A recent observational study pegged the CT radiation dose range at 6 to 10 mSv, according to Dr. Patrik Rogalla, professor of radiology at the University of Toronto. Even more concerning is the wide range cited in the study: 0.7 to 26 mSv, he said in a presentation at the 2009 RSNA meeting in Chicago.

“What we’re seeing is because ED physicians don’t want sedation, they are scanning several times until they get one right,” Rogalla said. “They didn’t know the patient was moving and they [rescanned] again and again.”

One way to stop motion at low-dose CT is to speed up the scan. Several presentations at the 2009 RSNA meeting used dual-source CT and high-pitch scanning to minimize motion artifacts in pediatric imaging, for example.

Another solution — the one chosen by radiologists at the University of Toronto and Charité Medical University in Berlin, who performed the present study — is the use of wide-area-detector scans with 320-detector-row CT. Each rotation yields 16 cm of anatomic coverage, enough to stop the fidgeting and cover the target in most patients in a single rotation.

To assess the scanner’s dose and image quality, they examined scans performed on a total of 39 young patients with abdominal complaints (mean age, 2.1 years; median, 0.8 years; range, 1 day to 14 years). All were scanned with dynamic volume CT on a 320-detector-row scanner (Aquilion One, Toshiba America Medical Systems, Tustin, CA).

Settings for the study included 80 kV for contrast-enhanced scans, 120 kV for noncontrast scans, and 10-50 mA and 0.35-0.5 sec gantry rotation time, with one to three rotations depending on the target.

Milliamperes were calculated using the following formula: (body weight [in kg] + 5) x f, with f = 1 for chest and f = 1.5 for abdominal scans at 120 kV. For 80-kV scans, radiologists multiplied the mAs value by a factor of 2.5.

Newborn with aortic hypoplasia and renal artery stenosis. Weight of 1.7 kg; single-rotation 320-detector-row scan at 0.5 sec, 80 kV, 40 mA, and dose of 0.3 mSv. All images courtesy of Dr. Patrik Rogalla.

“We varied mAs by patient weight, and sometimes we [needed] one or two rotations depending on the patient,” Rogalla said. For noncooperative patients and those who were unable to hold their breath, as many as three rotations at 0.35 seconds were acquired to shift the reconstruction within the acquisition window for motion artifact reduction. Every study used the 640-detector-row reconstruction mode (0.5 mm) available on the scanner.

Patient with stridor and giant cervical hemangioma was breathing continuously and not sedated during 320-detector-row CT, acquired in two rotations at 0.35 sec, 80 kV, 20 mA, and dose of 0.3 mSv. Below, additional rotation allows reconstruction of images at multiple time points, revealing air trapping that would have been missed at single-rotation scan.

Two expert readers evaluated all scans with respect to image quality on a scale of 1 to 3 (1 = poor). Radiation dose was calculated based on the dose-length product (DLP) displayed on the dose report and verified using commercially available software (CT-Expo, version 1.51d), Rogalla said.

In all but four patients (two chest and two abdominal scans), the 16-cm detector coverage sufficed for scanning the target area in a single gantry rotation. No scan was rated poor, and one patient moved despite manual fixation, so a repeat scan was needed, the authors wrote in an abstract.

Despite patients’ continuous breathing during image acquisition, axial slices were rated good. In one patient, motion blur was relevant but did not prevent a diagnosis. Radiation exposure (calculated by both the readout and sensors) ranged from 0.2 to 2.3 mSv (mean, 0.6 mSv), depending on the scanning area and parameters used.

Nearly whole-body imaging in a single rotation reveals lung changes and pleural thickening.

There were several limitations to the study, including a lack of comparison to helical scans and a very young cohort. “We did have predominance of neonates, so we have to be cautious in generalizing exposures rates,” Rogalla said of the results.

Feeding artery is visible at 320-detector-row CT in a patient with pulmonary blastoma.

“A dynamic volume 320-slice CT … potentially may reduce the overall radiation dose if used correctly,” he said. “In particular, we have reduced motion artifacts with ultrafast flash imaging — so even though the patients were breathing and moving, we didn’t have significant motion artifacts because it’s so fast.”

