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MR LINAC Personalising cancer treatment P04
SIR MIKE BRADY What AI and image analysis can achieve P06
Future of Imaging
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Radiation dose tracking Why it matters and what patients can ask to help clinicians
Six ways medical imaging must evolve Professor Parizel, European Society of Radiology
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Teleradiology “A fundamental part of radiology practice” Dr Nicola Strickland, President, the Royal College of Radiologists P10
The future of imaging: an issue that affects us all
As the pace of technological advancements continues to increase, so does the opportunity to improve the quality of medical imaging to help transform healthcare.
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n all areas of our lives the pace of technological possibilities and change is forever increasing. Healthcare is no different. Where we see advanced artificial intelligence (AI) potentially changing the way we drive, we also see AI driving advances in personalised medicine. Imaging procedures are increasing in number and the number of staff in post to deal with the extra demand is not keeping pace. In other words, medical imaging is certainly not immune from all the advances and societal pressures that touch our lives. One recent advance in the use of imaging is a new technology called the MRI-Linac. A Linac is the machine used in radiotherapy to fire high-energy radiation beams at cancerous cells to kill
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the cancer or provide palliation to the patient from their symptoms. Improvements in imaging the location of the tumour have enabled higher doses of radiation to be delivered with less radiation hitting nearby healthy tissues, thus reducing unnecessary sideeffects. Until recently this imaging has been done with X-rays but the integration of an MRI scanner with a Linac has vastly improved accuracy. This is truly a ground-breaking advance, whose full potential we are only just beginning to realise. AI and machine learning are now gaining traction in imaging. To predict patient outcomes, we require large datasets of patient information, all interconnected to gain the maximum benefit. However, clinical data sets are notorious for having incorrect manual entries and missing data. The
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“A ground-breaking advance.”
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better the data is, the more robust the final conclusion, so data integrity issues will be massively important in the future. Another issue not often appreciated is that imaging data is more useful to AI techniques when the scans are performed consistently. There are global initiatives to harmonise the way complex scans are performed to prepare the data we use in the future. The ultimate way to control data acquisition techniques is to be found in the BioBank initiative where 100,000 individuals are being imaged at a single facility in exactly the same way and lifestyle and health information tracked over many years to provide a vast data set of useful clinical data for future researchers. All of which raise valid ethical and privacy issues that have yet to be solved. @MediaplanetUK
The use of X-rays brings with it the need to minimise any potential harm that may be caused by those X-rays (in fact, a very, very small increased risk of cancer). There are many ways to minimise such harm that range from ensuring we image the correct patient, to identifying variations in practice that are not justified. This area of radiation control is also undergoing technological advances as new software tools are emerging to collect radiation dose information for every patient from imaging machines for data analysis in far greater numbers than we have previously been able to! This increase in information will definitely lead to better insights into how to improve the quality of medical imaging. We really are on the cusp of seeing healthcare IT and associated technologies move forward at pace, hopefully for the benefit of us all. Please Recycle
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Low-dose radiology system improves patient outcomes From diagnosis to follow-up, an EOS exam provides low dose, full body, 2D/3D images and patient-specific datasets for optimised patient outcomes. ADVERTORIAL
By Linda Whitney
The EOS medical imaging system, based on a Nobel prize-winning technology, offers a low-dose method to obtain 2D/3D clinical images and data to assist in the diagnosis and follow-up of musculoskeletal conditions and orthopaedic surgical planning. The EOS exam reduces the radiation dose delivered to the patient by around 85 per cent compared to conventional X-ray systems1. Patients stand upright or sit in a radiolucent chair, resulting in stereo-radiographic images of the patient’s anatomy in a functional position.
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According to Musculoskeletal radiology consultant Dr Simon Blease: “During the exam, collimated X-ray beams scan the patient from head to toe to acquire simultaneous frontal and lateral images in just 20 seconds. The sterEOS workstation can then generate 3D models of the patient’s skeleton.” “The slot scan technology reduces scatter radiation to optimise image quality while minimising the dose. Dose is reduced by two to fifty times compared to other common X-ray technologies2.” The capacity to produce continuous full-body images with EOS eliminates the need to digitally ‘stitch together’ several conventional images; image stitching can reduce the accuracy of measurements due to patient motion. The high image quality with EOS produces accurate, full-body, weight-bearing images that make it easier for clinicians to comprehend
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“The EOS exam reduces the radiation dose delivered to the patient by around 85 per cent.”
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compensatory mechanisms between the spine, hip and knee. The EOS solution also has the ability to collect patient-specific data, including 2D and 3D measurements. Dr Blease reports, “It can accurately measure spinal and femoral angles, rotations and limb lengths, compare patient clinical parameters against reference values, and easily share the information thanks to customised patient reports.” The associated sterEOS software assists clinicians in diagnosing current conditions, predicting future problems, planning treatments and monitoring the results to improve patient engagement and outcomes. “EOS is a great system for our aging patients with degenerative spine disease. With the full-body images, we can analyse a patient’s sagittal balance to understand the types of corrections that are required to
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restore a correct posture.” Dr Blease emphasises: “More patients and general practitioners need to know that this kind of system exists.”
1. Diagnostic imaging of spinal deformities: reducing patient’s radiation dose with a new slotscanning X-ray imager. Deschenes S et al. Spine (Phila Pa 1976)2010 Apr 20;35(9):989-9 2. EOS microdose protocol for the radiological follow-up of adolescent idiopathic scoliosis.
Ilharreborde B. et al. Eur Spine J. 2015
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Revolutionary radiotherapy system personalises cancer treatment Safer, more effective cancer treatment could be on the horizon as a new radiotherapy system targets tumours with greater precision.
