Questions from a Like-Minded Rad

An email “conversation” about 3D, etc….

Hi Sam,
My name is A…… I’m an interventional radiologist and the designated PACS maven for our group which practices in a 400 bed community hospital in the greater …… area. I’ve enjoyed and/or learned a bunch from many of your posts over the last couple ofyears and would really like to talk to you about a variety of topics including 3d, mdct, reporting dication and general workflow. I’ve spent the last three years reengineering all our departments processes during a Stentor PACS implimentation. Whilethe major stuff is done, there is a ton of tweaking left to do and I’d really like to just get some ofyour thoughts. Here are a few questions. If emailing takes too much time, I’d be happy to arrange a mutually convenient time to chat on the phone.

1. Does your Auntminnie “handle” have any religeousconnotation? I’ve been taking a Tibetan Buddhistmeditation class and just had to ask.

2. How much post processing beyond MPR do you thinkwe will be doing at our PACS workstations with MDCT? Should I make sure the techs stay real competent at all the 3D stuff or is it going to get so complicated (think coronaries) or fast (all automated) that we will do it? What are you using now?

That’s a start. ….Hope this isn’t too presumptious. Thanks, A….

A….:

Glad to talk with some like minded folks!

Actually, I am Jewish, quite reform, really. The Dalai Lama thing came about as an attempt to keep a vendor (ScImage) off my tail. I wanted a nickname that no one would ever associate with me, and the Dalai came to mind. I hope I am not showing any disrespect in this. Sadly, ScImage figured it out anyway. That’s a whole ‘nother topic.

I do Nuclear Med as a subspecialty; I’m one of the few who did a NM fellowship after DR. It is heavily computer oriented, and I have always enjoyed it. I’m an electrical engineer by training, although I never practiced as such.

I took over the PACs “guru” position in my group when the former guru got fed up with Columbia and went to Florida. He and I had a number of differences of opinion on how to do things. For example, he loved (and still uses to this day) ScImage, because they have one 3D module (Netra) that lets you view a whole volume with the sweep of a mouse. Basically it uses thick slap MIP reconstruction, and somehow loads it such that there is fast screen refresh. Sadly, the programming this one good module comes wrapped in is primitive, and it takes me longer to set up a study to be read than to actually read it. Bad sign. He insists that one must perform isometric imaging (thin enough slices that the voxels of a volume have all three dimensions equal), and then you have to visualize the new and old studies with a dual MPR program. Right now, ScImage and Philips are really the only ones that do this overtly. We have a GE AW (which I HATE!) but it can be conned into doing this as well. For what it’s worth, I still do my comparisons with the good old axial images, though matched by table positions.

For 95% of what I do, the onboard MPR Amicas provides (I call it baby-Voxar) is adequate. Beyond this, I’ll use the GE AW at the hospital that has that (If I really have to…) or full Voxar at the other. The other hospital has Siemens InSpace, and I really like that too, though I find I just don’t make myself use it enough. (The GE hospital is in the process of changing from Agfa 3.5 to 4.5, and Voxar-based 3D tools are included as well as full Voxar…I’m not sure of how many “seat” licenses we will have…)

As to your question….We really haven’t yet figured out the best workflow. My primitive thought is that still much can be handled with simple MPR, and I end up doing this on at least 50% of the CT’s I read. My former partner says that you have to do the isometric voxel thing on EVERY SINGLE CASE, or you’ll miss things, but I’m not convinced. I also must wonder if we are doing our patients a favor by picking up 2mm lung “nodules” that we end up following for years. Should the techs or the rads do the higher-level processing? That probably depends on your volume, your comfort level with the technology, the expectations of your referring docs, and a number of other factors. On more routine studies like angios and runoffs, where there is an easily-defined set of processed images, it certainly makes sense to have the techs take care of it. For the more esoteric stuff, it is probably wise for the rad and the tech to work together, at least until the tech is comfortable with it and the rad is comfortable with the tech’s abilities on that particular study. All that being said, I find it incredibly valuable to be able to jump to full Voxar 3D and do a volume rendering and segmentation or whatever on those occasions when doing so will actually answer a question. It makes me wonder if I am asking the right question often enough, though!

That’s a preliminary answer. I will attempt to hit SCAR this year and see what the rest of the world is doing. I’m thinking that no one has really found the perfect solution as yet. As with the adoption of PACS itself, it is a process everyone has to go through and mold (and be molded by) to reach the proper end. We are certainly not there yet!

I would really appreciate knowing your approach to all this!

Thanks for contacting me….

Sincerely,

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