Good Image Management: Infiltrating Molecular Imaging

The growing interest in nuclear medicine, especially the surge in hybrid imaging, calls for good workflow and plenty of storage. PET/CT and SPECT/CT are changing the way cancer is detected and tracked so vendors of information systems, PACS and software vendors are offering solutions designed to meet the new image management landscape.

It’s really demanding to manage images acquired in nuclear medicine, says Munir Ghesani, MD, clinical director of Nuclear Medicine at St. Luke’s Roosevelt Hospital and Beth Israel Medical Center in New York City.

He points out that most advances in imaging over the past several decades have been in anatomic imaging. Imaging is designed to help physicians see, for example, when a node reaches a certain size and therefore becomes more predictive of cancer. However, “not all lymph nodes involved in cancer are 1 cm or larger,” he says. Adding the molecular imaging component lets clinicians use biomarkers to detect malignant metabolic activity.

That requires equipment that allows for both kinds of imaging in one procedure. PET/CT does just that. Good image management calls for specialized systems that combine both images so that when a clinician is scrolling through image planes, all applicable parameters are available as part of the review.

Revolutionary changes

These changes in detecting and tracking cancer are “so revolutionary” that they have usurped the traditional criteria—based on structural changes—for cancer response, Ghesani says. As a result, Ghesani established a new imaging workflow when his facility installed MIMfusion from MIMvista. Since the images are very memory-intensive—with each requiring about one-quarter of a gigabyte—a smooth system was crucial. Routine image comparison requires that images are saved either on optical disks from the scanner itself or on PACS. Every patient study goes to PACS and physicians read studies right on the PACS and separately review molecular images on another workstation.

Rapid, easy access to studies is vital, Ghesani says. “We have a very elaborate IS group that is always looking for solutions.” IS uses a modular disk format and maintains dedicated storage space for nuclear medicine. As storage space runs out, a new slot becomes available with a new cassette. Given the size of studies, “fortunately, memory is improving and storage is becoming more and more cost effective.”

Martin Satter, PhD, chief physicist for Kettering Health System, based in Dayton, Ohio, uses ThinkingPACS and MDStation for PET and PET/CT image display and processing software from Thinking Systems. Nuclear medicine is independent of the facility’s radiology department and has its own mini-PACS.

The group has three PET scanners and more than two dozen SPECT cameras throughout the Kettering network. That results in about 15 PET scans a day and 60 to 75 nuclear medicine scans a day, Satter says. The nuclear medicine component does not require much in the way of storage. But, once CT was added for hybrid PET/CT imaging, it changed everything. When the group got into whole-body imaging about four years ago and began working with huge CT datasets.

They began seeking a solution for the storage challenge and came across Thinking Systems’ PACS. “They were unique in that they had a PACS component and had image display and analysis software specific to PET imaging—something fairly unique four years ago,” Satter says. The hospital worked with the vendor to create a system that allows for automated traffic control and monitoring of when scans appear on scanners. The system pulls studies off the scanners and sends them for storage and backup as well as distributes them for analysis. All nuclear medicine data are stored and backed up as well.

The hospital did not have enough storage for the nuclear medicine group to add their growing data. Plus, most patients return frequently to check on tumor status. “PET is really a biochemical image on which we can see the effects of treatment sooner, so we needed to keep the data in-house.”

Automated process

Tyson Miller, president of Progressive Technology, an IT consulting firm, worked with Hilton Head Hearts, a three-physician cardiology practice in Hilton Head, S.C., last year. The practice was using a capture station. Once the technologist was done processing images, they were submitted to the viewing station. However, physicians were getting copies on their viewing station where they read studies and printed out reports.

Essentially, “we had too many copies of studies floating around. Physicians frequently were working with outdated studies—a more current copy existed but there was no way to know that.” They had to know the last computer on which the study was worked on to get the more recent report. “We had cases where doctors were finalizing the wrong study.”

Miller wanted to centrally manage images and automate the process of updating studies, even DICOM images. “Numa did that beautifully,” he says. “It sits in the server room and reaches out to all the remote stations and merges all changes together. It keeps one central, global copy of a study as well as revisions so doctors don’t have to worry about where the most recent study is.”

He says the software, NumaStore from Numa, Inc., is “dummy-proof. It’s exactly what we were looking for and hoping for—under-the-hood automated workflow. No matter what workstation someone is on, we can confidently know he or she is working on the latest revision.”

Advice from the field

Comfort with the capabilities of your system is important, says Ghesani. “Don’t settle on something you find is suboptimal.” Proper set-up and protocols are required to avoid having the system populated with misleading information.

He has found that numerous third-party vendors now in the market can help create customized solutions. “Go out and search around,” he recommends.

Miller advises against waiting to improve a poor situation. “This practice hesitated for a long time,” he says, on whether to implement electronic image management. Waiting just makes small problems bigger and bigger. “They just kept dealing with their situation which caused a big mess.”

Satter recommends a single-vendor solution. “PET is still the new kid on the block and it’s very difficult to get components taken care of by separate vendors.” His solution did not originally include auto-pulling and they quickly found that the technologists did not have time to manually push the data to appropriate locations. “In a very short time, Thinking Systems came up with an auto-pull solution that yanks the data as they arrive and distribute them for storage and diagnosis. It’s the glue that puts it all together.”

Separate PACS and image display vendors would make it much more difficult to smooth out those kind of workflow issues, Satter says.