MR vendors balance patient comfort, technology drive

November 1, 2007

Breast MR is approaching celebrity status. A raft of expert opinions, notably from the American Cancer Society, has established MR in public and professional minds as a leading means to diagnose cancer among patients at high risk and possibly even among patients in the general population.

Breast MR is approaching celebrity status. A raft of expert opinions, notably from the American Cancer Society, has established MR in public and professional minds as a leading means to diagnose cancer among patients at high risk and possibly even among patients in the general population.

Vendors at the RSNA meeting will dress MR up in clinical wares, showing capabilities possible with specialty coils and tables, pulse sequences, and computing engines for processing data. This approach will come as anything but a surprise to veterans of this meeting, where vendors in past years have pinned the future of MR to continued development of advanced clinical applications.

From reimbursement erosion to concerns over the use of MR contrast agents, the economic and clinical climate has changed dramatically in North America, the world's number one marketplace for big-ticket imaging equipment. Corporate progress will depend on more than just a rising volume of MR procedures, a fact that has raised challenges and opportunities that the big four vendors of MR equipment will address on this year's exhibit floor.

Visitors to vendor booths will see new scanners at the 1.5T and 3T levels designed as much for productivity and low cost as clinical capability. A difficult year, the third in a row of flat or declining revenues from new equipment sales in the North American marketplace, has sensitized vendors to a budget-conscious customer base. Continuing demand for MR has saved the market from a worse fate, however, while planting the seeds for growth in the coming year or two. Driving that demand have been advanced applications. A twist this year will be a broadly based emphasis on techniques that eliminate or reduce the need for injectable contrast media for vascular studies.

Many other sophisticated applications are already on the market for breast MR, functional MRI, body diffusion-weighted imaging, and orthopedic and cardiac protocols. These will be enhanced and refined, partly through software and hardware developments that support faster scans and reconstructions. A major emphasis this year, likely to be obvious on the RSNA floor, will be software to make these advances easy to use and their results reproducible.

The new scanners slated for unveiling at the RSNA meeting will clearly reflect a maturing marketplace that must balance clinical and economic demands, patient and operator needs. Two new MR systems from Siemens exemplify this balancing act.

At 170 cm, Siemens' Verio will be the shortest 3T scanner in the industry. But the German company expects the bore diameter of 70 cm to be of greatest interest to prospective buyers. This is the same size as Siemens' so-called open-bore 1.5T Espree. Like the 1.5T scanner, the new 3T Verio will come equipped with the company's Tim (total imaging matrix) coil technology.

"Verio will allow customers to address two aspects: the need for patient comfort and the trend in the U.S. toward 3T," said Britta Funfstuck, Siemens vice president of global marketing. "Combining those two aspects with Tim provides for fast workflow and excellent image quality."

Actual price will depend on configuration, but Verio could be "reasonably" equipped for less than $2 million, said Jeffrey Bundy, vice president of the Siemens MR division USA.

Siemens will position its second new MR, the Essenza, as the industry's "most affordable 1.5T MRI," a very short, very lightweight system built from the ground up, Funfstuck said.

"It is a fundamentally exceptional opportunity to get into 1.5T at a very low cost of ownership," she said.

Economic challenges in the U.S. have led to a rise in demand for refurbished systems. The Essenza, bearing the company's Tim, will be priced under $1 million, a price point designed to take the wind out of used equipment sales, according to Bundy. Siemens trimmed production costs by not including the most advanced applications on its latest development, while preserving the workhorse platform that underlies its Magnetom product line.

"It fulfills classic requirements, addresses standard workflow issues," Funfstuck said. "It makes a very good solution for people who do not have extensive experience in MR."

Cost of ownership is minimized through ease-of-use features that hold down the cost of training and boost productivity, she said. Siemens engineers have built a major component of the spine array coil-the "isocenter matrix coil"-into the scanner bore, eliminating the need for technologists to place this coil and position the patient for each spinal exam. This reduces exam time, as well as wear and tear on the coil. It also ensures that the patient and coil will be correctly positioned, as the coil naturally defaults to the isocenter of the field-of-view.

