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acrac_69369_3 | Post Treatment Follow up of Prostate Cancer | Whole body planar scintigraphic bone scans have historically been frequently performed for detecting skeletal metastases in patients with rising PSA following definitive treatment but are very unlikely to be positive until relatively late in the course of advanced metastatic disease. It was previously thought that a bone scan was quite sensitive, but PET imaging with prostate-specific agents, such as those mentioned above and more sensitive bone agents like fluoride PET, have shown detectability of many lesions before a bone scan becomes positive [11]. Because planar bone scans are rarely positive without symptoms or without relatively high PSA levels, the routine use of this imaging technique at the post-treatment stage is considered ineffective by most investigators [5,12-14] and is not recommended by the National Comprehensive Cancer Network (NCCN). MRI may be helpful in the diagnosis of bone metastasis when other examinations are conflicting, and its combined use with PET imaging can be used to determine response to hormonal treatment [1]. It is notable that prostate cancer is the second leading cause of cancer related mortalities among Americans with prostates. The majority of these patients are not dying because of initial presentation of a high-stage incurable disease. Most of the patients who die from prostate cancer had originally presented with localized disease, underwent definitive primary management with curative intent, experienced treatment failure with BCR, and then their recurrent disease progressed while on nontargeted systemic therapy to become fatal. Recent imaging advances that allow identification of limited metastatic disease early in BCR rather than once the disease has become systemically advanced may hopefully lead to targeted treatments specifically for oligometastatic disease that will impact patient outcomes [18]. | Post Treatment Follow up of Prostate Cancer. Whole body planar scintigraphic bone scans have historically been frequently performed for detecting skeletal metastases in patients with rising PSA following definitive treatment but are very unlikely to be positive until relatively late in the course of advanced metastatic disease. It was previously thought that a bone scan was quite sensitive, but PET imaging with prostate-specific agents, such as those mentioned above and more sensitive bone agents like fluoride PET, have shown detectability of many lesions before a bone scan becomes positive [11]. Because planar bone scans are rarely positive without symptoms or without relatively high PSA levels, the routine use of this imaging technique at the post-treatment stage is considered ineffective by most investigators [5,12-14] and is not recommended by the National Comprehensive Cancer Network (NCCN). MRI may be helpful in the diagnosis of bone metastasis when other examinations are conflicting, and its combined use with PET imaging can be used to determine response to hormonal treatment [1]. It is notable that prostate cancer is the second leading cause of cancer related mortalities among Americans with prostates. The majority of these patients are not dying because of initial presentation of a high-stage incurable disease. Most of the patients who die from prostate cancer had originally presented with localized disease, underwent definitive primary management with curative intent, experienced treatment failure with BCR, and then their recurrent disease progressed while on nontargeted systemic therapy to become fatal. Recent imaging advances that allow identification of limited metastatic disease early in BCR rather than once the disease has become systemically advanced may hopefully lead to targeted treatments specifically for oligometastatic disease that will impact patient outcomes [18]. | 69369 |
acrac_69369_4 | Post Treatment Follow up of Prostate Cancer | Finally, it is important to recognize that the clinical scenarios here still represent broad ranges of risk for recurrence or metastases in individuals with prostates. For example, in Variant 1, clinically appropriate imaging may be different for a patient with initially detected BCR and a PSA <1 ng/mL, versus a PSA >40 ng/mL, or for a patient with persistently detectable PSA after surgery. We chose to avoid challenging subcategorizations of many individual patient scenarios encountered in clinical practice, such as by specific PSA ranges or PSA kinetics, or other clinical parameters. It is important to note that in general the yield of the various imaging studies can be related to these additional specific clinical risk parameters. Finally, it should be noted that this document includes analysis of imaging techniques that are formally approved by the FDA. Special Imaging Considerations TRUS Prostatectomy Bed: Drudi et al [19] showed contrast-enhanced color Doppler transrectal US (TRUS) performed as well as contrast-enhanced MRI in detecting local recurrence after prostatectomy; however, intravascular microbubble contrast agents are not FDA approved for this application. Discussion of Procedures by Variant Variant 1: Prostate cancer follow-up. Status post radical prostatectomy. Clinical concern for residual or recurrent disease. Following RP, serum PSA levels are expected to be undetectable within several weeks of surgery. Waiting 6 to 8 weeks after treatment is advisable before assessing the serum PSA value because the half-life of serum PSA is CT Abdomen and Pelvis CT is not effective for detecting recurrent tumors in the surgical bed. The mean PSA value associated with a positive CT scan after RP was 27.4 ng/mL, and this typically represents very large recurrent masses (>2 cm in size) [7]. | Post Treatment Follow up of Prostate Cancer. Finally, it is important to recognize that the clinical scenarios here still represent broad ranges of risk for recurrence or metastases in individuals with prostates. For example, in Variant 1, clinically appropriate imaging may be different for a patient with initially detected BCR and a PSA <1 ng/mL, versus a PSA >40 ng/mL, or for a patient with persistently detectable PSA after surgery. We chose to avoid challenging subcategorizations of many individual patient scenarios encountered in clinical practice, such as by specific PSA ranges or PSA kinetics, or other clinical parameters. It is important to note that in general the yield of the various imaging studies can be related to these additional specific clinical risk parameters. Finally, it should be noted that this document includes analysis of imaging techniques that are formally approved by the FDA. Special Imaging Considerations TRUS Prostatectomy Bed: Drudi et al [19] showed contrast-enhanced color Doppler transrectal US (TRUS) performed as well as contrast-enhanced MRI in detecting local recurrence after prostatectomy; however, intravascular microbubble contrast agents are not FDA approved for this application. Discussion of Procedures by Variant Variant 1: Prostate cancer follow-up. Status post radical prostatectomy. Clinical concern for residual or recurrent disease. Following RP, serum PSA levels are expected to be undetectable within several weeks of surgery. Waiting 6 to 8 weeks after treatment is advisable before assessing the serum PSA value because the half-life of serum PSA is CT Abdomen and Pelvis CT is not effective for detecting recurrent tumors in the surgical bed. The mean PSA value associated with a positive CT scan after RP was 27.4 ng/mL, and this typically represents very large recurrent masses (>2 cm in size) [7]. | 69369 |
acrac_69369_5 | Post Treatment Follow up of Prostate Cancer | In the evaluation of nodal disease, CT relies on size to detect nodal metastases, which is a significant limitation and confers poor sensitivity for prostate cancer nodal metastases because large numbers of metastatic nodes are known to be a normal size [26]. CT is useful in following the response of known enlarged metastatic lymphadenopathy to treatment. CT is useful in detecting sclerotic bone and visceral metastases, although bone scan and MRI are superior in both the diagnosis and follow-up of bone metastases [27], and choline PET is much better for detection and follow-up of bone metastases. Because bone metastases respond to treatment, they often become more densely sclerotic, which by CT is a common pitfall that can lead to false interpretation as disease progression. CT is useful when done with intravenous (IV) contrast for cancer detection and surveillance. There is no evidence to support use of CT without IV contrast or multiphasic scanning (ie, without and with IV contrast). CT Chest, Abdomen, and Pelvis There is rarely any indication for consideration of extension of coverage with CT of the chest for follow-up of a patient with a clinical concern for residual or recurrent disease, status after RP. Additionally, there is limited evidence to support the use of CT chest abdomen pelvis in this setting. MRI Pelvis Local recurrence seems to be a common site of initial disease recurrence, and MP-MRI is the most accurate imaging method for identifying sites of local recurrence after RP [6,28-32]. It is worth noting that, unlike with the Prostate Imaging Reporting and Data System (PI-RADS) applied to pretreatment imaging, there are no consensus technical standard or interpretation criteria for MRI in the BCR setting. In general, 3.0T performs better than 1.5T, and endorectal coil use can offer an improved signal-to-noise ratio and resolution to aid in detecting small early recurrences compared to surface coils. | Post Treatment Follow up of Prostate Cancer. In the evaluation of nodal disease, CT relies on size to detect nodal metastases, which is a significant limitation and confers poor sensitivity for prostate cancer nodal metastases because large numbers of metastatic nodes are known to be a normal size [26]. CT is useful in following the response of known enlarged metastatic lymphadenopathy to treatment. CT is useful in detecting sclerotic bone and visceral metastases, although bone scan and MRI are superior in both the diagnosis and follow-up of bone metastases [27], and choline PET is much better for detection and follow-up of bone metastases. Because bone metastases respond to treatment, they often become more densely sclerotic, which by CT is a common pitfall that can lead to false interpretation as disease progression. CT is useful when done with intravenous (IV) contrast for cancer detection and surveillance. There is no evidence to support use of CT without IV contrast or multiphasic scanning (ie, without and with IV contrast). CT Chest, Abdomen, and Pelvis There is rarely any indication for consideration of extension of coverage with CT of the chest for follow-up of a patient with a clinical concern for residual or recurrent disease, status after RP. Additionally, there is limited evidence to support the use of CT chest abdomen pelvis in this setting. MRI Pelvis Local recurrence seems to be a common site of initial disease recurrence, and MP-MRI is the most accurate imaging method for identifying sites of local recurrence after RP [6,28-32]. It is worth noting that, unlike with the Prostate Imaging Reporting and Data System (PI-RADS) applied to pretreatment imaging, there are no consensus technical standard or interpretation criteria for MRI in the BCR setting. In general, 3.0T performs better than 1.5T, and endorectal coil use can offer an improved signal-to-noise ratio and resolution to aid in detecting small early recurrences compared to surface coils. | 69369 |
acrac_69369_6 | Post Treatment Follow up of Prostate Cancer | Recurrences can be accurately identified very early in BCR at the time of initial laboratory diagnosis of BCR when the PSA is still well under 1 ng/mL [10]. Although most local recurrences are perianastomotic, retrovesical, or in the seminal vesicle bed, 30% may be elsewhere in the pelvis at sites that can be more readily assessed by MRI than by US [32]. MP-MRI studies for detecting local recurrence after prostatectomy have reported 84% to 100% sensitivity and 89% to 97% specificity [6,10,33]. Typically, in this setting, MRI of the pelvis only is performed, at least initially. Residual, recurrent, or metastatic disease are all most likely to be identified in the pelvis, and additional coverage of the abdomen is of little added value. Post-Treatment Follow-up of Prostate Cancer The accuracy of MRI for staging pelvic lymph nodes, similar to CT, is largely reliant on size criteria and is only minimally better than that of CT. MRI is more sensitive and specific in the diagnosis of bone metastases, with a much better spatial and contrast resolution when compared to scintigraphic bone scan [34,35]. Gutzeit et al [36] reported the use of whole body diffusion-weighted imaging (DWI)-MRI in 36 patients with 45 skeletal metastases from breast cancer and prostate cancer and concluded that markedly more metastases could be discovered using the whole body DWI technique than skeletal scintigraphy. Response of bone metastases to treatment can be more accurately monitored by serial MRI scans [37]. MRI has a similar performance in bone metastasis detection as choline PET [8]. Overall, pelvic MRI in the setting of Variant 1 is complementary to specialized PET examinations (choline or fluciclovine), and both categories of examinations may be beneficial to perform. | Post Treatment Follow up of Prostate Cancer. Recurrences can be accurately identified very early in BCR at the time of initial laboratory diagnosis of BCR when the PSA is still well under 1 ng/mL [10]. Although most local recurrences are perianastomotic, retrovesical, or in the seminal vesicle bed, 30% may be elsewhere in the pelvis at sites that can be more readily assessed by MRI than by US [32]. MP-MRI studies for detecting local recurrence after prostatectomy have reported 84% to 100% sensitivity and 89% to 97% specificity [6,10,33]. Typically, in this setting, MRI of the pelvis only is performed, at least initially. Residual, recurrent, or metastatic disease are all most likely to be identified in the pelvis, and additional coverage of the abdomen is of little added value. Post-Treatment Follow-up of Prostate Cancer The accuracy of MRI for staging pelvic lymph nodes, similar to CT, is largely reliant on size criteria and is only minimally better than that of CT. MRI is more sensitive and specific in the diagnosis of bone metastases, with a much better spatial and contrast resolution when compared to scintigraphic bone scan [34,35]. Gutzeit et al [36] reported the use of whole body diffusion-weighted imaging (DWI)-MRI in 36 patients with 45 skeletal metastases from breast cancer and prostate cancer and concluded that markedly more metastases could be discovered using the whole body DWI technique than skeletal scintigraphy. Response of bone metastases to treatment can be more accurately monitored by serial MRI scans [37]. MRI has a similar performance in bone metastasis detection as choline PET [8]. Overall, pelvic MRI in the setting of Variant 1 is complementary to specialized PET examinations (choline or fluciclovine), and both categories of examinations may be beneficial to perform. | 69369 |
acrac_69369_7 | Post Treatment Follow up of Prostate Cancer | MRI Functional and Multiparametric: Traditional T1- and T2-weighted MRI sequences can be supplemented with functional techniques: dynamic contrast-enhanced MRI (DCE-MRI) imaging, DWI-MRI including apparent diffusion coefficient map and high b value DWI-MRI (preferentially b >1400 sec/mm2). When these 2 are added to anatomic T2 and T2-weighted MRI, the term MP-MRI is often applied. These will be briefly discussed, but a detailed explanation of these techniques is beyond the scope of this document. In summary, all 3 have shown some evidence of incremental value when added to anatomic imaging (T2-weighted), and there is evidence that use of more than 1 functional technique can also be additive and complementary. Among the 3, DCE-MRI has the strongest evidence and has consistently shown the greatest use in the setting of BCR evaluation. DCE-MRI: DCE-MRI has been shown to be the most important sequence for evaluation of BCR post-RP [38]. Wu et al [39] in a meta-analysis to assess the effectiveness of MRI in detecting local recurrent prostate cancer after RP found that DCE-MRI, compared to T2-weighted imaging, showed a higher pooled sensitivity (85%) and specificity (95%). Roy et al [38] evaluated the performance of the 3 types of functional MRI techniques in the detection of local prostate cancer recurrence after RP and concluded DCE-MRI to be the most efficient tool to detect prostate cancer recurrence post-RP. Similarly, Casciani et al [30] and Cirillo et al [6] showed that DCE- MRI had a significantly higher sensitivity and accuracy than T2-weighted imaging alone in detecting local recurrences after RP. DWI-MRI: DWI-MRI can be helpful for local recurrence depiction, but DWI is typically lower in resolution and more often adversely affected by postoperative changes and surgical clip artifacts than DCE, making it less reliable for local recurrence. A combination of these functional sequences can be more accurate to evaluate for recurrence in the postprostatectomy bed [33]. | Post Treatment Follow up of Prostate Cancer. MRI Functional and Multiparametric: Traditional T1- and T2-weighted MRI sequences can be supplemented with functional techniques: dynamic contrast-enhanced MRI (DCE-MRI) imaging, DWI-MRI including apparent diffusion coefficient map and high b value DWI-MRI (preferentially b >1400 sec/mm2). When these 2 are added to anatomic T2 and T2-weighted MRI, the term MP-MRI is often applied. These will be briefly discussed, but a detailed explanation of these techniques is beyond the scope of this document. In summary, all 3 have shown some evidence of incremental value when added to anatomic imaging (T2-weighted), and there is evidence that use of more than 1 functional technique can also be additive and complementary. Among the 3, DCE-MRI has the strongest evidence and has consistently shown the greatest use in the setting of BCR evaluation. DCE-MRI: DCE-MRI has been shown to be the most important sequence for evaluation of BCR post-RP [38]. Wu et al [39] in a meta-analysis to assess the effectiveness of MRI in detecting local recurrent prostate cancer after RP found that DCE-MRI, compared to T2-weighted imaging, showed a higher pooled sensitivity (85%) and specificity (95%). Roy et al [38] evaluated the performance of the 3 types of functional MRI techniques in the detection of local prostate cancer recurrence after RP and concluded DCE-MRI to be the most efficient tool to detect prostate cancer recurrence post-RP. Similarly, Casciani et al [30] and Cirillo et al [6] showed that DCE- MRI had a significantly higher sensitivity and accuracy than T2-weighted imaging alone in detecting local recurrences after RP. DWI-MRI: DWI-MRI can be helpful for local recurrence depiction, but DWI is typically lower in resolution and more often adversely affected by postoperative changes and surgical clip artifacts than DCE, making it less reliable for local recurrence. A combination of these functional sequences can be more accurate to evaluate for recurrence in the postprostatectomy bed [33]. | 69369 |
acrac_69369_8 | Post Treatment Follow up of Prostate Cancer | DWI is helpful for detection of nodal and bone metastases and can be performed as a whole body screening examination [40]. However, the restricted diffusion at DWI can be nonspecific and can also be observed in normal sized or hyperplastic benign lymph nodes. MRI Abdomen and Pelvis In this setting, MRI of the pelvis only is performed, at least initially. Residual, recurrent, or metastatic disease are all most likely to be identified in the pelvis, and additional coverage of the abdomen is of little added value. Additionally, there is limited evidence to support the use of MRI abdomen and pelvis for follow-up of a patient with a clinical concern for residual or recurrent disease, status post-RP. TRUS-Guided Biopsy Prostatectomy Bed TRUS-guided biopsy can be performed in a systematic manner, often done as a random sampling of the areas that most likely harbor recurrence: the vesicourethral anastomosis, retrovesical region, and seminal vesicle beds. Negative results of TRUS-guided biopsy, regardless of a palpable mass or indurations, may be inconclusive because of sampling errors. Deliveliotis et al [41] reported negative predictive values of only 67% with TRUS- guided biopsy and 57% with digital rectal examination (DRE)-guided biopsy in patients with PSA >2 ng/mL and negative imaging for metastases after prostatectomy. The yield for detecting local recurrent tumor with TRUS with needle biopsy rises significantly with serum PSA levels [41]. Only about 25% of patients with prostatectomy PSA levels of <1 ng/mL have a histologic confirmation of local recurrence after systematic biopsy of the prostatic fossa, compared with 53% of patients with prostatectomy PSA levels >2 ng/mL [41]. | Post Treatment Follow up of Prostate Cancer. DWI is helpful for detection of nodal and bone metastases and can be performed as a whole body screening examination [40]. However, the restricted diffusion at DWI can be nonspecific and can also be observed in normal sized or hyperplastic benign lymph nodes. MRI Abdomen and Pelvis In this setting, MRI of the pelvis only is performed, at least initially. Residual, recurrent, or metastatic disease are all most likely to be identified in the pelvis, and additional coverage of the abdomen is of little added value. Additionally, there is limited evidence to support the use of MRI abdomen and pelvis for follow-up of a patient with a clinical concern for residual or recurrent disease, status post-RP. TRUS-Guided Biopsy Prostatectomy Bed TRUS-guided biopsy can be performed in a systematic manner, often done as a random sampling of the areas that most likely harbor recurrence: the vesicourethral anastomosis, retrovesical region, and seminal vesicle beds. Negative results of TRUS-guided biopsy, regardless of a palpable mass or indurations, may be inconclusive because of sampling errors. Deliveliotis et al [41] reported negative predictive values of only 67% with TRUS- guided biopsy and 57% with digital rectal examination (DRE)-guided biopsy in patients with PSA >2 ng/mL and negative imaging for metastases after prostatectomy. The yield for detecting local recurrent tumor with TRUS with needle biopsy rises significantly with serum PSA levels [41]. Only about 25% of patients with prostatectomy PSA levels of <1 ng/mL have a histologic confirmation of local recurrence after systematic biopsy of the prostatic fossa, compared with 53% of patients with prostatectomy PSA levels >2 ng/mL [41]. | 69369 |
acrac_69369_9 | Post Treatment Follow up of Prostate Cancer | MRI-Targeted Biopsy Prostatectomy Bed Similar to the greatly increased yields of targeted biopsy informed by targets identified on MRI in initial prostate cancer detection, biopsy in the setting of BCR is much more likely to identify a local recurrence when done targeting a suspicious lesion identified by MRI rather than systematic biopsy of the operative bed. In this setting, Post-Treatment Follow-up of Prostate Cancer it is the prostatectomy bed rather than the prostate itself. Because there is no commercial targeting application available in the postprostatectomy setting (there is no gland to segment), these targeted biopsies must be done with cognitive fusion or in-bore targeting [10]. Candidacy for salvage local therapy is largely determined by identification and characterization of a treatable local recurrence by biopsy. TRUS Prostatectomy Bed Several studies have shown the usefulness of color and power Doppler and contrast-enhanced color Doppler in detecting local recurrence after prostatectomy [19,42,43]. Choline PET/MRI Skull base to Mid-Thigh PET/MRI is a relatively newer imaging modality that allows simultaneous anatomic, functional, and molecular imaging of body parts. Few studies have evaluated the use of choline in PET/MRI. In 1 study with 75 patients with BCR, choline PET/MRI had a higher cancer detection rate compared with choline PET/CT (84.7% versus 77.3%) [58]. Fluciclovine PET/CT Skull Base to Mid-Thigh Fluciclovine (also known as anti-1-amino-3-[18-F]-fluorocyclobutane-1-carboxylic acid [FACBC]) is a synthetic amino acid PET radiotracer that was FDA approved in May 2016 for the imaging of patients with suspected prostate cancer recurrence based on elevated serum PSA levels following prior treatment. Odewole et al [59] reported superiority to 111 indium-capromab pendetide and to CT with detection of nodes as small as 5 mm and upstaging 25.7% of patients. | Post Treatment Follow up of Prostate Cancer. MRI-Targeted Biopsy Prostatectomy Bed Similar to the greatly increased yields of targeted biopsy informed by targets identified on MRI in initial prostate cancer detection, biopsy in the setting of BCR is much more likely to identify a local recurrence when done targeting a suspicious lesion identified by MRI rather than systematic biopsy of the operative bed. In this setting, Post-Treatment Follow-up of Prostate Cancer it is the prostatectomy bed rather than the prostate itself. Because there is no commercial targeting application available in the postprostatectomy setting (there is no gland to segment), these targeted biopsies must be done with cognitive fusion or in-bore targeting [10]. Candidacy for salvage local therapy is largely determined by identification and characterization of a treatable local recurrence by biopsy. TRUS Prostatectomy Bed Several studies have shown the usefulness of color and power Doppler and contrast-enhanced color Doppler in detecting local recurrence after prostatectomy [19,42,43]. Choline PET/MRI Skull base to Mid-Thigh PET/MRI is a relatively newer imaging modality that allows simultaneous anatomic, functional, and molecular imaging of body parts. Few studies have evaluated the use of choline in PET/MRI. In 1 study with 75 patients with BCR, choline PET/MRI had a higher cancer detection rate compared with choline PET/CT (84.7% versus 77.3%) [58]. Fluciclovine PET/CT Skull Base to Mid-Thigh Fluciclovine (also known as anti-1-amino-3-[18-F]-fluorocyclobutane-1-carboxylic acid [FACBC]) is a synthetic amino acid PET radiotracer that was FDA approved in May 2016 for the imaging of patients with suspected prostate cancer recurrence based on elevated serum PSA levels following prior treatment. Odewole et al [59] reported superiority to 111 indium-capromab pendetide and to CT with detection of nodes as small as 5 mm and upstaging 25.7% of patients. | 69369 |
acrac_69369_10 | Post Treatment Follow up of Prostate Cancer | In comparison to CT, the fluciclovine PET positivity rate for recurrent disease was 77.4% versus 18.9%, although sensitivity varies with PSA level, PSADT, and original Gleason Score [59]. One- hundred patients with biochemical failure after RP underwent choline PET and fluciclovine PET in a single-center trial [60-62]. The investigators reported choline and fluciclovine had overall sensitivities of 32% and 37%, specificities of 40% and 67%, and positive predictive values of 90% and 97%, respectively, with fluciclovine having a lower physiologic background, resulting in better lesion contrast, and the practical advantage of a longer half-life enabling more widespread distribution compared with a short half-life C-11 radiotracer. Notably, in this single-center comparison from Italy, the C-11 choline dose used was only about one-third of that used for most patients imaged clinically with choline in the United States, and the performance of both agents reported was much lower than that of many other studies, with the meta-analysis of choline showing a sensitivity of 85.6% and a specificity of 92.6% for all sites of recurrence, and a meta-analysis of fluciclovine that reported an 87% pooled Fluciclovine PET/MRI Skull Base to Mid-Thigh There is limited evidence to support the use of fluciclovine PET/MRI for the follow-up of a patient with a clinical concern for residual or recurrent disease, status post-RP. PET Using Other Agents: There are many additional prostate-specific tracers that are not FDA approved, including 11C-acetate [70,71], 18F-choline [72-75], Bombesin, and 18F-fluorodihydrotestosterone [76-78], that are in various stages of investigation and have been reported to detect local and metastatic recurrent disease in patients with biochemical failure after local treatment. These agents remain investigational, but some have shown excellent results and hold great potential. | Post Treatment Follow up of Prostate Cancer. In comparison to CT, the fluciclovine PET positivity rate for recurrent disease was 77.4% versus 18.9%, although sensitivity varies with PSA level, PSADT, and original Gleason Score [59]. One- hundred patients with biochemical failure after RP underwent choline PET and fluciclovine PET in a single-center trial [60-62]. The investigators reported choline and fluciclovine had overall sensitivities of 32% and 37%, specificities of 40% and 67%, and positive predictive values of 90% and 97%, respectively, with fluciclovine having a lower physiologic background, resulting in better lesion contrast, and the practical advantage of a longer half-life enabling more widespread distribution compared with a short half-life C-11 radiotracer. Notably, in this single-center comparison from Italy, the C-11 choline dose used was only about one-third of that used for most patients imaged clinically with choline in the United States, and the performance of both agents reported was much lower than that of many other studies, with the meta-analysis of choline showing a sensitivity of 85.6% and a specificity of 92.6% for all sites of recurrence, and a meta-analysis of fluciclovine that reported an 87% pooled Fluciclovine PET/MRI Skull Base to Mid-Thigh There is limited evidence to support the use of fluciclovine PET/MRI for the follow-up of a patient with a clinical concern for residual or recurrent disease, status post-RP. PET Using Other Agents: There are many additional prostate-specific tracers that are not FDA approved, including 11C-acetate [70,71], 18F-choline [72-75], Bombesin, and 18F-fluorodihydrotestosterone [76-78], that are in various stages of investigation and have been reported to detect local and metastatic recurrent disease in patients with biochemical failure after local treatment. These agents remain investigational, but some have shown excellent results and hold great potential. | 69369 |
acrac_69369_11 | Post Treatment Follow up of Prostate Cancer | Fluoride PET/CT Skull Base to Mid-Thigh Fluoride PET/CT is not routinely used in the evaluation of prostate cancer recurrence. There is limited evidence to support its use in this setting. FDG-PET/CT Some foci of metastatic prostate cancer demonstrate increased accumulation of fluorine-18-2-fluoro-2-deoxy-D- glucose (FDG) radiotracer, although this uptake is generally low compared to the other cancers. In 1 study, FDG- PET identified local or metastatic disease in only 28 of 91 patients (31%) with BCR after RP for prostate cancer [79]. FDG-PET is relatively insensitive in detecting osseous metastases compared to standard bone scintigraphy [80]. Ghanem et al [81] have demonstrated that FDG-PET alone or using PET/CT image fusion is less sensitive than MRI in the detection of bone metastases. In the routine setting, FDG-PET has little usefulness in the setting of BCR. However, as advanced metastatic prostate cancer migrates to a high Gleason grade, dedifferentiates, or transforms to other aggressive variants, such as small cell type, the tumor cells are more likely to convert to a higher glucose metabolism, and FDG can become useful in detection and monitoring of this subset of patients. Post-Treatment Follow-up of Prostate Cancer choline PET in staging and restaging of prostate cancer [84]. In intrapatient comparisons of PSMA and fluciclovine, a higher detection rate by PSMA for extraprostatic disease especially at lower PSA levels was reported, with superiority of fluciclovine for the prostate bed, because of significantly lower urinary excretion of fluciclovine compared with PSMA [85,86]. Ga-68 has a physical half-life of 68 minutes, and its production currently requires a generator, which can allow batch production of approximately 2 to 4 patient doses per generator elution [87]. In addition, PSMA PET radiotracers may be useful to select patients for PSMA radioligand therapy, which is recently FDA approved [88]. | Post Treatment Follow up of Prostate Cancer. Fluoride PET/CT Skull Base to Mid-Thigh Fluoride PET/CT is not routinely used in the evaluation of prostate cancer recurrence. There is limited evidence to support its use in this setting. FDG-PET/CT Some foci of metastatic prostate cancer demonstrate increased accumulation of fluorine-18-2-fluoro-2-deoxy-D- glucose (FDG) radiotracer, although this uptake is generally low compared to the other cancers. In 1 study, FDG- PET identified local or metastatic disease in only 28 of 91 patients (31%) with BCR after RP for prostate cancer [79]. FDG-PET is relatively insensitive in detecting osseous metastases compared to standard bone scintigraphy [80]. Ghanem et al [81] have demonstrated that FDG-PET alone or using PET/CT image fusion is less sensitive than MRI in the detection of bone metastases. In the routine setting, FDG-PET has little usefulness in the setting of BCR. However, as advanced metastatic prostate cancer migrates to a high Gleason grade, dedifferentiates, or transforms to other aggressive variants, such as small cell type, the tumor cells are more likely to convert to a higher glucose metabolism, and FDG can become useful in detection and monitoring of this subset of patients. Post-Treatment Follow-up of Prostate Cancer choline PET in staging and restaging of prostate cancer [84]. In intrapatient comparisons of PSMA and fluciclovine, a higher detection rate by PSMA for extraprostatic disease especially at lower PSA levels was reported, with superiority of fluciclovine for the prostate bed, because of significantly lower urinary excretion of fluciclovine compared with PSMA [85,86]. Ga-68 has a physical half-life of 68 minutes, and its production currently requires a generator, which can allow batch production of approximately 2 to 4 patient doses per generator elution [87]. In addition, PSMA PET radiotracers may be useful to select patients for PSMA radioligand therapy, which is recently FDA approved [88]. | 69369 |
acrac_69369_12 | Post Treatment Follow up of Prostate Cancer | DCFPyL has a half-life of 110 minutes, and its production does not require an on-site cyclotron. Similar to PSMA PET tracer, DCFPyL may be useful to select patients for PSMA therapy, which is recently approved by FDA [88]. Radiography Skeletal Survey Radiographic survey is not routinely used in the evaluation of prostate cancer recurrence. Variant 2: Prostate cancer follow-up. Clinical concern for residual or recurrent disease after nonsurgical local and pelvic treatments. This variant covers the evaluation of BCR in the setting of a broad range of failed treatments targeted locally or to the pelvis, other than RP that is specifically covered in Variant 1. This includes primary radiation therapies, ablation therapies, and secondarily failed salvage therapies, such as failed salvage RT done after RP. RT is commonly performed in the setting of BCR after RP. Guidelines were published in 2013 jointly by ASTRO/AUA and largely endorsed by the American Society of Clinical Oncology [23]. There are 2 distinct clinical scenarios: adjuvant therapy and salvage therapy. It is known that patients with adverse risk factors found at the time of RP (high Gleason scores and/or adverse pathology, extracapsular extension or T4 invasion, seminal vesicle invasion, or positive margins) are at increased risk for BCR [99-105]. In this subgroup, there is consideration for adjuvant RT intended to reduce the high Post-Treatment Follow-up of Prostate Cancer likelihood of recurrence and progression of disease, which is commonly performed approximately 4 to 6 months after surgery. There is strong evidence that adjuvant RT in this setting reduces the risk of BCR and clinical progression of cancer, but the evidence is much less clear on the impact on overall survival. BCR is associated with subsequent progression to metastatic disease and death. | Post Treatment Follow up of Prostate Cancer. DCFPyL has a half-life of 110 minutes, and its production does not require an on-site cyclotron. Similar to PSMA PET tracer, DCFPyL may be useful to select patients for PSMA therapy, which is recently approved by FDA [88]. Radiography Skeletal Survey Radiographic survey is not routinely used in the evaluation of prostate cancer recurrence. Variant 2: Prostate cancer follow-up. Clinical concern for residual or recurrent disease after nonsurgical local and pelvic treatments. This variant covers the evaluation of BCR in the setting of a broad range of failed treatments targeted locally or to the pelvis, other than RP that is specifically covered in Variant 1. This includes primary radiation therapies, ablation therapies, and secondarily failed salvage therapies, such as failed salvage RT done after RP. RT is commonly performed in the setting of BCR after RP. Guidelines were published in 2013 jointly by ASTRO/AUA and largely endorsed by the American Society of Clinical Oncology [23]. There are 2 distinct clinical scenarios: adjuvant therapy and salvage therapy. It is known that patients with adverse risk factors found at the time of RP (high Gleason scores and/or adverse pathology, extracapsular extension or T4 invasion, seminal vesicle invasion, or positive margins) are at increased risk for BCR [99-105]. In this subgroup, there is consideration for adjuvant RT intended to reduce the high Post-Treatment Follow-up of Prostate Cancer likelihood of recurrence and progression of disease, which is commonly performed approximately 4 to 6 months after surgery. There is strong evidence that adjuvant RT in this setting reduces the risk of BCR and clinical progression of cancer, but the evidence is much less clear on the impact on overall survival. BCR is associated with subsequent progression to metastatic disease and death. | 69369 |
acrac_69369_13 | Post Treatment Follow up of Prostate Cancer | In patients who experience BCR after RP, radiation can be given in this setting as a salvage treatment and per ASTRO/AUA should be offered to patients who do not have evidence of metastatic disease. Regarding imaging after failure of adjuvant or salvage therapy, the literature is less rigorous. However, there are some concepts that warrant recognition. The radiation port is designed to spare toxicity to the rectum, and, after failed whole-pelvis RT, the mesorectal and presacral regions that saw much lower radiation dose are a particular area where recurrences are often identified and warrant scrutiny [9]. Additionally, the nodal and bone metastases that are identified in this setting are often in the high pelvis near the level of the common iliac vasculature, at a level just cranial to the top of the radiation treatment port. Fortuin et al [26] noted in their study that 61% of metastatic prostate cancer nodes (in the setting of BCR, before salvage RT) were located in areas outside the conventional pelvic radiation target volume, which may explain the preponderance of nodes that later present after failure of salvage RT above the treated area. Local recurrence can also be seen after failed primary treatment and subsequent failed adjuvant or salvage RT but is much less common than in Variant 1. Local ablative therapies are much less common than RP and primary RT options and make up <5% of primary treatments overall in the United States, but there is great variation in practice, and in some centers, cryoablation is the dominant treatment comprising >70% of patients [106]. Although less well studied, recurrence after ablative therapies seems to be most common locally if the disease was localized initially. CT Abdomen and Pelvis CT is not effective for detecting locally recurrent tumor in an irradiated prostate gland or after ablative therapy because of its limited soft tissue resolution within the prostate gland. | Post Treatment Follow up of Prostate Cancer. In patients who experience BCR after RP, radiation can be given in this setting as a salvage treatment and per ASTRO/AUA should be offered to patients who do not have evidence of metastatic disease. Regarding imaging after failure of adjuvant or salvage therapy, the literature is less rigorous. However, there are some concepts that warrant recognition. The radiation port is designed to spare toxicity to the rectum, and, after failed whole-pelvis RT, the mesorectal and presacral regions that saw much lower radiation dose are a particular area where recurrences are often identified and warrant scrutiny [9]. Additionally, the nodal and bone metastases that are identified in this setting are often in the high pelvis near the level of the common iliac vasculature, at a level just cranial to the top of the radiation treatment port. Fortuin et al [26] noted in their study that 61% of metastatic prostate cancer nodes (in the setting of BCR, before salvage RT) were located in areas outside the conventional pelvic radiation target volume, which may explain the preponderance of nodes that later present after failure of salvage RT above the treated area. Local recurrence can also be seen after failed primary treatment and subsequent failed adjuvant or salvage RT but is much less common than in Variant 1. Local ablative therapies are much less common than RP and primary RT options and make up <5% of primary treatments overall in the United States, but there is great variation in practice, and in some centers, cryoablation is the dominant treatment comprising >70% of patients [106]. Although less well studied, recurrence after ablative therapies seems to be most common locally if the disease was localized initially. CT Abdomen and Pelvis CT is not effective for detecting locally recurrent tumor in an irradiated prostate gland or after ablative therapy because of its limited soft tissue resolution within the prostate gland. | 69369 |
acrac_69369_14 | Post Treatment Follow up of Prostate Cancer | In the evaluation of nodal disease, CT heavily relies on size to detect nodal metastases, which is a significant limitation and confers mediocre sensitivity for prostate cancer nodal metastases because large numbers of metastatic nodes are known to be a normal size [26]. CT is useful in following the response of known enlarged metastatic lymphadenopathy to treatment. CT is useful in detecting sclerotic bone and visceral metastases, although bone scan and MRI are superior in the diagnosis and follow-up of bone metastases [27], and choline PET is much better for the detection and follow-up of bone metastases. As bone metastases respond to treatment, they often become more densely sclerotic, which by CT is a common pitfall falsely interpreted as progression. CT is useful when done with IV contrast for cancer detection and surveillance. There is no evidence to support use of CT without IV contrast or multiphasic scanning (ie, without and with IV contrast). CT Chest, Abdomen, and Pelvis There is rarely any indication for consideration of extension of coverage with CT of the chest for follow-up of a patient with a clinical concern for residual or recurrent disease after nonsurgical local and pelvic treatments. Additionally, there is limited evidence to support the use CT chest abdomen and pelvis in this setting. MRI Pelvis MP-MRI has shown to be helpful in the detection of local recurrence after RT, and T2-weighted imaging by itself is very limited for detection of recurrence after RT [29]. Wu et al [39] in a meta-analysis to assess the effectiveness of an MP-MRI in detecting local recurrent prostate cancer post-RT found that DCE imaging, As with Variant 1, typically in this setting, MRI is performed on the pelvis only, at least initially. Residual, recurrent, or metastatic disease is all most likely to be identified in the pelvis, and additional coverage of the abdomen is of little added value. | Post Treatment Follow up of Prostate Cancer. In the evaluation of nodal disease, CT heavily relies on size to detect nodal metastases, which is a significant limitation and confers mediocre sensitivity for prostate cancer nodal metastases because large numbers of metastatic nodes are known to be a normal size [26]. CT is useful in following the response of known enlarged metastatic lymphadenopathy to treatment. CT is useful in detecting sclerotic bone and visceral metastases, although bone scan and MRI are superior in the diagnosis and follow-up of bone metastases [27], and choline PET is much better for the detection and follow-up of bone metastases. As bone metastases respond to treatment, they often become more densely sclerotic, which by CT is a common pitfall falsely interpreted as progression. CT is useful when done with IV contrast for cancer detection and surveillance. There is no evidence to support use of CT without IV contrast or multiphasic scanning (ie, without and with IV contrast). CT Chest, Abdomen, and Pelvis There is rarely any indication for consideration of extension of coverage with CT of the chest for follow-up of a patient with a clinical concern for residual or recurrent disease after nonsurgical local and pelvic treatments. Additionally, there is limited evidence to support the use CT chest abdomen and pelvis in this setting. MRI Pelvis MP-MRI has shown to be helpful in the detection of local recurrence after RT, and T2-weighted imaging by itself is very limited for detection of recurrence after RT [29]. Wu et al [39] in a meta-analysis to assess the effectiveness of an MP-MRI in detecting local recurrent prostate cancer post-RT found that DCE imaging, As with Variant 1, typically in this setting, MRI is performed on the pelvis only, at least initially. Residual, recurrent, or metastatic disease is all most likely to be identified in the pelvis, and additional coverage of the abdomen is of little added value. | 69369 |
