utilization management program - wake radiologymri is the most accurate imaging method to...
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Wake RadiologyUtilization Management Program
Cost-effective and efficient radiology ordering
WelcomeThis is a guide to the rational ordering of diagnostic imaging studies in a variety of relatively common clinical situations. This pamphlet should take some of the guesswork out of ordering imaging studies and it should help answer clinical questions in the most direct route possible.
This guide has been adapted from Cost-Effective Diagnostic Imaging by Zachary D. Grossman, MD. For a deeper understanding of the rationale in ordering imaging studies, the clinician is encouraged to consult this book.
We hope this directed set of guidelines will help in most clinical situations. Obviously, many situations arise that are either not included or require individualized approaches. In these instances, it is very important to consult our team of sub-specialty radiologists for the most expedient work-up strategy. The phone numbers for each sub-specialty team are located at the bottom of the respective ordering page.
For the most updated version of this guide, please visit us online at wakerad.com
Fourth EditionCopyright©2009 Wake Radiology Associates 10/09Additional copies of this publication can be ordered by emailing Wake Radiology Marketing Services. Referral Services Management: [email protected]
Adapted from:Cost-Effective Diagnostic Imaging: The Clinician’s Guide Zachary D. Grossman, MD, FACR, Douglas S. Katz, MD, Ronald A. Alberico, MD, Peter A. Loud, MD, Jonathan S. Luchs, MD, and Ermelinda Bonaccio, MD. ISBN: 978-0-323-03283-4. Publisher: St. Louis, Mosby ©2006
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CONTENTS
I. Gastrointestinal Imaging 1
II. Genitourinary Imaging 3
III. Chest Imaging 5
IV. Brain Imaging 6
V. Musculoskeletal Imaging 8
VI. Cardiovascular Imaging 10
VII. General Radiology 11
VIII. Endocrine Disorders 12
IX. Breast Imaging 13
X. Oncology and Radiation Therapy 15
XI. Interventional Imaging 16
XII. Pediatric Imaging 18
APPEnDICEsPhysician nPI numbers 19Our Physicians 20Office Locations and Affiliated Hospitals 24
Wake Radiology PACS(Picture Archive and Communication System)Using our easy single-login step, you will see a list of your patients who have been scheduled at our offices during a period that you select. For each patient you can view:
•examsscheduledinthefuture •status,includingcancelledandno-show •diagnosticreportandimages(printable)
•listofpriorexamsandreportsorderedbyyouorotherphysicians
•reportsandimagesfromallaffiliatedhospitalsincluding,WakeMed Health & Hospitals, Maria Parham Medical Center, Johnston Health and Dorothea Dix Hospital/Central Regional Hospital.
It’s easy to get started with this free service by visiting us at <wakerad.com> and pressing the PACs Login button and following the simple instructions.
For PACS assistance, you may always call our
IT Hotline: 919-788-7885 (M–F, 7:00 AM – 6:00 PM).
I. Gastrointestinal Imaging1. Acute Cholecystitis
• U/Sinitialstudy• Hepatobiliaryscan:ifdiagnosisisequivocal,performedtoestablishpatencyofcystic
duct• MRCP:pre-op–MRIismoresensitiveandspecificforacutecholecystitis.Many
times, MRI will be positive immediately after a negative U/S. Thus if clinical symptoms warrant further investigation after negative U/S, consider MRI. Please note that MRCP/MRI is the most accurate imaging method to non-invasively detect choledocholithiasis (bile ductal stones) – please see below.
2. Chronic Cholecystitis• U/Sinitialstudy• Hepatobiliaryscanwithgallbladderejectionfractionforgallbladderdysfunctionas
cause of abdominal pain
3. Gallstones or Bile Duct Stones (Choledocholithiasis) • U/Sisinitialstudy.• PreoperativeMRIshouldalwaysbeconsideredifstonesseenwithintheGBare
tiny or “granular”, even in the setting of “normal caliber ducts” by US. The risk of nonobstructing choledocholith increases as the size of the observed choleliths decrease.
4. Appendicitis• Oftenaclinicaldiagnosis• U/Sininfants,youngchildren,pregnantandchildbearing-agewomen,allowingfor
appropriate body habitus• CTrecommendedafterUSinallbutpregnantpatients.MRIispreferredinpregnant
patients, and is extremely sensitive to appendicitis.• IfsonogramandCTarenegative,inthesettingofstrongclinicalconcern,MRIshould
be considered in children and pregnant patients. CT should not be used in pregnant patients.
5. Biliary Obstruction (Jaundice or RUQ pain)• U/Sisinitialstudy• IfU/Sshowsdilatedduct,MRI/MRCPorCTusedtodifferentiatebetweencommon
duct stone and tumor of pancreatic head• HIDAscanmayplayroleinfunctionalevaluationofbenignappearingdilatedduct
6. Focal Liver Lesions• WhileinthepastmultiphasicCThasbeenusedtocharacterizeliverlesionsasbenign
or malignant, concerns for radiation exposure have emphasized that Liver MRI is a preferablefirstchoiceforliverlesioncharacterization.MultiphaseCTshouldonlybeused in patients who have contraindications to Liver MRI.
7. Bile Leak• Hepatobiliaryscan• T-tubecholangiogram,ifpresent• MRI/MRCPcanalsobeconsideredinselectedcases.Typicallyitismoreaccuratefor
chronic rather than acute bile leaks.
8. Pancreatic Mass• WhileinthepastmultiphasicCThasbeenusedtocharacterizepancreaticlesionsas
benign or malignant, concerns for radiation exposure have emphasized that Pancreatic MRIisapreferablefirstchoiceforpancreaticlesioncharacterization.MultiphaseCTshould only be used in patients who have contraindications to Pancreatic MRI.
