Images clockwise from top left: SonoSite’s series of Hand-carried ultrasound systems (clockwise from top left) Sonosite 180, sonoheart elite, ilook 25, and ilook 15; Philips’ HDI 5000; Clinical image from Cedara’s 3-D Baby Explorer; The Technos MPX from Biosound Esaote; Abdominal image from Toshiba’s Aplio system.

Ultrasound made an extra-splashy showing at the most recent RSNA. Instantaneous volumetric acquisition and display were front and center, jostling for attention with several completely new systems — which, by the way, just seem to get smaller and smaller.

At first glance, it may appear that all the new bells and whistles belong to cardiac systems. A closer look, however, shows that general imaging isn’t settling for the back seat. Live 3D, user-friendly features, and speedier processing topped the list of enhancements found in the latest products.

Volumetric imaging advances
Volumetric ultrasound, once considered a novelty, gets more sophisticated as time goes by. Biosound Esaote (Indianopolis) has an all-new 3D system called Technos MPX. Jim Chapman, director of marketing, says, “The system has many new capabilities such as 3D VPan, which is our extended-field-of-view imaging modality, and CnTI, which is the contrast option.”

Medison America (Cypress, Calif.) demonstrated its new Accuvix XQ at RSNA. The system reportedly gives the best 2D/3D imaging of all Medison systems so far. It offers freehand 3D, plus harmonic imaging and auto-imaging optimization. The company’s SonoAce 8000 Live system is now smaller and faster than earlier versions, utilizing the same beamformer technology found in Medison’s larger premium systems. The 3D system runs on a Windows 2000-based PC platform.

“Real-time 4D” are the buzz words at GE Medical Systems (GEMS of Waukesha, Wis.). That’s the company’s term for the live 3D technology it has aggressively developed since acquiring Kretztechnik AG (Tiefenach, Austria), a pioneer in 4D ultrasound, in 2001.

GEMS’s Voluson 730 is one of the new breed of systems that feature 2D, 3D, and 4D inclusively. It boasts a sleekly ergonomic design courtesy of Porsche, the race car folks. The Voluson line newly includes the 730 Expert, a real-time 4D system for fetal imaging that is half again as fast as the 730 Pro.

At RSNA, Siemens Medical Solutions Ultrasound Group (Issaquah, Wash.) also showed off a works-in-progress 4D version of the Sonoline Antares. It utilizes a real-time 3D technology Siemens calls fourSight, and it will ship by the end of this year.

Lars Shaw, director of worldwide ultrasound marketing for general imaging at Siemens, says, “It’s automatic acquisition, so when you put the transducer down it sweeps back and forth and gets you the image you need. It also incorporates tissue harmonics and TEQ. It also does really excellent 2D and 3D. It has great color and Doppler.”

Antares 4D includes StellarPlus, a new upgrade that adds SieClear (a compounding technology), SieScape (a wide field of view), 3-Scape real-time 3D imaging, and cadence contrast imaging.

Shaw notes that 4D on a 2D system should go far in winning over customers, some of whom can’t justify purchasing systems that perform only 3D or 4D ultrasound. Siemens and GEMS are both betting that doctors will find 4D beneficial once they try it.

Smaller package, greater functionality
The trend toward lighter, more compact portables continues to gain ground, while the equipment itself continues to gain features.

Medison’s new SonoAce Pico, for example, is a briefcase-sized system complete with digital beamforming, harmonic imaging, spectral and color Doppler, and freehand 3D. It is Linux-based and network capable.

GEMS has extended its Logiq line with Logiq 5, a smaller version of the premium Logiq 9 and 7, and Logiq Book, a laptop version that can store more than 4,000 images. Both the Logiq 5 and Logiq Book utilize GEMS’s TruScan architecture and have many of the same features of Logiq 9 and 7. Also, 3D is available on both as an option.

SonoSite, Inc. (Bothell, Wash.), which designs handheld ultrasound exclusively, delivered its 10,000th system in February. The SonoSite 180Plus is a general purpose, quick-look system with pulsed-wave Doppler, while SonoHeart Elite is a full echo system with color wave Doppler. Both weigh 5.7 pounds and are briefcase-sized. SonoSite’s newest entry, iLook, is a 3-pound, all-digital system available in two versions: iLook 15 for quick-look general imaging, and iLook 25 for guided vascular procedures. Both have color power Doppler and internal image storage. In December, Popular Science Magazine conferred its “Best of What’s New” award to iLook, naming it one of the top ten medical technology advances for 2002.