acrac_69369_15 | Post Treatment Follow up of Prostate Cancer | Overall, pelvic MRI in the setting of Variant 2 is complementary to specialized PET examinations (choline, PSMA, or fluciclovine), and both categories of examinations may be beneficial to perform. MRI Abdomen and Pelvis MRI is performed of the pelvis only, at least initially. Residual, recurrent, or metastatic disease is all most likely to be identified in the pelvis, and additional coverage of the abdomen is of little added value. Additionally, there is limited evidence to support the use of MRI abdomen and pelvis for follow-up of a patient with a clinical concern for residual or recurrent disease after nonsurgical local and pelvic treatments. TRUS Prostate Several studies have reported that TRUS is unreliable for the detection of cancer recurrence after EBRT, showing a limited sensitivity of 49% and a specificity of 57%, which is worse than DRE (sensitivity 73%, specificity 66%) [93,121]. TRUS-Guided Biopsy Prostate TRUS-guided sextant biopsy, commonly proposed as the reference standard for detection of local recurrence, may require repeated biopsies to reach a final diagnosis [122,123]. In addition to false-negative results due to sampling error, false-positive results may also occur because the presence of malignant cells in biopsy specimens may represent biologically inactive tumor remnants, especially in the first 1 to 2 years after RT [122,123]. Post-Treatment Follow-up of Prostate Cancer MRI-Targeted Biopsy Prostate Biopsy is best done when targeting suspicious lesions identified by MRI rather than as a nontargeted systematic TRUS biopsy of the region. However, because the native gland is still present, commercially available MRI-US fusion biopsy systems can be used to aid in targeting and improving biopsy accuracy. Candidacy for salvage local therapy is largely determined by identification and characterization of a treatable local recurrence by biopsy, often targeted by MRI. | Post Treatment Follow up of Prostate Cancer. Overall, pelvic MRI in the setting of Variant 2 is complementary to specialized PET examinations (choline, PSMA, or fluciclovine), and both categories of examinations may be beneficial to perform. MRI Abdomen and Pelvis MRI is performed of the pelvis only, at least initially. Residual, recurrent, or metastatic disease is all most likely to be identified in the pelvis, and additional coverage of the abdomen is of little added value. Additionally, there is limited evidence to support the use of MRI abdomen and pelvis for follow-up of a patient with a clinical concern for residual or recurrent disease after nonsurgical local and pelvic treatments. TRUS Prostate Several studies have reported that TRUS is unreliable for the detection of cancer recurrence after EBRT, showing a limited sensitivity of 49% and a specificity of 57%, which is worse than DRE (sensitivity 73%, specificity 66%) [93,121]. TRUS-Guided Biopsy Prostate TRUS-guided sextant biopsy, commonly proposed as the reference standard for detection of local recurrence, may require repeated biopsies to reach a final diagnosis [122,123]. In addition to false-negative results due to sampling error, false-positive results may also occur because the presence of malignant cells in biopsy specimens may represent biologically inactive tumor remnants, especially in the first 1 to 2 years after RT [122,123]. Post-Treatment Follow-up of Prostate Cancer MRI-Targeted Biopsy Prostate Biopsy is best done when targeting suspicious lesions identified by MRI rather than as a nontargeted systematic TRUS biopsy of the region. However, because the native gland is still present, commercially available MRI-US fusion biopsy systems can be used to aid in targeting and improving biopsy accuracy. Candidacy for salvage local therapy is largely determined by identification and characterization of a treatable local recurrence by biopsy, often targeted by MRI. | 69369 |
acrac_69369_16 | Post Treatment Follow up of Prostate Cancer | Choline PET/CT Skull Base to Mid-Thigh PET with newer prostate-specific radiotracers has shown excellent performance and great potential for revolutionizing the diagnosis and, consequently, the management of patients with BCR. Choline was the first to receive FDA approval and has been extensively used and studied with several large recent meta-analyses availalable [44,45]. For example, a meta-analysis by Evangelista et al [44] found a sensitivity of 85.6% and a specificity of 92.6% for all sites of recurrence, of which there was a pooled sensitivity of 100% for lymph node metastases with a corresponding 81.8% sensitivity. Note this study combines post-RP and post-RT patients, and there is no evidence of a significant difference in performance of choline PET between these 2 scenarios. It is inferior to MRI for detection of local recurrence, but the meta-analysis still showed a 75.4% sensitivity and an 82% specificity for prostatic fossa recurrence detection. In a study of 184 primary RT patients who experienced BCR, and over half of whom had positive confirmatory biopsies of the prostate and/or distant sites, the median PSA level of those patients having a positive choline PET scan was 6.3 ng/mL with a sensitivity and specificity of 95% and 73%, respectively [124]. In another study of 41 patients who underwent salvage RT to the prostate bed only following RP and subsequent biochemical failure, choline PET scans were positive with a median PSA of 3.1 ng/mL and an interquartile range of 1.9 to 5.6 ng/mL. The vast majority of patients had disease that was found outside of the irradiated prostate bed with 61% having disease outside of the pelvis [124,125]. Bone metastasis detection and treatment response evaluation is also very good. Choline requires an on-site cyclotron for generation of the agent because of the short half-life, which restricts where it is feasible to perform. | Post Treatment Follow up of Prostate Cancer. Choline PET/CT Skull Base to Mid-Thigh PET with newer prostate-specific radiotracers has shown excellent performance and great potential for revolutionizing the diagnosis and, consequently, the management of patients with BCR. Choline was the first to receive FDA approval and has been extensively used and studied with several large recent meta-analyses availalable [44,45]. For example, a meta-analysis by Evangelista et al [44] found a sensitivity of 85.6% and a specificity of 92.6% for all sites of recurrence, of which there was a pooled sensitivity of 100% for lymph node metastases with a corresponding 81.8% sensitivity. Note this study combines post-RP and post-RT patients, and there is no evidence of a significant difference in performance of choline PET between these 2 scenarios. It is inferior to MRI for detection of local recurrence, but the meta-analysis still showed a 75.4% sensitivity and an 82% specificity for prostatic fossa recurrence detection. In a study of 184 primary RT patients who experienced BCR, and over half of whom had positive confirmatory biopsies of the prostate and/or distant sites, the median PSA level of those patients having a positive choline PET scan was 6.3 ng/mL with a sensitivity and specificity of 95% and 73%, respectively [124]. In another study of 41 patients who underwent salvage RT to the prostate bed only following RP and subsequent biochemical failure, choline PET scans were positive with a median PSA of 3.1 ng/mL and an interquartile range of 1.9 to 5.6 ng/mL. The vast majority of patients had disease that was found outside of the irradiated prostate bed with 61% having disease outside of the pelvis [124,125]. Bone metastasis detection and treatment response evaluation is also very good. Choline requires an on-site cyclotron for generation of the agent because of the short half-life, which restricts where it is feasible to perform. | 69369 |
acrac_69369_17 | Post Treatment Follow up of Prostate Cancer | Choline PET/MRI Skull Base to Mid-Thigh There is limited evidence to support the use of choline PET/MRI for follow-up of a patient with a clinical concern for residual or recurrent disease after nonsurgical local and pelvic treatments. Fluciclovine PET/MRI Skull Base to Mid-Thigh There is limited evidence to support the use of fluciclovine PET/MRI for follow-up of a patient with a clinical concern for residual or recurrent disease after nonsurgical local and pelvic treatments. PET Using Other Agents: There are many additional prostate-specific tracers that are not FDA approved, including 11C-acetate [70,71], 18F-choline [72-74], Bombesin, 18F-fluorodihydrotestosterone [78] that are in various stages of investigation and have been reported to detect local and metastatic recurrent disease in patients with biochemical failure after local treatment. These agents remain investigational, but some have shown excellent results and hold great potential. Fluoride PET/CT Skull Base to Mid-Thigh Fluoride PET/CT is not routinely used in the evaluation of prostate cancer recurrence. PSMA PET/CT Skull Base To Mid-Thigh PSMA was approved by FDA in December 2020 for patients with suspected prostate cancer metastasis who are potentially curable with previous surgery or RT in the University of California, Los Angeles, and the University of California, San Francisco [82]. In a study with 50 patients with BCR after RT who underwent PSMA PET/CT and salvage prostatectomy, the sensitivity and positive predictive value of PSMA PET/CT were both 100%. A separate analysis per lymph node revealed a sensitivity, specificity, positive predictive value, and negative predictive value as 34.78%, 100%, 100%, and 97.52%, respectively [129]. Radiography Skeletal Survey Radiographic survey is not routinely used in the evaluation of prostate cancer recurrence. | Post Treatment Follow up of Prostate Cancer. Choline PET/MRI Skull Base to Mid-Thigh There is limited evidence to support the use of choline PET/MRI for follow-up of a patient with a clinical concern for residual or recurrent disease after nonsurgical local and pelvic treatments. Fluciclovine PET/MRI Skull Base to Mid-Thigh There is limited evidence to support the use of fluciclovine PET/MRI for follow-up of a patient with a clinical concern for residual or recurrent disease after nonsurgical local and pelvic treatments. PET Using Other Agents: There are many additional prostate-specific tracers that are not FDA approved, including 11C-acetate [70,71], 18F-choline [72-74], Bombesin, 18F-fluorodihydrotestosterone [78] that are in various stages of investigation and have been reported to detect local and metastatic recurrent disease in patients with biochemical failure after local treatment. These agents remain investigational, but some have shown excellent results and hold great potential. Fluoride PET/CT Skull Base to Mid-Thigh Fluoride PET/CT is not routinely used in the evaluation of prostate cancer recurrence. PSMA PET/CT Skull Base To Mid-Thigh PSMA was approved by FDA in December 2020 for patients with suspected prostate cancer metastasis who are potentially curable with previous surgery or RT in the University of California, Los Angeles, and the University of California, San Francisco [82]. In a study with 50 patients with BCR after RT who underwent PSMA PET/CT and salvage prostatectomy, the sensitivity and positive predictive value of PSMA PET/CT were both 100%. A separate analysis per lymph node revealed a sensitivity, specificity, positive predictive value, and negative predictive value as 34.78%, 100%, 100%, and 97.52%, respectively [129]. Radiography Skeletal Survey Radiographic survey is not routinely used in the evaluation of prostate cancer recurrence. | 69369 |
acrac_69369_18 | Post Treatment Follow up of Prostate Cancer | After an initial favorable response to ADT, a significant fraction of patients with advanced prostate cancer will develop CRPC with a median time to androgen independence of 14 to 30 months [130]. Patients invariably progress to a castration-resistant state in which the cancer will grow despite low levels of serum testosterone [131]. More than 90% of patients with CRPC have bone metastases [132]. Morbidity and mortality from prostate cancer is typically the result of metastatic CRPC. CRPC represents the lethal form of the disease and carries a poor prognosis with a median survival of <2 years for those with metastatic disease [133]. In this setting, imaging is not done for detection or diagnosis of disease, but the role shifts to one of monitoring response to therapy. Bone Scan Bone metastases are common in late-stage metastatic prostate cancer, particularly CRPC. Bone scan in this setting with PSA >60 ng/mL is greatly increased in yield compared to Variants 1 and 2. Bone scan can reflect changes in disease status post-treatment, and successfully treated metastases can become negative, which usually is accompanied by a corresponding marked decrease in serum PSA level. Bone scan can show a flare phenomenon after treatment initiation that could lead to false interpretation as progression [134]. Bone scan and CT are often performed as complimentary modalities, the pair serving as an alternative to specialized PET examinations (choline or fluciclovine). CT Chest, Abdomen, and Pelvis With advanced disease, nodal metastases progress in size and become diagnosable by CT. In this setting, CT is useful in following response of known enlarged metastatic lymphadenopathy to treatment. CT is useful in Post-Treatment Follow-up of Prostate Cancer detecting visceral metastases; liver metastases in particular are the most common visceral metastasis, and CT is very accurate for that evaluation [135]. | Post Treatment Follow up of Prostate Cancer. After an initial favorable response to ADT, a significant fraction of patients with advanced prostate cancer will develop CRPC with a median time to androgen independence of 14 to 30 months [130]. Patients invariably progress to a castration-resistant state in which the cancer will grow despite low levels of serum testosterone [131]. More than 90% of patients with CRPC have bone metastases [132]. Morbidity and mortality from prostate cancer is typically the result of metastatic CRPC. CRPC represents the lethal form of the disease and carries a poor prognosis with a median survival of <2 years for those with metastatic disease [133]. In this setting, imaging is not done for detection or diagnosis of disease, but the role shifts to one of monitoring response to therapy. Bone Scan Bone metastases are common in late-stage metastatic prostate cancer, particularly CRPC. Bone scan in this setting with PSA >60 ng/mL is greatly increased in yield compared to Variants 1 and 2. Bone scan can reflect changes in disease status post-treatment, and successfully treated metastases can become negative, which usually is accompanied by a corresponding marked decrease in serum PSA level. Bone scan can show a flare phenomenon after treatment initiation that could lead to false interpretation as progression [134]. Bone scan and CT are often performed as complimentary modalities, the pair serving as an alternative to specialized PET examinations (choline or fluciclovine). CT Chest, Abdomen, and Pelvis With advanced disease, nodal metastases progress in size and become diagnosable by CT. In this setting, CT is useful in following response of known enlarged metastatic lymphadenopathy to treatment. CT is useful in Post-Treatment Follow-up of Prostate Cancer detecting visceral metastases; liver metastases in particular are the most common visceral metastasis, and CT is very accurate for that evaluation [135]. | 69369 |
acrac_69369_19 | Post Treatment Follow up of Prostate Cancer | CT is also useful in detecting sclerotic bone metastases, although bone scan and MRI are superior in the diagnosis and follow-up of bone metastases [27], and choline PET is much better for detection and follow-up of bone metastases. As bone metastases respond to treatment, they often become more densely sclerotic, which by CT is a common pitfall falsely interpreted as progression. CT is useful when done with IV contrast for cancer detection and surveillance. There is no evidence to support use of CT without IV contrast or multiphasic scanning (ie, without and with IV contrast). In the setting of metastatic disease, chest CT becomes clinically relevant and is a first-line imaging modality for detection of pulmonary metastases. Bone scan and CT are often performed as complimentary modalities, the pair serving as an alternative to specialized PET examinations (choline or fluciclovine or PSMA). CT Abdomen and Pelvis With advanced disease, nodal metastases progress in size and become diagnosable by CT. In this setting, CT is useful in following response of known enlarged metastatic lymphadenopathy to treatment. CT is useful in detecting visceral metastases; liver metastases in particular are the most common visceral metastasis, and CT is very accurate for that evaluation [135]. CT is also useful in detecting sclerotic bone metastases, although bone scan and MRI are superior in the diagnosis and follow-up of bone metastases [27], and choline PET is much better for the detection and follow-up of bone metastases. As bone metastases respond to treatment, they often become more densely sclerotic, which by CT is a common pitfall falsely interpreted as progression. CT is useful when done with IV contrast for cancer detection and surveillance. There is no evidence to support use of CT without IV contrast or multiphasic scanning (ie, without and with IV contrast). | Post Treatment Follow up of Prostate Cancer. CT is also useful in detecting sclerotic bone metastases, although bone scan and MRI are superior in the diagnosis and follow-up of bone metastases [27], and choline PET is much better for detection and follow-up of bone metastases. As bone metastases respond to treatment, they often become more densely sclerotic, which by CT is a common pitfall falsely interpreted as progression. CT is useful when done with IV contrast for cancer detection and surveillance. There is no evidence to support use of CT without IV contrast or multiphasic scanning (ie, without and with IV contrast). In the setting of metastatic disease, chest CT becomes clinically relevant and is a first-line imaging modality for detection of pulmonary metastases. Bone scan and CT are often performed as complimentary modalities, the pair serving as an alternative to specialized PET examinations (choline or fluciclovine or PSMA). CT Abdomen and Pelvis With advanced disease, nodal metastases progress in size and become diagnosable by CT. In this setting, CT is useful in following response of known enlarged metastatic lymphadenopathy to treatment. CT is useful in detecting visceral metastases; liver metastases in particular are the most common visceral metastasis, and CT is very accurate for that evaluation [135]. CT is also useful in detecting sclerotic bone metastases, although bone scan and MRI are superior in the diagnosis and follow-up of bone metastases [27], and choline PET is much better for the detection and follow-up of bone metastases. As bone metastases respond to treatment, they often become more densely sclerotic, which by CT is a common pitfall falsely interpreted as progression. CT is useful when done with IV contrast for cancer detection and surveillance. There is no evidence to support use of CT without IV contrast or multiphasic scanning (ie, without and with IV contrast). | 69369 |
acrac_69369_20 | Post Treatment Follow up of Prostate Cancer | As opposed to Variants 1 and 2 in the setting of metastatic disease, chest CT becomes clinically relevant and is a first-line imaging modality for detection of pulmonary metastases. MRI Abdomen and Pelvis Local recurrence, even if present, becomes of lesser clinical importance in this setting, unless it is locally advanced and is causing urinary or bowel complications. MRI is capable of assessing response to metastatic nodal disease similar to CT based on size, with the addition of also being able to show functional changes. Post-ADT perfusion should greatly decrease with a positive response, and apparent diffusion coefficient values typically increase. Bone metastases can be followed for response by MRI as well in a similar way. In this clinical setting, the likelihood of metastatic disease outside the pelvis is increased. For example, liver metastases and nodal metastases in higher stations are most often seen in the setting of Variant 3. It is probable that coverage of the abdomen in addition to the pelvis would provide more benefit in this setting, but evidence is lacking. MRI Pelvis In this clinical setting, the likelihood of metastatic disease outside the pelvis is increased. For example, liver metastases and nodal metastases in higher stations are most often seen in the setting of Variant 3. It is probable that coverage of the abdomen in addition to the pelvis would provide more benefit, but evidence is lacking. Local recurrence, even if present, becomes of lesser clinical importance in this setting, unless it is locally advanced and is causing urinary or bowel complications. MRI-Targeted Biopsy Prostatectomy Bed Because local recurrence is of lesser clinical importance in the setting of metastatic prostate cancer, MRI-targeted biopsy of the prostate is not routinely used for evaluation. | Post Treatment Follow up of Prostate Cancer. As opposed to Variants 1 and 2 in the setting of metastatic disease, chest CT becomes clinically relevant and is a first-line imaging modality for detection of pulmonary metastases. MRI Abdomen and Pelvis Local recurrence, even if present, becomes of lesser clinical importance in this setting, unless it is locally advanced and is causing urinary or bowel complications. MRI is capable of assessing response to metastatic nodal disease similar to CT based on size, with the addition of also being able to show functional changes. Post-ADT perfusion should greatly decrease with a positive response, and apparent diffusion coefficient values typically increase. Bone metastases can be followed for response by MRI as well in a similar way. In this clinical setting, the likelihood of metastatic disease outside the pelvis is increased. For example, liver metastases and nodal metastases in higher stations are most often seen in the setting of Variant 3. It is probable that coverage of the abdomen in addition to the pelvis would provide more benefit in this setting, but evidence is lacking. MRI Pelvis In this clinical setting, the likelihood of metastatic disease outside the pelvis is increased. For example, liver metastases and nodal metastases in higher stations are most often seen in the setting of Variant 3. It is probable that coverage of the abdomen in addition to the pelvis would provide more benefit, but evidence is lacking. Local recurrence, even if present, becomes of lesser clinical importance in this setting, unless it is locally advanced and is causing urinary or bowel complications. MRI-Targeted Biopsy Prostatectomy Bed Because local recurrence is of lesser clinical importance in the setting of metastatic prostate cancer, MRI-targeted biopsy of the prostate is not routinely used for evaluation. | 69369 |
acrac_69369_21 | Post Treatment Follow up of Prostate Cancer | Choline PET/CT Skull Base to Mid-Thigh Although choline PET has been extensively used and studied, with several large meta-analyses available [44,45], the literature is less rigorous for this specific application. There are multiple studies showing its utility in this application [136-139], with no evidence that choline PET has any detriment in performance, and given that metastatic disease outside the pelvis is increased in frequency in this setting and that choline PET activity correlates well with disease activity, it likely is of increased utility for monitoring response to treatment, although there is insufficient data. There is some evidence that ADT decreases choline uptake in lesions that are not CRPC and that it is able to predict treatment response to various agents in the setting of CRPC. Choline requires an on- site cyclotron for generation of the agent because of its short half-life, which restricts where it is feasible to perform. Post-Treatment Follow-up of Prostate Cancer Choline PET/MRI Skull Base to Mid-Thigh There is limited evidence to support the use of choline PET/MRI for follow-up of a patient treated by systemic therapy. Fluoride PET/CT Skull Base to Mid-Thigh Fluoride is a tracer that has been available for clinical use for several decades, and it aims to demonstrate the increased uptake within foci in the bone with increased bone turnover in biologic processes such as metastatic involvement, fracture, or degenerative changes. Fluoride PET has a similar mechanism with bone scan; however, it is a much more sensitive imaging agent, and it offers tomographic evalaution. A recent meta-analysis revealed fluoride PET has a much higher sensitivity compared to bone scan (96% versus 86%) [140]. Another meta- analysis compared fluoride with bone scan and whole body MRI. | Post Treatment Follow up of Prostate Cancer. Choline PET/CT Skull Base to Mid-Thigh Although choline PET has been extensively used and studied, with several large meta-analyses available [44,45], the literature is less rigorous for this specific application. There are multiple studies showing its utility in this application [136-139], with no evidence that choline PET has any detriment in performance, and given that metastatic disease outside the pelvis is increased in frequency in this setting and that choline PET activity correlates well with disease activity, it likely is of increased utility for monitoring response to treatment, although there is insufficient data. There is some evidence that ADT decreases choline uptake in lesions that are not CRPC and that it is able to predict treatment response to various agents in the setting of CRPC. Choline requires an on- site cyclotron for generation of the agent because of its short half-life, which restricts where it is feasible to perform. Post-Treatment Follow-up of Prostate Cancer Choline PET/MRI Skull Base to Mid-Thigh There is limited evidence to support the use of choline PET/MRI for follow-up of a patient treated by systemic therapy. Fluoride PET/CT Skull Base to Mid-Thigh Fluoride is a tracer that has been available for clinical use for several decades, and it aims to demonstrate the increased uptake within foci in the bone with increased bone turnover in biologic processes such as metastatic involvement, fracture, or degenerative changes. Fluoride PET has a similar mechanism with bone scan; however, it is a much more sensitive imaging agent, and it offers tomographic evalaution. A recent meta-analysis revealed fluoride PET has a much higher sensitivity compared to bone scan (96% versus 86%) [140]. Another meta- analysis compared fluoride with bone scan and whole body MRI. | 69369 |
acrac_69369_22 | Post Treatment Follow up of Prostate Cancer | The results indicated that fluoride has a higher diagnostic accuracy compared to bone scan (0.97 versus 0.842), whereas the dianostic accuracy of fluoride was similar to that of whole body MRI for detecting bone lesions (0.97 versus 0.947) [141]. In addition to its use for detecting bone lesions in the setting of metastatic prostate cancer, quantitative features extracted from fluoride PET have been reported to be promising in treatment response evalaution and prognosis [141]. Although its higher sensitivity for detecting bone metastases, the actual clinical benefit of fluoride PET on patient outcomes is yet to be reported. Fluciclovine PET/CT Skull Base to Mid-Thigh Fluciclovine is FDA approved (May 2016) for imaging of prostate cancer patients with BCR, and its use in metastatic prostate cancer is not as commonly reported as in BCR naturally. There are in vitro studies and anecdotal experience suggesting the potential utility with CRPC [142-144]. In a recent study with 106 patients, fluciclovine PET/CT was compared with bone scan for detecting bone metastases. The sensitivity, specificity, positive predictive value, and negative predictive value for bone scan were 79%, 86%, 45%, and 96%, respectively, whereas corresponding performance metrics for fluciclovine PET/CT were 100%, 98%, 89%, and 100%, respectively [145]. Fluciclovine PET/MRI Skull Base to Mid-Thigh There is limited evidence to support the use of fluciclovine PET/MRI for follow-up of a patient treated by systemic therapy. A small study of patients with primary prostate cancer treated with ADT reported a decrease in radiotracer uptake in local and metastatic lesions on PET/MRI [146]. | Post Treatment Follow up of Prostate Cancer. The results indicated that fluoride has a higher diagnostic accuracy compared to bone scan (0.97 versus 0.842), whereas the dianostic accuracy of fluoride was similar to that of whole body MRI for detecting bone lesions (0.97 versus 0.947) [141]. In addition to its use for detecting bone lesions in the setting of metastatic prostate cancer, quantitative features extracted from fluoride PET have been reported to be promising in treatment response evalaution and prognosis [141]. Although its higher sensitivity for detecting bone metastases, the actual clinical benefit of fluoride PET on patient outcomes is yet to be reported. Fluciclovine PET/CT Skull Base to Mid-Thigh Fluciclovine is FDA approved (May 2016) for imaging of prostate cancer patients with BCR, and its use in metastatic prostate cancer is not as commonly reported as in BCR naturally. There are in vitro studies and anecdotal experience suggesting the potential utility with CRPC [142-144]. In a recent study with 106 patients, fluciclovine PET/CT was compared with bone scan for detecting bone metastases. The sensitivity, specificity, positive predictive value, and negative predictive value for bone scan were 79%, 86%, 45%, and 96%, respectively, whereas corresponding performance metrics for fluciclovine PET/CT were 100%, 98%, 89%, and 100%, respectively [145]. Fluciclovine PET/MRI Skull Base to Mid-Thigh There is limited evidence to support the use of fluciclovine PET/MRI for follow-up of a patient treated by systemic therapy. A small study of patients with primary prostate cancer treated with ADT reported a decrease in radiotracer uptake in local and metastatic lesions on PET/MRI [146]. | 69369 |
acrac_69369_23 | Post Treatment Follow up of Prostate Cancer | PET Using Other Agents: There are many additional prostate-specific tracers that are not FDA approved, including 11C-acetate [70,71], 18F-choline [72-74], Bombesin, 18F-fluorodihydrotestosterone [78], and a family of related PSMA tracers [76,77,140], that are in various stages of investigation and have been reported to detect local and metastatic recurrent disease in patients with biochemical failure after local treatment. These agents remain investigational, but some have shown excellent results and hold great potential. FDG-PET/CT FDG is an inferior tracer to choline and other prostate-specific agents [79,80,147-149] and has limited use in standard practice. However, as advanced metastatic prostate cancer migrates to a high Gleason grade, dedifferentiates, or transforms to other aggressive variants, such as small cell type, the tumor cells are more likely to convert to a higher glucose metabolism, and FDG can become useful in the detection and monitoring of this subset of patients, although the literature data are limited [150-152]. PSMA PET/CT Skull Base To Mid-Thigh PSMA was FDA approved in December 2020 for imaging of prostate cancer patients with BCR, and its use in metastatic prostate cancer is not as commonly reported as in BCR, and it is mostly limited to research use. In 1 study that compared visual and semiautomatic bone scan evaluations with PSMA PET/CT in 30 patients, visual and semiautomatic bone scan evaluation showed similar results with an average of 19.4 and 17.8 detected bone lesion per patient, whereas PSMA PET/CT revealed 40 lesions per patient [153]. In a study with 51 patients who had inconclusive F-18-NaF PET/CT findings for bone metastases, additional PSMA PET/CT ultimately diagnosed bone metastases in 13 patients (25% of the entire cohort). Patient-based sensitivity, specificity, and accuracy of additional PSMA PET/CT were 100%, 95%, and 96%, respectively [154]. | Post Treatment Follow up of Prostate Cancer. PET Using Other Agents: There are many additional prostate-specific tracers that are not FDA approved, including 11C-acetate [70,71], 18F-choline [72-74], Bombesin, 18F-fluorodihydrotestosterone [78], and a family of related PSMA tracers [76,77,140], that are in various stages of investigation and have been reported to detect local and metastatic recurrent disease in patients with biochemical failure after local treatment. These agents remain investigational, but some have shown excellent results and hold great potential. FDG-PET/CT FDG is an inferior tracer to choline and other prostate-specific agents [79,80,147-149] and has limited use in standard practice. However, as advanced metastatic prostate cancer migrates to a high Gleason grade, dedifferentiates, or transforms to other aggressive variants, such as small cell type, the tumor cells are more likely to convert to a higher glucose metabolism, and FDG can become useful in the detection and monitoring of this subset of patients, although the literature data are limited [150-152]. PSMA PET/CT Skull Base To Mid-Thigh PSMA was FDA approved in December 2020 for imaging of prostate cancer patients with BCR, and its use in metastatic prostate cancer is not as commonly reported as in BCR, and it is mostly limited to research use. In 1 study that compared visual and semiautomatic bone scan evaluations with PSMA PET/CT in 30 patients, visual and semiautomatic bone scan evaluation showed similar results with an average of 19.4 and 17.8 detected bone lesion per patient, whereas PSMA PET/CT revealed 40 lesions per patient [153]. In a study with 51 patients who had inconclusive F-18-NaF PET/CT findings for bone metastases, additional PSMA PET/CT ultimately diagnosed bone metastases in 13 patients (25% of the entire cohort). Patient-based sensitivity, specificity, and accuracy of additional PSMA PET/CT were 100%, 95%, and 96%, respectively [154]. | 69369 |
acrac_69369_24 | Post Treatment Follow up of Prostate Cancer | PSMA PET/CT has the potential to estimate tumor burden in metastatic prostate cancer for selecting patients who may benefit from PSMA radioligand therapies. For this purpose, the actual relationship between alterations in PSMA expression and PSMA uptake at PET/CT imaging versus ADT treatment status is yet to be reported. Post-Treatment Follow-up of Prostate Cancer DCFPyL PET/CT Skull Base To Mid-Thigh DCFPyL PET/CT was FDA approved in May 2021 for imaging of prostate cancer patients with BCR, and its use in metastatic prostate cancer is not routine clinically and is confined to research. In 1 prospective study with 15 patients with metastatic prostate cancer, DCFPyL PET/CT was compared with F-18-NaF PET/CT for detection of bone lesions. Results of this study revealed 405 bone lesions suggestive of sites of prostate cancer were identified on at least one scan. On DCFPyL PET/CT, 391 (96.5%) were definitively positive, 4 (1.0%) were equivocally positive, and 10 (2.5%) were negative. Whereas on F-18-NaF PET/CT, the corresponding values were 388 (95.8%), 4 (1.0%), and 13 (3.2%), respectively. Of the definitively negative lesions on DCFPyL PET/CT, 8 of 10 (80.0%) were sclerotic, and 2 of 10 (20.0%) were infiltrative or marrow-based. Additionally, 12 of 13 (92.3%) of the definitively negative lesions on F-18-NaF PET/CT were infiltrative or marrow-based, and 1 of 13 (7.7%) was lytic. Both tracers had similar sensitivities for detecting bone lesions in metastatic prostate cancer patients [155]. In a limited number of studies, utility of DCFPyL PET/CT is evaluated for therapeutic response to ADT in metastatic prostate cancer patients. In a prospective study with 6 patients with metastatic castration resistant prostate cancer, DCFPyL PET/CT was used at baseline and 3 months after treatment to monitor the therapy response to bipolar ADT. Results revealed that 3 of 6 (50%) patients had progression on DCFPyL PET/CT. | Post Treatment Follow up of Prostate Cancer. PSMA PET/CT has the potential to estimate tumor burden in metastatic prostate cancer for selecting patients who may benefit from PSMA radioligand therapies. For this purpose, the actual relationship between alterations in PSMA expression and PSMA uptake at PET/CT imaging versus ADT treatment status is yet to be reported. Post-Treatment Follow-up of Prostate Cancer DCFPyL PET/CT Skull Base To Mid-Thigh DCFPyL PET/CT was FDA approved in May 2021 for imaging of prostate cancer patients with BCR, and its use in metastatic prostate cancer is not routine clinically and is confined to research. In 1 prospective study with 15 patients with metastatic prostate cancer, DCFPyL PET/CT was compared with F-18-NaF PET/CT for detection of bone lesions. Results of this study revealed 405 bone lesions suggestive of sites of prostate cancer were identified on at least one scan. On DCFPyL PET/CT, 391 (96.5%) were definitively positive, 4 (1.0%) were equivocally positive, and 10 (2.5%) were negative. Whereas on F-18-NaF PET/CT, the corresponding values were 388 (95.8%), 4 (1.0%), and 13 (3.2%), respectively. Of the definitively negative lesions on DCFPyL PET/CT, 8 of 10 (80.0%) were sclerotic, and 2 of 10 (20.0%) were infiltrative or marrow-based. Additionally, 12 of 13 (92.3%) of the definitively negative lesions on F-18-NaF PET/CT were infiltrative or marrow-based, and 1 of 13 (7.7%) was lytic. Both tracers had similar sensitivities for detecting bone lesions in metastatic prostate cancer patients [155]. In a limited number of studies, utility of DCFPyL PET/CT is evaluated for therapeutic response to ADT in metastatic prostate cancer patients. In a prospective study with 6 patients with metastatic castration resistant prostate cancer, DCFPyL PET/CT was used at baseline and 3 months after treatment to monitor the therapy response to bipolar ADT. Results revealed that 3 of 6 (50%) patients had progression on DCFPyL PET/CT. | 69369 |
acrac_3178300_0 | Imaging after Breast Surgery | OR Discussion of Procedures by Variant Variant 1: Female. Age 40 years or older. Postsurgical excision with nonmalignant pathology. Asymptomatic. Initial imaging. Benign breast disease can be classified into 3 broad categories: nonproliferative lesions, proliferative lesions without atypia, and proliferative lesions with atypia. Nonproliferative lesions include benign calcifications, fibrocystic changes, fibroadenomas, lipomas, fat necrosis, and nonsclerosing adenosis. Proliferative lesions without atypia include usual ductal hyperplasia, sclerosing adenosis, complex fibroadenomas, radial scars/complex sclerosing lesions, papillomas, and papillomatosis. Proliferative lesions with atypia include atypical ductal hyperplasia, atypical lobular hyperplasia, lobular carcinoma in situ (LCIS), and flat epithelial atypia [4,5]. Benign breast disease and breast tissue density are independent risk factors for developing breast cancer [5,6]. One study of women from the Breast Cancer Surveillance Consortium (BCSC) reported breast cancer in 25% of women with excision for aUMass Memorial Medical Center, Worchester, Massachusetts. bPanel Chair, Alpert Medical School of Brown University, Providence, Rhode Island. cPanel Vice-Chair, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida. dWashington University School of Medicine, Saint Louis, Missouri. eUniversity of Cincinnati, Cincinnati, Ohio. fPenn State Health Hershey Medical Center, Hershey, Pennsylvania. gUniversity of Utah, Salt Lake City, Utah. hKaiser Permanente, Atlanta, Georgia. iMemorial Sloan Kettering Cancer Center, New York, New York. jUniversity of Michigan, Ann Arbor, Michigan. kSt. Bernards Healthcare, Jonesboro, Arkansas. lDuke Signature Care, Durham, North Carolina; American College of Physicians. mPrinceton Community Hospital, Princeton, West Virginia; American College of Surgeons. nProMedica Breast Care, Toledo, Ohio. oEmory University Hospital, Atlanta, Georgia; RADS Committee. | Imaging after Breast Surgery. OR Discussion of Procedures by Variant Variant 1: Female. Age 40 years or older. Postsurgical excision with nonmalignant pathology. Asymptomatic. Initial imaging. Benign breast disease can be classified into 3 broad categories: nonproliferative lesions, proliferative lesions without atypia, and proliferative lesions with atypia. Nonproliferative lesions include benign calcifications, fibrocystic changes, fibroadenomas, lipomas, fat necrosis, and nonsclerosing adenosis. Proliferative lesions without atypia include usual ductal hyperplasia, sclerosing adenosis, complex fibroadenomas, radial scars/complex sclerosing lesions, papillomas, and papillomatosis. Proliferative lesions with atypia include atypical ductal hyperplasia, atypical lobular hyperplasia, lobular carcinoma in situ (LCIS), and flat epithelial atypia [4,5]. Benign breast disease and breast tissue density are independent risk factors for developing breast cancer [5,6]. One study of women from the Breast Cancer Surveillance Consortium (BCSC) reported breast cancer in 25% of women with excision for aUMass Memorial Medical Center, Worchester, Massachusetts. bPanel Chair, Alpert Medical School of Brown University, Providence, Rhode Island. cPanel Vice-Chair, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida. dWashington University School of Medicine, Saint Louis, Missouri. eUniversity of Cincinnati, Cincinnati, Ohio. fPenn State Health Hershey Medical Center, Hershey, Pennsylvania. gUniversity of Utah, Salt Lake City, Utah. hKaiser Permanente, Atlanta, Georgia. iMemorial Sloan Kettering Cancer Center, New York, New York. jUniversity of Michigan, Ann Arbor, Michigan. kSt. Bernards Healthcare, Jonesboro, Arkansas. lDuke Signature Care, Durham, North Carolina; American College of Physicians. mPrinceton Community Hospital, Princeton, West Virginia; American College of Surgeons. nProMedica Breast Care, Toledo, Ohio. oEmory University Hospital, Atlanta, Georgia; RADS Committee. | 3178300 |
acrac_3178300_1 | Imaging after Breast Surgery | pHoag Family Cancer Institute, Newport Beach, California and University of Southern California, Los Angeles, California; Commission on Nuclear Medicine and Molecular Imaging. qSpecialty Chair, NYU Clinical Cancer Center, New York, New York. Reprint requests to: [email protected] Imaging after Breast Surgery proliferative lesions with atypia [7]. Almost 30% of women with breast cancer have a history of benign breast disease [4]. Although there are no relevant studies examining mammographic follow-up intervals of benign breast disease following surgical biopsy, there are some studies examining imaging intervals following benign core biopsy. In populations with nonproliferative lesions or proliferative lesions without atypia, imaging intervals of 6 months compared to routine annual screening did not improve cancer detection rates or change invasive cancer rates, stage, tumor size, or nodal status [11,12]. The studies on proliferative lesions with atypia, examining the need for excision and, if not excised, need for short interval follow-up, are varied [13-16] and are outside the scope of this document. Atypical ductal hyperplasia on core biopsy typically warrants surgical consultation and/or multidisciplinary discussion regarding the benefits and risks of subsequent excision. There is more varied practice in management of atypical lobular hyperplasia, LCIS, and flat epithelial atypia found on core biopsy. One study of more than 2 million screening mammograms in nearly 800,000 women, with 15% having a self- reported history of prior benign percutaneous or excisional breast biopsy, showed no difference in mammographic sensitivity; however, there was decreased specificity and mammographic performance, which was attributed to tissue characteristics rather than the biopsy itself [18]. | Imaging after Breast Surgery. pHoag Family Cancer Institute, Newport Beach, California and University of Southern California, Los Angeles, California; Commission on Nuclear Medicine and Molecular Imaging. qSpecialty Chair, NYU Clinical Cancer Center, New York, New York. Reprint requests to: [email protected] Imaging after Breast Surgery proliferative lesions with atypia [7]. Almost 30% of women with breast cancer have a history of benign breast disease [4]. Although there are no relevant studies examining mammographic follow-up intervals of benign breast disease following surgical biopsy, there are some studies examining imaging intervals following benign core biopsy. In populations with nonproliferative lesions or proliferative lesions without atypia, imaging intervals of 6 months compared to routine annual screening did not improve cancer detection rates or change invasive cancer rates, stage, tumor size, or nodal status [11,12]. The studies on proliferative lesions with atypia, examining the need for excision and, if not excised, need for short interval follow-up, are varied [13-16] and are outside the scope of this document. Atypical ductal hyperplasia on core biopsy typically warrants surgical consultation and/or multidisciplinary discussion regarding the benefits and risks of subsequent excision. There is more varied practice in management of atypical lobular hyperplasia, LCIS, and flat epithelial atypia found on core biopsy. One study of more than 2 million screening mammograms in nearly 800,000 women, with 15% having a self- reported history of prior benign percutaneous or excisional breast biopsy, showed no difference in mammographic sensitivity; however, there was decreased specificity and mammographic performance, which was attributed to tissue characteristics rather than the biopsy itself [18]. | 3178300 |
acrac_3178300_2 | Imaging after Breast Surgery | Another study comparing patients with history of proliferative lesions with atypia with matched screenings based on age, density, and breast cancer family history also found no differences in mammographic sensitivity or proportion of interval cancers; however, they also reported lower specificity in the atypical proliferative lesions group [19]. FDG-PET Breast Dedicated There is no relevant literature to support the use of fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET breast imaging in this clinical scenario. Although there are no relevant studies examining mammographic follow-up intervals of benign breast disease following surgical biopsy, there are some studies examining imaging intervals following benign core biopsy. In populations with nonproliferative lesions or proliferative lesions without atypia, imaging intervals of 6 months compared with routine annual screening did not improve cancer detection rates or change invasive cancer rates, stage, tumor size, or nodal status [11,12]. The studies on proliferative lesions with atypia, examining the need for Imaging after Breast Surgery excision and, if not excised, the need for short interval follow-up, are varied [13-16,20] and are outside the scope of this document. A majority agree that there is a need for surgical excision when atypical ductal hyperplasia is found on core biopsy. There is more varied practice in management of atypical lobular hyperplasia, LCIS, and flat epithelial atypia found on core biopsy. One study of more than 2 million screening mammograms in nearly 800,000 women, with 15% having a self- reported history of prior benign percutaneous or excisional breast biopsy, showed no difference in mammographic sensitivity; however, there was decreased in specificity and mammographic performance, which was attributed to tissue characteristics rather than the biopsy itself [18]. | Imaging after Breast Surgery. Another study comparing patients with history of proliferative lesions with atypia with matched screenings based on age, density, and breast cancer family history also found no differences in mammographic sensitivity or proportion of interval cancers; however, they also reported lower specificity in the atypical proliferative lesions group [19]. FDG-PET Breast Dedicated There is no relevant literature to support the use of fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET breast imaging in this clinical scenario. Although there are no relevant studies examining mammographic follow-up intervals of benign breast disease following surgical biopsy, there are some studies examining imaging intervals following benign core biopsy. In populations with nonproliferative lesions or proliferative lesions without atypia, imaging intervals of 6 months compared with routine annual screening did not improve cancer detection rates or change invasive cancer rates, stage, tumor size, or nodal status [11,12]. The studies on proliferative lesions with atypia, examining the need for Imaging after Breast Surgery excision and, if not excised, the need for short interval follow-up, are varied [13-16,20] and are outside the scope of this document. A majority agree that there is a need for surgical excision when atypical ductal hyperplasia is found on core biopsy. There is more varied practice in management of atypical lobular hyperplasia, LCIS, and flat epithelial atypia found on core biopsy. One study of more than 2 million screening mammograms in nearly 800,000 women, with 15% having a self- reported history of prior benign percutaneous or excisional breast biopsy, showed no difference in mammographic sensitivity; however, there was decreased in specificity and mammographic performance, which was attributed to tissue characteristics rather than the biopsy itself [18]. | 3178300 |
