id
stringlengths 13
16
| title
stringclasses 225
values | content
stringlengths 1.09k
2.04k
| contents
stringlengths 1.12k
2.05k
| ACRID
stringclasses 225
values |
|---|---|---|---|---|
acrac_3083061_15 | Thoracic Outlet Syndrome | If there are overlapping symptoms, review of the other Variants in this document may help with protocol optimization. Thoracic Outlet Syndrome MRI Chest MRI for aTOS is performed to delineate anatomy and evaluate the pertinent anatomic spaces in both neutral and arms-abducted positions. Noncontrast MRI findings include effacement of fat adjacent to the subclavian vein. T1- weighted imaging performed in sagittal and axial planes can also demonstrate causative lesions, including cervical ribs, congenital fibromuscular anomalies, and muscular hypertrophy. Given the need to assess the subclavian artery in aTOS, noncontrast MRI would be insufficient, with contrast- enhanced MR arteriography providing optimal assessment. The combination of soft-tissue and vascular assessment provided by MRI with contrast makes it an excellent modality when compared with US and CT; however, the longer acquisition times may prove difficult for highly symptomatic patients. MRI with IV contrast may also be performed in the postintervention setting to evaluate interval changes in the thoracic outlet and to assess adequate decompression. MRA Chest The primary MRA finding is narrowing of the subclavian artery; however, other findings, such as complete occlusion, collateral vessel formation, and visualization of thrombus, aid in the diagnosis of aTOS. MRA may help identify the severity of TOS and guide surgical or endovascular management [36]. If there is no evidence of compression on the abducted images, then imaging in the neutral position may be deferred. In the evaluation of TOS, if there is compression of the subclavian artery depicted on both sagittal T1-weighted and MRA, it may be denoted as aTOS. Further findings of aTOS that may be present include fixed or dynamic stenosis, aneurysm, mural thrombus, or distal emboli. | Thoracic Outlet Syndrome. If there are overlapping symptoms, review of the other Variants in this document may help with protocol optimization. Thoracic Outlet Syndrome MRI Chest MRI for aTOS is performed to delineate anatomy and evaluate the pertinent anatomic spaces in both neutral and arms-abducted positions. Noncontrast MRI findings include effacement of fat adjacent to the subclavian vein. T1- weighted imaging performed in sagittal and axial planes can also demonstrate causative lesions, including cervical ribs, congenital fibromuscular anomalies, and muscular hypertrophy. Given the need to assess the subclavian artery in aTOS, noncontrast MRI would be insufficient, with contrast- enhanced MR arteriography providing optimal assessment. The combination of soft-tissue and vascular assessment provided by MRI with contrast makes it an excellent modality when compared with US and CT; however, the longer acquisition times may prove difficult for highly symptomatic patients. MRI with IV contrast may also be performed in the postintervention setting to evaluate interval changes in the thoracic outlet and to assess adequate decompression. MRA Chest The primary MRA finding is narrowing of the subclavian artery; however, other findings, such as complete occlusion, collateral vessel formation, and visualization of thrombus, aid in the diagnosis of aTOS. MRA may help identify the severity of TOS and guide surgical or endovascular management [36]. If there is no evidence of compression on the abducted images, then imaging in the neutral position may be deferred. In the evaluation of TOS, if there is compression of the subclavian artery depicted on both sagittal T1-weighted and MRA, it may be denoted as aTOS. Further findings of aTOS that may be present include fixed or dynamic stenosis, aneurysm, mural thrombus, or distal emboli. | 3083061 |
acrac_3083061_16 | Thoracic Outlet Syndrome | Numerous MRA techniques have been described including noncontrast MRA, including inversion recovery methods for patients unable or unwilling to have contrast [42], simultaneous bilateral MRA [34], and dual-gadolinium injection protocols [35]. Ancillary findings include possible etiologies of aTOS, frequently cervical or anomalous first rib, scalene muscle, fibromuscular bands, or pectoralis minor tendon, and anomalous course of the subclavian artery within the scalene muscle. MRA may also be performed in the postintervention setting to evaluate interval changes in the thoracic outlet, assess adequate decompression, and confirm arterial patency. MRV Chest MRV is not needed in patients with aTOS. If there are overlapping symptoms, review of the other Variants in this document may help with protocol optimization. Radiography Chest Because of the importance of identifying osseous structures that may impinge on the spaces of the thoracic outlet, chest radiography is useful in performing a robust evaluation for all types of TOS. As opposed to directly evaluating vascular structures, osseous abnormalities associated with TOS are frequently easily diagnosed by chest radiographs. These include first rib anomalies [20], cervical ribs [23], congenital osseous malformations [24,25], and focal bone lesions [26]. In the postoperative setting, radiographs may be useful to confirm osseous changes and evaluate for postoperative complications such as pneumothorax. US Duplex Doppler Subclavian Artery and Vein As with vTOS, US is an excellent initial study in the evaluation of aTOS. The subclavian and axillary arteries can be directly visualized and assessed for aneurysmal change, arterial stenosis, and thrombosis. Dynamic arterial blood flow can be assessed during abduction. Findings include decrease in arterial diameter, changes in peak velocity, or reproducible symptoms considered to be diagnostic of aTOS. Evaluation of the cross-sectional area of the costocervical space may also be performed [28]. | Thoracic Outlet Syndrome. Numerous MRA techniques have been described including noncontrast MRA, including inversion recovery methods for patients unable or unwilling to have contrast [42], simultaneous bilateral MRA [34], and dual-gadolinium injection protocols [35]. Ancillary findings include possible etiologies of aTOS, frequently cervical or anomalous first rib, scalene muscle, fibromuscular bands, or pectoralis minor tendon, and anomalous course of the subclavian artery within the scalene muscle. MRA may also be performed in the postintervention setting to evaluate interval changes in the thoracic outlet, assess adequate decompression, and confirm arterial patency. MRV Chest MRV is not needed in patients with aTOS. If there are overlapping symptoms, review of the other Variants in this document may help with protocol optimization. Radiography Chest Because of the importance of identifying osseous structures that may impinge on the spaces of the thoracic outlet, chest radiography is useful in performing a robust evaluation for all types of TOS. As opposed to directly evaluating vascular structures, osseous abnormalities associated with TOS are frequently easily diagnosed by chest radiographs. These include first rib anomalies [20], cervical ribs [23], congenital osseous malformations [24,25], and focal bone lesions [26]. In the postoperative setting, radiographs may be useful to confirm osseous changes and evaluate for postoperative complications such as pneumothorax. US Duplex Doppler Subclavian Artery and Vein As with vTOS, US is an excellent initial study in the evaluation of aTOS. The subclavian and axillary arteries can be directly visualized and assessed for aneurysmal change, arterial stenosis, and thrombosis. Dynamic arterial blood flow can be assessed during abduction. Findings include decrease in arterial diameter, changes in peak velocity, or reproducible symptoms considered to be diagnostic of aTOS. Evaluation of the cross-sectional area of the costocervical space may also be performed [28]. | 3083061 |
acrac_3186697_0 | Imaging of Invasive Breast Cancer | 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] Imaging of Invasive Breast Cancer and later-stage breast cancer prior to treatment. Additionally, we investigate the use of surveillance imaging after completion of treatment, both in the asymptomatic and symptomatic settings. In the post-treatment setting, we differentiate recommended imaging algorithms by symptomatology, because routine screening of asymptomatic patients after treatment for metastatic disease does not provide survival benefit, but early detection of nonmetastatic recurrence does improve overall outcomes [10]. Special Imaging Considerations Although still investigational, whole body diffusion weighted imaging and whole body fluorine-18-2-fluoro-2- deoxy-D-glucose (FDG) PET/MRI may show improved staging compared with whole body FDG-PET/CT in patients with later-stage disease [11-15]. Further studies are warranted to support their use in routine practice. Discussion of Procedures by Variant Variant 1: Newly diagnosed. Clinical stage I-IIA (early stage) breast cancer at presentation. Evaluation for locoregional disease (includes invasive ductal carcinoma [IDC], or invasive lobular carcinoma [ILC], or not otherwise specified [NOS]). Bone Scan Whole Body There is no evidence to support the use of Tc-99m bone scan whole body to evaluate for locoregional disease. CT Chest, Abdomen, and Pelvis With IV Contrast Few studies have evaluated the use of CT chest, abdomen, and pelvis with intravenous (IV) contrast to determine locoregional disease. | Imaging of Invasive Breast Cancer. 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] Imaging of Invasive Breast Cancer and later-stage breast cancer prior to treatment. Additionally, we investigate the use of surveillance imaging after completion of treatment, both in the asymptomatic and symptomatic settings. In the post-treatment setting, we differentiate recommended imaging algorithms by symptomatology, because routine screening of asymptomatic patients after treatment for metastatic disease does not provide survival benefit, but early detection of nonmetastatic recurrence does improve overall outcomes [10]. Special Imaging Considerations Although still investigational, whole body diffusion weighted imaging and whole body fluorine-18-2-fluoro-2- deoxy-D-glucose (FDG) PET/MRI may show improved staging compared with whole body FDG-PET/CT in patients with later-stage disease [11-15]. Further studies are warranted to support their use in routine practice. Discussion of Procedures by Variant Variant 1: Newly diagnosed. Clinical stage I-IIA (early stage) breast cancer at presentation. Evaluation for locoregional disease (includes invasive ductal carcinoma [IDC], or invasive lobular carcinoma [ILC], or not otherwise specified [NOS]). Bone Scan Whole Body There is no evidence to support the use of Tc-99m bone scan whole body to evaluate for locoregional disease. CT Chest, Abdomen, and Pelvis With IV Contrast Few studies have evaluated the use of CT chest, abdomen, and pelvis with intravenous (IV) contrast to determine locoregional disease. | 3186697 |
acrac_3186697_1 | Imaging of Invasive Breast Cancer | A study investigating the use of CT at evaluating locoregional disease, stages I to III, adding CT to mammogram, ultrasound (US) and physical examination correctly changed the surgical approach in 13.1% of patients, based on final pathology. However, CT failed to show any disease (false-negative) in 10.8% and had a low sensitivity for detecting multicentric and multifocal tumors [20]. CT Chest, Abdomen, and Pelvis Without IV Contrast There is no evidence to support the use of CT chest, abdomen, and pelvis without IV contrast to evaluate for locoregional disease. Digital Breast Tomosynthesis Diagnostic Diagnostic mammography and US together can assess for extent of disease and tumor size. These imaging tests are usually already completed as part of the diagnostic workup (prior to pathological diagnosis). However, mammography is limited by breast density. In a prospective study of 111 consecutive women with newly diagnosed breast cancer, sensitivity of 2-D mammography for malignancy decreased from 100% in breasts that are almost entirely fatty to 45% in extremely dense breasts [22]. In addition, 2-D mammography was more sensitive than US in detecting ductal carcinoma in situ (DCIS) and less sensitive in detecting ILC. Digital breast tomosynthesis (DBT) shows a higher overall sensitivity, compared with 2-D mammography, with a similar specificity. Overall sensitivity for DBT was 88.2% compared with 78.3% for 2-D mammography [23]. DBT also has a higher sensitivity for detecting multifocal, multicentric, and contralateral breast cancer [24,25]. The improved diagnostic performance of DBT over 2-D mammography in breast cancer staging was limited to women with nondense breasts in 1 study [24], but not others [25]. Due to patient positioning constraints, 2-D mammography and DBT have limited value for evaluating the axilla. | Imaging of Invasive Breast Cancer. A study investigating the use of CT at evaluating locoregional disease, stages I to III, adding CT to mammogram, ultrasound (US) and physical examination correctly changed the surgical approach in 13.1% of patients, based on final pathology. However, CT failed to show any disease (false-negative) in 10.8% and had a low sensitivity for detecting multicentric and multifocal tumors [20]. CT Chest, Abdomen, and Pelvis Without IV Contrast There is no evidence to support the use of CT chest, abdomen, and pelvis without IV contrast to evaluate for locoregional disease. Digital Breast Tomosynthesis Diagnostic Diagnostic mammography and US together can assess for extent of disease and tumor size. These imaging tests are usually already completed as part of the diagnostic workup (prior to pathological diagnosis). However, mammography is limited by breast density. In a prospective study of 111 consecutive women with newly diagnosed breast cancer, sensitivity of 2-D mammography for malignancy decreased from 100% in breasts that are almost entirely fatty to 45% in extremely dense breasts [22]. In addition, 2-D mammography was more sensitive than US in detecting ductal carcinoma in situ (DCIS) and less sensitive in detecting ILC. Digital breast tomosynthesis (DBT) shows a higher overall sensitivity, compared with 2-D mammography, with a similar specificity. Overall sensitivity for DBT was 88.2% compared with 78.3% for 2-D mammography [23]. DBT also has a higher sensitivity for detecting multifocal, multicentric, and contralateral breast cancer [24,25]. The improved diagnostic performance of DBT over 2-D mammography in breast cancer staging was limited to women with nondense breasts in 1 study [24], but not others [25]. Due to patient positioning constraints, 2-D mammography and DBT have limited value for evaluating the axilla. | 3186697 |
acrac_3186697_2 | Imaging of Invasive Breast Cancer | In a single-institution retrospective study of 3,944 patients with breast cancer, mammography improved the sensitivity over US alone for distinguishing N0 to N1 from N2 and N3, but at a lower specificity [35]. After the American College of Surgeons Oncology Group (ACOSOG) Z0011 trial supported the omission of axillary lymph node dissection in women with <3 positive sentinel lymph nodes undergoing breast-conserving surgery and radiation therapy, some providers now request that radiologists not image the axilla in the setting of clinically node-negative disease [36]. Even when neoadjuvant chemotherapy is planned, radiologists should be thoughtful about whether to image the axilla, discussing risks and benefits with surgical colleagues, because it is not universally recommended [37]. PET/CT has the potential to have greater sensitivity than US for axillary staging because it uses a functional measurement instead of an anatomic determination (eg, cortical thickness, loss of fatty hilum) as criteria for determining suspicion for metastatic disease [42]. Surgical studies show that 21% to 33% of T1 and 45% to 60% T2 tumors with normal appearing lymph nodes have metastatic disease on pathological examination [43]. Thus, studies have queried whether a functional measurement might be better. One study retrospectively evaluated PET/CT in 826 consecutive patients with breast cancer and showed a sensitivity and specificity of 74.7% and 83,4%, respectively, for identifying metastatic disease. Studies show a negative predictive value (NPV) from 87% to 88% [39,44]. Other studies show the sensitivity and specificity for detecting lymph node metastasis as 79% and 100%, respectively [38]. However, Sohn et al [45] showed a higher sensitivity for US plus fine-needle aspiration (FNA) at determining lymph node status than PET/CT (83% versus 80%, respectively). | Imaging of Invasive Breast Cancer. In a single-institution retrospective study of 3,944 patients with breast cancer, mammography improved the sensitivity over US alone for distinguishing N0 to N1 from N2 and N3, but at a lower specificity [35]. After the American College of Surgeons Oncology Group (ACOSOG) Z0011 trial supported the omission of axillary lymph node dissection in women with <3 positive sentinel lymph nodes undergoing breast-conserving surgery and radiation therapy, some providers now request that radiologists not image the axilla in the setting of clinically node-negative disease [36]. Even when neoadjuvant chemotherapy is planned, radiologists should be thoughtful about whether to image the axilla, discussing risks and benefits with surgical colleagues, because it is not universally recommended [37]. PET/CT has the potential to have greater sensitivity than US for axillary staging because it uses a functional measurement instead of an anatomic determination (eg, cortical thickness, loss of fatty hilum) as criteria for determining suspicion for metastatic disease [42]. Surgical studies show that 21% to 33% of T1 and 45% to 60% T2 tumors with normal appearing lymph nodes have metastatic disease on pathological examination [43]. Thus, studies have queried whether a functional measurement might be better. One study retrospectively evaluated PET/CT in 826 consecutive patients with breast cancer and showed a sensitivity and specificity of 74.7% and 83,4%, respectively, for identifying metastatic disease. Studies show a negative predictive value (NPV) from 87% to 88% [39,44]. Other studies show the sensitivity and specificity for detecting lymph node metastasis as 79% and 100%, respectively [38]. However, Sohn et al [45] showed a higher sensitivity for US plus fine-needle aspiration (FNA) at determining lymph node status than PET/CT (83% versus 80%, respectively). | 3186697 |
acrac_3186697_3 | Imaging of Invasive Breast Cancer | Despite extensive scientific investigation, given the results above and the Z0011 trial, the role of PET/CT in determining locoregional extent is likely nominal. Mammography Diagnostic Diagnostic mammography and US together can assess for extent of disease and tumor size. These imaging tests are usually already completed as part of the diagnostic workup (prior to pathological diagnosis). However, mammography is limited by breast density. In a prospective study of 111 consecutive women with newly diagnosed breast cancer, the sensitivity of 2-D mammography for malignancy decreased from 100% in breasts that are almost Imaging of Invasive Breast Cancer entirely fatty to 45% in extremely dense breasts [22]. In addition, 2-D mammography was more sensitive than US in detecting DCIS and less sensitive in detecting ILC. DBT shows a higher overall sensitivity, compared with 2-D mammography, with similar specificity. Overall sensitivity for DBT was 88.2% compared with 78.3% [23]. DBT has a higher sensitivity for detecting multifocal, multicentric, and contralateral breast cancer [24,25]. The improved diagnostic performance of DBT over 2-D mammography in breast cancer staging was limited to women with nondense breasts in 1 study [24], but not others [25]. Due to patient positioning constraints, 2-D mammography and DBT have limited value for evaluating the axilla. In a single-institution retrospective study of 3,944 patients with breast cancer, mammography improved the sensitivity over US alone for distinguishing N0 to N1 from N2 and N3, but at a lower specificity [35]. After the ACOSOG Z0011 trial supported the omission of axillary lymph node dissection in women with <3 positive sentinel lymph nodes undergoing breast-conserving surgery and radiation therapy, some providers may request that radiologists not image the axilla in the setting of clinically node-negative disease [36]. | Imaging of Invasive Breast Cancer. Despite extensive scientific investigation, given the results above and the Z0011 trial, the role of PET/CT in determining locoregional extent is likely nominal. Mammography Diagnostic Diagnostic mammography and US together can assess for extent of disease and tumor size. These imaging tests are usually already completed as part of the diagnostic workup (prior to pathological diagnosis). However, mammography is limited by breast density. In a prospective study of 111 consecutive women with newly diagnosed breast cancer, the sensitivity of 2-D mammography for malignancy decreased from 100% in breasts that are almost Imaging of Invasive Breast Cancer entirely fatty to 45% in extremely dense breasts [22]. In addition, 2-D mammography was more sensitive than US in detecting DCIS and less sensitive in detecting ILC. DBT shows a higher overall sensitivity, compared with 2-D mammography, with similar specificity. Overall sensitivity for DBT was 88.2% compared with 78.3% [23]. DBT has a higher sensitivity for detecting multifocal, multicentric, and contralateral breast cancer [24,25]. The improved diagnostic performance of DBT over 2-D mammography in breast cancer staging was limited to women with nondense breasts in 1 study [24], but not others [25]. Due to patient positioning constraints, 2-D mammography and DBT have limited value for evaluating the axilla. In a single-institution retrospective study of 3,944 patients with breast cancer, mammography improved the sensitivity over US alone for distinguishing N0 to N1 from N2 and N3, but at a lower specificity [35]. After the ACOSOG Z0011 trial supported the omission of axillary lymph node dissection in women with <3 positive sentinel lymph nodes undergoing breast-conserving surgery and radiation therapy, some providers may request that radiologists not image the axilla in the setting of clinically node-negative disease [36]. | 3186697 |
acrac_3186697_4 | Imaging of Invasive Breast Cancer | Radiologists can be thoughtful about whether to image the axilla, discussing risks and benefits with surgical colleagues, because it is not universally recommended [37]. Mammography With IV Contrast Several retrospective studies have compared the sensitivity and specificity of CEM with conventional 2-D and 3-D mammography, US, and MRI. Overall, CEM and MRI are superior to DM and DM/DBT imaging [47]. The sensitivities between CEM and MRI are comparable, with some studies showing improved sensitivities with CEM [48] and some showing MRI to be superior [49,50]. Overall sensitivities ranged from 92% to 100% [16,49,51-53], including CEM detecting 92.3% of satellite masses and up to 100% of contralateral cancers [28]. CEM and MRI show similar abilities to estimate tumor size (r = 0.72-0.89 versus 0.65-0.84), but studies have shown an improved positive predictive value (PPV) of CEM (52%-93%) compared with MRI (28-60%) [16,49,53]. Despite increased specificity over MR, limitations of contrast mammography in determining disease extent include evaluation of the axilla and other nodal groups as well as chest wall involvement [47], and there is evidence against using CEM to determine disease extent in lobular cancer, due to lower conspicuity [54]. MRI Breast Without and With IV Contrast MRI breast is useful for detecting additional cancers in the ipsilateral or contralateral breast [16,55], particularly in women with dense breasts [23,56,57]. A meta-analysis of 22 studies investigated MRI screening of the contralateral breast in women with newly diagnosed breast cancer. This meta-analysis reported contralateral malignancies that were detected by MRI in 131 of 3,253 women. Thus, the summary estimate for incremental cancer detection rate was 4.1%. In studies in which pathologic tumor stage was reported, all but 2 tumors were in situ or stage I, and of those 2 tumors, 1 was node-negative ILC (42 mm). Summary estimates were as follows: MRI-directed additional | Imaging of Invasive Breast Cancer. Radiologists can be thoughtful about whether to image the axilla, discussing risks and benefits with surgical colleagues, because it is not universally recommended [37]. Mammography With IV Contrast Several retrospective studies have compared the sensitivity and specificity of CEM with conventional 2-D and 3-D mammography, US, and MRI. Overall, CEM and MRI are superior to DM and DM/DBT imaging [47]. The sensitivities between CEM and MRI are comparable, with some studies showing improved sensitivities with CEM [48] and some showing MRI to be superior [49,50]. Overall sensitivities ranged from 92% to 100% [16,49,51-53], including CEM detecting 92.3% of satellite masses and up to 100% of contralateral cancers [28]. CEM and MRI show similar abilities to estimate tumor size (r = 0.72-0.89 versus 0.65-0.84), but studies have shown an improved positive predictive value (PPV) of CEM (52%-93%) compared with MRI (28-60%) [16,49,53]. Despite increased specificity over MR, limitations of contrast mammography in determining disease extent include evaluation of the axilla and other nodal groups as well as chest wall involvement [47], and there is evidence against using CEM to determine disease extent in lobular cancer, due to lower conspicuity [54]. MRI Breast Without and With IV Contrast MRI breast is useful for detecting additional cancers in the ipsilateral or contralateral breast [16,55], particularly in women with dense breasts [23,56,57]. A meta-analysis of 22 studies investigated MRI screening of the contralateral breast in women with newly diagnosed breast cancer. This meta-analysis reported contralateral malignancies that were detected by MRI in 131 of 3,253 women. Thus, the summary estimate for incremental cancer detection rate was 4.1%. In studies in which pathologic tumor stage was reported, all but 2 tumors were in situ or stage I, and of those 2 tumors, 1 was node-negative ILC (42 mm). Summary estimates were as follows: MRI-directed additional | 3186697 |
acrac_3186697_5 | Imaging of Invasive Breast Cancer | Imaging of Invasive Breast Cancer biopsy in 9.3% of women (95% confidence interval [CI], 5.8%-14.7%) with PPV for malignancy of 47.9% (95% CI, 31.8%-64.6%). Where reported, 35.1% of MRI-detected cancers were DCIS (mean size = 6.9 mm) and 64.9% were invasive cancers (mean size = 9.3 mm) [58]. MRI can accurately assess tumor size for preoperative planning [50,59-61]. In a study involving 343 tumors, size measurements of cancers on breast MRI were within 5 mm of pathological size in 88% of patients [60]. Still, other studies using mastectomy specimens have shown that MRI underestimates primary tumor size in 21% and overestimates primary tumor size in 24% of cases [62]. MRI also overestimated the number of invasive lesions by 19% and underestimated the number of invasive lesions in 28% in the same study [62]. These data underscore the importance of using biopsy to pathologically confirm MRI findings instead of relying on them to alter surgical planning, especially when the MRI finding is nonmass enhancement [63]. In addition to tumor size assessment, some studies show a reduction in re-excision after preoperative MRI [64-68]. For example, in a study of 991 women, preoperative MRI changed the surgical procedure in 25% (157/626) of cases. In 81% (127/157), MRI benefited some patients, as otherwise occult carcinomas were removed (n = 122) and further biopsy prevented (n = 5) [67]. In this trial, the rate of mastectomy did not differ between patients undergoing preoperative MRI and those who did not. A recent multinational observational study at 27 centers also found that subjects receiving MR as part of routine clinical care had a significantly lower reoperation rate after breast conservation (8.5% versus 11.7%, P < . 001) [69]. | Imaging of Invasive Breast Cancer. Imaging of Invasive Breast Cancer biopsy in 9.3% of women (95% confidence interval [CI], 5.8%-14.7%) with PPV for malignancy of 47.9% (95% CI, 31.8%-64.6%). Where reported, 35.1% of MRI-detected cancers were DCIS (mean size = 6.9 mm) and 64.9% were invasive cancers (mean size = 9.3 mm) [58]. MRI can accurately assess tumor size for preoperative planning [50,59-61]. In a study involving 343 tumors, size measurements of cancers on breast MRI were within 5 mm of pathological size in 88% of patients [60]. Still, other studies using mastectomy specimens have shown that MRI underestimates primary tumor size in 21% and overestimates primary tumor size in 24% of cases [62]. MRI also overestimated the number of invasive lesions by 19% and underestimated the number of invasive lesions in 28% in the same study [62]. These data underscore the importance of using biopsy to pathologically confirm MRI findings instead of relying on them to alter surgical planning, especially when the MRI finding is nonmass enhancement [63]. In addition to tumor size assessment, some studies show a reduction in re-excision after preoperative MRI [64-68]. For example, in a study of 991 women, preoperative MRI changed the surgical procedure in 25% (157/626) of cases. In 81% (127/157), MRI benefited some patients, as otherwise occult carcinomas were removed (n = 122) and further biopsy prevented (n = 5) [67]. In this trial, the rate of mastectomy did not differ between patients undergoing preoperative MRI and those who did not. A recent multinational observational study at 27 centers also found that subjects receiving MR as part of routine clinical care had a significantly lower reoperation rate after breast conservation (8.5% versus 11.7%, P < . 001) [69]. | 3186697 |
acrac_3186697_6 | Imaging of Invasive Breast Cancer | However, other large multicenter studies, such as the comparative effectiveness of MRI in breast cancer (COMICE) trial, showed the addition of MRI to conventional imaging was not significantly associated with a reduced reoperation rate, with 153 (19%) needing reoperation in the MRI group versus 156 (19%) in the non-MRI group (odds ratio [OR], 0.96; 95% CI, 0.75-1.24; P = . 77) [70]. Although the findings are important, limitations from the COMICE trial are also noted, such as its inclusion of patients from several small centers where technical factors and varying degree of experience among interpreting radiologists could have influenced the MRI results. It is also not clear that the data from the MRI was incorporated into surgical planning, and nearly 7% of the group assigned to MRI did not actually have an MR interpreted (analyzed by intention to treat). When all breast cancer subtypes were included, a meta-analysis of 19 studies did not find evidence that MRI impacted the rates of re-excision, reoperation, or positive margins, but MRI was significantly associated with increased odds of receiving contralateral prophylactic mastectomy (OR, 1.91; 95% CI, 1.25-2.91; P = . 003) [71]. This analysis of 85,975 women also showed that preoperative MRI was associated with increased odds of receiving mastectomy (OR, 1.39; 95% CI, 1.23-1.57; P < . 001) [71]. Still, it is unknown whether some of the studies included in that meta-analysis had a bias in randomization (ie, women who were preplanned for mastectomies were more likely to have been referred rather than randomized to the preoperative MRI arm). As an example of this, in the multicenter international prospective analysis cited above [69], mastectomy was already planned based on conventional imaging in 22.4% (MRI group) versus 14.4% (no MRI group) (P < . 001). The data are different for ILC histological subtypes. For ILC, there is strong evidence that MRI improves surgical outcomes [72-81]. | Imaging of Invasive Breast Cancer. However, other large multicenter studies, such as the comparative effectiveness of MRI in breast cancer (COMICE) trial, showed the addition of MRI to conventional imaging was not significantly associated with a reduced reoperation rate, with 153 (19%) needing reoperation in the MRI group versus 156 (19%) in the non-MRI group (odds ratio [OR], 0.96; 95% CI, 0.75-1.24; P = . 77) [70]. Although the findings are important, limitations from the COMICE trial are also noted, such as its inclusion of patients from several small centers where technical factors and varying degree of experience among interpreting radiologists could have influenced the MRI results. It is also not clear that the data from the MRI was incorporated into surgical planning, and nearly 7% of the group assigned to MRI did not actually have an MR interpreted (analyzed by intention to treat). When all breast cancer subtypes were included, a meta-analysis of 19 studies did not find evidence that MRI impacted the rates of re-excision, reoperation, or positive margins, but MRI was significantly associated with increased odds of receiving contralateral prophylactic mastectomy (OR, 1.91; 95% CI, 1.25-2.91; P = . 003) [71]. This analysis of 85,975 women also showed that preoperative MRI was associated with increased odds of receiving mastectomy (OR, 1.39; 95% CI, 1.23-1.57; P < . 001) [71]. Still, it is unknown whether some of the studies included in that meta-analysis had a bias in randomization (ie, women who were preplanned for mastectomies were more likely to have been referred rather than randomized to the preoperative MRI arm). As an example of this, in the multicenter international prospective analysis cited above [69], mastectomy was already planned based on conventional imaging in 22.4% (MRI group) versus 14.4% (no MRI group) (P < . 001). The data are different for ILC histological subtypes. For ILC, there is strong evidence that MRI improves surgical outcomes [72-81]. | 3186697 |
acrac_3186697_7 | Imaging of Invasive Breast Cancer | In a study with 70 cases of ILC, preoperative MRI reduced re-excision rates, particularly in young women with dense breasts [82]. In another study with 369 women, preoperative breast MRI was also associated with a reduction in repeat surgery (OR, 0.140; P < . 001), without increasing mastectomy rates [76]. Although MR does lead to increased cancer detection, there is limited evidence that preoperative MRI improves survival or decreases recurrence, including data from multicenter analyses [61,68,83-85]. In 3,180 affected breasts in 3,169 women (median age, 56.2 years), 8-year disease-free survival did not differ between the MRI (97%) and the non-MRI (95%) groups (P = . 87), and the multivariable model showed no significant effect of MRI on disease- free survival: hazard ratio (HR) for MRI (versus non-MRI) was 0.88 (95% CI, 0.52-1.51; P = . 65); age, margin status, and tumor grade were associated with disease-free survival (all P < . 05) [85]. Of the 31,756 patients included in a survival cohort (70% non-MRI and 30% MRI), breast MRI was not significantly associated with overall survival (HR, 0.91; 95% CI, 0.74-1.11, P = . 35) or with disease-free survival (HR, 1.16; 95% CI, 0.81-1.67), even among the different histological subtypes. The lack of survival benefit extends also to patients with ILC, despite improved surgical outcomes in this population as described above [83]. One recent study did show lower recurrences (locoregional, distant and contralateral) in women who received a preoperative MRI, with a nonsignificant trend toward MR improving disease-free survival (P = . 057) [86], and another study of 1,199 subjects did show improved overall survival in the group who received MRI [87]. Given these data, benefits of preoperative MRI for additional cancer detection or delineating extent of disease should be balanced with the possibility of a false-positive diagnosis leading to additional biopsy, unnecessary additional imaging, and potential delays in definitive treatment. | Imaging of Invasive Breast Cancer. In a study with 70 cases of ILC, preoperative MRI reduced re-excision rates, particularly in young women with dense breasts [82]. In another study with 369 women, preoperative breast MRI was also associated with a reduction in repeat surgery (OR, 0.140; P < . 001), without increasing mastectomy rates [76]. Although MR does lead to increased cancer detection, there is limited evidence that preoperative MRI improves survival or decreases recurrence, including data from multicenter analyses [61,68,83-85]. In 3,180 affected breasts in 3,169 women (median age, 56.2 years), 8-year disease-free survival did not differ between the MRI (97%) and the non-MRI (95%) groups (P = . 87), and the multivariable model showed no significant effect of MRI on disease- free survival: hazard ratio (HR) for MRI (versus non-MRI) was 0.88 (95% CI, 0.52-1.51; P = . 65); age, margin status, and tumor grade were associated with disease-free survival (all P < . 05) [85]. Of the 31,756 patients included in a survival cohort (70% non-MRI and 30% MRI), breast MRI was not significantly associated with overall survival (HR, 0.91; 95% CI, 0.74-1.11, P = . 35) or with disease-free survival (HR, 1.16; 95% CI, 0.81-1.67), even among the different histological subtypes. The lack of survival benefit extends also to patients with ILC, despite improved surgical outcomes in this population as described above [83]. One recent study did show lower recurrences (locoregional, distant and contralateral) in women who received a preoperative MRI, with a nonsignificant trend toward MR improving disease-free survival (P = . 057) [86], and another study of 1,199 subjects did show improved overall survival in the group who received MRI [87]. Given these data, benefits of preoperative MRI for additional cancer detection or delineating extent of disease should be balanced with the possibility of a false-positive diagnosis leading to additional biopsy, unnecessary additional imaging, and potential delays in definitive treatment. | 3186697 |
acrac_3186697_8 | Imaging of Invasive Breast Cancer | Due to additional cancer detection on a per-patient Imaging of Invasive Breast Cancer level, MRI is considered optional, despite a lack of definitive data supporting classical improved outcomes and continued controversy regarding potential harms. Considering the evidence above, MRI-detected suspicious masses >2 cm from the index malignancy or nonmass enhancement significantly larger than expected from mammographic/sonographic findings should be sampled before using MRI findings to alter surgical planning or change treatment recommendations. MRI Breast Without IV Contrast There is no evidence to support the use of noncontrast breast MRI in evaluating extent of disease. US is the most established noninvasive imaging test for assessing the axilla following a clinically or imaging detected suspicious lymph node. US features associated with a higher likelihood of malignancy include short-axis lymph node size >1 cm, cortical thickness of >0.3 cm, and an absence of a fatty hilum [90-93]. There is a wide range of reported sensitivity and specificity for axillary US, and none of these imaging features are specific enough to avoid the need for histologic sampling. The sensitivity ranges from 26.4% to 94%, and the specificity ranges from 53% to 98% [94-97]. Axillary US alone has a relatively low NPV to rule out metastatic disease [36,98]. A meta-analysis of 21 studies showed that US combined with needle biopsy improved the sensitivity from 61% to 79% [99-101]. US-guided core needle biopsy was superior to US-guided FNA in a meta-analysis of 1,353 patients with newly diagnosed invasive breast carcinoma, with a reported sensitivity of 88% for core biopsy and 74% for FNA [102]. Axillary US and an MRI performed similarly (sensitivity of 99.1% versus 97.4% and specificity 15.4% versus 15.4%, respectively) in evaluating axillary lymph nodes. | Imaging of Invasive Breast Cancer. Due to additional cancer detection on a per-patient Imaging of Invasive Breast Cancer level, MRI is considered optional, despite a lack of definitive data supporting classical improved outcomes and continued controversy regarding potential harms. Considering the evidence above, MRI-detected suspicious masses >2 cm from the index malignancy or nonmass enhancement significantly larger than expected from mammographic/sonographic findings should be sampled before using MRI findings to alter surgical planning or change treatment recommendations. MRI Breast Without IV Contrast There is no evidence to support the use of noncontrast breast MRI in evaluating extent of disease. US is the most established noninvasive imaging test for assessing the axilla following a clinically or imaging detected suspicious lymph node. US features associated with a higher likelihood of malignancy include short-axis lymph node size >1 cm, cortical thickness of >0.3 cm, and an absence of a fatty hilum [90-93]. There is a wide range of reported sensitivity and specificity for axillary US, and none of these imaging features are specific enough to avoid the need for histologic sampling. The sensitivity ranges from 26.4% to 94%, and the specificity ranges from 53% to 98% [94-97]. Axillary US alone has a relatively low NPV to rule out metastatic disease [36,98]. A meta-analysis of 21 studies showed that US combined with needle biopsy improved the sensitivity from 61% to 79% [99-101]. US-guided core needle biopsy was superior to US-guided FNA in a meta-analysis of 1,353 patients with newly diagnosed invasive breast carcinoma, with a reported sensitivity of 88% for core biopsy and 74% for FNA [102]. Axillary US and an MRI performed similarly (sensitivity of 99.1% versus 97.4% and specificity 15.4% versus 15.4%, respectively) in evaluating axillary lymph nodes. | 3186697 |
acrac_3186697_9 | Imaging of Invasive Breast Cancer | Despite this performance, approximately 14% of women with breast cancer and negative imaging for axillary metastasis ultimately have metastatic disease on sentinel lymph node biopsy [103]. US Breast Diagnostic mammography and US together can assess for extent of disease and tumor size. These imaging tests are usually already completed as part of the diagnostic workup (prior to pathological diagnosis). The sensitivity of US for detecting cancer ranges from 79% to 94% [22,25,104,105]. The addition of DBT to US improved sensitivity for detecting both primary breast cancer and multicentric and multifocal disease, from 82.6% (nondense) and 91.6% (dense) with US alone to 97.7% with combined DBT and US [106]. However, DBT and mammography have limited added value over US alone for initial evaluation in women <40 years of age [105]. Although bilateral US use in women with primary breast cancer to evaluate for multicentric and multifocal disease shows a lower sensitivity than MRI (85.1% versus 71.1%), US showed higher accuracy and specificity than MRI (67.6% versus 39.3% and 69.2% versus 60.2%, respectively), suggesting that bilateral US may be an acceptable alternative to MRI for locoregional staging [57]. When compared with DM alone, supplemental US more accurately depicted the extent of disease needing wider excision in 17 of 96 (18%) breasts for which conservation was anticipated, corresponding to 17 of 30 (57%) breasts with mammographically occult disease [22]. Based on mammography/clinical examination, 2% to 3% of patients have synchronous bilateral cancer [107]. This risk for bilateral synchronous cancer is increased in patients less than 55 years of age or in those diagnosed with invasive lobular subtypes [108]. In 1 series with 9% contralateral synchronous malignancy, mammography detected 60%, US detected 80%, and MRI detected 90% (with the remainder detected on follow-up imaging) [22]. | Imaging of Invasive Breast Cancer. Despite this performance, approximately 14% of women with breast cancer and negative imaging for axillary metastasis ultimately have metastatic disease on sentinel lymph node biopsy [103]. US Breast Diagnostic mammography and US together can assess for extent of disease and tumor size. These imaging tests are usually already completed as part of the diagnostic workup (prior to pathological diagnosis). The sensitivity of US for detecting cancer ranges from 79% to 94% [22,25,104,105]. The addition of DBT to US improved sensitivity for detecting both primary breast cancer and multicentric and multifocal disease, from 82.6% (nondense) and 91.6% (dense) with US alone to 97.7% with combined DBT and US [106]. However, DBT and mammography have limited added value over US alone for initial evaluation in women <40 years of age [105]. Although bilateral US use in women with primary breast cancer to evaluate for multicentric and multifocal disease shows a lower sensitivity than MRI (85.1% versus 71.1%), US showed higher accuracy and specificity than MRI (67.6% versus 39.3% and 69.2% versus 60.2%, respectively), suggesting that bilateral US may be an acceptable alternative to MRI for locoregional staging [57]. When compared with DM alone, supplemental US more accurately depicted the extent of disease needing wider excision in 17 of 96 (18%) breasts for which conservation was anticipated, corresponding to 17 of 30 (57%) breasts with mammographically occult disease [22]. Based on mammography/clinical examination, 2% to 3% of patients have synchronous bilateral cancer [107]. This risk for bilateral synchronous cancer is increased in patients less than 55 years of age or in those diagnosed with invasive lobular subtypes [108]. In 1 series with 9% contralateral synchronous malignancy, mammography detected 60%, US detected 80%, and MRI detected 90% (with the remainder detected on follow-up imaging) [22]. | 3186697 |
acrac_3186697_10 | Imaging of Invasive Breast Cancer | In addition to its role in the initial diagnostic workup, US is important in the secondary evaluation of a suspicious finding on MRI in the setting of evaluation of disease extent. US sensitivity and NPV are higher than those of DBT [109]. Compared with DBT, US showed a lower specificity (98.1% versus 78.9%) and similar PPV (66.7% versus 52.2%). However, a meta-analysis of second-look US following a suspicious finding on MRI showed heterogeneity in US performance, with the detection rate ranging from 22.6% to 82.1% (pooled detection rate 57.5%) and an 87.8% pooled NPV [110]. Therefore, a negative US is insufficient to obviate the need for an MRI biopsy in this setting. There is no evidence supporting US as an accurate method for determining disease extent of those diagnosed with ILC subtype. Conventional imaging with mammography and/or US can significantly underestimate the extent of ILC [26,111-114]. For example, US specifically underestimated ILC tumor size by 27% (95% CI, 17%-37%) in a Imaging of Invasive Breast Cancer study [113], and a different study showed that the greatest discrepancy between tumor size and pathologic size using US measurements was for the ILC subtype [26]. Variant 2: Newly diagnosed. Clinical stage I-IIA (early stage) breast cancer at presentation. Evaluation for distant disease (includes IDC, or ILC, or NOS). It has long been recognized that steroid receptor expression reflects intrinsic biologic diversity in breast cancer with treatment and survival implications, also determining patterns of metastatic spread. Historically, bone is the most likely site of breast cancer metastases (51%), followed by liver/soft tissue (19%), pleura (16%), lung (14%), and brain (4%) [115]. The higher percentage of bone metastases from breast cancer appears to be driven primarily by the majority of primary tumors expressing ER and/or PR. | Imaging of Invasive Breast Cancer. In addition to its role in the initial diagnostic workup, US is important in the secondary evaluation of a suspicious finding on MRI in the setting of evaluation of disease extent. US sensitivity and NPV are higher than those of DBT [109]. Compared with DBT, US showed a lower specificity (98.1% versus 78.9%) and similar PPV (66.7% versus 52.2%). However, a meta-analysis of second-look US following a suspicious finding on MRI showed heterogeneity in US performance, with the detection rate ranging from 22.6% to 82.1% (pooled detection rate 57.5%) and an 87.8% pooled NPV [110]. Therefore, a negative US is insufficient to obviate the need for an MRI biopsy in this setting. There is no evidence supporting US as an accurate method for determining disease extent of those diagnosed with ILC subtype. Conventional imaging with mammography and/or US can significantly underestimate the extent of ILC [26,111-114]. For example, US specifically underestimated ILC tumor size by 27% (95% CI, 17%-37%) in a Imaging of Invasive Breast Cancer study [113], and a different study showed that the greatest discrepancy between tumor size and pathologic size using US measurements was for the ILC subtype [26]. Variant 2: Newly diagnosed. Clinical stage I-IIA (early stage) breast cancer at presentation. Evaluation for distant disease (includes IDC, or ILC, or NOS). It has long been recognized that steroid receptor expression reflects intrinsic biologic diversity in breast cancer with treatment and survival implications, also determining patterns of metastatic spread. Historically, bone is the most likely site of breast cancer metastases (51%), followed by liver/soft tissue (19%), pleura (16%), lung (14%), and brain (4%) [115]. The higher percentage of bone metastases from breast cancer appears to be driven primarily by the majority of primary tumors expressing ER and/or PR. | 3186697 |
