DynaCT Angiographic Computed Tomography Revolutionizes

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					     DynaCT: Angiographic
     Computed Tomography
     Interventional Radiology
     At the Methodist Hospital in Houston, Texas,
     a remarkable new angiography technology
     for interventional radiology called DynaCT is
     providing unprecedented, CT-like views into
     the human body while helping doctors to save
     time – and most importantly – lives.
     By Patrick Kurp

                       Late in September 2004, a 76-year-old man      pinpoint the problem. He was suffering from
                       from Houston, Texas, who was otherwise         bleeding in the posterior region of the brain,
                       feeling healthy and fit, had been experienc-   about the midline. The diagnosis was fast and
                       ing dizziness for nearly a month when he       focused, and without any difficulties. Treat-
                       suddenly collapsed in his home. He was         ment could begin at once.”
                       rushed by ambulance to the second floor        “With the aid of the hospital’s newly installed
                       of the Methodist Hospital in Houston, to       Siemens AXIOM Artis® dBA DynaCT system,
                       the endovascular department, where a team      we were readily able to isolate a dural arterio-
                       of interventional radiologists conducted a     venous fistula which appeared on the com-
                       series of emergency diagnostic tests on the    puter screen as a dark, irregularly shaped
                       patient.                                       mass at the center of a tangled web of blood
                       Shortly after the examinations were over,      vessels. The bleeding was quickly repaired
                       at a viewing station Dr. Strother commented    using a microcatheter that sealed the fistula
                       on the outcome of the tests: “Using angiog-    with an injection of acrylic glue, and the
                       raphy with DynaCT we were quickly able to      patient, three days after admission to the

46                                                                                                       MEDICAL SOLUTIONS RSNA 2004
 Department of Interventional
     Radiology, The Methodist
    Hospital in Houston, Texas.
        A SPECIAL CHALLENGE for designers and engineers: a biplane system for use in neuroradiology where two different sizes
        of flat detectors have to be operated in one system.

                                        Methodist Hospital, was tired and weak but         The Methodist Hospital in Houston is the
                                        scheduled to return to his family.“ Dr. Strother   first hospital in the world to have the system
                                        attributed the man’s rapid recovery and opti-      fully operational.
                                        mistic prognosis largely to the speed and
                                        acuity afforded by the AXIOM Artis DynaCT’s
                                                                                           Enhanced Diagnosis and
“With DynaCT                            capacity for clearly and quickly visualizing
                                        detailed anatomy.                                  Since the introduction of the AXIOM Artis

      we can                            “When we didn’t have DynaCT, we had to leave
                                        the sterile room of the angio lab, relocate the
                                                                                           DynaCT system at the Methodist Hospital
                                                                                           in mid-September, Dr. Strother and his col-

   get CT-like                          patient, perform a control CT and then go
                                        back to the lab…,” recalls Dr. Strother. “Now,
                                                                                           leagues feel they are on the cusp of a
                                                                                           revolution in interventional radiology called
                                        for the first time, with DynaCT we can get         Angiographic Computed Tomography (ACT),
      images                            a CT-like image immediately. We are able to        enabling them to perform soft tissue imaging
                                        achieve some of the sensitivity of a CT with       during the angio procedure, thus skipping an
immediately.“                           an angio system. It changes everything about       entire time-consuming step in the treatment
                                        what goes on in the angio lab. Endovascular        process. When fitted with flat detectors
           Dr. Charles M. Strother,
                                        techniques are becoming the treatment of           as part of a thoroughly integrated system,
     Department of Interventional
                                        choice for cerebrovascular disease, and this       AXIOM Artis DynaCT reduces the need to
Radiology, The Methodist Hospital,      new technology enhances this treatment,”           move the patient to CT during or after an
                   Houston, Texas       reports Strother, who, with other colleagues       interventional procedure.
                                        at the Methodist Hospital, has been con-           The interventional radiologists at the Methodist
                                        sulting with Siemens engineers in Germany          Hospital routinely use the device to enhance
                                        on the design of the AXIOM Artis DynaCT.           the diagnosis and treatment of such condi-

48                                                                                                                              MEDICAL SOLUTIONS RSNA 2004
              “WHAT WE CAN SEE, WE CAN DO. We have been limited in the past by what we could see. The more information you have about
              such delicate procedures, the more judgements you can make and the better and more informed they will be.”

          tions as aneurysms, carotid disease, arterio-         earlier technologies, Strother and several
          venous malformations, stroke and occasion-            other interventional radiologists agree, is
          ally tumors – all in the familiar setting of the      an increased sense of orientation combined
          angio lab. “The old angio system was essen-           with enhanced visual detail, the result of its
          tially like a plain old X-ray. Now, we still inject   unique biplane design. Richard Klucznik,
          dye to visualize the blood vessels, but are           M.D., one of Strother’s colleagues at the
          also able to observe soft tissue. We not only         radiology department at the Methodist
          see the vascular abnormality, we also see all of      Hospital, explains: “Each plane is a two-
          the surrounding environment with a degree             dimensional projection. You can very easily
          of detail we never could have before,” says           get lost about where you are in space
          Dr. Strother, who during his long career has          when you rely on a single plane. In a very
          personally witnessed an extraordinary revo-           literal sense, we are creating a new dimen-
          lution in imaging technology from the intro-          sion with this technology, a new, improved
          duction of the first generation of CT scan            way of viewing reality. We see something
          systems in the mid-1970s. He remembers the            other than just the blood vessels.”
          seemingly prehistoric, predigital days when,
          even at the most advanced healthcare facili-
                                                                Minimizing Risk, Maximizing
          ties, angiographs were shot on film and
          required a delay of 10 or 15 minutes before           Dr. Klucznik especially singles out for praise
          the developed images could be returned.               the AXIOM Artis DynaCT system’s increased
          “Now, we get almost instant images, and they          capacity for contrast sensitivity. Gradations
          have so much more information,” he observes.          of soft tissue density are readily identifiable
          Perhaps the system’s principle advantage over         in the high-resolution image, permitting

MEDICAL SOLUTIONS RSNA 2004                                                                                                             49

         THE METHODIST HOSPITAL’S angiography team:
         Dr. Charles M. Strother (right), and Dr. Richard Klucznik (left).

                            physicians even to distinguish various matters      by what we could see. The more information
                            in the brain – a capacity unimaginable with         you have about such delicate procedures,
                            earlier technologies. Also earning kudos from       the more judgments you can make and the
                            the radiologists is the AXIOM Artis DynaCT          better and more informed they will be.” Dr.
                            system’s compactness and openness in the            Strother cites a further advantage to the new
                            angio lab setting.                                  system: speed, especially during the critical
                            “Since we have the flat detector system, it is      minutes immediately following, say, a stroke
                            much less crowded in the room, which is             or aneurysm. “There’s less need to move the
                            already filled with equipment and people. It        patient to another room or to another imaging
                            gives you much better access to the imaging         modality somewhere else. We can stay right
                            equipment itself and to the patient,” notes         where we are, in the angio lab, and not
                            Klucznik. “And that brings up another point:        have to waste time shifting the patient
                            patient safety. Because we are better able to       about. In the case of a ruptured blood vessel,
                            visualize, for instance, the brain itself and the   for instance, that might easily be a matter of
                            damage it has suffered, our procedures go           life and death. We’re getting images com-
                            far more smoothly, with much less risk of           parable to CT during the angio procedure.
                            error or risk of any sort for the patient.”         On top of that, we have already made a
                            Dr. Klucznik finds using the AXIOM Artis            quantum leap forward in getting a 3D image,
                            DynaCT system liberating: “What we can see,         which enables us to give patients the best
                            we can do. We have been limited in the past         care there is,” says Dr. Strother.

50                                                                                                                MEDICAL SOLUTIONS RSNA 2004

                                                                                                                        “With DynaCT
                                                                                                                        there is no
                                                                                                                        need to move
                                                                                                                        the patient
                                                                                                                        to another
                                                                                                                        room or
                                                                                                                        to another
                                                                                                                        Dr. Richard Klucznik,
                                                                                                                        Department of
                                                                                                                        Interventional Radiology,
                              DYNACT IMAGES showing slices of the skull.
                                                                                                                        The Methodist Hospital,
                                                                                                                        Houston, Texas

          Both interventional radiologists agree that         for the staff and for the hospital itself. The
          the AXIOM Artis DynaCT system represents            presence of such a system brings us all great
          the state of the art in their business – the        prestige.”
          standard against which all other similar            Dr. Strother echoes his colleague’s sentiment:
          technologies must now be measured. Dr.              “It makes the environment we work in far
          Klucznik speaks for them all when he says,          more robust than ever before. It’s like being
          “The Methodist Hospital has made a very             able to see a new world in a new way.”
          wise decision to commit itself to this equip-
          ment. It is certain to be the best for the
                                                              Author: Patrick Kurp is a freelance medical and science
          patients, and that must always be our fore-         writer based in Texas. A former AP correspondent,
          most consideration, but it is also the best         his work has also appeared in the Houston Chronicle.