acrac_3178300_3 | Imaging after Breast Surgery | Another study comparing patients with history of proliferative lesions with atypia with matched screenings based on age, density, and breast cancer family history also found no differences in mammographic sensitivity or proportion of interval cancers; however, they also reported lower specificity in the atypical proliferative lesions group [19]. MRI Breast Without IV Contrast There is no relevant literature to support the use of MRI breast without IV contrast for screening in this clinical scenario. Sestamibi MBI There is no relevant literature to support the use of Tc-99m sestamibi molecular breast imaging (MBI) in this clinical scenario. Variant 2: Female. Age 30 to 39 years. Postsurgical excision with nonmalignant pathology. Asymptomatic. Initial imaging. Benign breast disease can be classified into 3 broad categories: nonproliferative lesions, proliferative lesions without atypia, and proliferative lesions with atypia. Nonproliferative lesions include benign calcifications, fibrocystic changes, fibroadenomas, lipomas, fat necrosis, and nonsclerosing adenosis. Proliferative lesions without atypia include usual ductal hyperplasia, sclerosing adenosis, complex fibroadenomas, radial scars/complex sclerosing lesions, papillomas, and papillomatosis. Proliferative lesions with atypia include atypical ductal hyperplasia, atypical lobular hyperplasia, LCIS, and flat epithelial atypia [4,5]. Benign breast disease and breast tissue density are independent risk factors for developing breast cancer [5,6]. One study of women from the BCSC reported breast cancer in 25% of women with excision for proliferative lesions with atypia [7]. Almost 30% of women with breast cancer have a history of benign breast disease [4]. Imaging after Breast Surgery FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET breast in this clinical scenario. | Imaging after Breast Surgery. Another study comparing patients with history of proliferative lesions with atypia with matched screenings based on age, density, and breast cancer family history also found no differences in mammographic sensitivity or proportion of interval cancers; however, they also reported lower specificity in the atypical proliferative lesions group [19]. MRI Breast Without IV Contrast There is no relevant literature to support the use of MRI breast without IV contrast for screening in this clinical scenario. Sestamibi MBI There is no relevant literature to support the use of Tc-99m sestamibi molecular breast imaging (MBI) in this clinical scenario. Variant 2: Female. Age 30 to 39 years. Postsurgical excision with nonmalignant pathology. Asymptomatic. Initial imaging. Benign breast disease can be classified into 3 broad categories: nonproliferative lesions, proliferative lesions without atypia, and proliferative lesions with atypia. Nonproliferative lesions include benign calcifications, fibrocystic changes, fibroadenomas, lipomas, fat necrosis, and nonsclerosing adenosis. Proliferative lesions without atypia include usual ductal hyperplasia, sclerosing adenosis, complex fibroadenomas, radial scars/complex sclerosing lesions, papillomas, and papillomatosis. Proliferative lesions with atypia include atypical ductal hyperplasia, atypical lobular hyperplasia, LCIS, and flat epithelial atypia [4,5]. Benign breast disease and breast tissue density are independent risk factors for developing breast cancer [5,6]. One study of women from the BCSC reported breast cancer in 25% of women with excision for proliferative lesions with atypia [7]. Almost 30% of women with breast cancer have a history of benign breast disease [4]. Imaging after Breast Surgery FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET breast in this clinical scenario. | 3178300 |
acrac_3178300_4 | Imaging after Breast Surgery | MRI Breast Without IV Contrast There is no relevant literature to support the use of MRI breast without IV contrast for screening in this clinical scenario. Sestamibi MBI There is no relevant literature to support the use of Tc-99m sestamibi MBI in this clinical scenario. Imaging after Breast Surgery Variant 3: Adult female younger than 30 years of age. Postsurgical excision with nonmalignant pathology. Asymptomatic. Initial imaging. Benign breast disease can be classified into 3 broad categories: nonproliferative lesions, proliferative lesions without atypia, and proliferative lesions with atypia. Nonproliferative lesions include benign calcifications, fibrocystic changes, fibroadenomas, lipomas, fat necrosis, and nonsclerosing adenosis. Proliferative lesions without atypia include usual ductal hyperplasia, sclerosing adenosis, complex fibroadenomas, radial scars/complex sclerosing lesions, papillomas, and papillomatosis. Proliferative lesions with atypia include atypical ductal hyperplasia, atypical lobular hyperplasia, LCIS, and flat epithelial atypia [4,5]. Benign breast disease and breast tissue density are independent risk factors for developing breast cancer [5,6]. One study of women from the BCSC reported breast cancer in 25% of women with excision for proliferative lesions with atypia [7]. Almost 30% of women with breast cancer have a history of benign breast disease [4]. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET breast in this clinical scenario. MRI Breast Without and With IV Contrast There is no relevant literature to support the routine use of MRI breast without and with IV contrast in an average- risk patient. Some benign breast disease, especially atypical ductal hyperplasia and lobular neoplasia can increase Imaging after Breast Surgery MRI Breast Without IV Contrast There is no relevant literature to support the use of MRI breast without IV contrast for screening in this clinical scenario. | Imaging after Breast Surgery. MRI Breast Without IV Contrast There is no relevant literature to support the use of MRI breast without IV contrast for screening in this clinical scenario. Sestamibi MBI There is no relevant literature to support the use of Tc-99m sestamibi MBI in this clinical scenario. Imaging after Breast Surgery Variant 3: Adult female younger than 30 years of age. Postsurgical excision with nonmalignant pathology. Asymptomatic. Initial imaging. Benign breast disease can be classified into 3 broad categories: nonproliferative lesions, proliferative lesions without atypia, and proliferative lesions with atypia. Nonproliferative lesions include benign calcifications, fibrocystic changes, fibroadenomas, lipomas, fat necrosis, and nonsclerosing adenosis. Proliferative lesions without atypia include usual ductal hyperplasia, sclerosing adenosis, complex fibroadenomas, radial scars/complex sclerosing lesions, papillomas, and papillomatosis. Proliferative lesions with atypia include atypical ductal hyperplasia, atypical lobular hyperplasia, LCIS, and flat epithelial atypia [4,5]. Benign breast disease and breast tissue density are independent risk factors for developing breast cancer [5,6]. One study of women from the BCSC reported breast cancer in 25% of women with excision for proliferative lesions with atypia [7]. Almost 30% of women with breast cancer have a history of benign breast disease [4]. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET breast in this clinical scenario. MRI Breast Without and With IV Contrast There is no relevant literature to support the routine use of MRI breast without and with IV contrast in an average- risk patient. Some benign breast disease, especially atypical ductal hyperplasia and lobular neoplasia can increase Imaging after Breast Surgery MRI Breast Without IV Contrast There is no relevant literature to support the use of MRI breast without IV contrast for screening in this clinical scenario. | 3178300 |
acrac_3178300_5 | Imaging after Breast Surgery | Sestamibi MBI There is no relevant literature to support the use of Tc-99m sestamibi MBI in this clinical scenario. Variant 4: Adult female. Postsurgical excision for breast cancer. Positive margins. Asymptomatic. Initial imaging. Margin status is an important predictor of local recurrence of invasive or in situ cancer after breast conservation surgery. For invasive breast cancer (with or without DCIS), a negative margin is defined as no tumor on ink by histology. In contrast, guidelines recommend that margins for pure DCIS (with or without microinvasion) be at least 2 mm [21]. Frequencies of positive margins after initial surgery vary based on multiple factors including type of breast cancer, appearance on imaging, breast density, and surgical technique. Positive margins at first surgery and at final breast surgery are predictors of breast cancer recurrence [23]. The goal of surgery is to remove the tumor and obtain negative margins. Re-excision is usually performed in the setting of positive margins, often without additional imaging evaluation. Imaging is sometimes used to help delineate residual disease before re-excision. Sometimes despite re-excision, margins remain close or positive. Digital Breast Tomosynthesis Diagnostic There is no relevant literature to support the routine use of diagnostic DBT in this clinical scenario. When diagnostic mammography is performed in this scenario, it is typically for evaluation of residual calcifications, which are better visualized on magnification mammograms rather than DBT. One small retrospective study evaluated postexcision mammography and MRI to assess for residual disease. Of 51 patients with malignant calcifications (32 with and 19 without residual disease), mammography sensitivity, specificity, and accuracy were 78.1%, 42.1%, and 62.7%, respectively. | Imaging after Breast Surgery. Sestamibi MBI There is no relevant literature to support the use of Tc-99m sestamibi MBI in this clinical scenario. Variant 4: Adult female. Postsurgical excision for breast cancer. Positive margins. Asymptomatic. Initial imaging. Margin status is an important predictor of local recurrence of invasive or in situ cancer after breast conservation surgery. For invasive breast cancer (with or without DCIS), a negative margin is defined as no tumor on ink by histology. In contrast, guidelines recommend that margins for pure DCIS (with or without microinvasion) be at least 2 mm [21]. Frequencies of positive margins after initial surgery vary based on multiple factors including type of breast cancer, appearance on imaging, breast density, and surgical technique. Positive margins at first surgery and at final breast surgery are predictors of breast cancer recurrence [23]. The goal of surgery is to remove the tumor and obtain negative margins. Re-excision is usually performed in the setting of positive margins, often without additional imaging evaluation. Imaging is sometimes used to help delineate residual disease before re-excision. Sometimes despite re-excision, margins remain close or positive. Digital Breast Tomosynthesis Diagnostic There is no relevant literature to support the routine use of diagnostic DBT in this clinical scenario. When diagnostic mammography is performed in this scenario, it is typically for evaluation of residual calcifications, which are better visualized on magnification mammograms rather than DBT. One small retrospective study evaluated postexcision mammography and MRI to assess for residual disease. Of 51 patients with malignant calcifications (32 with and 19 without residual disease), mammography sensitivity, specificity, and accuracy were 78.1%, 42.1%, and 62.7%, respectively. | 3178300 |
acrac_3178300_6 | Imaging after Breast Surgery | MRI was better than mammography, especially in the setting of low background parenchymal enhancement, in which sensitivity, specificity, and accuracy were 88.8%, 57.1%, and 76.5%, respectively [24]. Another small single institution study of 281 patients with ductal carcinoma in situ, of which 144 underwent postexcision preirradiation mammography, found postexcision preirradiation mammography resulted in a change in surgical management in 7% (10/144) and removal of residual ductal carcinoma in situ in 4% (6/144) of patients. More importantly there was no significant change in 10-year local recurrence-free survival (95% versus 92%, with and without postexcision preirradiation mammography) [25]. Digital Breast Tomosynthesis Screening There is no relevant literature to support the use of screening DBT in this clinical scenario. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET breast in this clinical scenario. Imaging after Breast Surgery Mammography Diagnostic There is insufficient evidence to support the routine use of diagnostic mammography in this clinical scenario. However, it can be helpful in a subset of patients in which there is concern for residual microcalcifications, which are better visualized on magnification mammograms rather than DBT. One small retrospective study evaluated postexcision mammography and MRI to assess for residual disease. Of 51 patients with malignant calcifications (32 with and 19 without residual disease), mammography sensitivity, specificity, and accuracy were 78.1%, 42.1%, and 62.7%, respectively. MRI was better than mammography, especially in the setting of low background parenchymal enhancement, in which sensitivity, specificity, and accuracy were 88.8%, 57.1%, and 76.5%, respectively [24]. | Imaging after Breast Surgery. MRI was better than mammography, especially in the setting of low background parenchymal enhancement, in which sensitivity, specificity, and accuracy were 88.8%, 57.1%, and 76.5%, respectively [24]. Another small single institution study of 281 patients with ductal carcinoma in situ, of which 144 underwent postexcision preirradiation mammography, found postexcision preirradiation mammography resulted in a change in surgical management in 7% (10/144) and removal of residual ductal carcinoma in situ in 4% (6/144) of patients. More importantly there was no significant change in 10-year local recurrence-free survival (95% versus 92%, with and without postexcision preirradiation mammography) [25]. Digital Breast Tomosynthesis Screening There is no relevant literature to support the use of screening DBT in this clinical scenario. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET breast in this clinical scenario. Imaging after Breast Surgery Mammography Diagnostic There is insufficient evidence to support the routine use of diagnostic mammography in this clinical scenario. However, it can be helpful in a subset of patients in which there is concern for residual microcalcifications, which are better visualized on magnification mammograms rather than DBT. One small retrospective study evaluated postexcision mammography and MRI to assess for residual disease. Of 51 patients with malignant calcifications (32 with and 19 without residual disease), mammography sensitivity, specificity, and accuracy were 78.1%, 42.1%, and 62.7%, respectively. MRI was better than mammography, especially in the setting of low background parenchymal enhancement, in which sensitivity, specificity, and accuracy were 88.8%, 57.1%, and 76.5%, respectively [24]. | 3178300 |
acrac_3178300_7 | Imaging after Breast Surgery | Another small single institution study of 281 patients with ductal carcinoma in situ, of which 144 underwent postexcision preirradiation mammography, found postexcision preirradiation mammography resulted in a change in surgical management in 7% (10/144) and removal of residual ductal carcinoma in situ in 4% (6/144) of patients. More importantly there was no significant change in 10-year local recurrence-free survival (95% versus 92%, with and without postexcision preirradiation mammography) [25]. Mammography Screening There is no relevant literature to support the use of screening mammography in this clinical scenario. MRI Breast Without and With IV Contrast There is insufficient evidence to support the routine use of MRI breast without and with IV contrast in this clinical scenario. MRI, when performed, is generally done before initial surgery. However, it may be performed following initial surgery in the setting of unsuspected positive margins. Evaluating residual disease in the surgical cavity is limited with MRI because of associated benign enhancement of the borders of the resection cavity obscuring residual disease. MRI may be helpful in identification of more widespread disease or remote disease [26,27]. This information can guide surgical planning for re-excision or need for mastectomy. One small retrospective study evaluated postexcision mammography and MRI to assess for residual disease in 51 patients with malignant calcifications (32 with and 19 without residual disease). MRI was better than mammography, especially in the setting of low background parenchymal enhancement, where sensitivity, specificity, and accuracy were 88.8%, 57.1%, and 76.5%, respectively. However higher background parenchymal enhancement did reduce sensitivity and accuracy [24]. MRI Breast Without IV Contrast There is no relevant literature to support the use of MRI breast without IV contrast for screening in this clinical scenario. | Imaging after Breast Surgery. Another small single institution study of 281 patients with ductal carcinoma in situ, of which 144 underwent postexcision preirradiation mammography, found postexcision preirradiation mammography resulted in a change in surgical management in 7% (10/144) and removal of residual ductal carcinoma in situ in 4% (6/144) of patients. More importantly there was no significant change in 10-year local recurrence-free survival (95% versus 92%, with and without postexcision preirradiation mammography) [25]. Mammography Screening There is no relevant literature to support the use of screening mammography in this clinical scenario. MRI Breast Without and With IV Contrast There is insufficient evidence to support the routine use of MRI breast without and with IV contrast in this clinical scenario. MRI, when performed, is generally done before initial surgery. However, it may be performed following initial surgery in the setting of unsuspected positive margins. Evaluating residual disease in the surgical cavity is limited with MRI because of associated benign enhancement of the borders of the resection cavity obscuring residual disease. MRI may be helpful in identification of more widespread disease or remote disease [26,27]. This information can guide surgical planning for re-excision or need for mastectomy. One small retrospective study evaluated postexcision mammography and MRI to assess for residual disease in 51 patients with malignant calcifications (32 with and 19 without residual disease). MRI was better than mammography, especially in the setting of low background parenchymal enhancement, where sensitivity, specificity, and accuracy were 88.8%, 57.1%, and 76.5%, respectively. However higher background parenchymal enhancement did reduce sensitivity and accuracy [24]. MRI Breast Without IV Contrast There is no relevant literature to support the use of MRI breast without IV contrast for screening in this clinical scenario. | 3178300 |
acrac_3178300_8 | Imaging after Breast Surgery | Sestamibi MBI There is no relevant literature to support the use of Tc-99m sestamibi MBI in this clinical scenario. US Breast There is no relevant literature to support the use of breast US in this clinical scenario. Variant 5: Adult female. Surveillance following completion of breast conservation therapy for breast cancer. Negative margins. With or without radiation. Asymptomatic. Margin status is an important predictor of local recurrence of invasive or in situ cancer after breast conservation surgery. For invasive breast cancer (with or without DCIS), a negative margin is defined as no tumor on ink by histology. The aim of surveillance in patients after primary breast cancer treatment is to detect local recurrence and/or second breast cancers before symptoms develop. Women with a personal history of breast cancer develop a second breast cancer at a rate of 5% to 10% within 5 to 10 years after initial diagnosis [28-30]. Factors predicting risk of locoregional recurrence include age, tumor grade and size, multifocality, nodal involvement, receptor status, and whether the patient received radiotherapy, chemotherapy, or hormonal therapy [31-33]. Interval breast cancers have been reported in 24% to 30% with mammographic surveillance [34-36], and 7% with the use of multimodality imaging with mammography, US, and MRI [37]. Interval cancers are more likely to occur in women <40 to 50 years of age, in those with primary cancers that are negative estrogen receptor/progesterone receptor (ER/PR) or triple negative (negative ER/PR and negative HER2), in those with primary cancers being interval cancers, in patients with history of breast conservation therapy without radiation, and in women with dense breast tissue [35,36,38,39]. These patients may benefit from supplemental screening. Please refer to the ACR Imaging after Breast Surgery | Imaging after Breast Surgery. Sestamibi MBI There is no relevant literature to support the use of Tc-99m sestamibi MBI in this clinical scenario. US Breast There is no relevant literature to support the use of breast US in this clinical scenario. Variant 5: Adult female. Surveillance following completion of breast conservation therapy for breast cancer. Negative margins. With or without radiation. Asymptomatic. Margin status is an important predictor of local recurrence of invasive or in situ cancer after breast conservation surgery. For invasive breast cancer (with or without DCIS), a negative margin is defined as no tumor on ink by histology. The aim of surveillance in patients after primary breast cancer treatment is to detect local recurrence and/or second breast cancers before symptoms develop. Women with a personal history of breast cancer develop a second breast cancer at a rate of 5% to 10% within 5 to 10 years after initial diagnosis [28-30]. Factors predicting risk of locoregional recurrence include age, tumor grade and size, multifocality, nodal involvement, receptor status, and whether the patient received radiotherapy, chemotherapy, or hormonal therapy [31-33]. Interval breast cancers have been reported in 24% to 30% with mammographic surveillance [34-36], and 7% with the use of multimodality imaging with mammography, US, and MRI [37]. Interval cancers are more likely to occur in women <40 to 50 years of age, in those with primary cancers that are negative estrogen receptor/progesterone receptor (ER/PR) or triple negative (negative ER/PR and negative HER2), in those with primary cancers being interval cancers, in patients with history of breast conservation therapy without radiation, and in women with dense breast tissue [35,36,38,39]. These patients may benefit from supplemental screening. Please refer to the ACR Imaging after Breast Surgery | 3178300 |
acrac_3178300_9 | Imaging after Breast Surgery | Digital Breast Tomosynthesis Diagnostic Annual mammography is the best imaging test for surveillance in this clinical scenario, with reduction of mortality compared with women with history of breast cancer who do not get annual mammography [40,41]. The most common presentation of a recurrent or second breast cancer in patients with a personal history of breast cancer is an abnormal mammogram in an otherwise asymptomatic patient [22,34,36]. This ACR practice parameter allows asymptomatic women with a personal history of breast cancer to undergo diagnostic mammography [42]. A survey of radiologists showed variability in recommendation of diagnostic versus screening mammography for women treated with breast conservation therapy. Most (79%) recommended at least 1 diagnostic mammogram, with 49% recommending diagnostic mammography up to 2 years and 33% recommending diagnostic mammography from 2 to 5 years [43]. This is supported by the fact that most locoregional recurrences occur within 5 years after diagnosis [34,35,44], with recurrence risk greatest 2 to 3 years after initial therapy [23,28,33,37]. There is suboptimal compliance of annual mammography in select patients with a history of breast cancer. Groups most impacted are younger women <45 to 50 years of age, older women >65 years of age, African Americans and other underrepresented minorities, and women who did not have a recent physician visit [34,45-50]. The American Society of Radiology Oncology (ASTRO) and National Comprehensive Cancer Network (NCCN) both recommend annual mammographic surveillance for women who have completed radiation therapy as part of breast conservation therapy, with the first imaging performed at 6 to 12 months [51,52]. Other studies have found imaging before 12 months is not beneficial and/or leads to unnecessary additional imaging because of acute breast changes, supporting the first mammogram to be at 12 months after the last mammogram [30,53-56]. | Imaging after Breast Surgery. Digital Breast Tomosynthesis Diagnostic Annual mammography is the best imaging test for surveillance in this clinical scenario, with reduction of mortality compared with women with history of breast cancer who do not get annual mammography [40,41]. The most common presentation of a recurrent or second breast cancer in patients with a personal history of breast cancer is an abnormal mammogram in an otherwise asymptomatic patient [22,34,36]. This ACR practice parameter allows asymptomatic women with a personal history of breast cancer to undergo diagnostic mammography [42]. A survey of radiologists showed variability in recommendation of diagnostic versus screening mammography for women treated with breast conservation therapy. Most (79%) recommended at least 1 diagnostic mammogram, with 49% recommending diagnostic mammography up to 2 years and 33% recommending diagnostic mammography from 2 to 5 years [43]. This is supported by the fact that most locoregional recurrences occur within 5 years after diagnosis [34,35,44], with recurrence risk greatest 2 to 3 years after initial therapy [23,28,33,37]. There is suboptimal compliance of annual mammography in select patients with a history of breast cancer. Groups most impacted are younger women <45 to 50 years of age, older women >65 years of age, African Americans and other underrepresented minorities, and women who did not have a recent physician visit [34,45-50]. The American Society of Radiology Oncology (ASTRO) and National Comprehensive Cancer Network (NCCN) both recommend annual mammographic surveillance for women who have completed radiation therapy as part of breast conservation therapy, with the first imaging performed at 6 to 12 months [51,52]. Other studies have found imaging before 12 months is not beneficial and/or leads to unnecessary additional imaging because of acute breast changes, supporting the first mammogram to be at 12 months after the last mammogram [30,53-56]. | 3178300 |
acrac_3178300_10 | Imaging after Breast Surgery | More frequent imaging of the ipsilateral affected breast beyond annual surveillance mammography, at 6-month intervals for the first 2 to 5 years, has also been studied. Two groups showed no benefits to this more frequent imaging [30,56]. One study found lower stage of recurrence in women undergoing 6-month surveillance compared with annual surveillance; however, this may be secondary to decreased compliance with imaging recommendations in the annual surveillance group and follow-up was insufficient to assess for any mortality differences [57]. The addition of DBT to 2-D digital mammography or 2-D synthetic images in the surveillance of patients with prior breast cancer history has been shown to reduce recall rates and indeterminate findings [58-61], without significant change in cancer detection rate [60,61]. Digital Breast Tomosynthesis Screening Annual mammography is the best imaging test for surveillance in this clinical scenario, with reduction of mortality compared with women with history of breast cancer who do not get annual mammography [40,41]. The most common presentation of a recurrent or second breast cancer in patients with a personal history of breast cancer is an abnormal mammogram in an otherwise asymptomatic patient [22,34,36]. The ACR practice parameters state asymptomatic women previously treated for breast cancer may undergo annual screening or diagnostic mammography, as determined by the imaging facility [42]. The most common factor influencing this decision is the number of years since cancer diagnosis and treatment. A survey of radiologists showed variability in recommendation of diagnostic versus screening mammography for women treated with breast conservation therapy. Most (79%) recommended at least 1 diagnostic mammogram, with 49% recommending diagnostic mammography up to 2 years and 33% recommending diagnostic mammography from 2 to 5 years [43]. | Imaging after Breast Surgery. More frequent imaging of the ipsilateral affected breast beyond annual surveillance mammography, at 6-month intervals for the first 2 to 5 years, has also been studied. Two groups showed no benefits to this more frequent imaging [30,56]. One study found lower stage of recurrence in women undergoing 6-month surveillance compared with annual surveillance; however, this may be secondary to decreased compliance with imaging recommendations in the annual surveillance group and follow-up was insufficient to assess for any mortality differences [57]. The addition of DBT to 2-D digital mammography or 2-D synthetic images in the surveillance of patients with prior breast cancer history has been shown to reduce recall rates and indeterminate findings [58-61], without significant change in cancer detection rate [60,61]. Digital Breast Tomosynthesis Screening Annual mammography is the best imaging test for surveillance in this clinical scenario, with reduction of mortality compared with women with history of breast cancer who do not get annual mammography [40,41]. The most common presentation of a recurrent or second breast cancer in patients with a personal history of breast cancer is an abnormal mammogram in an otherwise asymptomatic patient [22,34,36]. The ACR practice parameters state asymptomatic women previously treated for breast cancer may undergo annual screening or diagnostic mammography, as determined by the imaging facility [42]. The most common factor influencing this decision is the number of years since cancer diagnosis and treatment. A survey of radiologists showed variability in recommendation of diagnostic versus screening mammography for women treated with breast conservation therapy. Most (79%) recommended at least 1 diagnostic mammogram, with 49% recommending diagnostic mammography up to 2 years and 33% recommending diagnostic mammography from 2 to 5 years [43]. | 3178300 |
acrac_3178300_11 | Imaging after Breast Surgery | This is supported by the fact that most locoregional recurrences occur within 5 years after diagnosis [34,35,44], with recurrence risk greatest 2 to 3 years after initial therapy [23,28,33,37]. There is suboptimal compliance of annual screening mammography in select patients with a history of breast cancer. Groups most impacted are younger women <45 to 50 years of age, older women >65 years of age, African Americans and other underrepresented minorities, and women who did not have a recent physician visit [34,45-50]. The ASTRO and NCCN guidelines both recommend annual mammographic surveillance for women who have completed radiation therapy as part of breast conservation therapy, with the first imaging performed at 6 to 12 months [51,52]. Other studies have found imaging before 12 months is not beneficial and/or leads to unnecessary additional imaging due to acute breast changes, supporting the first mammogram to be at 12 months after the last mammogram [30,53-56]. Imaging after Breast Surgery More frequent imaging of the ipsilateral affected breast beyond annual surveillance mammography, at 6-month intervals for the first 2 to 5 years, has also been studied. Two groups showed no benefits to this more frequent imaging [30,56]. One study found lower stage of recurrence in women undergoing 6-month surveillance compared to annual surveillance; however, this may be secondary to decreased compliance with imaging recommendations in the annual surveillance group and follow-up was insufficient to assess for any mortality differences [57]. The addition of DBT to 2-D digital mammography or 2-D synthetic images in the surveillance of patients with prior breast cancer history has been shown to reduce recall rates and indeterminate findings [58-61], without significant change in cancer detection rate [60,61]. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET breast in this clinical scenario. | Imaging after Breast Surgery. This is supported by the fact that most locoregional recurrences occur within 5 years after diagnosis [34,35,44], with recurrence risk greatest 2 to 3 years after initial therapy [23,28,33,37]. There is suboptimal compliance of annual screening mammography in select patients with a history of breast cancer. Groups most impacted are younger women <45 to 50 years of age, older women >65 years of age, African Americans and other underrepresented minorities, and women who did not have a recent physician visit [34,45-50]. The ASTRO and NCCN guidelines both recommend annual mammographic surveillance for women who have completed radiation therapy as part of breast conservation therapy, with the first imaging performed at 6 to 12 months [51,52]. Other studies have found imaging before 12 months is not beneficial and/or leads to unnecessary additional imaging due to acute breast changes, supporting the first mammogram to be at 12 months after the last mammogram [30,53-56]. Imaging after Breast Surgery More frequent imaging of the ipsilateral affected breast beyond annual surveillance mammography, at 6-month intervals for the first 2 to 5 years, has also been studied. Two groups showed no benefits to this more frequent imaging [30,56]. One study found lower stage of recurrence in women undergoing 6-month surveillance compared to annual surveillance; however, this may be secondary to decreased compliance with imaging recommendations in the annual surveillance group and follow-up was insufficient to assess for any mortality differences [57]. The addition of DBT to 2-D digital mammography or 2-D synthetic images in the surveillance of patients with prior breast cancer history has been shown to reduce recall rates and indeterminate findings [58-61], without significant change in cancer detection rate [60,61]. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET breast in this clinical scenario. | 3178300 |
acrac_3178300_12 | Imaging after Breast Surgery | Mammography Diagnostic Annual mammography is the best imaging test for surveillance in this clinical scenario, with reduction of mortality compared to women with history of breast cancer who do not get annual mammography [40,41]. The most common presentation of a recurrent or second breast cancer in patients with a personal history of breast cancer is an abnormal mammogram in an otherwise asymptomatic patient [22,34,36]. The ACR practice parameters allows asymptomatic women with a personal history of breast cancer to undergo diagnostic mammography [42]. A survey of radiologists showed variability in recommendation of diagnostic versus screening mammography for women treated with breast conservation therapy. Most (79%) recommended at least 1 diagnostic mammogram, with 49% recommending diagnostic mammography up to 2 years and 33% recommending diagnostic mammography from 2 to 5 years [43]. This is supported by the fact that most locoregional recurrences occur within 5 years after diagnosis [34,35,44], with recurrence risk greatest 2 to 3 years after initial therapy [23,28,33,37]. There is suboptimal compliance of annual mammography in select patients with a history of breast cancer. Groups most impacted are younger women <45 to 50 years of age, older women >65 years of age, African Americans and other underrepresented minorities, and women who did not have a recent physician visit [34,45-50]. The ASTRO and NCCN guidelines both recommend annual mammographic surveillance for women who have completed radiation therapy as part of breast conservation therapy, with the first imaging performed at 6 to 12 months [51,52]. Other studies have found imaging before 12 months is not beneficial and/or leads to unnecessary additional imaging due to acute breast changes, supporting the first mammogram to be at 12 months after the last mammogram [30,53-56]. | Imaging after Breast Surgery. Mammography Diagnostic Annual mammography is the best imaging test for surveillance in this clinical scenario, with reduction of mortality compared to women with history of breast cancer who do not get annual mammography [40,41]. The most common presentation of a recurrent or second breast cancer in patients with a personal history of breast cancer is an abnormal mammogram in an otherwise asymptomatic patient [22,34,36]. The ACR practice parameters allows asymptomatic women with a personal history of breast cancer to undergo diagnostic mammography [42]. A survey of radiologists showed variability in recommendation of diagnostic versus screening mammography for women treated with breast conservation therapy. Most (79%) recommended at least 1 diagnostic mammogram, with 49% recommending diagnostic mammography up to 2 years and 33% recommending diagnostic mammography from 2 to 5 years [43]. This is supported by the fact that most locoregional recurrences occur within 5 years after diagnosis [34,35,44], with recurrence risk greatest 2 to 3 years after initial therapy [23,28,33,37]. There is suboptimal compliance of annual mammography in select patients with a history of breast cancer. Groups most impacted are younger women <45 to 50 years of age, older women >65 years of age, African Americans and other underrepresented minorities, and women who did not have a recent physician visit [34,45-50]. The ASTRO and NCCN guidelines both recommend annual mammographic surveillance for women who have completed radiation therapy as part of breast conservation therapy, with the first imaging performed at 6 to 12 months [51,52]. Other studies have found imaging before 12 months is not beneficial and/or leads to unnecessary additional imaging due to acute breast changes, supporting the first mammogram to be at 12 months after the last mammogram [30,53-56]. | 3178300 |
acrac_3178300_13 | Imaging after Breast Surgery | More frequent imaging of the ipsilateral affected breast beyond annual surveillance mammography, at 6-month intervals for the first 2 to 5 years, has also been studied. Two groups showed no benefits to this more frequent imaging [30,56]. One study found a lower stage of recurrence in women undergoing 6-month surveillance compared with annual surveillance; however, this may be secondary to decreased compliance with imaging recommendations in the annual surveillance group, and follow-up was insufficient to assess for any mortality differences [57]. The addition of DBT to 2-D digital mammography or 2-D synthetic images in the surveillance of patients with prior breast cancer history has been shown to reduce recall rates and indeterminate findings [58-61], without significant change in cancer detection rate [60,61]. Mammography Screening Annual mammography is the best imaging test for surveillance in this clinical scenario, with reduction of mortality compared with women with history of breast cancer who do not get annual mammography [40,41]. The most common presentation of a recurrent or second breast cancer in patients with a personal history of breast cancer is an abnormal mammogram in an otherwise asymptomatic patient [22,34,36]. The ACR practice parameters state asymptomatic women previously treated for breast cancer may undergo annual screening or diagnostic mammography, as determined by the imaging facility [42]. The most common factor influencing this decision is the number of years since cancer diagnosis and treatment. A survey of radiologists showed variability in recommendation of diagnostic versus screening mammography for women treated with breast conservation therapy. Most (79%) recommended at least 1 diagnostic mammogram, with 49% recommending diagnostic mammography up to 2 years and 33% recommending diagnostic mammography from 2 to 5 years [43]. | Imaging after Breast Surgery. More frequent imaging of the ipsilateral affected breast beyond annual surveillance mammography, at 6-month intervals for the first 2 to 5 years, has also been studied. Two groups showed no benefits to this more frequent imaging [30,56]. One study found a lower stage of recurrence in women undergoing 6-month surveillance compared with annual surveillance; however, this may be secondary to decreased compliance with imaging recommendations in the annual surveillance group, and follow-up was insufficient to assess for any mortality differences [57]. The addition of DBT to 2-D digital mammography or 2-D synthetic images in the surveillance of patients with prior breast cancer history has been shown to reduce recall rates and indeterminate findings [58-61], without significant change in cancer detection rate [60,61]. Mammography Screening Annual mammography is the best imaging test for surveillance in this clinical scenario, with reduction of mortality compared with women with history of breast cancer who do not get annual mammography [40,41]. The most common presentation of a recurrent or second breast cancer in patients with a personal history of breast cancer is an abnormal mammogram in an otherwise asymptomatic patient [22,34,36]. The ACR practice parameters state asymptomatic women previously treated for breast cancer may undergo annual screening or diagnostic mammography, as determined by the imaging facility [42]. The most common factor influencing this decision is the number of years since cancer diagnosis and treatment. A survey of radiologists showed variability in recommendation of diagnostic versus screening mammography for women treated with breast conservation therapy. Most (79%) recommended at least 1 diagnostic mammogram, with 49% recommending diagnostic mammography up to 2 years and 33% recommending diagnostic mammography from 2 to 5 years [43]. | 3178300 |
acrac_3178300_14 | Imaging after Breast Surgery | Most locoregional recurrences occur within 5 years after diagnosis [34,35,44], with recurrence risk greatest 2 to 3 years after initial therapy [23,28,33,37]. Imaging after Breast Surgery There is suboptimal compliance of annual screening mammography in select patients with a history of breast cancer. Groups most impacted are younger women <45 to 50 years of age, older women >65 years of age, African Americans and other underrepresented minorities, and women who did not have a recent physician visit [34,45-50]. The ASTRO and NCCN guidelines both recommend annual mammographic surveillance for women who have completed radiation therapy as part of breast conservation therapy, with the first imaging performed at 6 to 12 months [51,52]. Other studies have found imaging before 12 months is not beneficial and/or leads to unnecessary additional imaging due to acute breast changes, supporting the first mammogram to be at 12 months after the last mammogram [30,53-56]. More frequent imaging of the ipsilateral affected breast beyond annual surveillance mammography, at 6-month intervals for the first 2 to 5 years, has also been studied. Two groups showed no benefits to this more frequent imaging [30,56]. One study found lower stage of recurrence in women undergoing 6-month surveillance compared with annual surveillance; however, this may be secondary to decreased compliance with imaging recommendations in the annual surveillance group and follow-up was insufficient to assess for any mortality differences [57]. The addition of DBT to 2-D digital mammography or 2-D synthetic images in the surveillance of patients with prior breast cancer history, has been shown to reduce recall rates and indeterminate findings [58-61], without significant change in cancer detection rate [60,61]. MRI Breast Without and With IV Contrast There is insufficient literature to support the routine use of MRI breast without and with IV contrast in this clinical scenario. | Imaging after Breast Surgery. Most locoregional recurrences occur within 5 years after diagnosis [34,35,44], with recurrence risk greatest 2 to 3 years after initial therapy [23,28,33,37]. Imaging after Breast Surgery There is suboptimal compliance of annual screening mammography in select patients with a history of breast cancer. Groups most impacted are younger women <45 to 50 years of age, older women >65 years of age, African Americans and other underrepresented minorities, and women who did not have a recent physician visit [34,45-50]. The ASTRO and NCCN guidelines both recommend annual mammographic surveillance for women who have completed radiation therapy as part of breast conservation therapy, with the first imaging performed at 6 to 12 months [51,52]. Other studies have found imaging before 12 months is not beneficial and/or leads to unnecessary additional imaging due to acute breast changes, supporting the first mammogram to be at 12 months after the last mammogram [30,53-56]. More frequent imaging of the ipsilateral affected breast beyond annual surveillance mammography, at 6-month intervals for the first 2 to 5 years, has also been studied. Two groups showed no benefits to this more frequent imaging [30,56]. One study found lower stage of recurrence in women undergoing 6-month surveillance compared with annual surveillance; however, this may be secondary to decreased compliance with imaging recommendations in the annual surveillance group and follow-up was insufficient to assess for any mortality differences [57]. The addition of DBT to 2-D digital mammography or 2-D synthetic images in the surveillance of patients with prior breast cancer history, has been shown to reduce recall rates and indeterminate findings [58-61], without significant change in cancer detection rate [60,61]. MRI Breast Without and With IV Contrast There is insufficient literature to support the routine use of MRI breast without and with IV contrast in this clinical scenario. | 3178300 |
acrac_3178300_15 | Imaging after Breast Surgery | The utility for breast MRI surveillance in patients with a personal history of breast cancer depends upon associated risk factors of the studied populations, as well as institutional protocols. The ACR recommends annual breast MRI surveillance for any woman with a lifetime risk of breast cancer of ~20% or greater [8,10]. Annual breast MRI is recommended for women with a personal history of breast cancer and dense breasts as well as women diagnosed with breast cancer before 50 years of age [10], because these risk factor combinations likely result in a ~20% or greater estimated lifetime risk of developing breast cancer [10,62,63]. Annual breast MRI is also recommended for women with a mammographically occult primary breast cancer [62,63]. A large observational study from BCSC data of 812,164 women compared mammographic and MRI performance in women with and without a personal history of breast cancer. They found MRI was more likely to be performed in patients with a family history of breast cancer and personal history of breast cancer and in women with dense breast tissue. There were higher biopsy rates with MRI (6.3%) compared with mammography (2.2%), with lower cancer yield (19.5% versus 34.7%, respectively) [64]. The findings of higher cancer detection rates with MRI compared with mammography, with lower specificity and positive predictive value were confirmed [65,66]. Another large community-based study from BCSC data of 13,266 women with a personal history of breast cancer compared surveillance with MRI and mammography to mammography alone. The group with breast MRI had higher biopsy rates (odds ratio, 2.2) and cancer detection rates (odds ratio, 1.7), with no significant difference in sensitivity or interval cancers. This study did not control for confounders and suggested subgroup analysis was warranted to better delineate risks and benefits of breast MRI in this patient population [67]. | Imaging after Breast Surgery. The utility for breast MRI surveillance in patients with a personal history of breast cancer depends upon associated risk factors of the studied populations, as well as institutional protocols. The ACR recommends annual breast MRI surveillance for any woman with a lifetime risk of breast cancer of ~20% or greater [8,10]. Annual breast MRI is recommended for women with a personal history of breast cancer and dense breasts as well as women diagnosed with breast cancer before 50 years of age [10], because these risk factor combinations likely result in a ~20% or greater estimated lifetime risk of developing breast cancer [10,62,63]. Annual breast MRI is also recommended for women with a mammographically occult primary breast cancer [62,63]. A large observational study from BCSC data of 812,164 women compared mammographic and MRI performance in women with and without a personal history of breast cancer. They found MRI was more likely to be performed in patients with a family history of breast cancer and personal history of breast cancer and in women with dense breast tissue. There were higher biopsy rates with MRI (6.3%) compared with mammography (2.2%), with lower cancer yield (19.5% versus 34.7%, respectively) [64]. The findings of higher cancer detection rates with MRI compared with mammography, with lower specificity and positive predictive value were confirmed [65,66]. Another large community-based study from BCSC data of 13,266 women with a personal history of breast cancer compared surveillance with MRI and mammography to mammography alone. The group with breast MRI had higher biopsy rates (odds ratio, 2.2) and cancer detection rates (odds ratio, 1.7), with no significant difference in sensitivity or interval cancers. This study did not control for confounders and suggested subgroup analysis was warranted to better delineate risks and benefits of breast MRI in this patient population [67]. | 3178300 |
