My Fellow Radiology Residents; University of Illinois 1971

On the 1^st of July 1971, five young residents started a 3-year radiology residency. The department of Radiology had three divisions; Diagnostic, Therapy and Nuclear Medicine. In the Diagnostic division of that era chest x-rays and skeletal x-rays, were the majority of the studies. Upper and lower GIs were more numerous and detailed.  Intravenous pyelograms were fewer and more involved. Angiography was performed with needle sticks of the arteries of the organ to be studied.  Nuclear Medicine concentrated mainly on the thyroid gland, renal perfusion and bone and liver scanning. Radiation Therapy was performed with Ortho-voltage and Cobalt 60.  No hospital in Chicago and the country had Computed tomography.  Dr Huckman at Presbyterian Saint Lukes acquired the first EMI CT scanner in 1973, capable only of limited head CT imaging.  The fist high field 1.5T MRI by GE was acquired by University of Illinois in1977.  Interventional radiology was performed in few centers like University of Oregon but it was not done in Chicago when we completed our residency.  The first interventional procedure was a splenic embolization that was performed by Dr Spigos in 1977 on a patient with low platelet count.

My fellow residents in alphabetical order were:

James Doran.

A sociable young man from Ireland.  Upon his graduation he moved and worked in Saint John, New Brunswick in Canada.  This move brought him close to his native Ireland on the other side of the Atlantic.

Yuichi Inoue.

A young man from Japan.  Yuichi was always available to assist if workload required additional manpower. He did a fellowship in Neuroradiology.  Upon his graduation he returned and practiced in Osaka, Japan becoming one of the best Japanese neuroradiologists.

Frank Lopez 

A most pleasant Mexican American who began his career as a family practitioner . He struggled with the effects of multiple exostosis. He  unfortunately passed at an early age due to colon cancer.

 

Dimitrios Spigos

A young man who graduated from the University Athens Greece.  Upon his graduation he served in the Greek Navy as a physician assigned in destroyers and other vessels.  When he completed his residency in 1974 he stayed at UIC as faculty and chief of Angiography. His academic career was impressive and thus he was promoted to the rank of Professor.  In 1986 he became the Chairman of Radiology at Cook County Hospital and in 1992 he became the Chairman of Radiology at the Ohio State University. 

Albert Zuska

Al received his MD from the University of Illinois. As a native Chicagoan he was always helpful to us his fellow residents from abroad.  Al started his career at Saint Anne’s Hospital in Chicago.  In 1988 he moved to Allsaints Hospital in Racine, Wisconsin.  In 2004 he was the founder of Elk Grove Radiology and he and his group practiced at Alexian Brothers Hospital in Elk Grove, Illinois.  An eponymous disease, the Zuska's disease was first described by Al's uncle Joseph Zuska at the Cleveland Clinic in 1951. The patient involved was his wife with the only cure for this disease being surgical. A recent article by Serrano et al describes the breast imaging and histopathological findings of the disease.   

During our residency we were guided by our beloved Chairman Dr. Vlastimil Capek, his secretary Maria Surowiecki-Bass and Drs. Edwin Liebner in Therapy and Virginia Patterson in Nuclear Medicine.

This post Is dedicated to my wonderful friend Al Zuska who helped me to overcome the difficulties all new immigrants experience when first arrive to a new country.  We became and stayed friends although upon completion of our residency geography kept us apart.  I cannot find enough words to thank you Al for being a good friend during our formative years.  I also dedicate the post to Gianfranco Fizzotti who graduated from University of Pavia, Italy.  He did his residency at Cook County Hospital a program affiliated with UIC.  Gianfranco became attending at Grant Medical Center in Chicago.  He return to Italy for a brief period.  Upon his return to the States he joined the staff of Radiology at CCH and became the chief of mammography. After CCH he practiced in Glendive Montana and Kellogg Idaho.  The final of move of Gianfranco and his most gracious wife Pia was to Santa Fe, NM.  I visited the Fizzottis several times during their sojourn in the wild west.

