Saturday, December 11, 2010

RSNA 2010: Something Old, Something New,
Something Borrowed, Something....Green

For my final installment on RSNA 2010, I'm going to tie up a number of product observations into one rather large knot.  Hopefully it will all make sense in the end.

The software I'm going to discuss is in part stuff I've reviewed before, hence, something old.  There are some differences and enhancements here and there (something new) and some features that seem to cross vendor lines, although I'm sure they aren't really something borrowed.  And something green, well... that would of course refer to the larGE vendor that likes that color, which coincidentally is also my favorite.

After dabbling with the Discovery 670 SPECT/CT and the Xeleris station, I wandered over to the PACS-ville neighborhood of GE City at McCormick.  I met with some old friends, and made some new acquaintances.  I have to tell you, I really like the people at GE, especially those I have known from their previous lives.  These are good folks, and they are dedicated to releasing a decent product.  Which they will eventually. 

GE is still showing, and perhaps finally shipping, seven years after introduction, an integration of the Advantage Workstation to Centricity PACS.  AW Server, like pizza, is sold by the slice, with server configurations able to handle 8, 16, or 30 thousand concurrent sections.  Beyond this, one has to add more servers which are load-balanced.  Manipulation is then performed right in your Centricity 3.3 (or was that 3.2?) PACS window.  Very nice. 

Centricity 4, the latest version of the RA 1000 client, was on display, and it has some substantial improvements.  First, it is skinned in dark grey, much easier on the eye in a dark room than its predecessors.  It has the "SNAP!" tool (no, this is not a substitute for saying a dirty word) which basically is a tiny viewport pallette that appears upon double-clicking, and allows for image manipulation.  It is supposed to eliminate some back-and-forth to the toolbar, and I think it would be helpful after being used enough to become intuitive.  This component appears to be a direct port from the Dynamic Imaging Integradweb.  There is native MPR, and 3D images can be built into a hanging protocol.  But when I asked how many measurements could be displayed on an image, I was saddened to see that this number remains at four, and only four.  Why would we want to see more than that, after all?  Sadly, there are some nasty diseases that manifest themselves with more than two findings on any one image, and bidimensional measurements of more than two lesions require more than four measurements.  That's why.

It's nice to see Centricity 4 approching the usability of AMICAS 3 from 7 years ago.  I'm sorry, guys, but if you were to look at other products, such as the very fine software you purchased a few years ago, you would see where you need to be. 

Speaking of IntegradWeb, it does appear to be fully functional at last, reincarnated as the Centricity PACS Web Diagnostic (Web DX 2.0).  I presume this will finally take its place as the Centricity web viewer.  At least, I hope it will, as the old Centricity Web Viewer is without question the absolute worst viewing software on the market, bar none.  Nothing personal, guys, but it is literally that bad.  Burn it.  Seriously.  I mentioned this to a GE exec years ago, which shocked him to no end.  Maybe no one else has let GE know just how horrid this program really is, which would be very surprising.  I still have to use the old Centricity Web, and it is as much an exercise in agony as one can find in this business.  Have I said enough?

If I were running GE PACS, I would personally ditch the RA 1000/Centricity front end altogether in favor of IW, but that's just my own humble opinion.  I'm sure there are some legacy reasons for keeping the old Centricity alive.  Perhaps because there are a zillion Centricity sites out there that need care and feeding.  Oh, well.  I don't run GE.  I don't even run my house:  the two dogs have full control.

Let's shift gears to some different software, that for PET/CT viewing.  One of the old DI crew has prepared some very nice software for this purpose, based on the IntegradWeb 3.7 platform, although it is not yet released for public consumption.  I had the chance to compare it to the two big names in this venue, Mirada and MIM Software (formerly MIMVista). 

All three programs have mostly similar features, which I would deem necessary and sufficient for PET/CT reading.  No, neither my Siemens Leonardo or the AW 4.3 have many of these features at the moment, although my soon-to-be installed Segami system will.  At least I think it will. 

When one reads a PET/CT, there are several machinations involved.  First, you have to match the PET to the (almost) simultaneously acquired CT.  This shouldn't be a problem since the patient is scanned on the same gantry, hopefully without moving.  But sometimes they do move their heads or something, and it's nice for the machine to automatically register the PET to the CT.  (Note that this same mechanism can be used to match a PET to an MRI, saving $5 million on a new Siemens mMR hybrid.)  If there is a prior exam, and there usually is, you have to go through the same conniptions to match the old anatomy to the new.  These programs can all do so by rigid manipulation.  In other words, we take the old study, and shift it, zoom it, rotate it, basically do anything but distort it, and match it to the new exam as best as we can. 

Now, the Mirada 7D program can go one further, and actually deform the old study, pulling a bit here and tucking a bit there, to provide a more exact match.  I was told that the MIMfusion 5.1 could do this too, although I didn't have time to see this happen.  The DI, I mean GE prototype does not deform as yet.  This version registers via bones, the next will use organ margins for the match-up. 

All three can track a lesion from the old to the new study.  GE has the physician identify the border of a lesion with the computer creating an ROI, which is propagated to the new study.  The lesions are labelled, and a table created which documenting the change in size and/or uptake of the lesions.  Mirada and MIMfusion work similarly.  Mirada allows definition of a region via maximum SUV with subsequent edge-detection.  RECIST and PERCIST measurements are easily generated along with the table of other information.  MIM uses scripts to automate the workflow yielding automatic contouring for the lesions (PET EDGE gradient detection), again with manual definition or threshold-detection possible. 

Both MIMfusion and Mirada XD3 have versions of clinician portals.  Mirada is working on a rather nice feature, called Case Meeting, which encapsulates everything you need for a tumor-board presentation. MIM, of course, is working on the iPad/iPhone app, which is the reason I bought my first iPhone a few years back.  Their new version does a very nice job of displaying a fused study.  MIM also has access to cloud storage.

MIM has completely redone their interface with a new flexible layout and new icons.  There are multiple options on both for hanging protocols. 

The GE opus isn't available yet, but both MIMfusion and Mirada XD3 can be yours today for something like half the price of a Tesla Roadster.

Frankly, I am very impressed with both companies, (Mirada was recently bought back from Siemens by its founders) and both pieces of software.  When I encounter this situation, I usually punt, and I'll do so again in this manner.  Here we have two companies competing against each other, offering similar paths to the same end.  The obvious solution is for these two fine operations to merge in some fashion.  Their individual strengths could thus be compounded into a true killer-app.  I'll take a free copy of each program for providing that suggestion.

In the meantime, I do have to close with a report from another great company, Calgary Scientific.  I was able to visit with their principals, who appreciated the warm weather offered by Chicago this time of year relative to what they had back home.  I don't have a lot more to tell you than I did back when I wrote my iPad article last summer, but I got some more hands-on time with their products.   FDA approval for ResolutionMD, the client-server viewer, is apparently imminent, so it can be used diagnostically.  But the real show-stopper is Calgary's ability to port ANY software to the iPad, iPhone, or pretty much any other device with the PureWeb platform.  This is phenomenal, and opens up a lot of possibilities. 

And there you have it, my experiences at RSNA in several divided doses.  Did I mention that it was bloody cold in Chicago?  There are ways to warm up, however, as Mike Cannavo, the One and Only PACSMan, documents nicely:

That's me in the black with Mike and the crew.

El Grande!  See you next year at RSNA!

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