Learn More about Thermography
We receive questions every day regarding the use of medical infrared imaging (MIR). Most of these questions are generated by the vast amount of misinformation found on the internet. MIR is an incredible technology with a great deal of good to offer the health of every person. However, this misinformation can lead to the misuse of this lifesaving technology. As health care professionals we are extremely concerned about what we are hearing and seeing.
Education is the ultimate answer to this problem. With quality education, founded in research and following accepted standards and guidelines, the proper application of MIR benefits everyone. With quality instruction comes quality thermal imaging.
We hope that the following will help to dispel the misinformation we see on the internet and bring about an understanding of how this lifesaving technology may benefit you.
Please select from the following topics:
Choosing a Qualified Imaging Center
Thermal Imaging Interpretation
New Cutting-Edge Thermography Systems
Assorted thermography myths:
Imaging Tumors, Organs, and Other Deep Structures
Thermal Signs of Breast Fibrocysts and Cysts
Detecting Heart Problems
The 3 Month Follow-up to Establish a Baseline
What is thermography (medical infrared imaging)?
Thermography entails the use of specialized cameras that are sensitive to the detection of electromagnetic energy (light) in the infrared wavelengths (heat). As such, these imagers serve as a remote sensing system; nothing touches or harms the object under investigation. When the camera’s detectors sense the incoming infrared heat an electrical signal is produced that generates a visible image display.
Thermography, or infrared imaging, is used in numerous fields such as industrial fabrication, astronomy, building construction, military applications, surveillance, aerospace sciences, and of course medicine. Medical infrared imaging (MIR) entails the use of high-resolution infrared cameras and sophisticated computer processing to produce a topographic heat map display which bears a resemblance to the visible image of the body. Modern computerized thermography produces an accurate and reproducible high-resolution image that can be analyzed both qualitatively and quantitatively for minute changes in skin surface heat emissions.
MIR is applied in the clinical environment as an aid in the diagnostic process. It is used for the thermal analysis of patients with various conditions in acute, chronic, and preventative health care.
Is medical infrared imaging safe?
Yes! Infrared imaging (or thermography) uses no radiation or intravenous access and does not touch the body. The procedure is painless, completely safe, and FDA approved as an adjunctive imaging procedure (to be used in addition to other tests). Infrared imaging does not replace any other form of imaging (e.g. CT, MRI, mammography), but is designed to be used in addition to other tests to provide physiological information that cannot be obtained from any other examination procedure.
Is it true that MIR is only experimental and not approved by the FDA?
No! Based upon the available research data at the time, the U.S. Department of Health Education and Welfare (HEW) determined that thermography was beyond the experimental stage in 1972. Thermography (MIR) was approved as an adjunctive imaging procedure by the FDA in 1982 (Federal Register, Vol 47, No. 20, pp 4419-4420, January 29, 1982). The FDA approved MIR as: “Telethermographic systems intended for adjunctive diagnostic screening for the detection of breast cancer or other uses” (Code of Federal Regulations Title 21, Section 884.2980 Telethermographic Systems).
What makes MIR so different from other medical imaging technologies?
What most of us are accustomed to when we think of medical imaging is the use of X-ray, CT, MRI, or ultrasound. All of these imaging tools are considered structural imaging technologies; they look inside the body for structural changes such as broken bones, tumors, damage to organs, etc. What separates these technologies from infrared imaging is that MIR detects infrared (heat) markers that reflect the body’s subtle underlying chemical and nervous system signals. This allows us to look at how the body is functioning. These neurochemical signals may be the only sign that a problem exists, a remnant of injury indicating that healing has not finished, or a signal sent in advance of significant damage to the body. With this information in hand, you and your health care provider can outline a method for treating a current problem or possibly preventing future problems before they cause irreversible damage.
Many patients are also confused with regard to their condition. For example, patients with chronic pain who have had treatment with little or no relief may have been treated for the wrong condition. Infrared imaging has helped many patients get to the cause of their condition so that proper treatment can be rendered.
The applications of MIR are broad and range from simple soft tissue injury to a risk assessment marker for breast cancer. It is important to note that infrared imaging, like other imaging procedures (e.g. CT, MRI, mammography, ultrasound) does not provide a diagnosis. Infrared imaging cannot be used as a "body scan" to search for metastasis (the spread of cancer) or internal organ pathologies. Infrared imaging is an additional procedure that your doctor can use along with other tests to evaluate your health. Only your physician can provide you with a diagnosis. The following list is just some of the conditions that have associated infrared thermal emission markers:
Altered gait manifestations
Brachial Plexus Injury
Carotid Artery Stenosis
Carpal Tunnel Syndrome
Complex Regional Pain Syndrome (CRPS)
Diabetes (secondary complications)
Disc Syndromes (spinal discogenic pain)
Headache Evaluation (e.g. cervicogenic, migraine, sinus)
Herniated Disc/Ruptured Disc
Intervertebral Disc Disease
Lumbosacral Plexus Injury
Myofascial Pain Syndrome
Nerve Root Irritation
Nerve Stretch Injury
Peripheral Nerve Abnormalities
Referred Pain Syndromes
Reflex Sympathetic Dystrophy (RSD)
Repetitive Strain Injuries
Sacroiliac Ligament Tear
Sensory Nerve Abnormalities
Soft Tissue Injury
Spinal Cord Injury
Superficial Vascular Disease
Thoracic Outlet Syndrome
TMJ Dysfunction (TMD)
And many more …
Sources: Index Medicus - J Thermology, Acta Thermographica, J Breast
How does MIR help when imaging the breast?
