Pleuritic chest pain and shortness Pleuritic chest pain and shortness of breath one week post-of breath one week post-

hysterectomyhysterectomy

History suggests pulmonary embolusHistory suggests pulmonary embolusPE is important diagnosis to make because untreated PE is important diagnosis to make because untreated PE has risk of death due to additional PE, and PE has risk of death due to additional PE, and anticoagulation decreases that riskanticoagulation decreases that riskOn the other hand, if patient doesn’t have PE, On the other hand, if patient doesn’t have PE, anticoagulating patient gives them risk of serious anticoagulating patient gives them risk of serious bleeding for no benefitbleeding for no benefitD-dimer might be considered as a screen, but it is D-dimer might be considered as a screen, but it is non-specific and in this patient may be elevated just non-specific and in this patient may be elevated just because of recent surgerybecause of recent surgeryImaging plays big role in making the big decision: Imaging plays big role in making the big decision: anticoagulate or notanticoagulate or notWhat is initial imaging study?What is initial imaging study?

Start with CXRStart with CXREven though CXR is insensitive in diagnosis of PE Even though CXR is insensitive in diagnosis of PE (most common CXR finding in patient with PE is (most common CXR finding in patient with PE is normal, as on following CXR)normal, as on following CXR)And even though the most common CXR findings in And even though the most common CXR findings in PE patients are usually nonspecific (pleural effusion, PE patients are usually nonspecific (pleural effusion, consolidation, atelectasis)consolidation, atelectasis)Do the CXR to R/O other causes for symptoms (e.g., Do the CXR to R/O other causes for symptoms (e.g., pneumothorax), and should have baseline CXR with pneumothorax), and should have baseline CXR with potentially serious cardiopulmonary disease, in case potentially serious cardiopulmonary disease, in case patient goes bad. Also CXR will often be needed to patient goes bad. Also CXR will often be needed to interpret V/Q scan if done subsequentlyinterpret V/Q scan if done subsequently

Following CXR is on same patient whose Following CXR is on same patient whose CXR was initially normal, but now with left CXR was initially normal, but now with left basilar opacitybasilar opacity

This is at least partly due to pleural This is at least partly due to pleural effusion because of associated meniscus, effusion because of associated meniscus, but effusion is not specific to PE, having but effusion is not specific to PE, having many other causes as wellmany other causes as well

Old gold standard test for PE was catheter Old gold standard test for PE was catheter pulmonary angiography, now seldom donepulmonary angiography, now seldom doneIt showed PE as filling defect in pulmonary It showed PE as filling defect in pulmonary artery otherwise opacified with contrast, as artery otherwise opacified with contrast, as illustrated in the following image (same illustrated in the following image (same patient as on preceding CXRs)patient as on preceding CXRs)Currently contrast-enhanced CT is often used Currently contrast-enhanced CT is often used as the next imaging test, if PE is still possible as the next imaging test, if PE is still possible after CXR. CT shows PE in same way that after CXR. CT shows PE in same way that catheter angio had done in the past, but non-catheter angio had done in the past, but non-invasivelyinvasively

Because key question is anticoagulate or not, Because key question is anticoagulate or not, some algorithms start with Doppler US of leg veinssome algorithms start with Doppler US of leg veinsIf US is positive for DVT, then the key question is If US is positive for DVT, then the key question is answered (patient needs anticoagulation), answered (patient needs anticoagulation), although there is still some uncertainty as to although there is still some uncertainty as to whether patient had PE, and if so how bigwhether patient had PE, and if so how bigOther problem with US is that about half of Other problem with US is that about half of patients with PE will have negative leg venous USpatients with PE will have negative leg venous USUS is very useful in pregnant patients (radiation US is very useful in pregnant patients (radiation concerns)concerns)

Following image shows deep venous Following image shows deep venous thrombosis (common femoral vein)thrombosis (common femoral vein)

DVT is recognized on US by lack of full DVT is recognized on US by lack of full compressibility of deep veins (as compressibility of deep veins (as illustrated here) and lack of flow on color illustrated here) and lack of flow on color DopplerDoppler

