Februaury 2011

New Age Diagnostics

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New Age Diagnostics

Cutting-edge Radiology research is creating a revolution in the diagnosis of a range of ailments

By Dhirendra Pratap Singh

Any sufficiently advanced technology is indistinguishable from magic, Arthur C. Clarke once wrote. So it is with Radiology, and its almost miraculous potential to save our lives. Radiology is a method used for the evaluation of bony structures and soft tissues. It was not so long ago, when only conventional X-ray imaging was available, a Radiologist was perceived more as a technician or a ‘Medical Photographer/Radiographer’ rather than a clinical specialist. The late 70s and early 80s saw entry of first ultrasound and single slice translate-rotate CT scanners in India, suddenly emerging like sphinx and transforming the status of imaging technology from just simple hardware producing flat two dimensional images into orthogonal cross-sectional images of higher special and temporal resolution which revealed much more in terms of human anatomy and offered higher accuracy in diagnosis. This placed the radiologist in the driver’s seat in the clinical world and brought greater respect to him as the one whose acumen was necessary to get the diagnosis in most cases on which was based management of the diseases.

Says Dr Bharat Parekh, Chairman-Indian College of Radiology & Imaging, “The new position of the Radiologist became even more envious with introduction of multi-slice volume CT scanners, superconducting MRIs, SPECT and fusion imaging, and teleradiology. With emergence of interventional Radiology and its advantages of minimal invasiveness in treating diseases, the radiologist came close to becoming a surgeon.”

Indian health imaging market is expected to double from the existing Rs.1,575 crore in the next five years. X-ray, ultrasound, CT and MRI would drive this domain collectively accounting for 68.6 percent of the health imaging market. Teleradiology holds 90 percent of the market share in the country, growing at 50 percent year on year. Since the days of X-ray, various technologies have exploded the radiology market. Major evolution has been noticed in the domain of CT, MRI and ultrasound, while digital radiography and teleradiology have given a whole new meaning to diagnosis.

PACS

The increasing proportion of imaging modalities that generate images in digital form has lead to the development of digital image management systems. Such systems referred to as Picture Archiving and Communication Systems (PACS) are emerging in clinical and radiological environments. It is an integrated set of information technology systems designed to provide a complete solution for image management in a film-less radiology department. Says Tarit Mukhopadhyay, Head– HIS & PACS Business, Siemens Medical Solutions, “Emergence of high-end modalities in Cardiology and Oncology requires archiving and post-processing of images where PACS is becoming mandatory.”

When introducing PACS to the hospital environment, it is critical to establish a Hospital Information System (HIS) or Radiology Information System (RIS) beforehand. Integration of Radiology Information Systems (RIS) with PACS is a defining trend in the imaging market.  An integrated system, which already knows certain information like patient’s history, reason for the examination, and the tests ordered, these systems can now automatically predict or rather anticipate specific views to the radiologist. It lessens the manipulation of image manually and giving more time to the expert for faster evaluations.

The radiologists are too few in number compared to the increasing patient load all over the world. In such case, teleradiology improves patient care by allowing radiologists to provide services without actually having to be at the location of the patient.

Integration of  RIS with PACS is a defining trend in the imaging market.   These systems can now automatically predict or rather anticipate specific views to the radiologist

The innovation of digital radiography (DR) system has significantly improved the clinical workflow and efficiency of the department and has also helped shorten the diagnostic and therapeutic decision-making processes. Additional benefits are improved patient comfort, reduction in radiation doses, higher examination throughput (i.e. multiple examinations during one visit) and a more pleasant atmosphere in the waiting room (through shortened examination and waiting times for x-ray) as the x-ray images are available at any time, throughout the hospital, in a PACS environment. All represent major benefits for the patient and increased satisfaction.

Cancer diagnoses and therapy

It is estimated that in India there are nearly 1.5-2 million cancer cases at any given point of time. Over 7 lakh new cases of cancer and 3 lakh deaths occur annually due to cancer. Recent advances in Interventional Radiology (IR) have enabled the radiologist to bring about direct destruction of the tumour. For inoperable liver tumours, Radio-Frequency Ablation (RFA) offers a non-surgical, localised treatment that kills the tumour cells with heat, while sparing the adjacent healthy tissue. Being a local treatment, it is a very safe procedure that does not harm healthy tissue.

Tarit Mukhopadhyay 
Head — HIS & PACS Business, Siemens Medical Solutions

“For PACS to be working efficiently in hospitals, there needs to be a regular curriculum in universities”

Similarly, Radioembolisation is a latest technique of intra arterial radiotherapy. It involves delivery of Yttrium 90 labeled microspheres into the blood vessels supplying the tumour. These microspheres get embedded in small blood vessels inside the tumour and emit beta particles which treat the tumour. Since the average penetration of a beta particle is only two millimeters, the radiation therapy delivered is highly targeted and is limited to the area of interest.