Radiation Oncology; the years of maturity

As it was discussed in last month's post several doctors led the early developments of Radiation Oncology. The ones listed below led the specialty to maturity.

Frank Ellis (1905-2006) was a world leader in the field of Radiation Oncology.  He studied medicine at the University of Sheffield in England.  In 1943 he became the director of Radiation Therapy's department at Royal London Hospital.  Ellis was the President of the British Institute of Radiology and remained active until his passing at the age of 100.

Gilbert Fletcher (1911-1992) was born and educated in Paris.  He was a polymath and in addition to his medical degree, he had several others such as in Greek and Latin languages, Engineering and Physics.  He did a fellowship at Royal Cancer Hospital in London.  He was recruited to head the department of Radiology at M.D. Anderson hospital in Houston.  Dr. Fletcher practiced both diagnostic and therapeutic radiology something common in that era.  He rejected the prevailing opinion that large tumors should receive a lower radiation dose. He was instrumental in the designing of first Cobalt-60 unit and pioneered the high energy beam units such as the Betatron and the Linear accelerator. 

Herman Suit (1929-2022) was born in Waco Texas and got his MD degree from Baylor Medical School.  He got a PhD in Radiation Oncology at the University of Oxford where he studied the effect of Radiation on the cellularity of bone marrow.  Upon his return to the US he went to the National Cancer Institute to soon move to M.D. Anderson hospital in Houston.  It was at M.D. Anderson that under the tutorship of Dr. Fletcher he established the treatment of soft tissue sarcomas with radiation therapy and conservative therapy instead of amputation.  He also developed the Fletcher-Suit applicator for intra-cavitary radiation of women with cervical and/or endometrial cancer. In 1970, he became Professor at Harvard and Head of  Radiation Medicine at Massachusetts General Hospital in Boston.  Dr. Suit's lifetime achievements cannot be overstated regarding his studies of the response of tumors and normal tissues to radiation therapy.  He used his wide radiobiological and clinical knowledge to advance the safe and successful use of radiation therapy whether through fractionation, radiation doses based on tumor size or integration of radiation therapy with surgery and chemotherapy. 

Ellis, Fletcher, Suit and many others created the specialty of Radiation Oncology as we known it today.

This post is dedicated to the late Drs Edwin Liebner Chief of Radiation Therapy and Virginia Patterson Chief of Nuclear Medicine who offered me a position in the University of Illinois residency in 1971.  Also to the late Dr. Vlastimil Capek the Chairman of the Department who took me under his wing and was a second father to me.

Radiation Oncology, the early years

Radiation oncology is the medical specialty focused in the treatment of patients with cancer using ionizing radiation.  Before a treatment is initiated patients undergo imaging (CT, MRI, PET scans) to map out the location, size and shape of the tumors. Radiation oncologists then determine the appropriate dose and angles of radiation beams to maximize tumor control while minimizing damage to adjacent healthy tissues.

Radiation is delivered either with Linear Accelerators (LINACs) or with Proton Beam Therapy (PBT), brachytherapy with specialized applicators or with radioactive isotopes such as Iodine-131 for thyroid cancer. 

Diagnostic Radiology, Radiation Oncology and Nuclear Medicine were practiced for many decades as distinct divisions of departments called Radiology.  All three are now operated as separate departments and their residents upon the completion of their training take separate boards.  The individuals listed below are pioneers who advanced the field of Radiation Oncology and made it a distinct specialty.

Leopold Freund (1868-1943) a Viennese physician founded Radiation therapy 100 years ago.  He provided the first scientific proof of the biological effectiveness of ionizing radiation when he treated a 5-year-old girl with a huge nevus pigmentosus on her back with x-rays.  

Victor Despeines (1866-1937) treated a patient with stomach cancer with radiation therapy in July 1896.  He was also the first physician who published a radiation therapy paper in 1896, one year after publication of the discovery of x-rays by Wilhelm Röntgen.

Emil Grubbe(1875-1960) was likely the first American to use x-ray therapy in the treatment a 55-year-old woman suffering from inoperable recurrent breast cancer. 

Radiation Oncology is a dynamic field that plays a vital role in the multidisciplinary approach in the treatment of patients with cancer.