acrac_3188086_0 | Sepsis | Introduction/Background According to the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3), sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection [1]. Therefore, what differentiates sepsis from simple infection is the presence of an aberrant host response to the underlying infection and the presence of organ dysfunction. When unexplained organ dysfunction is present, a search for possible causes of infection should commence, and radiological imaging is an integral part of this investigation. In 2017, the global incidence of sepsis was estimated to be 48.9 million cases with 11 million sepsis-related deaths (accounting for nearly 20% of all global deaths) [2]. Within the United States, according to the Centers for Disease Control and Prevention, the incidence of sepsis is >1.7 million adults per year. Greater than 15% of Americans diagnosed with sepsis die as a result of sepsis each year, and the in-hospital mortality is >30%, exemplifying that prompt recognition and treatment is crucial. Furthermore, sepsis was shown to account for 5.2% of total United States hospital costs (>20 billion dollars) in 2011, and the incidence is only rising because of an aging population [3,4]. Risk factors for the development of sepsis overlap with risk factors for infection and include immune compromise, chronic diseases such as malignancy, certain patient demographics (infants and elderly persons, males, Black race), as well as numerous unidentified causes [5]. This ACR Appropriateness Criteria on Sepsis focuses on thoracic and abdominopelvic causes of sepsis. Other causes of sepsis such as osteomyelitis, diabetic foot infections, periprosthetic infections, and cardiovascular infections (including endocarditis and those due to implantable devices) are not addressed. OR aPortland VA Healthcare System and Oregon Health & Science University, Portland, Oregon. bOregon Health & Science University, Portland, Oregon. | Sepsis. Introduction/Background According to the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3), sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection [1]. Therefore, what differentiates sepsis from simple infection is the presence of an aberrant host response to the underlying infection and the presence of organ dysfunction. When unexplained organ dysfunction is present, a search for possible causes of infection should commence, and radiological imaging is an integral part of this investigation. In 2017, the global incidence of sepsis was estimated to be 48.9 million cases with 11 million sepsis-related deaths (accounting for nearly 20% of all global deaths) [2]. Within the United States, according to the Centers for Disease Control and Prevention, the incidence of sepsis is >1.7 million adults per year. Greater than 15% of Americans diagnosed with sepsis die as a result of sepsis each year, and the in-hospital mortality is >30%, exemplifying that prompt recognition and treatment is crucial. Furthermore, sepsis was shown to account for 5.2% of total United States hospital costs (>20 billion dollars) in 2011, and the incidence is only rising because of an aging population [3,4]. Risk factors for the development of sepsis overlap with risk factors for infection and include immune compromise, chronic diseases such as malignancy, certain patient demographics (infants and elderly persons, males, Black race), as well as numerous unidentified causes [5]. This ACR Appropriateness Criteria on Sepsis focuses on thoracic and abdominopelvic causes of sepsis. Other causes of sepsis such as osteomyelitis, diabetic foot infections, periprosthetic infections, and cardiovascular infections (including endocarditis and those due to implantable devices) are not addressed. OR aPortland VA Healthcare System and Oregon Health & Science University, Portland, Oregon. bOregon Health & Science University, Portland, Oregon. | 3188086 |
acrac_3188086_1 | Sepsis | cThe University of Texas MD Anderson Cancer Center, Houston, Texas. dPanel Chair, University of Kansas Medical Center, Kansas City, Kansas. ePanel Chair, Lauderdale Radiology Group, Florence, Alabama. fPanel Chair, UT Southwestern Medical Center, Dallas, Texas. gNational Jewish Health, Denver, Colorado. hUT Southwestern Medical Center, Dallas, Texas. iThe University of Texas MD Anderson Cancer Center, Houston, Texas. jDuke University Medical Center, Durham, North Carolina. kCreighton University School of Medicine, Omaha, Nebraska. lThe University of Chicago Medical Center, Chicago, Illinois; American College of Physicians. mMedstar Washington Hospital Center, Washington, District of Columbia; American College of Chest Physicians. nUT Southwestern Medical Center, Dallas, Texas; Commission on Nuclear Medicine and Molecular Imaging. oMayo Clinic Florida, Jacksonville, Florida. pBrigham & Women's Hospital, Boston, Massachusetts. qUniversity of Illinois at Chicago College of Medicine, Chicago, Illinois; American College of Physicians. rNew York University Langone Medical Center, New York, New York. sThe University of Texas MD Anderson Cancer Center, Houston, Texas. tBrigham & Women's Hospital, Boston, Massachusetts; Committee on Emergency Radiology-GSER. uSpecialty Chair, Northwestern University, Chicago, Illinois. vSpecialty Chair, Johns Hopkins University School of Medicine, Baltimore, Maryland. wSpecialty Chair, University of Chicago, Chicago, Illinois. 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] Sepsis Discussion of Procedures by Variant Variant 1: Suspected or confirmed sepsis. Cough or dyspnea or chest pain. Initial imaging. | Sepsis. cThe University of Texas MD Anderson Cancer Center, Houston, Texas. dPanel Chair, University of Kansas Medical Center, Kansas City, Kansas. ePanel Chair, Lauderdale Radiology Group, Florence, Alabama. fPanel Chair, UT Southwestern Medical Center, Dallas, Texas. gNational Jewish Health, Denver, Colorado. hUT Southwestern Medical Center, Dallas, Texas. iThe University of Texas MD Anderson Cancer Center, Houston, Texas. jDuke University Medical Center, Durham, North Carolina. kCreighton University School of Medicine, Omaha, Nebraska. lThe University of Chicago Medical Center, Chicago, Illinois; American College of Physicians. mMedstar Washington Hospital Center, Washington, District of Columbia; American College of Chest Physicians. nUT Southwestern Medical Center, Dallas, Texas; Commission on Nuclear Medicine and Molecular Imaging. oMayo Clinic Florida, Jacksonville, Florida. pBrigham & Women's Hospital, Boston, Massachusetts. qUniversity of Illinois at Chicago College of Medicine, Chicago, Illinois; American College of Physicians. rNew York University Langone Medical Center, New York, New York. sThe University of Texas MD Anderson Cancer Center, Houston, Texas. tBrigham & Women's Hospital, Boston, Massachusetts; Committee on Emergency Radiology-GSER. uSpecialty Chair, Northwestern University, Chicago, Illinois. vSpecialty Chair, Johns Hopkins University School of Medicine, Baltimore, Maryland. wSpecialty Chair, University of Chicago, Chicago, Illinois. 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] Sepsis Discussion of Procedures by Variant Variant 1: Suspected or confirmed sepsis. Cough or dyspnea or chest pain. Initial imaging. | 3188086 |
acrac_3188086_2 | Sepsis | CT plays an important role in the evaluation of patients with suspected sepsis because of its high positive predictive value (PPV) [6]. When performed as either an initial or follow-up imaging study, CT often leads to a change in management [7]. CT Chest With IV Contrast Pohlan et al [6] performed a retrospective study of 357 emergency department (ED) patients with suspected sepsis, of which 132 underwent CT scan within 72 hours of admission. The most commonly identified source of infection, which the authors refer to as septic foci, was in the chest (pneumonia) reported in 38.6% (49/127) of patients. A PPV of 81.82% (confidence interval [CI], 76.31%-86.28%) was calculated for septic foci identified by CT. However, the negative predictive value (NPV) was only 21.74% (CI, 10.73%-39.11%). Patients with suspected sepsis who received a CT within 72 hours of admission were given a final diagnosis of sepsis in 93.3% of cases (124/132). The detection of septic foci in 76.5% of CTs results in a high diagnostic yield for CT in septic ED patients, particularly in patients who are extremely ill and/or require intensive care unit (ICU) admission. Just et al [7] performed a single-center 1 year retrospective study of all CT scans of the chest, abdomen, or both ordered in pursuit of suspected infection in surgical ICU patients. A source of infection was found in 76/144 of cases (52.8%) and resulted in a change of management in 65/144 (45%) of patients, including a change in antimicrobial regimen, surgery, and nonsurgical interventions such as placement of drainage catheters. A pathologic infectious source was found in the chest in 72% of patients who underwent chest CT. Use of intravenous (IV) contrast was not specified, and preceding diagnostic procedures including chest radiography were not recorded. CT Chest Without and With IV Contrast There are no data to support the use of any added value of a CT chest without IV contrast immediately before acquisition of a contrast-enhanced CT in the diagnosis of sepsis. | Sepsis. CT plays an important role in the evaluation of patients with suspected sepsis because of its high positive predictive value (PPV) [6]. When performed as either an initial or follow-up imaging study, CT often leads to a change in management [7]. CT Chest With IV Contrast Pohlan et al [6] performed a retrospective study of 357 emergency department (ED) patients with suspected sepsis, of which 132 underwent CT scan within 72 hours of admission. The most commonly identified source of infection, which the authors refer to as septic foci, was in the chest (pneumonia) reported in 38.6% (49/127) of patients. A PPV of 81.82% (confidence interval [CI], 76.31%-86.28%) was calculated for septic foci identified by CT. However, the negative predictive value (NPV) was only 21.74% (CI, 10.73%-39.11%). Patients with suspected sepsis who received a CT within 72 hours of admission were given a final diagnosis of sepsis in 93.3% of cases (124/132). The detection of septic foci in 76.5% of CTs results in a high diagnostic yield for CT in septic ED patients, particularly in patients who are extremely ill and/or require intensive care unit (ICU) admission. Just et al [7] performed a single-center 1 year retrospective study of all CT scans of the chest, abdomen, or both ordered in pursuit of suspected infection in surgical ICU patients. A source of infection was found in 76/144 of cases (52.8%) and resulted in a change of management in 65/144 (45%) of patients, including a change in antimicrobial regimen, surgery, and nonsurgical interventions such as placement of drainage catheters. A pathologic infectious source was found in the chest in 72% of patients who underwent chest CT. Use of intravenous (IV) contrast was not specified, and preceding diagnostic procedures including chest radiography were not recorded. CT Chest Without and With IV Contrast There are no data to support the use of any added value of a CT chest without IV contrast immediately before acquisition of a contrast-enhanced CT in the diagnosis of sepsis. | 3188086 |
acrac_3188086_3 | Sepsis | FDG-PET/CT Skull Base to Mid-Thigh There are no data to support the use of fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET/CT as an initial diagnostic imaging study in the diagnosis of sepsis. MRI Chest Without and With IV Contrast Although MRI can readily detect pulmonary and pleural infections, there are no data to support the use of MRI chest without and with IV contrast as an initial diagnostic imaging study in the diagnosis of sepsis. MRI Chest Without IV Contrast Although MRI can readily detect pulmonary and pleural infections, there are no data to support the use of MRI chest without IV contrast as an initial diagnostic imaging study in the diagnosis of sepsis. Radiography Chest Chest radiography is a commonly obtained study in the ED because of its portability and rapid acquisition. Additionally, it has the potential of providing valuable information as an initial screening tool for infection/pneumonia, particularly in patients with sepsis who may not be able to provide a history. Furthermore, chest radiography is commonly obtained in septic patients for evaluation of adequate placement of external devices, such as endotracheal tubes and central venous catheters, at which time radiologists can concurrently evaluate for an underlying source of infection. Capp et al [8] performed a retrospective study of ED patients admitted to the ICU with the diagnosis of severe sepsis or septic shock over a 12 month period and evaluated the accuracy of chest radiography in the diagnosis of pneumonia. Of 1,400 patients admitted to the ICU, 170 met criteria for severe sepsis or septic shock, and 85 were diagnosed with pneumonia. The sensitivity and specificity of initial chest radiography was 58% (95% CI, 46%- 68%) and 91% (95% CI, 81%-95%), respectively, for the diagnosis of pneumonia. Sepsis Variant 2: Suspected or confirmed sepsis. Cough or dyspnea or chest pain. Normal or equivocal or nonspecific chest radiograph. Next imaging study. | Sepsis. FDG-PET/CT Skull Base to Mid-Thigh There are no data to support the use of fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET/CT as an initial diagnostic imaging study in the diagnosis of sepsis. MRI Chest Without and With IV Contrast Although MRI can readily detect pulmonary and pleural infections, there are no data to support the use of MRI chest without and with IV contrast as an initial diagnostic imaging study in the diagnosis of sepsis. MRI Chest Without IV Contrast Although MRI can readily detect pulmonary and pleural infections, there are no data to support the use of MRI chest without IV contrast as an initial diagnostic imaging study in the diagnosis of sepsis. Radiography Chest Chest radiography is a commonly obtained study in the ED because of its portability and rapid acquisition. Additionally, it has the potential of providing valuable information as an initial screening tool for infection/pneumonia, particularly in patients with sepsis who may not be able to provide a history. Furthermore, chest radiography is commonly obtained in septic patients for evaluation of adequate placement of external devices, such as endotracheal tubes and central venous catheters, at which time radiologists can concurrently evaluate for an underlying source of infection. Capp et al [8] performed a retrospective study of ED patients admitted to the ICU with the diagnosis of severe sepsis or septic shock over a 12 month period and evaluated the accuracy of chest radiography in the diagnosis of pneumonia. Of 1,400 patients admitted to the ICU, 170 met criteria for severe sepsis or septic shock, and 85 were diagnosed with pneumonia. The sensitivity and specificity of initial chest radiography was 58% (95% CI, 46%- 68%) and 91% (95% CI, 81%-95%), respectively, for the diagnosis of pneumonia. Sepsis Variant 2: Suspected or confirmed sepsis. Cough or dyspnea or chest pain. Normal or equivocal or nonspecific chest radiograph. Next imaging study. | 3188086 |
acrac_3188086_4 | Sepsis | CT plays an important role in the evaluation of patients with suspected sepsis because of its high PPV [6] when performed as either an initial or follow-up imaging study and which often leads to a change in management [7]. Septic foci are most commonly detected in the chest, abdomen, or pelvis. CT Chest With IV Contrast Pohlan et al [6] performed a retrospective study of 357 ED patients with suspected sepsis, of whom 132 underwent CT scan within 72 hours of admission. The most commonly identified source of infection, which the authors refer to as septic foci, was in the chest (pneumonia) reported in 38.6% (49/127) of patients. A PPV of 81.82% (CI, 76.31%-86.28%) was calculated for septic foci identified by CT. However, the NPV was only 21.74% (CI, 10.73%- 39.11%). Patients with suspected sepsis who received a CT within 72 hours of admission were given a final diagnosis of sepsis in 93.3% of cases (124/132). The detection of septic foci in 76.5% of CTs results in a high diagnostic yield for CT in septic ED patients, particularly in patients who are extremely ill and/or require ICU admission. Just et al [7] performed a single-center 1 year retrospective study of all CT scans of the chest, abdomen, or both ordered in pursuit of suspected infection in surgical ICU patients. A source of infection was found in 76/144 of cases (52.8%) and resulted in a change of management in 65/144 (45%) of patients, including a change in antimicrobial regimen, surgery, and nonsurgical interventions such as placement of drainage catheters. A pathologic infectious source was found in the chest in 72% of patients who underwent chest CT. Use of IV contrast was not specified in this study. Furthermore, preceding diagnostic procedures including chest radiography were not recorded. CT Chest Without and With IV Contrast There are no data to support the use of any added value of a CT chest without IV contrast immediately before acquisition of a contrast-enhanced CT in the diagnosis of sepsis. | Sepsis. CT plays an important role in the evaluation of patients with suspected sepsis because of its high PPV [6] when performed as either an initial or follow-up imaging study and which often leads to a change in management [7]. Septic foci are most commonly detected in the chest, abdomen, or pelvis. CT Chest With IV Contrast Pohlan et al [6] performed a retrospective study of 357 ED patients with suspected sepsis, of whom 132 underwent CT scan within 72 hours of admission. The most commonly identified source of infection, which the authors refer to as septic foci, was in the chest (pneumonia) reported in 38.6% (49/127) of patients. A PPV of 81.82% (CI, 76.31%-86.28%) was calculated for septic foci identified by CT. However, the NPV was only 21.74% (CI, 10.73%- 39.11%). Patients with suspected sepsis who received a CT within 72 hours of admission were given a final diagnosis of sepsis in 93.3% of cases (124/132). The detection of septic foci in 76.5% of CTs results in a high diagnostic yield for CT in septic ED patients, particularly in patients who are extremely ill and/or require ICU admission. Just et al [7] performed a single-center 1 year retrospective study of all CT scans of the chest, abdomen, or both ordered in pursuit of suspected infection in surgical ICU patients. A source of infection was found in 76/144 of cases (52.8%) and resulted in a change of management in 65/144 (45%) of patients, including a change in antimicrobial regimen, surgery, and nonsurgical interventions such as placement of drainage catheters. A pathologic infectious source was found in the chest in 72% of patients who underwent chest CT. Use of IV contrast was not specified in this study. Furthermore, preceding diagnostic procedures including chest radiography were not recorded. CT Chest Without and With IV Contrast There are no data to support the use of any added value of a CT chest without IV contrast immediately before acquisition of a contrast-enhanced CT in the diagnosis of sepsis. | 3188086 |
acrac_3188086_5 | Sepsis | FDG-PET/CT Skull Base to Mid-Thigh Tseng et al [9] performed a single-center retrospective observational study of 53 patients admitted with sepsis of unknown origin who underwent initial workup including unrevealing chest radiography followed by FDG-PET/CT within 2 weeks of sepsis diagnosis. Of these, 35/53 (66%) of patients had positive FDG-PET/CT findings and 13/53 (25%) of patients had treatment modified based on imaging results, which included surgery (9/13) and placement of drainage catheters (4/13). Although the majority of infections identified were musculoskeletal (19/53, 38%), the second most common site of infection was in the chest (13/53, 25%). Kluge et al [10] performed a single-center 6 year retrospective study of critically ill patients with severe sepsis or septic shock of unknown origin. Eighteen patients underwent initial workup, including unrevealing chest radiography followed by FDG-PET/CT (without any other prior cross-sectional imaging). Of these, 14/18 (78%) of patients had positive FDG-PET/CT findings, of which 3/18 (17%) of patients were false positives, 11/18 (61%) of patients were true positives, and 6/18 (33%) of patients had treatment modified based on imaging results, which included surgery and initiation/prolongation of antibiotic therapy. There were no false negatives (100% NPV). Brondserud et al [11] performed a single-center retrospective study of 157 patients with 165 separate episodes of bacteremia of unknown origin who had also undergone FDG-PET/CT as part of workup for infection or sepsis. FDG-PET/CT was able to detect the site of infection in 93/165 scans (56.4%). It was the first modality to identify the site of infection in 41.1% of cases, led to changes in antimicrobial therapy in 14.7% of patients, and resulted in a new infection-related diagnosis unrelated to bacteremia in 9.8% of episodes. FDG-PET/CT had a high clinical impact in 47.3% of cases and was independent of duration of preceding antimicrobial treatment as well as number of days of bacteremia. | Sepsis. FDG-PET/CT Skull Base to Mid-Thigh Tseng et al [9] performed a single-center retrospective observational study of 53 patients admitted with sepsis of unknown origin who underwent initial workup including unrevealing chest radiography followed by FDG-PET/CT within 2 weeks of sepsis diagnosis. Of these, 35/53 (66%) of patients had positive FDG-PET/CT findings and 13/53 (25%) of patients had treatment modified based on imaging results, which included surgery (9/13) and placement of drainage catheters (4/13). Although the majority of infections identified were musculoskeletal (19/53, 38%), the second most common site of infection was in the chest (13/53, 25%). Kluge et al [10] performed a single-center 6 year retrospective study of critically ill patients with severe sepsis or septic shock of unknown origin. Eighteen patients underwent initial workup, including unrevealing chest radiography followed by FDG-PET/CT (without any other prior cross-sectional imaging). Of these, 14/18 (78%) of patients had positive FDG-PET/CT findings, of which 3/18 (17%) of patients were false positives, 11/18 (61%) of patients were true positives, and 6/18 (33%) of patients had treatment modified based on imaging results, which included surgery and initiation/prolongation of antibiotic therapy. There were no false negatives (100% NPV). Brondserud et al [11] performed a single-center retrospective study of 157 patients with 165 separate episodes of bacteremia of unknown origin who had also undergone FDG-PET/CT as part of workup for infection or sepsis. FDG-PET/CT was able to detect the site of infection in 93/165 scans (56.4%). It was the first modality to identify the site of infection in 41.1% of cases, led to changes in antimicrobial therapy in 14.7% of patients, and resulted in a new infection-related diagnosis unrelated to bacteremia in 9.8% of episodes. FDG-PET/CT had a high clinical impact in 47.3% of cases and was independent of duration of preceding antimicrobial treatment as well as number of days of bacteremia. | 3188086 |
acrac_3188086_6 | Sepsis | Pijl et al [12] performed a single-center retrospective cohort study of all ICU patients with culture-proven blood stream infection over a 10 year period who had undergone FDG-PET/CT specifically to assess for source of Sepsis infection after an initial negative conventional workup. Of the 30 patients included in the study, FDG-PET/CT identified a source of infection in 70% of patients and had a sensitivity of 90.9% and a specificity of 87.5% with discharge diagnosis serving as the reference standard. The most common sources of infection found were pneumonia and septic arthritis. The overall PPV was 95.2%, and the NPV was 77.8% for identifying a focus of infection. Of the positive FDG-PET/CTs, 52% identified a new infectious focus that led to treatment modifications such as abscess drainage, removal of infected material, or change in antimicrobial therapy. FDG-PET/CT still resulted in treatment changes in an additional 14% who already had a known infectious focus. Given that PET/CT does not provide the same degree of anatomic localization as a dedicated diagnostic dose CT, PET/CT is not considered useful as the next imaging modality after chest radiograph. Therefore, it should only be considered for use after source localization with CT has failed. MRI Chest Without and With IV Contrast Although MRI can readily detect pulmonary and pleural infection, there are no data to support the use of MRI chest without and with IV contrast as the next diagnostic imaging study after normal, equivocal, or nonspecific chest radiography in the diagnosis of sepsis. MRI Chest Without IV Contrast Although MRI can readily detect pulmonary and pleural infection, there are no data to support the use of MRI chest without IV contrast as the next diagnostic imaging study after normal, equivocal, or nonspecific chest radiography in the diagnosis of sepsis. Variant 3: Suspected or confirmed sepsis. Acute abdominal pain. Initial imaging. | Sepsis. Pijl et al [12] performed a single-center retrospective cohort study of all ICU patients with culture-proven blood stream infection over a 10 year period who had undergone FDG-PET/CT specifically to assess for source of Sepsis infection after an initial negative conventional workup. Of the 30 patients included in the study, FDG-PET/CT identified a source of infection in 70% of patients and had a sensitivity of 90.9% and a specificity of 87.5% with discharge diagnosis serving as the reference standard. The most common sources of infection found were pneumonia and septic arthritis. The overall PPV was 95.2%, and the NPV was 77.8% for identifying a focus of infection. Of the positive FDG-PET/CTs, 52% identified a new infectious focus that led to treatment modifications such as abscess drainage, removal of infected material, or change in antimicrobial therapy. FDG-PET/CT still resulted in treatment changes in an additional 14% who already had a known infectious focus. Given that PET/CT does not provide the same degree of anatomic localization as a dedicated diagnostic dose CT, PET/CT is not considered useful as the next imaging modality after chest radiograph. Therefore, it should only be considered for use after source localization with CT has failed. MRI Chest Without and With IV Contrast Although MRI can readily detect pulmonary and pleural infection, there are no data to support the use of MRI chest without and with IV contrast as the next diagnostic imaging study after normal, equivocal, or nonspecific chest radiography in the diagnosis of sepsis. MRI Chest Without IV Contrast Although MRI can readily detect pulmonary and pleural infection, there are no data to support the use of MRI chest without IV contrast as the next diagnostic imaging study after normal, equivocal, or nonspecific chest radiography in the diagnosis of sepsis. Variant 3: Suspected or confirmed sepsis. Acute abdominal pain. Initial imaging. | 3188086 |
acrac_3188086_7 | Sepsis | CT plays an important role in the evaluation of patients with suspected sepsis because of its high PPV [6] when performed as either an initial or follow-up imaging study, and which often leads to a change in management [7]. Septic foci are most commonly detected in the chest, abdomen, or pelvis. CT Abdomen and Pelvis With IV Contrast Pohlan et al [6] performed a retrospective study of 357 ED patients with suspected sepsis, of whom 132 underwent CT scan within 72 hours of admission. The second and third most commonly identified septic foci were in the abdomen, 22.0% (28/127 patients), and pelvis/genitourinary tract 20.5% (26/127 patients). A PPV of 81.82% (CI, 76.31%-86.28%) was calculated for septic foci identified by CT. However, the NPV was only 21.74% (CI, 10.73%- 39.11%). Patients with suspected sepsis who received a CT within 72 hours of admission were given a final diagnosis of sepsis in 93.3% of cases (124/132). The detection of septic foci in 76.5% of CTs results in a high diagnostic yield for CT in septic ED patients, particularly in patients who are extremely ill and/or require ICU admission. Just et al [7] performed a single-center 1 year retrospective study of all CT scans of the chest and/or abdomen ordered in pursuit of suspected infection in surgical ICU patients. A source of infection was found in 76/144 of cases (52.8%) and resulted in a change of management in 65/144 (45%) of patients, including a change in antimicrobial regimen, surgery, and nonsurgical interventions such as placement of drainage catheters. A pathologic infectious source was found in up to 44% of patients who underwent abdominal CT (exact breakdown not provided). Use of IV contrast was not specified in this study. Furthermore, preceding diagnostic procedures such as abdominal radiography were not recorded. Hoddick et al [13] performed a prospective study of 12 patients with urosepsis who were evaluated with both ultrasound (US) and CT. | Sepsis. CT plays an important role in the evaluation of patients with suspected sepsis because of its high PPV [6] when performed as either an initial or follow-up imaging study, and which often leads to a change in management [7]. Septic foci are most commonly detected in the chest, abdomen, or pelvis. CT Abdomen and Pelvis With IV Contrast Pohlan et al [6] performed a retrospective study of 357 ED patients with suspected sepsis, of whom 132 underwent CT scan within 72 hours of admission. The second and third most commonly identified septic foci were in the abdomen, 22.0% (28/127 patients), and pelvis/genitourinary tract 20.5% (26/127 patients). A PPV of 81.82% (CI, 76.31%-86.28%) was calculated for septic foci identified by CT. However, the NPV was only 21.74% (CI, 10.73%- 39.11%). Patients with suspected sepsis who received a CT within 72 hours of admission were given a final diagnosis of sepsis in 93.3% of cases (124/132). The detection of septic foci in 76.5% of CTs results in a high diagnostic yield for CT in septic ED patients, particularly in patients who are extremely ill and/or require ICU admission. Just et al [7] performed a single-center 1 year retrospective study of all CT scans of the chest and/or abdomen ordered in pursuit of suspected infection in surgical ICU patients. A source of infection was found in 76/144 of cases (52.8%) and resulted in a change of management in 65/144 (45%) of patients, including a change in antimicrobial regimen, surgery, and nonsurgical interventions such as placement of drainage catheters. A pathologic infectious source was found in up to 44% of patients who underwent abdominal CT (exact breakdown not provided). Use of IV contrast was not specified in this study. Furthermore, preceding diagnostic procedures such as abdominal radiography were not recorded. Hoddick et al [13] performed a prospective study of 12 patients with urosepsis who were evaluated with both ultrasound (US) and CT. | 3188086 |
acrac_3188086_8 | Sepsis | Of these, 6/12 patients had renal abscesses, of whom 6/6 (100%) of the patients were identified on both US and contrast-enhanced CT. One patient had multiple perirenal abscesses, and another patient had a gas-forming perinephric abscess that were both missed by US but seen on CT. CT Abdomen and Pelvis Without and With IV Contrast There are no data to support the use of any added value of a CT abdomen and pelvis without IV contrast immediately before acquisition of a contrast-enhanced CT in the diagnosis of sepsis. Sepsis CT abdomen and pelvis with IV contrast but may be useful in specific clinical situations such as urosepsis from suspected obstructing renal calculi or ureteral calculi. FDG-PET/CT Skull Base to Mid-Thigh There are no data to support the use of FDG-PET/CT as an initial diagnostic imaging study in the diagnosis of sepsis. Fluoroscopy Contrast Enema There are no data to support the use of fluoroscopy contrast enema as an initial diagnostic imaging study in the diagnosis of sepsis. Fluoroscopy Upper GI Series with Small Bowel Follow-Through There are no data to support the use of fluoroscopy upper gastrointestinal (GI) series with small bowel follow- through as an initial diagnostic imaging study in the diagnosis of sepsis. MRI Abdomen and Pelvis Without and With IV Contrast There are no data to support the use of MRI abdomen and pelvis without and with IV contrast as an initial diagnostic imaging study in the diagnosis of sepsis. The majority of patients with sepsis are too unstable to undergo a relatively long imaging procedure, especially with the availability of alternate imaging modalities that are shorter and easier to obtain. However, in certain situations, such as targeting a specific source of clinically suspected infection, MRI has been shown to be useful. Given that perianal sepsis occurs in up to 10% of neutropenic patients, Ashkar et al [14] performed a retrospective review of neutropenic patients from hematologic malignancy who were given the diagnosis of perianal sepsis. | Sepsis. Of these, 6/12 patients had renal abscesses, of whom 6/6 (100%) of the patients were identified on both US and contrast-enhanced CT. One patient had multiple perirenal abscesses, and another patient had a gas-forming perinephric abscess that were both missed by US but seen on CT. CT Abdomen and Pelvis Without and With IV Contrast There are no data to support the use of any added value of a CT abdomen and pelvis without IV contrast immediately before acquisition of a contrast-enhanced CT in the diagnosis of sepsis. Sepsis CT abdomen and pelvis with IV contrast but may be useful in specific clinical situations such as urosepsis from suspected obstructing renal calculi or ureteral calculi. FDG-PET/CT Skull Base to Mid-Thigh There are no data to support the use of FDG-PET/CT as an initial diagnostic imaging study in the diagnosis of sepsis. Fluoroscopy Contrast Enema There are no data to support the use of fluoroscopy contrast enema as an initial diagnostic imaging study in the diagnosis of sepsis. Fluoroscopy Upper GI Series with Small Bowel Follow-Through There are no data to support the use of fluoroscopy upper gastrointestinal (GI) series with small bowel follow- through as an initial diagnostic imaging study in the diagnosis of sepsis. MRI Abdomen and Pelvis Without and With IV Contrast There are no data to support the use of MRI abdomen and pelvis without and with IV contrast as an initial diagnostic imaging study in the diagnosis of sepsis. The majority of patients with sepsis are too unstable to undergo a relatively long imaging procedure, especially with the availability of alternate imaging modalities that are shorter and easier to obtain. However, in certain situations, such as targeting a specific source of clinically suspected infection, MRI has been shown to be useful. Given that perianal sepsis occurs in up to 10% of neutropenic patients, Ashkar et al [14] performed a retrospective review of neutropenic patients from hematologic malignancy who were given the diagnosis of perianal sepsis. | 3188086 |
acrac_3188086_9 | Sepsis | Of the 19 included patients, 9 patients underwent pelvic MRI without and with IV contrast. Of these, 88% (8/9) of the patients were found to have a focal collection compatible with a perianal abscess. This resulted in intraoperative drainage of the fluid collection in 6 patients, of whom 80% (5/6) of patients were confirmed to have a purulent draining cavity intraoperatively; 20% (1/6) of the patients was deemed to be a false-positive result. MRI Abdomen and Pelvis Without IV Contrast There are no data to support the use of MRI abdomen and pelvis without IV contrast as an initial diagnostic imaging study in the diagnosis of sepsis. Nuclear Medicine Scan Gallbladder There are no data to support the use of nuclear medicine scan gallbladder as an initial diagnostic imaging study in the diagnosis of sepsis. Radiography Abdomen Although abdominal radiography is portable and rapidly acquired, it rarely provides a definitive diagnosis in the setting of sepsis. It may provide information that increases the probability of an abdominal source such as pneumoperitoneum, but these findings would likely be suspected by physical examination and necessitate further evaluation with CT or US regardless [15,16]. US Abdomen Abdominal/pelvic US is often chosen as the initial imaging modality in patients of child-bearing age in the evaluation of suspected intraabdominal sepsis. Potential diagnoses responsible for sepsis in this setting can be divided into gynecological causes (such as endometritis, salpingitis, oophoritis, tubo-ovarian abscess, pelvic peritonitis) and nongynecological causes (such as acute appendicitis, diverticulitis, ileitis/colitis, epiploic appendagitis, and urological causes), which can be assessed to varying degrees on US [17]. In the setting of urosepsis, US is often considered the first imaging modality of choice in part because of its portability and rapid acquisition [15,16]. | Sepsis. Of the 19 included patients, 9 patients underwent pelvic MRI without and with IV contrast. Of these, 88% (8/9) of the patients were found to have a focal collection compatible with a perianal abscess. This resulted in intraoperative drainage of the fluid collection in 6 patients, of whom 80% (5/6) of patients were confirmed to have a purulent draining cavity intraoperatively; 20% (1/6) of the patients was deemed to be a false-positive result. MRI Abdomen and Pelvis Without IV Contrast There are no data to support the use of MRI abdomen and pelvis without IV contrast as an initial diagnostic imaging study in the diagnosis of sepsis. Nuclear Medicine Scan Gallbladder There are no data to support the use of nuclear medicine scan gallbladder as an initial diagnostic imaging study in the diagnosis of sepsis. Radiography Abdomen Although abdominal radiography is portable and rapidly acquired, it rarely provides a definitive diagnosis in the setting of sepsis. It may provide information that increases the probability of an abdominal source such as pneumoperitoneum, but these findings would likely be suspected by physical examination and necessitate further evaluation with CT or US regardless [15,16]. US Abdomen Abdominal/pelvic US is often chosen as the initial imaging modality in patients of child-bearing age in the evaluation of suspected intraabdominal sepsis. Potential diagnoses responsible for sepsis in this setting can be divided into gynecological causes (such as endometritis, salpingitis, oophoritis, tubo-ovarian abscess, pelvic peritonitis) and nongynecological causes (such as acute appendicitis, diverticulitis, ileitis/colitis, epiploic appendagitis, and urological causes), which can be assessed to varying degrees on US [17]. In the setting of urosepsis, US is often considered the first imaging modality of choice in part because of its portability and rapid acquisition [15,16]. | 3188086 |
acrac_3188086_10 | Sepsis | Based on recent studies, there is potential value in employment of artificial intelligence techniques to enhance the value of abdominal US in the setting of sepsis, but this discussion is beyond the scope of this topic. Sorenson et al [18] performed a retrospective review of 221 patients with first-time bacteremia suspected to be urosepsis. Of these, 116/221 (52%) of the patients underwent further evaluation with either abdominal US or abdomen/pelvis CT. Major abnormalities were found in 37/115 (32%) of patients and most commonly included pyonephrosis and renal calculi. Of these, 15/115 (13%) of the patients underwent urological intervention as a result of imaging findings. Follow-up of the 105 patients who did not undergo initial imaging revealed that 10/105 (9.5%) Sepsis of the patients were readmitted the following year with urosepsis; of these patients, imaging by US or CT was indicated for 6/10, and a major abnormality was detected in 3/6 imaged patients. Hoddick et al [13] performed a prospective study of 12 patients with urosepsis who were evaluated with both US and CT. Of these, 6/12 patients had renal abscesses, of whom 6/6 (100%) of the patients were identified on both US and contrast-enhanced CT. One patient had multiple perirenal abscesses, and another patient had a gas-forming perinephric abscess that were both missed by US but seen on CT. WBC Scan Abdomen and Pelvis There are no data to support the use of white blood cell (WBC) scan abdomen and pelvis as an initial diagnostic imaging study added in the diagnosis of sepsis. Variant 4: Suspected or confirmed sepsis. No specific symptoms suggestive of origin, or symptoms cannot be assessed. Initial imaging. CT plays an important role in the evaluation of patients with suspected sepsis because of its high PPV [6] when performed as either an initial or follow-up imaging study, which often leads to a change in management [7]. Septic foci are most commonly detected in the chest, abdomen, or pelvis. | Sepsis. Based on recent studies, there is potential value in employment of artificial intelligence techniques to enhance the value of abdominal US in the setting of sepsis, but this discussion is beyond the scope of this topic. Sorenson et al [18] performed a retrospective review of 221 patients with first-time bacteremia suspected to be urosepsis. Of these, 116/221 (52%) of the patients underwent further evaluation with either abdominal US or abdomen/pelvis CT. Major abnormalities were found in 37/115 (32%) of patients and most commonly included pyonephrosis and renal calculi. Of these, 15/115 (13%) of the patients underwent urological intervention as a result of imaging findings. Follow-up of the 105 patients who did not undergo initial imaging revealed that 10/105 (9.5%) Sepsis of the patients were readmitted the following year with urosepsis; of these patients, imaging by US or CT was indicated for 6/10, and a major abnormality was detected in 3/6 imaged patients. Hoddick et al [13] performed a prospective study of 12 patients with urosepsis who were evaluated with both US and CT. Of these, 6/12 patients had renal abscesses, of whom 6/6 (100%) of the patients were identified on both US and contrast-enhanced CT. One patient had multiple perirenal abscesses, and another patient had a gas-forming perinephric abscess that were both missed by US but seen on CT. WBC Scan Abdomen and Pelvis There are no data to support the use of white blood cell (WBC) scan abdomen and pelvis as an initial diagnostic imaging study added in the diagnosis of sepsis. Variant 4: Suspected or confirmed sepsis. No specific symptoms suggestive of origin, or symptoms cannot be assessed. Initial imaging. CT plays an important role in the evaluation of patients with suspected sepsis because of its high PPV [6] when performed as either an initial or follow-up imaging study, which often leads to a change in management [7]. Septic foci are most commonly detected in the chest, abdomen, or pelvis. | 3188086 |
acrac_3188086_11 | Sepsis | Of note, transthoracic echocardiography, which plays an important role in the diagnosis of infective endocarditis and associated sepsis, is not addressed in this appropriateness criteria owing to the scope of the topic and that this imaging examination is typically performed outside of radiology. CT Abdomen and Pelvis With IV Contrast Pohlan et al [6] performed a retrospective study of 357 ED patients with suspected sepsis, of whom 132 underwent CT scan within 72 hours of admission. The second and third most commonly identified septic foci were in the abdomen, 22.0% (28/127 patients), and pelvis/genitourinary tract 20.5% (26/127 patients). A PPV of 81.82% (CI, 76.31%-86.28%) was calculated for septic foci identified by CT. However, the NPV was only 21.74% (CI, 10.73%- 39.11%). Patients with suspected sepsis who received a CT within 72 hours of admission were given a final diagnosis of sepsis in 93.3% of cases (124/132). The detection of septic foci in 76.5% of CTs results in a high diagnostic yield for CT in septic ED patients, particularly in patients who are extremely ill and/or require ICU admission. Just et al [7] performed a single-center 1 year retrospective study of all CT scans of the chest and/or abdomen ordered in pursuit of suspected infection in surgical ICU patients. A source of infection was found in 76/144 of cases (52.8%) and resulted in a change of management in 65/144 (45%) of patients, including a change in antimicrobial regimen, surgery, and nonsurgical interventions such as placement of drainage catheters. A pathologic infectious source was found in up to 44% of patients who underwent abdominal CT (exact breakdown not provided). Use of IV contrast was not specified in this study. Furthermore, preceding diagnostic procedures such as abdominal radiography were not recorded. | Sepsis. Of note, transthoracic echocardiography, which plays an important role in the diagnosis of infective endocarditis and associated sepsis, is not addressed in this appropriateness criteria owing to the scope of the topic and that this imaging examination is typically performed outside of radiology. CT Abdomen and Pelvis With IV Contrast Pohlan et al [6] performed a retrospective study of 357 ED patients with suspected sepsis, of whom 132 underwent CT scan within 72 hours of admission. The second and third most commonly identified septic foci were in the abdomen, 22.0% (28/127 patients), and pelvis/genitourinary tract 20.5% (26/127 patients). A PPV of 81.82% (CI, 76.31%-86.28%) was calculated for septic foci identified by CT. However, the NPV was only 21.74% (CI, 10.73%- 39.11%). Patients with suspected sepsis who received a CT within 72 hours of admission were given a final diagnosis of sepsis in 93.3% of cases (124/132). The detection of septic foci in 76.5% of CTs results in a high diagnostic yield for CT in septic ED patients, particularly in patients who are extremely ill and/or require ICU admission. Just et al [7] performed a single-center 1 year retrospective study of all CT scans of the chest and/or abdomen ordered in pursuit of suspected infection in surgical ICU patients. A source of infection was found in 76/144 of cases (52.8%) and resulted in a change of management in 65/144 (45%) of patients, including a change in antimicrobial regimen, surgery, and nonsurgical interventions such as placement of drainage catheters. A pathologic infectious source was found in up to 44% of patients who underwent abdominal CT (exact breakdown not provided). Use of IV contrast was not specified in this study. Furthermore, preceding diagnostic procedures such as abdominal radiography were not recorded. | 3188086 |