acrac_3186697_11 | Imaging of Invasive Breast Cancer | In 1 large multidecade study, 82% of patients with breast cancer who developed bone metastases had either ER and PR or ER positivity in the primary tumor [115]. A landmark study 2 decades ago transformed our field by discovering 5 distinct composite molecular portraits using quantitative analysis of breast cancer gene expression patterns; luminal A, luminal B, HER2-enriched, basal-like, and normal-like, providing a new type of disease characterization [116]. The molecular subtypes were linked to pattern and type of metastatic spread, as well as disease-specific survival [117,118]. For example, luminal cancers have a propensity to give rise first to bone metastases, HER2-enriched cancers to liver and lung metastases, and basal type cancers to liver and brain metastases [119,120]. These molecular subtypes share similarities with ER/PR expression and HER2 gene amplification but are not synonymous. Luminal subtypes more commonly have ER expression, HER2-enriched cancers more commonly exhibit HER2 expression, and triple-negative breast cancers are most often the basal breast cancer subtype. Although luminal subtypes have significantly better overall and relapse-free survival [118], they carry a long-term risk of recurrence, especially to bone, whereas basal and HER2 subtypes have a higher rate of recurrence in the first 4 years [121], which can be considered when planning frequency and type of surveillance imaging. Bone Scan Whole Body Bone is the most common site for breast cancer metastasis; up to 70% of women with stage IV disease have bone metastasis, with the predilection for bone metastases not applying to basal-like tumors [117]. Up to 13.6% of women diagnosed with early stage breast cancer will develop bone metastasis within 15 years of diagnosis [122], even if the parent tumor is low grade [123]. | Imaging of Invasive Breast Cancer. In 1 large multidecade study, 82% of patients with breast cancer who developed bone metastases had either ER and PR or ER positivity in the primary tumor [115]. A landmark study 2 decades ago transformed our field by discovering 5 distinct composite molecular portraits using quantitative analysis of breast cancer gene expression patterns; luminal A, luminal B, HER2-enriched, basal-like, and normal-like, providing a new type of disease characterization [116]. The molecular subtypes were linked to pattern and type of metastatic spread, as well as disease-specific survival [117,118]. For example, luminal cancers have a propensity to give rise first to bone metastases, HER2-enriched cancers to liver and lung metastases, and basal type cancers to liver and brain metastases [119,120]. These molecular subtypes share similarities with ER/PR expression and HER2 gene amplification but are not synonymous. Luminal subtypes more commonly have ER expression, HER2-enriched cancers more commonly exhibit HER2 expression, and triple-negative breast cancers are most often the basal breast cancer subtype. Although luminal subtypes have significantly better overall and relapse-free survival [118], they carry a long-term risk of recurrence, especially to bone, whereas basal and HER2 subtypes have a higher rate of recurrence in the first 4 years [121], which can be considered when planning frequency and type of surveillance imaging. Bone Scan Whole Body Bone is the most common site for breast cancer metastasis; up to 70% of women with stage IV disease have bone metastasis, with the predilection for bone metastases not applying to basal-like tumors [117]. Up to 13.6% of women diagnosed with early stage breast cancer will develop bone metastasis within 15 years of diagnosis [122], even if the parent tumor is low grade [123]. | 3186697 |
acrac_3186697_12 | Imaging of Invasive Breast Cancer | Tc-99m bone scans detect early bone metastasis because of the new bone formation occurring at these sites [124] and have a 98% sensitivity for detecting early bone metastasis in symptomatic patients. However, bone scan is not helpful for asymptomatic women with newly diagnosed early stage breast cancer due to the low prevalence of metastasis (<1%) at initial diagnosis [125]. Whole body bone scans are performed in up to 35% of women with newly diagnosed breast cancer despite National Comprehensive Cancer Network (NCCN) guidelines recommending against routine staging in asymptomatic women with early stage breast cancer [125,126]. The unnecessary use of this imaging test and the further evaluation of false-positive findings can result in treatment delay [127]. There is no evidence to use whole body bone scan in the evaluation of distant disease in stage I to IIA breast cancer. CT Chest, Abdomen, and Pelvis With IV Contrast National and international guidelines (American Board of Internal Medicine [ABIM]/ASCO, European Society for Medical Oncology [ESMO], and Spanish Society of Medical Oncology [SEOM]) discourage the use of imaging for staging in asymptomatic patients with newly diagnosed early stage breast cancer [128-130]. NCCN guidelines recommend chest, abdomen, and pelvic CT as an additional test prior to preoperative systemic therapy in clinical stage I to IIA if the tumor is >2 cm, >1 cm and immunohistochemical subtype is triple negative, or HER2+ or any size/subtype with known axillary nodal spread [126]. However, this test is often used in the staging evaluation of low-risk cancers, outside these guidelines, despite a lack of evidence suggesting that it improves detection of metastatic disease or increases survival. There is a lack of evidence demonstrating a benefit for the use of CT in asymptomatic individuals with clinical stage I or II disease outside the guidelines above. | Imaging of Invasive Breast Cancer. Tc-99m bone scans detect early bone metastasis because of the new bone formation occurring at these sites [124] and have a 98% sensitivity for detecting early bone metastasis in symptomatic patients. However, bone scan is not helpful for asymptomatic women with newly diagnosed early stage breast cancer due to the low prevalence of metastasis (<1%) at initial diagnosis [125]. Whole body bone scans are performed in up to 35% of women with newly diagnosed breast cancer despite National Comprehensive Cancer Network (NCCN) guidelines recommending against routine staging in asymptomatic women with early stage breast cancer [125,126]. The unnecessary use of this imaging test and the further evaluation of false-positive findings can result in treatment delay [127]. There is no evidence to use whole body bone scan in the evaluation of distant disease in stage I to IIA breast cancer. CT Chest, Abdomen, and Pelvis With IV Contrast National and international guidelines (American Board of Internal Medicine [ABIM]/ASCO, European Society for Medical Oncology [ESMO], and Spanish Society of Medical Oncology [SEOM]) discourage the use of imaging for staging in asymptomatic patients with newly diagnosed early stage breast cancer [128-130]. NCCN guidelines recommend chest, abdomen, and pelvic CT as an additional test prior to preoperative systemic therapy in clinical stage I to IIA if the tumor is >2 cm, >1 cm and immunohistochemical subtype is triple negative, or HER2+ or any size/subtype with known axillary nodal spread [126]. However, this test is often used in the staging evaluation of low-risk cancers, outside these guidelines, despite a lack of evidence suggesting that it improves detection of metastatic disease or increases survival. There is a lack of evidence demonstrating a benefit for the use of CT in asymptomatic individuals with clinical stage I or II disease outside the guidelines above. | 3186697 |
acrac_3186697_13 | Imaging of Invasive Breast Cancer | A survey of NCCN member institutions found that 11% of patients with stage I and 36.2% of patients with stage II received a staging CT of the chest. This resulted in 27% of patients diagnosed with pulmonary nodules requiring a mean 2.34 additional CTs (range 0-16) for follow-up. Of pulmonary nodules detected in asymptomatic women with early stage breast cancer, only 2% of these patients were ultimately diagnosed with pulmonary metastasis [131,132]. Imaging of Invasive Breast Cancer CT Chest, Abdomen, and Pelvis Without and With IV Contrast The majority of clinical questions for abdominal and/or pelvic CT can be appropriately answered with a single- phase study as detailed in the ACR-SABI-SPR practice parameter for the performance of CT of the abdomen and CT of the pelvis [21]. CT Chest, Abdomen, and Pelvis Without IV Contrast There is no evidence to support the use of CT chest, abdomen, and pelvis without IV contrast in identifying distant disease. Digital Breast Tomosynthesis Diagnostic There is no evidence to support the use of DBT to evaluate distant disease. FDG-PET/CT Skull Base to Mid-Thigh According to the ABIM/ASCO, ESMO, and SEOM guidelines, there is insufficient evidence to routinely use FDG- PET/CT to evaluate for distant disease in asymptomatic women with early stage breast cancer [128-130]. NCCN guidelines recommend chest, abdomen, and pelvic CT as an additional test prior to preoperative systemic therapy to evaluate for distant disease if the tumor size is >2 cm (T2) or there are positive lymph nodes, or the tumor size is >1 cm (T1c) and HER2+, or there is triple-negative disease [126]. Although not definitive, and not currently recommended in the guidelines above, there is evidence that PET/CT may be useful in early stage breast cancer [133]. | Imaging of Invasive Breast Cancer. A survey of NCCN member institutions found that 11% of patients with stage I and 36.2% of patients with stage II received a staging CT of the chest. This resulted in 27% of patients diagnosed with pulmonary nodules requiring a mean 2.34 additional CTs (range 0-16) for follow-up. Of pulmonary nodules detected in asymptomatic women with early stage breast cancer, only 2% of these patients were ultimately diagnosed with pulmonary metastasis [131,132]. Imaging of Invasive Breast Cancer CT Chest, Abdomen, and Pelvis Without and With IV Contrast The majority of clinical questions for abdominal and/or pelvic CT can be appropriately answered with a single- phase study as detailed in the ACR-SABI-SPR practice parameter for the performance of CT of the abdomen and CT of the pelvis [21]. CT Chest, Abdomen, and Pelvis Without IV Contrast There is no evidence to support the use of CT chest, abdomen, and pelvis without IV contrast in identifying distant disease. Digital Breast Tomosynthesis Diagnostic There is no evidence to support the use of DBT to evaluate distant disease. FDG-PET/CT Skull Base to Mid-Thigh According to the ABIM/ASCO, ESMO, and SEOM guidelines, there is insufficient evidence to routinely use FDG- PET/CT to evaluate for distant disease in asymptomatic women with early stage breast cancer [128-130]. NCCN guidelines recommend chest, abdomen, and pelvic CT as an additional test prior to preoperative systemic therapy to evaluate for distant disease if the tumor size is >2 cm (T2) or there are positive lymph nodes, or the tumor size is >1 cm (T1c) and HER2+, or there is triple-negative disease [126]. Although not definitive, and not currently recommended in the guidelines above, there is evidence that PET/CT may be useful in early stage breast cancer [133]. | 3186697 |
acrac_3186697_14 | Imaging of Invasive Breast Cancer | A recent study of 196 subjects [134] tested the utility of PET/CT in breast cancer and found the overall yield of unsuspected distant metastases was 14% (n = 27), including 0% for stage IIA, 13% for stage IIB (10/79), 22% for stage IIIA (9/41), 17% for stage IIIB (5/30), and 37% for stage IIIC (3/8). In another study of 303 patients, PET/CT demonstrated unknown metastatic disease in 4.9% (15/303), 0.8% in stage IIA, and 9.8% in stage IIB [135]. Finally, Groheux et al [136] performed a prospective study of 254 women with breast cancer, and PET/CT found unsuspected metastatic disease in 2.3% of stage IIA and 10.7% in stage IIB [128]. The performance of PET/CT was independent of cancer subtype, as shown in other studies on stage IIB disease [137]. Finally, a recent meta-analysis of 4,276 patients (29 studies) also found 11% (95% CI, 3%-22%) of patients with stage I and 20% (95% CI, 16%-24%) of patients with stage II breast cancer changed disease stage or management plan (including up or downstaging) with PET/CT [13]. Thus, there is some evidence to consider this test, even in early breast cancer, if the immunohistochemical subtype is HER2+/TN or the disease is locally advanced as described above. Mammography Diagnostic There is no evidence to support the use of diagnostic mammography to evaluate distant disease. Mammography With IV Contrast There is no evidence to support the use of diagnostic mammography with IV contrast to evaluate distant disease. MRI Breast Without and With IV Contrast There is no evidence to support the use of MRI breast to evaluate distant disease. MRI Breast Without IV Contrast There is no evidence to support the use of noncontrast breast MRI in evaluating extent of disease. US Axilla There is no evidence to support the use of US axilla to evaluate distant disease. US Breast There is no evidence to support the use of US breast to evaluate distant disease. Variant 3: Newly diagnosed. Clinical stage IIB-III (late stage) breast cancer at presentation. | Imaging of Invasive Breast Cancer. A recent study of 196 subjects [134] tested the utility of PET/CT in breast cancer and found the overall yield of unsuspected distant metastases was 14% (n = 27), including 0% for stage IIA, 13% for stage IIB (10/79), 22% for stage IIIA (9/41), 17% for stage IIIB (5/30), and 37% for stage IIIC (3/8). In another study of 303 patients, PET/CT demonstrated unknown metastatic disease in 4.9% (15/303), 0.8% in stage IIA, and 9.8% in stage IIB [135]. Finally, Groheux et al [136] performed a prospective study of 254 women with breast cancer, and PET/CT found unsuspected metastatic disease in 2.3% of stage IIA and 10.7% in stage IIB [128]. The performance of PET/CT was independent of cancer subtype, as shown in other studies on stage IIB disease [137]. Finally, a recent meta-analysis of 4,276 patients (29 studies) also found 11% (95% CI, 3%-22%) of patients with stage I and 20% (95% CI, 16%-24%) of patients with stage II breast cancer changed disease stage or management plan (including up or downstaging) with PET/CT [13]. Thus, there is some evidence to consider this test, even in early breast cancer, if the immunohistochemical subtype is HER2+/TN or the disease is locally advanced as described above. Mammography Diagnostic There is no evidence to support the use of diagnostic mammography to evaluate distant disease. Mammography With IV Contrast There is no evidence to support the use of diagnostic mammography with IV contrast to evaluate distant disease. MRI Breast Without and With IV Contrast There is no evidence to support the use of MRI breast to evaluate distant disease. MRI Breast Without IV Contrast There is no evidence to support the use of noncontrast breast MRI in evaluating extent of disease. US Axilla There is no evidence to support the use of US axilla to evaluate distant disease. US Breast There is no evidence to support the use of US breast to evaluate distant disease. Variant 3: Newly diagnosed. Clinical stage IIB-III (late stage) breast cancer at presentation. | 3186697 |
acrac_3186697_15 | Imaging of Invasive Breast Cancer | Evaluation for locoregional disease (includes IDC, or ILC, or NOS). Bone Scan Whole Body There is no evidence to support the use of bone scan whole body for determining locoregional disease. CT Chest, Abdomen, and Pelvis With IV Contrast Few studies have evaluated the use of CT to determine locoregional disease in breast cancer and so there is limited supporting evidence for this indication. In a study using CT to determine the size of the in-breast malignancy, surgical treatment was changed in 42 of 297 (14.1%) patients. The same study showed that CT failed to show the extent of disease in 10.8% of patients and overestimated the extent of disease in 1% of tumors. Notably, MRI was not included as a comparator [20]. An additional study looking at later stage (at least 2 cm) or higher risk (triple Imaging of Invasive Breast Cancer negative or other biomarkers of risk such as high Ki67 or HER2+) found that CT predicted the N stage correctly in 64 of 80 patients (80%, 95% CI,70.0%-87.3%), with a sensitivity of 61.5% (CI,45.9%-75.1%) and a specificity of 97.6% (CI, 87.4%-99.6%). Despite the higher specificity of CT, MRI has better performance to detect multicentric/multifocal disease and estimate final pathologic size. CT Chest, Abdomen, and Pelvis Without and With IV Contrast The majority of clinical questions for abdominal and/or pelvic CT can be appropriately answered with a single- phase study as detailed in the ACR-SABI-SPR practice parameter for the performance of CT of the abdomen and CT of the pelvis [21]. CT Chest, Abdomen, and Pelvis Without IV Contrast There is no evidence to support the use of CT chest, abdomen, and pelvis without IV contrast for determining locoregional disease and guiding surgical management in late-stage disease. Digital Breast Tomosynthesis Diagnostic Diagnostic mammography and US together can assess for extent of disease and tumor size. | Imaging of Invasive Breast Cancer. Evaluation for locoregional disease (includes IDC, or ILC, or NOS). Bone Scan Whole Body There is no evidence to support the use of bone scan whole body for determining locoregional disease. CT Chest, Abdomen, and Pelvis With IV Contrast Few studies have evaluated the use of CT to determine locoregional disease in breast cancer and so there is limited supporting evidence for this indication. In a study using CT to determine the size of the in-breast malignancy, surgical treatment was changed in 42 of 297 (14.1%) patients. The same study showed that CT failed to show the extent of disease in 10.8% of patients and overestimated the extent of disease in 1% of tumors. Notably, MRI was not included as a comparator [20]. An additional study looking at later stage (at least 2 cm) or higher risk (triple Imaging of Invasive Breast Cancer negative or other biomarkers of risk such as high Ki67 or HER2+) found that CT predicted the N stage correctly in 64 of 80 patients (80%, 95% CI,70.0%-87.3%), with a sensitivity of 61.5% (CI,45.9%-75.1%) and a specificity of 97.6% (CI, 87.4%-99.6%). Despite the higher specificity of CT, MRI has better performance to detect multicentric/multifocal disease and estimate final pathologic size. CT Chest, Abdomen, and Pelvis Without and With IV Contrast The majority of clinical questions for abdominal and/or pelvic CT can be appropriately answered with a single- phase study as detailed in the ACR-SABI-SPR practice parameter for the performance of CT of the abdomen and CT of the pelvis [21]. CT Chest, Abdomen, and Pelvis Without IV Contrast There is no evidence to support the use of CT chest, abdomen, and pelvis without IV contrast for determining locoregional disease and guiding surgical management in late-stage disease. Digital Breast Tomosynthesis Diagnostic Diagnostic mammography and US together can assess for extent of disease and tumor size. | 3186697 |
acrac_3186697_16 | Imaging of Invasive Breast Cancer | These imaging tests are usually already completed as part of the diagnostic workup (prior to pathological diagnosis). However, mammography is limited by breast density. In a prospective study of 111 consecutive women with newly diagnosed breast cancer, sensitivity of 2-D mammography for malignancy decreased from 100% in breasts that are almost entirely fatty to 45% in extremely dense breasts [22]. In addition, 2-D mammography was more sensitive than US in detecting DCIS and less sensitive at detecting ILC. DBT shows higher overall sensitivity, compared with 2-D mammography, with similar specificity. Overall sensitivity for DBT was 88.2% compared with 78.3% for 2-D mammography [23]. DBT also has a higher sensitivity for detecting multifocal, multicentric, and contralateral breast cancer [24,25]. The improved diagnostic performance of DBT over 2-D mammography was limited to women with nondense breasts in 1 study [24], but not others [25]. Due to patient positioning constraints, 2-D mammography and DBT have limited value for evaluating the axilla. In a single-institution retrospective study of 3,944 patients with breast cancer, mammography improved the sensitivity over US alone for distinguishing N0 to N1 from N2 and N3, but at a lower specificity [35]. After the ACOSOG Z0011 trial supported the omission of axillary lymph node dissection in women with <3 positive sentinel lymph nodes undergoing breast-conserving surgery and radiation therapy, some providers may request that radiologists not image the axilla in the setting of clinically node-negative disease [36]. Although axillary US is not recommended for every patient [37], axillary abnormality visible on mammography is still considered an appropriate indication for sonographic axillary evaluation. Also, when neoadjuvant chemotherapy is planned, the NCCN recommends consideration of axillary US, with marker placement if a biopsy is performed, in addition to mammography [126]. | Imaging of Invasive Breast Cancer. These imaging tests are usually already completed as part of the diagnostic workup (prior to pathological diagnosis). However, mammography is limited by breast density. In a prospective study of 111 consecutive women with newly diagnosed breast cancer, sensitivity of 2-D mammography for malignancy decreased from 100% in breasts that are almost entirely fatty to 45% in extremely dense breasts [22]. In addition, 2-D mammography was more sensitive than US in detecting DCIS and less sensitive at detecting ILC. DBT shows higher overall sensitivity, compared with 2-D mammography, with similar specificity. Overall sensitivity for DBT was 88.2% compared with 78.3% for 2-D mammography [23]. DBT also has a higher sensitivity for detecting multifocal, multicentric, and contralateral breast cancer [24,25]. The improved diagnostic performance of DBT over 2-D mammography was limited to women with nondense breasts in 1 study [24], but not others [25]. Due to patient positioning constraints, 2-D mammography and DBT have limited value for evaluating the axilla. In a single-institution retrospective study of 3,944 patients with breast cancer, mammography improved the sensitivity over US alone for distinguishing N0 to N1 from N2 and N3, but at a lower specificity [35]. After the ACOSOG Z0011 trial supported the omission of axillary lymph node dissection in women with <3 positive sentinel lymph nodes undergoing breast-conserving surgery and radiation therapy, some providers may request that radiologists not image the axilla in the setting of clinically node-negative disease [36]. Although axillary US is not recommended for every patient [37], axillary abnormality visible on mammography is still considered an appropriate indication for sonographic axillary evaluation. Also, when neoadjuvant chemotherapy is planned, the NCCN recommends consideration of axillary US, with marker placement if a biopsy is performed, in addition to mammography [126]. | 3186697 |
acrac_3186697_17 | Imaging of Invasive Breast Cancer | Mammography Diagnostic Diagnostic mammography and US together can assess for extent of disease and tumor size. These imaging tests are usually already completed as part of the diagnostic workup (prior to pathological diagnosis). However, mammography is limited by breast density. In a prospective study of 111 consecutive women with newly diagnosed breast cancer, the sensitivity of 2-D mammography for malignancy decreased from 100% in breasts that are almost entirely fatty to 45% in extremely dense breasts [22]. In addition, 2-D mammography was more sensitive in detecting DCIS and less sensitive, compared with US, in detecting ILC. DBT shows higher overall sensitivity, compared with 2-D mammography, with similar specificity. Overall sensitivity for DBT was 88.2% compared with 78.3% [23]. DBT has higher sensitivity for detecting multifocal, multicentric, and contralateral breast cancer than 2-D mammography alone [24,25]. The improved diagnostic performance of DBT over 2-D mammography in breast cancer staging was limited to women with nondense breasts in 1 study [24], but not others [25]. Due to patient positioning constraints, 2-D mammography and DBT have limited value for evaluating the axilla. In a single-institution retrospective study of 3,944 patients with breast cancer, mammography improved the sensitivity over US alone for distinguishing N0 to N1 from N2 and N3, but at a lower specificity [35]. After the ACOSOG Z0011 trial supported the omission of axillary lymph node dissection in women with <3 positive sentinel lymph nodes undergoing breast-conserving surgery and radiation therapy, some providers may request that radiologists not image the axilla in the setting of clinically node-negative disease [36]. When neoadjuvant chemotherapy is planned, the NCCN does recommend consideration of axillary US, with marker placement if a biopsy is performed, in addition to mammography [126]. | Imaging of Invasive Breast Cancer. Mammography Diagnostic Diagnostic mammography and US together can assess for extent of disease and tumor size. These imaging tests are usually already completed as part of the diagnostic workup (prior to pathological diagnosis). However, mammography is limited by breast density. In a prospective study of 111 consecutive women with newly diagnosed breast cancer, the sensitivity of 2-D mammography for malignancy decreased from 100% in breasts that are almost entirely fatty to 45% in extremely dense breasts [22]. In addition, 2-D mammography was more sensitive in detecting DCIS and less sensitive, compared with US, in detecting ILC. DBT shows higher overall sensitivity, compared with 2-D mammography, with similar specificity. Overall sensitivity for DBT was 88.2% compared with 78.3% [23]. DBT has higher sensitivity for detecting multifocal, multicentric, and contralateral breast cancer than 2-D mammography alone [24,25]. The improved diagnostic performance of DBT over 2-D mammography in breast cancer staging was limited to women with nondense breasts in 1 study [24], but not others [25]. Due to patient positioning constraints, 2-D mammography and DBT have limited value for evaluating the axilla. In a single-institution retrospective study of 3,944 patients with breast cancer, mammography improved the sensitivity over US alone for distinguishing N0 to N1 from N2 and N3, but at a lower specificity [35]. After the ACOSOG Z0011 trial supported the omission of axillary lymph node dissection in women with <3 positive sentinel lymph nodes undergoing breast-conserving surgery and radiation therapy, some providers may request that radiologists not image the axilla in the setting of clinically node-negative disease [36]. When neoadjuvant chemotherapy is planned, the NCCN does recommend consideration of axillary US, with marker placement if a biopsy is performed, in addition to mammography [126]. | 3186697 |
acrac_3186697_18 | Imaging of Invasive Breast Cancer | Mammography With IV Contrast Several retrospective studies have compared the sensitivity and specificity of CEM with conventional 2-D and 3-D mammography, US, and MRI. Overall, CEM and MRI are superior to DM and DM/DBT imaging [47]. The sensitivities between CEM and MRI are comparable, with some studies showing improved sensitivities with CEM Imaging of Invasive Breast Cancer [48], and some showing MRI to be superior [49,50]. Overall sensitivities ranged from 92% to 100% [16,49,51-53], including CEM detecting 92.3% of satellite masses and up to 100% of contralateral cancers [28]. CEM and MRI show similar abilities to estimate tumor size (r, 0.72-0.89 versus 0.65-0.84), but studies have shown improved PPV of CEM (52%-93%) compared with MRI (28-60%) [16,49,53]. Despite increased specificity over MR, limitations of contrast mammography in determining disease extent include evaluation of the axilla and other nodal groups as well as chest wall involvement [47], and there is evidence against using CEM to determine disease extent in lobular cancer, due to lower conspicuity [54]. MRI Breast Without and With IV Contrast MRI breast is useful for detecting additional cancers in the ipsilateral and contralateral breast [16,55], particularly in women with dense breasts [23,56,57]. A meta-analysis of 22 studies investigated MRI screening of the contralateral breast in women with newly diagnosed breast cancer. The study reported contralateral malignancies that were detected by MRI in 131 of 3,253 women. Thus, the summary estimate for incremental cancer detection rate was 4.1%. In studies in which pathologic tumor stage was reported, all but 2 tumors were in situ or stage I, and of those 2 tumors, 1 was a node-negative ILC (42 mm). Summary estimates were as follows: MRI-directed additional biopsy in 9.3% of women (95% CI, 5.8%-14.7%) with PPV for malignancy of 47.9% (95% CI, 31.8%- 64.6%). | Imaging of Invasive Breast Cancer. Mammography With IV Contrast Several retrospective studies have compared the sensitivity and specificity of CEM with conventional 2-D and 3-D mammography, US, and MRI. Overall, CEM and MRI are superior to DM and DM/DBT imaging [47]. The sensitivities between CEM and MRI are comparable, with some studies showing improved sensitivities with CEM Imaging of Invasive Breast Cancer [48], and some showing MRI to be superior [49,50]. Overall sensitivities ranged from 92% to 100% [16,49,51-53], including CEM detecting 92.3% of satellite masses and up to 100% of contralateral cancers [28]. CEM and MRI show similar abilities to estimate tumor size (r, 0.72-0.89 versus 0.65-0.84), but studies have shown improved PPV of CEM (52%-93%) compared with MRI (28-60%) [16,49,53]. Despite increased specificity over MR, limitations of contrast mammography in determining disease extent include evaluation of the axilla and other nodal groups as well as chest wall involvement [47], and there is evidence against using CEM to determine disease extent in lobular cancer, due to lower conspicuity [54]. MRI Breast Without and With IV Contrast MRI breast is useful for detecting additional cancers in the ipsilateral and contralateral breast [16,55], particularly in women with dense breasts [23,56,57]. A meta-analysis of 22 studies investigated MRI screening of the contralateral breast in women with newly diagnosed breast cancer. The study reported contralateral malignancies that were detected by MRI in 131 of 3,253 women. Thus, the summary estimate for incremental cancer detection rate was 4.1%. In studies in which pathologic tumor stage was reported, all but 2 tumors were in situ or stage I, and of those 2 tumors, 1 was a node-negative ILC (42 mm). Summary estimates were as follows: MRI-directed additional biopsy in 9.3% of women (95% CI, 5.8%-14.7%) with PPV for malignancy of 47.9% (95% CI, 31.8%- 64.6%). | 3186697 |
acrac_3186697_19 | Imaging of Invasive Breast Cancer | Where reported, 35.1% of MRI-detected cancers were DCIS (mean size = 6.9 mm) and 64.9% were invasive cancers (mean size = 9.3 mm) [58]. MRI can accurately assess tumor size for preoperative planning [50,59-61]. In a study involving 343 tumors, size measurements of cancers on breast MRI were within 5 mm of pathological size in 88% of patients [60]. Still, other studies using mastectomy specimens have shown that MRI underestimates primary tumor size in 21% and overestimates primary tumor size in 24% of cases. MRI also overestimated the number of invasive lesions by 19% and underestimated the number of invasive lesions in 28% in the same study [62]. These data underscore the importance of using biopsy to pathologically confirm MRI findings before using them to alter surgical planning, especially when the MRI finding is nonmass enhancement [63]. In addition to tumor size assessment, some studies show a reduction in re-excision after preoperative MRI [64-68]. For example, in a study of 991 women, preoperative MRI changed the surgical procedure in 25% (157/626) of cases. In 81% (127/157), MRI was beneficial for the patients, as otherwise occult carcinomas were removed (n = 122) or further biopsy could be prevented (n = 5) [67]. In this trial, the rate of mastectomy did not differ between patients undergoing preoperative MRI and those who did not. A recent multinational observational study at 27 centers also found that subjects receiving MR as part of routine clinical care had a significantly lower reoperation rate after breast conservation (8.5% versus 11.7%, P < . 001) [69]. However, other large multicenter studies, such as the COMICE trial, showed the addition of MRI to conventional imaging was not significantly associated with a reduced reoperation rate, with 153 (19%) needing reoperation in the MRI group versus 156 (19%) in the non-MRI group, (OR, 0.96; 95% CI, 0.75-1.24; P = . 77) [70]. | Imaging of Invasive Breast Cancer. Where reported, 35.1% of MRI-detected cancers were DCIS (mean size = 6.9 mm) and 64.9% were invasive cancers (mean size = 9.3 mm) [58]. MRI can accurately assess tumor size for preoperative planning [50,59-61]. In a study involving 343 tumors, size measurements of cancers on breast MRI were within 5 mm of pathological size in 88% of patients [60]. Still, other studies using mastectomy specimens have shown that MRI underestimates primary tumor size in 21% and overestimates primary tumor size in 24% of cases. MRI also overestimated the number of invasive lesions by 19% and underestimated the number of invasive lesions in 28% in the same study [62]. These data underscore the importance of using biopsy to pathologically confirm MRI findings before using them to alter surgical planning, especially when the MRI finding is nonmass enhancement [63]. In addition to tumor size assessment, some studies show a reduction in re-excision after preoperative MRI [64-68]. For example, in a study of 991 women, preoperative MRI changed the surgical procedure in 25% (157/626) of cases. In 81% (127/157), MRI was beneficial for the patients, as otherwise occult carcinomas were removed (n = 122) or further biopsy could be prevented (n = 5) [67]. In this trial, the rate of mastectomy did not differ between patients undergoing preoperative MRI and those who did not. A recent multinational observational study at 27 centers also found that subjects receiving MR as part of routine clinical care had a significantly lower reoperation rate after breast conservation (8.5% versus 11.7%, P < . 001) [69]. However, other large multicenter studies, such as the COMICE trial, showed the addition of MRI to conventional imaging was not significantly associated with a reduced reoperation rate, with 153 (19%) needing reoperation in the MRI group versus 156 (19%) in the non-MRI group, (OR, 0.96; 95% CI, 0.75-1.24; P = . 77) [70]. | 3186697 |
acrac_3186697_20 | Imaging of Invasive Breast Cancer | Although the findings are important, limitations from the COMICE trial are also noted, such as its inclusion of patients from several small centers where technical factors and varying degree of experience among interpreting radiologists could have influenced the MRI results. It is also not clear that the data from the MRI were incorporated into surgical planning, and nearly 7% of the group assigned to MRI did not actually have an MR interpreted (analyzed by intention to treat). When all breast cancer subtypes were included, a meta-analysis of 19 studies did not find evidence that MRI positively impacted the rates of re- excision, reoperation, or positive margins, and MRI was significantly associated with increased odds of receiving contralateral prophylactic mastectomy (OR, 1.91; 95% CI, 1.25-2.91; P = . 003) [71]. Primary analysis of 85,975 women also showed that preoperative MRI was associated with increased odds of receiving mastectomy (OR, 1.39; 95% CI, 1.23-1.57; P < . 001) [71]. Still, it is unknown whether some of the studies included in that meta-analysis had a bias in randomization (ie, women who were preplanned for mastectomies were more likely to have been referred rather than randomized to the preoperative MRI arm). As an example of this, in the multicenter international prospective analysis cited above [69], mastectomy was already planned based on conventional imaging in 22.4% (MRI group) versus 14.4% (no MRI group) P < . 001). The data are different for ILC histological subtypes. For ILC, there is strong evidence that MRI improves surgical outcomes [72-81]. In a study with 70 cases of ILC, preoperative MRI reduced re-excision rates, particularly in young women with dense breasts [82]. In another study with 369 women, preoperative breast MRI was also associated with a reduction in repeat surgery (OR, 0.140; P < . 001), without increasing mastectomy rates [76]. | Imaging of Invasive Breast Cancer. Although the findings are important, limitations from the COMICE trial are also noted, such as its inclusion of patients from several small centers where technical factors and varying degree of experience among interpreting radiologists could have influenced the MRI results. It is also not clear that the data from the MRI were incorporated into surgical planning, and nearly 7% of the group assigned to MRI did not actually have an MR interpreted (analyzed by intention to treat). When all breast cancer subtypes were included, a meta-analysis of 19 studies did not find evidence that MRI positively impacted the rates of re- excision, reoperation, or positive margins, and MRI was significantly associated with increased odds of receiving contralateral prophylactic mastectomy (OR, 1.91; 95% CI, 1.25-2.91; P = . 003) [71]. Primary analysis of 85,975 women also showed that preoperative MRI was associated with increased odds of receiving mastectomy (OR, 1.39; 95% CI, 1.23-1.57; P < . 001) [71]. Still, it is unknown whether some of the studies included in that meta-analysis had a bias in randomization (ie, women who were preplanned for mastectomies were more likely to have been referred rather than randomized to the preoperative MRI arm). As an example of this, in the multicenter international prospective analysis cited above [69], mastectomy was already planned based on conventional imaging in 22.4% (MRI group) versus 14.4% (no MRI group) P < . 001). The data are different for ILC histological subtypes. For ILC, there is strong evidence that MRI improves surgical outcomes [72-81]. In a study with 70 cases of ILC, preoperative MRI reduced re-excision rates, particularly in young women with dense breasts [82]. In another study with 369 women, preoperative breast MRI was also associated with a reduction in repeat surgery (OR, 0.140; P < . 001), without increasing mastectomy rates [76]. | 3186697 |
acrac_3186697_21 | Imaging of Invasive Breast Cancer | Imaging of Invasive Breast Cancer Still, there is no evidence that preoperative MRI leads to improved survival or decreased recurrence, including data from multicenter analyses [61,68,83-85]. In 3,180 affected breasts in 3,169 women (median age, 56.2 years), 8-year disease-free survival did not differ between the MRI (97%) and the non-MRI (95%) groups (P = . 87), and the multivariable model showed no significant effect of MRI on disease-free survival: HR for MRI (versus non-MRI) was 0.88 (95% CI, 0.52-1.51; P = . 65); age, margin status, and tumor grade were associated with disease-free survival (all P < . 05) [85]. Of the 31,756 patients included in a survival cohort (70% non-MRI and 30% MRI), breast MRI was not significantly associated with overall survival (HR, 0.91; 95% CI, 0.74-1.11, P = . 35) or with disease-free survival (HR, 1.16; 95% CI, 0.81-1.67), even among the different histological subtypes. The lack of survival benefit extends also to patients with ILC, despite improved surgical outcomes in this population as described above [83]. Given these data, benefits of preoperative MRI for additional cancer detection or delineating extent of disease should be balanced with the possibility of a false-positive diagnosis leading to additional biopsy or unnecessary additional imaging. MRI Breast Without IV Contrast There is no evidence to support the use of noncontrast breast MRI in evaluating extent of disease. US is the most established noninvasive imaging test for assessing the axilla following a clinically or imaging detected suspicious lymph node. US features associated with a higher likelihood of malignancy include short-axis lymph node size >1 cm, cortical thickness of >0.3 cm, and absence of a fatty hilum [90-93]. There is a wide range of reported sensitivity and specificity for axillary US, and none of these imaging features are specific enough to avoid the need for histologic sampling. | Imaging of Invasive Breast Cancer. Imaging of Invasive Breast Cancer Still, there is no evidence that preoperative MRI leads to improved survival or decreased recurrence, including data from multicenter analyses [61,68,83-85]. In 3,180 affected breasts in 3,169 women (median age, 56.2 years), 8-year disease-free survival did not differ between the MRI (97%) and the non-MRI (95%) groups (P = . 87), and the multivariable model showed no significant effect of MRI on disease-free survival: HR for MRI (versus non-MRI) was 0.88 (95% CI, 0.52-1.51; P = . 65); age, margin status, and tumor grade were associated with disease-free survival (all P < . 05) [85]. Of the 31,756 patients included in a survival cohort (70% non-MRI and 30% MRI), breast MRI was not significantly associated with overall survival (HR, 0.91; 95% CI, 0.74-1.11, P = . 35) or with disease-free survival (HR, 1.16; 95% CI, 0.81-1.67), even among the different histological subtypes. The lack of survival benefit extends also to patients with ILC, despite improved surgical outcomes in this population as described above [83]. Given these data, benefits of preoperative MRI for additional cancer detection or delineating extent of disease should be balanced with the possibility of a false-positive diagnosis leading to additional biopsy or unnecessary additional imaging. MRI Breast Without IV Contrast There is no evidence to support the use of noncontrast breast MRI in evaluating extent of disease. US is the most established noninvasive imaging test for assessing the axilla following a clinically or imaging detected suspicious lymph node. US features associated with a higher likelihood of malignancy include short-axis lymph node size >1 cm, cortical thickness of >0.3 cm, and absence of a fatty hilum [90-93]. There is a wide range of reported sensitivity and specificity for axillary US, and none of these imaging features are specific enough to avoid the need for histologic sampling. | 3186697 |
acrac_3186697_22 | Imaging of Invasive Breast Cancer | The sensitivity ranges from 26.4% to 94%, and the specificity ranges from 53% to 98% [94-97]. Although axillary US alone has a relatively low NPV to rule out metastatic disease [36,98], axillary imaging is significantly more likely to identify metastatic disease in patients with pN2-3 disease compared with low volume burden (ie, those eligible for axillary preservation according to the Z0011 trial). Therefore, detection of nodal disease can help identify patients who would benefit from neoadjuvant systemic therapy to help downstage and de-escalate their axillary surgery and avoid axillary lymph node dissection. However, imaging is less sensitive in detecting invasive lobular cancer metastasis compared with ductal type [140]. A meta-analysis of 21 studies showed that US combined with needle biopsy improved the sensitivity from 61% to 79% [99-101]. US- guided core needle biopsy was superior to US-guided FNA in a meta-analysis of 1,353 patients with newly diagnosed invasive breast carcinoma, with a reported sensitivity of 88% for core biopsy and 74% for FNA [102]. Axillary US and an MRI performed similarly at evaluating axillary lymph nodes in an additional study [103]. In a meta-analysis of 9,232 cases of preoperative axillary staging procedures in 9,212 patients with breast cancer, preoperative axillary US-guided biopsy was able to identify approximately 50% of women with axillary involvement, but the false-negative rate was 25% [141]. An additional meta-analysis reported similar findings [100]. The NCCN does recommend consideration of axillary US, with marker placement if biopsy is performed, prior to preoperative systemic therapy [126]. US Breast Diagnostic mammography and US together can assess for extent of disease and tumor size. These imaging tests are usually already completed as part of the diagnostic workup (prior to pathological diagnosis). The sensitivity of US for detecting cancer ranges from 79% to 94% [22,25,104,105]. | Imaging of Invasive Breast Cancer. The sensitivity ranges from 26.4% to 94%, and the specificity ranges from 53% to 98% [94-97]. Although axillary US alone has a relatively low NPV to rule out metastatic disease [36,98], axillary imaging is significantly more likely to identify metastatic disease in patients with pN2-3 disease compared with low volume burden (ie, those eligible for axillary preservation according to the Z0011 trial). Therefore, detection of nodal disease can help identify patients who would benefit from neoadjuvant systemic therapy to help downstage and de-escalate their axillary surgery and avoid axillary lymph node dissection. However, imaging is less sensitive in detecting invasive lobular cancer metastasis compared with ductal type [140]. A meta-analysis of 21 studies showed that US combined with needle biopsy improved the sensitivity from 61% to 79% [99-101]. US- guided core needle biopsy was superior to US-guided FNA in a meta-analysis of 1,353 patients with newly diagnosed invasive breast carcinoma, with a reported sensitivity of 88% for core biopsy and 74% for FNA [102]. Axillary US and an MRI performed similarly at evaluating axillary lymph nodes in an additional study [103]. In a meta-analysis of 9,232 cases of preoperative axillary staging procedures in 9,212 patients with breast cancer, preoperative axillary US-guided biopsy was able to identify approximately 50% of women with axillary involvement, but the false-negative rate was 25% [141]. An additional meta-analysis reported similar findings [100]. The NCCN does recommend consideration of axillary US, with marker placement if biopsy is performed, prior to preoperative systemic therapy [126]. US Breast Diagnostic mammography and US together can assess for extent of disease and tumor size. These imaging tests are usually already completed as part of the diagnostic workup (prior to pathological diagnosis). The sensitivity of US for detecting cancer ranges from 79% to 94% [22,25,104,105]. | 3186697 |
