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CURRENT PATHOLOGY IMAGING GUIDELINES

CONTENTS

A. Neck and thorax
Imaging resources

Problem management:

a. Neck imaging

  1. Lateral cervical mass
  2. Median or paramedian cervical mass
  3. Hyperparathyroidism
  4. Tumors of the larynx
  5. Tumors of the pharynx
  6. Salivary glands

b. Thoracic Imaging

  1. Infections
  2. Bronchial diseases
  3. Interstitial diseases
  4. Hemoptysis
  5. Acute thoracic pain breath-dependant with/without cough
  6. Acute thoracic pain not breath-dependant
  7. Thoracic pain, dyspnea or chronic cough
  8. 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).

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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 work-up

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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.

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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.

6. Salivary glands

  • US: mass, guided aspiration cytology; stone location, canalar dilation, atrophy, abscess
  • MRI: extension work-up, tumor characterization (multiparametric MRI, canals (IRM sialography)
  • CT: stone location, extension work-up
  • Mandible lateral radiography: submandibular stone

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 and acute situations. MRI may be useful for mediastinum and heart and in case of allergy to iodine contrast media.

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1. Infections

  • PA and lateral film: if clinical evolution is satisfactory, control 3-4 weeks after completion of the antibiotherapy 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).

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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.

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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: aortic dissection / dilation, pericardial effusion, mediastinitis, coronary arteries
  • arteriography: pre-operative status of the great vessels, coronarography, coronary angioplasty
  • echocardiography

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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 when 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

8. Cardiac diseases

  • PA and lateral film
  • echocardiography
  • cardiac MRI (ischemia, cardiomyopathy, tumors, congenital malformations)
  • Spiral multidetector CT with high time resolution (CT angiography of the coronary vessels)

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Pierre Bénédict, MD, radiologist, Lausanne, 1997-20013

References:

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