When breast MRI posed a workflow challenge, this practice implemented a CAD solution that improved efficiency.

Breast imaging has seen a transformation in technology over the past decade. From the days of analog mammography and subpar ultrasound, breast imaging has evolved to include digital mammography, sonography, and the addition of breast MRI as an essential tool in the early detection of curable breast cancer. In 2007, the American Cancer Society developed new recommendations for the use of MRI for women at increased risk for breast cancer, and recommends annual screening for women with a 20% to 25% or greater lifetime risk of the disease.

As the medical imaging community transitioned from film to digital imaging and the need for viewing and storage solutions emerged, breast imaging was not forgotten. Ten years ago, breast imaging entered the digital world with the introduction of digital mammography. Due to the high productivity of the digital systems, radiologists were now faced with the daunting task of reading exams that, in the initial phases, were actually taking longer than their reading protocols with analog films.

From left: Abraham Port, MD; George Autz, MD; and Michael V. Golia, MD.

Over the past several years, image display and management systems have evolved to streamline workflow and radiologist efficiency. The physicians at Complete Women?s Imaging in Oceanside, NY, were among the radiologists who faced the challenge of managing a heavy caseload with less than efficient means to interpret the images. Complete Women?s Imaging was opened in 2006 by Abraham Port, MD, with the goal of providing state-of-the-art women?s imaging services in a respectful and compassionate environment. It is designated as a Breast Imaging Center of Excellence by the American College of Radiology?s Commission on Quality and Safety and the Commission on Breast Imaging. Complete Women?s Imaging provides a full suite of breast imaging services. Digital mammography, sonography, and bone density are performed at its outpatient facility while MRI exams are done at South Nassau Communities Hospital, of which Complete Women?s Imaging is an affiliate.

Physicians at Complete Women?s Imaging are passionate about delivering the highest quality care to patients, and personally speak to every patient before they leave. The only way to spend more time face-to-face with the patients is to streamline and refine the reading workflow while continuing to maximize the functionality and quality of the imaging protocols. In order to effectively deliver this high level of patient care, reading efficiency must be optimized without sacrificing quality.

In the Beginning

Like many other breast imaging facilities, Complete Women?s Imaging started with dedicated reading workstations for digital mammography. At the time, this provided the best available tools and protocols, also allowing interpretation of ultrasound images. Breast MRI images, however, required a separate PACS workstation, necessitating multiple workstations to be used at the same time. The PACS workstation was utilized solely for viewing breast MRI studies, offering little post-processing functionality for breast MRI interpretation.

Growing Need for Efficiency

Of all the current methods of breast imaging, breast MRI has experienced unprecedented procedure growth. Early limitations of the clinical viability included the lack of an efficient way to analyze, display, and interpret images. Breast MRI exams are comprised of 1,600 images or more, increasing as coil technology advances and studies are done with higher Tesla MRI systems. Computer aided detection (CAD) was developed to provide an automated, more efficient, and standardized way to process and interpret diagnostic studies, as well as to provide interventional coordinates for procedures.

When George Autz, MD, joined Complete Women?s Imaging in 2007 as Director of Breast MRI Services, the growing practice was busier than ever, especially in breast MRI. With the MRI located in the hospital a half mile away and the necessary post-processing done at the MRI console, the productivity and throughput challenges were getting more and more difficult to manage. Since the radiologist often needed to be at the MRI console during post-processing, the diagnostic patients at the breast center had to wait for him to return before their exams could be completed. In an attempt to streamline workflow and improve overall efficiency, the CADstream solution from Merge Healthcare was introduced to the practice. As a result, breast MRI CAD has become an essential tool to assist the radiologists in managing large caseloads. The doctors now read all cases in the reading room at the breast center.

Top: Angiogenesis maps and curves are presented via Merge Healthcare?s CADstream, providing valuable kinetic data from breast MRI. Bottom: Maximum intensity projections (MIPs) provide interactive 3D viewing capability for breast MRI. Physicians use Merge Healthcare?s CADStream to create customized MIPs?slab, temporal, and oblique?all of which can include AngioMap overlays.

How CAD Makes a Difference

With more options to customize hanging protocols, CAD allows the radiologists to more easily develop an efficient workflow without compromising functionality. The kinetic data that the CAD system provides helps to differentiate between benign and suspicious masses. This kinetic data is represented by a color map, allowing for quick visualization by the radiologist as to what may be benign versus what may be suspicious. The color map allows the radiologist to focus attention on the pertinent information or suspicious data, showing the physician where to click to generate the related kinetic curve. ?With the click of a button, CAD calculates important lesion data such as lesion volume, distance to skin, chest wall, and nipple, as well as its location in relation to other lesions,? said Port. ?Using PACS, this was a laborious, multistep process.?

MRI CAD also allows for automated post-processing of images including subtractions, MIP imaging, and other multiplanar reformats, resulting in dramatic time savings for both the radiologist and the technologist. Prior to CAD, technologists would have to run this post-processing at the MRI console after each exam, taking up to 30 minutes to complete and wasting valuable scanner time. ?Using a CAD workstation streamlines my ability to use and interpret the images not authentically acquired by the MRI scanner (such as reformats, motion-corrected subtractions, and MIPs). These reconstructions allow me to evaluate the extent of disease, whether it is extensive DCIS (ductal carcinoma in situ) or multifocal/multicentric diseases of the breast. This time savings reduces radiologist reading time from up to 2 hours to 20 minutes or less,? said Autz.