GAsTROInTEsTInAL
| 1PHYSICIAN CONSULT LINES: Body Imaging 919-787-7951 Body MRI 919-788-7978
9. Hepatosplenomegaly• U/Sforspleen• Inthosepatientswheresurveillancemonitoringoftheliverorspleenvolumeis
required for treatment decision making, MRI is the most accurate method for volume quantification,withoutexposuretoradiation(CTshouldnotbeused).
10. Acute GI Bleeding• IfendoscopyorNGtubeaspirateisnegative,radiolabledRBCscan• Ifnegative,thenbleedingwillnotbedemonstratedbyangiography• Ifpositive,candirectangiographyforlocation
11. Chronic GI Bleeding• Upper/lowerendoscopy:initialstudy• CTenterography• Ifallstudiesarenegative,thenangiographymayfindangiodysplasia• Meckel’sscanmaybeusefulinchildren
12. Blunt Abdominal Trauma• Pertainstohospital-basedcasesonly• Instablepatient,CTscanofabdomenandpelviswithintravenouscontrastisinitial
study
13. Small Bowel Obstruction (SBO)• Startwithacuteabdomenseries• RoutineCTmaybedefinitiveandcandirectsurgicalplanning.Oralcontrastoptional.• MREnterographyispreferredforthesurveillanceimagingofthecomplicationsofinflammatoryboweldisease(IBD)toavoidunnecessaryexposuretoradiation,whichcan increase the risk of cancer development over the lifetime of the patient.
• CTEnterographytocharacterizepartialSBO
14. Dysphagia• Bariumswallowisinitialstudy• Suspiciousfindingsshouldbefollowedbyendoscopy.• Speechmodifiedbariumswallowtoinvestigateswallowingmechanismperformedinconjunctionwithspeechpathologist.
15. Screening for Colorectal Cancer and Polyps• Average-riskpatients:ColonoscopyandBEevery10years.CTcolongraphy(underdevelopment)every5years
• High-riskpatients:Startaboveatage40.ColonoscopyorBErecommendedevery3–5years
16. Chronic Inflammatory Bowel Disease• WhileCTEnterography(CTE)istheprimarymodalityforconfirmationofanewdiagnosisofCrohn’sDisease,MREnterography(MRE)ispreferredfortheirlongtermsurveillance.MREhasthesamesensitivityandspecificityasCTE,butwithoutradiation.Everyeffortmustbemadetoreduceapatient’slifetimeimagingradiationexposure.
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PHYSICIAN CONSULT LINES: Body Imaging 919-787-7951 Body MRI 919-788-7978
GI | GU
II. Genitourinary System1. Obstruction Uropathy
• Radiograph(stones)• HelicalCTusingrenalstoneprotocol• AfterinitialCT,follow-upradiographandU/Susedforrecurrentobstruction.Everyeffortmustbemadetoreducepatientexposuretoimagingradiation.Patientswithchronic stone disease and recurrent obstructive uropathy are best managed with the judiciousapplicationofCT.U/S,plainfilms,andoccasionallyMRIaremethodswhichcan be used to reduce exposure to imaging radiation in selected patients.
• RadionucliderenogramwithLasix:evaluationofphysiologicsignificanceofhydronephrosis(obstructionvs.reflux)
2. Painless Hematuria• KUBforstones• CTUrogram• MRIcanbeusedinselectedpatientsalongwithRenalMRangiography.
3. Renal Mass• U/Scystvs.solid• MRIispreferredoverCTforany“hyperechoic”lesionseenbyU/S.Also,“hyperdense”or“equivocallyenhancing”lesionsseenonCTareaccuratelycharacterizedasbenignor malignant by MRI without and with contrast, and subtraction imaging.
4. Renal Failure• U/Sassessesrenalsize,echotexture,corticalthickness,R/Ohydronephrosis• CTwithoutcontrastcanlookforsourceofobstructionifhydronephrosisispresent.Obstructionpresent,thengoto1
5. Suspected Renovascular Disease• MRangiography• CTangiography• Captoprilrenogram
6. Scrotal Imaging• Ultrasound
7. Penile Masses• MRIisthepreferredmodality.
8. Adnexal Masses• Ultrasound• PelvicMRIforcharacterization
9. Ectopic Pregnancy• Ultrasound
10. Dysfunctional Uterine Bleeding• Ultrasound• PelvicMRIforcharacterization
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11. UTI in Infants and Children•UTImustbeclinicallydocumented•R/OrefluxwithVCUG;followuprefluxwithNMcystogram•U/Stolookforhydro,anatomicanomalies,scar,renalsize,corticalthickness•DMSAforcorticalscarring
12. Prostate Cancer•MRIisusedforlocoregionalstaging•Bonescanforbonemets
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III. Chest Imaging1. Solitary Pulmonary Nodule
• CT(FleischnerSocietyrecommendations)• PET·CTscantohelpcharacterize
2. Mediastinal Mass • CTwithcontrastfirststudyforpatientswithabnormalCXRorclinicalsuspicionfor
mediastinal mass other than substernal thyroid• MRIforproblemsolving• PET·CTscanforstagingoflungcancerormalignantadenopathy
3. Pulmonary Embolism• CXRperformedtoexcludeothercausesofsymptoms.Assistsininterpretationofventilationperfusionlungscan(V/Qscan)
• PECT.Preferredinpregnancy• V/Qscan
4. Aortic Dissection• MRIisusedforsurveillanceimagingrequiredforchronicdissection.• MRIisalsopreferredforchronicdissectioncasesthathaveundergonesurgicalrepair.• CTisusedonlyforACUTEdissection.Every effort should be made to reduce exposure to
imaging radiation.