A new system from Toshiba, Vantage Titan, will enter at the top of the Toshiba 1.5T hierarchy, but with advantages that go beyond the advanced clinical capabilities it is designed to support. An extrawide bore will allow patients of substantial girth to be scanned, a homogenous field-of-view that completely fills the bore avoids diagnostic trade-offs, and powerful gradients provide the foundation for workhorse status.

At 71 cm, Vantage Titan has the largest aperture of any MR scanner

on the market, according to Bob Giegerich, director of the Toshiba MR business unit. The useful field-of-view completely fills the circular inner bore diameter of 69 cm.

"The key is to generate the radiofrequency in a big circle," he said. "To do it, we came up with a new RF power supply, which is 175% of the old one."

Whether it is displayed as a work-in-progress will depend on the FDA, which must yet review the device. Its first buyers, however, are scheduled to take delivery in February 2008.

The Titan's entry into the Toshiba portfolio means last year's wide-bore development, the elliptical 1.5T Vantage Atlas Plus, will not go into production. Soon after unveiling the Vantage Plus at RSNA 2006, Toshiba engineers had sufficiently evolved the concept for the Titan to doom to obsolescence the 60 x 65-cm elliptical field found in the Plus before the scanner even got off the drawing board.

"We didn't build it because we figured out how to make this one," Giegerich said.

The entry of Titan will also provide Toshiba with the broad-based offerings that company strategists believe are necessary to address the multifaceted North American market. If the FDA clears Titan, as expected, Toshiba will have in its MR portfolio three major products at different price points: Vantage as a value-oriented 1.5T, Vantage Atlas at the midrange high-performance level, and Titan at the top of the chain, competing directly with Siemens Espree as a wide-bore system capable of premium performance.

Recognizing the economic issues that have burdened the MR market for the past several years, Philips Medical Systems at last year's RSNA meeting introduced its Achieva XR, an MR system that could be upgraded in the field from 1.5T to 3T. The magnet built into this system is capable of generating 3T field strength but can be set to just 1.5T. The upgrade to 3T involves the replacement of components that allow an increase in the electrical current applied to the magnet and swapping the body coil for one compatible with this field strength. The gradients do not have to be changed.

The Achieva XR was designed to make the transition to 3T as simple as possible. Philips will sound this theme of simplicity again this year but in different ways, according to Conrad Smits, CEO of Philips MRI.

"It is our challenge to bring simplicity to imaging and to clinical applications so technologists and radiologists can focus on what they are being paid to do," Smits said.

The company will demonstrate at its RSNA booth how technologies acquired as part of its corporate takeover of Intermagnetics General last year-superconducting magnets, coil, and other peripherals-can be harnessed with Philips' in-house developments to achieve this goal, he said. The company will also continue its emphasis on 3T, as demonstrated in the Achieva XR, while maintaining its commitment to open MR with the Panorama 1.0T scanner introduced three years ago.

"It's easy to bring technological advancement, but in the end, if your customers can't make a better business out of it or better clinical analysis, it doesn't serve much purpose," Smits said.

The RSNA meeting will provide Philips a chance to shop its pending reorganization to the imaging community, whose response will play a big part in whether the company's Vision 2010 initiative, announced Sept. 10, will meet expectations. The company hopes to achieve cost savings through streamlined operations and increased revenues tallied by taking market share from competitors, partly by consolidating healthcare operations while focusing on key opportunities: women's health, cardiology, oncology, and critical care.

Specific efforts will happen in the broad context of a healthcare continuum that Philips executives say reflects the present and, increasingly, the future of healthcare in the U.S. Emphasis will be on managing the patient through the use of diagnostics, including imaging, to come up with the optimal therapy.