One of the most common artifacts seen on breast MRI images is motion. As coil and magnet technologies advance and imaging becomes more sensitive, the presence of motion becomes a bigger challenge. Inherently, the breast MRI study lends itself to the probability of some patient motion occurring. When motion is present during the exam, image misregistration occurs. MRI CAD applies an automated motion correction feature to studies that standardizes the quality of image appearance while increasing physician confidence. When a correction method is not used, there is a likelihood of identifying false positives. CAD motion correction algorithms help to minimize the motion artifact to increase the quality of image appearance while increasing physician confidence in the data. As an additional benefit, motion correction helps reduce the number of studies that need to be repeated due to patient movement.

Built-in reporting capability also adds to the overall efficiency of MRI CAD. By automating many of the routine measurements the radiologist must make, CAD provides pertinent morphological data about the lesion. This includes where the lesion is located; how far it is from the skin, the chest wall, and the nipple; and where it is located in relation to other lesions. ?CAD helps process images for nonradiologists, allowing referring physicians to easily look at their cases and provide improved patient data for surgical or treatment planning. Screen captures can be saved with the pertinent morphological features and useful graphical analyses the referring physician needs to evaluate the patient?s disease status. CAD also provides appropriate information for presentation at Tumor Board,? said Dana Rausch, MD, Complete Women?s Imaging.

A recent patient study demonstrated significant background enhancement, where CAD helped to differentiate a suspicious lesion from the background and direct a successful biopsy. The patient had a strong family history with multiple hypoechoic nodules in each breast identified on a recent ultrasound exam. An MRI of the breast was performed for the evaluation of multiple hypoechoic nodules in both breasts. The study demonstrated a 6 mm lesion with suspicious kinetic color curves in the upper outer quadrant of the right breast. With this knowledge, a targeted breast ultrasound was performed with subsequent biopsy demonstrating a mucinous carcinoma. The patient was then referred for a surgical consultation. CAD saved this patient from being subjected to multiple benign biopsies.

Like digital mammography, the breast MRI images at Complete Women?s Imaging are interpreted on a separate MRI CAD workstation. Utilizing dedicated workstations for different breast imaging modalities is neither practical nor economical, especially when cases are read in geographically dispersed locations. Having a system that could integrate all images across the IT infrastructure would be the ideal solution.

As Complete Women?s Imaging continued to grow, expansion to a second location became a necessity. Located 10 miles from the first site, Complete Women?s Imaging Garden City will be fully operational with integrated digital mammography, sonography, bone density, and BSGI (Breast Specific Gamma Imaging) in the summer of 2010. Planning for this facility included evaluating and selecting a new RIS/PACS system that could easily communicate with the hospital systems currently in use at Complete Women?s Imaging Oceanside. In addition, it is imperative that CADstream be an integral part of the package so that one radiologist can read all breast studies from any location.

?We were looking for a dedicated, long-term partner who could help us simplify our growing business infrastructure with a reliable and versatile solution, complete from scheduling through billing to image distribution and management,? said Port. ?The Merge Fusion RIS/PACS MX with the integrated Merge Mammo and MergeCAD applications completes the picture.? Complete Women?s Imaging needed an intuitive, intelligent solution that understood the reality of a radiologist?s fast-paced day. And we believe we have found it.

Michael V. Golia, MD, is a radiologist specializing in breast imaging at Complete Women?s Imaging, Oceanside, NY.

About the Physicians at Complete Women?s Imaging

Abraham Port, MD?Board certified in diagnostic radiology, Abraham Port graduated from Albert Einstein College of Medicine at Yeshiva University and completed his radiology residency at Montefiore Hospital Medical Center. Prior to starting Complete Women?s Imaging, Port served as the Director of Breast Imaging at The Mount Sinai Medical Center in New York City. In addition, he conducted breast cancer research at Memorial Sloan-Kettering Cancer Center and served as a clinical fellow in body imaging at New York Hospital-Cornell Medical Center. Currently Director of Breast Imaging at South Nassau Communities Hospital, Port is active in numerous national, state, and local professional radiological societies.

George Autz, MD?Board certified in internal medicine and diagnostic radiology with fellowship training in breast imaging, and specializing in MRI-guided breast biopsies, George Autz received his medical degree from Stony Brook University. Autz completed residency training in internal medicine at Lenox Hill Hospital and diagnostic radiology at St Luke?s-Roosevelt Hospital in New York City. Autz was previously Chief of Women?s Imaging at Long Island Jewish Hospital and Co-Director of the Breast Imaging Center at North Shore?LIJ Health System. Currently Director of Breast MRI Services at South Nassau Communities Hospital, Autz is a member of numerous national, state, and local professional radiological societies.

Michael V. Golia, MD?Michael Golia joined Complete Women?s Imaging as a radiologist specializing in breast imaging. Following his residency training in internal medicine at Staten Island University Hospital and diagnostic radiology at Richmond University Medical Center, Golia completed his fellowship training in women?s imaging at Columbia University-NY Presbyterian Hospital. Golia is a member of numerous national, state, and local professional radiological societies.

Dana Rausch, MD?Board certified in diagnostic radiology, Dana Rausch graduated from Albany Medical College. Following her residency training in diagnostic radiology at The Mount Sinai Medical Center, Rausch completed her fellowship training in women?s imaging at Northwestern Memorial Hospital. Prior to joining Complete Women?s Imaging, Rausch served on the faculty at Mount Sinai as Assistant Clinical Professor of Radiology. Rausch is an active breast subcommittee member of the American Roentgen Ray Society and is a member of numerous national, state, and local professional radiological societies.