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.
being performed to evaluate pancreatic lesions should be protocoled with Multihance, and MRCP’s being performed for biliary indications should be protocoled with Eovist.
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.
Routine: Hematuria - no known TCC. Split bolus
Hi Risk / Known Urothelial Cancer protocol - If ordered by urology or oncology. 3 phase - noncon, urothelial phase, and urogram.
There is some literature out there to suggest that we may better detect small plaque like urothelial lesions in a urothelial phase (like 60 sec delay). The urologist and GU oncologists have some pts who have had high risk TCC where they feel this would be helpful. Therefore, the high risk urothelial tumor protocol has a non con, a urothelial phase, and a delay (3 phases instead of the split bolus we use on routine CTU). Most of the time, for our TCC follow ups, we are just looking for mets so we do routine non urographic follow up. But in some cases that are considered higher risk, they want to look closely at the urothelium too, and should say high risk or request urothelial tumor follow up. The other difference in this protocol, since we are also looking for mets, is that it includes the whole abd pelvis (whole liver) so the z axis coverage is a little greater.