This post is dedicated to Reinhard Gahbauer MD who established the Radiation Oncology Division at James Cancer Hospital.  I met Dr. Gahbauer during my tenure as Radiology Chairman.  Dr. Gahbauer and his associates offered the most   advanced therapies to their patients.  His devotion to the wellbeing of his patients was recognized by all. I was fortunate that met and worked with him and for staying friends for many years after our retirement.

Nuclear Medicine; Part II

Rosalind Yalow and her colleague Solomon Benson were nuclear medicine and internal medicine physicians at Bronx Municipal Hospital in New Yolk.  Rosalind Yallow received the Nobel Prize for developing the radioimmunoassay in the 1950s.  Yalow and Benson employed Iodine 125 in their assay after years of failure attempting to employ Iodine 131 as the tracer.

William Myers at the Ohio State University introduced several radioisotopes including Iodine 125 and Cobalt 60.  He was able to convince Benson and Yalow to switch to Iodine 125 as a tracer leading to their success. 

Dr Myers and Charles Doan who was the Dean at Ohio State University College of Medicine introduced the first treatments of an overactive thyroid gland with Iodine 131. 

Drs Myers and Doan also assisted in the production of the first to commercial Nuclear Medicine camera as initially developed by Paul Anger. This production was contracted to Nuclear Chicago which was acquired by Searle and then by Siemens in the late 70s.  Their original camera is now in the Smithsonian Institute. 

Michel Ter-Pogossian, the father of PET, using filtered back projection mathematics introduced his PET scanner and enabled many companies such as General Electric, Siemens and others to copy the CT technology originally developed by EMI without regard to patents leading to the the rapid advance in CT imaging. 

Both computed tomography and immunoassay which were among the greatest medical developments in the second half of the 20th century had their roots in Nuclear Medicine.

Dedicated to Drs Mark Tetaleman and Ernest Mazzaferri.  Mark who was the chief of Nuclear Medicine at OSU met an untimely death when he was murdered while attending a meeting in Atlanta, Georgia.  Ernest Mazzaferri was an endocrinologist and Chairman of the Department of Internal Medicine at OSU.  Ernie was an ardent supporter of Nuclear Medicine and world recognized for the treatment of thyroid cancer.

Nuclear Medicine; Pioneers

Nuclear Medicine is the field that combines principles of chemistry, physics biology and medicine to develop diagnostic and therapeutic techniques with the use of a radioactive substance.  Several pioneers have contributed to the field:

Marie Currie (1861-1934) discovered the radioactive elements plutonium and radium.  Her work led to the use of radioactivity in medicine.

George de Hevesy (1885-1966) he suggested and developed the tracer principle, using radioactive isotopes to study chemical processes in living organisms. He won the Nobel Price in Chemistry in 1943 for his work on radioactive tracers.

Earnst Lawrence ( 1901-1958) he invented the cyclotron, a particle accelerator which was used to produce radioactive tracers in nuclear medicine 

Benedict Cassen (1902-1972) he developed the rectilinear scanner in 1950s, the first imaging device for nuclear medicine that preceded the gamma camera. 

Hal Anger (1920-2005) he invented the gamma camera (also known as Anger camera) in 1957.  The Anger camera is the key imaging device used in nuclear medicine today to detect radiation emitted by radioactive tracers in the body.

Michael Phelps, Edward Hoffman and Michael Ter-Pogossian are credited with the development of the modern PET scanner. Michael Phelps in particular is credited for his work in creating the first practical PET scanner in the mid-1970s.  The collective efforts of these researchers led to the establishment of PET as a powerful medical imaging technique.

The above mentioned pioneers, among others have contributed in the establishment and advancement of nuclear medicine, making it an important field in modern diagnostics and treatment. 

This post is dedicated to John Olsen who was the Chief of Nuclear Medicine during my tenure as Department Chairman at Ohio State University and Lyda Gogou the Dean of Health Sciences at West Attica University who was among the PET pioneers in Greece.