5. Aortic Aneurysm• CTfordetectionorfollow-up• MRIforsurveillanceimagingrequired
6. Interstitial Lung Disease• High-resolutionchestCTprotocol
7. Pleural Effusion• CXRfordetectionorfollow-up• CTtocharacterizepleuraleffusionandunderlyingdiseaseprocess
PHYSICIAN CONSULT LINES: Body Imaging 919-787-7951 Body MRI 919-788-7978
GU | CHEsT
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IV. Brain Imaging1. Cerebral Metastases
•MRIwithgadoliniumismostsensitiveandspecific• CTwithcontrastwhenMRIiscontraindicated•PET·CT
2. Acute Head Trauma• CTwithoutcontrastisfirstchoice• MRIsometimesusedforfollow-upofunexplainedsymptomology• Skullfilmshaveessentiallynorole
3. Acute Spine Trauma• Plainradiographsarebestusedwhenthesuspicionofsignificantinjuryislow.• CTisquickestandmostaccurateinacutesettingtoexcludefracture.Alsousedwhen
plain radiographs are equivocal or to further evaluate fractures.• MRIisusedwhenneurologicsymptomordeficitnotexplainedbyplainradiographsorCT.Mayalsobeusedincomatosepatient.
4. Normal-Pressure Hydrocephalus•MRIisfirstchoicetoscreenforhydrocephalusandtoexcludeothercausesof
symptoms•MRIcanalsoevaluateCSFflowdynamics(ifspecificallyrequested)•CTusedwhenMRIcontraindicated•RadionuclidecisternogramoftennecessarytofurthersupportNPHdiagnosisin
appropriate clinical setting
5. Nasal CSF Leak (CSF Rhinorrhea)• Unenhancedhigh-resolutionfacialboneCTmaysufficewhenrhinorrheaiscopious.• CTcisternography(CTofthesinusesafterintrathecalinjectionofmyelographiccontrast)maybeusedtodocumentthespecificlocationoftheleakwhenneeded.
•Radionuclidecisternogram,(measuringactivityincottonpledgetsinsertedinthenasalcavitiesafterintrathecalinjectionofradionuclide)maybeusedtoconfirmthepresenceof a CSF leak into the sinuses or nasal cavity when the rate of CSF leak is too low to be demonstratedbyCTcisternography.
6. Spinal CSF Leak• Radionuclidecisternogramisfirstchoice.• MRImaybeusedtoclarifyetiologyofleakifleakisdemonstratedinaspecificlocation
on Radionuclide cisternogram.
7. Encephalitis• MRIwithcontrastisbest.• CTwithcontrastifMRIiscontraindicated
8. New-Onset Seizures• MRIisfirstchoice.Contrastisgenerallyaddedforpatients>40yearsoldwithnew
seizures.• CTifMRIiscontraindicated
9. Chronic Intractable Epilepsy•MRIisfirstchoice.Pleaseincludeepilepsywhenrequestingthestudy(HighresolutioncoronalT2-weightedimagingofthehippocampiwillbeaddedfordetectionofmesialtemporalsclerosis).
6 | PHYSICIAN CONSULT LINES: neuroradiology 919-676-5090
10. Cerebral Aneurysms •CTwithoutcontrastforacutepresentationwhensubarachnoidhemorrhageis
suspected•MRIandheadMRA(usuallywithoutcontrast)innon-emergencysituations•HeadCTA(CTangiographywithcontrast)whenMRIiscontraindicated.•AngiographyusedtofurtherevaluateaneurysmdetectedbyMRA/CTA,ortodetecttinyaneurysmwhenMRA/CTAisnegativeandclinicalsuspicionremainsveryhigh.
11. Vascular Malfomations•UnenhancedCTusedforacutepresentationwhenhemorrhagesuspected•MRIwithheadMRA(usuallywithoutcontrast)innon-emergencysituations•HeadCTA(CTangiographywithcontrast)whenMRIiscontraindicated.•AngiographyusedtofurtherevaluatevascularmalformationdetectedbyMRI/CT,orwhenMRI/CTAisnegativeandclinicalsuspicionremainsveryhigh.
12. Vasculitis•MRIwithheadMRA(usuallywithoutcontrast)innon-emergencysituations•CTheadwithCTA(CTangiographywithcontrast)whenMRIiscontraindicated.•AngiographyusedwhenMRI/CTisnegativeandclinicalsuspicionremainsveryhigh.
13. Demyelinating Disease•MRIwithcontrastisexamofchoice.Pleasespecifysuspicionof,orhistoryof,demyelinatingdiseasewhenrequestingthestudy(Axialand/orcoronalFLAIRandSTIRimagingwillbeadded).
•CTwithcontrastwhenMRIunavailableorcontraindicatedtraindicated
14. Sellar and Juxtasellar Lesions•MRIwithcontrastisexamofchoice.PleasespecifypituitaryMRIwhenrequestingthestudy(HighresolutionT1weightedimagingofthepituitarywithoutandwithcontrastwillbeadded).
•CTwithcontrastissometimeshelpfulforcalcificationandbonedestruction•CTangiographyorMRAmaybeindicatediflesionappearstobeananeurysmon
MRI.
15. Stroke•CTwithoutcontrastisfirstchoiceintheacutesetting.•AfterCT,MRIisrecommendedtoconfirmandbettercharacterizeacuteinfarctions,
old infarctions, and chronic ischemic disease. •MRIisalsosuperiortoCTfordetectionofposteriorfossainfarctions,veryearlyinfarctions,orsmallinfarcts.MRIisalsosuperiortoCTinthedetectionofmimickersof ischemic disease.
•MRAisusedtoevaluatevascularluminalcompromise.•CTAifMRAiscontraindicated.(Please note: Within the first few hours after the onset of
stroke symptoms, it is sometimes possible to limit the extent of cerebral infarction by endovascular intervention. If a stroke is identified within several hours of onset, the patient should go directly to a designated Stroke Center, such as WakeMed Raleigh Campus (on New Bern Ave.), as quickly as possible. There, the patient can be evaluated with CT perfusion and examined for possible endovascular intervention that may limit the extent of infarction.)