Vascular ring and hypothesis of tracheal stenosis. Images at 320-detector-row CT.

Fast scanning reduces the need for sedation, which contributes to overall reduced risk for the patient, he added.

An audience member asked if this kind of scanning protocol could realistically be expected to be a dominant force in future imaging.

“My opinion is that the trend is toward wide-area CT,” Rogalla said. “So one rotation, half rotation, flat imaging is the way to go. I think there’s great potential for reducing the dose.”

By Eric Barnes
AuntMinnie.com staff writer
March 3, 2010

Medical groups representing radiology and radiation oncology tackled head-on the issue of rising exposure to medical radiation in congressional hearings on February 26. Six professional healthcare associations representing radiologists, radiation oncologists, technologists, medical physicists, and equipment manufacturers were invited to present testimony to the U.S. House of Representatives subcommittee on health on February 26.

Subcommittee chairman Rep. Frank Pallone Jr. (D-NJ), colleagues, and staff seemed pleasantly surprised that all organizations recommended changes that would add strength and uniformity to best-practice radiology and radiation oncology guidelines.

American College of Radiology (ACR)

The ACR of Reston, VA, recommended expanding existing federally mandated medical imaging accreditation requirements to encompass all clinical settings including radiation therapy modalities. The ACR also advised creating a national CT dose index registry, as well as passing legislation requiring minimum standards for radiology and radiation therapy technologists.

ACR board of chancellors member and former ACR chair Dr. E. Stephen Amis Jr. told the subcommittee that the associations representing radiology and radiation therapy would offer the best way to oversee and manage accreditation and other recommended initiatives because they have the hands-on professional expertise required. He reminded subcommittee members that beginning in 1987, the ACR initiated the first-ever voluntary accreditation programs. One of these, for mammography, led to the passage of the Mammography Quality Standards Act (MQSA) in 1992, and the ACR is the only national organization approved by the U.S. Food and Drug Administration (FDA) to oversee it.

While the ACR has been working with modality manufacturers to develop a CT dose index registry, Amis said that a congressional mandate requiring one would aid the process. He noted that not only would a national mandatory registry measure ongoing performance for accreditation of facilities performing CT exams, it might more rapidly help identify problems with equipment or inappropriate use.

American Society for Radiation Oncology (ASTRO)

Dr. Tim R. Williams, chairman of the board of directors of ASTRO of Fairfax, VA, advised the subcommittee of the association’s ongoing patient safety and quality assurance projects, and the society’s development of a six-point action plan to improve quality and reduce errors.

The plan includes creating a national database for reporting linear accelerator errors, enhancing the currently voluntary radiation oncology practice accreditation program, and expanding training programs. Williams also called for accelerating ASTRO’s Integrating the Healthcare Enterprise - Radiation Oncology (IHE-RO) initiative to facilitate the seamless transfer of radiotherapy treatment information to electronic medical records and related databases, as well as the immediate passage of legislation to enforce patient safety regulation.

In late 2008, ASTRO and the ACR initiated a program offering radiation oncology practice accreditation. However, as pointed out by Amis, fewer than 10% of U.S. radiation therapy practices have taken advantage of it. ASTRO recommends that all radiation oncology practices undergo accreditation.

Williams told Congress that from ASTRO’s perspective, it needs to provide increased funding for the National Cancer Institute (NCI) and for one of its branches, the Radiological Physics Center (RPC) at the M. D. Anderson Cancer Center at the University of Texas in Houston.

Pointing out that federal funding for the center, which obtains two-thirds of its operating budget from the NCI, has decreased steadily over the past 10 years, Williams said that ASTRO “believes that RPC’s auditing and monitoring tools have led to improved dosimetry, and identified the fact that approximately 30% of the hospitals applying to participate in radiation oncology clinical trials failed to accurately irradiate head and neck phantoms.”

ASTRO has incorporated information and tools from the RPC to develop enhanced quality assurance programs to educate its membership of more than 10,000 medical professionals affiliated with radiation oncology. Williams strongly recommended that a budget increase for RPC would be a prudent investment for Congress to make with respect to its overall objective to increase patient safety.

ASTRO also recommended board certification of medical physicists, as well as mandatory and standardized licensing requirements for them throughout the U.S.

