Look Ahead The Future of Abdominal Imaging

The Nexus Crisis

More than in any other area of the body, the abdomen encompasses a multiplicity of organs, each of which requires a distinct knowledge base. Abdominal radiologists serve other specialists including colon and rectal surgeons, gynecologists, gynecologic oncologists, urologists, gastroenterologists, vascular surgeons, endocrinologists, neurosurgeons and orthopedists. Each of these specialists is pushing the boundaries of understanding and treatment options in their niche field and requires evolving radiological data. At the same time, each referring colleague relies on our guidance to appropriately manage radiological findings in “those other abdominal organs” that are outside their field of expertise.

Imaging Modality Evolution

Not only must we adapt to the needs of our referring colleagues, but our own imaging modalities continue to evolve. Two to three decades ago, there were few abdominal CT and MRI protocols beyond a general-purpose protocol. Our main choices were to consider whether or not to administer contrast material and possibly to acquire arterial or delayed images in addition to the portal venous phase. Now, in many institutions, a general-purpose protocol is used for only a minority of CT and MRI scans. It is common to have 40 to 60 special case abdominal CT and MRI protocols from which to select the one best suited to the patient’s needs.

An Existential Moment

Our specialty’s trend toward complexity comes with both good and bad. The good is undoubtedly job security and limited turf wars. Few specialists dare interpret CT or MRI scans of the abdomen without a radiologist due to fear of missing important findings in the myriad abdominal tissues that are outside of their fields of expertise. Similarly, artificial intelligence (AI) and computer-aided diagnosis can only assist in a small fraction of tasks in our daily work. The bad is that we as abdominal imagers are pressed to keep up with rapid changes in our specialty and the needs of referring specialties. How do we navigate and thrive in the midst of this rising complexity? Paradoxically, many parallel technological advances will help simplify our workflow, including expert consensus reporting systems, hardware advances, new contrast agents and improved computerized support systems.

Rise of Templates and Expert Consensus Reporting Systems

Advisory documents — such as RSNA’s reporting templates (RadReport.org) the American College of Radiology’s (ACR) Reporting and Data Systems (x-RADS) and the Society of Abdominal Radiology’s disease focus panels — aim to distill critical information into user-friendly diagnostic flow diagrams for uniform reporting of findings and appropriate patient triage. Though these documents are valuable, the proliferation of such guidelines — and their rapid change and intricacy — serves as a barrier to their use. To address this concern, semi-automated report generation systems are increasingly tasked to guide radiologists quickly through these expert reporting systems with high accuracy. RSNA and the ACR recently launched an initiative to codify data elements from the ACR x-RADS datasets for use in reporting and decision support applications. This will align our reporting templates more closely with the guidelines provided by the system.

Advances in Hardware

Along with substantial annual incremental improvements in scanner hardware, we occasionally see major leaps that break through prior limitations in imaging. For example, clinical CT underwent several major leaps, including the introduction of helical scanning in the early 1990s, multi-detector row scanners in the late 1990s, and multi-energy CT (MECT) in the late 2000s. This most recent advance in CT may be the most profound. MECT lets us differentiate imaged materials of similar density, such as iodine contrast agent from bone and dense tissues. MECT also provides virtual unenhanced images, iodine density maps and a host of alternate image reconstructions that can remove common ambiguities (See Figure 1). MECT technology will further evolve as energy discriminating (photon counting) CT is eventually integrated into clinical machines. Such scanners promise to improve spatial resolution, minimize radiation dose and provide an ability to see different atomic composition (colors) of materials. Much like color television ultimately supplanted black and white models, MECT will in time supplant current single energy CT imaging with far richer information than what is currently available.

New Generation Contrast Agents

Each of our high spatial resolution imaging modalities (CT, MRI and ultrasound (US)) benefits greatly from the use of contrast agents. New contrast agents will expand our ability to visualize anatomy and organ function. For example, current CT iodine and barium CT contrast agents are limited in that they are the same color — they are indistinguishable except by anatomic context, even when using the most modern MECT scanners. Multiple research groups are now developing color contrast agents that are designed to be readily distinguished from each other at MECT.

These new generation contrast agents, instilled into different bodily compartments, promise to provide high spatial resolution, co-registered images of complex anatomy with a single pass of the CT scanner without added radiation dose or imaging time (See Figure 2). Such contrast agents promise to provide intuitively simple displays of complex anatomy at MECT imaging.

An analogy for understanding the value of multi-contrast MECT is PET/CT: PET and CT are each valuable scans, and the two combined is synergistic. Likewise, each added contrast agent color for multi-contrast MECT promises synergistic benefit. But unlike PET/CT, which doubles the dose over that of either PET or CT alone, MECT does not require additional radiation above that of a standard CT scan. MECT also provides perfect image co-registration of the different contrast agents because the images are derived from a single MECT scan.

Improved Image Displays and AI

Improved image displays will simplify our workflow. Just as clunky alternator film viewers disappeared soon after helical CT scanning arrived, the current iterations of PACS must be replaced by systems that can properly display the huge number of image reconstructions of modern imaging in a rapid and intuitive manner. For example, smart systems with the ability to shift effortlessly between MECT reconstructions (Figure 1) and contrast agent images, as well as fuse with MRI, PET and US images, will increase the accuracy and speed of image interpretation. These systems will also provide essential foundations for intelligent computer-assisted image interpretation systems.

In conclusion, abdominal imaging is headed toward a point of paradoxically simplified complexity. The increasingly detailed and evolving imaging needs of specialist referring colleagues will be met by computerized assistance devices to help abdominal radiologists organize and address the growing niche needs of specialists. At the same time, these tools will help us to provide accurate and helpful patient-specific guidance on findings in organs outside the referring colleague’s field of expertise. In parallel, major technological advances such as MECT will provide unprecedented high spatial resolution color detail to evaluate multi-organ disease. Improved computer interfaces that streamline integrative image evaluation will make our workflow more natural and intuitive.