It all began with a happy accident. In 1895, while exploring the path of electrical rays passing from an induction coil through a partially evacuated glass tube, Wilhelm Roentgen serendipitously discovered the x-ray.
Roentgen’s curiosity and follow-up research ushered in a new era of modern medicine. For the first time, the inner workings of the body were visible without having to perform surgery.
Since that time, there have been countless contributors to the field of diagnostic imaging. The 1970s brought the invention of the CT scanner and the MRI. Today, researchers and clinicians continue to make great strides in everything from women’s imaging to interventional radiology.
In the following pages, you’ll meet just a few of the pioneering practitioners who are embracing innovative procedures and the technology trailblazers who are pushing the limits of diagnostic imaging.
REED OMARY, MD, MS:
Practical Research with Interventional MRI
For Reed Omary, MD, MS, research has been a passion for almost as long as he can remember. When most of his high school classmates undoubtedly were spending summers working at food stands or lounging around a pool, Omary was in a laboratory surrounded by test tubes and petri dishes.
The research bug bit a second time while he was a diagnostic radiology resident. He took a year off to pursue an MS in research, a move that he credits with giving him the fundamentals that has served him to this day.
But Omary, an interventional radiologist and vice chair of research and professor of radiology and biomedical engineering at Northwestern, isn’t an ivory tower academic whose work’s end is purely research-based. Instead, his work has a decidedly practical end—to successfully treat patients with liver and pancreatic cancers. “The reason I perform research is so I can have a greater impact on patients’ lives,” he said.
Omary began his interventional MR career in 1998 studying renal artery disease. And while the techniques he was investigating were interesting, they weren’t “ready for prime time” as he put it, which ran counter to his overall goal. Instead, he moved on to liver cancer, where interventional radiologists have had greater success. “The liver is where there has been the greatest experience and the greatest success,” he said.
The techniques he has been perfecting involve the use of MR to monitor delivery of chemotherapy drugs to liver tumors. He recently moved to researching similar treatments for pancreatic cancer for a very ambitious, yet, again, practical reason. “Improving the treatment of liver cancer offers incremental gains, but with the pancreas, we have the potential to see really big improvements,” he said, noting that the 6- to 7-month median survival rate for pancreatic cancer hasn’t changed much in decades.
This is where the practical part of his research really comes into play. Omary notes that he can treat up to 40 patients a week or about 2,000 patients every year. There is no doubt that he’s hard working. But Omary has the ambition of a visionary—and that means impacting patients and their clinicians far beyond the confines of his laboratory and imaging suites at Northwestern.
Omary’s research, funded by the National Institutes of Health, has already had a number of long-range benefits. Because of data obtained by this interventional MRI monitoring, using Siemens equipment, clinicians now have a better understanding of how much drug to deliver locally to liver tumors. Omary and his colleagues’ use of MRI has proven to be a powerful, prognostic tool in helping to prove the efficacy of his concept. “It provides us feedback to improve our therapies,” he said.
Omary is quick to point out that he is not making breakthroughs alone. His research partners include MRI scientist Andrew Larson, PhD, and fellow interventional radiologists Riad Salem, MD, Bob Lewandowski, MD, and Bob Ryu, MD.
The team has been very successful, he says: “We’ve had very practical, usable results. Historically, we didn’t know how much of a drug we needed to inject into liver tumors—now we have an endpoint to target.”
But more important, Omary has taken steps to make his concept accessible to clinicians in any type of setting, correlating his highly advanced MRI-guided approach with x-ray fluoroscopy, making it a universally accessible technology.
He hopes to advance patient care by devising new local drug delivery strategies that can eventually be commercialized. Omary and his research partner at Northwestern have filed six patent applications and are currently “trying to develop novel therapies to benefit patients,” he said.
But it isn’t enough to develop the techniques; as an academic, Omary is also helping to train the next generation of interventional radiologists. He sees this as part of his obligation to medical research. “I try to give back to my mentors by training the future leaders of interventional radiology,” he said.
