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acrac_69372_12 | Staging of Renal Cell Carcinoma | However, given the paucity of litereature for utility of fluoride PET/CT in the initial staging of RCC, current guidelines from the EAU and NCCN do not support routine fluoride PET/CT to search for metastases in asymptomatic patients in the initial staging of RCC [5,13]. MRI Abdomen and Pelvis MRI of the abdomen without and with IV contrast is considered a reliable method for the staging of RCC. Various MR sequences, including T2-weighted, chemical shift T1-weighted, contrast-enhanced T1-weighted, and diffusion- weighted images, are typically obtained for the staging of RCC. In a study involving 40 patients with RCC, MRI was reported to have an accuracy of 81% to 86% for T staging [62]. Breath-hold MRI showing a lack of perinephric fat involvement is reported to have a high negative predictive value for no perinephric tumor invasion [63]. In a study of 73 RCCs, Roy et al [64] showed that the presence of a pseudocapsule on MRI had an accuracy of 93% for clear-cell carcinomas in separating T1/T2 tumors from T3a tumors. Lal et al [65] performed a prospective observational study in 50 patients with RCC, comparing MRI with histopathological findings. In this study, MRI was reported to have a 90% agreement with histopathology for detecting perirenal extension and a 97% agreement with histopathology for detecting tumor extension beyond Gerota fascia [65]. Both contrast-enhanced multidetector CT and MRI are helpful in detecting venous involvement, particularly in the main renal vein and the IVC [33,66]. Increased diameter of the IVC and renal vein, presence of tumor signal both inside and outside the vessel wall, altered signal intensity in the vessel wall, presence of flow around the tumor thrombus, and mobility in different phases are some of the MRI features that are helpful in detecting venous involvement [67,68]. | Staging of Renal Cell Carcinoma. However, given the paucity of litereature for utility of fluoride PET/CT in the initial staging of RCC, current guidelines from the EAU and NCCN do not support routine fluoride PET/CT to search for metastases in asymptomatic patients in the initial staging of RCC [5,13]. MRI Abdomen and Pelvis MRI of the abdomen without and with IV contrast is considered a reliable method for the staging of RCC. Various MR sequences, including T2-weighted, chemical shift T1-weighted, contrast-enhanced T1-weighted, and diffusion- weighted images, are typically obtained for the staging of RCC. In a study involving 40 patients with RCC, MRI was reported to have an accuracy of 81% to 86% for T staging [62]. Breath-hold MRI showing a lack of perinephric fat involvement is reported to have a high negative predictive value for no perinephric tumor invasion [63]. In a study of 73 RCCs, Roy et al [64] showed that the presence of a pseudocapsule on MRI had an accuracy of 93% for clear-cell carcinomas in separating T1/T2 tumors from T3a tumors. Lal et al [65] performed a prospective observational study in 50 patients with RCC, comparing MRI with histopathological findings. In this study, MRI was reported to have a 90% agreement with histopathology for detecting perirenal extension and a 97% agreement with histopathology for detecting tumor extension beyond Gerota fascia [65]. Both contrast-enhanced multidetector CT and MRI are helpful in detecting venous involvement, particularly in the main renal vein and the IVC [33,66]. Increased diameter of the IVC and renal vein, presence of tumor signal both inside and outside the vessel wall, altered signal intensity in the vessel wall, presence of flow around the tumor thrombus, and mobility in different phases are some of the MRI features that are helpful in detecting venous involvement [67,68]. | 69372 |
acrac_69372_13 | Staging of Renal Cell Carcinoma | Bland thrombus featuring a uniform signal intensity and lack of enhancement after gadolinium can be distinguished from tumor thrombus, which exhibits intermediate or high signal intensity, heterogeneous intensity, and, more reliably, the presence of small vessels. In a recent study involving 81 patients with RCC, MRI was reported to have a 92% sensitivity, an 86% specificity, an 89% positive predictive value, and a 91% negative predictive value for identifying IVC wall invasion [69]. Pitfalls of MRI include the potential for large tumors to compress the vena cava and cause flow-related artifacts. Such artifacts can be reduced with appropriate saturation pulses. Although MRI of the abdomen with IV contrast is considered in all major guidelines as an adequate method for the staging of RCC, imaging the pelvis for RCC staging is considered optional in the guidelines [5,13]. There is no relevant literature with high-quality evidence regarding the use of MRI of the pelvis in the staging of RCC. Although it is likely that MRI pelvis may not offer additional information in most patients with early stage RCC, pelvic imaging can be helpful in patients with more advanced RCC, in whom metastatic spread is suspected [47,48]. MRI Abdomen MRI of the abdomen without and with IV contrast is considered to be a reliable method for the staging of RCC. Various MR sequences, including T2-weighted, chemical shift T1-weighted, contrast-enhanced T1-weighted, and diffusion-weighted images, are typically obtained for the staging of RCC. In a study involving 40 patients with Staging of Renal Cell Carcinoma RCC, MRI was reported to have an accuracy of 81% to 86% for T staging [62]. Breath-hold MRI showing a lack of perinephric fat involvement is reported to have a high negative predictive value for no perinephric tumor invasion [63]. | Staging of Renal Cell Carcinoma. Bland thrombus featuring a uniform signal intensity and lack of enhancement after gadolinium can be distinguished from tumor thrombus, which exhibits intermediate or high signal intensity, heterogeneous intensity, and, more reliably, the presence of small vessels. In a recent study involving 81 patients with RCC, MRI was reported to have a 92% sensitivity, an 86% specificity, an 89% positive predictive value, and a 91% negative predictive value for identifying IVC wall invasion [69]. Pitfalls of MRI include the potential for large tumors to compress the vena cava and cause flow-related artifacts. Such artifacts can be reduced with appropriate saturation pulses. Although MRI of the abdomen with IV contrast is considered in all major guidelines as an adequate method for the staging of RCC, imaging the pelvis for RCC staging is considered optional in the guidelines [5,13]. There is no relevant literature with high-quality evidence regarding the use of MRI of the pelvis in the staging of RCC. Although it is likely that MRI pelvis may not offer additional information in most patients with early stage RCC, pelvic imaging can be helpful in patients with more advanced RCC, in whom metastatic spread is suspected [47,48]. MRI Abdomen MRI of the abdomen without and with IV contrast is considered to be a reliable method for the staging of RCC. Various MR sequences, including T2-weighted, chemical shift T1-weighted, contrast-enhanced T1-weighted, and diffusion-weighted images, are typically obtained for the staging of RCC. In a study involving 40 patients with Staging of Renal Cell Carcinoma RCC, MRI was reported to have an accuracy of 81% to 86% for T staging [62]. Breath-hold MRI showing a lack of perinephric fat involvement is reported to have a high negative predictive value for no perinephric tumor invasion [63]. | 69372 |
acrac_69372_14 | Staging of Renal Cell Carcinoma | In a study of 73 RCCs, Roy et al [64] showed that the presence of a pseudocapsule on MRI had an accuracy of 93% for clear-cell carcinomas in separating T1/T2 tumors from T3a tumors. Lal et al [65] performed a prospective observational study in 50 patients with RCC, comparing MRI with histopathological findings. In this study, MRI was reported to have a 90% agreement with histopathology for detecting perirenal extension and a 97% agreement with histopathology for detecting tumor extension beyond Gerota fascia [65]. Both contrast-enhanced multidetector CT and MRI are helpful in detecting venous involvement, particularly in the main renal vein and the IVC [33,66]. Increased diameter of the IVC and renal vein, presence of tumor signal both inside and outside the vessel wall, altered signal intensity in the vessel wall, presence of flow around the tumor thrombus, and mobility in different phases are some of the MRI features that are helpful in detecting venous involvement [67,68]. Bland thrombus featuring a uniform signal intensity and lack of enhancement after gadolinium can be distinguished from tumor thrombus, which exhibits intermediate or high signal intensity, heterogeneous intensity, and, more reliably, the presence of small vessels. In a recent study involving 81 patients with RCC, MRI was reported to have a 92% sensitivity, an 86% specificity, an 89% positive predictive value, and a 91% negative predictive value for identifying IVC wall invasion [69]. Pitfalls of MRI include the potential for large tumors to compress the vena cava and cause flow-related artifacts. Such artifacts can be reduced with appropriate saturation pulses. MRI Head Most patients with metastases to the central nervous system are symptomatic. Thus, current guidelines do not support routine imaging of the brain to search for metastases in asymptomatic patients in the initial staging of RCC. Brain imaging with contrast should be performed only in cases with suggestive signs or symptoms [5,13]. | Staging of Renal Cell Carcinoma. In a study of 73 RCCs, Roy et al [64] showed that the presence of a pseudocapsule on MRI had an accuracy of 93% for clear-cell carcinomas in separating T1/T2 tumors from T3a tumors. Lal et al [65] performed a prospective observational study in 50 patients with RCC, comparing MRI with histopathological findings. In this study, MRI was reported to have a 90% agreement with histopathology for detecting perirenal extension and a 97% agreement with histopathology for detecting tumor extension beyond Gerota fascia [65]. Both contrast-enhanced multidetector CT and MRI are helpful in detecting venous involvement, particularly in the main renal vein and the IVC [33,66]. Increased diameter of the IVC and renal vein, presence of tumor signal both inside and outside the vessel wall, altered signal intensity in the vessel wall, presence of flow around the tumor thrombus, and mobility in different phases are some of the MRI features that are helpful in detecting venous involvement [67,68]. Bland thrombus featuring a uniform signal intensity and lack of enhancement after gadolinium can be distinguished from tumor thrombus, which exhibits intermediate or high signal intensity, heterogeneous intensity, and, more reliably, the presence of small vessels. In a recent study involving 81 patients with RCC, MRI was reported to have a 92% sensitivity, an 86% specificity, an 89% positive predictive value, and a 91% negative predictive value for identifying IVC wall invasion [69]. Pitfalls of MRI include the potential for large tumors to compress the vena cava and cause flow-related artifacts. Such artifacts can be reduced with appropriate saturation pulses. MRI Head Most patients with metastases to the central nervous system are symptomatic. Thus, current guidelines do not support routine imaging of the brain to search for metastases in asymptomatic patients in the initial staging of RCC. Brain imaging with contrast should be performed only in cases with suggestive signs or symptoms [5,13]. | 69372 |
acrac_69372_15 | Staging of Renal Cell Carcinoma | Recent studies indicate that up to 4% of patients with advanced, metastatic RCC may harbor asymptomatic brain metastasis [56,57]. Hence, routine brain imaging with IV contrast may be considered in patients with advanced, metastatic RCC, even if they are asymptomatic [56,57]. MRU There is no relevant literature suggesting that MRU offers any additional benefit over conventional MRI of the abdomen in the initial staging of RCC, and thus, this method is not included in the guidelines from the EAU and NCCN [5,13]. Radiography Chest The lung is the most common site of metastases in patients with RCC presenting with synchronous metastases. Although the incidence of metastases in RCC <4 cm is low (approximately 1%-2%), it has been reported that 20% to 30% of T1a tumors may have potentially aggressive histologic features. Hence, chest radiography is usually performed in the staging of RCC [13]. However, CT is more sensitive than radiography for the detection of pulmonary metastases from RCC during staging. In addition to a high sensitivity for the detection of pulmonary metastases, chest CT has a high sensitivity for the detection of intrathoracic nodal metastases from RCC. Therefore, in patients with higher risk of pulmonary metastases (such as tumor >4 cm, cN1, presence of systemic symptoms), chest CT is preferred [54,55]. US Abdomen Ultrasound (US) can be useful in the characterization of renal masses because it can help in differentiating solid and cystic renal masses. However, it is seldom used in the staging of RCC because of its relatively poor performance in evaluating local tumor spread and metastatic disease [70,71]. US can be challenging to perform in patients with a high body mass index. Additional challenges in the use of US may be related to incomplete visualization of the mass, acoustic shadowing from partially calcified cysts or masses, variability in echogenicity of hemorrhagic cysts, and poor sensitivity in diagnosing isoechoic small renal tumors. | Staging of Renal Cell Carcinoma. Recent studies indicate that up to 4% of patients with advanced, metastatic RCC may harbor asymptomatic brain metastasis [56,57]. Hence, routine brain imaging with IV contrast may be considered in patients with advanced, metastatic RCC, even if they are asymptomatic [56,57]. MRU There is no relevant literature suggesting that MRU offers any additional benefit over conventional MRI of the abdomen in the initial staging of RCC, and thus, this method is not included in the guidelines from the EAU and NCCN [5,13]. Radiography Chest The lung is the most common site of metastases in patients with RCC presenting with synchronous metastases. Although the incidence of metastases in RCC <4 cm is low (approximately 1%-2%), it has been reported that 20% to 30% of T1a tumors may have potentially aggressive histologic features. Hence, chest radiography is usually performed in the staging of RCC [13]. However, CT is more sensitive than radiography for the detection of pulmonary metastases from RCC during staging. In addition to a high sensitivity for the detection of pulmonary metastases, chest CT has a high sensitivity for the detection of intrathoracic nodal metastases from RCC. Therefore, in patients with higher risk of pulmonary metastases (such as tumor >4 cm, cN1, presence of systemic symptoms), chest CT is preferred [54,55]. US Abdomen Ultrasound (US) can be useful in the characterization of renal masses because it can help in differentiating solid and cystic renal masses. However, it is seldom used in the staging of RCC because of its relatively poor performance in evaluating local tumor spread and metastatic disease [70,71]. US can be challenging to perform in patients with a high body mass index. Additional challenges in the use of US may be related to incomplete visualization of the mass, acoustic shadowing from partially calcified cysts or masses, variability in echogenicity of hemorrhagic cysts, and poor sensitivity in diagnosing isoechoic small renal tumors. | 69372 |
acrac_69372_16 | Staging of Renal Cell Carcinoma | There is no relevant literature suggesting that US offers any additional benefit over conventional CT or MRI of the abdomen in the initial staging of RCC, and thus, this method is not included in the guidelines from the EAU and NCCN [5,13]. However, intraoperative US may be helpful in performing partial nephrectomy, especially in patients with endophytic renal tumors [72,73]. Staging of Renal Cell Carcinoma Variant 2: Renal cell carcinoma. Contraindication to both iodinated CT and gadolinium-based MR intravenous contrast. Staging. Bone Scan Whole Body The prevalence of osseous metastases for localized RCC has been shown to be low in patients without symptoms (ie, bone pain) or without laboratory abnormalities suggestive of osseous metastases (ie, elevated serum alkaline phosphatase level) [11,12]. Furthermore, the sites commonly involved by osseous metastases, such as the thoracolumbar spine and ribs, are located in areas covered by chest and abdominal imaging. Thus, even though bone scanning can be helpful to confirm clinically or radiographically suspected metastatic disease, current guidelines do not support its routine use in the initial staging of asymptomatic RCC [5,13]. Bone Scan Whole Body with SPECT or SPECT/CT Area of Interest The prevalence of osseous metastases for localized RCC has been shown to be low in patients without symptoms (ie, bone pain) or without laboratory abnormalities suggestive of osseous metastases (ie, elevated serum alkaline phosphatase level) [11,12]. Furthermore, the sites commonly involved by osseous metastases, such as the thoracolumbar spine and ribs, are located in areas covered by chest and abdominal imaging. Thus, even though bone scanning can be helpful to confirm clinically or radiographically suspected metastatic disease, current guidelines do not support its routine use in the initial staging of asymptomatic RCC [5,13]. In patients with RCC with symptoms suspicious for bone metastases, bone scan may be useful. | Staging of Renal Cell Carcinoma. There is no relevant literature suggesting that US offers any additional benefit over conventional CT or MRI of the abdomen in the initial staging of RCC, and thus, this method is not included in the guidelines from the EAU and NCCN [5,13]. However, intraoperative US may be helpful in performing partial nephrectomy, especially in patients with endophytic renal tumors [72,73]. Staging of Renal Cell Carcinoma Variant 2: Renal cell carcinoma. Contraindication to both iodinated CT and gadolinium-based MR intravenous contrast. Staging. Bone Scan Whole Body The prevalence of osseous metastases for localized RCC has been shown to be low in patients without symptoms (ie, bone pain) or without laboratory abnormalities suggestive of osseous metastases (ie, elevated serum alkaline phosphatase level) [11,12]. Furthermore, the sites commonly involved by osseous metastases, such as the thoracolumbar spine and ribs, are located in areas covered by chest and abdominal imaging. Thus, even though bone scanning can be helpful to confirm clinically or radiographically suspected metastatic disease, current guidelines do not support its routine use in the initial staging of asymptomatic RCC [5,13]. Bone Scan Whole Body with SPECT or SPECT/CT Area of Interest The prevalence of osseous metastases for localized RCC has been shown to be low in patients without symptoms (ie, bone pain) or without laboratory abnormalities suggestive of osseous metastases (ie, elevated serum alkaline phosphatase level) [11,12]. Furthermore, the sites commonly involved by osseous metastases, such as the thoracolumbar spine and ribs, are located in areas covered by chest and abdominal imaging. Thus, even though bone scanning can be helpful to confirm clinically or radiographically suspected metastatic disease, current guidelines do not support its routine use in the initial staging of asymptomatic RCC [5,13]. In patients with RCC with symptoms suspicious for bone metastases, bone scan may be useful. | 69372 |
acrac_69372_17 | Staging of Renal Cell Carcinoma | If the bone scan shows areas of abnormal radiotracer uptake suspicious for osseous metastases, SPECT fused with CT can be used to provide detailed anatomic localization of the abnormal radiotracer uptake and further improve the characterization of the nature of the abnormality [14]. CT Abdomen Preoperative imaging of RCC provides critical information on staging and serves as a roadmap to the surgeon. Both CT and MRI are comparable in the staging of the primary tumor [15,16]. Advantages of CT include rapid acquisition time, which may translate to better patient compliance, and high spatial resolution. Hence it is often the most commonly used modality for this indication. CT abdomen without and with IV contrast is typically performed for charactering a renal mass as RCC and staging the tumor. However, in patients with contraindications to iodinated contrast, only unenhanced CT may be possible, limiting the assessment. MRI abdomen may be useful in this setting, given the superior soft tissue resolution of MRI compared to unenhanced CT. CT Abdomen and Pelvis Preoperative imaging of RCC provides critical information on staging and serves as a roadmap to the surgeon. Both CT and MRI are comparable in staging of the primary tumor [15,16]. Advantages of CT include rapid acquisition time, which may translate to better patient compliance, and high spatial resolution. Hence, it is often the most commonly used modality for this indication. CT abdomen without and with IV contrast is typically performed for charactering a renal mass as RCC and staging the tumor. However, in patients with contraindications to iodinated contrast, only unenhanced CT may be possible, limiting the assessment. MRI abdomen may be useful in this setting, given the superior soft tissue resolution of MRI compared to unenhanced CT. There is no relevant literature with high-quality evidence regarding the use of CT of the pelvis in the staging of RCC. | Staging of Renal Cell Carcinoma. If the bone scan shows areas of abnormal radiotracer uptake suspicious for osseous metastases, SPECT fused with CT can be used to provide detailed anatomic localization of the abnormal radiotracer uptake and further improve the characterization of the nature of the abnormality [14]. CT Abdomen Preoperative imaging of RCC provides critical information on staging and serves as a roadmap to the surgeon. Both CT and MRI are comparable in the staging of the primary tumor [15,16]. Advantages of CT include rapid acquisition time, which may translate to better patient compliance, and high spatial resolution. Hence it is often the most commonly used modality for this indication. CT abdomen without and with IV contrast is typically performed for charactering a renal mass as RCC and staging the tumor. However, in patients with contraindications to iodinated contrast, only unenhanced CT may be possible, limiting the assessment. MRI abdomen may be useful in this setting, given the superior soft tissue resolution of MRI compared to unenhanced CT. CT Abdomen and Pelvis Preoperative imaging of RCC provides critical information on staging and serves as a roadmap to the surgeon. Both CT and MRI are comparable in staging of the primary tumor [15,16]. Advantages of CT include rapid acquisition time, which may translate to better patient compliance, and high spatial resolution. Hence, it is often the most commonly used modality for this indication. CT abdomen without and with IV contrast is typically performed for charactering a renal mass as RCC and staging the tumor. However, in patients with contraindications to iodinated contrast, only unenhanced CT may be possible, limiting the assessment. MRI abdomen may be useful in this setting, given the superior soft tissue resolution of MRI compared to unenhanced CT. There is no relevant literature with high-quality evidence regarding the use of CT of the pelvis in the staging of RCC. | 69372 |
acrac_69372_18 | Staging of Renal Cell Carcinoma | Although it is likely that CT pelvis may not offer additional information in most patients with early stage RCC, pelvic imaging can be helpful in patients with more advanced RCC, in whom metastatic spread is suspected [47,48]. If pelvic imaging is indicated in patients with contraindications to iodinated contrast, pelvic MRI may be preferred to unenhanced CT pelvis. CT Chest Chest imaging is indicated in the staging of RCC, given that lungs are one of the most common sites of metastases in RCC [5,13]. There is a lack of literature that have directly compared the accuracy of chest CT with chest radiography for detecting pulmonary metastases in the initial staging of RCC. However, limited data have demonstrated that CT is more sensitive than radiography for the detection of pulmonary metastases from RCC [49]. Current literature supports use of IV contrast-enhanced CT chest for detecting pulmonary metastases, especially in patients with large renal tumors [5,13,34,63,64,74,75]. However, in patients with contraindications to iodinated contrast, unenhanced CT chest may be performed because that would be able to detect pulmonary nodules, despite the lack of IV contrast. Staging of Renal Cell Carcinoma CT Head Most patients with metastases to the central nervous system are symptomatic. Thus, current guidelines do not support routine imaging of the brain to search for metastases in asymptomatic patients in the initial staging of RCC. Brain imaging should be performed only in cases with suggestive signs or symptoms [5,13]. In patients with contraindication to IV contrast, MRI brain may be more helpful. CTU There is no relevant literature suggesting that CTU offers any additional benefit over conventional CT of the abdomen in the initial staging of RCC, and thus, this method is not included in the guidelines from the EAU and NCCN [5,13]. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT has a limited role in the diagnosis and the local staging of RCC [58]. | Staging of Renal Cell Carcinoma. Although it is likely that CT pelvis may not offer additional information in most patients with early stage RCC, pelvic imaging can be helpful in patients with more advanced RCC, in whom metastatic spread is suspected [47,48]. If pelvic imaging is indicated in patients with contraindications to iodinated contrast, pelvic MRI may be preferred to unenhanced CT pelvis. CT Chest Chest imaging is indicated in the staging of RCC, given that lungs are one of the most common sites of metastases in RCC [5,13]. There is a lack of literature that have directly compared the accuracy of chest CT with chest radiography for detecting pulmonary metastases in the initial staging of RCC. However, limited data have demonstrated that CT is more sensitive than radiography for the detection of pulmonary metastases from RCC [49]. Current literature supports use of IV contrast-enhanced CT chest for detecting pulmonary metastases, especially in patients with large renal tumors [5,13,34,63,64,74,75]. However, in patients with contraindications to iodinated contrast, unenhanced CT chest may be performed because that would be able to detect pulmonary nodules, despite the lack of IV contrast. Staging of Renal Cell Carcinoma CT Head Most patients with metastases to the central nervous system are symptomatic. Thus, current guidelines do not support routine imaging of the brain to search for metastases in asymptomatic patients in the initial staging of RCC. Brain imaging should be performed only in cases with suggestive signs or symptoms [5,13]. In patients with contraindication to IV contrast, MRI brain may be more helpful. CTU There is no relevant literature suggesting that CTU offers any additional benefit over conventional CT of the abdomen in the initial staging of RCC, and thus, this method is not included in the guidelines from the EAU and NCCN [5,13]. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT has a limited role in the diagnosis and the local staging of RCC [58]. | 69372 |
acrac_69372_19 | Staging of Renal Cell Carcinoma | Differentiating renal tumor from background normal renal tissue can be difficult because of renal excretion of FDG. Furthermore, RCC is reported to have variable FDG avidity, limiting its utility. Nakanishi et al [59] reported a 56% sensitivity, a 67% specificity, a 15% positive predictive value, a 57% negative predictive value, and a 65% accuracy for FDG-PET in the staging of RCC. A recent clinical trial from Turkey involving 62 patients with RCC reported an 84% accuracy for contrast-enhanced FDG-PET/CT in staging RCC [60]. However, further studies are warranted before PET/CT can be used in the routine initial staging of RCC. At present, given the paucity of literature to support the use of FDG-PET/CT, the guidelines from the EAU and NCCN do not recommend routine FDG-PET/CT in the initial staging of RCC [5,13]. Fluoride PET/CT Skull Base to Mid-Thigh Preliminary results for other PET tracers are also becoming available. In a small prospective study of 10 patients with metastatic RCC, 18F-NaF PET/CT was found to be significantly more sensitive for the detection of RCC skeletal metastases than Tc-99m bone scintigraphy or CT, with sensitivities of 100%, 29%, and 46%, respectively. CT and Tc-99m bone scintigraphy in this study identified only 65% of the metastases detected by fluoride PET/CT [61]. However, given the paucity of litereature for utility of fluoride PET/CT in the initial staging of RCC, current guidelines from the EAU and NCCN do not support routine fluoride PET/CT to search for metastases in asymptomatic patients in the initial staging of RCC [5,13]. MRI Abdomen and Pelvis MRI of the abdomen without and with IV contrast is considered to be a reliable method for the staging of RCC. Various MRI sequences, including T2-weighted, chemical shift T1-weighted, contrast-enhanced T1-weighted, and diffusion-weighted images, are typically obtained for the staging of RCC. | Staging of Renal Cell Carcinoma. Differentiating renal tumor from background normal renal tissue can be difficult because of renal excretion of FDG. Furthermore, RCC is reported to have variable FDG avidity, limiting its utility. Nakanishi et al [59] reported a 56% sensitivity, a 67% specificity, a 15% positive predictive value, a 57% negative predictive value, and a 65% accuracy for FDG-PET in the staging of RCC. A recent clinical trial from Turkey involving 62 patients with RCC reported an 84% accuracy for contrast-enhanced FDG-PET/CT in staging RCC [60]. However, further studies are warranted before PET/CT can be used in the routine initial staging of RCC. At present, given the paucity of literature to support the use of FDG-PET/CT, the guidelines from the EAU and NCCN do not recommend routine FDG-PET/CT in the initial staging of RCC [5,13]. Fluoride PET/CT Skull Base to Mid-Thigh Preliminary results for other PET tracers are also becoming available. In a small prospective study of 10 patients with metastatic RCC, 18F-NaF PET/CT was found to be significantly more sensitive for the detection of RCC skeletal metastases than Tc-99m bone scintigraphy or CT, with sensitivities of 100%, 29%, and 46%, respectively. CT and Tc-99m bone scintigraphy in this study identified only 65% of the metastases detected by fluoride PET/CT [61]. However, given the paucity of litereature for utility of fluoride PET/CT in the initial staging of RCC, current guidelines from the EAU and NCCN do not support routine fluoride PET/CT to search for metastases in asymptomatic patients in the initial staging of RCC [5,13]. MRI Abdomen and Pelvis MRI of the abdomen without and with IV contrast is considered to be a reliable method for the staging of RCC. Various MRI sequences, including T2-weighted, chemical shift T1-weighted, contrast-enhanced T1-weighted, and diffusion-weighted images, are typically obtained for the staging of RCC. | 69372 |
acrac_69372_20 | Staging of Renal Cell Carcinoma | Although MRI of the abdomen with IV contrast is considered in all major guidelines as an adequate method for the staging of RCC, imaging the pelvis for RCC staging is considered optional in the guidelines [5,13]. There is no relevant literature with high-quality evidence regarding the use of MRI of the pelvis in the staging of RCC. Although it is likely that MRI pelvis may not offer additional information in most patients with early stage RCC, pelvic imaging can be helpful in patients with more advanced RCC, in whom metastatic spread is suspected [47,48]. In patients with contraindications to both iodinated CT and gadolinium-based MRI IV contrast, unenhanced MRI may be preferred over noncontrast CT. This is due to the fact that unenhanced MRI has a superior soft tissue resolution compared to unenhanced CT, thereby increasing its diagnostic utility. MRI Abdomen MRI of the abdomen without and with IV contrast is considered to be a reliable method for the staging of RCC. Various MRI sequences, including T2-weighted, chemical shift T1-weighted, contrast-enhanced T1-weighted, and diffusion-weighted images, are typically obtained for the staging of RCC. In patients with contraindications to both iodinated CT and gadolinium-based MRI IV contrast, unenhanced MRI may be preferred over noncontrast CT. This is due to the fact that unenhanced MRI has a superior soft tissue resolution compared to unenhanced CT, thereby increasing its diagnostic utility. MRI Head Most patients with metastases to the central nervous system are symptomatic. Thus, current guidelines from the EAU and NCCN do not support routine imaging of the brain to search for metastases in asymptomatic patients in the initial staging of RCC. Brain imaging should be performed only in cases with suggestive signs or symptoms [5,13]. In symptomatic patients with contraindication to IV contrast, MRI brain without contrast may be helpful. Staging of Renal Cell Carcinoma | Staging of Renal Cell Carcinoma. Although MRI of the abdomen with IV contrast is considered in all major guidelines as an adequate method for the staging of RCC, imaging the pelvis for RCC staging is considered optional in the guidelines [5,13]. There is no relevant literature with high-quality evidence regarding the use of MRI of the pelvis in the staging of RCC. Although it is likely that MRI pelvis may not offer additional information in most patients with early stage RCC, pelvic imaging can be helpful in patients with more advanced RCC, in whom metastatic spread is suspected [47,48]. In patients with contraindications to both iodinated CT and gadolinium-based MRI IV contrast, unenhanced MRI may be preferred over noncontrast CT. This is due to the fact that unenhanced MRI has a superior soft tissue resolution compared to unenhanced CT, thereby increasing its diagnostic utility. MRI Abdomen MRI of the abdomen without and with IV contrast is considered to be a reliable method for the staging of RCC. Various MRI sequences, including T2-weighted, chemical shift T1-weighted, contrast-enhanced T1-weighted, and diffusion-weighted images, are typically obtained for the staging of RCC. In patients with contraindications to both iodinated CT and gadolinium-based MRI IV contrast, unenhanced MRI may be preferred over noncontrast CT. This is due to the fact that unenhanced MRI has a superior soft tissue resolution compared to unenhanced CT, thereby increasing its diagnostic utility. MRI Head Most patients with metastases to the central nervous system are symptomatic. Thus, current guidelines from the EAU and NCCN do not support routine imaging of the brain to search for metastases in asymptomatic patients in the initial staging of RCC. Brain imaging should be performed only in cases with suggestive signs or symptoms [5,13]. In symptomatic patients with contraindication to IV contrast, MRI brain without contrast may be helpful. Staging of Renal Cell Carcinoma | 69372 |
acrac_69372_21 | Staging of Renal Cell Carcinoma | MRU There is no relevant literature suggesting that MRU offers any additional benefit over conventional MRI of the abdomen in the initial staging of RCC, and thus, this method is not included in the guidelines from the EAU and NCCN [5,13]. Radiography Chest The lung is the most common site of metastases in patients with RCC presenting with synchronous metastases. Although the incidence of metastases in RCC <4 cm is low (approximately 1%-2%), it has been reported that 20% to 30% of T1a tumors may have potentially aggressive histologic features. Hence, chest radiography is usually performed in the staging of RCC [13]. However, CT is more sensitive than radiography for the detection of pulmonary metastases from RCC during staging. In addition to a high sensitivity for the detection of pulmonary metastases, chest CT has a high sensitivity for the detection of intrathoracic nodal metastases from RCC. Therefore, in patients with higher risk of pulmonary metastases (such as tumor >4 cm, cN1, presence of systemic symptoms), chest CT is preferred [54,55]. US Abdomen US can be useful in the characterization of renal masses as it can help in differentiating solid and cystic renal masses. However, it is seldom used in the staging of RCC because of its relatively poor performance in evaluating local tumor spread and metastatic disease [70,71]. Additional challenges in the use of US may be related to incomplete visualization of the mass, acoustic shadowing from partially calcified cysts or masses, variability in echogenicity of hemorrhagic cysts, and poor sensitivity in diagnosing isoechoic small renal tumors. There is no relevant literature suggesting that US offers any additional benefit over conventional CT or MRI of the abdomen in the initial staging of RCC, and thus, this method is not included in the guidelines [5,13]. However, intraoperative US may be helpful in performing partial nephrectomy, especially in patients with endophytic renal tumors [72,73]. Variant 3: Renal cell carcinoma. | Staging of Renal Cell Carcinoma. MRU There is no relevant literature suggesting that MRU offers any additional benefit over conventional MRI of the abdomen in the initial staging of RCC, and thus, this method is not included in the guidelines from the EAU and NCCN [5,13]. Radiography Chest The lung is the most common site of metastases in patients with RCC presenting with synchronous metastases. Although the incidence of metastases in RCC <4 cm is low (approximately 1%-2%), it has been reported that 20% to 30% of T1a tumors may have potentially aggressive histologic features. Hence, chest radiography is usually performed in the staging of RCC [13]. However, CT is more sensitive than radiography for the detection of pulmonary metastases from RCC during staging. In addition to a high sensitivity for the detection of pulmonary metastases, chest CT has a high sensitivity for the detection of intrathoracic nodal metastases from RCC. Therefore, in patients with higher risk of pulmonary metastases (such as tumor >4 cm, cN1, presence of systemic symptoms), chest CT is preferred [54,55]. US Abdomen US can be useful in the characterization of renal masses as it can help in differentiating solid and cystic renal masses. However, it is seldom used in the staging of RCC because of its relatively poor performance in evaluating local tumor spread and metastatic disease [70,71]. Additional challenges in the use of US may be related to incomplete visualization of the mass, acoustic shadowing from partially calcified cysts or masses, variability in echogenicity of hemorrhagic cysts, and poor sensitivity in diagnosing isoechoic small renal tumors. There is no relevant literature suggesting that US offers any additional benefit over conventional CT or MRI of the abdomen in the initial staging of RCC, and thus, this method is not included in the guidelines [5,13]. However, intraoperative US may be helpful in performing partial nephrectomy, especially in patients with endophytic renal tumors [72,73]. Variant 3: Renal cell carcinoma. | 69372 |
acrac_69372_22 | Staging of Renal Cell Carcinoma | Contraindication only to iodinated CT intravenous contrast. Staging. Bone Scan Whole Body The prevalence of osseous metastases for localized RCC has been shown to be low in patients without symptoms (ie, bone pain) or without laboratory abnormalities suggestive of osseous metastases (ie, elevated serum alkaline phosphatase level) [11,12]. Furthermore, the sites commonly involved by osseous metastases, such as the thoracolumbar spine and ribs, are located in areas covered by chest and abdominal imaging. Thus, even though bone scanning can be helpful to confirm clinically or radiographically suspected metastatic disease, current guidelines from the EAU and NCCN do not support its routine use in the initial staging of asymptomatic RCC [5,13]. Bone Scan Whole Body with SPECT or SPECT/CT Area of Interest The prevalence of osseous metastases for localized RCC has been shown to be low in patients without symptoms (ie, bone pain) or without laboratory abnormalities suggestive of osseous metastases (ie, elevated serum alkaline phosphatase level) [11,12]. Furthermore, the sites commonly involved by osseous metastases, such as the thoracolumbar spine and ribs, are located in areas covered by chest and abdominal imaging. Thus, even though bone scanning can be helpful to confirm clinically or radiographically suspected metastatic disease, current guidelines from the EAU and NCCN do not support its routine use in the initial staging of asymptomatic RCC [5,13]. In patients with RCC with symptoms suspicious for bone metastases, bone scan may be useful. If the bone scan shows areas of abnormal radiotracer uptake suspicious for osseous metastases, SPECT fused with CT can be used to provide detailed anatomic localization of the abnormal radiotracer uptake and further improve the characterization of the nature of the abnormality [14]. CT Abdomen Preoperative imaging of RCC provides critical information on staging and serves as a roadmap to the surgeon. | Staging of Renal Cell Carcinoma. Contraindication only to iodinated CT intravenous contrast. Staging. Bone Scan Whole Body The prevalence of osseous metastases for localized RCC has been shown to be low in patients without symptoms (ie, bone pain) or without laboratory abnormalities suggestive of osseous metastases (ie, elevated serum alkaline phosphatase level) [11,12]. Furthermore, the sites commonly involved by osseous metastases, such as the thoracolumbar spine and ribs, are located in areas covered by chest and abdominal imaging. Thus, even though bone scanning can be helpful to confirm clinically or radiographically suspected metastatic disease, current guidelines from the EAU and NCCN do not support its routine use in the initial staging of asymptomatic RCC [5,13]. Bone Scan Whole Body with SPECT or SPECT/CT Area of Interest The prevalence of osseous metastases for localized RCC has been shown to be low in patients without symptoms (ie, bone pain) or without laboratory abnormalities suggestive of osseous metastases (ie, elevated serum alkaline phosphatase level) [11,12]. Furthermore, the sites commonly involved by osseous metastases, such as the thoracolumbar spine and ribs, are located in areas covered by chest and abdominal imaging. Thus, even though bone scanning can be helpful to confirm clinically or radiographically suspected metastatic disease, current guidelines from the EAU and NCCN do not support its routine use in the initial staging of asymptomatic RCC [5,13]. In patients with RCC with symptoms suspicious for bone metastases, bone scan may be useful. If the bone scan shows areas of abnormal radiotracer uptake suspicious for osseous metastases, SPECT fused with CT can be used to provide detailed anatomic localization of the abnormal radiotracer uptake and further improve the characterization of the nature of the abnormality [14]. CT Abdomen Preoperative imaging of RCC provides critical information on staging and serves as a roadmap to the surgeon. | 69372 |
acrac_69372_23 | Staging of Renal Cell Carcinoma | Both CT and MRI are comparable in the staging of the primary tumor [15,16]. Some of the advantages of CT include rapid acquisition time, and hence it is often the most commonly used modality for this indication. CT abdomen without and with IV contrast is typically performed for charactering a renal mass as RCC and staging the tumor. However, in patients with contraindications to iodinated contrast, only unenhanced CT may be possible, limiting the assessment. MRI abdomen may be useful in this setting, given the superior soft tissue resolution of MRI compared to unenhanced CT. Staging of Renal Cell Carcinoma CT Abdomen and Pelvis Preoperative imaging of RCC provides critical information on staging and serves as a roadmap to the surgeon. Both CT and MRI are comparable in the staging of the primary tumor [15,16]. Some of the advantages of CT include rapid acquisition time, and hence it is often the most commonly used modality for this indication. CT abdomen without and with IV contrast is typically performed for charactering a renal mass as RCC and staging the tumor. However, in patients with contraindications to iodinated contrast, only unenhanced CT may be possible. However, in patients with contraindications to iodinated contrast, only unenhanced CT may be possible, limiting the assessment. MRI abdomen may be useful in this setting, given the superior soft tissue resolution of MRI compared to unenhanced CT. There is no relevant literature with high-quality evidence regarding the use of CT of the pelvis in the staging of RCC. Although it is likely that CT pelvis may not offer additional information in most patients with early stage RCC, pelvic imaging can be helpful in patients with more advanced RCC, in whom metastatic spread is suspected [47,48]. If pelvic imaging is indicated in patients with contraindications to iodinated contrast, pelvic MRI may be preferred to unenhanced CT pelvis. | Staging of Renal Cell Carcinoma. Both CT and MRI are comparable in the staging of the primary tumor [15,16]. Some of the advantages of CT include rapid acquisition time, and hence it is often the most commonly used modality for this indication. CT abdomen without and with IV contrast is typically performed for charactering a renal mass as RCC and staging the tumor. However, in patients with contraindications to iodinated contrast, only unenhanced CT may be possible, limiting the assessment. MRI abdomen may be useful in this setting, given the superior soft tissue resolution of MRI compared to unenhanced CT. Staging of Renal Cell Carcinoma CT Abdomen and Pelvis Preoperative imaging of RCC provides critical information on staging and serves as a roadmap to the surgeon. Both CT and MRI are comparable in the staging of the primary tumor [15,16]. Some of the advantages of CT include rapid acquisition time, and hence it is often the most commonly used modality for this indication. CT abdomen without and with IV contrast is typically performed for charactering a renal mass as RCC and staging the tumor. However, in patients with contraindications to iodinated contrast, only unenhanced CT may be possible. However, in patients with contraindications to iodinated contrast, only unenhanced CT may be possible, limiting the assessment. MRI abdomen may be useful in this setting, given the superior soft tissue resolution of MRI compared to unenhanced CT. There is no relevant literature with high-quality evidence regarding the use of CT of the pelvis in the staging of RCC. Although it is likely that CT pelvis may not offer additional information in most patients with early stage RCC, pelvic imaging can be helpful in patients with more advanced RCC, in whom metastatic spread is suspected [47,48]. If pelvic imaging is indicated in patients with contraindications to iodinated contrast, pelvic MRI may be preferred to unenhanced CT pelvis. | 69372 |