MEDICAL SOLUTIONS RSNA 2004                                                                                                                         51

      Symbia: a Merger of
      Two Equals
      Does the future for all SPECT systems include
      CT – or vice versa? The brilliant design of Symbia
      and TruePoint SPECT·CT will transform the
      delivery of diagnostic imaging as we know it.
                                    “If you had a CT engineer design a nuclear         an initial concept involving basic CT capabilities
                                    medicine system or had a nuclear medicine          added to the powerful SPECT capabilities of
                                    person design a CT system, you wouldn’t            the e.cam® Signature Series. The early design
                                    be happy with the result,” says John Pawlak,       concept was aimed at providing accurate
                                    senior project leader and system architect         attenuation maps to allow for attenuation
                                    at Siemens’ Nuclear Medicine division in           correction during the SPECT reconstruction,
                                    Hoffman Estates, Illinois. How, then, did the      but the success of PET/CT systems involving
                                    company manage to design the new Symbia®           high-end CT technology and the explosive
                                    TruePoint™ SPECT·CT system without making          growth in multislice CT studies ultimately led
                                    everyone unhappy? By forming a highly              the company to design the current lineup of
                                    qualified international team of both nuclear       Symbia scanners, the T, T2, and T6 systems,
                                    medicine and CT specialists who would work         involving single-, dual-, or six-slice CT tech-
                                    closely together, facilitated by countless phone   nology drawn directly from the company’s
                                    calls, e-mails, and long flights between           CT group.
                                    Hoffman Estates where Siemens Medical              This Symbia lineup would also incorporate
                                    Solutions’ Nuclear Medicine coordinated the        Siemens’ state-of-the-art SPECT technology,
                                    development of the system, and Forchheim,          found in the e.cam. Having already designed
                                    Germany, where the CT group is based.              the best in SPECT, the design team gave
                                    The design process began with surveys and          Symbia everything the e.cam has to offer,
                                    focus groups to determine the needs and            including HD detectors, and unparalleled
                                    desires of customers for such a system. “Of        image quality and speed in nuclear imaging.
                                    course, asking customers what they want            The team decided early on to avoid what
                                    in a hybrid system with which they have no         Pawlak calls the “washer-dryer” approach
                                    experience was not always an easy process,”        of simply coupling two existing systems with
 entertainment features, patients
 can watch movies during the        according to Keith Andress, director of soft-      a common patient bed, in favor of a more
 examination.                       ware engineering at the Nuclear Medicine           tightly integrated design, all while using as
                                    division. At that time, PET/CT systems were        many existing components as possible.
                                    recently introduced, and customers and engi-       The goal was to achieve a 200-cm scan range
                                    neers alike were already beginning to imagine      through both systems’ fields of view without
                                    the possibilities of SPECT and CT together.        requiring an impractically long patient motion
                                    The preliminary customer surveys lead to           range. An excessively long patient motion

52                                                                                                                          MEDICAL SOLUTIONS RSNA 2004
                THE OPEN AND INVITING integrated design of Symbia offers increased patient comfort and ease of operation.

          range would have made it difficult to site         mechanically and electronically,” says Pawlak.
          the system in standard nuclear medicine and        While striving to make use of existing compo-
          radiology rooms.                                   nents wherever possible, the team often had
          Minimizing the patient motion range meant          to reconfigure and redesign components from
          minimizing the distance between the CT and         each technology in the interest of meeting
          SPECT fields of view. One possible solution,       their compactness goals. The SPECT drive
          of course, would have been to mount the CT         system was pushed to the outside, which
          and SPECT components on the same rotation          allowed the CT components to be brought
          gantry so that they shared a field of view.        closer to the SPECT heads. The CT gantry was
          However, the team rejected this design             essentially redesigned, allowing the compo-
          because the weight of the SPECT heads              nents to be as close as possible.
          would have severely limited the gantry rota-       With the SPECT and CT components tightly
          tion speed and thus the imaging speed              integrated, the resulting system offers many
          achievable by the CT components. If high-          possible modes of operation. “The challenge
          end CT components were to be used, the             from an industrial design standpoint is to make
          system needed to be capable of the sub-            all of this usable,” says Ansgar Graw, principal
          second gantry rotation speeds expected             industrial designer for Siemens Nuclear
          in modern CT scanners. So the team opted           Medicine. In researching design options, the
          for maintaining distinct but closely spaced        team visited numerous hospitals to observe
          subsystems.                                        clinical workflow with the company’s e.cam
                                                             SPECT systems, as well as competitive prod-
          A Complex System in                                ucts. This inspired the incorporation of a wide
          Compact Form                                       range of new features into the Symbia system,
          Fusing the two technologies was not simply         such as the inclusion of a patient entertain-
          a matter of shoehorning the components             ment system. Incorporating the best features
          of two existing systems into a slightly larger     from other systems, such as the e.cam SPECT,
          housing. “The system is highly integrated,         the patient entertainment system idea origi-

MEDICAL SOLUTIONS RSNA 2004                                                                                                 53

                                               IMAGES OF A prostate cancer (left) and an Acth-producing tumor (right)
                                               acquired with the TruePoint SPECT·CT components.
                                               (Images courtesy of University Hospitals Cleveland and Erlangen-Nuremberg)

                                      nated from observing a technologist who           charge of the software development, “It was
                                      played fairy tales on a portable tape player      really my goal to make sure things would
                                      to distract and calm pediatric patients.          move smoothly between the CT and SPECT
                                      Symbia’s design is not simply the industrial      systems.” The team aimed at keeping the
                                      design of the outward appearance of an            individual user interfaces the same as those
                                      imaging modality, its hardware, software,         employed in the component systems. They
                                      technology and mechanics, but a design            modeled the three orthogonal screen views
                                      that incorporates the experience of Symbia        and their correlated cursor-image fusion dis-
                                      through the eyes of the customer and patient.     plays on the company’s PET/CT interface.
                                      In addition to the fact that Symbia TruePoint
                                      SPECT·CT is technologically advanced, includes
                                                                                        Taking Accuracy and
                                      the power and speed of a Siemens e.cam,
                                                                                        Clarity to the Next Level
     THIS BONE SCAN reveals
                                      diagnostic quality CT imaging, and is visually    At the heart of the software lies the Flash 3D
     multiple skeletal metastasis.
     (Images courtesy of University   welcoming to both user and patient, it is         SPECT image reconstruction software, based
     Hospital Erlangen-Nuremberg)     designed to be efficiently operated by its        on an iterative maximum-likelihood algorithm
                                      technicians.                                      that allows for modeling and correction of data
                                      The design team incorporated elements             degradations such as attenuation, collimator
                                      such as a large, easily visible progress bar      blurring, and scatter. Obviously, the CT images
                                      on the front of the unit, so that operators and   can be used to estimate the attenuation
                                      patients alike would be able to see the           experienced by the SPECT photons, but not
                                      progress of their scan. This is a key feature     directly. Gamma ray sources produce photons
                                      for technicians scanning multiple patients        with a broad range of energies, typically
                                      simultaneously. Designers also incorporated       centered around 70 keV, while SPECT radio-
                                      other features that facilitate ease of use.       nuclides most commonly emit photons of
                                      As far as the particular difficulties posed by    140 keV. To convert a CT image into a SPECT
                                      a hybrid system, Graw says that the prin-         attenuation map, says research lead Hans Vija,
                                      cipal goal was “to make the system seem           senior principal research scientist at Siemens
                                      open and friendly for the patient.” A number      Medical Solutions’ Nuclear Medicine division,
                                      of innovations were implemented towards           it is necessary first to determine the effective
                                      increased patient friendliness; for example,      average energy of the photons contributing
                                      the SPECT heads were designed to dock             to the CT image, and then to apply appropriate
                                      under the patient table during the CT scan,       conversion factors to each pixel. The conver-
                                      so as not to loom over patients as they are       sion has to be accurate for all isotopes and
                                      translated through the CT field of view.          SPECT acquisition parameters. Moreover, the
                                      The push for tight integration extended to        great difference in resolution between CT
                                      the software as well as the hardware.             and SPECT images must be bridged in order
                                      According to Andress, who was also in             for the CT images to be registered with SPECT

54                                                                                                                          MEDICAL SOLUTIONS RSNA 2004

             THE SYMBIA SYSTEM is both visually welcoming to the patient and designed to be efficiently operated.

