Approach to Diagnosis: Diagnostic Imaging Other Invasive Procedures

1. Approach toDiagnosis:Diagnostic Imaging Other Invasive Procedures

2. Digital Radiography (Computed radiography) Picture Archiving and Communication Systems (PACS)- Filmless ; best suited for Computed Tomography/ MRI/ PET scanning Imaging Modalities

3. Imaging Modalities • Ultra Sound • Safe/Low cost technologoy • Uses cross sectional imaging • Non invasive. • Detects tissue/water interfaces and causes echoes. • Displayed as static gray scale images or moving in real time images. • Doppler imaging with color (intensity) coding helps to measure direction, velocity, and magnitude of flow. • Recommended for children and women during pregnancy • Limitations- ‘acoustic barriers’- air/bone/barium/obese/chest and operator expertise

4. Imaging Modalities • Computed Tomography- measures relative linear attenuation coefficients for radiation absorption. Uses linear beam slice imaging and produces cross sectional images • Used with iv or oral contrast get high contrast imagery • MDCT – multi detector CT for 3-D imaging (allows faster san time and reduces radiation) most useful in angiographic vascular studies • Concerns about radiation makes it not the first choice. US/MRI are preferred choices

5. Imaging Modalities • MRI super conducting magnets measure H+ energy transfers and calculates the image display • T1 weighted- ‘bright’ signal by high intensity tissues- fat, sub acute hemorrhage, mucus. ‘dark’ signal by low intensity- CSF, fluid cysts. Soft tissues are in between. • T2 weighted-Water is ‘high’ (bright) signal intensity, whereas muscles/soft tissues/fat tned to have lower intensity and appear dark. Bone and air will appear very dark. • Safe –no radiation/ images multiple planes • Has increased sensitivity but less specificity

6. MRI… • In the cranium cannot distinguish between infarction/edema/tumor/infection/demyelination • High cost • Contraindicated in patients with metallic parts- pacemakers/internal clips/ claustrophobic • MR Angiography- with contrast

7. MRI the choice technology for • Nervous system- brain and spinal cord • Musculoskeletal system • Pelvis and retroperitoneal/ mediastinal/ large vessel imaging • Liver, spleen, pancreas and kidney • Difficult fetal problems

8. Contrast Media in imaging • Oral and IV • Increase contrast between tissues • Useful in hollow viscera imaging • Vascular studies • Kidney/ Gall Bladder functions • Barium Sulfate-GI tract imaging. ‘Double’ contrast with barium/air interface

9. Magnetic Resonance Spectroscopic Imaging (MRSI) • Measures choline/citrate ratio in cancer prostate. • Post treatment assessment of brain tumors • Useful in Breast cancer assessment

10. Water soluble iodinated contrast • Vascular imaging • Renal • Low osmolar contrast reduce the risk severe reactions. • For MRI gadolinium chelates are used and are safer

11. Contrast Induced Nephropathy • CRF cases- • DM/ CHF/ Sepsis/ Dehydration/70+yrs/ Chemo/Tx Pts/ • Nephrotoxic drugs/ • HIV-AIDS

12. Single Photon Emission Tomography (SPECT) • Uses radioactive carbon or oxygen • Used in search of metastases not seen on CT or MRI • Uses fluordexoyglucose (F-FDG) • Used in detection of epilepsy foci, in Alzheimer’s • High cost • PET/CT

13. Cost Comparison using CXR as base (x)

14. Imaging Radiation!

15. Neck and Face Chest Breast Cardiovascular Gastrointestinal Urinary Musculoskeletal Reproductive Obstetrics Neck and Face The Approach

16. US normal Crvical LN/ Metasttic LN

17. Post-contrast coronal T1-weighted MR image through the posterior neckdemonstrating metastatic right-sided cervical adenopathy (white arrows), followingthe lymphatic drainage from a primary nasopharyngeal carcinoma.

18. Post-contrast axial T1-weighted MR image that demonstrates an ill defined enhancing mass replacing the superficial and deep lobes of the left parotid gland (white arrow). Biopsy confirmed this to represent a mucoepidermoid carcinoma.

