At this year’s annual scientific meeting of the American College of Cardiology (ACC), which takes place on March 14–16 in Atlanta, Toshiba (booth #1944) will showcase a range of advances in and enhancements to its cardiac-imaging technology.  Following is an overview of what Toshiba will showcase:

Infinix-i Hybrid Lab

When performing patient procedures in a hybrid setting, it is critical that the imaging system provides the flexibility to quickly and easily access both the patient and ancillary equipment. Toshiba will showcase its Infinix™ VF-i vascular X-ray system with 12” x 12” flat panel detectors and CAT-880B hybrid catheterization table, designed to create a best-in-class hybrid suite.  The new mid-sized 12” x 12″ flat panel detector expands the versatility of the Infinix-i line that features a five-axis C-arm positioner and enables unprecedented patient access and coverage. Along with the new mid-sized detector, the Infinix-i five-axis systems are now available with the new CAT 880B tilt/cradle hybrid catheterization table. This table is designed to allow greater positioning flexibility and patient access during imaging and surgery. The table functionality, with side-to-side cradle and head-to-toe tilt, permits clinicians to angle the table in the optimal position to quickly and comfortably complete procedures. The system on display will also include ancillary equipment typically used in a hybrid suite.

Cardiac Ultrasound Capabilities

The cardiac capabilities of Toshiba’s ultrasound technology will also be featured. The Aplio Artida™ system is a dedicated cardiac system which provides unique 3D Wall Motion Tracking, allowing physicians to rapidly identify wall-motion defects and the timing of cardiac events, as well as real-time, multiplanar reformatting for assessing global and regional left ventricular function. Also on display is the new Aplio™ MX system, which is midsized and cart-based for better portability. Aplio MX is a multi-modality system which includes Differential Tissue Harmonic Imaging, for better results with bariatric patients; ApliPure, which enhances image clarity and detail definition; Advanced Dynamic Flow, which shows flow with directional information for even the smallest vessels.

Cardiac CT Software Enhancements

CT will highlight cardiac-software enhancements for the Aquilion^® ONE and Aquilion Premium, including new ONE Beat Prospective Reconstruction, which shortens the interval window and reduces radiation exposure time, reducing dose by 21 percent; Real Time Beat Control, which calculates the running real-time average of the heart rate to predict the next beat more precisely (and thus, to time the scan more accurately); and optimizing timing for ^SUREStart, which accurately determines contrast uptake time for a better image. Wide Volume Cardiac Protocol on the Aquilion ONE, a work-in-progress enhancement, will enable clinicians to image the entire heart, lungs, and aorta in two rotations.

Cardiac MR

The wide range of cardiac MR capabilities on the Vantage Titan™ and Vantage Atlas^® systems will be highlighted. The Vantage MRI product line offers a range of advanced cardiac capabilities, including a cardiac coil for the Vantage Titan and noncontrast imaging for patients with renal insufficiency.

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The American Heart Association estimates that nearly one million US residents die of heart disease annually, and according to the US Centers for Disease Control and Prevention it is the leading cause of death for both men and women. As a result, finding ways to detect heart disease earlier and more accurately are becoming increasingly important. Toshiba’s advancements in MRI are helping physicians quantify heart disease, thus improving diagnosis and treatment.

MRI has long been used to assess the structure and morphology of the heart, but as the technology advances, so do the procedures available to clinicians for quick and accurate diagnosis of heart disease in their patients. “The bread-and-butter sequence is called SSFP [steady-state free precession] cine imaging,” Erin Kelly, clinical science manager for MRI at Toshiba America Medical Systems, explains. “It gives an image of the heart as it moves through the cardiac cycle to tell the clinicians how the muscles are functioning, and they can use these images to calculate ejection fraction and left-ventricular volume.”