The use of MIR is based on the principle that metabolic activity and vascular circulation in both pre-cancerous tissue and the area surrounding a developing breast cancer is almost always higher than in normal breast tissue. In an ever-increasing need for nutrients, cancerous tumors increase circulation to their cells by holding open existing blood vessels, opening dormant vessels, and creating new ones (neoangiogenesis). This process frequently results in an increase in regional surface temperatures and vascular patterning of the breast. MIR uses ultra-sensitive medical infrared cameras and sophisticated computers to detect, analyze, and produce high-resolution images of these temperature variations and vascular patterns. Because of MIR’s extreme sensitivity, these thermovascular variations may be among the earliest signs of breast cancer or a pre-cancerous state of the breast (3,6,7,8,9)
While mammography, ultrasound, MRI, and other structural imaging tools rely primarily on finding the physical tumor, medical infrared imaging is based on detecting the heat produced by increased blood vessel circulation and metabolic changes associated with a tumor’s genesis and growth. By detecting minute variations in blood vessel activity, infrared imaging may find thermal signs suggesting a pre-cancerous state of the breast or the presence an early tumor that is not yet large enough to be detected by physical examination, mammography, or other types of structural imaging (3,6,7,8,9).
Studies also show that an abnormal infrared image is the single most important marker of high risk for developing breast cancer, 10 times more significant than a family history of the disease (5). Consequently, in patients with a persistent abnormal thermogram, the examination results become a marker of higher future cancer risk (4,5). Depending upon certain factors, re-examinations are performed at appropriate intervals to monitor the breasts. This gives a woman time to take a pro-active approach by working with her doctor to improve her breast health. By maintaining close monitoring of her breast health with the combined use of infrared imaging, self-breast exams, clinical examinations, mammography, and other tests, a woman has a much better chance of detecting cancer at its earliest stage and preventing invasive tumor growth.
1. American Cancer Society Breast Cancer Guidelines and Statistics, 2009-2010
2. I. Nyirjesy, M.D. et al; Clinical Evaluation, Mammography and Thermography in the Diagnosis of Breast Carcinoma. Thermology, 1986; 1: 170-173.
3. M. Gautherie, Ph.D.; Thermobiological Assessment of Benign and Malignant Breast Diseases. Am. J. Obstet. Gynecol., 1983; V 147, No. 8: 861-869.
4. C. Gros, M.D., M. Gautherie, Ph.D.; Breast Thermography and Cancer Risk Prediction. Cancer, 1980; V 45, No. 1: 51-56.
5. P. Haehnel, M.D., M. Gautherie, Ph.D. et al; Long-Term Assessment of Breast Cancer Risk by Thermal Imaging. In: Biomedical Thermology, 1980; 279-301.
6. P. Gamigami, M.D.; Atlas of Mammography: New Early Signs in Breast Cancer. Blackwell Science, 1996.
7. J. Keyserlingk, M.D.; Time to Reassess the Value of Infrared Breast Imaging? Oncology News Int., 1997; V 6, No. 9.
8. P.Ahlgren, M.D., E. Yu, M.D., J. Keyserlingk, M.D.; Is it Time to Reassess the Value of Infrared Breast Imaging? Primary Care & Cancer (NCI), 1998; V 18, No. 2.
9. N. Belliveau, M.D., J. Keyserlingk, M.D. et al ; Infrared Imaging of the Breast: Initial Reappraisal Using High-Resolution Digital Technology in 100 Successive Cases of Stage I and II Breast Cancer. Breast Journal, 1998; V 4, No. 4
Is infrared imaging of the body an alternative to X-ray, ultrasound, MRI, CT or any other type of imaging?
MIR is not an alternative to any other form of imaging. The technologies are completely different. One cannot compare a functional imaging technology (MIR) to a structural imaging tool. For example, an EKG does not replace an echocardiogram. The two technologies look at the heart in a completely different way, yet they complement each other. Infrared imaging provides information about the body that no other technology can offer, but it does not replace them. The reason why there are so many different medical imaging technologies is because no one technology can do it all. They all have strengths and weaknesses.
Infrared imaging does not replace any other form of imaging, but is designed to be used in addition to other tests to provide physiological information that cannot be obtained from other examination procedures. MIR is an adjunctive physiologic imaging procedure that does not look inside the body. If you are interested in looking for structural changes such as broken bones, or viewing the colon, female reproductive organs, or the arteries of the heart then structural imaging studies (e.g. MRI, CT, ultrasound) would be good choices.
Does MIR replace mammograms?
Absolutely not! However, do mammograms replace MIR? The answer to this is also a resounding no; the two tests complement each other. Thermography is adjunctive, it is to be used in addition to mammography as part of a woman's regular breast health care. The consensus among health care experts is that no one procedure or method of imaging is solely adequate for breast cancer screening. The false negative and positive rates for currently used examination tests (including MIR) are too high for the procedures to be used alone. However, MIR may pick up thermal markers that may indicate the risk of cancers not detected by other tests. A positive infrared image is also the single most important marker of high risk for developing breast cancer in the future. It is MIR’s unique ability to monitor the abnormal temperature (physiological) and blood vessel changes produced by pathological breast tissue that allows for extremely early detection. Since it has been determined that 1 in 8 women will get breast cancer, we should use every means possible to detect these tumors when there is the greatest chance for survival. Adding these tests together significantly increases the chance for early detection.
