Dr. Laurence Klotz discusses micro-ultrasound as a faster, less invasive, more cost-effective screening strategy compared to mpMRI in this podcast. 

Reading Room Podcast: Micro-Ultrasound for Easier Prostate Cancer Screening

New York-based start-up Ezra, a company focused on early cancer screening with MRI, has secured 510(k) clearance for its artificial intelligence (AI) tool for prostate cancer screening.

As the first prostate AI algorithm to receive clearance from the U.S. Food & Drug Administration, Ezra Prostate AI is designed to help radiologists analyze and segment prostate MRI while simultaneously reducing time and cost associated with MRI-based prostate cancer screening.

“Over the past two years, our team has worked tirelessly on building Ezra’s Prostate AI, and I’m thrilled to bring it to our imaging partners across the U.S.,” said Emi Gal, chief executive officer and co-founder of Ezra. “We will continue to work towards making the interpretation of prostate MRI scans faster and more affordable, in order to support the millions of men who are at risk of prostate cancer.”

Overall, company officials said, the prostate AI tool offers three capabilities:

Automatic lesion quantification: This tool helps providers segment lesions and can display lesion size automatically.

Automatic 3D volume rendering: Via the segmentation capabilities, radiologists can automatically render prostate gland and lesions 3D volumes, improving workflow efficiency.

According to company representatives, Ezra Prostate AI requires no software installation – the Ezra Plexo, a cloud-based PACS, has also received FDA clearance, and works directly in a web browser.

Ezra launched its MRI-based prostate cancer screening service in January 2019 and its full-body MRI scan in May 2019. In response to this FDA clearance, the company is dropping the price of an Ezra scan by 15 percent to $575.

For more coverage based on industry expert insights and research, subscribe to the Diagnostic Imaging e-Newsletter

Articles

Algorithm cleared to help radiologists analyze and segment prostate MRI.

Industry-First Prostate AI Cleared by FDA

Pre-operative MRI can catch more breast lesions in women with dense breasts who have receive their initial breast cancer diagnosis via digital breast tomosynthesis (DBT).

Together, investigators from a multi-institutional team determined that pre-operative MRI does perform differently between women who undergo DBT and those who have digital mammography (DM). They shared their results in the Oct. 13 

“In our study, we found a trend of increasing detection by MR of additional sites of malignancies in patients with dense breasts compared to those with non-dense breasts, irrespective of initial imaging modality – DM versus DBT,” said the team led by Elizabeth McDonald, M.D., Ph.D., assistant professor of radiology at the Hospital of the University of Pennsylvania.

Pre-Operative Breast MRI Diagnoses More Cancers in Women with DCIS

Based on their results, McDonald’s team discovered MRI detected additional malignant lesions in 57 percent of all women with dense breasts included in their study. This finding can be potentially critical because approximately 43 percent of American women between the ages of 40 and 74 have dense breasts, and evidence continues to mount that they could benefit from supplemental screening.

DBT is known to have a higher cancer detection rate in women regardless of their breast density, but little is know about how it compares to MRI in this regard.

“To optimize the use of breast MR in pre-surgical planning, it is necessary to identify a subset of patients who will benefit most from this exam,” they said.

To determine the impact of pre-operative MRI in detecting more cancers, the team conducted a retrospective analysis of 388 consecutive breast MRIs captured for newly diagnosed breast cancers between Oct. 1, 2013, to July 31, 2015. The original diagnosis was made either by DM or DBT, and the team stratified identified disease by modality, breast density, and background enhancement.

According to their analysis, pre-operative MRI picked up 50 additional malignancies – 37 ipsilateral and 13 contralateral. While there was no difference in MRI detection of additional disease between women imaged with either modality, MRI did detect more cancers in women with dense breasts who underwent DBT.

“There were significantly higher discordant MR findings in patients with dense breasts (p=0.004) with a trend toward significance for true-positive exams (p=0.06),” the team said. “In patients imaged with DBT, those with non-dense breasts had significantly fewer additional cancers detected by MR.”

Overall, they said, 7 percent of women with non-dense breasts had additional cancers identified versus 18 percent of women with dense breasts. In addition, background parenchymal enhancement on MRI was also significantly higher in patients with mammographically dense breasts.

“These findings suggest that in women imaged with DBT, MR may have less value for determining extent of disease in women with non-dense breasts,” the team said. “Among patients with DBT imaging at cancer diagnosis, women with dense breasts appear to benefit more from pre-operative MR than non-dense women.”

MRI catches more malignant lesions in women with dense breasts who undergo digital breast tomosynthesis than those who have digital mammography alone.

Pre-Operative MRI Catches More Cancers in Women with Dense Breasts

Adding a deep learning algorithm to standard CT technology can produce images that offer greater detail without the added radiation, new research has revealed.

a team of engineers from Rensselaer Polytechnic Institute demonstrated how using this type of algorithm with conventional CT scans can capture images that typically require dual-energy CT (DECT).