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By Kate Sharma
round 40 per cent of all cancer patients undergo radiotherapy, according to Cancer Research UK, which requires them to have a CT or MRI scan before treatment. The image created by the scan is then used to guide X-ray beams to a tumour within the body. However, both the tumour and surrounding organs may well have changed in position between scanning and start of treatment. As a result, radiation is generally applied using relatively large safety margins in order to ensure appropriate doses to the tumour, but this approach damages more healthy tissue, causing long-term side effects. For example, women with breast cancer have been known to develop heart conditions as a result of radiation damage. However, this could be decreased substantially with new technology. The Magnetic Resonance Linear Accelerator (MR Linac) could radically improve success rates for patients and reduce the side effects. By combining two technologies – an MRI scanner with
a linear accelerator – the system provides soft-contrast imaging throughout treatment, giving clinicians complete, real-time visibility of a tumour so they can direct X-ray radiation beams at it accurately, even as it moves. The accuracy that the MR-Linac brings is revolutionary and is a particularly important breakthrough for treating cancers such as lung, prostate, pancreas, bowel and liver, where the tumours often change position between scanning and treatment, and during treatment, for instance, due to breathing.
Precise treatment delivery “The main benefits come from the fact that you have real-time guidance during treatment delivery,” explains Dr Frank Lagerwaard, Radiation Oncologist at the VU University Medical Center in Amsterdam, who has been working with a similar MRI-guided radiation therapy system. “Now that we can see what we are doing, we only need very small safety margins, and can even treat during breath-hold, resulting in very precise treatment delivery with much less radiation to
surrounding healthy tissues.” “Typically we plan for an entire series of radiation fractions assuming that the situation in the patient doesn’t change,” continues Lagerwaard. “The new system allows you to perform MR imaging prior to each fraction, so you can optimise your treatment plan for each fraction of radiation delivery, a process called adaptive radiotherapy. This ensures optimal radiation delivery for virtually all fractions and increases the safety of critical organs.” The MR Linac doesn’t simply require new procedures of operation; it will require clinicians to work in new ways, too. Currently, oncologists aren’t present during the treatment delivery process, which is managed by technicians. With real-time scanning, that will all change and the oncologists will be required to assess imaging prior to and during delivery of the treatment, thus actually be present at the treatment machine.
Extra staff and money needed The system certainly has the power to revolutionise radiotherapy, but there
Dr Frank Lagerwaard Radiation Oncologist, VU University Medical Center, Amsterdam
“Heart conditions as a result of radiation damage could be decreased with new technology.”
are some limitations. There are currently very few machines in clinical use and the whole procedure requires extra staff and time which, of course, costs money. However, in the long run, there could be cost savings as more accurate treatment will reduce the need for multiple patient visits, and possibly a reduction in also costly side-effects. “Imaging, plan optimisation and delivery for a single fraction at this moment can mount up to 30 minutes for prostate cancer or 45 minutes for upper abdominal lesions. If you want to do this for 30 fractions, for instance, it will be way too time consuming for departments and patients,” explains Lagerwaard. “Theoretically, it could benefit all patients undergoing radiotherapy, but at this moment we need to select our patients carefully.” Technology is advancing at such a rapid pace and Lagerwaard is confident it won’t be too long before MRI-guided radiation therapy systems become the norm in hospitals across the world. Find out more on healthawareness.co.uk
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Real-time imaging improves tumour targeting SPONSORED
Revolutionary equipment that combines imaging and radiotherapy to more reliably target tumours could improve patient outcomes and cut treatment courses. The first Magnetic Resonance Linear Accelerator (MR Linac) in the UK – and the fourth in the world – should be in clinical use by the end of 2018. Dr Alison Tree, Clinical Oncologist at The Royal Marsden, working in partnership with the Institute of Cancer Research (ICR), says: “The MR Linac will allow us to better target tumours that move in response to natural changes in the body, such as breathing, the bladder filling or bowel changes.”
Tumours can move during treatment The MR Linac combines a magnetic resonance (MR) scanner and a linear accelerator, so that it can track tumours that move and change shape – even during a treatment – to precisely target the radiation beam on them. “Better targeting reduces the irradiation of surrounding healthy tissue, making it safer to deliver higher doses, and minimises side-effects says Dr Tree. Trials of the MRI scanning element of the MR Linac on healthy volunteers – including local MP Paul Scully – are already underway. The trial is part of the study that involves trials in seven international centres designed to help radiotherapists optimise MR Linac images in order to guide the radiation beam more accurately. Dr Tree says: “Being part of this study means we get faster results, so we can treat patients sooner.” Results already indicate that MR
Linac could improve outcomes for pancreatic cancer patients.
Live imaging can prevent radiotherapy beams hitting healthy tissue
Dr Alison Tree Clinical Oncologist, Royal Marsden, working in partnership with the Institute of Cancer Research
“Being part of this study means we get faster results.”
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The MR Linac is thought to be particularly valuable for treating any pancreatic, prostate and breast cancer, where the tumours are close to tissues that often move. The pancreas lies close to the stomach and small bowel, both of which can change in shape, even during a treatment. MR Linac allows targeted delivery of high doses of radiation with less risk to other, non-cancerous tissue.
Prostate cancer treatment and recovery times could be reduced The pioneering kit could also mean significant reduction in treatment times, side effects and inconvenience for patients. “Currently, patients receiving radiotherapy for prostate cancer
attend the hospital every day for four weeks. The outcomes are very good, but we want to minimise patient inconvenience and the MR Linac could help,” says Dr Tree. She explains: “Prostate cancer, unlike others, responds most effectively to large doses of radiation delivered over a short period. However, because the prostate lies close to the rectum, high doses risk damaging the rectum and increasing side effects. “With MR Linac we can better target the prostate while avoiding the rectum, so we can safely deliver higher doses of radiation. Treatment time could be reduced to five days – or even just one, which will save time and money for patients and the NHS.” Clinical trials on patients start soon, including a single-treatment trial for prostate cancer.
