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CURRENT PATHOLOGY IMAGING GUIDELINES CONTENTS A. Neck and thorax Imaging resources Problem management: a. Neck imaging Lateral cervical mass Median or paramedian cervical mass Hyperparathyroidism Tumors of the larynx Tumors of the pharynx b. Thoracic Imaging Infections Bronchial diseases Interstitial diseases Hemoptysis Acute thoracic pain breath-dependant with/without cough Acute thoracic pain not breath-dependant Thoracic pain, dyspnea or chronic cough Cardiac diseases B. Upper abdomen C. Genitourinary system D. Vascular system E. Central nervous system F. Spine G. Extremities H. Nuclear Medicine IMAGING RESOURCES neck lateral view foreign body detection thickening of prevertebral soft parts (abscess, haematoma) adenoid vegetations (children) plain chest radiograph upright and in PA view if possible without lateral view: only for cardiopulmonary screening (high risk of Tbc immigrants, pre-operative for older patients) sufficient for pneumothorax or air trapping (expirium) detection lateral view usually left sided, except for right-sided disease almost always mandatory (lung infection, tumor, cardiac failure, effusion, etc.) ribs view doesn't show associated chest lesions; has to be done only after plain chest diagnosis of bone metastasis, chronical intercostal pain, medicolegal concerns (fracture). mediastinum diaphragmed and higher voltage exposure for the analysis of the middle and posterior mediastinum (CT should be done if any doubt) apical lordotic view lung apices lesions (Tbc, fibrosis, radiotherapy sequelae) lateral horizontal view DD pleural thickening / effusion (can also be investigated by ultrasound) CT-scan first choice modality for trauma, lung, mediastinal and thoracic wall work-up neck: infections, trauma, tumors guided punction (biopsy and drainage) aortic aneurysms pulmonary arteries angioCT: first choice before conventional pulmonary artery angiography for embolism diagnosis precerebral arteries angioCT work-up coronary arteries: angioCT, calcium scoring MRI (Magneirc Resonance Imaging) cardiac and great vessels malformative and structural diseases neck: alternative to CT (tumors); has a better tissue differenciation power for initial et recurrence cancer work-up complementary to CT for analysis of mediastinum and thoracic wall disorders useful for patients allergic to iodine contrast medium MRI is less accurate than CT for lung parenchyma PROBLEMS MANAGEMENT a. NECK IMAGING (in bold: recommended examinations) 1. Lateral cervical mass DD: adenitis, abscess, metastatic node, salivary gland lesion, congenital cyst, aneurysm or carotid ectasy paraganglioma, hemangioma, cystic hygroma, schwannoma, laryngocele. Neck ultrasound: masses, lymph nodes (guided cytoponction) and vessels (carotid/jugular vein, color & spectral Doppler). Salivary glands: tubular ectasia, calculi; tumors, cysts, sialadenitis. [Plain film: calcifications (tuberculous, salivary calculi)] MRI: tumor staging. Tumor recurrence. Angio-MR of carotids. MR sialography (salivary ducts imaging) CT: infectious disorders and salivary lithiasis. Oncologic work-up. 2. Median or paramedian cervical mass DD: goiter, thyreoglossal cyst, lipoma, thyroid ultrasound (event. followed by thyroid scintigraphy), cytoponction of atypical nodules [plain chest radiograph: tracheal displacement if retrosternal goiter] MRI or CT for tumoral staging. CT will be chosen if chest exploration also indicated. 3. Hyperparathyroidism (primary) hands AP view (bone resorption signs, low sensitivity) neck ultrasound (sensitivity 80-85% for non ectopic adenomas), allows alcoholisation therapy MRI of neck and mediastinum (sens. 74-85 %): ectopic adenomas, recurrences 99mTc-sestamibi scintigraphy (sens. 70-90%): same as MRI CT of neck and mediastinum (sens. 46-87%) Thallium-technetium scintigraphy (sensitivity 75%, specificity 90%). 4. Tumors of the larynx CT thin sections (before biopsy!) MRI: sometimes provides better staging of mucous and cartilaginous invasion. 