19. US: Fibroadenoma/ Ca Breast

20. NECK and FACE issues • Thyroid Mass- Goiter/ Hashimotos/ Cyst/ Cancer- • ?I131 scan-’hot’ or ‘cold’ nodule • US – ?cyst/solid/ ?single/multiple and FNAC • MRI- extent of cancer Hypothyroidism (Myxedema): The diagnosis of hypothyroidism is made clinically by routine thyroid hormone determinations, and there usually is no need for routine imaging studies.

21. Other neck masses • Congenital cysts • Metastatic lymph nodes • Infected lymph nodes/abscess • Thin slice (<3mm) contrast CT is best • MRI- best for cancer of aero-digestive tract

22. Hypercalcemia issues • Asymptomatic • Constipation, anorexia, n/v, belly pain, absent bowel sounds • Renal stones/thirst/renal failure • Muscle weakness • Confusion/psychosis/coma • Hyperparathyorism • CRF/vit D excess/ Sarcoidosis/ Immobilization/ Drugs- thiazides, lithium, TUMS

23. Imaging for hypercalcemia • Clinical asssessment • Radiology of hands (hyperparathyroid)/ pelvis/spine (metastatic cancer/myeloma)

24. Presenting Signs and Symptoms Neck mass (cervical adenopathy) in a smoker older than age 40 (men more often than women) Hoarseness Stridor Common Sites - vocal cord Supraglottic soft tissues 1. Computed tomography ■ Thin-section CT is the best modality for demonstrating the extent of tumor and the presence of cervical adenopathy ■ 2. Magnetic resonance imaging- Preferred modality for evaluating the mucosa andcartilage involvement. ■ Superior to CT Cancer of the Larynx

25. Palpable mass (slightly tender or non tender) Facial palsy benign tumor, slow-growing, painless, non tender, and mobile malignant tumor, tends to enlarge rapidly over several weeks and be slightly painful and minimally tender, hard and fixed on palpation, and often associated with facial nerve paralysis Computed tomography or magnetic resonance imaging CT is superior to MRI for detecting an underlying calcified stone (calculus) MRI is superior to CT for sharply outlining the margins of the mass FNAC Bx Salivary Gland (Parotid) Neoplasm

26. Neck mass in a smoker older than age 40 (men more often than women) Common Causes Squamous carcinoma of the pharynx, tonsil, pyriform sinus, nasopharynx, or base of the tongue 1. Magnetic resonance imaging ■ Preferred imaging modality for evaluating the pharyngeal mucosa and other sites where the occult malignancy may reside 2. Computed tomography ■ High-speed studies may detect the site of an occult carcinoma in about 25% of cases (thus permitting directed biopsy by endoscopy) Occult Primary With PositiveLymphadenopathy

27. Clicking or popping soundwhen opening the mouth (anterior subluxation with reduction of the disk) Painful limitationof jaw movement (anterior subluxation without reduction of the disk) Chronic spasm of the lateral pterygoid muscle Trauma Arthritic changes in the TM joint 1 Magnetic resonance imaging ■ Preferred modality for evaluating displacement of the disk and whether there is reduction during function Internal Disk Derangement ofTM Joint Arthrography and CT are not as effective

28. Brain Neoplasm (primary or spread of existing tumor) Infection (viral or bacterial) Radiation therapy TRIGEMINAL NEUROPATHY (NOT TIC DOULOUREUX) Most commonly due to a cerebellopontine angle mass, schwannoma of the trigeminal nerve, or perineural spread of tumor from the oral cavity or the head and neck FACIAL PALSY- Most common cause is Bell’s palsy (viral neuritis) 1. Magnetic resonance imaging ■ Study of choice for assessing cranial neuropathy of undetermined cause 2. Computed tomography ■ Less sensitive than MRI Facials Palsy Does not require imaging confirmation unless facial function is slow to return or there is some other complicating factor (pain, dysfunction of other cranial nerves, parotid mass) Rare-Must exclude parotid malignancy and temporal bone tumors (hemangioma, cholesteatoma, neurinoma) skull base infections (diabetics), Brainstem lesions in children, and Lyme disease in patients living in endemic regions. Trauma is a leading cause of facial palsy and requires CT Cranial Neuropathy