The ability to perform SSFP cine imaging is one of many cardiac-friendly features included in Toshiba’s Vantage™ Titan MRI, a 1.5T system that also includes a 16-element cardiac coil that can be combined with the 32-element spine coil. The center elements are smaller, resulting in higher-resolution imaging of the heart, and “the elements in the coils can be turned on and off to optimize the signal-to-noise ratio,” Kelly notes. Various sequences and parameters are selectable from the scanner to facilitate successful evaluation of the heart, including delayed-enhancement, myocardial imaging, retrospective gating, black-blood imaging, and real-time motion correction to name a few. Non-contrast techniques are also available on all Toshiba MR systems. For example, Whole Heart Imaging is one contrast-free sequence that allows physicians to assess the coronary arteries without contrast.

Timothy Albert, MD, is medical director of the Cardiovascular Diagnostic Center at Salinas Valley Memorial Healthcare System, Salinas, California, and he uses the Vantage Atlas system. He says, “We try to use noncontrast imaging as much as possible, both for patient convenience and safety and because of concerns about patients with kidney problems. For scar imaging, you still need contrast, but the other stuff, we can often do without it.”

Albert says that MRI has an important place in the portfolio of modalities used to detect and plan treatment for heart disease. “I use CT for coronary imaging, but that’s a small part of the cardiac question,” he says. “MRI’s strengths are really in functional imaging—the shape of the heart and how it’s beating. There’s an increasing amount of scientific data coming out about new uses for MRI in cardiac care.” Albert and his team even run a two-day training course designed to help educate referring physicians on the robust applications of cardiac MRI.

“MRI is ideal for assessment of the heart-failure patient, looking at the potential causes to guide treatments and diagnostic tests, and we use it to determine whether someone would benefit from being revascularized after a heart attack,” Albert says. “For patients with congenital abnormalities, it’s the gold standard, since CT radiation could be cumulative over time. In the future, we hope physicians will hear about these new uses for MRI and recommend it more frequently.”

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ASD is a congenital heart defect that is ideally suited for evaluation using cardiac MRI. Cardiac MRI allows accurate assessment of heart structure, function, and blood flow. In addition, cardiac MRI is an ideal method of evaluation because it does not use radiation and is non-invasive.

Cardiac Magnetic Resonance imaging can be challenging due to the constant motion of a beating heart and respiration. To successfully image the heart using MR it is essential to acquire images rapidly with optimal resolution and contrast.

Toshiba uses a 16 element Atlas SPEEDER body array coil coupled with the 32 element Atlas SPEEDER spine array coil to produce the signal required for successful evaluation of the heart. Vantage MRI systems have a complete cardiac software package available which includes specialized sequences for speed and image quality as well as the post processing software for cardiac analysis.

Case Study: MRI of the heart to evaluate cause for shortness of breath and heart murmur.

Technology: Toshiba Vantage Atlas MRI system using body array and spine array coils. The heart is imaged using SSFP cine sequences in varying planes.

2D cine sequences clearly depict the atrial septal defect allowing blood to flow between the right and left atrium. High blood-flow between the atria leads to volume overload and can lead to right heart failure. In this patient the right ventricle is enlarged consistent with a large ASD. This contributes to the patient’s shortness of breath and can progress to heart failure if not treated.

By using Toshiba’s cardiac MR system and specialized sequences no contrast or radiation was necessary in making this diagnosis.

Four-chamber (left) and short axis (right) cine views of the heart demonstrating atrial septal defect (ASD). (Cines and images courtesy of Dr. T. Albert, MD, FACC, Cardiovascular Diagnostic Center, Monterey, CA.)

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While efficiency has always been important in health care, the changes we see in today’s environment are requiring the medical community to be even more diligent.  Many are starting to recognize that the right equipment can make important differences.  At this year’s RSNA, Toshiba showcased how its systems are helping health care professionals meet the demands for efficiency without sacrificing quality.

Magnetic Resonance

The patient-focused features of the Vantage Titan™ improve exam efficiency and accuracy while mitigating issues around imaging claustrophobic and bariatric patients.  The Vantage Titan features a large 71-cm aperture open bore and offers the industry’s largest clinical field-of-view (55×55×50 cm).  The bore’s diameter enables technologists to scan patients with greater ease and reduces the feeling of claustrophobia.  Toshiba’s patented Pianissimo™ technology, which reduces acoustic noise by as much as 90 percent, is also increasing the comfort level of patients during exams.  Improving comfort level is critical because it often reduces the need for re-scans, thus improving efficiency.

