NEJM - CPC on lung nodule management - non-small cell carcinoma

This week's issue of the NEJM has a CPC on a patient with a lung nodule and metastatic mediastinal adenopathy. The approach to such a patient with the use of PET and CT and the managemant methodology is lucidly discussed.

Full-text can be accessed from India.

8th RRC registrations closed

The 8th RRC registrations are closed. We have already exceeded our number of 225 and have 240 registrations. The list of registrants is up on the site. Please stay glued to the blog or to the site for more information.

Below-knee elastic compression for the post-thrombotic syndrome

This article in the current issue of Annals of Internal Medicine by Prandoni P et al from Italy and Netherlands shows that wearing below-knee elastic compression in patients with deep vein thrombosis can reduce the incidence of repeat thrombotic episodes by 50%.

Though not related to radiology this is useful information for many radiologists who see patients with DVT on color Doppler, CT or MRI or land up with DVT themselves.

CMR for the evaluation of ASD

A slightly older article in Radiology, in 2003, by Beerbaum P et al from Germany describes the use of CMR, mainly phase-contrast imaging, in the evaluation of ASDs.

Many patients with ASD now undergo transcatheter balloon closure and it is necessary to get adequate information about the size of the ASD, the rim and the distance of the rim from the SVC, coronary sinus, aortic root and AV valves prior to planning treatment.

Traditionally, trans-esophageal echocardiography (TEE) has been the mainstay of diagnosis and evaluation. CMR however is as good and can therefore be used in equivocal cases or in situations where the patient does not want a TEE.

Problems with referrers

Decisions in Imaging Economics has two editorials in two different issues that make very interesting reading.

The first is by the editor Cheryl Proval titled "Survival of the Slickest" that talks about a recent resolution by the American Medical Association that reaffirms the rights of physicians to self-referral for investigations performed in office practice. She mentions that during the deliberations, the AMA and other allied associations (OB-GYN, ortho, uro, etc) provided evidence that office practice by non-radiologists actually enhances patient care...when there is enough evidence that self-referral actually leads to poorer care and to increased unnecessary or unindicated referrals.

The other article is a guest editorial by Judy Wagner titled "Does Quality Drive Breast Biopsy?" in which she talks about her own experience when some microcalcification was detected in her breast on screening mammography. A surgeon tried to biopsy it blindly and failed and only when she went to an accredited breast imaging centre and had an accredited radiologist perform a guided biopsy that she had results. Her grouse is that when she went to the surgeon she was not given all the choices possible for her to be able to make an informed decision.

Both these editorials highlight the problems with referring doctors. Many want a cut of the radiology revenues one way or the other and want to do everything themselves if they can. We just need to be good at what we do and make sure that people know that we are good. That probably is the only way that we will be able to survive as time passes by.

A doctor's duty when death is inevitable

A New York Times article of Aug 10, 2004 talks about a letter written by the husband of a patient who died of cancer, to her oncologist, who according to them failed her in a big way at the end, by turning away from her, once it was certain that she was going to die.

Though as radiologists, we rarely are in such patient contact, it is worth reading this article to understand what it is that a dying patient might want from his/her treating physician. Respect, dignity, an anchor...issues that pertain to empathic human behavior, but are lost by many of us by the time we become trained physicians.

The normal hip joint space - variations

It is rare to find an article devoted only to plain radiographic appearances and that too on the normal appearance.

This article by Lequesne M et al from Paris published in this month's issue of the Annals of Rheumatic Diseases does just that. In a series of 223 radiographs (446 hips), variations in hip joint space (interindividual, intrajoint, etc) are discussed along with the incidence of findings such as acetabular dysplasia.

I am sure the findings of this article will get incorporated into the Atlas of Measurements textbook sooner or later.

This article is available as full-text if accessed from India.

MRI perfusion for coronary artery disease

Last week's issue of Circulation has a multi-centre study by Wolff et al on first-pass MRI perfusion in the evaluation of coronary artery disease. The results are good and the study also suggests that 0.05mmol of gadolinium is more that enough...this is a dosage we have used as well and found that it works well.

The whole problem is whether this modality will ever become useful. With the advent of 64-slice CT scanners and the improvement in image quality in CT coronary angiograms, the ability to pick up plaques and stenotic lesions with CT is becoming better and better. It may be of use in some situations to know what the functional significance of a stenotic lesion is...but to assume that indirect modalities will ever be used in the detection of coronary artery disease doesn't seem to make sense.

Both stress-thallium and MRI perfusion studies will probably be used only in equivocal cases with stenotic lesions to decide whether there is "signficant" narrowing. In the future it is possible that both these modalities may fall by the wayside when PET-CT scanners become mature enough to do both - CT coronary angiograms and a stress perfusion study, both at the same sitting with a fusion image of the two modalities.

As with the coronary artery CT articles in Radiology discussed last month, this again illustrates how time can play truant in clinical studies. When the study was probably conceptualized (probably 2001-2002?), 16 slice scanners were just on the horizon and 64-slice scanners had not yet started getting talked about. This article was submitted in December 2003 and has been published last week and is now a modality that almost certainly has missed the boat for clinical utility.