A true trailblazer, Omary is not content to sit back and rest on his laurels. He’s currently working on newer chemoembolization techniques with drug eluting beads. The goal is to measure how much drug is being delivered to tumors and, thus, to increase efficacy and decrease toxicity.
He’s also developing high-technology therapies by using nanoparticles as drug delivery vehicles for tumors. Omary is currently performing preclinical research in this area and hopes to translate these results to patients in the future.
Again, the goal is to concentrate the therapeutic drugs into the tumor and keep them away from the rest of the body. His goal with this new therapy is as straightforward as all of his other research: “We really want to develop drugs that can be delivered as precisely as a smart bomb.”
DANIEL P. KOPANS, MD:
Digital Breast Tomography Innovator
The last thing that Daniel P. Kopans, MD, ever thought he’d be was a trailblazer. “I expected to be a private practice radiologist,” he said. Instead, Kopans stayed in academia and helped developed, among other things, digital breast tomography.
His journey began with several serendipitous events after he was appointed head of the then xerography section (later Breast Imaging Division) at Massachusetts General Hospital (MGH) in 1978. His department did a handful of mammograms, and when an abnormality was found, a guidewire would be placed in the breast to pinpoint it for excision and biopsy. Often these guidewires moved out of position by the time the patient was wheeled into the operating room.
Kopans was given the task of improving the guidewire, and he did so, eventually developing one—which is still used to this day—with a spring release that helped anchor it in place. This was his first taste of inventing, and he enjoyed it. “I found that I got my jollies from discovery. I liked solving problems,” he said.
It was while working on the guidewire that he noticed images taken of the biopsied tissue were much clearer than they were in the breast. It was a classic “aha” moment. “I remember thinking how great it would be if we could see lesions with the same clarity while they were still in the breast,” he wrote in a biographical paper describing his later development of digital breast tomography.
It was at that moment that he remembered a paper on tomography he had found in his predecessor’s clipping files, and immediately saw that this could give him and other mammographers greater clarity when imaging the breast. While it was a promising concept, Kopans was faced with a number of limitations. First, he would need serious computing power to be able to synthesize the breast slices—which didn’t exist yet—and, second, there was concern about radiation exposure in mammography; tomography, at the time, required what could have been considered unsafe doses of radiation. So, Kopans had to wait 30 years until technology caught up to him.
The digital imaging revolution gave Kopans and his team the tools they needed to develop breast tomography. And serendipity, yet again, played a part in putting the right tools in his hands at the right time. Kopans and department physicist Loren Niklason, PhD, and head of research Richard Moore were invited to join the National Digital Mammography Development Group (NDMDG), which included General Electric as a manufacturer member. Niklason and Moore soon realized that GE’s new digital detector was the best bet in allowing them to fulfill Kopans’ dream and develop digital breast tomography.
While GE wasn’t very enthusiastic about Kopans’ idea, the MGH team pressed on, using phantom materials and mastectomy tissue as targets, eventually developing a working model and patentable idea. After contacting several companies about developing a commercial system, Kopans found himself in a unique position—approached at the same time by both GE and its competitor Hologic.
Kopans has written that the reason he has worked with multiple companies to develop digital breast tomography was that he “felt that this was the best way to advance the ‘art and science’ of breast cancer detection and diagnosis.”
While he continued shepherding GE’s research and development, his colleague Elizabeth Rafferty, MD, worked with Hologic. The medical research teams were careful to keep their work for each company compartmentalized so there was no conflict of interest. The system quickly showed that it could significantly decrease false-positives and provide the radiologic win-win of higher specificity and sensitivity.
And the arrangement was a success. Hologic, which trailed GE in developing two-dimensional digital breast imaging, recently received US Food and Drug Administration approval for its digital breast tomography system. The system, which can also deliver a standard digital mammogram, is poised to change mammography, fulfilling another of Kopans’ dreams. “My vision is that digital breast tomography will replace conventional two-dimensional mammography,” said Kopans.
In addition to GE and Hologic, Kopans and his team are working with Siemens and several international companies on their own digital breast tomography systems.