16. Dementia
• PET·CTisthemostsensitivetestforAlzheimer’sdisease.Medicareapprovedindication,CPT78608.
• MRIismostusefulinexcludingothercausesofdementia(e.g.multi-infarctdementia)• CTshouldbeusedifMRIiscontraindicated.
BRAIn IMAGInG
| 7PHYSICIAN CONSULT LINES: neuroradiology 919-676-5090
V. Musculoskeletal System1. Osteomyelitis
• Plainradiographsasbaselinestudy.Canbediagnostic.Withinitialnormalstudy,repeatin10–14dayscanbediagnostic
• MRIissensitiveandanatomicallyspecificindiagnosisofosteomyelitis• Triplephasebonescancanbeperformedifplainplainradiographsarenothelpfulor
patient cannot undergo MRI• Dual-isotopenuclearmedicinescancanofferincreasedspecificityforinfectionandincludeslabeled-WBCandsulfurcolloid(e.g.,fracturedeformityorCharcotfoot)
2. Skeletal Metastases• Startwithplainplainradiographsinpatientswithfocalpainandknownprimary.• PET·CTorbonescanusedforstaging• MRIcandetectdiseasewherebonescanisnegativeorwhenthereisafocal/isolated
lesion• Percutaneousbonebiopsywithimageguidancefortissuediagnosis• CTcanbehelpfulincharacterization
3. Stress Fractures• Plainplainradiographs:baseline,follow-up,andcomparison• MRIismostsensitiveformarrowabnormalitiesandperiostealinflammatory
processes. May be positive in presence of normal plain plain radiographs• BonescanismoresensitivethanplainplainradiographsandlessspecificthanMRI
4. Joint-replacement Failure• Plainplainradiographsareessentialforbaselineandcomparison• Bonescanissensitivebutnon-specific(infectionvs.loosening).Forincreasedspecificityregardinginfection,wouldrequiredual-isotopenuclearmedicinestudywithlabeled-WBC and Sulfur Colloid
• Jointaspirationwithcontrastadministration.Evidenceofloosening,aswellascultureof aspirated fluid
5. Child Abuse• Skeletalsurveyiscost-effectiveevaluationofareasofknowntrauma,aswellasadditionalareasofoldornewinjury
• Bonescanissensitive(althoughincreasedactivityatgrowthplatesmaybenormal)• CT/MRIforsuspectedintracranialinjury
6. Avascular Necrosis (Osteonecrosis) of the Hip• Plainradiographs:usedasbaseline(maybenormalearlyon)• MRIismostsensitiveforevaluationofosteonecrosis,aswellasevaluationofopposite
hip
7. Deep-Vein Thrombosis• ColordopplerU/S:VerysensitiveandspecificforDVTfromcommonfemoralveinto
popliteal vein • MRvenography(particularlyformorecentral(pelvic,IVC)clot• Venogram:Thegoldstandard,butuncommonlyutilized.BetterthanU/SfordetectionofcalfDVTwithnon-filling,canbedifficulttodistinguishchronicfromacuteDVT(U/Scanhelpsometimes)
8 | PHYSICIAN CONSULT LINES: MsK 919-782-4830
MSK Exams and ServicesAtWakeRadiology,weoffermorecomprehensivesportsmedicineimagingthananyoneinthearea.Withimagingspecialistsinallareas,we’reequippedtohandleanysportsinjuries.OurWestRaleighmusculoskeletalcenterisstaffeddailybytwosubspecialty-trainedradiologists.
•Conventionalradiography,CT,andMRIofalljoints
•Peripheralultrasoundwithspecialattentiontotheshoulder
•Conventional,CT,andMRarthrography· Shoulder, elbow, wrist, hip, knee and ankle
•Interventionalprocedures:· Extremity joint injections for pain management (e.g., upper or lower
extremities, spine, foot/ankle)
· Shoulder brisement for adhesive capsulitis
· Joint aspirations
· Ultrasound-guided cyst aspiration, and removal of bursal and tendon calcium deposits
· Sacroiliac joint injections
· Facet joint injections
· Traditional and caudal epidural injections (through sacral hiatus) for relief of sacrococcygeal, low back, and sciatic pain. This procedure is performed at Wake Radiology Cary Interventional Services by our MSK Radiologists.
•Bonedensitometry—InternationalSocietyfor Clinical Densitometry (IsCD) certified radiologists read all DXA exams at Wake Radiology. Wake Radiology is the only multi-site DXA provider in the country to have ISCD certification.
MUsCULOsKELETAL
| 9PHYSICIAN CONSULT LINES: MsK 919-782-4830
VI. Cardiovascular Imaging1. Elective evaluation of myocardial ischemia, CAD, and
myocardial viability myocardial perfusion with spect for suspected CAD or to follow CAD• CardiacMRI• MultidetectorCTforcalciumscreeningand/orCTcoronaryangiography• PET·CTformyocardialviability
2. Left ventricular ejection fraction• Radionuclideventriculogramandechocardiography• CardiacMRIalsoavailable• CXRisfirstexam.Cannotruleoutsmalleffusions• Echocardiogrampreferredmethodinmostsituations• CTorgatedMRIusedwhenechoisequivocal• MRIforconstrictivepericarditis