If patient can’t have contrast-enhanced chest CT If patient can’t have contrast-enhanced chest CT (contrast allergy, renal insufficiency), V/Q (contrast allergy, renal insufficiency), V/Q (ventilation/perfusion) scan is older but still (ventilation/perfusion) scan is older but still commonly used alternativecommonly used alternativeVentilation scan done by having patient breathe in Ventilation scan done by having patient breathe in radioactive gas (as in following image) or radioactive gas (as in following image) or radioactive aerosolradioactive aerosolPerfusion scan done by injecting radio-labelled Perfusion scan done by injecting radio-labelled microemboli (macro-agregated albumin in this microemboli (macro-agregated albumin in this case) into systemic vein, so that the emboli lodge case) into systemic vein, so that the emboli lodge in the first capillary bed they reach (the lungs if in the first capillary bed they reach (the lungs if there is no right-to-left shunt)there is no right-to-left shunt)

Perfusion scan is sensitive but nonspecific Perfusion scan is sensitive but nonspecific because other pathologies can cause because other pathologies can cause perfusion defects, such as airway disease (if perfusion defects, such as airway disease (if part of lung is hypoventilated, hypoxia in that part of lung is hypoventilated, hypoxia in that area will cause pulmonary arterial area will cause pulmonary arterial constriction, shunting blood away, resulting in constriction, shunting blood away, resulting in perfusion defect)perfusion defect)Ventilation scan allows recognition of airway Ventilation scan allows recognition of airway disease, improving specificity of perfusion disease, improving specificity of perfusion scanscan

Following 2 frames show a V/Q scan with a high probability of Following 2 frames show a V/Q scan with a high probability of PEPEVentilation scan is normal (symmetrical lung filling on single Ventilation scan is normal (symmetrical lung filling on single breath, prompt symmetrical washout without air trapping)breath, prompt symmetrical washout without air trapping)Perfusion scan is picture of pulmonary blood flow frozen in Perfusion scan is picture of pulmonary blood flow frozen in time, allowing images to be taken from multiple angles time, allowing images to be taken from multiple angles (anterior, posterior, both laterals, both posterior obliques)(anterior, posterior, both laterals, both posterior obliques)Note wedge-shaped perfusion defects in lingula of LUL and Note wedge-shaped perfusion defects in lingula of LUL and apical segment of LLLapical segment of LLLThis is high probability of PE because there are multiple This is high probability of PE because there are multiple segmental wedge-shaped perfusion defects unmatched by segmental wedge-shaped perfusion defects unmatched by ventilation defectsventilation defects

Because the perfusion scan is so sensitive, V/Q scans are very Because the perfusion scan is so sensitive, V/Q scans are very helpful when normal, effectively ruling out PEhelpful when normal, effectively ruling out PEV/Q scans also helpful when resulting in a high-probability reading V/Q scans also helpful when resulting in a high-probability reading associated with a high clinical suspicion (chance of PE is 96% -> associated with a high clinical suspicion (chance of PE is 96% -> anticoagulate)anticoagulate)V/Q scans also helpful when resulting in a low-probability reading V/Q scans also helpful when resulting in a low-probability reading associated with a low clinical suspicion (chance of PE is 4% -> associated with a low clinical suspicion (chance of PE is 4% -> withhold anticoagulationwithhold anticoagulationUnfortunately most V/Q scans are other than normal, high-high or Unfortunately most V/Q scans are other than normal, high-high or low-low, in part because ED patients with chest pain and shortness low-low, in part because ED patients with chest pain and shortness of breath include many who have lung disease which causes of breath include many who have lung disease which causes abnormal V/Q scans in the absence of PEabnormal V/Q scans in the absence of PEV/Q scans are most helpful in patients with no evidence of lung V/Q scans are most helpful in patients with no evidence of lung disease on history (non-smoker, no asthma), exam (clear lungs), disease on history (non-smoker, no asthma), exam (clear lungs), and CXR (normal lungs). Because 90% of ED patients with ? of PE and CXR (normal lungs). Because 90% of ED patients with ? of PE don’t have PE, if they don’t have lung disease otherwise, their V/Q don’t have PE, if they don’t have lung disease otherwise, their V/Q scan will probably be normal (a powerful result ending the PE W/U).scan will probably be normal (a powerful result ending the PE W/U).