St. Anthony Hospital in Gig Harbor, Wash., has experienced these benefits first hand.  “The Toshiba Titan has been the workhorse MR system for us and is able to accommodate the wide variety of MR exams we perform each day,” said Gary Leslie, MRI technologist at St. Anthony.  “We are imaging multiple patients a day and have received direct patient feedback that the system is quieter and feels less claustrophobic than other MR systems.  This has helped us to greatly improve exam efficiency and department throughput.”

Additionally, the system’s Atlas integrated coils allow physicians to perform multiple exams without repositioning the patient and also enable feet-first imaging for feet-to-shoulder exams.  This means a more comfortable exam experience and results in enhanced workflow and technologist productivity.  Also, Toshiba’s SPEEDER parallel imaging allows for increased acquisition speed and reduced examination times.

X-ray

Today’s emergency departments are challenged to provide rapid, accurate diagnoses for a variety of patient conditions when time is of the essence. Toshiba’s RADREX™-i digital radiographic system is designed to provide the features emergency departments require to offer the highest level of patient care.

The comprehensive RADREX-i offers a 600-lb. table weight limit, 600 kHU X-ray tube and an 80-kilowatt generator, allowing hospitals to image a variety of patients, including bariatric. The X-ray system enhances workflow with the RexView, a color LCD screen located on the overhead tube crane (OTC). Since the image appears on the OTC, technologists have immediate access to review the image and determine if they have what is needed for diagnosis, ultimately reducing exam time and increasing the chance of a positive patient outcome.

The RADREX-i’s automated features also save time in emergency settings by automating exam selection and X-ray positioning. These features include:

• Auto-tracking to eliminate the need to manually position the X-ray tube detector by providing synchronization for table and wall-stand tracking
• Auto-collimation to save crucial time for the patient and technologist by automatically selecting the correct collimation size for the patient’s body part
• Auto-program to eliminate the need for the technologist to manually select the program on the generator by automatically selecting the correct program
• Auto-center stop to provide visual guidance for fast, simple detector centering

St. Luke’s Community Hospital in Ronan, Mont. uses the RADREX-i in its emergency department.

“When treating emergency patients, acting quickly is critical,” said Steve Sivak, radiology manager, St. Luke Community Hospital. “The advanced features of the RADREX-i help us streamline workflow and accelerate throughput, providing a tremendous benefit to patients when time is limited.”

Ultrasound

Many hand-carried ultrasound systems offer better access to patients when space is compromised, but cannot provide all of the advanced radiology capabilities required to perform exams in today’s demanding ultrasound environment.  Toshiba’s new works-in-progress Viamo™ ultrasound system meets the needs of today’s hospitals by combining portability with high-end radiology features.  Viamo is the industry’s no compromise ultrasound system with advanced radiology capabilities, previously unavailable on hand carried systems.

The Viamo combines the portability of a laptop system with advanced radiology features to deliver outstanding image quality, enhance diagnostic confidence and improve ease-of-use. Developed from a radiology foundation, Toshiba’s Viamo provides the confidence to image patients at bedside, which generally require larger, more expensive cart-based systems. When an immobile patient needs a high-end ultrasound exam, the portable Viamo laptop ultrasound is brought to the patient to improve the patient’s comfort without compromising exam quality.

The new Toshiba Viamo laptop ultrasound system offers:

• Best-in-class imaging capabilities in a laptop size, making it ideal for high-end radiology, vascular, emergency and OB/GYN exams, even at bedside. For example, Viamo is beneficial during liver transplants when medical personnel must image the anastomoses to assess blood flow through the vessels.
• Excellent image quality and color flow comparable to larger, more expensive cart-based systems.
• Ease-of-use with a simple touch-screen interface that is programmable in panel or tablet modes.
• Ability to interchange Toshiba transducers while using the Viamo’s transportation pole, thus improving productivity and flexibility, while saving health care costs by reducing the need to purchase multiple transducers. This unique feature improves productivity and saves money for current customers by using their existing Toshiba transducers on the Viamo.  Additionally, new customers are able to use Viamo transducers with other Toshiba ultrasound systems they may purchase in the future.

