BBI Contributing Editor

CHICAGO About 27,000 exhibitor representatives of about 730 firms held forth at McCormick Place here during the week after Thanksgiving to showcase their imaging and information processing wares for radiologists and other clinicians attending the 90th annual meeting of the Radiological Society of North America (RSNA; Oak Brook, Illinois). Foot traffic at the exhibit halls seemed greater than in prior years, and the mood was definitely upbeat. Exhibits by the leading suppliers were more elaborate than ever and very well attended, in a few cases resulting in real foot-traffic jams. Quite a few newcomers also were present, resulting in perhaps 100 more exhibiting firms than were represented at the 2003 gathering. It is easy to conclude that medical imaging is alive and most certainly well at this juncture. Clinical progress will ultimately be the beneficiary of the new products and technologies on hand here in Chicago, as it has in decades past.

The commercial exhibits can be roughly characterized by imaging modality and image/data manipulation.

Computed tomography

All the leading computed tomography (CT) vendors GE Healthcare (Waukesha, Wisconsin), Philips Medical Systems (Andover, Massachusetts), Siemens Medical Solutions (Malvern, Pennsylvania) and Toshiba America Medical Systems (Tustin, California) now have announced the availability of 64-slice machines, and several of them already have enjoyed about a year's worth of sales. A key driver of these sales is the promise of small-vessel imaging, cardiac scanning in particular. Some argue that the cardiac application is the only legitimate need for these new high-end scanners. In any event, these products add sizzle to an otherwise modestly growing market. Make no mistake, the stakes for radiologists and cardiologists are substantial, as contrast-enhanced 64-slice imaging of the heart offers the potential for a noninvasive alternative to classical coronary angiography, a methodology of great clinical and economic importance. However, the remarkable images offered by these high-end machines cannot be justified for most CT studies, so the 16-slice versions still account for about 80% of scanner sales today.

In addition to ever more capable scanner hardware, all leading CT suppliers are offering software and services aimed at optimizing CT scanning protocols for various anatomical sites, providing volume visualization capabilities to avoid 2-D image overload, and image management and storage features. Multi-slice CT is also finding increasing application in emergency medicine, replacing classical X-ray studies in the ER. The images are better, and the hardware costs are becoming at least worthy of consideration, although overuse and patient X-ray dosage are lingering concerns in the trauma environment. As the advantages of contrast-enhanced CT studies of the vasculature become obvious to referring physicians, radiologists are increasingly opting for this approach for peripheral vascular studies, replacing more-invasive catheter techniques.

Magnetic resonance imaging

The situation in MRI is comparable to that in CT, with a high-end technology stimulating market growth. In this case it is high-field (3 tesla) scanners for routine use. Superior images delivered by these 3-tesla machines have stimulated the MRI market, and these high-end machines now constitute 25% to 30% of MRI scanner sales revenues. Other MRI innovations are also either contributing to market growth or soon will: short-bore systems, open-magnet systems, dedicated extremity scanning, and enhanced imaging performance. Short-bore and open-magnet systems are already here, both aimed at expanding the patient base and relieving patient anxieties.

Philips exhibited its new Panorama 1.0T scanner, a 1-tesla vertical-field open MRI system. Using a pair of superconducting magnets in a double-donut configuration (one each above and below the patient), this new architecture reportedly gives the system the openness of a lateral open scanner with the image quality characteristic of a high-field machine. The supplier is positioning this new instrument as an ideal complement to a 3-tesla scanner used for advanced studies. Siemens showed its Magnetom Espree 1.5-tesla ultra-short-bore MRI scanner, a machine based upon a cylindrical superconducting magnet with a bore 70 cm wide and just 1.25 meters long. The company claims that 60% of all routine exams can be conducted with the patient's head outside the bore. Toshiba exhibited its comparable Vantage 1.5-tesla ultra-short-bore offering with a 65.5-cm aperture and 1.4-meter magnet length.

Hitachi Medical Systems America (Twinsburg, Ohio) highlighted additions to its Airis Elite and Altaire scanners. The Airis Elite features a 0.3-tesla vertical configuration, while the Altaire uses a 0.7-tesla open-style superconducting magnet that allows lateral access to the breast for biopsy procedures. Fonar (Melville, New York) showed its Stand-Up MRI system, which, according to the vendor, is the only scanner that allows the patient to be scanned standing, sitting, bending or lying down in virtually any position.