acrac_3186697_23 | Imaging of Invasive Breast Cancer | The addition of DBT to US improved sensitivity for detecting both primary breast cancer and multicentric and multifocal disease, from 82.6% (nondense) and 91.6% (dense) with US alone to 97.7% with combined DBT and US [106]. However, DBT and mammography have limited added value over US alone for initial evaluation in women <40 years of age [105]. Although bilateral US use in women with primary breast cancer to evaluate for multicentric and multifocal disease shows lower sensitivity to MRI (85.1% versus 71.1%), US showed higher accuracy and specificity than MRI (67.6% versus 39.3% and 69.2% versus 60.2%, respectively), suggesting that bilateral US may be an acceptable alternative to MRI for locoregional staging [57]. When compared with DM alone, supplemental US more accurately depicted extent of disease needing wider excision in 17 of 96 (18%) breasts for which conservation was anticipated, corresponding to 17 of 30 (57%) breasts with mammographically occult disease [22]. Based on mammography/clinical examination, 2% to 3% of Imaging of Invasive Breast Cancer patients have synchronous bilateral cancer [107]. This risk of synchronous bilateral malignancy is increased for patients less than 55 years of age or those with diagnosis of invasive lobular subtype [108]. In 1 series with 9% contralateral synchronous malignancy, mammography detected 60%, US detected 80%, and MRI detected 90% (with the remainder detected on follow-up imaging) [22]. In addition to its role in the initial diagnostic workup, US is important in the secondary evaluation of a suspicious finding on MRI in the setting of evaluation for disease extent. US sensitivity and NPV are higher than DBT [109]. Compared with DBT, US showed a lower specificity (98.1% versus 78.9%) and a similar PPV (66.7% versus 52.2%). | Imaging of Invasive Breast Cancer. The addition of DBT to US improved sensitivity for detecting both primary breast cancer and multicentric and multifocal disease, from 82.6% (nondense) and 91.6% (dense) with US alone to 97.7% with combined DBT and US [106]. However, DBT and mammography have limited added value over US alone for initial evaluation in women <40 years of age [105]. Although bilateral US use in women with primary breast cancer to evaluate for multicentric and multifocal disease shows lower sensitivity to MRI (85.1% versus 71.1%), US showed higher accuracy and specificity than MRI (67.6% versus 39.3% and 69.2% versus 60.2%, respectively), suggesting that bilateral US may be an acceptable alternative to MRI for locoregional staging [57]. When compared with DM alone, supplemental US more accurately depicted extent of disease needing wider excision in 17 of 96 (18%) breasts for which conservation was anticipated, corresponding to 17 of 30 (57%) breasts with mammographically occult disease [22]. Based on mammography/clinical examination, 2% to 3% of Imaging of Invasive Breast Cancer patients have synchronous bilateral cancer [107]. This risk of synchronous bilateral malignancy is increased for patients less than 55 years of age or those with diagnosis of invasive lobular subtype [108]. In 1 series with 9% contralateral synchronous malignancy, mammography detected 60%, US detected 80%, and MRI detected 90% (with the remainder detected on follow-up imaging) [22]. In addition to its role in the initial diagnostic workup, US is important in the secondary evaluation of a suspicious finding on MRI in the setting of evaluation for disease extent. US sensitivity and NPV are higher than DBT [109]. Compared with DBT, US showed a lower specificity (98.1% versus 78.9%) and a similar PPV (66.7% versus 52.2%). | 3186697 |
acrac_3186697_24 | Imaging of Invasive Breast Cancer | However, a meta-analysis of second-look US following a suspicious finding on MRI showed heterogeneity in US performance, with the detection rate ranging from 22.6% to 82.1% (pooled detection rate 57.5%) and an 87.8% pooled NPV [110]. Therefore, a negative US is insufficient to obviate the need for an MRI biopsy in this setting. There is no evidence supporting US as an accurate method for determining disease extent in those diagnosed with the ILC subtype. Conventional imaging with mammography and/or US can significantly underestimate the span of ILC [26,111-114]. For example, US specifically underestimated ILC tumor size by 27% (95% CI, 17%-37%) in a study [113], and a different study showed that the greatest discrepancy between tumor size and pathologic size using US measurements was for those with the ILC subtype [26]. Variant 4: Newly diagnosed. Clinical stage IIB-III (late stage) breast cancer at presentation. Evaluation for distant disease. IDC or ILC that is ER+/HER2-. It has long been recognized that steroid receptor expression reflects intrinsic biologic diversity in breast cancer with treatment and survival implications, also determining patterns of metastatic spread. The specific response patterns and outcomes associated with ER/PR/HER2 status occur despite the known limitation of pathologic sampling and receptor expression heterogeneity [142]. Historically, bone is the most likely site of breast cancer metastases (51%), followed by liver/soft tissue (19%), pleura (16%), lung (14%), and brain (4%) [115]. The higher percentage of bone metastases from breast cancer appears to be driven primarily by the majority of primary tumors expressing ER and/or PR. In 1 large multidecade study, 82% of patients with breast cancer who developed bone metastases had either ER and PR or ER positivity in the primary tumor [115]. | Imaging of Invasive Breast Cancer. However, a meta-analysis of second-look US following a suspicious finding on MRI showed heterogeneity in US performance, with the detection rate ranging from 22.6% to 82.1% (pooled detection rate 57.5%) and an 87.8% pooled NPV [110]. Therefore, a negative US is insufficient to obviate the need for an MRI biopsy in this setting. There is no evidence supporting US as an accurate method for determining disease extent in those diagnosed with the ILC subtype. Conventional imaging with mammography and/or US can significantly underestimate the span of ILC [26,111-114]. For example, US specifically underestimated ILC tumor size by 27% (95% CI, 17%-37%) in a study [113], and a different study showed that the greatest discrepancy between tumor size and pathologic size using US measurements was for those with the ILC subtype [26]. Variant 4: Newly diagnosed. Clinical stage IIB-III (late stage) breast cancer at presentation. Evaluation for distant disease. IDC or ILC that is ER+/HER2-. It has long been recognized that steroid receptor expression reflects intrinsic biologic diversity in breast cancer with treatment and survival implications, also determining patterns of metastatic spread. The specific response patterns and outcomes associated with ER/PR/HER2 status occur despite the known limitation of pathologic sampling and receptor expression heterogeneity [142]. Historically, bone is the most likely site of breast cancer metastases (51%), followed by liver/soft tissue (19%), pleura (16%), lung (14%), and brain (4%) [115]. The higher percentage of bone metastases from breast cancer appears to be driven primarily by the majority of primary tumors expressing ER and/or PR. In 1 large multidecade study, 82% of patients with breast cancer who developed bone metastases had either ER and PR or ER positivity in the primary tumor [115]. | 3186697 |
acrac_3186697_25 | Imaging of Invasive Breast Cancer | A landmark study 2 decades ago transformed our field by discovering 5 distinct composite molecular portraits using quantitative analysis of breast cancer gene expression patterns; luminal A, luminal B, HER2-enriched, basal-like, and normal-like, providing a new type of disease characterization [116]. The molecular subtypes were linked to pattern and type of metastatic spread, as well as disease-specific survival [117,118]. For example, luminal cancers have a propensity to give rise first to bone metastases, HER2-enriched cancers to liver and lung metastases, and basal type cancers to liver and brain metastases [119,120]. These molecular subtypes share similarities with ER/PR expression and HER2 gene amplification but are not synonymous. Luminal subtypes more commonly have ER expression, HER2-enriched cancers more commonly exhibit HER2 expression, and triple-negative breast cancers are most often the basal breast cancer subtype. Although luminal subtypes have significantly better overall and relapse-free survival [118], they carry a long-term risk of recurrence, especially to bone, whereas basal and HER2 subtypes have a higher rate of recurrence in the first 4 years [121], which can be considered when planning frequency and type of surveillance imaging. Bone Scan Whole Body Bone is the most common site for breast cancer metastasis; up to 70% of women with stage IV disease have bone metastasis, with the predilection for bone metastases not applying to basal-like tumors [117]. Up to 13.6% of women diagnosed with early stage breast cancer will develop bone metastasis within 15 years of diagnosis [122], even if the parent tumor is low grade [123]. Tc-99m bone scans detect early bone metastasis because of the new bone formation occurring at these sites [124] and have a 98% sensitivity for detecting early bone metastasis in symptomatic patients. | Imaging of Invasive Breast Cancer. A landmark study 2 decades ago transformed our field by discovering 5 distinct composite molecular portraits using quantitative analysis of breast cancer gene expression patterns; luminal A, luminal B, HER2-enriched, basal-like, and normal-like, providing a new type of disease characterization [116]. The molecular subtypes were linked to pattern and type of metastatic spread, as well as disease-specific survival [117,118]. For example, luminal cancers have a propensity to give rise first to bone metastases, HER2-enriched cancers to liver and lung metastases, and basal type cancers to liver and brain metastases [119,120]. These molecular subtypes share similarities with ER/PR expression and HER2 gene amplification but are not synonymous. Luminal subtypes more commonly have ER expression, HER2-enriched cancers more commonly exhibit HER2 expression, and triple-negative breast cancers are most often the basal breast cancer subtype. Although luminal subtypes have significantly better overall and relapse-free survival [118], they carry a long-term risk of recurrence, especially to bone, whereas basal and HER2 subtypes have a higher rate of recurrence in the first 4 years [121], which can be considered when planning frequency and type of surveillance imaging. Bone Scan Whole Body Bone is the most common site for breast cancer metastasis; up to 70% of women with stage IV disease have bone metastasis, with the predilection for bone metastases not applying to basal-like tumors [117]. Up to 13.6% of women diagnosed with early stage breast cancer will develop bone metastasis within 15 years of diagnosis [122], even if the parent tumor is low grade [123]. Tc-99m bone scans detect early bone metastasis because of the new bone formation occurring at these sites [124] and have a 98% sensitivity for detecting early bone metastasis in symptomatic patients. | 3186697 |
acrac_3186697_26 | Imaging of Invasive Breast Cancer | The sensitivity of whole body bone scans for detecting bone metastases in patients with late-stage breast cancer ranges from 62% to 100%, regardless of tumor subtype [143]. Studies using bone scans to stage women with late- stage disease have shown the prevalence of osseous metastases ranging from 4.7% to 45% [144]. A study by Chu et al [145] on 256 women with N2/N3 disease showed a metastatic workup for asymptomatic patients was only indicated with T3 or T4 primary lesions. For patients with T0, T1, and T2 diseases, the incidence of stage IV disease was 0%, 0%, and 6%, respectively. The incidence increased with higher T stage; 22% for T3 and 36% for T4 tumors. Imaging of Invasive Breast Cancer Several studies comparing bone scan performance with CT and PET have been performed in women presenting with late-stage disease [144]. Some studies have shown up to 17.1% of women with extraosseous metastasis on CT had negative or inconclusive bone scans. One of the benefits of whole body bone scans is the detection of metastasis in the peripheral skeleton, areas not included by CT chest, abdomen, and pelvis with IV contrast. However, the presence of peripheral metastasis almost always (>99%) occurs in the context of extraosseous or central osseous metastasis, and detection of additional peripheral metastases does not typically result in a change in management [144,146]. CT Chest, Abdomen, and Pelvis With IV Contrast Correctly identifying the stage of breast cancer prior to surgery has important prognostic implications, because survival decreases as stage increases [145]. In a study of 1,329 patents with breast cancer, metastatic disease of any type was identified by imaging between 15% to 16% and 22% to 36% based on N2/3 and T3/4 status, respectively [145]. | Imaging of Invasive Breast Cancer. The sensitivity of whole body bone scans for detecting bone metastases in patients with late-stage breast cancer ranges from 62% to 100%, regardless of tumor subtype [143]. Studies using bone scans to stage women with late- stage disease have shown the prevalence of osseous metastases ranging from 4.7% to 45% [144]. A study by Chu et al [145] on 256 women with N2/N3 disease showed a metastatic workup for asymptomatic patients was only indicated with T3 or T4 primary lesions. For patients with T0, T1, and T2 diseases, the incidence of stage IV disease was 0%, 0%, and 6%, respectively. The incidence increased with higher T stage; 22% for T3 and 36% for T4 tumors. Imaging of Invasive Breast Cancer Several studies comparing bone scan performance with CT and PET have been performed in women presenting with late-stage disease [144]. Some studies have shown up to 17.1% of women with extraosseous metastasis on CT had negative or inconclusive bone scans. One of the benefits of whole body bone scans is the detection of metastasis in the peripheral skeleton, areas not included by CT chest, abdomen, and pelvis with IV contrast. However, the presence of peripheral metastasis almost always (>99%) occurs in the context of extraosseous or central osseous metastasis, and detection of additional peripheral metastases does not typically result in a change in management [144,146]. CT Chest, Abdomen, and Pelvis With IV Contrast Correctly identifying the stage of breast cancer prior to surgery has important prognostic implications, because survival decreases as stage increases [145]. In a study of 1,329 patents with breast cancer, metastatic disease of any type was identified by imaging between 15% to 16% and 22% to 36% based on N2/3 and T3/4 status, respectively [145]. | 3186697 |
acrac_3186697_27 | Imaging of Invasive Breast Cancer | NCCN guidelines recommend chest, abdomen, and pelvic CT as an additional test prior to preoperative systemic therapy to evaluate for distant disease if the tumor size is >2 cm (T2) or there are positive lymph nodes, or the tumor size is >1 cm (T1c) and HER2+, or there is triple-negative disease [126]. In asymptomatic women with late-stage breast cancer, metastatic disease to the thorax is identified in 5% to 9% of patients [17,132,147]. The false-positive rate requiring additional imaging studies for further evaluation or follow-up ranged from 10% to 33% [17,132,148]. CT Chest, Abdomen, and Pelvis Without and With IV Contrast The majority of clinical questions for abdominal and/or pelvic CT can be appropriately answered with a single- phase study as detailed in the ACR-SABI-SPR practice parameter for the performance of CT of the abdomen and CT of the pelvis [21]. CT Chest, Abdomen, and Pelvis Without IV Contrast There is no evidence to support the use of CT chest, abdomen, and pelvis without IV contrast. Chest CT without IV contrast is often used to evaluate for metastatic disease to the lung. In asymptomatic women with late-stage breast cancer, metastatic disease to the thorax is identified in 5% to 9% of patients [17,132,147]. The false-positive rate requiring additional imaging studies for further evaluation or follow-up ranged from 10% to 33% [17,132,148]. Digital Breast Tomosynthesis Diagnostic There is no evidence to support the use of DBT to evaluate for distant disease. FDG-PET/CT Skull Base to Mid-Thigh There is a large body of evidence that FDG-PET/CT is useful to detect metastatic disease in stage IIB to III breast cancer [136-139,149-158]. This is important because patients with locoregional breast malignancy have 5-year survival rates of 76% to 99%, but for patients with distant metastases, 5-year survival rates decreases to 20% to 28% [159]. | Imaging of Invasive Breast Cancer. NCCN guidelines recommend chest, abdomen, and pelvic CT as an additional test prior to preoperative systemic therapy to evaluate for distant disease if the tumor size is >2 cm (T2) or there are positive lymph nodes, or the tumor size is >1 cm (T1c) and HER2+, or there is triple-negative disease [126]. In asymptomatic women with late-stage breast cancer, metastatic disease to the thorax is identified in 5% to 9% of patients [17,132,147]. The false-positive rate requiring additional imaging studies for further evaluation or follow-up ranged from 10% to 33% [17,132,148]. CT Chest, Abdomen, and Pelvis Without and With IV Contrast The majority of clinical questions for abdominal and/or pelvic CT can be appropriately answered with a single- phase study as detailed in the ACR-SABI-SPR practice parameter for the performance of CT of the abdomen and CT of the pelvis [21]. CT Chest, Abdomen, and Pelvis Without IV Contrast There is no evidence to support the use of CT chest, abdomen, and pelvis without IV contrast. Chest CT without IV contrast is often used to evaluate for metastatic disease to the lung. In asymptomatic women with late-stage breast cancer, metastatic disease to the thorax is identified in 5% to 9% of patients [17,132,147]. The false-positive rate requiring additional imaging studies for further evaluation or follow-up ranged from 10% to 33% [17,132,148]. Digital Breast Tomosynthesis Diagnostic There is no evidence to support the use of DBT to evaluate for distant disease. FDG-PET/CT Skull Base to Mid-Thigh There is a large body of evidence that FDG-PET/CT is useful to detect metastatic disease in stage IIB to III breast cancer [136-139,149-158]. This is important because patients with locoregional breast malignancy have 5-year survival rates of 76% to 99%, but for patients with distant metastases, 5-year survival rates decreases to 20% to 28% [159]. | 3186697 |
acrac_3186697_28 | Imaging of Invasive Breast Cancer | The sensitivity, specificity, PPV, NPV, and accuracy of PET/CT in identifying metastatic disease in this population are 100%, 96%, 80%, 100%, and 97%, respectively [41]. The false-positive rate of PET/CT was 19%. In comparison with CT and other modalities, 80% of patients with distant disease had the metastases exclusively identified on PET/CT [41]. Groheux et al [136] investigated 254 patients and found previously unknown metastases in 1 of 44 (2%) women with stage IIA breast cancer, 6 of 56 (11%) women with stage IIB cancer, 11 of 63 (18%) women with stage IIIA cancer, 27 of 74 (37%) women with stage IIIB cancer, and 8 of 17 (47%) women with stage IIIC cancer. PET/CT has especially high yields in patients newly diagnosed at <40 years of age, revealing distant metastases in 17% of asymptomatic stage IIB [155]. PET/CT modified staging between 14% and 28% of patients with late-stage disease, regardless of tumor receptor status [138,139]. In a study of 163 women, PET/CT and whole body bone scan demonstrated concordance in identifying osseous metastases in 81% of cases. Also, PET/CT had the added benefit of detecting extraosseous metastasis in 62% of patients with osseous metastasis. Of those patients with extraosseous metastases, 6% had equivocal and 42% had negative bone scans [160]. The sensitivity and specificity for PET/CT in the detection of distant metastases is higher than conventional imaging, with a 97% sensitivity and 91% specificity versus an 86% sensitivity and 67% specificity (P = . 009 and P < . 001, respectively) [161]. However, PET/CT has limited sensitivity for ILC [162]. NCCN guidelines recommend FDG-PET/CT as an optional additional test prior to preoperative systemic therapy to evaluate for distant disease if the tumor size is >2 cm (T2) or there are positive lymph nodes, or the tumor size is >1 cm (T1c) and HER2+, or there is triple-negative disease [126]. | Imaging of Invasive Breast Cancer. The sensitivity, specificity, PPV, NPV, and accuracy of PET/CT in identifying metastatic disease in this population are 100%, 96%, 80%, 100%, and 97%, respectively [41]. The false-positive rate of PET/CT was 19%. In comparison with CT and other modalities, 80% of patients with distant disease had the metastases exclusively identified on PET/CT [41]. Groheux et al [136] investigated 254 patients and found previously unknown metastases in 1 of 44 (2%) women with stage IIA breast cancer, 6 of 56 (11%) women with stage IIB cancer, 11 of 63 (18%) women with stage IIIA cancer, 27 of 74 (37%) women with stage IIIB cancer, and 8 of 17 (47%) women with stage IIIC cancer. PET/CT has especially high yields in patients newly diagnosed at <40 years of age, revealing distant metastases in 17% of asymptomatic stage IIB [155]. PET/CT modified staging between 14% and 28% of patients with late-stage disease, regardless of tumor receptor status [138,139]. In a study of 163 women, PET/CT and whole body bone scan demonstrated concordance in identifying osseous metastases in 81% of cases. Also, PET/CT had the added benefit of detecting extraosseous metastasis in 62% of patients with osseous metastasis. Of those patients with extraosseous metastases, 6% had equivocal and 42% had negative bone scans [160]. The sensitivity and specificity for PET/CT in the detection of distant metastases is higher than conventional imaging, with a 97% sensitivity and 91% specificity versus an 86% sensitivity and 67% specificity (P = . 009 and P < . 001, respectively) [161]. However, PET/CT has limited sensitivity for ILC [162]. NCCN guidelines recommend FDG-PET/CT as an optional additional test prior to preoperative systemic therapy to evaluate for distant disease if the tumor size is >2 cm (T2) or there are positive lymph nodes, or the tumor size is >1 cm (T1c) and HER2+, or there is triple-negative disease [126]. | 3186697 |
acrac_3186697_29 | Imaging of Invasive Breast Cancer | Mammography Diagnostic There is no evidence to support the use of diagnostic mammography to evaluate for distant disease. Imaging of Invasive Breast Cancer Mammography With IV Contrast There is no evidence to support the use of mammography with IV contrast to evaluate distant disease. MRI Breast Without and With IV Contrast There is no evidence to support the use of MRI breast without and with IV contrast to evaluate for distant disease. MRI Breast Without IV Contrast There is no evidence to support the use of noncontrast breast MRI in evaluating extent of disease. US Axilla There is no evidence to support the use of US axilla to evaluate for distant disease. US Breast There is no evidence to support the use of US breast to evaluate for distant disease. Variant 5: Newly diagnosed. Clinical stage IIB-III (late stage) breast cancer at presentation. Evaluation for distant disease. IDC or ILC that is HER2+ or triple negative (ER, PR, and HER2-). It has long been recognized that steroid receptor expression reflects intrinsic biologic diversity in breast cancer with treatment and survival implications, also determining patterns of metastatic spread. The specific response patterns and outcomes associated with ER/PR/HER2 status occur despite the known limitation of pathologic sampling and receptor expression heterogeneity [142]. Historically, bone is the most likely site of breast cancer metastases (51%), followed by liver/soft tissue (19%), pleura (16%), lung (14%), and brain (4%) [115]. The higher percentage of bone metastases from breast cancer appears to be driven primarily by the majority of primary tumors expressing ER and/or PR. In 1 large multidecade study, 82% of patients with breast cancer who developed bone metastases had either ER and PR or ER positivity in the primary tumor [115]. | Imaging of Invasive Breast Cancer. Mammography Diagnostic There is no evidence to support the use of diagnostic mammography to evaluate for distant disease. Imaging of Invasive Breast Cancer Mammography With IV Contrast There is no evidence to support the use of mammography with IV contrast to evaluate distant disease. MRI Breast Without and With IV Contrast There is no evidence to support the use of MRI breast without and with IV contrast to evaluate for distant disease. MRI Breast Without IV Contrast There is no evidence to support the use of noncontrast breast MRI in evaluating extent of disease. US Axilla There is no evidence to support the use of US axilla to evaluate for distant disease. US Breast There is no evidence to support the use of US breast to evaluate for distant disease. Variant 5: Newly diagnosed. Clinical stage IIB-III (late stage) breast cancer at presentation. Evaluation for distant disease. IDC or ILC that is HER2+ or triple negative (ER, PR, and HER2-). It has long been recognized that steroid receptor expression reflects intrinsic biologic diversity in breast cancer with treatment and survival implications, also determining patterns of metastatic spread. The specific response patterns and outcomes associated with ER/PR/HER2 status occur despite the known limitation of pathologic sampling and receptor expression heterogeneity [142]. Historically, bone is the most likely site of breast cancer metastases (51%), followed by liver/soft tissue (19%), pleura (16%), lung (14%), and brain (4%) [115]. The higher percentage of bone metastases from breast cancer appears to be driven primarily by the majority of primary tumors expressing ER and/or PR. In 1 large multidecade study, 82% of patients with breast cancer who developed bone metastases had either ER and PR or ER positivity in the primary tumor [115]. | 3186697 |
acrac_3186697_30 | Imaging of Invasive Breast Cancer | A landmark study 2 decades ago transformed our field by discovering 5 distinct composite molecular portraits using quantitative analysis of breast cancer gene expression patterns; luminal A, luminal B, HER2-enriched, basal-like, and normal-like, providing a new type of disease characterization [116]. The molecular subtypes were linked to pattern and type of metastatic spread, as well as disease-specific survival [117,118]. For example, luminal cancers have a propensity to give rise first to bone metastases, HER2-enriched cancers to liver and lung metastases, and basal type cancers to liver and brain metastases [119,120]. These molecular subtypes share similarities with ER/PR expression and HER2 gene amplification but are not synonymous. Luminal subtypes more commonly have ER expression, HER2-enriched cancers more commonly exhibit HER2 expression, and triple-negative breast cancers are most often the basal breast cancer subtype. Although luminal subtypes have significantly better overall and relapse-free survival [118], they carry a long-term risk of recurrence, especially to bone, where basal and HER2 subtypes have a higher rate of recurrence in the first 4 years [121], which can be considered when planning frequency and type of surveillance imaging. Bone Scan Whole Body Bone is the most common site for breast cancer metastasis; up to 70% of women with stage IV disease have bone metastasis, with the predilection for bone metastases not applying to basal-like tumors [117]. Up to 13.6% of women diagnosed with early stage breast cancer will develop bone metastasis within 15 years of diagnosis [122], even if the parent tumor is low grade [123]. Tc-99m bone scans detect early bone metastasis because of the new bone formation occurring at these sites [124] and have a 98% sensitivity for detecting early bone metastasis in symptomatic patients. | Imaging of Invasive Breast Cancer. A landmark study 2 decades ago transformed our field by discovering 5 distinct composite molecular portraits using quantitative analysis of breast cancer gene expression patterns; luminal A, luminal B, HER2-enriched, basal-like, and normal-like, providing a new type of disease characterization [116]. The molecular subtypes were linked to pattern and type of metastatic spread, as well as disease-specific survival [117,118]. For example, luminal cancers have a propensity to give rise first to bone metastases, HER2-enriched cancers to liver and lung metastases, and basal type cancers to liver and brain metastases [119,120]. These molecular subtypes share similarities with ER/PR expression and HER2 gene amplification but are not synonymous. Luminal subtypes more commonly have ER expression, HER2-enriched cancers more commonly exhibit HER2 expression, and triple-negative breast cancers are most often the basal breast cancer subtype. Although luminal subtypes have significantly better overall and relapse-free survival [118], they carry a long-term risk of recurrence, especially to bone, where basal and HER2 subtypes have a higher rate of recurrence in the first 4 years [121], which can be considered when planning frequency and type of surveillance imaging. Bone Scan Whole Body Bone is the most common site for breast cancer metastasis; up to 70% of women with stage IV disease have bone metastasis, with the predilection for bone metastases not applying to basal-like tumors [117]. Up to 13.6% of women diagnosed with early stage breast cancer will develop bone metastasis within 15 years of diagnosis [122], even if the parent tumor is low grade [123]. Tc-99m bone scans detect early bone metastasis because of the new bone formation occurring at these sites [124] and have a 98% sensitivity for detecting early bone metastasis in symptomatic patients. | 3186697 |
acrac_3186697_31 | Imaging of Invasive Breast Cancer | The sensitivity of whole body bone scans for detecting bone metastases in patients with late-stage breast cancer ranges from 62% to 100%, regardless of tumor subtype [143]. Studies using bone scans to stage women with late- stage disease have shown the prevalence of osseous metastases ranging from 4.7% to 45% [144]. A study by Chu et al [145] on 256 women with N2/N3 disease showed a metastatic workup for asymptomatic patients was only indicated with T3 or T4 primary lesions. For patients with T0, T1, and T2 diseases, the incidence of stage IV disease was 0%, 0%, and 6%, respectively. The incidence increased with higher T stage; 22% for T3 and 36% for T4 tumors. Several studies comparing bone scan performance with CT and PET have been performed in women presenting with late-stage disease [144]. Some studies have shown up to 17.1% of women with extraosseous metastasis on CT had negative or inconclusive bone scans [144]. One of the benefits of whole body bone scans is the detection of metastasis in the peripheral skeleton, areas not included by CT chest, abdomen, and pelvis with IV contrast. Imaging of Invasive Breast Cancer However, the presence of peripheral metastasis almost always (>99%) occurs in the context of extraosseous or central osseous metastasis, and detection of additional peripheral metastases does not typically result in a change in management [144,146]. CT Chest, Abdomen, and Pelvis With IV Contrast Correctly identifying the stage of breast cancer prior to surgery has important prognostic implications, because survival decreases as stage increases [145]. In a study of 1,329 patents with breast cancer, metastatic disease of any type was identified by imaging between 15% to 16% and 22% to 36% based on N2/3 and T3/4 status, respectively [145]. | Imaging of Invasive Breast Cancer. The sensitivity of whole body bone scans for detecting bone metastases in patients with late-stage breast cancer ranges from 62% to 100%, regardless of tumor subtype [143]. Studies using bone scans to stage women with late- stage disease have shown the prevalence of osseous metastases ranging from 4.7% to 45% [144]. A study by Chu et al [145] on 256 women with N2/N3 disease showed a metastatic workup for asymptomatic patients was only indicated with T3 or T4 primary lesions. For patients with T0, T1, and T2 diseases, the incidence of stage IV disease was 0%, 0%, and 6%, respectively. The incidence increased with higher T stage; 22% for T3 and 36% for T4 tumors. Several studies comparing bone scan performance with CT and PET have been performed in women presenting with late-stage disease [144]. Some studies have shown up to 17.1% of women with extraosseous metastasis on CT had negative or inconclusive bone scans [144]. One of the benefits of whole body bone scans is the detection of metastasis in the peripheral skeleton, areas not included by CT chest, abdomen, and pelvis with IV contrast. Imaging of Invasive Breast Cancer However, the presence of peripheral metastasis almost always (>99%) occurs in the context of extraosseous or central osseous metastasis, and detection of additional peripheral metastases does not typically result in a change in management [144,146]. CT Chest, Abdomen, and Pelvis With IV Contrast Correctly identifying the stage of breast cancer prior to surgery has important prognostic implications, because survival decreases as stage increases [145]. In a study of 1,329 patents with breast cancer, metastatic disease of any type was identified by imaging between 15% to 16% and 22% to 36% based on N2/3 and T3/4 status, respectively [145]. | 3186697 |
acrac_3186697_32 | Imaging of Invasive Breast Cancer | NCCN guidelines recommend chest, abdomen, and pelvic CT as an additional test prior to preoperative systemic therapy to evaluate for distant disease if the tumor size is >2 cm (T2) or there are positive lymph nodes, or >1 cm (T1c) and HER2+, or triple-negative disease [126]. In asymptomatic women with late-stage breast cancer, metastatic disease to the thorax is identified in 5% to 9% of patients [17,132,147]. The false-positive rate requiring additional imaging studies for further evaluation or follow-up ranged from 10% to 33% [17,132,148]. CT Chest, Abdomen, and Pelvis Without and With IV Contrast The majority of clinical questions for abdominal and/or pelvic CT can be appropriately answered with a single- phase study as detailed in the ACR-SABI-SPR practice parameter for the performance of CT of the abdomen and CT of the pelvis [21]. CT Chest, Abdomen, and Pelvis Without IV Contrast There is no evidence to support the use of CT chest, abdomen, and pelvis without IV contrast. Chest CT without IV contrast is often used to evaluate for metastatic disease to the lung. In asymptomatic women with late-stage breast cancer, metastatic disease to the thorax is identified in 5% to 9% of patients [17,132,147]. The false-positive rate requiring additional imaging studies for further evaluation or follow-up ranged from 10% to 33% [17,132,148]. Digital Breast Tomosynthesis Diagnostic There is no evidence to support the use of DBT to evaluate for distant disease. FDG-PET/CT Skull Base to Mid-Thigh NCCN guidelines recommend PET/CT as an optional additional test prior to preoperative systemic therapy if the tumor size is greater than T2, or there are positive lymph nodes, any HER2+, or triple-negative disease [126]. There is a large body of evidence that FDG-PET/CT is useful to detect metastatic disease in stage IIB to III breast cancer [136-139,149-158]. | Imaging of Invasive Breast Cancer. NCCN guidelines recommend chest, abdomen, and pelvic CT as an additional test prior to preoperative systemic therapy to evaluate for distant disease if the tumor size is >2 cm (T2) or there are positive lymph nodes, or >1 cm (T1c) and HER2+, or triple-negative disease [126]. In asymptomatic women with late-stage breast cancer, metastatic disease to the thorax is identified in 5% to 9% of patients [17,132,147]. The false-positive rate requiring additional imaging studies for further evaluation or follow-up ranged from 10% to 33% [17,132,148]. CT Chest, Abdomen, and Pelvis Without and With IV Contrast The majority of clinical questions for abdominal and/or pelvic CT can be appropriately answered with a single- phase study as detailed in the ACR-SABI-SPR practice parameter for the performance of CT of the abdomen and CT of the pelvis [21]. CT Chest, Abdomen, and Pelvis Without IV Contrast There is no evidence to support the use of CT chest, abdomen, and pelvis without IV contrast. Chest CT without IV contrast is often used to evaluate for metastatic disease to the lung. In asymptomatic women with late-stage breast cancer, metastatic disease to the thorax is identified in 5% to 9% of patients [17,132,147]. The false-positive rate requiring additional imaging studies for further evaluation or follow-up ranged from 10% to 33% [17,132,148]. Digital Breast Tomosynthesis Diagnostic There is no evidence to support the use of DBT to evaluate for distant disease. FDG-PET/CT Skull Base to Mid-Thigh NCCN guidelines recommend PET/CT as an optional additional test prior to preoperative systemic therapy if the tumor size is greater than T2, or there are positive lymph nodes, any HER2+, or triple-negative disease [126]. There is a large body of evidence that FDG-PET/CT is useful to detect metastatic disease in stage IIB to III breast cancer [136-139,149-158]. | 3186697 |
acrac_3186697_33 | Imaging of Invasive Breast Cancer | This is important because patients with locoregional breast malignancy have 5-year survival rates of 76% to 99%, but for patients with distant metastases, 5-year survival rates decreases to 20% to 28% [159]. The sensitivity, specificity, PPV, NPV, and accuracy of PET/CT in identifying metastatic disease in this population are 100%, 96%, 80%, 100%, and 97%, respectively [41]. The false-positive rate of PET/CT was 19%. In comparison with CT and other modalities, 80% of patients with distant disease had the metastases exclusively identified on PET/CT [41]. Groheux et al [136] investigated 254 patients and found previously unknown metastases in 1 of 44 (2%) women with stage IIA breast cancer, 6 of 56 (11%) women with stage IIB cancer, 11 of 63 (18%) women with stage IIIA cancer, 27 of 74 (37%) women with stage IIIB cancer, and 8 of 17 (47%) women with stage IIIC cancer. PET/CT has especially high yields in the case of patients newly diagnosed at <40 years of age, revealing distant metastases in 17% of asymptomatic patients with stage IIB breast cancer <40 years of age [155]. PET/CT modified staging between 14% and 28% of patients with late-stage disease, regardless of tumor receptor status [138,139]. In a study of 163 women, PET/CT and whole body bone scan demonstrated concordance in identifying osseous metastases in 81% of cases. Also, PET/CT had the added benefit of detecting extraosseous metastasis in 62% of patients with osseous metastasis. Of those patients with extraosseous metastases, 6% had equivocal and 42% had negative bone scans [160]. The sensitivity and specificity for PET/CT in the detection of distant metastases is higher than conventional imaging, with a 97% sensitivity and 91% specificity versus an 86% sensitivity and 67% specificity, respectively (P = . 009 and P < . 001, respectively) [161]. However, PET/CT has limited sensitivity for ILC [162]. | Imaging of Invasive Breast Cancer. This is important because patients with locoregional breast malignancy have 5-year survival rates of 76% to 99%, but for patients with distant metastases, 5-year survival rates decreases to 20% to 28% [159]. The sensitivity, specificity, PPV, NPV, and accuracy of PET/CT in identifying metastatic disease in this population are 100%, 96%, 80%, 100%, and 97%, respectively [41]. The false-positive rate of PET/CT was 19%. In comparison with CT and other modalities, 80% of patients with distant disease had the metastases exclusively identified on PET/CT [41]. Groheux et al [136] investigated 254 patients and found previously unknown metastases in 1 of 44 (2%) women with stage IIA breast cancer, 6 of 56 (11%) women with stage IIB cancer, 11 of 63 (18%) women with stage IIIA cancer, 27 of 74 (37%) women with stage IIIB cancer, and 8 of 17 (47%) women with stage IIIC cancer. PET/CT has especially high yields in the case of patients newly diagnosed at <40 years of age, revealing distant metastases in 17% of asymptomatic patients with stage IIB breast cancer <40 years of age [155]. PET/CT modified staging between 14% and 28% of patients with late-stage disease, regardless of tumor receptor status [138,139]. In a study of 163 women, PET/CT and whole body bone scan demonstrated concordance in identifying osseous metastases in 81% of cases. Also, PET/CT had the added benefit of detecting extraosseous metastasis in 62% of patients with osseous metastasis. Of those patients with extraosseous metastases, 6% had equivocal and 42% had negative bone scans [160]. The sensitivity and specificity for PET/CT in the detection of distant metastases is higher than conventional imaging, with a 97% sensitivity and 91% specificity versus an 86% sensitivity and 67% specificity, respectively (P = . 009 and P < . 001, respectively) [161]. However, PET/CT has limited sensitivity for ILC [162]. | 3186697 |
acrac_3186697_34 | Imaging of Invasive Breast Cancer | NCCN guidelines recommend PET/CT as an optional additional test prior to preoperative systemic therapy to evaluate for distant disease if the tumor size is >2 cm (T2) or there are positive lymph nodes, or tumor size is >1 cm (T1c) and HER2+, or there is triple-negative disease [126], because these subtypes tend to be more aggressive with earlier spread to extraosseous locations compared with other molecular subtypes as described above. Mammography Diagnostic There is no evidence to support the use of diagnostic mammography to evaluate for distant disease. Imaging of Invasive Breast Cancer Mammography With IV Contrast There is no evidence to support the use of mammography with IV contrast to evaluate for distant disease. MRI Breast Without and With IV Contrast There is no evidence to support the use of MRI breast without and with IV contrast to evaluate for distant disease. MRI Breast Without IV Contrast There is no evidence to support the use of noncontrast breast MRI in evaluating the extent of disease. MRI Head Without IV Contrast There is no evidence to support the use of MRI head without IV contrast to evaluate for distant disease. US Axilla There is no evidence to support the use of US axilla to evaluate for distant disease. US Breast There is no evidence to support the use of US breast to evaluate for distant disease. Variant 6: Surveillance. Regardless of clinical stage of breast cancer at time of original presentation. Evaluation for local recurrence in patient with history of BCT. Breast-conserving treatment (BCT) of lumpectomy followed by whole-breast radiation is the most common treatment following a diagnosis of stage I and II breast cancer. Long-term studies show no significant difference in survival rates of patients treated with BCT versus mastectomy. Locoregional recurrence typically occurs 3 to 6 years post-treatment, at an average annual rate of 1% to 2.5% per year [167,168]. | Imaging of Invasive Breast Cancer. NCCN guidelines recommend PET/CT as an optional additional test prior to preoperative systemic therapy to evaluate for distant disease if the tumor size is >2 cm (T2) or there are positive lymph nodes, or tumor size is >1 cm (T1c) and HER2+, or there is triple-negative disease [126], because these subtypes tend to be more aggressive with earlier spread to extraosseous locations compared with other molecular subtypes as described above. Mammography Diagnostic There is no evidence to support the use of diagnostic mammography to evaluate for distant disease. Imaging of Invasive Breast Cancer Mammography With IV Contrast There is no evidence to support the use of mammography with IV contrast to evaluate for distant disease. MRI Breast Without and With IV Contrast There is no evidence to support the use of MRI breast without and with IV contrast to evaluate for distant disease. MRI Breast Without IV Contrast There is no evidence to support the use of noncontrast breast MRI in evaluating the extent of disease. MRI Head Without IV Contrast There is no evidence to support the use of MRI head without IV contrast to evaluate for distant disease. US Axilla There is no evidence to support the use of US axilla to evaluate for distant disease. US Breast There is no evidence to support the use of US breast to evaluate for distant disease. Variant 6: Surveillance. Regardless of clinical stage of breast cancer at time of original presentation. Evaluation for local recurrence in patient with history of BCT. Breast-conserving treatment (BCT) of lumpectomy followed by whole-breast radiation is the most common treatment following a diagnosis of stage I and II breast cancer. Long-term studies show no significant difference in survival rates of patients treated with BCT versus mastectomy. Locoregional recurrence typically occurs 3 to 6 years post-treatment, at an average annual rate of 1% to 2.5% per year [167,168]. | 3186697 |
acrac_3186697_35 | Imaging of Invasive Breast Cancer | More recent studies indicate the risk of developing locoregional recurrence in patients with early stage disease treated with breast-conserving surgery, whole-breast radiation, and appropriate systemic treatments is approximately 0.5% per year [169]. In 1 meta-analysis, the 10-year local recurrence rate in patients after neoadjuvant chemotherapy and breast conservation was 6.5% and locoregional disease recurrence was 10.3%. Factors found to be associated with a higher risk of local recurrence were ER-negative disease, axillary spread, especially in >3 nodes or clinically palpable disease, and a lack of pathologic complete response [170]. Studies have shown that early detection of recurrence (prior to clinical detection) improves long-term survival by approximately 17% to 28% [171]. Therefore, imaging surveillance remains important in this patient population. Digital Breast Tomosynthesis Diagnostic The most widely accepted guidelines regarding the surveillance of asymptomatic women with a history of breast cancer come from 2 national organizations: ASCO and NCCN [172,173]. Both organizations state that routine surveillance with an annual mammogram can detect an in-breast recurrence or a new primary breast cancer in women with an average risk for recurrence. However, there is institutional variation on the frequency (every 6 months versus annual) and time period (1-5 years post-BCT) for surveillance after BCT. There is also variation on whether to include women in the screening versus diagnostic patient populations, in which women in the diagnostic population wait for possible additional imaging needed to reach a final assessment prior to leaving the imaging facility. The sensitivity of mammography is decreased due to post-treatment changes from surgery and radiation therapy, and some institutions prefer closer follow-up after BCT to assess changes due to radiation and surgery and potentially detect local recurrences earlier than on annual follow-up imaging. | Imaging of Invasive Breast Cancer. More recent studies indicate the risk of developing locoregional recurrence in patients with early stage disease treated with breast-conserving surgery, whole-breast radiation, and appropriate systemic treatments is approximately 0.5% per year [169]. In 1 meta-analysis, the 10-year local recurrence rate in patients after neoadjuvant chemotherapy and breast conservation was 6.5% and locoregional disease recurrence was 10.3%. Factors found to be associated with a higher risk of local recurrence were ER-negative disease, axillary spread, especially in >3 nodes or clinically palpable disease, and a lack of pathologic complete response [170]. Studies have shown that early detection of recurrence (prior to clinical detection) improves long-term survival by approximately 17% to 28% [171]. Therefore, imaging surveillance remains important in this patient population. Digital Breast Tomosynthesis Diagnostic The most widely accepted guidelines regarding the surveillance of asymptomatic women with a history of breast cancer come from 2 national organizations: ASCO and NCCN [172,173]. Both organizations state that routine surveillance with an annual mammogram can detect an in-breast recurrence or a new primary breast cancer in women with an average risk for recurrence. However, there is institutional variation on the frequency (every 6 months versus annual) and time period (1-5 years post-BCT) for surveillance after BCT. There is also variation on whether to include women in the screening versus diagnostic patient populations, in which women in the diagnostic population wait for possible additional imaging needed to reach a final assessment prior to leaving the imaging facility. The sensitivity of mammography is decreased due to post-treatment changes from surgery and radiation therapy, and some institutions prefer closer follow-up after BCT to assess changes due to radiation and surgery and potentially detect local recurrences earlier than on annual follow-up imaging. | 3186697 |