Prasanna Vadhana Kannan, Research Analyst, Frost & Sullivan says, “Advances in interventional radiology have simplified most of the procedures while retaining safety and fewer traumas to patients. Besides angioplasty, drainage procedures, tumor ablations, and embolizations are now increasingly becoming image-guided minimally invasive interventions with the refinement of technologies. Successful evolution of IR procedures could be attributed to advances such as improved multidimensional imaging techniques, microcatheter technology, improved guide wires, small sized balloon catheters, vertebroplasty, drug eluting and flexible stents and removable vena cava filters.”

Interventional radiology (IR) utilizes various imaging techniques such as CT, MRI to guide percutaneous minimally invasive procedures for both diagnosis and therapy. This has paved the way for applying IR to a vast number of medical conditions that are otherwise performed using invasive methods.

PET scanning

 Dr Bharat Parekh
Chairman-Indian College of Radiology & Imaging

“With emergence of interventional Radiology and its advantages of minimal invasiveness in treating diseases, the radiologist came close to becoming a surgeon”

In the course of a Single Photon Emission Computed Tomography (SPECT) scan, a three-dimensional image is obtained by rotating the detectors of the gamma camera around the patient. For evaluation, slices in any orientation can be reconstructed from the original three-dimensional scan. PET scanning is a nuclear medicine procedure that deals with positrons. The positrons annihilate to produce two opposite travelling gamma rays to be detected coincidentally, thus improving resolution. With the introduction of improved instruments allowing acquisition of whole body images in under an hour, applications in oncology have opened avenues for expanded clinical use of PET. SPECT is a well-established imaging method that is widely used in modern nuclear medicine diagnostics. In particular, tomographic scans have almost completely replaced planar acquisitions in the fields of cardiology and neurology.

Image Guided Radiotherapy (IGRT) is another big step in the advancement of radiotherapy. IGRT helps to know exactly where the planned IMRT is going. The arrival of the futuristic, highly refined robotic system-Cyber Knife has revolutionised radio surgery.  In many cancers, the advantages of Cyber Knife and IMRT-IGRT can be combined for optimum effect-least side effects and best levels of cure or control.

Interventional radiology  has paved the way for applying to conditions that are otherwise performed using invasive methods

However, there are still challenges. Says Tarit Mukhopadhyay, Head – HIS & PACS Business, Siemens Medical Solutions, “PACS technicians are not readily available in India.

Those who are available learn PACS by usage and are not updated with the latest technology. For PACS to be working efficiently in hospitals, there needs to be a regular curriculum in universities to understand the fundamentals of PACS in a total IT perspective.” Also, there is an alarming rise in the number of medico-legal cases in radiology.

Says Dr Bharat Parekh, “Future in Radiology will see enhanced efforts towards greater use of molecular imaging to be able to detect lesions before they attain even pin-head size and which are yet only at cellular levels. By understanding the molecular basis of disease and developing methods to detect and treat changes in the body at the molecular level, physicians will be able to identify diseases in the earliest possible stages.” This will by far remain the major focus of research and development in clinical medicine in the 21st century.

New Technology, New ProspectsDCT Scanner: Dual source CT scanners are the latest revolution in the field of CT imaging. Also, there are multi-slice CT scanners which have the capability of rapidly scanning large longitudinal (z) volume with high z-axis resolution. Multi Slice CT is a light speed VCT. Its unprecedented coverage speed allows clinicians to capture whole organs in a second, the heart in 5 beats, or go head to toe in less than 10 seconds.

MRI: MRI scans give the best soft tissue contrast of all the imaging modalities. It has become an important tool in musculoskeletal radiology and neuro radiology. Areas of potential advancement include functional imaging, cardiovascular MRI, as well as MR image guided therapy. Interventional MRI is one of the latest trends in this field.

Single Photon Emission Computed Tomography (SPECT) is widely used in modern nuclear medicine diagnostics. SPECT scan, a three-dimensional image is obtained by rotating the detectors of the gamma camera around the patient. While planar lung scans yield sensitivity between 0.76 and 0.81, in SPECT imaging, a substantial improvement up to 1.0 was found.

Image Guided Radiotherapy (IGRT) is another big step in the advancement of radiotherapy. IGRT helps to know exactly where the planned IMRT is going. The arrival of the futuristic, highly refined robotic system-Cyber Knife has revolutionised radio surgery. In many cancers, the advantages of Cyber Knife and IMRT-IGRT can be combined for optimum effect-least side effects and best levels of cure or control.

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