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ARDMS Headlines:
Spotlight on a Sonographer: Pat Grier, RDMS, RT
Headlines in the News:
New Type of Ultrasound Might Substitute for Some Biopsies
A technique called elastography is being tested that can distinguish between malignant and benign tissue without using a needle or scalpel...
The study found that the groundbreaking technology used in TechniScan's Warm Bath Ultrasound (WBU) produced promising results and indicated that it may have a future role in the evaluation of breast lesions...
Low Cancer Risk with Septated Ovarian Tumors
Septated ovarian tumors have a low risk of malignancy and can be followed safely with ultrasound...
Ultrasound Performs Solidly in Superficial Masses
Ultrasound can accurately evaluate superficial soft-tissue masses...
Spotlight on a Sonographer: Pat Grier
ARDMS Registrant: Pat Grier, RDMS, RT
ARDMS Registrant Since: 1992
Current Position: Lead Exam Clinical Specialist at ARDMS
 If this issue’s Spotlight Sonographer seems familiar to you, that is because you may have seen her picture in ARDMS’s publications such as the application booklet, the How to
Apply Guides, on the ARDMS booth, and many more!
Pat Grier joined the ARDMS staff in 2006. Since then, she has been an integral part of the Testing Department. “The clinical expertise that Pat brings to the ARDMS Testing Department allows us to continue our path of rigorous quality assurance for our credentials,” said ARDMS CEO and Executive Director, Dale R. Cyr. Ms. Grier, a graduate of the Johns Hopkins Hospital School of Radiologic Technology in Baltimore, Maryland and Thomas Jefferson University in Philadelphia, Pennsylvania, joined ARDMS with more than 20 years of diagnostic imaging experience.
Previously, Ms. Grier held supervisory and senior‐level positions at Johns Hopkins Hospital, Johns Hopkins Health Plan, Sinai Hospital, and Siemens Medical Systems. While at ARDMS, Pat works closely with the clinical subject matter experts who develop and oversee ARDMS examinations. One of her many responsibilities include working with the Exam Development Task Force members in developing the extensive and detailed Job Task Analysis surveys that are sent to a representative sample of medical practitioners to determine the frequency and importance of tasks performed for a particular sonography discipline.
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New Type of Ultrasound Might Substitute for Some Biopsies
A technique called elastography is being tested that can distinguish between malignant and benign tissue without using a needle or scalpel...
Every year in the United States, more than 5 million biopsies are performed on suspicious tissue from all parts of the body, primarily to detect cancer. Biopsies are most commonly done by taking a tissue sample for lab analysis using a needle, and remain the best test for diagnosing and staging cancer.
But biopsies are not without risk: They can cause infection, major blood vessels can be punctured, untargeted organs can be injured. And they are expensive: from $135 and up for suspicious skin growths to $1,950 for the liver and $4,500 for the prostate. As of now, up to 80 percent of biopsied tissue proves to be benign. Now, a technique called elastography is being tested that can distinguish between malignant and benign tissue without using a needle or scalpel.
Elastography produces an image of tissue that has been compressed: Healthy tissue compresses more readily than cancerous tissue. The technique is sufficiently promising for the major medical equipment manufacturers -- GE, Siemens, Hitachi, Aloka -- to be investing large sums in the technology.
Elastography is based on ultrasound, which employs the principle that high-frequency sound waves travel through different parts of the body at different speeds. In diagnostic ultrasound, doctors place a hand-held device, called a transducer, on a specific part of the body. The transducer broadcasts sound waves and receives waves reflected back to it by tissue it cannot penetrate. These reflected waves are processed into an image, which is projected onto a monitor.
Unlike X-ray, CT and MRI images, which are produced according to preset protocols, ultrasound images are heavily dependent on the talents of the administering doctor or technician. A judicious twist of the transducer or a subtle increase in finger pressure can turn a blurry, inconclusive image into a definitive diagnosis. Performing an ultrasound scan is much like playing a musical instrument.
