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: info@wakerad.com

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: info@wakerad.com

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.