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Research
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Clinical Practice
Leading the News
Using CT Scans to Screen for Lung Cancer May Carry Risks
Lung cancer screenings may carry hidden risks, according to researchers who presented their findings at the American Society of Clinical Oncology meeting in Orlando, Fla., over the weekend. Approximately 215,000 new cases of lung cancer are diagnosed every year and 162,000 deaths are attributed to the disease annually, according to the American Cancer Society. The National Institutes of Health (NIH) is running a large study to find out if screening patients with CT scans can save lives, and some physicians are already offering the screenings in the hopes of finding tumors early. But according to the new research, a scan's results are not always clear or easy to interpret, which can lead to false alarms. In presenting initial findings from NIH's National Lung Screening Trial, which includes 50,000 patients, lead author Jennifer Croswell said that the study showed people who are screened have a 21 percent chance of being unnecessarily alarmed by findings that at first seem suspicious but later turn out to be benign. Suspicious findings can also lead to unnecessary invasive follow-up exams, such as biopsies or even surgeries. Because lung surgeries are risky, Croswell said that it is possible for the screenings themselves to cause death, in addition to exposing patients to radiation. According to Peter Bach, a pulmonologist at New York's Memorial Sloan-Kettering Cancer Center who authored a 2007 study on lung cancer screening, people having CT scans are 100 times more likely to get a false alarm then they are to die of lung cancer. The American Cancer Society does not recommend lung screenings, and insurance does not cover the screenings.
From "Using CT Scans to Screen for Lung Cancer May Carry Risks"
USA Today (05/30/09) Szabo, Liz
Research
LD Unenhanced CT Identifies Normal Appendix Using the Sliding Slab Averaging Technique
Seoul National University researchers have found that thin-section low-dose (LD) unenhanced CT can be used to image the majority of normal appendices when reviewed using the sliding slab averaging technique. In order to determine the frequency of normal appendix visualization with LD unenhanced CT, the researchers studied a total of 259 patients using either a 16- or 64-detector row scanner to assess urinary colic. Three readers then used the sliding slab averaging technique to review the thin-section images. By doing so, each reader was able to identify the entire appendix in 96 percent, 94.1 percent, and 92.3 percent of patients, respectively. The study was published in the June 2009 issue of Radiology.
From "Detection of the Normal Appendix With Low-Dose Unenhanced CT: Use of the Sliding Slab Averaging Technique"
Radiology (06/01/09) Vol. 251, No. 3, P. 780; Joo, Seung-Moon; Lee, Kyoung Ho; Kim, Young Hoon
PET Scans Non-invasively Provide Early Assessment of Treatment for Estrogen Receptor Positive Breast Cancer
According to a presentation scheduled for the American Society of Clinical Oncology (ASCO) annual meeting, it is possible to non-invasively measure how well patients with estrogen receptor positive breast cancer - the most common type of breast cancer - respond to standard aromatase inhibitor therapy after just two weeks. A study of 21 patients in Washington state found that for 16 of the 21 patients, the combination of positron emission tomography (PET) scanning and the glucose analogue FDG was a perfect parallel to earlier work in the United Kingdom done with needle biopsies. "Our findings are exciting because they suggest that we can measure a patient's response to therapy non-invasively, and PET scanning provides us simultaneous quantitative metabolic measurements at multiple tumor sites," says research co-lead Hannah Linden, MD, of the Seattle Cancer Care Alliance and the University of Washington. "PET has the potential to be a powerful tool to help doctors make important treatment decisions in as little as two weeks instead of two or more months."
From "PET Scan Can Non-invasively Measure Early Assessment of Treatment for Common Type of Breast Cancer"
EurekAlert (05/26/09)
Radiofrequency Ablation Treats Barrett's Esophagus With Dysplasia
A multi-center trial of radiofrequency ablation as a treatment for dysplastic Barrett's esophagus found that the technique is "associated with a high rate of complete eradication of both dysplasia and intestinal metaplasia and a reduced risk of disease progression." A total of 127 patients with dysplastic Barrett's esophagus were divided into an ablation group that received radiofrequency ablation and a control group that received a sham procedure. Complete eradication of dysplasia was seen in 90.5 percent of the patients in the ablation group who had low-grade dysplasia, compared to 22.7 percent of control-group patients with low-grade dysplasia. For patients with high-grade dysplasia, 81.0 percent of those in the ablation group had complete eradication, compared to 19.0 percent of those in the control group. While patients in the ablation group had less disease progression and fewer cancers, there were more reports of chest pain after the ablation procedure than after the sham procedure; one ablation patient had upper gastrointestinal hemorrhage and five had esophageal stricture.