“We hope that this technique will help extract more information from a regular single-spectrum X-ray CT scan, make it more quantitative, and improve diagnosis,” said study co-author Ge Wang, an endowed professor of biomedical engineering and director of the Biomedical Imaging Center in the Center for Biotechnology and Interdisciplinary Studies (CBIS).

Although CT scans are widely used in the United States – studies have spiked nearly 30-fold in the past 40 years to more than 80 million annual exams – they cannot give providers enough detail about the composition of imaged tissues. DECT can offer that information, but it comes with both higher radiation dose and cost.

Dual-Energy CT in the ED Brings Greater Confidence

To avoid these issues and still give radiologists the information necessary for more informed interpretations, Wang’s team trained their neural network, dubbed ResNet DL, on DECT-derived virtual monoenergetic (VM) images. Their deep learning approach is designed for extraction of a non-linear transform from a single-spectrum CT image training dataset to reconstruct VM images using only a single-spectrum dataset.

According to their tests, this trained neural network produced high quality approximations of VM images with a relative error rate of less than 2 percent, Wang said. The structural similarity was 0.9991 +/- 0.0018, and it showed structural information, particularly texture features, were well preserved by the machine learning method. In addition, bone images were clearly separated from reconstructed VM images.

“It has been clearly demonstrated in our study that a conventional CT energy-integrating dataset coupled with [deep learning] can deliver a close approximation of DECT images,” the team said. “Thus, it is potentially feasible to just use conventional CT to perform some important tasks of DECT.”

Ultimately, from a clinical perspective, they said, the potential exists for this VM imaging method to significantly reduce scan times and radiation dose associated with a photon-counting micro-CT scan.

“Professor Wang and his team’s expertise in bioimaging is giving physicians and surgeons ‘new eyes’ in diagnosing and treating disease,” said Deepak Vashishth, CBIS director. “This research effort is a prime example of the partnership needed to personalize and solve persistent human health challenges.”

Training a neural network with images captured by dual-energy CT can produce high quality studies without the added dose or expense.

Deep Learning Plus CT Produces Spectral Images Without Higher Radiation

Introduced during RSNA 2019, GE Healthcare’s Serena Bright™ -- the industry’s first contrast-enhanced biopsy solution for mammography – received 510(k) clearance Tuesday from the U.S. Food & Drug Administration.

This technology enables providers to perform contrast-guided breast biopsies without changing mammography equipment, rooms, or staff after a screening or diagnostic mammogram. Results, company officials said, can be available a few days rather than the several weeks needed for an MRI biopsy.

These biopsies and malignant lesions identifications are possible, the company said, because Serena Bright™ uses GE Healthcare’s SenoBright™ HD Contrast Enhanced Spectral Mammography. This diagnostic breast exam performed with iodine-based contrast pinpoints unusual blood flow areas, helping to localize lesions requiring biopsy. In doing so, the tool can improve a radiologist’s diagnostic confidence and accelerate patient care.

GE Healthcare Introduces First Contrast-Enhanced Mammography Biopsy

“Now, more than ever, it is critical we put the comfort of patients first and get them answers as fast as possible,” said Agnes Berzsenyi, president and chief executive officer of women’s health and X-ray at GE Healthcare. “We hope this technology can help improve breast cancer outcomes for women during this time of uncertainty.”

In fact, according to one published study, the United States can anticipate a potential increase of 33,890 cancer deaths. It is in the climate of the lingering pandemic that the quicker turn-around of biopsy results can be particularly valuable, said one physician familiar with Serena Bright™.

“In the current COVID-19 environment and requirements for shorter appointments to allow physical distancing, time has become our most precious asset,” said Anat Kornecki, M.D., head of the division of breast imaging in the St. Joseph’s Health Care London Breast Care Program and scientist with Lawson Health Research Institute in Ontario. “This new mammography-guided biopsy technique is a game changer, and patients tell us it’s a very tolerable experience.”

Overall, she said, the technology enables a woman to stay in a setting that is more familiar and comfortable than an MRI machine where she must lie face down for the exam.

Serena Bright™ has already been tested in clinics in France and Spain, and Jefferson Health in Philadelphia is slated to be the first healthcare system in the United States to begin offer this technology to its patients later this year.

Serena Bright™ shortens time to biopsy results, a critical capability during the COVID-19 pandemic.

GE Healthcare Captures FDA Clearance for Industry-First Contrast-Enhanced Mammography Biopsy

BI-RADS, LI-RADS, and Lung-RADS have helped countless radiologists classify breast, liver, and lung lesions. But, to date, little has been done to improve how providers understand the every-growing volume of artificial intelligence (AI) algorithms.

