CT Scanners – Aiming Higher

Systems continue to evolve and expand in ways that benefit radiologists, providers, and patients.

With the advent of high-speed and multi-slice computed tomography (CT) scanners, healthcare providers have changed their approach to imaging, diagnosis, and treatment of patients as new ways for clinical applications in areas such as trauma, vascular, pediatric, and cardiac imaging are possible due to the higher speeds at which scanning can be done. CAD software has been pivotal in bringing new applications to CT, for example, making cancer detection possible with CT.

The multi-slice feature has made CT evolve from simply being a diagnostic tool into an interventional modality. Though most CT scanners are still used for general purposes, some are being modified for specific purposes such as bone densitometry and cardiovascular studies. The innovation cycle of CT has indeed become very short with new and cutting-edge technology getting introduced in the market and each being more efficient and faster. There is an increasing demand for high-slice CT. The high-slice CT scan is expected to improve the clinical utility considerably, as the introduction of the 256-slice scanner, which has a detector width of 10–12 cm would help in scanning organs, including the brain, heart, entire joints, and lungs and liver, within a single rotation. It is also expected to have the feature to scan the heart with a single heartbeat.

Rapidly growing demand for bedside imaging, home healthcare, and growing use of CT scan to assess the accuracy of post interventional medical procedures, medical implants, and anatomical confirmation are some of the main factors driving industry growth. Increasing prevalence of diseases such as cancer, orthopedic, cardiovascular, and dental disorders will also enhance the growth of the market. Also, a never-ending increase in the number of medical implant surgeries owing to unhealthy lifestyles as well as growing base of geriatric population is likely to increase demand. Other drivers of growth include the growing demands from governments for premium healthcare delivery. Significant advances in imaging technologies promise to improve wellness through quicker and more precise detection of medical conditions. A rising fiscal deficit is expected to hinder the growth of the CT scan market in developed nations. Also, CT imaging radiation dose continues to be an area of concern. A lot of patients and medical associations have raised this issue and raised their voice against the possible side-effects of CT scanning. The industry continues to try to reduce exposure while ensuring image quality.

In the coming years, companies will need to offer product portfolios that meet current demands. Indeed, providing systems with a wide range of imaging applications and economical prices will be vital for key players in the CT systems market.

Indian market dynamics
The Indian CT scanners market in 2017 is estimated at Rs. 1150 crore, translating to 944 units in quantity terms. While average unit prices remained steady, it is the 64–128 slice category which jumped from 48 units in 2016 to 100 units in 2017, an increase of 11 percent in value terms over 2016. The major contributor was a 22 units order received by GE from HLL. The >128 slice machines continue to constitute 5 percent of the market in value terms, with the Indian buyer in no hurry to invest in high-end technology, albeit dose reduction is the most important criteria when selecting a model. The 11 percent increase in share for 64–128 slice machines came from the two categories less than 64 slices. The market is dominated by GE and Siemens, with Philips a close second.

The portable CT scanners segment is gaining popularity at a rapid rate, which is a reflection of increasing number of device installations, lower switching costs provided by these portable products, and growing application horizons. Most of the makers are concentrating on developing portable products and increasing their geographical presence to strengthen their position in the market.

The evolution of CT scanners has advanced to the point where the number of slices per rotation is no longer the benchmark for performance. With the advent of high-speed and multi-slice CT scanners, healthcare providers have changed their approach to imaging, diagnosis, and treatment of patients as new ways for clinical applications in areas such as trauma, vascular, pediatric, and cardiac imaging are possible due to the higher speeds at which scanning can be done. CAD software has been pivotal in bringing new applications to CT, for example, making cancer detection possible with CT.

Ayushman Bharat program is expected to provide a major impetus to this segment. The National Health Policy, 2017 has envisioned Health and Wellness Centers as the foundation of India’s health system. Under this, 1.5 lakh centers will bring the healthcare system closer to the homes of people. These centers will provide comprehensive healthcare including diagnostic services, including the installation of CT scan facilities. An allocation of Rs. 1200 crore has been made for this flagship program.

Major players – an update, 2017-18

GE Healthcare
In July 2017, GE Healthcare licensed the CT organ dosimetry technology developed at Duke University. The technology enables automatic calculation of organ dose, helping the clinician to better estimate the radiation exposure to the patient. The automatic calculation reduces the time needed to perform assessments for large numbers of patients, enabling epidemiologic and dose trend analysis studies. The technology will be incorporated into an organ dose module within GE’s DoseWatch, a digital informatics solution that automatically collects, monitors, and reports on radiation dose indices for diagnostic imaging exams.

Philips
In November 2017, Philips unveiled the IQon Elite spectral CT to provide clinicians with increased diagnostic certainty in every scan, with zero compromise. The IQon Elite spectral CT, a new configuration of the world’s first spectral detector-based CT scanner, debuts a suite of features that will enhance the clinical benefits of the IQon platform to improve diagnostic confidence while enhancing the patient experience, and supporting the needs of emergency/trauma and oncology care. Representing an evolution of the original IQon spectral CT scanner, the IQon Elite advances the capabilities of its predecessor through a series of key benefits that support emergency/trauma department care and Philips’ commitment to oncology excellence. This new configuration provides a number of enhanced features and benefits, including enhanced diagnostic certainty, increased patient volume, and enhanced clinical breadth.