Breast imaging: newer developments

 Mammography is a medical imaging study that uses low dose x-rays to examine the human breast.  It can detect tumors before they are felt on physical examinationand can find microcalcifications that may indicate breast cancer.  Recently digital imaging has replaced film/screen mammography as it provides better image quality and allows easier storage and image sharing. Three dimensional mammography known as tomosynthesis is a newer mamographic technique which is useful in women with dense breast parenchyma.  Multiple randomized studies have demonstrated decreases in mortality from breast cancer by approximately 30% when screening mammograms are performed annually in women whose age is between 40 to 70. 

In 1990, Jackson in a Radiology article suggested ultrasound as a valuable tool in breast imaging especially when a mass is felt clinically or detected on mammography. Ultrasound helps in differentiating between solid masses that can be cancerous and fluid filled cysts that are benign.  In cases when a cancer is suspected ultrasound is used to guide needle biopsies and other therapeutic procedures such as breast cancer ablation. While useful, ultrasound is not a replacement for mammography.  For women with dense breasts when combined with mammography and clinical examination they provide a comprehensive evaluation.

In 1976, Frank, Ferris et al in a NEJM article described the technique of needle localization that allows placement of a wire with its tip adjacent to the lesion.  The technique ensures tat the surgeon can remove the suspicious finding with minimal tissue removal.  Wire localization can be performed either under mammographic or ultrasound guidance.

Magnetic resonance imaging (MRI) is using a magnetic field and radio waves to create detailed images of the breast.  Research in breast MRI started in 1980 in the USA and Germany.  MRI is highly sensitive and can detect abnormalities not seeing in either mammography or ultrasound.  In 1986, Heywang et al demonstrated that breast cancers enhance following gadolinium administration. In 1990, Kuhl et al published their study in the use of MRI in the screening of women at high risk for breast cancer, such as those with strong family history or genetic mutations like BRCA1 or BRCA2.

This post is dedicated to my friend and associate John Olsen MD who introduced the concept of mobile mammography and was the first who did stereotactic biopsies at Ohio State University.  He was the chief of Nuclear Medicine and Breast imaging at OSU and President of our departmental corporation URI.  I had the pleasure working with him during my tenure at OSU and learning from him on how to allay cancer patients fears.

Breast Imaging; the early years

In 1913, Albert Salomon, a surgeon, described differences between benign and malignant findings in mastectomy specimens.

In 1949, Raul Leborgne, pioneered mammography by calling attention to patient's positioning, image quality, and the differences between benign and malignant calcifications.

In 1962, Robert Egan reported the first 53 cases of occult breast cancer detected at 2,000 mammograms.  He used films developed by Kodak, that allowed high MA and Kvp technique thus minimising the dose delivered to the breast.  He is considered the father of mammography due to his pioneering work at MD Anderson and Emory University. 

In 1965, Charles Gross, developed the first unit dedicated to mammography. It provided high differential contrast between the breast parenchyma, fat and microcalcifications. The unit came with a compression device that further improved the quality of imaging. 

As younger women get breast cancer the United States Preventive Services Task Force updated its recommendations last week and suggested that women make an individual choice at starting screening mammography at the age 40. 

This post is dedicated to my Chairman the late Vlastimil Chapek who introduced and taught me mammography at the University of Illinois in the early 70s and two young radiologists whom I met when I returned to Greece after 40 years; 

Stamatis Merkouris and Fotis Constandinidis.  They were eager to learn things I thought them and I learned from them too.  Stamatis is now the head of breast imaging at Metropolital General Hospital in Athens and Fotis practices breast imaging at the New Victoria Hospital in Glasgow UK

Pioneers; Purcell, Bloch, Mansfield, Damadian, Lauterbur

In 1946 Edward Purcell (1912-1977) and Felix Bloch (1905-1983) independently discovered Nuclear Magnetic Resonance (NMR) which is the basis for Magnetic Resonace Imaging (MRI).  In 1952 Purcell and Block shared the Nobel Price in Physics for their discovery.