Read more at: royalmarsden.nhs.uk
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Artificially intelligent breast cancer screening
Artificial intelligence could save the NHS money and time
Dr Hugh Harvey Radiologist and Member of the Royal College of Radiologists Informatics Committee and AI Working Group
By Kate Sharma
By Linda Whitney Within a few years, artificial intelligence may improve the detection of breast cancer and reduce the workload for radiologists.
Deep learning technology and data are on the verge of creating the most effective screening for breast cancer.
A bit of history In 1986, US researchers worked out how to dramatically improve image perception, and by 2012, processing power was finally enough to allow deep learning at scale. By 2016, clinically-proven deep learning software was first applied to radiology. Today, deep learning systems can learn for themselves – and the UK breast screening programme has the ideal database for them to learn from. The NHS national breast screening programme, considered the world gold standard, successfully discovers over 50 per cent of the target female population’s breast cancers before symptoms show. Digital mammography makes medical imaging data amenable to computational analysis. Since 2004, Computer Assisted Diagnosis systems (CAD) have been created, handtaught by humans to highlight suspicious regions on a mammograms.
Problems with CAD However, traditional CAD systems are not good at discerning true positives from false positives. This, plus the fact that up to 30 per cent of cancers still present after a ’normal’ mammogram, mean radiologists on the whole do not trust CAD as unnecessary numbers of patients are subject to the heart-wrenching stress of recall. False positive results from CAD have also driven up costs. In the UK there are currently too few radiologists to handle the workload.
AI could alleviate workload for radiologists Fortunately, breast screening programmes provide a wealth of digitised imaging and patient outcome data that can be used by systems to teach themselves, so deep learning could bring new levels of accuracy to breast screening.
How close are we? Early work in the UK shows that deep learning can at least equal the performance of human readers. Now the algorithms must pass medical device regulatory scrutiny to ensure they do what they claim. The holy grail is to prove conclusively that deep learning systems can accurately make recall decisions equal to, or better than, the UK practice of using two radiologists to decide on recall – so far, the most accurate method. Before that, however, we may see double-reader programmes replaced by systems in which single-readers are supported by deep learning, potentially halving the workload for radiologists. Deep learning support in national screening may be just a few years away.
Progress in artificial intelligence is radically changing medical imaging techniques, easing the burden on over-stretched NHS staff and speeding up diagnosis in the process.
Artifical intelligence (AI) is the buzz word of the moment, but Sir Michael Brady, Professor in Oncological Imaging in the Department of Oncology at the University of Oxford, is keen to point out that it’s not a new idea. Computer technology has been evolving since the 1950s, when the term AI was coined by the computer scientist, John McCarthy. “McCarthy said ‘today’s AI is tomorrow’s computer science’,” recalls Brady. There is certainly no denying that medical science has come a long way in the last few decades thanks to the developments in computer technology. “When I was co-director of AI at MIT in the 80s, we had one of the most advanced computing systems in the world. But the total computing power we had in that lab was still considerably less than I have in my mobile phone today,” says Brady.
AI can save money and time Apply the power of computing technology to advances that have been taking place independently in image analysis and the opportunities to increase both the speed and the accuracy of imaging techniques are extensive. By drawing on a bank of hundreds of thousands of images, machines have learnt to set parameters that differentiate things like texture and contrast in organs, tissue and bone to support diagnosis. Brady is quick to point out that a growth in AI is not going to replace
that will radically improve the process. “We’ve developed a system that can identify those nodules that are obviously benign. If you can cut by 50 per cent the number of nodules the radiologist has to assess, then you’ll save them half the time,” says Brady. The company behind the technology believes that more than 4,000 cancer patients a year could get an earlier diagnosis as a result of the system, saving billions of pounds in the process.
Professor Sir Mike Brady Professor of Oncological Imaging, Department of Oncology, University of Oxford
AI can support increase in breast screenings
“More than 4,000 cancer patients a year could get an earlier diagnosis”
medical staff completely any time soon. “It would be unethical and improper to replace radiologists, but all these systems will help them do their jobs much better.”
Earlier lung cancer diagnosis Its application in the detection of lung cancer is a good example of what the future could hold. Hundreds of nodules, most of which are harmless, show up when a patient has a CT scan of their lungs, and yet a radiologist will have to painstakingly go through each one to determine whether they are benign or malignant. Brady has helped develop technology
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Breast cancer diagnosis is another key area where AI could improve care. The number of women being screened for breast cancer is increasing, but the number of trained radiologists is decreasing. Considering it is mandatory in the EU that every mammogram is independently read by two qualified individuals, this is a concerning problem. Help is at hand. “We have systems that can detect early signs of cancer,” continues Brady. “We have also run trials where we have taken radiologists with a range of experience and asked them to work blindly and then alongside the systems. We found that the systems helped to equal out their performance and could therefore help to reduce the postcode lottery.” With breakthroughs in diagnosing heart conditions and Alzheimer's disease, it’s not just cancer patients benefitting from new imaging techniques. As Brady concludes, “There’s no reason to suppose we are anywhere near the limit of what AI and image analysis can achieve.” The best, it seems, is yet to come.
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AI can be an evolution, not a revolution
The use of AI in imaging need not be confined to radical changes in healthcare delivery. It can also be used with existing systems to save time and improve patient outcomes. By Linda Whitney SPONSORED
M
uch has been made of how AI could change the face of healthcare and many have expressed concern about such a disruptive revolution in the clinical world. However, applied to existing, everyday healthcare tasks, AI can make a difference – without the wait for clinical trials required to validate major technological innovations. So says Hugh Bettesworth, Chief Executive at Mirada Medical, a company that specialises in software for
radiation oncology and diagnostic imaging. “There are many innovative, deep learning (AI) technologies being developed to aid diagnostic imaging, but radical new technology has to be validated by clinical trials to prove that it is at least as effective as an experienced reading radiologist. These processes take time, which means the patients, clinicians and the NHS must wait many years for the benefits to be delivered,” says Bettesworth. However, he says, AI can–and increasingly will–be used to improve the efficiency of existing techniques without the need for revolutionary technology. “AI can also be applied to the existing technology used in many simple, everyday healthcare tasks. There is a whole range of day-to-day healthcare problems where AI technology can be applied today,” he says. For instance, he points to the value of using AI in organs-at risk-contouring–the process of delineating on an
Hugh Bettesworth Chief Executive, Mirada Medical
“There is a whole range of day-to-day healthcare problems where AI technology can be applied.”
image the physiological structures and healthy tissue that need to be avoided when a radiotherapy beam is targeting a tumour. “Good contouring improves patient outcomes because it improves the accuracy of the treatment plan and its ability to avoid, as far as possible, the irradiation of areas of healthy tissue around tumours,” says Bettesworth. “However, contouring is very time consuming and studies show significant inconsistency in the accuracy of contours drawn.” A pre-treatment CT scan is carried out and the radiation oncologist uses drawing software to draw round the healthy structures to be avoided. “This can take up to two hours and it is tedious work,” says Bettesworth. “Alternatively, contouring is carried out automatically by a software programme, but as these use older technology, they do not always produce contours that compete with those drawn by the most experienced radiation oncologists, and thus require
time-consuming editing.” Dr Mark Gooding, the Chief Scientist who was closely involved in the development of Mirada Medical’s DLCExpert™ technology, which uses AI to learn the user’s contouring preferences and automatically apply them to images, says: “This improves consistency and saves time for the radiation oncologist, while still giving them the chance to amend the contouring themselves. Improved contouring could lead to a reduced chance of sideeffects or recurrence for patients.” He adds: “This shows that AI is not just about huge technological leaps forward. It can be more rapidly applied to everyday tasks to make incremental improvements to the effectiveness of treatment planning, saving time for oncologists and potentially improving patient care.”
Read more on mirada-medical.com
Pioneering the application of deep learning in breast imaging ADVERTORIAL
Over the past several years, Artificial Intelligence (AI), or deep learning, has become a much buzzed-about term in research and development, despite the fact that it has been utilised by many of us in the healthcare industry for quite some time.
In fact, in the breast screening category in particular, Hologic has been the pioneer in applying machine learning in breast imaging and developed the first-ever commercial computer-aided cancer detection software product, which was based on conventional machine learning algorithms. More recently, AI has been an extremely influential tool in Hologic’s breast screening product suite because it provides a multitude of benefits
for radiologists, from impacting the accuracy of cancer detection, to helping with workflow. This exciting era of AI research means we are experiencing deep learning technology having a wide-spread and powerful impact on many applications, both inside and outside of the medical imaging space. AI, with deep learning, is rapidly approaching human-level performance in many cases previously considered to be very difficult challenges. In breast screening in particular, we see that deep learning algorithms can learn from massive amounts of data and generate impressive results in both cancer detection and diagnosis. At Hologic, we believe any viable future breast screening products and devices will have AI and deep learning as a fully integrated and built-in key component – and we are committed to continuing to lead from the front with the introduction of such products. For example, AI played a large role in the development of Hologic’s 3D MammographyTM exam, which has been clinically proven to detect breast
Tracy Accardi Global Vice President of Research and Development, Breast and Skeletal Health Solution, Hologic, Inc.
cancer earlier than traditional mammography. In fact, the 3D Mammography™ exam detects up to 65 per cent more invasive breast cancers compared to 2D alone, with an average increase of 41 per cent1. In this way, and many others, the application of AI has become more and more a partner in helping radiologists. It is a mutually interactive environment in which the AI algorithm learns from the radiologist; while the radiologist, with the help of AI algorithms, can find more cancers, find them earlier, and most likely become more efficient – without becoming overwhelmed
with the large amount of 3D screening data to review. We’ve seen this first hand with Intelligent 2DTM imaging technology, a feature available on Hologic’s 3DimensionsTM mammography system, introduced in Europe in July 2017. Intelligent 2DTM 2 is a synthetic image product that has a built-in machine learning algorithm known as smart mapping, enabling radiologists to instantly move from suspicious areas detected on the 2D image to the point of interest on the 3D slice, saving time and optimising workflow3,4. Yet another example of AI in action is the QuantraTM 2.2 breast density assessment software, developed by matching thousands of mammographic images with corresponding radiologist assigned BI-RADS density categories, training and achieving a fully automated breast density categorisation. With this product, radiologists can deliver unbiased breast density assessment that removes the potential for visual subjectivity; a big feat for clinicians and women with dense breasts. Breast cancer screening on a
whole has – and will continue to have – tremendous benefits from the application of deep learning technology. The participating populations will see improved detection accuracy with reduced false positive findings. The clinicians will see increased productivity and better clinical performance. And, while AI will never take the place of radiologists and the great work that they do, with ongoing innovation, AI has a promising future to positively impact these areas of breast imaging to help radiologists provide the best possible care to patients. 1 Friedewald SM, Rafferty EA, Rose SL, et al. Breast cancer screening using tomosynthesis in combination with digital mammography. JAMA. 2014 Jun 25;311(24):2499-507. 2 CE marked only at this time, pending FDA approval 3 Compared with combo mode ~10 second scan time per view. 4 Feature is used in combination with SecurViewâDX diagnostic review workstation mapping tool in v9.0.1 and above.
Read more on 3dimensionssystem.eu/
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Dose management software: safer scanning and closer co-operation Dose management software provides robust, timely data enabling collaboration between clinical and technical teams to give a better service and comply with tighter regulations.
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By Chris Partridge
hen dose management software (DMS) first came on the market, some professionals dismissed it as an expensive luxury. In practice, it has proved its worth as a tool for bringing clinicians, technicians and medical physicists together to deliver the best outcomes for patients and facilitate learning and best practice for operators. And, of course, DMS is an essential tool for compliance with an ever-tighter regulatory environment. While the primary function of DMS is to collect data automatically to prevent errors from user- entered data, such as incorrect units, its true value is the way it presents robust data for analysis, says Michael Barnard, Clinical Scientist at Oxford University Hospitals NHS Foundation Trust. “Once the data collection and data presentation work is automated you can quickly find what exactly what you need to change, such as optimising the exposure to
balance the radiation dose and image quality,” he explains.
Software that supports collaborative working
Michael Barnard Clinical Scientist, Oxford University Hospitals NHS Foundation
“Using DMS, we could see immediately that something was not quite right.”
The data generated by DMS is in a standard format that can be used by all the people involved, Barnard says. “The DMS ensures you have one source of data that can be shared with the radiologists so we can work in a more collaborative manner; all on the same page with the same information.” Data is also available immediately, so it can have a direct impact on clinical practice. “With computer tomography (CT scans), we have auto exposure control, which means patients have to be centred as accurately as possible for it to work effectively,” he says. “The DMS allows us to drill deeper into the data to get this sort of information.”
Technical inconsistencies are easier to spot with DMS data DMS data can even be used as a problem-solving
tool for the equipment. “What we have noticed is, because of the speed at which the data is available, we can spot technical problems more easily,” says Barnard. “Using the DMS, we noticed a CT scanner wasn’t performing as it should when comparing a single protocol on our CT scanners in our Trust. Using data displayed in the DMS, we could see immediately that something was not quite right. We got together with a radiologist, radiographer and the manufacturer to solve the problem, which had been caused by a very obscure software update and inadvertent change to an embedded setting.” The adoption of DMS may also enable automated image analysis in the future. “All the information is there, but it needs an image quality metric, which is very difficult,” Mr Barnard says. “DMS is being used in a lot of medical research.” Read more on healthawareness.co.uk
Read more insight from leading experts in the field of imaging online at healthawareness.co.uk
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From art to science: the evolution of imaging The past decade has seen a paradigm shift in radiology in medical practice. Still a cornerstone of advanced diagnostics and quality care, it is now increasingly used for follow-up and monitoring. However, imaging is still more art than science. By Linda Whitney
In the future, I see the radiologist evolving into an imaging data science expert, integrating multiple datasets to allow early precision diagnosis and therapy. Six ways that medical imaging must evolve in order to move forward into an ethical, safe, qualitative, and value-based future. The imaging of the future will be: 1. Standardised The huge variety of equipment and acquisition protocols, and lack of benchmarked standards hinders interpretation of imaging results from different centres, and even within one centre. Standardisation and tight control are vital to the big data approach, and to combining data from different sites. 2. Calibrated Imaging equipment must be calibrated carefully and traceably, and fine-tuned regularly.
Professor Dr Paul M Parizel Chair of the Board of Directors, European Society of Radiology (ESR) Professor and Chair, Department of Radiology Antwerp University Hospital (UZA)
“I see the radiologist evolving into an imaging data science expert.”
Vista Diagnostics and InHealth are the UK’s largest specialist provider of diagnostic and healthcare solutions by offering patients and referrers a range of services including MRI and Ultrasound.
3. Quantitative Today, radiologists still rely mainly on visual image interpretation, good enough to suggest an initial diagnosis, but unacceptable for interpreting follow-up examinations. It is hard to accurately assess subtle changes from one examination to the next. Visual assessment is also prone to subjective interpretations and human error. The introduction of imaging biomarkers with quantitative, objective, reproducible parameters, will help. 4. (Artificially) Intelligent AI techniques currently used in CAD for breast screening, are now being used for other tasks where there is evidence that AI can be equal or better than radiologists. AI can draw on all available patient information and vast amounts of data. Radiologists will no longer “force” a diagnosis, but will ensure that the diagnosis is relevant for the patient.
5. Functional Imaging techniques now contribute to our fundamental understanding of physiological processes. New imaging and post processing techniques (such as perfusion imaging, diffusion weighted imaging and spectroscopy), have helped patient management, therapeutic decision-making, and outcome prediction.
6. Ethical, safe, qualitative, and value-based Quality of care and patient safety are vital in imaging. The ESR has taken several initiatives on this. All organisations or individuals in radiology should be developing and implementing a comprehensive quality and safety agenda. The quality of imaging services can be measured by outcome, so the radiology of the future will evolve towards an evidence- and value-based discipline rather than a volume-based production unit.
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Dr David Wilson Past President, British Institute of Radiology (BIR)
The information revolution that saves lives By Ailsa Colquhoun
Virtual technology is giving NHS diagnostic services a healthy new image, says Dr David Wilson, past president of the British Institute of Radiology. In a medical emergency such as a stroke, the difference between waiting one or two hours to receive your scan results can mean the difference between life and death. So, what happens if your medical emergency happens out of hours, or in a place where the specialist help you need is just not available? Thanks to teleradiology, the process in which radiological patient images, such as X-rays, CTs, and MRIs are shared virtually using technology, avoidable delays in producing vital medical information are increasingly a thing of the past. Better still, smaller hospitals are now able to access specialist expertise – for example, in brain or muscular injuries, or in children – that might otherwise be unavailable. Dr David Wilson, past president of the British Institute of Radiology, and auditor of teleradiology services used by the NHS, says: “Teleradiology is a way to get the doctor you want, rather than the doctor you have to have.”
