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Clinical Case of the Month: Ectopic Pregnancy

April 1, 2010

An ectopic pregnancy is a condition in which an abnormal pregnancy occurs and the fertilized egg attaches to a region outside of the womb (uterus). It is estimated that 20 of every 1,000 pregnancies are ectopic. 95% occur in the ampulla or isthmus of the fallopian tube, 2-3% are interstitial, while cervical, ovarian, and abdominal ectopics are rare. While there is no way to save the fetus during an ectopic pregnancy, quick treatment of this condition is necessary as continued growth of the egg may cause damage or rupture of the attached region.

Clinically, patients present 6-8 weeks after their last menstrual period, however it may be later. Classic symptoms include amenorrhea followed by vaginal bleeding, and localized pelvic pain. If the fallopian tube ruptures, the patient may present with sharp stabbing pain in the pelvis, vaginal bleeding, dizziness, and possible hypotension.

Ultrasound is a non-invasive imaging procedure used to visualize the condition of a pregnancy. Abdominal and transvaginal ultrasound is often used to visualize the intrauterine gestational sac – absence of this intrauterine gestational sac suggests the presence of an ectopic pregnancy.

Case Study: Abdominal ultrasound imaging of the pelvis was used to diagnose this right-side ectopic pregnancy.
Technology: Toshiba Aplio XG ultrasound.

Patient History: A 25 year old female presented to the emergency room with right lower quadrant pain, nausea, and vomiting. The patient was gravid 3 Para 1. The patient’s quantitative beta-hcg level was 1,843 IU. The patient’s clinical history was significant for prior ectopic pregnancy.

Ultrasound imaging of the pelvis shows a normal appearing uterus with a normal endometrial stripe. No intrauterine pregnancy is noted. The images of the right adnexa show a right paraovarian cystic lesion with thick echogenic rim. A small amount of free fluid is located in the posterior cul-de-sac.

The ultrasound findings, combined with the patient’s beta-hcg levels, are diagnostic of a right sided ectopic pregnancy. The ectopic gestation contains a yolk sac and possibly a fetal pole; however, no embryonic cardiac activity was identified.

Image Gallery

Normal uterus with abnormal right ovary show paraovarian cyst small pocket of fluid in the posterior cul de sac. Images courtesy of Amy Rutledge, RDMS Chief Sonographer, University Hospital Case Medical Center

Reference:
E A. Lyons, The first trimester, C M Rumack, Diagnostic Ultrasound, Third edition 2005, Obstetrics and Gynecology, Volume 1, Berman, Craig, and Kawamura.

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Cardiac MRI on the Leading Edge

February 8, 2010

The American Heart Association estimates that nearly one million US residents die of heart disease annually, and according to the US Centers for Disease Control and Prevention it is the leading cause of death for both men and women. As a result, finding ways to detect heart disease earlier and more accurately are becoming increasingly important. Toshiba’s advancements in MRI are helping physicians quantify heart disease, thus improving diagnosis and treatment.

MRI has long been used to assess the structure and morphology of the heart, but as the technology advances, so do the procedures available to clinicians for quick and accurate diagnosis of heart disease in their patients. “The bread-and-butter sequence is called SSFP [steady-state free precession] cine imaging,” Erin Kelly, clinical science manager for MRI at Toshiba America Medical Systems, explains. “It gives an image of the heart as it moves through the cardiac cycle to tell the clinicians how the muscles are functioning, and they can use these images to calculate ejection fraction and left-ventricular volume.”

The ability to perform SSFP cine imaging is one of many cardiac-friendly features included in Toshiba’s Vantage™ Titan MRI, a 1.5T system that also includes a 16-element cardiac coil that can be combined with the 32-element spine coil. The center elements are smaller, resulting in higher-resolution imaging of the heart, and “the elements in the coils can be turned on and off to optimize the signal-to-noise ratio,” Kelly notes. Various sequences and parameters are selectable from the scanner to facilitate successful evaluation of the heart, including delayed-enhancement, myocardial imaging, retrospective gating, black-blood imaging, and real-time motion correction to name a few. Non-contrast techniques are also available on all Toshiba MR systems. For example, Whole Heart Imaging is one contrast-free sequence that allows physicians to assess the coronary arteries without contrast.