Keep in mind that no one test or imaging technology can provide a warning for 100% of all cases. As such, all tests and imaging technologies are adjunctive. As an example, no doctor would tell a woman that all she needs is a mammogram and that she does not need to come in for her yearly physical breast exam. All doctors know that a certain number of breast cancers will be detected on a physical exam of the breasts and not detected on a mammogram. As such, a mammogram is also adjunctive it must be used along with a yearly physical exam of the breast.
Another example of this “adjunctive” principle is the all too common experience of women having their yearly physical breast exam followed by their mammogram and then having to have a follow-up ultrasound to check on something seen on the mammogram. Now we are up to three “adjunctive” exams before a woman is told that everything looks fine. Now in some cases, if something needs to be watched on the mammogram and/or ultrasound, a woman might need to be called back in 6 months for another mammogram. MIR might be the added technology that calls attention to something that needs a closer look.
It should be understood that all of these imaging technologies (MIR included) cannot tell you if you have breast cancer. They only provide a certain amount of suspicion based on what the individual technologies “see”. Only a biopsy can tell you if you have breast cancer.
There just isn’t one single magic bullet that will do it all. As such, the best approach to providing every woman with the best in early breast cancer detection is a multi-modal approach (multiple modality multiple tests).
I have seen websites that say that thermography can detect problems with the stomach, colon, heart, immune system, female reproductive organs, prostate, and other internal organs.
The easy answer here is no. Thermography can only detect heat to a depth of 5mm from the surface of the body. As such, thermography cannot see into the cranial vault, thoracic cavity, abdomen, or pelvic areas. Remember the “visible man” model for kids? It had a clear plastic outer shell so that you could see the internal organs. With thermography, one cannot simply create a “visible man” image with heat at the surface of the body and think that you can transpose it to underlying anatomical structures. We have seen infrared images like this, but they are completely false and misleading.
Now, if an internal organ is damaged enough it may send a neural reflex message to the surface of the body creating an infrared marker (viscerosomatic reflex). This surface signal is rarely associated with the location of the underlying organ and is usualy found in a remote location that only a well-trained board certified thermologist knows to look for. The problem is that by the time an internal organ is sending this signal there is usually a fair amount of damage. In some cases MIR may been able to warn patients that something might be wrong, but the technology is not sensitive enough to be used for screening as an early warning for internal disorders. There are much better tests and imaging tools that can provide for the early detection of pathologies of this type.
If you are concerned about a possible internal disorder, or the spread of cancer (metastasis), there are tests and imaging technologies that are better suited for this purpose. Please see your doctor for the most appropriate tests for your condition.
CHOOSING A QUALIFIED IMAGING CENTER
How do I find a qualified thermography center?
Choosing a qualified office or imaging center should be as simple as performing an internet search for an office in your area, but unfortunately it isn’t. We have come across too many offices that have very poorly trained personnel using substandard imaging systems and doctors that are providing image interpretation without a proper education.
Just like any office or imaging center offering radiology services, a qualified MIR center should have certified technicians performing the imaging and a board certified thermologist providing the interpretation of the images. But are these “certified” technicians and “board certified” thermologists really well-educated and certified? This is the problem we are currently running into. The caliber of the training of the technician and thermologist is of the utmost importance. I guess the best way to understand the current problems we encounter, and the solution to this problem, is to use an example that we can all understand.
I think that all of us could agree that Harvard University is a good example of a quality institution of higher learning. But how do we know this? Well, Harvard has a long history of providing an exceptional education through their well-educated faculty. And the students who graduate are a reflection of this level of education. The foundation of this level of quality education is lineage. The professor that is currently teaching was taught by professor who also had this level of quality instruction and this professor also had ……… you get the point. Without a quality lineage of educators you cannot produce a quality educated student.
Now it is up to you to ask the right questions when interviewing an office or imaging center providing MIR. Is the technician certified by an association or group that has a faculty that can trace their lineage? Does the technician provide imaging under recognized standards and guidelines? Has the thermologist providing their interpretations been board certified by a recognized group that can trace their lineage? Does the thermologist provide interpretation of breast thermograms using peer-reviewed and accepted guidelines is each breast given a TH grading?
You will need to make the decision if the answer is no to any one of the above.
Are there standards and guidelines under which thermograms need to be taken?
Yes, and without them the images would be useless. The standards and guidelines under which technicians provide MIR have been in-place since the early 1980’s. There are both pre-imaging protocols that patients must follow before coming in for imaging and there are also strict protocols under which the images are taken in the laboratory.
In order to prevent artifacts on the images, every patient must be provided with a list of pre-imaging instructions that must be strictly followed. The imaging room must also be designed properly and environmentally controlled within strict guidelines. The room itself should be draft free and relatively cool (68-73 degrees F) with no incandescent lighting, no heat or cooling sources near the patient, no windows without coverings, and environmentally held steady within 1 degree C during the entire time of the imaging study. In other words, you should be placed in a draft-free cool room that is very thermally stable. You will also need to spend 15 minutes acclimating to the room before imaging (nude from the waist up for breast imaging or with suitable underwear and a loose fitting gown for body imaging). And lastly, the imaging system itself must meet minimum acceptable specifications for medical use and be registered with the FDA in order to provide MIR. Without these standards in place the images would be useless.
I was told to come to a certain office because they had a better imaging system.
I find it sad that when providing a lifesaving service that some cannot put the patient first. Our policy is to always refer patients to the imaging center closest to them for their convenience. Using fallacious marketing practices that are designed to force patients into one’s own office is truly unacceptable.