acrac_69372_24 | Staging of Renal Cell Carcinoma | CT Chest Chest imaging is indicated in the staging of RCC, given that lungs are one of the most common sites of metastases in RCC [5,13]. There is a lack of literature that have directly compared the accuracy of chest CT with chest radiography for detecting pulmonary metastases in the initial staging of RCC. However, limited data have demonstrated that CT is more sensitive than radiography for the detection of pulmonary metastases from RCC [49]. Current literature supports use of IV contrast-enhanced CT chest for detecting pulmonary metastases, especially in patients with large renal tumors [5,13,34,63,64,74,75]. However, in patients with contraindications to iodinated contrast, unenhanced CT chest may be performed because that would be able to detect pulmonary nodules, despite the lack of IV contrast. CT Head Most patients with metastases to the central nervous system are symptomatic. Thus, current guidelines from the EAU and NCCN do not support routine imaging of the brain to search for metastases in asymptomatic patients in the initial staging of RCC. Brain imaging should be performed only in cases with suggestive signs or symptoms [5,13]. In symptomatic patients with contraindication to IV contrast, MRI brain without contrast may be helpful. CTU CTU There is no relevant literature suggesting that CTU offers any additional benefit over conventional CT of the abdomen in the initial staging of RCC, and thus, this method is not included in the guidelines from the EAU and NCCN [5,13]. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT has a limited role in the diagnosis and local staging of RCC [58]. Differentiating renal tumor from background normal renal tissue can be difficult because of renal excretion of FDG. Furthermore, RCC is reported to have variable FDG avidity, limiting its utility. Nakanishi et al [59] reported a 56% sensitivity, a 67% specificity, a 15% positive predictive value, a 57% negative predictive value, and a 65% accuracy for FDG-PET in the staging of RCC. | Staging of Renal Cell Carcinoma. CT Chest Chest imaging is indicated in the staging of RCC, given that lungs are one of the most common sites of metastases in RCC [5,13]. There is a lack of literature that have directly compared the accuracy of chest CT with chest radiography for detecting pulmonary metastases in the initial staging of RCC. However, limited data have demonstrated that CT is more sensitive than radiography for the detection of pulmonary metastases from RCC [49]. Current literature supports use of IV contrast-enhanced CT chest for detecting pulmonary metastases, especially in patients with large renal tumors [5,13,34,63,64,74,75]. However, in patients with contraindications to iodinated contrast, unenhanced CT chest may be performed because that would be able to detect pulmonary nodules, despite the lack of IV contrast. CT Head Most patients with metastases to the central nervous system are symptomatic. Thus, current guidelines from the EAU and NCCN do not support routine imaging of the brain to search for metastases in asymptomatic patients in the initial staging of RCC. Brain imaging should be performed only in cases with suggestive signs or symptoms [5,13]. In symptomatic patients with contraindication to IV contrast, MRI brain without contrast may be helpful. CTU CTU There is no relevant literature suggesting that CTU offers any additional benefit over conventional CT of the abdomen in the initial staging of RCC, and thus, this method is not included in the guidelines from the EAU and NCCN [5,13]. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT has a limited role in the diagnosis and local staging of RCC [58]. Differentiating renal tumor from background normal renal tissue can be difficult because of renal excretion of FDG. Furthermore, RCC is reported to have variable FDG avidity, limiting its utility. Nakanishi et al [59] reported a 56% sensitivity, a 67% specificity, a 15% positive predictive value, a 57% negative predictive value, and a 65% accuracy for FDG-PET in the staging of RCC. | 69372 |
acrac_69372_25 | Staging of Renal Cell Carcinoma | A recent clinical trial from Turkey involving 62 patients with RCC reported an 84% accuracy for contrast- enhanced FDG-PET/CT in staging RCC [60]. However, further studies are warranted before PET/CT can be used in the routine initial staging of RCC. At present, given the paucity of literature to support the use of FDG-PET/CT, the guidelines from the EAU and NCCN do not recommend routine FDG-PET/CT in the initial staging of RCC [5,13]. Fluoride PET/CT Skull Base to Mid-Thigh Preliminary results for other PET tracers are also becoming available. In a small prospective study of 10 patients with metastatic RCC, 18F-NaF PET/CT was found to be significantly more sensitive for the detection of RCC skeletal metastases than Tc-99m bone scintigraphy or CT, with sensitivities of 100%, 29%, and 46%, respectively. CT and Tc-99m bone scintigraphy in this study identified only 65% of the metastases detected by fluoride PET/CT [61]. However, given the paucity of litereature for utility of fluoride PET/CT in the initial staging of RCC, current guidelines from the EAU and NCCN do not support routine fluoride PET/CT to search for metastases in asymptomatic patients in the initial staging of RCC [5,13]. Staging of Renal Cell Carcinoma MRI Abdomen and Pelvis MRI of the abdomen without and with IV contrast is considered to be a reliable method for the staging of RCC and may be of greater benefit in patients with contraindications for iodinated contrast for CT. Various MR sequences, including T2-weighted, chemical shift T1-weighted, contrast-enhanced T1-weighted, and diffusion-weighted images, are typically obtained for the staging of RCC. In a study involving 40 patients with RCC, MRI was reported to have an accuracy of 81% to 86% for T staging [62]. Breath-hold MRI showing lack of perinephric fat involvement is reported to have a high negative predictive value for no perinephric tumor invasion [63]. | Staging of Renal Cell Carcinoma. A recent clinical trial from Turkey involving 62 patients with RCC reported an 84% accuracy for contrast- enhanced FDG-PET/CT in staging RCC [60]. However, further studies are warranted before PET/CT can be used in the routine initial staging of RCC. At present, given the paucity of literature to support the use of FDG-PET/CT, the guidelines from the EAU and NCCN do not recommend routine FDG-PET/CT in the initial staging of RCC [5,13]. Fluoride PET/CT Skull Base to Mid-Thigh Preliminary results for other PET tracers are also becoming available. In a small prospective study of 10 patients with metastatic RCC, 18F-NaF PET/CT was found to be significantly more sensitive for the detection of RCC skeletal metastases than Tc-99m bone scintigraphy or CT, with sensitivities of 100%, 29%, and 46%, respectively. CT and Tc-99m bone scintigraphy in this study identified only 65% of the metastases detected by fluoride PET/CT [61]. However, given the paucity of litereature for utility of fluoride PET/CT in the initial staging of RCC, current guidelines from the EAU and NCCN do not support routine fluoride PET/CT to search for metastases in asymptomatic patients in the initial staging of RCC [5,13]. Staging of Renal Cell Carcinoma MRI Abdomen and Pelvis MRI of the abdomen without and with IV contrast is considered to be a reliable method for the staging of RCC and may be of greater benefit in patients with contraindications for iodinated contrast for CT. Various MR sequences, including T2-weighted, chemical shift T1-weighted, contrast-enhanced T1-weighted, and diffusion-weighted images, are typically obtained for the staging of RCC. In a study involving 40 patients with RCC, MRI was reported to have an accuracy of 81% to 86% for T staging [62]. Breath-hold MRI showing lack of perinephric fat involvement is reported to have a high negative predictive value for no perinephric tumor invasion [63]. | 69372 |
acrac_69372_26 | Staging of Renal Cell Carcinoma | In a study of 73 RCCs, Roy et al [64] showed that the presence of a pseudocapsule on MRI had an accuracy of 93% for clear-cell carcinomas in separating T1/T2 tumors from T3a tumors. Lal et al [65] performed a prospective observational study in 50 patients with RCC, comparing MRI with histopathological findings. In this study, MRI was reported to have a 90% agreement with histopathology for detecting perirenal extension and a 97% agreement with histopathology for detecting tumor extension beyond Gerota fascia [65]. Both contrast-enhanced multidetector CT and MRI are helpful in detecting venous involvement, particularly in the main renal vein and the IVC [33,66]. Increased diameter of the IVC and renal vein, presence of tumor signal both inside and outside the vessel wall, altered signal intensity in the vessel wall, presence of flow around the tumor thrombus, and mobility in different phases are some of the MRI features that are helpful in detecting venous involvement [67,68]. Bland thrombus featuring a uniform signal intensity and lack of enhancement after gadolinium can be distinguished from tumor thrombus, which exhibits intermediate or high signal intensity, heterogeneous intensity, and, more reliably, the presence of small vessels. In a recent study involving 81 patients with RCC, MRI was reported to have a 92% sensitivity, an 86% specificity, an 89% positive predictive value, and a 91% negative predictive value for identifying IVC wall invasion [69]. Pitfalls of MRI include the potential for large tumors to compress the vena cava and cause flow-related artifacts. Such artifacts can be reduced with appropriate saturation pulses. Although MRI of the abdomen with IV contrast is considered in all major guidelines as an adequate method for the staging of RCC, imaging the pelvis for RCC staging is considered optional in the guidelines [5,13]. There is no relevant literature with high-quality evidence regarding the use of MRI of the pelvis in the staging of RCC. | Staging of Renal Cell Carcinoma. In a study of 73 RCCs, Roy et al [64] showed that the presence of a pseudocapsule on MRI had an accuracy of 93% for clear-cell carcinomas in separating T1/T2 tumors from T3a tumors. Lal et al [65] performed a prospective observational study in 50 patients with RCC, comparing MRI with histopathological findings. In this study, MRI was reported to have a 90% agreement with histopathology for detecting perirenal extension and a 97% agreement with histopathology for detecting tumor extension beyond Gerota fascia [65]. Both contrast-enhanced multidetector CT and MRI are helpful in detecting venous involvement, particularly in the main renal vein and the IVC [33,66]. Increased diameter of the IVC and renal vein, presence of tumor signal both inside and outside the vessel wall, altered signal intensity in the vessel wall, presence of flow around the tumor thrombus, and mobility in different phases are some of the MRI features that are helpful in detecting venous involvement [67,68]. Bland thrombus featuring a uniform signal intensity and lack of enhancement after gadolinium can be distinguished from tumor thrombus, which exhibits intermediate or high signal intensity, heterogeneous intensity, and, more reliably, the presence of small vessels. In a recent study involving 81 patients with RCC, MRI was reported to have a 92% sensitivity, an 86% specificity, an 89% positive predictive value, and a 91% negative predictive value for identifying IVC wall invasion [69]. Pitfalls of MRI include the potential for large tumors to compress the vena cava and cause flow-related artifacts. Such artifacts can be reduced with appropriate saturation pulses. Although MRI of the abdomen with IV contrast is considered in all major guidelines as an adequate method for the staging of RCC, imaging the pelvis for RCC staging is considered optional in the guidelines [5,13]. There is no relevant literature with high-quality evidence regarding the use of MRI of the pelvis in the staging of RCC. | 69372 |
acrac_69372_27 | Staging of Renal Cell Carcinoma | Although it is likely that MRI pelvis may not offer additional information in most patients with early stage RCC, pelvic imaging can be helpful in patients with more advanced RCC, in whom metastatic spread is suspected [47,48]. MRI Abdomen MRI of the abdomen without and with IV contrast is considered to be a reliable method for the staging of RCC and may be of greater benefit in patients with contraindications for iodinated contrast for CT. Various MR sequences, including T2-weighted, chemical shift T1-weighted, contrast-enhanced T1-weighted, and diffusion-weighted images, are typically obtained for the staging of RCC. In a study involving 40 patients with RCC, MRI was reported to have an accuracy of 81% to 86% for T staging [62]. Breath-hold MRI showing lack of perinephric fat involvement is reported to have a high negative predictive value for no perinephric tumor invasion [63]. In a study of 73 RCCs, Roy et al [64] showed that the presence of a pseudocapsule on MRI had an accuracy of 93% for clear-cell carcinomas in separating T1/T2 tumors from T3a tumors. Lal et al [65] performed a prospective observational study in 50 patients with RCC, comparing MRI with histopathological findings. In this study, MRI was reported to have a 90% agreement with histopathology for detecting perirenal extension and a 97% agreement with histopathology for detecting tumor extension beyond Gerota fascia [65]. Both contrast-enhanced multidetector CT and MRI are helpful in detecting venous involvement, particularly in the main renal vein and the IVC [33,66]. Increased diameter of the IVC and renal vein, presence of tumor signal both inside and outside the vessel wall, altered signal intensity in the vessel wall, presence of flow around the tumor thrombus, and mobility in different phases are some of the MRI features that are helpful in detecting venous involvement [67,68]. | Staging of Renal Cell Carcinoma. Although it is likely that MRI pelvis may not offer additional information in most patients with early stage RCC, pelvic imaging can be helpful in patients with more advanced RCC, in whom metastatic spread is suspected [47,48]. MRI Abdomen MRI of the abdomen without and with IV contrast is considered to be a reliable method for the staging of RCC and may be of greater benefit in patients with contraindications for iodinated contrast for CT. Various MR sequences, including T2-weighted, chemical shift T1-weighted, contrast-enhanced T1-weighted, and diffusion-weighted images, are typically obtained for the staging of RCC. In a study involving 40 patients with RCC, MRI was reported to have an accuracy of 81% to 86% for T staging [62]. Breath-hold MRI showing lack of perinephric fat involvement is reported to have a high negative predictive value for no perinephric tumor invasion [63]. In a study of 73 RCCs, Roy et al [64] showed that the presence of a pseudocapsule on MRI had an accuracy of 93% for clear-cell carcinomas in separating T1/T2 tumors from T3a tumors. Lal et al [65] performed a prospective observational study in 50 patients with RCC, comparing MRI with histopathological findings. In this study, MRI was reported to have a 90% agreement with histopathology for detecting perirenal extension and a 97% agreement with histopathology for detecting tumor extension beyond Gerota fascia [65]. Both contrast-enhanced multidetector CT and MRI are helpful in detecting venous involvement, particularly in the main renal vein and the IVC [33,66]. Increased diameter of the IVC and renal vein, presence of tumor signal both inside and outside the vessel wall, altered signal intensity in the vessel wall, presence of flow around the tumor thrombus, and mobility in different phases are some of the MRI features that are helpful in detecting venous involvement [67,68]. | 69372 |
acrac_69372_28 | Staging of Renal Cell Carcinoma | Bland thrombus featuring a uniform signal intensity and lack of enhancement after gadolinium can be distinguished from tumor thrombus, which exhibits intermediate or high signal intensity, heterogeneous intensity, and, more reliably, the presence of small vessels. In a recent study involving 81 patients with RCC, MRI was reported to have a 92% sensitivity, an 86% specificity, an 89% positive predictive value, and a 91% negative predictive value for identifying IVC wall invasion [69]. Pitfalls of MRI include the potential for large tumors to compress the vena cava and cause flow-related artifacts. Such artifacts can be reduced with appropriate saturation pulses. MRI Head Most patients with metastases to the central nervous system are symptomatic. Thus, current guidelines do not support routine imaging of the brain to search for metastases in asymptomatic patients in the initial staging of RCC. Staging of Renal Cell Carcinoma Brain imaging should be performed only in cases with suggestive signs or symptoms [5,13]. In symptomatic patients with contraindication to IV contrast, MRI brain without contrast may be helpful. MRU There is no relevant literature suggesting that MRU offers any additional benefit over conventional MRI of the abdomen in the initial staging of RCC, and thus, this method is not included in the guidelines from the EAU and NCCN [5,13]. Radiography Chest The lung is the most common site of metastases in patients with RCC presenting with synchronous metastases. Although the incidence of metastases in RCC <4 cm is low (approximately 1%-2%), it has been reported that 20% to 30% of T1a tumors may have potentially aggressive histologic features. Hence, chest radiography is usually performed in the staging of RCC [13]. However, CT is more sensitive than radiography for the detection of pulmonary metastases from RCC during staging. | Staging of Renal Cell Carcinoma. Bland thrombus featuring a uniform signal intensity and lack of enhancement after gadolinium can be distinguished from tumor thrombus, which exhibits intermediate or high signal intensity, heterogeneous intensity, and, more reliably, the presence of small vessels. In a recent study involving 81 patients with RCC, MRI was reported to have a 92% sensitivity, an 86% specificity, an 89% positive predictive value, and a 91% negative predictive value for identifying IVC wall invasion [69]. Pitfalls of MRI include the potential for large tumors to compress the vena cava and cause flow-related artifacts. Such artifacts can be reduced with appropriate saturation pulses. MRI Head Most patients with metastases to the central nervous system are symptomatic. Thus, current guidelines do not support routine imaging of the brain to search for metastases in asymptomatic patients in the initial staging of RCC. Staging of Renal Cell Carcinoma Brain imaging should be performed only in cases with suggestive signs or symptoms [5,13]. In symptomatic patients with contraindication to IV contrast, MRI brain without contrast may be helpful. MRU There is no relevant literature suggesting that MRU offers any additional benefit over conventional MRI of the abdomen in the initial staging of RCC, and thus, this method is not included in the guidelines from the EAU and NCCN [5,13]. Radiography Chest The lung is the most common site of metastases in patients with RCC presenting with synchronous metastases. Although the incidence of metastases in RCC <4 cm is low (approximately 1%-2%), it has been reported that 20% to 30% of T1a tumors may have potentially aggressive histologic features. Hence, chest radiography is usually performed in the staging of RCC [13]. However, CT is more sensitive than radiography for the detection of pulmonary metastases from RCC during staging. | 69372 |
acrac_69405_0 | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs | In patients with chronic chest pain with a high clinical probability of CAD or known ischemic heart disease (IHD), imaging is used to characterize known and unknown IHD. In patients with no known IHD, imaging is valuable in determining and documenting the presence, extent, and severity of obstructive coronary narrowing as well as the presence of myocardial ischemia. Imaging also allows for exclusion of nonocclusive atherosclerotic CAD and/or aHarvard Medical School, Boston, Massachusetts. bPanel Chair, Duke University Medical Center, Durham, North Carolina. cPanel Vice-Chair, Massachusetts General Hospital, Boston, Massachusetts. dUniversity of Michigan, Ann Arbor, Michigan. eUniversity of Virginia Health System, Charlottesville, Virginia; Nuclear cardiology expert. fUniversity of Michigan Health System, Ann Arbor, Michigan. gThe University of Chicago Medical Center, Chicago, Illinois; American College of Physicians. hOregon Health & Science University, Portland, Oregon. iQueen's University, Kingston, Ontario, Canada; Cardiology expert. jUniversity of California San Diego, San Diego, California. kVA Palo Alto Health Care System, Palo Alto, California and Stanford University, Stanford, California. lNaval Medical Center Portsmouth, Portsmouth, Virginia. mMassachusetts General Hospital, Boston, Massachusetts. nWake Forest University Health Sciences, Winston Salem, North Carolina; Society for Cardiovascular Magnetic Resonance. oUniversity of Virginia Health Center, Charlottesville, Virginia; Society of Cardiovascular Computed Tomography. pSpecialty Chair, UT Southwestern Medical Center, Dallas, Texas. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through representation of such organizations on expert panels. | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs. In patients with chronic chest pain with a high clinical probability of CAD or known ischemic heart disease (IHD), imaging is used to characterize known and unknown IHD. In patients with no known IHD, imaging is valuable in determining and documenting the presence, extent, and severity of obstructive coronary narrowing as well as the presence of myocardial ischemia. Imaging also allows for exclusion of nonocclusive atherosclerotic CAD and/or aHarvard Medical School, Boston, Massachusetts. bPanel Chair, Duke University Medical Center, Durham, North Carolina. cPanel Vice-Chair, Massachusetts General Hospital, Boston, Massachusetts. dUniversity of Michigan, Ann Arbor, Michigan. eUniversity of Virginia Health System, Charlottesville, Virginia; Nuclear cardiology expert. fUniversity of Michigan Health System, Ann Arbor, Michigan. gThe University of Chicago Medical Center, Chicago, Illinois; American College of Physicians. hOregon Health & Science University, Portland, Oregon. iQueen's University, Kingston, Ontario, Canada; Cardiology expert. jUniversity of California San Diego, San Diego, California. kVA Palo Alto Health Care System, Palo Alto, California and Stanford University, Stanford, California. lNaval Medical Center Portsmouth, Portsmouth, Virginia. mMassachusetts General Hospital, Boston, Massachusetts. nWake Forest University Health Sciences, Winston Salem, North Carolina; Society for Cardiovascular Magnetic Resonance. oUniversity of Virginia Health Center, Charlottesville, Virginia; Society of Cardiovascular Computed Tomography. pSpecialty Chair, UT Southwestern Medical Center, Dallas, Texas. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through representation of such organizations on expert panels. | 69405 |
acrac_69405_1 | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs | Participation on the expert panel does not necessarily imply endorsement of the final document by individual contributors or their respective organization. Reprint requests to: [email protected] Chronic Chest Pain-High Probability of CAD demonstration of abnormalities (eg, congenital or acquired coronary artery anomalies) as well as other etiologies for CAD that can produce chest pain in the absence of coronary obstructive disease. In patients with known IHD, imaging findings are important in determining the management of patients with chronic myocardial ischemia and can serve as a decision-making tool for medical therapy, angioplasty, stenting, or surgery. Imaging can help understand long-term prognosis and expected benefit from various therapeutic options by evaluating disease location, plaque characteristics, and pre-existing myocardial infarction, as well as determining ventricular function, diastolic relaxation, and end-systolic volume [7]. OR Discussion of Procedures by Variant Variant 1: Chronic chest pain; high probability of coronary artery disease. No known ischemic heart disease. Initial imaging. Arteriography Coronary Catheter-based selective coronary angiography is historically considered the coronary imaging modality of choice with the highest spatial and temporal resolution. Although only 2-D projection images are obtained (as opposed to 3-D volumes in coronary CTA [CCTA]), selective coronary angiography is considered to be the reference standard for depicting the anatomy and the severity of obstructive CAD and other coronary abnormalities (eg, congenital variants, coronary spasm, dissection, vasculitis) [8]. In addition to visualizing the coronary arteries, the procedure is used to guide percutaneous coronary interventions to the site of the blockage. Hemodynamic relevance of coronary stenosis identified on invasive coronary angiography (ICA) is assessed by measuring fractional flow reserve (FFR) [9,10]. | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs. Participation on the expert panel does not necessarily imply endorsement of the final document by individual contributors or their respective organization. Reprint requests to: [email protected] Chronic Chest Pain-High Probability of CAD demonstration of abnormalities (eg, congenital or acquired coronary artery anomalies) as well as other etiologies for CAD that can produce chest pain in the absence of coronary obstructive disease. In patients with known IHD, imaging findings are important in determining the management of patients with chronic myocardial ischemia and can serve as a decision-making tool for medical therapy, angioplasty, stenting, or surgery. Imaging can help understand long-term prognosis and expected benefit from various therapeutic options by evaluating disease location, plaque characteristics, and pre-existing myocardial infarction, as well as determining ventricular function, diastolic relaxation, and end-systolic volume [7]. OR Discussion of Procedures by Variant Variant 1: Chronic chest pain; high probability of coronary artery disease. No known ischemic heart disease. Initial imaging. Arteriography Coronary Catheter-based selective coronary angiography is historically considered the coronary imaging modality of choice with the highest spatial and temporal resolution. Although only 2-D projection images are obtained (as opposed to 3-D volumes in coronary CTA [CCTA]), selective coronary angiography is considered to be the reference standard for depicting the anatomy and the severity of obstructive CAD and other coronary abnormalities (eg, congenital variants, coronary spasm, dissection, vasculitis) [8]. In addition to visualizing the coronary arteries, the procedure is used to guide percutaneous coronary interventions to the site of the blockage. Hemodynamic relevance of coronary stenosis identified on invasive coronary angiography (ICA) is assessed by measuring fractional flow reserve (FFR) [9,10]. | 69405 |
acrac_69405_2 | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs | CT Coronary Calcium Coronary artery calcification is an indicator of coronary atherosclerosis presence and can be assessed using ECG- gated noncontrast CT of the heart [11]. There are limited data on the use of CT coronary calcium in symptomatic patients at a high risk for CAD. CCS has been shown to provide value in symptomatic individuals presenting with chest pain for risk assessment for future events [12]. A zero CCS in patients undergoing CT scanning for suspected stable angina has a high negative predictive value (NPV) for the exclusion of obstructive CAD and is associated with a good medium-term prognosis [13]. In one large multicenter study (Prospective Multicenter Imaging Study for Evaluation of Chest Pain [PROMISE] trial) that included patients with stable chest pain and no history of CAD, presence of measurable coronary artery calcification at the baseline was associated with clinical events [14]. A substudy of another larger multicenter trial (Coronary Evaluation Using Multi-Detector Spiral Computed Tomography Angiography Using 64 Detectors [CORE-64]) demonstrated that in patients with high probability of CAD and no known CAD, the absence of coronary calcification does not exclude obstructive stenosis [15]. Conversely, a prospective randomized controlled trial (Computed Tomography vs. Exercise Testing in Suspected Coronary Artery Disease [CRESCENT]) showed that in patients with stable chest pain and no known CAD, the presence of a coronary calcium and even a high total coronary artery calcification score is not clearly associated with ischemia [16]. Chronic Chest Pain-High Probability of CAD CT Heart Function and Morphology CT heart function and morphology can provide assessment of ventricular morphology and function as well as assessment of myocardial perfusion and infarction. | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs. CT Coronary Calcium Coronary artery calcification is an indicator of coronary atherosclerosis presence and can be assessed using ECG- gated noncontrast CT of the heart [11]. There are limited data on the use of CT coronary calcium in symptomatic patients at a high risk for CAD. CCS has been shown to provide value in symptomatic individuals presenting with chest pain for risk assessment for future events [12]. A zero CCS in patients undergoing CT scanning for suspected stable angina has a high negative predictive value (NPV) for the exclusion of obstructive CAD and is associated with a good medium-term prognosis [13]. In one large multicenter study (Prospective Multicenter Imaging Study for Evaluation of Chest Pain [PROMISE] trial) that included patients with stable chest pain and no history of CAD, presence of measurable coronary artery calcification at the baseline was associated with clinical events [14]. A substudy of another larger multicenter trial (Coronary Evaluation Using Multi-Detector Spiral Computed Tomography Angiography Using 64 Detectors [CORE-64]) demonstrated that in patients with high probability of CAD and no known CAD, the absence of coronary calcification does not exclude obstructive stenosis [15]. Conversely, a prospective randomized controlled trial (Computed Tomography vs. Exercise Testing in Suspected Coronary Artery Disease [CRESCENT]) showed that in patients with stable chest pain and no known CAD, the presence of a coronary calcium and even a high total coronary artery calcification score is not clearly associated with ischemia [16]. Chronic Chest Pain-High Probability of CAD CT Heart Function and Morphology CT heart function and morphology can provide assessment of ventricular morphology and function as well as assessment of myocardial perfusion and infarction. | 69405 |
acrac_69405_3 | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs | There are no relevant data published on the use of CT heart for assessment of heart function and regional wall motion abnormalities in patients with chronic chest pain who have a high probability for CAD. Several studies have validated stress CT myocardial perfusion against SPECT, stress cardiac MR (CMR), and invasive FFR in patients with suspected or known CAD (no clinical data reported on the presence or absence of chronic chest pain), and it was shown, when combined with CTA, to accurately predict perfusion abnormalities related to atherosclerotic luminal narrowing [19-23]. CTA Chest CTA chest has been shown to be effective in excluding noncardiac causes for chronic chest pain. It has also been shown in some studies to facilitate the diagnosis of acute coronary syndrome and the decision on emergent catheterization, when left ventricular (LV) myocardial ischemia is identified [24]. There is no relevant literature to support non-ECG-gated CTA of the chest in the evaluation of chronic chest pain for the initial evaluation of CAD in patients who are high risk and without known IHD. CTA Triple Rule Out Triple rule out (TRO) is used for diagnosis of acute chest pain and simultaneous assessment of aorta, coronary arteries, and pulmonary arteries. There is no relevant literature to support the use of TRO in patients with chronic chest pain and a high probability of CAD with no known IHD. CCTA obtained in addition to standard of care in patients with stable chest pain with a high pretest probability of CAD has been demonstrated to result in a significantly lower rate of death from coronary heart disease or nonfatal myocardial infarction at 5 years compared with standard of care alone [32]. | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs. There are no relevant data published on the use of CT heart for assessment of heart function and regional wall motion abnormalities in patients with chronic chest pain who have a high probability for CAD. Several studies have validated stress CT myocardial perfusion against SPECT, stress cardiac MR (CMR), and invasive FFR in patients with suspected or known CAD (no clinical data reported on the presence or absence of chronic chest pain), and it was shown, when combined with CTA, to accurately predict perfusion abnormalities related to atherosclerotic luminal narrowing [19-23]. CTA Chest CTA chest has been shown to be effective in excluding noncardiac causes for chronic chest pain. It has also been shown in some studies to facilitate the diagnosis of acute coronary syndrome and the decision on emergent catheterization, when left ventricular (LV) myocardial ischemia is identified [24]. There is no relevant literature to support non-ECG-gated CTA of the chest in the evaluation of chronic chest pain for the initial evaluation of CAD in patients who are high risk and without known IHD. CTA Triple Rule Out Triple rule out (TRO) is used for diagnosis of acute chest pain and simultaneous assessment of aorta, coronary arteries, and pulmonary arteries. There is no relevant literature to support the use of TRO in patients with chronic chest pain and a high probability of CAD with no known IHD. CCTA obtained in addition to standard of care in patients with stable chest pain with a high pretest probability of CAD has been demonstrated to result in a significantly lower rate of death from coronary heart disease or nonfatal myocardial infarction at 5 years compared with standard of care alone [32]. | 69405 |
acrac_69405_4 | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs | CCTA has been shown to change treatment among 23% of patients in the CCTA arm compared with 5% in the standard-of-care arm with increased use of preventive therapy when atherosclerosis was identified and cancellations of preventive and antianginal therapy with normal coronaries [32]. CCTA and FFR-CT FFR-CT allows for determination of lesion-specific ischemia associated with a coronary arterial narrowing. FFR- CT is performed in conjunction with CCTA [33,34]. FFR-CT has a high diagnostic performance when compared against invasive FFR as the reference standard: 82% specificity and 74% PPV [33]. In a multicenter trial (Assessing Diagnostic Value of Non-invasive FFRCT in Coronary Wave [ADVANCE]), 5,083 patients demonstrated the prognostic value of CTA with FFR-CT in patients with stable chest pain with a trend to lower major adverse cardiac events and lower cardiovascular death or myocardial infarction with a negative FFR- CT [39]. MRA Coronary Arteries Without and With IV Contrast Coronary MR angiography (MRA) does not assess late gadolinium enhancement or viability. MRA coronary arteries can demonstrate lumen narrowing of the proximal coronary arteries. There are limited data on the use of MRA coronary arteries without and with intravenous (IV) contrast in symptomatic patients with a high probability for CAD. In a single-center prospective study in patients with suspected CAD, 82% sensitivity, 90% specificity, 88% PPV, and 86% NPV for detecting significant CAD were demonstrated [40]. MRA Coronary Arteries Without IV Contrast There is limited data on the use of MRA coronary arteries without IV contrast in symptomatic patients with a high probability for CAD. | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs. CCTA has been shown to change treatment among 23% of patients in the CCTA arm compared with 5% in the standard-of-care arm with increased use of preventive therapy when atherosclerosis was identified and cancellations of preventive and antianginal therapy with normal coronaries [32]. CCTA and FFR-CT FFR-CT allows for determination of lesion-specific ischemia associated with a coronary arterial narrowing. FFR- CT is performed in conjunction with CCTA [33,34]. FFR-CT has a high diagnostic performance when compared against invasive FFR as the reference standard: 82% specificity and 74% PPV [33]. In a multicenter trial (Assessing Diagnostic Value of Non-invasive FFRCT in Coronary Wave [ADVANCE]), 5,083 patients demonstrated the prognostic value of CTA with FFR-CT in patients with stable chest pain with a trend to lower major adverse cardiac events and lower cardiovascular death or myocardial infarction with a negative FFR- CT [39]. MRA Coronary Arteries Without and With IV Contrast Coronary MR angiography (MRA) does not assess late gadolinium enhancement or viability. MRA coronary arteries can demonstrate lumen narrowing of the proximal coronary arteries. There are limited data on the use of MRA coronary arteries without and with intravenous (IV) contrast in symptomatic patients with a high probability for CAD. In a single-center prospective study in patients with suspected CAD, 82% sensitivity, 90% specificity, 88% PPV, and 86% NPV for detecting significant CAD were demonstrated [40]. MRA Coronary Arteries Without IV Contrast There is limited data on the use of MRA coronary arteries without IV contrast in symptomatic patients with a high probability for CAD. | 69405 |
acrac_69405_5 | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs | In symptomatic patients with an intermediate or high pretest probability for disease, noncontrast coronary MRA had a patient-based sensitivity of 96%, specificity of 68%, PPV of 79%, and NPV of 93% in the detection of functionally significant CAD as defined by a >90% stenosis or FFR <0.8 on catheter angiography. When added to a comprehensive stress-rest MRI protocol, it had a nonsignificant increase in diagnostic accuracy [42]. MRI Heart Function and Morphology Without and With IV Contrast MRI heart function and morphology without and with IV contrast can demonstrate myocardial infarction and ischemia secondary to CAD and can provide assessment of LV wall function. Areas of myocardial infarction detected on MRI have been shown to be a predictor of mortality and major adverse cardiac events, compared with clinical data, coronary sclerosis at angiography, or LV end-systolic volume index (ESVI) and LV ejection fraction (LVEF) in patients with suspected CAD, even when areas of infarction are small. Even a small area of infarction (<2% of LV mass) was associated with a greater than 7-fold increase in risk for a major adverse cardiac event. Delayed-enhancement MRI in patients without known CAD is associated with lower LVEF and greater LV mass [43]. A single-center observational prospective study with 376 patients with a history suggesting stable CAD but with no history of myocardial ischemia demonstrated that evidence of myocardial infarction on CMR is an independent noninvasive marker of prognosis in stable CAD patients [44] and remains the strongest predictor of adverse events, even after adjustment for significant CAD on angiogram, LVEF, and wall motion abnormality [44,45]. MRI Heart Function and Morphology Without IV Contrast MRI heart function and morphology without IV contrast provides assessment of ejection fraction and ventricular volumes including LVEF and ESVI with a higher sensitivity to detect prior myocardial infarct than ischemia. | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs. In symptomatic patients with an intermediate or high pretest probability for disease, noncontrast coronary MRA had a patient-based sensitivity of 96%, specificity of 68%, PPV of 79%, and NPV of 93% in the detection of functionally significant CAD as defined by a >90% stenosis or FFR <0.8 on catheter angiography. When added to a comprehensive stress-rest MRI protocol, it had a nonsignificant increase in diagnostic accuracy [42]. MRI Heart Function and Morphology Without and With IV Contrast MRI heart function and morphology without and with IV contrast can demonstrate myocardial infarction and ischemia secondary to CAD and can provide assessment of LV wall function. Areas of myocardial infarction detected on MRI have been shown to be a predictor of mortality and major adverse cardiac events, compared with clinical data, coronary sclerosis at angiography, or LV end-systolic volume index (ESVI) and LV ejection fraction (LVEF) in patients with suspected CAD, even when areas of infarction are small. Even a small area of infarction (<2% of LV mass) was associated with a greater than 7-fold increase in risk for a major adverse cardiac event. Delayed-enhancement MRI in patients without known CAD is associated with lower LVEF and greater LV mass [43]. A single-center observational prospective study with 376 patients with a history suggesting stable CAD but with no history of myocardial ischemia demonstrated that evidence of myocardial infarction on CMR is an independent noninvasive marker of prognosis in stable CAD patients [44] and remains the strongest predictor of adverse events, even after adjustment for significant CAD on angiogram, LVEF, and wall motion abnormality [44,45]. MRI Heart Function and Morphology Without IV Contrast MRI heart function and morphology without IV contrast provides assessment of ejection fraction and ventricular volumes including LVEF and ESVI with a higher sensitivity to detect prior myocardial infarct than ischemia. | 69405 |
acrac_69405_6 | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs | Chronic Chest Pain-High Probability of CAD There is no relevant literature to support the use of MRI heart function and morphology without IV contrast in the initial evaluation of patients with chronic chest pain and a high probability of CAD with no known IHD. MRI Heart Function with Stress Without and With IV Contrast MRI with function/wall motion (dobutamine stress test) and MRI with vasodilator stress perfusion (adenosine/regadenoson stress test) have been used to diagnose hemodynamically significant CAD in patients with an intermediate to high likelihood of having significant stenosis. Investigations of MRI heart function stress for patients with known CAD indicate that patients with known (70%) or suspected (30%) CAD with inducible LV wall motion abnormalities during dobutamine CMR predict cardiac death and myocardial ischemia [46]. A single-center prospective study focusing on women with known or suspected CAD and variable clinical symptoms demonstrated that, similar to men, dobutamine CMR can identify cardiac risk in women with known or suspected IHD [47]. A single-center study of 815 consecutive patients referred for evaluation of suspected myocardial ischemia over a 10 year period has shown that stress CMR with its protocol including stress and rest myocardial perfusion, ventricular function, and late gadolinium enhancement, effectively reclassifies patient risk beyond standard clinical variables, specifically in patients at moderate to high pretest clinical risk and in patients with established CAD [48]. MRI heart function stress has a high NPV for adverse cardiac events in patients with known or suspected CAD [46,47]. | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs. Chronic Chest Pain-High Probability of CAD There is no relevant literature to support the use of MRI heart function and morphology without IV contrast in the initial evaluation of patients with chronic chest pain and a high probability of CAD with no known IHD. MRI Heart Function with Stress Without and With IV Contrast MRI with function/wall motion (dobutamine stress test) and MRI with vasodilator stress perfusion (adenosine/regadenoson stress test) have been used to diagnose hemodynamically significant CAD in patients with an intermediate to high likelihood of having significant stenosis. Investigations of MRI heart function stress for patients with known CAD indicate that patients with known (70%) or suspected (30%) CAD with inducible LV wall motion abnormalities during dobutamine CMR predict cardiac death and myocardial ischemia [46]. A single-center prospective study focusing on women with known or suspected CAD and variable clinical symptoms demonstrated that, similar to men, dobutamine CMR can identify cardiac risk in women with known or suspected IHD [47]. A single-center study of 815 consecutive patients referred for evaluation of suspected myocardial ischemia over a 10 year period has shown that stress CMR with its protocol including stress and rest myocardial perfusion, ventricular function, and late gadolinium enhancement, effectively reclassifies patient risk beyond standard clinical variables, specifically in patients at moderate to high pretest clinical risk and in patients with established CAD [48]. MRI heart function stress has a high NPV for adverse cardiac events in patients with known or suspected CAD [46,47]. | 69405 |
acrac_69405_7 | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs | A meta-analysis of 14 studies has shown that MRI heart function stress has a high NPV for adverse cardiac events, and the absence of inducible perfusion defect or wall motion abnormality shows a similar ability to identify patients with a low risk for adverse cardiac events among patients with known or suspected CAD [49]. The MR- INFORM trial investigated MRI perfusion versus combined invasive angiography with invasive FFR in patients with stable angina and an intermediate to high risk of disease. The study showed that MRI perfusion had noninferior major adverse cardiac events compared with invasive FFR with the added patient benefit of a lower incidence of revascularization [50]. A meta-analysis from pooled studies found that perfusion MRI heart function stress has a sensitivity of 89.1% and a specificity of 84.9% on a patient-based analysis using FFR as a reference, suggesting that stress perfusion MRI remains an accurate test for the detection of flow-limiting stenosis in patients with suspected or established CAD [6]. In another meta-analysis of 37 studies, including 2,191 patients with high CAD prevalence, stress CMR, using either wall motion abnormality or perfusion abnormality technique, demonstrates overall good sensitivity and specificity for the diagnosis of CAD; stress-induced wall motion abnormalities imaging demonstrated a sensitivity of 0.83 and specificity of 0.86 on a patient level (disease prevalence = 70.5%). Stress perfusion imaging demonstrated a sensitivity of 0.91 and specificity of 0.81 on a patient level (disease prevalence = 57.4%) [51]. In patients with known or suspected CAD, the presence of late gadolinium enhancement and stress perfusion defect plus abnormal wall motion are independent predictors of all hard cardiac events [52]. MRI Heart Function with Stress Without IV Contrast MRI heart function stress without IV contrast can provide assessment of ventricular function/wall motion abnormalities. | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs. A meta-analysis of 14 studies has shown that MRI heart function stress has a high NPV for adverse cardiac events, and the absence of inducible perfusion defect or wall motion abnormality shows a similar ability to identify patients with a low risk for adverse cardiac events among patients with known or suspected CAD [49]. The MR- INFORM trial investigated MRI perfusion versus combined invasive angiography with invasive FFR in patients with stable angina and an intermediate to high risk of disease. The study showed that MRI perfusion had noninferior major adverse cardiac events compared with invasive FFR with the added patient benefit of a lower incidence of revascularization [50]. A meta-analysis from pooled studies found that perfusion MRI heart function stress has a sensitivity of 89.1% and a specificity of 84.9% on a patient-based analysis using FFR as a reference, suggesting that stress perfusion MRI remains an accurate test for the detection of flow-limiting stenosis in patients with suspected or established CAD [6]. In another meta-analysis of 37 studies, including 2,191 patients with high CAD prevalence, stress CMR, using either wall motion abnormality or perfusion abnormality technique, demonstrates overall good sensitivity and specificity for the diagnosis of CAD; stress-induced wall motion abnormalities imaging demonstrated a sensitivity of 0.83 and specificity of 0.86 on a patient level (disease prevalence = 70.5%). Stress perfusion imaging demonstrated a sensitivity of 0.91 and specificity of 0.81 on a patient level (disease prevalence = 57.4%) [51]. In patients with known or suspected CAD, the presence of late gadolinium enhancement and stress perfusion defect plus abnormal wall motion are independent predictors of all hard cardiac events [52]. MRI Heart Function with Stress Without IV Contrast MRI heart function stress without IV contrast can provide assessment of ventricular function/wall motion abnormalities. | 69405 |