          for attenuation correction. These technical         enhanced by this dual modality system.
          challenges had been addressed and incorpo-          Because of earlier and more accurate diagno-
          rated into previous versions of the Siemens         sis of prostate cancer, for example, physicians
          e.soft™ package installed on the company’s          will be able to plan treatment more effectively
          stand-alone e.cam SPECT systems. However,           and provide feedback on treatment efficacy,
          notes Vija, that software package was               as well as avoid unnecessary invasive surgery
          designed with an eye toward the ultimate            and reduce the risks of necessary surgery.
          development of the Symbia TruePoint                 According to Homer A. Macapinlac, M.D.,
          SPECT·CT system, where performing the CT            deputy chairman, department of nuclear
          scan immediately after the SPECT scan makes         medicine, MD Anderson Cancer Center in
          accurate registration of the two data sets          Houston, Texas, “MD Anderson Cancer Cen-
          more likely than if the patient needs to be         ter’s goal is to eliminate cancer… TruePoint
          moved to a different scanner.                       SPECT·CT is going to help us significantly in
                                                              the diagnostic interpretation of clinical exams.
          Transforming Diagnosis and                          Ultimately, the person who benefits from
          Treatment                                           this new technology is the patient.” MD
          According to Symbia’s marketing manager             Anderson Cancer Center plans to install
          Reinout Vogt, the most compelling appli-            five Siemens Symbia systems, incorporating
          cations of the TruePoint SPECT·CT system are        TruePoint SPECT·CT technology, in early 2005.
          in oncology, where the addition of the CT           “That a world-renowned institution such as
          modality for anatomical localization can be         MD Anderson Cancer Center is making such a
          essential, and in cardiology, where the accu-       significant investment in our Symbia systems
          rate attenuation correction provided by the         confirms that this technology is at the lead-
          CT is most important. The hybrid SPECT·CT           ing edge of cancer diagnosis and patient
          system will no doubt impact the future of           care,” says Michael Reitermann, president of
          molecular imaging. The anatomical informa-          Siemens Medical Solutions’ Nuclear Medicine
          tion provided by CT will become even more           division.
          significant as increasingly specific molecular      Siemens expects the Symbia system to
          imaging agents are developed. SPECT studies         appeal to a number of different medical
          using such biomarkers might produce little          specialists, including radiologists, cardiologists
          more than isolated hot spots, with very little      and, of course, nuclear medicine specialists.
          background activity to provide even a crude         Fittingly for a system born of cooperation
          anatomical roadmap, says Vogt, “The more            and integration, it may actually realize its
          specific the SPECT marker, the higher the           full potential when used in concert across
          need for anatomical information.”                   departmental lines, with interpretation of
          Tumor detection, disease management and             the diagnostic-quality CT scans and SPECT
          staging of cancer treatment are significantly       data ultimately improving patient care.

MEDICAL SOLUTIONS RSNA 2004                                                                                                    55
     THE SOMATOM SPIRIT is a dual-slice system for the ambitious entry into the fascinating world of CT.

56                                                                                                         MEDICAL SOLUTIONS RSNA 2004
                                                                                                                COMPUTED TOMOGRAPHY

          Computed Tomography
          Is Multislice
          With this year’s RSNA, Siemens Medical Solutions
          offers multislice computed tomography systems for
          all markets, medical purposes and budgets.

          No other area of medical imaging has wit-         slice scanner SOMATOM® Spirit to the latest
          nessed an explosion of performance com-           flagship model SOMATOM Sensation 64.
          parable to the one which has occurred in
          computed tomography (CT). Just several years
                                                            Clinical Advantages
          ago almost all CT systems had only a single       Compared to single-slice systems, multislice
          detector row. Scan times of 30 seconds were       CT scanners represent a technological mile-
          state of the art for a head CT scan. Cardiac      stone with respect to increased volume cover-
          CT was possible, however, limited to the dis-     age, shorter examination times, improved
          play of calcifications in the coronary vessels.   axial image resolution and better utilization of
          Furthermore, due to breath-hold times of          the X-ray tube output. Examination protocols
          approximately 40 seconds, cardiac CT also         can thus be optimized for maximal volume
          demanded a high willingness to cooperate,         coverage, shortest scan times, highest spatial
          even from healthy patients. The detail resolu-    resolution or fastest temporal resolution. At
          tion was in the 0.7-millimeter range, and more    the same time, Siemens’ development team
          than one millimeter in the axial direction.       has improved dose efficiency and minimized
          The explosion in performance capability noted     radiation exposure. And it was not just the
          above was sparked at the 1998 convention          technology that leaped forward: CT has grown
          of the Radiological Society of North America      from a purely diagnostic method for already
          (RSNA) in Chicago, where all major CT manu-       symptomatic diseases to a patient-friendly
          facturers presented systems with four detector    and reliable tool for the early visualization of,
          slices. Scan times suddenly decreased to just     for example, lung and colorectal cancer, or
          a fraction of what they had been; improved        coronary heart disease.
          volume coverage and reduced gantry rotation
          time enabled new types of applications such
                                                            Completing the
          as CT examinations of the heart and coronary
                                                            High-End Portfolio
          vessels. As multislice CT is coming of age,       This development culminates in the
          Siemens Medical Solutions now offers multi-       SOMATOM Sensation 64 and SOMATOM
          slice systems for all markets, medical purposes   Sensation Cardiac 64 that firmly established
          and budgets – from the new economical two-        a new benchmark for diagnostic excellence.

MEDICAL SOLUTIONS RSNA 2004                                                                                                           57
     THE SOMATOM SENSATION 64 completes the                            THE LARGE bore of the SOMATOM Sensation Open
     high-end CT portfolio.                                            eases patient positioning.

     THE SOMATOM EMOTION’S wide gantry enables                         THE SOMATOM SPIRIT comes with a comprehensive
     easy patient access.                                              set of applications.

                                Siemens proprietary z-Sharp Technology™        storage capacity and enables the industry’s
                                enables the industry’s best isotropic reso-    fastest CT rotation time of 0.33 seconds.
                                lution of smaller than 0.4 mm in clinical      SOMATOM Sensation 64’s unmatched clinical
                                routine. The STRATON® X-ray tube utilizes      performance finally eliminates the necessity
                                an electron beam that is accurately and        to compromise between image resolution
                                rapidly deflected, creating two alternating    and scan speed.
                                and overlapping X-ray projections reaching     With the introduction of the new SOMATOM
                                each detector element. This doubles the scan   Sensation 40, Siemens continues the tradition
                                information without a corresponding increase   of the SOMATOM Sensation product line to
                                in dose, resulting in substantially enhanced   continually integrate cutting-edge imaging
                                spatial resolution and image quality. Addi-    applications into daily clinical practice. It
                                tionally, the unique STRATON X-ray tube’s      benefits from the revolutionary z-Sharp Tech-
                                direct cooling eliminates the need for heat    nology and the unique STRATON X-ray tube,

58                                                                                                              MEDICAL SOLUTIONS RSNA 2004
                                                                                                                COMPUTED TOMOGRAPHY

          enabling an acquisition of 40 slices with           dures and imaging of bariatric patients
          unprecedented image quality and 0.4-mm              with excellent performance in routine and
          isotropic detail. Together with it’s gantry rota-   advanced CT examinations. The 20-slice
          tion speed of 0.37 seconds, the SOMATOM             system delivers an image resolution of 1.2
          Sensation 40 opens the world of high-end            millimeters. Gantry rotation speeds of
          computed tomography to hospitals, imaging           one and 0.5 seconds are available. The
          centers and private practices. As on all            SOMATOM Sensation Open’s generous 82-
          SOMATOM Sensation scanners, Siemens’                centimeter gantry bore allows increased
          Speed4D Technology™ also supports work-             accessability and easy positioning of virtually
          flow and dose management on the                     all patients. Its 82-centimeter field of view
          SOMATOM Sensation 40.                               provides visualization of the entire anatomy,
          Both SOMATOM Sensation 40 and SOMATOM               improving both therapy planning and diag-
          Sensation 64 – which even further expands           nostic examinations.
          the scope of applications – provide breath-         The first installations were successfully com-
          taking image sharpness and clarity. With its        pleted in early summer 2004. Customers
          faster rotation and increased scan speed            are very pleased with its performance and
          the SOMATOM Sensation 64 and SOMATOM                its enhanced specifications. “The SOMATOM
          Sensation Cardiac 64 push the boundaries of         Sensation Open gives us the flexibility of a
          temporal resolution to a new level, enabling        large-bore CT while having a solution for
          cardiac examinations with previously un-            virtually all advanced CT examinations at the
          achievable image quality. The SOMATOM               same time,” says Professor Jürgen Debus,
          Sensation upgrade philosophy allows every           M.D., Medical Director of Radiology Depart-
          SOMATOM Sensation scanner to easily                 ment, University of Heidelberg, Germany,
          develop with the clinical necessities of users.     where one of the first systems was installed.
          In fact, the SOMATOM Sensation 40 can
          easily be upgraded to a 64-slice system if
                                                              The Best of Both Worlds
          need arises.                                        Smaller hospitals and practices with a lot
          The SOMATOM Sensation 16, with the                  of routine CT examinations are equally
          industry’s largest installed base of 16-slice CT    well equipped with the scanners of the
          scanners, represents a time-tested reliable         SOMATOM Emotion series. With 3 000 systems
          CT system that combines high-end perfor-            installed, they are among the most popular
          mance and investment protection. “The fact          CT systems in the world. And not without
          that the SOMATOM Sensation 16 itself was            reason: SOMATOM Emotion scanners com-
          introduced just three years ago illustrates         bine the best of both worlds: a comprehensive
          the momentum innovations have gained                portfolio of clinical applications with low
          since CT became multislice,” explains Bernd         siting requirements and low running costs.
          Ohnesorge, Ph.D., Vice President Marketing          The SOMATOM Emotion was first introduced
          and Sales of Siemens Computed Tomography            in 1999 as a single-slice spiral CT scanner.
          division. “And the fact that it was again           Since then, Siemens has continually im-
          Siemens who first announced the first 64-           proved its performance. A dual-slice version
          slice system at last year’s RSNA underlines         was added in 2000 providing faster scanning
          our mission as innovation leaders.”                 capabilities, better anatomical coverage,
                                                              and the possibility to scan routinely with
          High Performance for All                            thin slices. In 2003, Siemens added the
          Patients                                            SOMATOM Emotion 6.
          With the SOMATOM Sensation Open, Siemens            This scanner is living proof that advanced
          introduces a large-bore CT system that deliv-       clinical applications – for example syngo®
          ers a new level of diagnostic support for radi-     VRT and syngo Colonography – and a cost-
          ation therapy planning, as well as CT-based         conscious budget do not have to be mutually
          trauma examinations, interventional proce-          exclusive. Rapid 3D-based visualization of

