Top 5 Trends from RSNA 2018 in Chicago: PART TWO

As most of you in the industry know, the Radiological Association of North America (RNSA) held it's annual conference at the end of November... Countless vendors showed off their latest and greatest developments pertaining to medical imaging, and professionals and industry intellectuals informed us about what we can expect in the next few years.

We know that with so much information coming from the show, it's hard for important information to get lost in the shuffle. Well, the gracious folks at Aunt Minnie have compiled their Top 5 Trends again for us this year so that even if you didn't attend the conference, you now know some of the highlights. Read below for Trends #3, 4 and 5 in this second part of the 2-part series...

3. 3D Printing Approaches Key Milestone

Since RSNA launched its 3D Printing Special Interest Group in 2013, the amount of time and space dedicated to the field during the annual meeting has grown enormously each year. RSNA 2018 was no exception to this trend, with a generous number of posters, refresher courses, technical exhibits, and oral presentations aimed at increasing the awareness of 3D printing.

The technology's pervasiveness this year -- especially in scientific sessions -- made clear that medical 3D printing long ago transitioned from being merely a flashy idea into an effective application grounded in clinical work. This year's conference included discussions ranging from the logistics of starting a hospital 3D printing lab and creating cost-effective 3D-printed anatomical models to the various ways in which clinicians have been using such models to boost treatment efficiency.

Research presentations at RSNA 2018 demonstrated the potential benefits of 3D-printed models in improving presurgical planning and intraoperative guidance, as well as patient education. In previous years, these presentations were primarily case studies involving a dozen or so 3D-printed models. At RSNA 2018, however, several groups showed the technology to be useful on an even grander scale, to the tune of hundreds of distinct patient-specific models created for the evaluation of a particular organ or disease.

Furthermore, growth in medical 3D printing seems primed to continue full steam ahead in light of the American Medical Association's acceptance of a category III current procedural terminology (CPT) proposal for 3D anatomic modeling; the proposal was led by the American College of Radiology.

The four new CPT codes, slated to be effective starting July 2019, will finally allow radiologists and other clinicians to seek reimbursement from the U.S. Centers for Medicare and Medicaid Services (CMS) for 3D printing services -- possibly surmounting one of the chief barriers to the integration of 3D printing in healthcare. Researchers from multiple U.S. institutions underscored the magnitude of this event in a Sunday refresher course on 3D printing at RSNA 2018.

"Before now, all 3D printing was volunteer work, but now there's a way to actually get reimbursement from CMS for patients who need 3D printing," Dr. Frank Rybicki, PhD, chair of radiology at the Ottawa Hospital, told AuntMinnie.com. "The fact that the codes exist and they cleared is huge. It's a really big deal in radiology."

The coding decision will also apply to other advanced 3D imaging techniques, which are increasingly becoming intertwined with 3D printing. In one such example at RSNA 2018, investigators from New York created both augmented reality and 3D-printed kidney and prostate models using the same MRI and CT scans. The shared processing steps required for 3D printing and other forms of 3D modeling -- most notably virtual and augmented reality -- may ease the partial unification of their workflows.

As 3D printing research expands and the technology ramps up its integration into hospitals around the world, radiologists appear positioned to cement their place as leading figures in the discipline. Medical 3D printing, like artificial intelligence, has the earmarks of a medium through which radiologists may be able to situate themselves at the "epicenter of care," as Rao urged the community to do in her opening address.

What's more, the early application of 3D printing in medicine has highlighted its collaborative nature: Every scientific presentation depended upon a joint effort among scientists, engineers, and clinicians from a variety of specialties, including radiology. Collaboration to this degree may ultimately improve the quality of research and, perhaps most importantly, of patient care.

"Being able to see and hold these tangible 3D models brings everything together," Nicole Wake, PhD, from NYU Langone Health told AuntMinnie.com.

4. CEUS Emerges As Ultrasound's Growing Edge

At this year's RSNA meeting, contrast-enhanced ultrasound (CEUS) seemed poised to come into its own. Studies presented in Chicago demonstrated that ultrasound offers benefits such as cost-effectiveness, convenience, and a lack of radiation; what's more, with contrast enhancement, it can be used for increasingly sophisticated applications such as cancer interventions and image guidance for percutaneous procedures.

CEUS can even support molecular imaging, as microbubble-based contrast agents accumulate at tissue sites in the body that are expressing molecular markers. CEUS has been shown to help characterize breast, kidney, and liver lesions, and it can be used instead of more expensive modalities for patient follow-up, according to Alexander Klibanov, PhD, from the University of Virginia in Charlottesville. Klibanov presented RSNA 2018 attendees with a primer on the use of contrast ultrasound.

