The Medical Imaging Detective Solving Medical Mysteries...
Transcript of The Medical Imaging Detective Solving Medical Mysteries...
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Richard S. Breiman, M.D.Professor of Radiology and
Biomedical Imaging(Medical Imaging Detective)
UCSF
Solving Medical Mysteries with
Imaging
The Medical Imaging Detective
• Role in Patient Care
• History of Radiology
• Imaging Tools
• Radiologist’s Method
• Cases
• Non-Medical Applications
• Discussion
Peering into the Patient to Solve Mysteries
What Does a Radiologist Do?
• Designs & Monitors Exams• Interprets Exams for Dx & F/U• Communicates Results, Consults with Clinicians• Performs Interventions for Dx or Rx
• Percutaneous biopsy, drainage (abscess, etc)• Tumor ablation (kill tumor) • Open obstructed ducts and vessels• Embolize bleeding vessels, aneurysms, vascular
malformations, tumor blood supply
Radiology Subspecialities•Neuroradiology•Thoracic Imaging
•Pulmonary•Cardiac
•Abdominal Imaging•Gastrointestinal•Genitourinary
•Musculoskeletal Imaging
•Vascular Imaging•Interventional Radiology
•Pediatric Imaging•Women’s Imaging
•Breast•OB/GYN
•Nuclear Medicine•Radiation Oncology •Molecular Imaging •Future new fields
dependent on technology development
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Non-Medical Applications
• Industrial Applications • Forensic Medicine• Historical Investigation• Image Mummies, Artifacts
• Study Prehistoric Creatures• X-ray Art
History of Radiology
• 1895: X-rays discovered by W.C. Roentgen, Nobel Prize 1901
• Edison develops the intensifying screen (& explores non-medical applications of X-ray tube: light bulb, photography)
• 1896: 1st (accidental) application of X-ray for therapy, deliberate XRT 1898
• Early 1900’s: Tube & intensifier developments, methods for opacification
• 1971: Godfrey Hounsfield invents CT, 1st computer-based imaging, Nobel Prize
The Appearance of Materials and Tissues on X-ray Depends on the Amount of X-rays they Absorb
Abdominal X-Ray
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Diaphragm
Liver Spleen
Kidney
Psoas M
Stomach
Radiology Developments Prior to Computer-based Imaging
• Improved X-ray tubes & films
• Fluorescent screens, image intensifiers
• Automated film developers
• Large viewboxes, alternators
• Fluoroscopy: real-time X-ray
• Contrast to opacify structures: Oral, Rectal, Injected
Computer-based Medical Imaging The Radiology Detective’s Tools
• Powerful Imaging Exams: X-ray, CT, US, MR, NM (PET/CT), Interventional Techniques & Hardware
• PACS: Digital Archival, Retrieval & Display System
• Computer Workstations for Interpretation & Review: display, manipulation, comparison, editing, demonstration
• Voice Activated Transcription for Rapid Reports
• Remote Access (Teleradiology):
• LAN: Department, Clinics, Surgery, Regional Facilities
• WAN: Distant Facilities, Mobile, Patient CD’s
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CT: Technological Advancements• Cross-sectional
• Eliminates problem of overlying dense structures obscuring less dense structures
• Utilizes detectors rather than film
• Distinguish tissues by X-ray absorption
• Digital data
• Image processing
• Digital archive
• Transmission of scans
CT: Volume Data Isotropic Data: X=Y=Z
Pixel=X+Y Voxel=X+Y+Z
Hounsfield #’s (HU)CT #’s
The Appearance of Materials & Tissues on CT
Depends on the Amount of X-rays they Absorb
The Appearance of Materials & Tissues on CT
Depends on the Amount of X-rays they Absorb
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Higher Quality & # of ImagesVolume Rendering
Manipulate•Color•Opacity•Perspective•Cut Planes•Movement•Digital Access
Volume RenderingManipulate•Color•Opacity•Perspective•Cut Planes•Movement•Digital Access
• Improved detection of subtle abnormalities• More efficient review of large datasets• Improved confidence• Better communication of results to physicians & patients
• Demonstrate findings with fewer images• Easier to understand complex anatomy
3D Applications in Diagnosis
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3D of Complex Pelvic Fractures Virtual Colonoscopy (CT)
• Simulation• Procedure planning• Pre-op practice• Reduce complications?
• Intra-operative guidance• Instrument position & imaging anatomy correlation• Robotic surgery• Remote procedures - performed by distant
specialist - battlefield for eg.
3D ApplicationsSimulation & Guidance of Invasive Procedures
Ruptured Aneurysm
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The Radiologist’s Method
• Create & Manipulate Data (Medical Images)
• Search for Clues
• Analyze Findings
• Communicate Results
The Radiologist’s MethodCreate Data
• Select Appropriate Exam
• Assess Risk vs. Reward
• Minimize cost, radiation and risk where possible
• Design Appropriate Exam Protocol
• Monitor/Modify Exam
The Radiologist’s MethodSystematic Review of Images
• Display & Manipulate Images
• Search for Clues (Findings)
• Related to Clinical Problem
• Related to Other Significant Problem
• Incidental Findings
"It has long been an axiom of mine that the little things are infinitely the most important" Sherlock Holmes in A Case of Identity
The Radiologist’s MethodAnalysis
• Correlate with Clinical Presentation
• Assess Stability
• Determine Effect on Management & Urgency
• Determine if Results are Adequate or if Additional Exams Needed
• For Diagnosis
• For F/U
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The Radiologist’s MethodCommunication of Results
• Dictate Report
• Conversation with Provider
• Communicate Urgent Results Effecting Management
• Correlate Clinical & Imaging Findings
• Assess Significance
• Patient Access to Results
• Report, CD
• Discussion, Educate
Radiology Workstation
65 yo Woman with Abdominal Pain 65 yo Woman with Abdominal Pain
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Smoker: Difficulty Breathing Left Flank Pain + Hematuria - Why?
Left Adrenal Gland CancerExtent? Ultrasound
• High frequency sound
• Sound reflected back to probe
• Appearance depends on tissue characteristics + distance
• Real-time
• Doppler - Blood flow
• Intra-cavitary probes
• Air, calcium block sound
• Cyst vs. solid, abdominal & pelvic organs, vessels, biopsy guide
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Magnetic Resonance• Magnetic field aligns nuclei, RF flips
nuclei, RF off, returning RF signal detected by an antenna
• No radiation, expensive, long exams, claustrophobia
• Good tissue discrimination
• Brain, spine, abdominal, pelvic organs, vessels
• Not good for air, movement
• MR Imaging (MRI)
• MR Spectroscopy (MRS)
• Assess quantity of creatine, choline, citrate
MR - Glial Tumor
T1 T2
Nuclear Medicine
• Radionuclide injected, accumulates in organs or tumor, emits radioactivity
• Whole body survey
• Limited anatomic detail
• Bone scan - 99mTc
• Thyroid scan - I131
• Liver scan - 99mTc
• Positron Emission Tomography (PET) + CT PET/CT - 18-FDG accumulates in areas of increased metabolism (certain tumors)
• Brain, head & neck, lung ca, colon ca, breast ca, lymphoma, melanoma
PET/CT
• Detect malignant foci
• Often before other imaging exams
• Direct attention to possible imaging abnormality
• Determine significance of imaging findings
• Assess success of therapy or detect recurrence
• May miss small (<5mm) malignant foci
• Not all FDG avid foci are malignant or even abnormal
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Interventional RadiologyPancreatitis
Drainage for Diagnosis & Therapy
Thank You!
Richard S. Breiman, MD