29. Pain, tenderness, and swelling over the involved sinus Eye pain, fever, chills (suggesting extension of infection beyond the sinuses) Recent acute viral upper 1. Computed tomography ■ Procedure of choice for exquisitely defining the sinonasal anatomy and infections of the paranasal sinuses and the soft tissues of the head and neck Sinusitis Plain radiograph (sinus) ■ Limited role in assessing sinus disease

30. Respiratory system • CXR- If it will alter management, then it is justified • The X-ray beam passes from posterior to anterior (PA). • The X-ray beam passes from anterior to posterior (AP) • Lateral • US- Good for effusions • CT- Two types • Standard- stage lung tumors, investigate lung masses and to assess the mediastinum and pleura

31. Coughing up blood (resulting from bleeding from the respiratory tract) Infection (pneumonia, tuberculosis, fungal infection, lung abscess) Bronchogenic carcinoma Bronchiectasis Bronchitis Pulmonary infarction (secondary to embolism) Congestive heart failure Pulmonary hemorrhage syndromes CXR- Initial imaging procedure CT- Suspected malignancy Fiberoptic bronchoscopy Hemoptysis

32. Pain that is aggravated by breathing or coughing (maybe of sudden onset, chronic, or recurring) Rapid and shallow respiration Limited motion of the affected side Decreased breath sounds on the affected side Pleural friction rub Pneumonia/ Tuberculosis/ Pulmonary embolism/ Trauma/ Neoplasm/ Occult rib fracture/ Congestive heart failure/ Mixed connective tissue disease/ Pancreatitis CXR CT Pleuritic Pain

33. obstruction to the flow of air at some level- (Most commonly heard on expiration) Asthma Congestive heart failure Pneumonia Bronchogenic tumor Pulmonary embolus Tracheobronchomalacia Foreign body CXR CT- noninvasively evaluate the trachea and central airways for masses, narrowing, or compression that is not evident on plain chest radiographs. Wheezing

34. Insidious onset of exertional dyspnea and reduced exercise tolerance Symptoms of airways disease (cough, sputum, wheezing) occurring primarily in heavy smokers Occupational exposure CXR- Preferred initial imaging (irregular or linear small opacities (usually most prominent in the lower zones) and characteristic diffuse or localized pleural thickening HRCT- High resolution CT (eliminates CXR-false +) Asbestosis

35. Episodic respiratory distress, often with tachypnea, tachycardia, and audible wheezes Anxiety and struggling for air Use of accessory muscles of respiration Hyperexpansion of the lung (due to air trapping) Prolonged expiratory phase CXR Spirometry Skin Tests Asthma

36. Chronic productive cough (excessive tracheo-bronchial mucus secretion sufficient to cause cough with expectoration of sputum that occurs on most days for at least 3 consecutive months in at least 2 consecutive years) Cigarette smoking Occupational exposure Air pollution and other types of bronchial irritation Chronic pneumonia Superimposed emphysema CXR Spirometry Bronchitis (Chronic)

37. Pleuritic pain Dyspnea Often asymptomatic and discovered as incidental finding on chest radiograph Decreased or absent breath sounds, percussion dullness, and decreased motion of hemithorax Congestive heart failure (usually bilateral but larger on the right) Neoplasm (primary or metastatic lung cancer, lymphoma) Pneumonia/abscess Ascites Pancreatitis (usually left-sided) Tuberculosis Pulmonary embolism (small) Mixed connective tissue disease (lupus, rheumatoid arthritis) Trauma (hemothorax) CXR CT US Pleural Effusion

