What Radiology Test Disclosure Should I Order? David M. Naeger, MD - - PDF document

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What Radiology Test Disclosure Should I Order? David M. Naeger, MD - - PDF document

Oct 07, 2022 207 likes •454 views

5/23/19 What Radiology Test Disclosure Should I Order? David M. Naeger, MD Consultant to CMEinfo/Ebix Associate Professor and Associate Chair for Education david.naeger@ucsf.edu University of California, San Francisco Dept of Radiology and

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What Radiology Test Should I Order?

David M. Naeger, MD

Associate Professor and Associate Chair for Education david.naeger@ucsf.edu University of California, San Francisco Dept of Radiology and Biomedical imaging

Disclosure

Consultant to CMEinfo/Ebix

What to Order?

“I got this!“

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Q1: For which condition is a radiograph likely “enough” without needing a Chest CT?

  • A. Nodule follow up
  • B. Recurrent hemoptysis
  • C. Blunt chest trauma
  • D. Chest pain, concern for dissection
  • E. Acute coronary syndrome

Q2: What is different about a high- resolution chest CT (HRCT) compared to a conventional Chest CT?

  • A. Thinner slices
  • B. Higher resolution per slice
  • C. More radiation
  • D. Reconstruction algorithm
  • A. 20%
  • B. 50%
  • C. 80%

Q3: Low Dose Chest CTs administer how much less radiation than conventional chest CT?

  • A. 2 days
  • B. 6 months
  • C. 2 years

Q4: The radiation dose from a low dose chest CT equals what duration of background radiation??

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Q5: Which test is best to order for acute onset flank pain with suspicion for stone disease?

  • A. Radiograph (KUB)
  • B. Ultrasound
  • C. CT without contrast
  • D. CT with contrast
  • E. MR urography

Q6: Which test is best for a 1st time presentation of acute pancreatitis (typical pain, + amylase/lipase)?

  • A. Radiograph (KUB)
  • B. Ultrasound
  • C. CT without contrast
  • D. CT with contrast
  • E. MR with MRCP

Topics

When is CXR enough? Types of chest CTs and indications Radiation When is contrast needed? Nodules, nodules, and more nodules Types of abdomen CTs and indications

Message

Becoming an “Appropriateness Criteria” expert will help you use better (and less) imaging.

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When do I get one?

  • Daily ICU films on unchanged patients?

– No!

  • Pre op CXR?

– Symptomatic or diagnosed heart/lung disease – >70 and no CXR in last 6 mo – Surgery on heart/lungs

ACR Appropriateness Criteria: Intensive care unit patients, variant 2 Choosing wisely: chest X-rays Before Surgery

When do I get one? When is CXR enough?

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For which condition is a radiograph likely “enough” without needing a Chest CT?

  • A. Nodule follow up
  • B. Recurrent hemoptysis
  • C. Blunt chest trauma
  • D. Chest pain, concern for dissection
  • E. Acute coronary syndrome

For which condition is a radiograph likely “enough” without needing a Chest CT?

  • A. Nodule follow up
  • B. Recurrent hemoptysis
  • C. Blunt chest trauma
  • D. Chest pain, concern for dissection
  • E. Acute coronary syndrome

https://www.acr.org/Clinical-Resources/ACR-Appropriateness-Criteria

ACR Appropriateness Criteria

  • Evidence-based guidelines
  • Multi-speciality
  • 235 topics with over 900 “variants”

– “Radiographically Detected Solitary Pulmonary Nodule” – “Solid nodule < 1 cm, low clinical suspicion for cancer”

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Radiologic Procedure Rating Comments Relative Radiation Level

Watchful waiting with CT follow up 8 Varies CT Chest without IV Contrast 7 9 8 7 6 5 4 3 2 1

Usually Appropriate May be appropriate Usually not appropriate

ACR’s a qPLE for PAMA!

Qualifies for Upcoming Medicare Rules

Protecting Access to Medicare Act (PAMA)… …requires consultation with appropriateness criteria (AC)… …when ordering advanced imaging (CT, MRI, PET/CT, NM)… …created by qualified provider-led entities (qPLE)… …such as the American College of Radiology (ACR). Free web version and integrated paid version.

qPLE

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When is CXR enough?

Check the AC’s!