Computed Tomography

Overall, Toshiba’s Aquilion® line continues to be focused on exam efficiency and the company has added several new features to help the medical community.  The Aquilion line comes with a host of ^SURETechnologies that automate parts of the exam, which not only provides efficiencies, but also safer exams.  For example, Variable Helical Pitch (vHP) ensures greater workflow efficiency by enabling physicians to complete an exam of more than one anatomical region consecutively – i.e. without stopping to alter the helical pitch of the exam.  Toshiba’s CT line also features items like the iStation, a screen on the gantry that provides automatic exam feedback to the technologist, and a table with a 660-lb. weight limit that also lowers within inches of the ground, enabling patients to sit on the table more easily.

While the entire Aquilion line boasts efficiencies, Toshiba’s Aquilion® ONE is designed for today’s health care environment because it can streamline workflow by providing a more accurate, complete and timely diagnosis with one exam.  The Aquilion ONE can image a patient in 0.35 seconds, whereas conventional helical CTs can take four or five seconds, approximately 10 to 12 times slower.  Beyond its fast acquisition time, the Aquilion ONE can replace several tests with one exam, eliminating the time, cost and staff required to perform additional unnecessary exams.  It also allows physicians to treat at-risk patients immediately and send healthy patients home without additional testing and staff support.

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When patients have to have any diagnostic imaging exam, they are understandably nervous.  Often times the anxiety they feel comes from thinking that a particular exam is going to be difficult, time consuming or uncomfortable.  Toshiba has developed its technology with patients in mind and incorporates many patient friendly features into its systems.  At this year’s RSNA, Toshiba highlighted its patient friendly features.

Magnetic Resonance

For patients undergoing an MR exam, discomfort from claustrophobia and the loud noise of the magnet are among the highest complaints.  To address this, Toshiba developed the Vantage Titan^TM MR, which features a large 71-cm aperture and open bore, offering the industry’s largest clinical field-of-view (55×55×50 cm).  The bore’s diameter reduces the feeling of claustrophobia.  Titan’s ultra short, open bore was designed to increase comfort and improve the imaging of all patients, especially those who are claustrophobic and/or bariatric.  The open bore’s larger diameter enables facilities to scan bariatric patients with greater ease and provides patients with a greater feeling of openness to reduce claustrophobia.

Toshiba’s Pianissimo^TM technology reduces noise by up to 90 percent, making Toshiba’s MR systems the quietest available.  Since the patient experiences lower noise levels with Pianissimo, patients stay more relaxed during exams and fewer motion artifacts are acquired, which helps improve image quality.  Useful for imaging pediatric patients, Pianissimo helps technologists image patients more successfully and reduces repeat exams.

With all of the concern surrounding gadolinium, Toshiba’s proprietary contrast-free MRA techniques enable safer MRA imaging of patients with known renal compromise. These techniques include Fresh Blood Imaging (FBI) for evaluating peripheral vascular diseases of the lower legs and extremities; Contrast-free Improved Angiography (CIA) for easier visualization of smaller vessels; Time-Spatial Labeling Inversion Pulse (Time-SLIP) for evaluating hemodynamic, functional assessments, and visualization of vascular structures; and Time Space Angiography (TSA) to create non-contrast time-resolved imaging with high temporal resolution.  Contrast-free techniques are safer for patients with renal conditions and require less set-up time, so the overall MR exam is completed faster, without compromising image quality.

Computed Tomography

The Aquilion® ONE was specifically developed with patients in mind.  Not only is the comprehensive exam much faster than traditional CT exams – 0.35 seconds versus conventional helical CTs that can take approximately 10 to 12 times longer – but also radiation exposure is dramatically reduced because of volume acquisition.  These patient benefits are especially important during neuro and pediatric procedures.

