Ct mri c ontrol t esting m inimize r edundant i maging
Download
1 / 61

CT-MRI C ontrol T esting- M inimize R edundant I maging - PowerPoint PPT Presentation


  • 85 Views
  • Uploaded on

CT-MRI C ontrol T esting- M inimize R edundant I maging. CT-MRI. Two part program Radiology Support Service Lecture Series and Attending Department Meetings Reduce unnecessary radiation exposure Reduce unnecessary costs to health care system and patients

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' CT-MRI C ontrol T esting- M inimize R edundant I maging' - gwendolyn-fuller


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Ct mri c ontrol t esting m inimize r edundant i maging
CT-MRIControl Testing-Minimize Redundant Imaging


Ct mri
CT-MRI

  • Two part program

    • Radiology Support Service

    • Lecture Series and Attending Department Meetings

  • Reduce unnecessary radiation exposure

  • Reduce unnecessary costs to health care system and patients

  • Improve peer-peer communication between radiologists and ordering physicians


Ct mri1
CT-MRI

  • Radiology Support Service

    • Reduce inappropriate and unnecessary high-cost imaging studies including: CT, MRI and PET

    • “Radiology consultant”

    • Assist in determining the most appropriate imaging study

    • Review clinical findings and make recommendations based on current established guidelines

    • Do the right test the first time


Ct mri2
CT-MRI

  • Directly available by phone from 8:00 am to 5:00 pm, 5 days a week.

  • Successful program used elsewhere in our practice and has shown a decrease in high-cost imaging.

  • As always, we’re available in the main reading room weekdays, evenings and weekends to discuss results of specific patient cases.

    (978) 275-1319


Ct mri3
CT-MRI

  • Lectures and Discussions

    • Delivered regularly at clinical department meetings.

    • Focus on one imaging modality/disease process in a major radiologic subspecialty- Neuro, MSK, Pediatric, Body and Vascular/Interventional Radiology.

    • Focus all modalities including ultrasound, nuclear medicine, CT, and MRI.

    • Review the needs of your departments and any issues that we can help you with.


Ct mri4
CT-MRI

  • Cystic Renal Lesions in the General Population

    • Dr. Hanks at 5/18/11 AQC-PCP Meeting

  • Guidelines for the Management of Pulmonary Nodules

    • Dr. Abel at 3/1/11 IM Quarterly Meeting

  • Management of Ovarian Lesions Identified with Ultrasound

    • Dr. Hall at OB/GYN 12/10 Quarterly Meeting

    • Open to any other topics of interest


Cystic Renal Masses

Bad News: No 0.25 CME

Good News: <15 minutes


Cystic Renal Masses:

Assessment and Management in the General Population

Patrick Hanks, MD


Statement of the Problem

It has been estimated that over half of patients over the age of 50 years harbor at least one renal mass, and often several are found during one radiologic examination.1


Statement of the Problem

  • Approximately 10-15% of all renal cell carcinomas can appearas complex cystic lesions on imaging studies

  • Nonmalignant renal cysts can have a complex appearanceon CT, usually as a result of hemorrhage, infection, or inflammation


The Role of the Radiologist

  • What is the imaging appearance of the mass?*

  • Suggest management options.

*Along with the determining the likely diagnosis, this is the sine qua non of the radiology report.


Dr. Morton Bosniak, MD

Professor Emeritus at NYU Department of Radiology


The Bosniak Classification Scheme

An imaging and clinical management scheme for cystic renal masses.


The Bosniak Classification Scheme

  • Category 1 and 2: Simple and minimally complicated cysts.

  • Category 2f: Indeterminate complicated cysts.

  • Categories 3 and 4: Suspicious complex cystic masses.


The Bosniak Classification Scheme

  • Category 1 and 2: Ignore.

  • Category 2f: Observe.

  • Categories 3 and 4: Intervene.


The Bosniak Classification Scheme

Minimally complicated

Indeterminate, probably benign

Indeterminate, surgical lesions

RCC until proven otherwise


Category 1: Simple Cysts

  • Simple cysts contain low-attenuation fluid.

  • A hairline-thin smooth wall.

  • No septations, calcifications, or enhancing nodular soft tissue.



