William F. Auffermann

Conventional Medical Education and the History of Simulation in Radiology

Simulation is a promising method for improving clinician performance, enhancing team training, increasing patient safety, and preventing errors. Training scenarios to enrich medical student and resident education, and apply toward competency assessment, recertification, and credentialing are important applications of simulation in radiology. This review will describe simulation training for procedural skills, interpretive and noninterpretive skills, team-based training and crisis management, professionalism and communication skills, as well as hybrid and in situ applications of simulation training. A brief overview of current simulation equipment and software and the barriers and strategies for implementation are described. Finally, methods of measuring competency and assessment are described, so that the interested reader can successfully implement simulation training into their practice.

Radiographic Imaging for Patients With Contagious Infectious Diseases: How to Acquire Chest Radiographs of Patients Infected With the Ebola Virus

OBJECTIVE Contagious infectious diseases add a new dimension to radiology and pose many unanswered questions. In particular, what is the safest way to image patients with contagious and potentially lethal infectious diseases? Here, we describe protocols used by Emory University to successfully acquire chest radiographs of patients with Ebola virus disease. CONCLUSION Radiology departments need to develop new protocols for various modalities used in imaging patients with contagious and potentially lethal infectious diseases.

Online Social Networking for Radiology

Online social networking services have changed the way we interact as a society and offer many opportunities to improve the way we practice radiology and medicine in general. This article begins with an introduction to social networking. Next, the latest advances in online social networking are reviewed, and areas where radiologists and clinicians may benefit from these new tools are discussed. This article concludes with several steps that the interested reader can take to become more involved in online social networking.

A Translational, Pharmacodynamic, and Pharmacokinetic Phase IB Clinical Study of Everolimus in Resectable Non-Small Cell Lung Cancer.

Purpose: The altered PI3K/mTOR pathway is implicated in lung cancer, but mTOR inhibitors have failed to demonstrate efficacy in advanced lung cancer. We studied the pharmacodynamic effects of everolimus in resectable non–small cell lung cancer (NSCLC) to inform further development of these agents in lung cancer. Experimental Design: We enrolled 33 patients and obtained baseline tumor biopsy and 2[18F]fluoro-2-deoxy-D-glucose-positron emission tomography/computed tomography (FDG-PET/CT) imaging followed by everolimus treatment (5 or 10 mg daily, up to 28 days), or without intervening treatment for controls. Target modulation by everolimus was quantified in vivo and ex vivo by comparing metabolic activity on paired PET scans and expression of active phosphorylated forms of mTOR, Akt, S6, eIF4e, p70S6K, 4EBP1, and total Bim protein between pretreatment and posttreatment tissue samples. Results: There were 23 patients on the treatment arm and 10 controls; median age 64 years; 22 tumors (67%) were adenocarcinomas. There was a dose-dependent reduction in metabolic activity (SUVmax: 29.0%, −21%, −24%; P = 0.014), tumor size (10.1%, 5.8%, −11.6%; P = 0.047), and modulation of S6 (−36.1, −13.7, −77.0; P = 0.071) and pS6 (−41.25, −61.57, −47.21; P = 0.063) in patients treated in the control, 5-mg, and 10-mg cohorts, respectively. Targeted DNA sequencing in all patients along with exome and whole transcriptome RNA-seq in an index patient with hypersensitive tumor was employed to further elucidate the mechanism of everolimus activity. Conclusions: This “window-of-opportunity” study demonstrated measurable, dose-dependent, biologic, metabolic, and antitumor activity of everolimus in early-stage NSCLC. Clin Cancer Res; 21(8); 1859–68. ©2015 AACR.

Characterization of cardiac quiescence from retrospective cardiac computed tomography using a correlation-based phase-to-phase deviation measure