3. Pericardial effusion•Echoisthefirstline.• MRIisusedwhenechoisnondiagnostic.
10 | PHYSICIAN CONSULT LINES: Body Imaging 919-787-7951 Body MRI 919-788-7978
VII. General1. Abdominal and pelvic masses in children
• Plainradiographs(bowelgaspatterns/Ca++)• History/physicalshoulddirectimaging(e.g.,bowel:bariumstudies;extra-gastricorintestinal:U/S;renal:U/S(maybefurtherevaluatedwithCT,MRI,VCUG,ornuclearrenalscan)
2. Pelvis• Plainradiographs• U/Sisprimarymodality• Forolderpediatricpatientswithindeterminateornon-diagnosticU/S,useCT,MRI,ornuclearmedicinestudies)
3. Occult bacterial infection• CXR• Abdomen/pelvisCT(diverticulitis,abscess,visceralinfection)• RadionuclideWBCscan
4. Sinusitis• Standardplainradiographs• CTforfurtherevaluationandpreoperativeplanning
5. Patients with elevated creatinine and need for contrast-enhanced cross-sectional exam• MRI
6. Patients with severe allergy to iodinated contrast and need for contrast-enhanced sectional exam• MRI
7. Patients who are unable to follow commands. CT is less sensitive to motion• CT
CARDIO | GEnERAL
| 11PHYSICIAN CONSULT LINES: Body Imaging 919-787-7951 Body MRI 919-788-7978
VIII. Endocrine Disorders1. Adrenal
• Pheochromocytoma:10%multiple,bilateral;10%extra-adrenal,10%malignant- Thorough clinical work-up- Firstimagingstudy:CTabdomen/pelvisandpossiblychestwithoutcontrast.- MRI- Nuclearmedicinestudy(MIBG):occultsites
• Smallnon-functioningincidentaladenomasinpatientswithnohistoryofmalignancy,nopriorCT:- If<10HU,nofurtherimaging- If>10HU,MRIorCTfollow-up- If>5cm,surgery- If increase in size, biopsy- CharacterizewithwashoutCT
2. Thyroid• Solitarypalpablemassineuthyroidpatient
- U/Sallowsforconfirmationoforiginandcharacterization(cysticorsolid).- Biopsy
• MultinodularglandonPE- U/Sallowsforconfirmationoforiginandcharacterization(cysticorsolid).- Biopsy
• Toxicmultinodulargoiter:clinicalhyperthyroid- 131-Ithyroidscananduptake-TreatwithI-131
• Graves’Disease:clinicalhyperthyroid(incrTSH)- 131-Iscananduptake- TreatwithI-131
• Evaluationformetastasisin-patientwiththyroidCa.- I-131wholebodyscan.- TreatwithhighdosesofI-131
•PET·CT/CTasindicated
3. Parathyroid Tumor• Sestamibiscanisexamofchoice.Imageneck,mediastinum
12 | PHYSICIAN CONSULT LINES: Body Imaging 919-787-7951 Body MRI 919-788-7978
IX. Breast Imaging 1. Screening
•Screening Mammography- Guidelines
•Asymptomatic•Age40-80yearly•Exceptions
Baselineat35+OKStrongfamilyhx(motherorsisterwithpre-menopausalbrca)startatage30
and screen yearly.Prior to augmentation or reduction
•Highriskwomen(personalhxofbrca,LCISorADH;strongfamilyhx)- Diagnostic mammography-BSGI(BreastSpecificGammaImagingorMolecularBreastImaging)-BMRI(BreastMRI)
2. Diagnostic Breast Imaging •Indications:
- Significantsymptoms- Abnormal screening mammogram
•Tools:- Diagnostic mammography
- U/S•Indications:
Evaluation of mammographic or palpable lesionNot for screening at this timeStaging •Determination of multifocality •EvaluationofipsilateralaxillaInterventional procedures
•Limitations:Will usually miss DCISSignificantfalsepositives(specificity=25-55%)Inaccurateinareasofpriorsurgery(especiallylumpectomy)
- Aspiration and pneumocystography•Further evaluation of questionable cyst found at U/S•Therapeutic
- Ductography Indications•Persistent bloody nipple discharge• Copious, spontaneous serous discharge from a single duct
- BMRI•Indications:
Staging for breast cancer•Determinationofmultifocality/multicentricity•Pre/postneo-adjuvantchemotherapytoassesstumorresponsiveness
Positive nodes but negative mammogramQuestionablerecurrenceafterbreastconservingtherapyEvaluationofindeterminatefindinginareaofpriorbiopsyEvaluationofnon-specificmammographicandU/SfindingsScreening in some women with dense breasts who are at high riskEvaluation of implant integrity (when clinically indicated)
•LimitationsCost and accessClaustrophobia (IV Valium highly successful for anxiolysis)Pacemakers, etc.
EnDOCRInE | BREAsT
| 13PHYSICIAN CONSULT LINES: Breast Imaging services 919-233-5338 x2123 Breast MRI 919-788-7978
Breast Imaging (Continued)- BSGI
•IndicationsEssentiallythesameasMRI(exceptnotforimplantintegrity)In our practice used primarily for screening •Womenwithlowtomoderateincreasedriskanddensebreasts •Womenwithnormalrisk,butwithverydifficultmammograms
•LimitationsEssentially none
3. Diagnosis1.FNA(FineNeedleAspiration)
ToconfirmmalignancyinBIRADS5lesionToR/Omalignancyinnon-suspiciouspalpablemass
2. Core bx
•Indications:Replacesurgicalbiopsyin~80%ofcasesProbably benign lesions
•Onlyifpt.isveryanxious•Shouldnotbedoneiflesionwillberemovedanyway
•Limitations:RadialscarorotherpoorlydefinedarchitecturaldistortionLooselyclusteredmicrocalcificationsDifficult location of lesion or very small breastsAnticoagulant therapy or bleeding disorderMayunder-diagnose(ADH/DCIS,DCIS/IDC)Cannot determine multifocality or multicentricity with single biopsy
•Sensitivity:2-4%falsenegativeresults
•Notes:StereotacticwithVACBbestforcalcificationsU/Sguidancewith12-14gbiopsyneedlebestformostsolidlesions(VACBusuallynotnecessary)
14 | PHYSICIAN CONSULT LINES: Breast Imaging services 919-233-5338 x2123 Breast MRI 919-788-7978
X. PET·CT and Oncology1. PET·CT for Staging and Differentiating Benign from
Malignant Mass
PET·CT CPT Codes• 78814(limitedarea)• 78815(skullbasetomid-thigh)• 78816(wholebody)
Solitary Pulmonology• CharacterizationofindeterminateSPN
Lung Cancer – non small cell• Diagnosis,initialstagingandrestaging
Colorectal Cancer• Diagnosis,initialstagingandrestaging
Melanoma• Diagnosis,initialstagingandrestaging
Lymphoma• Diagnosis,initialstagingandrestaging
Head & Neck Cancer (excluding thyroid and CNS cancers)• Diagnosis,initialstagingandrestaging
Esophageal Cancer• Diagnosis,initialstagingandrestaging
Breast Cancer• Imagingforbreastca,stagingfordistantmetastases,orrestagingloco-regional
recurrence or metastasis i.e. staging/restaging after or prior to course of treatment, monitoring tumor response to treatment in locally advanced and metastatic br ca when a change in therapy is contemplated.