Timothy Albert, MD, is medical director of the Cardiovascular Diagnostic Center at Salinas Valley Memorial Healthcare System, Salinas, California, and he uses the Vantage Atlas system. He says, “We try to use noncontrast imaging as much as possible, both for patient convenience and safety and because of concerns about patients with kidney problems. For scar imaging, you still need contrast, but the other stuff, we can often do without it.”

Albert says that MRI has an important place in the portfolio of modalities used to detect and plan treatment for heart disease. “I use CT for coronary imaging, but that’s a small part of the cardiac question,” he says. “MRI’s strengths are really in functional imaging—the shape of the heart and how it’s beating. There’s an increasing amount of scientific data coming out about new uses for MRI in cardiac care.” Albert and his team even run a two-day training course designed to help educate referring physicians on the robust applications of cardiac MRI.

“MRI is ideal for assessment of the heart-failure patient, looking at the potential causes to guide treatments and diagnostic tests, and we use it to determine whether someone would benefit from being revascularized after a heart attack,” Albert says. “For patients with congenital abnormalities, it’s the gold standard, since CT radiation could be cumulative over time. In the future, we hope physicians will hear about these new uses for MRI and recommend it more frequently.”

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3D Wall-Motion Tracking Offers Quantitative Data

Echocardiography is a valuable tool in the diagnosis of coronary artery disease, but evaluation of myocardial function using 2D echocardiography relies primarily on visual detection of wall-motion abnormalities. In 2009, Toshiba America Medical Systems introduced a proprietary 3D Wall Motion Tracking (WMT) tool for its Aplio™ Artida ultrasound system, which helps clinicians quantify the function of the left ventricle in 3D—including left-ventricular ejection fraction, volume, and strain information.

“3D Wall Motion Tracking allows sonographers and physicians to quickly and accurately identify wall motion defects and the timing of cardiac events,” Berkeley Cameron, cardiac marketing manager for Toshiba, explains. “This greatly improves the detection of wall motion abnormalities in many cardiac disease states and Cardiac Resynchronization Therapy (CRT), and helps physicians optimize pace maker settings.”

In addition, the tool can be useful in diagnosing heart disease in women. Although stress studies have been shown to detect heart disease fairly accurately in men, women sometimes experience an increased risk of false-positive results. “Usually, for women, physicians want to do stress echocardiography instead of a treadmill study,” Cameron says. “That’s one area where Wall Motion Tracking is particularly useful for women. Having quantitative data help make the diagnosis more accurate.”

The response from clinicians using the tool has been enthusiastic, Cameron says. “We’ve gotten quite a bit of positive feedback,” she notes. “The clinicians using WMT feel it’s going to help them diagnose coronary artery disease. Anything they can do to diagnose disease earlier and to be more accurate—to make echocardiography less subjective—is a big benefit.”

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Clinical Case of the Month: Atrial Septal Defect (ASD)

ASD is a congenital heart defect that is ideally suited for evaluation using cardiac MRI. Cardiac MRI allows accurate assessment of heart structure, function, and blood flow. In addition, cardiac MRI is an ideal method of evaluation because it does not use radiation and is non-invasive.

Cardiac Magnetic Resonance imaging can be challenging due to the constant motion of a beating heart and respiration. To successfully image the heart using MR it is essential to acquire images rapidly with optimal resolution and contrast.

Toshiba uses a 16 element Atlas SPEEDER body array coil coupled with the 32 element Atlas SPEEDER spine array coil to produce the signal required for successful evaluation of the heart. Vantage MRI systems have a complete cardiac software package available which includes specialized sequences for speed and image quality as well as the post processing software for cardiac analysis.

Case Study: MRI of the heart to evaluate cause for shortness of breath and heart murmur.

Technology: Toshiba Vantage Atlas MRI system using body array and spine array coils. The heart is imaged using SSFP cine sequences in varying planes.

2D cine sequences clearly depict the atrial septal defect allowing blood to flow between the right and left atrium. High blood-flow between the atria leads to volume overload and can lead to right heart failure. In this patient the right ventricle is enlarged consistent with a large ASD. This contributes to the patient’s shortness of breath and can progress to heart failure if not treated.

By using Toshiba’s cardiac MR system and specialized sequences no contrast or radiation was necessary in making this diagnosis.

Four-chamber (left) and short axis (right) cine views of the heart demonstrating atrial septal defect (ASD). (Cines and images courtesy of Dr. T. Albert, MD, FACC, Cardiovascular Diagnostic Center, Monterey, CA.)