One-button simplicity plus ergonomic ease
Vendors are increasingly aware that user comfort matters, big time. The result is strides in design that, while cool-looking, are far more than cosmetic. Deluxe ease-of-use features found on more expensive systems are trickling downward in a steady stream, much to the delight of overstressed sonographers everywhere.

Siemens’s Sonoline Antares system, for instance, utilizes a tissue equalization technology called TEQ. Shaw says, “TEQ is our proprietary way to optimize an image with one button, not only throughout the field of view that you see, but also the side of the image. This gives the clinician the ability to focus on the pathology and get the diagnosis, versus continually tweaking the image. It’s migrated from our Sequoia platform. Not only does it do the deep gain, it does the lateral gain. Often, you’ll see chunks out of the image or, as you get to the end of the transducer, some splaying or spreading. Lateral gain will allow that to be optimized, so you see all the image in the image.”

Philips Medical Systems (Bothell, Wash.) demonstrated iSCAN at RSNA, a new feature on its HDI 5000 systems that simplifies 2D and Doppler operations. Victor Reddick, senior V.P. and general manager of Philips’s high-performance general imaging business, says, “With one button, you’re able to optimize the image quality as well as the Doppler signals. For a user who may not be utilizing the machine all the time, it makes it much simpler to operate.”

Biosound’s Technos MPX has a sonographer-loving keyboard. Chapman says it’s “a Windows-based platform. The screen controls are logically grouped and there’s a help menu available. The keyboard itself is backlit. There’s also an additional lighting system for the keyboard, which comes on automatically when the keys are depressed, and then goes off a few seconds after the last keystroke. It’s one of the things that everybody looks at and says, ‘Ooh — that’s nice!’

Siemens’ Sonoline Antares features 4D ultrasound imaging technology, which allows for real-time display of 3D images.

“One of the biggest problems right now in sonographer retention is losing them due to repetitive stress-type of injuries,” says Chapman. “That’s why we designed the Technos system to be ergonomic. It allows sonographers to work from a variety of postures, and have a keyboard laid out so there is little stress on the hand and wrist and arm as they move across the keyboard. Technos transducers are ergonomically designed and weigh under 4 ounces.”

Lightening up probes is a top design priority for many vendors. Siemens made its Antares 4D transducers 25 percent less weighty than most others on the market. The new ones at Toshiba America Medical Systems (TAMS of Tustin, Calif.) are also smaller, lighter, and have more flexible cables.

TAMS has a new ultrasound line called Aplio that features many ergonomic design points. David Rolph, TAMS ultrasound product manager, says, “On the interface, we can actually reposition our keys on the keyboard so they’re easier for the operator to access, and are perhaps more similar to a layout they have in an existing technology. The control panel can be moved up, down, left, right, so they can position it just right while they’re doing their scanning. There’s also a larger monitor.”

The new EnVisor system from Philips is also full of user-friendly features. David McCarty, senior marketing manager for Philips’s specialty ultrasound solutions business unit, says, “The control panel can be raised and lowered so that it can adapt to sonographers’ different heights, or different scanning styles — whether they prefer to stand or sit. The keyboard and the monitor also can rotate to a more comfortable position, which reduces extended reaching. There are time-saving features, such as extremely fast boot-up of under a minute, nearly instantaneous mode changes, and factory pre-sets that enable the user to get a clear image easily and more consistently. The control keys are very logically grouped.”

Philips’s redesigned HDI 5000 also boasts ergonomic enhancements. Reddick says they include “a monitor that articulates over toward the patient, allowing the physician or sonographer not to have to strain or move his or her neck out of alignment with the patient while they’re scanning. It significantly reduces repetitive stress and injury” in the head/neck/shoulder area associated with performing ultrasound.

TAMS’ aplio ultrasound system

The latest thing
“New from the ground up” is how ultrasound vendors at RSNA were describing their latest systems. Some, it turns out, really are. They’re capable of tricks previously performed only by top-of-the-line ultrasound or picture archiving and communications systems (PACS).