MEDICAL SOLUTIONS RSNA 2004                                                                                                           59

                                                                                      pulmonary nodules with syngo LungCARE CT,
                                                                                      semiautomated vessel quantification with
                                                                                      syngo Vessel View, and advanced diagnostic
                                                                                      perspectives like syngo Fly Through are just
                                                                                      some of the features that can be added
                                                                                      to the customer’s clinical routine. Patients
                                                                                      appreciate the slim system with its 70-cen-
                                                                                      timeter gantry opening, and also the numer-
                                                                                      ous dose reduction features – for example
                                                                                      CARE Dose4D™ – available for the SOMATOM
                                                                                      Emotion scanners.
                                                                                      Reliably performing routine and advanced
                                                                                      applications today, they also leave the future
                                                                                      open for further system enhancements
                                                                                      and upgrades, growing with the customer’s
                                                                                      clinical needs and budget. With the great
                                                                                      success of the SOMATOM Emotion and its
                                                                                      evolution throughout its five-year history,
                                                                                      Siemens remains committed to this impor-
                                                                                      tant member of its SOMATOM product family.
                                                                                      Development of the SOMATOM Emotion,
                                                                                      even beyond six slices, persists, ensuring that
     THE SOMATOM EMOTION 6 is the right CT system designed for routine and            it will continue to evolve and meet the future
     advanced clinical applications. Courtesy of H.-Hart Ziekenhuis, Lier, Belgium.   clinical requirements of multislice CT.

                                                                                      Join the World of
                                                                                      Multislice CT
                                                                                      The newest member of Siemens’ Computed
                                                                                      Tomography family is the trendsetting, sub-
                                                                                      second, dual-slice SOMATOM Spirit, a cost-
                                                                                      effective system for day-to-day clinical routine.
                                                                                      “Multislice CT is strongly implemented into
                                                                                      clinical routine today. We feel that every
                                                                                      patient – and physician – should profit from
                                                                                      the advantages a multislice CT system offers,”
                                                                                      says Ohnesorge.
                                                                                      With its extremely attractive price, the
                                                                                      SOMATOM Spirit is the multislice CT for both
                                                                                      small and large facilities. It is not only the
                                                                                      ideal system to replace outdated scanners or
                                                                                      to add an additional CT to an overworked
                                                                                      facility, it is also the multislice scanner of
                                                                                      choice for an affordable, easy entry into the
                                                                                      fascinating world of CT. With its specifi-
                                                                                      cations, the SOMATOM Spirit is the perfect
                                                                                      multislice CT for day-to-day examinations. It
                                                                                      is also ideally suited for small, outlying clinics
                                                                                      utilizing teleradiology, as well as medical
     USERS OF the SOMATOM Spirit need not compromise when it comes to
     achieving clinical performance.
                                                                                      fields other than radiology, such as ENT
                                                                                      and urology practices, dental surgeons and

60                                                                                                                         MEDICAL SOLUTIONS RSNA 2004
                                                                                                              COMPUTED TOMOGRAPHY

          general practitioners. By adding CT to their       and syngo Osteo CT are also on hand. These
          medical services, virtually any practice or        features make the SOMATOM Spirit a good
          facility can improve the quality of patient        investment also for dental surgeons, ortho-
          care and increase patient volume.                  pedic physicians and general practitioners.
          The SOMATOM Spirit acquires two slices per         The CT-specific elements of syngo, Siemens’
          rotation, but has the price tag of a single-       intuitive multimodality user interface, were
          slice scanner, thus making multislice CT           simplified especially for the SOMATOM Spirit
          universally affordable. With the introduction      to further increase user comfort. syngo can
          of the SOMATOM Spirit, a new era of afford-        be learned and applied without extensive
          able, efficient multislice CT begins.              training. The user is “guided” through exami-
          It is not just the purchase price that makes       nations, and the workflow is automated
          the SOMATOM Spirit economical: low instal-         wherever possible. The intuitive handling and
          lation and space requirements – only 17 square     the automation give the user confidence
          meters (183 square feet) – fast installation       from the very beginning.
          time, efficient preventive maintenance, its        With a gantry aperture of 70 centimeters
          fast breakeven, high reliability and uptime        (27.6 inches), and a patient table load of
          ensure a good return on investment. The            200 kg (450 lbs), the patient spectrum of
          breakeven point can be reached in a short          the SOMATOM Spirit is virtually unlimited.
          period of time with only a few patients            The flared, wide gantry opening and the
          per day. However, depending on the type            short bore allow for easy patient positioning
          of examinations, up to fifty patients can          and access, making the SOMATOM Spirit a
          be examined in an eight-hour workday*,             comfortable CT for both patient and medical
          making it one of the most cost-effective,          staff. The appealing, esthetic design also
          multislice CTs on the market today.                helps to alleviate patient inhibitions.
          With the SOMATOM Spirit’s spatial resolution       The SOMATOM Spirit is Siemens’ latest CT
          of one millimeter and its gantry rotation time     and incorporates over 30 years of CT know-
          of one second, physicians do not have to           how and expertise of the world’s leader in
          compromise when it comes to clinical per-          multislice CT. It combines new innovations
          formance. For even better results, 0.8 seconds     with successful and proven functions, tech-
          gantry rotation time is available as an option.    nologies, and components of other SOMATOM
          X-ray efficiency is assured by the optimized       products.
          system geometry of the SOMATOM Spirit,             “Who would have thought, just a year ago,
          the highly efficient UFC (UltraFastCeramic)        that a subsecond, multislice CT would
          detector material, and Siemens’ dose reduc-        be affordable as an entry-level system?”
          tion software CARE Dose and CARE Bolus.            comments Ohnesorge. “With the SOMATOM
          All these features lead to excellent image         Spirit, we offer our customers just that – to
          quality and, at the same time, significantly       enhance their clinical portfolio for providing
          reduce dose.                                       better patient care.” The SOMATOM Spirit will
          Additionally, the SOMATOM Spirit offers            be available worldwide in Spring 2005.
          a comprehensive spectrum of routine CT             With its extensive portfolio of forward-
          applications. The standard application port-       looking, patient-friendly CT scanners, the
          folio includes real-time multi-planar refor-       Siemens SOMATOM family offers the right
          matting (MPR), syngo 3D SSD (Shaded                multislice CT system for any size hospital
          Surface Display), volume measurements,             or practice, any diagnostic need and any
          and CT-angiography. The optional syngo VRT         reasonable budget.
          (Volume Rendering Technique) software
          facilitates 3D display. To support examination
          and diagnosis of lumen, syngo Fly Through is
          available as an option. Further specialized,
          optional applications like syngo Dental CT        *Results may vary. Data on file.