Siemens Healthineers
In April 2018, the U.S. Food and Drug Administration (FDA) cleared the Somatom go.All and Somatom go.Top CT systems from Siemens Healthineers. These additions to the company’s go.CT platform expand its concept of patient-centric mobile workflow, which is controlled via tablet and remote, into advanced clinical fields and applications such as cardiology, CT-guided intervention, and dual energy CT. With a 0.33-second rotation time, Stellar detector technology, and a robust 75 kW generator, the 64-slice Somatom go.All meets a wide range of clinical needs. The 128-slice Somatom go.Top leverages the same technologies as well as a large detector to deliver an acquisition speed of up to 175 mm in 1 second, making it ideal for trauma scanning. Interventional procedures benefit from Guide&Go, the first tablet-based solution for CT-guided interventions, which enables the interventional radiologist to use traditional touch features rather than a joystick for more precise image manipulation.

Global market dynamics
The global CT scanners market is estimated to be worth USD 6429.8 million by 2022, considerably up from its estimated value of USD 4834.1 million by 2017. When segmented by product type, trends reveal that the O-arm dominates over its counterpart C-arm with a 70.2 percent market share, poised to grow at a CAGR of 6 percent during 2017–2022, to USD 4530.6 million.

The multi-slice feature has caused CT to evolve from simply being a diagnostic tool into an interventional modality. Though most CT scanners are still used as general systems, some are being modified for specific purposes such as bone densitometry or cardiovascular studies. The innovation cycle of CT has indeed become very short with new and cutting-edge technologies getting introduced in the market with each being more efficient and faster. There is an increasing demand for high-slice CT. The high-slice CT scan is expected to improve the clinical utility considerably, as the introduction of the 256-slice scanner, which has a detector width of 10–12 cm would help in scanning organs including the brain, heart, entire joints, lungs, and liver, within a single rotation. It is also expected to have the feature to scan the heart with a single heartbeat.

North America is anticipated to remain the leading region over the next 5 years. Growth in the region is attributed to high adoption and high installation number of CT scan devices. Increasing healthcare infrastructure and rising government policies for CT scan devices will fuel the growth significantly in the Asia-Pacific region. Developing countries like India and China are the most prominent markets owing to the rapid growth potential for market players that are involved in the expansion and promotion of diagnostic devices for the healthcare industry.

Trends and advances in CT technology
Artificial intelligence. Artificial intelligence (AI) integration across vendors aids quantification and workflow and advanced algorithms to pull more diagnostic data out of CT image datasets. Deep learning will maximize efficiency. This includes automatic iso-centering of patients on the scanner, automated identification of anatomy, specific coronary vessel segments, plaque, and calcium detection.

Fractional flow reserve CT (FFR-CT). It can non-invasively derive FFR blood flow readings for the entire coronary tree using computational fluid dynamics supercomputing algorithms. This can show if intermediate or significant coronary plaques are actually flow limiting or not to definitively screen a patient to be sent to the cath lab for an intervention, eliminating the need for diagnostic catheterizations.

CT perfusion. It maps the iodine contrast levels in the myocardium through the cardiac cycle, and is starting to gain market traction thanks to validation studies showing its diagnostic accuracy compared with the gold standards of magnetic resonance imaging (MRI) and nuclear perfusion exams.

Spectral CT. It is likely going to become a standard part of CT imaging in the years to come. The ability to look at images at different kV energy levels allows cardiologists and radiologists to see different things than on average kV range images. This includes the ability to better image myocardial perfusion deficits, aid in metal artifact reduction to see restenosis inside stents, reduce metal blooming due to pacemaker leads or surgical clips, enhance plaque imaging, direct infarct imaging, and to better identify thrombus.

CT detector technology. This is a more sensitive CT detector technology and can reduce dose and increase image resolution. Two CT vendors now offer systems with resolutions down to 0.25 mm, when the standard today is 0.5. The newest generation detectors in development use computer power and photon counting to improve image quality beyond today’s generation of detectors.

New CT scanner technology. The biggest advances in CT scanners over the past few years have been the introduction of new dose-lowering technologies, easily upgradeable scanners to allow conversion to high-slice systems, and faster gantry speeds to freeze cardiac motion. Additionally, the concept of slices a scanner can image at once is less important today than the total anatomical coverage the scanner can image in one rotation. All the major CT vendors have introduced new CT systems in recent years with enhanced cardiac scanning capability.

Dose tracking software. The advent of dose tracking software in the last decade or so has, for the first time, allowed hospitals and radiology departments to aggregate all of their dose data in one place, protected behind firewalls. Rather than simply tracking patient dose and scanner output, however, these next-generation systems allow users to take a deep dive into the data to help with quality improvement, training, and a host of other functions. At the moment, dose tracking is a retrospective activity – it can really only monitor events as they happen and shed light on them after the fact. Eventually, the goal is to have the technology evolve into a predictive analytics tool, a feat that could be accomplished in the very near future.

>Outlook
Most agree that the market will continue to grow in the future. Future imaging systems may include new features like data analysis tools and automatic measurements, and, in the coming years, volume of extremity exams is expected to increase, as musculoskeletal conditions and injuries affect patients of all ages. Moving forward, spectral/multi-energy technology will continue to evolve, providing the ability to obtain more information from images – an important factor as the industry shifts to population health management. Spectral detector CT will be able to routinely deliver anatomical information as well as characterize structures based on their material makeup, within a single scan. This will change and improve clinical pathways to personalized medicine. It is also anticipated that the biggest change in CT will be driven by AI, computer-aided diagnosis, data integration, and expanded analytics for both clinical purposes and productivity.

Vendors will continue to develop solutions for lower dose, improved resolution, and improved workflow that will remain important in busy environments where CT systems are typically found. Additionally, using big data and AI, the utility of CT exams will continue to grow, and the market will see improvements on how big data is used to change clinical pathways and improve care.