acrac_3188086_12 | Sepsis | CT Abdomen and Pelvis Without and With IV Contrast There are no data to support the use of any added value of a CT abdomen and pelvis without IV contrast immediately before acquisition of a contrast-enhanced CT in the diagnosis of sepsis. CT Chest, Abdomen, and Pelvis With IV Contrast Pohlan et al [6] performed a retrospective study of 357 ED patients with suspected sepsis, of whom 132 underwent CT scan within 72 hours of admission. The most commonly identified source of infection, which the authors refer to as septic foci, was in the chest (pneumonia) reported in 38.6% (49/127) of patients. The second and third most commonly identified septic foci were in the abdomen, 22.0% (28/127 patients), and pelvis/genitourinary tract, 20.5% (26/127 patients). A PPV of 81.82% (CI, 76.31%-86.28%) was calculated for septic foci identified by CT. However, the NPV was only 21.74% (CI, 10.73%-39.11%). Patients with suspected sepsis who received a CT within 72 hours of admission were given a final diagnosis of sepsis in 93.3% of cases (124/132). The detection of Sepsis septic foci in 76.5% of CTs results in a high diagnostic yield for CT in septic ED patients, particularly in patients who are extremely ill and/or require ICU admission. Just et al [7] performed a single-center 1 year retrospective study of all CT scans of the chest, abdomen, or both ordered in pursuit of suspected infection in surgical ICU patients. A source of infection was found in 76/144 of cases (52.8%) and resulted in a change of management in 65/144 (45%) of patients, including a change in antimicrobial regimen, surgery, and nonsurgical interventions such as placement of drainage catheters. A pathologic infectious source was found in the chest in 72% of patients who underwent chest CT. A pathologic infectious source was found in up to 44% of patients who underwent abdominal CT (exact breakdown not provided). Use of IV contrast was not specified in this study. Furthermore, preceding diagnostic procedures including chest radiography were not recorded. | Sepsis. CT Abdomen and Pelvis Without and With IV Contrast There are no data to support the use of any added value of a CT abdomen and pelvis without IV contrast immediately before acquisition of a contrast-enhanced CT in the diagnosis of sepsis. CT Chest, Abdomen, and Pelvis With IV Contrast Pohlan et al [6] performed a retrospective study of 357 ED patients with suspected sepsis, of whom 132 underwent CT scan within 72 hours of admission. The most commonly identified source of infection, which the authors refer to as septic foci, was in the chest (pneumonia) reported in 38.6% (49/127) of patients. The second and third most commonly identified septic foci were in the abdomen, 22.0% (28/127 patients), and pelvis/genitourinary tract, 20.5% (26/127 patients). A PPV of 81.82% (CI, 76.31%-86.28%) was calculated for septic foci identified by CT. However, the NPV was only 21.74% (CI, 10.73%-39.11%). Patients with suspected sepsis who received a CT within 72 hours of admission were given a final diagnosis of sepsis in 93.3% of cases (124/132). The detection of Sepsis septic foci in 76.5% of CTs results in a high diagnostic yield for CT in septic ED patients, particularly in patients who are extremely ill and/or require ICU admission. Just et al [7] performed a single-center 1 year retrospective study of all CT scans of the chest, abdomen, or both ordered in pursuit of suspected infection in surgical ICU patients. A source of infection was found in 76/144 of cases (52.8%) and resulted in a change of management in 65/144 (45%) of patients, including a change in antimicrobial regimen, surgery, and nonsurgical interventions such as placement of drainage catheters. A pathologic infectious source was found in the chest in 72% of patients who underwent chest CT. A pathologic infectious source was found in up to 44% of patients who underwent abdominal CT (exact breakdown not provided). Use of IV contrast was not specified in this study. Furthermore, preceding diagnostic procedures including chest radiography were not recorded. | 3188086 |
acrac_3188086_13 | Sepsis | CT Chest, Abdomen, and Pelvis Without and With IV Contrast There are no data to support the use of any added value of a CT chest, abdomen, and pelvis without IV contrast immediately before acquisition of a contrast-enhanced CT in the diagnosis of sepsis. CT Chest With IV Contrast Pohlan et al [6] in a retrospective study of 357 ED patients with suspected sepsis, of whom 132 underwent CT scan within 72 hours of admission, the most commonly identified source of infection, which the authors refer to as septic foci, was in the chest (pneumonia) reported in 38.6% (49/127) of patients. A PPV of 81.82% (CI 76.31%-86.28%) was calculated for a septic focus identified by CT. However, the NPV was only 21.74% (CI 10.73%-39.11%). Patients with suspected sepsis who received a CT within 72 hours of admission were given a final diagnosis of sepsis in 93.3% of cases (124/132). The detection of septic foci in 76.5% of CTs results in a high diagnostic yield for CT in septic ED patients, particularly in patients who are extremely ill and/or require ICU admission. Just et al [7] performed a single-center 1 year retrospective study of all CT scans of the chest and/or abdomen ordered in pursuit of suspected infection in surgical ICU patients. A source of infection was found in 76/144 of cases (52.8%) and resulted in a change of management in 65/144 (45%) of patients, including a change in antimicrobial regimen, surgery, and nonsurgical interventions such as placement of drainage catheters. A pathologic infectious source was found in the chest in 72% of patients who underwent chest CT. Use of IV contrast was not specified in this study. Furthermore, preceding diagnostic procedures including chest radiography were not recorded. CT Chest Without and With IV Contrast There are no data to support the use of any added value of a CT chest without IV contrast immediately before acquisition of a contrast-enhanced CT in the diagnosis of sepsis. | Sepsis. CT Chest, Abdomen, and Pelvis Without and With IV Contrast There are no data to support the use of any added value of a CT chest, abdomen, and pelvis without IV contrast immediately before acquisition of a contrast-enhanced CT in the diagnosis of sepsis. CT Chest With IV Contrast Pohlan et al [6] in a retrospective study of 357 ED patients with suspected sepsis, of whom 132 underwent CT scan within 72 hours of admission, the most commonly identified source of infection, which the authors refer to as septic foci, was in the chest (pneumonia) reported in 38.6% (49/127) of patients. A PPV of 81.82% (CI 76.31%-86.28%) was calculated for a septic focus identified by CT. However, the NPV was only 21.74% (CI 10.73%-39.11%). Patients with suspected sepsis who received a CT within 72 hours of admission were given a final diagnosis of sepsis in 93.3% of cases (124/132). The detection of septic foci in 76.5% of CTs results in a high diagnostic yield for CT in septic ED patients, particularly in patients who are extremely ill and/or require ICU admission. Just et al [7] performed a single-center 1 year retrospective study of all CT scans of the chest and/or abdomen ordered in pursuit of suspected infection in surgical ICU patients. A source of infection was found in 76/144 of cases (52.8%) and resulted in a change of management in 65/144 (45%) of patients, including a change in antimicrobial regimen, surgery, and nonsurgical interventions such as placement of drainage catheters. A pathologic infectious source was found in the chest in 72% of patients who underwent chest CT. Use of IV contrast was not specified in this study. Furthermore, preceding diagnostic procedures including chest radiography were not recorded. CT Chest Without and With IV Contrast There are no data to support the use of any added value of a CT chest without IV contrast immediately before acquisition of a contrast-enhanced CT in the diagnosis of sepsis. | 3188086 |
acrac_3188086_14 | Sepsis | FDG-PET/CT Skull Base to Mid-Thigh There are no data to support the use of FDG-PET/CT as an initial diagnostic imaging study in the diagnosis of sepsis. Fluoroscopy Contrast Enema There are no data to support the use of fluoroscopy contrast enema as an initial diagnostic imaging study in the diagnosis of sepsis. Sepsis Fluoroscopy Upper GI Series with Small Bowel Follow-Through There are no data to support the use of fluoroscopy upper GI series with small bowel follow-through as an initial diagnostic imaging study in the diagnosis of sepsis. MRI Abdomen and Pelvis Without and With IV Contrast There are no data to support the use of MRI abdomen and pelvis without and with IV contrast as an initial diagnostic imaging study in the diagnosis of sepsis. The majority of patients with sepsis are too unstable to undergo a relatively long imaging procedure, especially with the availability of alternate imaging modalities that are shorter and easier to obtain. However, in certain situations, such as targeting a specific source of clinically suspected infection, MRI has been shown to be useful. Given that perianal sepsis occurs in up to 10% of neutropenic patients, Ashkar et al [14] performed a retrospective review of neutropenic patients from hematologic malignancy who were given the diagnosis of perianal sepsis. Of the 19 included patients, 9 patients underwent pelvic MRI without and with IV contrast. Of these, 88% (8/9) of the patients were found to have a focal collection compatible with a perianal abscess. This resulted in intraoperative drainage of the fluid collection in 6 patients, of whom 80% (5/6) of patients were confirmed to have a purulent draining cavity intraoperatively; 20% (1/6) of the patients was deemed to be a false-positive result. MRI Abdomen and Pelvis Without IV Contrast There are no data to support the use of MRI abdomen and pelvis without IV contrast as an initial diagnostic imaging study in the diagnosis of sepsis. | Sepsis. FDG-PET/CT Skull Base to Mid-Thigh There are no data to support the use of FDG-PET/CT as an initial diagnostic imaging study in the diagnosis of sepsis. Fluoroscopy Contrast Enema There are no data to support the use of fluoroscopy contrast enema as an initial diagnostic imaging study in the diagnosis of sepsis. Sepsis Fluoroscopy Upper GI Series with Small Bowel Follow-Through There are no data to support the use of fluoroscopy upper GI series with small bowel follow-through as an initial diagnostic imaging study in the diagnosis of sepsis. MRI Abdomen and Pelvis Without and With IV Contrast There are no data to support the use of MRI abdomen and pelvis without and with IV contrast as an initial diagnostic imaging study in the diagnosis of sepsis. The majority of patients with sepsis are too unstable to undergo a relatively long imaging procedure, especially with the availability of alternate imaging modalities that are shorter and easier to obtain. However, in certain situations, such as targeting a specific source of clinically suspected infection, MRI has been shown to be useful. Given that perianal sepsis occurs in up to 10% of neutropenic patients, Ashkar et al [14] performed a retrospective review of neutropenic patients from hematologic malignancy who were given the diagnosis of perianal sepsis. Of the 19 included patients, 9 patients underwent pelvic MRI without and with IV contrast. Of these, 88% (8/9) of the patients were found to have a focal collection compatible with a perianal abscess. This resulted in intraoperative drainage of the fluid collection in 6 patients, of whom 80% (5/6) of patients were confirmed to have a purulent draining cavity intraoperatively; 20% (1/6) of the patients was deemed to be a false-positive result. MRI Abdomen and Pelvis Without IV Contrast There are no data to support the use of MRI abdomen and pelvis without IV contrast as an initial diagnostic imaging study in the diagnosis of sepsis. | 3188086 |
acrac_3188086_15 | Sepsis | MRI Chest Without and With IV Contrast Although MRI can readily detect pulmonary and pleural infection, there are no data to support the use of MRI chest without and with IV contrast as an initial diagnostic imaging study in the diagnosis of sepsis. MRI Chest Without IV Contrast Although MRI can readily detect pulmonary and pleural infection, there are no data to support the use of MRI chest without IV contrast as an initial diagnostic imaging study in the diagnosis of sepsis. Nuclear Medicine Scan Gallbladder There are no data to support the use of nuclear medicine scan gallbladder as an initial diagnostic imaging study in the diagnosis of sepsis. Radiography Abdomen Although abdominal radiography is portable and rapidly acquired (which is of obvious benefit for a suspected or confirmed septic patient), it rarely provides a definitive diagnosis in the setting of sepsis. It may provide information that increases the probability of an abdominal source such as pneumoperitoneum, but these findings would be suspected by physical examination and would still necessitate further evaluation with CT or US regardless [15,16]. Radiography Chest Chest radiography is a commonly obtained study in the ED because of its portability and rapid acquisition. Additionally, it has the potential of providing valuable information as an initial screening tool for pneumonia, particularly in patients with sepsis who may not be able to provide a history. Furthermore, chest radiography is commonly obtained in septic patients for the evaluation of adequate placement of external devices such as endotracheal tubes and central venous catheters at which time radiologists can concurrently evaluate for an underlying source of infection. Capp et al [8] performed a retrospective study of ED patients admitted to the ICU with the diagnosis of severe sepsis or septic shock over a 12 month period and evaluated the accuracy of chest radiography in the diagnosis of pneumonia. | Sepsis. MRI Chest Without and With IV Contrast Although MRI can readily detect pulmonary and pleural infection, there are no data to support the use of MRI chest without and with IV contrast as an initial diagnostic imaging study in the diagnosis of sepsis. MRI Chest Without IV Contrast Although MRI can readily detect pulmonary and pleural infection, there are no data to support the use of MRI chest without IV contrast as an initial diagnostic imaging study in the diagnosis of sepsis. Nuclear Medicine Scan Gallbladder There are no data to support the use of nuclear medicine scan gallbladder as an initial diagnostic imaging study in the diagnosis of sepsis. Radiography Abdomen Although abdominal radiography is portable and rapidly acquired (which is of obvious benefit for a suspected or confirmed septic patient), it rarely provides a definitive diagnosis in the setting of sepsis. It may provide information that increases the probability of an abdominal source such as pneumoperitoneum, but these findings would be suspected by physical examination and would still necessitate further evaluation with CT or US regardless [15,16]. Radiography Chest Chest radiography is a commonly obtained study in the ED because of its portability and rapid acquisition. Additionally, it has the potential of providing valuable information as an initial screening tool for pneumonia, particularly in patients with sepsis who may not be able to provide a history. Furthermore, chest radiography is commonly obtained in septic patients for the evaluation of adequate placement of external devices such as endotracheal tubes and central venous catheters at which time radiologists can concurrently evaluate for an underlying source of infection. Capp et al [8] performed a retrospective study of ED patients admitted to the ICU with the diagnosis of severe sepsis or septic shock over a 12 month period and evaluated the accuracy of chest radiography in the diagnosis of pneumonia. | 3188086 |
acrac_3188086_16 | Sepsis | Of 1,400 patients admitted to the ICU, 170 met criteria for severe sepsis or septic shock, and 85 were diagnosed with pneumonia. The sensitivity and specificity of initial chest radiography was 58% (95% CI, 46%- 68%) and 91% (95% CI, 81%-95%), respectively, for the diagnosis of pneumonia. US Abdomen Abdominal/pelvic US is often chosen as the initial imaging modality in patients of child-bearing age in the evaluation of suspected intraabdominal sepsis. Potential diagnoses responsible for sepsis in this setting can be divided into gynecological causes (such as endometritis, salpingitis, oophoritis, tubo-ovarian abscess, pelvic peritonitis) and nongynecological causes (such as acute appendicitis, diverticulitis, ileitis/colitis, epiploic appendagitis, and urological causes), which can be assessed to varying degrees on US [17]. In the setting of Sepsis urosepsis, US is often considered the first imaging modality of choice in part because of its portability and rapid acquisition (which is of obvious benefit for a suspected or confirmed septic patient) [15,16]. Based on recent studies, there is potential value in employment of artificial intelligence techniques to enhance the value of abdominal US in the setting of sepsis, but this discussion is beyond the scope of this topic. Sorenson et al [18] performed a retrospective review of 221 patients with first-time bacteremia suspected to be urosepsis. Of these, 116/221 (52%) of the patients underwent further evaluation with either abdominal US or abdomen/pelvis CT. Major abnormalities were found in 37/115 (32%) of the patients and most commonly included pyonephrosis and renal calculi. Of these, 15/115 (13%) of the patients underwent urological intervention as a result of imaging findings. | Sepsis. Of 1,400 patients admitted to the ICU, 170 met criteria for severe sepsis or septic shock, and 85 were diagnosed with pneumonia. The sensitivity and specificity of initial chest radiography was 58% (95% CI, 46%- 68%) and 91% (95% CI, 81%-95%), respectively, for the diagnosis of pneumonia. US Abdomen Abdominal/pelvic US is often chosen as the initial imaging modality in patients of child-bearing age in the evaluation of suspected intraabdominal sepsis. Potential diagnoses responsible for sepsis in this setting can be divided into gynecological causes (such as endometritis, salpingitis, oophoritis, tubo-ovarian abscess, pelvic peritonitis) and nongynecological causes (such as acute appendicitis, diverticulitis, ileitis/colitis, epiploic appendagitis, and urological causes), which can be assessed to varying degrees on US [17]. In the setting of Sepsis urosepsis, US is often considered the first imaging modality of choice in part because of its portability and rapid acquisition (which is of obvious benefit for a suspected or confirmed septic patient) [15,16]. Based on recent studies, there is potential value in employment of artificial intelligence techniques to enhance the value of abdominal US in the setting of sepsis, but this discussion is beyond the scope of this topic. Sorenson et al [18] performed a retrospective review of 221 patients with first-time bacteremia suspected to be urosepsis. Of these, 116/221 (52%) of the patients underwent further evaluation with either abdominal US or abdomen/pelvis CT. Major abnormalities were found in 37/115 (32%) of the patients and most commonly included pyonephrosis and renal calculi. Of these, 15/115 (13%) of the patients underwent urological intervention as a result of imaging findings. | 3188086 |
acrac_3188086_17 | Sepsis | Follow-up of the 105 patients who did not undergo initial imaging revealed that 10/105 (9.5%) of the patients were readmitted the following year with urosepsis; of these patients, imaging by US or CT was indicated for 6/10, and a major abnormality was detected in 3/6 imaged patients. Hoddick et al [13] performed a prospective study of 12 patients with urosepsis who were evaluated with both US and CT. Of these, 6/12 patients had renal abscesses, of whom 6/6 (100%) of the patients were identified on both US and contrast-enhanced CT. One patient had multiple perirenal abscesses, and another patient had a gas-forming perinephric abscess that were both missed by US but seen on CT. WBC Scan Abdomen and Pelvis There are no data to support the use of WBC scan abdomen and pelvis as an initial diagnostic imaging study in the diagnosis of sepsis. Variant 5: Suspected or confirmed sepsis. No specific symptoms suggestive of origin, or symptoms cannot be assessed. Normal or equivocal or nonspecific chest radiograph. Next imaging study. CT plays an important role in the evaluation of patients with suspected sepsis because of its high PPV [6] when performed as either an initial or follow-up imaging study, which often leads to a change in management [7]. Septic foci are most commonly detected in the chest, abdomen, or pelvis. Of note, transthoracic echocardiography, which plays an important role in the diagnosis of infective endocarditis and associated sepsis, is not addressed in this appropriateness criteria owing to the scope of the topic and that this imaging examination is typically performed outside of radiology. CT Abdomen and Pelvis With IV Contrast Pohlan et al [6] in a retrospective study of 357 ED patients with suspected sepsis, of whom 132 underwent CT scan within 72 hours of admission, the second and third most commonly identified septic foci were in the abdomen, 22.0% (28/127 patients), and pelvis/genitourinary tract, 20.5% (26/127 patients). | Sepsis. Follow-up of the 105 patients who did not undergo initial imaging revealed that 10/105 (9.5%) of the patients were readmitted the following year with urosepsis; of these patients, imaging by US or CT was indicated for 6/10, and a major abnormality was detected in 3/6 imaged patients. Hoddick et al [13] performed a prospective study of 12 patients with urosepsis who were evaluated with both US and CT. Of these, 6/12 patients had renal abscesses, of whom 6/6 (100%) of the patients were identified on both US and contrast-enhanced CT. One patient had multiple perirenal abscesses, and another patient had a gas-forming perinephric abscess that were both missed by US but seen on CT. WBC Scan Abdomen and Pelvis There are no data to support the use of WBC scan abdomen and pelvis as an initial diagnostic imaging study in the diagnosis of sepsis. Variant 5: Suspected or confirmed sepsis. No specific symptoms suggestive of origin, or symptoms cannot be assessed. Normal or equivocal or nonspecific chest radiograph. Next imaging study. CT plays an important role in the evaluation of patients with suspected sepsis because of its high PPV [6] when performed as either an initial or follow-up imaging study, which often leads to a change in management [7]. Septic foci are most commonly detected in the chest, abdomen, or pelvis. Of note, transthoracic echocardiography, which plays an important role in the diagnosis of infective endocarditis and associated sepsis, is not addressed in this appropriateness criteria owing to the scope of the topic and that this imaging examination is typically performed outside of radiology. CT Abdomen and Pelvis With IV Contrast Pohlan et al [6] in a retrospective study of 357 ED patients with suspected sepsis, of whom 132 underwent CT scan within 72 hours of admission, the second and third most commonly identified septic foci were in the abdomen, 22.0% (28/127 patients), and pelvis/genitourinary tract, 20.5% (26/127 patients). | 3188086 |
acrac_3188086_18 | Sepsis | A PPV of 81.82% (CI 76.31%- 86.28%) was calculated for a septic focus identified by CT. However, the NPV was only 21.74% (CI 10.73%- 39.11%). Patients with suspected sepsis who received a CT within 72 hours of admission were given a final diagnosis of sepsis in 93.3% of cases. The detection of septic foci in 76.5% of CTs results in a high diagnostic yield for CT in septic ED patients, particularly in patients who are extremely ill and/or require ICU admission. Just et al [7] performed a single-center 1 year retrospective study of all CT scans of the chest, abdomen, or both ordered in pursuit of suspected infection in surgical ICU patients. A source of infection was found in 76/144 of cases (52.8%) and resulted in a change of management in 65/144 (45%) of patients, including a change in antimicrobial regimen, surgery, and nonsurgical interventions such as placement of drainage catheters. A pathologic infectious source was found in up to 44% of patients who underwent abdominal CT (exact breakdown not provided). Use of IV contrast was not specified in this study. Furthermore, preceding diagnostic procedures including chest radiography were not recorded. Hoddick et al [13] performed a prospective study of 12 patients with urosepsis who were evaluated with both US and CT. Of these, 6/12 patients had renal abscesses, of whom 6/6 (100%) of patients were identified on both US and contrast-enhanced CT. One patient had multiple perirenal abscesses, and another patient had a gas-forming perinephric abscess that were both missed by US but seen on CT. CT Abdomen and Pelvis Without and With IV Contrast There are no data to support the use of any added value of a CT abdomen and pelvis without IV contrast immediately before acquisition of a contrast-enhanced CT in the diagnosis of sepsis. Sepsis CT Chest, Abdomen, and Pelvis With IV Contrast Pohlan et al [6] performed a retrospective study of 357 ED patients with suspected sepsis, of whom 132 underwent CT scan within 72 hours of admission. | Sepsis. A PPV of 81.82% (CI 76.31%- 86.28%) was calculated for a septic focus identified by CT. However, the NPV was only 21.74% (CI 10.73%- 39.11%). Patients with suspected sepsis who received a CT within 72 hours of admission were given a final diagnosis of sepsis in 93.3% of cases. The detection of septic foci in 76.5% of CTs results in a high diagnostic yield for CT in septic ED patients, particularly in patients who are extremely ill and/or require ICU admission. Just et al [7] performed a single-center 1 year retrospective study of all CT scans of the chest, abdomen, or both ordered in pursuit of suspected infection in surgical ICU patients. A source of infection was found in 76/144 of cases (52.8%) and resulted in a change of management in 65/144 (45%) of patients, including a change in antimicrobial regimen, surgery, and nonsurgical interventions such as placement of drainage catheters. A pathologic infectious source was found in up to 44% of patients who underwent abdominal CT (exact breakdown not provided). Use of IV contrast was not specified in this study. Furthermore, preceding diagnostic procedures including chest radiography were not recorded. Hoddick et al [13] performed a prospective study of 12 patients with urosepsis who were evaluated with both US and CT. Of these, 6/12 patients had renal abscesses, of whom 6/6 (100%) of patients were identified on both US and contrast-enhanced CT. One patient had multiple perirenal abscesses, and another patient had a gas-forming perinephric abscess that were both missed by US but seen on CT. CT Abdomen and Pelvis Without and With IV Contrast There are no data to support the use of any added value of a CT abdomen and pelvis without IV contrast immediately before acquisition of a contrast-enhanced CT in the diagnosis of sepsis. Sepsis CT Chest, Abdomen, and Pelvis With IV Contrast Pohlan et al [6] performed a retrospective study of 357 ED patients with suspected sepsis, of whom 132 underwent CT scan within 72 hours of admission. | 3188086 |
acrac_3188086_19 | Sepsis | The most commonly identified source of infection, which the authors refer to as septic foci, was in the chest (pneumonia) reported in 38.6% (49/127) of patients. The second and third most commonly identified septic foci were in the abdomen, 22.0% (28/127 patients), and pelvis/genitourinary tract, 20.5% (26/127 patients). A PPV of 81.82% (CI, 76.31%-86.28%) was calculated for septic foci identified by CT. However, the NPV was only 21.74% (CI, 10.73%-39.11%). Patients with suspected sepsis who received a CT within 72 hours of admission were given a final diagnosis of sepsis in 93.3% of cases (124/132). The detection of septic foci in 76.5% of CTs results in a high diagnostic yield for CT in septic ED patients, particularly in patients who are extremely ill and/or require ICU admission. Just et al [7] performed a single-center 1 year retrospective study of all CT scans of the chest, abdomen, or both ordered in pursuit of suspected infection in surgical ICU patients. A source of infection was found in 76/144 of cases (52.8%) and resulted in a change of management in 65/144 (45%) of patients, including a change in antimicrobial regimen, surgery, and nonsurgical interventions such as placement of drainage catheters. A pathologic infectious source was found in the chest in 72% of patients who underwent chest CT. A pathologic infectious source was found in up to 44% of patients who underwent abdominal CT (exact breakdown not provided). Use of IV contrast was not specified in this study. Furthermore, preceding diagnostic procedures including chest radiography were not recorded. CT Chest, Abdomen, and Pelvis Without and With IV Contrast There are no data to support the use of any added value of a CT chest, abdomen, and pelvis without IV contrast immediately before acquisition of a contrast-enhanced CT in the diagnosis of sepsis. | Sepsis. The most commonly identified source of infection, which the authors refer to as septic foci, was in the chest (pneumonia) reported in 38.6% (49/127) of patients. The second and third most commonly identified septic foci were in the abdomen, 22.0% (28/127 patients), and pelvis/genitourinary tract, 20.5% (26/127 patients). A PPV of 81.82% (CI, 76.31%-86.28%) was calculated for septic foci identified by CT. However, the NPV was only 21.74% (CI, 10.73%-39.11%). Patients with suspected sepsis who received a CT within 72 hours of admission were given a final diagnosis of sepsis in 93.3% of cases (124/132). The detection of septic foci in 76.5% of CTs results in a high diagnostic yield for CT in septic ED patients, particularly in patients who are extremely ill and/or require ICU admission. Just et al [7] performed a single-center 1 year retrospective study of all CT scans of the chest, abdomen, or both ordered in pursuit of suspected infection in surgical ICU patients. A source of infection was found in 76/144 of cases (52.8%) and resulted in a change of management in 65/144 (45%) of patients, including a change in antimicrobial regimen, surgery, and nonsurgical interventions such as placement of drainage catheters. A pathologic infectious source was found in the chest in 72% of patients who underwent chest CT. A pathologic infectious source was found in up to 44% of patients who underwent abdominal CT (exact breakdown not provided). Use of IV contrast was not specified in this study. Furthermore, preceding diagnostic procedures including chest radiography were not recorded. CT Chest, Abdomen, and Pelvis Without and With IV Contrast There are no data to support the use of any added value of a CT chest, abdomen, and pelvis without IV contrast immediately before acquisition of a contrast-enhanced CT in the diagnosis of sepsis. | 3188086 |
acrac_3188086_20 | Sepsis | CT Chest With IV Contrast Pohlan et al [6] in a retrospective study of 357 ED patients with suspected sepsis, of whom 132 underwent CT scan within 72 hours of admission, the most commonly identified source of infection, which the authors refer to as septic foci, was in the chest (pneumonia) reported in 38.6% (49/127) of patients. A PPV of 81.82% (CI 76.31%-86.28%) was calculated for a septic focus identified by CT. However, the NPV was only 21.74% (CI 10.73%-39.11%). Patients with suspected sepsis who received a CT within 72 hours of admission were given a final diagnosis of sepsis in 93.3% of cases (124/132). The detection of septic foci in 76.5% of CTs results in a high diagnostic yield for CT in septic ED patients, particularly in patients who are extremely ill and/or require ICU admission. Just et al [7] performed a single-center 1 year retrospective study of all CT scans of the chest, abdomen, or both ordered in pursuit of suspected infection in surgical ICU patients. A source of infection was found in 76/144 of cases (52.8%) and resulted in a change of management in 65/144 (45%) of patients, including a change in antimicrobial regimen, surgery, and nonsurgical interventions such as placement of drainage catheters. A pathologic infectious source was found in the chest in 72% of patients who underwent chest CT. Use of IV contrast was not specified in this study. Furthermore, preceding diagnostic procedures including chest radiography were not recorded. Sepsis CT Chest Without and With IV Contrast There are no data to support the use of any added value of a CT chest without IV contrast immediately before acquisition of a contrast-enhanced CT in the diagnosis of sepsis. FDG-PET/CT Skull Base to Mid-Thigh Tseng et al [9] performed a single-center retrospective observational study of 53 patients admitted with sepsis of unknown origin who underwent initial workup including unrevealing chest radiography followed by FDG-PET/CT within 2 weeks of sepsis diagnosis. | Sepsis. CT Chest With IV Contrast Pohlan et al [6] in a retrospective study of 357 ED patients with suspected sepsis, of whom 132 underwent CT scan within 72 hours of admission, the most commonly identified source of infection, which the authors refer to as septic foci, was in the chest (pneumonia) reported in 38.6% (49/127) of patients. A PPV of 81.82% (CI 76.31%-86.28%) was calculated for a septic focus identified by CT. However, the NPV was only 21.74% (CI 10.73%-39.11%). Patients with suspected sepsis who received a CT within 72 hours of admission were given a final diagnosis of sepsis in 93.3% of cases (124/132). The detection of septic foci in 76.5% of CTs results in a high diagnostic yield for CT in septic ED patients, particularly in patients who are extremely ill and/or require ICU admission. Just et al [7] performed a single-center 1 year retrospective study of all CT scans of the chest, abdomen, or both ordered in pursuit of suspected infection in surgical ICU patients. A source of infection was found in 76/144 of cases (52.8%) and resulted in a change of management in 65/144 (45%) of patients, including a change in antimicrobial regimen, surgery, and nonsurgical interventions such as placement of drainage catheters. A pathologic infectious source was found in the chest in 72% of patients who underwent chest CT. Use of IV contrast was not specified in this study. Furthermore, preceding diagnostic procedures including chest radiography were not recorded. Sepsis CT Chest Without and With IV Contrast There are no data to support the use of any added value of a CT chest without IV contrast immediately before acquisition of a contrast-enhanced CT in the diagnosis of sepsis. FDG-PET/CT Skull Base to Mid-Thigh Tseng et al [9] performed a single-center retrospective observational study of 53 patients admitted with sepsis of unknown origin who underwent initial workup including unrevealing chest radiography followed by FDG-PET/CT within 2 weeks of sepsis diagnosis. | 3188086 |
acrac_3188086_21 | Sepsis | Of these, 35/53 (66%) of the patients had positive FDG-PET/CT findings, and 13/53 (25%) of the patients had treatment modified based on imaging results, which included surgery (9/13) and placement of drainage catheters (4/13). Although the majority of infections identified were musculoskeletal (19/53, 38%), the second most common site of infection was in the chest (13/53, 25%). The presence of liver cirrhosis was the only variable significantly associated with the likelihood of negative PET data (P = . 005). Kluge et al [10] performed a single-center 6 year retrospective study of critically ill patients with severe sepsis or septic shock of unknown origin. Eighteen patients underwent initial workup, including unrevealing chest radiography followed by FDG-PET/CT (without any other prior cross-sectional imaging). Of these, 14/18 (78%) of the patients had positive FDG-PET/CT findings, of whom 3/18 (17%) of the patients were false positives, 11/18 (61%) of the patients were true positives, and 6/18 (33%) of the patients had treatment modified based on imaging results, which included surgery and initiation/prolongation of antibiotic therapy. There were no false negatives (100% NPV). Brondserud et al [11] performed a single-center retrospective study of 157 patients with 165 separate episodes of bacteremia of unknown origin who had also undergone FDG-PET/CT as part of the workup for infection or sepsis. FDG-PET/CT was able to detect the site of infection in 93/165 scans (56.4%). It was the first modality to identify the site of infection in 41.1% of cases, led to changes in antimicrobial therapy in 14.7% of patients, and resulted in a new infection-related diagnosis unrelated to bacteremia in 9.8% of episodes. FDG-PET/CT had a high clinical impact in 47.3% of cases and was independent of the duration of the preceding antimicrobial treatment as well as the number of days of bacteremia. | Sepsis. Of these, 35/53 (66%) of the patients had positive FDG-PET/CT findings, and 13/53 (25%) of the patients had treatment modified based on imaging results, which included surgery (9/13) and placement of drainage catheters (4/13). Although the majority of infections identified were musculoskeletal (19/53, 38%), the second most common site of infection was in the chest (13/53, 25%). The presence of liver cirrhosis was the only variable significantly associated with the likelihood of negative PET data (P = . 005). Kluge et al [10] performed a single-center 6 year retrospective study of critically ill patients with severe sepsis or septic shock of unknown origin. Eighteen patients underwent initial workup, including unrevealing chest radiography followed by FDG-PET/CT (without any other prior cross-sectional imaging). Of these, 14/18 (78%) of the patients had positive FDG-PET/CT findings, of whom 3/18 (17%) of the patients were false positives, 11/18 (61%) of the patients were true positives, and 6/18 (33%) of the patients had treatment modified based on imaging results, which included surgery and initiation/prolongation of antibiotic therapy. There were no false negatives (100% NPV). Brondserud et al [11] performed a single-center retrospective study of 157 patients with 165 separate episodes of bacteremia of unknown origin who had also undergone FDG-PET/CT as part of the workup for infection or sepsis. FDG-PET/CT was able to detect the site of infection in 93/165 scans (56.4%). It was the first modality to identify the site of infection in 41.1% of cases, led to changes in antimicrobial therapy in 14.7% of patients, and resulted in a new infection-related diagnosis unrelated to bacteremia in 9.8% of episodes. FDG-PET/CT had a high clinical impact in 47.3% of cases and was independent of the duration of the preceding antimicrobial treatment as well as the number of days of bacteremia. | 3188086 |
acrac_3188086_22 | Sepsis | Pijl et al [12] performed a single-center retrospective cohort study of all ICU patients with culture-proven blood stream infection over a 10 year period who had undergone FDG-PET/CT specifically to assess for source of infection after an initial negative conventional workup. Of the 30 patients included in the study, FDG-PET/CT identified a source of infection in 70% of patients and had a sensitivity of 90.9% and a specificity of 87.5% with discharge diagnosis serving as the reference standard. The most common sources of infection found were pneumonia and septic arthritis. The overall PPV was 95.2%, and NPV was 77.8% for identifying a focus of infection. Of the positive FDG-PET/CTs, 52% identified a new infectious focus that led to treatment modifications such as abscess drainage, removal of infected material, or change in antimicrobial therapy. FDG-PET/CT still resulted in treatment changes in an additional 14% who already had a known infectious focus. Given that PET/CT does not provide the same degree of anatomic localization as a dedicated diagnostic dose CT, PET/CT is not considered useful as the next imaging modality after chest radiograph. Therefore, it should only be considered for use after source localization with CT has failed. Fluoroscopy Contrast Enema There are no data to support the use of fluoroscopy contrast enema without contrast as a diagnostic imaging study in the diagnosis of sepsis. Fluoroscopy Upper GI Series with Small Bowel Follow-Through There are no data to support the use of upper GI series with small bowel follow-through as a diagnostic imaging study in the diagnosis of sepsis. MRI Abdomen and Pelvis Without and With IV Contrast There are no data to support the use of MRI abdomen and pelvis without and with IV contrast as the next diagnostic imaging study after normal, equivocal, or nonspecific chest radiography in the diagnosis of sepsis. The majority of Sepsis | Sepsis. Pijl et al [12] performed a single-center retrospective cohort study of all ICU patients with culture-proven blood stream infection over a 10 year period who had undergone FDG-PET/CT specifically to assess for source of infection after an initial negative conventional workup. Of the 30 patients included in the study, FDG-PET/CT identified a source of infection in 70% of patients and had a sensitivity of 90.9% and a specificity of 87.5% with discharge diagnosis serving as the reference standard. The most common sources of infection found were pneumonia and septic arthritis. The overall PPV was 95.2%, and NPV was 77.8% for identifying a focus of infection. Of the positive FDG-PET/CTs, 52% identified a new infectious focus that led to treatment modifications such as abscess drainage, removal of infected material, or change in antimicrobial therapy. FDG-PET/CT still resulted in treatment changes in an additional 14% who already had a known infectious focus. Given that PET/CT does not provide the same degree of anatomic localization as a dedicated diagnostic dose CT, PET/CT is not considered useful as the next imaging modality after chest radiograph. Therefore, it should only be considered for use after source localization with CT has failed. Fluoroscopy Contrast Enema There are no data to support the use of fluoroscopy contrast enema without contrast as a diagnostic imaging study in the diagnosis of sepsis. Fluoroscopy Upper GI Series with Small Bowel Follow-Through There are no data to support the use of upper GI series with small bowel follow-through as a diagnostic imaging study in the diagnosis of sepsis. MRI Abdomen and Pelvis Without and With IV Contrast There are no data to support the use of MRI abdomen and pelvis without and with IV contrast as the next diagnostic imaging study after normal, equivocal, or nonspecific chest radiography in the diagnosis of sepsis. The majority of Sepsis | 3188086 |
acrac_3188086_23 | Sepsis | patients with sepsis are too unstable to undergo a relatively long imaging procedure especially with the availability of alternate imaging modalities that are shorter and easier to obtain. However, in certain situations such as targeting a specific source of clinically suspected infection, MRI has been shown to be useful. Given that perianal sepsis occurs in up to 10% of neutropenic patients, Ashkar et al [14] performed a retrospective review of neutropenic patients from hematologic malignancy who were given the diagnosis of perianal sepsis. Of the 19 included patients, 9 patients underwent pelvic MRI without and with IV contrast. Of these, 88% (8/9) of the patients were found to have a focal collection compatible with a perianal abscess. This resulted in intraoperative drainage of the fluid collection in 6 patients, of whom 80% (5/6) of patients were confirmed to have a purulent draining cavity intraoperatively; 20% (1/6) of the patients was deemed to be a false-positive result. MRI Abdomen and Pelvis Without IV Contrast There are no data to support the use of MRI abdomen and pelvis without IV contrast as a diagnostic imaging study in the diagnosis of sepsis. MRI Chest Without and With IV Contrast Although MRI can readily detect pulmonary and pleural infection, there are no data to support the use of MRI chest without and with IV contrast as the next diagnostic imaging study after normal, equivocal, or nonspecific chest radiography in the diagnosis of sepsis. MRI Chest Without IV Contrast Although MRI can readily detect pulmonary and pleural infection, there are no data to support the use of MRI chest without IV contrast as the next diagnostic imaging study after normal, equivocal, or nonspecific chest radiography in the diagnosis of sepsis. Nuclear Medicine Scan Gallbladder There are no data to support the use of nuclear medicine scan gallbladder as a diagnostic imaging study in the diagnosis of sepsis. | Sepsis. patients with sepsis are too unstable to undergo a relatively long imaging procedure especially with the availability of alternate imaging modalities that are shorter and easier to obtain. However, in certain situations such as targeting a specific source of clinically suspected infection, MRI has been shown to be useful. Given that perianal sepsis occurs in up to 10% of neutropenic patients, Ashkar et al [14] performed a retrospective review of neutropenic patients from hematologic malignancy who were given the diagnosis of perianal sepsis. Of the 19 included patients, 9 patients underwent pelvic MRI without and with IV contrast. Of these, 88% (8/9) of the patients were found to have a focal collection compatible with a perianal abscess. This resulted in intraoperative drainage of the fluid collection in 6 patients, of whom 80% (5/6) of patients were confirmed to have a purulent draining cavity intraoperatively; 20% (1/6) of the patients was deemed to be a false-positive result. MRI Abdomen and Pelvis Without IV Contrast There are no data to support the use of MRI abdomen and pelvis without IV contrast as a diagnostic imaging study in the diagnosis of sepsis. MRI Chest Without and With IV Contrast Although MRI can readily detect pulmonary and pleural infection, there are no data to support the use of MRI chest without and with IV contrast as the next diagnostic imaging study after normal, equivocal, or nonspecific chest radiography in the diagnosis of sepsis. MRI Chest Without IV Contrast Although MRI can readily detect pulmonary and pleural infection, there are no data to support the use of MRI chest without IV contrast as the next diagnostic imaging study after normal, equivocal, or nonspecific chest radiography in the diagnosis of sepsis. Nuclear Medicine Scan Gallbladder There are no data to support the use of nuclear medicine scan gallbladder as a diagnostic imaging study in the diagnosis of sepsis. | 3188086 |