Usual imaging test to follow CXR in PE W/U Usual imaging test to follow CXR in PE W/U is contrast-enhanced chest CT, the new gold-is contrast-enhanced chest CT, the new gold-standard, replacing old catheter angiogramstandard, replacing old catheter angiogramMulti-detector spiral CT on modern scanners Multi-detector spiral CT on modern scanners results in multi-planar images that are usually results in multi-planar images that are usually diagnostic even in patients who can’t diagnostic even in patients who can’t suspend respirationsuspend respirationIf PE is not shown on good quality CT, If PE is not shown on good quality CT, diagnosis has essentially been ruled out, and diagnosis has essentially been ruled out, and patient has no increased risk of death from patient has no increased risk of death from subsequent PE if not anticoagulatedsubsequent PE if not anticoagulated

BREAST IMAGINGBREAST IMAGING

Screening asymptomatic women for early breast CA is Screening asymptomatic women for early breast CA is meant to decrease deaths from the diseasemeant to decrease deaths from the diseaseTopic continues to be very controversialTopic continues to be very controversialAm Cancer Society recommends screening with Am Cancer Society recommends screening with physical exam by trained health pro and physical exam by trained health pro and mammography (annually starting age 40 in average mammography (annually starting age 40 in average risk patient)risk patient)Others recommend starting mammo later and only Others recommend starting mammo later and only every 2 yearsevery 2 yearsMammo screening probably prevents only about 30% Mammo screening probably prevents only about 30% of potential deaths related to breast CA (for most of potential deaths related to breast CA (for most breast CAs, death or survival will occur regardless of breast CAs, death or survival will occur regardless of whether mammo is done or not)whether mammo is done or not)

Screening mammo consists of 2 images, one Screening mammo consists of 2 images, one from above (craniocaudal, to cover medial from above (craniocaudal, to cover medial breast) and one in oblique projection (medio-breast) and one in oblique projection (medio-lateral oblique, to cover axillary tail of breast)lateral oblique, to cover axillary tail of breast)

Views done with compression, sometimes Views done with compression, sometimes uncomfortable for patient, but important to uncomfortable for patient, but important to decrease motion blurring, decrease decrease motion blurring, decrease necessary radiation dose, and separate necessary radiation dose, and separate possible CA from overlying glandular tissuepossible CA from overlying glandular tissue

Following image is normal CC projectionFollowing image is normal CC projection

This breast is composed mostly of fat This breast is composed mostly of fat (hence the visibility of blood vessels in this (hence the visibility of blood vessels in this case)case)

Following image is normal MLO projection Following image is normal MLO projection on different patienton different patient

Note that this patient has a dense breast Note that this patient has a dense breast composed mainly of fibroglandular tissue composed mainly of fibroglandular tissue and relatively little fatand relatively little fat

One of the main findings of breast CA on One of the main findings of breast CA on mammo is a dominant mass that stands out mammo is a dominant mass that stands out from the background pattern of normal from the background pattern of normal glandular densitiesglandular densitiesFollowing image shows an obvious CA Following image shows an obvious CA presenting as a mass, easily seen in this presenting as a mass, easily seen in this breast which is mostly fatbreast which is mostly fatThis same mass might be invisible if present This same mass might be invisible if present in a breast composed mostly of dense in a breast composed mostly of dense fibroglandular tissuefibroglandular tissue

The problem of dense tissue obscuring CA on The problem of dense tissue obscuring CA on mammography is why the overall sensitivity of mammo mammography is why the overall sensitivity of mammo for breast CA detection is no better than 75-80%for breast CA detection is no better than 75-80%Therefore, physical exam is still important as a Therefore, physical exam is still important as a complement to mammography when screening for complement to mammography when screening for breast CAbreast CAA suspicious finding on physical exam should not be A suspicious finding on physical exam should not be discounted in the face of a normal mammogram discounted in the face of a normal mammogram reading, particularly if breast has a lot of normal dense reading, particularly if breast has a lot of normal dense fibroglandular tissue (it may still be a cancer!)fibroglandular tissue (it may still be a cancer!)In Connecticut and many other states, breast density In Connecticut and many other states, breast density must be reported on the mammo dictationmust be reported on the mammo dictation