Thyroid Cancer• Imagingrestagingorrecurrentorresidualthyroidcanceroffollicularcelloriginpreviouslytreatedbythyroidectomy&radiationablation,afternegativeI–131wholebodyscanandthyroglobulinlevels>10ng/ml.
Cervical Cancer• Imagingforstagingnewlydiagnosedandlocallyadvancedcervicalcancerwithnoextra-pelvicmetastasisonconventionalimagingtest,suchasCTorMRI.
BREAsT | PET·CT
| 15PHYSICIAN CONSULT LINES: Radiation Oncology 919-854-4588 PET·CT 919-233-7280
XI. Interventional Radiology1. Varicose Veins
• Venousinsufficiencyiscommonwithhalfofalladults>ageof40 Common symptoms:• Chroniclegpain• Unsightlyvarices• Venousstasisulcers•Spontaneousbleedingandpossiblelimbloss,insomecases• Conservativemanagement:usingsurgicalcompressionstockingsandlegelevation• Laser ablation of greater saphenous vein under U/S guidance• Microphlebectomyusedwhenlargesuperficialveinsneedtoberemoved
2. Sclerotherapy• Appropriateforsmallerveinsnotrequiringphelbectomy• Usedforthetreatmentof“spiderveins”
3. Compression Fractures• Vertebroplasty:methylmethacrylate(akacement)isinjecteddirectlyintoafractured
vertebral body, resulting in pain relief by stabilizing the fracture• Balloonkyphoplasty:utilizesaballoontocreateavoidforthecementaswellastoattempttocorrectthefracturedeformity,obtainingfracturereductionandfixation•Usedprimarilyfortreatmentoffracturesassociatedwithosteoporosis•Usedinthetreatmentofpainfulbonetumorsinvolvingthevertebrae
including metastatic disease• Lowriskofcomplication(<1%)
4. Sacral Insufficiency Fractures• Sacroplasty–Internallysettingafractureviathepercutaneousapproach
5. Uterine Fibroids• Uterinearteryembolization:analternativetosurgeryforthetreatmentofsymptomaticuterinefibroids.•Thenumberofwomenwhohavefibroidsincreaseswithageuntilmenopause•Approximately20%ofwomenwhohavefibroidsalsohavesymptomsthat
merit treatment
6. Venous Access (Port, PICC, Hickman)• Animportantpartofoutpatientchemotherapyandlong-termantibioticadministration(e.g.,osteomyelitisandLyme’streatment)isvenousaccess
7. Thyroid Biopsy•Thyroidnodulesareaverycommonentityinthepopulation,approachingratesof50%• Anultrasoundguidancebiopsyhasaveryhighrateofgainingsufficienttissuefor
pathologic diagnosis8. Pleural Effusion and Ascites Management
• Malignantpleuraleffusionsandascitescanseverelycompromiseapatient’spulmonaryfunction and quality of life
• Repeatedproceduresareveryinconvenientforthepatientandintroducetheriskofinfection with each intervention
• PlacingaDenverPleurex®cathetercanallowthepatienttodrainascitesorpleuraleffusionathome,withouttheneedforrepeatedneedlepuncturesofthepleuraandperitoneum
16 |
9. Peripheral Angiography and Angioplasty• Peripheralvasculardisease(PVD)orperipheralarterialdisease(PAD)isacommon
circulation problem in which the arteries that carry blood to the legs or arms become narrowed or clogged
• Affects10millionpeopleintheUnitedStates,including5%oftheoverage50population
• Angioplasty:treatmentofnarrowedarteriesusingballooncatheters;sometimescombined with the placement of a vascular stent
10. Interventional Oncologic Radiation Therapies• PrimaryLiverCancer(hepatocellularcarcinoma,HCC).Livercancerisoneofthe
most commonly occurring solid tumors worldwide • SecondaryLiverCancer
•Colorectalmetastasestoliver:ColorectalcanceristhefourthmostcommonmalignancyintheUnitedStates.About70%ofpatientswithcoloncancereventuallydeveloplivermetastases.Atthetimeofdiagnosis,30%to40%ofpatientswithcolorectalmetastaseshavediseaselocalizedtotheliver;however,onlya1/4ofthesepatientsaresurgicalcandidates
•Theliverisacommonsiteforspreadoftumorsofthebreast,colon,stomach,pancreas,lung,andskin(melanoma)
• Incidenceratesofprimaryandsecondarylivercancerincreasewithanagingpopulation and new therapies are needed to prolong survival
• Currenttreatmentforlivercancer:•Systemic chemotherapy•Hepaticarterychemoembolization• Surgicalresection•Ablations(e.g.,cryoablation,RFablation,alcoholablation)•Targetedradioembolization(SIR-spheres®)