acrac_3188086_24 | Sepsis | Radiography Abdomen Although abdominal radiography is portable and rapidly acquired (which is of obvious benefit for a suspected or confirmed septic patient), it rarely provides a definitive diagnosis in the setting of sepsis. It may provide information that increases the probability of an abdominal source such as pneumoperitoneum, but these findings would be either suspected by physical examination or at least partially visualized on chest radiography and would still necessitate further evaluation with CT or US regardless [15,16]. US Abdomen Abdominal/pelvic US is often chosen as an imaging modality in patients of child-bearing age in the evaluation of suspected intraabdominal sepsis. Potential diagnoses responsible for sepsis in this setting can be divided into gynecological causes (such as endometritis, salpingitis, oophoritis, tubo-ovarian abscess, pelvic peritonitis) and nongynecological causes (such as acute appendicitis, diverticulitis, ileitis/colitis, epiploic appendagitis, and urological causes), which can be assessed to varying degrees on US [17]. In the setting of urosepsis, US is often useful as the first imaging modality of choice, in part because of its portability and rapid acquisition, which is of obvious benefit for a suspected or confirmed septic patient [15,16]. Based on recent studies, there is potential value in employment of artificial intelligence techniques to enhance the value of abdominal US in the setting of sepsis, but this discussion is beyond the scope of this topic. Sorenson et al [18] performed a retrospective review of 221 patients with first-time bacteremia suspected to be urosepsis. Of these, 116/221 (52%) of the patients underwent further evaluation with either abdominal US or abdomen/pelvis CT. Major abnormalities were found in 37/115 (32%) of patients and most commonly included pyonephrosis and renal calculi. Of these, 15/115 (13%) of the patients underwent urological intervention as a result of imaging findings. | Sepsis. Radiography Abdomen Although abdominal radiography is portable and rapidly acquired (which is of obvious benefit for a suspected or confirmed septic patient), it rarely provides a definitive diagnosis in the setting of sepsis. It may provide information that increases the probability of an abdominal source such as pneumoperitoneum, but these findings would be either suspected by physical examination or at least partially visualized on chest radiography and would still necessitate further evaluation with CT or US regardless [15,16]. US Abdomen Abdominal/pelvic US is often chosen as an imaging modality in patients of child-bearing age in the evaluation of suspected intraabdominal sepsis. Potential diagnoses responsible for sepsis in this setting can be divided into gynecological causes (such as endometritis, salpingitis, oophoritis, tubo-ovarian abscess, pelvic peritonitis) and nongynecological causes (such as acute appendicitis, diverticulitis, ileitis/colitis, epiploic appendagitis, and urological causes), which can be assessed to varying degrees on US [17]. In the setting of urosepsis, US is often useful as the first imaging modality of choice, in part because of its portability and rapid acquisition, which is of obvious benefit for a suspected or confirmed septic patient [15,16]. Based on recent studies, there is potential value in employment of artificial intelligence techniques to enhance the value of abdominal US in the setting of sepsis, but this discussion is beyond the scope of this topic. Sorenson et al [18] performed a retrospective review of 221 patients with first-time bacteremia suspected to be urosepsis. Of these, 116/221 (52%) of the patients underwent further evaluation with either abdominal US or abdomen/pelvis CT. Major abnormalities were found in 37/115 (32%) of patients and most commonly included pyonephrosis and renal calculi. Of these, 15/115 (13%) of the patients underwent urological intervention as a result of imaging findings. | 3188086 |
acrac_3188086_25 | Sepsis | Follow-up of 105 patients who did not undergo initial imaging revealed that 10/105 (9.5%) of the patients were readmitted the following year with urosepsis; of these patients, imaging by US or CT was indicated for 6/10, and a major abnormality was detected in 3/6 imaged patients. Hoddick et al [13] in a prospective study of 12 patients with urosepsis who were evaluated with both US and CT. Of these, 6/12 of the patients had renal abscesses, of whom 6/6 (100%) of the patients were identified on both US and contrast-enhanced CT. One patient had multiple perirenal abscesses, and another patient had a gas-forming perinephric abscess that were both missed by US but seen on CT. Sepsis WBC Scan Abdomen and Pelvis When initial cross-sectional imaging is inconclusive in determining the origin of sepsis, radiolabeled WBC scans may be useful as a subsequent imaging study in providing diagnostic information. There is a relative paucity of recent literature regarding the usefulness of WBC scans in the setting of sepsis, and the majority of studies were performed before the routine use of SPECT/CT, which improves the accuracy of radiolabeled WBC scans by co- registering scintigraphic and CT data [19]. Carter et al [20] performed a retrospective review on the usefulness of Indium-111-tagged WBC scan and US in 45 patients with suspected intraabdominal sepsis but without localizing abdominal signs, of whom 22 were ultimately determined to have intraabdominal abscesses. Indium-111-tagged WBC scan correctly identified the intraabdominal abscess in 21/22 patients (sensitivity 95%) and incorrectly predicted abscesses in 2 patients (specificity 91%). All patients had a concurrent US performed and Indium-111-tagged WBC scan was shown to be more sensitive but less specific (US sensitivity was 45% and specificity was 100%). | Sepsis. Follow-up of 105 patients who did not undergo initial imaging revealed that 10/105 (9.5%) of the patients were readmitted the following year with urosepsis; of these patients, imaging by US or CT was indicated for 6/10, and a major abnormality was detected in 3/6 imaged patients. Hoddick et al [13] in a prospective study of 12 patients with urosepsis who were evaluated with both US and CT. Of these, 6/12 of the patients had renal abscesses, of whom 6/6 (100%) of the patients were identified on both US and contrast-enhanced CT. One patient had multiple perirenal abscesses, and another patient had a gas-forming perinephric abscess that were both missed by US but seen on CT. Sepsis WBC Scan Abdomen and Pelvis When initial cross-sectional imaging is inconclusive in determining the origin of sepsis, radiolabeled WBC scans may be useful as a subsequent imaging study in providing diagnostic information. There is a relative paucity of recent literature regarding the usefulness of WBC scans in the setting of sepsis, and the majority of studies were performed before the routine use of SPECT/CT, which improves the accuracy of radiolabeled WBC scans by co- registering scintigraphic and CT data [19]. Carter et al [20] performed a retrospective review on the usefulness of Indium-111-tagged WBC scan and US in 45 patients with suspected intraabdominal sepsis but without localizing abdominal signs, of whom 22 were ultimately determined to have intraabdominal abscesses. Indium-111-tagged WBC scan correctly identified the intraabdominal abscess in 21/22 patients (sensitivity 95%) and incorrectly predicted abscesses in 2 patients (specificity 91%). All patients had a concurrent US performed and Indium-111-tagged WBC scan was shown to be more sensitive but less specific (US sensitivity was 45% and specificity was 100%). | 3188086 |
acrac_3188086_26 | Sepsis | Baba et al [21] performed a retrospective review of the 45 Indium-111-tagged WBC scans that were performed in the aforementioned study by Carter et al in order to evaluate the usefulness of having performed these examinations. Of these, 34/45 (76%) of the studies were determined to be helpful in furthering patient management, even though only half (50%) of the 34 studies were positive, and 8/45 (18%) were considered to be unhelpful in furthering patient management, and 3/45 (6%) were considering to be misleading and led to inappropriate treatment from study results. Uslu et al [22] performed a prospective study involving 15 women with clinically suspected pyogenic pelvic inflammatory disease who underwent Tc-99m-HMPAO (hexamethylpropyleneamine oxime)-tagged WBC scan. All patients had previously undergone another study by either US or CT before the WBC scan. Tc-99m-HMPAO- tagged WBC correctly identified pyogenic pelvic inflammatory disease in all 5 surgically confirmed cases (sensitivity 100%) and incorrectly reported pyogenic pelvic inflammatory disease in 1/10 surgically confirmed negative cases (specificity 90%). Given that the above-mentioned studies are from older literature before the routine use of cross-sectional CT studies, WBC scans are no longer considered useful as the next imaging modality after chest radiograph, given that a WBC scan cannot provide exact anatomic localization in the manner comparable to a CT scan. Therefore, it should only be used after source localization with CT has failed. Sepsis examination is usually appropriate or may be appropriate as the next imaging study. The panel did not agree on recommending CT abdomen and pelvis without IV contrast or CT chest abdomen and pelvis without IV contrast as the next imaging study for this clinical scenario. There is insufficient medical literature to conclude whether or not these patients would benefit from these modalities. Imaging with the mentioned examinations in this patient population is controversial but may be appropriate. | Sepsis. Baba et al [21] performed a retrospective review of the 45 Indium-111-tagged WBC scans that were performed in the aforementioned study by Carter et al in order to evaluate the usefulness of having performed these examinations. Of these, 34/45 (76%) of the studies were determined to be helpful in furthering patient management, even though only half (50%) of the 34 studies were positive, and 8/45 (18%) were considered to be unhelpful in furthering patient management, and 3/45 (6%) were considering to be misleading and led to inappropriate treatment from study results. Uslu et al [22] performed a prospective study involving 15 women with clinically suspected pyogenic pelvic inflammatory disease who underwent Tc-99m-HMPAO (hexamethylpropyleneamine oxime)-tagged WBC scan. All patients had previously undergone another study by either US or CT before the WBC scan. Tc-99m-HMPAO- tagged WBC correctly identified pyogenic pelvic inflammatory disease in all 5 surgically confirmed cases (sensitivity 100%) and incorrectly reported pyogenic pelvic inflammatory disease in 1/10 surgically confirmed negative cases (specificity 90%). Given that the above-mentioned studies are from older literature before the routine use of cross-sectional CT studies, WBC scans are no longer considered useful as the next imaging modality after chest radiograph, given that a WBC scan cannot provide exact anatomic localization in the manner comparable to a CT scan. Therefore, it should only be used after source localization with CT has failed. Sepsis examination is usually appropriate or may be appropriate as the next imaging study. The panel did not agree on recommending CT abdomen and pelvis without IV contrast or CT chest abdomen and pelvis without IV contrast as the next imaging study for this clinical scenario. There is insufficient medical literature to conclude whether or not these patients would benefit from these modalities. Imaging with the mentioned examinations in this patient population is controversial but may be appropriate. | 3188086 |
acrac_69463_0 | Ovarian Cancer Screening | Introduction/Background There has been much debate about the role of imaging in ovarian cancer screening based on currently available evidence [1]. Ovarian cancer has low disease prevalence, yet is the leading cause of mortality due to gynecologic malignancy in women in the United States [2]. It is estimated that there will be 22,440 new cancer diagnoses and 14,080 cancer deaths in 2017 [2]. The high mortality rate observed is largely due to late detection, as it is commonly discovered only after its widespread dissemination. Metastatic disease is present in 60% of cases at the time of diagnosis and is associated with a low 5-year relative survival rate of 28% [2]. Only 15% of women have organ-confined disease at the time of detection, and these women have a substantially higher 5-year relative survival rate (92%) [2], suggesting that screening could be of benefit if aggressive cancers can be reliably detected at earlier stages. The average lifetime risk for developing ovarian cancer for a woman in the United States is approximately 1.3% [2]. Women with certain risk factors are known to be at increased risk, including presence of BRCA1 or BRCA2 mutations, strong family history (ie, first-degree relative, particularly if premenopausal at the time of diagnosis), nulliparity, lack of breastfeeding, lack of hormonal contraception use, and postmenopausal status [9]. Among all risk factors, a genetic predisposition is associated with the highest increase in cancer risk. A recent meta-analysis projected that 20-year-old BRCA1 and BRCA2 mutation carriers have 39% and 16% mean cumulative risks of developing ovarian cancer, respectively, by age 70 [10]. At present, risk reduction in women with a strong genetic predisposition to ovarian cancer centers on bilateral salpingo-oophorectomy [11]. | Ovarian Cancer Screening. Introduction/Background There has been much debate about the role of imaging in ovarian cancer screening based on currently available evidence [1]. Ovarian cancer has low disease prevalence, yet is the leading cause of mortality due to gynecologic malignancy in women in the United States [2]. It is estimated that there will be 22,440 new cancer diagnoses and 14,080 cancer deaths in 2017 [2]. The high mortality rate observed is largely due to late detection, as it is commonly discovered only after its widespread dissemination. Metastatic disease is present in 60% of cases at the time of diagnosis and is associated with a low 5-year relative survival rate of 28% [2]. Only 15% of women have organ-confined disease at the time of detection, and these women have a substantially higher 5-year relative survival rate (92%) [2], suggesting that screening could be of benefit if aggressive cancers can be reliably detected at earlier stages. The average lifetime risk for developing ovarian cancer for a woman in the United States is approximately 1.3% [2]. Women with certain risk factors are known to be at increased risk, including presence of BRCA1 or BRCA2 mutations, strong family history (ie, first-degree relative, particularly if premenopausal at the time of diagnosis), nulliparity, lack of breastfeeding, lack of hormonal contraception use, and postmenopausal status [9]. Among all risk factors, a genetic predisposition is associated with the highest increase in cancer risk. A recent meta-analysis projected that 20-year-old BRCA1 and BRCA2 mutation carriers have 39% and 16% mean cumulative risks of developing ovarian cancer, respectively, by age 70 [10]. At present, risk reduction in women with a strong genetic predisposition to ovarian cancer centers on bilateral salpingo-oophorectomy [11]. | 69463 |
acrac_69463_1 | Ovarian Cancer Screening | By mathematically modeling the behavior of ovarian cancers in hypothetical populations of BRCA mutation carriers and average-risk patients, researchers have gained insight into their natural history and have investigated a potential role for screening [3,4]. Based on their findings, current screening tools are expected to have low effectiveness because of the tendency for small cancers to spread rapidly [3,4]. Brown and Palmer [3], when Reprint requests to: [email protected] Ovarian Cancer Screening modeling serous cancers in high-risk patients, projected that an annual screening tool for ovarian cancer would need to detect tumors as small as 0.5 cm in diameter in order to achieve a 50% mortality reduction. After evaluating the current literature on this topic, there is no clear evidence to support screening women of average risk (no personal history, no family history, no known or suspected genetic predisposition, and no elevated CA-125). However, this document provides an update on areas of investigation that may support a future role for imaging and serum biomarkers in special cases. Overview of Imaging Modalities Most of the peer-reviewed imaging literature on ovarian cancer screening to date has evaluated the use of pelvic ultrasound (US), as it is generally considered the first-line imaging modality for evaluation of the adnexa. US is particularly attractive as a potential screening modality as it is inexpensive and does not expose patients to ionizing radiation. Other cross-sectional imaging methods, including magnetic resonance imaging (MRI), fluorine-18-2-fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET), computed tomography (CT), and FDG-PET/CT, have no known or foreseeable role in screening. Attention has also been directed to the role of CA-125 (a widely known serum tumor biomarker) for screening, either alone or in combination with imaging (eg, US and CA-125). | Ovarian Cancer Screening. By mathematically modeling the behavior of ovarian cancers in hypothetical populations of BRCA mutation carriers and average-risk patients, researchers have gained insight into their natural history and have investigated a potential role for screening [3,4]. Based on their findings, current screening tools are expected to have low effectiveness because of the tendency for small cancers to spread rapidly [3,4]. Brown and Palmer [3], when Reprint requests to: [email protected] Ovarian Cancer Screening modeling serous cancers in high-risk patients, projected that an annual screening tool for ovarian cancer would need to detect tumors as small as 0.5 cm in diameter in order to achieve a 50% mortality reduction. After evaluating the current literature on this topic, there is no clear evidence to support screening women of average risk (no personal history, no family history, no known or suspected genetic predisposition, and no elevated CA-125). However, this document provides an update on areas of investigation that may support a future role for imaging and serum biomarkers in special cases. Overview of Imaging Modalities Most of the peer-reviewed imaging literature on ovarian cancer screening to date has evaluated the use of pelvic ultrasound (US), as it is generally considered the first-line imaging modality for evaluation of the adnexa. US is particularly attractive as a potential screening modality as it is inexpensive and does not expose patients to ionizing radiation. Other cross-sectional imaging methods, including magnetic resonance imaging (MRI), fluorine-18-2-fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET), computed tomography (CT), and FDG-PET/CT, have no known or foreseeable role in screening. Attention has also been directed to the role of CA-125 (a widely known serum tumor biomarker) for screening, either alone or in combination with imaging (eg, US and CA-125). | 69463 |
acrac_69463_2 | Ovarian Cancer Screening | When evaluating the use of an imaging modality for screening, an important metric to consider is positive predictive value (PPV), which is defined as the number of true-positive cases divided by the total number of test- positive cases. Unlike the sensitivity and specificity of a diagnostic test, PPV incorporates both test performance and disease prevalence. A minimum PPV of 10% has been suggested as necessary for an ovarian cancer screening tool [9,12]. This implies that at least one cancer should be diagnosed in every 10 patients who undergo salpingo- oophorectomy for suspicion of malignancy. Given the low prevalence of ovarian cancer, very high specificity is needed for a successful screening tool. At an assumed prevalence of one case per 2,500 postmenopausal women per year, a test with perfect sensitivity (100%) would require a specificity of 99.6% to achieve a 10% PPV, and a test with 50% sensitivity would require an even higher specificity of 99.8% [9,12-14]. Discussion of Procedures by Variant Variant 1: Ovarian cancer screening. Premenopausal. Average risk. To our knowledge, the relevant literature on ovarian cancer screening in average-risk women is limited to studies in postmenopausal women. US There is currently no evidence to support the use of US or color Doppler for ovarian cancer screening in premenopausal women without risk factors. Most studies discussed in this document have addressed the use of transvaginal US. In general, transabdominal US should be reserved for women in whom transvaginal US is not technically feasible, or used as a complement to transvaginal US. CT There is currently no evidence to support the use of CT for ovarian cancer screening in premenopausal women without risk factors. MRI There is currently no evidence to support the use of MRI for ovarian cancer screening in premenopausal women without risk factors. | Ovarian Cancer Screening. When evaluating the use of an imaging modality for screening, an important metric to consider is positive predictive value (PPV), which is defined as the number of true-positive cases divided by the total number of test- positive cases. Unlike the sensitivity and specificity of a diagnostic test, PPV incorporates both test performance and disease prevalence. A minimum PPV of 10% has been suggested as necessary for an ovarian cancer screening tool [9,12]. This implies that at least one cancer should be diagnosed in every 10 patients who undergo salpingo- oophorectomy for suspicion of malignancy. Given the low prevalence of ovarian cancer, very high specificity is needed for a successful screening tool. At an assumed prevalence of one case per 2,500 postmenopausal women per year, a test with perfect sensitivity (100%) would require a specificity of 99.6% to achieve a 10% PPV, and a test with 50% sensitivity would require an even higher specificity of 99.8% [9,12-14]. Discussion of Procedures by Variant Variant 1: Ovarian cancer screening. Premenopausal. Average risk. To our knowledge, the relevant literature on ovarian cancer screening in average-risk women is limited to studies in postmenopausal women. US There is currently no evidence to support the use of US or color Doppler for ovarian cancer screening in premenopausal women without risk factors. Most studies discussed in this document have addressed the use of transvaginal US. In general, transabdominal US should be reserved for women in whom transvaginal US is not technically feasible, or used as a complement to transvaginal US. CT There is currently no evidence to support the use of CT for ovarian cancer screening in premenopausal women without risk factors. MRI There is currently no evidence to support the use of MRI for ovarian cancer screening in premenopausal women without risk factors. | 69463 |
acrac_69463_3 | Ovarian Cancer Screening | FDG-PET/CT There is currently no evidence to support the use of FDG-PET/CT for ovarian cancer screening in premenopausal women without risk factors. Variant 2: Ovarian cancer screening. Postmenopausal. Average risk. US US has been the most heavily investigated imaging modality for ovarian cancer screening to date, both alone and in conjunction with biomarker screening of serum CA-125. Most studies discussed in this document have addressed the use of transvaginal US. In general, transabdominal US should be reserved for women in whom transvaginal US is not technically feasible, or used as a complement to transvaginal US. A recent meta-analysis [15] of 10 randomized trials of ovarian cancer screening using US and/or serum CA-125 measurements found that the included trials did not demonstrate a significant reduction in mortality. Below we describe the studies that are Ovarian Cancer Screening most relevant for decision making concerning ovarian cancer screening in average-risk postmenopausal women. The majority were designed to accrue a dominant population of average-risk postmenopausal women. However, across studies, exclusion criteria intended to exclude high-risk women were heterogeneous. In the University of Kentucky Ovarian Cancer Screening Study, investigators deliberately also included a subset of premenopausal high-risk women, as detailed below. Of note, the methodologic detail provided in the studies described below does not allow for uniform determination of the use, or potential benefits, of color Doppler. Therefore, the benefits of US performed with, versus without, color Doppler cannot be determined. Shizuoka District (Japan) Trial In 2008, Kobayashi et al [17] published a randomized controlled trial in which postmenopausal women were randomized to a control group (n = 40,799) or to five screening rounds of CA-125 and US (n = 41,688). US was predominantly performed using a transvaginal approach. | Ovarian Cancer Screening. FDG-PET/CT There is currently no evidence to support the use of FDG-PET/CT for ovarian cancer screening in premenopausal women without risk factors. Variant 2: Ovarian cancer screening. Postmenopausal. Average risk. US US has been the most heavily investigated imaging modality for ovarian cancer screening to date, both alone and in conjunction with biomarker screening of serum CA-125. Most studies discussed in this document have addressed the use of transvaginal US. In general, transabdominal US should be reserved for women in whom transvaginal US is not technically feasible, or used as a complement to transvaginal US. A recent meta-analysis [15] of 10 randomized trials of ovarian cancer screening using US and/or serum CA-125 measurements found that the included trials did not demonstrate a significant reduction in mortality. Below we describe the studies that are Ovarian Cancer Screening most relevant for decision making concerning ovarian cancer screening in average-risk postmenopausal women. The majority were designed to accrue a dominant population of average-risk postmenopausal women. However, across studies, exclusion criteria intended to exclude high-risk women were heterogeneous. In the University of Kentucky Ovarian Cancer Screening Study, investigators deliberately also included a subset of premenopausal high-risk women, as detailed below. Of note, the methodologic detail provided in the studies described below does not allow for uniform determination of the use, or potential benefits, of color Doppler. Therefore, the benefits of US performed with, versus without, color Doppler cannot be determined. Shizuoka District (Japan) Trial In 2008, Kobayashi et al [17] published a randomized controlled trial in which postmenopausal women were randomized to a control group (n = 40,799) or to five screening rounds of CA-125 and US (n = 41,688). US was predominantly performed using a transvaginal approach. | 69463 |
acrac_69463_4 | Ovarian Cancer Screening | At US, ovaries were considered suspicious for malignancy if ovarian size was >4 cm and a complex morphology was apparent. In the screening group, further management ranged from annual follow-up to surgical intervention, depending on combined test results. Salient trial findings were 2-fold. First, ovarian cancer prevalence was lower (0.31/1,000) than in an expected United States population. Second, a statistically significant shift in stage distribution was not achieved. Ovarian Cancer Screening Lu, Skates, Hernandez, and Colleagues In 2013, Lu et al [22] reported results from a single-arm prospective trial of ovarian cancer screening in 4,051 postmenopausal women using the Risk of Ovarian Cancer Algorithm (ROCA) score based on serum CA-125 measurements (described below). In this trial, women with ROCA scores indicating intermediate risk (risk of ovarian cancer between 1 in 2,000 and 1 in 500) had a repeat CA-125 measurement in 3 months, and women with ROCA scores indicating elevated risk (>1 in 500) were referred for transvaginal US and gynecologic oncology consultation. After 11 years of follow-up, 10 women underwent surgery based on US findings, and 4 of these women were found to have invasive ovarian cancer (PPV, 40%). Specificity was 99.9%. These results support the notion that assessment of changing levels in biomarkers over time may be a more useful screening tool than single values, such as those used in the PLCO trial, and can improve PPV and specificity. However, this trial was not designed to assess mortality outcomes. United Kingdom Collaborative Trial of Ovarian Cancer Screening The United Kingdom Collaborative Trial of Ovarian Cancer Screening [23,24] is the largest randomized controlled trial of ovarian cancer screening to date, with over 200,000 postmenopausal women randomized to either a control group, multimodal screening (ie, annual CA-125 with transvaginal US as a follow-up test), or annual transvaginal US alone. | Ovarian Cancer Screening. At US, ovaries were considered suspicious for malignancy if ovarian size was >4 cm and a complex morphology was apparent. In the screening group, further management ranged from annual follow-up to surgical intervention, depending on combined test results. Salient trial findings were 2-fold. First, ovarian cancer prevalence was lower (0.31/1,000) than in an expected United States population. Second, a statistically significant shift in stage distribution was not achieved. Ovarian Cancer Screening Lu, Skates, Hernandez, and Colleagues In 2013, Lu et al [22] reported results from a single-arm prospective trial of ovarian cancer screening in 4,051 postmenopausal women using the Risk of Ovarian Cancer Algorithm (ROCA) score based on serum CA-125 measurements (described below). In this trial, women with ROCA scores indicating intermediate risk (risk of ovarian cancer between 1 in 2,000 and 1 in 500) had a repeat CA-125 measurement in 3 months, and women with ROCA scores indicating elevated risk (>1 in 500) were referred for transvaginal US and gynecologic oncology consultation. After 11 years of follow-up, 10 women underwent surgery based on US findings, and 4 of these women were found to have invasive ovarian cancer (PPV, 40%). Specificity was 99.9%. These results support the notion that assessment of changing levels in biomarkers over time may be a more useful screening tool than single values, such as those used in the PLCO trial, and can improve PPV and specificity. However, this trial was not designed to assess mortality outcomes. United Kingdom Collaborative Trial of Ovarian Cancer Screening The United Kingdom Collaborative Trial of Ovarian Cancer Screening [23,24] is the largest randomized controlled trial of ovarian cancer screening to date, with over 200,000 postmenopausal women randomized to either a control group, multimodal screening (ie, annual CA-125 with transvaginal US as a follow-up test), or annual transvaginal US alone. | 69463 |
acrac_69463_5 | Ovarian Cancer Screening | US results were considered abnormal if ovaries demonstrated a complex morphology or had simple cysts >60 mL or if ascites was present [24]. Rather than using standard single cutoffs for CA-125 positivity, CA-125 results were designated based on the ROCA algorithm described by Menon et al [25] in earlier work. This algorithm incorporates patient age and CA-125 trends to triage further management, and it is expected to improve CA-125 test performance, particularly its PPV and specificity [25]. MRI To our knowledge, there have been no trials evaluating the use of MRI for ovarian cancer screening in women at average risk. Although MRI is a valuable tool for characterizing adnexal masses that are indeterminate based on US features [26], there has been little interest in its use as a population screening tool given its cost and unclear advantage. CT To our knowledge, there have been no trials evaluating the use of CT for ovarian cancer screening in women at average risk. CT is routinely used for ovarian cancer staging to assess for distant metastases, but it has limited use in the evaluation of the adnexa given its limited ability to distinguish between benign and malignant lesions. For example, in a study of 2,869 postmenopausal women undergoing CT screening colonography [27], 118 (4.1% of the cohort) had incidentally detected adnexal lesions noted at interpretation. Of these, 80 were referred for additional imaging workup and/or surgery. In the 26 women who underwent surgical excision, no ovarian cancers were identified. Furthermore, four women in the cohort subsequently developed ovarian cancer after a negative CT evaluation. The limited discriminatory ability of CT renders it impractical for use as a screening tool in this setting. FDG-PET/CT To our knowledge, there have been no trials evaluating the use of FDG-PET/CT for ovarian cancer screening in women at average risk. | Ovarian Cancer Screening. US results were considered abnormal if ovaries demonstrated a complex morphology or had simple cysts >60 mL or if ascites was present [24]. Rather than using standard single cutoffs for CA-125 positivity, CA-125 results were designated based on the ROCA algorithm described by Menon et al [25] in earlier work. This algorithm incorporates patient age and CA-125 trends to triage further management, and it is expected to improve CA-125 test performance, particularly its PPV and specificity [25]. MRI To our knowledge, there have been no trials evaluating the use of MRI for ovarian cancer screening in women at average risk. Although MRI is a valuable tool for characterizing adnexal masses that are indeterminate based on US features [26], there has been little interest in its use as a population screening tool given its cost and unclear advantage. CT To our knowledge, there have been no trials evaluating the use of CT for ovarian cancer screening in women at average risk. CT is routinely used for ovarian cancer staging to assess for distant metastases, but it has limited use in the evaluation of the adnexa given its limited ability to distinguish between benign and malignant lesions. For example, in a study of 2,869 postmenopausal women undergoing CT screening colonography [27], 118 (4.1% of the cohort) had incidentally detected adnexal lesions noted at interpretation. Of these, 80 were referred for additional imaging workup and/or surgery. In the 26 women who underwent surgical excision, no ovarian cancers were identified. Furthermore, four women in the cohort subsequently developed ovarian cancer after a negative CT evaluation. The limited discriminatory ability of CT renders it impractical for use as a screening tool in this setting. FDG-PET/CT To our knowledge, there have been no trials evaluating the use of FDG-PET/CT for ovarian cancer screening in women at average risk. | 69463 |
acrac_69463_6 | Ovarian Cancer Screening | Although FDG-PET/CT is an important oncologic imaging tool for cancer staging and detection of recurrence, it has no clear value for detecting ovarian cancer in asymptomatic individuals. In a Ovarian Cancer Screening systematic review of imaging modalities for preoperative evaluation of adnexal lesions, the sensitivity of PET was substantially lower than that of US or MRI [28], possibly because of the composition of ovarian neoplasms, many of which tend to be predominantly cystic with small solid components that may be below the size threshold for detection by PET. Variant 3: Ovarian cancer screening. Premenopausal. High risk (personal history or family history or known or suspected genetic predisposition or elevated CA-125). US Most studies discussed in this document have addressed the use of transvaginal US. In general, transabdominal US should be reserved for women in whom transvaginal US is not technically feasible, or used as a complement to transvaginal US. The University of Kentucky Ovarian Cancer Screening Study cohort [20] also included premenopausal women with a family history of ovarian cancer. The study results were reported in aggregate for patients with and without a family history of ovarian cancer. However, the authors note that there was no significant difference in the incidence of malignant or benign ovarian tumors between these groups. Although the results of this single-arm study were promising, a definitive mortality reduction has not been observed in randomized controlled trials [18,23]. MRI To our knowledge, there are no trials for the use of MRI as an ovarian cancer screening tool in high-risk women. MRI is unlikely to be investigated as a screening tool. CT To our knowledge, there are no trials of the use of CT as an ovarian cancer screening tool in high-risk women. | Ovarian Cancer Screening. Although FDG-PET/CT is an important oncologic imaging tool for cancer staging and detection of recurrence, it has no clear value for detecting ovarian cancer in asymptomatic individuals. In a Ovarian Cancer Screening systematic review of imaging modalities for preoperative evaluation of adnexal lesions, the sensitivity of PET was substantially lower than that of US or MRI [28], possibly because of the composition of ovarian neoplasms, many of which tend to be predominantly cystic with small solid components that may be below the size threshold for detection by PET. Variant 3: Ovarian cancer screening. Premenopausal. High risk (personal history or family history or known or suspected genetic predisposition or elevated CA-125). US Most studies discussed in this document have addressed the use of transvaginal US. In general, transabdominal US should be reserved for women in whom transvaginal US is not technically feasible, or used as a complement to transvaginal US. The University of Kentucky Ovarian Cancer Screening Study cohort [20] also included premenopausal women with a family history of ovarian cancer. The study results were reported in aggregate for patients with and without a family history of ovarian cancer. However, the authors note that there was no significant difference in the incidence of malignant or benign ovarian tumors between these groups. Although the results of this single-arm study were promising, a definitive mortality reduction has not been observed in randomized controlled trials [18,23]. MRI To our knowledge, there are no trials for the use of MRI as an ovarian cancer screening tool in high-risk women. MRI is unlikely to be investigated as a screening tool. CT To our knowledge, there are no trials of the use of CT as an ovarian cancer screening tool in high-risk women. | 69463 |
acrac_69463_7 | Ovarian Cancer Screening | CT has a limited role in the evaluation of adnexal lesions and would be an impractical screening modality because of its poor discriminatory ability between benign and malignant adnexal lesions and the associated risks of ionizing radiation. FDG-PET/CT To our knowledge, there have been no trials evaluating the use of FDG-PET/CT as an ovarian cancer screening tool in high-risk women. FDG-PET/CT has poor performance in this setting and is impractical as a screening modality. Ovarian Cancer Screening Variant 4: Ovarian cancer screening. Postmenopausal. High risk (personal history or family history or known or suspected genetic predisposition or elevated CA-125). US Most studies discussed in this document have addressed the use of transvaginal US. In general, transabdominal US should be reserved for women in whom transvaginal US is not technically feasible, or used as a complement to transvaginal US. To our knowledge, randomized controlled trials analogous to those in average-risk populations have not been conducted in definitively high-risk populations. Several related studies have been reported, all relatively small in sample size and most of which include a mix of premenopausal and postmenopausal women at high risk [29-33]. In 2006, Lacey et al [35] performed a secondary analysis of PLCO data to compare, within the screening arm, differences in screening outcomes (after the first four rounds of screening) between women of varying risk for ovarian cancer. Risk was classified based on personal history of breast cancer and family history of breast or ovarian cancer. Although the PPV of screening was marginally higher for women in specified moderate- and high-risk groups compared to those at average risk (PPV of 1.3% and 1.6% in the moderate- and high-risk groups, respectively, compared to 0.7% in the average-risk group), this difference was not statistically significant. | Ovarian Cancer Screening. CT has a limited role in the evaluation of adnexal lesions and would be an impractical screening modality because of its poor discriminatory ability between benign and malignant adnexal lesions and the associated risks of ionizing radiation. FDG-PET/CT To our knowledge, there have been no trials evaluating the use of FDG-PET/CT as an ovarian cancer screening tool in high-risk women. FDG-PET/CT has poor performance in this setting and is impractical as a screening modality. Ovarian Cancer Screening Variant 4: Ovarian cancer screening. Postmenopausal. High risk (personal history or family history or known or suspected genetic predisposition or elevated CA-125). US Most studies discussed in this document have addressed the use of transvaginal US. In general, transabdominal US should be reserved for women in whom transvaginal US is not technically feasible, or used as a complement to transvaginal US. To our knowledge, randomized controlled trials analogous to those in average-risk populations have not been conducted in definitively high-risk populations. Several related studies have been reported, all relatively small in sample size and most of which include a mix of premenopausal and postmenopausal women at high risk [29-33]. In 2006, Lacey et al [35] performed a secondary analysis of PLCO data to compare, within the screening arm, differences in screening outcomes (after the first four rounds of screening) between women of varying risk for ovarian cancer. Risk was classified based on personal history of breast cancer and family history of breast or ovarian cancer. Although the PPV of screening was marginally higher for women in specified moderate- and high-risk groups compared to those at average risk (PPV of 1.3% and 1.6% in the moderate- and high-risk groups, respectively, compared to 0.7% in the average-risk group), this difference was not statistically significant. | 69463 |
acrac_69463_8 | Ovarian Cancer Screening | In 2016, Lai et al [36] published a subgroup analysis of PLCO data to determine whether annual screening with pelvic US and serum CA-125 reduced ovarian cancer mortality in a subgroup of women with a first-degree relative with breast or ovarian cancer. The authors compared outcomes for 11,293 women in the screening group and 11,062 women in the control group, who were followed for a minimum of 10 years. As seen in the parent PLCO study, there was no significant difference in ovarian cancer mortality between the screening and control groups. There was evidence of a stage shift and improved survival among patients with ovarian cancer in the screening group (relative risk, 0.66; 95% CI, 0.47-0.93). The authors acknowledged the potential for standard epidemiologic biases to affect their results, despite specific methodologic measures taken, and emphasized the need for further related investigation in high-risk individuals. MRI To our knowledge, there are no trials for the use of MRI as an ovarian cancer screening tool in high-risk women. MRI is unlikely to be investigated as a screening tool. CT To our knowledge, there are no trials of the use of CT as an ovarian cancer screening tool in high-risk women. CT has a limited role in the evaluation of adnexal lesions and would be an impractical screening modality because of its poor discriminatory ability between benign and malignant adnexal lesions and the associated risks of ionizing radiation. Ovarian Cancer Screening FDG-PET/CT To our knowledge, there are no trials of the use FDG-PET/CT as an ovarian cancer screening tool in high-risk women. FDG-PET/CT has poor performance in this setting and is impractical as a screening modality. Summary of Recommendations Ovarian cancer screening is not recommended for average-risk premenopausal women. Ovarian cancer screening is not recommended for average-risk postmenopausal women, as randomized controlled trials have not demonstrated a definitive mortality benefit in this population. | Ovarian Cancer Screening. In 2016, Lai et al [36] published a subgroup analysis of PLCO data to determine whether annual screening with pelvic US and serum CA-125 reduced ovarian cancer mortality in a subgroup of women with a first-degree relative with breast or ovarian cancer. The authors compared outcomes for 11,293 women in the screening group and 11,062 women in the control group, who were followed for a minimum of 10 years. As seen in the parent PLCO study, there was no significant difference in ovarian cancer mortality between the screening and control groups. There was evidence of a stage shift and improved survival among patients with ovarian cancer in the screening group (relative risk, 0.66; 95% CI, 0.47-0.93). The authors acknowledged the potential for standard epidemiologic biases to affect their results, despite specific methodologic measures taken, and emphasized the need for further related investigation in high-risk individuals. MRI To our knowledge, there are no trials for the use of MRI as an ovarian cancer screening tool in high-risk women. MRI is unlikely to be investigated as a screening tool. CT To our knowledge, there are no trials of the use of CT as an ovarian cancer screening tool in high-risk women. CT has a limited role in the evaluation of adnexal lesions and would be an impractical screening modality because of its poor discriminatory ability between benign and malignant adnexal lesions and the associated risks of ionizing radiation. Ovarian Cancer Screening FDG-PET/CT To our knowledge, there are no trials of the use FDG-PET/CT as an ovarian cancer screening tool in high-risk women. FDG-PET/CT has poor performance in this setting and is impractical as a screening modality. Summary of Recommendations Ovarian cancer screening is not recommended for average-risk premenopausal women. Ovarian cancer screening is not recommended for average-risk postmenopausal women, as randomized controlled trials have not demonstrated a definitive mortality benefit in this population. | 69463 |
acrac_69423_0 | Chronic Elbow Pain | Imaging plays an important role in assessment of chronic elbow pain. Electromyography assists in the workup related to nerve symptoms. Management for epicondylalgia and osteoarthritis includes conservative measures such as rest, activity modification, analgesia, physical therapy, and corticosteroid injections. Surgery may be indicated for more severe or refractory cases and cases of collateral ligament injury, biceps injury, cubital tunnel syndrome, or osteochondral abnormalities. Special Imaging Considerations Stress radiographs to detect medial joint line opening and/or asymmetry to the contralateral elbow are available to evaluate valgus instability of the elbow. OR aPenn State Milton S. Hershey Medical Center, Hershey, Pennsylvania. bPanel Chair, VA San Diego Healthcare System, San Diego, California. cPanel Vice- Chair, University of Washington, Seattle, Washington. dWeill Cornell Medical College, New York, New York. eUniversity of California San Francisco, San Francisco, California. fMoffitt Cancer Center and University of South Florida Morsani College of Medicine, Tampa, Florida; MSK-RADS (Bone) Committee. gVA San Diego Healthcare System, San Diego, California. hMayo Clinic Arizona, Phoenix, Arizona. iUniversity of Texas Health Science Center, Houston, Texas; Committee on Emergency Radiology-GSER. jThe Centers for Advanced Orthopaedics, George Washington University, Washington, DC and Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland; American Academy of Orthopaedic Surgeons. kUniversity of Wisconsin School of Medicine & Public Health, Madison, Wisconsin. lPenn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, Primary care physician. mThe University of Texas MD Anderson Cancer Center, Houston, Texas; Commission on Nuclear Medicine and Molecular Imaging. nSpecialty Chair, University of Kentucky, Lexington, Kentucky. | Chronic Elbow Pain. Imaging plays an important role in assessment of chronic elbow pain. Electromyography assists in the workup related to nerve symptoms. Management for epicondylalgia and osteoarthritis includes conservative measures such as rest, activity modification, analgesia, physical therapy, and corticosteroid injections. Surgery may be indicated for more severe or refractory cases and cases of collateral ligament injury, biceps injury, cubital tunnel syndrome, or osteochondral abnormalities. Special Imaging Considerations Stress radiographs to detect medial joint line opening and/or asymmetry to the contralateral elbow are available to evaluate valgus instability of the elbow. OR aPenn State Milton S. Hershey Medical Center, Hershey, Pennsylvania. bPanel Chair, VA San Diego Healthcare System, San Diego, California. cPanel Vice- Chair, University of Washington, Seattle, Washington. dWeill Cornell Medical College, New York, New York. eUniversity of California San Francisco, San Francisco, California. fMoffitt Cancer Center and University of South Florida Morsani College of Medicine, Tampa, Florida; MSK-RADS (Bone) Committee. gVA San Diego Healthcare System, San Diego, California. hMayo Clinic Arizona, Phoenix, Arizona. iUniversity of Texas Health Science Center, Houston, Texas; Committee on Emergency Radiology-GSER. jThe Centers for Advanced Orthopaedics, George Washington University, Washington, DC and Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland; American Academy of Orthopaedic Surgeons. kUniversity of Wisconsin School of Medicine & Public Health, Madison, Wisconsin. lPenn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, Primary care physician. mThe University of Texas MD Anderson Cancer Center, Houston, Texas; Commission on Nuclear Medicine and Molecular Imaging. nSpecialty Chair, University of Kentucky, Lexington, Kentucky. | 69423 |