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The Drive for Efficiency in Imaging

December 7, 2009

While efficiency has always been important in health care, the changes we see in today’s environment are requiring the medical community to be even more diligent.  Many are starting to recognize that the right equipment can make important differences.  At this year’s RSNA, Toshiba showcased how its systems are helping health care professionals meet the demands for efficiency without sacrificing quality.

Magnetic Resonance

The patient-focused features of the Vantage Titan™ improve exam efficiency and accuracy while mitigating issues around imaging claustrophobic and bariatric patients.  The Vantage Titan features a large 71-cm aperture open bore and offers the industry’s largest clinical field-of-view (55×55×50 cm).  The bore’s diameter enables technologists to scan patients with greater ease and reduces the feeling of claustrophobia.  Toshiba’s patented Pianissimo™ technology, which reduces acoustic noise by as much as 90 percent, is also increasing the comfort level of patients during exams.  Improving comfort level is critical because it often reduces the need for re-scans, thus improving efficiency.

St. Anthony Hospital in Gig Harbor, Wash., has experienced these benefits first hand.  “The Toshiba Titan has been the workhorse MR system for us and is able to accommodate the wide variety of MR exams we perform each day,” said Gary Leslie, MRI technologist at St. Anthony.  “We are imaging multiple patients a day and have received direct patient feedback that the system is quieter and feels less claustrophobic than other MR systems.  This has helped us to greatly improve exam efficiency and department throughput.”

Additionally, the system’s Atlas integrated coils allow physicians to perform multiple exams without repositioning the patient and also enable feet-first imaging for feet-to-shoulder exams.  This means a more comfortable exam experience and results in enhanced workflow and technologist productivity.  Also, Toshiba’s SPEEDER parallel imaging allows for increased acquisition speed and reduced examination times.

X-ray

Today’s emergency departments are challenged to provide rapid, accurate diagnoses for a variety of patient conditions when time is of the essence. Toshiba’s RADREX™-i digital radiographic system is designed to provide the features emergency departments require to offer the highest level of patient care.

The comprehensive RADREX-i offers a 600-lb. table weight limit, 600 kHU X-ray tube and an 80-kilowatt generator, allowing hospitals to image a variety of patients, including bariatric. The X-ray system enhances workflow with the RexView, a color LCD screen located on the overhead tube crane (OTC). Since the image appears on the OTC, technologists have immediate access to review the image and determine if they have what is needed for diagnosis, ultimately reducing exam time and increasing the chance of a positive patient outcome.

The RADREX-i’s automated features also save time in emergency settings by automating exam selection and X-ray positioning. These features include:

• Auto-tracking to eliminate the need to manually position the X-ray tube detector by providing synchronization for table and wall-stand tracking
• Auto-collimation to save crucial time for the patient and technologist by automatically selecting the correct collimation size for the patient’s body part
• Auto-program to eliminate the need for the technologist to manually select the program on the generator by automatically selecting the correct program
• Auto-center stop to provide visual guidance for fast, simple detector centering

St. Luke’s Community Hospital in Ronan, Mont. uses the RADREX-i in its emergency department.

“When treating emergency patients, acting quickly is critical,” said Steve Sivak, radiology manager, St. Luke Community Hospital. “The advanced features of the RADREX-i help us streamline workflow and accelerate throughput, providing a tremendous benefit to patients when time is limited.”

Ultrasound

Many hand-carried ultrasound systems offer better access to patients when space is compromised, but cannot provide all of the advanced radiology capabilities required to perform exams in today’s demanding ultrasound environment.  Toshiba’s new works-in-progress Viamo™ ultrasound system meets the needs of today’s hospitals by combining portability with high-end radiology features.  Viamo is the industry’s no compromise ultrasound system with advanced radiology capabilities, previously unavailable on hand carried systems.

The Viamo combines the portability of a laptop system with advanced radiology features to deliver outstanding image quality, enhance diagnostic confidence and improve ease-of-use. Developed from a radiology foundation, Toshiba’s Viamo provides the confidence to image patients at bedside, which generally require larger, more expensive cart-based systems. When an immobile patient needs a high-end ultrasound exam, the portable Viamo laptop ultrasound is brought to the patient to improve the patient’s comfort without compromising exam quality.

