Volumetric 4D CT from a Research Perspective:
An Interview with Dr. Patrik Rogalla
Toronto, Ontario, July 16, 2014 – An interview with Dr. Patrik Rogalla, Director of Research, Director of CT and Head of Abdominal Division, at the Joint Department of Medical Imaging (JDMI), University of Toronto Research.
Dr. Patrick Rogalla is Professor of Radiology, and Head of Abdominal Imaging at the University of Toronto. He also serves as Vice Chief, Research Head of Abdominal Division Director, CT, Joint Department of Medical Imaging, University of Toronto and Toronto General Hospital. He studied at the Free University of Berlin in Germany and the University of California UCSF. Dr. Rogalla is actively involved in many professional and radiological societies. His areas of focus include: cardiac CT, gastro-intestinal imaging, interventional CT, perfusion imaging and three-dimensional post-processing techniques. His academic work includes authoring or co-authoring of 150 peer-reviewed publications, 156 scientific presentations and posters and more than 321 educational lectures in national and international meetings.
Tell us a little about your role as the Director of CT and Head of Abdominal Division, at the Joint Department of Medical Imaging (JDMI), University of Toronto.
As Director of Research, I oversee all aspects of research related to medical imaging including the development of new techniques and clinical applications, collaboration with other departments including the radiation medicine program, and interaction with our industrial partners to bring our developments to a wider audience. I envision my role as a catalyst to advance Radiologic knowledge, engender a passion for academic discovery at JDMI, and promote cutting-edge research on both a basic and applied level to drive medical imaging forward and to better help our patients.
What aspect of your clinical research has been the most challenging?
There are really two main arms of the research work that I do: translational, clinical research where we apply existing techniques to clinical patients to prove the efficacy and power of these techniques and fundamental, development research where we create novel techniques and advanced imaging procedures. The main challenge with the clinical research is that Radiology departments do not have direct access to the patients and are dependent on referrals to enroll patients into research programs. This dependence on other clinical departments is most challenging when the goals and initiatives of that department are not directly aligned with our own. In order to address this challenge, we must make a concerted effort to build excellent relationships with our clinical partners and to communicate the extremely positive impact our work has in streamlining their diagnosis-to treatment workflow, providing them with clear and confident answers to their clinical questions, and ultimately improving the lives of their patients. On the other hand, for the fundamental research, the challenges are a bit different. To create new imaging techniques, it requires more direct collaboration with our industrial partners to pull together the required technical resources since we do not always have this sort of expertise in house. Of course, there is healthy but stiff competition between the vendors and they each have their own take on what the next best step is. This means that their ideas for the future are not always directly aligned with ours and some discussion and negotiation has to take place. This is a very positive process as it often pushes both the vendors and our own researchers in new directions. In the end, it has driven us to a great deal of success over the years.
How can medical vendors help you deal with these challenges?
The relationship between academics and industry is a critical one to drive the technology forward. Industry has the technical expertise, we have the patients and clinical knowledge, and ideas are generated on both sides for new innovations. However, in this relationship there is a natural conflict of interest that must be acknowledged and mitigated. As a business entity, any industrial partner has financial success at the forefront of their motivation. They have a vested interest in research studies that have positive results that are favorable to their technology. It is critical, however, that we maintain complete independence in our research and that we avoid any potential for the appearance of collusion. This is in the best interest of both parties. We, as academics, need to maintain our scientific integrity and be able to develop and publish solid, quality research independent of the results. The vendors benefit from that reputation of integrity since any results we do publish will be received with trust from the scientific and clinical community who are the vendor's customers and potential customers.
In the end, though, the vendors share a common goal with us as researchers: improved patient care. The best industrial partners recognize that the most sustainable path to success lies along the path of sound, independent scientific research carried out by respected academic partners such as UHN. This will improve patient care, enhance scanner technology, and ultimately drive corporate profitability for them. As an academic institution, we must follow the path of independence and scientific integrity even as we collaborate and are funded by our industrial partners.
When it comes to medical imaging systems, what is important to you and why?
Medical imaging is at the fundamental core of modern patient care. The diagnosis and treatment of every major disease is, at a minimum, facilitated by imaging. At JDMI, the imaging systems need to feed directly into our philosophy, vision, and values which all focus on creating and delivering the best possible patient care. For CT, in particular, the scanners need to be fast, accurate, and safe. Fast scans minimize motion artifacts for all exams and are critical for cardiac imaging. Furthermore, rapid scanning opens the way for other motion imaging and perfusion. Scanners also must produce accurate representations of the underlying anatomy and physiology of the patients, faithfully reproducing details of the patient's body. Finally, we must minimize the potential harm from ionizing radiation making sure we use the smallest radiation dose necessary to accomplish our task. We are responsible to account for every aspect of the imaging process in order to give the best patient care. Medical imaging technology should help us to achieve that vision.