acrac_69423_1 | Chronic Elbow Pain | The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through representation of such organizations on expert panels. Participation on the expert panel does not necessarily imply endorsement of the final document by individual contributors or their respective organization. Reprint requests to: [email protected] Chronic Elbow Pain Discussion of Procedures by Variant Variant 1: Chronic elbow pain. Initial imaging. 3-Phase Bone Scan Elbow There is limited evidence to support the use of 3-phase bone scan as the initial imaging study for the evaluation of chronic elbow pain. CT Arthrography Elbow There is limited evidence to support the use of CT arthrography elbow as the initial imaging study for the evaluation of chronic elbow pain. CT Elbow There is limited evidence to support the use of CT elbow as the initial imaging study for the evaluation of chronic elbow pain. MR Arthrography Elbow There is limited evidence to support the use of MR arthrography elbow as the initial imaging study for the evaluation of chronic elbow pain. MRI Elbow There is limited evidence to support the use of MRI elbow as the initial imaging study for the evaluation of chronic elbow pain. Radiography Elbow Radiographs are beneficial as the initial imaging for chronic elbow pain. Radiographs may show intra-articular bodies, heterotopic ossification, osteochondral lesion, soft tissue calcification, occult fracture, or osteoarthritis. Radiographs complement subsequent MRI elbow examination [4]. Radiographs have been shown to aide the diagnosis of valgus instability [5] and ulnar collateral ligament (UCL) injury [6]. Comparison with the asymptomatic side is often useful [7]. US Elbow There is limited evidence to support the use of ultrasound (US) elbow as the initial imaging study for the evaluation of chronic elbow pain. Variant 2: Chronic elbow pain with mechanical symptoms such as locking, clicking, or limited range of motion. | Chronic Elbow Pain. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through representation of such organizations on expert panels. Participation on the expert panel does not necessarily imply endorsement of the final document by individual contributors or their respective organization. Reprint requests to: [email protected] Chronic Elbow Pain Discussion of Procedures by Variant Variant 1: Chronic elbow pain. Initial imaging. 3-Phase Bone Scan Elbow There is limited evidence to support the use of 3-phase bone scan as the initial imaging study for the evaluation of chronic elbow pain. CT Arthrography Elbow There is limited evidence to support the use of CT arthrography elbow as the initial imaging study for the evaluation of chronic elbow pain. CT Elbow There is limited evidence to support the use of CT elbow as the initial imaging study for the evaluation of chronic elbow pain. MR Arthrography Elbow There is limited evidence to support the use of MR arthrography elbow as the initial imaging study for the evaluation of chronic elbow pain. MRI Elbow There is limited evidence to support the use of MRI elbow as the initial imaging study for the evaluation of chronic elbow pain. Radiography Elbow Radiographs are beneficial as the initial imaging for chronic elbow pain. Radiographs may show intra-articular bodies, heterotopic ossification, osteochondral lesion, soft tissue calcification, occult fracture, or osteoarthritis. Radiographs complement subsequent MRI elbow examination [4]. Radiographs have been shown to aide the diagnosis of valgus instability [5] and ulnar collateral ligament (UCL) injury [6]. Comparison with the asymptomatic side is often useful [7]. US Elbow There is limited evidence to support the use of ultrasound (US) elbow as the initial imaging study for the evaluation of chronic elbow pain. Variant 2: Chronic elbow pain with mechanical symptoms such as locking, clicking, or limited range of motion. | 69423 |
acrac_69423_2 | Chronic Elbow Pain | Suspect intra-articular pathology such as osteocartilaginous body, osteochondral lesion, or synovial abnormality. Radiographs normal or nonspecific. Next imaging study. 3-Phase Bone Scan Elbow There is limited evidence to support the routine use of 3-phase bone scan elbow for evaluation of osteochondral bodies, osteochondral lesions, or synovial abnormalities. However, the early phase of a 3-phase bone scan can identify the inflammatory component of heterotopic ossification. The delayed images demonstrate increased tracer uptake due to bone formation [8,9]. CT Arthrography Elbow CT arthrography elbow is useful in the assessment of heterotopic ossification, loose bodies, and osteoarthritis. CT elbow has a sensitivity and specificity of 93% and 66% for detection of loose bodies [10]. It has a reported accuracy of 79% for the detection of loose bodies and 76% for osteophytes [10]. However, small intra-articular bodies may be obscured by contrast. CT arthrography is helpful for evaluation of osteochondral lesion stability [11]. CT Elbow CT elbow is useful in the assessment of heterotopic ossification, loose bodies, and osteophytosis. CT elbow has a sensitivity and specificity of 93% and 66% for the detection of loose bodies [10]. CT elbow without intravenous (IV) contrast is less useful than CT arthrography elbow for the assessment of osteochondral lesion stability. MR Arthrography Elbow MRI arthrography elbow is useful for detection of intra-articular bodies, with a reported sensitivity of 100% and a specificity of 67% [12]. MR arthrography elbow also plays an important role in evaluation of osteochondral lesion stability [13,14]. MRI may also show the presence of enlarged synovial plica, which can result in symptoms of locking and/or pain with extension [15]. However, MR arthrography elbow is limited in the detection of cartilage Chronic Elbow Pain abnormalities. Accuracy is reported as 45% for the radius, 64% for the capitellum, 18% for the ulna, and 27% for the trochlea [16]. | Chronic Elbow Pain. Suspect intra-articular pathology such as osteocartilaginous body, osteochondral lesion, or synovial abnormality. Radiographs normal or nonspecific. Next imaging study. 3-Phase Bone Scan Elbow There is limited evidence to support the routine use of 3-phase bone scan elbow for evaluation of osteochondral bodies, osteochondral lesions, or synovial abnormalities. However, the early phase of a 3-phase bone scan can identify the inflammatory component of heterotopic ossification. The delayed images demonstrate increased tracer uptake due to bone formation [8,9]. CT Arthrography Elbow CT arthrography elbow is useful in the assessment of heterotopic ossification, loose bodies, and osteoarthritis. CT elbow has a sensitivity and specificity of 93% and 66% for detection of loose bodies [10]. It has a reported accuracy of 79% for the detection of loose bodies and 76% for osteophytes [10]. However, small intra-articular bodies may be obscured by contrast. CT arthrography is helpful for evaluation of osteochondral lesion stability [11]. CT Elbow CT elbow is useful in the assessment of heterotopic ossification, loose bodies, and osteophytosis. CT elbow has a sensitivity and specificity of 93% and 66% for the detection of loose bodies [10]. CT elbow without intravenous (IV) contrast is less useful than CT arthrography elbow for the assessment of osteochondral lesion stability. MR Arthrography Elbow MRI arthrography elbow is useful for detection of intra-articular bodies, with a reported sensitivity of 100% and a specificity of 67% [12]. MR arthrography elbow also plays an important role in evaluation of osteochondral lesion stability [13,14]. MRI may also show the presence of enlarged synovial plica, which can result in symptoms of locking and/or pain with extension [15]. However, MR arthrography elbow is limited in the detection of cartilage Chronic Elbow Pain abnormalities. Accuracy is reported as 45% for the radius, 64% for the capitellum, 18% for the ulna, and 27% for the trochlea [16]. | 69423 |
acrac_69423_3 | Chronic Elbow Pain | MRI Elbow MRI elbow may detect loose bodies, and this is enhanced in the presence of joint fluid. Thus, T2-weighted images are recommended for the evaluation of loose bodies in the elbow [17]. MRI may also show the presence of enlarged plica, which can result in symptoms of locking and/or pain with extension [15]. MRI is often suggested as the initial study to assess for osteochondral lesion [12,17]. MRI is less sensitive than radiographs in the detection of heterotopic ossification/calcification [18]. Similar to MR arthrography, MRI elbow is limited in the evaluation of cartilage defects [16]. US Elbow Although US may demonstrate early-stage osteochondral lesions and medial epicondylar fragmentation [10], the details of an osteochondral lesion are better defined by CT arthrography or MR arthrography. Because of shadowing, evaluation of heterotopic ossification and loose bodies is limited on US. Variant 3: Chronic elbow pain. Suspect occult stress fracture or other bone abnormality. Radiographs normal or nonspecific. Next imaging study. 3-Phase Bone Scan Elbow Bone scan is extremely sensitive for detection of stress fractures and trauma related fractures [19-21]. Radiopharmaceutical uptake occurs in areas of active bone turnover, and thus, imaging may be positive in the presymptomatic stage of stress injuries [20]. CT Arthrography Elbow There is limited evidence to the support the use of CT arthrography elbow for the detection of occult fractures following radiographs. CT Elbow CT elbow is helpful in identifying complex fracture patterns, the origin of dislocated fragments, and positions of displaced fragments [22]. However, it has poor sensitivity in the detection of early stress fractures [20]. MR Arthrography Elbow There is limited evidence to the support the use of MR arthrography elbow for the detection of occult fractures following radiographs. MRI Elbow MRI is as sensitive as 3-phase bone scan for detection of stress fractures [20]. | Chronic Elbow Pain. MRI Elbow MRI elbow may detect loose bodies, and this is enhanced in the presence of joint fluid. Thus, T2-weighted images are recommended for the evaluation of loose bodies in the elbow [17]. MRI may also show the presence of enlarged plica, which can result in symptoms of locking and/or pain with extension [15]. MRI is often suggested as the initial study to assess for osteochondral lesion [12,17]. MRI is less sensitive than radiographs in the detection of heterotopic ossification/calcification [18]. Similar to MR arthrography, MRI elbow is limited in the evaluation of cartilage defects [16]. US Elbow Although US may demonstrate early-stage osteochondral lesions and medial epicondylar fragmentation [10], the details of an osteochondral lesion are better defined by CT arthrography or MR arthrography. Because of shadowing, evaluation of heterotopic ossification and loose bodies is limited on US. Variant 3: Chronic elbow pain. Suspect occult stress fracture or other bone abnormality. Radiographs normal or nonspecific. Next imaging study. 3-Phase Bone Scan Elbow Bone scan is extremely sensitive for detection of stress fractures and trauma related fractures [19-21]. Radiopharmaceutical uptake occurs in areas of active bone turnover, and thus, imaging may be positive in the presymptomatic stage of stress injuries [20]. CT Arthrography Elbow There is limited evidence to the support the use of CT arthrography elbow for the detection of occult fractures following radiographs. CT Elbow CT elbow is helpful in identifying complex fracture patterns, the origin of dislocated fragments, and positions of displaced fragments [22]. However, it has poor sensitivity in the detection of early stress fractures [20]. MR Arthrography Elbow There is limited evidence to the support the use of MR arthrography elbow for the detection of occult fractures following radiographs. MRI Elbow MRI is as sensitive as 3-phase bone scan for detection of stress fractures [20]. | 69423 |
acrac_69423_4 | Chronic Elbow Pain | MRI findings include bone marrow edema and/or periosteal fluid at the site of abnormality [20]. MRI elbow has the advantage of demonstrating associated soft tissue injuries. US Elbow US can demonstrate a lipohemarthrosis in children with occult elbow fractures [23]. However, poor penetration of sound through the bone limits characterization of fractures. Variant 4: Chronic elbow pain. Suspect chronic epicondylalgia or tendon tear. Refractory to empirical treatment. Radiographs normal or nonspecific. Next imaging study. 3-Phase Bone Scan Elbow Although there is limited evidence to support the routine use of 3-phase bone scan in this setting, bone scans can detect chronic epicondylalgia [24]. CT Arthrography Elbow There is limited evidence to the support the use of CT arthrography elbow for the detection of tendon tears or chronic epicondylalgia. CT Elbow There is limited evidence to the support the use of CT elbow for detection of tendon tears or chronic epicondylalgia. MR Arthrography Elbow MR arthrography does not add additional information compared with noncontrast MRI for the diagnosis of biceps tendon tear or chronic epicondylalgia [25]. Chronic Elbow Pain MRI Elbow MRI has high inter- and intraobserver reliability for the diagnosis of epicondylalgia [26]. It also has a sensitivity of 90% to 100% and a specificity of 83% to 100% [27]. The most specific findings of medial epicondylalgia include intermediate to high T2 signal or high T2 signal within the common flexor tendon and paratendinous soft tissue edema [28]. MRI has the benefit of demonstrating associated findings in epicondylalgia, including radial collateral and lateral UCL injuries [26]. MRI may also facilitate surgical planning [29]. MRI is useful for the diagnosis of biceps tendon injury. Sensitivity and specificity are reported at 92.4% and 100%, respectively, in detecting distal biceps tendon ruptures and 59.1% and 100%, respectively for partial tears [30]. | Chronic Elbow Pain. MRI findings include bone marrow edema and/or periosteal fluid at the site of abnormality [20]. MRI elbow has the advantage of demonstrating associated soft tissue injuries. US Elbow US can demonstrate a lipohemarthrosis in children with occult elbow fractures [23]. However, poor penetration of sound through the bone limits characterization of fractures. Variant 4: Chronic elbow pain. Suspect chronic epicondylalgia or tendon tear. Refractory to empirical treatment. Radiographs normal or nonspecific. Next imaging study. 3-Phase Bone Scan Elbow Although there is limited evidence to support the routine use of 3-phase bone scan in this setting, bone scans can detect chronic epicondylalgia [24]. CT Arthrography Elbow There is limited evidence to the support the use of CT arthrography elbow for the detection of tendon tears or chronic epicondylalgia. CT Elbow There is limited evidence to the support the use of CT elbow for detection of tendon tears or chronic epicondylalgia. MR Arthrography Elbow MR arthrography does not add additional information compared with noncontrast MRI for the diagnosis of biceps tendon tear or chronic epicondylalgia [25]. Chronic Elbow Pain MRI Elbow MRI has high inter- and intraobserver reliability for the diagnosis of epicondylalgia [26]. It also has a sensitivity of 90% to 100% and a specificity of 83% to 100% [27]. The most specific findings of medial epicondylalgia include intermediate to high T2 signal or high T2 signal within the common flexor tendon and paratendinous soft tissue edema [28]. MRI has the benefit of demonstrating associated findings in epicondylalgia, including radial collateral and lateral UCL injuries [26]. MRI may also facilitate surgical planning [29]. MRI is useful for the diagnosis of biceps tendon injury. Sensitivity and specificity are reported at 92.4% and 100%, respectively, in detecting distal biceps tendon ruptures and 59.1% and 100%, respectively for partial tears [30]. | 69423 |
acrac_69423_5 | Chronic Elbow Pain | US Elbow US elbow has moderate agreement with MR elbow for the diagnosis and grading of common extensor tendon tears. US sensitivity, specificity, and accuracy are reported at 64.25%, 85.19%, and 72.73%, respectively [31]. Recently, sonoelastography has shown more promising outcomes for detection of medial epicondylalgia with a sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of 95.2%, 92%, 93.5%, 90.9%, and 95.8%, respectively [32]. Another new technique, superb microvascular imaging, can be used to detect subtle low blood flow. The combination of superb microvascular imaging with conventional US performed best for the diagnosis of epicondylalgia, with sensitivity of 94%, specificity of 98%, accuracy of 96% [33]. US is also useful for detection of biceps tendon abnormalities. It performs similar to slightly better than MRI for the diagnosis of distal biceps brachii tendon tear [34]. Reports show 95% sensitivity, 71% specificity, and 91% accuracy for the diagnosis of complete versus partial distal biceps tendon tears with US [35]. Variant 5: Chronic elbow pain. Suspect collateral ligament tear. Radiographs normal or nonspecific. Next imaging study. 3-Phase Bone Scan Elbow There is limited evidence to support the routine use of 3-phase bone scan for the diagnosis of collateral ligament injury following radiographs. CT Arthrography Elbow CT arthrography has a sensitivity of 86%. The sensitivity for full-thickness tears and partial tears is reported at 100% and 71%, respectively. The overall specificity is 91% [36]. CT Elbow There is limited evidence to support the routine use of CT elbow for the diagnosis of collateral ligament injury following radiographs. MR Arthrography Elbow MR arthrography elbow is accurate for the diagnosis of collateral ligament injuries [37]. At 3T, it is more accurate than noncontrast MRI [38]. The reported sensitivity, specificity, and accuracy for UCL tears are 81%, 91%, and 88%, respectively [39]. | Chronic Elbow Pain. US Elbow US elbow has moderate agreement with MR elbow for the diagnosis and grading of common extensor tendon tears. US sensitivity, specificity, and accuracy are reported at 64.25%, 85.19%, and 72.73%, respectively [31]. Recently, sonoelastography has shown more promising outcomes for detection of medial epicondylalgia with a sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of 95.2%, 92%, 93.5%, 90.9%, and 95.8%, respectively [32]. Another new technique, superb microvascular imaging, can be used to detect subtle low blood flow. The combination of superb microvascular imaging with conventional US performed best for the diagnosis of epicondylalgia, with sensitivity of 94%, specificity of 98%, accuracy of 96% [33]. US is also useful for detection of biceps tendon abnormalities. It performs similar to slightly better than MRI for the diagnosis of distal biceps brachii tendon tear [34]. Reports show 95% sensitivity, 71% specificity, and 91% accuracy for the diagnosis of complete versus partial distal biceps tendon tears with US [35]. Variant 5: Chronic elbow pain. Suspect collateral ligament tear. Radiographs normal or nonspecific. Next imaging study. 3-Phase Bone Scan Elbow There is limited evidence to support the routine use of 3-phase bone scan for the diagnosis of collateral ligament injury following radiographs. CT Arthrography Elbow CT arthrography has a sensitivity of 86%. The sensitivity for full-thickness tears and partial tears is reported at 100% and 71%, respectively. The overall specificity is 91% [36]. CT Elbow There is limited evidence to support the routine use of CT elbow for the diagnosis of collateral ligament injury following radiographs. MR Arthrography Elbow MR arthrography elbow is accurate for the diagnosis of collateral ligament injuries [37]. At 3T, it is more accurate than noncontrast MRI [38]. The reported sensitivity, specificity, and accuracy for UCL tears are 81%, 91%, and 88%, respectively [39]. | 69423 |
acrac_69423_6 | Chronic Elbow Pain | MR arthrography may also assist in differentiation between partial and complete UCL tear [40,41]. Presence of soft tissue and bone marrow edema occurs more often in symptomatic patients [42]. Additionally, a more distal ligamentous insertion of the UCL (T sign) has recently been suggested to result from repetitive overhead activity and injury rather than representing a normal anatomic variant [42]. In patients with posterolateral rotatory instability, MR arthrography can assess the integrity of the ulnar band of the radial collateral ligament [43] and demonstrate radiocapitellar incongruity [44]. MRI Elbow A 3T MR arthrography is more accurate than noncontrast MRI elbow for detection of collateral ligament injuries [38]. Radiography Elbow Stress View Measurement of medial joint space opening on stress radiographs correlates with severity of UCL injury in throwing athletes [6]. Additionally, medial joint vacuum phenomenon on valgus stress radiographs is specific for UCL injury [45]. However, radiographs do not directly provide information on the location of collateral ligament injury or associated soft tissue injuries as can be done on MR arthrography. Chronic Elbow Pain US Elbow For full-thickness UCL tears, conventional US has a sensitivity of 79%, a specificity of 98%, and an accuracy of 95% (38). For partial thickness UCL tears, conventional US has a sensitivity of 77%, a specificity of 94%, and an accuracy of 90% (38). Stress US can accurately detect UCL tears when there is medial joint gapping [46,47]. The sensitivity and specificity of valgus stress US for all UCL tears is 96% and 81%, respectively [36]. Variant 6: Chronic elbow pain. Suspect nerve abnormality. Radiographs normal or nonspecific. Next imaging study. 3-Phase Bone Scan Elbow There is limited evidence to support the routine use of 3-phase bone scan elbow for nerve abnormalities at the elbow following radiographs. | Chronic Elbow Pain. MR arthrography may also assist in differentiation between partial and complete UCL tear [40,41]. Presence of soft tissue and bone marrow edema occurs more often in symptomatic patients [42]. Additionally, a more distal ligamentous insertion of the UCL (T sign) has recently been suggested to result from repetitive overhead activity and injury rather than representing a normal anatomic variant [42]. In patients with posterolateral rotatory instability, MR arthrography can assess the integrity of the ulnar band of the radial collateral ligament [43] and demonstrate radiocapitellar incongruity [44]. MRI Elbow A 3T MR arthrography is more accurate than noncontrast MRI elbow for detection of collateral ligament injuries [38]. Radiography Elbow Stress View Measurement of medial joint space opening on stress radiographs correlates with severity of UCL injury in throwing athletes [6]. Additionally, medial joint vacuum phenomenon on valgus stress radiographs is specific for UCL injury [45]. However, radiographs do not directly provide information on the location of collateral ligament injury or associated soft tissue injuries as can be done on MR arthrography. Chronic Elbow Pain US Elbow For full-thickness UCL tears, conventional US has a sensitivity of 79%, a specificity of 98%, and an accuracy of 95% (38). For partial thickness UCL tears, conventional US has a sensitivity of 77%, a specificity of 94%, and an accuracy of 90% (38). Stress US can accurately detect UCL tears when there is medial joint gapping [46,47]. The sensitivity and specificity of valgus stress US for all UCL tears is 96% and 81%, respectively [36]. Variant 6: Chronic elbow pain. Suspect nerve abnormality. Radiographs normal or nonspecific. Next imaging study. 3-Phase Bone Scan Elbow There is limited evidence to support the routine use of 3-phase bone scan elbow for nerve abnormalities at the elbow following radiographs. | 69423 |
acrac_69423_7 | Chronic Elbow Pain | CT Arthrography Elbow There is limited evidence to support the routine use of CT arthrography elbow for nerve abnormalities at the elbow following radiographs. CT Elbow CT axial images in flexion and extension can demonstrate recurrent ulnar nerve dislocation because of a snapping of the medial head of the triceps [47]. MR Arthrography Elbow There is limited evidence to support the routine use of MR arthrography elbow for nerve abnormalities following radiographs. MRI Elbow T2-weighted MR neurography is the reference standard for imaging ulnar nerve entrapment (UNE) [48-50]. Most common findings include high signal intensity and nerve enlargement [50]. Diagnostic confidence can be increased with the use of diffusion-tensor imaging [49,51]. Diffusion-tensor imaging and tractography also provide quantitative information in 3-D perspective [47,49]. However, 3T MRI has only fair-to-moderate agreement for localization of compression points in UNE [52,53]. Radial nerve, median nerve, and other entrapment syndromes can also be evaluated with MRI [54,55]. US Elbow US elbow is another option for evaluation of UNE. Assessment of cross-sectional area/nerve thickness has high accuracy rates [48,56-58]. US also accurately demonstrates hourglass constriction of the nerve [59]. Dynamic US is helpful in demonstrating nerve dislocation in ulnar nerve neuropathy and snapping triceps syndrome [59-62]. Shear-wave elastography is a newer method used for the diagnosis of ulnar neuropathy at the elbow. Values of 100% specificity, sensitivity, and both positive and negative predictive value have been reported [63,64]. Chronic Elbow Pain 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. | Chronic Elbow Pain. CT Arthrography Elbow There is limited evidence to support the routine use of CT arthrography elbow for nerve abnormalities at the elbow following radiographs. CT Elbow CT axial images in flexion and extension can demonstrate recurrent ulnar nerve dislocation because of a snapping of the medial head of the triceps [47]. MR Arthrography Elbow There is limited evidence to support the routine use of MR arthrography elbow for nerve abnormalities following radiographs. MRI Elbow T2-weighted MR neurography is the reference standard for imaging ulnar nerve entrapment (UNE) [48-50]. Most common findings include high signal intensity and nerve enlargement [50]. Diagnostic confidence can be increased with the use of diffusion-tensor imaging [49,51]. Diffusion-tensor imaging and tractography also provide quantitative information in 3-D perspective [47,49]. However, 3T MRI has only fair-to-moderate agreement for localization of compression points in UNE [52,53]. Radial nerve, median nerve, and other entrapment syndromes can also be evaluated with MRI [54,55]. US Elbow US elbow is another option for evaluation of UNE. Assessment of cross-sectional area/nerve thickness has high accuracy rates [48,56-58]. US also accurately demonstrates hourglass constriction of the nerve [59]. Dynamic US is helpful in demonstrating nerve dislocation in ulnar nerve neuropathy and snapping triceps syndrome [59-62]. Shear-wave elastography is a newer method used for the diagnosis of ulnar neuropathy at the elbow. Values of 100% specificity, sensitivity, and both positive and negative predictive value have been reported [63,64]. Chronic Elbow Pain 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. | 69423 |
acrac_69476_0 | Suspected Small Bowel Obstruction | Introduction/Background Small-bowel obstruction (SBO) is responsible for up to 16% of hospital admissions for abdominal pain with mortality ranging between 2% to 8% overall, and as high as 25% when associated with bowel ischemia [1,2]. Radiologic imaging plays the key role in the diagnosis and management of SBO because neither patient presentation, the clinical examination, nor laboratory testing are sufficiently sensitive or specific enough to diagnose or guide management [2-8]. Imaging not only diagnoses the presence of SBO but also can aid in the differentiation of high-grade from low-grade obstruction. This differentiation helps to guide referring physicians between surgical treatment for high-grade or complicated SBO versus conservative management with enteric tube decompression. Imaging also serves to localize the site of obstruction and evaluate possible causes of obstruction with the most common cause being adhesions, accounting for 70% of all cases. Other causes include hernias, malignancies, Crohn disease, intussusception, volvulus, gallstone ileus, obstructive foreign bodies and bezoars, trauma, endometriosis, and iatrogenic causes. Finally, imaging can play a role in the detection of related findings that may prompt surgical treatment such as ischemia, internal hernia, or volvulus [2-8]. This document refers to imaging appropriateness in diagnosis of adult patients, >18 years of age. Discussion of Procedures by Variant Variant 1: Suspected small-bowel obstruction. Acute presentation. Initial imaging. The typical acute presentation of a patient suspected of having SBO includes intermittent crampy central abdominal pain, distension, nausea, and vomiting. Physical examination findings include abdominal distension with either absent or high-pitched bowel sounds. Abnormal laboratory findings such as an elevated white blood cell count, elevated lactic acid, or elevated serum amylase raise the suspicion for a complication such as ischemia. | Suspected Small Bowel Obstruction. Introduction/Background Small-bowel obstruction (SBO) is responsible for up to 16% of hospital admissions for abdominal pain with mortality ranging between 2% to 8% overall, and as high as 25% when associated with bowel ischemia [1,2]. Radiologic imaging plays the key role in the diagnosis and management of SBO because neither patient presentation, the clinical examination, nor laboratory testing are sufficiently sensitive or specific enough to diagnose or guide management [2-8]. Imaging not only diagnoses the presence of SBO but also can aid in the differentiation of high-grade from low-grade obstruction. This differentiation helps to guide referring physicians between surgical treatment for high-grade or complicated SBO versus conservative management with enteric tube decompression. Imaging also serves to localize the site of obstruction and evaluate possible causes of obstruction with the most common cause being adhesions, accounting for 70% of all cases. Other causes include hernias, malignancies, Crohn disease, intussusception, volvulus, gallstone ileus, obstructive foreign bodies and bezoars, trauma, endometriosis, and iatrogenic causes. Finally, imaging can play a role in the detection of related findings that may prompt surgical treatment such as ischemia, internal hernia, or volvulus [2-8]. This document refers to imaging appropriateness in diagnosis of adult patients, >18 years of age. Discussion of Procedures by Variant Variant 1: Suspected small-bowel obstruction. Acute presentation. Initial imaging. The typical acute presentation of a patient suspected of having SBO includes intermittent crampy central abdominal pain, distension, nausea, and vomiting. Physical examination findings include abdominal distension with either absent or high-pitched bowel sounds. Abnormal laboratory findings such as an elevated white blood cell count, elevated lactic acid, or elevated serum amylase raise the suspicion for a complication such as ischemia. | 69476 |
acrac_69476_1 | Suspected Small Bowel Obstruction | Most cases of SBO are low grade and may be treated conservatively with enteric tube decompression, intravenous (IV) fluids, aBoston University Medical Center, Boston, Massachusetts. bDuke University Medical Center, Durham, North Carolina. cPanel Chair, University of Wisconsin Hospital & Clinics, Madison, Wisconsin. dPanel Vice-Chair, University of California San Diego, San Diego, California. eThe University of South Florida Morsani College of Medicine, Tampa, Florida. fUniversity of Texas Health Science Center at Houston and McGovern Medical School, Houston, Texas; American Gastroenterological Association. gVirginia Tech Carilion School of Medicine, Roanoke, Virginia. hUniversity of Colorado School of Medicine Anschutz Medical Campus, Aurora, Colorado; American College of Emergency Physicians. iMassachusetts General Hospital, Boston, Massachusetts. jMedstar Georgetown University Hospital, Washington, District of Columbia. kCleveland Clinic, Cleveland, Ohio. lEmory University, Atlanta, Georgia. mPenn State Health, Hershey, Pennsylvania. nUniversity of Alabama at Birmingham, Birmingham, Alabama. oDartmouth-Hitchcock Medical Center, Lebanon, New Hampshire. pUniversity of California San Francisco, San Francisco, California. qSpecialty Chair, Virginia Commonwealth University Medical Center, Richmond, Virginia. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document. Reprint requests to: [email protected] Suspected Small-Bowel Obstruction pain medication, and sometimes antibiotics. | Suspected Small Bowel Obstruction. Most cases of SBO are low grade and may be treated conservatively with enteric tube decompression, intravenous (IV) fluids, aBoston University Medical Center, Boston, Massachusetts. bDuke University Medical Center, Durham, North Carolina. cPanel Chair, University of Wisconsin Hospital & Clinics, Madison, Wisconsin. dPanel Vice-Chair, University of California San Diego, San Diego, California. eThe University of South Florida Morsani College of Medicine, Tampa, Florida. fUniversity of Texas Health Science Center at Houston and McGovern Medical School, Houston, Texas; American Gastroenterological Association. gVirginia Tech Carilion School of Medicine, Roanoke, Virginia. hUniversity of Colorado School of Medicine Anschutz Medical Campus, Aurora, Colorado; American College of Emergency Physicians. iMassachusetts General Hospital, Boston, Massachusetts. jMedstar Georgetown University Hospital, Washington, District of Columbia. kCleveland Clinic, Cleveland, Ohio. lEmory University, Atlanta, Georgia. mPenn State Health, Hershey, Pennsylvania. nUniversity of Alabama at Birmingham, Birmingham, Alabama. oDartmouth-Hitchcock Medical Center, Lebanon, New Hampshire. pUniversity of California San Francisco, San Francisco, California. qSpecialty Chair, Virginia Commonwealth University Medical Center, Richmond, Virginia. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document. Reprint requests to: [email protected] Suspected Small-Bowel Obstruction pain medication, and sometimes antibiotics. | 69476 |
acrac_69476_2 | Suspected Small Bowel Obstruction | However, imaging and laboratory findings that suggest a higher grade SBO with a complication, such as ischemia, closed-loop obstruction, volvulus, or complete obstruction, may prompt more urgent surgical treatment. Patients with high-grade SBO may present with more severe abdominal pain, as well as a higher risk of bowel ischemia and perforation. However, physical examination and laboratory tests are neither sufficiently sensitive nor specific to determine which patients with SBO have coexistent strangulation or ischemia. Early imaging diagnosis and intervention is therefore critical for successful treatment and minimization of mortality, which can be as high as 25% in the setting of ischemia. The goals of imaging in high-grade SBO are to evaluate the severity of the obstruction, identify the etiology/site of the obstruction, and to detect the presence of complications, such as volvulus, strangulation, closed-loop obstruction, and ischemia. Specific imaging signs that suggest ischemia include abnormally decreased or increased bowel wall enhancement, intramural hyperdensity on noncontrast CT, bowel wall thickening, mesenteric edema, ascites, and pneumatosis or mesenteric venous gas. The presence of ischemia warrants immediate surgery. CT Abdomen and Pelvis Multiple publications have confirmed the use and accuracy of a standard abdominal and pelvic CT examination in patients with a suspected high-grade SBO. A diagnostic accuracy of more than 90% has been reported [4,5,17], with high accuracy for distinguishing SBO from an adynamic small-bowel ileus [6], and for identifying the cause of obstruction [17-20]. Patients with a suspected high-grade obstruction do not require any oral contrast medium because the nonopacified fluid in the bowel provides adequate intrinsic contrast. | Suspected Small Bowel Obstruction. However, imaging and laboratory findings that suggest a higher grade SBO with a complication, such as ischemia, closed-loop obstruction, volvulus, or complete obstruction, may prompt more urgent surgical treatment. Patients with high-grade SBO may present with more severe abdominal pain, as well as a higher risk of bowel ischemia and perforation. However, physical examination and laboratory tests are neither sufficiently sensitive nor specific to determine which patients with SBO have coexistent strangulation or ischemia. Early imaging diagnosis and intervention is therefore critical for successful treatment and minimization of mortality, which can be as high as 25% in the setting of ischemia. The goals of imaging in high-grade SBO are to evaluate the severity of the obstruction, identify the etiology/site of the obstruction, and to detect the presence of complications, such as volvulus, strangulation, closed-loop obstruction, and ischemia. Specific imaging signs that suggest ischemia include abnormally decreased or increased bowel wall enhancement, intramural hyperdensity on noncontrast CT, bowel wall thickening, mesenteric edema, ascites, and pneumatosis or mesenteric venous gas. The presence of ischemia warrants immediate surgery. CT Abdomen and Pelvis Multiple publications have confirmed the use and accuracy of a standard abdominal and pelvic CT examination in patients with a suspected high-grade SBO. A diagnostic accuracy of more than 90% has been reported [4,5,17], with high accuracy for distinguishing SBO from an adynamic small-bowel ileus [6], and for identifying the cause of obstruction [17-20]. Patients with a suspected high-grade obstruction do not require any oral contrast medium because the nonopacified fluid in the bowel provides adequate intrinsic contrast. | 69476 |
acrac_69476_3 | Suspected Small Bowel Obstruction | Additionally, oral contrast use in a known or suspected high-grade SBO does not add to diagnostic accuracy and can delay diagnosis, increase patient discomfort, and increase the risk of complications, particularly vomiting and aspiration. The use of positive oral contrast agents can also potentially limit the ability to detect abnormal bowel wall enhancement in the case of ischemia and hypoperfusion. However, SBO may be identified in patients who have undergone CT with oral (with or without IV) contrast (ie, when SBO was not specifically suspected at the time the study was ordered/protocolled). Multidetector CT scanners with multiplanar reconstruction capabilities have been noticeably more effective for evaluating SBO and other abdominal pathology [21-26]. Multiplanar reformations have also been found to increase accuracy and confidence in locating the transition zone in SBO, which can be a useful adjunct if an operative intervention is planned [24,27,28]. CT with IV contrast is preferable for routine imaging of suspected SBO, in part to demonstrate whether the bowel is perfusing normally or is potentially ischemic, and in a minority of cases, to provide information about the potential etiology, such as Crohn disease and neoplasm. Noncontrast CT appears to have comparable accuracy for diagnosing or excluding high-grade SBO, although determination for ischemia is reduced [29]. CT Enteroclysis In the clinical setting of acute pain and distention, the use of CT enteroclysis is not favorable, because patients cannot tolerate the active infusion of oral contrast into an obstructed small-bowel. CT enteroclysis is generally favored over conventional enteroclysis because it avoids the problem of overlapping small-bowel loops, and it has been shown to demonstrate a larger number of bowel abnormalities and more abnormalities outside the bowel [61]. | Suspected Small Bowel Obstruction. Additionally, oral contrast use in a known or suspected high-grade SBO does not add to diagnostic accuracy and can delay diagnosis, increase patient discomfort, and increase the risk of complications, particularly vomiting and aspiration. The use of positive oral contrast agents can also potentially limit the ability to detect abnormal bowel wall enhancement in the case of ischemia and hypoperfusion. However, SBO may be identified in patients who have undergone CT with oral (with or without IV) contrast (ie, when SBO was not specifically suspected at the time the study was ordered/protocolled). Multidetector CT scanners with multiplanar reconstruction capabilities have been noticeably more effective for evaluating SBO and other abdominal pathology [21-26]. Multiplanar reformations have also been found to increase accuracy and confidence in locating the transition zone in SBO, which can be a useful adjunct if an operative intervention is planned [24,27,28]. CT with IV contrast is preferable for routine imaging of suspected SBO, in part to demonstrate whether the bowel is perfusing normally or is potentially ischemic, and in a minority of cases, to provide information about the potential etiology, such as Crohn disease and neoplasm. Noncontrast CT appears to have comparable accuracy for diagnosing or excluding high-grade SBO, although determination for ischemia is reduced [29]. CT Enteroclysis In the clinical setting of acute pain and distention, the use of CT enteroclysis is not favorable, because patients cannot tolerate the active infusion of oral contrast into an obstructed small-bowel. CT enteroclysis is generally favored over conventional enteroclysis because it avoids the problem of overlapping small-bowel loops, and it has been shown to demonstrate a larger number of bowel abnormalities and more abnormalities outside the bowel [61]. | 69476 |
acrac_69476_4 | Suspected Small Bowel Obstruction | Suspected Small-Bowel Obstruction To our knowledge; however, CT enteroclysis is not widely used in the United States at present, especially for acute presentations of bowel obstruction. CT Enterography CT enterography does not require intubation of the small-bowel but instead relies on large volumes of orally ingested contrast in a set time interval. In the setting of suspected obstruction of this clinical scenario, patients cannot generally tolerate the oral contrast administration requirements. As in the case of CT enteroclysis, the use in the acute patient presentation is not favorable because of a lack of tolerance to ingest a relatively large volume of fluid if the bowel is obstructed. Fluoroscopy Small Bowel Enteroclysis There is solid evidence that enteroclysis is highly reliable in revealing sites of low- and high-grade SBO [62,63], as well as for distinguishing adhesions from obstructing neoplasms or other etiologies [62]. Despite this evidence, enteroclysis is not useful in the acute situation of suspected obstruction in which the patient is ill. In this clinical scenario, such patients cannot tolerate the invasive nature of the examination. Fluoroscopy Small Bowel Follow-Through Opinions remain divided on the usefulness of SBFT examinations with an orally administered barium contrast or water-soluble contrast. Some investigators have found this examination useful for managing suspected SBO in 68% to 100% of cases [64]. However, the ability to diagnose ischemic loops or bowel perforation can be limited. SBFT does not typically evaluate for other etiologies of abdominal pain that may be detected on CT. As such, the SBFT could be considered a problem-solving examination following an equivocal CT, particularly with suspected low- grade or intermittent or partial obstruction [65]. Early reports of possible therapeutic benefits of the use of water- soluble contrast agents in patients with postoperative SBO remain controversial and uncertain [14-16]. | Suspected Small Bowel Obstruction. Suspected Small-Bowel Obstruction To our knowledge; however, CT enteroclysis is not widely used in the United States at present, especially for acute presentations of bowel obstruction. CT Enterography CT enterography does not require intubation of the small-bowel but instead relies on large volumes of orally ingested contrast in a set time interval. In the setting of suspected obstruction of this clinical scenario, patients cannot generally tolerate the oral contrast administration requirements. As in the case of CT enteroclysis, the use in the acute patient presentation is not favorable because of a lack of tolerance to ingest a relatively large volume of fluid if the bowel is obstructed. Fluoroscopy Small Bowel Enteroclysis There is solid evidence that enteroclysis is highly reliable in revealing sites of low- and high-grade SBO [62,63], as well as for distinguishing adhesions from obstructing neoplasms or other etiologies [62]. Despite this evidence, enteroclysis is not useful in the acute situation of suspected obstruction in which the patient is ill. In this clinical scenario, such patients cannot tolerate the invasive nature of the examination. Fluoroscopy Small Bowel Follow-Through Opinions remain divided on the usefulness of SBFT examinations with an orally administered barium contrast or water-soluble contrast. Some investigators have found this examination useful for managing suspected SBO in 68% to 100% of cases [64]. However, the ability to diagnose ischemic loops or bowel perforation can be limited. SBFT does not typically evaluate for other etiologies of abdominal pain that may be detected on CT. As such, the SBFT could be considered a problem-solving examination following an equivocal CT, particularly with suspected low- grade or intermittent or partial obstruction [65]. Early reports of possible therapeutic benefits of the use of water- soluble contrast agents in patients with postoperative SBO remain controversial and uncertain [14-16]. | 69476 |