MRI in cholangiocarcinoma

There is a full-text article in Medscape from Seminars in Liver Diseases, by Manfred R et al on the role of MRI in cholangiocarcinoma. It is a review article that discusses epidemiology, clinical features, pathology and the MRI appearances well. As with featured Medscape articles, this is a full-text article, but cannot be saved as a .pdf file.

Optical breast imaging, Dobi Medical Systems and United Telecom Ltd

Dobi Medical Systems and United Telecoms Ltd, India have signed a deal wherein UTL will sell the ComfortScan of Dobi Medical in India. According to the press release, UTL has agreed to buy 40 ComfortScan machines in the next 18 months.

The ComfortScan appears to be a machine using optical technology with LEDs to detect angiogenesis in breast nodules and is to be used as an adjunct to mammography for the detection of malignant breast lesions. It won the "Most Innovative Product for 2002" by NJTC. However, the Dobi Medical website presents no clinical data. A quick Pubmed search threw up a couple of "concept" articles, but no clinical data.

If a modality has to become clinically useful there has to be a signficant body of literature to support its use. If that modality is to be used for screening the body of literature has to be vast and time-tested. In the breast, it has to compete with mammography and contrast-enhanced breast MRI.

Even if these machines are priced equivalent to analog mammography machines, in India at least, I can't see how these machines would sell. Mammography is a difficult concept to sell...add to that another modality at a similar cost with no large clinical study to prove its utility? UTL is very brave to think that it can sell 40 such machines in the next 18 months. Moreover a quick search of the UTL site shows that it has no background in healthcare. Wow! All the best to them.

MRI in Wilson's disease

There is a case report in this week's auntminnieindia.com from AFMC Pune on MRI brain appearances in a patient with Wilson's disease.

Meckel diverticulum: radiology and pathology

The CPC from NEJM described last week led to a search for a definitive article on Meckel diverticulum.

This Radiographics article by Levy AD and Hobbs CM in the March-April issue is an excellent review article on the anatomy, pathology and radiology of Meckel diverticulum. A case similar to the one described in the NEJM CPC has been shown in this article as well.

Real-time MRI for gastric emptying and motility disorders

There is one more article from the Essen group by Ajaj J et al in Gut describing the role of real-time MRI in gastric motility disorders. The article concludes that real-time MRI can accurately evaluate motility disorders and is a better alternative to the current invasive modalities. The study takes about 30 minutes and therefore can be easily applied to clinical practice.

This article follows on the heels of two previous articles by the same group. An earlier article in JMRI in April this year describes the use of this technique to determine a gastric motility index. Based on this technique, the current article in Gut shows its applicability in clinical practice.

In the May 2003 issue of AJR, the same group had described how three-dimensional MRI can assess the effect of IV erythromycin on gastric emptying.

The GUT article is available as full-text if you log in from India.

Dynamic MRI in the TM joint

Now that dynamic real-time MRI with TrueFISP imaging at 1 frame/second or better is feasible on high-end MRI scanners, the applications for this modality are growing as well.

One article by Abolmaali et al from Frankfurt in European Radiology, explores the use of this technique in the TM joint. They have been able to visualize the disk as well as assess the dynamics of movement at the TM joint well.

Other areas that can be routinely assessed with this technique include the patello-femoral joint and the cranio-vertebral junction. This technique can also be used to evaluate gastric empyting.

Imaging of insulitis in type 1 diabetes

To get an idea of where eventually MRI with molecular imaging is headed, this article makes an interesting read. This is a very early "proof of concept" article by Denis MC et al in the Proceedings of the National Academy of Sciences using long-circulating magnetoflourescent nanoparticles, in rats.

The authors were able to detect the presence of "insulitis" in real-time in these rats. Sometime in the future this is the kind of work that we will all be doing with MRI in different parts of the body for early detection of possible disease.

This article is available as full-text if you log in from India.

MRI in hip fractures

As in scaphoid fractures, the role of MRI in occult hip fractures is also obvious. An article in European Radiology by Veerbeten et al from Denmark shows that not only does MRI pick up these fractures well, it saves money by allowing earlier diagnosis and junior radiologists do almost as well as senior radiologists for making the diagnosis.

It is a good idea to reiterate this concept again. In patients with suspected hip fractures and normal radiographs, MRI is probably the next best modality for confirming and/or ruling out hip fractures or other soft tissue injuries.

MRI in scaphoid fractures

A new article by Bhat M et al in the July issue of JBJS (Br) shows the relative dismal performance of plain radiographs in assessing the displacement of scaphoid fractures, a parameter that helps to predict possible non-union.

This is one more article that helps establish the role of MRI in suspected and established scaphoid fractures. An earlier article by Brydie A et al in 2003 in the British Journal of Radiology showed that in patients with suspected scaphoid fractures and normal plain radiographs, MRI changed management in about 92% of patients, half of whom had scaphoid fractures.

In another interesting paper by Moller JM from Denmark in Academic Radiology, MRI technicians alone were able to diagnose all 36 scaphoid fractures eventually confirmed by radiologists, in 224 consecutive patients with suspected scaphoid fractures and normal radiographs. There were 7 more false positive diagnoses by these technicians, but the use of technicians and MRI led to significant savings in cost due to the earlier diagnosis.

All in all it is time to accept that for diagnosing scaphoid fractures not seen on initial plain radiographs, MRI should be performed as quickly as possible.