How long have you been involved as a research partner with Toshiba?
My initial contact with Toshiba was in 1997 and I have been actively working with them as a research partner for nearly 15 years, since 1999.
What were the circumstances that persuaded you to work as a research associate with Toshiba?
Toshiba has always been a technology-driven company that focuses on innovations and pushing the technical boundaries. For a field like medical imaging, this outlook helps to keep the field growing and improving. I love working with a company that is committed to excellence and innovation.
What do you believe are the benefits of working with Toshiba's Research and Development team?
There are distinct benefits across the board in our collaboration with Toshiba, from personal benefits to me, benefits to the patient, our academic department, and to Toshiba itself. This is critical since for any partnership to be fruitful; all parties must realize some advantage.
On a personal level, I have had access to cuttingedge technology and been able to collaborate with innovative engineers and scientists. Through the process, I have not only contributed to the development of this technology but have also learned a great deal myself. I am grateful for this opportunity. Our work together has opened up many new imaging possibilities and created some truly unique ideas.
From the patient point-of-view, the creation of this new technology opens the doors to new diagnostic techniques that are safer, more accurate, and can be captured in a fraction of the time. Just imagine going back to the days of exploratory surgery for abdominal pain! Also, the new technology that we have worked on with Toshiba has dramatically reduced the radiation dose to the patients without compromising diagnostic quality, making CT imaging much safer for the patient.
On an institutional level, working with an industrial partner allows us to have access to equipment before it is commercially available. While there can be a risk with such underdeveloped technology that it doesn't always provide the intended benefit, the ability to pioneer new techniques and publish on them helps to bring these new innovations to our patients at a very early stage and ultimately works to raise the reputation of the entire hospital. Finally, Toshiba benefits from this partnership by getting access to our patients, clinical expertise, and knowledge of the specific clinical problems that would benefit most from technological innovation. Furthermore, Toshiba receives early feedback on their new developments and gains a tremendous partner to participate in the creation of new diagnostic pathways. When you put everything together, this partnership can only work if there is significant benefit for all, the most important of which is the patient.
What do you feel will be the benefit of your research with the Aquilion ONE and the ViSION with respect to patient care?
I am always wary of such questions that seek to compare technologies. All vendors have great products and each one has distinct strengths and weaknesses with respect to certain aspects of performance. What I will say regarding the ViSION is that, at its current level, it has many attributes which are the best available. Overall, balancing its strengths and weaknesses, the scanner is on the stronger side. Rapid patient imaging with low dose is available. Furthermore, its perfusion imaging, subtraction, and dual energy techniques are excellent. Finally, its flagship application is cardiac imaging. Its capability in cardiac imaging is the biggest reason that I would decide to work with the ViSION over other CT systems.
And what comments can you make with regards to your research with the Aquilion ONE?
With respect to cardiac imaging, the introduction of the ViSION system has removed some of the original weaknesses of the Aquilion ONE and it is a huge step forward. The ViSION has created a new era and has put Toshiba back into the pole position in CT technology.
What differentiates Toshiba from other leading medical imaging companies in the CT arena?
In CT especially, a medical imaging company needs to strike a balance between developing the novel imaging of the future and maintaining a solid base of the standard bread-and-butter utilization of their equipment. Very often, cutting-edge technology tends to be somewhat fragile at the beginning and unable to meet the demands of high patient throughput, reliability, and predictable operating costs that are common in a busy, large institution. Most centers, including ours, will not consider a scanner that falls short in these areas. Toshiba has always done a good job at providing this balance between robust and reliable systems that still are associated with cutting-edge applications and technology. I think this positioned Toshiba uniquely against many other companies. That is not to say that there are no other good companies in the market. All companies have strengths and weaknesses. One of the things that differentiates Toshiba, however, is that they place a high value on the identification of a weakness so that it can be addressed and overcome. One of the great benefits of our collaboration with Toshiba has been in our ability to help identify elements of sub-optimal performance and then work to advance the quality of their product for patient benefit. We do not have a commercial interest, but rather a desire to help create the best possible technology and to translate its operation into better patient care.
What do you believe to be the major challenge for companies involved in developing CT technology?
While we, as academic collaborators, have to walk the fine line of avoiding being compromised by commercial interest and maintaining neutrality, imaging companies need to ensure that they receive a return on their research investment. It is critical for the company to fund research projects that are directly in line with their own development plans and it is natural for them to avoid collaborations that would develop a technology that the company could never produce or turn into a commercial product. The ability to navigate this narrow path and to avoid commercially compromised research while still working on projects that support the company's goals is the mark of a successful collaboration.
