Axillary Ultrasound Order
Adimar Poynter
Screening mammography should be performed annually starting at age 40 for all women. Patients do not need an order or referral from their doctor to schedule a screening mammogram. Patients can select date, time, and location for screening mammograms online through MyChart and results are released automatically to MyChart.
Digital breast tomosynthesis (DBT) is a quasi-3D mammogram which allows radiologists to see more details of the breast tissue. With DBT, breast radiologists can find more breast cancers and call back fewer patients for additional imaging. DBT is beneficial to all women but is most beneficial in women with dense breast tissue. Both screening mammography and diagnostic mammography can be performed with DBT.
Screening breast ultrasound can be used as a supplemental screening modality with mammography. This slightly increases cancer detection, but also a high false positive rate. Screening ultrasound is recommended for high risk women who are unable to have breast MRI.
High risk patients include women with a BRCA gene mutation and their untested first degree relatives, women with chest irradiation between 10 to 30 years of age, and women with >20% lifetime risk of breast cancer.
When a suspicious finding is seen on breast imaging, a biopsy should be performed. The biopsy is performed using the modality that best visualizes the finding (mammogram, ultrasound, or MRI). All biopsies are performed using a local anesthetic. Breast biopsies are very safe. Prior to a breast biopsy, the radiologist will explain the procedure in detail to the patient and answer any questions.
Most breast cysts can be safely assessed as benign and do not require an aspiration. However, if a patient has a symptomatic breast cyst or a suspected breast abscess, an ultrasound guided aspiration can be performed. This can be both therapeutic and diagnostic.
A: Most palpable breast lumps are benign. However, a new palpable mass can be a presenting symptom of breast cancer. All new palpable breast lumps should be further evaluated with diagnostic mammogram and ultrasound.
A: No. Mammography is the only screening modality proven to decrease breast cancer mortality. We recommend annual screening mammography for all women starting at the age of 40. Screening ultrasound can be used as a supplement screening modality in some subsets of patients.
This work is intended for use to assist hospital and healthcare audiences; however, Johns Hopkins makes no representations or warranties concerning the content or clinical efficacy of this work, its accuracy or completeness. Johns Hopkins is not responsible for any errors or omissions or for any bias, liability or damage resulting from the use of this work. This work is not intended to be a substitute for professional judgment, advice or individual root cause analysis.
With the exception of a few procedures below, providers cannot place modality-specific procedure requests. The referral/consult requests will be reviewed by the radiologist and changed to the appropriate modality-, site-specific procedure.
This exam has two parts: a pelvic US followed by transvaginal US with distension of the uterine cavity (aka saline-infused sonohysterogram). A catheter is inserted through the cervical os to the uterine cavity, and the uterine cavity is distended with sterile saline. Distention of the uterine cavity allows better assessment of the endometrium and potential abnormalities such as polyps or submucosal fibroids. A common indication for this test is abnormal uterine bleeding.
Fluoroscopic HSG is an examination of the uterus and fallopian tubes using a special form of x-ray called fluoroscopy and iodinated contrast material. The main purpose of the exam is to evaluate the shape or inner cavity of the uterus and for tubal obstruction and/or hydrosalpinx. A catheter is inserted into the uterine cavity (see US HSG above) and contrast is injected into the uterine cavity and fallopian tubes.
In recent years, ultrasound with an intra-cavitary ultrasound contrast agent has been added as an alternative to fluoroscopic HSG. Hysterosalpingo-Contrast Sonography (HyCoSy) involves instilling ultrasound contrast through a transcervical catheter to assess the uterine cavity for filling defects and for tubal patency. Like US hysterosonogram and fluoroscopic HSG, the exam is minimally invasive with rare complications. Advantages include the lack of ionizing radiation and more comprehensive evaluation with ultrasound evaluation of the uterus, endometrial cavity, ovaries, fallopian tubes, and pelvis in one setting.