acrac_69405_8 | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs | A single-center prospective study of 884 patients with known (70%) or suspected (30%) CAD demonstrated that inducible LV wall motion abnormalities during dobutamine CMR predicts cardiac death and myocardial ischemia [46]. A single-center prospective study focusing on women with known or suspected CAD and variable clinical symptoms demonstrated that, similar to men, dobutamine CMR can identify cardiac risk in women with known or suspected IHD [47]. A single-center prospective study of 208 patients with suspected CAD has demonstrated a high accuracy for detecting wall motion abnormalities related to ischemia with 86.2% sensitivity and 85.7% specificity [53]. A single-center prospective study of 153 patients with suspected or know CAD, with and without chest pain, has demonstrated 83% sensitivity and 83% specificity for detecting a >50% luminal diameter narrowing based on stress- induced abnormal LV contractility [54]. Chronic Chest Pain-High Probability of CAD Nuclear Medicine Ventriculography Stress radionuclide ventriculography includes measurement of the ejection fraction and assessment of regional wall motion at rest and during stress. There is no relevant literature to support nuclear medicine ventriculography in the initial evaluation of patients with chronic chest pain and a high probability of CAD with no known IHD. Rb-82 PET/CT Heart Rb-82 PET/CT heart assesses rest myocardial perfusion and stress LVEF and quantifies rest myocardial blood flow and coronary flow reserve [55,56]. PET/CT has a reported higher accuracy over conventional nuclear techniques, MPI, and viability [55,57]. Rb-82 PET/CT has shown that myocardial perfusion, stress LVEF, and ischemic LV dysfunction are prognostically important in CAD in patients with suspected or known CAD [48]. | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs. A single-center prospective study of 884 patients with known (70%) or suspected (30%) CAD demonstrated that inducible LV wall motion abnormalities during dobutamine CMR predicts cardiac death and myocardial ischemia [46]. A single-center prospective study focusing on women with known or suspected CAD and variable clinical symptoms demonstrated that, similar to men, dobutamine CMR can identify cardiac risk in women with known or suspected IHD [47]. A single-center prospective study of 208 patients with suspected CAD has demonstrated a high accuracy for detecting wall motion abnormalities related to ischemia with 86.2% sensitivity and 85.7% specificity [53]. A single-center prospective study of 153 patients with suspected or know CAD, with and without chest pain, has demonstrated 83% sensitivity and 83% specificity for detecting a >50% luminal diameter narrowing based on stress- induced abnormal LV contractility [54]. Chronic Chest Pain-High Probability of CAD Nuclear Medicine Ventriculography Stress radionuclide ventriculography includes measurement of the ejection fraction and assessment of regional wall motion at rest and during stress. There is no relevant literature to support nuclear medicine ventriculography in the initial evaluation of patients with chronic chest pain and a high probability of CAD with no known IHD. Rb-82 PET/CT Heart Rb-82 PET/CT heart assesses rest myocardial perfusion and stress LVEF and quantifies rest myocardial blood flow and coronary flow reserve [55,56]. PET/CT has a reported higher accuracy over conventional nuclear techniques, MPI, and viability [55,57]. Rb-82 PET/CT has shown that myocardial perfusion, stress LVEF, and ischemic LV dysfunction are prognostically important in CAD in patients with suspected or known CAD [48]. | 69405 |
acrac_69405_9 | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs | A single-center prospective study of 510 patients with suspected CAD has shown that Rb-82 PET/CT has demonstrated sensitivity and specificity of 90% and 88% for the detection of obstructive coronary disease compared with ICA [52]. Among patients with suspected CAD, gated Rb-82 PET/CT can also identify a subset of patients with 3-vessel or left main coronary artery CAD [57]. A single-center study of 1,432 patients with known or suspected CAD has shown that the inherent ability of Rb-82 PET/CT to collect LV function data at rest and during peak stress leads to an improved detection of multivessel CAD [58]. LVEF reserve provides significant independent and incremental value to Rb-82 MPI for predicting the risk of left main/3-vessel disease [57] and future adverse events [59]. A multicenter registry study included 7,061 patients with known or suspected CAD who underwent a clinically indicated rest/stress Rb-82 PET MPI (66% of patients had chronic chest pain as the reason for the test). The extent and severity of ischemia and scarring on Rb-82 PET MPI provided powerful and incremental risk estimates of cardiac death and all-cause death compared with traditional coronary risk factors [60]. PET/CT and CCTA Hybrid PET scanners use CT for attenuation correction (PET/CT) following completion of the PET study. By coupling the PET perfusion examination findings to a CCTA, PET/CT permits the fusion of complementary anatomic coronary arterial and functional (perfusion) myocardial information and enhances diagnostic accuracy [60]. The results of the combined examinations can more accurately identify patients for revascularization. In a study of 110 consecutive patients with combined stress Rb-82 PET perfusion imaging and CCTA, nearly half of the significant angiographic stenoses (47%) occurred without evidence of ischemia, whereas 50% of normal PET studies were associated with some CCTA abnormality [61]. | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs. A single-center prospective study of 510 patients with suspected CAD has shown that Rb-82 PET/CT has demonstrated sensitivity and specificity of 90% and 88% for the detection of obstructive coronary disease compared with ICA [52]. Among patients with suspected CAD, gated Rb-82 PET/CT can also identify a subset of patients with 3-vessel or left main coronary artery CAD [57]. A single-center study of 1,432 patients with known or suspected CAD has shown that the inherent ability of Rb-82 PET/CT to collect LV function data at rest and during peak stress leads to an improved detection of multivessel CAD [58]. LVEF reserve provides significant independent and incremental value to Rb-82 MPI for predicting the risk of left main/3-vessel disease [57] and future adverse events [59]. A multicenter registry study included 7,061 patients with known or suspected CAD who underwent a clinically indicated rest/stress Rb-82 PET MPI (66% of patients had chronic chest pain as the reason for the test). The extent and severity of ischemia and scarring on Rb-82 PET MPI provided powerful and incremental risk estimates of cardiac death and all-cause death compared with traditional coronary risk factors [60]. PET/CT and CCTA Hybrid PET scanners use CT for attenuation correction (PET/CT) following completion of the PET study. By coupling the PET perfusion examination findings to a CCTA, PET/CT permits the fusion of complementary anatomic coronary arterial and functional (perfusion) myocardial information and enhances diagnostic accuracy [60]. The results of the combined examinations can more accurately identify patients for revascularization. In a study of 110 consecutive patients with combined stress Rb-82 PET perfusion imaging and CCTA, nearly half of the significant angiographic stenoses (47%) occurred without evidence of ischemia, whereas 50% of normal PET studies were associated with some CCTA abnormality [61]. | 69405 |
acrac_69405_10 | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs | SPECT or SPECT/CT MPI Rest and Stress Stress SPECT MPI can identify relative myocardial perfusion defects, indicating the presence of myocardial ischemia and/or infarction. The territory of the perfusion defect identifies the likely coronary artery involved and can usually distinguish between significant single-vessel and multivessel coronary arterial obstructions [62,63]. A single-center study of >900 diabetic patients demonstrated that SPECT MPI has a reported sensitivity of 87% to 89% and a specificity of 73% to 75% for detecting angiographically significant CAD [62]. Another single-center study evaluated 100 consecutive patients referred for SPECT MPI because of either chronic chest pain and no known CAD (55%) or patients with a documented history of myocardial infarction (29%) referred for risk stratification [64]. MPI and poststress and reversible regional wall motion abnormalities on exercise stress Tc-99m- gated SPECT MPI were significant predictors of angiographic disease and add incremental value to MPI for the assessment of angiographic severity [64,65]. In patients with typical angina (high pretest likelihood of disease), stress SPECT MPI is useful for estimating the extent (single vessel versus multivessel disease) and severity of coronary stenosis, which has relevance for prognosis, choice among therapeutic options, and advisability of performing coronary arteriography. A meta- analysis including 114 SPECT studies of patients with suspected or established CAD has shown the sensitivity and specificity for the detection of significant CAD and/or myocardial ischemia was 78% and 52%, respectively, with an NPV of 83% [66]. | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs. SPECT or SPECT/CT MPI Rest and Stress Stress SPECT MPI can identify relative myocardial perfusion defects, indicating the presence of myocardial ischemia and/or infarction. The territory of the perfusion defect identifies the likely coronary artery involved and can usually distinguish between significant single-vessel and multivessel coronary arterial obstructions [62,63]. A single-center study of >900 diabetic patients demonstrated that SPECT MPI has a reported sensitivity of 87% to 89% and a specificity of 73% to 75% for detecting angiographically significant CAD [62]. Another single-center study evaluated 100 consecutive patients referred for SPECT MPI because of either chronic chest pain and no known CAD (55%) or patients with a documented history of myocardial infarction (29%) referred for risk stratification [64]. MPI and poststress and reversible regional wall motion abnormalities on exercise stress Tc-99m- gated SPECT MPI were significant predictors of angiographic disease and add incremental value to MPI for the assessment of angiographic severity [64,65]. In patients with typical angina (high pretest likelihood of disease), stress SPECT MPI is useful for estimating the extent (single vessel versus multivessel disease) and severity of coronary stenosis, which has relevance for prognosis, choice among therapeutic options, and advisability of performing coronary arteriography. A meta- analysis including 114 SPECT studies of patients with suspected or established CAD has shown the sensitivity and specificity for the detection of significant CAD and/or myocardial ischemia was 78% and 52%, respectively, with an NPV of 83% [66]. | 69405 |
acrac_69405_11 | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs | Chronic Chest Pain-High Probability of CAD SPECT and CCTA Hybrid SPECT/CCTA combines the anatomical information provided by CCTA with the functional perfusion evidence of SPECT, resulting in enhanced diagnostic accuracy for detecting significant CAD compared with SPECT and CCTA alone: the sensitivity and specificity of hybrid SPECT/CCTA were 96% and 95%, respectively, compared with SPECT (93% and 79%) and CCTA (98% and 62%) alone [68]. There was 92% agreement on the necessity of revascularization in the treatment decisions based on hybrid SPECT/CCTA versus SPECT and coronary angiography alone [69]. US Echocardiography Transesophageal Ultrasound (US) echocardiography transesophageal provides assessment of LVEF and ESVI and structural assessment of the heart and ascending aorta. There is no relevant literature to support the use of transesophageal echocardiography in the initial evaluation of patients with chronic chest pain and a high probability of CAD with no known IHD. US Echocardiography Transthoracic Resting US echocardiography transthoracic resting provides assessment of ejection fraction and ventricular volumes such as LVEF and ESVI with a higher sensitivity to detect prior myocardial infarct than ischemia. Although there is no relevant literature to support transthoracic echocardiography resting in the initial evaluation of patients with chronic chest pain and a high probability of CAD with no known IHD, this modality could be used to assess new wall motion abnormalities that might raise a concern for IHD. In a meta-analysis of 435 patients (299 with and 136 without angiographically assessed CAD), dobutamine stress contractility echocardiography had 84% accuracy, 86% specificity, and 86% sensitivity for detecting CAD [71]. | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs. Chronic Chest Pain-High Probability of CAD SPECT and CCTA Hybrid SPECT/CCTA combines the anatomical information provided by CCTA with the functional perfusion evidence of SPECT, resulting in enhanced diagnostic accuracy for detecting significant CAD compared with SPECT and CCTA alone: the sensitivity and specificity of hybrid SPECT/CCTA were 96% and 95%, respectively, compared with SPECT (93% and 79%) and CCTA (98% and 62%) alone [68]. There was 92% agreement on the necessity of revascularization in the treatment decisions based on hybrid SPECT/CCTA versus SPECT and coronary angiography alone [69]. US Echocardiography Transesophageal Ultrasound (US) echocardiography transesophageal provides assessment of LVEF and ESVI and structural assessment of the heart and ascending aorta. There is no relevant literature to support the use of transesophageal echocardiography in the initial evaluation of patients with chronic chest pain and a high probability of CAD with no known IHD. US Echocardiography Transthoracic Resting US echocardiography transthoracic resting provides assessment of ejection fraction and ventricular volumes such as LVEF and ESVI with a higher sensitivity to detect prior myocardial infarct than ischemia. Although there is no relevant literature to support transthoracic echocardiography resting in the initial evaluation of patients with chronic chest pain and a high probability of CAD with no known IHD, this modality could be used to assess new wall motion abnormalities that might raise a concern for IHD. In a meta-analysis of 435 patients (299 with and 136 without angiographically assessed CAD), dobutamine stress contractility echocardiography had 84% accuracy, 86% specificity, and 86% sensitivity for detecting CAD [71]. | 69405 |
acrac_69405_12 | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs | A meta-analysis of 44 studies including patients with suspected or known CAD indicated that stress echocardiography has a sensitivity of 85% and a specificity of 77% in detection of CAD (defined as >50% coronary artery luminal diameter stenosis) [72]. In patients with suspected or known CAD, inducible wall motion abnormality during dobutamine stress echocardiography is associated with a higher risk for subsequent cardiac events. Patients with negative dobutamine stress echocardiography exhibited a lower event rate [47]. US contrast-enhanced stress echocardiography improves endocardial visualization. A single-center prospective randomized trial that included 229 patients with suspected or know CAD has demonstrated diagnostic test rates of 100% for contrast-enhanced stress echocardiography [73]. A single-center prospective study of 101 patients with an intermediate to high probability of CAD based on clinical parameters and risk factors has demonstrated that administration of an echocardiography contrast agent (ie, microbubbles) improves endocardial visualization at rest and more so during stress, leading to a more precise interpretation with greater accuracy in evaluating CAD in patients with 2 or more nonvisualized segments and low confidence of interpretation [71,74]. Variant 2: Chronic chest pain; high probability of coronary artery disease. Known ischemic heart disease with no prior definitive treatment. Initial imaging. In this clinical scenario, prior definitive treatment is defined as previous coronary artery angioplasty, stent placement, or coronary arteries bypass graft. Arteriography Coronary Catheter-based selective coronary angiography is historically considered the coronary imaging modality of choice with the highest spatial and temporal resolution. | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs. A meta-analysis of 44 studies including patients with suspected or known CAD indicated that stress echocardiography has a sensitivity of 85% and a specificity of 77% in detection of CAD (defined as >50% coronary artery luminal diameter stenosis) [72]. In patients with suspected or known CAD, inducible wall motion abnormality during dobutamine stress echocardiography is associated with a higher risk for subsequent cardiac events. Patients with negative dobutamine stress echocardiography exhibited a lower event rate [47]. US contrast-enhanced stress echocardiography improves endocardial visualization. A single-center prospective randomized trial that included 229 patients with suspected or know CAD has demonstrated diagnostic test rates of 100% for contrast-enhanced stress echocardiography [73]. A single-center prospective study of 101 patients with an intermediate to high probability of CAD based on clinical parameters and risk factors has demonstrated that administration of an echocardiography contrast agent (ie, microbubbles) improves endocardial visualization at rest and more so during stress, leading to a more precise interpretation with greater accuracy in evaluating CAD in patients with 2 or more nonvisualized segments and low confidence of interpretation [71,74]. Variant 2: Chronic chest pain; high probability of coronary artery disease. Known ischemic heart disease with no prior definitive treatment. Initial imaging. In this clinical scenario, prior definitive treatment is defined as previous coronary artery angioplasty, stent placement, or coronary arteries bypass graft. Arteriography Coronary Catheter-based selective coronary angiography is historically considered the coronary imaging modality of choice with the highest spatial and temporal resolution. | 69405 |
acrac_69405_13 | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs | Although only 2-D projection images are obtained (as opposed to 3-D volumes CCTA), selective coronary angiography is considered useful for depicting the anatomy and the severity of obstructive CAD and other coronary abnormalities (eg, coronary spasm, dissection, vasculitis) [8]. In addition to visualizing the coronary arteries, the procedure is used to guide percutaneous coronary interventions to Chronic Chest Pain-High Probability of CAD the site of blockage. LV catheterization and left ventriculography are generally indicated but not always necessary to define ventricular function in patients with known angina and IHD. FFR measurement accurately estimates the functional severity of stenosis in obstructive CAD [75-77]. The ISCHEMIA trial has shown that, among patients with stable coronary disease and moderate or severe ischemia, there was no evidence that an invasive diagnostic and therapeutic strategy, compared with an initial conservative strategy, reduced the risk of ischemic cardiovascular events or death from any cause over a median of 3.2 years [78,79]. CT Coronary Calcium There is no relevant literature to support the use of CT coronary calcium in the initial evaluation of patients with chronic chest pain and a high probability of CAD with known IHD. CT Heart Function and Morphology CT heart function and morphology can provide assessment of ventricular morphology and function as well as assessment of myocardial perfusion and infarction. There are no relevant data published on the use of CT heart for assessment of heart function and regional wall motion abnormalities in patients with chronic chest pain who have a high probability for CAD. | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs. Although only 2-D projection images are obtained (as opposed to 3-D volumes CCTA), selective coronary angiography is considered useful for depicting the anatomy and the severity of obstructive CAD and other coronary abnormalities (eg, coronary spasm, dissection, vasculitis) [8]. In addition to visualizing the coronary arteries, the procedure is used to guide percutaneous coronary interventions to Chronic Chest Pain-High Probability of CAD the site of blockage. LV catheterization and left ventriculography are generally indicated but not always necessary to define ventricular function in patients with known angina and IHD. FFR measurement accurately estimates the functional severity of stenosis in obstructive CAD [75-77]. The ISCHEMIA trial has shown that, among patients with stable coronary disease and moderate or severe ischemia, there was no evidence that an invasive diagnostic and therapeutic strategy, compared with an initial conservative strategy, reduced the risk of ischemic cardiovascular events or death from any cause over a median of 3.2 years [78,79]. CT Coronary Calcium There is no relevant literature to support the use of CT coronary calcium in the initial evaluation of patients with chronic chest pain and a high probability of CAD with known IHD. CT Heart Function and Morphology CT heart function and morphology can provide assessment of ventricular morphology and function as well as assessment of myocardial perfusion and infarction. There are no relevant data published on the use of CT heart for assessment of heart function and regional wall motion abnormalities in patients with chronic chest pain who have a high probability for CAD. | 69405 |
acrac_69405_14 | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs | Several studies have validated stress CT myocardial perfusion against SPECT, stress CMR, and invasive FFR in patients with suspected or known CAD (no clinical data reported on presence or absence of chronic chest pain) and was shown when combined with CTA to accurately predict perfusion abnormalities related to atherosclerotic luminal narrowing [19-23]. Patients with suspected or known CAD were evaluated with MPI using cardiac CT either in a single-phase mode for qualitative identification of ischemic myocardium [22] or in a multiphase mode for quantitative assessment of the myocardial blood flow [80]. Chronic infarction can often be differentiated from acute hypoperfusion by myocardial wall thinning or lower attenuation values (low or negative HU) as a result of fat tissue within the scar and/or calcifications [81]. CTA Chest CTA chest has been shown to be effective in excluding noncardiac causes for chronic chest pain narrowing the differential diagnosis and facilitating the appropriate triage for ICA. It has also been shown in some studies to facilitate the diagnosis of acute coronary syndrome and the decision on emergent catheterization, providing information on the ischemic myocardial area by detection of a localized decrease in LV enhancement [24]. There is no relevant literature to support the use of CTA chest in the initial evaluation of patients with chronic chest pain and a high probability of CAD with known IHD. CTA Triple Rule Out There is no relevant literature to support the use of TRO in the initial evaluation of patients with chronic chest pain and a high probability of CAD with known IHD. Chronic Chest Pain-High Probability of CAD thresholds of 50% [25]. In the CORE-64 study, the ROC area for cardiac CT was 0.93 using quantitative coronary angiography as the reference standard. | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs. Several studies have validated stress CT myocardial perfusion against SPECT, stress CMR, and invasive FFR in patients with suspected or known CAD (no clinical data reported on presence or absence of chronic chest pain) and was shown when combined with CTA to accurately predict perfusion abnormalities related to atherosclerotic luminal narrowing [19-23]. Patients with suspected or known CAD were evaluated with MPI using cardiac CT either in a single-phase mode for qualitative identification of ischemic myocardium [22] or in a multiphase mode for quantitative assessment of the myocardial blood flow [80]. Chronic infarction can often be differentiated from acute hypoperfusion by myocardial wall thinning or lower attenuation values (low or negative HU) as a result of fat tissue within the scar and/or calcifications [81]. CTA Chest CTA chest has been shown to be effective in excluding noncardiac causes for chronic chest pain narrowing the differential diagnosis and facilitating the appropriate triage for ICA. It has also been shown in some studies to facilitate the diagnosis of acute coronary syndrome and the decision on emergent catheterization, providing information on the ischemic myocardial area by detection of a localized decrease in LV enhancement [24]. There is no relevant literature to support the use of CTA chest in the initial evaluation of patients with chronic chest pain and a high probability of CAD with known IHD. CTA Triple Rule Out There is no relevant literature to support the use of TRO in the initial evaluation of patients with chronic chest pain and a high probability of CAD with known IHD. Chronic Chest Pain-High Probability of CAD thresholds of 50% [25]. In the CORE-64 study, the ROC area for cardiac CT was 0.93 using quantitative coronary angiography as the reference standard. | 69405 |
acrac_69405_15 | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs | CCTA also similarly predicted revascularization within 30 days as invasive angiography (ROC area 0.84 versus 0.82 for CCTA and quantitative coronary angiography, respectively) [30]. The CONFIRM registry (Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter Registry) showed that patients with nonobstructive and obstructive CAD have incrementally higher rates of mortality, whereas the absence of atherosclerosis is associated with a very favorable prognosis [83]. Presence of extensive nonobstructive CAD have higher rates of adverse cardiovascular events than patients with less extensive but obstructive disease (14.5% versus 13.6%), underscoring the prognostic value of plaque burden only available with CCTA [83]. Presence of high-risk plaque features has been shown as an independent predictor of major acute coronary events in patients with nonobstructive CAD [84-87]. In patients who underwent previous coronary stenting, CCTA can identify in-stent re-stenosis. Andreini et al [88] have demonstrated specificity, PPV, NPV, and diagnostic accuracy for in-stent re-stenosis detection were 91%, 99%, 60% and 91%, respectively. In a meta-analysis conducted by Kumbhani et al [89], the overall sensitivity, specificity, PPV, and NPV for assessable stents were 91%, 91%, 68%, and 98%. No relevant data currently exists on using CCTA for initial evaluation of patients with suspected in-stent re-stenosis with chronic chest pain and a high probability of CAD with known IHD. FFR-CT FFR-CT allows for the determination of lesion-specific ischemia associated with a coronary arterial narrowing. FFR-CT is performed in conjunction with CCTA [33,34]. FFR-CT is available for native coronary arteries and not available in patients who underwent coronary artery bypass grafts, and it is not available for assessment of stented coronary arteries [33,34]. There is no current data on use of FFR-CT in selected groups of patients with known CAD. | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs. CCTA also similarly predicted revascularization within 30 days as invasive angiography (ROC area 0.84 versus 0.82 for CCTA and quantitative coronary angiography, respectively) [30]. The CONFIRM registry (Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter Registry) showed that patients with nonobstructive and obstructive CAD have incrementally higher rates of mortality, whereas the absence of atherosclerosis is associated with a very favorable prognosis [83]. Presence of extensive nonobstructive CAD have higher rates of adverse cardiovascular events than patients with less extensive but obstructive disease (14.5% versus 13.6%), underscoring the prognostic value of plaque burden only available with CCTA [83]. Presence of high-risk plaque features has been shown as an independent predictor of major acute coronary events in patients with nonobstructive CAD [84-87]. In patients who underwent previous coronary stenting, CCTA can identify in-stent re-stenosis. Andreini et al [88] have demonstrated specificity, PPV, NPV, and diagnostic accuracy for in-stent re-stenosis detection were 91%, 99%, 60% and 91%, respectively. In a meta-analysis conducted by Kumbhani et al [89], the overall sensitivity, specificity, PPV, and NPV for assessable stents were 91%, 91%, 68%, and 98%. No relevant data currently exists on using CCTA for initial evaluation of patients with suspected in-stent re-stenosis with chronic chest pain and a high probability of CAD with known IHD. FFR-CT FFR-CT allows for the determination of lesion-specific ischemia associated with a coronary arterial narrowing. FFR-CT is performed in conjunction with CCTA [33,34]. FFR-CT is available for native coronary arteries and not available in patients who underwent coronary artery bypass grafts, and it is not available for assessment of stented coronary arteries [33,34]. There is no current data on use of FFR-CT in selected groups of patients with known CAD. | 69405 |
acrac_69405_16 | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs | In patients with stable chest pain and suspected or established CAD, FFR-CT has a high diagnostic performance when compared against invasive FFR as the reference standard: 82% specificity and 74% PPV [33]. FFR-CT provides incremental improvement in the accuracy over CCTA alone (84% versus 59%), mitigating the high sensitivity/low specificity tradeoff of CCTA [33]. Another study of patients with suspected and established CAD (no data provided on clinical symptoms) has demonstrated that FFR-CT has correctly reclassified 68% of false-positive patients as true negatives, highlighting the potential role of FFR-CT as a gatekeeper to cardiac catheterization [35,36]. MRA Coronary Arteries Without and With IV Contrast Coronary MRA does not include delayed gadolinium enhancement or viability. Coronary MRA can demonstrate lumen narrowing of the proximal coronary arteries. There is limited data on the use of MRA coronary arteries without and with IV contrast in a symptomatic patient with a high probability for CAD. In a single-center prospective study in patients with suspected CAD, 82% sensitivity, 90% specificity, 88% PPV, and 86% NPV for detecting significant CAD were demonstrated [40]. There are no relevant data evaluating MRA coronary arteries without and with IV contrast in symptomatic patients with a high probability for CAD. MRA Coronary Arteries Without IV Contrast There is limited data on the use of MRA coronary arteries without IV contrast in symptomatic patient with a high probability for CAD. Chronic Chest Pain-High Probability of CAD high sensitivity (88%), moderate specificity (72%), a moderate PPV (71%), and a high NPV (88%) with an AUC of 0.87 for detecting significant coronary artery stenosis were demonstrated [41]. | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs. In patients with stable chest pain and suspected or established CAD, FFR-CT has a high diagnostic performance when compared against invasive FFR as the reference standard: 82% specificity and 74% PPV [33]. FFR-CT provides incremental improvement in the accuracy over CCTA alone (84% versus 59%), mitigating the high sensitivity/low specificity tradeoff of CCTA [33]. Another study of patients with suspected and established CAD (no data provided on clinical symptoms) has demonstrated that FFR-CT has correctly reclassified 68% of false-positive patients as true negatives, highlighting the potential role of FFR-CT as a gatekeeper to cardiac catheterization [35,36]. MRA Coronary Arteries Without and With IV Contrast Coronary MRA does not include delayed gadolinium enhancement or viability. Coronary MRA can demonstrate lumen narrowing of the proximal coronary arteries. There is limited data on the use of MRA coronary arteries without and with IV contrast in a symptomatic patient with a high probability for CAD. In a single-center prospective study in patients with suspected CAD, 82% sensitivity, 90% specificity, 88% PPV, and 86% NPV for detecting significant CAD were demonstrated [40]. There are no relevant data evaluating MRA coronary arteries without and with IV contrast in symptomatic patients with a high probability for CAD. MRA Coronary Arteries Without IV Contrast There is limited data on the use of MRA coronary arteries without IV contrast in symptomatic patient with a high probability for CAD. Chronic Chest Pain-High Probability of CAD high sensitivity (88%), moderate specificity (72%), a moderate PPV (71%), and a high NPV (88%) with an AUC of 0.87 for detecting significant coronary artery stenosis were demonstrated [41]. | 69405 |
acrac_69405_17 | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs | In symptomatic patients with an intermediate or high pretest probability for disease, noncontrast coronary MRA had a patient-based sensitivity of 96%, a specificity of 68%, a PPV of 79%, and an NPV of 93% in the detection of functionally significant CAD as defined by a >90% stenosis or FFR <0.8 on catheter angiography. When added to a comprehensive stress-rest MRI protocol, it had a nonsignificant increase in diagnostic accuracy [42]. MRI Heart Function and Morphology Without and With IV Contrast MRI heart function and morphology without and with IV contrast can demonstrate myocardial infarction and ischemia secondary to CAD and can provide assessment of LV wall function. Extrapolation of data on MRI heart function and morphology without and with IV contrast for patients with known CAD is provided below, with a note that no information is available regarding the presence or absence of chest pain in patients included in these studies [70,90-98]. In a multicenter study, assessment of a consecutive 1,560 patients with established or suspected CAD has shown that both LVEF and the amount of myocardial damage are independent predictors of all-cause mortality. Even in patients with near-normal LVEF, significant infarction identifies a cohort with a high risk for early mortality [70]. Demonstration of residual contractile function in dysfunctional segments in response to dobutamine stimulation at cine MRI has been shown to be better than delayed-enhancement MRI alone for prediction of recovery of segmental function 3 months after revascularization [98]. Late gadolinium enhancement MRI can demonstrate the presence, location, and transmural extent of acute and chronic myocardial infarctions [90,95], with a sensitivity of 99% for the detection of acute infarction and 94% for the detection of chronic infarction [95]. | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs. In symptomatic patients with an intermediate or high pretest probability for disease, noncontrast coronary MRA had a patient-based sensitivity of 96%, a specificity of 68%, a PPV of 79%, and an NPV of 93% in the detection of functionally significant CAD as defined by a >90% stenosis or FFR <0.8 on catheter angiography. When added to a comprehensive stress-rest MRI protocol, it had a nonsignificant increase in diagnostic accuracy [42]. MRI Heart Function and Morphology Without and With IV Contrast MRI heart function and morphology without and with IV contrast can demonstrate myocardial infarction and ischemia secondary to CAD and can provide assessment of LV wall function. Extrapolation of data on MRI heart function and morphology without and with IV contrast for patients with known CAD is provided below, with a note that no information is available regarding the presence or absence of chest pain in patients included in these studies [70,90-98]. In a multicenter study, assessment of a consecutive 1,560 patients with established or suspected CAD has shown that both LVEF and the amount of myocardial damage are independent predictors of all-cause mortality. Even in patients with near-normal LVEF, significant infarction identifies a cohort with a high risk for early mortality [70]. Demonstration of residual contractile function in dysfunctional segments in response to dobutamine stimulation at cine MRI has been shown to be better than delayed-enhancement MRI alone for prediction of recovery of segmental function 3 months after revascularization [98]. Late gadolinium enhancement MRI can demonstrate the presence, location, and transmural extent of acute and chronic myocardial infarctions [90,95], with a sensitivity of 99% for the detection of acute infarction and 94% for the detection of chronic infarction [95]. | 69405 |
acrac_69405_18 | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs | Other studies have shown that delayed-enhancement MRI findings can be predictive of the potential for recovery of function in LV dysfunctional segments in chronic IHD [90,94]. Transmural extent of infarction can predict recovery of regional function in dysfunctional segments in patients evaluated before and several months after surgical revascularization [96]. Late gadolinium enhancement with a microvascular obstruction pattern is associated with greater infarct mass, infarction size, and extent of transmurality, lower ejection fraction, more adverse cardiac events early and late, and more severe late LV remodeling [91]. Infarct size at the baseline has proved to be the strongest predictor of adverse long-term LV remodeling [92]. There is a strong linear relation between scar size, LV end-systolic and end-diastolic volumes, and LVEF. Scar size is the strongest predictor of LVEF, independent of scar location and transmurality [97]. Baseline infarct size, infarct heterogeneity, and myocardial salvage are significantly associated with 90-day LVEF [93]. MRI Heart Function and Morphology Without IV Contrast MRI heart function and morphology without IV contrast provides assessment of ejection fraction and ventricular volumes including LVEF and ESVI with a higher sensitivity to detect prior myocardial infarct than ischemia. There is no relevant literature to support the use of MRI heart function and morphology without IV contrast in the initial evaluation of patients with chronic chest pain and a high probability of CAD with known IHD. MRI Heart Function with Stress Without and With IV Contrast MRI with function/wall motion (dobutamine stress test) and MRI with vasodilator stress perfusion (adenosine/regadenoson stress test) have been used to diagnose hemodynamically significant CAD in patients with an intermediate to high likelihood of having significant stenosis. | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs. Other studies have shown that delayed-enhancement MRI findings can be predictive of the potential for recovery of function in LV dysfunctional segments in chronic IHD [90,94]. Transmural extent of infarction can predict recovery of regional function in dysfunctional segments in patients evaluated before and several months after surgical revascularization [96]. Late gadolinium enhancement with a microvascular obstruction pattern is associated with greater infarct mass, infarction size, and extent of transmurality, lower ejection fraction, more adverse cardiac events early and late, and more severe late LV remodeling [91]. Infarct size at the baseline has proved to be the strongest predictor of adverse long-term LV remodeling [92]. There is a strong linear relation between scar size, LV end-systolic and end-diastolic volumes, and LVEF. Scar size is the strongest predictor of LVEF, independent of scar location and transmurality [97]. Baseline infarct size, infarct heterogeneity, and myocardial salvage are significantly associated with 90-day LVEF [93]. MRI Heart Function and Morphology Without IV Contrast MRI heart function and morphology without IV contrast provides assessment of ejection fraction and ventricular volumes including LVEF and ESVI with a higher sensitivity to detect prior myocardial infarct than ischemia. There is no relevant literature to support the use of MRI heart function and morphology without IV contrast in the initial evaluation of patients with chronic chest pain and a high probability of CAD with known IHD. MRI Heart Function with Stress Without and With IV Contrast MRI with function/wall motion (dobutamine stress test) and MRI with vasodilator stress perfusion (adenosine/regadenoson stress test) have been used to diagnose hemodynamically significant CAD in patients with an intermediate to high likelihood of having significant stenosis. | 69405 |
acrac_69405_19 | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs | Extrapolation of data from MRI heart function and morphology without and with IV contrast for patients with known CAD is provided below with a note that there is no information available regarding the presence or absence of chest pain in patients included in those studies [46,48,49,51,52]. A single-center prospective study of 884 patients with known (70%) or suspected (30%) CAD demonstrated that inducible LV wall motion abnormalities during dobutamine CMR predicts cardiac death and myocardial ischemia [46]. A single-center prospective study focusing on women with known or suspected CAD and variable clinical symptoms demonstrated that, similar to men, dobutamine CMR can identify cardiac risk in women with known or suspected IHD [47]. A single-center study of 815 consecutive patients referred for evaluation of suspected myocardial ischemia over a 10-year period has shown that stress CMR with protocol, including stress and rest myocardial perfusion, ventricular function, and late gadolinium enhancement, effectively reclassifies patient risk beyond standard clinical variables, specifically in patients at a moderate to high pretest clinical risk and in patients with established CAD [48]. Chronic Chest Pain-High Probability of CAD Stress CMR has a high NPV for adverse cardiac events in patients with known or suspected CAD [46,47]. A meta- analysis of 14 studies has shown that MRI heart function stress has a high NPV for adverse cardiac events, and the absence of inducible perfusion defect or wall motion abnormality shows a similar ability to identify patients with a low risk for adverse cardiac events among patients with known or suspected CAD [49]. | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs. Extrapolation of data from MRI heart function and morphology without and with IV contrast for patients with known CAD is provided below with a note that there is no information available regarding the presence or absence of chest pain in patients included in those studies [46,48,49,51,52]. A single-center prospective study of 884 patients with known (70%) or suspected (30%) CAD demonstrated that inducible LV wall motion abnormalities during dobutamine CMR predicts cardiac death and myocardial ischemia [46]. A single-center prospective study focusing on women with known or suspected CAD and variable clinical symptoms demonstrated that, similar to men, dobutamine CMR can identify cardiac risk in women with known or suspected IHD [47]. A single-center study of 815 consecutive patients referred for evaluation of suspected myocardial ischemia over a 10-year period has shown that stress CMR with protocol, including stress and rest myocardial perfusion, ventricular function, and late gadolinium enhancement, effectively reclassifies patient risk beyond standard clinical variables, specifically in patients at a moderate to high pretest clinical risk and in patients with established CAD [48]. Chronic Chest Pain-High Probability of CAD Stress CMR has a high NPV for adverse cardiac events in patients with known or suspected CAD [46,47]. A meta- analysis of 14 studies has shown that MRI heart function stress has a high NPV for adverse cardiac events, and the absence of inducible perfusion defect or wall motion abnormality shows a similar ability to identify patients with a low risk for adverse cardiac events among patients with known or suspected CAD [49]. | 69405 |
acrac_69405_20 | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs | A meta-analysis from pooled studies found that perfusion MRI heart function stress has a sensitivity of 89.1% and a specificity of 84.9% on a patient-based analysis using FFR as a reference, suggesting that stress perfusion MRI remains an accurate test for the detection of flow-limiting stenosis in patients with suspected or established CAD [6]. Another meta-analysis of 37 studies, including 2,191 patients with high CAD prevalence, stress CMR, using either wall motion abnormality or perfusion abnormality technique, demonstrates overall good sensitivity and specificity for the diagnosis of CAD: stress-induced wall motion abnormalities imaging demonstrated a sensitivity of 0.83 and specificity of 0.86 on a patient level (disease prevalence = 70.5%). Stress perfusion imaging demonstrated a sensitivity of 0.91 and specificity of 0.81 on a patient level (disease prevalence = 57.4%) [51]. In patients with known or suspected CAD, the presence of late gadolinium enhancement and stress perfusion defect plus abnormal wall motion are independent predictors of all hard cardiac events [52]. MRI Heart Function with Stress Without IV Contrast MRI heart function stress without IV contrast can provide assessment of ventricular function/wall motion abnormalities. A single-center prospective study of 884 patients with known (70%) or suspected (30%) CAD demonstrated that inducible LV wall motion abnormalities during dobutamine CMR predicts cardiac death and myocardial ischemia [46]. A single-center prospective study focusing on women with known or suspected CAD and variable clinical symptoms demonstrated that, similar to men, dobutamine CMR can identify cardiac risk in women with known or suspected IHD [47]. A single-center prospective study of 208 patients with suspected CAD has demonstrated a high accuracy for detecting wall motion abnormalities related to ischemia with 86.2% sensitivity and 85.7% specificity [53]. | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs. A meta-analysis from pooled studies found that perfusion MRI heart function stress has a sensitivity of 89.1% and a specificity of 84.9% on a patient-based analysis using FFR as a reference, suggesting that stress perfusion MRI remains an accurate test for the detection of flow-limiting stenosis in patients with suspected or established CAD [6]. Another meta-analysis of 37 studies, including 2,191 patients with high CAD prevalence, stress CMR, using either wall motion abnormality or perfusion abnormality technique, demonstrates overall good sensitivity and specificity for the diagnosis of CAD: stress-induced wall motion abnormalities imaging demonstrated a sensitivity of 0.83 and specificity of 0.86 on a patient level (disease prevalence = 70.5%). Stress perfusion imaging demonstrated a sensitivity of 0.91 and specificity of 0.81 on a patient level (disease prevalence = 57.4%) [51]. In patients with known or suspected CAD, the presence of late gadolinium enhancement and stress perfusion defect plus abnormal wall motion are independent predictors of all hard cardiac events [52]. MRI Heart Function with Stress Without IV Contrast MRI heart function stress without IV contrast can provide assessment of ventricular function/wall motion abnormalities. A single-center prospective study of 884 patients with known (70%) or suspected (30%) CAD demonstrated that inducible LV wall motion abnormalities during dobutamine CMR predicts cardiac death and myocardial ischemia [46]. A single-center prospective study focusing on women with known or suspected CAD and variable clinical symptoms demonstrated that, similar to men, dobutamine CMR can identify cardiac risk in women with known or suspected IHD [47]. A single-center prospective study of 208 patients with suspected CAD has demonstrated a high accuracy for detecting wall motion abnormalities related to ischemia with 86.2% sensitivity and 85.7% specificity [53]. | 69405 |
