September 2023 Ebrief

Radiomics- Beyond Imaging….

Radiation Oncology and Radiology share a fascinating history, from Roentgen to Marie Curie to the orthovoltage, megavoltage era when the first treating radiation oncologists were in fact radiologists.

It is fascinating how as the fields diverged, radiology continues to play an important role in oncology and will continue to be the cornerstone of oncology management decisions. Radiological imaging has long been an important tool to aid in clinical decision making. This role is rapidly evolving from being a diagnostic tool to playing a central role in personalized medicine, most notably cancer.Radiomics is the bridge between imaging and clinical decision making. Radiomics is a field combining computer science, artificial intelligence, and radiology to enhance the precision of medical imaging. Data is obtained by extracting many numerical attributes from radiographic medical images. These numerical radiomics data can reveal disease attributes invisible to the naked eye. For example, a multislice image of a patient contains millions of voxels. In addition, a tumor is expressed with hundreds of features that define the tumor’s structure, size, shape, and textures. Radiomics attempts to combine this data to a clinical outcome. When this process is applied, medical images are converted into a high dimensional mineable space.

This leads to the determination of subtype and genotype of tumors with the use of radiomics. The application has important advances in histopathological diagnoses because they are non-invasive and obtain information from the entire tissue. In oncology, radiomics has shown great potential for the characterization and clinical monitoring of various disease including brain tumors, breast cancer, and prostate cancer. Examples of this exciting work include using a trained DL network to predict response of brain mets after stereotactic radiotherapy and differentiation of radionecrosis from tumor progression following treatment. Early success of radiomics has been observed in the setting of tumors being treated with immunotherapy. For example, radiomic signatures that correlate with tumor infiltration of lymphocytes or that predict benefit from immunotherapy have been described. This allows medical imaging to provide diagnostic and prognostic data and potentially identify patients that would benefit from therapy. As radiomics becomes increasingly more important, there has been an explosion of medical imaging data. There are many challenges that need to be faced including large-scale data sharing to validate findings. In addition, standardization of data collection, evaluation criteria and reporting guidelines will be necessary as the field of radiomics progresses. 

The NIH has released a new dataset that could provide insights for radiology researchers. The dataset standardizes genomic, proteomic, imaging, and clinical data from individual studies of more than 1,000 tumors across 10 disease sites. This imaging and clinical data could depict patterns in tumor development, growth, and location. This data set generated at the NCI is a publicly available resource. Click Here 

Radiology and radiation oncology share history and with future “omics” research, will share an incredible future with improved diagnostics leading to personalized precision therapies.
 

Remote MRI – Are We There Yet?

As we navigate the post-COVID waters of a “return to normal” mentality, one thing is for certain; the definition of normal has evolved.  Prior to 2020, the footprint of home delivery for everything from groceries to telehealth was not widely adapted. Since that time; however, many people now consider Door Dash, Uber Eats, and Instacart part of their daily routine. Front porches appear awkwardly out of place if there are no Amazon boxes piled next to the door.  From a healthcare perspective, the option to see your provider in-person or via zoom is now commonplace and gaining in popularity.  The option to work remotely from home has transitioned from an employment perk to a job search requirement, particularly from the standpoint of a generation raised with online learning, socialization, and the awareness that everything can be done from the comfort of your couch.    

During the pandemic, we made arrangements for many non-patient-facing positions to continue their roles remotely.  Some of these roles continue today as hybrid positions with the ability to work remotely as needed.  The only area seemingly tied to the traditional workplace are those individuals who work directly with the patients performing their diagnostic imaging, our technologists. This too, however, is now becoming blurry with the evolution and growing momentum of remote scanning in radiology.  The primary modality gaining in popularity for this shift in health care delivery is MRI.  

What does remote scanning in MRI entail and why are organizations leaning towards this evolving trend? With continued reimbursement cuts and escalating staffing costs, businesses are faced with the challenge of increasing efficiency and throughput to offset their declining collections. Maximizing schedules and capacity of equipment carrying price tags in the millions must be a focus for any imaging department or center to survive and thrive.  The simple answer, extend hours and days of operation. A solution that provides improved access to care for our patients and increased contribution to the bottom line.   The simple answer, however, is not so simple as it relies on a critical variable in order to succeed; the availability of technical staff to perform the studies during these expanded hours.  It is already difficult to hire and retain quality technologists during a time when competitors are throwing pay scales out the window and traveling companies are offering the ultimate carrot of “discovering the world while making big money”.  The prospect of adding additional afterhours and weekend shifts is one that must be carefully planned and often not feasible for a staff that is already pushed to their limits with add-on patients, overtime and callouts. Enter in the possibility of remote scanning. 

Remote scanning allows a technologist to scan a patient from a different location than the scanner itself. The patient is screened, prepped and positioned by an ancillary staff member trained in MRI and patient safety.  The software required for remote scanning is already offered by companies such as Siemens and Philips to provide oversight and operation of their equipment. The remote scanning can be performed from an alternate location or fully remote, providing greater patient access without the limitation of onsite technologist availability. This capability, like teleradiology, can remove the 24/7 staffing constraints along with the geographic barriers common in rural areas. It can also allow for more advanced studies to be performed by quality technologists who are specialty trained, broadening the offerings for our patients. 

Considerations for implementing this type of program are significant. The greatest limiting factor that seems to be keeping the process from moving at break-neck speed is patient safety and quality of care. An organization interested in implementing a remote MRI platform must take the time to develop a comprehensive plan that documents all policies and procedures necessary to insure our patients’ well-being.  The most common question and area of concern is determining who the individual will be assisting the patient while the technologist is remote.  Whether this is a technologist assistant, medical assistant, nurse or another technologist, clear expectations for training and responsibilities of the attending staff are crucial.  Although we all have safety protocols for contrast reactions, emergency responses and MRI specific shutdowns and quenches, it is important to address these protocols within the context of remote scanning.  The timing for pre-screening patients who are scheduled for after hour or weekend scans along with determinations for contrast use must also be considered.  As with other remote processes, back-up staffing and procedures need to be put in place in the event there is a connectivity failure for the remote technologists. 

Remote scanning has arrived in Florida for our MRI patients. For anyone who is considering implementing a program, great care must be taken to ensure that the level of safety and quality oversight is exceptionally high.  As our equipment manufacturers become more sophisticated in their offerings, the appeal for being able to provide MRI service to our patients with less constraints on on-site staffing will certainly grow and the landscape of this service line will evolve. 

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