The correct exam to order for evaluation of a palpable abnormality, such as localized swelling or mass, is US Soft Tissue (Radiology Performed) (Mass or Lump Evaluation) - Procedure Code: IMG6330. This includes ultrasound of the extremities (arm and leg).
Microbubble contrast agents can be injected to evaluate vessel or tube patency and characterize lesion enhancement. Ultrasound contrast agents (Lumason) are not nephrotoxic, as they contain gas, which is breathed out. Example indications include: assessment of renal or liver lesions, checking for perutaneous nephrostomy/ureteral patency, fallopian tube patency (HyCoSy), etc. They can be ordered as: US Abdomen Limited with Contrast IMG5488 or US Abdomen Complete with Contrast IMG5485. US Hysterosonogram with CONTRAST ENHANCED IMG6311 should be used for fallopian tube checks. Please call a radiologist to discuss the exam indication if you are uncertain if contrast is needed.
US Hysterosonogram with CONTRAST ENHANCED IMG6311 ("HyCoSy") evaluates for fallopian tube patency under ultrasound. This procedure involves cannulating the cervix with an HSG catheter and instilling saline and ultrasound contrast agent. It can evaluate the endometrial lining and the fallopian tubes. This procedure will be performed by specially trained sonographers and radiologists.
The correct exam to order to evaluate for breast abscess is US Chest/Mediastinum IMG521. This exam is intended for urgent or acute cases of suspected infection. This exam will be performed by the ultrasound section, rather than the breast imaging center. If you have any concern for a breast mass, please refer the patient to our breast imaging department.
Both Interventional Radiology and Ultrasound services can perform percutaneous drainage of an abscess, but only IR will place a drainage catheter for ongoing drainage. For ultrasound, this order is US Guided Abscess Drain IMG508 - this includes percutaneous aspiration of the abscess under ultrasound guidance. For placement of drainage catheters, please consult Interventional Radiology.
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A treating provider's (physician or qualified non-physician practitioner) referral is required for a diagnostic mammography (except when performed at the discretion of the radiologist when prompted to do so by findings on the same day of the screening mammography). The referral should specify the diagnosis prompting the request for a diagnostic mammogram. When a screening mammogram is converted to a diagnostic mammogram, a note in the radiologist's report will fulfill this provision. This requirement is not applicable to hospital based radiologists for inpatient or outpatient diagnostic mammography.
Diagnostic mammography must be performed under the direct supervision of an interpreting physician qualified in mammography. The physician must be present and immediately available to furnish assistance and direction throughout the performance of the procedure. In the case of digital mammography, direct supervision may also be accomplished via telemammography. The radiologist need not be present as long as the interpreting physician is immediately available.
Diagnostic mammography may require that the performing radiologist review the history with the patient, review the prior mammograms, and perform an examination as part of the mammography. Also, the findings of the examination are typically discussed with the patient at the completion of the mammogram. Therefore, if telemammography is being used with digital diagnostic mammography, the radiologist need not be present for the mammography, however, he/she must be available to discuss the history with the patient, examine the patient and to discuss results of the findings of the examination with the patient within an acceptable period of time.
A diagnostic mammography is covered when provided by a hospital, physician (in office or clinic), independent diagnostic testing facility (IDTF) or portable x-ray supplier.
Breast Sonography
Breast sonography may be indicated for conditions such as:
Breast ultrasonography may be performed, in some cases, without having a diagnostic mammography first. However, an order from the treating physician for the ultrasonography is required. For example: a 22-year-old female presents with a painful breast lump. An ultrasound is performed and documents a large simple cyst, which subsequently is aspirated and resolved without the need for a prior diagnostic mammography.
A treating provider's (physician or qualified non-physician practitioner) order is required for breast ultrasound. This requirement is not applicable to hospital based radiologists for inpatient or outpatient breast ultrasound.
Breast sonography should be performed under the general supervision of a physician qualified in breast ultrasonography.
Breast MRI
Breast MRI studies are to be used very selectively. The modality should be restricted to: