New applications made possible by improved transducer technology and system software are having an impact on radiologists' practice patterns
Premium ultrasound carries a significant price tag, thanks to its configuration rich with applications intended to deliver real-time views of the anatomy. Nonetheless, price appears to pose no impediment to an expanding group of imaging departments and imaging centers sold on the idea of possessing ultrasound technology so advanced that it can, in some instances, rival or surpass the utility and diagnostic value of MRI or multidetector CT.
For the purposes of this article, premium ultrasound is defined as a high-quality, general-radiology ultrasound system capable of compound and advanced harmonic imaging, with dedicated applications for abdominal, breast, small-parts, and vascular ultrasound, based on an advanced architecture with software-based updating and multifrequency transducers, priced at or above $100,000.
Ronald S. Adler, MD, PhD, is chief of the division of ultrasound and body CT in the radiology and imaging department at the Hospital for Special Surgery, New York. “Most often MRI, and to a much lesser extent CT, feeds into ultrasound for guided interventions. An abnormality initially identified on, say, an MRI, such as a paralabral cyst in the shoulder, may then be referred for an ultrasound-guided intervention,” he explains. “Not infrequently, however, we are asked to evaluate a suspected abnormality directly using ultrasound and inject if appropriate. An example might be a patient with wrist pain who is clinically suspected of having a ganglion cyst. The guided interventions are largely cortisone shots, but these may also refer to aspirations or even targeted anesthetic injections.”
In those instances when ultrasound stands in for MRI or CT, the greater clarity and resolution provided by premium systems pays dividends. “I recently handled a case where both an MRI and an ultrasound were taken in order to help us ascertain the presence of a suspected ulnar-nerve abnormality. The quality of the MRI we get here is usually exquisite, and thus the modality is ideal for making this kind of determination, but in this instance, the patient had indwelling metallic hardware. While there have been improvements in MRI—and CT, for that matter—to address the indwelling-metallic-hardware issue, the fact remains that indwelling metallic hardware produces artifact, always.”
Adler continues, “This, in combination with the claustrophobic patient’s difficulty remaining motionless while in the MRI gantry, resulted in an MRI image that was virtually uninterpretable. We then took an ultrasound using one of our high-end machines. It beautifully depicted the abnormal ulnar nerve—and the precise location of that abnormality,” shown in Figure 1.
Adler and many others have come to recognize premium ultrasound as a tool for producing definitive answers that obviate any need for further diagnostic procedures. “In some cases, ultrasound proves to be the only way to get the answer,” he says.
A similar view is held by Margaret Szabunio, MD, director of breast imaging and ultrasound at the H. Lee Moffitt Cancer Center and Research Institute in Tampa, Fla. “High-end ultrasound enables us to see lesion morphology in remarkable detail, which is very important in order to characterize breast lesions correctly, so that we can determine into which ACR BI-RADS® category we will place them,” she says. “A key part of the evaluation of a breast lesion is the margins. You can see these very nicely with high-end ultrasound.”
Premium ultrasound is also prized by decision makers at Johns Hopkins Medical Institutions in Baltimore; they elected to acquire roughly a dozen such systems. Robert deJong, RDMS, RDCS, RVT, radiology technical manager of ultrasound, says, “Yes, premium ultrasound is very expensive, but we have several ways of justifying the cost. One way is by taking into consideration the marketing edge that premium ultrasound gives us. In our messages to the referring-physician community and to consumers, we’re able to trumpet the fact that we possess the technology and related expertise to perform certain diagnostic tests better, more safely, and more rapidly.”
He adds, “We believe this is a strong selling point that opens the door to increased case volume. It ties directly into the Johns Hopkins brand; patients come here because they see us as the best