American Society of Radiologic Technologists (ASRT)

A major theme at the hearing was developing ways to ensure that competent medical staff members are operating the increasingly sophisticated equipment used at radiology and radiation therapy facilities. The ASRT lobbied passing the Consistency, Accuracy, Responsibility, and Excellence in Medical Imaging and Radiation Therapy (CARE) Act, which would require minimum educational and credentialing standards for technical staff.

The most recent iteration of the CARE Act is working its way through the House of Representatives as HR 3652. It was introduced in September 2009 by Rep. John Barrow (D-GA), also a member of the subcommittee on health.

“Cancer patients should not have to wonder whether the person performing their CT scan or planning their radiation therapy treatment is competent,” said Sandra Hayden, a member of ASRT’s board of directors. She pointed out to incredulous congressional delegates and House staff that radiologic technologists are not licensed or regulated in eight states, radiation therapists are not regulated in 17 states, 31 states do not oversee medical physicists, and no state licenses medical dosimetrists.

“Even in states with some type of regulation, the rules are sometimes so weak that they offer patients little protection,” Hayden emphasized. “In some states hairdressers are better regulated than people who perform medical radiation procedures.”

Hayden also lambasted the current status of reporting radiation-associated adverse events. “State and federal oversight … is uncoordinated and inconsistent,” she said. The ASRT calls for establishing consistent and mandatory public methods of reporting errors, and for establishing a consistent system of data collection and tracking.

American Association of Physicists in Medicine (AAPM)

Association president Michael Herman, Ph.D., told Congress that only AAPM seems to have a clear definition of a qualified medical physicist, pointing out that there is no consistent national recognition of this medical credential.

Herman bluntly stated that “medical physicists are licensed in only four states. There are no consistent national staffing guidelines for medical physics services, nor are there consistent standards for accrediting medical centers that use the services of medical physicists.”

The AAPM recommended that this change immediately, through the passage of the CARE Act and with congressional support of the AAPM 2012/2014 initiative, which would require completion of an accredited clinical residency. The society also called for passing an examination to become certified by the American Board of Radiology. Federal funding of residency programs would help meet the demand for board-certified medical physicists, and this is needed now, Herman said.

The AAPM also advocated legislation establishing rigorous minimum standards for accrediting clinical practices, linking U.S. Centers for Medicare and Medicaid Services (CMS) reimbursement to these rigorous practice accreditation standards, and establishing a centralized national data collection system.

The use of both mandatory public reporting and anonymous reports of radiation therapy “near misses” would be beneficial, because in that manner trends of weaknesses and problems could be more easily identified. During a question-and-answer session, Herman pointed out that near-miss analysis is one of the most valuable tools to improve quality assurance programs.

Medical Imaging and Technology Alliance (MITA)

Executive director David Fisher testified for MITA, an association representing more than 50 companies whose products comprise more than 90% of the radiology and radiation therapy market. MITA is a division of the National Electrical Manufacturers Association of Rosslyn, VA, and created headlines the day before the hearings with the announcement of a CT radiation dose safeguard program.

MITA recommended the development of radiation dose reference levels. Fisher pointed out that once these are established, they could serve as data points at which physicians, medical physicists, and technologists could compare the dose level of a specific procedure they are administering to a wide sample of similar tests.

The industry association also voiced its support for the recommendations of the professional associations invited to present testimony at the health subcommittee hearings.

By Cynthia E. Keen
AuntMinnie.com staff writer
March 1, 2010

Because medical images significantly affect all aspects of patient care, Janice Honeyman-Buck, Ph.D., stressed the importance of imaging informatics being an integral part of any hospital’s planned healthcare IT upgrade to receive American Recovery and Reinvestment Act (ARRA) stimulus funds.

There was some irony associated with this message, however: The HIMSS 2010 meeting dedicated only two educational programs out of more than 300 to imaging-related topics, a fact not lost upon the more than 200 commercial exhibitors offering imaging informatics products and services.

Using a fable and the analogy of a line drawn in the sand, over which neither healthcare IT nor radiology PACS professionals crossed, Honeyman-Buck, a consultant with Medical Imaging Consultants of Gainesville, FL, bluntly explained why this situation needs to change.