  • Milder, less dangerous respiratory complaints
  • When you find the answer enough to treat.
  • Rib fractures
  • Possible TB
  • Lines and Tubes
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After Treatment (No Change)

When is a CXR not enough?

  • Dangerous: immunocompromise, traumatic injury,

Acute Ao injury

  • Cancer: hemoptysis, staging, (met surveillance?)
  • Chronic unexplained symptoms: dyspnea
  • Occupational Lung Disease
  • Some “concerning” radiographic findings

For which condition is a radiograph likely “enough” without needing a Chest CT?

  • A. Nodule follow up
  • B. Recurrent hemoptysis
  • C. Blunt chest trauma
  • D. Chest pain, concern for dissection
  • E. Acute coronary syndrome
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Acute Coronary Syndrome

Myocardial Perfusion Imaging Coronary Arteriography (Cath) CXR = 5 (“May be appropriate”) Comment: “survey for noncardiac etiologies”

What is different about a high- resolution chest CT (HRCT?)

  • A. Thinner slices
  • B. Higher resolution per slice
  • C. More radiation
  • D. Reconstruction algorithm

What is different about a high- resolution chest CT (HRCT?)

  • A. Thinner slices
  • B. Higher resolution per slice
  • C. More radiation
  • D. Reconstruction algorithm

A Long Sordid Tale….

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A Long Sordid Tale….

Same thickness Same in-plane resolution Similar radiation

Reconstruction Kernel / Filter / Algorithm Reconstruction Kernel / Filter / Algorithm

Expiratory Views: “Air Trapping”

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High-Resolution Chest CT (HRCT)

Interstitial lung disease Air Trapping (BO, post lung transplant)

Non-contrast Chest CT Non-contrast Chest CT

  • Lung nodules
  • Pneumonias
  • Airways
  • Bones
  • (AoSize, or changes)

Contrast Enhanced Chest CT

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Contrast Enhanced Chest CT

  • Mediastinum
  • Lymph Nodes
  • Pluera
  • Chest wall
  • Trauma
  • Cancer

CT Angiogram

Pulmonary Emboli Aorta Great Arteries

CT Angiogram Dual Energy CT

40 keV Iodine Map

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Special CT “Angiograms”

Delayed

  • Vascular extravasation
  • Endoleaks
  • Left Atrial Appendage
  • Venograms

Low Dose (Non-Con) Low Dose (Non-Con)

  • Lung CA Screening
  • Nodule Follow Up
  • Radiation Sensitive

How much less radiation?

  • A. 20%
  • B. 50%
  • C. 80%
  • A. 2 days
  • B. 6 months
  • C. 2 years

Equals how much background radiation?

Low Dose Chest CTs….

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How much less radiation?

  • A. 20%
  • B. 50%
  • C. 80%
  • A. 2 days
  • B. 6 months
  • C. 2 years

Equals how much background radiation?

Low Dose Chest CTs….

Low Dose (Non-Con)

80% fewer photons

Radiation

Dental x-ray Flight CXR Low Dose Chest CT Head CT Living on Earth Chest CT Abd CT PET/CT

https://www.radiologyinfo.org/en/info.cfm?pg=safety-xray

14 hrs 4 days 12 days 6 months 8 months 1 year 2 years 3 years 8 years

How much less radiation?

  • A. 20%
  • B. 50%
  • C. 80%
  • A. 2 days
  • B. 6 months
  • C. 2 years

Equals how much background radiation?

Low Dose Chest CTs….

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20 days = 1.7 CXRs Lung Cancer Screening

High risk:

  • > 30 pack years
  • Current smoker, quit <15 Years
  • >55 years old

Sufficient Benefit:

  • <77-80 years old (USPSTF, CMS)
  • Good life expectancy
  • Willingness to undergo treatment

Crazy Facts

  • Must be asymptomatic
  • Must have documented clinical visit, shared

decision making with an aid, smoking cessation counseling

  • Data uploaded to a registry, including
  • utcomes.

Nodules, Nodules, and More Nodules!

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5/23/19 16 Fleischner, Lung-RADS, Gestalt, Oh my!

Flieschner Lung-RADS Oncology Patients Young Patients Incidental Screening Depends Depends

When a Nodule is Seen

  • 1. We look for definitively benign features.

Not definitely benign?

  • 2. If small (<8 mm), we recommend follow up.

Not small?

  • 3. We help assess risk of malignancy

Help guide management.