A growing industry Teleradiology connecting the NHS with commercial radiology suppliers has been part of NHS care for around 20 years, and it’s a growth industry: each year there are around 15 per cent more scans but only around two per cent more new radiologists – and that’s before the NHS achieves its ambitions of 24/7 care. Using standard network technologies such as the internet, telephone lines, local area networks (LAN) and computer clouds, combined with specialised, encrypted software radiologists can now easily and securely transmit what can be up to thousands of images for a given patient. Due to the specialist equipment and processes required, there are four main UK companies active in this sector, and it is Dr Wilson’s view that the industry may consolidate further, using technology to communicate between ‘super’ specialists who work remotely, as well as with radiologists on staff. He also expects virtual multidisciplinary meetings between hospital and commercial staff to become more common, giving non-hospital staff the clinical ‘big picture’ that can inform improved care. As an auditor of the standards of care offered by commercial teleradiology companies, Dr Wilson is responsible for protecting patient safety from challenges such as under-performing staff or faulty systems. He says a fixed proportion of reports are always second-checked for discrepancies. He says: “Audit is far from a token gesture. Days of work go into this process and the independent sector is really setting the standard for patient safety.”
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Why we need teleradiologists and hospitalbased consultants With an ever-increasing demand for patient scans, teleradiology is now a key part of radiology practice. However, remote clinicians need comprehensive IT connectivity, and teleradiology will not negate the need for hospital-based imaging experts, argues The Royal College of Radiologists. What is teleradiology? Teleradiology refers to the assessment of scans taken at a site different from the hospital where the original images were taken. This technology allows consultant radiologists – doctors who are experts in image interpretation – to report in their own homes, in a reporting hub, even in a different country from where a particular patient was just scanned.
Hospital IT systems must be accessible “The key thing is the teleradiologist should not be at a disadvantage compared with a radiologist who is reporting in his or her own hospital, and that the patient should get an equally good report from a teleradiologist,” says Dr Nicola Strickland, President of The Royal College of Radiologists (RCR). According to Dr Strickland, doctors working from home could be on the back foot, as they may not have access to all of a patient’s previous imaging studies due to how hospitals organise their IT. “With many cases, knowing a patient’s full imaging and medical history is vital to making a good diagnosis,” says Dr Strickland. Ever-growing demand for radiological imaging investigations means it is now routine for UK radiology departments to have their night time out-of-hours reporting outsourced to private teleradiology companies. Teleradiology is a fundamental part of radiology practice – without it, NHS hospitals simply would not cope, as most do not have enough radiologist doctors on site to interpret and report the volumes of scans that get done every night as emergencies.
How can we make the most of teleradiology? To help departments overcome fragmented access to radiology studies and make the
Ultimately, UK hospitals need more radiologists on the ground
Dr Nicola Strickland President, the Royal College of Radiologists
“Radiologists perform all sorts of needle biopsies to test suspicious tissue to diagnose cancer.”
most of teleradiology, a “vendor neutral” network in every region of the UK could be a solution. Such networks allow teleradiologists working off-site to see all the previous radiology examinations a patient has had, regardless of which hospital they had them done in – helping teleradiologists to make the best diagnoses they can for patients, with all the imaging information they need at their fingertips.
However, Dr Strickland points out that even if these regional teleradiology networks were set up across the UK, they will not work without several hundred more consultant radiologists to man them, and this means urgently training more radiologist doctors. She says: “At present, there simply aren’t enough radiologists in the UK to cope with all the radiology examinations that need to be done every day. The government needs to wake up to this fact and do something about it.” But just because remote teleradiology reporting is now a ubiquitous necessity in the UK does not mean hospitals can do without radiologists on the ground, stresses Dr Strickland.
Teleradiology can support radiologists to continue their other, vital work “Radiologist doctors do far more than just report scans and other radiological imaging studies. In the hospital, radiologists perform all sorts of needle biopsies to test suspicious tissue to diagnose cancer, and interventional radiologists use their radiology skills to guide them as they carry out key hole procedures on patients – from draining away infected pus near a vital organ, to saving the life of someone bleeding to death or removing a blood clot in someone’s brain that is causing a stroke. Obviously, none of these things can be done remotely by teleradiology!” “Radiologists are still primarily clinical doctors and it is absolutely vital they remain on the ground in hospitals,” she says. “In the hospital, radiologists spend a lot of time explaining the findings on radiology examinations to other doctors, advising on the best scans and investigations the patients need next, and keeping up-to-date with the care of the patients whose radiology scans they have been responsible for diagnosing and on whom they have done interventional procedures. Best practice teleradiology and hospital-based radiologists complement one another, and both are needed so that patients get excellent radiological care.” Read more on healthawareness.co.uk
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Interventional oncology is now the fourth pillar of cancer care Interventional radiology offers cancer patients an alternative form of treatment that may reduce risk, pain and recovery time.
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By Kate Sharma
he field of oncology continues to change rapidly and tremendous progress has been made in the past decade in interventional oncology. The term describes minimally-invasive techniques whereby a radiologist uses image-guiding technology to place fine needles into a tumour, through which they can fire heat, cold or, most recently, electrical energy to destroy the tumour. Typically, cancer patients have benefited from medical, surgical or radiation oncology, but Professor Tze Min Wah, IOUK (British Society of Interventional Radiology) Chair and Clinical Lead for Leeds Teaching Hospitals Trust’s Interventional Oncology Programme, believes that interventional oncology has advanced to the point where it is now the fourth pillar of cancer care.
Pioneering nanoknife treatment In 2015, the first patient in the UK successfully underwent image guided irreversible electroporation
(IRE), a technique that has been dubbed ‘nanoknife treatment’, to destroy a tumour in his kidney at Leeds Teaching Hospitals Trust and was performed by Professor Tze Min Wah. Instead of using extreme heat or cold energy, potentially damaging surrounding tissue, IRE uses image-guided technology to place tiny needles that fire electrical pulses into the walls of the cancer cell, creating nano holes in the cell walls and lead to cancer cell death. “The technology has particular applications for patients where other forms of surgery are not an option, for example when the tumour is very small or near to other important organs e.g. blood vessels, bile duct and ureter,” continues Professor Wah. “It could really help to improve the quality of life for patients with liver, pancreatic and kidney cancer and especially patients with a single kidney with cancer located in an awkward location close to bowels, ureter or vessels.” The technique requires the needles to be placed with pin-point accuracy, so not only is the tumour targeted directly, but surrounding vital structures and blood vessels are unaffected.