PURPOSE Accurate knowledge of cardiac quiescence is crucial to the performance of many cardiac imaging modalities, including computed tomography coronary angiography (CTCA). To accurately quantify quiescence, a method for detecting the quiescent periods of the heart from retrospective cardiac computed tomography (CT) using a correlation-based, phase-to-phase deviation measure was developed. METHODS Retrospective cardiac CT data were obtained from 20 patients (11 male, 9 female, 33-74 yr) and the left main, left anterior descending, left circumflex, right coronary artery (RCA), and interventricular septum (IVS) were segmented for each phase using a semiautomated technique. Cardiac motion of individual coronary vessels as well as the IVS was calculated using phase-to-phase deviation. As an easily identifiable feature, the IVS was analyzed to assess how well it predicts vessel quiescence. Finally, the diagnostic quality of the reconstructed volumes from the quiescent phases determined using the deviation measure from the vessels in aggregate and the IVS was compared to that from quiescent phases calculated by the CT scanner. Three board-certified radiologists, fellowship-trained in cardiothoracic imaging, graded the diagnostic quality of the reconstructions using a Likert response format: 1 = excellent, 2 = good, 3 = adequate, 4 = nondiagnostic. RESULTS Systolic and diastolic quiescent periods were identified for each subject from the vessel motion calculated using the phase-to-phase deviation measure. The motion of the IVS was found to be similar to the aggregate vessel (AGG) motion. The diagnostic quality of the coronary vessels for the quiescent phases calculated from the aggregate vessel (PAGG) and IVS (PIV S) deviation signal using the proposed methods was comparable to the quiescent phases calculated by the CT scanner (PCT). The one exception was the RCA, which improved for PAGG for 18 of the 20 subjects when compared to PCT (PCT = 2.48; PAGG = 2.07, p = 0.001). CONCLUSIONS A method for quantifying the motion of specific coronary vessels using a correlation-based, phase-to-phase deviation measure was developed and tested on 20 patients receiving cardiac CT exams. The IVS was found to be a suitable predictor of vessel quiescence. The diagnostic quality of the quiescent phases detected by the proposed methods was comparable to those calculated by the CT scanner. The ability to quantify coronary vessel quiescence from the motion of the IVS can be used to develop new CTCA gating techniques and quantify the resulting potential improvement in CTCA image quality.

Deep Learning in Radiology

As radiology is inherently a data-driven specialty, it is especially conducive to utilizing data processing techniques. One such technique, deep learning (DL), has become a remarkably powerful tool for image processing in recent years. In this work, the Association of University Radiologists Radiology Research Alliance Task Force on Deep Learning provides an overview of DL for the radiologist. This article aims to present an overview of DL in a manner that is understandable to radiologists; to examine past, present, and future applications; as well as to evaluate how radiologists may benefit from this remarkable new tool. We describe several areas within radiology in which DL techniques are having the most significant impact: lesion or disease detection, classification, quantification, and segmentation. The legal and ethical hurdles to implementation are also discussed. By taking advantage of this powerful tool, radiologists can become increasingly more accurate in their interpretations with fewer errors and spend more time to focus on patient care.

The Dubious Value of Coronary Calcium Scoring on Lung Cancer Screening CT.

Coronary artery disease is responsible for approximately 620,000 new acute myocardial infarctions each year in the United States and accounts for approximately 380,000 annual deaths [1]. On the basis of data released from the National Lung Screening Trial, CMS ruled in February of 2015 that it will cover annual lung cancer screening with low-dose CT for asymptomatic individuals aged 55-77 with a tobacco smoking history of at least 30 pack-years who are currently smoking or who had quit within the past 15 years [2]. Even within this segment of the population that is at substantively increased risk of lung cancer (the number one cancer killer in both men and women), heart disease is still the most likely cause of death [3]. Therefore, there have been a number of proponents suggesting that coronary calcium scoring, whether performed quantitatively or qualitatively, could and/or should be reported on lung cancer screening CT reports [4]. The thought of coupling screening of lung cancer with coronary arterial calcium assessment, thus simultaneously assessing two leading causes of death, has been enticing. However, upon further examination, it may be best to temper enthusiasm for the value of coronary artery calcification. In the overwhelming majority of lung cancer screening

Teaching search patterns to medical trainees in an educational laboratory to improve perception of pulmonary nodules

Abstract. The goal of this research is to demonstrate that teaching healthcare trainees a formal search or scan pattern for evaluation of the lungs improves their ability to identify pulmonary nodules on chest radiographs (CXRs). A group of physician assistant trainees were randomly assigned to control and experimental groups. Each group was shown two sets of CXRs, each set with a nodule prevalence of approximately 50%. The experimental group received search pattern training between case sets, whereas the control group did not. Both groups were asked to mark nodules when present and indicate their diagnostic confidence. Subject performance at nodule detection was quantified using changes in area under the localization receiver operating characteristic curve (ΔAUC). There was no significant improvement in performance between case sets for the control group. There was a significant improvement in subject performance after training for the experimental group, ΔAUC=0.1539, p=0.0012. These results demonstrate that teaching a search pattern to trainees improves their ability to identify nodules and decreases the number of perceptual errors in nodule identification, and suggest that our knowledge of medical image perception may be used to develop rational tools for the education of healthcare trainees.

