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Introduction i-RAD Radiation in Medical Imaging Acute Abdominal Pain Acute Lower Back Pain CT CT Coronary Angiography MRI Nuclear Medicine Ultrasound Mammography Bone Densitometry 1 Nuclear Medicine SPECT CT Angiography Saturday am Service • • • • • • • • • • PET Imaging MRI • Bone Densitomentry CT Scan • Mammography Ultrasound • OPG General X-ray DIRECTORY OF SERVICES CENTRAL St Andrew’s Hospital 1st Floor, 350 South Tce, Adelaide Tel: 8402 4401 Fax: 8402 4430 MRI & Breast Imaging Ground Floor, 350 South Tce Tel: 8402 4424 Fax: 8223 7060 • W akefield Hospital 270 Wakefield St, Adelaide Tel: 8306 5612 Fax: 8306 5623 • • • • B urnside (Attunga Medical Centre) 97 Hewitt Ave, Toorak Gardens Tel: 8403 3100 Fax: 8403 3120 • • • • Adelaide Women’s Imaging Suite 3, Tennyson Centre, 520 South Road, Kurralta Park Tel: 8193 9522 Fax: 8193 9518 K urralta Park (Tennyson Centre) 520 South Rd, Kurralta Park Tel: 1300 435 566 Fax: 8193 9550 • • • • M odbury 27 Smart Rd, Modbury Tel: 8397 5800 Fax: 8397 5811 • • • • M unno Para 2 Main North Rd, Blakeview Tel: 8307 9700 Fax: 8307 9709 • • • • • P rospect 294 Main North Rd, Prospect Tel: 8309 4130 Fax: 8309 4142 • • • • • N oarlunga Hospital Alexander Kelly Drv, Noarlunga Centre Tel: 8307 3400 Fax: 8307 3420 • • • • S outhern Specialist Centre Cnr Main South/O’Sullivan Beach Rds, Morphett Vale Tel: 8307 3450 Fax: 8307 3460 • • • • • M ount Barker District Hospital Wellington Rd, Mount Barker Tel: 8393 7400 Fax: 8393 7410 • • • • • S tirling District Hospital 20 Milan Tce, Stirling Tel: 8131 9100 Fax: 8131 9105 • • A lice Springs Hospital Gap Rd, Alice Springs Tel: 8951 7870 Fax: 8953 4300 • • • • • P ort Augusta Hospital Hospital Rd, Port Augusta Tel: 8642 5322 Fax: 8642 6255 • • • • • P ort Lincoln Hospital Oxford Tce, Port Lincoln Tel: 8683 2227 Fax: 8683 2090 • • • • • P ort Pirie Hospital The Terrace, Port Pirie Tel: 8638 4519 Fax: 8638 4368 • • • • • S outh Coast District Hospital Harborview Tce, Victor Harbor Tel: 8552 0590 Fax: 8552 0597 • • • • S outhern Yorke Peninsula Hospital Yorketown Tel: 8852 1200 Fax: 8852 1664 • W allaroo District Hospital Wallaroo Tel: 8823 0235 Fax: 8823 0232 • • • • W hyalla Hospital Wood Tce, Whyalla Tel: 8645 5486 Fax: 8645 5584 • • • • • • • • • • • • NORTH • • • SOUTH / HILLS • • • • COUNTRY CLINICS - Country Freecall 1800 804 887 • • Your feedback is important to us. Please contact our Medical Liaison Officers if you have any queries: Katrina Mantzarapis 0439 874 817 Candice Brown 0437 717 422 Amy Sancilio 0400 636 272 2 • • • Lorne Klassen 0437 064 786 • • Introduction A General Practitioners’ guide to Medicare requirements in Medical Imaging Every year, more people rely on Dr Jones & Partners for expert radiological services for all types of conditions. Today, we are the largest provider of radiology services in South Australia, with 20 hospital and community based clinics in the Adelaide metropolitan area and country SA. Dr Jones & Partners is part of the I-MED Network, a national network of radiology providers. With specialist radiologists and the latest in technology, Dr Jones & Partners has the experience and expertise to ensure your patients are afforded the very best care. This brochure is designed to help General Practitioners understand the Medicare requirements for Medical Imaging. In order for your patients to receive a Medicare rebate, certain requirements may need to be met and benefits may only be payable when relevant clinical indications are written on the request by the referrer. This booklet outlines some of the Medicare requirements for common diagnostic tests. It is designed as a guide only and General Practitioners should always consult the Medicare Schedule for current requirements. As there is an ever widening range of diagnostic imaging options, radiologists are increasingly involved in clinical management, not only in interpreting results, but actively participating to determine appropriate tests for particular clinical problems. Our experienced and respected radiologists are always available to discuss your patient’s diagnostic imaging and clinical management issues. 3 i-RAD Secure Online Radiology Access i-RAD provides secure online access to your patients’ radiology images and reports on your Windows or MAC PC laptop, Smart Phone or Tablet. Dr Jones & Partners have the most extensive PACS (Picture, Achiving & Communication System) network in South Australia. This enables us to send and receive digital X-rays, Mammograms, CT, MRI, Ultrasound and Nuclear Medicine images quickly and securely between our clinics. i-RAD enables your practice to connect to our network and realise the benefits of digital radiology for your patients and practice. For further information or application for i-RAD visit www.iradsa.com.au. We are pleased to have the latest accessibility to your patients’ images and reports 24/7 via your iPhone or iPad. This application can be downloaded by https://iradsa.com.au/Portal/app 4 Radiation in Medical Imaging Radiation within Australia is commonly measured in millisieverts (mSv). The average background radiation dose for Australians is 3mSv. The dose from a chest x-ray is extremely small - 0.02mSv. Common factors that increase background radiation are: • • • Smoking Watching TV Air Travel = = = 8mSv per year 0.3mSv per year 0.17mSv Typical Radiation Doses in Medical Imaging (not specific to Dr Jones & Partners) •X-ray Chest<0.02mSv Limb<0.01mSv Lumbar Spine 1mSv •CT Brain2mSv Chest4mSv Abdomen 7mSv • Nuclear Medicine Brain1-7mSv Bone4mSv Liver2.8mSv Risk vs Benefit The benefits received from providing the correct diagnosis and consequently the most appropriate treatment far outweigh the very small risk involved. Dr Jones & Partners abides by the South Australian Radiation Safety Act and adopts the guidelines of the Australian Radiation Protection and Nuclear Safety Agency (ARPANSA). The staff are trained in radiation safety and are licensed to operate x-ray equipment. The Health Physics Society stated that the risk to health relating to doses less than 100mSv are either too small to be observed or non-existent. The University of Iowa states that no studies have found an increase of cancer in populations who received doses less than 100mSv. (Radiation Exposure: The Fact vs Fiction, University of Iowa, 2001. http://www.uihealthcare.com). The body can repair radiation-induced damage when the radiation exposure is spread out over long periods of time. That is one reason why higher-than-average cancer rates or genetic defects are not found in populations living in areas where excessively high background exposures exist. 