Dartmouth-Hitchcock Medical Center recently addressed this problem head-on by launching AI-RADS – an artificial intelligence curriculum for its radiology residents. Through a specifically designed set of lectures, residents not only reported they have a much greater understanding of AI, but they also indicated they were extremely satisfied with the program. Faculty shared these outcomes in an Oct. 17 article published in 

“As artificial intelligence continues to reshape the world of medicine, it will become imperative that physicians are familiar with fundamental algorithms and technique in artificial intelligence,” said the team led by Petra J. Lewis, MBBS, professor of radiology and vice chair of radiology education. “This will become an essential skill for interpreting medical literature, assessing potential clinical software augmentation, formulating research questions, and purchasing equipment.”

The field of AI in radiology is constantly shifting, Lewis’s team said, and the level of instruction radiologists have received in how to understand and implement these tools has been uneven at best. In their pilot course, they designed a series of lectures that offer guidance on the strengths and limitations of machine learning with the goal of helping providers better understand the scientific literature being published on the subject.

To maximize AI understanding, the team crafted each of seven lectures around specific algorithms and supporting fundamental concepts in computer science. The team selected which algorithms to include based upon how commonly they are used and the problems they were designed to solve, using them to build an intellectual foundation for data representation. Lectures were held monthly for seven months.

Simultaneously, residents participated in a journal club where participants discussed each lecture’s algorithm. These two-hour meetings were held within two weeks of each lecture and included study guides that defined unfamiliar terms and broke down complicated mathematical expressions into simpler terms.

Overall, the team said, after attending the lecture series, residents were expected to be able to:

Describe the foundational algorithms, intellectual underpinning, and clinical radiology applications of AI.

Read journal articles on AI in radiology proficiently.

Pinpoint potential weaknesses in the design, database features, and performance reports of these AI algorithms.

Identify instances where AI techniques can be employed to address problems.

Describe the different ways information can be abstractly represented and exploited.

Showcase their fluency in AI “buzzwords.”

The team surveyed residents with content questions to assess how much their understanding of AI improved after the lectures, and they also asked participants to rate their satisfaction with lecture series. Exit surveys indicated a high level of happiness – 9.8 out of 10.

“Trainees overwhelmingly feel that the content depth of the AI-RADS lecture series is ideal, and the examples used are helpful vehicles to understand the key concepts in artificial intelligence,” the team said.

Although the pilot program was implemented as an in-person curriculum, the team said there are plans underway to transition it to an online curriculum. In this way, they said, it can better accommodate the scheduling needs of a wider group of residents. In fact, they said, videos will be uploaded to the medical center’s 

Ultimately, the team said, their goal is to ensure the highest level of training for the next generation of radiologists.

“Residency programs are only beginning to employ basic computing concepts in their training, a skill that will become essential for the radiologists of tomorrow,” they said. “Proficiency in artificial intelligence will be a required skill in the near future of imaging services.”

A pilot lecture series at one medical center is designed to provide residents with in-depth instruction in commonly used artificial intelligence algorithms.

Mastering AI-RADS: Resident Curriculum Introduces Standardized Artificial Intelligence Instruction

In this week’s preview, here are some highlights of what you can expect to see soon on 

In our continued coverage of Breast Cancer Awareness month, breast imaging radiologist, Daniel Shekleton, M.D., from Raleigh Radiology in North Carolina examines recent investigations in the United Kingdom into the effects of launching annual mammography screening at age 40, underscoring the recommendations from the American College of Radiology and the Society of Breast Imaging. Look for his article later this week.

To read insights from his clinical colleague on breast imaging during COVID-19, 

For more coverage based on industry expert insights and research, subscribe to the Diagnostic Imaging e-Newsletter 

Staying knowledgeable of how a woman’s breast density affects imaging is critical, and knowing whether a patient has dense breast can influence your use of preoperative MRI. Investigators from University of Pennsylvania have examined in what circumstances this modality and technique works best. We explore their findings in an article that will appear later this week.

Corporatization is not new in radiology, but the trend is definitely growing. 

 spoke this week with Dr. Rich Heller, associate chief medical officer, and Dr. Nina Kottler, vice president of clinical operations, with Radiology Partners about how corporatization benefits radiology as an industry and the impacts it can have at the local level. Keep an eye out for their video interview this week.

Here's what is coming soon to Diagnostic Imaging.

Diagnostic Imaging's A Look Ahead: Oct. 19 to Oct. 25, 2020

Years before I even thought of writing my first blog, I made a series of attempts at fiction-writing. I’m pretty creative, and as a young ‘un I did more than a little reading, so I had seen plenty of examples of others’ successfully-finished products.

I never completed one myself, except for the occasional short story. I would get a great idea and dive into it, churning out page after page while I had time and a good head of steam. Then, life would get in the way, and it might be hours or days before I had another chance to sit at the keyboard…during which my mind would be moving further and further ahead of what I’d written. Eventually, the volume of ideas which awaited transmogrification into actual writing was sufficient to quench my enthusiasm.

The notion occurred to me recently: Never having gotten more than a couple-dozen pages into my would-be novels, I wondered how much blog-volume I’d written by now. Windows readily informed me that there were 459 files in my “blogs” folder. They’ve averaged around 2 pages each…Good Lord, I’ve written enough to fill three respectable volumes.

