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

1. CT-MRIControl Testing-Minimize Redundant Imaging

2. 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

4. 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

5. 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

6. 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.

7. 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

9. Cystic Renal Masses Bad News: No 0.25 CME Good News: <15 minutes

10. Cystic Renal Masses: Assessment and Management in the General Population Patrick Hanks, MD

11. 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

12. 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

13. 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.

14. Dr. Morton Bosniak, MD Professor Emeritus at NYU Department of Radiology

15. The Bosniak Classification Scheme An imaging and clinical management scheme for cystic renal masses.

16. 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.

17. The Bosniak Classification Scheme • Category 1 and 2: Ignore. • Category 2f: Observe. • Categories 3 and 4: Intervene.

18. The Bosniak Classification Scheme Minimally complicated Indeterminate, probably benign Indeterminate, surgical lesions RCC until proven otherwise

19. Category 1: Simple Cysts • Simple cysts contain low-attenuation fluid. • A hairline-thin smooth wall. • No septations, calcifications, or enhancing nodular soft tissue.

20. Category 1: Simple Cysts

21. Category 1: Simple Cysts Hairline thin wall, no septa, calcifications or solid elements; water attenuation, no enhancement

22. Category 1: Simple Cysts Hairline thin wall, no septa, calcifications or solid elements

23. Category 1: Simple Cysts

24. 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

25. Category 2: Minimally Complicated Cysts Few hairline-thin septa with or without perceived (not measurable) enhancement

26. Category 2: Minimally Complicated Cysts Fine calcification or short segment of slightly thickened calcification in the wall or septa

27. Category 2: Minimally Complicated Cysts Homogeneously high-attenuating masses (≤3 cm) that are sharply marginated and do not enhance

28. 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

29. Dismiss Follow/Observe

30. Category 2f: Indeterminate Complicated Cysts Increased number and thickness of septa. Stable for 4 yrs.

31. Category 2f: Indeterminate Complicated Cysts Thick and irregular calcifications in wall. There is high-attenuation material (arrow) within the mass that does not enhance.

32. 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

33. 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.

34. 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.

35. Follow/Observe Intervene

36. 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.

37. Category 3: Indeterminate Complicated Cysts Thickened septa (arrows) in which measurable enhancement could be demonstrated.

38. Refer for Intervention(Surgery /Biopsy/RFA)

39. Category 4 Renal cancer until proven otherwise

40. 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

41. Morphologic Criteria: Number of Septa Qualitative assessment

42. Morphologic Criteria: Thickness of Wall/Septa Qualitative assessment

43. Relative Value of Different Imaging Modalities • CT • MRI • US • 1A • 1B • 2

44. Relative Value of Different Imaging Modalities 3 2f Dx: Benign hemorrhagic cyst.

45. 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?

46. The Bosniak Classification Scheme Minimally complicated Indeterminate, probably benign Indeterminate, surgical lesions

47. 2f 3 CT: Numerous hairline thin septa. MRI (T2) shows many more septa. Stable for 1 year; 75 yo man who refused surgery.

48. 3 4 CT; enhanced irregular thickened wall. T1 w/gad 65 yo man. Dx: RCC

49. 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.

50. Relative Value of Different Imaging Modalities 15HU 32 HU T2 T1FS Simple cyst in 28 yo man