acrac_69405_21 | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs | A single-center prospective study of 153 patients with suspected or know CAD with and without chest pain has demonstrated 83% sensitivity and 83% specificity for detecting a >50% luminal diameter narrowing based on stress- induced abnormal LV contractility [54] Nuclear Medicine Ventriculography Stress radionuclide ventriculography includes measurement of the ejection fraction and assessment of regional wall motion at rest and during stress. There is no relevant literature to support nuclear medicine ventriculography in the initial evaluation of patients with chronic chest pain and a high probability of CAD with no known IHD. Rb-82 PET/CT Heart Rb-82 PET/CT heart assesses rest myocardial perfusion and stress LVEF and quantifies rest myocardial blood flow and coronary flow reserve [55,56]. PET/CT has reported a higher accuracy over conventional nuclear techniques, MPI, and viability [55,57]. The data cited below for Rb-82 PET/CT heart are for patients with known CAD, but no information is available regarding the presence or absence of chest pain in patients included in those studies. Gated Rb-82 PET/CT has shown that myocardial perfusion, stress LVEF, and ischemic LV dysfunction are prognostically important in CAD in patients with suspected or known CAD [48]. The inherent ability of Rb-82 PET/CT to collect LV function data at rest and during peak stress seems to result in improved detection of multivessel CAD with LVEF reserve assessment providing significant independent and incremental value to Rb-82 MPI for predicting the risk of future adverse events [59]. An increasing percentage of ischemia on PET-MPI is associated with an increase in the risk of cardiac events and all-cause death [59]. A single-center study of 1,432 patients with known or suspected CAD has shown that the inherent ability of Rb-82 PET/CT to collect LV function data at rest and during peak stress leads to an improved detection of multivessel CAD [58]. | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs. A single-center prospective study of 153 patients with suspected or know CAD with and without chest pain has demonstrated 83% sensitivity and 83% specificity for detecting a >50% luminal diameter narrowing based on stress- induced abnormal LV contractility [54] Nuclear Medicine Ventriculography Stress radionuclide ventriculography includes measurement of the ejection fraction and assessment of regional wall motion at rest and during stress. There is no relevant literature to support nuclear medicine ventriculography in the initial evaluation of patients with chronic chest pain and a high probability of CAD with no known IHD. Rb-82 PET/CT Heart Rb-82 PET/CT heart assesses rest myocardial perfusion and stress LVEF and quantifies rest myocardial blood flow and coronary flow reserve [55,56]. PET/CT has reported a higher accuracy over conventional nuclear techniques, MPI, and viability [55,57]. The data cited below for Rb-82 PET/CT heart are for patients with known CAD, but no information is available regarding the presence or absence of chest pain in patients included in those studies. Gated Rb-82 PET/CT has shown that myocardial perfusion, stress LVEF, and ischemic LV dysfunction are prognostically important in CAD in patients with suspected or known CAD [48]. The inherent ability of Rb-82 PET/CT to collect LV function data at rest and during peak stress seems to result in improved detection of multivessel CAD with LVEF reserve assessment providing significant independent and incremental value to Rb-82 MPI for predicting the risk of future adverse events [59]. An increasing percentage of ischemia on PET-MPI is associated with an increase in the risk of cardiac events and all-cause death [59]. A single-center study of 1,432 patients with known or suspected CAD has shown that the inherent ability of Rb-82 PET/CT to collect LV function data at rest and during peak stress leads to an improved detection of multivessel CAD [58]. | 69405 |
acrac_69405_22 | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs | LVEF reserve provides significant independent and incremental value to Rb-82 MPI for predicting the risk of left main/3-vessel disease [57] and future adverse events [59]. Chronic Chest Pain-High Probability of CAD A multicenter registry study included 7,061 patients with known or suspected CAD who underwent a clinically indicated rest/stress Rb-82 PET MPI (66% of patients had chronic chest pain as the reason for the test). The extent and severity of ischemia and scarring on Rb-82 PET MPI provided powerful and incremental risk estimates of cardiac death and all-cause death compared with traditional coronary risk factors [60]. PET and CCTA Hybrid PET scanners use CT for attenuation correction (PET/CT) following completion of the PET study. By coupling the PET perfusion examination findings to a CCTA, PET/CT permits the fusion of complementary anatomic coronary arterial and functional (perfusion) myocardial information and enhances diagnostic accuracy [60]. The results of the combined examinations can more accurately identify patients for revascularization. In a study of 110 consecutive patients with a combined stress Rb-82 PET perfusion imaging and CCTA, nearly half of significant angiographic stenoses (47%) occurred without evidence of ischemia, whereas 50% of normal PET studies were associated with some CCTA abnormality [61]. SPECT or SPECT/CT MPI Rest and Stress Stress SPECT MPI can identify relative myocardial perfusion defects, indicating the presence of myocardial ischemia and/or infarction. By acquiring rest and stress perfusion scans, it is possible to demonstrate reversibility (ischemia) or irreversibility (infarction) of a myocardial perfusion defect. The territory of the perfusion defect identifies the likely coronary artery involved and can usually distinguish between significant single-vessel and multivessel coronary arterial obstructions. | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs. LVEF reserve provides significant independent and incremental value to Rb-82 MPI for predicting the risk of left main/3-vessel disease [57] and future adverse events [59]. Chronic Chest Pain-High Probability of CAD A multicenter registry study included 7,061 patients with known or suspected CAD who underwent a clinically indicated rest/stress Rb-82 PET MPI (66% of patients had chronic chest pain as the reason for the test). The extent and severity of ischemia and scarring on Rb-82 PET MPI provided powerful and incremental risk estimates of cardiac death and all-cause death compared with traditional coronary risk factors [60]. PET and CCTA Hybrid PET scanners use CT for attenuation correction (PET/CT) following completion of the PET study. By coupling the PET perfusion examination findings to a CCTA, PET/CT permits the fusion of complementary anatomic coronary arterial and functional (perfusion) myocardial information and enhances diagnostic accuracy [60]. The results of the combined examinations can more accurately identify patients for revascularization. In a study of 110 consecutive patients with a combined stress Rb-82 PET perfusion imaging and CCTA, nearly half of significant angiographic stenoses (47%) occurred without evidence of ischemia, whereas 50% of normal PET studies were associated with some CCTA abnormality [61]. SPECT or SPECT/CT MPI Rest and Stress Stress SPECT MPI can identify relative myocardial perfusion defects, indicating the presence of myocardial ischemia and/or infarction. By acquiring rest and stress perfusion scans, it is possible to demonstrate reversibility (ischemia) or irreversibility (infarction) of a myocardial perfusion defect. The territory of the perfusion defect identifies the likely coronary artery involved and can usually distinguish between significant single-vessel and multivessel coronary arterial obstructions. | 69405 |
acrac_69405_23 | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs | The magnitude of the abnormality and the presence of high-risk findings also assist in clinical decision making [62,63]. The data cited below for SPECT or SPECT/CT MPI rest and stress are for patients with known CAD, but no information is available regarding the presence or absence of chest pain in patients included in these studies. A single-center study evaluated 100 consecutive patients referred for SPECT MPI due to either chronic chest pain and no known CAD (55%) and patients with a documented history of myocardial infarction (29%) referred for risk stratification [64]. MPI and poststress and reversible regional wall motion abnormalities on exercise stress Tc-99m- gated SPECT MPI were significant predictors of angiographic disease and add incremental value to MPI for the assessment of angiographic severity [64,65]. In patients with typical angina (high pretest likelihood of disease), stress SPECT MPI is useful for estimating the extent (single vessel versus multivessel disease) and severity of coronary stenosis, which has relevance for prognosis, choice among therapeutic options, and advisability of performing coronary arteriography. A meta- analysis including 114 SPECT studies of patients with suspected or established CAD have shown sensitivity and specificity for the detection of significant CAD and/or myocardial ischemia was 78% and 52%, respectively, with an NPV of 83% [66]. SPECT and CCTA Hybrid SPECT/CCTA combines the anatomical information provided by CCTA with the functional perfusion evidence of SPECT, resulting in an enhanced diagnostic accuracy for detecting significant CAD compared with SPECT and CCTA alone: the sensitivity and specificity of hybrid SPECT/CCTA were 96% and 95%, respectively, compared with SPECT (93% and 79%) and CCTA (98% and 62%) alone [68]. There was 92% agreement on the necessity of revascularization in the treatment decisions based on hybrid SPECT/CCTA versus SPECT and coronary angiography alone [69]. | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs. The magnitude of the abnormality and the presence of high-risk findings also assist in clinical decision making [62,63]. The data cited below for SPECT or SPECT/CT MPI rest and stress are for patients with known CAD, but no information is available regarding the presence or absence of chest pain in patients included in these studies. A single-center study evaluated 100 consecutive patients referred for SPECT MPI due to either chronic chest pain and no known CAD (55%) and patients with a documented history of myocardial infarction (29%) referred for risk stratification [64]. MPI and poststress and reversible regional wall motion abnormalities on exercise stress Tc-99m- gated SPECT MPI were significant predictors of angiographic disease and add incremental value to MPI for the assessment of angiographic severity [64,65]. In patients with typical angina (high pretest likelihood of disease), stress SPECT MPI is useful for estimating the extent (single vessel versus multivessel disease) and severity of coronary stenosis, which has relevance for prognosis, choice among therapeutic options, and advisability of performing coronary arteriography. A meta- analysis including 114 SPECT studies of patients with suspected or established CAD have shown sensitivity and specificity for the detection of significant CAD and/or myocardial ischemia was 78% and 52%, respectively, with an NPV of 83% [66]. SPECT and CCTA Hybrid SPECT/CCTA combines the anatomical information provided by CCTA with the functional perfusion evidence of SPECT, resulting in an enhanced diagnostic accuracy for detecting significant CAD compared with SPECT and CCTA alone: the sensitivity and specificity of hybrid SPECT/CCTA were 96% and 95%, respectively, compared with SPECT (93% and 79%) and CCTA (98% and 62%) alone [68]. There was 92% agreement on the necessity of revascularization in the treatment decisions based on hybrid SPECT/CCTA versus SPECT and coronary angiography alone [69]. | 69405 |
acrac_69405_24 | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs | US Echocardiography Transesophageal There is no relevant literature to support the use of transesophageal echocardiography in the initial evaluation of patients with chronic chest pain and a high probability of CAD with known IHD. US Echocardiography Transthoracic Resting US echocardiography transthoracic resting provides assessment of ejection fraction and ventricular volumes such as LVEF and ESVI with a higher sensitivity to detect prior myocardial infarct than ischemia. Although there is no relevant literature evaluating the use transthoracic echocardiography resting in the initial evaluation of patients with Chronic Chest Pain-High Probability of CAD chronic chest pain and known IHD, this modality provides information about wall motion abnormality and left ventricular function which may inform next step management of patients with IHD. US Echocardiography Transthoracic Stress US stress 2-D echocardiography depiction of myocardial contractility during rest and stress is used for the evaluation of patients with suspected regional wall motion abnormalities secondary to inducible regional ischemia. The data cited below for US Echocardiography transthoracic stress are for patients with known CAD, but no information is available regarding the presence or absence of chest pain in patients included in those studies. In a meta-analysis of 435 patients (299 with and 136 without angiographically assessed CAD), dobutamine stress contractility echocardiography had 84% accuracy, 86% specificity, and 86% sensitivity for detecting CAD [71]. A meta-analysis of 44 studies including patients with suspected or known CAD indicated that stress echocardiography has a sensitivity of 85% and a specificity of 77% in detection of CAD (defined as >50% coronary artery luminal diameter stenosis) [72]. | Chronic Chest Pain High Probability of Coronary Artery Disease PCAs. US Echocardiography Transesophageal There is no relevant literature to support the use of transesophageal echocardiography in the initial evaluation of patients with chronic chest pain and a high probability of CAD with known IHD. US Echocardiography Transthoracic Resting US echocardiography transthoracic resting provides assessment of ejection fraction and ventricular volumes such as LVEF and ESVI with a higher sensitivity to detect prior myocardial infarct than ischemia. Although there is no relevant literature evaluating the use transthoracic echocardiography resting in the initial evaluation of patients with Chronic Chest Pain-High Probability of CAD chronic chest pain and known IHD, this modality provides information about wall motion abnormality and left ventricular function which may inform next step management of patients with IHD. US Echocardiography Transthoracic Stress US stress 2-D echocardiography depiction of myocardial contractility during rest and stress is used for the evaluation of patients with suspected regional wall motion abnormalities secondary to inducible regional ischemia. The data cited below for US Echocardiography transthoracic stress are for patients with known CAD, but no information is available regarding the presence or absence of chest pain in patients included in those studies. In a meta-analysis of 435 patients (299 with and 136 without angiographically assessed CAD), dobutamine stress contractility echocardiography had 84% accuracy, 86% specificity, and 86% sensitivity for detecting CAD [71]. A meta-analysis of 44 studies including patients with suspected or known CAD indicated that stress echocardiography has a sensitivity of 85% and a specificity of 77% in detection of CAD (defined as >50% coronary artery luminal diameter stenosis) [72]. | 69405 |
acrac_3128014_0 | Syncope | Elucidating the underlying cause of a syncopal or presyncopal episode can be challenging. There are numerous potential cardiovascular or neurologic etiologies, many of which rely on appropriate imaging for identification and classification; these include coronary artery disease, aortic disease, and cardiomyopathies. Although the etiology is never discovered in one-third of patients [10], and some causes such as vasovagal syncope are relatively innocuous, others, such as cardiac-related syncope, carry a significant increased risk of death [10-13]. The mainstay of syncope and presyncope assessment is a detailed history and physical examination. The assessment should include measurement of postural changes in blood pressure to diagnose orthostatic-related syncope and a detailed neurologic history and physical examination to exclude symptoms or signs of a separate neurologic process, which would require a different course of evaluation [14]. In addition to a detailed cardiac examination assessing for structural heart disease, certain patient characteristics are associated with an increased risk of cardiac-related syncope and include the following: age >60 years, male gender, known underlying congenital or acquired cardiac disease, palpitations or other cardiac-related symptoms prior to syncopal episode, syncope during exertion, syncope in supine position, low number of prior syncopal episodes, and family history of sudden cardiac death [3]. Studies have shown that patients with syncope and presyncope have a low yield of 5% to 6.4% of an acute abnormality on head CT, nearly all with external evidence of head trauma or a focal neurological deficit on examination [15-19]. Increasing age has been associated with higher odds for a CT abnormality compared with younger patients with syncope, however, the age cutoffs of >55 [15] or 60 and older [19] have not been validated across studies as independent predictive factors in absence of trauma or neurologic deficit [20]. | Syncope. Elucidating the underlying cause of a syncopal or presyncopal episode can be challenging. There are numerous potential cardiovascular or neurologic etiologies, many of which rely on appropriate imaging for identification and classification; these include coronary artery disease, aortic disease, and cardiomyopathies. Although the etiology is never discovered in one-third of patients [10], and some causes such as vasovagal syncope are relatively innocuous, others, such as cardiac-related syncope, carry a significant increased risk of death [10-13]. The mainstay of syncope and presyncope assessment is a detailed history and physical examination. The assessment should include measurement of postural changes in blood pressure to diagnose orthostatic-related syncope and a detailed neurologic history and physical examination to exclude symptoms or signs of a separate neurologic process, which would require a different course of evaluation [14]. In addition to a detailed cardiac examination assessing for structural heart disease, certain patient characteristics are associated with an increased risk of cardiac-related syncope and include the following: age >60 years, male gender, known underlying congenital or acquired cardiac disease, palpitations or other cardiac-related symptoms prior to syncopal episode, syncope during exertion, syncope in supine position, low number of prior syncopal episodes, and family history of sudden cardiac death [3]. Studies have shown that patients with syncope and presyncope have a low yield of 5% to 6.4% of an acute abnormality on head CT, nearly all with external evidence of head trauma or a focal neurological deficit on examination [15-19]. Increasing age has been associated with higher odds for a CT abnormality compared with younger patients with syncope, however, the age cutoffs of >55 [15] or 60 and older [19] have not been validated across studies as independent predictive factors in absence of trauma or neurologic deficit [20]. | 3128014 |
acrac_3128014_1 | Syncope | There is a consensus across multidisciplinary task forces, clinical guidelines, and the ACR Choosing Wisely review that brain CT and MRI should be avoided in uncomplicated syncope [3,8,21]. Cohort studies and a meta-analysis of 12 additional studies reported <1% occurrence of new neurological diagnosis (including stroke) within 30 days from original presentation of syncope or presyncope [4,18,22,23]. aUniversity of California San Diego, San Diego, California. bUniversity of California San Diego, San Diego, California. cPanel Chair, Duke University Medical Center, Durham, North Carolina. dPanel Chair, University of Iowa Hospitals and Clinics, Iowa City, Iowa. ePanel Vice-Chair, Massachusetts General Hospital, Boston, Massachusetts. fMichigan State University, East Lansing, Michigan; American College of Emergency Physicians. gThe University of Chicago Medical Center, Chicago, Illinois; American College of Physicians. hAlpert Medical School of Brown University, Providence, Rhode Island. iSanger Heart and Vascular Institute, Charlotte, North Carolina; Cardiology expert. jVancouver General Hospital, Vancouver, British Columbia, Canada. kUniversity of California Los Angeles, Los Angeles, California. lGill Heart & Vascular Institute, University of Kentucky, Lexington, Kentucky; Society for Cardiovascular Magnetic Resonance. mUniversity of California Los Angeles, Los Angeles, California; American Academy of Neurology. nHarvard Medical School, Boston, Massachusetts. oNaval Medical Center Portsmouth, Portsmouth, Virginia. pUniversity of California San Diego, San Diego, California. qUniversity of North Carolina School of Medicine, Chapel Hill, North Carolina; American Academy of Neurology. rUniversity of Virginia Health System, Charlottesville, Virginia; Society of Cardiovascular Computed Tomography. sUniversity of Cincinnati Medical Center, Cincinnati, Ohio. tAscension Healthcare Wisconsin, Milwaukee, Wisconsin; Nuclear cardiology expert. | Syncope. There is a consensus across multidisciplinary task forces, clinical guidelines, and the ACR Choosing Wisely review that brain CT and MRI should be avoided in uncomplicated syncope [3,8,21]. Cohort studies and a meta-analysis of 12 additional studies reported <1% occurrence of new neurological diagnosis (including stroke) within 30 days from original presentation of syncope or presyncope [4,18,22,23]. aUniversity of California San Diego, San Diego, California. bUniversity of California San Diego, San Diego, California. cPanel Chair, Duke University Medical Center, Durham, North Carolina. dPanel Chair, University of Iowa Hospitals and Clinics, Iowa City, Iowa. ePanel Vice-Chair, Massachusetts General Hospital, Boston, Massachusetts. fMichigan State University, East Lansing, Michigan; American College of Emergency Physicians. gThe University of Chicago Medical Center, Chicago, Illinois; American College of Physicians. hAlpert Medical School of Brown University, Providence, Rhode Island. iSanger Heart and Vascular Institute, Charlotte, North Carolina; Cardiology expert. jVancouver General Hospital, Vancouver, British Columbia, Canada. kUniversity of California Los Angeles, Los Angeles, California. lGill Heart & Vascular Institute, University of Kentucky, Lexington, Kentucky; Society for Cardiovascular Magnetic Resonance. mUniversity of California Los Angeles, Los Angeles, California; American Academy of Neurology. nHarvard Medical School, Boston, Massachusetts. oNaval Medical Center Portsmouth, Portsmouth, Virginia. pUniversity of California San Diego, San Diego, California. qUniversity of North Carolina School of Medicine, Chapel Hill, North Carolina; American Academy of Neurology. rUniversity of Virginia Health System, Charlottesville, Virginia; Society of Cardiovascular Computed Tomography. sUniversity of Cincinnati Medical Center, Cincinnati, Ohio. tAscension Healthcare Wisconsin, Milwaukee, Wisconsin; Nuclear cardiology expert. | 3128014 |
acrac_3128014_2 | Syncope | uSpecialty Chair, Atlanta VA Health Care System and Emory University, Atlanta, Georgia. vSpecialty Chair, UT Southwestern Medical Center, Dallas, Texas. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through representation of such organizations on expert panels. Participation on the expert panel does not necessarily imply endorsement of the final document by individual contributors or their respective organization. Reprint requests to: [email protected] Syncope Although there is conflicting data regarding its utility, multisociety guidelines suggest a resting 12-lead electrocardiogram (ECG) for all patients to detect arrhythmias or abnormality indicative of higher risk for arrhythmia (eg, prolonged QT interval) [7-9,11]. Although additional laboratory, physiologic, and image-based testing can be performed, it is recommended that testing be limited to select patients based on clinical assessment. In most instances, nonfocused additional testing in a patient with syncope or presyncope does not improve diagnostic yield, however, it does increase the hospitalization rate and significantly increases cost, and therefore is not endorsed by any major medical society [3,8,9,20,24]. All elements are essential: 1) timing, 2) reconstructions/reformats, and 3) 3-D renderings. Standard CTs with contrast also include timing issues and reconstructions/reformats. Only in CTA, however, is 3-D rendering a required element. This corresponds to the definitions that the CMS has applied to the Current Procedural Terminology codes. Syncope Discussion of Procedures by Variant Variant 1: Presyncope or syncope. Clinical suspicion for cardiovascular etiology based on history, physical examination, and ECG findings. Initial imaging. CT Head Serial studies of patients with syncope or presyncope have shown that head CT does not influence treatment management in this clinical scenario [15-19]. | Syncope. uSpecialty Chair, Atlanta VA Health Care System and Emory University, Atlanta, Georgia. vSpecialty Chair, UT Southwestern Medical Center, Dallas, Texas. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through representation of such organizations on expert panels. Participation on the expert panel does not necessarily imply endorsement of the final document by individual contributors or their respective organization. Reprint requests to: [email protected] Syncope Although there is conflicting data regarding its utility, multisociety guidelines suggest a resting 12-lead electrocardiogram (ECG) for all patients to detect arrhythmias or abnormality indicative of higher risk for arrhythmia (eg, prolonged QT interval) [7-9,11]. Although additional laboratory, physiologic, and image-based testing can be performed, it is recommended that testing be limited to select patients based on clinical assessment. In most instances, nonfocused additional testing in a patient with syncope or presyncope does not improve diagnostic yield, however, it does increase the hospitalization rate and significantly increases cost, and therefore is not endorsed by any major medical society [3,8,9,20,24]. All elements are essential: 1) timing, 2) reconstructions/reformats, and 3) 3-D renderings. Standard CTs with contrast also include timing issues and reconstructions/reformats. Only in CTA, however, is 3-D rendering a required element. This corresponds to the definitions that the CMS has applied to the Current Procedural Terminology codes. Syncope Discussion of Procedures by Variant Variant 1: Presyncope or syncope. Clinical suspicion for cardiovascular etiology based on history, physical examination, and ECG findings. Initial imaging. CT Head Serial studies of patients with syncope or presyncope have shown that head CT does not influence treatment management in this clinical scenario [15-19]. | 3128014 |
acrac_3128014_3 | Syncope | CT Heart Function and Morphology There is no relevant literature that examines the use of ECG-gated CT heart in this clinical scenario. CT heart can identify hypertrophic cardiomyopathy and thrombus in the cardiac chambers. CTA Coronary Arteries One small retrospective study found that patients with cardiac-related syncope or presyncope had a greater extent and severity of coronary artery disease by coronary CTA (CCTA) compared with those with noncardiac-related syncope and matched patients with chest pain and no syncope [48]. Additionally, anomalous coronary arteries can be a cause of exercise-induced syncope or presyncope, especially in younger patients [49,50]. However, there are no prospective or large retrospective studies assessing the utility of CCTA in patients with syncope or presyncope as the only presenting finding. MRI Head There is no relevant literature to support the use of head MRI in this clinical scenario. MRI Heart Function and Morphology There is no relevant literature that examines the use of cardiac MRI in this clinical scenario. MRI heart can provide detailed analysis of cardiac function, morphology, and physiology. MRI is a valuable tool in the diagnosis of infiltrative cardiomyopathies that can manifest with episodes of syncope and presyncope including hypertrophic cardiomyopathy [51,52], sarcoid [53,54], myocarditis [55-57], amyloid [58], arrhythmogenic right ventricular dysplasia [58], and nonischemic dilated cardiomyopathy [58,59]. In both ischemic and nonischemic cardiomyopathies, MRI can assess for areas of scarring, which can serve as an arrhythmogenic focus and can lead to syncope or sudden cardiac death [60]. Although not routinely utilized as an initial imaging tool, cardiac MRI could be utilized in stable patients as an alternative to echocardiography when image quality is not diagnostic or optimal. Radiography Chest There are no prospective studies that examine the use of chest radiographs in patients with syncope or presyncope. | Syncope. CT Heart Function and Morphology There is no relevant literature that examines the use of ECG-gated CT heart in this clinical scenario. CT heart can identify hypertrophic cardiomyopathy and thrombus in the cardiac chambers. CTA Coronary Arteries One small retrospective study found that patients with cardiac-related syncope or presyncope had a greater extent and severity of coronary artery disease by coronary CTA (CCTA) compared with those with noncardiac-related syncope and matched patients with chest pain and no syncope [48]. Additionally, anomalous coronary arteries can be a cause of exercise-induced syncope or presyncope, especially in younger patients [49,50]. However, there are no prospective or large retrospective studies assessing the utility of CCTA in patients with syncope or presyncope as the only presenting finding. MRI Head There is no relevant literature to support the use of head MRI in this clinical scenario. MRI Heart Function and Morphology There is no relevant literature that examines the use of cardiac MRI in this clinical scenario. MRI heart can provide detailed analysis of cardiac function, morphology, and physiology. MRI is a valuable tool in the diagnosis of infiltrative cardiomyopathies that can manifest with episodes of syncope and presyncope including hypertrophic cardiomyopathy [51,52], sarcoid [53,54], myocarditis [55-57], amyloid [58], arrhythmogenic right ventricular dysplasia [58], and nonischemic dilated cardiomyopathy [58,59]. In both ischemic and nonischemic cardiomyopathies, MRI can assess for areas of scarring, which can serve as an arrhythmogenic focus and can lead to syncope or sudden cardiac death [60]. Although not routinely utilized as an initial imaging tool, cardiac MRI could be utilized in stable patients as an alternative to echocardiography when image quality is not diagnostic or optimal. Radiography Chest There are no prospective studies that examine the use of chest radiographs in patients with syncope or presyncope. | 3128014 |
acrac_3128014_4 | Syncope | In one large retrospective multi-institution study evaluating syncope and presyncope in 3,686 patients >60 years of Syncope age, 2,767 (75.1%) had a chest radiograph performed [61]. Of those, 182 (6.6%), had a radiograph interpreted as abnormal. In a smaller retrospective study performed at a single institution, only 4.5% of patients with syncope had an abnormal chest radiograph. However, patients with syncope or presyncope who had abnormal chest radiographs were more likely to have serious adverse events compared with those with normal radiographs [62]. SPECT or SPECT/CT MPI Rest and Stress There is no relevant literature to support the routine use of a Tc-99m single-photon emission CT (SPECT) or SPECT/CT myocardial perfusion imaging (MPI) rest and stress in most patients with syncope. Limited data from one large retrospective study assessing the use of MPI in 700 patients with syncope of any cause and no known coronary artery disease concluded there was no significant utility for rest and stress testing [63]. SPECT or SPECT/CT MPI Stress Only There is no relevant literature that examines the use of Tc-99m SPECT or SPECT/CT MPI stress only study in this clinical scenario. US Duplex Doppler Carotid Artery Multiple studies have shown no benefit of carotid artery Doppler ultrasound (US) in patients with syncope or presyncope in the absence of neurologic findings or carotid bruit [20,64-66]. US Echocardiography Transesophageal There is no relevant literature to support the use of a transesophageal echocardiography in the evaluation of syncope or presyncope. Transesophageal echocardiography can further elucidate abnormal findings visualized on transthoracic echocardiogram. US Echocardiography Transthoracic Resting Transthoracic resting echocardiography provides a noninvasive assessment of cardiac structure and function. | Syncope. In one large retrospective multi-institution study evaluating syncope and presyncope in 3,686 patients >60 years of Syncope age, 2,767 (75.1%) had a chest radiograph performed [61]. Of those, 182 (6.6%), had a radiograph interpreted as abnormal. In a smaller retrospective study performed at a single institution, only 4.5% of patients with syncope had an abnormal chest radiograph. However, patients with syncope or presyncope who had abnormal chest radiographs were more likely to have serious adverse events compared with those with normal radiographs [62]. SPECT or SPECT/CT MPI Rest and Stress There is no relevant literature to support the routine use of a Tc-99m single-photon emission CT (SPECT) or SPECT/CT myocardial perfusion imaging (MPI) rest and stress in most patients with syncope. Limited data from one large retrospective study assessing the use of MPI in 700 patients with syncope of any cause and no known coronary artery disease concluded there was no significant utility for rest and stress testing [63]. SPECT or SPECT/CT MPI Stress Only There is no relevant literature that examines the use of Tc-99m SPECT or SPECT/CT MPI stress only study in this clinical scenario. US Duplex Doppler Carotid Artery Multiple studies have shown no benefit of carotid artery Doppler ultrasound (US) in patients with syncope or presyncope in the absence of neurologic findings or carotid bruit [20,64-66]. US Echocardiography Transesophageal There is no relevant literature to support the use of a transesophageal echocardiography in the evaluation of syncope or presyncope. Transesophageal echocardiography can further elucidate abnormal findings visualized on transthoracic echocardiogram. US Echocardiography Transthoracic Resting Transthoracic resting echocardiography provides a noninvasive assessment of cardiac structure and function. | 3128014 |
acrac_3128014_5 | Syncope | In patients with an abnormal ECG or findings on history or physical examination suggesting a cardiac etiology of syncope or presyncope, transthoracic echocardiography can be used to assess for structural heart disease or to help identify risk factors for malignant arrhythmias and is validated by multiple studies and supported by numerous societies [3,8,67-69]. Possible etiologies include various cardiomyopathies, valvular disease, pericardial disease, and tumors. US Echocardiography Transthoracic Stress There are no prospective studies that examine the use of transthoracic stress echocardiography in patients with cardiac etiology for syncope or presyncope. Stress echocardiography can be used to assess for left ventricular outflow obstruction in patients with left ventricular hypertrophy and hypertrophic cardiomyopathy. In both of these populations, outflow tract obstruction is associated with increased future episodes of presyncope and syncope [70,71]. Variant 2: Presyncope or syncope. Low probability of cardiovascular etiology based on history, physical examination, and ECG findings. Initial imaging. CT Head Serial studies of patients with syncope or presyncope have shown that CT head does not influence treatment management in this clinical scenario [15-19]. CT Heart Function and Morphology There is no relevant literature that examines the use of ECG-gated CT heart in this clinical scenario. CTA Chest There is no relevant literature that examines the use of CTA of the chest in this clinical scenario. CTA Coronary Arteries There is no relevant literature that examines the use of ECG-gated CCTA in this clinical scenario. Syncope MRI Head There is no relevant literature to support the use of head MRI in this clinical scenario. MRI Heart Function and Morphology There is no relevant literature that examines the use of cardiac MRI in this clinical scenario. Radiography Chest There are no prospective studies that examine the use of chest radiographs in patients with syncope or presyncope. | Syncope. In patients with an abnormal ECG or findings on history or physical examination suggesting a cardiac etiology of syncope or presyncope, transthoracic echocardiography can be used to assess for structural heart disease or to help identify risk factors for malignant arrhythmias and is validated by multiple studies and supported by numerous societies [3,8,67-69]. Possible etiologies include various cardiomyopathies, valvular disease, pericardial disease, and tumors. US Echocardiography Transthoracic Stress There are no prospective studies that examine the use of transthoracic stress echocardiography in patients with cardiac etiology for syncope or presyncope. Stress echocardiography can be used to assess for left ventricular outflow obstruction in patients with left ventricular hypertrophy and hypertrophic cardiomyopathy. In both of these populations, outflow tract obstruction is associated with increased future episodes of presyncope and syncope [70,71]. Variant 2: Presyncope or syncope. Low probability of cardiovascular etiology based on history, physical examination, and ECG findings. Initial imaging. CT Head Serial studies of patients with syncope or presyncope have shown that CT head does not influence treatment management in this clinical scenario [15-19]. CT Heart Function and Morphology There is no relevant literature that examines the use of ECG-gated CT heart in this clinical scenario. CTA Chest There is no relevant literature that examines the use of CTA of the chest in this clinical scenario. CTA Coronary Arteries There is no relevant literature that examines the use of ECG-gated CCTA in this clinical scenario. Syncope MRI Head There is no relevant literature to support the use of head MRI in this clinical scenario. MRI Heart Function and Morphology There is no relevant literature that examines the use of cardiac MRI in this clinical scenario. Radiography Chest There are no prospective studies that examine the use of chest radiographs in patients with syncope or presyncope. | 3128014 |
acrac_3128014_6 | Syncope | In one large retrospective multi-institution study evaluating syncope and presyncope in 3,686 patients >60 years of age, 2,767 (75.1%) had a chest radiograph performed [61]. Of those, 182 (6.6%), had a radiograph interpreted as abnormal. In a smaller retrospective study performed at a single institution, only 4.5% of patients with syncope had an abnormal chest radiograph. However, patients with syncope or presyncope who had abnormal chest radiographs were more likely to have serious adverse events compared with those with normal radiographs [62]. SPECT or SPECT/CT MPI Rest and Stress There is no relevant literature to support the routine use of a Tc-99m SPECT or SPECT/CT MPI rest and stress in most patients with syncope. Limited data from one large retrospective study assessing the use of MPI in 700 patients with syncope of any cause and no known coronary artery disease concluded there was no significant utility for testing [63]. SPECT or SPECT/CT MPI Rest Only There is no relevant literature that examines the use of Tc-99m SPECT or SPECT/CT MPI rest only study in this clinical scenario. SPECT or SPECT/CT MPI Stress Only There is no relevant literature that examines the use of Tc-99m SPECT or SPECT/CT MPI stress only study in this clinical scenario. US Duplex Doppler Carotid Artery Multiple studies have shown no benefit of carotid artery Doppler US in patients with syncope or presyncope in the absence of neurologic findings or carotid bruit [20,64-66]. US Echocardiography Transesophageal There is no relevant literature that examines the use of transesophageal echocardiography in this clinical scenario. sSecac US Echocardiography Transthoracic Resting There is no relevant literature that examines the use of transthoracic resting echocardiography in this clinical scenario, especially if a patient who has syncope or presyncope in the setting of a normal ECG and low probability of a cardiac cause of symptoms [66,69,72,73]. | Syncope. In one large retrospective multi-institution study evaluating syncope and presyncope in 3,686 patients >60 years of age, 2,767 (75.1%) had a chest radiograph performed [61]. Of those, 182 (6.6%), had a radiograph interpreted as abnormal. In a smaller retrospective study performed at a single institution, only 4.5% of patients with syncope had an abnormal chest radiograph. However, patients with syncope or presyncope who had abnormal chest radiographs were more likely to have serious adverse events compared with those with normal radiographs [62]. SPECT or SPECT/CT MPI Rest and Stress There is no relevant literature to support the routine use of a Tc-99m SPECT or SPECT/CT MPI rest and stress in most patients with syncope. Limited data from one large retrospective study assessing the use of MPI in 700 patients with syncope of any cause and no known coronary artery disease concluded there was no significant utility for testing [63]. SPECT or SPECT/CT MPI Rest Only There is no relevant literature that examines the use of Tc-99m SPECT or SPECT/CT MPI rest only study in this clinical scenario. SPECT or SPECT/CT MPI Stress Only There is no relevant literature that examines the use of Tc-99m SPECT or SPECT/CT MPI stress only study in this clinical scenario. US Duplex Doppler Carotid Artery Multiple studies have shown no benefit of carotid artery Doppler US in patients with syncope or presyncope in the absence of neurologic findings or carotid bruit [20,64-66]. US Echocardiography Transesophageal There is no relevant literature that examines the use of transesophageal echocardiography in this clinical scenario. sSecac US Echocardiography Transthoracic Resting There is no relevant literature that examines the use of transthoracic resting echocardiography in this clinical scenario, especially if a patient who has syncope or presyncope in the setting of a normal ECG and low probability of a cardiac cause of symptoms [66,69,72,73]. | 3128014 |
acrac_69337_0 | Chronic Chest Pain Noncardiac Etiology Unlikely Low to Intermediate Probability of Coronary Artery Disease PCAs | Introduction/Background Chronic chest pain (CCP) with low to intermediate probability of coronary artery disease (CAD) can arise from cardiac and noncardiac etiologies. While there are multiple potential noncardiac causes of CCP, such as costochondritis, arthritic or degenerative diseases, prior trauma, primary or metastatic tumors, pleural disease, or gastrointestinal causes, the scope of this document is focused on evaluating chest pain when a cardiac etiology is the concern. Multiple imaging tools can be used to evaluate CCP in symptomatic patients with low to intermediate probability for CAD. The imaging modalities available include: (1) multidetector coronary computed tomography angiography (CCTA); (2) stress and rest radionuclide single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI); (3) catheter-based invasive coronary angiography (ICA) with or without ventriculography; (4) chest radiography; (5) stress echocardiography; (6) PET; and (7) cardiac MRI and MR angiography (MRA). Special Imaging Considerations Advances in cardiac CT imaging technology have further reduced radiation dose in CCTA examinations [4]. New and available dose-reducing techniques include prospective triggering [5-7], iterative reconstruction algorithms [8], long z-axis coverage, and high-pitch spiral acquisition [9]. However, these newer low-dose techniques may not be available or appropriate for all patients. Although these techniques can reduce patient radiation dose, there may be patients for whom these radiation dose techniques are not optimal. In all cases, the imaging physician must select the appropriate combination of imaging parameters to acquire a diagnostic examination at a radiation dose that is as low as reasonably achievable. Variant 1: Chronic chest pain, noncardiac etiology unlikely: low to intermediate probability of coronary artery disease. Initial imaging. | Chronic Chest Pain Noncardiac Etiology Unlikely Low to Intermediate Probability of Coronary Artery Disease PCAs. Introduction/Background Chronic chest pain (CCP) with low to intermediate probability of coronary artery disease (CAD) can arise from cardiac and noncardiac etiologies. While there are multiple potential noncardiac causes of CCP, such as costochondritis, arthritic or degenerative diseases, prior trauma, primary or metastatic tumors, pleural disease, or gastrointestinal causes, the scope of this document is focused on evaluating chest pain when a cardiac etiology is the concern. Multiple imaging tools can be used to evaluate CCP in symptomatic patients with low to intermediate probability for CAD. The imaging modalities available include: (1) multidetector coronary computed tomography angiography (CCTA); (2) stress and rest radionuclide single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI); (3) catheter-based invasive coronary angiography (ICA) with or without ventriculography; (4) chest radiography; (5) stress echocardiography; (6) PET; and (7) cardiac MRI and MR angiography (MRA). Special Imaging Considerations Advances in cardiac CT imaging technology have further reduced radiation dose in CCTA examinations [4]. New and available dose-reducing techniques include prospective triggering [5-7], iterative reconstruction algorithms [8], long z-axis coverage, and high-pitch spiral acquisition [9]. However, these newer low-dose techniques may not be available or appropriate for all patients. Although these techniques can reduce patient radiation dose, there may be patients for whom these radiation dose techniques are not optimal. In all cases, the imaging physician must select the appropriate combination of imaging parameters to acquire a diagnostic examination at a radiation dose that is as low as reasonably achievable. Variant 1: Chronic chest pain, noncardiac etiology unlikely: low to intermediate probability of coronary artery disease. Initial imaging. | 69337 |