When a patient comes to a hospital’s emergency department exhibiting stroke symptoms, it can take hours to diagnose and treat the patient when time is of the essence. Toshiba’s Aquilion ONE dynamic volume CT system has the ability to improve the quality of life for patients with neurological symptoms, especially related to stroke, by reducing diagnosis time to minutes. In fact, the system allows physicians to reduce diagnosis time for life-threatening conditions, such as a stroke, from hours or days to minutes. Unlike any other CT system available, the Aquilion ONE covers up to 16 cm of anatomy using 320 ultra high resolution 0.5 mm detector elements to image an entire organ, including the brain, in a single rotation. It can show the organ’s dynamic blood flow and real-time function.  The ability to see dynamic function, such as blood flowing through the brain, is critical for stroke patients in emergency settings and enables rapid and accurate diagnosis when time is critical.

Another reason to select dynamic volume CT is for its pediatric applications.  The Aquilion ONE can significantly lower patient radiation dose exposure and decrease the sedation needed for exams.  Traditionally, when children are imaged using multi-detector CT, sedation is required to keep the patient still long enough to obtain a clear diagnostic image.  The Aquilion ONE’s fast exam time means less patient sedation is required. The system also features Toshiba’s ^SUREExposure™ Pediatric software, which automatically takes inputs on the size and age of each patient and tailors radiation dose to achieve the best and safest image quality for each exam. The software uses protocols selected based on the patient’s age, size and type of exam to ensure patients receive only the radiation required to obtain a clear diagnostic image.  ^SUREExposure Pediatric software comes standard on all Aquilion products.

X-ray Vascular

CT is not the only modality in which radiation is a concern.  Toshiba’s Infinix-i product line incorporates features that help to reduce exposure.  For example, the systems come with fluoro dose level settings and fluoro pulse rate settings.  Toshiba offers the industry’s widest range of pulse rates, which means that physicians have the ability to reduce flyoro pulse rate and fluoro dose level in an exam, providing two quick methods of reducing radiation exposure to the patient.  Additionally, Toshiba’s lateral plane variable isocenter on its biplane systems saves time and exposure.  During biplane positioning, the user will fluoro frontal plane and adjust table panning to center the part of interest.  Next, they will fluoro the lateral plane and adjust lateral isocenter to match the frontal set-up.  No additional fluoro is needed.  Not only does this cut down on fluoro exposure, but it also speeds the exam time, reducing the risk to the patient.

Infinix-i systems also provide the greatest anatomical coverage and patient access in the industry, providing more efficient and safer patient care.  Greater anatomical coverage means that the system moves around the patient, rather than moving the patient.  Moving the patient can introduce greater risk.

The Infinix-i’s tables also are more patient friendly.  Not only are the systems’ table weights the highest in the industry at 550 lbs., but also the tables include thicker pads complete with Tempur-Pedic^® technology, making extended procedures more comfortable.  Also, the new the CAT-880B hybrid catheterization table introduced at RSNA offers the lowest table top height of any catheterization table in the industry.  Toshiba has even introduced accessories that expand the width of the system tables to accommodate larger patients and make the exams more comfortable.

Ultrasound

The move toward portability in ultrasound is helping physicians deliver more comfortable patient care.  The ability to bring a diagnostic imaging system to the patient can often mean that someone already in discomfort does not have to be moved in order to be scanned.

In addition to the Viamo handheld system, Toshiba has continued its focus on portability by introducing the Aplio MX.  Thirty percent lighter than traditional cart-based systems, the Aplio MX enables hospitals to complete advanced ultrasound exams, usually performed with larger systems, on a more portable system without sacrificing quality.  Furthermore, it enables medical staff to easily bring the system directly to the point-of-care.  For example, if someone is on a gurney and should not be moved, medical professionals can easily transport the MX to the patient’s location and get a high quality exam.