The new Toshiba Viamo laptop ultrasound system offers:

• Best-in-class imaging capabilities in a laptop size, making it ideal for high-end radiology, vascular, emergency and OB/GYN exams, even at bedside. For example, Viamo is beneficial during liver transplants when medical personnel must image the anastomoses to assess blood flow through the vessels.
• Excellent image quality and color flow comparable to larger, more expensive cart-based systems.
• Ease-of-use with a simple touch-screen interface that is programmable in panel or tablet modes.
• Ability to interchange Toshiba transducers while using the Viamo’s transportation pole, thus improving productivity and flexibility, while saving health care costs by reducing the need to purchase multiple transducers. This unique feature improves productivity and saves money for current customers by using their existing Toshiba transducers on the Viamo.  Additionally, new customers are able to use Viamo transducers with other Toshiba ultrasound systems they may purchase in the future.

Computed Tomography

Overall, Toshiba’s Aquilion® line continues to be focused on exam efficiency and the company has added several new features to help the medical community.  The Aquilion line comes with a host of ^SURETechnologies that automate parts of the exam, which not only provides efficiencies, but also safer exams.  For example, Variable Helical Pitch (vHP) ensures greater workflow efficiency by enabling physicians to complete an exam of more than one anatomical region consecutively – i.e. without stopping to alter the helical pitch of the exam.  Toshiba’s CT line also features items like the iStation, a screen on the gantry that provides automatic exam feedback to the technologist, and a table with a 660-lb. weight limit that also lowers within inches of the ground, enabling patients to sit on the table more easily.

While the entire Aquilion line boasts efficiencies, Toshiba’s Aquilion® ONE is designed for today’s health care environment because it can streamline workflow by providing a more accurate, complete and timely diagnosis with one exam.  The Aquilion ONE can image a patient in 0.35 seconds, whereas conventional helical CTs can take four or five seconds, approximately 10 to 12 times slower.  Beyond its fast acquisition time, the Aquilion ONE can replace several tests with one exam, eliminating the time, cost and staff required to perform additional unnecessary exams.  It also allows physicians to treat at-risk patients immediately and send healthy patients home without additional testing and staff support.

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AHRA and Toshiba Announce 2009 Putting Patients First Grant Recipients

At this year’s RSNA, the AHRA: The Association for Medical Imaging Management and Toshiba announced the six recipients of the second annual Putting Patients First grant program.

This year’s Putting Patients First grant program was expanded to include imaging centers and three additional grants specifically for pediatric programs. The six recipients were selected by the AHRA selection committee to receive up to $7,500 grants to fund programs, trainings or seminars aimed at improving patient care and safety in diagnostic imaging.

In its second year, this program has expanded its scope to include improving the imaging of children.  Children have special imaging needs – exposure to radiation and contrast are concerns within the industry, as is ensuring that children are well prepared for the imaging experience.  Putting Patients First will help facilities address these very specific needs.

“Grant programs like Putting Patients First are critical given today’s health care environment and the pressures hospitals face due to limited resources and other financial challenges,” said Debra A. Lopez, AHRA president, CRA, FAHRA. “This year’s winning programs demonstrated quality and innovation in patient care. They will make significant improvements to patient care and better the imaging experience for physicians and patients, alike.”

The programs funded by the AHRA/Toshiba Patient First grants include:

Children’s Healthcare of Atlanta at Egleston – Use of Bismuth Shields in All CT Exams

• Several recent publications report radiation dose reduction benefits when using bismuth shielding for pediatric patients undergoing multidectector CT. Therefore, Children’s Healthcare of Atlanta at Egleston will implement the use of bismuth shields in all patients undergoing CT examinations. Implementation of this shielding program will entail staff training, purchase of bismuth breast and thyroid shields, ongoing review of images, development of resident and parental educational programs, and a cost analysis.

Community Health Network – Pediatric CT Imaging Simulation Program

• By enabling pediatric patients to better understand the CT imaging process, radiation dose will effectively be reduced, patient comfort will be improved and the overall imaging experience will be safer. Therefore, Community Health Network will create an Internet-based simulation program to educate pediatric patients and their caregivers about the diagnostic imaging process (focused on CT).  By incorporating audio, avatars and animation through a user-friendly computer program, patients will know what to expect of the imaging process and be more comfortable and compliant during the procedure.