That, in turn, helps to shorten a patient’s recovery time and ensure they are back home much sooner.
Applications of interventional oncology
Professor Tze Min Wah Clinical Lead for LTHT IO Programme, IOUK Chair (British Society of Interventional Radiology), Consultant Interventional Radiologist
“It could really help to improve the quality of life for patients with liver, pancreatic and kidney cancer.”
In addition to IRE, there is a range of interventional oncology procedures that destroy tissue using extreme heat or cold temperatures. There are also vascular interventions that include small embolic particles coated with chemotherapy drugs that are injected selectively through a catheter into an artery directly supplying the cancer to block the blood supply and induce cytotoxicity, Occasionally, this technique involves combining radiotherapy with embolisation, and it is also known as radioembolisation or selective internal radiation therapy (SIRT). Interventional oncology is also supporting the palliative care of patients by helping to control symptoms. Image-guided techniques can help to block nerves and tackle pain; to place catheters that drain excess fluid; and to treat obstructions in the intestine or oesophagus with the insertion of feeding tubes or metal stents.
More research is required Professor Tze Min Wah is quick to point out that, as with all new technologies, it will take time before the latest interventional oncology techniques are routine practice. “There is a need for proof that this is effective. As with any new intervention, there is limited data on its long-term efficacy,” says Professor Tze Min Wah. “Unlike drug trials, it is difficult to produce randomised controlled studies and we also have to consider patient preference.” Professor Tze Min Wah is working hard to establish a centre in Leeds where specialists can get the training they need to be able to offer interventional oncology on a much broader scale. As technology continues to develop, it will be exciting to see how the application of interventional oncology can help to improve patient outcomes, while minimising discomfort, pain and recovery times.
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The transformation of UK cancer care with proton therapy in 2018
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here is a pressing need to make specialised cancer care more accessible worldwide, and high energy proton therapy can play an essential role in delivering better care. Proton Partners International Ltd is a company in the vanguard of advancing high energy proton therapy in the UK and was established on World Cancer Day, 4th February 2015 by international cancer and healthcare specialists. The vision of Proton Partners International is to create a better future for cancer patients by developing a network of cancer centres, committed to providing innovative cancer care with the most advanced proton therapy and imaging technology on the market.
Latest advances in proton therapy
The Rutherford Cancer Centre South Wales is the first place in the UK to offer high energy proton therapy and will start treating the first proton therapy patient in April 2018. The network of Rutherford Cancer Centres have been named as such in tribute to the renowned scientist Ernest Rutherford’s contribution in identifying and naming the proton in 1911. Each centre aims to treat up to 500 patients annually. Protons deliver the same damage to cancer cells as radiotherapy; however, they can be controlled to stop at a defined point in the body, a technique known as the Bragg peak, which means that there is less collateral damage to surrounding
Professor Karol Sikora Chief Medical Officer, Proton Partners International
“Protons deliver the same damage to cancer cells as radiotherapy; however, they can be controlled to stop at a defined point in the body, which means that there is less collateral damage to surrounding healthy tissues and organs.”
healthy tissues and organs. The single room Proteus®ONE proton therapy solution installed and maintained by IBA (Ion Beam Applications S.A.), delivers the latest advances in proton therapy and will be installed at each of the Rutherford Cancer Centres. The Proteus®ONE system allows for the most advanced imaging techniques to be carried out at the same time. Tumours are targeted with Cone Beam Computerised Tomography (CBCT), a volumetric visualisation of the tumour and the body. The precise dose delivery is achieved through Pencil Beam Scanning (PBS) which enables a highly precise scanning, layer by layer, pixel by pixel, to perfectly match the shape of the patient’s tumour. This along with the dimensionally accurate imaging of 3D CBCT, enables physicians to truly track where protons will be targeting tumor cells.
Accurate patient treatment
The advanced imaging technologies integrated in the Proteus®ONE ensures quick and accurate patient positioning by comparing diagnostic CT images, taken during the treatment planning process. Image-Guided Proton Therapy (IGPT) relies on high-resolution and high-sensitivity X-Ray digital imaging systems that provide low-dose stereoscopic and 3D imaging in various geometrical arrangements. CBCT offers soft-tissue contrast, providing much more information than a conventional stereoscopic alignment system, and allowing more accurate patient treatment
through anatomical modification assessment, the first step towards adaptive radiation therapy. The system has also been designed to optimise the patient experience by providing a soothing patient environment while enhancing the medical staff work experience and efficiency. By working with the world’s leading technology partners, Proton Partners International is ensuring that its Rutherford Cancer Centres are equipped with the latest cancer technology and the aim is that the centres will evolve into centres of excellence for cancer treatment.
A network of accessible centres
Proton Partners International plans to build at least eight centres across the UK within the next four years. In addition to its South Wales centre in Newport, a further three oncology centres are already under construction in Northumberland, Reading and Liverpool, with an additional site under consideration in London. The ambition is to have a Rutherford Cancer Centre within 90 minutes of the front door of 75 per cent of the UK population by 2021, meaning that patients will not have to travel for several hours or abroad for cancer treatment that is best delivered close to home. In addition to proton therapy, the centres will offer traditional imaging, chemotherapy, radiotherapy, immunotherapy and a range of supportive care services including survivorship and recovery. The centres
will be staffed by one clinical team across the multiple sites who will all work from a shared central system. This will allow oncologists to work remotely and treat patients on any of the Rutherford sites. Treatment will be available to medically-insured private patients, self-paying patients and patients referred by the NHS.