5 Acute Abdominal Pain Patients presenting with acute abdominal pain are diagnostically challenging because of a multitude of potential diagnoses and the diversity of presentations. When the initial signs and symptoms are non-specific, the patient is elderly or those with significant co-morbidity or excessive body habitus, diagnosis can be difficult. The aim in assessment is to ascertain which patients may require surgical intervention or those who require further investigation and definitive treatment. Investigation of Choice: Abdominal CT With current CT technology, the images acquired have exquisite anatomical detail which are able to provide an accurate assessment of the intra-abdominal organs and identification of causative pathology. It is important that clinical information be provided to assist in providing a differential diagnosis. What is involved? A recent creatinine or eGFR level is require if the patient has compromised renal function. Generally a 4 hour fast from food prior to the scan is recommended. The study involves an IV contrast injection. The scan is usually acquired in the “portal venous phase” although multiple phases including pre-contrast, arterial phase and delayed phase imaging can also be acquired within any study to increase the diagnostic accuracy. Each extra phase does add to the overall radiation dose to the patient, and therefore clinical information is important to allow the radiologist to target the study for each patient and the diagnostic problem they pose. Most studies also require some form of oral contrast. Oral contrast has traditionally been a “positive” contrast such as dilute barium and increasingly for certain indications, water is being used as the oral contrast of choice. The acquired data is transferred for image interpretation and reporting by the radiologist. Indications For patients presenting with acute abdominal pain and associated symptoms (eg nausea, vomiting, fever), CT has a high sensitivity and specificity for diagnosis including: • Renal colic • Acute appendicitis •Diverticulitis • Acute Cholecystitis and Pancreatitis • Small or Large Bowel Obstruction • Bowel Perforation Contraindications • • • Previous IV contrast reaction Renal Impairment Haemodynamically unstable patient, where resuscitation at an emergency department prior to urgent investigation is warranted Alternative Investigations • Abdominal Ultrasound Good results can be achieved with this examination. It is a non-invasive investigation and the preferred choice for examining the gallbladder and biliary tract along with the pelvis. It has limitations including the fact that images can be degraded by overlying gas filled structures, obesity and the inability of the patient to tolerate the examination due to pain. •MRI No current indication in the setting of the acute abdomen. • Plain Abdominal X-ray Can be useful when there is a clinical suspicion and performed in conjunction with an erect chest X-ray. It is a good test to exclude free air under the diaphragm as a result of a perforated viscus. This may also be the first line of investigation in suspected constipation, bowel obstruction or abdominal pain in a child. 6 Gastrointestinal: Acute Abdominal Pain / Suspected Bowel Obstruction Gastrointestinal: Acute Abdominal Pain / Suspected Bowel Obstruction Suspected Bowel Obstruction Plain X-Ray Suspected small bowel obstruction Acute ‘high grade’ symptoms Non-acute ‘low grade’ symptoms CT CT enterography Small bowel follow through Contrast enema Signs of volvulus CT Suspected large bowel obstruction Suspected complicated diverticulitis Likely obstructing lesion Site of obstruction unknown CT Contrast enema 7 CT Contrast enema CT Gastrointestinal: Acute Abdominal Pain / Suspected Acute Cholecystitis Chest X-Ray US Positive for acute cholecystitis Treat Negative, but high clinical suspicion of acute cholecystitis, or equivocal / technically inadequate US Negative, low clinical suspicion Consider alternative diagnosis Tc-HIDA scan Peptic ulcer disease Positive for acute cholecystitis Negative, but continuing high clinical suspicion of acute cholecystitis Endoscopy Treat Consider alternative diagnosis Consider CT 8 Other nontraumatic acute abdominal pain Gastrointestinal: Acute Abdominal Pain / Suspected Acute Cholecystitis Suspected Acute Cholecystitis Gastrointestinal: Acute Abdominal Pain / Acute Left Iliac Fossa Pain Gastrointestinal: Acute Abdominal Pain / Acute Left Iliac Fossa Pain Acute Left Iliac Fossa Pain Clinical History and Examination Female of reproductive age Transabdominal +/- Transvaginal Ultrasound Otherwise Suspected Renal Colic Suspected Acute Diverticulitis Majority of other clinical scenarios CT Conservative treatment CT No response to treatment or suspected complications CT Acute Diverticulitis and no abscess Acute Diverticulitis with abscess Other cause found or CT normal Conservative treatment Percutaneous drainage or surgery Treat or further investigate as necessary 9 Gastrointestinal: Acute Abdominal Pain / Pancreatitis Acute severe undifferentiated / generalised pain Clinical History and Examination Biochemical Evaluation US Indications for CT in acute pancreatitis include: • Diagnostic uncertainty • Assessment of severe cases • Failure to improve or sudden clinical deterioration • of a developing complication • Follow-up of established complications • habitus or overlying bowel gas CT Note: No cause is found in approximately 30% of cases 10 Gastrointestinal: Acute Abdominal Pain / Pancreatitis Suspected Acute Pancreatitis Gastrointestinal: Acute Abdominal Pain / Acute Pyelonephritis Gastrointestinal: Acute Abdominal Pain / Acute Pyelonephritis Acute Pyelonephritis Ultrasound No obstruction but continued clinical concern Obstruction CT CT Treat 11 Suspected Renal Colic Clinical History, Examination, Pathology Young or pregnant patients Other patients CT X-Ray or Ultrasound 12 Gastrointestinal: Acute Abdominal Pain / Suspected Renal Colic Gastrointestinal: Acute Abdominal Pain / Suspected Renal Colic Gastrointestinal: Acute Abdominal Pain / Acute Right Iliac Fossa Pain Gastrointestinal: Acute Abdominal Pain / Acute Right Iliac Fossa Pain Acute Right Iliac Fossa Pain Patient of reproductive age B hcg-ve Yes Young patient Pelvic US No High likelihood of appendicitis Atypical for appendicitis Other causes of right iliac fossa pain that merit further investigation Evidence suggests that imaging, provided treatment is not delayed, negative appendectomy rate. This is especially important in young women where pelvic US is done to exclude gynaecological problems Young or pregnant patients CT Other patients Ultrasound Thin patient Ultrasound 13 Obese or older patient CT Musculoskeletal: Acute Lower Back Pain Acute Lower Back Pain Red Flags No Red Flag Possible Cord or Cauda Equina Compression Initial conservative treatment is usually reasonable Red Flag present Imaging indicated Urgent Imaging MRI If pain not improving or progressive neurological deficit Conservative treatment Possible Spinal Canal Stenosis MRI is most appropriate MRI is most appropriate Not improved If MRI not available CT Cause found CT Cause uncertain Treat If suspected stress fracture Bone Scan or CT If suspected infection If suspected bony metastases Bone Scan MRI Red Flags Patients with any of the following Red Flags may benefit from plain X-Ray: • Age of onset < 20 years or > 55 years • Recent history of violent trauma • Constant progressive, non mechanical pain (no relief with bed rest) • Thoracic pain • Past medical history of malignant tumour • Prolonged use of corticosteroids • Drug abuse, immunosuppression, HIV • Systemically unwell • Unexplained weight loss • Widespread neurological symptoms (including cauda equina syndrome) • Structural deformity • Fever 14 Bone Scan Musculoskeletal: Acute Lower Back Pain Sciatica / Radiculopathy Back Pain only CT Quick Reference Guide This quick reference guide outlines the uses and benefits of CT Scanning for investigation of various organs and body systems. CT allows information to be gained using extremely thin slices, which can be reviewed in multiple planes or 3 dimensions to provide more accurate diagnosis. Head CT is the examination of choice for trauma, suspected intra-cranial haemorrhage, CVA and post-operative follow-up. It is a good alternative to MRI for aneurysm screening. Fracture Assessment CT is particularly good at assessment of all complex fractures, in particular of the hip, knee, ankle and shoulder. MRI remains the examination of choice for ligamentous damage in the knee and the ankle, avascular necrosis in the hip and TMJ pathology. Neck For assessment of masses, lymphadenopathy & vascular abnormalities, post contrast CT is the examination of choice. Abdomen Non-contrast CT has replaced IVP’s for the assessment of calculi. Following oral & IV contrast, assessment of all abdominal organs is superb. CT assesses abdominal masses & acute inflammatory processes such as diverticulitis & appendicitis along with lesion assessment & characterisation, ascites & AAA assessment. 