Reflections on RSNA 2010: Radiation Dose, Workflow, Collaboration & PET/MR
The pre-show buzz for the 96th annual scientific meeting of the Radiological Society of North America (RSNA) amounted to a near crescendo. And the world’s largest medical meeting certainly didn’t disappoint; RSNA 2010 will be remembered for a long list of highlights.

A top few include:
  • New insights into the CT dose debate, complemented by vendor advances in dose reduction software and hardware;
  • A stampede of iPad apps;
  • The birth of a new hybrid molecular imaging modality;
  • The pairing of  meaningful use and medical imaging; and
  • A renewed commitment to clinical collaboration, conversations and quality.

Even in a tough financial climate, optimism was in the air. RSNA President Hedvig Hricak, MD, PhD, chair of radiology at Memorial Sloan-Kettering Cancer Center in New York City, claimed the opportunities for imaging have never been greater and identified new opportunities in the era of personalized medicine:
  • Molecular imaging, as a new developing radiology subspecialty;
  • Integration of imaging and pathology;
  • Biology-driven intervention for diagnosis and treatment with gene-expression holding the potential to reduce “blind” biopsies; and
  • Theranostics, which combines targeted imaging and targeted therapy, and may better determine mixed responses to therapy within tumors.
Other indicators suggested that the economic gloom and doom that pervaded the last two years may be waning. Clinical leaders are in the market for new technology as vendor leads across the board exceeded last year’s mark, signaling the jump start radiology has been expecting. RSNA 2010 professional attendance outpaced 2009 figures by nearly 5 percent, and total attendance nearly topped the 60,000 mark. Read on for a condensed version of highlights of radiology’s annual show and revisit for additional features.

Appropriateness criteria in question

The need for radiologists to collaborate with clinical partners is crystal clear and was well-reinforced at RSNA 2010. A few of the new faces in the crowd were those of referring physicians who offered revealing insights into their needs. Apparently, one size does not fit all.

While surgeons and oncologists want the big picture (preferably in the form of structured reports), emergency physicians want concise, rapid fire results sans suggestions for follow-up studies. Clinical panelists reinforced the role of radiologists as an integral member of the clinical team. However, they expressed conflicting opinions about the value of American College of Radiology (ACR) Appropriateness Criteria.

Every family physician needs to see the ACR Appropriateness Criteria, according to Robert W. Bales, MD, MPH, assistant professor, family and community medicine, University of Illinois College of Medicine, Rockford. In the pro-appropriateness criteria model, clinician knowledge and use of appropriateness criteria fosters collaboration and helps radiologists and referring physicians to work together to improve patient care.

In contrast, Jeffrey G. Graff, MD, head, emergency medicine, NorthShore University Health System, in Chicago, was less certain of the utility of ACR Appropriateness Criteria for ED physicians. “I had never heard of it. I found it fascinating but not very useful for what I do. All these criteria look at populations not individual patients. I look at patients and make informed decision based on patients,” he said.

Minnesota and meaningful use

As the ACR and other professional societies focus on dissemination of appropriateness criteria and clinicians debate the merits of the criteria, others are putting them into practice and reporting compelling results. Take, for example,  the state of Minnesota. In bypassing prior authorization in favor of ACR decision support criteria for ordering CT, MRI and other scans, the state saved $28 million in healthcare costs and halted the growth of imaging among 2,300 providers.

As Minnesota counted its dollars, RSNA panelists identified other potentially untapped funds for cash-strapped radiology practices. Modifications to meaningful use criteria, in fact, allow most radiologists to qualify for significant financial incentives to encourage health IT adoption. With the recent passage of the U.S. Federal Health IT rulings for meaningful use, it is estimated that more than 90 percent of all U.S. radiologists will be eligible for substantial Centers for Medicare & Medicaid Services’ (CMS) incentives. Collectively, these incentives total more than $1 billion for radiologists. More specifically, for large practices, these incentives will approach $10 million.

