Prepare for AOCR 2014

This year, the largest radiology meeting in Asia will be held in Kobe, Japan!

Many big names in radiology from around the world will be joining as invited speakers including JKT Lee, AR Margulis, M Prokop, D Resnick and H Hricak.

Scientific programs include all radiology subspecialties with interesting additions of IT, Radiation Safety and Emergency Radiology.

Kobe is an international port city with a long historical importance. The city is famous for European bakeries, Kobe beef, and fresh seafood. Sightseeing spots like Kyoto, Osaka, Nara and Hiroshima are reachable by day trips. During this time of the year, Kobe temperature ranges between 21 and 29 degrees Celsius. 

Details and registration information can be found at this LINK.

Endovascular Treatment Not Superior to Intravenous TPA for Acute Stroke

A study published in the New England Journal of Medicine (6 Feb 2013) did not find different outcomes of acute stroke patients treated with endovascular therapy vs intravenous TPA

Background

• IV recombinant tissue plasminogen activator (t-PA) is the standard treatment for acute ischemic stroke
• Endovascular (intraarterial) treatment has higher recanalization rates but whether this translates into more favorable clinical outcome is unknown
• Prior trials of endovascular treatment showed promising results but there were problems with 1) limited generalizability, 2) lack of comparison between endovascular Rx and IV t-PA, 3) endovascular Rx was not assessed as a multimodality procedure

Study Methods and Results

• Multicenter, open-treatment clinical trial with a blinded end point
• Questions: whether outcomes were better with endovascular Rx than with IV t-PA
• Included patients are between 18-80 years, with a clearly defined time of stroke onset that was less than 4.5 hours (for IV t-PA) or 6 hours (for endovascular Rx)
• 362 patients with acute ischemic stroke were randomized to either endovascular Rx (IA thrombolysis with rt-PA, mechanical clot disruption or retrieval, or a combination of these) or to IV rt-PA
• Primary outcome = disability-free survival at 90 days, secondary outcome = proportion of patients with mild neurologic deficit or none and several safety measures
• Disability-free survival at 90 days = 30% in endovascular group, 35% in IV group. This did not change after adjustment for age, sex, stroke severity or presence of atrial fibrillation

Reference:
Ciccone A et al. Endovascular treatment for acute ischemic stroke. N Eng J Med 2013 Feb 6.
Read the full study HERE

Happy New Year 2013!

Screening Mammography Overdiagnoses Breast Cancer?

The recently published NEJM's original article describes effect of screening mammography on breast cancer incidence in the USA. Bleyer A and Welch HG. N Eng J Med 2012;367:1998 (22 Nov 2012)

Facts: Aim of Cancer Screening

• We expect cancer screening program to lower cancer-related mortality by a means of 1) earlier detection of disease destined to be fatal and 2) early Rx of screen-detected cancers
• A cancer screening program should 1) increase incidence of cancer detected at an earlier stage and 2) decrease incidence of cancer presenting at a late stage

What Study Is About And What It Has Found:

• Breast cancer rate from 1976 through 1978 (mammography was uncommon) ~ baseline incidence
• Breast cancer rate from 2006 through 2008 ~ current incidence
• Confounding effects of menopausal hormone therapy were minimized by not including transitory increase in incident breast cancers from 1990 through 2005. Underlying incidence of breast cancer assumed to rise by 0.25% annually
• Number of cases of early-staged breast cancer rises from 112 to 234 cases per 100,000 women
• Number of cases of late-staged breast cancer decreases from 102 to 94 cases per 100,000 women
• "With an assumption of a constant underlying disease burden, only 8 of the 122 additional early-stage cancers diagnosed were expected to progress to advanced disease." This was estimated that breast cancer was overdiagnosed. In 2008, the overdiagnosis would account for 31% of all breast cancer diagnosed

Other Studies Said?

Results of this study concur with other reports (references 2-3) and suggest that improvements in treatment are the main drive in reducing breast cancer mortality - rather than screening mammography. 

It is suggested that "pros and cons of mammography should be incorporated into the counseling that women receive as they decide whether an when to be screened". 