5. Tumors of the pharynx MRI: extension (mucous membranes, cranial basis, vessels) CT: localization of the mass, lymph nodes, bone destruction, metastases. b. THORACIC IMAGING Plain chest view always mandatory (most often sufficient for diagnosis, localization of the pathology, view of the whole, survey). CT remains the preferred modality for more precise diagnosis. MRI may be useful for mediastinal masses work-up and patients allergic to contrast media. MRI also first choice (except acute aortic dissecting aneurysm) or complementary to CT. 1. Infections PA and lateral film: if clinical evolution is satisfactory, one film after completion of the antibiotherapy is sufficient to rule out complications. Radiological resolution sometimes delayed. Ultrasound: confirmation of effusion, guided thoracentesis. CT: all infiltrates with or without atelectasis not evolving satisfactorily. Suspicion of empyema, abscess, pneumatocele, underlying tumor. Placement of a thoracic drainage. 2. Bronchial diseases PA and lateral film: overinflation, bullae, bronchiectasis, interstitial disease, superinfection (comparative films mandatory), atelectasis. high resolution CT: fine analysis of the pulmonary parenchyma (emphysema, alveolitis, fibrosis, bronchiectasis, tumor). 3. Interstitial diseases PA and lateral film: tuberculous sequelae, interstitial infiltrate, lymph nodes, pleural lesions High resolution CT: precise diagnosis of parenchymal disease, detection of pleural calcifications (asbestosis). 4. Hemoptysis PA and lateral film: infection, neoplasia, bronchiectasis, lung infarction, congestive heart failure. CT-scan or bronchoscopy depending on emergency level and availability bronchial arteriography, arterial embolisation for massive hemoptysis. 5. Acute thoracic pain breath related with/without cough PA and lateral film: pneumothorax, pleural effusion (empyema, pleurisy, lung infarction, haemothorax), rib fracture, lung infection. Ultrasound: rib fracture (higher sensitivity than X-rays), confirmation of pleural effusion, guided thoracentesis CT: chest trauma (lesion of the great vessels); guided thoracentesis Pulmonary embolism (chest x-ray +...): D-dimers (highly sensitive but very low specificity) pulmonary angioCT echoDoppler of the lower extremities (fair specificity, low sensitivity) pulmonary ventilation-perfusion scintigraphy (useful if negative, low specificity) pulmonary angiography 6. Acute thoracic pain, not breath related PA and lateral film: widening of the aorta, morphology of the heart, congestion, pneumomediastinum CT: suspicion of aortic dissection, pericardial effusion, mediastinitis, coronary arteries arteriography: pre-operative status of the great vessels, coronarography, coronary angioplasty echocardiography 7. Thoracic pain, dyspnea or chronic cough PA and lateral film: overinflation, infiltrates, effusion, atelectasis, mass, cardiac failure signs, hiatal hernia, etc. CT: tumor suspicion or staging, tbc, pleura, chest wall MRI: tumoral staging (mediastinum, thoracic wall, neck extension) ultrasound: rib lesion, effusion; guided puncture of a mass possible if lying in contact with the parietal pleura Positron emission Tomography (PET-scan): high sensitivity and specificity for nodal staging. PET-CT combination for optimal spatial resolution. Very expansive. 8. Cardiac diseases PA and lateral film echocardiography cardiac MRI (cardiomyopathy, tumors, congenital malformations) Spiral multidetector CT with high time resolution Pierre Bénédict, MD, radiologist, Lausanne, 1997-2008 References: Eisenberg R.L., Margulis A.R.: "Radiology Pocket Reference: what to order when", Lippincott, 2nd ed., 1999 ACR (American College of Radiology) guidelines Radiation protection 118: Referral guidelines for imaging (Office for official publications of the European Communities) Paul Rodriguez "MRI Indications for the Referring Physician", Aurora, 1997