While a new, effective, safe digital breast modality is exciting news, Kopans is still on the search for answers. His team is currently exploring other modalities and possibilities—including MR, optical imaging, and electrical impedance. “We’re figuring out ways to do better imaging,” he said.
COLIN BARKER, MD:
Leading the Charge for Transradial PCI
Inspiration comes from many sources. For Colin Barker, MD, it came out of a tragedy. When he was a young physician, he performed a femoral percutaneous coronary intervention (PCI) on a female patient. “We had a great intervention,” he said. “But there was a bleeding complication and the patient ultimately died.”
It was in light of this bad outcome—which resulted from a common problem with femoral PCI—that Barker looked for and found a better, safer way to perform the procedure: transradial PCI. This is now his “default” way of performing PCI, accounting for about 80% of his procedures. Transradial PCI is commonly used in Europe and is growing in popularity in the United States thanks to Barker and other trailblazers in New York, the Carolinas, and elsewhere. He used the method sporadically for several years, but committed to it about 2 years ago, when he and his colleague Richard Smalling championed it at Memorial Hermann Heart and Vascular Institute ? Texas Medical Center.
While the procedure could be viewed as “cutting edge” due to its novelty in the United States, Barker, an assistant professor at The University of Texas Health Science Center at Houston (UTHealth), says its efficacy and its advantages have been well documented. And he makes a good case as to why it should be used whenever possible. First, it is more comfortable and convenient for the patient. But more important in these days of economic uncertainty are its tremendous economic benefits for the health enterprise, including taking less time (2 hours instead of 10) and needing less equipment and staff.
Barker says that Smalling has expanded the use of transradial PCI for his heart attack patients. It is much safer for these patients since many are already on blood thinners, so the bleeding risk is minimized with the transradial approach, saving about $5,000 per patient. Barker, seizing on a good idea, has followed suit and added this to his menu of transradial PCI “defaults.”
But, as pioneering practitioners know, having the right idea at the right time isn’t always enough. The biggest stumbling block to universal adoption of transradial PCI is its steep learning curve. Even Barker admits that it’s “painful to learn and takes a lot of practice to perfect your technique.”
Making the technique easier to learn at Memorial Hermann is the fact that the institute is equipped with Toshiba America Medical Systems’ Infinix-i vascular labs. Barker says that he really never thought much about the imaging side of the intervention before using the Infinix-i. For him, every machine was about the same. But this changed with the Infinix-i. “All of a sudden, I was using an ergonomically friendly system. The Infinix-i has made a difference in the ease of the procedure,” he said. “It’s probably led to making it safer.”
The design of the Infinix-i allows clinicians to access the patient from either side, moving the five-axis C-arm seamlessly and situating the monitors and control panel to meet the needs of the interventional team. For the most common approach of right arm access, the C-arm can be positioned to provide access to the right arm of the patient with the ability to maneuver over the heart and down to the wrist, but if it is necessary to work on a patient from the left side, the clinician can have easy access and movement on that side as well. The Infinix-i’s tableside control cart and foot switch position provide a comfortable location for the interventionalists who can still reach the table panning handle. The system’s flexible design allows the user to switch from radial to femoral interventions during procedures with minimal disruption to the interventional team and patient.
While some of Barker’s colleagues initially balked at having to spend the time to learn a new, difficult, albeit safer technique, his fellows were eager to learn it and for good reason—it sets them apart from other interventional colleagues, meaning they have an attractive, marketable skill. These fellows will undoubtedly be advocates for and, eventually, teachers of transradial PCI at other institutions, increasing its use and acceptance. And it isn’t just the fellows who are eagerly adopting the technique. Memorial Hermann’s nurses and other staff are buying into it and patients are asking for it. This has had a pleasant side effect, said Barker. His colleagues are slowly coming around to the transradial technique, asking him to show them how to do it. He understands the trepidation, but points out the benefit: “It’s harder to learn, but it’s safer.”
So, with Barker’s quiet evangelizing, does he foresee a day when femoral PCI will be an antiquated, fondly remembered technique? Hardly. “It will always have a role,” he said. “There’s a role for both of them. They complement each other.”
C.A. Wolski is a contributing writer for Axis Imaging News.