Memorial Hermann Outpatient Imaging Division – Improved Process Program

• Memorial Hermann’s goal is to emphasize the importance of keeping radiation dose during CT procedures as low as reasonably achievable for pediatric patients, while still maintaining good image quality. It also recognizes the need for more education for the technologists and pediatricians on pediatric radiation safety. Therefore, Memorial Hermann will implement the Improvement Process Program to: 1) document the dose electronically PACs; 2) scan once – multiphase scanning is usually not necessary in children; 3) reduce or “child-size” the amount of radiation used; 4) audit and evaluate image quality monthly; and 5) provide physician and technologist continued education.

Highline Medical Center – Improvement Project for Scheduling Inpatients for Imaging Exams

• One of Highline Medical Center’s goals is to provide a patient-centered environment that personalizes, humanizes and demystifies patient care. Therefore, Highland Medical Center is undertaking an improvement project to develop, implement and spread a process for scheduling inpatients for imaging exams to accomplish safer patient care through: 1) better communication among the staff caring for the patient; 2) increasing involvement of the patient in his/her own care; 3) better coordination between services for tests and treatments leading to streamlined clinical pathway; 4) eliminating delayed/missed or incorrect imaging exams; 5) improving patient flow to potentially decrease overall length of stay; and 6) having imaging techs rounding on patients prior to high risk, invasive or advanced imaging procedures.

Shields Health Care – Understanding and Reducing Patient Anxiety

• Shields Health Care wants to engage the patient in a common language that educates and reduces patient anxiety. Therefore, Shields Health Care will develop multi-lingual web-based tools as well as professional staff training. Phase one of the program will be to research causes and develop solutions; phase two will be to implement and cross train professionals and technical staff; and phase three will be dedicated to reflection on lessons learned and measuring program effectiveness and outcomes.

St. Patrick Hospital – Interactive Utility to Improve the Imaging Process

• Inaccurate or inappropriate exam orders contribute to increased costs to patients, staff and facilities in terms of dose, money and time. Therefore, St. Patrick Hospital will create on its intranet Web site an interactive utility that is readily accessible to all staff to provide guidance regarding appropriate imaging studies and help facilitate clear exam orders to maximize the value of imaging studies. Once the program is developed for intranet users, St. Patrick Hospital will provide a condensed version of the utility on its hospital Web site with more links to helpful information in order to improve patient understanding of the process. This version also will be a tool used by clinicians and staff when discussing exam specifics with patients.

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Clinical Case of the Month: Congenital Heart, Double Aortic Arch

According to the March of Dimes, congenital heart defects affect more than 25,000 infants every year in the United States.

Imaging children has many challenges due to their unique imaging requirements compared to adults. The best benchmark for a pediatric CT scanner should include the ability to acquire images as fast as possible, with the best image quality, and at the lowest possible x-ray dose.

Aquilion ONE can capture whole anatomical regions in a single rotation of the gantry. This ability can dramatically reduce the amount of contrast, radiation and possibly the need for sedation. Aquilion ONE also comes equipped with ^SUREExposure Pediatric which incorporates the unique imaging requirements of pediatric imaging and ensures the lowest possible dose while maintaining diagnostic image quality.

Case: CTA of the chest to evaluate congenital heart defect in a 9 month old infant with respiratory distress noted at birth.

Scan Parameters: 80kV, 25mAs, 0.35 second rotation.

3D volume rendered and MPR views clearly demonstrate this double aortic arch causing stenosis of the left main stem bronchus, most likely causing the infants continued respiratory distress. 3D images can give surgeons a roadmap for intervention, making it safer and saving time. No sedation was need for this scan due to the very short scan time of 0.35 seconds.

Challenges and Solutions in Imaging Children

November 1, 2009

In 2008, an alliance of radiology organizations was formed to launch the Image Gently campaign, emphasizing the importance of child sizing radiation dose to image pediatric patients more safely. The renewed focus on improving the safety of imaging for children has prompted hospital radiology departments and imaging centers to reexamine every aspect of their pediatric care. By reducing exam times, eliminating the need for follow-up exams and providing automated dose protocols for a range of weights and sizes, the right imaging technology can help facilitate safer imaging for the youngest patients.

Robb Young, senior manager of the CT business unit at Toshiba America Medical Systems, Inc., asks, “What are the greatest challenges in imaging small children? Children, especially young children, have a hard time taking instructions, and they tend to be a little squirmy. That’s the main challenge in pediatric imaging versus adult imaging: How do you get the diagnostic image you need so you don’t have to re-image?”