There are established thermography imaging system standards that need to be met in order for an imaging center to provide MIR. These standards were drafted in the 1980’s and have been recently validated and updated. Almost all quality modern IR camera systems that are designed for medical use exceed the minimum standards for MIR. The most important issue here is the phrase “designed for medical use”. Unfortunately, there are companies that claim that their imaging systems are “designed for medical use”, but in reality they are far from it. There are quite a few technical aspects of infrared imaging that need to be met in order to accurately analyze the surface temperatures of the human body. Most infrared cameras are designed to meet the average needs for military uses, police surveillance, or industrial applications. The demands of an MIR imaging system far exceed these applications.
The question then remains, are there MIR imaging systems that just meet standards and others that far exceed them? Yes, but the question is are these exceptional systems better? In 2003, Dr. Amalu was asked by the board of the International Thermographic Society (ITS) to investigate the need for a change in the imaging system standards. In other words, based on the quality of the newer imaging systems will offices and imaging centers need to retire their older equipment and purchase state-of-the-art imagers? At this point we need to be careful with what we are defining as quality in an imaging system. We need to be comparing apples to apples. The older equipment we are talking about was the state-of-the-art at the time and met every imaging qualification needed for accurate assessments of human infrared emissions. The newer imaging systems also meet or exceeded these standards along with a significant improvement in image quality.
At the 2004 ITS symposium, Dr. Amalu presented his findings. He had gathered 100 patients totaling 200 image sets for analysis. Each of the patients had to have images taken on both 1980’s imaging systems and modern MIR imagers for comparison. He used the current interpretation guidelines to analyze all of the images. Dr. Amalu was able to demonstrate that offices and imaging centers using the older imaging systems did not need to update their systems to the state-of-the-art. Now does this mean that we don’t appreciate the significant improvements in image quality, ease of use, and reduced cost? No, of course we do. But to say to a patient that because your office has the latest and greatest that you are better than the office down the street is simply not true.
Now, we have just made a comparison between apples and apples older quality MIR imaging systems designed for medical use versus newer systems also designed for medical use. However, the real problem is that we are currently dealing with apples and oranges. Some companies and offices claiming that their imaging system is better actually have equipment that does not meet the requirements for medical imaging. Both the office using the equipment and the public have no idea that the images being produced may be completely inaccurate and a health risk.
Here we come back to education. If an office or imaging center has a well-educated staff, you may rest assured that they will have a quality MIR system. Educational courses at this level have sufficiently covered both infrared physics and the design requirements needed when choosing a MIR imaging system meant for medical uses. As such, the imaging center will be adhering to established standards and guidelines. The current problem is that some health care offices and imaging centers are not sending their staff for quality training before they purchase an imaging system. Without the knowledge gained in a quality course there is no way an office or imaging center will be able to know the difference between a real MIR imaging system or a costly substandard camera.
Can I trust an office who has a mobile thermography service that comes in on occasion to provide imaging?
Due to the costs involved in providing MIR, some offices elect to have a mobile thermography service come in to provide imaging for their patients and/or the patients in their area. Having a standing office with a fixed imaging lab is certainly the easiest and most convenient way of meeting the standards and guidelines necessary for MIR. But this doesn’t mean that mobile MIR cannot be done. Mobile MIR is perfectly acceptable as long as the standards and guidelines for imaging are not violated.
The single greatest obstacle to mobile MIR are the offices the technician is going to. Will the room and its environmental controls be in place to start the stabilization phase for the imaging system (approximately 1 hour before seeing the first patient)? Does the office ignore the temperature and draft-free requirements of the imaging room by turning on and off the AC or heat? Does this happen even if the technician has their own AC or heating unit? If the office does this, will the technician be able to work with the clinic director or owner to insure that this doesn’t continue to happen? Or will the technician become frustrated, feel pressured by the presence of the patient and/or the owner of the office, and end up “bending the rules” and taking the images anyway? If this happens the patient will never know that their images were taken improperly and are useless.
What do I look for when trying to find a quality educational course in medical infrared imaging?
The same qualifications that you would use in selecting a university should be used in choosing a quality course of education in clinical thermology. The foundation of your choice should be grounded in the education of your instructor, his or her lineage, and the lineage of the certifying body behind the course. For example, one would likely choose Harvard University for long standing proof of excellence in education as an institution. The quality of the education of the professors (lineage) providing instruction and the quality of the graduating students are a reflection of the institution.
I would look to the association providing the MIR instruction first. Trace its lineage. How long has it been around? Who are the founding officers? What is their lineage? This does not mean that new associations cannot provide good instruction. However, you would need to trace the lineage of their founding officers and instructors. That brings us to the next area of investigation instructors. You need to trace the credentials of the instructors. What organization provided their instruction and board certification? Who were their instructors and where did they get their credentialing? In other words, who taught your instructor and who taught your instructor’s instructor? Is your instructor a properly credentialed thermologist, or are they part of an association where they simply placed letters behind their names and began to teach others?
And lastly, what is the caliber of the certified students from the course? Do they understand and provide thermal imaging services under accepted standards and guidelines? In the end, the legitimacy of one's credentials is directly proportional to the lineage of one’s education.
What is a provisionally certified technician?
This question is asked for obvious reasons. The title of “provisionally certified” technician is very confusing. Is the technician certified and credentialed to be performing thermograms or not?