Philips’s EnVisor, for instance, was tailored specifically to appeal to new markets. McCarty says, “This is a lower-cost system than the HDI 5000. It’s more appropriate for the clinic or the office setting, perhaps a smaller rural hospital that’s more price-sensitive. It is a portable system that can be taken to the bedside, like the neo-natal and intensive care units. It features a migration of key imaging technologies from our two premium-class imaging lines, the HDI and the Sonos. So we start to see pulse-inversion harmonics and intelligent Doppler in this price class for the first time.”

EnVisor’s image and data management capabilities are as sophisticated as those of some enterprise systems, yet accessible on a much smaller scale. McCarty notes, “In an office or clinic setting, EnVisor can eliminate the need for separate image management workstations. Users can archive still images and loops on the system itself. They can edit them, they can create patient reports onboard the system, they can even embed the images in the patient report,” a feature once only found on large RIS/PAC systems. “You no longer have to have separate reports and images that have a potential for getting lost. It makes recordkeeping and getting information to referring physicians easier.”

At TAMS, power processing is the operative new term. The fundamental new technology on Aplio, says Rolph, “is something we call intelligent component architecture. We give each component its own processor. As a result, they don’t need to negotiate with a central processor to achieve a task. They all work in synchronization, kind of like your brain does. Intelligent component architecture allows these elements to be self-coordinating. As a result, we can process complex data more quickly, increase our image quality, and improve artifact suppression.”

Aplio also incorporates a new Doppler technology, advanced dynamic flow, which improves microvessel visualization, as well as ApliPure, a next-generation compound imaging technology. “ApliPure combines frequency and spacial compounding in real time,” says Rolf. “We get really excellent contrast and detailed resolution. The images are actually quite staggering. That’s highly applicable to ob/gyn and particularly radiology for visualization of tumors or subtle variation in grayscale image.”

Biosound’s Technos MPX is another example of a smaller system that’s big on ability. Chapman says, “It’s a multi-specialty, multi-application system that can be used in abdominal, obstetrics, musculoskeletal, cardiac, and vascular imaging. The main [interest] has been in abdominal and vascular applications. It has the advanced technologies that are being required in those areas, such as 3D and extended-field-of-view imaging. Our typical user is in either a small hospital or an imaging center/clinic environment where they use the system for a whole range of applications. They need to do everything and do it well. Technos also has full online digital capability for image review and image management. It has native DICOM capabilities, and it can archive to any PAC system.”

When Biosound says Technos MPX is all new, they mean it. “It’s driven through a purpose-designed transducer and software applications packages,” says Chapman. “It has a new-generation digital beamformer that ensures the best possible image quality, and frame rates as a function of being able to implement advanced focusing and image acquisition algorithms. The system includes TEI, our brand of harmonics. The harmonics are facilitated through a transducer that’s been designed to operate at narrow bandwidths. It’s an offshoot of the research work we’ve been doing in contrast applications. It’s based on a match of the transducers and the processing of the system. One of the results is an extremely sensitive Doppler. That’s in all Doppler modes — color, pulse Doppler, and especially CW in the cardiac mode. We have a good signal-to-noise ratio.” Chapman calls Technos MPX “an artifact-free Doppler modality.”

Thanks for the memories
The craze for prenatal baby portraits shows no signs of waning. Parents love taking home fetal ultrasound scans — even more so when they can e-mail them to family and friends. Vendors are happy to keep up with the demand for previews of patients’ progeny.

Earlier this year, Cedara Software Corp. (Toronto, Ontario, Canada) began offering 3D Baby Explorer, a software application for providing fetal images to expectant parents in an affordable, easy-to-use format. The program adds 3D imaging to any existing ultrasound system and enables sonographers to capture images during exams without disrupting their workflow routine. The images can then either be printed or saved to electronic media in JPEG, BMP, or AVI formats.

E-Touch form Novint Technologies is an add-on technology to ultrasound that simulates the textures of the image and allows the user to “feel” what’s being imaged.

Philips’s EnVisor and HDI 5000 now have built-in CD-ROM capability for saving images. Reddick says, “We call it ‘Performance 2004.’ It’s a new release of software that we’re going to be introducing in the second quarter. It includes a new CD-write capability that will enable our customers to easily and quickly save JPEG compressed images or AVI files to a CD-ROM. It also can be used to store real-time images on a CD that the patient can take home as a keepsake, which is something our customers have asked for. It also allows [users] to capture images and insert them easily into presentations.”