GE Healthcare has its own continuum. At this year's RSNA meeting, the company will further evolve its existing Signa HD x (high definition x) platform.

"We will continue refining and improving the platform, taking it to the next level," said Dave Handler, general manager of global MR marketing.

To GE, high definition means optimizing each exam by tweaking the pulse sequence, parallel imaging technique, and coil for specific parts of the body, such as the brain or breast. This approach is exemplified by the company's development over the last several years of the breast-specific Vibrant package for breast MR and the integration of breast-specific tables with high-density coils that together deliver high-definition breast imaging, Handler said.

Last year, GE's agenda in breast imaging was advanced in collaboration with Sentinelle Medical, which commercialized a new table dedicated to interventional breast MR, shown at the GE booth as well as its own. The table, which supports bilateral and unilateral imaging and biopsy, is enabled for parallel imaging, features guidance software, and comes equipped with disposable biopsy plates. Look for the next step in the development of these technologies from both GE and Sentinelle, Handler said.

Echoing Philips' theme of simplicity, GE will look for ways to optimize exams to improve consistency both in and outside of breast MR.

"The key for MR is to make (procedures) easy and consistent for every technologist at every site to produce that image patient after patient, exam after exam," he said. "So we continue to enhance the simplicity and user-friendliness of our systems."

Techniques for doing vascular imaging without injectable contrast will figure prominently at this year's meeting. Toshiba's proprietary contrast-free imaging technologies bear familiar acronyms: Fresh Blood Imaging (FBI) and Contrast Improved Angiography (CIA). FBI is used for slower blood flow as occurs in the hands and feet. CIA is for peripheral runoffs.

The company developed the noncontrast forerunners of these techniques in 1998, eight years before concerns surfaced over the use of gadolinium-based agents and nephrogenic systemic fibrosis (NSF). Last year, the company featured vascular images made using its Vantage MR scanners under a banner asking booth visitors to find "what's missing from the images," Giegerich said.

"The answer was contrast," he said. "This year, we're going to play it really big."

Along with FBI and CIA, the company plans to feature a new contrast-free technique called TimeSlip. This technique is optimized for imaging the kidneys.

"The kidneys are the problem, when it comes to NSF," Giegerich said. "Therefore, imaging the kidney presents the biggest problem. You don't want to image the kidney in people with kidney disease using (gadolinium) contrast media, but this will do it."

Toshiba will not be alone in its effort to provide alternatives to injectable contrast agents. Siemens plans to prominently feature a noncontrast product of its own called arterial spin labeling. ASL is designed specifically for vascular imaging of the head, visualizing blood flow without enhancement by contrast agents.

Its ability to do so depends on having enough signal-to-noise to distinguish changes in tissue magnetization resulting from blood versus tissue water. The increased signal-to-noise ratio allows for a more precise visualization of the affected brain area than can be achieved with conventional methods.

The current version of ASL works only at 3T and requires a 12-channel head coil. The company plans to offer a 1.5T version that will use similar technologies, including a 12-channel head coil.

Siemens will show at RSNA 2007 another alternative to the current practice of contrast-enhanced MR, a noncontrast technique called Native, which is optimized for parts of the body other than the head. Native has been applied to visualize the aorta, as well as vasculature in the legs and hands.

Breast MR will share the spotlight with non-contrast-enhanced MR angiography. Some products already on the market will be emphasized to take advantage of increased interest in breast MR. These will include Siemens' syngoGrace, a spectroscopy package designed to measure metabolites in breast lesions; syngoBrace, software for correcting motion artifact in breast tissue; and syngoViews for water excitation-based visualization. Others will include recent iterations of GE's Vibrant and Toshiba's Radiance breast imaging packages, as well as Philips' Sense-powered breast MR. This year, GE plans to take breast MR from 1.5T to 3T

"We have continued to see debate in the industry about the capability of 3T to do breast imaging," Handler said. "We feel strongly that our 3T system is ready and able to do it."