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CURRENT PATHOLOGY IMAGING GUIDELINES
CONTENTS
A. Neck and thoraxC. Genitourinary system
Imaging resources
- urinary lithiasis
- nephretic pain or mass
- recurrent infections of the superior urinary tract
- hematuria
- renovascular hypertension
- renal failure
- lower urinary tract obstruction
- urinary incontinence
- pelvic mass and pain
- menstrual disorders
- infertility (female)
- pregnancy
- mass or scrotal pain
- infertility (male)
- hernia of the abdominal wall
- Breast nodule
F. Spine
G. Extremities
IMAGING RESOURCES (listed in alphabetic order)
Abdomen supine film
- calcifications (renal, ureteral, vascular, myoma, stercolith, gallstone), foreign body, surgical clips
- mass effect, fecaloma, bladder distension
- extraluminal air, intestinal dilatation
- bone abnormalities
- upright or left lateral decubitus view: sometimes useful (pneumoperitoneum, bowel air-fluid levels, mobility of a calcification)
Arteriography
- renovascular hypertension, preoperative work-up
- dilatation, embolisation (tumors, acute haemorrhage)
Barium enema
- intrinsic colonic disorders, extrinsic compression (endometriosis, adhesive bands, pelvic tumors), distal obstruction, fistula work-up
- double contrast enema for optimal depiction of mucosal surface
- contraindications: toxic megacolon, imminent perforation, pseudomembranous colitis, recent endoscopic biopsy, pregnancy, poor colonic cleansing, recent barium meal, CT-scan scheduled for the next few days
CT-scan
- highly accurate diagnostic tool for evaluation of abdominal diseases
- trauma
- suspicion of diverticulitis, of intraperitoneal or retroperitoneal abscess
- obese patients, ileus or post-operative status where ultrasound is diffucult to perform
- more accurate than ultrasound for: retroperitoneum (lymph nodes), digestive tract, peritoneal surfaces, deep peritoneal recesses
- less accurate than US or MRI for exact depiction of uterus and adnexa
- CT colonography (virtual endoscopy)
- guided puncture and drainage
Micturating cystourethrography (MCU)
- reflux (children), urethra, bladder abnormalities, stress incontinence
- contraindications: acute infection, recent pelvis trauma
Defaecography
- functional and morphological anomalies (rectocele, intussusception, prolapse, perineal ptosis, flap-valve, etc.)
Fistulography
- opacification of the sinus tract of an perineal, enterocutaneous, peritoneal, etc. fistula
Hysterosalpingography
- infertility, repetitive abortions, uterine malformations
IVU
- hematuria, recurrent urinary infections or lithiasis, cause and level of urinary obstruction
- ultrasound first choice imaging when looking for renal mass or pyelic dilatation; CT urography has replaced IVU for most other indications due to its much higher accuracy
- contraindications: iodine allergy, myeloma, unstable diabetes mellitus, renal failure, pregnancy
Lymphography
- still rarely used for metastatic staging of lymphomas and testicular tumors
Mammography
- cancer screening after 40-50 years or earlier in case of high risk factors
- palpable mass, axillary lymph nodes or metastastatic adenocarcinoma of unknown origin
- galactography: opacification of lactiferous ducts with a contrast medium for workup of pathologic discharge (bloody or unilateral spontaneous discharge from a single duct)
MRI
- complementary to ultrasound for uterine and adnexae (uterine masses, endometriosis, ovaries, local staging of endometrium and cervix neoplasms)
- local staging of prostate tumors
- pelvimetry; fetal diagnosis in pregnant women
- breast MRI: see hereafter
Peritoneography (mostly abandoned): hernias of the abdominal wall
Retrograde pyeloureterography (urological procedure), percutaneous pyelography, ascending urethrography (urethral stenosis, tears, congenital abnormalities, fistulae)
Ultrasound
- first choice modality for any lower abdomen disorder (including bladder and abdominal wall) and pregnancy monitoring
- better tissue differenciation of internal genitalia than CT
- very sensitive for small amounts of intraperitonal fluid
- bladder residual urine measurement, prostatic, ovarian, follicular volume measurement, etc.