SIRT(SelectiveInternalRadiationTherapy)•SIR-spheres are biocompatible yttrium-90 microspheres, which are selectivelyinjectedthroughtranscathetermethodsdirectlyintoalivertumor, destroying it while simultaneously preserving most normal liver tissue
RadiofrequencyAblation(RFA)
•Atreatmentoptionforpatientswithprimaryormetastaticliverlesionswhoare currently deemed inoperable
•RFAisalsoanoptionforthetreatmentofrenalcellcarcinoma.RFAemploysimagingguidance(CTorU/S)toachievethermaldestructionofindividualsolid tumors
•RFAhasbeenperformedonlung,kidney,pancreas,bone,andretroperitoneal soft tumors
IR/RADIATIOn THERAPy
| 17PHYSICIAN CONSULT LINES: Interventional Radiology 919-854-2180
18 | PHYSICIAN CONSULT LINES: Pediatric Radiology 919-782-4830
Affiliated HospitalsWakeMedRaleighCampus3000 New Bern AvenueRaleigh,NC27610(919)350-8511(919)350-8959Fax
WakeMedApexHealthplex120HealthplexWayApex,NC27502(919)350-4300
WakeMedBriarCreekMedicalPark10208CernyStreetRaleigh,NC27617(919)350-0978
WakeMedCaryHospital1900KildaireFarmRoadCary,NC27511(919)350-2412(919)350-2418Fax
WakeMedClaytonMedicalPark555MedicalParkPlaceClayton,NC27520(919)350-4242
WakeMedNorthHealthplex10000FallsofNeuseRoadRaleigh,NC27614(919)350-1300
MariaParhamMedicalCenter1805RuinCreekRoadHenderson,NC27536(252)436-1145(252)436-1173Fax
JohnstonHealth509BrightleafBlvd.Smithfield,NC27577(919)934-8171(919)934-1920Fax
CentralRegionalHospital–Raleigh820 S. Boylan Avenue Raleigh, North Carolina 27603(919)733-5540
CentralRegionalHospital–Butner300VeazeyRoadButner,NC27509(919)764-2000
Office LocationsAdministrativeandBusinessOffice3949 Browning Place Raleigh, NC 27609(919)787-8221
WakeRadiologyNorthHills3821MertonDriveRaleigh, NC 27609
WakeRadiologyWestRaleighImaging4301LakeBooneTrailRaleigh, NC 27607(3Offices)
WakeRadiologyNorthwestRaleigh American Institute of Healthcare & Fitness8300HealthPark,Ste221Raleigh,NC27615
WakeRadiologyCary300AshvilleAvenue,Ste100Cary,NC27518(6Offices)
WRComprehensiveBreastServices300 Ashville Avenue, Ste 260Cary,NC27518
WRInterventionalServices300AshvilleAvenue,Ste160Cary,NC27518Scheduling:(919)854-2180
WakeRadiologyOncologyServices300AshvilleAvenue,Ste110Cary,NC27518Scheduling:(919)854-4588
WRRaleighMRICenter3811MertonDriveRaleigh, NC 27609
WakeRadiologyWakeForest American Institute of Healthcare & Fitness3150RogersRoad,Ste115WakeForest,NC27587
WakeRadiologyGarner300HealthParkDrive,Ste100Garner,NC27529
WakeRadiologyChapelHill 110S.EstesDriveChapelHill,NC27514
OffICEs/HOsPITALs/nPI
| 19
Physician NPI Numbers
Bird,RichardE. 1982669909
Burge,HollyJ. 1710944186
Burke,EithneT. 1568429942
Caskey,CynthiaI. 1316904790
Cerwin,RobertA. 1962467944
Chandler,Kerry 1285692244
Coates,G.Glenn 1609833011
Coates,KarenA. 1376501239
Cornett,JosephB. 1629036439
Djang,WilliamT. 1548228372
Douglas,M.Rans 1396703153
Douglas,MargaretR. 1710945571
Dziedzic,T.Scott 1073719746
Fein,AlanB. 1588622351
Gaal,Imre 1609834613
Gullotto,Carmelo 1720046634
Haugan,PaulA. 1841258761
Jordan,III,LyndonK. 1407895154
Kennedy,AndrewS. 1467491019
Kennedy,SusanL. 1679512313
Kwong,MichaelD. 1154361301
Lerner,CatherineB. 1467631523
Leuchtmann,PeterL. 1396791745
Ling,David 1376583419
Lipton,MelissaC. 1407896566
Marchand,MarkD. 1710959804
Matzko,John 1578503645
Max,RichardJ. 1518913458
Melamed,Joseph 1851330534
Merten,DavidF. 1568402568
Meyer,LauraT. 1124293014
Mihalovich,TimothyJ. 1497779961
Mills,StevenR. 1285674283
Mintz,R.David 1598704298
O’Donnell,DennisM. 1023057734
Overton,CarrollC. 1154361160
Peters,BryanM. 1063451706
Pope,CharlesV. 1982644902
Posillico,LouisF. 1457308595
Poyet,ClaireM. 1609823418
Presson,Jr.,Thomas 1568419398
Pretter,PhilipC. 1689621492
Ross,MichaelL. 1982643607
Rougier-Chapman,DuncanP. 1134176019
Rush,ElizabethA. 1700833860
Saba,PhilipR. 1265489124
Sailer,ScottL. 1336196203
Schaaf,RobertE. 1942265475
Schulz,DavidI. 1578734208
Secrist,RandyD. 1861432080
Sierra,John 1710927744
Spargo,J.Mark 1407896244
Townsend,BrentA. 1457565806
Vanarthos,WilliamJ. 1578519872
Wasudev,NikunjP. 1639286651
Way,WilliamG. 1740220003
Weeks,SusanM. 1174579817
Wilson,RussellC. 1124068432
Wu,AndrewC. 1699714212
