Ultrasound / Interventional Radiology
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imaging
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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 clipses
- 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
- dilatations, embolisations (tumors, acute haemorrhage)
Barium enema
- intrinsic pathologies of the colon, extrinsic compression (endometriosis, adhesive bands, pelvic tumors), cause of a low obstruction, search of fistula
- in double contrast for a good demonstration of the mucosal surface
- contraindications: toxic megacolon, imminent perforation, pseudomembranous colitis, recent endoscopic biopsy, pregnancy, poor colonic cleaning, recent barium meal, Ct-scan to be done during 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 surface, 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 (intussusception, prolapse, perineal ptosis, flap-valve, etc.)
Fistulography
- opacification of the sinus tract of an anal, enterocutaneous, peritoneal, perineal, etc. fistula
Hysterosalpingography
- infertility, repetitive abortions, uterine malformations
IVU
- hematuria, recurrent urinary infections or lithiasis, cause and level of an urinary obstruction
- ultrasound is the 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 sometimes used for metastatic staging of lymphomas
and testicular tumors
Mammography
- cancer screening after 40-50 years or soner if high risk factors are present
- palpable mass, axillary lymph nodes or metastastatic adenocarcinoma of unknown origin
- galactography: examination 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 adnexa lesions (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 (practically abandoned): hernia 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 abdominal wall) and pregnancy monitoring
- better tissue differenciation of internal genital organs than CT
- very sensitive for small quantities 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
Voiding cystourethrography (VCU)
- search of 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 diagnosis (appendicitis, ovarian cyst, extrauterine pregnancy, etc.). Often shows prevesical calculi. Urine stream into the bladder can be shown with color Doppler.
- CT urography: 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 in case of 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 at ultrasound. Renal infarct. Percutaneous drainage.
- MRI: tumoral staging (invasion of other organs, of vessels); mass or atypical cyst at 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 is normal, to verify the urinary tract integrity and monitor renal excretion. Detection of renal stones
- VCU or scintigraphy: for demonstration of reflux
(children).
- Ultrasound: renal masses, vascular lesions, papillary necrosis, lithiasis, lesions of the bladder, prostate morphology
- CT (or IVU): pelvic and ureteral abnormalities, urothelial tumor, stone, clot; not always able to rule out a lesion of the bladder
- Renal arteriography: embolisation in case of hemorrhage.
- EchoDoppler: morphology (atrophy, tumor, polycystic disease); renal arteries and parenchymal Doppler (patient fasting and not obese); fairly specific but limited sensitivity
- Angio-MRI (to be preferred to CT in case of renal failure) or CT angiography of the renal arteries
- Captopril renoscintigraphy: sensitivity ³ 90% only if stenosis is unilateral
- Arteriography: allows definitive diagnosis and sometimes treatment (dilatation, stent).
- Ultrasound: atrophy, hydronephrosis, diffuse changes of the renal cortex, calcifications, malformations. Arterial or venous thrombosis (Doppler)
- CT: injection of contrast media possible if patient under dialysis, or if creatinine < 150 umol/l. Hypernephroma 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, postmiction volume; prostate morphology, tumor (low sensitivity), abscess. Kidney abnormalities.
- Endorectal Ultrasound: a little more sensitive for the detection of prostatic tumors, allows guided needle biopsy. First diagnostic approach of prostate cancer is done by a rectal touch and PSA dosage (prostate specific antigen)
- Endorectal MRI: more sensitive than endorectal ultrasound for localisation of a prostatic tumor and staging (operability)
- CT urography (IVU): malformations of the urinary tract, stenosis, renal function, permictional films (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 bed, 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 (with full 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; 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 (with full bladder!), endovaginal ultrasound: uterus (myoma, endometrial hyperplasia, polyps, endometriosis, hematometrocolpos, etc.), ovaries (cyst, solid mass), peritoneal fluid, pregnancy
- MRI: cf. above (§ 9.).
- Ultrasound (full 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 in the mother
- transvesical: at 20-23 weeks
- fetus life signs, fetus position, fetal growth, fetal malformations
- abnormalities of the placenta, membranes (amount of amniotic liquid) and umbilical cord
- US-Doppler: determination of vasular 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 fetopelvic disproportion)
- Ultrasound: first choice examination (hernia, hydrocele, varicocele, cyst, trauma, infections, malformations, testicular ectopy); rules out testicular tumor; makes a 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 (full 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. Experience 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, feeding, mammar dysplasia, hormonal replacement therapy)
- US:
- first choice for young or pregnant women and during feeding
- as a complement to mammography: palpable nodule and negative mammography, mass characterization, collection, axillary nodes, guided biopsy, preoperative marking
- ultrasound is not aimed at cancer screening (too many false positives and false negatives)
- MRI:
- lesion not sufficiently characterized by mammography and ultrasound (suspicion of neoplasia or recurrence)
- depiction of synchronous tumours in the same breast or contralateral
- 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: before treatment or when bone metastases are supsected
Pierre Bénédict, MD, FMH 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