Just think of the interaction between a patient calling an office and speaking with a “provisionally certified” technician: Q. Are you a certified technician? A. Yes, provisionally. Q. So you are not yet certified? A. No I am certified, provisionally. Q. But provisionally means you are “conditionally” certified. A. Yes, I still need to perform a certain number of images and time of experience in the field. Q. I see. Since you haven’t really finished your certification, how are you allowed to be a technician?
In the past, for a brief amount of time, some associations thought that technicians should have a time of field experience along with performing a certain number of thermograms before being granted full certification. This followed one of the important requirements that doctors go through to become board certified as clinical thermologists. Doctors are required to have a certain amount of field experience and a sufficient number of thermograms co-read with a thermologist instructor before they are board certified. This makes sense, as doctors need this level of exposure to pathologies in order to becoming proficient as an interpreting thermologist. These are the same requirements for radiologists. But what benefit is this to a technician? How does doing more thermograms and more time in the field make a better technician? The current requirements fully prepare the technician to provide quality imaging in a clinical environment. Doing more thermograms may make a technician more efficient in taking the images (repetition experience), but it does not make them take better images. Either the technician is certified and ready to provide thermal imaging or they are not.
If you find a course that is still mandating the additional field time and a certain number of images taken, you may want to ask how this is to benefit the patients you will be serving. Perhaps these extra images and time are really benefiting someone else in some way.
Do I need to find a thermologist that will interpret our thermograms before I enroll in the course?
No, why would you? Do colleges and universities mandate that you find a job and a radiologist before you can enroll in a radiological technician course? Why would a course place this requirement on a student? Perhaps this benefits someone else?
I saw a technician course that was taught by another technician.
We are unaware of any of the major associations or societies that allow technicians as sole instructors for technician courses. Depending on the size of a class, experienced technicians may be enlisted to assist board certified thermologist instructors during the course. However, even with a great deal of field experience, a technician does not have the clinical acumen or thermology training necessary to insure that a student technician is provided with an educational atmosphere that insures a well-rounded education.
THERMAL IMAGING INTERPRETATION
What should I look for in choosing a qualified interpreting thermologist?
The answer to this question is much the same as choosing a qualified imaging center based on the education of the technician it’s all about tracing the lineage of the thermologist. What association credentialed the thermologist? How long has it been around? Who are the founding officers? What is their lineage? This does not mean that new associations cannot provide good instruction. However, you would need to trace the lineage of their founding officers and instructors.
Now let’s get specific. Who were the thermologist's instructors? What is their lineage? Is the thermologist part of a group that just placed letters behind their names or did they earn their board certification through examination and years of field experience from an association of instructors that can trace their lineage? Does the interpreting thermologist use the internationally accepted TH grading standard for interpreting breast thermograms? Are the reports clear with regard to recommended follow-up tests?
Like other doctors who have undergone a quality education in clinical thermology, Dr. Amalu underwent instruction that encompassed many hours of post-graduate classroom instruction, two years of supervised field experience, hundreds of sets of images co-read by a thermologist instructor, a written examination and a practical examination before earning his board certification. In order to immerse himself in the interpretation of thermal breast images, Dr. Amalu spent another two years of mentoring under the personal tutelage of the world’s leading expert in this field Dr. William Hobbins, MD, FACS.
What kind of doctor can provide interpretation of thermograms?
With radiology, DCs (Doctors of Chiropractic), MDs (Medical Doctors), and DOs (Doctors of Osteopathy) can become radiologists. Just as with radiology, DCs, MDs, and DOs can become thermologists. All of these doctors have the clinical acumen necessary to take additional training to become radiologists or thermologists.
Are there standards and guidelines for the interpretation of thermograms?
Absolutely! How could any medical imaging technology provide service without standards and guidelines? Quality peer-reviewed and published research studies performed in leading universities have established a normative database of objective topographic thermal gradients and temperature values. Almost 10,000 references exist in the literature using this normative database to examine for pathology.
With regard to breast thermography, over 800 references exist in the literature to support the standards and guidelines under which breast thermograms are interpreted. All breast thermogram reports should contain a TH (thermobiological) grading of each breast. If a report does not grade each breast into one of 5 TH grades, the competency of the interpreting thermologist comes into question. The TH grading system was devised in order to provide a method for the universal interpretation of both qualitative and quantitative thermal data and to use this data to convey the level of risk and concern. Without a grading system there would also be no way to objectively monitor the progression of possible pathology or provide an objective indicator of improvement of the health of the breasts under medical care.
The TH grading system has been in place since the early 1980’s. The American College of Radiology (ACR) established the BIRADS (Breast Imaging Reporting and Data System) grading system for mammography in order to provide the same information when interpreting a mammogram, MRI, or ultrasound of the breast. The ACR states the following: “The BI-RADS provides standardized breast imaging findings terminology, report organization, assessment structure and a classification system for mammography, ultrasound and MRI of the breast. The report organization enables radiologists to provide a succinct review of mammography, ultrasound and MRI findings and to communicate the results to the referring physician in a clear and consistent fashion with a final assessment and a specific course of action.” MIR imaging uses the TH grading system to accomplish the same objectives.
Why do reports need to be clear on exactly what follow up tests are needed?
If a thermologist sees something on a thermogram that needs further study, recommendations for specific follow-up tests and or examinations become a very important part of a thermogram report. Take a look at mammogram, ultrasound, MRI, and other imaging reports as examples for specific recommendations for follow-up tests. For example, you may see recommendations for follow-up ultrasounds or biopsies on mammogram reports. What you will not see is an ambiguous recommendation for the patient to simply see their doctor. This is not the standard of care (see the BIRADS definition above). A good report will make specific recommendations that will convey the level of concern to the patient and their doctor along with the next likely step to take. This is what the patient’s doctor wants and expects to see on a properly written report.
When I get my report will you provide me with treatment recommendations?
Absolutely not! As a thermologist providing MIR interpretations it is my duty to NOT intervene in treatment. Your treatment must be directed by your primary care physician and/or medical specialist(s).
Even though I am a doctor who provides patient care on a daily basis, do I know your complete health history? Have I reviewed all of your recent and past laboratory exams? Do I know all of the medications, supplements, herbals, etc. you are taking? Have I consulted with or at least have your complete health history from all the other health care providers/specialists involved in your care? Have I provided you with a recent physical examination to be sure of certain health markers? Can you imagine the level of irresponsibility a doctor would have to undertake to make treatment recommendations simply off the findings of a thermogram? There is a real possibility here that a patient could be seriously injured or worse.
As a doctor, who is also a thermologist, I would never write a report containing recommendations for treatment. The findings and recommendations on the report are sufficient enough for your doctor to use in providing care. Have you ever seen a radiologist recommend anything other than further follow-up testing on a mammogram, X-ray, CT, ultrasound, or MRI report?
I’ve heard that there are computer programs that can read thermograms.
I think that we need to clarify this question first. If you are asking if there is an FDA approved computer program that will read the images and create a report without a board certified thermologist also reading the images, the answer is no. There is no place anywhere in health care where a machine provides interpretation of a test and creates a report without a doctor’s interpretation of the results. Have you ever seen a report from any imaging procedure that did not have a doctor’s signature (electronic or otherwise)? This is completely unacceptable in health care. Also, can you imagine the liability! No company would be foolish enough to want to accept this level of responsibility for their software program.
On the other hand, there are quite a few experimental programs currently being studied that are designed to aid thermologists when interpreting thermograms. However, we are not aware of any programs that have been proven to be accurate and approved by the FDA. As such, there is no adequate research proving that any of these programs are of value to the thermologist.
These programs are designed to work just like the FDA approved programs presently being used to aid radiologists when reading mammograms (e.g. ImageChecker). Dr. Amalu is currently working with a group of experts in the field of remote sensing to create one of these digital CAD (computer aided detection) programs for use in MIR. However, a bit more time and a great deal of research will be needed before seeking FDA approval.
On a side note, research has shown that the skill level of radiologists in detecting suspicious areas on a mammogram is far greater than that of the CAD programs designed to aid them. It’s nice to know that we humans are still better than machines.
I've been told that when doing a breast thermogram a cold-challenge must be done.
The use of the cold-challenge (placing the patient's hands in ice-water, using ice mitts, or using ice packs placed on the mid-back) was stopped in the late 1980's. The research at the time showed that using the cold-challenge did not increase the sensitivity or specificity of breast thermography. What we are finding is that some offices have websites telling women that they should never go to any office or imaging center that is not doing the cold-challenge. We have no idea why they are doing this as this is simply false information. Fortunately, the number of offices we see doing this is decreasing.
Back in the late 1990's and early 2000's the problem was so bad that Dr. William Hobbins (the leading expert in breast thermography) encouraged Dr. Amalu to review his database of cold-challenges and present a paper at the yearly symposium of the American Academy of Thermology (AAT). Dr. Hobbins and other experts in this field were concerned that these misleading offices were claiming that experts in this field were missing things by not performing breast thermography correctly. The paper went on to be presented at the international conference of the IEEE Engineering in Medicine and Biology Society. The end result was acceptance of the paper for peer-review and publication (click here or go to Medline/PubMed). As recently as 2013, the AAT formed a standards and guidelines committee that included Dr. Amalu, along with Dr. William Hobbins and a group of experts in this field, to review the current status of breast thermography and create an updated internationally peer-reviewed standards and guidelines document. With regard to the cold-challenge, a review of the literature along with a consensus among the experts reaffirmed that the cold-challenge did not improve the sensitivity or specificity of breast thermography; and as such, its use was not necessary to provide accurate medical infrared imaging of the breast.
NEW CUTTING-EDGE THERMOGRAPHY SYSTEMS
What about the new thermography systems I have heard of?
From time-to-time we see new MIR systems that make claims to significant superiority to the current imaging systems. What we find is that these systems are usually using methodologies that are untested and/or ignore the laws of thermodynamics. One of the most misleading of these "new" infrared imaging technologies is the claim of being able to look deep into the body (see below for a more detailed explanation).
One of the problems we see are the use of imaging equipment in a manner that either introduces thermal artifacts or temperature measurement errors. This alone causes inaccurate data collection and interpretation errors. Another cause of errors comes in the form of unproven software interpretation programs that are used without a board certified thermologist interpreting the images. There is no place in healthcare where a machine provides an interpretation of a medical imaging procedure without a board certified radiologist or thermologist reading the images and signing the report (see previous topic above). Software programs such as ImageChecker (e.g. use in mammography) are used to assist the radiologist, but are not used alone.
The current MIR imaging system standards and interpretation guidelines have been established for over 34 years. These equipment and interpretation standards and guidelines have been continually monitored and updated by experts in this field through major associations worldwide. We are currently using the state-of-the-art in MIR imaging systems and interpretation methodologies. This involves MIR imaging systems that can withstand the scrutiny of the finest engineers in infrared sciences and the interpretation expertise from highly educated board certified thermologists.