Peter Mansfield (1933–2017) was an English physicist and a Professor at the University of Nottingham shared the 2003 Nobel Prize in Physiology or Medicine with Paul Lauterbur, for discoveries concerning (MRI).  His Echo Planar Imaging (EPI) method allowed later techniques like fMRI, diffusion ,DTI and perfusion to be developed. 

Raymond Damadian (1936-2022) an American physician and inventor of the first MRI machine.  In a 1971 paper in the journal of Science professor Damadian reported that tumors can be detected in vivo by nuclear magnetic resonance because of much longer relaxation times (which means the return of a perturbed system into equilibrium) than normal tissues and suggested that these differences can be used to detect cancers. Damadian perfomed the first full body scan in 1977.

Professor Paul C Lauterbur (1929-2007) was awarded the Nobel Prize in 2003 in Physiology or Medicine for his ground breaking research in the department of Chemistry at Stony Brook University that led to the invention of magnetic resonance imaging.

The above post is dedicated to my colleagues and prominent neuro-radiologists, Drs Don Chakeres, Eric Bourekas, Greg Christoforidis who worked with me during my tenure as Radiology Chairman at Ohio State University and Stathis Gotsis PhD whith whom I collaborated at the University of Illinois in Chicago and who introduced  NMR in Greece. 

Pionners; Dussik, Donald, Brown, Wild, Reid

 Ultrasound was first introduced in the practice of medicine approximately 90 years ago when Theodore Dussik and his brother Friederich attempted to use ultrasound to diagnose brain tumors.  In the ensuing time, ultrasound has become an important diagnostic modality in medicine.

Karl Theo Dussik (1908-1962) was born in Vienna, Austria and graduated from the University of Vienna Medical school where he worked as neurologist and psychiatrist.  Because of the difficulty in the diagnosis of brain tumors, Dussik, in 1937 started exploring the visualizatn of intracranial structures such as the ventricles with ultrasound. In 1945, Dussik together with his brother Friedrich constructed an apparatus and was able to visualise the brain and the ventricles. In 1947 he published his findings and thus is considered the "father of ultrasonic diagnosis" 

Ian Donald (1910-1987) was a Scottish physician who pioneered the use of ultrasound in obstetrics and gynecology. Donald graduated from the University of London in 1930.  During WWII he was drafted into the Royal Air Force during which time he developed an interest in radar and sonar.  After the war he became a Professor at Glasgow University where he explored the use of ultrasound in obstetrics in 1950 in collaboration with John MacVicar and Tom Brown an industrial engineer.  They developed the first compact contact ultrasound and were able to obtain an ultrasound image of a fetus. 

John J Wild (1914-2009) was an English-born American physician who received his medical degree from Cambridge in 1942 an immigrated to the United States in 1946 when he became a faculty at the University of Minnesota. Wild used ultrasound for body imaging notably for diagnosing cancer.  Modern ultrasonic medical scanners are descendants of the equipment Wild and his colleagues developed in 1950s.  In 1951 he and Dr. John Reid gained access to a unit that operated at the 15 MHz range, providing the detail needed to distinguish between healthy and cancerous tissues.  They were able to scan the breast and make the diagnosis of tumors by noninvasive means.  Reid and Wild developed tools for scanning the vaginal and rectal tissues.  Their work was published in the journal The Lancet in 1951 and in Science in 1952. They were credited as the first to develop equipment specifically designed for breast scanning and were able to differentiate between cystic and solid masses in the breast by means of ultrasonography. 

In the last 50 years due to technological advances, ultrasound units have changed from large machines to small user-friendly and sophisticated instruments.  Such evolution required contributions from the fields of physics, medicine and engineering.  Today ultrasound units are the sine qua non in the diagnosis of cardiac, abdominal musculoskeletal diseases and are also used in the guidance of interventional procedures. 

The post above is dedicated to Dr Nicholas Zannes who performed an ultrasound study on me recently for which I thank him. His contributions in radiology especially in the field of interventional radiology are noteworthy and help established the subspecialty in Greece.  In addition to being a good colleague I also thank him for being a good friend to me and my family for the past 50 years. 