MEDICAL SOLUTIONS RSNA 2004                                                                                                         61

     A Closer Look at 4D
     Imaging Capabilities
     Demand for the new fourSight 4D ultrasound
     imaging technology on the SONOLINE Antares
     ultrasound system continues to increase since
     the 4D imaging capabilities started shipping
     earlier this summer.
     By Amy Cook

                           During an 11-city symposium tour through-        Frank Craparo, M.D., chief of Maternal Fetal
                           out the United States, the fourSight™ 4D tech-   Medicine at Abington Memorial Hospital in
                           nology was demonstrated to the medical           Abington, PA, was one of the early evaluators
                           community where it received overwhelming         of the new 4D capabilities on the Antares
                           positive feedback. Clinical evaluators pre-      system. In an interview, Dr. Craparo says
                           sented their experience with the fourSight       that the fourSight 4D technology really helps
                           4D technology on the SONOLINE Antares™           physicians and sonographers to clarify exactly
                           system to more than 1500 attendees in total,     what they are seeing in 2D imaging for pre-
                           and highlighted how the advent of real-time      natal diagnosis. And, because the SONOLINE
                           4D imaging enables interactive examination       Antares system has excellent image quality
                           of internal structures from any viewpoint, and   with high contrast and detail resolution, his
                           can assure better accuracy of measurements,      staff is able to enhance the images already
                           detection of potential abnormalities and         obtained in 2D imaging at the push of a button,
                           improved diagnostic assessments, all at the      and in real-time, have a diagnostic 4D image.
                           push of a button. Additionally, evaluators       “We use the 4D imaging for fetal evaluations,
                           felt the fourSight 4D technology is perfectly    primarily for facial and digit abnormalities, as
                           suited for the premium performance Antares       well as imaging the fetal spine,” he says.
                           system because it already offers state of the    Dr. Craparo adds that the new fourSight 4D
                           art 2D, 3D and Doppler performance, and it       imaging capabilities on the Antares system
                           provides a full range of advanced imaging        are also helpful in demonstrating to parents
                           capabilities for a broad range of diagnostic     the stages of fetal development. Additionally,
                           applications.                                    the pediatric surgeons find the new technol-

62                                                                                                             MEDICAL SOLUTIONS RSNA 2004
             4D IMAGING HELPS physicians and sonographers to clarify exactly what they are seeing in 2D imaging.
             In addition, it helps to demonstrate the stages of fetal development and may contribute to fetal-maternal bonding.

          “Using fourSight 4D we were able to show the
          anomalies in much better detail…, and we could talk
          about what they might need to correct after birth.“
          Jiri D. Sonek, M.D., RDMS, Medical Director for the Perinatal Ultrasound Department at the Miami Valley Hospital, Dayton, Ohio.

MEDICAL SOLUTIONS RSNA 2004                                                                                                                 63

                  ogy useful for counseling parents about their      Valley Hospital concurs with Dr. Craparo in
                  baby’s surgery and post-natal repair.              that fourSight 4D imaging is both easy to use
                                                                     and has been very helpful for communica-
                  Wider Range of Applications                        tion with expectant parents. Dr. Sonek had
                  Because diagnostic imaging modalities such         one case where the fetus had an extremely
                  as Ultrasound, MRI and CT have become              depressed nasal bridge and it was hard to
                  essential in identifying, diagnosing and local-    show or explain the image in 2D to the
                  izing structures and abnormalities, it’s not       expecting parents. “With 4D we were able to
                  surprising that 4D ultrasound is being adopted     show the parents exactly what the fetus
                  by the medical community as an easy and            looked like, as well as show them what the
                  accurate way to diagnose certain conditions        baby would look like after being born.“
                  for obstetrics, gynecology, abdominal and
                  vascular imaging, some of which were only
                                                                     Easy Understanding
                  done before by other modalities.                   “Another example was a case where the
                  The Antares ultrasound system offers the           fetus had micrognathia (small chin), so in
                  combination of 3-Scape™ real-time 3D imag-         order to provide the parents an accurate
                  ing and fourSight 4D imaging, and provides         picture of their fetus, we were able to use
                  physicians access to both free-hand 3D             fourSight 4D technology to show the parents
                  and 4D imaging to accommodate a wider              what the baby would look like,” he con-
                  range of clinical applications. Additionally,      tinues. “This has been quite useful for preg-
                  the fourSight 4D capabilities on the system        nancy management and may contribute to
                  feature two ergonomically designed 4D              parental bonding with their unborn child.”
                  transducers with MultiHertz™ multiple fre-         Dr. Sonek also finds the fourSight 4D imaging
                  quency imaging for greater sensitivity and         to be very useful when discussing a patient’s
                  imaging bandwidth. This technology incor-          exam with referring physicians or physicians
                  porates a complete set of 3D and 4D imaging        outside the field of radiology due to the fact
                  features, including flexible image formats         that the 4D reconstructions can be easily
                  that enable a one-to-one, two-to-one or            downloaded and forwarded to referring
                  four-to-one display to facilitate surface          physicians from the Antares system or work-
                  rendering, as well as intuitive volume edit-       station.
                  ing, data storage and retrieval with DIMAQ-IP      As an example, one of Dr. Sonek’s patients
                  study management programs.                         had a complicated defect affecting the lower
                  Clinical evaluators believe the fourSight 4D       extremities of the fetus. She wanted to see
                  technology may be especially helpful in high       an orthopedic doctor before the birth of the
                  risk obstetrics because physicians can use it      baby. “We were able to show the orthopedic
                  to facilitate diagnosis of fetal malformations,    surgeon the anomalies in much better detail
                  such as cranio-facial abnormalities, and to        using fourSight 4D imaging, and we could
                  improve communication with neonatal spe-           talk about what they might need to correct
                  cialists and parents. Additionally, 4D imaging     after birth in much more detail versus dis-
                  may also provide physicians with a more            cussing the details while simply viewing a 2D
                  complete view of the uterus and breast, and        image,” says Dr. Sonek.
                  could be used during interventional proce-         At Miami Valley Hospital, Dr. Sonek and his
                  dures such as 4D needle-guided biopsies.           staff do not subscribe to the use of ultra-
                  Indeed, a sharper picture of a fetus is nice for   sound as entertainment, or unnecessary
                  expectant parents, but more importantly, it        medical exams for patients to determine the
                  serves as a powerful tool that can help phy-       sex of their unborn baby. It is the same for
                  sicians study the fetus’ motion and behavior,      Dr. Craparo and the department of Maternal
                  as well as its surface anatomy. Jiri D. Sonek,     Fetal Medicine at Abington Memorial Hospital.
                  M.D., RDMS, the medical director for the           But both colleagues agree there are definitely
                  Perinatal Ultrasound Department at the Miami       valid and exciting diagnostic uses for the new

64                                                                                                     MEDICAL SOLUTIONS RSNA 2004

             THE SONOLINE ANTARES ultrasound system provides best-in-class Doppler, 2D and 3D imaging, and
             for real-time premium performance 4D studies, new fourSIGHT 4D ultrasound imaging technology.

          technology when it is part of a premium          in 4D and reconstructed, physicians may be
          ultrasound system such as the Antares plat-      able to see more fetal activity, or certain
          form.                                            aspects not obtained in a 2D exam. Finally, as
                                                           genetic sonograms or expanded ultrasound
          Benefits for Physicians and                      exams that look for characteristics associated
          Patients                                         with chromosomal defects are requested
          In the future, physicians like Dr. Craparo and   prior to making a decision regarding amnio-
          Dr. Sonek believe 4D ultrasound will play an     centesis testing, 4D imaging can offer very
          even more important role in diagnostic ultra-    practical benefits to physicians and patients,
          sound. It may help to assess fetal well-being    and may make a significant difference in
          by allowing physicians to view movement          definitive diagnoses.
          and breathing more easily than with 2D.
          Additionally, in 2D imaging there are aspects    Author: Amy Cook is a freelance writer and a frequent
          of the fetus that cannot be seen, but if taken   contributor to Medical Solutions.

MEDICAL SOLUTIONS RSNA 2004                                                                                                     65
            IMAGING IN THE OR

     Notes from Two
     Physicians’ Practice
     A profile of ARCADIS Varic.
     Two doctors in a private practice in New York City
     speak out.
     By Mitchell Hovey Brock

                                Doctors Gene Meisenberg, M.D., and Michael      out glare.“ Doctor Kogan likes the size of the
                                Kogan, M.D., are physicians with private        screen: “I have been a pain management
                                practices at the Columbus Medical Institute     specialist for six years, and I have seen a lot
                                of New York, located in Rego Park, in the       of C-arms. The monitor is very big, which is
                                New York City borough of Queens. Dr.            unusual in a system of this size.”
                                Meisenberg, a urologist specializing in uro-    The procedures for which Dr. Meisenberg
                                dynamics, also works at the Cornell Medical     has used the ARCADIS Varic include video
                                Center, Long Island College Hospital, and       urodynamics, retrograde pyleograms, and
                                New York Methodist Hospital. Dr. Kogan is a     exchanging stents. The video urodynamic
                                pain management specialist and an assistant     images are so sharp that he sends all of his
                                professor at Amherst Hospital. They offer the   patients to the Columbus Medical Center.
                                readers of Medical Solutions several examples   With retrograde pyleograms, the maneuver-
                                of how ARCADIS® Varic works for them.           ability of the ARCADIS C-arm makes the
                                                                                presence of an assistant almost superfluous.
                                Image Quality in Diagnosis                      As for the exchanging of stents, the image
                                and Treatment                                   is considered to be so precise that the proce-
                                Both Dr. Meisenberg and Dr. Kogan have only     dure can be performed more quickly.
                                expresse praise for the image quality of the    In Dr. Kogan’s practice, he typically first takes
                                ARCADIS Varic’s dual 1024k x 1024k monitors.    an X-ray of the region he will administer
                                Says Meisenberg: “Quite honestly, the image     the injection, usually in the lumbar area.
                                quality of the system is excellent.” The flat   He explains: “For a selective neural block,
                                screen is important to him. “I am able to get   the image, rotated 45 degrees, shows me
                                viewing angles of almost 180 degrees with-      where to put the needle.” Prior to acquiring

66                                                                                                                  MEDICAL SOLUTIONS RSNA 2004
                                                                                                    IMAGING IN THE OR

               THE IMAGE QUALITY of ARCADIS Varic is excellent, according to doctors Meisenberg and Kogan.