I have heard that with certain newer imaging systems pre-imaging acclimation is no longer needed.
The sophistication of an MIR imaging system has nothing to do with human physiology. All patients must undergo 15 minutes of acclimation in an environmentally controlled room.
It doesn’t matter what type of imaging system you have, if you have been driving with your arm out the window and the AC blowing on the other side of your face you cannot be suddenly placed in front of a heat sensing camera to take images. When going from a hot environment to a cool one, and vice versa, the body needs to become attuned to the environment in order to express accurate thermal information. Clothing will also leave marks on the surface of the body (thermal artifacts) that have to be removed before imaging can take place.
You could have the most accurate and sensitive thermometer in the world, drink a hot cup of coffee and stick the thermometer in your mouth. Do you think that you would get an accurate representation of temperature?
ASSORTED THERMOGRAPHY MYTHS
I've heard of a new advancement that allows infrared imaging to see deep into the body to detect tumors, organ pathologies, and other deep structures.
There is nothing new here. These claims were made in the 1990's, 2000's, and now again in the 2010's. Everytime this has occured no one has ever been able to prove it. They will tell you that research has been done. They will show you images that claim to prove that their system is the only one that can do this. In most of these instances what you are being shown is common digital subtraction methods that are built into all quality imaging systems.
In all of these instances basic research studies have never been replicated. We know that MIR can only see to a depth of 5mm. How do we know this? Two research studies were performed long ago using both animals and humans. Multiple volunteers had heat generating modules surgically implanted at varying depths from the bone to the surface of the skin. The surgical procedures were allowed to completely heal and basline MIR images taken to demonstrate normal thermal patterns. Each module was turned on individually and heated to just under the point of causing cellular death (This is well over any temperature that would be generated from a pathology). It was discovered that until the heat source was within 5mm of the surface of the skin it could not be detected. Now, has infrared technology advanced since then? Absolutely, but have the laws of thermodynamics changed? When asked if these "new" imaging systems have undergone research by reproduced these studies you will find that the answer is no. Until they do there is no proof.
At this point we have something that may be very dangerous. If these claims were true why would we need basic radiology, CT, MRI, ultrasound, mammography, or any other medical imaging technology? MIR offers significant advantages in many areas, but if patients are allowed to believe that MIR can see deep into the body and provide screening for the early detection of internal disorders we are endangering their lives.
My breast thermogram report mentioned lymphatic congestion.
There are no thermal patterns or markers of any type that would allow for an interpretation of lymphatic congestion. It doesn’t matter if the image is of the breast or the axilla (under arm area).
In breast cancer patients who have undergone the removal of a significant number of axillary (under arm) lymph nodes, and have obvious visual proof of lymphedema in the upper extremity, the resulting thermogram of the affected arm would then be a result of lymphatic congestion. However, without knowing the history of this patient, and visually confirming the condition, the interpretation of the upper extremity thermogram would be indistinguishable between some other form of circulatory and/or neurological abnormality.
My report noted “thermal findings indicative of fibrocysts and cysts”.
Interpretations of thermal findings indicating cysts and fibrocysts shows a lack of the basic understandings of thermodynamics. Not to mention the research showing that we can only detect heat sources to a depth of 5mm from the surface of the skin.
You will notice on these types of reports that the interpreter routinely calls attention to “cold areas” or “cold spots” as the location of cysts and/or fibrocysts in the breast. Since cysts are fluid filled sacs, one might think that this area under the skin would create a cold area at the surface. However, simple thermal conduction will not allow for a temperature difference between the cyst and the surrounding tissue. Take for example that a balloon filled with cold water (acting as the cyst) is placed inside a larger balloon filled with warm water (acting as the breast). What will happen over time? Both of the balloons will reach equilibrium and become the same temperature (Zeroth Law of Thermodynamics). This is the same thing that happens with cysts and fibrocysts in the breast. As such, there are no thermal signs of cysts or fibrocysts in the breasts.
The side view of my neck showed carotid inflammation.
This is another example of an inadequate education in thermal imaging. In this instance the interpreting thermologist is looking at a view of the side of the neck and sees a hot stripe leading from the area near the rear of the jaw down toward the front of the neck. This hot stripe is thought to be heat from an inflamed carotid artery.
We have three very elementary errors here. The first is basic anatomy. We have seen websites that state that since the carotid artery is so close to the surface of the skin that it is easily evaluated using infrared imaging. I won't bore you with an anatomy lesson numerating the layers of muscle, fascia, and other blood vessels that cover and protect this vital structure that conveys blood to the brain. Suffice it to say that the carotid artery is safely located deep in the neck close to the cervical spine. Remember that we cannot see anything deeper than 5mm from the surface of the skin. Secondly, if this heat stripe is a blood vessel how can one prove that it is inflamed only from the thermal image? Simply changing the volume of blood flow will change the size of the vessel; and thus, the appearance of increased heat. And lastly, true carotid inflammation (carotid vasculitis) carries with it a very specific set of symptoms.
So what is this heat stripe? It is the external jugular vein. One of the technical advantages inherent in performing MIR is that a live image is generated. As such, the technician or doctor can approach the patient and investigate the surface of the body for any interesting finding that appears on the live computer image. When seeing this hot stripe the technician could use a pen to point at an obvious bluish line on the neck (external jugular vein) while looking at the infrared image. The results are obvious.
My report noted “thermal findings over the chest indicating heart problems”.