“Health IT support may not have the skill set to manage images, and radiology support does not have the skill set to manage integration of all hospital information, so we need both groups to work together to create a much stronger system,” she said.

The difference in perspectives is considerable. For hospital IT staff, priority is placed on utilizing the HL-7 standard for fast processing of text data rapidly, privately, and securely. For dedicated radiology IT staff, concerns are focused on image acquisition, manipulation, and image storage, as well as the ability to provide rapid access to online and archived images both within an internal network and through Internet access.

This is a major task, she explained, because storing all diagnostic images performed at a 600-bed hospital can easily exceed 25 terabytes a year. Electronic storage, itself, is not the expense it used to be, but managing the storage is expensive. Storage also needs to be secure and redundant, as downtime of a PACS is unacceptable.

What needs to be overcome is territorial turf protection. Everyone wants ownership of the network, according to Honeyman-Buck, who is also a fellow of the Society for Imaging Informatics in Medicine (SIIM), co-sponsor of the session. But healthcare reform demands interoperability of medical records among healthcare providers, and diagnostic imaging is a critical part of the medical record. An EHR must contain images as well as a way to display at least a subset of images identified as key, she explained.

This capability was first proved with the VistA electronic medical record system that manages text, DICOM, and non-DICOM images for all hospitals and outpatient clinics of the Veterans Health Administration. It is becoming commercially available as well. A number of vendors at the HIMSS meeting were demonstrating EMR products and electronic dashboards that merged text and images.

Medical images in a patient’s record are not limited to diagnostic radiology and advanced visualization 3D reconstructed images. They also include endoscopy images, cardiology images with huge datasets, dental images, and pathology images, which may contain as much as 40 GB per slide. JPEGs such as dermatology images, documentation of anatomy, and/or a patient ID photo should also be part of an EMR.

Honeyman-Buck recommended that hospital administrators start now to create a bridge between imaging informatics and hospital IT, fostering an environment for these professionals to work together to create a system with meaningful use.

She pointed out that while imaging does not appear to be addressed until 2015 with multimedia support in the national healthcare IT implementation schedule, hospital administrators must realize they need to add imaging and multimedia to the meaningful use scenarios as soon as reasonably possible.

She concluded by referencing an open letter written to Dr. David Blumenthal, national coordinator for health IT of the U.S. Department of Health and Human Services, from Joe Marion, a healthcare industry consultant with more than 30 years of experience in diagnostic imaging communications technology, and a principal with the consulting firm Healthcare Integration Strategies of Waukesha, WI.

“It appears that the healthcare providers I have spoken with are consumed with just addressing their own priorities in order to be positioned to take advantage of ARRA. … What is being missed is imaging, which has the largest impact on systems capacity with respect to infrastructure and EHRs,” Marion wrote in a blog posted August 23, 2009, on the Healthcare Informatics magazine Web site.

“The travesty in waiting to address imaging in terms of a priority will be that whatever early initiatives are put in place may not be capable of supporting imaging when 2015 multimedia support rolls around,” he warned. “As one who has lived through inception and implementation of DICOM, letting nature take its course will never enable the objectives of meaningful use to be achieved in the time frame suggested.”

By Cynthia E. Keen
AuntMinnie.com staff writer
March 9, 2010

“Implementing evidence-based practice [EBP] into your radiography department is not an overwhelming or impossible task — and, once you do it, you will find that it enhances your job satisfaction as well as the quality of your practice,” said Nina Kleven-Madsen of Haukeland University Hospital in Bergen, Norway.

In an attempt to show that the advantages of evidence-based practice can translate into superior service and experience for patients, a research group comprising students and management evaluated the benefits of introducing EBP to a pediatric diagnostic radiography department.

Radiographers are skilled in their practice and tend to seek the most efficient and effective methods. Yet, the challenge to base EBP routinely at the heart of decisions is exacerbated by their lack of time, knowledge, and specific evidence-interrogation competencies.

Many overworked radiographers will choose to consult with senior colleagues in preference (and in place of) scanning the published evidence and research. Other barriers include a lack of support from peers and a “human resistance to change.”

