Integrated Imaging Comes of Age: Cross-modality Solutions Fuel Better Disease Detection

Cross-modality solutions fuel better disease detection

Truly integrated imaging has arrived. The lines between radiology and nuclear medicine have blurred with increased utilization of cross-modality solutions. Several factors are fueling the uptake of PET/CT—the primary integrated imaging solution. Combining a diagnostic CT study with a diagnostic PET scan addresses a number of challenges; it facilitates improved patient care, boosts efficiency and enables more cost-effective healthcare. The core value of integrated imaging rests in its ability to combine and optimize patient information. “It isn’t good enough to know where a lesion is, we need to know where and what it is. Integrated imaging solves the problem. We can’t practice good cancer care without it,” says Joseph Busch, MD, medical director of Diagnostic Radiology Consultants in Chattanooga, Tenn.

Integrated imaging continues to fuel improvements in cancer staging, treatment and diagnosis. Plus, when systems and processes are configured correctly, the combination of form and function delivers increased efficiency and cost-effectiveness. Still, the integrated imaging process can be fairly complex. Progressive-thinking clinical leaders with well-defined staffing, reporting and IT structures offer insight into the model.

Diagnostic PET/CT delivers

Nearly 10 years have passed since the initial launch of PET/CT, making it the pioneer of hybrid imaging. Yet the original hybrid solution continues to evolve. Protocols are changing, new applications are gaining traction and next-generation systems are opening new doors.

PET/CT offers unique opportunities to streamline patient care and workflow while providing high-quality diagnostic data, says Busch. The ideal protocol combines a diagnostic quality CT and PET scan in a single visit to conserve time and resources and facilitate optimal patient care. The scan itself, however, represents only one portion of the diagnostic imaging process. “Quality of care is our primary goal,” says Homer Macapinlac, MD, chair of the Department of Nuclear Medicine at the University of Texas, M. D. Anderson Cancer Center in Houston. Multiple factors including reporting accuracy, clinical collaboration and the speed of decision-making influence patient care. Macapinlac, Busch and other leaders are developing the next generation of PET/CT protocols to harness additional benefits.

Performing a diagnostic CT immediately before a PET study delivers multiple advantages. Consider for example the traditional model. A lung cancer patient undergoes a diagnostic CT and is referred to a surgeon. At that point, however, the surgeon does not have a complete picture of the patient’s disease. It’s not unusual for integrated PET/CT data to identify distant metastases, says Macapinlac. In fact, PET/CT shows distant metastases in 13 to 20 percent of lung cancer patients. In many cases, the presence of distant metastases changes therapeutic options. Patients who appear to be surgical candidates based on CT results may be classified as non-surgical based on PET/CT findings. Instead of referring the patient to a surgeon, it’s more appropriate to refer the patient for a PET/CT study and use that data to refer the patient to the appropriate physician, Macapinlac says.

Integrated imaging represents the evolution of PET/CT. “In the past, we used PET/CT as a problem-solver, but diagnostic CT optimizes PET/CT, transforming it into a way to triage patients,” explains Macapinlac. Under this model, PET/CT combines more accurate staging and high-quality, efficient reporting to enable proactive patient care. Currently, M.D. Anderson reserves the PET/CT triage model for lung cancer patients; however, the center hopes to expand it to other oncologic applications in the future.

The model sees robust use in a variety of countries. Take for example Copenhagen University Hospital in Denmark. Most of Copenhagen University Hospital’s 5,000 annual PET studies incorporate diagnostic-quality CT with the hybrid study seeing broad use in oncology staging, relapse, evaluation, radiation therapy treatment planning and treatment evaluation.

In addition to improving patient care, the integrated diagnostic model offers other advantages. “When diagnostic PET/CT is configured correctly, it is very cost-effective,” shares Busch of Diagnostic Radiology Consultants. In addition, it enhances patient comfort and convenience.

The traditional model often refers a patient for two separate studies—a diagnostic CT scan and a PET/CT—for the same purpose, which doubles the scheduling burden. Plus, two physicians review the same datasets, producing separate reports that may or may not agree. Finally, the two-physician model is far from economical. “It’s not affordable to pay two private-practice physicians to read the same exam,” Busch says. Integrated imaging offers a better model. “Integrated diagnostic PET/CT unifies image acquisition, scheduling and patient preparation. It limits review of prior studies to a single physician,” explains Macapinlac. 