Of course, this is the result of pacing: Putting together a few hundred words once per week, rather than trying to crank out the Great American Novel before I get bored with it and would rather be doing something else. If you told me, back when I started this column in 2011, that I would be writing close to a thousand pages in the next decade, I might not have believed you. Even now, the thought is rather exhausting.

There’s a parallel to be drawn between this and one’s body of work as a diagnostic radiologist. If an early-in-career rad is sizing up a prospective job that expresses an expectation of X number of RVUs a year, or Y number of cases per day, that might sound daunting. The young rad might not even know how many cases, let alone RVUs, he’s able to do comfortably/competently. Or how the particulars of a given workplace will help or hinder that.

Learning one’s capabilities doesn’t make this entirely vanish. Knowing in the abstract that I’m capable of X amount of work is one thing. Being told that I can expect to 

 X amount is another, potentially anxiety-provoking matter: Will I continue to perform as I have? What if they give me more than X? What if what they give me turns out to be more complex than I’ve previously seen, and I can only do 80 percent of X? Will they expect me to ramp up and do more than X in the future? How can I increase my capacity?

I’ve probably mentioned at some point that my first job after fellowship was in an outpatient practice that routinely maintained a backlog of cases. You’d walk into whatever reading-room you were assigned for the day, and there would be shelves and stacks of folders waiting for you. Almost every day I was there began with a withering sense of “How on Earth am I going to get through all of this?”

Each case can feel like a drop in the ocean, especially if you’re sizing up everything you’ve got ahead of you all at once. Heck, even in hindsight: there have been times I look back on a busy workday, or some other task, and thought, “How on Earth did I do all of that?”

One way to get through it is to avoid focusing on the individual drops. Back when I ran on my school’s “track and field” and “cross-country” teams, I found out for myself that it was an awful lot easier to run my miles when they weren’t divvied up into countable things like laps. One “away” meet was at a school with an eighth-mile track instead of the usual quarter; having to do twice as many circles, even though it was the same distance, was a killer. I maintain to this day, that gave them an unfair home-field advantage.

In our line of work, however, I try to resist seeing the forest instead of the trees. Each one of these cases is our contribution to someone’s life. Whether it’s checking up on the status of their cancer or screening for it. Evaluating their bone density or carotid arteries to see if anything might be done to avoid hip fractures or strokes. Finding potentially-treatable reasons for symptoms…or evidence for reassurance that nothing bad is going on.

Just as I look back on my 900-plus pages of blog-writing, a rad might think back on however many thousands of lives he’s touched each year. If you’ve been in this game for even a little while, chances are excellent there’s a decent number of people alive today who might not have been without your contribution to their care. Or enjoying better quality of life.

On top of that, there are more than a few clinicians who are now wiser as a result of having interacted with you. You might have taught one how ultrasound is better than CT in a given situation, or why it’s worthwhile to give oral contrast rather than just throw someone on the scanner in the name of “throughput.”

There are surely also other rads who have learned by reviewing cases with you, or seeing your work when it’s a prior study they’re using for comparison against a current case. Indirectly, your impact on them has benefitted the innumerable drops in their oceans, as well.

Follow Diagnostic Imaging Editorial Board Member Eric Postal, M.D. -- @EricPostal_MD

How many lives have you changed, one scan at a time?

Another Drop in the Ocean

When teleradiology first came onto the industry’s stage, it was controversial. Would it siphon work away from facility- or office-based providers or would it pave the way for even greater productivity? As its use has grown, the benefits have come into clear view, but, according to some industry leaders, teleradiology still has more to offer.

In particular, the lingering COVID-19 pandemic has shown a bright spotlight on how integral teleradiology has become – and will stay – in the specialty. It has allowed providers nationwide to continue processing images while practicing social distancing, said a group for researchers from Emory University School of Medicine.

“Teleradiology has evolved from an occasional tool for convenience and, at times, a perceived marketplace disruption and threat into an increasingly systems-focused healthcare partner in improving access to imaging care across the nation,” said lead study author Tarek N. Hanna, M.D., an emergency and trauma radiologist in Emory’s radiology and imaging sciences department. “Technologic limitations and regulatory hurdles still hinder the optimal practice of teleradiology, and future attention to these issues may help ensure broader patient access to high-quality imaging across the United States.”

Hanna’s group outlined four challenges that face teleradiology in the Oct. 14 

This process can be difficult for teleradiologists. Each state is individualized, and teleradiologists must be knowledgeable of the requirements at both the sending and receiving sites. Consequently, because teleradiologists work with several facilities across state lines, this can be a stumbling block.

“These barriers result in practice inefficiencies and restricted access to emergent and subspecialty care, especially in rural markets,” the team said.

In 2014, the Interstate Medical Licensure Compact smoothed the path somewhat, making it easier for providers practicing in multiple states, but not every state participates. Larger states, including Texas, California, New York and Florida, are not included, making the more difficult for providers to practice.