With a team comprising both experienced and student (2nd and 3rd year) radiographers, plus a university librarian, Kleven-Madsen assessed their cooperation in performing effective literature searches and procedure evaluation, and judged their collective ability to distill and implement the best practice available.

Participants were tasked specifically with finding the best answer to the question, “Is there a dose reduction to mammary glands when anteroposterior is switched to posteroanterior in scoliosis imaging of adolescent girls?”

The exercise revealed that while contemporary practice is to a degree aligned with evidence-based practice, more systematic work would help to establish consensus on best practice — thereby raising the advantages of EBP in imaging in general.

The Norwegian researchers also concluded that collaboration in implementing evidence-based practice might improve the learning environment for students, making them more accountable during their practical placements.

The project was a joint program between Haukeland University Hospital and Bergen University College, also in Norway. In summing up, Kleven-Madsen encouraged the full room of ECR delegates to see beyond the barriers in bringing EBP into routine practice.

“An evidence-based approach to your work is not difficult — team up with colleagues who are interested and just get started,” she said.

New thinking from Switzerland

In another presentation, early findings were offered from a collaboration between three tertiary health schools and one teaching referral hospital in the French-speaking area of Switzerland that partnered up to develop a new initiative in evidence-based practice, titled BEST (Bureau d’echanges des savoirs pour des pratiques exemplaires de soins).

The two-year pilot study, led by the University of Applied Sciences of Western Switzerland in Lausanne, is currently ongoing and was set up to evaluate BEST as a new tool to assist local radiographers in embracing EBP.

In the study, radiographers gather evidence to produce the “best practice” answer to a wealth of clinical questions, with the ultimate aim of improving the quality of care for patients through EBP.

For French-speaking researchers in this part of Europe, the common use of English in publishing and presenting “evidence” is an additional barrier to EBP implementation, as was noted in BEST.

Lead researcher Nicole Richli Meystre’s Swiss team commenced a six-step process bringing together clinical expertise, patient preferences, and locally relevant standards under a single EBP umbrella:

1. Formulate the right clinical question.
2. Perform a targeted literature search.
3. Provide a critical appraisal of the evidence.
4. Feed local experience and expertise into the process, and assess how to implement.
5. Implement best practice.
6. Reflect and embed EBP into daily practice.

Initial results available to date suggest that with the right approach, the benefits of EBP can be translated into clinical advantages in radiography, and that projects such as BEST are useful in spotlighting means for improvement and encouraging progress within busy radiography departments.

Supporting evidence in ethical dilemmas

Finally, a group from the Oulu University of Applied Sciences in Oulu, Finland, recognized the need for clear EBP, as the continually expanding job role of radiographers now means they face increasingly difficult ethical dilemmas, calling for moral clarity and robust decision-making support. These include the use of radiation (with access to higher doses) and patient care, requests to deal with more complex medical cases, plus escalating demands to operate a broader range of technical equipment efficiently.

The aim of the study was to shine the light on a range of issues where comparatively little research has been undertaken.

Through interviews with a small group of radiographers (n = 8), the Finnish group ascertained that “in the use of radiation, justification and optimization principles were found to be lacking.”

They noted, too, that radiographers frequently encounter dilemmas in patient care, feeling powerless and unable to intervene in ethical problems when trying to deal with particularly challenging patients.

“However, often they do not recognize these issues as ethical dilemmas; rather, they simply see them as problems in daily practice,” the Oulu team observed.

“The concept of ‘ethics’ seems separate and distant, as these issues and feelings are simply part of the everyday world, occurring in everyday situations across Europe.”

In conclusion, the group highlighted the importance of recognizing ethical dilemmas in radiographers’ work community to act effectively and appropriately, in accordance with the evidence for best practice.

The study is ongoing, with further results scheduled for presentation at ECR 2011.

By Rob Skelding
AuntMinnie.com contributing writer
March 7, 2010

“Most of the cancers missed by mammography will be found by automated whole-breast ultrasound [AWBU],” said Dr. Kevin Kelly of the Huntington Hill Breast Center in Los Angeles.

“The performance of all readers in this study improved from using mammography alone to mammography plus AWBU — however, there is considerable variability in breast ultrasound screening skills between radiologists,” he said. “This is a problem that needs to be addressed with teaching specifically tailored to the technique.”