ONI Medical Systems (Andover, Massachusetts) exhibited its interesting and apparently unique second-generation OrthOne XT 1-tesla scanner designed for imaging the elbow, hand, wrist, knee, ankle and foot. The company anticipated shipments starting by year-end, with pricing at about $500,000. GE Healthcare unveiled its new Propellor technology for so-called high-definition magnetic resonance (HDMR). According to the company, HDMR combines an extremely fast data processing engine, high-density surface coils and extremely accurate gradients to enable a greater range of targeted MRI studies in critical areas such as the brain, heart, liver and lower legs despite patient motion. The technology is available on GE's Signa 1.5-tesla and 3.0-tesla MRI scanners.

Breast imaging

X-ray mammography and its complementary techniques for screening and diagnosis of breast cancer ultrasound, MRI, nuclear medicine and computer-aided detection (CAD) received strong emphasis on the exhibit floor. For example, Fischer Imaging (Denver), GE Healthcare, Hologic (Bedford, Massachusetts), Philips, Planmed (Roselle, Illinois), Sectra (Linkoping, Sweden) and Siemens all demonstrated commercially available or developmental full-field digital mammography (FFDM) systems at RSNA. The Philips entry, MammoDiagnost MD, is a new flat-panel digital mammography system under development featuring 50-micron pixel size in screening mode, 25 microns in diagnostic mode. The Planmed Nuance FFDM also is a work in progress. Sectra's Microdose Mammography FFDM, not yet approved for sale in the U.S., features a detector that absorbs almost 100% of the X-rays that strike it, which reduces the required dose by 80% compared to conventional analog systems. The Siemens entry, Novation DR, was cleared for U.S. sale last August. It features a 24 cm x 29 cm flat panel amorphous selenium digital detector.

Hologic showcased SecurView, a new multimodality workstation supporting the display and interpretation of screening and diagnostic digital mammograms and images generated by MRI, CT, PET and ultrasound. The company also featured its development work in breast tomosynthesis. Agfa HealthCare (Greenville, South Carolina) debuted its Impax MA3000 mammography diagnostic workstation, a device that can display diagnostic-quality images from multiple modalities for soft-copy diagnosis. Eastman Kodak Health Imaging (Rochester, New York) introduced a competitive offering, DirectView PACS System 5 Mammography Upgrade. The upgrade package consists of an image review and storage workstation supporting FFDM, ultrasound and MRI products from multiple vendors. Two developers of optical imaging technologies for breast studies, DOBI Medical International (Mahwah, New Jersey) and Imaging Diagnostic Systems (Plantation, Florida), featured works in progress on adjuncts to X-ray mammography in the form of product prototypes.

VuCOMP (Plano, Texas) showcased its developmental M-Vu mammography CAD system that uses proprietary image-understanding algorithms to highlight mammographic abnormalities. Confirma (Kirkland, Washington), another CAD supplier, demonstrated CADstream, its breast MRI image processing technology along with its SureLoc analysis tool for MRI-guided interventional procedures. iCAD (Nashua, New Hampshire) displayed its Second Look line of CAD products spanning a wide range of products to support X-ray mammography and breast MRI.

Molecular imaging

Functional imaging methods are gaining traction commercially in addition to their early clinical successes, in no small measure owing to some favorable reimbursement decisions by CMS. Several vendors some niche players and others major multi-modality suppliers exhibited their molecular imaging wares at RSNA. The high-profile vendors included Hitachi, Philips, Siemens and Toshiba. The exhibiting niche suppliers included CTI Molecular Imaging (Knoxville, Tennessee), Gamma Medica (Northridge, California), Naviscan PET Systems (Rockville, Maryland) and Positron (Houston). Hitachi debuted its SceptreP3 PET/CT scanner, which received U.S. marketing go-ahead in September.

Philips exhibited the broadest molecular imaging line at McCormick Place, including new offerings in gamma cameras, PET/CT systems, SPECT/CT systems and integrating multimodality software. Siemens highlighted its TruePoint SPECT/CT hybrid imaging capabilities available on its Symbia line of scanners, while Toshiba showed a few upgrades for its T.Cam Signature Series of gamma cameras. Despite their relatively high costs, typically exceeding $1 million, these hybrid systems attracted large crowds on the exhibit floor.