In many instances, individual states have put rules in place that control certain aspects of workflow that can make daily activities harder for teleradiologists, the team said.

For example, they said, New York conducts quality control testing every two weeks on diagnostic monitors for remote reading. They also conduct quarterly evaluations, as well as annual testing by a licensed medical physicist. Complying with the regulations can be expensive and complicated for teleradiologists who live in rural areas, they said. Given that, some states with more rural populations, such as Minnesota and Wisconsin, have more relaxed mandates.

“Radiologists must stay engaged and use their (individual or collective voices to influence regulatory legislation,” the team said. “ We support evidence-based regulation; standardization of regulation across geography; and regulation that does not result in disparities in the quality of, or access to, imaging care.”

It can also be harder for teleradiologists to collect all relevant clinical information since they interpret studies from a variety of facilities that use different PACS and electronic medical record systems. Because of this, there is a need for augmented efforts to break down data-sharing barriers without weakening security and safety measures, such as statewide teleradiology networks.

In addition, interpreting radiologists are responsible for overseeing clinicians who complete the imaging exams. Consequently, because they are working remotely, there is a larger onus on these physicians to ensure streamlined communicate between themselves, the technologists, and the ordering provider. One strategy that has proven effective, the team said, is the virtual consult with instant messaging.

After-Hours Staffing Models and Reimbursement Implications

One of the biggest factors behind teleradiology’s growth is its ability to provide night and emergency coverage. But, just like with other facility-based radiologists, this schedule, as well as working rotating shifts, can lead to decreased job satisfaction, higher safety risks, and make it more difficult to recruit providers to work these hours. These schedules are also less attractive because there is not a CPT code that provides for adequate reimbursement.

“Radiologists should work with specialty societies to address such care discrepancies, understanding that this may involve more rigorous staffing (of both physicians and technologists) after-hours,” the team said, “and that such change may require both culture shifts and support from new reimbursement models.”

Despite these challenges, there are still several opportunities around the growing use of teleradiology, the team said. Alongside continuing to expand sub-specialty coverage to more rural locations and bolster care during public emergencies, such as the pandemic, teleradiology also stands to benefit from the continued growth of artificial intelligence. There is room for smart work lists that can rapidly triage urgent cases and more effectively match the studies with the best-trained teleradiologist who is available for interpretation, the team said.

Overall, the team said, even though challenges remain, teleradiology has proven itself to be a beneficial component to diagnostic imaging.

“In recent years, teleradiology has evolved from an occasional tool for convenience and, at times, a perceived marketplace disruption and threat into an increasingly systems-focused health care partner in improving access to imaging care across the nation,” they said.

Four challenges are preventing more institutions from implementing remote reading.

What’s Standing in Teleradiology’s Way?

When you were in medical school, your stethoscope likely felt like an extension of your hand – always by your side and your go-to tool for conducting exams and assessing your patients. For the next generation of medical students, point-of-care ultrasound could take that coveted spot.

At least, that is the goal of a burgeoning partnership between the College of Osteopathic Medicine at Touro University in Nevada and point-of-care ultrasound manufacturer Vave Health, said Amin Nikoozadeh, Vave founder and chief executive officer.

“We want to empower doctors, and ultrasound is the best tool to do that,” he said. “Ultrasound has a lot of utility. In a lot of senses, it is better than the stethoscope in that it allows students to see instead of just hear.”

Starting this semester, Vave will outfit Touro’s medical students with wireless pocket-sized ultrasound devices – that can sync with tablets and smartphones – that they can use for hands-on training in a variety of settings, including clinical rotations, in-person lab classes, or remotely from their home. In addition, each student will also receive a Vave EduPlus Membership that gives them access not only to ultrasound experts, but also to in-app content that can help with medical exam preparation and offer clinical context. The details of what educational details will be included in the app are still under discussion.

But, by putting a portable ultrasound in the hands of every medical student, they can begin learning – from day one – how what they read about in their textbooks actually appears in real patients.

“Putting…ultrasound in the hands of our students provides them with cutting-edge technology to further their hands-on education, something that is so critical, especially in a time when traditional forms of learning have been rattled by the pandemic,” said Wolfgang Gillar, D.O., dean of the College of Osteopathic Medicine. “We’re proud to provide our students with a probe that allows them to practice in a variety of environments, whether in a hospital, rural area, or an underserved community.”

Integrating ultrasound during the first two years of training could fundamentally change medical education, said Renee Dversdal, M.D., Vave’s chief medical officer.

“It’s taking advantage of different educational concepts, longitudinal learning, and applying ultrasound,” she said. “For example, when they’re studying the carotid artery, we can show them the three layers, as well as show them where plaque accumulates and what happens with turbulent flow.”

The idea, she said, is to weave point-of-care ultrasound seamlessly into medical training and patient care. While receiving didactic training, students will also gain instruction and experience in image acquisition, image interpretation, and clinical integration.