acrac_3186697_36 | Imaging of Invasive Breast Cancer | A single-institution study of 2,329 women following BCT showed that a 6- month interval for surveillance detected a higher proportion of local recurrences at an earlier stage compared with annual surveillance [174]. In a single-institution study of 789 asymptomatic women after BCT, 1.2% had cancer diagnosed at the 6-month timepoint following treatment (n = 169), and 0.6% had cancer detected in women who Imaging of Invasive Breast Cancer underwent routine mammographic screening a year after treatment (n = 620) [175]. However, earlier diagnosis did not result in a difference in local and distant disease-free survival. In summary, there is insufficient evidence demonstrating superior outcomes with diagnostic versus screening mammography for breast cancer surveillance. Expert consensus is to perform an annual diagnostic examination for the first 3 years, followed by routine annual screening, due to the increased complexity of interpretation from postsurgical and postradiation changes [176] and the increased risk of recurrence in the first 3 years following treatment [177-180]. There have been multiple studies evaluating the performance of DM versus DBT for surveillance. Chikarmane et al [181] compared tomosynthesis with 2-D mammography in women with a personal history of breast cancer treated with lumpectomy and mastectomy. They reported a significant decrease in recall rate (7.9% versus 10.1%, respectively) and increased sensitivity (92.3% versus 90.0%, respectively) with tomosynthesis with no significant difference in the cancer detection rate (6.1 versus 6.0 per 1,000 women screened, respectively) or PPV (12.0% versus 6.4%, respectively). These changes in interpretive performance were similar regardless of whether the women underwent breast-conserving surgery or mastectomy. There is evidence that mammography alone may not be sufficient for surveillance in this population. | Imaging of Invasive Breast Cancer. A single-institution study of 2,329 women following BCT showed that a 6- month interval for surveillance detected a higher proportion of local recurrences at an earlier stage compared with annual surveillance [174]. In a single-institution study of 789 asymptomatic women after BCT, 1.2% had cancer diagnosed at the 6-month timepoint following treatment (n = 169), and 0.6% had cancer detected in women who Imaging of Invasive Breast Cancer underwent routine mammographic screening a year after treatment (n = 620) [175]. However, earlier diagnosis did not result in a difference in local and distant disease-free survival. In summary, there is insufficient evidence demonstrating superior outcomes with diagnostic versus screening mammography for breast cancer surveillance. Expert consensus is to perform an annual diagnostic examination for the first 3 years, followed by routine annual screening, due to the increased complexity of interpretation from postsurgical and postradiation changes [176] and the increased risk of recurrence in the first 3 years following treatment [177-180]. There have been multiple studies evaluating the performance of DM versus DBT for surveillance. Chikarmane et al [181] compared tomosynthesis with 2-D mammography in women with a personal history of breast cancer treated with lumpectomy and mastectomy. They reported a significant decrease in recall rate (7.9% versus 10.1%, respectively) and increased sensitivity (92.3% versus 90.0%, respectively) with tomosynthesis with no significant difference in the cancer detection rate (6.1 versus 6.0 per 1,000 women screened, respectively) or PPV (12.0% versus 6.4%, respectively). These changes in interpretive performance were similar regardless of whether the women underwent breast-conserving surgery or mastectomy. There is evidence that mammography alone may not be sufficient for surveillance in this population. | 3186697 |
acrac_3186697_37 | Imaging of Invasive Breast Cancer | In a large study involving 32,331 women with a history of breast cancer undergoing 117,971 surveillance mammographic examinations (112,269 digital mammographic examinations and 5,702 DBT examinations), surveillance mammography performance in the detection of interval cancers was inferior to established screening mammography benchmarks [182]. The main limitation of this study was the relative low proportion of DBT examinations, because DBT does detect more cancer than DM alone [183]. Women <50 years of age at primary breast cancer diagnosis appear to be at highest risk of a missed interval cancer using surveillance mammography [184]. These data suggest a need for evolving evidence-based surveillance recommendations on supplemental screening. Digital Breast Tomosynthesis Screening The most widely accepted guidelines regarding the surveillance of asymptomatic women with a history of breast cancer come from 2 national organizations: ASCO and NCCN [172,173]. Both organizations state that routine surveillance with an annual mammogram can detect an in-breast recurrence or a new primary breast cancer in women with an average risk for recurrence. However, there is institutional variation on the frequency (every 6 months versus annual) and time period (1-5 years post-BCT) for surveillance after BCT. There is also variation on whether to include women in the screening versus diagnostic patient populations, in which women in the diagnostic population wait for possible additional imaging needed to reach a final assessment prior to leaving the imaging facility, whereas women in the screening population could leave after their standard views are performed. The sensitivity of mammography is decreased due to post- treatment changes from surgery and radiation therapy, and some institutions prefer closer follow-up after BCT to assess changes due to radiation and surgery and potentially detect local recurrences earlier than on annual follow- up imaging. | Imaging of Invasive Breast Cancer. In a large study involving 32,331 women with a history of breast cancer undergoing 117,971 surveillance mammographic examinations (112,269 digital mammographic examinations and 5,702 DBT examinations), surveillance mammography performance in the detection of interval cancers was inferior to established screening mammography benchmarks [182]. The main limitation of this study was the relative low proportion of DBT examinations, because DBT does detect more cancer than DM alone [183]. Women <50 years of age at primary breast cancer diagnosis appear to be at highest risk of a missed interval cancer using surveillance mammography [184]. These data suggest a need for evolving evidence-based surveillance recommendations on supplemental screening. Digital Breast Tomosynthesis Screening The most widely accepted guidelines regarding the surveillance of asymptomatic women with a history of breast cancer come from 2 national organizations: ASCO and NCCN [172,173]. Both organizations state that routine surveillance with an annual mammogram can detect an in-breast recurrence or a new primary breast cancer in women with an average risk for recurrence. However, there is institutional variation on the frequency (every 6 months versus annual) and time period (1-5 years post-BCT) for surveillance after BCT. There is also variation on whether to include women in the screening versus diagnostic patient populations, in which women in the diagnostic population wait for possible additional imaging needed to reach a final assessment prior to leaving the imaging facility, whereas women in the screening population could leave after their standard views are performed. The sensitivity of mammography is decreased due to post- treatment changes from surgery and radiation therapy, and some institutions prefer closer follow-up after BCT to assess changes due to radiation and surgery and potentially detect local recurrences earlier than on annual follow- up imaging. | 3186697 |
acrac_3186697_38 | Imaging of Invasive Breast Cancer | A single-institution study of 2,329 women following BCT showed that a 6-month interval for surveillance detected a higher proportion of local recurrences at an earlier stage, compared with annual surveillance [174]. In a single-institution study of 789 asymptomatic women after BCT, 1.2% had cancer diagnosed at the 6- month timepoint following treatment (n = 169) and 0.6% had cancer detected in women who underwent routine mammographic screening a year after treatment (n = 620) [175]. However, earlier diagnosis did not result in a difference in local and distant disease-free survival. In summary, there is insufficient evidence demonstrating superior outcomes with diagnostic versus screening mammography for breast cancer surveillance. Expert consensus is to perform an annual diagnostic examination for the first 3 years, followed by routine annual screening, due to the increased complexity of interpretation from postsurgical and post radiation changes [176] and the increased risk of recurrence in the first 3 years following treatment [177-180]. FDG-PET/CT Skull Base to Mid-Thigh There is no literature to support the use of FDG-PET/CT to evaluate local recurrence of breast cancer. Mammography Diagnostic The most widely accepted guidelines regarding the surveillance of asymptomatic women with a history of breast cancer come from 2 national organizations: ASCO and NCCN [172,173]. Both organizations state that routine surveillance with an annual mammogram can detect an in-breast recurrence or a new primary breast cancer in women with an average risk for recurrence. However, there is institutional variation on the frequency (every 6 months versus annual) and time period (1-5 years post-BCT) for surveillance after BCT. There is also variation on whether to include women in the screening versus | Imaging of Invasive Breast Cancer. A single-institution study of 2,329 women following BCT showed that a 6-month interval for surveillance detected a higher proportion of local recurrences at an earlier stage, compared with annual surveillance [174]. In a single-institution study of 789 asymptomatic women after BCT, 1.2% had cancer diagnosed at the 6- month timepoint following treatment (n = 169) and 0.6% had cancer detected in women who underwent routine mammographic screening a year after treatment (n = 620) [175]. However, earlier diagnosis did not result in a difference in local and distant disease-free survival. In summary, there is insufficient evidence demonstrating superior outcomes with diagnostic versus screening mammography for breast cancer surveillance. Expert consensus is to perform an annual diagnostic examination for the first 3 years, followed by routine annual screening, due to the increased complexity of interpretation from postsurgical and post radiation changes [176] and the increased risk of recurrence in the first 3 years following treatment [177-180]. FDG-PET/CT Skull Base to Mid-Thigh There is no literature to support the use of FDG-PET/CT to evaluate local recurrence of breast cancer. Mammography Diagnostic The most widely accepted guidelines regarding the surveillance of asymptomatic women with a history of breast cancer come from 2 national organizations: ASCO and NCCN [172,173]. Both organizations state that routine surveillance with an annual mammogram can detect an in-breast recurrence or a new primary breast cancer in women with an average risk for recurrence. However, there is institutional variation on the frequency (every 6 months versus annual) and time period (1-5 years post-BCT) for surveillance after BCT. There is also variation on whether to include women in the screening versus | 3186697 |
acrac_3186697_39 | Imaging of Invasive Breast Cancer | Imaging of Invasive Breast Cancer diagnostic patient populations, in which women in the diagnostic population wait for possible additional imaging needed to reach a final assessment prior to leaving the imaging facility. The sensitivity of mammography is decreased due to post-treatment changes from surgery and radiation therapy, and some institutions prefer closer follow-up after BCT to assess changes due to radiation and surgery and potentially detect local recurrences earlier than annual follow-up. A single-institution study of 2,329 women following BCT showed that a 6-month interval for surveillance detected a higher proportion of local recurrences at an earlier stage compared with annual surveillance [174]. In a single-institution study of 789 asymptomatic women after BCT, 1.2% had cancer diagnosed at the 6-month timepoint following treatment (n = 169), and 0.6% had cancer detected in women who underwent routine mammographic screening a year after treatment (n = 620) [175]. However, earlier diagnosis did not result in a difference in local and distant disease-free survival. In summary, there is insufficient evidence demonstrating superior outcomes with diagnostic versus screening mammography for breast cancer surveillance. Expert consensus is to perform an annual diagnostic examination for the first 3 years, followed by routine annual screening, due to the increased complexity of interpretation from postsurgical and postradiation changes [176] and the increased risk of recurrence in the first 3 years following treatment [177-180]. There is evidence that mammography alone may not be sufficient for surveillance in this population. | Imaging of Invasive Breast Cancer. Imaging of Invasive Breast Cancer diagnostic patient populations, in which women in the diagnostic population wait for possible additional imaging needed to reach a final assessment prior to leaving the imaging facility. The sensitivity of mammography is decreased due to post-treatment changes from surgery and radiation therapy, and some institutions prefer closer follow-up after BCT to assess changes due to radiation and surgery and potentially detect local recurrences earlier than annual follow-up. A single-institution study of 2,329 women following BCT showed that a 6-month interval for surveillance detected a higher proportion of local recurrences at an earlier stage compared with annual surveillance [174]. In a single-institution study of 789 asymptomatic women after BCT, 1.2% had cancer diagnosed at the 6-month timepoint following treatment (n = 169), and 0.6% had cancer detected in women who underwent routine mammographic screening a year after treatment (n = 620) [175]. However, earlier diagnosis did not result in a difference in local and distant disease-free survival. In summary, there is insufficient evidence demonstrating superior outcomes with diagnostic versus screening mammography for breast cancer surveillance. Expert consensus is to perform an annual diagnostic examination for the first 3 years, followed by routine annual screening, due to the increased complexity of interpretation from postsurgical and postradiation changes [176] and the increased risk of recurrence in the first 3 years following treatment [177-180]. There is evidence that mammography alone may not be sufficient for surveillance in this population. | 3186697 |
acrac_3186697_40 | Imaging of Invasive Breast Cancer | In a large study involving 32,331 women with a history of breast cancer undergoing 117,971 surveillance mammographic examinations (112,269 digital mammographic examinations and 5,702 DBT examinations), surveillance mammography performance in the detection of interval cancers was inferior to established screening mammography benchmarks [182], with the main limitation of this study being the relative low proportion of DBT examinations because DBT does detect more cancer than DM alone [183]. Women <50 years of age at primary breast cancer diagnosis appear to be at highest risk of a missed interval cancer using surveillance mammography [184]. These data suggest a need for evolving evidence-based surveillance recommendations on supplemental screening. Mammography Screening The most widely accepted guidelines regarding the surveillance of asymptomatic women with a history of breast cancer come from 2 national organizations: ASCO and NCCN [172,173]. Both organizations state that routine surveillance with an annual mammogram can detect an in-breast recurrence or a new primary breast cancer in women with an average risk for recurrence. However, there is institutional variation on the frequency (every 6 months versus annual) and time period (1-5 years post-BCT) for surveillance after BCT. There is also variation on whether to include women in the screening versus diagnostic patient populations, in which women in the diagnostic population wait for possible additional imaging needed to reach a final assessment prior to leaving the imaging facility, whereas women in the screening population could leave after their standard views are performed. The sensitivity of mammography is decreased due to post- treatment changes from surgery and radiation therapy, and some institutions prefer closer follow-up after BCT to assess changes due to radiation and surgery and potentially detect local recurrences earlier than on annual follow- up imaging. | Imaging of Invasive Breast Cancer. In a large study involving 32,331 women with a history of breast cancer undergoing 117,971 surveillance mammographic examinations (112,269 digital mammographic examinations and 5,702 DBT examinations), surveillance mammography performance in the detection of interval cancers was inferior to established screening mammography benchmarks [182], with the main limitation of this study being the relative low proportion of DBT examinations because DBT does detect more cancer than DM alone [183]. Women <50 years of age at primary breast cancer diagnosis appear to be at highest risk of a missed interval cancer using surveillance mammography [184]. These data suggest a need for evolving evidence-based surveillance recommendations on supplemental screening. Mammography Screening The most widely accepted guidelines regarding the surveillance of asymptomatic women with a history of breast cancer come from 2 national organizations: ASCO and NCCN [172,173]. Both organizations state that routine surveillance with an annual mammogram can detect an in-breast recurrence or a new primary breast cancer in women with an average risk for recurrence. However, there is institutional variation on the frequency (every 6 months versus annual) and time period (1-5 years post-BCT) for surveillance after BCT. There is also variation on whether to include women in the screening versus diagnostic patient populations, in which women in the diagnostic population wait for possible additional imaging needed to reach a final assessment prior to leaving the imaging facility, whereas women in the screening population could leave after their standard views are performed. The sensitivity of mammography is decreased due to post- treatment changes from surgery and radiation therapy, and some institutions prefer closer follow-up after BCT to assess changes due to radiation and surgery and potentially detect local recurrences earlier than on annual follow- up imaging. | 3186697 |
acrac_3186697_41 | Imaging of Invasive Breast Cancer | A single-institution study of 2,329 women following BCT showed that a 6-month interval for surveillance detected a higher proportion of local recurrences at an earlier stage compared with annual surveillance [174]. In a single-institution study of 789 asymptomatic women after BCT, 1.2% had cancer diagnosed at the 6- month timepoint following treatment (n = 169), and 0.6% had cancer detected in women who underwent routine mammographic screening a year after treatment (n = 620) [175]. However, earlier diagnosis did not result in a difference in local and distant disease-free survival. In summary, there is insufficient evidence demonstrating superior outcomes with diagnostic versus screening mammography for breast cancer surveillance. Expert consensus is to perform an annual diagnostic examination for the first 3 years, followed by routine annual screening, due to the increased complexity of interpretation from postsurgical and postradiation changes [176] and the increased risk of recurrence in the first 3 years following treatment [177-180]. Mammography With IV Contrast A large study (n = 858) comparing the use of mammography with IV contrast to 2-D mammography showed an increase in the sensitivity of cancer detection from 50% to 87.5% with minimal changes to the specificity (97.1% versus 93.7%, respectively) and PPV (25.0% versus 20.9%, respectively) [185]. This study cohort included a large portion of women with a personal history of breast cancer (40.2%) and women with dense breasts (77.5%), although no information is given about the time since breast cancer diagnosis or stage at presentation in the surveillance population. Imaging of Invasive Breast Cancer MRI Breast Without and With IV Contrast For most breast cancer survivors, there is insufficient evidence for or against the use of breast MRI to detect disease recurrence in women of average risk. | Imaging of Invasive Breast Cancer. A single-institution study of 2,329 women following BCT showed that a 6-month interval for surveillance detected a higher proportion of local recurrences at an earlier stage compared with annual surveillance [174]. In a single-institution study of 789 asymptomatic women after BCT, 1.2% had cancer diagnosed at the 6- month timepoint following treatment (n = 169), and 0.6% had cancer detected in women who underwent routine mammographic screening a year after treatment (n = 620) [175]. However, earlier diagnosis did not result in a difference in local and distant disease-free survival. In summary, there is insufficient evidence demonstrating superior outcomes with diagnostic versus screening mammography for breast cancer surveillance. Expert consensus is to perform an annual diagnostic examination for the first 3 years, followed by routine annual screening, due to the increased complexity of interpretation from postsurgical and postradiation changes [176] and the increased risk of recurrence in the first 3 years following treatment [177-180]. Mammography With IV Contrast A large study (n = 858) comparing the use of mammography with IV contrast to 2-D mammography showed an increase in the sensitivity of cancer detection from 50% to 87.5% with minimal changes to the specificity (97.1% versus 93.7%, respectively) and PPV (25.0% versus 20.9%, respectively) [185]. This study cohort included a large portion of women with a personal history of breast cancer (40.2%) and women with dense breasts (77.5%), although no information is given about the time since breast cancer diagnosis or stage at presentation in the surveillance population. Imaging of Invasive Breast Cancer MRI Breast Without and With IV Contrast For most breast cancer survivors, there is insufficient evidence for or against the use of breast MRI to detect disease recurrence in women of average risk. | 3186697 |
acrac_3186697_42 | Imaging of Invasive Breast Cancer | However, the ACR recommends annual surveillance with breast MRI in women with a personal history of breast cancer and dense breast tissue, or those diagnosed before age 50 [186]. This ACR recommendation is partially due to data showing that women with a personal history of premenopausal breast cancer benefited from MRI screening [187]. Data from the Breast Cancer Surveillance Consortium (BCSC) showed that, compared with mammography, MRI identified more cancers (10.8 versus 8.2 per 1,000 women screened) at the expense of a higher biopsy rate (10.1% versus 4.0%). However, multivariate models showed no difference in interval cancer detection rate or sensitivity (61.4% versus 70.3%, respectively) [188]. Wernli et al [188] also found that surveillance breast MRI leads to higher biopsy rate (OR, 2.2; 95% CI, 1.9-2.7; P < . 001) and cancer detection rate (OR, 1.7; 95% CI, 1.1-2.7; P = . 03) than mammography alone. However, there were no differences in sensitivity (OR, 1.1; 95% CI, 0.4-2.9; P = . 84) or interval cancer rate (OR, 1.1; 95% CI, 0.6-2.2; P = . 70) compared with mammography. Single-institutional studies at academic centers evaluating MRI for surveillance report sensitivities between 75% to 100% [189-193]. The cancer detection rate ranges from 1% to 2.9% for women whose only risk factor is a personal history of breast cancer [190-192]. However, this increases to 5.4% in patients with a personal history of breast cancer and dense breasts [194]. Another study from the BCSC group showed that women with a personal history of breast cancer undergoing MRI had a 2-fold increase in biopsy rate per 1,000 screening episodes (57.1% versus 23.6%) and lower cancer yield (267.6 versus 404.6 per 1,000 episodes with biopsy) than following mammography [195]. | Imaging of Invasive Breast Cancer. However, the ACR recommends annual surveillance with breast MRI in women with a personal history of breast cancer and dense breast tissue, or those diagnosed before age 50 [186]. This ACR recommendation is partially due to data showing that women with a personal history of premenopausal breast cancer benefited from MRI screening [187]. Data from the Breast Cancer Surveillance Consortium (BCSC) showed that, compared with mammography, MRI identified more cancers (10.8 versus 8.2 per 1,000 women screened) at the expense of a higher biopsy rate (10.1% versus 4.0%). However, multivariate models showed no difference in interval cancer detection rate or sensitivity (61.4% versus 70.3%, respectively) [188]. Wernli et al [188] also found that surveillance breast MRI leads to higher biopsy rate (OR, 2.2; 95% CI, 1.9-2.7; P < . 001) and cancer detection rate (OR, 1.7; 95% CI, 1.1-2.7; P = . 03) than mammography alone. However, there were no differences in sensitivity (OR, 1.1; 95% CI, 0.4-2.9; P = . 84) or interval cancer rate (OR, 1.1; 95% CI, 0.6-2.2; P = . 70) compared with mammography. Single-institutional studies at academic centers evaluating MRI for surveillance report sensitivities between 75% to 100% [189-193]. The cancer detection rate ranges from 1% to 2.9% for women whose only risk factor is a personal history of breast cancer [190-192]. However, this increases to 5.4% in patients with a personal history of breast cancer and dense breasts [194]. Another study from the BCSC group showed that women with a personal history of breast cancer undergoing MRI had a 2-fold increase in biopsy rate per 1,000 screening episodes (57.1% versus 23.6%) and lower cancer yield (267.6 versus 404.6 per 1,000 episodes with biopsy) than following mammography [195]. | 3186697 |
acrac_3186697_43 | Imaging of Invasive Breast Cancer | Most recently, a meta-analysis from 2000-2019 evaluating MRI as a screening modality in 8,338 women with a history of breast cancer (12,335 MRI examinations) found insufficient data to recommend for or against MRI as a surveillance examination in addition to mammographic screening [196]. Cancer detection rates of a second breast cancer by MRI were 8 to 20 per 1,000 examinations, but the sensitivity range was from 61% to 100%, with BI- RADS benchmark for MRI screening of at least 80%. Thus, clinical performance benchmarks have not been met in this population. Still, with the exception of the study on the BCSC cohort, other studies did not account for patient characteristics that could increase risk, such as premenopausal status, breast density, mutation status, or family history, through adjustment, stratification, or descriptive analysis. MRI Breast Without IV Contrast There is no evidence to support the use of noncontrast breast MRI in evaluating extent of disease. US Breast There is limited evidence to support the use of US breast for surveillance in women with history of BCT. A single study in Asian patients with a personal history of breast cancer treated with breast-conserving surgery or mastectomy showed diagnostic performances for the sensitivity, specificity, PPV, and accuracy of US of 95.8%, 97.8%, 27.1%, and 97.9% after BCS and 42.9%, 97.5%, 9.4%, and 97.2% after mastectomy [197]. There is additional evidence that whole breast US, as an adjunct to screening mammography in all women with dense breasts, detects additional 0.3 to 7.7 cancers per 1,000 at the expense of 11.7 to 106.6 biopsies per 1,000 women [198]. Although useful as a general supplemental screening tool, these limited data do not support US breast as supplemental screening after breast cancer conservation, with more data needed to determine how postoperative changes and fat necrosis specific to this population might impact specificity and sensitivity. Variant 7: Surveillance. | Imaging of Invasive Breast Cancer. Most recently, a meta-analysis from 2000-2019 evaluating MRI as a screening modality in 8,338 women with a history of breast cancer (12,335 MRI examinations) found insufficient data to recommend for or against MRI as a surveillance examination in addition to mammographic screening [196]. Cancer detection rates of a second breast cancer by MRI were 8 to 20 per 1,000 examinations, but the sensitivity range was from 61% to 100%, with BI- RADS benchmark for MRI screening of at least 80%. Thus, clinical performance benchmarks have not been met in this population. Still, with the exception of the study on the BCSC cohort, other studies did not account for patient characteristics that could increase risk, such as premenopausal status, breast density, mutation status, or family history, through adjustment, stratification, or descriptive analysis. MRI Breast Without IV Contrast There is no evidence to support the use of noncontrast breast MRI in evaluating extent of disease. US Breast There is limited evidence to support the use of US breast for surveillance in women with history of BCT. A single study in Asian patients with a personal history of breast cancer treated with breast-conserving surgery or mastectomy showed diagnostic performances for the sensitivity, specificity, PPV, and accuracy of US of 95.8%, 97.8%, 27.1%, and 97.9% after BCS and 42.9%, 97.5%, 9.4%, and 97.2% after mastectomy [197]. There is additional evidence that whole breast US, as an adjunct to screening mammography in all women with dense breasts, detects additional 0.3 to 7.7 cancers per 1,000 at the expense of 11.7 to 106.6 biopsies per 1,000 women [198]. Although useful as a general supplemental screening tool, these limited data do not support US breast as supplemental screening after breast cancer conservation, with more data needed to determine how postoperative changes and fat necrosis specific to this population might impact specificity and sensitivity. Variant 7: Surveillance. | 3186697 |
acrac_3186697_44 | Imaging of Invasive Breast Cancer | Regardless of clinical stage of breast cancer at time of original presentation. Evaluation for local recurrence in patient with history of mastectomy. Minimal residual breast tissue remains after all forms of mastectomy [199]. Although locoregional recurrence is typically detected clinically, some are incidentally detected by imaging, during the screening examination of the native contralateral breast. For these reasons, ASCO recommends frequent clinical surveillance with physical examination and history every 3 to 12 months for the first 5 years after mastectomy, followed by annual clinical breast examination in subsequent years [173]. Digital Breast Tomosynthesis Diagnostic There is no evidence to support the use of DBT to evaluate for recurrence after mastectomy in an asymptomatic patient. Digital Breast Tomosynthesis Screening There is no evidence to support the use of screening DBT to evaluate for recurrence after mastectomy. Imaging of Invasive Breast Cancer FDG-PET/CT Skull Base to Mid-Thigh In asymptomatic patients with a history of breast cancer who received treatment for curative intent, there is no role for imaging to screen for locoregional recurrences with FDG-PET/CT skull base to mid-thigh. ASCO, NCCN, and ESMO all recommend against the routine use of imaging to screen for distant disease recurrence [172,173,200]. Mammography Diagnostic There is no evidence to support the use of diagnostic mammography to evaluate for recurrence after mastectomy in asymptomatic women. Mammography Screening There is no evidence to support the use of screening mammography to evaluate for recurrence after mastectomy. Mammography With IV Contrast There is no evidence to support the use of CEM to evaluate for recurrence after mastectomy in asymptomatic women. MRI Breast Without and With IV Contrast High-risk women with mastectomies may benefit from MRI surveillance of their remaining breast. | Imaging of Invasive Breast Cancer. Regardless of clinical stage of breast cancer at time of original presentation. Evaluation for local recurrence in patient with history of mastectomy. Minimal residual breast tissue remains after all forms of mastectomy [199]. Although locoregional recurrence is typically detected clinically, some are incidentally detected by imaging, during the screening examination of the native contralateral breast. For these reasons, ASCO recommends frequent clinical surveillance with physical examination and history every 3 to 12 months for the first 5 years after mastectomy, followed by annual clinical breast examination in subsequent years [173]. Digital Breast Tomosynthesis Diagnostic There is no evidence to support the use of DBT to evaluate for recurrence after mastectomy in an asymptomatic patient. Digital Breast Tomosynthesis Screening There is no evidence to support the use of screening DBT to evaluate for recurrence after mastectomy. Imaging of Invasive Breast Cancer FDG-PET/CT Skull Base to Mid-Thigh In asymptomatic patients with a history of breast cancer who received treatment for curative intent, there is no role for imaging to screen for locoregional recurrences with FDG-PET/CT skull base to mid-thigh. ASCO, NCCN, and ESMO all recommend against the routine use of imaging to screen for distant disease recurrence [172,173,200]. Mammography Diagnostic There is no evidence to support the use of diagnostic mammography to evaluate for recurrence after mastectomy in asymptomatic women. Mammography Screening There is no evidence to support the use of screening mammography to evaluate for recurrence after mastectomy. Mammography With IV Contrast There is no evidence to support the use of CEM to evaluate for recurrence after mastectomy in asymptomatic women. MRI Breast Without and With IV Contrast High-risk women with mastectomies may benefit from MRI surveillance of their remaining breast. | 3186697 |
acrac_3186697_45 | Imaging of Invasive Breast Cancer | In a small study evaluating MRI in women with a unilateral mastectomy, the cancer detection rate was 10 per 1,000 in the asymptomatic mastectomy side, and these cancers would have otherwise been undetected until symptomatic because screening mammography is not performed after mastectomy. In this population, surveillance MR had a sensitivity of 66.7%, a specificity of 99.2%, a PPV of 57.1%, and an NPV of 99.5%. Larger studies are needed to assess the utility of surveillance MR in the setting of mastectomy [201]. MRI Breast Without IV Contrast There is no evidence to support the use of noncontrast breast MRI in surveillance. US Breast There is limited evidence to support the use of US breast for surveillance in the women with history of mastectomy. Variant 8: Suspected local recurrence of breast cancer based on symptoms, physical examination, or laboratory value in patient with history of BCT. Regardless of clinical stage at time of original presentation. Digital Breast Tomosynthesis Diagnostic Mammography can assist in monitoring women with a history of breast cancer and evaluating for suspicion of local recurrence. Diagnostic DBT improves lesion characterization in noncalcified lesions when compared with conventional mammographic workup [202]. The performance of DM versus DBT has not been determined for symptomatic imaging specifically in the post-BCT population. FDG-PET/CT Skull Base to Mid-Thigh There is no evidence to support the use of FDG-PET/CT to evaluate for locoregional recurrence after BCT. Mammography Diagnostic Mammography can assist in monitoring women with a history of breast cancer and evaluating for suspicion of local recurrence. Diagnostic DBT improves lesion characterization in noncalcified lesions when compared with conventional mammographic workup [202]. The performance of DM versus DBT has not been determined for symptomatic imaging specifically in the post-BCT population. | Imaging of Invasive Breast Cancer. In a small study evaluating MRI in women with a unilateral mastectomy, the cancer detection rate was 10 per 1,000 in the asymptomatic mastectomy side, and these cancers would have otherwise been undetected until symptomatic because screening mammography is not performed after mastectomy. In this population, surveillance MR had a sensitivity of 66.7%, a specificity of 99.2%, a PPV of 57.1%, and an NPV of 99.5%. Larger studies are needed to assess the utility of surveillance MR in the setting of mastectomy [201]. MRI Breast Without IV Contrast There is no evidence to support the use of noncontrast breast MRI in surveillance. US Breast There is limited evidence to support the use of US breast for surveillance in the women with history of mastectomy. Variant 8: Suspected local recurrence of breast cancer based on symptoms, physical examination, or laboratory value in patient with history of BCT. Regardless of clinical stage at time of original presentation. Digital Breast Tomosynthesis Diagnostic Mammography can assist in monitoring women with a history of breast cancer and evaluating for suspicion of local recurrence. Diagnostic DBT improves lesion characterization in noncalcified lesions when compared with conventional mammographic workup [202]. The performance of DM versus DBT has not been determined for symptomatic imaging specifically in the post-BCT population. FDG-PET/CT Skull Base to Mid-Thigh There is no evidence to support the use of FDG-PET/CT to evaluate for locoregional recurrence after BCT. Mammography Diagnostic Mammography can assist in monitoring women with a history of breast cancer and evaluating for suspicion of local recurrence. Diagnostic DBT improves lesion characterization in noncalcified lesions when compared with conventional mammographic workup [202]. The performance of DM versus DBT has not been determined for symptomatic imaging specifically in the post-BCT population. | 3186697 |
acrac_3186697_46 | Imaging of Invasive Breast Cancer | Mammography With IV Contrast There are limited data on the use of CEM in breast cancer surveillance. Sorin et al [203] did show a high incremental cancer detection rate (13.1 cancers per 1,000 women) when mammography with IV contrast replaced DM in patients with a personal history of breast cancer or with an intermediate lifetime risk. US (targeted and whole breast) increased the number of women needing biopsy from 80 to 134 without detecting additional malignancy. MRI Breast Without and With IV Contrast Although MRI does have greater sensitivity for malignancy than diagnostic mammogram alone, this use serves to detect asymptomatic disease. If there is a finding on the mammogram or US, then workup may be performed based on the most suspicious finding identified during the standard diagnostic workup. A mammographic finding can be sampled using tomosynthesis or stereotactic biopsy, and a sonographic finding can be sampled using US-guided biopsy. If mammogram and US are unrevealing, MRI is not useful as a problem-solving test, and, therefore, further management should be based upon the clinical symptoms. For example, evidence does not support the use of MRI Imaging of Invasive Breast Cancer in cases of a palpable breast mass without corresponding suspicious finding on mammography or US. In a study, 2 of 82 patients were subsequently diagnosed with malignancy with PPV of 25% [204], and in another, 3 of 167 women with PPV of 13% [205]. Finally, a third study starting with 22,004 women with palpable abnormalities demonstrated 9,334 with negative mammogram and/or US. Thirty-one of these patients underwent subsequent MRI, with 8 subsequent biopsies and no malignancies found [206]. MRI Breast Without IV Contrast There is no role for noncontrast MRI in the setting of suspected local recurrence based on signs and symptoms. | Imaging of Invasive Breast Cancer. Mammography With IV Contrast There are limited data on the use of CEM in breast cancer surveillance. Sorin et al [203] did show a high incremental cancer detection rate (13.1 cancers per 1,000 women) when mammography with IV contrast replaced DM in patients with a personal history of breast cancer or with an intermediate lifetime risk. US (targeted and whole breast) increased the number of women needing biopsy from 80 to 134 without detecting additional malignancy. MRI Breast Without and With IV Contrast Although MRI does have greater sensitivity for malignancy than diagnostic mammogram alone, this use serves to detect asymptomatic disease. If there is a finding on the mammogram or US, then workup may be performed based on the most suspicious finding identified during the standard diagnostic workup. A mammographic finding can be sampled using tomosynthesis or stereotactic biopsy, and a sonographic finding can be sampled using US-guided biopsy. If mammogram and US are unrevealing, MRI is not useful as a problem-solving test, and, therefore, further management should be based upon the clinical symptoms. For example, evidence does not support the use of MRI Imaging of Invasive Breast Cancer in cases of a palpable breast mass without corresponding suspicious finding on mammography or US. In a study, 2 of 82 patients were subsequently diagnosed with malignancy with PPV of 25% [204], and in another, 3 of 167 women with PPV of 13% [205]. Finally, a third study starting with 22,004 women with palpable abnormalities demonstrated 9,334 with negative mammogram and/or US. Thirty-one of these patients underwent subsequent MRI, with 8 subsequent biopsies and no malignancies found [206]. MRI Breast Without IV Contrast There is no role for noncontrast MRI in the setting of suspected local recurrence based on signs and symptoms. | 3186697 |
acrac_3186697_47 | Imaging of Invasive Breast Cancer | US breast may be helpful to further evaluate women with suspected recurrence unless the findings on mammography corresponding to the physical examination finding are classic for a benign etiology (eg, fat necrosis). Variant 9: Suspected local recurrence of breast cancer based on symptoms, physical examination, or laboratory value in patient with history of mastectomy. Regardless of clinical stage at time of original presentation. Digital Breast Tomosynthesis Diagnostic There is no evidence to support the use of DBT to evaluate suspected local recurrence in the setting of mastectomy unless the local recurrence suspected is in the axillary region or the patient has a history of breast reconstruction. FDG-PET/CT Skull Base to Mid-Thigh There is no evidence to support the use of FDG-PET/CT to evaluate suspected local recurrence in the setting of mastectomy. Mammography Diagnostic There is no evidence to support the use of mammography to evaluate suspected local recurrence in the setting of mastectomy unless the local recurrence suspected is in the axillary region or the patient has a history of breast reconstruction. Mammography With IV Contrast There is no evidence to support the use of mammography with IV contrast to evaluate suspected local recurrence in the setting of mastectomy unless the local recurrence suspected is in the axillary region or the patient has a history of breast reconstruction. MRI Breast Without and With IV Contrast Although breast MR has been evaluated in the setting of asymptomatic screening after mastectomy, there is insufficient evidence to support the use of MR as a problem-solving tool after a negative mammogram (axillary finding/reconstructed breast) and/or US. Therefore, management should be based on clinical suspicion rather than additional imaging. MRI Breast Without IV Contrast There is no evidence to support the use of noncontrast breast MRI in evaluating disease suspected recurrence. Variant 10: Surveillance. | Imaging of Invasive Breast Cancer. US breast may be helpful to further evaluate women with suspected recurrence unless the findings on mammography corresponding to the physical examination finding are classic for a benign etiology (eg, fat necrosis). Variant 9: Suspected local recurrence of breast cancer based on symptoms, physical examination, or laboratory value in patient with history of mastectomy. Regardless of clinical stage at time of original presentation. Digital Breast Tomosynthesis Diagnostic There is no evidence to support the use of DBT to evaluate suspected local recurrence in the setting of mastectomy unless the local recurrence suspected is in the axillary region or the patient has a history of breast reconstruction. FDG-PET/CT Skull Base to Mid-Thigh There is no evidence to support the use of FDG-PET/CT to evaluate suspected local recurrence in the setting of mastectomy. Mammography Diagnostic There is no evidence to support the use of mammography to evaluate suspected local recurrence in the setting of mastectomy unless the local recurrence suspected is in the axillary region or the patient has a history of breast reconstruction. Mammography With IV Contrast There is no evidence to support the use of mammography with IV contrast to evaluate suspected local recurrence in the setting of mastectomy unless the local recurrence suspected is in the axillary region or the patient has a history of breast reconstruction. MRI Breast Without and With IV Contrast Although breast MR has been evaluated in the setting of asymptomatic screening after mastectomy, there is insufficient evidence to support the use of MR as a problem-solving tool after a negative mammogram (axillary finding/reconstructed breast) and/or US. Therefore, management should be based on clinical suspicion rather than additional imaging. MRI Breast Without IV Contrast There is no evidence to support the use of noncontrast breast MRI in evaluating disease suspected recurrence. Variant 10: Surveillance. | 3186697 |