Definitively Benign Features

“Long Term” Stability Classic Perifissural nodules

Small Nodules

Fleischer Society Guidelines of 2017 Multiplicity, density, risk factors Some “optional” Up to 5 years

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5 Years!?

8 Yrs

Large Nodules

Short interval CT PET/CT Biopsy (Treat)

When is an Abdominal X-Ray Enough?

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Lines and Tubes Bowel Gas Abnormalities

No! Suspected Small Bowel Obstruction: CT = 9

Which test is best to order for acute onset flank pain with suspicion for stone disease?

  • A. Radiograph (KUB)
  • B. Ultrasound
  • C. CT without contrast
  • D. CT with contrast
  • E. MR urography
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Which test is best to order for acute onset flank pain with suspicion for stone disease?

  • A. Radiograph (KUB)
  • B. Ultrasound
  • C. CT without contrast
  • D. CT with contrast
  • E. MR urography

Non-Contrast vs Contrast Non-Contrast vs Contrast Non-Contrast vs Contrast

Arterial Venous

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Abdominal CT protocols

  • Multiphase Liver
  • Adrenal
  • CTA
  • Venogram
  • Pancreatic
  • Renal stone
  • Renal mass/hematruia
  • Without the Pelvis
  • CT Colonography
  • Enterography

Contrast, Timing, Radiation Dose Less about processing

Abdominal CT protocols

  • Multiphase Liver
  • Adrenal
  • CTA
  • Venogram
  • Pancreatic
  • Renal stone
  • Renal mass/hematruia
  • Without the Pelvis
  • CT Colonography
  • Enterography

Non-Contrast Abd CT

The ACR Appropriateness Criteria

Non-Con CT = 8 Con and Non-con CT = 6 US = 6 X-ray = 4 MR Urography = 4

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Which test is best for a 1st time presentation of acute pancreatitis (typical pain, + amylase/lipase)?

  • A. Radiograph (KUB)
  • B. Ultrasound
  • C. CT without contrast
  • D. CT with contrast
  • E. MR with MRCP

Which test is best for a 1st time presentation of acute pancreatitis (typical pain, + amylase/lipase)?

  • A. Radiograph (KUB)
  • B. Ultrasound
  • C. CT without contrast
  • D. CT with contrast
  • E. MR with MRCP

The ACR Appropriateness Criteria

Gastrointestinal and Urologic Sections 40 topics and many variants!

The ACR Appropriateness Criteria

Variant 1

First time presentation, typical abdominal pain, and increased amylase and lipase with high clinical certainty of diagnosis; <48–72 hours after onset of symptoms; clinical score irrelevant; unknown cause.

Appropriate Tests US Abdomen= 9 (assess for gallstones) Con CT, MRI = 4

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The ACR Appropriateness Criteria

  • Non-localized Abd pain: CT with con
  • Palpable Abd mass: CT with con (or MR)
  • R/o Appendicitis: CT with con
  • R/o Diverticulitis: CT with con
  • R/o BPH: None (US= 6 “may be” appropriate)

Use of the ACR AC leads to…

More Imaging Better Imaging Less Imaging

Use of the ACR AC leads to…

More Imaging Better Imaging Less Imaging

Topics

When is CXR enough? Types of Chest CTs and Indications Radiation When is Contrast needed? Nodules, Nodules, and More Nodules Types of Abdomen CTs and Indications

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Message

Becoming an “Appropriateness Criteria” expert will help you use better (and less) imaging.

References

  • Choosing Wisely: Chest X-rays Before Surgery.

http://www.choosingwisely.org/patient-resources/chest-x-rays-before- surgery/

  • Radiation Dose in X-Ray and CT Exams.

https://www.radiologyinfo.org/en/info.cfm?pg=safety-xray

  • Guidelines for Management of Incidental Pulmonary Nodules Detected
  • n CT Images: From the FleischnerSociety 2017.

https://pubs.rsna.org/doi/10.1148/radiol.2017161659

  • ACR Appropriateness Criteria. https://www.acr.org/Clinical-

Resources/ACR-Appropriateness-Criteria

Thank you!

What Radiology Test Should I Order?

David M. Naeger, MD

Associate Professor and Associate Chair for Education david.naeger@ucsf.edu University of California, San Francisco Dept of Radiology and Biomedical imaging