MEDFDN / Modifying Imaging Procedure Orders …



TITLE: Breast Imaging Standard Operating ProcedureAPPROVED BY: Diagnostic Imaging Oversight CommitteeCHAPTER: Sutter Epic WeblinksSECTION: Specialty/Clinical Topic>RadiologyISSUED: 7/1/2011 Updated: 01/06/2012REVIEWED:DIOC ChairREPLACES:N/APAGE 1/4Purpose - These operating procedures allow Sutter Health imaging departments and breast centers to efficiently generate and fulfill compliant orders for indicated breast imaging and diagnostic studies as needed based upon radiologist recommendations. Sutter Health imaging departments and breast centers will recommend additional breast imaging and diagnostic studies, including mammography, breast ultrasound, Breast MRI and image guided breast aspiration and/or biopsy, based upon the clinical history, physical findings and/or Breast Imaging Reporting and Data System (BI-RADS) classification as developed by the American College of Radiology. What is the Breast Imaging Reporting and Database System (BI-RADS)?The American College of Radiology (ACR) has established a uniform system for radiologists to describe and manage mammogram findings. The system includes seven standardized Categories, or Assessments. Each BI-RADS Category has an associated recommended Follow-up plan to assist radiologists and other physicians in appropriately managing a patient’s care.Breast Imaging Reporting and Database System (BI-RADS)CategoryAssessmentFollow-up0Need additional imaging evaluationAdditional imaging needed before a category can be assigned1NegativeContinue routine screening mammograms (for women over age 40)2Benign (noncancerous) findingjContinue routine screening mammograms (for women over age 40)3Probably benignReceive a 6-month follow-up mammogram or ultrasound, then every 6-12 months for 1-2 years.4Suspicious abnormalityRequires biopsy5Highly suggestive of malignancy (cancer)Requires biopsy6Known biopsy-proven malignancy (cancer)Assure that treatment for known cancer is completed.Additional information about BI-RADS is available on the ACR Web site at or by calling the ACR at 1–800–ACR–LINE (1–800–227–5463).There are certain clinical situations that BI-RADS do not address, where it is clinically appropriate for the radiologist to modify the referring physician's order based on prior history or patient current conditions, the radiologist may change the patient's referral order to the appropriate study under the general SOP permission given by the referring physician. Examples include:Patients that present with orders for screening mammograms who report a palpable abnormality or history of prior abnormal breast imaging studyPatients who present with a diagnostic mammogram order with no signs or symptoms or history of breast cancer that should undergo screening mammographyPatient with a palpable abnormality whose diagnostic mammogram order does not include breast ultrasound and for which ultrasound is indicatedPALPABLE BREAST LUMPS and FOCAL BREAST PAIN WORKFLOWPatient < 30Patient > 30Diagnostic US first. Add diagnostic mammogram based on radiologist recommendationsDiagnostic mammogram and likely USBI-RADS 0Assessment incompleteSpecific imaging findingsNeed to complete additional imaging or obtain and review prior studiesBI-RADS 4 & 5SuspiciousBI-RADS 3Probably benignBI-RADS 1 & 2Negative / benignImage guided core needle biopsyFollow-up by PCP, continued routine screeningFollow up as specified by radiologistIf not available refer to surgeon for excisional biopsyBiopsy results reviewed by radiologist & communicated to PCPBenignAtypiaDiscordantMalignantRefer to surgeonRe-biopsyRefer to surgeon6 month possible follow-up mammo or U/SSCREENING MAMOGRAM – WORKFLOWBI-RADSCategory 4 & 5BI-RADSCategory 1 & 2BI-RADSCategory 0 & 3If not available or amenable, refer to surgeon for excisional biopsyBiopsy results reviewed by radiologist and communicated to PCPMalignantAtypiaBenignFollow up by PCP continue routine screeningImage guided core needle biopsyFollow radiology advice for follow up imagingRefer to surgeonRefer to surgeon6 month follow-up mammo/ultrasound possible ................
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