Today's research heads toward tomorrow's clinical practice

April 1, 2007

Women's health and imaging's role in it are of enormous social, economic, and psychological importance. Recognition of this importance prompted the University of Rochester Medical Center's imaging sciences department to hold its first annual Women's Health and Imaging in a Digital Environment conference in San Antonio, TX, in January 2007.

Women's health and imaging's role in it are of enormous social, economic, and psychological importance. Recognition of this importance prompted the University of Rochester Medical Center's imaging sciences department to hold its first annual Women's Health and Imaging in a Digital Environment conference in San Antonio, TX, in January 2007.

One of the biggest topics in women's imaging is the transition from traditional screen-film mammography to digital imaging. Currently, fewer than 10% of breast imaging facilities offer digital mammography, but the decision to make the transformation is no longer one of if but when.

Results of the American College of Radiology's Digital Mammography Imaging Screening Trial of more than 49,000 women were published in The New England Journal of Medicine in September 2005. DMIST demonstrated that the accuracy of digital mammography was significantly higher than film in three specific subgroups: women under the age of 50, pre- and perimenopausal women, and women with dense breasts.

Before a practice goes digital, however, it must have Mammography Quality Standards Act certification, with a minimum of eight hours of certified training for both radiologists and technologists. Important topics to address before going digital include PACS technology and workflow issues, information storage requirements, and reporting and communications needs.

Breast ultrasound has been an adjunct to mammography for many years. New developments include sonoelasticity for diagnosis, high-intensity focused ultrasound as a therapeutic modality, and computer-aided detection for screening and diagnosing.

Breast MR imaging was first performed in 1985. Two decades later, the indications for breast MRI include extent-of-disease evaluation, postlumpectomy situations with close or positive margins, and monitoring of response to neoadjuvant chemotherapy. Breast MRI can assist the surgeon in identifying candidates for breast conservation and in planning the extent of resection. Detection of cancer recurrence and the search for occult primary lesions are also indications for MRI, but its use in screening is indicated only in certain high-risk patients.

Other exciting developments in breast imaging include digital tomosynthesis and conebeam CT. These technologies both overcome the fundamental limitation of 2D mammography, which causes difficulty when overlapping dense tissue masks tumors, creating a "find the snowman in a snowstorm" situation.

Imaging of the female pelvis is central to disease management, and here ultrasound is the preferred initial modality for women of childbearing age. CT is also commonly used in the diagnosis of acute pelvic pain, but its radiation dose should be kept in mind. MRI has a role in pelvic disease, especially for the evaluation of ovarian and uterine masses. PET and PET/CT are extremely useful in the initial evaluation, staging, radiation therapy planning, and monitoring of response to therapy and recurrence of gynecologic malignancies.

MR spectroscopy also has great potential in monitoring the response of tumors to therapy. Electronic impedance scanning uses the changes in basement membrane porosity to detect malignant lesions, and this approach is being tested for possible screening use.

Osteoporosis is an insidious disease with major mortality and morbidity outcomes. Approximately eight million U.S. women have osteoporosis of the hip, and many more have osteopenia. A 50-year-old white woman has a 40% lifetime risk of hip fracture. In the event of hip fracture, there is a 10% to 20% mortality rate within one year, 25% of patients will require long-term nursing care, and only 30% will regain their prefracture level of independence. The best predictor of osteoporotic fracture is low bone mineral density, which is usually detected by dual x-ray absorptiometry.

If we are to fulfill our role as physicians first and imagers second, we must expand our outlook to consider the whole woman. The number one killer of women in this country is heart disease. Whereas screening mammography has been shown to reduce mortality from breast cancer, the death rate for heart disease has not decreased despite many advances in healthcare. Women fare poorly with coronary artery disease; they are more likely to have atypical presentations and consistently have longer time to presentation. Imaging cannot help much here, but 64-slice CT scanning may in the future screen high-risk patients for preclinical heart disease. Prevention and early intervention may improve future outcomes.

We are constantly being reminded that today's research is tomorrow's clinical practice. This has never been truer than it is today.

Dr. O'Connell is director of women's imaging and an associate professor of imaging sciences at the University of Rochester Medical Center in New York.