15 Spine MRI is indicated when the patient has neurological symptoms. CT is the examination of choice for the assessment of fractures, examination for bone and disc pathology and is also useful for assessment where MRI is not available or is contra-indicated. Angiography After a bolus of contrast and multi-planar reconstructions, excellent demonstration of the arterial system is obtained in the head, neck, chest and abdomen with CT. Pulmonary angiography is used for exclusion of pulmonary embolism. Clinical Indications Chest Head and Facial • Head injury •Headache • Sinus disease • Facial trauma • Conductive hearing loss • Stroke investigation • Tinnitus (where MRI unavailable) • Intracerebral arteries, aneurysm screening or work-up, (where MRI is unavailable or inappropriate) •Haemoptysis •Trauma •Bronchiectasis • Mediastinal mass • Tumour staging • Atypical pneumonia • Chronic & interstitial lung disease • Solitary, multiple pulmonary nodules • CT pulmonary angiography Extremity • Detection of subtle fractures • Work-up of complex fractures • Assessment of bony fusion, delayed healing • Bone tumour • CT arthrography (loose bodies, labral abnormalities, meniscal tears – where MR not available) • Osteochondral defects Spine • Spinal canal stenosis •Radiculopathy •Spondylolisthesis • Assessment of surgical bony fusion • Acute crush fracture assessment Abdomen • Lesion assessment & characterisation • Carcinoma staging • Renal colic • Inflammatory processes •Pelvimetry •Trauma • Obstructive jaundice, pancreatic pathology • Distal CBD stone (CT cholangiography) • AAA diagnosis, pre-operative planning & post-op follow-up Neck • Tumour, mass assessment •Multinodular goitre, tracheal narrowing and retrosternal extension (non contrast) •Tracheomalacia •Tumour staging and diagnosis CT Angiography •Carotids • Circle of Willis • Abdominal aorta • Renal arteries • Thoraco-abdominal aorta • Popliteal arteries • Subclavian arteries • Visceral vessels • Aortobifemoral and lower limb runoffs • Extremity vessels (wrist/forearm arteries, ankle/foot arteries) Interventional • Facet joint injections • Nerve root, foraminal injections •Biopsies •Drainages • Cyst aspirations • Epidurals 16 CT CORONARY ANGIOGRAM (CTCA) Clinical Indications Asymptomatic patients with increased risk factors for coronary artery disease. • Family history • Hypertension • Abnormal lipid profile This scan can provide not only a coronary artery calcium score but also accurately identify and quantify the amount and distribution of soft plaque and coronary stenosis. This can provide useful additional prognostic information and help tailor medical management or triage those for specialist referral and more invasive investigation. Symptomatic patients considered at low to intermediate risk for coronary artery disease. • Due to atypical nature of symptoms • Negative/equivocal stress test This scan can reliably exclude significant coronary disease in many patients, providing reassurance and avoiding the need for more invasive investigations such as coronary catheterisation. Alternatively in a small number of this patient group significant coronary disease will be identified and in these the type and distribution of plaque, as well as the degree and location of stenosis can all be identified - helping to guide decision making regarding the need for further investigation with either catheter angiography or functional myocardial imaging. Patient Preparation When referring for CTCA please be aware of the following: • Patients will need to fast for 4 hours prior to their appointment (can drink water or clear fluids) • Patients should not have any stimulants ie tea, coffee, chocolate etc on the morning of the appointment. •For the sharpest images at the lowest X-ray dose the patient must have a stable heart rate of 60 bpm or lower. If patient’s heart rate is not <60 bpm the following beta blocker protocol is recommended: -<68 bpm 1 x 50mg Metoprolol per day, taken in the morning, starting 3 days before appointment + 1tablet 2 hrs before the appointment. 4 tablets total ->68 bpm 1 x 50 mg Metoprolol taken morning and night, starting 3 days before appointment + 1 tablet 2 hrs before appointment. 7 tablets total If the patient is contra-indicated for beta blocker the scan can still be performed however, there is an increase in the x-ray dose in order to gain sufficient resolution. •CTCA scan requires the administration of IV contrast therefore we must receive the CREATININE or eGFR result for patients with known renal impairment, diabetes or myeloma. - Must be current within the previous 3 months - eGRR >60 proceed as normal - eGFR 30 > 60 then review with Radiologist as it may be possible to proceed under strict supervision. - eGFR <30 it is not recommended - With regards to Metformin patients it is no longer necessary to stop medication in diabetic patients with normal renal function (eGFR >60) 17 FLASH CT News Flash Significant improvements in This significant reduction in radiation dose and the exceptionally fast acquisition time means patients who previously may not have been considered for CTCA may now realise the benefits of an accurate diagnosis of the structure and health of their coronary arteries. CT scanner technology increases the value of CTCA (CT Coronary Angiography) for a much broader patient population. • Family history of cardiovascular disease • Hypertension • Abnormal lipid profile • Atypical symptoms • Negative/equivocal stress test. Dr Jones & Partners Medical Imaging has South Australia’s first and only Dual Source CT which is located at our Wakefield Hospital Clinic. This advanced scanner technology means that CTCA examinations are now achieved with the highest resolution and at the lowest radiation dose. This scan not only provides a coronary artery calcium score but also accurately identifies and quantifies the amount and distribution of soft plaque and coronary stenosis. 