Category 1: Simple Cysts

Hairline thin wall, no septa, calcifications or solid elements; water attenuation, no enhancement


Category 1: Simple Cysts

Hairline thin wall, no septa, calcifications or solid elements



Category 2: Minimally Complicated Cysts

  • May contain a few hairline-thin septa

  • Fine calcification or short segment of slightly thickened calcification may be present in the wall and/or septa.

  • Homogeneously high-attenuating masses (≤3 cm) that are sharply marginated and do not enhance

  • Perceived, but not measurable, enhancement may be appreciated


Category 2: Minimally Complicated Cysts

Few hairline-thin septa with or without perceived (not measurable) enhancement


Category 2: Minimally Complicated Cysts

Fine calcification or short segment of slightly thickened calcification in the wall or septa


Category 2: Minimally Complicated Cysts

Homogeneously high-attenuating masses (≤3 cm) that are sharply marginated and do not enhance


Category 2f: Indeterminate Complicated Cysts

  • Increased number of hairline thin septa

  • Minimal thickening of cyst wall and/or septa

  • Perceived, but not measurable, enhancement*

  • Calcification, which may be thick and/or nodular

  • Totally intrarenal, nonenhancing, high-attenuating masses >3cm


Dismiss

Follow/Observe


Category 2f: Indeterminate Complicated Cysts

Increased number and thickness of septa. Stable for 4 yrs.


Category 2f: Indeterminate Complicated Cysts

Thick and irregular calcifications in wall. There is high-attenuation material (arrow) within the mass that does not enhance.


Category 2f: Follow-Up

  • 6 month intervals for the first year

  • Then annually for 5 years

*42 Category 2f lesions followed for at least 2 years, only 2 lesions showed progression


Category 2f: Follow-Up

  • Images from the same modality at both initial and follow-up evaluations are compared.

  • In younger patients (or in patientswith renal insufficiency) who will undergo multiple follow-up examinations, an early switch to MR imaging is suggested.

*Inyounger patients, a longer follow-up period may be necessary.


Category 2f: Follow-Up

  • Growth rate is not a feature of the Bosniak cyst classification.

  • For this reason, morphologic change (eg, septa becoming thicker or more nodular) should be assessed; overall growth and lesion size are less important.


Follow/Observe

Intervene


Category 3: Indeterminate Complicated Cysts

  • Contain thickened walls or septa in which measurable enhancement is present.

  • Category III cystic renal masses have a reasonable chance of being benign or malignant.


Category 3: Indeterminate Complicated Cysts

Thickened septa (arrows) in which measurable enhancement could be demonstrated.



Category 4

Renal cancer until proven otherwise


Size and Growth of Cystic Renal Masses

  • Size is not an important feature of the Bosniak classification.

  • Small cystic masses may be malignant and large ones may be benign.

  • Likewise, growth is not considered as important as morphologic features





Relative Value of Different Imaging Modalities

3

2f

Dx: Benign hemorrhagic cyst.


Relative Value of Different Imaging Modalities

  • How to handle those cases in which a cystic renal mass appears benign at CT, yet more complex at MR imaging?


The Bosniak Classification Scheme

Minimally complicated

Indeterminate, probably benign

Indeterminate, surgical lesions


2f

3

CT: Numerous hairline thin septa.

MRI (T2) shows many more septa.

Stable for 1 year; 75 yo man who refused surgery.


3

4

CT; enhanced irregular thickened wall.

T1 w/gad

65 yo man. Dx: RCC


Relative Value of Different Imaging Modalities

  • We believe that, in this scenario, factors such as the size of the lesion or the condition and age of the patient dictates the treatment options.


Relative Value of Different Imaging Modalities

15HU

32 HU

T2

T1FS

Simple cyst in 28 yo man


Relative Value of Different Imaging Modalities

15HU

32 HU

Simple cyst in 28 yo man


These are “guidelines” and the evaluation and treatment of each case must be individualized depending on the imaging findings, the age and condition of the patient, and the diagnostic and treatment options available.


Summary of each case must be individualized depending on the imaging findings, the age and condition of the patient, and the diagnostic and treatment options available.