acrac_3186697_48 | Imaging of Invasive Breast Cancer | Regardless of clinical stage of breast cancer at time of original presentation. Evaluation for distant metastatic disease. Bone Scan Whole Body In asymptomatic patients with a history of breast cancer who received treatment for curative intent, there is no evidence to support the use of bone scan whole body for surveillance of distant metastatic disease. The ASCO, NCCN, ESMO, and ESO all recommend against the routine use of imaging to screen for distant disease recurrence [126,128,209,210]. Imaging of Invasive Breast Cancer CT Chest, Abdomen, and Pelvis With IV Contrast In asymptomatic patients with a history of breast cancer who received treatment for curative intent, there is no evidence to support the use of CT chest, abdomen, and pelvis for surveillance of distant metastatic disease. The ASCO, NCCN, ESMO, and ESO all recommend against the routine use of imaging to screen for distant disease recurrence [126,128,209,210]. CT Chest, Abdomen, and Pelvis Without and With IV Contrast In asymptomatic patients with a history of breast cancer who received treatment for curative intent, there is no evidence to support the use of CT chest, abdomen, and pelvis for surveillance of distant metastatic disease. The ASCO, NCCN, ESMO, and ESO all recommend against the routine use of imaging to screen for distant disease recurrence [126,128,209,210]. CT Chest, Abdomen, and Pelvis Without IV Contrast In asymptomatic patients with a history of breast cancer who received treatment for curative intent, there is no evidence to support the use of CT chest, abdomen, and pelvis for surveillance of distant metastatic disease. The ASCO, NCCN, ESMO, and ESO all recommend against the routine use of imaging to screen for distant disease recurrence [126,128,209,210]. Digital Breast Tomosynthesis Diagnostic There is no evidence to support the use of DBT in asymptomatic women for surveillance of distant metastatic disease. | Imaging of Invasive Breast Cancer. Regardless of clinical stage of breast cancer at time of original presentation. Evaluation for distant metastatic disease. Bone Scan Whole Body In asymptomatic patients with a history of breast cancer who received treatment for curative intent, there is no evidence to support the use of bone scan whole body for surveillance of distant metastatic disease. The ASCO, NCCN, ESMO, and ESO all recommend against the routine use of imaging to screen for distant disease recurrence [126,128,209,210]. Imaging of Invasive Breast Cancer CT Chest, Abdomen, and Pelvis With IV Contrast In asymptomatic patients with a history of breast cancer who received treatment for curative intent, there is no evidence to support the use of CT chest, abdomen, and pelvis for surveillance of distant metastatic disease. The ASCO, NCCN, ESMO, and ESO all recommend against the routine use of imaging to screen for distant disease recurrence [126,128,209,210]. CT Chest, Abdomen, and Pelvis Without and With IV Contrast In asymptomatic patients with a history of breast cancer who received treatment for curative intent, there is no evidence to support the use of CT chest, abdomen, and pelvis for surveillance of distant metastatic disease. The ASCO, NCCN, ESMO, and ESO all recommend against the routine use of imaging to screen for distant disease recurrence [126,128,209,210]. CT Chest, Abdomen, and Pelvis Without IV Contrast In asymptomatic patients with a history of breast cancer who received treatment for curative intent, there is no evidence to support the use of CT chest, abdomen, and pelvis for surveillance of distant metastatic disease. The ASCO, NCCN, ESMO, and ESO all recommend against the routine use of imaging to screen for distant disease recurrence [126,128,209,210]. Digital Breast Tomosynthesis Diagnostic There is no evidence to support the use of DBT in asymptomatic women for surveillance of distant metastatic disease. | 3186697 |
acrac_3186697_49 | Imaging of Invasive Breast Cancer | FDG-PET/CT Skull Base to Mid-Thigh In asymptomatic patients with a history of breast cancer who received treatment for curative intent, there is no evidence to support the use of FDG-PET/CT for surveillance of distant metastatic disease. The ASCO, NCCN, ESMO, and ESO all recommend against the routine use of imaging to screen for distant disease recurrence [126,128,209,210]. Mammography Diagnostic There is no evidence to support the use of mammography to evaluate suspected distant metastatic disease unless the recurrence suspected is in the axillary region. MRI Head Without and With IV Contrast There is no evidence supporting the use of MRI head without and with IV contrast in asymptomatic women for surveillance. In asymptomatic patients with a history of breast cancer who received treatment for curative intent, there is no role for imaging to screen for distant recurrences. The ASCO, NCCN, ESMO, and ESO all recommend against the routine use of imaging to screen for distant disease recurrence [126,128,209,210]. MRI Head Without IV Contrast There is no evidence supporting the use of MRI head without IV contrast in asymptomatic women for surveillance. US Axilla There is no evidence supporting the use of US axilla in asymptomatic women for surveillance of distant metastatic disease. Variant 11: Suspected distant recurrence of breast cancer based on symptoms, physical examination, or laboratory value. Regardless of clinical stage at time of original presentation. Bone Scan Whole Body In the setting of suspected distant recurrence, bone scan along with chest, abdomen, and pelvis CT is recommended by the NCCN [126]. CT Chest, Abdomen, and Pelvis With IV Contrast In the setting of suspected distant recurrence, bone scan plus chest, abdomen, and pelvis CT is recommended by the NCCN [172]. | Imaging of Invasive Breast Cancer. FDG-PET/CT Skull Base to Mid-Thigh In asymptomatic patients with a history of breast cancer who received treatment for curative intent, there is no evidence to support the use of FDG-PET/CT for surveillance of distant metastatic disease. The ASCO, NCCN, ESMO, and ESO all recommend against the routine use of imaging to screen for distant disease recurrence [126,128,209,210]. Mammography Diagnostic There is no evidence to support the use of mammography to evaluate suspected distant metastatic disease unless the recurrence suspected is in the axillary region. MRI Head Without and With IV Contrast There is no evidence supporting the use of MRI head without and with IV contrast in asymptomatic women for surveillance. In asymptomatic patients with a history of breast cancer who received treatment for curative intent, there is no role for imaging to screen for distant recurrences. The ASCO, NCCN, ESMO, and ESO all recommend against the routine use of imaging to screen for distant disease recurrence [126,128,209,210]. MRI Head Without IV Contrast There is no evidence supporting the use of MRI head without IV contrast in asymptomatic women for surveillance. US Axilla There is no evidence supporting the use of US axilla in asymptomatic women for surveillance of distant metastatic disease. Variant 11: Suspected distant recurrence of breast cancer based on symptoms, physical examination, or laboratory value. Regardless of clinical stage at time of original presentation. Bone Scan Whole Body In the setting of suspected distant recurrence, bone scan along with chest, abdomen, and pelvis CT is recommended by the NCCN [126]. CT Chest, Abdomen, and Pelvis With IV Contrast In the setting of suspected distant recurrence, bone scan plus chest, abdomen, and pelvis CT is recommended by the NCCN [172]. | 3186697 |
acrac_3186697_50 | Imaging of Invasive Breast Cancer | CT Chest, Abdomen, and Pelvis Without and With IV Contrast The majority of clinical questions for abdominal and/or pelvic CT can be appropriately answered with a single- phase study as detailed in the ACR-SABI-SPR practice parameter for the performance of CT of the abdomen and CT of the pelvis [21]. Imaging of Invasive Breast Cancer CT Chest, Abdomen, and Pelvis Without IV Contrast There is no evidence to support the use of CT chest, abdomen, and pelvis without IV contrast to evaluate for distant recurrence. FDG-PET/CT Skull Base to Mid-Thigh In symptomatic patients with a history of breast cancer who received treatment for curative intent, PET/CT can be used to evaluate for recurrence according to NCCN guidelines [126]. Imaging of Invasive Breast Cancer Supporting Documents The evidence table, literature search, and appendix for this topic are available at https://acsearch. acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation. For additional information on the Appropriateness Criteria methodology and other supporting documents go to www. acr.org/ac. Appropriateness Category Names and Definitions Relative Radiation Level Information Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). | Imaging of Invasive Breast Cancer. CT Chest, Abdomen, and Pelvis Without and With IV Contrast The majority of clinical questions for abdominal and/or pelvic CT can be appropriately answered with a single- phase study as detailed in the ACR-SABI-SPR practice parameter for the performance of CT of the abdomen and CT of the pelvis [21]. Imaging of Invasive Breast Cancer CT Chest, Abdomen, and Pelvis Without IV Contrast There is no evidence to support the use of CT chest, abdomen, and pelvis without IV contrast to evaluate for distant recurrence. FDG-PET/CT Skull Base to Mid-Thigh In symptomatic patients with a history of breast cancer who received treatment for curative intent, PET/CT can be used to evaluate for recurrence according to NCCN guidelines [126]. Imaging of Invasive Breast Cancer Supporting Documents The evidence table, literature search, and appendix for this topic are available at https://acsearch. acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation. For additional information on the Appropriateness Criteria methodology and other supporting documents go to www. acr.org/ac. Appropriateness Category Names and Definitions Relative Radiation Level Information Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). | 3186697 |
acrac_69466_0 | Clinically Suspected Adnexal Mass No Acute Symptoms | Introduction/Background Ovarian cancer is the fifth leading cause of cancer mortality among women in the United States, showing little improvement in survival over the last several decades [1,2]. In 2023, it is estimated that 19,710 women will be diagnosed with ovarian cancer in the United States, and 13,270 will die from their disease [3]. Prognostic factors associated with survival include both stage at diagnosis and treatment at a high-volume center with management by a gynecologist oncologist [4,5]. High-grade serous carcinoma, now thought to arise typically from fallopian tube epithelium, is most often diagnosed at late stage and accounts for nearly 80% of ovarian cancer deaths [1,6]. Identification of early-stage cancers is paramount for cancer-specific survival in ovarian cancer, but only 16% of patients are diagnosed at early stages. Although the 5-year relative survival for ovarian cancer is 49.1%, it increases to nearly 93% for stage I disease (confined to the ovaries/adnexa) [3]. Special Imaging Considerations Contrast-enhanced ultrasound: Contrast-enhanced ultrasound (CEUS) can be a useful real-time technique to demonstrate the presence of internal vascular soft tissue component in an indeterminate ovarian lesion that increases the risk of malignancy. Soft tissue enhancing earlier than or concurrent to the myometrium was found in 93.8% of malignant lesions in 1 study compared with 12.5% of benign lesions [11]. The International Ovarian Tumor Analysis (IOTA) simple rules performed well when applied to CEUS in 1 study, with reduction in indeterminate masses from 36.7% to 11.7% when using CEUS after conventional pelvic ultrasound (US) in a surgical cohort of suspected malignant masses [12]. Three-dimensional CEUS and 3-D contrast-enhanced power Doppler may be useful as adjunct to conventional US and 2-D CEUS [13,14]. | Clinically Suspected Adnexal Mass No Acute Symptoms. Introduction/Background Ovarian cancer is the fifth leading cause of cancer mortality among women in the United States, showing little improvement in survival over the last several decades [1,2]. In 2023, it is estimated that 19,710 women will be diagnosed with ovarian cancer in the United States, and 13,270 will die from their disease [3]. Prognostic factors associated with survival include both stage at diagnosis and treatment at a high-volume center with management by a gynecologist oncologist [4,5]. High-grade serous carcinoma, now thought to arise typically from fallopian tube epithelium, is most often diagnosed at late stage and accounts for nearly 80% of ovarian cancer deaths [1,6]. Identification of early-stage cancers is paramount for cancer-specific survival in ovarian cancer, but only 16% of patients are diagnosed at early stages. Although the 5-year relative survival for ovarian cancer is 49.1%, it increases to nearly 93% for stage I disease (confined to the ovaries/adnexa) [3]. Special Imaging Considerations Contrast-enhanced ultrasound: Contrast-enhanced ultrasound (CEUS) can be a useful real-time technique to demonstrate the presence of internal vascular soft tissue component in an indeterminate ovarian lesion that increases the risk of malignancy. Soft tissue enhancing earlier than or concurrent to the myometrium was found in 93.8% of malignant lesions in 1 study compared with 12.5% of benign lesions [11]. The International Ovarian Tumor Analysis (IOTA) simple rules performed well when applied to CEUS in 1 study, with reduction in indeterminate masses from 36.7% to 11.7% when using CEUS after conventional pelvic ultrasound (US) in a surgical cohort of suspected malignant masses [12]. Three-dimensional CEUS and 3-D contrast-enhanced power Doppler may be useful as adjunct to conventional US and 2-D CEUS [13,14]. | 69466 |
acrac_69466_1 | Clinically Suspected Adnexal Mass No Acute Symptoms | In a meta-analysis, CEUS had higher accuracy for differentiating benign and malignant lesions than conventional US (94% versus 83%); however, further evaluation of the clinical use of CEUS is needed [15]. aVanderbilt University Medical Center, Nashville, Tennessee. bPanel Chair, University of Michigan, Ann Arbor, Michigan. cThe George Washington University Medical Center, Washington, District of Columbia; Commission on Nuclear Medicine and Molecular Imaging. dVanderbilt University Medical Center, Nashville, Tennessee; O-RADS Committee. eMedstar Georgetown University Hospital, Washington, District of Columbia. fBeth Israel Deaconess Medical Center, Boston, Massachusetts. gUniversity of California San Diego, San Diego, California; American College of Obstetricians and Gynecologists. hCleveland Clinic, Cleveland, Ohio. iHospital of the University of Pennsylvania, Philadelphia, Pennsylvania. jAscension St. Vincent's, Jacksonville, Florida and University of South Florida, Tampa, Florida; Gynecologic oncologist. kMayo Clinic Arizona, Phoenix, Arizona; IF Committee. lDepartment of Medical Imaging, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada. mYale University School of Medicine, New Haven, Connecticut; Committee on Emergency Radiology-GSER. nMayo Clinic, Rochester, Minnesota. oUniversity of California San Diego, San Diego, California; Commission on Radiation Oncology. pSpecialty Chair, New York University Medical Center, New York, New York. Reprint requests to: [email protected] OR Discussion of Procedures by Variant Variant 1: Adult patient assigned female at birth. Clinically suspected adnexal mass, no acute symptoms. Premenopausal or postmenopausal. Initial imaging. CT Pelvis With IV Contrast CT pelvis with intravenous (IV) contrast is typically not useful for the initial workup and characterization of adnexal masses due to suboptimal delineation of soft tissue in the adnexal region. | Clinically Suspected Adnexal Mass No Acute Symptoms. In a meta-analysis, CEUS had higher accuracy for differentiating benign and malignant lesions than conventional US (94% versus 83%); however, further evaluation of the clinical use of CEUS is needed [15]. aVanderbilt University Medical Center, Nashville, Tennessee. bPanel Chair, University of Michigan, Ann Arbor, Michigan. cThe George Washington University Medical Center, Washington, District of Columbia; Commission on Nuclear Medicine and Molecular Imaging. dVanderbilt University Medical Center, Nashville, Tennessee; O-RADS Committee. eMedstar Georgetown University Hospital, Washington, District of Columbia. fBeth Israel Deaconess Medical Center, Boston, Massachusetts. gUniversity of California San Diego, San Diego, California; American College of Obstetricians and Gynecologists. hCleveland Clinic, Cleveland, Ohio. iHospital of the University of Pennsylvania, Philadelphia, Pennsylvania. jAscension St. Vincent's, Jacksonville, Florida and University of South Florida, Tampa, Florida; Gynecologic oncologist. kMayo Clinic Arizona, Phoenix, Arizona; IF Committee. lDepartment of Medical Imaging, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada. mYale University School of Medicine, New Haven, Connecticut; Committee on Emergency Radiology-GSER. nMayo Clinic, Rochester, Minnesota. oUniversity of California San Diego, San Diego, California; Commission on Radiation Oncology. pSpecialty Chair, New York University Medical Center, New York, New York. Reprint requests to: [email protected] OR Discussion of Procedures by Variant Variant 1: Adult patient assigned female at birth. Clinically suspected adnexal mass, no acute symptoms. Premenopausal or postmenopausal. Initial imaging. CT Pelvis With IV Contrast CT pelvis with intravenous (IV) contrast is typically not useful for the initial workup and characterization of adnexal masses due to suboptimal delineation of soft tissue in the adnexal region. | 69466 |
acrac_69466_2 | Clinically Suspected Adnexal Mass No Acute Symptoms | The presence of macroscopic fat, with or without the presence of calcification and/or Rokitansky nodule, is diagnostic of a dermoid if seen on CT. CT Pelvis Without and With IV Contrast CT pelvis without and with IV contrast is typically not useful for the initial workup and characterization of adnexal masses due to suboptimal delineation of soft tissue in the adnexal region. The presence of macroscopic fat, with or without the presence of calcification and/or Rokitansky nodule, is diagnostic of a dermoid if seen on CT. CT Pelvis Without IV Contrast CT pelvis without IV contrast is typically not useful for the initial workup and characterization of adnexal masses due to suboptimal delineation of soft tissue in the adnexal region. The presence of macroscopic fat, with or without the presence of calcification and/or Rokitansky nodule, is diagnostic of a dermoid if seen on CT. FDG-PET/CT Skull Base to Mid-Thigh Fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET/CT is not useful for the initial workup and characterization of adnexal masses due to suboptimal delineation of soft tissue in the adnexal region. MRI Pelvis Without and With IV Contrast MRI can accurately diagnose the presence of adnexal lesions and identify enhancing soft tissue as well as other distinguishing characteristics such as the type of fluid content, presence of fat, or presence of septations in a cystic lesion. It performs superior to US; however, it is not the first-line modality for initial evaluation [16,17]. If a patient with a suspected adnexal lesion is unable to be evaluated via US (due to large size of lesion >10 cm, poor acoustic window from adjacent viscera or body habitus, or unclear organ of origin), MRI would be the best alternative imaging modality for evaluation. MRI Pelvis Without IV Contrast If MRI is being used for evaluation of a suspected adnexal lesion, IV contrast is recommended to evaluate for any internal enhancing component. | Clinically Suspected Adnexal Mass No Acute Symptoms. The presence of macroscopic fat, with or without the presence of calcification and/or Rokitansky nodule, is diagnostic of a dermoid if seen on CT. CT Pelvis Without and With IV Contrast CT pelvis without and with IV contrast is typically not useful for the initial workup and characterization of adnexal masses due to suboptimal delineation of soft tissue in the adnexal region. The presence of macroscopic fat, with or without the presence of calcification and/or Rokitansky nodule, is diagnostic of a dermoid if seen on CT. CT Pelvis Without IV Contrast CT pelvis without IV contrast is typically not useful for the initial workup and characterization of adnexal masses due to suboptimal delineation of soft tissue in the adnexal region. The presence of macroscopic fat, with or without the presence of calcification and/or Rokitansky nodule, is diagnostic of a dermoid if seen on CT. FDG-PET/CT Skull Base to Mid-Thigh Fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET/CT is not useful for the initial workup and characterization of adnexal masses due to suboptimal delineation of soft tissue in the adnexal region. MRI Pelvis Without and With IV Contrast MRI can accurately diagnose the presence of adnexal lesions and identify enhancing soft tissue as well as other distinguishing characteristics such as the type of fluid content, presence of fat, or presence of septations in a cystic lesion. It performs superior to US; however, it is not the first-line modality for initial evaluation [16,17]. If a patient with a suspected adnexal lesion is unable to be evaluated via US (due to large size of lesion >10 cm, poor acoustic window from adjacent viscera or body habitus, or unclear organ of origin), MRI would be the best alternative imaging modality for evaluation. MRI Pelvis Without IV Contrast If MRI is being used for evaluation of a suspected adnexal lesion, IV contrast is recommended to evaluate for any internal enhancing component. | 69466 |
acrac_69466_3 | Clinically Suspected Adnexal Mass No Acute Symptoms | Contrast-enhanced MRI performs superiorly to both US and noncontrast MRI due to its ability to confirm the presence of internal enhancing soft tissue components [18]. A recent study evaluating the usefulness of noncontrast MRI in 350 lesions in a population with 15% malignancies demonstrated a sensitivity of 85%, specificity of 96%, and accuracy of 94.2% to detect cancer [19]. Noncontrast MRI may be used in adnexal mass characterization when the use of IV contrast is precluded. US Duplex Doppler Pelvis Although considered a separate examination in the ACR documentation, color and power Doppler evaluation is considered an integral part of the complete transabdominal and transvaginal sonographic assessment of an adnexal lesion. Doppler can help identify internal soft tissue with vascular flow within a suspected adnexal lesion that can help differentiate a malignancy from a solid-appearing component such as a clot or debris [20-22]. Optimal sonographic evaluation is achieved by using a combination of grayscale morphologic assessment and color or power Doppler imaging to detect flow within any solid areas. Color Doppler characteristics, namely a color score of 1 to US Pelvis Transabdominal Transabdominal US may be performed without transvaginal imaging when the transvaginal examination cannot be tolerated. A full bladder provides a better acoustic window for the evaluation of pelvis/adnexa. US Pelvis Transabdominal and US Pelvis Transvaginal Transvaginal US is the most useful initial imaging modality in the assessment of adnexal pathology with a sensitivity >90%, and diagnostic performance is likely improved when undertaken by experienced operators [27,28]. It is widely accepted clinically as the initial imaging modality of choice [29-31]. | Clinically Suspected Adnexal Mass No Acute Symptoms. Contrast-enhanced MRI performs superiorly to both US and noncontrast MRI due to its ability to confirm the presence of internal enhancing soft tissue components [18]. A recent study evaluating the usefulness of noncontrast MRI in 350 lesions in a population with 15% malignancies demonstrated a sensitivity of 85%, specificity of 96%, and accuracy of 94.2% to detect cancer [19]. Noncontrast MRI may be used in adnexal mass characterization when the use of IV contrast is precluded. US Duplex Doppler Pelvis Although considered a separate examination in the ACR documentation, color and power Doppler evaluation is considered an integral part of the complete transabdominal and transvaginal sonographic assessment of an adnexal lesion. Doppler can help identify internal soft tissue with vascular flow within a suspected adnexal lesion that can help differentiate a malignancy from a solid-appearing component such as a clot or debris [20-22]. Optimal sonographic evaluation is achieved by using a combination of grayscale morphologic assessment and color or power Doppler imaging to detect flow within any solid areas. Color Doppler characteristics, namely a color score of 1 to US Pelvis Transabdominal Transabdominal US may be performed without transvaginal imaging when the transvaginal examination cannot be tolerated. A full bladder provides a better acoustic window for the evaluation of pelvis/adnexa. US Pelvis Transabdominal and US Pelvis Transvaginal Transvaginal US is the most useful initial imaging modality in the assessment of adnexal pathology with a sensitivity >90%, and diagnostic performance is likely improved when undertaken by experienced operators [27,28]. It is widely accepted clinically as the initial imaging modality of choice [29-31]. | 69466 |
acrac_69466_4 | Clinically Suspected Adnexal Mass No Acute Symptoms | Initial evaluation by transabdominal and transvaginal US can often definitively characterize ovarian lesions, specifically those that demonstrate classically benign US features (eg, follicles, functional cysts, hemorrhagic cysts, dermoids, and endometriomas). Lesions that demonstrate solid components such as irregular thick septations, papillary projections, or mural nodules have variable risk of malignancy. Various US and combined US/clinical based criteria have been proposed for standardized interpretation and characterization of adnexal masses to improve risk-stratified management of these lesions [23,24,32-37]. These includes the IOTA simple rules, O-RADS, Society of Radiologists in Ultrasound (SRU) consensus statement for incidental adnexal masses, and Assessment of Different NEoplasias in the adneXa (ADNEX) model. These are beyond the scope of discussion for this document, and the readers are directed to the respective literature for details [23,24,34,37-41]. These systems use some combination of classically benign imaging features, lesion size, locularity, size and number of solid components, and degree of vascularity for categorization and determining overall risk of malignancy. The SRU consensus statement [42] has been shown to decrease unnecessary follow-up care of benign adnexal lesions, correlate with the risk of malignancy in symptomatic women, and demonstrate high sensitivity and specificity for detecting ovarian malignancy [43-45]. O-RADS [23,38] has demonstrated significantly higher sensitivity for malignancy than the IOTA simple rules (96.8% versus 92.1%) and no significant difference in specificity (92.8% versus 93.2%) [46]. Combined transvaginal and transabdominal technique allows for the identification of pertinent features relevant for characterization and categorization of these lesions. | Clinically Suspected Adnexal Mass No Acute Symptoms. Initial evaluation by transabdominal and transvaginal US can often definitively characterize ovarian lesions, specifically those that demonstrate classically benign US features (eg, follicles, functional cysts, hemorrhagic cysts, dermoids, and endometriomas). Lesions that demonstrate solid components such as irregular thick septations, papillary projections, or mural nodules have variable risk of malignancy. Various US and combined US/clinical based criteria have been proposed for standardized interpretation and characterization of adnexal masses to improve risk-stratified management of these lesions [23,24,32-37]. These includes the IOTA simple rules, O-RADS, Society of Radiologists in Ultrasound (SRU) consensus statement for incidental adnexal masses, and Assessment of Different NEoplasias in the adneXa (ADNEX) model. These are beyond the scope of discussion for this document, and the readers are directed to the respective literature for details [23,24,34,37-41]. These systems use some combination of classically benign imaging features, lesion size, locularity, size and number of solid components, and degree of vascularity for categorization and determining overall risk of malignancy. The SRU consensus statement [42] has been shown to decrease unnecessary follow-up care of benign adnexal lesions, correlate with the risk of malignancy in symptomatic women, and demonstrate high sensitivity and specificity for detecting ovarian malignancy [43-45]. O-RADS [23,38] has demonstrated significantly higher sensitivity for malignancy than the IOTA simple rules (96.8% versus 92.1%) and no significant difference in specificity (92.8% versus 93.2%) [46]. Combined transvaginal and transabdominal technique allows for the identification of pertinent features relevant for characterization and categorization of these lesions. | 69466 |
acrac_69466_5 | Clinically Suspected Adnexal Mass No Acute Symptoms | The transvaginal component allows for detailed evaluation with the transabdominal component helpful for larger lesions that may be suboptimally seen transvaginally. US Pelvis Transvaginal The most useful modality for evaluation of adnexal masses includes transvaginal US combined with a transabdominal US approach. Variant 2: Adult patient assigned female at birth. Adnexal mass, likely benign, no acute symptoms. Premenopausal. Follow-up imaging. CT Pelvis With IV Contrast CT pelvis with IV contrast is usually not useful to follow likely or known benign adnexal masses. Because the roles of US and MRI are well established, there is little reason presently to obtain a CT for benign mass follow-up. CT Pelvis Without and With IV Contrast CT pelvis without and with IV contrast is usually not useful to follow likely or known benign adnexal masses. Because the roles of US and MRI are well established, there is little reason presently to obtain a CT for benign mass follow-up. CT Pelvis Without IV Contrast CT pelvis without IV contrast is usually not useful to follow likely or known benign adnexal masses. Because the roles of US and MRI are well established, there is little reason presently to obtain a CT for benign mass follow-up. Clinically Suspected Adnexal Mass FDG-PET/CT Skull Base to Mid-Thigh There is no role for the use of FDG-PET/CT in the follow-up of benign adnexal masses in premenopausal patients. MRI Pelvis Without and With IV Contrast Although MRI can accurately characterize these benign lesions, it is not the first-line modality [16,17]. If a known lesion requiring surveillance is unable to be followed via US, MRI would be the alternative imaging modality of choice for follow-up. Classically benign lesions such as simple cysts, endometriomas and dermoid, and extraovarian benign lesions have characteristic appearances on MRI and can be confidently diagnosed as almost certainly benign [17]. | Clinically Suspected Adnexal Mass No Acute Symptoms. The transvaginal component allows for detailed evaluation with the transabdominal component helpful for larger lesions that may be suboptimally seen transvaginally. US Pelvis Transvaginal The most useful modality for evaluation of adnexal masses includes transvaginal US combined with a transabdominal US approach. Variant 2: Adult patient assigned female at birth. Adnexal mass, likely benign, no acute symptoms. Premenopausal. Follow-up imaging. CT Pelvis With IV Contrast CT pelvis with IV contrast is usually not useful to follow likely or known benign adnexal masses. Because the roles of US and MRI are well established, there is little reason presently to obtain a CT for benign mass follow-up. CT Pelvis Without and With IV Contrast CT pelvis without and with IV contrast is usually not useful to follow likely or known benign adnexal masses. Because the roles of US and MRI are well established, there is little reason presently to obtain a CT for benign mass follow-up. CT Pelvis Without IV Contrast CT pelvis without IV contrast is usually not useful to follow likely or known benign adnexal masses. Because the roles of US and MRI are well established, there is little reason presently to obtain a CT for benign mass follow-up. Clinically Suspected Adnexal Mass FDG-PET/CT Skull Base to Mid-Thigh There is no role for the use of FDG-PET/CT in the follow-up of benign adnexal masses in premenopausal patients. MRI Pelvis Without and With IV Contrast Although MRI can accurately characterize these benign lesions, it is not the first-line modality [16,17]. If a known lesion requiring surveillance is unable to be followed via US, MRI would be the alternative imaging modality of choice for follow-up. Classically benign lesions such as simple cysts, endometriomas and dermoid, and extraovarian benign lesions have characteristic appearances on MRI and can be confidently diagnosed as almost certainly benign [17]. | 69466 |
acrac_69466_6 | Clinically Suspected Adnexal Mass No Acute Symptoms | MRI Pelvis Without IV Contrast If MRI is being used for follow-up of a benign lesion, IV contrast is recommended to evaluate for any developing enhancing component. Contrast-enhanced MRI performs superiorly to both US and noncontrast MRI due to its ability to confirm the presence of internal enhancing soft tissue components [18]. A recent study evaluating the usefulness of noncontrast MRI in 350 lesions in a population with 15% malignancies and demonstrated a sensitivity of 85%, specificity of 96%, and accuracy of 94.2% to detect cancer [19]. Noncontrast MRI may be used in adnexal mass characterization when the use of IV contrast is precluded. US Duplex Doppler Pelvis Color or power Doppler should be included in the US examination of the pelvis. Color Duplex is used to evaluate vascularity of any developing solid component. US Pelvis Transabdominal Transabdominal US may be performed without transvaginal imaging when the transvaginal examination cannot be tolerated. The bladder should be full to provide the best acoustic window for evaluation. US Pelvis Transabdominal and US Pelvis Transvaginal US can accurately diagnose benign adnexal lesions including simple cysts, hemorrhagic cysts, endometriomas, and dermoids as well as extraovarian cystic lesions such as parovarian cysts, hydrosalpinx, and peritoneal inclusion cysts. Adnexal lesions that can be adequately assessed and characterized on US may be followed-up with US. The vast majority of simple cysts in premenopausal patients are functional cysts, which will wax and wane over time or resolve, with a small portion reflecting benign neoplasms. A large body of evidence including several large recent studies has shown that simple cysts, regardless of size and menopausal status, are not associated with an increased risk of cancer [35,47-49]. | Clinically Suspected Adnexal Mass No Acute Symptoms. MRI Pelvis Without IV Contrast If MRI is being used for follow-up of a benign lesion, IV contrast is recommended to evaluate for any developing enhancing component. Contrast-enhanced MRI performs superiorly to both US and noncontrast MRI due to its ability to confirm the presence of internal enhancing soft tissue components [18]. A recent study evaluating the usefulness of noncontrast MRI in 350 lesions in a population with 15% malignancies and demonstrated a sensitivity of 85%, specificity of 96%, and accuracy of 94.2% to detect cancer [19]. Noncontrast MRI may be used in adnexal mass characterization when the use of IV contrast is precluded. US Duplex Doppler Pelvis Color or power Doppler should be included in the US examination of the pelvis. Color Duplex is used to evaluate vascularity of any developing solid component. US Pelvis Transabdominal Transabdominal US may be performed without transvaginal imaging when the transvaginal examination cannot be tolerated. The bladder should be full to provide the best acoustic window for evaluation. US Pelvis Transabdominal and US Pelvis Transvaginal US can accurately diagnose benign adnexal lesions including simple cysts, hemorrhagic cysts, endometriomas, and dermoids as well as extraovarian cystic lesions such as parovarian cysts, hydrosalpinx, and peritoneal inclusion cysts. Adnexal lesions that can be adequately assessed and characterized on US may be followed-up with US. The vast majority of simple cysts in premenopausal patients are functional cysts, which will wax and wane over time or resolve, with a small portion reflecting benign neoplasms. A large body of evidence including several large recent studies has shown that simple cysts, regardless of size and menopausal status, are not associated with an increased risk of cancer [35,47-49]. | 69466 |
acrac_69466_7 | Clinically Suspected Adnexal Mass No Acute Symptoms | Invasive serous cystadenocarcinoma is now thought to primarily originate from solid precursors in the fallopian tube and serous tubal intraepithelial carcinoma, further supporting the benignity of simple ovarian cysts [50]. A recent consensus update to the SRU in 2019 regarding management of simple cysts reflects these findings with higher threshold for follow-up of simple cysts [42]. Namely, in premenopausal women, simple cysts, including paraovarian and paratubal cysts <5 cm, do not need to be followed. The rationale of follow- up for simple cysts >5 cm (and 7 cm for exceptionally well seen cysts) is based on a potential risk of mischaracterization of larger cysts and potential clinical value of size monitoring growth rates of larger cysts, which may reflect benign neoplasms and warrant clinical follow-up along with a very small predisposition for torsion or rupture [51]. Classic benign lesions include endometriomas, hemorrhagic cysts, and dermoids as well as benign extraovarian lesions such as paraovarian cysts, hydrosalpinx, and peritoneal inclusion cysts have characteristic appearances on US [23,34]. Hemorrhagic functional cysts will decrease or resolve on sonographic follow-up in 8 to 12 weeks versus nonfunctional cysts, which will persist. Endometriomas may change in appearance with age, losing the classic unilocular ground glass appearance with multilocular appearance and presence of nonvascular papillary or other solid components more common in older premenopausal women [52]. These changes can overlap with malignancy and endometriomas and require yearly follow-up due to a small risk of malignant transformation [53]. Sonographically diagnosed dermoids, if not excised, can be safely followed with yearly US with the risk of missing malignant degeneration quite low [54]. | Clinically Suspected Adnexal Mass No Acute Symptoms. Invasive serous cystadenocarcinoma is now thought to primarily originate from solid precursors in the fallopian tube and serous tubal intraepithelial carcinoma, further supporting the benignity of simple ovarian cysts [50]. A recent consensus update to the SRU in 2019 regarding management of simple cysts reflects these findings with higher threshold for follow-up of simple cysts [42]. Namely, in premenopausal women, simple cysts, including paraovarian and paratubal cysts <5 cm, do not need to be followed. The rationale of follow- up for simple cysts >5 cm (and 7 cm for exceptionally well seen cysts) is based on a potential risk of mischaracterization of larger cysts and potential clinical value of size monitoring growth rates of larger cysts, which may reflect benign neoplasms and warrant clinical follow-up along with a very small predisposition for torsion or rupture [51]. Classic benign lesions include endometriomas, hemorrhagic cysts, and dermoids as well as benign extraovarian lesions such as paraovarian cysts, hydrosalpinx, and peritoneal inclusion cysts have characteristic appearances on US [23,34]. Hemorrhagic functional cysts will decrease or resolve on sonographic follow-up in 8 to 12 weeks versus nonfunctional cysts, which will persist. Endometriomas may change in appearance with age, losing the classic unilocular ground glass appearance with multilocular appearance and presence of nonvascular papillary or other solid components more common in older premenopausal women [52]. These changes can overlap with malignancy and endometriomas and require yearly follow-up due to a small risk of malignant transformation [53]. Sonographically diagnosed dermoids, if not excised, can be safely followed with yearly US with the risk of missing malignant degeneration quite low [54]. | 69466 |
acrac_69466_8 | Clinically Suspected Adnexal Mass No Acute Symptoms | Clinically Suspected Adnexal Mass managed conservatively with 2-year follow-up was 0.3% to 0.4% for malignancy and 0.2% to 0.4% for acute complications such as torsion or cyst rupture [51]. Unilocular cysts, as a whole, in the premenopausal population similarly have a very low risk of malignancy. A recent meta-analysis by Parazzini et al [56] demonstrated that in 987 unilocular cysts removed surgically in premenopausal women, the risk of malignancy was 0.6%. Similar findings were found by Valentin et al [57], with a rate of malignancy of 0.5% in 981 surgically resected lesions. Surgical cohorts have a bias of increased risk of malignancy due to persistent cysts, and thus, this can be extrapolated into an even lower theoretical risk of malignancy in the general population. The most common benign solid adnexal mass is the uterine fibroid. Pedunculated lesions or broad ligament fibroids can often be mistaken for solid adnexal mass. Fibroids are present in up to 20% to 30% of reproductive age women, and the presence of bridging vessels can help identify uterine origin along with careful search for the ovaries [25]. US Pelvis Transvaginal The most useful modality for evaluation of adnexal masses includes transvaginal US combined with transabdominal US approach. Variant 3: Adult patient assigned female at birth. Adnexal mass, likely benign, no acute symptoms. Postmenopausal. Follow-up imaging. CT Pelvis With IV Contrast CT pelvis with IV contrast is usually not useful to follow likely or known benign adnexal masses. Because the roles of US and MRI are well established, there is little reason presently to obtain a CT for benign mass follow-up. CT Pelvis Without and With IV Contrast CT pelvis without and with IV contrast is usually not useful to follow likely or known benign adnexal masses. Because the roles of US and MRI are well established, there is little reason presently to obtain a CT for benign mass follow-up. | Clinically Suspected Adnexal Mass No Acute Symptoms. Clinically Suspected Adnexal Mass managed conservatively with 2-year follow-up was 0.3% to 0.4% for malignancy and 0.2% to 0.4% for acute complications such as torsion or cyst rupture [51]. Unilocular cysts, as a whole, in the premenopausal population similarly have a very low risk of malignancy. A recent meta-analysis by Parazzini et al [56] demonstrated that in 987 unilocular cysts removed surgically in premenopausal women, the risk of malignancy was 0.6%. Similar findings were found by Valentin et al [57], with a rate of malignancy of 0.5% in 981 surgically resected lesions. Surgical cohorts have a bias of increased risk of malignancy due to persistent cysts, and thus, this can be extrapolated into an even lower theoretical risk of malignancy in the general population. The most common benign solid adnexal mass is the uterine fibroid. Pedunculated lesions or broad ligament fibroids can often be mistaken for solid adnexal mass. Fibroids are present in up to 20% to 30% of reproductive age women, and the presence of bridging vessels can help identify uterine origin along with careful search for the ovaries [25]. US Pelvis Transvaginal The most useful modality for evaluation of adnexal masses includes transvaginal US combined with transabdominal US approach. Variant 3: Adult patient assigned female at birth. Adnexal mass, likely benign, no acute symptoms. Postmenopausal. Follow-up imaging. CT Pelvis With IV Contrast CT pelvis with IV contrast is usually not useful to follow likely or known benign adnexal masses. Because the roles of US and MRI are well established, there is little reason presently to obtain a CT for benign mass follow-up. CT Pelvis Without and With IV Contrast CT pelvis without and with IV contrast is usually not useful to follow likely or known benign adnexal masses. Because the roles of US and MRI are well established, there is little reason presently to obtain a CT for benign mass follow-up. | 69466 |
acrac_69466_9 | Clinically Suspected Adnexal Mass No Acute Symptoms | CT Pelvis Without IV Contrast CT pelvis without IV contrast is usually not useful to follow likely or known benign adnexal masses. Because the roles of US and MRI are well established, there is little reason presently to obtain a CT for benign mass follow-up. FDG-PET/CT Skull Base to Mid-Thigh There is no role for the use of FDG-PET/CT in the follow-up of benign adnexal masses in postmenopausal patients. MRI Pelvis Without and With IV Contrast Although MRI can accurately characterize these benign lesions, it is not the first-line imaging modality [16,17]. If a known lesion requiring surveillance is unable to be followed via US, MRI would be the alternative imaging modality of choice for follow-up. Classical benign lesions such as simple cysts, endometriomas and dermoid, and extraovarian benign lesions have characteristic appearances on MRI and can be confidently diagnosed as almost certainly benign [17]. MRI Pelvis Without IV Contrast If MRI is being used for follow-up of a benign lesion, IV contrast is recommended to evaluate for any developing enhancing component. Contrast-enhanced MRI performs superiorly to both US and noncontrast MRI due to its ability to confirm the presence of internal enhancing soft tissue components [18]. A recent study evaluating the usefulness of noncontrast MRI in 350 lesions in a population with 15% malignancies demonstrated a sensitivity of 85%, specificity of 96%, and accuracy of 94.2% to detect cancer [19]. Noncontrast MRI may be used in adnexal mass characterization when the use of IV contrast is precluded. US Duplex Doppler Pelvis Color or power Doppler should be included in the US examination of the pelvis. Color Duplex is used to evaluate vascularity of any developing solid component. US Pelvis Transabdominal Transabdominal US may be performed without transvaginal imaging when the transvaginal examination cannot be tolerated. The bladder should be full to provide the best acoustic window for evaluation. | Clinically Suspected Adnexal Mass No Acute Symptoms. CT Pelvis Without IV Contrast CT pelvis without IV contrast is usually not useful to follow likely or known benign adnexal masses. Because the roles of US and MRI are well established, there is little reason presently to obtain a CT for benign mass follow-up. FDG-PET/CT Skull Base to Mid-Thigh There is no role for the use of FDG-PET/CT in the follow-up of benign adnexal masses in postmenopausal patients. MRI Pelvis Without and With IV Contrast Although MRI can accurately characterize these benign lesions, it is not the first-line imaging modality [16,17]. If a known lesion requiring surveillance is unable to be followed via US, MRI would be the alternative imaging modality of choice for follow-up. Classical benign lesions such as simple cysts, endometriomas and dermoid, and extraovarian benign lesions have characteristic appearances on MRI and can be confidently diagnosed as almost certainly benign [17]. MRI Pelvis Without IV Contrast If MRI is being used for follow-up of a benign lesion, IV contrast is recommended to evaluate for any developing enhancing component. Contrast-enhanced MRI performs superiorly to both US and noncontrast MRI due to its ability to confirm the presence of internal enhancing soft tissue components [18]. A recent study evaluating the usefulness of noncontrast MRI in 350 lesions in a population with 15% malignancies demonstrated a sensitivity of 85%, specificity of 96%, and accuracy of 94.2% to detect cancer [19]. Noncontrast MRI may be used in adnexal mass characterization when the use of IV contrast is precluded. US Duplex Doppler Pelvis Color or power Doppler should be included in the US examination of the pelvis. Color Duplex is used to evaluate vascularity of any developing solid component. US Pelvis Transabdominal Transabdominal US may be performed without transvaginal imaging when the transvaginal examination cannot be tolerated. The bladder should be full to provide the best acoustic window for evaluation. | 69466 |