3D Cardiac image captured in 0.23sec and with a radiation dose of only 0.67mSv. CASE STUDY Diagnosis – 70% stenosis of the Right Coronary Artery, (arrow) Male, 55 years, asymptomatic, family history of heart disease. When referred by a medical specialist CTCA is Medicare rebated (a gap may also apply). When referred by a GP, CTCA attracts a private fee of $400. Wakefield Bookings call 08 8306 5612. A MEMBER OF THE I-MED NETWORK | i-med.com.au | 38 Payneham Rd Stepney SA 5069 18 | T 8309 2222 CT Coronary Angio diagram.pdf 1 1/05/12 4:56 PM CT Coronary Angiography & CAD - A NEW Algorithm The Medical Journal of Australia has recently published the following algorithm for management of patients with stable Coronary Artery Disease. Step 1: Diagnosis of coronary atherosclerosis Suspected CAD Known CAD CTCA Normal coronary arteries = Risk factor management Atherosclerosis but all lesions < 50% stenosis = Medical therapy Atherosclerosis and lesion(s) > 50% stenosis Step 2: Diagnosis of myocardial ischaemia Non-invasive functional testing: ECG or echo stress test No or mild ischaemia = Medical therapy Significant ischaemia Step 3: Invasive angiography + FFR-guided revascularisation CTCA = computed tomography coronary angiography. ECG = electrocardiogram. FFR = fractional flow reserve. The full article can be viewed via the following link: https://www.mja.com.au/public/issues/194_04_210211/har11106_fm.html CTCA with FLASH CT has a significantly lower x-ray dose. When investigating low to intermediate risk CAD patients, a CTCA investigation on the FLASH CT carries a considerably lower radiation risk. CT SCANNER Average CTCA Dose 64 slice 12 mSv 128 slice 5 mSv FLASH CT < 1mSv Flash CT is available only at Dr Jones & Partners Wakefield Street Clinic. A single Hip X-ray is < 1mSv A MEMBER OF THE I-MED NETWORK | i-med.com.au 19 | 38 Payneham Rd Stepney SA 5069 | T 8309 2222 CT Coronary Angiography with Unparalleled Image Quality for Accurate Diagnosis and Planning Plaques appear sharper and stents are highly delineated. The Definition FLASH enables unparalleled precision for lumen measurement, determination of degree of stenosis, or accurate stent planning. The temporal, resolution without motion artefacts, enables clear visualisation of even the smallest coronary vessels. Patients benefit from the diagnostic accuracy when planning appropriate treatment and management of cardiac conditions. Temporal Resolution of 75msec “Freezes” the Heart Temporal resolution is equivalent to the “shutter speed” of a camera. The Definition FLASH has a temporal resolution less than half that of other scanners - a result of the 280msec gantry rotation and dual source technology. This allows scanning of patients with high or unstable heart rate and even AF where the still period in the diastolic phase of the cardiac cycle is much shorter. Flash Speed, Low Dose - Sub-mSv CTCA FLASH offers the possibility to completely eliminate high dose cardiac CT. Even under unfavourable conditions the patient exposure will be less than what is required for diagnostic cardiac catheterisation. Such low dose values with exceptionally high temporal resolution can open realistic discussions about the use of CTCA for early detection of coronary artery disease in low-to-intermediate-risk patients. With beta blocker, the FLASH Spiral Cardio mode is a revolutionary new scanning technique unique to this scanner which achieves ultra fast scanning at ultralow dose, scanning the heart in as little as 230msec. This mode can be utilised if the patient has a low stable heart rate <60bpm (beta blockers can be used if required). The result is a superb quality image at an X-ray dose as low as 0.4msv. (equivalent to a plain hip X-ray). Without beta blockers, the benefits of CTCA can now be extended to patients who previously could not be scanned due to high or unstable heart rates, arrhythmias or who could not tolerate beta blockers. Imaging these patients was previously difficult or impossible but can be achieved routinely with the FLASH using Adaptive Cardio Sequence. The result is a superb quality image at an X-ray dose as low as 2.4mSv. This technology opens the benefits of CTCA to almost any patient. 20 21 22 MRI Clinical Indications The Federal Government has limited the Medicare rebates for Magnetic Resonance Imaging (MRI) to referrals from Specialist Practitioners since MRI rebates were introduced in 1997. GP’s are able to refer for a limited non medicare funded MRI service. Non-rebateable MRI is performed at St Andrew’s Hospital or the Tennyson Centre at Kurralta Park. GP referred MRI is available for the following clinical indications: • Knee Meniscal Tear/Pathology, Internal Derangement (eg ACL/PCL or Collateral Ligament Tear), Haemarthrosis, Patellar Chondromalacia, Pain or Subluxation, Locking Systems, Osteochondritis Dissecans. • Cervical Spine Radicular Pain, Paraesthesia or Sensory Loss in the upper limbs, Canal Stenosis, Cervical Myelopathy, Crush fractures. • Thoracic Spine Radicular Pain, Crush Fracture, Myelopathy, Spinal Canal Stenosis. • Lumbar Spine Spinal Canal Stenosis, Sciatica, Radicular symptoms, Crush fractures. •Brain ?MS (Demyelination), Acoustic Neuroma. All other indications not listed above can still be performed but will incur the full fee of the scan. MRI has become the initial investigation in the management of certain conditions in the primary care setting, as determined by the Established Standard of Care. The value of MRI in the investigation of patients at a specialist level has become well established. The publication “Imaging Guidelines of the Royal Australian and New Zealand College of Radiologists”, Fourth Edition, exemplifies the place of MRI in numerous algorithms. Some of the advantages of MRI examinations are: • Avoid unnecessary radiation exposure, especially for younger patients. • Accurate knowledge will facilitate appropriate management by health professionals. • Fast track onward specialist referral, especially when immediate intervention is required. •The high field strength, short bore MRI scanners installed at Dr Jones & Partners allows image sequences that increase patient comfort and combat claustrophobia. Please note the absolute and relative contra-indications for MRI examinations. There are many other indications for MRI and these are appropriately performed after specialist referral. 23 Contra-Indications Absolute Contra-indications: • • • • Previous eye injury with retained intraocular metal (common in welders and metal workers). This can be excluded by plain film radiography Cardiac pacemaker or intracardiac defibrillator Neurostimulator Residual pacing wires still in situ Relative Contra-indications/Safety Considerations: Many prostheses are quite safe but precise knowledge of the prosthesis is required before scanning begins. We maintain documentation to allow assessment of the safety of various specific prostheses. • Cochlear implant • Bionic ear or other ear implants • Bone growth stimulator • Aneurysm clip • Pregnancy (a relative contra-indication requiring counselling) • Artificial heart valve (depending upon type) • Vascular clips to coronary or cerebral arteries (depending upon type) • Ventriculoperitoneal (VP) shunt • Indwelling drug infusion device • Ocular prosthesis • Embolism coils • IVC filter • Intrauterine contraceptive device The high intensity of the magnetic field can cause displacement or breakdown of certain kinds of implant and prostheses. In certain cases MRI is absolutely contra-indicated. Many orthopaedic implants, surgical clips or staples, shrapnel, pellets or bullet fragments may cause an artefact on the images. This may limit the diagnostic value of some of the images. Some objects cause more artefact than others. If you have any concerns regarding this, please feel free to discuss it with us. Referring Patients for MRI Changes to Medicare rebates for MRI have been announced and MRI will become accessible to a broader patient group in future for General Practitioners. 