Better pictures
Elastography provides two basic add-ons to basic ultrasound: It uses software that produces pictures that enhance the edges and texture of a tumor; and, in advanced elastography systems, it uses sophisticated transducers that further improve the visibility of the tumor and provide data to measure tissue stiffness.
With first-generation elastography machines, dating to around 2000, diagnosticians could measure tumor stiffness by applying hand pressure to the transducer to compress the organ. (In a standard ultrasound exam, there is no application of pressure.) This resulted in significantly variable results from examiner to examiner. In recent months, second-generation systems have been developed in which the sound waves rather than the human hand compress the organ, thereby minimizing the human factor. This second-generation technique is known as ARFI (acoustic radiation force impulse).
Elastograms of the suspected tumor are compared with images taken via standard ultrasound. When malignant tissue is present, it will appear larger in the elastogram than in the standard image. (This is because elastography can detect and project the dense, fibrous tissue that grows around malignant tumors, making the tumor appear larger.) Tumor shapes are irregular and hard to measure; second-generation elastography provides tools to make more accurate computations than human estimates can provide.
Aiming for accuracy
Since organs at or near the body's surface are easier to image with ultrasound, most research using elastography has focused on the skin, breast and thyroid.
Stamatia V. Destounis, a radiologist at Elizabeth Wende Breast Care, an imaging center in Rochester, N.Y., estimates that breast radiologists will be able to begin passing up biopsies based on elastography within four to five years. Her ongoing research shows 98 percent accuracy (58 of 59 cases) in predicting malignant breast tumors, but only 78 percent accuracy (54 of 69 cases) in predicting non-malignant tumors. All of these cases were confirmed by biopsy. Thus, had elastography findings alone been used to determine which patients would receive biopsies, 15 would have received biopsies unnecessarily and one patient who had breast cancer would have gone untreated. For elastography to become widely accepted as the final arbiter of which patients will receive biopsies, such false negatives must approach zero.
At the Radiological Society of North America meeting in December, Bahar Dasgeb, a Wayne State University dermatologist who is also board-certified in radiology, and Eliot Siegel, a University of Maryland radiologist, presented a paper reporting an ability to differentiate with almost 100 percent accuracy between malignant skin cancers and benign conditions of the skin. But because skin is so easy to biopsy and few dermatology practices have ultrasound expertise, elastography is unlikely to reduce the number of skin biopsies.
Where elastography is likely to be most useful in skin therapy, Dasgeb said in her presentation is in streamlining Mohs surgery, a common procedure that removes successive amounts of skin until abnormal tissue is no longer visible under the microscope. Mohs surgery for a simple tumor can take up a good part of a patient's day, with most of the time spent waiting for lab results. With elastography, the surgeon can get an immediate view of how much skin to remove, shortening the procedure and avoiding disfiguring results that require complicated reconstructive surgery.
The thyroid gland, a common site for cancer, illustrates some of the pitfalls in elastography. Although easily accessible from the patient's neck, the thyroid sits adjacent to the trachea and the common carotid artery. Because both of these are harder than a thyroid tumor, false negatives often result when the gland is imaged using elastography. This same limitation arises when a tumor is located next to bone.
Doctors say second-generation elastography will prove particularly useful in treating such internal organs as the liver, lungs, prostate and kidneys. Duan Li, an ultrasound specialist and interventional radiologist at Memorial Sloan-Kettering Cancer Center in New York, noted that, in addition to avoiding biopsies of the deep organs, elastography can guide the surgeon to be more precise in removing cancerous tissue.
Li said that elastography can also be helpful in determining how much cancerous tissue remains after tumor ablation. A problem with ablation -- a procedure in which heat or extreme cold are administered to the tumor to kill it -- is that the doctor often is not sure how much of the tumor has been killed. "Elastography can provide immediate answers," Li said.
Article written by staff at washingtonpost.com and adapted for the purposes of this newsletter.
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Groundbreaking Whole Breast, Warm Bath Ultrasound Technology is Producing Promising Results
The study found that the groundbreaking technology used in TechniScan's Warm Bath Ultrasound (WBU) produced promising results and indicated that it may have a future role in the evaluation of breast lesions...