MEDICAL SOLUTIONS RSNA 2004                                                                                             67

     PHYSICIANS Gene Meisenberg, M.D. (left), and Michael Kogan, M.D. (right),
     offer several examples of how ARCADIS Varic works for them.

                               the ARCADIS Varic, Dr. Kogan was intrigued        and proves his point by pushing the C-arm
                               to learn that it could produce three-dimen-       into place with his finger. He is also impressed
                               sional post-processed views based on two or       by the maneuverability of the monitor trolley.
                               more images of the same area. The system’s        Jokes Dr. Meisenberg: “I only wish it were
                               ability to take 15 images per second to           small enough to put in my car, so I could take
                               produce a real-time video interested him          it to the other places where I work.” In a more
                               less, although he saw its potential application   serious vein he adds, “I feel that it has the
                               in surgical procedures.                           best ergonomics of any instrument that I
                                                                                 have come across.”
                               Ergonomics and Design
                               ARCADIS Varic has a color-coded system to
                                                                                 User Interface and DICOM
                               ease the process of adjusting the position of
                               the X-ray tube. According to Dr. Meisenberg,      Dr. Meisenberg claims setting the right X-ray
                               the color coding was easy to understand:          level is simply a matter of pointing and clicking.
                               “I didn’t even attend the in-service session –    Selecting a “task card” in the user interface
                               my PA did. But I was still able to use it         automatically sets the machine to suit the
                               immediately. Very intuitive.” Dr. Kogan says      requirements of his specialty. After selecting
                               he found the C-arm so simple to manipulate        the appropriate “task card”, he clicks on an
                               that he could work alone, explaining, “It’s       icon of a human body called the Virtual Patient
                               very important for me to be able to work          Anatomy (VPA), choosing the body part he
                               without having to explain to an assistant         wants to x-ray. Accordingly, the VPA recali-
                               what to do. When you move the machine,            brates the dose of radiation to low, middle
                               it stays in place – it doesn’t rock,” he says,    or high. Denser areas like the pelvis or the

68                                                                                                                    MEDICAL SOLUTIONS RSNA 2004
                                                                                                                     IMAGING IN THE OR

          lumbar spine are automatically assigned the
          strongest dose, up to 2.3 kW. “This machine
          also works fine with obese patients,” ob-
          serves Meisenberg. Dr. Kogan is especially
          taken with the VPA: “I don’t even have to
          adjust the dose. The system does it for me.”
          Kogan has praise for the straightforward
          nature of the user interface: “The program is
          very familiar to anyone who uses Windows.”
          And Meisenberg observes that the point-
          and-click look and feel of the application
          made it very easy to pick up. “I am not very
          computer literate, but I had no problem. It
          seemed that there was no learning curve.
          The technology is changing so fast – it’s nice
          to have something that’s so easy to master.”
          He goes on to say that sharing the ARCADIS
          Varic with other specialists has not been diffi-
          cult, because it resets quickly, using the task
          card feature.
          The syngo® platform of ARCADIS Varic sup-
          ports a suite of functionalities beyond the
          VPA. Dr. Meisenberg often uses the Query/
          Retrieve function, which allows him to query
          the database on Columbus Medical’s LAN and
          retrieve images from it. Other functions got
          comparatively less usage or no usage at all.
          Neither doctor has tried printing or burning
          CDs from the image data bank. Says Meisen-                  EASY TO USE and small enough to fit in almost any size room:
          berg: “I have no reason to print out the                    the ARCADIS Varic C-arm.
          images, because I prefer to pick them up off
          of the network.” Dr. Kogan plans to use the
          printing function in the future, but the neces-
          sary printer has not yet been hooked up to
          the network.

          In Dr. Meisenberg’s experience, the workflow       once they enter the database archives. “I use
          from patient registration to examination           images from the network all the time. I can
          to archiving has always been transparent.          even log in from home or from another hos-
          “The secretary at the front desk registers the     pital.”
          patient information, and I get it off the net-     What makes the ARCADIS Varic so useful in
          work.” He appreciates ARCADIS Varic’s ability      Dr. Kogan’s private practice is the unit’s com-
          to post MRI and CT images from the data-           pactness and maneuverability. “You have to
          base. “Then I don’t have to waste time going       be in private practice a long time before you
          over to a light board,” he says. In his urologi-   have an office big enough for most C-arms,”
          cal practice, this is an important feature,        he says. “But seriously, this unit is very easy
          because radiolucent stones are visible only        to use and small enough to fit in almost any
          on a CT. Meisenberg had no complaints              Author: Mitchell Hovey Brock is a New York journalist
          about the quality of the ARCADIS’ images           specializing in technology and health-related topics.

MEDICAL SOLUTIONS RSNA 2004                                                                                                              69
            ONCOLOGY CARE

     Implementing Next-
     Generation Radiation
     Therapy Today
     The Department of Radiation Oncology at the
     David Geffen School of Medicine at UCLA opted
     for a complete radiation therapy solution from
     Siemens. UCLA staff share their criteria – and
     more importantly their vision.
     By Amy Cook
                            Imaging equipment is a very large capital          department of radiation oncology. Two of the
                            expenditure for any healthcare center,             ONCOR linear accelerators are now treating
                            whether it is a large university teaching insti-   patients, and the third is expected to be
                            tution or a community hospital. The imaging        installed and clinical before the end of this
                            technologies that make the most sense these        year.
                            days are the ones that enable the healthcare
                            center to streamline processes and work-
                                                                               Vision for Next-Generation
                            flow, allowing the center to maximize patient
                                                                               Radiotherapy Technologies
                            volume, schedule exams in a timely fashion,
                                                                               and Processes
                            improve patient throughput, and offer cen-         The search committee, charged with the task
                            tralized digital patient data input, review, and   of selecting new radiotherapy technology
                            reporting.                                         which would meet the demands of today’s
                            The Department of Radiation Oncology at            busy radiation oncology department and
                            the David Geffen School of Medicine at UCLA        have an upgrade path that will evolve in the
                            in Los Angeles, CA, replaced its existing linear   direction of future healthcare needs, created
                            accelerators after a thorough, 12-month search     a priority list of technology characteristics.
                            and selection process. Their overall goal was      These technology essentials included a next-
                            to equip the department with the latest            generation linear accelerator and Multileaf
                            in radiotherapy technology, and ensure a           Collimator (MLC) technology with accurate and
                            continuous upgrade path concurrent with            efficient Intensity-Modulated Radiotherapy
                            continued technology evolution.                    (IMRT) and motion compensation capabilities
                            In August 2003, the first of three Siemens         as well as a large format flat panel for elec-
                            ONCOR™ linear accelerators and the syngo®-         tronic portal imaging. Additionally, informa-
                            based COHERENCE™ Oncology Workspaces               tion technology systems that facilitated the
                            platform, including the LANTIS® Oncology           elimination of hard-copy patient records and
                            Information Management System, were suc-           films, including a record and verify system
                            cessfully installed in the healthcare center’s     that was powerful, expandable, and very

70                                                                                                               MEDICAL SOLUTIONS RSNA 2004
             DR. H. RODNEY WITHERS found that the Siemens solution fitted best to his medical center’s vision of healthcare.

          easy to use, were of paramount importance           reviewing would facilitate a paradigm in
          to the department. It was imperative that the       image-guided therapy, and in the greater
          department no longer be an isolated field or        diagnose, image, treat, and follow-up
          modality, but rather become integrated with         process.”
          the healthcare center’s diagnostic radiology        As a result, it was necessary for vendors to
          departments.                                        demonstrate core competencies in imaging,
          “Our fundamental requirement was equip-             and to formulate a vision for the next
          ment and processes that would serve our             generation of radiotherapy technologies and
          current and future needs,” says Timothy             processes. To improve overall workflow and
          D. Solberg, Ph.D., professor and vice chair,        patient treatment, this new technology
          Director of medical physics, Department             needed to be integrated with existing imag-
          of Radiation Oncology and a researcher at           ing technology throughout the institution,
          UCLA’s Jonsson Cancer Center. “Clearly IMRT         and with treatment-planning systems.
          was a primary clinical capability, and upgrade      The ONCOR linear accelerator is a key com-
          paths were essential as we could not afford         ponent in Siemens’ Oncology Workflow
          to go out and spend six million dollars every       Solutions portfolio and the COHERENCE
          three or four years as equipment evolved.           Suite of Oncology Workspaces. The linear
          Additionally, a key question we continually         accelerator brings together autosequencing
          asked during the vendor evaluation process          and OPTIFOCUS™ MLC with automated portal
          was whether or not the systems we were              imaging in order to provide maximum effi-

