Embrace image-guided intervention or perish

"Medicine is interventional - fundamentally and intrinsically. From Hippocrates to today's interventionalists, physicians throughout history have seen the value of the rapid diagnosis and intervention that today's technologies are enabling," Vannier said. "Central to today's diagnosis and treatment paradigm is imaging, which is well understood and accepted by the public, and a common entry point into the healthcare system. Technology is also doing its part to reshape and often eliminate the dividing lines between medical practices and practitioners."

Vannier believes that as technological advances continue to blur the lines between medical specialties, interventional radiology is destined to play a central role in medicine's future. "Although future multimodality image-guided operating systems will bear little resemblance to the interventional radiology practices of today, their core function, combining minimally-invasive diagnosis and therapy in an effective, time and cost-efficient manner, will not change," Vannier said.

"Those kinds of distinctions, about what your specialty is and what services you provide, are becoming indistinct. Procedures are offered by radiologists that used to be offered by surgeons. Now there are combination therapies, including chemoradiotherapy and others, where the distinctions are blurred." This observation has many examples; such as how cardiac surgeons trained in coronary artery bypass surgery might find much of their work taken over by interventional cardiologists, who can take the patient to the cath lab and perform balloon angioplasty. Again, the advancement of technology is dictated by change - where CT is taking over angiography procedures, even in the emergency setting, maybe virtual colonoscopy will in the future perform the majority of colorectal cancer screening examinations.

In other cases, technology paves the way to new and highly complex surgeries that can only be performed by teams of physicians from different specialties. Vannier cited the example of a complex tumor surgery or the separation of conjoined twins - for diagnosis, through surgery, to follow-up imaging is the common thread. "Of course, interventional medicine is very disruptive to hospitals and to healthcare organizations. There are simply so many technologies that it is not realistic to think that a single organization can offer state-of-the-art services in every one of these areas - every institution needs to focus and specialize to use its scarce resources judiciously," he said.

Vannier said that the need for such complex requirements has not gone unnoticed by the corporations who are developing their own strategies to claim a stake in the increasingly broad and complex marketplace for technology, developing the infrastructure to support the new treatment paradigms - the ability to provide earlier detection and faster, better treatment at a reasonable cost.

According to Vannier, such developments will arrive as part of a four part strategy; the digitization and distribution of imaging data; investment in minimally-invasive therapies; the ability to prevent disease at an earlier stage using a variety of imaging and non-imaging tests; and to use advanced technologies to better predict who is likely to develop certain diseases and who is not.

It is then the responsibility of the institution to bring the developments together into workable models. Vannier cited the example of Boston's Massachusetts General Hospital, which has a center for minimally-invasive therapies that is working on the operating room of the future. "They have a very deliberate process to both develop the technologies, and then clinically validate them in a real environment and to give guidance that is central to the thinking of many," he said.

Moreover, at the University of Washington School of Medicine in St Louis, Professor of Surgery, Dr Richard Satava has defined several intrinsic elements of the operating room of the future, including imaging, robotics and interactive displays and instruments. Vannier said Dr Ferenc Jolesz from Brigham and Women's Hospital in Boston has been a visionary in the field with his group's development of an image-guided therapy program.

The intraoperative MRI has double-doughnut design, features intraoperative viewing and important innovations in 3D navigation in the clinical setting. The Brigham and Women's group has also been very innovative in the development of MRI-guided cryoablative therapies, and MRI-guided focused ultrasound technology built into the scanner table. "Many of us can do breast imaging, but what is added is the ability to target that lesion, and thermally ablate it percutaneously using focused ultrasound," Vannier said.

The same technology can be used to treat uterine fibroids, non-invasively, inside the scanner. Focused ultrasound has even been used to ablate brain tumors. Drugs or gene therapy agents can be administered systemically prior to focused ultrasound to manipulate the treatment in still more ways. Focused ultrasound can be used to occlude blood vessels, sparing invasive surgery or embolization, Vannier said.

More recently, Brigham and Women's has been cooperating with Cambridge, MA-based CIMIT to develop an advanced multi-modality image-guided operating system (AMIGO) that is nearly ready to open as an OR, Vannier said. AMIGO combines state-of-the-art imaging systems (3-tesla MRI, PET/CT, fluoroscopy, ultrasound, and optical imaging) designed to work together using advanced information technology within the operating suite.

This type of imaging for surgery touches virtually all the surgical subspecialties and it is an important test ground for the development of other new technologies as well. Indeed, several imaging modalities enable new procedures that would not otherwise be possible, offering real outcome benefits for the patient, he said.

"Many other technologies in development have breakthrough potential and could very easily eclipse the practice as it exists today. The forefront of change is really in image-guided intervention. Those who understand and accommodate these changes will do very well, and those that do not face a perilous future," Vannier said.