Toshiba’s Aplio MX ultrasound system includes:

• 4D imaging to produce high resolution renderings and arbitrary volume cuts in real-time or offline allowing virtual reconstruction in formats similar to CT and MRI.
• Differential Tissue Harmonic Imaging for better imaging of difficult-to-image patients, like bariatric, without sacrificing resolution to give superior border and tissue definition.
• ApliPure to enhance both image clarity and detail definition with real-time compounding technology to simultaneously perform spatial and frequency compounding during transmitting and receiving.
• Advanced Dynamic Flow to provide color Doppler imaging at an unprecedented level and show flow with directional information for even the smallest vessels.
• Precision Imaging to provide more detailed ultrasound images by capturing information from multiple lines to improve definition of the structure and minimizing noise and clutter.
• Elastography to enable a non-invasive medical imaging technique that evaluates tumors based on their stiffness (elasticity) compared to normal tissue.
• MicroPure to help physicians detect micro-calcifications using ultrasound, an imaging technique that is less strenuous on the technician and the patient than mammography, the current gold standard.

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The journey from bench to bedside is a long one in medicine, but breast MRI received a boost in March 2007 when the American Cancer Society (ACS) revised its guidelines for breast cancer screening to include annual MRI for high-risk women, a group representing about 2 percent of the US population. That same month, a report¹ on the ACR Imaging Network 6667 trial was published in the New England Journal of Medicine, recommending contralateral breast MRI for women recently diagnosed with breast cancer. In addition, the ACS recommends that women with extremely dense breasts, a personal history of breast cancer, and atypical hyperplasia receive breast MRI at their physicians’ discretion.

Another adjunct breast-imaging modality is poised to assume an even greater role in breast cancer screening and diagnosis. Ultrasound, long used to help evaluate suspicious lesions and cysts and to guide breast biopsies, has been generating a growing list of scientific citations since emerging as a hot topic at the 2006 meeting of the European Congress of Radiology (ECR) for a different reason: elastography.

Numerous studies have indicated that elastography, which uses ultrasound waves to measure the elasticity of tissue, could be a useful diagnostic tool for several cancers, including breast malignancies. Cancerous tissue is less pliant than regular breast tissue; according to the results of one British study presented at ECR 2006,² the sensitivity and specificity of breast elastography are 96 percent and 53 percent, respectively, meaning that the technique could be used to determine whether a lesion is benign or malignant without invasive biopsy. Later that year, a poster presentation³ at the annual RSNA meeting showed similar results.

An article⁴ published in the July 2008 issue of Breast Cancer, “Cost-effective Screening for Breast Cancer Worldwide: Current State and Future Directions,” provided another argument for the use of elastography in breast cancer diagnosis: its affordability. “Clinical results demonstrate that elasticity imaging, even in its simplest and least sophisticated versions, like tactile imaging, has significant diagnostic potential comparable and exceeding that of conventional imaging techniques,”⁴ the study’s authors wrote. “Tactile imaging is one method that has the potential to provide cost-effective breast cancer screening and diagnostics.”⁴

A National Cancer Institute clinical trial to validate the use of elastography in breast cancer evaluation was launched in July of 2008 and is currently recruiting participants.

Meanwhile, ultrasound guidance for breast biopsy and surgery continues to gain momentum. A recent study⁵ published in Breast looks at the use of vacuum-assisted, ultrasound-guided breast biopsy for difficult indications, including lesions with scarring or distortion, and small tumors or microcalcifications. The study indicates that the technique helped patients avoid difficult surgery in 41 of 51 cases. Another study,⁶ published in the August 2009 issue of the American Journal of Surgery, looks at using an ultrasound-guided electrosurgical loop to excise breast lesions, noting that the technique shortened procedure times and allowed incisions to be smaller.

As breast MRI proliferates around the country following the 2007 ACS revisions to its screening guidelines, research into the diagnostic potential of the modality for breast cancer continues apace. The ACS recommendation came with a caveat: The relatively low specificity of MRI could lead to false positives, resulting in unnecessary biopsies. Some hope computer-aided detection could be a solution. A study⁷ published online in September 2009 in European Radiology evaluated the accuracy of a computer-aided detection program against manual interpretation by radiologists, finding that interpretation based on computer-aided detection had a specificity of 86.4 percent. Without computer-aided detection, the specificity of MRI was found to be around 69 percent.