MEDICAL SOLUTIONS RSNA 2004                                                                                                    71
                                                                                           the department immediately adopted the
                                                                                           LANTIS system to integrate and consolidate
                                                                                           all the information critical to the delivery
                                                                                           of treatment to patients.
                                                                                           “We were able to start using the quality
                                                                                           checklists as a means of tracking the pro-
                                                                                           gress of patients through the process, which
                                                                                           immediately became invaluable to us. We
                                                                                           can track exactly where each patient is in his
                                                                                           or her process of treatment, and also prepare
           DANIELLE DI ANGELO, radiation technician, finds full digital integration
           of processes convenient.                                                        for the next step in a patient’s treatment well
                                                                                           in advance,” continues Solberg.
                                                                                           And, because of the electronic portal imaging
                                         ciency of treatment delivery. The technologies    capabilities, the department will be able
                                         are integrated with the COHERENCE Therapist       to completely replace film with electronic
                                         Workspace to optimize workflow by increas-        images. The requirement for staff to move
                                         ing treatment efficiency and overall quality.     and retrieve charts and images from one
                                         With the LANTIS Oncology Information              area to another, or “play messenger”, will be
                                         Management System, a patient’s entire therapy     eliminated. Dr. Solberg says the department
                                         process is centralized and data can be accessed   is also benefiting from cost savings in more
“From the overall perspec-               easily. This provides therapists and caregivers   tangible items as well, including reduced
                                         with full digital integration of information      material costs in charts, film, and other
tive of providing the patient
                                         management, imaging, treatment, and follow-       supplies.
with high-quality, tech-                 up processes, with the results empowering
                                         all members of the oncology team to set a
                                                                                           Improving Treatment Delivery
nologically sophisticated                new standard in the delivery of oncology care.    With the many requirements of maintaining
                                                                                           a busy cancer center while providing very
medical care, the total                  syngo Addresses Digital Data                      precise and complex treatments, the depart-
Siemens concept will link
                                         Eruption                                          ment’s cutting-edge equipment also means
                                         All of these new developments have led to         that patients are treated more rapidly, and
a versatile range of infor-              an eruption of digital data and images that       with less inconvenience. The new innovations
                                         must be managed and made useful for every         of the ONCOR linear accelerator enable thera-
mation and imaging facili-
                                         step in the process – from imaging to plan-       pists to efficiently deliver treatment while
ties distributed across                  ning, simulating, verifying, and delivering       patient safety is enhanced simultaneously.
                                         treatments to patients. To help address           “Since two of the three ONCOR Linear
the medical center with a                technology integration, Siemens’ common           Accelerators have been clinical, there are
cutting-edge radiation                   workstation interface, syngo, is built into the   many features that have improved treatment
                                         imaging product lines and integrates existing     delivery, especially the auto-sequencing,”
therapy capacity, ensuring               networks and hospital information systems.        says Ruben Gomez, chief therapist, Depart-
                                         “The syngo platform is crucial to the future      ment of Radiation Oncology. “Because it
efficient and effective care             of the radiotherapy process because it opens      automatically delivers the treatments, there
for people with cancer.”                 up so many opportunities,” comments Dr.           is no need to repeatedly pause the machine
                                         Solberg. “The crucial missing link at present     to go in and move the gantry into a different
H. Rodney Withers, M.D., D.Sc.,          is how one uses images to adapt therapy.          position. Additionally, we no longer need to
                                         This is a software-driven process that syngo      go in and get the X-ray, then turn around and
professor and chair,
                                         is best suited to facilitate.”                    go back out again. This has resulted in great
Department of Radiation Oncology,                                                          time savings for us.”
                                         Optimizing Workflow                               According to Gomez, all of these benefits will
UCLA, researcher,
                                         After the first ONCOR treatment delivery          really translate into more time available to
UCLA’s Jonsson Cancer Center             system became clinical in October 2003,           spend with patients and less time setting up or

72                                                                                                                            MEDICAL SOLUTIONS RSNA 2004
          monitoring the process. Because of its speed,
          ease, and precision, IMRT will be routine for
          the cancer center, and the radiation oncology
          staff will be able to treat a wider base of
          patients more quickly and efficiently with the
          new ONCOR systems.

          Grander Picture for the
          Healthcare System
          For H. Rodney Withers, M.D., D.Sc., professor
          and chair, Department of Radiation Oncology,
          the decision to go with Siemens radiation
          therapy technology entailed a critical look at
          future needs. With Siemens, not only does
          the treatment technology complement the
          direction of the medical center’s vision for
          healthcare, but the syngo-based COHERENCE
          Oncology Workspaces and information tech-
          nology help streamline processes and optimize
          workflows, which are increasingly relevant
          His view is one of a grander picture for
                                                                 TIMOTHY D. SOLBERG, PH.D., Director of Medical Physics at UCLA,
          the healthcare system and what the future
                                                                 wanted equipment that would serve current and future needs.
          will bring. “Once the three Siemens ONCOR
          Linear Accelerators, the syngo-based work-
          spaces, and information management are
          all up and running, the department will
          be able to very quickly and efficiently coordi-
                                                             The David Geffen School of
          nate all of the aspects involved in treating
                                                             Medicine at UCLA
          cancer patients with radiation,” comments          People who come to UCLA for cancer care
          Dr. Withers.                                       benefit from the most advanced forms of
          And he continues, “from the overall perspec-       therapy available, and from a variety of
          tive of providing the patient with high-quality,   supportive services. UCLA’s Jonsson Cancer
          technologically sophisticated medical care,        Center has been designated a “comprehen-
          the total Siemens concept will link a versatile    sive cancer center” by the National Cancer
          range of information and imaging facilities        Institute in recognition of its exemplary inter-
          distributed across the medical center with a       disciplinary programs and in cancer research,
          cutting-edge radiation therapy capacity,           patient care, professional education and
          ensuring efficient and effective care for          community outreach in cancer prevention.
          people with cancer.”                               According to a 2004 US News and World
          With the integrated Siemens oncology               Report survey, the UCLA Medical Center is
          solution, an easy-to-use and comprehensive         considered the best healthcare center in the
          system throughout the healthcare center            Western United States and was ranked fifth
          has freed up radiotherapy staff to streamline      overall in the nation. US News also ranked
          and refine processes. Workflow, as a result,       the Jonsson Cancer Center the best cancer
          is optimized and, most importantly, patient        center in the Western United States for the
          treatment is improved on all levels. The Depart-   fifth consecutive year. The David Geffen
          ment of Radiation Oncology is already reaping      School of Medicine at UCLA is considered
          the benefits of improved efficiencies in work-     one of the nation’s elite medical schools, and
          flow and patient treatment.                        among the best in the world.

MEDICAL SOLUTIONS RSNA 2004                                                                                                        73
                                                                                                      POSITRON EMISSION TOMOGRAPHY

          Painting a Picture of
          Alzheimer’s Disease
          It has been said many times that a picture is
          worth a thousand words, and in the diagnosis of
          Alzheimer’s disease that saying rings especially
          true. PET images of the brain’s function can
          indicate a diagnosis of this progressive disease
          earlier and more reliably than any other method.
          By Dr. Joanna B. Downer

