients with proliferative malignant neoplasms or benign skin lesions utilizing an ultra-high frequency sonography system. According to Siegel, the ultrasound and elastographic analysis visualized and quantified the elasticity of the skin and superficial soft tissue lesions with 100 percent accuracy.

“Dermatologists tend to biopsy any lesions that seem visually suspicious for disease,” said co-author and co-presenter Bahar Dasgreb, from the department of dermatology at Wayne State University. “Consequently, many benign lesions are needlessly biopsied to avoid the risk of missing a potentially deadly melanoma.”

In a more traditional use of elastography, Stamatia Destounis, MD, a radiologist at Elizabeth Wende Breast Care in Rochester, N.Y., conducted a study in which she and her colleagues used the technique along with breast ultrasound to measure tissue elasticity to help distinguish between benign and malignant lesions and avoid biopsies. The value of measuring tissue elasticity, she said, is that cancerous tissue is likely to be stiffer than surrounding healthy tissue.

“Elastography could potentially decrease the need to perform a biopsy, or it could reduce the need for increased imaging of benign lesions,” she said, “thus reducing the anxiety and stress on the patient, and also the financial hardship that unnecessary biopsy procedures can cost.”

CT screening: Increasing lung cancer curability, decreasing mortality
While it has long been known that CT screening can significantly increase lung cancer curability, a new study shows that it can significantly reduce lung cancer mortality as well.

“Clearly there’s a relationship between the two, but it’s a complex relationship,” said Claudia Henschke, MD, PhD, of the NewYork-Presbyterian Hospital—Weill Cornell Medical Center.

A comparison group of 8,000 smokers who had baseline CT screening for cancer in New York to an unscreened cohort of 308,000 smokers who were enrolled in the American Cancer Society Prevention Study II found a 36 percent mortality reduction in the group who had baseline CT screening.

One caveat, according to Henschke, mortality reduction only became evident after several years of continual screening, so that it “needs to be understood that to have mortality reduction screening must be continuous.”

Now is the time for IHE, REM and XDS-I profiles
The passage of the American Recovery and Reinvestment Act and the need for institutions to achieve EHR meaningful use standards means that there is a strong need for a certified system that has achieved certain standards, according to David Mendelson, MD, chief of clinical informatics and director of radiology information systems at Mount Sinai Medical Center in New York City. That, Mendelson says, means IHE “has found its moment in time.”

The IHE profiles that also could be finding their moments in time include the Radiation Exposure Monitoring (REM) profile and the profile for Cross-enterprise Document Sharing for Imaging (XDS-I). Eight vendors are already working to adopt REM standard for the automatic capture of radiation dose exposure information during imaging procedures, while the RSNA has just received a contract from the National Institutes of Health to construct an image sharing network involving 300,000 patients.

Speech software introduces errors
While the adoption of speech recognition technology has decreased report turnaround time, it also has been the cause of error in the radiology report. In a study by Zombor Zoltani and colleagues at the University of Maryland, it was found that 68 percent of more than 17,000 finalized reports contained errors, 15 percent of which could have changed the factual meaning of the report.

“Radiologists must vigilantly edit and read each report before sign-off. Further work is needed to reduce errors in SR from both radiologists and SR vendors,” said Zoltani.

In another educational session, Ramin Khorasani, MD, of Brigham and Women’s Hospital in Boston, argued that improving the ability of radiologists to communicate critical results can’t wait for improvements in technology

“We cannot wait for the technology to develop. We need to act now,” said Khorasani, who added that the best way to handle the communication of critical education is to develop a standardized approach, institution by institution so that each can take the necessary action to improve the timeliness of reporting and the speed at which physicians receive results.

But, while technology may not be a “silver bullet,” in improving the reporting of critical results, it can help, said Nabile Safder, MD, of the University of Maryland School of Medicine, in yet another session on critical information reporting.

The future for IT solutions in facilitating critical information communication lies in “master physician indexes,” said Safder, referring to a form of white pages for physicians that provides up-to-date contact information of the physicians, as well as presence technology, a solution that allows users to post his/her availability status to other users.