- essential diagnostic tool for breast diseases: mass characteristics, nodule without mammographic evidence, guided puncture
- Doppler ultrasound: tumor vascularization, testicle torsion, blood vessels
- elastography: breast nodule elasticity
Voiding cystourethrography (VCU)
- reflux (children), study of the urethra, abnormalities of the bladder, stress incontinence
- contraindication: urinary infection, recent pelvis trauma
- (Abdomen supine film or) high collimation CT without contrast: localization of the stones (80-90% of stones are radioopaque)
- Ultrasound: pelvic dilatation, perirenal effusion, calcifications, bladder abnormalities, other diagnoses (appendicitis, ovarian cyst, extrauterine pregnancy, etc.). Prevesical stones fairly easy to detect. Urine stream into the bladder can be shown with color Doppler.
- CT urography with contrast injection: superinfection; suspicion of tumor.
- CT urography (IVU): recurrent lithiases (urinary tract abnormalities), protracted course, level of obstruction, atypical symptomatology, gross hematuria
- Ultrasound: hydronephrosis, tumor, haematoma, perinephretic abscess. No specific signs for uncomplicated pyelonephritis (PN). Less sensitive than CT for small tumors and calcifications. Renal vein thrombosis (Doppler).
- CT: tumoral staging. PN not satisfactorily responding to treatment (focal, xanthogranulomatous, diffuse pyelonephritis, renal or perinephretic abscess, Tbc). Atypical cyst on ultrasound. Renal infarct. Percutaneous drainage.
- MRI: tumoral staging (invasion of other organs/vessels); mass or atypical cyst on ultrasound and CT. Allergy to iodinated contrast media, pregnancy.
3. Recurrent infections of the superior urinary tract
- Ultrasound: hydronephrosis, ureteral dilatation, malformations, calculi, atrophy, renal mass
- CT (or IVU): if ultrasound negative, verifies urinary tract integrity and monitors renal excretion. Detection of renal stones
- VCU or scintigraphy: for demonstration of reflux (children).
- Ultrasound: renal masses, vascular lesions, papillary necrosis, lithiasis, bladder wall, prostate
- CT (or IVU): pelvic and ureteral abnormalities, urothelial tumor, stone, clot; not always able to rule out a lesion of the bladder wall
- Renal arteriography: arterial embolisation in case of hemorrhage.
- EchoDoppler: morphology (atrophy, tumor, polycystic disease); renal arteries and parenchymal Doppler (fasting and non obese patients); fairly specific but limited sensitivity
- Angio-MRI (preferred to CT when renal failure) or CT angiography of the renal arteries
- Captopril renoscintigraphy: sensitivity ³ 90% only if stenosis unilateral
- Arteriography: definitive diagnosis and eventual treatment (dilatation, stent).
- Ultrasound: atrophy, hydronephrosis, renal parenchmyma alterations, calcifications, malformations. Arterial or venous thrombosis (Doppler)
- CT: injection of contrast media possible if patient under dialysis, or if creatinine < 150 umol/l. Complication detection in case of chronically dialysed patients or polycystic kidneys.
- MRI: no potentially nephrotoxic iodine load but possibility of NFS (nephrogenic systemic fibrosis) if creatinin clearance < 60 ml/min. Radiologist must be informed if renal failure is known or suspected.
7. Lower urinary tract obstruction
- Transparietal ultrasound (needs full bladder!): bladder wall ( muscular hypertrophy, diverticules), tumor, ureterocele, stones, postmicturition volume; prostate morphology, tumor (low sensitivity), abscess. Kidney abnormalities.
- MRI: localisation of a prostatic tumor and staging (operability)
- Endorectal ultrasound: allows guided needle biopsy. Prostate cancer suspicion usually based on rectal touch and PSA dosage (prostate specific antigen)
- CT urography (IVU): malformations of the urinary tract, stenosis, renal function, permictional views (urethra, reflux)
- Ascending urethrography (stenosis, urethral valves)
- MRI: staging of a bladder tumor (more accurate than CT for local extension evaluation)
- CT: metastatic tumor staging
- Ultrasound: hydronephrosis, bladder overdistension (overflow incontinence); vesical diverticula, prostatic resection cavity, postmiction volume, reflux (children)
- Cystography, IVU, dynamic MRI: morphology of the bladder, cystocele, depression of the pelvic floor, neurogenic bladder, fistula, malformation (children).
- Cerebral or lumbar MRI: unexplained neurogenic bladder.