Another European Radiology study⁸ published online in September 2009 looks at the use of MR elastography (MRE), an experimental technique that uses MRI instead of ultrasound to look at tissue elasticity. According to the results of the study, the addition of MRE to conventional MRI of the breast resulted in sensitivity approaching 98 percent, leading the study’s authors to conclude the combination of MRE and contrast-enhanced MRI could increase the diagnostic performance of breast MRI.

References

1. Lehman CD, Gatsonis C, Kuhl CK, et al. MRI evaluation of the contralateral breast in women with recently diagnosed breast cancer. N Engl J Med. 2007;356(13):1295-1303.

2. Proceedings of the European Congress of Radiology. ECR: Vienna, Austria; 2006.

3. Thomas A, Fischer T. An advanced method of ultrasound: realtime elastography—first experience in 300 patients with breast lesions. Poster presented at: 92nd Scientific Assembly and Annual Meeting of the Radiological Society of North America; November 26–December 1, 2006; Chicago, IL.

4. Sarvazyan A, Egorov V, Son JS, Kaufman CS. Cost-effective screening for breast cancer worldwide: current state and future directions. Breast Cancer: Basic and Clinical Research. 2008;1:91-99.

5. Abbate F, Bacigalupo L, Latronico A, et al. Ultrasound-guided vacuum assisted breast biopsy in the assessment of C3 breast lesions by ultrasound-guided fine needle aspiration cytology: results and costs in comparison with surgery. Breast. 2009;18(2):73-77.

6. Fine RE, Schwalke MA, Pellicane JV, Attai DJ. A novel ultrasound-guided electrosurgical loop device for intra-operative excision of breast lesions: an improvement in surgical technique. Am J Surg. 2009;198(2):283-286.

7. Meeuwis C, van de Ven SM, Stapper G, et al. Computer-aided detection (CAD) for breast MRI: evaluation of efficacy at 3.0 T [published online ahead of print September 2, 2009]. Eur Radiol.

8. Siegmann KC, Xydeas T, Sinkus R, Kraemer B, Vogel U, Claussen CD . Diagnostic value of MR elastography in addition to contrast-enhanced MR imaging of the breast—initial clinical results [published online ahead of print September 1, 2009]. Eur Radiol.

ACS Breast MRI Recommendations

The American Cancer Society (ACS) recommends¹ an annual MRI exam for women who have the following indications:

• the BRCA1 or BRCA2 genetic mutations, or a first-degree relative with either;

• a lifetime risk for breast cancer that has been scored at 20 percent or higher;

• receipt of chest radiation between the ages of 10 and 30; and

• Li–Fraumeni syndrome, Cowden syndrome, Bannayan–Riley–Ruvalcaba syndrome, or a first-degree relative with any of these.

The ACS acknowledges that while data are insufficient to make a recommendation either for or against screening with MRI in the following risk subgroups, physicians should make individualized decisions on whether women with the following risk factors receive breast MRI exams:

• a personal history of breast cancer,

• carcinoma in situ,

• atypical hyperplasia, and

• extremely dense breasts on mammography.

Reference

1. American Cancer Society Guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin. 2007;57:75-89.

When Steinberg Diagnostic Medical Imaging (SDMI), Las Vegas, Nev., installed the Vantage Titan™ MRI system from Toshiba America Medical Systems (Tustin, Calif.) a few months ago, founder Mark Winkler, MD, was particularly looking forward to adding high-resolution breast MRI to SDMI’s capabilities. The addition of Toshiba’s Radiance Plus breast-imaging coil, available on both Vantage Atlas and Vantage Titan systems, meant SDMI could perform high-resolution breast imaging without needing a dedicated breast MRI unit.

SDMI selected the Vantage Titan MRI, a 1.5T system, because, in Winkler’s words, “It’s short, wide, and quiet.” The system features a 71-cm patient aperture and a field of view of 55 by 55 by 50 cm; it also includes Toshiba’s patented Pianissimo^TM technology, which helps to limit MRI acoustic noise. Winkler says the Vantage Titan is “more open than what is considered a conventional open system.”