Mammographic Breast Density Mammographic Breast Density ClassesClasses

1.1. Almost Entirely Fat (0-25% dense) – Almost Entirely Fat (0-25% dense) – 10% of cases10% of cases

2. Scattered Fibroglandular Densities (25-2. Scattered Fibroglandular Densities (25-50% dense) – 40% of cases50% dense) – 40% of cases

3. Heterogeneously Dense (50-75% dense) 3. Heterogeneously Dense (50-75% dense) – 40% of cases– 40% of cases

4. Extremely Dense (75-100% dense) – 4. Extremely Dense (75-100% dense) – 10% of cases10% of cases

Following are 4 normal CC mammo images Following are 4 normal CC mammo images from patients representing the 4 classes of from patients representing the 4 classes of breast densitybreast densityBreast density tends to decrease with age, Breast density tends to decrease with age, mostly a reflection of weight gain and more mostly a reflection of weight gain and more fat depositionfat depositionHowever, young obese patients may have However, young obese patients may have fatty breasts and thin elderly patients may fatty breasts and thin elderly patients may have dense breasts (the fourth image below have dense breasts (the fourth image below is from an 80-yr-old patient)is from an 80-yr-old patient)

Sensitivity of mammography for breast CA Sensitivity of mammography for breast CA detection is very good (97-98%) in the detection is very good (97-98%) in the “Almost Entirely Fat” breast“Almost Entirely Fat” breast

However, in the “Extremely Dense” breast However, in the “Extremely Dense” breast the sensitivity is only 30-60% (it’s a polar the sensitivity is only 30-60% (it’s a polar bear in a snowstorm)bear in a snowstorm)

In addition to a dominant mass, the other main In addition to a dominant mass, the other main mammographic sign of breast CA is clustered mammographic sign of breast CA is clustered microcalcifications (this is dystrophic calcification microcalcifications (this is dystrophic calcification in debris resulting from cellular necrosis, which is in debris resulting from cellular necrosis, which is often associated with cancers that outgrow their often associated with cancers that outgrow their blood supply)blood supply)Although benign calcifications of many causes are Although benign calcifications of many causes are common on mammo, clustered microcalcifications common on mammo, clustered microcalcifications are suspicious for CA, particularly if they are are suspicious for CA, particularly if they are irregular, poorly defined, linear/branching, and irregular, poorly defined, linear/branching, and new on comparison with prior imagingnew on comparison with prior imaging

Following mammo image shows malignant Following mammo image shows malignant clusterd microcalcifications in upper part of clusterd microcalcifications in upper part of imageimage

Note that there are also benign Note that there are also benign calcifications, including arterial calcifications, including arterial atherosclerotic calcifications in lower part atherosclerotic calcifications in lower part of imageof image

Because mammo findings fall on a continuous spectrum of Because mammo findings fall on a continuous spectrum of suspicion (from normal to obvious CA), essentially all mammo suspicion (from normal to obvious CA), essentially all mammo reports will have a final Category reading given at the end of the reports will have a final Category reading given at the end of the dictationdictationThe Category reading is required by the FDA (all mammo facilities The Category reading is required by the FDA (all mammo facilities in USA must be accredited by FDA)in USA must be accredited by FDA)The Category indicates the level of suspicion, and the The Category indicates the level of suspicion, and the recommended F/Urecommended F/U– Category 0 means the W/U is not finished (may need diagnostic Category 0 means the W/U is not finished (may need diagnostic

mammo with additional mammo views, or US, before final Category mammo with additional mammo views, or US, before final Category reading is given)reading is given)

– Category 1 and 2 indicate return to routine annual screeningCategory 1 and 2 indicate return to routine annual screening– Category 3 is a low suspicion lesion that usually is re-imaged in 6 Category 3 is a low suspicion lesion that usually is re-imaged in 6

months instead of 12months instead of 12– Category 4 and 5 are suspicious enough that needle biopsy is indicatedCategory 4 and 5 are suspicious enough that needle biopsy is indicated

Mammo Reading CategoriesMammo Reading Categories

Required by FDARequired by FDA

CategoryCategory– 00 Incomplete: Need Additional Imaging Incomplete: Need Additional Imaging