- Ultrasound (filled bladder!): fluid collection, tumor, ovarian cyst, uterus (myoma, tumor, adenomyosis), haemoperitoneum (extrauterine pregnancy), pregnancy, hydatidiform mole, appendicitis, Crohn's, bladder overdistension, hernia
- Endovaginal ultrasound: extrauterine pregnancy, other gynecological disorders
- [Abdomen supine film: fecaloma, mass effect, calcif. (myoma)]
- MRI: uterine or ovarian abnormalities uncompletely characterized by ultrasound, endometriosis, staging of uterine cervix and body tumors, rectum, prostate or bladder neoplasias, soft parts tumors of the pelvis
- CT: diverticulitis, appendicitis, enteritis, lymphadenitis, abscess, mass, haematoma, hernia, epiploic appendagitis; less accurate that ultrasound for gynecological diseases. Only superior to MRI for peritoneal metastases.
- CT colonography (or barium enema): intrinsic pathologies of the colon, compression, extrinsic (endometriosis, adhesive bands, pelvic tumors), etiology of a low obstruction, sinus tracts.
- Ultrasound (filled bladder!), endovaginal ultrasound: uterus (myoma, endometrial hyperplasia, polyps, endometriosis, hematometrocolpos, etc.), ovaries (cyst, solid mass), peritoneal fluid, pregnancy
- MRI: cf. above (§ 9).
- Ultrasound (filled bladder!), endovaginal ultrasound: uterine malformations, myoma, ovarian cysts, endometriosis, etc.
- Hysterosalpingography: tubal obstruction, hydrosalpynx, adhesive bands, endometriosis, malformations and other uterine abnormalities.
- MRI: uterine malformations, endometriosis, myoma, etc.
- Ultrasound (± Doppler)
- transvesical or endovaginal: at 10-12 weeks
- ortho- ou ectopic pregnancy statement, gemellarity
- fetal vital signs, gestation age and pregnancy term calculation
- fetal malformations (nuchal translucency), uteroplacental and ovary disorders of the mother
- transvesical: at 20-23 weeks
- fetus life signs, fetus position, fetal growth, fetal malformations
- disorders of the placenta, membranes (amount of amniotic liquid) and umbilical cord
- US-Doppler: vascular resistance indexes (umbilical arteries, fetal middle cerebral arteries, uterine arteries) in case of intrauterine growth retardation
- transvesical or endovaginal: at 10-12 weeks
- MRI: complex fetal malformations; MRI pelvimetry (suspicion of foetopelvic disproportion)
- Ultrasound: first choice examination (hernia, hydrocele, varicocele, cyst, trauma, infections, malformations, testicular ectopy); rule out testicular tumor; distinction between epididymitis and testicular torsion (color Doppler).
- MRI: additional to ultrasound diagnosis.
- Thoraco-abdominal CT: metastatic staging of testicular tumors.
- Scrotal ultrasound: testicular atrophy, ectopia, varicocele (color Doppler), tumor, cyst.
- Pelvic ultrasound (filled bladder): prostate and seminal vesicles.
15. Hernia of the abdominal wall
- Ultrasound: fairly sensitive, allows erect testing and Valsalva manoeuvre. Sufficient to rule out a postoperative eventration, umbilical, linea alba or Spiegel's hernia. Expertise needed to diagnose small inguinal or crural hernias.
- CT: still doubtful diagnosis, other pathology.
- Barium enema or meal: intestinal relationships with the hernial sac. Search of an associated colon tumor.
- Peritoneography mostly abandoned.
16. Breast lump
- mammography: mass, architectural distorsion, microcalcifications; lower accuracy in case of dense breasts (young age, breast feeding, mammar dysplasia, hormonal replacement therapy)
- US:
- first choice for young or pregnant women and during breast feeding
- as a complement to mammography: high density gland, palpable nodule and negative mammography, mass characterization, collection, axillary nodes, guided biopsy, preoperative marking
- ultrasound alone is not aimed at cancer screening (too many false positives and false negatives)
- MRI:
- lesion not well characterized by mammography and ultrasound (suspicion of neoplasia or recurrence)
- depiction of synchronous tumours in the same breast or contralateral breast
- metastatic breast cancer histologically proven without mammographic evidence of cancer
- local invasion staging (thoracic wall)
- treatment follow-up; suspicion of recurrence
- Chest X-ray, US (liver), CT: local and metastatic initial workup
- bone scintigraphy: suspicion of bone metastases
Pierre Bénédict, MD, FMH radiologist, Lausanne, 1997-2018
References:
- Guide du bon usage de la SFR
- ACR (American College of Radiology) guidelines
- Radiation protection 118: Referral guidelines for imaging (Office for official publications of the European Communities)