A 68-Year-Old Musician With Cough, Wheezing, and a Lung Mass

A 68-year-old man was referred to the pulmonary clinic for evaluation of cough and a 5-cm right upper lobe mass. He was in his usual state of health until 1 year prior when he developed intermittent cough, wheezing, and sinus congestion. He denied any sputum production or hemoptysis. He also denied any fevers, chills, or weight loss. He had received various treatments within the prior 6 months, including short courses of oral prednisone, levofloxacin, and bronchodilators, without any relief of his symptoms.

Abstract LB-194: Window of opportunity preoperative interrogation of mTOR pathway in patients with resectable non-small cell lung cancer (NSCLC).

Proceedings: AACR 104th Annual Meeting 2013; Apr 6-10, 2013; Washington, DC Background: We conducted this ‘window- of-opportunity’ study to characterize the biologic activity of everolimus, an allosteric inhibitor of mTOR pathway, in patients with surgically resectable NSCLC. Methods: Patients with surgically resectable NSCLC (Stage I-III) underwent baseline tumor biopsy and FDG PET/CT scan followed by treatment with everolimus (5 or 10mg daily for up to 28 days). A repeat PET/CT scan was obtained 24 hours prior to surgery. Blood samples for pharmacokinetic (PK) assay for drug levels were collected at 0.5, 1, 2, 5, 8 and 24 hours post drug ingestion on Days 1, 8 and 21. Control patients not treated with everolimus also had paired FDG PET/CT scans prior to surgery. Target modulation by everolimus was assessed in vivo by PET and ex vivo by immunohistochemical detection of total and phosphorylated mTOR, Akt, S6, eIF4e and 4EBP1 in pretreatment and posttreatment tissue samples. Alterations in common driver mutations in NSCLC were assessed using SnapShot minisequencing technique. Results: We enrolled 33 patients; 23 on everolimus and 10 on the control arm. Median age: 64 yrs (range 36-77), gender: (14/19 -M/F), stage (I - 14; II - 13; IIIA - 6); histology (adenocarcinoma - 22; squamous - 7; others - 4). Treatment was tolerated well with mostly grade 1/2 toxicities (hyperglycemia, hypertriglyceridemia, anemia and fatigue) and 32 of 33 patients proceeded with surgery on schedule. Compared to controls, there was significant reduction in SUVmax and median anatomic tumor size in a dose-dependent manner in everolimus-treated patients (15.38 vs. -21.74 vs. -23.23; p=0.012 and 4.39 vs. 0 vs.-13.33; p=0.039 in the control, 5mg and 10mg cohorts respectively). There was a similar trend in reduced metabolic activity in Ras mutant tumors treated with 10mg everolimus compared to control (88% vs. -28%). Comparison of baseline biopsy samples and resected tumor specimens in control and everolimus-treated patients showed reduction of S6 (-27.38 vs. 0 vs. -78.95; p=0.0536), pS6 (-20 vs. -29.17 vs. -57.14; p=0.0233) and p4EBP1 (-45.83 vs. 0 vs. -75; p=0.057) with greatest reduction observed in patients treated with higher dose of everolimus. Conclusions: Everolimus exerts a measurable, dose-dependent biologic activity in NSCLC tumors. ‘Window of opportunity’ studies in early stage NSCLC provide strong mechanistic insights and guide development of novel targeted agents. Acknowledgements: This study was supported by NCI grant P01 CA116676. Everolimus was provided by Novartis Oncology. TKO, GS, SS, SSR and FRK are Georgia Cancer Coalition Distinguished Cancer Scholars. Citation Format: Taofeek Kunle Owonikoko, Daniel L. Miller, Seth Force, Gabriel Sica, Scott Kono, Madhusmita Behera, Jennifer Mendel, Zhengjia Chen, Allan Pickens, Robert W. Fu, William F. Auffermann, Jaqueline Rogerio, William E. Torres, Haian Fu, John Hohneker, Shi-Yong Sun, Anthony A. Gal, Suresh S. Ramalingam, Fadlo R. Khuri. Window of opportunity preoperative interrogation of mTOR pathway in patients with resectable non-small cell lung cancer (NSCLC). [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr LB-194. doi:10.1158/1538-7445.AM2013-LB-194