EvaluationEvaluation– 11 NegativeNegative– 22 Benign FindingBenign Finding– 33 Probably Benign, Short Interval Follow-Probably Benign, Short Interval Follow-

Up IndicatedUp Indicated– 44 Suspicious for Malignancy (do biopsy)Suspicious for Malignancy (do biopsy)– 55 Highly Suggestive of MalignancyHighly Suggestive of Malignancy (do (do

biopsy)biopsy)

Biggest problem with mammo as Biggest problem with mammo as screening test is its poor sensitivity 75-screening test is its poor sensitivity 75-80%)80%)

However, its positive predictive value is However, its positive predictive value is also pooralso poor

Only about 25% of patients recommended Only about 25% of patients recommended to have needle biopsy turn out to have CAto have needle biopsy turn out to have CA

Following diagnostic mammo image done Following diagnostic mammo image done for patient with palpable mass (marked for patient with palpable mass (marked with BB)with BB)

The mass is hard to see because of The mass is hard to see because of superimposed fibroglandular tissuesuperimposed fibroglandular tissue

This is situation where US has traditionally This is situation where US has traditionally been used (to characterize mass, felt on been used (to characterize mass, felt on exam or seen on mammo, as cyst or solid)exam or seen on mammo, as cyst or solid)

Following image shows that mass on Following image shows that mass on preceding mammo is typical cyst (no preceding mammo is typical cyst (no internal echoes, sharp back wall, good internal echoes, sharp back wall, good sound transmission, orientation parallel to sound transmission, orientation parallel to skin)skin)

Cyst is much more common cause of Cyst is much more common cause of breast mass than CAbreast mass than CA

Because US can detect CAs not visible on mammo (hidden Because US can detect CAs not visible on mammo (hidden by normal dense tissue), US may be used as supplement to by normal dense tissue), US may be used as supplement to mammo to screen for breast CAmammo to screen for breast CAUS can see CAs within dense glandular tissue, mammo’s US can see CAs within dense glandular tissue, mammo’s weak pointweak pointThis practice is not universally accepted because although This practice is not universally accepted because although additional CAs are found on US, it has not been proven that additional CAs are found on US, it has not been proven that this decreases death from breast CAthis decreases death from breast CAHowever, use of US to screen for CA in patients with However, use of US to screen for CA in patients with mammographically dense breasts is increasing and is in mammographically dense breasts is increasing and is in common use in Connecticut common use in Connecticut Although by itself US sensitivity for breast CA detection is Although by itself US sensitivity for breast CA detection is about the same as mammo, because they pick up different about the same as mammo, because they pick up different cancers, mammo and US are complementary and together cancers, mammo and US are complementary and together have a higher sensitivity than either one alonehave a higher sensitivity than either one alone

Following image shows a typical CA within Following image shows a typical CA within glandular tissueglandular tissue

Note that this solid lesion does not look Note that this solid lesion does not look like a cyst (internal echoes, irregular wall, like a cyst (internal echoes, irregular wall, decreased sound transmission, orientation decreased sound transmission, orientation perpendicular to skin) perpendicular to skin)

Compared to mammo and US, MRI has a very high Compared to mammo and US, MRI has a very high sensitivity for detection of invasive breast CAsensitivity for detection of invasive breast CADetection relies on contrast (gadolinium) enhancement Detection relies on contrast (gadolinium) enhancement of breast CA (typically have increased vascularity), so of breast CA (typically have increased vascularity), so normal dense tissue is not an issuenormal dense tissue is not an issueBecause of cost and limited availability MRI not Because of cost and limited availability MRI not suitable as screening tool for general population, but suitable as screening tool for general population, but useful to screen patients at very high risk (based on useful to screen patients at very high risk (based on family history) and for surgical planning in patients with family history) and for surgical planning in patients with recently diagnosed CArecently diagnosed CAFollowing 2 images show enhancing CA in patient with Following 2 images show enhancing CA in patient with implants and a lot of dense tissue (note enlarged implants and a lot of dense tissue (note enlarged axillary lymph nodes due to mets)axillary lymph nodes due to mets)