Breast imaging shinesamong ultrasound advances

Ultrasound will step into the politically charged environs of women's health and address the vagaries of today's financial challenges at this year's RSNA meeting. New products will promise diagnostic information to help clarify suspicious lesions found on screening mammograms. Workflow enhancements will boost productivity and reduce variability of results among users. The combination of real-time ultrasound data with previously captured CT and MR exams will put a new spin on interventional procedures, while miniaturization will open new opportunities for clinical usage.

Of these, none will be more obvious on the RSNA exhibit floor than efforts by the major ultrasound manufacturers to reduce uncertainties raised during mammography screening. Vendors' pitches will hinge on the lower cost and greater availability of this modality compared with MR as they home in on methods to better characterize lesions uncovered by mammography. Toshiba will position its MicroPure technology as a possible way to better characterize microcalcifications. Philips will present its tissue aberration correction technology as a means for better visualizing tissue in fatty breasts. And Siemens will unveil a new automated ultrasound breast scanner that reduces operator dependence, particularly in dense breasts.

These are certainly not the first attempts by ultrasound vendors to gain ground in breast imaging. The modality has long served as an effective means for distinguishing cysts from solid masses. Vendors have tried to add to this basic capability, most notably ATL, before its purchase by Philips, with a capability designed for its premium system, the Ultramark 9 HDI. ATL developed the breast imaging technology as a way to add details that might obviate at least some biopsies.

Philips' latest capabilities in breast imaging are embedded in an upgrade for its radiological flagship, the iU22. Called Vision 2009, the upgrade encompasses tissue aberration correction technology and algorithms designed to improve overall image clarity as part of an integrated effort to better define tissue in fatty breasts. An enabling technology is the Philips PureWave transducer and its coded beamformer, which have been present on earlier technologies. Tissue aberration correction technology itself was devised initially to look at challenging patients, according to Jim Brown, director of clinical and technical marketing for the ultrasound business unit at Philips Healthcare.

"We started using it for several applications and found it was perfect for breast imaging," Brown said. At the highest end of specialty ultrasound, Siemems will feature a system that automatically scans the breast, acquiring a 3D data set that can be read out much like the data sets obtained with CT or MR, according to Klaus Hambuechen, CEO of Siemens Ultrasound. The scanner will feature a transducer mounted on a mechanical arm that moves across the breast under its own control. "This is completely automatic," Hambuechen said. "It does not depend on the user holding the transducer."

The system, dubbed the Automated Breast Volume Scanner, excels at the visualization of any breast, including those with dense tissue, he said. The company will frame the ABVS, which will be available for sale when the RSNA meeting opens, as the means for evaluating suspicious lesions found on screening mammograms in women who have dense breasts but are not at high risk of developing cancer.

Toshiba will leverage its MicroPure technology to improve the detection of small calcifications that otherwise may evade discovery with ultrasound. Emphasizing that mammography remains the gold standard for detecting such lesions, Gordon Parhar and his Toshiba colleagues will position MicroPure as an adjunct to this x-ray assessment that helps visualize and characterize such microcalcifications. "It just makes the calcifications pop," said Parhar, business unit director for ultrasound at Toshiba America Medical Systems.

The company will be careful, however, not to overstate the capabilities of MicroPure. Although cleared by the FDA, the technology has not yet been clinically validated, he said, which is why Toshiba has decided to show only early results from its clinical collaborators, leaving claims to a later date. Elastography, which identifies masses as tumors based on their stiffness or elasticity, will complement efforts by Toshiba as well as other vendors, including Siemens. Toshiba, for example, will highlight its approach to displaying relative elasticity between the tumor and surrounding tissues by assigning colors to a tomographic image or, alternatively, by presenting the data as a graph. The company will promote elastography as the means to assess tumors while positioning MicroPure as a possible complementary way to detect small calcifications.

Reimbursement concerns have transformed workflow into the poster child for 21st century radiology. Addressed widely on RSNA exhibit floors in recent years and sure to reappear in grand style this year, the subject will shine especially bright in quarters dedicated to ultrasound, where vendors will cite the need to conduct studies more efficiently. Philips will showcase its Smart- Exam protocols as the way to make ultrasound more efficient. Smart- Exam records the steps for new exams, saving study requirements for views, annotations, body markers, mode changes, and quantification.

Some advances in workflow have come with the migration of ultrasound to points of care outside radiology. At the RSNA meeting, GE will address opportunities, both in and outside the traditional bounds of this modality, made possible by the miniaturization of ultrasound products.

The company's newly developed compact system, the Logiq P6, will debut at RSNA 2008 as the first member of a new "performance" platform of GE products that will cross segments of healthcare including cardiology and radiology, according to Terri Bresenham, vice president of GE Healthcare's diagnostic ultrasound and IT business. The console-based system will feature several transducers and onboard image display and archive capabilities.

"From talking with radiologists, we have defined a need for high-end performance in a more affordable platform with a footprint size that will allow it to go into small rooms and easily maneuver down hallways and into elevators," Bresenham said. "The P6 will provide high-end performance with high-end image quality and applications in a very compact package."

GE will also add an optional cart for its otherwise hand-carried Logiq i, a move designed to fill a ready-made niche for use in interventional and surgical suites, as well as in the ER. The docking station will support peripheral devices for storing and printing images yet allow the Logiq i to undock to get wherever else it needs to go.

ULTRASOUND MEETS MR, CT Philips will highlight its own special blend of ultrasound and other modalities, which is designed to improve interventional guidance. Last year, the company showed in its booth a combination of the iU22 and an interventional navigation system developed by Traxtal to guide soft-tissue biopsy and ablation procedures. The combination fuses realtime ultrasound into MR or CT images. This year, the two companies have tightened their link with a digital connection between the freestanding PercuNav workstation and the iU22 that allows better image quality and communications. GE presented its idea of data fusion this summer with the unveiling of flagship Logiq E9. The new scanner's Volume Navigation continuously updates the volumetric model of a patient, created from CT or MR, with real-time ultrasound data, offering moment-to-moment guidance for interventionalists. A GPS-like function visually tracks the surgical instrument in real-time in a context provided by CT or MR. The transducer is registered in 3D space using a magnetic field that serves as a virtual stereotactic frame.

The new scanner's architecture and novel technologies go well beyond interventional applications to enable real-time volumetric scanning throughout the body. The Logiq E9 represents a level of performance not before seen on the market, according to Bresenham.

Matched with GE's new breed of Agile beamformer, which works with the Logiq E9's advanced ESeries transducers, this architecture provides extraordinary image quality and uniformity, she said.

Bresenham and colleagues will promote at RSNA 2008 the increased penetration and sensitivity possible with the system, which makes use of a new acoustic amplifier built into the transducers. This allows structures to be visualized regardless of their depth in the patient, especially important when scanning obese patients.

Workflow tools built into the new system streamline routine scans, reducing the time and effort needed to do an exam. These tools, packaged as the E9's Scan Assistant program, can cut keystrokes by 79%, according to the company. Fewer key strokes, along with automation that makes and records needed measurements, for example, or steers color Doppler to create optimal images, can reduce exam time by 54%.

Countering weaknesses inherent in ultrasound, whether through more efficient protocols, increased automation, or novel technologies, constitutes a type of innovation tailor-made for this year's RSNA meeting. The true value of these innovations will be appreciated, however, in the marketplace, where we're seeing some tough economic challenges.