From "Radiofrequency Ablation in Barrett's Esophagus With Dysplasia"
New England Journal of Medicine (05/28/09) Vol. 360, No. 22, P. 2277; Shaheen, Nicholas J.; Sharma, Prateek; Overholt, Bergein F.; et al.
Technology
CT Scans of Soldiers Killed in Combat Reveal Ways to Save Others
Autopsies were rare and CT scans unheard of in combat deaths prior to the 21st century, but since 2004, every service man and woman killed in Iraq or Afghanistan has been given a CT scan, and since 2001, all have had autopsies, performed by pathologists in the Armed Forces Medical Examiner System. This has provided medical professionals with an enormous amount of new information about injuries from bullets, blasts, burns, and shrapnel, helping uncover problems with body armor and vehicle shielding as well as improving helmets and battlefield medicine. The idea of scanning the bodies of war dead was met with skepticism by the military at first, but medical examiners say the military is eager for such information now, and Armed Forces Medical Examiner System head Capt. Craig T. Mallak says that "we've created a huge database that's never existed before." The medical examiners have scanned about 3,000 corpses, more than any other institution in the world, providing a detailed 3D record of combat information that has also helped guide pathologists in their autopsies. One important improvement thanks to the scans has been the lengthening of the tubes used to relieve collapsed lungs from the previous length of 5 centimeters - which was too short for half the personnel - to a new length of 8 centimeters, which is sufficient for 99 percent of them. Information about insufficient body armor coverage on the torso and shoulders has also spurred the military to send more armor plates to Iraq. The CT scans and autopsies give the families of the slain a detailed accounting of what happened to their loved ones and can help clear up common concerns such as whether a person burned to death or drowned or whether they were already dead before they were burned or hit the water.
From "Autopsies of War Dead Reveal Ways to Save Others"
New York Times (05/26/09) Grady, Denise
More Physicians Use Smartphones to View Diagnostic Images
According to a recent report by market research firm Manhattan Research, approximately 64 percent of physicians are now using smartphones for tasks varying from looking up drug-to-drug interactions to viewing X-rays and MRI scans to streaming music from the Internet during surgery. The iTunes store lists 674 applications related to medicine available for the iPhone, and there are a number of apps running on the Windows operating system for BlackBerry users as well.
From "New Tool in the MD's Bag: A Smartphone"
Washington Post (05/19/09) Bhanoo, Sindya N
Medical-Legal Issues
Researchers Support CMS Decision on CTC Coverage
Researchers writing in the New England Journal of Medicine say the Centers for Medicare and Medicaid Services' (CMS) recent decision to deny coverage of computed tomographic (CT) colonography for cancer screening on the basis of inadequate evidence is a valid one. CMS determined that the mean age of participants in trials cited in support of coverage was substantially lower than that of Medicare beneficiaries. The researchers note that there often has been no mandate that a new therapy should be demonstrated to benefit Medicare patients before taxpayers pay for it. "We believe that the CMS's decision in the CT colonography case, therefore, is a long-overdue step toward meaningful validation of clinical-trial evidence in Medicare beneficiaries," they write. The decision diverges from some previous CMS decisions, although the researchers point out that the agency backpedaled on an earlier draft decision to withdraw broad coverage of cardiac CT because of congressional pressure and protests. "Given this history, we worry that the CMS may waver in the face of the struggle between science and politics," they say. The researchers argue that future coverage decisions also should account for other subgroup data, such as gender and race. "Researchers need to carefully consider the epidemiology of the relevant disease and to ensure that studies are adequately powered to provide meaningful data on discrete subgroups," they write. "We hope that this decision by the CMS will spur the enrollment of older patients, women, members of racial minorities, and other poorly studied subgroups and the reporting of subgroup data in more published clinical trials."
From "CMS's Landmark Decision on CT Colonography—Examining the Relevant Data"
New England Journal of Medicine (05/27/09) Vol. 360, No. 22, Dhruva, Sanket S.; Phurrough, Steve E.; Salive, Marcel E.; et al.