acrac_69337_1 | Chronic Chest Pain Noncardiac Etiology Unlikely Low to Intermediate Probability of Coronary Artery Disease PCAs | CTA Coronary Arteries In patients with low to intermediate probability of CAD, multidetector CCTA can be performed for direct coronary artery evaluation. CCTA has been shown to be of value when evaluating patients with CAD because of its high negative predictive value. The use of CCTA has advantages when compared to other testing modalities. CCTA has superior diagnostic accuracy compared to other examinations, may identify high-probability patients The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document. Reprint requests to: [email protected] Specifically, recent trials from the Computed Tomography versus Exercise Testing in Suspected Coronary Artery Disease (CRESCENT), the Scottish COmputed Tomography of the HEART (SCOT-HEART), the Prospective Multicenter Imaging Study for Evaluation of Chest Pain trial (PROMISE trial), the Cardiac CT for the Assessment of Chest Pain and Plaque (CAPP) study, and COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter Registry (CONFIRM) registry provide additional support for the use of CCTA into the diagnostic algorithm when evaluating patients with chest pain. The CRESCENT investigators suggest that the use of CCTA in combination with calcium scoring may allow for a structured protocol that allows a diagnosis to be reached faster with no increase in the referral rate for ICA [20]. The CCTA can also reduce the time to diagnosis and determine which patients need invasive testing [12,13,21- 23]. | Chronic Chest Pain Noncardiac Etiology Unlikely Low to Intermediate Probability of Coronary Artery Disease PCAs. CTA Coronary Arteries In patients with low to intermediate probability of CAD, multidetector CCTA can be performed for direct coronary artery evaluation. CCTA has been shown to be of value when evaluating patients with CAD because of its high negative predictive value. The use of CCTA has advantages when compared to other testing modalities. CCTA has superior diagnostic accuracy compared to other examinations, may identify high-probability patients The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document. Reprint requests to: [email protected] Specifically, recent trials from the Computed Tomography versus Exercise Testing in Suspected Coronary Artery Disease (CRESCENT), the Scottish COmputed Tomography of the HEART (SCOT-HEART), the Prospective Multicenter Imaging Study for Evaluation of Chest Pain trial (PROMISE trial), the Cardiac CT for the Assessment of Chest Pain and Plaque (CAPP) study, and COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter Registry (CONFIRM) registry provide additional support for the use of CCTA into the diagnostic algorithm when evaluating patients with chest pain. The CRESCENT investigators suggest that the use of CCTA in combination with calcium scoring may allow for a structured protocol that allows a diagnosis to be reached faster with no increase in the referral rate for ICA [20]. The CCTA can also reduce the time to diagnosis and determine which patients need invasive testing [12,13,21- 23]. | 69337 |
acrac_69337_2 | Chronic Chest Pain Noncardiac Etiology Unlikely Low to Intermediate Probability of Coronary Artery Disease PCAs | Specifically in patients in whom angina that is due to CAD was suspected, the SCOT-HEART investigators showed that CCTA clarified the diagnosis by providing added certainty, enabling targeted interventions, and potentially reducing the risk of future myocardial infarction [24]. The PROMISE investigators evaluated patients with stable chest pain to either CCTA or functional testing. Their work has shown that patients who underwent CCTA had a lower risk of death and lower risk of myocardial infarction (not leading to a fatality) compared to patients who underwent conventional functional testing. The investigators suggest that CCTA can be a safe alternative to functional testing in a low-risk population [25,26]. CCTA has also provided prognostic information beyond that of clinical risk scores [27]. Data from the CAPP and CONFIRM investigators have provided additional information. The CAPP investigators have shown that patients undergoing CCTA identified significant disease, underwent more revascularizations, less diagnostic testing, and fewer admissions for chest pain [28]. The CONFIRM investigators have also shown that CCTA better predicted risk compared to well-established clinical risk scores and reclassified approximately one [29]. CT Chest When CAD and other cardiac etiologies of chest pain, such as aortic disease pericardial disease, are suspected, a chest CT may be appropriate. SPECT or SPECT/CT MPI Stress SPECT MPI [41] is a central part of the diagnostic pathway when evaluating patients with CCP. A SPECT MPI scan is performed with either exercise-induced or pharmacologically induced stress to demonstrate myocardial perfusion or contraction abnormalities. Use of stress imaging can be performed rapidly and increasingly through protocol optimization, with lower radiation doses [42]. Patients who undergo SPECT imaging have outcomes similar to CCTA in terms of outcomes [25,43]. | Chronic Chest Pain Noncardiac Etiology Unlikely Low to Intermediate Probability of Coronary Artery Disease PCAs. Specifically in patients in whom angina that is due to CAD was suspected, the SCOT-HEART investigators showed that CCTA clarified the diagnosis by providing added certainty, enabling targeted interventions, and potentially reducing the risk of future myocardial infarction [24]. The PROMISE investigators evaluated patients with stable chest pain to either CCTA or functional testing. Their work has shown that patients who underwent CCTA had a lower risk of death and lower risk of myocardial infarction (not leading to a fatality) compared to patients who underwent conventional functional testing. The investigators suggest that CCTA can be a safe alternative to functional testing in a low-risk population [25,26]. CCTA has also provided prognostic information beyond that of clinical risk scores [27]. Data from the CAPP and CONFIRM investigators have provided additional information. The CAPP investigators have shown that patients undergoing CCTA identified significant disease, underwent more revascularizations, less diagnostic testing, and fewer admissions for chest pain [28]. The CONFIRM investigators have also shown that CCTA better predicted risk compared to well-established clinical risk scores and reclassified approximately one [29]. CT Chest When CAD and other cardiac etiologies of chest pain, such as aortic disease pericardial disease, are suspected, a chest CT may be appropriate. SPECT or SPECT/CT MPI Stress SPECT MPI [41] is a central part of the diagnostic pathway when evaluating patients with CCP. A SPECT MPI scan is performed with either exercise-induced or pharmacologically induced stress to demonstrate myocardial perfusion or contraction abnormalities. Use of stress imaging can be performed rapidly and increasingly through protocol optimization, with lower radiation doses [42]. Patients who undergo SPECT imaging have outcomes similar to CCTA in terms of outcomes [25,43]. | 69337 |
acrac_69337_3 | Chronic Chest Pain Noncardiac Etiology Unlikely Low to Intermediate Probability of Coronary Artery Disease PCAs | In addition, the use of stress MPI improved clinical decision making for chest pain patients [44]. calcified coronary plaque, does not exclude acute coronary syndrome, significant coronary plaque burden, or plaque, which suggests that additional testing beyond CCS may be needed [48-50]. US Echocardiography Transthoracic Stress When echocardiography is performed, stress contraction abnormalities are induced by either exercise or inotropic stimulation. In any situation where a SPECT MPI study cannot be performed, an exercise-stress or dobutamine- stress echocardiogram may be substituted [51,52]. Stress echocardiography is used to evaluate for wall motion abnormalities and can provide data regarding flow reserve, which can aid in patient risk stratification [53]. US Echocardiography Transthoracic Resting In certain cases, if valvular heart disease, hypertrophic cardiomyopathy, or pericardial disease is the primary diagnostic concern, an echocardiogram at rest may be the preferred examination. The use of nonstress echocardiography in patients with stable chest pain when coronary artery disease is suspected may not reveal additional diagnostic information [54]. MRI Heart MRI is an emerging technology, and its clinical applications to cardiac imaging continue to develop. Currently, stress cardiac MRI and coronary MRA are available to diagnose CAD. Cardiac MRI without stress can be performed to evaluate valvular heart disease, nonischemic etiologies of chest pain, such as hypertrophic cardiomyopathy, or evaluate for pericardial disease. Stress cardiac MRI can be performed with dobutamine, adenosine, or dipyridamole. Dobutamine-stress functional cardiac MRI may also play a role in the assessment of chronic CCP [55]. This is especially true when the echocardiographic examination is nondiagnostic. | Chronic Chest Pain Noncardiac Etiology Unlikely Low to Intermediate Probability of Coronary Artery Disease PCAs. In addition, the use of stress MPI improved clinical decision making for chest pain patients [44]. calcified coronary plaque, does not exclude acute coronary syndrome, significant coronary plaque burden, or plaque, which suggests that additional testing beyond CCS may be needed [48-50]. US Echocardiography Transthoracic Stress When echocardiography is performed, stress contraction abnormalities are induced by either exercise or inotropic stimulation. In any situation where a SPECT MPI study cannot be performed, an exercise-stress or dobutamine- stress echocardiogram may be substituted [51,52]. Stress echocardiography is used to evaluate for wall motion abnormalities and can provide data regarding flow reserve, which can aid in patient risk stratification [53]. US Echocardiography Transthoracic Resting In certain cases, if valvular heart disease, hypertrophic cardiomyopathy, or pericardial disease is the primary diagnostic concern, an echocardiogram at rest may be the preferred examination. The use of nonstress echocardiography in patients with stable chest pain when coronary artery disease is suspected may not reveal additional diagnostic information [54]. MRI Heart MRI is an emerging technology, and its clinical applications to cardiac imaging continue to develop. Currently, stress cardiac MRI and coronary MRA are available to diagnose CAD. Cardiac MRI without stress can be performed to evaluate valvular heart disease, nonischemic etiologies of chest pain, such as hypertrophic cardiomyopathy, or evaluate for pericardial disease. Stress cardiac MRI can be performed with dobutamine, adenosine, or dipyridamole. Dobutamine-stress functional cardiac MRI may also play a role in the assessment of chronic CCP [55]. This is especially true when the echocardiographic examination is nondiagnostic. | 69337 |
acrac_69337_4 | Chronic Chest Pain Noncardiac Etiology Unlikely Low to Intermediate Probability of Coronary Artery Disease PCAs | In settings where the study may be adequately monitored, dobutamine-stress functional cardiac MRI provides high sensitivity and specificity for ischemia by the induction of wall motion abnormality [56]. However, adenosine-stress cardiac MRI perfusion imaging is easier to perform and also has been shown to have relatively high sensitivity and specificity for the presence of CAD [56-59]. Dipyridamole-stress MRI can also show ischemia-related wall motion abnormalities, perfusion defects and scar and can help direct revascularization [60]. MRA Coronary Arteries Coronary MRA is a developing modality to evaluate the coronary arteries. Coronary MRA has been shown to identify severe stenosis, but its sensitivity and specificity for moderate or mild lesions is lower [61,62]. Technological developments may make the use of coronary MRA more widespread and result in shorter acquisition times and improved spatial resolution [63]. Arteriography Coronary ICA may be used if less-invasive imaging was consistent with the presence of significant CAD. However, the use of ICA as a first-line tool to evaluate for CAD in patients who are low to intermediate probability will not have a high diagnostic yield [64], and utilizing noninvasive testing prior to ICA increases the yield of positive ICA [64]. Exercise Treadmill Testing Exercise treadmill testing can be of value in the assessment of patients with low to intermediate probability for CAD. Among patients who are low to intermediate probability, exercise treadmill testing in the acute setting showed a high specificity for detecting CAD with a greater than 50% stenosis [65]. This procedure is not included on the variant table because generally only imaging procedures are assessed for appropriateness in the ACR Appropriateness Criteria documents. | Chronic Chest Pain Noncardiac Etiology Unlikely Low to Intermediate Probability of Coronary Artery Disease PCAs. In settings where the study may be adequately monitored, dobutamine-stress functional cardiac MRI provides high sensitivity and specificity for ischemia by the induction of wall motion abnormality [56]. However, adenosine-stress cardiac MRI perfusion imaging is easier to perform and also has been shown to have relatively high sensitivity and specificity for the presence of CAD [56-59]. Dipyridamole-stress MRI can also show ischemia-related wall motion abnormalities, perfusion defects and scar and can help direct revascularization [60]. MRA Coronary Arteries Coronary MRA is a developing modality to evaluate the coronary arteries. Coronary MRA has been shown to identify severe stenosis, but its sensitivity and specificity for moderate or mild lesions is lower [61,62]. Technological developments may make the use of coronary MRA more widespread and result in shorter acquisition times and improved spatial resolution [63]. Arteriography Coronary ICA may be used if less-invasive imaging was consistent with the presence of significant CAD. However, the use of ICA as a first-line tool to evaluate for CAD in patients who are low to intermediate probability will not have a high diagnostic yield [64], and utilizing noninvasive testing prior to ICA increases the yield of positive ICA [64]. Exercise Treadmill Testing Exercise treadmill testing can be of value in the assessment of patients with low to intermediate probability for CAD. Among patients who are low to intermediate probability, exercise treadmill testing in the acute setting showed a high specificity for detecting CAD with a greater than 50% stenosis [65]. This procedure is not included on the variant table because generally only imaging procedures are assessed for appropriateness in the ACR Appropriateness Criteria documents. | 69337 |
acrac_69469_0 | Colorectal Cancer Screening | A number of organizations have issued recommendations for colorectal cancer screening, which are presented as lists of options. Recommendations for average-risk individuals from the United States Preventative Services Task Force include either colonoscopy every 10 years, computed tomographic colonography (CTC) every 5 years, or a stool-based test every 1 to 3 years, depending on the sensitivity of the stool-based test [25]. In addition to these options, the American Cancer Society (ACS) also includes double-contrast barium enema (DCBE) every 5 years in its list of recommended screening tests [26]. The ACS guidelines also separate colorectal cancer screening tools into 2 categories: 1) those that can screen for both adenomatous polyps and cancer (CTC, colonoscopy, and DCBE); and 2) those that are intended to screen for cancer only (fecal occult blood test [FOBT], fecal immunochemical test, and stool DNA test) [26]. The ACS recommends that tests that simultaneously screen for polyps and cancers should be preferred over tests that detect cancers only when resources permit [26]. aPrincipal Author, Emory University, Atlanta, Georgia. bCo-author and Panel Chair, University of Wisconsin Hospital & Clinics, Madison, Wisconsin. cGlobal Advanced Imaging, PLLC, Little Rock, Arizona. dUniversity of South Alabama, Mobile, Alabama; American Gastroenterological Association. eNewton-Wellesley Hospital, Newton, Massachusetts. fUniversity of Texas MD Anderson Cancer Center, Houston, Texas; American College of Surgeons. gMallinckrodt Institute of Radiology, Saint Louis, Missouri. hVirginia Tech Carilion School of Medicine, Roanoke, Virginia. iMassachusetts General Hospital, Boston, Massachusetts. jUniversity of Virginia Health System, Charlottesville, Virginia. kMedstar Georgetown University Hospital, Washington, District of Columbia. lDuke University Medical Center, Durham, North Carolina. mPenn State Hershey Radiology, Hershey, Pennsylvania. | Colorectal Cancer Screening. A number of organizations have issued recommendations for colorectal cancer screening, which are presented as lists of options. Recommendations for average-risk individuals from the United States Preventative Services Task Force include either colonoscopy every 10 years, computed tomographic colonography (CTC) every 5 years, or a stool-based test every 1 to 3 years, depending on the sensitivity of the stool-based test [25]. In addition to these options, the American Cancer Society (ACS) also includes double-contrast barium enema (DCBE) every 5 years in its list of recommended screening tests [26]. The ACS guidelines also separate colorectal cancer screening tools into 2 categories: 1) those that can screen for both adenomatous polyps and cancer (CTC, colonoscopy, and DCBE); and 2) those that are intended to screen for cancer only (fecal occult blood test [FOBT], fecal immunochemical test, and stool DNA test) [26]. The ACS recommends that tests that simultaneously screen for polyps and cancers should be preferred over tests that detect cancers only when resources permit [26]. aPrincipal Author, Emory University, Atlanta, Georgia. bCo-author and Panel Chair, University of Wisconsin Hospital & Clinics, Madison, Wisconsin. cGlobal Advanced Imaging, PLLC, Little Rock, Arizona. dUniversity of South Alabama, Mobile, Alabama; American Gastroenterological Association. eNewton-Wellesley Hospital, Newton, Massachusetts. fUniversity of Texas MD Anderson Cancer Center, Houston, Texas; American College of Surgeons. gMallinckrodt Institute of Radiology, Saint Louis, Missouri. hVirginia Tech Carilion School of Medicine, Roanoke, Virginia. iMassachusetts General Hospital, Boston, Massachusetts. jUniversity of Virginia Health System, Charlottesville, Virginia. kMedstar Georgetown University Hospital, Washington, District of Columbia. lDuke University Medical Center, Durham, North Carolina. mPenn State Hershey Radiology, Hershey, Pennsylvania. | 69469 |
acrac_69469_1 | Colorectal Cancer Screening | nLahey Hospital and Medical Center, Burlington, Massachusetts. oBeth Israel Deaconess Medical Center, Boston, Massachusetts. pUniversity of California San Francisco, San Francisco, California. qSpecialty Chair, Virginia Commonwealth University Medical Center, Richmond, Virginia. Reprint requests to: [email protected] Colorectal Cancer Screening of adenoma or carcinoma), and 3) high risk (individuals with hereditary syndromes, such as hereditary nonpolyposis colorectal cancer (HNPCC), or a personal history of ulcerative colitis or Crohn colitis). The ACR practice parameter also includes suggestions regarding the interpretation and reporting of extracolonic findings [28]. To avoid unnecessary further workup and patient anxiety, caution is emphasized when reporting findings that are likely to be of low clinical significance. There is evidence that using structured reporting constructs, such as CT Colonography Reporting and Data System, can decrease workups related to incidental extracolonic findings to <10% [30-32]. Unsuspected extracolonic malignancies and previously unknown aortic aneurysms are detected with CTC examinations in approximately 2% to 3% of patients [30,31,33-36]. Regarding barium enema, as utilization of DCBE has declined, training in this modality has also decreased [37], and it is not known if the barium enema data collected from studies performed by radiologists with extensive experience in the technique can be extrapolated to radiologists with lesser experience. For this document, it is assumed procedures are performed and interpreted by experts. Colorectal Cancer Screening sensitivities by patient of 85% and 93%, with pooled specificities of 97% [43,44]. Some older studies have shown poorer performance of CTC (sensitivity of 55% to 59%) [45,46]. These discrepant results were likely related to differences in study design, lack of reader training, and CTC technique (eg, no fecal tagging) in these older studies. | Colorectal Cancer Screening. nLahey Hospital and Medical Center, Burlington, Massachusetts. oBeth Israel Deaconess Medical Center, Boston, Massachusetts. pUniversity of California San Francisco, San Francisco, California. qSpecialty Chair, Virginia Commonwealth University Medical Center, Richmond, Virginia. Reprint requests to: [email protected] Colorectal Cancer Screening of adenoma or carcinoma), and 3) high risk (individuals with hereditary syndromes, such as hereditary nonpolyposis colorectal cancer (HNPCC), or a personal history of ulcerative colitis or Crohn colitis). The ACR practice parameter also includes suggestions regarding the interpretation and reporting of extracolonic findings [28]. To avoid unnecessary further workup and patient anxiety, caution is emphasized when reporting findings that are likely to be of low clinical significance. There is evidence that using structured reporting constructs, such as CT Colonography Reporting and Data System, can decrease workups related to incidental extracolonic findings to <10% [30-32]. Unsuspected extracolonic malignancies and previously unknown aortic aneurysms are detected with CTC examinations in approximately 2% to 3% of patients [30,31,33-36]. Regarding barium enema, as utilization of DCBE has declined, training in this modality has also decreased [37], and it is not known if the barium enema data collected from studies performed by radiologists with extensive experience in the technique can be extrapolated to radiologists with lesser experience. For this document, it is assumed procedures are performed and interpreted by experts. Colorectal Cancer Screening sensitivities by patient of 85% and 93%, with pooled specificities of 97% [43,44]. Some older studies have shown poorer performance of CTC (sensitivity of 55% to 59%) [45,46]. These discrepant results were likely related to differences in study design, lack of reader training, and CTC technique (eg, no fecal tagging) in these older studies. | 69469 |
acrac_69469_2 | Colorectal Cancer Screening | DCBE DCBE also requires a preprocedural bowel cleansing preparation. The study is performed by administration of a liquid barium-based contrast agent and air-insufflation of the colon via a tube inserted into the rectum. Images are acquired with the patient in different obliquities and at different table angulations ranging from supine to standing. Performance of DCBE is dependent on optimal patient positioning because patient anatomy varies. The Colorectal Cancer Screening perforation rate during DCBE is approximately 1 in 25,000 [56] as compared to 1 in 22,000 for CTC and 1 in 1,000 for diagnostic colonoscopy [38,39]. Additional data on the effectiveness of the DCBE for detecting colorectal cancer comes from studies in which the imaging history of patients with colorectal cancer was reviewed. In many of these studies, the risk level of patients undergoing DCBE was not reported. Based on this methodology, the sensitivity of DCBE ranges from 75% to 95% [64-66]. This correlates with a large, population-based study that found the overall rate of new or missed cancers following a DCBE was 22% [67]. SCBE Single-contrast barium enema (SCBE) studies are performed by administration of liquid barium via a rectal tube. Unlike a DCBE, the colon is not insufflated with air. SCBE studies are generally performed when patients are unable to tolerate a DCBE (eg, patients unable to stand upright) and a CTC cannot be performed. A minority of studies have suggested that a SCBE has the potential to be as sensitive as a DCBE for detecting cancer and large polyps. The reported sensitivity for cancer ranges from 82% to 95% [65,66] and is approximately 95% for large polyps [69]. In a retrospective evaluation of individuals diagnosed with colorectal cancer who had undergone a prior DCBE or SCBE, the cancer miss rate was 4.8% for SCBE and 4.7% for DCBE [65]. | Colorectal Cancer Screening. DCBE DCBE also requires a preprocedural bowel cleansing preparation. The study is performed by administration of a liquid barium-based contrast agent and air-insufflation of the colon via a tube inserted into the rectum. Images are acquired with the patient in different obliquities and at different table angulations ranging from supine to standing. Performance of DCBE is dependent on optimal patient positioning because patient anatomy varies. The Colorectal Cancer Screening perforation rate during DCBE is approximately 1 in 25,000 [56] as compared to 1 in 22,000 for CTC and 1 in 1,000 for diagnostic colonoscopy [38,39]. Additional data on the effectiveness of the DCBE for detecting colorectal cancer comes from studies in which the imaging history of patients with colorectal cancer was reviewed. In many of these studies, the risk level of patients undergoing DCBE was not reported. Based on this methodology, the sensitivity of DCBE ranges from 75% to 95% [64-66]. This correlates with a large, population-based study that found the overall rate of new or missed cancers following a DCBE was 22% [67]. SCBE Single-contrast barium enema (SCBE) studies are performed by administration of liquid barium via a rectal tube. Unlike a DCBE, the colon is not insufflated with air. SCBE studies are generally performed when patients are unable to tolerate a DCBE (eg, patients unable to stand upright) and a CTC cannot be performed. A minority of studies have suggested that a SCBE has the potential to be as sensitive as a DCBE for detecting cancer and large polyps. The reported sensitivity for cancer ranges from 82% to 95% [65,66] and is approximately 95% for large polyps [69]. In a retrospective evaluation of individuals diagnosed with colorectal cancer who had undergone a prior DCBE or SCBE, the cancer miss rate was 4.8% for SCBE and 4.7% for DCBE [65]. | 69469 |
acrac_69469_3 | Colorectal Cancer Screening | However, because of the paucity of studies and limitations of the study designs, questions have been raised about the reproducibility of the results, particularly for large polyps. With current techniques, MR colonography does not perform as well as CTC for detection of polyps, especially for small lesions. Fewer published studies are available evaluating MR colonography as compared to CTC, and sample sizes are generally small for MR colonography studies, which remains primarily an investigational technique. In a systematic review of 13 prospective studies evaluating MR colonography performance in 1,285 Colorectal Cancer Screening Variant 2: Colorectal cancer screening. Moderate-risk individual. First-degree family history of cancer or adenoma. Initial screening, then follow-up every 5 years after initial negative screen. CTC Less evidence is available assessing the performance of CTC in moderate-risk as compared to average-risk individuals. In a study evaluating 156 asymptomatic individuals with a family history of colorectal cancer (defined as a first-degree relative [parent, sibling, or child] diagnosed with colorectal cancer before 60 years of age, or 2 first-degree relatives diagnosed with colorectal cancer at any age) and 8,857 subjects without family history of colorectal cancer, the referral rate for colonoscopy was higher in the family history cohort (16.0% versus 10.5%; P=0.035), but the frequencies of proven cancer (0.0% versus 0.4%), advanced adenoma (4.5% versus 3.2%), and nonadvanced adenoma (5.1% versus 2.6%) were not significantly increased [78]. The results of this study suggest that CTC is a viable screening option for individuals at moderate risk due to family history. DCBE Limited evidence is available regarding the performance of DCBE in individuals with a family history of colorectal cancer. | Colorectal Cancer Screening. However, because of the paucity of studies and limitations of the study designs, questions have been raised about the reproducibility of the results, particularly for large polyps. With current techniques, MR colonography does not perform as well as CTC for detection of polyps, especially for small lesions. Fewer published studies are available evaluating MR colonography as compared to CTC, and sample sizes are generally small for MR colonography studies, which remains primarily an investigational technique. In a systematic review of 13 prospective studies evaluating MR colonography performance in 1,285 Colorectal Cancer Screening Variant 2: Colorectal cancer screening. Moderate-risk individual. First-degree family history of cancer or adenoma. Initial screening, then follow-up every 5 years after initial negative screen. CTC Less evidence is available assessing the performance of CTC in moderate-risk as compared to average-risk individuals. In a study evaluating 156 asymptomatic individuals with a family history of colorectal cancer (defined as a first-degree relative [parent, sibling, or child] diagnosed with colorectal cancer before 60 years of age, or 2 first-degree relatives diagnosed with colorectal cancer at any age) and 8,857 subjects without family history of colorectal cancer, the referral rate for colonoscopy was higher in the family history cohort (16.0% versus 10.5%; P=0.035), but the frequencies of proven cancer (0.0% versus 0.4%), advanced adenoma (4.5% versus 3.2%), and nonadvanced adenoma (5.1% versus 2.6%) were not significantly increased [78]. The results of this study suggest that CTC is a viable screening option for individuals at moderate risk due to family history. DCBE Limited evidence is available regarding the performance of DCBE in individuals with a family history of colorectal cancer. | 69469 |
acrac_69469_4 | Colorectal Cancer Screening | An older investigation of screening with colonoscopy or sigmoidoscopy and DCBE compared to no screening found a reduction in colorectal cancer incidence with screening in families with hereditary nonpolyposis colorectal cancer [79]. SCBE SCBE generally does not perform as well as DCBE for detection of polyps and cancers and should be used if CTC or DCBE cannot be performed. Limited evidence is available regarding the performance of SCBE in individuals with a family history of colorectal cancer. Colorectal Cancer Screening In studies comparing DCBE to endoscopy, when used to evaluate individuals with a positive FOBT, most reports indicate a sensitivity of 75% to 80% [85,86]. In a study comparing DCBE to endoscopy in 71 patients with rectal bleeding, the sensitivity of DCBE for detecting adenomas >6 mm was 58% [87]. SCBE SCBE generally does not perform as well as DCBE for detection of polyps and cancers and should be used if CTC or DCBE cannot be performed. In a retrospective evaluation of 165 patients who underwent SCBE, the sensitivity for colorectal cancer was 81.8% [66]. The majority of these patients were symptomatic (eg, bleeding, anemia, altered bowel habit) at time of imaging [66]. In a FOBT trial, SCBE was used as a diagnostic follow-up and the sensitivity for cancer was 80% [88]. Variant 4: Colorectal cancer screening. High-risk individual. Hereditary nonpolyposis colorectal cancer; ulcerative colitis or Crohn colitis. The risk of cancer in individuals with ulcerative colitis increases after the disease has been present 8 to 10 years, and it correlates with the extent of the disease. The cumulative probability of colorectal cancer in an ulcerative colitis patient is 2% by 10 years, 8% by 20 years, and 18% by 30 years [91]. The risk for individuals with Crohn colitis may be comparable. | Colorectal Cancer Screening. An older investigation of screening with colonoscopy or sigmoidoscopy and DCBE compared to no screening found a reduction in colorectal cancer incidence with screening in families with hereditary nonpolyposis colorectal cancer [79]. SCBE SCBE generally does not perform as well as DCBE for detection of polyps and cancers and should be used if CTC or DCBE cannot be performed. Limited evidence is available regarding the performance of SCBE in individuals with a family history of colorectal cancer. Colorectal Cancer Screening In studies comparing DCBE to endoscopy, when used to evaluate individuals with a positive FOBT, most reports indicate a sensitivity of 75% to 80% [85,86]. In a study comparing DCBE to endoscopy in 71 patients with rectal bleeding, the sensitivity of DCBE for detecting adenomas >6 mm was 58% [87]. SCBE SCBE generally does not perform as well as DCBE for detection of polyps and cancers and should be used if CTC or DCBE cannot be performed. In a retrospective evaluation of 165 patients who underwent SCBE, the sensitivity for colorectal cancer was 81.8% [66]. The majority of these patients were symptomatic (eg, bleeding, anemia, altered bowel habit) at time of imaging [66]. In a FOBT trial, SCBE was used as a diagnostic follow-up and the sensitivity for cancer was 80% [88]. Variant 4: Colorectal cancer screening. High-risk individual. Hereditary nonpolyposis colorectal cancer; ulcerative colitis or Crohn colitis. The risk of cancer in individuals with ulcerative colitis increases after the disease has been present 8 to 10 years, and it correlates with the extent of the disease. The cumulative probability of colorectal cancer in an ulcerative colitis patient is 2% by 10 years, 8% by 20 years, and 18% by 30 years [91]. The risk for individuals with Crohn colitis may be comparable. | 69469 |
acrac_69469_5 | Colorectal Cancer Screening | Unlike the other forms of colorectal cancer screening, the screening of ulcerative colitis patients focuses on detecting dysplasia (which may be flat and identified only by random biopsies, or it may be macroscopically visible) and a subsequent prophylactic colectomy. There is no evidence of a reduction in mortality resulting from colorectal cancer screening in these patients, although annual colonoscopy screening has demonstrated a shift to early-stage detection. For patients at high risk because of known ulcerative colitis or Crohn colitis, a colonoscopy is preferred over CTC, MR imaging, or barium examinations because of its ability to obtain biopsies to look for dysplasia. Individuals with HNPCC, also known as Lynch syndrome, are at increased risk for colorectal cancer. Colorectal cancers tend to occur at a younger age and with a shorter dwell time in individuals with HNPCC [92]. Colorectal cancer screening recommendations for individuals with HNPCC or at risk (first-degree relatives) are colonoscopy every 1 to 2 years beginning at 20 to 25 years of age or earlier if familial diagnosis of colorectal cancer before age 25 years [92]. CTC Colonoscopy is preferred over CTC because of its ability to obtain biopsies to look for dysplasia. DCBE Colonoscopy is preferred over barium examinations because of its ability to obtain biopsies to look for dysplasia. Colorectal Cancer Screening MR Colonography Colonoscopy is preferred over MR imaging because of its ability to obtain biopsies to look for dysplasia. SCBE Colonoscopy is preferred over barium examinations because of its ability to obtain biopsies to look for dysplasia. DCBE Limited data have been published on the accuracy of DCBE following incomplete colonoscopy. In a study of 233 patients who underwent DCBE following incomplete colonoscopy, polyps were reported in 2.1% of patients (5 patients; 5 of 6 polyps >5 mm) [101]. | Colorectal Cancer Screening. Unlike the other forms of colorectal cancer screening, the screening of ulcerative colitis patients focuses on detecting dysplasia (which may be flat and identified only by random biopsies, or it may be macroscopically visible) and a subsequent prophylactic colectomy. There is no evidence of a reduction in mortality resulting from colorectal cancer screening in these patients, although annual colonoscopy screening has demonstrated a shift to early-stage detection. For patients at high risk because of known ulcerative colitis or Crohn colitis, a colonoscopy is preferred over CTC, MR imaging, or barium examinations because of its ability to obtain biopsies to look for dysplasia. Individuals with HNPCC, also known as Lynch syndrome, are at increased risk for colorectal cancer. Colorectal cancers tend to occur at a younger age and with a shorter dwell time in individuals with HNPCC [92]. Colorectal cancer screening recommendations for individuals with HNPCC or at risk (first-degree relatives) are colonoscopy every 1 to 2 years beginning at 20 to 25 years of age or earlier if familial diagnosis of colorectal cancer before age 25 years [92]. CTC Colonoscopy is preferred over CTC because of its ability to obtain biopsies to look for dysplasia. DCBE Colonoscopy is preferred over barium examinations because of its ability to obtain biopsies to look for dysplasia. Colorectal Cancer Screening MR Colonography Colonoscopy is preferred over MR imaging because of its ability to obtain biopsies to look for dysplasia. SCBE Colonoscopy is preferred over barium examinations because of its ability to obtain biopsies to look for dysplasia. DCBE Limited data have been published on the accuracy of DCBE following incomplete colonoscopy. In a study of 233 patients who underwent DCBE following incomplete colonoscopy, polyps were reported in 2.1% of patients (5 patients; 5 of 6 polyps >5 mm) [101]. | 69469 |
acrac_69469_6 | Colorectal Cancer Screening | However, 2 patients with 4- and 10-mm polyps reported on DCBE underwent repeat colonoscopy, and no polyps were found. The remaining 3 patients with polyps reported on DCBE refused repeat colonoscopy. Thirteen patients whose DCBE studies were reported as of suboptimal quality underwent repeat colonoscopy, and 5 patients were found to have polyps (one 1-cm tubular adenoma, 4 <5-mm hyperplastic polyps). In a study of 103 patients who underwent DCBE performed immediately after incomplete colonoscopy, the entire colon was visualized in 94% of subjects [102]. Five malignant neoplasms (size not reported) were identified at DCBE [102]. SCBE Very limited data are available regarding the accuracy of SCBE performed after incomplete colonoscopy. In a study of 118 patients who underwent barium enema following incomplete colonoscopy (103 double contrast, 15 single contrast), 2 polyps were found (4 and 5 mm) and removed at subsequent repeat colonoscopy [103]. Repeat colonoscopic findings were not available for the vast majority of study subjects [103]. Summary of Recommendations For average-risk individuals, CT colonography is usually appropriate for colorectal cancer screening. For moderate-risk individuals (eg, first-degree family history of cancer or adenoma), CT colonography is usually appropriate for colorectal cancer screening. For moderate-risk individuals after positive FOBT or positive fecal immunochemical test, CT colonography is usually appropriate for colorectal cancer detection. For high-risk individuals (eg, hereditary nonpolyposis colorectal cancer, ulcerative colitis, or Crohn colitis), colonoscopy is preferred over imaging tests because of its ability to obtain biopsies to look for dysplasia. For colorectal cancer screening after incomplete colonoscopy, CT colonography is usually appropriate for individuals at average, moderate, or high risk for colorectal cancer. Colorectal Cancer Screening | Colorectal Cancer Screening. However, 2 patients with 4- and 10-mm polyps reported on DCBE underwent repeat colonoscopy, and no polyps were found. The remaining 3 patients with polyps reported on DCBE refused repeat colonoscopy. Thirteen patients whose DCBE studies were reported as of suboptimal quality underwent repeat colonoscopy, and 5 patients were found to have polyps (one 1-cm tubular adenoma, 4 <5-mm hyperplastic polyps). In a study of 103 patients who underwent DCBE performed immediately after incomplete colonoscopy, the entire colon was visualized in 94% of subjects [102]. Five malignant neoplasms (size not reported) were identified at DCBE [102]. SCBE Very limited data are available regarding the accuracy of SCBE performed after incomplete colonoscopy. In a study of 118 patients who underwent barium enema following incomplete colonoscopy (103 double contrast, 15 single contrast), 2 polyps were found (4 and 5 mm) and removed at subsequent repeat colonoscopy [103]. Repeat colonoscopic findings were not available for the vast majority of study subjects [103]. Summary of Recommendations For average-risk individuals, CT colonography is usually appropriate for colorectal cancer screening. For moderate-risk individuals (eg, first-degree family history of cancer or adenoma), CT colonography is usually appropriate for colorectal cancer screening. For moderate-risk individuals after positive FOBT or positive fecal immunochemical test, CT colonography is usually appropriate for colorectal cancer detection. For high-risk individuals (eg, hereditary nonpolyposis colorectal cancer, ulcerative colitis, or Crohn colitis), colonoscopy is preferred over imaging tests because of its ability to obtain biopsies to look for dysplasia. For colorectal cancer screening after incomplete colonoscopy, CT colonography is usually appropriate for individuals at average, moderate, or high risk for colorectal cancer. Colorectal Cancer Screening | 69469 |
acrac_3097211_0 | Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs | Introduction/Background Types of nondegenerative arthritides resulting in chronic extremity pain can be broadly divided into seropositive inflammatory arthritis, seronegative inflammatory arthritis (spondyloarthritis), and crystalline arthritis. Although erosive osteoarthritis is often classified as a subset of osteoarthritis [1], the severity of clinical symptoms often put it in the realm of inflammatory arthritis in terms of differential diagnosis. Although it is much less common than osteoarthritis, millions of Americans suffer from chronic extremity pain from inflammatory and crystalline arthropathies. The prevalence of rheumatoid arthritis (RA), the most common inflammatory arthritis, has been reported to be between 0.5% and 1% [2], and the prevalence of gout, the most common crystalline arthritis, is as high as 3.9% of adults in the United States [3]. Imaging plays an important role in the diagnosis and management of inflammatory and crystalline arthritis. It is important to consider global distribution of skeletal involvement, and correlating findings on multiple studies/modalities may be necessary. Furthermore, it is critical that imaging results are interpreted in the context of clinical and serologic results to add specificity because there is significant overlap of imaging findings amongst the various types of arthritis. Imaging can be used to identify osseous and/or soft tissues abnormalities that are seen with inflammatory and crystalline arthritis. In addition to joint space narrowing, the osseous abnormalities of the extremities that are assessed include erosions, bone proliferation in the form of enthesitis and periostitis, and bone marrow edema. The location of the erosions with respect to the joint (ie, marginal, para-articular, central, and subenethesial) is helpful in differential diagnosis. | Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs. Introduction/Background Types of nondegenerative arthritides resulting in chronic extremity pain can be broadly divided into seropositive inflammatory arthritis, seronegative inflammatory arthritis (spondyloarthritis), and crystalline arthritis. Although erosive osteoarthritis is often classified as a subset of osteoarthritis [1], the severity of clinical symptoms often put it in the realm of inflammatory arthritis in terms of differential diagnosis. Although it is much less common than osteoarthritis, millions of Americans suffer from chronic extremity pain from inflammatory and crystalline arthropathies. The prevalence of rheumatoid arthritis (RA), the most common inflammatory arthritis, has been reported to be between 0.5% and 1% [2], and the prevalence of gout, the most common crystalline arthritis, is as high as 3.9% of adults in the United States [3]. Imaging plays an important role in the diagnosis and management of inflammatory and crystalline arthritis. It is important to consider global distribution of skeletal involvement, and correlating findings on multiple studies/modalities may be necessary. Furthermore, it is critical that imaging results are interpreted in the context of clinical and serologic results to add specificity because there is significant overlap of imaging findings amongst the various types of arthritis. Imaging can be used to identify osseous and/or soft tissues abnormalities that are seen with inflammatory and crystalline arthritis. In addition to joint space narrowing, the osseous abnormalities of the extremities that are assessed include erosions, bone proliferation in the form of enthesitis and periostitis, and bone marrow edema. The location of the erosions with respect to the joint (ie, marginal, para-articular, central, and subenethesial) is helpful in differential diagnosis. | 3097211 |