Benefits for patients
By offering a variety of cancer therapies, our centres will deliver a fully comprehensive level of cancer care, tailored to fit the different needs of each patient – something which is not available in the UK at the moment. There are more than 150,000 cancer patients in the UK every year who are treated with radiation therapy, of which 90,000 require radical radiotherapy. Around 10 per cent of these patients could be better treated with proton therapy. More patients will benefit from better diagnosis and newer treatments, with a greater emphasis on the quality of life. The market for proton therapy is rapidly evolving and Proton Partners International, with its Rutherford Cancer Centres, will be at the forefront of this growth and will continue to invest in centres and innovation to maintain its position as a market leader. The next 10 years will be a time of unprecedented change in the ongoing battle against cancer. Read more or contact us on therutherford.com 01633 740005
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How focusing on the optimal dose benefits patients There’s a new focus on radiation dose monitoring. Here’s how new technology can help clinicians, and how patients can help themselves.
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By Linda Whitney
Matthew Dunn Head of Radiology Physics, Medical Physics and Clinical Engineering, Nottingham University Hospitals NHS Trust
East Midlands group breaks new ground in radiology The UK’s biggest radiology consortium is set to benefit millions of patients in the East Midlands with real-time dosage monitoring and faster reporting to improve breast screening.
In a world first, a radiology information system is being used to collect data to improve breast cancer screening. “It can collect various data from scans including the level of breast compression,” says Matthew Dunn, Head of Radiology Physics, Medical Physics and Clinical Engineering at Nottingham University Hospitals NHS Trust. “Breast compression varies slightly among scanner operators. Too little means a cancer may be missed. Too much can be painful, deterring the woman from further scans,” says Dunn. “Determining optimum compression means better image quality and better detection.This is the first time this work has been done.” This system enables faster diagnosis, more accurate dose management and better cancer detection. It is in use across the East Midlands. Dunn says: “It reduces logistical bottlenecks too. If a radiologist is unavailable locally, the record can be moved elsewhere for reporting by another radiologist – we can electronically move images created by X-rays, CT scans and fluoroscopy, alongside a patient’s reports and clinical opinions, between clinical sites.” The system is being used by the East Midland Radiology Consortium (EMRAD) – a group of seven NHS trusts covering six million people – the largest such group in the UK. “The shared system also has dosage tracking software, so we can check, in real time, that national benchmarks for radiation dosages are being met and spot anomalies, a capacity currently unique to EMRAD,” says Dunn. “If a dose is too high or low, we can find out why, and try to stop it recurring. Correct dosages ensure safety and optimal images for diagnosis.” Read more on healthawareness.co.uk
adiation dose tracking might sound esoteric, but it is increasingly important to everyone involved in imaging – including patients. Dr Mahadevappa Mahesh, Professor of Radiology, Cardiology and Chief physicist at Johns Hopkins Hospital in Baltimore, USA, says: “Dose tracking helps us ensure that the doses of ionising radiation delivered to patients when they have X-rays, CT scans, fluoroscopy and nuclear medicine are within specified ranges. “It is growing in importance around the world as the use of radiation-based imaging increases.”
Why dose tracking matters The levels of radiation used in imaging are thought to increase the risk of developing cancer only by a very marginal degree. However, when results showed that in 2006, Americans were exposed to more than seven times as much ionizing radiation from medical procedures as was the case in the early 1980s, and that the increase was largely a result of the growth in CT scans and nuclear medicine, it triggered action internationally to limit exposures. However, simply reducing the dosage of radiation used in imaging could lead to grainier and ‘nosier’ images, which increase the chances of missed or inaccurate diagnosis. “The key is optimising the dose, so that we get the most useful image possible at the lowest dosage level,” says Dr Mahesh.
Government incentives for dose tracking In the USA, these considerations led the American College of Radiology (ACR) to establish diagnostic reference levels (DRLs) that specify optimal, size-specific dosages required to produce the most diagnostically-useful images of patients. The ACR has developed a Dose Image Registry (DIR), in which
Dr Mahadevappa Mahesh Professor of cardiology and chief physicist, Johns Hopkins Hospital, Baltimore, USA
“The key is optimising the dose, so that we get the most useful image possible at the lowest dosage level.”
data from 42 million exams (82 million scans) as of 2017, forms the basis of a radiation dosage tracking system. “It means that clinics can collect their own data, send it to the ACR, and receive reports on how their dosages compare with the averages locally, regionally and nationally,” says Dr Mahesh. Clinics are not required to take part in the dose tracking initiative, but the government provides incentives for them to do so, while insurance companies and regulators are starting to demand it. The UK has had DRLs since 1989, which local imaging departments use to set and measure acceptable dosing, depending on what kind of equipment they use. National DRLs are in place to guide hospital trusts and imaging centres.
How technology helps Manufacturers have responded to the pressure for dose limitation
by producing technology that uses lower radiation doses to achieve optimum images. Dr Mahesh says: “Automatic tube current modulation allows CT scanners to automatically vary the dosage according to the thickness of the body part being scanned. “Iterative reconstruction technology allows for CT scan images that have been acquired at lower dosages, normally associated with higher levels of image ‘noise’, to be reconstructed to produce levels of quality normally only achievable with the use of higher dosages.” Manufacturers have also improved detector technology, enabling better image results at lower dosage levels. Meanwhile, computerised clinical decision support systems have been developed to help clinicians select the most appropriate image modality for a particular patient’s condition.
How patients can help “All of these factors help ensure the use of appropriate doses, but even the best dose tracking systems will fail if clinicians do not use the resulting reports to review their practices,” says Dr Mahesh. Patients can help themselves and clinicians here. Dr Mahesh says: “There is a thirst among patients for more information on imaging risks and, as clinicians, we are beholden to them to reduce their anxieties. Asking clinicians about the level of dosage used in any CT scan you are prescribed, tends to mean that the clinician will be more careful about optimising the image.”
He suggests asking the following questions: • • • •
Is this study necessary for me? Is your facility meeting a minimum standard? Is the facility using the right scanners? Is the facility routinely checked to make sure that this is safe?
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