acrac_69466_10 | Clinically Suspected Adnexal Mass No Acute Symptoms | Clinically Suspected Adnexal Mass US Pelvis Transabdominal and US Pelvis Transvaginal Likely benign adnexal lesions that can be adequately assessed and characterized on US may be followed sonographically. A large body of evidence including several large recent screening studies has shown that unilocular simple cysts, regardless of size and menopausal status, are not associated with an increased risk of cancer [35,47-49]. In a large series, approximately 13% to 14% of women over 50 to 55 years of age, respectively, had simple ovarian cysts, with 8% demonstrating new cysts and 32% with no cyst at 1-year follow-up, with a near nonexistent risk of malignancy [47]. A second recent study of 72,093 women, those with simple cysts, demonstrated an absolute 3- year risk of ovarian cancer, 0 to 0.5 cases per 10,000 women, not dissimilar to women with normal ovaries [47,49]. Invasive serous cystadenocarcinoma is now primarily thought to originate from solid precursors in the fallopian tube, serous tubal intraepithelial carcinoma, further supporting the benignity of simple ovarian cysts [50]. A recent consensus update to the SRU in 2019 regarding management of simple cysts reflects these findings with higher threshold for follow-up of simple cysts [42]. For postmenopausal patients, the SRU endorses follow-up of simple cysts >3 cm (and 5 cm for those that are exceptionally well seen) rather than the previous 1-cm threshold [42,58]. The rationale of follow-up for simple cysts is based on a potential risk of mischaracterization of larger cysts and potential clinical value of size monitoring growth rates of larger cysts, which may reflect benign neoplasms and warrant clinical follow-up. Unilocular cysts, as a whole, in the postmenopausal population similarly have a very low risk of malignancy. | Clinically Suspected Adnexal Mass No Acute Symptoms. Clinically Suspected Adnexal Mass US Pelvis Transabdominal and US Pelvis Transvaginal Likely benign adnexal lesions that can be adequately assessed and characterized on US may be followed sonographically. A large body of evidence including several large recent screening studies has shown that unilocular simple cysts, regardless of size and menopausal status, are not associated with an increased risk of cancer [35,47-49]. In a large series, approximately 13% to 14% of women over 50 to 55 years of age, respectively, had simple ovarian cysts, with 8% demonstrating new cysts and 32% with no cyst at 1-year follow-up, with a near nonexistent risk of malignancy [47]. A second recent study of 72,093 women, those with simple cysts, demonstrated an absolute 3- year risk of ovarian cancer, 0 to 0.5 cases per 10,000 women, not dissimilar to women with normal ovaries [47,49]. Invasive serous cystadenocarcinoma is now primarily thought to originate from solid precursors in the fallopian tube, serous tubal intraepithelial carcinoma, further supporting the benignity of simple ovarian cysts [50]. A recent consensus update to the SRU in 2019 regarding management of simple cysts reflects these findings with higher threshold for follow-up of simple cysts [42]. For postmenopausal patients, the SRU endorses follow-up of simple cysts >3 cm (and 5 cm for those that are exceptionally well seen) rather than the previous 1-cm threshold [42,58]. The rationale of follow-up for simple cysts is based on a potential risk of mischaracterization of larger cysts and potential clinical value of size monitoring growth rates of larger cysts, which may reflect benign neoplasms and warrant clinical follow-up. Unilocular cysts, as a whole, in the postmenopausal population similarly have a very low risk of malignancy. | 69466 |
acrac_69466_11 | Clinically Suspected Adnexal Mass No Acute Symptoms | In a surgical cohort of 3,511 masses, 217 of which were unilocular cysts in postmenopausal women, the rate of malignancy was 3%, with hemorrhagic contents more common in malignant unilocular lesions [57]. In a second study of 15,106 women with 3,259 unilocular cystic lesions, there were 10 cancers detected over a 6.3-year period, none of which developed from the isolated cystic lesion [59]. A more recent meta-analysis demonstrated that of 372 unilocular cysts removed surgically in postmenopausal women, the risk of malignancy was 3.2% [56]. US Pelvis Transvaginal The most useful modality for evaluation of adnexal masses includes transvaginal US combined with transabdominal US approach. Variant 4: Adult patient assigned female at birth. Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Premenopausal or postmenopausal. Next imaging study for characterization. Up to 22% to 24% of adnexal masses remain indeterminate after US evaluation [61,62]. No single definition exists for these indeterminate lesions. Some examples include multilocular cysts, or lesions with avascular or low level vascular internal solid components. In a multicenter prospective study of 303 indeterminate adnexal cysts, the incidence of malignancy was 3.6% [61]. In a second multicenter prospective study of 697 women, the prevalence of malignancy in indeterminate lesions ranged from 4.8% to 10.7% using SRU guidelines and IOTA simple rules, respectively [45]. Lesions that are not classically benign appearing have a risk of malignancy ranging from 8% to 50% [55]. CT Pelvis With IV Contrast CT pelvis with IV contrast is usually not useful in further characterization of indeterminate adnexal masses. Because the role of MRI is well established, there is little reason presently to obtain a CT for further characterization of an indeterminate lesion. | Clinically Suspected Adnexal Mass No Acute Symptoms. In a surgical cohort of 3,511 masses, 217 of which were unilocular cysts in postmenopausal women, the rate of malignancy was 3%, with hemorrhagic contents more common in malignant unilocular lesions [57]. In a second study of 15,106 women with 3,259 unilocular cystic lesions, there were 10 cancers detected over a 6.3-year period, none of which developed from the isolated cystic lesion [59]. A more recent meta-analysis demonstrated that of 372 unilocular cysts removed surgically in postmenopausal women, the risk of malignancy was 3.2% [56]. US Pelvis Transvaginal The most useful modality for evaluation of adnexal masses includes transvaginal US combined with transabdominal US approach. Variant 4: Adult patient assigned female at birth. Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Premenopausal or postmenopausal. Next imaging study for characterization. Up to 22% to 24% of adnexal masses remain indeterminate after US evaluation [61,62]. No single definition exists for these indeterminate lesions. Some examples include multilocular cysts, or lesions with avascular or low level vascular internal solid components. In a multicenter prospective study of 303 indeterminate adnexal cysts, the incidence of malignancy was 3.6% [61]. In a second multicenter prospective study of 697 women, the prevalence of malignancy in indeterminate lesions ranged from 4.8% to 10.7% using SRU guidelines and IOTA simple rules, respectively [45]. Lesions that are not classically benign appearing have a risk of malignancy ranging from 8% to 50% [55]. CT Pelvis With IV Contrast CT pelvis with IV contrast is usually not useful in further characterization of indeterminate adnexal masses. Because the role of MRI is well established, there is little reason presently to obtain a CT for further characterization of an indeterminate lesion. | 69466 |
acrac_69466_12 | Clinically Suspected Adnexal Mass No Acute Symptoms | CT Pelvis Without and With IV Contrast CT pelvis without and with IV contrast is usually not useful in further characterization of indeterminate adnexal masses. Because the role of MRI is well established, there is little reason presently to obtain a CT for further characterization of an indeterminate lesion. Clinically Suspected Adnexal Mass CT Pelvis Without IV Contrast CT pelvis without IV contrast is usually not useful in further characterization of indeterminate adnexal masses. Because the role of MRI is well established, there is little reason presently to obtain a CT for further characterization of an indeterminate lesion. FDG-PET/CT Skull Base to Mid-Thigh PET/CT cannot reliability differentiate between benign and malignant adnexal lesions [63]. In premenopausal women, normal ovaries with late follicular or early luteal cysts can have mildly increased uptake [64]. Although maximum standardized update value (SUVmax) are higher in malignant tumors and low in benign lesions, there is no clear SUVmax cutoff value to differentiate the two [65]. Additionally, PET/CT cannot reliably differentiate between borderline tumors and benign lesions and has low uptake on clear cell and mucinous invasive adenocarcinoma subtypes [66,67]. Although PET-avid lesions in postmenopausal women are concerning for malignancy, its use to detect primary cancer is not recommended [68]. MRI Pelvis Without and With IV Contrast MRI is the most useful modality for further evaluation of the subset of lesions that remain indeterminate after sonographic evaluation [69]. A recent study assessing the SRU guidelines ability to risk stratify lesions demonstrated potential of MRI to decrease surgical evaluation for benign cysts by 89% [44]. MRI has an excellent accuracy of >90% for the diagnosis of malignancy [69-71]. MRI can accurately identify solid tissue from nonsolid tissue such as fat, blood, or debris that may appear solid on initial US [72]. | Clinically Suspected Adnexal Mass No Acute Symptoms. CT Pelvis Without and With IV Contrast CT pelvis without and with IV contrast is usually not useful in further characterization of indeterminate adnexal masses. Because the role of MRI is well established, there is little reason presently to obtain a CT for further characterization of an indeterminate lesion. Clinically Suspected Adnexal Mass CT Pelvis Without IV Contrast CT pelvis without IV contrast is usually not useful in further characterization of indeterminate adnexal masses. Because the role of MRI is well established, there is little reason presently to obtain a CT for further characterization of an indeterminate lesion. FDG-PET/CT Skull Base to Mid-Thigh PET/CT cannot reliability differentiate between benign and malignant adnexal lesions [63]. In premenopausal women, normal ovaries with late follicular or early luteal cysts can have mildly increased uptake [64]. Although maximum standardized update value (SUVmax) are higher in malignant tumors and low in benign lesions, there is no clear SUVmax cutoff value to differentiate the two [65]. Additionally, PET/CT cannot reliably differentiate between borderline tumors and benign lesions and has low uptake on clear cell and mucinous invasive adenocarcinoma subtypes [66,67]. Although PET-avid lesions in postmenopausal women are concerning for malignancy, its use to detect primary cancer is not recommended [68]. MRI Pelvis Without and With IV Contrast MRI is the most useful modality for further evaluation of the subset of lesions that remain indeterminate after sonographic evaluation [69]. A recent study assessing the SRU guidelines ability to risk stratify lesions demonstrated potential of MRI to decrease surgical evaluation for benign cysts by 89% [44]. MRI has an excellent accuracy of >90% for the diagnosis of malignancy [69-71]. MRI can accurately identify solid tissue from nonsolid tissue such as fat, blood, or debris that may appear solid on initial US [72]. | 69466 |
acrac_69466_13 | Clinically Suspected Adnexal Mass No Acute Symptoms | MRI can also help determine the origin of the lesion, with up to 9% of presumed adnexal lesions on US being nonadnexal origin [73]. Sonographically visualized lesions >10 cm may need contrast-enhanced MRI to ensure complete visualization and assessment of the lesion and ensure there are no associated solid components. The presence or absence of enhancing solid tissue and enhancement curve characteristics as evaluated on perfusion dynamic contrast-enhanced imaging drives the risk of malignancy on MRI [17,69,71,74-80]. The absence of enhancement renders the risk of malignancy to nearly 0%, which is of particular value in the sonographically indeterminate lesions because it confirms the benignity of the lesion [71]. Solid tissue with time intensity curves (TIC) with rapid enhancement greater than the myometrium (type 3) are only found in invasive malignant tumors with a sensitivity of 67% versus slow low level enhancement (type 1) found in benign tumors with a sensitively of 70% and specificity of 89% [79]. Diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) values of benign and malignant lesions overlap, with Fujii et al [81] demonstrating teratomas, some endometriomas, and malignant tumors demonstrating abnormal DWI signal. The primary value of DWI is in the setting of a low T2 signal mass, with low signal on DWI predicting a high likelihood of benignity [69,81,82]. MRI Pelvis Without IV Contrast Contrast-enhanced MRI performs superiorly to both US and noncontrast MRI due to its ability to confirm the presence of internal enhancing soft tissue components [18]. Both the ADNEX and O-RADS MRI risk stratification systems will have some decreased usefulness in the noncontrast setting given the limited ability to identify enhancing solid tissue and its enhancement pattern, both crucial for characterizing indeterminate lesions [17,71,73]. | Clinically Suspected Adnexal Mass No Acute Symptoms. MRI can also help determine the origin of the lesion, with up to 9% of presumed adnexal lesions on US being nonadnexal origin [73]. Sonographically visualized lesions >10 cm may need contrast-enhanced MRI to ensure complete visualization and assessment of the lesion and ensure there are no associated solid components. The presence or absence of enhancing solid tissue and enhancement curve characteristics as evaluated on perfusion dynamic contrast-enhanced imaging drives the risk of malignancy on MRI [17,69,71,74-80]. The absence of enhancement renders the risk of malignancy to nearly 0%, which is of particular value in the sonographically indeterminate lesions because it confirms the benignity of the lesion [71]. Solid tissue with time intensity curves (TIC) with rapid enhancement greater than the myometrium (type 3) are only found in invasive malignant tumors with a sensitivity of 67% versus slow low level enhancement (type 1) found in benign tumors with a sensitively of 70% and specificity of 89% [79]. Diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) values of benign and malignant lesions overlap, with Fujii et al [81] demonstrating teratomas, some endometriomas, and malignant tumors demonstrating abnormal DWI signal. The primary value of DWI is in the setting of a low T2 signal mass, with low signal on DWI predicting a high likelihood of benignity [69,81,82]. MRI Pelvis Without IV Contrast Contrast-enhanced MRI performs superiorly to both US and noncontrast MRI due to its ability to confirm the presence of internal enhancing soft tissue components [18]. Both the ADNEX and O-RADS MRI risk stratification systems will have some decreased usefulness in the noncontrast setting given the limited ability to identify enhancing solid tissue and its enhancement pattern, both crucial for characterizing indeterminate lesions [17,71,73]. | 69466 |
acrac_69466_14 | Clinically Suspected Adnexal Mass No Acute Symptoms | For example, the overall specificity for malignancy of the ADNEX MR system falls below 90% if used without dynamic contrast enhancement [71,87]. Sahin et al [19] proposed a noncontrast MRI score based on ADNEX and O-RADS models using morphologic assessment and DWI with an 84.9% sensitivity, 95.9% specificity, and 94% accuracy with the caveat of a population with a lower malignancy rate (15.1%) than the original ADNEX and O- RADS models population (18.8% and 18.4%). Noncontrast MRI may be used in adnexal mass characterization when the use of IV contrast is precluded. Clinically Suspected Adnexal Mass Variant 5: Adult patient assigned female at birth. Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Premenopausal. Follow-up imaging. CT Pelvis With IV Contrast CT pelvis with IV contrast is usually not useful for follow-up of an indeterminate adnexal mass. Because the role of US and MRI is well established, there is little reason presently to obtain a CT for follow-up of an indeterminate lesion. CT Pelvis Without and With IV Contrast CT pelvis without and with IV contrast is usually not useful for follow-up of an indeterminate adnexal mass. Because the role of US and MRI is well established, there is little reason presently to obtain a CT for follow-up of an indeterminate lesion. CT Pelvis Without IV Contrast CT pelvis without IV contrast is usually not useful for follow-up of an indeterminate adnexal mass. Because the role of US and MRI is well established, there is little reason presently to obtain a CT for follow-up of an indeterminate lesion. FDG-PET/CT Skull Base to Mid-Thigh There is no role for the use of FDG-PET/CT in the follow-up of indeterminate adnexal masses in premenopausal patients. MRI Pelvis Without and With IV Contrast An indeterminate mass can be followed by contrast-enhanced MRI. This is helpful if the mass cannot be optimally visualized by US or if the mass shows suspicious change of appearance during US surveillance. | Clinically Suspected Adnexal Mass No Acute Symptoms. For example, the overall specificity for malignancy of the ADNEX MR system falls below 90% if used without dynamic contrast enhancement [71,87]. Sahin et al [19] proposed a noncontrast MRI score based on ADNEX and O-RADS models using morphologic assessment and DWI with an 84.9% sensitivity, 95.9% specificity, and 94% accuracy with the caveat of a population with a lower malignancy rate (15.1%) than the original ADNEX and O- RADS models population (18.8% and 18.4%). Noncontrast MRI may be used in adnexal mass characterization when the use of IV contrast is precluded. Clinically Suspected Adnexal Mass Variant 5: Adult patient assigned female at birth. Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Premenopausal. Follow-up imaging. CT Pelvis With IV Contrast CT pelvis with IV contrast is usually not useful for follow-up of an indeterminate adnexal mass. Because the role of US and MRI is well established, there is little reason presently to obtain a CT for follow-up of an indeterminate lesion. CT Pelvis Without and With IV Contrast CT pelvis without and with IV contrast is usually not useful for follow-up of an indeterminate adnexal mass. Because the role of US and MRI is well established, there is little reason presently to obtain a CT for follow-up of an indeterminate lesion. CT Pelvis Without IV Contrast CT pelvis without IV contrast is usually not useful for follow-up of an indeterminate adnexal mass. Because the role of US and MRI is well established, there is little reason presently to obtain a CT for follow-up of an indeterminate lesion. FDG-PET/CT Skull Base to Mid-Thigh There is no role for the use of FDG-PET/CT in the follow-up of indeterminate adnexal masses in premenopausal patients. MRI Pelvis Without and With IV Contrast An indeterminate mass can be followed by contrast-enhanced MRI. This is helpful if the mass cannot be optimally visualized by US or if the mass shows suspicious change of appearance during US surveillance. | 69466 |
acrac_69466_15 | Clinically Suspected Adnexal Mass No Acute Symptoms | Suspected classic lesions (cysts, endometriomas, dermoid) >10 cm, which are suboptimally seen on US due to size, can be confirmed as almost certainly benign, which may alter further imaging follow-up intervals [17]. MRI Pelvis Without IV Contrast Contrast-enhanced MRI performs superiorly to both US and noncontrast MRI due to its ability to confirm the presence of internal enhancing soft tissue components [18]. Both the ADNEX and O-RADS MRI risk stratification systems will have some decreased usefulness in the noncontrast setting given the limited ability to identify enhancing solid tissue and its enhancement pattern, both crucial for characterizing indeterminate lesions [17,71,73]. For example, the overall specificity for malignancy of the ADNEX MR system falls below 90% if used without dynamic contrast enhancement [71,87]. Sahin et al [19] proposed a noncontrast MRI score based on ADNEX and O-RADS models using morphologic assessment and DWI with an 84.9% sensitivity, 95.9% specificity, and 94% accuracy with the caveat of a population with a lower malignancy rate (15.1%) than the original ADNEX and O- RADS models population (18.8% and 18.4%). Noncontrast MRI may be used in adnexal mass characterization when the use of IV contrast is precluded. US Duplex Doppler Pelvis Color or power Doppler should be included in the US examination of the pelvis. Color Duplex is used to evaluate vascularity of any developing solid component. US Pelvis Transabdominal Transabdominal US may be performed without transvaginal imaging when the transvaginal examination cannot be tolerated. The bladder should be full to provide the best acoustic window for evaluation. US Pelvis Transabdominal and US Pelvis Transvaginal Indeterminate lesions are typically benign. In a multicenter prospective study of 303 indeterminate adnexal cysts, the incidence of malignancy was 3.6% [61]. | Clinically Suspected Adnexal Mass No Acute Symptoms. Suspected classic lesions (cysts, endometriomas, dermoid) >10 cm, which are suboptimally seen on US due to size, can be confirmed as almost certainly benign, which may alter further imaging follow-up intervals [17]. MRI Pelvis Without IV Contrast Contrast-enhanced MRI performs superiorly to both US and noncontrast MRI due to its ability to confirm the presence of internal enhancing soft tissue components [18]. Both the ADNEX and O-RADS MRI risk stratification systems will have some decreased usefulness in the noncontrast setting given the limited ability to identify enhancing solid tissue and its enhancement pattern, both crucial for characterizing indeterminate lesions [17,71,73]. For example, the overall specificity for malignancy of the ADNEX MR system falls below 90% if used without dynamic contrast enhancement [71,87]. Sahin et al [19] proposed a noncontrast MRI score based on ADNEX and O-RADS models using morphologic assessment and DWI with an 84.9% sensitivity, 95.9% specificity, and 94% accuracy with the caveat of a population with a lower malignancy rate (15.1%) than the original ADNEX and O- RADS models population (18.8% and 18.4%). Noncontrast MRI may be used in adnexal mass characterization when the use of IV contrast is precluded. US Duplex Doppler Pelvis Color or power Doppler should be included in the US examination of the pelvis. Color Duplex is used to evaluate vascularity of any developing solid component. US Pelvis Transabdominal Transabdominal US may be performed without transvaginal imaging when the transvaginal examination cannot be tolerated. The bladder should be full to provide the best acoustic window for evaluation. US Pelvis Transabdominal and US Pelvis Transvaginal Indeterminate lesions are typically benign. In a multicenter prospective study of 303 indeterminate adnexal cysts, the incidence of malignancy was 3.6% [61]. | 69466 |
acrac_69466_16 | Clinically Suspected Adnexal Mass No Acute Symptoms | In a second multicenter prospective study of 697 women, the prevalence of malignancy in indeterminate lesions ranged from 4.8% to 10.7% using SRU guidelines and IOTA simple rules, respectively [45]. If an indeterminate mass is identified on initial US, then follow-up may be performed either by serial US or by MRI. For example, the former may be helpful to assess a suspected atypical appearing hemorrhagic cyst that is either resolving or undergoing evolution. A reasonable time frame for US follow-up in this setting would be 8 to 12 weeks (as is performed in typical hemorrhagic cysts of larger size in premenopausal women) to permit time for resolution or confirm persistence of a nonphysiologic cyst [23]. If the lesion persists and is stable in size and appearance, further evaluation with MRI may be appropriate, depending on the clinical context and features present. Clinically Suspected Adnexal Mass MRI may be able to assign a specific benign diagnosis or stratify for risk of malignancy, thus requiring no further US follow-up in the majority of cases [17,73]. If not requiring surgical management, indeterminate lesions that are well seen on US may be followed sonographically. US Pelvis Transvaginal The most useful modality for evaluation of adnexal masses includes transvaginal US combined with transabdominal US approach. Variant 6: Adult patient assigned female at birth. Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Postmenopausal. Follow-up imaging. CT Pelvis With IV Contrast CT pelvis with IV contrast is usually not useful for follow-up of an indeterminate adnexal mass. Because the role of US and MRI is well established, there is little reason presently to obtain a CT for follow-up of an indeterminate lesion. CT Pelvis Without and With IV Contrast CT pelvis without and with IV contrast is usually not useful for follow-up of an indeterminate adnexal mass. | Clinically Suspected Adnexal Mass No Acute Symptoms. In a second multicenter prospective study of 697 women, the prevalence of malignancy in indeterminate lesions ranged from 4.8% to 10.7% using SRU guidelines and IOTA simple rules, respectively [45]. If an indeterminate mass is identified on initial US, then follow-up may be performed either by serial US or by MRI. For example, the former may be helpful to assess a suspected atypical appearing hemorrhagic cyst that is either resolving or undergoing evolution. A reasonable time frame for US follow-up in this setting would be 8 to 12 weeks (as is performed in typical hemorrhagic cysts of larger size in premenopausal women) to permit time for resolution or confirm persistence of a nonphysiologic cyst [23]. If the lesion persists and is stable in size and appearance, further evaluation with MRI may be appropriate, depending on the clinical context and features present. Clinically Suspected Adnexal Mass MRI may be able to assign a specific benign diagnosis or stratify for risk of malignancy, thus requiring no further US follow-up in the majority of cases [17,73]. If not requiring surgical management, indeterminate lesions that are well seen on US may be followed sonographically. US Pelvis Transvaginal The most useful modality for evaluation of adnexal masses includes transvaginal US combined with transabdominal US approach. Variant 6: Adult patient assigned female at birth. Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Postmenopausal. Follow-up imaging. CT Pelvis With IV Contrast CT pelvis with IV contrast is usually not useful for follow-up of an indeterminate adnexal mass. Because the role of US and MRI is well established, there is little reason presently to obtain a CT for follow-up of an indeterminate lesion. CT Pelvis Without and With IV Contrast CT pelvis without and with IV contrast is usually not useful for follow-up of an indeterminate adnexal mass. | 69466 |
acrac_69466_17 | Clinically Suspected Adnexal Mass No Acute Symptoms | Because the role of US and MRI is well established, there is little reason presently to obtain a CT for follow-up of an indeterminate lesion. CT Pelvis Without IV Contrast CT pelvis without IV contrast is usually not useful for follow-up of an indeterminate adnexal mass. Because the role of US and MRI is well established, there is little reason presently to obtain a CT for follow-up of an indeterminate lesion. FDG-PET/CT Skull Base to Mid-Thigh There is no role for the use of FDG-PET/CT in the follow-up of indeterminate adnexal masses in postmenopausal patients. MRI Pelvis Without and With IV Contrast An indeterminate mass can be followed by contrast-enhanced MRI. This is helpful if the mass cannot be optimally visualized by US or if the mass shows suspicious change of appearance during US surveillance. Suspected ovarian thecoma-fibroma group tumors, typically classified as indeterminate based on US features can go on further imaging with MRI, with characteristics feature of T2 homogeneous hypointensity and low signal on DWI rendering the lesion almost certainly benign [17,88]. MRI Pelvis Without IV Contrast Contrast-enhanced MRI performs superiorly to both US and noncontrast MRI due to its ability to confirm the presence of internal enhancing soft tissue components [18]. Both the ADNEX and O-RADS MRI risk stratification systems will have some decreased usefulness in the noncontrast setting given the limited ability to identify enhancing solid tissue and its enhancement pattern, both crucial for characterizing indeterminate lesions [17,71,73]. For example, the overall specificity for malignancy of the ADNEX MR system falls below 90% if used without dynamic contrast enhancement [71,87]. | Clinically Suspected Adnexal Mass No Acute Symptoms. Because the role of US and MRI is well established, there is little reason presently to obtain a CT for follow-up of an indeterminate lesion. CT Pelvis Without IV Contrast CT pelvis without IV contrast is usually not useful for follow-up of an indeterminate adnexal mass. Because the role of US and MRI is well established, there is little reason presently to obtain a CT for follow-up of an indeterminate lesion. FDG-PET/CT Skull Base to Mid-Thigh There is no role for the use of FDG-PET/CT in the follow-up of indeterminate adnexal masses in postmenopausal patients. MRI Pelvis Without and With IV Contrast An indeterminate mass can be followed by contrast-enhanced MRI. This is helpful if the mass cannot be optimally visualized by US or if the mass shows suspicious change of appearance during US surveillance. Suspected ovarian thecoma-fibroma group tumors, typically classified as indeterminate based on US features can go on further imaging with MRI, with characteristics feature of T2 homogeneous hypointensity and low signal on DWI rendering the lesion almost certainly benign [17,88]. MRI Pelvis Without IV Contrast Contrast-enhanced MRI performs superiorly to both US and noncontrast MRI due to its ability to confirm the presence of internal enhancing soft tissue components [18]. Both the ADNEX and O-RADS MRI risk stratification systems will have some decreased usefulness in the noncontrast setting given the limited ability to identify enhancing solid tissue and its enhancement pattern, both crucial for characterizing indeterminate lesions [17,71,73]. For example, the overall specificity for malignancy of the ADNEX MR system falls below 90% if used without dynamic contrast enhancement [71,87]. | 69466 |
acrac_69466_18 | Clinically Suspected Adnexal Mass No Acute Symptoms | Sahin et al [19] proposed a noncontrast MRI score based on ADNEX and O-RADS models using morphologic assessment and DWI with an 84.9% sensitivity, 95.9% specificity, and 94% accuracy with the caveat of a population with a lower malignancy rate (15.1%) than the original ADNEX and O- RADS models population (18.8% and 18.4%). Noncontrast MRI may be used in adnexal mass characterization when the use of IV contrast is precluded. US Duplex Doppler Pelvis Color or power Doppler should be included in the US examination of the pelvis. Color Duplex is used to evaluate vascularity of any developing solid component. US Pelvis Transabdominal Transabdominal US may be performed without transvaginal imaging when the transvaginal examination cannot be tolerated or is contraindicated (eg, no prior history of sexual activity). The bladder should be full to provide the best acoustic window for evaluation. Clinically Suspected Adnexal Mass US Pelvis Transabdominal and US Pelvis Transvaginal Indeterminate lesions are typically benign. In a multicenter prospective study of 303 indeterminate adnexal cysts, the incidence of malignancy was 3.6% [61]. In a second multicenter prospective study of 697 women, the prevalence of malignancy in indeterminate lesions ranged from 4.8% to 10.7% using SRU guidelines and IOTA simple rules, respectively [45]. If an indeterminate mass is identified on initial US, then follow-up may be performed either by serial US or by MRI. In a study of 1,363 postmenopausal women, complex adnexal masses ranging in size from 1 to 6 cm had an overall low risk of malignancy of 1.3%, with all epithelial cancer and borderline tumors demonstrating growth by 7 months of sonographic observation [89]. Similarly, in women diagnosed with early-stage high-grade serous cancers, these were rarely <5 cm or without solid components other than septations, further supporting potential observation in small masses [90]. | Clinically Suspected Adnexal Mass No Acute Symptoms. Sahin et al [19] proposed a noncontrast MRI score based on ADNEX and O-RADS models using morphologic assessment and DWI with an 84.9% sensitivity, 95.9% specificity, and 94% accuracy with the caveat of a population with a lower malignancy rate (15.1%) than the original ADNEX and O- RADS models population (18.8% and 18.4%). Noncontrast MRI may be used in adnexal mass characterization when the use of IV contrast is precluded. US Duplex Doppler Pelvis Color or power Doppler should be included in the US examination of the pelvis. Color Duplex is used to evaluate vascularity of any developing solid component. US Pelvis Transabdominal Transabdominal US may be performed without transvaginal imaging when the transvaginal examination cannot be tolerated or is contraindicated (eg, no prior history of sexual activity). The bladder should be full to provide the best acoustic window for evaluation. Clinically Suspected Adnexal Mass US Pelvis Transabdominal and US Pelvis Transvaginal Indeterminate lesions are typically benign. In a multicenter prospective study of 303 indeterminate adnexal cysts, the incidence of malignancy was 3.6% [61]. In a second multicenter prospective study of 697 women, the prevalence of malignancy in indeterminate lesions ranged from 4.8% to 10.7% using SRU guidelines and IOTA simple rules, respectively [45]. If an indeterminate mass is identified on initial US, then follow-up may be performed either by serial US or by MRI. In a study of 1,363 postmenopausal women, complex adnexal masses ranging in size from 1 to 6 cm had an overall low risk of malignancy of 1.3%, with all epithelial cancer and borderline tumors demonstrating growth by 7 months of sonographic observation [89]. Similarly, in women diagnosed with early-stage high-grade serous cancers, these were rarely <5 cm or without solid components other than septations, further supporting potential observation in small masses [90]. | 69466 |
acrac_69466_19 | Clinically Suspected Adnexal Mass No Acute Symptoms | Solid hypoechoic masses with smooth margins and acoustic shadowing and minimal Doppler flow are characteristic features of ovarian thecoma-fibroma group tumors, sex cord stromal neoplasms most commonly seen in the postmenopausal patient [91]. In a small study of 99 benign-appearing smooth purely solid masses, those with IOTA color score of 1 or 2, the risk of malignancy at 3 year follow-up was low, at 2%, suggesting conservative management may be an option for some patients with serial US imaging follow-up [92]. MRI may be able to assign a specific benign diagnosis or stratify for risk of malignancy, which may alter further imaging follow-up intervals [17,73]. If not requiring surgical management, indeterminate lesions that are well seen on US may be followed sonographically. US Pelvis Transvaginal The most useful modality for evaluation of adnexal masses includes transvaginal US combined with transabdominal US approach. CT Pelvis Without and With IV Contrast CT pelvis without and with IV contrast is not useful for further characterization of a suspicious adnexal lesion. Although not supported by the existing literature, CT of the pelvis without and with IV contrast may be potentially useful to determine if a suspected solid component within an adnexal lesion demonstrates enhancement. CT Pelvis Without IV Contrast CT pelvis without IV contrast is not useful for further characterization of a suspicious adnexal lesion. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT is useful for staging of ovarian cancer, specifically for identifying other sites of disease, and with better detection of lymph node metastasis than conventional CT [93]. MRI Pelvis Without and With IV Contrast On US, solid adnexal lesions with irregular contour are highly suspicious for malignancy with a 93% PPV for malignancy [24]. Similarly, lesions with >4 papillary structures or solid tissue with increased color or spectral Doppler flow are concerning for malignancy [34,37,62]. | Clinically Suspected Adnexal Mass No Acute Symptoms. Solid hypoechoic masses with smooth margins and acoustic shadowing and minimal Doppler flow are characteristic features of ovarian thecoma-fibroma group tumors, sex cord stromal neoplasms most commonly seen in the postmenopausal patient [91]. In a small study of 99 benign-appearing smooth purely solid masses, those with IOTA color score of 1 or 2, the risk of malignancy at 3 year follow-up was low, at 2%, suggesting conservative management may be an option for some patients with serial US imaging follow-up [92]. MRI may be able to assign a specific benign diagnosis or stratify for risk of malignancy, which may alter further imaging follow-up intervals [17,73]. If not requiring surgical management, indeterminate lesions that are well seen on US may be followed sonographically. US Pelvis Transvaginal The most useful modality for evaluation of adnexal masses includes transvaginal US combined with transabdominal US approach. CT Pelvis Without and With IV Contrast CT pelvis without and with IV contrast is not useful for further characterization of a suspicious adnexal lesion. Although not supported by the existing literature, CT of the pelvis without and with IV contrast may be potentially useful to determine if a suspected solid component within an adnexal lesion demonstrates enhancement. CT Pelvis Without IV Contrast CT pelvis without IV contrast is not useful for further characterization of a suspicious adnexal lesion. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT is useful for staging of ovarian cancer, specifically for identifying other sites of disease, and with better detection of lymph node metastasis than conventional CT [93]. MRI Pelvis Without and With IV Contrast On US, solid adnexal lesions with irregular contour are highly suspicious for malignancy with a 93% PPV for malignancy [24]. Similarly, lesions with >4 papillary structures or solid tissue with increased color or spectral Doppler flow are concerning for malignancy [34,37,62]. | 69466 |
acrac_69466_20 | Clinically Suspected Adnexal Mass No Acute Symptoms | When a lesion has sonographic features worrisome for malignancy, the PPV of cancer ranges from 29% to 50% [23,45,55,61,62]. For example, in a prospective multicenter study of 970 lesions, solid component with blood flow had a 32% frequency of malignancy and up to 50% in women >60 years of age [55]. Contrast-enhanced MRI can be used to increase the specificity for malignancy, which may aid in surgical decision making and preoperative planning [17,71,73]. The presence or absence of enhancing solid tissue and enhancement Clinically Suspected Adnexal Mass curve characteristics as evaluated on perfusion dynamic contrast-enhanced imaging drives the risk of malignancy on MRI [17,69,71,74-80]. Solid components with TIC with rapid enhancement greater than the myometrium (type 3) are only found in invasive malignant tumors with a sensitivity of 67% versus slow low level enhancement (type 1) found in benign tumors with a sensitively of 70% and specificity of 89% [79]. Evaluation with TIC performs better than visual assessment with respective sensitivities of 96% and 76% in detection of borderline and invasive tumors in a set of 320 lesions [94]. MRI Pelvis Without IV Contrast Contrast-enhanced MRI performs superiorly to both US and noncontrast MRI due to its ability to confirm the presence of internal enhancing soft tissue components [18]. Both the ADNEX and O-RADS MRI risk stratification systems will have some decreased usefulness in the noncontrast setting given the limited ability to identify enhancing solid tissue and its enhancement pattern, both crucial for characterizing indeterminate lesions [17,71,73]. For example, the overall specificity for malignancy of the ADNEX MR system falls below 90% if used without dynamic contrast enhancement [71,87]. | Clinically Suspected Adnexal Mass No Acute Symptoms. When a lesion has sonographic features worrisome for malignancy, the PPV of cancer ranges from 29% to 50% [23,45,55,61,62]. For example, in a prospective multicenter study of 970 lesions, solid component with blood flow had a 32% frequency of malignancy and up to 50% in women >60 years of age [55]. Contrast-enhanced MRI can be used to increase the specificity for malignancy, which may aid in surgical decision making and preoperative planning [17,71,73]. The presence or absence of enhancing solid tissue and enhancement Clinically Suspected Adnexal Mass curve characteristics as evaluated on perfusion dynamic contrast-enhanced imaging drives the risk of malignancy on MRI [17,69,71,74-80]. Solid components with TIC with rapid enhancement greater than the myometrium (type 3) are only found in invasive malignant tumors with a sensitivity of 67% versus slow low level enhancement (type 1) found in benign tumors with a sensitively of 70% and specificity of 89% [79]. Evaluation with TIC performs better than visual assessment with respective sensitivities of 96% and 76% in detection of borderline and invasive tumors in a set of 320 lesions [94]. MRI Pelvis Without IV Contrast Contrast-enhanced MRI performs superiorly to both US and noncontrast MRI due to its ability to confirm the presence of internal enhancing soft tissue components [18]. Both the ADNEX and O-RADS MRI risk stratification systems will have some decreased usefulness in the noncontrast setting given the limited ability to identify enhancing solid tissue and its enhancement pattern, both crucial for characterizing indeterminate lesions [17,71,73]. For example, the overall specificity for malignancy of the ADNEX MR system falls below 90% if used without dynamic contrast enhancement [71,87]. | 69466 |
acrac_69466_21 | Clinically Suspected Adnexal Mass No Acute Symptoms | Sahin et al [19] proposed a noncontrast MRI score based on ADNEX and O-RADS models using morphologic assessment and DWI with an 84.9% sensitivity, 95.9% specificity, and 94% accuracy with the caveat of a population with a lower malignancy rate (15.1%) than the original ADNEX and O- RADS models population (18.8% and 18.4%). Noncontrast MRI may be used in adnexal mass characterization when the use of IV contrast is precluded. Variant 8: Clinically suspected adnexal mass, no acute symptoms. Pregnant. Initial imaging. CT Pelvis With IV Contrast CT pelvis with IV contrast has no role in the initial evaluation for an adnexal lesion and should be avoided in pregnant patients due to radiation dose. CT Pelvis Without and With IV Contrast CT pelvis without and with IV contrast has no role in the initial evaluation for an adnexal lesion and should be avoided in pregnant patients due to radiation dose. CT Pelvis Without IV Contrast CT pelvis without IV contrast has no role in the initial evaluation for an adnexal lesion and should be avoided in pregnant patients due to radiation dose. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT has no role in the initial evaluation for an adnexal lesion and should be avoided in pregnant patients due to radiation dose. MRI Pelvis Without and With IV Contrast Gadolinium-based contrast agents should not be routinely administered to pregnant patients [95]. Free gadolinium is toxic and thus administered in its chelated form. Gadolinium has been shown to cross the placenta and enter fetal circulation in nonhuman primate models. It has potential but is unclear or has unknown risks of exposure to the developing fetus [95,96]. A study by Ray et al [97] in 2016 showed a slightly increased risk of stillbirth or neonatal death (17.6/1,000 in exposed fetuses versus 6.9/1,000 in fetuses not undergoing MRI) and a slightly increased risk of childhood rheumatological, inflammatory, or infiltrative skin conditions. | Clinically Suspected Adnexal Mass No Acute Symptoms. Sahin et al [19] proposed a noncontrast MRI score based on ADNEX and O-RADS models using morphologic assessment and DWI with an 84.9% sensitivity, 95.9% specificity, and 94% accuracy with the caveat of a population with a lower malignancy rate (15.1%) than the original ADNEX and O- RADS models population (18.8% and 18.4%). Noncontrast MRI may be used in adnexal mass characterization when the use of IV contrast is precluded. Variant 8: Clinically suspected adnexal mass, no acute symptoms. Pregnant. Initial imaging. CT Pelvis With IV Contrast CT pelvis with IV contrast has no role in the initial evaluation for an adnexal lesion and should be avoided in pregnant patients due to radiation dose. CT Pelvis Without and With IV Contrast CT pelvis without and with IV contrast has no role in the initial evaluation for an adnexal lesion and should be avoided in pregnant patients due to radiation dose. CT Pelvis Without IV Contrast CT pelvis without IV contrast has no role in the initial evaluation for an adnexal lesion and should be avoided in pregnant patients due to radiation dose. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT has no role in the initial evaluation for an adnexal lesion and should be avoided in pregnant patients due to radiation dose. MRI Pelvis Without and With IV Contrast Gadolinium-based contrast agents should not be routinely administered to pregnant patients [95]. Free gadolinium is toxic and thus administered in its chelated form. Gadolinium has been shown to cross the placenta and enter fetal circulation in nonhuman primate models. It has potential but is unclear or has unknown risks of exposure to the developing fetus [95,96]. A study by Ray et al [97] in 2016 showed a slightly increased risk of stillbirth or neonatal death (17.6/1,000 in exposed fetuses versus 6.9/1,000 in fetuses not undergoing MRI) and a slightly increased risk of childhood rheumatological, inflammatory, or infiltrative skin conditions. | 69466 |