acrac_3097211_1 | Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs | Bone proliferation, in the form of enthesitis, is a hallmark of spondyloarthropathies and may occur at any cortical bone, including both tendon and ligament attachments. Soft tissue abnormalities of the extremities that are assessed with imaging include soft tissue crystal deposition and synovial hypertrophy, which may be intraarticular or involve tendon sheaths and bursae. This document discusses 5 variants: 1) Chronic extremity joint pain. Suspect inflammatory (seropositive or seronegative arthritis), crystalline (gout or pseudogout), or erosive osteoarthritis. Initial imaging. 2) Chronic extremity joint pain. Suspect inflammatory arthritis (seropositive or seronegative arthritis). Radiographs normal or inconclusive. Next imaging study. 3) Chronic extremity joint pain. Suspect gout. Radiographs normal or inconclusive. Next imaging study. 4) Chronic extremity joint pain. Suspect calcium pyrophosphate (CPP) dihydrate disease (pseudogout). Radiographs normal or inconclusive. Next imaging study. 5) Chronic extremity joint pain. Suspect erosive osteoarthritis. Radiographs normal or inconclusive. Next imaging study. aCleveland Clinic, Cleveland, Ohio. bResearch Author, Cleveland Clinic Foundation, Cleveland, Ohio. cPanel Chair, Mayo Clinic Arizona, Phoenix, Arizona. dPanel Vice-Chair, University of Virginia Health System, Charlottesville, Virginia. eMayo Clinic, Scottsdale, Arizona, Rheumatologist. fUniversity of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. gMoffitt Cancer Center and University of South Florida Morsani College of Medicine, Tampa, Florida; MSK-RADS (Bone) Committee. hCleveland Clinic Foundation, Cleveland, Ohio, Primary care physician. iMayo Clinic, Rochester, Minnesota. jHospital for Special Surgery, New York, New York. kDuke University Medical Center, Durham, North Carolina. | Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs. Bone proliferation, in the form of enthesitis, is a hallmark of spondyloarthropathies and may occur at any cortical bone, including both tendon and ligament attachments. Soft tissue abnormalities of the extremities that are assessed with imaging include soft tissue crystal deposition and synovial hypertrophy, which may be intraarticular or involve tendon sheaths and bursae. This document discusses 5 variants: 1) Chronic extremity joint pain. Suspect inflammatory (seropositive or seronegative arthritis), crystalline (gout or pseudogout), or erosive osteoarthritis. Initial imaging. 2) Chronic extremity joint pain. Suspect inflammatory arthritis (seropositive or seronegative arthritis). Radiographs normal or inconclusive. Next imaging study. 3) Chronic extremity joint pain. Suspect gout. Radiographs normal or inconclusive. Next imaging study. 4) Chronic extremity joint pain. Suspect calcium pyrophosphate (CPP) dihydrate disease (pseudogout). Radiographs normal or inconclusive. Next imaging study. 5) Chronic extremity joint pain. Suspect erosive osteoarthritis. Radiographs normal or inconclusive. Next imaging study. aCleveland Clinic, Cleveland, Ohio. bResearch Author, Cleveland Clinic Foundation, Cleveland, Ohio. cPanel Chair, Mayo Clinic Arizona, Phoenix, Arizona. dPanel Vice-Chair, University of Virginia Health System, Charlottesville, Virginia. eMayo Clinic, Scottsdale, Arizona, Rheumatologist. fUniversity of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. gMoffitt Cancer Center and University of South Florida Morsani College of Medicine, Tampa, Florida; MSK-RADS (Bone) Committee. hCleveland Clinic Foundation, Cleveland, Ohio, Primary care physician. iMayo Clinic, Rochester, Minnesota. jHospital for Special Surgery, New York, New York. kDuke University Medical Center, Durham, North Carolina. | 3097211 |
acrac_3097211_2 | Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs | lUniversity of Washington Medical Center, Seattle, Washington; Committee on Emergency Radiology-GSER. mMayo Clinic, Jacksonville, Florida; Commission on Nuclear Medicine and Molecular Imaging. nUniversity of Missouri Health Care, Columbia, Missouri. oPenn State Milton S. Hershey Medical Center, Hershey, Pennsylvania and Uniformed Services University of the Health Sciences, Bethesda, Maryland. pSpecialty Chair, VA San Diego Healthcare System, San Diego, California. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through representation of such organizations on expert panels. Participation on the expert panel does not necessarily imply endorsement of the final document by individual contributors or their respective organization. Reprint requests to: [email protected] Chronic Extremity Joint Pain Special Imaging Considerations Image-guided aspiration may be helpful in confirming and characterizing crystal deposition disease and excluding infection. Image-guided aspiration may be challenging; however, depending on the amount of fluid present [6,7]. OR Discussion of Procedures by Variant Variant 1: Chronic extremity joint pain. Suspect inflammatory (seropositive or seronegative arthritis), crystalline (gout or pseudogout), or erosive osteoarthritis. Initial imaging. The area of interest for this variant include: the ankle, elbow, foot, hand, hip, knee, shoulder, and wrist. Bone Scan Whole Body There is no relevant literature supporting the use of bone scan whole body as the initial imaging modality in this clinical scenario. CT Area of Interest With IV Contrast There is no relevant literature supporting the use of CT area of interest with intravenous (IV) contrast as the initial imaging modality in this clinical scenario. | Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs. lUniversity of Washington Medical Center, Seattle, Washington; Committee on Emergency Radiology-GSER. mMayo Clinic, Jacksonville, Florida; Commission on Nuclear Medicine and Molecular Imaging. nUniversity of Missouri Health Care, Columbia, Missouri. oPenn State Milton S. Hershey Medical Center, Hershey, Pennsylvania and Uniformed Services University of the Health Sciences, Bethesda, Maryland. pSpecialty Chair, VA San Diego Healthcare System, San Diego, California. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through representation of such organizations on expert panels. Participation on the expert panel does not necessarily imply endorsement of the final document by individual contributors or their respective organization. Reprint requests to: [email protected] Chronic Extremity Joint Pain Special Imaging Considerations Image-guided aspiration may be helpful in confirming and characterizing crystal deposition disease and excluding infection. Image-guided aspiration may be challenging; however, depending on the amount of fluid present [6,7]. OR Discussion of Procedures by Variant Variant 1: Chronic extremity joint pain. Suspect inflammatory (seropositive or seronegative arthritis), crystalline (gout or pseudogout), or erosive osteoarthritis. Initial imaging. The area of interest for this variant include: the ankle, elbow, foot, hand, hip, knee, shoulder, and wrist. Bone Scan Whole Body There is no relevant literature supporting the use of bone scan whole body as the initial imaging modality in this clinical scenario. CT Area of Interest With IV Contrast There is no relevant literature supporting the use of CT area of interest with intravenous (IV) contrast as the initial imaging modality in this clinical scenario. | 3097211 |
acrac_3097211_3 | Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs | CT Area of Interest Without and With IV Contrast There is no relevant literature supporting the use of CT area of interest without and with IV contrast as the initial imaging modality in this clinical scenario. CT Area of Interest Without IV Contrast There is no relevant literature supporting the use of CT area of interest without IV contrast as the initial imaging modality in this clinical scenario. FDG-PET/CT Whole Body There is no relevant literature supporting the use of fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET/CT whole body as the initial imaging modality in this clinical scenario. MRI Area of Interest Without and With IV Contrast There is no relevant literature supporting the use of MRI area of interest without and with IV contrast as the initial imaging modality in this clinical scenario. MRI Area of Interest Without IV Contrast There is no relevant literature supporting the use of MRI area of interest without IV contrast as the initial imaging modality in this clinical scenario. Radiography Area of Interest Radiographs are beneficial as the initial imaging study for chronic extremity joint pain where inflammatory arthritis, crystalline arthritis, or erosive osteoarthritis is suspected. Radiography has a low sensitivity compared with other modalities including CT, MRI, US, and tomosynthesis [8-12] for the detection of erosions, and multiple radiographic views of a joint are often needed to improve erosion identification. Nevertheless, the location and distribution of osseous erosions and/or productive change are often adequate for diagnosis. Other causes of pain such as osteoarthritis, infection, and trauma may also be apparent. Thus, radiographs potentially avoid the need for further workup and delays in treatment. Even in the case of RA, in which early treatment is associated with improved Chronic Extremity Joint Pain | Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs. CT Area of Interest Without and With IV Contrast There is no relevant literature supporting the use of CT area of interest without and with IV contrast as the initial imaging modality in this clinical scenario. CT Area of Interest Without IV Contrast There is no relevant literature supporting the use of CT area of interest without IV contrast as the initial imaging modality in this clinical scenario. FDG-PET/CT Whole Body There is no relevant literature supporting the use of fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET/CT whole body as the initial imaging modality in this clinical scenario. MRI Area of Interest Without and With IV Contrast There is no relevant literature supporting the use of MRI area of interest without and with IV contrast as the initial imaging modality in this clinical scenario. MRI Area of Interest Without IV Contrast There is no relevant literature supporting the use of MRI area of interest without IV contrast as the initial imaging modality in this clinical scenario. Radiography Area of Interest Radiographs are beneficial as the initial imaging study for chronic extremity joint pain where inflammatory arthritis, crystalline arthritis, or erosive osteoarthritis is suspected. Radiography has a low sensitivity compared with other modalities including CT, MRI, US, and tomosynthesis [8-12] for the detection of erosions, and multiple radiographic views of a joint are often needed to improve erosion identification. Nevertheless, the location and distribution of osseous erosions and/or productive change are often adequate for diagnosis. Other causes of pain such as osteoarthritis, infection, and trauma may also be apparent. Thus, radiographs potentially avoid the need for further workup and delays in treatment. Even in the case of RA, in which early treatment is associated with improved Chronic Extremity Joint Pain | 3097211 |
acrac_3097211_4 | Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs | outcomes, the 2013 European League Against Rheumatism (EULAR) guidelines on imaging of the joints in RA recommends radiographs of the hand and feet as the initial imaging technique [13]. Assessment for synovitis and tenosynovitis is limited on radiography, although soft tissue swelling can be seen in the affected regions. Soft tissue and intraarticular crystal deposition as seen with gout or CPP deposition (CPPD); however, are readily apparent on radiographs in the form of tophi and chondrocalcinosis, respectively. US Area of Interest There is no relevant literature supporting the use of ultrasound (US) area of interest as the initial imaging modality in this clinical scenario. Variant 2: Chronic extremity joint pain. Suspect inflammatory arthritis (seropositive or seronegative arthritis). Radiographs normal or inconclusive. Next imaging study. Seropositive (rheumatoid) arthritis and seronegative spondyloarthritides including psoriatic arthritis, ankylosing spondylitis, reactive arthritis, and arthritis associated with inflammatory bowel disease share many clinical, pathologic, and imaging similarities. Thus, a uniform approach in the imaging workup of these entities is reasonable. Features of osseous erosions and soft tissue findings of synovitis and tenosynovitis may be seen in both seropositive and seronegative inflammatory arthritis, whereas enthesitis and dactylitis are typically seen only with the spondyloarthritis. The area of interest for this variant include: the ankle, elbow, foot, hand, hip, knee, shoulder, and wrist. Bone Scan Whole Body Tc-99m scintigraphy has been shown to be sensitive but not specific in the diagnosis of inflammatory arthritis, but it can detect inflammation and predict cortical erosions [9,14]. | Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs. outcomes, the 2013 European League Against Rheumatism (EULAR) guidelines on imaging of the joints in RA recommends radiographs of the hand and feet as the initial imaging technique [13]. Assessment for synovitis and tenosynovitis is limited on radiography, although soft tissue swelling can be seen in the affected regions. Soft tissue and intraarticular crystal deposition as seen with gout or CPP deposition (CPPD); however, are readily apparent on radiographs in the form of tophi and chondrocalcinosis, respectively. US Area of Interest There is no relevant literature supporting the use of ultrasound (US) area of interest as the initial imaging modality in this clinical scenario. Variant 2: Chronic extremity joint pain. Suspect inflammatory arthritis (seropositive or seronegative arthritis). Radiographs normal or inconclusive. Next imaging study. Seropositive (rheumatoid) arthritis and seronegative spondyloarthritides including psoriatic arthritis, ankylosing spondylitis, reactive arthritis, and arthritis associated with inflammatory bowel disease share many clinical, pathologic, and imaging similarities. Thus, a uniform approach in the imaging workup of these entities is reasonable. Features of osseous erosions and soft tissue findings of synovitis and tenosynovitis may be seen in both seropositive and seronegative inflammatory arthritis, whereas enthesitis and dactylitis are typically seen only with the spondyloarthritis. The area of interest for this variant include: the ankle, elbow, foot, hand, hip, knee, shoulder, and wrist. Bone Scan Whole Body Tc-99m scintigraphy has been shown to be sensitive but not specific in the diagnosis of inflammatory arthritis, but it can detect inflammation and predict cortical erosions [9,14]. | 3097211 |
acrac_3097211_5 | Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs | There is insufficient evidence to support routine use of bone scans for evaluation of seropositive or seronegative inflammatory arthritis in the extremities following initial radiographs. Bone Scan Whole Body with SPECT or SPECT/CT Area of Interest When adding single-photon emission CT (SPECT), RA could be differentiated from osteoarthritis given the added information from tomographic images [14]. There is insufficient evidence to support routine use of bone scans with SPECT or SPECT/CT for evaluation of seropositive or seronegative inflammatory arthritis in the extremities following initial radiographs. CT Area of Interest With IV Contrast There is insufficient evidence to support the routine use of CT area of interest with IV contrast for the evaluation of seropositive or seronegative inflammatory arthritis in the extremities following initial radiographs. Although CT can show bony erosions and productive changes with high diagnostic confidence, the ability of CT to identify and characterize associated inflammatory soft tissue findings and bone marrow edema is limited. Newer techniques of iodine-dual-energy CT (DECT) mapping and high-resolution peripheral quantitative CT have shown promise in detection and quantification of periarticular/tenosynovial inflammation and bony changes respectively [15]. Further validation is needed; however, and these techniques are not widely used in clinical practice. CT Area of Interest Without and With IV Contrast There is insufficient evidence to support routine use of CT area of interest without and with IV for the evaluation of seropositive or seronegative inflammatory arthritis in the extremities following initial radiographs. As mentioned before, although CT can show bony erosions and productive changes with high diagnostic confidence, the ability of CT to identify and characterize associated inflammatory soft tissue findings and bone marrow edema is limited. | Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs. There is insufficient evidence to support routine use of bone scans for evaluation of seropositive or seronegative inflammatory arthritis in the extremities following initial radiographs. Bone Scan Whole Body with SPECT or SPECT/CT Area of Interest When adding single-photon emission CT (SPECT), RA could be differentiated from osteoarthritis given the added information from tomographic images [14]. There is insufficient evidence to support routine use of bone scans with SPECT or SPECT/CT for evaluation of seropositive or seronegative inflammatory arthritis in the extremities following initial radiographs. CT Area of Interest With IV Contrast There is insufficient evidence to support the routine use of CT area of interest with IV contrast for the evaluation of seropositive or seronegative inflammatory arthritis in the extremities following initial radiographs. Although CT can show bony erosions and productive changes with high diagnostic confidence, the ability of CT to identify and characterize associated inflammatory soft tissue findings and bone marrow edema is limited. Newer techniques of iodine-dual-energy CT (DECT) mapping and high-resolution peripheral quantitative CT have shown promise in detection and quantification of periarticular/tenosynovial inflammation and bony changes respectively [15]. Further validation is needed; however, and these techniques are not widely used in clinical practice. CT Area of Interest Without and With IV Contrast There is insufficient evidence to support routine use of CT area of interest without and with IV for the evaluation of seropositive or seronegative inflammatory arthritis in the extremities following initial radiographs. As mentioned before, although CT can show bony erosions and productive changes with high diagnostic confidence, the ability of CT to identify and characterize associated inflammatory soft tissue findings and bone marrow edema is limited. | 3097211 |
acrac_3097211_6 | Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs | Newer techniques of iodine-DECT mapping and high-resolution peripheral quantitative CT have shown promise in detection and quantification of periarticular/tenosynovial inflammation and bony changes, respectively [15]. Further validation is needed; however, and these techniques are not widely used in clinical practice. CT Area of Interest Without IV Contrast There is insufficient evidence to support the routine use of CT area of interest without IV contrast for the evaluation of seropositive or seronegative inflammatory arthritis in the extremities following initial radiographs. As mentioned before, although CT can show bony erosions and productive changes with high diagnostic confidence, the ability of CT to identify and characterize associated inflammatory soft tissue findings and bone marrow edema is limited. Chronic Extremity Joint Pain FDG-PET/CT Whole Body FDG-PET uptake can be seen at sites of inflammation but is limited by being nonspecific [14,16]. Novel PET tracers targeting specific immunological targets in RA have been described but only tested preclinically or in small patient cohorts [17]. Further research is needed to validate these early results and determine their clinical role, if any. The literature suggests that PET/CT studies are not routinely obtained for evaluation of seropositive or seronegative inflammatory arthritis in the extremities following initial radiographs. Image-Guided Aspiration Area of Interest Image-guided aspiration is generally not useful in the seropositive or seronegative inflammatory arthritis in the extremities following initial radiographs. Image-guided aspiration may be helpful in excluding crystal deposition disease and infection. | Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs. Newer techniques of iodine-DECT mapping and high-resolution peripheral quantitative CT have shown promise in detection and quantification of periarticular/tenosynovial inflammation and bony changes, respectively [15]. Further validation is needed; however, and these techniques are not widely used in clinical practice. CT Area of Interest Without IV Contrast There is insufficient evidence to support the routine use of CT area of interest without IV contrast for the evaluation of seropositive or seronegative inflammatory arthritis in the extremities following initial radiographs. As mentioned before, although CT can show bony erosions and productive changes with high diagnostic confidence, the ability of CT to identify and characterize associated inflammatory soft tissue findings and bone marrow edema is limited. Chronic Extremity Joint Pain FDG-PET/CT Whole Body FDG-PET uptake can be seen at sites of inflammation but is limited by being nonspecific [14,16]. Novel PET tracers targeting specific immunological targets in RA have been described but only tested preclinically or in small patient cohorts [17]. Further research is needed to validate these early results and determine their clinical role, if any. The literature suggests that PET/CT studies are not routinely obtained for evaluation of seropositive or seronegative inflammatory arthritis in the extremities following initial radiographs. Image-Guided Aspiration Area of Interest Image-guided aspiration is generally not useful in the seropositive or seronegative inflammatory arthritis in the extremities following initial radiographs. Image-guided aspiration may be helpful in excluding crystal deposition disease and infection. | 3097211 |
acrac_3097211_7 | Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs | MRI Area of Interest Without and With IV Contrast Regarding the diagnosis of RA, the 2013 EULAR task force recommendations on use of imaging of the joints in RA state that when there is diagnostic doubt following radiographs, either US or MRI can be used to improve certainty of diagnosis of RA above clinical criteria as well as to detect early joint damage before it is radiographically visible [13]. Both MRI and US outperform clinical evaluation in the detection of inflammation and structural damage and provide prognostic information concerning radiographic progression [18-20]. The evidence is inconclusive as to whether MRI or US should be considered the preferred method for evaluation of RA [18]. However, MRI with IV gadolinium contrast has been shown to be more sensitive compared with US in the early stages of RA [21] and aids in detection of synovitis and tenosynovitis [22,23]. Therefore, when safe to do so, MRI of the area of interest should ideally be performed without and with IV contrast. MRI area of interest without IV contrast can show cortical erosions, bone edema, synovial hypertrophy, and soft tissue abnormalities such as tenosynovitis and dactylitis. The use of IV gadolinium is less important in the detection of osseous erosions and bone edema but enhances detection of synovitis and tenosynovitis [22,23]. Cortical irregularity from inflammatory enthesitis and periostitis and increased fluid signal in the subjacent bone marrow may be seen on MRI without IV contrast [24]. Entheseal involvement in a characteristic distribution can suggest the diagnosis of seronegative spondyloarthropathy [25]. | Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs. MRI Area of Interest Without and With IV Contrast Regarding the diagnosis of RA, the 2013 EULAR task force recommendations on use of imaging of the joints in RA state that when there is diagnostic doubt following radiographs, either US or MRI can be used to improve certainty of diagnosis of RA above clinical criteria as well as to detect early joint damage before it is radiographically visible [13]. Both MRI and US outperform clinical evaluation in the detection of inflammation and structural damage and provide prognostic information concerning radiographic progression [18-20]. The evidence is inconclusive as to whether MRI or US should be considered the preferred method for evaluation of RA [18]. However, MRI with IV gadolinium contrast has been shown to be more sensitive compared with US in the early stages of RA [21] and aids in detection of synovitis and tenosynovitis [22,23]. Therefore, when safe to do so, MRI of the area of interest should ideally be performed without and with IV contrast. MRI area of interest without IV contrast can show cortical erosions, bone edema, synovial hypertrophy, and soft tissue abnormalities such as tenosynovitis and dactylitis. The use of IV gadolinium is less important in the detection of osseous erosions and bone edema but enhances detection of synovitis and tenosynovitis [22,23]. Cortical irregularity from inflammatory enthesitis and periostitis and increased fluid signal in the subjacent bone marrow may be seen on MRI without IV contrast [24]. Entheseal involvement in a characteristic distribution can suggest the diagnosis of seronegative spondyloarthropathy [25]. | 3097211 |
acrac_3097211_8 | Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs | MRI-detected erosions as defined by the Rheumatoid Arthritis MRI Scoring System (RAMRIS) criteria [26] can be observed in the metacarpophalangeal and metatarsophalangeal joints of symptom-free individuals in the general population and in different types of rheumatologic diseases and are thus nonspecific [27]. Although synovial hypertrophy can be appreciated on unenhanced sequences, the use of IV gadolinium aids in the evaluation of synovitis because it helps differentiate joint effusion from synovium, which may demonstrate similar signal characteristics on unenhanced sequences [23,28]. MRI Area of Interest Without IV Contrast Regarding the diagnosis of RA, the 2013 EULAR task force recommendations on the use of imaging of the joints in RA state that when there is diagnostic doubt following radiographs, either US or MRI can be used to improve certainty of diagnosis of RA above clinical criteria as well as to detect early joint damage before it is radiographically visible [13]. Both MRI and US outperform clinical evaluation in the detection of inflammation and structural damage and provide prognostic information concerning radiographic progression [18-20]. The evidence is inconclusive as to whether MRI or US should be considered the preferred method for evaluation of RA [18]. MRI area of interest without IV contrast can show cortical erosions, bone edema, synovial hypertrophy, and soft tissue abnormalities such as tenosynovitis and dactylitis. Cortical irregularity from inflammatory enthesitis and periostitis and increased fluid signal in the subjacent bone marrow may be seen on MRI without IV contrast [27]. Entheseal the diagnosis of seronegative spondyloarthropathy [26]. | Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs. MRI-detected erosions as defined by the Rheumatoid Arthritis MRI Scoring System (RAMRIS) criteria [26] can be observed in the metacarpophalangeal and metatarsophalangeal joints of symptom-free individuals in the general population and in different types of rheumatologic diseases and are thus nonspecific [27]. Although synovial hypertrophy can be appreciated on unenhanced sequences, the use of IV gadolinium aids in the evaluation of synovitis because it helps differentiate joint effusion from synovium, which may demonstrate similar signal characteristics on unenhanced sequences [23,28]. MRI Area of Interest Without IV Contrast Regarding the diagnosis of RA, the 2013 EULAR task force recommendations on the use of imaging of the joints in RA state that when there is diagnostic doubt following radiographs, either US or MRI can be used to improve certainty of diagnosis of RA above clinical criteria as well as to detect early joint damage before it is radiographically visible [13]. Both MRI and US outperform clinical evaluation in the detection of inflammation and structural damage and provide prognostic information concerning radiographic progression [18-20]. The evidence is inconclusive as to whether MRI or US should be considered the preferred method for evaluation of RA [18]. MRI area of interest without IV contrast can show cortical erosions, bone edema, synovial hypertrophy, and soft tissue abnormalities such as tenosynovitis and dactylitis. Cortical irregularity from inflammatory enthesitis and periostitis and increased fluid signal in the subjacent bone marrow may be seen on MRI without IV contrast [27]. Entheseal the diagnosis of seronegative spondyloarthropathy [26]. | 3097211 |
acrac_3097211_9 | Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs | MRI-detected erosions as defined by the RAMRIS criteria [24] can be observed in the metacarpophalangeal and metatarsophalangeal joints of symptom-free individuals in the general population and in different types of rheumatologic diseases and are thus nonspecific [25]. US Area of Interest As mentioned before, the 2013 EULAR task force recommendations on use of imaging of the joints in RA state that when there is diagnostic doubt following radiographs, US, or MRI can be used to improve the certainty of diagnosis of RA above clinical criteria as well as to detect early joint damage before it is radiographically visible [13]. Although MRI with IV contrast has been shown to be more sensitive compared with US and has higher diagnostic performance [21], both outperform clinical evaluation and provide prognostic information concerning Chronic Extremity Joint Pain radiographic progression [10-12]. The evidence is inconclusive as to whether MRI or US should be considered the preferred method for evaluation of RA [18]. US has been used to evaluate for osseous abnormalities in the setting of chronic inflammatory arthritis. Compared with radiography, US has been shown to demonstrate a 6.5-fold increase in the number of detected erosions of the metacarpophalangeal joints [12], but it is less accurate when compared with CT [11]. The false-positive rate for US in detection of metacarpophalangeal joint erosions has been reported as high as 29% [29]. Regardless, large erosions identified with US at the second and third metacarpophalangeal joints, the distal ulna, and the fifth metatarsophalangeal joint are highly specific for and predictive of RA [30]. US may also show imaging findings associated with enthesitis [25], with findings of enthesitis on power Doppler imaging having an accuracy of 85.6% in distinguishing peripheral spondyloarthritis versus nonspondyloarthropathy [31]. | Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs. MRI-detected erosions as defined by the RAMRIS criteria [24] can be observed in the metacarpophalangeal and metatarsophalangeal joints of symptom-free individuals in the general population and in different types of rheumatologic diseases and are thus nonspecific [25]. US Area of Interest As mentioned before, the 2013 EULAR task force recommendations on use of imaging of the joints in RA state that when there is diagnostic doubt following radiographs, US, or MRI can be used to improve the certainty of diagnosis of RA above clinical criteria as well as to detect early joint damage before it is radiographically visible [13]. Although MRI with IV contrast has been shown to be more sensitive compared with US and has higher diagnostic performance [21], both outperform clinical evaluation and provide prognostic information concerning Chronic Extremity Joint Pain radiographic progression [10-12]. The evidence is inconclusive as to whether MRI or US should be considered the preferred method for evaluation of RA [18]. US has been used to evaluate for osseous abnormalities in the setting of chronic inflammatory arthritis. Compared with radiography, US has been shown to demonstrate a 6.5-fold increase in the number of detected erosions of the metacarpophalangeal joints [12], but it is less accurate when compared with CT [11]. The false-positive rate for US in detection of metacarpophalangeal joint erosions has been reported as high as 29% [29]. Regardless, large erosions identified with US at the second and third metacarpophalangeal joints, the distal ulna, and the fifth metatarsophalangeal joint are highly specific for and predictive of RA [30]. US may also show imaging findings associated with enthesitis [25], with findings of enthesitis on power Doppler imaging having an accuracy of 85.6% in distinguishing peripheral spondyloarthritis versus nonspondyloarthropathy [31]. | 3097211 |
acrac_3097211_10 | Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs | Studies have also found US to be helpful in differentiating RA and psoriatic arthritis [32,33]; for example, enthesitis is a finding often seen in spondyloarthritis but not seen in RA. Increased distance between the nail and distal phalanx in patients with psoriatic arthritis and cutaneous psoriasis is reported to have an 80% sensitivity and a 71% specificity [34]. US is also useful in the evaluation for synovitis and tenosynovitis, aided by the detection of hyperemia via color or Doppler signal [23]. Power Doppler US is more accurate for the diagnosis of synovitis and has a higher correlation with disease activity compared with grayscale US [35,36]. Synovitis on power Doppler US and grayscale US are both associated with the development of radiographic erosions in patients with RA compared with grayscale US [37,38]. Newer techniques for detecting microvascularization associated with joint inflammation like multimodal photoacoustic/US and ultra-microangiography have shown promise as indicators of disease activity [39,40]. US also provides prognostic information (such as detecting synovitis) that is linked to disease progression [13], although mild synovial hypertrophy as an isolated finding is not specific and has limited relevance [41]. In the evaluation of the finger joints with US, dorsal evaluation is recommended over palmar [42]. Abbreviated US scanning protocols of the hands, wrists, and feet to improve efficiency have been described [43-46]. Variant 3: Chronic extremity joint pain. Suspect gout. Radiographs normal or inconclusive. Next imaging study. The area of interest for this variant include: the ankle, elbow, foot, hand, hip, knee, shoulder, and wrist. Bone Scan Whole Body There is no relevant literature supporting the use of bone scan whole body for the evaluation of gout in the extremities following initial radiographs. | Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs. Studies have also found US to be helpful in differentiating RA and psoriatic arthritis [32,33]; for example, enthesitis is a finding often seen in spondyloarthritis but not seen in RA. Increased distance between the nail and distal phalanx in patients with psoriatic arthritis and cutaneous psoriasis is reported to have an 80% sensitivity and a 71% specificity [34]. US is also useful in the evaluation for synovitis and tenosynovitis, aided by the detection of hyperemia via color or Doppler signal [23]. Power Doppler US is more accurate for the diagnosis of synovitis and has a higher correlation with disease activity compared with grayscale US [35,36]. Synovitis on power Doppler US and grayscale US are both associated with the development of radiographic erosions in patients with RA compared with grayscale US [37,38]. Newer techniques for detecting microvascularization associated with joint inflammation like multimodal photoacoustic/US and ultra-microangiography have shown promise as indicators of disease activity [39,40]. US also provides prognostic information (such as detecting synovitis) that is linked to disease progression [13], although mild synovial hypertrophy as an isolated finding is not specific and has limited relevance [41]. In the evaluation of the finger joints with US, dorsal evaluation is recommended over palmar [42]. Abbreviated US scanning protocols of the hands, wrists, and feet to improve efficiency have been described [43-46]. Variant 3: Chronic extremity joint pain. Suspect gout. Radiographs normal or inconclusive. Next imaging study. The area of interest for this variant include: the ankle, elbow, foot, hand, hip, knee, shoulder, and wrist. Bone Scan Whole Body There is no relevant literature supporting the use of bone scan whole body for the evaluation of gout in the extremities following initial radiographs. | 3097211 |
acrac_3097211_11 | Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs | CT Area of Interest With IV Contrast There is no relevant literature supporting the use of CT area of interest with IV contrast for the evaluation of gout in the extremities following initial radiographs. CT Area of Interest Without and With IV Contrast There is no relevant literature supporting the use of CT area of interest without and with IV for the evaluation of gout in the extremities following initial radiographs. CT Area of Interest Without IV Contrast DECT allows visualization of monosodium urate deposition with a sensitivity ranging from 81% to 88% and a specificity ranging from 90% to 93% [47-49]. However, DECT is less accurate in early stages of gout, with a sensitivity in initial stages of gout flare (<6 weeks) ranging between 36% and 80% [15,47]. Sensitivity is also low for deeper structures such as the shoulder and hip [16]. DECT outperforms clinical assessment in the diagnosis of gout [50] and has been shown to be more sensitive for the diagnosis of gout compared to US in studies of patients in mixed stages of disease [51-53]. DECT has been shown to be helpful in assessment of tophus resolution in response to treatment [54]. Although conventional CT area of interest without IV contrast can show characteristic osseous erosions and soft tissue tophi [38], the 2018 EULAR recommendations state that conventional CT without IV contrast has limited utility for diagnosis of gout compared with US and DECT [55]. However, for the purposes of this document, DECT is considered a technique categorized under this procedure subheading. FDG-PET/CT Whole Body There is no relevant literature supporting the use of FDG-PET/CT whole body for the evaluation of gout in the extremities following initial radiographs. Chronic Extremity Joint Pain Image-Guided Aspiration Area of Interest Image-guided aspiration may be helpful in confirming and characterizing crystal deposition disease and excluding infection. | Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs. CT Area of Interest With IV Contrast There is no relevant literature supporting the use of CT area of interest with IV contrast for the evaluation of gout in the extremities following initial radiographs. CT Area of Interest Without and With IV Contrast There is no relevant literature supporting the use of CT area of interest without and with IV for the evaluation of gout in the extremities following initial radiographs. CT Area of Interest Without IV Contrast DECT allows visualization of monosodium urate deposition with a sensitivity ranging from 81% to 88% and a specificity ranging from 90% to 93% [47-49]. However, DECT is less accurate in early stages of gout, with a sensitivity in initial stages of gout flare (<6 weeks) ranging between 36% and 80% [15,47]. Sensitivity is also low for deeper structures such as the shoulder and hip [16]. DECT outperforms clinical assessment in the diagnosis of gout [50] and has been shown to be more sensitive for the diagnosis of gout compared to US in studies of patients in mixed stages of disease [51-53]. DECT has been shown to be helpful in assessment of tophus resolution in response to treatment [54]. Although conventional CT area of interest without IV contrast can show characteristic osseous erosions and soft tissue tophi [38], the 2018 EULAR recommendations state that conventional CT without IV contrast has limited utility for diagnosis of gout compared with US and DECT [55]. However, for the purposes of this document, DECT is considered a technique categorized under this procedure subheading. FDG-PET/CT Whole Body There is no relevant literature supporting the use of FDG-PET/CT whole body for the evaluation of gout in the extremities following initial radiographs. Chronic Extremity Joint Pain Image-Guided Aspiration Area of Interest Image-guided aspiration may be helpful in confirming and characterizing crystal deposition disease and excluding infection. | 3097211 |
acrac_3097211_12 | Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs | The identification of urate crystals in the aspirate is diagnostic of gout. If urate crystals are not seen in the aspirate; however, this does not necessarily exclude gout. Up to 16% patients diagnosed with acute gout can have negative aspirates [56]. MRI Area of Interest Without and With IV Contrast MRI can show the presence of tophi, crystal induced synovitis, and joint damage [57]; however, the 2018 EULAR recommendations state that MRI has limited utility for diagnosis of gout compared with US and DECT. MRI with or without IV contrast is not supported for routine evaluation of gout in the extremities following initial radiographs [55]. MRI Area of Interest Without IV Contrast MRI can show the presence of tophi, crystal induced synovitis, and joint damage [57]; however, the 2018 EULAR recommendations state that MRI has limited utility for diagnosis of gout compared with US and DECT. MRI without IV contrast is not supported for routine evaluation of gout in the extremities following initial radiographs [55]. US Area of Interest The 2018 EULAR recommendations favor US over other modalities [55]. The Outcome Measures in Rheumatology definitions of US elementary lesions in gout include double contour sign, tophus, aggregates, and erosions [58]. Identification of the double contour sign and soft tissue tophi are highly sensitive, specific, and accurate for the diagnosis of gout [59,60], with double contour sign having excellent reliability [61]. US has been shown to outperform clinical assessment in the diagnosis of gout [50] and outperforms radiography in the detection of erosions, although limitations exist if an erosion involves an area of bone that is inaccessible to US evaluation [62]. There is evidence that US may have higher sensitivity for detection of gout compared with DECT in early gout (duration <1 year) [63]. | Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs. The identification of urate crystals in the aspirate is diagnostic of gout. If urate crystals are not seen in the aspirate; however, this does not necessarily exclude gout. Up to 16% patients diagnosed with acute gout can have negative aspirates [56]. MRI Area of Interest Without and With IV Contrast MRI can show the presence of tophi, crystal induced synovitis, and joint damage [57]; however, the 2018 EULAR recommendations state that MRI has limited utility for diagnosis of gout compared with US and DECT. MRI with or without IV contrast is not supported for routine evaluation of gout in the extremities following initial radiographs [55]. MRI Area of Interest Without IV Contrast MRI can show the presence of tophi, crystal induced synovitis, and joint damage [57]; however, the 2018 EULAR recommendations state that MRI has limited utility for diagnosis of gout compared with US and DECT. MRI without IV contrast is not supported for routine evaluation of gout in the extremities following initial radiographs [55]. US Area of Interest The 2018 EULAR recommendations favor US over other modalities [55]. The Outcome Measures in Rheumatology definitions of US elementary lesions in gout include double contour sign, tophus, aggregates, and erosions [58]. Identification of the double contour sign and soft tissue tophi are highly sensitive, specific, and accurate for the diagnosis of gout [59,60], with double contour sign having excellent reliability [61]. US has been shown to outperform clinical assessment in the diagnosis of gout [50] and outperforms radiography in the detection of erosions, although limitations exist if an erosion involves an area of bone that is inaccessible to US evaluation [62]. There is evidence that US may have higher sensitivity for detection of gout compared with DECT in early gout (duration <1 year) [63]. | 3097211 |
acrac_3097211_13 | Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs | US has also been shown to be helpful in assessment of tophus resolution in response to treatment [64,65]. Variant 4: Chronic extremity joint pain. Suspect calcium pyrophosphate deposition disease (pseudogout). Radiographs normal or inconclusive. Next imaging study. The EULAR defines CPPD as a general term encompassing variable phenotypes, including asymptomatic involvement, acute CPP crystal arthritis, osteoarthritis with CPPD, and chronic CPP crystal inflammatory arthritis [66]. CPPD is thought to have high prevalence in the elderly [67] but is underdiagnosed. CPPD joint involvement as defined by EULAR is when CPP is detected in the synovial fluid from affected joints [66]. Diagnosis is often challenging; however, because the reference standard of synovial fluid analysis has been shown to have a high specificity (100%) but a lower sensitivity (75%) [68]. Chondrocalcinosis is defined as cartilage calcification detected by imaging or histological examination and is most commonly due to CPPD. However, the relationship between chondrocalcinosis and commonly coexisting conditions like osteoarthritis and hemochromatosis is poorly understood. The area of interest for this variant include: the ankle, elbow, foot, hand, hip, knee, shoulder, and wrist. Bone Scan Whole Body There is no relevant literature supporting the use of bone scan whole body for the evaluation of CPPD in the extremities following initial radiographs. CT Area of Interest With IV Contrast There is no relevant literature supporting the use of CT area of interest with IV contrast for the evaluation of CPPD in the extremities following initial radiographs. CT Area of Interest Without and With IV Contrast There is no relevant literature supporting the use of CT area of interest without and with IV for the evaluation of CPPD in the extremities following initial radiographs. | Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs. US has also been shown to be helpful in assessment of tophus resolution in response to treatment [64,65]. Variant 4: Chronic extremity joint pain. Suspect calcium pyrophosphate deposition disease (pseudogout). Radiographs normal or inconclusive. Next imaging study. The EULAR defines CPPD as a general term encompassing variable phenotypes, including asymptomatic involvement, acute CPP crystal arthritis, osteoarthritis with CPPD, and chronic CPP crystal inflammatory arthritis [66]. CPPD is thought to have high prevalence in the elderly [67] but is underdiagnosed. CPPD joint involvement as defined by EULAR is when CPP is detected in the synovial fluid from affected joints [66]. Diagnosis is often challenging; however, because the reference standard of synovial fluid analysis has been shown to have a high specificity (100%) but a lower sensitivity (75%) [68]. Chondrocalcinosis is defined as cartilage calcification detected by imaging or histological examination and is most commonly due to CPPD. However, the relationship between chondrocalcinosis and commonly coexisting conditions like osteoarthritis and hemochromatosis is poorly understood. The area of interest for this variant include: the ankle, elbow, foot, hand, hip, knee, shoulder, and wrist. Bone Scan Whole Body There is no relevant literature supporting the use of bone scan whole body for the evaluation of CPPD in the extremities following initial radiographs. CT Area of Interest With IV Contrast There is no relevant literature supporting the use of CT area of interest with IV contrast for the evaluation of CPPD in the extremities following initial radiographs. CT Area of Interest Without and With IV Contrast There is no relevant literature supporting the use of CT area of interest without and with IV for the evaluation of CPPD in the extremities following initial radiographs. | 3097211 |