24 Nuclear Medicine How is Nuclear Medicine Different from Radiology? Both Nuclear Medicine and Radiology use low level radiation to produce diagnostic images. Radiology uses radiation generated by the scanner whereas the radiation in Nuclear Medicine comes from radioactive pharmaceuticals, known as radiopharmaceuticals, administered to the patient. The scanning camera collects the emitted radiation photons to create an image. Positron Emission Tomography (PET) is a specialised form of nuclear scanning used predominantly for cancer imaging. What is a Radiopharmaceutical? The radiopharmaceutical consists of a radioactive atom, also called a radioisotope or radionuclide, attached to a pharmaceutical molecule. Although called a pharmaceutical, only minute quantities are injected and there is no pharmacological effect in the body. The commonest radionuclide used is technetium-99m, abbreviated as Tc-99m. The purpose of the radionuclide is to allow camera localisation of the tagged pharmaceutical. The radiation comes from the nucleus of the radionuclide, hence the term “nuclear medicine” with its application in medicine. The nuclear radiation is also known as gamma rays and the scanning camera is therefore often referred to as a gamma camera. How does Nuclear Medicine Scanning Work? Depending on the organ to be imaged, an appropriate pharmaceutical is tagged with the radionuclide. For example, in bone scanning, a phosphonate compound is used which binds to calcium within newly forming bone. The phosphonate compound is tagged or radiolabelled with Tc-99m. The intensity of localised radiation depends on the metabolic activity. With most disease states, there is increased metabolic activity. With bone scanning, for example, there is increased bone deposition of radiolabelled phosphonate due to the reparative mechanisms at sites of fractures or osteoblastic metastatic skeletal deposits. These are seen as “hot” spots in the bone scan. As the radiopharmaceutical traces metabolic function, it is also often called a radiotracer. The image in the example shows a scaphoid fracture of the left wrist. Why is Functional or Metabolic Imaging Valuable? The functional nature of Nuclear Medicine is valuable because with disease processes, functional change precedes structural or anatomical change. For example, delineation of sclerosis on X-ray requires an increase in bone mineral content of at least 30%. Bone scanning using a radiolabelled phosphonate is very sensitive and is able to identify a 5-15% alteration in local bone turnover. What is the Radiation Exposure with Nuclear Medicine? The low-level radiation used in Nuclear Medicine or Radiology is safe. We are constantly exposed to low levels of radiation every moment of every day from naturally occurring radioactive elements every time we breathe or fly in aeroplanes. Radiation is a natural part of our lives. The dose from common Nuclear Medicine scans such as bone scans is less than that of CT scans. 25 Clinical Indications Endocrine Pulmonary •Hypertension • Function of thyroid nodules • Radio-iodine therapy • Localisation of parathyroid adenomas • • • Pulmonary embolis Preoperative evaluation Evaluation following lung transplant Nuclear Medicine provides accurate assessment of lung perfusion and ventilation. Renal • Renal artery stenosis • Urinary tract obstruction • Measurement of differential renal function • Renal scars Bone Scan • Tumour/Metastatic Sites • Occult/stress fractures • Unexplained bone pain • Arthritic changes •Osteomyelitis • Paget’s disease • Avascular necrosis • Painful joint prostheses Nuclear Medicine can evaluate renal perfusion, filtration and excretion. Nuclear Medicine can be appropriate where plain films are negative or equivocal despite strong clinical evidence. GT/Biliary • Gastric emptying and colonic transit • Acute or chronic cholecystitis • Calculation of biliary ejection fraction • GI bleeding Other • Sentinal node localisation • Lacrimal scans • Lymphoedema studies • Whole body tumour imaging with gallium or thallium Cardiac •Accurate assessment of left ventricular ejection fraction • Diagnosis of exclusion of myocardial ischaemia Nuclear Medicine can detect disease in sites that can be difficult to evaluate anatomically, eg scaphoid or sternum fractures. 26 Common Procedures Musculoskeletal • Avascular necrosis • Bone Ischaemia • Bone tumours – primary & secondary • Hip pain in children • Joint disease • Metastases • Osteomyelitis • Paget’s disease • Periosteal tumours • Prosthetic loosening • Sports injuries • Stress fracture • Suspected fracture with normal X-ray Bone Scan Lung • Pre-operative evaluation of pulmonary function • Pulmonary embolism Ventilation & Perfusion Scan (VQ) Preparation: None; but chest X-ray may be required Procedure: Inhalation and/or injection of tracer is given to the patient and then imaged (duration 1 hour) Renal • Renal function assessment • Renovascular hypertension • Urinary outflow obstruction • Renal abnormalities • Renal scarring Renal Scan Dt Pa/Mag 3 Preparation:None Procedure: Part 1: IV injection of radiopharmaceutical (duration 20 minutes) Part 2: scan performed 3-4 hours later (duration 1 hour) Patient can leave clinic between Part 1 and Part 2 of the procedure Gallium Scan (Infection) Preparation: None Procedure: Part 1: IV Injection of radiopharmaceutical (duration 20 minutes) Part 2: scan performed 48 hours later. (duration 1 hour) Preparation: Drink 500ml of water prior to study Procedure: IV Injection and imaging (duration 1 hour) Renal Scan Dmsa Preparation: None Procedure: Part 1: IV injection of radiopharmaceutical Part 2: Scan performed 3 hours later (duration 1 hour) patients can leave clinic between Part 1 and 2 Thyroid/Parathyroid • Thyrotoxicosis • Thyroiditis • Thyroid nodules • Retrosternal goitre • Parathyroid adenoma Thyroid Scan Preparation: No iodine for 6 weeks; discuss with Nuclear Medicine Physician Cease carbimazole & PTU for 48 hours prior to scan Procedure: IV injection of tracer, with 20 minute delay then scan (duration 1 hour) 27 Common Procedures Lymphoma Tumour Scan • Staging & therapy monitoring Preparation: None Procedure: IV injection & imaging 2-3 days later (duration 1 to 1.5 hours) Cardiac Assessment Myocardial Perfusion • lnfarction Preparation: No caffeine or theophyline 24 hours prior. • Ischaemia • Myocardial viability Procedure: See instruction booklet “Nuclear Cardiac Scan” for detailed instructions • Regional wall motion assessment/ ejection fraction Preparation: None Gated blood pool scan Procedure: IV injection wait 15 minutes Take blood and reinject (duration 1-1.5 hours) Brain Cerebral Perfusion Using Hmpao Spect • Alzheimer’s Preparation:None • Cerebrovascular disease • Dementia Procedure: IV injection (duration injection 0.5 hour and scan 0.5 hour) Biliary Hepato Biliary Imaging (Hida Scan) ± Cck Ejection Fraction • Biliary obstruction Preparation: Fast for 4 hours • Gall bladder disease Procedure: IV injection and then imaging (scan duration 2.5 hours) Liver Liver Scan • Cirrhosis Preparation: None • Hepatocellular disease Procedure: IV injection and then imaged (duration 1.5 hours) GI Tract To differentiate prolonged constipation from delayed evacuation. Solid and liquid studies demonstrating delayed gastric emptying. Demonstrates oesophageal transit, spasm and reflux. • Colonic transit • Gastric emptying • Oesophageal motility 28 SPECT CT IMAGING UPDATE THE HIGH SENSITIVITY OF NUCLEAR MEDICINE COMBINED WITH THE RELEVANT ANATOMICAL DETAIL OF LOW DOSE CT* Dr Jones & Partners Medical Imaging is pleased to advise that we have SPECT/CT scanners located at our Tennyson Centre and Noarlunga Hospital clinics. SPECT/CT provides much improved localisation of SPINAL “hot spots.” We can determine which facet joint/s to inject. These SPECT/CT scanners enable us to provide more information on previously challenging regions for SPECT-only including WRIST/HAND, ANKLE/FOOT and PELVIS. Improved image detail may provide the additional information required for a faster, more accurate diagnosis and treatment/management outcome for your patient. 57 year old female with 3 month history of foot pain. SPECT scan shows increased uptake in the mid-foot, localised to the Calcaneo-cuboid joint on the fusion images. Pain relieved by U/S guided administration of steroid. * SPECT/CT utilises a low dose CT scan which provides the relevant anatomical detail with a lower x-ray dose and lower resolution than a standard diagnostic CT. 29 IMAGING UPDATE 68 year old male presents with left sided back & hip pain. Previously well. SPECT/CT scan shows a destructive lesion in body of L3 with soft tissue extension and adjacent reactive bony uptake. 73 year old male with known Prostate cancer and increasing back pain. SPECT/CT scan shows bilateral degenerative facet joint disease at L4/5 and a prominent bony osteophyte on the right anterior aspect of L5/S1 and no evidence of a destructive lesion. Should you wish to discuss the relevance of a SPECT/CT study for a specific patient case you are managing, please don’t hesitate to contact one of our Nuclear Medicine Physicians. For bookings call: St Andrew’s Hospital Wakefield Hospital Tennyson Centre Noarlunga Hospital 8402 4401 8306 5612 1300 435 566 8307 3400 If you have any queries please do not hesitate to contact one of our Medical Liaison Officers. Lorne Klassen 0437 064 786, Julie Murphy 0439 874 817 or Candice Brown 0437 717 422. 30 Ultrasound Clinical Indications for Musculoskeletal Ultrasound Medicare benefits for shoulder and knee musculoskeletal ultrasounds are payable when the following clinical indications are written on the request by the referrer. Shoulder or Upper Arm: •Evaluation of injury to tendon, muscle or muscle / tendon junction •Rotator cuff tear / calcification / tendinosis (biceps, subscapular, supraspinatus, infraspinatus) • Biceps subluxation • Capsulitis and bursitis • Evaluation of mass including ganglion • Occult fracture • Acromioclavicular joint pathology Knee: • • • • Abnormality of tendons or bursae about the knee Meniscal cyst, popliteal fossa cyst, mass or pseudomass Nerve entrapment, nerve or nerve sheath tumour Injury of collateral ligaments Imaging of tendons on Ultrasound can diagnose: • Tears – partial or complete • Tendinosis / tendinitis • Tendon stability, adhesion, entrapment, triggering • Insertional abnormalities • Tendon calcification Please contact our Radiologists to discuss any issues related to the above Medicare requirements. Benefits are not payable when referred for non specific shoulder or knee pain alone or other conditions. 31 Quick Reference Guide Shoulder Thoracic Outlet • Rotator cuff - bursitis (subacromial/subdeltoid), tendinosis, tears (muscles, tendons, coracoacromial ligament, posterior labrum), calcification, impingement • AC joint - effusion, degenerative change, instability • Biceps - tenosynovitis, tendinosis, muscle/tendon tears, subluxation/dislocation out of bicipital groove • Cervical ribs • Compression of nerves and/ or major vessels Forearm/Thigh/Calf • Nerve entrapment, muscle/tendon tears, and inflammation • Examination of a mass Hip/Groin/Buttocks Elbow • Hip – joint effusions, synovial thickening, iliopsoas bursitis, dislocation (paediatric) • Greater trochanter – gluteal tendinopathy, trochanteric bursitis • Groin – hernias, tears (e.g. conjoint tendon) • Buttocks – tears (e.g. hamstring origin), Nerve abnormalities (e.g. sciatic) • Piriformis syndrome • Ischial Bursitis • Joint effusions, synovial thickening, loose bodies • Tears - muscles, tendons (e.g. biceps, triceps or common extensor), ligaments • Bursitis - (e.g. olecranon) • Nerve abnormalities - (e.g. ulnar, median, radial and posterior interosseous branch) Hand/Wrist Knee • Joint effusions, synovial thickening • Ganglia and tenosynovitis • Tears – muscles, tendons, ligaments (e.g.scapholunate), triangular fibrocartilage • Intersection or cross-over syndrome (e.g. 1st over 2nd or 3rd over 2nd extensor compartments) • Carpal tunnel syndrome • Nerve abnormalities (e.g. ulnar, median, radial) • Joint effusions, synovial thickening, loose bodies • Tears – muscle, tendons, collateral ligaments, menisci • Bursitis (e.g. prepatellar, infrapatellar) • Ganglia and parameniscal cysts • Baker’s cyst Foot Ankle • Joint effusions, synovial thickening • Ganglia and tenosynovitis • Tears – muscle, tendons (e.g. tibialis posterior, peroneal), ligaments • Morton’s neuroma • Plantar fasciitis or fibromatosis • Joint effusions, synovial thickening • Ganglia and tenosynovitis • Tears – muscle, tendons (e.g. tibialis posterior, peroneal, Achilles), ligaments • Tarsal tunnel syndrome • Nerve abnormalities In addition to diagnostic examinations, Ultrasound can be used to guide injections of joints, bursae, tendon sheaths, and ganglia along with aspiration of collections and muscle haematomas. Plain films are recommended, in addition to an Ultrasound examination, to exclude any bony pathology. 32 Clinical Indications for Obstetric Ultrasound Medicare benefits for obstetric ultrasounds are payable when the following clinical indications are written on the request by the referrer. Please ensure that you clearly state clinical indications on your referral. <12 weeks Where one or more conditions in Clinical Indications 1 applies. *Early Dating: 6 to 11 Weeks. 12 to 16 weeks Where one or more conditions in Clinical Indications 1 applies. * Nuchal Translucency: 11 weeks, 4 days to 13 weeks, 6 days 17 to 22 weeks Referred by any Medical Practitioner, but not exceeding one service per pregnancy, or; Referred by an O&G or a GP with a Diploma of Obstetrics, where further examination is clinically indicated. *Morphology: 18-20 Weeks. > 22 weeks Referred by any Medical Practitioner, where one or more conditions in Clinical Indications 2 applies but not exceeding one service per pregnancy, or; Referred by an O&G or a GP with a Diploma of Obstetrics, where further examination is clinically indicated and one or more conditions in Clinical Indications 2 applies. 33 Clinical Indications 2 Clinical Indications 1 (i) Hyperemesis gravidarum (ii) Diabetes mellitus (iii)Hypertension (iv) Toxaemia of pregnancy (v) Liver or renal disease (vi) Autoimmune disease (vii) Cardiac disease (viii)Alloimmunisation (ix) Maternal infection (x) Inflammatory bowel disease (xi) Bowel stoma (xii) Abdominal wall scarring (xiii) Previous spinal or pelvic trauma or disease (xiv) Drug dependency (xv)Thrombophilia (xvi) Significant maternal obesity (xvii) Advanced maternal age (xviii) Abdominal pain or mass (xix) Uncertain dates (xx) High risk pregnancy (xxi) Previous post dates delivery (xxii) Previous caesarean section (xxiii) Poor obstetric history (xxiv) Suspicion of ectopic pregnancy (xxv) Risk of miscarriage (xxvi) Diminished symptoms of pregnancy (xxvii) Suspected or known cervical incompetence (xxviii) Suspected or known uterine abnormality (xxix) Pregnancy after assisted reproduction (xxx) Risk of fetal abnormality Medicare Benefits Schedule Book Pages 569 -570 (i) Known or suspected foetal abnormality or foetal cardiac arrhythmia (ii) Fetal anatomy (late booking) (iii)Malpresentation (iv) Cervical assessment (v) Clinical suspicion of amniotic fluid abnormality (vi) Clinical suspicion of placental or umbilical cord abnormality (vii) Previous complicated delivery (viii) Uterine scar assessment (ix) Uterine fibroid (x) Previous foetal death in utero or neonatal death (xi) Antepartum haemorrhage (xii) Clinical suspicion or intra uterine growth retardation (xiii) Clinical suspicion of macrosomia (xiv) Reduced fetal movements (xv) Suspected fetal death (xvi) Abnormal cardiotocography (xvii) Prolonged pregnancy (xviii) Premature labour (xix) Fetal infection (xx) Pregnancy after assisted reproduction (xxi)Trauma (xxii) Diabetes mellitus (xxiii)Hypertension (xxiv) Toxaemia of pregnancy (xxv) Liver or renal disease (xxvi) Autoimmune disease (xxvii) Cardiac disease (xxviii)Alloimmunisation (xxix) Maternal infection (xxx) Inflammatory bowel disease (xxxi) Abdominal wall scarring (xxxii) Previous spinal or pelvic trauma or disease (xxiii) Drug dependency (xxxiv)Thrombophilia (xxxv) Significant maternal obesity (xxxvi) Advanced maternal age (xxxvii)Abdominal pain or mass 34 Nuchal Translucency Nuchal Translucency screening is a test to assess the risk of chromosomal abnormality, particularly Down Syndrome. Early in pregnancy a certain amount of fluid collects behind the baby’s neck. We measure the fluid using ultrasound to see if there is a normal amount. At our specialised obstetric clinic, Adelaide Women’s Imaging located at the Tennyson Centre, Kurralta Park, a risk estimate is generated using the Fetal Medicine Foundation risk calculations software. This incorporates maternal age, nuchal thickness, maternal serum BHCG and PAPP-A. The risk is then given to the patient, its relevance discussed and the results sent to the referring doctor. At all other sites, the nuchal results are sent to South Australian Maternal Serum Antenatal Screening (SAMSAS), based at the Women’s and Children’s Hospital. The combined risk is calculated using their database and the results sent to the referring doctor. A Medicare rebate is only claimable when a request form is completed with one or more of the clinical indicators from Appendix One. • When is the test performed? The Ultrasound is performed between 11 weeks 3 days and 13 weeks 6 days of pregnancy, under the direction of our Medical Specialists, by an accredited Sonographer. The test has the highest detection rate of any “no risk” test for chromosomal abnormality. One service only in any one pregnancy. CRL = 45-80mm. • What happens if the result puts your patient into a High Risk Category? A high risk result does not necessarily mean Down Syndrome is present as there can be other causes of increased nuchal fluid being seen in entirely normal babies. Most women with an “increased risk” result will go on to have a normal baby. The test simply identifies women who should be offered further testing to determine if their baby is affected. There are two diagnostic tests that may be offered which can determine if there is a chromosomal abnormality. These tests are Chorion Villus Sampling (CVS) or amniocentesis and are offered at Adelaide Women’s Imaging clinic. Both tests provide the same result and either may be offered. Both have a small risk of miscarriage. Preliminary results from either of these tests may be available within 24 hours. • What happens if the screening test puts your patient into a low risk category? 19 out of 20 women will have a low risk result. This means that the risk for Down Syndrome is very low however, a low risk does not mean that there is no risk. • Does the test pick up other birth defects? Although the test is designed to detect babies at risk for Down Syndrome, babies with other chromosomal abnormalities may also be identified. In addition the ultrasound may identify a baby with an obvious physical birth defect. Most women also have a 19-20 week ultrasound that is better at assessing the anatomy of the baby. • Preparation The patient needs to drink water. The examination is performed primarily through the abdominal wall but sometimes an internal (vaginal) scan is required in order to obtain the best possible images. Ultrasound has no known harmful effects on the foetus. Shared Care Obstetric Patients - Under the Shared Care Program, patients will have a fee reduction of 50% for their obstetric imaging at Dr Jones & Partners. 35 Clinical Indications for Vascular Ultrasound of Lower Limbs Vascular Ultrasound studies of the lower limbs can often be time-consuming and demanding on the patient. As a result, differentiation between Arterial and Venous studies is of importance in enabling us to help aid in diagnosis of your patient’s concerns. All leg ultrasound examinations involve uncovering the affected leg completely of clothing and bandages, gel is applied, and mild to moderate pressure is used to compress the vessels. Depending on the type of study requested and clinical concern, the patient may be recumbent or standing during the examination. B-Mode (grey scale) imaging plus Colour Doppler and Pulsed Wave Doppler images are obtained. Vascular Sonography is often termed Duplex as it incorporates 2-D grey scale imaging plus a combination of the variants of Doppler imaging. Urgent scans include DVT and acute/sudden arterial compromise (i.e. blue limb/appendage). Varicose Vein/ Venous Incompetence and Leg Artery imaging for stenosis are non-urgent and can be examined at the patient’s convenience. 36 Leg Vein Examinations Examination Clinical Symptom/Presentation DVT Ultrasound • • • • • • • • • • Pain/Swelling of calf +/- thigh Previous DVT – review or new pain Superficial Thrombophlebitis Recent surgery – leg pain/swelling Recent travel – leg pain/swelling Immobilisation – leg pain/swelling History of cancer/ chemo – pain/swelling Positive D-dimer Pulmonary Embolism (PE) Other risk factors include SLE, history of myocardial infarct, congestive heart failure, pregnancy, OCP/HRT, Tamoxifen, hyperlipidaemia, local trauma. Venous Incompetence Ultrasound Study • • • • • • • • Chronic/long term swelling and ache Varicose veins Venous dermatitis/eczema Venous ulcer Recurrent veins/Review post surgery Abnormal visible veins Night cramps/heaviness of legs/itching Other risk factors include pregnancy, Family history, occupation involving prolonged standing Leg Artery Examinations Examination Leg Arteries Ultrasound Clinical Symptom/Presentation • • • • • • Intermittent Claudication – pain with exercise Rest pain/pain with leg elevated Skin ulceration - ischaemic Absent/weak foot pulses, cold Foot/toe discolouration, gangrene Peripheral Vascular Disease (PVD) Risk factors – smoking, diabetes, hypertension, obesity, hyperlipidaemia, family history • Review of graft or stent • Sudden/acute arterial compromise. This is URGENT and the patient should be sent to a Vascular Surgeon or hospital. 