ECR 2013: Q&A with Dr. Les Folio, Radiologist at the National Institutes of Health Clinical Center

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Dr. Les Folio, Radiologist, NIH and Adjunct Clinical Professor, Radiology, George Washington University Hospital

Dr. Les Folio is a radiologist at the National Institutes of Health Clinical Center and an adjunct Clinical Professor, Radiology, George Washington University Hospital has recently completed research titled, “Automated Registration, Segmentation, and Measurement of Metastatic Melanoma Tumors in Serial CT Scans,” which will be published in Academic Radiology in the next few months. Dr Folio will be presenting at ECR2013 and we’ll be interviewing him at the show following this presentation – we caught up with him this week to gauge what he thinks he can expect at the show.

What will be the first reaction from radiologists when they see this research? How will you respond?

Judging from the US and local presentations I’ve already given, I’d expect them to be mixed.

General radiologists that do not do oncology regularly may be excited that the segmentation capabilities are now within PACS to save time assessing volumes across serial images. Some will wonder if there will be more expectations from radiologists with this capability, a genuine concern, at the same time; perhaps radiologists should be more quantitative in reports; beyond the scope of my presenting the current research.

Just to clarify this point: Are you suggesting that radiologists ought to be producing more quantitative reports, or that they might think they should be producing more quantitative reports?

Simply put, I believe radiology departments will be producing more quantitative reporting; in addition to the current qualitative reports we traditionally provide. Some radiologists, like myself, will include in the report; most will likely depend on radiologist extenders that many cancer centers now have. Of note, there has been initial success in providing an additional charge for the quantitative report; since it is often a separate event, but another radiologist (for example). Ability to obtain RVU’s should provide a funding source to provide these additional reports.

Radiologists that perform staging exams in metastatic cancer should be glad to see PACS providers are moving towards image post processing self-sufficiency. Specifically lesion measurements, which will now include volumes and volumetric density, exporting of bookmark annotations in organized tables associated with organs and tumor trajectory plots.

One common reaction I experience is the surprise that we will be assessing all lesions rather than a select few as all other criteria currently do. Especially in the disease we are currently studying: ASPS (Aveolar Soft Parts Sarcoma), where some patients have nearly 100 metastatic lesions. It is undoubtedly a monumental effort and I do not expect all lesions to be successfully segmented, at least in the initial years. But this could well be a trend – I believe this may be the direction the oncology community goes, Of course nobody can say that for sure, but what better tumor burden assessment than to look at all lesions volumes and densities, at least in targeted therapy cancers?

How will the automation of this process eventually work into the radiologist’s workflow? What benefits will this ultimately have?

I can only speak for those radiologists such as myself aiming toward providing more comprehensive tumor burden reporting. National surveys confirm most radiologists provide select tumor measurements, providing image-series number in reports. However, most in the US do not provide RECIST reports, and many for good reasons. Unless one knows the history, baseline, and to what exam to compare, tumor assessments are left to radiologist extenders, nurse managers or the oncology teams themselves. Also, there is a lack of agreed-upon standards as to how to report, tabulate, save annotations and what format to save in.

At NIH and many other cancer centers, we are providing more comprehensive reports by working with individual teams on the way they assess tumors since there are assessment modifications depending on cancer type (mesothelioma, GIST and ovarian cancer each have specific ways of assessing, for example). We provide the unique criteria, with teams providing specific histories and constant feedback through emails, calls and meetings. We have a radiologist dedicated to tumor assessment, with other radiologists working with individual teams through investigation associations (for example).

I can speak best for myself in that the registration and key image capability has saved me many hours over the last few years. With the one-button lesion-tracking tool we co-developed, the time savings will save at least half the time (as we showed in a study accepted for publication in AJR). I am looking forward to the next version where we have the ability to segment baseline and fully automatic serial exams. The survey I mentioned earlier said that 86% of radiologists would provide tumor measurements if it were possible to do it with one mouse click; that is what we created.

 What is a “steeper tumor trajectory” and what does this capability mean for patients and for cancer treatment as a whole?

The tumor trajectory is the direction and magnitude that metastatic lesions decrease or increase in size; and in our case how necrotic they get as they sometimes disappear now with targeted therapy. Of course we hope that the direction for steep trajectories is to disappear (indicating cancer therapy is working), however, it is just as important to demonstrate when tumors are growing, or not responding to therapy. This will save on patients getting unnecessary treatments (and side effects) and save money by discontinuing medications earlier.

Taking density into account may help make the trajectory steeper in that some tumors (like sarcomas) do not decrease in size as much as they do become necrotic (less density). Our TVVT is a product of density (throughout every lesion) and volumetric size (of all lesions). We cannot think of a more comprehensive way of assessing metastatic cancer.

How will this affect the relationship between the radiologist and  oncologist?

It could mean a stronger, more cooperative relationship. I believe that improved automatic segmentation within PACS that allows radiologists to instantly compare and import measurements and comparisons into reports will bring oncologists to radiology more often for guidance such as more complete histories and what exams to compare with. The ultimate result being improved patient care.

The views expressed here are of Dr. Folio and are not necessarily of the NIH or the U.S. government. Also, Dr. Folio is a member of Carestream’s advisory board.

UPDATE – March 14, 2013:

Below is an interview with Dr. Folio about his research that was conducted in Vienna at ECR 2013. You can click on the link to read more about Carestream’s lesion management assessment technology.

[youtube http://www.youtube.com/watch?v=-Jfx22sJXps?rel=0&w=560&h=315]