RSNA’s annual meeting in Chicago is expansive.  Even at approximately one-third of normal attendance, RSNA 2021’s in-person meeting still felt huge. Most notably, the north and south industry halls both appeared to have a full showing of vendors to highlight the latest technical innovations in medical imaging.  On the other hand, the audiences in the educational sessions was noticeably less than in prior years.

Given the sheer size of the McCormick Place Convention Center, I logged around 20,000 steps per day attending the meeting. One of my colleagues from work who was attending RSNA for the first time in many years remarked that he forgot how overwhelming the meeting can feel.  This is something I have heard many times before.  RSNA can feel overwhelming.  You can feel lost in the crowd—even at one-third capacity.  You can get turned around navigating the convention center.  You can puzzle over how to best spend your time given multiple offerings at any given hour.   

What this means is that the experience of RSNA is unique for all individuals, as only a small fraction of what is offered can be experienced by any individual. It is impossible, unlike much smaller meetings, for any individual to see the entire conference presentation. In this brief article, I will share a few thoughts from my RSNA 2021 experience, focusing on my own subspecialty areas of breast imaging and nuclear radiology.  

Breast Imaging:

For me, the underlying theme of breast imaging at RSNA 2021 it is this: breast imagers are ready to embrace emerging technologies such as contrast-enhanced mammography and more expansive use of breast MRI to improve breast cancer detection for all individuals.  One particularly memorable comment I heard from a notable leader in breast imaging is this (paraphrased): “It is time for breast imaging 2.0…It is time for vascular-based screening with contrast enhanced mammography and abbreviated breast MRI to lead us into a future where more breast cancer is detected”.   There seemed to be agreement among the speakers of sessions that I attended that expanded use of contrast-enhanced breast imaging, for appropriately selected patients, is necessary for the subspecialty of breast imaging to advance. 

There was a lot of discussion about the limited sensitivity of mammography for detection of breast cancer in individuals with dense breast tissue. Potential solutions to solve this problem that were presented included whole breast ultrasound, contrast-enhanced mammography, and contrast-enhanced breast MRI. Missing in the educational sessions was discussion of molecular breast imaging (MBI), although some impressive advances in MBI were showcased in the exhibit hall such as molecular breast imaging biopsy and new software algorithms to further lower the radiation dose of an MBI exam without lowering signal to noise.

Pros and cons regarding using ultrasound or MRI to detect axillary nodal metastatic disease in individuals with known breast cancer was discussed in more than one session. Extensive discussion of how our different methods of detecting axillary nodal metastatic disease pre-operatively can change patient management was presented.

From the industry floor, notable recent advances I saw include the incorporation of biopsy capability for contrast-enhanced mammography that is now FDA-approved from one vendor.  Use of artificial intelligence algorithms to reduce the number of slices on a tomosynthesis study without losing diagnostic information was another advance that could potentially be helpful that I saw showcased.

From RSNA 2021, it is clear to me that as we move into “breast imaging 2.0” (or whatever one chooses to term our future), there is building momentum to implement new technologies to advance our performance and address current limitations.  

Nuclear Medicine:

Nuclear medicine is a field that is rapidly advancing, particularly in the arena of PET imaging. The newest FDA approved PET radiopharmaceuticals, PSMA for prostate cancer and FES for breast cancer, received a lot of attention at RSNA 2021. Included among lectures that discussed FES, I was able to present results from my initial clinical trial on FES-PET/CT for evaluation of invasive lobular carcinoma (link here to AuntMinnie.com article; at the time of posting, RSNA members can view my scientific oral presentation by clicking here and my educational presentation on FES-PET/CT by clicking here). Presenting at RSNA is always a meaningful experience. The opportunity to share data with others in the radiology community, and collectively discuss the research following the presentation, frequently fosters ideas for future research, which was true for me in this instance. Thank you RSNA for the opportunity to present and share!

As expected, PSMA received much deserved attention.  Upon returning from RSNA, one of my body-imaging colleagues came into our nuclear radiology reading room and asked, “Have you heard about PSMA PET imaging?  This has really impressive sensitivity for prostate cancer detection based on what I saw at RSNA!”.

The nuclear medicine field anticipates PSMA to transform current diagnostic and therapeutic paradigms for prostate cancer. PSMA is currently FDA approved (at least in one form) for diagnostic imaging use. Pending additional FDA approval of PSMA-based radiotherapeutic agents, this could really be something.  It is appropriate, in my opinion, for so much attention to be placed on PSMA at RSNA 2021.  Radiologists and nuclear medicine physicians need to become educated on the potential benefits and limitations of PSMA-based diagnostic and therapeutic agents. I've had my own discussions with more senior nuclear radiologists that PSMA-PET and PSMA-based therapeutics could increase nuclear medicine volumes by 1/3 or higher in the near future. There may be a huge demand for this PSMA-based diagnostic and therapeutic paradigm for prostate cancer diagnosis and therapy.

I saw relatively little this year at RSNA on FAPI PET imaging.  This was disappointing as FAPI drew a lot of attention at prior RSNA meetings.  Could this agent be the new FDG for PET imaging?  The collective radiology community will have to wait until future RSNA meetings to find out. 

Other Themes:

 “Recruiters Row”, where practices seek to recruit radiologists at the meeting, had a strong showing.  My take-away message from discussions with those radiology practices who attended RSNA for recruitment of radiologists is this: the radiology job market favors the radiologist more than I previously anticipated. I knew the number of available jobs was plentiful for radiologists, but I did not know that the number of needed radiologists by some of these organizations was as large as stated by them.  One prominent institution has openings for 40 radiologists on their own!  Practices told me that they have had to hit the pause button on new hospital contracts because they can’t hire enough radiologists to fulfill their current obligations.  As I’ve discussed before (link here) the radiology job market does cycle, but at present we are in a state of demand for radiologists that I have not yet observed. Although I can’t quantify this in numbers, it is possible that there are simply not enough radiologists coming out of training to meet the demand of current job openings.  

If workload will exceed the supply of radiologists, this means that practicing radiologists will need to read more, faster.  Will we find technical innovations to help us collectively navigate the growth in both volume and complexity of imaging studies to better match our available radiology workforce?  Time will tell.  Perhaps AI and deep learning will be helpful here.  For example, as mentioned above, I saw one vendor of mammography equipment present a new AI algorithm that reduces the number of tomosynthesis images that a radiologist must interpret while still depicting all relevant pathology, in order to speed mammography interpretation times.  Measures to simplify and quicken imaging interpretation via AI and deep learning algorithms could be helpful, if proven to maintain diagnostic accuracy.

This goes hand-in-hand with issues of radiologist burnout and quality of life that were discussed, along with additional important topics of workforce equity, diversity, and the environmental impact of radiology, as part of the excellent RSNA 2021 Fast 5 presentations.  In past years, RSNA Fast 5 presentations have been uploaded to YouTube for free viewing by all. I have not yet seen these on YouTube but suggest, reader, that if you are not an RSNA member able to view these through the RSNA website, that you check back later you YouTube to view this content.

This comprises only a fraction of the knowledge and innovation that was presented at RSNA 2021. If you participated in this meeting, I hope you left RSNA 2021 better informed, and better prepared for our collective future in medical imaging. Despite the ongoing pandemic, the medical imaging community continues to innovate, and educate, and question, and improve. RSNA 2021 was a reminder, to me, that our collective work to provide the most helpful medical imaging to all individuals is a work in progress, yet is advancing in many important ways.

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