acrac_3097211_14 | Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs | CT Area of Interest Without IV Contrast CT without IV contrast can identify chondrocalcinosis and mineralization of tendons, ligaments, and joint capsules as well as show that osseous changes related to CPPD, such as arthropathy characteristically involving the radiocarpal, metacarpophalangeal, atlantoaxial, and patellofemoral joints, are also well demonstrated by CT [69]. Chronic Extremity Joint Pain Both conventional CT without IV contrast and DECT have similarly high sensitivity for the detection of chondrocalcinosis [69-71]. DECT combines the information offered by conventional CT and adds information about the molecular compositions of the tissues. Therefore, the potential advantage of DECT over conventional CT is not an increased sensitivity but the ability to characterize (for example in distinguishing gout and pseudogout) and quantify crystal deposition. For the purposes of this document, DECT is considered a technique categorized under this procedure subheading. FDG-PET/CT Whole Body There is no relevant literature supporting the use of FDG-PET/CT whole body for the evaluation of CPPD in the extremities following initial radiographs. Image-Guided Aspiration Area of Interest Image-guided aspiration may be helpful in confirming and characterizing crystal deposition disease and excluding infection [68]. Diagnosis is often challenging; however, because the reference standard of synovial fluid analysis has been shown to have a high specificity (100%) but a lower sensitivity (75%) [68]. MRI Area of Interest Without and With IV Contrast Chondrocalcinosis may be seen as foci of low signal on MRI, and detection may be improved on gradient echo and ultra-short time to echo sequences [72]. Future research is needed to determine the role of MRI in the evaluation of CPPD in the extremities. There is insufficient evidence to support routine use of MRI with or without IV contrast in the diagnosis of CPPD. | Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs. CT Area of Interest Without IV Contrast CT without IV contrast can identify chondrocalcinosis and mineralization of tendons, ligaments, and joint capsules as well as show that osseous changes related to CPPD, such as arthropathy characteristically involving the radiocarpal, metacarpophalangeal, atlantoaxial, and patellofemoral joints, are also well demonstrated by CT [69]. Chronic Extremity Joint Pain Both conventional CT without IV contrast and DECT have similarly high sensitivity for the detection of chondrocalcinosis [69-71]. DECT combines the information offered by conventional CT and adds information about the molecular compositions of the tissues. Therefore, the potential advantage of DECT over conventional CT is not an increased sensitivity but the ability to characterize (for example in distinguishing gout and pseudogout) and quantify crystal deposition. For the purposes of this document, DECT is considered a technique categorized under this procedure subheading. FDG-PET/CT Whole Body There is no relevant literature supporting the use of FDG-PET/CT whole body for the evaluation of CPPD in the extremities following initial radiographs. Image-Guided Aspiration Area of Interest Image-guided aspiration may be helpful in confirming and characterizing crystal deposition disease and excluding infection [68]. Diagnosis is often challenging; however, because the reference standard of synovial fluid analysis has been shown to have a high specificity (100%) but a lower sensitivity (75%) [68]. MRI Area of Interest Without and With IV Contrast Chondrocalcinosis may be seen as foci of low signal on MRI, and detection may be improved on gradient echo and ultra-short time to echo sequences [72]. Future research is needed to determine the role of MRI in the evaluation of CPPD in the extremities. There is insufficient evidence to support routine use of MRI with or without IV contrast in the diagnosis of CPPD. | 3097211 |
acrac_3097211_15 | Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs | MRI Area of Interest Without IV Contrast Chondrocalcinosis may be seen as foci of low signal on MRI, and detection may be improved on gradient echo and ultra-short time to echo sequences [72]. Future research is needed to determine the role of MRI in the evaluation of CPPD in the extremities. There is insufficient evidence to support routine use of MRI without IV contrast in the diagnosis of CPPD. US Area of Interest CPPD can be seen as echogenic foci in in hyaline cartilage, tendons, and the menisci. US has been shown to outperform radiography in detection of chondrocalcinosis [73,74]. Filippou et al [75] found that US had an overall diagnostic accuracy of 75%, with a sensitivity of 91% and a specificity of 59% with histology as the reference standard. The positive predicative value and negative predicative value were 88% and 76%, respectively. When considering combination of medial meniscus and medial condyle hyaline cartilage in combination, US has a sensitivity and specificity of 88% and 76%, respectively. Variant 5: Chronic extremity joint pain. Suspect erosive osteoarthritis. Radiographs normal or inconclusive. Next imaging study. Bone Scan Whole Body There is no relevant literature supporting the use of bone scan whole body for the evaluation of erosive osteoarthritis in the extremities following initial radiographs. CT Area of Interest With IV Contrast There is no relevant literature supporting the use of CT area of interest with IV contrast for the evaluation of erosive osteoarthritis in the extremities following initial radiographs. CT Area of Interest Without and With IV Contrast There is no relevant literature supporting the use of CT area of interest without and with IV contrast for the evaluation of erosive osteoarthritis in the extremities following initial radiographs. | Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs. MRI Area of Interest Without IV Contrast Chondrocalcinosis may be seen as foci of low signal on MRI, and detection may be improved on gradient echo and ultra-short time to echo sequences [72]. Future research is needed to determine the role of MRI in the evaluation of CPPD in the extremities. There is insufficient evidence to support routine use of MRI without IV contrast in the diagnosis of CPPD. US Area of Interest CPPD can be seen as echogenic foci in in hyaline cartilage, tendons, and the menisci. US has been shown to outperform radiography in detection of chondrocalcinosis [73,74]. Filippou et al [75] found that US had an overall diagnostic accuracy of 75%, with a sensitivity of 91% and a specificity of 59% with histology as the reference standard. The positive predicative value and negative predicative value were 88% and 76%, respectively. When considering combination of medial meniscus and medial condyle hyaline cartilage in combination, US has a sensitivity and specificity of 88% and 76%, respectively. Variant 5: Chronic extremity joint pain. Suspect erosive osteoarthritis. Radiographs normal or inconclusive. Next imaging study. Bone Scan Whole Body There is no relevant literature supporting the use of bone scan whole body for the evaluation of erosive osteoarthritis in the extremities following initial radiographs. CT Area of Interest With IV Contrast There is no relevant literature supporting the use of CT area of interest with IV contrast for the evaluation of erosive osteoarthritis in the extremities following initial radiographs. CT Area of Interest Without and With IV Contrast There is no relevant literature supporting the use of CT area of interest without and with IV contrast for the evaluation of erosive osteoarthritis in the extremities following initial radiographs. | 3097211 |
acrac_3097211_16 | Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs | CT Area of Interest Without IV Contrast Although CT is well-suited for demonstration of osseous erosions, there is no relevant literature supporting the use of CT area of interest without IV contrast for the evaluation of erosive osteoarthritis in the extremities following initial radiographs. FDG-PET/CT Whole Body There is no relevant literature supporting the use of FDG-PET/CT whole body for the evaluation of erosive osteoarthritis in the extremities following initial radiographs. Chronic Extremity Joint Pain Image-Guided Aspiration Area of Interest There is no relevant literature supporting the use of image-guided aspiration for the evaluation of erosive osteoarthritis in the extremities following initial radiographs. MRI Area of Interest Without and With IV Contrast MRI can show the features of erosive osteoarthritis, although the findings may be nonspecific, potentially mimicking other types of joint inflammation. The addition of IV contrast may aid in the differentiation of synovitis from joint effusion [23]. MRI Area of Interest Without IV Contrast MRI can show the features of erosive osteoarthritis, although the findings may be nonspecific, potentially mimicking other types of joint inflammation. US Area of Interest US may demonstrate synovial hypertrophy, marginal osteophytes, and central erosions [76] but is not routinely used in clinical practice for the evaluation of erosive osteoarthritis. Both US and contrast-enhanced MRI have been shown to perform equally in the demonstration of synovitis of the fingers associated with erosive osteoarthritis [76]. However, synovitis on US is nonspecific and may be seen with erosive osteoarthritis and inflammatory arthritis. Supporting Documents The evidence table, literature search, and appendix for this topic are available at https://acsearch. acr.org/list. | Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs. CT Area of Interest Without IV Contrast Although CT is well-suited for demonstration of osseous erosions, there is no relevant literature supporting the use of CT area of interest without IV contrast for the evaluation of erosive osteoarthritis in the extremities following initial radiographs. FDG-PET/CT Whole Body There is no relevant literature supporting the use of FDG-PET/CT whole body for the evaluation of erosive osteoarthritis in the extremities following initial radiographs. Chronic Extremity Joint Pain Image-Guided Aspiration Area of Interest There is no relevant literature supporting the use of image-guided aspiration for the evaluation of erosive osteoarthritis in the extremities following initial radiographs. MRI Area of Interest Without and With IV Contrast MRI can show the features of erosive osteoarthritis, although the findings may be nonspecific, potentially mimicking other types of joint inflammation. The addition of IV contrast may aid in the differentiation of synovitis from joint effusion [23]. MRI Area of Interest Without IV Contrast MRI can show the features of erosive osteoarthritis, although the findings may be nonspecific, potentially mimicking other types of joint inflammation. US Area of Interest US may demonstrate synovial hypertrophy, marginal osteophytes, and central erosions [76] but is not routinely used in clinical practice for the evaluation of erosive osteoarthritis. Both US and contrast-enhanced MRI have been shown to perform equally in the demonstration of synovitis of the fingers associated with erosive osteoarthritis [76]. However, synovitis on US is nonspecific and may be seen with erosive osteoarthritis and inflammatory arthritis. Supporting Documents The evidence table, literature search, and appendix for this topic are available at https://acsearch. acr.org/list. | 3097211 |
acrac_3083064_0 | Pelvic Floor Dysfunction in Females | Support to the pelvic floor is provided by a combination of muscular and connective tissue structures. Direct or denervation injury to the pelvic floor musculature is postulated to increase stress on the fascia and lead to weakening of the pelvic floor. Risk factors for pelvic floor dysfunction include advanced age, menopause, vaginal multiparity, obesity, chronic straining, and conditions that result in chronic increase in intra-abdominal pressures [10]. Special Imaging Considerations Use of Contrast Material Pelvic floor imaging may require the instillation of contrast media in the bladder, vagina, rectum, and small bowel, depending on the specific examination to be performed. Fluoroscopy of the pelvic floor may be performed with Reprint requests to: [email protected] Pelvic Floor Dysfunction in Females oral, rectal, bladder, and vaginal contrast (cystocolpoproctography [CCP]), or only with rectal contrast (defecography or proctography), or any combination thereof. For these guidelines, fluoroscopic CCP will be the default fluoroscopic defecation examination of the pelvis unless noted. Voiding cystourethrogram (VCUG) has been used for evaluation of the anterior compartment and necessitates instillation of radiopaque contrast in the urinary bladder [14]. MRI of the pelvic floor allows for direct visualization of the intrapelvic contents, precluding need for contrast within the bladder, vagina, and small bowel; however, use of contrast in the rectum for MR defecography facilitates defecation and improves detection of prolapse compared with dynamic pelvic floor MRI without rectal contrast [15]. Various types and volumes of contrast media have been reported and may depend on the preference of the institution, although US gel or sterile lubricating jelly are the most commonly used rectal contrast agents for MR defecography. MR defecography is performed without IV contrast. | Pelvic Floor Dysfunction in Females. Support to the pelvic floor is provided by a combination of muscular and connective tissue structures. Direct or denervation injury to the pelvic floor musculature is postulated to increase stress on the fascia and lead to weakening of the pelvic floor. Risk factors for pelvic floor dysfunction include advanced age, menopause, vaginal multiparity, obesity, chronic straining, and conditions that result in chronic increase in intra-abdominal pressures [10]. Special Imaging Considerations Use of Contrast Material Pelvic floor imaging may require the instillation of contrast media in the bladder, vagina, rectum, and small bowel, depending on the specific examination to be performed. Fluoroscopy of the pelvic floor may be performed with Reprint requests to: [email protected] Pelvic Floor Dysfunction in Females oral, rectal, bladder, and vaginal contrast (cystocolpoproctography [CCP]), or only with rectal contrast (defecography or proctography), or any combination thereof. For these guidelines, fluoroscopic CCP will be the default fluoroscopic defecation examination of the pelvis unless noted. Voiding cystourethrogram (VCUG) has been used for evaluation of the anterior compartment and necessitates instillation of radiopaque contrast in the urinary bladder [14]. MRI of the pelvic floor allows for direct visualization of the intrapelvic contents, precluding need for contrast within the bladder, vagina, and small bowel; however, use of contrast in the rectum for MR defecography facilitates defecation and improves detection of prolapse compared with dynamic pelvic floor MRI without rectal contrast [15]. Various types and volumes of contrast media have been reported and may depend on the preference of the institution, although US gel or sterile lubricating jelly are the most commonly used rectal contrast agents for MR defecography. MR defecography is performed without IV contrast. | 3083064 |
acrac_3083064_1 | Pelvic Floor Dysfunction in Females | Dynamic US of the pelvic floor enables direct visualization of the pelvic floor organs and is most commonly performed without installation of contrast. MRI with Endorectal/Endoanal Coil The use of endorectal coil may help better visualize the supporting ligaments in the pelvis, and assessment of baseline external anal sphincter thickness on endoanal MRI in patients with fecal incontinence can help predict outcomes after sphincter repair [16]; however, endoanal MRI is relatively invasive and may decrease patient acceptance and compliance. The coil can cause distortion of the pelvic tissues in patients who have a small pelvis. During functional assessment, the coil in the rectum may temporarily prevent prolapse [17]. For these reasons, endoanal MRI is not routinely performed at most centers, and the high-resolution images achievable with external phased-array coils are utilized. Echodefecography Echodefecography, a US technique performed with an endorectal probe and gel in the rectum, has been described for evaluation of posterior compartment dysfunction [18,19]. Echodefecography is not routinely available at most centers and thus is not discussed as a separate procedure in these guidelines. OR Discussion of Procedures by Variant Variant 1: Vaginal protrusion or bulge, or clinically suspected pelvic organ prolapse. Initial imaging. POP is the excessive descent of organs through the pelvic floor hiatus and typically involves protrusion of anterior or posterior vaginal walls and/or descent of the vaginal apex [20]. Patients usually present with pelvic pressure or bulge and often have other associated pelvic floor dysfunction. POP may involve various compartments of the pelvic floor, including the anterior (cystocele and/or urethrocele), apical (uterine/cervical and/or vaginal prolapse), and posterior (rectocele). In addition, pelvic contents at the posterior cul-de-sac may herniate into the rectovaginal space. | Pelvic Floor Dysfunction in Females. Dynamic US of the pelvic floor enables direct visualization of the pelvic floor organs and is most commonly performed without installation of contrast. MRI with Endorectal/Endoanal Coil The use of endorectal coil may help better visualize the supporting ligaments in the pelvis, and assessment of baseline external anal sphincter thickness on endoanal MRI in patients with fecal incontinence can help predict outcomes after sphincter repair [16]; however, endoanal MRI is relatively invasive and may decrease patient acceptance and compliance. The coil can cause distortion of the pelvic tissues in patients who have a small pelvis. During functional assessment, the coil in the rectum may temporarily prevent prolapse [17]. For these reasons, endoanal MRI is not routinely performed at most centers, and the high-resolution images achievable with external phased-array coils are utilized. Echodefecography Echodefecography, a US technique performed with an endorectal probe and gel in the rectum, has been described for evaluation of posterior compartment dysfunction [18,19]. Echodefecography is not routinely available at most centers and thus is not discussed as a separate procedure in these guidelines. OR Discussion of Procedures by Variant Variant 1: Vaginal protrusion or bulge, or clinically suspected pelvic organ prolapse. Initial imaging. POP is the excessive descent of organs through the pelvic floor hiatus and typically involves protrusion of anterior or posterior vaginal walls and/or descent of the vaginal apex [20]. Patients usually present with pelvic pressure or bulge and often have other associated pelvic floor dysfunction. POP may involve various compartments of the pelvic floor, including the anterior (cystocele and/or urethrocele), apical (uterine/cervical and/or vaginal prolapse), and posterior (rectocele). In addition, pelvic contents at the posterior cul-de-sac may herniate into the rectovaginal space. | 3083064 |
acrac_3083064_2 | Pelvic Floor Dysfunction in Females | The cul-de-sac hernia may contain peritoneal fat (peritoneocele), small bowel (enterocele), or sigmoid colon (sigmoidocele). Infolding of the rectal wall into its lumen, rectal intussusception, can be partial thickness (involving only the mucosa) or full-wall thickness and may involve either only the anterior wall or both the anterior and posterior wall. Based on location, it may be classified as internal rectal prolapse (intrarectal, intra-anal), or external (extra-anal) intussusception (beyond the anal verge, also called complete rectal prolapse). The appearance of these findings is well described in the imaging literature [21,22]. Initial evaluation of patients with POP symptoms is clinical and begins with the physical examination. Imaging may be obtained when clinical evaluation is difficult or considered inadequate by the physician, or if patients present with persistent or recurrent prolapse symptoms after attempted surgical or nonsurgical treatments. Goals of imaging in this setting may include confirm clinically suspected Pelvic Floor Dysfunction in Females prolapse, assess severity of prolapse, evaluate for associated structural defects or functional abnormalities, differentiate between cul-de-sac hernias and anterior rectoceles (both of which can present clinically with posterior vaginal bulge), determine contents of cul-de-sac hernias, and evaluate for occult pelvic floor disorders in compartments other than those apparent on physical examination. CT Pelvis Although CT may be able to depict large levator muscle defects, to our knowledge there is no relevant literature regarding the use of CT, either with or without IV contrast, for assessment of a protruding or bulging vaginal mass or clinically suspected POP. Fluoroscopy Cystocolpoproctography Dynamic CCP is one of the imaging tests of choice for evaluation of a protruding or bulging vaginal mass or clinically suspected POP and may be an initial imaging test in the setting of posterior compartment prolapse. | Pelvic Floor Dysfunction in Females. The cul-de-sac hernia may contain peritoneal fat (peritoneocele), small bowel (enterocele), or sigmoid colon (sigmoidocele). Infolding of the rectal wall into its lumen, rectal intussusception, can be partial thickness (involving only the mucosa) or full-wall thickness and may involve either only the anterior wall or both the anterior and posterior wall. Based on location, it may be classified as internal rectal prolapse (intrarectal, intra-anal), or external (extra-anal) intussusception (beyond the anal verge, also called complete rectal prolapse). The appearance of these findings is well described in the imaging literature [21,22]. Initial evaluation of patients with POP symptoms is clinical and begins with the physical examination. Imaging may be obtained when clinical evaluation is difficult or considered inadequate by the physician, or if patients present with persistent or recurrent prolapse symptoms after attempted surgical or nonsurgical treatments. Goals of imaging in this setting may include confirm clinically suspected Pelvic Floor Dysfunction in Females prolapse, assess severity of prolapse, evaluate for associated structural defects or functional abnormalities, differentiate between cul-de-sac hernias and anterior rectoceles (both of which can present clinically with posterior vaginal bulge), determine contents of cul-de-sac hernias, and evaluate for occult pelvic floor disorders in compartments other than those apparent on physical examination. CT Pelvis Although CT may be able to depict large levator muscle defects, to our knowledge there is no relevant literature regarding the use of CT, either with or without IV contrast, for assessment of a protruding or bulging vaginal mass or clinically suspected POP. Fluoroscopy Cystocolpoproctography Dynamic CCP is one of the imaging tests of choice for evaluation of a protruding or bulging vaginal mass or clinically suspected POP and may be an initial imaging test in the setting of posterior compartment prolapse. | 3083064 |
acrac_3083064_3 | Pelvic Floor Dysfunction in Females | Dynamic CCP involves fluoroscopic imaging during defecation with the patient sitting in physiologic upright position on a fluoroscopic commode. Images are obtained during rest, Kegel (contraction of the pelvic floor muscles), strain, and defecation. CCP demonstrates good agreement with surgical findings for detection of full-thickness rectal prolapse, posterior colpocele, rectocele, and peritoneocele and demonstrates excellent correlation for internal rectal prolapse (intrarectal and intra-anal). Sensitivities of CCP for detection of internal rectal prolapse and peritoneocele are 88% and 83%, respectively. [23]. There are few studies comparing CCP to surgical findings for assessment of anterior and middle compartment prolapse. The degree of concordance between CCP and physical examination varies based on the site of prolapse. Relative to physical examination, sensitivity of CCP for detection of cystoceles, rectoceles, and enteroceles is 96%, 94%, and 35%, respectively. Conversely, physical examination detects 83% of cystoceles, 77% of rectoceles, and 51% of enteroceles seen on CCP [11]. Thus, CCP may detect prolapse that is clinically occult. In general, the biggest advantage of CCP is that it allows for functional evaluation in the physiologic upright seated positioning. CCP also allows for assessment of barium contrast retention within rectoceles, which favors clinically relevant rather than incidental findings when present. Known limitations of fluoroscopic CCP include the lack of soft-tissue contrast resolution and the inability to directly visualize pelvic floor anatomy, particularly the pelvic floor muscles and fascia or postsurgical changes in the pelvic floor. As previously mentioned, dynamic CCP also requires installation of contrast in the bladder and vagina as well as administration of oral contrast prior to the examination in order to adequately assess all pelvic floor compartments. | Pelvic Floor Dysfunction in Females. Dynamic CCP involves fluoroscopic imaging during defecation with the patient sitting in physiologic upright position on a fluoroscopic commode. Images are obtained during rest, Kegel (contraction of the pelvic floor muscles), strain, and defecation. CCP demonstrates good agreement with surgical findings for detection of full-thickness rectal prolapse, posterior colpocele, rectocele, and peritoneocele and demonstrates excellent correlation for internal rectal prolapse (intrarectal and intra-anal). Sensitivities of CCP for detection of internal rectal prolapse and peritoneocele are 88% and 83%, respectively. [23]. There are few studies comparing CCP to surgical findings for assessment of anterior and middle compartment prolapse. The degree of concordance between CCP and physical examination varies based on the site of prolapse. Relative to physical examination, sensitivity of CCP for detection of cystoceles, rectoceles, and enteroceles is 96%, 94%, and 35%, respectively. Conversely, physical examination detects 83% of cystoceles, 77% of rectoceles, and 51% of enteroceles seen on CCP [11]. Thus, CCP may detect prolapse that is clinically occult. In general, the biggest advantage of CCP is that it allows for functional evaluation in the physiologic upright seated positioning. CCP also allows for assessment of barium contrast retention within rectoceles, which favors clinically relevant rather than incidental findings when present. Known limitations of fluoroscopic CCP include the lack of soft-tissue contrast resolution and the inability to directly visualize pelvic floor anatomy, particularly the pelvic floor muscles and fascia or postsurgical changes in the pelvic floor. As previously mentioned, dynamic CCP also requires installation of contrast in the bladder and vagina as well as administration of oral contrast prior to the examination in order to adequately assess all pelvic floor compartments. | 3083064 |
acrac_3083064_4 | Pelvic Floor Dysfunction in Females | Fluoroscopy Voiding Cystourethrography VCUG is a fluoroscopic technique that focuses on the bladder and urethra in the anterior compartment. Contrast is instilled into the bladder via a Foley catheter. Images are then taken in the upright position at rest and strain and during voiding. Cystocele is defined on VCUG as extension of the opacified urinary bladder below the level of the pubic symphysis and the urethral angle can be measured relative to the vertical axis of the patient [14]. VCUG can be used as an objective measure of change in cystocele height and urethral angle after surgical repair [14]. Wu et al [24] demonstrated a correlation between the shape of a cystocele seen on VCUG and outcomes after cystocele repair with anterior vaginal wall suspension procedure. A significant limitation of VCUG for assessment of POP is its focused evaluation that is limited to the anterior compartment (cystocele and urethral hypermobility). VCUG does not provide information regarding global function of the pelvic floor. Furthermore, a recent study showed lower prevalence and degree of cystoceles and urethral hypermobility on upright VCUG compared to supine MR defecography [25]. Because of its narrow focus on anterior compartment structures, utility of VCUG is limited to patients with suspected concomitant urinary dysfunction. Thus, it is rarely used for initial evaluation of patients with POP. To our knowledge, there is no relevant literature to support the use of VCUG for functional assessment of a protruding or bulging posterior vaginal mass or for clinically suspected POP in the middle or posterior compartment. MR Defecography MR defecography is one of the initial imaging tests of choice for evaluation of a vaginal protrusion or bulge, or clinically suspected POP. It allows for comprehensive anatomic and functional evaluation of the entire pelvic floor. | Pelvic Floor Dysfunction in Females. Fluoroscopy Voiding Cystourethrography VCUG is a fluoroscopic technique that focuses on the bladder and urethra in the anterior compartment. Contrast is instilled into the bladder via a Foley catheter. Images are then taken in the upright position at rest and strain and during voiding. Cystocele is defined on VCUG as extension of the opacified urinary bladder below the level of the pubic symphysis and the urethral angle can be measured relative to the vertical axis of the patient [14]. VCUG can be used as an objective measure of change in cystocele height and urethral angle after surgical repair [14]. Wu et al [24] demonstrated a correlation between the shape of a cystocele seen on VCUG and outcomes after cystocele repair with anterior vaginal wall suspension procedure. A significant limitation of VCUG for assessment of POP is its focused evaluation that is limited to the anterior compartment (cystocele and urethral hypermobility). VCUG does not provide information regarding global function of the pelvic floor. Furthermore, a recent study showed lower prevalence and degree of cystoceles and urethral hypermobility on upright VCUG compared to supine MR defecography [25]. Because of its narrow focus on anterior compartment structures, utility of VCUG is limited to patients with suspected concomitant urinary dysfunction. Thus, it is rarely used for initial evaluation of patients with POP. To our knowledge, there is no relevant literature to support the use of VCUG for functional assessment of a protruding or bulging posterior vaginal mass or for clinically suspected POP in the middle or posterior compartment. MR Defecography MR defecography is one of the initial imaging tests of choice for evaluation of a vaginal protrusion or bulge, or clinically suspected POP. It allows for comprehensive anatomic and functional evaluation of the entire pelvic floor. | 3083064 |
acrac_3083064_5 | Pelvic Floor Dysfunction in Females | MR defecography is a specialized type of dynamic MRI of the pelvic floor that is typically performed with rectal contrast but without IV contrast and includes MRI acquisition during active defecation of rectal contrast. Multiple Pelvic Floor Dysfunction in Females studies have demonstrated the added benefit of MRI with rectal contrast and the defecation phase for assessment of POP compared with dynamic straining MRI without rectal contrast or defecation [15,26-29]. Although MR defecography can be performed in upright or supine positions, most centers lack an open magnet to allow imaging in the upright position. Studies comparing MR defecography in supine position to that in upright position have shown variable results depending on site of prolapse. Some authors have reported that MR defecography in supine positioning may underestimate detection and size of rectal intussusception and rectocele [30,31], whereas other authors [32] demonstrated no significant difference in prevalence of cystocele or anorectal descent during defecation when comparing the two positions. Regardless of positioning, patients should be asked to perform repeated strain/defecation maneuvers to maximize the size of organ prolapse seen on MRI [33]. MR defecography has moderate correlation with surgical findings for diagnosis of full thickness rectal prolapse, internal rectal prolapse, posterior colopocele, rectocele, and peritoneocele; however, agreement between imaging and surgical findings is lower for MR defecography than CCP for full-thickness rectal prolapse, internal rectal prolapse, and peritoneocele. MR defecography sensitivity for internal rectal prolapse and peritoneocele was not significantly lower than that of CCP in one study [23]. MR defecography agreement with physical examination is best for prolapse in the anterior compartment (85%) compared with middle compartment (63%) and posterior compartment (79%). | Pelvic Floor Dysfunction in Females. MR defecography is a specialized type of dynamic MRI of the pelvic floor that is typically performed with rectal contrast but without IV contrast and includes MRI acquisition during active defecation of rectal contrast. Multiple Pelvic Floor Dysfunction in Females studies have demonstrated the added benefit of MRI with rectal contrast and the defecation phase for assessment of POP compared with dynamic straining MRI without rectal contrast or defecation [15,26-29]. Although MR defecography can be performed in upright or supine positions, most centers lack an open magnet to allow imaging in the upright position. Studies comparing MR defecography in supine position to that in upright position have shown variable results depending on site of prolapse. Some authors have reported that MR defecography in supine positioning may underestimate detection and size of rectal intussusception and rectocele [30,31], whereas other authors [32] demonstrated no significant difference in prevalence of cystocele or anorectal descent during defecation when comparing the two positions. Regardless of positioning, patients should be asked to perform repeated strain/defecation maneuvers to maximize the size of organ prolapse seen on MRI [33]. MR defecography has moderate correlation with surgical findings for diagnosis of full thickness rectal prolapse, internal rectal prolapse, posterior colopocele, rectocele, and peritoneocele; however, agreement between imaging and surgical findings is lower for MR defecography than CCP for full-thickness rectal prolapse, internal rectal prolapse, and peritoneocele. MR defecography sensitivity for internal rectal prolapse and peritoneocele was not significantly lower than that of CCP in one study [23]. MR defecography agreement with physical examination is best for prolapse in the anterior compartment (85%) compared with middle compartment (63%) and posterior compartment (79%). | 3083064 |
acrac_3083064_6 | Pelvic Floor Dysfunction in Females | MR defecography detects 45% of enteroceles seen on physical examination; however, physical examination only demonstrates 30% of enteroceles seen on MR defecography and misdiagnoses of 10% for enteroceles as rectoceles. Thus MR defecography is beneficial in detecting or differentiating cases of enteroceles in apical or posterior compartment prolapse [34]. Additional utility of MR defecography lies in its ability to demonstrate associated pelvic floor abnormalities in multiple compartments in addition to the expected clinical diagnoses [35,36]. Finally, the static high-resolution T2-weighted images performed as part of a routine MR defecography may be used for anatomic evaluation. The inherent high soft-tissue contrast resolution of MRI allows for assessment of the pelvic organs including the bladder and urethra as well as the urethral ligaments [37]. Routine T2-weighted images acquired at rest have utility in detecting and quantifying levator muscle defects in patients with prolapse [38] with high interobserver reliability [39]. Muscle defects seen on MRI correlate with symptoms of POP or histories of prior vaginal reconstructive surgery or episiotomy [40]. Muscle thickness is measured reliably on MRI with external phased array coils [41]. Secondary findings of vaginal support defects such as displaced lateral and apical vaginal wall are also seen on MRI [42,43]. MRI Pelvis Dynamic Maneuvers without Defecation Pelvic floor MRI with dynamic maneuvers (dynamic pelvic floor MRI) is similar to MR defecography; however, rectal gel or IV contrast are not generally administered, and the cine images are obtained during maximal straining or Valsalva rather than during defecation. MRI allows for comprehensive anatomic and functional evaluation of the entire pelvic floor. The inherent high soft-tissue contrast resolution of MRI allows for direct visualization of the pelvic organs and pelvic floor muscles and fascia [37-39]. | Pelvic Floor Dysfunction in Females. MR defecography detects 45% of enteroceles seen on physical examination; however, physical examination only demonstrates 30% of enteroceles seen on MR defecography and misdiagnoses of 10% for enteroceles as rectoceles. Thus MR defecography is beneficial in detecting or differentiating cases of enteroceles in apical or posterior compartment prolapse [34]. Additional utility of MR defecography lies in its ability to demonstrate associated pelvic floor abnormalities in multiple compartments in addition to the expected clinical diagnoses [35,36]. Finally, the static high-resolution T2-weighted images performed as part of a routine MR defecography may be used for anatomic evaluation. The inherent high soft-tissue contrast resolution of MRI allows for assessment of the pelvic organs including the bladder and urethra as well as the urethral ligaments [37]. Routine T2-weighted images acquired at rest have utility in detecting and quantifying levator muscle defects in patients with prolapse [38] with high interobserver reliability [39]. Muscle defects seen on MRI correlate with symptoms of POP or histories of prior vaginal reconstructive surgery or episiotomy [40]. Muscle thickness is measured reliably on MRI with external phased array coils [41]. Secondary findings of vaginal support defects such as displaced lateral and apical vaginal wall are also seen on MRI [42,43]. MRI Pelvis Dynamic Maneuvers without Defecation Pelvic floor MRI with dynamic maneuvers (dynamic pelvic floor MRI) is similar to MR defecography; however, rectal gel or IV contrast are not generally administered, and the cine images are obtained during maximal straining or Valsalva rather than during defecation. MRI allows for comprehensive anatomic and functional evaluation of the entire pelvic floor. The inherent high soft-tissue contrast resolution of MRI allows for direct visualization of the pelvic organs and pelvic floor muscles and fascia [37-39]. | 3083064 |
acrac_3083064_7 | Pelvic Floor Dysfunction in Females | Muscle defects seen on MRI correlate with symptoms of POP or histories of prior vaginal reconstructive surgery or episiotomy [40]. Secondary findings of vaginal support defects such as displaced lateral and apical vaginal wall are also seen on MRI [42,43]. Imaging during dynamic maneuvers provides functional assessment of the pelvic floor. Dynamic pelvic floor MRI can detect POP in multiple compartments and may be most beneficial for diagnosis of enteroceles [44]. Although interobserver agreement for anterior and middle compartment prolapse is good to excellent [45,46], studies have shown variability in terms of correlation of findings on dynamic pelvic floor MRI with that on physical examination [45]. Furthermore, the detection rate of POP has been reported to be lower on MRI scans without rectal contrast than with rectal contrast [15]. Multiple studies have shown that dynamic pelvic floor MRI with straining rather than defecation demonstrates lower prevalence of prolapse in multiple compartments [12,15,26-29]. Thus, although it may be used for assessment of POP, dynamic pelvic floor MRI during straining (without defecation) is inferior to MR defecography for evaluation of a protruding or bulging vaginal mass or clinically suspected POP and is not considered the initial imaging examination of choice. MRI Pelvis To our knowledge, there is no relevant literature regarding the use of MRI pelvis without defecation or straining for functional assessment of a protruding or bulging vaginal mass or clinically suspected POP. MRI pelvis either without or with IV contrast may be used for anatomic evaluation. The inherent high soft-tissue contrast resolution of MRI allows for assessment of the pelvic organs, including the bladder and urethra, as well as Pelvic Floor Dysfunction in Females the urethral ligaments [37]. | Pelvic Floor Dysfunction in Females. Muscle defects seen on MRI correlate with symptoms of POP or histories of prior vaginal reconstructive surgery or episiotomy [40]. Secondary findings of vaginal support defects such as displaced lateral and apical vaginal wall are also seen on MRI [42,43]. Imaging during dynamic maneuvers provides functional assessment of the pelvic floor. Dynamic pelvic floor MRI can detect POP in multiple compartments and may be most beneficial for diagnosis of enteroceles [44]. Although interobserver agreement for anterior and middle compartment prolapse is good to excellent [45,46], studies have shown variability in terms of correlation of findings on dynamic pelvic floor MRI with that on physical examination [45]. Furthermore, the detection rate of POP has been reported to be lower on MRI scans without rectal contrast than with rectal contrast [15]. Multiple studies have shown that dynamic pelvic floor MRI with straining rather than defecation demonstrates lower prevalence of prolapse in multiple compartments [12,15,26-29]. Thus, although it may be used for assessment of POP, dynamic pelvic floor MRI during straining (without defecation) is inferior to MR defecography for evaluation of a protruding or bulging vaginal mass or clinically suspected POP and is not considered the initial imaging examination of choice. MRI Pelvis To our knowledge, there is no relevant literature regarding the use of MRI pelvis without defecation or straining for functional assessment of a protruding or bulging vaginal mass or clinically suspected POP. MRI pelvis either without or with IV contrast may be used for anatomic evaluation. The inherent high soft-tissue contrast resolution of MRI allows for assessment of the pelvic organs, including the bladder and urethra, as well as Pelvic Floor Dysfunction in Females the urethral ligaments [37]. | 3083064 |
acrac_3083064_8 | Pelvic Floor Dysfunction in Females | Routine T2-weighted images acquired at rest have utility in detecting and quantifying levator muscle defects in patients with prolapse with high interobserver reliability [38,39]. Muscle defects seen on MRI correlate with symptoms of POP or histories of prior vaginal reconstructive surgery or episiotomy [40]. Muscle thickness is measured reliably on MRI with external phased-array coils [41]. Secondary findings of vaginal support defects such as displaced lateral and apical vaginal wall are also seen on MRI [42,43]. US Pelvis Transabdominal To our knowledge, there is no relevant literature regarding the use of transabdominal US (TAUS) for assessment of a protruding or bulging vaginal mass or clinically suspected POP. US Pelvis Transperineal Transperineal US (TPUS) or translabial US can be used for anatomic and functional evaluation of the pelvic floor, including evaluation of a protruding or bulging vaginal mass or clinically suspected POP. Images are obtained via cine loops in multiple planes during rest, strain, and Kegel maneuvers, with both 2-D and 3-D imaging for anatomic and functional pelvic floor assessment. Patients may be positioned semi-upright or in the dorsal lithotomy position. With regards to anatomic evaluation, TPUS can detect levator muscle avulsion, a predictor of prolapse recurrence after surgical repair [47]. Patients with signs of POP tend to demonstrate a larger pelvic floor hiatal area [48]. Translabial US shows moderate-to-good agreement with MRI for detection of levator ani defects and moderate-to- very-good agreement with MRI for measurement of hiatal biometry [49]. With regards to functional evaluation, dynamic TPUS performed during maximal strain or Valsalva demonstrates bladder and cervical prolapse and can demonstrate rectocele, enterocele/sigmoidocele, and rectal intussusception in the posterior compartment [50]. Detailed evaluation of urethral dysfunction including descent, kinking, and funneling can be obtained during the evaluation. | Pelvic Floor Dysfunction in Females. Routine T2-weighted images acquired at rest have utility in detecting and quantifying levator muscle defects in patients with prolapse with high interobserver reliability [38,39]. Muscle defects seen on MRI correlate with symptoms of POP or histories of prior vaginal reconstructive surgery or episiotomy [40]. Muscle thickness is measured reliably on MRI with external phased-array coils [41]. Secondary findings of vaginal support defects such as displaced lateral and apical vaginal wall are also seen on MRI [42,43]. US Pelvis Transabdominal To our knowledge, there is no relevant literature regarding the use of transabdominal US (TAUS) for assessment of a protruding or bulging vaginal mass or clinically suspected POP. US Pelvis Transperineal Transperineal US (TPUS) or translabial US can be used for anatomic and functional evaluation of the pelvic floor, including evaluation of a protruding or bulging vaginal mass or clinically suspected POP. Images are obtained via cine loops in multiple planes during rest, strain, and Kegel maneuvers, with both 2-D and 3-D imaging for anatomic and functional pelvic floor assessment. Patients may be positioned semi-upright or in the dorsal lithotomy position. With regards to anatomic evaluation, TPUS can detect levator muscle avulsion, a predictor of prolapse recurrence after surgical repair [47]. Patients with signs of POP tend to demonstrate a larger pelvic floor hiatal area [48]. Translabial US shows moderate-to-good agreement with MRI for detection of levator ani defects and moderate-to- very-good agreement with MRI for measurement of hiatal biometry [49]. With regards to functional evaluation, dynamic TPUS performed during maximal strain or Valsalva demonstrates bladder and cervical prolapse and can demonstrate rectocele, enterocele/sigmoidocele, and rectal intussusception in the posterior compartment [50]. Detailed evaluation of urethral dysfunction including descent, kinking, and funneling can be obtained during the evaluation. | 3083064 |
acrac_3083064_9 | Pelvic Floor Dysfunction in Females | A large cystocele may impair evaluation of urethral hypermobility, and TPUS can ensure empty bladder and/or manual replacement of a cystocele at the point of care. Studies comparing US to CCP have shown variable degrees of agreement for different measures of POP, including anorectal angle measurement, cystocele, rectocele, enterocele, descending perineum syndrome, and rectal prolapse [51-53], without emergence of a clear reference standard. For optimal multicompartment evaluation, CCP is performed with filling of the bladder, rectum, large and small bowel, whereas TPUS is generally performed without intraluminal contrast, although US gel can be instilled intravaginally or rectal as indicated. Appropriately performed TPUS with dynamic maneuvers can identify cul-de-sac herniation, although the exact contents may be more challenging to define than on MRI or CCP. Studies have shown significant correlation between TPUS and physical examination, for measures of prolapse, particularly in the anterior compartment [54,55], although US only predicted 59.6%, 61.5%, and 32.6% of prolapse cases in the anterior, posterior, and middle compartments, respectively, in one of these studies [55]. Another study demonstrated that TPUS failed to demonstrate abnormality in up to one-third of clinical cases of rectoceles [56]. In general, the main advantage of TPUS is that it is a noninvasive and less expensive technique with dynamic real- time functional assessment of the multiple compartments. US Pelvis Transrectal To our knowledge, there is no relevant literature to support the use of transrectal US (TRUS) alone for functional assessment of a protruding or bulging anterior vaginal mass or clinically suspected POP, particularly in the anterior or middle compartments. TRUS can be used for anatomic assessment of anal sphincter tears or defects, which can be associated with pelvic floor weakness. | Pelvic Floor Dysfunction in Females. A large cystocele may impair evaluation of urethral hypermobility, and TPUS can ensure empty bladder and/or manual replacement of a cystocele at the point of care. Studies comparing US to CCP have shown variable degrees of agreement for different measures of POP, including anorectal angle measurement, cystocele, rectocele, enterocele, descending perineum syndrome, and rectal prolapse [51-53], without emergence of a clear reference standard. For optimal multicompartment evaluation, CCP is performed with filling of the bladder, rectum, large and small bowel, whereas TPUS is generally performed without intraluminal contrast, although US gel can be instilled intravaginally or rectal as indicated. Appropriately performed TPUS with dynamic maneuvers can identify cul-de-sac herniation, although the exact contents may be more challenging to define than on MRI or CCP. Studies have shown significant correlation between TPUS and physical examination, for measures of prolapse, particularly in the anterior compartment [54,55], although US only predicted 59.6%, 61.5%, and 32.6% of prolapse cases in the anterior, posterior, and middle compartments, respectively, in one of these studies [55]. Another study demonstrated that TPUS failed to demonstrate abnormality in up to one-third of clinical cases of rectoceles [56]. In general, the main advantage of TPUS is that it is a noninvasive and less expensive technique with dynamic real- time functional assessment of the multiple compartments. US Pelvis Transrectal To our knowledge, there is no relevant literature to support the use of transrectal US (TRUS) alone for functional assessment of a protruding or bulging anterior vaginal mass or clinically suspected POP, particularly in the anterior or middle compartments. TRUS can be used for anatomic assessment of anal sphincter tears or defects, which can be associated with pelvic floor weakness. | 3083064 |