TechniScan, Inc.'s unique whole breast ultrasound technology, which provides a comfortable, radiation-free method for assessment of breast lesions was part of a scientific presentation at the National Consortium of Breast Centers (NCBC) conference.
Yuri Parisky, radiologist, vice president and trustee of the NCBC organization and consultant to TechniScan, Inc. participated in the Orange County, CA research study that was presented at the conference. The objective of the study was to determine the usability of the new Warm Bath Ultrasound (TM) technology in a standard breast diagnostic practice. The study found that the groundbreaking technology used in TechniScan's Warm Bath Ultrasound (WBU) produced promising results and indicated that it may have a future role in the evaluation of breast lesions.
"Ultrasound technology is playing a larger role in breast diagnostics because it images cysts, fibroadenomas and cancers differently than mammography. Ultrasound is much better at seeing through dense breasts and finding cancers when they are smaller," said Parisky. "The emergence of whole breast ultrasound technology and specifically the WBU system is providing us with 3-D images of the entire breast, and will hopefully become a standard imaging modality in the next few years."
TechniScan's Warm Bath Ultrasound system is designed to capture three-dimensional images of the breast as a woman lies prone on a table and state-of-the art ultrasound technology is used in a warm water tank to capture images of the breast anatomy.
The company's science is revolutionary since it is the first high-resolution, 3-D system to deliver quantitative data. The WBU system uses traditional reflection imaging, but uniquely, it also measures the speed of sound and attenuation as sound waves travel through the breast.
At the breast center conference in Las Vegas on March 21, Parisky presented the clinical experience using TechniScan's whole breast ultrasound system. He explained that of the 34 patients participating in the study at the Breast Care and Imaging Center of Orange County, there were 14 cases with cysts, one case of silicone granulomas from a breast implant, 14 benign masses and eight biopsy-confirmed malignancies. The Warm Bath Ultrasound images were able to provide 3-D visualization of lesion location within the breast.
The study also found that the WBU scanning system was easy to use and required minimal training. A sonographer is not necessary to administer the scan since the system is automated. Additionally the scans were quick (approximately 12 minutes per breast) and required no breast compression.
"The WBU system was clearly able to distinguish between fibroglandular and other complex structures within the breast. Combined, the speed of sound, reflection and attenuation images are expected to improve 3-D visualization and improve specificity of breast lesions," said Parisky.
The future for whole breast ultrasound is encouraging. The radiologist panel at the Emerging Technologies Lecture at NCBC acknowledged that ultrasound paired with mammography is finding more cancers than mammography alone and 3-D imaging provides greater insight into the breast anatomy.
"We expect whole breast ultrasound will become a widely adopted modality for 3-D breast imaging in the coming years as radiologists begin to recognize the ease of use and imaging capabilities of automated breast ultrasound systems. We believe that our whole breast ultrasound will be competitive with technologies like breast MRI, and study after study is validating that ultrasound is finding cancers that mammography alone can't image," said Dave Robinson, chief executive officer at TechniScan.
Article written by staff at prnewswire.com and adapted for the purposes of this newsletter.
Low Cancer Risk with Septated Ovarian Tumors
Septated ovarian tumors have a low risk of malignancy and can be followed safely with ultrasound...
Septated ovarian tumors have a low risk of malignancy and can be followed safely with ultrasound, data from a large prospective cohort study showed. During a median follow-up of more than five years, one patient of 1,191 with persisting septated ovarian tumors developed ovarian cancer, and that lesion arose in the contralateral ovary.
Among 30,000 patients involved in the screening study, surgery led to removal of about 500 ovarian lesions, more than 90% of which proved to benign.