The wide bore enables the Titan system to accommodate more patients while leaving ample space for the Radiance coil. “It helps make the experience nicer because it’s wider, it’s more open, and we can physically accommodate larger patients,” Winkler says. “The very short and wide bore (as well as the quietness of the system) makes it very patient friendly.”

The versatility and high image quality of the Vantage Titan have inspired SDMI to install the system in multiple facilities. “We are getting a new Titan next month and upgrading two systems to Titans, so we’ll have four within six months,” he says. “At that point, most of our breast MRI will be done on a Titan. It’s equivalent to a dedicated breast MRI, but it’s also a great open whole-body system.”

During the past two decades, there has been a dramatic increase in obesity among U.S. residents, according to the Centers for Disease Control and Prevention; in 30 states, more than a quarter of the population is obese (see figure above). The rise in obesity has led, in turn, to an increase in the incidence of diabetes, presenting the radiology community with a fresh challenge: How can radiologists accurately and safely image patients with comorbidities ranging from slow blood flow to kidney disease?

“Vascular disease is obviously a huge problem in the diabetic population and is a major cause of morbidity and mortality, with limb loss and gangrene,” according to Timothy Albert, MD, medical director of the Cardiovascular Diagnostic Center of Salinas Valley Memorial Healthcare System, Monterey, Calif. “At a minimum, it prevents patients from being active, so one of the things we try to emphasize in our community is the importance of aggressively working up this disease. If you can diagnose it, you can treat some patients with cholesterol medications, blood-pressure medications, and so on. For those who have a blockage, you can fix it.”

In 2008, Salinas Valley installed a Vantage™ Atlas MRI system from Toshiba America Medical Systems, Inc. in Tustin, Calif., and began using the scanner’s non-contrast protocol to image more than 90 percent of its patients. “We prefer to image these patients without contrast for a couple of reasons,” Albert notes. “A lot of times, these diabetic patients have some early kidney disease (if not advanced kidney disease), and you’ve got issues with veins not getting enough contrast, especially in the lower extremities.”

The 1.5T Atlas uses Toshiba’s proprietary contrast-free imaging techniques. “In terms of image quality in the renal area, I’d say it’s one-to-one with contrast-enhanced MRI. It’s as good, if not even better; there’s often some improvement, in that you can actually see the branching vessels better than when you’re using contrast, which can wash the image out,” Albert says.

Using non-contrast MRI, however, eliminates other timing issues, such as the need to take the scan while the contrast is flowing through the vessels at an optimal level. “Up to 5 percent of the time, even with an experienced technologist, you can miss it,” he says, “and you’ll still have problems with the veins getting enough contrast.”

Use of the non-contrast technique improves workflow and throughput, Albert says, by eliminating the obstacles that come in tandem with using gadolinium or other contrast agents. “With contrast-enhanced imaging, there’s always a certain percentage of patients whose exams you may need to redo,” he notes. “IV issues themselves—plus the risk of reactions or complications from the IV (although low)—also contribute to the amount of time it can take to scan one patient.”

There are throughput benefits specific to imaging the bariatric/diabetic population, he adds. “With diabetic patients, it can be hard to find a vein, and sometimes you can’t get an IV the size you need for a rapid injection. You can spend 20 minutes looking for the right size IV,” Albert says. “For patients with kidney disease, logistically, it’s nice not to have to make sure you’ve got their latest kidney-function tests, because that can slow the process of getting patients through, and for patients who do have a contraindication for gadolinium, we’re not dusting off the books and trying something new. This is what we do routinely.”

Non-contrast MRI also saves money—well over $100 per study, according to Albert. “We’re in a day and age when reimbursement is getting cut and cut, and this is a big way to save,” he says. “It’s not only the contrast bill, which could be up to $100 for the average study. You’ve also got IV supplies, and nursing time to put in the IV. We’re working on some financial models to compare the two, but you’re probably looking at saving up to $150 per study.”

Albert emphasizes that while the non-contrast technique is particularly beneficial in imaging the diabetic population, it can be used on any patient. “There are a lot of misconceptions out there regarding who is the ideal patient for this,” he says. “We’ve done a cross-section of patients of every size in the past year, and we’ve had very good results. This really is a robust technique.”