DIAGNOSTIC & INTERVENTIONAL RADIOLOGYNAVIGATING THROUGH THE DARK

Tara Graham, MD FRCPC

Diagnostic & VIR THP

tara.graham@thp.ca

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• Imaging follow-up :

• Lung: Fleishner guidelines 2017

• Ovarian cyst: Society of Radiologists in Ultrasound Consensus conference Statement

• GB polyps Joint Guidelines (Eur Radiol 2017)

• Thyroid: TIRADS

• Cancer staging

• Breast : Cone views and pearls

• Tubes and lines

OVERVIEW

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LUNG NODULES: FLEISHNER GUIDELINES 2017

• Does not apply to lung cancer

screening,

immunosuppression, known

cancer, <35 years

• DAP referral: THP and

Brampton (thoracic surgery)

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LUNG CANCER SCREENING

• William Osler: Etobicoke, Brampton

Referral form:

• http://www.williamoslerhs.ca/docs/default-

source/healthcare-professionals-documents/ct-

lung-screening-.pdf?sfvrsn=2

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• Pre-menopausal vs post-menopausal

• PEARL: ‘Cysts’ are often used to described NORMAL PHYSIOLOGIC FOLLICLES in menstruating women

• Concerning features: mural nodularity, internal vascularity on doppler, free fluid

• MRI is used for further characterization

• No role for CT

OVARIAN CYSTS

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OVARIAN CYSTS

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OVARIAN CYSTS

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GALLBLADDER POLYPS

• Eur Radiol (2017) 27:3856-3866

• Joint guidelines

• Not every radiologist follows these

guidelines

• PEARLS:

• Management of GB polyps is

contentious

• Cholecystectomy is

recommended in polyps > 10 mm

• Management of polyps <10 mm

depends on patient and polyp

• Research is required

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THYROID NODULES

• TIRADS

• Composition

• Echogenicity

• Shape

• Margin

• Echogenic Foci

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• NCCN guidelines

• Staging CT/MRI, Bone Scan, PET depends on: • Local stage (ie. Breast)

• Type of Cancer

• MRI staging: Rectal, Endometrial, Cervical, Breast (lobular)

• PET limited indications : most commonly NSCLC, SCLC (See NCCN guidelines for PET)

CANCER STAGING

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BREAST CONE/SPOT COMPRESSION VIEWS: WHY?

• One of the ‘supplementary’ views (ML, LM, magnification,

cone, rolled)

• Spot compression displaces away normal fibroglandular

tissue

• Assesses the shape and margins of a potential lesion

• “architectural distortion” , “focal asymmetry”, ”density”

• Used to guide the need for targeted US

• High Risk OBSP MRI : Does your patient meet high risk criteria? Refer to this link to identify patients appropriate for referral to the high risk program:

https://www.cancercareontario.ca/en/guidelines-advice/cancer-continuum/screening/breast-cancer-high-risk-women

• Screening or surveillance breast US is ONLY indicated for high risk patients (as per OBSP) who are not eligible for MRI

• Patients with a PERSONAL history of breast cancer require ANNUAL surveillance mammograms

• In a young patient (<35 years) with a palpable breast mass, request a breast US (not mammography) and indicate the side & quadrant of the abnormality

• There is no role for whole breast US for bilateral breast pain

• Prior imaging is essential for comparison and work-up! Ideally imaging is completed at the same institution. Imaging performed at multiple sites results in incomplete and inaccurate interpretations and can lead to unnecessary follow-up and intervention

BREAST IMAGING PEARLS

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BASIC TUBE TROUBLE SHOOTINGNOMENCLATURE

TENCKHOFF PIGTAIL/COPE-LOOP BALLOON-TIP

Tunneled Pleural

Tunneled Abdominal

Reaccumulating fluid

Non-tunneled

Pleural/abdominal drainage

Abscess

GB, nephrostomy

G/GJ tube

G/GJ

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TUBE BASICS: NOMENCLATURE

Nephroureterostomy aka

Hobbs I/E drainage

Can be capped! Neph

tubes cannot!

Double J

Nephroureterostomy

Internal drainage

only

PTCD

I/E drainage

Can be capped for internal

drainage

Cholecystostomy tube

External drainage only

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• Don’t get tubes wet

• Routine flushing 10 cc NS/Sterile water prevents blockage

• Keep leg bag ABOVE the knee to prevent dislodgement

• Peritubal leakage/leaking around tube: request tube check/change

• Tube is partially or completely blocked : attempt flush 10 cc NS/Sterile water

• Tube is partially or completely displaced : withdrawn outside of patient (visibly longer, sideholes visible)-needs repositioning

• More emergent evaluation needed: Tube not draining (obstruction) in the setting of infection

• Blocked G/GJ: HARD flushed with 10 cc NS/Sterile water can unblocked tube

• Red flag G/GJ: Abdominal pain, fever, leakage of feeds around tube. STOP FEEDS, call IR. Peritoneal feeding + morbidity, mortality if tract not mature (4 weeks or less)

TUBE TROUBLE SHOOTING/PEARLS

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• Withdrawn PICC - OK to use. Don’t push back in. Tape down and request change

• Blocked PICC• 10 cc syringe NS/sterile water and flush HARD ++++ repeat prn

• tpA protocol

• Call Interventional Radiology at hospital for check/change (Don’t send to ER first)

• Flush but can’t aspirate blood?• Ok to use. Fibrin ‘valve’ at catheter tip

• Request PORT/PICC check/change

• Arm swelling ?• Infection – Abx and resite

• DVT – Order US. If +ve for DVT – anticoagulate. Typically we don’t pull line//port

PORTS & PICCS – TROUBLE SHOOTING

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• Guidelines exist!

• Radiologist SHOULD be making recommendations for follow-up and further imaging based on these guidelines

• A good history and previous imaging are essential

• Unclear?

• Talk to your radiologist!

• Request an addendum for clarification

• Submit a consult on outside imaging (hospital)

SUMMARY

THANK YOU

QUESTIONS?

tara.graham@thp.ca

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Questions: tara.graham@thp.ca

https://www.cairweb.ca