His work aimed to evaluate the impact of AWBU on the diagnostic competence of 12 community radiologists experienced in mammography, after just four hours of training on the 2D automated system. Kelly, inventor of the SonoCine ABS scanner used in the study (and majority stockholder in the company), noted that ABS could be performed successfully on a high-resolution ultrasound scanner.

Reader performance in diagnosing breast cancer in women with high breast density was assessed using mammography alone, and then again with the addition of ABS. Location information was recorded, along with ACR BI-RADS and Digital Mammographic Imaging Screening Trial (DMIST) likelihood ratings.

Average reading time using AWBU was approximately eight minutes, ranging from slightly less than six minutes to almost 13 minutes. Reader performance across the screening modalities was compared using jackknife alternative free-response receiver operator characteristics (JAFROC).

This defines a figure of merit (FOM), reflecting the probability that a cancer on an abnormal image is scored higher than a falsely marked location on a normal image. Higher FOM indicates superior reader performance, similar to ROC analysis.

Enhanced performance

AWBU added to standard digital mammography, versus mammography alone, saw reader-averaged FOM scores improve significantly by BI-RADS (0.783 versus 0.671; p < 0 .001) and likelihood (0.789 versus 0.674; p < 0.001).

Overall, Kelly observed that AWBU plus mammography saw the average performance of every reader in the study improve across the board:

“Over the past 30 years, there has been considerable debate about screening breast ultrasound, but now AWBU has given us a standardized method for testing ultrasound as an adjunct to mammography,” Kelly noted.

Discrepancy between readers

However, the study also revealed considerable variation in skill between breast radiologists when using AWBU. Kelly deemed the degree of inconsistency as unacceptably extensive, a feature highlighted also by a separate new, Norwegian study presented at ECR.

“ABS as adjunct to mammography in screening should be performed by the same radiologist that interprets the original mammogram,” asserted Dr. Per Skaane, of Ullevaal University Hospital in Oslo.

His team examined 114 breasts using digital mammography (Senographe D/DS, GE Healthcare, Chalfont St. Giles, U.K.) and a 3D ABS system (SomoVu, Siemens Healthcare, Erlangen, Germany).

Five radiologists experienced in breast imaging using BI-RADS assessment categories 1-5 interpreted the images, using ABS alone at first reading; this was followed by ABS plus mammography six weeks later. Reader performance was assessed with ROC analysis.

Echoing the findings from Kelly’s study, Skaane too observed universal improvement in reader competence for diagnosis of breast cancer through combined ABS-mammographic interpretation, though the degree of improvement between readers was significant.

Sensitivity varied from 50% to 97% and specificity ranged between 33% and 96%.

“ABS is a promising technology,” he noted. “However, there was considerable interobserver variability” — which he accounted for through differences in the interpretation environment, ABS reading protocol, and the learning curve.

ABS versus handheld ultrasound — first results

A third new study presented on Friday reported preliminary results from a comparison of ABS with a more traditional handheld ultrasound device for breast cancer identification and diagnosis.

A team led by Dr. Dirk Clevert of the University of Munich in Germany compared lesion visibility in 53 breasts between March and May 2009 using ABS (Acuson S2000 ABVS, Siemens Healthcare, Erlangen, Germany) with images acquired using a handheld ultrasound device with a 13-MHz transducer (Acuson Antares, Siemens). All lesions were classified according to BI-RADS assessment.

The handheld ultrasound device depicted 25 lesions in 17 of a total 27 patients, which were confirmed by the ABVS. Lesion size ranged from 5 to 35 mm (median, 17 mm). Median scanning time for the ABVS was 8.2 minutes for each breast, with interpretation time spanning three to 18 minutes.

The ABVS found all breast cancers, and there was good agreement regarding BI-RADS classification with the handheld method.

Based on these initial findings, Clevert suggested that ABVS imaging allows “detection of solid and cystic lesions and their BI-RADS classification with a high reliability,” in comparison to handheld ultrasound.

In summary, the three new studies appear to align in their findings that automated breast ultrasound scanning can improve breast cancer detection and diagnosis, whether added to standard digital mammography or as a standalone modality.