37 Mammography Medicare Rebate Guide Medicare will only pay for a Diagnostic Mammogram if there is reason to suspect the presence of malignancy because of: (i) the past occurrence of breast malignancy in the patient or members of the patient’s family; or (ii) symptoms or indications of malignancy found on an examination of the patient by a medical practitioner In any other circumstance Medicare will not pay a rebate for the patient’s mammogram. Please note that HRT or a history of other cancer, pain or tenderness, general soreness, general lumpiness and the monitoring of benign breast conditions are not eligible criteria. Furthermore, the request MUST contain clinical notes that detail why you, the referrer, require the mammogram for your patient. If there is no past or family history of breast cancer the clinical notes must include signs or symptoms which raise concern in regard to malignancy. The patient has: Diagnostic Mammogram Clinical Notes • Past history of breast cancer • Family history of breast cancer • Symptoms or indications of malignancy found on an examination of the patient by a medical practitioner • Previous history of breast cancer • Family history of breast cancer • Symptoms or indications of malignancy found on an examination of the patient – - Breast thickening or dimpling - Nipple change or discharge - Focal tenderness (including a diagram on the referral) - Focal lump - Possible lesion - Any other suggestion / finding that could represent or question malignancy as long as the doctor highlights this is concerning for underlying malignancy Note: • • Screening mammograms are for patients with no past or family history of breast cancer, no clinical breast symptom(s) and for monitoring benign breast conditions. BreastScreen SA is not appropriate for patients with breast symptoms. If you suspect your patient has symptoms, we recommend they have a diagnostic mammogram. 38 Specialist Breast Imaging Services Dr Jones & Partners provides you with two comprehensive Breast Imaging sites, as well as three outer metropolitan and three country sites. The specialist Breast Imaging sites have been established to provide you with easy access to a team of sub-specialist Radiologists with extensive breast imaging experience. Our two specialist Breast Imaging sites have a strong affiliation with the multi-disciplinary clinics at Burnside War Memorial Hospital and St Andrew’s Hospital. In these clinics our Radiologists work together with specialist breast clinicians to provide an integrated clinical and imaging service. These teams also include highly skilled, accredited Mammographers and Sonographers specifically trained in breast imaging. The Breast Imaging sites are equipped with digital capture Mammography technology. We are committed to ensuring patients are presented with the most up to date options in diagnositc breast imaging. There have been recent technological advances in Mammography, allowing us to produce clearer images whilst reducing the radiation dose and significantly improving patient comfort. We also perform Breast MRI, which is available via specialist referral and this compliments our existing services, thus allowing us to perform accurate image interpretation. Services available include: • Digital Mammography • Breast Ultrasound • Fine Needle Apsiration (under ultrasound or stereotactic guidance) • Core Biopsy (under ultrasound or stereotactic guidance) • Carbon Track and Hookwire Localisation for surgery •MRI 39 Diagnostic Breast Imaging Patient has SYMPTOMS - for example •Lump •Thickening • Nipple discharge •Pain Is the patient pregnant or lactating? YES NO Under 35 35 and over Targeted Ultrasound +/- Mammogram +/- FNA Mammogram + Ultrasound +/- FNA Normal/Benign Abnormal Ultrasound FNA Clinician review-> Concordant with Triple Test - STOP Clinician review-> Discordant with Triple Test - Breast Surgical referral May require Breast Surgical referral 40 All women all ages: Biennial Clinical Breast Examination and Self Breast Examination monthly day 7-14 cycle Breast Screening High Risk Asymptomatic Women Asymptomatic Women <40 No Mammogram/ Ultrasound screening for normal risk women 40 - 70 >70 Biennial Mammogram +/- Ultrasound Assess other comorbidities •Consider National Screening •Consider Private Screening Risk assessment 1) BRCA 1, 2 + 2) Strong FHx/first degree relative - commerce Mammogram 5-10yrs earlier to youngest relative age at diagnosis Breast Surgeon referral for: Clinical breast examination + Annual Mammogram +/- Ultrasound Biennial screening Mammogram if patient well 41 ? MRI eligible Additional Comments ULTRASOUND is NOT a screening investigation All women all ages: Biennial Clinical Breast Examination and Self Breast Examination monthly day 7-14 cycle It is safe for women with IMPLANTS to have Mammogram Always correlate with TRIPLE TEST Core biopsy referred only by Breast specialist IMPLANT integrity assessment 1. Implant MRI 2. Refer to Plastic Surgeon or Breast Surgeon for clinical assessment of BAKER’S grade High risk patients should be referred to Breast Surgeon annually for clinical review and management, including MRI consideration If ever unsure....refer to breast surgeon or discuss with ONE of OUR radiologistS at ST ANDREW’S OR BURNSIDE 42 Bone Densitometry (DEXA) Bone Densitometry services provide the most sensitive and accurate technology to detect subtle bone changes to help diagnose osteoporosis and monitor changes in bone density. • Advantages of Bone Densitometry - DEXA Bone Densitometry testing is the most accurate method available for testing for osteoporosis and the only testing method endorsed by Osteoporosis Australia - Increased clinical precision of greater diagnostic accuracy • Benefits of Bone Densitometry Testing (DEXA) - Safe, low radiation - Faster and more comfortable procedure – full scan done in only 10 minutes - Painless, non invasive, no injections - DEXA is the only recommended standard test to measure bone strength and for monitoring of fracture risk • Screening vs Diagnostic Scanning: the importance of clinical notes - Patients below 70 years of age, without clinical indications will be considered as presenting for screening for which no Medicare rebate is payable - Patients with clinical indications* will attract a Medicare rebate with no out-of-pocket expense for Pensioners and Health Care Card Holders * See chart on the following page to assist you to determine if your patient requires screening or diagnostic scanning. 43 Bone Mineral Density (BMD) Scanning Using DEXA A Medicare rebate is claimable only when a request form is completed with one or more of the following clinical indicators. Categories for BMD Request Item 12306 • 1 or more fractures occurring after minimal trauma • Monitoring of low BMD proven by previous bone densitometry. 1 service only in 24 months • Prolonged glucocorticoid therapy • Conditions associated with excess glucocorticoid secretion Item 12312 • Male hypogonadism •Female hypogonadism lasting more than 6 months before the age of 45. 1 service only in 12 months • Primary hyperparathyroidism • Chronic liver disease Item 12315 1 service only in 24 months • Chronic renal disease • Proven malabsorption disorders • Rheumatoid arthritis • Conditions associated with thyroxine excess Item 12321 Item 12323 No Rebate Osteoporosis •Measurement of BMD 12 months following a significant change in therapy for established low BMD •Measurement of BMD after confirmation of a presumptive diagnosis of low BDM after one or more fractures 1 service only in 12 months • Available to patients 70 years and older • Patient is asymptomatic • Patient is below 70 years of age and does not fit into another group = Low bone densitometry with a T-Score more than 2.5 standard deviations below young normal mean Common request on referrals that are not covered by Medicare include: • Joint pain • Menopausal • Family history • Osteopaenia • Arimidex - Breast cancer drug for osteoporosis 44