Quick Phone NumbersWR EXPREss sCHEDULInG: 919-232-4700
EXPREss fAX sCHEDULInG: 919-235-3940
CHAPEL HILL sCHEDULInG: 919-942-3196
CHAPEL HILL EXPREss fAX: 919-933-9925
IT HELP DEsK (PACs InfO): 919-788-7885
QuESTIONS?ADMIN,BILLING,IT: [email protected]
20 |
Wake Radiology Physicians
ROBERT A. CERWIN, MDBody Imaging Radiologist
ROBERT E. SCHAAF, MDDiagnostic Radiologist
President & Managing Partner
RICHARD J. MAX, MDWomen’s Imaging Radiologist
BRyAN M. PETERS, MDNeuroradiologist
CHARLES V. POPE, MDMusculoskeletal Radiologist
ALAN B. FEIN, MDInterventional Radiologist
DAVID LING, MDBody Imaging Radiologist
CLAIRE M. POyET, MDWomen’s Imaging Radiologist
WILLIAM T. DJANG, MDNeuroradiologist
HOLLy J. BURGE, MDBody Imaging Radiologist
Director of PET·CT Services
JOHN SIERRA, MDNeuroradiologist
MICHAEL L. ROSS, MDNeuroradiologist
Co-director of Neuroradiology
ANDREW C. WU, MDInterventional Radiologist
WILLIAM G. WAy JR., MDBody Imaging Radiologist
Director of Diagnostic Imaging
DENNIS M. O’DONNELL, MDBody Imaging Radiologist
OUR PHysICIAns
| 21
KAREN A. COATES, MDBody Imaging Radiologist
J. MARK SPARGO, MDBody Imaging Radiologist
SUSAN L. KENNEDy, MDWomen’s Imaging Radiologist
JOSEPH W. MELAMED, MDMusculoskeletal Radiologist
G. GLENN COATES, MS, MDBody Imaging Radiologist
Director of Body MRI
ELIzABETH A. RUSH, MDWomen’s Imaging Radiologist
JOHN MATzKO, MDBody Imaging Radiologist
KERRy E. CHANDLER, MDWomen’s Imaging RadiologistDirector of Women’s Imaging
CARROLL C. OVERTON, MDInterventional Radiologist
Director of Interventional Services
WILLIAM J. VANARTHOS, MDMusculoskeletal Radiologist
LyNDON K. JORDAN III, MDMusculoskeletal Radiologist
JOSEPH B. CORNETT, MDNeuroradiologist
PHILIP C. PRETTER, MDInterventional Radiologist
M. RANS DOUGLAS, MDBody Imaging Radiologist
DAVID F. MERTEN, MDPediatric Radiologist
22 |
IMRE GAAL JR., MDBody Imaging Radiologist
RANDy D. SECRIST, MDDiagnostic Radiologist
THOMAS L. PRESSON JR., MDInterventional RadiologistRadiation Safety Officer
PHILIP R. SABA, MDNeuroradiologist
Co-director of Neuroradiology
ANDREW S. KENNEDy, MD, FACRORadiation Oncologist
Co-director of Oncology Services
STEVEN R. MILLS, MDBody Imaging Radiologist
CyNTHIA I. CASKEy, MDEmergency Department Radiologist
MICHAEL D. KWONG, MDInterventional Radiologist
MELISSA C. LIPTON, MDEmergency Department Radiologist
LOUIS F. POSILLICO, MDEmergency Department Radiologist
SCOTT L. SAILER, MDRadiation Oncologist
Co-director of Oncology Services
DUNCAN P. ROUGIER-CHAPMAN, MDBody Imaging RadiologistCo-director of Breast MRI
PAUL A. HAUGAN, MDBody Imaging Radiologist
Wake Radiology Physicians
R. DAVID MINTz, MDEmergency Department Radiologist
MARGARET R. DOUGLAS, MDPediatric Radiologist
Director of Pediatric Imaging
OUR PHysICIAns
| 23
CARMELO GULLOTTO, MDBody Imaging Radiologist
RICHARD E. BIRD, MD, FACRWomen’s Imaging Radiologist
RUSSELL C. WILSON, MDMusculoskeletal Radiologist
Director of MSK Imaging Services
EITHNE T. BURKE, MDWomen’s Imaging Radiologist
SUSAN M. WEEKS, MDInterventional Radiologist
PETER L. LEUCHTMANN, MDMusculoskeletal RadiologistInterventional Radiologist
TIMOTHy J. MIHALOVICH, MDMusculoskeletal Radiologist
NIK P. WASUDEV, MDMusculoskeletal Radiologist
MARK D. MARCHAND, MDNeuroradiologist
Physicians EmeritusJULIUS A. GREEN, JR., MD
ALBERT M. JENKINS, MD
HERBERT R. MADRy, JR., MD
LEO FRANK MAzzOCCHI, MD
BEN M. MEARES, MD
WILLIAM H. SPRUNT, III, MD
(1921-2007)
LOUIS M. PERLMUTT, MD
(1949-2001)
DAVID I. SCHULz, MD Body Imaging Radiologist
CATHERINE B. LERNER, MD Pediatric Radiologist
LAURA T. MEyER, MD Pediatric Radiologist
BRENT A. TOWNSEND, MD Pediatric Radiologist
T. SCOTT DzIEDzIC, MS, MDEmergency Department Radiologist
24 |
Notes
WAKE RADIOLOGy ADMInIsTRATIVE sERVICEs | 3949 Browning Place | Raleigh, NC 27609 Administrative Line: 919-787-8221 | WR Express scheduling: 919-232-4700
wakerad.com
Wake Radiology provides imaging services for WakeMed Health & Hospitals, Maria Parham Medical Center, Johnston Health and Dorothea Dix Hospital/Central Regional Hospital.