The challenge surrounding ABS lies in the implementation of bespoke training for radiologists on its use during breast scanning, with the aim of achieving greater consistency between readers and translating the enhanced performance into tangible clinical benefits.

By Rob Skelding
AuntMinnie.com contributing writer
March 5, 2010

The research from University Hospital of Ioannina in Greece also found that MRI can estimate the local extent of disease in patients with malignant tumors. The lead author of the study, Dr. Athina Tsili, is from the hospital’s department of clinical radiology (AJR, Vol. 194:3, pp. 682-689).

Although sonography traditionally has been the primary imaging modality to evaluate scrotal contents, the authors noted previous research indicating the technology does not always offer “confident characterization” of the nature of testicular masses.

MRI, on the other hand, can simultaneously image both testicles and both sides of the inguinal region and provides adequate anatomic information and tissue contrast. Past studies also have concluded that MRI may be beneficial when sonography’s results are equivocal or inconclusive for testicular disease.

Patient enrollment

For the current study, the researchers enrolled 33 patients with a mean age of 35 years, ranging from 17 to 70 years. All patients had the presence of masses conformed by surgery, pathology, or both. Radical orchiectomy was performed on 29 patients, three patients had a testicular biopsy, and one patient had both radical orchiectomy and biopsy of the contralateral testis.

MRI scans were performed on a 1.5-tesla system (Gyroscan and Intera, Philips Healthcare, Andover, MA), with a 17-cm circular surface coil used with 27 patients and a pelvic phased-array coil with the other six patients. The patients were examined in the supine position, and gadolinium contrast was administered intravenously in all cases.

Two radiologists blinded to the surgical and histopathologic results interpreted the MR images. The researchers also recorded the presence or absence of intratesticular lesions and evaluated tumor size, signal homogeneity or heterogeneity, and patterns of contrast enhancement, among other variables.

Lesion detection

Through surgery and histopathologic examination, the study tallied 36 intratesticular lesions among the 33 patients. Of those 36 masses, 28 (78%) lesions were malignant, while eight lesions (22%) were found to be benign.

Within the group, 27 patients had intratesticular malignant tumors, three patients had benign testicular lesions, two patients had benign intratesticular masses in both testicles, and one patient had both a malignant and a benign testicular lesion.

Analysis showed that MRI produced correct preoperative characterization of all intratesticular malignant tumors and seven of eight benign testicular lesions. Sensitivity and specificity in differentiating benign from malignant intratesticular lesions were 100% and 88%, respectively.

The mean diameter of testicular neoplasms detected at MRI was 5.2 cm, ranging from 1.1 to 12 cm, “which was in accordance with the histopathologic results,” the authors noted.

In addition, MRI showed its prowess in accurately staging the tumors. Twelve (92%) of 13 category T1 testicular tumors were correctly staged by MRI, while the modality accurately assessed the local extent of 11 (92%) of 12 category T2 malignant testicular tumors.

The authors noted one major limitation of the study: “Although all patients underwent both sonography and MRI evaluation of the scrotum, no direct evaluation of the results with these techniques was performed,” they stated. “A comparison of the diagnostic performances of sonography and MRI might justify the role of MRI compared with ultrasound in the diagnosis and characterization of testicular disease.”

Images are of a 40-year-old man with right testicular seminoma invading the spermatic cord. Left: Transverse T1-weighted MR image of a large right testicular tumor. The area of high signal intensity (arrow) within the lesion corresponds to histopathologic finding of hemorrhage. Center and right images are coronal T2-weighted MR, depicting a tumor of mainly low signal intensity invading the distal part of the ipsilateral spermatic cord (arrow). All images courtesy of the American Journal of Roentgenology.

Based on the results, the researchers concluded that MRI is an “efficient diagnostic tool for the evaluation of testicular masses,” adding that the modality is “accurate in the preoperative differentiation of benign and malignant intratesticular masses, facilitating accurate estimation of the local extent of disease in patients with malignant tumors.”