          Until recently, Alzheimer’s disease was barely    ity at these stages than other methods.“
          diagnosed at all – some cognitive tests, done     PET with FDG has a sensitivity of about 96
          by the right people, could suggest someone        percent and a specificity of 100 percent
          was suffering from Alzheimer’s disease, but       when patients have questionable results
          the only surefire diagnostic criteria were the    on clinical diagnostic criteria, Carlisle says,
          presence of beta-amyloid plaques and neuro-       although single-baseline PET has been
          fibrillary tangles in the brain at autopsy.       reported to have a specificity of roughly 73
          But now, ever more commonly, images pro-          to 78 percent. In contrast, clinical diagnosis
          vided by Positron Emission Tomography (PET)       via cognitive testing and related methods is
          of the brain’s uptake of F-18 fluorodeoxyglu-     reported to have a sensitivity of 83 to 85
          cose (FDG) are being used to reveal meta-         percent and a specificity of only 50 to 55
          bolic changes characteristic of Alzheimer’s       percent. And it’s nearly impossible for
          disease even before clinical symptoms             clinical or neuropsychological testing alone
          become significant. Images showing low            to determine whose mild cognitive impair-
          metabolic activity in the posterior parietal      ment is really prodromal Alzheimer’s and
          and posterior temporal lobes can indicate         whose is not – information critical for proper
          that mild cognitive impairment is in fact         application of drugs to fight Alzheimer’s.
          early Alzheimer’s, also known as prodromal
                                                            A Picture of Progress
          “You have to diagnose Alzheimer’s in the early    PET for Alzheimer’s diagnosis has been avail-
          stages because that’s when you can do the         able in certain circles for ten to twelve years.
          most good with today’s drugs,“ says Marie         For example, the NCPIC’s eightieth patient,
          Carlisle, M.D., Ph.D., and comedical director     imaged on a Siemens PET scanner twelve
          of the Northern California PET Imaging            years ago, had Alzheimer’s and a strikingly
          Center (NCPIC) in Sacramento, California.         abnormal FDG image. But only very recently
          “PET has far superior sensitivity and specific-   has FDG-PET been accepted as a tool for

MEDICAL SOLUTIONS RSNA 2004                                                                                                          75

      IMAGES SHOWING low metabolic activity in the posterior parietal and posterial temporal lobes.

     diagnosing Alzheimer’s disease in the United      tage of everything PET can provide for
     States. Insurance companies’ coverage is in-      Alzheimer’s diagnosis – especially seeing
     creasing. The federal government has recently     that four million Americans are affected by
     adopted limited coverage guidelines for           Alzheimer’s now, but if prevention doesn’t
     Medicare, the health care reimbursement           improve, the Alzheimer’s Association says
     program that benefits Americans over the age      7.7 million Americans will likely have Alz-
     of 65. In September 2004, the Centers for         heimer’s by 2030 as the “baby boomers“
     Medicare and Medicaid Services approved           surpass age 65. As it stands, Medicare will
     Medicare coverage of FDG-PET for selected         reimburse for patients whose symptoms
     patients whose cognitive and neuropsycho-         are not the usual battery of memory and
     logical tests point to a possible, but incon-     cognitive problems, but that instead overlap
     clusive, Alzheimer’s diagnosis.                   with those more typical of front-temporal
     While it’s a critical development, the federal    dementia. Medicare reimbursement of FDG-
     reimbursement program isn’t taking advan-         PET for Alzheimer’s, then, would generally

76                                                                                                    MEDICAL SOLUTIONS RSNA 2004
                                                                                                                     POSITRON EMISSION TOMOGRAPHY

                       QUANTITATIVE tools to evaluate brain function.

          apply to patients whose symptoms are                             list of the nation’s top killers – as they’ve
          primarily behavioral rather than cognitive.                      addressed the top two causes of death in
          “The pattern of FDG uptake in Alzheimer’s                        the United States.
          disease is very different from the pattern                       “For cancer and cardiovascular disease, there
          of uptake in frontal lobe dementia – the                         has been great progress in advancing early
          reduced uptake in Alzheimer’s is posterior,                      diagnosis, offering preventive strategies and
          while that in frontal lobe dementia is anterior,“                developing effective treatments. We were not
          notes Elma Abella, M.D., comedical director                      able to do as much for dementia, and our
          of NCPIC. “So it’s a fairly straightforward                      future is fairly obvious if nothing changes –
          distinction,“ she adds.                                          we’re going to live longer and die demented,“
          While many clinicians waited for Medicare                        says Jorge R. Barrio, Ph.D., a professor of
          coverage, researchers have been using FDG-                       molecular and medical pharmacology at the
          PET to capture in “pictures“ the natural history                 University of California in Los Angeles (UCLA).
          of Alzheimer’s disease and mild cognitive                        “There are still many things we don’t know
          impairment. High-resolution PET scanners,                        about Alzheimer’s, but it can be predicted that
          such as those using Siemens LSO HI-REZ                           a better understanding of food constituents,
          detector technology, allow ever more precise                     anti-inflammatory drugs and (future) devel-
          localization of FDG and experimental tracers                     opment of antiaggregation drugs will help
          in the brain. Studies have been conducted,                       us prevent or slow down progression of the
          for example, at the Duke Evidence-based                          disease.“
          Practice Center in 2001*, to determine the
          effectiveness of PET in the diagnosis and
                                                                           A Picture of the Possibilities
          management of Alzheimer’s disease and                            And PET isn’t just helping doctors diagnose
          dementia. The knowledge gained from this                         Alzheimer’s disease, it’s actually helping
          and other studies will help researchers begin                    researchers identify and improve strategies
          to address Alzheimer’s – number 7 on the                         to prevent and treat the disease. In the
          Center for Disease Control and Prevention’s                      experimental arena, researchers are testing
                                                                           radiolabeled compounds that actually reveal
        * “Use of Positron Emission Tomography and other neuroimaging      the presence and number of plaques and
          techniques in the diagnosis and management of Alzheimer’s
          disease and dementia“, December 14 2001                          tangles in a living person’s brain, offering the
          Prepared for the Agency for Healthcare Research and Quality by
          David B. Matchar, M.D.                                           chance to identify the disease even before

MEDICAL SOLUTIONS RSNA 2004                                                                                                                         77

                                                                                    action for nonsteroidal anti-inflammatories
                                                                                    other than their intrinsic anti-inflammatory
                                                                                    properties. F-18 FDDNP could eventually pro-
                                                                                    vide even earlier diagnoses of Alzheimer’s
                                                                                    disease in populations at particular risk, too.
                                                                                    “We’re thinking ahead. We’re thinking about
                                                                                    being able to identify the very earliest stages
                                                                                    of Alzheimer’s disease, before pathology
                                                                                    can cause neuronal death and well before
                                                                                    neuronal death can cause symptoms,“ says
                                                                                    Barrio. “But we studied FDG in Alzheimer’s
                                                                                    for 25 years and just got Medicare approval,
                                                                                    so we expect it will be some time before we
                                                                                    really know what role FDDNP and other
                                                                                    radiotracers will have in Alzheimer’s disease.“
                                                                                    PET with FDG and perhaps newer tracers will
                                                                                    be quite important in evaluating new treat-
                                                                                    ments for a disease whose course can run
                                                                                    for decades, which makes prospective, longi-
            POSTERIOR view demonstrates reduced uptake of FDG.
                                                                                    tudinal studies of a potential drug’s effects
                                                                                    and benefits daunting. “PET gives you an
                                                                                    earlier chance to see what’s happening,“
                                   neurons die, track plaques and tangles as        says Abella of NCPIC. “Are there changes in
                                   brain function declines, and determine           uptake of FDG after giving the drug? Are the
                                   how treatments affect these harbingers of        changes taking place because the patient
                                   destruction.                                     has clinically improved? Is hypometabolism
                                   So far, the Food and Drug Administration         of the posterior parietal or posterior temporal
                                   has approved only two classes of drugs for       lobe improving, is it changing, is it staying
                                   Alzheimer’s, and both provide the most           the same? With the medication, does the
                                   benefit when started as early in the course      brain continue to deteriorate, does the dete-
                                   of the disease as possible. Around the           rioration stop, or does it even get better?“
                                   world, scientists are evaluating the abilities   Carlisle adds: “There will definitely be more
                                   of new agents, and even existing drugs,          studies using PET as insurance coverage
                                   to help prevent the buildup of plaques           increases and as people become more
                                   and tangles, “dissolve“ them once they are       aware of the value of PET in diagnosing
                                   present, or keep them from killing neurons.      Alzheimer’s. A lot of people have heard of
                                   Experimental PET radiotracers such as            PET, mostly for applications in cancer, but we
                                   F-18 FDDNP, or 2-(1-{6-[(2-[F-18]fluoroethyl)    still have a long way to go in educating
                                   (methyl) amino]-2-naphthyl} ethylidene)          patients and physicians about the ability
                                   malonitrile, both developed at UCLA, can         of PET to quickly and accurately diagnose
                                   help measure those agents’ effects and           Alzheimer’s disease.“
                                   reveal how they work.                            With PET imaging to diagnose the disease
                                   For example, Barrio and his colleagues           as early as possible and to help develop
                                   reported last year that two over-the-counter     and evaluate new drugs, the future of
                                   pain relievers, Ibuprofen and Naproxen, bind     Alzheimer’s disease is likely to shift from
                                   to plaques at the same active site as FDDNP      a picture of inevitable decline to one of
                                   and showed that all three compounds              promise and hope.
                                   prevent or reduce aggregation of plaques in
                                                                                    Author: Joanna B. Downer, Ph.D., a science writer living
                                   laboratory experiments. Their work suggests      in Baltimore, MA, holds a doctorate in nuclear chemistry
                                   a potential neuroprotective mechanism of         from Washington University in St. Louis.

78                                                                                                                           MEDICAL SOLUTIONS RSNA 2004

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