"The risk of malignancy in complex ovarian tumors with septations but without solid areas or papillary projections is extremely low," Brook Saunders, MD, of the University of Tennessee in Knoxville, said at the Society of Gynecologic Oncologists meeting. "Patients with these tumors can be followed sonographically without surgery." Among gynecologic malignancies, ovarian cancer has the highest mortality, and in most cases, diagnosis occurs in late stages. Earlier diagnosis could have a major impact on morbidity and mortality associated with ovarian cancer, but clinical signs and symptoms do no appear until late. Transvaginal ultrasound (TVS) has been evaluated as a means of achieving earlier diagnosis and distinguishing between benign and malignant lesions.
Saunders and colleagues recently reported that the combination of TVS and symptoms had poor sensitivity for detecting malignancies, but had a 98% specificity, reflecting accuracy for detecting benign ovarian lesions (Cancer 2009; 115: 3606-08).
So the researchers extended the assessment of TVS to septated cystic ovarian tumors, believed to have greater malignant potential than simple cysts. To that end, they analyzed records from a database at the University of Kentucky in Lexington, where a TVS screening program has enrolled 30,000 since 1987.
Participants in the screening program have annual TVS. For women who have persisting septated ovarian tumors, the screening interval is shortened to every four to six months.
Saunders reported findings for 1,319 patients who had 2,870 complex cystic ovarian tumors with septations detected by TVS. Subsequently, 1,114 (39%) of the tumors resolved spontaneously, and 1,756 (61%) persisted. He said that 1,191 women with persistent tumors agreed to defer surgery and continue follow-up with TVS.
One patient developed a papillary projection in the contralateral ovary 3.2 years after diagnosis of a septated cystic lesion. Histologic evaluation showed the contralateral lesion to be ovarian adenocarcinoma. The remaining 1,190 patients remained free of cancer during 7,642 patient/years of follow-up.
In the total screened population, 492 ovarian tumors have been removed surgically, and 62 of those proved to be malignancies or tumors with borderline malignancy characteristics. The remaining 430 tumors were benign, resulting in a positive predictive value of 12.6%, increasing to 22.3% if unilocular cystic and septated tumors were not removed but followed with TVS.
The Kentucky screening program has been instrumental in changing the clinical management of incidentally found adnexal masses, Susan C. Modesitt, MD, of the University of Virginia in Charlottesville, said during an invited discussion of Saunders' presentation. Its findings contributed to the introduction of the morphology index in the 1990s, confirmed the benign nature of simple postmenopausal cysts, and led to elimination of septations as an independent prognostic factor in the morphology index.
The latest data from the screening program confirm the benign nature of isolated septated tumors, said Modesitt. Saunders' data also showed that a malignancy was detected for every eight tumors that were surgically removed, a much lower ratio than seen in other large cohort studies. Those notably included the NCI-sponsored Prostate, Lung, Colorectal, and Ovarian (PLCO) screening trial, which had a ratio of 19.5:1. Modesitt asked whether investigators in the screening program had an explanation for the surgical efficiency. Saunders pointed out that the PLCO was a multicenter study, involving different surgeons, radiologists, and ultrasound technicians, all of whom could have contributed to the higher ratio.
"As you mentioned, the morphology index was developed at the University of Kentucky, so I think we're more comfortable following certain tumors that other surgeons would remove," said Saunders.
In response to another question from Modesitt, Saunders said surgeons in the Kentucky program do not have any specific thresholds for recommending removal of a tumor from an asymptomatic woman.
"It's just a clinical thing that will require taking into consideration how comfortable [surgeons] are following these, how comfortable is the patient allowing you to follow her," said Saunders. "Some of the newer tests coming out may play into that as well."
Article written by staff at medpagetoday.com and adapted for the purposes of this newsletter.
Ultrasound Performs Solidly in Superficial Masses
Ultrasound can accurately evaluate superficial soft-tissue masses...
Ultrasound can accurately evaluate superficial soft-tissue masses, according to a presentation at the American Institute of Ultrasound in Medicine (AIUM) annual meeting.