While it has been predicted time and again that CT imaging was dead, quite the opposite has proven true. There is a tremendous investment in technology development and so much use of the modality that there has been some concern about its overuse. With that explosion in technological development, the cost of building new technology has become very expensive. Now more than ever, companies need to be very strategic about their investments and future directions. They have to make difficult decisions about where to invest and which technologies have the largest potential upside. This is clearly the most significant challenge for imaging companies: which technology to invest in. This is where we, as collaborators, can help. However, in that, we need to stay neutral. There is no obligation on our part to work only with a single company or technology. The partnership is based on the mutual goal of benefiting the patient and it is important for us to maintain independence.
The other major challenge we all face is the bureaucracy within Health Canada that can cause significant delays in the introduction of new technology in Canadian Hospitals. There is clearly a need for a system that ensures the safety and efficacy of devices to be used on patients, but the current level of overhead and time that it takes for a new or improved device to be cleared results in our patients being denied access to some of the best new technology well after it is in common use in Europe, the United States, and the rest of the world. I am not suggesting that we compromise the safety of our patients in any way, but there needs to be a significant improvement to the process to align the timing of the Canadian introduction of technology with the rest of the world. There was recently a similar challenge with the FDA in the United States, and they have found ways to improve their process by working collaboratively with both academics and industry. We can do the same thing here in Canada, but we need to be vocal about the need in order to change.
What is your personal vision in terms of where CT technology is likely to go in the next ten years?
At its core, CT imaging is about the optimal use of x-ray technology. I feel that the current state-of- the-art in CT is still fairly basic in the way that the x-ray photons are turned into information in the image. There is an assumption in imaging that the photons that pass through the body had no interactions and were not altered in any way, but this is often not true as many x-rays are scattered. Also, knowing more about the energy x-rays that make it through the body can lead to greater insight about the patient's anatomy and physiology. Also, there is always discussion about improving acquisition speed and spatial resolution. These will continually evolve and increase, but I like to look beyond the race to be faster. Furthermore, there is currently too much hysteria about radiation dose in CT. We will, of course, continue to reduce the dose and minimize the risk to the patient. However, the hysteria is causing a bigger problem which is that patients who need CT are afraid to get one. This can lead to insufficient diagnosis and compromise their care. We need to get beyond the notion that CT is defined by radiation dose alone. The next five to ten years will see tremendous improvements in the leveraging of x-rays to produce more precise anatomical and functional information. Ultimately, this will translate into new horizons in CT and a completely different way of looking at the images. We are only at the earliest stages of this development and the coming years will be very exciting for CT.
Thank you for this interview.
About Toshiba of Canada Limited, Medical Systems Division
With headquarters in Markham, Ontario, Toshiba of Canada Limited, Medical Systems Division (TCL), markets, sells, distributes and services radiology and cardiovascular systems, including CT, MR, ultrasound, X-ray and cardiovascular equipment, and coordinates clinical diagnostic imaging research for all modalities in Canada. For more information, visit the TCL Medical Systems Division website at www.toshiba-medical.ca
About Toshiba Medical Systems Corporation
Toshiba Medical Systems Corporation is a leading worldwide provider of medical diagnostic imaging systems and comprehensive medical solutions, such as CT, X-ray and vascular, ultrasound, nuclear medicine and MRI systems, as well as information systems for medical institutions. Toshiba Medical Systems Corporation has been providing medical products for over 80 years. Toshiba Medical Systems Corporation is a wholly owned subsidiary of Toshiba. Visit Toshiba Medical Systems Corporation’s website at www.toshibamedicalsystems.com.
Toshiba Corporation, a Fortune 500 company, channels world-class capabilities in advanced electronic and electrical products and systems into five strategic business domains: Energy & Infrastructure, Community Solutions, Healthcare Systems & Services, Electronic Devices & Components, and Lifestyles Products & Services. Guided by the principles of The Basic Commitment of the Toshiba Group, “Committed to People, Committed to the Future,” Toshiba promotes global operations towards securing “Growth Through Creativity and Innovation” and is contributing to the achievement of a world in which people everywhere live in a safe, secure and comfortable society. Founded in Tokyo in 1875, today’s Toshiba is at the heart of a global network of over 590 consolidated companies employing over 200,000 people worldwide, with annual sales surpassing 6.5 trillion yen (US$63 billion). To find out more about Toshiba, visit www.toshiba.co.jp/index.htm.