John R Leyendecker MD Vice Chairman of Clinical Operations and Professor of Radiology UT Southwestern Medical Center Dallas TX Who am I I am a practicing Radiologist with 23 years experience ID: 550796
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June 29, 2016 Presentation to the Interagency Working Group on Medical Imaging
John R. Leyendecker, M.D.Vice Chairman of Clinical OperationsandProfessor of RadiologyUT Southwestern Medical CenterDallas, TXSlide2
Who am I?
I am a practicing Radiologist with 23 years experience.Vascular and interventional radiology (USAF)Abdominal imaging and interventionUTSA, Wake Forest, UT SouthwesternMy time is spent:Clinical (30%)Educational (10%)Research (10%)Administrative (50%) I receive no federal research funding.
But I will be a patient some day!Slide3
Outline
Why focus on imaging?A tale of two patients: Present care versus future care.How do we get there from here? Slide4
Detection
Localization and severity assessment
Diagnosis
Treatment planning
Treatment
treatment response
ImagingSlide5
Precision Medicine
Cancer moonshot
Imagine fighting a war in which you…
can’t find the enemy
can’t determine the enemy’s strength
have limited means to deliver weapons to the battlefield
have no idea whether your weapons are effectiveSlide6
Image processing and enhancementFeature extraction
Noise reductionData compressionData mining/Machine learning Information systems integration and data sharingWe all share the same challengesSlide7
“What frustrates you that you wish you could change?”
A tale of two patientsSlide8
A 75 year old man has blood in his urine detected at a routine physical exam. His primary care doctor refers him to a urologist
The urologist accesses the patient’s electronic medical record to order an imaging exam.
The urologist accesses the patient’s electronic medical record to order an imaging exam.
Documentation regarding the patient’s allergy history and CKD are buried deep in the medical record and go unnoticed.
The order is placed for a contrast-enhanced CT
Cumulative
radiation
dose
Allergies
Implanted devices
Warning: This patient has had a prior severe reaction to iodinated contrast and grade 3 CKD
click here for details
Based on the information you entered and published evidence, the following imaging tests are considered appropriate and do not require pre-approval
Ultrasound of kidneys
MRI of kidneys
WHERE WE ARE NOW WHERE WE CAN BE
Systems integration and data sharing
Evidence-based decision supportSlide9
Assessment of the kidneys is performed on a high field open MRI scanner using rapid free-breathing sequences that generate a portfolio of reproducible and standardized quantitative measurements displayed as parametric maps overlaying high spatial resolution anatomic images.
The patient arrives for his CT scan. Although the scan is completed, he has a reaction to the intravenous contrast material necessitating resuscitation and an overnight admission to a nearby hospital. The prolonged hypotensive episode further worsens his renal function.
T1= 800
msec
T2 = 24
msec
R2* = 22
ADC = 0.923
Ve
= 10 mL/100mL
Vp
= 9 mL/100mL
Fat content = 0%
WHERE WE ARE NOW WHERE WE CAN BE
Technological innovation
Standardization and quantificationSlide10
Computer Assisted Functions identify and volumetrically measure a mass in the kidney.
Segmentation software estimates the risk of surgical resection based on lesion size and location (nephrometry).
The
quantitative MRI data is digitally compared to an extensive open-access national database of renal tumors, correlating the tumor’s
imaging “fingerprint”
with biomarkers associated with specific genetic mutations, biologic behavior, and molecular targets.
A mass is identified in the kidney and measured manually by the radiologist in a single axial dimension.
WHERE WE ARE NOW WHERE WE CAN BE
Data/image analysis software
Databases correlating imaging phenotypes with genomics and outcomesSlide11
WHERE WE ARE NOW WHERE WE CAN BE
Image data is integrated with information available in the patient’s portable medical database to determine a risk/benefit profile for various treatment strategies. Software surveys the rest of the image data for additional findings and lesions demonstrating a similar molecular signature. It detects a 6 mm lung nodule. Software automatically calculates a risk profile for the nodule.
Software also determines risk profile for diabetes, heart disease, and osteoporosis-related fractures
.
The busy radiologist quickly looks through the 800 acquired images for evidence of metastatic disease.
A small lung nodule is missed.