By now I think you have learned that we cannot see heat coming from the heart through layers of muscle, fascia, and bone. Remember that we cannot see anything deeper than 5mm from the surface of the skin. And by the time a viscerosomatic reflex occurs, creating a thermal signal from the heart, the patient already has obvious cardiac symptomatology. MIR cannot provide any type of early warning of cardiac disease.
I saw an office’s website that mentioned that with their special camera they can offer “privacy imaging” I won’t need to be undressed in front of a technician.
First, this has nothing to do with the type of camera used. Any office with a reasonable mount for the camera can leave the patient behind a wall or drape and provide imaging without the technician seeing the patient. However, this is not allowed in MIR imaging.
We all understand that we would prefer not to be undressed in front of a technician or doctor. But all of us also understand that when entering any health care facility the likelihood of having to disrobe is fairly high. As mature adults we understand that this can cause some anxiety, but disrobing in front of a technician or doctor of the same gender is something that is fairly common.
The real problem here is that providing imaging without the technician visually seeing the patient is against the standards and guidelines in MIR imaging. It would be irresponsible of the technician not to observe the surface of the body being imaged. During the acclimation process the technician needs to properly position the patient as to be sure that thermal artifacts will not be introduced into the images. Once the acclimation time has passed, the technician must re-enter the room to verify that the patient has not changed this position. This is part of the verification of proof of proper acclimation.
When performing breast imaging the technician has special responsibilities that would also preclude “privacy imaging’. Certain changes to the surface of the breast may occur due to surgeries or when a cancerous growth is present. It is the technician’s responsibility to visualize the surface of the breast in order to inform the interpreting thermologist if anything other than smooth uniformly colored skin is present. Surface changes can be critical in the thermal grading of the breast and the proper management of the follow-up recommendations.
With imaging the rest of the body the technician must also be observant for surface evidence of surgical sites (e.g. scars). At times, patients can forget these things when filling out their intake forms. Depending on the extent of certain surgical procedures, the thermal pattern in these regions of the body can be significantly altered. Without having a technician present to observe the surface of the body the interpretation of the thermogram may be in error due to the interpretation of a surgical artifact as a pathology.
It has also been said that many of these things can be overcome by having the patient acclimate in front of the camera in a “privacy imaging” setting. However, one cannot “see” these things in infrared, it’s just not possible. Even if a particular camera was able to provide additional visual imaging just like a regular video camera, you would have to let the patient know that you were looking at them just as if you were in the room. At this point you would be violating the entire “privacy imaging” idea. After decades of experience in MIR imaging I can assure you that patients do not like having an infrared camera, much less a regular video camera, pointed at them during the acclimation time. It creeps them out.
“Privacy imaging” introduces the possibility of significant errors and violates the standards and guidelines in MIR imaging.
I've been told that after my intial thermogram I will need to return in 3 months for another thermogram so that a stable baseline can be established. Is this necessary?
Absolutely not! The argument for this practice seems to be that there is no way to know on your first thermogram whether or not your body was changing at the time. I have another question, if the follow-up 3 month thermogram showed that there was change, which image set would be the stable baseline? Would it be the first set or the 3 month later set? It sounds like you would need to do another set of images in another 3 months as a tie breaker. But what if this set also showed change? The bottom line here is that if you did need to return to do any of this the technology must be useless.
What would you think if your doctor took your temperature, noted it as a fever, and then told you to return the next day to see if this first reading was right? Reading core temperature is no different than a surface recording taken under proper thermal imaging guidelines. Either the information taken on the first thermogram is valuable or the technology is unstable and useless due to some variable in the patient’s physiology. Research following patients for over 5 years has proven that the thermal patterns and differential temperatures at the surface of the body are remarkably stable and held within a very narrow range. These research studies were used to establish the normative database to which we compare patients when reading thermograms. Thermovascular patterns are as unique as a fingerprint and can be followed with accuracy for decades. It is when there is a change to this stable thermal fingerprint that a problem is signaled.
This begs the question as to why patients are being asked to return in 3 months. I would ask one of these offices for at least one peer-reviewed and published research paper demonstrating the need for this in order to establish a stable baseline. The research has already been done. In the early days of thermography each set of thermal images were taken in triplicate. The patient was acclimated in a temperature controlled imaging room under standard protocols for 15 minutes and then imaged. The patient would then be left for another 15 minutes and imaged again. This was finally repeated once more. In these early days thermologists were unsure about the stability of the process and the possibility of changes. Once the stability of the thermal data was established this practice was stopped. Then, as mentioned above, this was taken a step further by watching the thermal stability of patients for over 5 years. Studies have proven that a single set of thermal images taken under proper guidelines is completely accurate for analysis.
Under the established standards and guidelines for medical infrared imaging, recalling patients for follow-up thermograms is based solely on clinical need. When it comes to breast thermography, follow-up thermograms are performed based on the known metabolism of breast cancers. Under these guidelines each breast must be graded into one of 5 thermobiological (TH) categories. The level of TH grading acts as an individualized risk assessment based on the patients own biology. Depending on the TH grading, and taking into consideration the metabolism of breast cancers, the patient will be asked to return in a reasonable amount of time.
Since it was established decades ago that a single thermogram is all that is needed for immediate analysis, why are some offices having all their initial thermogram patients return in 3 months?
Are there any research papers I can read about thermography?
There are approximately 10,000 literature citations regarding the use of thermography in the clinical setting. Over 800 research papers alone are focused on the uses of MIR in evaluating the breast.
Considering the enormous amount of research available regarding the use of MIR, we would recommend that you avail yourself of Medline and your local medical school library.