Researchers from the University of Wisconsin School of Medicine and Public Health in Madison found that ultrasound can be utilized to diagnose subcutaneous lipomas with a high degree of accuracy, sensitivity, and specificity. Sonographic features such as wavy echogenic lines, a wider-than-tall shape, minimal to no Doppler signal, and a lack of acoustic shadowing were most helpful in diagnosing lipoma, said presenter Dr. Jason Wagner.
Soft-tissue tumors occur at an incidence of three in 1,000 adults and are increasingly leading to imaging evaluation. Although superficial structures are well visualized by ultrasound, previous research has reported a substantial variation in the modality's accuracy in diagnosing soft-tissue masses, Wagner said.
Seeking to evaluate the diagnostic accuracy of ultrasound in evaluating superficial masses and to determine the sonographic features that are most characteristic of lipomas, the researchers performed a three-phase study involving cases performed by Wagner during a previous stint as a radiologist at the 72nd Medical Group clinic at Tinker Air Force Base in Oklahoma.
Between August 1, 2005, and November 15, 2008, Wagner evaluated 62 patients with 72 superficial masses. Breast lesions, organ-based lesions, obvious joint-related ganglion cysts, and morphologically normal lymph nodes were not included in the study.
The patients included 26 females and 36 males with an age range of 6 to 64 years and a mean age of 35.
All patients received sonographic evaluation using an Acuson Sequoia scanner (Siemens Healthcare, Malvern, PA) with a 15 LH transducer, with the studies performed by Wagner. In the first phase, the study team retrospectively reviewed ultrasound exams and patient records, comparing the initial diagnosis with the reference standard of the final pathology. In cases involving two foreign bodies and six hernias, the surgical procedure note was used as the standard because no tissue was resected.
Thirty-nine lipomas were found during surgical treatment and histologic examination, including four angiolipomas and one fibrolipoma. Also discovered were six hernias, four hemangiomas, four foreign bodies, three epidermal inclusion cysts, three benign fibrotic lesions, two neurofibromas, one accessory breast tissue, one aneurysm (superficial temporal artery), one endometriosis, one ganglion cyst, one hematoma, one Hodgkin's lymphoma, one pilar cyst, one pilomatricoma versus foreign body reaction, one venous malformation, and one venous thrombus.
The preoperative sonographic diagnosis was concordant with the pathology findings in 67 cases (93%). For the specific diagnosis of lipoma, ultrasound yielded 96% accuracy, 97% sensitivity (one false negative), and 94% specificity (two false positives). The second phase of the study involved a reader review by three attending radiologists with an interest in ultrasound. Blinded to the surgical outcome/pathology findings, the readers were provided with patient demographic information, body side, and clinical history. They viewed all of the ultrasound images and classified each case on a per-lesion basis into one of 14 diagnostic categories.
Results were similar to the first phase of the study. Overall, the three readers had concordant diagnoses with pathology findings of 89%. In diagnosing lipomas, the three readers turned in accuracy of 94%, sensitivity of 97%, and specificity of 91%.
In the final phase of the study, images were reviewed for lesion characteristics including echogenicity, borders, shape, homogeneity, internal features, Doppler signal, shadowing, deep acoustic enhancement, edge artifact/refractive shadowing, and size.
All lipomas were wider than tall, had minimal or no internal Doppler signal, and had no acoustic shadowing; 30% of nonlipoma lesions had at least partial shadowing. The researchers also found wavy echogenic lines in 29 of 39 (74%) lipomas and four of six hernias; this feature was not present in any other lesions.
In other findings, six (15%) lipomas were hypoechoic, 23 (59%) were isoechoic, and 10 (26%) were hyperechoic. Wagner acknowledged a number of limitations in the study, including its reliance on only subcutaneous lipomas. There was also only one malignancy in the study and no elderly patients, and the cases were generated from a primary care referral base; results may differ in a major referral center, Wagner said. In addition, the characterization of imaging features was not performed by a blinded reader.
"Further study would be helpful to validate these results in another setting and to potentially look at the cost-effectiveness of this approach for superficial masses," Wagner said.
Article written by staff at auntminnie.com and adapted for the purposes of this newsletter.
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