Body Protocols
MRI:
Liver lesion
Most likely going to be Eovist (FYI, this goes for possible hemangiomas. Do not use Multihance just because hemangioma is in the differential. There is no evidence to show that it is better and if it doesn’t turn out to be a hemangioma, you are hamstrung). The 20 minute delayed images are powerful for differentiating many of the potential differential considerations and thus it will be superior to Multihance in most cases. Main exception is cirrhotics. Still looking at Multihance most of the time there.
- Anything biliary is generally going to be better off with Eovist. Keep in mind that if the bilirubin is above 3, then the Eovist will not be excreted, so in that case, it may be better to just go with Multihance.
MRCP
being performed to evaluate pancreatic lesions should be protocoled with Multihance, and MRCP’s being performed for biliary indications should be protocoled with Eovist.
CT:
Pancreas
- Use pancreas neoplasm screening protocol for all cases of known or r/o neoplasm. DO NOT use the pancreas pre-op protocol any longer :
For the pancreas protocol, the neoplasm screening has a late arterial phase (40 sec delay) where the panc parenchyma should be optimally enhancing and therefore we should be able to best delineate a hypovascular mass. Our preop protocol had an early arterial (true CT angio) and pv phase, but no late arterial which sometimes made the mass more difficult to delineate. Also, we are building a DECT version of the procotol, and most centers use DECT on that late arterial phase. We were also having a lot of confusion about which to use. Spoke with the HPB surgeons, GI onc, they felt that we would get a good enough look at the vessels on the late arterial and could probably get away without a true CT angio (added the recons described to aid this). If for some reason both an early and late arterial phase are needed in addition to pv phase (a triphasic pancreas if you will), then we can use the triphasic liver protocol and just specify to include the whole pancreas.
GU:
Regarding flank pain/renal stone follow up CT:
For patients with acute pain or have hydronephrosis, or who are being evaluated for renal stones but don’t have a prior study, we are performing a full flank pain CT (non contrast abd/pelvis) For patients with known stones (based on prior flank pain CT) who are asymptomatic and being evaluated for stone burden, we are doing the limited renal stone follow up (limited z axis coverage of the kidneys just to look at stone burden). There was a lot of confusion about the low dose flank pain protocol (mainly used for stone follow up and now supplanted by limited renal stone follow up)—so we have eliminated this protocol.
Regarding patients with hematuria (no known history of TCC) being sent for CT urography, we have 2 protocols.
Routine CT urography: Split IV contrast bolus technique, where we do a non contrast to look for stones, then a second phase that has contrast in the kidneys and the collecting system to look for renal lesions and urothelial lesions. Urothelial tumor follow up: Single bolus 3 phase exam—a non con (to look for stones), a portal venous phase (to look for plaque like enhancement of urothelial lesions, thought more sensitive for subtle lesions; note the z axis coverage includes the whole abd/pelvis) and a delay where the collecting system in filled with contrast and we get a second look for urothelial lesions. This is a little more robust in looking for TCC, but the radiation dose is a little higher. I would propose the following change (this is based on my survey of the literature and other institutions) for patients with hematuria: Patients < age 45: routine split bolus CT urogram (2 phases, lower radiation dose) Patients > 45: Urothelial tumor follow up, single bolus urogram (3 phases, higher radiation dose but higher sensitivity for TCC)
Regarding follow up of patients with known TCC:
There has been a lot of confusion in this group of patients. The issue is that for some patients with history of TCC, we are just screening for or following metastatic disease. These orders usually come from GU onc, and we do a High image quality cancer follow up protocol. We created the urothelial tumor follow up (3 phase, single bolus urogram) for patients with high risk TCC where in addition to looking for metastatic disease we are looking for urothelial lesions (these orders can come from urology or GU onc). We were told when we created this protocol that people would ask for it by name, but we rarely see that. So when we get orders for TCC follow up, we look at the words used (metastatic disease vs tumor recurrence, or high risk) but we are often making our best guess and this causes a lot of confusion and phone calls. I would propose the following: For patients with known metastatic disease or screening for metastatic disease: Use words metastatic disease in history, will do non urographic exam: High image quality cancer follow up protocol For all others (recurrence, high risk etc): Use words like assess for recurrence, evaluate urothelium, high risk TCC in history. Will scan with urothelial tumor follow up (3 phase single bolus urogram)
Both urology and GU onc were on board with this, and will distribute to their groups. Would welcome thoughts and comments, hopefully this will decrease confusion and streamline work flow in these patient groups. Pete, are you also able to distribute this info to the techs?