It’s likely that funds aren’t destined for doctors’ pockets, but rather for IT investments. However, a few dollars might make their way toward one of 2010’s hottest selling items. Can you say iPad? Robust screen resolution for CT and MRI, solid encryption measures and new radiology vendor apps render the iPad (Apple) suitable for CT and MR image reading and “help combat the trend of decreasing radiologist-patient and -clinician interaction,” according to Toshi Clark, MD, radiology resident at Nassau University Medical Center in East Meadow, N.Y., who presented the findings at RSNA.

iPads do represent a handy arrow in the much-needed quiver to help radiologists boost their collaborative value, which was an oft-repeated theme at RSNA 2010. In the “Saving our Profession: How Radiologists Can Thrive in Challenging Times Ahead” session, Bruce J. Hillman, MD, scientific affairs director for the ACR Medical Advisory Panel, opined that radiologists should reassume their roles as consulting physicians and spend more time with patients as well as referring physicians.

Indeed, a trek through the technical exhibits included a few iPad-based works-in-progress that address clinical collaboration, cost-cutting and efficiency. A few vendors touted mobile apps to enable image and report review and “drive” radiology reading and report workflow.

From pocket-size to grand

Other highly anticipated launches at RSNA 2010 included the first whole-body PET/MR systems in two flavors—sequential and simultaneous scanning. Sequential hybrid PET/MR scanning may be a more effective way of acquiring PET and MRI data in cases where both datasets are needed, offered Osman

M. Ratib, MD, PhD, chair of radiology and head of nuclear medicine at University Hospital of Geneva in Switzerland. Preliminary clinical results of whole-body sequential PET/MR imaging in oncology indicate the hybrid modality may be comparable to PET/CT and useful in certain types of cancer. Applications under investigation include locating distant metastases in head and neck cancers, detecting prostate cancer recurrence and screening for breast cancer metastases.

Another approach to hybrid PET/MR imaging, simultaneous scanning, incorporates an integrated architecture and can scan the entire body in 30 minutes for the combined exams, according to initial research. Simultaneous PET/MR scanning offers the potential to identify neurological, oncological and cardiac conditions and support planning of appropriate therapies. Clinical applications include the early identification and staging of malignancies, therapy planning (including surgical planning) and therapy control. The first commercial systems are expected to hit the market in 2011.

CT dose: Consensus & calculations

It was nearly impossible to wander through McCormick Place without hearing mentions of CT radiation dose. Whether the topic was the National Lung Cancer Screening Trial, screening mammography or fluoroscopy, radiation dose wrangled its way into many conversations, educational sessions, panel discussions and vendor presentations.

Optimization has become an operative term in CT imaging. A debate about the point—cancer induction should not be a consideration in ordering a medical imaging study—might have ended in blows. Instead it ended with a high five when an expert panel agreed that CT scans should be limited to justified and optimized studies, during the “Radiation Dose: Can it be Too Low”  session. The right dose for the patient is the lowest dose possible at sufficient image quality.

Panelists urged radiologists to temper the radiation risk debate by also focusing on the known benefits of CT. Despite the consensus among panelists, an informal poll of the audience at the end of the session revealed that the issue was not resolved, with the group evenly split on the questions of considering cancer risk in ordering CT studies.

Recognizing the public relations challenge, RSNA and ACR joined forces with the American Association of Physicists in Medicine (AAPM) and the American Society of Radiologic Technologists (ASRT) to launch a task force and create the Image Wisely campaign to raise awareness about limiting radiation exposure in adults. As of December, nearly 1,500 professionals signed a pledge to optimize the use of radiation during imaging.

Vendors are doing their part, as well, with all major CT system makers touting advances in adaptive statistical iterative reconstruction technology and referencing potential CT dose reductions in the 50 percent range. However, iterative reconstruction is in its infancy. The radiology community needs more time to measure it impact and understand its implications, offers Eliot L. Siegel, MD, professor of diagnostic radiology and nuclear medicine at the University of Maryland Medical Center and director of radiology at the Baltimore Veterans Affairs Medical Center in Baltimore.

While applauding technical advances in dose exposure, Siegel pegged the increased awareness of radiation dose as the top development in the CT world in 2010 and noted that legislation mandating dose tracking such as a California law will continue to raise awareness of CT radiation dose among healthcare providers and patients. Radiologists will continue to play a central role in dose management, which brings the discussion full circle to collaboration as collaborative development and sharing of dose reduction strategies among all stakeholders—radiologists, medical physicists, technologists, referring physicians and patients—is essential for a successful dose management program.