acrac_69466_22 | Clinically Suspected Adnexal Mass No Acute Symptoms | Gadolinium-based contrast agents are category C drugs as determined by the FDA, with adverse effects in animal studies without adequate studies in humans, and their use in pregnancy is restricted to situations where the potential benefits of imaging far outweigh the potential risk to the fetus [98]. A study by Thomassin-Naggara et al [99] in 2017 demonstrated an overall accuracy of MRI in up to 88% in pregnant patients using the ADNEX MR score in a subset of 36 masses. In this study, 7 of 31 patients received gadolinium contrast based on radiologist discretion during the examination, with all 7 demonstrating malignant tumors on final pathology. MRI Pelvis Without IV Contrast Although MRI can accurately diagnose the presence of adnexal lesions and identify distinguishing characteristics such as the type of fluid content, presence of fat, or presence of septations in cystic lesions [16,17], it is not the first- line modality for initial evaluation. MRI does not use ionizing radiation and is deemed safe in pregnant patients [95]. Although contrast-enhanced MRI performs superiorly to both US and noncontrast MRI due to its ability to confirm the presence of internal enhancing soft tissue components [18], gadolinium-based contrast agents should not be routinely administered to pregnant patients [95]. Although not specifically assessed in the pregnant Clinically Suspected Adnexal Mass population, in a recent study of 350 lesions in a population with 15% malignant lesions, noncontrast MRI demonstrated a sensitivity of 85%, specificity of 96%, and accuracy of 94.2% to detect cancer [19]. If a pregnant patient with a suspected adnexal lesion is unable to be evaluated via US (due to large size of lesion >10 cm, poor acoustic window from adjacent viscera or body habitus, or unclear organ of origin), noncontrast MRI would be the best alternative imaging modality for evaluation. | Clinically Suspected Adnexal Mass No Acute Symptoms. Gadolinium-based contrast agents are category C drugs as determined by the FDA, with adverse effects in animal studies without adequate studies in humans, and their use in pregnancy is restricted to situations where the potential benefits of imaging far outweigh the potential risk to the fetus [98]. A study by Thomassin-Naggara et al [99] in 2017 demonstrated an overall accuracy of MRI in up to 88% in pregnant patients using the ADNEX MR score in a subset of 36 masses. In this study, 7 of 31 patients received gadolinium contrast based on radiologist discretion during the examination, with all 7 demonstrating malignant tumors on final pathology. MRI Pelvis Without IV Contrast Although MRI can accurately diagnose the presence of adnexal lesions and identify distinguishing characteristics such as the type of fluid content, presence of fat, or presence of septations in cystic lesions [16,17], it is not the first- line modality for initial evaluation. MRI does not use ionizing radiation and is deemed safe in pregnant patients [95]. Although contrast-enhanced MRI performs superiorly to both US and noncontrast MRI due to its ability to confirm the presence of internal enhancing soft tissue components [18], gadolinium-based contrast agents should not be routinely administered to pregnant patients [95]. Although not specifically assessed in the pregnant Clinically Suspected Adnexal Mass population, in a recent study of 350 lesions in a population with 15% malignant lesions, noncontrast MRI demonstrated a sensitivity of 85%, specificity of 96%, and accuracy of 94.2% to detect cancer [19]. If a pregnant patient with a suspected adnexal lesion is unable to be evaluated via US (due to large size of lesion >10 cm, poor acoustic window from adjacent viscera or body habitus, or unclear organ of origin), noncontrast MRI would be the best alternative imaging modality for evaluation. | 69466 |
acrac_69466_23 | Clinically Suspected Adnexal Mass No Acute Symptoms | US Pelvis Transabdominal Although the most useful modality for the evaluation of adnexal masses is combined transabdominal and transvaginal pelvis US, a sole transabdominal approach is reasonable and may be the best option for the assessment of adnexal lesions late in gestation when the ovaries are displaced higher in the pelvis. US-based ovarian scoring systems have been applied to adnexal lesions in pregnant patients in a limited fashion in a few small studies. Czekierdowski et al [112] compared subjective assessment, Simple Rules Risk, and ADNEX models and found that subjective assessment performed best in a small study of 36 patients. Another larger study by Lee et al [113] with 236 women compared IOTA ADNEX and Sassone and Lerner systems, with the Sassone system or a combined model using 6 features that were found to be significant in their study performing the best. Clinically Suspected Adnexal Mass US Pelvis Transvaginal The most useful modality for evaluation of adnexal masses includes transvaginal US combined with transabdominal US approach. Variant 9: Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Pregnant. Next imaging study for characterization. CT Pelvis With IV Contrast CT pelvis with IV contrast has no role in the further characterization for an indeterminate adnexal lesion and should be avoided in pregnant patients due to radiation dose. CT Pelvis Without and With IV Contrast CT pelvis without and with IV contrast has no role in the further characterization for an indeterminate adnexal lesion and should be avoided in pregnant patients due to radiation dose. CT Pelvis Without IV Contrast CT pelvis without IV contrast has no role in the further characterization for an indeterminate adnexal lesion and should be avoided in pregnant patients due to radiation dose. | Clinically Suspected Adnexal Mass No Acute Symptoms. US Pelvis Transabdominal Although the most useful modality for the evaluation of adnexal masses is combined transabdominal and transvaginal pelvis US, a sole transabdominal approach is reasonable and may be the best option for the assessment of adnexal lesions late in gestation when the ovaries are displaced higher in the pelvis. US-based ovarian scoring systems have been applied to adnexal lesions in pregnant patients in a limited fashion in a few small studies. Czekierdowski et al [112] compared subjective assessment, Simple Rules Risk, and ADNEX models and found that subjective assessment performed best in a small study of 36 patients. Another larger study by Lee et al [113] with 236 women compared IOTA ADNEX and Sassone and Lerner systems, with the Sassone system or a combined model using 6 features that were found to be significant in their study performing the best. Clinically Suspected Adnexal Mass US Pelvis Transvaginal The most useful modality for evaluation of adnexal masses includes transvaginal US combined with transabdominal US approach. Variant 9: Adnexal mass, indeterminate on initial pelvic US, no acute symptoms. Pregnant. Next imaging study for characterization. CT Pelvis With IV Contrast CT pelvis with IV contrast has no role in the further characterization for an indeterminate adnexal lesion and should be avoided in pregnant patients due to radiation dose. CT Pelvis Without and With IV Contrast CT pelvis without and with IV contrast has no role in the further characterization for an indeterminate adnexal lesion and should be avoided in pregnant patients due to radiation dose. CT Pelvis Without IV Contrast CT pelvis without IV contrast has no role in the further characterization for an indeterminate adnexal lesion and should be avoided in pregnant patients due to radiation dose. | 69466 |
acrac_69466_24 | Clinically Suspected Adnexal Mass No Acute Symptoms | FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT has no role in further characterization of an indeterminate adnexal lesion in pregnancy, given the accuracy of US and MRI. MRI Pelvis Without and With IV Contrast Gadolinium-based contrast agents should not be routinely administered to pregnant patients [95]. Free gadolinium is toxic and thus administered in its chelated form. Gadolinium has been shown to cross the placenta and enter fetal circulation in nonhuman primate models. It has potential but is unclear or has unknown risks of exposure to the developing fetus [95,96]. A study by Ray et al [97] in 2016 showed a slightly increased risk of stillbirth or neonatal death (17.6/1,000 in exposed fetuses versus 6.9/1,000 in fetuses not undergoing MRI) and slightly increased risk of childhood rheumatological, inflammatory, or infiltrative skin conditions. Gadolinium-based contrast agents are category C drugs as determined by the FDA, with adverse effects in animal studies without adequate studies in humans, and their use in pregnancy is restricted to situations where the potential benefits of imaging far outweigh the potential risk to the fetus [98]. A study by Thomassin-Naggara et al [99] in 2017 demonstrated an overall accuracy of MRI in up to 88% in pregnant patients using the ADNEX MR score in a subset of 36 masses. In this study, 7 of 31 patients received gadolinium contrast based on radiologist discretion during the examination, with all 7 demonstrating malignant tumors on final pathology. MRI Pelvis Without IV Contrast MRI without contrast is useful for the evaluation of an US indeterminate adnexal lesion in pregnant patients who cannot receive gadolinium. MRI does not use ionizing radiation and is deemed safe in pregnant patients [95]. Up to 22% to 24% of adnexal masses remain indeterminate after US evaluation [61,62]. MRI can be helpful in the setting of indeterminate masses, large lesions >10 cm in size, and determination of origin in adnexal masses. | Clinically Suspected Adnexal Mass No Acute Symptoms. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT has no role in further characterization of an indeterminate adnexal lesion in pregnancy, given the accuracy of US and MRI. MRI Pelvis Without and With IV Contrast Gadolinium-based contrast agents should not be routinely administered to pregnant patients [95]. Free gadolinium is toxic and thus administered in its chelated form. Gadolinium has been shown to cross the placenta and enter fetal circulation in nonhuman primate models. It has potential but is unclear or has unknown risks of exposure to the developing fetus [95,96]. A study by Ray et al [97] in 2016 showed a slightly increased risk of stillbirth or neonatal death (17.6/1,000 in exposed fetuses versus 6.9/1,000 in fetuses not undergoing MRI) and slightly increased risk of childhood rheumatological, inflammatory, or infiltrative skin conditions. Gadolinium-based contrast agents are category C drugs as determined by the FDA, with adverse effects in animal studies without adequate studies in humans, and their use in pregnancy is restricted to situations where the potential benefits of imaging far outweigh the potential risk to the fetus [98]. A study by Thomassin-Naggara et al [99] in 2017 demonstrated an overall accuracy of MRI in up to 88% in pregnant patients using the ADNEX MR score in a subset of 36 masses. In this study, 7 of 31 patients received gadolinium contrast based on radiologist discretion during the examination, with all 7 demonstrating malignant tumors on final pathology. MRI Pelvis Without IV Contrast MRI without contrast is useful for the evaluation of an US indeterminate adnexal lesion in pregnant patients who cannot receive gadolinium. MRI does not use ionizing radiation and is deemed safe in pregnant patients [95]. Up to 22% to 24% of adnexal masses remain indeterminate after US evaluation [61,62]. MRI can be helpful in the setting of indeterminate masses, large lesions >10 cm in size, and determination of origin in adnexal masses. | 69466 |
acrac_69432_0 | Chronic Knee Pain | Variant 2: Adult or child greater than or equal to 5 years of age. Chronic knee pain. Initial knee radiograph negative or demonstrates joint effusion. Next imaging procedure. Chronic Knee Pain Variant 3: Adult or child greater than or equal to 5 years of age. Chronic knee pain. Initial knee radiograph demonstrates osteochondritis dissecans (OCD), loose bodies, or history of cartilage or meniscal repair. Next imaging procedure. Variant 4: Adult or child greater than or equal to 5 years of age. Chronic knee pain. Initial knee imaging radiograph demonstrates degenerative changes or chondrocalcinosis. Next procedure. Chronic Knee Pain Variant 5: Adult or child greater than or equal to 5 years of age. Chronic knee pain. Initial knee radiograph demonstrates signs of prior osseous injury (ie, Segond fracture, tibial spine avulsion, etc). Next imaging procedure. Chronic Knee Pain CHRONIC KNEE PAIN Expert Panel on Musculoskeletal Imaging: Michael G. Fox, MD, MBAa; Eric Y. Chang, MDb; Behrang Amini, MD, PhDc; Stephanie A. Bernard, MDd; Tetyana Gorbachova, MDe; Alice S. Ha, MDf; Ramesh S. Iyer, MDg; Kenneth S. Lee, MD, MBAh; Darlene F. Metter, MDi; Pekka A. Mooar, MDj; Nehal A. Shah, MDk; Adam D. Singer, MDl; Stacy E. Smith, MDm; Mihra S. Taljanovic, MD, PhDn; Ralf Thiele, MDo; Kathy M. Tynus, MDp; Mark J. Kransdorf, MD. q Typically, radiography is the initial imaging study used to evaluate chronic pain in a native knee. When pain persists but the initial radiographs are normal or demonstrate a joint effusion, MRI is usually considered the next imaging study. However, the use of MRI may be premature and unnecessary in some patients, as it is estimated that approximately 20% of patients with chronic knee pain have had an MRI performed without recent (within the prior year) radiographs [2]. | Chronic Knee Pain. Variant 2: Adult or child greater than or equal to 5 years of age. Chronic knee pain. Initial knee radiograph negative or demonstrates joint effusion. Next imaging procedure. Chronic Knee Pain Variant 3: Adult or child greater than or equal to 5 years of age. Chronic knee pain. Initial knee radiograph demonstrates osteochondritis dissecans (OCD), loose bodies, or history of cartilage or meniscal repair. Next imaging procedure. Variant 4: Adult or child greater than or equal to 5 years of age. Chronic knee pain. Initial knee imaging radiograph demonstrates degenerative changes or chondrocalcinosis. Next procedure. Chronic Knee Pain Variant 5: Adult or child greater than or equal to 5 years of age. Chronic knee pain. Initial knee radiograph demonstrates signs of prior osseous injury (ie, Segond fracture, tibial spine avulsion, etc). Next imaging procedure. Chronic Knee Pain CHRONIC KNEE PAIN Expert Panel on Musculoskeletal Imaging: Michael G. Fox, MD, MBAa; Eric Y. Chang, MDb; Behrang Amini, MD, PhDc; Stephanie A. Bernard, MDd; Tetyana Gorbachova, MDe; Alice S. Ha, MDf; Ramesh S. Iyer, MDg; Kenneth S. Lee, MD, MBAh; Darlene F. Metter, MDi; Pekka A. Mooar, MDj; Nehal A. Shah, MDk; Adam D. Singer, MDl; Stacy E. Smith, MDm; Mihra S. Taljanovic, MD, PhDn; Ralf Thiele, MDo; Kathy M. Tynus, MDp; Mark J. Kransdorf, MD. q Typically, radiography is the initial imaging study used to evaluate chronic pain in a native knee. When pain persists but the initial radiographs are normal or demonstrate a joint effusion, MRI is usually considered the next imaging study. However, the use of MRI may be premature and unnecessary in some patients, as it is estimated that approximately 20% of patients with chronic knee pain have had an MRI performed without recent (within the prior year) radiographs [2]. | 69432 |
acrac_69432_1 | Chronic Knee Pain | Special Imaging Considerations Knee radiographs should include at least one frontal projection of one or both knees (anteroposterior, Rosenberg, or tunnel), a tangential patellar view, and a lateral view of the affected knee [2,9]. Standing radiographs more accurately reflect medial and lateral compartment cartilage loss than supine radiographs with the posteromedial and posterolateral joint compartments more accurately assessed using a weight-bearing flexion posteroanterior radiograph [9,10]. Discussion of Procedures by Variant Variant 1: Adult or child greater than or equal to 5 years of age. Chronic knee pain. Initial imaging. Radiography Knee Radiographs should be the initial imaging study for chronic knee pain. In elderly patients, the most common source of chronic knee pain is osteoarthritis. Conventional radiographic diagnosis of osteoarthritis includes joint space narrowing, osteophytes, subchondral cysts, and subarticular sclerosis [11]. Articular cartilage is evaluated Reprint requests to: [email protected] Chronic Knee Pain Radiography Hip An ipsilateral hip radiograph is usually not indicated as a first imaging examination. CT Knee CT is usually not indicated as a first imaging examination. CT Arthrography Knee CT arthrography is usually not indicated as a first imaging examination. MRI Knee MRI is usually not indicated as a first imaging examination. To avoid unnecessary MRI, assessment of current radiographs (within the prior year) is required [2]. MR Arthrography Knee MR arthrography is usually not indicated as a first imaging examination. US Knee Ultrasound (US) is usually not indicated as a first imaging examination. Bone Scan Knee Radionuclide bone scan is usually not indicated as a first imaging examination. Image-Guided Aspiration Knee Joint aspiration is usually not indicated as a first imaging examination. Variant 2: Adult or child greater than or equal to 5 years of age. Chronic knee pain. Initial knee radiograph negative or demonstrates joint effusion. | Chronic Knee Pain. Special Imaging Considerations Knee radiographs should include at least one frontal projection of one or both knees (anteroposterior, Rosenberg, or tunnel), a tangential patellar view, and a lateral view of the affected knee [2,9]. Standing radiographs more accurately reflect medial and lateral compartment cartilage loss than supine radiographs with the posteromedial and posterolateral joint compartments more accurately assessed using a weight-bearing flexion posteroanterior radiograph [9,10]. Discussion of Procedures by Variant Variant 1: Adult or child greater than or equal to 5 years of age. Chronic knee pain. Initial imaging. Radiography Knee Radiographs should be the initial imaging study for chronic knee pain. In elderly patients, the most common source of chronic knee pain is osteoarthritis. Conventional radiographic diagnosis of osteoarthritis includes joint space narrowing, osteophytes, subchondral cysts, and subarticular sclerosis [11]. Articular cartilage is evaluated Reprint requests to: [email protected] Chronic Knee Pain Radiography Hip An ipsilateral hip radiograph is usually not indicated as a first imaging examination. CT Knee CT is usually not indicated as a first imaging examination. CT Arthrography Knee CT arthrography is usually not indicated as a first imaging examination. MRI Knee MRI is usually not indicated as a first imaging examination. To avoid unnecessary MRI, assessment of current radiographs (within the prior year) is required [2]. MR Arthrography Knee MR arthrography is usually not indicated as a first imaging examination. US Knee Ultrasound (US) is usually not indicated as a first imaging examination. Bone Scan Knee Radionuclide bone scan is usually not indicated as a first imaging examination. Image-Guided Aspiration Knee Joint aspiration is usually not indicated as a first imaging examination. Variant 2: Adult or child greater than or equal to 5 years of age. Chronic knee pain. Initial knee radiograph negative or demonstrates joint effusion. | 69432 |
acrac_69432_2 | Chronic Knee Pain | Next imaging procedure. Radiography Hip In patients with chronic knee pain, referred pain from the hip must be considered, especially if the knee radiographs are unremarkable and there is clinical evidence or concern for hip pathology [14]. Radiography Lumbar Spine In patients with chronic knee pain, referred pain from the lower back must be considered, especially if the knee radiographs are unremarkable and there is clinical evidence or concern for lumbar spine pathology. CT Knee CT without intravenous (IV) contrast may be indicated to evaluate the patellofemoral anatomy in the setting of chronic knee pain related to repetitive patellofemoral subluxation or maltracking [15]. CT can also be used to evaluate trochlear morphology and the tibial tubercle-trochlear groove distance. CT with IV contrast is usually not indicated when initial radiograph is negative or demonstrates a joint effusion. CT without and with IV contrast is not routinely performed when initial radiographs are negative. CT Arthrography Knee When an intra-articular abnormality is suspected, CT arthrography may be used instead of MRI to evaluate the menisci and articular cartilage [16]. MRI Knee When initial radiographs are normal or reveal a joint effusion but pain persists, the next indicated study is usually MRI without IV contrast, which is more sensitive than radiography [11]. MRI accurately depicts the extent of an effusion, presence of synovitis, and presence or rupture of a popliteal cyst [17]. Subchondral cysts, articular cartilage, and meniscal abnormalities are easily detected on MRI [13,18,19]. However, meniscal tears are often incidental findings in older patients with the majority of people over 70 years Chronic Knee Pain of age having an asymptomatic meniscal tear, and the likelihood of a meniscal tear being present in either a painful or asymptomatic knee not significantly different in patients 45 to 55 years of age [20,21]. | Chronic Knee Pain. Next imaging procedure. Radiography Hip In patients with chronic knee pain, referred pain from the hip must be considered, especially if the knee radiographs are unremarkable and there is clinical evidence or concern for hip pathology [14]. Radiography Lumbar Spine In patients with chronic knee pain, referred pain from the lower back must be considered, especially if the knee radiographs are unremarkable and there is clinical evidence or concern for lumbar spine pathology. CT Knee CT without intravenous (IV) contrast may be indicated to evaluate the patellofemoral anatomy in the setting of chronic knee pain related to repetitive patellofemoral subluxation or maltracking [15]. CT can also be used to evaluate trochlear morphology and the tibial tubercle-trochlear groove distance. CT with IV contrast is usually not indicated when initial radiograph is negative or demonstrates a joint effusion. CT without and with IV contrast is not routinely performed when initial radiographs are negative. CT Arthrography Knee When an intra-articular abnormality is suspected, CT arthrography may be used instead of MRI to evaluate the menisci and articular cartilage [16]. MRI Knee When initial radiographs are normal or reveal a joint effusion but pain persists, the next indicated study is usually MRI without IV contrast, which is more sensitive than radiography [11]. MRI accurately depicts the extent of an effusion, presence of synovitis, and presence or rupture of a popliteal cyst [17]. Subchondral cysts, articular cartilage, and meniscal abnormalities are easily detected on MRI [13,18,19]. However, meniscal tears are often incidental findings in older patients with the majority of people over 70 years Chronic Knee Pain of age having an asymptomatic meniscal tear, and the likelihood of a meniscal tear being present in either a painful or asymptomatic knee not significantly different in patients 45 to 55 years of age [20,21]. | 69432 |
acrac_69432_3 | Chronic Knee Pain | Bone marrow lesions (BML) are readily depicted on MRI as areas of increased edema-like signal in the subchondral bone. New or increasing BMLs are associated with increased knee pain, especially in males or patients with family history of osteoarthritis [22]. Conversely, decreasing BMLs are associated with reduced knee pain [23]. A systematic review of 22 articles concluded that both BMLs and synovitis/effusion may indicate the origin of knee pain in patients with osteoarthritis [24-26]. Some patients with normal knee radiographs and anterior knee pain have abnormal cartilage on 3 T MRI using quantitative imaging [29]. In particular, patients 45 to 55 years of age with knee pain but normal radiographs exhibited elevated T2 mapping values on 3 T MRI [20]. Patellofemoral cartilage loss is also associated with chronic knee pain, with active knee pain correlated with BMLs [30,31]. Similar to CT, MRI can calculate various anatomic measurements associated with patellofemoral subluxation/dislocation and lateral patellofemoral friction syndrome [32-34]. Bone marrow edema in the classic location for patellofemoral dislocation/relocation injuries is also identified by MRI [15]. MRI may also differentiate patients with more severe patellofemoral osteoarthritis who may not benefit from supervised exercise therapy from patients with medial or lateral knee compartment arthritis who might benefit [35]. MR Arthrography Knee MR arthrography performed with an intra-articular injection of dilute gadolinium solution is typically not indicated as a second examination but rather reserved for patients with known prior meniscal surgery, chondral and osteochondral lesions, and suspected loose bodies [10]. US Knee US is not often useful as a screening test or a comprehensive examination. It may be appropriate to confirm a suspected effusion and to guide a potential aspiration [10]. US is as accurate in diagnosing a popliteal cyst and detecting cyst rupture when compared to MRI [10]. | Chronic Knee Pain. Bone marrow lesions (BML) are readily depicted on MRI as areas of increased edema-like signal in the subchondral bone. New or increasing BMLs are associated with increased knee pain, especially in males or patients with family history of osteoarthritis [22]. Conversely, decreasing BMLs are associated with reduced knee pain [23]. A systematic review of 22 articles concluded that both BMLs and synovitis/effusion may indicate the origin of knee pain in patients with osteoarthritis [24-26]. Some patients with normal knee radiographs and anterior knee pain have abnormal cartilage on 3 T MRI using quantitative imaging [29]. In particular, patients 45 to 55 years of age with knee pain but normal radiographs exhibited elevated T2 mapping values on 3 T MRI [20]. Patellofemoral cartilage loss is also associated with chronic knee pain, with active knee pain correlated with BMLs [30,31]. Similar to CT, MRI can calculate various anatomic measurements associated with patellofemoral subluxation/dislocation and lateral patellofemoral friction syndrome [32-34]. Bone marrow edema in the classic location for patellofemoral dislocation/relocation injuries is also identified by MRI [15]. MRI may also differentiate patients with more severe patellofemoral osteoarthritis who may not benefit from supervised exercise therapy from patients with medial or lateral knee compartment arthritis who might benefit [35]. MR Arthrography Knee MR arthrography performed with an intra-articular injection of dilute gadolinium solution is typically not indicated as a second examination but rather reserved for patients with known prior meniscal surgery, chondral and osteochondral lesions, and suspected loose bodies [10]. US Knee US is not often useful as a screening test or a comprehensive examination. It may be appropriate to confirm a suspected effusion and to guide a potential aspiration [10]. US is as accurate in diagnosing a popliteal cyst and detecting cyst rupture when compared to MRI [10]. | 69432 |
acrac_69432_4 | Chronic Knee Pain | US is also useful in evaluating medial plicae and following patients with iliotibial band syndrome [17,44]. More recently, shear wave elastography has been used to evaluate female patients with patellofemoral pain by demonstrating reduced contraction ratio in the vastus medialis oblique but not the vastus lateralis muscles [49]. Finally, US can diagnose a cyst and determine the vascularity of a mass [37]. Bone Scan Knee Radionuclide bone scan is usually not indicated when initial radiograph is negative or demonstrates a joint effusion. Chronic Knee Pain Image-Guided Aspiration Knee If an aspiration for crystals or atypical/low-grade chronic infection is indicated, it can be facilitated by US or fluoroscopy [10]. Variant 3: Adult or child greater than or equal to 5 years of age. Chronic knee pain. Initial knee radiograph demonstrates osteochondritis dissecans (OCD), loose bodies, or history of cartilage or meniscal repair. Next imaging procedure. Radiography Hip An ipsilateral hip radiograph is usually not indicated to evaluate patients with osteochondritis dissecans (OCD), loose bodies, or history of cartilage repair. CT Knee CT without IV contrast may be indicated to evaluate patients with OCD or a history of cartilage repair, especially to confirm loose bodies or when MRI is not definitive. CT with IV contrast is not usually indicated to evaluate patients with OCD, loose bodies, or history of cartilage repair. CT without and with IV contrast is not usually indicated to evaluate patients with OCD, loose bodies, or history of cartilage repair. CT Arthrography Knee CT arthrography may be used instead of MRI to evaluate the menisci, articular cartilage, and the presence of loose bodies [16]. MRI Knee In patients with OCD or subchondral insufficiency fracture on radiographs, MRI without IV contrast may be indicated if an additional injury is suspected clinically or to clarify the status of the overlying articular cartilage [41]. | Chronic Knee Pain. US is also useful in evaluating medial plicae and following patients with iliotibial band syndrome [17,44]. More recently, shear wave elastography has been used to evaluate female patients with patellofemoral pain by demonstrating reduced contraction ratio in the vastus medialis oblique but not the vastus lateralis muscles [49]. Finally, US can diagnose a cyst and determine the vascularity of a mass [37]. Bone Scan Knee Radionuclide bone scan is usually not indicated when initial radiograph is negative or demonstrates a joint effusion. Chronic Knee Pain Image-Guided Aspiration Knee If an aspiration for crystals or atypical/low-grade chronic infection is indicated, it can be facilitated by US or fluoroscopy [10]. Variant 3: Adult or child greater than or equal to 5 years of age. Chronic knee pain. Initial knee radiograph demonstrates osteochondritis dissecans (OCD), loose bodies, or history of cartilage or meniscal repair. Next imaging procedure. Radiography Hip An ipsilateral hip radiograph is usually not indicated to evaluate patients with osteochondritis dissecans (OCD), loose bodies, or history of cartilage repair. CT Knee CT without IV contrast may be indicated to evaluate patients with OCD or a history of cartilage repair, especially to confirm loose bodies or when MRI is not definitive. CT with IV contrast is not usually indicated to evaluate patients with OCD, loose bodies, or history of cartilage repair. CT without and with IV contrast is not usually indicated to evaluate patients with OCD, loose bodies, or history of cartilage repair. CT Arthrography Knee CT arthrography may be used instead of MRI to evaluate the menisci, articular cartilage, and the presence of loose bodies [16]. MRI Knee In patients with OCD or subchondral insufficiency fracture on radiographs, MRI without IV contrast may be indicated if an additional injury is suspected clinically or to clarify the status of the overlying articular cartilage [41]. | 69432 |
acrac_69432_5 | Chronic Knee Pain | A hyperintense rim or cysts at the osteochondral fragment periphery on MRI are less specific for OCD fragment instability in children compared to adults; however, MRI is still useful to determine the best method of treatment [41,50]. Following cartilage repair, MRI can grade the repair site and even guide the retrograde drilling of the OCD lesion [51-54]. MRI with and without IV contrast is not usually indicated to evaluate patients with OCD, loose bodies, or history of cartilage repair because of the usual larger volume of joint fluid, the lesser degree of synovial invagination, and the longer time required to achieve steady state gadolinium in the joint compared to the shoulder [16]. MR Arthrography Knee MR arthrography is typically reserved for patients with known prior meniscal surgery, chondral and osteochondral lesions, prior cartilage repair procedures, or suspected loose bodies [10,16]. US Knee US is not often useful as a screening test or a comprehensive examination. It may be appropriate to localize suspected loose bodies, especially if the loose bodies might be within a popliteal cyst, lateral recess, or suprapatellar recess. Bone Scan Knee Radionuclide bone scan is usually not indicated to evaluate patients with OCD, loose bodies, or history of cartilage repair. Image-Guided Aspiration Knee Joint aspiration is usually not indicated to evaluate patients with OCD, loose bodies, or history of cartilage repair. Variant 4: Adult or child greater than or equal to 5 years of age. Chronic knee pain. Initial knee radiograph demonstrates degenerative changes or chondrocalcinosis. Next imaging procedure. Radiography Hip An ipsilateral hip radiograph is usually not indicated to evaluate patients with osteoarthritis or chondrocalcinosis. Chronic Knee Pain CT Knee Dual-energy CT without IV contrast may be indicated if gout or mixed crystal disease is a consideration. Otherwise, CT is not commonly used as a diagnostic test to evaluate patients with osteoarthritis or chondrocalcinosis. | Chronic Knee Pain. A hyperintense rim or cysts at the osteochondral fragment periphery on MRI are less specific for OCD fragment instability in children compared to adults; however, MRI is still useful to determine the best method of treatment [41,50]. Following cartilage repair, MRI can grade the repair site and even guide the retrograde drilling of the OCD lesion [51-54]. MRI with and without IV contrast is not usually indicated to evaluate patients with OCD, loose bodies, or history of cartilage repair because of the usual larger volume of joint fluid, the lesser degree of synovial invagination, and the longer time required to achieve steady state gadolinium in the joint compared to the shoulder [16]. MR Arthrography Knee MR arthrography is typically reserved for patients with known prior meniscal surgery, chondral and osteochondral lesions, prior cartilage repair procedures, or suspected loose bodies [10,16]. US Knee US is not often useful as a screening test or a comprehensive examination. It may be appropriate to localize suspected loose bodies, especially if the loose bodies might be within a popliteal cyst, lateral recess, or suprapatellar recess. Bone Scan Knee Radionuclide bone scan is usually not indicated to evaluate patients with OCD, loose bodies, or history of cartilage repair. Image-Guided Aspiration Knee Joint aspiration is usually not indicated to evaluate patients with OCD, loose bodies, or history of cartilage repair. Variant 4: Adult or child greater than or equal to 5 years of age. Chronic knee pain. Initial knee radiograph demonstrates degenerative changes or chondrocalcinosis. Next imaging procedure. Radiography Hip An ipsilateral hip radiograph is usually not indicated to evaluate patients with osteoarthritis or chondrocalcinosis. Chronic Knee Pain CT Knee Dual-energy CT without IV contrast may be indicated if gout or mixed crystal disease is a consideration. Otherwise, CT is not commonly used as a diagnostic test to evaluate patients with osteoarthritis or chondrocalcinosis. | 69432 |
acrac_69432_6 | Chronic Knee Pain | Limited CT without IV contrast can be used for surgical planning. CT Arthrography Knee CT arthrography is not commonly utilized as a second test in patients with arthritis even though CT is the most accurate method for evaluating cartilage abnormalities extending to the articular surface that is due to the high spatial resolution between the contrast and the cartilage [11]. MRI Knee MRI without IV contrast is not usually indicated in patients for whom radiographs are diagnostic of osteoarthritis unless symptoms are not explained by the radiographic findings (eg, stress fractures) or the appropriate treatment option requires additional imaging [11,19]. Patellofemoral cartilage loss is closely associated with chronic knee pain with active knee pain correlated with BMLs [56]. Since MRI is more accurate than physical examination in identifying severe grades of chondromalacia patellae, it may be an appropriate screening tool prior to arthroscopy [58]. MR Arthrography Knee MR arthrography is usually not indicated to evaluate patients with osteoarthritis or chondrocalcinosis. US Knee US is not often useful as a screening test or a comprehensive examination. US can detect synovial pathology, effusions, and cortical erosive changes [11]. Power Doppler US can demonstrate increased synovial blood flow that is associated with knee pain and can demonstrate reduced blood flow, which correlates with reduced knee pain following joint injections [60]. US can also demonstrate meniscal extrusion, a finding that suggests an underlying meniscal tear, and, on occasion, chondrocalcinosis and peripheral meniscal tears [11]. Bone Scan Knee Radionuclide bone scan is usually not indicated to evaluate patients with chronic knee pain given the low specificity and decreased anatomic resolution compared to CT or MRI [11]. However, it may help distinguish between bone and soft-tissue origins for pain as well as localize pain to one or more joints [11]. | Chronic Knee Pain. Limited CT without IV contrast can be used for surgical planning. CT Arthrography Knee CT arthrography is not commonly utilized as a second test in patients with arthritis even though CT is the most accurate method for evaluating cartilage abnormalities extending to the articular surface that is due to the high spatial resolution between the contrast and the cartilage [11]. MRI Knee MRI without IV contrast is not usually indicated in patients for whom radiographs are diagnostic of osteoarthritis unless symptoms are not explained by the radiographic findings (eg, stress fractures) or the appropriate treatment option requires additional imaging [11,19]. Patellofemoral cartilage loss is closely associated with chronic knee pain with active knee pain correlated with BMLs [56]. Since MRI is more accurate than physical examination in identifying severe grades of chondromalacia patellae, it may be an appropriate screening tool prior to arthroscopy [58]. MR Arthrography Knee MR arthrography is usually not indicated to evaluate patients with osteoarthritis or chondrocalcinosis. US Knee US is not often useful as a screening test or a comprehensive examination. US can detect synovial pathology, effusions, and cortical erosive changes [11]. Power Doppler US can demonstrate increased synovial blood flow that is associated with knee pain and can demonstrate reduced blood flow, which correlates with reduced knee pain following joint injections [60]. US can also demonstrate meniscal extrusion, a finding that suggests an underlying meniscal tear, and, on occasion, chondrocalcinosis and peripheral meniscal tears [11]. Bone Scan Knee Radionuclide bone scan is usually not indicated to evaluate patients with chronic knee pain given the low specificity and decreased anatomic resolution compared to CT or MRI [11]. However, it may help distinguish between bone and soft-tissue origins for pain as well as localize pain to one or more joints [11]. | 69432 |
acrac_69432_7 | Chronic Knee Pain | Image-Guided Aspiration Knee If an effusion is present, US- or fluoroscopically guided joint aspiration can be performed for synovial fluid analysis if there is concern for crystal disease or infection. Corticosteroid injections can also be performed as they may result in a 1 to 2 week reduction in synovitis on MRI in two-thirds of patients. MRI also demonstrates a subsequent increase in the synovial volume in approximately 70% of patients that develop recurrent pain [61]. Chronic Knee Pain Radiography Hip An ipsilateral hip radiograph is usually not indicated to evaluate patients with signs of prior (chronic) osseous knee injury. CT Knee CT without IV contrast may be indicated to evaluate the patellofemoral anatomy in the setting of chronic knee pain related to repetitive patellofemoral subluxation, which can be suggested by a small osseous fragment along the medial patellar margin on axial knee radiographs [15]. CT knee without IV contrast may also be useful to confirm a prior osseous injury. CT with IV contrast is not usually indicated to evaluate patients with signs of prior (chronic) osseous knee injury. CT without and with IV contrast is not usually indicated to evaluate patients with signs of prior (chronic) osseous knee injury. CT Arthrography Knee CT arthrography may be used to evaluate the menisci, articular cartilage, and the presence of loose bodies with reported sensitivities and specificities ranging from 86% to 100% [16,62-64]. MRI Knee MRI without IV contrast may be indicated when radiographs demonstrate a small osseous fragment along the medial patellar margin or if there is a clinical concern for prior or chronic patellar dislocation-relocation. MRI can assess the integrity of the medial patellofemoral ligament and medial patellar retinaculum, define the extent of cartilage injury, and identify loose bodies [41]. MRI is useful for evaluating Osgood-Schlatter or Sinding-Larsen- Johansson syndrome [41]. | Chronic Knee Pain. Image-Guided Aspiration Knee If an effusion is present, US- or fluoroscopically guided joint aspiration can be performed for synovial fluid analysis if there is concern for crystal disease or infection. Corticosteroid injections can also be performed as they may result in a 1 to 2 week reduction in synovitis on MRI in two-thirds of patients. MRI also demonstrates a subsequent increase in the synovial volume in approximately 70% of patients that develop recurrent pain [61]. Chronic Knee Pain Radiography Hip An ipsilateral hip radiograph is usually not indicated to evaluate patients with signs of prior (chronic) osseous knee injury. CT Knee CT without IV contrast may be indicated to evaluate the patellofemoral anatomy in the setting of chronic knee pain related to repetitive patellofemoral subluxation, which can be suggested by a small osseous fragment along the medial patellar margin on axial knee radiographs [15]. CT knee without IV contrast may also be useful to confirm a prior osseous injury. CT with IV contrast is not usually indicated to evaluate patients with signs of prior (chronic) osseous knee injury. CT without and with IV contrast is not usually indicated to evaluate patients with signs of prior (chronic) osseous knee injury. CT Arthrography Knee CT arthrography may be used to evaluate the menisci, articular cartilage, and the presence of loose bodies with reported sensitivities and specificities ranging from 86% to 100% [16,62-64]. MRI Knee MRI without IV contrast may be indicated when radiographs demonstrate a small osseous fragment along the medial patellar margin or if there is a clinical concern for prior or chronic patellar dislocation-relocation. MRI can assess the integrity of the medial patellofemoral ligament and medial patellar retinaculum, define the extent of cartilage injury, and identify loose bodies [41]. MRI is useful for evaluating Osgood-Schlatter or Sinding-Larsen- Johansson syndrome [41]. | 69432 |
acrac_3158169_0 | Hernia | Introduction/Background Abdominal wall hernias are common clinical entities presenting to a wide variety of clinical practices, from primary care to the emergency department. Presenting symptoms vary, including vague discomfort, intractable pain, or a palpable mass, which may be persistent or intermittent, symptoms of bowel obstruction, abdominal wall erythema, or it may be occult. Up to 15.2% of hernias are identified incidentally at imaging [1]. Hernias may be congenital, iatrogenic, traumatic, or related to any of the multiple causes of elevated intraabdominal pressure. The initial imaging in four hernia categories are covered in this document: 1) suspected abdominal wall hernia, such as umbilical, ventral, incisional, lumbar, spigelian; 2) suspected groin hernia, such as inguinal or femoral; 3) suspected deep pelvic hernia such as obturator, sciatic, perineal hernias; and 4) suspected diaphragmatic hernia such as traumatic, Bochdalek, or Morgagni. Imaging diagnosis of hiatal hernias is not included in this document. OR Reprint requests to: [email protected] Hernia Discussion of Procedures by Variant Variant 1: Suspected abdominal wall hernia such as umbilical, ventral, incisional, lumbar, or spigelian. Initial imaging. Surgical procedures create measurable alterations in the abdominal wall, which may be identified and quantified with cross-sectional imaging [5]. Shifts in relative position and atrophy of musculature are identified and may contribute to the development of incisional hernias. Abdominal wall hernias may be challenging to diagnose clinically and are prone to complications if not addressed in a timely fashion [6]. Diagnosis and presurgical planning may be achieved through several imaging modalities. Spigelian hernia is a rare form of hernia, occurring through a defect adjacent to the linea semilunaris with a reported incidence of 0.12% of all abdominal hernias [7]. | Hernia. Introduction/Background Abdominal wall hernias are common clinical entities presenting to a wide variety of clinical practices, from primary care to the emergency department. Presenting symptoms vary, including vague discomfort, intractable pain, or a palpable mass, which may be persistent or intermittent, symptoms of bowel obstruction, abdominal wall erythema, or it may be occult. Up to 15.2% of hernias are identified incidentally at imaging [1]. Hernias may be congenital, iatrogenic, traumatic, or related to any of the multiple causes of elevated intraabdominal pressure. The initial imaging in four hernia categories are covered in this document: 1) suspected abdominal wall hernia, such as umbilical, ventral, incisional, lumbar, spigelian; 2) suspected groin hernia, such as inguinal or femoral; 3) suspected deep pelvic hernia such as obturator, sciatic, perineal hernias; and 4) suspected diaphragmatic hernia such as traumatic, Bochdalek, or Morgagni. Imaging diagnosis of hiatal hernias is not included in this document. OR Reprint requests to: [email protected] Hernia Discussion of Procedures by Variant Variant 1: Suspected abdominal wall hernia such as umbilical, ventral, incisional, lumbar, or spigelian. Initial imaging. Surgical procedures create measurable alterations in the abdominal wall, which may be identified and quantified with cross-sectional imaging [5]. Shifts in relative position and atrophy of musculature are identified and may contribute to the development of incisional hernias. Abdominal wall hernias may be challenging to diagnose clinically and are prone to complications if not addressed in a timely fashion [6]. Diagnosis and presurgical planning may be achieved through several imaging modalities. Spigelian hernia is a rare form of hernia, occurring through a defect adjacent to the linea semilunaris with a reported incidence of 0.12% of all abdominal hernias [7]. | 3158169 |
acrac_3158169_1 | Hernia | They may be congenital, secondary to high-energy trauma such as motor vehicle collisions, or found in high-level athletes [8]. Presenting signs and symptoms may be vague and nonspecific. Clinical examination has demonstrated high sensitivity of 100%, but a poor positive predictive value (PPV) at 36% [9]. Primary lumbar hernias are protrusions of the abdominal contents through the superior or inferior lumbar triangles. The first branches of the iliolumbar vessels may pass through the superior triangle, found in 46% of patients in a series of 50 upper abdominal CTs evaluating triangle anatomy [10]. The second, third, and fourth lumbar nerve branches may traverse the inferior triangle and were found in 9%, 67%, and 8%, respectively. These anatomic channels may contribute to the development of hernias because they represent natural weak points in the abdominal wall. Umbilical hernia is a common abdominal wall defect because the healed site of traverse of the umbilical vasculature represents a congenital abdominal wall weak point. Umbilical hernias are associated with causes of increased intraabdominal pressure. Among these causes are ascites, bland and malignant, and masses [11,12]. Ascites volume in cirrhotic patients was positively associated with development of umbilical hernias (P < . 0001, r = 0.4579). In many cases, umbilical hernias become apparent during pregnancy. An ultrasound (US) examination of the abdominal wall in a series of 302 patients referred for unrelated reasons yielded a prevalence of paraumbilical hernia in 24.9% of women and 23.3% of men [13]. Diastasis recti, weakened linea alba without disruption, may have a similar presentation. If possible, width should be measured and reported. Clinically, incisional hernia is defined as a detectable abdominal wall defect following surgical intervention with protrusion of abdominal contents or preperitoneal fat beyond the aponeurosis. Incidence is variable and related to patient characteristics and procedure. | Hernia. They may be congenital, secondary to high-energy trauma such as motor vehicle collisions, or found in high-level athletes [8]. Presenting signs and symptoms may be vague and nonspecific. Clinical examination has demonstrated high sensitivity of 100%, but a poor positive predictive value (PPV) at 36% [9]. Primary lumbar hernias are protrusions of the abdominal contents through the superior or inferior lumbar triangles. The first branches of the iliolumbar vessels may pass through the superior triangle, found in 46% of patients in a series of 50 upper abdominal CTs evaluating triangle anatomy [10]. The second, third, and fourth lumbar nerve branches may traverse the inferior triangle and were found in 9%, 67%, and 8%, respectively. These anatomic channels may contribute to the development of hernias because they represent natural weak points in the abdominal wall. Umbilical hernia is a common abdominal wall defect because the healed site of traverse of the umbilical vasculature represents a congenital abdominal wall weak point. Umbilical hernias are associated with causes of increased intraabdominal pressure. Among these causes are ascites, bland and malignant, and masses [11,12]. Ascites volume in cirrhotic patients was positively associated with development of umbilical hernias (P < . 0001, r = 0.4579). In many cases, umbilical hernias become apparent during pregnancy. An ultrasound (US) examination of the abdominal wall in a series of 302 patients referred for unrelated reasons yielded a prevalence of paraumbilical hernia in 24.9% of women and 23.3% of men [13]. Diastasis recti, weakened linea alba without disruption, may have a similar presentation. If possible, width should be measured and reported. Clinically, incisional hernia is defined as a detectable abdominal wall defect following surgical intervention with protrusion of abdominal contents or preperitoneal fat beyond the aponeurosis. Incidence is variable and related to patient characteristics and procedure. | 3158169 |