• CT is the modality of choice for evaluating indeterminate renal lesions that are suspicious for malignancy.

• For those patients who cannot tolerate iodinated IV contrast material due to allergy, MRI with gadolinium contrast is advised.

• US may be useful to clarify a mass seen on CT that is probably a hyperdense cyst.

• When CT and MRI are compared in the evaluation of cystic renal masses, MRI appears to be more sensitive and tends to upgrade cystic lesions. Thus caution is advised when using MRI findings to direct clinical management at this time.

• Renal aspiration or biopsy has few but emerging indications: confirming an infected cyst, identifying lymphoma or a metastasis as the cause of the indeterminate renal mass, and confirming renal cell carcinoma in certain circumstances, including prior to ablative therapies.

• Angiography is used primarily to define vascular anatomy before nephron-sparing surgery.


www.commonwealthradiologyassociates.com of each case must be individualized depending on the imaging findings, the age and condition of the patient, and the diagnostic and treatment options available.

Radiology Links

CRA Lectures and Educational Materials


REFERENCES of each case must be individualized depending on the imaging findings, the age and condition of the patient, and the diagnostic and treatment options available.

  • Tada S, Yamagishi J, Kobayashi H, Hata Y, Kobari T. The incidence of simple renal cyst by computed tomography. ClinRadiol 1983; 34: 437–439.

  • 2. The current radiological approach to renal cysts. Bosniak MA.

  • Radiology. 1986 Jan;158(1):1-10.

  • PMID: 3510019 [PubMed]

  • http://radiology.rsna.org/content/158/1/1.abstract?ijkey=541a2c692fdb1f5b4705312c16b0b6a21955d73e&keytype2=tf_ipsecsha

  • 3. How I Do It: Evaluating Renal Masses. Israel GM, Bosniak MA.

  • Radiology. 2005 Aug;236(2):441-50.

  • PMID: 16040900

  • http://radiology.rsna.org/content/236/2/441.full


REFERENCES of each case must be individualized depending on the imaging findings, the age and condition of the patient, and the diagnostic and treatment options available.

  • 4. Evaluation of cystic renal masses: comparison of CT and MR imaging by using the Bosniak classification system. Israel GM, Hindman N, Bosniak MA. Radiology. 2004 May;231(2):365-71.

  • PMID: 15128983

  • http://radiology.rsna.org/content/231/2/365.full

  • American College of Radiology: ACR Appropriateness Criteria. Indeterminate Renal Masses .

  • http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonUrologicImaging/IndeterminateRenalmassesDoc8.aspx


REFERENCES of each case must be individualized depending on the imaging findings, the age and condition of the patient, and the diagnostic and treatment options available.

6. Should we biopsy complex cystic renal masses (Bosniak category III)? Bosniak MA.

AJR Am J Roentgenol. 2003 Nov;181(5):1425-6; author reply 1426. No abstract available.

PMID: 14573452

http://www.ajronline.org/cgi/content/full/181/5/1425

7. Management of the Incidental Renal Mass. Stuart G. Silverman, MD, Gary M. Israel, MD, Brian R. Herts, MD and Jerome P. Richie, MD. 10.1148/radiol.2491070783 October 2008 Radiology, 249, 16-31.

http://radiology.rsna.org/content/249/1/16.full#content-block

8. Follow-up CT of moderately complex cystic lesions of the kidney (Bosniak category IIF). Israel GM, Bosniak MA. AJR Am J Roentgenol. 2003 Sep;181(3):627-33.

PMID: 12933451

http://www.ajronline.org/cgi/content/full/181/3/627?ijkey=0856370e427035f403e417dfc9604b930892c068


REFERENCES of each case must be individualized depending on the imaging findings, the age and condition of the patient, and the diagnostic and treatment options available.

9. Pitfalls in Renal Mass Evaluation and How to Avoid Them. Gary M. Israel, MD and

Morton A. Bosniak, MD. 10.1148/rg.285075744 September 2008 RadioGraphics, 28, 1325-1338.

http://radiographics.rsna.org/content/28/5/1325.full


COMING SOON! of each case must be individualized depending on the imaging findings, the age and condition of the patient, and the diagnostic and treatment options available.

SOLID RENAL

MASSES


ad