Young says that Toshiba’s Aquilion^® ONE 320-detector row, dynamic volume CT scanner is optimal for pediatric imaging in terms of both speed and dose. “With this technology, we can image children so quickly that we need less – sometimes even no – sedation, and often without them having to hold their breath.” he says. “You can image 16 cm in 0.35 seconds, whereas on a conventional CT it could take four or five seconds.”

 The Aquilion ONE’s automated dose protocols take the guesswork out of imaging children by automatically child sizing dose, so the technologist can focus on the patient, not the control board. “This is a real issue,” Young says. “Should the technologists be focused on the scanner or the patient? Our design philosophy has always been to automate everything so they can focus on the child.”

Sometimes pediatric imaging goes beyond the diagnosis, and physicians are faced with performing interventional procedures where imaging plays a key role in the care delivered. Allan Berthe, product manager for Toshiba’s X-ray vascular business unit, notes that in some pediatric hospitals, cardiac imaging is performed alongside surgery to repair congenital heart defects. While this can help minimize disturbance to patients, it also creates unique challenges in the cardiac-catheterization suite. Toshiba’s Infinix-i™ C-arm addresses this issue with a unique five-axis positioner, enabling multiple clinicians to work around the patient while gathering high-quality images.

“There’s always a challenge with maneuverability around the room because the patient doesn’t give you any cooperation,” Berthe says. “It was paramount that the entire system design philosophy was changed to accommodate greater patient access and coverage. The five-axis positioner enables us to park the C-arm in a position that, when combined with the ceiling C-arm, gives 180° open head-end access while maintaining the C-arm coverage you want, the motion in various directions, the speed and the right angles.”

The Gentler Approaches

Ultrasound is often used as the frontline modality in imaging children because it is noninvasive and emits no radiation. Erin Owen, senior manager for Toshiba’s ultrasound business unit, says, “If they can diagnose it with ultrasound, they’re going to do that first.” Toshiba’s ultrasound technology facilitates rapid, high-quality pediatric imaging through a multitude of proprietary features. One such feature is differential tissue harmonic imaging (D-THI), which offers superior penetration at the high frequency needed to maintain image quality. “The higher the frequency, the better the image quality,” she says. “D-THI gives us image quality throughout without losing the penetration and while maintaining the resolution.”

Toshiba also offers two transducers that are ideal for pediatric imaging. One condition often experienced by infants in the neonatal ICU is bleeding in the brain; Toshiba’s neonatal head transducer offers high-frequency imaging in a nickel-sized package designed to fit the smallest patients. Another transducer, the 745 BTV, is “a very small convex transducer that is good for neonatal heads and also for looking at the livers or kidneys of very tiny babies,” Owen says. “For some of these babies, a regular transducer would be too powerful, and that would negatively affect image quality.” Precision Imaging, a feature available on most TAMS transducers, also enhances image quality by providing superior definition of lesions. “It helps us get a clearer understanding of what’s going on, and might help eliminate a more costly or frightening exam,” Owen says.

Pediatric MRI represents a multitude of challenges.  Most MRI exams are lengthy and children might require sedation to keep still.  Additionally, anyone who has experienced an MRI exam can testify to the loud noise, which can frighten young patients. Joel Urick, product manager in Toshiba’s MRI business unit, explains how the company’s MRI technology addresses these issues by shortening exam length and improving image quality. “Our coils are integrated into the table.  Therefore, instead of having to go into the MRI room to reposition the child, you can continue the scan without stopping.  This not only makes the exam faster when performing multiple exams, but also makes the exam more comfortable for the patient,” he says. “You landmark the patient ahead of time and the table moves from location to location.”

Toshiba’s non-contrast MRI techniques can eliminate the need for an IV for a child prior to a scan, enabling users to perform contrast-free imaging for full runoffs down the legs, renal exams, pulmonary embolism and more. The manufacturer’s proprietary JET™ sequence offers motion correction, a valuable benefit with imaging patients who have a hard time holding still. “Even if a patient turns his or her head to the side, JET can extrapolate the data where the patient wasn’t moving and produce a detailed image,” Urick says. “Even if a child moves during a scan, it might not be necessary to repeat it.”

Improving the safety of pediatric imaging yields benefits across the board, Young notes. “If you are able to image children at the lowest possible dose, you can image everyone that way,” he says. “If it’s safe for kids, it’s safe for everyone.”