38. Cough with sputum production Fever and chills Chest pain and dyspnea Viral respiratory infection Cigarette smoking Chronic obstructive pulmonary disease Alcoholism Loss of consciousness Dysphagia with aspiration Hospitalization or institutionalization Surgery/trauma Heart failure Immunosuppressive disorders and therapy Central obstructing neoplasm (e.g., bronchogenic carcinoma) CXR Pneumonia

39. Sudden, sharp chest pain, severe dyspnea, shock, and life-threatening respiratory failure Pain may be referred to corresponding shoulder, across the chest, or over the abdomen (simulating acute coronary occlusion or acute abdomen) Markedly depressed or absent breath sounds Shift of mediastinum to opposite side and ipsilateral diaphragmatic depression (with large or tension pneumothorax) Spontaneous (rupture of small, usually apical bleb) Trauma (penetrating or blunt, rib fracture, tracheobronchial injury) Complication of mechanical ventilation (barotrauma) Chronic obstructive pulmonary disease Chronic pulmonary disease (e.g., sarcoidosis, Pneumocystis jiroveci pneumonia (formerly Pneumocystis carinii) CXR Pneumothorax

40. Nonspecific tachypnea, dyspnea, and hemoptysis pleuritic chest pain in pulmonary embolism with infarction CXR CT- Has replaced V/Q lung scanning in most institutions as the preferred imaging and excluding PE (a filling defect within the pulmonary artery or as an abrupt cutoff (complete obstruction) of a pulmonary artery branch) Radionuclide ventilation–perfusion (V/Q) lung scan Pulmonary arteriography- rarely used Pulmonary Embolism

41. Varies from asymptomatic exposure to fever, productive cough, and night sweats CXR Sputum tests Skin tests Tuberculosis

42. Cough (with or without hemoptysis) Dyspnea, wheezing, pneumonia Chest pain Weight loss History of smoking Pleural effusion Recurrent Horner’s syndrome Superior vena cava syndrome Symptoms relating to distal metastases (e.g., occult fracture, seizure) CXR- inital CT- PET/CT- Definitive noninvasive study ■ Detects hilar and mediastinal lymphadenopathy and bronchial narrowing ■ May show metastases in the liver and adrenal glands Lung Cancer

43. Palpable Breast Mass • 1. Mammography • ■ Procedure of choice for determining whether a palpable mass is unequivocally benign (fibroadenoma) In young women (under age 30) the initial assessment of a palpable breast mass should be done with ultrasound; if a cyst is detected, no imaging with radiation exposure is needed All suspicious masses must be biopsied

44. Palpable Breast Mass 2. Ultrasound ■ Indicated as a confirming procedure if physical examination or mammography suggests that the palpable mass may repre sent a simple cyst or intramammary lymph node. • cannot provide a definitive diagnosis of other solid or complex masses. Routine Mammography American Cancer Society Guidelines For women age 40 and older, yearly mammograms are recommended

45. BENIGN (90%) Normal (physiological) Papilloma (intraductal) Mammary duct ectasia Fibrocystic changes MALIGNANT (10%) 1. Galactography (ductography) 2. Ultrasound ■ Directed sonography may be helpful in imaging the lesion if palpation of a single point in the breast expresses a nipple discharge Nipple Discharge

46. Screening Outcomes • 70–100 (7–10%) will be recalled for more studies (magnification or other special views; US) • 15–20 (1.5–2%) will require biopsy, with carcinoma detected • in only 20–45% of recommended biopsies 5–7 (0.5–0.7%) will have cancer detected (1–3/1,000 womenscreened) • Recall rate, biopsy rate, and cancer detection rate will beapproximately 50% of subsequent screening examinations

47. High-Risk Screening • Annual mammography before age 40, and/or additional annual screening with MRI (or US if MRI is not available). • Family history of breast cancer in premenopausal women (especially first-degree relatives and bilateral cancers) • Genetic risk for breast cancer • BRCA-positive women • Biopsy diagnosis of atypical or lobular carcinoma in situ • Personal history of breast cancer • Mantle radiation for Hodgkin’s disease

50. The lungs are a common site of haematogenous metastatic disease. • Common primary sites include: • Breast • Kidney • Head and neck • Colorectal.