“Radiologists should stand up for themselves”

Takamichi Murakami is Professor and Chairman of the Department of Radiology at Kinki University Faculty of Medicine in Osaka, Japan. Besides being a liver specialist, he advocates stronger radiology recognition in Japan.

radiology.bayer.com (rbc): How has hepatocellular carcinoma (HCC) imaging in Japan changed over the years?
Takamichi Murakami: Dynamic CT or MR imaging with an intravenous injection of contrast medium is essential for HCC detection, characterization and staging. MRI use has increased in general, but especially for detecting early HCC. Dynamic CT or MR imaging has also gained importance for treatment monitoring in trans-arterial chemoembolization (TACE) or radiofrequency ablation (RFA).

However, these treatment methods may not be suitable for advanced HCC, especially multiple and diffuse HCC. In this case, we have another option, the combination of chemotherapy – continuous local arterial infusion of 5-Fluorouracil – with intramuscular interferon-alpha injections and a molecular target drug. It is very effective, but placing the catheter into the tumor is very challenging. 3D CT angiography and DSA help a lot by guiding the catheter to the right artery.

Secondly, the hepatocyte-specific contrast agent Gd-EOB-DTPA has changed HCC imaging. It is already a part of the Japanese guidelines. The guideline for hypervascular advanced HCC is well established, but surveillance guidelines for hypovascular lesions are still not quite satisfactory. We need to depict the change of a hypovascular early lesion to a hypervascular “small HCC” – because we need to treat HCC at an early stage.

Hepatitis prevention is a key measure against HCC

rbc: What do you consider necessary to further reduce HCC mortality in the future?
Murakami: A key step is hepatitis prevention – which we have successfully established in Japan a while ago. I still remember doctors using the same needle for vaccinating all children in my childhood, thus increasing the risk of hepatitis infection. Since this has changed and pre-checked blood transfusions to reduce infection risk are now common, new infections with hepatitis B and C have dropped dramatically. As a result, HCC cases in Japan have decreased drastically.
We also have a mandatory hepatitis B vaccination program. Moreover, Japan still takes action against hepatitis and involves very early anti-viral treatment with the newest drugs available.

rbc: Would you recommend a similar program for other Asian countries?
Murakami: Yes, and I would definitely recommend to start early on. The Japanese government focuses very much on early education. Children are taught about hepatitis prevention. A newborn is vaccinated when the mother is known to be infected with hepatitis. The new anti-viral drugs are also very effective.
In Japan, alcoholic hepatitis is not much of an issue, but we have to keep an eye on our diet. Japanese food tends to get fatter.

rbc: With your broad perspective on radiology, what do you consider current trends in liver imaging?
Murakami: Ultrasound is a useful imaging method for screening HCC. Dynamic CT and Gd-EOB-DTPA (EOB)-MRI are good for detecting hypervascular lesions. EOB-MRI can also detect hypovascular HCC. In addition, CT perfusion and EOB-MRI may deliver excellent information on liver function.

Guidelines are not only about medicine

rbc: Back to the guidelines: What do they say about transplantation?
Murakami: We do very few brain death liver transplants in Japan. Legally, in Japan an individual is dead after the heart has stopped beating. However, this does not apply for organ donations, because it would not be effective to remove organs after cardiac death. So it is recommended to remove organs after brain death in our organ donation guideline. That’s the point where difficulties arise, because a patient has to give his consent during his lifetime. If the patient did not give his consent, it is not possible. Even if the patient gave his consent, the family still has the right to object towards donating the organs. These are very important issues in Japan. The whole process often takes too long.

rbc: The guidelines exist, but they are difficult to follow?
Murakami: In Japan, surgeons, hepatologists, pathologists and radiologists are often organized in liver cancer groups or in hepatologic societies. Normally the guidelines are easily followed, because a lot of doctors are part of liver cancer groups in Japan. If one doctor encounters problems, the patient is referred to a specialized hospital. We use a multidisciplinary approach where everybody knows what to do.

rbc: Is there any chance that the global community will develop an international guideline?
Murakami: Well, in an ideal world maybe. However, guidelines are not only about top-notch medicine; they are also about cost. Japanese guidelines cause high costs, because they recommend dynamic CT or MRI including EOB. In Japan, we do an ultrasound for monitoring HCC patients every three months, and we use CT or MRI in high-risk patients every six months. Some developing countries cannot afford expensive examinations such as EOB-MRI.
I am also afraid that the medical and technical advances between Asian countries differ too much. Chances for a general guideline are probably higher in Europe. However, many developing countries have visited the AOCR in Kobe this year, so maybe in the future we will agree at least on an overall Asian guideline.

Healthcare is evenly distributed

rbc: Knowing that there are good guidelines and excellent medicine in Japan: Where do people go when they have early stage HCC?
Murakami: In Japan, each prefecture has at least one national university hospital. Every big city has its own center. Many middle-size hospitals can also treat HCC. This means that Japanese patients do not have to travel very far to get specialized treatment. Patients receive excellent HCC treatment even in local areas, for example in the Kinki area, where I work.

Patients need to travel longer distances only for very specialized treatments. One example would be proton therapy and heavy particle radiotherapy, which is only available in specialized institutes. In general, hospitals are well equipped for HCC treatment.

Raising the visibility of radiologists

rbc: Radiologists are often complaining that they are not visible. How do clinicians perceive radiologists in general?
Murakami: Usually, patients do not know about radiologists. Some patients still do not say “radiological department”, but Roentgen department. They usually think radiologists only write a report about the finding. I think that radiologists should stand up for themselves more strongly. No one really knows about interventional radiology, which means minimal invasive image guided treatment. Radiologists do many kinds of interventional radiology, such as TACE, for example, but patients do not know this – and even if they encounter a radiologist, they probably still think he is a hepatologist.
Physicians and surgeons changed their attitude towards radiologists only recently. MRI and CT have become more complicated, and usually only a radiologist can read the images. Moreover, there is now an additional reimbursement if a board-certified radiologist writes the reports. We have 20 radiologists including 17 board-certified ones at my hospital. Every year, the additional reimbursement for our hospital is almost two million US dollars. So nowadays, each hospital wants its own radiologist, due to the additional reimbursement.

However, radiologists are scarce. Many middle-sized hospitals have no radiologist, but they have a CT or MRI scanner. So in many institutions, physicians inject the contrast media and interpret the images. However, if the images are difficult to read, radiologists from other institutes are asked to visit to do the reading – usually as a part-time job in the evening. Radiologists are really in demand.

rbc: How do you see the future of radiology in Japan?
Murakami: There is no easy answer. I think imaging is important and might even become more important.
Masatoshi Kudo, the director of hepatology at our hospital, says it is impossible to diagnose and treat HCC without imaging. However, it also seems to me that radiologists are sometimes so caught up in their reading routines that they might miss out on opportunities for their specialty. In the Tokyo area, for example, hepatologists and other specialists perform interventional radiology, which they call endovascular surgery – not interventional radiology.

Radiologists, on the other hand, are busy reading CT and MR images, and do not perform interventional radiology so much, although they could. We are in a turf battle. I think that this is a common situation, not only in Japan.

rbc: What would help to raise the number of radiologists in Japan?
Murakami: Reputation is one point. I think that radiological education in Japan is excellent, but radiological departments are viewed as minor departments, while they are seen as top departments in other countries.

After students graduate from medical school in Japan, they have to do rotations in several departments for two years – such as internal medicine, surgery, anesthesia, OB/GYN etcetera. However, radiology is not included, because 30 percent of all hospitals, where they do rotations, do not have a radiologist. This has to change.