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Keeping Kids Comfortable During Exams

Imaging can be intimidating for patients of all ages, but for children in particular, the technology poses a unique challenge. To image young patients safely, it is crucial to minimize the number of scans needed for fast and accurate diagnosis. To minimize the number of scans performed, it is equally crucial that patients be as comfortable as possible during their exams. “The whole objective is to achieve a gentle experience,” Robb Young, senior product manager, CT business unit, Toshiba America Medical Systems, Inc., explains.

To that end, Toshiba has developed a series of innovations to boost the comfort of pediatric imaging. These include a miniature CT scanner designed to help educate children about the procedure and help them exert a degree of control over the process. Prior to undergoing their own scans, children can watch a favorite toy go into the miniature CT. The mini-CT will be introduced at this year’s RSNA meeting, alongside a dedicated version of the Aquilion^® ONE unit designed for pediatric imaging and decorated with a playful jungle theme. “If a child is more comfortable, it’s going to be a better patient experience and ultimately a higher quality scan,” Young says.

With MRI, noise reduction is a key element to helping children relax and feel more comfortable during the scan process. Toshiba’s groundbreaking noise-reduction technology, Pianissimo™, and the short, open-bore design of all MRI units raise the pediatric comfort level. Joel Urick, product manager, MRI business unit, says, “Our Pianissimo technology makes our scanners much quieter than standard MR scans – up to 90 percent quieter with many sequences. Reducing the noise makes it much less scary. It allows us to make working with kids a little easier, and if they do need to be sedated, the odds of them waking up are reduced.” Bore design reduces the level of intimidation children feel; in many cases, kids can be imaged feet first. “That way, their parents can be at the front part of the scanner, holding their hands and doing whatever else is needed to make them more comfortable,” Urick notes.

In the case of ultrasound, often considered the frontline technology in pediatric imaging, room design can go a long way toward reducing the intimidation factor. Erin Owen, product manager in Toshiba’s ultrasound business unit, says, “Children will fuss with ultrasound, like anything else, but the transducers are designed to be comfortable, they have warm gel, and there’s usually a television where children can choose what they want to watch during exams.” Toshiba will also showcase a decorated pediatric ultrasound unit at this year’s RSNA meeting.  The unit will be decorated in a manner similar to that of the pediatric Aquilion ONE.

“Lowering dose is of utmost importance, but it’s also important to make imaging comfortable, fast, and the best experience it can be,” Young says. “These children deserve it.”

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MRI and Ultrasound Gain Ground in Breast Imaging

October 1, 2009

The journey from bench to bedside is a long one in medicine, but breast MRI received a boost in March 2007 when the American Cancer Society (ACS) revised its guidelines for breast cancer screening to include annual MRI for high-risk women, a group representing about 2 percent of the US population. That same month, a report¹ on the ACR Imaging Network 6667 trial was published in the New England Journal of Medicine, recommending contralateral breast MRI for women recently diagnosed with breast cancer. In addition, the ACS recommends that women with extremely dense breasts, a personal history of breast cancer, and atypical hyperplasia receive breast MRI at their physicians’ discretion.

Another adjunct breast-imaging modality is poised to assume an even greater role in breast cancer screening and diagnosis. Ultrasound, long used to help evaluate suspicious lesions and cysts and to guide breast biopsies, has been generating a growing list of scientific citations since emerging as a hot topic at the 2006 meeting of the European Congress of Radiology (ECR) for a different reason: elastography.

Numerous studies have indicated that elastography, which uses ultrasound waves to measure the elasticity of tissue, could be a useful diagnostic tool for several cancers, including breast malignancies. Cancerous tissue is less pliant than regular breast tissue; according to the results of one British study presented at ECR 2006,² the sensitivity and specificity of breast elastography are 96 percent and 53 percent, respectively, meaning that the technique could be used to determine whether a lesion is benign or malignant without invasive biopsy. Later that year, a poster presentation³ at the annual RSNA meeting showed similar results.

An article⁴ published in the July 2008 issue of Breast Cancer, “Cost-effective Screening for Breast Cancer Worldwide: Current State and Future Directions,” provided another argument for the use of elastography in breast cancer diagnosis: its affordability. “Clinical results demonstrate that elasticity imaging, even in its simplest and least sophisticated versions, like tactile imaging, has significant diagnostic potential comparable and exceeding that of conventional imaging techniques,”⁴ the study’s authors wrote. “Tactile imaging is one method that has the potential to provide cost-effective breast cancer screening and diagnostics.”⁴

A National Cancer Institute clinical trial to validate the use of elastography in breast cancer evaluation was launched in July of 2008 and is currently recruiting participants.