By Wayne Forrest
AuntMinnie.com staff writer
March 4, 2010

Dr. Christiane Kuhl, from the University of Bonn in Germany, and colleagues investigated the effectiveness in terms of cancer yield and stage at diagnosis of clinical breast examination (CBE), mammography, ultrasound, and breast MRI. The researchers assessed each modality alone and in combination for screening women at elevated risk for breast cancer as part of the Evista Alendronate Comparison (EVA) trial, a multicenter randomized study (JCO, online February 22, 2010).

Between 2002 and 2007, the trial recruited 687 women with moderately increased risk of breast cancer (lifetime risk of 20% or greater). The women had 1,679 annual screening rounds with the different screening options. In a subgroup of 371 women, additional half-yearly ultrasound and CBE were performed in more than 869 screening rounds.

Twenty-seven women were diagnosed with ductal carcinoma in situ (DCIS) or invasive cancer: 11 had DCIS (41%) and 16 had invasive cancers (59%). Three (11%) of the 27 were node positive. All of the found cancers were detected during annual screening, Kuhl and colleagues wrote.

Of the imaging methods under investigation (digital mammography, ultrasound, and MRI), MRI was the most sensitive, finding 93% of breast cancers. Ultrasound found 37% and digital mammography found 33%.

MRI’s superior performance suggests that in high-risk women it should be used as the annual screening exam, according to the authors.

“Our findings suggest that in these [high-risk] women, MRI is essential for early diagnosis — and that a mammogram or an ultrasound examination does not increase the ‘cancer yield’ compared to what is achieved by MRI alone,” they wrote. “We conclude that annual MRI is not only necessary, but in fact sufficient for screening young women at elevated risk of breast cancer. In women undergoing screening MRI, mammograms will have no benefit and should be discontinued.”

Although the radiation dose associated with regular mammographic screening is safe, high-risk women, who begin annual screening earlier, at age 25 or 30, will be exposed to more cumulative lifetime radiation dose — and these women have breast tissue that is already more vulnerable to cancer, according to the researchers.

“It is no longer justifiable to insist on annual mammographic screening for women in their 30s if they have access to screening MRI,” they wrote.

The Department of Radiology at the King Faisal Specialist Hospital and Research Centre in Jeddah, Saudi Arabia, has 6 radiologists on staff and provides services such as General Radiography (x-ray), CT/MRI, Ultrasound, Nuclear Medicine, Mammography, and Bone Mineral Densitometry (BMD).
Requirements

* American Boards or Canadian FRCPC in Radiology.
* A minimum of ten years post-specialty certification experience in Radiology in North America, including a minimum of three years of experience as a department head.

Benefits

* Tax-free income
* Married-status contract
* Accommodations provided
* Relocation allowance
* Education allowance for up to four eligible dependents
* Professional leave and allowance
* Six calendar weeks of vacation

Apply to this Job

To apply to this job please email your resume to hza@hziegler.com or call u at 1-800-387-4616.

Since we are a North American based recruitment company we are only able to recruit citizens of Canada and the United States.

The Job

You will perform PET, CT and Nuclear Medicine Imaging Procedures on patients to produce quality images for diagnostic interpretation.

Requirements

*Degree or Diploma in Radiography or Medical Imaging Science
*Experience in CT Imaging will be an advantage

Interested applicants are invited to send in a detailed resume , stating full personal particulars, educational qualifications, career history, present and expected salary to:

Singapore General Hospital
Human Resource Division
167 Jalan Bukit Merah
Connection One,Tower 5,#19-10
Singapore 150617

Alternatively you can also submit your application online via website www.sgh.com.sg/JoinUs

We regret only shortlisted candidates will be notified.

We wish to invite committed individuals to fill the above positions in our dynamic team delivering compassionate care in a fully integrated setting.

Radiologic Technologist for Bangkok Hospital Phuket 1 position

* Bachelor’s degree in Radiological Science.
* Completed Radiology License Certificate.
* At least 2 years experience.
* Be able to work in Phuket.

Please apply in person or mail application to:

Corporate Human Resources
Bangkok Dusit Medical Services Public Co.,LTD.
2 Soi Soonvijai 7, New Petchburi Rd., Bangkapi, Huaykwang, Bangkok 10310
Tel. 0-2310-3303 Fax: 0-2755-1108
Email: nattaya.wi@bgh.co.th