acrac_3158169_2 | Hernia | The rate of occurrence in laparoscopic procedures were as low as 2% [14]. However, the increased size of the fascial defect predisposes to increased incidence of port-site hernias. In a retrospective review of 787 patients who underwent single-incision laparoscopic procedures, Buckley et al [15] found that 2% to 6.35% developed port-site incisional hernias. Risk factors found to be associated with increased likelihood of developing an incisional hernia included pre-existing hernia (P = . 00212), body mass index (P = . 0307), and morbid obesity (P = . 02). In a series of 589 patients who underwent abdominal free flap reconstruction, Kappos et al [16] found symptomatic incisional hernias were significantly associated to low rectus abdominis muscle area, obtained through morphometric measurements on preoperative CT angiograms, and increased interrectus distance. Parastomal hernias are a specific type of incisional hernia seen most often in oncology patients. Rate of occurrence of parastomal hernias were found up to 65% in ileal conduits [17], and 30% to 50% of colostomies [18]. The majority of parastomal hernias in permanent colostomy patients occur within the first 2 years [19]. Complications include pain, stoma obstruction, bowel obstruction, and strangulation. Because the stoma itself is effectively an iatrogenic hernia, with a specific clinical purpose and necessary disruption of abdominal wall integrity, clinical diagnosis is difficult with interobserver kappa values of 0.29 to 0.73 [20]. Umbilical hernia is a common abdominal wall defect because the healed site of traverse of the umbilical vasculature represents a congenital abdominal wall weak point. Umbilical hernias are associated with causes of increased intraabdominal pressure. Among these causes are ascites, bland and malignant, and masses [11,12]. Ascites volume in cirrhotic patients was positively associated with development of umbilical hernias (P < . 0001, r = 0.4579). | Hernia. The rate of occurrence in laparoscopic procedures were as low as 2% [14]. However, the increased size of the fascial defect predisposes to increased incidence of port-site hernias. In a retrospective review of 787 patients who underwent single-incision laparoscopic procedures, Buckley et al [15] found that 2% to 6.35% developed port-site incisional hernias. Risk factors found to be associated with increased likelihood of developing an incisional hernia included pre-existing hernia (P = . 00212), body mass index (P = . 0307), and morbid obesity (P = . 02). In a series of 589 patients who underwent abdominal free flap reconstruction, Kappos et al [16] found symptomatic incisional hernias were significantly associated to low rectus abdominis muscle area, obtained through morphometric measurements on preoperative CT angiograms, and increased interrectus distance. Parastomal hernias are a specific type of incisional hernia seen most often in oncology patients. Rate of occurrence of parastomal hernias were found up to 65% in ileal conduits [17], and 30% to 50% of colostomies [18]. The majority of parastomal hernias in permanent colostomy patients occur within the first 2 years [19]. Complications include pain, stoma obstruction, bowel obstruction, and strangulation. Because the stoma itself is effectively an iatrogenic hernia, with a specific clinical purpose and necessary disruption of abdominal wall integrity, clinical diagnosis is difficult with interobserver kappa values of 0.29 to 0.73 [20]. Umbilical hernia is a common abdominal wall defect because the healed site of traverse of the umbilical vasculature represents a congenital abdominal wall weak point. Umbilical hernias are associated with causes of increased intraabdominal pressure. Among these causes are ascites, bland and malignant, and masses [11,12]. Ascites volume in cirrhotic patients was positively associated with development of umbilical hernias (P < . 0001, r = 0.4579). | 3158169 |
acrac_3158169_3 | Hernia | An ultrasound (US) examination of the abdominal wall in a series of 302 patients referred for unrelated reasons yielded a prevalence of paraumbilical hernia in 24.9% of women and 23.3% of men [13]. Diastasis recti, weakened linea alba without disruption, may have a similar presentation. If possible, width should be measured and reported. Hernia CT Abdomen and Pelvis Incidence of incisional hernia of 33% was found by Bjork et al [21] with clinical examination yielding a Kappa of 0.81 and CT yielding Kappas of 0.94 and 0.89, respectively, for supine and prone positioning. In one series with surgical confirmation, CT demonstrated high sensitivity and PPV, both at 100%, in diagnosis of Spigelian hernia [9]. Stoma closure sites are common incisional weak points in the abdominal wall. CT demonstrates a low PPV of 33% with a high negative predictive value (NPV) of 95% in the diagnosis of parastomal hernia [22]. This compares favorably with a clinical detection rate of 14%. There are no specific data differentiating diagnostic efficacy of intravenous (IV) contrast versus noncontrast examination. There are no specific data regarding the use of CT without and with IV contrast, but theoretically, the additional information gained between comparison of a noncontrast and postcontrast series would not be beneficial for hernia detection and characterization. Fluoroscopy Upper GI Series There is no relevant literature regarding the use of fluoroscopy upper gastrointestinal (GI) series in the evaluation of abdominal wall hernia. Fluoroscopy Upper GI Series with Small Bowel Follow-Through Anterior abdominal wall hernia may be diagnosed with fluoroscopic studies. Barium is the most common contrast employed. Hernias are recognized when bowel loops are seen extending beyond the fascial planes, focal luminal narrowing at entry and/or exit sites, and displacement or deformity of bowel loops [23]. | Hernia. An ultrasound (US) examination of the abdominal wall in a series of 302 patients referred for unrelated reasons yielded a prevalence of paraumbilical hernia in 24.9% of women and 23.3% of men [13]. Diastasis recti, weakened linea alba without disruption, may have a similar presentation. If possible, width should be measured and reported. Hernia CT Abdomen and Pelvis Incidence of incisional hernia of 33% was found by Bjork et al [21] with clinical examination yielding a Kappa of 0.81 and CT yielding Kappas of 0.94 and 0.89, respectively, for supine and prone positioning. In one series with surgical confirmation, CT demonstrated high sensitivity and PPV, both at 100%, in diagnosis of Spigelian hernia [9]. Stoma closure sites are common incisional weak points in the abdominal wall. CT demonstrates a low PPV of 33% with a high negative predictive value (NPV) of 95% in the diagnosis of parastomal hernia [22]. This compares favorably with a clinical detection rate of 14%. There are no specific data differentiating diagnostic efficacy of intravenous (IV) contrast versus noncontrast examination. There are no specific data regarding the use of CT without and with IV contrast, but theoretically, the additional information gained between comparison of a noncontrast and postcontrast series would not be beneficial for hernia detection and characterization. Fluoroscopy Upper GI Series There is no relevant literature regarding the use of fluoroscopy upper gastrointestinal (GI) series in the evaluation of abdominal wall hernia. Fluoroscopy Upper GI Series with Small Bowel Follow-Through Anterior abdominal wall hernia may be diagnosed with fluoroscopic studies. Barium is the most common contrast employed. Hernias are recognized when bowel loops are seen extending beyond the fascial planes, focal luminal narrowing at entry and/or exit sites, and displacement or deformity of bowel loops [23]. | 3158169 |
acrac_3158169_4 | Hernia | No specific data are available relative to the sensitivity, specificity, or accuracy of upper GI with small bowel follow-through in the diagnosis of abdominal wall hernias. MRI Abdomen Without and With IV Contrast There is no relevant literature regarding the use of MRI abdomen in the evaluation of abdominal wall hernia. However, the modality would be able to depict the anatomy, and theoretically, visualize a hernia. The specific performance attributes are unknown. MRI Abdomen Without IV Contrast There is no relevant literature regarding the use of MRI abdomen in the evaluation of abdominal wall hernia. However, the modality would be able to depict the anatomy, and theoretically, visualize a hernia. The specific performance attributes are unknown. MRI Pelvis There is no relevant literature regarding the use of MRI pelvis in the evaluation of abdominal wall hernia. However, the modality would be able to depict the anatomy, and theoretically, visualize a hernia. The specific performance attributes are unknown. Radiography Abdomen and Pelvis There is no relevant literature regarding the use of radiography abdomen and pelvis (KUB) in the evaluation of abdominal wall hernia. However, there may be utility if there is concern for bowel obstruction. US Abdomen US has long been used in the evaluation of the palpable abdominal masses. The ability to differentiate the abdominal wall from intraabdominal processes and distinguish the abdominal wall layers is well established. Use of high- frequency transducers and dynamic maneuvers frequently demonstrate the fascial defect and herniated abdominal structures with their characteristic US features [24]. In a case series with surgical confirmation of presence of Spigelian hernia, US demonstrated a sensitivity of 90% and a PPV of 100% [9]. Dynamic US demonstrated a high sensitivity, specificity, PPV, and NPV of 98%, 88%, 91%, and 97%, respectively, in the diagnosis of incisional hernias in a prospective study of 181 patients. | Hernia. No specific data are available relative to the sensitivity, specificity, or accuracy of upper GI with small bowel follow-through in the diagnosis of abdominal wall hernias. MRI Abdomen Without and With IV Contrast There is no relevant literature regarding the use of MRI abdomen in the evaluation of abdominal wall hernia. However, the modality would be able to depict the anatomy, and theoretically, visualize a hernia. The specific performance attributes are unknown. MRI Abdomen Without IV Contrast There is no relevant literature regarding the use of MRI abdomen in the evaluation of abdominal wall hernia. However, the modality would be able to depict the anatomy, and theoretically, visualize a hernia. The specific performance attributes are unknown. MRI Pelvis There is no relevant literature regarding the use of MRI pelvis in the evaluation of abdominal wall hernia. However, the modality would be able to depict the anatomy, and theoretically, visualize a hernia. The specific performance attributes are unknown. Radiography Abdomen and Pelvis There is no relevant literature regarding the use of radiography abdomen and pelvis (KUB) in the evaluation of abdominal wall hernia. However, there may be utility if there is concern for bowel obstruction. US Abdomen US has long been used in the evaluation of the palpable abdominal masses. The ability to differentiate the abdominal wall from intraabdominal processes and distinguish the abdominal wall layers is well established. Use of high- frequency transducers and dynamic maneuvers frequently demonstrate the fascial defect and herniated abdominal structures with their characteristic US features [24]. In a case series with surgical confirmation of presence of Spigelian hernia, US demonstrated a sensitivity of 90% and a PPV of 100% [9]. Dynamic US demonstrated a high sensitivity, specificity, PPV, and NPV of 98%, 88%, 91%, and 97%, respectively, in the diagnosis of incisional hernias in a prospective study of 181 patients. | 3158169 |
acrac_3158169_5 | Hernia | Patients with stoma, fistula, and/or abdominal wall infection were excluded [25]. US Pelvis There is no relevant literature regarding the use of US pelvis in the evaluation of abdominal wall hernia. Variant 2: Suspected groin hernia such as inguinal or femoral. Initial imaging. Inguinal hernias are common entities. Clinical diagnosis and differentiation of direct inguinal, indirect inguinal, and femoral hernias may be difficult. These hernias present in similar fashion with bulge, pain, and potentially signs and symptoms of bowel obstruction. In addition, the hernia may be occult, presenting with groin or pelvic pain in the absence of a palpable bulge or any other typical clinical examination findings. They may also present as an Hernia incidental finding in patients with athletic pub algia or chronic pain following herniorrh aphy [2 6,27]. Imag ing techniques p rovide visualization of the key anatomic landmarks and the relative position of herniated tissues, allowing differentiation of these entities. In addition, the impact of herniated tissues on the adjacent structures such as compression of the femoral vein in femoral hernia may be identified, aiding specific diagnosis [28]. CT Pelvis In a single prospective study, specifically evaluating CT imaging limited to the lower abdomen and pelvis evaluated prone patient positioning for hernia specific CT, there were 914 patients included in this prospective study and surgery was the reference standard. A prone CT protocol yielded an accuracy rate of 95.8% [33]. There are no specific data regarding the use of CT without and with IV contrast, but theoretically, the additional information gained between comparison of a noncontrast and postcontrast series would not be beneficial for hernia detection and characterization. Fluoroscopy Small Bowel Follow-Through There is no relevant literature regarding the use of fluoroscopy small bowel follow-through in the evaluation of groin, inguinal, or femoral hernia. | Hernia. Patients with stoma, fistula, and/or abdominal wall infection were excluded [25]. US Pelvis There is no relevant literature regarding the use of US pelvis in the evaluation of abdominal wall hernia. Variant 2: Suspected groin hernia such as inguinal or femoral. Initial imaging. Inguinal hernias are common entities. Clinical diagnosis and differentiation of direct inguinal, indirect inguinal, and femoral hernias may be difficult. These hernias present in similar fashion with bulge, pain, and potentially signs and symptoms of bowel obstruction. In addition, the hernia may be occult, presenting with groin or pelvic pain in the absence of a palpable bulge or any other typical clinical examination findings. They may also present as an Hernia incidental finding in patients with athletic pub algia or chronic pain following herniorrh aphy [2 6,27]. Imag ing techniques p rovide visualization of the key anatomic landmarks and the relative position of herniated tissues, allowing differentiation of these entities. In addition, the impact of herniated tissues on the adjacent structures such as compression of the femoral vein in femoral hernia may be identified, aiding specific diagnosis [28]. CT Pelvis In a single prospective study, specifically evaluating CT imaging limited to the lower abdomen and pelvis evaluated prone patient positioning for hernia specific CT, there were 914 patients included in this prospective study and surgery was the reference standard. A prone CT protocol yielded an accuracy rate of 95.8% [33]. There are no specific data regarding the use of CT without and with IV contrast, but theoretically, the additional information gained between comparison of a noncontrast and postcontrast series would not be beneficial for hernia detection and characterization. Fluoroscopy Small Bowel Follow-Through There is no relevant literature regarding the use of fluoroscopy small bowel follow-through in the evaluation of groin, inguinal, or femoral hernia. | 3158169 |
acrac_3158169_6 | Hernia | However, the modality would be able to depict the anatomy and, theoretically, visualize a hernia. The specific performance attributes are unknown. MRI Pelvis MRI is useful and can help visualize anatomic structures. In a retrospective review of 36 patients with suspected occult inguinal hernia, MRI demonstrated a sensitivity, a specificity, a PPV, and an NPV of 91%, 92%, 95%, and 85%, respectively, correctly diagnosing hernia in 10 of 11 patients [32]. In a retrospective review of 117 athletes who underwent MRI for groin pain, inguinal hernia was diagnosed in 35% of patients [26]. There are no specific data differentiating diagnostic efficacy of IV contrast versus noncontrast examination. Radiography Abdomen and Pelvis In case series of 170 and 204 herniographies for diagnosis of occult groin hernia, 49% and 35% were positive, respectively [34,35]. However, in the Ward et al study [35], 6 of 41 patients undergoing surgical repair, 16% were found to not have a hernia in the series. Whereas, in the Hachem et al study [34], all 84 patients with positive herniogram had hernia confirmed at surgery. In a third series of patients suspected of having occult inguinal hernia, herniography was found to have a sensitivity and specificity of 91% and 83%, respectively [31]. US Pelvis Diagnostic performance of US is common in the diagnosis of occult inguinal hernia. In a retrospect analysis of 297 patients, 116 went on to surgery. Based on surgical findings, US had a sensitivity of 94% with a PPV of 73% [36]. When US was performed by musculoskeletal experts, US had a sensitivity of 96.3% [37]. Hernia examination yielded a sensitivity and specificity of 96% [42]. In a case series of 18 consecutive pregnant patients with groin pain and swelling with clinical suspicion of hernia, hernia was not present in any patient and symptoms resolved following delivery [43]. Color Doppler US was positive for enlarged veins around the round ligament. Variant 3: Suspected deep pelvic hernia including obturator, sciatic, or perineal. | Hernia. However, the modality would be able to depict the anatomy and, theoretically, visualize a hernia. The specific performance attributes are unknown. MRI Pelvis MRI is useful and can help visualize anatomic structures. In a retrospective review of 36 patients with suspected occult inguinal hernia, MRI demonstrated a sensitivity, a specificity, a PPV, and an NPV of 91%, 92%, 95%, and 85%, respectively, correctly diagnosing hernia in 10 of 11 patients [32]. In a retrospective review of 117 athletes who underwent MRI for groin pain, inguinal hernia was diagnosed in 35% of patients [26]. There are no specific data differentiating diagnostic efficacy of IV contrast versus noncontrast examination. Radiography Abdomen and Pelvis In case series of 170 and 204 herniographies for diagnosis of occult groin hernia, 49% and 35% were positive, respectively [34,35]. However, in the Ward et al study [35], 6 of 41 patients undergoing surgical repair, 16% were found to not have a hernia in the series. Whereas, in the Hachem et al study [34], all 84 patients with positive herniogram had hernia confirmed at surgery. In a third series of patients suspected of having occult inguinal hernia, herniography was found to have a sensitivity and specificity of 91% and 83%, respectively [31]. US Pelvis Diagnostic performance of US is common in the diagnosis of occult inguinal hernia. In a retrospect analysis of 297 patients, 116 went on to surgery. Based on surgical findings, US had a sensitivity of 94% with a PPV of 73% [36]. When US was performed by musculoskeletal experts, US had a sensitivity of 96.3% [37]. Hernia examination yielded a sensitivity and specificity of 96% [42]. In a case series of 18 consecutive pregnant patients with groin pain and swelling with clinical suspicion of hernia, hernia was not present in any patient and symptoms resolved following delivery [43]. Color Doppler US was positive for enlarged veins around the round ligament. Variant 3: Suspected deep pelvic hernia including obturator, sciatic, or perineal. | 3158169 |
acrac_3158169_7 | Hernia | Initial imaging. Deep pelvis hernias are exceedingly rare, and little current literature is available, with the majority addressing obturator hernias and primarily case reports for the other entities. Obturator hernias comprise <1% of hernias [46]. Presenting symptoms are vague and varied and may be completely absent. Signs and symptoms include small- bowel obstruction (63%), vague and/or intractable abdominal/groin pain (57%), palpable medial thigh lump (10%), and thigh pain referred to the knee (37%) [46-48]. Referred pain is secondary to compression of the obturator nerve within the obturator foramen. Elderly women are most commonly affected, and diagnosis is most commonly made at surgery, often for inguinal hernia repair [47,49]. In a case series by Light et al [49] of 30 patients, 5 patients were suspected to have obturator hernia on clinical examination alone, with only 3 confirmed surgically. Because of the lack of specific symptoms and signs in the primarily elderly population, diagnosis is often delayed with significant morbidity (30%) and mortality (10%), with small-bowel resection performed in 47% of patients in one study [46,47]. Nasir et al [47], in a retrospective review, demonstrated diagnosis preoperatively in only 30% of patients, 3% clinically, and 27% with CT. Perineal hernias may be congenital or acquired. They are classified as anterior or posterior based on relative position to the superficial transverse perineal muscle [52]. Acquired perineal hernias are rare surgical complications, most often associated with oncologic surgeries for colorectal and genitourinary neoplasm such as abdominoperineal resection and cystectomy. Postprocedural pelvic floor weakening is implicated [53]. CT Abdomen and Pelvis Preoperative CT is excellent in diagnosing obturator hernia, although the diagnosis is seldom suspected, most often incidentally identified at abdominal pelvic imaging for the diagnosis of small-bowel obstruction. | Hernia. Initial imaging. Deep pelvis hernias are exceedingly rare, and little current literature is available, with the majority addressing obturator hernias and primarily case reports for the other entities. Obturator hernias comprise <1% of hernias [46]. Presenting symptoms are vague and varied and may be completely absent. Signs and symptoms include small- bowel obstruction (63%), vague and/or intractable abdominal/groin pain (57%), palpable medial thigh lump (10%), and thigh pain referred to the knee (37%) [46-48]. Referred pain is secondary to compression of the obturator nerve within the obturator foramen. Elderly women are most commonly affected, and diagnosis is most commonly made at surgery, often for inguinal hernia repair [47,49]. In a case series by Light et al [49] of 30 patients, 5 patients were suspected to have obturator hernia on clinical examination alone, with only 3 confirmed surgically. Because of the lack of specific symptoms and signs in the primarily elderly population, diagnosis is often delayed with significant morbidity (30%) and mortality (10%), with small-bowel resection performed in 47% of patients in one study [46,47]. Nasir et al [47], in a retrospective review, demonstrated diagnosis preoperatively in only 30% of patients, 3% clinically, and 27% with CT. Perineal hernias may be congenital or acquired. They are classified as anterior or posterior based on relative position to the superficial transverse perineal muscle [52]. Acquired perineal hernias are rare surgical complications, most often associated with oncologic surgeries for colorectal and genitourinary neoplasm such as abdominoperineal resection and cystectomy. Postprocedural pelvic floor weakening is implicated [53]. CT Abdomen and Pelvis Preoperative CT is excellent in diagnosing obturator hernia, although the diagnosis is seldom suspected, most often incidentally identified at abdominal pelvic imaging for the diagnosis of small-bowel obstruction. | 3158169 |
acrac_3158169_8 | Hernia | Nasir et al [47], in a retrospective review, found that patients diagnosed with obturator hernia on preoperative CT are less likely to develop postoperative complications (odds ratio: 0.8, P = . 04). Preoperative diagnosis did not impact length of stay, bowel resection, or mortality rates. CT has also been found to be efficacious in the diagnosis of sciatic and perineal hernias [51,53]. Because of the infrequency of these entities and the majority of literature being in the form of case reports, sensitivities, specificities, and accuracy ranges are not available. There are no specific data differentiating diagnostic efficacy of an IV contrast versus noncontrast examination. There are no specific data regarding the use of CT without and with IV contrast, but theoretically, the additional information gained between comparison of a noncontrast and postcontrast series would not be beneficial for hernia detection and characterization. CT Pelvis Retrospective reviews of clinical databases regarding imaging diagnosis of these rare deep pelvic hernias do not separate abdominal pelvic CT from pelvic CT alone [47,51,53]. Depending upon the area of coverage, CT pelvis can be useful in diagnosis and pre-operative planning. There are no specific data differentiating diagnostic efficacy of an IV contrast versus noncontrast examination. There are no specific data regarding the use of CT without and with IV contrast, but theoretically, the additional information gained between comparison of a noncontrast and postcontrast series would not be beneficial for hernia detection and characterization. Of note, CT without and with IV contrast is not typically performed for this scenario. Hernia Fluoroscopy Small Bowel Follow-Through There is no relevant literature regarding the use of small bowel follow-through in the evaluation of deep pelvic hernia. However, demonstration of abnormal bowel configuration suggesting herniation may be helpful in complex cases. | Hernia. Nasir et al [47], in a retrospective review, found that patients diagnosed with obturator hernia on preoperative CT are less likely to develop postoperative complications (odds ratio: 0.8, P = . 04). Preoperative diagnosis did not impact length of stay, bowel resection, or mortality rates. CT has also been found to be efficacious in the diagnosis of sciatic and perineal hernias [51,53]. Because of the infrequency of these entities and the majority of literature being in the form of case reports, sensitivities, specificities, and accuracy ranges are not available. There are no specific data differentiating diagnostic efficacy of an IV contrast versus noncontrast examination. There are no specific data regarding the use of CT without and with IV contrast, but theoretically, the additional information gained between comparison of a noncontrast and postcontrast series would not be beneficial for hernia detection and characterization. CT Pelvis Retrospective reviews of clinical databases regarding imaging diagnosis of these rare deep pelvic hernias do not separate abdominal pelvic CT from pelvic CT alone [47,51,53]. Depending upon the area of coverage, CT pelvis can be useful in diagnosis and pre-operative planning. There are no specific data differentiating diagnostic efficacy of an IV contrast versus noncontrast examination. There are no specific data regarding the use of CT without and with IV contrast, but theoretically, the additional information gained between comparison of a noncontrast and postcontrast series would not be beneficial for hernia detection and characterization. Of note, CT without and with IV contrast is not typically performed for this scenario. Hernia Fluoroscopy Small Bowel Follow-Through There is no relevant literature regarding the use of small bowel follow-through in the evaluation of deep pelvic hernia. However, demonstration of abnormal bowel configuration suggesting herniation may be helpful in complex cases. | 3158169 |
acrac_3158169_9 | Hernia | MRI Pelvis No specific data are available relative to the sensitivity, specificity, or accuracy of MRI in the diagnosis of deep pelvic hernias. However, case reports demonstrate efficacy, particularly in patients with orthopedic instrumentation limiting CT imaging [54]. There are no specific data differentiating diagnostic efficacy of IV contrast versus noncontrast examination. However, the modality would be able to depict the anatomy, and theoretically, visualize a hernia. The specific performance attributes are unknown. Radiography Abdomen and Pelvis There is no relevant literature regarding the use of KUB in the evaluation of deep pelvic hernia. However, there may be utility if there is a concern for bowel obstruction. US Pelvis There is no relevant literature regarding the use of US of the pelvis in the evaluation of deep pelvic hernia. Variant 4: Suspected diaphragmatic hernia including traumatic, Bochdalek, or Morgagni. Initial imaging. Diaphragmatic hernias are rare and diagnosis may be difficult despite high -resolution multiplanar imaging techniques. Congenital, traumatic, and iatrogenic etiologies are evaluated primarily with CT and MRI. Congenital, Bochdalek and Morgagni hernias are most often diagnosed in the prenatal or neonatal period because o f abnormalities detected on obstetric US. Diagnosis of traumatic diaphragmatic rupture with herniation of abdominal contents into the thorax is often delayed because of subtle initial imaging findings and late herniation of abdominal contents into the thorax. Congenital diaphragmatic hernias are rare, occurring in approximately 1 per 2,000 pregnancies with 5% Morgagni and 90% Bochdalek hernias [55]. Most are diagnosed on prenatal imaging and present in the neonatal period with cardiorespiratory compromise and are surgically corrected. Bochdalek hernias are the result of improper fusion of the septum transversarium and pleuroperitoneal fo lds and are present in 1:2 ,200 to 12 ,500 live births [56,57] . | Hernia. MRI Pelvis No specific data are available relative to the sensitivity, specificity, or accuracy of MRI in the diagnosis of deep pelvic hernias. However, case reports demonstrate efficacy, particularly in patients with orthopedic instrumentation limiting CT imaging [54]. There are no specific data differentiating diagnostic efficacy of IV contrast versus noncontrast examination. However, the modality would be able to depict the anatomy, and theoretically, visualize a hernia. The specific performance attributes are unknown. Radiography Abdomen and Pelvis There is no relevant literature regarding the use of KUB in the evaluation of deep pelvic hernia. However, there may be utility if there is a concern for bowel obstruction. US Pelvis There is no relevant literature regarding the use of US of the pelvis in the evaluation of deep pelvic hernia. Variant 4: Suspected diaphragmatic hernia including traumatic, Bochdalek, or Morgagni. Initial imaging. Diaphragmatic hernias are rare and diagnosis may be difficult despite high -resolution multiplanar imaging techniques. Congenital, traumatic, and iatrogenic etiologies are evaluated primarily with CT and MRI. Congenital, Bochdalek and Morgagni hernias are most often diagnosed in the prenatal or neonatal period because o f abnormalities detected on obstetric US. Diagnosis of traumatic diaphragmatic rupture with herniation of abdominal contents into the thorax is often delayed because of subtle initial imaging findings and late herniation of abdominal contents into the thorax. Congenital diaphragmatic hernias are rare, occurring in approximately 1 per 2,000 pregnancies with 5% Morgagni and 90% Bochdalek hernias [55]. Most are diagnosed on prenatal imaging and present in the neonatal period with cardiorespiratory compromise and are surgically corrected. Bochdalek hernias are the result of improper fusion of the septum transversarium and pleuroperitoneal fo lds and are present in 1:2 ,200 to 12 ,500 live births [56,57] . | 3158169 |
acrac_3158169_10 | Hernia | Morgagni hernia is a defect in the anterior diaphragm between the costal and sternal portions of the muscle [58]. Adult presentation is uncommon and usually an incidental finding on imaging performed for unrelated reasons. Retrospective review series of multidetector CT performed for unrelated indications identified Bochdalek hernia in 10.5% to 12.7% of adults [59,60]. However, these hernias may also present with acute symptoms related to complications of obstruction, perforation, or necrosis of the herniated organs [56,61-63]. CT Chest and Abdomen CT is an efficacious method for the diagnosis of traumatic diaphragmatic hernia with a sensitivity, a specificity, a PPV, an NPV, and an accuracy ranging from 56.5% to 82%, 69.6% to 100%, 69% to 100%, 88.4% to 93%, and 89% to 90.6%, respectively [64-66]. For the diagnosis of congenital hernia, there is particular emphasis on the utility of multiplanar technique [59-63,67- 69]. Data on sensitivity, specificity, and accuracy are not available because the majority of literature is comprised of case reports. There is n o specific data differentiating diagnostic efficacy of IV contrast versus n oncontrast examination. There is no specific data regarding the use of CT without and with IV contrast, but theoretically, the additional information gained between comparison of a noncontrast and postcontrast series would not be beneficial for hernia detection and characterization. Fluoroscopy Upper GI Series Upper GI diagnosed congenital diaphragmatic hernia in one case report of Morgagni hernia [61], and contrast swallow was diagnostic on one reported case of Bochdalek hernia [63]. Fluoroscopy Upper GI Series with Small Bowel Follow-Through There is no relevant literature regarding the use of fluoroscopy upper GI series with small bowel follow-through in the evaluation of diaphragmatic hernia. However, demonstration of abnormal bowel configuration suggesting herniation may be helpful in complex cases. | Hernia. Morgagni hernia is a defect in the anterior diaphragm between the costal and sternal portions of the muscle [58]. Adult presentation is uncommon and usually an incidental finding on imaging performed for unrelated reasons. Retrospective review series of multidetector CT performed for unrelated indications identified Bochdalek hernia in 10.5% to 12.7% of adults [59,60]. However, these hernias may also present with acute symptoms related to complications of obstruction, perforation, or necrosis of the herniated organs [56,61-63]. CT Chest and Abdomen CT is an efficacious method for the diagnosis of traumatic diaphragmatic hernia with a sensitivity, a specificity, a PPV, an NPV, and an accuracy ranging from 56.5% to 82%, 69.6% to 100%, 69% to 100%, 88.4% to 93%, and 89% to 90.6%, respectively [64-66]. For the diagnosis of congenital hernia, there is particular emphasis on the utility of multiplanar technique [59-63,67- 69]. Data on sensitivity, specificity, and accuracy are not available because the majority of literature is comprised of case reports. There is n o specific data differentiating diagnostic efficacy of IV contrast versus n oncontrast examination. There is no specific data regarding the use of CT without and with IV contrast, but theoretically, the additional information gained between comparison of a noncontrast and postcontrast series would not be beneficial for hernia detection and characterization. Fluoroscopy Upper GI Series Upper GI diagnosed congenital diaphragmatic hernia in one case report of Morgagni hernia [61], and contrast swallow was diagnostic on one reported case of Bochdalek hernia [63]. Fluoroscopy Upper GI Series with Small Bowel Follow-Through There is no relevant literature regarding the use of fluoroscopy upper GI series with small bowel follow-through in the evaluation of diaphragmatic hernia. However, demonstration of abnormal bowel configuration suggesting herniation may be helpful in complex cases. | 3158169 |
acrac_69369_0 | Post Treatment Follow up of Prostate Cancer | Introduction/Background Prostate cancer is primarily managed by 4 standard treatment methods: radical prostatectomy (RP), radiation therapy (RT), androgen deprivation therapy (ADT), and active surveillance (AS). A detailed discussion of relatively new focal therapies, such as cryotherapy, high-intensity focused ultrasound (US), and MRI-guided ablative techniques are beyond the scope of this document. The treatment choice is based on the tumor stage, histology, and grade and is influenced to a certain extent by the preference of the treating physician and the patient. After treatment, patients are followed at periodic intervals with the measurement of serum prostate- specific antigen (PSA) levels. RP and RT, which includes brachytherapy, are considered definitive treatment therapies. Biochemical recurrence (BCR), also referred to as PSA recurrence, PSA failure, or biochemical failure, is the most clinically used endpoint for identification of treatment failure. A number of clinical nomograms are available to predict BCR, time to metastasis, and prostate cancer-specific mortality [1-3]. Approximately 10% to 53% of patients undergoing primary intended curative therapy will develop BCR, depending on their preoperative disease risk and stage of cancer [4]. For localized low-risk prostate cancer, the rate of BCR is as low as 9% after RP [2,4]. A first serum total PSA assay is recommended during the first 3 to 12 months after RP or RT. When PSA is detectable following RP, a PSA assay should be repeated 1 to 3 months later to confirm this elevation and to estimate the PSA doubling time (PSADT). In the absence of residual or recurrent cancer, PSA becomes undetectable by the first month after total prostatectomy (<0.1 ng/mL) [5]. No imaging study is necessary after definitive treatment for clinically localized prostate cancer before BCR unless there are concerns for complications such as a fistula or abscess [6]. | Post Treatment Follow up of Prostate Cancer. Introduction/Background Prostate cancer is primarily managed by 4 standard treatment methods: radical prostatectomy (RP), radiation therapy (RT), androgen deprivation therapy (ADT), and active surveillance (AS). A detailed discussion of relatively new focal therapies, such as cryotherapy, high-intensity focused ultrasound (US), and MRI-guided ablative techniques are beyond the scope of this document. The treatment choice is based on the tumor stage, histology, and grade and is influenced to a certain extent by the preference of the treating physician and the patient. After treatment, patients are followed at periodic intervals with the measurement of serum prostate- specific antigen (PSA) levels. RP and RT, which includes brachytherapy, are considered definitive treatment therapies. Biochemical recurrence (BCR), also referred to as PSA recurrence, PSA failure, or biochemical failure, is the most clinically used endpoint for identification of treatment failure. A number of clinical nomograms are available to predict BCR, time to metastasis, and prostate cancer-specific mortality [1-3]. Approximately 10% to 53% of patients undergoing primary intended curative therapy will develop BCR, depending on their preoperative disease risk and stage of cancer [4]. For localized low-risk prostate cancer, the rate of BCR is as low as 9% after RP [2,4]. A first serum total PSA assay is recommended during the first 3 to 12 months after RP or RT. When PSA is detectable following RP, a PSA assay should be repeated 1 to 3 months later to confirm this elevation and to estimate the PSA doubling time (PSADT). In the absence of residual or recurrent cancer, PSA becomes undetectable by the first month after total prostatectomy (<0.1 ng/mL) [5]. No imaging study is necessary after definitive treatment for clinically localized prostate cancer before BCR unless there are concerns for complications such as a fistula or abscess [6]. | 69369 |
acrac_69369_1 | Post Treatment Follow up of Prostate Cancer | Although serum PSA alone does not differentiate local recurrence from distant metastatic disease, the patterns of PSA rise after failed primary therapy have been incorporated into clinical nomograms to predict whether recurrence is more likely local versus distant metastatic disease. Patients with late BCR (>24 months after local treatment), low PSA velocity (change in PSA over time), and/or prolonged PSADT (>6 months) most likely have recurrent local disease [7]. Conversely, patients with a rapid PSA recurrence (<24 months after local treatment), high PSA velocity, or short PSADT (<6 months) are more likely to have metastatic recurrence [7]. This can serve as a clinical guide in selecting the appropriate imaging test to confirm diagnosis. In evaluating patients with recurrent or metastatic prostate cancer, it is important to define the location, size, and extent of local and/or distant tumors. Use of more conventional imaging studies (eg, bone scan and CT) to document recurrent or metastatic disease using clinical parameters is challenging. Choueiri et al [1] demonstrated that with a PSA of <5 ng/mL and a PSADT <10 months, both scintigraphic bone scan and CT are very unlikely to detect the recurrence. The common sites of BCR after failure of definitive management are local recurrence and regional nodal metastasis [8,9]. Although early bone metastases can also be seen, bone metastases are relatively uncommon until later in the course of more advanced metastatic spread when serum PSA values correspondingly tend to also be aNational Cancer Institute, National Institutes of Health, Bethesda, Maryland. bPanel Chair, University of Chicago, Chicago, Illinois. cPanel Vice-Chair, Duke University Medical Center, Durham, North Carolina. dMemorial Sloan Kettering Cancer Center, New York, New York. eMayo Clinic, Jacksonville, Florida. fThe University of Chicago, Chicago, Illinois, Primary care physician. gMayo Clinic, Rochester, Minnesota. | Post Treatment Follow up of Prostate Cancer. Although serum PSA alone does not differentiate local recurrence from distant metastatic disease, the patterns of PSA rise after failed primary therapy have been incorporated into clinical nomograms to predict whether recurrence is more likely local versus distant metastatic disease. Patients with late BCR (>24 months after local treatment), low PSA velocity (change in PSA over time), and/or prolonged PSADT (>6 months) most likely have recurrent local disease [7]. Conversely, patients with a rapid PSA recurrence (<24 months after local treatment), high PSA velocity, or short PSADT (<6 months) are more likely to have metastatic recurrence [7]. This can serve as a clinical guide in selecting the appropriate imaging test to confirm diagnosis. In evaluating patients with recurrent or metastatic prostate cancer, it is important to define the location, size, and extent of local and/or distant tumors. Use of more conventional imaging studies (eg, bone scan and CT) to document recurrent or metastatic disease using clinical parameters is challenging. Choueiri et al [1] demonstrated that with a PSA of <5 ng/mL and a PSADT <10 months, both scintigraphic bone scan and CT are very unlikely to detect the recurrence. The common sites of BCR after failure of definitive management are local recurrence and regional nodal metastasis [8,9]. Although early bone metastases can also be seen, bone metastases are relatively uncommon until later in the course of more advanced metastatic spread when serum PSA values correspondingly tend to also be aNational Cancer Institute, National Institutes of Health, Bethesda, Maryland. bPanel Chair, University of Chicago, Chicago, Illinois. cPanel Vice-Chair, Duke University Medical Center, Durham, North Carolina. dMemorial Sloan Kettering Cancer Center, New York, New York. eMayo Clinic, Jacksonville, Florida. fThe University of Chicago, Chicago, Illinois, Primary care physician. gMayo Clinic, Rochester, Minnesota. | 69369 |
acrac_69369_2 | Post Treatment Follow up of Prostate Cancer | hUrology Clinics of North Texas, Dallas, Texas; American Urological Association. iUniversity of Wisconsin, Madison, Wisconsin. jUPMC, Pittsburgh, Pennsylvania; American Urological Association. kSutter Medical Group, Sacramento, California; Commission on Radiation Oncology. lOttawa Hospital Research Institute and the Department of Radiology, The University of Ottawa, Ottawa, Ontario, Canada. mEmory University, Atlanta, Georgia; Commission on Nuclear Medicine and Molecular Imaging. nThe University of Texas MD Anderson Cancer Center, Houston, Texas. oSpecialty Chair, University of Alabama at Birmingham, Birmingham, Alabama. 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] Post-Treatment Follow-up of Prostate Cancer much higher. MRI can identify isolated local recurrences very early, with PSA levels <1 ng/mL [10]. Nodal staging is still a significant diagnostic challenge, because CT and MRI have limited accuracy because of the dependence on size criteria, which is a poor predictor of prostate cancer nodal metastasis. There are currently 4 FDA-approved prostate-specific PET agents for prostate cancer recurrence: 1) carbon-11 choline (C-11 choline), 2) F-18 fluciclovine (also known as anti-1-amino-3-[18-F]-fluorocyclobutane-1-carboxylic acid, [FACBC]), 3) Ga-68-prostate-specific membrane antigen (PSMA)-11, and 4) DCFPyL (2-(3-{1-carboxy-5-[(6-[(18)F]fluoro- pyridine-3-carbonyl)-amino]-pentyl}-ureido)-pentanedioic acid). There is a great deal of data for all 4 radiotracers on the performance showing their usefulness for nodal and bone lesion identification. | Post Treatment Follow up of Prostate Cancer. hUrology Clinics of North Texas, Dallas, Texas; American Urological Association. iUniversity of Wisconsin, Madison, Wisconsin. jUPMC, Pittsburgh, Pennsylvania; American Urological Association. kSutter Medical Group, Sacramento, California; Commission on Radiation Oncology. lOttawa Hospital Research Institute and the Department of Radiology, The University of Ottawa, Ottawa, Ontario, Canada. mEmory University, Atlanta, Georgia; Commission on Nuclear Medicine and Molecular Imaging. nThe University of Texas MD Anderson Cancer Center, Houston, Texas. oSpecialty Chair, University of Alabama at Birmingham, Birmingham, Alabama. 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] Post-Treatment Follow-up of Prostate Cancer much higher. MRI can identify isolated local recurrences very early, with PSA levels <1 ng/mL [10]. Nodal staging is still a significant diagnostic challenge, because CT and MRI have limited accuracy because of the dependence on size criteria, which is a poor predictor of prostate cancer nodal metastasis. There are currently 4 FDA-approved prostate-specific PET agents for prostate cancer recurrence: 1) carbon-11 choline (C-11 choline), 2) F-18 fluciclovine (also known as anti-1-amino-3-[18-F]-fluorocyclobutane-1-carboxylic acid, [FACBC]), 3) Ga-68-prostate-specific membrane antigen (PSMA)-11, and 4) DCFPyL (2-(3-{1-carboxy-5-[(6-[(18)F]fluoro- pyridine-3-carbonyl)-amino]-pentyl}-ureido)-pentanedioic acid). There is a great deal of data for all 4 radiotracers on the performance showing their usefulness for nodal and bone lesion identification. | 69369 |
Subsets and Splits