“It’s a cooler way to learn anatomy and highlight the clinical exam,” she said. “You’re simultaneously sneaking in image acquisition and image interpretations skills. They’re subtly learning the basics of these skills. The goal is to have ultrasound so woven into their education that by the time they graduate, they won’t even have to think about doing ultrasound – it’ll just be second nature.”

Most importantly, she said, this partnership is not one-size-fits-all. It can be customized to meet the needs and adhere to the curriculum designs of individual medical schools. Basically, administrations can create their own programs.

And, from a partnership perspective, Nikoozadeh said, this is not a one-time interaction. The business model is designed to be low-cost for the medical school, and Vave will routinely provide updates and upgrades to the software as needed to ensure students have access to the most current information.

“We want our partners to know that they are getting a platform that evolves with them – that they’re not going to get left behind,” he said. “They will have access to the latest technologies in hardware, software, and artificial intelligence. This is a change that will lead to faster adoption of ultrasound technology at both the medical school and clinical levels.”

A partnership between one medical school and an ultrasound manufacturer is intended to re-design how students learn.

Is Ultrasound the New Stethoscope?

There is more disagreement between radiologists and more errors identified on secondary interpretations of body MRI scans than previous studies have reported, leading some experts to call for more sub-specialty interpretations.

Nearly 70 percent of body MRI interpretations have at least one discrepancy, according to researchers at the University of Vermont and the University of Southern California Medical Center. And, since most of these errors are cognitive – a misidentification of a finding – lead study author Danielle E. Kostrubiak, M.D., a diagnostic radiology resident at the University of Vermont Medical Center, said there should be a push for having sub-specialty trained providers read these studies.

“The data suggest that sub-specialty interpretations should be encouraged at tertiary care centers,” she said, “and institutions should provide adequate resources for these interpretations to occur.”

It is the first study to focus on secondary interpretations of body MRI evaluated by type of likely error, they said.

Diagnostic Errors: Lessons Learned and Mitigation Strategies

Interpretation errors are common in radiology, particularly with MRI scans, and those mistakes frequently lead to delayed or incorrect treatment plans. According to existing research, discrepancy rates can range from between 2 percent and 6 percent for resident reports over-read by attending providers to up to 56 percent for secondary interpretations. Most of these problems occur with pelvic and abdominal imaging, they said.

To determine the actual discrepancy rate, as well as why these mistakes happen, Kostrubiak’s team retrospectively reviewed 357 secondary body MRI reports that were captured between January 2015 and December 2018. They also analyzed the initial reports and divided the discrepancies by the most likely underlying reason.

Based on their evaluation, they identified at least one discrepancy in 246 cases (68.9 percent), and they pinpointed a second discrepancy in 54 of those cases. Cognitive errors accounted for most discrepancies – 68.8 percent of errors – perceptual errors accounted for 59.3 percent of secondary discrepancies.

“This difference [between cognitive and perceptual errors] may be explained by the fact that abdominal and pelvic MRI is frequently not the first imaging modality used and is often performed to characterize an abnormality detected on CT or ultrasound,” they said. “Therefore, the abnormality has already been perceived by the time MRI is performed.”

When they drilled down in the underlying reasons behind these discrepancies, they found that faulty reasoning – a misclassification of the abnormality – was responsible for 34.3 percent of all instances, as well as 37.8 percent of primary discrepancies. In addition, satisfaction of search occurred with 37 percent of second discrepancies, and 15 percent of overall discrepancies. In these instances, the team said, an MRI scan has likely been ordered to answer a specific question, and once that answer has been determined, the radiologist likely did not examine the rest of the scan for any other abnormalities.

There could be several reasons why these discrepancy rates are higher than what has been previously reported, the team said. Existing research already shows that body imaging frequently has highest error rates, and double-reading by sub-specialists also increases the discrepancy rate, they added. In addition, general radiologists may be unaware of MRI’s high sensitivity can be used to determine specific diagnoses.

It is possible that similar studies will be limited by the innate subjectivity of error classification, but the team said related research should be easier to conduct in the future as medical practices expand their use of electronic medical records.

“The next step,” they said, “would be to explore how these discrepancies may impact patient outcomes and overall cost to the system associated with these radiologic errors.”

Mistakes highlight the need for more sub-specialty reads with MRI, particularly abdominal and pelvic scans.

Discrepancy Rates and Errors a Bigger Problem with Body MRI Than Realized

A recently published study from the United Kingdom (UK) confirms that mammography screening, beginning at age 40, significantly reduces breast cancer mortality. The results appeared in 

 in August 2020. These study results reaffirm the recommendations of the American College of Radiology and the Society of Breast Imaging. Both organizations recommend that most women begin annual mammography at age 40 – earlier than when most women have their first screening.

What does this UK study mean to us here in the United States?