A novel extension of the e-family-album concept is provided by e-Touch from Novint Technologies, Inc. (Albuquerque, N.M.). E-Touch allows parents to not only see their babies prenatally, but also to feel them.

Tom Anderson, CEO of Novint, explains. “You transfer the three-dimensional data set over to our e-Touch sono system. Our software then allows you to touch the images through the touch device. As you hold onto that handle, you can move it right and left and forward and backward, just like a mouse, but you can also move it up and down. It has motors attached. When the cursor touches something, the motors turn on and that’s what creates the sense of touch. It updates the currents to the motors a thousand times per second. That gives you a realistic, smooth sensation of touch as you ‘touch’ the surface of an object. The technology has an amazing ‘wow’ factor. People’s mouths drop open when they actually feel the sense of touch on the computer.”

E-Touch additionally enables users to clean up images by eliminating unwanted portions of scans or filling in missing parts. Images can then be written to DVDs that allow interactive rotation of the baby’s face and can be taken home by parents. Deals are in the works to include e-Touch as an option with ultrasound systems.

Beyond basics
Lately, researchers and vendors alike seem delighted to poke the edges of the ultrasound envelope. New applications and add-ons are handily trouncing any lingering notions of it being a stodgy modality.

Hitachi’s EUB 2000 ultrasound and EUP-U533 probe are part of a new prostate brachytherapy system that features seed implant monitoring.

Many of these focus on oncology. The December issue of the American Journal of Roentgenology published a study showing that ultrasound is better than MRI, previously thought superior, in preoperative assessment of breast cancer. In April, AJR published a different study indicating that sonography is more accurate than mammography in detecting breast cancer in symptomatic women 45 years old or younger. And while mammography, CT and PET still represent the gold standard in oncology imaging, they are not capable of distinguishing between benign and malignant cancers. Ultrasound can. That’s why there’s a flurry of anticipation that it may be able to improve early detection and reduce the need for biopsies.

In January, TechniScan Inc. (Salt Lake City) concluded phase I clinical trials of a new product for early breast cancer detection. The TechniScan system utilizes inverse scattering (reflection ultrasound tomography) to produce sectional slices like those produced by MR and CT. The slices are then analyzed for tissue characteristics. The system proved successful at distinguishing benign lesions from malignant ones. It is intended as a back-up screening tool for mammography, and for primary screening of patients with dense breasts and implants.

The Mayo Clinic (Rochester, Minn.) is investigating the use of computer-aided detection (CAD) ultrasound in differentiating benign and malignant tumors of the liver. Researchers use CAD to first detect halos that exist around the tumors, then to classify the tumors by comparing their halos’ gray-level intensity with that of surrounding normal liver tissue. Manual tracing, a function of CAD, identified halos with 100 percent specificity and 100 percent sensitivity, while the semiautomatic edging function detected tumors with a specificity of 93 percent and a sensitivity of 100 percent.

Hitachi Medical Systems America (Twinsburg, Ohio) is testing an ultrasound-guided prostate cancer treatment. The company is developing convex and linear brachytherapy solutions for monitoring seed implant progress with its EUB 2000 ultrasound and EUP-U533 probe. Hitachi’s partner is Rosses Medical Systems (Columbia, Md.), developer of the Real-time Operating Room Dosimetry Module used in the project. The project’s brachytherapy guidance and monitoring occur in real time, enabling dosing adjustments to be made during the procedure.

Other specialties where ultrasound is on trial include evaluation of rheumatoid arthritis treatment and posterior tibial tendon. Musculoskeletal ultrasound, it turns out, is big business these days. Thomas Jefferson University (TJU in Philadelphia) reported an explosion in its use for Medicare patients from 1996 to 2000: 1,025 percent in podiatry, 250.2 percent for general practitioners, 38.6 percent for other specialties, and 15.3 percent for radiologists.

With baby boomers poised to swamp the healthcare system, replacing musculoskeletal MRI with musculoskeletal ultrasound, says TJU, could realize savings of $40.3 million to $153.4 million annually.

As for all those other modalities, they may as well make room on the front seat. Ultrasound’s moving in.