Configuring the PET/CT program

Optimizing PET/CT balances multiple components including staffing and IT. Knowledge is critical; physicians and technologists must understand both nuclear medicine and CT. Physicians require a thorough knowledge of diagnostic body CT, clinical PET and PET/CT technology. Human resources needs may extend beyond physicians and techs. Additional staff can help PET/CT providers achieve maximum patient throughput. Diagnostic Radiology Consultants streamlines throughput of its PET/CT scanner by using an assistant to help get patients on and off the table in 20 minutes. As sites deploy the newest generation of PET/CT solutions, it becomes possible to further accelerate throughput.

Other factors also facilitate enhanced patient throughput. On the IT side, PACS must be appropriately scaled. The size of image datasets is exploding, and effective IT solutions offer a way to tame the upsurge. “Cancer patients are living longer, which means they return for care multiple times. Physicians always need to review the initial and post-therapeutic datasets,” explains Busch.

Diagnostic Radiology Consultants is making use of clinical IT to enable a just-in-time PET/CT model in which Busch and the oncologist collaboratively review PET/CT datasets immediately after the scan. Busch uses a workstation that launches PET/CT software from the RIS server to maximize efficiency gains. He says eliminating trips between the PACS and PET/CT workstations saves him approximately 45 minutes daily. The software allows Busch to remotely load and review PET/CT datasets on his laptop. The software streamlines the tumor board process, particularly for physicians who travel among multiple hospitals, he says. 

At M.D. Anderson, Macapinlac and his colleagues review PET/CT data on the PET/CT workstation for improved convenience and efficiency. The department taps into an intelligent worklist to prioritize and streamline PET/CT review; the RIS sorts studies in the order of patients’ next physician appointments to ensure that reports are read and available for clinicians within 24 hours of acquisition.

One of the primary shifts since the initial availability of integrated diagnostic PET/CT imaging comes on the reporting front. Some sites employ a collaborative approach. At Copenhagen University Hospital, each PET/CT study is read by a nuclear medicine physician and radiologist, and the pair produces an integrated PET/CT report, explains Liselotte Hojgaard, MD, director, department of clinical physiology, nuclear medicine and PET. Other sites exercise a different approach to reporting. Clinicians need the PET and CT reports to concur, says Macapinlac. M.D. Anderson assigns a single physician to each PET/CT study to produce an optimal report. “Surgeons prefer this approach because it increases the accuracy and timeliness of the report,” shares Macapinlac.

Future models at a glance

As PET/CT evolves, clinical leaders are exploring new models to deliver further improvements in the integrated imaging process. For example, at M.D. Anderson, Macapinlac plans to transition to a structured reporting model to improve reporting accuracy and accommodate any upcoming increases in PET/CT volume. “Structured reporting decreases the likelihood that physicians will overlook a portion of the data, and it simplifies database management and searches,” explains Macapinlac. For example, if a researcher needs to gather data about the FDG uptake of specific tumors, the data can be pulled from the structured report into a database. In addition to facilitating clinical research, the structured report should support patient care. “The most important information is patient history—medical notes, prior imaging studies, pathology results and radiation therapy plans. The structured report should contain each type of data,” says Macapinlac.

M.D. Anderson has launched a patient checklist as an interim step to structured reporting, charging technologists with completing a patient checklist that includes critical data like surgery, radiation treatment and recent infections, prior to each patient visit. Another initiative to improve the PET/CT report process is the Society of Nuclear Medicine’s PET Utilization Task Force report template. The template is designed to guide communication about PET/CT findings to ensure that reports incorporate all essential information about specific cancers.

Not all solutions originate in the IT or imaging modality world. Busch predicts integrated imaging will usher in a new breed of radiologist. The diagnostic oncological radiologist will combine radiology and nuclear medicine expertise with a solid understanding of radiation and medical therapy to better meet the needs of the oncological patient population.

PET/CT: The first decade

PET/CT has grown tremendously since its introduction nearly a decade ago. Each new generation of systems has brought significant improvements in image quality and scan speed. At the same time, the clinical arena continues to evolve. Data challenges are on the rise as patients live longer and additional clinicians join the clinical team. Integrated imaging addresses many of the challenges the PET/CT community faces. It reduces costs and accelerates reporting and decision-making. Back-end IT solutions like structured reporting, remote access and integrated workstations help sites gain further efficiencies and improvements.