The UK study provides valuable additional data for those of us in the breast imaging field. This recent update confirms, again, that annual breast cancer screening beginning at age 40 saves lives. Breast cancer death rates were reduced by approximately 25 percent for women who began screening at age 40, averting one death per 1,000 women screened, and this absolute gain remained constant until the end of the study. The UK study also confirmed that there is little fear of over-diagnosis in the 40-to-49 age category with a rate similar to what is commonly encountered in women over 50.

The UK Breast Screening Age Trial recruited 53,883 women to begin annual mammography screenings at age 40. Researchers placed twice as many women (106,953) in the control group. The control group participated in the UK’s National Health Service (NHS) standard breast cancer screening. The NHS provides breast cancer screenings to women aged 50 until age 71 every three years.

Women Who Survive Childhood Cancer Benefit From Earlier Breast Screening

Researchers sent randomly selected women invitations through the mail, offering annual breast cancer screening beginning at age 40. These women were recruited from general practitioners’ lists, held by Family Health Services Authorities. The women who responded were ages 39-to-41, from 23 breast screening sections in England, Scotland, and Wales.

Researchers also randomly chose women for the control group. These women were not aware of the research project and received the standard breast cancer screening with no departure from standard care.

The younger annual mammogram group received annual mammograms until they received their invitation from NHS for breast screening. The control group of women began their breast cancer screenings once they reached age 50, following NHS recommendations.

Recruitment began on October 14, 1990, and ended on September 24, 1997. Researchers followed patients for a median time of 22.8 years.

The trial used two-view film (analog) mammography for each participant’s first screening. Afterward, single view was utilized. The local facility staff double-read each participant’s mammogram. If a woman moved, she could self-refer to the nearest center taking part in the trial. Women in the trial transitioned to the regular NHS breast cancer screening program once they received their invitation around age 50.

The NHS Central Register and all trialists were notified of every breast cancer diagnosis, breast cancer death, and other death causes for trial members through February 28, 2017.

The primary endpoint for the UK Breast Screening Age Trial was death by breast cancer in both groups. Researchers compared deaths from both groups that occurred before their invitation to the standard NHS breast screening program.

Participation from screening invitations was similar in both groups of women:

68.1 percent (36,622 women out of 53,801 women invited in the interventional group) had their first mammogram.

69.1 percent (176,746 women, out of 255,618 women invited in the control group) had their first mammogram.

False-positive results in the interventional group were modest. Researchers saw a 4.9 percent false-positive rate for participants’ first screen mammogram, and a 3.2 percent false-positive rate occurred for later screenings in the interventional group. Breast cancer incidence rates between the interventional group and the control group showed similar incidence rates.

Researchers saw a significant difference in death rates from breast cancer by 10 years. The interventional group experienced just 83 deaths compared to 219 deaths in the control group. There was no significant difference during the next 10-plus years of follow-up. Of the breast cancer deaths, 126 occurred in the early intervention study group and 255 in the control group.

The newest study update comes 23 years after recruitment ended. The study confirms that annual breast cancer screenings that begin at age 40 reduce breast cancer mortality.

In summary, the UK study confirms that screening mammography beginning at age 40 significantly reduces breast cancer mortality as compared to women who wait to begin screening mammography until age 50. These findings validate both the ACR and the SBI recommendations that women of average risk begin having annual mammograms beginning at age 40.

“Breast cancer screening saves lives, annual screening mammography beginning at age 40 saves the most lives.”

Daniel Shekleton, M.D., is a breast imaging radiologist and breast intervention specialist with Raleigh Radiology. He is a member of the RSNA, ACR, and SBI. He earned his bachelor’s degree at the U.S. Military Academy at West Point and completed his medical degree and residency in radiology and internal medicine at the Southern Illinois University School of Medicine. He joined Raleigh Radiology in 2019.

Screening mammography begins to reduce breast cancer mortality at an age earlier than when most women begin screening.

UK Study: Benefits of Breast Cancer Screening Begins at 40

Even though CT scans have not been widely used to diagnose COVID-19 infection, new research shows that using spectral CT with electron density (ED) imaging can make it much easier to assess the extent of lung lesion in patients who have early-stage disease.

Using a small group of case studies, published Oct. 21 in the 

a team of clinicians from Antony’s Private Hospital in France showed that electron density (ED) imaging can improve ground-glass opacity (GGO) visualization compared to conventional CT studies.

“ED imaging may improve the detection of early-stage COVID-19, a stage for which conventional CT has shown limited sensitivity for detection,” said lead study author Beatrice Daoud, an associate radiologist at Antony's. “Spectral CT may also provide a better assessment of the extent of the lung lesions.”

Although GGOs do show up on conventional CT scans, the visualization is subtle, Daoud’s team said, revealing only very small increases in attenuation compared with normal lungs. Consequently, accurate identification can be difficult, particularly during early infection. This study marks the first time investigators have looked into whether spectral CT scans can improve providers’ abilities to assess lung lesion extent.