acrac_69476_5 | Suspected Small Bowel Obstruction | MR Enteroclysis MR enteroclysis is not useful in the acute situation of suspected obstruction in which the patient is ill. In this clinical scenario, such patients cannot tolerate the invasive nature of the examination. MR enteroclysis appears to compare favorably with CT enteroclysis in evaluating a low-grade obstruction [66], although neither MR enteroclysis nor CT enteroclysis are in wide use because patients are often unable to tolerate the degree of small-bowel distension necessary. Children, and particularly pregnant patients, with known or suspected SBO, as well as younger patients with repetitive episodes of obstruction, are the ideal population to undergo MRI. In pregnant patients, only noncontrast sequences are obtained. In other patients, MR enteroclysis can be performed either as an IV contrast enhanced study or a noncontrast study. MR Enterography In the setting of suspected obstruction of this clinical scenario, patients cannot generally tolerate the oral contrast administration requirements related to the enterography technique. To our knowledge; however, little data are available on comparing MR enterography with other imaging examinations in patients with a suspected SBO. MRI Abdomen and Pelvis Increasing evidence supports the role of MRI for detecting and characterizing SBO. Because of absent evidence of any incremental diagnostic gain, compared with CT, MRI should not be used routinely to evaluate suspected high- grade SBO [67]. However, there may be situations in which MRI could be an appropriate alternative to CT, particularly for those who have had multiple prior CT examinations or are expected to get multiple future imaging examinations. Examinations may be difficult to interpret related to patient pain and discomfort and associated patient motion in the acute setting. Radiography Abdomen and Pelvis Abdominal radiography has been the traditional starting point for the imaging evaluation of suspected SBO [68]. | Suspected Small Bowel Obstruction. MR Enteroclysis MR enteroclysis is not useful in the acute situation of suspected obstruction in which the patient is ill. In this clinical scenario, such patients cannot tolerate the invasive nature of the examination. MR enteroclysis appears to compare favorably with CT enteroclysis in evaluating a low-grade obstruction [66], although neither MR enteroclysis nor CT enteroclysis are in wide use because patients are often unable to tolerate the degree of small-bowel distension necessary. Children, and particularly pregnant patients, with known or suspected SBO, as well as younger patients with repetitive episodes of obstruction, are the ideal population to undergo MRI. In pregnant patients, only noncontrast sequences are obtained. In other patients, MR enteroclysis can be performed either as an IV contrast enhanced study or a noncontrast study. MR Enterography In the setting of suspected obstruction of this clinical scenario, patients cannot generally tolerate the oral contrast administration requirements related to the enterography technique. To our knowledge; however, little data are available on comparing MR enterography with other imaging examinations in patients with a suspected SBO. MRI Abdomen and Pelvis Increasing evidence supports the role of MRI for detecting and characterizing SBO. Because of absent evidence of any incremental diagnostic gain, compared with CT, MRI should not be used routinely to evaluate suspected high- grade SBO [67]. However, there may be situations in which MRI could be an appropriate alternative to CT, particularly for those who have had multiple prior CT examinations or are expected to get multiple future imaging examinations. Examinations may be difficult to interpret related to patient pain and discomfort and associated patient motion in the acute setting. Radiography Abdomen and Pelvis Abdominal radiography has been the traditional starting point for the imaging evaluation of suspected SBO [68]. | 69476 |
acrac_69476_6 | Suspected Small Bowel Obstruction | However, studies testing the use of abdominal radiographs have yielded disparate results [4,5,18,69]. Although some investigators have reported an 80% to 90% success rate in diagnosing SBO using radiographs [5], an overall accuracy somewhat approaching that of CT [7], others have achieved rates only in the 30% to 70% range [4,7,18]. In other studies, abdominal radiographs proved to be of little or no help in assessing the site or cause of SBO [70,71] and were even misleading in 20% to 40% of patients [18]. A relatively recent study; however, found that abdominal radiographs were accurate for detecting acute SBO. It should be stressed; however, that it may be difficult to differentiate an SBO from a postoperative ileus in the perioperative period based on a single examination. Serial examinations showing persistent dilated small-bowel loops with air-fluid levels and relative or complete paucity of gas in the colon favor SBO. Suspected Small-Bowel Obstruction Despite the relatively high accuracy of abdominal radiographs in detecting SBO, CT provides much more information, including the site and cause of the obstruction and complications of SBO. As a result, CT findings generally influence patient management much more than do abdominal radiographs. In light of these inconsistent results, it is reasonable to expect that abdominal radiographs will not be definitive in many patients with a suspected SBO. Radiographs could prolong the evaluation period. Therefore, in patients with a known or suspected SBO, fluoroscopic-contrast examinations (SBFT, conventional enteroclysis), and particularly, cross-sectional imaging examinations (CT, MRI, ultrasound [US]), as well as specialized cross-sectional imaging examinations (CT enterography, CT enteroclysis, MR enterography, and MR enteroclysis), may be more useful options for diagnosis. Variant 2: Suspected intermittent or low-grade small-bowel obstruction. Indolent presentation. | Suspected Small Bowel Obstruction. However, studies testing the use of abdominal radiographs have yielded disparate results [4,5,18,69]. Although some investigators have reported an 80% to 90% success rate in diagnosing SBO using radiographs [5], an overall accuracy somewhat approaching that of CT [7], others have achieved rates only in the 30% to 70% range [4,7,18]. In other studies, abdominal radiographs proved to be of little or no help in assessing the site or cause of SBO [70,71] and were even misleading in 20% to 40% of patients [18]. A relatively recent study; however, found that abdominal radiographs were accurate for detecting acute SBO. It should be stressed; however, that it may be difficult to differentiate an SBO from a postoperative ileus in the perioperative period based on a single examination. Serial examinations showing persistent dilated small-bowel loops with air-fluid levels and relative or complete paucity of gas in the colon favor SBO. Suspected Small-Bowel Obstruction Despite the relatively high accuracy of abdominal radiographs in detecting SBO, CT provides much more information, including the site and cause of the obstruction and complications of SBO. As a result, CT findings generally influence patient management much more than do abdominal radiographs. In light of these inconsistent results, it is reasonable to expect that abdominal radiographs will not be definitive in many patients with a suspected SBO. Radiographs could prolong the evaluation period. Therefore, in patients with a known or suspected SBO, fluoroscopic-contrast examinations (SBFT, conventional enteroclysis), and particularly, cross-sectional imaging examinations (CT, MRI, ultrasound [US]), as well as specialized cross-sectional imaging examinations (CT enterography, CT enteroclysis, MR enterography, and MR enteroclysis), may be more useful options for diagnosis. Variant 2: Suspected intermittent or low-grade small-bowel obstruction. Indolent presentation. | 69476 |
acrac_69476_7 | Suspected Small Bowel Obstruction | Patients with suspected intermittent or low-grade SBO may have a more indolent presentation in which the patient may be asymptomatic at baseline with intermittent symptoms. If a SBO is present, it may be intermittent or very low-grade, requiring provocative measures such as bowel distention to visualize this process on a consistent basis. In low-grade SBO, there is sufficient luminal patency to allow contrast to flow beyond the point of obstruction. Low-grade or intermittent SBO can therefore be more difficult to diagnose with modalities that do not maximally distend or exaggerate the caliber of the small-bowel lumen. The patient may be relatively asymptomatic and with a more nonspecific presentation with other differential considerations possible. On imaging, it may be difficult to visualize dilated abnormal loops and a transition point. In these cases, volume-challenge or dynamic enteral examinations may be preferred to accentuate mild or subclinical obstructions and to better challenge the distensibility of small-bowel. The multiplanar reformatting capabilities of multidetector CT scanners has also helped in evaluating these patients. CT Abdomen and Pelvis Although standard abdominal and pelvic CT examinations in patients with a suspected high-grade SBO have shown diagnostic accuracies of greater than 90% [4,5,17], low-grade or intermittent obstruction has been less accurately diagnosed with a sensitivity of only 48% to 50% and a specificity of 94% [7,80]. In this situation of suspected intermittent or low-grade SBO, the bowel loops may look unremarkable with intrinsic enteral fluid or standard oral contrast administration at CT. Oral contrast may be purposefully given to these patients when SBO is a consideration. When a transition point is identified without passage of orally administered positive contrast, optional re-imaging within 24 hours may depict passage of oral contrast beyond the transition point, indicating incomplete or partial obstruction [81]. | Suspected Small Bowel Obstruction. Patients with suspected intermittent or low-grade SBO may have a more indolent presentation in which the patient may be asymptomatic at baseline with intermittent symptoms. If a SBO is present, it may be intermittent or very low-grade, requiring provocative measures such as bowel distention to visualize this process on a consistent basis. In low-grade SBO, there is sufficient luminal patency to allow contrast to flow beyond the point of obstruction. Low-grade or intermittent SBO can therefore be more difficult to diagnose with modalities that do not maximally distend or exaggerate the caliber of the small-bowel lumen. The patient may be relatively asymptomatic and with a more nonspecific presentation with other differential considerations possible. On imaging, it may be difficult to visualize dilated abnormal loops and a transition point. In these cases, volume-challenge or dynamic enteral examinations may be preferred to accentuate mild or subclinical obstructions and to better challenge the distensibility of small-bowel. The multiplanar reformatting capabilities of multidetector CT scanners has also helped in evaluating these patients. CT Abdomen and Pelvis Although standard abdominal and pelvic CT examinations in patients with a suspected high-grade SBO have shown diagnostic accuracies of greater than 90% [4,5,17], low-grade or intermittent obstruction has been less accurately diagnosed with a sensitivity of only 48% to 50% and a specificity of 94% [7,80]. In this situation of suspected intermittent or low-grade SBO, the bowel loops may look unremarkable with intrinsic enteral fluid or standard oral contrast administration at CT. Oral contrast may be purposefully given to these patients when SBO is a consideration. When a transition point is identified without passage of orally administered positive contrast, optional re-imaging within 24 hours may depict passage of oral contrast beyond the transition point, indicating incomplete or partial obstruction [81]. | 69476 |
acrac_69476_8 | Suspected Small Bowel Obstruction | When a transition point is not identified, optimized distention of the bowel (through either CT enteroclysis or CT enterography) may be needed to make an intermittent or mild obstruction apparent. CT Enteroclysis CT enteroclysis offers improved sensitivity and specificity over standard CT examinations in evaluating suspected intermittent or low-grade SBO [68,82-84]. The placement of a nasoduodenal tube with active controlled infusion of oral contrast optimizes detection of subtle causes of mild obstructions. There is solid evidence that enteroclysis is highly reliable in revealing sites of low-grade SBO [62,63,85], as well as for distinguishing adhesions from obstructing neoplasms or other etiologies [62]. CT enteroclysis is generally favored over conventional enteroclysis because it avoids the problem of overlapping small-bowel loops; it also has been shown to demonstrate a larger number of bowel abnormalities and more abnormalities outside the bowel [61]. CT enteroclysis should be considered, especially for patients who have a history of malignancy [68]. To our knowledge; however, CT enteroclysis is not widely used in the United States at present because of the practical challenges of nasojejunal intubation and the often-associated issues related to conscious sedation and continuous patient monitoring. Suspected Small-Bowel Obstruction CT Enterography CT enterography does not require intubation of the small-bowel and, therefore, has greater patient acceptance [86]. The increased distention of small-bowel related to the oral contrast ingestion protocol optimizes detection of bowel pathology. To our knowledge; however, its clinical usefulness for diagnosing intermittent or low-grade SBO has not been convincingly established, although one small series showed promise [87]. | Suspected Small Bowel Obstruction. When a transition point is not identified, optimized distention of the bowel (through either CT enteroclysis or CT enterography) may be needed to make an intermittent or mild obstruction apparent. CT Enteroclysis CT enteroclysis offers improved sensitivity and specificity over standard CT examinations in evaluating suspected intermittent or low-grade SBO [68,82-84]. The placement of a nasoduodenal tube with active controlled infusion of oral contrast optimizes detection of subtle causes of mild obstructions. There is solid evidence that enteroclysis is highly reliable in revealing sites of low-grade SBO [62,63,85], as well as for distinguishing adhesions from obstructing neoplasms or other etiologies [62]. CT enteroclysis is generally favored over conventional enteroclysis because it avoids the problem of overlapping small-bowel loops; it also has been shown to demonstrate a larger number of bowel abnormalities and more abnormalities outside the bowel [61]. CT enteroclysis should be considered, especially for patients who have a history of malignancy [68]. To our knowledge; however, CT enteroclysis is not widely used in the United States at present because of the practical challenges of nasojejunal intubation and the often-associated issues related to conscious sedation and continuous patient monitoring. Suspected Small-Bowel Obstruction CT Enterography CT enterography does not require intubation of the small-bowel and, therefore, has greater patient acceptance [86]. The increased distention of small-bowel related to the oral contrast ingestion protocol optimizes detection of bowel pathology. To our knowledge; however, its clinical usefulness for diagnosing intermittent or low-grade SBO has not been convincingly established, although one small series showed promise [87]. | 69476 |
acrac_69476_9 | Suspected Small Bowel Obstruction | Although there is little evidence that CT enterography can be used reliably to identify intermittent- or low-grade SBO, the bowel is typically distended to a greater degree than with standard CT and potentially may be of benefit if CT enteroclysis is not performed at an institution. Fluoroscopy Small-Bowel Enteroclysis Methods of examination that challenge the distensibility of the small-bowel, including conventional (ie, fluoroscopic) enteroclysis and CT enteroclysis, offer improved sensitivity and specificity over standard barium small-bowel and CT examinations in evaluating suspected intermittent or low-grade SBO [18,68,82-84,88]. There is solid evidence that enteroclysis is highly reliable in revealing sites of low-grade SBO [62,63], as well as for distinguishing adhesions from obstructing neoplasms or other etiologies [62]. However, enteroclysis has low patient acceptance. Fluoroscopy Small-Bowel Follow-Through Opinions remain divided on the usefulness of SBFT examinations with an orally administered barium contrast. Some investigators have found this examination useful for managing suspected SBO in 68% to 100% of cases [64]. The SBFT could be considered a problem-solving examination following an equivocal CT, particularly with low- grade or intermittent or partial obstruction [65]. Because SBFT is limited by nonuniform small-bowel filling, it cannot test distensibility and has limitations posed by intermittent fluoroscopy; some authorities argue that enteroclysis is the more appropriate imaging examination in problematic SBO cases, especially in low-grade or intermittent obstruction [62,89]. Early reports of possible therapeutic benefits of the use of water-soluble contrast agents in patients with postoperative SBO remain controversial and uncertain [14-16]. | Suspected Small Bowel Obstruction. Although there is little evidence that CT enterography can be used reliably to identify intermittent- or low-grade SBO, the bowel is typically distended to a greater degree than with standard CT and potentially may be of benefit if CT enteroclysis is not performed at an institution. Fluoroscopy Small-Bowel Enteroclysis Methods of examination that challenge the distensibility of the small-bowel, including conventional (ie, fluoroscopic) enteroclysis and CT enteroclysis, offer improved sensitivity and specificity over standard barium small-bowel and CT examinations in evaluating suspected intermittent or low-grade SBO [18,68,82-84,88]. There is solid evidence that enteroclysis is highly reliable in revealing sites of low-grade SBO [62,63], as well as for distinguishing adhesions from obstructing neoplasms or other etiologies [62]. However, enteroclysis has low patient acceptance. Fluoroscopy Small-Bowel Follow-Through Opinions remain divided on the usefulness of SBFT examinations with an orally administered barium contrast. Some investigators have found this examination useful for managing suspected SBO in 68% to 100% of cases [64]. The SBFT could be considered a problem-solving examination following an equivocal CT, particularly with low- grade or intermittent or partial obstruction [65]. Because SBFT is limited by nonuniform small-bowel filling, it cannot test distensibility and has limitations posed by intermittent fluoroscopy; some authorities argue that enteroclysis is the more appropriate imaging examination in problematic SBO cases, especially in low-grade or intermittent obstruction [62,89]. Early reports of possible therapeutic benefits of the use of water-soluble contrast agents in patients with postoperative SBO remain controversial and uncertain [14-16]. | 69476 |
acrac_69476_10 | Suspected Small Bowel Obstruction | MR Enteroclysis MR enteroclysis appears to compare favorably with CT enteroclysis in evaluating a low-grade obstruction [66], although neither MR enteroclysis nor CT enteroclysis are in wide use because patients are often unable to tolerate the degree of small-bowel distension necessary. The ability of MR enteroclysis to monitor small-bowel filling in real-time without the use of ionizing radiation is an advantage over fluoroscopic and CT enteroclysis. Children and, particularly, pregnant patients with known or suspected SBO, as well as younger patients with repetitive episodes of obstruction, are the ideal population to undergo MRI. In pregnant patients, only noncontrast sequences are obtained. In other patients, MR enteroclysis can be performed either as an IV-contrast enhanced study or a noncontrast study. MR Enterography MR enterography may be superior to routine MRI examinations and is better accepted by patients than MR enteroclysis. To our knowledge; however, little data are available on comparing MR enterography with other imaging examinations in patients with a suspected SBO. MRI Abdomen and Pelvis Increasing evidence supports the role of MRI for detecting and characterizing SBO. The use of fast multiplanar pulse sequences such as half-Fourier acquisition single-shot turbo spin-echo and balanced gradient-echo sequences allow for functional assessment of the distensibility of strictures. Without optimized bowel preparation, bowel loops at MR with standard protocol (ie, without bowel distension) may be unremarkable at intermittent or low-grade obstructions. Radiography Abdomen and Pelvis Abdominal radiography has been the traditional starting point for the imaging evaluation of suspected SBO [68]. However, studies testing the use of abdominal radiographs have yielded disparate results [4,5,18,69]. | Suspected Small Bowel Obstruction. MR Enteroclysis MR enteroclysis appears to compare favorably with CT enteroclysis in evaluating a low-grade obstruction [66], although neither MR enteroclysis nor CT enteroclysis are in wide use because patients are often unable to tolerate the degree of small-bowel distension necessary. The ability of MR enteroclysis to monitor small-bowel filling in real-time without the use of ionizing radiation is an advantage over fluoroscopic and CT enteroclysis. Children and, particularly, pregnant patients with known or suspected SBO, as well as younger patients with repetitive episodes of obstruction, are the ideal population to undergo MRI. In pregnant patients, only noncontrast sequences are obtained. In other patients, MR enteroclysis can be performed either as an IV-contrast enhanced study or a noncontrast study. MR Enterography MR enterography may be superior to routine MRI examinations and is better accepted by patients than MR enteroclysis. To our knowledge; however, little data are available on comparing MR enterography with other imaging examinations in patients with a suspected SBO. MRI Abdomen and Pelvis Increasing evidence supports the role of MRI for detecting and characterizing SBO. The use of fast multiplanar pulse sequences such as half-Fourier acquisition single-shot turbo spin-echo and balanced gradient-echo sequences allow for functional assessment of the distensibility of strictures. Without optimized bowel preparation, bowel loops at MR with standard protocol (ie, without bowel distension) may be unremarkable at intermittent or low-grade obstructions. Radiography Abdomen and Pelvis Abdominal radiography has been the traditional starting point for the imaging evaluation of suspected SBO [68]. However, studies testing the use of abdominal radiographs have yielded disparate results [4,5,18,69]. | 69476 |
acrac_69402_0 | Suspected Acute Aortic Syndrome | Introduction/Background Acute aortic syndrome (AAS) includes the entities of acute aortic dissection (AD), intramural hematoma (IMH), and penetrating atherosclerotic ulcer (PAU). AAS typically presents with sudden onset of severe, tearing, anterior, or interscapular back pain [1]. Symptoms may be dominated by malperfusion syndrome due to obstruction of the lumen of the aorta and/or a side branch when the intimal and medial layers are separated. Risk factors include hypertension, family history, and underlying collagen vascular disorders [2]. Timely diagnosis of AAS is crucial to permit prompt management; early mortality rates are reported to be 1% to 2% per hour after the onset of symptoms for untreated ascending AD [3]. Medical management of acute ascending AD is associated with a mortality rate of nearly 20% by 24 hours after presentation, 30% by 48 hours, 40% to 70% by day 7 [4], and 50% by 1 month [3,5]. The major cause of early death with AAS is aortic rupture [6]. AAS limited to the descending aorta may be managed medically and/or with open surgical or endovascular treatment based on extent of disease, aortic size, malperfusion of end organs, and clinical parameters; medical management is usually undertaken unless the aorta is dilated and/or there is mesenteric or limb ischemia [6]. IMH occurs with approximately 10% of the frequency of AD [7], and can be seen in isolation or in conjunction with AD and PAU. Imaging findings of AAS include any disruption of the intimal and medial layers, either with an IMH within the media (with or without the presence of a penetrating ulcer) or with an intimal flap. The prevalence of isolated IMHs in patients with suspected AAS is reported to be 21% to 30% [3]. Over time, 28% to 47% of patients may progress to a classic AD, and in other patients, the IMH will resolve with or without aneurysmal enlargement of the aorta [6]. PAUs that disrupt the intima most commonly occur in the mid and distal descending aorta [8]. | Suspected Acute Aortic Syndrome. Introduction/Background Acute aortic syndrome (AAS) includes the entities of acute aortic dissection (AD), intramural hematoma (IMH), and penetrating atherosclerotic ulcer (PAU). AAS typically presents with sudden onset of severe, tearing, anterior, or interscapular back pain [1]. Symptoms may be dominated by malperfusion syndrome due to obstruction of the lumen of the aorta and/or a side branch when the intimal and medial layers are separated. Risk factors include hypertension, family history, and underlying collagen vascular disorders [2]. Timely diagnosis of AAS is crucial to permit prompt management; early mortality rates are reported to be 1% to 2% per hour after the onset of symptoms for untreated ascending AD [3]. Medical management of acute ascending AD is associated with a mortality rate of nearly 20% by 24 hours after presentation, 30% by 48 hours, 40% to 70% by day 7 [4], and 50% by 1 month [3,5]. The major cause of early death with AAS is aortic rupture [6]. AAS limited to the descending aorta may be managed medically and/or with open surgical or endovascular treatment based on extent of disease, aortic size, malperfusion of end organs, and clinical parameters; medical management is usually undertaken unless the aorta is dilated and/or there is mesenteric or limb ischemia [6]. IMH occurs with approximately 10% of the frequency of AD [7], and can be seen in isolation or in conjunction with AD and PAU. Imaging findings of AAS include any disruption of the intimal and medial layers, either with an IMH within the media (with or without the presence of a penetrating ulcer) or with an intimal flap. The prevalence of isolated IMHs in patients with suspected AAS is reported to be 21% to 30% [3]. Over time, 28% to 47% of patients may progress to a classic AD, and in other patients, the IMH will resolve with or without aneurysmal enlargement of the aorta [6]. PAUs that disrupt the intima most commonly occur in the mid and distal descending aorta [8]. | 69402 |
acrac_69402_1 | Suspected Acute Aortic Syndrome | Classification of Acute Aortic Syndrome Classification of AAS is based on identifying the location of the most proximal location of the intimal flap and/or IMH. In DeBakey classification type I and type II ADs, the proximal intimal tear is located in the ascending aorta, usually just a few centimeters above the aortic valve. In type I dissection, the intimal flap extends for a variable distance beyond the aortic arch and usually into the descending aorta, whereas in type II the intimal flap is confined to the ascending aorta. DeBakey type III dissection originates in the descending aorta, usually just beyond the origin aUniversity of Washington, Seattle, Washington. bPanel Chair, Duke University Medical Center, Durham, North Carolina. cPanel Vice-Chair, Massachusetts General Hospital, Boston, Massachusetts. dUniversity of Louisville School of Medicine, Louisville, Kentucky. eUniversity of Michigan Health System, Ann Arbor, Michigan. fThe University of Chicago Medical Center, Chicago, Illinois; American College of Physicians. gKaiser Permanente, Los Angeles, California. hVancouver General Hospital, Vancouver, British Columbia, Canada. iUniversity of California San Diego, San Diego, California. jHarvard Medical School, Boston, Massachusetts. kSentara Norfolk General/Eastern Virginia Medical School, Norfolk, Virginia; American College of Emergency Physicians. lNaval Medical Center Portsmouth, Portsmouth, Virginia. mMassachusetts General Hospital, Boston, Massachusetts. nOhio State University, Nationwide Children's Hospital, Columbus, Ohio; Society for Cardiovascular Magnetic Resonance. oUniversity of Virginia Health Center, Charlottesville, Virginia; Society of Cardiovascular Computed Tomography. pAscension Healthcare Wisconsin, Milwaukee, Wisconsin; Nuclear cardiology expert. qSpecialty Chair, UT Southwestern Medical Center, Dallas, Texas. | Suspected Acute Aortic Syndrome. Classification of Acute Aortic Syndrome Classification of AAS is based on identifying the location of the most proximal location of the intimal flap and/or IMH. In DeBakey classification type I and type II ADs, the proximal intimal tear is located in the ascending aorta, usually just a few centimeters above the aortic valve. In type I dissection, the intimal flap extends for a variable distance beyond the aortic arch and usually into the descending aorta, whereas in type II the intimal flap is confined to the ascending aorta. DeBakey type III dissection originates in the descending aorta, usually just beyond the origin aUniversity of Washington, Seattle, Washington. bPanel Chair, Duke University Medical Center, Durham, North Carolina. cPanel Vice-Chair, Massachusetts General Hospital, Boston, Massachusetts. dUniversity of Louisville School of Medicine, Louisville, Kentucky. eUniversity of Michigan Health System, Ann Arbor, Michigan. fThe University of Chicago Medical Center, Chicago, Illinois; American College of Physicians. gKaiser Permanente, Los Angeles, California. hVancouver General Hospital, Vancouver, British Columbia, Canada. iUniversity of California San Diego, San Diego, California. jHarvard Medical School, Boston, Massachusetts. kSentara Norfolk General/Eastern Virginia Medical School, Norfolk, Virginia; American College of Emergency Physicians. lNaval Medical Center Portsmouth, Portsmouth, Virginia. mMassachusetts General Hospital, Boston, Massachusetts. nOhio State University, Nationwide Children's Hospital, Columbus, Ohio; Society for Cardiovascular Magnetic Resonance. oUniversity of Virginia Health Center, Charlottesville, Virginia; Society of Cardiovascular Computed Tomography. pAscension Healthcare Wisconsin, Milwaukee, Wisconsin; Nuclear cardiology expert. qSpecialty Chair, UT Southwestern Medical Center, Dallas, Texas. | 69402 |
acrac_69402_2 | Suspected Acute Aortic Syndrome | 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] Suspected Acute Aortic Syndrome of the left subclavian artery, and propagates antegrade along the descending aorta. Rarely, the proximal intimal tear occurs in an unusual location, such as the abdominal aorta [6]. Stanford type A dissection refers to any dissection involving the ascending aorta and therefore is equivalent to DeBakey type I and type II. Stanford type B dissection is any AD that does not involve the ascending aorta, including dissections that originate in the aortic arch. Stanford type B dissection is therefore equivalent to DeBakey type III [10]. Both the DeBakey and Stanford classifications are ambiguous in regard to AD starting on the aortic arch. Such lesions may be best described as Stanford type B with arch involvement [6,11]. All elements are essential: 1) timing, 2) reconstructions/reformats, and 3) 3-D renderings. Standard CTs with contrast also include timing issues and reconstructions/reformats. Only in CTA, however, is 3-D rendering a required element. This corresponds to the definitions that the CMS has applied to the Current Procedural Terminology codes. Discussion of Procedures by Variant Variant 1: Acute chest pain; suspected acute aortic syndrome Aortography Chest Historically, conventional angiography was considered the reference standard for diagnosing AAS with sensitivity, specificity, positive predictive value, and negative predictive value of 88%, 94%, 96%, and 84%, respectively, reported for identification of an intimal flap [13]. | Suspected Acute Aortic Syndrome. 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] Suspected Acute Aortic Syndrome of the left subclavian artery, and propagates antegrade along the descending aorta. Rarely, the proximal intimal tear occurs in an unusual location, such as the abdominal aorta [6]. Stanford type A dissection refers to any dissection involving the ascending aorta and therefore is equivalent to DeBakey type I and type II. Stanford type B dissection is any AD that does not involve the ascending aorta, including dissections that originate in the aortic arch. Stanford type B dissection is therefore equivalent to DeBakey type III [10]. Both the DeBakey and Stanford classifications are ambiguous in regard to AD starting on the aortic arch. Such lesions may be best described as Stanford type B with arch involvement [6,11]. All elements are essential: 1) timing, 2) reconstructions/reformats, and 3) 3-D renderings. Standard CTs with contrast also include timing issues and reconstructions/reformats. Only in CTA, however, is 3-D rendering a required element. This corresponds to the definitions that the CMS has applied to the Current Procedural Terminology codes. Discussion of Procedures by Variant Variant 1: Acute chest pain; suspected acute aortic syndrome Aortography Chest Historically, conventional angiography was considered the reference standard for diagnosing AAS with sensitivity, specificity, positive predictive value, and negative predictive value of 88%, 94%, 96%, and 84%, respectively, reported for identification of an intimal flap [13]. | 69402 |
acrac_69402_3 | Suspected Acute Aortic Syndrome | The diagnostic accuracy of digital subtraction angiography approaches 98% in some series for identification of an AD. Angiography permits management of patients who are critically ill and can also assess aortic regurgitation and aortic branch vessel involvement (including the coronary arteries) [14]. High frame rates facilitate identification of the intimal tear and the degree of aortic insufficiency. False-negative arteriograms may occur when the false lumen is not opacified, when there is simultaneous opacification of the true and false lumen, and when the intimal flap is not displayed in profile. Disadvantages of angiography include the fact that it is invasive, requires iodinated contrast material, and that it has a limited ability to assess the surrounding structures (eg, presence of mediastinal hemorrhage), which is readily detected by other cross-sectional imaging modalities [1,3]. CT Chest Without IV Contrast CT chest without intravenous (IV) contrast cannot assess the lumen of that aorta, but AAS can be inferred by identifying displaced aortic calcifications or IMHs, findings that are shown to be 94% and 71% sensitive for diagnosing AAS when using contrast-enhanced CTA as the reference standard [15]. Another study found that abnormal aortic wall contour and paraaortic hematoma were also predictive of AAS. These imaging findings were incorporated into a decision-rule that predicted the presence of AAS with a mean sensitivity of 93% [16]. However, few patients in the derivation data set had PAU as a diagnosis, and the number of patients with AAS in the validation data set was not reported. CT without IV contrast can identify complications from AAS, such as mediastinal, pericardial, and/or pleural hematoma. CT Chest With IV Contrast CT chest with IV contrast can identify the presence of an AAS and the presence of complications such as mediastinal, pericardial, and/or pleural hematoma. | Suspected Acute Aortic Syndrome. The diagnostic accuracy of digital subtraction angiography approaches 98% in some series for identification of an AD. Angiography permits management of patients who are critically ill and can also assess aortic regurgitation and aortic branch vessel involvement (including the coronary arteries) [14]. High frame rates facilitate identification of the intimal tear and the degree of aortic insufficiency. False-negative arteriograms may occur when the false lumen is not opacified, when there is simultaneous opacification of the true and false lumen, and when the intimal flap is not displayed in profile. Disadvantages of angiography include the fact that it is invasive, requires iodinated contrast material, and that it has a limited ability to assess the surrounding structures (eg, presence of mediastinal hemorrhage), which is readily detected by other cross-sectional imaging modalities [1,3]. CT Chest Without IV Contrast CT chest without intravenous (IV) contrast cannot assess the lumen of that aorta, but AAS can be inferred by identifying displaced aortic calcifications or IMHs, findings that are shown to be 94% and 71% sensitive for diagnosing AAS when using contrast-enhanced CTA as the reference standard [15]. Another study found that abnormal aortic wall contour and paraaortic hematoma were also predictive of AAS. These imaging findings were incorporated into a decision-rule that predicted the presence of AAS with a mean sensitivity of 93% [16]. However, few patients in the derivation data set had PAU as a diagnosis, and the number of patients with AAS in the validation data set was not reported. CT without IV contrast can identify complications from AAS, such as mediastinal, pericardial, and/or pleural hematoma. CT Chest With IV Contrast CT chest with IV contrast can identify the presence of an AAS and the presence of complications such as mediastinal, pericardial, and/or pleural hematoma. | 69402 |
acrac_69402_4 | Suspected Acute Aortic Syndrome | There is no relevant literature that compares the diagnostic accuracy of CT chest with IV contrast (delayed-phase enhancement) versus CTA chest (arterial-phase contrast). Suspected Acute Aortic Syndrome Dual-energy multidetector CT enables generation of CT chest images without and with IV contrast enhancement by producing virtual unenhanced imaging studies. However, the use of these virtual unenhanced images in place of true unenhanced images remains controversial [18-20]. CTA Coronary Arteries There is no relevant literature supporting the use of CTA of the coronary arteries for the diagnosis of AAS. CTA of coronary arteries may be used in patients with known AD for which coronary arterial disease classification is needed prior to open surgical repair for an AD involving the ascending aorta. This document includes the triple-rule-out (TRO) protocol under the topic of CTA of coronary arteries as the TRO includes simultaneous assessment of the pulmonary arteries, aorta, and coronary arteries. CTA Chest With IV Contrast CTA can demonstrate the presence of aortic intimal flaps, branch vessel involvement, and entry and reentry sites, as well as identification of penetrating ulcers. The addition of a noncontrast acquisition as part of the CTA examination can be used to confirm the presence of an IMH. CTA chest can also allow for simultaneous assessment of adjacent mediastinal, pericardial, and pleural spaces. CTA chest was the most common initial diagnostic test performed in patients enrolled in the International Registry of Acute Aortic Dissection, and is being used with increasing frequency [21]. CTA was used to diagnose AD with 82% sensitivity and 100% specificity [22]. Numerous prior studies evaluating the accuracy of CT use in diagnosing AD have demonstrated sensitivities of 90% to 100% but lower specificities ranging from 87% to 100% [23-26]. However, these studies evaluated conventional CT, which has largely been supplanted by faster multidetector CT. | Suspected Acute Aortic Syndrome. There is no relevant literature that compares the diagnostic accuracy of CT chest with IV contrast (delayed-phase enhancement) versus CTA chest (arterial-phase contrast). Suspected Acute Aortic Syndrome Dual-energy multidetector CT enables generation of CT chest images without and with IV contrast enhancement by producing virtual unenhanced imaging studies. However, the use of these virtual unenhanced images in place of true unenhanced images remains controversial [18-20]. CTA Coronary Arteries There is no relevant literature supporting the use of CTA of the coronary arteries for the diagnosis of AAS. CTA of coronary arteries may be used in patients with known AD for which coronary arterial disease classification is needed prior to open surgical repair for an AD involving the ascending aorta. This document includes the triple-rule-out (TRO) protocol under the topic of CTA of coronary arteries as the TRO includes simultaneous assessment of the pulmonary arteries, aorta, and coronary arteries. CTA Chest With IV Contrast CTA can demonstrate the presence of aortic intimal flaps, branch vessel involvement, and entry and reentry sites, as well as identification of penetrating ulcers. The addition of a noncontrast acquisition as part of the CTA examination can be used to confirm the presence of an IMH. CTA chest can also allow for simultaneous assessment of adjacent mediastinal, pericardial, and pleural spaces. CTA chest was the most common initial diagnostic test performed in patients enrolled in the International Registry of Acute Aortic Dissection, and is being used with increasing frequency [21]. CTA was used to diagnose AD with 82% sensitivity and 100% specificity [22]. Numerous prior studies evaluating the accuracy of CT use in diagnosing AD have demonstrated sensitivities of 90% to 100% but lower specificities ranging from 87% to 100% [23-26]. However, these studies evaluated conventional CT, which has largely been supplanted by faster multidetector CT. | 69402 |
acrac_69402_5 | Suspected Acute Aortic Syndrome | One multidetector CT study enrolling 57 patients has reported sensitivities and specificities of 100% [22]. CT findings may also be used to predict patient outcome. For example, in one retrospective study of 83 patients with type B dissections, the morphologic features of a dissection were associated with an increase in late adverse events [27]. CTA with IV contrast also enables detection of focal intimal disruptions or also ulcer-like projections as prognostic indicators in IMH. In one study of 107 patients, aorta-related death or need for invasive surgery was increased when focal intimal disruptions or ulcer-like projections were present (hazard ratio, 24.43) [29]. CTA with IV contrast can be used to diagnose penetrating PAU, but contrast does not enable additional prognostic imaging findings. PAU prognosis has been associated with the presence or absence of aortic rupture, but in one study, aortic diameter, ulcer size, or the presence of IMH did not affect prognosis [30]. Compared with CTA chest, TRO CT protocols can be used to assess for additional, potentially fatal possibilities such as pulmonary embolism and acute coronary syndrome [31,32]. It has been reported that TRO CT can safely eliminate further diagnostic testing in >75% of patients in the appropriate patient population performed specifically for assessing AD [33]. CTA Chest, Abdomen, and Pelvis With IV Contrast CTA of the chest, abdomen, and pelvis allows for imaging of both the thoracic and abdominal aorta, and it provides assessment of extension of the dissection along the thoracic, abdominal, and pelvic branch vessels with one injection of IV contrast and a single breath-hold acquisition. Postprocessing of the volumetric data set, using multiplanar reformatting and 3-D volume rendering, facilitates evaluation of the location and course of the intimal flap [34], branch vessel, and visceral organ involvement. | Suspected Acute Aortic Syndrome. One multidetector CT study enrolling 57 patients has reported sensitivities and specificities of 100% [22]. CT findings may also be used to predict patient outcome. For example, in one retrospective study of 83 patients with type B dissections, the morphologic features of a dissection were associated with an increase in late adverse events [27]. CTA with IV contrast also enables detection of focal intimal disruptions or also ulcer-like projections as prognostic indicators in IMH. In one study of 107 patients, aorta-related death or need for invasive surgery was increased when focal intimal disruptions or ulcer-like projections were present (hazard ratio, 24.43) [29]. CTA with IV contrast can be used to diagnose penetrating PAU, but contrast does not enable additional prognostic imaging findings. PAU prognosis has been associated with the presence or absence of aortic rupture, but in one study, aortic diameter, ulcer size, or the presence of IMH did not affect prognosis [30]. Compared with CTA chest, TRO CT protocols can be used to assess for additional, potentially fatal possibilities such as pulmonary embolism and acute coronary syndrome [31,32]. It has been reported that TRO CT can safely eliminate further diagnostic testing in >75% of patients in the appropriate patient population performed specifically for assessing AD [33]. CTA Chest, Abdomen, and Pelvis With IV Contrast CTA of the chest, abdomen, and pelvis allows for imaging of both the thoracic and abdominal aorta, and it provides assessment of extension of the dissection along the thoracic, abdominal, and pelvic branch vessels with one injection of IV contrast and a single breath-hold acquisition. Postprocessing of the volumetric data set, using multiplanar reformatting and 3-D volume rendering, facilitates evaluation of the location and course of the intimal flap [34], branch vessel, and visceral organ involvement. | 69402 |
acrac_69402_6 | Suspected Acute Aortic Syndrome | A meta-analysis of 3 studies examining CTA for the diagnosis of dissection showed a pooled sensitivity of 100% and a specificity of 98% [21]. When CTA is used as a first-line test, the International Registry of Acute Aortic Dissection reported a sensitivity of 93% for diagnosing dissection [35]. Suspected Acute Aortic Syndrome MRA Chest Without IV Contrast There is no relevant literature supporting the use of MR angiography (MRA) chest without IV contrast for the diagnosis of AAS. Several studies report noncontrast MRA techniques and compare them with contrast-enhanced techniques, but studies were neither blinded to the reference standard or nor did they contain control subjects [36,37]. MRA Chest, Abdomen, and Pelvis Without IV Contrast There is no relevant literature supporting the use of MRA chest, abdomen, and pelvis without IV contrast for the diagnosis of AAS. Although no literature directly examines the accuracy of diagnosing AAS with MRA chest, abdomen, and pelvis without IV contrast, the accuracy for identification of an AD in the chest is similar to that of an isolated MRA chest without IV contrast with the addition of MRA abdominal and pelvic assessment. MRA Chest, Abdomen, and Pelvis Without and With IV Contrast There is no relevant literature supporting the use of MRA chest, abdomen, and pelvis without and with IV contrast for the diagnosis of AAS. Although no literature directly examines the accuracy of diagnosing AAS with MRA chest, abdomen, and pelvis without IV contrast, the accuracy for identification of an AD in the chest is similar to that of an isolated MRA chest without IV contrast with the addition of MRA abdominal and pelvic assessment. MRI Chest, Abdomen, and Pelvis Without IV Contrast There is no relevant literature supporting the use of MRI chest, abdomen, and pelvis without IV contrast for the diagnosis of AAS. | Suspected Acute Aortic Syndrome. A meta-analysis of 3 studies examining CTA for the diagnosis of dissection showed a pooled sensitivity of 100% and a specificity of 98% [21]. When CTA is used as a first-line test, the International Registry of Acute Aortic Dissection reported a sensitivity of 93% for diagnosing dissection [35]. Suspected Acute Aortic Syndrome MRA Chest Without IV Contrast There is no relevant literature supporting the use of MR angiography (MRA) chest without IV contrast for the diagnosis of AAS. Several studies report noncontrast MRA techniques and compare them with contrast-enhanced techniques, but studies were neither blinded to the reference standard or nor did they contain control subjects [36,37]. MRA Chest, Abdomen, and Pelvis Without IV Contrast There is no relevant literature supporting the use of MRA chest, abdomen, and pelvis without IV contrast for the diagnosis of AAS. Although no literature directly examines the accuracy of diagnosing AAS with MRA chest, abdomen, and pelvis without IV contrast, the accuracy for identification of an AD in the chest is similar to that of an isolated MRA chest without IV contrast with the addition of MRA abdominal and pelvic assessment. MRA Chest, Abdomen, and Pelvis Without and With IV Contrast There is no relevant literature supporting the use of MRA chest, abdomen, and pelvis without and with IV contrast for the diagnosis of AAS. Although no literature directly examines the accuracy of diagnosing AAS with MRA chest, abdomen, and pelvis without IV contrast, the accuracy for identification of an AD in the chest is similar to that of an isolated MRA chest without IV contrast with the addition of MRA abdominal and pelvic assessment. MRI Chest, Abdomen, and Pelvis Without IV Contrast There is no relevant literature supporting the use of MRI chest, abdomen, and pelvis without IV contrast for the diagnosis of AAS. | 69402 |
Subsets and Splits