Pioneers; Hounsfield & Cormack

Godfrey Hounsfield (1919-2004) was a British electrical engineer who developed computed tomography (CT). 

In 1949, Hounsfield began working at EMI, Ltd where he researched guided weapon systems and radar.  At EMI, he became interested in computers and in 1958, he helped in the design of the first computer system in Great Britain. Shortly afterwork he started work on CT scanner.   

Hounsfield came up with the idea that one could determine what was inside a box by taking x-ray readings at multiple angles around an object.  He then built a computer that could take input from x-rays at various angles to create an image of the object in slices.  Applying this idea to the medical field led him to what is known today as computed tomography. The scale of units he used (HD), running from -1000 HD for air, 0 HD for water, and +1000 HD for cortical bone are the quantitive measures used in obtaining, depicting and evaluating a CT scan.

At that time, Hounsfield was not aware of the work and the two papers Allan Cormack (1924-1988) had published in 1956 on the theoretical basis of such a device when he worked at the University of Cape Town and Groote Schuur Hospital.

Hounsfield built a prototype head CT scanner and tested it first on a cadaver's brain and soon after on a cow's brain and finally on himself.  On October 1st 1971, CT scanning was introduced in medical practice with a brain scan performed on a patient and in 1975 Hounsfield built a whole body scanner. 

In 1979, Hounsfield and Cormack received the Nobel Prize in Physiology and Medicine.  Both received numerous awards in addition to the Nobel and Hounsfield was also knighted in 1981.

The above post is dedicated to Dr John Andreou and Professor A Gouliamos  prominent Greek radiologists whose expertise in computed tomography contributed in establishing it as a pre-eminent diagnostic method in Greece.  in addition to being a good colleagues I also thank them for being good friends to me for the past 50 years.

A Pioneer; Michel Haïssaguerre

Atrial fibrillation (AF) is the most common heart rythm disorder, affecting 0.5% of the world's population and 3% of the population of Europe and North America.  According to the CDC approximately 2% of people younger than 65 years old have atrial fibrillation, while 9% of those over 65 are afflicted by AF and it is the cause of 20-25% of ischemic brain strokes.

Atrial fibrillation is treated with lifestyle changes, medicines such as beta and calcium channel blockers, anti-arrhythmics, anticoagulants and procedures such as catheter ablation in order to slow the heart rate and restore a normal heart rhythm.

In 1988, Michel Haïssaguerre a cardiac electrophysiologist in Bordeaux, France described the use of catheter ablation for patients with atrial fibrillation.  He founded that in 95% of the patients, AF episodes were caused by abnormal electrical "triggers" originating from within or the viscinity of pulmonary veins in the left atrium.  By mapping the triggers and ablating them, he was able to render 62% of patients free of AF without the need of using anti-arrhythmic drugs.  This landmark finding has led to the development of catheter ablation as a routine management strategy for atrial fibrillation.  His technique prevents this abnormal electric activity from reaching the atria  and is the sine qua non in the treatment of AF.  Although the patients may experience a return of the arrhythmia, the procedure is considered a safe, effective and minimally invasive method.  Studies have shown that the overall complication rate of cardiac ablation procedures is about 6%.

Michel Haissaguere was born in Bayonne, France on October 5th, 1955.  He became a Professor of Cardiology in 1994 and is the Chief of Cardiac Pacing and Electrophysiology Department at the Haut-Leveque Cardiology Hospital, part of the Bordeaux University.  Professor Haissaguerre was elected member of the French Academy of Sciences in 2010 and has received multiple awards such as the Best Scientist Gruntzig of the European Society of Cardiology, Pioneer of Electrophysiology of the North American Rhythm Society, the Gold Medal of the European Society of Cardiology and numerous others.  He and his associates have published more than 800 papers on this subject.  

The above post is dedicated Dr Mahmood Houmsee, an expert electrophysiologist at Ohio State. He took care of me both as an outpatient and inpatient and keeps me in good condition. Also to Dr Peter Danias who has been my cardiologist in Greece.  Dr. Danias' expertise in cardiac computed tomography and magnetic resonance imaging established these diagnostic methods in Greece.