References:

1. Bleyer A and Welch HG. Effect of three decades of screening mammography on breast cancer incidence. N Eng J Med 2012;367:1998
2. Kalager M et al. Effect of screening mammography on breast cancer mortality in Norway. N Eng J Med 2010;363:1203
3. Autier P et al. Breast cancer mortality in neighbouring European countries with different levels of screening but similar access to treatment: trend analysis of WHO mortality database. BMJ 2011;343:d4411
4. Kaunitz AM. Screening mammography: does overdiagnosis overshadow prevention of advanced breast cancer? Journal Watch Women's Health November 21, 2012

USPSTF Recommends Against PSA-based Prostate Cancer Screening

In its newest Statement published yesterday in the Annals of Internal Medicine, the U.S. Preventive Services Task Force (USPSTF) recommends against PSA-based screening for prostate cancer. Read the full paper (free) here.

Prostate Cancer: Facts

• Most commonly diagnosed non-skin cancer in men in USA, estimated lifetime risk 15.9%
• Most cases have good prognosis even without treatment
• Lifetime risk of dying of prostate cancer 2.8%

Screening with PSA

• PSA-based screening programs detect many cases of asymptomatic prostate cancer but evidence suggests that many of them will not progress or will progress slowly that it would have remained asymptomatic for the lifetime
• "Overdiagnosis" of prostate cancer based on PSA is between 17-50% 
• Screening resulted in none or minimal reduction in prostate cancer mortality (0 to 1 prostate cancer deaths avoided per 1000 men screened)
• "False positivity" near 80% (cutoffs value 2.5-4 ug/L)

Recommendation

• Applies to men in general US population. Although older age is the strongest risk factor for development of prostate cancer, neither screening nor treatment trials show benefit in men older than 70 years
• Decision to initiate or continue PSA screening should be understood by patients about possible benefits and harms of screening

Recommendations of Others

• The American Urological Association, the American Academy of Family Physicians and the American College of Physicians: currently updating their guideline
• The American Cancer Society: men at average risk beginning at age 50 years and black men or men with a family history of prostate cancer beginning at age 45 years

Reference:

Annals of Internal Medicine May 21, 2012  LINK

Nephrogenic Systemic Fibrosis Disappeared After Restrictive Use of Gadolinium?

According to a large (50 000+) retrospective cohort of patients who underwent contrast-enhanced MR examinations at a single academic institution pre- and post-adoption of strict gadolinium guidelines:-

• No new cases of nephrogenic systemic fibrosis (NSF) were diagnosed
• During the pre-guidelines adoption and transitional period, the incidence of NSF was 3 cases per 10,000 contrast-enhanced MRI
• After the adoption of guidelines, the incidence was 0 per all examinations

The Guidelines for Imaging Adult Patients

• Based on renal disease severity
• eGFR 60 or greater - GBCA can be administered as indicated
• eGFR 30-59 - weight-based dose of GBCA (0.2 mL/kg) can be administered with maximal dose of 20 mL allowed within 24 hours
• eGFR less than 30 - GBCA cannot be administered except in cases of medical necessity; informed consent required; nephrology consultation required; hemodialysis should be considered
• Very rarely that any patients with eGFR less than 30 would get contrast-enhanced MR exams (36 in 52 954 exams; 0.07%)

eGFR = estimated glomerular filtration rate; GBCA = gadolinium-based contrast agent

Reference:

Wang Y, Alkasab TK, Narin O, et al. Incidence of nephrogenic systemic fibrosis after adoption of restrictive gadolinium-based contrast agent guidelines. Radiology 2011; 260:105-111.

The Price of Being a Doctor

How one patient makes a doctor question his decision to be a physician, while another does the opposite? Follow the link to the Insights on Residency Training blog by the Journal Watch.

Nuclear Accident And Potassium Iodide

Given the current situation in Japan, some of you may be interested in this topic.

The full FAQ is located at the National Regulatory Committee (NRC) website, here.

Potassium Iodide

• Blocks thyroid uptake of radioactive iodine, therefore it reduces the risk of thyroid cancers that might be caused by exposure to radioactive iodine that could be dispersed in a severe nuclear accident
• It is ingested, then taken up by thyroid gland -- if taken in a proper dosage at an appropriate time, it saturates the thyroid gland so that inhaled or ingested radioactive iodine will not be accumulated in the thyroid
• Two KI tablets will protect the thyroid gland for approx 48 hours
• Population within 10 mile emergency planning zone to the nuclear power plant are at the greatest risk of exposure to radiation, therefore KI is provided to protect them from effect of exposure after an accident
• Best protective measures for nuclear accident are evacuation and sheltering. KI tablets are used to supplement evacuation or sheltering

Image from www.ask.com

RiT Has Reached 100,000 Visitors!