Clinical Practice
Recording Image-guided Procedures Can Improve Performance
In order to improve performance during image-guided procedures, radiologists should consider recording the procedures followed by detailed analysis of those recordings. This improvement is the result of important insights into how visual information is used during these procedures, according to a recent study conducted by researchers at the Washington University's Mallinckrodt Institute of Radiology in St. Louis, Missouri. As part of their study, the researchers made multiple video and audio recordings of several image-guided procedures, including uterine artery embolization, transjugular intrahepatic portosystemic shunt creation, and Port-a-Cath placement. These recordings were then used to assess how physicians use visual and auditory information to drive decisions during image-guided procedures. Several patterns emerged, including that fluoroscopy was used to guide decisions for the vast majority of each procedure; acquisition of digital subtraction angiographic images caused a substantial increase in radiation flux; and clear instances in which additional information provided by the increased dose was considered essential to the decision-making process.
From "Capture and Analysis of Data From Image-guided Procedures"
Journal of the Society for Interventional Radiology (06/09) Vol. 20, No. 6, P. 769; Beta, Elio; Parikh, Ashesh S.; Street, Mandie
Quality and Patient Satisfaction Incentives Drive Imaging Rapidity and Modality Choices
Looking to clarify factors associated with possible overuse of medical services, researchers analyzed Medicare claims from over 35,000 Medicare beneficiaries with acute low back pain (LBP), using a modified version of a National Committee on Quality Assurance measure of inappropriate imaging. Of the people studied, 28.8 percent had imaging done within 28 days, while 4.6 percent more had imaging done within 28 to 180 days. Radiography was performed on 88.2 percent of patients who underwent imaging, while CT/MRI was used for the initial study on 11.8 percent of patients. White patients had higher levels of imaging than people from other races, while Medicaid patients had less rapid or advanced imaging than non-Medicaid recipients. Patients whose primary care physician worked in a large practice had higher levels of imaging. Clinical quality-based incentives were associated with less advanced imaging as compared with no incentives, while more rapid and advanced imaging was seen with incentive combinations including satisfaction measures. The researchers conclude, "Rapidity and modality of imaging for LBP is associated with patient and physician characteristics but the directionality of associations with desirable care processes is opposite of associations for measures targeting underuse." They add, "Rapidity and modality of imaging for LBP is associated with patient and physician characteristics but the directionality of associations with desirable care processes is opposite of associations for measures targeting underuse."
From "Rapidity and Modality of Imaging for Acute Low Back Pain in Elderly Patients"
Archives of Internal Medicine (05/25/09) Vol. 169, No. 10, P. 972; Pham, Hoangmai H.; Landon, Bruce E.; Reschovsky, James D.; et al.
Side Discrepancy Errors in Radiology Reports Are Rare but Often Clinically Significant
A study performed at Massachusetts General Hospital in Boston found that side discrepancy errors in radiology reports, although infrequent, are significant enough to warrant that radiologists, referring physicians, and patients communicate well to help prevent mistakes in clinical management. "Side discrepancy errors refer to instances when the side of the lesion is incorrectly noted in one or more sections of the radiology report," said lead study author Minal Jagtiani Sangwaiya, MD. Over 1 million radiology reports were covered in the study, and Sangwaiya noted that "88 side discrepancy errors were reported and 80 percent of those errors were rated as clinically important. The errors in mislabeling the side of the lesion were almost twice as frequent in female patients as in males. Mammography and radiography, followed by MRI and ultrasound were the most commonly reported techniques with mislabeling of the side of the lesion in identified errors." Sangwaiya pointed out that, despite the rarity of side discrepancy errors, "most reports describing medical errors are self-reports or surveys and they almost certainly underestimate the incidence, perhaps by a factor of 20 or more." She stressed that radiologists ought to check for such errors and physicians also should correspond the laterality of the radiological lesions with clinical complaints and images. "Patients should also discuss their radiology findings with their physicians, especially in light of their presenting symptoms and clinical signs," advised Sangwaiya. The study was published in the American Journal of Roentgenology.
From "Side Discrepancy Errors in Radiology Reports Rare but Often Clinically Significant"
American Journal of Roentgenology (05/01/2009) Vol. 192, No. 5, P. W239
RSNA Weekly is a briefing of the latest radiology-related news selected from hundreds of sources by the editors of Information, Inc. While care is taken to use good sources, inaccuracies in source material are not the responsibility of RSNA or Information, Inc.
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