To make this determination, the team retrospectively examined data from spectral CT scans conducted in four patients who have had confirmed COVID-19 cases with an RT-PCR test, they said. They reconstructed the spectral CT images using the same standard soft kernel (filter B) and a similar iterative method that is used to capture conventional CT images. They, then, compared initial conventional CT images with the follow-up conventional CT scans.

Based on their analysis, all 45 GGOs identified in the four patients showed up better on the ED images than the conventional CT scans, and the follow-up conventional CT images confirmed their presence. In addition, the lesion extent, which they assessed with semi-quantitative reporting scale denoting surface area involvement for each lobe, was much easier to determine on ED images, the team said.

“We reviewed conventional chest CT images obtained with a parenchyma kernel and standard lung window setting, as is usually the case in everyday radiology practices,” Daoud said.

The team compared the ED images to conventional images obtained using a soft mediastinum kernel and standard lung window setting, as well as conventional images captured with a soft mediastinum kernel and narrow lung window setting, virtual low-monoenergy images, virtual high-monoenergy images, and electron density images.

Based on these comparisons, the team discovered ED images made a difference in evaluating each of the four patients:

 A 39-year-old man diagnosed via conventional CT with lesions in both the right upper and lower lobes was found – with ED imaging – to have lesions in the upper left lobe that were barely noticeable previously.

 A 41-year-old woman with GGOs in both lower lobes discovered with conventional CT had additional lesions identified in the upper right lobe with ED imaging.

 A 64-year-old man had a conventional CT that showed peripheral bilateral diffuse GGOs. ED imaging revealed the GGOs to be more extensive and conspicuous than initially believed.

 An 80-year-old man had barely noticeable peripheral GGOs in the left upper lobe. Follow-up ED imaging showed the extent of these GGOs.

Overall, these results show that ED imaging offers greater detail for early assessment of GGOs that can be overlooked with conventional CT. The results are most promising, they said, by enhancing the contrast of GGOs compared with the normal lung.

“Our results suggest that the better ground-glass opacity visualization obtained using electron density imaging may be chiefly related to the increased visual noise in the image with soft kernel reconstruction and narrow lung window setting compared with electron density imaging, for which narrowing the window does not impair image quality,” they said.

Still, they said, a more systematic analysis of the different available image reconstruction is needed.

Spectral CT provides greater detail about the extent of ground-glass opacities than conventional CT scans.

Spectral CT Makes Detecting Early-Stage COVID-19 Easier

CT colonography (CTC) exams occur less often in patients over age 65, a new study has found, and this downward trend could affect racial and ethnic minority patients the most.

Journal of the American College of Radiology

 a team of investigators from Emory University School of Medicine, led by Courtney Moreno, M.D., associate professor of radiology and imaging sciences in the Winship Cancer Institute, revealed the impetus for this drop could be because Medicare does not cover the exam.

“We observed that the relative utilization of screening CTC in individuals typically eligible for Medicare coverage decreased after age 65, suggesting access barriers related to a more restrictive Medicare coverage policy,” the team said.

Despite being a preventable condition with appropriate screening, colorectal cancer remains the second leading cause of cancer death in the United States. CTC is designed to detect colorectal cancer, as well as other types of colon cancer, but the Center for Medicare & Medicaid Services (CMS) announced in 2009 that evidence on the efficacy of CTC was lacking.

CT Colonography Has Higher Cancer Detection Rate Among S

Given the agency’s position, Moreno’s team set out to determine whether this stance is detrimentally impacting the quality of care given to patients. To do so, they examined CTC use, pulling 12,648 screening exams from the American College of Radiology’s CTC registry. They looked at both the age of patients, as well as any association between use of the exam and Medicare-eligible patient race.

Based on their analysis, the team identified a significant uptick in colon cancer rates in patients over age 50 – an annual increase of 5.3 percent in individuals between ages 52 and 64. On the flip-side, though, CTC screening rates began a noticeable decline after age 65, falling off by 6.9 percent for each additional year of age.

In addition, they noticed a difference in the screening rates between white and African American patients. For white patients, the CTC screening rate was highest between ages 65 and 69, but the test was administered most often in African American patients between ages 55 and 59.

This difference, the team said, could be attributed to Medicare’s lack of CTC coverage for patients over age 65. The average out-of-pocket expense for CTC screening, according to Costhelper.com, is $2,400, they said. Consequently, by not covering the test, the agency is likely making it harder for patients who cannot afford to pay for the test without insurance to secure the screening.

The factors behind this disparity are largely social and structural in nature, the team concluded, and they equate to a reduced ability to afford effective screening services. Not only is the average annual income lower for African American patients than it is for white patients, but African American Medicare beneficiaries also have, on average, lower levels of savings.

African American, as well as other racial and ethnic minority, patients likely have lower levels of CTC screening due to out-of-pocket costs.

UK Study: Benefits of Breast Cancer Screening Begins at 40

Spectral CT Makes Detecting Early-Stage COVID-19 Easier

Lack of Medicare Coverage Limits CT Colongraphy Use in Minority Patients