Today marks another important milestone for RiT, we have reached 100,000 visitors! We would like to thank everyone for your interest and continued support. We also have been grateful to have a great partner like radRounds.com.

Happy New Year 2011! We would love to see you more and more.

Thank you very much!

The RiT Team

National Lung Screening Trial (NLST) Initial Results

What is the NLST?

• A multicenter, randomized controlled trial (RCT) comparing low-dose helical CT with standard chest radiography in the screening of men and women at risk for lung cancer
• Sponsored by the National Cancer Institute
• Starting in August 2002, the trial enrolled more than 53,000 participants, current or former heavy smokers, ages 55 to 74, at 33 sites over a 20 month period
• Participants were randomly assigned to received 3 annual screens with either low-dose helical CT or standard chest radiograph. Endpoint = death from lung cancer
• "Heavy smoker" = at least 30 pack-years and were either current or former smokers without signs, symptoms or history of lung cancer
• "Low-dose CT" = helical CT with 120-140 kVp, 40-80 mAs, detector collimation equal to or less than 2.5 mm

Findings To Date

• 354 deaths from lung cancer among participants in the CT arm of the study, v.s. 442 lung cancer deaths in the chest radiograph arm. 20% reduction in lung cancer mortality among participants screened with low-dose helical CT.
• All-cause mortality (deaths due to any factor) was 7% lower in those screened with low-dose CT than in those with chest radiograph

Reference:

National Lung Screening Trial Research Team. The National Lung Screening Trial: overview and study design. Radiology 2010, published online before print on November 2, 2010.

RiTradiology Celebrating 5,000 and 50,000 Strong

For the first time, we hit the record high of 5,000 visitors per month today and reach an all-time high for total visits of 50,000 as well. We would like to thank you for continued interest. We'll do our best to keep the blog going forward.

If you have more time, please check out our partner social networking site, www.radRounds.com, and blogs of interest - Roentgen Ray Reader (Radiology) and BeyondApples.org (Preventive Medicine).

-RiTradiology Team

Radiation Exposure from CT, PET/CT Will Be Tracked at the NIH

Current Issues & Debates

• Controversies exist whether low-dose (less than 150 mSv) medical radiation tests are related to development of cancer.
• Model used to extrapolate the cancer risk from low-dose medical radiation exposure is a "linear-no-threshold hypothesis", which implies that any amount of ionizing radiation (even small) has a finite probability of inducing cancer.
• This approach is widely accepted and used for radiation protection regulations and guidelines by the International Commission on Radiological Protection.
• Several recent studies and news reports have raised concerns regarding radiation exposure from medical devices (particularly CT and nuclear cardiology)
• A recent study published in the Archives of Internal Medicine estimated that radiation from CT might cause 29,000 new cancers and 14,500 deaths a year. Another study in the same journal pointed out that patients may have received much higher radiation from imaging tests than previous believed. Read synopsis in the older RiT post.

Addressing These Issues by NIH

• Radiology and Imaging Sciences at the National Institutes of Health (NIH) Clinical Center will incorporate radiation dose exposure reports into the electronic medical record (EMR)
• The process will be developed in corporation with major equipment vendors beginning with exposures from CT and PET/CT
• Radiation dose will be recorded, entered into DICOM header for CT and PET/CT and stored either in radiology information system or preferably hospital-based EMR. It should be trackable by patients in their own personal health records

What Will It Do?

• It is the first step toward monitoring patient dose
• It is the basis for future research on this subject
• Who knows, in the future this may be required in all institutions...

Are you monitoring patient dose of CT and PET/CT in your institution? If yes, how?

Reference:

Neumann RD, Bluemke DA. Tracking radiation exposure from diagnostic imaging devices at the NIH. J Am Coll Radiol 2010;7:87-89.

CT Radiation Exposure in Real Clinical Practice and Cancer Risk Estimation

Two recent studies published in the Archives of Internal Medicine in December 2009 could serve as an eye opener for every physicians ordering CT scans as well as radiologists.