"Enabling molecular imaging potential in an ultrasound setting will lead to the expanded and improved clinical diagnostic benefit," he said. "Ultrasound contrast microbubbles are already used in the clinic as blood-pool contrast agents, with excellent detection sensitivity. Overall, targeted microbubbles empower molecular ultrasound imaging and could be used in conjunction with image-guided interventions, such as biopsy and therapy."

The technology also shows potential for cancer interventions, according to Dr. Dean Huang of King's College Hospital in London, who facilitated a digital education session on contrast ultrasound at RSNA 2018. Possible uses of CEUS in this capacity could include the following:

• Characterization of focal lesions, particularly by evaluating intralesional vascularity

• Percutaneous procedure image guidance, including CEUS-assisted fine-needle aspiration cytology, biopsy, and thermal ablation therapies

• CEUS-assisted percutaneous oncological interventions such as biliary stenting, nephrostomy insertion, and radiologically inserted gastrostomies

• Evaluation of treatment response after locoregional hypothermal and hyperthermal and intra-arterial embolization therapies

In the New Horizons lecture delivered at RSNA 2018, titled "Oscillating Microbubbles: Driving Innovation in Ultrasound," Flemming Forsberg, PhD, of Thomas Jefferson University in Philadelphia shared results from a study that produced the first human subharmonic images using ultrasound with microbubbles. The technology shows promise in a variety of ways, including for monitoring interventions such as transarterial chemoembolization and evaluating kidney cancer recurrence, Forsberg said.

"[Contrast-enhanced ultrasound imaging] may be a useful alternative to catheter-based measurements of cardiac conditions and for diagnosing portal hypertension, or as a novel biomarker for monitoring neoadjuvant chemotherapy of breast cancer," he said. "[There's also] the intriguing possibility of using targeted microbubbles for drug or gene delivery."

Another emerging ultrasound trend is elastography. The term refers to a variety of techniques used to map the elastic properties and stiffness of soft tissue (with the understanding that increased tissue stiffness is associated with disease). These techniques include shear-wave elastography (SWE), MR elastography, and transient elastography. SWE was of particular interest to researchers at the meeting; it uses an acoustic pulse sequence to generate sound waves that are then measured to assess tissue elasticity for applications ranging from tracking patellar tendinopathy in athletes to assessing liver fibrosis.

But elastography aside, ultrasound fans should definitely keep their eyes open for CEUS developments, according to Klibanov.

"[CEUS offers many] opportunities for clinical translation in diagnostic imaging and image-guided interventions," he said.

5. Radiology Regains Footing As Threats Recede

The last major trend at RSNA 2018 isn't a clinical topic but rather a pervasive sense that much of the uncertainty that has plagued the specialty for years has begun to recede.

Uncertainty has been the norm in radiology for the past decade, starting with the Great Recession and giving way to the great job crisis a few years later, in which the job market for radiologists dried up and medical students avoided the specialty in droves. This was followed by years of political uncertainty, as the passage of the Affordable Care Act (ACA) and then the threat to dismantle the legislation left all healthcare professionals unsure of where they stood.

The next threat to radiology was artificial intelligence, in which it was prophesied that machines would soon be doing the jobs of radiologists, who after all were just "wasted protoplasms," in the infamous words of an executive at one AI start-up.

But a funny thing happened on the way to radiology's demise: The specialty turned out to be more resilient than expected. The ACA still stands and seems to have affected healthcare professionals less than was expected. The job market for radiologists has stabilized, and medical students once again see radiology as an attractive specialty, with radiology programs reporting that they were 100% filled in the 2018 National Residency Match.

In fact, U.S. radiology appears to be on the verge of a shortage of radiologists, something that would have seemed unthinkable a few short years ago. There are some 8,000 radiologists in the U.S. older than 65 who are still in clinical practice -- a number that is very high, according to Daniel Corbett of physician management recruiting firm Radiology Business Solutions. These physicians now have retirement plans that are flush with cash, and they are looking for the exit.

Which all brings us back to RSNA 2018. Presentations at McCormick Place were refreshingly free of the doom and gloom of past years. There was little discussion of attendance figures, booth square footage, and all the other minutiae that veteran RSNA attendees use to gauge the market's health.

Instead, the gestalt in Chicago seemed to be that radiology's best years are ahead of it. Radiologists may evolve in years to come from being the masters of big iron to the lords of big data, but one thing is certain if RSNA 2018 is any indication -- they will most likely control their own destiny.