She doesn’t mention the indicators of metabolic syndrome, such as fatty liver disease, or the coronary artery calcifications, because that takes additional time and she knows the urologist won’t follow-up on those findings
Image analysis software
Seamless integration of imaging, clinical, and risk stratification dataSlide12
Lungs: normal
Liver: normalGallbladder: normalSpleen: normalPancreas: normalAdrenal glands: normalKidneys: a 2.0 cm solid enhancing mass is seen in the right kidneyBowel: normalMusculoskeletal: normalLymph nodes: normalOther: No free air, no free fluidImpression: Enhancing mass in the right kidney concerning for renal cell carcinoma.
Right renal mass
5-30-2020
1
st
follow-up
2
nd
follow-up
Location
Upper pole, right kidney
Volume
35 ml
Metastasis
#1
N/A
Metastasis
#2
N/A
Mutated genes
MET
SETD2BAP1Diabetes
ModIschemic heart diseaseModOsteoporosis-related fracture
LowNASHMod
Click here for a 3D printed modelClick here for interactive virtual resection
Name: BobNational medical record number: 33333Age: 75
Lifetime effective medical radiation dose: 23 mSvImplanted devices: noneAllergies: iodinated contrast material
Contrast administered: 8 ml brand X Complications
: noneCritical Findings
Right renal mass
99% probability of Renal Cell Carcinoma
97% probability of type I papillary typeStage T1aNephrometry score = 4p
Findings requiring follow-up
Finding
MethodInterval
6 mm pulmonary noduleChest CT6 months
Based on your patient’s risk factors, the risk of malignancy is 8%
Click here to enroll your patient in a lung nodule registry and clinicAdditional FindingsHepatic steatosis (fatty liver)Colonic diverticulosis Click here for more informationClick here for more informationClick here for more informationRisk profileClick here for more informationClick here for more informationClick here for more informationCoronal MR imageClick here to view all imagesImaging-based genomic analysisOncologic follow-upImaging features suggest a significant likelihood that mutations in the following genes are presentSlide13
Evidence-based outcomes data is combined with patient-specific data to determine
the relative risk of disease progression, complications, and
cost vis-à-vis various
treatment
strategies.
His cancer qualifies as low risk for progression. Surveillance has the highest area under risk/benefit/cost curve of all possible treatment strategies.
Based on this data, the patient chooses annual imaging surveillance.
The urologist performs a partial nephrectomy in the operating room under general anesthesia, because that’s what the urologist does for all small renal masses.
Pathology
report: Renal cell carcinoma, papillary type,
T1a.
The
patient undergoes repeat imaging every 6 months
.
The
patient’s renal
function
never fully recovers from his contrast reaction and deteriorates further after surgery, necessitating dialysis.
WHERE WE ARE NOW WHERE WE CAN BE
Outcomes data
Cost effectiveness dataSlide14
The patient is referred back to his primary doctor for follow-up of his lung nodule and for lifestyle and medical interventions for type II diabetes, mild renal insufficiency, fatty liver disease, and coronary artery disease.
The patient develops complications related to poorly controlled diabetes/metabolic syndrome and renal insufficiency and spends his final days in and out of hospitals
He dies a short time later from a heart attack.
He spends many happy years enjoying the company of his grandchildren.
WHERE WE ARE NOW WHERE WE CAN BESlide15
How do we get there from here?Slide16
STANDARDIZATION
Image acquisitionImage analysisImage reportingSlide17
Support and Encourage…
Glycosylated liposome
Core contrast
Continued technological innovation
Faster
, safer, more effective
Vendor neutral quantitative imaging
Data management and integrated information systems
Large databases
with
clinical
trials data
Machine learning and computer aided diagnostic tools
Outcomes data (also emphasizing when NOT to treat)
Contrast agents with better safety profiles and targeted ligands for diagnosis, therapy, and surveillance.
Minimally invasive
procedures
Insertion of novel imaging into therapeutic clinical
trials
Potential to accelerate clinical translationSlide18
Build a research infrastructure that fosters innovation
We can’t just invest in tools, we also need to invest in people and processes.Create the next generation of radiologist (translational) scientistsDebt, lack of time, lack of training are all barriersDevelop and encourage successful industry/investigator collaborative modelsRevamp the grants review processShould every grant be treated like an R01?Reinvigorate the R21/R33 grant?Slide19
Industry
Clinical
researchers
Basic
scientists
Translational
scientists
universities
Advocacy
groupsSlide20
Industry
Clinical
researchers
Basic
scientists
Translational
scientists
universities
Advocacy
groups
patientsSlide21
Thank you