Smith-Bindman et al collected CT dose data of 11 most common CT study types performed in 4 hospitals in San Francisco Bay Area. They found that there were wide variations in dose within each study type and between different types. For example, routine chest CT dose ranged from 2 to 24 mSv, routine abdomen-pelvis CT with IV contrast dose ranged from 4-45 mSv. Median effective doses for each exam were higher than they were commonly quoted in the literature, for example, 8-10 mSv is common quote for a chest CT examination. They also estimated the risk of developing cancer related to CT in several patient groups according to patient's age at the time of CT. Based on their calculation, 1 in every 80 women who undergo a chest CT for suspected pulmonary embolism at age 20 will develop cancer. Similarly, 1 in every 270 women who undergo coronary CT angiography at age 40 will develop cancer.

Berrington de Gonzalez et al utilized Medicare claim data and IMV Medical Information Division survey to project estimated age-specific cancer risk from CT studies performed in the U.S. in 2007. Excluding CT studies done for cancer diagnosis and within the last 5 years of life, 2% (29,000) excess cancers caused by CT scans in 2007 were predicted.

What is needed?

1. Optimization and standardization of CT protocols and techniques to limit radiation
2. Reduction of number of CT scans
3. Collection of dose information at patient level to educate patients and health care providers about radiation exposure

References

1. Smith-Bindman R et al. Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. Arch Intern Med 2009; 169:2078. PubMed abstract

2. Berrington de González A et al. Projected cancer risks from computed tomographic scans performed in the United States in 2007. Arch Intern Med 2009; 169:2071. PubMed abstract

Image credit: www.topnews.us

Happy New Year 2010

It's 01.01.10!

Have a very Happy New Year from the RiTradiology Team!

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Above picture: Singapore's Flyer by Paithoon Wichiwaniwate, M.D.

Updated ACR Appropriateness Criteria

The American College of Radiology (ACR) Appropriateness Criteria has recently been updated and published online on September 30, 2009.

The "Appropriateness Criteria" is evidence-based guidelines for physicians and providers to help making the most appropriate imaging or treatment decision for a given clinical condition. This latest release include 167 topics with over 800 variants addressing various radiology subspecialty, including radiation oncology.

Click here to go to the ACR Appropriateness Criteria page.

RiTradiology Celebrating 11,111 visitors

"Illumination" by Tanop Srisuwan, MD

We are celebrating our 11,111 visitors on June 12, 2009 with a certification from Health On the Net (HON) Foundation and a couple new features you may be interested in:

• "RiT ILLUMINATIONS" is a new section showcasing non-radiologic pictures. The very first picture on this section is shown above and a regular posting is on the right sidebar on the main page (upper right corner). Pictures are acquired by editor's solicitation and it is now open for submission from anyone interested.
• "ShareThis". Now you can share any post you like with friends via email, AIM, social bookmarking and networking (i.e. Facebook, MySpace, Digg, Delicious, Twitter, etc.). Simply click the link 'sharethis' on the bottom of the post.

Check them out and thanks for subscribing to RiT!

Prepare for the AOCR 2010

The Asian Oceanian Congress of Radiology (AOCR) is to be held in Taipei, Taiwan from March 20 to 23, 2010.

"AOCR 2010 will be featured with the main theme of this congress: Radiology – The Core of Healthcare. Recent progress in radiology will be highlighted in the whole scientific program. A large panel of experts, within or outside the Asian Oceanian region, will share their experiences and present their best in this congress. It will definitely provide the best atmosphere for discussing the groundbreaking researches and progresses in the field of radiology. We believe this congress will provide a good opportunity for all of us to update ourselves on the knowledge of radiology and to share clinical experiences as well as basic researches." - Organizer

Details of meeting can be found at www.aocr2010.org

Updates from RiT

New Features

Rate It!

Why not saying whether you like, or hate, the post? You can simply do that by clicking the star icon at the bottom of each post. Like this:

Your contribution will add up and make what would be the 'most popular' post in the whole site. See it on the right sidebar. Like this:

Twitter Update

Now you can follow the RiT on a fresh, new social messaging, micro-blogging service. It is another way to view the post as it is updated close to real time. Simply click on the logo on the right side bar and sign into your twitter account.

And...Our New Name and Logo!

Some of you may have noticed it already. We now call it 'RiT' (R-I-T), just to make it brief. We still use the same web address, and are with Google's Blogger though.

Annual Meeting of the Royal College of Radiologists of Thailand

Key Speakers:

• Robert Novelline, MD (Massachusetts General Hospital and Harvard Medical School)
• Theresa McLoud, MD (Massachusetts General Hospital and Harvard Medical School)
• Chusilp Charnsangavej, MD (MD Anderson Cancer Center)

More Information HERE