Naviscan's positron emission mammography Flex Solo PET scanner was an interesting attraction. Its clinical application was described in the first installment of our RSNA coverage in last month's issue of The BBI Newsletter. It is a compact PET scanner intended to provide high-resolution breast images to guide radiological and surgical procedures. Gamma Medica showed its X-O micro CT system for pre-clinical small animal imaging. Positron exhibited its mPower whole-body PET scanner for cardiology, oncology and neurology applications. And PET veteran CTI focused its RSNA exhibit on peripheral products and services deemed essential for market expansion, namely PET.Connect, an integrated group of software tools and workstations for image analysis, PET education and marketing, and practice management.

Ultrasound imaging

The ultrasound modality cemented its position as the value leader in medical imaging at RSNA with all the leading multimodality suppliers exhibiting their ultrasound wares, as did a few ultrasound specialty houses. And the technology is not static. Progress along three lines is expanding ultrasound's applications and corresponding markets: breast imaging, 3-D and compact systems. Philips well represented the large imaging vendors with the RSNA introduction of its iU22 flagship ultrasound scanner, featuring real-time 4-D imaging, voice-activated control and annotation, and automated image optimization. The system has been optimized for ob/gyn and breast examinations.

Compact scanners were represented by ultrasound veteran SonoSite (Bothell, Washington) and newcomer Zonare Medical Systems (Mountain View, California). SonoSite exhibited several upgrades to its Titan platform along with work in progress on SonoCalc IMT software implementing automated edge-detection software for measuring intima-media thickness of the carotid artery, considered an independent risk factor for cardiovascular disease. Zonare signaled its inaugural RSNA participation by launching its z.one cart-based scanner that converts to a portable system. The system captures information in zones rather than individual lines, resulting in shifting functionality from hardware to software.

Digital radiography (DR)

The popularity of direct digital X-ray systems continues to grow as a stimulant of improved workflow efficiencies when combined with PACS (picture archiving and communication systems). These systems are now working their way down-market and into alternate sites of care. Several RSNA exhibits in this space were noteworthy. Lodox Systems (South Lyon, Michigan) highlighted upgrades to its Statscan low-dose system appropriate for trauma and emergency settings. According to the company, the Statscan Critical Imaging System is the first digital X-ray system capable of performing full-body DR in a single image. Veteran DR supplier Swissray International (Elizabeth, New Jersey) demonstrated its ddRCombi Trauma system for emergency departments, which makes images available in five seconds according to the vendor. And Shimadzu Medical Systems (Torrance, California) exhibited its MobileDART Plus mobile DR system.

Visualization and image management

Workflow and productivity in the radiology department, and increasingly in patient-contact departments as well, have never been unimportant issues, but they are now front and center as multi-slice scanners proliferate and the number of images available for interpretation explodes. Shrinking insurance reimbursements don't help either. As a result, PACS and RIS (radiology information systems) have become mandatory in all but the most modestly sized radiology practice. 3-D visualization and CAD also have become increasingly pervasive out of necessity. The problem: bringing all these solutions together in a given installation. The burden of solving this problem is, ever so slowly, shifting from the radiology administrator/IT manager to equipment and software vendors. Evidence of the problem and potential solutions were everywhere on the sprawling McCormick Place exhibit floor.

Capturing all the products and development initiatives on display in the visualization/image management space is an impossible task. Rather, we will highlight a few of them that seemed to us particularly noteworthy:

  • PC-based workstations from 3mensio Medical Imaging (Bilthoven, the Netherlands).
  • Impax 6.0 PACS software from Agfa HealthCare.
  • Vision Series PACS, RIS and financials software from Amicas (Boston).
  • MIStar 3.2 visualization software from Apollo Medical Imaging Technology (Melbourne, Australia).
  • CD/DVD case record creation products from both DatCard Systems (Irvine, California) and Sorna (Eagan, Minnesota).
  • Intelligent Visual Medical System software from Emageon (Birmingham, Alabama).
  • Horizon Radiology Manager workflow system from McKesson Information Solutions (Alpharetta, Georgia).
  • Analytical/visualization software from Medis Medical Imaging Systems (Leesburg, Virginia).
  • Visualization software for functional MRI studies from Neurognostics (Milwaukee).
  • PacsScan Enterprise document scanning software from PACSGear (Pleasanton, California).
  • iVault archiving software from Stentor (Brisbane, California).