Meanwhile, ultrasound guidance for breast biopsy and surgery continues to gain momentum. A recent study⁵ published in Breast looks at the use of vacuum-assisted, ultrasound-guided breast biopsy for difficult indications, including lesions with scarring or distortion, and small tumors or microcalcifications. The study indicates that the technique helped patients avoid difficult surgery in 41 of 51 cases. Another study,⁶ published in the August 2009 issue of the American Journal of Surgery, looks at using an ultrasound-guided electrosurgical loop to excise breast lesions, noting that the technique shortened procedure times and allowed incisions to be smaller.

As breast MRI proliferates around the country following the 2007 ACS revisions to its screening guidelines, research into the diagnostic potential of the modality for breast cancer continues apace. The ACS recommendation came with a caveat: The relatively low specificity of MRI could lead to false positives, resulting in unnecessary biopsies. Some hope computer-aided detection could be a solution. A study⁷ published online in September 2009 in European Radiology evaluated the accuracy of a computer-aided detection program against manual interpretation by radiologists, finding that interpretation based on computer-aided detection had a specificity of 86.4 percent. Without computer-aided detection, the specificity of MRI was found to be around 69 percent.

Another European Radiology study⁸ published online in September 2009 looks at the use of MR elastography (MRE), an experimental technique that uses MRI instead of ultrasound to look at tissue elasticity. According to the results of the study, the addition of MRE to conventional MRI of the breast resulted in sensitivity approaching 98 percent, leading the study’s authors to conclude the combination of MRE and contrast-enhanced MRI could increase the diagnostic performance of breast MRI.

References

1. Lehman CD, Gatsonis C, Kuhl CK, et al. MRI evaluation of the contralateral breast in women with recently diagnosed breast cancer. N Engl J Med. 2007;356(13):1295-1303.

2. Proceedings of the European Congress of Radiology. ECR: Vienna, Austria; 2006.

3. Thomas A, Fischer T. An advanced method of ultrasound: realtime elastography—first experience in 300 patients with breast lesions. Poster presented at: 92nd Scientific Assembly and Annual Meeting of the Radiological Society of North America; November 26–December 1, 2006; Chicago, IL.

4. Sarvazyan A, Egorov V, Son JS, Kaufman CS. Cost-effective screening for breast cancer worldwide: current state and future directions. Breast Cancer: Basic and Clinical Research. 2008;1:91-99.

5. Abbate F, Bacigalupo L, Latronico A, et al. Ultrasound-guided vacuum assisted breast biopsy in the assessment of C3 breast lesions by ultrasound-guided fine needle aspiration cytology: results and costs in comparison with surgery. Breast. 2009;18(2):73-77.

6. Fine RE, Schwalke MA, Pellicane JV, Attai DJ. A novel ultrasound-guided electrosurgical loop device for intra-operative excision of breast lesions: an improvement in surgical technique. Am J Surg. 2009;198(2):283-286.

7. Meeuwis C, van de Ven SM, Stapper G, et al. Computer-aided detection (CAD) for breast MRI: evaluation of efficacy at 3.0 T [published online ahead of print September 2, 2009]. Eur Radiol.

8. Siegmann KC, Xydeas T, Sinkus R, Kraemer B, Vogel U, Claussen CD . Diagnostic value of MR elastography in addition to contrast-enhanced MR imaging of the breast—initial clinical results [published online ahead of print September 1, 2009]. Eur Radiol.

ACS Breast MRI Recommendations

The American Cancer Society (ACS) recommends¹ an annual MRI exam for women who have the following indications:

• the BRCA1 or BRCA2 genetic mutations, or a first-degree relative with either;

• a lifetime risk for breast cancer that has been scored at 20 percent or higher;

• receipt of chest radiation between the ages of 10 and 30; and

• Li–Fraumeni syndrome, Cowden syndrome, Bannayan–Riley–Ruvalcaba syndrome, or a first-degree relative with any of these.

The ACS acknowledges that while data are insufficient to make a recommendation either for or against screening with MRI in the following risk subgroups, physicians should make individualized decisions on whether women with the following risk factors receive breast MRI exams:

• a personal history of breast cancer,

• carcinoma in situ,

• atypical hyperplasia, and

• extremely dense breasts on mammography.

Reference

1. American Cancer Society Guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin. 2007;57:75-89.