acrac_3083064_10 | Pelvic Floor Dysfunction in Females | US Pelvis Transvaginal To our knowledge, there is no relevant literature regarding the use of transvaginal US (TVUS) alone for functional assessment of a protruding or bulging anterior vaginal mass or clinically suspected POP. Variant 2: Female. Urinary dysfunction (involuntary leakage of urine, or frequent urination, or urgency, straining to void, incomplete voiding, splinting, or digital maneuvers to void). Initial imaging. Urinary dysfunction may present as UI, which is the involuntary leakage of urine, classified as stress, urge, overflow, or mixed type of incontinence [57,58]. Initial evaluation of patients with urinary dysfunction may include physical examination, urinalysis, urinary stress testing, voiding diary, and urodynamic testing with cystourethrography. [58]. Imaging may be requested to assess postvoid bladder volume or evaluate for associated abnormalities in atypical or complex cases to confirm or further Pelvic Floor Dysfunction in Females characterize clinical findings. For instance, imaging can confirm presence of urethral diverticula or other anatomic abnormalities, which may be suspected, based on physical examination, or demonstrate bladder-neck/urethral hypermobility in patients with stress UI (SUI) [59]. In such cases, management of SUI may be aimed at correcting the urethral hypermobility. Imaging can depict bladder wall thickness, which may be increased in the setting of detrusor muscle instability [50]. Imaging may also be indicated in patients who present with persistent or recurrent urinary dysfunction after attempted surgical or nonsurgical treatments. Urinary dysfunction may also include incomplete or difficulty voiding, which can be caused by anatomic or functional abnormalities, for example, urethral or bladder masses; cystocele without urethral rotation, resulting in urethral kinking; neurogenic bladder; or as a complication of urethral sling or bulking agent procedures. | Pelvic Floor Dysfunction in Females. US Pelvis Transvaginal To our knowledge, there is no relevant literature regarding the use of transvaginal US (TVUS) alone for functional assessment of a protruding or bulging anterior vaginal mass or clinically suspected POP. Variant 2: Female. Urinary dysfunction (involuntary leakage of urine, or frequent urination, or urgency, straining to void, incomplete voiding, splinting, or digital maneuvers to void). Initial imaging. Urinary dysfunction may present as UI, which is the involuntary leakage of urine, classified as stress, urge, overflow, or mixed type of incontinence [57,58]. Initial evaluation of patients with urinary dysfunction may include physical examination, urinalysis, urinary stress testing, voiding diary, and urodynamic testing with cystourethrography. [58]. Imaging may be requested to assess postvoid bladder volume or evaluate for associated abnormalities in atypical or complex cases to confirm or further Pelvic Floor Dysfunction in Females characterize clinical findings. For instance, imaging can confirm presence of urethral diverticula or other anatomic abnormalities, which may be suspected, based on physical examination, or demonstrate bladder-neck/urethral hypermobility in patients with stress UI (SUI) [59]. In such cases, management of SUI may be aimed at correcting the urethral hypermobility. Imaging can depict bladder wall thickness, which may be increased in the setting of detrusor muscle instability [50]. Imaging may also be indicated in patients who present with persistent or recurrent urinary dysfunction after attempted surgical or nonsurgical treatments. Urinary dysfunction may also include incomplete or difficulty voiding, which can be caused by anatomic or functional abnormalities, for example, urethral or bladder masses; cystocele without urethral rotation, resulting in urethral kinking; neurogenic bladder; or as a complication of urethral sling or bulking agent procedures. | 3083064 |
acrac_3083064_11 | Pelvic Floor Dysfunction in Females | Imaging may be obtained as an adjunct to clinical evaluation when needed to depict these abnormalities. Although multiple imaging examinations may be needed depending of specific patient scenarios, this variant focuses on the initial imaging test that should be obtained when deemed necessary in patients with urinary dysfunction. CT Pelvis To our knowledge, there is no relevant literature regarding the use of CT, either with or without IV contrast for functional assessment of urinary dysfunction. CT can depict anatomic abnormalities such as bladder masses, bladder wall thickening, large urethral diverticula, or urethral masses that may be associated with urinary dysfunction. CT may demonstrate signs of urinary tract infection. CT with IV contrast is generally preferred over CT without IV contrast for anatomic evaluation unless evaluating for small urinary calculi. Fluoroscopy Cystocolpoproctography Dynamic CCP involves fluoroscopic imaging during defecation with the patient sitting upright on a fluoroscopic commode. Images are obtained during rest, Kegel (contraction of the pelvic floor muscles), strain, and defecation. A dedicated cystographic phase with bladder opacification can be performed either prior to instillation of rectal contrast or after complete rectal emptying, in order to avoid underestimation of bladder prolapse due to mass effect from a distended rectum [22]. Although cystocele and bladder-neck mobility may be directly visualized when intravesical contrast is used or may be inferred from posterior displacement of vaginal contrast, the urethra is not typically visible on this examination [22]. When contrast is administered in the bladder, stress incontinence may be visualized during straining or defecation; however, to our knowledge, there is no relevant literature regarding the utility of fluoroscopic CCP specifically for assessment of urinary dysfunction. | Pelvic Floor Dysfunction in Females. Imaging may be obtained as an adjunct to clinical evaluation when needed to depict these abnormalities. Although multiple imaging examinations may be needed depending of specific patient scenarios, this variant focuses on the initial imaging test that should be obtained when deemed necessary in patients with urinary dysfunction. CT Pelvis To our knowledge, there is no relevant literature regarding the use of CT, either with or without IV contrast for functional assessment of urinary dysfunction. CT can depict anatomic abnormalities such as bladder masses, bladder wall thickening, large urethral diverticula, or urethral masses that may be associated with urinary dysfunction. CT may demonstrate signs of urinary tract infection. CT with IV contrast is generally preferred over CT without IV contrast for anatomic evaluation unless evaluating for small urinary calculi. Fluoroscopy Cystocolpoproctography Dynamic CCP involves fluoroscopic imaging during defecation with the patient sitting upright on a fluoroscopic commode. Images are obtained during rest, Kegel (contraction of the pelvic floor muscles), strain, and defecation. A dedicated cystographic phase with bladder opacification can be performed either prior to instillation of rectal contrast or after complete rectal emptying, in order to avoid underestimation of bladder prolapse due to mass effect from a distended rectum [22]. Although cystocele and bladder-neck mobility may be directly visualized when intravesical contrast is used or may be inferred from posterior displacement of vaginal contrast, the urethra is not typically visible on this examination [22]. When contrast is administered in the bladder, stress incontinence may be visualized during straining or defecation; however, to our knowledge, there is no relevant literature regarding the utility of fluoroscopic CCP specifically for assessment of urinary dysfunction. | 3083064 |
acrac_3083064_12 | Pelvic Floor Dysfunction in Females | Although dynamic CCP can depict urinary abnormalities on the cystographic phase, it is a relatively invasive and time intensive examination and is generally not considered the initial imaging test of choice for patients with urinary dysfunction. Fluoroscopy Voiding Cystourethrography VCUG is a fluoroscopic technique that focuses on the bladder and urethra in the anterior compartment. Contrast is instilled into the bladder via a Foley catheter. Images are then taken in the upright position at rest and strain and during voiding. Cystocele is defined on VCUG as extension of the opacified urinary bladder below the level of the pubic symphysis, and the urethral angle can be measured relative to the vertical axis of the patient [14]. Change in position or angle of the urethra during straining can assess urethral hypermobility; however, a study by Walsh et al [60] in patients with SUI and POP demonstrated variable correlation in this regard between VCUG and the Q-tip test. A recent study demonstrated lower prevalence and degree of urethral hypermobility and cystoceles on VCUG compared with supine MR defecography [25]. VCUG may demonstrate opacification of urethral diverticula during the voiding phase, which can be associated with UI. In patients with suspected voiding dysfunction, VCUG may demonstrate funneling or involuntary leakage of urine during the straining phase, as well as indirect and direct findings of voiding dysfunction such as a trabeculated bladder, large postvoid bladder residual, inability to void during the examination, and urethral narrowing with or without upstream dilatation during the voiding phase. In the setting of severe voiding dysfunction, the urethra may not opacify, thus limiting evaluation. | Pelvic Floor Dysfunction in Females. Although dynamic CCP can depict urinary abnormalities on the cystographic phase, it is a relatively invasive and time intensive examination and is generally not considered the initial imaging test of choice for patients with urinary dysfunction. Fluoroscopy Voiding Cystourethrography VCUG is a fluoroscopic technique that focuses on the bladder and urethra in the anterior compartment. Contrast is instilled into the bladder via a Foley catheter. Images are then taken in the upright position at rest and strain and during voiding. Cystocele is defined on VCUG as extension of the opacified urinary bladder below the level of the pubic symphysis, and the urethral angle can be measured relative to the vertical axis of the patient [14]. Change in position or angle of the urethra during straining can assess urethral hypermobility; however, a study by Walsh et al [60] in patients with SUI and POP demonstrated variable correlation in this regard between VCUG and the Q-tip test. A recent study demonstrated lower prevalence and degree of urethral hypermobility and cystoceles on VCUG compared with supine MR defecography [25]. VCUG may demonstrate opacification of urethral diverticula during the voiding phase, which can be associated with UI. In patients with suspected voiding dysfunction, VCUG may demonstrate funneling or involuntary leakage of urine during the straining phase, as well as indirect and direct findings of voiding dysfunction such as a trabeculated bladder, large postvoid bladder residual, inability to void during the examination, and urethral narrowing with or without upstream dilatation during the voiding phase. In the setting of severe voiding dysfunction, the urethra may not opacify, thus limiting evaluation. | 3083064 |
acrac_3083064_13 | Pelvic Floor Dysfunction in Females | Because VCUG is performed in the physiologic upright position and involves focused imaging of the bladder and urethra during active voiding, it may be used as the initial imaging test for evaluation of patients with urinary dysfunction when deemed necessary after appropriate clinical evaluation. The general limitation of this minimally invasive study is that it is limited to anterior compartment structures. MR Defecography MR defecography has utility in global functional and anatomic assessment of the pelvic floor, including depiction of cystoceles, location of urethrovesical junction at rest and defecation, assessment of urethral angle, urethral Pelvic Floor Dysfunction in Females hypermobility and/or kinking [50,61]. To our knowledge, there is no relevant literature regarding the utility of MR defecography specifically in patients with UI or voiding dysfunction. The inherent high soft-tissue contrast resolution of MRI allows for anatomic evaluation of the pelvic organs, including the bladder and urethra, as well as urethral ligaments [37], and postoperative changes if present. MRI of the pelvis can demonstrate differences in pelvic floor musculature and bladder-neck morphology and urethrovesical angle when comparing patients with SUI, mixed UI, and continence [62]. MRI can also depict morphological alterations in the urethra, urethral ligaments, and vaginal fascia in patients with SUI [63-65]. Although MR defecography provides evaluation of all pelvic floor compartments and is not considered the initial imaging test of choice, it may be utilized for assessment of patients with urinary dysfunction in the appropriate clinical setting. | Pelvic Floor Dysfunction in Females. Because VCUG is performed in the physiologic upright position and involves focused imaging of the bladder and urethra during active voiding, it may be used as the initial imaging test for evaluation of patients with urinary dysfunction when deemed necessary after appropriate clinical evaluation. The general limitation of this minimally invasive study is that it is limited to anterior compartment structures. MR Defecography MR defecography has utility in global functional and anatomic assessment of the pelvic floor, including depiction of cystoceles, location of urethrovesical junction at rest and defecation, assessment of urethral angle, urethral Pelvic Floor Dysfunction in Females hypermobility and/or kinking [50,61]. To our knowledge, there is no relevant literature regarding the utility of MR defecography specifically in patients with UI or voiding dysfunction. The inherent high soft-tissue contrast resolution of MRI allows for anatomic evaluation of the pelvic organs, including the bladder and urethra, as well as urethral ligaments [37], and postoperative changes if present. MRI of the pelvis can demonstrate differences in pelvic floor musculature and bladder-neck morphology and urethrovesical angle when comparing patients with SUI, mixed UI, and continence [62]. MRI can also depict morphological alterations in the urethra, urethral ligaments, and vaginal fascia in patients with SUI [63-65]. Although MR defecography provides evaluation of all pelvic floor compartments and is not considered the initial imaging test of choice, it may be utilized for assessment of patients with urinary dysfunction in the appropriate clinical setting. | 3083064 |
acrac_3083064_14 | Pelvic Floor Dysfunction in Females | MRI Pelvis Dynamic Maneuvers without Defecation To our knowledge, there is no relevant literature regarding the utility of MRI pelvis with dynamic maneuvers (dynamic pelvic floor MRI) specifically in patients with UI or voiding dysfunction; however, dynamic pelvic floor MRI allows for global functional and anatomic assessment of the pelvic floor, including depiction of cystoceles, location of urethrovesical junction, assessment of urethral angle, urethral hypermobility and/or kinking [50,61]. Dynamic pelvic floor MRI with straining rather than defecation demonstrates lower prevalence of prolapse in multiple compartments [12,15,26-29]. This may lower detection rates of cystoceles in patients with UI, although the clinical impact of this lower detection rate has not been reported in the literature to our knowledge. Furthermore, the inherent high soft-tissue contrast resolution of MRI allows for anatomic evaluation of the pelvic organs, including the bladder and urethra, as well as urethral ligaments [37], and postoperative changes if present. MRI of the pelvis can demonstrate differences in pelvic floor musculature and bladder-neck morphology and urethrovesical angle when comparing patients with SUI, mixed UI, and continence [62]. MRI can also depict morphological alterations in the urethra, urethral ligaments, and vaginal fascia in patients with SUI [63-65]. Although not considered the initial imaging test of choice, MR pelvis dynamic maneuvers without defecation may be utilized for assessment of patients with urinary dysfunction in the appropriate clinical setting. MRI Pelvis To our knowledge, there is no relevant literature regarding the use of MRI pelvis without defecation or straining for functional evaluation of urinary dysfunction; however, pelvic floor MRI allows for anatomic assessment of the pelvic floor, including location of urethrovesical junction, and assessment of urethral angle at rest [61]. | Pelvic Floor Dysfunction in Females. MRI Pelvis Dynamic Maneuvers without Defecation To our knowledge, there is no relevant literature regarding the utility of MRI pelvis with dynamic maneuvers (dynamic pelvic floor MRI) specifically in patients with UI or voiding dysfunction; however, dynamic pelvic floor MRI allows for global functional and anatomic assessment of the pelvic floor, including depiction of cystoceles, location of urethrovesical junction, assessment of urethral angle, urethral hypermobility and/or kinking [50,61]. Dynamic pelvic floor MRI with straining rather than defecation demonstrates lower prevalence of prolapse in multiple compartments [12,15,26-29]. This may lower detection rates of cystoceles in patients with UI, although the clinical impact of this lower detection rate has not been reported in the literature to our knowledge. Furthermore, the inherent high soft-tissue contrast resolution of MRI allows for anatomic evaluation of the pelvic organs, including the bladder and urethra, as well as urethral ligaments [37], and postoperative changes if present. MRI of the pelvis can demonstrate differences in pelvic floor musculature and bladder-neck morphology and urethrovesical angle when comparing patients with SUI, mixed UI, and continence [62]. MRI can also depict morphological alterations in the urethra, urethral ligaments, and vaginal fascia in patients with SUI [63-65]. Although not considered the initial imaging test of choice, MR pelvis dynamic maneuvers without defecation may be utilized for assessment of patients with urinary dysfunction in the appropriate clinical setting. MRI Pelvis To our knowledge, there is no relevant literature regarding the use of MRI pelvis without defecation or straining for functional evaluation of urinary dysfunction; however, pelvic floor MRI allows for anatomic assessment of the pelvic floor, including location of urethrovesical junction, and assessment of urethral angle at rest [61]. | 3083064 |
acrac_3083064_15 | Pelvic Floor Dysfunction in Females | The inherent high soft-tissue contrast resolution of MRI allows for anatomic evaluation of the pelvic organs, including the bladder and urethra, as well as urethral ligaments [37], and postoperative changes if present. MRI of the pelvis can demonstrate differences in pelvic floor musculature and bladder-neck morphology and urethrovesical angle when comparing patients with SUI, mixed UI, and continence [62]. MRI can also depict morphological alterations in the urethra, urethral ligaments, and vaginal fascia in patients with SUI [63-65]. Routine MRI of the pelvis with IV contrast may be preferred over MR defecography or MRI pelvis dynamic maneuvers without defecation for evaluation of pelvic floor anatomy and postoperative changes only, however, is not generally used for assessment of urinary dysfunction. US Pelvis Transabdominal To our knowledge there is no relevant literature regarding the use of TAUS for functional evaluation of the urethra or bladder neck in patients with urinary dysfunction. TAUS has utility for measurement of postvoid residual bladder volume and anatomic assessment of the bladder during evaluation of patients with urinary dysfunction. US Pelvis Transperineal TPUS can be used for anatomic and functional evaluation of the pelvic floor. Images are obtained via cine loops in multiple planes during rest, strain, and Kegel maneuvers with both 2-D and 3-D imaging for anatomic and functional pelvic floor assessment. Patients may be positioned semi-upright or in the dorsal lithotomy position. Postvoid residual bladder volume can be measured, and bladder wall thickening or trabeculation can be seen. TPUS can evaluate the morphology and volume of the circular urethral rhabdosphincter muscle; muscle volume has been associated with urethral closure pressures and SUI [66]. TPUS can also assess for anatomic abnormalities that can cause a bulge in the anterior vaginal wall, such as a urethral diverticulum, vaginal wall cyst, or mass [67]. | Pelvic Floor Dysfunction in Females. The inherent high soft-tissue contrast resolution of MRI allows for anatomic evaluation of the pelvic organs, including the bladder and urethra, as well as urethral ligaments [37], and postoperative changes if present. MRI of the pelvis can demonstrate differences in pelvic floor musculature and bladder-neck morphology and urethrovesical angle when comparing patients with SUI, mixed UI, and continence [62]. MRI can also depict morphological alterations in the urethra, urethral ligaments, and vaginal fascia in patients with SUI [63-65]. Routine MRI of the pelvis with IV contrast may be preferred over MR defecography or MRI pelvis dynamic maneuvers without defecation for evaluation of pelvic floor anatomy and postoperative changes only, however, is not generally used for assessment of urinary dysfunction. US Pelvis Transabdominal To our knowledge there is no relevant literature regarding the use of TAUS for functional evaluation of the urethra or bladder neck in patients with urinary dysfunction. TAUS has utility for measurement of postvoid residual bladder volume and anatomic assessment of the bladder during evaluation of patients with urinary dysfunction. US Pelvis Transperineal TPUS can be used for anatomic and functional evaluation of the pelvic floor. Images are obtained via cine loops in multiple planes during rest, strain, and Kegel maneuvers with both 2-D and 3-D imaging for anatomic and functional pelvic floor assessment. Patients may be positioned semi-upright or in the dorsal lithotomy position. Postvoid residual bladder volume can be measured, and bladder wall thickening or trabeculation can be seen. TPUS can evaluate the morphology and volume of the circular urethral rhabdosphincter muscle; muscle volume has been associated with urethral closure pressures and SUI [66]. TPUS can also assess for anatomic abnormalities that can cause a bulge in the anterior vaginal wall, such as a urethral diverticulum, vaginal wall cyst, or mass [67]. | 3083064 |
acrac_3083064_16 | Pelvic Floor Dysfunction in Females | TPUS can assess for urethral and bladder-neck mobility and urethral funneling in real time during maximal strain or Valsalva [54,59,68]; however, in contrast to VCUG, TPUS does not assess the bladder or urethra during active voiding. In addition to bladder-neck mobility and postvoid residual, TPUS may have utility in predicting response to treatment in patients with SUI with urethral sling placement based on preoperative measurement of pubourethral Pelvic Floor Dysfunction in Females distance and angle [69]. Although not the initial imaging test of choice, it may be used for assessment of urinary dysfunction in the appropriate clinical setting. US Pelvis Transrectal A few studies have reported the use of TRUS for assessment of the bladder neck and urethra in patients with SUI; however, these studies are dated [70-73]. To our knowledge, there is no relevant literature comparing TRUS to TPUS or TVUS for evaluation of patients with urinary dysfunction and no recent literature to support its use for evaluation of female patients with urinary dysfunction. US Pelvis Transvaginal To our knowledge, there is no relevant literature regarding the use of TVUS for functional evaluation of patients with urinary dysfunction; however, TVUS can be used to assess for anatomic abnormalities (other than a cystocele) causing a bulge in the anterior vaginal wall, such as a urethral diverticulum, vaginal wall cyst, or mass [67]. It can also be used to assess postvoid residual bladder volume and bladder wall thickness. Bladder wall thickness on TVUS has been shown to correlate with results of urodynamic testing in patients with voiding dysfunction [74]. TVUS can evaluate the morphology and volume of the circular urethral rhabdosphincter muscle; muscle volume has been associated with urethral closure pressures and SUI [66]. | Pelvic Floor Dysfunction in Females. TPUS can assess for urethral and bladder-neck mobility and urethral funneling in real time during maximal strain or Valsalva [54,59,68]; however, in contrast to VCUG, TPUS does not assess the bladder or urethra during active voiding. In addition to bladder-neck mobility and postvoid residual, TPUS may have utility in predicting response to treatment in patients with SUI with urethral sling placement based on preoperative measurement of pubourethral Pelvic Floor Dysfunction in Females distance and angle [69]. Although not the initial imaging test of choice, it may be used for assessment of urinary dysfunction in the appropriate clinical setting. US Pelvis Transrectal A few studies have reported the use of TRUS for assessment of the bladder neck and urethra in patients with SUI; however, these studies are dated [70-73]. To our knowledge, there is no relevant literature comparing TRUS to TPUS or TVUS for evaluation of patients with urinary dysfunction and no recent literature to support its use for evaluation of female patients with urinary dysfunction. US Pelvis Transvaginal To our knowledge, there is no relevant literature regarding the use of TVUS for functional evaluation of patients with urinary dysfunction; however, TVUS can be used to assess for anatomic abnormalities (other than a cystocele) causing a bulge in the anterior vaginal wall, such as a urethral diverticulum, vaginal wall cyst, or mass [67]. It can also be used to assess postvoid residual bladder volume and bladder wall thickness. Bladder wall thickness on TVUS has been shown to correlate with results of urodynamic testing in patients with voiding dysfunction [74]. TVUS can evaluate the morphology and volume of the circular urethral rhabdosphincter muscle; muscle volume has been associated with urethral closure pressures and SUI [66]. | 3083064 |
acrac_3083064_17 | Pelvic Floor Dysfunction in Females | Patients with SUI demonstrate thinner urethral rhabdosphincter muscles than continent patients [75], and urethral sphincter volume on preoperatively TVUS can predict surgical outcomes [76]. Variant 3: Female. Defecatory dysfunction (incontinence of stool or liquid or gas, straining during defecation, difficulty initiating defecation, incomplete evacuation, or splinting or digital maneuvers to defecate). Initial imaging. Defecatory dysfunction may result from either structural or functional etiologies. Obstructed defecation is suspected in patients who have difficulty defecating and may require excessive straining or manual pressure for evacuation. Mechanical or structural etiologies include rectocele, enterocele, sigmoidocele, rectal intussusception, or rectal prolapse, whereas anatomically normal patients may have disordered defecation due to functional dyssynergia. Patients are assessed clinically with a digital rectal examination, anal manometry, and balloon expulsion test [77]. Imaging may be obtained for further evaluation, particularly in patients with discordant findings on manometry and the balloon expulsion test [78-80]. Imaging may also be obtained to either confirm clinically suspected or exclude occult structural or functional abnormalities such as rectal prolapse, excessive perineal descent, rectal intussusception, or pelvic floor dyssynergia, and to differentiate rectocele from cul-de-sac hernia in the posterior compartment. Finally, patients with fecal incontinence may present with anal sphincter abnormalities, and preoperative imaging may be obtained for surgical planning. Imaging may also be indicated in patients who present with persistent or recurrent defecatory dysfunction after attempted surgical or nonsurgical treatments. CT Pelvis To our knowledge, there is no relevant literature regarding the use of CT for functional assessment of defecatory dysfunction. | Pelvic Floor Dysfunction in Females. Patients with SUI demonstrate thinner urethral rhabdosphincter muscles than continent patients [75], and urethral sphincter volume on preoperatively TVUS can predict surgical outcomes [76]. Variant 3: Female. Defecatory dysfunction (incontinence of stool or liquid or gas, straining during defecation, difficulty initiating defecation, incomplete evacuation, or splinting or digital maneuvers to defecate). Initial imaging. Defecatory dysfunction may result from either structural or functional etiologies. Obstructed defecation is suspected in patients who have difficulty defecating and may require excessive straining or manual pressure for evacuation. Mechanical or structural etiologies include rectocele, enterocele, sigmoidocele, rectal intussusception, or rectal prolapse, whereas anatomically normal patients may have disordered defecation due to functional dyssynergia. Patients are assessed clinically with a digital rectal examination, anal manometry, and balloon expulsion test [77]. Imaging may be obtained for further evaluation, particularly in patients with discordant findings on manometry and the balloon expulsion test [78-80]. Imaging may also be obtained to either confirm clinically suspected or exclude occult structural or functional abnormalities such as rectal prolapse, excessive perineal descent, rectal intussusception, or pelvic floor dyssynergia, and to differentiate rectocele from cul-de-sac hernia in the posterior compartment. Finally, patients with fecal incontinence may present with anal sphincter abnormalities, and preoperative imaging may be obtained for surgical planning. Imaging may also be indicated in patients who present with persistent or recurrent defecatory dysfunction after attempted surgical or nonsurgical treatments. CT Pelvis To our knowledge, there is no relevant literature regarding the use of CT for functional assessment of defecatory dysfunction. | 3083064 |
acrac_3083064_18 | Pelvic Floor Dysfunction in Females | CT may depict masses or other anatomic conditions in the pelvic floor at rest that may result in obstructed defecation or fecal incontinence; however, CT is not a test of choice for evaluation of anal sphincter defects. Fluoroscopy Cystocolpoproctography Fluoroscopic CCP is one of the initial imaging tests of choice for evaluation of defecatory dysfunction and augments the clinical examination by revealing clinically occult sigmoidoceles, enteroceles, and rectoanal intussusceptions, which can be present in isolation or in combination with other abnormalities [81,82]. The detection of these diagnoses on defecography has been shown to alter or clarify the initial clinical assessment in a significant percentage of patients with constipation [83]. Approximately one-third of patients with bulging of the posterior vaginal wall have been shown to have enteroceles or sigmoidoceles [11]. Opacification of small bowel with oral contrast allows for easier detection of enteroceles. A significant proportion of enteroceles may be seen only upon complete rectal emptying or on postdefecation strain images [11], because rectal or bladder distention with contrast may prevent the peritoneal sac from herniating into the rectovaginal space [22]. CCP can also be used to assess for presence and size of rectocele and to evaluate for contrast material retention within rectoceles. CCP may be obtained in patients with suspected dyssynergic defecation. Unlike manometry and the balloon expulsion test, defecography directly images the process of rectal evacuation and may identify associated structural abnormalities in the pelvic floor. Failed or prolonged evacuation of contrast on CCP is sensitive and specific for Pelvic Floor Dysfunction in Females diagnosing dyssynergia [84]. However, a meta-analysis demonstrated lower prevalence of findings of dyssynergic defecation on CCP compared with the balloon expulsion test and anal manometry [80]. | Pelvic Floor Dysfunction in Females. CT may depict masses or other anatomic conditions in the pelvic floor at rest that may result in obstructed defecation or fecal incontinence; however, CT is not a test of choice for evaluation of anal sphincter defects. Fluoroscopy Cystocolpoproctography Fluoroscopic CCP is one of the initial imaging tests of choice for evaluation of defecatory dysfunction and augments the clinical examination by revealing clinically occult sigmoidoceles, enteroceles, and rectoanal intussusceptions, which can be present in isolation or in combination with other abnormalities [81,82]. The detection of these diagnoses on defecography has been shown to alter or clarify the initial clinical assessment in a significant percentage of patients with constipation [83]. Approximately one-third of patients with bulging of the posterior vaginal wall have been shown to have enteroceles or sigmoidoceles [11]. Opacification of small bowel with oral contrast allows for easier detection of enteroceles. A significant proportion of enteroceles may be seen only upon complete rectal emptying or on postdefecation strain images [11], because rectal or bladder distention with contrast may prevent the peritoneal sac from herniating into the rectovaginal space [22]. CCP can also be used to assess for presence and size of rectocele and to evaluate for contrast material retention within rectoceles. CCP may be obtained in patients with suspected dyssynergic defecation. Unlike manometry and the balloon expulsion test, defecography directly images the process of rectal evacuation and may identify associated structural abnormalities in the pelvic floor. Failed or prolonged evacuation of contrast on CCP is sensitive and specific for Pelvic Floor Dysfunction in Females diagnosing dyssynergia [84]. However, a meta-analysis demonstrated lower prevalence of findings of dyssynergic defecation on CCP compared with the balloon expulsion test and anal manometry [80]. | 3083064 |
acrac_3083064_19 | Pelvic Floor Dysfunction in Females | CCP demonstrates good agreement with surgical findings for detection of full-thickness rectal prolapse, posterior colopocele, rectocele, and peritoneocele, and excellent correlation for detection of internal rectal prolapse (intrarectal and intra-anal). Relative to surgical findings, sensitivities of CCP for detection of internal rectal prolapse and peritoneocele are 88% and 83%, respectively [23], whereas comparisons to physical examination demonstrate sensitivity of CCP for detection of rectoceles and enteroceles to be 94% and 35%, respectively. Nonetheless, physical examination only detected 7% of rectoceles and 51% of enteroceles seen in CCP in that study [11]. Thus, CCP may detect rectoceles or enteroceles that are clinically occult. In patients with fecal incontinence, anorectal angle measured on CCP has been shown to correlate with severity of fecal incontinence [85]. Fluoroscopy Voiding Cystourethrography To our knowledge, there is no relevant literature to support the use of VCUG in assessment of patients with defecatory dysfunction. MR Defecography MR defecography with rectal contrast is one of the initial imaging tests of choice for evaluation of patients with defecatory dysfunction. The inherent high soft-tissue contrast resolution of MRI allows for direct visualization of pelvic organs, pelvic floor muscles and fascia, and associated anatomic abnormalities or masses that may cause rectal obstruction or incontinence. MR defecography can confirm suspected structural and functional abnormalities in patients with defecatory dysfunction such as rectal intussusception or prolapse, rectocele, and pelvic floor dyssynergia. Findings of pelvic floor dyssynergia on MR defecography include impaired evacuation, abnormal anorectal angle change, and paradoxical sphincter contraction [86]. | Pelvic Floor Dysfunction in Females. CCP demonstrates good agreement with surgical findings for detection of full-thickness rectal prolapse, posterior colopocele, rectocele, and peritoneocele, and excellent correlation for detection of internal rectal prolapse (intrarectal and intra-anal). Relative to surgical findings, sensitivities of CCP for detection of internal rectal prolapse and peritoneocele are 88% and 83%, respectively [23], whereas comparisons to physical examination demonstrate sensitivity of CCP for detection of rectoceles and enteroceles to be 94% and 35%, respectively. Nonetheless, physical examination only detected 7% of rectoceles and 51% of enteroceles seen in CCP in that study [11]. Thus, CCP may detect rectoceles or enteroceles that are clinically occult. In patients with fecal incontinence, anorectal angle measured on CCP has been shown to correlate with severity of fecal incontinence [85]. Fluoroscopy Voiding Cystourethrography To our knowledge, there is no relevant literature to support the use of VCUG in assessment of patients with defecatory dysfunction. MR Defecography MR defecography with rectal contrast is one of the initial imaging tests of choice for evaluation of patients with defecatory dysfunction. The inherent high soft-tissue contrast resolution of MRI allows for direct visualization of pelvic organs, pelvic floor muscles and fascia, and associated anatomic abnormalities or masses that may cause rectal obstruction or incontinence. MR defecography can confirm suspected structural and functional abnormalities in patients with defecatory dysfunction such as rectal intussusception or prolapse, rectocele, and pelvic floor dyssynergia. Findings of pelvic floor dyssynergia on MR defecography include impaired evacuation, abnormal anorectal angle change, and paradoxical sphincter contraction [86]. | 3083064 |
acrac_3083064_20 | Pelvic Floor Dysfunction in Females | MR defecography can also add clinical benefit in patients with rectal disorders by revealing additional clinically occult abnormalities such as enteroceles that alter patient management [35,87,88]. A study by Rentsch et al [36] demonstrated that, in patients with posterior compartment symptoms and defecatory dysfunction, MR defecography demonstrated multifocal defects in a significant number of patients and revealed defects in addition to clinical diagnoses in 34% of cases. Use of rectal contrast and imaging during defecation are particularly important when performing MR defecography for assessment of defecatory dysfunction [89]. Multiple studies have demonstrated the added benefit of MRI with rectal contrast and the defecation phase for assessment of POP compared with dynamic straining MRI without rectal contrast or defecation [15,26-29]. Although upright MR defecography may be preferred over supine MR defecography for evaluation of defecatory dysfunction, most centers lack an open magnet to allow imaging in upright position. Studies comparing MR defecography in supine position to that in upright position have shown variable results, with some reporting that MR defecography in supine positioning may underestimate detection and size of rectal intussusception and rectocele [30,31], whereas others [32] demonstrate no significant difference in prevalence of anorectal descent during defecation when comparing the two positions. Regardless of positioning, patients should be asked to perform repeated strain/defecation maneuvers to maximize pelvic floor dysfunction seen on MRI [33]. MR defecography in patients with fecal incontinence reveals excessive perineal descent, rectoceles, and rectal intussusceptions, which can alter surgical management [90]. MR defecography has moderate to good correlation with surgical findings for diagnosis of full thickness rectal prolapse, internal rectal prolapse, posterior colopocele, rectocele, and peritoneocele [23]. | Pelvic Floor Dysfunction in Females. MR defecography can also add clinical benefit in patients with rectal disorders by revealing additional clinically occult abnormalities such as enteroceles that alter patient management [35,87,88]. A study by Rentsch et al [36] demonstrated that, in patients with posterior compartment symptoms and defecatory dysfunction, MR defecography demonstrated multifocal defects in a significant number of patients and revealed defects in addition to clinical diagnoses in 34% of cases. Use of rectal contrast and imaging during defecation are particularly important when performing MR defecography for assessment of defecatory dysfunction [89]. Multiple studies have demonstrated the added benefit of MRI with rectal contrast and the defecation phase for assessment of POP compared with dynamic straining MRI without rectal contrast or defecation [15,26-29]. Although upright MR defecography may be preferred over supine MR defecography for evaluation of defecatory dysfunction, most centers lack an open magnet to allow imaging in upright position. Studies comparing MR defecography in supine position to that in upright position have shown variable results, with some reporting that MR defecography in supine positioning may underestimate detection and size of rectal intussusception and rectocele [30,31], whereas others [32] demonstrate no significant difference in prevalence of anorectal descent during defecation when comparing the two positions. Regardless of positioning, patients should be asked to perform repeated strain/defecation maneuvers to maximize pelvic floor dysfunction seen on MRI [33]. MR defecography in patients with fecal incontinence reveals excessive perineal descent, rectoceles, and rectal intussusceptions, which can alter surgical management [90]. MR defecography has moderate to good correlation with surgical findings for diagnosis of full thickness rectal prolapse, internal rectal prolapse, posterior colopocele, rectocele, and peritoneocele [23]. | 3083064 |
acrac_3083064_21 | Pelvic Floor Dysfunction in Females | [23][23]MR defecography agrees with physical examination in 79% of cases of clinically significant posterior compartment prolapse and, in one study, detected 45% of cases of enteroceles seen on physical examination; however, physical examination only demonstrated 30% of enteroceles seen on MR defecography and also misdiagnosed 10% of enteroceles seen as rectoceles. Thus, MR defecography is beneficial in detecting or characterizing enteroceles as cause of posterior vaginal bulge [34]. Cul-de-sac hernias such as enteroceles are best seen at the end of the defecation acquisition upon complete rectal emptying. This may require multiple defecation attempts and/or additional imaging with maximal Valsalva after complete rectal emptying. Additional utility of MR defecography lies in its ability to demonstrate often unsuspected pelvic floor abnormalities in other compartments. Pelvic Floor Dysfunction in Females MRI Pelvis Dynamic Maneuvers without Defecation Use of rectal contrast and imaging during defecation are particularly important when performing MRI for assessment of defecatory dysfunction [89]. Multiple studies have demonstrated the added benefit of MRI with rectal contrast and the defecation phase for assessment of POP compared with dynamic straining MRI without rectal contrast or defecation [15,26-29]. Thus, the utility of MRI pelvis with dynamic maneuvers (dynamic pelvic floor MRI) to demonstrate functional abnormalities or occult multicompartment defects in the setting of defecatory dysfunction is relatively limited when compared with MR defecography. The inherent high soft-tissue contrast resolution of MRI allows for anatomic evaluation by direct visualization of the pelvic organs and pelvic floor muscles and fascia. Pelvic masses that may cause rectal obstruction would be well seen on MRI. Levator muscle defects may be well depicted in patients with fecal incontinence. | Pelvic Floor Dysfunction in Females. [23][23]MR defecography agrees with physical examination in 79% of cases of clinically significant posterior compartment prolapse and, in one study, detected 45% of cases of enteroceles seen on physical examination; however, physical examination only demonstrated 30% of enteroceles seen on MR defecography and also misdiagnosed 10% of enteroceles seen as rectoceles. Thus, MR defecography is beneficial in detecting or characterizing enteroceles as cause of posterior vaginal bulge [34]. Cul-de-sac hernias such as enteroceles are best seen at the end of the defecation acquisition upon complete rectal emptying. This may require multiple defecation attempts and/or additional imaging with maximal Valsalva after complete rectal emptying. Additional utility of MR defecography lies in its ability to demonstrate often unsuspected pelvic floor abnormalities in other compartments. Pelvic Floor Dysfunction in Females MRI Pelvis Dynamic Maneuvers without Defecation Use of rectal contrast and imaging during defecation are particularly important when performing MRI for assessment of defecatory dysfunction [89]. Multiple studies have demonstrated the added benefit of MRI with rectal contrast and the defecation phase for assessment of POP compared with dynamic straining MRI without rectal contrast or defecation [15,26-29]. Thus, the utility of MRI pelvis with dynamic maneuvers (dynamic pelvic floor MRI) to demonstrate functional abnormalities or occult multicompartment defects in the setting of defecatory dysfunction is relatively limited when compared with MR defecography. The inherent high soft-tissue contrast resolution of MRI allows for anatomic evaluation by direct visualization of the pelvic organs and pelvic floor muscles and fascia. Pelvic masses that may cause rectal obstruction would be well seen on MRI. Levator muscle defects may be well depicted in patients with fecal incontinence. | 3083064 |
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